Indian Journal of Forensic Medicine & Toxicology July-September 2018.pdfDr. Lav Kesharwani...

INTERNATIONAL EDITORIAL ADVISORY BOARD1. Dr Nuwadatta Subedi (In Charge) Dept of Forensic Med and

Toxicology College of Medical Sciences, Bharatpur, Nepal2. Dr. Birendra Kumar Mandal (In charge) Forensic Medicine and

Toxicology, Chitwan Medical College, Bharatpur, Nepal3. Dr. Sarathchandra Kodikara (Senior Lecturer) Forensic Medicine,

Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya,Sri Lanka

4. Prof. Elisabetta Bertol (Full Professor) Forensic Toxicology at the University of Florence, Italy

5. Babak Mostafazadeh (Associate Professor) Department of Forensic Medicine & Toxicology, Shahid Beheshti University of Medical Sciences, Tehran-Iran

6. Dr. Mokhtar Ahmed Alhrani (Specialist) Forensic Medicine & Clinical Toxicology, Director of Forensic Medicine Unit, Attorney General’s Office, Sana’a, Yemen

7. Dr. Rahul Pathak (Lecturer) Forensic Science, Dept of Life Sciences Anglia Ruskin University, Cambridge, United Kingdom

8. Dr. Hareesh (Professor & Head) Forensic Medicine, Ayder Referral Hospital,College of Health Sciences,Mekelle University, Mekelle Ethiopia East Africa

SCIENTIFIC COMMITTEE1. Pradeep Bokariya (Assistant Professor) Anatomy Dept.

Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra

2. Dr Anil Rahule (Associate Professor) Dept of Anatomy, Govt Medical College Nagpur

3. Dr Yadaiah Alugonda (Assistant Professor) Forensic Medicine, MNR Medical College, Hyderabad

4. Dr Vandana Mudda (Awati) (Associate Prof) Dept of FMT, M.R.Medical College,Gulbarga, Karnataka,

5. Dr. Lav Kesharwani (Asst.Prof.) School of Forensic Science, Sam Higginbottom Institute of Agriculture Technology & Sciences, Allahabad U.P,

6. Dr. NIshat Ahmed Sheikh (Associate Professor) Forensic Medicine, KIMS Narketpally, Andhra Pradesh

7. Dr K. Srinivasulu (Associate Professor) Dept of Forensic Medicine & Toxicology, Mediciti Institute of Medical sciences, Ghanpur, MEDCHAL Ranga Reddy. Dist.AP_501401.

8. Dr. Mukesh Sharma (Senior Scientific Officer) Physics Division, State Forensic Science Laboratory, Jaipur, Rajasthan

9. Dr. Amarantha Donna Ropmay (Associate Professor) NEIGRIHMS, Shillong

10. Dr Basappa S. Hugar (Associate Professor) Forensic Medicine, M.S. Ramaiah Medical College, Bangalore

11. Dr. Anu Sharma (Associate Prof) Dept of Anatomy, DMCH, Ludhiana (PB)

Indian Journal of Forensic Medicine & ToxicologyEDITOR

Prof. R K SharmaFormerly at All India Institute of Medical Sciences, New Delhi

E-mail: [email protected]

“Indian Journal of Forensic Medicine & Toxicology” is peer reviewed six monthly journal. It deals with Forensic Medicine, Forensic Science, Toxicology, DNA fingerprinting, sexual medicine and environment medicine. It has been assigned International standard serial No. p-0973-9122 and e- 0973-9130. The Journal has been assigned RNI No. DELENG/2008/21789. The journal is indexed with Index Copernicus (Poland) and is covered by EMBASE (Excerpta Medica Database). The journal is also abstracted in Chemical Abstracts (CAS) database (USA. The journal is also covered by EBSCO (USA) database. The Journal is now part of UGC, DST and CSIR Consortia. It is now offical publication of Indian Association of Medico-Legal Experts (Regd.).

NATIONAL EDITORIAL ADVISORY BOARD1. Prof. Shashidhar C Mestri (Professor) Forensic Medicine &

Toxicology, Karpaga Vinayaga Institute of Medical Sciences, Palayanoor Kanchipuram Distric, Tamil Nadu

2. Dr. Madhuri Gawande (Professor) Department of Oral Pathology and Microbiology, Sharad Pawar Dental College, Sawangi, Wardha.

3. Dr. T.K.K. Naidu (Prof & Head) Dept of Forensic Medicine, Prathima Institute of Medical Sciences, Karimnagar, A.P.

4. Dr. Shalini Gupta (Head) Faculty of Dental Sciences, King George Medical University, Lucknow, Uttar Pradesh

5. Dr. Pratik Patel (Professor & Head) Forensic Medicine Dept, Smt NHL Mun Med College, Ahmedabad

6. Devinder Singh (Professor) Department of Zoology & Environmental Sciences, Punjabi University, Patiala

7. Dr. Pankaj Datta (Principal & Head) Department of Prosthodontics, Inderprasth Dental College & Hospital, Ghaziabad

8. Dr. Mahindra Nagar (Head) Department of Anatomy, University College of Medical Science & Guru Teg Bahadur Hospital, Delhi

9. Dr. D Harish (Professor & Head) Dept. Forensic Medicine & Toxicology, Government Medical College & Hospital, Sector 32, Chandigarh

10. Dr. Dayanand G Gannur (Professor) Department of Forensic Medicine & Toxicology, Shri B M Patil Medical College, Hospital & Research centre, Bijapur-586101, Karnataka

11. Dr. Alok Kumar (Additional Professor & Head) Department of Forensic Medicine & Toxicology, UP Rural Institute of Medical Sciences and Research, Saifai, Etawah. -206130 (U.P.), India.

12. Prof. SK Dhattarwal, Forensic Medicine, PGIMS, Rohtak, Haryana

13. Prof. N K Aggrawal (Head) Forensic Medicine, UCMS, Delhi14. Dr. Virender Kumar Chhoker (Professor) Forensic Medicine and

Toxicology, Santosh Medical College, Ghaziabad, UP

Website: www.ijfmt.com

Print-ISSN:0973-9122 Electronic - ISSn: 0973-9130Frequency: Six Montlhly © All Rights reserved The views and opinions expressed are of the authors and not of the Indian Journal of Forensic Medicine & Toxicology. Indian Journal of Forensic Medicine & Toxicology does not guarantee directly or indirectly the quality or efficacy of any products or service featured in the advertisement in the journal, which are purely commercial.

EditorDr. R.K. Sharma

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CONTENTS

Volume 12, Number 3 July-September 2018

I

Indian Journal of Forensic Medicine & Toxicology

1. TheProfileofSuicidesEncounteredduringAutopsyinaTeachingHospitalinCentralKerala: ADescriptiveStudy..........................................................................................................................................01 Hitheshsanker, Ajay Balachandran

2. ARetrospectiveAnalysisofPoisoningCasesBroughtforPostmortemExaminationatMortuaryofR.C.S.M GovertmentMedicalCollegeKolhapur...........................................................................................................06 N S Jagtap, H R Thube, DA Pawale

3. StudyofPatternofUnnaturalDeathsatRuralGovernmentMedicalCollege&HospitalinMaharashtra.....11 Dode P S, V G Pawar, R V Kachare

4. TumourMarkerandDiagnosisofCancer.........................................................................................................14 Kamini Kiran, Shailesh Kumar, Rameshwar Singh

5. AnAnalyticalStudyof118HangingCasesAutopsiedatDr.B.R.AmbedkarMedicalCollege,Bengaluru,Karnataka..........................................................................................................................................................21 Karthik SK, Nagaraj BM, Jayaprakash G, Manjunath KH

6. PatternandOutcomesofHeadInjuriesinEgypt:AStudyoftheEgyptianRevolution..................................25Ragab T, Samar A Ahmed, Abuanza R A, Akid Y F

7. ProfileofFatalRoadTrafficAccidentsatPuducherry–AnAutopsybasedStudy..........................................31T MadhuVardhana, M Kumaran, Ananda Reddy, N Naveen, M Arun, Balaraman, R N Kagne

8. StudyonPrevailingFactorsofDomesticViolenceDeathsinandaroundGunturCity,AndhraPradesh........37Srinivasu Rao Palagani, K Ravimuni, K Usha Rani

9. AStudyofHomicideinNagpurwithRespecttoMethodAdoptedforHomicide...........................................43 Nitin S Barmate, D S Akarte, Amit Themke

10. RetrospectiveAnalysisofUnclaimed/UnknownDeadBodies........................................................................48Rajeshwar S Pate, Mangesh R Ghadge, Dinesh Samel

11. AStudyofHeadInjuriesinFatalRoadTrafficAccidents................................................................................54 J Venkatesaprasanna, Dhritiman Nath

12. DrugsinOrthodontics:AReview.....................................................................................................................58 Subin Samson Daniel, Chaithra Laxmi B, Harshitha V, Mithun K, Abhinay Sorake

13. StudyofElectrocutionDeathsinMumbai:AthreeYearRetrospectiveAnalysis............................................64N B Kumar, H G Kukde, M R Sabale, A K Jaiswani, R R Savardekar

II

14. ARetrospectiveStudyofPatternofOrgansInvolvedinNaturalDeathsatAutopsy—RoleofHistopathology asAncillaryTool...............................................................................................................................................69 RaviRaj K G, Shobhana S S

15. KnowledgeandAttitudeofMedicalStudentsTowardsMedicoLegalPostmortemsatNSCBMedicalCollegeJabalpurMP......................................................................................................................................................75 Ashok B Najan, Vivek Srivastava, Nidhi Sachdeva

16. DowryandDomesticViolenceAgainstWomen–KnowledgeandAwarenessamongMedicalStudents.......79 Rajeshkumar R Bhoot, Pragnesh B Parmar

17. RetrospectiveAnalysisofAsphyxialDeathsAutopsiedinBareillyRegion....................................................82 Jaswinder Singh, Pranav Kumar, Somshekhar Sharma

18. EpidemiologicalStudyofDeathsDuetoElectrocution:AthreeYearRetrospectiveStudy............................86 Sushim A Waghmare, Satin K Meshram, Santosh B Bhoi, Rizwan A Kamle, Kunal B Shirsat

19. PatternofHeadInjuryinRoadTrafficAccidentsinMewarRegion,Rajasthan:ARetrospectiveStudyatTertiaryCareTeachingHospital.......................................................................................................................91Dushyant B Barot, Sanjeev Kumar Choudhary, G L Dad, Rajkumar Patil

20. PatternofMaternalDeaths:AThreeYearAutopsybasedRetrospectiveStudy...............................................96Satin Kalidas Meshram, Sushim Amrutrao Waghmare, Santosh Baburao Bhoi, Rizwan Allaudin Kamle, Kunal Bhimrao Shirsat

21. StudyofPatternofUnnaturalDeathsinWomenofReproductiveAgeGroup..............................................103 Anitha Shivaji, S Harish, Girish Chandra YP, Akshith Raj S Shetty, Chethan Kishanchand

22. StudyofDistribution,NatureandTypeofInjuryinRoadTrafficAccidents.................................................110T Selvaraj, R Mohamed Nasim

23. AStudy–TrendsofUnnaturalDeathsinFullMoon(Purnima)andNoMoon(Amavasya)Conditionsas ComparedtootherDays..................................................................................................................................114 Uttam Solanki, Vijay Shah, Hitesh Rathod, Sunil Surve

24. ADemographicProfileofVoientAsphyxialDeathsataTertiaryCareCentre-AFiveYear RetrospectiveStudy.........................................................................................................................................117Biradar Gururaj, B S Satishbabu,V Yogiraj, N G Tejaswini

25. EpidemiologicalStudyofCasesofCustodialDeathsinNorthBengalRegionDuringLastFiveYears.......121Vivek Kumar, Priyankar Roy, Rajib Prasad, Prabir Kumar Deb

26. AStudyofSuicideinNagpurwithRespecttoDemographicProfileandMethodAdoptedforSuicide........124 Dinesh S Akarte, Nitin S Barmate, M S Vyawahare

27. LipPrintsanditsRelationshipwithAngle’sClassificationofMolarRelation-AnObservationalStudy......130 Uma Maheswari T N, Archana Venugopal

28. Awareness&PracticeofPatientRights–ACrossSectionalStudyinaTeachingHospitalinTelangana....135Prashanth Mada, Punuri Sanjay, G Surendar Reddy

III

29. SociologicalExplanationoftheEffectsofSocialandCulturalFactorsAffectingAttitudetowardDivorcein2016(CaseStudy:CouplesReferringtoGuilanWelfareCenters).................................................................141 Reza Jafari Sadhi, Hossin Aghajani Mersa, Amir Masoud Amir Mazaheri

30. ProfileandPatternofHomicidalInjuriesinCentralIndianPopulation.........................................................147Vishwajit Kishor Wankhade, M S Vyawahare

31. StudyofElbowJointforEstimationofAgeinMaharashtraPopulation........................................................152 Mohammad Abdul Mateen

32. ACrossSectionalEvaluationofSuicidesinFemales....................................................................................156 Priyadarshee Pradhan, Jagdish Kamal Chander U, Venkatesan M, P Sampath Kumar

33. TraditionalMedicineinTreatmentofWomenwithPremenstrualSyndrome,ASystematicReview............161 Eslamnik Parvin Alsadat, Parand Abdolmajid, Aghamohammadi Maryam

34. EstimationofDrugContainingTranquilizersbyThinLayerChromatography(TLC)................................166 Sushma Upadhyay

35. IntensiveCareafterCardiacSurgery..............................................................................................................172Mehdi Molavi Vardanjani, Davoud Mardani, Nikghadam Hormoz, Narges Kalvandi

36. AnInvestigationintotheCorrelationbetweenEmotionalIntelligenceandCommunicationSkillsamong NursingStudents.............................................................................................................................................178 Shahnaz Salawati Ghasemi, Nazila Olyaie, Sholeh Shami

37. PatternsandProfileofPoisoningCasesatBidarInstituteofMedicalSciences,Bidar(Karnataka).............184 Syed Hissamuddin Uzair, Mohsenul Haq

38. TheEffectofLavenderScentontheSeverityofPainCausedbyBoneMarrowBiopsy..............................189 Reyhaneh Abbaszadeh, Fariba Tabari, Mohammad Asghari Jafarabadi , Sedigheh Torabi

39. ClinicalandParaclinicalSignsandSymptomsofPatientswithIngestedProcessedCannabis(MajoonBirjandi)intheEasternIran............................................................................................................................195 Reza Afshari, Zohreh Oghabian, Jelveh Gharavairoodsari, Saeedeh Khosravi, Alireza Noorollahi, Omid Mehrpour

40. ProblemsofAutisticChildren-ASystematicReview....................................................................................200Bafahm Fatemeh, Parand Abdolmajid, Kalvandi Narges, Jokar Mozhgan

41. FacilitatingFactorsinthePreventionandControlofNosocomialinfectionsintheIntensiveCareUnits: AQualitativeStudy.........................................................................................................................................206Ayshe Hajiesmaeilpoor, Abbas Abbaszadeh, Hamid Soori, Shirin Afhami, Esmaeil Mohammadnejad

42. TheAssociationbetweentheTypeofDrugsSubstancesUsedandSeverityofHeadInjuryFollowingRoadAccidentsorUnexpectedEvents.....................................................................................................................211Mohammad Davood Sharifi, Amir Masoud Hashemian, Elham Masoumzadeh,

43. TherapeuticInterventionsinPremenstrualSyndrome....................................................................................217 Karami Fatemeh, Parand Abdolmajid, Kalvandi Narges, Bafahm Fatemeh

IV

44. ComparisonofParentalSatisfactionwithPosttonsillectomyPainManagementwithTwoMethodsofAcupressureandPharmacologicalAnalgesicsinChildren:AClinicalTrialStudy........................................223 Somaye Pouy, Bahram Naderi Nabi, Yasaman Yaghobi

45. TheEffectofTimeManagementTrainingonthePerformanceofHeadNursesWorkinginEducationalHospitalsAffiliatedtoJondishapurUniversityofMedicalSciences,Ahwaz.................................................229 Neda Ghannad, Nasrin Elahi, Abdolali Shariati, Amal Saki Malehi

46. AnalysisofHardDentalTissuesandBoneExposedtoConcentratedAcids:AnObservationalStudy.........235Vidya Kadashetti, K.M. Shivakumar, Rajendra Baad, Nupura Vibhute, Uzma Belgaumi, Sushma Bommanavar, Wasim Kamate

47. StabilityEnhancementUsingRegionbasedCertificationMechanisminManet...........................................242 P B Edwin Prabhakar, K Thirunadana Sikamani

48. DeterminationofHighDensityImpactforCognitiveVariationsfromBrainMRIAnalysis.........................248S Rani, D Gladis

49. DeterminationBreastCancerAccuracyUsingDataMining..........................................................................253 R Roseline, S Manikandan

50. DeterminationofBreastCancerUsingDataMiningTechniques...................................................................259 R Roseline, S Manikandan

51. DeterminationofCognitiveVariationsUsingClassificationTechniques.......................................................265 A Clementking

52. AnalysisofHospital’sFinancialLiquidityUsingtheLinearRegressionModel:APanelDataStudyin AhvazTeachingHospitals...............................................................................................................................270Gazal Zolfi, Arash Jamalmanesh, Amin Torabipour

53. AProspectiveStudyoftheCorrelationbetweenNon–FatalRoadTrafficAccidentsandAgeofVictims...276Prasanna P, Dhritiman Nath, Pramod Kumar GN, S Kumar

54. EffectivenessofErgonomicGymnasticsonDecreasingBloodPressureinPatientswithStageOneHypertension,Indonesia..................................................................................................................................280 Masriadi, Febrianto Arif

55. EffectofColdandHotNaturedDietonLevelofThyroidHormones,Epinephrine,Norepinephrine,Cortisol,TestosteroneandLHinHuman.......................................................................................................................286 Mohamad Masoumzadeh, Abbasali Abbasnezhad, Hamid Rasekhi, Reza Ghiassi, Mojtaba Kianmehr

56. AReviewoftheRiskFactors,DiagnosisandTreatmentofColorectalCancerinPatientswithChronicDiseasesinIran...............................................................................................................................................292 Zahra Movlavi Choobini, Sedighe Movlavi Choobini

57. EffectivenessofProlanisGymnasticsonDecreasingBloodPressureinPatientswithStageOneHypertension,Indonesia.........................................................................................................................................................297 Abidin Armawati, Masriadi, Sumantri Eha

58. AnalysisofIngredientsofaTraditionalSolidformofCannabis(MajoonBirjandi)ProducedinSouthernKhorasanProvince..........................................................................................................................................303 Tahereh Aminifard, Maryam Akhgari, Roland Lamarine and Omid Mehrpour

59. EffectivenessofCognitiveRestructuringonReducingLearnedHelplessnessinEducableStudentswithIntellectualDisability......................................................................................................................................308Ali MotallebZadeh, Jahanshir Tavakolizadeh, Somayeh Safarzade

60. AwarenessofthestaffofSlaughterhousesandAnimalHusbandriesofCrimean-CongoHemorrhagicFeverinShoushtar,Iranin2017....................................................................................................................................314 Elham Abdolahi Shahvali, Mohammad Adineh, Azam Jahangiri mehr, Akram Hemmatipour, Tahereh Nasrabadi

61. AutopsyStudyofDeathsduetoFallfromHeight:AThreeYearProspectiveStudy.....................................320Ramesh C, Viswakanth B

62. EvaluationoftheEffectofDifferentFinishLinesandLutingAgentsonMarginalFitandMicroleakageinDirectMetalLaserSinteredCopings–AninVitroStudy..............................................................................324 Pallavi Chavan, Thilak Shetty, Mahesh Mundathaje, Shobha J Rodrigues, Sharon Saldanha, Umesh Pai, Puneeth Hegde

63. Transferrin(re3811647)GenePolymorphisminIronDeficiencyAnemiainSaudiArabia...........................329 Osama Al-Amer, Atif Abdulwahab A Oyouni , Mohammed Alshehri, Riyadh A Alzaheb

64. ComparisonEffectsofAcuteandChronicIntra-peritonealInjectionsofSaffronStigmaExtractand Safranal-CrocinMixtureonAnxiety,inMice................................................................................................335 Mahdi Torkamani Noughabi, Jahanshir Tavakolizadeh, Maryam Moghimian, Sayed-Hossein Abtahi –Eivari

V

The Profile of Suicides Encountered during Autopsy in a Teaching Hospital in Central Kerala: A Descriptive Study

Hitheshsanker1, Ajay Balachandran2

1Associate Professor, Department of Forensic Medicine, Government Medical College, Ernakulam. Kerala University of Health Sciences, 2Professor, Department of Forensic Medicine, Kochi,

Amrita Institute of Medical Sciences, Amrita University, India

ABSTRACT

KeralahasoneofthehighestsuicideratesinIndia.PriorstudiesconductedinThiruvananthapuraminthesouthofKeralaandKozhikkodewhichisanortherndistricthaveidentifiedthedemographicprofileandthemethodsusedforcommittingsuicides.Thepresentstudy,conductedinErnakulamdistrictwhichliesincentralKeralaattemptedtoanalyzethemethodsemployedforcommittingsuicide,aswellastheageandsexprofileofthesuicides.ThecasesautopsiedatateachinghospitalincentralKeraladuringan18monthperiodwereanalyzedusingdescriptivestatisticsandANOVAforthispurpose.Thestudyrevealedthatthefemalepreferenceofselfimmolation(P0.000)isstatisticallysignificant.Malesontheotherhand,showedasignificantpreferenceforpoisoning(P0.048).Seniorcitizens(agedabove60)hadalessstrongpreferenceforhangingasamethodofsuicide(P0.038),buttheyshowedastatisticallysignificantpreferenceforselfimmolation(P0.027).Thoseaged30orlessshowedstatisticallysignificantpreferencefordrowningasamethodforcommittingsuicide(P0.011).

Keywords: Cut Throat, Drowning, Electrocution, Hanging, Jumping, Kerala, Poisoning, Rail Track, Self Immolation, Suicide

INTRODUCTION

KeralahasoneofthehighestsuicideratesinIndiaof 39.3/1,00,000person-years.1 Analysis of the profileof suicide is of paramount importance in combatingthis health hazard. Assessment of the factors whichpredispose suicidal ideation, intent formation, attemptandcompletionareimportanttoformulatestrategiestoreduce2suicide.

A study published in 2016, which used Beck’ssuicide intent scale to assess those who attemptedsuicide,showedthatfactorssuchasageandgenderarenot associated with high suicidal intent.3 Completedsuicides, though, aremoreprevalent amongmen thanwomen,with themale:female ratioof3:1–7.5:1.Mengenerally employ more lethal methods, show greateraggressiveness,andusuallythereisahigherintenttodieamongmen. However,thistrendisnotobservedinIndia(♂:♀ ratioof1.3:1)andmainlandChina(0.9:1).4 Astudypublished in2013whichanalysed the suicide rates inShandong,China,from1991to2010revealedthatthe

higherratesamongfemalesversusmaleswasbecominglesspronouncedsincethe1990s.5Theprevalenceofselfimmolation, which is a highly lethal method, amongwomeninIndiaisspeculatedtobeoneof thereasonswhythereisnopronouncedgenderdifferenceinIndia.6

Seniorcitizensshowadifferentpreferenceforthemethodof suicide than thegeneralpopulation. InUS,those older than 65 years weremore likely (72%) todieoffirearmsthanthegeneralpopulation(52%).7 The easy availability of firearms in the US contributes tothis.Incontrast,astudyconductedinAustraliashowedthattheuseoffirearmsandexplosivesforendinglivesdecreasedwithage,whilesuffocationbyplasticbaganddrowningincreasedwithage.8

Astudyconductedintheyear2001inKozhikodedistrict ofKerala compared thosewho unsuccessfullyattempt suicides and thosewho complete the attempt.The teachinghospitalwhere thisstudywasconductedcatered to the northern districts of Kerala, namelyKasargod, Kannur, Kozhikode, Wayanad and

DOI Number: 10.5958/0973-9130.2018.00120.2

2 Indian Journal of Forensic Medicine & Toxicology, July-September 2018, Vol. 12, No. 3

Malappuram.Outof689suicidevictims,426(61.8%)weremalesand263 (38.2%)were femalesasper thisstudy.Hangingwasthecommonestmethodusedbythevictims.51.9%ofmalesand42.2%femaleshadusedthismethod.Poisoningwasthesecondcommonestmethodemployedbythemaleswhosucceededinendingtheirlives.34.3%ofmaleshadconsumedsomepoison,thecommonestpoisonemployedbeingorganophosphates.Forfemales,selfimmolationwasthesecondcommonestmethodemployed(30%).Only20.1%ofthefemaleshadconsumedpoison tocommit suicideasper this study.Themeanageofmaleswhocompletedsuicidewas41±17.11andforfemales,itwas29.76±12.05.Theauthorspeculatesthatstrongersuicidalintentionmaycompelapersontousemorelethalmethodslikehanging.9

AlandmarkstudyconductedinThiruvananthapuram,whichfollowedupthemortalityofacohortof1,31,881participants above the age of 35, from 1996 to 2005,with87%participationrate.Itwasobservedthatofthe11,608deathsduringthisperiod,385weresuicides.Thecommonestmethod of suicidewas hanging, followedby poisoning and drowning.Male gender,middle-age(40–60 years), Hindu religion, alcohol drinking habitandsecondaryeducationlevel(<7years)weresuicidedeterminants.Lowsocioeconomiclevel,livingalone,orbeingamarriedwomanwasnotassociatedwithsuiciderisk.1

EventhoughtwosuchstudieshavebeenconductedinnorthernandsouthernKerala,nostudywhichlooksintothemethodsusedforsuicideandtheirrelationshipwiththeageandsexoftheindividualhasbeenconductedin the central Kerala so far. The authors feel that ananalysisofthefactorswhichinfluencesuicideandthemethodsemployedwouldbevaluableincombatingthismenace.

MATERIALS AND METHOD

The cases which were brought for autopsyexaminationintheCochinMedicalCollegeduringtheeighteenmonthperiodfromJanuary2016toJune2017(bothmonthsincluded)wereanalysed.Thestudydesignwas descriptive. The deaths which were identifiedas suicides during the inquest process and where nocontradictoryfindingwasdetectedduringautopsywereincluded in the sample. Themajority of the hanging,poisoning, self immolation and rail track death caseswererevealedtobesuicidalinnatureduringtheinquestitselfandtheautopsyexaminationdidnotthrowupany

findingwhich indicatedanothermannerofdeath.Thecaseswheretherethesuspicionofaccidentalcausationcouldnotberuledoutwhereexcludedfromthesample.

Inthecaseofdrowningandfallfromheight,morethan50%ofthecaseswhererevealedtobeaccidentalinnature in the inquest.Only thosecaseswhichwereidentifiedassuicidalwhereincludedinthestudy.Theageandsexoftheindividualswereextractedfromtherequisitionforpostmortemexamination.

SPSS16.0softwarewasusedforstatisticalanalysis.Pearson chi-squared test, uncorrected for continuity,wasdone.Cramer’sV testwasdone todetermine thestrength of association. Fisher’s exact test was alsoemployed where chi-squared test was statisticallyunreliable.OnewayANOVAandTurkeyposthoctestswerealsoused.

FINDINGS

The total number of cases included in the studywas120(seeTable1).Themalesfaroutnumberedthefemales (85 to 35). Themean age of the samplewas44.73(Std.Deviation17.579).Forthemales(n=85),themeanagewas44.71 (SD=16.085),while for thefemalesubjects(n=35)themeanagewas44.8(SD=21.033).

Eight different methods (hanging, poisoning,self immolation, death by train, drowning, cut throat,jumpingfromaheightandelectrocution)wereusedinthesample.SeeFig1.

Hangingwas thepreferredmethodof committingsuicideinbothmales(43.5%)andfemales(37.1%),buttheselectionofthemethodwasindependentofgender(P0.519).In thewholesample,41.7%of thesubjectsemployed hanging to end their lives. The secondcommonest method was poisoning in males (23.3%)and self immolation in females (31.4%). This genderdifference in the second rank method of suicide wasalso observed in the study conducted in Kozhikode.9 Atotalof14subjectsinoursamplehademployedselfimmolation as themethodof suicide (3males and11females).Theselectionofselfimmolationasamethodofsuicidewasfoundtobegenderdependent(P0.000as perFisher’sExactTest).TheCramer’sVvalueof0.395(P 0.000)indicatedaverystrongassociationwithfemale gender and self immolation. The selection ofselfpoisoningasamethodofsuicidewasdependentonmalegender(P0.048)atαlevel0.05.TheCramer’sV

Indian Journal of Forensic Medicine & Toxicology, July-September 2018, Vol. 12, No. 3 3

valueof.181indicatedasmallassociationwiththemalegenderandpoisoning.

Thethirdcommonestmethodemployedwasdeathbytrain,wherethevictimeitherliesontherailwaytrackor deliberately gets in front of it. 10% of the samplehademployed thismethod,allbutoneofwhomweremale(12.9%ofmalesendedtheirlivesbythismeans).Althoughonlyonefemaleinthesamplehadendedherlifeintherailtrackwhereas11maleshaddoneso,thismethoddidnotshowasstrongastatisticalrelationshipwith gender (p 0.177 as per Fischer’s exact test). Forfemales,poisoning(11.4%)anddrowning(11.4%)werethethirdpreferredmethod.Drowningdidnotshowanysignificant relationship with gender (P 0.445 as perFischer’sexacttest).

In the sample, there was only one case ofelectrocution, twocasesof jumpingfromaheightandfour casesof suicidal cut injuries.Fischer’s exact testwasusedtoassesswhetherthereisagenderpreferencefor these cases. Electrocution (P 1.000), jumping (P 1.000)andsuicidalcutinjuries(P0.579)didnotshowanystatisticallysignificantassociationwithgender.

ANOVA test was done to analyze if there wasstatistically significant difference between the meanages of those who committed suicide by a particularmethod.Electrocution,jumpingandcutthroatwoundswere excluded from the analysis because of low n. The difference between the mean ages of those whocommittedsuicidebytheothermethodswasstatisticallysignificant (P0.016,F3.210).ATurkeyposthoc testrevealed that the mean age was significantly lowerfor hanging (40.68±16.492 years), when comparedto poisoning (52.64±16.308), P value being 0.031.The mean ages of those who committed suicide byself immolation was 50.36±19.226. For rail tracksuicides,itwas39.83±13.037andfordrowningitwas37.44±23.912.

Theyoungestsuicidevictiminoursamplewasaged

16andtheoldestwasaged86.19.2%ofthesamplewasagedabove60(seniorcitizens)while25.8%wereagedbelow30.55%belongedtotheagegroup31–60.SeeFig2fortheagewisedistributionofthesuicidemethodsemployed.

In those aged 60 years or less, hanging was thepredominant method employed. However, this trendchanged after the age of 60 years. In the 61- 70 agegroup,selfimmolationwastheleadingcause.3femalesand2malesinthisagegroupchosetoendtheirlivesbymeansoffire.Inthe23seniorcitizensincludedinoursample,only5 chosehanging to end their lives. Theapparent preference of senior citizens for methods ofsuicideother thanhangingwas statistically significant(P0.038)atαlevel0.05.

Selfimmolationwasamethodapparentlypreferredbyseniorcitizensinoursample.Sixindividualsabovethe age of 60 committed suicide by self immolation.There was a significant association (at α level 0.05)betweentheageabove60andselfimmolation,withP valueof0.027asperFisher’sexacttest.

Poisoningwas resorted tobyeight seniorcitizensin our sample.Thiswashowever, not significant at α level 0.05 (P 0.078) as perFisher’s exact test.At theotherendoftheagespectrum,forthoseaged30orless,poisoningdidnotfigureinthetopthreerankmethodsemployed. Only one individual below this age hadconsumedpoisontoendhislife.Thislackofpreferenceforpoisoninginthoseaged≤30yearswasstatisticallysignificant(P0.001).

Inthoseaged30yearsorless,thecommonmethodsadoptedwerehanging,drowning,self immolationanddeath by train. There was no significant associationbetweenhanging (P0.051), self immolation (0.758asperFisher’sexact test),deathbytrain(P0.731asperFisher’s exact test) and age of less than 30.Howeverdrowning (P 0.011 as per Fisher’s exact test) had astrongstatisticalassociationwithagelessthan30years.

Table 1: Suicide methods among the sample.

First Rank Method n % Second Rank

Method n % Third Rank Method n %

Entire Sample(n 120) Hanging 50 41.7% Poisoning 28 23.3% Train 12 10%

Sex

♂ (n 85) Hanging 37 43.5% Poisoning 24 28.2% Train 11 12.9%

♀(n 35) Hanging 13 37.1% SelfImmolation 11 31.4%

Poisoning 4 11.4%

Drowning 4 11.4%


Agegroups

11- 20(n 11) Hanging 6 54.6% Drowning 4 36.4%

SelfImmolation 1 4.5%

Train 1 4.5%

21- 30 (n 21) Hanging 12 57.1% Train 3 14.3%


Drowning 2 9.5%

31- 40(n 21) Hanging 8 38.1% Poisoning 7 33.4%


Train 2 9.5%

41- 50(n 18) Hanging 8 44.4% Poisoning 5 23.8% Train 4 22.2%

51- 60(n 26) Hanging 11 42.3% Poisoning 7 26.9% SelfImmolation 3 11.5%

61- 70(n 15)

SelfImmolation 5 33.3% Poisoning 4 26.7% Hanging 3 20%

71- 80(n 5) Poisoning 3 60%

SelfImmolation 1 20%

Hanging 1 20%

81- 90(n 3)

Poisoning 1 33.4%

Drowning 1 33.3%

Hanging 1 34.3%

Fig 1: The distribution of different methods adopted to commit suicide.

Fig 2: The age wise distribution of the methods employed in committing suicide. Cut injuries, jumping from a height and electric shock are methods which are considered together as “others”.

CONCLUSIONS

The study revealed that the female preferenceof self immolation is statistically significant. Maleson the other hand, showed a significant preference

for poisoning. It is possible that as per the traditionalgenderrolesplayedbythemaleandthefemale,femaleshaveeasyaccesstokeroseneinthekitchenandmaleshave access to agricultural poisons in the farms. Thedemographic background of the deceased were notcollectedasapartofthisstudy,henceitisnotpossibletodrawconclusionsinthatregardinthepresentstudy.Morestudiesarerequiredtounderstandthisissuebetter.

Eventhoughhangingwasthesinglemostcommonmethodusedinbothsexes,itwasseenthatseniorcitizens(aged above 60) had a lesser preference for hangingas a method of suicide compared to those younger.The senior citizens also had a statistically significantpreferenceforself immolation. Itwasseen that in theUS, those states which enacted a law stipulating thatthosewhowished to purchase guns had towait for aperiod had a statistically significant reduction in thesuicidesduetofirearmsinthoseagedabove55years.10

Those aged 30 or less showed statistically significantpreference for drowning as a method for committingsuicide.Intheseconddecadeoflife,drowningwasthesecondrankmethod;while in the thirddecadeof life,itwasthethirdrankmethod.Whetherthosewhochosedrowning to end their lives actually knew swimmingwasnotavailabletous.

The authors hope that the knowledge gainedthrough this study would be helpful in formulatingpoliciestocombatthismenace.Eventhoughswimminglessons cannot ensure that children of any age are

Cont... Table 1: Suicide methods among the sample.


completelyprotectedfromdrowning,11theauthorsfeelthatformalswimminglessonsinschoolsmaybehelpfulin reducing deaths due to suicidal drowning, since itdisproportionatelyaffectstheyoung.

Kerosene is themost common accelerant used insuicidal burns in India.6 Intentional as well as Non-Intentional burns are associated with availability ofkeroseneathome.12Discontinuingitssupplythroughthepublicdistribution systemand shifting to cookinggasis likely to help in reducing self immolation suicides,whichdisproportionatelyaffect thewomenandseniorcitizens.

Conflict of Interest: Theauthorsdeclarenoconflictofinterest.

Source of Funding & Acknowledgements: Theresearchwasselffunded.

Ethical Clearance:Ethicalclearancewasobtainedfromtheinstitutionalethicscommittee.

REFERENCES

1. SauvagetC,RamadasK,Fayette JM,ThomasG,TharaS,SankaranarayananR.Completed suicidein adults of rural Kerala: rates and determinants.NatlMedJIndia.2009Sep-Oct;22(5):228-33.

2. Gunnell D, Frankel S. Prevention of suicide:aspirations and evidence. BMJ. 1994 May 7;308(6938):1227-33.

3. Ramanathan R, Ramachandran AS, PeriasamyK, SaminathanK.Assessment of Suicidal Intent.Indian J Psychol Med. 2016 Nov-Dec; 38(6): 529–32.

4. NockMK,BorgesG,BrometEJ,ChaCB,KesslerRC,LeeS.Suicideandsuicidalbehavior.EpidemiolRev.2008;30:133-54.doi:10.1093/epirev/mxn002.Epub2008Jul24.

5. SunJ,GuoX,ZhangJ,JiaC,XuA.SuicideratesinShandong,China,1991–2010:Rapiddecreaseinruralratesandsteadyincreaseinmale–femaleratio.JAffectDisord.2013Apr25;146(3):361-8

6. KumarV.Burntwives--astudyofsuicides.Burns.2003Feb;29(1):31-5.

7. YeatesC,ThompsonC.SuicidalBehaviorinEldersPsychiatrClinNorthAm.2008Jun;31(2):333–56.

8. KooYW,KõlvesK,DeLeoD. Suicide in olderadults:differencesbetweentheyoung-old,middle-old, and oldest old. Int Psychogeriatr. 2017Aug;29(8):1297-306.

9. SureshKumarPN,Ananalysisofsuicideattemptersversus completers inKerala. Indian J Psychiatry.2004Apr;46(2):144-9.

10. Ludwig J, Cook PJ. Homicide and suicide ratesassociated with implementation of the BradyHandgun Violence Prevention Act. JAMA. 2000Aug2;284(5):585-91.

11. American Academy of Pediatrics Committee onInjury,Violence,andPoisonPrevention.Preventionofdrowning in infants, children, and adolescents.Pediatrics.2003Aug;112(2):437-9.

12.NatarajanM.Differences between intentional andnon-intentional burns in India: implications forprevention.Burns.2014Aug;40(5):1033-9.

A Retrospective Analysis of Poisoning Cases Brought for Postmortem Examination at Mortuary of R.C.S.M

Govertment Medical College Kolhapur

N S Jagtap1, H R Thube1, DA Pawale2

1Assistant Professor, 2Professor Head of Dept. of FMT, RCSM GMC Kolhapur

ABSTRACT

Introduction:PoisoningisamajorhealthproblemindevelopingcountrieslikeIndia.Recently,itisincreaseddueto thefrequentuseofpesticides inagricultureandexposure tohazardouschemicalcompoundsasaresultofrapidindustrialization.

Aim:Aimofthisstudywastodeterminethevariousparametersofpoisoningsuchasmodeandtypeofpoisoning,relationtoage&sex,occupation,maritalstatus,vulnerableagegroup,andtofindoutthemostcommontypeofpoisonusedintheKolhapurregion.

Materials and Method:ThepresentstudywasconductedretrospectivelyduringJanuary2016toDecember2016,whichincluded252casesofdeathduetopoisoningbroughtforpost-mortemexaminationatmortuaryofRCSMMedicalCollege&CPRHospitalKolhapur.

Results:Outof1560postmortemexaminationsdoneduringthestudyperiod,252(16.15%)caseswerethatofpoisoning.Weobservedthatmajorityvictimsweremalefromruralarea.Peakincidencewasobservedin theagegroupof21-30years.Majorityofdeathswere suicidal, followedbyaccidentalhowever fewhomicidalpoisoningweredetected.

Conclusion:Organphosphorusinsecticidewastheprimeculpritamongallpoisons.Trendsofthisregionwererevealedandattemptwasmadetocomparewithpreviousstudies.

Keywords: Poison, Autopsy, Insecticide, Organ phosphorus, Paraquat

Corresponding author:Dr. N. S. JagtapAssistantProfessorofForensicMedicine&Toxicology,RCSMGovernmentMedicalCollege,[email protected] Mobileno-9967857455,9403367084

INTRODUCTION

Poisonswereknowntoantiquity.Referencestothepoisonsare found in theoldestEgyptian,Babylonian,Hebrew and Greek records. The ancient IndianScripturescontainreferencestothepoisoningofkings,thedoingsofprofessionalpoisonersandofwidespreadorganizedpoisoninginprehistorictimes.Inthosetimes,cases of poisoning the portions of stomach and heart

wereputonfireandthenatureofflameandsoundwerenotedtodeterminethenatureofpoison1.

Orfila,ProfessorofChemistryandLegalMedicineat Paris is considered as the Father of ModernToxicology. In the Nineteen Century, Orfila broughtprecisechemicalmethodintotoxicology2.Theproblemisgettingworsewithtimeasnewerdrugsandchemicalsare developed in vast numbers.Today there aremorethan9millionnaturalandsyntheticchemicals,andthelistkeepsgrowinginexorably.However,lessthan3000ofthesecausemorethan95%ofthereportedcasesofpoisoning.

The commonest agents in India appear to bepesticides(organophosphates,carbamates,chlorinated,hydrocarbons, and pyrethroids), sedative drugs,

DOI Number: 10.5958/0973-9130.2018.00121.4


chemicals(corrosiveandcoppersulfate),alcohol,planttoxinsandhouseholdpoisons(mostlycleaningagentsoflate,aluminiumphosphidehasbeguntoemergeasamajorplayerinthetoxicologicalfield,particularlyinthesomenorthernIndianstates3.ThefirsttreatiseonIndianMedicinewastheAgnivesaCharakaSamhita,supposedtohavebeencomposedabouttheseventhcenturyBC.It laysdownanelaborate code regarding the training,duties,privilegesandsocialstatusofphysicians.Itcanbeconsideredastheoriginofmedicalethics.Italsogivesadetaildescriptionofvariouspoisons,symptoms,signsand treatments of poisoning2. The Greek PhilosopherSocrateswasexecutedbytheState throughtheuseofhemlock, plant poison. A ChineseMateriamedica ofabout 3000 B.C. gives information on poisons1. The firsttextbookonpoisonwaswrittenin1814byMatthewJosephOrfila,aSpanishchemist,whoisconsideredtobe the Father of Toxicology. Orfila extracted arsenicfromhumantissuesusingaprocedureforidentification,developed several years before by JamesMarsh.Thisevidencewasusedinthecourt(1840)toconvictMarieLefarge of a homicidal poisoning. Thiswas the firsttimethatthetoxicologicaldatahadbeenasevidenceinthetrial2.InancientIndia,thepoisons–arsenic,aconiteandopium–wereknown.Theywereusedbywomentogetridofoppressivehusbands.Theword“Toxicology”is derived from the Greek word “Toxicon‟ whichwas used as a poisonous substance to arrowheads.The substance inflicting toxic effect may be a drug,an insecticide or pesticide or any chemical substancein the environment (Methyl isocyanate leakage at theUnionCarbidePlantinBhopalin1984resultedinhighmortalityandmorbidity).


The present retrospective study conducted inDept. of Forensic Medicine & Toxicology, RCSMGovt. Medical College, Kolhapur included fatalpoisoning cases brought for post-mortem examinationat mortuary of CPR Hospital, Kolhapur during theperiod of Jan.-2016 to Dec.-2016. During this periodtotal1560autopsieswereconducted,outof them252cases (poisoning cases and Animal envenomationcases)wereselectedforstudy.Detailedandcompletedpostmortemexaminationofthebodieswasdone.The

routine viscera were preserved by using appropriatepreservativeaccording tonatureofpoisonandsent toRegionalForensicScienceLaboratory,PuneaswellasRegional Forensic Science Laboratory, Kolhapur forchemicalexamination.Thecaseswereevaluatedonthebasisofhospitalcases,policepapers,availablehistoryfromrelativesorpolice,andchemicalanalysisreport.

RESULTS

Outoftotal1560post-mortemcases,252casesofdeathduetopoisoningwereselectedforpresentstudy.Incidence of death due to poisoning, were more inseconddecade (24.20%)and fourthdecade (10.31%)as compare to both extremes of age. Themajority ofvictimsweremales (69.02%) as compare to females(30.92%)(Table-1)andoutofthem,majorityofvictimsweremarried.Significantdifferenceswereobservedindeath due to poisoning in respectwith locality (rural/urban). The victims of poisoning death cases weremoreinruralarea(63.64%)ascomparedtourbanarea(36.37%).(Table3)Themannerofdeathwasdecidedfromhistory given by relative and police papers.Thesuicidal death cases (191 cases and 75.79 %) weremorefollowedbyaccidentaldeathcases(58casesand23.01%).(Table 4) Most common cause of the fatalpoisoning was financial problem in 63 cases (25%),followed by family problems 48 cases (19.04 %),failureineducation32cases(12.69%),dowry28cases(11.11%),illhealthormentalillness26cases(10.31%)andtheleastcommoncausewasbereavementas7cases(2.77%)and9undeterminedcases(3.57%)ofchronicillness.(Table7).Outoftotal165casesofpoisoning,5 cases of animal envenomation were observed.AccordingtochemicalAnalysisreportsof252casesofpoisoning,inmajorityofcases(201cases&79.71%),insecticides were found followed by Aluminium andZincPhosphide(12cases&4.76%)andethylalcoholfoundin17cases(Table6).Amongalltheinsecticides,the organo-phosphorus compounds were more innumber than organochloro compound. Paraquat wasdetected in93(36.90%)caseswhileMethylparathionin40cases(15.87%),chlorpyrifosin27cases(10.71%),Monochroptophos in 24 cases (9.52%),Dichlorvos in15 cases (5.95%), Aluminium phosphide in 11 cases(4.36%)Table5.


Table 1- Age & Sex wise distribution of poisoning cases

Age group (in yrs) Male Cases in % Females Cases in % Total cases Total cases in %

0-10 6 2.38% 5 1.98% 11 4.36%

11-20 26 10.31% 15 5.95% 39 15.47%

21-30 61 24.20% 27 10.71% 88 34.92%

31-40 24 9.52% 13 5.15% 33 13.09%

41-50 20 7.93% 11 4.36% 37 14.68%

51-60 22 8.73% 5 1.98% 27 10.71%

Above60 15 5.95% 2 0.79% 17 6.74%

Total 174 69.02% 78 30.92% 252 100%

Table 2- Month wise distribution of poisoning cases

Month Cases Cases in %January 18 7.14%February 25 9.92%March 21 8.33%April 22 8.73%May 13 5.15%June 15 5.95%July 24 9.52%August 28 11.11%September 27 10.71%October 25 9.92%November 17 6.74%December 17 6.74 Total 252 100%

Table 3- Distribution of poison according to location

Sex Rural Urban No of cases Cases in %

Male 115 59 174 69.04%

Female 55 23 78 30.95%

Total 170 82 252 100%

Table 4- Distribution of poisoning cases according to manner of death

Manner Cases Cases in %

Suicidal 191 75.79%

Accidental 58 23.01%

Homicidal 3 1.19%

Total 252 100%

Table 5-Distribution of poisoning cases according to poisonous compound from chemical analysis report

Compound Cases Cases in %

Aluminiumphosphide 11 4.36%

Monochroptophos 24 9.52%

Methylparathion 40 15.87%

Paraquat 93 36.90%

Dichlorovos 15 5.95%

Chlorpyrifos 27 10.71%

Hydroquinone 3 1.19%

Endosulfan 2 0.79%

Zincphosphide 1 0.39%

Kerosene 2 0.79%

Ethylalcohol 17 6.74%

Hydrochloricacid 5 1.98%

Nopoisondetected 7 2.77%

Animalenvenomation 5 1.98%

Total 252 100%

Table 6- Distribution of Poisoning cases according to type of poison, chemical examination, from history & external examination

Poison No of cases Cases in %

Insecticide 201 79.76%

Aluminiumphosphide 11 4.36%


Zincphosphide 1 0.39%

HCL 5 1.98%

Kerosene 2 0.79%

Hydroquinone 3 1.19%

Ethylalcohol 17 6.74%

Nopoisondetected 7 2.77%

Animalenvenomation 5 1.98%

Total 252 100%

Table 7-Cases according to motive

Motivation No of cases Cases in %

Bereavement 7 2.77%

Dowry 28 11.11%

FailureinEducation 32 12.69%

Familyproblems 48 19.04%

Financialproblems 63 25%

Illhealth/mentalillness 26 10.31%

Lovefailure 17 6.74%

Unemployment 22 8.73%

Undetermined 9 3.57%

Total 252 100%

DISCUSSION

Total1560post-mortemexaminationswerecarriedoutduringthestudyperiodandoutofthem252cases(16.15 %) of death due to poisoning were observedwhichwasconsistentwithKapoorAK5,DalalJSetal6 andVaghelaPC9,whileDhattarwlSKetal7exhibitedhigher incidenceofdeathduetopoisoning(23.42%).Inthepresentstudy,poisoningdeathcaseswerehigheras (69.04%) inmales than females deaths (30.95%)whichwasalsosupportedbypreviousstudieslikeDalalJSetal6,VaghelaPC9,ZineK.Uetal10andChaudhryS12 . Though all studies were conducted in differentpartsofIndia,malepredominancewasacommonand

constantfeature.Inpresentstudy,higherincidenceofdeathduetopoisoningwasfoundinyoungagegroup21–30yrs followedby11-20yearsof agewhichwasalso observed in previous studies like Varma N4 ,KapoorAK5,DalalJSetal6GuptaSetal8,VaghelaPC9,SharmaBRetal12,NigamMetal11.Itcouldbeexplainedbythefactthatthepersonsofthisyoungagegrouparesufferingfromstressofthemodernlifestyle,familyproblems,financialproblemsand failure in theexamsetc.Maximumnumbersofpoisoningcaseswereobserved in the monsoon month of Aug-2016, Sept-2016,andOct.2016especiallyintheruralareabecauseofincreasedfarmingactivitylikesprayingofpesticidein these seasons which was consistent with previousstudieslikeVarmaN4,VaghelaPC9,DhattarwalS.Ketal7.Maximumnumbersofpoisoningcaseswereobservedinruralareaascomparetourbanareaduetoilliteracyorlesseducation,lessavailabilityofimmediatetreatmentwhich was consistent with Varma N4, Kapoor AK5,VaghelaPC9studies,whileChaudharySetal14showed64.90%caseswereobservedinurbanascomparedtoruralarea(35.10%).Accordingtothemannerofdeath,majorityofdeathweresuicidal(75.79%)followedbyaccidental(23.01%)whichwasconsistentwithstudieslikeSharmaBRetal12 ,Karamjitsinghetal13ChaudhryS et al14. The accidental poisoning cases were more(23.01 %) in rural area due to spraying of pesticideduringfarmingactivityandanimalenvenomation.`

CONCLUSION

Patternofpoisoninginpresentstudywasmoreorless similar to the pattern found inmost of the otherstudies. These similarities were present in almost allparametersusedinthisstudy.Majorityofvictimsweremale.Fromthechemicalanalysisreportswefoundthatmost commonly used poisonwas agricultural. In thatcategory organophosphorus compunds and aluminiumphosphide were top on the list of poisons. TheInsecticides were most preferred poisons for suicidalpurpose.Strictimplementationofthepesticideactandinvolving a newpolicyby the government to educatethepublicandyouthinlargeaboutthedangerous,lifethreatening effects of Organophosphorus compoundscould help amelerioating the harmful effects of suchpoisoning. Establishment ofmore Poison InformationCentres provide toxicity assessment and treatmentrecommendationsoverphonethroughoutthedayforallkinds of poison similarly strict implementation of the

Cont.. Table 6- Distribution of Poisoning cases according to type of poison, chemical examination, from history & external examination


pesticide act and special policy by the government toeducateandcreateawarenessaboutthemagnitudeofthemenacecouldhelpamelioratetheproblem.Governmentgrants for the setting up of better poison informationcentersandresearchonrecentadvancesinthetreatmentofpoisoningcaseswouldberecommendedforreducingthemortalityrates.

Ethical Clearance –Taken

Source of Funding- Self

Conflict of Interest-Nil

REFERENCES

1. ReddyKSN.The essentials ofForensicMedicineandToxicology.33rded.2014Hyderabad,India,KSugunaDevi,Hyderabadp.4,449.

2. Vij K. Text Book of Forensic Medicine andToxicology. 4th ed.NewDelhi: Elsevier; 2008.p.6,562.

3. PillayVV.ComprehensiveMedicalToxicology,1st ed.Hyderabad:ParasPublisher,2003.p.2,3.4

4. Varma N, Kalele SD. Original Research PaperStudy of Profile of Deaths due to Poisoning inBhavnagarRegion.JIAFM;2011;33(4):313318.

5. KapoorAKAnepidemiologicalstudyofAluminiumPhosphidepoisoningatAllahabad.IIJFMT;2006:4(1).

6. DalalJSetal.PoisoningTrends–apostmortemstudy.JIAFM.1998;20(2):27-31.

7. DhattarwalSK,SinghH.Profile of death due topoisoning in Rohtak, Haryana, JIAFM; 2001:14(1);51.

8. Gupta S, Shaikh MI. Study and changing trendsof poisoning in year 2004-05 at Surat, India.International Journal of Medical Toxicology andlegalMedicine;2007:10(1):16-19.7.

9. GuptaBD,VaghelaPC.ProfileoffatalpoisoninginandaroundJamnagar.JIAFM.2005;27(3):145148.

10. Zine KU. Pattern of acute poisoning at IndiraGandhi Medical College and Hospital, Nagpur.JIAFM.1998:20(2):37–39.

11. Nigam M et al. Trends of organ phosphoruspoisoning in Bhopal region – An autopsy basedstudy,JIAFM.2004;26(2),62–65.

12. SharmaBRetal.Theepidemiologyofpoisoning:AnIndianViewpoint,JournalofForensicMedicineandToxicology,2002:19(2),5-11.

13. Karamjitsinghetal.PoisoningTrendsintheMalwaRegionofPunjab, Journal ofPunjabAcademyofForensicMedicineandToxicology;2003:3,26-29.

14. Chaudhary S et al. An Epidemiological Study ofFatal Aluminium Phosphide Poisoning at Rajkot,IOSRJournalofpharmacy.2013;3(1):17-23.

Study of Pattern of Unnatural Deaths at Rural Government Medical College & Hospital in Maharashtra

Dode P S1, V G Pawar2, R V Kachare3

1Assistant Professor, 2Associate Professor, 3Professor and Head, SRTRGMC, Ambajogai, Dist Beed, Maharshtra

ABSTRACT

Deathisanunavoidableultimatefateofanyhumanbeing.Thanatologyisabranchofsciencewhichdealswithdeathinallitsaspects.Theincidenceofunnaturaldeathsisfoundtobepersistentlyincreasing.SothisstudyisaimedtoknowthepatternofunnaturaldeathsatruralregionofMaharashtra.

Keywords: Unnatural Deaths, Road Traffic Accident, Suicide, Autopsy, Rural Population.

Corresponding author: Dr. Pawar V. G.,,

AssociateProfessor,SRTRGMC,Ambajogai, DistBeed,Maharshtra.MobileNo.9922086138,emailid:[email protected]

INTRODUCTION

Death may be natural (resulting from disease)or unnatural deliberate action of other (homicide),intentionally self inflected (suicide), result of anenvironmentalinfluence(accident).(1)

Death which occurs exclusively by injury or ishastenedduetoinjuryinapersonsufferingfromnaturaldisease, the manner of death is unnatural or violent.Violencemay be suicidal, homicidal, accidental or ofundeterminedorunexplainedorigin.(2)

The incidence of unnatural deaths is found to bepersistentlyincreasing.(3)

Unnaturaldeathisoneoftheindicatorsofthelevelofsocial&mentalhealth.(4)

WhenunnaturalcausesofdeathareconsideredtheRTAismostcommonandaboveallthemajorissueisthenumberofpersonsdiedincreasingyearbyyearduetogrowthinautomobilecompaniesandeasyavailabilityofvehiclestoyoungeragegroup.Suicidalandhomicidalfatalitiesarecommonamongboththeurbanasandruralpopulation.


ThisstudyisaretrospectivestudyundertakenattheMortuaryofRuralHospitalduringtheperiod1stJanuary2015 to31stDecember2015.All theunnaturaldeathswere included in the study.Naturaldeaths anddeathsinwhichopinionwasreservedwereexcluded.Thedatawascompiled,tabulatedandanalysedstatistically.

OBSERVATIONS

1. Total number of post-mortems conducted duringyear2015was398(Table-1)

2. Outoftotal398cases,322wereofunnaturaldeaths.(Table2)

3. Sexprofileofunnaturaldeaths:Among322casesofunnaturaldeaths,215(66.8%)casesweremalesand107(33.2%)caseswereoffemales.(Table3)

4. Ageandsexwisedistributionofunnaturaldeaths:Themostcommonagegroupinvolvedinunnaturaldeathswas 21 to 30 years in both the sexes.Theyoungest casewasof age1month and theoldestcasewasof80yearsage.(Table4)

5. Outof322cases,dependinguponthecauseofdeath,most of the cases 90 (27.9%) were due to RTAfollowedby74(22.9%)casesduetoPoisoningandleastnumberofcases4(1.2%)duetosnakebiteoranimalbites.(Table5)

6. Regardingmannerofdeath,outof322cases,202(62.7%) caseswere accidental, 103 (31.9%)weresuicidaland17(5.3%)werehomicidal.(Tale6)

DOI Number: 10.5958/0973-9130.2018.00122.6


Table 1: Total Number of postmortems Performed in Year 2015.

Year 2015

Totalnumberofpostmortems 398

Table 2: Number of Unnatural and Natural Deaths

Total Deaths Unnatural Natural

398 322 76

Percentage 80.9 19.0

Table 3 : Sex wise distribution of Unnatural Deaths.

Unnatural Deaths Male Female

322 215 107

Percentage(%) 66.8 33.2

Table 4 : Age group and sex wise distribution of Unnatural Deaths.

Age Group Male Female Total Percentage

(%)

0-10 14 4 18 5.6

11-20 10 28 38 11.8

21-30 61 36 97 30.1

31-40 47 14 61 18.9

41-50 37 13 50 15.5

51-60 24 06 30 9.3

61-70 17 06 23 7.1

71-80 05 0 05 1.5

Total 215 107 322 100

Table 5 : Cause of Death and sex wise distribution of Unnatural Deaths

Cause Of Death Male Female Total Percentage

(%)

Neckcompression 47 21 68 21.1

Poisoning 49 25 74 22.9

Burn 15 53 68 21.1

RTA 85 5 90 27.9

Assault 6 2 8 2.4

Electrocution 9 1 10 3.1

Snakebite 4 0 4 1.2

Total 215 107 322 100

Table 6 : Manner of Death wise distribution of Unnatural Deaths.

Manner of death Number Of Cases Percentage (%)

Accidental 202 62.7

Suicidal 103 31.9

Homicidal 17 5.3

Total 322 100

DISCUSSION

In our study, (Table 1) out of total 398 deaths,unnaturaldeathswere322 (80.9%)andnaturaldeathswere76(19.0%).OurstudyfindingsaresimilartothestudyconductedbySrivastavaPetal.(5)

Sex profile (Table3) of unnatural deaths in ourstudyshowed66.8%ofthecasesweremales&33.2%caseswerefemales.Similarresultswereseeninstudiesconducted by Santhosh. C. S et al (6) also in studyconductedbySinghDetal(7).

Oneofthereasonsformalesbeingmajorportionofvictimsofunnaturaldeathsismalesinvolvedinoutsidework, travels more so prone for RTA. In our studypercentageof females isdue toaccidentalburnsas inruralareatheyusewoodsorstoveforcombustion.


Age group wise, maximum numbers of casesof unnatural deaths 97 (30.1%) deaths involving 61(18.9%)malesand36(11.1%)femaleswereseenintheagegroupof21-30yearsfollowedby61(18.9%)casesinagegroupof31to40years.

Mostoftheunnaturaldeaths90(27.9%)wereduetoRTA.SimilarresultswereseeninstudybySantoshCetal(6)

Increasing density of vehicles, rash driving, non-maintained vehicles and roads are few reasons forincreasing RTA. Younger age group drive vehiclescarelessly, without proper training and prone foraccidents. The situation ismoreworsened as this agegroupisearninginfamilysothiswillcreateeconomicalaswellasotheralliedproblemsintheirfamilies.

Regardingmannerofdeath,inourstudyoutof322cases,202(62.7%)caseswereaccidental,103(31.9%)weresuicidaland17(5.3%)werehomicidalwhicharesimilartostudybySanthosh.C.Setal(6)alsoinstudyconductedbySinghDetal(7)InstudybySrivastavaPetal (5)

Unnaturaldeathsareknowntoclaimasubstantialnumberoflives,intheworldover,withtheVehicularaccidents accountingmost important case of deaths.(8) Beinginruralareamostofthesuicidesarebyfarmersbypoisoningaseasilyavailable.In2014,5650farmerscommitted suicide as per National Crime RecordsBureau(NCRB)(9)

CONCLUSION

Unnatural deaths are one of themost preventableculprit who takes number of lives in India. Studyand pattern of unnatural deaths reflects the socio-economicstatusofthesociety.Theongoingincreaseinmechanization, fastmovingvehicles, drunkendrivers,non-maintained roads especially in rural region hasledtotheincreaseinthenumberofRTAs.Suicidesbypoisoningaremostcommoninfarmersduetoeconomical

andotherproblems.Byimprovingtheliteracyrateandproviding employment to the youth, crime rate andultimatelyunnaturaldeathscanbelowered.Preventivemeasuresshouldbeadoptedpromptlywhereverpossibletoavoidallunnaturaldeaths.Ifnotpreventable,promptandimmediatecareshouldbeprovidedinordertosavethelifeofthevictim.

Conflict of Interest:None.

Source of Funding:Nil.

Ethical Clearance:Obtainedfromtheinstitutionalethicalcommittee.

REFERENCES

1. Gautam Biswas; thanatology; review of forensicmedicineandtoxicology;2ndedition;2013;Jaypeebrothersmedicalpublishers(p)LTD;PP:110.

2. ReddyKSN.TheEssentialsofForensicMedicine&Toxicology.33rded.NewDelhi:JaypeeBrothersMedicalPublishers(P)Ltd;2014.Pg142.

3. Sharma BR etal Unnatural deaths in NorthernIndia – a profile. J Indian Acad Forensic Med2004;26(4):140-6.

4. AhmedM.etalPatternofunnaturaldeath in twodistricts.TAJ.1992;5:65-66.4.

5. Srivastava P et al Journal of Indian MedicalAssociation2010Nov;108(11):730-3.

6. Santhosh.C.SetalJIndianAcadForensicMed.Jan-Mar2011,Vol.33,No.1.

7. SinghDetal,SpectrumofunnaturalfatalitiesintheChandigarh zone ofNorth-West India, Journal ofClinicalForensicMedicine2003;10(3):145-152.

8. Aryappan A and Jayadev CJ. Society in India;SocialSciencePublication;1985.

9. National Crime Records Bureau. ADSI Reportannual2014,GOIp.242,table2.11

Tumour Marker and Diagnosis of Cancer

Kamini Kiran1, Shailesh Kumar2, Rameshwar Singh3

1Senior Lecturer, Department of Oral Maxillofacial Pathology & Microbiology, Seema Dental Collegeand Hospital, Rishikesh (U.K.), India, 2Senior Resident, Department of Oral & Maxillofacial Surgery, All India Institute of Medical Sciences, Rishikesh, (U.K), India, 3Professor, Dental College Azamgarh, Department of Prosthodontics

Crown Bridge and Implantology, Uttar Pradesh, India

ABSTRACT

Tumourmarkers in clinical oncology comprises substances that are produced bymalignant cells or thesubstancesthatareproducedbyothercellsundertheinfluenceofmalignantcellsandthatcanbedeterminedin body fluids. Tumour markers can be found in cells, tissues or body fluids. These are biochemicalsubstance.Tumourmarkerscanbeclassifiedinaccordingtotheirchemicalstructure,theirtissueoforigin,typesofmalignancies inwhich theyare elevated.The concentrationof tumormarker are related to thegrowthofmalignanttumoursinpatients.Applicationofmoleculartumormarkers,whichmakehistologymoreaccurateandadditionallyhelptoprognosticatecancer.Earlydetectionwouldsignificantlydecreasethemortalityrateoforalcancer.Theutilizationoftumourmarkersdependsuponthesensitivity,specificityanduponreliabilityofmethodsthatarebeingusedforthesamepurpose.Thisreviewincludedifferenttypesofmarkerstheirapplicationandlimitation.

Keywords: tumour markers, oncology, biochemical substance.

Corresponding author: Dr. Kamini Kiran, Deptt.Oralpathology&Microbiology,E-mail:[email protected]

INTRODUCTION

“A tumor marker is a substance present inor produced by a tumor or by the tumor’s host inresponse to the tumor’s presence that can be used todifferentiateatumorfromnormaltissueortodeterminethepresenceof a tumorbasedonmeasurement in theblood or secretions1. can also be defined as “specific,novelorstructurallyalteredcellularmacromoleculesortemporarily spatially or quantitatively altered normalmolecules that are associated with malignant (and insomecasesbenign)neoplasticcells2.

Markerscanbeendogenousortheproductsofnewlymutated genes that remained dormant in the normalcells.Theymaybe present as intracellular substancesin tissues, body fluid or in serum. Continuing search

forsuitabletumourmarkersinserum,tissueandbodyfluids duringneoplastic process is of clinical value inthemanagementofpatientswithvariousmalignancies.

The first tumour marker described in EgyptianPapyruswas2000years ago formalignancy inbreastcancer3.ThefirsttumormarkerwasidentifiedbyBenceJonesin1846:detectedaproteinprecipitateinboiledacidified urine from patient of MultipleMyeloma In1965GoldidentifiedthefirsttumorantigenCEAfromspecimens of human colonic cancer. It is detectedin solid tumors, tumor cells circulating in peripheralblood,lymphnodes,bonemarrow.Itisuseinscreeningdiagnosis, staging, prognosis, localization, therapy,surveillance,monitoring.

DOI Number: 10.5958/0973-9130.2018.00123.8


Classification of tumour markers:

AccordingtoT.Malati 4

1 Oncofetalantigens(e.g.alpha-fetoprotein[AFP],carcinoembryonicantigen,pancreaticoncofetalantigen,fetalsulfoglycoprotein).

2 Tumorassociatedantigens/cancerantigense.g.CA-125,CA19-9,CA15-3,CA72-4,CA50etc.

3 Hormones,e.g.betaHCG,calcitonin,placentallactogen,etc.

4 Hormonereceptors(e.g.estrogenandprogesteronereceptors)

5Enzymesandiso-enzymes(e.g.prostatespecificantigen,prostaticacidphosphatase,neuronspecificenolase,glycosyltransferases,placentalalkalinephosphatase,terminaldeoxynucleotidyltransferase[TdT],lysozyme,alphaamylase)

6 Serumandtissueproteins(beta-2microglobulin,monoclonalimmunoglobulin/paraproteins,glialfibrillaryacidicprotein(GFAP),proteinS-100,ferritin,fibrinogendegradationproducts)

7 Otherbiomolecules,e.g.polyamines.

B. AccordingtoKüstner et al. in 20045

1 Tumorgrowthmarkers 1.Epithelialgrowthfactor(EGF)2.Cyclins3.Nuclearcellproliferationantigens4.Agryophilicnucleolarorganizerregion5.S-phasekinase-interactingprotein26.Heatshockproteins27and707.Telomerase.

2 Markersoftumorsuppressionandan-ti-tumorresponse

1.Retinoblastomaprotein(pRb)2.Cyclindependantkinaseinhibitors3.p534.bax5.Fas/FasL.

3 Angiogenesismarkers 1.Vascularendothelialgrowthfactor/receptor2.Platelet-derivedendothelialcellgrowthfactor3.Fibroblastgrowthfactor.

4 Markersoftumorinvasionandmetastat-icpotential

1.Matrix-metalloproteases2.Cathepsins3.Cadherinsandcatenins4.Desmoplakin

5 Cellsurfacemarkers 1.Carbohydrates2.Histocompatibilityantigen(HLA)3.CD57antigen

6 Intracellularmarkers Cytokeratins(CKs).7 Markersofanomalouskeratinization 1.Filagrins

2.Invoulcrin3.Desmosomalproteins4.Intercellularsubstanceantigen5.Nuclearanalysis.


8 Arachidonicacidproducts 1.ProstaglandinE2(PGE2)2.Hydroxyeicosatetraenoicacid3.LeucotrieneB4.

9 Enzymes GlutathioneS-transferase.

C.According to Scully and Burkhardt (1993)6

1 Cellsurfacemarker 1.Carbohydrates-particularlybloodgroupantigen.2.SquamouscarcinomaantigenCa-1,TA-4,SQM-1,3H-1.3.HLA.4.Growthfactorandreceptors.

2 Intercellularmarker 1.Cytoskeletalcomponents–CKs2.Markersofabnormalkeratinization–filaggrin,involucrin,desmosomalproteins3.Carcinomaantigen17,134.Silverbindingnucleolarorganizingregions5.Oncogenes6.Tumorsuppressorgenes7.Arachidonicacidproducts-PGE2,leukotrineB4and5,12,and15hydroxyeicosatetraenoicacids8.Enzymes–gamma-glutamyltranspeptidase,lactatedehydrogenase

3 Basementmembranemarker 1.Fibronectin,2.Laminin.

4 Matrixmarker 1. Tenascin

D.By Enzinger & Weiss7

1 Intermediatefilament VimentinCytokeratin

2 MarkersofMuscleDifferentiation DesminActinMyoglobin&othermarkersMyogenictranscriptionfactor

3 MarkersofEndothelialDifferentiation FactorviiirelatedantigensCD34CD31FLI-1UlexlectinVEGFR-3LANATypeivcollagen

4 MarkersofdistinctionbetweenMyoepitheliomaandcarcinoma

CarcinoembryonicantigenCD15TumorassociatedglycoproteinWT-1

5 MarkersofNerveSheathdifferentiation S-100Claudin-1Glut-1CD57p57NTR

6 Neuroectodermalmarkers CD99CD56NB84

7 MarkerofMelanocytedifferentiation MelanAMicrophthalmiatranscriptionfactorTyrosinase


8 Markersforgastrointestinalstromaltumors CD117Proteinkinase

9 Othermarkers CD88BetacateninMDM-2Bcl-2

10 Prognosticmarkers Ki-67P53 P 21p27p16

E. Markers according to cell of origin8

1 Epithelialmarkers CKsEpithelialmembraneantigenOncofetalantigensDesmoplakin.

2 Mesenchymalmarkers Muscleantigens•Desmin•Actin•Myoglobin•Myosin.Vascularantigen•CD34.Neuralmarkers•S-100•GFAP•neurofilaments•CD57Endothelialmarkers•CD31,CD34,andfactorVIII–relatedantigen.Lymphoidmarkers•CD3,CD15,CD20,CD30,CD45,CD68,CD79a,anaplasticlymphomakinase-1,andTdT.

F. Classification by Virji3

1 Tumorderived HormonesHCGADHParathyroidCalcitoninInsulinlikegrowthfactorsCatecholamines&metabolites

2 MUCINS&OTHERGLYCOPROTEIN CA–125CA–19-9CA-15-3OncofetalantigensAlphafetoproteinsCarcinoembryonicantigenOncogenes&theirproductsSrcN-mycH-ras

Cont... D.By Enzinger & Weiss7


3 ISOENZYMES ProstaticacidphosphataseNeuronspecificenolaseReganALPLDH1OthersPolyamidesSialicacidGlycolipids

4 SPECIFICPROTEINS ImmunoglobulinsProstratespecificantigenAlphalactalbuminBetamicroglobulin

5 TUMORASSOCIATED(HOSTRESPONSE)

FerritinImmunecomplexesEnzymes(LDH,GDH,CK-BB)Acutephaseproteins

Criteria for ideal tumour marker

• Shouldbehighlyspecific

• Shouldbehighlysensitive

• Should provide a lead time over clinicaldiagnosis

• Levels should correlate reliably with tumorburden

Role of markers

Alpha-Fetoprotein (AFP)

AFP isa70kDaglycoproteinhomologous toalbumin. Itperformsomeof the functionsof albumininthefoetalcirculation.Referencerangeis0-10kU/Lor0-12mg/L.Halflifeinserumapprox.5days.Mainlyconfinedtothreemalignancies,i.e.

a.Non-seminomatousgermcelltumours(NSGCT)oftestis,ovaryandothersites.

b.Hepatocellularcarcinoma(HCC).

c. Hepatoblastoma (in children, extremely rare inadults).

d. AFP may be occasionally elevated in patientswithothertypesofadvancedadenocarcinoma.

CA 125

CA 125 refers to the antigen originallydetectedbytheOC-125antibody.Theproteindetectedby this antibody is Muc16, a mucin with a single

transmembranedomain.Themajorformsinserumhavemolecularweights of 200 kDa to 400 kDa.Epithelialovariancancer;80-85%ofallcases;butincreasedinonlyhalfofearly(stage1)cancer.Maybeelevatedinanyadenocarcinomawithadvanceddisease.Referencerange0-35kU/L.Halflifeinserumapprox.5-7days.

CA 15-3

Ca 15-3 is heterogeneous 300 KD glycoproteinantigenwasdefinedbyusingtwomonoclonalantibodies115D8andDF3raisedagainstbreastcarcinomacells.The diagnostic sensitivity of the CA15.3 for breastcarcinomaislowasitselevatedlevelsarealsoobservedin benign breast diseases and in liver cirrhosis, acuteand chronic hepatitis. The marker concentrations isalsoelevatedinmetastaticcancersofpancreas,ovary,colorectal,lung,stomach,uterus

CEA

A200kDa(approx.)glycoprotein.Appearstoplayaroleincelladhesionandinhibitionofapoptosis.Malignancies with elevated levels Can be elevatedin almost any advanced adenocarcinoma, i.e., wheredistantmetastasesarepresent.Almostneverelevatedinearlymalignancy.Referencerange0-3.5μg/L to0-5.0μg/L.Halflifeinserumapprox.3daysbutcanvaryfrom1to5days.

Thyroglobulin

It is an intracellular glycoprotein responsiblefor the production and storage of thyroxine. In lowconcentrations, it can be found in the sera of most

Cont... F. Classification by Virji3


healthy persons (0-75 ng/ml), while extremely highconcentrations can be detected in the patients withwelldifferentiatedfollicular(rarelyanaplastic)thyroidcarcinoma

S-100

Itisaproteinwasfirstisolatedfrombovinebrain.Normalserumconcentrationofthismarkerisbelow0.3ng/ml.InadditiontobeingagoodindicatoroftraumastoCNS,S-100canbeappliedas tumormarker in thepatients with neurinoma, glioblastoma, astrocytoma,and meningeoma. It has a special role as prognosticfactorandinthefollow-upofthepatientswithmalignantmelanoma(<0.3ng/ml-85%3years′survival;0.3-0.6ng/ml-50%3years′survival;>0.6ng/ml-10%3years′survival).

Cytokeratin

Epithelialmarkerfoundinintermediatefilament.Ithas19Typesand2subfamilies:Acidic&Basic.ItistodistinguishingepithelialfromnonepithelialtumorsandIndistinguishingthetypeofepithelialtumor.IsReliablemarker for Undifferentiated & Anaplastic carcinomaMetastasizingcarcinomas

Vimentin

It is Mesenchymal marker, Predominant subunitof fibroblastic Intermediate filament. Expressed in atissuespecificpattern incellsofmesenchymalorigin(fibroblast&hemopoieticcells)alsoinExpressedinallcellsduringembryogenesis&isgraduallyreplacedbytypespecificintermediatefilaments.IthasDrawback:Expressedinsarcomatoidcarcinomasalsosocannotbeusedtodifferentiatesarcomasfromcarcinomas

Desmin

It ismesenchymalmarkerPredominantsubunitoffibroblasticandinintermediatefilament.Itisexpressedinmuscletissueduringearlyembryogenesis,increasesincellsnearterminaldifferentiation.Ishighlysensittivemarker for endothelial cell differentiation & tumorinvasiveness in colon cancers, GI stromal tumors,embryonalsarcomas&endometrialcarcinomas

Tissue polypeptide antigen (TPA)

TPA, which is regarded as a marker of cellproliferation, is a mixture of proteolytic fragmentscontainingtherelativelystableα-helicalroddomainsof

simple epithelium-type cytokeratins. These fragmentsare probably releasedduringnecrosis and lysis of thecarcinoma cells. Thus TPA should be regarded as abroad-spectrum epithelial tumor marker and not as aspecific molecular marker for epithelial neoplasms.TPAisaconstituentofintermediaryfilamentproteins.Ithasamixtureoflowmolecularweightcytokeratins8,18and19.

Epidermal growth factor receptor (EGFR)

EGFRa170KD,glycoproteinbindstoepidermalgrowth factor (EGF) with high affinity and showssignificantsequencehomologywithV-erbDoncogeneproduct. EGFR gene over expression is observed inSCC.EGFRlevelsareraisedinbreastcancer,gliomas,lungcancer,bloodcancer,SCCand tumorsof femalegenitaltract.

Proliferating cell nuclear antigen (PCNA)

These are nuclear proteins associated withDNApolymerase. They appear in the final phase ofG1 and in the S-phase. In addition, they are thoughtto form part of theD-cdkcyclin complex,where theyare involved in phases of the cell cycle. They areindicative of cell proliferation.PCNA is an auxiliaryproteintoDNApolymerase-delta,anuclearnon-histoneantigen[27]andisessentialforthesynthesisofDNAincells.

Limitations of markers in diagnosis

LackofSpecificityandsensitivity,heterogenecityofcancer.

BenigndiseasesshowspositiveforCA125orCEA.SmokershaveraisedCEA.

Normalpersonsalsohavesmallamounts.

High levels onlywith large tumor volume. Somecancersneverhavehighlevels.

Thus, it becomes necessary to choose a thresholdatwhichlevelparticularmarkerisconsideredabnormalandsuggestiveofthepresenceofthattumortype

Factors (in addition to malignant disease) that affect serum concentrations of tumor markers

False positive results

Presence of inflammatory processes; benign liver


diseasesandconsequentialdisturbanciesinmetabolisman excretion (AFP, TPA, CEA, CA 19-9, CA 15-3);disturbancies of renal function (beta-2-microglobulin,calcitonin, PSA,CEA,CA19-9,CA15-3); extensivetumor necrosis; as a consequence of diagnostic andtherapeutic procedures (digitorectal examination,mamography, surgery, radio and chemotherapy); asa consequence of different physiological conditions(pregnancy - ßHCG, CA 125, CA 15-3,MCA, AFP,menstrualcycle-CA125).

False negative results

complete absence of production (e.g. CA 19-9 inLe(a-b-) persons); insufficient expression of a certainantigenic determinan (or production in only some oftumorcells);insufficientbloodcirculationinthetumor;productionofimmunecomplexeswithautoantibodies;rapiddegradationandclearanceofantigens.

CONCLUSION

Biomarkers help in detection of genetic &molecularchangesrelatedtoearly,intermediate&lateend points in the process of oral carcinogenesis Useof tumor markers in clinical oncology has increasedtremendouslywithidentificationofnewtumormarkers&expansionoftechniquesofdetection.However,suchuseisnotwithoutitspitfalls.Hence,thesearchforsuchdefinitemarkersofpotentialmalignancyshouldbetheultimategoalinoralpathology.

Ethical Clearance- Taken


Conflict of Interest: Nil

REFERENCE

1. SharmaU, Rathore VPS, DiagnosticMarkers intheHeadandNeckMalignancy,JAdvOralRes,2014;5(1):17-24.

2. Lehto VP, Pontén J. Tumor markers in humanbiopsymaterial.ActaOncol1989;28:743-62.

3. Virji MA, Mercer DW, Herberman RB. Tumormarkersandtheirmeasurements.PatholResPract1988;183:95-9.

4. MalatiT.Tumourmarkers:Anoverview.IndianJClinBiochem2007;22:17-31.

5. KüstnerCE,CostaFI,LópezLJ.Oralcancerriskandmolecularmarkers.MedOralPatolOralCirBuccal2004;9:377-84.

6. Scully C, Burkhardt A. Tissue markers ofpotentiallymalignanthumanoralepitheliallesions.JOralPatholMed1993;22:246-56.

7. Enzinger&Weiss soft tissue tumor, 5th edition,Elsevier2008

8. Jordan RC, Daniels TE, Greenspan JS, RegeziJA. Advanced diagnostic methods in oral andmaxillofacial pathology. Part I: Molecularmethods.OralSurgOralMedOralPathol

An Analytical Study of 118 Hanging Cases Autopsied at Dr. B.R. Ambedkar Medical College, Bengaluru, Karnataka

Karthik SK1, Nagaraj BM2, Jayaprakash G3, Manjunath KH4

1Assistant Professor, 2Professor & Head, Dept. of Forensic Medicine & Toxicology, Dr.B.R. Ambedkar Medical College, Bengaluru, 3Professor & Head, Dept. of Forensic Medicine & Toxicology, Rajarajeshwari Medical

College & Hospital, Bengaluru, 4Professor, Dept. of Forensic Medicine & Toxicology, Dr.B.R. Ambedkar Medical College, Bengaluru

ABSTRACT

Suicidaltendenciesareincreasingatanalarmingrateallovertheworld.Hangingisoneofthecommonmethodofcommittingsuicideandisconsideredasapainlessformofdeath.ThisprospectivestudywasconductedamongvictimsofhangingbroughttoDr.B.R.Ambedkarmedicalcollegemortuary,BengaluruduringJune2016toDecember2016.Atotalof118casesofallegedhangingwereselectedforthisprospectivestudy.Thepatternofhangingrevealedfromthisstudyshowedamalepredominance.Themaximumnumberofcaseswereinthe21to30yearsagegroup.Overallthemostcommonligaturematerialusedforhangingwassareeanddupatta.Hangingwastypicalin06cases(5.08%)andatypicalin112cases(94.91%).Salivarydribblemarkswasseenin29(24.57%)casesandprotrusionoftonguepresentin37(31.35%)cases.Thedirectionofligaturemarkwasobliquein105(88.98%)casesandtransversein13(11.01%)cases.Ligaturemarkwasabovethethyroidcartilagein92.37%casesandoverthethyroidcartilagein7.62%cases.Hyoidbonefracturewasnotedin05casesandthyroidcartilagefracturewasseenin01case.

Keywords : Hanging, Suicide, Ligature material, Ligature mark, Hyoid bone, Thyroid cartilage.

Corresponding author:Dr. S.K. KarthikAssistantProfessor,Dept.ofForensicmedicine&Toxicology,Dr.B.R.Ambedkarmedicalcollege,Bengaluru.E-mail:[email protected]

INTRODUCTION

Hanging is a form of asphyxia death, which iscaused by the suspension of the body by a ligaturethatencirclestheneck,theconstrictingforcebeingtheweightofthebody.Asphyxiainhangingissecondarytocompressionorconstrictionoftheneckstructuresbyanooseorotherconstrictingbandtightenedbytheweightofthebody.Incompletehanging,theconstrictingforceistheweightofthebodyasthebodyisfullysuspendedin air. In partial hanging, the constricting force is theweightoftheheadandthelowerpartofthebodysuchas toes, feet, knees or buttocks touches the ground.Hangingisordinarilypresumedtobesuicidalunlessthecircumstantialandotherevidencesarestrongenoughto

rebutthepresumption1.

Hanging is the most common method of suicidebecause of painless death and easy availability of theligaturematerialatthesurroundings.Suicideisamajorsocio-economic and public health issue worldwide.Hanging is one of the 10 leading causes of death intheworld, accounting formore than amillion deathsannually.(2)

The number of hanging deaths is increasing dayby day. Even though hanging is suicidal, postmortemsuspension is not uncommon. Most of the cases ofhanging encountered at autopsy are atypical hanging.Theligaturemarkisavitalevidenceofasphyxiadeaths.Thesourceanddirectionof theligaturemarkhelpsindifferentiatingthetypeofasphyxiadeathashangingorstrangulation.(3)

Medico-legal questions likely to arise in case ofhangingaremainly,whetherthedeathcausedbyhangingwassuicidal,homicidaloraccidental,orwhetherperson

DOI Number: 10.5958/0973-9130.2018.00124.X


was intoxicatedwith anydrugsor alcohol, time sincedeath, any concealed injuries over body. Simulatedsuicidal hanging interferes the investigating processin unnatural deaths. To arrive at conclusion, detailedexternaland internalexamination,analysisofsamplesplayvitalrole.Apartfromautopsytheligaturematerialused,place,pointofsuspensionandreviewofsceneofcrimemayaddtotheconclusion.(4)

MATERIAL AND METHOD

The prospective study was conducted amongvictims of hanging brought to Dr.B.R.Ambedkarmedicalcollegemortuary,BengaluruduringtheperiodJune 2016 to December 2016. Cases with allegedhistory of hanging by the investigating officer areconsideredforthisstudy.Thenaturaldeaths,accidentaldeathsanddeathsduetomultipleinjuriesareexcludedinthispresentstudy.Detailedinformationregardingthedeceasedandcircumstancesofdeathwascollectedfromthepoliceandrelatives.Insomecases,thisinformationwassupplementedbyeither,visittosceneofoccurrenceorfromthephotographsofsceneofoccurrence.

Neckdissectionisdoneinbloodlessfield.Dissectionisdonelayerbylayerwithrespecttoskin,neckmuscles,vessels,othersofttissueandinternaldeepstructuresofneck.Hyoidbone and thyroid cartilage examinedanddissected to ruleout injuryor fracture.Focusing lightandmagnifyinglensisusedduringexternalandinternalexamination. All the data was analyzed, comparedstatisticallyandtheresultsaretabulated.

Table 1 : Age wise distribution of cases.

Age group (Years) Cases Percentage

0–10 0 0

11–20 10 8.47

21–30 45 38.13

31–40 43 36.44

41–50 13 11.01

51–60 03 2.54

>60 04 3.38

Table 2 : Ligature materials used for hanging.

Ligature material used Cases Percentage

Saree 46 38.98

Dupatta 42 35.59

Rope 15 12.71

Dhothi 06 5.08

Others 09 7.62

Table 3 : Sex wise case distribution.

Sex Cases Percentage

Male 79 66.94

Female 39 33.05

Table 4 : External postmortem findings.

Postmortem finding Number of cases

Salivarydribblemarks 29(24.57%)

Protrusionoftongue 37(31.35%)

Purgingofstools 18(15.25%)

Nasalbleeding 05(4.23%)

Postmortemstainingoverbacksurface 84(71.18%)

Postmortemstainingoverlowerlimbs 34(28.81%)

Seminalejaculation 9outof79(11.39%)

Menstruation 10outof39(25.64%)

Table 5 : Characteristics of ligature mark.

Ligature mark Number of cases

Typical 06(5.08%)

Atypical 112(94.91%)

Obliquedirection 105(88.98%)

Transversedirection 13(11.01%)

Ligaturemarkabovethyroidcartilage 109(92.37%)

Ligaturemarkoverthyroidcartilage 09(7.62%)

Parchmentisationofskin 100(100%)

Peri-ligatureinjuries 15(12.71%)

RESULTS AND DISCUSSION

Deaths due to hanging constituted 31.97% of thetotal 369 cases thatwere brought to themortuary forpostmortemexaminationduring the studyperiod.Outof118casesofhanging,79weremales(66.94%)and


39 were females (33.05%). The most vulnerable sexwas male and the male to female ratio being 2.02:1.These were consistent with other authors (2,3,4). Malepreponderance can probably be due to the fact thatfemaleshavehighermentalstabilitythanmales.

Thehighestincidencewasintheagegroupof21to30years(38.13%),whichissimilartotheobservationsmadebyotherauthors(3,4,5),followedby31–40years(36.44%)and41–50years(11.01%).Tencaseswerefrom juvenile tender age group below 18 years. Themostvulnerableagegroupforhangingwasobservedas21 to 40 years. This particular age group is themoststressful period as it is the time for oneself to settlein life like education, getting job,marriage, starting abusiness.Failuredrivestheindividualtofrustrationandmaydecidetoendlife.

According tomarital status inourstudy,86cases(72.88%) were married and 32 cases (27.11%) wereunmarried.Nodeceasedindivorcedstatefound.Thesefindingswereconsistentwithotherauthors.(4,5,6)

Placeofhangingwashome in91cases (85.04%)of the total 107 cases which took place indoor. 11cases(9.32%)ofhangingoccurredoutdoor.Homewasthe preferred site of hanging because usually victimsprefer any secludedplacewhichwill suit the purposeof committing suicide. Few authors are of the sameopinion.(4,5,6)

Overall the most common ligature material usedforhangingwassaree(38.98%)anddupatta(35.59%).Thisisprobablyduetotheeaseofavailabilityofthesematerialstothedeceasedpersonsatthetimeofhanging.

Typicalhangingwasobservedin5.08%casesandatypicalhangingin94.91%cases.Similarresultswerenotedbyauthors.(3,5,6)

On external examination, salivary dribble marksseen in 29 cases (24.57%), protrusion of tongue waspresent in 37 cases (31.35%), purging of stools waspresent in 18 cases (15.25%), nasal bleedingnoted in4.23% cases. Postmortem staining over the back wasnoted in 84 cases (71.81%) and over the lower limbsin34cases (28.81%).Semenemissionwaspresent in9cases(11.39%)outof79males.Menstrualbleedingwas seen in 10 cases (25.64%) out of 39 females.Similarobservationswerenotedbyauthors. (3,4,6,7)The probablereasonforprotrusionoftonguecouldbethat

the constricting force of the ligature caused upwardpressureontheneckstructurecausingelevationofthetongue.

Salivarydribblemarksisanimportantantemortemsignofhangingasstimulationofsalivaryglandsbytheligatureleadstosecretionofsaliva,whichbeingavitalfunctioncannotoccurafterdeath.

Directionofligaturemarkwasobliquein105cases(88.98%), whereas in 11.01% of cases, the ligaturemarkwasrunninginatransversemanner.Thesimilarpatternswereobservedinthestudiesconductedbyotherauthors.(6,8,9)

Inourstudy,itwasobservedthatin118cases,thelevelofligaturemarkwasabovethethyroidcartilagein109cases(97.37%)andoverridingthethyroidcartilagein9cases(7.62%).Thiswasalsoobservedinvariousotherauthors’studies.(3,4,6,8,9)

Periligatureinjuriesintheformofropeburnsaroundthe ligature were found in 15 cases (12.71%). Theseoccur due to the friction produced by the tighteningligaturematerialontheskinoftheneckatthepointofcontactandtheseareofimmensevalueinestablishingtheantemortemnatureofhanging.

In our study, injuries to the soft tissue under theligature mark were present in 16 (13.55%) cases,fractureofhyoidbonewaspresentin5(4.23%)casesandfractureofthyroidcartilagewaspresentin1(0.84%)case.Fractureofcricoidcartilagewasnotfoundinourstudy. Similar findings were observed in the studiesconducted by other authors. (3,4,6,8,9) Neck structurefractures increases with age. There is significantlyhigher incidence of fractures in individuals aged 40yearsormore,duetocalcificationandfragilityofbonystructures.

CONCLUSION

Thenumberofdeathsbyhangingisincreasingasitisconsideredasapainlessdeath,non-expensiveandligaturematerialiseasilyavailable.Hangingisalwaysconsidered suicidal in nature until contrary is proved.High incidence of suicidal hanging in themiddle agegroup, especially the males impose huge economicburdenonthefamiliesofthevictims.Awelldesigned,comprehensive and targeted program to identify themajor causative factors behind suicidal hanging andtheir appropriate preventivemodalities is the need of


thehour.

Ethical Clearance – Obtained from Institutionalethicscommittee.

Financial Assistance–None

Conflict of Interest–None

REFERENCES

1. P.C.Dikshit. Textbook of Forensic medicine andToxicology. 2nd ed.NewDelhi. PawaninderP.VijandAnupamVij.2014:297–303.

2. BharathiRamaRao,VChandBasha,KSudhakarReddy. A study of ligature mark in deaths dueto hanging in Warangal area, Andhra Pradesh.IJFM&T2014;8(2):85–88.

3. PradeepkumarMV,AnandPRayamane.Patternofneckinjuries inhangingdeathsanditscorrelationwithrecentconceptsandtheories.J-SIMLA2015;7(1):20–25.

4. P.B.Waghmare, B.G.Chikhalkar, S.D.Nanandkar.Analysisofasphyxiadeathsduetohanging.JIAFM2014;36(4):343–345.

5. Narendra kumar Vaishnawa, Shashank Sharma,M.P.Joshi, Jagdish Jugtawat, P.C.Vyas. Studyof epidemiological profile of hanging in Jodhpurregion of Rajasthan : An autopsy based study.JIAFM2016;38(3):306–312.

6. Bharath Kumar Guntheti, Sheik Khaja, UdayPal singh. Profile and pattern of hanging cases ata tertiary care hospital, Khammam; Telangana.JIAFM2016;38(1):67–71.

7. AshwiniNarayanK,BharathiVaidyam.Anautopsystudy conducted at district hospital mortuary,MIMS, Mandya on violent asphyxia deaths.J-SIMLA2016;8(1):26–31.

8. RajeevSharma,Rajeshkumar,NehaGupta,ManojkumarPanigrah.Aretrospectivestudyofpatternofneckinjuriesinthecasesofhanging.IJFM&T2015;9(2):160–162.

9. T.SaisudheerandT.V.Nagaraja,Astudyofligaturemark in cases of hanging deaths. Int J PharmBiomedSci2012;3(3):80–84.

Pattern and Outcomes of Head Injuries in Egypt: A Study of the Egyptian Revolution

Ragab T1, Samar A Ahmed1, Abuanza R A1, Akid Y F1

1Forensic Medicine and Clinical Toxicology Department, Ainshams University Faculty of Medicine, Abbassia Square, Cairo, Egypt

ABSTRACT

Likemanyothertraumas,headinjuriesisagrowinghealthproblemandisattributedtodeathsamongtheyoungandproductivepopulation.Theintentionofthisstudywastocomparethedifferenceinthepatternandoutcomeofheadinjuriesbetweenyear2010versus2011.Aretrospectivecomparativestudycarriedoutbasedupondatacollectedfrommedicalrecordsofpatientwithheadinjuriesadmittedtoemergencyroom,El-Demerdash ,AinShamsUniversityHospitals starting from January 2010 toDecember 2011. Socio-demographic,fullhistory,clinicalexaminationandcriteriaofseveritywerecollectedfromthesheetsforthestudy.Duringthestudyperiod,thetotalnumberofheadinjuredcasesreceivedbyEL-Demerdashhospitalwas1020;407in2010and613in2011.Duetoin-completedsheets206oftheheadinjuredpatientswerediscardedfromthestudy,72in2010and134in2011,outofthe134cases69wereheadgunshots.Sotheactualnumbersofcasessubjectedtothisstudywere335casesin2010and479in2011.Themalepercentagewashigherthanfemaleinbothyears.In2011,themeanagewas24.63±19.19.In2010,Post-concussionstatewasin82.4%ofpatients,whilepoly-traumawerepresentinonly17.6%andnocasesofheadgunshotwerepresent.In2011,poly-traumawere53.03%,whilepost-concussionwerepresentin34.86%andheadgunshotsin12.11%ofcases.In2010,fall37.6%followedbymotorcaraccidents(28.4%).

Keywords: Head Trauma, Brain Traumatic Injury, Post-Concussion, Head Gunshots, Egyptian Revolution, Accident.

INTRODUCTION

ThemostcommoncauseofdeathanddisabilityintheUKunder40yearswasidentifiedasheadinjuries.Most thecasesofhead injuriesdevelop intocompleterecoverybutothers lead todisabilityordeathbothofwhichmightbepreventedbyproperinvestigationsandmanagement.(1)Despitethefactthatgunsareprohibitedin the Egyptian law, yet all types of assault werewitnessed(2)

Articles that describe head injuries among adultsarestillinsufficientandmayfocusononeaspectratherthan others. A lot of information exists about headinjuriesanditsepidemiologybutverylittleisspecificto

Corresponding author:Samar Abdelazim Ahmed Email:[email protected]

Egyptespeciallyduring theEgyptianrevolution2011,so there isan increasingneedforstudying thepatternandoutcomeofheadinjuriesespeciallyintheperiodofrevolution.(3)

AIM OF THE WORK

1-Portray the pattern of head injuries via a cross-sectionalhospital-basedstudyonpatientspresentedtoemergencyroom,El-Demerdash,AinShamsUniversityhospitalsfromJanuary2010toDecember2011.

2-To Evaluate and compare the difference in thepatternandoutcomeofheadinjuriesbetweenyear2010versus2011.

METHODOLOGY

This cross-sectional retrospective comparativestudy was performed based on data collected frommedicalrecordsofheadinjuredpatients,admittedtoEl-

DOI Number: 10.5958/0973-9130.2018.00125.1


Demerdash,AinShamsUniversityhospitalsindurationoftwoyearsfromthebeginningofJanuary2010totheendofDecember2011.

Patients:

Thisstudyincludedheadinjuredpatientsattendingemergency room in El-Demerdash hospital. Approvalof the director of El-Demerdash hospital was taken.Theobtaineddataweredocumentedandrecordedinaspecialsheetconstructedforeachpatient.

METHOD

Thesheetsobtainedrecordedthefollowingdataforeachpatient:

1-Sociodemographic Data:

• Age.

• Gender.

• Residence.

• Occupation.

• Levelofeducation.

2-Full history including:

• Dateofinjury.

• Delay time between injury and medicalconsultation.

• Causativeagents.

• Presentingsymptoms.

• Modeoftransportation.

• Mannerofinjury.

• Presenceofunderlyingmedicalorpsychiatricdisease.

3- Clinical examination:

• GeneralExamination.

• Localexamination.

4- Criteria of severity: (according to hospitaldisposition):

• Durationofhospitalization.

• CausesanddurationofadmissiontotheICU.

• Outcome (complete recovery- recovery withcomplications-death).

The obtained results were revised, coded andorganized for statistical analysis. SPSS (Statisticalpackage for Social Science) version 19 software wasused. Data were presented and suitable analysis wasdone according to the type of data obtained for eachparameter.

Theresultsfromstatisticalanalysisweretabulatedandpresentedinfiguresforinterpretationanddiscussion.

FINDINGS

Table (1): Chi square test for comparison of the socio-demographic data of cases of head injuries arrived to El-Demerdash hospital during the year 2010 versus cases of head injuries arrived during the year 2011 (gender, residence, education, occupation).

Year 2010(N=335)

Year 2011(N=479) Chi Square test P value

N % N %

GenderFemale 104 31.0% 108 22.5%

7.39 0.01Male 231 69.0% 371 77.5%

Residence

Cairo 328 98.5% 427 89.1%

29.80 <0.001Delta 5 1.5% 49 10.2%

Upper Egypt 0 0% 3 0.6%

Education

Highly educated 38 13.4% 32 22.5%

18.28 <0.001Educated 117 41.2% 75 52.8%

Un-educated 129 45.4% 35 24.6%

Occupation Office Job 14 23.0% 34 37.4% 3.51 0.06

Manual worker 47 77.0% 57 62.6%

N:number,Pvalue<0.05=Significant,Pvalue>0.05=Non-significant.


Table (2): Chi square test for comparison of the type of wound, causative instrument, leading cause of injury and manner of injury in cases of head injuries arrived to El-Demerdash hospital during the year 2010 versus cases of head injuries arrived during the year 2011.

Year 2010(N=335)


N % N %

Type of injury

Post-concussion 276 82.4% 167 34.9%

186.67 <0.001Poly-traumatized 59 17.6% 254 53.0%

Head gunshots 0 0% 58 12.1%

Causative instrument

Broad, blunt 332 99.1% 408 85.2%

49.14 <0.001

Localized blunt 0 0% 17 3.5%

Sharp 3 0.9% 8 1.7%

Firearm 0 0% 45 9.4%

Electric shock 0 0% 1 0.2%

Leading cause of head injury

Fall from height 73 21.8% 76 15.9%

72.14 <0.001

Motor car accident 95 28.4% 159 33.2%

Direct trauma 14 4.2% 59 12.3%

Fall 126 37.6% 89 18.6%

Quarrel 27 8.1% 70 14.6%

Firearm 0 0% 24 5.0%

Animal attack 0 0% 2 0.4%

Manner

Accidental 311 92.8% 374 78.1%35.99 <0.001Homicidal 22 6.6% 102 21.3%

Suicidal 2 0.6% 3 0.6%


Table (3): Chi square test for comparison of the complications following the injury and management in cases of head injuries arrived to El-Demerdash hospital during the year 2010 versus cases of head injuries arrived to El-Demerdash hospital during the year 2011.

Year 2010(N=335)


N % N %

Complications

Negative 294 90.5% 369 77.0%

27.21 <0.001

Hemorrhagic shock 1 0.3% 5 1.0%

Respiratory failure (ventilated) 3 0.9% 5 1.0%

Diffuse axonal injury 3 0.9% 5 1.0%Rupture globe 0 0% 2 0.4%

Arrest 24 7.4% 93 19.4%

ManagementConservative 319 95.2% 408 85.2%

20.84 <0.001Operative 16 4.8% 71 14.8%



Table (4): Chi square test for comparison of the outcome and permanent complications in cases of head injuries arrived to El-Demerdash hospital during the year 2010 versus cases of head injuries arrived to El-Demerdash hospital during the year 2011.

Year 2010(N=335)


N % N %

Patient’s outcome

Complete recovery 278 86.1% 351 73.3%

23.62 <0.001Complicated 21 6.5% 34 7.1%

Death 24 7.4% 94 19.6%

Permanent complications

Scar 9 2.8% 11 2.3%

27.60 <0.001

Motor, sensory loss 4 1.2% 13 2.7%

Epilepsy 2 0.6% 2 0.4%

Special sensory loss 4 1.2% 4 0.8%

Amnesia 2 0.6% 4 0.8%


In the present study males predominate in bothstudyyears;69%,77.5%in2010and2011respectively.

AccordingtotheretrospectivestudyofGisladottiret al. (2014), male victims constituted 67% of thesample.(4)

Males showed and expected domination of thesample for many proposed reasons including thelikelihood that they engage in high risk sports likeboxingforexample.Theyalsotendtoengageinstreetfightsandaggressivebehaviorsfarmorethanfemalesaswellasthefactthatmanuallaborandjobsinvolvinguseofheavyequipmentareusuallyoccupiedbymales.(5)

These results in this study highlighting residenceof victims were in concordance with Halldorsson etal. (2007) where 409 cases were recorded from theReykjavikareawhichisanurbanareacomparedto141casesfromtheruralareas.(6)

It may be inferred that cases of head injuries inurban areas are more likely receive diagnosis andtreatment,while in ruralareas thereare relatively fewrecordedheadinjurycases.Also,thecommonoutdoorworkingtime,heavytrafficsandovercrowdinginurbanandindustrialareasincreasetheriskforaccidentsandviolence.(6)

However, Peek-Asa et al. (2004) concluded thatheadtraumawasmorecommoninruralratherthanurban

areasandthisisbecauseruralhighwaysarenarrowandnot well equipped for high speed or big traffic flow.Certaintypesofcrashes,suchasthoseinvolvingfarmmachinery, are unique to rural environments. Ruralresidentswearseatbeltsandusesafetychildseatslessthanurbanresidents. It isalsoa fact thatRural trafficaccidents result inmore deaths thanUrban accidents.This is probably attributed to the delay in seekingmedicalattentionanddelayindiscovery(7).

In IndiaaRetrospective,cross-sectional,hospital-basedstudywasconductedwheremostpatientsresidedinnearbyruralareas.(4)

AnanalysisoftheAustralianInstituteofHealthandWelfareNationalHospitalMorbidityDatabaseshowedthatyouthandyoungadultsfromruralareashadathreetimesgreater rateofhead injury thanurbanareasandatwoandahalfgreaterrateofinjuriesthatwerehighthreattolife.(8)

Findingsrelatedtocausativeinstrumentscoincideswiththestudyofsethietal.(2014)inwhich64%oftheinjurieswerecausedbybluntobjects.(9)

Thesamewasfoundinstudyofakberetal.(2016(10)

In2011firearmwasthecauseofinjuryin5%ofthecases. In2010 therewasn’tanycaseoffirearminjuryandthiscanbeduetotheeventswhichhadhappenedintherevolution.


Firearm injuries were exclusively found in casespresented during 2011 and there wasn’t any case in2010. By analysis firearm related cases in relation togenderitwasfoundthatfirearminjurieswerefoundin5.4%ofmalecasesandin3.7%offemalecasesin2011.Thismaybeduetothespreadoffirearmexistenceaftertherevolution.

Thiscoincideswith thestudyofAhmedandZaki(2013)duringtheyear2011.Theynoticedasignificantrise in the percentage of homicidal injuries especiallythosecausedfromnon-rifledweapons.(11)

Similar to thecurrent study,a studyconducted in2013; where the three leading causes responsible forhead injurieswere falls (42.17%), blunt force injuries(27.46%)androadtrafficinjuries(23.33%).(12)

In a study by Xu et al. (2015) 62% victims ofmotoraccidentsand27%werevictimsoffallswhichisconcomitantwiththepresentstudy.(13)

In the present study accidental manner is thecommonest in both years 92.8%, 78.1% in 2010 and2011respectively.Therewasincreaseinthehomicidalmannerin2011.Thismay-beduetoabsenceofsecurityintheyear2011aftertherevolution.

The same results were recorded in UniversityHospital forhead injuries in theyears2000-2005and2008-2009.Themanneroftheinjurieswereaccidental(80,5%)andhomicidal(12.7%)(14)

On the contrary Kamp et al. (2011) conducted astudyon704TBIscasesandtheyfoundthatthemajorcauseoftraumawasduetoassault(98.8%).(15)

In this study most of the injuries passeduncomplicatedasin2010,mostofthecasesshowednocomplications(90.5%)and7.4%developedarrestaftertheheadinjury.In2011,mostofthecasesshowednocomplications(77%)and19.4%developedarrestaftertheheadinjury.

In the study of Yu et al. (2012), analysis of thetrauma registry databasewas done and data collectedat two trauma centers and from698patients includedin the study 581 (83.2%) had no complications andrecoveredcompletely.(13)

ThesameinstudyofSmitsetal.(2008)whichwas

aprospectivestudy,amulti-centerstudyofconsecutivepatients, 63%of the cases showed complete recoverywithoutanycomplication.(16)

In the present study management was mainlyconservative inbothyears,95.2% in2010and85.2%in2011.

According to a prospective observational studyof Chongetal. (2016)utilizingdatafromthe traumasurveillancesystemfromJanuary2011toMarch2015,only 5.5% of the head injured patients underwentneurosurgery.(17)

In the current study, in 2010, 86.1%of the casesrecovered, 6.5% had complications and 7.4% died.In 2011, 73.3% of patients recovered, 7.1% hadcomplications and 19.6% died. The commonestcomplicationin2010wasscar(2.8%)but in2011thecommonestcomplicationwasmotorand\orsensoryloss(2.7%).

This can be explained by the fact that in 2011thereweremanyriots,thatiswhytherewasincreaseinmortalitiesinthisyear.

Most head injuries are non-life threatening andrequire no admission to the hospital and generally donotresultindeath. (9)

Headandnecktraumaresultsininjuriesfromminorlacerations to life-threateningairwayobstruction.Fewstudiesprovideanalysisofinjuriestotheheadandneckaimingtodescribeprevalenceandinvestigatemortality.Themajorityofpatients(97%)weredischargedhome.Mortalityratewaslessthan1%.(9)

CONCLUSION

Regarding filing and documentation of traumatichead injuries cases in El-Demerdash hospital, manyimportantdatawerenotavailableorimproperlyrecorded(i.e.misseddata).Timedelaybetweenoccurrenceoftheinjuryandhospitaladmission,meanoftransportationtothehospital,maritalstatusandoccupationofthevictimwere not available at all.Vital signs, site and type ofinjurieswerenotrecordedinsomefiles.

Therewasadiscrepancyinprevalenceandpatternof head injuries between the year 2010 and the year2011indicatingastrongchangeintheviolencepatternofEgyptianstreetsduringtheyearoftherevolution.


Conflict of Interest: Nondeclared

Funding: Thisresearchdidnotreceiveanyspecificgrantfromfundingagenciesinthepublic,commercial,ornotforprofitsectors.

Ethical Clearance:TakenfromAinshamsFacultyofMedicineIRBcommittee

REFERENCES

1. RoYS,ShinSD,HolmesJF,SongKJ,ParkJO,ChoJS,etal.Comparisonofclinicalperformanceofcranialcomputedtomographyrulesinpatientswithminorheadinjury:amulticenterprospectivestudy.AcadEmergMed.2011;18(6):597-604.

2. El-Bakary AA, Hamed SSh, Ismaeel HKh.Homicidal injuriesduring January andFebruary,2011 in Mansoura City, Egypt. J Forensic LegMed.2013;20(6):740-6.

3. AbdelazizOS,ElwanyMN,AbbassyMA,MostafaMS. Profile of Road Traffic Accidents–relatedHeadInjuries inAlexandriaDuringtheEgyptianRevolution 2011. Neurosurgery Quarterly.2015;25(1):1-5.

4. AgrawalA,GalwankarS,KapilV,CoronadoV,BasavarajuSV,McGuireLC,etal.Epidemiologyand clinical characteristics of traumatic braininjuries in a rural setting inMaharashtra, India.2007-2009.IntJCritIllnInjSci.2012;2(3):167-71.

5. Al-Habib A, A-Shail A, Alaqeel A, Alqeel A,ZamakhsharyM,Al-BedahK, et al.Causes andpatternsofadult traumaticheadinjuriesinSaudiArabia: implications for injury prevention. AnnSaudiMed.2013;33(4):351-5.

6. Halldorsson JG, Flekkoy KM, GudmundssonKR, Arnkelsson GB, Arnarson EO. Urban-ruraldifferencesinpediatrictraumaticheadinjuries:Aprospectivenationwidestudy.NeuropsychiatrDisTreat.2007;3(6):935-41.

7. Peek-Asa C, Zwerling C, Stallones L. Acutetraumatic injuries in rural populations. Am JPublicHealth.2004;94(10):1689-93.

8. Harrison JE,Berry JG, JamiesonLM.Head andtraumatic brain injuries among Australian youthandyoungadults,July2000-June2006.BrainInj.

2012;26(7-8):996-1004.

9. SethiRK,KozinED,FagenholzPJ,LeeDJ,ShrimeMG, Gray ST. Epidemiological survey of headandneckinjuriesandtraumaintheUnitedStates.Otolaryngol Head Neck Surg. 2014;151(5):776-84.

10. AkberEB,AlamMT,RahmanKM,JahanI,MusaSA.PatternofHeadInjuries(Cranio-cerebral)dueto Homicide in Association with Other Injuries:A Retrospective Post-mortem Study Autopsiedat Dhaka Medical College Morgue House.MymensinghMedJ.2016;25(2):296-302.

11. S.A.Forensicanalysisoffirearmocularinjuries.In:ZakiR,editor.

12. JiC,DuanL,WangL,WuC,WangY,ErY,etal.[StudyonheadinjuriesthroughdatafromtheNational Injury Surveillance System of China,2013]. Zhonghua Liu Xing Bing Xue Za Zhi.2015;36(4):360-3.

13. Yu AH, Cheng CH, Yeung JH, Poon WS, HoH, Chang A, et al. Functional outcome afterhead injury: comparison of 12-45 year oldmaleand female hormonally active patients. Injury.2012;43(5):603-7.

14. Gisladottir EH, Karason S, Sigvaldason K,UlfarssonE,MogensenB.[Visitstoanemergencydepartment due to head injuries]. Laeknabladid.2014;100(6):331-5.

15. KampMA,SlottyP,Sarikaya-SeiwertS,SteigerHJ, Hänggi D. Traumatic brain injuries inillustrated literature: experience from a series ofover700headinjuriesintheAsterixcomicbooks.Acta Neurochir (Wien). 2011;153(6):1351-5;discussion5.

16. Smits M, HuninkMG, van Rijssel DA, DekkerHM, Vos PE, Kool DR, et al. Outcome aftercomplicated minor head injury. AJNR Am JNeuroradiol.2008;29(3):506-13.

17. Chong SL, Chew SY, Feng JX, Teo PY, ChinST, Liu N, et al. A prospective surveillance ofpaediatricheadinjuriesinSingapore:adual-centrestudy.BMJOpen.2016;6(2):e010618.

Profile of Fatal Road Traffic Accidents at Puducherry – An Autopsy based Study

T MadhuVardhana1, M Kumaran2, Ananda Reddy3, N Naveen4, M Arun4, Balaraman5, R N Kagne6

1Assistant Professor, Department of Forensic Medicine, Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry, 2Assistant Professor, Department of Forensic Medicine, Sri Manakula Vinayagar Medical College

and Hospital, Puducherry, 3Associate Professor, Department of Forensic Medicine, The Oxford Medical College Hospital and Research Centre, Karnataka, 4Assistant Professor, Department of Forensic Medicine, Melmaruvathur Adhiparashakthi Institute of Medical Sciences & Research, Tamil Nadu, 5Department of Forensic Medicine, Indira Gandhi Government General Hospital and Post Graduate Institute, Puducherry, 6Professor and Head, Department

of Forensic Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry

ABSTRACT

Roadtrafficaccident(RTA)istheleadingcauseofmortalityanddisabilityallovertheworld.Thescenarioismuchworse in Indiawhere there is high density of vehicles on the roads.This study highlights theprofileoffatalroadtrafficaccidentsoccurredintheUnionTerritoryofPuducherryinthecalendaryears2012and2013.Malefatalitiesoutnumberedthefemalefatalitiesandagegroupbetween21and30years(28%)wasmostcommonlyaffected.Majorityofthefatalaccidentsoccurredinnationalhighways(36.5%)andoccupantsoftwowheelervehiclesweremorevulnerable(40.3%).Highestnumberoffatalitieswerereportedduringfirst2hoursofaccident(47.3%),anditwasobservedthatheadinjurieswerethedominantcauseofdeath(41.9%).

Keywords: Road Traffic Accidents, Fatalities, Cause of death, Vehicles.

Corresponding author:Dr T. MadhuVardhanaAssistantProfessor,DepartmentofForensicMedicine,SriLaksmiNarayanaInstituteofMedicalSciencesOsudu,AgaramVillage,VillianurCommune,KudapakkamPost,[email protected]:09994908281

INTRODUCTION

Accidentisanunplanned,unexpectedeventwhichcauses harm, injury, damageor loss of lives. About50millionpeopleareinjuredand1.2millionpeopledieworldwideeveryyearduetoRTA.1 womenorchildrenwalking, biking or riding to school or work, playingin the streets or setting out on long trips, will neverreturn home, leaving behind shattered families andcommunities.Millionsofpeopleeachyearwill spendlongweeks in hospital after severe crashes andmanywillneverbeabletolive,workorplayastheyusedtodo.Currentefforts toaddress roadsafetyareminimal

in comparison to this growing human suffering. TheWorldHealthOrganization and theWorldBankhavejointlyproducedthisWorldreportonroadtrafficinjuryprevention. Its purpose is to present a comprehensiveoverviewofwhat is knownabout themagnitude, riskfactors and impact of road traffic injuries, and aboutwaystopreventandlessentheimpactofroadcrashes.Thedocument is theoutcomeofacollaborativeeffortby institutions and individuals. Over 100 experts,from all continents and different sectors - includingtransport, engineering, health, police, education andcivil society - have worked to produce the report.Roadtrafficinjuriesareagrowingpublichealthissue,disproportionately affectingvulnerablegroupsof roadusers, including thepoor.But road trafficcrashesandinjuriesarepreventable.Roadtrafficinjurypreventionmust be incorporated into a broad range of activities,such as the development and management of roadinfrastructure, mobility planning, the provision ofhealthandhospitalservices,childwelfareservices,andurban and environmental planning. The health sector

DOI Number: 10.5958/0973-9130.2018.00126.3


isan importantpartner in thisprocess. Its rolesare tostrengthen theevidencebase,provideappropriatepre-hospital and hospital care and rehabilitation, conductadvocacy, and contribute to the implementation andevaluationofinterventions.Thetimetoactisnow.Roadsafetyisnoaccident.Itrequiresstrongpoliticalwillandconcerted, sustained efforts across a range of sectors.Actingnowwillsavelives.“,“author”:[{“dropping-particle”:“”,“family”:“WorldHealthOrganisation”,“given” : “”, “non-dropping-particle” : “”, “parse-names” : false,“suffix” :“”},{“dropping-particle” :“”, “family” : “Who”, “given” : “”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } ],“container-title”:“World”,“id”:“ITEM-1”,“issued”:{“date-parts”:[[“2004”]]},“page”:“244”,“title”:“Worldreportonroadtrafficinjuryprevention”,“type”: “article-journal” }, “uris” : [ “http://www.mendeley.com/documents/?uuid=992c0ecc-65a3-45ee-9ca8-9251f59e3b96”]}],“mendeley”:{“formattedCitation”:“<sup>1</sup>”,“plainTextFormattedCitation”:“1”,“previouslyFormattedCitation” : “<sup>1</sup>” },“properties”:{“noteIndex”:0},“schema”:“https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}TheRTAistheeighthleadingcauseof death in theworld and is projected to become thefifthpositionbytheyear2030.Furthertrafficaccidentsarethechiefcauseofdeathin15-29yearsofageintheworld.2andtheleadingcauseofdeathforyoungpeopleaged15\u201329(1,2

Thetrafficaccidentsnotonlyleadtomorbidityandmortality but also pose an economic threat to familyconcernedand thenation. Indiahasoneof the largestroadnetworksintheworldwithabout73millionmotorvehiclesonroad.3Everyyearmorethanalakhpeopledieduetothispreventablenoncommunicableailment.4 The recent economic development andmodernisationof India may aggravate the existing scenario. So animmediatepreventivestrategyis theneedof thehour.Implementationstrategycannotbeformulatedwithoutadetailedprofileofaccidents.Buttheironyiscompleteaccident data is not available even inmost developedcountrieslikeNewZealandandUnitedKingdom5.ThisstudywasconductedinPuducherry,asmalltownshipinsouthernIndia,withanaimtoprovideastrategicdataforthepolicymakerstoimplementeffectivepreventiveandlifesavingmeasuresagainstRTA.


Thepresentstudywasconductedinthedepartmentof Forensic Medicine, Indira Gandhi GovernmentGeneral hospital and Post-Graduate research institute(IGGGH&PGI),Puducherryinthecalendaryear2012and2013.All theautopsycases inwhich fatalitywasduetoRTAwereincludedinthisstudy.Theinformationregardingthedeceasedanddetailsoftheaccidentfromthetimeofoccurrencetillthedeathofthedeceasedweregathered from police, inquest report, deceased familymembers,witnesspresentat the timeofaccidentsandhospitalrecords.Thesiteoffatalinjuriesoverthebodyand cause of deathwas determined based on autopsyfindings.

OBSERVATIONS AND RESULTS

Outof2878autopsiesconductedduringthecalendaryear2012and2013,575diedduetofatalRTA.Inthepresentstudy487casesweremalesand88caseswerefemales.Malesoutnumberedfemalesinallagegroupswithmaximumgenderratio(10.9:1)in31-40yearsagegroup.There is a swift increase in fatalitiesup to21-30 years age group and declines gradually thereafter.Maximumfatalitieswerenoticedinthe21-30yearsagegroup(28%).Theleastnumberoffatalitieswasin0-10year group (2.6%) followed by above 70 years group(4.7%).Age-gendertrendsofRTAfatalitiesaredepictedin Figure I. About 75% of victims belonged to ruralregion(75.7%)followedbysemiurbanregion(16.5%).Out of 575 fatalities 340weremarried and 213wereunmarriedandmostvictimsareHindus(TableI).

Majority ofRTAs were occurred on nationalhighways(36.5%)andstatehighways(21.9%),andonroads connecting to highways (23.5%).Fatalitiesweremaximumamongroadusersoftwo-wheelersoccupants(40.3%) and pedestrians (32%). Two wheelers weremostcommonoffendingvehiclesdue towhich46.3%fatalitiesoccurred.Thesecondmostcommonoffendingvehiclesinourstudywasheavynon-transportvehicles(18.6%) shadowed by heavy transport vehicles (15%)and light transport vehicles (12.3%)(Table II). RTAfatalitiesarehighestinthemonthofSeptember(11.8%)comparedtonexthighernumberinApril(11.5%)andOctober(10.8%).SincemonthofAprilandSeptemberrecordedhighincidenceofRTAabiphasicpatternwasobtained (Figure II). About 35 % of RTA fatalitiesoccurred in weekends and maximum on Saturdays


(18.1%). In the weekdays more road traffic fatalitiesoccurredonMondays(15.3%)andtheleastonFridays(10%) (Figure III). Maximum of fatalities occurredbetween3pmand6pm(23%)followedby9amto12pm(21.4%)andbetween6pmand9pm(18.8%).About272casesdiedwithin2hoursofaccident,ofwhich103casesdiedonspotand45casesdiedduringtransportation.90cases diedwithin 3 to 6 hours of the accident. In thepresent study the fatalities gradually decreased as thesurvivalperiodincreased.(TableII)

Inthepresentstudythemostcommonsiteofinjuryisheadandface(40.5%)followedbyinjurytomultipleregionsofthebody(35.5%)(FigureIV)andmostofthefatalitiesareduetoheadinjuries(41.9%)followedbyhaemorrhagicshock(18.6%)(TableIII)

Figure I: Age-gender wise distribution of fatalities.

Table I: Distribution of demographic characters in RTA victims

Demographic Characters Trait Number &

Percentage

Gender Male 487(84.8%)

Female 88(15.3%)

Residence Rural 435(75.7%)

Semi-urban 95(16.5%)

Urban 41(7.1%)

Notknown 04(0.7%)

Marital status Married 340(59.1%)

Unmarried 213(37.0%)

Widow/divorced 22(3.8%)

Notknown 10(1.7%)

Religion Hindu 497(86.4%)

Muslim 40(6.9%)

Christian 34(5.9%)

Others 05(0.9%)

Figure II: Month-wise distribution of fatalities

Figure III: Distribution of fatalities in different days of the week

Table II: Distribution of epidemiological characters in RTA fatalities

Epidemiological characters Trait

Number and percentage

Roads involved Nationalhighway 210(36.5%)

Statehighway 126(21.9%)

Connectingroads 135(23.5%)

Villagehighway 104(18.1%)

Road users Two-wheeler 232(40.3%)

Three-wheeler 21(3.6%)

Lightmotorvehicle 37(6.4%)Heavynon-transportvehicle 48(8.3%)Heavytransportvehicle 42(7.3%)

Pedestrians 184(32.0%)

Others 11(1.9)

Offending vehicles Twowheelers 266(46.3%)

Threewheelers 32(5.6%)

Fourwheelers 71(12.3%)Heavynon-transportvehicle 107(18.6%)Heavytransportvehicle 86(15.0%)

Others 13(2.3%)Time of occurrence 12AM-6AM 30(5.2%)


6AM-9AM 74(12.9%)

9AM-12PM 123(21.3%)

12PM-3PM 59(10.2%)

3PM-6PM 132(22.9%)

6PM-9PM 108(18.8%)

9PM-12AM 49(8.5%)

Survival period 0-2hour 272(47.3%)

3-6hour 90(15.7%)

7-12hour 58(10.1%)

13-24hour 39(6.8%)

2-6days 52(9.0%)

7-30days 41(7.1%)

>30days 23(4.0%)

Cause of death Haemorrhage&shock 107(18.6%)

Headinjuries 241(41.9%)

Spinalinjuries 16(2.8%)

Chestinjuries 40(6.9%)Abdomen-pelvicinjuries 33(5.7%)

Polytrauma 103(17.9%)

Sepsis 35(6.1%)

Figure IV: Distribution of fatalities withregional site of fatal injury

DISCUSSION

RTA fatalities constituted nearly 20 percentageof total unnatural deaths in the present study whichis much lower compared with studies conducted inChandigarh(50.3%)6,Rohthak (29%).7 Male fatalities(84.7%) outnumbered females (15.3%) in all agegroupswithagender ratioof5.5:1and thisfinding isin comparable with many studies conducted in India8,9,10the Injury Severity Score (ISSand abroad11 exceptforastudyconducted inNorway121446violentdeathswereexamined--82.6%malesand17.4%females.The

Cont... Table II: Distribution of epidemiological characters in RTA fatalities

meanagewas40.2years(range0-98wherethefemalesoutnumberedmalefatalities.Thediscrepancyingendermight be becausemales contribute a greater share offamily’s economy and have to travel more comparedwithfemales.

Persons in 3rd decade of life are more prone forfatal accidents according to the present study whichissimilartomanyotherstudies8,9,10theInjurySeverityScore(ISS,13.Peoplebelongingtothisagegrouphaveacompulsiontotravelforeducation,employmentandforrecreationpurposes.8

The accidents were minimum when the age wasless than20yearsandgreater than50years which issimilartoastudyconductedbyJhaetal8,Sharmetal9 andRautji et al 10the Injury Severity Score (ISS. Thereasonbeingtheyoungerandtheolderagegroupswereunder supervisionof the elders anduse vehicles lessfrequentlyrespectively.8

Mostofthefatalitiesoccurredinruralareafollowedbysemiurbanwhich iscomparable tovariousstudiesconducted.14sex, area of residence, etc. These deathsconstituted9.4%oftotalroadaccidentdeathsreportedat this hospital. Out of a total of 709 RTA deaths inchildren,about16%werereportedintheblockyearof1974\u201378 and this proportion decreased to 9.4%duringtheblockyearof1984\u201388andhasremainedalmost constant since then. The maximum numberof victims belonged to the states of Haryana (36%,15 The rural dominancemight be because of inadequateknowledgeabouttrafficrules,poorlymaintainedroads,lackofemergencycareservicesanddecreaseprotectivegearswhileridingvehicles.16

FatalRTA occurred more commonly in nationalhighways (36.5%) followed by state highways 21.9% which is similar to a study conducted in Rohtak,Haryana7. This is because of vulnerability of localpopulation living besides highway which harbours avitalinterandintrastatetraffic.17

Accordingtothepresentstudythemostcommonoffendingvehiclesaretwowheelers(46.3%)followedby heavy non-transportmotor vehicle (18.6%), but inastudyconductedatDelhithemostcommonoffendingvehicle was bus (25.5%)10the Injury Severity Score(ISS. Two wheeler occupants fatalities contributeda major share of total fatalities (40.3%) which iscomparabletomanyotherstudies.10theInjurySeverity


Score (ISS,16These resultsvarywith the resultsof Jhaet al where the pedestrian fatalities top the list8. The incidence is high because the number ofmotorcycleisfivetimesasnumerousascomparedwithcars3andthetravelingintwowheelersisanaffordablemeansoftransport.Furthermorethehelmetwearinglawsarenotstrictlyenforced.

In the current study about 46 % of fatalitiesoccurred within 2 hours of accident and 79 % offatalitiesoccurredwithin24hoursofaccidentandthefindingisconsistentwiththefindingsofRautjietal10theInjurySeverityScore(ISSandChandraetal18.ButtheincidenceisslightlyhighercomparedstudybySharmaetal.

Month of September (11.8%) recorded highestfatalitieswhereasastudybyJhaetalhadhighestnumberofaccidentsintheofJanuary8.Thismaybeattributedtothemonsoonseasonprevailingduringthismonthwhereroadbecomewetandslippery.

Maximum fatalities occurred during 3pm-6pm(23%)followedby9am-12pm(21.4%)andthefindingsare comparable with the other studies conducted atPondicherry. On the contrary studies conducted atChandigarh had more fatalities between 4pm to 8pmandaccording to NationalcrimerecordsbureaumostoftheaccidentfatalitiesinIndiaoccurredbetween6pmand9pm4.Thiscouldbebecauseinthesehourspeopleusetheroadtogoandreturnfromworkplaces,offices,factories, business place, and drop & pick-up theirchildrenfromschools.

Inthepresentstudyweekendscontributedtoaboutone-third of total fatalities compared with weekdays.Saturdayhashighestnumberofaccidents similar toastudy conducted in Delhi13. The possible explanationis people use the road more frequently on Saturdaysfor shopping, recreation and for household purposes.FurthermorePondicherryisalsoatouristplacewhichattractstouristsfromthesurroundingregionsleadingtoincreasedtrafficintheweekends.

Themostcommonregioninvolvedinfatalaccidentsisheadandfaceandthisfindingiscongruentwiththestudy conducted in a study conducted at Delhi,10theInjurySeverityScore(ISSChandigarh16andHaryana7.

AccordingtoRautjietal10theInjurySeverityScore(ISSthemostcommoncauseofdeathinRTAishead

injuriesfollowedbyhaemorrhageshock.Inthepresentstudyasimilarpatternwasobserved.Alsoheadinjuriesweretheleadingcauseofdeathinstudiesconductedatvarious regions in india7,16. The head injuriesmay beduetothevulnerabilityofheadtoinjuriesandreduceduseofhelmetsamongthelocalpopulation.

CONCLUSION AND RECOMMENDATIONS

RTAistheleadingcauseofdeathin15-29yearsagegroupintheworld.Aboutalakhpeoplearekilledeveryyear because of this non-communicable ailment. Therecent economicdevelopment in Indiamay acceleratethedeathsduetoroadaccidents.Soanimmediateandeffectivestrategyistheneedofthehour.

Recommendations from the authors based on thepatternofRTA-

Except for a short stretch, most of the roads inPondicherry lack median dividers. Installing suchdividersmaysegregatethevehiclesmovinginoppositedirections.

Strict helmetwearing practice should be imposedasheadinjuriesandtwowheelersoccupantscontributeagreatershareofaccidentfatalities.

Sidewalks for pedestrians shall be constructed ineveryroad.

Educatingthepublicregardingtrafficrules,accidentscenariosshallbedoneperiodically.

Mostoftheaccidentfatalitiesdiewithin2hoursofincident, somobileunits suchasambulanceequippedwithlifesavingequipmentshallbestationedataccidentpronelocations.

ExpertcommitteesshallbeformedtopreventandreviewtheaccidentstatusinPondicherry.

Ethical Clearance: Taken from the InstitutionalEthicalCommittee

Source of Funding: Self

Conflict of Interest: None

REFERENCES

1. PedenM,ScurfieldR,SleetDetal.Worldreporton road traffic injury prevention. Geneva:WorldHealth Organization, 2004. www.who.int/world-


health-day/2004/infomaterials/ world_report/en/summary_en_rev.pdf(accessed5March,2010).

2. Globalstatusreportonroadsafety2013-Supportingadecadeofaction.WHO2013.http://www.who.int/violence_injury_prevention/road_safety_status/2013/en/index.html(accessedFeb2013)

3. Mohan D, Tsimhoni O, Michael S et al. Roadsafety in India: Challenges and Opportunities.h t tp : / /deepb lue . l ib .umich .edu /b i t s t r eam/handle/2027.42/61504/102019.pdf?sequence=1(accessed3Aug2015)

4. AccidentaldeathsandsuicidedeathsinIndia2010:NationalCrimeRecordsBureauMinistryofHomeAffairs. http://ncrb.nic.in/ADSI2010/ADSI2010-full-report.pdf(accessed1Dec2012)

5. Ameratunga S, Hijar M, Norton R. Road-trafficinjuries:Confrontingdisparitiestoaddressaglobal-healthproblem.Lancet2006;367(9521):1533-40

6. SinghD,DewanI,PandeyANetal.SpectrumofunnaturalfatalitiesintheChandigarhzoneofnorth-westIndia–a25-yearautopsystudyfromatertiarycarehospital.JClinForensicMed2003;10:145–52

7. SinghH,Dhattarwal SK. Pattern and distributionof injuries in fatal road traffic accidents inRohtak (Haryana). J Indian Acad Forensic Med2004;26:20–3

8. JhaN,SrinivasaDK,RoyGetal.Epidemiologicalstudyofroadtrafficaccidentscases:AstudyfromsouthIndia.IndianJournalofCommunityMedicine.2004;24(1):20–4.

9. Sharma D, Singh US, Mukherjee S. A study onroadtrafficaccidentsinAnand-Gujarat.Healthline.2011;2(2):12–5

10. Rautji R, Bhardwaj D N, Dogra T D. TheAbbreviated InjuryScale and itsCorrelationwithPreventableTraumaticAccidentalDeaths:AstudyfromSouthDelhi.MedSciLaw2006;46:157-65

11. JhaN,AgrawalCS.EpidemiologicalStudyofRoadTraffic Accident Cases: A Study from EasternNepal.RegHealForum.2004;8(1):15–22.

12. Nordrum I, Eideo T, Jorgensen L. Medicolegalautopsies of violent deaths in northern Norway1972–1992.ForensicSciInt.1998;92:39–48.

13. MehtaSP.Anepidemiologicalstudyofroadtrafficaccident cases admitted in Safdarjang Hospital,New Delhi. Indian Journal of Medical Research1968;56(4):456-66.

14. Singh D, Singh SP, Kumaran M, Goel S.Epidemiology of road traffic accident deaths inchildren inChandigarhzoneofNorthWest India.EgyptJForensicSci.2015;:4–10

15. Kanchan T, Menezes RG, Bakkannavar SM.Ageandgendervariations in trendof road trafficfatalities.MedSciLaw2010;50:192-6

16. SinghD,MoorthiK,SinghSP,GoelS.ProfileofRoadTrafficFatalitiesinAdults-A40YearStudyinChandigarhZoneofNorthWestIndia.JIndianAcadForensicMed2014;36:47-51

17. The global impact - Chapter 2. World report onroadtraffic injuryprevention.http://www.who.int/violence_injury_prevention/publications/road_traffic/world_report/chapter2.pdf (accessed 12 Dec2012)

18. ChandraJ,DograTD,DikshitPC.Patternofcranio-intracranial injuries in fatal vehicular accidents inDelhi,1966--76.MedSciLaw.1979;19(3):186–94.

Study on Prevailing Factors of Domestic Violence Deaths in and around Guntur City, Andhra Pradesh

Srinivasu Rao Palagani,1 K Ravimuni2, K Usha Rani3

1Assistant Professor, Department of Forensic Medicine, Nimra Institute of Medical Sciences, Nimra Nagar, Jupudi, Ibrahimpatnam,Vijayawada, 2Assistant Professor, NRI Medical College, Chinakakani, Guntur District,

3Assistant Professor, K.L.E.F, Vaddeswaram, Guntur District

ABSTRACT

DomesticviolenceinIndiaisendemicandwidespreadpredominantlyagainstwomen.Around70%ofwomeninIndiaarevictimstodomesticviolenceaccordingtoministryforwomenandchilddevelopment.WorldHealthOrganization(WHO)definesviolenceastheintentionaluseofphysicalforceorpower,threatenedoractual,againstagrouporcommunity,whicheitherresultsinorhasahighlikelihoodofresultingininjury,death,psychologicalharm,maldevelopment,ordeprivation.Violence,ingeneralisprevalentallovertheworld.Nogroup,sex,caste,religion,region,raceetc.isexceptiontothisviolence.Irrespectiveofthecauseofviolence,itfinallyleadstodisease,disability,infirmityordeathoftheindividual.Mostofthevictimsofviolencearewomen.

Keywords: Domestic violence, women, intentional, injury.

INTRODUCTION

Humans are described as social animals capableofshowingsympathywithotherbeings,andlivinglifewith values and ethics. There are various species intheuniverse; among thesehumansarehighlyevolvedspecies.Weareintheformofsociety.Basicunitofthesociety isFamily.Family is thepeacefulrestingplaceforallfamilymemberswhichhaveinherentcentripetalforceactingonthemembersof thefamily.Thehouseshould have an ideal civil masonry structure and thepeopleresidinginitshouldhavesentimental,emotionaland social adjustment mutually and adjustment witheachother,likemutuallytakingcareofsmallchildrenand elderly and indirectly preventing any type ofdomesticviolence.

WorldHealthOrganization(WHO)definesviolenceas the intentional use of physical force or power,

Corresponding author:Dr. K Ravimuni,AssistantProfessor,DepartmentofForensicMedicine,NRIMedicalCollege,Chinakakani,GunturDistrict.E-mailID:[email protected]:9502852356

threatened or actual, against a group or community,whicheitherresultsinorhasahighlikelihoodofresultingininjury,death,psychologicalharm,maldevelopment,ordeprivation. 1Itfurtherdividesthegeneraldefinitionofviolenceintothreesub-typesaccordingtothevictim-perpetrator relationship i.e. Self-directed violence,InterpersonalviolencenadCollectiveviolence.

Domesticviolence is considered tohaveoccurredwhen one intimate partner uses physical violence,coercion, threats, intimidation, isolation, and/oremotional, sexual, and economic abuses over theotherintimatepartnertomaintainpowerandcontrol. 2

AccordingtotheMerriam-Websterdictionarydefinition,domesticviolence is: “the inflictingofphysical injurybyonefamilyorhouseholdmemberoranother;alsoarepeated/habitualpatternofsuchbehavior.”3

According to NCRB (National Crime RecordsBureau) the total number of domestic violence casesregisteredare89,646intheyear2007including8,093deaths,95,071casesintheyear2008including8,172deaths, 1,03,579 cases in the year 2009 including8,383deaths,1,07,614casesintheyear2010including8,391deaths,1,14,372casesintheyear2011including8,618deaths.1,23,798casesintheyear2012including

DOI Number: 10.5958/0973-9130.2018.00127.5


8233deaths.4

According to DCRB (District Crime RecordsBureau),Guntur,thetotalnumberofdomesticviolencecasesregisteredwas491intheyear2010including35deaths,550casesintheyear2011including56deaths,597 cases in the year 2012 including 66 deaths. 5 Itemphasizestherequirementofthepresentstudy.

Somefactsaboutdomesticviolenceare

Aroundtheworld,atleastoneineverythreewomenhasbeenbeaten,coercedintosexorotherwiseabusedduringherlifetime.Mostoften,theabuserisamemberofherownfamily.

Domesticviolenceistheleadingcauseofinjurytowomen—morethantrafficaccidents.

Studies suggest that up to 10 million childrenwitnesssomeformofdomesticviolenceannually.

Nearly 1 in 5 teenage girls who have been in arelationshipsaidaboyfriendthreatenedviolenceorself-harmifpresentedwithabreakup.


This studyhas been carriedout in the year 2012,after from the ethical committee of Guntur MedicalCollege/GeneralHospital.

ThepresentstudywasconductedintheDepartmentofForensicMedicine,GunturMedicalCollege,GunturfromJanuary2012toDecember2012i.e.,12months,total postmortem cases were 1448. An attempt wasmadetoworkoncaseswithhistoryofdomesticviolencethatcametoourdepartmenti.e.,51casesoutof1448cases.Thestatisticsofthesecaseswereanalyzedwithavailabledatainourdepartment,crimescenevisitsandbypsychologicalautopsy.

The records maintained for each case in thisdepartment are post mortem requisition given byInvestigatingOfficerintheirinquests,treatmentrecordsfromhospitaliftreated,historyfrombloodrelativesandfriends,observationofthecircumstancesatthescenebyvisiting the scene of offence, photographs taken fromthe scene of offence and findings in the PostmortemExamination certificates. In cases of deaths due topoisoning,chemicalanalysisreportsfromtheForensicScienceLaboratoryweretakenintoconsideration.

The materials used are inquest Reports, inpatientCasesheets,perusualofpolicepapers,datafromdistrictcrime records bureau (DCRB),Guntur, Records fromMedical Record Section of Guntur General Hospital,PostmortemReportsofallcases,InformationcollectedfromtheInvestigationOfficer,Relativesandfriendsofthedeceasedaccompanyingdeadbodies.

The factors taken to enumerate the study are,prevalenceofdeathsincomparisonwithruralandurbanareas,prevalence of cases in different family types,maritalperiodofwomen indomesticviolencedeaths,casesassociatedwith thesocio-economicstatusof thedeceased,prevalence of deaths in relation to literacyanddifferentcausesofviolence.


Violence,ingeneralisprevalentallovertheworld.No group, sex, caste, religion, region, race etc. isexceptiontothisviolence.Irrespectiveof thecauseofviolence,itfinallyleadstodisease,disability,infirmityor death of the individual. Most of the victims ofviolencearewomen.

Inthepresentstudy,anattemptwasmadetoanalyzethescenarioofdomesticviolencedeathsinandaroundGuntur during the period January 2012 to December2012.

InthisstudyfromTableNo.1itcanbeconcludedthat incidence of deaths due to domestic violence ismore or less equal in Urban and Rural areas i.e., 29cases(56.8%)and22cases(43.1%)respectively.TheincidenceofdeathsinUrbanandRuralareasmaybedueto traditional cultures likemale dominations, demandfordowryordemand for extramoneyand lowsocio-economicstatus.

InthisstudyonperusalofTableNo.2,thedeathsare more in nuclear families i.e., 35 cases (68.6%),followedby Joint families i.e., 15 cases (29.4%).Butverylowno.ofcaseswereseeninthewomenwhoarelivingalonei.e.,onecase(1.9%).

TableNo.3showsthat,outof51deaths,42casesarefemaledeaths.Outofwhich4cases(7.8%)areinvolvedinlessthan1yearofmaritallife,8cases(15.6%)in1–3yearsofmaritallife,13cases(25.4%)in3–7yearsofmaritallifeand17cases(33.3%)in>7yearsofmaritallife.Moreno.ofcasesi.e.,25deaths(48.8%)occurred


within7yearsofmarriage.

InthisstudyonperusalofTableNo.4,theincidenceof domestic violence deaths is more or less same inlowerandmiddlesocio-economicgroupi.e.,27(52.9%)and24(47%)respectively.Nocasewasrecordedeitherintheuppermiddleclassortheuppersocio-economicgroup.ThehighincidenceintheLowersocio-economicgroupismainlyduetoeconomiccrisis,alcoholismandtraditionalcultureslikemaledominance,dowryrelatedcomplicationsetc.

TableNo. 5 indicatesmore number of cases i.e.,33 cases (64.7%) are moderately literate personsfollowed by illiterate persons i.e., 18 cases (35.2%).No cases were recorded in my study in the Literatepersons.Theincidenceofthesecasesinilliterateandmoderately literate persons ismainly due to lack ofawareness of the legislativemeasures, and the genderinequalitythatisprevalentintheIndiansociety.

TableNo.6indicates,thecommoncauseofviolenceisAlcohol consumption followedbyViolence i.e., 14cases (27.4%). The next common causes of violenceareHarassment by husband and relatives includes 13cases(25.4%),dowryrelatedissuesincludes10cases(19.6%),extramaritalaffairsincludes6cases(11.7%)andothers include8cases(15.6%).AcombinationofalcoholconsumptionfollowedbyViolence,Harassmentbyhusbandandrelatives,dowryrelatedissuesandextramaritalaffairsconstitute43cases(84.1%)ofthecases,which indicate thatmaledominance is theunderlyingfactor.

Figure 1

Figure 2

Figure 3

Figure 4

27

52.90%

24

47.00% 0 0% 0 0%0

5

10

15

20

25

30

Lower Middle Upper middle Upper

Cases Associated with the Socio-Economic Status of the Deceased

No. Of CasesPercentage

35

68.60%

15

29.40% 1 1.90%

0

5

10

15

20

25

30

35

Nuclear Joint Living Alone

Prevalence of Cases in Different Family Types

No. of CasesPercentage

29

22

56.80% 43.10%

0

5

10

15

20

25

30

No of Cases Percentage

Prevalence of Deaths in Comparison with Rural to Urban Areas

UrbanRural

4

7.80%

8

15.60%

13

25.40%

17

33.30%

0

2

4

6

8

10

12

14

16

18

Less than 1 yr 1 – 3 yrs 3 – 7 yrs >7 yrs

Marital Period of Women in Domestic Violence Deaths

No. of CasesPercentage


Table 1: Prevalence of Deaths in Relation to Literacy

Educational Status No. Of cases Percentage

Illiterate 18 35.2%

ModeratelyLiterate 33 64.7%

Literate 0 0.0%

Table 2: Different Causes of Violence

Cause of Violence No. Of Cases Percentage

DowryRelated 10 19.6%

Harassmentbyhusbandandrelatives. 13 25.4%

AlcoholconsumptionfollowedbyViolence 14 27.4%

Extramaritalaffair 06 11.7%

Others 08 15.6%

DISCUSSION

Violence,ingeneralisprevalentallovertheworld.No group, sex, caste, religion, region, race etc. isexceptiontothisviolence.Irrespectiveof thecauseofviolence,itfinallyleadstodisease,disability,infirmityor death of the individual. Most of the victims ofviolencearewomen.

InthisstudyfromTableNo.1itcanbeconcludedthat incidence of deaths due to domestic violence ismore or less equal in Urban and Rural areas i.e., 29cases(56.8%)and22cases(43.1%)respectively.TheincidenceofdeathsinUrbanandRuralareasmaybedueto traditional cultures likemale dominations, demandfordowryordemand for extramoneyand lowsocio-economicstatus.Ina2000multi-sitehouseholdsurveyconducted in India, it was found that while overallapproximately50%ofwomensurveyedhadexperiencedsomeformofdomesticviolencethroughouttheirmarriedlife,theratesvariedsignificantlybyspecificlocationaswellasoverallregion.Inruralareasandurbanslums,thatratewasapproximately55%,whereasinurbannon-slumareastheratewaslessthan40%.6

InthisstudyonperusalofTableNo.2,thedeathsare more in nuclear families i.e., 35 cases (68.6%),

followedby Joint families i.e., 15 cases (29.4%).Butverylowno.ofcaseswereseeninthewomenwhoarelivingalonei.e.,onecase(1.9%).Biggsetal.7(2009)reportthat51%ofabuseincidentsarecommittedbyapartnerorspouse,49%byanotherfamilymember,13%byacareworker,and5%byaclosefriendorneighbor.The effect of analyzing the problem in this fashionmeansthatabuseisviewedasafamilyproblemandisnotasocialconcern.

TableNo.3showsthat,outof51deaths,42casesarefemaledeaths.Outofwhich4cases(7.8%)areinvolvedinlessthan1yearofmaritallife,8cases(15.6%)in1–3yearsofmaritallife,13cases(25.4%)in3–7yearsofmaritallifeand17cases(33.3%)in>7yearsofmaritallife.Moreno.ofcasesi.e.,25deaths(48.8%)occurredwithin7yearsofmarriage.15

InthisstudyonperusalofTableNo.4,theincidenceof domestic violence deaths is more or less same inlowerandmiddlesocio-economicgroupi.e.,27(52.9%)and24(47%)respectively.Nocasewasrecordedeitherintheuppermiddleclassortheuppersocio-economicgroup.ThehighincidenceintheLowersocio-economicgroupismainlyduetoeconomiccrisis,alcoholismandtraditionalcultureslikemaledominance,dowryrelatedcomplicationsetc.

A1998studyconductedbyBinaAgarwalfoundthatwhileonly13%ofallwomeninIndiawithlandowningfathers inherited that land as daughters, 24% of suchwomenwereabletodosointhestateofKerala.Thisis importantbecause it hasbeen shown thatmeasuresto improve such access to property and economicindependence through channels such as educationnot only directly improve women’s wellbeing andcapabilities, but also reduce their risk of exposure tomaritaloranysortofdomesticviolence.8AccordingtoastudymadebyMichaelKoenigaboutthedeterminantsofdomesticviolenceinIndiapublishedbytheAmericanJournalofPublicHealthin2006,highersocioeconomicstatus tends to be protective against physical but notsexualviolence. 9

TableNo.5indicatesmorenumberofcasesi.e.,33cases(64.7%)aremoderatelyliteratepersonsfollowedby illiterate persons i.e., 18 cases (35.2%). No caseswererecordedinmystudyintheLiteratepersons.Theincidenceofthesecasesinilliterateandmoderatelyliteratepersons ismainlydue to lackof awarenessof


the legislative measures, and the gender inequalitythat is prevalent in the Indian society.11 Women whoare educatedare less likely than thosewhoarenot toreturn to an abusive partner. Itwas hypothesized thathighereducationcancontributetothepresenceofsocialnetworks(Schutte,Malouff,&Doyle,1988).10

TableNo.6indicates,thecommoncauseofviolenceisAlcohol consumption followedbyViolence i.e., 14cases (27.4%). The next common causes of violenceareHarassment by husband and relatives includes 13cases(25.4%),dowryrelatedissuesincludes10cases(19.6%),extramaritalaffairsincludes6cases(11.7%)andothers include8cases(15.6%).AcombinationofAlcoholconsumptionfollowedbyViolence,Harassmentbyhusbandandrelatives,dowryrelatedissuesandextramaritalaffairsconstitute43cases(84.1%)ofthecases,which indicate thatmaledominance is theunderlyingfactor.Devi 13(2005) states that domestic violenceagainstwomenisaglobalphenomenon.Thedomesticviolencemaytaketheformofwifebattering,demandformoredowry,divorce,brideburning,psychologicaltorture,pettyquarrels,neglectedattentionandsoon.Theincreasedeconomicinsecurity,unemployment,poverty alcoholism, lack of mutually satisfyingrelationshipandlackofasenseofbelongingarethereasonsfortheincreaseddomesticviolence.12

DeviandPrema16(2005)explainthatthemaincauseofdomestic violence against women are unequalpowerrelationsgenderdiscrimination,patriarchy,economic dependence of women, dowry, low moralvalues, negative portrayal of women’s images inmedia,noparticipationindecision-making,genderstereotypesandanegativemindset.Therearevariousmanifestations of violence, which includes beating,mentaltorture,forcedpregnancy,femaleinfanticide,rape,denialofbasic necessities and battering. Theworstformofviolenceisdowrymurder.14

CONCLUSION

TheIndiansocietyisbuildupwiththerelationshipbetween the human beings among the families andit is often associated with love, support and bondingamongmembers.Thoughthesecharacteristicsareoftenpresent,ithasbecomeevidentthroughrecentresearchesthatthehomeisalsofrequentlythesiteofviolenthumanrelationships.

By comparing the data of the present study of2012 with that of the previous studies, the incidenceofdomesticviolencecasesaregradually increasing innumberdaybyday.

• Femaleswerepredominantlyaffectedthanthemales.

• Thevulnerableagegroupwas11–40yearsascomparedtootheragegroup.

• Married women were most predominantlyaffectedthantheunmarriedwomen.

• Most of the female deaths occurred within 7yearsofmarriage.

• Prevalenceofdeathismorecommoninurbanareascomparedtoruralareas.

• Prevalenceofdomesticviolencecasesismostcommon in nuclear families than the jointfamilies.

• Lowsocio-economicpeoplearemoreaffectedthanothersocio-economicpeople.

• Our study showed a greater percentage ofdomestic violence cases in the moderatelyliterate group of people compared to theilliterategroup.

• The victim was mostly harassed by both thespouseandin-lawscomparedtoothers.

• Alcohol consumption played prime role indomestic violence deaths followed by dowryharassmentandextramaritalaffair.

Ethical Clearance: Thisstudyhasbeencarriedoutin the year 2012, after from the ethical committee ofGunturMedicalCollege/GeneralHospital.



REFERENCES

1. Krugetal.,“Worldreportonviolenceandhealth”,WorldHealthOrganization,2002.

2. Nageshkumar G Rao – Textbook of ForensicMedicineandToxicology,2ndedition,2010,338.

3. Merriam Webster, Domestic Violence. Retrieved14Nov.2011.

4. Nationalcrimerecordsbureau(NCRB)–statistics,2012.


5. District crime records bureau (DCRB) Guntur,AP.—statistics,2012.

6. International Centre for Research on Women.Domestic Violence in India. International Centrefor Research on Women and The Centre forDevelopment and PopulationActivities, 2000. 18Mar.2013.

7. Biggs, S., Manthorpe, J., Tinker, A., Doyle, M.andErens,B.“MistreatmentofOlderPeopleintheUnitedKingdom:FindingsfromtheFirstNationalPrevalence Study”. Journal of Elder Abuse andNeglect,2009,21,1-14

8. Martin,Sandra;AmyTsui,KuhuMaitra,andRuthMarinshaw(1999).“DomesticViolenceinNorthernIndia”.AmericanJournalofEpidemiology:150.

9. Koenig, Michael. “Individual and ContextualDeterminants of Domestic Violence in NorthIndia.”AmericanJournalofPublicHealth(2006).18Mar.2013.

10. Schutte, N.S., Malouff, J.M., Doyle, J.S. (1988).The relationship between characteristics of thevictim, persuasive techniques of the batterer, andreturning to a battering relationship. Journal ofSocialPsychology,128(5),605-610.

11. Gordon, J.S. (1996). Community services forabusedwomen:A reviewof perceivedusefulnessandefficacy.journalofFamilyViolence,11(4),315-329.

12. Levendosky, A.A., Bogat, G.A., Theran, S.A.,Trotter, J.S., von Eye,A.,&Davidson,W.S. II.(2004).Thesocialnetworksofwomenexperiencingdomesticviolence.AmericanjournalofCommunityPsychology,34(1-2),95-109.

13. Devi,KamalaandPremaPandey(2005)“CombatingViolence Against Women: Some Initiatives”,Women’sLink,Vol.12,No.3,July-September.

14. Roberts, Gwenneth. “The Impact of DomesticViolence onWomen’sMental Health.”Australianand New Zealand Journal of Public Health 22(1998).17Mar.2013.

15. Ackerson,Leland,andS.Subramanian.“DomesticViolenceandChronicMalnutritionamongWomenand Children in India.” American Journal ofEpidemiology167(2008).17Mar.2013.

16. Devi,KamalaandPremaPandey(2005)“CombatingViolence Against Women: Some Initiatives”,Women’sLink,Vol.12,No.3,July-September

A Study of Homicide in Nagpur with Respect to Method Adopted for Homicide

Nitin S Barmate1, D S Akarte1, Amit Themke2

1Assistant Professor, Forensic Medicine, Govt. Medical College, Nagpur, Maharashtra, India, 2Junior Resident , Forensic Medicine, Govt. Medical College, Nagpur, Maharashtra, India

ABSTRACT

Homicideisoneoftheheinouscrimesagainsthumanityandsociety,anditisasolderasourcivilizationorhistoryofhumanity.ThepresentstudywascarriedoutintheDepartmentofForensicMedicine,Govt.MedicalCollege&HospitalNagpur.Inpresentstudy,males(85.51%)wereexclusivelypredominatefemales(14.49%).mostcommonlyaffectedvictimswerefromagegroup21to30years(35.18%)followedby31to40years(24.14%).Amongallhomicidaldeaths55.86%ofvictimswereconsumedalcoholatthetimeofincidenceofhomicidewhile35.17%werenotconsumedalcohol.Hardandbluntweapon(46.89%)wastheweaponofchoicelikestone,woodenstick,ironpipe,ironrodetcinthemajorityofcasesfollowedbysharpedgedweapon(35.18%).WithHeadInjuryastheleadingcauseofdeath(45.52%).

Keywords: Homicide, male victim, hard and blunt weapons, head injury.

INTRODUCTION

Corresponding author:Dr. Nitin S. BarmateAssistantProfessor,ForensicMedicine,Govt.MedicalCollege,Nagpur,Maharashtra,India440003Mobileno–08805081979,[email protected]

Homicide is one of the heinous crimes againsthumanityandsociety,anditisasolderasourcivilizationorhistoryofhumanityand reportedasearlyas in thebiblewhenCanewasmurderedbythehandsofAbel.1

Pattern of homicide may be a useful indicatorof the social stresses in the community and provideinformationaboutlawandordersituationofsocietyaswell as valuable information to law and enforcementstrategies.

MATERIAL METHOD

ThepresentstudywascarriedoutoveraperiodoftwoyearstartingfromNovember2012toOctober2014intheDepartmentofForensicMedicine,Govt.MedicalCollege & Hospital Nagpur. Such a study was notcarriedoutinourregiontothebestofourknowledge.

Thehistoryandsociologicalaspectsofthedeceasedwere obtained from accompanying persons/relativesand police. Each homicidal case was examined andevaluatedatautopsy,bothexternallyandinternally.

Inclusion Criteria: All the cases of assault byhardandblunt,sharpedgedweapon,firearm,assaultbyviolentasphyxiaandbythermalinjurywereincludedinthestudy.

Exclusion Criteria:Allthecasesotherthanassaultorhomicideandcaseswherethecauseofdeathcouldnotbeascertaineddue to insufficient/improperhistorywereexcludedfromthestudy.

EthicalCommitteeapprovalNo369/12

RESULT

Table No. 1 : Gender Wise Distribution:

GENDER NO.OF CASES %

MALE 124 85.51

FEMALE 21 14.49

TOTAL 145 100

DOI Number: 10.5958/0973-9130.2018.00128.7


Table No. 2: Age Wise Distribution:

AGE MALE FEMALE

GROUP IN TOTAL %NO.OF

%NO.OF

%YEARS

CASES CASES

0-10 2 1.6 1 4.77 3 2.07

11-20 8 6.4 4 19.04 12 8.27

21-30 46 36.8 5 23.80 51 35.18

31-40 27 22.4 8 38.10 35 24.14

41-50 23 18.4 3 14.29 26 17.93

51-60 11 8.8 0 0 11 7.59

61-70 6 4.8 0 0 6 4.13

71-80 1 0.8 0 0 1 0.69

81-90 0 0 0 0 0 0

TOTAL 124 85.51 21 14.49 145 100

Asthemale(85.51%)predominatedthefemale(14.49%),themostlyaffectedagegroup(bothsexescombined)was21–30years,constituting35.18%ofallhomicidaldeaths,while24.14werefoundin31-40yearsgroup.

Table No. 3 : Distribution Of Cases According Consumption of Alcohol By Victim At The Time Of Incidence:

Male Female

CONSUMPTIONOFALCOHOL

TOTAL %

NO.OFCASES % NO.OF

CASES %

YES 81 65.32 00 00.00 81 55.86

NO 30 24.19 21 100 51 35.17

NOTKNOWN 13 10.48 00 00.00 13 08.97

TOTAL 124 85.51 21 14.49 145 100

55.86%ofthevictimsfoundtohaveconsumptionofalcoholatthetimeofincidenceofhomicideascomparedto35.17%whowerenothavingconsumptionofalcohol.In8.97%ofthecases,thestatusofalcoholconsumptionwasnotknown.


Table No. 4 : Distribution Of Cases According Type Of Weapon Used.

KIND OF WEAPON

MALE FEMALE

TOTAL %NO.OFCASES % NO.OF

CASES %

FIREARM 02 01.61 00 00.00 02 01.38

HARDANDBLUNT 61 49.19 07 33.33 68 46.89

SHARP 45 36.29 06 28.57 51 35.18

THERMAL 02 01.61 07 33.33 09 06.20

SHARP+HARD&BLUNT 11 08.87 01 04.76 12 08.26

OTHER 03 02.42 00 00.00 03 02.06

TOTAL 124 85.51 21 14.49 145 100

In46.89%(n-68)casesonlyhardandbluntweaponwasusedwhileitwasusedalongwithotherweaponintotal80cases.Sharpcuttingweaponalonewasusedin51(35.18%)casesandalongwithotherweaponitwasusedintotal63cases.Total2cases(1.38%)ofinjurybyfirearmweaponwerefound.

Table No. 5: Distribution Of Cases According Cause of Death of Victim:

Cause Of Death No. Of Cases Total %

Male % Female %

InjuryToVitalOrgans 14 11.29 01 04.76 15 10.34

HeadInjury 58 46.77 08 38.10 66 45.52

ShockAndHaemorrhageFollowingInjury 29 23.38 04 19.04 33 22.76

DeathDueToBurn 02 1.61 07 33.33 09 6.20

Strangulation 07 5.64 01 04.76 08 5.51

Drowning 01 0.80 00 00 01 0.69

CutThroat 03 2.41 00 00 03 2.07

LigatureStrangulationWithHeadInjury 01 0.80 00 00 01 0.69

InjuryToSpineAndSpinalCord 03 02.41 00 00.00 03 02.07

SepticaemiaDueToInjurySustained 06 04.83 00 00.00 06 04.14

Total 124 100 21 100 145 100

DISCUSSION

The pattern of homicides varies from country tocountry and influenced by many factors like social,moral, political and cultural and the availability ofweapons. The pattern of homicide has importantimplicationsfor thecreationofstrategies toreduceits

incidence.2

Inpresentstudy,males(85.51%)wereexclusivelypredominatefemales(14.49%).WhichwerecorrelatedbyMarriM.etal.(2006)4Ghangaleetal.(2003)3CooperA.etal.(2011)6,BradyB.etal.(2006)5.


InIndia,malesaregenerallyworkingoutdoorandareaggressiveinnaturemoreovertheyaremoreexposedtostress,frustration,physicalconfrontationandviolenceandaremostlikelytobeonreceivingendofaggression.Henceareatgreaterriskofbeingvictimized.7

Women often become victims of domestichomicideduetophysicaldisadvantageandincapabilityofresistancetoviolence.8

Inthepresentstudy,theagegroupwisedistributionof victim of homicide shows that among both gendermostcommonlyaffectedvictimswerefromagegroup21 to 30 years (35.18%) followed by 31 to 40 years(24.14%).SimilarfindingswereobservedbyMohantyS.et al. (2013),9 Edirisinghe et al.(2009)10 GhangaleS.etal (2003)3BhupinderS.etal (2010)11MarriM.etal(2006)4HugarB.etal(2011)6MittalS.etal(2007)12

Itisexplainbythefactthatmalesinthisagegroupareaggressiveinnature.Theymayindulgeincriminalactivities due to unemployment, financial instabilityexposing them toviolent trauma leading to homicidaloutput.Thisisthemostactivephaseofanindividual‘slife, including outdoor activities, increased aggressionandearly losingof temper,which leads to increase incrimeratebythisagegroup.

Amongallhomicidaldeaths55.86%ofvictimswereconsumedalcoholatthetimeofincidenceofhomicidewhile35.17%werenotconsumedalcohol.ThisfindingswereconsistentwithMohantyS.etal.(2013)9AvisSP.(1996)13HugarB.etal.(2011)7

Alcohol consumption affects one’s personalityand social temperament, decreases the threshold ofinhibitionandpotentiallyprovocativethevictimstobeaggressiveandquarrelsomeleadingtoviolence.

Inthepresentstudyhardandbluntweapon(46.89%)wastheweaponofchoicelikestone,woodenstick,ironpipe,ironrodetcinthemajorityofcasesfollowedbysharpedgedweapon(35.18%).Firearmwasusedonlyin1.38%casesasweaponofoffencebyaccused.Ourfindingswere consistentwith another Indian studybyMohantyM.K.et al.(2010)14 and study fromDelhi byAggarwalNK.etal.15OberoiS.S.etal.(2011)16.RathodSN.et al(2013)17 reported that the weapon used forassaultwashard&bluntin65.6%ofthecasesfollowedbysharpcuttingin16.6%ofcases.

The reason behind it may be, because when any

person comes in heat of passion at anyplace, hefindall thesetypesofhardandbluntobjectsfromconcernfield work, which are easily available without anypreparation.30also thecheaperandeasyavailabilityofbluntweapons.

Among all the cases of homicide, Head Injury(45.52%) was the most common cause of deathfollowed by shock and haemorrhage due to injuriessustained(22.76%).andinjuriestovitalorgans.Burnsandstrangulationformedaverysmallportionofvictiminjuries as cause of death. consistence with RathodSN.et.al.(2013)17GadgeS.etal(2011)18

Asthehardandbluntweaponwasmostcommonlyadoptedforhomicide,withtheheadbeingthetargetedforinflictingtheinjuriesinamajorityofcases.Asmostof external injuries either by hard and blunt or sharpedgedweaponmostlyonthehead,Itcanbeexplainedbythefactthatmajorityofthehomicidewereexecutedbyusingcommonlyavailablehouseholdweaponslikewoodenstick,axe,spade,ironpipe,stone,etc

CONCLUSION

Fromthepresentstudyweconcludedthat..

1. Malepredominatefemale.

2. Mostcommonlyaffectedagegroupwas21-30years,followedby31-40yearsagegroup.

3. 56.86%ofvictimswereconsumedalcoholatthetimeofincidenceofhomicide

4. Hard and blunt weapon (46.89%) was theweaponofchoice.

5. Inmajorityofcases(45.52%)Headinjurywasthecauseofdeath

Conflict of Interest : No

Source of Funding: No

REFERENCES

1. Patel DJ. Analysis of Homicidal Deaths in andAround Bastar Region of Chhattisgarh.J IndianAcadForensicMed.April-June2012;Vol.34(2):139-42.

2. Metwally ES, Madboly AG. Homicidal DeathsAnalysis inTwoEgyptianGovernorates (Gharbiaand Qalubia):A Five-Year RetrospectiveComparative Study (2006-2010).Egypt J Forensic


Sci.Appli.Toxicol.2014;14(1):143-59.

3. GhangaleAL,DhawaneSG,MukherjeeAA.Studyof Homicidal deaths at Indira Gandhi MedicalCollege,Nagpur.Journal of ForensicMedicine andToxicology.2003;20(1):47-51.

4. Marri MZ, Bashir MZ. Analysis of homicidaldeaths in Peshawar,Pakistan. J Ayub Med. Coll.Abbottabad.2006;18(4):30.

5. Brady B, Clarke L.The Changing Pattern ofHomicide in Ireland. Trinity student medicalJournal.2006;7.

6. Cooper A, Smith EL. PATTERNS &TRENDS:Homicide Trends in the UnitedStates, 1980-2008. U.S. Department of Justice,Office of Justice Programs, Bureau of JusticeStatistics.2011;NCJ236018.

7. HugarB,ChandraGYP,HarishS.Victimprofilein homicides.Indian Journal ofForensicMedicineToxicology.2011;5(1):16-19.

8. AliEM,ElbakryAA,AliMA.Astudyofelderlyunnatural deaths in medicolegal autopsies atDakahlia locality.Mansoura J.Forensic Med.Clinical.Toxicology.2007;XV(1):38-41.

9. Mohanty S,Mohanty SK, PatnaikKK.Homicidein southern India—A five-year retrospectivestudy.ForensicMedicine andAnatomyResearch.2013;1(2):18-24.

10. Edirisinghe PAS, Kitulwatte IDG. Extremeviolence–HomicideAnanalysisof265casesfromtheofficesofJMOColomboandRagama–AStudy

fromSriLanka.LegalMedicine11(2009):S363–65.

11. Bhupinder S, Kumara TK, Syed AM. Pattern ofhomicidal deaths autopsied at Penang Hospital,Malaysia, 2007-2009: a preliminary study.MalaysianJPathol.2010;32(2):81–86.

12. MittalS,GargS,MittalMS.HomicidesbySharpWeapons.JIAFM.2007;29(2):61-63.

13. Avis SP.Homicide in New Foundland- A 9-yearreview.JournalofforensicScience,1996;41:101-05.

14. Mohanty MK,Panigrahi MK. Socio-demographicstudyofhomicidalvictims.JournalofSouth IndiaMedico-legalAssociation.2010;2(1):3-7.

15. AggarwalNK, BansalAK.Trends of homicide incapital city of India. Medico-Legal Update.2004;4:41-45.

16. Oberoi SS, Singh SP, Aggarwal KK, BhullarDS,AggarwalA,WaliaDS,ThindAS.ProfileoffatalassaultcasesinPatiala.JPunjabAcadForensicMedToxicology.2011;11(2):87-89.

17. Rathod SN, Bharatwaj RS.A Five year Study ofHomicides in Aurangabad, Maharashtra. IndianJournalofForensicMedicine&Toxicology.2013;7(1):27-31.

18. Gadge S, Zine KU, Batra AK, Kuchewar SV,Meshram RD, Dhawane SG.Medico-Legal Studyof Homicide in and Around GMC Aurangabad.Medico-LegalUpdate.2011;11(2):56-58.

Retrospective Analysis of Unclaimed/Unknown Dead Bodies

Rajeshwar S Pate1, Mangesh R Ghadge2, Dinesh Samel3

1Assistant Professor, Dept of Forensic Medicine, 2Associate Professor, Dept of Forensic Medicine, 3Associate Professor, Dept of Community Medicine, Rajiv Gandhi Medical College, Thane Maharashtra

ABSTRACT

Background: Unclaimedbodyreferstoapersonwhodiesinahospital,prisonorpublicplace,andwhohasnotbeenclaimedbyanynearrelativesorpersonalfriendswithinsuchtimeperiodasmaybeprescribed.Suchunknownpeopleareexposedtoincreasedincidenceofdiseases,accidentsandmortality.Thanecitysituated inwestern regionof India, is surroundedby rural towns andvillages andhas seen tremendousgrowthinthepastfewyears;withincreaseinjobopportunity,theproblemofmigrantsandhomelessnessandthusunknowndeathhasalsoincreased.

Method: AretrospectivestudywasconductedindepartmentofForensicmedicine,ofatertiarycareinstituteduringtheperiodfromJanuary2011toDecember2015,whichincludes297unknowndeceasedpersonsbroughtforautopsy.

Results: During the periodof 5 years, 297(10.74%) cases out of a total 2870 autopsieswere unknownandunclaimedpersons.Thepresent studydemonstratedpreponderanceofmalevictimsandmajorbulkofthevictimsbelongedtoagegroup31-40years.Mostofthepeopleaffectedwerebeggarsordestitute,majorityofwhomdiedfromdiseaseslikechronicinfectivelungdiseases(n=92,55.42%),mostcommonlytuberculosis(n=59,19.87%).

Conclusion: Thefindingsofourstudyindicatethatlackofshelterisanimportantcauseofmorbidityandmortalityinthestudyareaandnaturalcausesaremajorcauseforunknowndeaths

Keywords: Unknown, unclaimed, natural, identification, cause of death.

Corresponding author:Dr Mangesh R Ghadge,MD,DFMAssociateProfessor,DepartmentofForensicMedicineRajivGandhiMedicalCollege,ThaneMaharashtra400605.EmailID:[email protected]:09594975245

INTRODUCTION

‘‘Unclaimed body’’ refers to a person who diesin ahospital, prisonorpublicplace, andwhohasnotbeenclaimedbyanynearrelativesorpersonalfriendswithin such time period as may be prescribed.1 The body is preserved in themortuary for 72 hours, fromthetimeitisreceivedinthemortuary.Ifnooneclaimsthebodyafter72hoursthepolicearelegallyauthorizedto dispose of the body. However, if the police thinkthat thebodymaybe identifiedby relatives, it should

bepreserveduntila relativecomes toclaimthebody.Thecostofdisposingofthebodyinunidentifiedcasesisbornbythepolicedepartment.Thisisapplicableinmedicolegalcaseswherethepersondieseitherinsideoroutsideofthehospital.2

Indianmetropolitanareasaredevelopingfastwithlotofconstructionactivitiesofferingjobstothousandsofunskilledworkers,leadingtouncontrolledmigrationnot only from India, but also from neighboringcountries,whomakeittheirabode3.Thisputstrainonthe local authorities to provide themwith shelter andsecurity to these unknown people.As a consequence,these people are faced with grave difficulties in selfmaintenancewhicharefurtherexacerbatedbyadverseweatherconditions.4,5

According to statistics compiled by the NationalCrime Record Bureau (NCRB) in 2012, Maharashtra

DOI Number: 10.5958/0973-9130.2018.00129.9


hasthelargestnumberofdeathsonrailwaytracksandhighwaysinthecountry,andalsoearnedthenotorietyof having the highest number of unidentified humanbodies in thecountrywhere5,906unidentifiedbodieswereleftunclaimedinthestate’smorgues.With5,319unidentifiedbodies recoveredduring the sameperiod,TamilNaduisthesecondmostcommonstateandUttarPradeshisthirdwith3996unidentifiedpeople.6

Postmortemexaminationsrevealsthediseaseandlesions thataffected theperson inhis lifetimeandnotnecessarily those that killed him.7 Therefore, not justthe physical injuries, and poisoning but also diseasesthe dead bodies should be noted. The final opinionregardingthecauseofdeathisgivenafterreceivingtheChemicalanalysisreportandhistopathologyreports.Asfaraspossible,anattemptismadeatgivingadefiniteopinion;otherwise“nodefiniteopinion”ismentionedinthereportasregardsthecauseofdeath.

AIM AND OBJECTIVES

1. To study the socio demographic factorsassociatedwithdeadbodies.

2. To analyze the various efforts made on thepart of the investigating officers and the

autopsysurgeonstoestablishtheidentityoftheunidentifiedbodies.

3. To study the annual pattern of the cause andmannerofdeath.

MATERIAL AND METHOD

The study was conducted in the Department ofForensic Medicine and Toxicology, Rajiv GandhiMedicalCollege,Thane,MH,India.Thisisaretrospectivestudy of the five-year period from 1 January 2011 to31December2015.All themedico legal autopsiesofunknown/unclaimed bodies during this period wereincludedinthestudy.Informationregardingunclaimedbodies with regard to age, sex, cause of death andmannerofdeathwassourcedfromtheautopsyreportsandtheinquestpapersoftheinvestigatingofficers.Theageofthedeceasedwasascertainedwiththeavailabledatafromtheinvestigatingofficerandwascorroboratedwithanatomicalfeaturesonthedeadbody.

RESULTS

DuringtheperiodofJan2011toDec2015,atotal2870autopsycaseswerereceivedatmortuaryofdeptofForensicMedicine,ofamedicalcollegeinThane,ofwhich297(10.74%)caseswereunknownandunclaimeddeadpersons.

Table 1. Gender-wise trend of Unknown /unclaimed bodies.

Year Male % Female % Total %

2011 52 17.51 9 3.03 61 20.542012 40 13.47 12 4.04 52 17.512013 40 13.47 13 4.38 53 17.852014 60 20.20 9 3.03 69 23.232015 48 16.16 14 4.71 62 20.88Total 240 80.81 57 19.19 297 100.00

Outof297casesmajorityofunknowndeceasedweremales240(80.81%)comparedwithfemales57(19.19%).Thusoverallgenderratioformaleandfemalewas4.21:1(Table1)

Table 2. Age-wise trend of Unknown /unclaimed bodies

Age/Year 2011 2012 2013 2014 2015 Total %

0-10 3 4 0 3 0 10 3.37

11-20 2 3 2 2 3 12 4.04

21-30 8 12 9 8 9 46 15.49

31-40 21 14 21 25 25 106 35.69


41-50 13 10 10 17 11 61 20.54

51-60 9 5 2 9 4 29 9.76

61-70 3 4 5 3 5 20 6.73

>71 2 0 4 2 5 13 4.38

Total 61 52 53 69 62 297 100.00

Majorityofcasesbelongstoagegroupof31to40yearscomprises106,(35.69%)casesfollowedby41to50yearsand21to30yearsagegroups.Thusalmost72%deceasedbelongsto21to50yearsagegroup.Thenumberofunknowndeathwereleastinagegroupslessthan10andabove70years.(Table2)

Table 3. Trend of Unknown death by month.

Month/Year 2011 2012 2013 2014 2015 Total %

Jan 3 5 3 4 4 19 6.40

Feb 6 2 4 7 5 24 8.08

March 3 3 4 3 4 17 5.72

April 3 7 8 3 10 31 10.44

May 4 6 10 5 11 36 12.12

June 5 5 4 5 4 23 7.74

July 13 10 8 15 9 55 18.52

Aug 3 4 4 3 4 18 6.06

Sept 6 4 3 7 4 24 8.08

Oct 3 3 3 4 3 16 5.39

Nov 12 3 0 6 0 21 7.07

Dec 0 0 2 7 3 12 4.04

Total 61 52 53 69 62 297 100.00

MaximumnumberofunknowndeathwereencounteredinthemonthofJuly,18.52%;followedbyMay,12.12%;andApril,10.44%whiletheleastnumberofcaseswasseeninthemonthsofOctoberandDecember.(Table3)

Table 4. Age and sex wise pattern of natural cause of death.

Cause of death FEMALE MALE Grand Total %

AcuteandChronicLungdiseases 5 26 31 10.44

PulmonaryTuberculosis 17 44 61 20.54

AcuteandChronicLiverdiseases 4 27 31 10.44

HeartDiseases 4 14 18 6.06

DiseasesofCentralNervousSystem 2 9 11 3.70

Kidneydisease 2 2 4 1.35

Gastro-Intestinaldiseasesdisease 1 2 3 1.01

Septicemia 0 4 4 1.35

Stillbirth 1 2 3 1.01

Table 2. Age-wise trend of Unknown /unclaimed bodies


Mostof thepeopleaffectedwerebeggarsordestitutewhodied fromchronic infective lungdiseases (n=92,55.42%),mostcommonlytuberculosis(n=59,19.87%).Thisisfollowedbydrowning(42,14.4%).Otherdiseasessuchasalcoholicliverdisease,coronaryarteryheartdiseases,cerebro-vascularaccidentandsepticaemia(Table4)

Table 5. Gender distribution as per manner of death.

Manner of Death MALE % FEMALE % TOTAL %

Natural 129 54.0 37 63.8 166 55.9

Accidental 41 17.2 7 12.1 48 16.2

Suicidal 35 14.6 8 13.8 43 14.5

Homicidal 9 3.8 2 3.4 11 3.7

Undermined 25 10.5 4 6.9 29 9.8

Total 239 100.0 58 100.0 297 100.0

Naturaldeathwere theforemostcauseofdeath(n=166,55.89%)followedbyaccidentalandsuicidaldeathswhich comprises 16.16% and 14.48%, respectively. However, 9.76% deaths were undeterminedmostly due toadvancedstateofdecomposition(Table5).Proportionofnaturaldeathsismoreinfemalesthaninmales.Likewise,amongmales,proportionofaccidentaldeaths(17.2%)ismorethaninfemales(12.1%).

Table 6. Frequency of presence of distinguishing identification marks such as a tattoo and mark of identification

Year Clothes Handed over Tattoos Marks of identification Bone piece for DNA

2011 61 24 4 19

2012 52 15 5 12

2013 53 16 9 16

2014 69 22 3 23

2015 62 19 6 18

Total 297 96 27 88

The investigating authority had routine protocolto take photographs, collect their clothes and giveadvertisementsindailyineveryunknowncase.Policehad collected fingerprints in75.75 % cases. Autopsysurgeonnotedthetattoos,deformitiesandothermarksof identification in41.41%ofcases. In88casesbonepiecesentforDNAanalysis.(Table6).Duetotheeffortsof theinvestigatingauthorityandforensicexperts,outofthe297unknowndeceased,27personsgotidentifiedaftertheinvestigations.

DISCUSSION

Post-mortem examination of unknown bodiescomprisesasmallportionbutsignificantandimportantgroup in which forensic medicine specialists have to

opineregardingcause,mannerandnatureofdeath,timesincedeathandprovidedetaileddatagathered fromathoroughexaminationdissectionofbody.Identificationofdeceasedisimportanttohelpthelegalsystemincaseof homicides and suicides to establish their identitiesandknowtheirmotives.Itisalsobeneficialtothelegalheir of the deceased to claim their insurance and theproperty.

Mostoftheliteratureemphasisedontheindividualbodyidentificationoridentificationofvictimsofmassdisasters8,9,10. In the present study, unidentified bodiescomprised 10.74% of the total autopsy load of thedepartment during period under consideration similartootherstudiesaccountedforabout4-10%ofthetotalautopsyload.11,12Malepredominanceaccountedfor81%


ascomparedto97%ofcasesinastudyinChandigarh13 and 87% in Kolkata14. In India rural populationmigrates to urban regions in search of earning theirlivelihood.Manyatimes,thefamilyisevennotawareof the place of employment of the person because ofcontinuous change of contract work. In case of hisdeathatsuchplaces,hisbodyisbroughttothemorgueas “unidentifiedor unknown”,where legal formalitiesdictate a post-mortem examination. The age group21-50, themostmobileagegroup for socio-economicreasons,wasresponsiblefor72%ofcases.KumarA13 andChattopadhyay14 reportedsimilarfindings.

Duringstudyperiodoffive-yearitwasexaminedthatmoredeathswerereportedduringthemonthsofJulyi.e.rainyseason,similarwiththestudydonebyKumaretal3.Theworseningofunhygieniclivingconditionduringthe rainy season, together with increased exposure toinfectiousagents,makehomelesspeoplemorepronetodevelopingdiseases.

Deathduetonaturalcauseswerethemostcommonfollowed by accident and suicide and least due tohomicide (Table 6) These results are similar to otherstudiesinsouthDelhi15andBuyukuetal16andincontrastwith study done byKumar S2where accidental deathwerepredominant.Suchpeopleareatincreasedriskofinfections because of the high prevalence of tobaccochewing, alcoholism, smoking and chronic diseases.In addition, poor socioeconomic conditions, lack ofaccesstohealthcare,unhygieniclivingconditionsandmalnutritionaresignificantcontributorstodiseaseanddeath3.

Accidental deathswere the secondmost commoncauseofdeath.Thehighriskofdeathfromaccidentisapredictableresultofpoverty,substanceabuseandlivingonthestreets,footpathandalongrailwaytracksandarethusverypronetoaccidents.3

During the process of identification autopsysurgeonhasmostvitalrolecollectionandpreservationofappropriatematerial.Frequentlybodiesofunknownpeople were brought by investigating authority in anadvanced state of decomposition. With advancingputrefaction, peculiar physical characteristics of thedeceased may get distorted or disappear, hamperingidentification and at times causing difficulty inascertaining the cause of death, manner of death.Otherfactorscontributingtothisproblemareskeleton

remains, disfigurement of the body. In India, exceptfor mortuaries attached to government hospitals andmedical colleges, most mortuaries lack the basicinfrastructureforpreservingdeadbodies.Investigatingofficerstakephotographsofthedeceasedforpurposesofidentificationandalsodisplayedinleadingnewspapersbut they are usually in black and white and of poorquality3.Thesephotographsarealsodisplayedonofficialgovernmentsiteswithitsproperdescriptionbutduetolackofinterneteducation,notapproachableforpeople.Decompositionanddisfigurementseen inphotographscanalsohamperidentification.

CONCLUSION

Thefindingsofourstudyindicatethatlackofshelterisanimportantcauseofmorbidityandmortalityinthestudy area. Males are the most affected population;the common age group affected is 21–50 years andthe predominant manner of death is natural death.However, more studies are recommended to find theactualprevalenceofhomelessnessanditshealth-relatedeffectsonmorbidityandmortality,whichwillhelp inprovidinghealthcarefacilitiestotheneedy.

RECOMMENDATIONS

1. The Standard Operative Procedures (SOP) foridentification of unknown deceased which is inplace,bythepartofpolicepersonnelandshouldbefollowedstrictly.

2. Bodies that are unknown/ unclaimed should bepresentedforautopsyforthwithwithoutanydelay,so that decomposition and other artefacts do notset inandobscure thefindingsof thepostmortemexamination.

3. Active investigation and modern investigativetechniques are to beused,workloadof thepoliceofficersneedstoberedistributed,andaccountabilityofthepolicehastobefixedtogetthebodyidentified.

4. Topreventunknowndeath,Governmentauthoritiesshouldtakeaproactiveapproachincitiestomakesheltersforthehomelessandvagabonds,particularlyduring the months of extreme temperatures andrainyseason.

5. In cases, especially in accidents, where there isdisfigurementoffaceandmutilationofbodypartsor decomposition, it becomes difficult to identify


thedeceased.Inthesecases,ifsometypeofidentitycardiskeptinthepocketofthevictim,(inlieuofmetallicIDlocketsasinarmedforces)containingsomeUIDNumber(Adhar)willbeuseful.Thisismorepracticalincaseofhomelesspersons.

6. Illegalimmigrantsfromnearbycountriesarepresentinlargenumberinthisregion.Thesepeoplecannotbe identified easily. Hence illegal immigrationshouldbecurbed.

Ethical Clearance: Thestudywascarriedoutafterobtaining ethical clearance from the InstitutionalEthicsCommittee.



REFERENCES

1. SauravC,AayushiG,BeheraC,KarthikK,MilloT,GuptaSK.Medico-legalautopsyof1355unclaimeddead bodies brought to a tertiary care hospital inDelhi, India (2006–2012). Medico-Legal Journal.2014;82(3):112-5.

2. Millo T, Agnihotri A, Gupta S, Dogra TD.Procedure for preservation and disposal of deadbodies in hospital. Journal of the academy ofhospitaladministration.2007;13(2).

3. KumarA, Lalwani S,BeheraC,RautjiR,DograTD. Deaths of homeless unclaimed persons inSouth Delhi (2001-2005): a retrospective review.Medicine,ScienceandtheLaw.2009;49(1):46-50.

4. Altun G, Yilmaz A, Azmak D. Deaths amonghomeless people in Istanbul. Forensic scienceinternational.1999;99(2):143-7.

5. KumarS,VermaAK,AliW,SinghUS.Homelessandunclaimedpersons’deaths innorthIndia(Jan2008–Nov2012):Aretrospectivestudy.Medicine,ScienceandtheLaw.2015;55(1):11-5.

6. Hindustan times.Unclaimed bodies fill up state’smorgues. ,ht tp:/ /www.hindustantimes.com/mumbai/unclaimed-bodies-fill-up-state-s-morgues/story-amIJuMUjKd9O85RyH1Q59H.html. (2013,

accessedon20July2017)

7. ReddyKSN.The essentials ofForensicMedicineand Toxicology 28th ed; K Sugna Devi 2009;p.112-3.

8. KumarA,ChavaliKH,HarishD,SinghA.Patternof causeof death inunknowndeadbodies: a oneyear prospective study. J Punjab Acad ForensicMedToxicol.2012;12:92-5.

9. Job C. Determination of cause of death indecomposedbodies–aregionalstudy.JIndianAcadForensicMed.2009;31(1):11-7.

10. LudesB,TracquiA,PfitzingerH,KintzP,LevyF,DisteldorfM,HuttJM,KaessB,HaagR,MemheldB, Kaempf C.Medico-legal investigations of theAirbusA320crashuponMountSte-Odile,France.JournalofForensicScience.1994;39(5):1147-52.

11. Hanzlick R, Smith GP. Identification of theunidentifieddeceased: turnaround times,methods,and demographics in Fulton County, Georgia.The American journal of forensic medicine andpathology.2006;27(1):79-84.

12. EvertL.UnidentifiedbodiesinforensicpathologypracticeinSouthAfricaDemographicandmedico-legal perspective [MSc Thesis] University ofPretoria 2011.Available from http://upetd.up.ac.za/thesis/submitted/etd-05232012- 113345/unrestricted/dissertation.pdf

13. KumarA,HarishD,ChavaliKH,SinghA.Patternsofcauseofdeathinunknowndeadbodiesa threeyearstudyinatertiarycarehospital.JIndianAcadForensicMed2012;34(4):304-8.

14. Chattopadhyay S, Shee B, Sukul B. Unidentifiedbodiesinautopsy–Adisasterindisguise.EgyptianJournalofForensicSciences.2013;3(4):112-5.

15. Yadav A, Kumar A, Swain R, Gupta SK. Five-yearstudyofunidentified/unclaimedandunknowndeathsbroughtformedicolegalautopsyatPremierHospital in New Delhi, India. Medicine, ScienceandtheLaw.2017;57(1):33-8.

16. BuyukY,Uzunİ,EkeM,CetiG.Homelessdeathsin Istanbul, Turkey. Journal of forensic and legalmedicine.2008;15(5):318-21.

A Study of Head Injuries in Fatal Road Traffic Accidents

J Venkatesaprasanna1, Dhritiman Nath2

1Assistant Professor, Dept. of Forensic Medicine, Government Villupuram Medical College & Hospital, Tamilnadu, 2Associate Professor, Dept. of Forensic Medicine and Toxicology, Mahatma Gandhi Medical

College & Research Institute, Pondicherry

ABSTRACT

Introduction:Tostudytheepidemiologicaldistributionoffatalheadinjuriesduetoroadtrafficaccidents(RTA)broughtforautopsytoatertiary–levelhospitalinPondicherryinbetweenSeptember2011toAugust2013.

Materials and Method: This study was conducted in Indira Gandhi Government General Hospital,Pondicherryfrom1stSeptember,2011to31stMarch,2013.OnlyfatalheadinjurycasesduetoRTAwastakenupforthestudy.Bodiesinadvancedstagesofdecomposition,headinjuriesduetosuicideorhomicide,caseswherethehistoryofoccurrenceisambiguous,intracranialhaemorrhages,infarctionorlesionsduetonaturaldiseaseswereexcludedfromthestudy.

Results: Atotalof165caseswere takenupfor thestudy.Malevictimsconstituted131cases(79.39%)andfemales34(20.6%).Agreaternumberofvictimswerepedestrians(94casesor56.96%ofallcases).Majorityofincidences(79casesor47.87%)tookplaceonthehighways.Youngpeopleintheagegroupof21to30yearsweretheworstaffected(34casesor20.61%).Majorityofcases(63cases38.18%)occurredinthewinterseasonbetweenOctobertoJanuary.Bruiseonscalpwasthemostcommoninjurypresented(75cases45.45%).Amongtheinternalinjuriesofthehead,subarachnoidhaemorrhageaccountedfor107casesor64.8%ofallcases.Mostofthevictimsdiedonthespot(61casesor36.96%).Agreaternumberofincidences(29casesor17.57%)occurredinbetween5PM–8PM.Morethanhalfofthevictims(115or69.69%)werefromruralareas.Mostofthevictims(63casesor38.18%)wereunskilledworkerslikedailywageworkers.

Conclusion: RTA, presently, have assumed an epidemic proportion, especially in developing countries,with increasedmorbidity andmortality and associated colossal economic losses. Effective steps to cutdownonitsincidencesistheneedofthehour.Withaviewtoachievethisobjective,WHOrecommendsamultidisciplinaryapproachtoroadsafety,enforcementofstrictlegislations,useofhelmets,childrestraintsandseatbelts,safespeedlimitsandestablishmentoftraumacarefacilitiesinprimary,secondaryandtertiaryhealthcarecentres.

Keywords: Head injury, road accident, fatal.

Corresponding author:Dhritiman NathAssociateProfessor,Dept.ofForensicMedicineandToxicology,MahatmaGandhiMedicalCollege&ResearchInstitute,PondicherryEmail:[email protected]:8903733042/9047333041

INTRODUCTION

Roadtrafficaccidents(RTA)arealeadingcauseofmortalityandmorbidityglobally. AsperWorldHealthOrganization,1.3millionpeopledieeveryyearduetoRTA.Ninetypercentofthesedeathsoccurinlow–to– middle income countries. Economic burden on theworldcountriesisestimatedtobeabout1to3%ofthe

DOI Number: 10.5958/0973-9130.2018.00130.5


respectiveGNP,reachinguptoatotalstaggeringamountof $500 billion.1 By 2020, RTA, if left unchecked, ispredictedtobethethirdleadingcontributortotheglobalburdenofdiseaseandinjury.2

Presently,RTAisthesixthleadingcauseofdeathin Indiawith increased hospitalization,morbidity andeconomic losses affecting the young and the middle-agedpopulation.3 HeretheauthorsattempttostudythepatternofcraniocerebralinjuriesinfatalRTAbroughtforautopsytoatertiary–levelhospitalinPondicherryinbetweenSeptember2011toAugust2013.


ThisstudyfocussedonfatalheadinjurycasesduetoRTAbroughtforautopsytoIndiraGandhiGovernmentGeneralHospital,Pondicherrybetween1stSeptember,2011to31stMarch,2013.EthicalclearancewasobtainedfromtheInstitutionalHumanEthicalCommittee(IHEC).Historyanddatawascollectedfromtherelativesofthedeceasedand the accompanyingpolice in the formofa proforma asking for details of age, sex, occupation,placeofresidence,placeofoccurrence,survivalperiodand nature of injury. Bodies in advanced stages ofdecomposition,headinjuriesduetosuicideorhomicide,cases where the history of occurrence is ambiguous,cases with intracranial haemorrhages, infarction orlesionsduetonaturaldiseaseswereexcludedfromthestudy. Statistical analyses were done with SPSS 16.0software.

RESULTS

A total of 165 cases of fatal head injury due toRTAbroughtforautopsytoIndiraGandhiGovernmentGeneralHospital,Pondicherrybetween1stSeptember,2011to31stMarch,2013wereconsideredforthisstudy.Ofthesecases,131(79.39%)weremaleand34(20.6%)female.

Pedestriansconstitutedthemostnumberofvictims(94 cases or 56.96% of all cases) followed by two– wheeler occupants (59 cases or 35.75%) and four-wheeleroccupants(8casesor4.85%).

On the circumstances leading to accidents,pedestrianshitbytwo–wheelersaccountedfor48cases(29.09%)and thosehitbyfour–wheelersconstituted45cases(27.27%).Self–slipandaccidentalfallduringridingoftwo–wheelersaccountedfor3cases(01.82%).

79cases(47.87%)offatalheadinjuryoccurredonhighway followedby39 cases (23.63%) in towns, 29cases(17.57%)invillagesand18cases(10.9%)incrossroads.

Mostofthesedeaths(34casesor20.61%)occurredintheagegroupof21–30yearswhiletheagegroupof0–10yearsconstitutedtheleastnumberofcases(02casesor1.21%)(Table 1).

Table 1: Distribution of cases according to age of victim

Age in years Total cases % of cases

0–10 02 1.21

11–20 10 6.06

21–30 34 20.61

31–40 24 14.55

41–50 22 13.33

51–60 33 20

>60 26 15.76

Unknown 14 8.48

104ofthesecases(63.03%)werehospitalizedpriortodeathwhile61cases(36.96%)diedonthespot.

63cases (38.18%)occurred inwinter (October toJanuary) while 52 cases (31.51%) occurred in rainyseason (June to September) and 50 cases (30.3%) insummer(FebruarytoMay).

Amonginjuriestothescalp,bruisewaspresentin75 cases (45.45%) followedby laceration in 29 cases(17.57%)andabrasionin6cases(3.6%).

Among the internal injuries to the cranium,mostcommonwassubarachnoidhaemorrhage(107casesor64.8%)followedbysubduralhaemorrhagein102casesor61.8%(Table 2).

Table 2: Distribution of cases according to internal injuries to the cranium

Internal Injuries Number of cases % of casesSkullfracture 52 31.5Extraduralhaemorrhage 23 13.9Subduralhaemorrhage 102 61.8Subarachnoidhaemorrhage 107 64.8Intracerebralhaemorrhage 05 3.0Injurytobrain 28 17.0Basalfracture 08 4.8


Most of the cases died on the spot (61 cases or36.96%).45cases(27.27%)hadasurvivalperiodof1–7daysfollowedby24cases(14.54%)withasurvivalperiodof0–6hours(Table 3).

Table 3: Survival period of victims

Survival period Total cases % of cases

Spotdeath 61 36.96

0–6hours 24 14.54

7–12hours 10 6.06

13–24hours 08 4.84

1–7days 45 27.27

8–14days 11 6.66

>14days 06 3.63

Mostoftheincidents(29casesor17.57%)occurredinbetween5PM–8PMfollowedby27cases(16.36%)occurringbetween8PM–11PM,26cases(15.75%)between8AM–11AM,24cases (14.54%)between2PM–5PM,20cases(15.15%)between12AM–5AM,16cases(9.69%)between5AM–8AM,12cases(7.27%)between11AM–2PMand6cases(3.63%)between11PM–12AM.

115 victims (69.69%) were from rural areas, 37victims (22.42%) from urban localities and, place ofresidencewasunknownfor13(7.87%).

Most of the victims (63 cases or 38.18%) wereunskilledworkerslikedailywageworkers.35victims(21.21%)wereunemployedatthetimeoftheincident.Shopownersorsmallbusinessentrepreneursconstitutedtheleastnumberofvictims(4casesor2.42%)(Table 4).

Table 4: Occupation of victims

Occupation Number of cases % of cases

Professionals 6 3.63

Semi–professionals 15 9.09

Shopowners 4 2.42

Skilledworkers 18 10.9

Semi–skilledworkers 7 4.24

Unskilledworkers 63 38.18

Unemployed 35 21.21

Unknown 17 10.3

DISCUSSION

Thisprospectivestudywasconductedoveraperiodof one and half years and a total of 165 cases werestudied.

ThepreponderanceofmalevictimsinfatalaccidentswasalsoobservedinanotherstudyconductedbyShettyBSKinManipal,Indiawheretheyfoundthat86%ofthevictimsweremale.4

Inourstudy,pedestrianinvolvementwas56.96%,two –wheeler occupants 35.75% and four – wheeleroccupants were 4.85% of all cases. These results areincontrasttoanotherstudydonebyJhaNilambaretalwhoconcludedthatpedestriansconstituted22%ofallvictims,two–wheelers10.9%andfourwheelers48%.5

Thehighpercentageofpedestrianinvolvementmaybeduetothefactthatinthisplaceofstudy,mostpeopletendtotravelonfoot.Duetolessnumberoffootpathsandnarrowroads,peopletendtowalkbythesideoftheroadandconsequentlymoreincidencesofRTAoccur.

Inour study,most of the cases (20.61%)wereoftheagegroupof21–30years.ThisresultcorrespondstoastudyconductedbyJunaidMuhammadetalwhowitnessedsimilarresults.5

Inthisstudy,mostofthecases(38.18%)occurredin thewinter season (October to January).This resultcontradictsthefindingsofastudydonebyRaviKiranetalwhoconcludedthatmostoftheaccidents(48.5%)occurduringtherainyseason.Weinferthatthewintermonthsistheperiodofrainsinthispartofthecountry.Consequently,thereisaspurtofincidenceofsuchcasesduringthisperiod.

Mostofthecasesinourstudypresentedwithscalpbruises(45.45%).ThisfindingcorrespondstothestudydonebyJunaidMetalwhoobserved thatbruisewaspresentin11.7%ofcases.5

Mostcommoninjurytothebrainandmeningeswassubarachnoidhaemorrhage(64.8%).SharmaBRetalin their studyconcluded that themostcommon injurywas subdural haemorrhage (62.40%) followed by subarachnoidhaemorrhage(23.5%).7

Inthisstudy,mostofthevictims(36.96%)diedonthespot.SharmaBRetal,intheirstudyobservedthatmostofthevictims(72%)hadsurvivedfor6hoursto24hoursaftertheaccident.7Thisdifferencemaybedueto


thelevelofposttraumatichealthcarefacilitiesprovidedbythehospitals.Betterthehealthcarefacilities,betteristhesurvivalperiodofthevictims.

Incidenceofmostof thecases (17.57%)occurredbetween5to8PMinourstudy.SinghHarnametal,intheirstudyalsonotedthatmostofthefatalaccidentshadoccurredbetween6to8PM.8

CONCLUSION

There can be no doubt that RTA presentlyhave assumed an epidemic proportion, especially indeveloping countries, with increased morbidity andmortality andassociatedcolossalburden to thepublicexchequer.Effectivestepstocontainitsincidenceistheneedofthehour.Tothisend,WHOhadmadeseveralrecommendationsintheir“WorldReportonroadtrafficinjury prevention”.9 Some of the recommendationsincluded a multidisciplinary approach to road safety,enforcement of strict legislations, use of helmets,child restraints and seat belts, safe speed limits andestablishment of trauma care facilities in primary,secondaryandtertiaryhealthcarecentres.

Conflict of Interests:Nil

Source of Funding:Self

Ethical Clearance: Study was conducted afterapproval of Institutional Ethics Committee, MahatmaGandhi Medical College & Research Institute,Pondicherry,India.

REFERENCES

1. WorldHealthOrganization(WHO).GlobalPlanfortheDecadeofActionforRoadSafety2011–2020[internet]. 2011[cited on 2017 Feb 28].Availablefrom: http://www.who.int/roadsafety/decade_of_

action/plan/plan_english.pdf

2. Sreedharan J, Muttappillymyalil J, Divakaran B, HaranJC.DeterminantsofsafetyhelmetuseamongmotorcyclistsinKerala,India.JInjViolenceRes. 2010Jan;2(1):49–54.

3. TripathiM,TewariMK.,MukherjeeKK,MathuriyaSN. Profile of patients with head injuries amongvehicularaccidents:Anexperiencefromatertiarycare centre of India.Neurology India. 2014Nov-Dec;62(6):610–617.

4. ShettyBSK,KanchanT,MenezesRG,BakkanavarSM,NayakVC,YoganarasimhaK.Victimprofileand pattern of thoraco – abdominal injuriessustained in fatal road traffic accidents. J IndianAcadForensicMed.2012;34(1):16–19.

5. JunaidM,RashidM,AfsheenA,TahirA,BukhariSS, KalsoomA. Changing spectrum of traumaticheadinjuries:Demographicsandoutcomeanalysisinatertiarycarereferralcentre.JPakMedAssoc.July2016;66(7):864–868.

6. RaviKiran E,Mudalidhar SaralayaK,VijayaK.Prospectivestudyonroadtrafficaccidents.JPunjabAcadForensicMedToxicol.2004;4(3):12–16.

7. SharmaBR,HarishD, SinghGauri,VijKrishan.Patterns of Fatal Head Injury in Road TrafficAccidents. Bahrain Medical Bulletin. 2003 Mar;Vol.25(1):22–25.

8. Singh Harnam, Aggarwal AD. Fatal road trafficaccident in motorcyclists not wearing helmets. JPunjabAcadForensicMedToxicol2011;11(1):9–11.

9. World report on road traffic injury prevention,Conclusion and Recommendations.World HealthOrganization;Geneva:2004.

Drugs in Orthodontics: A Review

Subin Samson Daniel1, Chaithra Laxmi B1, Harshitha V2, Mithun K3, Abhinay Sorake2

1Post graduate Student, 2Reader, 3Assistant Professor, Department of Orthodontics, A.J Institute of Dental Sciences, Mangalore

ABSTRACT

Orthodontictoothmovementisacomplexprocedureinwhichchangesoccurfromthetissueleveltothemolecularlevel.Orthodonticforcewhenappliedgivesrisetoacascadeofinflammatorystepsinwhichchemicalmediatorsareinvolved.Variousmetabolitesinhumanbodylikeprostaglandins,cytokines,interleukinsareinvolved in themolecular level of toothmovement.There is a significant increase in the adult patientsseekingorthodontictreatment.Soinfluenceofsystemicdiseasesandtheirmedicationsseemtopositivelyornegativelyeffecttherateoforthodontictoothmovement.Alsotheanalgesicsadvisedalsoshowedvaryingresponses to tooth movement. Therefore a detailed knowledge of the molecular mechanisms of toothmovementandeffectsofdrugsonitshouldbeunderstoodbytheOrthodontist.Thisreviewprovidesabriefoutlineonthemechanismoftoothmovementandeffectofcommonlyuseddrugs

Keywords : Hormones, Bisphosphontes, Prostaglandins, NSAIDs, orthodontic tooth movement

INTRODUCTION

Orthodontictoothmovementisacomplexprocess.A combination of certain mechanical, chemical andcellular events take place in teeth surrounding tissuesdue to orthodontic forces allowing structural changesthat cause orthodontic tooth movement. The briefoutlineof thesequencesofevents thatoccurs in toothmovement is as follows: on the pressure side there isresorptionwhichcreates thespacenecessaryfor toothmovementandsimultaneousdepositiononthe tensionsidetohealthepathofadvancingsocket.

As the complete maneuver of orthodonticmovement by cellular activities remains a mystery,recent researchers have duly discovered some factorslikecyclicadenosinemonophosphate(cAMP),calcium,collagenase, and prostaglandins (PGs) which play animportantroleintoothmovement.

The constituents of nutrients of food as well asdrugsalike,consumedbothregularlyandoccasionallyby patients reach the periodontal tissues involvedwithorthodonticmovementandtarget localcells.The

cumulative effects could be inhibitory, additive, orsynergistic. This article discusses in general variousdrugs and their desired and undesired effects onorthodontictoothmovement.

DrugsAffectingToothMovement

WHO (1966) defined drug as any substance orproductthatisusedtomodifyorexplorephysiologicalsystems or pathological states for the benefit of therecipient. During orthodontic treatment, drugs areprescribed to manage pain from force application tobiological tissues, manage temporomandibular joint(TMJ)problemsand tacklesome infection throughoutthe course of treatment. Table 1 depicts the generaleffectsofdrugsinfluencingtherateoftoothmovement

Apart from these drugs, patients who consumevitamins, minerals, hormonal supplements, and othercompounds for thepreventionor treatment of varioussystemicdiseasescanalsobefoundineveryorthodonticpractice.Hence,itisnecessarytoreviewthemechanismofactionandeffectsofcommonlyuseddrugsontissueremodelingandorthodontictoothmovement.

DOI Number: 10.5958/0973-9130.2018.00131.7


Table: 1 Drugs altering rate of tooth movement

Drugs increasing rate of tooth movement Drugs decreasing rate of tooth movement

ProstaglandinsVitaminDPTHThyroidhormoneCorticosteroidsRelaxin

NSAID’sFluoridesBis-phosphonatesEstrogenCalcitonin

Noeffectontoothmovement-Acetaminophen

Analgesics

An analgesic or painkiller is any member of thegroupof drugs used to achieveanalgesia, relief frompain. Analgesic drugs act in various ways on theperipheralandcentralnervoussystems.Theyaredistinctfromanesthetics,whichtemporarilyaffect,andinsomeinstances completely eliminate, sensation. AnalgesicisadrugthatselectivelyrelievespainbyactingontheCNS or peripheral pain mechanisms (COX-1,2,& 3)withoutsignificantlyalteringconsciousness.

NSAIDs

NSAIDsinhibitsPGsynthesisandanti-inflammatoryaction may be exerted by reduced generation ofsuperoxidebyneutrophils,andTNFrelease,freeradicalscavenging,andinhibitionofmetalloproteaseactivityincartilage.Theysuppresstheproductionofallprostanoids(thromboxanes, prostacyclins, and prostaglandins)because of their inhibition of COX-1 and COX-2,whichareessentialenzymesinthesyntheticpathwaysof the prostanoids.Most commonly usedmedicationsinorthodonticsare forcontrolofpainfollowingforceapplication to tooth. Inhibition of the inflammatoryreaction producedbyPGs slows the toothmovement.Also NSAIDs like aspirin(salicylates) decreases thetooth movement by effecting the differentiation ofosteoclastthusdecreasingtherateofboneresorption.1,2

Acetaminophen (Paracetamol)

Analgesia and hypothermia due to paracetamolaremediatedby inhibitionof a thirdCOX isoenzyme(designatedCOX-3)which is seen inbrainandspinalcord, thus doesn’t have any effect on prostaglandinsynthesis. Ithas shownnoeffectonorthodontic toothmovement.Acetaminophen iseffective forcontrollingpain and discomfort associated with the orthodontictreatment.3,4

Vitamin D

Aweeklyintraligamentousinjectionofa1,25,2(OH)D3solutionproducedasignificantlyincreasedamountoforthodontictoothmovementaftera21-dayexperimentalperiod. There was an increased rate of recruitmentand activationofmononuclearosteoclasts resulting ingreaterboneresorptionofthealveolusonthepressuresideoftheperiodontalligamentthanincontrolteeth5

1,25,2(OH)D3 acts directly on the nucleus of thecirculatingmonocytesandosteoprogenitorcells,whichhavespecificreceptorsforit.Cellsintheearlystagesoftheresorptioncyclebeforetheyfuseandbecomeclassicmultinucleated osteoclasts. Vitamin D and its activemetabolite, 1,25,2(OH)D3, together with parathyroidhormone(PTH)andcalcitonin,regulatetheamountofcalcium and phosphorus levels. Vitamin D receptorshavebeendemonstratednotonlyinosteoblastsbutalsoinosteoclastprecursorsandinactiveosteoclasts.

Fluorides

Fluorideisoneofthetraceelementshavinganeffectontissuemetabolism.Fluorideincreasesbonemassandmineraldensity,andbecauseoftheseskeletalactions,ithasbeenusedinthetreatmentofmetabolicbonedisease,osteoporosis.Evenaveryactivecaries treatmentwithsodiumfluorideduringorthodontictreatmentmaydelayorthodontic toothmovement and increase the time oforthodontictreatment.6Sodiumfluoridehasbeenshowntoinhibittheosteoclasticactivityandreducethenumberof activeosteoclasts.On the cellular level it hasbeenshown to stimulate bone formation and, recently, itwas discovered that the osteoclastic activity in rats isinhibited.7

Bisphosphonates

Pharmacologicalsiteofactionisintheosteoclast,which removes the outer ruffled border, inactivates


function,anddecreasesthelifespanofthecell.Alsoitinhibits formation of actin ring in the cytoskeleton ofosteoclasts.Thereissomeevidencethatthisdruggroupmightalso inhibitosteoclastprecursorsandosteoblastcommunicationwithosteoclasts.8.9

Bisphosphonates (BPNs) have strong chemicalaffinitytothesolid-phasesurfaceofcalciumphosphate;this causes inhibition of hydroxyapatite aggregation,dissolution, and crystal formation. Bisphosphonatescause a rise in intracellular calcium levels inosteoclastic-like cell line, reduction of osteoclasticactivity, prevention of osteoclastic developmentfrom hematopoietic precursors, and production of anosteoclastinhibitoryfactor.

Studies have shown that BPNs can inhibitorthodontictoothmovementanddelaytheorthodontictreatment..Histologic examination showed that in theexperimentalanimalsfewerosteoclastsappearedonthealveolarbonesurface,andbothboneresorptionandrootresorptionwereinhibited.TopicalapplicationofBPNscouldbehelpfulinanchoringandretainingteethunderorthodontictreatment.

Parathyroid hormone

By local admistration PTH analogues bothosteoblastandosteoclastactivitiesarestimulated.Thereceptorsofparathyroidhormoneareonlyexpressedonthecellmembraneofosteoblasts.After thebindingofparathyroid hormonemolecules to their receptors, theosteoblastsarestimulatedtoproducemoreIGF-Iviaacyclic adenosine monophosphate (cAMP)-dependentmechanism,which functionsasanautocrine/paracrinefactorandactivatesitsadaptormoleculeinsulin-receptorsubstrate-1 in osteoblast precursors in bone marrow,andcausesosteoblastproliferation,differentiation,andfunction.10,11On the other hand, osteoblasts stimulatedby parathyroid hormonemolecules also expressmoreRANKL on the cell membrane, which binds to thereceptor activator of nuclear factor kappa B (RANK)on the cell membrane of osteoclastic precursorsthrough cell-to-cell contact and stimulates osteoclastproliferation,differentiation,andactivation.

RANKL/osteoprotegerin and IGF-1 are essentialmolecules for the effect of parathyroid hormoneon bone metabolism. RANKL/osteoprotegerinmediates osteoclastogenesis, whereas IGF-1mediates osteoblastogenesis. the expression levels

of both RANKL and IGF-1 increased, indicatingthat intermittent parathyroid hormones stimulatedboth osteoclastogenesis and osteoblastogenesis. Thebiphasic effect of intermittent parathyroid hormoneadministration resulted in an increased bone turnoverrate;thisacceleratedtoothmovement

Unlike other osteoporosis-treating medicines (eg,bisphosphonates), parathyroid hormone has a morebalanced effect on bonemetabolism, stimulating bothosteoblasticandosteoclasticactivities

Estrogens

Estrogen is known to inhibit osteoclasts bothdirectly and indirectly.It inhibits the production ofvariouscytokineswhichareinvolvedinboneresorptionby stimulating osteoclast formation and osteoclastbone resorption. Studies have shown that estrogensdecrease the velocity of tooth movement12,13. Oralcontraceptives, taken for long periods of time, caninfluence the rateof toothmovement.Androgensalsoinhibit bone resorption, modulate the growth of themuscularsystem,andmayaffectthelengthandresultsof the orthodontic treatment. Orthodontic therapyshould be planned according to the menstrual cyclesince toothmovement, under the applicationof force,is faster during low estrogen levels. Hypothesis werestated that orthodontic force after eachovulationmaypromotetoothmovement,therebyshorteningthecourseoforthodontictreatment.14

Thyroid hormones

Thyroidhormonesarerecommendedforthetreatmentof hypothyroidism and used after thyroidectomy insubstitutive therapy. Thyroxin administration lead toincreased bone remodeling, increased bone resorptiveactivityandreducedbonedensity.Effectsonbonetissuemayberelatedtotheaugmentationofinterleukin-1(IL-1B) production induced by thyroid hormones at lowconcentrations,cytokinestimulatedosteoclastformationandosteoclasticboneresorption.

The thyroid hormone increases the speed oforthodontic tooth movement in patients undergoingsuchmedication.15Lowdosageandshort-termthyroxineadministration are reported to lower the frequency of“force-induced”rootresorption.Decreaseinresorptionmay be correlated to a change in bone remodelingprocess and a reinforcement of the protection of the


cementum and dentin to “force-induced” osteoclasticresorption.

Relaxin

Relaxinhasbeenknownasapregnancyhormone.It is released just before child birth to loosen thepublicsymphysis,sothattherelaxedsuturewillallowwidening of the birth canal for parturition. In 2005,Liu and colleagues showed that the administration ofrelaxinmightacceleratetheearlystagesoforthodontictooth movements in rats. 16 Stewart and colleaguesusedgingivalinjectionsofRelaxintorelieverotationalmemory in the connective tissues ofmaxillary lateralincisors that had been orthodontically rotated. In2000, Nicozis and colleagues suggested that Relaxinmight be used as an adjuvant to orthodontic therapy,during or after tooth movement, for promotion ofstability,forrapidremodelingofgingivaltissueduringextraction space closure, for orthopedic expansion innon–growingpatients,byreducingthetensionofthestretchedsofttissueenvelope,particularlytheexpandedpalatalmucosa,afterorthognathicsurgery.17

Calcitonin

Calcitonininhibitsboneresorptionbydirectactionon osteoclasts, decreasing their ruffled surface whichformscontactwithresorptivepit.Italsostimulatestheactivity of osteoblasts. Because of its physiologicalrole, it is considered to inhibit the tooth movement;consequently, delay in orthodontic treatment can beexpected.

Corticosteroids

Glucocorticoids enhance the responsiveness ofosteoblaststoPTHbyincreasingtheexpressionofPTHreceptors in thesecells.As thebone-resorbingactionsofPTHrequirethepresenceofosteoblasts,anincreasein PTH receptors in osteoblasts by glucocorticoids18 .Evidenceindicatesthatthemaineffectofcorticosteroidonbonetissueisdirectinhibitionofosteoblasticfunctionand thus decreases total bone formation. Decrease inbone formation is due to elevated PTH levels causedbyinhibitionof intestinalcalciumabsorptionwhichis

inducedbycorticosteroids.Corticosteroidsincreasetherateoftoothmovement,andsincenewboneformationcan be difficult in a treated patient, they decrease thestabilityoftoothmovementandstabilityoforthodontictreatment in general.19 When they are used for longerperiodsoftime,themainsideeffectisosteoporosis.Ithasbeendemonstratedinanimalmodelswiththistypeofosteoporosis that therateofactivetoothmovementis greater, but tooth movement is less stable sincelittleboneispresentandthereisnoindicationofboneformation.Amoreextensiveretentionmayberequired.

Phenytoin

It inducesgingivalhyperplasiadue toovergrowthofgingivalcollagenfibers,whichinvolvetheinterdentalpapilla, making application of orthodontic mechanicsand maintaining oral hygiene difficult. Valproic acidhas a potential to induce gingival bleeding evenwithminortrauma,makingorthodonticmaneuversdifficult.Gabapentinproducesxerostomia,makingoralhygienemaintenancedifficultduringorthodontictreatment.

Significant histologic changes in the periodontaltissues such as increased density of fibroblasts,decreasednumberofosteoclastsincontactwithalveolarbonewallofthepressuresideanddeeperlayerofnon-mineralizedosteoidonthetensionsidewereobservedinthephenytoingroup.20

Prostaglandins

Experiments have shown that PGs may bemediators of mechanical stress during orthodontictoothmovement.Theystimulatebone resorption, rootresorption, decrease collagen synthesis, and increasecAMP. They stimulate bone resorption by increasingthenumberofosteoclastsandactivatingalreadyexistingosteoclasts. A lower concentration of PGE2 (0.1 μg)appears tobe effective in enhancing toothmovement.Higherconcentrationleadstorootresorption.Systemicadministrationisreportedtohavebettereffectthanlocaladministration. Researchers have injected PGs locallyat the site of orthodontic toothmovement to enhancethe bone remodeling process and the pace of toothmovement.


CONCLUSION

Drugs affectingOrthodontic toothmovementRedindicatingInhibitionandGreenindicatingPromotion

The flowchart represents a brief outline of themolecular level of orthodontic tooth movement andeffect of drugs on it. All the aspects of the factorsaffecting tooth movement are yet to be unraveled.Some differences that take place are caused by boneremodelingratechangesthatmaybeinducedbyvarioussystemic and local drugs and varied systemic factors.Not all, but many of the drugs studied have usefultherapeuticeffectsandaccompanyingsideeffects thatmayinfluencethecellsinstrumentalinorthodontictoothmovement caused by different levels of orthodonticforces.Since,inthisera,theconsumptionofdrugshasgoneupinallagegroupsduetoincreasedillnessesintoday’s living conditions. Therefore, itmust bemadea routine investigation for the orthodontists to checkdruglevels,consumptionandthoroughhistoryofeverypatient, before and during the course of orthodontictreatment, so that the best treatment protocol couldbe considered individually. Since, Acetaminophen inparticulardoesnothavesignificantinfluenceontherateoftoothmovement,itcanbeprescribedforpaincontrolduringorthodontictoothmovement.

Conflict of Interest:Nil

Source of Funding:Self

Ethical Clearance:Nil

REFERENCES

1. VaydaP,Loveless J,MillerR,TherouxK.Theeffect or shortterm analgesic usage on the rateof orthodontic tooth movement.J Dent Res2000;79:614

2. Chumbley AB, Tuncay OC. The effect ofindomethacin (an aspirin-like drug) on the rateof orthodontic tooth movement. Am J Orthod.1986;89:312–4.

3. Kehoe, M.J.; Cohen, S.M.; Zarrinnia, K.; andCowan, A.: The effect of acetaminophen,ibuprofen,andmisoprostolonprosta-glandinE2synthesisand thedegreeand rateoforthodontictooth movement, Angle Orthod. 66:339-349,1996.24.

4. Roche,J.J.;Cisneros,G.J.;andAcs,G.:Theeffectofacetaminophenontoothmovementinrabbits,AngleOrthod.67:231-236,199

5. Monte K. Collins, DDS, MSD, and Peter M.Sinclair,DDS,MSD,Thelocaluse-ofvitaminDtoincreasetherateoforthodontictoothmovement.AmJOrthodDentofacOrthop1988;94:278-84.

6. Hellsing E, Hammarström L. The effects of


pregnancy and fluoride on orthodontic toothmovements in rats. Eur JOrthod. 1991;13:223–30.

7. Sven Lindskog,Myrae. Flores,Eva Lilja,LarsHammarströmEffectofahighdoseoffluorideonresorbing osteoclasts in vivoAuthors, ,EuropeanJournalofOralSciences

8. Rogers MJ, Gordon S, Benford HL, CoxonFP, Luckman SP, Monkkonen J, et al. Cellularand molecular mechanisms of action ofbisphosphonates.Cancer2000;88.2961-78.

9. Igarashi K, Mitani H, Adachi H, ShinodaH. Anchorage and retentive effects of abisphosphonate (AHBuBP) on toothmovementsin rats. Am J Orthod Dentofacial Orthop. 1994Sep;106(3):279-89.

10. Jilka RL. Molecular and cellular mechanismsof theanaboliceffectof intermittentPTH.Bone2007;40:1434-46.

11. Bikle DD, Sakata T, Leary C, Elalieh H,Ginzinger D, Rosen CJ, Beamer W,MajumdarS, Halloran BP. Insulin-like growth factor I isrequired for theanabolic actions of parathyroidhormone on mouse bone. J Bone Miner Res.2002Sep;17(9):1570-8.

12. TyrovolaJB,SpyropoulosMN.Effectsofdrugsand systemic factors on orthodontic treatment.QuintessenceInt.2001;32:365–71.

13. Harris SA, Tau KR, Turner RT, Spelsberg TC(1996). Estrogens and progestins. In: Principlesofbonebiology.BilezikianJP,RaiszLG,Rodan

GA,editors.SanDiego:AcademicPress,pp.507-520

14. XuX,ZhaoQ,YangS,FuG,ChenY.Anewapproachto accelerate orthodontic tooth movement inwomen: Orthodontic force application afterovulation.MedHypotheses. 2010Oct;75(4):405-7.

15. ShiraziM,DehpourAR, Jafari F. The effect ofthyroidhormoneonorthodontictoothmovementinrats.JClinPediatrDent.1999;23:259–64.

16. MadanMS,LiuZJ,GuGM,KingGJ.Effectsofhuman relaxin on orthodontic tooth movementand periodontal ligaments in rats. Am JOrthod.2007;131:8.e1–8.10

17. A randomized, placebo-controlled clinical trialon the effects of recombinant human relaxin ontooth movement and short-term stability SusanP. McGorray,a Calogero Dolce, Am J Orthod.2012;141:196-203

18. Clinicalreview83:Mechanismsofglucocorticoidaction in bone: implications to glucocorticoid-inducedosteoporosis.ECanalis -The Journalofclinicalendocrinology&metabolism,1996

19. Kalia S,MelsenB,VernaC.Tissue reaction toorthodontictoothmovementinacuteandchroniccorticosteroid treatment. Orthod Craniofac Res.2004;7:26–34

20. Effectofphenytoinonperiodontaltissuesexposedto orthodontic force--an experimental study inrat J Karsten & E Hellsing,British Journal ofOrthodonticsVolume24,1997-Issue3.

Study of Electrocution Deaths in Mumbai: A three Year Retrospective Analysis

N B Kumar1, H G Kukde2, M R Sabale3, A K Jaiswani3, R R Savardekar4

1Assistant Professor, 2Associate Professor, 3Junior Resident, 4Professor, Dept of FMT, LTMMC & GH, Sion, Mumbai

ABSTRACT

Background-AveragefatalitiesduetoelectrocutioninIndiahaveremainedmoreorlessthesameovertheyears.Thesedeathsareofconcernmainlybecausetheyareoccurringduetocontactwithlowvoltagecurrentwhichisemployedathome.

Material & Method-ThestudywasconductedretrospectivelybetweenJanuary2014toDecember2016at a tertiary health care centre inMumbai and 87 deaths out of total 7432 autopsieswere attributed toElectrocutioninthisperiod.

Observations-Fatalitieswereseenmostlyinmales(92%)withthemajority(63%)fallingintheworkingagegroupof21-50years.Allthecaseswereaccidentalandmajorityofvictimsgotelectrocutedathome(57.47%)withcommonestcausativeagentbeinghomeappliances(36.78%)&openwires(24.13%).Skilledorunskilledlabourerswerecommonlyinvolvedinelectrocution(50.56%)andthefatalitiesweremostlyseeninuneducatedandinthosewhostudiedbelowmatriculation(81.6%).Electricalmarkswereseenin70%caseswiththemarkmostlypresentontheupperlimbs.In16.09%victimssustainedflashburnsandnoinjurywasseenin13.79%cases.

Conclusion-Majorityofdeathsduetoelectrocutionispreventablebysimplyeducatingpeopleregardinghandlingofelectricappliancesandthehazardsassociatedwithitsilluse.Forautopsysurgeons,postmortemfindingsalongwithcircumstantialevidenceareimportantnotonlytoarriveatadiagnosisbutalsotostudythefactorsresponsibleinsuchfatalities.

Keywords- fatal, electrocution, current, accidental, entry wound, exit wound.

Corresponding author: Dr H G KukdeAssociateProfessor,DeptofFMT,LTMMC&GH,Sion,Mumbai.

INTRODUCTION

As per the National crime records bureau data,Electrocution accounted for 2.6%, 2.1% & 2.4%fatalities amongst major causes of deaths in the year2013, 2014 & 2015 respectively.1 Further, in India,42% of total fires occur due to electrical sources and8%deathsthatoccurinfactoriesareduetoelectricity.2 Suchhighelectrocution fatality indevelopingcountrylikeIndiaisexpectedwiththeincreasedavailabilityofelectricityovertheyearscompoundedwithinadequate

safety measures and lack of awareness among thegeneralpublic.DeathsduetoElectrocutionarealmostalways accidental and in India they occur commonlyduetoaccidentalcontactwithlow-voltagecurrent(AC,220–240V)usedinhousesandsmall-scaleindustries.3

The severity of tissue damage including deathis directly related to a number of physical factors,which include current, voltage, resistance and time.For biological damage to occur, the body must beincorporated into an electrical circuit, so that thereis a passage of electrons through the tissues. Amereaccumulationofelectronsintheformofastaticchargecandonoharm.4 TheonlymajorevidenceofdeathsduetoelectrocutionisanElectricmark,whichisoften,eithernot found or confused with other superficial surface

DOI Number: 10.5958/0973-9130.2018.00132.9


injuries.Hence,many times, thedeath is attributed toelectrocutiononlyafterrulingoutotherpossibilities.

Withthisstudy,anattemptismadetoanalysethevariousfactorsinvolvedinelectrocutiondeathsaswellastostudythepatternofinjuriessustained.

MATERIAL & METHOD

A retrospectively analysis was done involvingall electrocution deaths coming for autopsy at thedepartment of forensic medicine, Lokmanya TilakMunicipal Medical College & General Hospital,Mumbai,betweentheyearJanuary2014toDecember2016. In the study period, a total of 87 electrocutiondeaths were identified. Autopsy reports and policerecords were used as the source of information. Theinformation gathered was entered in a standardizedproforma and analysed further to obtain results. Allthecaseswereevaluatedfordemographicdata,timeofincident,placeofoccurrence,causativeagent,autopsyfindingsandmannerofdeath.

OBSERVATIONS & DISCUSSION

Atotalof7432autopsieswereperformedbetweenJanuary 2014 to December 2016 and 87 deaths wereattributedtoelectrocution,i.e1.17%cases.

Table 1- Distribution of cases according to age and sex

Age group (years) Male Female Total

0-10 2 0 2

11-20 9 1 10

21-30 22 1 23

31-40 19 3 22

41-50 14 2 16

51-60 8 0 8

>60 6 0 6

Total 80 07 87

Considering the sex of the victims, malesoutnumbered femaleswith ratio of 11:1 andmajorityofmales(63%)belongedtotheworkingagegroupof21-50 years. Our observation is consistent with otherIndian studies.5-10 The youngest & oldest victim was6yrs&72yrsoldrespectively.Higherfatalitiesinmales

are due to their risk taking behaviour aswell as theiremploymentinindustriesandasanelectrician.

Table 2- Place of incident

Place of incident No of cases Percentage

Home 50 57.47

Workplace 19 21.83

Road 04 4.60

Railway 14 16.09

Total 87 100

Comparing the place of incident, 57.47% deathsoccurredathomewhereasonly21.83%incidentoccurredatworkplace.14deathswereduetocontactwithhightension railway lines. Higher incidences at home orindoorsweresimilarlynotedbyGuptaetal.5(73.54%)inGujarat,byDokovW11(78.06%)inVarna,Bulgaria& by Blumenthal R13 (78.41%) in Gauteng region ofSouthAfrica. In contrast to our observation, Ragui Setal6.inManipurandKumarSetal12.inNorthernIndiarevealed majority deaths (68% & 59% respectively)occurring outdoors.Higher incidences at home in ourstudycouldbeattributedtoroundtheclockavailabilityofelectricityinallhouseholdsinourcityandtheuseofmultipleelectricalappliancesrequiringhighvoltagelikerefrigerator,geysers,airconditioners,waterpumpsetc.Incontrast,theavailabilityofelectricityinhouseholdsis far less inManipurasstatedbyRaguiSetal6.andhenceonly32%deathswereobservedathomebythem.

Table 3- Time of incident

Time of incident No of cases Percentage

06.00–12.00hours 25 28.73

12.00–18.00hours 39 44.82

18.00–00.00hours 17 19.54

00.00–06.00hours 06 6.89

Total 87 100

About 74% cases in our study occurred duringday time between 6am to 6pm followed by 19.54%& 6.89% cases between 6pm to 12am and 12am to


6am respectively. A higher incidence during daytimeis obvious in our study due tomore usage of electricappliancesathomeandworkplaceanduseoflocaltrainsforcommutinginourcity.Similarly71%electrocutionaccidentswereobservedduringdaytimeinPuducherrybyReddyAetal.7

Table 4- Occupation of victims

Occupation No of cases Percentage

Housewives 07 8.04

Students 10 11.49

Electricians 11 12.64

Skilledlaboursotherthanelectrician

25 28.73

Labourers 19 21.83

Officeworkers 10 11.49

Oldage 05 5.74

Total 87 100

Themajorityofvictimsinourstudywereskilledandunskilledlabourers(28.73%&21.83%).Only12.64%victimswere employedas electricians.All the femalevictims(7)werehousewives.Thoughtheelectriciansareathighrisk,theytakeenoughprecautionswhileworking.Lackofawareness&safetymeasuresalongwithstressofworkamongstlabourerscouldbethepossiblefactorsforsuchhigherfatality.Ahigherincidenceinworkersother thanelectricianswasalsoobservedbyReddyAet al.7& ShrigiwarM et al.10 In contrast, Gadge S etal.8 in study around GMC Aurangabad, Maharashtra,reportedmore fatalitiesamongstelectricians (30.61%)ascomparedtolabourers(12.24%).

Averyhighpercentageof fatal electrocutionwasnoted amongst uneducated (32.18%) and in thosewhostudiedonlyupto10thstandard(49.42%).SimilarobservationwasmadebyGadgeSetal.8where87.75%deathsduetoelectrocutionwereamongstpeoplehavingeducationlessthanmatriculation.

Table 5- Causative agent of electrocution

Causative agent No of cases Percentage

Homeappliance 32 36.78

Openwires 21 24.13

Hightensionrailwaylines 14 16.09

Heavymachinery 15 17.24

Waterpumps 05 5.74

Total 87 100

Thecausativeagents responsible forelectrocutionin our study showed Home appliances to be themain culprit (36.78% cases) followed by open wires(24.13%), Heavy machinery (17.24%), High tensionrailway lines (16.09%) and water pumps in 5.74%cases.UseofmultipleelectricalappliancesathomeisacommonthinginbigcitieslikeMumbai,whichifnothandled with due precautions can become hazardous.AllHightensionrailwaylinefatalitiesinourstudywereseenamongstdailycommutersonly.InMumbai,localtrainsarethemostcommonlyusedtransportsystemfordailycommuting.Often,peoplesiton topof the trainduetoexcessiverushorasapartoffun,whichincreasestheriskofcomingincontactwithhightensionlinesbymany folds. Amongst the 21 fatalities due to contactwithopenwires,9belongedtotheagegroupbetween0-20years.

Allthedeathsinourstudywereaccidentalinnature,homicideorsuicidewasnotallegedinanyofthecase.Studies related to electrocution by various Indian &internationalauthors5-13toosuggeststhemostcommonmannerofdeathtobeaccidental.SuicidalorhomicidaldeathswerealsonotreportedbyRaguiSetal6&ReddyAetal.7intheirstudyaroundManipurandPuducherryrespectively.

Table 6- Type of injury sustained

Type of injury No of cases Percentage

Entrywoundonly 52 59.77

Bothentry&exitwounds 09 10.34

Burns 14 16.09

Noinjury 12 13.79

Total 87 100


OnlyEntrymarkwasseenin52(59.77%)casesandbothentryandexitmarkswerepresent in9 (10.34%)cases. In 9 cases, where entry & exit wounds wereseen, 7 victims had come in contact with openwiresand rest 2got electrocutedbyheavymachineries.All14burncases(16.09%)wereduetocontactwithhightensionrailwaylines.Noelectricmarkswereseenin12(13.79%)cases.Thecausativeagentin09caseswithoutelectricmarkswasHomeapplianceandWaterpumpinremaining3cases.

Electricalinjuryintheformofentry&exitwoundsor burns was seen in 86% cases in our study and isin concurrence with various national & internationalstudies.5-14 Few authors observed only exit wounds,7-8 which is in contrast with our observations. A higherpercentage of both entry & exit marks in the rangeof 17% to 28% were observed in other studies.5,7,12,14 Presenceofbothentry&exitmarkswereobservedin72%casesinstudydonebyRaguiSetal6inManipur,whichisprobablyduetotheinvolvementofhightensionwires in 60% fatalities. Other injuries in the form ofabrasion&contusionwereseeninfewcasesbutnofatalmechanicaltraumawasnotedinthepresentstudy.

Table 7- Distribution of entry and exit wounds on the body surface.

Site of wound

Entry wound Exit wound Total

Upperlimbs 54 04 58

Lowerlimbs 06 05 11

Chest 01 00 01

Total 61 09 70

Aswithallotherstudies5-14,theelectricmarksinthepresentstudywascommonlyseenonupperextremities(66.66%),followedbylowerextremities(12.64%)andon chest in 1 case. Entrymarkwas present on upperlimbs in 54 cases (62.06%), lower limbs in 06 cases(6.89%) and on the chest in 1 case. Exitmarkswereseenonupperlimbsin4cases(4.59%)andonthelowerlimbsin5cases(5.74%).Inall9cases(10.34%)wherebothentryandexitwoundswerepresent;theentrymarkwasalwaysontheupperlimbs.

SUMMARY & CONCLUSION

In our study period of three years, only 1.17%

deaths were attributed to electrocution. All the caseswereaccidentalandmajorityofvictimsgotelectrocutedat homewith commonest causative agent beinghomeappliances&openwires.Skilledorunskilledlabourerswerecommonlyinvolvedinelectrocution.Thefatalitieswere mostly seen in uneducated and in those whostudiedbelowmatriculation.Electricalmarkswereseenin70%caseswiththemarkmostlypresentontheupperlimbs. In12caseswherenoelectricmarkwas found,thedeathwasattributedtoelectrocutionafterrulingoutothercausesandbasedonthecircumstantialevidence.

Deaths in electrocution are mostly instantaneousand the chances of revival areminimal. The issue ofmaximumnumberof fatalitiesoccurring indoors isofconcernanddecreasingsuchincidentsisaresponsibilitytogether of legislators, government authorities andcommunities.Forforensicexperts,electrocutiondeathsmaybecome tedious in theabsenceof injuryorwhenthe injury mimics other superficial trauma. Thoroughmedical autopsy along with circumstantial evidencemustbesoughtforbeforearrivingattheconclusion.

Conflict of Interest- Nil


Ethical Clearance- Notrequiredas it isa reviewarticle.

REFERENCES

1. National Crime Records Bureau. Ministry ofHome Affairs. Accidental deaths and Suicides inIndia 2015. Available at:http://ncrb.nic.in/CD-ADSI-2015/ADSI2015.pdf (last accessed May,2017).

2. Sreejith PG. Global development in electricalsafety.Electricalsafetyweek,ICF,Perambur,June2003.

3. Vij K. Textbook of Forensic Medicine andToxicology: Principles and Practice. 4th edition.Noida,UP:Elsevier;2009.pp.237–8.

4. SaukkoP,KnightB.Knight’s forensicpathology.3rded.London:Arnold;2004.p.326-38.

5. GuptaBD,MehtaRA,TrangadiaMM.Profile ofdeaths due toelectrocution:A retrospective study.JIAFM2012;34(1):13–15.

6. RaguiS,MeeraT,SinghKP,DeviPM,DeviAS.AstudyofelectrocutiondeathsinManipur.JMed


Soc2013;27:124-6.

7. ReddyA,BalaramanR,SengottuvelP.Accidentalelectrocution fatalities in Puducherry: A 3- yearretrospective study. Int J Med Sci Public Health2015;4:48-52.

8. SachinGadge,KUZine,AKBatra,SVKuchewar,RDMeshram,SGDhawane.Medico-legalstudyofcases of death due to electrocution in and aroundGmc Aurangabad. Medico-Legal Update. July -December,2011;11(2):53-55.

9. RautjiR,RudraA,BehraC,dograTD.ElectrocutioninsouthDelhi:aretrospectivestudy.MedSciLaw2003;(43):350-2.

10. ShrigiriwarM,BardaleR,DixitPG.Electrocution:Asixyearstudyofelectricalfatalities.JournalofIndianAcademyofforensicmedicine.2007;29(2):50-53.

11. DokovW.Electrocution-relatedmortality:Areviewof 351 deaths by low-voltage electrical current.UlusTravmaAcilCerrahiDerg2010;16:139-43.

12. Kumar S, Verma AK, Singh US. Electrocution-related mortality in northern India – A 5-yearretrospective study. Egyptian Journal of ForensicSciences2014;4:1–6.

13. Blumenthal R. A retrospective descriptivestudy of electrocution deaths in Gauteng, SouthAfrica:2001–2004. Burns (2009), doi:10.1016/j.burns.2009.01.009.

14. Kuhtic I, Bakovic M, Mayer D, Strinovic D,Petrovecki V. Electrical mark in electrocutiondeaths: A 20-years study. Open Forensic SciJ.2012;5:23-7.

A Retrospective Study of Pattern of Organs Involved in Natural Deaths at Autopsy—Role of Histopathology

as Ancillary Tool

RaviRaj K G1, Shobhana S S1

1Assistant Professor, Department of Forensic Medicine & Toxicology, Vydehi Institute of Medicine Sciences & Research Centre Bangalore

ABSTRACT

Thedeathsduetonaturalcauseinvolvingorgansystemlikecardiovascular,respiratoryorcentralnervoussystemeitherasasinglesystemorwithcombinationofseveralsystemshaveincreasedinyoungeragegroupindividualswiththeincreaseinriskfactorssuchassmoking,consumptionofalcohol,stress,foodhabitsandsedentarylifestyle.Thedeterminationofthecommonorgansinvolvedwillprovidevaluabledatainthediagnosisandtreatmentoftheconditionatanearlystageandalsotofocusmoreonthevulnerablegroup.ThecurrentstudyisaretrospectiveanalysisofgrossandhistopathologyfeaturesoforganscontributingfornaturaldeaththatwereautopsiedatVydehiInstituteofMedicalSciencesandResearchCentre,Bangalore.Wheretheincidencewasmoreamongtheagegroupof40to60yearswithmalepredominance,Heartisthemostcommonorganinvolvedbothingrossandmicroscopy.Thehistopathologicalexaminationalsohadamajorcontributionasancillarytoolinconcludingthecauseofdeath.

Keywords: Natural Death, Heart, Gross examination, Histopathological examination.

Corresponding author:Dr Shobhana S SAssistantProfessor,DepartmentofForensicMedicine&Toxicology,VydehiInstituteofMedicineSciences&ResearchCentreBangalore,Mobileno:[email protected]

INTRODUCTION

In the routine practice ofmedicolegal autopsies,encounteringthecasesofsuddennaturaldeath,especiallythedeceasedbeingyoungadultorinthemiddleageisa matter of concern. Detecting the cause of death insuchcasesbecomesanimportantchallengeinForensicpractice, as obscure autopsies andnegative autopsiesarecommonlyencountered.Insuchsituations,ancillaryinvestigations like chemical analysis, microbiology,serologyandhistopathologicalexaminationwillbecomeimportant.But incasesassociatedwithdecompositionand negative chemical analysis, autopsy surgeon hasto completely rely on gross findings of post-mortemexamination.

Sudden death is that of a death that is rapidand unexpected or unforeseen both subjectivelyand objectively occurring without any prior clinicalevaluation in apparently healthy people or in patientduring an apparent benign phase in the course of adisease.1

According to Knight’s Forensic Pathology, thedeathmayappearsuddenandunexpectedbuttheremaybechronicsymptomsandalsowouldhaveinterpretedasharmless.Insuddendeaththeimmediatecauseisalmostalwaysfoundinthecardiovascularsystem,eventhoughtopographicallythelesionisnotinheartorgreatvessels.Massivecerebralhaemorrhage,subarachnoidbleeding,rupturedectopicpregnancy,haemoptysis,haematemesisand pulmonary embolism may also join with heartdisease andaortic aneurysm to contributemostof thevascularsystemreasonsforsuddenunexpecteddeaths.2

Among the natural deaths, ischemic heart diseaseis considered as leading cause of death followed byCerebrovascular disease and Lower respiratory tractinfection in 2004. It is projected to remain same in2030.3

DOI Number: 10.5958/0973-9130.2018.00133.0


The term natural death encounter difficulty indefiningnatural.Itisthoughtasanoppositeofunnaturaltypeofdeathsuchasaccidental,suicidalandhomicidaldeath.Thetermbecomesmeaningfulifitisappliedwithspecificmeaning in definite situation.4 Natural deathmeansthat thedeathiscausedentirelybydiseaseandthetraumaorpoisondidnotplayanypartinbringingitabout.5 Inthecurrentstudynaturaldeathislinkedwithinvolvementoforgans.

In the current study cases considered are thosewhich were brought dead to mortuary or casualty ofvydehiinstituteofmedicalsciencesandresearchcentreBangalore,herethemannerofdeathisattributedtobenatural.Amongthe totalnumberofcasessomeof thecasesareadmitted inhospital and somewerebroughtfromresidenceorworkplacedirectlytomortuary.

Thesecasesarefromdifferentpartsofthecountry,assomeofthemaremigratedindividualwhohadcomewith the history of pre existing disease for treatmentpurpose and some migrated for job as this part ofBangaloreisanIThubandheretheopportunityforjobismore.

AIMS & OBJECTIVES

Todeterminetheorgan/sinvolvedinNaturaldeaths.

To determine the correlation of gross andmicroscopic findings in the most common organ/scausingNaturaldeath.

MATERIALS AND METHODOLOGY

The data for the current study are collectedretrospectively from the inquest forms 146(i) & (ii),autopsy case reports and relevant histopathologicalexamination report, for a period of five years thatis between 2010 to 2014. Data related to age, sex,gross pathological findings in the organs involvedand histopathological findings are collected from allthe cases where themanner of death is proved to benatural at autopsy.Descriptive analysiswas done andchisquaretesthasbeenusedtofindthesignificanceofhistopathologyexamination.

Inclusion criteria:

All themedicolegalautopsyconductedduring thestudyperiodwherethemannerofdeathrevealedtobenatural.

Exclusion criteria.

1. Alldeathsduetounnaturalcauses.

2. Allunknownandunidentifiedcasesbroughtforautopsy.

3. Alldecomposedcases.

OBSERVATION AND RESULTS

In the current study total numberofmedico legalcaseswere1140cases,outofwhichcauseofdeathwasnatural in 183 cases (16%).Themost common organinvolvedincausationofdeathwasheart, in109casesfollowedbylungsin39cases.

Among involvement of heart the incidence iscommon in male than in case of female. Age ofoccurrenceismoreinagegroupof41-60yearsfollowedby21-40years.

Among 109 cases of death involving heart 70cases were send for histopathological examinationfor confirmation of cause of death. Significance ofhistopathologyovergrossexaminationwascarriedovercriteria’slikeweightofheart,thicknessofleftventricularwall,stenosisofcoronaries,plaquesinaorticwallandinfarctofheart.ThesignificanceofhistopathologywaselicitedbyapplyingchisquaretestandanalysingdatabySPSSsoftwareitwasfoundthatdetectinginfarcttherewas significant role of histopathology, in remainingcriteriathesignificancewasnotfound.

Table 1: Total number of Natural Deaths out of total medicolegal autopsies conducted during study period.

Year Total autopsy Total Natural Death

2010 173 26(15%)

2011 193 28(15%)

2012 232 35(15%)

2013 251 43(17%)

2014 291 51(17%)

Total 1140 183(16%)


Table 2:Age and Sex distribution of Natural Death according to organ system involvement

Age CVS RS GI CNS GUS Multiorgan

M F M F M F M F M F M F

1-20yrs 4 1 2 0 0 0 0 0 0 0 1 1

21-40yrs 31 4 11 3 3 2 3 1 0 0 5 1

41-60yrs 47 3 10 4 1 0 5 1 0 1 1 03

61-80yrs 12 2 7 2 1 0 0 0 0 0 3 1

81-100yrs 4 1 0 0 0 0 0 0 0 0 1 0

Total 98 11 30 09 05 02 08 02 00 01 11 06

Table 3: Male and Female Sex ratio in relation to cardiovascular system involvement.

Cardiac case year wise Males Females

2010 11 03

2011 16 00

2012 22 01

2013 18 05

2014 30 03

Total 97 12

Table 4: Increase in Weight of heart in gross and in histopathology among 70 specimens sent for histopathology examination.

Year Gross Histopathology

2010 09 10

2011 14 12

2012 13 12

2013 07 10

2014 12 13

Total 55 57

Table 5: Increase in thickness of left ventricular wall of heart in gross and in histopathology among 70 specimens sent for histopathology examination.


2010 08 08

2011 10 09

2012 10 08

2013 08 07

2014 07 15

Total 43 47

Table 6: Stenosis of coronaries of heart in gross and in histopathology among 70 specimens sent for histopathology examination.


2010 08 08

2011 15 13

2012 13 12

2013 09 09

2014 09 11

Total 54 53


Table 7: Plaques in Aorta of heart in gross and in histopathology among 70 specimens sent for histopathology examination.


2010 08 08

2011 10 05

2012 10 08

2013 09 09

2014 08 11

Total 45 41

Table 8: Infarcts in the heart; Gross and in histopathology among 70 specimens sent for histopathology examination.


2010 02 03

2011 03 08

2012 03 11

2013 00 00

2014 06 10

Total 14 32

Table 9: Data analysed after using SPSS software

+veValues -veValues Calculated Chi Square Test value

P- Value

WeightGross 55 18

0.15 0.69HPE 57 16

LeftventricleGross 43 30

0.46 0.49HPE 47 26

CoronaryGross 53 20

0.03 0.65HPE 52 21

InfarctGross 14 59

8.32 0.004HPE 30 43

AortaGross 45 28

0.45 0.50HPE 41 32

DISCUSSION

The current study is the retrospective analysis ofNaturaldeathsforaperiodoffiveyearsinDepartmentofForensicMedicineandToxicology,VydehihospitalBangalorefromtheyear2010to2014.Thetotalcasesautopsied during these five years were 1,140 out ofwhich, in 183 casesmanner of death is Natural. Theratiooftotalnumberofcasesinrelationtodeathduetonaturalcause remainedrelativelyconstantduringeveryear.ThiswassimilartothestudydoneinKaramasad,Gujarat, where the incidence of natural death wasconstantduringstudyperiod.6

On considering systems involved cardiovascularsysteminvolvementisseenin109casesofnaturaldeath

followed by respiratory system which was 39 cases,multiorganfailurein17cases,10casesincentralnervoussystem,gastrointestinalsystemin7casesand1caseingenitourinary system. The present study is similar tothestudydoneKhetreRRetalandSreeLakshmietalhadshownHeartisthemostcommonorganinvolvedinsuddendeathsfollowedbylungs.7,8However thestudyisincontrarywithastudydoneinMunicipalMedicalcollegeMumbai,India.Wheremajorityofdeathsduetononcardiaccausesweremore.9

The age of occurrence of the natural deathsweredividedin20yearsrange.Theyoungest incidencewasnoticed ina femaleof9yearsand theoldest casewasmale aged about 97years, and both the cases showed


involvementofHeart.TheageofoccurrenceamongtheHeart involvement was commonly observed between41-60yearsthereare50cases.Therateofcasesismoreinthisagegroupmaybeduetoriskfactorsandalsoduetoincreaseinincidenceofsomeofnoncommunicabledisease like diabetes, hypertension and increasecholesterollevel.ThiswascomparabletoastudydoneinKaramsad Gujarat,KumarV et al,DineshSRao,KhetreRR,BatraAKetal.6,7,10,12

The incidence was more in males compared tofemales in all the organs considered in the study.Significanceweremoresointheheart.Ratiowas97casesinmaleand12cases in females.Thisgenderdisparityobserved is similar to a study done among Nigerianpopulationmaybedue tocardioprotective effectsofestrogens inwomen beforemenopause as opposed totestosteroneinducedincreaseincardiovascularrisk.11

In the current study out of 109 cardiac cases 70casesweresentforhistopathologyexamination.

In the current study where the gross evidence ofcardiovascular disease, microscopic examination wasdoneasanancillaryinvestigation.Incaseswherethereis dispute in approaching to cause of death by grossfinding, microscopic examination had been done andin cases with obvious disease on gross, microscopywas avoided to prevent delay in giving opinion.Histopathologicalexaminationisdonein70cases.Mostofthecaseswheremicroscopyisdonethereweremorethanonefinding.

On considering the microscopic findingsindividuallycoronaryarterystenosiswasnoticedin54caseswhichweremoreintheagegroupof41-60years.Increase in weight of heart has been noticed for thegivenageandbuiltofindividualwhichwere55cases,tampanodewasnoticedin3casesandvalvulardiseasein 1case. The youngest case that was noticed in thisstudywas9yearsfemale,thecasehadcongenitalheartdisease.Thestudycanbecomparedtothestudydoneby Dinesh S.Rao where the occlusion of coronarieswascommonlynoticed.AnotherstudydonebyThomasA. Gaziano et al and David S. Celermajer et al hadshowntheinvolvementofcoronaryheartdiseaseweremorecomparedtoothercausesmoresoindevelopingcountries.10,13,14

The histopathology examination showed positivefindingin65cases,positivefindingsweremoreinthe

individual of age ranging between 41-50 yearswhichwere about 20 cases of microscopy. Coronary arterydisease were seen inmaximumwhichwas in similarwiththestudydonebySreeLakshmiKetal.8

On comparing gross finding with histopathologyfindingsofthosecaseswhichweresentformicroscopy,amongallthecriteriahistopathologyhadamajorroleindetectingtheinfarctofheartthushavingsignificantvaluecomparedtoothercriteria.RoleofhistopathologywasstudiedinarticlesbyFDCBernardiandGeoffoyLorinDeLaGrandmaison histological analysis has amajorimpactespecially in the lungs, liverandkidney.15,16 IncontrarytotheabovestudyJudithFronczekconcludedthathistologicalexaminationofallorgansinallforensiccases for thepurposeofprovidingamedicalcauseofdeathisnotsupported.17

CONCLUSION

Thestudywasinvolvingthenaturaldeathsamongall the medicolegal autopsies. Cardiovascular relateddeathsoverweighedcomparedtoothersystem,withtheriskgroupamong41-60yearsofage.Theconditionisfrequentlyseeninmaleonconsideringgender.Ongrossandmicroscopy coronary artery diseasewas commonamong cardiac cause. In cases of dispute and for theconfirmation of diagnosis of death due to systemsinvolvedhistopathologyexaminationplayedsignificantroleasanancillaryinvestigation.Astheriskgrouparewell identified in the current study, it also provides astatisticdataforthispartofBangalore,totakeprotectiveandprecautionarymeasuresforthesame.


Ethical Clearance- Taken

Source of funding: Self

REFERENCE

1. MichaelTsokos.Suddendeathfromnaturalcausesin: Forensic Pathology Reviews. Vol 1. Newjersey:Humanapress,2004.P.141.

2. Pekka saukko, BernardKnight. The pathology ofsuddendeathin:Knight’SForensicPathology.3Ed.London:Arnold,2004.p.493.

3. G.Gururaj.InjuryandviolenceinIndia:FactsandFiguresinNationalinstituteofMentalHealthandNeurosciences,PublicationNO82,Bangalore.


4. Oehmichen M, Meissner C. Natural Death.Gerontology.2000Mar-Apr:46(2):105-10

5. K.S Narayana Reddy, O.P.Murthy. Death and itscauses :The essentials of Forensic Medicine andToxicology.33rdEd.Jaypee,2014.P-150.

6. SanjayGupta,RaviPanchal,DivyeshSondarva.AnApproachtoSuddenNaturalDeathsinMedicolegalAutopsies at Karamsad, Gujarat. J Indian AcadForensicMed.Jan-Mar2011,Vol.33,No.1.

7. KhetreRR,BatraAK,ShrigiriwarMB,KuchewarSV, JambureM P. A prospective autopsy basedstudy of sudden natural non-traumatic deaths ina rural district. International Journal of Recent Trends in Science and Technology12(2):243-246http://www.statperson.com(accessed02September2015)

8. SreeLakshmiK,AshalathaN,SVenkataRaghava,RaghupathiAR,5DayanandaSBiligi,SiddiqueMAhmed,NatarajanM.EvaluationofHistopathologicRole in Providing Cause of Death in SuddenUnexpectedNaturalDeath.JIndianAcadForensicMed.January-March2014,Vol.36,No.1

9. ChaturvediM,SatoskarM,KhareMS,KalgutkarA D. Sudden, unexpected and natural deathin young adults of age between 18-35 years.A clinicopathologial study. Indian journalpatholmicrobial2011:54;47-50.

10. Dinesh.S.Rao, Yadakul. SUDDEN ANDUNEXPECTEDNATURALDEATHS-AFOUR-YEAR AUTOPSY REVIEW. JPAFMAT 2008;8(2).

11. OlumuyiwaEyitayopelemoetal.Anautopsyreviewof sudden unexpected natural deaths in suburbanNigerianpopulation.Biomedcentral2014:12;26

12. Kumar V, San KP, Idwan A, Shah N, Hajar S,Norkahfi M. A study of sudden natural deathsin medicolegal autopsies in University MalayaMedicalCentre(UMMC),KualaLumpur.JournalofForensicandLegalMedicine.2007;14:151–154

13. ThomasA.Gaziano,,AsafBitton,,ShuchiAnand,,*ShafikaAbrahams-Gessel,andAdriannaMurphy.Growing Epidemic of Coronary Heart Disease inLow- and Middle-Income Countries. Curr ProblCardiol. 2010 Feb; 35(2): 72–115. Accessed on02/11/15

14. DavidS.Celermajer,ClaraK.Chow,EloiMarijon,Nicholas M. Anstey, Kam S. Woo. Prevalences,Patterns, and the Potential of Early DiseaseDetection. J AmColl Cardiol. 2012;60(14):1207-1216.Accessedon02/11/15.

15. F D C Bernardi, P H N Saldiva, T Mauad,histological examination has a major impact onmacroscopic necropsy diagnosis. J Clin Pathol2005:58:1261-1264

16. Fronczek, J, Hollingbury, F., Biggs, M.et al.ForensicSciMedPathol(2014)10:39.

17. DeLaGrandmaison,G.LCharlier,PandDurigonM(2010), usefulness of systematic histologicalexamination in routine ForensicAutopsy. JournalofForensicsciences,55:85-88.

Knowledge and Attitude of Medical Students Towards Medico Legal Postmortems at NSCB Medical College Jabalpur MP

Ashok B Najan1, Vivek Srivastava2, Nidhi Sachdeva1

1Assistant Professor, 2Associate Professor, Department of Forensic Medicine, NSCB Medical College, Jabalpur

ABSTRACT

ThereisshortageofspecialistsinForensicmedicine.MostoftheautopsiesinIndiaareconductedbynon-specialistdoctors.Toframestrategiesforimprovingtheknowledgeandattitudeofmedicalstudentstowardsmedicolegalpostmortems,wemustknowthecurrentstatusoftheseaspects.Thisstudyisconductedtoknowtheattitudeofmedicalstudentstowardsmedico-legalautopsy.204medicalstudentsinsecondyearandthirdyearofNetajiSubhashChandraBosemedicalCollegeJabalpurwereaskedtorespondtoapremadequestionnaire.85.29%studentsreportedthatrelativescannotrequestamedicolegalautopsywithoutpoliceinformation.73.52%thinkthatifthecaseisbroughtdeadtocasualty,itismandatorytosenddeadbodyforpostmortemexamination.42.15%studentsopinedthatdoctorcanreferautopsycasetoanotherdoctorinadifferenthospital/city.80.39%respondedthatinformationaboutpostmortemreportcanbedivulgedunderRTI(RighttoInformation)act.74.50%studentsreportedthatpartialautopsyisnotpermissibleinIndia.42.15%studentsrecordedpositiveresponsetospecializeinforensicmedicine.

Keywords : Knowledge, attitude, medico legal postmortems

Corresponding author: Vivek SrivastavaAssociateProfessor,DepartmentofForensicMedicine,NSCBMedicalCollege,[email protected]

INTRODUCTION

Conducting medico legal postmortems andfurnishing the postmortem report is a very importantduty of an autopsy surgeon. There is shortage ofspecialists inForensicmedicinewhoare theexpert inconductingautopsy1,2.MajorfractionoftotalautopsiesinIndia,areconductedbynon-specialistdoctors.Soitisveryimportantforthesenon-specialistdoctorstobeknowledgeableandalso tohaverightattitude towardsmedicolegalpostmortems.Thebestwaytoachievethisis training of medical students in this area. To framestrategiesforimprovingtheknowledgeandattitudeofmedical students towards medico legal postmortems,wemustknowthecurrentstatusoftheseaspectsamongthemandthisstudyisanattempttoknowthesame.

AIMS AND OBJECTIVES

To study the attitude ofmedical students towardsmedicolegalautopsy.

MATERIAL AND METHOD

In the year of 2016, 204 medical students insecondyear (thirdandfourthsemester)and thirdyearof Netaji Subhash Chandra Bose medical CollegeJabalpur, participated voluntarily in the study. Apremadequestionnairewasdistributedamongthemandtheirresponseswerenoted.Questionnairecontainsthequestions regarding autopsy practice, the knowledgeof the procedure and attitude and perception towardspostmortemexamination.Questionnaireresponsesweresubmitted anonymously.Time limitwas set to submittheresponses.

FINDINGS/ RESULTS

Out of 250 questionnaires distributed among thestudents 204were submitted back successfullywithintime limit.All the students participated in study havewitnessedatleast10postmortemsduringtheirforensic

DOI Number: 10.5958/0973-9130.2018.00134.2


medicineautopsydemonstrationclasses.ResponsestothequestionswereasshowninTable1.

RESULTS

Table 1:

1 Canrelativesrequestamedicolegalautopsywithoutpoliceinformation?

Yes=28(13.72%)

No=174(85.29%)

don’tknow=2(0.98%)

2Doyouthinkbodycanbehandedovertotherelativeswithoutpostmortemexamination,ifthecauseofdeathknowninMLCCases

Yes=28(13.72%)

no=172(84.31%)


3 Canvisceralorgansberemovedduringpostmortemexaminationforresearchandstudypurposes

Yes=138(67.64%)

no=64(31.37%)


4 Ifthecaseisbroughtdeadtocasualty,isitmandatorytosenddeadbodyforpostmortemexamination?

Yes=150(73.52%)

no=52(25.49%)


5 Candoctorreferautopsycasetoanotherdoctorinadifferenthospital/city

Yes=86(42.15%)

no=112(54.90%)


6 CaninformationaboutpostmortemreportbedivulgedunderRTIact?

Yes=36(17.64%)

no=164(80.39%)


7 IspartialautopsypermissibleinIndia? Yes=24(11.76%)

no=152(74.50%)


8 Doyouthinkpostmortemexaminationdoesdisfigurementofbody?

Yes=116(56.86%)

no=78(38.23%)


9 Whatwasyourfirstresponseonobservingautopsy?comfortable=180(88.23%)

uncomfortable=18(8.82%)

can’tsay=6(2.94%)

10 Didyoulearnanythingfromautopsyyouwatched? Yes=184(90.19%)

no=8(3.92%)

can’tsay=12(5.88%)

11 ShouldwitnessingautopsybescrappedfromUGcurriculum? Yes=20(09.82%)

no=170(83.33%)

can’tsay=14(06.86%)

12 Wouldyourecommendthatmedicalstudentsshouldwatchmoreautopsies?

Yes=200(98.03%)

no=4(1.96%)

can’tsay=0(00%)

13 Afterdeathwouldyoulikeautopsybeperformedonyouoranyofyournearrelative?

Yes=124(60.78%)

no=74(36.27%)

can’tsay=6(02.94%)

14 Wouldyouliketospecializeinforensicmedicine? Yes=86(42.15%)

no=116(56.86%)

can’tsay=290.98%)

DISCUSSION

85.29% students reported that relatives cannotrequestamedicolegalautopsywithoutpoliceinformationand contrarywas reported by 13.72% students.Manyatimesrelativesrequestthatinvestigatingofficerisonhiswayandyoupleasestartpostmortemexaminationorsometimeseventheydon’tknowthatrequisitionfrompoliceismusttostartexamination.

67.64%studentsopinedthatvisceralorganscanberemoved during postmortem examination for researchand study purposes. No is the opinion of 31.36%students. Practically other departments Pathology,Anatomy,Medicineaskforvisceralorgansfromautopsy

forresearchandstudypurposewhichisnotlegal.

In response to thequestion, if thecase isbroughtdead to casualty, is it mandatory to send dead bodyfor postmortem examination?Yeswas the opinion of73.52%students,noistheopinionof25.48%students.Whenapersondiesataplaceother thanhospitalandheisbroughtincasualty,asaproceduredoctorsenditforpostmortemexamination.Relativesusuallyrequestto the police and doctors not to conduct postmortemexamination.

42.15%studentsopinedthatdoctorcanreferMLCAutopsy to another doctor in a different hospital/city,nowastheopinionof54.90%students.Usuallyatour


center,we ask the referring doctor to accompany andthen he proceeds to postmortem examination underdirectsupervisionofforensicmedicineexperts.

Inresponsetothequestion,CaninformationaboutpostmortemreportbedivulgedunderRTIact?17.64%students replied yes and 80.39% students replied no.Lawyers,relativesandevensometimesNGOsaskforinformationaboutpostmortemunderRTIAct.

11.76% students reported that partial autopsy ispermissible inIndiaandnois theresponseof74.50%students.Manytimesrelativesrequestdoctortoconductas less dissection as possible and this point arises inmindofthedoctor,canwedothatlegally?

Alltheabovequestionscommonlyrosepracticallyduring conducting postmortem examinations. Thoughmost of the students have correct knowledge, asignificant number of students don’t have sufficientinformation regarding postmortem examinations.Beforethestudentsactuallybecomedoctors,andreadyto conduct postmortem examinations, an orientationprogramcanhelpthemtocorrecttheirknowledgeaboutprocedurefollowedduringpostmortemexaminations.

84.31% students were aware that medico-legalautopsyisrequiredinallMLCcasesevenifthecauseofdeathisknown.However,13.72%studentshaveraisedobjectionstoautopsiesinMLCcasesinwhichcauseofdeathisknown.Thiscomparesfavorablywiththestudyof EWBenbow3 and Jadav et al4.wheremajority ofthe respondentswereaware thatmedico-legalautopsyisrequiredinallMLCcases.

In response to the question, do you think postmortem examination does disfigurement of body?Yes was the response of 56.86% students, no is theresponse of 38.23%. This is in accordance with thestudy done byGVenkatRao and SKrishna Prasad5

in which 57% students were of the opinion that postmortem examination causes disfigurement of body.This is in contrast to the studies who gave variableresponseof65%and27%byEkanem6andAhmadetal7respectively.

88.23% students reported comfortable experienceon observing their first autopsy.This is in contrast tostudydonebyGVenkatRao andSKrishnaPrasad5,Ehsan et al8 and NihalAhmed 7 where only 36.66%,36.5% and 21% students answered that they were

comfortable on the first exposure to post-mortemexaminationrespectively.

90.19%studentsreportedtheylearnsomethingfromautopsytheywatched.InstudydonebyGVenkatRao,SKrishnaPrasad582%ofthestudentswereofopinionthattheylearnedsubjectafterwitnessingautopsies.97.66%gave positive response in the study done by Ahmadetal7,whereasRautji9 foundthat in theirstudy80.7%subjectslearnedsomethingafterwitnessingautopsies.

In response to the question, Should witnessingautopsybescrappedfromUGcurriculum?Yeswastheresponse of 09.82%, no was the response of 83.33%students. Previous studies regarding same questiongave variable results. In the study done byGVenkatRao,SKrishnaPrasad5yeswastheresponseby25.33%students,withNihalAhmad7,finding97.66%studentsagreeingtoscrapeautopsyfromcurriculumandRautji8 findingthatonly6%favoredscrapingautopsy.

Inresponsetothequestion,wouldyourecommendthat medical students should watch more autopsies?Yeswas the responseof98.03%students, nowas theresponseof1.96%students.InastudydonebyJadavetal4,88%ofthestudentsrecommendedthatstudentsshould watch more postmortem examination alsofavored by the study of Ekanem6. Whereas Rautji8,Ekanem6andNihalAhmad7foundthat72.3%,57%and62.3% of the participants agreed that the numbers ofautopsieswatchedaresufficientrespectively.

Yes 60.78% was the response recorded to thequestionthatafterdeaththeywouldlikeautopsytobeperformedonthemoranyoftheirnearrelative?Nowastheresponseof36.27%.ThisisfavoredbystudydonebyJadavetal4andSanner10,where82.5%and90%ofthe student respectively, answered positive onwishedtohavepostmortemexaminationonself/relativewhenrequired.InstudydonebyRautjietal951%ofstudentswouldnotwantautopsies tobeperformedon themortheirrelativesafterdeath.

In response to the question would you like tospecialize in Forensic Medicine? 42.15% studentsreported positive response, no was the response of56.86%.EarlierstudiesgavevariableresponsesIn thestudy done by GVenkat Rao and S Krishna Prasad5,21.66% of the students answered positively for thesame.Ekanem6,Rautji9andfound66%and17%oftheparticipantsfavoringtospecializeinForensicMedicine


specialtyrespectively.

CONCLUSION

Knowledge which is not reciprocating in attitudeiswaste.Thoughafractionofstudentsarenothavingknowledgeaboutmedicolegalpostmortemsthosehavingit are not showing right attitude towards it. Thoughmany have right knowledge and attitude it is neededthat teaching in the subject should have considerableportionofpracticalaspects.Thiscanfulfillourgoalofproducingundergraduateswhoarereadytodomedicolegal work including postmortem examinations withcorrectknowledgeandrightattitude.

Ethical Clearance:EthicalclearanceforthestudywastakenfrominstitutionalethicalcommitteeofNSCBMedicalCollegeJabalpurbeforestartingthestudy

Source Funding : Self.Thestudywasfundedbyauthorsthemselves.


REFERENCES

1. http://indianexpress.com/article/cities/mumbai/mumbais-deadly-mortuaries-acute-lack-of-forensic-experts-medical-staff-at-post-mortem-centres-2884457/

2. http://www.indiamedicaltimes.com/2012/06/30/medical-colleges-facing-shortage-of-teachers-in-anatomy-forensic-medicine/

3. Benbow EW. Why show autopsies to medicalstudents?JPathol1990;162:187-8.

4. Jadav JC, Patel BN, Shah KA, Tandon RN.Knowledge and attitude of medical students onforensicautopsyinAhmedabadcity.JIndianAcadForensicMed.2013;35(1):26–28.

5. G Venkat Rao, S Krishna Prasad. Autopsy -PerceptionandAttitudesofUndergraduateMedicalStudents in South India:AQuestionnaire Survey.IAIM,2016;3(10):204-211.

6. Ekanem VJ, Akhigbe KO. Attitudes of Nigerianmedicalstudentstoautopsy.TurkJMedSci.,2006;36:51-6.

7. AhmadNetal.AttitudeandKnowledgeofMedicalStudentsonPracticalAspectsofForensicMedicine.JournalofEvidencebasedMedicineandHealthcare,2015;2(27):4002-4008.

8. Ehsan R, et al. Prejudice of Medical StudentsTowardsMedico-LegalAutopsy.MC,2015;21(4):27-32.

9. RautjiR,KumarA,BeheraC.AttitudesofMedicalStudentstowardsMedico-legal/ClinicalAutopsy.JIndianAcadForensicMed.,2013;35(4):358-361.

10. Sanner MA. Medical student’s attitudes towardautopsy. How does experience with autopsiesinfluenceopinion?ArchPatholLabMed.,119:851-8,1995.

Dowry and Domestic Violence Against Women – Knowledge and Awareness among Medical Students

Rajeshkumar R Bhoot1, Pragnesh B Parmar2

1Assistant Professor, Department of Forensic Medicine, GMERS Medical College, Gandhinagar, Gujarat, India, 2Associate Professor, Department of Forensic Medicine, GMERS Medical College, Valsad, Gujarat, India

ABSTRACT

Background: Dowryanddomesticviolenceagainstwomen is stillmuchcommon incountry like IndiaeventhoughvariousstepshavebeentakenbyGovernmenttimetotime.Aboveissuesmustbeabolishedbybringingawarenessamongcitizensandasadoctoronemustawareofit.Presentstudywasundertakentoassesstheknowledgeandawarenessamongmedicalstudentsregardingaboveissue.

Materials and Method: Total145medicalstudentsof2ndMBBSofGMERSMedicalCollege,Gujaratwereexposed topre-testedandpre-validatedLikertscale typequestionnaire(1 to7,1–Notatall true,7–Verytrue)regardingknowledgeandawarenessofdowryanddomesticviolenceagainstwomen.Dataobtainedwereanalyzedviamedianscoreandtabulated.

Results:Mostofthestudentsknowthatdemandofdowryisagainstthelawanddomesticviolenceagainstwomen is associatedwith dowry. Students had poor awareness regarding ‘TheDowry ProhibitionAct,1961’,‘TheProtectionofWomenfromDomesticViolenceAct,2005’and‘TheProtectionofHumanRightsAct,1993’.StudentswerewellawareofIndianPenalCodedealswithdowrydeathandpunishmentasperIndianPenalCodedealswithdowrydeath.

Conclusion:Knowledgeandawarenessregardingbasicideaofdowryanddomesticviolenceagainstwomenamong2ndMBBSstudentsaregoodbutinrelationwithvariousactandlawispoorwhichinturnmayleadtopoorunderstandingofburningsubject.

Keywords: Dowry, Domestic violence, Women, Knowledge, Awareness, Medical students.

Corresponding author:Dr. Pragnesh B. ParmarAssociateProfessor,DepartmentofForensicMedicine,GMERSMedicalCollege,Valsad,Gujarat,IndiaMob.:–8141904806,Email:[email protected]

INTRODUCTION

Dowry and domestic violence against women isstillmuch common in country like India even thoughvariousstepshavebeen takenbyGovernment time totime. Medical students of 2nd MBBS as part of theirsyllabususually learn IndianPenalCodedealingwithdowrydeathandotheraspectsofitbutindepthstudyofvariouslawsandactsrelatedtoabovematterarenottaughtinmedicalcollegeatpresentneitherintheschool

life.DowryanddomesticviolenceagainstwomenareburningissuesofIndiansocietywhichmustbeabolishedbybringingawarenessamongcitizensandasadoctoronemustawareof it [1].Presentstudywasundertakentoassesstheknowledgeandawarenessamongmedicalstudentsregardingaboveissue.


Total145medicalstudentsof2ndMBBSofGMERSMedical College, Gujarat were exposed to pre-testedandpre-validatedLikertscale typequestionnaire(1 to7,1–Notatalltrue,7–Verytrue)regardingknowledgeandawarenessofdowryanddomesticviolenceagainstwomenafterobtaining their informedwrittenconsent.Studywasundertakenafterobtainingethical approvalfromtheInstitutionalEthicalCommittee.Dataobtained

DOI Number: 10.5958/0973-9130.2018.00135.4


wereanalyzedviamedianscoreandtabulated.

RESULTS

Total145studentsof2ndMBBSwereparticipatedin the present study, out of which properly filledand responded 125 questionnaires were taken intoconsiderationfordataanalysiswhilerestofimproperlyfilled questionnairewere not taken into consideration.Out of 125 respondents, 73 were male and 52 werefemale.

Mostofthestudentsknowthatdemandofdowryisagainstthelaw.Studentswerealsoawareofthatmany

times domestic violence against women is associatedwith dowry. Students had poor awareness regarding‘TheDowryProhibitionAct,1961’,‘TheProtectionofWomenfromDomesticViolenceAct,2005’and‘TheProtectionofHumanRightsAct,1993’.Fewstudentscameacross tortureofwomenindemandofdowry intheirlifeandfewstudentsknewthatdowrymayleadtojudicialseparation/divorceofmarriedcouple.Mostofthestudentswereawareofthathusbandaswellashisrelativesmaybeinvolvedindemandofdowry.StudentswerealsoawareofIndianPenalCodedealswithdowrydeath andpunishment asper IndianPenalCodedealswithdowrydeath(Table–1).

Table – 1: Knowledge and Awareness regarding dowry and domestic violence against women (Likert scale: 1 to 7, 1 – Not at all true, 7 – Very true)

Sr. No. Perceptions of students Median score

1 Iknowthatdemandofdowryisagainstthelaw. 6

2 Iamawareof‘TheDowryProhibitionAct,1961’. 2

3 Iknowthatmanytimesdomesticviolenceagainstwomenisassociatedwithdowry. 4

4 Icameacrosstortureofwomenindemandofdowryinmylife. 3

5 Iamawareof‘TheProtectionofWomenfromDomesticViolenceAct,2005’. 2

6 Iknowthatdowrymayleadtojudicialseparation/divorceofmarriedcouple. 3

7 Iamawareof‘TheProtectionofHumanRightsAct,1993’. 2

8 Iknowthathusbandaswellashisrelativesmaybeinvolvedindemandofdowry. 6

9 IamawareofIndianPenalCodedealswithdowrydeath. 5

10 IamawareofpunishmentasperIndianPenalCodedealswithdowrydeath. 5

DISCUSSION

TheProtectionofWomenfromDomesticViolenceAct, 2005 defines violence as any act, omission orcommission or conduct of any adult male person ofthe family, which harms or injures or endangers thehealth,safety,life,limborwell-being,whethermentalorphysicalofthewomenortendstodosoandincludescausing physical abuse, sexual abuse, verbal andemotional abuse, andeconomicabuseandharassmentorcoerciontomeetanyunlawfuldemandforanydowryconstitutesdomesticviolence”[2].

After independence, many acts and laws wereenactedaswellasamendedtimetotimetoenhancethepower ofwomen in India.Gender justice is of primeimportance in Indian law at present. Constitution of

Indiaprovidesactionandpositivelookafterforwomenissueswithspecialprovisions[3].

Dowry ProhibitionAct, 1961; Indian Penal Code(IPC)like228A,294A,304-B,306,354,376,376-BarethedifferentlawsframedtoempowerwomeninIndia.Women’sempowermentmaybedefinedas“abottom-up process of transforming gender power relations,through individuals or groups developing awarenessofwomen’s subordination and building their capacitytochallengeit”[4-7].Women’sempowermentdoesnotimplythatwomentakeovercontrolpreviouslyheldbymen.Rather,itliesintheneedtotransformthenatureofpowerrelations[5].

In present study, most of the students know thatdemandofdowryisagainstthelawbecausenowadays


newspapers as well as social media are bringingawareness. Students were also aware of that manytimes domestic violence against women is associatedwith dowry. Students had poor awareness regarding‘TheDowryProhibitionAct,1961’,‘TheProtectionofWomenfromDomesticViolenceAct,2005’and‘TheProtectionofHumanRightsAct,1993’maybeduetoinstitutesorschoolsarenotteachingfundamentalrightsoritistherawsubjectsmanytimewithlittleinterestfromthestudentsside.Fewstudentscameacross tortureofwomenindemandofdowryintheirlifeandfewstudentsknewthatdowrymayleadtojudicialseparation/divorceofmarriedcouple.Mostofthestudentswereawareofthathusbandaswellashisrelativesmaybeinvolvedindemandofdowry.StudentswerealsoawareofIndianPenalCodedealswithdowrydeathandpunishmentasperIndianPenalCodedealswithdowrydeathassubjectofForensicMedicinein2ndMBBSisfocusingtosomeextentonabovelegalmatters.

A study at Sophia College, Mumbai showedthat 50% of home victims were ignorant about thelaws protecting women from violence [8]. Anotherstudy conducted in the state of Madhya Pradesh andMaharashtrashowed thatassaultedwomenwereoftenunaware of their legal rights, and preferred to remainintheoffensiverelationship[9].Ifpeoplearewellawareof their fundamental rights and duties, the carriageof justice in humanity becomes much easier. Lawfulawareness and legal literacy make radical deviationsinourdemocracy.Awarenessof lawshelps academicprofessionals aswell as the general public to use thelegal system more effectively. Only two percent ofwomeninruralareasgainaccesstojustice,eventhoughseverallawshavebeenenactedinParliamentprotectingthemagainstviolenceandabuse[10].

CONCLUSION

Knowledgeandawarenessregardingbasicideaofdowryanddomesticviolenceagainstwomenamong2nd MBBS students are good but in relationwith variousact and law is poor which in turn may lead to poorunderstandingofburningsubject.Educationalprogramslike interactive lectures, debate as well various casescenarios of subjects should be required to increaseknowledgeandawarenessamongmedicalstudents.

Source of Funding:Self.

Conflict of Interest:Nonedeclared.

REFERENCES

1. ParmarP.Dowrydeathandlaw–Indianscenario.IAIM,2014;1(2):44-49.

2. JethiJ.CommentaryonProtectionofWomenfromDomesticViolenceAct-2005.LawHouse,Cuttack,Odisha,2007,1-37.

3. Dejene A. Integrated Natural ResourcesManagementtoEnhanceFoodSecurity;theCaseofCommunityBasedApproachesinEthiopia.Rome,Food and Agricultural Organization of UnitedNations,Report,2003;16:11-30.

4. Syed S.A.J. Women in India, Legal and HumanRights. Centre for Professional Developmentin Higher Education and Women’s Studies andDevelopment Centre. University of Delhi, 2004;1-24.

5. Baden, S., Oxaal, Z. Gender and DevelopmentDefinitions, Approaches and Implications forPolicy. BRIDGE (Development-Gender) Brigton,Institute of Development Studies, Report, 1997;No-40,1-32.

6. Ogato G.S. The Quest for Gender Equity andWomen’s Empowerment in Least DevelopedCountries, Policy and Strategy Implication forAchieving Millennium Development Goals inEthiopia. International Journal of Sociology andAnthropology,2013;5:358-372.

7. Baden S., Reeves, H. Gender and Development.ConceptsandDefinition,BRIDGE(Development-Gender),Briton,InstituteofDevelopmentStudies,2000;23-65.

8. RaoA.StressandHealthImplicationsofDomesticViolence in Women in Difficult Circumstances.NIPCCD, New Delhi. Summaries of Research,2008;65:52-53.

9. Mitra N. Domestic Violence as a Public Issue:A Review Response in Women in DifficultCircumstances. NIPCCD, NewDelhi. SummariesofResearch,2008;63:13-40.

10. StaffReporter.Legal Issues andViolence againstWomeninDomesticFront.TheHindu,September,2010;27,4-5.

Retrospective Analysis of Asphyxial Deaths Autopsied in Bareilly Region

Jaswinder Singh1, Pranav Kumar2, Somshekhar Sharma3

1Associate Professor, 2Assistant Professor, 3Postgraduate, Department of Forensic Medicine, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh

ABSTRACT

Asphyxialdeathsareacommonincidenceinforensicpractice,anddeterminationofthemannerofdeathwhetheritisaccidental,suicidal,homicidal,ornaturalisofutmostsignificance.Insuchdeaths,adetailedandmeticulousautopsyplaysamajorroletosolvethequestionsthatarise,whilethesceneinvestigationandcollectionofsampleshavetheirownsignificance,thoughconsiderederroneouslymarginalinourcountry.Variousepidemiologicalanddemographicalparametersofasphyxialdeathsasrecordedbytheauthorsaredescribedinthepresentstudy.Increasingdeathsduetoasphyxiaareoneofthemostimportantcausesinviolentdeaths.Thechangingdemographicsalongwiththeincreasedincidenceamongcertainagegroupsaswellasthevariationsasobservedintermsofvariousdurationsoftimearedepictedhere.Theauthorswouldalsoliketostressonthedifferentiationaswasnotedinmodeofdeathalongwiththeintentionoftheperpetratoriehomicidal,suicidaloraccidental.Theauthorsalsoconcludedthatcertainstepscanbetakenastoavoidfatalitieshowevertheyaremoreofapreventivethanacurativeplan.

Keywords: asphyxia, death, suicide, homicide,

INTRODUCTION

Asphyxiaisdefinedas“abroadtermencompassinga variety of conditions that result in interferencewiththeuptakeorutilizationofoxygentogetherwithfailuretoeliminatecarbondioxide(CO2)”.

(1)

In medico-legal usage, ‘‘asphyxia’’ almostexclusivelyreferstoformsofexternalhypoxiaandcanbe further divided intomechanical and environmentalasphyxia.Inpracticehoweverenvironmentalasphyxiaisofsecondary importance,asadeficiencyofoxygenin theenvironmentdemandsa specialconstellationofcircumstances,e.g.entrapmentinanair-tightenclosureetc(2). Violent asphyxial deaths are of commonoccurrence and classified as Hanging, Drowning,

Corresponding author:Dr. Pranav Kumar, AssistantProfessor,Dept.ofForensicMedicine,ShriRamMurtiSmarakInstituteofMedicalSciences,Bareilly,UttarPradesh.9458705936,E-mail:[email protected]

Strangulation,SuffocationandTraumaticasphyxia.Thehanging anddrowning are commonly seen in suicidalcaseswhilestrangulationincludingthrottlingisusuallyhomicidal.Inadditiontotheseaccidentalcompressionortraumatochestthatpreventsrespiratorymovement,known as traumatic asphyxia or crush injury is alsoone of the cause of violent asphyxial death.(3) Due topopulationexplosion,povertyandincreasingstressandstraininourdailylife,wefrequentlycomeacrosscasesofsuicides,homicidesandaccidents.Malesandfemalesarebothexposedtosuchstressesbutitseemthatoursbeing a male dominated society and males havingmore exposure to external environment, such casesarecommonlyseen inmales.Withurbanization, ruralareasarealsonotleftaloofandthiscanbeseenfromtheincreasingincidenceofsuchcasesfromtheseareas(4).

BareillyisacityinNorthwestUttarPradeshwhichisflankedonallsidesbyarichlyruralpopulationwhilehavinganurbanpopulaceinthemaincity.Thisprovidesa unique opportunity to ascertain if the demographicsare skewed or uniform in this mixed population citywith reference to asphyxia deaths. The aim of thestudywastostudythedemographicsandepidemiology

DOI Number: 10.5958/0973-9130.2018.00136.6


behindviolent asphyxialdeaths.Theauthors includedall cases with a data on drowning, strangulation, alltypesofhangingsandsmothering.Wetookthevictimo-epidemiologicalprofilesocreatedandattemptedtoco-relate thesefindingswith similar studies conducted invariouspartsoftheworld,inliteraturewehadaccessto.


The studywas conducted on a total of 135 casesofasphyxialdeathsthatwererecordedandautopsiedinDistrictMortuary,BareillyinthetimeperiodfromMay2015toMay2016.

The data was collected from the previous casereports andpostmortemsheets thatwere stored in themortuary.

Institutionalethicalclearancewasobtainedpriortodatacollection.

Thedatawasrecordedinthetabulatoryformusingamicrosoftwindowsexcelsheets.

Thedata collectedwas sorted in categories basedonsex,age,dateofincidenceaswellaspolicereportsthat depicted that intent behind the act i.e. homicidalor suicidal. The place and time of occurrence wasdeciphered from police inquest reports and that datacollected in hospital case sheets by the clinicians inchargeofthepatientsadmittedifany.

TheresultantdatawasherebyanalyzedwiththeaidofastatisticianinsoftwareSPSS11.5.

RESULTS

After an analysis of the results so decipheredwearrivedatthefollowingconclusions.

Of the total number of autopsies carried outbetweenthestudyperiod,thetotalnumberofautopsiesofasphyxialdeathswas9%i.e.135casesoutof1370totalautopsieswhichwereconductedintheperiodfromMay2015toMay2016.

Month wise demograph showed an increasingtrendamongthespateandincidenceofasphyxialdeathswith a maximum incidence of 38 cases which wereautopsied in the period from February toApril 2016,whichcontributessingularlytoanapproximate28.14%of the totalcase load.ThenextamountofcaseswerefoundintheperiodofNovember2015toJanuary2016

with37casescontributingtoanincidenceof27.40%.

The lowest numberof caseswere recorded in themonthsofMaytoJuly2015i.e.24cases(17%).LargestnumberofcaseswerefoundinthemonthofFebruary2016 at 19 cases(14%), followed by September 2015at15cases(11%).LowestnumberofcasesinasinglemonthcameinMay2015at7cases(5%).

(b) Gender based distribution wasdeterminedfortheautopsiedcasesanditwasfoundthatthedistributionintotalcaseswasalmostequalinbothsexes.Ofthetotal135cases,67casesofmalesand68casesof femaleswere found. The reports that males are predominantvictims in cases of asphyxia deathswas not found inourstudy.

(c) Age wise distribution asassessedforthesametime period and the results concluded that the largestnumber of cases in both sexeswere in the age groupof21-30yearswhichmeansthethirddecadeoflifeisthemostcommonagefortheoccurrenceandincidenceof asphyxial deaths. In males the highest incidencewas reported in the agegroupsof21-30, followedbythefourthandfifthdecadesoflife.Howeverinfemalesthelargestincidenceswerereportedinthethirddecade,withseconddecadeandfourthdecadeshowingsecondandthirdhighestincidencerespectively.

(d) Time wise distribution wascalculatedbasedonthetimeofoccurrenceoftheincidentofasphyxiaasdecipheredfromhistorybyrelativesandpoliceinquest.Maleshadahigherprevalenceof26.66%ofincidenceinthehoursbetweennoonandearlyevening(12-6pm),whileinfemalesthehighestnumberofcasesie14.81%werereportedbetweenearlymorningandnoon(6am-12noon). The highest number of cases irrespective ofsex were reported in the time from noon to eveningwhile the lowest incidencewas among the time fromlatenighttoearlymornings.

(f) Method wise distribution wasdoneonallthecasesasperthemethodcausingtheasphyxia.Thebroadcategories were chosen as drowning, strangulation,hanging and throttling. In both sexes and among allagegroups, the largestnumberofcasesreportedwereof hanging as themethodof inducement of asphyxia.Inmales hanging contributed to 30.07% of the totalnumber of cases while amongst females the numberwas a substantial 19.22%. As far as drowning andstrangulation were concerned they were placed as


second and third respectively. Throttling was lowestwithonecaseeachreportedinmalesandfemales.

(g) Location wise distribution wasdecidedonthebasisoftheplaceofoccurrenceoftheincidence.Itwascategorizedashouse,workplace,hotel,outdooretc incasesofhangingandotherswhileincasesofdrowningtheplaceofimmersionsuchaspond,lake,welletcwerecategorized. In cases of the highest asphyxial deathswhichwerehangingswefoundthatthelargestnumbersoccurredintheplaceofresidencewithatallyof40.96%.

Males and females showed a similar preferenceforhanginginplaceofresidencewith82.66%femaleschoosing their house and 62.59% males showingpreference.Indrowningdeaths,femalespreferredwellswith a tally of 5.18%of the total number of cases ascomparedtomaleswhopreferredriversandponds.

(h) Manner of death distribution was assessedon thebasisof the intentbehind thedeathwhichwasbroadlycategorizedashomicide,suicideandaccidental.The largest number of caseswere reported as suicideinbothsexeswithavalueof31.07%amongmalesinhangingand20.20%amongfemalesincasesofhangingwhileinsuicidaldrowningamongmaleswas7.40%andfemaleswas4.44%.Incasesofaccidentaldrowningtheincidenceamongmaleswas15.55%andamongfemaleswas 5.92%/ homicidal drowningwas reported as onecase each in both the sexes. Homicidal hanging andthrottlingwasreportedas5.18%amongmaleswhileinfemaleswas3.70%.

(i) Occupation wise Distribution was assessedfromthepoliceinquestandpostmortemreports.Inmalesthesalariedindividualswereatthehighestincidenceofsuicidaldeathsnumbering22cases(16.29%),followedby studentswho held 14 cases (10.37%). In femalesthe suicidal cases were highest among housewives/unemployed persons numbering 16 (11.8%) followedby students comprising 11 cases (8.1%). Individualsinvolved in farming and agriculturewere found in 11and6casesinmalesandfemalesrespectively.

DISCUSSION

With the gradual improvement of our society,although we are able to control death rate by usingadvancedtechnologybutwecannotoverlookthatthereis certainly increase in unnatural deaths may be dueto accidents, suicides and even homicidal deaths are

reporteddaybyday.(5)

InastudybyShankarBakkannavaretal,publishedin 2015, a 5 year retrospective analysis of asphyxiadeaths in Manipal region of Karnataka revealed amalepredominance indeathsaswellapreponderanceinchoosinghangingasamethodof suicide (6). Inourstudywefoundanalmostequaldistributionofmaleandfemaleinvictims.Suicidewasthecommonestmannerofdeathinboththesestudies.Anotherfactorconcurringwith our study was the fact that most of the victimspreferredplaceofresidenceforcommittingsuicide.

In a study in 2014 by Bhosale SH, conducted inYavatmal regionofMaharashtra,Theauthors foundamalepredominancewhichwasnotfoundinourstudy.The commonest place for suicide was home whichis concurrent with our study. The study conflicts usin age groupwherein our study found 21-30 years ascommonest age group, Bhosale SH concluded a agegroup od 21-40 years. Farmers and laborerswere thecommonest occupational category committing suicidewhereasinourstudyitwasthesalariedmales.(7)

Another study that correlated with our findingswasconductedovera4yearperiodinvaranasiregion.It also stated that thecommonestfindingwas suicidalhanging with a predominance in age group of 21-30years.Howeverourobservationthattherewasaequaldistribution in terms of gender is not concurrentwiththisstudyalso.(1)

Anotherconclusiveevidencepointedtothefactthatsuicidalhanginginresidentialpremiseswasfarmoreascomparedtootheravenues.ThisdatawascorroboratedwithasimilardatapresentedintheUnitedKingdom.(8)

In a study conducted in Oslo, it was concludedthatasphyxialhomicideseemstobeamethodfavoredby a physically superior person toward a victimwithconsiderably less physical strength(8,9). Howeverour studywas limited by the lownumber of cases ofasphyxialhomicide.Theauthorfeelsthatthereshouldbeasimilarscopestudyconductedwithspecialattentiontobloodalcohollevelsandapsychiatricevaluationoftheperpetrator’sifpossible(9).

A study published in 2015 made a statisticalanalysis of asphyxia deaths and focused on both theplaceof suicideandmannerofdeath.This studyalsocorroboratedourfindings that21-30years is themost


susceptiblegroupwithanincreasedincidenceofsuicidebyhangingintheplaceofresidence.(10)

CONCLUSION

Asisprevalentwithglobalstandardsweconcludedthat theratesofsuicidalhangingwascommonamongtheyoungergeneration(21-30years)whichleadsustorecommend focused preventive strategies for the agegroup.Awell-designedandcomprehensiveprogrammeisneededtoidentifythecausativefactorsandpreventionofsuicidalbehaviors.

Inreviewingliteraturepresentinthefieldweweremade aware of various factors such as peer pressure,poor socio-economic status, failed relationships andimpairedsocialskillsledtothespateofsuicidesinthisparticularagegroup.AstudyconductedintheUNITEDSTATESOFAMERICAfocusedonthespecificentityof depression and suicides in adolescents and youngadultsandfoundthatidentifyingspecificstressorsandsigns of depression early and providing appropriatepsychologicalsupportmayleadtoimprovementinthepsychologicalwellbeingandpsycho-socialbehavioroftheindividuals.

Drowning prevention strategies should becomprehensive and include: engineering methodswhichhelptoremovethehazard,legislationtoenforcepreventionandassuredecreasedexposure,educationforindividualsandcommunitiestobuildawarenessofriskandtoaidinresponseifadrowningoccurs.

Anotheraspectthatcameupinourstudywasthatfemales in the elderly age group (51-70) were moreprone to choosing suicide by hanging or drowning ascompared tomenwhoaccount fora lowerpercentageintheabovestudy.Thelacunaebehindthisneedstobefurtherevaluated.

Thestudywaslimitedinthefactthatthedurationof cases evaluated was small as well as the factthat homicidal asphyxia cases were not in adequaterepresentativesample,hencetheauthorschoosenottoconcludeonthesame.


REFERENCES

1. Chaurasia N, Pandey SK, Mishra A (2012) AnEpidemiologicalStudyofViolentAsphyxialDeathinVaranasiRegion(India)aKillingTool.JForensicRes3:174.doi:10.4172/2157-7145.1000174.

2. Franklin CA: Modi’s text book of MedicalJurisprudence and Toxicology, 23rdedition;188-220.

3. Parikh C K. Textbook ofMedical Jurisprudence,ForensicMedicineandToxicology,CBSpublishersNewDelhi6thedition2002;3.33-3.40.

4. GargiJ,GoreaRK,ChananaA,MannG.Violentasphyxial deaths. Journal of Indian Academy ofForensicMedicine.1992;12(4):171-176.

5. TrendsinSuicidebyMethodinEnglandandWales,1979to2001”.OfficeofNationalStatistics.

6. Shankar M Bakkannavar Et Al, Victimo-Epidemiological Profile Of Violent AsphyxialDeaths InManipal,Karnataka. Ind JOf ForensicAndCommunityMed,Jan–Mar2015;2(1):29-34

7. Bhosle Sh, Batra Ak, Kuchewar Sv, ViolentAsphyxialDeathDueToHanging:AProspectiveStudy.JournalOfForensicMedicine,ScienceAndLaw.Vol23,Number1.Jan-June2014

8. SidselRogde et al ;AsphyxialHomicide in TwoScandinavianCapitals.Am J Forensic Med Pathol, Vol. 22, No. 2, June 2001 .pg 128-133

9. DiMaio VJ. Homicidal asphyxia. Am J ForensicMedPathol.2000Mar;21(1):1-4

10. GuptaVP,MahantaP,AStudyofAsphyxialDeathCases inMedico-LegalAutopsy. IJHRMLP,Vol:02No:02,July,2016

11. Fernando, Kumari; Carter, Janet D.; Frampton,Christopher M.A.; Luty, Suzanne E.; McKenzie,Janice;etal.ComprehensivePsychiatry52.6 (Nov2011):623-629.

Epidemiological Study of Deaths Due to Electrocution: A three Year Retrospective Study

Sushim A Waghmare1, Satin K Meshram2, Santosh B Bhoi1, Rizwan A Kamle3, Kunal B Shirsat3

1Associate Professor, 2Professor & Head, 3Assistant Professor, Dept. of Forensic Medicine, Dr. V. M. Govt. Medical College and Shree. C.S.M.G. Hospital, Solapur

ABSTRACT

Background:Owingtoextensiveuseofelectricityinhomeandindustries,electrocutioninjuriesareoneofthecommoncausesofmorbidityandmortalityinIndia.Mostofthedeathswereeitherinstantaneousorimmediateandmostofthedeathswerepreventablebyelectrocution.Itsignifiesthatpeoplelivingathomedidnothaveelementaryknowledgeofrisksofelectrocution;thereforeawarenessaboutuseofgoodqualityelectricappliancesandcablesistheneedofthehour.Aims-Thisstudywascarriedoutwiththeaimtofindoutprofileofdeathdueelectrocutionandspreadawarenessforit.Materials & Method-Thisretrospective3yearautopsystudyduringtheperiodofJanuary2014toDecember2016ofdeathsduetoelectrocutionfromthemedico-legaldeathsreportedtoourinstitution.Results-Ourstudyrevealedthatthemostofthevictimsweremenagedbetween20and50yearswhodiedatworkingplaceduetoaccidentalmanner.Thisstudyalsoshowsatypicalseasonalanddiurnalvariation,accordingtowhichtheincidencesofelectrocutionweretypicallyhigherintheseasonofmonsoon.Mostofthecaseswerespotdead.Conclusion-Majorityoftheelectrocutiondeathsoccurredinthedaytime.Preventionisthegoldstandardanditcanbeachievedwithproperawarenessabouthandlingofelectricalappliances.

Keywords- Electrocution, Fatal, Accidental deaths, electrical injury.

Corresponding author:Dr Satin K MeshramDept.ofForensicMedicine&Toxicology,Dr.V.M.Govt.MedicalCollegeandShree.C.S.M.G.Hospital,Solapur,Maharashtra413003Email:[email protected]:9960473500

INTRODUCTION

In thismodern era, electricity is such an integralpartoflife,thatit‘shardtoimaginelifewithoutit.But,withtheadvantagesandconvenienceofelectricitycomethehazardsaswell.Injuryanddeathfromthepassageofelectriccurrentthroughthebodyarecommoninbothindustrialanddomesticcircumstances.Electricalinjuriescurrently remain aworldwideproblem.These injuriesareresponsibleforconsiderablemorbidityandmortality,butareusuallypreventablewithsimplesafetymeasures.InIndia,thevoltageofdomesticsupplyisusually220Vto240V.Electrocutionfatalitiesarerareatlessthan

100Vandmoredeathsoccuratvoltagesabove200V.1 Themaineffectofelectricityisshockproducedbyitscurrentandtheinjuriesduetoelectrocutiondependonmanyfactorssuchasvoltageandfrequencyofcurrent,durationofcontactwithbody,atmosphericconditions,androuteofcurrentinthebody.2Thetermelectrocutionhasbeencoinedforskinlesions,organdamageordeathcaused by the passage of electric current through thebodytissues.Butsometimesthetermhasbeenusedonlyincasesoffatalinjuriesordeathcausedbyelectricity.Majority of the electrical injuries are as a result ofignorance,misuseorcarelessness.3

In a developing country like India deaths due toelectrocutionduring2008and2009are8067and8539deaths respectively, i.e., 2.4%of all accidental deaths(National Crime Reports Bureau).4 Mortality rate is3%to5%intheUnitedStates.5Thoughtheincidencesofdeathduetoelectrocutionare less,but thecasesofinjuriesarequitecommonduetoaccidentaltouchingofacurrent.

DOI Number: 10.5958/0973-9130.2018.00137.8


Hence, the present study has been carried out tostudy the various epidemiological factors related toelectrical fatalities in thispartofour state togeneratepublicawareness.


Thisisa3yearsretrospectivestudywasconductedintheDepartmentofForensicMedicineandToxicologyofDr.V.M.GovernmentMedicalCollege&S.C.S.M.G.Hospital, Solapur,WesternMaharashtra region duringtheperiodofJanuary2014toDecember2016.Total6057autopsieswereconductedoutofwhich78cases(1.28%)inwhich deathwas alleged due to fatal electrocutionwereselectedforthisstudy.

Allthesecaseswerestudiedirrespectiveoftheirageandgender,andwealsotriedtofoundouttheseasonalanddiurnalvariations,ifany,incasesofelectrocution.Information regarding the incidence of electrocutionwascollectedfromthehistoryof thecases, thepolicepapers,andautopsyreports.Thefindingswererecordedin proformas, and theywere scrutinised and staticallyanalysed.Deathscausedduetolightningwereexcludedfromthisstudy.

OBSERVATIONS & RESULTS

Table No. 1: Incidence of Electrocution Deaths.

YearTotal Autop-

sies done

Number of Fatal Electro-

cution%

2014 2014 21 1.04%

2015 2048 26 1.26%

2016 1995 31 1.55%

3 year 6057 78 1.28%

Out of 6057 cases ofmedico-legal autopsydoneduring the study period January 2014 to December2016, a total 78 number of cases were due to fatalelectrocution(1.28%cases).

Table No. 2: Cases according to Age.

Age No. Percentage (%)

1-10 02 2.56

11-20 16 20.51

21-30 26 33.33

31-40 13 16.66

41-50 12 15.38

51-60 06 7.69

61-70 03 3.84

Total 78 100

Most of the victims (33.33%) were in the thirddecadeoftheirlife,whilearoundthree-fourthsbelongedto younger and adult age groups (e.g., from 21 to 50years).Inourstudy,2victimsoffatalelectrocutionwerefoundtobebelowtheageof10years.

Cases according to Sex

Majority of the victimsweremen 70(89.74%) ascompared to women 08(10.25%), with amale/femaleratioof8.75:1.

Table No. 3: Cases according to Place of Occurrence with sex.

Place Male Female Percentage (%)

Domestic 25 07 41.02

Outdoor 06 01 08.97

WorkPlace 39 00 50.00

Inmostoftheincidences,victimswereinjuredbyelectrocution and diedwhen theywere atwork placei.e.39(50.00%)andworkingwithsomeelectricsource.Whileallthewomen’sdiedathome.


Table No. 4: Seasonal and diurnal variations in cases of electric injury.

Months of Incidence During Daytime7am to 7pm

During Night time7pm to 7am Total

January-March 14(17.94%) 4(5.12%) 18(23.07%)

April-June 17(21.79%) 6(7.69%) 23(29.48%)

July-September 19(24.35%) 7(8.97%) 26(33.33%)

October-December 09(11.53%) 2(3.84%) 11(14.10%)

Total 59(75.64%) 19(24.35%) 78(100%%)

In this study, incidences of death due electricinjuryweretypicallyhigherintheseasonofmonsoon,whichwas in themonths of July to September i.e.26cases (33.33%), Majority of the incidences (75.64%)happenedduringthedaytimebetween7AMand7PMascomparedtonight.

Inourstudy,allcasesoffatalelectricinjurieswereaccidentalinnature,andwedidnotfoundanycaseofsuicidalorhomicidalelectrocution.

Table No. 5: Cases according to Site of Marks present over body.

Site of Marks No. Percentage (%)

UpperLimb 43 55.12

LowerLimb 19 24.35

Head&Neck 08 10.25

Chest 05 6.41

Abdomen 03 3.84

Total 78 100

Inthisstudy,Upperlimbswerethemostcommonsitestoshowtheelectrocutionmarks,43cases(55.12%).Thiswasfollowedbylowerlimbs19cases(24.35%).

Table No. 6: Cases according to Period of Survival.

Period of Survival. No. Percentage (%)

Instant(Spot)Death 64 82.05

Within24hours 14 17.94

Morethan24hours 10 12.82

Mostofthecaseswerespotdeadwithatotalnumberof64cases(82.05%),while14victims(17.94%) died within 24hours after hospitaladmission.

DISCUSSION

Thewide-spreadcommercialutilizationofelectricalpowerhasbeenassociatedwitharapidincreaseofbothfatalandnon-fatalinjuries.

In the present study, incidence of electrocutiondeathsaccountedfor1.28%oftotal,whichcoincideswithRautji6etalasof1.98percent.Gupta7etalreportedthefigureof2.02%andTirascietal3reported3.3%whichdoesnotconsistentwiththepresentstudy.Intermsofdeathsduetoelectrocutionperonelakhpopulationthefigure turns out to be 4.4.This is significantly higherwhen compared to studies done by Dokovet al8 inBulgariaandLauplandetal9inCanadawhoreportedthefiguresof0.94and0.14respectively.Somedifferenceintheincidencemaybeduetogeographicalvariation.

Most of the victims (33.33%) were in the thirddecadeof their life as themostvulnerable agegroup,which may be due to the fact that this is the mostproductive age group who often remain outdoors insearchofoccupationsandinvolvedinproductionunitsof factories wherein power source is electricity. ThefindingsofthisstudyaresimilartothestudiesconductedbyChakrobortyetal10i.e.26.39%.

Whilemostof thecasesbelonged toyoungerandadultagegroupfrom21to40yearsi.e.65.37%whichalsoconsistentfindingsofstudyofRautiji6.Obviouslymanyfactorslikeilliteracyamongstthegeneralpublicregardingelectricappliances,lackofawarenessaboutthehazardsofelectricity,poormaintenanceofequipment’sandwireliningsetc.musthavebeenresponsibleforany


difference.

Majority of the victimsweremen 70(89.74%) ascomparedtowomen08(10.25%),thisisinconsistencywith the work of other researchers 3,6,7,9 with a male/female ratio of 8.75:1 which coincides with study ofChakrobortyetal10.In the study region generally themales were mostly involved with the household skillfullrepairingworkandinproductionunitoftheworkplacewhile femaleswere involved inhouseholdworkandatworkplacetheywereplacedinsafeenvironmentusuallyofficeworkrespectivelyhencefemalesexposuretoelectricappliancesislessascomparedtomales.

Inmostofthecasesregardingplaceofincidences,male victims were injured by electrocution whentheywere atwork i.e. 39 (50.00%)andworkingwithsome electric source while all the women’s died athomedue to some faultywiring and exposure of livewire of the appliances of routine use. These findingsare coincides with studies conducted by ArdeshirSheikhazadi11&Chakrobortyetal10.ButdoesnotcoincidewithstudyofGuptaetal7asplaceofincidenceishome.

Wemadeaneffort toanalyze thecasesaccordingto seasonal and diurnal variations and observedcharacteristic higher incidences of fatal electrocutionin the season ofmonsoon, a rainy seasonwhich is inthe months of July to September in this area. i.e. 26cases (33.33%), Majority of the incidences (75.64%)happenedduringthedaytimebetween7AMand7PMascomparedtonight.Theseresultswereconsistentwiththe observationsmade byGupta et al.7 andKumar etal.13,whereasSheikhazadietal11foundhigherincidencesof fatalelectrocution insummerseasons.Thewetnessoftheenvironmentinrainyseasonisresponsiblefortheincreasedincidencesaswaterisaverygoodconductorofelectricity.

Mannerofdeathinthisstudywasconcludedwiththe help of alleged history regarding the incidence,informationfrompolicepapers,andfinding’sofautopsyreport,andwefoundthatalldeaths inourstudywereaccidentalinmannerandtherewasnocaseofdeathdueto suicidal or homicidal electrocution.Almost similartypesoffindingswereobservedbyotherauthorsintheirstudiesofGuptaetal7andRautiji6foundonlyonecaseof suicide whereas Sheikhazadi et al 11reported 3.4%casesofsuicide.

Ourstudyshowsthatinmajorityofthecasesupperlimbswerethemostcommonbodypartaffectedfollowedbylowerlimbs,whichissimilartotheobservationsofalmostallotherIndianauthorslikeGuptaetal7,KumarSetal12,Rautjietal6andDokovetal8.

Shows the period of survival of the victims fromfatalelectrocutionanditisseenthat82.05%ofthecasesdiedonthespotandonly10victimsurvivedformorethan24hours.ThefindingsareconsistentwiththestudyfindingsofSheikhazadi11,Kumar12.

CONCLUSION

Electricinjuryvariesfromniltoseveredestructionoftissues,soinallcasesofdeathduetoelectrocutionmeticulous autopsy should be performed to help theinvestigations for thepurposeof compensationand toplan future safety measures. Our study revealed thatthemostofthevictimsweremenagedbetween20and50yearswhodiedatworkingplacedue to accidentalmanner. Hence mere use of nonconductive rubbergloveswhiledealingwithelectricappliancesmighthavebeensavedtheselives.Thisstudyalsoshowsatypicalseasonalanddiurnalvariation,according towhich theincidences of electrocution were typically higher inthe seasonofmonsoon as compared toother seasons.Mostof thecaseswerespotdeadi.e. fatal.Inall thesecases, history regarding the incidence with detailedexaminationofsceneofcrimeandautopsyreportmayhelpustoconcludethecauseofdeathanditsmannersothedatacanbeusedfurthertoplanandimplementthepreventivepoliciestoreducesuchincidences.

Conflict of Interest:None

Source of Funding–Self

Ethical Clearance--- Aretrospectivestudywithoutdisclosure of any identity. Permission of head ofdepartmentistakenforretrievalofdata

REFERENCES

1. ReddyKSN.Theessentialsofforensicmedicine&toxicology. 31st edn. Hyderabad, K SugunaDevi2012:314.

2. Modi JP In:ATextbook ofMedical Jurisprudenceand Toxicology, Kannan K, Mathiharan K(Eds.), 24th ed. Nagpur, India: LexisNexisButterworthsWadhwa,2012.pp.494–96.


3. Tirasci Y, Goren S, Subasi M, Grukan F.Electrocutionrelatedmortality:AReviewof123Deaths in Diyarbakir, Turkey between 1996 and2002.TohokuJExpMed2006;(208):141-45

4. Accidental Deaths and Suicides in India-NationalCrime Records Bureau. Available from: http://www.ncrb.nic.in/CD-ADSI2009/ADSI2009-full-report.pdf.[Lastaccessedon2013Jan2].

5. Lucas J. Electrical fatalities in Northern Ireland.UlsterMedJournal2009;78(1):37-42.

6. RautjiR,RudraA,BehraC,dograTD.ElectrocutioninsouthDelhi:aretrospectivestudy.MedSciLaw2003;(43):350-2.

7. GuptaBD,MehtaRA,TrangadiaMM. Profile ofdeathsduetoelectrocution:Aretrospectivestudy.JIndianAcadForensicMed2012;34(1):13–15.

8. DokovW, Baltov M.A study of Fatal ElectricalInjuiresinSmolyanDistrict.RepublicofBulgaria.Anil Aggrawal‘s Internet Journal of Forensic

Medicine and Toxicology[serial online] 2009; (10):6

9. LauplandKB,Korbeek JB, FinlayC,KirkpatrickAW,HameedSM.Populationbasedstudyofseveretraumadue toelectrocution in theCalgaryHealthRegion1996-2002.CanJsurg2005;(48):289-92

10. PradiptaChakroborty, Prasenjit Das.Epidemiologicalstudyoffatalelectrocutioncases-a mortuary based 3 years retrospective study. J.EvolutionMed.Dent.Sci:2017;6(09);665-67.

11. Sheikhazadi A, Kiani M, Ghadyani MH.Electrocutionrelated mortality: a survey of 295deathsinTehran,Iranbetween2002and2006.AMJForensicMedPathol2010;31(1):42-5.

12. Kumar S, Verma AK, Singh US. Electrocution-related mortality in northern India: A 5 yearretrospective study. Egyptian J Forensic Sci2014;4(1):1–6.

Pattern of Head Injury in Road Traffic Accidents in Mewar Region, Rajasthan: A Retrospective Study at Tertiary Care

Teaching Hospital

Dushyant B Barot1, Sanjeev Kumar Choudhary2, G L Dad3, Rajkumar Patil4

1Assistant Professor, Dr. M K Shah Medical College and Research Centre, Ahmedabad, 2Professor, 3Professor & Head, Department of Forensic Medicine, Geetanjali Medical College and Hospital, Udaipur, 4Professor, Department of Community Medicine, Mahatma Gandhi Medical College and Research Institute, Sri Balaji

Vidyapeeth Deemed University, Pondicherry

ABSTRACT

The incidencesofhead injuries aregrowingwith increasingnumberofhigh speedmotorvehicle,moremovement ofthepublicandmechanizationinindustry.Headinjuryismostcommoncauseofmortalityinroadtrafficaccidents.Aretrospectiverecordbasedstudywasconducted.InformationpertinenttoallheadinjurycasesreportingtoTrauma&EmergencyandNeurosurgeryDepartment,GeetanjaliMedicalCollegeandHospital,UdaipurduringtheperiodbetweenJanuary2015toDecember2015wascollected. The studywasundertakeninvictimsofroadtrafficaccidents tofindoutthepatternofheadinjuries,theirageandsex distributionandsitedistributionofdifferenttypesoffractures.

Thehighestincidence (31.32%) wasseeninagegroupof21-30yearsandamongmales(76.6%).Inpresentstudy,most(49.8%) accidentsoccurredbetween6PMto12AM.Themotor-cyclistswerethecommonestgroupofvictims(38.49%)andfourwheelerbeingthecommonestoffendingvehicles(50.56%).Intracranialhaemorrhageswere seenin248(93.6%)cases,skullfractureswerefoundin190(71.69%)cases.Subduralhaemorrhagewasthecommonest(40.72%)haemorrhageobserved.Linearfractureofskull(24.5%)wasthecommonesttypeandfrontalregion(25.28%)wasinvolvedpredominantly.

Ourstudyshowsthatheadinjuriesareverycommoninroadtrafficaccidents,malesaremostlyaffectedandmainlyfourwheelersaretheoffendingvehiclesresponsibleforaccidentsofmotorcyclistsandpedestrians.Headinjuryisthemainreasonformortalityanditisalarmingandhighlightstheneedforurgentaction.

Keywords: Head Injury, Skull Fractures, Intracranial Haemorrhages, Road Traffic Accidents

Corresponding author:Sanjeev Kumar ChoudharyProfessor,DepartmentofForensicMedicine,GeetanjaliMedicalCollegeandHospital,UdaipurE-mail:[email protected]

INTRODUCTION

Head Injury is defined by the NationalAdvisoryNeurological DiseasesandStrokeCouncilas“amorbidstate resulting fromgross or subtle structural changesin the scalp, skull and/or the contents of the skull, produced bymechanical forces”1. Headisalsoaneasyand successful target for homicidal injuries. Headinjuriesare responsible for morethanone-fourthofall

traumatic deaths and nearly two-third deaths amongroadtrafficaccidentcases2. It is a modernepidemicwithrisingvehiclesdensity,highvelocity,technology,along with congestion of roads and traffic rules violation. Indiahasjust1%ofthetotal vehiclesintheworldbutitcontributes to6%oftheglobal RoadTrafficCases3. The burdenisseriousasmajority ofhead injury victims belong to young andproductiveagegroup.

Unintentional head injuryvarieswithextremesofoutcome from goodrecoveryto death. The lethalityofinjurydependsonamountof strikeforce,skullpropertiesatthepoint ofthecontact,thicknessof scalp,amountofhairandthicknessandelasticityofindividual skull,etc4. It is observed that the victimis more vulnerable in

DOI Number: 10.5958/0973-9130.2018.00138.X


frontalcollision,sidecollisionandifhitbyheavymotorvehicle5.

Although many head injury related studies areconductedfromdifferentpartsofIndia,onlyfewstudieshavebeenreportedfromRajasthanspecificallyMewarregion,thusthepresentstudywasplannedtoknowthepatternofheadinjuryinMewarregionofRajasthan.

MATERIAL AND METHOD

Presentstudyisaretrospectivestudycomprisingof265headinjurycasesfromroadtrafficaccidentvictims.These were reported to Trauma & Emergency and

NeurosurgeryDepartment,GeetanjaliMedicalCollegeandHospital,Udaipur,RajasthanduringJanuary2015toDecember 2015.The studywas undertaken to findout thepatternofheadinjuries, theirage,sexandsite wisedistribution.Aproformawasdevelopedtocollectthe information fromMedicalRecordsDepartment ofthe hospital. Studywas conducted after obtaining thenecessary ethical permission from institutional ethicalcommittee. Brought dead road traffic accident caseswereexcludedfromthestudy.DataentryandanalysiswasdoneMSexcel.Frequenciesandpercentageswereusedtopresentthedata.

RESULTS

Table 1: Distribution of head injury cases according to age and gender (n 265)

Age Group(years) Male Female Number (%)

0-10 7(3.45) 2(3.23) 9(3.39)

11-20 25(12.32) 7(11.3) 32(12.07)

21-30 64(31.53) 19(30.6) 83(31.32)

31-40 46(22.66) 15(24.2) 61(23.02)

41-50 30(14.78) 11(17.7) 41(15.47)

51-60 19(9.36) 6(9.68) 25(9.43)

>60 12(5.91) 2(3.23) 14(5.28)

Total 203 (76.60) 62 (23.39) 265

Mostcommonagegroup involved inhead injurywas21-30 yearscomprisingof31.32%ofthecasesfollowedby23.02%casesinagegroup31-40years. Individualsin the age group 0-10 years were the least affected(3.39%). Outoftotal265cases,majority(76.60%)were male.(Table1)

Table 2: Distribution of head injury cases according to the time of event (n=265).

Time of Incident Number (%)

12AM-6AM 41(15.47)

6AM-12NOON 13(4.9)

12NOON-6PM 79(29.81)

6PM-12AM 132(49.8)

In the present study, nearly half (49.8%) of theincidentsoccurredbetween6PMto12AM. (Table2)

Table 3: Distribution of head injury cases according to site of skull fracture (n 190)

Region of skull involved in fracture Number (%)

Frontal 67(35.26)

Temporal 33(17.36)

Parietal 40(21.05)

Occipital 13(6.84)

Base 15(7.89)

Multiple 22(11.58)

Outof total265, skull fracturewas seen in190cases(73.58%).Outofthese190cases,mostcommonsiteofskull fracturewas frontalbone (35.26%), followedbyparietalbone(21.05%).Total11.58%caseswerehaving


involvementofmorethanonebone.(Table3)

Table 4: Distribution of head injury cases according to type of skull fracture (n 190)

Type of skull fracture Number (%)

Fissure/Linear 65(34.21)

Comminuted 52(27.36)

Depresses 17(8.94)

Hinge 7(3.68)

Multiple(>1Type) 49(25.79)

Among 190 skull fractures commonest type offracture was Fissure/Linear (34.21), followed byComminuted(27.36).(Table4)

Table 5: Distribution of head injury cases according to type of intra cranial haemorrhage (ICH) (n 248)

Types of Hemorrhage Number (%)

Extradural 53(21.37)

Subdural 101(40.72)

Subarachnoid 62(25)

Combined(>1Type) 32(12.9)

Among 265 head injury cases, 248 (93.58%) hadintracranial haemorrhage. Out of these 248 cases,subdural haemorrhage was most common (40.72%).(Table5)

Table 6: Distribution of head injury cases according to offending vehicle and type of road users killed (n265)

Offending VehicleTypes of Road user

Pedestrian Bicyclist Motorcyclist Car/ Truck/ Tractor Total

TwoWheeler 45(44.55) 9(52.94) 27(26.5) 2(4.44) 83(31.32)

ThreeWheeler 7(6.93) 1(5.88) 6(5.88) 1(2.22) 15(5.66)

FourWheeler 36(35.64) 4(23.52) 55(53.9) 39(86.67) 134(50.56)

Undetermined 13(12.87) 3(17.65) 149(13.7) 3(6.67) 33(12.45)

Total 101(38.11) 17(6.42) 102(38.49) 45(16.98) 265

Motorcyclists(38.49%)andpedestrians(38.11%)werealmostequallyinvolvedintheincident.Mostcommonoffendingvehiclewasfourwheeler(50.56%).(Table6)

Table 7: Distribution of head injury cases according to Seasonal variations (n=265).

Season Number (%)

Summer(MartoJun) 85(32.07)

Monsoon(JultoOct) 78(29.43)

Winter(NovtoFeb) 102(38.49)

Winterseason(NovtoFeb)recordedmaximumnumberofcases(38.49%).(Table7)

DISCUSSION

In present study, total 265 subjects were studied.In this study,most of the accident victimsweremale

asmalesareoftenoutoftheirhomesfortheworkandfemalesareinhomes.Similarfindingwasreportedbysomeotherstudies.6,7

Highestnumbersofvictimswere found in the21-30years agegroup, accidentswere least in childrenand old age people.This pattern of age group can beexplainedby thefact thatat theyoungagepeoplearemore mobile, go out for work and may have riskybehavior during driving such as rash driving, alcoholintake;while elderly people and children usually stayathomeandsafe,hencetheyoungaremoreatrisktounnatural events like, road traffic accidents. Similarfindingswereseeninsomeotherstudies.8,9,10,11


In present study, maximum accidents were seenduring6PM-12AM.Itmaybedue toheavytrafficaswellaslowvisibilityduringeveningandnight.Nationalcrimes record Bureau also recorded high number ofdeathsduringeveninghours.12

In our study,most common typeof skull fracture due to head injury was linear fracture andmost common site ofskull fracturewasfrontalbonefracture.Thistypeof fracture ismore common in cases where the headstrikes by forcible contact withabroadresistingsurface in RTA.Similarresultswerereportedbysomestudies.7,8,13

In our study, most common type of intracranial haemorrhage due to head injury wasSubdural type of haemorrhage, followedby subarachnoidhaemorrhage. ThisfindingissimilartoTandleRMetal.9

Themotor-cyclistswere the commonest group of victims, followed by pedestrians. Similar pattern ofvehicleusewasseenbyPathaketal.7 Fourwheelerwasthe commonest offending vehicle being involved in, followedbytwowheeler. Similar typeof involvementwasseenbyothersalso.14-18

Inourstudy,wefoundthatwinterseasonrecordedmaximum number of incidents, followed by summerseason. The Rainy season recorded the least numberofcases.Thiscanbeexplainedbythefactthatduringwinterseason, thereislongerdurationofnightandthusvisibilityispoorformorenumberofhourscomparedtootherseasons.Anotherfactisthatearlyhoursofthe dayarefoggyandthereisslow reactiontimedue to extreme cold affecting both drivers and road users. SimilarfindingswerereportedbyKaulAetal.19 andDhattarwalSKetal.14

CONCLUSION

Ourstudyshowsthatheadinjuriesareverycommonin road traffic accidents, males are most commonlyaffected and mainly four wheelers are the offendingvehicles responsible for deaths of motorcyclists andpedestrians.Headinjuryisthemainreasonformortalityand it is alarming and highlights the need for takingurgentstepssuchasuseofhelmetbyallmotorcyclistsandestablishinggoodpre-hospitalcareandprovisionoftraumaservicesatsite.

Source of Funding – Self

Conflict of Interest–Nil

REFERENCES

1. Vij K. Textbook of forensic medicine andtoxicology. 5th ed. Elsevier India, New Delhi;2011:270-86.

2. ReddyKSN. The EssentialsofForensicMedicineandToxicology.29thed.Hyderabad:KSugunaDevi2009:319.

3. Biswas G,VermaSK, Sharma J, et al. Pattern ofRoadtraffic accidentsin NorthEastDelhi.Journalof Forensic Medicine and Toxicology 2003(20):27-32.

4. DhillonS,KapilaP,SekhonHS. Patternofinjuriespresent in road traffic accident in shimla hills.JournalofPunjabAcademyofForensicMedicineandToxicology2007(7):7-10.

5. Yavuz MS, Asirdizer M, Cetin G et al. The correlationbetweenskullfracturesandintracraniallesionsdueto traffic accidents.AmericanJournalof ForensicMedicine andPathology 2003;24(4):339-45.

6. Honnungar RS, Aramani SC,Vijay Kumar,etal. An EpidemiologicalSurvey ofFatalRoad Traffic Accidents and their Relationship with Head Injuries, Journal of IndianAcademy of Forensic Medicine 2011;32(2):239-42.

7. Pathak A , Desania NL, Verma R. Profile ofroad traffic accidents & head injury in Jaipur(Rajasthan).JournalofIndianacademyofforensicmedicine2008;30(1);6-9.

8. Rastogi AK, Agarwal A, Srivastava AK et al. Demographic Profile of Head Injury Cases inAgra Region. Journal of Indian Academy ofForensicMedicine2012;34(2):117-9.

9. Tandle RM, Keolya AN. Patterns of head injuries in fatal road traffic accidents in a Rural district of Maharashtra- Autopsy based study. JournalofIndian Academy of Forensic Medicine2011;33(3):228-31.

10. Patil AM, Waz WF. Pattern of fatal blunt headinjury: A two year retrospective / prospectivemedico legal autopsy study. Journal of IndianAcademyofForensicMedicine2010;32(2):144-9

11. JhaS,YadavBN,AgrawalAetal.ThePatternofFatalHeadInjuryinaTeachingHospitalinEastern


Nepal.JournalofClinicalandDiagnosticResearch2011;5(3):592-6.

12. National Crimes Records Bureau. AccidentalDeaths and Suicides in India 2012. New Delhi:MinistryofHomeAffairs,GovernmentofIndia.

13. AgarwalSS, SheikhI,KumarL.Cranio–Cerebral Trauma Deathsa post-mortem study on 1-15yrsagegroup.JournalofIndianAcademyofForensicMedicine2005;27(3):103-7.

14. Dhattarwal SK, Singh H. Pattern and distributionof injuriesinfatal road traffic accidents in Rohtak(Haryana).Journalof IndianAcademy of ForensicMedicine2004;26(1):20-23.

15. Sharma BR, SharmaAK, Sharma S et al. Fatal road traffic injuries in Northern India: Can they be prevented?. Trends in medical Research 2007;2(3):142-8.

16. Biswas G, VermaSK,AgrawalNKetal. Pattern ofroad trafficaccidents innorth eastDelhi. JournalofForensicMedicineandToxicology2003;20(1):27-32.

17. AccidentalDeathsinIndia. NationalCrimeRecordBureau, 2007. New Delhi: Ministry of HomeAffairs,GovernmentofIndia.

18. YadavA,KohliA, AggarwalNK. Studyofpatternof skull fractures in fatal accidents in north eastDelhi.Medico-Legal Update2008;8(2):7-12.

19. Kaul A, Sinha US, Kapoor AK et al. An epidemiological studyoffatalroadtrafficaccidentsin Allahabad region. Indian Internet Journal ofForensic Medicine&Toxicology.2005;3(1).

Pattern of Maternal Deaths: A Three Year Autopsy based Retrospective Study

Satin Kalidas Meshram1, Sushim Amrutrao Waghmare2, Santosh Baburao Bhoi2,

Rizwan Allaudin Kamle3, Kunal Bhimrao Shirsat3

1Professor & Head, 2Associate Professor, 3Assistant Professor, Dept. of Forensic Medicine, Dr. V. M. Govt. Medical College and Shree. C.S.M.G. Hospital, Solapur

ABSTRACT

Background: Complete autopsies were important for the establishment of accurate cause of maternaldeathsandanauditofpostmortemmemorandumwasusefultoestablishpatternifanyamongsuchdeaths.Aims:Thisretrospectivestudywascarriedout toknowthedifferentaspectsofmaternaldeaths.Material and method:This threeyearretrospectivestudywascarriedout indepartmentofForensicMedicine&Toxicology,Dr.V.M.GovernmentMedicalCollegeSolapur,MaharashtrafromJanuary2014toDecember2016.Thisstudyisbasedonthemedico-legalautopsyrecordofMaternaldeaths.Results:OverallMMRoftheInstitutionwas369andtheincidenceofmaternaldeathsascomparedtooverallmedico-legalautopsieswas 1.70.A 43.68% of deaths occurredwithin 1-5 days of delivery. 87.37%maternal deaths occurredduringthethirdtrimesterofpregnancies.A55.33%ofdeathswerecontributedasadirectpregnancyrelateddeathsand44.66%werepregnancyassociateddeaths.ConclusionComprehensiveautopsyonallformsofmaternaldeathsisnecessary.Socialawareness,earlydiagnosisofcomplications,earlyinstitutionalization,andtimelytertiarycareshouldbeahighpriority.

Keywords: Maternal deaths, autopsy, maternal mortality.

INTRODUCTION

Maternaldeathisanimportantindicatorofthereachofeffectiveclinicalhealthservices to thepoor,and isregardedasoneofthecompositemeasuretoassessthecountry’s progress. Reliable estimation of levels andtrendsofmaternalmortalityisthusextremelyessential1.

Amaternal death is the death of a womanwhilepregnantorwithin42daysofterminationofpregnancy,irrespectiveofthedurationandthesiteofthepregnancy,from any cause related to or aggravated by thepregnancyor itsmanagement,butnot fromaccidentalor incidentalcauses2.Directobstetricdeathsare those

Corresponding author:Dr. Santosh B BhoiDept.ofForensicMedicine&Toxicology,Dr.V.M.Govt.MedicalCollegeandShree.C.S.M.G.Hospital,Solapur,Maharashtra413003E-mail:[email protected]:9860106123

resultingfromobstetriccomplicationsofthepregnancystate (pregnancy, labour and the puerperium), frominterventions,omissions,incorrecttreatment,orfromachainofeventsresultingfromanyoftheabove.Indirectobstetric deaths are those resulting from previousexisting disease or disease that developed duringpregnancy and which was not due to direct obstetriccauses,butwhichwasaggravatedbyphysiologiceffectsofpregnancy.3

Maternal mortality is a major health problemconcentrated in resource-poor regions. Accurate dataonitscausesusingrigorousmethodsis lacking,butisessentialtoguidepolicy-makersandhealthprofessionalsto reduce this intolerable burden.4 Maternal mortalityis considered a basic health indicator that reflects theadequacy of health care5,6.Making efforts to decreasematernalmortalityrateisamoral,economicandhumanrights related issue. This issue could not be handledwithout investigation of maternal mortality relatedfactors5.Despitenumerousimprovementsinhealthcare,pooroutcomeintheparturientremainsamajorpublic

DOI Number: 10.5958/0973-9130.2018.00139.1


health concern that follows us into the 21st century7.The large regional differences in maternal deathsdemonstratethatmanyofthesedeathsarepreventable8. Avalidandreliableautopsybasedcauseofdeathdataofamotherduringpregnancywouldbeveryusefultounderstandthemagnitudeandrootcauseoftheproblemandtherebytodevelopthehealthpoliciesandprogramstosavethemother’satriskinfuture.

Information provided by medical autopsies hasplayedanimportantrole in increasingtheaccuracyofcause-of-death reports and improving clinical practicein the developed world.9 Autopsies may also provideimportant data on the causes of maternal death, anessentialcomponenttoreducingmaternalmortalityandtodirectingpublichealthefforts4.

Inordertodeterminethecausesofmaternaldeathand other relevant associated factors,we conducted aretrospectivestudy.

MATERIAL AND METHOD

This3year retrospectivestudywascarriedout intheDepartmentofForensicMedicineandToxicology,Dr Vaishampayan Memorial Government MedicalCollege Solapur, aWestern Maharashtra region fromJanuary2014toDecember2016.

Thisstudyisbasedontherecordofmaternaldeathsthathadbeenbrought formedico-legalautopsy in thedepartment.All theautopsieshavebeenconductedbythepanelofexpertscomprisingofForensicMedicine,Pathology,GynecologyandMicrobiologydepartment.Thedetailedpertainingtoperiodlapsedafterdelivery,period of gestation, mode of delivery, outcome ofdelivery and cause of death have been taken frompostmortemmemorandumand investigating agenciesdocuments submitted for requesting autopsy such aspanchanamaandtreatmentrecord.Thedatawasenteredon predesigned data sheet to maintained uniformity,tabulatedandthenstatisticallyanalyzed.

Inclusion criterion:Allthematernaldeathsbroughttothedepartmentduringthestudyperiodeitherdirectlyorindirectlyrelatedtothecomplicationsofpregnancy.

Exclusion criterion: All the un-natural maternaldeaths.

Ethical committee clearance: As the data wasretrospectively collected and as no revelations of

identityethicalcommitteeclearancenotrequired.

Conflict of Interest and Sources of Funding: None

RESULTS

A total 6057 medico-legal autopsies have beendoneduringthethreeyearofstudyperiodoutofwhichatotal103autopsieshavebeencontributedtomaternaldeaths.Atotal27852femaleshavebeenadmittedintheInstitution for delivery hence the Maternal MortalityRatiowastobe369.

Sincemost of the cases succumb to deathwithinthe 24 hours of delivery a total 24 cases (23.30%)inclusiveofcasesdied immediatelyafterdeliveryandbroughtdeadatarrivalofhospital.Butmaximumdeathsoccurredwithin1to5daysofhospitalizationatotal45cases (43.68%). 34 cases (33.00%) have died after 5daysofhospitalizationbutwithin42daysafterdelivery.(Table1)

Maximumnumber90(87.37%)ofdeathsoccurredinthethirdtrimesterofpregnancy,followedbysecondtrimester7.76%andleastinthefirsttrimester4.85%.

In maximum cases 45 (43.68%) CS has beenperformed (outofwhich41casesareofCSonlyandin 4 casesCS has been followedwith hysterectomy).In37cases(35.92%)themodeofdeliverywasvaginaldelivery(outofwhichin2casesvaginalhysterectomyhasbeendone). In14cases (13.59%)nodeliveryhasbeentakenplaceandthedeadfetushasbeenrecoveredduringtheautopsy.(Table2)

Out of 103 cases in 84 cases (81.55%) outcomeofthepregnancyresults intodelivery,7caseswereofabortion (6.79%) and 14 cases remains undelivered(13.59%)whereinmaternaldeathoccursbeforedeliveryandthefetuswasrecoveredduringtheautopsy.(Table3)

Indirect causes account for 38.83% of the totaldeathsduringpregnancy.Amongtheindirectcausesofdeathduring thepregnancyrespiratorysystemdiseasecauses outnumbered all other systems and accountfor a maximum of 20.38% of total deaths followedby gastrointestinal system as 7.76%, Central nervoussystem 5.82%, urinary system 4.85% and lastly bycardiovascular systemaccounts3.88%of totaldeaths.(Table4-A)


A total 63 (61.16%) pregnant females died as adirect result of complications of pregnancy. Amongthe causes of death of obstetric origin post partumhemorrhageaccountsformaximumnumberoffatalitiesi.e. 16.50% followed by puerperal sepsis (9.70%),post-operative hemorrhagic shock (8.73%), Ante-partumhemorrhage6.79%,posteclamptic intracranial

hemorrhageandDisseminatedintravascularcoagulation5.82% respectively, Eclampsia 2.91%, pre-eclamptictoxemia1.39%andin2.91%thecauseofdeathremainsundetermined in spite of meticulous autopsy andthat was either due to decomposition or due to somemetabolic causes rendering the autopsy as a negativeautopsy. (Table4-B)

Table 1: Distribution of maternal deaths according to delivery-death interval.

Periodofsurvivalafterdelivery. Number of cases Percentage

Diedimmediatelyafterdelivery/broughtdead. 2 1.94

Lessthan24hours 22 21.35

1to5days 45 43.68

6to10days 19 18.44

11to20days 11 10.67

Morethan21andlessthan42 4 3.88

Total 103 100

Table 2: Mode of delivery.

Mode of delivery Number of cases Percentage

VaginalDelivery(VD) 35 33.98

CaesarianSection(CS) 41 39.80

CSwithhysterectomy 4 3.88

VDwithhysterectomy 2 1.94

Abortion 7 6.79

Nodelivery 14 13.59

Total 103 100

Table 3: Outcome of pregnancy.

Pregnancy outcome Number of cases Percentage

Delivered 67 65.04

IUD(butdelivered) 9 8.73

Abortion 7 6.79

Stillborn. 8 7.76

Undelivered 14 13.59

Total 103 100


Table 4: Causes of death in maternal mortality.

IndirectCauses

Cause of death Number Percentage

I. Respiratory

Acuteinterstitialpneumonia 16 15.53%

AcuteRespiratoryDistressSyndrome 1 0.97%

Lungabscess 2 1.39%

PulmonaryTuberculosis 2 1/39%

Total 21 20.38 %

II. Cerebral

Meningitis 3 2.91%

Braininfarct 1 0.97%

Intraventricularhemorrhage 2 1.39%

Total 6 5. 82 %

III. GIS

Hepaticfailure 4 3.88%

Peritonitis 4 3.88%

Total 8 7.76 %

IV. Cardiac

Coronaryarterydisease 1 0.97%

Cardiactemponade 2 1.39%

Pericarditis 1 0.97%

Total 4 3.88%

V. Urinary system

Nephritis 5 4.85%

Total 5 4.85%

Total 40

Direct

Cause of death Number Percentage

PostPartumHemorrhage 17 16.50%

Puerperalsepsis 10 9.70%

Hemorrhagicshockpostoperative 9 8.73%

Antepartumhemorrhage 7 6.79%

PosteclampticIntracranialhemorrhage 6 5.82%

DIC 6 5.82%

Eclampsia 3 2.91%

Undetermined 3 2.91%

Preeclamptictoxemia 2 1.39%

Total 63 61.16 %


DISCUSSION

Motherhoodisthebasicrightofeverychildandtopreserveitbydecreasingmaternalmortalityistheprimeduty of every cultured society. In India, theMaternalMortality Ratio was 167 in the year 2013 and theMaternalMortalityRatio ofMaharashtrawas 6811andinourstudyMaternalMortalityRatiowas369.AsthisInstitutionisatertiarycareunitandcomplicatedcasesfromperipheral areasandprivatehospitalsof thecityreferredtothishospitalhencehighMMR.

Period of survival after delivery

In present study 23.30% of cases died within 24hours after delivery while 43.68% succumb to deathwithin1to5daysoftheperiodafterdelivery.

AnnLMontgomerryetal3fromthedatafromIndiareported 51.6% mothers died within 1-5 days afterdeliverywhichnearlycoincideswiththisstudy.WhileJadhavet al12 reported46.83casesdiedwithin the24hours after hospitalization while Panchabhai et al13 reported 31.40%andRatanDas et al14 (WestBengal)85.13%within24hours..VidyadharBangaletal15was39.47%.

Deaths occurred within 12 hours of admissionsuggesting majority patients reach the tertiary carehospitalquitelate.

Hence our study was in consistent with most ofthe studies having similar topographical background.The only contrast arises in the methods of collectionofdata.Mostofthestudieshaveconsideredtheperiodofhospitalizationorhospitalstaywhenthepatienthasbeen treatedafterdeliveryatoutsidecentersandhavebeenreferredonlywhenthepatientwasseriousandindistress,whileotherconsideredtheperiodlapsedafterdeliveryanddeathwhilecollectingthedata.

Period of gestation

In present study maximum number 87.37% ofdeaths occurred in the third trimester of pregnancywhichcoincidewithstudyofAnnLMontgomerryetal3 fromthedatafromIndiareporteddeathinthirdtrimesteroccurred in 82.8% & Panchabhai et al13 (Mumbai,Maharashtra)reported77.62%inIIIrdtrimester.RatanDasetal14reported8.98%,11.71%in1stand2ndtrimesterandcollectively72.28%in3rdtrimesterandpostpartumperiod.VidyadharBangaletal15reported5.26%,23.68

% in1st and2nd trimester and collectively71.04% in3rd trimester and postpartum period. Hence our studycoincideswithmostofthestudiesinthisarena.

High numbers of deaths in third trimester periodindicatethatmostofthepatientsarrivedinadistressedcondition at hospital and much complications ofpregnancy in the advanced stage giving rise to highmorbidityinpostpartumperiodtoo.

MODE OF DELIVERY

Inpresent studymaximumcases45 (43.68%)CShasbeenperformed(outofwhich41casesareofCSonlyandin4casesCShasbeenfollowedwithhysterectomy).In37cases(35.92%)themodeofdeliverywasvaginaldelivery(outofwhichin2casesvaginalhysterectomyhasbeendone). In14cases (13.59%)nodeliveryhasbeentakenplaceandthedeadfetushasbeenrecoveredduringtheautopsy.

AnnLMontgomerryetal3fromthedatafromIndiashowedthatvaginaldeliveryin88.5%andCSin11.5%.Panchabhaietal13reportedVaginaldeliveryin40.43%,Surgicalin19.13%andAbortionin9.75%.

HenceinthepresentstudyrateofCSisathighersidecomparedwithotherstudiessuggestingtheavailabilityofsurgicalmaternalcareinthestudiedregion.

Manystudieshavefoundthattheriskformaternaldeath is significantly greater for women undergoingcesareansectionalongwithspecificrisksofanesthesiathanforthosewhohaveavaginaldelivery.

Outcome of delivery

Inpresentstudyoutof103cases84cases(81.55%)havebeendeliveredbeforedeath,7caseswereofabortion(6.79%) and 14 cases remains undelivered (13.59%)whichcoincideswithstudyofVidyadharBangaletal15 recordedoutcomeofpregnancyasdeliveredin81.57%andundeliveredin15.78%andabortionin2.63%.ThestudycoincidewithVidyadharBangaletal15.Thehigherrateofspontaneousmiscarriagepre-termsuggestiveofhigherratesofartificialabortioninthepopulationofhisstudiedregion.

Causes of death

A total 63 (61.16%) pregnant females died as adirect result of complications of pregnancy. Amongthe causes of death of obstetric origin post partum


hemorrhageaccountsformaximumnumberoffatalitiesi.e. 16.50% followed by puerperal sepsis (9.70%),post-operative hemorrhagic shock (8.73%), Ante-partumhemorrhage6.79%,posteclamptic intracranialhemorrhageandDisseminatedintravascularcoagulation5.82% respectively, Eclampsia 2.91%, pre-eclamptictoxemia1.39%andin2.91%thecauseofdeathremainsundetermined

In our study 38.83%of thematernal deathsweredue to indirect causes. Acute interstitial pneumonia,hepaticfailure,peritonitisaccountedfor15.53%,3.88%and3.88%ofmaternaldeathsrespectively.

AnnLMontgomerryetal3studyfromIndiareporteddirectcausesas81%andIndirectas16%Amongdirectpredominantlyhaemorrhage38%,sepsis11%, Jadhavetal12reportedHaemorrhagein27.84%fromthestudyatSolapur,VidyadharBangaletal15direct50%andindirect50% predominantly among direct were hemorrhage21.05%, Eclampsia 10.52% and sepsis 7.89% RatanDasetal14Eclampsia43.75%,hemorrhage21.87%andsepsis13.28%.ClaraMenedezetal4reportedeclampsiain 8.74%, hemorrhage in 16.6% and indirect causesaccountsfor56.1%ofdeaths.

Hence our study is in consistentwithmajority ofthe studies in this aspect. Even today large numberof maternal deaths is due to the classical triad ofhaemorrhage, sepsis, and eclampsia. All these arepreventable causesofmaternalmortalityprovided thetreatmentstartedintime.

CONCLUSIONS

Reviewofautopsyreportscanprove tobeoneoftheusefulsourcestoidentifypregnancy-relateddeathsand elucidating the emerging trends. But the autopsybased maternal mortality figures does not reflect thetrue picture in the community. Still such review ofmaternaldeathswouldbehelpfulinformulatingclinicalguidelines and health system policies by providinga thorough assessment of cause of death and othercontributoryfactors.

Ethical Clearance: Aretrospectivestudywithoutdisclosureofanyidentity.

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factors,RegistrarGeneralIndia,NewDelhi,

2. WorldHealthOrganization(WHO):WHOHealthReport2005.

3. AnnL.Montgomery,UshaRam,RajeshKumar,PrabhatJha,MaternalMortalityinIndia:CausesandHealthcareServiceUseBasedonaNationallyRepresentativeSurveyPublishedonline2014Jan15. doi: 10.1371/journal.pone.0083331;PMCID:PMC3893075.

4. Mene´ndez C, Romagosa C, Ismail MR,Carrilho C, Saute F, et al.(2008) An autopsystudyofmaternalmortalityinMozambique:Thecontribution of infectious diseases. PLoS Med5(2):e44.doi:10.1371/journal.pmed.0050044.

5. Ahmed A. EI Daba, Yasser M. Amr, HeshamM. Marouf, and Manal Mostafa, Retrospectivestudyofmaternalmortality in a tertiaryhospitalinEgypt,AnesthEssaysRes.2010Jan-Jun;4(1):29–32.

6. Panting-KempA,GellerSE,NguyenT,SimonsonL,NuwayhidB,CastroL.Maternaldeathsinanurbanperinatalnetwork,1992–1998.AmJObstetGynecol.2000;183:1207–12.)

7. HawkinsJL,BirnbachDJ.MaternalMortalityintheUnitedStates:WhereAreWeGoingandHowWillWeGetThere?AnesthAnalg.2001;93:1–3.

8. ChowdhuryME,RonsmansC,KillewoJ,AnwarI,GausiaK,Das-GuptaS,etal.Equityinuseofhome-based or facility-based skilled obstetriccareinruralBangladesh:Anobservationalstudy.Lancet.2006;367:327–32.

9. Sonderegger-Iseli K, Burger S, Muntwyler J,Salomon F (2000) Diagnostic errors in threemedicaleras:anecropsystudy.Lancet355:2027–203

10. BhaskarKMurthy,MangalaBMurthy,andPriyaMPrabhu “MaternalMortalityinaTertiaryCareHospital:A10-yearReview”IntJPrevMed.2013Jan;4(1):105–109.PMCID:PMC3570901

11. censusindia.gov.in/.../Sample_Registration_System.html: Sample registration system -2011CensusofIndia;MaternalMortalityRatioBulletin2011-13.

12. Jadhav CA , Gavandi Prabhakar , Shinde MA ,Tirankar VR” Maternal Mortality: Five YearExperienceinTertiaryCareCentre”IndianJournal


ofBasic&AppliedMedicalResearch;June2013:Issue-7,Vol.-2,P.702-709.

13. Panchabhai TS, Patil PD, Shah DR, Joshi AS“An autopsy study of maternal mortality: Atertiary healthcare perspective” J Postgrad Med2009;55:8-11

14. Ratan Das, Soumya Biswas and AmitavaMukherjee, “Maternal Mortality at a Teaching

Hospital ofRural India:ARetrospective Study”InternationalJournalofBiomedicalAndAdvanceResearch(IJBAR)(2014)05(02)pg155-117.

15. Vidyadhar B. Bangal*a, PurushottamA. Giri b,RuchikaGargMaternalMortalityataTertiaryCareTeachingHospitalofRuralIndia:ARetrospectiveStudy” Int J BiolMed Res. 2011; 2(4): 1043 –1046.

Study of Pattern of Unnatural Deaths in Women of Reproductive Age Group

Anitha Shivaji1, S Harish2, Girish Chandra YP2, Akshith Raj S Shetty3, Chethan Kishanchand4

1Assistant Professor, Dept of Forensic Medicine, Kasturba Medical College, Manipal University, 2Professor, 3Assistant Professor, Dept of Forensic Medicine, MS Ramaiah Medical College, Bangalore, 4Associate Professor,

Department of General Surgery, Kasturba Medical College, Manipal

ABSTRACT

Introduction:Reproductiveageisanimportantcrucialperiodandamarkerforhumandevelopmentandanyimbalancecanaffectthehealthofnextgeneration,socialandeconomicdevelopmentandtherebythesociety.Indianwomenhavehighmortalityrateparticularlyinchildhoodandreproductiveagethecausesofwhichareusuallynatural.Butunnaturalcauseshaveincreasedinrecenttimeswithfactorsaffectingbeingrelationshipbetweenspouseandfamily,statusinsociety,health,educationandfinancialindependence.Theaimofpresentstudyistostudythepatternofunnaturaldeathsinwomenofreproductiveageandtoanalysetheprobablereasonsandthesocioetiologicalfactorsinvolved.

Materials and Method:Thestudyperiodwas16monthsfromSeptember2010toDecember2011,amongautopsycasesofwomenaged15to44years.

Results: Unnaturaldeathcasesinreproductiveagegroupconstituted17%ofwhichmaximumnumbersofcaseswereseeninwomenbetweentheages20-24years.Themannerofdeathbeingsuicideandhanging,poisoningand road trafficaccidentwere themost commoncausesofdeath. Marriedwomenconstitutedmaximumnumberofwhich33.65%caseswerewithin7yearsofmarriage.WomenbelongingtogradeIIIsocioeconomicstatusconstituted57%casesofwhichmaximumwerehousewives.

Conclusions:Unnaturaldeathinwomenofreproductiveageconstitutedsignificantnumberofwhichage20 to24yearswerevulnerable.Suicide constitutedmajorityof the cases.Marriedwomenwithmaritaldisharmonyfollowedbyloveaffair,physicalillnessanddowrydeathwerecommonreasons.

Keywords: Unnaturaldeath,Reproductiveagewomen,mannerofdeath,causeofdeath.

Corresponding author: Dr Anitha Shivaji, AssistantProfessor,DepartmentofForensicMedicine,KasturbaMedicalCollege,ManipalUniversity,Manipal,Karnataka-576104E-mail:[email protected]

INRODUCTION

Aquotebyagreatlaw-giverManu“YatraNaryastuPujyante, Ramante Tatra Devata” meaning the Godsresideinplaceswherewomenareworshipped.WomeninIndiahavedistinguishedthemselvestoplayactiveroles

invariousprofessions.Theyarealsoinvolvedinpoliticsandadministration.Butinspiteofthisameliorationinthestatusofwomen, theevilsof illiteracy,dowryandother marital problems, ignorance, economic slaveryandcrimeslikehomicideandsexualassaultstillexist.Therefore,protectingawomanfromtheseevilsbenefitsnotonlyafamilybutalsooursociety.

Reproductiveageisanimportantcrucialperiodandamarkerforhumandevelopment.Anyimbalanceintheirhealthandstatusinsocietycanaffectthehealth,socialandeconomicdevelopmentofnextgeneration.Naturalcausesofmorbidityandmortalityarecommonamongreproductive age group women. However, unnatural

DOI Number: 10.5958/0973-9130.2018.00140.8


causes have increased in recent times. The factorswhich affect are economic circumstances, education,employment,livingconditionsandfamilyenvironment,socialandgenderrelationshipsandtraditionalandlegalstructurestheylivein.1

Violence against women is an internationallyrecognizedpublichealthproblem,occurringinvariousformsandlevelsofseverityinsociety,homicidebeingthe commonest form. Contrary to the popular belief,women are more than 11-12 times more likely to bekilledbyamantheyknowthanastranger.2

The unnatural death of women is not uncommoninIndiansociety.3Arapidincreaseinunnaturaldeathsespecially in first few years of married life is a darkspot of our society.4 The most obvious reason areunending demands of dowry by their husbands and/or in laws.5 Thepurposeof thispracticewasmeant tohelpnewcouplesstart their life incomfort. Inseveralcommunitiesof India,dowry isamajorconstituent inmarriagenegotiations.6

Deathisunnaturalwhencausedprematurelyagainsttheorderofnaturedue to injury,accident,poisonandother means of violence.7WHO defines reproductiveage in women to be between 15 and 44 years andreproductivehealthas“astateofphysical,mentalandsocialwellbeinginallmattersrelatingtoreproductivesystems at all stages of life.”8 In India 22% of totalpopulationisconstitutedbywomenofreproductiveagegroup.9

Thegender-basedviolenceisamajorpublichealthconcern and an intolerable violation of human rights.TheWHO estimated that rape and domestic violencetogetheraccountfor5%ofthehealthyyearsoflifelosttowomenofreproductiveageindevelopingcountries.Mostabuseandtortureremainshidden,undisclosedtoneighbours, relatives, clinicians and researchers dueto the prevailing values and individual shame, guilt,fear of recrimination and social taboo associatedwithvictimization. In nearly 50 populations based surveysaround the world, from 10% to over 50% of womenreport being hit, physically ill treated or harmedby amaleatsomepointoftheirlives.10

Thesocioeconomicdifferencesinhealthylifestyleareassociatedwiththedifferencesinattitudestowardslifeandaccordinglytheincidencesofphysicalviolence,suicides, etc are encountered. Understanding thevariationsinsociety,betweendifferentformsofinjuriesmayhelptoexplainthemechanism.3

Thefactorsaffectingunnaturaldeathinwomenarerelationshipbetweenspouseandfamilymembers,statusinsociety,health,educationandfinancialindependencewhichare important forwellbeingofawomanoranyperson.Thisstudyaimstoassessthepattern,socialandmedicolegalaspectsofunnaturaldeathsinreproductiveagewomenandestablishingmethodstopreventthem.

MATERIAL AND METHOD

ThestudywasconductedatDepartmentofForensicMedicine, MS Ramaiah Medical College, Bangalorefor 16 months (September 2010 to December 2011).Informationwascollectedfrompoliceandrelativesofthedeceasedwomenbroughtformedicolegalautopsyaged 15 to 44 years and details were entered in aproforma. Standard autopsy protocolwas followed toarriveataconclusion.Allcasesofwomenaged15to44yearswereincludedinthestudy.Caseswhosedeathwasopinedtobeduetoanaturalcauseandunidentifieddeceasedwereexcluded.

Samplesizewasestimatedusingnmastersoftware.Fromthecitedliterature“UnnaturaldeathsinNorthernIndia:AProfile”, to estimate the proportion of deathsamongwomen in reproductive age group consideringtheproportionofroadtrafficaccidentas36%,levelofconfidenceas95%withalphaerrorat5%andrelativeprecision of 20%, the sample size (n) was calculatedtobe171.Inthepresentstudy205caseswerestudied.Descriptive analysis of baseline characteristics wereanalysedandsummarized.

RESULTS

ThetotalnumberofcasesautopsiedfromSeptember2010toFebruary2012are1207ofwhich17%(n=205)cases constituted women of reproductive age group.Maximumnumberofcasesbelongedtoagegroup20-24years (31.70%).Agegroup35-39years (7.80%)wereleastaffected.(Figure1)


Figure 1: Age

Basedonoccupation(table1),46.8%werehousewivesfollowedbyworkingwomenandstudents.Amongthese,suicideaccountedformaximumcasesinalloccupationalcategory.

Table 1: Occupation

Occupation Suicide Homicide Accidental Suspicious Total(n=205)

Professional 07 - 01 02 10(04.88)

Student 32 - 03 01 36(17.56)

Shop/Business 31 - 06 01 38(18.53)

Agriculture 01 - 02 - 03(01.46)

Housewife 79 03 13 01 96(46.83)

Labourer/Maid 13 01 02 02 18(08.78)

Unemployed 04 - - - 04(01.95)

Based on manner and cause of death, 81% hadcommitted suicide followed by 13% of accidentaldeaths. Suspicious and homicide cases accountedfor 3.4% and 1.95% respectively. Suicide by hangingaccounted for 63% of the case followed by 11% ofpoisoningcases.Suicidebyrailwayinjuries,drowningand burns accounted for 3.4% and 2% respectively.Road traffic accident accounted for 10%.Among the4homicidecases,3caseswereduetomanual/ligaturestrangulationand1casewasduetostabinjury.Amongthe7casesofsuspiciousdeathautopsied,4wereopinedasnaturaldeath,followedby2casesopinedassuicideand1casewasaccidental.

As per marital status, 63.90% were married and31.22% were unmarried and remaining were widow/separated.Noneofthemweredivorced.Amongmarried,33.65%weremarriedforlessthan7yearsofwhich11%ofsuicideswereduetodowryharassmentand3outof4casesofhomicidewerealsomarried for less than7years.

Regarding education, maximum number ofwomenwere educated up to high school followed byintermediatedegreeanddiploma.Least incidencewasobserved in women who had a professional degree.Illiteratewomenconstituted5.36%.(Table2)


Table 2: Education

Education No of cases Percentage

Professionaldegree 02 00.97

Graduate 16 07.80

Intermediate/Diploma 44 21.46

Highschool 90 43.90

Middleschool 39 19.02

Primaryschool 03 01.46

Illiterate 11 05.36

Total 205 100

Incidenceofunnaturaldeathwasmoreinsocio-economicstatusgradeIIIfollowedbygradeIIandIV.TherewerenocasesbelongingtogradeIandV.Amongallgrades,suicidebyhangingaccountedformaximumnumberofcases.(Table3)

Table 3: Socio-economic status

SE I SE II SE III SE IV SE V

Suicide - 44 98 25 -

Homicide - 01 03 - -

Accidental - 10 13 04 -

Suspicious - 02 03 02 -

Total - 57(27.80) 117(57.07) 31(15.12) -

Themotiveofdeathinmaximumcaseswasmaritaldisharmony,followedbyloveaffairs,physicalillnessanddowrydeaths.(Table4)

Table 4: Motive of death

MOTIVE FOR DEATH No. Of cases (n=177) Percentage

Maritaldisharmony 26 14.69

Dowrydeath 20 11.30

Extramaritalaffair 10 05.65

Family 10 05.65

Loveaffair 24 13.56

Education 11 06.21

Childrenrelated 07 03.41

Physicalillness 22 12.43


Psychiatricreasons

Depression 16 09.04

Mooddisorders 06 03.39

PostpartumDepression 03 01.69

Financialproblems 12 06.78

Unemployment 0 0

Notknown 10 05.65

Maximumcaseswereseeninnuclearfamilyfollwedbyjointfamily.2%caseswereseeninwomeninlivinginrelationship.(Figure2)

Figure 2: Distribution according to family pattern

DISCUSSION

Thepresentstudyshowedahigherincidencein20-24yearsagegroup,thefactorswhichwereresponsibleweremaritaldisputes,dowryrelatedissues.Similarfindingswere observed by Radhika11and Srivastava5 where inmost victims belonged to 18-25 years. Kulshrestha12

and Rajesh13 reported majority of deaths belonged to26-30 years.According to RosaM. Gonzalez-Guardaetal2,victimsforcontemporaryhomicideriskbelongedtoagegroupof20-44years.NadimAl-Adili14reportedthatwomen aged25 accounted formaximumnumberofcases.HussainRYusufetal15,20-29yearsagegroupwere involved in injury related deaths. Kailash4 andAkhilesh4reportedmaximumincidencein3rddecadeintheirrespectivestudies.

Accordingtomannerandcauseofdeath,thepresentstudyshowedahigherincidenceofsuicidesaccountingfor81%ofthetotalcases.Similarfindingswerenotedby Srivastava5, Radhika11 and studies by Hussain RYusuf15, M KapilAhmad10. However, contrary to ourstudy, Kailash3 reported 53.7% were accidental inmanner,40.4%suicidesand5%werehomicides.Burnsconstituted 49.4%, poisoning 15.8%, RTA 12% and

Cont... Table 4: Motive of death

drowning 10%. Suicide due to dowry was the mostcommon manner. Similar findings were observed byAkhileshPathak4,Kulshrestha12andRajeshC.Dere13

63.90% women were married and 31.22% wereunmarried and remaining cases were widow orseparated.SimilarfindingswereobservedbyKailashUZine3,Kulshrestha12,RajeshCDere13,AKSrivastava5,Radhika11andAkhileshPathak4.

Maximum number of women were educated tillhigh school followed by intermediate degree anddiploma. Least incidence was observed in womenwith professional degree. A K Srivastava5 reported37%womeneducated tillprimaryschool followedbyilliterate women. Kailash U. Zine3 reported 27% and29%wereeducatedtillprimaryandmiddleschooland12.5%wereilliterate.Hussain15notedmaximumcasesin the illiterate group. Similar findings were seen instudybyKulshrestha.12

MostunnaturaldeathsbelongedtogradeIIIsocio-economic status followed by grade II and IV. Nonebelonged to grade I and gradeV. Suicide by hangingwasthecommonmannerofdeath.SimilarfindingswerenotedbyKulshresta12.Kailash3notedmaximumcasesingradeIVfollowedbygradeV.Burnswascommoncauseofdeathinallgradesandaccountedfor34.4%casesingrade IV. Srivastava5 reported 55% women belongedto grade IV followed by grade III.YusufRHussain15 showedmaximum incidence in grade IV followed bygradeIII.

Marital disharmony/love affair, physical illnessand dowry death accounted for maximum numberof cases, followed by depression, extramarital affair,financialproblem,andfamilialdisputes.Thereasonofphysical illness in women who committed suicide asstated by police or relatives could not be observed at


autopsy.Diminishingcapacity foradjustmentbetweenthespouse,infertility,dowryandin-lawsrelatedissueswerecommon.Education relatedmotivesweredue toscoring less marks of failing in any particular exam.Women with known history of depression or mooddisorderswith orwithout treatment attributed to 12%cases.Postpartumdepressionwasobserved in3caseswhocommittedsuicidewithin6monthsafterdelivery,which was elicited in the history. Kailash3 reported44% cases were due to dowry followed by maritaldisharmony, abuse by husband. Similar results wereseenbyKulshrestha12Srivastava5.

Maximum cases were seen in nuclear familyfollowedbyjointfamily.2%caseswereseeninwomenin living in relationship. Similar resultswere seen byKulshrestha12.HoweverBharathK.Guntheti16reportedmaximumincidenceofpoisoninginjointfamilies(63%)followedbynuclearfamily(36%).

CONCLUSION

Women of reproductive age constituted 17% oftotal cases autopsied in the study period. Maximumnumberofcasesbelongedtoagegroupof20to24yearsconstituting31.70%.Agegroup35-39yearswas leastaffectedwith7.80%oftotalcases.Suicideconstituted81%casesfollowedby13%ofaccidentalcases,3.4%caseswassuspiciousand1.95%caseswerehomicidalinmanner.Causeofdeathwasopinedashangingin63%cases,poisoningin11%androadtrafficaccidentin10%cases.Amonghomicidaldeaths,3caseswereopinedasmanualorligaturestrangulationand1casewasopinedas stab injury.Among the7 casesof suspiciousdeathautopsied, 4 were opined as natural death, followedby 2 cases opined as suicide and 1 case opined to beaccidental in manner. Married women constitutedmaximum number of cases with 63.9% cases beingautopsied of which 33.65% cases were married forlessthan7years.57%ofwomenbelongedtogradeIIIsocio-economicgroupfollowedby27.8%fromgradeII.Maritaldisharmonyandloveaffair,physicalillnessanddowrydeathaccountedformaximumnumberofcases.

By addressing the issues related to women andby implementing the preventive measures like usingdedicated suicide help lines for professional andessentiallyconfidentialcareandsupporttothedepressed&thesuicidal,discouragingearlymarriage,pre-maritalcounselling and counselling to dealwith love failure,

exam stress and inter-familial disputes which arereasonforahandfulnumberofcases,unnaturaldeathsinwomenof reproductiveagecanbereduced therebyhelpinginprogressionofthesociety,community,stateandthenation.

The authors declare that there isNo Conflict of Interestregardingthepublicationofthisarticle.

This research received No Funding from anyagency.

Ethical Clearance was taken from the EthicalCommitteeoftheinstitutionbeforestartingtheresearch.

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8. World Health Organization[Internet].[Placeunknown]: Women’s Health; Nov 2009 [cited15.05.2017]. Available from: http://www.who.int/mediacentre/factsheets/fs334/en/


9. Rathi C,Gajria K, Soni N. Review of referredobstetric cases-Maternal and Perinatal outcome.BombayHospitalJournal.2010;52(1):52-56.

10. AhmedKM,Ginneken JV,RazzaqueA,AlamN.ViolentdeathsamongwomenofreproductiveageinruralBangladesh.SocialScience&Medicine.2004;59(2):311-319.

11. RadhikaRH,AnandaK.AnAutopsystudyofSocio-EtiologicalAspectsinDowryDeathCases.Journalof Indian Academy of Forensic Medicine. 2011;33(3):224-227.

12. KulshresthaP, Sharma RK, Dogra TD. The Studyof Sociological and Demographical Variables ofUnnatural Deaths amongYoungWomen in SouthDelhi within Seven Years of Marriage. Journalof Punjab Academy of Forensic Medicine &Toxicology.2002;2:0975-0983.

13. Dere RC, Col. Rajoo KM. Study of UnnaturalDeaths inFemales.AMedicolegalStudyatRuralMedicalCollege,Loni.JournalofIndianAcademyofForensicMedicine.2011;33(3):211-213.

14. Al-AdiliN,ShaheenM,BergstromS,JohanssonA.DeathsamongYoung,SingleWomenin2000-2001

intheWestBank,PalestinianOccupiedTerritories.Reproductive Health Matters.2008; 16(31):112-121.

15. HussainRY,HalidaHA,RahmanHM,ChowdhuryMEK, Rochat RW. Injury related deaths amongwomenaged10-50yearsinBangladesh,1996-97.THELANCET.2000;355:220-1224.

16. GunthetiBK,SinghUP.ThepatternofpoisoninginKhammam.JournalofIndianAcademyofForensicMedicine.2011;33(4):296-300.

17. VanezisP.Deathsinwomenofreproductiveageandrelationshipwithmenstrualcyclephase.Anautopsystudy of cases reported to the coroner. ForensicScienceInternational.1990;47(1):39-57.

18. LeenaarsAA, Dogra TD, Girdhar S, DattaguptaS, Leenaars L.. Menstruation and suicide: Ahistopathological study. Crisis: The Journal ofCrisis Intervention and Suicide Prevention. 2009;30(4):202-207

19. Baca-Garcia E, et al. Suicide attempts amongwomen during low estradiol/low progesteronestates. Journal of Psychiatric Research. 2010;44:209-214.

Study of Distribution, Nature and Type of Injury in Road Traffic Accidents

T Selvaraj1, R Mohamed Nasim2

1Professor and Head. Department of Forensic Medicine, Madurai Medical College, Madurai, 2Assistant Professor. Department of Forensic Medicine, Thoothukudi Medical College

ABSTRACT

Duringoneyearstudyperiod,medico-legalautopsieswereconductedon1800casesoffatalroadtrafficaccidentsatthemortuaryofMaduraiMedicalCollege,TamilNadu.Male:femaleratio3:1,38.8%wereintheagegroupof25-44years.Motorizedtwowheelersweremostvulnerableaccountingfor35%oftotalfatalitiesfollowedbypedestrians30%.Heavyvehicleswerefoundtobemostlyinvolved50.44%ofcasesandmultiple injuriesweresustained inmostnumberofcases.Primary impact injurieswere recorded in900cases,secondaryimpactinjuriesin950casesandsecondaryinjuriesin1200cases.Mostlylowerlimbs28.37%andpelvis26.63%receivedprimaryimpact,headandneck58.62%thesecondaryimpactwhilesecondaryinjuriesweremostlylocatedinlowerlimbs38.38%.

Keywords: Accidents, Primary and Secondary impact injuries, Head injury, Haemorrhage.

INTRODUCTION

Road trafficaccidents tend tobe themost seriousproblemclaimingmanyhumanlivesworldwide.NumberofpeoplekilledinRTAworldwideisestimatedatalmost1.25million,while thenumberof injuredcouldbeashighas50million(1).Currentlymotorvehicleaccidentsareranked9th inorderofdiseaseburden.Nearlythreequarterofdeathsresultingfrommotorvehiclecrashesoccur indevelopingcountry(2).Most important factorscontributingarehumanerrors,poor trafficsense,poorroadcondition,roadencroachmentetc.

Theprimaryroleofautopsysurgeonistofindoutthecauseofautomobiledeathsmayitbeaccidents,rash/ negligent driving, suicide and homicide. Recordingof injuries postmortem may facilitate in awardingcompensationbycourtandinapprehendingdefaultingdrivers.

Thepresentstudyhasbeencarriedouttostudythedistribution, nature and types of injuries in fatal roadtraffic accidents and to suggest possible preventivemeasures.


The present study was conducted at Madurai

Medical College mortuary, Tamil Nadu. The studyperiodwasfromJanuary2016toDecember2016.Thematerial for present study included all deadbodies offatalroadtrafficaccidentsbroughttoMaduraiMedicalCollege mortuary. Only those cases where properrecordswereavailable,wereconsidered.

RTAvictimsdyingwithin21daysofaccidentwereincludedinthestudy.Inthepresentstudy,aroadtrafficaccidentswasdefinedasaccidentswhichtookplaceontheroadbetweentwoormoreobjects,oneofwhichmustbeanykindofamovingvehicle(8).Apretestedproformawasusedtoextractinformationbyinterrogatingpolicepersonally, as well as friends, neighbours, etc. Otherdata was collected from the inquest reports and FIRwerealsostudied.

All 1800 cases were examined in depth atpostmortem for the presence of external injuriesincludingboneandjointsandfinallycharacteristicsofinjurieswereanalysedregardingtheirnature,type,areaofbodyinjuredanddistributionofinjuries.Additionally,placeofdeathofRTAvictims,periodofsurvivalandalcoholicinfluencewerealsorecorded.Safetymeasuresiffollowedornotwerealsonoted.

DOI Number: 10.5958/0973-9130.2018.00141.X


RESULT

Table 1 : Age group and gender involved in fatal RTA

S.NO AGE GROUP MALE FEMALE

1. <10 70 15

2. 10-24 380 70

3. 25-44 450 250

4. 45-64 350 65

5. 65&ABOVE 100 50

TOTAL 1350 450

Table 2 : Types of road - users involved in fatal RTA

S.NO TYPE OF ROAD USERS NO PERCEN-TAGE (%)

1. PEDESTRIAN 540 30%

2. MOTORIZEDTWOWHEELERVEHICLE 630 35%

3. VEHICLEOCCUPANTS 360 20%

4. CYCLISTS 126 7%

5. OTHERS 126 7%

6. UNKNOWN 18 1%

Table 3 : Distribution of external injuries amongst different types of road users

NATURE OF EXTERNAL INJURY

PEDESTRIANS PEDAL CYCLIST

MOTOR CYCLIST UNKNOWN TOTAL

NO % NO % NO % NO % NO %

PRIMARYIMPACTINJURY 326 36.26% 189 21% 169 18.74% 216 24% 900 100%

SECONDARYIMPACTINJURY 362 38.15% 156 16.36% 224 23.64% 208 21.85% 950 100%

SECONDARYINJURY 192 16% 370 30.85% 386 32.15% 252 21% 1200 100%

Table 4: Distribution of injuries on different parts of the body

PART OF BODY INJURED

PRIMARY IMPACT INJURY SECONDARY IMPACT INJURY SECONDARY INJURY

NO % NO % NO %

HEADANDNECK 45 5% 557 58.62% 230 19.18%

UPPEREXTREMITIES 162 18% 146 15.38% 220 28.33%

THORAX 126 14% 27 3% 120 9.97%

ABDOMEN 72 8% 30 3.10% 60 5%

PELVIS 240 26.63% 65 6.78% 110 9.14%

LOWEREXTREMITIES 255 28.37% 125 13.12% 460 38.38%

TOTAL 900 100% 950 100% 1200 100%


Table 5 : Distribution of avulsion, crushing injuries and contre loup injuries amongst different types of road users

S.NO TYPES OF ROAD USER

AVULSION INJURY CRUSHING INJURY CONTRE LOUP INJURY

NO % NO % NO %

1. PEDESTRIAN 136 34.01% 401 42.20% 108 71.77%

2. PEDALCYCLIST 5 1.36% 33 3.4% 9 5.88%

3. MOTORCYCLIST 166 41.50% 282 29.75% 3 2.35%

4. VEHICLEOCCUPANT 90 22.45% 191 20.11% 27 17.65%

5. OTHER - - 30 3.12% 4 2.35%

6. UNKNOWN 3 0.69% 13 1.42% - -

TOTAL 400 100% 950 100% 150 100%

Table 6 : Distribution of visceral injuries

VISCERAL INJURIES NO PERCENTAGE (%)

BRAIN 481 22.92%

HEART&VESSELS 200 9.56%

LUNGS 326 15.50%

LIVER 416 19.82%

SPLEEN 238 11.34%

KIDNEY 178 8.47%

STOMACH 74 3.50%

INTESTINE 187 8.89%

TOTAL 2100 100%

DISCUSSION

Roadtrafficaccidentsareincreasingwithrapidpaceandpresentlytheseareoneoftheleadingcauseofdeathindevelopingcountries.Vandersluisetal(5)hasreportedthattrafficisthemostimportantcauseofsevereinjuriesand three quarters of severely injured caseswho diedduringhospitalizationarevictimsoftrafficaccidents.

In thepresentstudy,a totalof1800casesoffatalroad traffic accidents have been studied in respect todistribution,natureandtypesofinjuries.AmajorityoffatalRTAhavesustainedmultiple injuries.Ekenetal(3)havealsoreportedoccurrencesofmultipleinjuriesin93.5%ofvictims.

Inthepresentstudy,aprepondenanceofmalesoverfemalesM/F ratio 3:1 have been observed.This is incontrasttoratioof9:1asithasbeenobservedbySinghandDhattarwal(2).Highestincidenceoffatalitieshaveoccuredintheagegroup25-44years(33.3%).thisisinaccordancewithKocharetal(4)andSingh&Dhattarwal(2).

Motorized twowheeler drivers have beenmostlyinvolved followed by pedestrians. This can beexplainedbythefactthatlackoftrafficrules,nilorlittleknowledge about traffic sign boards, rash / negligentdriving,narrowroads,drivingunder the influenceandmanyother factors are contributing to the facilities intheregion.

In the present study, heavy vehicles are morecommonly involved in fatal RTA followed by lightvehicles.This canbe attributed tohigh speed,greatermomentum,presenceofsinglespaceroads,overtaking,volume of traffic, etc. The findings are in conformitywithSingh&Dhattarwal(2).

OurfindingsareinvariancewithEkenetal(3)whohaveobservedthatcarandbusesarecommonlyinvolvedin the casualties followed bymotorcycle, lorries, etc.Contributing factors like alcohol in fatal RTA in ourstudyaccountedfor5.5%ofcases.ThisisinvariancewithKocharetal(4)whohavereportedabout28.3%andSoderstrom et al (7) . But this can be attributed to thefact that postmortem detection of alcohol depends onvariousfactorslikegastriclavage,timelapsedbetweenadmissionanddeath,improperviscerahandling,etc.


Multipleexternalinjuriesnotedinmajorityofcases.ThisisinaccordancetoSingh&Dhattarwal(2)primaryimpactinjuriesarenotedin900cases,secondaryimpactinjuries are noted in 950 cases, whereas secondaryinjuriesarenotedin1200cases.Pedestriansaremainlyinvolved in primary and secondary impacts whereasmotorcyclistsaremainlyinvolvedinsecondaryinjuries.

Lower extremities andpelvis aremostly involvedinprimaryimpactinjuriesandheadandneckaremostlyinvolved in secondary impact injuries. Secondaryinjuriesareseenmostlyinlowerextremities(460cases).Crushinginjuriesareresponsibleformoreincidencesofsecondaryinjuries.Inmajorityofcases,frontofvehicleisfoundresponsibleforinitialimpactandroadusersareatfaultinmajorityofcases.ThisisincontrasttoSinghandDhattarwal(2)whonotedthatdriversareatfaultinmajorityofcases(55.6%).

Crushing injuries are noted in 950 cases andpedestrians andmotor cyclists are primarily involved.Lowerextremities,headandneck,pelvisandabdomenin descending order bears the brunt. Degloving andavulsioninjuriesaremorecommoninmotorcyclists.

Brainhasbeenchieflyinjuredinmajorityofcasesfollowedbyliver,legsandspleen(2,3,5).Inthisstudyall1800 cases have sustained injuries, this is in contrastto Eken et al(3) who observed that as many as 100RTAvictimshadnoevidenceofviolenceonphysicalexamination.

Inthispresentstudy, it isobservedthat492cases(27.32%)diedonspot.This is invariancewithSinghand Dhattarwal (2)who have reported an incidence of15.4%on spot.Our study records that a total of 62%ofRTAvictimshavebeenadmittedinhospitalwhereas10.68% have died on way to hospital. This can beexplainedbythefactthatmoretraumacarecentresareavailableintheregion.

RegardingperiodofsurvivaloffatalRTAvictims,wehavenotedthatagreatmajorityofcaseshavediesdwithin24hours.Hencefirst24hoursarequitecrucialforRTAvictims.800casessurvivedbeyond24hours,buttheytoolatersuccunbedtoinjurieswithaperiodof21days.ThisisinaccordancewithSingh&Dhattarwal(2).

CONCLUSION

It may be concluded that there is urgent need toaddresstheepidemicofcarnageontheroads.Inmany

cases fatal RTA’s are caused by human errors andare therefore preventable. A stricter licensing policy,especially for four wheelers, a greater awarenessabout traffic rules, cultivation of road traffic sense,curbing drug abuse, and a proper road networkconformingtothevolumeoftrafficwillgoalongwayincurbingtheincidenceoffatalRTA’s.Moreover,therecommendationsfromtheworldreportonroadtrafficinjury prevention should be considered and promptlyimplemented.

Conflict of Interest : None

Source of Funding : Self

Ethical Clearance: It is retrospective involvingstatistics,ethicalclearanceisnotneededforthisstudy.

REFERENCES

1. WHO: World Report on road traffic injuryprevention.Genevea:WHO;2004.p3-29.

2. Singh Harnam and Dhattarwal SK. Pattern anddistribution of injuries in fatal RTA’s in Rohtak2004;26:20-23.

3. Eke N, Etebu En and Nwosu SO. Road trafficaccident mortalities in port Harcourt. Nigeria.JournalofForensicMedicineandToxicology2000;1:1-5.

4. KocharA,SharmaGK,AtulMurariandRehanHS.Roadtrafficaccidentsandalcohol:Aporspectivestudy.InternationalJournalofMedicalToxicologyandLegalMedicine.2002,5:22-24.

5. VanderSluis.CK,GeertzenJHB,WerkcmanHAandDuisHJT:Epidemiologicaldatafromseverelyin jured patients : A retrospective study over theperiod1985-1989.

6. SrivastavaAKandGuptaRK.AstudyoffatalroadaccidentsinKanpur.JournalofIndianAcademyofForensicMedicine.1989;11:24-28.

7. Soderstrom CA, Dischinger PC, Ho SM andSodestromMT. Alcohol use, driving records andcrashculpabilityamonginjuredmotorcycledrivers.Accidentanalysisandprevention.1993;25:711-16.

8. JhaN,SrinivasaDK,GautamRoyandJagdishS.EpidemiologicalstudyofRTAcases:AstudyfromSouthIndia.IndianJournalofCmmunityMedicine.2004;29:1-8.

A Study – Trends of Unnatural Deaths in Full Moon (Purnima) and No Moon (Amavasya) Conditions as

Compared to other Days

Uttam Solanki1, Vijay Shah2, Hitesh Rathod3, Sunil Surve4

1Assistant Professor, 2Professor and Head, 3Associate Professor, 4Tutor, Department of Forensic Medicine and Toxicology, GMERS Medical College and General Hospital, Gotri, Vadodara

ABSTRACT

AncientbeliefinIndiasaysthatthemoonisthecontrollerofthewater,andcirculatingthroughtheuniverse,sustaining all living creatures. It is believed that themoon, like theotherplanets, exerts a considerabledegree of influence on human beings. It has been observed that people suffering frommental ailmentsinvariablyhavetheirpassionsandemotionalfeelingsaffectedduringfullmoondays.Somepeople,sufferingfromvariousformsofillnessinvariablyfindtheirsicknessaggravatedduringsuchperiods.Low-tidesandhigh-tidesareadirectresultoftheoverpoweringinfluenceofthemoon.Ourhumanbodyconsistsofaboutseventy percent liquid. It is accepted by physicians that our bodily fluids flowmore freely at the timeoffullmoon.Peoplesufferingfromasthma,bronchitisandevencertainskindiseases,findtheirailmentsaggravatedunder the influenceof themoon.Duringafullmoon,apersonmaytend tobecomerestless,irritableandill-tempered.Sameway,humanbehaviorisalsoinfluenced,suchastrafficaccidents,crimesandsuicide.SointhisstudywetookrecordofunnaturaldeathrecordedatSSGHospital,Vadodaraoftheyear2013.Duringtheyear,13nomoondaysand12fullmoondaysrecorded.Totalnumberofincidenceofunnaturaldeathsrecordedis2134.

Keywords: Full moon, No Moon, Accidental death

Corresponding author:Dr Uttam SolankiDepartmentofForensicMedicineandToxicology,GMERSMedicalCollege,Gotri,Vadodara

INTRODUCTION

Theword ‘lunatic’ derived from theword ‘lunar’(or moon) is most significant and indicates veryclearly the influence of themoon on human life. Theorganisms’ behavior throughout a 24-hour periodresults from the interaction between the endogenousprogrammingandthemodificationscausedbyexternalstimuli, both environmental and social. Human andanimal physiology is subject to seasonal, lunar, andcircadian rhythms. Circadian1 and seasonal rhythms 2 arewelldescribed,buttheeffectsofthelunarcycleonhumans have beenmuch less explored.Roman et al.3 haveexaminedtheprevalenceofgastrointestinal(GI)bleeding in relation to the fullmoon.The aimof this

article was to review available data regarding effectsof the lunar cycleonhuman,withparticular attentionpaid tounnaturaldeathsonfullmoondaysandonnomoon days.Benadis et al.4 examined the influence ofthefullmoononthenumberofseizures(epilepticandnonepileptic) recorded in their epilepsy monitoringunit.Theyreportnosignificantdifferenceintheratesofepilepticseizuresaccording to thephaseof themoon,althoughanincreaseinnonepilepticseizureswasnotedduringthefullmoon.


In this retrospective study,we recorded cases ofunnaturalincidenceswhichultimatelyresultedindeathof that person. Incidences are recorded from inquestpanchnama of all cases of the year 2013 from SSGHospital, Vadodara. From 1st January 2013 to 31st December2013,total2134casesarerecorded.DaysoffullmoonandnomoonaredecidedbystandardBAPSswaminarayanpanchang.Total13nomoondaysand

DOI Number: 10.5958/0973-9130.2018.00142.1


12fullmoondaysarerecorded.Unnaturalincidencesrecordedofalldaysofcalendaryear.Comparisondoneofunnatural incidencesonfullmoondayswithotherdaysandunnatural incidencesonnomoondayswithother days byusing standard statisticalT test. In thetest, we compared unnatural incidences recorded on12fullmoondayswithunnaturalincidencesrecordedonother340days.Weexcluded13daysofnomoonforthiscomparison.Similarly,wecomparedunnaturalincidencesrecordedon13nomoondayswithunnaturalincidencesrecordedonother340days.Duringthisweexcluded12daysoffullmoonforthiscomparison.Inthis study we consider death incidence as unnaturalwhich are not natural, meaning that incidences ofaccidents,falls,suicidesandhomicides.

OBSERVATIONS AND DISCUSSION

Inthisstudywehaverecordedcasesofunnaturalincidences on full moon and no moon days, whichultimately resulted in death of the person. Total 12full moon days and 13 no moon days are recorded.Totalnumberofunnaturalincidencesrecordedduringthe year 2013 is 2134, on 12 fullmoondays 89 andon 13 no moon days 76. Total unnatural incidencesrecorded on other 340 days, when we excluded 12fullmoondays and13nomoondays froma year is1969. We found that there is statistically significantrelation, p value 0.016 found during comparison ofunnaturalincidencesrecordedonfullmoondayswithunnatural incidences recorded of other days. Thiscomparisonshowsthatduringtheyear2013,unnaturalincidences which ultimately resulted in death aresignificantlymoreonfullmoondays.Barrreportsthatthementalhealthofpatientslivingwiththeconditionofschizophreniawilldeteriorateduringthetimeofthefullmoon.5Theincidenceofcrimesreportedtothreepolicestationsindifferent townsin theperiodof1978–1982wasalsostudied.6Theincidenceofcrimescommittedonfull-moondayswasmuchhigherthanonallotherdays.Acomplexstudyevaluatedbycomputerwasconductedin Dade County, Florida.7 Homicides and aggravatedassaultsdemonstratedstatisticallysignificantclusteringaround the full moon. Like abovementioned studies,significant correlation found of unnatural incidencesbetween full moon days and other days in presentstudy.Andnocorrelationfoundbetweennomoondaysandotherdays.Asduringcomparison,nostatisticallysignificantresultfound,pvalue0.46.

CONCLUSION

Duringthisstudywecouldfindnumberofunnaturalincidences, which ultimately resulted in death, issignificantly high on full moon days as compared tootherdaysinwhichnomoondayswerenotincluded.

Table – 1 : The comparison of the mean of incidents of full moon days with mean of incidents of other days

Variable 1 Variable 2

Mean 7.416666667 5.791176471

Variance 5.174242424 7.180452889

Observations 12 340

HypothesizedMeanDifference 0

df 12

tStat 2.416953267

P(T<=t)one-tail 0.016248857 p-value

tCriticalone-tail 1.782287556

P(T<=t)two-tail 0.032497714

tCriticaltwo-tail 2.17881283

Table – 1 : The comparison of the mean of incidents of no moon days with mean of incidents of other days

Variable 1 Variable 2

Mean 5.846153846 5.791176471

Variance 5.807692308 7.180452889

Observations 13 340

HypothesizedMeanDifference 0

df 13

tStat 0.080375546

P(T<=t)one-tail 0.468581381 p-value

tCriticalone-tail 1.770933396

P(T<=t)two-tail 0.937162761

tCriticaltwo-tail 2.160368656

Ethical Clearance- Taken from InstitutionalHuman Ethics Committee GMERSMedical College


Gotri, Vadodara (Gujarat) 390021(Registration No.ECR/28/Inst./GJ/2013)

Source of Funding -Self

Conflict of Interest -Nil

REFERENCES

1. HausE,SmolenskyM.H.Biologicrhythmsintheimmunesystem.ChronobiologyInternational. 1999 Sep;16(5):581-622

2. NelsonRJ,DemasGE.Seasonalchangesinimmunefunction. The Quarterly Review of Biology.1996Dec;71(4):511-548

3. RomanEM,SorianoG,FuentesM,Luz-GalvezM,FernandezC.Theinfluenceofthefullmoononthenumber of admissions related to gastrointestinalbleeding.InternationalJournalofNursingPractice.

2004Dec;10(6):292-296.

4. Benadis SR, Chang S, Hunter J,Wang W. Theinfluence of the full moon on seizure frequency:mythor reality?Epilepsy&Behavior.2004Aug;5(4):596-597.

5. BarrW.Lunacyrevisited:theinfluenceofthemoonon mental health and quality of life. Journal ofPsychosocialNursing andMentalHealth Service.2000May;38(5):28-35.

6. ThakurCP,SharmaD.Fullmoonandcrime.BritishMedicalJournal(ClinicalResearchEd.).1984Dec;289(6460):1789–1791

7. LieberAL.Humanaggressionandthelunarsynodiccycle. Journal of Clinical Psychiatry. 1978 May;39(5):385-392.

A Demographic Profile of Voient Asphyxial Deaths at a Tertiary Care Centre- A Five Year Retrospective Study

Biradar Gururaj1, B S Satishbabu2,V Yogiraj3, N G Tejaswini4

1Assistant Professor, Dept. of Forensic Medicine, VIMS, Ballari, 2Associate Professor, Dept. of Forensic Medicine, JJM Medical College, Davangere, 3Professor & Head, Dept. of Forensic Medicine, VIMS, Ballari. 4Assistant

Professor, Dept. of Oral Medicine & Radiology,C.O.D.S, Davangere

ABSTRACT

Fiveyearretrospectivestudywasconductedbyevaluatingatotalof1250deathsduetomechanicalasphyxiafrom01-01-2010to01-01-2015,autopsiedatVijayanagarinstituteofmedicalsciencesatBallari,Karnataka.Analysisoftherecordeddatarelatedtoautopsyexaminationalongwithage,sexofthedeceased,seasonandmannerofdeathwasdone.Asphyxialdeathswere26.59%oftotalautopsiesandnumberofmales(60.00%)was more than females (40.00%). In our study commonest method of asphyxial death was drowning(56.00%),followedbyhanging(40.00%),ligaturestrangulation(2.4%)andthrottling(1.6%).16-30yearsagegroupweremorepronetoviolentasphyxialdeaths(45.28%)andmorecaseswerenoticedinwinterseason(48.0%)constitutingmajorityofaccidentalcases(48.96%).

Keywords: Asphyxia, Hanging, Drowning, Strangulation, Throttling

Corresponding author: B. S. Satish Babu,AssociateProfessor,DepartmentofForensicMedicine,J.J.M.MedicalCollege,Davangere,Karnataka,India577004,Emailid:[email protected]:09986587292

INTRODUCTION OR BACK GROUND

Asphyxia is a state in which there is preventionof exchange of air between the atmosphere and thepulmonary alveoli. Adelson defined asphyxia as thephysiologic and chemical state in a living organismin which acute lack of oxygen available for cellmetabolism is associated with inability to eliminateexcessofcarbondioxide1.Asphyxialdeathsarecausedbythefailureofcellstoreceiveorutilizeoxygen.Thedeprivationofoxygencanbepartial(hypoxia)ortotal(anoxia). The classical signs of asphyxia are visceralcongestion,petechiae,cyanosisandfluidityofblood 2. Asphyxialdeathsmaybecausedbydifferentmethods,such as hanging, strangulation (manual and ligature),suffocations (environmental, smothering, choking,mechanical and suffocating gases), chemical asphyxia(carbon monoxide, hydrogen cyanide and hydrogen

sulphide) and drowning3. Violent asphyxial deathshave contributed considerably to unnatural homicidal,suicidal and accidental deaths4, So it is essential todiagnoseanddifferentiatebetweendifferent asphyxialdeaths,especiallybetweenhangingandstrangulationbyligature. In addition to the cause of death, the carefulexaminationcanalsohelp the investigator toarriveata conclusion aboutmanner of death5. The purpose ofthis studywas to investigate some features related toasphyxialdeathsintheBellaryregionofKarnatakaandtocomparethemwithotherstudies.

MATERIAL AND METHOD

The study comprised of all the cases of deathsdue to mechanical asphyxia that were autopsiedat VIMS,Ballari from 01-01-2010 to 01-01-2015.Hanging,drowning,ligaturestrangulationandthrottlingwere included. Relationship of asphyxial deaths withtheageandsexofthedeceased,seasonandmannerwasanalyzed.Basedonpostmortemreportsandonperusaloftheinformationcollectedfrompoliceandtherelativesofthedeceased,mannerofdeathwasdetermined.

FINDINGS: RESULT

Atotalof4700casesbeingautopsiedinmortuary,

DOI Number: 10.5958/0973-9130.2018.00143.3


outofwhich1250caseswereofmechanicalasphyxia(26.59%).Drowning(700cases;56.00%)wasthecommonesttype of asphyxial death followed byHanging (500 cases; 40.00%),Ligature Strangulation (30 cases; 2.4%) andThrottling(20cases;1.6%)werenoticed.SexwisedistributionandprofileofdifferentasphyxialdeathsareshowninTable01.

Table No. 01: Profile of Asphyxial Deaths

Type of AsphyxiaMale Female Total

No % No % No %

Drowning 400 32.00 300 24.00 700 56.00

Hanging 320 25.60 180 14.40 500 40.00

Ligaturestrangulation 20 01.60 10 0.80 30 02.40

Throttling 10 0.80 10 0.80 20 01.60

Total 750 60.00 500 40.00 1250 100

Wefoundthat16-30yearsagegroupweremorepronetoviolentasphyxialdeath(45.28%),31-45yearsweresecondlargestgroup(32.08%)asshowninTable02.

Table No. 02: Age and Sex Wise Distribution of Asphyxial Deaths

Age (In years)Male Female Total

No. % No. % No. %

Lessthan1 2.0 0.16 2.0 0.16 4.0 0.32

15 108.0 8.64 30.0 02.40 138.0 11.04

16-30 300.0 24.00 264.0 21.12 564.0 45.12

31–45 310.0 24.8 200.0 16.00 510 40.80

Morethan46 30.0 02.40 04.0 0.32 34.0 02.72

Total 750.0 60.00 500.0 40.00 1250 100

Morecasesrecordedinwinterseason(613cases;49.04%)followedbysummerseason(344cases;27.52%)andrainyseason(293cases;23.44%)asshowninTable03.

Table No. 03: Season Wise Distribution of Asphyxial Deaths

Season Male Female Total

No. % No. % No. %

Rainy 200 16.00 93 07.44 293 23.44

summer 150 12.00 194 15.52 344 27.52

winter 400 32.00 213 17.04 613 49.04

Total 750 60.00 500 40.00 1250 100

Thecommonestmannerofasphyxialdeathswasaccidental(612cases;48.96%)innaturefollowedbysuicidal(580cases;46.40%)andhomicidal(48cases;3.84%)showninTable4.


Table No. 04: Manner Wise Distribution of asphyxial deaths

Manner Accidental Homicidal Suicidal Total

Hanging 10 00 490 500

Ligaturestrangulation 02 28 00 30

Drowning 600 10 90 700

Throttling 00 20 00 20

Total 612 48 580 1250

DISCUSSION

Theincidenceofmechanicalasphyxiawas26.59%whichissignificantlymorethantheresultoftheotherstudies6,7,8,9 and in few studies1,10 the incidence waslower.Thisdifference in the incidencemaybedue togeographicalvariationsinthepopulation.

In our study, drowning was the commonest typeof asphyxial death followed by hanging, which isconsistentwith the study7and wasobserved that theincidenceofdrowningbeingthecommonest(56.00%)which could be due to the presence ofwater reservesin the regionof thestudy.Butvariedof thestudiesbyvarious authors1,6,7,9,10,11. According to WHO report20007, Both China and India have particularly highdrowningmortality rates and together contribute 43%of alldrowning deaths worldwide.Most of the deathscausedduetodrowning(nearly97%)occurindevelopingcountrieslikeIndia.Drowningisacommonmethodofcommitting suicide especially amongst women, andmore particularly in localitiesnearby the sea, river,dam or canal.The asphyxial deaths was more in agegroupof16-30yrs(45.28%)whichcanbecomparedto other studies3,5,7,10 , followed by the age group 31-40yrs(32.08%)whichgoesinfavourofanotherstudy7 .Males predominancewas noticed in our study.Thishighincidencemaybebecausemalesaremoreexposedtostress, strainandoccupationalhazardscompared tofemales which is similar to the observations reportedindifferentstudies1,3,5-11.MajorityofcasesoccurredinwinterseasonwhichissimilartothestudybyDhobleetal12butdifferedfromthatofstudybymujamdar13.Allhanging cases were suicidal, which is similar to theother studies14, 15 and is the most commonest methodused to commit suicide.All strangulation cases werehomicidalinourstudywhichissimilartothestudydonebyAzmakD14,15

CONCLUSION

Asphyxialdeathsaccountedfor26.59%ofthetotalautopsiedCases in the period between 01-01-2010 to01-01-2015.

The most frequent method of asphyxial death isdrowning((700cases;56.00%%)followedbyhanging(500cases;40.00%).

Males were twicemore commonly involved thanfemalesandMaletofemaleratiowas3:2.

Manner of death was found to be suicidal in allhanging cases except 10 cases which were due toaccidental. And all throttling cases were homicidaldeaths.

Seasonal asymmetry is observed with maximummortalitiesoccurringduringwintermonthsfollowedbysummermonths.

Conflict of Interest–None

Source of Funding-none

Ethical Clearance–EthicalapprovalwasdeclaredfromtheUniversityethicscommittee

REFERENCES

1. GurudattKS,KumarSA,GoudaHS.Analysisoffatal cases of mechanical asphyxia at Belgaum,Karnataka2011;28(2):51-53.

2. DimaioVJ,DmaioD.ForensicPathology,2nded.Washington,DC:CRCPress;2001:

3. Sharma BR, Harish D, Sharma A, Sharma S,SinghH.Injuriestoneckstructuresindeathsduetoconstrictionofneck,withaspecialreferencetohanging. J Forensic LegMed. 2008 Jul; 15 (5):298-305.


4. ReddyKSN.TheessentialsofForensicMedicine&Toxicology,19thed.Hyderabad:SugunaDeviKMedicalBookCompany;2000:283-295.

5. PatelAP, Bhoot RR, Patel DJ. Study ofViolentAsphyxialDeath.IntJMedToxicolForensicMed2013;3(2):48-57.

6. Tirmizi SZ, Mirza FH, Paryar HA.Medicolegalinvestigation of violent asphyxial deaths – anautopsy based study. JDowUni Health Sci2012;6(3):86-90.

7. Chaurasia N, Pandey SK and Mishra A. AnEpidemiological Study of Violent AsphyxialDeathinVaranasiRegion(India)aKillingTool.JForensicRes2012;3(10):174.

8. SinghA, Gorea RK, Dalal JS, ThindAS,WaliaDA. Study of demographic variables of violentasphyxial death.Journalof Punjab academy ofForensicMedicine&Toxicology2003;3:22-5.

9. GargiJ,GoreaRK,ChananaA,MannG.Violentasphyxial deaths- A six years study. Journal ofIndian Academy ofForensic Medicine 1992; 171-6.

10. Reddy PS, Kumar RR, Rudramurthy.AsphyxialDeathsatDistrictHospital,TumkurARetrospectiveStudy.JIAFM2012;34(2):146-147.

11. Momonchand A, Devi TM, Fimate L. Violentasphyxial deaths in Imphal. Journal of ForensicMedicine&Toxicology1998;15(1):60-4.

12. Socio-Demographic profile of Asphyxial deathsin Female : 2 yr study. Dr. Shashikant V., Dr.ShitalS.Dhoble,Dr.H.G.Kukde.volume5.issue2.february2016.ISSNNo2277-8179Volume:5 |Issue:2|February2016•ISSNNo

13. MajumdarBC.Studyofviolentasphyxiadeaths.JIAFM2002;24(2):8-10.

14. AzmakD.Asphyxialdeaths–Aretrospectivestudyand reviewof the literature.AmJForensicMedPathol.2006;27(2):134-44.

15. ShaikhMMM,ChotaliyaHJ,ModiAD,ParmarAP,KaleleSD.AStudyofGrossPostmortemFindingsinCases ofHanging andLigature Strangulation.JIAFM2013;35(1):63-65.

Epidemiological Study of Cases of Custodial Deaths in North Bengal Region During Last Five Years

Vivek Kumar1, Priyankar Roy1, Rajib Prasad2, Prabir Kumar Deb3

1Assistant Professor,2Associate Professor, 3Professor and Head, Department of Forensic Medicine, North Bengal Medical College, Darjeeling

ABSTRACT

Custodialdeathreferstothedeathofapersoninthepolicecustody,lockuporinthejudicialcustody.Suchdeathsdrawsundueattentionofpublicandmediaaswellasallegationsoftorturebytherelativesofdeceasedonpolicepersonnel.Ithasbeenobservedthatinthepastdecadethetollofdeathsinpolicelock-upsisontherise.Theaimofthestudywastostudyofepidemiologicaldataincasesofcustodialdeathswithspecialemphasistofindoutthecauseandmannerofdeathandrecommendingsomepreventivemeasuretoreduceincidencesofsuchdeaths.Inthisstudy,wehaveanalyzedthe42casesofcustodialdeathsthathadbeenautopsiedinthemortuaryofDepartmentofForensicMedicine,NBMCH,Darjeeling,WestBengalinthelast5years(January2011–November2016).AlldatawereanalyzedwiththehelpofSPSSsoftware.Usingappropriatestatisticaltoolwehavefoundthatmales(95.2%)predominatedoverfemales,custodialdeathsmostlyfoundamongthemiddleaged(45.23%)Hindupopulation(85.7%).64.3%deathswereattributedtonaturalcauses,while9.5%caseswereduetohomicide,11.9%caseswereduetosuicideandin14.3%casesopinionwerekeptpendingtillreceiptofchemicalexaminer’sandhistopathologicalreports.

Keywords – Custodial deaths, Natural deaths, Unnatural deaths, Suicide, Homicide.

Corresponding author:Priyankar Roy,AssistantProfessor,DepartmentofForensicMedicine,NorthBengalMedicalCollege,Darjeeling,E-mailid–[email protected]

INTRODUCTION

Custody as defined by oxford dictionary is“protective care or guardianship of someone orsomething”, whereas as per the legal dialect/sense,“ Custody is defined as any point in time when aperson’sfreedomofmovementhasbeendeniedbylawenforcement agencies, such as during transport priorto booking, or during arrest, prosecution, sentencing,and correctional confinement.”1 Thus, custodial deathincludes the death of a person in the police custody,lockuporinthejudicialcustody.

Any death in police custody is a serious mattercausingpublicconcernevenraisingmajorhumanrightissue.2Ithasbeenobservedthatinthepastdecadethe

toll of deaths in police lockups is on the rise.As perNCRB data, 115 cases of custodial deaths occurredin2013followedby93casesin2014and97casesin2015.3

Such deaths draws undue attention of public andmediaaswellasallegationsoftorturebytherelativesofdeceasedonthepolicepersonnel.Apersondoesnothaveanyconstitutionalrightsincludingaccesstohealthcarewhence brought under custody and the custodialauthoritiesareresponsibleforprovidingsuchcare.Asper theNHRCguidelines, anydeathoccurringduringthecustodyisconsideredasunnaturalandsuchdeathsaretobereportedwithin24hrs.andapanelofdoctorswill conduct the post-mortem examination undervideography.4

It also been found that, unawareness andcarelessness of custodial authorities in healthcareprovisionisthemajorreasonsbehindcustodialdeaths.Unhealthyinhabitableconditionofthecellsworseningthesituationaswell.5

DOI Number: 10.5958/0973-9130.2018.00144.5


The Article 21, which is one of the luminaryprovisions in the Constitution of India, also laysemphasis on the fact that noperson shall bedeprivedofhislifeandpersonallibertyexceptaccordingtotheprocedureestablishedbylaw.

OBJECTIVES

Retrospective study of epidemiological data incasesofcustodialdeathswithspecialemphasistofindoutthecauseandmannerofdeathandrecommendingsome preventivemeasure to reduce the incidences ofsuchdeaths.


Inthisstudywehaveanalysedthecasesofcustodialdeaths(n=42)thathadbeenautopsiedinthemortuaryof Department Of Forensic Medicine, NBMCH,Darjeeling,West Bengal in the last 5 years (January2011–December2016).

All data were analysed with the help of SPSSsoftware.

Table 1: Gender

Sex Frequency Percent

Male 40 95.2

Female 2 4.8

Total 42 100

Table 2: Religion

Religion Frequency Percent

Hindu 36 85.7

Christian 1 2.4

Muslim 5 11.9

Total 42 100.0

Table 3: Age

Age Frequency Percent

Lessthan20 0 0

21-40 15 35.7

41-60 19 45.2

Morethan60 8 19.1

42 100

Table 4: Manner of death

Frequency Percent

Natural(Illness) 27 64.3

Homicidal 4 9.5

Keptpending 6 14.3

Suicide 5 11.9

Total 42 100

FINDINGS

Mostofthevictimofcustodialdeaths(n=42)weremale(95.2%).

Incidences of custodial deaths (45.23%) weremostly belong to the middle age group (i.e. 41 – 60years).

Majorityofcases(64.3%)wereattributedtonaturalcauses(illness)while11.9%caseswereduetosuicide,9.5%casesweredue tohomicideand in14.3%casesopinionregardingthecauseofdeathwerekeptpendingforchemicalexaminer’sandhistopathologicalreports.

CONCLUSION

Most of the deaths happened inside the police orjudicial custodywere due to natural diseases (Illness)followedbysuicideandmiddleagedmalesoutnumberedfemales.

RECOMMENDATIONS

Themostimportantremedialmeasuresisprovisionof proper healthcare facilities, equivalent to thatavailableinthecommunity.

The adequate treatment facility should makeavailable for eachprisoner forgruesomediseases likeHIV,TBandothercommunicablediseases.

Drugandalcoholdeaddictioncenter.

Periodic health checkup and psychologicalcounselling should be done inside the correctionalhomes especially in middle & old aged persons toreducethemorbidityandmortality.

All investigations and autopsies have to beconductedaspertheNHRCguidelines.

Propersecurityarrangementsinsidethecorrectional


homestopreventanytypeofviolence.CCTVcamerasupervision of police station and correctional homeshouldbedone.

Conflict of Interest –NoCOI.

Source of Funding – Self

Ethical Clearance –EthicalclearancewasobtainedfromEthicalcommittee,NorthBengalMedicalCollege,Darjeeling.

REFERENCES

1. Gill J, Koelmeyer TD. Death in Custody andUndiagnosedCentralNeurocytoma.AmJForensicMedPathol2009;30:289–291

2. AgnihhotriAK,GangadinSK.Torturevolume15,Number1,2005

3. www.ncrb.gov.in/

4. www.nhrc.nic.in/

5. Jhamad AR, Sikary AK, Millo T. Analysis ofcustodialdeathsinNewDelhi:A13yearsstudy.JIndianAcad.ForensicMed2014;36:19-22.

A Study of Suicide in Nagpur with Respect to Demographic Profile and Method Adopted for Suicide

Dinesh S Akarte1, Nitin S Barmate1, M S Vyawahare2

1Assistant Professor, Forensic Medicine, Govt. Medical College, Nagpur, Maharashtra, India, 2Professor, Forensic Medicine, Govt. Medical College, Gondia, Maharashtra

ABSTRACT

‘Suicide is characterized as the final common pathway of diverse circumstances, of an interdependentnetworkratherthananisolatedcause,awebofcircumstancestighteningaroundasingletimeandspace1.

Themaximumnumberofsuicideinyoungadult(20-40years)maybeattributedtovariousfactor.Victimwhobelongs toupper lowerclasswhichconstitutes50.33%ofcasesfollowedby lowerclass (17.67%),Mostofthesuicideswereseeninunemployed(26%),ofwhich16%(i.e.46.15%outoftotaloftotalfemale)werehousewivesfollowedbystudents(18.33%).Inpresentstudymostofthevictims,i.e.41.33%caseswereeducatedupto8-12standardfollowedby24.67%casesupto7thstandard,21.34%themethodusedbyyoungadult(20-40)yearsforcommittingsuicideswascommonlyhanging(20.66%)closelyfollowedbyPoisoning60(20%),

Keywords: Suicide, Unemployed, young adult, hanging and poisoning.

INTRODUCTION

‘Suicide is characterized as the final commonpathwayofdiversecircumstances,ofaninterdependentnetwork rather than an isolated cause, a web ofcircumstances tightening around a single time andspace1AsperNationalcrimerecordbureaudataintheyear2013,thetotalunnaturaldeathwas5,68,517outofwhich33,201casesareofhomicide,4,00,517casesofaccidentand1,34,799caseswasofsuiciderespectively.It indicates thathomicideaccount for5.84%,accident70.45%andsuicide23.72%respectively.Thisindicatesthatsuicideissecondmostcommoncauseofunnaturaldeath. Out of all the suicide in India Maharashtraaccounts for 12.33%, of which 523 suicides occurin study region accounting for 3.1% of total suicidein Maharashtra and 0.38% of suicide in India. ThisindicatesthatMaharashtrahasmaximumsuicidalloadallovertheIndia.

Themeansadoptedforcommittingsuicidesvariesfromeasilyavailableandlesspainfulsuchashanging,poisoning and drowning to more painful means suchas self inflicted injuries, burning and shooting etc. Inthe year 2013 out of total suicide hanging accountedfor 39.8%, poisoning 27.9%, Self-Immolation 7.4%

and drowning 5.7% were the prominent means ofcommittingsuicides.2

The present study was performed to evaluate thevariousaspectsofsuicidaldeaths in thisregionwhichmayhelpthesocietytoreducetherateofsuicide.

MATERIAL METHOD

The study was carried out in the Department ofForensic Medicine Government Medical College andHospital,Nagpur.Aprospective studywas conductedfrom Jan 2013 to nov2014. Various informationwas collected from inquest papers, autopsy report,information from relative, police, chemical analysisreportsand treatment record. Thedatawereanalysedby using analysed and tabulated in Microsoft Excelsoftwarepackages.

Inclusion criteria

All the dead bodies brought to department offorensicmedicineformedico-legalautopsywithhistoryofsuicidaldeath.

Exclusion criteria

Unknown,unclaimeddeadbodies.

DOI Number: 10.5958/0973-9130.2018.00145.7


Deadbodiesknownbutnorelativesavailable.

Caseswherethemannerofdeathisdoubtful.

Caseswhere theproperhistoryaboutall theassessingparameters taken in studycouldnotbeelicited frominvestigatingofficersandrelatives.

RESULT

TABLE ON 1- SHOWS SUICIDE WITH RESPECT TO AGE

Sex Number of cases % of cases

Male 196 65.34

Female 104 34.66

Total 300 100%

TableNo.1-showsthatoutoftotal300cases,196weremaleand104werefemale.Maletwotimesofoutnumberthefemale.

TABLE NO: 02 SHOWS THE SUICIDAL DEATHS WITH RESPECT TO AGE.

AgeSex

Total %Male % Female %

Child(0-12) 0 0 0 0 0 0

Adolescent(13-19) 11 3.67 22 7.33 33 11

Youngadult(20-40) 106 35.33 67 22.33 173 57.67

Adult(41-64) 46 15.33 13 4.33 59 19.67

Older65orabove 33 11 2 0.66 35 11.66

Total 196 65.33 104 34.67 300 100

TABLE NO: 3 DISTRIBUTION OF SUICIDAL DEATHS AS PER SOCIOECONOMIC STATUS

Social classMale Female Total

Cases % Cases % Cases %

Lowerclass 33 11 20 6.67 53 17.67

Upper lowerclass 104 34.67 47 15.66 151 50.33

Middleclass 25 8.33 15 5 40 13.33

Upper middleclass 22 7.33 14 4.67 36 12

Upperclass 12 4 8 2.67 20 6.67

Total 196 65.33 104 34.67 300 100

Upperlowerclassconstitutes151(50.33%)cases,ofwhich104(34.67%)casesweremaleswhile47(15.66%)caseswerefemales


TABLE NO 4: DISTRIBUTION OF SUICIDAL DEATHS AS PER OCCUPATION

OccupationMale Female Total


Unemployed 27 9 51 17 78 26

Student 27 9 28 9 55 18.33

Labourer 49 16.33 5 1.67 54 18

Farmer 23 7.67 2 0.67 25 8.33

PrivateService 15 5 7 2.33 22 7.33

Govt.service 13 4.33 6 2 19 6.33

Privatebusiness 42 14 5 1.67 47 15.67

Total 196 65.34 104 34.67 300 100

Maximumsuicideswereseeninunemployed(26%),followedbystudents(18.33%),andleastcasesofsuicidefoundingovernmentservice(6.33%).Outoftotal78unemployedmaximumcasesfoundinwerehousewiveswhichaccountsfor46.16%oftotalfemales.

TABLE NO: 5 DISTRIBUTION OF SUICIDAL DEATHS AS PER LOCALITY

Male Female Total


Urban 161 53.67 80 26.66 241 80.33

Rural 35 11.67 24 8 59 19.67

Total 196 65.34 104 34.67 300 100

Maximumcasesofsuicidaldeathsurbanareaconstitutes241(80.33%)cases,ofwhich161(53.67%)casesweremaleswhile80(26.66%)caseswerefemales.Ruralareasconstitute59(19.67%)cases,ofwhich35(11.67%)casesweremaleswhile24(8%)caseswerefemales.

TABLE NO: 6 DISTRIBUTION OF SUICIDAL DEATHS WITH RESPECT TO EDUCATION

EducationMale Female Total


Illiterate 13 4.34 11 3.66 24 8

Upto7thstd. 60 20 14 4.67 74 24.67

8–12std. 70 23.33 54 18 124 41.33

Graduate 45 15 19 6.33 64 21.34

Postgraduate 8 2.66 6 2 14 4.66

Total 196 65.34 104 34.67 300 100

Maximumcasesofsuicidaldeathinvictimswhowereeducatedupto8-12standardconstitutes124(41.33%)cases, of which 70(23.33%)weremales while 54 (18%) cases were females.While minimum cases found inpostgraduateconstitute14(4.66%)cases,ofwhich8(2.66%)casesweremaleswhile6(2%)caseswerefemales.


TABLE NO: 7 DISTRIBUTION OF SUICIDAL DEATHS WITH RESPECT TO METHOD OF COMMITTING SUICIDE

MethodSex

Total %Male % Female %

Hanging 85 28.34 30 10 115 38.34

Poisoning 71 23.67 30 10 101 33.67

Burns 15 5 33 11 48 16

Drowning 22 7.33 11 3.67 33 11

Railwaycutting 2 0.66 0 0 2 0.66

Firearm 1 0.33 0 0 1 0.33

Total 196 65.33 104 34.67 300 100

Maximum cases committed suicide by Hangingconstitutes 115(38.34%) cases, of which 85(28.34%)casesweremaleswhereas30(10%)werefemales.Whileminimumcasesofcommittingsuicidebyfirearmwhichconstitute1(0.33%)cases.

DISCUSSION

Inspiteof itswiderperspectives, theaetiologyofsuicideisillunderstood.Inthemoderncivilizedsociety,suicideingeneraltermshasalwaysbeendesignatedasacowardlyandshamefulact,eventhoughitisviewedwithsympathyinminorproportionofcircumstances.Aproperunderstandingof these etiological aspectswithrespecttothepractisingareaisaprerequisiteforsuicideinvestigation.Thepresentstudyconsistedof300caseswhocommittedsuicideandweresubjectedtoautopsyatourinstitution.Theresultsofthepresentstudywerecompared with the studies by different workers fromotherpartsofthecountryandabroadaswell.

Age

Inthecurrentstudyoutoftotal300cases,maximumnumberofcaseswereofyoungadults(20-40years).Not a single case of suicide was seen in children(0-12years).

OurstudyisinaccordancewithstudiesofRaneAetal3,TannaJAetal4,KaduSSetal6,,Sahoo,Bardaleet.al5,,SinghPet.al7GururajG8,ElfawalMA9,PCetal10R.,AauerMed11,Ponnuduraietal12,.

The maximum number of suicide in young adult(20-40years)maybeattributedtovariousfactorsuchas:-Prevalenceofpsychiatricriskfactorsinyouthespeciallyconduct disorder, substance abuse or depression, a

higherproportionofyouthinsocietyresultingincreasecompetitionforeducationalaccessorjobopportunitiesandifnotfulfilledmayresultinsenseofhopelessnessordepressioninthemandchangeinfamilystructure.

Theyareatthethresholdofbuildingtheircareerandhavethemostzealandurgetobeaheadofothers.Itwasnoticed that stressdidnot spare even theprofessionalstudents like medical and engineering students whocommittedsuicideafterexamsandresults.Unsuccessfulacademics and romance were attributed to suicide inadolescents.

Socioeconomic status –

Victim who belongs to upper lower class whichconstitutes 50.33% of cases followed by lower class(17.67%), middle class (13.33%), upper middle class(12%) and upper class (6.67%) cases respectively.Present study is in accordance with Tanna JA et al4,KaduSSetal6,andAauerMed11.

Thehigh rateof suicideamong lowerclasscouldbe due to financial and health problems. Because oflowincome,anindividualcannotfulfilthedailyneedsof family. Lower socioeconomic status is linked todomestic crowding, a condition which has negativeconsequencesforadultsandchildren,includinghigherpsychologicalstressandpoorhealthoutcomes.Theyareassociatedwithmanyaddiction(cigarettesmoking)andengaginginepisodicheavydrinking.

Occupation

Most of the suicides were seen in unemployed(26%), of which 16% (i.e.46.15% out of total oftotal female) were housewives followed by students


(18.33%).CurrentstudyisinaccordancewithNCRB2,RaneAet.al3,,andGururajGetal8.B.L.Meel13.

Inour studyunemployed andhousewife accountsfor maximum number of suicide. Unemployed malesfrequently facedebts, familypressure for earning andconsequent mental stress etc. Males are supposed toearnforthefamilyandifheremainsunemployedthereistremendousmentalpressureonhimtoearn,somalesaremoreproneforsuicide.

Housewives are thepersonwithno income.Suchdependentfemalesarefrequentlytorturedphysicallyandmentally,andtheyusesuicideasameanforescapingthetorture.Themostcommoncauseofsuicidaldeathistorturebythein-laws.Itisknownfactthatforthefemaleaftermarriage she has to adjustwith her in laws andotherrelatives.Shehastocompromisewithherdreamsandwishesateverystageaftermarriage.Togetridofallthesethorn–pricks,shepreferscommittingsuicide.

Locality

Maximum suicide (80.33%) were in the peoplelivinginurbanareaswhilepeoplelivinginruralareasconstituted(19.67%)cases.

Our study is in accordance with Rane A et al3 whofoundthatmostofthesuicidepersonswerefroman urban background (70%), rural areas (10%) andsuburbanareas(20%).

It has been proposed that the risk of suicidein general population increases progressively withincreasingdegreeofurbanicityofthelivingplace.

Education

In present studymost of the victims, i.e. 41.33%caseswereeducated up to8-12standardfollowedby24.67%casesupto7thstandard,21.34%

Current study is in accordance with Tanna JA etal4,,KaduSSetal6,GururajGetal8andChandrashekarTN14.

Suicide is more prevalent in persons with loweducationlevelattributedtomanyfactorssuchas lowincomeandunstablejobtothesepersons.Hence,suchpersonswhethermaleorfemalewithloweducationlevelare always vulnerable for committing suicide. More

elusiveisanexplanationofwhymoreeducatedpersonsmightexperiencemoreprotectionviasupportfromthehomethanlesseducatedpersons.Thereforethosewithhigheducationachievedsolidfamilialintegration.

Method use and age

In present study themethod used by young adult(20-40) years for committing suicideswas commonlyhanging (20.66%) closely followed by Poisoning60(20%),Burning(10.33%),Drowning(6%),Railwaycutting (0.33%) and Firearm (0.33%) respectively.TheseallformofsuicideweremostcommoninYoungadult (20-40) years of which hanging and poisoningcontributedalmostequally.

Current study was in accordance with NCRB2,RaneAet al3,Bardale et.al5, R. Elfawal MA9, SahooPC et al10, Ponnudurai et al12,BL.Meel13, andKeithMant15.

Themain reasons forpeoplechoosinghangingasthe most common method of committing suicide areeasyavailabilityofligaturematerial,simpleprocedure,immediate,painlessandsuretyofdeath.Poisoningwassecond common method of committing suicide afterhangingduetothefactthatitiseasilyavailableandnostrictlegislationforacquiringpoison.Suicidebyfirearmis least commonly encountered method which mayattributetofactorslikelessaccessibility,highcostandstrictlawenforcementinbothregardtopossessionandusageoffirearms.

SummaryandConclusions

Deathsarealwayspainfulforfamiliesandfriendsbutsomearemoretragicthanothers.Suiciderepresentsamajorpublichealthproblemandadrainonoureconomywith loss of human resources. The current studywascarried outwith the aim to analyse and aware aboutthevariousaspectofsuicide.andsuggestthelegalandpreventivemeasures.Keepinginmindthesignificanceand importance of knowing the scenario of suicides,thepresentstudyentitledas‘Studyofsuicidaldeathincentral Indian population’was undertaken.Maximumnumberofcaseswasinyoungadult(20-40years.Malesnearly two times outnumbered the females. Majoritywerebelongingtoupperlowerclasswhichconstituting50.33% cases followed by lower class 17.67% casesMaximum suicideswere unemployed (26%) cases, ofwhich16%(i.e.46.15%outoftotaloftotalfemale)were


housewivesfollowedbystudent(18.33%)cases.Urbanvictims constituting 80.33% cases outnumbered rural19.67%cases.Majorityofvictimswereeducatedupto8-12standardi.e.41.33%casesfollowedbyupto7th.Overallmostcommonmethodforcommittingsuicidewas hanging (38.34%) cases followed by poisoning(33.67%)cases.

No Conflict of Interest and No Source of Funding.

Ethical Approval. No: Takenfromthecommittee.156-57/2013Date24/01/2013.

REFERENCES

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2. Suicide in India .National Crime Record Bureau.Ministry of Home Affair. (internet)2013.Retrieved from: http://ncrb.gov.in/ suicides2013.pdf;p.169-189.

3. RaneA,NadkarniA.SuicideinIndia:asystematicreview. Shanghai Archives of Psychiatry. 2014;26(2):69-80

4. JATanna, PNPatel, SDKalele. PsychologicalautopsyofsuicidecasesinBhavnagargujrath,india.medico-legalupdatejan-jun2013,vol.13,no1.

5. Bardale R, Tumram N, Dake M, Shrigiriwar M,Dixit P. Trends of suicide in urban area:a 5 yearstudy. IntJmedToxicalLegalMed.2011;13(3):28-37.

6. Kadu S S, Asawa R.Medicolegal evaluation ofsuicidal deaths in rural area. journal of forensicmedicineandlaw.Jan-Jun2011;20(1):8-11.

7. SinghP,MarakFK,LongkumerK,MomonchandA.Suicidesinimphal.JIAFM.2005;27(2):85-86

8. GururajG,IsaacMK.EpidemiologyofsuicidesinBangalore.NationalInstituteofMentalHealthandNeuroSciences,publicationno.43;2001.

9. Elfawal,MA.Cultural influence on the incidenceand choiceofmethodof suicide inSaudiArabia.American journal of forensic medicine andpathology.1999;201:163–68.

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11. Aauer Med. “Suicide by drowning in UusimaaProvince inSouthernFinland”.Medicine,ScienceandLaw.1990;30(2):175-179.

12. RPonnudurai,JJeyakar.Suicideinmadras.IndianjournalofPsychiatry.1980;22:203-5.

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14. Chandrashekar TN. “A study of incidence ofsuicideduringdifferentphasesofMenstrualCycle”.International Journal of Medical Toxicology andLegalMedicine.2001;3(2):30-32.

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Lip Prints and its Relationship with Angle’s Classification of Molar Relation- An Observational Study

Uma Maheswari T N1, Archana Venugopal2

1Professor, 2Post Graduate, Department of Oral Medicine and Radiology, Saveetha Dental College and Hospitals, Saveetha University, No-162, Poonamallee High Road, Velappanchavadi, Chennai

ABSTRACT

Introduction: InOrthodontics, competency of lip is one of themost important assessment to be donefortreatmentplanning.Therearestudiesoncorrelationoflipprintsandskeletalmalocclusions,andnotmuchstudiesfocusedonrelationshipbetweenthelipprintandmolarrelation.OcclusionhasbeenbroadlyclassifiedasClassI,ClassIIandClassIII.Thisstudyaimsinstudyingtheprevalenceof5typesoflipprintsin threedifferentgroupsofmolar relation. Theresultsof thisprevalencestudy,mayaid inevidence inpersonalidentificationinthefieldofForensicOdontology.

Aim:TofindifthereisanysignificantrelationbetweenthetypeoflipprintandtheAngle’smolarrelation.

Materials and Method:60subjectswereincludedandweredividedtothreegroupscorrespondingtotheAnglesclassificationofmalocclusionasClass-I,Class-IIandClass-III.20subjectswereincludedineachgroup.Thelipprintpatternofallthe60subjectswastracedusinglipstickonacellophanetapeandwaspastedonachartpaperforfutureanalysis.Therelationbetweentypeoflipprintandthetypeofmolarrelationwasassessed.

Results: ThecorrelationcoefficientwasestablishedtoassessrelationshipwithAngle’sMolarrelationandlipprintswhichprovedtobestatisticallyinsignificant(p->0.05).

Conclusion: Type I is themost prevalent lip print in all the 3molar relations.There is no significantrelationshipbetweenthetypeoflipprintandthemolarrelation.Unique12digitlipprinttypingestablishedinthisstudycanbefurtherexploredtoprovethesignificanceoflipprintinbiometrics.

Keywords: Dental Malocclusion, lip print, forensic odontology, Angle’s Molar relation

Corresponding author: Dr. Uma Maheswari T NProfessor,SaveethaDentalCollegeandhospital,SaveethaUniversity,No-162,PoonamalleeHighRoad,Velappanchavadi,Chennai-77Emailid:[email protected]:09840958339

INTRODUCTION

Everyindividualisuniquesoaretheirfeatures,likefingerprintandlipprintthatdonotchangesignificantlywith age(1). These features have largely been used inforensicodontology.

Forensic odontology is that branch of forensicmedicinewhichintheinterestofjusticedealswiththeproperhandlingandexaminationofdentalevidenceandwiththeproperevaluationandpresentationofthedentalfindings.(2)

The main purpose of forensic odontology is toidentify individuals with their unique features after amassdisasterlikeearthquake,landslide,flood,tsunamietc, by comparing the ante mortem and post mortemrecord(3). For this to be carriedout a proper treatmentrecord has to be maintained by the dentist. Lips aresoft tissues thatcanbedestroyedwith time,hence lipprintsarenotmuchusedinpostmortalidentification.Lip print patterns are used in individual identificationin criminology(4) . The tooth in the jaw are the best

DOI Number: 10.5958/0973-9130.2018.00146.9


identification tool even at a latter period after thedisaster, as they are not destroyed by heat or otherphysical changes. So the molar relation can also beusedastoolinforensicodontology.Themolarrelationbetween the upper and the lower jaw can also be animportantantemortemrecord.

The wrinkles and grooves on the labial mucosaextendingfromtheregionthatchangesfromthelabialmucosa to the outer skin is called sulcus labiorum(5). This forms the characteristic pattern which is calledthelipprint.Lipisavitaltissuethatisanalyzedduringeveryorthodontictreatment.Howeverlipprinthasnotbeenrecordedasanantemortemrecord.

There are studies that correlates the skeletal jawrelationwithlipprints.Thisisthestudythatcorrelatesthesagitalocclusionoffirstpermanentmolar,classifiedasAnglesClass I,Class II andClass IIIwith5 typesof lip prints. Development of lip occurs during thesixthweekofintrauterinelife(5),whiletheeruptionof1st permanentmolar occurs from 6 to 7 years of age.The objective of the study is to know if there is anyrelationbetweenthemolarrelationandthelipprinttypeof the individual, there by using them together as anidentificationtoolinmassdisaster.


In the current study a sample size of 60with 20ineachgroupofClass-I(GroupA),Class-II(GroupB)and Class III(Group C) molar relations(6) were taken.Individualsintheagegroupof15-60weretakenwithall their teethwithorwithout3rdmolarwere includedthestudy.

CLASSI-

Themesiobuccalcuspof thepermanentmaxillaryfirstmolar occludes at themesiobuccal groove of thepermanentmandibularfirstmolar.(Figure1)

CLASSII-

Themesiobuccalcuspof thepermanentmaxillary first molar occludes mesial to the buccalgrooveofthepermanentmandibularfirstmolar.(Figure2)

CLASSIII-

Themesiobuccalcuspofthepermanentmaxillaryfirstmolaroccludesmesialtothebuccalgrooveofthepermanentmandibularfirstmolar.(Figure3)

Figure 1:CLASS I MOLAR RELATION

Figure 2:CLASS II MOLAR RELATION

Figure 3: CLASS III MOLAR RELATION

The individuals with any missing tooth or anylesionsof lipordevelopmentaldisturbancesof the lipor any surgery hindering the morphology of the lipwere excluded from the study. Informed consentwasobtainedfromalltheparticipants.Afterthisprocedurethe maxillary and mandibular molar relation wasassessed.Thenthelipwaswipedcleanandlipstickwasappliedwithcottonbudallover the lip, everychanceofcrosscontaminationwaseliminated.5cmlongcellotapewasplacedover the lipand gentlepressurewasapplied. Then the cello tapewas peeled off fromonecorneroftheliptotheotherandpastedonachartpaper.Thewholelipwasdividedinto12compartmentswitheachof upper and lower lip into 6 compartments andeachquadrantofrightupper,leftupper,rightlowerandleft lowerinto3compartments (7).Amagnifyingglasswas used to examine the lip pattern in each quadrantand was typed according to Suzuki and Tsuchihashi


classification(1974)

FIGURE 4: Types of lip print

RESULTS

Inthisstudy41femalesand29maleswereincluded.GroupA(ClassI)included7maleand13female,GroupB(Class II) included 6 male and 14 female, GroupC(ClassIII)included6maleand14female.ThemeanageofpatientsinGroupA(ClassI)hadameanageof27.75+/-8.552years, inGroupB(ClassII)hadameanageof26+/-8.55,andthoseinGroupC(ClassIII)hadameanageof27.85+/-11.96years.

After analyzing 60 lip prints in 12 compartmentsa 12 digit coding was generated for each of the 60samples.Fromtheaboveanalysisof12quadrantsofthelipitwasfoundthattheeachlipprintwasunique.Therebymakingthethreedigittypingineachquadrantoflipanditscombinationwiththemolarrelationunique.

There was no significant correlation between theliptypingandtheageandsexofthepatient.Thestudyalsoprovedtherewasnocorrelationbetweenthemolarrelationandthetypeoflipprint(Table1).HoweverthepredominatetypeoflipprintinthedifferentquadrantsofdifferentgroupremainstobeType1(Table2).

TABLE 1: Correlation between the molar relation and the lip print type

Quadrant R Value P Value

Rightupper 0.093 0.480

Leftupper 0.066 0.619

Leftlower 0.240 0.065

Rightlower -0.118 0.369

TABLE 2: The predominant type of lip print in each quadrant for each group

GROUP QUADRANT TYPE OF LIP PRINT

GroupA

Rightupperquadrant TypeI

Leftupperquadrant TypeI

Leftlowerquadrant TypeI

Rightlowerquadrant TypeII

GroupB


Leftupperquadrant TypeIandTypeV

Leftlowerquadrant TypeI,TypeIIandTypeIII

Rightlowerquadrant TypeI

GroupC


Leftupperquadrant TypeI

Leftlowerquadrant TypeIII

Rightlowerquadrant TypeII

DISCUSSION

Themolarrelationslikethelipprintarefoundtobehereditary.Cheiloscopyand its relation to theskeletalmalocclusion has been previously discussed In twostudies (8,9), but there were no study correlating theAngle’smolarrelationwithlipprint.ThestudybyUmaMaheswari et al(7) in the year 2010 in 750 samples,analyzedthetypeof lipprint in12compartmentsforthefirsttime.Thisstudyhasfollowedasimilarwayofanalysisandinaddition12digitcodeforeachlipprintwasgeneratedtoprovetheuniquenessofthelipprint.


In agreement with the study by Vahanwala andParekh(10) done in Indian population, current studyfoundverticalprintstobethemostcommonpattern.Onthe contrary, study by Sivapatha Sundaram(11) foundintersecting lippatternwaspredominateandVergheseetal(12)foundreticularpatternishighlypredominate.In comparison of observations reported by previousstudiesbyTsuchihashi(5)andPradeepRagavetal(9),current study proves there is no significant variationbetweenthelipprintofmaleandfemaletherebystatesthereexistsnosexualdimorphismbetweenthem.

PreviousstudybyPradeepRagavetal(9)donein114subjectsfromtheagegroupof18-30foundreticularpatterntobesignificantlyhighinclassI,ClassIIdidnotshowanypredominanceoflipprinttypingandverticalpatterntobehighinskeletalClassIII.WhilethestudybyNarayanKulkarnietal(8)donein90subjects,statedType-I.Type-IIIandType-II,Type-IIITypesoflipprinttobepredominantinclassI,Type,Type-IIcombinationto be predominant in Class II and Type I, Type IVand Type III, Type IV to be predominant in ClassIII.Both the studies(8)(9)(p-0.05), state no significantcorrelation between the lip print type and the skeletaljawrelation.Unlikethepreviousstudydonetocorrelatethe skeletal jaw relation and the lip print by PradeepRagavetal(9)andNarayanKulkarnietal(8),currentstudyhasfoundthedominantlipprintineachquadrantseparately.Thecurrent study saysverticalpatternandbranchedgroovetobedominantinClassI.Theverticalgrooves,forkedgroovesandreticulargroovesexcept, intersectedgrooves tobedominant inClass II .Theverticalgrooves, fork shapedgrooves and intersectinggrovestobedominantinclassIII.Howeverthestudydidnotshowasignificant(p->0.05)differenceinthelipprintbetweenthegroups.

Correlationstudiesdoneinlipprintpatternincludestudy done with blood group(13)(p->0.05)fingerprint(14)(p-not mentioned), caries (15)(p-0.725) andskeletal jaw relations(8)(9)(p->0.05). This study hasprobed for the prevalence of the lip print pattern indifferent molar relations. This study proves the needtouselipprintasantemortemrecordandalsoshowsthereislesspossibilityofusinglipprintasapredictorofAngle’smolarrelation.

The current study concludes lip prints cannotbe employed for recognition of molar relation in theexperimental population. However the study also

concluded Type I lip print to be predominant in thepopulation with no sexual dimorphism or variationswith age. The future recommendations of this study,henceisnotinsupportofcorrelationstudyoflipprintwithanydisorders.Theunique12digitcodingsystemgeneratedforlipprintsamplescanbefurtherexploredusing technologic innovation toprove thesignificanceandapplicationoflipprintinbiometrics.

Conflict of Interest: Noconflictofinterest

Source of Funding: Selffunded

Ethical Clearence: Ethicalclearanceobtainedfromscientific review board of Saveetha Dental College,SaveethaUniversity.

REFERENCE

1. Randhawa K, Narang RS, Arora PC. Study oftheeffectofagechangesonlipprintpatternandits reliability in sex determination. J ForensicOdontostomatol.2011Dec1;29(2):45–51.

2. O’Shaughnessy PE. Introduction to forensicscience. Dent Clin North Am. 2001Apr;45(2):217–227,vii.

3. PramodJB,MaryaA,SharmaV.Roleofforensicodontologistinpostmortempersonidentification.DentResJ.2012;9(5):522–30.

4. Utsuno H, Kanoh T, Tadokoro O, Inoue K.Preliminary study of postmortem identificationusing lip prints. Forensic Sci Int. 2005 May10;149(2–3):129–32.

5. Suzuki K., Tsuchihashi Y. A new attempt ofpersonalidentificationbymeansoflipprints.CanSocForensicSciJ.1971;(4):154–158.

6. Angle’s classification of malocclusion[Internet]. TheFreeDictionary.com. [cited2017 May 21]. Available from: http://medical-dictionary.thefreedictionary.com/Angle%27s+classification+of+malocclusion

7. Paper5:RoleofLipprintsinPersonalIdentificationandcriminalizationbyT.N.UmaMaheswari&N. Gnanasundaram: Anil Aggrawal’s InternetJournal of Forensic Medicine: Vol. 12, No. 1(January-June2011)[Internet].[cited2017May21]. Available from: http://www.anilaggrawal.com/ij/vol_012_no_001/papers/paper005.html

8. Kulkarni N, Vasudevan S, Shah R, Rao P,


BalappanavarAY.Cheiloscopy:Anewroleasamarker of sagittal jaw relation. JForensicDentSci.2012;4(1):6–12.

9. Raghav P, Kumar N, Shingh S, Ahuja NK,Ghalaut P. Lip prints: The barcode of skeletalmalocclusion. J Forensic Dent Sci. 2013;5(2): 110–7.

10. VahanwalaSP,ParekhBK.Studyoflipprintsasanaidtoforensicmethodology.JForensicMedToxicol.2000;17:12–8.

11. sivapatha sundaram, ajay prakash, siva kumargopalakrishnan.LipPrints(Cheiloscopy).IJDR.2001Dec;12(4):234–7.

12. A. J. Vergese, Soma sekaran, Umesh Babu.A Study on lip print types among the peopleof Kerala. J Indian Acad Forensic Med. 2010Jan;32(1):6–7.

13. Rahulpateletal,AssessmentofcorrelationoflipprintwithgenderandbloodgroupamongdentalstudentsofVisnagar,Gujrat, India.IJPPS.May-Jun2015,1(1);14-18

14. Murugan1 M, Karikalan2 T. study of telativecorrelationbetweenthepatternoffingerprintandlipprint.JEMDS.2014oct;56(3):12768-12772

15. 785_IJAR-6356.pdf [Internet]. [cited 2017 Jul15].Availablefrom:http://www.journalijar.com/uploads/785_IJAR-6356.pdf.

Awareness & Practice of Patient Rights – A Cross Sectional Study in a Teaching Hospital in Telangana

Prashanth Mada1, Punuri Sanjay2, G Surendar Reddy3

1Associate Professor, Forensic Medicine & Toxicology, Apollo Institute of Medical Sciences & Research, Apollo Health City Campus, Jubilee Hills, Hyderabad, Telangana, 2Associate Professor, Forensic Medicine & Toxicology,

Alluri Sitarama Raju Academy of Medical Sciences, Eluru, West Godavari, District, Andhra Pradesh, 3Professor & HOD, Forensic Medicine & Toxicology, Apollo Institute of Medical Sciences & Research, Apollo

Health City Campus, Jubilee Hills, Hyderabad, Telangana

ABSTRACT

Introduction: Ahealthydoctor-patientrelationshipiscardinalineffectivetreatmentofthepatient.Thisrelationshipstrengthenswhenthephysicianrespectsthepatientrights.Improvementinqualityofhealthservicesispossiblewiththepatients’contributionintreatmentprocess.Thiscanbeaccomplishedonlywhenpatientsareawareoftheirrights.Giventhis,currentstudywastakenuptoevaluatepatients’awareness&practiceoftheirrights.

Method: Thiswasacross-sectional,questionnairebasedstudy,inwhichthesubjects,wererecruitedfromoutpatientdepartmentsandinpatientwardsofthehospital.In&outpatientsofpsychiatryandpediatricdepartmentswereexcluded.

Results: Ofthe300subjects,97%hadawarenessthattheycanconsentorrefuseanyspecificorallmeasuresand85%knewthatthedoctorsshouldkeepallinformationabouttheirillnessconfidential.Thoughawarenesstoexpresstheirgrievanceswashigh,thephysicianspracticetoaddresstheseissueswaslow.Statisticallysignificantassociationwasobservedbetweenliteracystatusandawarenessofpatient’srightsfor14ofthe15itemstestedandforpracticeofgivinginformationaboutillness,treatmentoptionsandgivingopportunityinmakingdecision.

Conclusion: The awareness among patients regarding rights needs to be increased, and the awarenessamongphysiciansregardingcommunicationofalltheissuestothepatientsneedstobeincreasedwhichwillincreasepracticeofpatientrights.

Keywords: Patient rights, awareness, practice

INTRODUCTION

Ahealthy doctor - patient relationship is cardinalineffective treatmentof thepatient.Oneof thefacetsof healthy doctor-patient relationship is the physician

Corresponding author: Dr. P. Sanjay,AssociateProfessor,ForensicMedicine&Toxicology,AlluriSitaramaRajuAcademyofMedicalSciences,Eluru–534005,WestGodavariDistrict,AndhraPradesh.E-mail:[email protected].:9885419291

respecting the patient rights. A doctor who respectstherightsofpatientgainstheconfidenceofthepatient,which is crucial in strengthening the doctor-patientrelationship. Patient rights are a fundamental humanrightthatprotectspatientsagainstabuse,favoritismandadvocatesethicalpractices.

The rights of patient cannot be the same all overtheworldduetodifferentculturalandsocialcustoms.InNorthAmericaandEurope,thereexistfourmodels,which depict the doctor-patient relationship: thepaternalistic, the informative, the interpretive, and thedeliberative.Inpaternalisticmodelthedoctorsdecision

DOI Number: 10.5958/0973-9130.2018.00147.0


is given more importance than the patients right toinformation & participation in decision making as ininformativemodel.(WHO). 1However,patient-centeredmedicine has not always been common practice. Forexample,inthe1950sto1970s,mostdoctorsconsideredit inhumane and detrimental to patients to disclosebad news because of the bleak treatment prospect forcancers. Themedicalmodelhasmorerecentlyevolvedfrompaternalismtoindividualism.2

Themedical council of India (MCI) under IndianMedical Council (Professional conduct, Etiquette andEthics) Regulations, 2002 defines certain duties andresponsibilities aswell as some rights of physician’s.Moreorlessthedutiesofthephysician’smentionedinthecodeofethicsregulations2002becometherightsofthepatient.

One of the most important aspects, which leadto improvement in quality of health services, is thepatients’ contribution in treatment process. This canbe accomplished only when patients are reasonablyaware of their rights. However, with ever increasingcomplexity in the health systems and fast growingmedical technologies, together with a big rural,uneducated patient population in India, the awarenessofpatientsabouttheirrightshasbeenchallenged.Giventhis, current study is taken up to evaluate patients’awareness&practiceoftheirrights.

MATERIALS & METHOD

Thiswas a prospective, questionnaire-based crosssectionalstudydoneatdepartmentofForensicMedicine&Toxicology,Mediciti InstituteofMedicalSciences.Telangana.ThestudywasapprovedbytheInstitutionalEthics Committee and was done in accordance toDeclarationofHelsinkiandprinciplesofICH-GCP.

The subjects, (patients & their attendants) wererecruited from out patient departments and in patientwards of the hospital.Adults of either genderwillingtogivewritten informedconsentwere included in thestudy. In & out patients of psychiatry and pediatricdepartmentswereexcluded.

After taking written informed consent, eligiblesubjects were recruited into the study. Each subjectwasaskedthequestionsfromthequestionnairebytheinvestigator and the response to eachof thequestionsasked,wasrecordedinthecaserecordform.

Statistical analysis: The data thus obtained wasanalyzed and presented asmean± SD for continuousvariables and percentages for categorical variable.Associationbetween literacyandawarenessofpatientrights and that between literacy status andpractice ofpatientrightsweretestedusingChiSquarewithYatescorrectionconsideringp<0.05assignificant.

RESULTS

In this study, 300 eligible subjects were enrolledinaperiodof4months.Ofthem,55%(166/300)weremale and rest were female with a mean age of 36.6yrs.Amongthesubjectsenrolled,35%(104/300)wereliterate;majoritywerepatientattendantsandwerefromruralbackground.

Beforetakingtheresponsesforquestionnaire-baseditems,eachsubjectwasasked,“whethertheyknowthatpatients have some rights”. The responsewas ‘no’ in249(83%)subjects.

Regardingawarenessofpatientrights(TableNo.1),97% of subjects had awareness that they can consentor refuse any specific or all measures, 93% wereawareregardinggivingcomplaintsandrectificationofgrievances followedby92%withawareness that theyshouldbeinformedregardingdaytodayprogress,lineofaction,diagnosisandprognosisand90%wereawarethattheyshouldbetreatedwithoutanydiscrimination.

87% of subjects were aware that they should betreatedinprivacyand85%knewthattheallinformationabouttheirillnessandanyotherdetailsareconfidential.

However,only23%wereawarethattheycanhaveaccesstotheirmedicalrecords,24%thattheycanobtaincompensationformedicalnegligence,only28%knewthattheyshouldbetreatedwithcomfortduringillnessandfollow-up,30%that theycantakesecondopinionandlastlyonly35%thattheycanchoosehospitalfreelyand40%knewthattheycanchoosedoctorfreely.

In this study, statistically significant associationbetween literacy status and awareness of patient’srights was observed for 14 of the 15 items tested.(FigureNo. 1)However, associationwas found to benon-significant, between literacy status and awarenessregardingreceivingcontinuouscareforillness.

Among the responses,given regardingpracticeofpatient’srights(TableNo.2),100%ofsubjectssaidthat


they were being treated without discrimination, 98%agreedthattheirrecordswerekeptconfidentialand94%respondedpositivelyoninformedconsent.

However,itwasobservedthatonly4%ofsubjectsresponded that thegrievance redressalwasdone,only12%saidthattheclaimsandprovisionswereaddressed,18%felt that theyweregivenopportunityofdecisionmakingintreatmentandonly26%,32%and34%feltthat they were informed about diagnostic procedures,illnessandtreatmentoptionsrespectively.

Theassociationbetweenliteracystatusandpracticeof patient’s rights (Figure No 2) was found to bestatisticallysignificantforpracticeofgivinginformationabout illness (p<0.01), treatment options (<0.05)and giving opportunity in making decision (p<0.05).However, it was found to be non-significant betweenliteracy status and practice of treatment with respectand dignity, giving information regarding diagnosticprocedures,confidentiality,informedconsent,grievanceredressalandclaimsandprovisions.

DISCUSSION

This study reveals that only 17% of subjects areawarethataspatientstheydohavesomerights.InstudiesdonebyFernandesetal3,Yousufetal,4Ducineskieneetal5 andKagoyaetal.,6although76%ofpatientsknewthemeaningofpatientrights,only43%knewthatitwasacceptableinIndia,irrespectiveofabsenceoflegalbill;90%ofpatientshadawarenessof rights;only56%ofpatientswereawareoftheLawonPatient’sRightsandmostpatients (81.5%)hadneverheardof theUgandaPatients’Charterrespectively.

In this study, therewasgood awareness that theyshouldbetreatedwithcarewithoutanydiscrimination;they should be informed about day-to-day progress,lineofaction,diagnosisandprognosis.Similarratesofawarenesswas reported inastudydonebyFernandeset al.3 In this study, 35% and 40% of subjects wereaware that they can choose hospital anddoctor freelyrespectively; similar rates (41.5% & 40.1%) werereportedinastudydoneatLithuania.5

Amongthe97%ofsubjects,whowereawarethattheycouldconsentorrefuseanyspecificorallmeasures,all think that it should be taken from the attendant.Majorityfeel thatconsent is takenonly to informriskin the procedure and some feel it as binding towards

paying the fees. Likewise in a study by Fernandes etal.,363%ofpatientsknewthataconsentwasrequiredfor common procedures. In a study on perception ofinformed consent, it was reported that most patients(86%) thought that their consent confirmed that theyunderstoodthattherearerisksinvolved(82%).7

Inthisstudy,85%knewthatallinformationabouttheirillnessandanyotherdetailsshouldbeconfidentialand 98% felt that confidentiality was maintained. Ina study done at Lithuania, 40.9% of the respondentsreported that patient’s permission was obtained forprovidingtheinformationtorelatives.5

Though, 92% of subjects were aware that theyshouldbeinformedregardingdaytodayprogress,lineof action, diagnosis and prognosis, only about 30%agreed that theywere informed about these issues. InFernandesetal.,study,85%ofpatientsrespondedthatthey were informed regarding illness and modalityof treatment and only 45% were informed regardingalternative procedures. 3 In Yousuf RM et al., study,treatment options were discussed with 45% of casesonly,and65%ofpatientswereinformedoftheirdurationof treatment.4 In another study done at Lithuania, theauthors felt that health care professionals who knewaboutthelawofpatientrightsweremorelikelytoshareinformationthanunknowledgeableprofessionals.5

Ofthesubjects,32%wereunawareregardingsafetyofdiagnosticandtherapeuticprocedures,ofthem,25%felt that it was not necessary to know about safetyof these procedures, as they felt that doctor does anyprocedureinthebestinterestofthepatient.

65% of subjects were unaware about choosinghospital freely; they felt someone should refer them.70% were unaware regarding taking second opinion.Whetherawareornot,theytakesecondopinionwithoutinformingtheprimarydoctor.

In this study, though the awareness to expressgrievanceswashigh,thephysicianspracticetoaddresstheseissueswaslow.Inastudy,though67%ofpatientswereawareofgrievanceredressal,itwasaddressedinpracticeinonly21%ofcases.3

Inthisstudy,35%oftheparticipantswereliterate,incontrasttoastudydoneinMalaysia4inwhich86%wereliterateandastudydoneinSaudiArabia,76.8%had high school education 8, similarly in one study,


55.5% indicated that they did not know about theirrightsdespite72%havingsecondaryeducation.6

The significant association found between theliteracy status and awareness of most of the patientrights, indicates that in illiterates the awareness ofpatient rights is less. In the studies done at Iran9 andUganda6,significantrelationshipwasreportedbetweenpatientawarenessandeducationallevel(P<0.001),withincreasing education, awareness improved. Similarresultswere reported ina studydonebyFaridaetal.,where, higher education level was associated withincreaseoftotalawarenessscore(p=0.000).8

In this study, 18% felt that they were givenopportunityofdecisionmakingintreatment.Incontrary,in a study done atKarnataka, India,3 64%of patientsfeltthattheirchoiceregardingtreatmentwasrespectedandthiscanbeattributedto86%literatepatientsinthatstudywhileonly35%wereliterateinthisstudyandasignificantassociationbetweenpracticeofthisrightandliteracysupportsthesame.

Regarding grievance redressal system, the resultsofthisstudyareinlinewiththoseofastudydoneatKarnataka,India,3whereonly21%respondentsagreedthattherewasgrievanceredressalsystemexisting.

The non significant association between literacystatus and practice of patient rights with regard to

treating with respect, informing about diagnosticprocedures,maintainingconfidentiality,takingconsent,indicatesthatthephysiciansexecutedpracticeoftheserightsirrespectiveofliteracystatus.

The non-significant association between literacystatusandpracticeofgrievanceredressalandclaimandprovisions, indicates that physicians had low level ofcomplianceinexecutionoftheserightsirrespectiveofpatientawareness.

Practice of giving information about illness,treatment options and giving opportunity of decisionmakingintreatmentweresignificantlyassociatedwithliteracystatus,showingthatphysiciansexecutedthesepracticesmoretowardsliteratepopulation.

CONCLUSION

The awareness among patients regarding rightsneeds to be increased, and the awareness amongphysiciansregardingcommunicationofalltheissuestothepatientsneeds tobe increasedwhichwill increasepractice of patient rights.As the awareness of patientrights is associated with literacy status, governmentshouldtakegoodmeasurestoincreasetheliteracyratein population. Compliance with MCI regulations canincreasethepracticeofpatientrightsbyphysicians.

Table No. 1: Showing number and percentage of subjects who were aware and unaware of patient rights (n=300).

S.No Right ToAware of Patient Rights (n=300)

Aware n (%) Unaware n (%)

1 Choosethehospitalfreely 105(35%) 195(65%)

2 Choosethedoctorfreely 125(40%) 175(60%)

3 Betreatedwithcare,compassion,respectanddignitywithoutanydiscrimination 272(90%) 28(10%)

4 Betreatedinprivacyduringconsultationandtherapy 261(87%) 39(13%)

5 Keepallinformationabouthis/herillnessandanyotherbekeptconfidential 255(85%) 45(15%)

6 Receivefullinformationabouthis/herdiagnosis,investigation,treatmentandalternativeplans 111(37%) 189(63%)


7 Informationregardingsafetyofdiagnosticandtherapeuticprocedures 204(68%) 96(32%)

8 Knowthedaytodayprogress,lineofactiondiagnosisandprognosis 276(92%) 24(8%)

9 Consentorrefuseanyspecificorallmeasures 291(97%) 9(3%)

10 Secondopinion 90(30%) 210(70%)

11 Accessrecordsanddemandsummaryorotherdetailspertainingtoit 69(23%) 231(77%)

12 Receivecontinuouscareforillnessfromthephysicianorinstitute 114(38%) 186(62%)

13 Betreatedwithcomfortduringillnessandfollowup 85(28%) 215(72%)

14 Complainandrectificationofgrievances 279(93%) 21(7%)

15 Obtaincompensationformedicalnegligence 72(24%) 228(76%)

Table No. 2 showing number and percentage of subjects who responses were positive and negative towards practice of patient rights (n=300).

S.No Practice of

Practice of patient rights (n=300)

Yesn (%)

Non (%)

1 Treatmentwithrespect&dignity 294(98%) 6(2%)

2 Treatmentwithoutdiscrimination(Gender,religion,financialstatus) 300(100%) 0

3 Givinginformationaboutdiagnosticprocedures 78(26%) 222(74%)

4 Givinginformationaboutillness 96(32%) 204(68%)

5 Givinginformationabouttreatmentoptions 102(34%) 198(66%)

6 Confidentiality 293(98%) 7(2%)

7 Informedconsent 280(94%) 20(6%)

8 Respect/opportunityofdecisionmakingintreatment 52(18%) 248(82%)

9 Grievanceredressalsystem 14(4%) 286(96%)

10 Claims&provisions 35(12%) 265(88%)

Cont... Table No. 1 showing number and percentage of subjects who were aware and unaware of patient rights (n=300).


Figure No 1: Showing percentage of subjects with awareness of patient rights among literate and illiterate.

* indicates p < 0.0001; @ indicates p < 0.01; $indicatesp<0.05and#indicatesp>0.05forassociationbetweenawarenessofpatientrightsandliteracystatus

Figure No 2: Showing percentage of subjects with positive response towards practice of patient rights among literate and illiterate.

* indicates p < 0.01, $ indicates p < 0.05 and #indicatesp>0.05 for associationbetweenpracticeofpatientrightsandliteracystatus

Conflict of Interest: Authorsdeclare that there isnoconflictofinterest.

Source of Funding-Self

Ethical Clearance-Obtained

REFERENCES

1. Genomic research centre. Patients’ rights. WorldHealthOrganisation.http://www.who.int/genomics/public/patientrights/en/accessedon03/08/2016

2. Ha,JenniferFong,andNancyLongnecker.“Doctor-PatientCommunication:AReview.” TheOchsnerJournal 10.1(2010):38–43.

3. Fernandes.Awarenessofpatientsrights.IntJResFoundationHospHealthcAdm,2014.

4. YousufRM,FauziARM,HowSH,AkterSFU,ShahA.Hospitalised patients’ awareness of theirrights:across-sectionalsurveyfromatertiarycarehospital on the east coast ofPeninsularMalaysia.SingaporeMedJ2009;50(5):494

5. Ducinskiene D, Vladickiene J, KaledieneRandHaapalaI.Awarenessandpracticeofpatient’srightslawinLithuania.BMCInternationalHealthandHumanRights2006,6:10 doi:10.1186/1472-698X-6-10.

6. Kagoya HR, Kibuule D, Mitonga-Kabwebwe H,Ekirapa-KirachoE, Ssempbwa JC.Awareness of,responsiveness to and practice of patients’ rightsat Uganda’s national referral hospital. Afr J PrmHealthCareFamMed.2013;5(1),Art#491,7pages.http://dx.doi.org/10.4102/phcfm.v5j1.491

7. AndreaAkkad,ClareJackson,SaraKenyon,MaryDixon-Woods,NickTaub,MarwanHabiba.Patients’perceptions of written consent: questionnairestudy. BMJ, doi:10.1136/bmj.38922.516204.55(published31July2006)

8. Farida M, Habib and Hind Sulaiman Al-Siber.Assessmentofawarenessandsourceofinformationof patients’ rights: a cross-sectional survey inRiyadhSaudiArabia.AmericanJournalofResearchCommunication,2013,1(2):1-9

9. Mastaneh Z, Mouseli L. Patients awareness oftheir rights: insight from a developing country.International Journal of Health Policy andManagement2013;1:x-x.

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Sociological Explanation of the Effects of Social and Cultural Factors Affecting Attitude toward Divorce in 2016 (Case Study:

Couples Referring to Guilan Welfare Centers)

Reza Jafari Sadhi1, Hossin Aghajani Mersa2, Amir Masoud Amir Mazaheri2

1Ph.D. Student of Social Sociology of Iran, Department of Social Sciences, Central Tehran Branch, Islamic Azad University , 2Associate professor of Sociology, Department of Social Sciences, Central Tehran Branch,

Islamic Azad University

ABSTRACT

The family as a major social institution has historically played important roles such as socialization,preservationofsocialcohesion, the transferofculturalheritage to futuregenerations,socialcontrolandmonitoring,thereductionofexternalpressureandtheformationofcultural–socialpersonalityandidentity.However,recently,chronicdiseaseofdivorcehasbecomeprevalentandfamilieshavebeenchangedintothecrisiscentersinthecontemporaryworld.Attitudetowarddivorceislikeamirrorthatreflectstheevolvingtrendsandperspectivesofthefamily’sfutureanditcanbeusedasanindicatorformeasuringfamilyhealthand stability.This study aims to investigate the attitude toward divorce in couples referring towelfarecentersaswellasthesocialandculturalfactorsaffectingitsformationusingsurveyandKineard’sAttitudeMeasurementQuestionnaireandLifeStyleQuestionnairebasedonrandomsamplingmethodon282couplesapplicantfordivorce.Theresultsoftheresearchshowthatthereisasignificantrelationshipbetweenthesocio-economicstatusofcouples,thelevelofparentaleducationandthefather’sjob,lifestyleandattitudetowarddivorce.Multipleregressionanalysisshowsthatthelifestyleandeducationallevelofcouplesintotalexplain34%ofthevarianceintheattitudetodivorce.

Keyword: Attitude to Divorce; Lifestyle; Economic and Social Status; Parental Education; Father’s Job.

Corresponding author:Reza Jafari Sadhi,Ph.D.StudentofSocialSociologyofIran,DepartmentofSocialSciences,CentralTehranBranch,IslamicAzadUniversityE-mail:[email protected]

INTRODUCTION

Among the social institutions affecting theformationofthepersonalityandsocio-culturalidentityofhumans, includingeducation,government, religion,massmedia, economics, and the peer group, one cansafely assert that the role of the family is unique andirreplaceable1. The family is the place where talentsandcreativitygrow. It is theplace forcultivationandperfection of human beings and the source of loveand affection. History shows that nations with stablefamilieshavebeenstrongerandthedecadenceofeverynationhasbegunsincethefoundationofitsfamilyhasbeen weakened2. As a mirror, the family reflects the

socio-cultural,economic,andpoliticalconditionsofthesociety,inotherwords,itcanbeinterpretedasarulerandacriterion formeasuringpoliciesandpracticesatthemacrolevelofthesociety3.Ontheotherhand,thefamilyisconsideredasaprotectiveandshockingshieldinsociety.Therefore,itcannotberegardedasmerelyaninstitutionbasedonintenseemotionsbecauseitssocialfunctions are also important andmeaningful, and thatiswhyanychange infamilygreatlyaffects thewholesocial structure4. According to Tofler, the family iswhereaninjuredpersonreturnstoitafterabattlewiththeoutsideworld,asafeandlivelyenvironment;withtheexpansionoftheover-industryrevolution,thefamilyasashockingshieldisalsoconsiderablyaffected5.Despitethe importance of family in all cultures and societies,divorceisanotheraspectofthefactthatnoindividual,grouporcommunityisimmunefromitsconsequences.Asa society in transitionand in the turbulenceof thedualthemesoftraditionalismandmodernity,theIraniansociety is experiencing special economic, social and

DOI Number: 10.5958/0973-9130.2018.00148.2


culturalconditionsthathaveexposedittonewharmfulsocial problems or deepened its traditional traumaticaspects,includingincreasingtrendofdivorce.EverykindofchangeinIraniansocietyisrootedinthefamily.ThemainchangesinthesocialsystemofIranwererealizedeither by the family or oriented towards the family.OneofthesignsofachangeintheIranianfamilyistheincreasingrateofdivorceinthecitiesandthevillages;divorce for the new generation has been regardedas a way of transition from intra-familial problems(especiallybetweenmenandwomen),whileinthelastgeneration,especiallyamongthefirstgeneration,therewasnotsuchanattitudetowarddivorce6.

Therefore, given the increasing trend of divorce,it can be claimed that divorce has become a “socialproblem” in Iranian society and involves all socialstrata and groups and nobody is immune from itsconsequences. Consequences such as instability andimbalance in family mental health7, adversely affectparents and children, increase crime among the girlsand boys, disrupt children’s development, especiallyboys, increase antisocial behaviors in children8, leadsto occurrence of physical and psychological disorderssuchasalcoholism,suicide,mentalweaknessandlesssatisfactionwith life in divorced people9,more socialisolation,problemsinparentalduties,lowlevelofmentalhealthof thedivorced couples, loweropportunitiesofchildren for academic achievements, psychologicaladjustment, social competitions and physical health10,less involvement insocialactivities, increase insocialisolation, losing contacts and social interactions withfriendsandneighbors,andultimatelylosingemotionalsupport11.

In addition to the consequences of divorce,the reason for increased divorce rate has also beenexaminedfromdifferentperspectives,becausedivorceisamultidimensionalphenomenonwithseveralcauses,rooted indifferentmicro,macro,andmiddle levelsofsocial life8. Some describe it as a postmodern worldandopen-mindedmodernity,andtalkabouttheendofromanticloveandthereplacementofmutualsatisfactioninmarriage,questioningthedefinitiveaffairsinthefieldofbeliefsandknowledge, includingmarriage 12.Elkincallsthepostmodernfamily“permeable,”meaningthefamilycanbeinfluencedinawaythatitssignificanceisreformedorchanged13.

Others believe that the family is affected by the

processofglobalization,aprocess thathasshifted thetraditionalorderofspace-timeandputtraditionalsocialinstitutions, including the family, into an uninhabitedstate, cutback its stability and integrity andcreatedakindofthepermeableandubiquitoussocialenvironmentbasedonthecharacteristicsof“difference”,“fluidity”,“paradox” and “networking”14. As mentioned above,therelationshipbetweendivorceandvaluesandrelateddevelopments is well known. According to Nizbet,socialproblems,eventheworstone,arerootedinvaluesthatarestronglyendorsedbythecommunity15.Inotherwords, social problems have a functional relationshipwith the institutions and values that we live with.Accordingly,divorcederivesmainly fromsocietyanditsvaryingvaluesthanfromthecollapseanddestructionof the family as a social institution3. Divorce rate isconsideredasindicatorforfamilyhealthandwell-beinginacommunity.Manysociologistsregardtheriseandfallofmarriagerateasageneralindicatorofthequalityof marriage, social order and stability. The family isthe point of intersection of various trends that affecttheentirecommunity16.Hence,anypolicymakinganddecisionmakingtoreduceandcontroldivorcerequiresawarenessoftherateofdivorceinsociety.

METHODOLOGY

Method, statistical population, sample size:Thisisasurveythatiscarriedoutusingacausal-comparativemethod.Thestatisticalpopulationofthisstudyconsistsof all couples referring to intervention centers in thefamily in order to reduce the divorce in Guilan fortwomonths,with a total of 1000 people.The samplesizewas determined usingMorganTable, taking intoaccount5%samplingerror17andCochran’sformulaas278 people selected by systematic random sampling.Theinclusioncriteriaforthestudyincludedtherequestforthedivorceofcouplesreferringfromfamilycourtstowell-beingcentersandconsenttoenterthestudy.Afterconfirmingthecontentvalidityofthequestionnaire,thereliabilityofthetool(includingattitudetowarddivorce,lifestyle,andobjectiveculturalcapital)wascalculatedusingCronbach’salphacoefficientwhichwas83.3,90.7and 80.8, respectively. Data were collected using theinterviewtechniqueandphysicalpresence.

FINDINGS

Basedontheresultsoftheresearchatthedescriptivelevel,46.1%oftherespondentsaremenand53.9%are


womenatthelevelofdemographicvariables.2.5%oftherespondentsareilliterateand76.6%ofthemhavediplomadegreeorarelowerthanthediplomaleveland20.8%haveassociate’sdegreeorabove.3.9%ofrespondentsareunder20yearsold,53.2%are21-30yearsold,30.5%are31-40yearsold,11%are41to50yearsold,and1.4%are51-60yearsoldandolder.68.3%oftherespondentsareruraland31.7%areurban.Intermsofeconomicstatus,44.3%oftherespondentsareinactive,31.9%areworker,9.6%areemployed,and14.2%areself-employed.

Thefirsthypothesis:Thereisasignificantrelationshipbetweendemographicvariables(sex,age,andlocation)andattitudetowarddivorceofthecouplesapplicantfordivorce.

Table 1: Independent t-test results for the first hypothesis

Confidence 95%T test of equality of variancesLevene’s test for equality of variance

Independent variable

highlowDifference in SEdifference in averageTwo way sigdftSigF

1.6220-2.6641.08870.52110.6332800.4790.5260.430Sex

1.6294-2.6711.08870.52110.634269.3890.477

3.8989-0.699101.167931.599930.1722801.3700.9180.011Location

3.8794-0.679541.154891.599930.168172.8271.385

Table 2: Results of One-Way Variance Analysis of the first hypothesis

SigFAverage of squaresfdSum of squaresSource of

changes

.710.534

44.5714178.282intergroup

Age groups83.388

27723098.597intragroup

28123276.879total

Table 3: Relationship between couples’ level of education and Income with attitude toward divorce for the second hypothesis

Pearson correlation Attitude toward divorce

Couples’levelofeducationPearsonvalue 0.428**

Sig 0.020

IncomePearsonvalue 0.225**

Sig 0.020

Testingthefourthhypothesis:Thereisasignificantrelationshipbetweenincomeandattitudetowarddivorceofthecouplesreferringtodivorcereductioncenters.


Table 4: Results of One-Way Variance Analysis of the second hypothesis

SigFAverage of squares

fdSum of squaresSource of changes

.00013993.00032981.000intergroupDifferent jobs

73.00027820260.000intragroup28123242.000total


SigFAverage of squaresfdSum of squaresSource of

changes

.0033.000

269.04961614.000intergroup

Father’sjob78.000

27521662.000intragroup

28123276.000total


SigFAverage of squares

fdSum of squaresSource of changes

.0033.000269.04943795.000intergroupFather’s job

78.00027719481.000intragroup

28123276.000total

.0007.041537.07342148.000intergroupmother’s job

76.00027721128.000intragroup

28123276.000total

Step by step multiple regression testing:

Table 7: Output of multiple regression testing of the factors affecting attitude to divorce

Stepwise theoretical model 2

R R Square Adjusted R Square

Std. Error of the Estimate

Unstandardized Coefficients

Standardized Coefficients

t Sig.

B Std. Error Beta

(Constant) - - - - 24.918 2.593 - 9.611 .000

Educational level .490 .240 .238 7.9460 9.132 1.171 .409 7.798 .000

lifestyle .522 .305 .300 7.6152 .102 .020 .267 5.085 .000

Dependentvariable:attitudetodivorce


DISCUSSION AND CONCLUSION

As a developing society, Iran’s society graduallymoves away from its past structure and conventions,andmovestowardsnewstructuresandconventionsbutnotyetestablished,therefore,ithasakindofambiguityanddualityintermsofbeliefs,thoughts,behaviors,andpractices.Itisnaturalthattherearedualandsometimescontradictory themes affecting lifestyle of the peoplethatleadtofundamentalchanges.

The results of this study indicate that 3.5% ofcouples applicant for divorce had negative attitudetoward divorce, 33.4% showed neither agreement nordisagreement (Interstitial state) toward divorce, and63.1%hadapositiveattitudetowarddivorce.Obtainedlevels of attitude toward divorce reflect the image ofasociety that isexperiencingakindof familialcrisis,a fact that can be justified by the state of divorce inIran, a situation that if the dimensions and scope ofemotionaldivorceorsilentlivesareaddedtoit,itwillbecomemorepainful. Soleimani18showedthestudents’attitude towarddivorcemore thanmoderate,however,Fatehi et al. 19 showed that52.7%of respondentshadmoderate tendency to the divorce and nearly 7.6%hadstrongtendencytowardit.ItseemsthatoneofthemostimportantfactorsinincreasingdivorceinIraniansocietyisthechangeinlifestyleinthesocietyaffectedbymodernizationandrelatedchangesparticularlyintheareaofthefamily.

Investigationof thehypothesison therelationshipbetween lifestyleandattitude towarddivorcesuggeststhatlifestyleaffectsattitudetowarddivorce,sothatwithincreasing the attitude of individuals towardsmodernlifestyle patterns, the attitude toward divorce is alsomorepositive.Thelifestyleistheobjectiveaspectandtheexternalmanifestationofhumanbehavior inareassuch as body management, consumption of culturalproducts,patternsofcoverage,patternsofnutrition,andsoonbasedonthementalstructureorhabitusofactivistsduringtheprocessofsocializationortheinternalizationofthestructuresofthesocialworldbasedontheirpositionwithinsocialspaces,throughwhichactivistsareabletounderstandandevaluatethesocialworld.Therefore,itcanbeassumedthatlifestyleshavedifferentmeanings,that is, they include certain values that each activistimplicitlyconsidersthemandthesereflecttheparticularvaluesandnormsofasocietythatpeopletendtoadoptsomeofparticularlifestylesbasedonthementalworld

included in it.The resultsof the studyalso show thatwithincreasingsocioeconomicstatusintermsoffactorssuch as job, education and income, coupleswill haveamore flexible attitude toward divorce. For example,analysisshowsthatincreasingeducationallevelofthecouplesincreasestheirtendencytowarddivorceandthisisconsistentwiththeresultsofSaroukhani’s20studyontheeffectofeducationon increasingdivorce,and thisrelationshipisalsoobservedinotherfactors,suchasjobstatusandincomelevels.Itseemsthatoneofthemainreasonsisthatthehighsocio-economicstatushasamajorrole in providing thefields of financial and economicindependence, providing social-psychological securityin divorce and separation situations, especially forwomen,andincreasingtheexpectationsoflife,adoptinglifestyle based on pleasure, happiness, intolerance ofhardshipsanddifficultiesoflifeareotherrelatedresults.

Another important finding of the research is theexistenceofarelationshipbetweentheeducationalstatusand the jobof theparentsof thecouplesandcouples’attitudetowardthedivorce.Themostimportantreasonseems tobe the formationof the typeof socializationandhabitusofpeopleandfamilieswithsimilarsocio-economic status aswell as subsequent tendencies andattitudes.

Resultsalsoshowthelackofarelationshipbetweenthe underlying variables (sex, age, and location) andattitude toward divorce; of course, due to the processofglobalizationandtheformationofvaluesandnormsarising from the expansion of communications andmass media, the prevalence of the positive attitudetoward divorce among individuals and group, sucha phenomenon is expected. In the end, according tostepbystepmultiple regressionanalysis, lifestyleandeducationhavebeenabletoexplainatotalof305%ofthevarianceofattitudestowarddivorce.

Ethical Clearance:isadheredallethicalinterests:(Theethicsofrecordingdata, therightofrespondentsto end involvement in the research, the disclosureby respondents of sensitive material, the ethics ofethnographic fieldwork, the ethics of the researchinterview,andethicsintheuseofquestionnaires).

Conflict of Interest: Theauthorsreportnoconflictofinterest.



REFERENCES

1. Asghari, F., Saadat, S.,AtefiKarajvandani, S.,&JanalizadehKokaneh,S.(2014).TheRelationshipbetweenAcademicSelf-EfficacyandPsychologicalWell-Being,FamilyCohesion,andSpiritualHealthamong Students of Kharazmi University. IranianJournalofMedicalEducation,14(7),581-593.

2. Walsh,F.(2015).Strengtheningfamilyresilience.GuilfordPublications.

3. SaeiArasi,I.(2003).AnIntroductiontoSociologyand Pathology of the Unhappy Family, IslamicAzadUniversityofAbhar.

4. Demir, Sevim Atila. (2013). Attitudes towardconcepts of marriage and dirvorce in turkey.American intenational journal of contemporaryresearch.Vol.3NO.12.

5. Taflor, A. (2014). Third Wave. Translated byKharazmi,Sh.Tehran:AsemanPublishing.

6. Aazd Ormaki, T. (2015). Changes, Challengesand Future of the Iranian Family, Tehran: TisaPublishing.

7. Boulhari,J.etal.(2012).Examinationofsomesocialcausesleadingtocouples’applicantfordivorceinTehran courts. Iranian Journal of Epidemiology,Volume8,Issue1.

8. Sotoudeh, H. (2007). Family Pathology. Tehran:Neda-yeArianPublishing.

9. Bernards, J. (2005). An Introduction to FamilyStudies. Translated by Ghazian, H. Tehran: NeyPublishing.

10. Shokr Beigi, A. (2011). Modernism and FamilySocialCapital.Tehran:Sociologists’publication.

11. Waite, L. & Gallagher, M. (2012).what are thepossible consequence of divorce for adults,www.divorce.usu.edu/files/uploads/lesson.pdf.

12. Giddens,A.(2014).Modernityandself-Identity:Selfandsocietyinthelatemodernage.TranslatedbyofMovafaghian,N.Tehran:NeyPublishing.

13. Kandal, D. (2014). Contemporary Sociology.Translated by Hemmati, F. Tehran: Sociologists’Publishing.

14. Ahmadi,O.A.(2015).SocialAnalysisoftheSocialStatusandChangeofMarriageandDivorce.SocialStatus Report of Women in Iran (2001-2011).Tehran:NeyPublishing.

15. Moayedfar (2006). Sociology of Social Issues inIran.Tehran:Nour-eElmPublication.

16. Giddens,A.(1998).GlobalPerspective.TranslatedbyJalaipour,M.R.Tehran:Nashr-eNoPublishing.

17. Azkia,M.&DarbanAstaneh,M.(2003),AppliedResearchMethods,Tehran:KeihanPublications.

18. Soleimani, I. (2015). A changing attitude towarddivorce among students (Ardabil Universities).JournalofSocialSciences,IslamicAzadUniversityofShoushtarBranch,Vol.9,No.4,pp.239-252.

19. Fatehi, A. et al. (2010). Sociological analysis offactors affecting couples’ tendency to divorcein Isfahan province, Quarterly Journal of SocialSecurityStudies.

20. Sarukhani, B. (1993), Divorce, research on itsrecognitionandfactors.Tehran,TehranUniversityPress.

Profile and Pattern of Homicidal Injuries in Central Indian Population

Vishwajit Kishor Wankhade1, M S Vyawahare2

1Assistant Professor, 2Professor and Head, Department of Forensic Medicine & Toxicology, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India

ABSTRACT

ThepresentstudywasconductedindepartmentofForensicMedicineandToxicologyatatertiarycarecentreinNagpurforaperiodof2yearsfromJuly2015-2017withanaimtoevaluatethepatternofhomicidalinjurieswithspecial reference to injuriessustainedduring these incidences.Total99caseswerestudiedfromthedetailsmentionedininquest,policereports,postmortemreportsandstatementsoftherelatives.Injuriesoverparticularpartsofthebodywerenotedindetailwhilekeepingintoconsiderationthetypeofweaponused,internalorgansinvolvedandcauseofdeath.Mostcasesoccurredinsummerseason(37.37%)andevening(32.32%)beingpreferredtimeforassaultwithisolatedandremoteplaces(28.28%)beingmostpreferredsite.Malesintheagegroupof21-30years(32.32%)dominatedthescenariowithhardandbluntweapon(36.36%)beingusedmostcommonly followedbysharpandpointed (35.35%)weapons. Headinjury(40.4%)andhemorrhagicshock(40.4%)wereequallyresponsiblefordeathsalongwithhead,neckand face region (80.8%)being themost targeted region.Brain (42.42%)wasmost commonlydamagedorganfollowedbyneckstructures.

Keywords -Pattern of Injuries, Homicide, Weapon, Cause of death, Inquest.

Corresponding author:Dr. Vishwajit Kishor WankhadeAssistantProfessor,DepartmentofForensicMedicine&Toxicology,IndiraGandhiGovernmentMedicalCollege,Nagpur,Maharashtra,IndiaPhoneno:+919860841184E-mail:[email protected]

INTRODUCTION

Violence is a significant health problem andhomicide is the severest form of violence, deprivinghumanbeingofhisfundamentalrighttolive.Homicideisprevalentwidelyalmostallovertheworld.1Homicideis defined as killing of one human being by anotherhuman being and is one among the leading causes ofunnaturaldeaths.2Notallhomicideismurder,assomekillingsaremanslaughter,andsomearelawful,suchaswhenjustifiedbyanaffirmativedefence,likeinsanityorselfdefence.3

Homicide is the most serious crime as old ascivilization and reported as early as in theBible.4 To

commitmurder,twoelements(Mens–rea)whichmeanspreplanningoraforethoughtand–(Actus-reus)whichmeans the actual execution should work together toconstitutethecrime.5

Population explosion, changing lifestyle, stressesof life due to monitory, emotional, health issues,negative impact of movies and media, addiction andeasy availability of the weapons has led to increasein the incidence of homicide and also the change ofpatterninhomicidehasbeenobserved.Consideringthemagnitudeand frequencyof thedeathsand its impactonthesociety,thepresentstudyisundertakensoastofindoutthemostvulnerableagegroup,sexincidence,seasonalvariation,patternofinjuriesandweaponsused.

MATERIAL AND METHOD

A retrospective study of 2 years was conductedfromJuly2015toJune2017anddataof99caseswascollectedfrompost-mortemreports,policeinquestandother relevant documents in a predetermined format.In few cases multiple methods of homicide, multipleweaponswereused in a singlecaseandalsomultiple

DOI Number: 10.5958/0973-9130.2018.00149.4


type of injuries sustained therefore all were recordedand only one homicide was counted. The selectioncriteriaforthecasesareasfollows:

All cases referred as homicide and confirmed onpost-mortemwereincludedinthestudy.

All cases which were investigated as accidentaldeathsbutlaterturnedouttobehomicidaldeathswereincluded.

Victimsfromallagegroupswereincluded.

Proforma is prepared citing numerous variablessuchasage,sex,seasonofincidence,timeofincidence,placeofincidence,typeofinjury,typeofweaponused,region of body targeted, internal organ involved andcauseofdeath.

Postmortemexaminationsofthecaseswerecarriedoutasperstandards.


Present study demonstrated dominance of malevictims68(68.68%)ascomparedtofemalevictims31(31.31%). Age group between 21-30 years was mostvulnerable with 32 cases (32.32%). In both cases ofinfanticidefemalechildrenwerevictimized.Regardingseasonalvariationmostcasesweredistributedequallywith summer 37 (37.37%) being most common andwinter being least common30 (30.3%).Most victimswereassaultedintheevening32(32.32%)whileeveningtimeandlatenightcombinedtogether52(52.52%)wasthepreferredtimeofassaultinmorethanhalfofcases.

Most victims were done to death at isolatedplaces(28.28%)followedcloselybyvictimsresidence(26.26%) and public places (24.24%). Domestichomicideswerenotedin(15.15%)caseswhereaccusedaswellasvictimssharedcommonresidence.Husband(33.33%)wasthemainperpetratorfollowedbybrother(26.33%). Blunt trauma injuries like abrasions 61(61.61%), contusions 59 (59.59%) and lacerations 32(32.32%)weremost commonly encountered followedby stab injuries 28 (28.28%) and incised wounds20 (20.20%). Firearm injuries 2 (2.02%) were leastcommonly observed. Head, neck and face region 80(80.8%)wasmosttargetedregionfollowedbythorax39(39.39%)andgenitals5(5.05%)wereamongtheleasttargetedareas.

Hardandblunt36(36.36%)alongwithsharpandpointedinstruments/objects35(35.35%)wereweaponsofchoiceforassault.Headinjury40(40.4%)andshockduetohaemorrhage40(40.4%)wereequalcontributorsamong cause of deaths followed by asphyxia 17(17.17%).Amonginternalstructuresbrain42(42.42%)was most commonly damaged followed by neckstructures29(29.29%)andlungs12(12.12%).

Male6(6.06%)andfemale6(6.06%)wereequallyvictimized using ligature strangulation as a means ofhomicide.2(2.02%)casesofsmotheringwereobserved,femalebeingcommonvictimandoutofwhichonecasealsohadligaturestrangulationassociatedwithit.

Shockandhaemorrhage32(32.32%)followedbyhead injury30 (30.3%)weremost commoncausesofdeath in males while mechanical asphyxia 9 (9.09%)wasmostcommoncauseofdeathinfemale.Homicidalburninjuries4(4.04%)weremoreprominentinfemalepopulation.

DISCUSSION

The ratio ofmale victims 68 (68.68%) to femalevictims 31 (31.31%) in the present study is 2.19:1whichisconsistentwithobservationsmadebyBuchade,Mohite6;Ghangale,DhawaneandMukherjee7;Mohanty,Mohanty and Acharya8 and Scott KWM 9 and canbe attributed tomore aggressive nature ofmales thanfemales.Mostvulnerablevictimagegroupwasbetween21-30 years 32 (32.32%) followed by 31-40 years 25(25.25%)which is consistentwith studiesofAgrawaland Bansal10; Ghangale, Dhawane and Mukherjee7;ScottKWM9;SinhaUS,KapoorAKandSurendraKumar Pandey11. However present study findings areincontrastwiththeobservationsmadebyWahlstenP12 andKominatoY13wheremostvictimsbelongedto31-40yearsand36-45yearsrespectively.

Incidence of homicides were highest in summerseasonandthesefindingsareconsistentwithobservationsmadebyR.Y.Padmaraj(2010)14andPradeepKMishra(2012)15 while these findings are in contrast withobservations made by Sinha.U.S 11 where incidencewas least in summer.Maximum incidences i.e. morethan 50% took place in evening and late nightwhichmaybeduetolackoflightwherechancesofassailantbeingexposedarelessormaybeduetoindulgenceinheatedarguments,itbeingdomesticorfinancialduringthe recreational activities after the days hard work.


Similar findings were observed byWahlsten P.12 andGuptaAvnesh4whereasstudybyVougiousklakisT.16,maximumcases(26.9%)occurredduringnoon.

Isolatedorremoteplacesweremorepreferredsitebyassailants in thepresentstudywhichareconsistentwith findings by Vougiousklakis T.16 where desertedarea or place close to agricultural sitewas commonlyfound and with the observations of Mohanty M.K.8 wheremajorityofcasestookplaceoutdoors.Victim’sresidence (26.26%)was secondmost common site ofincidence which implies that these homicides weredone in cold blood and perpetrators were aware ofwhereaboutsofthevictim.Publicplaces(24.24%)likestreets and common gathering places, third leadingplace of incidence in the present study are the placeswhere old rivalries, arguments and revenge murderstooktheirtoll.

Hard and blunt weapons 36 (36.36%) were mostcommonlyusedfollowedshortlybysharpandpointed35 (35.35%). Thus findings in the present study areconsistent with Buchade, Mohite6 while contradictsfindings of Ghangale, Dhawane and Mukherjee7;Aggarwal andBansal10 andRouseDA17where sharpedgedweaponsweremostcommonlyusedfollowedbyhardandbluntweapons.Firearms2(2.02%)wasleastusedweapon in the present studywhich is consistentwithfindingsofJhaveriS,RalotiS,PatelR,BrahbhattJ,KaushikV3;Buchade,Mohite6howevercontradictstheobservationsmadebySinhaUS,KapoorAK,SurendraKumar Pandey11 andBamideleAdeagbo, ColinClarkand Kim Collins18 where firearms were mostly used.Strictrulesforcarryingafirearmlicense,harshpenaltiesandstrictvigilanceofillegalblackmarketsaleoffirearmweapons has led to less popularity of these weaponswhilehardandbluntweaponsbeingeasilyavailablearemorepopular.

Multiple parallel, uniformly deep, stab injuriesconcentrated in a particular region with or withoutmutilationwhich are emotionallymotivated occurringin jealousy, intense hatred and sexual overtones isknownasoverkill.Such7caseswereobserved in thepresentstudy.

Head,neckandfaceregion80(80.8%)ofthebodywasthemosttargetedareasofthebodyfollowedbythorax

39(39.39%).Similarfindingsregardinginvolvementofhead,neckandfaceregionwereobservedbyBuchade,Mohite6;Mohanty,MohantyandPanigrahietal19;SinhaUS,KapoorAK,SurendraKumarPandey.11Brainwasmostcommonorganinvolvedinthepresentstudywhichis consistent with observations made by Sinha U S,KapoorAK,SurendraKumarPandey11andcontradictsthefindingmadebyBuchade,Mohite.6

Head injury and shock with haemorrhage wereequally responsible for the deaths of victims in thepresent studywhile studiesbyAggrawalandBansal10 showedshockandhaemorrhagebeingmoreprominentcauseofdeathandSinhaUS,KapoorAK,SurendraKumar Pandey11 reported head injury being morecommon. Homicidal burns were more common infemaleandsimilarfindingswereobservedbyGhangale,DhawaneandMukherjee.7

LIMITATION

Study was confined to a particular jurisdiction,rathersensitivezoneofagreaterpartofcity.

The data was based mainly on the informationprovidedbylawenforcingagencies,reports,statements,victimrelativesandfriendsinafewcases.

CONCLUSION

Government should survey and address theproblems of the youth like unemployment, povertyandillegalactivitiesbytargetingsensitiveareasinthecommunityasmajorityofthevictimsbelongedtoagegroupbetween21-30yearswhichiscrucialforaneveryindividualtobeindependent.

Strictlawsshouldbeimplementedforpossessionofpotentiallydangerousweapons.

Loopholesarecreatedwhenmultiplelawenforcingagencies act independently. So a common unit as insomewestern countrieswhich is entirelydedicated tohomicidal investigation may yield fruitful and rapidresultsinmerefutureinIndianscenario.


Table I: Age distribution of Cases

AGE Cases (n) Percent

<1 2 2.02%

1-10 YEARS 5 5.05%

11-20 YEARS 7 7.07%

21-30 YEARS 32 32.32%

31-40 YEARS 25 25.25%

41-50 YEARS 17 17.17%

51-60 YEARS 7 7.07%

61-70 YEARS 2 2.02%

71-80 YEARS 2 2.02%

81-90 YEARS 0 0%

TOTAL 99 100%

Table II: Sex distribution of cases.

2015 2016 2017 TO-TAL Percent

MALE 16 38 14 68 68.68%

FE-MALE 7 16 8 31 31.31%

TOTAL 23 54 22 99 100%

Table III- Time of Incidence

MORNING 5 5.05%

AFTERNOON 26 26.26%

EVENING 32 32.32%

LATE NIGHT 20 20.20%

NOT AVAILABLE 16 16.16%

TOTAL 99 100%

Table IV: Place of Incidence

PLACE OF INCIDENCE Cases (n) Percent

VICTIM 26 26.26%

ACCUSED 3 3.03%

VICTIM ACCUSED 15 15.15%

PUBLIC PLACE 24 24.24%

WORK PLACE 1 1.01%

ISOLATED/REMOTE 28 28.28%

OTHER 2 2.02%

TOTAL 99 100%

Table V- Seasonal Variation

2015 2016 2017 TOTAL Percent

SUMMER 0 24 13 37 37.37%

RAINY 16 15 1 32 32.32%

WINTER 7 15 8 30 30.30%

TOTAL 23 54 22 99 100%

Table VI: Injury constellation with respect to kind of injuries, type of weapon, region of body targeted, internal organs involved and cause of death.

Kind of Injuries inflicted*

Abrasion 61 61.61%

Contusion 59 59.59%

Laceration 32 32.32%

Incised 20 20.20%

Stab 28 28.28%

Chop 12 12.12%

Firearm 2 2.02%

Ligaturestrangulation 12 12.12%

Throttling 4 4.04%

Smothering 2 2.02%

Burns 6 6.06%

Type of Weapon used*

Hardandblunt 36 36.36%

SharpandPointed 35 35.35%

sharpandheavy 13 13.13%

Ligature 12 12.12%

Firearm 2 2.02%

Manual 5 5.05%

Region of the body targeted*

Head,Neck,face 80 80.80%

Thorax 39 39.39%

Abdomen 30 30.30%

limbs 30 30.30%

Genitals 5 5.05%

Internal organs involved*

Brain 42 42.42%

Heart 8 8.08%

Lungs 12 12.12%

Liver 4 4.04%

Spleen 2 2.02%


Kidneys 1 1.01%

NeckStructures 29 29.29%

Cause of Death*

HeadInjury 40 40.40%

Shockandhaemorrhage 40 40.40%

Asphyxia 17 17.17%

Burns 5 5.05%

Complications 5 5.05%

*Kindofinjury,typeofweapon,regionofthebodytargeted, internal organs involved and cause of deathoutnumbered the actual cases as all parameters weretakenintoconsiderationineachcase.


Source of Funding: None.

Ethical Clearance: Notrequired.

REFERENCES

1. Gupta S. and Prajapati P. Homicide Trends atSuratRegionofGujarat,India.JournalofForensicMedicine&Toxicology.2009:26(1):45-48.

2. Narayana ReddyK.S., 2007.―The Essentials ofForensicMedicine andToxicologyMedicalBookCompany,Hyderabad,26thedition:251–252PP.

3. JhaveriS,RalotiS,PatelR,BrahbhattJ,KaushikV.ProfileofHomicidaldeaths:a threeyearstudyatSuratMunicipal instituteofMedicalEducationand Research, surat during 2011-2013. Natl JCommunityMed2014:5(4);406-9.

4. GuptaAvneshetal.2004.―AstudyofHomicidalDeaths in Delhi,Medicine, Science and Law, 44(2):127-132.

5. ParikhC.K.,1990.―Parikh‘sTextBookofMedicaljurisprudence, ForensicMedicine and Toxicologyfor Classrooms and Courtrooms, CBC Publishersand Distributors, New Delhi, 6th Edition: 2.1pp,3.51pp,4.23pp.

6. Buchade D, Mohite S: Pattern of injuries inHomicidalCasesinGreaterMumbai:aThreeyearstudy; J IndianAcadForensicMedicine. Jan-Mar

2011.Vol.33,no1.46-49.

7. Ghangale A.L, Dhawane S.G, Mukherjee A.A.Study of Homicidal Deaths at Indira GandhiMedical College, Nagpur. J For Med and Tox;2003,20(1):47-50.

8. Mohanty M K, Mohanty S and Acharya S:CircumstancesofCrimeinHomicidalDeaths.MedSciLaw;2004,44(2):160-64.

9. ScottKWM.HomicidepatterninWestMidlands.MedSciLaw;1990,30(3),234-38.

10. AggarwalNK,BansalAK.;Trendsofhomicidesincapital city of India.Medico-legalUpdate;April-June2004,4(2):41-45.

11. Sinha U S, Kapoor A K and Surendra KumarPandey. Pattern of Homicidal deaths in SRNhospitals mortuary at Allahabad. Journal of ForMed&Toxico;July-Dec2003,20(2);33-36.

12. WahlstenPet al., 2007. “SurveyofMedico legalinvestigation of Homicides in the city of Turku,Finland”, Journal of Clinical Forensic Medicine,14:243-252.

13. KominatoYetal.,1997.“HomicidePatternsintheToyomaPrefecture,Japan”,MedicineScienceandLaw,37(4):316-320.

14. PadmarajR.Y.,TandonR.N. “Pattern of homicideatmortuary of civil hospital, ahmedabad” JIAFM2010;27(2):51-55.

15. MishraPradeepK.,YadavJ.,SinghSetal.“PatternofinjuriesinHomicidaldeathsinBhopalregion”,IAFM2012,Vol34,No3,Page195-198.

16. VougiouklakisT., TsiligianniC., 2006. “ForensicandCriminologicaspectsofMurderinNorth-West(Epirus) Greece”, Journal of Clinical ForensicMedicine,13:316-320.

17. RouseDA.Patternofstabwounds:asixyearstudy.MedSciLaw;1994,34(1)67-71.

18. Bamidele A, Colin C., Kim C.; Homicidescommitted by Youth Assailants: A RetrospectiveStudy.AmericanJForMedandPath;2008,29(3):219-23.

19. MohantyS.,MohantyMK.,PanigrahiMKetal.Fatal head injury inHomicidalVictims.Med SciLaw;2005,45(2):244-248.

Cont... Table VI: Injury constellation with respect to kind of injuries, type of weapon, region of body targeted, internal organs involved and cause of death.

Study of Elbow Joint for Estimation of Age in Maharashtra Population

Mohammad Abdul MateenAssistant Professor, Department of Forensic Medicine JIIUS Indian Institute of Medical Science and Research Warudi, Badnapur (Tq), Jalna (Dist) Maharashtra

ABSTRACT

40boysand40girlsofnormalheightweightagedbetween11to18yearswereselectedandstudiedradiologically,elbowjoint(APandLatview).Appearanceoftrochleain11yearinfemale.Fusionoftrochleawas12to14yearinfemalesand14to15yearinmales.AppearanceofLat.Epicondyleinmaleswas11to12yearsandfemales11years.FusionofLat.Epicondylewas13to16yearinmalesand13to14yearinfemales.Fusionofmed.Epicondyleinmaleswas14to16yearsandfemales11to15years.Fusionofheadofradiusinmalewas14to16years.Andinfemales11to13years.Appearanceofolecranonprocessinmaleswas11to13yearandfemale11year.Fusionofolecranonprocessinmales17to18andinfemales15to16years.Thisradiologicalstudyhasmedicolegalandarcheologicalimportance.Moreoverithasorthopedic and radiological importance alsobecause inexperienced radiologistororthopedician may thinktheseepiphyseallinesandnon-fusionsecondarycentersasfractures.AstheybelongtoMaharashtrapopulationthisstudyhasethnicimportancealso.Thisstudyofestimationofagecancontributetothefactorsofdeterminationofage,butcannotbetheparamountconclusive(1)

Keywords – Medical Epicondyle, Lateral Epicondyle, age, Maharashtra.

Address for Correspondence :Dr. Mohammad Abdul MateenAssistantProfessor,DepartmentofForensicMedicineJIIUSIndianInstituteofMedicalScience andResearchWarudi,Badnapur(Tq),Jalna(Dist)Maharashtra, Email:[email protected]

INTRODUCTION

Therearemanycriteriaforidentificationsofagelikeeruptionofteeth,height,pubertalchanges,butfusionofossificationvariesregionallyvowingtomultiplefactors.Ossificationofisthegrowth ofthebonetomeettherequired height and girth of the individual body. ThecenterappearsatIULorfetallivesareprimarycenters.Thecentersofossificationappearsafterbirtharecalledsecondary centers, but in the present study most ofsecondary canters are not considered because theseappearatearlyagei.ecapitulumat1year,radialheadat3years,medialEpicondyleat5yearstrochleaat4year,olecranonat9yearsbecauseradiationofx-ray

may cause Hazard to the growing children’s. Hencetheseagegroupsofchildrenwereexcluded.

Estimationofageisquiteimportantjobformedico-legalexpertinlivinganddeadinhisdaytodaymedico-legalpracticebutossificationcentresseenearlierintrophicalcountriesandfemalesmoreovervariationinappearance or fusion isattributed tomultiple factorslikeclimate,hereditary,race,dietaryhabits,nutrition,socio-economic status of population, gender etc.Because bone is themost plastic tissue which adaptswiththeenvironmentalfactors.HenceattemptismadetostudytheboysandgirlsofMaharashtrafrom11yearto18yearssothatItwillnotonlyhelpthemedico-legalexpertbutnutritionalexpertalsotoruleoutthevariationinappearanceandunionofcentresofossificationandtotheorthopedicianwhorepairtheelbowjoint.


40Boys and 40 girl of different age group 11to18areselectedtostudytheossificationofelbowjointradiologically,Boysandgirlsregularlyvisitingto IIMS& R Warudi Hospital along with patients as

DOI Number: 10.5958/0973-9130.2018.00150.0


attendantareselectedforstudy.theAPandLat.Viewof elbow joint studied. The subjects with obviousgross skeletal deformities, fractures of elbow joints,malnutritiousandchronicillnessinvolvingbonegrowthareexcluded.APviewistakenbyplacingtheupperlimbinfullextensionandsupinepositiontovisualizemedial,lateralepicondyleandradiocapitularjoint.Lateralviewistakenbyflexingtheelbowat90degreeandforearminsemipronatedpositiontovisualizeolecranonprocessandhumeroulnarjoint.(2).Thedurationofthisstudywasabouttwoyears.


I)AppearanceofTrochlea

a) Notobservedinmalesat11yearbut

b) Observedinfemale

II)FusionofTrochlea

a) InMales12 to13year ,14 to15year showprocessoffusion

b) But in female 12 to 13 , 14 to 15 year showmajorityoffusion

III)AppearancelateralEpicondyle

a) Inmale11to12yearofagelateralepicondyleisnotseen

b) Butinfemaleat11to12yearthereisappearancelateralepicondyle

IV)Fusionoflateralepicondyle

a) Inmalesof13 to15yearand16yearof theshowsnearertofusion

b) But in females in majority shows completefusion.

Fusionofmedialepicondyle:

a) InMales14to16yearofagenearertofusionand17to18showscompletefusion

b) Infemales11to15yearofageshowsnearertofusionand16thanwordshowcompletefusion

FusionofHeadofRadios:

a) Inmales14to16yearshownearfusion17to18showcompletefusion

b) Inthefemales11to13shownearthefusionand14to15onwardsshowcompletefusion

Appearanceofolecranon

a) In males 11 slightly, in 13 year completeappearance

b) In females 11 year complete appearance isobserved

Fusionofolecranon

a) Males 14 to 16 show near fusion 17 to 18onwordscompletefusion,

b) In females15 to16onwards complete fusionoccurs.

Table –No-1: Study of different age in both sexes

(Boys-40-50%&Girls-40-50%)

Age in Year Boys -40 Girls Total

No % No % % %

11year 5 12.5 5 12.5 10 12.5

12year 7 17.5 7 17.5 14 17.5

13year 8 20 8 20 16 20

14year 6 15 6 15 12 15

15year 3 7.5 3 7.5 6 7.5

16year 4 10 4 10 8 10

17year 3 7.5 3 7.5 6 7.5

18year 4 10 4 10 8 10

Table No-2: Study of fusion of elbow joint in both sexes (Boys-40-50%&Girls-40-50%)

Appearance of trochlea

Fusion of trochlea

AppearanceLat. epicondyle

Fusion of Lat. epicondyle

Fusion of med. epicondyle

Fusion of Hd.of radius

Appearance of Olecranon

Fusion of Olecranon

M F M F M F M F M F M F M F M F

- 11yr 14 to15 12to14 11to12 11 13to16

13 to14

14to16

11to15

14 to16

11 to13

11to13 11 17to18

15to16


DISCUSSION

Inthepresentstudyofestimationofagebyelbowjoint(11to18years)thehighestpercentsare(20%)are13year(17.5%,)(15%)in14year,in12year(12.5%.)in11years(10%)Inboth16yearand18yearisnotedinbothsexes.(Table-1)

a) Appearanceoftrochleain11yearsoffemalebutabsentinmales,fusionoftrochleainmales14to15butinfemales11to12years.

b) Appearanceoflatepicondyleinmales11to12yearsbutinfemale11yearsandfusionatmalesis13to16yearbutinfemale13to14yearsofage.

c) Fusionofmedialepicondyleinmalesat14to16yearofagebutinfemale11to15years.

d) Fusionofheadof radius inmales is14 to16yearandinfemale11to13yearofage.

e) Appearanceofsecondarycentresofolecranoninmales17to18yearinfemale15to16years.Thesepresent values are more or less in agreement withprevious studies of India (3) (4) (5) but varies withstandard test book anatomy as they of copied fromwesternstudies(6)(7)butinbothstudiesofIndiaandabroad females bones have earlier fusion thanmalebones because centres of fusion act according to thestate of endocrine secretion, health, and nutrition ofindividual.Undoubtedly there are racial, geographicalandhereditarydifferencesallthosethishavenotyetbeenadquetlydetermined(8)Ayoungsterwhoislargerthantheaverageorwhoisobeseisoftenissubjectedtounwarrantedepiphysealstresses.Hisbulkmaygiveafalseimpression of degree of bonymaturity. Earlier fusionof epiphysis in female was observed in all previousstudiesof Indiaandabroad (9)but fusionofbones inour study 2-3 year earlier than western studies. NoliteratureavailableinEnglishtojustifythesedifferencesinossificationorfusion.Theprobablereasonscouldbe

a) The dates of fusion are usually delayed innormalindividualsofshortstatureaslongbonesgrowbyaccretionaccompaniedbyabsorptionmechanismofremodeling(10)

b) Rate of bone growth fusion (maturation) isinfluenced not only by age and sex but by economicstatus,theindividualtotalbodyweightandpossiblyby

function.Racialdifferenceisalsorequiredtobetakenintoaccount.

c) The interval structure of bone in adapted ina very remarkableway to resist the stresses towhichit is subjected during the life. Hence tubercles andtuberosities are formed in direct response to pull oftendonsandligaments(11)

d) The process of ossification associated withappearance of local enzyme called phosphates thedegreeossificationprocessislargelyinfluencedbythisenzyme(12)

e) More over deposition of calcium salt in abiochemical phenomenon not directly determined byanylocalcellularelementsbutcontrolledbyextrinsicchemicalfactorsrelatedtogeneralmetabolismofthebodyandlocalvariationinthebloodsupply(13)

SUMMARY AND CONCLUSION

The present radiological study of estimationof age by elbow joint in both sexes ofMaharashtrapopulation very much helpful to the medico-legalandarcheologicalexperttodeterminetheageandfororthopedicsurgeon,radiologistmoreoverasthestudybelongstoMaharashtrathesepresentsignificantvalueshaveethicimportancebutthispresentstudydemandfurther embryological,Histological, bio-Mechanical,geneticstudiesbecausetheoriginofosteoblasticcellsremainindoubtbecausetheycanbedifferentiatedfrommesenchymalcellsandfibroblast.Thegreateractivitiesofosteoclastcellsalsostillremainuncertain.Aboveallthefactorswhichdeterminethetimeofossificationareobscure.

This research paper is approved by ethicalCommitteeofIIMS&Rwarudi,Badnapur(Tq)Jalna(Dist)Maharashtra.

NoConflict of Interest

NoFunding

REFERENCES

1. ChoudharyAmitAnand-BoneTest not enough tofixagesupremecourt-AIIMSreport&accused’sclaimofbeingminorsatthetimeofcrimerejects-Timesof India–DailyEnglishnewpaper (Hubliedition).3-12-2016.Page-9.

2. DavidEGrayson-Theelbowradiographicimaging


4theditor1990pearlsandpitfallspublication

3. NemadeKSKamadi:NYMeshramMM-Theageorderofepiphysisunionelbowjoint.Aradiologicalstudy in vidarbha. International journal of recenttrends in sciences and technology ISSN 2277-2812EISSN2249-8109WI10(2)2014251-255

4. Bhise ss, Nanandkar SD- Age determinationfromradiologicalstudyof epiphysealappearanceandfusionaroundelbowjoint, journalof forensicmedicine, Science and law Vol-20(1), 2011officialpublicationofmedico-legalAssociationofMaharashtra.

5. DixitSP:BansalRK-studyofossificationcentresfusionofelbowjoint in15 to17year Gharawalifemales of Dehradun region J.Indian Acad.Forensic.Med.2014Oct-Decvol.36(4)396-398

6. Dutta A K Essential of human Anatomy Sup &Inf Extremities ISt Edittion 1992 current books IinternationalpublicationCulcuta,Bombay,Madras12to15

7. Mitras – Anatomy Osteology IInd edition 1982AcademicpublicationCalcutta,NewDehli.8-101,8-908,8-1011

8. Rasch P J- Kinesiology and Applied Anatomy7th edition /1977 Lea & Febiger 200 chesterfed,park way Malveron Pennsylvania 19355 USAPublication21-23.

9. KrogmanWM, IscanM Y-The human skeletonin forensicmedicine second addition.Charles.CThomas.Publisherspringfield,Illions,USA,92-94

10. PaytonCG-ThegrowthofepiphysisoflongbonesinMadderfed.JofAnatvol-671933.25-26

11. Arey D Thespan w- growth and form 1942Cambridgeuniversitypublication92-95

12. HugginsCB-Influenceofurinarytractmucousonexperimental formationofboneproc.SOC.Exp.Biomed1930,27

13. ClarkL.G-thetissuesofthebody6thedition1971chapteroxfordAttheclarendonpress77-79.

A Cross Sectional Evaluation of Suicides in Females

Priyadarshee Pradhan1, Jagdish Kamal Chander U2, Venkatesan M3, P Sampath Kumar4

1Associate Professor, 2Assistant Professor, 3Assistant Professor, 4Professor and HOD, Department of Forensic Medicine, Sri Ramachandra Medical College & RI, Chennai

ABSTRACT

Thedeathsoccurringduetocauseswhicharenotanydiseaseprocessorageingarecalledunnaturaldeaths.Theunnaturaldeathscanbedividedasperthemannerassuicidal,accidental,homicidalorundetermined.The term‘suicide’ refers to thedeliberateactof takingone’sown life.Commonmethodsof suicidebyfemaleinIndiaincludehanging,poisoning,immolation,drowningandfallfromheight.Thetotalnumberof107casesconstitutedunnaturalfemaledeathsautopsiedfromJune2013toAugust2014outofwhich44caseswereconfirmedtobesuicidesconstituting41%.Maximumsuicidalfemaledeathsoccurredbetweentheagegroupof21–30years i.e.13cases(30%).Thenumberofcasesof femalesuicidewerehighestamongstmarriedgroupwith29cases(66%),theilliterateandhighschoolpopulationhadthemaximumnumberofdeathswith13(31%).Itwasobservedthatthemiddleclasssocioeconomicgrouphadthehighestdeaths(43%)amongdifferentgroupssegregatedonmodifiedKuppuswamyclassification.Hangingwasthemethodadoptedby24numberofvictimstocommitsuicide(54%)followedbypoisoning11victims(23%).Maritaldisharmonywasthemajorcauseconstitutedto24cases(54%).

Keywords: Female, Suicide, Hanging, Marital disharmony

Corresponding author:Dr Jagdish Kamal Chander U.AssistantProfessor,DepartmentofForensicMedicineSriRamachandraMedicalCollege&RI,Porur,Chennai–116,Ph:9884413225E-mail:[email protected]

INTRODUCTION

Accordingto the2011census, [1] Indiarecordedasexratioof940femalesper1000males,whichislowestamongthe10mostpopulouscountriesoftheworld.ThefascinatingstateofTamilNaduistheemerginghuboftechnologyandmodern lifestyle in India.TamilNaduisoneofthemostdevelopedstatesofIndiawith44%ofitspopulationlivinginurbanareasandseventhmostpopulous state in India. The statewitnessed a growthof15.6%initspopulationbetweenyears2001to2011.Thestatealsomaintainsagoodsexratioof995femalesforevery1000males. [1]TamilNaduisoneofthetopstatesofIndiaasfaraseducationisconcerned.Outoftotal population, 80.3% of people in Tamil Nadu areliterates.Femaleliteracyrateis73.9%ascomparedtomales 86.8%. Hinduism is most dominant religion in

TamilNaduwith over 88% of the total population isHindus. Two Sociologists predict the skewed femaletomaleratiowillproducegreaterlevelsoftensionthatwillresultinincreasedoccurrencesofviolenceagainstwomen.Suchactsagainstwomenhavebeenagrowingsocialphenomenon in the lastdecade. In2010,outofthetotalIPCcrimes,9.6%werecrimesagainstwomen,whichincludedtorture,sexualharassment,molestation,kidnapping/abduction,rapeandcruelestofall–dowrydeaths.[2]Thedeathsoccurringduetocauseswhicharenotanydiseaseprocessorageingarecalledunnaturaldeaths.Unnaturaldeathsarefoundtobehigherinruralthaninurbanareas.Theunnaturaldeathscanbedividedasperthemannerassuicidal,accidental,homicidalorundetermined.[3]

Unnatural deaths are ofmajor concern for publichealth care and politics. Among married females,unnaturaldeathsaremorecommoninmiddleandlowermiddle socio-economic groups. Several other factorssuchasage,occupation,lackofemotionalandfinancialsupport, inability to bear a child, sexual jealousy andmaritalinfidelity,failureinloveandscoldingbyparentsof unmarried girls are the reasons which may alsoinfluencetheunnaturaldeath.

DOI Number: 10.5958/0973-9130.2018.00151.2


Theterm‘suicide’referstothedeliberateactoftakingone’sownlife,thecommonreasonsbeingendogenousdepression,harassmentofamarriedwomanbyhusbandfor dowry, harassment for other reasons, familial andsocialdisharmony,failuresinexams,lovefailuresetc.Ascompared to themalecounterparts thefemalesareforced to bear the social burdensmorewhich rendersthem vulnerable to any kind of socialmaladjustment.CommonmethodsofsuicidebyfemaleinIndiaincludehanging,poisoning,immolation,drowningandfallfromheight.[4]

AIMS AND OBJECTIVES

To study the various patterns of suicidal femaledeaths

To analyze and indentify the preventable riskfactorsinsuchdeaths.


All cases of unnatural female deaths brought tothemortuaryofSriRamachandraMedicalCollegeandResearchInstitute,Chennaiforpostmortemexaminationduring theperiodofMay2013 toAugust 2014,werestudied in detail. This cross-sectional observationalstudy was undertaken in which all suicidal deathsoccurringincasesadmittedinSriRamachandraMedicalCollegeandHospitaloradmittedinanyotherhospitalandreferredtoSriRamachandraMedicalCollegeandHospital and suicidal death cases received as broughtdead to the mortuary of Sri Ramachandra MedicalCollege and Hospital were included in the study andall other female deaths due to anymanner other thansuicideornotconfirmedcasesofsuicidewereexcluded.

Astandardproformaspeciallydesignedwasusedtocollectinformationregardingthedemographicpattern. The history and data were obtained after detailedinterviews with investigating officers, deceased’skith and kin in addition to hospital records of thedeceased. All the cases were analyzed according totheir age, marital status and educational status. The socioeconomic classification of all the cases in thestudy was done into five groups based on modifiedKuppusamy classification attained through standardscale of educational, occupational and per capitalincomeoftheindividuals. Incasesoffemalesuicides,theantecedentfactorsincludedinthestudywerefamilialdisharmony, educational issues, financial dispute,

infertility, earlymarriage, depression /maladjustmentand victimswhowere unablefind a life partner. Anyhindrance in victim’s regular behavior which is wellestablishedintheirroutineisnotedasabstinencefromhernormalbehavior.Detailedexaminationfindingsofall external and internal injuries were also recorded. Datawereanalyzedusingcomputersoftware,StatisticalPackageforSocialSciences(SPSS)version11.5.Datawereexpressedinitsfrequencyandpercentage.

RESULTS

Thetotalnumberof107casesconstitutedunnaturalfemaledeathsautopsiedfromJune2013toAugust2014out of which 44 cases were confirmed to be suicidesconstituting 41%, based on history collected frompolice, inquest report, history from relatives, hospitalcase sheets and also medical opinion formed afterpostmortemexamination.Segregating thecasesasperagegroupsitwasnotedthatmaximumsuicidalfemaledeathsoccurredbetweentheagegroupof21–30yearsi.e.13cases (30%)followedby11 to20years (23%)andleastinolderagegroups.Meanagegroupwas39yrs,withthemaximumageof92yrsandminimumagebeing2yrs.(Fig:1)

Fig: 1

Themaximumnumberofcasesbelongedtomarriedgroup with 29 cases (66%) followed by unmarriedpopulation with 10 (23%) and widow with 5 (11%).Therewerenocasesbelongingtoseparatedanddivorcedgroup.Theilliterateandhighschoolpopulationhadthemaximumnumberofdeathswith13(31%)followedbyposthighschooldiplomasvictimswith7(15%)eachandleastbyprimaryschoolpassedoutwith2cases(4%).

Thecasesweredividedaspertheirsocio-economicstatus which was based on modified KupussamyClassification and it was observed that the middleclasssocioeconomicgrouphadthemaximumnumberofdeathswith19cases(43%)followedby the lowermiddleclass,i.e.,13cases(31%)andtheleastbyupper


classwith2case.

Hangingwasthemethodadoptedby24numberofvictimstocommitsuicide(54%)followedbypoisoning11victims(23%),burns7victims(15%),jumpingfromheights and suicideon roadwith1 case each (4%).(Fig:2)

Fig: 2

The antecedent factors leading to committingtheactof suicidewasstudied ineachcaseand itwasobservedthatmaritaldisharmonywasthemajorcauseconstitutedto24cases(54%)andsterilityconstitutedto8(15%)followedbyissuesineducationalenvironmentwith5(11%),financialdisputewith3cases(8%),oldagelonelinesswith3cases(8%)and1victimhaddiedduetoinabilitytofindlifepartner.(Table–1)

Table – 1 : Antecedent factors for suicide

Antecedent Factor No. of Cases (n=44) Percentage (%)

Maritaldisharmony 24 54

Sterility 8 15

Educationalenvironment 5 11

Financialdispute 3 8

Oldageloneliness 3 8

Inabilitytofindlifepartner 1 4

DISCUSSION

ThemaximumoccurrenceoffemalesuicidesinourstudywasbetweenMaximumof21–30years i.e.15cases(30%)withmeanagebeing39yrs.PrajapatiPetal[5]foundthatmaximumprevalencewas21–30years(36.23%).DereRCetal, [6]foundthatthecommonestagegroupaffectedwas26-30years(24.56%)followed

by21-25years(21.93%).

In this study, the maximum number of casesbelonged to married group with 66% followed byunmarriedpopulationwith23%andwidowwith11%.AsimilartrendwasalsoobservedbyPathakAetal,[7] as75.63%marriedand20.2%unmarriedandbyZineKUetal[8]as83.7%and10.8%respectively.PrajapatiP et al, [5] found thatmore than half of victimsweremarried (69.57%) while 25.36% were unmarried and5.07%werewidow.HoweverthepercentageofmarriedvictimswasveryhighasperthestudybyDereRCetal,[6]inwhichtheincidenceinmarriedfemalewas92.86%.

The illiterate and high school population had themaximum number of deaths with 31 % followed byposthighschooldiplomavictimswith15%eachandgraduateswith 11%. This finding is inconsistentwiththefollowingstudiessuchasbyPrajapatiPetalstudy,[5] which support the fact that the incidence of femalesuicide is high in population lower education status.ThesefindingsareinaccordancewithstatisticsofNCBI2008,[9] which reported that the maximum numberof suicide victimswere educated up to Primary level(25.3%) followed by Illiterate and Middle educatedpersonsaccountedfor20.7%suicidevictimsand23.7%respectively.HoweverinthestudybyAfzaliSetal,[10] theyfoundthatthehighestfrequencyofsuicidewasintheunderdiplomagroup,whereasthelowestfrequencywasforilliteratewomen.

In the present study, on dividing the cases as permodified Kuppuswamy scale we observed that themiddlesocioeconomicstatushadthemaximumnumberof deaths with 43 % followed by upper lower socioeconomic status with 31%. This finding is consistentwith Shrivastava AK, [11] studies also. According toShrivastavaAKmaximumnumbersofcasesbelongtosocioeconomicclassIV,56%.Butincontrast,PrajapatiPetal,[5]foundthathighestnumbersofcases(40.58%)wereinclassII(upper–middle).

In this present study, Hanging was the methodadopted by maximum number of victims to commitsuicide(54%)followedbypoisoning(23%)andburns(15%).ThisresultisconsistentwithKumarSetal[12] andKumarAetal[13] studies.ButPrajapatiPet al, [5] found that Poisoning (35.51%) as the most commoncause and K.D. Chavan et al, [14] found that Burns(31.3%)wasthemostcommoncauseofsuicide.


In the present study, we observed that maritaldisharmony was the major cause constituted to 50%of the cases followedby sterility (15%) and issues ineducational environment (12%) financial disputewith2 cases (8%), old age lonelinesswith 2 cases (8%)and inability to adapt earlymarriage (4%). 1 victimhad died due to inability to find life partner. SimilarfindingisseenwithstudiesbyGeetaSetal(2008)[15] andSrivastavaAKetal(2007)[11]studies.ButZineKUetal[8]foundintheirstudythatdowrydeathsin44.5%followedbytorturebyinlaws&husband(16.7%)andrash&negligenthusband(10.2%).AccordingtoSinghAK et al (2009),[16] depression, insecurity and excessworkloadresponsibleforthehighincidenceofsuicidaldeaths.PrajapatiPetal[5]andKumarSetal[12]foundthatmostcommonmotiveforsuicidaldeathswasmentalstress due to unknown reasons followed by familyquarrel. These varying findings could be attributed tovariousfactorslikesocial,economic,familial,culturalvariationsseenindifferentplacesinourcountryaswellasothercornersofworldalso.

SUMMARY AND CONCLUSION

Maximum numbers of unnatural female deathsare found in adolescent age group (21 – 30 yrs).Majority of the unnatural female deaths are found inlowsocioeconomicgroupwithlesseducationalstatus.Hanging is themost commonmethod adopted by thefemales to commit suicide.Marital disharmony is thecommonestcausebehind femalesuicideshowever theantecedentfactorsbehindsuicideinfemalesmayvaryindifferentplacesdue to thedifferentsocial,cultural,familial,economicandpsychologicalvariables.

Ethical Clearance: Obtained from InstitutionalResearchEthicsCommittee,SriRamachandraMedicalCollege&ResearchInstitute(DeemedtobeUniversity)

Ref:CSP-MED/13/JUN/07/19

Source of Funding: Selffunded


REFERENCES

1. GovernmentofIndia.CensusofIndia2011.StateLit [Internet]. 2011;3–4. Available from: http://www.censusindia.gov.in/2011-prov results/datafiles/india/Final_PPT_2011_chapter6.pdf.

2. Crime against women, 2010. [Internet] NationalCrimeRecordBureau,MinistryofHomeAffairs,India.Availablefrom:http://www.ncrb.gov.in.

3. AliEM,ElbakryAA,AliMA.AstudyofUnnaturalDeaths in Medicolegal Autopsies At DakahliaLocality.Mansoura JForensicMedClinToxicol.2007;XV(1):33–43.

4. V.V. Pillay. Textbook of Forensic Medicine &Toxicology.16thedn;ParasPublishers,Hyderabad:251.

5. PrajapatiP,PrajapatiS,PandeyA,JoshiV,PrajapatiN.PatternOfSuicidalDeathsInFemalesOfSouthGujaratRegion.NatlJMedRes.2012;2(1):31–4.

6. Dere RC, RajooKM. Study of Unnatural DeathsinFemalesAMedicolegalStudyatRuralMedicalCollege,Loni.JIndianAcadForensicMed.2011;33(3):211–3.

7. Pathak A, Sharma S. The Study of Un-NaturalFemale Deaths in Vadodara City. J Indian AcadForensicMed.2008;32(3):220–3.

8. Zine KU, Mugadlimath A, Gadge SJ, Kalokhe,Bhusale RG. Study of some socio-etiologicalaspects of unnatural female deaths at governmentmedicalcollege,AurangabdJIndianAcadForensicMed.2008;31(3):210–17.

9. Accidental and Suicidal deaths in India 2008.National Crime Bureau of India. Available from:URL:http://ncrb.nic.in/ADSI2008/accidental-deaths-08.pdfandSuicidaldeaths08.pdf

10. Afzali S, Taheri SK, JamilianM, Eslambolchi P.TheRelationshipbetweenMenstrualCyclePhasesandSuicideAttemptsinSuicidalWomenAdmittedto the Poisoning Ward of Farshchian Hospital,Hamedan,Iran.IranJToxicol.2012;5(15):531–4.

11. Srivastava AK, Arora P. Suspicious Deaths inNewlyMarriedFemales–AMedicolegalAnalysis.JIndianAcadForensicMed.2007;29(4):63–7.

12. KumarS,VermaAK,AliW,PandeyA,AhmadI,SinghUS.Astudyofunnaturalfemaledeathprofilein Lucknow, India. Am J Forensic Med Pathol[Internet].2013Dec[cited2014Oct31];34(4):352–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24141355

13. Kumar A, Pandey SK. Prevalence of UnnaturalDeath among Reproductive Aged Females inVaranasi Area India. Int J Sci Res. 2014; 3(6):


2144–7.

14. Chavan KD and Kachare RV. Study of suicidaldeaths. Int J ofMedToxicol andLegMed. 1999Jan-Jun;1(2):29-31.

15. Geeta S, SachidanandaM,_Sekhar TC,_Manju P.Victimiologic Study of Female Suicide, Medico-LegalUpdate -An International Journal,Volume8,Issue1,2008.

16. SinghAK,VermaAK,SinghK,SinghM,KumarS. Pattern of Un-natural Deaths in Lucknow,Capital of Uttar Pradesh. Paper presented inScientificSessionofForensicMedicon2010,XXXAnnualconferenceofIndianAcademyofForensicMedicine(IAFM)onJanuary2010atNagpur.

Traditional Medicine in Treatment of Women with Premenstrual Syndrome, A Systematic Review

Eslamnik Parvin Alsadat1, Parand Abdolmajid2, Aghamohammadi Maryam3

1Gynecologist, Social Determinants of Health Research Center, Yasuj University of Medical sciences, Yasuj, Iran, 2Instructor, MSc in Medical Surgical Nursing, Department of Medical-Surgical Nursing, Ahvaz University of

Medical Sciences, Ahvaz, Iran, 3Department of Medical-Surgical Nursing, Qazvin University of Medical Sciences, Qazvin, Iran

ABSTRACT

Premenstrualsyndromeisthecommondisorderamongwomenthatareinthechildbearingage, thisdisordermaydisturbmaritalrelationship,causesocialisolation,schoolandworkabsenteeism,poorperformance,reducedattention,increasedcomplaintsaboutpsychologicaldiseasesandevensuicideanditslegalproblems. Inthisstudy,thestudylookedatthewell-knowndatabases,herbaltreatmentsandcomplementarytherapiesin the syndrome,which,given thehighprevalenceof this syndromeand thecomplicationsof chemicaltreatments,shouldbeused.

Keywords: Treatment, Complementary Medicine, Premenstrual syndrome

Corresponding author: Aghamohammadi Maryam, DepartmentofMedical-SurgicalNursing,QazvinUniversityofMedicalSciences,Qazvin.

INTRODUCTION

Premenstrual syndrome is the common disorderamongwomen that are in thechildbearingage, and itappearsperiodically in lutealphaseof theirmenstrualcycle and ends with onset of menstrual bleeding1. Symptomsof this syndrome appear seven to tendaysbeforemenstrualbleedinganddisappearatthefirstdaysof bleeding2-4. Women with premenstrual syndromehave low quality of life and this syndrome increasesuse of health care and reduces working efficiency.Premenstrualsyndromeoccursin80percentofwomenofchildbearingage6.Epidemiological reviewssuggestthat about 85 percent of women experience physicalandpsychological premenstrual symptoms7.However,its severe caseswere reported by only 5 - 10 percentofwomen8.Underlyingdisordersandmedicaldisordersincluding hyperthyroidism and hypothyroidism,migraineheadache,chronicfatiguesyndromesymptoms,irritable bowel syndrome, hyperprolactinemia andpolycysticovarysyndrome,endometriosisandadrenal

disordersmayhavesimilarsymptoms topremenstrualsyndrome,whichthesedisordersshouldbepassed9-10. Thehighestprevalenceofdysmenorrhea is in thefirst20yearsoflifeandbeginstodecreaseafterage35-3011, 12. Premenstrual syndrome occurs in 80 percent ofwomenofchildbearingage.Prevalenceofthisdisorderhas been reported as 13 - 80 percent in adolescentgirls13. Premenstrual syndrome (PMS) symptoms aredivided into threeclassesofbehavioral,psychologicalandphysicalsymptoms,includingasfollows:Stomachbloating, anxiety or tension, breast tenderness, cryingperiods, depression, fatigue, lack of energy, anger orirritability without reason, concentration problems,appetite changes, thirst, and variable degree ofendometrial edema.This disordermaydisturbmaritalrelationship, cause social isolation, school and workabsenteeism, poor performance, reduced attention,increased complaints about psychological diseasesand even suicide and its legal problems14. Variousassumptions have been proposed for PMS, including:Progesterone deficiency, hormonal imbalance, sodiumandwater retention (increased aldosterone), excessiveprolactin overload and nutritional factors (pyridoxinedeficiency)15.Althoughetiologyof thisdisorder isnotclear, researchers suggest that neurohormones andneurotransmitters are unclear in its etiology, thus no

DOI Number: 10.5958/0973-9130.2018.00152.4


definitive treatment for it has been proposed.VarioustherapeuticstrategiesforPMShavebeenused,suchashormone therapy, replacementof essential fattyacids,and the use of pyridoxine and psychoactive drugs16. Nowadayswomenmostlyprefertotreattheirsymptomsusing complementary and natural medicine17. Givenhighprevalenceofthissyndromeamongwomen,currentresearchaddressesherbaltreatmentandcomplementarymedicineforpremenstrualsyndrome.

METHODS FOR REVIEW OF LITERATURE

Thisisareviewpaper,inwhichresearchscientificpapers, data in Google scholar search engine, Up todate,pubmed,scopus,webofsciencedatabasesaswellasrelatedbookswereanalyzed.

FINDINGS

Herbal treatments and complementary medicineaffectingpremenstrualsyndromearehighlydiversifiedand extensive.Recognized risk factors are verywide,some of which will be explained below. Eveningprimrose oil: There are many evidence suggestingeffectiveness of evening primrose oil in treatment ofpremenstrualsyndrome.ThemainoriginofthisplantisinNorthAmerica,andithasbeentransmittedtoothersareasfromthereandhuiledonageroilistakenfromseedsofthisplant.Huiledonageroilhasgreenishyellowcolor.This oil ismade up of various acids such as palmiticacid (6.5%), stearic (1.5%), oleic (11%), linoleic acid(72%),alphalinolenic,gammalinoleicandarachidonicacid.Thevalueofthisoilisduetoitsdryingpropertiesand presence of gamma linoleic acid in it. There arealso agents that provide prostaglandin biosynthesis inthisoil18.Fallahetal.(2008)conductedastudyentitled“The effect ofEveningPrimroseOil onPremenstrualSyndrome” in IsfahanUniversityofMedicalScienceson76womenabove18yearsoldwithPMSreferringtohealthcenterofIsfahan.Itwasadoubleblindtrialstudy.Participantswere randomly classified into two groups(n=38),andweretreatedfortwoconsecutivecycleatleast14daysbeforemenstrualcycle.Threecapsulesofevening primrose oil (1000 mg) in three consecutivedosesweregiventothefirstgroup(38)andthesecondgroup (38) received a placebo capsule in three doses,whichwas inamedicinal formsimilar to theeveningprimrose oil. They received it daily (morning, noon,evening)fortwoconsecutivemonthsinthelutealphase

ofthemenstrualcycle.Researchfindingsindicatedthatevening primrose oil is effective in improving PMSsymptoms19.

Vitamin E: The other treatment is using Alphatocopherol(vitaminE).Themechanismofthisvitaminin relation with PMS is not clear20. However, it mayinhibits release of arachidonic acid, and prohibitsconversion of arachidonic acid into prostaglandinvia the action of the phospholipase AZ enzyme andcyclooxygenase20. Akhlaghietal. (2009)conductedarandomizedclinicaltrialentitled“EffectofVitaminEonPrimaryDysmenorrhea”on200studentswithprimaryDysmenorrhea in Mashhad University of MedicalSciences. Students received vitamin E200 mg gelatincapsules.Theytookonepilleverydayfor5daysfrom2daysbeforestartingmenstruationforuptoits3firstdays.ResultssuggestedthatvitaminEcausedsignificantdecreaseindurationandseverityofpaininpatientswithprimaryDysmenorrheaanditcanbeusedasatreatmentmethod21.Inaddition,Proctoretal.(2001)conductedareviewstudyentitled“Herbalanddietarytherapiesforprimaryandsecondarydysmenorrhoea”.In thisstudy,impactofusingdifferenttreatmentssuchasMagnesium,Omega-3,VitaminE,andMefenamicwasinvestigated.ComparisonofVitaminEandMefnamicAcidindicatedthatdailyconsumptionofvitaminEalongwithusageofIbuprofenduringmenstruationwithconsumptionofIbuprofenaloneinmenstruationwascomparedandnodifference was observed between relief of symptomsin both groups20. Fenugreek Seed: Using Trigonellafoenum-graecum is one of the herbal treatmentsproposed forprimarydysmenorrhoea.Theherbaceousfenugreek belongs to the legumes family of lemongrass.Diosuginininfenugreekseedhasestrogenicandanti-inflammatoryeffectsand itsmucilagecompoundscan have anti-inflammatory and healing properties.It has many therapeutic effects, including analgesic,anti-inflammatory, anti-inflammatory, anti-cancer,lowering blood glucose, enhancing libido, astringent,cardioprotective, bile duct, laxative, corticosteroids,lowering blood cholesterol, lowering blood lipids,decreasing Hypertension, hypoglycemic agents,serum triglyceride, lactation, laxatives, tonsillitis, andmenstrual bleeding reduction effects 23, 24. Younesy etal.(2014)conductedadouble-blindclinicaltrialentitled“EffectsofFenugreekSeedontheSeverityandSystemicSymptoms of Dysmenorrhea”. 101 female singlestudents living in dormitory were randomly divided


intotest(n=51)andcontrol(n=50)groups.2-3capsulescontaining fenugreek seed (900 mg) were given toparticipantsthreetimesperdayfor2consecutivecycles.PainseveritywasmeasuredusingVisualAnalogScale(VAS)form.Finallyitwasfoundthatusingfenugreekduring menstruation may reduce Dysmenorrheasymptoms25. Yan et al. (2010) conducted a randomclinical trial entitled “Effect observation on treatmentof dysmenorrhea due to endometriosis (adenomyosis)withModifiedFenugreekBolus in40cases” inchina.40 mg fenugreek was given to 40 participants withDysmenorrheaandheadacheandvasculardistensionduetoendometriosis.SymptomsofDysmenorrheareducedin them after three months following the treatment,andqualityoflifewasimproved.ItwasconcludedthatDysmenorrhea symptomswere reduced in 95 percentof students,whichwas statistically significant. Thus,fenugreekwaseffectiveintreatmentofDysmenorrhea26.

Vitamin B6:TheotherproposedtreatmentisusingVitaminB6.Themechanismofactionof thisvitamininrelationtoPMSisunclear,butmaycausereductionofproductionofprostaglandinsbyinhibitingreleaseofarachidonicacid.Sabet-Birjandietal.(2010)conducteda studyentitled“Comparison theeffectofHypericumperforatum and vitamin B6 in the treatment ofpremenstrualsyndrome”.Itwasadouble-blindclinicaltrialon72studentswithpremenstrualsyndromelivingin Ahvaz Shahid Chamran Dormitory. The sampleswererandomlyassignedtotwogroupsof50.Hypericumperforatumwasgiventostudentsforthreedaysduring7 days. 80 mg pills of B6 vitamin were given tointerventiongroupfor7dayswithintwo-monthperiod.Psychological and physical symptomsweremeasuredafter twomonths throughdaily status form separatelyforbeforeandafterintervention.Finally,itwasfoundthatbothHypericumperforatumandvitaminB6wereeffectiveinreducingpremenstrualsyndromesymptoms,butHypericumperforatumwaslesseffectiveinreducingphysicalsymptomscomparedtovitaminB627.Whelanet al. (2009) conducted a systematic review entitled“vitaminsandmineralsinthetreatmentofpremenstrualsyndrome: a systematic review”. Itwas a randomizedclinical trialwith inclusioncriteria.Herbalmedicines,vitamins, and minerals were compared to placeboin treatment or reduction of premenstrual syndromesymptoms. Data were collected from databases likeCochrane Library، Embase، IBID، IPA، Mayoclinic،Medscape، MEDLINE Plus and Database Natural

MedicinesComprehensive.Theyreviewedstudiesthatsupported using calcium in premenstrual syndrome.TheyalsoreportedthatvitaminB6andVitagnusmightalso be useful in this regards. No evidence of usingeveningprimroseoilandmagnesiumoxidewasfoundto improve the symptoms of premenstrual syndrome.These researchers concluded that more research withadequate sample size and suitable classification areneeded for measurement of effects on severity ofmenstruationsymptoms28.

Calcium: Somestudieshaveindicatedthatcalciumiseffectiveintreatmentofpremesntruationsyndrome.Sutariya et al. (2011) conducted a study entitled“Interventional study (calcium supplementation &health education) on premenstrual syndrome-effecton premenstrual and menstrual symptoms” on 355womenatagesof15-45yearsoldduringlutealphase.Inthefirststage,400womenwerescreened.355onesincluded in thestudywith inclusioncriteria.215oneswereassignedininterventiongroupand140oneswereassignedincontrolgroup.Theyusedcalciumcarbonateor calcium gluconate 500 mg supplementationtwice daily, and health and nutrition education wasgiven for 3 consecutive cycles, then the data wereanalyzed.Finally,itwasreportedthatimprovementofpremenstrual syndrome symptomswas observed afteronemonthoftreatmentandallsymptomsexceptfatigueandinsomniashowedsignificantreductionaftersecondandthirdmonthsininterventiongroup.However,backpainwasmoreininterventiongroupand55percentofwomenininterventiongroupreportedover50percentimprovement and 30 percent ofwomen reported over75 percent improvement in premenstrual syndromesymptoms.Significantdifferencewasobservedbetweentwo groups at the end of thirdmonth 29. Pourmohsenetal.(2010)conductedastudyentitled“EvaluationofeffectofvitaminEonpremenstrualsyndrome”.Itwasatriple-blindclinicaltrialon87femalestudentslivingindormitoriesofIranUniversityofMedicalSciences.100 qualified individuals were included in the study,and were randomly assigned into two groups. In theplacebogroup(n=50),1000mgofstarchpowderwasusedin2capsulesperday.Inthecontrolgroup(n=50),2capsules,onecontaining1000mgofcalciumandtheothercontaining400unitsofvitaminE,wereusedasone capsule in the morning and one at night. At theend of research, the difference between two groupswas statistically significant and caused 63 percent


reductioninmoodsymptomsand49percentreductionin behavioral symptoms and 55 percent reduction inphysical symptoms. In addition, there was significantstatisticaldifferencebetween2groupsofcalciumandvitaminEandplacebo30.

CONCLUSION

Conclusion Herbal and chemical treatments havebeenreportedforpremenstrualsyndrome.Consideringcomplications of chemicalmedicines and tendency touseherbalmedicines,thesemedicinescanbeprescribed.Eveningprimroseoil,calcium,vitaminE,B6,fenugreekcanbementionedherbaltreatmentsandcomplementarymedicine,whichareavailableascapsuleandpills,andtheycanbeusedforrelievingseverityofsymptoms.

Ethical Clearance: This research project wasapprovedbytheethicscommitteeofQazvinUniversityofMedicalsciences.

Source of Funding:Qazvin,UniversityofMedicalsciences.


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4. JokarS,MotamedN,KamaliF,AzodiF,KhaliliA,JahanpourF.TheattitudesandpracticeofmotherswhowerereferredtothehealthcarecentersinIranfor theuseofmedicinalplants in thetreatmentofchildren’s diseases. J Pharm Sci Res. 2017;9(3):2349-52.

5. Alizadeh Z, Paymard A, Khalili A, Hejr H. Asystematic review of pain assessment method inchildren.AnnalsofTropicalMedicine andPublicHealth.2017;10(4):847-49.

6. Shooshtari MH, Tirandaz F. Prevalence of

Premenstrualdysphoricdisorderinfemalestudentsofmedicalsciences,2010.

7. PaymardA,Bargrizan S,Ramezani S,KhaliliA,Vahdatnejad J. Comparing changes in pain andlevelofconsciousnessinopenendotrachealsuctioncatheterswithtwosizes:12and14:Arandomizedclinical trial. Eurasian Journal of AnalyticalChemistry.2017;12(5):591-97.

8. Domoney, C.L., A. Vashisht, and J.W.W. StuddPremenstural Syndrom and the use of alternativeTherapies. Annals of The Newyork Acodemy ofsciences,womenshealthandDiseses.GynecologicAndReprodutiveissue,2003.997(3):330-40.

9. Pearlstein T, Steiner M. Premenstrual DysphoricDisorder:BurdenofIllnessandTreatmentUpdate.FOCUS: The Journal of Lifelong Learning inPsychiatry.2012;10(1):90-101.

10. Fritz A, LeonSperoff M. clinical GynecologicEndocrinologyandInfertility.eighth,editor,2011.

11. DawoodMY.Primarydysmenorrhea:advances inpathogenesis and management. Obstet Gynecol.2006;108(2):428-41.

12. Talaei A, Bordbar MRF, Nasiraei A, PahlavaniM, Dadgar SA. Epidemiology of premenstrualsyndrome(PMS)inStudentsofMashhadUniversityofMedicalScience.IranJObstetGynecolInfertil.2009;12(2):15-22.

13. RasoolzadeN,ZebardastJ,ZolfaghariM..Effectsofrelaxationonprimarydysmenorheaamongfirstyearnursingandmidwiferyfemalestudents.Hayat2007;13:23-30.

14. Alimohammadi N, Jokar M, Khalili A,Aghamohammadi M. The requirements of thecaregiversofpatientshospitalizedinintensivecareunits.NatlJPhysiolPharmPharmacol.2018;8(4):18-26.

15. Eftekhari,N.,Eslamnik,P.A.,Khalili,A.,Davoodi,M. Comparing cesarean wound complications inhigh-riskwomenwithandwithoutanticoagulation.Journal of Mazandaran University of MedicalSciences.2015:25(124):48-55.

16. Loch,E.,H.Selleh,andN.Boblitz,TreatmentofpremenstrualsyndromwithaphytopharmaceuticalFormulationvitexagnuscastus.JournalofwomanshealthandgenderbasedMedicine.2000.9(3):315-20.


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19. Fallah,L.T.,etal.,TheeffectofEveningPrimroseOil on Premenstrual Syndrom. scientific journalHamadan nursing & midwifery faculty, 2010.16(1):35-39.

20. HarelZ.Dysmenorrhea in adolescents and youngadults: from pathophysiology to pharmacologicaltreatmentsandmanagementstrategies.ExpertOpinPharmacother.2008;9(15):2661-72.

21. Akhlaghi F, Zyrak N, Nazemian S. Effect ofVitaminEonPrimaryDysmenorrhea.Hayat.2009;15(1):13-9.

22. Proctor ML, Murphy PA. Herbal and dietarytherapiesforprimaryandsecondarydysmenorrhoea.Cochrane Database Syst Rev. 2001; 4(3):CD002124.

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24. Mandegary A, Pournamdari M, Sharififar F,Pournourmohammadi S, Fardiar R, Shooli S.Alkaloidandflavonoidrichfractionsoffenugreekseeds (Trigonella foenum-graecum L.) withantinociceptiveandanti-inflammatoryeffects.Food

ChemToxicol.2012;50(3):2503-07.

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Estimation of Drug Containing Tranquilizers by Thin Layer Chromatography (TLC)

Sushma Upadhyay

Assistant Professor, Department of Forensic Science, Guru Ghasidas Vishwavidyalaya, Koni, Bilaspur (C.G.)

ABSTRACT

Consideringthehighconsumptionofbenzodiazepinesworldwide,thereisincreasedpotentialforaddictionandabuseincasesofcrime,drivingundertheinfluenceofdrugs,suicideanddrug-facilitatedsexualassault(DFSA).Forthesereasons,thisclassofdrugsandtheirmetabolitesarefrequentlypresentinbothclinicalandforensiccases.Therefore,itisimportanttodevelopanefficientsamplepreparationprocedureaswellasmethodabletodeterminebenzodiazepinesindifferentmatrices.Inthisarticletheinformationconcerningthecurrentavailableanalyticalmethodsforthedeterminationoftranquilizersinbiologicalmaterialsandpharmaceuticalformulationsarereviewed.Developedmethodsareclassifiedaschromatography(TLC).ThepresentworkismainlybasedondrugscreeningthroughTLC.InthisstudythecomparisonwasmadebetweenRf-valueandstandardRf-valuetoestablishtheidentity.

Keywords- Tranquilizer, Drug facilitated sexual assault, TLC, Benzodiazepines.

Corresponding author: Sushma UpadhyayAssistantProfessor, DepartmentofForensicScienceGuruGhasidasVishwavidyalaya,Koni,Bilaspur(C.G.)[email protected],Mob.No.9479071547,08130864569

INTRODUCTION

Tranquilizersarethechemicalshavingtheversatilemedicinal values. These are the type of psychotropicdrug, that is, they concern the mind and can amendframe of mind. Benzodiazepines enhance the effectof the neurotransmitter gamma- aminobutyric acid(GABA) and are subsequently used therapeutically asanxiolytics, tranquilizers, hypnotics, anticonvulsantsin epilepsy and centrally acting muscle relaxants.Benzodiazepines(BDZs)aregenerallycommonlyusedas anxiolytic and/orhypnoticdrugs as a ligandof theGABA-benzodiazepine receptor. Moreover, some ofbenzodiazepinesarewidelyusedasananti-depressiveandsedativedrugs,andalsoasanti-epilepticdrugsandin some cases can be useful as an adjunct treatmentin refractory epilepsies or anti-alcoholic therapy.Procedures for quantification of drugs reviewed bydifferentauthors1,2includedbenzodiazepinesinthebio-samplesblood,plasma,serum,ororalfluid(saliva,etc.)

An overview included elaborated sample preparationand isolation technologies for the chromatographicdetermination of 1,4-benzodiazepines in biologicalmatrices.3Asbenzodiazepinederivativesendupontheillicit market from diversion from legitimate sources,reference should bemade to national pharmacopoeiasand drug tablet and capsule identification guides forpreliminaryscreening information.Referencecanalsobe made to the Multilingual Dictionary of NarcoticDrugsandPsychotropicSubstancesunderInternationalControl.4 Becauseofitssimplicityandspeed,thinlayerchromatography (TLC) has found many applicationsin medical, biological, chemical and pharmaceuticalsciences.5,6 Some of the more common componentsfound in over-the-counter analgesic products includeaspirin,phenacetin (withdrawn),caffeine,paracetamol(acetaminophen), and codeine, (methylmorphine).7

Paracetamol (acetaminophen) is one of the mostpopular over-the-counter analgesic and antipyreticdrugs. Paracetamol is available in different dosageforms: tablet, capsules, drops, elixirs, suspensionsand suppositories. Dosage forms of paracetamol andits combinationswith other drugs have been listed invarious pharmacopoeias.8,9. Numerous methods havebeen reported for the analysis of paracetamol and itscombinationsinpharmaceuticalsorinbiologicalfluids.

DOI Number: 10.5958/0973-9130.2018.00153.6


Paracetamolhasbeendetermined incombinationwithotherdrugsusing quantitative thin-layerchromatography(TLC)10.

Thechromatographymethodofseparation,ingeneral,involvesthefollowingsteps:

Table-1: Various Types of Coating Materials Used in TLC

S.no. Adsorbent Acidic or Basic Activity Separatory mechanism Component to be separated

1. Silicagel Acidic Active Adsorptionpartition Acidicandneutralsubstance

2. Alumina Basic Active Adsorptionpartition Basicandneutral

3. Kiesleguhr Neutral Inactive Partition Stronglyhydrophilicsubstance

4. Cellulosepowder Neutral None Partition Watersolublecompounds

EutrophicseriesofselectedoneandtwocomponentsolventsystemswithincreasingelutingpowerorpolaritySolvent System

1. Cyclohexane,ethylacetate(95:5)

2. Chloroform,acetate(9:1)

3. Ethylacetate,methanol(99:1)

4. Benzene,acetone(1:1)

5. Chloroform,acetone(85:15)

METHODOLOGY

Step-1: Collection of Drug Sample:

i) All the testing drugs samples containingtranquilizers in their chemical composition werecollectedfromlocalmedicalstoresofBilaspurDistrict(C.G).

ii) Total 25 samples of drugs containingTranquilizerswerecollected.

iii)Thetranquilizersnamelyviz.chlorpromazine,promazine,Diphenylhydramine,methanol,Pheniraminewasanalyzedamongabovementioneddrugs.

iii)All these 25 drugs samples were screenedoutfortheirpresenceorabsencebyscreeningtesti.e.colourtests.

iv)ThequantitativeanalysiswasdonewiththeuseofThinLayerChromatography

Method(TLC).

v)AfterdetectionoftranquilizerindrugsampleitsRf- valuewere calculated by applying given standardformula.

vi)Thecommonname ,tradenameand chemicalcompositionoftestingdrugsamplesaregivenunderthefollowingtable.

TotalDistancetravelledbytheSolute

Rf-Value=------------------------------------------------------------

TotalDistancetravelledbytheSolvent

Table-2: Relative Information of Drugs

S. No. Common name Trade name Chemical Composition Quantity (mg)

1 Pheniramine Avil • DiphenylhydraminehydrochlorideIP• PheniraminemaleateIP

20.00mg

2.00mg

2 Diphenhydramine Benadryl • Diphenhydramine• HydrochrorideIP

14.08mg138.0mg


3 Acetaminophen Paracetamol• Paracetamol,• Phenylephrinehydrochloride,• chlorpheiramine,

500.0mg2.00mg30.00mg

4 DextromethorphanOr/PhenylPropanamine Lysocof

• HydrobromideIP• chlorpheiramine,maleateIP• phenylephrine,hydrochlorideIP

10.00mg2.00mg5.00mg

5 Dextromethorphan Tus.Q.D

• Dextromethorphanhydro-bromideIP,• chlorpheiraminemaleateIP,• PhenylephrinebhydrochlorideIP.

15.00mg

2.00mg5.00mg

Requirements:

Roundbottomflask(500ml),beaker(100ml),separatingfunnel(500ml),conicalflask,column,TLCplates,ammoniumsulphate,methanol,bismuthsubnitrate,potassiumiodide,fluorosis,diethylether,silicagel-G,anhydroussodiumsulphateetc.arerequiredforexperiment.

B) Processing of Samples:

Took1-gmofdrug

I

Crushit

I

Add5-mlmethanolanddissolveit

I

NowperformspottingonpreviouslysaturatedTLCplateswiththehelpofcapillarytube

I

PutthespottedTLCplateonsaturationchambercontainingsolventsystem(Chloroform:Methanol(9:1)

I

Runitfor45-minutes

I

RemovetheTLCPlateandleftitfor5-minutes

I

VisualizedthespotswiththehelpoffreshlypreparedDragendroff’sReagent

C) Calculation:

• AftervisualizationofthespotscalculatedtheirRf-Values.

• FortheeveryspotthreereadingweretakenandthemeanvaluewasunderconsideredforitsRf-Value.

• TheRf-ValueofthesamplewascalculatedbyapplyingthefollowingFormula.

Cont... Table-2: Relative Information of Drugs


CombinedAvil1and2 Lysocof1 Fig. 1 Fig. 2

Combinedparacetamol1and2Lysocof1

Fig. 3 Fig. 4

Table-3: Observations

Name of Drug Tranquilizer S.S.* V.R.** Rf-ValueStandard

Rf-ValueMeasured

Avil

Pheniramine CH3Cl:CH3OH(9:1)

Dragendroff’s 0.33-0.58

Sample-10.74

Sample-2 0.39

Sample-30.67

Sample-4 0.49

Sample-50.56

Benadryl Diphenhydramine CH3Cl:CH3OH(9:1)

Dragendroff’s 0.85-0.93 Sample-10.81

Sample-2 0.96

Sample-30.91

Sample-4 0.83

Sample-50.87

Sinarest

AcetaminophenCH3Cl:CH3OH(9:1)


Sample-10.78

Sample-2 0.81

Sample-30.75

Sample-4 0.68

Sample-50.84


Lysocof

DextromethorphanOr/PhenylPropanamine

CH3Cl:CH3OH(9:1)


Sample-10.94

Sample-2 0.94

Sample-30.91

Sample-4 0.89

Sample-50.86

Tus.Q.D.

Dextromethorphan CH3Cl:CH3OH(9:1) Dragendroff’s 0.85-0.93

Sample-10.97

Sample-2 0.89

Sample-30.95

Sample-4 0.94

Sample-50.90

*SolventSystem**VisualizingReagent

SUMMARY

ThetotalfivedrugssampleweretakennamelyvizAvil,Benadryl,Paracetamol,LysocofandTus.Q.DFromdifferentcompaniesofeachdrugwhereanalyzedwiththehelpofTLCandmeasuredthereRf-value.ThemeasuredRf-valuewerecomparedwiththeirstandardRf-value to know the exact chemical composition ofTranquilizer,oranyalternationorimpuritiespresentintesteddrugsample.TriceRf-valueweretakenunderconsiderationand finallymeanvaluewerecalculatedforeachdrugortestedsample.

In case of Avil (Pheniramine) red spot wereobservedandtherangeofstandardRf-valuewas0.33-0.58andthesamplereadingsrangesfrom0.39-0.74.thisvalueswerefoundtoclosetostandardRf–value.

In case of paracetamol (Acetaminophen) orange-redspotwereobservedandthemeasuredRf-valuewasrangesfrom0.68-0.84andthismeasuredRfvaluewasfoundtoclosetostandardRfvaluerangethatis0.65-0.88.

In case of cough syrup such asBenadryl (Diphenylhydramine) and Lysocof(Phenylpropanolamine) and Tus.Q.D(Dextromethorphan) red spot were observed and therangeofabovementiondrugthatisBenadryl,Lysocof,andTus.Q.DthemeasuredRfvaluewere0.81-0.96,0.86-0.94 and 0.89-0.97 respectively.in case of Benadryl,

Cont... Table-3: Observations

Lysocofall themeasuredvaluewere foundtoclose tostandardRfvaluethat is0.85-0.93.incaseofTus.Q.DmeasuredRfvaluewerefoundlittlebitfluctuatingthatis0.89-0.97fromstandardrangethatis0.85-0.93thatismightbebecauseofourconcentrationinthechemicalcompositionofdrugorduetomanufacturingalterationduringitspreparation.

CONCLUSION

Tranquilizersarethedrugwhichreliveanxietyand mental tension without producing sedation orsleep. They are used in various neurotic conditions,anxietystatesandfor the reliefof tension,socommonnowadayduetocomplexitiesoflife.Theyarealsousedin anaesthesia for their muscle-relaxant properties.A large number of Tranquilizers are available in themarket under different trade names. The commondrugswhichwere taken for the studyofRf-value areBenadryl, Lysocof, Tus.Q.D, Avil, Pheniramine, andacetaminophen.

Theforensicaspectsrelatedtosocialcostsofdrugsinclude property crime, this drug effect on cognitivefunction can influence alleged cognitive disability asrelevanttobraininjuryclaims,employmentdisabilityclaims and can interfere with performance in theneuropsychologicaltestsusedtoevaluatesuchbrainfunction.ThepresentworkwasmainlybasedondrugscreeningthroughTLC.InthisstudythecomparisonwasmadebetweenRf-valueandstandardRf-valuetoestablishtheidentitybyitspresenceandabsence.


Ethical Clearance-NotRequired


Conflict of Interest –NIL

REFERENCES

1. Kintz P (2007) Bioanalytical procedures fordetectionofchemicalagentsinhairinthecaseofdrug-facilitated crimes. Anal Bioanal Chem 388:1467-1474

2. DrummerOH(2006)Drugtestinginoralfluid.ClinBiochemRev27:147-159.

3. Uddin MN, Samanidou VF, PapadoyannisIN (2010) Sample preparation overviewfor the chromatographic determination of1,4-benzodiazepinesinbiologicalmatrices(Chapter7), Reviews in Pharmaceutical and BiomedicalAnalysis, Editors: Constantinos K, Zacharis andParaskevas D, Tzanavaras. 84-107, Bentham

SciencePublishersLtd.

4. Multilingual Dictionary of Narcotic Drugs andPsychotropic substances under InternationalControl, ST/NAR/1/Rev. 2, 2006. Available atwww.unodc.org

5. Stahl, E. Thin Layer Chromatography, 1st. Ed.(1969).

6. Lieu, V.T. Journal of Chem. Educ., 48(7) 479(1971).

7. Ganshirt,H.,Malzacher,A.,Arch.Pharmz.293(65)925(1960).

8. J.E.F. Reynolds,“Martindale The ExtraPharmacopoeia”,31sted.,pp.27-28,PharmaceuticalPress,London,1996.

9. TheUnitedStatesPharmacopoeia,24threvision,pp.17-39,U.S.PharmacopeialConvention,Rockville,MD,2000

10.P.Kahela,E.LaineandM.Anttila,DrugDev.Ind.Pharm.,13(2),213-224(1987).

Intensive Care after Cardiac Surgery

Mehdi Molavi Vardanjani1, Davoud Mardani2, Nikghadam Hormoz3, Narges Kalvandi4

1Department of Medical Surgical Nursing, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran, 2Member of Chamran Heart Center, Isfahan University of Medical Sciences, Isfahan, Iran, 3Nurse, Hamadan University of Medical Scinces, Hamadan, Iran, 4Master of Community Health Nursing

Student, Hamadan University of Medical Sciences, Hamadan, Iran

ABSTRACT

Post-surgical cardiac surgery is one of the most critical therapeutic courses in patients undergoingcardiovascular surgery. Complications such as bleeding, heart failure, arrhythmias, organ failure,neurological disorders, respiratory failure, infection, and hemodynamic disorders are some of themostprominentand life-threateningevents in thisperiod.Themanagementand treatmentof thesepatients isdoneinpartnershipwithateamthatplaysakeyrolefornurses.Aprospectivereviewarticleisanintegratedreviewofthearticleswhichhavebeenevaluatedandanalyzedduringthreestagesofthesearchoftexts.Searchingfor texts invaliddatabaseswassearchedusing thekeywords“nursingcare”,“heart surgery”,“nursing”and“cardiacsurgerycomplications”,subjecttotheirpublicationperiodfrom2000to2016.Thedataextractedfromthereviewedarticlesisanalyzedandcategorized.Amongthecriticalnursingpracticesinthemanagementofthiscriticalperiod,onecanexploreandidentifypeopleatrisk,heartratemonitoringandmonitoring,hemodynamicmonitoring,correctionofhypertensiondisorders,diagnosisandtreatmentofhemodynamicdisorders,andpreventionand treatmentofneurologicaldisorders.BeTheforthcomingreviewstudyattempts toexplainandexplain thenurses’ responsibilities tospecializedcareunitsduringpost-operativeheartsurgerybysystematicallyreviewingnursingtexts.

Keywords: Nursing care, postoperative period, complications

INTRODUCTION

Thepost-cardiacperiodisoneofthemostcriticalandcriticalmomentsduring thehospitalizationperiodforpatientsunderlyingthesesurgeries.Becauseof therisk of complications such as bleeding, heart failure,arrhythmias, organ failure, neurological disorders,respiratory failure, infections and low cardiac output,this course is one of themost challenging acute life-threatening situations. Patients1,2. Many deaths ofpatientsundergoingheart surgeryoccurat the timeofadmission to theCICU3,4.Openheart surgery requirestheircardiachypothermiawithacardiologiccoldsolutionandplacementofpatientsonacardiopulmonarybypass

Corresponding author: Narges Kalvandi, MasterofCommunityHealthNursingStudent, HamadanUniversityofMedicalSciences,Hamadan,Iran

pump5.TheCPBdevicealwayshasmanycomplications.The spinal exertion of blood in tubes and syntheticfilterstriggersinflammatoryreactionsthatoccurduetoinflammatoryfactorsandinflammatorymediators.Theoccurrence of these inflammatory reactions increasesthepermeabilityofthevascularwall,whichleadstotheoutflowofintravascularfluidtotheinterstitialspaceandedema6,7.Thetissueedemaleadstoorganfailure,knownas the systemic inflammatory response. Incidence ofsmall and large embolisms, coagulation disorders,acute respiratory distress syndrome and electrolyte,including other complications ofCPB and open heartsurgery5.Managementandtreatmentofpatientsinthepost-cardiac period is responsible for awide rangeofhealthcareprofessionalswhoactasatherapeuticteam.Meanwhile,duetothetimespentbynurseswiththesepatientsandtheirexistenceasthefirstlineoftreatmentinmanycases,nursesplayakeyroleinmanagingandtreatingpatientsinpost-cardiacsurgery8.Nowadays,therelevantexpertsbelievethatevenwithaperfectsurgery,

DOI Number: 10.5958/0973-9130.2018.00154.8


advanceddevicesandtechnologies,ifthereisnopropernursingcare,surgicalprocedureswillnotcomewithgoodresults9.Thelackofinformationaboutnursingcareinthepost-cardiacsurgeryperiodandthelackofliteratureonthissubjectmadeussearchforavailableinformationandprovideareviewarticle.Thepurposeofthisarticleistoreview,describeanddescribepossibleeventsandcomplicationsinpost-cardiacsurgerythatnursesplayintheprevention,diagnosisandmanagementoftheheart.


The forthcoming review study is an integratedoverviewof articles thatwere conducted during threestagesofthesearchoftexts,evaluationandanalysisofdata.IranMedex,Magiran,Pubmedcentral,EMBACE,EBSCO and CINAHL databases using the keywords“nursingcare”,“cardiacsurgery”,“nursing”and“cardiacsurgery complications”, subject to their publicationfrom 2000 to 2016 searches. Out of 897 articles, 7papers1,2,6,8,10-12,havebeenstudiedbasedonthecriteriaforentry.Focusonpost-cardiaccare,accesstofulltextof thearticle,andwriting.After selecting thearticles,thequalityofthesearticleswasreviewedandapprovedbytheauthors.Inthenextstep,thedataofeachresourcewas explored and extracted one by one. Interventionsandactionsthathavenotbeenperformedbynurseshavebeenexcludedfromclassifiedinformationbasedontheconsensusoftheauthors.Finally,theextracteddataisintegratedandcategorized,summarizedandpresented.

Recognizing Patients at Risk

Knowing as soon as possible the at-risk patientswill greatly reduce the complications and mortalityof patients undergoing cardiac surgery. Investigatingand identifying risk factors in these patients is alsoimportantduetothenecessityofremediationtopreventsecondary complications 13. So far, many institutions,associationsandcentershavebeenstudyingtheseriskfactorsandweightingthem.Theresultsoftheactivitiesof these centers are presented as tools that are basedon regression models. Scores between 0 and 4 goodresults, grades 5 to 9 average results, scores 10 to 14poorresults,grades15to19,highriskandscoresabove20indicateahighriskofsurgery(Table1).

Transferring the Patient to the CICU Department

Afterthecompletionofheartsurgery,patientsarein averyunstable condition.Transmissionofpatients

is considered tobea seriousconditionbecauseof thevariousrisksthatthreatenthesepatientsinthisperiod.In order to minimize possible risks, patients shouldfully transfer to the CICU 1,2, along with ECG andhemodynamicmonitoringdevices,withfullcompliancewithsafetyrequirementsformovement.Somepatientsmay be treated with anesthetic drugs before beingtransferred to the CICU, in order to avoid unwantedwaking in the route of transmission. Such patientsare at risk for hypotension, and if they develop suchan event, they can be treated with colloidal fluids orincreaseddosesofinjectableinotropicdrugs12,14.OncepatientsarriveattheCICU,patientsaremonitoredandmonitored by the hemodynamic and ECGmonitoringdevicesinthedepartment.Incaseofanydisturbanceinthemonitoringsystems,thepulsesofthepatientshouldbecontrolledby thehandandensure that theyhaveanaturalpulse 15.Ventilation is appropriate forpatientswithcasesofairbornehearinginlungs,bilaterallyraisedlungs,favorablepulseoximetry,andnaturalarterialgasanalysis(ABG)10,15.

Monitoring of Cardiac Rate and Rhythm

In order to increase the strength of the surgeon’smaneuver, theheartofpatientsundergoingopenheartsurgery is immobilized by cardioplasty. On the rightventricular epidermal suture,most patientswith heartsurgery are a stitch suture that can be attached to thepacemakergeneratorat the timeofarrhythmias.Mostexpertshaveaheartrateabove90beatsperminutetoensure adequate tissueperfusion andbalancebetweenthesupplyanddemandformyocardialoxygenation.Anelectrocardiogram isalsoa shock to theheartwithanelectrocauterydevice1,12.Applyinghigh-speedimpulsestotheheart,inmanycasesleadstoarrhythmias.Intheabsenceofarrhythmiaorsuccessfularrhythmiacontrol,thepacemakercanberemovedonthefourthdayaftersurgery,withanINRof<2.56,16.

Monitoring of Cardiac Output

One of the most important goals of nursing carefor patients in the post-surgical period is to monitor,maintain and restore normal cardiovascular outcomes.Heart transplantation and normal hemodynamicsrequireadequateperfusionofvitalorgansandorgans.Even short periods of hypoperfusion of vital organscan lead to lethal events, such as organ failure andMODS11,17. Diagnostic procedures for ventricular


functionandventriculardysfunctiondiagnosis includeTEE and TTE echocardiography 17.Management andtreatment ofLOCS is based on drug support,with orwithoutmechanicalsupportfortheheart.Theneedfordrug support ismore likely to be needed, despite theamount of circulation in circulation; the ventricularfunction is still low. These drugs often includecatecholamines such as adrenaline, dopamine, anddibutamine, or phosphodiesterase inhibitors such asmelirinone. Mechanical support of the heart is oftendone by inserting a balloon into the aortic pump 16,18. IABPreducesmyocardialoxygendemandbyreducingpostpartum and increasing myocardial oxygenationthroughincreasedcoronarybloodflow6,19.

Hypotension

Most cases of hypotension occur at the timeof admission of the patient to the CICU due tohypovolaemia.Inthefirststep,thenursecanperformthefluidchallengetestanddifferentiatethehypovolaemiafrom other causes of hypotension (Table 2). In thistest, about 250CC of colloidal or crystalloid fluids isinfusedover5minutes6,20.Incaseofhypovolaemia,thepatient’sresponsetofluidtherapyisaformofincreasedblood pressure; otherwise blood pressure will notchangeordiminish. In theabsenceoformodificationof the hypovolaemia, other treatments include theadministrationofinotropicdrugsandtheeliminationofunderlyingcauses1,21.

Hypertension

The incidence of hypertension following CABGsurgeryincreasesthepressureonthegraftsand,inthepresence ofweak aortic sutures in the aortic surgery,causesruptureofthemuzzlers.Hence,theoccurrenceofhypertensionafterheartsurgerycanbeverydangerousand fatal.Hypertensiondue tohigh systemicvascularresistance can cause impairment and impairment ofleft ventricular and myocardial function 1,21. One oftherationalstrategies in thisarea is tomaintainbloodpressure at low levels in the earlyhours after surgeryandtoincreaseprogressivelyandgraduallyinthenexthours.Infusionofvasodilatorssuchasnitratesisoneoftheacceptabletreatments9,11.

Monitoring of Bleeding

Postoperative hemorrhage occurs due to surgery,coagulationdisorders,orboth.Coagulopathyfollowed

by a multifactorial CPB. Examples of anticoagulantdrugs,re-surgery,prolongedCPB,plateletdysfunction,hypothermia, excessive blood dilatation, high bloodtransfusion, blood dyskrasia, hypothermia, uremiaand hepatic impairment are among the risk factorsfor the riskofbleeding.Cardiac tamponadeformsareformed within the first 24 hours after heart surgery.Theincidenceofthiscomplicationisgreaterinsurgicalvalves replacing mechanical valves due to the earlyonset of anticoagulant drugs. The classic symptomsof this complication are threythabs. A person witholiguriamayalsobediagnosed18,21.Topreventbleedingcomplications and control bleeding, a series of bloodcoagulationtestsisrecommendedfor10minutesafteradministration of protamine sulfate at the end of thesurgery.

Monitoring Neurological Complications

Theprevalenceofneurologicaldisordersfollowingcardiac surgeries is very high and a wide range of18-80% is reported. Occurrence of neurologicalcomplications leads to a sharp increase in CICUresidence, hospitalization time, complicationsand mortality after cardiac surgery. Post-cardiacneurological disturbances are divided into two types,which include more severe and permanent disorderssuch as CVA and TIA, and type II, which includesmilderandmoretemporarydisorderssuchasdeliriumand cognitive impairment 3,7,9,17. Improvement andmaintenance of acceptable hemodynamics of patientsis one of the effective measures in the prevention ofneurological disorders. Also, correction of glycemiclevel, timely treatment of arrhythmias, such as atrialfibrillation, isanotherpreventivemeasure 22.Ensuringadequatebrainoxygenationisoneofthemosteffectivemeasures to reducebrain ischemia. It shouldbenotedthat, based on evidence, long-term hyperactivation ofpatients increases the releaseof radicalsand increasesthe risk of neurological disorders 15. In the event ofagitation, norepinetics such as haloperidol are moreeffective, risperidone and olanzapine, sedative drugssuchasbenzodiazepinesandinveryseverecaseswithlowdoseanesthetics.Itshouldbenotedthatprescribingbenzodiazepinesandopiatesisoneofthemaincausesof Delirium after cardiac surgery. Physical restraintssuch as closinghis hands can alsobeused in caseofagitationofseverepsychomotorinpatientsandtheriskofinjurytothemselvesorothers3,7,9.


Table 1. Pursount Scale

Variable Factors Weight

Associated illnesses

Obesity 3

Diabetesmellitus 3

Hypertension 3

Dependenceondialysis 2

DependenceonPacemaker 2

Leftventricularaneurism 5

EmergencySurgery(FollowingPTCA) 5

ARF 10

Cardiogenicshock 10

Ejection fraction

50%)well (LVEF≥ 0

(LVEF=30-40%)moderate 2

poor (LVEF<30%) 4

Age

Lessthan70yearsold 0

70-74 7

75-79 12

Age>80 20

Surgery againFirstsurgery 5

SecondSurgery 10

Table 2. Common causes of hypotension after cardiac surgery

Cause Examples

CirculationHypovolumiaSeverebleedingSIRS

Cardiac myocardialischemia

Decreased cardiac contractility

VentricularfailureCoronaryarteryocclusionarrhythmiatamponade

Respiratory TensionpneumothoraxHyperventilation

DrugAnestheticdrugsandsedativenitratesDiscontinueinotropicdrugs

Technical errors incorrectcalibrationofthemonitoringsystem

DISCUSSION

Post-surgical cardiac surgery is one of the mostchallenging therapeuticcourses inpatientsundergoingcardiovascular surgery. The patient’s placement ontheCPBcausesalotofcomplicationsonthepatient’sbody.CPBreducestheoverallbodytissueovergrowth,long-termischemicdamagetotheheartandothervitalorgans, triggers inflammatory reactions and SIRS,hypothyroidismandcoagulationdisorders. Inadditionto CPB complications, heart surgeries also have theirown complications, including bleeding and variousarrhythmias. Themanagement and treatment of thesepatients are closely coordinatedwith a teamofhealthprofessionalswho play a key role in nursing.One ofthe special nursingmeasures inmanaging this criticalperiod can be the examination of individuals at risk,heart rate monitoring, hemodynamic monitoring,correction of blood pressure disorders, diagnosis andtreatmentofLOCS,andthepreventionandtreatmentofneurologicaldisorders23.TheaboveisonlypartofthecriticalresponsibilitiesofnursesintheCICIUsections.Sufficientknowledgeofnursesintheseareascanreducethecomplications andmortalityofpatients afterheartsurgery and improve the clinical outcomes of heartsurgery.

CONCLUSION

This review article has been confronted withlimitations, including the scope of post-surgicalcare for nursing care. This part of the knowledge ofcardiovascular care is so extensive that it cannot befullydescribedinanarticle.However,ithasbeentriedto review the articles briefly and simply by referringto the sources searched and relyingonmanyyearsofexperienceintheCICU’sauthors.

Ethical Clearance: This research project wasapproved by the ethics committee of HamadanUniversityofMedicalSciences.

Source of Funding: Hamadan, University ofMedicalSciences.


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5. Fazelifar S, Bigdelian H. Effect of esmololon myocardial protection in pediatricscongenital heart defects. Advanced BiomedicalResearch.2015;4(2):246-55.

6. AlizadehZ,PaymardA,Khalili A,HejrH.Asystematicreviewofpainassessmentmethodinchildren.AnnalsofTropicalMedicineandPublicHealth.2017;10(4):847-49.

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18. BigdelianH,MardaniD,SedighiM.Comparativeeffects of pulmonary valve replacement (PVR)surgery with bioprosthetic and mechanicalvalvesonearlyandlateoutcomeofpatientsaftercongenitalheartsurgeries:10yearsofexperience.Indian Journal of Thoracic and CardiovascularSurgery.2014;30(4):257-63.

19. BridgewaterB,SoonSY.Theintra-aorticballoonpump.Surgery(Oxford).2012;30(1):17-8.

20. VincentJ-L,WeilMH.Fluidchallengerevisited.CriticalCareMedicine.2006;34(5):1333-37.


21. Bigdelian H, Mardani D, Sedighi M. TheEffect of Pulmonary Valve Replacement(PVR) Surgery on Hemodynamics of PatientsWho Underwent Repair of Tetralogy of Fallot(TOF). Journal of Cardiovascular and ThoracicResearch.2015;7(3):122-25.

22. Masoumi G, Frasatkhish R, Bigdelian H,Ziyaefard M, Sadeghpour-Tabae A, MansouriM, et al. Insulin infusion on postoperativecomplications of coronary artery bypass graft

in patients with diabetes mellitus. Research inCardiovascularMedicine.2014;3(2):e17861.

23. Shayan A, Jamshidi F, Tahmasebiboldaji V,Khani S, Babaei M, Havasian MR, MasoumiSZ.ImpactofaStressManagementInterventionProgram on Sexual Functioning and StressReductioninWomenwithBreastCancer.AsianPacific journal of cancer prevention: APJCP.2017;18(10):2787-93.

An Investigation into the Correlation between Emotional Intelligence and Communication Skills among

Nursing Students

Shahnaz Salawati Ghasemi1, Nazila Olyaie2, Sholeh Shami2

1M.Sc. in Nursing, Instructor, Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran, 2Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran

ABSTRACT

Background: Nursing is an importantfieldof study inwhichmultiple intelligences suchas emotionalintelligenceandspiritualintelligenceplayamoreimportantrolethaninotherfieldsofstudy.Aims:ThepresentstudywasaimedatexaminingthecorrelationbetweenemotionalintelligenceandcommunicationskillsamongnursingstudentsstudyinginKurdistanUniversityofMedicalSciences.Method:Inthepresentdescriptive-correlational study, 286 nursing studentswere selected by a convenience samplingmethod.The required datawere collected by a self-reportmethod using Siberia Sharing Emotional IntelligenceQuestionnaireandBartonCommunicationSkillsQuestionnaire.ThecollecteddatawereanalyzedusingdescriptivestatisticsandcorrelationalteststhroughSPSS21.0. Results :AccordingtoPearsoncorrelationcoefficient,thelevelofcorrelationbetweencommunicationskillsandemotionalintelligenceanditsareaswassignificantandpositive(p<0.001). Conclusion:Emotionalintelligenceandcommunicationskillsarecloselycorrelated.Payingattentiontothisimportantissueamongstudentsalongwithphysical,mental,andsocialdimensionscanleadtoanimprovementincommunicationskillsofthiscommunityandqualityofnursingcareinthefuture.

Keywords: Emotional intelligence, communication skill, students, nursing

INTRODUCTION

Emotional intelligence is one of the phenomenathathaspaidspecialattentioninrecentdecades.Thisisbecauseofthesignificantroleofemotionalintelligencereducing the level of conflict between intellectualand emotional perceptions, which leads to optimalcommunicationwithothers,self-regulation,complianceandmotivationincrease,stressmanagement,andgeneralmood.1,2Bar-onconsidersemotionalintelligenceasthemerecauseofdevelopmentoftheindividuals’capacitytosucceedinlife,andbelievesthatitiscorrelatedwithemotionalhealthandingeneraltheindividual’smental

Corresponding author: Nazila Olyaie, FacultyofNursingandMidwifery,KurdistanUniversityofMedicalSciences,Sanandaj,Iran.Email;[email protected]

health.Bar-onputsmuchemphasisontheinterpersonalcomponent in emotional intelligence.This componentreferstotheindividual’scapabilitytobeawareofandcontrolling his/her emotions which are self-esteem,excitement, assertiveness, independence, and self-actualization.4,3

It seems that multiple intelligences such asemotional intelligence and spiritual intelligence playa more important role in nursing than other fields ofstudy.5Such intelligenceshavea remarkableeffectonhownursesandnursingstudentscommunicate.

Communication is one of the essential needsof human, which is uniquely important in nursingprofession. Among the health groups, nurses are theonlygroupthathavealongdirectcommunicationwithpatients. In nursing science, nurse-patient relationshipis the core of health care.6 This relationship is aprofessionaloneandbasedonmutualtrustandrespect.

DOI Number: 10.5958/0973-9130.2018.00155.X


Thecommunication isbecauseofcollaborationwhichforms between the nurse and the patient in order topromote the patient’s health.7 In order to establish acommunication tohelp thepatient, thenurseneeds tobe familiar with communication skills without whichit is impossible to create a relationship, and sincepatientsbelongtodifferentage,belief,social,cultural,and economic groups, there should be a commoncomprehensible language for the care providers(nurses) and care receivers (patients).8 The quality ofthe provided health services improves if nurses canestablish anappropriate relationshipwith thepatients,their relatives, doctors, other nurses and care teammembers,andotherpersonnelworkinginothersectorsofhealthcenter;therefore,itisnecessaryforthenursestohavemorecommunicationcapacity.9

Nursing students play a unique role in thephenomenon of health, because nursing if theprofessionofhelping,andnursesneedtobeequippedwith sufficient knowledge and skills in order to beable topredict the situations andoutcomes.However,havingmereknowledgeisnotenough,theyneedtobeequippedwithmethods of how to deal with differentbehaviors of individuals.10 Emotional intelligence isuniquely important in individuals’ success in healthcareorganizations,andsuchskillsenableindividualstothinkbetterinhardsituations,preventthewasteoftimeasaresultofemotionssuchasanger,anxiety,andfear,pacifytheirbraineasily,andopenupthewayfortheirinnerinsightandcreativeideas.11

Nursingstudents,asfuturenurses,playasignificantroleinthetreatmentteam.theresearchersofthepresentstudydecidedtoinvestigateintothecorrelationbetweenemotionalintelligenceandcommunicationskillsamongnursing students so as to take an effective step tounderstandthestudents’problemsandhelppromotethehealthofindividualsandcommunity.

METHOD

The present descriptive-correlational study wascarried out from September to December 2017 inNursing Faculty, Kurdistan University of MedicalSciences.Thestudysamplewasselectedbyastratifiedsampling method. In so doing, the nursing studentswhostudiedover2013-17werechosen.Afterwards,anumberofstudentswereselectedinacertainproportionandbyarandomizedsampling.Accordingtopreviously

conducted studies,5 by considering p=77%, d=0.05(precision),confidenceintervalof95%,andbasedonthefollowingformula,thesamplesizewascalculatedtobe283whichwasraisedto300inordertoincreasethelevelofprecision.Finally, since someof thequestionnaireswerenotfilledoutcompletely, thedataobtainedfrom286 individuals were analyzed. The study’s inclusioncriteria included studying nursing bachelor, lack ofconfirmedmentalillness,andwillingnesstoparticipatein the study. The study’s exclusion criterion was theindividuals’unwillingnesstoparticipateinthestudy.

Thedatacollectioninstrumentswereademographicinformation questionnaire, Siberia Sharing EmotionalIntelligenceQuestionnaire,andBartonCommunicationSkills Questionnaire. Siberia Sharing EmotionalIntelligence Questionnaire was developed in 1999 bySiberia Sharing. It consists of the subscales of self-motivation (7 items), self-awareness (8 items), self-regulation (7 items), social intelligence (6 items), andsocialskills(5items).Itisscoredusinga5-pointLikertscale(Never=5toAlways=1).Thescorerangeforeachindividualisbetween33and165,andhigherscoresonthisscaleindicateshigheremotionalintelligence.

CommunicationSkillsQuestionnairewasdevelopedbyBartonin1990.Itconsistsof18itemsin3subscalesincludingverbalskill(6items),listeningskill(6items),andfeedbackskill(6items).Higherscoresindicatethatthe individual uses more communication skills. ThevalidityandreliabilityofBartonCommunicationSkillsQuestionnairewere confirmed in the study conductedbyRaeissi.12Inthepresentstudy,Cronbach’sAlphawasused todetermine the reliabilityof thequestionnaires.Cronbach’s Alpha for emotional intelligence andcommunication skills questionnaires was respectively0.814 and0.750,which shows that the questionnaireshadappropriatereliability.

Afterthenecessarypermissionletterswereobtainedfrom Kurdistan University of Medical Sciences andNursingandMidwiferyFaculty,theresearchersreferredtothestudents.Afterthestudentswereprovidedwiththeintroductionletter,theaimsofthestudywereexplainedto them,andwrittenconsent letterwas retrievedfromthem.Thestudy’sinstrumentsweregiventothestudents.The collected data were analyzed using descriptivestatisticsandcorrelationtestsataconfidenceintervalof95%throughSPSS16.0.


RESULTS

Theresultsofthepresentstudyshowedthatthemean(±standarddeviation)ageofthestudentswas21.37(±2.39).Most of the studentsweremen (55%), single (85%), and second child (34.6%).Moreover,most of them livedin dormitories (61.9%) and studied in fourth year (30%) (7th semester (17.1%)).Themean score of emotionalintelligence among the students was 104.04 (13.75). In addition, the mean (standard deviation) score of theircommunicationskillswas51.83(10.10)(Tables1and2).AccordingtotheresultsofPearsoncorrelationcoefficient,the levelofcoefficientamongcommunicationskillsandemotional intelligenceand itsfieldswassignificantandpositive(p<0.001)(Table3).

Table 1. Description of the studied students based on the variables of emotional intelligence and communication skill

Variable Min. Max. Mean SD

Emotional Intelligence (33-165) 67 151 104.04 13.75

Self-motivation(7-35) 13 35 21.79 3.35

Self-awareness(8-40) 16 37 26.74 4.86

Self-regulation(7-35) 10 35 21.14 3.56

Socialintelligenceorempathy(6-30) 9 30 18.83 3.76

Socialskills(5-25) 9 23 15.53 2.75

Communication skills (18-90) 27 86 51.83 10.10

Verbalskill(6-30) 8 30 17.58 4.38

Listeningskill(6-30) 7 26 16.37 3.96

Feedbackskill(6-30) 7 30 17.88 4.15

Table 2. Frequency distribution of the students based on emotional intelligence and communication skill

Variable Frequency Frequency percentage Mean SD

Emotional intelligence (0-100)

Low(0-25) 0 0 0 0

Moderate(25-75) 277 96.90 52.91 9.24

High(75-100) 9 3.10 81.73 2.99

Communication skills (0-100)

Low(0-25) 18 6.30 18.82 3.66

Moderate(25-75) 260 90.90 47.77 10.63

High(75-100) 8 2.80 85.41 7.04


Table 3. The relationship between communication skills and emotional intelligence and its aspects among the students under study

Emotional intelligence

Emotional intelligence

Self-motivation

Self-awareness

Self-regulation

Social intelligence or empathy

Social skills

Communicationskill

Correlationcoefficient 0.396 0.175 0.281 0.255 0.315 0.373

Probability p<0.001 0.003 p<0.001 p<0.001 p<0.001 p<0.001

VerbalskillCorrelationcoefficient 0.313 0.181 0.262 0.209 0.257 0.257

Probability p<0.001 0.002 p<0.001 p<0.001 p<0.001 p<0.001

ListeningskillCorrelationcoefficient 0.196 0.056 0.062 0.238 0.175 0.256

Probability 0.001 0.345 0.299 p<0.001 0.003 p<0.001

FeedbackskillCorrelationcoefficient 0.380 0.180 0.348 0.173 0.327 0.390

Probability p<0.001 0.002 p<0.001 0.003 p<0.001 p<0.001

DISCUSSION

The present study was aimed at investigatinginto the relationship between emotional intelligenceand communication skills among nursing students.According to the results, there was a significantrelationship between emotional intelligence andcommunication skills of the students, which meansthat individuals with high emotional intelligence areexpected to listenwell, accept others, and actwell intheir interactions with others.As future nurses, thosenursingstudentswhohavehighemotionalintelligencepossess higher communication skills, which affectsnot only the patients’ satisfaction but also the nurses’job satisfaction. Higher emotional intelligence andcommunicationskillsleadtoself-efficacyinindividualsandcancausethenursestocarryouttheirresponsibilitieswith higher occupational skills.Although the conceptof communication and communication skills is anessentialelementindeliveringcareandaneffectivetoolinnursingprofession,nursesarenotprovidedwithanydirecteducationinthisregard(itisonlyreferredtointheformofdifferentlessons,though)andtheyacquirecommunication skill to a to a moderate extent by

workinginmedicalteamsandrespondingtothepatients.Inexplainingtheresultsoftheirstudy(communicationskills and its related factors), Safavi et al, stated thatnurseshaveanaveragelevelofcommunicationskills.13

In agreement with the results of the presentstudy, Yousefi et al.,14 carried out a study entitled,“The relationship between emotional Intelligenceand communication skills in university students” andstatedthatthereisastatisticallysignificantrelationshipbetween emotional intelligence and communicationskills in university students.14 Despite the differencebetweentheparticipants(nursingstudentsinthepresentstudy, and nursesworking in psychiatric clinic in thestudy above) of the two studies and use of differentinstruments, similar resultswereobtained.The resultsofotherstudieshavealsoshowedthatgoodrelationshipbetweenthemedicalstaffandpatientsandcompanionsplays a significant role in quality of services andsatisfaction among patients. Moreover, in agreementwiththeresultsofthepresentstudy,Aslefattahietal.,15 examined the relation between emotional intelligenceand self-esteem and social skills and concluded thattherewasasignificantrelationshipbetweenemotional


intelligence and social skills and between self-esteemandsocialskills,andthisrelationshipissignificantataconfidenceintervalof99%.15

Inthepresentstudy,mostofthestudentsobtainedan average score on emotional intelligence (54.5%).Ghaderi et al.,16 studied emotional intelligence amongthestudentsattending theuniversitiesofAhvaz.Theirstudysampleconsistedof303students.Theresultsoftheir study showed that the emotional intelligence ofmost of the students was moderate (77.23%). 16 The resultsofthepresentstudyarenotinagreementwiththeresultsof the studyconductedbyChinipardazet al.,17 whoexaminedemotionalintelligenceanditsrelationshipwith academic achievement among medicine internstudentsofTehranUniversityofMedicalSciences.Theresultsoftheirstudyshowedthattheaverageemotionalintelligencescoreinall15subscalesofthequestionnairewas lower than the defined standard. The reason forsuch a difference is probable due to difference in thesamples and their size.The present studywas carriedout onnursing studentswhilemedicine studentswerethe focus of the study conducted by Chinipardaz etal.,17.Moreover, the resultsof the studyconductedbyShahbazi,18indicatedthatemotionalintelligenceamongnursingstudentswasnotatastandardlevelbecausenoformal training is presented for it; however, this skillcanbeimprovedbytrainingthestudents,whichisnotinlinewiththepresentstudy.

Inthepresentstudy,mostofthestudentsobtainedamoderatescoreontheircommunicationskill(90.90%).Amongthecommunicationskills,verbalskillreceivedthe highestmean. In disagreementwith the results ofthepresentstudy,Baghiyanietal .,19 reported that thehighestmeanscoreofcommunicationskillswasrelatedto feedbackskill.19Thisdifferencecan tosomeextentbeattributed to thedifference in thenatureofnursingprofessionandotherprofessionsofmedicine,becausean importantroleofnurses is to train thepatientsandtheir families, and this training occurs in each verbalcommunication.Therefore,itisobviousthatestablishingverbal communication is more important in nursingprofession thanothermedicalprofessions.The resultsof different studies that utilized different instrumentsand scoring systems reported that nurses and nursingstudentshadamoderatelevelofcommunicationskill.

The results of the present study canbe employedto promote the level of communication skills among

nursingstudents.Itisrecommendedthatstudiesshouldbecarriedoutinordertounderstandbarrierstopromoteemotional intelligenceamonguniversitystudents. It isalsosuggestedthatstudentsofotherfieldsofstudyshouldbestudiedandcomparedwithnursingstudents.Inordertoachievemorepreciseresultsandgeneralizethemtocommunities of nursing students, studies with largersamplesizeshouldbecarriedout.Sincequestionnairesarefilled out by self-reportmethod, studentsmaynotpayenoughattentionwhilecompletingthem,whichisoneofthelimitationsofthepresentstudy.

4paragraphs (suggested):Short summaryof yourdata, results of this study compared to other similarstudies in the literature, strengths and limitations ofthis study, implications for practice and policy orimplicationsforfutureresearch.

CONCLUSION

Theresultsof thepresentstudyshowedthat therewasapositivecorrelationbetweenthenursingstudents’emotional intelligenceand theircommunicationskills.Nowadays,trainingthemanpoweristhemostimportantelement of higher education and one of the mostoutstanding factors of national development. Studentcommunity is one of the largest groups of society.It is highly significant to pay attention to emotionalintelligenceandcommunicationskillsof thisgroupofstudentsinordertopromotetheiremotionalintelligenceandthustheircommunicationskills.

Conflict of Interest : There are no conflicts ofinterestbetweentheauthors.

Funding: Kurdistan University of MedicalSciences,FacultyofNursingandMidwifery

Ethics Committee Approval : Thepresent studywasretrievedfromaresearchprojectapprovedbytheResearchCouncil ofKurdistanUniversity ofMedicalSciencesandHealthServices.Theprojectisregisteredin Ethics Committee under the code of IR.MUK.REC.1396/145

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PhysicalActivityinUniversityStudents.ScientificInformationDatabase.2009;16(53):142-49.

3. Bar-OnR.TheBar-Onmodelofemotional-socialintelligence (ESI). Psicothema, 18, supl., 13-25.Model overview retrieved from the Consortiumfor Research on Emotional Intelligence inOrganizationswebsite.2006.

4. BeshlidehK.EffectsofEmotionalIntelligenceonGeneral Health of Divorced Women. QuarterlyJournalofSocialWork.2015;3(4):28-39.

5. HosseiniFH,AnariAMZ.TheCorrelationbetweenEmotionalIntelligenceandInstablePersonalityinSubstanceAbusers.Addiction&health.2011;3(3-4):130.

6. Barth J, Lannen P. Efficacy of communicationskills training courses in oncology: a systematicreview and meta-analysis. Annals of oncology.2010;22(5):1030-40.

7. MoorePM,RiveraMercadoS,GrezArtiguesM,Lawrie TA. Communication skills training forhealthcareprofessionalsworkingwithpeoplewhohavecancer.TheCochraneLibrary.2013.

8. Bowles N, Mackintosh C, Torn A. Nurses’communicationskills:Anevaluationoftheimpactof solution‐focused communication training.JournalofAdvancedNursing.2001;36(3):347-54.

9. Wysong PR, Driver E. Patients’ perceptions ofnurses’ skill. Critical CareNurse. 2009;29(4):24-37.

10. JavaherAa, khaghanizadeM, EbadiA. Study ofCommunication Skills in Nursing Students anditsAssociationwithDemographicCharacteristics.Iranian Journal of Medical Education.2014;14(1):23-31.

11. Stichler JF. Emotional intelligence. AWHONNlifelines.2006;10(5):422-5.

12. RaeissiP,KalhorR,AzmalM.Correlationbetweenemotional intelligence and communication skillsin managers in educational hospitals of Qazvin.JournalofQazvinUniversityofMedicalSciences.2010;13(4):57-62.

13. SafaviM,GhasemiPS,FesharakiM,EsmaeilpourBM. Communication skills and related factorsgualansteachinghospitals’nurses94.2016.

14. Yousefi F. The relationship between emotionalIntelligenceandcommunicationSkillsinuniversitystudents.2006.

15. Aslefattahi B, S N. The relationship betweenemotional intelligence and self-esteem andsocial skills. Journal ofTeaching andEvaluation.2013;6(23):123-36.

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17. ChinipardazZAGB,Mehri%APasalar,Parvin%AShiravy khozany,Abofazl%AKeshavarz,Athefe.Investigation of Emotional Intelligence and ItsRelationship with Academic Achievement inMedicalStudentsofTehranUniversityofMedicalSciencesin2008-2009.StridesinDevelopmentofMedicalEducation.2012;8(2):167-72.

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19. Shahbazi S, Hazrati M, Moattari M, Heidari M.The Effect of Problem Solving Skills Trainingon Emotional Intelligence of Nursing Studentsof Shiraz (2008). Iranian Journal of MedicalEducation.2012;12(1):67-76.

Patterns and Profile of Poisoning Cases at Bidar Institute of Medical Sciences, Bidar (Karnataka)

Syed Hissamuddin Uzair1, Mohsenul Haq2

1Assistant Professor, 2Associate Professor, Department of Forensic Medicine, BRIMS,Bidar. (Karnataka)

ABSTRACT

Poisoningisoneofthecausesofunnaturaldeathworldwideandismoreindevelopingcountriesandthemethodsofpoisoningvariesfromoneplacetoother

Aim:TostudythepatternandprofileofpoisoningcasesatBidarInstituteofMedicalSciences,Bidar

Material & Method: Thepresent study isaprospectivestudyconductedatBidar InstituteofMedicalSciences,Bidarfrom1stJanuary2016to31stDecember2017.

Total158poisoningcaseswerestudiedfromOPDtoIPD,followedfromadmissiontorecoveryordeathinasystematicmanner.Allthesecaseswereanalyzedwithanobjectiveofknowingage&sexdistributionofvictims,commonesttypeofpoison,themannerofpoisoning,occupation,andalsotherural&urbantrends.

Among158cases,male(58.22%)predominatedfemales(41.77%)withmajority(41.30%)belongingto21-30yrsagegroup.ThecommonestpoisonencounteredwastheOrganophosphorouscompounds(66.45%).Suicide(71.74%)wasthecommonestmannerthanaccidentalpoisoning.

Agriculturalfarmerswithruralbackground,belongingtolowersocioeconomicstratawerethecommonestvictims(72.78%)comparedtoothers.

Keywords: Poisoning cases, Organophosphorous compounds, Suicide, Accident.

Corresponding author: Dr Mohsenul Haq AssociateProfessor,DepartmentofForensicMedicine,BidarInstituteofMedicalSciences,BIDAR

INTRODUCTION

Among unnatural deaths poisoning is one of thesecondcommoncausefollowingroadtrafficaccidents.It is one of the methods of taking one’s life, whichmay be suicidal, homicidal or accidental in nature.Acutepoisoningformsoneofthecommonestcausesofemergencyhospitaladmissions1.

Pattern of poisoning in a region depends uponvarietyoffactors,rangingfromavailabilityandaccessofpoisontothesocio-economicstatusoftheindividual;alsonottoforgetoftheculturalandreligiousinfluences.Poisoning forms amajor problem all over theworld,

thoughthetypeofpoison,theassociatedmorbidityandmortalityvariesfromplacetoplaceandchangesoveraperiodoftime 2.

Poisonings claim substantial numbers of livesthroughouttheworld,intheformofSuicide,AccidentorHomicide.Suicidesbypoisoningareincreasingrecently,possiblyduetothestressandstrainofmodernlifestyle.Thisisinturncouldbefromthechangesoccurringdueto globalization and urbanization. Extensive usage ofchemicalsinindustries,agriculturalsectoranddomesticfrontiscausingincreasedaccidentalpoisoning.

The traditional methods of suicide by drowning,hanging etc. are being replaced by poisoning. Thepoisons and their compounds are cheap and easilyavailable with out any questions or documentation,especiallyindevelopingcountrieslikeIndia.

Adetailedstudyabourtheprofilesofthepoisoning

DOI Number: 10.5958/0973-9130.2018.00156.1


casesobservedinaparticularareaisnotonlyimportantfor immediate diagnosis and treatment, but also isnecessary for evaluation of the current scenario andintroduction of new means to curb the increasingincidencesofpoisoning.

The aimwas to collect authenticated data of thepoisoningcasesandanalyzetheminallrespects.Thesekinds of data are in turn helpful for the concernedauthorities to look for solutions to the problem andevolvenecessarypoliciestoreduceorpreventthem.


Study design- Descriptive

This study was conducted in the Department ofForensicMedicine and Toxicology, Bidar Institute ofMedicalSciences,Bidar,Karnataka.

Studyperiod-01-01-2016to31-12-2017

Study Method- A total of 158 poisoning casesadmitted and autopsied at District hospital & BidarInstituteofMedicalSciences,Bidar Karnataka wereanalyzedduring2016-2017.

The victims were studied from the time of OPDadmission to wards and followed up till recovery ordeath. Data were collected in a Performa, from thehistory given by the patient, hospital records, policeinquest reports, postmortem reports,FSL reports andalso personal interview with the concerned relatives.Theemphasiswason theage, sex, rural /urban, typeof poison and manner of poisoning. All data wasdocumentedandstatisticallyanalyzed.

RESULTS

Thefollowingresultswereobserved inourstudy.Among 158 cases of poisoning studied during 2016 -2017, majority of the victims were males (58.22%)(TableNo.1)andmaleandfemaleratiowas1.3:1.21-30yrs(41.77%)(TableNo.2)wasthecommonestagegroup involved andwere residents of (in and around)Bidar.

The commonest type of poison encountered wasthecompoundsofOrganophosphorus(66.45%)(TableNo.3) and last was the Datura & scorpion bite withsinglecase(0.63%).

Thecommonestmanner(TableNo.4)ofpoisoning

wassuicidebothinmale(71.74%)andfemale(72.73%)followed by accidental poisoning accounting for 25%and 25.75% inmale and female respectively. 3 casesof homicidal poisoning was observed in our study.Occupation wise (Table No 5) agricultural farmerstoppedthelist(37.34%)followedbylaborers(24.05%).Most of the victims belonged to rural area i.e. 102(64.55%)comparedtourbanarea(TableNo.6).

Persons of low socio-economic strata are thecommonest victims (72.78%) followed by middleclass(24.68%)andleastinvolvedweretheupperclass(1.90%)(TableNo.7).

Table.No.(1) Sex wise Distribution of victims

AgeMales Females

No % No %

0-10 1 1.08 3 4.54

11-20 09 9.78 18 27.27

21-30 38 41.30 28 42.42

31-40 24 26.08 11 16.66

41-50 12 13.04 6 9.09

51-60 6 6.52 0 0.00

61andAbove 2 2.17 0 0.00

Total 92 100.00 66 100.00

Table .No.(2) Age wise distribution of victims

Age No of patients Percentage

0-10 4 2.53

11-20 27 17.08

21-30 66 41.77

31-40 35 22.15

41-50 18 11.39

51-60 6 3.79

61andAbove 2 1.26

Total 158 100


Table No (3) Commonest type of poison

Poison No of Cases Percentage

Organophosphoruscompounds

105 66.45

AluminiumPhosphide 16 10.13

Organochlorine 09 5.70

Alcohol 12 7.60

Kerosene 2 1.30

Snakebite 8 5.06

Datura 1 0.63

Cyanide 3 1.90

Scorpionbite 1 0.63

Carbamates 1 0.63

Total 158 100.00

Table No.(4) Manner of poisoning

Manner

Males Females

No % No %

Accidental 23 25.00 17 25.75

Suicidal 66 71.74 48 72.73

Unknown 1 1.08 0 0.00

Homicidal 2 2.17 1 1.51

Total 100 100.00 66 100.00

Table. No (5) Occupation of Victims

Occupation No of patients Percentage

Farmer 59 37.34

Labourer 38 24.05

Housewife 29 18.35

Student 16 10.12

Driver 6 3.80

Clerk 4 2.53

Others 6 3.80

Total 158 100

Table. No.(6) Rural / Urban distribution of victims

Areas No of patients Percentage

Rural 102 64.55

Urban 56 35.44

Total 158 100.00

Table.No. (7) Socio- economic status of victims.

Status No of Cases Percentage

Lowerclass 115 72.78

Middleclass 39 24.68

Upperclass 3 1.90

Unknown 1 0.63

Total 158 100

DISCUSSION

The study included 158 cases with a history ofpoisoning.The followingwere theobservationsnotedafteranalysisoftherecordeddata.

Thepresentscenarioofglobalization,urbanizationand industrialization is creating lot of stress onindividuals in particular as well as on the society incommon. Persons who are not able to sustain thesestressful situations are the major victims of eithersuicidaloraccidentalpoisonings

Malesoutnumberedthefemalesandmajoritywereintheagegroupof21-30yrs(41.30%).Thisparticularagegroupisthemostactivephaseoflifeformenwhoareinvolvedmentally,physicallyandsocially.Theyareexposedtodaytodaystressesoflifethanfemales.Thisobservationisconsistentwithpreviousstudies3-8.

The commonest poison observed was theOrganophosphorus compounds and least encounteredwas the scorpion bite. This is consistent with theobservationsmadebyearlierstudies9-11.Suicidebeingthe commonest manner of poisoning (71.74%) withagricultural farmersbeing themajorvictims (66.45%)residing in rural setup (64.55%) belonging to lowersocioeconomicstrata(72.78%).Theseobservationsaresimilartotheotherearlierworkers12-14.Thisispossiblyduetoilliteracyandpovertyoftheagriculturalfarmers


residing in rural parts. They solely depend on theagriculturalincomefortheirliving.Duetosomereason(i.e.eitherlackofwaterorflood)iftheyarenotabletogeneratetherequiredincomefortheirdaytodaylivingandcommitments,theymaygetfrustratedandresorttosuicidebytheseagriculturalinsecticides,pesticidesorweedkillerswhichareavailableintheirbackyard.

Even though the government and other agenciesaretryingtheirbesttopreventtheseunfortunateeventsbyvariousprojectsandprogrammes,butstillthetrendcontinues..Knowingthepatternofpoisoninginanarea,notonlyhelpsinearlymanagementofpoisoningcasesbutalsosuggeststakingearliestpreventivemeasures15.

CONCLUSION

Thestudyidentifiedthemostvulnerablestratumofthesocietyagainstpoisoning,andalsothemostcommoncausesofpoisoningobserved.

The study clearly highlights the pattern ofpoisoning inBidar (Karnataka)area, showing that themales of 21-30 yrs age group are the major victims.It also point towards the commonest poison used i.e.Organophosphorous compounds to commit suicide byagricultural farmers of rural area belonging to lowersocio-economicstrata.

Theincidence,trendsofpoisoning,themorbidity&mortalityduetopoisoningcanbepossiblycurtailedbyfollowingmeans:

The more stringent legislation and enforcementregardingthesaleanddistributionofthetoxicsubstanceis needed and substitution of the pesticide with saferagentsisnecessary..

Bycreatingawarenessaboutfirstaidmeasuresandpropermedicalcareat theearliest thatcanprove life-saving,insteadofthecommonpracticeofvisitinglocalquacks.

Goodtreatmentfacilities(i.e.antidotesetc)atruralareaslikePHC’s&PHU’s.

EstablishingPoisonInformationCenters.

Apartfrommedicalefforts,socialeffortsonthepartofGovernment,NGOsandothersocialgroupsthroughsincereworkatmanylevelslikeboostingtheeconomy,poverty,eradication,irrigationschemes,agricultureandmarketsistheneedofthehour.

Conflict of Interest:ThefindingsinthisresearchworkfoundtobesimilartomostoftheresearchworkconductedinIndia.

Source of Funding:SelfFunding.

Ethical Clearance:NotApplicable.

REFERENCES

1. Zhou L et al. Poisoning deaths in Central China(Hubei):A10-yearretrospectivestudyofforensicautopsycases;J.ForensicSci.2011:56(1):234-237.

2. Sharma B R ,Harish Dasari, Sharma, Vivek VijKrishnan. Poisoning in Northern India ,changingtrends, causes and prevention there of. Med.Sci.Law.2002;42(3),251-255.

3. Escoffery T Carlos, Shirley E Suzane. Fatalpoisoning in Jamaica .ACoroner’s autopsy studyfromtheUniversityhospitalofWestIndies;2004;44(2),116–120.

4. Peterson H , Brosstad F. Pattern of acute drugpoisoning inOslo.Acta-Med-Scand.1977 ;201 (3).233-37.

5. Dalal , Poisoning trends – a post mortem study.J.Ind.Acad.ForensicMed.1998;20(2);27-31.

6. KarllieddeLakshman,SenanayakeNimal.AcuteOrgano phosphorous insecticide poisoning in SriLanka.For.Sci.Int.1988;36,97-100.

7. JamilH.Organophosphorousinsecticidepoisoning.J.-Pak-Med.Asso.1989;39(2),27-31

8. Dogra. Trends of pesticides consumption andpoisoninginDistrictofFaridabad.(Haryana)Med.LegalUpdate,1996;1(2),32-34.

9. OttoKR,SpateHF.SuicidaltrendsinUrbanandRuraldistrictsofBrandenburg,Psychiatr–Neurol–Med–Psychol,1975;27(4);239–46.

10. KumarA,VijK.TrendsofpoisoninginChandigarh– A six year autopsy study. Journal of ForensicMedicineandToxicology2001;18(1):8-11.

11. Gupta S. Kumar S and SheikhM I. comparativestudy and changing trends of poisoning in year2004-2005,atSurat,India:InternationalJournalofMedicalToxicology&LegalMedicine:2007:10(1).

12. Gargi J, RaiH,ChananaA,RaiG et al. Currenttrendofpoisoning-ahospitalprofile:JIndianMed.Assoc.2006;104(2):72-3.


13. Sharma B.R, et al.Poisoning in Northern India:ChangingTrends,CausesandPreventionsthereof.MedSciLaw.2002:42(3):251-257.

14. KiranN,ShobaRaniRH, JaiPrakashV,VanajaK,PatternofPoisoningReportedataSouthIndian

TertiaryCareHospital.IJFMT.2008:2(2):17-19.

15. Aggarwal N.K, Aggarwal B.B.L, Trends ofPoisoning in Delhi. Journal Ind Acad For Med.1998:20(2):32-36.

The Effect of Lavender Scent on the Severity of Pain Caused by Bone Marrow Biopsy

Reyhaneh Abbaszadeh1, Fariba Tabari2, Mohammad Asghari Jafarabadi 3, Sedigheh Torabi4

1Critical Care Nursing, Tehran, Iran, 2Assistant Professor, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran, 3Road Traffic Injury Research Center, Tabriz University of Medical Sciences,

Tabriz, Iran, Sciences, Tabriz, Iran, 4M.sc, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

ABSTRACT

Introduction:Painisthemostfrequentcomplaintinbonemarrowbiopsy.Theaimofthisstudywastodeterminetheeffectoflavenderscentontheseverityofpaincausedbybonemarrowbiopsy.Materials and Method:Thisclinicaltrialwasperformedon80patientsattendingImamKhomeiniHospitalinTehranforbonemarrowbiopsy.Sampleswereselectedusingconveniencesamplingmethodandwereassignedintoaninterventionandacontrolgroupsusingrandomblocksof4.ArandomsequencewasgeneratedusingRASsoftware.Dropsofdistilledwaterwereplacedoncottonballforthecontrolgroupanddropsoflavenderessentialoilwereplacedoncottonballfortheinterventiongroup,thentheintensityofpainwasimmediatelyassessedafterbiopsysampling.TheresultswereanalyzedbySPSSsoftwareversion25usingcovarianceanalysisandrankingregressionforthescoresandlevelsofpainvariables,respectively.Results:Theresultsshowedthat,themeanscoresofpaininthecontrolandinterventiongroupswere6.9±1.37and4.1±1.24,respectively.Therewasasignificantdifferenceinpainscoresbetweenthetwogroups(P<0.05).Also,theresultsshowedthat,byadjustingthevariablessuchasage,gender,physicianexperience,biopsyhistoryandbiopsylocation,asignificantdifferenceoccurredinpainscoresbetweentheinterventionandcontrolgroups(P<0.05).Theadjustedpainscore(-1.3)intheinterventiongroupwaslessthanthecontrolgroup.

Conclusion:Theresultsofpresentstudyshowedthat,patientsundergoingbonemarrowbiopsyreportamoderatetoseverelevelsofpainduringbiopsy,andsmellingthelavenderscentiseffectiveinreducingthepaintheyexperience.

Keywords: Pain, Lavender scent, Bone marrow biopsy and aspiration.

Corresponding Author: Fariba Tabari, AssistantProfessor,SchoolofNursingandMidwifery,TehranUniversityofMedicalSciences,Tehran,Iran.Email:[email protected]

INTRODUCTION

Painisacommoncomplaintincancer,andmedicalproceduressignificantlycontributetothepainthatcancerpatients endure.1 Bone marrow biopsy and aspirationis an invasive method that is routinely performedby hematologists and oncologists to diagnose blooddisordersandtumors.2Nearly15,000peopleworldwideundergobonemarrowbiopsyeveryyear.3Among the

limitationofthisprocedureisadiscomfortexperiencedbypatients.4Painisthemostfrequentcomplaintinthesepatients,which in recent studieshasbeen reportedby1.3%ofpatientsasmoderatetoseverepain.2 Thepainexperienced during and after the procedure createsfear and anxiety, anddiscouragespatients to continuewith thebiopsy. In an attempt to relieve thepain anddiscomfort caused by this procedure, some healthcareproviders choose a sedationmethod, but the sedationitselfwillexposethepatienttomanyphysicalrisksandincreasestheworkloadofserviceprovidersasitrequiresmonitoring during and after the procedure.4 Even ifsedationandanalgesiaarewelltoleratedandeffective,theyarenotabletorelievethepaincompletely.1

DOI Number: 10.5958/0973-9130.2018.00157.3


Despiteprogressinmedicalsciences,therearenotmanystudiesregardingthepaincausedbybonemarrowbiopsy.5Informationontheprevalence,predictorfactors,and pain prevention associatedwith this procedure isalsolimited5,6andthereisnoofficialguidelinetohelpreducethepainexperiencedbypatientsundergoingsuchprocedures.2,5,7Therearehowevertwopharmacologicaland non-pharmacological methods to relieve the painassociatedwith bonemarrow biopsy and aspiration .5

Today, the use of non-pharmacological methods forcontrolling pain is being evermore considered and isadvancing.8Aromatherapyisoneoftheeffectivenon-pharmacologicalmethodsofpainrelief.9

Aromatherapyissimple,fastandnon-invasive,andcanbeusedinindependentnursinginterventions.Effortstodemonstratetheimportanteffectsofaromatherapyasacomprehensiveinterventionandtranquilizermediatorhave been actively pursued in nursing profession.10

Aromatherapy among nurses is the second mostcommonlyusedmethodofcomplementarymedicine,11

andisthesecondmostcommonlyusedcomplementarytherapyintheclinicalpracticetoreducepain.12Amongthedifferentplants,lavenderhasbeenthemainchoiceoftheresearchersforaromatherapy.9

Lavenderisthemostusedpureessentialoil13andisthemostimportantessentialoilforthereliefofpainandrelaxation.14Lavenderhasalonghistoryofdruguse,15 asithasanalgesiceffects.16Thelavenderplant,duetolinalyl acetate that it contains, has an analgesic effectanditsflowersandleavesareusedforpainrelieve.9

Sincethepaincausedbytheprocedureisconsideredarestriction,patientsarereluctanttocontinuewiththeirbiopsy, and also as the relief of pain are the basis ofnursing care and the analgesic effects of lavender arewellknown, this studywasconducted to examine theeffectoflavenderscentontheseverityofpaincausedbybonemarrowbiopsy.


This research was a clinical trial with the code:2016121431417 N1, which was performed on 80patientsattendingImamKhomeiniHospital inTehranIn 2018 to have bone marrow biopsy. The sampleswere divided into two groups of intervention andcontrol(N=40).Theresearchsampleswereselectedbyconveniencesamplingmethodandthenassignedintoan

interventionandacontrolgroupsusingrandomblocksof4aftergivingtheirwrittenconsentandbeinginformedabouttheresearchobjectives.ArandomsequencewasgeneratedusingRASsoftware.

Entryrequirementsincluded;being18yearsoldorabove,beingawareoftime,placeandpeopleduringdatacollection,lackofallergytolavenderfragrance,lackofalcoholanddrugabuse,havingabilitytosmell,havingat least reading andwriting ability, having no historyofmental illness ,andnotsufferingfrommoderateorseverepain.Exclusioncriteriaincluded;havingaseverecold,useofanalgesicdrugsupto8hoursbeforebiopsy,unwilling tocontinuewith thestudy,anddeathof thepatient.

Data collection tool consisted of a demographicquestionnaire and visual pain scale. The demographicquestionnaire included variables such as age, gender,levelofeducation,maritalstatus,occupation,diagnosis,frequencyofbiopsy(firstornexttime),andexperienceofphysician.Thevisualpain scale, formeasuring theintensity of pain, was a horizontal line that had beennumberedfrom0to10.Usingthisscale,theresearchercould measure the severity of pain based on thecommentsofthesamples.Afterdeterminingtheamountofpainfeltbyeachsample,thepainscoresweredividedinto5levels,including(0)nopain,(1-3)mildpain,(4-6)moderatepain,(7-9)severepain,and(10)themostseverepainever.

Patients inthecontrolgroup,beforebonemarrowbiopsy, smelled3dropsofdistilledwaterona cottonballplacedinacontainerinapackagefromadistanceof7-10cm for15minutes, and immediately after thebiopsy,painintensityofthepatientwasevaluatedusingvisualpainscale.Intheinterventiongroup,3dropsof10%lavenderessentialoilwereplacedonacottonballandwasplacedinsideacanister15minutesbeforethebiopsy,andthenthepatientswereaskedtoopenthelidofthecontainerandfrom7-10centimeterdistancesmellnormallyfor15minutes.Then,theseverityofpainwasmeasuredimmediatelyaftertheprocedure.Lateron,theresultswerecomparedwitheachother.

Dataweresummarizedandreportedforqualitativevariables with frequency and percentage and forquantitativevariableswithmeanandstandarddeviation(SD). Normality of the quantitative variables wasassessed by K-S test. To compare demographic and


baseline variables, as well as scores and levels ofpain, Chi-square and independent t-test were usedfor qualitative and quantitative variables. Covarianceanalysis was used to assess the effect of interventionandtomoderatethepotentialconfounders.Regressionanalysiswasusedforscoresandlevelsofpainvariables,respectively. Data analysis was done using SPSSsoftwareversion25atasignificantlevelof0.05.

RESULTS

The results of study showed that, 67.5% of thepatients in the control and intervention groups werebetween 30-50 years old and therewas no significantdifferencebetween the twogroups in termofage (P>

0.05),(Table1).Theresultsofthestudyalsoshowedthat,themeanscoreofpaininthecontrolandinterventiongroupswas6.9±1.37and4.1±1.24,respectivelyandthere was a significant difference between the painscoresofthetwogroups(P<0.05).Thepainscore(-2.8)in the intervention group was lower than the controlgroup(Table2).

Theresultsshowedasignificantdifferencebetweenthepain scores in the twogroups (P<0.05)when thevariablesofage,gender,physicianexperience,biopsyhistory and location of biopsy were adjusted. Theadjustedpainscore(-1.3)intheinterventiongroupwaslowerthanthecontrolgroup(Table3).Nosideeffectsoflavendersmellingwerereported.

Table 1: Demographic characteristics

Comparison Control groupNumber (percentage)

Control groupNumber (percentage) P-Value

Age (mean ± standard deviation) 43±10.01 40±10.26 0.396

SexMan 19(47.5) 22(55.0)

0.655Woman 21(52.5) 18(45.0)

Marital statusMarried 36(90.0) 34(85.0)

0.737Single 4(10.0) 6(15.0)

Occupation

Unemployed 20(50.0) 18(45.0)

0.344

Laborer 0 1(2.5)

Office worker 10(25.0) 13(32.5)

Self-employed 7(17.5) 8(20)

Retired 3(7.5) 0

Education

Under diploma 9(22.5) 9(22.5)

0.408Diploma 23(57.5) 18(45)

University education 8(20.0) 13(32.5)

Diagnosis

Leukemia 24(60.0) 18(45.0)

0.478Lymphoma 8(20.0) 6(15.0)

Osteosarcoma 2(5.0) 6(15.0)

Other 6(15.0) 10(25.0)

Medical history (year)

0-5 32(80.0) 37(92.5)0.1935-10 8(20.0) 3(7.5)

History of bone marrow biopsy

None 27(67.5) 32(80.0)

0.360Second time 10(25.0) 7(17.5)

Several times 3(7.5) 1(2.5)

Location of bone marrow biopsy Iliac crest 40(100) 40(100) 0.057


Table 2: The mean score of pain caused by bone marrow biopsy in the control and intervention groups

Comparison Control groupMean ± standard deviation

Control groupMean ± standard deviation Independent t-test

Pain score 6.9±1.37 4.1±1.24 P<0.05

Table 3: Comparison of pain score in the two groups by adjusting the confounding variables based on covariance analysis

Variable SS Df MS F P-Value

Age 13.827 1 13.827 12.942 0.001

Gender 3.949 1 3.949 3.696 0.058

Physician experience 16.108 1 16.108 15.077 0.000

History of biopsy 4.026 1 4.026 3.376 0.056

Location of biopsy 0.219 1 0.219 0.205 0.652

Group 170.137 1 170.137 159.243 0.000

Error 77.994 73 1.068

DISCUSSION

Theresultsofstudyshowedthat,thecontrolgroupexperiencedmoderate to severe levels of pain duringbonemarrowbiopsy.InastudybyLidenetal,70%ofpatients reported moderate to unimaginable levels ofpainduring thebonemarrowbiopsy,andone thirdofthemhad experienced a severe pain.17 In thePortnowstudyofcancerpatientsundergoinginvasiveprocedures,40%ofthepatientsreportedmoderatetoseverelevelsofpainduringbonemarrowbiopsy.18

The results of present study showed a significantdifferencebetween thepain scoresof the interventionandcontrolgroups(P<0.05).

In the study of Huang in 2014 entitled; “thebeneficial effect of lavender scent on pain relief afterarthroscopy”patientsweredividedintotwogroups,and28patientsintheinterventiongroupreceivedanecklacebottle containing 0.5 ml of 2% lavender oil and 32patients in the control groupwore an empty necklacebottle. The 2% lavender oil effectively decreased theseverityofpaininlong-term(72hours),andasignificantdifferenceinpainlevelwasobservedbetweenthetwogroups. No significant difference in both groups wasobserved in 15 minutes and 4, 8, 24, and 48 hours.However,thedecreasetrendinpainscoreat72hoursin

theinterventiongroupwasmorethanthecontrolgroup.Thepainscoreintheinterventiongroupdecreasedfrom6.9to1.8,whileinthecontrolgroupitdecreasedfrom6.4to3.5.19

The results of Olupur’s study showed that, painaftercesareansectiondecreasedsignificantlyin4,8and12hoursaftertheonsetofsymptomsfollowingsmellingoflavenderessentialoilcomparedtoplacebogroup.20

TheGorgi’sstudyshowedthat,lavenderiseffectiveontheseverityofpaincausedbycoronaryarterybypassgraft.21AstudybyHadietal,onpost-cesareansectionpainshowedthat,themeanscoreofpainafterlavenderinhalation decreased significantly.22 In another studyby Mir-Mohammad Ailiei et al, the results showedthat inhalation of lavender scentwas effective on thepaincausedbyIUDinsertion.9StudyofKimetal,onthe effect of lavender on the severity of venipuncturepain found that, the stress level, tolerance index forsedationmonitoring,andtheseverityofpainassociatedwithneedleinsertioninagroupthatwasusingoxygenmixed with lavender for 5 minutes significantlydecreasedcomparedtothecontrolgroupthatwasonlyreceiving pure oxygen.23 Study of Saeki et al showedthat, aromatherapywith lavenderwas not effective inreducingpain,24whichisnotconsistentwiththeresultsofpresentstudy.


CONCLUSION

Theresultsofpresentstudyindicatedthat,smellinglavenderscentiseffectiveinreducingthepainassociatedwith bonemarrow biopsy. Therefore, considering theeffectsandbenefitsoflavenderanditseasyapplication,itisrecommendedtobeusedinthehematologyandnon-hematologyclinics to reduce thepaincausedbybonemarrowbiopsy. It isalsosuggested that,morestudiesshould be conducted on how and when the lavendershouldbeusedtoreducethepainassociatedwithbonemarrowbiopsy.

Among the limitations of this research was thepreviousexperiencesandpatients’mentalstatusduringbonemarrowbiopsy,whichwasaffectingtheseverityofpain.

Conflict of Interest:Theauthorsdeclarethattheyhavenoconflictofinterest.

Source of Funding : ThereislfinancialsupportforthisresearchworkbyTUMS.

Ethical Clearance :Thisstudyhasanethicalcodenumber( IR.TUMS.FNM.REC.1395.780 ) Which istakenfromtheEthicsCommitteeofTehranUniversityofMedicalSciences.

REFERENCES

1. Lechtzin N, Busse AM, Smith MT, GrossmanS,Nesbit S,DietteGB.ARandomizedTrial ofNatureSceneryandSoundsVersusUrbanSceneryandSoundstoReducePaininAdultsUndergoingBoneMarrowAspirate andBiopsy.The Journalof Alternative and Complementary Medicine.2010;16(9):965-72.

2. Degen C, Christen S, Rovo A, Gratwohl A.Bonemarrowexamination: aprospective surveyon factors associated with pain. Annals ofHematology.2010;89(6):619-24.

3. Azizi-FiniI,Adib-HajbagheryM,Salahshoorian-Fard A,KhachianA.Theeffectofhealth-promotionstrategies education on self-care selfefficacy inpatientswithbonemarrowtransplantation.IranianJournalofCriticalCareNursing.2011;4(3):109-16.

4. Miller LJ, Philbeck TE, Montez DF, Puga TA,Brodie KE, Cohen SC, et al. Powered bonemarrow biopsy procedures produce larger core

specimens,with lesspain, in less timethanwithstandard manual devices. Hematology Reports.2011;3:e8:22-5.

5. Hjortholm N, Jaddini E, Hałaburda K, SnarskiE. Strategies of pain reduction during the bonemarrowbiopsy.AnnHematol.2013;93:145-49.

6. Vanhelleputte P, Nijs K, DelforgeM, Evers G,Vanderschueren S. Pain During Bone MarrowAspiration:PrevalenceandPrevention.JournalofPainandSymptomManagement.2003;26(3):860-66.

7. Faizan-ZahidM.Methodsofreducingpainduringbone marrow biopsy: a narrative review. AnnPalliatMed.2015;4(4):184-93.

8. AsgariMR,MotlaghNH,SoleimaniM,GhorbaniR. The comparison of effect of TranscutaneousElectricalNerveStimulation(TENS)andlidocainesprayonpainintensityduringinsertionofvascularneedles inhemodialysispatients. Iranian Journalof Critical Care Nursing. 2012;5(3):117-24.(persian).

9. MirmohamadAliei M, Khazaie F, Rahnama P,Rahimikian F, Modarres M, Bekhradi R, et al.Effect of Lavender on Pain during Insertion ofIntrauterine Device: A Clinical Trial. J BabolUnivMedSci.2013;15(4):93-9.(Persian).

10. ChoM-Y,Min ES, HurM-H, LeeMS. Effectsof Aromatherapy on the Anxiety, Vital Signs,and Sleep Quality of Percutaneous CoronaryIntervention Patients in Intensive Care Units.Evidence-BasedComplementary andAlternativeMedicine.2012;2013(381381)((381381)):1-6.

11. Ghods AA, Hoseini-Abforosh N, Ghorbani R,AsgariMR.Effectoflavenderinhalationonpainintensity during insertion of vascular needles inhemodialysis patients. J Babol Univ Med Sci.2014;16(10):7-14.(persian).

12. Heidari-Gorji MA, Ashrastaghi OG, Habibi V,Yazdani-Charati J, Ebrahimzadeh MA, AyasiM. The effectiveness of lavender essence onstrernotomy related pain intensity after coronaryartery bypass grafting. Adv Biomed Res.2015;4(127):1-10.

13. DamianP,DamianK.Aromatherapy:ScentandPsyche: Using Essential Oils for Physical andemotionalwell-being.U.S.A.1995.


14. EnteenS. EssentialOilsforPainRelief.MassageToday.2005;5:2(2):1-4.

15. Koulivand PH, GhadiriMK, Gorji A. Lavenderand the Nervous System. Evidence-BasedComplementary and Alternative Medicine.2013;2013(681304)((681304)):1-10.

16. Schiller C, Schiller D. The AromatherapyEncyclopedia:AConciseGuidetoOver385PlantOils.U.S.A.2008.

17. Lidén Y, Landgren O, Arnér S, Sjölund K,JohanssonE.Procedure-relatedpainamongadultpatients with hematologic malignancies. ActaAnaesthesiolScand.2009;53(3):354-63.

18. Portnow J, Lim C, Grossman SA. Assessmentof pain causedby invasiveprocedures in cancerpatients. JNatl ComprCancNetw. 2003;1:435-39.

19. HuangS-H,FangL,FangS-H.TheEffectivenessofAromatherapywithLavenderEssentialOil inRelieving PostArthroscopyPain.JMEDResearch.2014;2014(2014):1-9.

20. OlapourA,BehaeenK,AkhondzadehR,SoltaniF, Razavi FAS, Bekhradi R. The Effect ofInhalation of Aromatherapy Blend containingLavenderEssentialOilonCesareanPostoperativePain.Anesth Pain.2013;3:1(1):203-7.

21. Heidari-Gorji MA, Ashrastaghi OG, Habibi V,Yazdani J, Ebrahimzadeh ME, Ayasi M. Theeffectivenessoflavenderessenceonstrernotomyrelated pain intensity after coronary arterybypassgrafting.AdvancedBiomedicalResearch. 2015;4(127):1-10.

22. HadiN,HanidAA.LavenderEssence for Post-Cesarean Pain. Pakistan Journal of BiologicalSciences.2011;14(11):664-67.

23. KimS,KimHJ,YeoJS,HongSJ,LeeJM,JeonY.Theeffectoflavenderoilonstress,bispectralindexvalues,andneedleinsertionpaininvolunteers.JAlternComplementMed.2011;17(9):823-6.

24. Saeki Y, Tanaka YL. Effect of inhaling fra-granceson relievingprickingpain. Int JAroma-ther2005;12(2):74-80.

Clinical and Paraclinical Signs and Symptoms of Patients with Ingested Processed Cannabis (Majoon Birjandi) in the

Eastern Iran

Reza Afshari1, 2, Zohreh Oghabian3, Jelveh Gharavairoodsari4 , Saeedeh Khosravi 5, Alireza Noorollahi6, Omid Mehrpour4

1BC Centre for Disease Control, Vancouver, Canada, 2Occupational and Environmental Health Division, School of Population and Public Health, University of British Columbia, Vancouver, Canada, 3Department of Clinical

Toxicology, Kerman University of Medical Sciences, Kerman, Iran, 4Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Moallem Avenue, Birjand, Iran,

5Cardiovascular Diseases Research Center, 6Student Research Committee, Birjand University of Medical Sciences. Birjand, Iran

ABSTRACT

Background:Thepatternofdrugabusevariesindifferentpartsoftheworld.YoungstersintheeastofIranabuseprocessedcannabiswhichisaningredientofatraditionalpiecalledMajoonBirjandi(MB).TheaimofthisstudywastoevaluatetheclinicalandparaclinicalsignsandsymptomsinpatientspoisonedwithMB.

Method:Wedesignedacross-sectionaldescriptivestudyusingastandardizedquestionnaireadministeredtoallcaseswithMBpoisoningwhowasadmittedtothetoxicologyEmergencydepartmentoftheVali-AsrhospitalinBirjand,IranfromMarch2010-2012.Demographic,medical,psychiatricandelectrocardiographicindices,vitalsignsonadmissionwerestudied.

Results:Thestudyincluded69patientsaged23.5yearsinaverage,64ofwhomweremenandfivewomen.Patientshadconsumedameanof1.36(0.8,0.5-5)pie.Allpatientswerepositivetotetrahydrocannabinol(THC) by urinary immunoassay.CommonSymptoms reported according to frequencywere sore throat(94.2%)followedbydrymouth(91.3%),flashing(81.2%),panic(75.4%),conjunctivitis(69.6%),vertigo(65.2%),agitation(56.5%).Mostpatientshadmydryasis.

Conclusion:ItappearsthatthemajoringredientofMBiscannabis.Incomparisontotheliteraturesrelatedtosomkingcannabis,clinicalmanifestationofingestingMBappearslaterandlastlonger.

Keywords: Majoon Birjandi, Cannabis, Overdose, Poisoning

Corresponding author:Omid MehrpourMedicalToxicologyandDrugAbuseResearchCenter(MTDRC),BirjandUniversityofMedicalSciences(BUMS),MoallemAvenue,Birjand,9717853577Iran.Tel&Fax:+98-5632381270,Mobilephone:+989155598571Email:[email protected]

INTRODUCTION

Substance and illicit drug abuse is amajor healthprobleminIran1,2.Basedoninternationalreports,Iran

hasthehighestrateofrawopiumuseintheworldwhichcan be related to culturalmedicinal use of opioids aswellasorneighboringAfghanistan,whichisthemajorproductivecountryproducingopioids in theworld 3,4. Cannabishas longbeenused in thiscountrybya lessfrequency.

Thepatternofdrugabusevaries indifferentpartsof theworld. In thiscountry,adulterationof thestreetdrugsiswidespreadandthemostcommonadulterantsinclude lead, corticosteroids, and thallium5-7. Werecently reported recreational use and overdose ofingested processed cannabis (Majoon Birjandi) in the

DOI Number: 10.5958/0973-9130.2018.00158.5


eastern Iran 8, but there is no study evaluated clinicalandparaclinicalsignsandsymptomsofthepatientswithMBoverdoseintheliterature.

In east of Iran, a special traditional solid pieconsistingoftheprocessedcannabisexistsandislocallycalledMajoonBirjandi(MB).Itisfrequentlyabusedbyyoungsters to induceeuphoria.Wepreviously showedthat Urinary delta-q-tetra-hydrocannabinol (THC) andUrinaryimminoassytestforcannabisispositiveinthesecases8.

Cannabioid is one of themain ingredients of thisillicitsolidlozenge.Otheringredientsandadulterantsofthiscocktailincludesaffron,date,cardamom,coconut,ginger,pistachio,andsugar.Becauseofitssolidnature,itiseasilysmuggledandstoredforalongtime.

Inrecentyears,orallyadministeredcannabisextracthasbeenmedicallyused to increaseappetiteand treatcancer-related anorexia 9, 10.While smoking cannabis-inducedsideeffectsandoverdosesarewidelyreported11, very limited information is available in regard toillicit oral cannabis. Clinical findings, efficacy andbioavailabilityofthemedicationvarieswheningested.Overdose or drug-induced side effects of ingestedcannabiscanprovidevaluableinformationinregardtocannabisingestion.

This study aimed at evaluate the clinical andparaclinicalsignsandsymptomsofthepatientswithMBoverdosewhoreferredtoImamRezaHospitalwhichisthereferralhospitalofpoisoningintheeastofIran.Thisisthefirststudyinthisregardintheliterature.

METHOD

We designed a cross-sectional descriptive studyusingastandardizedquestionnairefilledoutforallcaseswithMBpoisoningwhowereadmittedtothetoxicologyemergency department of the Vali-Asr hospital inBirjand, Iran from March 2010 to March 2012.Urinary imminoassy test for marijuana, methadone,tramadol,morphine, amphetamine,methamphetamine,benzodiazepine,tricyclicantidepressant,phenothiazinewere performed for admitted cases, and those whohad positive for other toxicant exept marijuana wereexcludedfromstudy.Moreover,thosewhohadingestedothertoxicants,hadunreliablehistoryofMBoverdose,and would not like to be interviewedwere excluded.This study was approved by the ethics committee

of the faculty of medicine. Variables includingdemographic characteristics, neurological, psychiatric,gastrointestinal, ophtalmological, and cardiovascularsignsandsymptoms,electrocardiographicindices,vitalsigns on admission, time elapsed between ingestionandhospitalpresentation,andthetreatmentperformedwererecordedandstudied.ThedatawasanalyzedusingStatisticalPackage for theSocialSciences (SPSS Inc.Chicago, IL, USA) version 22. chi-square and t-testwereusedforanalysisofvariables.P-values<0.05wereconsideredtobesignificant.

RESULTS

Socio-demographic

A total of 69 patientswere included.Theyweremainlymen(92.6%)withamean(SD,min-max)ageof23.5(6.64,14-60)years.67.6percentofpatientsweresingle.Almosthalfofcases(46.4%)hadaneducationlevelofdiploma.Workerwerethemostfrequentjobinourcases(34.8%ofcaseswereworkers).

Thedrugwasmostlyabusedintheafternoonsandevenings(19.35(2.47,14-23:30).Elapsedtimebetweeningestion and hospital presentation was 3.29 hours(1.23,0-6)hourswithameanhospitalizationperiodof2.88 (3.04, 0-22) hours. Patients consumed 1.36 (0.8,0.5-5) pie in average. 27.5 percent of the patientsreportedprevioususe.

CLINICAL FINDINGS

General

Themost common reported symptoms were sorethroat(94.2%)followedbydrymouth(91.3%).Flashing(81.2%),muscularpain(21.7%)andsweating(14.5%)were of the other signs and symptoms. Mean Bloodsugarwas114.75(36.52,56-273)mg/dL.

Neurologic and psychiatric

Panic(75.4%),vertigo(65.2%),agitation(56.5%),feeling freezing time(56.5%), delirium (40.6%),auditory hallucination (37.7%), talkativeness (43.5%),relaxation(20.3%), visual hallucination (33.2%), anddermalhallucination(39.1%)wereofthemostcommonneurologicalsignsandsymptoms.

Gastrointestinal

Increased appetite (51.2%), abdominal


fullness(35%), nausea (4.3%), and vomiting (27.5%)weremostcommon.

Cardiovascular and pulmonary

Mean pulse rate of 97.75 (18.90,64-169) bpm,respiratory rate of 19.36 (8.13,13-80), sitting systolicblood pressure of 11.12 (1.60, 6-17) mmHg, sittingdiastolic blood pressure of 6.99 (0.99,5-11), sleepingsystolic blood pressure of 11.20 (1.52, 9-16) mmHg,and sleeping diastolic blood pressure of 6.89 (0.85,6-10) were detecetd. There is no statistically diffrencesbetween sleeping and sittting of sistolic and diastolicbloodpressure.

Ophthalmology

Conjunctivitis(69.6%)andblurredvision(55.1%)were mostly detecetd. Most cases had mydriasis(67.2%),whilemidsizepupilandmiosiswerefoundin27.9%and4.9%ofthecases,respectively.

Electrocardiographic indices

MeanPRintervalwas146.28(28.49,13-200)msec,mean QRS duration was 96.52 (37.65, 64-283) msecandmeanQTcwas424.15(46.14,340-628)msec.Axis66.70(28.27,7-141)msec.

24.1%ofpatientshadQRSgreaterthan100msec.QTintervalofjustonepatient(1.9%)wasgreaterthan450msec.

Treatment

Charcoalwas given to 84.1% of the cases.Othertreatments included fluid therapy (56.5%), gastriclavage(15.9%),oxygen therapy(7.2%), intramusculardiazepam (4.3%), and metoclopramide (2.9%). Mostof the patients (92.3 %) were discharged from theemergency department around 5 hours and only 3pateints were admitted to the poisoning ward. UsingPearsoncorrelationrevealedthattherewasnosignifactdiffenetbetweentheamountofingestedMBanddurationof hospitalization (p-value= 0.126) aswell asElapsetime (p-value = 0.893) was observed. Comparison ofclinicalfindingsinpatientswithprioruseofMBandthosewhodidn’thavehistoryofMBusedidn’tshowanysignificantdiffentce(p-value>0.05).

DISCUSSION

Abuse of the cannabinoids has been popular for

milleniums.Althoughmarijuanaisthemostcommonlyabusedagentaftersmokingcigarettesandalcohol12,itisnotreportedtobecommoninIran.Inrecentreports,cannabis was the most commonly abused drug instudents13,14;afactthatisontherise15.

Smokingisthemostcommonmethodofcannabisabuse.Ingestionhasrearelybeenreported16.Generally,2.5mg ofTHC in amarijuana cigarette is enough toinducementalandphysicaleffectsinanormalperson16. Wheningested,thecannabinoidlevelsarealmost25to30 percent less than that comparedwith the smokingmethodand theonsetof itsactionmaybedelayedby0.5to2hours17.Inaddition,thedurationofeffectmaybeprolonged16.

Cannabinoidsarealsousedformedicinalpurposes16.Marinol®isoneoftheavailablecanabinoidtablets.Todateverylimiteddataisavailableaboutitstoxicityintheliterature18.Similarly,dataonrecreationaloraluseofcanabinoidsisscarce.

In eastern Iran, a special traditional solid pie,locally called Majoon Birjandi (MB) is frequentlyabused.Mostof theeuphoriceffects inducedbyitarerelatedtothecannabinoidingredient.Potentialsaffroneuphoric effects may be ignored due to its very lowconcentration.MB is traditionallyproducedmainly intheSouthKhorasanprovinceespecially in theBirjandandKhoosfcity.It isalsotransferredtootherpartsofIranincludingKhorasanRazaviprovinceandMashhadcity. Majority of the moderate to severe intoxicatedpatientsarereferredtothehospitals.

InacuteintoxicationwithMB,drynessoftheairwaymucosa andmouth,flushingof the face, panic attack,congestion of the conjunctiva, weakness, dyspnea,hallucination(especiallytactile),mydriasis,abdominalfullness,andnauseaandvomitingare themajor signsandsymptoms.

Psychiatricfindingsincludeanxiety17,19,dysphoria,euphoria, and paranoid and psychotic thoughts 17, 19. Tachycardia17,drymouth17,19,gaitdisorders,memoryloss,disordersofconcentration,andvisualandhearingloss15mayalsobepresent.MostoftheTHCeffectsaredose-related19.

Signs and symptoms similar to the oral ingestionof cannabis can be seen in body packers who haveingested cannabis-containing packs. Centers for


DiseaseControlandPrevention(CDC)inyearof2009reportedInadvertentmarijuanaingestioninagroupof6preschool teachers 20.Theconstellationof symptomsdescribedinthisreportsareasbelow:

1. Neurological: drowsiness ,fatigue ,ataxia,dizziness ,Weakness, Dizziness, Unbalanced/Ataxia,Headache,Agitation,Anxiety,Giddiness,Alteredmood,Numbness,Tingling,Muscletwitching,Chills.

2. Gastrointestinal symptoms: Altered taste,Increasedappetite,Drymouth/throat,Mouthirritation,Nausea,Vomiting.

3. Cardiopulmonary: Shortness of breath,Palpitations.

4. Integumentary: Excess sweating, Itching,Burningeyes,Itchingeyes

Since almost 25% to 30% of the smoked THCis absorbed, signs and symptoms of equal amountof ingestion overdoses should be less severe than thetoxicity induced by its smoking. The general beliefof the people that the cannabioids are harmless 16 isincorrect15.

In these patients, delirium, becoming talkative,auditory, tactile and visual hallucinations, increasedappetite,fearsensationanddrymouthhavebeenreportedwhicharesimilartothesignsandsymptomsofthecasesintoxicatedbysmokingcannabis.However,thereweresomesignsandsymptomsinourpatientswhichhadnotpreviouslybeenreported insmokingcannabis toxicityincluding sweating, abdominal fullness, dizziness,diplopia,muscularpain,andhypoandhyperglycemia.AlthouthdizzinessandsweatingareseeninacaseseriesofaccidentallycanabisingestionIt,therefore,seemsthatthesignsandsymptomsinthesepatientsarenotexactlycompatible with cannabis overdose. These effectsmay be related to other ingredient of MB includingsafferon. It seems that ingestion of cannabioids maygeneratesymptomslaterandlastlongerincomparisontosmokingmethods.

Limitation: Electrolytes were not checked formajorityofcasesastheywerestayedinhospitalforashortperiodandnotadmitted.

Conflict of Interest: Nonetobedeclared.

Ethical Clearance: This study was approved by

the ethics committee ofBirjand university ofmedicalsciences.

Source of Funding: ThisstudywassupportedbyBirjanduniversityofmedicalsciences.

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Problems of Autistic Children- A Systematic Review

Bafahm Fatemeh1, Parand Abdolmajid2, Kalvandi Narges3, Jokar Mozhgan4

1Instructor, Abadan School of Medical Sciences, Abadan, Iran, 2Instructor, Amir Al-Momenin Hospital, Ahvaz University of Medical Sciences, Ahvaz, Iran, 3Master of Community Health Nursing Student, Hamadan University

of Medical Sciences, Hamadan, Iran, 4Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

ABSTRACT

Autismisthesocialinteractionofabnormal,delayedandabnormalcommunicationskillsandlimitationofthecomplexofactivitiesandinterestsoftheindividual.Duetothenatureofthedisorder,thechildrenarealwaysfacingsignificantchallengesintheirlives.Thisstudyaimedatsystematicallyreviewingthestudiesthatexaminedtheproblemsofautisticchildren,inviewoftheiridentificationandcomparison.Allstudiesperformedduring2010-2018usingautism,autisticchildren,autismdisorders,childhoodautismproblemsof country and abroad databases includingMagiran, SID,Medlib, CINHAL, PubMed, Scopus, web ofscience.Datawereanalyzedusingmeta-analysis.Autismcoversawiderangeofdisorders.Disordersandproblemsassociatedwithautismchildrenareclassifiedintonineareas:PhysiologicalPathDisorders,SocialDisorders,DisordersofBehavioralandExerciseSkills,Sensory-MotorDisorders,DisordersofAttentionDeficit-Hyperactivity Disorders, Family-Related Disorders, Nutrition Disorders, Sleep Disorders andDisordersOralandtoothache.Autismchildrenwithmanydisordersandproblemsareencountered.Family-relatedproblemsinthesechildrenareverymuchwelcomedbytheresearchers.Moreattentionisbeingpaidtoidentifyingthisafterproblemsassociatedwithfamily-basedtherapeuticinterventionsbytheresearcher.

Keywords: Autism, Autism Children, Disorders

Corresponding author: Mozhgan Jokar, FacultyofNursingandMidwifery,IsfahanUniversityofMedicalSciences,Isfahan,Iran.E-mail:[email protected]

INTRODUCTION

Pervasive developmental disorders arecharacterized by destruction in social interactions anddoing imaginative activities, interpersonal verbal andnonverbalinterpersonalskills,aswellaslimitedinterestsandactivities1.Thesedefectsare revealed in theearlyyears and affect the person’s life during his lifetime.Therecentreportsuggeststhattheprevalenceofautismdisorders is much higher than previously reported2. According to studies The prevalence of autism andrelateddisordersistwentycasesper10,000livebirths,with children between the ages of two and five yearsmostlikelytosufferfromthisdisorder3,4.Thetimeandenergyneededtotreatachildwithautismcanseriously

threatentheresourcesofthefamilyandsociety,sothatinAsian countries, the cost of the treatment and careofthesechildrenis70%ofthesalaryofagovernmentemployee5,6. In spite of the contradictory results ofsome studies,manyof the Iranian society still do nothaveaproperattitudeandknowledgeaboutthedisease,whichmaybethemaincauseofthenewandunknownstatusofmanyaspectsofautism,andinparticulartheidentification of the problems of children with it 7,8. Therefore,asafirststepindesigninginterventionandplanning in order to reduce these problems, it is firstnecessary to explain the existing problems and then,by solving these problems, planners and members ofthe care systemwill be able to address the child andthefamilyinthiscomplexdisorderandfacilitatetheseproblemshelp9.Nurses as an important groupof careproviders can play a significant role in identifyingtheseproblemsinorder tocontrolandreduce theminthesepatients10.Theaimof thisstudywastoexaminethe system and to better understand these challenges.Available tohelpdeeper thinking todevelopeffective

DOI Number: 10.5958/0973-9130.2018.00159.7


interventionstoreducetheseproblems.


In this structured review, all studies conductedinside and outside the country during 2010-2018usingthekeywordsofautism,autisticchildren,autismdisorders,autisticchildren’sproblemsfromthecountry’sdatabases,includingMagiran–Med-lib-SID-Iran-medexand Latin databases like CINHAL, PubMed-Scopus-webofscienceisinvestigatedandthedataareanalyzedusingthemeta-analysismethod(Randomeffectsmodel)wereinvestigated;Andthedataoftheselectedarticleswere collected. All articles were analyzed regardlessofthelocationandlocationofthepublication,andthemanner inwhich theworkwasdone.After reviewingandcollectingallthearticlesbeingsearched,thearticleswereduplicatedandunrelated.Subsequentarticles.Thefindingswereevaluatedbasedonthecriteriaforenteringthe study, which included: studies that examined orintervenedtheproblemsanddisordersofchildrenwithautismthathadbeenpublishedintheyears2018-2010.Exclusioncriteriaalsoincludeddatafromcasereportsand posters, conferences and review articles. Finally,selected articles aimed at investigating the problemsand disorders of childrenwith autismwere reviewed.Alltheethicalissuesnecessaryforthecorrectuseoftheextractedarticlesandthestandardsfor thepublicationoftheworkwereobserved.

FINDINGS

236 studies with autism disease content werecollected.191didnotstudy theproblemswithautismautism problems. Therefore, 43 studies according tothe entry criteria were carefully examined to identifyand prioritize problems in children with autism. Thedisordersthatwereincludedinthereviewofthestudiesby the investigators and interventions were classifiedintonineareas.Theautism-relateddisorder,accordingto the number of studies thatwas done in the specialfield, was as follows: Pathophysiological disorders 37,socialskillsdisorders10,behavioralandexecutiveskillsdisorders 9, sensory-motordisorders 7,attentiondeficithyperactivity disorder (6studies), disorders Familystructure (4studies), nutritional disorders (3studies),sleep disorders (2studies), oral and dental disorders(2studies).

DISCUSSION

Themostcommonlydiagnoseddisorderwasautisminthepathophysiologyofthedisease.Theresearchersidentified several factors that predispose autism.Neurobiological,genetic,Regionalcerebralbloodflow,delivery,foodallergies,andbirthrearingrateswerethemostcommonlystudiedinthesestudies.10studiesaimedatanalyzingtheproblemsofsocialskillsinchildrenwithautism. Interventions included communication skillstraining, intervention based on individual differencesbased on the expressed emotion, using responsivetherapy, game therapy, animal communication, horseriding,music therapy, and therapeutic treatment.Datacollectiontoolsinthesestudies,children’ssocialskills,intelligence tests, ASSQ, ATEC, ADI-R, Intelligencetests,StanfordBinet,Gilliam’stestandsocialadjustmentwereanalyzed.AnalysisandanalysisofdatarelatedtodisorderTheconnectionwassentinthesetests,whichisaprofounddifferenceBetweenautisticchildrenandhealthychildren,socialskillsaremorelikelytobeduetospeechimpairment,andtheeliminationofconsonants,the transference of consonants, the inappropriate useof reliance on proper syllables, unusual words, theinappropriate use of grammatical timing, The lack ofapplicationormisuseofprepositions, thedifficulty inaddingnames, the lackofuseofcompoundsentencesin children with autism and healthy. Interventionshadapositiveeffectontheincreaseofsocialskills inthesechildren11-20.Accordingtoinferioritystudies,themost important cognitive impairment that formed thebasisofstereotypicalbehaviorinchildrenwithautism.Interventions included environmental modification,neurofeedback therapy, occupational therapy, theatertherapy,useofresponsivetrainingmethod,andtheuseof clinical teaching methods, the tools for collectinginformation were Gilliam, vanilla, adi-r, Wisconsinand Tower of London and at the level of the brainelectroencephalogram. Interventions had a significantimpacton the improvementof thebehavioral-acousticbehaviorofchildren29-21.Astudyonthestudyofsensory-motor disorders of children with autism. The resultsshowedthatchildrenwithautismhavedifferentpatternsof sensory-motor processing. Certain interventionswere performed by the researchers. Interventionsincludedcognitive-motorexercises,exercisesSenseofintegration motor, frequency filter visual informationandbasicexercisesgymnasticsBvdnd.mdakhlatmadeagreatimpactonparticularsensoryandmotorskillswere


30-36.Astudyofattentiondeficithyperactivitydisorderinchildrenwithautismhasbeenstudied.Theresultsofthese studies showed that hyperactivity and attentiondeficit disorders interferewith the learningprocess ofseventypercentofthepatients,andthemostimportantbarrierinthelearningprocess,thedisorderwasreportedin these studies.Another important problem for thesechildren was the difficulty in identifying certainemotions,especiallyangerandfear.Thedatacollectiontoolinthesestudieswasachecklistforassessingautism,theWorldHealthOrganization’sQualityofLifeScale,Conner and Davidson’s Resilience Scale, self-reportquestionnaires on depression and anxiety, and qualityoflifeinWHOQOL-BREF.Theresultsofthesestudiesarethefrequencyofhighdepressionscoresandshowedanxietyinmothersofchildrenwithautism.Thus,72.4%ofmothersreportedsomedegreeofanxietyandhalfofthemreportedsomedegreeofdepression.Educationalsessions are done individually and collectively formothers.Resultsshowedthataftermothers’trainingandsupport interventions, they experienced less stress43-44. Interventions the prescribing and use of omega-3fattyacids,zinc,iron,andvitaminBsupplementswaseffective.Results showed that the use of supplementshasbeneficialeffectsinreducingotitismbehaviors45-47. Findingsshowedthat55.4%ofchildrenhadaproblemwithsleeplatencyand51.8%hadanxietyduringsleep.In general sleep score, 30.4%of children had a sleepproblem. Also, father’s education and the birthrightareapowerfulpredictorofchildren’ssleepproblems48. Twostudiesonoralhygieneproblemsinchildrenwithautism were studied. The data collection tool was asurveyofdentalexaminationsofchildren.DataanalysisandanalysisrevealedthatchildrenwithautismdidnotmeetmoredentalneedsDentalsystemwassignificantlyhigherthanhealthychildren(P=0.002),andalsochildrenwithautismshowedahigherprevalenceofcariesandpoororalhygiene.

CONCLUSION

Recent studies have shown that this group ofpeoplehasalwaysfacedmanyproblemsin thefuture.Interviewsforthesepatientsshouldalwaysbeaccessibleand cost-effective. The result is the highest range ofstudies conducted specifically by in-house researchersConcentrated on the pathophysiology of this disease.This research concludes the poor participation ofresearchersandfamiliesofchildrenwithautismaswellascostlyandfar-reachinginterventions,andemphasizes

the need to promote more family-based therapeuticinterventions,alongwithlow-costaccesstoit.

Ethical Clearance: This research project wasapprovedbytheethicscommitteeofAbadanUniversityofMedicalSciences.

Source of Funding:Abadan,UniversityofMedicalSciences.


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Facilitating Factors in the Prevention and Control of Nosocomialinfections in the Intensive Care Units:

A Qualitative Study

Ayshe Hajiesmaeilpoor1, Abbas Abbaszadeh2, Hamid Soori3, Shirin Afhami4, Esmaeil Mohammadnejad5

1Department of Nursing, School of Nursing and Midwifery, Sanandaj branch, Islamic Azad University, Sanandaj, Iran, 2Professor, Dept. of Nursing and Midwifery School, Shahid Beheshti University of Medical Sciences, Tehran, Iran, 3Professor, Dept. of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences,

Tehran, Iran, 4Assoc. Professor, Dept. Infectious Disease, 5Asst. Professor, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

ABSTRACT

Nosocomialorhospital-acquiredinfections(HAI)areamajorprobleminICUsandoneofthemajorcausesofhospitalization,medicalcosts,andmortality.Thepurposeofthisstudywastoinvestigatethefacilitatingfactorsinthepreventionandcontrolofnosocomialinfectionsintheintensivecareunit.Thepresentstudywasaqualitativeresearchwithconventionalcontentanalysisapproach.Twenty-onehealthcareworkerswereselectedbypurposivesamplingmethodandadeepandsemi-structuredinterviewwasconductedwiththem.Datawereanalyzedusingqualitativecontentanalysismethod.Dataanalysis revealed themain themeoffacilitatingfactors,whichincludedthreecategoriesofexternal,internalandorganizationalstimuli.Accordingtothefindings,itisnecessarytoidentifyfacilitatorstomakenosocomialinfectionsbetterdiagnosedandprovideappropriateandeffectiveplanningtoimprovethesafetyandqualityofpatientcare.

Keywords: qualitative study, nosocomial infection, intensive care.

INTRODUCTION

Ifweconsiderhealthasthefinalproductofcareandtreatmentinanorganizationcalledhospital,nosocomialinfectionshouldbeconsideredasaside-effect.1butalsopreventable by the organization.Nosocomial infectionrefers to an infection that occurs after the patient’sadmission to the hospital (48 to 72 hours), during acertainperiodoftime(10to30days)afterthepatientdischarge,doesnotexistat the timeofadmissionandshouldnotbeinitsincubationperiod.2-3

AccordingtotheWorldHealthOrganization(WHO),in developing countries, the number of preventableinfectionscausedbyhealthcareisestimatedat40%ormore.4-5TheWorldHealthOrganizationestimates that

Corresponding author: Dr. Esmaeil Mohammadnejad, SchoolofNursingandMidwifery,TehranUniversityofMedicalSciences,Tehran,Iran.Mobile:+98-9126124176,Email:[email protected]

1.4million people every year suffer fromnosocomialinfectionsworldwide.Thisratefordevelopingcountriesisabout5to10percent,andinsomeofthesecountries,morethan25percentandaccordingtostudiesconductedin some middle-income countries, about $ 8 billionworthofeconomicdamageisspentannuallytoaddresstheproblemsassociatedwiththeseinfections.6-7

ThecontrolofnosocomialinfectionsinIranhasnolonghistory.Despitethefactthattherecordsofinfectioncontrol since 1972 are available at the universities ofAhvazandShirazandthenseveralhospitalsinTehran,however, only in Shiraz, since 1981, special attentionhasbeenpaidtocontrollinghospitalinfectionsinShirazsince1980,andpreventionandcontrolprogramshavebeenfollowedup.Thescatteredstatisticsofdevelopingcountriesreflectthefactthattheexactrateofnosocomialinfectionsinsuchcountriesvariesduetomanyfactorssuchasthenumberofhospitalbeds,thelevelofreferralof the hospital,whether or not hospitals are teaching,the existence or absence ofmonitoring programs, thetypeofstudiedwardsandtheamountoffacilitiesand

DOI Number: 10.5958/0973-9130.2018.00160.3


financialresourcesforsuchcareprograms.8

In Iran, according to claim of hospitals there isno infection or about 1%, while actual prevalenceis estimated to be about 15%.Thismeans that out ofevery 7 patients one patient suffers from nosocomialinfections that imposeaveryhighcost to thecountry.The latest reports in 2010 in Iran,9 indicated that thestatus of control of nosocomial infections is in badcondition. Unfortunately, in this field in our countrywe do not have access to accurate data, however theprevalence of nosocomial infections afflicting mostcountriesandnotonlyforIran.Inorderforthestatisticstobereal,facilitativefactorsneedtobeidentifiedsothattheplanningcanbedonecorrectly.


Data were analyzed using conventional contentanalysismethod.21 Participants in this studywere 21healthcare workers included faculty member of thecriticalnursingdepartment,clinicalpharmacistresidentinICU,expertofthedepartmentofinfectioncontroloftheUniversity,headofICUservicesDepartment,headofhospital,patientsafetyexpert(oneperson),staffnurse,hospital administrator, infection control physician (2persons), infectioncontrolsupervisor, ICUheadnurseandheadofICU(3persons).

To reach the data immersion, the researcherslistened to the interviews several times, transcribedword by word, and reviewed them repeatedly.Then,in order to extract the codes, the datawas readwordby word, and the highlight words of the text weremarked and codedwith the annotation on themarginofthetext.Forinitialcoding,theparticipants’wordsandresearcher’sperceptionsofparticipants’statementswereused.10Bycoding,thesemanticunitwasextractedfromthestatementsof theparticipants, thenthecodeswereclassifiedaccordingto thesimilaritiesanddifferences,andbycomparison, themaincategorieswere formed.Theinclusioncriteriainthisstudyincluded:havingatleastoneyearofworkexperienceinthecriticalcareunitandoneyearofmanagementexperienceincenterswithacriticalcareunit.

The data collection method was semi-structuredface-to-face interviews. Of the 21 participants, 23interviews were conducted in total.The first and keyparticipant,aMasterofScience(MSc)inNursingandsupervisorofnosocomialinfectioncontrol,voluntarily

expressedtheirwillingnesstoparticipateintheinterview.14 interviews were conducted in unannounced hoursaccording toanagreementbetween theparticipants inthestudyandtheresearchteam.

In semi-structured interviews, at least guidance isprovidedtothecollaboratorsbytheresearcher,andtheresult of the first interviewwill guide the subsequentstages of the interview so that, with the progressionof the interview process, the researcher will focusonthespecificsubjectsoftheparticipantsandleadtotheemergenceofnewdata.Semi-structuredinterviewbeginswithanopenquestionandgraduallyprogress tomorefocusinterviewingwiththeadvancementofinterviews.11 Accordingly, the interview time was matched to thefreetimeofthemedicalstaffparticipatinginthestudy,mostof them in theafternoon.To listendeeply to theparticipants’ conversations, a recorder was used.Theresearcher tried to enter the participants’ experienceswithoutgivingaspecificdirectiontoconversationsandinterviewing.Theinterviewtimewas35to145minutes,withanaverageof50minutes.Thedataanalysisprocesswas performed by adopting conventional contentanalysismethodandusingMAXQDAqualitativedataanalysis software based on the three main phases ofpreparation,organizationandreporting.

Themainquestioninthisstudywas“Whatdoyoudo to control infection in the ICU?” In general, thepurpose of the interviewswas to collect and discovertheexperiencesof themedicalstaff incontrollingandpreventingnosocomial infections in the intensivecareunit.Inthepresentstudy,therigorwasassuredthroughfourcriteriaofdependability,credibility,transformabilityandconfirmabilityasintroducedbyLincolnandGuba.12

RESULTS

The majority of participants (57.1%) were maleandmost of them (42.8%) in the age range of 36-45years.In terms of education, 9 (42.8%)were bachelorand 7 (33.3%)were specialistsinmedicine.At the endof the data analysis, 173 codes, 21 sub-categoriesand 6 categories of interviews were developed.Bycontinuously reviewing extracted codes, removingduplicatesandmergingsimilaritems,atlast,68codesremainedinthe7sub-categoriesand3maincategories.Facilitating factors in controlling and preventingnosocomial infections include organizational, externalandinternalstimuli.(Table1)


Table (1): Facilitating factors in controlling and preventing nosocomial infections in intensive care unit

Main categories Sub-categories

Externalstimuli

Materialrewards

Spiritualrewards

Verbalencouragement

OrganizationalstimuliOrganizationalsupport

Transparencyofprocedures

Internalstimuliprofessionalcommitment

Adherencetostandards

External stimuli

Today, infection control is based on thestandardprecautions. Some factors can act as externalstimuli in controlling and preventingnosocomialinfection in theICU.It should be planned to use thesestimuli.

Material rewards

“Inthisward,theyonlyseeusforeverything,nottobeabletodothingsforpatients,whenwedothingsfor our patients, we are constantly expecting to beon theway toGod’ssake,finally,our lifealsohas itsown expense, asmore authorities support us,wewilldefinitelyfurthersupportthepatients...“(Participant17)

Spiritual rewards

“Because of the timely service to these patients,whichIseealotofplacesGodhelpme,IreallyfeelthehandofGodinthesufferingofmylife,providingservicetothepatientsincludesallaspects,suchaspatientsafety,infectioncontrol,familyeducation”(Participant8)

Verbal encouragement

“Alongwith all the actions taken in the intensivecareunits,themedicalandnursingstaffworkinginthisdepartmentshouldbeseeninparticular,wearealwayslooking forward to special measures from hospitalmanager and the nursing office for the intensive careunit, andweexpect to thankusmoreon special days…”(Participant12)

Organizational stimuli

One of the criteria for controlling nosocomialinfection, especially in the intensive care units, isorganizationalstimuli.Forthispurpose,theorganizationshould obviously protect the implementation ofprinciples and regulations and reduce the deficienciesthatexistinimplementingtheprocedures.

Organizational support

“Iamasupervisorofinfectiousdiseasecontrolinthiseducationalhospital;Icannotgetintouchandstrugglewith all the managers and head of the department tocontroltheinfection,andI’llgoberserk,thedeputyandheadofthehospitalmustsupportme,whentheheadofthehospital isworse thanexpected,whatelse is theretoexpectfromtherestofthedepartment,especiallytheICU?,when Iwent to the ICUdepartment personnel,especiallydoctorandresearcher,tofollowtheinfectioncontrol instructions, those who violate the principlesshouldbepunishedsothatIcanbesurethatsomeonewillprotectme…”(Participant1)

Transparency of procedures

In order to control infections in the hospital,especiallytheintensivecareunit,allguidelinesneedtobeexplicit,clearanddistinct,andthereisnoambiguityforimplementingtheprocedures.

“We have guidelines for all procedures from theWorldHealthOrganizationandtheCenterforDiseaseControl;wecopiedsomeofthemequally,whichisnotefficientforourcountry,theirpoliciesandmethodsaredifferentfromthoseofourcountry…”(Participant19)

Internal stimuli

Internalstimulimakehealthcareworkersawareofnosocomial infections. These stimuli can provide thebasis for the emergence of science, especially in thefieldofnosocomialinfections.

Professional commitment

Aprofessionalcommitmentisbasedonthesenseofresponsibilityandinterestintheindividual’sprofession,whichisthesenseofone’scommitmenttothetasksthattheyarerequiredtoperformbyassumingarole.


Adherence to the standards

Intheimplementationofinfectioncontrol,standardsandproceduresmustbe identifiedandmonitoringandtrainingsystemsmustbeimplementedathealthcenters.

“Thedoctorandthemembersoftheinfectioncontrolteamshouldtakeprecedenceoverthebasicprinciplesofinfectioncontrol,whichmeansthattheymustadheretothebasicprinciplesofstandardprecautions,whicharethesameashygiene,soastobetemplateforothers...”(Participant7)

DISCUSSION

The results of qualitative content analysis usingconventional approach in the field of the facilitatingfactors in the prevention and control of nosocomialinfections in the intensive careunits, revealed3mainthemes: “organizational stimuli “,”external stimuli”,and“internalstimuli”.

Organizationalsupportisoneofthesubsetsoftheorganizational stimuli factors.Today, organizationalsupportisusedasanimportantexplanatoryframeworkfor understanding the relationship between employeesand the organization.13 Incuriosity takes thework andeffortmotivation from themedical staff incontrollingthe nosocomial infection, and consequently, incuriousemployees form an incurious organization that causesthedevelopmentofnosocomialinfectionandbacterialresistance.When employees feel that theorganizationvaluestheiropinionsandfeelingsintheworkplaceandsupportstheiremployeesatalltimesandsituations,theydo not separate themselves from the organization andfeel responsibility and committed to the organization.Organizational support has a positive effect on theindividual and the organization, which increases jobsatisfaction,motivates progress and creates a positiveattitudeinthestaff,therebyalsoaffectingthephysicalhealth of personnel and, at the organizational level,also increases commitment and improveperformance,citizenshipbehaviorandemployeeparticipation,and,ontheotherhand,reducethedesertionandorganizationaldestructivebehaviorsamongpersonnel.

Monitoring and controlling nosocomial infectionsare nowworldwide a global priority,with the goal ofminimizinginfections,inadditiontoreducingmortality,it reduces the hospitalization time for patients andsignificantly reduce therapeutic costs. By observing

andimplementingfacilitatorsincontrollingnosocomialinfections, we can reduce nosocomial infections andincreasepatientsafetyandimprovethequalityofcare.Nurses areoneof themost important groups that canbe effective in identifying and controllingnosocomialinfections.Given that the nurses are the largesttreatmentgroupinthehealthcarecenters,14-15theycanbe encouraged in identifying and controlling hospitalinfections by encouraging them to attend infectiousdiseasecontroltrainingcourses.

Conflict of Interest:Theauthorshavenoconflictsofinteresttodeclare.

Funding: This dissertation was approved at theresearch deputy of Shahid Beheshti University ofMedicalSciencesinTehran.

Ethics Committee Approval : This researchprojectwasconductedwith theapprovalof theEthicsCommittee of ShahidBeheshtiUniversity ofMedicalSciences in Tehran, Iran.Other ethical issues in thisstudyincludedtheensureconfidentialityandinterviewinformation.

REFERENCES

1- Akbari, M., Nejad, Rahim R., Azimpour, A.,Bernousi, I., Ghahremanlu, H.(2013).A surveyofnosocomial infections in intensive careunitsinanImamRezahospitaltoprovideappropriatepreventive guides based on internationalstandards .Urmia Medical Journal, 6(23), 591-596.[Persian]

2- Mohammadnejad E, Abbaszadeh A, Soori H,AfhamiS.Preventionandcontrolofnosocomialinfections proceeding in intensive care units:Acontentanalysisstudy.ActaMedicaMediterranea,2016,32:1295.

3- Dasgupta S, Das S, Chawan NS, Hazra A.Nosocomialinfectionsintheintensivecareunit:incidence, risk factors, outcome and associatedpathogens in a public tertiary teaching hospitalofEastern India. Indian JCritCareMed2015;19(1):14-20

4- Abbaszadeh A, Mohamamdnejad E, Souri H,AfhamiS.Resourceallocation:themainproblemin infection control in intensive care units ofhospitals. Journal of Nursing and MidwiferyScienc2016;3(2):19-24.


5- Ducel G, Fabry J, Nicolle L. Prevention ofhospital acquired infections: a practical guide.2nded.Cambodia:DepartmentofCommunicableDisease,SurveillanceandResponse;2002.

6- Mohammadnejad E, Abbaszadeh A, Soori H,AfhamiS.Controlandpreventionofnosocomialinfection: A must for medical centers.Cardiovascular Nursing J. 2015; 4(1) :58-65(Persian).

7- Kalantarzadeh M, Mohammadnejad E, EhsaniSR,TamiziZ.Knowledgeandpracticeofnursesaboutthecontrolandpreventionofnosocomialinfectionsinemergencydepartments.ArchClinInfectDis2014;9(4):e18278.

8- Masoomi asl, H. ,Zahraiee S,M. ,Majidpoor,A. ,Nateghian ,AR. ,Afhami, SH. ,Rahbar,AR. ,et al. National guidline of nosocomialinfections survilance.2rd ed.Tehran: Center forcommunicable Disease Control, Ministry ofHealth,2007.[Persian]

9- Bagheri, P. (2014). The Review Systematicand Meta Analysis of Prevalence and Causesof Nosocomial Infection in Iran. Iran J MedMicrobiol,8(4);1-12..[Persian]

10- Abbaszadeh,A,. Ehsani, SR,. Begjani, J,. Kaji,MA,. Dopolani, FN,. Nejati,A,. et al. Nurses’perspectives on breaking bad news to patientsandtheirfamilies:aqualitativecontentanalysis.JMedEthicsHistMed2014.12;7:18.eCollection2014.

11- MohammadnejadE,NayeriND,HajiesmaeilpoorA.Liveexperienceofnursesaboutoccupationalexposures in emergency wards. World FamilyMedicine.2017;(10):170-175.

12- GraneheimUH,LundmanB.Qualitativecontentanalysisinnursingresearch:concepts,proceduresandmeasures to achieve trustworthiness.NurseEducToday2004;24(2):105-12

13- Mohammad Nejad E, Begjani J, Abotalebi G,SalariA,EhsaniSR.Nursesawarenessofpatientsrightsinateachinghospital.JournalofMedicalEthicsandHistoryofMedicine.2011;4:2.

14- Ehsani SR, Cheraghi MA, Nejati A, Salari A,EsmaeilpoorAH,NejadEM.Medication errorsofnurses in theemergencydepartment. Journalof Medical Ethics and History of Medicine.2013;6:11.

The Association between the Type of Drugs Substances Used and Severity of Head Injury Following Road Accidents

or Unexpected Events

Mohammad Davood Sharifi1, Amir Masoud Hashemian1, Elham Masoumzadeh1, Hamideh Feiz Disfani1, Roohie Farzaneh1, Omid Mehrpour2

1Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran, 2Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences,

Moallem Avenue, Birjand, Iran

ABSTRACT

Background: Thereisverylessknowledgeabouttheseverityofheadinjuryduetoconsumingpsychotropicdrugs and psychoactive substances. Hence, the present study aimed to assess the relation between theseverityofhead traumaand the typeofdrugsused includingopiates, cannabis,methamphetaminesandbenzodiazepines.

Method:Seventyfivepatientswithmoderatetosevereheadtraumawereincludedintothepresentcross-sectionalstudy.TheseverityofinjurieswasscaledbasedontheInjurySeverityScore(ISS)andGlasgowComascale(GCS).Urinesamplewasscreenedfordrugsandsubstancesusingtheimmunochromatographyassay.

Results:Withrespecttothetypeofdrugused,32.0%ofcaseshadnohistoryofdrugorsubstanceabuse,whereas45.3%usedoneofthesubstancesstudiesasbenzodiazepinesin8%,cannabisormarijuanain9.3%andopiatesin28%.Also,22.6%usedacombinationofthesedrugs.TheseverityofinjurybasedonGCSscorewasindependenttothetypeofdrugorsubstancesmisused(p=0.780).Similarly,nodifferencewasfoundinthemeanISSscoreasanotherscoreforassessingseverityofinjuryandtypeofdrugsused(p=0.208).Usingthemultivariablelinearregressionmodels,therewasnorelationshipbetweenthetypeofdrugusedandbraininjuryseverityinheadtraumapatientsadjustedforgender,age,andinjuredsite.

Conclusion:Abouttwo-thirdofpatientswithbraintraumaduetoroadaccidentsorunexpectedeventshadrecenthistoryofdrugsorsubstanceconsuming.Theseverityofbraininjurymaybeindependenttothetypedrugorsubstancemisused.

Keywords: Head injury, Trauma, Drug, Substance use

Corresponding author: Omid MehrpourMedicalToxicologyandDrugAbuseResearchCenter(MTDRC),BirjandUniversityofMedicalSciences(BUMS),MoallemAvenue,Birjand,9717853577Iran.E-mail:[email protected]&Fax:+98-5632381270Mobilephone:+989155598571

INTRODUCTION

Brainfunctionalstatuscanpotentiallyimpactedbyconsumingdrugsespeciallypsychologicalmedications

andnarcotics.Following theuseof theseagents,bothcognitive and psychomotor are adversely affectedleading disability to drive safety1. In fact, by usingthe psychotropic drugs, psychomotor skills such astimely reaction to risky situations, attentiveness andconcentration, appropriate coordination of hands andeyes in these conditions and totally suitable decisionon thebestperformancemaybe significantlyaltered2. This alteration may finally contribute to increase thelikelihoodofsevereaccidentsandheadtrauma.Alargerangeof substances anddrugshavebeen identified toimpairneuralskillsandreactionsthatrequiredforsafe

DOI Number: 10.5958/0973-9130.2018.00161.5


driving. For instance, the use of antidepressants orhypnoticdrugsmayreducevigilance,increasereactiontime in urgent situation such as speed control aswellas decrease the ability to timely decision making 3. Some psychological drugs can adversely exaggerateunpleasantbehavioraltraits4,5.

Besides, Benzodiazepines and substance use hasbeenalsorevealedasamaindeterminantforhighrateof trauma due to accidents. Some studies could showthatusingpsychoactivesubstancesparticularlycannabisandopiatesledtohighincidencerateofdriverskilledinroadaccidentsduetoheadandvitalorganstrauma6-8.

Despite the well-known fact that psychotropicdrugs and psychoactive substances can increase thelikelihoodofheadinjuriesduetoroadaccidents,thereisverylessknowledgeabouttheseverityofheadinjuryduetoconsumingtheseagents.Hence,thepresentstudyaimedtoassesstherelationbetweentheseverityofheadtrauma and the type of drugs used (opiates, cannabisand benzodiazepines) in injured subjects brought to areferraltraumacenterinIran.


All patientswithmoderate to severe head traumawho referred toHasheminejadhospital inTehran Iranduring 2014 were included into the present cross-sectionalstudy.Thepatientswithoutaconsciousdesireto takingurine sample to analyze the levelofpointeddrugsandsubstances,anuricpatientsorthoseinshockstatedidnotincludedintotheassessment.Thepatientswhounstable toprovidesampleor thosewithhepato-renalimpairmentwerealsoexcluded.Patients/guardianswere first approached immediately after arriving inthe emergency room and were explained about thestudy and were asked for consent to participate. Allpatientswere visited by the emergency physician andthe observed injuries were all recorded in the studychecklist.Then,laboratoryparametersandradiographyrequiredformanagingtraumapatientswereorderedandrequestedforallsubjectsandtheseverityofinjurieswasscaledbasedontheInjurySeverityScore(ISS).Urinesamplewasscreenedfordrugsandsubstances(opiates,cannabis and benzodiazepines) using rapid detectionkits based on the immunochromatography assay. Allurinepositivescreeningcaseswereconsideredas truepositive for drugs.All different stages of study wereconductedafterdueethical approval at theUniversity

of Medical Sciences and receiving written informedconsentfromthesubjects.

Continuous variables were compared using ttest orANOVA test orwithMann-WhitneyU test orKruskal-Wallis test whenever the data did not appeartohavenormaldistributionorwhentheassumptionofequal varianceswas violated across the study groups.Categoricalvariableswere,ontheotherhand,comparedusing chi-square test. For the statistical analysis, thestatistical software SPSS version 16.0 for windows(SPSSInc.,Chicago,IL)wasused.Pvaluesof0.05orlesswereconsideredstatisticallysignificant.

RESULTS

Totalof75patientswhosufferedaccidentaltraumawere assessed.Themeanageofpatientswas42.08±21.10 ranged 13 to 91 years and 92% of them weremale. Regarding reasons for trauma (Figure 1), themostcommoncauseoftraumaincludedcarcrashwithpedestrian (25.3%) followed by car crash withmotorrider (21.3%), and twomotorcycles accident (10.6%).Overall,headinjuryledtoEDHin12.0%,SDHin8.0%,ASHin13.3%,braincontusionin5.3%,skullfracturein10.7%,orbitalfracturein4.0%,andcombinedinjuriesinother28.0%.TheaverageofGCSscorewas11.45±2.59(ranged5to14)that18.7%hadaGCSscorelowerthan10.Inthisregard,mildunconsciousness(>13)wasfoundinnoneofthesubjects,whilemoderate(GCS:8to13)andsevere(GCS<8)unconsciousnesswasrevealedin73.3%and26.6%, respectively.With respect to thetype of drug used, 32.0% of cases had no history ofdrugorsubstanceabuse,whereas45.3%usedoneofthesubstancesstudiesasbenzodiazepinesin8%,cannabisormarijuanain9.3%andopiatesin28%.Also,22.6%usedacombinationofthesedrugs.Table1summarizesageandgenderdistributionofdrugsused.Therewasnodifferencebetweenmenandwomeninthetypeofdrugandsubstancesused(p=0.150).Also,nodifferencewasrevealedin thetypeofdrugorsubstancesusedacrossthedifferenceagesubgroups(p=0.902).Moreover,thetypeofinjurywasnotassociatedwiththetypeofdrugused(p=0.732).AsshowninTable2,themeanGCSscoredidnot significantlydifferbetween thedifferenttypesofsubstancesused.Inotherword,theseverityofinjurybasedonGCSscorewasindependenttothetypeofdrugorsubstancesmisused(p=0.780).Similarly,nodifferencewasfoundinthemeanISSscoreasanotherscoreforassessingseverityofinjuryandtypeofdrugs


used (p=0.208) (Table2).Using themultivariable linear regressionmodel (Table3), therewasno relationshipbetweenthetypeofdrugusedandGCSscoreonadmissioninheadtraumapatientsadjustedforgender,age,andinjuredsite.SimilarmodelalsoshowednoassociationbetweentheseverityofinjuryassessedbytheISSscoreandtypeofdrugused(Table4).

Table 1: Types of drugs and substances used according to gender, age, and type of injury

None Benzodiazepines Cannabis Opiate Combined

Gender

Male 20(29.0) 5(7.2) 21(30.4) 6(8.7) 17(24.6)

Female 4(66.7) 1(16.7) 0(0.0) 1(16.7) 0(0.0)

P-value 0.150

Agegroup

≤20y 5(45.5) 0(0.0) 3(27.3) 1(9.1) 2(18.2)

21–40y 11(35.5) 4(12.9) 8(25.8) 1(3.2) 7(22.6)

41–60y 4(23.5) 1(5.9) 5(29.4) 3(17.6) 4(23.5)

>60y 4(25.0) 1(6.2) 5(31.2) 2(12.5) 4(25.0)

P-value 0.902

Causeoftrauma

Car-car 0(0.0) 1(50.0) 0(0.0) 0(0.0) 1(50.0)

Caroverturning 2(40.0) 0(0.0) 2(40.0) 1(20.0) 0(0.0)

Car-motorrider 5(33.3) 2(13.3) 5(33.3) 0(0.0) 3(20.0)

Motorcycleoverturning 2(25.0) 0(0.0) 2(25.0) 1(12.5) 3(37.5)

Motor-motor 1(16.7) 0(0.0) 3(50.0) 1(16.7) 1(16.7)

Car-pedestrian 7(36.8) 1(5.3) 7(36.8) 1(5.3) 3(15.8)

Motor-pedestrian 0(0.0) 2(50.0) 0(0.0) 0(0.0) 2(50.0)

Directtrauma 1(20.0) 0(0.0) 0(0.0) 3(60.0) 1(20.0)

Fallfromalowheight 2(40.0) 0(0.0) 2(40.0) 0(0.0) 1(20.0)

Fallfromahighheight 1(33.3) 0(0.0) 0(0.0) 0(0.0) 2(66.7)

Falldown 3(100) 0(0.0) 0(0.0) 0(0.0) 0(0.0)

P-value 0.732

Table 2: Severity of injury based on the mean GCS and ISS scores according to the types of drugs and substances used

Type of drug used GCS score(mean ± SD)

ISS score(mean ± SD)

None 11.20±2.39 8.71±3.92

Benzodiazepines 10.50±2.88 14.00±10.88

Cannabis 11.67±3.03 10.19±4.80

Opiate 11.28±2.13 9.14 ± 2.91

Combined 11.94±2.46 8.47±5.33

P-value 0.780 0.208


Figure 1: Types of drugs and substances used

DISCUSSION

Inlinewiththerecentthesisontheadverseimpactofdrugsandsubstancesuseandincreasethelikelihoodofbraininjuriesduetoaccidentsandtrauma,ourstudycouldinterestinglydemonstratedthatabouttwo-thirdofthosewithbraintraumaduetocarormotoraccidentsorduetofallinghadrecenthistoryofdrugsorsubstanceconsuming. More interestingly, about one-fourth ofthemexpressedtouseacombinationofthesematerials

Table 3: Multivariable linear regression model to determine association between severity of injury based on GCS score adjusted for age, gender, and types of drugs and substances used

Unstandardized Coefficients Standardized Coefficients t P-value

Variable B Std. Error Beta

(Constant) 9.785 1.437 6.809 .000

Typeofdrugused .260 .206 .161 1.261 .212

Sex 1.734 1.100 .196 1.576 .120

Age -.013 .015 -.111 -.901 .371

Typeofheadinjury .000 .001 -.052 -.434 .666

Table 4: Multivariable linear regression model to determine association between severity of injury based on ISS score adjusted for age, gender, and types of drugs and substances used

Unstandardized Coefficients Standardized Coefficients t P-value

Variable B Std. Error Beta

(Constant) 10.936 3.061 3.573 .001

Typeofdrugused -.393 .440 -.116 -.894 .375

Sex -1.870 2.343 -.101 -.798 .428

Age .035 .031 .141 1.128 .263

Typeofheadinjury .000 .002 -.020 -.159 .874

including opiates, cannabis or methamphetaminesor benzodiazepines. In other words, in majority ofsubjects exposed to accidents or falling form heightbecauseofdrowsiness,lackofconcentration,delayingdecision making, and even psychosis. Unfortunately,the use of different types of substances especiallyopioids,narcotics,hashish,andmethamphetamineshasrisen dramatically among our young people 9-13.Also,consuming antidepressants and anti-stress drugs wasaberrantly increased. Thus, adverse outcome of usingthese substances and drugs as trauma to brain andvital organs due to accidental events are expectable.However the type of substance or drug used did notaffecttheseverityofinjuryassessedbythetwocommonseverityscoresincludingtheGCSandISSscores.InasimilarstudybyAndelicetal14in2010,about47%ofpatientswerepositive for substanceuseon admissiontohospitaldue tobrain injury.Overall, thenumberofpatients who have used substances while sustainingtraumaticbraininjuryisconsiderable,withanestimateof36-51%showingsomesubstanceuseonemergencyadmission to hospital 15,16. Besides, although the ratesfor using substances obtained in our surveywas near


to previous reports, the association between the typeand pattern of substance use and severity of braininjuryremainsparadoxical.Comparabletoourstudy,inAndelicetalstudy 14,althoughacutesubstanceuseattimeofinjurytendedtodecreasetheprobabilityofmoresevereintracranialinjury,theeffectwasnotstatisticallysignificantafteradjustingforage,gender,education.Intotal,theassociationbetweentheuseofillicitdrugsandseverityof injurymightbebiasedbyclinical routineson admission and the clinical definition of substanceusesoopiatesarethemostcommonsubstancesusedbyour subjects,while the cannabis is themost prevalentin most western countries. As shown by some otherstudies14,17,cannabiswasthemostfrequentlydetecteddrug.ItiswellknownthatcannabisandmarijuanaarethemostfrequentlyusedillegaldrugsintheEuropeanandAmerican populations respectively and thusmostaccidentsmayoccurfollowingtheuseofthesedrugs.

Another important point that may be evenconsidered as a potential limitation in various studiesis the use of GCS score as a single severity scoringsystem to assess level and severity of consciousness.The level of consciousness seems to be obscured inacutesettingsduetosubstanceuseatthetimeofinjury,medicalsedationorparalysis18.Inthisstudy,themeanGCS score did not differ significantly between thesubstance-positive and substance-negative groups ofpatients,agreeingwithresultsreportedbySperry19,20.Incontrast,itisnowrecommendedtoapplyacombinationofdifferentscoringsystems(asusedinourstudy)ortoapplyneuroimagingmodalitiessuchasbrainCT.Infact,stratifyingtheseverityofinjurybyusingacombinationof both subjective and imaging methods can lead toaccurately assess brain injury severity and thus canobtain valid relationship between types of substancesandseverityofbraininjury.

Inconclusion,abouttwo-thirdofthosereferredtoemergencydepartmentsdue tobrain traumafollowingaccidents or falling express recent history of drugs orsubstancesabuse.Regardlessofbaselinecharacteristicsincludingdemographics,theseverityofbraininjuryisindependenttothetypeofdrugsorsubstancesused.

Source of Funding:ItwassupportedbytheGrantofMashhadUniversityofmedicalsciences.

Conflict of Interest :Non

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Therapeutic Interventions in Premenstrual Syndrome

Karami Fatemeh1, Parand Abdolmajid2, Kalvandi Narges3, Bafahm Fatemeh4

1Master of Psychiatric Nursing, Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran, 2Instructor, Amir Al-Momenin Hospital, Ahvaz University of Medical Sciences, Ahvaz, Iran, 3Master of Community Health Nursing Student, Hamadan University of Medical Sciences, Hamadan, Iran,

4Instructor, Abadan School of Medical Sciences, Abadan, Iran

ABSTRACT

Premenstrualsyndromeisapsychological,neurological,gangliadisorderthatinterfereswithcommunicationanddisruptsthenaturalactivitiesofwomeninthecommunity.Thisstudyaimedtoinvestigatetheeffectof therapeutic interventionson reducing the symptomsofpremenstrual syndrome In thesepatients.Thesearchofelectronic informationwasdonebyusing thekeywordsofpremenstrualsyndrome,preventionofpremenstrualsyndrome.ThestudiedbasesincludedtheIranmedexdatabase,SID,Magiran,Pubmed,ElsevierandScopus.TheabovementioneddatabasewassearchedfromJanuary2017toMarch2018.52studieswereconductedtoevaluatetheeffectofinterventionsonreducingthesymptomsofpremenstrualsyndrome.Finally,interventionswerecategorizedintoeightfields.Theinterventionsweremostusefulinthefollowingareas,respectively:Nutrition,exerciseandstretchingleadtomuscleausterity,druginterventions,training, massage, acupuncture, cognitive-behavioral interventions, and interventions in managementstrategies.The results suggest that the use of newmethods and traditionalmedicine can greatly reducethe erosive symptoms of premenstrual syndrome, but the inaccessibility along with the costs of theseinterventions,themostimportantpillarinthelackofFollowupofthesetreatmentinterventionsinwomenwiththisdisease.Therefore,itissuggestedbytheresearchertopayattentiontotheeffectiveandlesscostlyinterventionalinterventionswitheaseofuseinhealthcenters.

Keywords: Premenstrual syndrome, prevention, Behavior.

Corresponding author: Fatemeh Bafahm, AbadanSchoolofMedicalSciences,Abadan,Iran

INTRODUCTION

Menstruation, likeotherphysiologicalphenomenain the body,may be disturbed1. It is one of themostcommon menstrual disorders of the premenstrualsyndrome.Pre-menstrual syndrome isamental illnesscharacterizedbyawiderangeofemotionalandphysicalchanges, andwith The performance ofwomen in thecommunityandfamilyisdirectlyrelated2.Sincewomenplayakeyroleinthefamily,theonsetofthissyndromecan have an important effect on the performance ofone’s familyand the family.Theclassicsymptomsofpremenstrual syndrome are often stress, irritability,anger, depression, feelings of self-control, Excessiveappetite for food, swelling and puffiness, breast pain

and headache3. The early prostatic syndrome wasdiscoveredbyFrankfirst in1931,buthisresultswerelargelyforgotten,andlatermorestudiesweredoneonthe subject later on because of the suicide or familylife impaired by women with this syndrome. Theresults show that only 10% of women do not sufferfrom premenstrual syndrome, while 50% of womenhavemild symptoms and30%have severe symptomsrequiring treatment. In tenmonths, the syndromealsocausesThe inabilityofwomenhasbeen5,6.Therefore,this syndrome is an important clinical situation thataffects the majority of women in the community7. Therefore, a broad study to examine therapeuticinterventionstoimprovethequalityofwomen’shealthin thisfieldseemstobenecessary8. Inrelationtopre-syndrome sincemenstruation, there is nounit therapythatisgloballyaccepted,andtherapeuticinterventionsareonlyusedtocontrolsymptomsofthesyndrome9.Thepurposeofthisstudywastosystematicallyreview

DOI Number: 10.5958/0973-9130.2018.00162.7


healthinterventionsandtoanalyzetheireffectivenessinhelpingwomendecidingtoadoptappropriatetreatmentsforreducingsymptomsofpremenstrualsyndrome.


This systematic review was aimed at identifyingandcollectingstudiesinwhichinterventionswereusedto reduce the symptoms of premenstrual syndrome.An electronic searchof databases using thekeywordsofpremenstrualsyndrome,preventionofpremenstrualsyndrome from January 2017 to March 2018.Thestudied sites consisted of the Iran Medex database,Scientific Information Base, Pub-med,.Magiran,Scopus. Inclusioncriteriawere:Empirical studies thatinterventionsarethemainframeworkforreducingthesymptoms of premenstrual syndrome in individualsand studies published between 2008 and 2018. Also,the criteria for the withdrawal of descriptive studiesand studies that were conducted on non-teachinginterventions.Accordingtothecriteriaforentryandthestudy,thepaperswerestudiedandarticlesthatdidnothavetherequiredqualitywereexcludedfromthestudyaccording to the purpose of the study. An overviewofthedetailsofthestudiesstudiedisprovided.Allofthequestionsrelatedtothecorrectuseoftheextractedarticlesand the standards related topublicationof theworkwereobserved.

FINDINGS

Having searched the databases and abandoneda largenumberofarticleson thebasisof the titleandabstract,215articles(88articlesfromPersiansourcesand 127 articles from non-English sources) wereinvestigated.Of these,92articlesweredeleteddue tothe lack of educational intervention. The study wasconducted in which 71 of the interventions based onreducingthesymptomsofPMSwerenotconsideredasthemaininterventioninthisstudy.Atotalof52articleswereincludedinthisreviewstudy.Finally,interventionswerecarriedout ineightareas. Interventionswere themost commonly used interventions in the followingareas:Nutrition,exercise,andstretchingleadtomusclerelaxation, drug interventions, training, massage,acupuncture, cognitive-behavioral interventions, andinteractions inmanagement strategies. A summary ofthestudieshasbeendone.

DISCUSSION

Twenty-fourmaininterventionstudieswerebasedon nutritional behaviors that included more of thesestudies.Researchersfromthestudyconsideredtheuseof traditional medicine, herbal medicines and dietarysupplementstobethebestwaytorelievethesymptomsof premenstrual syndrome. 12The studyof the effectofmedicinal herbs such asGhorbakhsh,Grasshopper,Fingerprint, Sevilla, Valeriana, Saffron, Razineh,GolgarizadeandRedRootwasstudiedinreducingthesymptoms of premenstrual syndrome. Twelve studieshave also tested the effect of dietary supplements onrelievingsymptomsofpremenstrualsyndromeinatestcase, including the effects of carbohydrate foods, twostudiesoncalcium-richfoods,threestudiesofvitaminB6 foods, a study of ingredients containing VitaminDexamined fourand fourstudiesof foodscontainingsteroids,especiallyomega-3,inreducingthesymptomsofpremenstrualsyndrome10-33.Astudyofinterventionsintensileandathleticstretchingwasconsideredbytheresearchers.Thestudyfoundexercisessuchasaerobicsandwalking, comparedwith other uncomplicated andcompletely safe treatments, andbelieved that exercisestretchingandMusclerelaxation,suchasyoga,canbeused as a non-specific analgesic to control symptomsof premenstrual syndrome 34-43. 6 studies of varioushypothesesabout thecauseofpremenstrual syndromeandthetherapeuticinterventionstrategiesusedtocopewith it. The effect of the relief of these drugs on thecontrol of symptoms of premenstrual syndrome wasconfirmed49-44.Fivestudieswereconductedinthefieldofeducationalintervention.Educationalmaterialsincludethedefinitionofpremenstrualsyndrome,itsstages,waysofhavingahealthylifestylesuchasreducingsmokingandtobaccocontrol,waystocontrolstress,andenoughsleep50-54.Theresultsofthedataanalysisshowedthattotal massage can be very effective in reducing thesymptomsofpremenstrualsyndrome,butprofessionalmassage can affect the effect of this intervention 55-58.An acupuncture studywas conducted as a primaryintervention to reduce the symptoms of premenstrualsyndrome in women with this syndrome betweenseven and ten days beforemenstruation.The samplesparticipated in several acupuncture sessions, and self-reportedpaindatatheresultsshowedthatacupuncturewas able to reduce the symptoms of this syndromeafterafewsessions59.Twostudieswereconductedoncognitive-behavioral interventions and management


strategies.Thesesessionsincludedacombinationofthementionedmethodsandpsychologicalcounseling.

CONCLUSION

The results of these studies indicate that allinterventionstoreduceerosivesymptomsAndanxietyrelated to premenstrual syndrome But interventionssuch as yoga, acupuncture, herbalmedicine, complexstretching and exercise, drug therapy, psychologicalinterventions,andreflexologyexercisesarecommonlyused and supervised by a caregiver in the field ofintervention, which involves the availability of cost-free servicesAs a result, it is amajor obstacle to theuseofhealthservices,whileinterventionssuchasself-care education and psychological counseling, whichareoftenmorecosteffectiveandeffectiveinwomen’saccess to self-care, are lesswelcomed by researchers.Therefore, interventionssuchasself-careeducation inwomenwith this syndromeand theeaseofuseof theaboveinterventionsinhealthcentersRecommendedbytheresearcher.

Ethical Clearance:This research project wasapprovedbytheethicscommitteeofAbadanUniversityofMedicalSciences.

Source of Funding:Abadan,UniversityofMedicalSciences.


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Comparison of Parental Satisfaction with Posttonsillectomy Pain Management with Two Methods of Acupressure and

Pharmacological Analgesics in Children: A Clinical Trial Study

Somaye Pouy1, Bahram Naderi Nabi2, Yasaman Yaghobi3

1Master of Nursing Student- School of Nursing and Midwifery, 2Associate Professor-Anesthesiology Department, 3Assistant Professor-School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

ABSTRACT

Background: Tonsillectomyisoneofusualsurgeriesinchildrenpopulationworldwide.Oneofthecommoncomplicationafterthissurgeryispainandcontrolofitisveryimperative.Therearemanypaincontrolwaysuchaspharmacologictreatmentsandcomplementarytreatment.Oneofacceptablepaincontrolinchildrenisacupressure.

Objective: Thepresentstudyaimtosurveythecomparisoneffectofacupressurewithanalgesicdrugsonthepainandparentalsatisfactionaftertonsillectomyinchildrenaged5to12yearsold.

Method: Inthisstudy144childrenaged5-12yearsoldwereallocatedintooneofthreegroupsofcontrol,interventionsandplacebo.Intheinterventiongroup,childrenreceiveacupressureplusanalgesictreatmentasroutineandintheplacebogroup,childrenreceiveshamacupressureplusanalgesictreatment.Inthecontrolgroup justanalgesic treatmentprovided.Theacupressurewasperformedat three sessionafteroperation.Beforeandaftereachsessionamountofpainandparentsatisfactionwasmeasured.DatagatheredwereanalyzedbySPSS16softwarewithdescriptiveandnon-parametricinferentialstatisticaltests.

Results: Theresultofstudyshowthattheamountofpainreductionandparentsatisfactionwasastatisticallysignificantatthreesessionafteroperationinacupressuregroup(P=0.002).Furthermore,itwasfoundthatamountofpaininthecontrolgroupandtheplacebogroupdidnotstatisticallysignificant(respectively:P=0.546,P=0.332).

Conclusion: The results indicated that acupressure technique is very useful on pain reduction aftertonsillectomy and use of acupressure along with pharmacological drugs, will decrease the amount ofanalgesicrequirementinchildrenandwillimproveparentalsatisfactionwithpaincontroloftheirchildrenafteroperation.

Keywords: Acupressure, Postoperative pain, Tonsillectomy, Complementary medicine.

Correspondence:Yasaman YaghobiAssistantProfessor-SchoolofNursingandMidwifery,GuilanUniversityofMedicalSciences,Rasht,Iran.BSc,MSc,PhD([email protected])

INTRODUCTION

Maintaining a child’s health is very important (1-3). Adenotonsillectomy is a very usualoperation inchildrenwordwide(4,5).HospitalbeddingcausesStress

for the child(6, 7).Tonsillectomy is the most commonindication for surgery in pediatric population age 1to15years (8-12).Pain isthemost important sideeffectofsurgery in children. Severe pain result in prolongmorbidity, abstinence eating foods and liquid andcan cause dehydration and many complications (9-13). There are a lot of studies have been doneabout posttonsillectomypainmanagementinpediatric.Painreliefmethods in children include pharmaceutical and non-pharmaceuticalmethods.Although pain control drugs

DOI Number: 10.5958/0973-9130.2018.00163.9


areeffective,theyhavemanysideeffectssuchasnauseaandvomiting,dehydration,suppressionoftherespiratorysystem after the use of opiates, and in rare cases ofdeath.(13-15). In regardwith this side effects, researchersuggest to use of non-pharmacological methods withpharmacological methods such as acupressure thathavea littlesideeffects (14,16-19).Acupressuredoesnotuse special devices and it is done by hand alone (20).Acupressureisasubsetofacupuncture.Inacupressure,pressureonacupuncturepointsleadstostimulationoftheenergychannelsinthebodythatrelievespainthroughincreasedcirculationandrelaxationofthenervesofthebody. Today we know that applying pressure on theacupointscancasetoreducepainbyincreasethelevelofendorphins,serotonin,encephalin(21).Acupressureisapurposefulmassageofacupointsthatareusedinmildtomoderatepain(22).Acupressureisnotinvasiveandismore acceptable inpediatricgroupincomparisonwithacupuncture(23).Acupressureisveryinexpensiveandhasnosideeffectsanddoesnotrequirespecialfacilities(21).Variousstudieshaveshownthatacupressureisoneofthetasksofnursesandnursescaneasilyusethismethodtocontrolchildren’spainalongwithdrugtherapy.(23).Inregardtostudies,tonsillectomyisacommonsurgeryintheword(13,24-27),andtherearealittleresearchontheuseofacupressurefortonsillectomypainrelief(15),Providingnursingassistanceisveryimportant(28,29).Nursesarethemostimportantprovidersofservicestochildren(30).and Pain plays an important role in the health of theindividual(31,32)Thisstudyconducted.Wehypnotizedthatacupressurehavepositiveeffectonpostoperativepainreductioninpediatricaged5to12yearsoldadmittedtohospitalandcanimproveparentalsatisfactionforpainrelief.


This study has a randomized clinical trial design.Inthisstudy,144childrenaged12to5yearsoldwhowere candidates for tonsillectomy,were assigned withrandomallocationinthreegroups:control,acupressureandplacebo,andineachgroupwas48.Inclusioncriteriawas children aged between5 to 12who candidate fortonsillectomy.Exclusioncriteriawas:mentaldisorders,skininjury near acupressure area and severe pain thatprohibited the child from participating in research.Surgical indications were: tonsillar hypertrophy withsleepdisturbancebreathingand.Theobjectivesofstudywere described to the parents.To start the sampling,children who had inclusion criteria were randomly

allocated into intervention, control or placebo groups.Sampling period was from November 2016 to April2017. Intervention with acupressurewas done threesession after tonsillectomy in the form of one hour,2-4 hours and 8-6 hours after the surgery. In the thisgroup, the child pain was measured and recorded,then acupressure on acupoints of LI-4(Hego), ST-44(Neiting) and ST-36 (Zusanli) was done on thehands and legs(figure 1-3). In acupressure group, thedeep massage was done. The period of interventionof each areawas twominutes, so theoverall pressureperiod for six acupoints was 12minutes. At the end,thelevelofchildpainwasmeasured.Inplacebogroup,pressurewasappliedtotheidenticalacupointswiththisdifferencethatthepressurewasnotdeep.Inthecontrolgroupjustroutinecarewasdelivered.Thepainlevelinchildrenwasrecordedbeforeandafterthethreesessionsof intervention.Thepediatricpainwasmeasuredwithpain scale of Oucher.Inaddition, parents were requestto say a score, on a five-pointscale (1= not satisfied,5 = good satisfied),their general satisfaction with thepostoperative analgesictreatment. The instrumentusedinthisstudywasaquestionnairefordemographicinformation and record of pain and analgesicconsumptionand Ocher pain scale.The personalinformation questionnaire in the first part contains 3questions about demographic characteristics includingage, sex and weight, and the second part consists of6 parts for recording the child pain score before andafterthefirststageofacupressure,thesecondstageofacupressure,andthethirdstageacupressure.Thethirdpartwasusedtorecordtheanalgesicconsumptionandparentalsatisfaction.Oucherpaininstrumentisatoolformeasureintensityofpaininchildrenaged5to12yearsold. This instrument is used in a lot of study aroundtheworld and is valid and reliable. (33-35).Present studywasregisteredintheIranianRegistryofClinicalTrials(IRCTID:IRCT2017100836651N1)andwasapprovedbytheEthicsCommitteeofGuilanUniversityofMedicalSciences (Ethical Code: IR.GUMS.REC.1396.229).Aftergatheringdata,theinformationwereanalyzedbydescriptive statistical methods (median, and standarddeviation) and inferential statistics (Kruskal Wallis,Wilcoxon). The significance level of the tests wasconsideredwithP<0.05.

RESULTS

ThedemographicdataofthesamplespresentedinTable1.Theresultsofthisstudyshowedthatacupressure


groupshowedlesspaincomparedtoplaceboandcontrolgroupinallthreeinterventionstages.Parentalsatisfactionintheacupressuregroupwasmorethanothertwogroup.Therewasastatisticallysignificantrelationshipbetweenpainreductioninacupressuregroupincomparisontocontrolandplacebogroup(Table2and3).

Table 1. The Demographic Characteristics of the Children undergoing tonsillectomy

Variable CategoryControl Acupressure Sham Acupressure Total

P-ValueNumber Percent Number Percent Number Percent Number Percent

GenderFemale 20 41.7 22 45.8 20 41.7 62 43.1 0.89

Male 28 58.3 26 54.2 28 58.3 82 56.9

Age(year)8>age 25 52.1 27 56.2 19 39.6 71 49.3 0.23

8<age 23 47.9 21 43.8 29 60.4 73 50.7

AgeMean(year) 7.67 7.75 8.27 7.89 0.35

WeightMean(Kg) 28.25 30.36 29.06 29.22 0.58

Table 2-Pain score changes before and after three session intervention

GroupOne hour after surgery 4-2 hour after surgery 6-8 hour after surgery P-Value

M±SD M±SD M±SD

Control 1.25±4.43 0.62±2.44 0.62±2.44 P=0.546

Acupressure 6.04±6.76 5.62±8.22 10±4.61 P=0.002

Placebo 1.25±3.92 -0.04±6.78 1.04±3.71 P=0.332

Table 3-The amount of analgesic medication consumption and parental satisfaction about pain reduction in three groups

P- valueControlPlaceboAcupressure

VariableM± SDM± SDM± SD

0.051.1±1.61.6±1.21±1.2IntravenousAcetaminophen(Totalnumberofadministereddoses)

0.180.8±1.11.3±1.10.9±0.7OralAcetaminophen(Totalnumberofadministereddoses)

0.0013.8±0.63.9±1.24.8±0.7ParentalSatisfactionwithpostoperativeanalgesictreatment


Figure1. Li 4 acupoint

Figure2. St 44 acupoint

Figure3. St 36 acupoint

DISCUSSION

Tonsillectomyisoneofthemostsurgeriesaroundtheworldinchildrenpopulation,andtheuseofdrugsforpost-surgerypaincontrolcancasemanycomplications.Thestudiesshowthatmanyparentaredissatisfiedwithdrug therapyafter surgery.This study is anovel studythatwasdonepertain toeffectofacupressureonpainafter tonsillectomyinchildrenaged5 to12yearsold.Sofar,studies in theareaofpainreliefafterpediatric

tonsillectomyhavefocusedontheuseofacupunctureinchildren.Basedontheresultsofthesestudies, theuseofacupuncturehasledtoareductioninpainscoreaftertonsillectomyinchildrenandthesatisfactionofparentsbutontheotherhand,theuseofneedlesinacupunctureleads to fear and panic, especially in young children.This restricts the widespread use of acupuncture inchildren (36-39). Therefore, the use of other traditionalmedicinemethods inchildrensuchasacupressurecanbemoreeffective.

Acupressureisapurposefulmassageofacupuncturepoints that are used in mild to moderate pains. Theresults of this study showed that there is a significantstatisticaldifferencebetweentheaverageofchangesinthepainscorebeforeandafter the interventionduringtimeintervalsofonehour,2-4hoursand6-8hoursafterthetonsillectomyintheacupressuregroup(P=0/002)but there is no significant difference in control groupandplacebogroup(respectively:P=0.546,P=0.332).

As a result, acupressure onST-36,Li-4 andST-44acupointshashadapositiveimpactonpainreliefinchildren.Withregardtotheprobabilityoftheexistenceofthepsychologicaleffectofacupressureonpain,theplacebogroupwasusedinthisstudy.Shamacupressureintheplacebogroupdidnotaffectpainreduction(P=0.332),thereforeitisconcludedthatthepositiveeffectsofacupressureonpainreliefwasrealandnotsuggestive.

The subjectivity of pain variable was the mostimportant limitations of this study. In this studySelf-reportpainOucherinstrumentwasusedtomeasurepainthatyoungchildrenmaynothavebeenabletoaccuratelyexpresstheiramountofpainandtherewasapossibilityof error. Also in this study, researchers investigatedtheanalgesiceffectofacupressureup to8hoursaftersurgery,anditslong-termeffectsonpainandalsoafterdischargeofthechildhavenotbeeninvestigated.

CONCLUSION

This study proposes acupressure as a non-pharmacological treatment for the pain control aftertonsillectomy inchildrenaged5 to12yearsold.Thisis a clear perspective on the use of alternative andcomplementary medicine especially acupressure toreduce pain by nurses who cares for these children.Thistechniqueevencanbeeasilyimplementedbytheparentsofchildren.Therefore,inthefuture,consideringtheeffectivenessofacupressure,suggestedthatnurses


participateinretrainingandtrainingprogramsaswellasreinforcementandbuildingthenecessaryskillsinorderto use acupressure for reducing children’s pain aftertonsillectomy.

Conflict of Interest: Thereisnoconflictofinterestbetweenauthors.

Source of Funding:This article is a researchpaper from a dissertation approved by the Faculty ofNursingandMidwiferyofRashtandGuilanUniversityof Medical Sciences at No. 9605072 and approvedin Guilan University of Medical Sciences EthicsCommittee(EthicalCode:IR.GUMS.REC.1396.229).

Acknowledgement: The researchers are thereforegrateful to all the officials of the Faculty of Nursingand Midwifery of Rasht and the Deputy Director ofResearch and Technology at Guilan University ofMedicalSciences.

Ethical Clearance: Informedconsent, Nocost tothepatient.

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The Effect of Time Management Training on the Performance of Head Nurses Working in Educational Hospitals Affiliated to

Jondishapur University of Medical Sciences, Ahvaz

Neda Ghannad1, Nasrin Elahi2, Abdolali Shariati3, Amal Saki Malehi4

1Master Student of Internal Nursing Surgery, Ahvaz Jundishapur University of Medical Sciences, 2Assistance Professor, Nursing Care Research Center in Chronic Diseases, Nursing & Midwifery Faculty, Department of

Nursing of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, 3Master of Nursing, Faculty of Nursing and Midwifery, Ahwaz Jundishapur University of Medical Sciences, Ahvaz, 4Ph.D. Student of Statistic, Faculty of

Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz

ABSTRACT

Managersandprofessionalsinthefieldofhealthareworkinginanenvironmentwithalotofworkloadthatrequireseffectiveleadershipandmanagementskills.ThepurposeofthisstudywastodeterminetheeffectoftimemanagementtrainingontheperformanceofheadnursesworkinginteachinghospitalsinAhwaz.Thisstudy isanexperimentalstudyofclinical trial type.110headnursesworking in teachinghospitalsin2017wereselectedbycensusmethodbasedoninclusioncriteriaandweredividedintotwogroupsof55testandcontrolgroups.Forthetestgroup,a two-dayworkshopwasconductedontimemanagementtraining.DatawereanalyzedbySPSSversion23.0.Mostofthewomen’sstudyunits(96.4%)withtheagerangeof49-40years(70.9%)hadbachelordegree(96.4%),married(58.2%),withworkexperienceof11-15years(43.6%)andnursingworkexperiencefrom6to10years(43.6%).Therewasnosignificantdifferencebetween the two groups in determining the goals, organization and performance before and after theintervention(P>0.05).Theobserveddifferencewassignificantfortwoskillsofmechanicalandtimecontrolinthetestgroupbeforeandaftertraining(P<0.05).Thefindingsoftheresearchshowedthatpromotingtheperformanceandempowermentoftimemanagementbehaviorsthroughtrainingandimprovingtheskillsoftimemanagementmechanicsandcontrolovereffectivetime.Suggestedthatbypromotingawarenessofnursesaboutmanagingtheirtimethroughacademicplanningandin-servicetrainingperiods,theprinciplesofscientificmanagementandperformanceamongthemwillbepromoted.

Keywords: head nurses, time management, performance.

INTRODUCTION

The pace of progress in science and technologyindicatestheimportanceandvalueoftimeasapreciousresource1.Timeisthemostvaluableresourceavailable

Corresponding author: Nasrin Elahi, AssistanceProfessor,NursingCareResearchCenterinChronicDiseases,Nursing&MidwiferyFaculty,DepartmentofNursinofAhvazJundishapurUniversityofMedicalSciences,Ahvaz,Iran.email:[email protected],PhN:+986133738071Postcode:61357-15794

to humans, because other sources are valuable onthe condition of the existence of time2.As in today’srapidly changing environment and widespread globalcompetition, there is a continuous and growingawareness of the concept of time management, andtime management has become a key indicator oforganizationalcompetencesuccess3. Timemanagementis the effective use of time that is achieved throughcertain targeted activities4. The management of timeor,infact,theeffectiveuseofindividualsfromtimetotime,inthetodayworld,requiresthedevelopmentandpromotionof human activities to achieve their goals5. Sincetheworkenvironmentofmanagersandemployeesin the field of health, especially teaching hospitals, is

DOI Number: 10.5958/0973-9130.2018.00164.0


accompaniedwithalotofworkloadandlargenumberofpatients,itisessentialtoimplementeffectiveleadershipandmanagementskillssuchastimemanagementskillinsuchenvironments6.Thisskillhasabroadconceptinawiderangeofexecutiveandmanagerialrelationshipsthat is closely related to the improvement of thequality of performance and its application can reduceor eliminatemany of the daily pressures ofmanagers7-8.Accordingtothementionedissues,consideringthatoneoftheimportanttasksofnursesismanagementandthemainpartofmanagementisknowledgeofnursingmanagementactivities9.Putzstatesthatcareplanningisagoodexampleofhowtoapplytimemanagement10. Nematistudyshowstheimportanceandthenecessityofplanningandarranging time inhealthcareworkers toreducestressbyemployingtimemanagementskills11. Hence,healthworkerswithawiderangeofnursescanbenefitfromtimemanagementbytakingadvantageofreducedfatigue,stress,andincreasedqualityofnursingcare 12. Terry’s study showed that there is a positiverelationshipbetweentimemanagement,self-regulationandself-efficacy13. Unfortunately,despitethefactthattheuseofthesetimemanagementskillsisanimportantcomponentofnursingmanagers’professionalpractice,it has not been considered 14. The correct recognitionandontimeoffactorsthatwastetimeisveryimportant.Meanwhile, managers must organize their activitiesbased on all factors that affect performance15. Dueto the relationship between time management andperformanceenhancement,performancecansimplybeconsideredasrecordingtherateofascertainedresults.Kanebelievesthatperformanceiswhatapersoncreatesbyhisendeavoranditisaspartofagoal16.Zoghietal.concludedthat theneedfor timemanagement trainingcourses isessential to improveperformance 17.Mccanbelieves that time management training programscan be used to reinforce three types of target settingand prioritization, time management mechanics, andorganization,18thatthegoalsofthisresearcharebasedonthesefactors.Thepositiveresultoftimemanagementtraining is the results ofVan Eerde’s research, whichshows that the use of timemanagement training is inreducing worry and procrastination in work 19. The aim of this studywas to determine the effect of timemanagementtrainingontheperformanceofheadnursesworkingin teachinghospitalsaffiliated toJondishapurUniversityofMedicalSciencesinAhwaz,2017.

This research is an experimental study of clinical

trial which was conducted after obtaining permissionfrom the deputy of the research affairs of medicaluniversityandofficialsofteachinghospitalsaffiliatedtoJondishapourUniversity ofAhwaz.Sampling consistsof131headnursesworkingineducationalhospitalsofImamKhomeini,Razi,Golestan,Sina,Shafa,TaleghaniandAbuzar.Theinclusioncriteriaincludedemploymentin Hospital as head nurse with at least 1 year ofexperience in this position, having undergraduate orhigher education, absence from the timemanagementworkshopinthelastyear,andwillingnessandsatisfactionto participate in the research. 110 head nurses wereselectedandafterobtainingwrittenconsent,theywererandomlydividedintotwogroupsof55testandcontrolgroupstoparticipateintheresearch.Forbothgroups,aself-reportquestionnaireoftimemanagementskillsbyhead nurses and a head-nurse performance evaluationchecklist by the researcher were done indirectly atthreedifferent times inorder toreducetheprobabilityof error before and one month after the intervention.In this study, training how to use time managementforthetestgroupfromtheworkshopclasseswasheldin two sessions for 8 hours for two consecutivedays. Discussions of the first session based on the first andsecondobjectivesoftheresearch,whichcomprisegoalsand prioritization and time management mechanicsincluding:Analysisofthestatusquo,Factorsaffectingtimewasting,PrioritizationoftasksandExaminationofdifferences Individual topics and topics of the secondsession are based on the third and fourth objectivesof the research, which control time and organization,including: admission styles, empowerment andmanagementofthesessions.Inordertomotivatethemto attend the workshop, one of the requirements tohave a degree in clinical governance is to spend timemanagement. The control group did not receive anytraining.Followingthecompletionoftheintervention,the ethicalguidelinesweregiven to the controlgroupofthetrainingpackage.Thecurrentquestionnairewasdesigned by McCann and used by Hashemizadeh inIran.Thecorrelationcoefficientbetween the two testswas 0.8120. The headliners performance evaluationchecklistconsistsof63questionsin7dimensions.ThisformwasapprovedbytheMinistryofHealthandwasapproved by the relevantministry and communicatedtoallhospitals.Inbothinstruments,theLikertgradingscalehasbeenusedandtherequestedresearchunitsareone of the columns of always(4 points),most often(3points),rarely(2points)andnever(1point),andthesign


makeadifference.DatawereanalyzedbySPSSversion23.0 and Chi-square, Mann-Whitney, covarianceanalysis,TtestandWilcoxonstatisticaltests.

FINDINGS

The results showed that most female studyunits(96.4%)withbachelordegree(96.4%)withmaritalstatus(58.2%) with a work experience of 11-15 yearsYear(43.6%) and nursing work experience were 6-10years old(43.6%) in general(78.2%). Most of thesubjects(81.8%)didnotstudytimemanagementbooks.(54.5%) did not attend management training courses,and management training courses(80%) were withouttime management content. Demographic variablesbased on chi-square test(P=0.716), sex(P=0.647),marital status(P=0.856), education(P=1), sectiontype(P=0.82), total records Nursing work(P=0.725),totalheadwork record(P=0.432), all threedimensions

oftimemanagementstudybooks(P=482),participationin management training courses(P=0.702) and withthe content ofmanagement of time(P=0.815)was notstatistically significant between the two groups andtheywereidentical.Byadjustingtheinitialsignificantdifferencebeforeintervention,therewasnosignificantdifference based on the results of covariance analysisfor post intervention(P=0.267). Also, there was nosignificantdifferenceinthefieldoforganizationfortheexperimental and control groups before interventionbasedontheresultsoftheMann-Whitneytest(P=0.535).There was a significant difference between the twogroupsafterintervention(P=0.333)(Table1).Accordingto the results of t-test for the test group(P=0.06) andcontrol group (P=0.206), there was no statisticallysignificantdifferenceintragroupsinbothgroups(Table2).Butinthetwoareasoftimemanagementmechanicsand time control before intervention for both groups,based on the results of Wilcoxon test, there was nosignificantdifferencebetween the twogroups(P=0.29)and(P=0.641), but after intervention, there was a

significantdifference(P=0.009)and(P=0.047),respectively(Table3).Comparisonofresearchfindingsintheareasofgoalsettingandorganizationandperformanceofheadnursesbeforeandafterinterventioninbothgroupsdidnotchange(P>0.05).

Table 1. Comparison of mean and standard deviation in two areas of goal setting and prioritizing and organizing before and after intervention

Setting goals and prioritizing

Group

Time

Test ControlP-value

SD±Mean SD ±Mean

Before intervention 26.3091±1.46 26.8545±1.47 0.331

After intervention 28.2182±1.43 28.1091±1.54 0.267

OrganizingBefore intervention 28.2182±1.61 28.0545±1.73 0.535


Table 2. Comparison of mean and standard deviation of head nurses’ performance before and after intervention

Group

Time

Test ControlP-value

SD±Mean SD±Mean


After intervention 183.1818±13.63 179.8727±15.170.232

P-value 0.06 0.206


Table 3. Comparison of mean and standard deviation in two areas of time management mechanics and control over time before and after intervention

Group

Time

Test ControlP-value

Time management mechanics

SD±Mean SD±Mean



Control on timeBefore intervention 21.6364±2.05 21.4364±1.88 0.641


DISCUSSION

Findings of the research showed that timemanagement training through promotion andempowermentoftimemanagementmechanicsandtimecontrol has improved the skills of time managementandperformance inheadnurses.The lackofeffectoftrainingonskilldevelopmentgoalsandprioritizationinthisstudycanberecognizeduetothisfact,theabove-mentioned skills were often taught during nursingeducationandnursingcourseswithspecialemphasisonthenursingprocessandasanintegralpartofthenursingskills 21. The results of various studies on the use ofnurses from a limited time period can be mentioned,includingKhodam andKollagari (2009), showed thatthe application rate in the area of setting goals andprioritizingbeforetrainingwas83.9%andaftertrainingincreasedto91.8%,whichindicatesthelackofeffectoftimemanagementtraininginthisareabeforeandafterintervention21. Bahadori et al. study showed that thehighestaverageofapplicationtimemanagementskillswasrelatedtogoalsettingandprioritizationwith1.79points22.TheresultsofstudiesconductedbyHafezieetal.(2008)andSteineretal.(2003)alsoshowthatnursesuse several time management strategies, but settingtheirgoalsandtheirmainprioritiesarethemain23-24.IntheconductedstudybyOrpen, therewasa significantdifferencebetween theuseof skilldevelopmentgoalsand prioritization of timemanagement in the traininggroup compared to the control group, which did notadheredtotheresultsofthisstudy25.Amanagerinsucha situationandstresscausedby that situationwillnotfacewithwastingoftime20.So,itseemsquitelogicalthat for a head nurse in one part always everythingare in theirplace,orderedandorganizedso thatworkcanbedoneon time.Therefore, the ineffectivenessofeducational intervention in the field of organization

seems quite logical. Hashemizadeh’s study (2006)showedthatheadnursesintheleveloforganizationandorder are in a good level of 90%,which is consistentwith the present study 20.The limitation in the abovestudy, ie, thestudyonlybeforeandafter,andthelackofconsiderationoftheinterventionandcontrolgroup,couldbethereasonforthedifferenceinresultswiththepresentstudy.ThestudyofZiapouretal.(2015)suggeststhatnursesarewell-organizedintheorganizationwithameanof4.2426.Inordertoachievetheperformanceofheadnurseswithregardtothelackofchangeinthetwostagesbeforeandaftertheinterventioninthetwogroups, it should be noted that in the present study,performance measurement was performed one monthaftertheintervention.Otherstudies,suchasBoost,didnotshowasignificantdifferenceintheperformanceofmedical studentsafter completinga timemanagementtraining program, and the results of the interventionwere immediately evaluated after education, whichisinlinewiththeresultsofthisstudy27.ThestudyofEl-Shaer(2015)indicatesasignificantimprovementinheadnurses’performance3monthsaftertheinterventionfromameanscoreof85.25to93.5.Thereasonforthedifferencesinthefindingsoftheabovestudieswiththepresentstudycanbeduetothedifferencebetweentheinterventionperiodandtheperformanceevaluation.

CONCLUSION

The findings of this study indicate the promotionof performance and the empowerment of timemanagement behaviors by training and improving theskills of timemanagementmechanics and controllingtime.Therefore,itissuggestedthatknowledgeofnursesaboutmanaging their time throughacademicplanningand in-service training will promote the principles ofscientificmanagementandperformanceamongthem.


Acknowledgment: This article is part of theMaster’s thesis work. Authors require stating theirgratitudeandthankstothecooperationoftheuniversity’sresearchingdeputy andheadnursesworking inhealthcentersaffiliatedtoJundishapurUniversityofMedicalSciencesinAhvaz.


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Analysis of Hard Dental Tissues and Bone Exposed to Concentrated Acids: An Observational Study

Vidya Kadashetti1, K.M. Shivakumar2, Rajendra Baad3, Nupura Vibhute1, Uzma Belgaumi1, Sushma Bommanavar1, Wasim Kamate1

1Oral Pathology & Microbiology, Forensic Odontology, 2Professor & Head, Public Health Dentistry, 3Professor & HOD, Oral Pathology & Microbiology, Forensic Odontology, School of Dental Sciences, Krishna

Institute of Medical Sciences Deemed to be University

ABSTRACT

Daybyday thenatureof crime is changedbyusing fire andacid attackor chemical attackas expertof witness for identification as forensic scientist is difficult because different nature of attack in theprocessof identificationofpersons.Teetharealsogoodreservoirsoffor identificationof individualsbymorphological aswell as identification extractionmitochondrialDNA.The present studywas aimed toassess themorphological changes and duration of dissolution of teeth and bone immersed in differentformsofconcentratedacids.MaterialsandMethods:differentgradesofhydrochloricacid,nitricacid,andsulphuricacidwereusedfortoothandbone. Results: Hydrochloricacidandafterthisnitricacidhasmoredestructivecapacitycomparedtosulphuricacid.Conclusion:Sulphuricacid,nitricacidandhydrochloricacidcriminalmayusedtodestroythepersonsidentificationstilltheindividualscanidentifiedbyusingteethbecauseitisstrongeststructureofhumanbodyandcanpreservesomestructuresevenafterexposingtotheconcentratedacids.

Keywords: Acid-immersed teeth, forensic odontology, forensic sciences, sulphuric acid, nitric acid, hydrochloric acid.

INTRODUCTION

Forensic odontology was defined as “that branchof forensic medicine which in the interest of justicedeals with the proper handling and examination ofdental evidence and with the proper evaluation andpresentation of the dental findings.” Forensic sciencereferstoareasofundertakethatcanbeusedinajudicialsetting and accepted by the court and the generalscientificcommitteetoseparatetruthfromuntruth.[1]

Now days’ criminals are using acids to destroybodies in order to avoid any personal identification.

Destroying the human body partially or totally byimmersing it in an acid and if so, howmuch time isnecessary for its complete destruction the forensicscientistneedstoknowwhetheritispossible.Anotherimportant question is whether any measures ofidentifying the affected individual from the residualremains.[2]Very fewstudies thathaveactuallypointedon the chemical means of human body destructionandtheissueofpositiveidentificationofpersonsafteraciddissolution.ThereisabriefmentionintheItalianjournalArchivio di Medicina Legale ofanexperimentalanimal destruction in an acidic environment.[3] The identificationofdentalhardtissuesremainisofprimeimportancewhenthedeceasedpersonis,decomposed,burned,ordismembered.[4,5]Sincethenaturalteetharethemostdurableandstrongestofall tissues, theycanretain their identityevenafterotherskeletalstructureshavebeendestroyedbyphysical agentsandalsowithchemicalmeans.Further, it is nowpossible to extractDNAfromtoothevendecadesafterdeath.Itispossible

Corresponding author:Dr. Vidya KadashettiOralPathology&Microbiology,ForensicOdontologySchoolofDentalSciences,KIMSDUKarad-415110,Satara,Maharashtra,India.Phone:91-8055234191E-mail:[email protected]

DOI Number: 10.5958/0973-9130.2018.00165.2


toemploytheseidentificationtechniquesuntiltherehasbeencompletedestructionoftheteeth.[6,7]

Theaimofthisstudywasfindouttheandcomparethe approximate time taken for total destruction of atoothandboneafterimmersionindifferentconcentratedacids.Theobjectivewastoobservethemorphologicalchanges in natural human teeth and bone when theywerekeptimmersedindifferentacids.

METHODOLOGY

A total 60 specimens containing 30 single rootedteethand30of1x1cmbonespecimensareusedforthestudy.Allteethwerenon-cariousandhadbeenextractedbecause of periodontal reasons. Bone specimenfrom radius bone specimens from the archives of theDepartmentofGeneralPathology.Acidswereusedinthisstudyare25mlofAqueoussolutionofhydrochloricacid (HCl), 25ml of Aqueous solution of nitric acid(HNO3)and25mlofAqueoussolutionofsulfuricacid(H2SO4).25mleachforteethandbonespecimens.10Samplesofteethandbonewereimmersedin25mlofeachacidsolutionandobserved.

All specimens were immersed separately indifferentcontainerscontainingthethreedifferentacids.Atvariousintervalsthesamplesweretakenoutofthecontainer and observed any morphological changesand noted changes and time of interval, they werethen photographed and placed back in the containers.The specimens were under observation until theyhad completely dissolved or completely precipitated.Morphologicalchangeswereobservedinthefollowingpoints;Effervescence,colouralterations, transparency,disintegration, complete dissolution and precipitation.Each specimen’s morphology based on macroscopicwasnotedateverytimeintervals.

RESULTS

Table 1 and Figure 1 and 2:Foratoothandboneplaced in 37% HCl effervescence, colour change,Transparency and disintegration were observed atvariousintervals.

Table 2 and Figure 3 and 4:Toothandboneplacedin 65% HNO3 yellowish discoloration, Transparencyanddisintegrationwereobservedatvariousintervals.

Table 3 and Figure 5 and 6: In 96% H2SO4 Effervescence,discolouration,whiteprecipitationwith

fragmentationandcompletedissolutionobserved.

DISCUSSION

Acidsareknowntobeusedinlaboratoryproceduresandinsomecasescriminalsareusedtoerasethepersonalidentification. In such a case,Human dentition servesviable evidence in this scenario. Dental professionalshave a major role to play in keeping accurate dentalrecordsandprovidingallnecessaryinformationsothatlegalauthoritiesmayrecognizemalpractice,negligence,fraudorabuse,andidentityofunknownindividuals.[8] Thepresentpaperissummarizehowteetharestrongenough to help in identifying the individuals even inacidicconditions.Theaimofpresentstudywastofindout and compare the approximate time taken for totaldestruction of a hard tissues (teeth and bone) afterimmersion in an acids andobserve themorphologicalchanges in natural human teeth and bone when theywerekeptimmersedinanacids.

Inthepresentstudyshowsthetotaldestructionoftoothin37%HCLwas14-16hour,for65%HNO3 was13-14hoursandfor95%H2SO4wasalmost120hoursforcompletedissolution.Similarlyforbonespecimens37%HCLwas8hour,for65%HNO3 was8hoursandfor95%H2SO4was9-10hours.Theseresultsshowthattooth is stronger than bone it canwithstand for somehours even complete immersion of tooth specimennot only acid spill or splashing attack. These resultconcordance with the study conducted by Jadhav, et al.[9] The use of dentition in forensic approach foridentification of individuals and gender determinationinthisstudytheevidencethatthenaturalteetharethemoredurablethanthebone.Theycansurviveevenafterotherskeletalstructuresofbodyhavebeendestroyedbyphysicalagents.Morphologicalchangesanddurationoftooth andbonewithdifferent concentrated acidshavebeensummarisedinTable1,2and3.

Thus,differentdestructivecapacitiesofthedifferentacidsintoothandboneareclearanddifferenceswereobservedinthepresentstudy.Theinformationderivedinthisstudyonthechangeinthemorphologyofteethand bone immersion in acid solution after particularperiods[Table1,2and3]canbeutilizedforrecognitionof theacidusedandtoinfer theapproximatedurationof immersionintheacid.Morphologicalchangesmayvary when the uses of different acids and differentconcentrationareused indifferent tissues;however, it


mustbenotedthattheconcentratedacidsthatwehaveusedarecommonlyavailablecommercially.Someotherfactorshavealsotobeconsidered.Minimumof80–100littersofacidisrequiredforcompletedissolutionofabody. [6]Criminals are always think in their choicebyeasilyavailabilityoftheacid,cost,andeffect.Theywillbemore likely to use an acid that is easily available,cheap,andwiththeabilitytodestroythebodyrapidly.Tooth isbeinghardestandchemically themost stableanddurabletissueinthebody,inforensicinvestigativeteeth can be an importantmedium in both living andnonliving populations. Teeth are also good reservoirsofbothcellularandmitochondrialDNA;however,thequalityandquantityofDNAobtainedvariesaccordingtotheenvironmentthetoothhasbeensubjectedto.[10,11]. Thus,basedontheseobservationalresults,weconcludethat commonly used acids like HCL, HNO3 andH2SO4 thatwouldbemost likelyused insuchcrimes.Morphological Recognizable appearances of teethretainedfor8hinHCI,10hinHNO3,andupto85hinH2SO4.Among the these threeacids,dissolutionofteethwasfasterinconcentratedhydrochloricacidthanthenitricacidandfollowedbyinsulfuricacid.SimilarfindingswerefoundinstudiesconductedbyMazzaet al. [6] and Jadhav,et al.[9]Theduration fordissolutionisdifferent in these studiesas theacidswithdifferentconcentrations. Changes in theMorphology of teethcanhelp the forensic identification todeduce the acidusedandthetimetakensinceplungeofthebodyintheaciduntilitcanbegivesupportwithotherbiochemicalinvestigations. From the observation of the presentstudy it is concluded that hard tissues like teeth andbone will not react in the same way with differentacid environment. Soluble salts of calcium chlorideandcalciumnitrateareformedfromtoothwhenplacedin theHClandHNO3 respectively,dissolving themintoto. Insoluble calcium sulfate salt failing to dissolvecompletely forming an insoluble precipitate whentoothplacedinconc.H2SO4.

[6,9]Hence,teethcanserveas important evidencewhen a person is affectedwithhighly concentrated acids aiming at destruction ofpersonsidentification.

By the this observation a positive diagnosis canbemadewitha tooth,whenavictim’sbodyis treatedwithH2SO4 (80-100hours).Comparativelyifbodiesareplungeintheconc.HClandconcandHNO3(within8-10hours).Suchkindofsituationswhereitisimpossibletoidentify the dental structures, other investigations canbeconsidered, suchas:DNAanalysis (mitochondrial)oftheresidues.

Analysis of DNA has brought about a revolutioninthefieldofforensicidentification,includingforensicodontology, anthropology, and archaeology, hasmadeidentificationeasierandmoreaccurate.[12]

Furtherstudiesshouldbeconductedfortheeffectsof acids surrounding structures of the tooth, restoredtoothandprostheticapplianceshavenotbeenassessed.Realistically,thepresentstudydoesnottakeintoaccounttheinfluencesofallpossiblefactorsthatmaybepresentinreallifeconditions.Forexample,rootportionoftoothis surroundedby the soft andhard tissuesmakes therootpartmoreresistanttoacidinsults.

CONCLUSION

HydrochloricacidisthemostcommonlyusedacidItcanbeused todestroy thehumanbodycompletely.Thecrimesof thisnature, changes in themorphologyof toothcanhelptheforensicscientiststodeducethetimeelapsedsinceplungeof thebody in theacid.Bykeepinginmindthelikelychoicesofthecriminalandby observing the changesmorphology in the tooth, itmay be possible to deducewhich acid has been usedto destroy the body and helpful in identification ofindividuals.However,thefinaldecisioncanbemadeonwhichacidhasbeenusedonthebasesofbiochemicaltests.

From this studywe observed that sulphuric acid,nitricacidandhydrochloricacidcriminalmayusedtodestroythepersonsidentificationstilltheindividualscanidentifybyusingteethbecauseitisstrongeststructureofhumanbodyandcanpreservesomestructuresevenafterexposingtotheconcentratedacids.Furtherstudiescan be performed such as to assess if DNA from thetoothpulpcanbeextractedinsuchteethspecimens.


RESULTS

Table 1: Sequential morphological changes along with Duration, in teeth and bone after the immersion of specimens in 37% HCL acid

Morphological changes Tooth Bone

Effervescenceseen 10 min 10/10teeth100%

5 min8/10bonespecimens(80%)

Yellow-colouredresiduedeposited Nocolourchanges

1 h notverysignificantcolourchangesinbone2/10bonespecimens(20%)

Transparency

2.5 h 4/10teeth(40%) Notseeninbone

4 hAllteethshowntransparency Notseeninbone

Disintegration

6 h Disintegrationfromperipherysurfaces10/10teeth(100%)

3 h DisintegrationStartedfromperiphery10/10bonespecimens(100%)

8 h DisintegrationExtendedtomiddlethird8/10(80%)

5 hExtendedtocentreofbone

10 h Extensionofdisintegration

Dissolution

12 h 6/10(60%)teethwereseendissolving

8 -10 hCompletedissolutionofbone

14-16 h Nearcompletedissolution8/10(80%)

18-20h Completedissolution10/10(100%)

Table 2: Sequential morphological changes along with Duration, in teeth and bone after the immersion of specimens in 65% HNO3 acid


Effervescenceseen Immediately 10/10teeth100%

Immediately min8/10bonespecimens(80%)

yellow-colouredresiduedeposited

15minYellowdiscolourationseen10/10teeth(100%)

5 min Yellowdiscolourationseen10/10bonespecimens(100%)

Transparency

1-2 h 4/10teeth(40%) Notseeninbone

By the end of 4 hAllteethshowntransparency


Disintegration

5 h Disintegrationstarted10/10teeth(100%)

3 h DisintegrationStartedfromperiphery10/10bonespecimens(100%)

7-8 h DisintegrationExtendedtomiddlethird8/10(80%)

5 hExtendedtocentreofbone

By 10 hBreakageoftooth Nobreakageinbone

Dissolution

12 h 6/10(60%)teethwereseendissolving

6 hSoft

13-14 h Nearcompletedissolution8/10(80%)

8 hCompletedissolutionofbone

16 h Completedissolution10/10(100%)

Table 3: Sequential morphological changes along with Duration, in teeth and bone after the immersion of specimens in 95% H2SO4 acid


Effervescenceseen Immediately 10/10teeth100%

Immediately min8/10bonespecimens(80%)

Colourchanges

15minbrowndiscolourationseen10/10teeth(100%)AfterthecolourchangeNochangesseentill4h

5 min browndiscolourationseen10/10bonespecimens(100%)AfterthecolourchangeNochangesseentill3h

Transparency Notseenteeth Notseeninbone

Whiteprecipitatewithfragmentation

Whiteprecipitationstaredat5hours12 hTeethin4/20(20%).Toothwasabletorecognize

20h--Whiteprecipitatewasincreasedin10/20teeth(50%),withsplinterThetoothwasRecognizeablein20/20teeth(100%)

30h-Increasedwhiteprecipitatewasin16/20teeth(80%),withsplinterin14/20teeth(70%).Thetoothwasstillrecognizeablein10/10cases(50%)

60h–Increasedwhiteprecipitatewasin16/20teeth(80%),withsplinterseenin16/20teeth(80%).Toothwasrecognizeablein6/20cases(30%)130h-Completeprecipitatein16/20teeth(80%)Stillsomebrokentoothfragmentswereintact

Whiteprecipitationstaredat4hours8hbonein20/20(100%).Bonewasnotablerecognize

14 hbonein20/20(100%).Bonewasnotablerecognize

Cont... Table 2: Sequential morphological changes along with Duration, in teeth and bone after the immersion of specimens in 65% HNO3 acid


Tooth With HCL

Figure. 1 Complete dissolution of tooth in HCL at 18 hours Bone With HCL

Figure. 2 Disintegration of bone in HCL at 4 hours Tooth With HNO3

Figure.3 Yellow Discolouration of tooth in HNO3 at 15 min

Bone With HNO3

Figure. 4 Yellow Discolouration of bone in HNO3 at within 5 minTooth With H2SO4

Figure 5. White precipitation and Fragmentation of tooth in H2SO4 at 20 hoursBone With H2SO4

Figure. 6 White precipitation and Fragmentation of bone in H2SO4 at 8 hours


Ethical Clearance-TakenfromInstitutionalethicscommittee

Source of Funding- Self.


REFERENCES

1. O’Shangnessy PE. Introduction to forensicscience.DentClinNorthAm.2001;45:217–27.

2. RajM,BoazK, SrikantN.Are teeth evidence inacid environment. J ForensicDent Sci 2013;5(1):7-10.

3. Danesino P, Alonzo M, Carlesi G. Experimentalevaluation of the biological samples dissolutionperformed by three different acids: preliminaryresults.ArchiviodiMedicinaLegale1998;1:23-6.

4. Avon SL. Forensic Odontology: The roles andresponsibilities of the dentist. J Can DentAssoc2004;70:453-8.

5. ZappaJ,Cieslik-BielrckaA,AdwentM,CieslikT,Sabat D. Comparison of different decalcificationmethods to hard teeth tissues morphologicalanalysis.DentMedProbl2005:42:21-6.

6. MazzaA,MeralatiG,SavioC,FassinaG,MenaghiniP,DanesinoP.Observationofdentalstructurewhenplacedincontactwithacids:anexperimentalstudy.JForensicSci2005;50:406-10.

7. GintherC,Issel-TarverL,KingMC.Identificationof DNA from human extracted teeth. NatureGenetics1992;2:135-8

8. Rothwell BR. Principles of dental identification.DentClinNorthAm2001;45:253-69.

9. JadhavK,GuptaN,MujibBR,AmberkarVS.Effectofacidsontheteethanditsrelevanceinpostmortemidentification.JForensicDentSci.2009;1:93–8.

10. Sowmya, K., Sudheendra, U., Khan, S., Nagpal,N.,&Prathamesh,S.AssessmentofmorphologicalchangesandDNAquantification:Aninvitrostudyonacid-immersedteeth.JournalofForensicDentalSciences,2013;5(1),42–46.

11. Linjen I, Willems G. DNA research inforensic dentistry. Methods Find Exp ClinPharmacol.2001;23:1–7.

12. PreseckiA,BrkicH,PrimoracD,DrmicI.Methodsof preparing the tooth for DNA isolation. ActaStomatolCroat2000;34:21-4.

Stability Enhancement Using Region based Certification Mechanism in Manet

P B Edwin Prabhakar1, K Thirunadana Sikamani2

1Research Scholar, 2Professor & Head, Department of Computer Science and Engineering, St. Peter’s College of Engineering and Technology, Chennai

ABSTRACT

Clustering in mobile ad-hoc networks (MANETs) is one of the effective ways to organize a networkaccording to thenetwork topological changes. In thispaper,wepropose aStabilityEnhancementusingRegionbasedcertificationMechanisminMANETtoimprovescalabilityandstabilityofoverallnetwork.Forproperuseofresourcesandtoreduceextraenergyconsumption,analgorithmisalsoproposedtohandletheisolatednodes.Ad-hocon-demanddistancevectorwillbeaddressedbyusingcryptographytechniqueforsecuringroutediscoveryanddatatransmission.SimulationresultsusingNS2depicttheimprovementofpacketdeliveryrateandnetworkthroughput.

Keywords: mobile ad-hoc networks, Stability Enhancement, route discovery, energy consumption, Simulation results.

INTRODUCTION

MANEThasasignificantpotentialinmultiplefieldswithnumerousapplications.Itisrapidlyimprovingandevolving for the practical implementation in severalcivilianandmilitary real time scenarios.MANEThasapotentialtoactasabackupnetworktofacilitateusersincaseoffailureofothernetworksinanydisaster.Thefeature of data transmission at multiple hops throughnodeswithlargecoverageareamakesitanidealchoicetobeusedinnaturaldisasterandemergencysituations.Furthermore, MANETs consists of mobile nodescapable of creating a network topologywith dynamicenvironment.

In MANETs, main challenges for clusteringalgorithmsareoptimalCHselection,networktopologymanagementandimprovementofnetworkperformanceinthepresenceofmobilityalongwithminimizationofenergyconsumptionateverynode.SelectioncriteriaofaCHareuniqueineverycategoryofclusteringscheme.Thedecision regarding theselectionofCHamongallmembernodestakesplaceonthebasisofweightvalueofanode.Aweightvalueofeachnodeiscalculatedbasedonthecombinedvalueofnodedegree,nodeenergyandrelative speedofanode.StabilityEnhancementusingRegion based Certification Mechanism (SERCM) isproposedinthispaper.

The rest of this paper is proposed as follows: therelatedworksisfollowedinthenextsection.StabilityEnhancement using Region based CertificationMechanism is explained in the third section, followedby performance analysis and comparative evaluation.Finally,theconclusioniswritteninthelastsection.

RELATED WORKS

Cognitive radio (CR) is viewed as a promisinginnovation for giving a high ghastly effectiveness toportable clients by utilizing heterogeneous remotesystemstructuresanddynamic rangeget tostrategies.Rangeadministrationcapacitieswith self-organizationhighlights can be utilized to address these difficultiesand understand this new systemworldview.Basics ofCR, including range detecting, range administration,range portability and range sharing, have beenreviewed,with their idealmodels of self-organizationbeingunderlined[1].SmartandBalancedClusteringforMANETs (SALSA) presents another group adjustinginstrument and a best clustering metric, expecting togivealessenedsupportoverhead.SALSAwasassessedand contrasted and theNovelStable andLow-upkeepClustering Scheme (NSLOC), highlighting topologieswithupto1000hubsandspeedsof20metersforeachsecond[2].

DOI Number: 10.5958/0973-9130.2018.00166.4


Enhanced maximum stability weighted clusteringalgorithm(EMSWCA)wasbasedontheWCAandtheMSWCAalgorithm.TheEMSWCAexplicitlyidentifiesthemaximum load parameters of clusters, acceleratestheconvergencespeed,andprovideacertaindegreeofQualityofService(QoS)[3].Bio-inspiredself-organizingLow-Complexity Clustering (B-LCC) algorithm doesnot require sensor locations, time synchronization orany prior knowledge of the network. It is completelydistributed and can achieve a well-distributed clusterheads.The processing time complexity of theB-LCCalgorithmisO(1)percluster,whichoutperformsmostof the existing clustering algorithms as they haveprocessing time complexity of O(n) per node in theworstcase[4].Additionally,theB-LCCalgorithmhasastableperformanceintopologycontrolandtheformedtopologyisrobusttonodefailure.

The main contributions include providingprinciplesandoptimizationapproachesofvariantbio-inspired algorithms, surveying and comparing criticalSON issues from the perspective of physical-layer,MediaAccessControl(MAC)-layerandnetwork-layeroperations, anddiscussingadvantages, drawbacks andfurther design challenges of variant algorithms, andthenidentifyingtheirnewdirectionsandapplications[5]. Mobility prediction-based clustering (MPBC) schemefor ad hoc networks with high mobility nodes wasdeveloped, where a node may change the associatedclusterhead (CH) several timesduring the lifetimeofitsconnection.Theproposedclusteringschemeincludesan initial clustering stage and a cluster maintainingstage.TheDoppler shifts associatedwith periodicallyexchangedHellopacketsbetweenneighbouringnodesare used to estimate their relative speeds, and theestimationresultsareutilizedasthebasicinformationinMPBC.Intheinitialclusteringstage,thenodeshavingthe smallest relativemobility in their neighbourhoodsareselectedastheCHs.Intheclustermaintainingstage,mobilitypredictionstrategiesare introduced tohandlethevariousproblemscausedbynodemovements,suchas possible association losses to currentCHs andCHrolechanges,forextendingtheconnectionlifetimeandprovidingmorestableclusters[6].

Three different clustering methods are applied toclassify the RSSI and Link Quality Indicator (LQI)data recorded from the unknown wireless topologyintoa certainnumberofgroups inorder todeterminethe number of active sensor nodes in the unknown

wireless topology [7].AnUnobservable secure routingscheme offers complete unlinkability and contentunobservabilityforalltypesofpackets.ThisprotocolisefficientasitusesacombinationofgroupsignatureandIDbasedencryptionforroutediscovery[8].

CBMD takes into consideration the parameters:connectivity (C), residual battery power (B), averagemobility(M),anddistance(D)ofthenodestochooselocally optimal cluster heads [9]. The goals of thisalgorithm are maintaining stable clustering structurewithalowestnumberofclustersformed,tominimisetheoverheadfortheclusteringformationandmaintenanceand to maximise the lifespan of mobile nodes in thesystem.InDecentralizeddistributedSpaceTimeBlockCoding (Dis-STBC) system, the knowledge about theChannelStateInformation(CSI)isnotavailableatthetransmitter[10].

Stability Enhancement using Region basedCertificationMechanism

Inthispaper,StabilityEnhancementusingRegionbasedCertificationMechanismisproposedinMANETs.TheproposedmechanismusesRouteRequest(RREQ),Route Reply (RREP) and Route Error (RRER)messages.Anoveltechniqueisproposedwhichsecuresnotonlytheroutediscoverybutalsothetransmissionofdatausingcryptographictechnique.

Figure 1 Unicasting RREP message

Figure1showstheunicastingRREPmessage.Thenovelideasareasdescribedasfollows:TheCertificationAuthority (CA)will be utilized to ask for destinationpublickeybyjustsourcenode.Theideaofasymmetriccryptographywillbeutilizedforthesaferoutediscoveryandexchangeofsessionkey.SymmetriccryptographictechniquessuchasAdvanceEncryptionStandard(AES)areusedfordataencryption.


SERCMhassource(S),destination(D),intermediatenode (I), Source IP address ( )IPS , Destination IPaddress ( )IPD ,publickeyof ( ),BXx K

privatekeyof( ),AXx K where x denotes the source or destination,

encryptionkey ( )kE ,decryptionkey ( )kD andsessionkey ( )sK .

It is expected that the source hub has effectivelygotten the destination public key ( ),BDK from CA.The originating node or source node creates a RouteRequest (RREQ), and appends its public key ( )BsK decryptedbydestinationpublickey ( )BDK fromCAandisdescribedinequation1.

(1)

Onreceptionofthepacket,the intermediate node checks the IP address of thedestinationinRREQbycheckingthisIPaddressinitsrouting table. The RREQ+E (K )

BDk BS packet willbe forwarded with increasing hop count and one inRREQ if this node is not a destination.Typically, theRREQ+E (K )

BDk BS packet will be forwarded bythe intermediate nodes until it reaches the destinationwithoutdecryptingthesourcepublickeyE (K )

BDk BS .

The destination node gets the source public key( )BsK after checking its IP address in RREQ byutilizingitsprivatekey ( ),ADK todecrypt E (K )

BDk BSandisgiveninequation2.

D (E (K ))AD BDk k BS

(2)

A session key ( )sK andRREP are generated bydestinationnode anddestinationnodeuses the sourcepublickey ( )BSK toencryptthesessionkey ( )sK anddestinationIPaddress ( )IPD asshowninequation3.

K ( +D )BS s IPk

(3)

For authentication, the destination node thenencrypts K ( +D )BS s IPk with itsprivatekey ( )ADKasinequation4.

E (K ( +D ))ADk BS s IPk

(4)

TheRREPattachedisunicastedtowardsthesourcenode along the route by the destination node as inequation5.

RREQ+E (K ( +D ))ADk BS s IPk

(5)

Theoriginatingnodeor sourcenode receives twopackets from its neighbours.The source node obtainsthesourceanddestinationIPaddressfromRREP.Thesourcenodeconfirmstheauthenticityofdestinationnodebyusingthedestinationpublickey ( )BDK todecryptdestinationprivatekey ( )ADK asgiveninequation6.

KD (E (E ( +D )))BD AD BSk k s IPk (6)

Thesourcenodedecrypts KE ( +D ))BS s IPk from

equation6byusing thesourceprivatekey ( )ASK forsession key ( )sK and destination IP address ( )IPD asshowninequation7.

KD (E ( +D ))AS BSk s IPk

(7)

ThesourcenodewillverifywhetherthedestinationIP address are from RREP packet and its encryptedattachment KE (E ( +D ))

AD BSk s IPk are equal with

high destination sequence number ( )SEQD and Lowhop count. Otherwise, the other received packet willbediscardedbysourcenode.Thesourcenodeusesthesession key ( )sK generated by destination node forsecuredata transmissionbetween thesourcenodeanddestinationnodeinthecommunicationnetwork.

PERFORMANCE EVALUATION

TheperformanceoftheproposedschemeisanalyzedbyusingtheNetworkSimulator(NS2).TheNS2isanopensourceprogramminglanguagewritteninC++andOTCL (Object Oriented Tool Command Language).NS2 is a discrete event time driven simulator whichis used to model the network protocols mainly. Thenodes are distributed in the simulation environment.TheparametersusedforthesimulationoftheproposedschemearetabulatedinTable1.

Table 1 Simulation Parameters of SERCM

Parameter ValueNumberofnodes 50Routingscheme SERCMandMPBCTrafficmodel ConstantBitRateSimulationArea 900×900m2

Channel WirelessChannelTransmissionrange 250mCommunicationProtocol UDPAntenna OmniAntenna

RREQ+E (K )BDk BS

RREQ+E (K )BDk BS


The simulation of the proposed scheme has 50nodes deployed in the simulation area 900×900. Thenodesarecommunicatedwitheachotherbyusing thecommunicationprotocolUserDatagramProtocol(UDP).ThetrafficishandledusingthetrafficmodelConstantBit Rate (CBR). The radio waves are propagated byusing the propagationmodel two ray ground.All thenodes receive the signal from all direction by usingtheOmnidirectionalantenna.Theperformanceof theproposedschemeisevaluatedbytheparameterspacketdeliveryrate,packetlossrate,averagedelay,throughputandresidualenergy.

Packet Delivery Rate

The Packet Delivery Rate (PDR) is the rate ofthenumberofpacketsdeliveredtoallreceivers to thenumber of data packets sent by the source node.ThePDRiscalculatedbyequation8.

0

0

n

n

Packets ReceivedPDR

Packets Sent=∑

∑

(8)

FromFigure2,thePDRoftheproposedschemeisincreasedcomparedtotheexistingschemeMPBC.ThisisbecauseoftheQoSimprovedduringtheestimationoftheconnectiondensityandresidualenergyparametersintherouteselectionprocessof themethodproposed.ThegreatervalueofPDRmeansthebetterperformanceofthenetworkprotocol.

Figure 2 Packet delivery Rate

PacketLossRate

PLR isdefinedas thedifferencebetween thesentpackets and received packets in the network per unittimeasinequation9.

Figure 3 Packet Loss rate

0

n Number of Packets droppedPLRNumber of Packets Sent

= ∑ (9)

Figure3showsthePLRofMPBCisgreaterwhencompared to that of SERCM. The number of nodesis increased when the number of packets dropped isincreased.

Average Delay

Theaveragedelayisdefinedasthetimedifferencebetween the current packets received and the currentpacketsent.Itismeasuredbyequation10.

(10)

Figure 4 Average Delay

Figure4showsthattheaveragedelayislowbyfortheproposedschemeSERCMthantheexistingMPBC.

The minimum value of delay means producesthe higher value of the throughput in the network.Thisgraph justifies the fact that thehindrances in thecommunication are lesser among the nodes in thenetwork,whichshowsasignificantaveragedelay.

( )0

1 nAverage Delay Pkt Recvd Time Pkt Sent Timen

= −∑

020000400006000080000

100000120000140000160000180000200000

0 10 20 30 40 50 60 70 80 90 100

No o

f pac

kets

del

iver

ed

Simulation Time (s)

SERCM

MPBC

0

500

1000

1500

2000

2500

3000

3500

0 10 20 30 40 50 60 70 80 90 100

No o

f pac

kets

dro

pped

Simulation Time (s)

SERCM

MPBC

02468

101214161820

0 10 20 30 40 50 60 70 80 90 100

Aver

age

Dela

y (m

s)

Simulation Time (s)

SERCM

MPBC


Throughput

Throughput is defined as the data that can betransferredfromsourcetothereceiverinagivenamountoftime.Throughputisobtainedusingequation11.

(11)

Figure 5 Throughput

It is observed from figure 5 that the number ofpackets received successfully for SERCM is greatercomparedtothatoftheMPBC.

Residual Energy

Theamountof energy remaining in anodeat thecurrentinstanceoftimeiscalledasresidualenergy.Ameasureoftheresidualenergygivestherateatwhichenergyisconsumedbythenetworkoperations.

Figure 6 shows that the residual energy of thenetwork is better for the proposed scheme SERCMwhencomparedwiththeexistingschemeMPBC.

Figure 6 Residual Energy

CONCLUSION

Stability Enhancement using Region basedcertificationMechanisminMANETisproposedinthispaper to improve scalability and stability of overall

network.Acertificatemechanismisproposedtohandlethe isolated nodes for proper use of resources and toreduce extra energy consumption. Image result forAODVwww.slideshare.net

Ad-hoc On-Demand Distance Vector (AODV)will be addressed by using cryptography techniquefor securing route discovery and data transmission.Simulation results usingNS2 depict the improvementofpacketdelivery rate andnetwork throughput in thecommunicationnetwork.

Ethical Clearance- St.Peter’s InstituteofHigherEducationandResearch,Chennai


Conflict of Interest - Nil

REFERENCES

[1] Xu,X.,Xiaomeng,C.,&Zhongshan,Z. (2014).Self-organization approaches for optimization incognitiveradionetworks.ChinaCommunications,11(4),121-129.

[2] Conceição, L., & Curado, M. (2011, July).Smart and balanced clustering for MANETs. InInternational Conference on Ad-Hoc Networksand Wireless (pp. 234-247). Springer, Berlin,Heidelberg.

[3] Tao,Y.,Wang, J.,Wang,Y.L.,&Sun,T. (2008,October). An enhanced maximum stabilityweightedclusteringalgorithminadhocnetwork.In Wireless Communications, Networking andMobile Computing, 2008. WiCOM’08. 4thInternationalConferenceon(pp.1-4).IEEE.

[4] Zhang, Q., Jacobsen, R. H.,&Toftegaard, T. S.(2012, December). Bio-inspired low-complexityclustering in large-scale dense wireless sensornetworks.InGlobalCommunicationsConference(GLOBECOM),2012IEEE(pp.658-663).IEEE.

[5] Zhang, Z., Long, K., Wang, J., & Dressler, F.(2014). On swarm intelligence inspired self-organized networking: its bionic mechanisms,designingprinciplesandoptimizationapproaches.IEEECommunicationsSurveys&Tutorials,16(1),513-537.

[6] Ni,M.,Zhong,Z.,&Zhao,D.(2011).MPBC:Amobility prediction-based clustering scheme foradhocnetworks.IEEETransactionsonVehicular

0

Ren Number of Packets ceivedThroughputTime Taken

= ∑

02000000400000060000008000000

100000001200000014000000160000001800000020000000

0 10 20 30 40 50 60 70 80 90 100

Thro

ughp

ut (b

ps)

Simulation Time (s)

SERCM

MPBC

8

8.5

9

9.5

10

10.5

0 10 20 30 40 50 60 70 80 90 100

Resid

ual E

nerg

y (J)

Simulation Time (s)

SERCM

MPBC


Technology,60(9),4549-4559.

[7] Wang,Y.,Guardiola,I.G.,&Wu,X.(2014).RSSIand LQI data clustering techniques to determinethenumberofnodesinwirelesssensornetworks.International Journal of distributed sensornetworks,10(5),380526.

[8] Pravin,R.A&Mageswari,U.PreservingPrivacyUsing anUnobservable SecureRouting ProtocolforMANETs,InternationalJournalofMCSquareScientificResearchVol.5,No.1Nov2013.

[9] Hussein, A., Yousef, S., Al-Khayatt, S., &Arabeyyat,O.S. (2010,November).Anefficientweighted distributed clustering algorithm formobileadhocnetworks.InComputerEngineeringand Systems (ICCES), 2010 InternationalConferenceon(pp.221-228).IEEE.

[10]Pravin, R.A & Dani, D.D.K. Allocating powerefficiently for Decentralized Distributed Space-TimeBlockCoding, InternationalJournalofMCSquareScientificResearchVol.3,No.1Nov2011.

Determination of High Density Impact for Cognitive Variations from Brain MRI Analysis

S Rani1, D Gladis2

1Research Scholar, 2Head of Department, PG and Research Department of Computer Science, Presidency College, Chepauk, Chennai, Tamilnadu, India

ABSTRACT

Medicalanalysisimprovisedday-by-dayprocessinghugeamountofdatarelatedtobrainMRI(MagneticResonance Imaging) reports which ensures gray matter stability in human through various cognitiveperformances.Epidemiologicalincludesdistributionandcontrolofdisease,toviewgeneticvariationwhichsymbolizesandcharacterizethedetailedmolecularandcellularmechanismsthatforwardsviaactivelyandprivatelyrelevanttocheckbrainfunction.Also,thisinformationfeaturestheimmensecapabilityofnon-humanprimatemodelsinpropellingourcomprehensionofhumanhereditaryvarietyaffectingconductandneuropsychiatricillnessrisk.Inthepaper,toenhancetheperformanceanddecreasethecomplexityincludesin themedicinal picture segmentation process. Brain tumor segmentation process depends onBerkeleywavelet transform (BWT)mechanism. The SupportVectorMachine (SVM) based classifier utilized toenhancetheaccuratenessandqualityrateandrelatedfeaturesareextricatedfromeveryfragmentedtissue.TheproposedframeworkaccomplishedforrecognizingnormalandabnormaltissuesfromcerebrumMRIpictures.Itestimatedandverifiedforperformanceandqualityinvestigationonmagneticresonancecerebrumpictures. Based on Experimental evaluations, proposed algorithm enhances sensitivity 2.6%, specificity14.46%,andaccuracy6.47%oftheproposedframeworkcontrastedthanpreviousclassifiers.

Keywords:- Neural system, cognitive analysis, risk factors, genetic variations, human brain, MRI (Magnetic Resonance Imaging) analysis, Berkeley wavelet change (BWT), Support Vector Machine (SVM), accuracy, specificity and sensitivity.

Correspondence author:S RaniE-mail:[email protected]

INTRODUCTION

A typical utilitarian hereditary polymorphismaccepted to affect serotonin flagging has been theconcentration of much enthusiasm for endeavorsto comprehend fundamental organic instruments ofindividual contrasts in complexbehavioralproceduresand related hazard for neuropsychiatric clutters.In particular, in contrast with the Long allele of anaddition/cancellationvariation in thepromoterareaofthehumanserotonintransporterquality,theShortallelehas been connected to generally expanded hazard fortheadvancementofdepressiveissueandliquorabuse,particularlywith regards to ecologicalmisfortune and

stress.Ahumanimaginghereditaryqualitypondersshowthis expanded hazard for neuropsychiatric disarrangesmight be intervened by expanded amygdale reactivityinSallelebearers.Allthemoreasoflate,allelicstatusatthisqualityconnectedpolymorphicdistricthasbeenappeared to influence subjective capacity in people.In particular, S allele transporter’s display enhancedexecutiononerrands includingvisualwordymemory,set-moving, and probabilistic reward learning. TheenhancedsubjectiveexecutionissteadywithimprovedexecutioncheckingactioninthefrontcingulatecortexofSallelebearers.

Cerebralagerelatedwhiteissuechangesareeverynowandagaindepictedonbrain imaging inmaniacalandnon-psychoticelderlysubjects.Somestatisticandvascularhazardfactorsarerelatedwithahigherdangerofcreating,withrealaccentuationonage,hypertensionand stroke. Then again, late epidemiological

DOI Number: 10.5958/0973-9130.2018.00167.6


confirmationshowsthatvascularhazardfactorsassumeapartintheadvancementofintellectualdisabilityanddementia, including degenerative dementia, can be agobetweenvascular hazard factors andpsychologicaldecrease,while some statistic qualities can contributetowardssecuringsubjectivecapacity.Notwithstanding,extraresearchisessentialbeforetheutilityofthismodelforilluminatinghumanbraincapacityandconductcanbe completely deciphered. In particular, the potentialeffect on subjective capacity, brain morphology, andflaggingpathwaysoughttobesetup.Ontheoffchancethat parallel neurobiological impacts are recognizedbetweenthehumanandrhesusthenextraexaminationsjust possible in non-human primate models can beattempted to distinguish particular atomic instrumentsintervening the impacts of the hereditary variationsonbrain capacity andconduct and in addition intensereactivitytoecologicalcontrol.

Related Work

Dodge et al [1] discussed a nutrient biomarkersselectedaprioricapitalizingonexistingknowledgeofanassociationwithneurodegeneration,butthismaynotreflecttheidealset,cross-sectionaldesignwasnotsuitedfor inferringanycausalassociationsincethe temporalrelationship is unattainable.Duning et al [2] illustratedthe phenomenon of cognitive aging characterized bydeficits inexecutive functions, informationprocessingspeed, and attention. The similarity in functional andstructural effects of increased serum CRP and aging,CRP might contribute to the process of cognitiveaging, particularly as aging was directly associatedwith increased inflammatory activity. Ferris et al [3] usedactive electrodes for this study thatpassedhigh-levelsignalsthroughtheelectrodecables.Undoubtedly,passiveelectrodeswouldbemoreprone tomovementartifactsarisingfromcablesway.Theartifactremovalmethod proposed here should be re-evaluated usingwireless electrodes. Fukushima et al [4] discussed thedifference between pre- and post-test measures wereusedasdependentvariablesandthepretestscoreswereused as covariates to exclude the possibility that anypre-existing difference in measurement between thegroupsaffectedtheresultofeachmeasure.Frodletal.[5] discussed age- and gender-matched subjects wereinlinewithtwoofthreevolumetricMRIlearning’s.Itmanuallyassessedtheglobuspallidusandreducedthevolumes in kids with ADHD contrasted with healthykids.

Morrisetal[6]investigatedaVBMandfMRIusedtodeterminetheimpactoftheNOS1variantrs6490121onbrainstructureandfunctioninhealthycontrols.Inaselectrangeofareasinprefrontalandparietalcortices,including BA10/vmPFC, risk carriers exhibited aload-independent increase in activity compared tohomozygous non-risk individuals. Wallace et al [7] developedaneuralcircuitryanditalteringconnectionsamong disparate brain factors of the active areas ofneuro-imagingstudyutilizinggraphtheorytocalculatesuchassmallnetworkpropertiesofthecerebrum.Coolset al [8] presented a task-phase-dependent genotypeeffectsmighthelptoresolvesomeapparentlyconflictingresultsfromrecentgeneticimagingstudiesthatfocusedonpolymorphismsinthegenecodingforthedopamineD2receptor(DRD2).Swansonetal[9]designeda‘Ex-Gaussian’modelaccountsfortheempiricaldistributionof RTs based on an assumption of two underlyingprocesses, with one generating a normal (‘Gaussian’)distribution of RTs described by the parameters μ(mu;mean)andσ(sigma;standarddeviation)and theother generating an exponential (‘Ex’) distribution ofinfrequent long response described by a parameter τ(tau;thetailoftheempiricaldistribution).Willeitetal[10] introduced the reduction in radiology and bindingis indirectly proportional to the amount of dopaminereleased into the extracellular space, competitionexperimentsallowforanestimateofrelativechangesinextracellulardopaminelevelsinthelivinghumanbrain.

Proposed System

ThesourceofbrainMRIdataset,andtheclassifierutilizedtoperformcerebrumMRItissuesegmentation.TheproposedBWT+SVMstrategy isapplied tobraintumordatasetcontainingbrainMRIof512×512pixelsizeandchangedoverintograyscalebeforeadditionallyprocessing. Figure.1 demonstrates the architecturediagram.

Preprocessing

The preprocessing is an essential task to enhancethequalityof theMRIsandcreate it inprocessingbyhumanormachinevisionframework.Thepreprocessingsupported to enhance certain aspects of MRIs, forinstance,thevisualappearanceofMRI,enhancingthesignal-to-noise ratio, removing the unrelated noise,improving and undesired parts, smoothing is piece oftheregion,andsavingitsedges.Itenhancingthesignal-


to-noiseproportionandthelucidityofthecrudeMRIsand connected adaptive density upgrade depends onmodifiedsigmoidfunction.

Skull Stripping

Oneoftheessentialproceduresofskullstrippinginbiomedicalpicture investigation,and it isnecessitatedfortheviableinvestigationofcerebrumtumorfromtheMRIs. It is removing all non cerebrum tissues in thecerebrumpictures. It is conceivable toeliminateextrabrainy tissues, for example, fat, skin, and skull in thecerebrumpictures. It is accessing someprocedures ofprominentframeworksofautomaticskullstrippingandit utilizing picture shape. The picture shape dependson segmentation and morphological activity. It alsodependsonhistograminvestigationorathresholdvalue.Utilizing threshold value in skull stripping strategydependsonathresholdactivitytoeliminateskulltissues.

Figure.1 Architecture Diagram

ImageSegmentationandMorphologicalProcess

The contaminated cerebrum MRI regions ofsegmentationareaccomplishedthroughthesubsequentstagessuchaschangingthepreprocessedcerebrumMRIintoabinarypicturewithathresholdforthecut-offof

128 being chosen. The pixel values prominent thanchosenthresholdvaluesaremappedtowhiteandothersare fixed as dark. The diverse regions are conformedto thecontaminated tumor tissuesand it iseditedout.Next, an erosion activity ofmorphology is utilized toremovewhitepixel.Lastly,theoriginalpictureandtheeroded regionare splits into twoequivalent areas andtheerodetaskseparatedthedarkpixelareaisconsidereda cerebrumMRI cover. In the examination, BerkeleywavelettransformisutilizedforefficientsegmentationofbrainMRI.

Feature Extraction

It is the way of gathering higher level data ofa picture, for example, shape, surface, shading,and differentiation. An essential feature of surfaceinvestigation is human visual observation andmachine learning framework. It utilized to enhancethe accurateness of analysis framework efficiently bychoosing unmistakable constraints. It mainly utilizedpicture investigation applications of Gray Level Co-eventMatrix (GLCM)andsurfaceelement. It followstwo stages for feature extraction from the therapeuticpictures. First, estimating the GLCM and the secondstage, computing the surface features depends on theGLCM.Becauseofthecomplexstructureofenhancedtissues, for example, white matter, gray matter, andcerebrospinal fluid in the cerebrum MRIs, extractionof related features is an important operation.Texturaldiscoveriesandinvestigationcouldenhancetheanalysis,diversephasesofthe(tumororganizing),andtreatmentreactionevaluation.

Classification

The features identification creates on SVM thedefault decision for classification of a cerebrumtumor. Assessing the SVM algorithm’s performanceissensitivity,specificityandaccuracy. In termsof theconfusiongridischaracterizingtheTruePositive(TP),True Negative (TN), False Positive (FP), and FalseNegative(FN)fromthenormalresultandgroundtruthoutcomefor thecomputationof sensitivity, specificityand accuracy.Where the quantity of true positives iscalledTPand it iseffectivelyclassified tospecify theaggregateamountofabnormalcases.ThequantityoftruenegativesiscalledTNanditisaccuratelyclassifiedtoevaluatedoutcomecases.Thequantityoffalsepositiveis calledFP, and it is specifying incorrectly identified

\

Figure.1 Architecture Diagram

InputMRI Preprocessing

SkullStripping

ImageSegmentation

MorphologicalActivity

FeatureExtraction

Classification

BWT+SVM

NormalTissue

AbnormalTissue

RemovalofSkull

RegionExtraction


or classified abnormal cases. The quantity of falsenegativesiscallednormalcasesandFN;itisutilizedtospecifyincorrectlyclassifiedoridentifiednormalcases.Whentheyareabnormalcases,theresultvariablesarecomputed utilizing the aggregate number of samplesanalyzedfor theidentificationof thetumor.Anextentofaggregateaccuratelyclassifiedcasesiscalledqualityrate constraint accurateness. The aggregate numberof cases classified abnormally is called abnormal andclassifiednormallyiscalledordinary.

Result and Discussion

The proposed classifier done utilizing Matlab7.12.0(R2011a)anditkeepsrunningontheWindows8OSandithasanIntelcorei3processoranda4GBRAM. To verify the performance of our classifierutilized twobenchmarkdatasets.TheDigital ImagingandCommunicationsinMedicine(DICOM)datasetisprimarydataset.DICOMdatasetcontainedare tumor-contaminated brain tissues. The Brain Web datasetis secondary data set and it comprises of full three-dimensionalrecreatedbrainMRI informationutilizingsequencesofmodalitiessuchasT1-weightedMRI,T2-weightedMRI,andprotonthicknessweightedMRI.

TheproposedBWT+SVMclassifierdiscovers theevaluation parameters such as specificity, sensitivityandaccuracytoestimateeffectivenessoftheproposedclassifier and defeat the previous classifiers in braintumordetection.Intheclassifierimprovesbraintumordetectionextractionandclassification.Themethodologyestimatesthespecificity,sensitivityandaccuracy.

Accuracy

Accuracy is the popular of common evaluationmethod to estimate the performanceof the classifiers.Accuracyhasbeenestimateddependsontheamountofcorrectlyclassifiednormal/abnormalpicturestoestimatethe effectiveness and robustness of the classifier. Theevaluationmetricisasfollows:

Sensitivity

Thesensitivitycomputedtoensure the testabilityoftheclassifier.Itisestimatedinthesamewayasthecategorizationaccuracy.Thesensitivityconsidersonlypositive cases, for instance, it can be utilized to findbraintumorwithobservedfinalanalysis.Thesensitivity

100(%) xpatterntestedofnumberTotal

tionclassificacorrectofnumberTotalAccuracy =

estimatedasaquantityoftruepositivedecisionsoveraquantityofactualpositivecases.Itcanbeillustratedasfollows:

( )FNTPTPySensitivit+

=

Where TP =True Positive cases and FN= FalseNegativecases.

Specificity

Thespecificitycanbecomputedasthequantityoftruenegativedecisionsoverquantityofactualnegativecases.Itcanbeillustratedasfollows:

( )TNFPTNySpecificit+

=

WhereTN=TrueNegativecasesandFP=FalsePositivecases.

Table1demonstratesthespecificity,sensitivityandaccuracyfor inputparameterwithpreviousclassifiers.Table 1 shows the average value of all evaluationmetricswithinputparameter.TheproposedBWT+SVMframework is evaluated with following previousclassifierssuchasAnAdaptiveFuzzyInferenceSystem(ANFIS) and K-Nearest Neighbor (KNN) classifiers.AlongwithTable1,itnoticedthatBWT+SVMalgorithmhas the best score on each particular parameter forclassification.

Table.1 Comparison of Sensitivity, Specificity and Accuracy

Classifiers Sensitivity (%)

Specificity (%)

Accuracy (%)

KNN 93.33 77.77 87.06

ANFIS 95.12 79.74 90.04

SVM 97.72 94.2 96.51

AlongwithTable1clarifications,itexaminedthattheproposedBWT+SVMclassifierisestimateddependson specificity, sensitivity and accuracy. ProposedBWT+SVM are computed with An Adaptive FuzzyInference System (ANFIS) and K-Nearest Neighbor(KNN) classifiers behalf of specificity, sensitivity andaccuracy.ANFISisthenearestchallenger.Itimprovestheclassificationproblemofbraintumorclassification.However, ANFIS is provided with the less accuracy.A BWT+SVM classifier improves the brain tumor


classificationwithsensitivity2.6%,specificity14.46%,and accuracy 6.47%. Finally, the paper announcesthe proposed BWT+SVMmethodology is best on allseveralparameters.

CONCLUSION

Inthepaper,developingamedicaldecisionsupportsystemwithnormalandfindingtwocertainabnormalities.Thepreprocessingisutilizedtoeliminatetheunwantednoise and improving the signal-to-noise ratio. It usedis to improvetheskullstrippingperformanceutilizingthethresholdtechniquecalledskullstrippingalgorithm.Segmenting the imagesutilizing theBerkeleywavelettransformsmechanismand toclassify the tumorstageutilizing support vectormachine by analyzing featurevectorsandareaofthetumor.Ithelpedtogetpromisingoutcomesinclassifyingthenormalimages,imageswithtumor and image of multiple sclerosis. The proposedapproach can aid in the accurate and timelydetectionofbraintumoralongwiththeidentificationofitsexactlocationanditsignificantforbraintumordetectionfromMRIs.ABWT+SVMclassifierenhancesthebraintumorclassificationwithsensitivity2.6%,specificity14.46%,and accuracy 6.47%. Finally, the paper announcesthe proposed BWT+SVMmethodology is best on allseveralparameters.

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REFERENCES

1. Bowman, G. L., Silbert, L. C., Howieson, D.,Dodge,H.H.,Traber,M.G.,Frei,B.,&Quinn,J.F.,“Nutrientbiomarkerpatterns,cognitivefunction,andMRImeasuresofbrainaging”,Neurology,Vol.78,No.4,pp.241-249,2012.

2. Wersching, H., Duning, T., Lohmann, H.,Mohammadi,S.,Stehling,C.,Fobker,M.,&Deppe,M.,“SerumC-reactiveproteinislinkedtocerebralmicro-structural integrity and cognitive function”,Neurology,Vol.74,No.13,pp.1022-1029,2010.

3. Gwin, J. T., Gramann, K., Makeig, S., & Ferris,D.P., “Removalofmovementartifact fromhigh-densityEEGrecordedduringwalkingandrunning”,

Journal of neurophysiology, Vol. 103, No. 6, pp.3526-3534,2010.

4. Takeuchi,H.,Taki,Y.,Sassa,Y.,Hashizume,H.,Sekiguchi,A., Fukushima,A.,&Kawashima,R.,“Workingmemorytrainingusingmentalcalculationimpacts regional gray matter of the frontal andparietalregions”,PLoSOne,Vol.6,No.8,e23175,pp.1-12,2011.

5. Frodl, T., & Skokauskas, N., “Meta-analysis ofstructuralMRIstudies inchildrenandadultswithattention deficit hyperactivity disorder indicatestreatmenteffects”,ActaPsychiatricaScandinavica,Vol.125,No.2,pp.114-126,2012.

6. Rose,E. J.,Greene,C.,Kelly,S.,Morris,D.W.,Robertson, I. H., Fahey, C., & Bokde, A., “TheNOS1variantrs6490121isassociatedwithvariationin prefrontal function and grey matter density inhealthy individuals”,Neuroimage,Vol.60,No.1,pp.614-622,2012.

7. Giedd,J.N.,Stockman,M.,Weddle,C.,Liverpool,M.,Alexander-Bloch,A.,Wallace,G.L.,&Lenroot,R. K., “Anatomic magnetic resonance imagingof the developing child and adolescent brain andeffects of genetic variation”, Neuropsychologyreview,Vol.20,No.4,pp.349-361,2010.

8. Aarts, E., Roelofs, A., Franke, B., Rijpkema,M., Fernández, G., Helmich, R. C., & Cools,R., “Striatal dopamine mediates the interfacebetween motivational and cognitive controlin humans: evidence from genetic imaging”,Neuropsychopharmacology, Vol. 35, No. 9, pp.1943,2010.

9. Swanson,J.,Baler,R.D.,&Volkow,N.D.(2011).Understandingtheeffectsofstimulantmedicationson cognition in individuals with attention-deficithyperactivity disorder: a decade of progress.Neuropsychopharmacology,36(1),207.

10. Willeit,M.,&Praschak-Rieder,N.(2010).Imagingtheeffectsofgeneticpolymorphismsonradioligandbinding in the living human brain: a review ongenetic neuroreceptor imaging of monoaminergicsystemsinpsychiatry.Neuroimage,53(3),878-892.

Determination Breast Cancer Accuracy Using Data Mining

R Roseline1, S Manikandan2

1Research Scholar, Department of Computer Science, Mother Teresa Women’s University, Kodaikanal, Tamilnadu, India, 2Professor, Department of Computer Science & Engineering,

Sriram Engineering College, Chennai, Tamilnadu, India

ABSTRACT

Breastcancerdiseaseistheworld’ssecondleadingkillersamongcancercausingdeathinwomen.Regardlessof the fact that cancer is curable andpreventable in early stages, still there arepatientswhohavebeendiagnosedinlaterstages.Theproposingpapercorroboratesseveraldetectinganddiagnosingmethodsofcancer,althoughfullydependedonmedicaltechniciansandwithmedicalimagesupportingtechniqueonecandetectthecancercausingsymptomsinallthestagesspecificallyonlaterstages.Thework’sobjectiveistoestablishthefeaturesandpossibilitiestoachieveaccuraciesinthebreastcanceraseitherbenignormalignant.Thework,exploresdecision treesapplicability inpredicting theoccurrenceofbreastcancer.Finally performance evaluation analysis ismade on several conventional learning algorithmsviz. SMO(SequentialMinimalOptimization),RandomForests,J48,RandomtreeandNaiveBayes.TheInvestigationsandExperimentsprovedthatSMOplacedtopmostwithhigheraccuracy.BasedonExperimentalevaluations,SMOclassifierenhancesaccuracy2%,precision0.018,recall0.014andF-measure0.08oftheproposedclassifiercomparedthanpreviousclassifiers.

Keywords: Accuracy, Breast Cancer, Random forest, Sequential Minimal Optimization (SMO), Random Tree, J48, Naïve Bayes

INTRODUCTION

In current world’s scenario, there are more than600000malignanciespassingeveryyearinAfrica.By2020,70%of the15millionnewyearlydiseasecaseswill be in creating nations. In South Africa bosomdiseaseisthemostwidelyrecognizedgrowthinladies.The lifetimedangerof creatingbosomdisease is1ofevery 26 ladies over all populace gatherings. Everyyearmorethan3000ladiespassonfrombosomgrowthin South Africa. Over 60% of ladies give privatelypropelledbosomdisease.Ithasbeenestimatedthattheabsenceofearlytumordetectionistheprimaryreasonthat tookdominantpartof ladiesintroducingatalate,symptomaticstagewhencureisinconceivable.

The work discovers that other bosom masseslike fibro-adenoma (54.8%) and fibrocystic

changes (17%) were regular in young people in aninvestigation done on anAfrican populace. The earlydetermination and administration of bosom massesis along these lines imperative to diminish mortality.The set up administration of substantial bosominjuries incorporates the triple appraisal of physicalexamination,mammographyandpercutaneousbiopsy.Without substantial bosom masses, mammography isregularlydoneeven insymptomatic ladiesunderneath30years toavoidamysterious injury,despite the factthatultrasoundisthemethodologyofdecision.

A mammography is considered as negativefor bosom growth when grouped into BI-RADSclassifications1,2and3,andpositiveintherestoftheclasses.Atclassification1,thereisnohugefindingthebosoms are symmetrical, without any calcifications,masses, asymmetries, and central twists or differentmodifications.Atclass2,certainlyamiablediscoveriesaredepicted,andatclassification3discoverieswith<2% shot of harm are portrayed, with suggestion of asix-month follow-upassessment.Class0 relates to an

Correspondence author:R RoselineE-mail:[email protected]

DOI Number: 10.5958/0973-9130.2018.00168.8


inadequateinvestigation,requiringareciprocalimagingstudyorevencorrelationwithpastpictures.Itisquiteoften suggested in a screening circumstance. Theprecisionofbosomimagingstudiesmightbeinfluencedbyvariouscomponents,forexample,specializedangles,contrasts identified with the qualities of the populaceunderinvestigation,patient’sage,radiologistencounter,utilizationoftwofoldperusingmethodorPCsupportedlocationframeworks–CADS),andthefluctuationintheunderstandingbytheradiologistusingtheBI-RADS.

Related Work

Delenetal.[1]providedananalysisonpredictingthebreastcancerpatient’ssurvivabilityratewithsupportofdatamining. It utilizedSEERPublic-UseDatawhichisaround151,886records,alongwith16fieldswhichbelongs to SEERdatabase.Delen further investigateddata mining techniques: the back- propagated neuralnetwork, the Naive Bayes, and C4.5 decision treealgorithms. With the experiment results from thesealgorithms, the prediction performances compared totheconventionaltechniques.Hencetheresultsuggestedthat C4.5 algorithms provided the better performancethat the two alternative techniques. Safavi et al. [2] investigated the efficient and suitable networks forthe breast cancer information collection from that ofthe collected clinical data sets. The results providedtheguidanceinchoosingtheappropriatetreatmentforthe patients. For those investigations, there evaluatedseveral neural networks.The performance evaluationsof the several neural networks like Radial BasisFunctionnetwork(RBF),SelfOrganizingMap(SOM),Probabilistic Neural Network (PNN) and GeneralRegressionNeuralNetwork(GRNN)arecomparedandtestedonbothShirazNamaziHospitalbreastcancerdata(NHBCD)andWisconsinBreastCancerData(WBCD).Itovercamethedilemmaofhighdimensionsthatexistsonthedatasetsandrealizingtheassociatednatureofthedata.Withthehelpofprinciplecomponenttechniquesthedimensionofappropriatedataisbeenreducedandtheappropriatenetworksarefounded.

Lin et al. [3] described the SVM (Support VectorMachine)apopularpatternclassificationmethodwiththosediverseapplications.Whilediscoveringa subsetfeatures, it concurrently demonstrated the parametervalues, which is provided without reducing SVMclassificationaccuracies.AParticleSwarmOptimization(PSO) based technique determined the parameter and

selection feature of the SVM, the termed PSO withthat of SVMwas developed. Gupta [4] elucidated thecuringprocessofbreastcancerandprognosiswas thechallenging medical applications for the researchers.Breast cancerdiagnosisdifferentiates thebenign fromthatof themalignantbreast lumps. ThebreastcancerPrognosis predicts the occurrence of cancer causingcells inthepatients.Antonieetal. [5]developedtumordetectionthroughdigitalmammography.Itinvestigatedthe data mining techniques usage capabilities, neuralnetworkingandassociationruleminingforthepurposeof anomaly detection and classifications. The resultsshownthat theapproachesperformedwell,obtainedaclassificationof70%overaccuracyinbothtechniques.

Chen et al. [6] designed aSA-SVMmethod and anumberofdatasetsinUCImachinelearningrepositoryutilized to compute the classification accuracy rate.It described the approach that is compared with aconventional grid search method performing boundsettings,andalsovariousothermethods. Fisheretal.[7] illustrated the agreement percentage of principlediagnosis of the re-abstracted record and the actualhospital record, when analyzed on the 3rd digit,enhanced from 73.2% to 78.2% in the years 1977 to1985respectively.Ontheotherhand,1985analyzeddataillustratedtheaccuracyofthediagnosisandprocedurecodingwhichvariessubstantiallyonseveralconditions.Sousa et al. [8] extracted the concept that data wassourcedandutilizedintentativetestingwhicharemostcommonlyusedandconsideredasthedefactostandardin the reliability ranking in rulediscovery algorithms.The results generated in these domains seemed toindicatethoseParticleSwarmDataMiningAlgorithmswhichhighlycompetitive,ratheronlywithevolutionarytechniques,alsoalongwithindustrystandardalgorithmslike J48 typeofalgorithm,andcanalsobeapplied toseveredomainproblems.

Proposed System

TheworkfocusesondataminingtechniqueswhichareappliedtopredictthebreastcancerinWisconsindataset.Themodelestimatesfollowingaccuracyconstraintssuch as Accuracy, Precision, Recall, and F-measure.To obtain the accuracy constraints the supervisedlearningalgorithmsareused,viz.Randomforest,SMO(SequentialMinimalOptimization),Random tree, J48and Naive Bayes. Those algorithms try to improvetheclassification issuesofbreastcancer identification.


The research ismadeondifferent supervised learningalgorithms that are contrasted to predict the bestclassifier. Breast cancer in a human being are said tooccurwhenamalignanttumorproducedinthebreasts.The occurrence happens both in men and women.In broad-spectrum cancers is one of life-threateningmalignancies thatoccur inoneor inbothbreasts.Theinterior tissue of a human breast is usually made upof fattyorfibrousconnective tissues.Breast cancer isnotmeanttooccuronlyinwomen,itaffectsbothmenand women. But, it is less possible to occur in men.Theobjectiveofthosepredictionsistoassignpatientseithera“benign”or“malignant”thatisnon-cancerousand cancerous respectively. Figure.1 demonstrates theprocessflowdiagramofbreastcancerprediction.

Preprocessing

Thefundamentalobjectiveofthepre-processingisto enhance the picture quality to create it prepared toadditionally processing by removing or lessening theunrelatedandsurpluscomponentsinthebackgroundofthemammogrampictures.Mammogramsaretherapeuticpicturesthatcomplextotranslate.Pre-processingisbasictoenhancethequality.Itwillpreparethemammogramforthefollowingtwo-processsegmentationandfeatureextraction. The noise and high recurrence factors areremoved by filters. The collected information waspreprocessed to add value to that of information.Therawinformationincludesvariousmissingvalues.LinearInterpolationtechniqueisusedtodealwiththemissingvalues.

Figure.1 Process Flow Diagram of Breast Cancer Prediction

TrainingData

BreastCancerDataSet

Pre-ProcessingtheData

HandlingMissingValue

LinearInterpolation

Classification Model

Randomforest,SMO,J48,Randomtreeandnaïvebayes

KnowledgeBase

RulesfromBestClassifier

PredictionModel

BestClassifier

PredictedPatterns TestData

Model Estimation

Accuracy,Precision,Recall andF-measure


Segmentation

Picturesegmentationimpliesseparatingthepictureinto comparable essential components, containingrecognizing and partitioning regions of interests.Segmentationisanimperativepartandthefundamentalstage in picture preparing, which must be effectivelytaken before consequent assignments, for example,include extraction and classification. In the strategyis imperative in breast applications, for example,restricting suspicious regions, giving aim quantitativeappraisalandobservingofthebeginningandmovementofbreast illnesses,andalso investigate theanatomicalstructures.

Feature Extraction

Feature extraction strategy is another region inwhich it is necessitated to have proficient method inorder to acquire enhanced recognition accurateness.Utilizing features of a picture segmented picture ischaracterized into three sorts, for example, ordinary,benign,andmalignant.Thefeaturesutilizedtoremovethe malignancy are mean, fluctuation, relationship,differentiate,andso forth, tumorpicturesegmentationutilizingsurfacetechniquesegmentationisdonedependsonthequantityofpixels.Intheapproachdistinguishedabnormal mass recognition on the clinical database.It decreases the consistency on stricture to create ourstrategyadaptivetopolesseparatedpictures.

Classification

In the phase, a proficient classification approachdependsonsupervisedlearningalgorithmsviz.Randomforest, SMO (Sequential Minimal Optimization),Random tree, J48 andNaiveBayes are built. Prior tothedevelopmentofsupervisedlearningalgorithms,theelementvectorisshapedbyintegratingattributesofeachbandfortheclassificationandstoredinthedatabase.Insupervisedlearningalgorithms,attributeorinformationis illustrated by a various leveled informationstructurethroughadivideandconquerprocedure.Itiscommunicated regarding cyclic separation of attributespace. Supervised learning algorithms comprise ofvarious hubs based on the feature space. It beginswiththeprimaryhubcalledasroot,andtheremainingis called as leaves. For a given preparing dataset orsamples, best supervised learning algorithms aredevelopedwiththegoalthatthemistakeisinsignificant.The cost function is optimized in supervised learning

techniques with the goal that supervised learningmethodsarebuilt.Byutilizingdifferentclassifiers thedatasetwas investigated.The accuracymeasures, likePrecision,RecallandF-measurearemadepurposefultoestimatetheexecutionoftheclassifiers.

RESULT AND DISCUSSION

WisconsinBreastCancerdatasetisthesetofdata,thatarecollectedfromuniversityofwisconsinhospitals.Thedatasets includedaround699casesalongwith10features.TheclassisframedasBenignandmalignant.Therewas around 1 dependent variable and that of 9independentvariableswith thevalues for independentvariablesrangingfrom1-10andforthoseclassvariable2asBenignand4formalignantcancer.Thepossibilitytooccurbreastcancerinhumanbeingrangesfrom1asleastand10ashighest.

Thesectionillustratesthemathematicalevaluationconstraints to measure the accuracy of supervisedlearningalgorithms.Thesupervisedlearningalgorithmsare determined to calculate the accuracy utilizingWisconsinBreastcancerdataset.Itestimatesfollowingaccuracy constraints such asAccuracy, Precision andRecall,F-measure.

Accuracy

Accuracy is described as the sum of the truepredictions such as divided by the entire amount ofmalignant and benign predictions. True positivesand true negatives are illustrated as the number ofbreast cancer dataset correctly estimated as positiveand negative. False positives and false negatives aredescribedasthenumberofmalignantandbenigndataincorrectlycomputedaspositiveandnegative.

Precision

Precisionisillustratedastheratioofbreastcancerdatasetiscorrectlypredictedpositivesdividedbytotalcancer data set are correctly and incorrectly predictedpositives.


Recall

Therecallisdescribedastheratioofbreastcancerdatasetcorrectlypredictedaspositivesdividedbythesum of breast cancer data set is correctly predictedas positives and breast cancer data set are incorrectlypredictedasnegatives.

F-measure

F-measurecanbesaidasthoseweightedharmonicmean of precision and recall. The F1 measurecommunicates the balance between the precision andtherecall.

Table 1 illustrates theAccuracy,Precision,Recalland F-measure for several input constraints withsome supervised learning techniques. It verified onnumerouskindsofalgorithmslikeRandomforest,SMO(SequentialMinimalOptimization),Random tree, J48and Naive Bayes methodologies. Depends on tabularresultclarificationsomesupervisedlearningalgorithmsperformwellinbreastcancerdataset.

Table 1: Comparison of Accuracy, Precision, Recall, and F-measure

Algorithm Accuracy Precision Recall F-measure

Randomtree 95.13 0.952 0.942 0.951

J48 95.135 0.919 0.956 0.930

RandomForest 95.42 0.943 0.954 0.948

NaïveBayes 95.99 0.962 0.965 0.969

SMO 97.99 0.980 0.979 0.977

According to Table 1 clarifications, it monitoredthat the supervised learning techniques are estimatedbased on accuracy, precision, recall, and F-measure.It estimated with Random forest, SMO (SequentialMinimal Optimization), Random tree, J48 and NaiveBayesmethodologiesbehalfofaccuracy,precision,recallandF-measure.NaïveBayes is theclosestcompetitor.

It improves the classification issues of breast canceridentification. However, Naïve Bayes is offered withthelessaccuracy.ASMOalgorithmenhancesthebreastcancer feature extraction and classification accuracy2%,precision0.018,recall0.014andF-measure0.08.ThusitconcludesthattheprojectedSMOalgorithmisbestonallseveralconstraints.

CONCLUSION

In the research different supervised learningalgorithmsarecontrastedtopredictthebestclassifier.Inareaswheremammographyisn’topenoroutstandinglyexpensive especially in making groups, ultrasoundmay be utilized as a fundamental approach to surveya discernable breast mass and for ultrasound guidedframeworks.Aninvestigationalresultdemonstratestheviabilityof theproposed technique.Model isassessedutilizingaccuracy,precision,recallandF-measure.Thereoccursthediscoveriesofseveraldifferentcategorizationtechniquesthatrandomtreeoutperformsofeveryothermethodologiesathigheraccuracyrates.Awellproficientclassifierisbeenrenownedtofixonthedecisionmakingprocessofdetectingthetypeofdiseasewhichismeanttobeknownasessentialintheclinicalresearchofaffectedsickenedbreastmalignancy.TheSMOclassificationtypeimprovesthedetection,extractionandotherfeaturesofbreastcancerandclassificationaccuraciesaround2%,precisionaround0.018,recallaround0.014andfinallyF-measureisaround0.08.Thus,theworkconcludesthatSMOclassifier is said tobe thebest among theotherconstraints.

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[1] DelenD.,WalkerG., andKadamA., “Predictingbreastcancersurvivability:acomparisonofthreedata mining methods”, Artificial intelligence inmedicine,Vol.34,No.2,pp.113-127,2005.

[2] SarvestaniA.S.,SafaviA.A.,ParandehN.M.,andSalehiM.,“Predictingbreastcancer survivabilityusing data mining techniques”,In Softwaretechnology and Engineering (ICSTE), 2010 2ndinternationalConferenceon IEEE,Vol.2,pp.V2-


227,2010.

[3] Lin S.W.,Ying K. C., Chen S. C., and Lee Z.J., “Particle swarm optimization for parameterdeterminationandfeatureselectionofsupportvectormachines”, Expertsystemswithapplications,Vol.35,No.4,pp.1817-1824,2008

[4] GuptaS.,KumarD.,andSharmaA,“Dataminingclassificationtechniquesappliedforbreastcancerdiagnosis and prognosis” Indian Journal ofComputerScienceandEngineering (IJCSE),Vol.2,No.2,pp.188-195,2011.

[5] Antonie M. L., Zaiane O. R., and Coman A,“Applicationofdataminingtechniquesformedicalimageclassification”,InProceedingsoftheSecondInternational Conference on Multimedia DataMining,pp.94-101,Springer-Verlag,2001.

[6] ChenS.C.,LinS.W.,LeeZ.J.,andTsengT.Y.,“Parameterdeterminationofsupportvectormachineand feature selection using simulated annealingapproach” Applied soft computing, Vol.8, No.4,pp.1505-1512,2008.

[7] Fisher E. S., Whaley F. S., Krushat W. M.,MalenkaD.J.,FlemingC.,BaronJ.A.,andHsiaD. C., “The accuracy of Medicare’s hospitalclaimsdata:progresshasbeenmade,butproblemsremain”, American journal of public health,Vol.82,No.2,pp.243-248,1992.

[8] SousaT.,SilvaA.,andNevesA.,“Particleswarmbased data mining algorithms for classificationtasks”, ParallelComputing,Vol.30,No.5,pp.767-783,2004.

Determination of Breast Cancer Using Data Mining Techniques

R Roseline1, S Manikandan2

1Research Scholar, Department of Computer Science, Mother Teresa Women’s University, Kodaikanal, Tamilnadu, India 2 Professor, Department of Computer Science & Engineering, Sriram Engineering College,

Chennai, Tamilnadu, India

ABSTRACT

Breastcanceremergedquicklytowomenabove40yearswhichcausedeath.Whereasothercancershasless comparedwith breast cancer, similarly it spreads among rural and urban areas. Smokingwomen’saffectmorethan30-40%,long-termsmokershasincreaseinriskfactorontheotherside.Theutilizationofmachine learninganddataminingapproach’shaschanged theentireprocedureofbreastmalignancyverdict and prediction. Breast Cancer verdict recognizes kindhearted from dangerous breast knots andBreastCancerdiagnosispredictswhenBreastCancerisprobablygoingtorepeatinpatientsthathavehadtheirtumorsextracted.Theproposalistocompareabettersolutionforanalyzingbreastcancerusingdataminingtechniquesandwhichensureshighaccuracy.Thedisclosureoftheendurancerateorsurvivabilityofaspecificdiseaseisconceivablebyextricatingtheinformationfromtheinformationidentifiedwiththatdisease.Measurable learning anddatamining, canbuildup the relationshipof the factors to the result.Themajor aim of this research is to discover the overview of the present research being approved oututilizingthedataminingtechniquestoimprovethebreastcancerdetermination.Mostly,itdiscussesabouttheperformanceofconventionaltheclassificationstrategiesC4.5,ID3,C5.0,Apriori,andNaiveBayesinbreastcancerinvestigation.Theclassificationprocessbeginswithstatisticaldatafetchedfromhealthcares,utilizesWekasoftwaretoanalyzeresultsandpredictingendurancerateofbreastcancerpatients.BasedonExperimentalevaluations,C5.0classifierenhancesaccuracy4.56%,andreducedtheMeanAbsoluteError(MAE)0.141andRootMeanSquaredError(RMSE)0.155oftheproposedC5.0classifiercomparedthanexistingclassifiers.

Keywords: Data mining techniques, breast cancer, classification, Weka software, diagnosis and prediction, C5.0, ID3, APRIORI, C4.5, and Naive Bayes.

Correspondence author: R RoselineE-mail:[email protected]

INTRODUCTION

Therisingbreastdiseaserateandmortalityspeaktoahugeanddevelopingriskforthecreatingscene.Breastmalignancy is on the ascent crosswise over creatingcountries,forthemostpartbecauseoftheexpansioninfutureandwayoflifechangesbyhormonalintercessionand post-menopausal hormonal treatment. In theselocales,deathratesareintensifiedbythelaterstageatwhichtheillnessisanalyzed,andinadditionconstrainedaccess to treatment, displaying a ‘ticking time bomb’whichwellbeingframeworksandapproachproducersin

thesenationsneedtoendeavortodefuse.Theforecastissue is the long haul standpoint for the sickness forpatientswhosegrowthhasbeensurgicallyexpelled.Inthe issue apatient is nameda ‘repeat’ if the infectionisseenatsomeensuingtimetotumorextractionandapatientforwhomgrowthhasnotrepeatedandmayneverrepeat.Thetargetoftheseforecastsistodealwithcasesforwhichmalignancyhasnotrepeatedandinadditioncaseforwhichgrowthhasrepeatedataparticulartime.

In theway,breastdiseaseanalytic andprognosticissuesareforthemostpartintheextentofthebroadlytalkedaboutgroupingissues.Theseissueshavepulledin numerous analysts in computational knowledge,information mining, and insights fields. Diseaselookinto isbyandlargeclinicalaswellasorganic in

DOI Number: 10.5958/0973-9130.2018.00169.X


nature, information driven factual research has turnedintoatypicalsupplement.Anticipatingtheresultofaninfectionisastandoutamongstthemostfascinatingandtestingundertakingswheretocreateinformationminingapplications. As the utilization of PCs fueled withrobotizedapparatuses,substantialvolumesofmedicinalinformation are being gathered and made accessibleto the therapeutic research gatherings. Subsequently,Knowledge Discovery in Databases incorporates dataminingstrategiesandithasturnedintoaknownresearchinstrument for therapeutic forecasters to identify andmisuse examples and connections among substantialquantity of aspects, and made it ready to predict theresult is difficult toutilize the chronicled cases storedinsidedatasets.

Related Work

Demireletal.[1]suggestedtreatmenttypeaccordingtopathologyresultofcancertissuebiopsyandpatient’sdemographicdatawas foundusingWekadataminingtoolclasses.Yoonetal.[2]discussedthemalignantandbenign tumor patterns, several symbolic tumors havebeenformedinboththemalignantandbenigndatasets.Zeidetal.[3]introducedeffectivenessoftheclassificationmethod was computed the quantity of correctly andincorrectly classification in every probable value ofthevariablebeingcategorizedintheconfusionmatrix.Jacobetal.[4]elaboratedthetargetattributeandallotherattributeswereforecasterattributeswhosevaluesresolvetheoutcome.ThebreastcancercasesinthePrognosticBreastCancerdatasetutilizingnumerousclassificationstrategies.Rani[5]discussedtheclassificationproblemssolvedbyneuralnetwork techniques are construction,training and testing. Pollard et al. [6] illustrated anexperiments indicated that CCL2 synthesized bymetastatictumorcellsandthetargetsitetissuestromawascriticalforrecruitmentofasub-populationofCCR2expressed monocytes that enhanced the subsequentextravasationsofthetumorcells.Leeetal.[7]describedalowpositivepredictivevalueofbreastbiopsyresultingfrommammograminterpretationleadstoapproximately70%unnecessarybiopsieswithbenignoutcomes.

Gandhi et al.[8] discussed the intention enforcedcompetition between particles by making successfulparticles repel their neighbors. Shah et al.[9] executedinbuilt algorithm ofWEKA tool andmeasure varioustypesofparameter,andbasedondifferentparameter’svalue, deciding which one was best algorithm

for prediction. Kalakech et al.[10] introduced theeffectiveness of one technique over another and themodel produced by the supervised technique RBF(RadialBasisFunction)anditwasasuccessfulmethodfor the identification and classificationof somebreastcancers. Mohantyetal. [11]discussedthecancervaluesand the normality values change extensively, whichleads tomoreoverlappingbetween thenormal clusterspace and the cancerous cluster space. Ilayaraja &Meyyappan[12]collecteddatafromHospitalInformationSystem(HIS)whichhadthesufficientdetailsofpatientincludingpatient’sname,age,disease,location,district,date from laboratories which keeps on growing yearafter year. Napoleon & Pavalakodi [13] eliminated theweaker components from this PC set and calculatedthe corresponding variance, percentage of varianceandcumulativevariancesinpercentage.Guptaetal.[14] suggestedahighvalueofaccuracyrateandlowvalueoferrorrateforaclassificationtechniqueappliedonadatasetandshowthat thedatasetwashighlycorrectlyclassifiedbytheobtainedclassifier.Jacob&Ramani[15] developed aRandomTree algorithm and it generatedbestaccuracyandabsoluteprecisioninclassifyingthebreasttissuedataset.

Proposed Work

OneofthemainconcernsindataminingfunctionisClassification.Themainpurposeofclassificationis toidentifythetargetclassforallcaseintheinformation.Classificationisutilizedtocategorizethedataitemsintoclassifications. Many scholars are applying differentstrategiestosupporthealthcarespecialistswithimprovedaccuratenessintheidentificationofbreastmalignancy.In the paper explored data mining methods such asC5.0,ID3,APRIORI,C4.5,andNaiveBayestoidentifytherepeatofbreasttumorfrombreastmalignancydatacollection. It utilizedWekamachine learning tool foreveryoneofourclassifications.CollectionofmachinelearningstrategiesfordataminingoperationsiscalledWEKA. It utilized Weka for all our preprocessingand classifying. It maintains a reasonablemeasure ofthe performance of the classifier and utilized 10 foldcross verification system for each of the data miningalgorithms.Figure.1demonstratestheworkprocessofdeterminationofbreastcancer.

Preprocessing

Picturepre-processingframeworksaresignificantto


discovertheorientationofthemammogram.Itutilizedto remove thenoiseand toenhance thequalityof thepicture.Allpicturesprocessingstrategycanbeappliedinmammogrampreprocessingstepsanditsignificanttorestrain the search for variations without unnecessaryimpact from background of the mammogram.Computerized mammograms are therapeutic pictures

thatarehardtobetranslated,subsequentlyapreparationstage is required to enhance the picture quality andcreate thesegmentationresultsmoreexact.Themajorobjectiveoftheprocedureistoenhancethequalityofthepicturetocreateitpreparedtohandlingbyremovingtheirrelevantandsurpluspartsinthebackgroundofthemammogram.

Figure.1 Determination of Breast Cancer Work Process

Image Segmentation

Picture segmentation is described as the essential picture processing that subdivides acomputerizedpictureintoitscontinuous,detachandnonemptysubset,whichgivesexpediencytoextraction of property. Image segmentation range from filtering of noisy pictures, restorativeapplications(Locatecancers anddifferentpathologies,Calculatetissuevolumes,Computerguidedsurgery,Diagnosis,Treatmentplanning,investigationofanatomicalstructure),Locateentities in

DatasetRepository

Preprocessing

Segmentation

FeatureExtractionandClassification

FeatureSubset

CancerIdentificationTool

TrainData

ClassifierPerformance

C5.0 ID3

Apriori C4.5

NaïveBayes

BestClassifier

CancerResult

ValidationResult Inputfeaturesforcancerdataset

Patient


Image Segmentation

Picture segmentation is described as the essentialpicture processing that subdivides a computerizedpictureintoitscontinuous,detachandnonemptysubset,whichgivesexpediencytoextractionofproperty.Imagesegmentation range from filtering of noisy pictures,restorative applications (Locate cancers and differentpathologies,Calculatetissuevolumes,Computerguidedsurgery,Diagnosis,Treatmentplanning,investigationofanatomicalstructure),Locateentitiesinsatellitepictures(streets,forests,andsoforth.),FaceRecognition,FingerprintRecognition, and soon.Numerous segmentationtechniqueshavebeenappliedintheliterature.

Feature Extraction & Classification

In data mining field, an attribute extraction andclassification strategies can benefit fundamentallyfrom utilizing significant information in learningperformance and educated outcomes, for example,enhanced comprehensibility. Attribute is utilizedto signify a part of data which is significant forilluminating the computational operation identifiedwith a specific application. Features can refer to theconsequenceofacommonneighborhoodtask(attributeextractororfeatureidentifier)connectedtothepicture.Particularstructuresinthepictureitself,extendingfromsimplestructures,forexample,indicatesoredgesmorecompound structures, for example, entities. Featuredetermination is a broadly connected strategy foridentifying important information through removingdisconnected and repetitive information. There arenumerousfeaturestofabricatetheconnectionbetweenbreast disease and its attributes, important attributesshould be picked out to be utilized as a part of theclassification technique. The separated features areinputtotheclassifier.Here,itcontraststheperformanceestimation of C5.0, ID3,APRIORI, C4.5, and NaiveBayesClassifiers.Byapplyingdifferentclassifiers thedatasetisinvestigatedandcomputetheaccurateness.


InvestigatethebreastCancerinformationaccessiblefrom the Wisconsin dataset from UCI machinelearning with the objective of designing accuratenessidentification models for breast malignancy utilizingdata mining methods. The information utilized as apart of this examination are given by the UC Irvinemachine learning repository located in breast –tumor

Wisconsin sub-index, filenames root: breast tumorWisconsin having 699 instances, 2 classes (malignantandbenign), and9 integer number esteemed features.It removed the16 instanceswithmissingvalues fromthe dataset to build new dataset with 683 instances.It utilized theWeka toolbox to experimentwith thesedata mining classifiers.All investigations depicted inthepaperwereperformedutilizinglibrariesfromWekamachine learning condition. TheWEKAwas used asa data mining tool to compute the performance andadequacyofthebreastmalignancyidentificationmodelsconstructedfromafewmethods.

The section defines the mathematical estimationconstraints to calculate the accuracy of data miningalgorithms.Thedataminingalgorithmstocomputetheaccuracy utilizing Breast cancer data set. It evaluatesfollowing constraints such as Accuracy, Root MeanSquared Error (RMSE) and Mean Absolute Error(MAE).

Accuracy

Accuracy is illustrated as the sum of the truepredictions such as divided by the entire amount ofmalignant and benign predictions. True positivesand true negatives are illustrated as the number ofbreast cancer dataset correctly estimated as positiveand negative. False positives and false negatives aredescribedasthenumberofmalignantandbenigndataincorrectlycomputedaspositiveandnegative.

Mean Absolute Error (MAE)

MAE defined as the average over the validationsample of the absolute values of the contrasts amongforecastandthecorrespondingobservation.Itisalinearscoreanditmeansalltheindividualdissimilaritiesareweightedequallyintheaverage.

Where xi is an actual known value and yi is anidentifiedvalue.

Root Mean Squared Error (RMSE)

Itisaquadraticscoringimperativeanditcomputestheaveragemagnitudeofthefault.Thedifferentiation


amongforecastandcorrespondingobservedvaluesareeverysquaredandthenaveragedoverthesample.Lastly,thesquarerootoftheaverageisacquired.Thefaultsaresquaredbeforeaveraged;theRMSEoffersarelativelyhighweighttohugefaults.ItmeanstheRMSEismainlyusefulwhenhugefaultsareparticularlyundesirable.

Where xi is an actual known value and yi is anidentifiedvalue.

Table 1 demonstrates the Accuracy, Root MeanSquared Error (RMSE) and Mean Absolute Error(MAE)fornumerousinputparameterswithsomedatamining techniques. It validated on numerous types ofalgorithms likeC5.0, ID3,APRIORI,C4.5 andNaiveBayesclassifiers.Dependsontabularresultclarificationsome data mining algorithms perform well in breastcanceranalysis.Table1demonstratestheaveragevalueofallevaluationparameterswithinputparameter.AlongwithTable1,itnoticedC5.0algorithmhasthebestscoreoneachparticularconstraintforclassification.

Table 1: Comparison of Accuracy, Root Mean Squared Error (RMSE) and Mean Absolute Error (MAE)

Algorithm Accuracy

Mean Absolute Error (MAE)

Root Mean Squared Error (RMSE)

C4.5 75.15 0.361 0.436

ID3 77.56 0.326 0.422

APRIORI 79.16 0.312 0.413

NaïveBayes 90.69 0.215 0.339

C5.0 95.25 0.074 0.184

According to Table 1 clarifications, it monitoredthatthedataminingalgorithmsarecomputeddependsonAccuracy, RootMean Squared Error (RMSE) andMeanAbsolute Error (MAE). It evaluatedwith C5.0,ID3,APRIORI,C4.5andNaiveBayesalgorithmsbehalfofAccuracy, Root Mean Squared Error (RMSE) andMeanAbsoluteError(MAE).NaïveBayesisthenearestchallenger. It enhances the classification problems ofbreastcancerdetection.However,NaïveBayesisofferedwiththelessaccuracy.AC5.0algorithmimprovesthebreastcancerfeatureextractionandclassificationwith

accuracy4.56%,andreducedtheMeanAbsoluteError(MAE) 0.141 andRootMeanSquaredError (RMSE)0.155. Finally, the paper declares the proposed C5.0algorithmisbestonallsomeparameters.

CONCLUSION

Data mining techniques investigates the differentspecialized and breast cancer disease finding andanticipation issues that offer incredible guarantee toreveal designs covered up in the information that canhelpthecliniciansinbasicleadership.Fromtheaboveexaminationit iswatchedthattheaccuracy,MAEandRMSE for the conclusion investigation of differentconnected data mining arrangement strategies isprofoundlyworthyandcanhelptherestorativeexpertsinbasicleadershipforearlydeterminationandtoevadebiopsy.TheanalyticalissueisprimarilyanalyzedunderC5.0anditsaccuracycamehigherincontrastwithotherclassification algorithms connected for the same. TheexactnessofordermethodsisassessedbasedontheC5.0algorithmcomputation,recommendedfordeterminationof Breast Cancer based classification to show signsof enhancement aboutwith accuracy, lowRootMeanSquaredErrormistake rate andMeanAbsoluteError.A C5.0 algorithm improves the accuracy 4.56%, andreduced theRootMeanSquaredError (RMSE)0.155and MeanAbsolute Error (MAE) 0.141. Finally, thepaperdeclares theproposedC5.0algorithmisbestonallsomeparameters.




REFERENCES

1. Çakır, A., & Demirel, B., “A software tool fordetermination of breast cancer treatmentmethodsusing data mining approach”, Journal of medicalsystems,Vol.35,No.6,pp.1503-1511,2011.

2. Zheng, B., Yoon, S. W., & Lam, S. S., “Breastcancerdiagnosisbasedonfeatureextractionusinga hybrid ofK-means and support vectormachinealgorithms”, Expert Systems with Applications,Vol.41,No.4,pp.1476-1482,2014.

3. Salama,G. I.,Abdelhalim,M.,&Zeid,M.A.E.,“Breastcancerdiagnosisonthreedifferentdatasets


using multi-classifiers”, Breast Cancer (WDBC),Vol.32,No.569,pp.36-43,2012.

4. Jacob,S.G.,&Ramani,R.G.,“Efficientclassifierfor classification of prognostic breast cancer datathroughdataminingtechniques”,InProceedingsoftheWorldCongressonEngineeringandComputerScience,Vol.1,pp.24-26,2012.

5. Rani, K. U., “Parallel approach for diagnosis ofbreast cancer using neural network technique”,International Journal of Computer Applications,Vol.10,No.3,pp.1-5,2010.

6. Qian,B.Z.,Li,J.,Zhang,H.,Kitamura,T.,Zhang,J.,Campion,L.R.,&Pollard,J.W.,“CCL2recruitsinflammatorymonocytes to facilitatebreast tumormetastasis” Nature,Vol. 475, No. 7355, pp. 222-236,2011.

7. Huang,M.L.,Hung,Y.H.,Lee,W.M.,Li,R.K.,&Wang, T. H., “Usage of case-based reasoning,neuralnetworkandadaptiveneuro-fuzzyinferencesystem classification techniques in breast cancerdatasetclassificationdiagnosis”,Journalofmedicalsystems,Vol.36,No.2,pp.407-414,2012.

8. Gandhi, K. R., Karnan, M., & Kannan, S.,“Classification rule construction using particleswarmoptimizationalgorithmforbreastcancerdatasets”, InSignalAcquisitionandProcessing,2010,ICSAP’10. InternationalConferenceon IEEE,pp.233-237,2010.

9. Shah, C., & Jivani, A. G., “Comparison of datamining classification algorithms for breast cancerprediction”, In Computing, Communications andNetworkingTechnologies(ICCCNT),2013Fourth

InternationalConferenceonIEEE,pp.1-4,2013.

10. Raad, A., Kalakech, A., & Ayache, M., “Breastcancerclassificationusingneuralnetworkapproach:MLPandRBF”,Networks,Vol.7,No.8,pp.9-14,2012.

11. Mohanty,A.K.,Senapati,M.R.,&Lenka,S.K.,“RETRACTED ARTICLE: An improved datamining technique for classification and detectionof breast cancer from mammograms”, NeuralComputing andApplications, Vol. 22, No. 1, pp.303-310,2013.

12. Ilayaraja,M.,&Meyyappan,T.,“Miningmedicaldata to identify frequent diseases using Apriorialgorithm”,InPatternRecognition,InformaticsandMobile Engineering (PRIME), 2013 InternationalConferenceonIEEE,pp.194-199,2013.

13. Napoleon, D., & Pavalakodi, S., “A newmethodfor dimensionality reduction using K-meansclusteringalgorithmforhighdimensionaldataset”,International Journal of Computer Applications,Vol.13,No.7,pp.41-46,2011.

14. Gupta,S.,Kumar,D.,&Sharma,A.,“Performanceanalysis of various data mining classificationtechniquesonhealthcaredata”,Internationaljournalof computer science & Information Technology(IJCSIT),Vol.3,No.4,pp.155-169,2011.

15. Jacob, S. G., & Ramani, R. G., “Discovery ofknowledge patterns in clinical data through datamining algorithms: Multi-class categorizationof breast tissue data”, International Journal ofComputerApplications(IJCA),Vol.32,No.7,pp.46-53,2011.

Determination of Cognitive Variations Using Classification Techniques

A Clementking

Associate Professor, Department of Computer Science, King Khalid University, Abha, KSA

ABSTRACT

Cognitive variation is concerned about the improvement of instructional strategies which proficientlyutilizeindividuals’,restrictedfromsubjectivepreparingabilitytofortifytheircapacitythatappliesobtainedlearning and aptitudes to new circumstances, psychological design comprises a constrained workingmemory, with incompletely free handling units for visual/spatial and sound-related/verbal data, whichconnects with a relatively boundless long harvest memory. A computer aided classification techniqueintegratingconventionalMagneticResonanceImaging(MRI)andperfusionMRIisdesignedandutilizedfor differential analysis.The classification depends onClassification andRegressionTrees (CART) andPitteway-WatkinsonAlgorithm(PWA)proposedtodarkpixelbasedpicturesegmentationanditfunctionsareactuatedtocerebrumpictureclassification.IntheproposedworkCART+PWAstrategyforautomaticclassificationoftheMagneticResonanceImaging(MRI)cerebrumpicturesasnormalvariationorirregularvariation.Theproposedstrategycomprisesofnumerousstages,suchaspictureacquisition,segmentation,featureextraction,andclassification.Tochangingpicturesintosetofregionsforsegmentationphase,aninputoffeatureextractionphaseis theoutputofsegmentationphase.ThefeatureextractionphasemultiextractedsurfacefeaturesutilizingPitteway-Watkinsoncalculation(PWA)andthesefeaturesareutilizedinclassificationphase.BasedonExperimentalevaluations,proposedalgorithmimprovesaccuracy15.05%,precision 13.7%, recall 15.59%andF-measure 15.07%of the proposed system compared than existingmethodologies.

Keywords:- Classification, data mining, cognitive variations, cognitive science, cognitive classification technique and individual psychology.

Correspondence author:A ClementkingE-mail:[email protected]

INTRODUCTION

Vital psychological examination is the idea ofworkingmemoryengineeringanditsrestrictionsoughttobeasignificantthoughtwhenplanningguideline.Themostvital learning forms forbuildingup thecapacitytoexchangegainedinformationandabilitiesareoutlinedevelopment and computerization. As indicated byCognitiveinvestigation,variouscomponentsofdatacanbepiecedassinglecomponentsinsubjectivemappings,whichcanberobotizedtoavastdegree.

Almost, they can sidestep working memory ofmental preparing accordingly departing around the

confinementsofworkingmemory.Theprimeobjectivesofguidelinearethedevelopmentandmechanizationofmappings.Before,thedatacanbemovedinschematicshapeoflongharvestmemory;itmustberemovedandcontrolled in working memory. Exertion within theCognitivesystemhasfocusedontheplanofimaginativeinstructional strategies that effectively utilize theworking memory limit. General assessments are notsufficientforcorrelationamonganalysissinceexaminingaccompliceswhichmay differ in their age structures.Although, ordering remotely detected informationintoatopicalguideremainsatestofthefactformanyessentials,theintricacyofthesceneinaninvestigationrange,choseremotelydetectedinformation,andimage-processing and collection approaches, may influencetheachievementofacharacterization.Constantriseofnewgroupingcalculationsandstrategieslatelyrequiressuch an audit,whichwill be extremely significant for

DOI Number: 10.5958/0973-9130.2018.00170.6


controlling or choosing a reasonable characterizationstrategyforaparticularreport.

Related Work:-

Duval[1]investigatedthethresholdofmathematicalcomprehension for learners at each stage of thecurriculum. Liu [2] represented the difference in thecomplexityofcognitiveanalysesinvolvedincollocationlearning, a teacher should be prepared to provideappropriate assistance to the students, based on thelevelofthedifficultyofthecollocationsbeinglearned.Cellard et al.[3] discovered the essential elements ofsuccessful treatment; researchers need to begin toidentify key issues for therapy implementation, suchas acceptability. Van Der Spek et al.[4] predicted thatinstructionwithseriousgamesyieldsahigherlevelofretention than trainingwith conventional instructionalmethods.Williams-Grayetal.[5]describedaproportionofpatientswithMCIwas similar to the resultsof themain analysis, suggesting that the use of differentdementia criteria did not meaningfully influence theresults. Simmons et al.[6] the accuracies for correctlyclassifyingMCIsubjectsasADlikeatbaselineusingthefollow-updiagnosisat24monthsand36monthswere75.4%and68.0%respectively.Wardetal.[7]discussedaclassificationwithLSN investigationand itdependson the intrinsic spontaneousBOLDsignalacquired intherestingstateandseveraltechnologicissuesneedtobeaddressed.Tanneretal.[8]illustratedtheintegrationof multiple indices with diffusion together with fibercountmeasuresprovidedWeeandcolleagueswith an“enriched” classifier. It produced an accuracy of 88%forcontrolandMCIclassificationanditcomparabletotheaccuracy.

Rodrigo et al.[9] suggested boredom and it wasthe main cognitive-affective state which interactivelearning infrastructures should focus on identifyingand speedily responding. Betts et al.[10] designed therobustnessofthisobservationdiminishedbythesmallnumbers in the twogroups, reflected in thewide95%confidence intervals, indicating that this result needsto be validated by further research. Papageorgiou[11] exploredthefuzzyrulebaseddecisionsupportsystemin the education process provides a more usefulenvironment for the physicians and students thanhuge, hard covered materials. Insel et al.[12] assumedthe data from genetics and clinical neuroscience andit yield bio-signatures that was augmented clinical

symptoms and signs for clinical organization. Setzet al. [13] illustrated the classifiers perform betterwithnon-relative features. Relative features were utilizedthatmeans theestimationof thebaselinefeatureswasnot required, and no calibration procedure would benecessitated for a realistic framework. Hernández etal[14]discussedthesuseoftwoMRsequencesreducesproblems due to movement and field heterogeneityduring scan acquisition, and the lengthy processingtimes and computational requirements of traditionalmethods.Kellyetal[15]evaluatedthebrain’sfunctionalorganizationtowardunderstandinghowinter-individualvariation in brain organization and function underlienormal and abnormal variation in cognition, emotionandbehavior.

Proposed System

Theproposedclassificationframeworkisutilizingadigitalimageasinputofthebrainwithsomeformat.Insegmentationstageispassingeveryimagebyutilizingweighted k-meansmethodology.An input of featuresextraction stage is the output of segmentation stageand this stage set of features extraction from picturesby utilizing PWA methodology. Lastly, the CARTclassifier isutilized inclassificationstage fordecisionmakingand it ismostcommonlyutilizedmethods forcognitivevariationssuchasusualvariationorunusualvariationdetections.Figure.1showstheblockdiagramofbrainMRIclassification.

Image Acquisition Stage

To enhance the quality of pictures utilizing thepreprocessingoracquisitionphase.Avariouskindsofnoises corrupted themedicinal pictures. It is essentialfor exact perceptions having good quality of picturesfor the provided application. Set of cerebrum MRIsaregatheringanditwillbechangedintosomepictureformat.

Segmentation Stage

Procedure of segmentation is partitions a pictureintoconstituentregionsorentities.Inimageprocessing,themain complicated task is segmenting unimportantpictures. Segmentation accurateness decides theexpectedachievementordisappointmentofmechanizedinvestigation strategy. Two fundamental propertiesdepend on segmentation algorithms such as intensityvalues discontinuity and similarity. Initial type, the


sudden modification doing to segment a picture inintensity,forinstance,edgesinapicture.Secondtype,thepictureisdividingintoregionsthatarecomparableasperpredefinedcriteria. In thephase isutilizing theHistogramthresholdingmechanism.GrayPixelutilizedover Histogram is developed by dividing the scopeof the information into equalized containers (calledclasses).Foreverycontainer,thequantityofpointsfromtheinformationalindexthatfallintoeverycontaineriscalculated.

Feature Extraction Stage

Theprocedureoffeaturesextractionisinvestigatingandmeasuringthesurfaceinsideapicture.Itextractstheunmistakable features in investigated pictures that areillustrativeof thedifferentclassesofentities.Featuresare utilized as inputs to classifier that allocate to theclass. In the feature extraction framework is providedavarioussurfacequalitiesinstatisticalmeasurewhichactualizethefeaturesofaMRIcerebrumpictures.

Classification Stage

Classificationmethodisidentifyingusualvariationand unusual variations of MRI cerebrum picture.CARTutilizing to enhanceprecision rate and reducesmistake rate of MRI brain tumor classification. Theclassification procedures dependonClassification andRegressionTrees(CART)andhistogrambasedpicturesegmentationanditarrangedwithappliedtocerebrumpicture classification. CART framework enhancesexactness rate and decreases mistake rate of MRIcerebrumtumorclassification.


Image segmentation and classification approachinvestigates theperformanceutilized threebenchmarkdata sets. The first data set isBRAT. It comprises of142picturesandincludescerebrumtumorstestsimages.AllBRATpicturetestsdocumentsareinGrayImagesexchange linguistic structure with PWA expansion.TheBrainsetisaseconddataset.ItincludessimulatedcerebrumMRIinformationdependsontwoanatomicalapproaches:completedimensionalinformationvolumeshave been reproduced utilizing three successions andan assortment of slice thicknesses, noise levels, andlevelsofintensitynon-consistency.ThepictureformatsincludedinthisdatasethaveexpansionofPWA.

TheproposedPWA+CART techniquediscoversthe estimation constraints such as accuracy anderror rate to compute efficiency of the proposedPWA+CARTclassifierandbeattheearlierclassifiersinbrainvariations.Intheclassifierimprovesbraintumorvariation detection and classification. The classifierevaluatestheaccuracyanderrorrate.

Accuracy

Accuracy is estimated based on the amount ofcorrectlyclassifiedusual/unusualvariationstocomputethe efficiency and robustness of the classifier. Theevaluationmetricisasfollows:

Error Rate

Error rate describes mathematical model forwronglypredictedclassifieddata.Itcomputesthebrainvariation classified data with respect of total brainvariations.ErrorRate(ER)iscomputedas:

Table1demonstratestheaccuracyanderrorrateforinputconstraintswithearlierclassifiers.Table1showstheaveragevalueofallcomputationmetricswithinputconstraints. The proposed PWA + CART frameworkiscomputedwith followingearlier techniquessuchasGenerativeModel(GM)andHierarchal-SVM(HSVM)classifiers.AlongwithTable1, it noticed thatPWA+CART algorithm has the best score on every specificconstraintforclassification.

Table 1: Comparison of Sensitivity, Specificity and Accuracy

Classifiers Accuracy (%) Error Rate

GM 88.16 11.84

HSVM 90.56 9.44

PWA+CART 98.72 1.28

AlongwithTable1clarifications,itobservedthattheproposedPWA+CARTtechniqueiscomputeddependsonaccuracyanderrorrate.ProposedPWA+CARTarecomputedwithGenerativeModel(GM)andHierarchal-SVM(HSVM)techniquesbehalfofaccuracyanderrorrate. HSVM is the nearest competitor. It enhancesthe classification problem of brain tumor variationclassification.However,HSVMisofferedwiththelessaccuracy. A PWA+CART mechanism enhances the

100(%) xpatterntestedofnumberTotal

tionclassificacorrectofnumberTotalAccuracy =


braintumorusualandunusualvariationswithaccuracy8.16%anderrorrate8.16.Lastly,thepaperdeclarestheproposedPWA+CARTmechanismisbestonallseveralconstraints.

CONCLUSION

TheCART+PWAstrategyforautomaticclassificationof theMagnetic Resonance Imaging (MRI) cerebrumpicturesasnormalvariationorirregularvariation.Braintumorvariationsareinitiatedbyirregularwithdiscardeddesignedofinsideandoutsidethecerebrum.Cureofabrain tumor reliesupon itsmeasurementandposition.In the paper classification mechanisms depends onCARTareproposedandconnectedtocerebrumpictureclassification.Theproposed cerebrum tumorvariationpicture segmentation depends on CART overall pixelHistogram thresholding. A PWA+CART techniqueimprovesthebraintumorusualandunusualvariationswith accuracy 8.16% and error rate 8.16. Lastly, thepaperdeclarestheproposedPWA+CARTmethodologyisbestonallseveralparameters.




REFERENCES

1. Duval, R., “A cognitive analysis of problems ofcomprehension in a learning of mathematics”,Educationalstudiesinmathematics,Vol.61,No.1,pp.103-131,2006.

2. Liu, D., “Going beyond patterns: Involvingcognitiveanalysisinthelearningofcollocations”,TESOLQuarterly,Vol.44,No.1,pp.4-30,2010.

3. Wykes, T., Huddy, V., Cellard, C., McGurk, S.R., & Czobor, P., “A meta-analysis of cognitiveremediation for schizophrenia: methodology andeffectsizes”,AmericanJournalofPsychiatry,Vol.168,No.5,pp.472-485,2011.

4. Wouters,P.,VanNimwegen,C.,VanOostendorp,H.,&VanDer Spek, E.D., “Ameta-analysis ofthe cognitive and motivational effects of seriousgames”,Vol.105,No.2,249-267,2013.

5. Aarsland, D., Bronnick, K., Williams-Gray, C.,Weintraub, D., Marder, K., Kulisevsky, J., &

Santangelo, G., “Mild cognitive impairment inParkinson disease amulticenter pooled analysis”,Neurology,Vol.75,No.12,pp.1062-1069,2010.

6. Westman, E., Muehlboeck, J. S., & Simmons,A., “Combining MRI and CSF measures forclassificationofAlzheimer’sdiseaseandpredictionof mild cognitive impairment conversion”,Neuroimage,Vol.62,No.1,pp.229-238,2012.

7. Chen, G.,Ward, B. D., Xie, C., Li,W.,Wu, Z.,Jones,J.L.,&Li,S.J.,“ClassificationofAlzheimerdisease, mild cognitive impairment, and normalcognitive statuswith large-scale network analysisbased on resting-state functional MR imaging”,Radiology,Vol.259,No.1,pp.213-221,2011.

8. O’Dwyer,L.,Lamberton,F.,Bokde,A.L.,Ewers,M., Faluyi, Y. O., Tanner, C., & Coughlan, T.,“Using support vector machines with multipleindicesofdiffusionforautomatedclassificationofmildcognitiveimpairment”,PloSone,Vol.7,No.2,pp.1-11,e32441,2012.

9. Baker,R.S.,D’Mello,S.K.,Rodrigo,M.M.T.,&Graesser,A.C.,“Bettertobefrustratedthanbored:Theincidence,persistence,andimpactoflearners’cognitive–affective states during interactionswith three different computer-based learningenvironments”, International Journal of Human-Computer Studies, Vol. 68, No. 4, pp. 223-241,2010.

10. Taylor, P. J.,Betts,G.A.,Maroulis, S.,Gilissen,C.,Pedersen,R.L.,Mowat,D.R..,&Buckley,M.F.,“Dystrophingenemutationlocationandtheriskof cognitive impairment in Duchenne musculardystrophy”,PloSone,Vol.5,No.1,pp.1-9,e8803,2010.

11. Papageorgiou, E. I., “A new methodology fordecisions in medical informatics using fuzzycognitive maps based on fuzzy rule-extractiontechniques”,AppliedSoftComputing,Vol.11,No.1,pp.500-513,2011.

12. Insel, T.,Cuthbert,B.,Garvey,M.,Heinssen,R.,Pine, D. S., Quinn, K., & Wang, P., “Researchdomaincriteria(RDoC):towardanewclassificationframeworkforresearchonmentaldisorders”,2010.

13. Setz, C.,Arnrich, B., Schumm, J., LaMarca, R.,Tröster, G., & Ehlert, U., “Discriminating stressfromcognitiveloadusingawearableEDAdevice”,IEEE Transactions on information technology in


biomedicine,Vol.14,No.2,pp.410-417,2010.

14. Hernández,M.D.C.V.,Ferguson,K.J.,Chappell,F. M., & Wardlaw, J. M., “New multispectralMRI data fusion technique for white matterlesion segmentation: method and comparisonwith thresholding in FLAIR images”, European

radiology,Vol.20,No.7,pp.1684-1691,2010.

15. Kelly, C., Biswal, B. B., Craddock, R. C.,Castellanos,F.X.,&Milham,M.P.Characterizingvariation in the functional connectome: promiseandpitfalls.Trendsincognitivesciences,Vol.16,No.3,pp.181-188,2012.

Analysis of Hospital’s Financial Liquidity Using the Linear Regression Model: A Panel Data Study in

Ahvaz Teaching Hospitals

Gazal Zolfi1, Arash Jamalmanesh2, Amin Torabipour3

1Master’s Student of Management, 2Faculty member, Department of Management, Islamic Azad University of Shushtar, Iran, 3Assistant Professor, Department of Health Services Management, Faculty of Health, Ahvaz

Jundishapur University of Medical Sciences, Ahvaz, Iran

ABSTRACT

Liquidityreferstoanorganization’sabilitytopayofftheirdebts.Themainobjectiveofthisstudywastodeterminethefactorsaffectingthehospital’sfinancialliquidityinselectedteachinghospitalinAhvaz,Iran. Thepresentresearchwasacross-sectionalandpaneldatastudywhichwasconductedusingeconometricmethods.ThestatisticalpopulationconsistedofallteachinghospitalsofAhwaz,southwestofIran(N=6).Thedataobtainedonvariablessuchashospitalsize,profitrate,debts,andratiosofcurrentliquidity,quasi-liquidity, and liquiditywere statistically analyzed using the linear regression analysis inEviews-8.TheresultsofValeridgetestanddatapaneltestshowedthatthereisasignificantrelationshipbetweenthestudiedfinancialindicatorsandliquidityofhospital.Theresultsalsoindicatedthat,basedonthe5-yearmeanvalues,currentliquidity(0.036),quasi-liquidity(0.086),profitability(0.218),debts(0.344),andliquidity(0.453)hadthehighesttothelowestimpactontheliquidityofstudiedhospital,respectively.Accordingtothestudyfindings,itcanbeconcludedthathospitalcanraisetheirliquiditybyincreasingtheirsize,improvingtheirperformanceinlinewiththeoptimalutilizationofassetsusingoptimalmethodstoprovidecapitalstructure,andpromotingtheirservicedelivery.

Keywords: Hospital liquidity; Profitability; Capital structure; Financial indicator; Regression model.

Corresponding author: Amin TorabipourDepartmentofHealthServicesManagement,SchoolofHealth,AhvazJundishapurUniversityofMedicalSciences,Ahvaz,Iran,ORCIDID:http//www.orcid.org/0000-0002-8937-8004.Tel:+98-61-33738269,E-mail:[email protected]

INTRODUCTION

Nowadays, hospitals are considered enterpriseswhich need a strong economic structure. A properfinancialstructureisthemostimportantfactoraffectingvaluation and orientation in differentmarkets such asthehealthmarket.[1]Incountrieswherethegovernmentownsthehealthcaresector,lessattentionispaidtothefinancial management of hospitals. Some researchershave studied the issue of profitability in hospitals butmost of them have focused on budget deficit rather

than financial management and investment. Zeilieret al.(1996)introducedsixareasoffinancialmanagementin hospitals which included profitability, fixed assets,capital structure, fixed asset life, impact investment,and liquidity.[2] Liquidity is one of the key financialindicators in this regard,[3] which is related to otherfinancial indicators.Studieshaveshown thathospitalswithahigherprofitabilityratearemoreabletopayofftheirdebts.[4]LiquiditywasfirstintroducedbyKeynesasoneof thedeterminantsof returnonassets (ROA).Hestatedthatanassetismoreliquidthanotherswhenitcanbeexchangedintheshortesttimepossiblewithoutanyloss.Fernandez(1999)arguedthatliquiditycannotbemeasuredbyanabsolutecriterion,but it shouldbeevaluatedonascalethatincorporatesthekeyelementsofliquidity,suchasvolume,time,andtransactioncosts.Given the importanceof liquidity, itwouldbehelpfulto identify and understand the factors affecting it.Profitabilitycannotbethemaingoalofapublichospital.

DOI Number: 10.5958/0973-9130.2018.00171.8


[5] Goals and missions of public hospitals involvedecisionsonmaintainingthehealthandincreasingthelongevity of patients. [6] However, hospitals shouldestablishabalancebetweentheirincomeandexpenses,as the income should not completely go for currentcostsbutitshouldbealsospentonthedevelopmentofequipmentbeforetheybecomeobsolete.[7]Maintainingfinancial liquidity is a prerequisite to achieving thesegoals. Nowadays, health systems make up one ofthe largest sectors of the world’s economy. Globalhealthcare costs account for roughly 8% of GDP. Inmostdevelopedcountries,about5-10%ofgovernmentspendingisallocatedtothehealthsector.[7]Amongallhealth-relatedentities,hospitalsaloneaccountforabout50-80%ofthetotalhealthbudgetandalargeshareoftrainedandspecializedstaff,themainpartofwhichisfundedbythepublicsector.[8]Formerly,theperformanceofhealthcareorganizationsusedtobeassessedthroughtherapeuticindices.Nowadays,theseorganizationsarecomplexandrequirethestrongsupportofmanagementfor the evaluation of economic performance.[9] The economic-financial analysis provides a logical andspecific framework for the evaluation ofmajor issuesinthehealthcaresector.[10]Sinceresourcemanagementis not properly done in hospitals, it is necessary forhospitals tomanagemoreeconomically. Improvementoffinancialmanagementinhospitalswillincreasetheirefficiencyandproductivity.[11]Hence,thepresentstudyaims to analyze the factors affecting the liquidity ofteachinghospitalsinAhwaz.


Thepresentresearchwasacross-sectionalandpaneldata study which was conducted using econometricmethods. The statistical population consisted of allteaching hospitals of Ahwaz (N=6). In this study,variables such as hospital size, profit rate, debts, andratiosofcurrentliquidity,quasi-liquidity,andliquidityweremeasured to determine the financial liquidity ofhospitals. The required data were extracted from thehospitalinformationsystemsandtheaccrualaccountingsoftware in the period 2012-2016. The obtained datawereanalyzedbydescriptiveandinferentialstatisticsinExcel andEviews-8.Thenormaldatapanelwasusedfortestingthehypotheses.Inaddition,themodelsweredescribedusingthelinearregressionanalysisasfollows:

Cliq=β0+β1sizeijt+β1profijt+β1debtijt+β1serijtεit

Where,b0,liqit,sizeit,profit,debtit,andseritrepresenttheintercept,thecurrentliquidityofHospitali in theyear t, thesizeofHospital i in theyear t, theprofitabilityofHospitaliintheyeart,debtsofHospitali intheyeart,andtheseverityofhealthservicesprovidedinHospitaliintheyeart,respectively.

Hliq=β0+β1sizeijt+β1profijt+β1debtijt+β1serijtεit

Where,b0,liqit,sizeit,profit,debtit,andseritrepresent the intercept, the quasi-liquidity ofHospitali in theyear t, thesizeofHospital i in theyear t, theprofitabilityofHospitaliintheyeart,debtsofHospitali intheyeart,andtheseverityofhealthservicesprovidedinHospitaliintheyeart,respectively.

Liq=β0+β1sizeijt+β1profijt+β1debtijt+β1serijtεit

Where,b0,liqit,sizeit,profit,debtit,andseritrepresenttheintercept,thecurrentliquidityofHospitali in theyear t, thesizeofHospital i in theyear t, theprofitabilityofHospitaliintheyeart,debtsofHospitali intheyeart,andtheseverityofhealthservicesprovidedinHospitaliintheyeart,respectively.

RESULTS

Thefindingsofthisstudyarepresentedintwopartsof descriptive and analytical. In descriptive findingssections, the performance indicators of the studiedhospitals and financial indicators related to each areexplained.Inaddition,themeanandstandarddeviationofthedataofthese6hospitalsina5-yearperiodwillbepresented.Table1showsgeneralinformationofstudiedhospitals during the period 2012-2016. As it can beobserved,theoccupancyratehasincreasedconsideringthe increase in the number of beds over these years,patient stay duration has remained almost unchanged,andthenumberofbeds(hospitalsize)hasincreased.Thesignificanceofthesedifferenceswillbedescribedintheinferentialresults.Accordingtotable2,liquidity,currentliquidity, quasi-liquidity, profitability, and debts haveslightly increasedduring the studyperiod.The resultsalsoindicatethatthehighestandthelowestvaluesarerelated to current liquidity and liquidity, respectively.In table 3, mean values were presented based on the5-yearsperiod.Currentliquidity(0.036),quasi-liquidity(0.086),profitability(0.218),debts(0.344),andliquidity(0.453) had the highest to the lowest impact on the


liquidityofstudiedhospital,respectively.Accordingtotable4,F-value (54.99)and significance level (0.001)confirmthesignificanceof themodelfor thetest.TheresultsoftheValeridgetestalsodemonstratethatthereis no autocorrelation between the sentences.Adjustedcoefficient of determination was equal to 0.21. Theseverityofhealthservicesdelivery,profitability,debts,and hospital size were the independent variables andcurrentliquiditywasconsideredthedependentvariableofthisresearch.Giventhesignificancelevelinthetablebelow,independentvariableshaveadirectandpositiverelationship with the current liquidity of hospitals.Therefore, the first model for testing the hypothesesisacceptable.Theresultsoftable5alsoshowthatthemodel is optimal for testing the hypothesis. F-value(78.34) and significance level (0.001) corroborate thesignificanceofthemodelfortestingthehypotheses.TheresultsoftheValeridgetestalsodemonstratethatthere

is no autocorrelation between the sentences.Adjustedcoefficient of determination was equal to 0.27. Theseverityofhealthservicesdelivery,profitability,debts,and hospital size were the independent variables andquasi-liquiditywas considered the dependent variableofthisresearch.Giventhesignificancelevelinthetablebelow,independentvariableshaveadirectandpositiverelationship with the quasi-liquidity of hospitals.Therefore,thesecondmodelfortestingthehypothesesisalsoacceptable.Theresultsoftable6indicatethatthemodelisoptimalfortestingthehypothesis,consideringtheF-value(91.37)andsignificancelevel(0.001).TheresultsoftheValeridgetestalsodemonstratethatthereis no autocorrelation between the sentences. Giventhe significance level in the table below, independentvariables have a direct and positive relationship withtheliquidityofhospitals.Therefore,thethirdmodelfortestingthehypothesesisalsoacceptable.

Table 1. The performance indicators of the studied hospitals during 2012-2016

The number of beds

Total mean

Bed occupancy rate (BOR)

Totalmean

Length of stay (LOS)

Hospitals 2016201520142013201220162015201420132012

19981.6187.387.882.370.1680.493.323.33.23.33.43.4GH1

59478.2484.681.474.974.8675.453.944.243.83.93.8GH2

54475.4877.478.278.672.4770.746.245.86.16.15.77.5GH3

15174.4982.687.175.267.9559.64.23.73.84.14.35.1SH4

9063.8366.762.161.258.570.656.044.85.15.56.48.4SH5

16287.9288.593.298.382.4877.165.285.65.45.25.34.9SH6

*GH:generalhospital;SH:specialtyhospital

Table 2. Financial indicators of the studied hospital during 2012-2016

yearMinMaxMeanStd. dev.VariableAbbreviation

2012

0.0170.3750.1110.103liquidityliq

0.0040.09770.060.044currentliquiditycliq

0.0090.1070.0870.101quasi-liquidityqliq

0.160.580.250.12profitabilityprof

0.190.690.350.19debtsdebt


2013

0.020.410.1050.17liquidityliq


0.0130.230.0910.11quasi-liquidityhliq


0.190.690.350.19debtsdebt

2014





0.190.690.330.18debtsdebt

2015





0.190.690.350.19debtsdebt


2016



0.130.480.19/09profitabilityprof

0.190.690.340.18debtsdebt

Table 3. The mean financial indicators of the studied hospital during 2012-2016

MeanIndicators

0.453Liquidity

0.036Currentliquidity

0.086Quasi-liquidity

0.218Profitability

0.344Debts

Table 4. The regression model of the effect of indicators on current liquidity

Variable Abbrev Significance level T value coefficient

Hospitalsize size 0.001 3.28 0.13

Profitability Prof 0.031 2.39 0.047

Debt debt 0.001 4.45- 0.29-

Hospitalservicesdelivery ser 0.015 2.64 0.15

Intercept 0β 0.001 3.09 0.14

Adjustedcoefficientofdetermination - 0.21

Fvalue=54.99Pvalue<0.001

Cont... Table 2. Financial indicators of the studied hospital during 2012-2016


Table 5. The regression model of the effect of indicators on quasi-liquidity




Debt debt 0.001 4.17- 0.54-


Intercept 0β 0.241 1.16 0.04



Table 6. The regression model of the effect of indicators on liquidity




Debt debt 0.001 -3.82 -0.34


Intercept 0β 0.263 1.04 0.08



DISCUSSION

Thepresentstudyaimedtodeterminetheliquidityof teaching hospitals in Ahwaz based on financialindicators.Manystudieshavebeenconductedtoidentify,design,andusefinancialindicatorsforhospitalsaroundtheworld, inwhich financial indicatorswere selectedwith regard to unique features of each hospital. Thisis due to the difference betweenhospitals in terms ofmission and objectives, financing methods, the needsof the population under coverage, reimbursementstrategiesofinsurancecompanies,ownershiptype,etc.[12]Generally, each of the newmethods for evaluatingfinancial performance has been developed in order toimprove and remove the problems of previous ones.Lowe et al. and Pink et al., respectively, proposed13 and 6 indicators as the most important financialindicatorsfordecision-makersinthehealthcaresector.[13] Generally, 9 indicators in 5 functional dimensionshave been introduced as key indicators for acute carehospitals. [14] In a study conducted by Watson, the

Management Information System (MIS) of Canadawas accepted as a data source for calculating andcomparingfinancialindicatorsinacutecarehospitalsofManitoba State.They showed accrual and cash ratiosfor the evaluation of organizational performance byreviewing the increasing informational content. [15] Inanotherstudytoachievetherealvalueofeachindicatorin teaching hospitals affiliated with Tabriz UniversityofMedicalSciences,the“NewFinancialSystem”wasusedasthedatasourceineachhospital.[12]Theresultsofmultivariate regression testandpaneldata testalsoindicated that hospital liquidity has a significant andpositive relationship with hospital size (number ofbeds), profitability, debts, and the severity of healthservicesdelivery.TheseareconsistentwiththefindingsofZeileret al. using the proposedmodel and learningthe measures and indicators of financial performanceevaluation,managersandpolicymakersofhospitalscanincrease theproductivityof their hospital by focusingonoutcomesandpavethewayfortheestablishmentof


adynamically-managedhealthcaresystem.Moreover,accordingtothefirstresearchhypothesis,

CONCLUSIONS

The results of study showed that liquidity ofhospitalscanbeincreasedbyincreasingtheirsizeandcreating more spaces. This can lead to the improvedstructureofcapitalandfinancinginhospitals.Thestudyfindings also suggest that improved performance ofhospitalscanbefollowedbytheoptimaluseofassetsandincreasedliquidityofthem.Thiscanbelaterutilizedinthelinewiththedevelopmentandprogressofhospitals.In addition,hospitals canuse the issuanceof thenewstock to provide their capital structure and increasetheirliquiditybyimprovingthequantityandqualityoftheirhealthcareservices. It isalso recommended thathospitalstakeadvantageofnewsoftwareapplicationsinordertocorrecthospitaldepreciationandincreasetheirliquidity.

Ethical Clearance: This research project wasapproved by the ethics committee of Islamic AzadUniversityofShushtar.

Source of Funding: Islamic Azad University ofShushtar.


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1- Nelson Ec, Splain, ME, Batalen PB. Buildingmeasurement and data collection into medicalpractice.AnninternMed.1998;128(6):460-66.

2- ZellerTL,Stanko,BB,ClevereyWO.Arevisedclassification pattern of hospital financial ratios.Journal of Accounting and Public Policy.1996;15(2):161–81.

3- Cleverley W, Harvey R. Does hospitalfinancial performance measure up? CleverleyWO& Harvey, RK. Does hospital financialperformance measure up?. Healthcare financialmanagement.1992;46(5):20-6.

4- Rauscher S, Wheeler J. The importance ofworking capital management for hospitalprofitability:evidencefrombond-issuing,not-for-profit U.S. hospitals. Health Care ManagementReview2012;37(4):339-46.

5- Nowicki M. The Financial Management ofHospitalsandHealthcareOrganizationIL;HealthOrganizationPress,2008.

6- Kachniarz M. Commercialization of anindependent public health care facility. The keyconditionsforSuccess,2008.

7- Rój J, Sobiech J. Financial management of thehospital.Warsaw:WoltersKluwerABCPublishingHouse,2006.

8- Rezapour A, Arabloo J, Soleimani MJ,EbadiFardAzar F, Safari H. MicroeconomicAnalysis ofHealthcare Services inBouAli SinaUniversity Hospital. International Journal ofHospitalResearch.2012;1(1):41-50.

9- Smith PC. Elias Mossialos E, Papanicolas I.Principles of performance measurement. EuroObserver.2008;10(1):1-4.

10- Rezapur, ah and ghost, h. Performance ofProduction Inputs in Public Hospitals of theUniversity of Medical Sciences Iran. Journalof Shahrekord University of Medical Sciences.2006;10(1):109-14.

11- TavakoliG,MahdaviS,ShokrolahzadehM.TheComparative Survey on Deductions Appliedby Khadamat-eDarman Insurance Company onPatients’ Bills at teaching hospital ofKerman inthe first quarter of 2001. Proceedings of the 1stNationalConferenceonResourceManagementinHospital;2003Jan:8-9;Tehran,Iran,2003.

12- Janati A, Valizadeh S, Asghari-Jafarabadi M.Development of Financial Indicators of HospitalPerformance. Journal of Clinical Research &Governance.2014;3(2):92-8.

13- LoveD,RevereL,BlackK.ACurrentLookattheKey Performance Measures Considered CriticalbyHealthCareLeaders.JOURNALOFHEALTHCAREFINANCE.2008;34(3):19–33.

14- Pink GH, Holmes GM, D’Alpe C, Strunk LA,McGee P. Slifkin RT. Financial indicatorsfor critical access hospitals. Journal of RuralHealth.2006;22(3):229-36.

15- BarakAZ.CashFlowRatiosvs.AccrualsRatios:Empirical Research on Incremental InformationContent.TheBusinessReview.2010;15(3):206-13.

A Prospective Study of the Correlation between Non – Fatal Road Traffic Accidents and Age of Victims

Prasanna P1, Dhritiman Nath2, Pramod Kumar GN3, S Kumar4

1Assistant Professor, 2Associate Professor, 3Professor, 4Professor and Head, Department of Forensic Medicine & Toxicology, Mahatma Gandhi Medical College & Research Institute, Pondicherry, India

ABSTRACT

Introduction:RoadTrafficAccidents(RTA)areoneoftheleadingcausesofdeathanddisabilityworldwide.Inthisstudy,theauthorshaveattemptedtostudythecorrelationbetweennon–fatalRTAandageofvictimsbroughttoMahatmaGandhiMedicalCollege&ResearchInstitute,Pondicherry.

Materials and Method: The prospective study was jointly conducted by the Department of ForensicMedicine&ToxicologyandDepartmentofEmergencyMedicine,MahatmaGandhiMedicalCollege&ResearchInstitute,Pondicherry.ItwasdonefromNovember2012toMay2014andatotalof186caseswerestudied.RTAcasesadmittedinthehospitalwereonlyincludedandcasesotherthanRTA,RTAcasesadmittedelsewhereorbrought–deadcaseswereexcludedfromthestudy.Datawasobtainedbyinterviewingthevictimsorrelativesofthevictims.Informedwrittenconsentwastaken.Medicolegalrecords,casesheetsandlaborradiologicalreportswereusedforcollectingadditionaldata.

Results: Mostvictims(61or32.8%)belongedtotheagegroupof21-30years.Nextcommonagegroupwasthe31–40yearsgroupwith37victims(19.9%).Leastcommongrouptobeaffectedwasthe1-10yearsgroupwith7victims(3.8%).

Discussion :IncidencesofRTAareincreasingbyleapsandboundsinIndia.Indiahastotakeconcretestepstobringdownsuchcases.Withthisview,thegovernmenthasformulatedtheNationalRoadSafetyPolicy.Itislefttouscitizenstoseethatsuchpoliciesarestrictlyadheredtoandimplementedsuccessfullysothatthecomingyearsseeadeclineintheincidencesofthesecases.

Keywords: Accidents, age, Pondicherry

Corresponding author: Dhritiman Nath,AssociateProfessor,DepartmentofForensicMedicine&ToxicologyEmail:[email protected],Ph:8903733042/9047333041.

INTRODUCTION

As per WHO, Road Traffic Accidents (RTA)are one of the leading causes of death and disabilityglobally.Every year, they account for about 20 to 50millionnon– fatal injuriesworldwide.1 It is projectedthatby2020,non–fatalRTAwillbethethirdleadingcauseofdisability–adjustedlifeyears(DALYs)lost.2

The incidences of these events are on an increasing

trendeveryyearandcanbeattributedtorapideconomicgrowthandresultantmotorization.3,4

This situation is of major concern in developingeconomies like India where sales and purchase ofvehicles peaks up every year but development ofinfrastructurelikeroadwayshasnotbeenabletokeeppacewithit.5Asofnow,inIndia, theaccidentrateof35per1000vehiclesisoneofthehighestintheworld.6

In this article, the authors attempt to study thecorrelationbetweennon–fatalroadtrafficaccidentsandageofvictimsbroughtfortreatmenttoMahatmaGandhiMedical College & Research Institute, PondicherrybetweenNovember2012toMay2014.Presently,thereis limited studyavailable from thisareaon this topic.The authors hope that the data retrieved in this study

DOI Number: 10.5958/0973-9130.2018.00172.X


willbeofhelptothepolicymakersanddecisiontakerssothattheseincidencescanbereasonablycontainedinthetimetocome.


This study was conducted by the Department ofForensic Medicine & Toxicology and Departmentof Emergency Medicine, Mahatma Gandhi MedicalCollege&ResearchInstitute,Pondicherry.TimeperiodtakenwasforoneandhalfyearsfromNovember2012toMay2014. A total of 186 caseswere studied andanalysed.

Inclusion Criteria: onlycasesofRTAadmittedinthehospital

Exclusion Criteria: any trauma not due to RTAmedicalorsurgically intervenedcasesdoneelsewherebrought–deadcases.

METHOD

The study was proposed to be done on atleast 100 cases ofRTA.Datawas obtained byinterviewing the victims or the accompanyingpersonsincaseswherethevictimswereunableto communicate. Informedwritten consentwastaken and a pretested proforma was used forthis purpose. Medicolegal records, case sheetsand lab or radiological reports were used forcollecting additional information. All findingswererecordedintheproformaandtheparameterswere charted in diagrams. SPSS program wasusedforthispurpose.

RESULTS

From this study, it is concluded that mostof thevictimsofRTA(61or32.8%)belongtothe age group of 21- 30 years (Table 1). Nextcommon age group to be affected is the 31 –40 years groupwith 37 victims (19.9%).Leastcommongrouptobeaffectedistheagegroupof1-10yearswith7victims(3.8%).

Table 1: Distribution of cases of RTA according to age of victims.

Age of victims Number of cases %

1-10years 7 3.8

11-20years 17 9.1

21-30years 61 32.8

31to40years 37 19.9

41to50years 35 18.8

51to60years 14 7.5

>61years 15 8.1

Total 186 100.0

DISCUSSION

Rapidindustrializationwithincreasedmotorizationandscantregardtolegal,healthcareandsafetyreformshasledtoasurgeofincidencesofRTAindevelopingcountries.7Globally,itistheeight-leadingcauseofdeathandthemostimportantcauseofdeathintheproductiveagegroupof15–29years.8

Amongallnations,IndiahasthehighestnumberofcasualtiesduetoRTA,withaquantum17.6%increaseinnumberofdeathsinbetween2008to2012. Indiaspendsabout 12.5 billion dollars every year for prehospitalcare, emergency care, and rehabilitation of victims ofRTA.Itisequivalentto3%ofthenationalGDP.9 Thisestimateisexclusiveoftheeconomicburdenonaccidentsurvivorswithpermanentdisabilities.10Thus the socioeconomicandfinancialimplicationsofRTAarecolossalfor a developing country like India. If the number ofcases keep on increasing every year, as predicted byseveral studies, the economical burden will increasesimultaneously and is likely to affect the financialstabilityandhampergrowthanddevelopment.11,12

Risk factors for RTA are broadly classified ashumanandenvironmental factors.Ageofvictims fallundertherealmofhumanfactors.13

In our study, most of the victims (61 or 32.8%)belonged to the age group of 21 – 30 years. Otherstudiesalsonotedsimilarresults.13,14,15Thereasonmaybe that people in this age group aremore inclined todisobeytrafficrulesandregulationsandalsolimittheiruseofsafetyequipmentslikehelmets,seatbelts,gloves,protectivejacketsetc.Othercontributingfactorsareapoorsenseofjudgement,risk–takingaptitude,senseofinvulnerabilityandinexperience.


Inourstudy,theleastaffectedgroupwaschildrenfrom 1 to 10 years of age. The reason may be theirlimitedtimespentontravellingontheroad.Moreover,thefactthatthisgroupdoesnotdrivemakesincidenceofsuchcaseslessinnumber.

Thesocio–economicburdenofRTAisincreasingyearafteryearandIndiacannolongeraffordtoturnablindeyetothisproblem.Theneedofthehouristobringdown thenumberofcases.Manydevelopedcountrieshave intensified their approach to road safety withspecial emphasis on traffic management, appropriateinfrastructure, road designs, law enforcement andprovision for prompt accident care.15 Considering thescenario here, certain steps may be taken. Potholes,roaderosion,trafficsignalshavetobemendedonawarfooting. Protective devices like suitable sign – ages,markings etc should be installed. Rules like lawfullimitofspeed,useofbreathanalyzerstodetectalcoholconsumption at check points, imposing fines for notwearinghelmet, banning cellphones duringdrivingorwearing seat belts have to be strictly implementedbytheconcernedauthorities.16

As a long-felt need, the government has initiatedcertainsteps to improveroadsafety inIndia.NationalRoadSafetyPolicyhasbeenimplementedandaNationalRoad Safety Council is in the offing. Tamilnadu hasstarted a Road Accident Data Management System.Manystatesacross thecountryhaveshowninterest inthesystemandareeagertoimplementit.17Amendmentshave been brought to existing laws concerning roadsafety. However, implementation of these laws isstill amatter of anguish. It augurs well if people areardentlysensitizedtothedifferentrulesandregulationsconcerning the road safety.Todecreasemortalityandmorbidity, interested volunteersmust be trainedon atleastbasicfirstaidmanagementskills.Morenumberofadequatelystaffedclinics,bothgovernmentandprivate,with requisite infrastructure are an absolute must,especiallyintheremoteandnot–so–accessibleareas.Peopleofthiscountryshouldwholeheartedlycooperatewiththegovernmentforimplementationofthelawsandschemes concerning road safety so that incidences ofRTAcanbegradually reined inwithinanappropriatetimeperiod.

Conflict of Interests: Theauthorsdeclarethattheyhavenocompetinginterests.


Ethical Clearance: Ethicalclearancewasobtainedfrom the Institutional Ethical Committee ofMahatmaGandhiMedicalCollege&ResearchInstitute(DeemedUniversity),Pondicherry.

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2. Nantulya VM, Reich MR. The neglectedepidemic: road traffic injuries in developingcountries.BMJ2002;324:1139–41.

3. GargN,HyderAA.RoadtrafficinjuriesinIndia:areviewofliterature.ScanJPublicHealth2006;34:100–9.

4. Moniruzzaman S, Andersson R. Economicdevelopmentasadeterminantofinjurymortality–alongitudinalapproach.SocSciMed2008;66:1699–708.

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10. Government of India. Ministry of Home Affairs.National Crime Records Bureau. AccidentalDeaths and Suicides in India. 2012 [internet].[Cited 2017 Sept 23]. Available from: http://www.ncrb.gov.in/CD-ADSI-2012/ADSI2012.pdf .

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12. PedenM,McGeeK.,SharmaG.Theinjurychartbook. A graphical overview of global burdenofinjuries.Geneva.WorldHealthOrganization2002.

13. AnnaduraiK,ManiG,DanasekaranR.Recurringtragedy of road traffic accidents in India:Challengesandopportunities.IndianJCritCareMed2015Jul;19(7):434–435.

14. SinghA,BhardwajA,PathakR,AhluwaliaSK.AnepidemiologicalstudyofroadtrafficaccidentcasesatatertiarycarehospitalinruralHaryana.IndianJournalofCommunityHealth2011July-Dec;23(2):53–55.

15. Tripathi M, Tewari MK, Mukherjee KK,Mathuriya SN. Profile of patients with headinjuryamongvehicularaccidents:Anexperiencefrom a tertiary care centre of India.NeurologyIndiaNov-Dec2014;62(6):610–17.

16. JoshiAK,JoshiC,SinghM,SinghV.RoadtrafficaccidentsinhillyregionsofnorthernIndia:Whathastobedone?WorldJEmergMed2014;5(2):112–15.

17. Singh V.P., Banerji A.K. Head injury due tovehicular accidents.Neurology India.Nov-Dec2014;62(6):585–87.

Effectiveness of Ergonomic Gymnastics on Decreasing Blood Pressure in Patients with Stage One Hypertension, Indonesia

Masriadi1, Febrianto Arif2

1Associate Professor, Institute of Health Science Tamalatea, Makassar, Indonesia, 2Lecturer, Institute of Health Science Batara Guru, Luwu Timur, Indonesia

ABSTRACT

Background:Increasedageisonefactorcausingtheoccurrenceofhypertension,thisisduetotheincreasingageoforganfunctiondecreasedmarkedbydecreasedelasticityofthearteriesandstiffnessoccursbloodvessels sovulnerable toan increase inbloodpressure.Thisergonomicgymnastics isaphysicalactivitythat can to smoothbloodcirculation and increasepulse and canburn fat.This studyaims todeterminethe effectiveness of ergonomic exercise in lowering blood pressure in patients with hypertension afterintervention.Theeffectivenessoftheinterventioncanbeknownbylookingattheresultsofpre-testandpost-test blood pressure of hypertensive patients.Material andMethods: The type of research is quasiexperimentalwithnonequivalent controlgroupdesign.Sampleinthisresearchispatientofhypertensionstageonethatis33people.DataanalysiswasperformedbyusingWilcoxontestwithα=0.05.Results.Theresultofthisstudyshowedthatergonomicgymnasticsexperimentsgrouponetimesaweekp–valueonsystolicbloodpressurewas0.317>0.05,p-valuediastolic0.216>0.05,ergonomicgymnasticsgrouptwotimesaweekp–valueonsystolicbloodpressurewas0.043<0.05p-valuediastolic0.078>0.05,ergonomicgymnasticgroupthreetimesaweeksystolicbloodpressurewas0.043<0.05p-valuediastolic0.144>0.05.DataanalysiswasperformedusingKruskalWallistestexplainsthatprepost-testsystolicbloodpressureafterergonomicexercise in theexperimentalgroup1,2and3 timesaweekp-value0.019<0.05meansthatthereisasystolicbloodpressuredifferencebeforeergonomicexercise,whereasdiastolicprepost-testafterergonomicexercisesp-value0.465>0.005meansthereisnodifferenceindiastolicbloodpressure.Conclusion.Theconclusionoftheresearchresultsistheinterventionwithtwotimeergonomicgymnasticsinaweekmoreeffectiveforloweringbloodpressureinpeoplewithhypertension.Itisthereforeadvisableforpatientswithhypertensionstage1toalwaysperformphysicalactivitiessuchasergonomicexerciseandcheckbloodpressuretohealthworkersonaregularbasissothatbloodpressurecanbecontrolled.

Keywords: Hypertension, Blood Pressure, ergonomic, gymnastics, physical activities

Corresponding author: Masriadi E-mail;[email protected]

INTRODUCTION

Increasedageisonefactorcausingtheoccurrenceofhypertension,thisisduetotheincreasingageoforganfunctiondecreasedmarkedbydecreasedelasticityofthearteriesandstiffnessoccursbloodvesselssovulnerabletoanincreaseinbloodpressure. Hypertensionisoneofthemanydegenerativediseasesoccurandhaveafairlyhighmortalityrateandaffectsthequalityoflifeanda

peopleproductivity.Hypertension, amajor risk factorfor cardiovascular disease, is also a leading cause ofprematuredeathandathirdcauseofdisability.Itaffects1 billion people worldwide, leading to heart attacks,strokes,andkidneyfailure.[2],[3],[4],[5],[6]

The total number of people with hypertension isexpectedtoincreaseto1.56billionby2025.[7]Therefore,a prevention approach that focuses onmodifying riskfactors for hypertension is essential to control thisgrowing epidemic.Over the last 4 to 5 decades, datacollection has resulted in consistent findings on theprotective effects of physical activity in preventinghypertension.[8],[9],[10],[11]

DOI Number: 10.5958/0973-9130.2018.00173.1


Arecentsystematicreviewofaprospectivecohortstudyshowedaninverserelationshipbetweenphysicalactivity and incident hypertension. One activity thatcan lower blood pressure is ergonomic exercise. Thisergonomicgymnasticsisaphysicalactivitythatcantosmooth blood circulation and increase pulse and canburnfat.Thisstudyaimstodeterminetheeffectivenessofergonomicexerciseinloweringbloodpressure.

MATERIAL AND METHOD

ThisstudywasconductedonApril2st-June9th,2018. The type of this study was quasi experimentalwithnonequivalentcontrolgroupdesign.Thesampleinthis studywas the first stage hypertension patient, 33peopleconsistingof3experimentalgroupsand3control

groups.Eachexperimentalgroupconsistedof5peoplewhoweregivenergonomicgymnasticsinterventions1timeaweek,2timesaweek,and3timesaweek,whileeach control group consisted of 6 people who werenot intervened.DataanalysiswasperformedbyusingWilcoxon andKruskalwallis testwith α = 0.05. Thepopulationandsampleofthestudywereallfirststagehypertensionpatientsof100people.Thisresearchusespurposivesamplingtechnique.

RESULTS

Totalsamplethatwouldbeanalyzedin thisstudywas33samples.BasedonbivariateanalysisintheTable1,analysisofergonomicgymnasticwithbloodpressuredrop(pvalue<0.005).

Table 1. Analysis Wilcoxon of Ergonomic Gymnastic Effectiveness once a Week, Twice Weekly and Three Times a Week on Decreasing Blood Pressure in Patients with Stage One Hypertension

Systolic_After Systolic_Before

Diastolic_Aftre Diastolic_Before

Groupgymnastics1timesaweekp-value

-1.000.317

-1.236.216

Controlgroup1p-value

-1.414.157

-.1095.273


-2.023.043

-1.761.078


-1.633.102

-.000.1000


-2.032.043

-1.461.144


-1.414.157

-1.633.102

Table 2. Analysis Kruskal wallis test Systolic and Diastolic Blood Pressure before and after Ergonomic Exercise on Decreasing Blood Pressure in Patients with Stage One Hypertension (experimental group)

Week Frek Mean Rank p-value

Systolicpre-test Intervention1timeaweek 5 9

Intervention2timeaweek 5 7.8 0.707

Intervention3timeaweek 5 7.2

Systolicpost-test Intervention1timeaweek 5 12.5



Diastolicpre-test Intervention1timeaweek 5 9.6



Diastolicpost-test Intervention1timeaweek 5 9.9




Table 3. Analysis Kruskal wallis test Systolic and Diastolic Blood Pressure before and after Ergonomic Exercise on Decreasing Blood Pressure in Patients with Stage One Hypertension (control group)


Systolicpre-test Intervention1timeaweek 6 10


Intervention3timeaweek 6 10







Diastolicpost-test Intervention1timeaweek 6 10



DISCUSSION

Table1.showsthattheexperimentalgroupofonesystolicbloodpressurebeforeandaftertheinterventionhasp-value0.317>0.05meaningthereisnosignificantdrop in blood pressure, whereas the diastolic bloodpressure before and after intervention p-value 0.216>0.05meansthereisnopressuredropsignificantblood.

Decrease in systolic and diastolic blood pressurein patients with stage 1 hypertension with 1 weekgym intervention for 3 weeks in a row still need toincreaseregularlytonormalizebloodpressure,physicalactivity like ergonomic gymnastics is one factor thatvery important role todecrease riskof atherosclerosiswith strengthen the heart and reduce the work of theheart.Physicalexerciselikeregularexercisealsohelpspreventchronicconditionsorillness,suchashighbloodpressure.[12]

Rizqiyatiningsih,S(2014)explainsthatergonomicgymnasticsisabletorestorethepositionandflexibilityof the nervous system and blood flow, maximize thesupplyofoxygentothebrain,abletomaintainthebody’sfreshness system and negative energy exhaust systemfromthebody.InadditionergonomicGymnasticscanalso increasemuscle strength and the effectiveness ofheartfunction,preventhardeningofarteriesaswellas

launchingtherespiratorysystem.Ergonomicgymnasticscanbedonebyallages.Gymnasticsergonomicsconsistsofmovements that resemble themovementofprayersso that theelderlyeasy toapply themovementof thegymnastics.[12]

TheresultsofstatisticaltestanalysisusingWilcoxontestinTable1.Showthatgroup2gotsystolicbeforeandafterinterventionp-value0.043<0.05meansthereisasignificant decrease in blood pressure, while diastolicsignificationvaluebeforeandafterp-value0.078>0.05meansthereisadecreaseinbloodpressuresignificant.

Samples with systolic blood pressure droppednearly half of the sample as they actively followedgymnastics and followed proper ergonomic exerciseprocedures on a continuous basis warm up exercises,coreexercisesaswellascoolingorclosingexercises.Sampleswhosebloodpressureremainedandincreasedbecause of excess body weight and gymnastics werenot done continuously. Ergonomic gymnastics is afairlydifficultexercisetodoperfectlybecausethereareseveralmovementssuchassittingmotionwhilesittingand sitting resigned that is difficult to do perfectlyaffectingsystolicbloodpressureanddiastolic.


Ergonomic gymnastics is one type of exercisecombined with muscle movement and breathingtechniques.Respiratory technique is done consciouslyandusingadiaphragm,sotheabdomenisliftedslowlyland and chest fully inflate. This breathing techniqueprovidesaheartmassage,opensblockagesandsmoothsblood flow to the heart and increases blood flowthroughoutthebody.[13]

The statistic test using Wilcoxon test in Table1 explains that group 3 obtained systolic before andafter p-value 0.043<0.05means there is a significantdecreaseinbloodpressure,whilediastolicsignificancevalue before and after p-value 0.144> 0.05means nodecreaseinbloodpressurewhichissignificant.

Sampleswithsystolicbloodpressuredecreasedbyalmost half of the sample because theywere activelyfollowinggymnasticsandfollowingcorrectergonomicgymnastics procedures for continuous warmingexercises, core exercises and cooling exercises orclosingexercises.Sampleswhosebloodpressureisfixedandtheirbloodpressurehasincreasedbecausetheyarestarting to look lazy in doing gymnasticsmovementslikejoking,notdoingthemovementperfectlybecauseergonomicexercisesdonein3timesaweekmakethesampleboredandanxiousandtherearesomewhothinkwork at home so as not can achieve optimal calm infollowingergonomicgymnasticactivities.

Table 2 explains that pre-test systolic bloodpressure after ergonomic exercise in the experimentalgroupof1,2and3timesaweekp-value0.019<0.05meansthatthereisasystolicbloodpressuredifferencebefore ergonomic exercise, whereas pre-post-testergonomic exercise diastolic p-value 0.019> 0.005means there is diastolic difference. The results of thestudy with the theory of Tangkudung (2004) andRevisionofPrimeMission(2014)whichexplainsthatthereareergonomicexercises that can lowerblood inhypertensive patients. [14], [15] Ergonomic gymnastics isa fundamental gymnastics movement in accordancewith the order and physiological body. The body isautomaticallypreservedhomeostatisnya(regularityandbalance)Stateinafitstate.[16]Movementinergonomicgymconsistsof5basicmovementsand1covermotion.Basic ergonomic gymnastics movement consists of abroadmovement of chest, thanksgiving dance, sittingmighty,sittingfireandwildresigned.Movementcoverergonomicgymnasticsisamovementofenergycalled

themovementofenergy.Eachmovementincludestheusualbenefitsindiseasepreventionandhealthcare.[17]

Table 3 explains that pre post-test systolic bloodpressure in thecontrolgroup1,2and3 timesaweekp-value 0.080> 0.005means no difference in systolicbloodpressure,whereasdiastolicbloodpressureprepostp-value 0.514> 0.005means there is no difference indiastolicbloodpressureinthecontrolgroup.Oneeffortthatcanbedonetostabilizeandlowerbloodpressureinpeoplewithhypertensionandpreventcomplicationsthat is by doing ergonomic gymnastics. Ergonomicgymnastics can be applied both in experiment andcontrol group with frequency 2 times a week doneregularly, regularly and continuously in order to getbiggerbenefit.

Ergonomic gymnastics is a technique of exerciseand breathing to restore or improve the position offlexibilityofthenervoussystemandbloodflow.Iftheflexibilityofbloodflowisgooditwillallowthebloodvessels to relax quickly as the heart pumps blood. Inthe less elastic or rigid blood vessels can complicatethe saggingbloodvesselsquicklyas theheartpumps,resulting in increased blood pressure as the heartcontracts. Ergonomic gymnastics also maximize thesupplyofoxygento thebrain,so thebrainisnot lackofoxygenandnutrientsandavoidthedamageofbloodvessels in the brain. Ergonomic gymnastics can alsomaximizethecombustionsystemoneofwhichburningcholesterol.BurningcholesterolwillaffectthelevelofLDL(low density lipoprotein)inthebloodandincreaseHDL (high density lipoprotein) whichwill reduce theatherosclerosis that inhibits blood flow. Movementcontainedinergonomicgymnasticsisaveryeffective,efficientandlogicalmovementbecauseitisaseriesofmovementsperformedbyhumans from thebeginninguntilnow.[18]

The results of the statistical test using Kruskalwellis were obtained before the ergonomic exercisep-value0.322>0.05andafter thep-value0.465meanthattherewasnodifferenceinsystolicbloodpressureintheexperimentalgroupaswellasthecontrolgroupwithp-value0.514>0.05.Samplesthatdonotdecreasebloodpressure because the movement of gymnastics is notcontinuity. The more frequent ergonomic gymnasticsperformed causing the respondents to start saturatedand bored so that the exercises do not mean it. Inaddition,longtermresearchfactors,lackofseriousness


ingymnastics,movementsnot in accordancewith thetempoand themovementhasnotbeendonecorrectlyastaught.

The results of this study are consistent with theresearchconductedbyZulaikha(2016)explainingthatp-value 0.376> 0.05, meaning there is no differencein diastolic blood pressure in the three study groups(experimental group 1 with elderly gymnastics 2times a week, experimental group 2 with gymnasticselderlygymnastics3timesaweekandgroup3withoutintervention)inelderlyhypertensioninBulucommunityhealth service center working Area. Each groupconductedastudywiththesameperiodof2weeks.[19]

CONCLUSION

The conclusion of the research results is theintervention with two time ergonomic gymnastics inaweekmore effective for lowering blood pressure inpeoplewithhypertension.Itisthereforeadvisableforpatients with hypertension stage 1 to always performphysicalactivitiessuchasergonomicexerciseandcheckbloodpressuretohealthworkersonaregularbasissothatbloodpressurecanbecontrolled.

Finacial support and sponsorship: Owncost

Ethical considerations: Ethical clearance wasobtained from Institute of Health Science “MalukuHusada”, Ambon, Indonesia; with number” RK.03/KEPK/STIK/I/2018. Justbefore the interview,written(or thumb impression) consent was obtained fromeachparticipant in InstituteofHealthScienceAmbonguidelines.

Conflicts of Interest : The authors alone areresponsible for theviewsexpressed in this articleandtheydonotnecessarilyrepresenttheviews,decisions,orpoliciesoftheinstitutionswithwhichtheyareaffiliated.

REFERENCES

[1] Masriadi, Azis R, Sumantri E, Mallongi A. Effectiveness of non-pharmacologic therapythroughsurveillanceapproach tobloodpressuredegradation in primary hypertension patients,Indonesia. Indian Journal of Public HealthResearch&Development.2018;9(4):249-255.

[2] Global Public Health Crisis [internet]. WorldHealthDay,2013.[Cited2018June19].Available

from:http://www.who.int.

[3] Cao X. A call for global research on non-communicable diseases. Lancet. 2015; 385:e5–e6.

[4] Mozaffarian D, Benjamin EJ, Go AS, ArnettDK, Blaha MJ, Cushman M, Das SR, FerrantiSD,DesprésJP,FullertonHJ.Heartdiseaseandstroke statistics-2016 update: a report from theAmericanHeart Association. Circulation. 2015;133:e38–e360.

[5] Murray CJ, Lopez AD. Measuring the globalburdenofdisease.N Engl J Med. 2013;369 (5):448-57.

[6] Masriadi, Mega Ermasari. The Relationship offamily history, usage of wasted cooking oil,alcoholconsumption,smokinghabittheincidenceof essential hypertension at two areas of healthCenter of North Buton Regency, Province ofSouthEastSulawesi. JournalofSciences:Basicand Applied Research (IJSBAR), 2015; 24 (1):146-155

[7] XuejiaoLiu,D.Z.,YuLiu,XizhuoSun,ChengyiHan, BingyuanWang,YongchengRen, JunmeiZhou,YangZhao,YuanyuanShi,DongshengHu,MingZhang.Dose–responseassociationbetweenphysical activity and incident hypertension. Hypertension.2017;69(10):1-48.

[8] White DK, Gabriel KP, Kim Y, Lewis CE,SternfeldB.Doshortspurtsofphysicalactivitybenefit cardiovascular health?The cardia study.Med Sci Sports Exerc. 2015;47(11):2353-8.

[9] Jackson C, Herber G GC, Brown W. Jointeffects of physical activity and BMI on risk ofhypertension in women: a longitudinal study. J Obes. 2014;271532:1-7.

[10] Williams PT, Thompson PD. Walking versusrunningforhypertension,cholesterol,anddiabetesmellitusriskreduction.ArteriosclerThrombVascBiol.2013;33:1085–1091.

[11] HuaiP,XunH,ReillyKH,WangY,MaW,XiB. Physical activity and risk of hypertension:a meta-analysis of prospective cohort studies.Hypertension.2013;62:1021–6.

[12] Rizqiyatiningsih,S,The influenceofergonomicgymnastics on decreasing blood pressure withdegree1 hypertension inLansia inWironustom


Village Gatak Sukoharjo District. Scientificwritingstrataone,UniversityofMuhammadiyahSurakarta.2014.

[13] Prime, R.M., Effectiveness of ergonomicgymnasticswith aerobic low impact gymnasticsonbloodpressurelevelsinhypertensiveelderly.Critical, Medical & Surgical Nursing Journal. 2014;2(2):2014-04

[14] Tangkudung, James. Smart and fit withgymnastics.2004.Jakarta:Gramedia.

[15] Revision of the First Mission. Ergonomicergonomiceffectivenesswithaerobiclowimpactagainst level of blood pressure in [Cited 2018June19].Availablefrom:http://eprints.ums.ac.id

[16] Sagiran. Miracle Movement of Prayer, 2013.

Jakarta:QultumMedia.

[17] Wratsongko. Guidelines for healthy withoutdrugs. Ergonomic gymnastics, 2006. Jakarta:Gramedia.

[18] Syahrani,Theinfluenceofergonomicgymnasticson systolic blood pressure in elderly withhypertensioninSocialInstitutionTresnaWerdhaBudi Mulya 3 Margaguna Jakarta Selatan.2,Syarif Hidayatullah State Islamic UniversityJakarta,2017.

[19] Zulaikha,I.,Effectivenessofelderlygymnasticsagainst blood pressure lowering hypertensiveelderlyinWorkAreaofBuluCommunityHealthServiceCenterSukoharjoDistrict.Thesis.FacultyofHealthSciencesUniversityofMuhammadiyahSurakarta,2016.

Effect of Cold and Hot natured Diet on Level of Thyroid Hormones, Epinephrine, Norepinephrine, Cortisol,

Testosterone and LH in Human

Mohamad Masoumzadeh1, Abbasali Abbasnezhad2, Hamid Rasekhi3, Reza Ghiassi4, Mojtaba Kianmehr5

1Anesthesiologist, Bohlool Hospital, Gonabad University of Medical Sciences, Gonabad, Iran, 2PhD in Medical Physiology, Department of Physiology, Gonabad University of Medical Sciences, Gonabad, Iran, 3PhD in

Nutrition, Department of Nutrition Research, National Nutrition and Food Technology Research Institute and Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran,

Iran, 4MSc in English education, Faculty Member of Gonabad University of Payam Noor, Gonabad, Iran, 5PhD in Biophysics, Associate Professor, Department of Medical Physics, Faculty of Medicine, Gonabad University of

Medical Sciences, Gonabad, Iran

ABSTRACT

Introduction:Basedon Iranian traditionalmedicine, foodsareclassifiedunder twogroups:hot-naturedandcold-natured.Thepresentstudy,therefore,undertakestodeterminetheeffectsofhot-andcold-naturedfoodsontheamountofthyroidhormones,epinephrine,norepinephrine,cortisol,testosteroneandLHinthehuman.

Method: The studywasquasi-experimental and theparticipants in the experimentwere60 students, inGonabadUniversityofMedicalSciences,whohad,duringsummersemester,beenselectedanddependingontheirtemperamentplacedintothreesamplegroupsatduration3weeks,eachofthemhavingtheirowndietary program: one to be servedwith hot-natured foods for theirmeals, onewith cold-natured foods,and the one as reference groupwithmixed undifferentiated foods.The thyroid hormones, epinephrine,norepinephrine,cortisol,testosteroneandLHweremeasuredpre-andpost-intervention.Duetothenormalityofthedatadistribution,thegathereddatawereanalyzedusingSPSSsoftwareprogram(Ver.19)andpairedt-testandANOVAinameaningfullevelofp<0.05.

Results:AccordingtoANOVA(P>0.05),thestudentsofthethreegroupsshowednosignificantdifferencesindemographiccharacteristicsandmedical examinationspre-andpost-intervention.TheamountofT4,T3,cortisol,testosteroneandLHinbloodandcortisol,VMAandNormetanephrineinurinenosignificantdifferencesbetweenthethreegroupspre-andpost-intervention(p>0.05).

Conclusion:Theresultsofthisstudyshowedthatdietaryintakeofnormalnature,hotorcoldfor3weekstherewasnosignificantdifferenceintheamountofthyroidhormones,cortisol,testosterone,LH,cortisol,VMAandNormetanephrine.

Keywords: Hot- and cold-natured foods; hormones; Human

Corresponding author: Mojtaba Kianmehr, AssociateProfessor,DepartmentofMedicalPhysics,FacultyofMedicine,GonabadUniversityofMedicalSciences,Gonabad,Iran.E-mail:[email protected];Tel:05157223028

INTRODUCTION

Complementary and alternative medicine isincreasingly used in different countries; this is due tothe proven effectiveness ofmany of these substancesin scientificcommunitiesand itsacceptability inmosthuman societies.1,2 One of the beliefs of traditional

DOI Number: 10.5958/0973-9130.2018.00174.3


Iranian medicine is that some foods are hot and, incontrast,othersarecoldnatured.Excessivepartakeofcoldorhotfoodscanbeharmful.3-5

The health is a state of equilibrium between hotand cold elements in the body. A disease developswhen the body imbalances in excessive hotness orcoldness.However,thebalancecanberegainedthroughfoodtreatment.6Thenotionofhotnessandcoldnessisaccepted not only in traditional medicine of Iran butalso in traditional medicine of India, Europe,Arabia,Romania,GreeceandChina.4,7AccordingtotraditionalIranianmedicine,mainelementsoflivingorganismsarefire,air,waterandsoil.Hotness,coldness,wetnessanddroughtarebasicqualities;eachoftheaboveelementsiscomposedoftwoqualities.Fireishotanddry,airishotandwet,wateriscoldandwet,andsoiliscoldanddry.Ineachindividual,oneortwostatesaredominant;thisdominantstateiscalledtemperament.8,9

Intraditionalmedicine,foodslikehumanbodyaremadeupofsubstanceswhichmakethemhotorcold,wetordry.Humansneedtokeeptheirtemperatmoderatelevelsinordertoavoiddiseases.8IntheEncyclopediaofFoods,Woodstatesthathotandcoldnatureoffoodshasbeennoted in theancient literatureof Iran,ChinaandIndia.10Foodswhichcauseorexacerbatesymptomssuchas weakness, drowsiness, impatience are called cold-natured foods. Foods which cause symptoms such asfaster thanusualmovements, restlessness, disturbanceandinsomniaarecalledhot-naturedfoods.2,3,9

Thyroidstimulatinghormone(TSH)stimulatestheproduction of thyroid hormones from follicular cellsof the thyroid.11 Thyroxin (T4) and triiodothyronine(T3) are two main thyroid gland hormones whichgreatlyincreasemetabolicrateofthebody.Luteinizinghormone (LH) is secreted from the anterior pituitaryglandanditstimulatestesticularleydigcellstosecretetestosterone. Testosterone is secreted by testicularleydigcells;itisresponsibleformalesexualtraitsinthebodyandincreasesmusclemass.Cortisolsecretedfromglomerularregionoftheadrenalglandcortex.Cortisolincreases glucose, amino acids and free fatty acids oftheblood.12

If effectofhot andcolddieton functionof theseglandsisproven,itcanbeaharmless,low-costalternativewithlesspsychologicalandphysicalcomplicationsthanmedications (8). Therefore, this study examined the

effectsofcoldandhot-naturedfoodsonlevelofthyroidhormones, epinephrine, norepinephrine, cortisol,testosteroneandLHinstudents.

MaterialsandMethods

Thiswasaquasi-experimentalstudyon60healthymale students (18-22 years) at Gonabad Universityof Medical Sciences. After filling the consent form,studentsunderwentamedicalexamination.

Temperament of students was determined basedon their self-declaration. Hot-tempered students wereplaced in the cold diet group, cold-tempered studentswereplacedinthehotdietgroupandstudentswhodidnotknowtheirtemperamentwereplacedinthenormaldietgroupforthreeweeks.

Hot food items included saffron, walnuts, dates,grape juice, honey, banana, apricots, flixweed, garlic,onions, shallot, peppermint, pastries, raisins, coconut,rockcandy,melons,pears,zinger,cinnamon,cardamom,pepper,lamb,cocoa,sesame,eggs,peas,butter,cumin,fig, almonds, celery, chives, quince, carrot, pistachio,blackolives,hazelnuts,roostermeat,peanuts,mangoes,pennyroyal,horseradish,parsley,tea,persimmons,basil,yellowchubs,fenugreek, leeksandostrichmeat.Coldfoodsalsoincludedrice,yogurt,dough,milk,cucumber,tomato, pickles, cherries, peaches, watermelons,potatoes,veal,lemons,verjuice,pomegranates,sumac,barberry, spinach, lettuce, pumpkin, cabbage, whey,mushrooms, chicken, cheese, prunes, sour apple, ricemilk, sea-buckthorn, beans, lentils, broad bean,mungbean,fishmeat,goatmeat,starch,barleybread,barleysoup, animal brain, eyes, rumen, gizzard , vinegar,qaraqurot,citron,pumpkinseeds,corn,rhubarb,chicoryandcoriander.Normalfooditemsincludedwheatbread,kofta, kookoo sabzi, partridges, porridge, beet leaves,coffee, jujube, and a balanced blend of some hot andcoldfoods.3,13

Itwastendedtoavoidsignificantdifferenceinmeanenergyandprotein,carbohydrateandfatmacronutrientsbetween three groupswhichweremeasured by usingFoodProcessorIIsoftware.

TSH,T3,T4,cortisol,testosteroneandbloodLHand24-hoururinecortisolweremeasuredatthebeginningand the end of the intervention. Metabolites ofcatecholaminesincludingvanillylmandelicacid(VMA)andnormetanephrineof24-hoururineweremeasuredat


thebeginningandtheendoftheintervention.

NormetanephrinewasmeasuredbyELISAmethodwithHUMANdevice,andusing theLDNkit,Germany.VMAwasmeasuredbychromatographywithaBiosystemkit,Spain.TherestofhormonesweremeasuredbyusingfullyautomatedBellinidevice,thetkamodel,Italy,andbyusingmonobindkits.

DatawasinsertedinSPSS(Ver.19).Analysiswasdonebyusingpairwiset-testandone-wayanalysisofvarianceaswellasanalysisofvarianceofrepetitiveobservations(P<0.05).

RESULTS

Thedemographiccharacteristicsandpre-interventionalmedicalexaminationsarelistedinTable1.

Table 1: comparison of mean of age, BMI and vital signs in 3 groups before the intervention

p-valueCold dietHot dietNormal dietVariable

0.7862055±1.4620.85±1.4920.62±1.32Age(y)

0.21822.05±2.9321.81±2.7422.18±3.09BMI(kg/m2)

0.33636.86±0.34036.75±0.39436.89±0.175Temperature(°C)

0.075113.25±8.92119.30±7.65115.10±8.61SystolicBP (mmHg)

0.12674.45±5.1478.00±5.2975.95±5.83Diastolic BP (mmHg)

0.18774.95±11.6070.25±5.0471.52±6.83HR(permin)

0.78617.70±1.3017.80±1.7318.05±1.85RR(permin)

Intermsofage,BMIandvitalsigns,ANOVAshowednosignificantdifferencebetweenthreegroupsbeforeandaftertheintervention(P>0.05).

Table 2: comparison of mean of the measured hormones in 3 groups before the intervention


0.0899.14±1.279.07±1.269.92±1.51T4(µg/ml)

0.622156.50±23.00152.50±40.50162.38±31.76T3(ng/dl)

0.7531.44±0.651.62±0.881.49±0.80TSH(U/L)

0.2981.65±0.611.90±0.701.92±0.49LH(mu/L)

0.585487.00±153.68426.11±94.87413.83±191.11Cortisolinblood(nmol/L)

0.890105.70±29.20107.45±29.19103.42±21.29Cortisolinurine(nmol/L)

0.632362.00±131.97364.00±62.51391.90±126.00Testostrone(ng/dl)

0.9985.28±2.945.31±2.455.26±1.91VMA(mg/day)

0.993193.15±99.07192.50±90.06189.52±113.81Normetanephrine(µg/day)

ANOVAwasused.

Intermsofthyroidhormones,cortisol,testosteroneandbloodLHandcortisol,urineVMAandnormetanephrine,ANOVAshowednosignificantdifferencebetweenthreegroupsbeforetheintervention(P>0.05).


Table 3: comparison of mean of the measured hormones in 3 groups after the intervention


0.89210.84±2.2410.97±2.3611.19±2.43T4(µg/ml)

0.469139.50±30.51143.00±40.53152.85±35.93T3(ng/dl)

0.8382.56±1.442.35±0.932.39±1.15TSH(U/L)

0.1061.97±1.041.89±0.902.54±1.19LH(mu/L)

0.371499.00±111.44480.00±122.66407.33±134.53Cortisolinblood(nmol/L)

0.69275.60±32.2783.40±27.0479.85±26.48Cortisolinurine(nmol/L)

0.729361.50±137.39366.00±81.58390.00±141.27Testostrone(ng/dl)

0.6484.35±1.744.59±1.924.85±1.48VMA(mg/day)

0.861155.70±75.17165.90±78.26153.90±72.37Normetanephrine(µg/day)

ANOVAwasused.

Intermsofthyroidhormones,cortisol,testosteroneandbloodLHandcortisol,urineVMAandnormetanephrine,ANOVAshowednosignificantdifferencebetweenthreegroupsaftertheintervention(P>0.05).

DISCUSSION

Theresultsshowedthathot,coldandnormalfoodsconsumed by three groups did not have a significantdifference in levels of thyroidhormones, epinephrine,norepinephrine, cortisol, testosterone and LH. Thesefindings were inconsistent with Shahabi et al.4 The reason for thedifferencebetween resultsof this studyand the present study is that they classified samplesbased on temperament and therewas no intervention,whilethepresentstudyperformedfoodinterventionaftergroupingbasedonself-reportedtypeoftemperament.

Findings showed that T4 significantly increasedafter intervention, while there was no significantdifference between the three groups before and afterthe intervention. There was a significant decrease inT3 after intervention, while there was no significantdifference between the three groups before and afterthe intervention. There was a significant increase inTSH level after the intervention, while there was nosignificantdifferencebetweenthreegroupsbeforeandafter the intervention. However, all three hormonelevels were normal before and after the intervention.The active hormone of thyroid gland is T3, which isderivedfromconversionofT4toT3.

14

Thyroid hormones increase metabolic activity ofalltissuesofthebody.Whenalargeamountofthyroidhormoneissecreted,thebasemetabolismcanincreaseto 60 to 100% higher than normal; this increases the

amount of food used to generate energy. Thyroidhormones increase active transfer of ions from cellmembranes. Activity of the enzyme Na+, K+-ATPaseincreasesinresponsetothyroidhormones.Thisenzymeincreases transfer of both sodium and potassium ionsfrom the cell membrane of some tissues. Since thisprocessincreasestheheatproducedbythebodyduetoenergyconsumption,itisbelievedthatthisprocessmaybeoneofthemechanismsofthyroidhormoneeffectinincreasingmetabolisminthebody.15Thyroidhormonesstimulate glucose uptake, glycolysis exacerbation,gluconeogenesis, and increased absorption fromdigestivetractandevenincreasedinsulinsecretionbyitssecondaryeffectoncarbohydratemetabolism.16Normalsexual function requires normal secretion of thyroidhormones.Probably,deficiencyofthyroidhormonesinmenmayreducesexualdesire.15

In this study, there was no significant differencein post- and pre-interventional blood cortisol levels.Bloodcortisol levelwasnotdifferentbeforeandafterthe intervention in three groups. Post-interventionaland pre-interventional urinary cortisol levels weresignificantly different; urinary cortisol level was notdifferent before and after the intervention in threegroups.Themost famousmetabolic action of cortisoland other glucocorticoids is their ability to stimulategluconeogenesis by liver, which often increases it by6to10timesandultimatelyincreasesbloodglucose.15 Cortisol naturally exists early in the morning at the


highest level and in the evening and at night at thelowestlevel.Therefore,itisessentialtostatethetimetomeasurecortisollevels.17

Inthisstudy,therewasnosignificantdifferenceinpost- and pre-interventional blood testosterone levels.Blood testosterone level was not different before andaftertheinterventioninthreegroups.Testosteronealsoincreases base metabolism. Administration of largeamounts of testosterone can increase basal metabolicrate by up to 15%. Even secretion of usual levels oftestosteronefromthetestesduringadolescenceandearlyadulthoodalsoincreasesbasemetabolismby5to10%comparedwiththatinwhichtesticlesarenotactive.Thisincrease inmetabolism is probably the indirect resultof testosterone effect on protein anabolism, becauseincreasedvalueofproteinsincreasestheactivityofallcells.18

The results showed that post-interventional LHlevelwassignificantlydifferentfrompre-interventionalLH level only in the normal diet group, while LHlevel was not different in three groups before andafter the intervention.LH is secreted fromananteriorpituitary cell called gonadotroph, which affects thetarget tissues in testicles mainly by activating cyclicadenosine monophosphate (cAMP) system. This, inturn, activates certain enzyme systems in target cells.ValueoftestosteronesecretedisapproximatelydirectlyproportionaltoavailableLH.15

Inthisstudy,therewasnosignificantdifferenceinpost- and pre-interventional urineVMA. UrineVMAwas not different before and after the intervention inthreegroups.Therewasasignificantdifferenceinpost-and pre- interventional urine epinephrine,while urinenorepinephrine was not different before and after theinterventioninthreegroups.Circulatingnorepinephrinecausescontractionofmostbloodvessels.Thishormoneincreases heart activity, inhibits digestive system,dilates pupil eyes, and so on. Epinephrine causesapproximatelythesameeffectsasnorepinephrine,whileepinephrine ismore effective in stimulating the heartduetoitsstrongereffectonstimulationofbetareceptorsthannorepinephrine.19Epinephrine increase totalbodymetabolism by up to 100% of normal levels, therebyincreaseactivityandexcitabilityofthebody.15Adrenalglandsmakelargeamountsofcatecholamineinresponseto stress. The main catecholamines are epinephrine,norepinephrine and dopamine. Catecholamines break

downintoVMA,norepinephrineandnormetanephrine.20

Thisstudyonlyexaminedthequalifiedstudentsinthreeweeks.Sinceitwassummersemester,quantitativemeasurementofhot-naturedandcold-naturedfoodsandtemperament of samples were based on self-reporteddata. In addition, thenumberof interventional studiesconducted in this area is very limited, which limitscomparabilityoftheresults.

CONCLUSION

Based on results of this study, consumption ofnormal, hot or cold natured diet for 3 weeks did notsignificantly influence the levelsof thyroidhormones,cortisol,testosterone,bloodLHandcortisol,urineVMAandnormetanephrine.

Conflict of Interests: Nil

Ethical Considerations: Ethical matters e.g.plagiarism, informed consent, misconduct, datafabrication and/or falsification, double publicationand/or submission, redundancy, etc. have been totallyobservedbytheauthors.

Source of Funding: Deputy of Research ofGonabadUniversityofMedicalSciences

Ethics Clearance: Not required as it is a reviewarticle.

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8. Parvinroo S, Zahediasl S, Sabetkasaei M,KamalinejadM,NaghibiF.Theeffectsofselectedhot and cold temperament herbs basedon Iraniantraditionalmedicineonsomemetabolicparametersin normal rats. Iranian journal of pharmaceuticalresearch:IJPR.2014;13(Suppl):177.

9. Faridi P, Zarshenas MM, Abolhassanzadeh Z,Mohagheghzadeh A. Collection and storage ofmedicinal plants in The Canon of Medicine.PharmacognosyJournal.2010;2(8):216-8.

10. Wood RT, Pitchford P. new whole foodsencyclopedia:PenguinBooks;2010.

11. Sarapura VD, Samuels M, Ridgway C. Thyroidstimulatinghormone.ThePituitary.1995:187-229.

12. Hall JE. Guyton and Hall textbook of medicalphysiology:ElsevierHealthSciences;2015.

13. Avicenna. Canon of Medicine. Reprinted bythe Institute of Medical History: Islamic andComplementaryMedicinePublication;2004.

14. Gardas A. [Laboratory tests: level of T3, T4,TSH and antithyroid gland autoantibodies in thePolish population]. Endokrynologia Polska. 1990;42(2):353-8.

15. Longo DL, Fauci AS, Kasper DL, Hauser SL,Jameson JL, Loscalzo J. Harrison’s Principles ofInternal Medicine 18E Vol 2 EB: McGraw HillProfessional;2012.

16. Brenta G. Diabetes and thyroid disorders. TheBritish Journal of Diabetes & Vascular Disease.2010;10(4):172-7.

17. Findling JW, Raff H. Diagnosis and differentialdiagnosis of Cushing’s syndrome. Endocrinologyand metabolism clinics of NorthAmerica. 2001;30(3):729-47.

18. SimonD,NahoulK,CharlesMA.Sexhormones,aging, ethnicity and insulin sensitivity inmen: anoverviewoftheTELECOMstudy.AndrogensandtheAgingMale,ParthenonPublishing,NewYork.1996:85-102.

19. KrakoffLR,DziedzicS,MannSJ,FeltonK,YeagerK. Plasma epinephrine concentration in healthymen: correlation with systolic pressure and rate-pressureproduct.JournaloftheAmericanCollegeofCardiology.1985;5(2):352-6.

20. AliS,KieferS.SemanticCoordinationofAmbientIntelligentMedicalDevicesinFutureLaboratories.MASAUMJournalofBasicandAppliedSciences(MJBAS).2009;1(2).

A Review of the Risk Factors, Diagnosis and Treatment of Colorectal Cancer in Patients with Chronic Diseases in Iran

Zahra Movlavi Choobini1, Sedighe Movlavi Choobini2

1Deputy Research and Technology, University of Shahrekord Medical Sciences, Shahrekord, Iran, 2M.S.c in Community Health Nursing, Faculty of Nursing and Midwifery, University of Shahrekord Medical

Sciences, Shahrekord, I.R. Iran

ABSTRACT

Introduction:Colorectalcancerisoneofthewide-spreaddiseasesinmanyhumansocietiesandnumerousfactorslikeinflammations,oxidantsandchronicdiseasesaremajorriskfactorsforthisdisease.Investigationaboutitisimportantasageneralhygieneissue.

Analysis method: In this reviewresearch, information related to colorectal cancer, the risk factors,treatmentandrelatedpreventionwayswereextractedandstudiedbysearchingkeywordslike:colorectalcancer,chronicdiseases,chronicdiseasesandcolorectalcancerandriskfactorsofcolorectalcancer,amongpublishedarticlesindatabankssuchasIranmedex,Webofscience,Pubmed,ScienceDirect,SID,Ebsco,GooglescholarandMagiran.

Results:Generallyage,diet,colonpolyps,positivefamilyhistoryforcolorectalcancer,someunderlyingdiseasessuchasulcerativecolitis,historyofcancerintheperson,lackofphysicalactivity,obesity,diabetes,metabolicsyndrome,smokingandalcoholareeffectivefactorsincolorectalcancerincidence.Ontheotherhand,inspiteoftakenactions,differentreportsshowthattherateofcolorectalcancerisontheriseinIran.

Conclusion: Propernutritionalhabits,physicalactivitysuitabletoeachpatient’sability,attendingmuscularrelaxationplanfordiabeticpatientsandthepatientswithhighbloodpressurecanbepromisingforreducingthecasesofcolorectalcancer.

Keywords: Colorectal cancer, chronic diseases, risk factors.

INTRODUCTION

The studies shownowadays, cancer is one of thereasonsofmortalityanditisoneofthemajorproblemsinglobalhygiene (1-4) and ithasagreat importanceasoneoftheimportantsubjectsingeneralhygieneanditgainsmoreattentioninallcountriesdaybyday.Inthepresentera,bychanginglifestylesandurbanization,therate of some cancers like gastrointestinal cancer havebeenincreased(5-7).Colorectalcancerhasbeengrowingexponentially(8)andbasedonepidemiologicstudies,itis thesecondreasonformortality in theUSA.InIran

Corresponding author: Sedighe Movlavi ChobiniEmail:[email protected]

also,therateofcolorectalcancerhasincreasedinrecentdecadessignificantlyanditsprevalenceintheworldisinhighlevels.AccordingtotheannualreportsofIrannationalcancerregistrycenter,colorectalcanceristhefourthreasonforthemortalityofmenafterlung,liverandgastriccancersand it is the thirddeathreasonforthewomenafter lungandbreast cancers. In Iran, thiscancer is reported7 casesper 100000people (9).Thatiswhy, this researchwas carriedoutwith thegoalofreviewingtheriskfactors,diagnosisandthetreatmentofcolorectalcanceramongthepatientswiththechronicdiseasesinIran.

ANALYSIS METHOD

In this review, by searching keywords like:colorectal cancer, chronic disease, chronic disease

DOI Number: 10.5958/0973-9130.2018.00175.5


andcolorectalcancer, riskfactorsofcolorectalcanceramong the published articles in databanks such asmagiran,Iranmedex, web of science, pubmed, sciencedirect, SID and Google scholar, information aboutcolorectal cancer were extracted and studied. Amongthosearticles,40articleswereselectedthatstudiedtherelationshipbetweenthechronicdiseasesandcolorectalcancer.Then allfindings related to the risk factors ofcolorectalcancer,itsdiagnosis,treatmentandpreventionwayswereevaluatedandcollected.

RESULTS

Effective factors contributing to colorectal cancer in Iran

Itismentionedinsomeinvestigationsthatincidenceofcolorectalcancerinoneoffirst-degreerelativescanincreasethepossibilityofthisdiseaseby2or3times.Accordingly, the people with the family history aremore in danger of colorectal cancer incidence. Thestudieshaveshownthat15%ofcolorectalcancershavegenetic background and 50% of 70 years old peoplesuffer from colorectal cancer (10, 11). High prevalenceofcolorectalcancer in thepresent timeisdue todietsfullofanimalfats,lowconsumptionoffiberrichfoodslikefruits,vegetables,wheatbranandlackofphysicalactivity.NumerousstudieshaveshownthatincreaseinBMIcan lead to thehighrisksofcolorectalcancer inmenbutthiscaseisnottrueaboutwomen.

Ontheotherhand,diabetesandhighbloodpressurecanincreasetherisksofmanydiseases likecolorectalcancer. The findings of these researches show thatsurvivaltimeofthepatientswithdiabetestypeIIislessthanthosewithhighbloodpressurewhilebothofthemdo not have any effect on the painful survival of thepatientswithcolorectalcancerandsurvivaltimeofthecolorectalcancerpatientsdependsonotherfactorssuchas:cancerposition,diagnosticstageandtreatment,thetypeoftreatment,nutritionandsoon(12).

Basedonthestudies,theprevalenceofhighbloodpressure among the patients with colorectal cancer ismore than diabetes type II.Colorectal cancer ismoreprevalentamongthepeoplewithcolitis,InflammatoryBowelDisease(IBD)andCrohn’sdisease(13,14).Basedon the analysis, BMI,Inflammatory Bowel Disease(IBD),alcoholabuse, tumorgrade,metastasis tootherlymphoid nodes depending on tumor penetration ratetointestinewall,metastasis tootherorgansandtumor

stagearealleffectivefactorsondeathtimeduetocoloncancerwhile BMI,metastasis to lymphoid nodes andotherorgans,thekindofthefirsttreatmentareworkingfactors fordeath timedue to rectumcancer.So it canbesaidthattheeffectofriskfactorsondifferentpartsof large intestine are different and they should beinvestigated separately. In a study which was carriedouton100patientswithrectumcancer,itwasreported,the diet full of fiber is the most promising factor inreductionofrectumcancer’srisksamongenvironmentalfactors in an effective diet for this disease whereasmetabolic syndromes andphysical activitieshave lessimpactintheincidenceofit.Thestudiesrevealedthatdiabetes slows down material transfer along intestineanditincreasesretentionoftoxicmaterialsinintestine.Diabetes contributes to the production of mutagenicbileacidsandanincreaseininsulinlevelofthebloodcangrowthe tumorsextensively.Inaddition,diabetescreates damages to DNA and other cells by delayedtransfer of mutagens(15, 16). Some other researchersstudiedtheeffectofhighbloodpressureoncolorectalcancerand theysuggesteddailyconsumptionof thosefoodswhichleadtolowbloodpressure,aresoinfluentialinreducingtheriskofcolorectalcancer(12).Soworkingonthesechronicdiseaseswhicharemoreprevalent inthepatientswithcolorectalcancer,isvitalasapriorityinhealthsystem.

2. Diagnostic methods of colorectal cancer in Iran

Inmajorityof thestudieson thiscancer, the timeof diagnosis influences the survival timeof colorectalcancerpatients.

Colorectal cancer due to high load (incidence,disability and death), availability of the tests for thediagnosisofpre-cancerouslesionsandcurabilityatfirststages,isagoodchoiceforscreening.

Screening for colorectal cancer is done by FecalOccult Blood Test (FOBT), Sigmoidoscopy orcolonoscopyinpeopleover50yearsoldandalsointhefollowingcases:

Nopersonalhistoryofcolorectalcancer,polyporIBD.

Nofamilyhistoryofcolorectalcancerinfirstclassfamilymembersthatarediagnosedbefore65yearsoldorin2firstclassfamilymembersthatarediagnosedin


anyage.

Nofamilyhistoryofadenomatouspolypinonefirstclassfamilymemberthatisdiagnosedbefore65yearsold.

Thistestisannuallyanditcontinuesuntil75yearsold.

Inpatientswith IBD (chroniculcerativecolitisorCrohn’s disease), colonoscopy is done every 1 or 2yearsor8yearsafterpancolitisstartor12-15yearsafterthestartofleftcolitis(18,17).

3. The treatment of colorectal cancer

In recent years, survival of the patients withcolorectal cancer has been improved in someparts oftheworldbutitisnotclearwhichfactorsareresponsibleforthis.Investigationonthesurvivalofthepatientswithcancerisoneofthekindsoftheresearchesthatclarifiestheconditionofthediseaseandthefactorsrelatedtoit.Considering the high rate of colorectal cancer in pastdecades in Iran, studies about the effective factors onprognosis of survival time for the treatment of thesepatientsisextremelysignificant.Inastudy,thesurvivaltimeofthepatientswithdiabetestypeIIaccompaniedby colorectal cancer is shorter than the patients withhigh blood pressure and survival time of the patientswith colorectal cancer in both diseases, high bloodpressure anddiabetes type II is predicted the same incomparison to each other. This result was obtainedwhiletheprevalenceofhighbloodpressurewasmorethan diabetes type II in these patients. Generally,survivaltimeofthepatientswiththiscancerisrelatedtootherfactorslike:cancerposition,diagnosisstageandtreatment,thetypeoftreatment,thetypeofdietandsoon(13,19).

Furthermore, the average survival time of thepatientswhoarecuredbydrugs,islongerandgenerallytheresultsofchemicaltherapyleadtotheimprovementinthesurvivaltimeofthemetastasticcolorectalcancerpatients.

In some researches, it is suggested that drugcombination of Bevacizumab Plus Irinotecan andFluorouracil for chemical therapy can improve thesurvival time of the metastastic colorectal cancerpatientssignificantly(20).

The researchers found, among rectum cancer

patients those patients who their first treatment waslaparoscopicsurgery,hadhighersurvivalpossibility(21).

Inastudy, theextractofbrownalgae (Cystoseira indica) is suggested to be used as an antioxidant andanticancer agent in clinical and preclinical treatments(22).

4. Colorectal cancer prevention methods

The studies reveal that the suitable diet andconsumption of unsaturated oils can play role inpreventionofcolorectalcancer.Inflammationincreasestherisksoftumorformation.

Furthermore, lifestyle is one of the major riskfactors for increasing the risk of colorectal cancer.Lack of physical activity, unsuitable diet, smoking,metabolic syndrome (obesity, diabetes, high bloodpressure anddyslipidemia) alongwithpositive familyhistoryofcancerinpatientandpolyparemajorreasonsfor colorectal cancer while suitable lifestyle, diet fulloffibers,vegetables,fruitsandkeepingthebalanceofhigh-fatfoodsandredmeet,properphysicalactivityandavoiding alcohol and smoking can prevent colorectalcancersignificantly(17).

By reviewing various studies, we can understandthat Conjugated Linoleic Acid (CLA) is one of thecompounds that canbe effective on the preventionofcolorectal cancer.Thiscompound is anomega-6 fattyacidsanditisfoundinthefoodsnaturallybutitsmajorsourceisdairyproductsandthefoodproductsproducedfrom themeatof ruminating animals.This compoundplays a critical role in reducing the progression ofcolorectalcancerinpatientsbyincreasingtheexpressionof mRNA CD36 and PPAR-γ and reducing COX-2. In addition, this agent can increase the activity ofantioxidantfactors(14).Somemedicinalplantslikegarlicarestrongantioxidantsinadditiontotheirantibacterialeffectandtheycaninhibittheformationandgrowthofcanceroustumors.

This property is found in raw garlic more thancookedone,soitisrecommendedtouserawgarlic(23,24).

DISCUSSION

Cancer imposes different effects on the patients(25),inawaycolorectalcancerisafetalcanceranditisalmostprevalentinbothgenders.


Annually,1.2millionpeoplegetcolorectalcancerintheworldand608000peoplediebecauseofthiscancer.Infact,colorectalcanceraccountsfor9.7%ofallcancersand8%ofallcancermortalityworldwide(5).ThisdiseaseisthethirdprevalentcancerintheUSAanditismostseeninmarriedpeople.Itisfoundamong45-65yearsold people and it is observed amongmen abundantly(26).Obesityisoneofthereasonsthatexposemenandwomenindangerofcolorectalcancer.Almost11%ofcoloncancersarerelevanttoweighgaininEurope(27). Diabetes, acromegaly and probably Cholecystectomyandslowintestinemovementsincreasethepossibilityofcolorectalcancer(11).Diabetesandhighbloodpressurediseasesareincreasingdaybydayworldwideandthesediseasescanincreasethemortalityincolorectalcancerpatients(28).

CONCLUSION

Propernutritionalhabits,physicalactivitysuitabletoeachpatient’sability,attendingmuscularrelaxationplan for diabetic patients and the patients with highbloodpressurecanbepromisingforreducingthecasesofcolorectalcancer.

Conflict of Interest: Thereisnoconflictofinterestbetweenauthors.

Source of Funding : Self

Ethical Clearance: Informedconsent, Nocost tothepatient.

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5. Boji M, Tarjoman A, Rahmani R, Safari S,Patients’AttitudesTowardtheCancerPainRelief,AsianPacificJournalofCancerPrevention,2018.

6. Pouy S AF, Nourmohammadi H, Sanei P,Tarjoman A, Borji M., Investigating the EffectsofMindfulness-Based Training on PsychologicalStatusandQualityofLifeinPatientswithBreastCancer.AsianPacificJournalofCancerPrevention,2018. .

7. Borji M, Tarjoman A, and Nourmohammadi H,InvestigatingtheEffectofHomeCareUsingEyeMovement Desensitization and Reprocessing onPatients with Gastrointestinal Cancer. IranianJournal of Psychiatry and Behavioral Sciences,2018.INPRESS.

8. Borji M. Investigating the effect of home careon death anxiety in patientswith gastrointestinalcancer.Govaresh.2017;22(2):131-2.

9. Bayat M, Shamsabadi F, Amini F, Dayyani M,MehradMajdH.EpidemiologyofGastrointestinalCancers(Stomach,EsophagealandColorectal)inNeyshabur City during 2006-2012. J NeyshaburUnivMedSci.2016;3(4):37-44.

10. PrenenH,VecchioneL,VanCutsemE.Role oftargeted agents in metastatic colorectal cancer.Targetedoncology.2013;8(2):83-96.

11. Sæterdal I, Bjørheim J, Lislerud K, GjertsenMK, Bukholm IK, Olsen OC, et al. Frameshift-mutation-derived peptides as tumor-specificantigens in inherited and spontaneous colorectalcancer. Proceedings of theNationalAcademy ofSciences.2001;98(23):13255-60.

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CancerInstitute.2008:123-33.

14. Beheshti N, Ajami M, Kamal Z, Abdollahi M,Davoodi Sh. The Effect of Dietary ConjugatedLinoleic Acid and Assessment of Anti-OxidantFactors on the Risk of Developing ColorectalCancer.2017.

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19. AhmadiA,Hashemi-NazariS,Molavi-ChoobiniZ,NasriH.PattenComparisonofHypertensionandType2DiabetesMellitusinPatientswithColorectalCancer.JIsfahanMedSch.2014;32(302).

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22. TaheriA,GhaffariM,Houshmandi S,NamavariMM.Investigationoftheanticancerandantioxidantactivity of the brown algae (Cystoseira indica)extractagainstthecolorectalcancercells.KAUMSJournal(FEYZ).2017;21(4):317-25.

23. Shirzad H, Taji F, Pourgheysari B, Raisi S,Rafieian-Kopaei M. Comparison of antitumouractivities of heated and raw garlic extracts onfibrosarcomainmice.JournalofBabolUniversityOfMedicalSciences.2012;14(6):77-83.

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Effectiveness of Prolanis Gymnastics on Decreasing Blood Pressure in Patients with Stage One Hypertension, Indonesia

Abidin Armawati1, Masriadi2, Sumantri Eha3

1 Lecturer, Institute of Health Science Batara Guru, Luwu Timur, Indonesia, 2Associate Professor, 3 Lecturer, Institute of Health Science Tamalatea, Makassar, Indonesia

Background: Hypertension is one of the degenerative diseases commonly found in Indoensia. It ischaracterizedbyanincreaseofbloodpressureaboveitsnormallevelandiscausedbyvariousfactors.OneofthegovernmentprogramsofProlanisgymnastics(ChronicDiseaseManagementProgram)isaformofaerobicphysicalexercise.ThisstudyaimstodeterminetheeffectivenessofProlanisexerciseinloweringbloodpressure inpatientswithhypertensionafter intervention.Theeffectivenessof the interventioncanbeknownbylookingattheresultsofprepost-testbloodpressureofhypertensivepatients.Material and Methods:Thetypeofresearchisquasi experimentalwithnonequivalent controlgroupdesign.Sampleinthis research isfirst stagehypertensionpatient that is60peopleconsistingof3experimentgroupand3controlgroup.Eachexperimentalgroupconsistedof10peoplewhoweregiven1,2and3timesaweekgymnasticsinterventions.Thecontrolgroupalsoconsistedof10peoplewhodidnotreceivetheintervention.Thecontrolgroupalsocomprised30peoplewhodidnotreceivetheintervention.ThestatisticaltestusedisthetestofWilxoconandKruskalWallis.Results.TheresultsshowedthatProlanisgymnasticsexperimentalgroup1timesaweeksystolicvaluep-value0.005<0.05diastolicp-value0.005<0.05,Prolanisgymnasticgroup2timesaweeksystolicp-value0.005<0.05diastolicp-value0.005<0.05,Prolanisexercisegroup3 timesweek systolic p-value 0.005<0.05 diastolic p-value 0.012<0.05.Conclusion.The conclusionsfromtheresultsofthestudyistheinterventionwith1to2timestheprolineinaweekmoreeffectivelytolowerbloodpressure inpeoplewithhypertension. It is thereforerecommendedforpatientswithstage1hypertensiontoalwaysperformphysicalactivitiessuchasprolineexercises.

Keywords: Prolanis, gymnastics, physical activities, Hypertension, Blood Pressure

Corresponding author: Masriadi E-mail:[email protected]

INTRODUCTION

Hypertension is a major problem in developingcountries.Hypertensionisoneofthemanydegenerativediseasesoccurandhaveafairlyhighmortalityrateandaffectsthequalityoflifeandapeopleproductivity.Oneofthemajorriskfactorsofhypertensionisstroke,heartfailure,chronickidneydisease,andvisualimpairment.Increased age is one factor causing the occurrence ofhypertension,thisisduetotheincreasingageoforganfunctiondecreasedmarkedbydecreasedelasticityofthearteriesandstiffnessoccursbloodvesselssovulnerableto an increase in blood pressure. Hypertension is aconditioninwhichsystolicbloodpressure>130mmHg

and diastolic pressure> 80mmHg.Hypertension doesnotprovidetypicalcomplaintsandsymptomsthatmanypeoplewhodonotrealizeit.HencehypertensionissaidtobeTheSilentKiller.[1],[2],[3],[4]

Hypertension risk factors are genetic, obese, sex,stress, salt consumption patterns, smoking habits andlackofphysicalactivity.Lackofphysicalactivitycanlead to overweight and tend to have higher heart ratefrequency so the heart muscle must work hard whencontraction and the pressure on the arteries is gettingbigger.Regular physical exercise can improveoverallphysicalandspiritualhealth, improvebody immunity,regulatebloodglucoselevels,preventobesity,increaseinsulin receptor sensitivity, normalize blood pressureandimproveworkability.[5],[6],[7],[8],[9],[10]

DOI Number: 10.5958/0973-9130.2018.00176.7


Exercise causes major changes in the circulatoryand respiratory systems where both occur togetheras a homeostatic response. Sports exercise that isoften used in people with hypertension is aerobicexercise.Many forms of aerobic exercise that can betaken by hypertensive patients include jogging andaerobic exercise. Regular exercise can reduce bothsystolic and diastolic pressure in people with mild hypertension.[11],[12]

Oneformofexercisethatcanlowerbloodpressureis prolanis exercise.Oneof thegovernmentprogramsofProlanisgymnastics (ChronicDiseaseManagementProgram) is a formof aerobic physical exercise.Thisgymnasticsalsoincludesagovernmentprogramrunbythe Social Security EntrepreneurshipAgency (BPJS).Prolanis is a system of health services and proactiveapproach that is implemented inan integratedmannerinvolvingparticipants,healthfacilitiesandBPJS(SocialSecurity Administration Agency) Health in order tomaintainhealthforparticipantswhohavechronicillnesstoachieveoptimalqualityoflifewiththecostofhealthserviceseffectiveandefficient.[13]

WHO(WorldHealthOrganization)(2011)explainsthat1billionpeopleworldwidesufferfromhypertension,2/3ofwhomareinlow-andmiddle-incomedevelopingcountriesandestimatethatnon-communicablediseasescauseabout60%deathand43%morbidityworldwideisthethirdleadingcauseofdeathintheworld.Changesin community lifestyles from argument to industry,lifestyle changes and socioeconomic societies aresuspectedtobethecauseoftheincreasingprevalenceofnon-communicablediseasessothattheincidenceofnon-communicablediseasesvariesgreatlyinepidemiologicaltransitions.Oneofthediseasesincludedinthegroupofnon-communicablediseasesishypertension.[14],[15],[16]

TheprevalenceofhighbloodpressureisincreasinginAfricancountriesby46%ofmaleandmiddle-incomemale sex. In theUnited States,which has high bloodpressureinthemalesexof39%andfemalesexof32%.TheprevalenceofhypertensioninthePeople’sRepublicof China (PRC) is similar to the prevalence in someothercountries.TheFourthHealthandNutritionSurvey(2002)statesthattheprevalence,treatmentandcontrolrates for hypertension are 18.8%, 24.7%, and 6.1%,respectively.[14],[15]

ThenumberofhypertensionsufferersinIndonesia

aged≥18years in2007amounted to31.7%. In2013therewasadecreaseof5.9%(31.7%to25%)Whereasin2016peoplewithhypertensionincreasedby30.9%.Theprevalenceofhighbloodpressureinfemalesexwas32.9%andmalegenderwas28.7%.Urbanprevalenceisslightlyhigher,at31.7%comparedtoruralareaswhichisonly30.2%.[17],[18]

TheprevalenceofhypertensioninMakassarCityin2015was11,596cases,consistingofmaleasmanyas4,277casesand7,319casesofwomen.TheincidenceofhypertensiondiseaseinEastLuwuregencyin2015was 7566 cases, in 2016 new cases were 4902 casesand old cases 7097 cases. Prevalence of hypertensionis increased due to lack of physical activity, wherephysical exercises is very influential for people withhypertensioninimprovingbodyimmunityafterregularexercise. Prolanis gymnastics is an effort to improve,maintainhealthand increasephysical activity throughsportsactivities.[10],[19],[20],[21]

Prevalenceofhypertensionisincreasedduetolackof physical activity, where physical exercise is veryinfluential for people with hypertension in improvingbody immunity after regular exercise. Prolanisgymnasticsisanefforttoimprove,maintainhealthandincreasephysicalactivitythroughsportsactivities.[10]

MATERIAL AND METHOD

ThisstudywasconductedonApril2st-June9th,2018. The type of this study was quasi experimentalwithnonequivalentcontrolgroupdesign.Thesampleinthis studywas the first stage hypertension patient, 60peopleconsistingof3experimentalgroupsand3controlgroups.Eachexperimentalgroupconsistedof10peoplewho were given prolanis gymnastics interventions 1timeaweek,2timesaweek,and3timesaweek,whileeach control group consisted of 10 people who werenot intervened.DataanalysiswasperformedbyusingWilcoxon andKruskalWellis testwith α= 0.05.Thepopulationandsampleofthestudywereallfirststagehypertensionpatientsof124people.Thisresearchusespurposivesamplingtechnique.

RESULTS

Totalsample thatwouldbeanalyzed in thisstudywas60samples.BasedonbivariateanalysisintheTable1, analysis of prolanis gymnasticwith blood pressuredrop(pvalue<0.005).


Table 1. Analysis Wilcoxon of Prolanis Gymnastic Effectiveness once a Week, Twice Weekly and Three Times a Week on Decreasing Blood Pressure in Patients with Stage One Hypertension

Systolic_After Systolic_Before

Diastolic_Aftre Diastolic_Before


-2.810.005

-2.821.005

Controlgroup1p-value -1.342

.180-1.778.075


-2.805.005

-1.761.005

Controlgroup2p-value -1.414

.157-.316.075


-2.803.005

-2.527.012


-1.633.102

-1.279.201

Table 2. Analysis Kruskal wallis test Systolic and Diastolic Blood Pressure before and after Prolanis Exercise on Decreasing Blood Pressure in Patients with Stage One Hypertension (experimental group)


Systolicpre-test Intervention1timeaweek 10 21.90











Intervention3timeaweek 10 1070


Table 3. Analysis Kruskal wallis test Systolic and Diastolic Blood Pressure before and after Prolanis Exercise on Decreasing Blood Pressure in Patients with Stage One Hypertension (control group)


Systolicpre-test Intervention1timeaweek 10 17.10












DISCUSSION

Table1showsthattheexperimentalgroups1and2ofsystolicandsystolicbloodpressurebeforeandaftertheinterventionhadp-value0.005<0.05whichmeanstherewasasignificantdropinbloodpressurewhilethediastolic blood pressure of the control group 1 and 2before and after the intervention p-value 0.180> 0.05and 0.075> 0.05 means no significant drop in bloodpressure.

The statistic test usingWilcoxon test in Table 1explainsthatgroup3obtainedsystolicbeforeandafterp-value 0.005 <0.05 meaning there is a significantdecrease in blood pressure whereas diastolic bloodpressure after Prolanis exercise has p-value 0.012<0.05meaningthere isasignificantdecrease inbloodpressure. Systolic blood pressure without pro-poorexercise interventionp-value0.102>0.05meansthereisnosignificantdropinbloodpressurewhilediastolicbloodpressurewithout the interventionofgymnasticshasp-value0.201>0.05meaningthereisnosignificantdropinbloodpressure.

Decreasedsystolicanddiastolicbloodpressure inpatientswith stage1hypertensionwith1and2 timesweekly gymnastics interventions for 3 consecutiveweeksstillneedtobeincreasedregularlytonormalizeblood pressure, physical activity such as gymnasticsprolanis is one factor that plays an important role in

reducingriskatherosclerosisbystrengtheningtheheartand reducing thework of the heart. Physical exerciselikeregularexercisealsohelpspreventchronicillness,suchashighbloodpressure.[22]

Sportsexercisesaredoneinordertoaffecttheworkefficiencyoftheheart.Werecommendthatexerciseisatamoderateintensityofheartrate150-170/minute.Medium intensity ≤70-80% of maximum aerobiccapacity.The intensityof theexercise is the lengthoftimeittakes,especiallytheaerobicexerciseandthemostimportantexerciseintensitymustbemet.Frequencyofexercise3-5timesaweekwithanexerciselengthof20-60minutes once practice. Exercise can cause dilationof the blood vessels so that blood pressure decreases.People who exercise 3 times a week will experienceincreased cardiorespiratory endurance and regularexercisecanreducetheriskofheartdisease.[23],[24]

Table2explainsthatpre-testpost-testsystolicbloodpressure after prolanis exercise in the experimentalgroup 1, 2 and 3 times a week p-value 0.002 <0.05,meansthatthereisasystolicbloodpressuredifferencebefore prolanis exercise, whereas diastolic pre postexercise prolanis p- value 0.097> 0.005 means thereis a difference in diastolic.All samples with systolicbloodpressuredecreasedallbecausetheywereduetoactively follow the exercises andprocedures correctlyfor continuous heating exercises, core exercises andcooling exercises or closure exercises, whereas post-


test diastolic blood pressure did not decrease becausediastolic blood pressurewas pressure on thewalls ofthearteries andbloodvesselsdue to the relaxationofthe heart’s ventricularmuscles (the pressure atwhichtheatrialmusclecontrastsandthebloodgoesintotheventricle). Cardiacoutputisdefinedastheamountofblood volume pumped per ventricle per minute. Thedeterminantsofcardiacoutputarethespeedoftheheartbeats per minute and the volume of blood the heartpumps per stroke (cardiac output = heart frequency).Thiscanbeaffectedbypsychologicalstate.[25]

Table3explainsthatpre-testsystolicbloodpressurein the control group 1, 2 and 3 times aweek p-value0.936> 0.005, means no difference in systolic bloodpressure, whereas diastolic pre-post p-value 0.248>0.005mean therewasnodifference indiastolicbloodpressure in the control group. One effort that can bedone to stabilize and lower blood pressure in peoplewith hypertension and prevent complications that isbydoinggymnasticsprolanis.Prolanisgymnasticscanbe applied in both experimental and control groupswithfrequencies1and2timesaweekdoneregularly,regularlyandcontinuouslytogaingreaterbenefits

Rismayanthi explained that aerobic exercise isespeciallybeneficialforimprovingandmaintainingthehealthandenduranceofheart, lung,bloodcirculation,muscle,andjoints.Lowimpactaerobicgymnasticshasagreat influenceon thebody, especiallyonheart andlungresistance.Physicalexerciseisveryinfluentialforpeoplewithhypertension.[26]

Improvedimmunesysteminthebodyafterregularexercise, regulating blood glucose levels, preventingobesity, increasing insulin receptor sensitivity,normalizingbloodpressureandimprovingworkability.Aerobicaerobicscanhelpimprovebloodlipidprofile,lowertotalcholesterol,LowDensityLipoprotein(LDL),triglycerides and increase High Density Lipoprotein(HDL) and improve hemostatic system and bloodpressure.[27]

CONCLUSION

The conclusions from the results of the study istheinterventionwith1to2timestheprolineinaweekmoreeffectivelytolowerbloodpressureinpeoplewithhypertension.It is thereforerecommendedforpatientswith stage 1 hypertension to always performphysicalactivitiessuchasprolineexercises.

Finacial support and sponsorship: Owncost

Ethical considerations: Ethical clearance wasobtained from Institute of Health Science “MalukuHusada”, Ambon, Indonesia; with number” RK.03/KEPK/STIK/I/2018. Just before the interview,written(or thumb impression) consent was obtained fromeachparticipant in InstituteofHealthScienceAmbonguidelines.

Conflicts of Interest : The authors alone areresponsible for theviewsexpressed in this articleandtheydonotnecessarilyrepresent theviews,decisions,or policiesof the institutionswithwhich they are affiliated.

REFERENCES

[1] American heartAssociation [internet].Guidelinefor the prevention, detection, evaluation andmanagement of high blood pressure in adults.2017. [Cited 2018 Mart 11]. Available from:http://www.acc.org.

[2] Masriadi, Azis R, Sumantri E, Mallongi A.Effectiveness of non-pharmacologic therapythroughsurveillanceapproachtobloodpressuredegradation in primary hypertension patients,Indonesia. Indian Journal of Public HealthResearch&Development.2018;9(4):249-255.

[3]MinistryofHealthoftheRepublicofIndonesia.HealthprofileoftheRepublicofIndonesia,2015.

[4] Masriadi, Mega Ermasari. The Relationshipof family history, usage ofwasted cooking oil,alcoholconsumption,smokinghabittheincidenceofessentialhypertensionat twoareasofhealthCenter of North Buton Regency, Province ofSouthEastSulawesi.JournalofSciences:BasicandAppliedResearch (IJSBAR), 2015; 24 (1):146-155

[5] ShrutiPrabhakaranNair,S.S.G.,FarhinIdariya.Impactofkinesiophobiaonphysical activity inpatients with arterial hypertension. Journal ofHealthSciences&Research,2017;7(5):170-5.

[6] Osamor, P.E. Social support and managementof hypertension in south-west Nigeria. Cardiovascular Journal OfAfrica, 2015. 26(1):29-33.

[7] Shen,Y.,etal.Familymember-basedsupervisionof patients with hypertension: a cluster


randomized trial in rural China. Journal ofHumanHypertension,2017;31:29-36.

[8] Situmorang, P.R., Factors associated withhypertension incidence in inpatient patientsat Sari Mutiara General Hospital MedanYear,2014.JournalofScientificNursing,2015;1(1):569-74.

[9] EkaNurSo’emah,A.H.,AmarAkbar.Effectofergonomicgymnastic to lipidprofile andbloodpressureinpatientswithhypertensionAtSumberAgung Village Jatirejo District MojokertoRegency. Journal Of Nursing and Midwifery,2017;2(2):155-163

[10] DeibyO.Lumempouw,HerlinaI.S.Wungouw,Hedison Polii. Effect of prolanis gymnasticson people with hypertension. E-BiomedicineJournal(eBm),2016;4(1):1-18

[11] RidjabDA.EffectofPhysicalActivityonBloodPressure.JournalofAtmajayaMedicine.2005;4(2):73

[12] MinistryofHealthoftheRepublicofIndonesia.BasicHealthResearch(RISKESDAS)2007.

[13] MinistryofHealthoftheRepublicofIndonesia.Health Profile of the Republic of Indonesia,2017.

[14] XuejiaoLiu,D.Z.,YuLiu,XizhuoSun,ChengyiHan,BingyuanWang,YongchengRen, JunmeiZhou,YangZhao,YuanyuanShi,DongshengHu,MingZhang.Dose–responseassociationbetweenphysical activity and incident hypertension. Hypertension.2017;69(10):1-48.

[15] SusanHuang,Y.C.,JingZhou,JianmingWang.Useoffamilymember-basedsupervisioninthemanagement of patients with hypertension inrural China. Patient Preference andAdherence,2014;8:1035–1042.

[16] WHO.WorldHealthOrganization-InternationalSociety of Hypertension Guidelines for the

Management Of Hypertension. Journal ofHypertension,1999;151-183.

[17] MinistryofHealthoftheRepublicofIndonesia.TheDataandinformationCenter,2014.

[18] MinistryofHealthoftheRepublicofIndonesia.Health Profile of the Republic of Indonesia,2016.

[19] Makassar CityHealthOffice.Health Profile ofMakassarCity,2015.

[20 EastLuwuHealthOffice.HealthProfileofEastLuwuHealthOffice,2018.

[21] WotuCommunityHealthCenter.ProfileofWotuCommunityHealthCenter,2018.

[22] Rizqiyatiningsih,S,Theinfluenceofergonomicgymnastics on decreasing blood pressure withdegree1hypertensioninLansiainWironustomVillage Gatak Sukoharjo District. Scientificwritingstrataone,UniversityofMuhammadiyahSurakarta.2014.

[23] Kusmana, D. Sports For Healthy People andHeart Disease Patients. Faculty of MedicineUniversityofIndonesia,2006;Jakarta.

[24] Kusmana, D. Sports for Heart Health, 2002.Faculty of Fisheries University of Indonesia:Jakarta.

[25] Guyton.TextbookofMedicalPhysiology,1997.Jakarta:EGC

[26] RismayanthiC.TheEffectof IndonesianHeartGymnastics Exercise Against Blood PressureDrop on Hypertension Patients [Thesis].Yogyakarta:PPSIKUNY,2009.

[27] Syahrani,Theinfluenceofergonomicgymnasticson systolic blood pressure in elderly withhypertensioninSocialInstitutionTresnaWerdhaBudi Mulya 3 Margaguna Jakarta Selatan.2,Syarif Hidayatullah State Islamic UniversityJakarta,2017.

Analysis of Ingredients of a Traditional Solid form of Cannabis (Majoon Birjandi) Produced in Southern Khorasan Province

Tahereh Aminifard1, Maryam Akhgari2, Roland Lamarine3, Omid Mehrpour1

1Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran, 2Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran,

3Professor of Public Health, California State University Chico, California, U.S.A.

ABSTRACT

Background:An issue that threatens the foundation of family in modern society is addiction to licitand illicit euphoric substances.Among themarecannabis and itsderivatives (e.g.,Majoonproduced inSothernKhorasan in Iran).Cannabinoids are substanceswith effects such as euphoria, excitation, anti-nausea,agitation,andpsychologicaldependence.TheaimofthisstudywastoinvestigateandanalyzetheingredientsoftheediblecannabisprodictMajoonproducedinSouthKhorasanprovince.

Methods:Inordertocollectdata,threesamplesofeachdifferenttypeofMajoonwereanalyzedbyGC/MSmethod.Gaschromatography-massspectrometrywasusedtoanalyzethesamples.Theresultsfromsampleanalyseswereexaminedinreferencetoextensive,libraryanddescriptive-analyticalstudies.Thefrequencyofeachoftheingredientsobtainedfromthesampleswasdetermined.

Results:Theresultsshowedthattherearecannabinoidssuchascannabidiol,cannabinol,anddronabinolwithintheproductssampled.TheresultsofthecurrentstudyindicatethattherearepsychoactivecannabinoidsinMB.TheactiveingredientsofcannabisareobtainedfromthefloweringtopsandleavesofthefemalecannabisplantcalledCannabissativa.

Conclusion:TheresultsobtainedfromtheanalysisoftheingredientsofMajoonBirjanditypessuggestthatnonconventionaltypeshavemoreeuphoriceffectsthanthetraditionalandcurrenttypesbecausetheyhavedronabinolandcannabinolinadditiontocannabidiol.Sotheirtoxicologicaleffectsmaybedifferent.Furtherstudiesinthisregardisrecommended.

Keywords: Cannabinoids, Cannabis, Gas chromatography-Mass spectrom, Majoon Birjandi, Toxicological analysis

Corresponding author: Omid MehrpourTel:+985632381270,Fax:+985632381270E-mail:[email protected]

INTRODUCTION

Oneof the issues that threatens the foundationofthe family inmodern society is addiction to licit andillicitpsychoactivesubstances,whichhasspreadwidelyespeciallyamongtheyouth1.Amongthesepsychoactivesubstances are cannabis and its derivatives includingmarijuana (leaves, stems, and flowering tops) andhashish(resinfromthefemalefloweringplant).Asthe

mostwidelyusedillegalpsychoactivedrugworldwide,cannabis has approximately 163 million users in theworld and 14.5 million abusers in the United Statesalone. Cannabis contains more than 400 identifiedchemicals,includingcannabinoidsandterpenoids.9Δ-tetrahydrocannabinol(THC)istheprimarypsychoactiveconstituent2. THC content varies in different parts oftheplant.TheamountofTHC ishighest inbloomingflowers and, to a lesser degree, in the leaves, lowerleavesofstems,andseedsrespectively3.Sinceancienttimes, people in the eastern parts of Iran have beenmaking a traditional lozenge, calledMajoon Birjandi(MB). MB is mainly produced in South KhorasanProvince, particularly in Birjand and Khoosf out of

DOI Number: 10.5958/0973-9130.2018.00177.9


saffron, date, cardamom, ginger, cinnamon, coconut,pistachio,walnut,almond,hazelnut,sesameseedsandflowers (Cannabis sativa), as well as hemp oil andseveralothersubstancesItismostlyusedbythegeneralpublicinIran4.

Accordingtohistorians,Cannabissativaisamongthefirstplantscultivatedbyman,anditsuseasadrugdatesback tomore than3000yearsB.C. 5.Given theeasyaccessanduseofedibles(similartosweets),risksoftheirabuseincrease4.

According to Noorollahi’s study conducted in2012,88casesofMBpoisoningwerereportedinVali-Asr Hospital of Birjand (the central city of SouthernKhorasan province) from 2010-2011. Moreover, ina previous study, we found thatMB users for whomurinarytestsforTHCwerepositiveshowedsomesignsandsymptomsofcannabisuse4.

Identificationof ingredientsofMBcanhelp legalandregulatory investigations, includingrecognitionofsynthesis of the potion, the source of its production,andpossiblewaystotransferthesecompoundstootherprovinces.Itcanalsocontributetosecurityandjudiciaryissuesaswellasclinicalcentersinadoptingtreatmentprotocols for dealing with patients poisoned by thesechemicals.The aimof this studywas to evaluate andanalyzethepsychoactiveconstituentsofMB.

MATERIAL AND METHOD

During this investigation, the ingredients ofMajoon Birjandi were analyzed following five steps:1.samplecollection,2.analysisofphysicalpropertiesofthesamples,3.sampleextractionandpreparation,4.toxicologicalanalysis,and5.dataprocessing.

AtotaloffourtypesofBirjandisamples,includingthe traditional type, the current type, and two non-conventional typeswere put in special containers andcoded(Table1).

The samples were first prepared by grinding andmixing with 0.1 M phosphate buffer. The pH of themixturewasadjusted toacidic(pH=2),basic(pH=12)and neutral (pH=7) in three parts. After overtaxingthe mixtures, aqueous solutions were extracted withthreealiquotsofchloroform/isopropanol(8:2v/v).Theorganiclayerwascollectedandevaporatedtodryness.Methanol(100μL)wasaddedtotheextractedproductand2μLofeachsamplewasinjectedtoGC-MS.

The results of sample analyses were interpretedin light of extensive library research and descriptiveandanalyticalexamination,whereby,thefrequencyofeachof thesubstancesobtainedfromthesampleswasdetermined.

Toanalyzethesamples, gas chromatography–mass spectrometry [made byAgilentCompany,GC7890A(Agilent Technologies, Sdn Bhd, Selangor, and MS5975Cmodel;AgilentTechnologies)]which operatedbyelectronimpact(70eV)infullscanmode(50–550m/z)wasused.HP5-MScapillarycolumn(cross-linked5% methyl phenyl silicone, 30 m length×0.25 mmID×0.25μmfilmthickness)ofthechromatographywasutilized.Helium carrier gaswas used at a rate of 1.5mL/minute.Thetemperatureprogramwassetwiththefollowingparameters:injectortemperature,250ºC;andinterface temperature, 280ºC. The oven temperaturewasprogrammedasfollows:initial temperature,60ºC;initialhold,1min;temperatureprogramrate,2ºC/min;finaltemperature,280ºC.ThelibraryofthesystemwassupportedbythreedatabasesofNIST,Pest,andWiley,which provided the possibility of checking 50,000differentcombinations.

RESULTS

Examination of “Unconventional Type 1” usingGC/MSrevealedcannabidiol(Fig2),dronabinol(Fig4)andcannabinol(Fig3)(cannabisplantalkaloids).

Examination of “Unconventional Type 2” usingGC/MSrevealedcannabidiol(Fig2),dronabinol(Fig4)andcannabinol(Fig3)(cannabisplantalkaloids).

Examination of “Current Type” using GC/MSshowedcannabidiol(Fig.2)(cannabisplantalkaloids).

Examination of “Traditional Type” usingGC/MSrevealedcannabidiol(Fig.2)(cannabisplantalkaloids).

Table 1.Specifications of Birjandi potion

No. Shape Color Total weight

Unconventional1 3 Lozenge Mustard 57.661

Unconventional2 2 Lozenge Mustard 41.761

Current 3 Rectangle Mustard 46.051

Traditional 3 Rectangle Mustard 29.803


Figure 1. Chemical formula of tetrahydrocannabinol

Figure 2. Chemical formula of cannabidiol

Figure 3. Chemical formula of cannabinol

Figure 4. Chemical formula of dronabinol

DISCUSSION

Thepsychoactiveconstituentsofthecannabisplantare called cannabinoids. A variety of cannabinoidsincludingtetrahydrocannabinol,cannabinol,cannabidiol,cannabinolidic acid, cannabigerol, and cannabicromenare synthesized by plants. TetrahydrocannabinolDelta-9(Δ-9THC)isknowntoberesponsibleformostof the psychoactive effects of cannabis absorbed bycannabinoid receptors in the brain6. Sativa and Indicaare two major Cannabis species. The sativa specieshave amore psychological and stimulating effect andthe indica species have amore physical and soothingeffect6.Inthehumanbody,therearemanycannabinoidreceptorsinthebrain,liver,lungs,kidneys,andvesselwalls. These receptors are sensitive to cannabinoids.The bodies of all mammals produce cannabinoidsubstances,whicharesimilartonaturalplantcannabis(marijuana); these animal produced cannabinoids arereferred to as endogenous cannabinoids. Endogenousorendocannabinoidsstimulatecannabinoidreceptorsinthebody.Cannabinoidscanbefoundinlargeamountsincommerciallyproducedcannabisplants.

Thecannabinoidsystemofthehumanbodyisverysimilartothesystemofinternalmorphine(endorphins),and their functions are comparable. Two types ofcannabinoidreceptorshavebeenidentifiedinthehumanbody:CB1,whicharefoundprimarilyinthebrain,liver,lungs, pituitary, adrenal, digestive system, testicles,ovaries,uterus,vesselwallsandtheheart;andCB2aremore often located in bonemarrow, thymus, and theimmunesystemofthebody7.

In the cannabis plant, there are more than 85differentcannabinoidsforms,themostprominenttypeis tetrahydrocannabinol (Fig 1), which can producehallucinations. The main ingredient in the naturalcannabis plant is cannabidiol, which has medicinalproperties and is effective in the treatment of variousdiseases such asmultiple sclerosis (MS), diabetes, orotherautoimmunediseasessuchasrheumatoidarthritis.

Cannabidiol has several medicinal properties anddoes not create hallucinations and euphoria; however,itisverydifficulttoextractitfromthecannabisplant.Cannabidiol has many therapeutic effects. In fact,almost all antibacterial and anti-cancer and healingeffectsofthecannabisplantarerelatedtocannabidiol8. Anti-cancereffectsofcannabis(marijuanaandhashish)


arerelatedtocannabidiol9.

Also, the resultsof thepresent study showed thatcannabinol, an ingredient of cannabis, is found inMajoonBirjandi.Basedon laboratory research, it canbeconcludedthatthereiscannabinolin(type1and2of)theMajoonsampled.

Cannabinol is a mildly psychoactive substancefoundincannabis.Itis,infact,ametaboliteofthedrugTHC (tetrahydrocannabinol) which has fewer effectsoncannabinoid receptors1 (agonist)andmoreeffectson type 2 of cannabinoid receptors. For this reason,cannabinolhasmostlyatherapeuticeffectandenhancestheimmunesystemofthehumanbody10.

The results of the present study also showeddronabinol, one of the psychoactive componentsof cannabis, exists in Majoon Birjandi. Accordingto laboratory research, it can be concluded thatthere is dronabinol in type 1 and 2 of the MajoonBirjandisampled.THCin thecannabisplanthasbothmedical and harmful properties. Despite the legalrestrictions, cannabis is often used to relieve chronicand neuropathic pain, and it carries psychotropic andphysicaladverseeffectswithatendencyforaddiction11.

Harmful properties of THC:

Themostcommonsideeffectsofcannabinoidsaretirednessanddizziness(inmorethan10%ofpatients),psychologicaleffects,anddrymouth.Tolerancetothesesideeffectsnearlyalwaysdevelopswithinashorttime.Withdrawalsymptomsarehardlyeveraprobleminthetherapeutic setting 11. Itwas shown that heavy use ofcannabismay induce greymatter alterations 12. Oralorsublingualformsofcannabissignificantlyhavelessharmful effects than smoked cannabis due to slowerabsorptionoforalform11.

THCaffectsthecentralnervoussystemandcausessymptoms such as lethargy, increased sensitivity tolight and sound, and confusion in understanding theenvironment.ThephysiologicaleffectsofTHCincludeincreasedheartrate,drymouth,increasedappetite,andlowbloodpressure.

Useful properties of THC:

CannabishasbeenlegalizedinseveralstatesintheU.S.forrecreationalpurposes,aswellas,medicaluse.Recreationallegalizationisabigstepforwardinthatit

removes thenecessityofhaving tohaveclinical trialsthatshowapreponderanceof theevidencesupportingthe efficacy of cannabis products. In otherwords, instatesthathavelegalizedcannabisforrecreationaluse(e.g.Colorado&Oregon)potentialusers21andoldercanbuytheseproductsforwhateverusetheyprefer.Toour knowledge, there are no products currently beingmarketedintheU.S.thatwouldbeconsideredtraditionalfolkmedicines,likeMajoonBirjandi.

MedicalmarijuanaisavailableinsomeU.S.stateseither in herbal form or via prescription forMarinol.Dronabinol(Marinol)isasyntheticversionofTHC13. Itresembles9-tetrahydrocannabinolTHCinchemicalstructure. Dronabinol is used as a strong antiemeticin the treatment of chemotherapy-induced nausea andanorexia-related weight loss in patients with AIDS.However, dataon the toxicityof thismedicine is stillscarce. Moreover, Nabiximol, which is still underevaluationbyclinicaltrialsintheUS,iscommerciallyavailable in Canada and the UK and is administeredto relievepainandspasticity inpatientswithmultiplesclerosis. Marijuana has been mainly used to treatnausea,lossofappetite,andpain14.

MBis theonlyexistingsolid formofcannabis inIran and other countries (except US) and due to thesimilarity between MB and Marinol®, MB may beusedformedicalpurposesinthefutureinIranandothercountriessuchastheU.S.

Theresultsofthecurrentstudyindicatethatthereare psychoactive cannabinoids in MB. The activeingredientsofcannabisareobtainedfromthefloweringtops and leaves of the female cannabis plant calledCannabissativa5.

The results obtained from the analysis of theingredients of Majoon Birjandi types suggest thatnonconventionaltypeshavemoreeuphoriceffectsthanthe traditional and current types because they havedronabinolandcannabinolinadditiontocannabidiol.

Conflict of Interest: Thereisnoconflictofinteresttobedeclared.

Ethical Clearance: This studywas approvedbytheethicscommitteeofIslamicAzadUniversity.

Source of Funding: This study was supportedby IslamicAzadUniversityandBirjandUniversityofmedicalsciences.


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1. Karrari P, Mehrpour O, Afshari R, Keyler D.Pattern of illicit drug use in patients referred toaddiction treatment centres in Birjand, EasternIran.JPMATheJournalof thePakistanMedicalAssociation.2013;63(6):711-6.

2. Martin-SantosR,FagundoAB,CrippaJA,AtakanZ,BhattacharyyaS,AllenP,etal.Neuroimagingin cannabis use: a systematic review of theliterature.PsycholMed.2010;40(3):383-98.Epub2009/07/25.doi:10.1017/s0033291709990729.

3. ElSohly MA, Mehmedic Z, Foster S, Gon C,Chandra S, Church JC. Changes in CannabisPotency Over the Last 2 Decades (1995-2014):AnalysisofCurrentDataintheUnitedStates.BiolPsychiatry.2016;79(7):613-9.

4. Mehrpour O, Karrari P, Afshari R. Recreationaluseandoverdoseof ingestedprocessedcannabis(MajoonBirjandi) in the eastern Iran.HumExpToxicol. 2012;31(11):1188-9. Epub 2012/07/04.doi:10.1177/0960327112446814.

5. MerlinMD.COVERARTICLE:ArchaeologicalEvidencefor theTraditionofPsychoactivePlantUseintheOldWorld.EconBot.2003;57(3):295-323.

6. HuC, Zawistowski J, LingW,KittsDD.Blackrice (Oryza sativa L. indica) pigmented fractionsuppressesbothreactiveoxygenspeciesandnitricoxide inchemicalandbiologicalmodelsystems.J Agric Food Chem. 2003;51(18):5271-7. Epub2003/08/21.

7. KleinTW,NewtonC,LarsenK,LuL,PerkinsI,NongL,etal.Thecannabinoidsystemandimmunemodulation.JLeukocBiol.2003;74(4):486-96.

8. MechoulamR,ParkerLA,GallilyR.Cannabidiol:an overviewof somepharmacological aspects. JClinPharmacol.2002;42(11Suppl):11s-9s.

9. Alexander A, Smith PF, Rosengren RJ.Cannabinoids in the treatment of cancer.CancerLett.2009;285(1):6-12.

10. GrotenhermenF,Muller-VahlK.Thetherapeuticpotential of cannabis and cannabinoids. DtschArzteblInt.2012;109(29-30):495-501.

11. Lamarine RJ. Marijuana: modern medicalchimaera. J Drug Educ. 2012;42(1):1-11. Epub2012/08/10. doi: 10.2190/DE.42.1.a. PubMedPMID:22873011.

12. CousijnJ,WiersRW,RidderinkhofKR,vandenBrinkW,VeltmanDJ,GoudriaanAE.Greymatteralterationsassociatedwithcannabisuse:resultsofaVBMstudyinheavycannabisusersandhealthycontrols.NeuroImage.2012;59(4):3845-51.

13. Leung L. Cannabis and its derivatives: reviewof medical use. J Am Board Fam Pract.2011;24(4):452-62.

14. Woolridge E, Barton S, Samuel J, Osorio J,DoughertyA,HoldcroftA.CannabisuseinHIVforpainandothermedicalsymptoms.JPainSymptomManage. 2005;29(4):358-67. Epub 2005/04/29.doi:10.1016/j.jpainsymman.2004.07.011.PubMedPMID:15857739.

Effectiveness of Cognitive Restructuring on Reducing Learned Helplessness in Educable Students with Intellectual Disability

Ali MotallebZadeh1, Jahanshir Tavakolizadeh2,3, Somayeh Safarzade4

1MA in Psychology and Education of Exceptional Children, Islamic Azad University, Qaen Branch, Qaen, Iran 2PhD in Psychology, Professor of Psychiatry Department, Social Development and Health Promotion Research

Center, Gonabad University of Medical Sciences, Gonabad, Iran, 3PostDoc Student in Psychosomatic Medicine and Psychotherapy, Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran,

4MA in Clinical Psychology, Gonabad University of Medical Sciences, Gonabad, Iran

ABSTRACT

Background and Objective: ThisstudyaimedtodeterminetheeffectivenessoftrainingbasedoncognitiverestructuringinreducinglearnedhelplessnessamongeducablestudentswithintellectualdisabilityinQaen,Iran.

Method:Thisappliedresearchadoptedaquasi-experimentalpretest-posttest-follow-updesignandrandomlyrecruited60students.Thestudentswererandomlyallocatedtothecaseandcontrolgroups.Atbaseline,bothgroupscompletedtheLearnedHelplessnessQuestionnaire.Thecasegroupthenreceivedninesessionsoftrainingbasedoncognitiverestructuring.Results:Thequestionnairewasreadministeredimmediatelyandonemonthaftertheintervention(posttestandfollow-up).Thedatawereanalyzedusingindependentandpairedt-testsandanalysisofcovariance(ANCOVA)inSPSS19.Therewasasignificantdifferencebetweenthecaseandcontrolgroupsafter covariate adjustment (P<0.001). In fact, trainingbasedoncognitiverestructuringexplained4.22%and9.17%thevarianceinthecasegroup’sposttestandfollow-upscoresoflearnedhelplessness,respectively.

Conclusion:Sinceourconfirmedtheeffectivenessoftrainingbasedoncognitiverestructuringindecreasingthelevelsoflearnedhelplessnessinstudentswithintellectualdisability,similartrainingprogramsshouldbeusedtoimprovetheattitudesofeducablechildrenwithintellectualdisabilitytowardsproblemsandfailures.

Key-words: Cognitive Restructuring, Learned Helplessness, Intellectual disability, students.

INTRODUCTION

One of the most important needs of the studentsis to identify their capabilities and to understand thattheyhavetoassumeresponsibilityfortheiractionsandlearningprocessandtotakecontroloftheiraffairs.1Onthisbasis, the attribution theorydiscusses the concept

of “learned helplessness” which is the most negativeself-concept.Leanerswithlearnedhelplessnessdonotassociateeffortwithprogress2andbelievethattheywillnever succeednomatter howhard they try.Seligmanwasthefirsttoproposetheideathattheconsequencesofbehaviorsareindependentofthebehaviorsthemselves.Seligmandefinedtheconceptoflearnedhelplessnessasaspecialstateofmindcausedbyaperson’sbeliefthatalleventsareoutofhis/hercontrol.Inotherwords,afteraseriesofexperienceswhereaperson’sactionsdonotaffecttheoutcomesofhis/herbehaviors,he/shelearnsthatbehaviorsandtheirconsequencesareindependent.3, 4 Seligman also argued that learned helplessnesscaused by uncontrollable events leads to a negativecognitive structure and the belief that success and

Corresponding author:Somayeh SafarzadeMAinClinicalPsychology,GonabadUniversityofMedicalSciences,Gonabad,IranPostalAddress:HealthCenter,GonabadUniversityofMedicalSciences,Gonabad,KhorasanRezavi,Iran

DOI Number: 10.5958/0973-9130.2018.00178.0


failure are independent of behaviors. In fact, people’snegativeandpessimisticattributionalstyleregardingtheconsequencesoftheiractionscanresultinhelplessness.5

Intellectual disability, also called intellectualdisability, is a special mental condition caused byspecific circumstances before, during, and after birth.Duetotheir impairedordelayedmentaldevelopment,individualswithintellectualdisabilitycannotgenerallybenefit from the regular educational programs. Theyalsofaceproblemsinsocialadjustmentandadaptationtotheenvironment.6

A person’s thoughts and attitudes are amongthe major factors affecting the development andconsistency of helplessness. In fact, perceiveduncontrollability, and not actual controllability, is adeterminant of helplessness. Moreover, rather thanbeing determined by external events, the actions andfeelingsofpeoplearemainlyaffectedbytheirthoughtson and attitudes toward external events.7Apparently,changing a person’s feelings and behaviors wouldrequire the modification of his/her thoughts andperceptions.Therefore,insteadoffocusingonexternal,environmental, genetic, and hereditary factors andchildhood events, cognitive therapists seek tomodifytheirclients’thinking,cognition,andinterpretationandtohelpthemdevelopreasonableattitudes.8,9,10,11Thus,sincelearnedhelplessnessisbelievedtobetheresultofunhealthycognitionsandattributionalprocesses,itcanbeeliminatedorcontrolledthroughthemodificationofunhealthyattitudesandcognitiveapproaches.

The cognitive approach identifies dysfunctional(irrational) beliefs, thinking errors, and cognitivedistortions as the main cause of all emotional andbehavioralproblems.Basedonthisapproach,duringtheperceptionandinterpretationoftheirsocialinteractionsandexperiencesofvariousevents,mostpeopledevelopthinking errors such as exaggeration, catastrophizing,distortion, hasty conclusions, and exaggeratedgeneralizations. 12 No events can cause a problem byitself,i.e.people’swayofthinking,processingpatterns,and interpretation of the events can lead to negativefeelings and emotions. The main goal of cognitivetherapy is toempower theclients to identifyandfightagainst their automatic thoughts and wrong cognitivedistortionsandtonotonlyachieveapositivesense,butalsodevelopacorrectandrealisticcognitiveschema.8,13

One of the effective methods based on cognitivetherapyiscognitiverestructuring.Thismethodusesthechallenge between the therapist and the client to helpthe client change his/her negative and dysfunctionalbeliefs.Itis,hence,appliedtoreduceundesirablecovertcognitive behaviors (undesirable thoughts). 14Throughthismethod,theclientslearntochangetheirperceptionsof self, the world, and the future, substitute negativethoughts with more positive beliefs, and utilize moreappropriate techniques to deal with their emotionalproblems.15

Although numerous studies have evaluatedcognitive restructuring and learned helplessness invariouscountries,noneofsuchstudieshasfocusedonstudentswithintellectualdisability.Therefore,thisstudyexamined the effectiveness of cognitive restructuringin decreasing learned helplessness among educablechildrenwithintellectualdisability.

METHOD

Thisappliedresearchadoptedaquasi-experimentalpretest-posttest-follow-up designwith a control and acasegroup.

Sample

The statistical population in this study consistedofall75educablestudents(40boysand35girls)withintellectualdisabilityinQaen,Iranduringtheacademicyear 2014-15. Considering the size of the populationandtheresearchtype,themethodproposedbyMorganandKrejciewasused to randomly select30boysand30girlsandallocatethemtotwogroupsof30(caseandcontrolgroups).

Measures

The Learned Helplessness Questionnaire (LHQ)was used to collect data. TheLHQ is a 20-item self-administeredtooldevelopedbySolomonandRothblumin 1989. The items are scored on a four-point Likertscale (from “Not at all true of me” to “Very true ofme”) and items 1, 7, 17, 19, 21, and 23 are reversescored.ThetotalscoresoftheLHQrangebetween20and80withhigherscoresreflectingagreaterdegreeoflearned helplessness. The internal consistency of thequestionnairewasconfirmedinhealthypopulations(α=0.85andα=0.92),individualswithdrugdependence(α = 0.90), and chronically ill oncology patients (α =


0.83),hemodialysispatients(α=0.92),andindividualswithspinalcordinjury(α=0.94).16,17ThereliabilityoftheLHQwasalsoconfirmedinthepresentstudy(α=0.76).

Statistical analysis

Pairedandindependentt-testsalongwiththeanalysisofcovariance(ANCOVA)wereappliedtoanalyzethedata.AllanalyseswereperformedusingSPSS19.0(SPSSInc.,Chicago,IL,USA)andPvalueslessthan0.05wereconsideredsignificant.

RESULTS

Table1comparesthecaseandcontrolgroupsintermsofthemeanscoresoflearnedhelplessness.Asseen,inthecasegroup(inbothgendersandthewholegroup),themeanposttestandfollow-upscoresoflearnedhelplessnesswerelowerthanthepretestscores.

Table 1: The mean scores of learned helplessness in the male and female students of the case and control groups

SDMean

NumberGendergroupFollow upPosttestPretestFollow upPosttestPretest

5.664.635.6050.1350.2051.0015FemaleControl

4.786.245.9050.0049.4750.6015Male

5.155.415.6550.0649.8350.8030Total

6.706.714.5943.8643.8050.0715FemaleExperimental

5.765.805.6145.7345.3349.9315Male

6.216.215.0344.8044.5750.0030Total

Table2showstheresultsofpairedt-testcomparingthepretestandposttestscoresoflearnedhelplessnessinthecasegroup.

AccordingtoTable2,thecasegroup’sposttestscoreoflearnedhelplessnesswassignificantlylowerthanitspretestscore(44.57±6.21vs.50.00±5.03;P<0.005).Moreover,themeanscoresoflearnedhelplessnessamongbothboysandgirlssignificantlyreducedinposttest(incomparisontopretest).

Table 2: Comparison of pretest and posttest scores of learned helplessness in the case group (paired t-test results)

Mean differencepdfT testMean Standard deviationSDgroups

6.260.000145.551.1274.367Female

4.604.60142.272.0267.845Male

5.435.43294.721.1496.296Total

Theresultsofindependentt-testscomparingthepretestscoresofthecaseandcontrolgroupsaresummarizedinTable3.


Table 3: The results of independent t-tests comparing the pretest scores of the case and control groups

T-TestLevene-Test

Gender MeanMean differencepdftpf

ExperimentControl

50.0751.000.930.622280.490.6490.21Female

49.9350.600.660.754280.310.9190.01Male

50.0050.800.800.565580.5780.8250.05Total

As Table 3 shows, therewere no significant differences in themean pretest scores of learned helplessnessbetweenthecaseandcontrolgroups(thetotalscoresandthescoresofmaleandfemalestudents).Therefore,thetwogroupswerematchedintermsoflearnedhelplessnessbeforetheintervention.Table4presentstheresultsofindependentt-testscomparingthetwogroupsintermsofposttestscoresoflearnedhelplessness.

Table 4: The results of independent t-tests comparing the case and control groups in terms of scores of learned helplessness after the intervention based on cognitive restructuring

T-TestLevene Test

Gender MeanMean differencepdftpf

ExperimentControl

43.8050.20-6.400.00528-3.040.1632.05Female

45.3349.47-4.130.00628-1.870.9040.01Male

44.5749.83-5.160.001583.500.2201.54Total

AsseeninTable4,theposttestscoresweresignificantlylowerinthecasegroupthaninthecontrolgroup(44.57±6.21vs.49.83±5.41;P<0.005).Likewise,theposttestscoresofbothmaleandfemalecasesweresignificantlylowerthanthoseoftheircontrolcounterparts(P<0.006andP<0.005,respectively).However,thisreductionwasgreaterinfemalesthanmales.

Table5comparesthedifferencesbetweenpretestandposttestscoresoflearnedhelplessnessinboththecaseandcontrolgroups.

Table 5: The results of independent t-tests comparing the difference between pretest and posttest scores of learned helplessness in the case and control groups

T-TestLevene Test

Gender MeanMean differencePdftpf

ExperimentControl

6.260.80-5.460.00028-4.080.1433.49Female

4.601.13-3.460.00528-1.680.7400.01Male

5.430.97-4.460.00158-3.670.2203.24Total

According to Table 5, the difference between the mean pretest and posttest scores of the case group wassignificantlylargerthanthatofthecontrolgroup(5.43±6.29vs.0.97±2.17).Sincethelevelofsignificancewasdeterminedas>0.05basedonLevin’stest,thefirstrowoftheresultswasusedtocomparethemaleandfemalestudentsofthetwogroups.Thedifferencesbetweenthemeanscoresoffemalecasesandcontrolsandmalecasesandcontrolswereagainsignificantandequalto6.26and4.60,respectively.


Table6showstheresultsofamultivariateANCOVAofthescoresoflearnedhelplessnessinthecaseandcontrolgroups.

Table 6: The results of analysis of covariance (ANCOVA) of the scores of learned helplessness (pretest-posttest) in the case and control groups

Eta coefficientpfMean SquaredfSum of squaresSource changesTest

0.09141.335827.8931827.893Pretest

0.2240.00016.466

329.8031329.803group

20.029571141.640Error

60136056.000Total

0.0885.502166.4551166.445Pretest

Followup0.1790.00112.394

374.8981374.898group

30.250571724.222Error

60137302.000Total

DISCUSSION

SimilarresultswerereportedbyShikatanietal18,Ghamarietal19,Asikhia20,andTavangaretal.21AccordingtoHooper 22andMcHugh 5, trainingbasedoncognitivetherapysignificantlydecreasedlearnedhelplessnessandthus increased self-efficacy. It is important for students to rely on their own capabilities and to understand thatpositivechangeswithinone’sselfcanyieldverypositiveresultsinlife..Thisindicatesthatone’sassessmentofa

particularsituationisgenerallybetterthantheobjectivenatureofthesituation.Apersonwithimproperfunctionininformationprocessingwilldevelopcognitiveerrorsand psychological disorders. Among themajor issuesdiscussed in educational and psychological literatureis the ability of individuals to analyse their successesand failures.However, leaving success to chance andotheruncontrollable factorswilldecrease theperson’sperseverance. Therefore, the development of learnedhelplessness prevents any hopes and efforts and linksanymovementtofurtherfailures.23

It can, hence, be concluded that cognitivetechniquesandtrainingbasedoncognitiverestructuringcan decrease the students’ tendency to attribute theirfailures to external factors and consequently reducetheirlevelsoflearnedhelplessness.Themostimportantgoalofcognitiverestructuringistohelppeopleinterpretvarious events based on their own abilities and theexistingrealities.Misinterpretationofevents,i.e.linkingsuccesstoexternalfactorsandfailuretointernalfactors,willleadtofalseattributions,learnedhelplessness,andultimately low self-esteem. Cognitive restructuring isconsistentwith attributional restructuring and can notonlyeliminate falseattributions,but alsodecrease thelevelsofhelplessness.

Conflict of Interests: Nil.

Source of Funding: Thisstudywasderivedfroman MSc thesis financed by Azad Islamic University,QaenBranch.

Ethics Clearance: The study was performed incompliancewithallethicalconsiderationsandstandardsof the journal. All procedures were conducted inaccordancewiththeethicalstandardsoftheInstitutionaland/or National Research Committee and with the1964HelsinkiDeclarationanditslateramendmentsorcomparableethicalstandards.

REFERENCES

1. SanjuanP,PerezA,RuedaB,RuizA.Interactiveeffects of attributional styles for positive andnegative events on psychological distress.Personality and Individual Differences, 2008; 45:187-190.

2. Swanson JN, Dougall AL, Baum A. Learnedhelplessness. In V. S. Ramachandran (Ed.),Encyclopedia of Human Behavior (2nd ed). SanDiego:AcademicPress,2012;15:525-530.

3. Isaacowitz DM, Seligman MEP. Learned


Helplessness. Encyclopedia of Stress (2nd ed),2007;12(3):567-570

4. Hunziker MH, Dos Santos CV. Learnedhelplessness: effects of response requirement andintervalbetweentreatmentandtesting.BehaviouralProcesses,2007;76(29):183-91.

5. McNattDB,JudgeTA.Self-efficacy intervention,jobattitudes,andturnover:Afieldexperimentwithemployees in role transition. Human Relations,2008;61(37):783-810.

6. Esmaeeli-Nieh S, Sherr EH. Mental Retardation/IntellectualDisability. InM. J. Aminoff&R. B.Daroff (Eds.), Encyclopedia of the NeurologicalSciences (Second Edition). Oxford: AcademicPress.2014;12(6):1090-1094.

7. Greenberg JL, Mothi SS, Wilhelm S. Cognitive-Behavioral Therapy for Adolescent BodyDysmorphic Disorder: A Pilot Study. BehaviorTherapy,2016:47(2):213-224.

8. Dimitriu O. Empathy Insertion in Cognitive-behaviouralPsychotherapy.Procedia–SocialandBehavioralSciences,2014;127:707-711.

9. AlexopoulosGS,RaueP,AreanP.Problem-solvingtherapy versus supportive therapy in geriatricmajordepressionwithexecutivedysfunction.TheAmericanJournalofGeriatricPsychiatry,2003;11:46-52.

10. Beail N.Whatworks for peoplewith intellectualdisability? Critical commentary on cognitive-behavioral and psychodynamic psychotherapyresearch.IntellectualDisability,2003;41:468-472.

11. Benedict RH, Shapiro A, Priore R.Neuropsychological counseling improves socialbehaviorincognitively-impairedmultiplesclerosispatients.MultipleSclerosisJournal,2000;6:391-396.

12. BeckAT,RushAJ,ShawBF,EmeryG.Cognitivetherapyofdepression.NewYork:Wiley.1979.

13. HoFY,ChanCS,TangKN.Cognitive-behavioraltherapy for sleep disturbances in treatingposttraumatic stress disorder symptoms: A meta-analysis of randomized controlled. ClinicalPsychologyReview,2016;43:90-102.

14. DeldinPJ,ChiuP.CognitiverestructuringandEEGinmajordepression.BiologicalPsychology,2005;70(18):141-151.

15. Hagen R, Hjemdal O. Cognitive BehaviouralTherapy.EncyclopediaofHumanBehavior(Secondedition).Elsevier.2012;24(9):525-530.

16. Quinless FW, Nelson MA. Development of ameasureoflearnedhelplessness.NursingResearch,1988;37(16):11-15.

17. Sullivan DR, Liu X, Corwin DS, Verceles AC,McCurdyMT.Learnedhelplessnessamongfamiliesandsurrogatedecision-makersofpatientsadmittedtomedical,surgical,andtraumaICUs.Chest,2012;142(78):1440-1446.

18. ShikataniB,AntonyMM,KuoJR,CassinSE.Theimpactof cognitive restructuring andmindfulnessstrategies on post event processing and affectin social anxiety disorder. Journal of AnxietyDisorders,2014;28(11):570-579.

19. GhamariKiviH,RafeieSH,KianiAR.EffectivenessofCognitiveRestructuringandProperStudySkillsintheReductionofTestAnxietySymptomsamongStudents in Khalkhal, Iran. American Journal ofEducationalResearch,2015;3(1):1230-1236.

20. Asikhia OA. Effect of cognitive restructuring onthe reduction of Cognitive-Restructuring trainingonmathematics anxiety inMathematics among agroupofSeniorSecondarySchoolStudentsinOgunState,Nigeria.InternationalJournalofEducationalResearch,2014;2(1):1-20.

21. TavangarL,YazdKhastiF.EffectivenessofEclecticIntervention (Cognitive Restructuring, CognitiveCoping Skills and Role playing Approaches) onself-Assertiveness and Social Anxiety amongIsfahanUniversityStudents.ThescientificJournalofZANJANUniversityofMedicalSciences,2013;21(3):76-85.

22. HooperN,McHughL.CognitiveDiffusionversusThoughtDistraction in theMitigation of LearnedHelplessness. The Psychological Record, 2013;63(26):1-10.

23. TylerA. The relationship between optimistic andwomendepression.EuropeanJournalofPersonality,2008;23(16):71-84.

Awareness of the Staff of Slaughterhouses and Animal Husbandries of Crimean-Congo Hemorrhagic Fever in

Shoushtar, Iran in 2017

Elham Abdolahi Shahvali1, Mohammad Adineh2, Azam Jahangiri mehr3, Akram Hemmatipour1, Tahereh Nasrabadi4

1Department of Nursing, Shoushtar Faculty of Medical Sciences, Shoushtar, Iran, 2Nursingcare Research Centerin Chronic Diseases, Department of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran, 3MSc of Biostatistics, Department of Health, Faculty of Medical Sciences of Shoushtar, Shoushtar,

Iran, 4Department of Nursing, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran

ABSTRACT

Field: SinceCrimean-CongoHemorrhagicFever(CCHF)hasnoindicativeclinicalsymptomintheinfectedlivestock,thecurrentresearchwasconductedtocomparetheawarenessofthestaffofslaughterhousesandanimalhusbandriesinShoushtar,Iranin2015.

Method: In this descriptive-analytical study, 200 staff of slaughterhouses and animal husbandrieswereselectedbycensussampling.Datawerecollectedbyaresearcher-madequestionnaire,whichwascompletedby the study units.Datawere analyzed by SPSS statistical software (version 20) using descriptive andinferential statistics, including independent t-test,PearsonCorrelationCoefficient,Spearman, chi-squaretestandKolmogorov-Smirnovtest.

Finding: Theresultsshowedthattheawarenessofthestaffofslaughterhousesandanimalhusbandrieswasatalowlevel.Themeanawarenesswas6.46±2.61amongthestockbreeders)and8.01±2.89amongtheslaughterhousestaff,indicatingasignificantrelationshipbetweenthetwogroups(P<0.001).

Conclusion: According to the obtained results, it is necessary to develop educational programs andworkshopstoraisetheknowledgeofstaffaboutCCHFinslaughterhousesandanimalhusbandries.

Keywords: Crimean-Congo Hemorrhagic Fever, Awareness, Slaughterhouses, Staff, Animal Husbandries

Corresponding author: Tahereh Nasrabadi(BSc.MSc.Ph.D),DepartmentofNursing,TehranMedicalSciencesBranch,IslamicAzadUniversity,Tehran,Iran.Email:[email protected],Tel:+98021-22006632&+98021-47351501 Fax:021-22006632

INTRODUCTION

Adopting health measures to maintain health,increasing the life expectancy and average life andimprovingthequalityoflifearesaferthanperforming

treatment.Althoughthehealthcaresandhealth-relatedplansaremoreexpensiveinshortterm,butinthelongterm and considering all people in the community,healthandpreventivemeasuresaremoreadvantageousand more economical than treatment. However,hygiene is not limitedmerely to human but it shouldbegivenaspecialattentionalongwithall factors thatplay a key role in human’s life such as the health ofdomestic animalswe dealwith directly or indirectly.1 Humanbeingsneedpowertodotheirworks,andtheyshouldprovidethispowerandenergyfromhealthyandnutritiousfood.Ifthisfoodisexposedtocontamination,itcanendangertheirlifebecausefoodcontainshealthyandnutritiousmaterialsandmicrobesneednutrientsas

DOI Number: 10.5958/0973-9130.2018.00179.2


well,sofoodcanbethesourceofdiseases.Thatiswhyweneedtoknowaboutfoodpreparationmethods,foodcontamination,maintenancemethodsandtheprinciplesofcombatinggermsandpathogensinordertobeableto prevent the diseases caused by consumption ofcontaminatedfood.Thelivestockproductssuchasmilkandmeatareundoubtedlythemostfrequentlyusedfoodsperhousehold,andtheseproductshavenumerousrolesinthelife,nutritionandthesurvivalofhumanandplayanessentialroleinensuringfoodsafetyandcommunityhealth.Ifthesekindsoffoodproductsarepreparednon-sanitarily,theycancausemanydiseases.Amongtheseproducts,meat is themost importantsourceofanimalprotein.2

Todaythecommondiseasesamonghumanbeingsandanimals includeviral fevers,whichareoneof themost dangerous, deadliest and most common humandiseases.3OnecanpointtoCCHFthatisacomponentof thediseasewhoseagent isofTyrovirusgenusandBinovaridae family, which is mostly transmitted byarthropods.4ThisdiseaseisanacuteinfectionthatwasdiagnosedfirstinCrimeain1944andlaterwasknownwiththisnameduetoitsoutbreakinCongo.5TheCCHFviruswas introduced as one of the deadliest viruses.6 Thediseasedoesnotcauseanyapparentsymptomsinanimalsandplaystheroleofatankforthevirus.7,8

Theincubationperiodis2-9days.9ThehighestlevelofprevalencehasbeenreportedinsummerinJulyandthelowestlevelofinfectionhasbeenreportedtobeinfall.10TheWorldHealthOrganization(WHO)haslistedCCHFinnewbiediseases,whichrequirescontrollingandpreventivemeasures.Pakistan,Tajikistan,Afghanistan,IranandTurkeyarefivecountrieswherethediseasehasbeenobserved.11,12Possible casesofCCHFhavebeenreportedinIransince1999.

This disease is considered an endemic diseasein Iran.13 The severity of the disease was reported tobe 15% inKhorasanRazavi14 and 20% in Zahedan.15 Also,confirmedcaseshavebeenreportedbypeopleinSistan and Baluchistan, Khuzestan, Chaharmahal andBakhtiary,WesternAzerbaijan,Bushehr,Yazd,Kerman,Tehran, Isfahan, Golestan, Fars and Qom provincesof Iran in recentdecades,whichhave led todeath.16,17 Therefore, it isnecessarytohaveadequateknowledgeaboutthisdisease.

Regarding the job, Rezai et al (2012) found

the greatest number of confirmed positive cases inslaughterhouse staff and butchers (37.5%) and inlivestock breeders (31.2%). This disease is moreprevalent inmen than inwomen,which is due to thenatureofmen’s jobs inwhich theyhavemorecontactwithlivestock.18Further,Sargolzaietal(2012)evaluatedthe physicians’ awareness of the healthcare systemofCCHFandfoundthatamong112attendingphysicians,42.9%hadlowlevelofinformation,42.1%hadaveragelevelofinformation,8%hadgoodinformationandnoneofthemhadexcellentinformationaboutthehealthcaresystemofCCHF.19

Thehighriskgroupsinendemicareasincludepeoplewho have contact with livestock and other animals,includingfarmers,petowners,slaughterhousestaffandveterinarians.20 If no training is provided to them topreventandrecognizethedisease,theywillbeexposedto the disease directly.The purpose of this studywascomparingtheawarenessofthestaffofslaughterhousesandanimalhusbandriesabouttheCCHFinShoushtar,Iranin2015.


This cross-sectional, descriptive-analytical studycomparedtheknowledgeofthestaffofslaughterhousesand stockbreeders about in Shoushtar, Iran in 2017.Samplingwas done by censusmethod.The inclusioncriterionwas having the experienceofworking for atleastoneyearandtheexclusioncriterionwasincompletecompletionofthequestionnaire.Atotalof200samples(40 slaughterhouse staff and 160 livestock breeders)werechoseandinvestigatedinthisstudy.

The data collection tool in this study included aresearcher-madequestionnaire.Toassessitsvalidity,itwasgiventotenexpertsandspecialistsfromTehranAzadUniversityofMedicalSciences.Thefinalquestionnairewas obtained after considering the suggestions andmodifying and eliminating some of the items. Thereliability of the scale was determined by internalconsistency.For this purpose, thequestionnairesweregivento20individualswhohadthesamples’profiles,thentheywereexcludedfromthestudy.Thereliabilityofthequestionnairewasobtainedtobeα=0.78accordingtoCronbach’salpha,indicatingadesiredreliabilityforthequestionnaire.Thequestionnaireincludedquestionsaboutdemographicinformationsuchasage,genderandeducationlevelaswellas20questionsaboutknowledge


ofCCHF(9questionsabouttheknowledgeofdisease,3 questions about the symptoms, 3 questions aboutdiseasetransmissionand5questionsaboutprevention).Thequestionsweredesigned in suchaway that therewasonlyonecorrectoptionperquestion.Eachcorrectresponsewas assigned one score, and zero scorewasgiven to wrong responses. Then, the scores wereclassified into three levels: the score below ten wasconsidered weak, 10-15 was considered average andabove15wasconsideredasgood.

The questionnaire was distributed among thesamples and was completed in person. Data wereanalyzed by SPSS statistical software (version 20)using descriptive statistics, including mean, standarddeviation, maximum and minimum scores, frequencyand percentage as well as inferential statistics,

including, Pearson correlation coefficient, Spearman,chi-squaretestandKolmogorov-Smirnovtesttoassessthenormalityofdatadistribution.Theacceptablelevelofsignificancetotestthehypothesiswassetat0.05.

RESULTS

In this descriptive-analytical study, 200 staff ofslaughterhouses and animal husbandries in Shoushtarwere included (40 staff of slaughterhouses (20%) and160staffofanimalhusbandries(80%).Theaverageageof animal husbandry staff was (39.23 ±12.5) and theaverage age of slaughterhouse staffwas (37.7±12.5).100% of slaughterhouse staff were male and 20% ofanimal husbandry staff were female. The data weredistributednormallyaccordingtoKolmogorov-Smirnovtest(p>0.05).

Table 1. The demographic data

Variable Number Percentage

Gender

SlaughterhouseStaffs

Men 0 0Woman 40 100

AnimalhusbandryStaffs

Men 22 13.8Woman 138 86.2

EducationLevel


Illiterate 7 17.5Pre-Diploma 9 22.5Diploma 15 37.5Associate 3 7.5BachelororHigher 6 15.0


Illiterate 33 20.6Pre-Diploma 40 25.0Diploma 57 35.6Associate 9 3.8BachelororHigher 24 15.0

Age


Lessthanorequal30Years 21 52.531to40 3 7.541to50 9 22.5GreaterthanorEqualto51 7 17.5


Lessthanorequal30Years 71 44.4

31to40 7 4.4

41to50 53 33.1GreaterthanorEqualto51 29 18.1

WorkExperience


Lessthan10years 23 57.510to20 7 17.5Morethan20years 10 25.0


Lessthan10years 77 48.110to20 47 29.4Morethan20years 36 22.5


Table 2. The Medial and the standard deviation of the samples ‘scores in the research variable

Group Number Standard deviation ± Average T Test Significance level

AgeRanchers 160 (39.23±12.5)

0.692 0.489Staffs 40 (37.7±12.5)

WorkExperienceRanchers 160 (13.03±9.55)

0.589 0.557Staffs 40 (12.04±9.12)

AwarenessRanchers 160 (6.46±2.61)

-3.33 <0.001Staffs 40 (8.01±2.89)

There was no statistically significant differencebetween the ages of two groups (table 2). Therewas a statistically significant difference between theawareness of two groups (p<0.001), the awarenessscore of slaughterhouse staffs (8.01 ± 2.89) wasmore than that of the animal husbandry staff (6.46±2.61) (table 2).Therewas no statistically significantdifference in education level between the two groups(Chi-Square=1.269,p=0.867).Therewasnosignificantassociation between the education and awarenessamongtheanimalhusbandrystaff (r=0.700,p=0.629),but there was a significantly inverse relationshipbetweenageandawareness(r=0.224,p=0.004).Therewasasignificantlydirectassociationbetweeneducationand awareness (r=0.238, p=0.002) (table 2). Therewas no statistically significant relationship betweeneducation and awareness (r=.145, p=0.371), but therewasasignificantlyinverserelationshipbetweenageandawareness(r=0.343,p=0.03).Therewasasignificantlydirect relationship between awareness and education(r=0.397,p=0.01)(Table2)

DISCUSSION

Looking at the incidence of CCHF in Iran andother countrieswhere the disease is native to the,wefindout that thegreatestdanger is illegalcontactwithand illegal slaughter of the livestock.3 The results ofthis study showed the awareness of the study groupswas at a low level.However, therewas a statisticallysignificant difference in the level of awarenessbetweenthetwogroups,andtheslaughterhousestaff’sawarenesswasmorethanthatoftheanimalhusbandrystaff,whichcouldbeduetoresidenceincity,veterinaryorganization supervision and providing information

to the slaughterhouse staff by environmental healthexperts.Yavarian(2013)alsoshowedthattheawarenessof the slaughterhouse staff and livestock breeders ofthis diseasewas not at an appropriate level.21 In theirstudy,Sargolzai(2012)concludedthattheawarenessofZahedangeneralpractitionersof thecontrolsystemofCCHFwasat anundesirable level,but thephysicianswhohadtheexperienceoftakingtheretrainingcoursesof the disease had more information.19 Çİlİngİroğlu (2010) conducted a study inTurkey and reported that85% of women did not have sufficient knowledge.22 However,Ghasemirad(2013)claimedthattheawarenessofbutchersandslaughterhousestaffwasatanaveragelevel in Yazd but their performance to prevent thediseasewasundesirable.23

Thefindingsofthisstudyindicatedasignificantlyinverserelationshipbetweenageandawareness,asthehigherwaseducation,thehigherwasawareness,whichisconsistentwiththeresultsofÇilingiroğlu.18ButintheresearchdonebyFarzinnia(2013)inQom,therewasnosignifycantassociationbetweentheageandattitudeofthestudiedsubjects,24whichisnotconsistentwiththeresultsofthecurrentstudy.

The findings also showed a significantly directrelationshipbetweentheeducationandawarenessofthetwogroups, thehigher the education level, thehighertheir awareness of CCHF, which is consistent withtheresultsofÇilingiroğlu.22However,AliZ(2013) inPakistan found no statistically significant relationshipbetween education level and awareness,12 confirmingthefindingsofthecurrentstudy.


CONCLUSION

Theresultsofthisstudyshowedthattheknowledgeof slaughterhouse and animal husbandry staff aboutCCHF and the danger of contact with livestock andmiteswasnotatadesirablelevel.So,itisessentialtoprevent thisdiseasebynecessarytrainingsandraisingtheknowledgeofthepersonnelofhigh-riskjobsaboutthisdisease.

Conflict of Interests: Nil

Ethical Considerations: Ethical matters e.g.plagiarism, informed consent, misconduct, datafabrication and/or falsification, double publicationand/or submission, redundancy, etc. have been totallyobservedbytheauthors.

Source of Funding: Nil

REFERENCES

1. Mousavi S, Siranvand M. Community HealthNursing.MoeinInstituteofScienceandTechnologyPublication.2011.

2. Ghaneian M.T, Ehrampoush M.H, Farsad M,Dehvari M. Evaluation of Health Conditions ofLivestock and Poultry Slaughterhouses in YazdProvince. Journal of Science and Research,YazdSchoolofPublicHealth.2013;2(12):124-135.

3. Abdollahi Shahvali E, Nasrabadi T,Fesharaki M. TheeffectofCrimeanCongofevertrainingontheknowledgeandpracticeofSlaughterhouseStaffinshoushtar. Journal of nurse and physician withinwar. 2016;3(8):12-19.

4. Saghafipour A., Norouzi M., Sheikholeslami N.,MostafaviR.Epidemiologic status of the patientswith Crimean Congo Hemorrhagic Fever and itsassociatedrisk factors. IranianJournalofMilitaryMedicine.2012;14(1):1-5.

5. Leblebicioglu H, Ozaras R, Irmak H, Sencan I.Crimean-Congo Hemorrhagic Fever in Turkey.Current Status and Future Challenges. Antiviral Res.2016;126:21–34.

6. Ergonul O. (2016). Crimean-Congo HemorrhagicFever,JournalEid.19:200-215.

7. Appannanavar SB, Mishra B. An Update onCrimean Congo Hemorrhagic Fever. Journal of GlobInfectiousDiseases.2011;3(3):285–292.

8. Jane P. Messina, David M. Pigott, NickGolding, Kirsten A. Duda, John S.Brownstein,DanielJ.Weiss,andetal.TheGlobalDistributionofCrimean-Congo HemorrhagicFever.Transactionsof theRoyalSocietyandofTropicalMedicineandHygiene.2015;109(8):503–513.

9. AkuffoR,BrandfulJA,ZayedA,AdjeiA,WatanyN, FahmyNT, and et al. (2016). Crimean-CongoHemorrhagic FeverVirus in Livestock Ticks andAnimal Handler Seroprevalence at an Abattoirin Ghana. BMC Infect Dis.2016; 16: 324 .doi:10.1186/s12879-016-1660-6.

10. Saberianpour Sh. Crimean-Congo HemorrhagicFever,PeriodicaloftheStudentResearchCommitteeofSabzevarUniversityofMedicalScience. 2014;2(19):30-40.

11. YolcuS,KaderC,KayipmazAE,OzbayS,ErbayA. Knowledge Levels Regarding Crimean CongoHemorrhagicFeveramongEmergencyHealthcareWorkers inanEndemicRegion.Journalofclinicalmedicine research. 2014; 6(3):197-204. doi:10.14740/jocmr1801w.

12. Ali Z, Kumar R, Ahmed J, Ahmed J, Ghaffar A,Mureed SH. Mureed Knowledge Attitude andPractice of Crimean-Congo Hemorrhagic FeverAmongRuralPopulationOfBaluchistan,Pakistan.APublicHealthNutritionalAssessmentofElderlyin Islamabad A Mixed Method Study. J PublHealth.2013;3(4):11–13.

13. Ergonul O, Whitehouse CA. Crimean-CongoHemorrhagicFever:AGlobal Perspective.Berlin:Springer; 2007 Disease and Tropical MedicineTehran–Iran.2010.

14. EbadiF,EsmaeilRA,ZohoorA.Epidemiologicalsurvey of Crimean Congo hemorrhagic fever inKhorasan Razavi. MEDICAL SCIENCES. 2011;21(1):61-66.

15. Sharifi-MoodB,MetanatM,Hashemi-ShahriSM,MardaniM,HashemiSA,FayyazjahaniF.Crimean-CongoHemorrhagicFeverFollowingConsumptionofUncooked Liver:CaseSeriesStudy.IranJClinInfectDis.2011;6(3):128-30.

16. Chinikar S, Ghiasi SM, Moradi M, GoyaMM, Shirzadi MR, Zeinali M, and et al.Geographical Distribution and Surveillance ofCrimeancongoHemorrhagicFever in Iran.VectorBorne Zoonotic Dis. 2010; 10(7):705-8. doi:


10.1089/vbz.2009.0247.

17. ChinikarS,GhiasiSM,Ghalyanchi-Langeroudi,GoyaMM,ShirzadiMR,ZeinaliM.andetal.AnOverviewofCrimean-CongoHemorrhagicFeverinIran.IranianJournalofMicrobiology.2009;1(1):7-12.

18. Rezaei F, Rezazadeh A, Moghaddami M, MirAhmadizadeh A.R,Rezazadeh F.Reporting FiveCasesinfectedbyCrimean-CongoHemorrhagicinFarsProvincein2010,SouthMedicinePeriodical,Bushehr University of Medical Sciences, 2012;15(3):241-248.

19. Sargolzai N, Dehghan Haghighi J, KharazmiF. Care System of CrimeanCongoHemorrhagicFeverandGeneralPhysiciansinZahedan.Journalof Medical University o, Mashhad University ofMedical Sciences, Mashhad, Iran.2013; 56(1):21-25.doi:10.22038/mjms.2013.454.

20. ErbayA.In:MolecularDetectionofHumanViralPathogens.LiuD,Editor.BocaRaton, FL,US:CRCPress Taylor and Francis Group; 2010. Crimean-

CongoHemorrhagicFever Virus;Pp.617–629.

21. Yavrian H. Considering The Impact of CrimeanCongo Hemorrhagic Fever Training (CCHF)on of Health Behavior Changes of ZahedanSlaughterhouse Staffs, Master’s Thesis, Tehran,TarbiatModaresUniversity.2013.

22. Çilingiroğlu N, Temel F, Altıntaș H. PublicsKnowledge, Opinions and Behaviors aboutCrimean-CongoHemorrhagic Fever:AnExamplefrom Turkey. Kafkas Üniversitesi VeterinerFakültesi Dergisi. 2010; 16 (Suppl-A): S17-S22.DOI:10.9775/kvfd.2009.814.

23. Omrani M. Considering the Awareness andPerformance of Yazd City Butchers andSlaughterhouse Staffs about Crimean CongoHemorrhagic Fever (CCHF), PhD Dissertation,IslamicAzadUniversity,YazdUnit.2013.

24. FarzinniaB,SaghafipourA,TelmadarraiyZ.Studyof the Epidemiological Status of Crimean-CongoHemorrhagic Fever Disease in Qom Province,2011,Iran.QomUnivMedSciJ.2013;7(4):42-48.

Autopsy Study of Deaths due to Fall from Height: A Three Year Prospective Study

Ramesh C1, Viswakanth B2

1Assistant Professor, Department of Forensic Medicine and Toxicology, Kempegowda, Institute of Medical Sciences, Bangalore, Karnataka, 2Associate Professor, Department of Forensic Medicine and Toxicology,

P K Das, Institute of Medical Sciences, Vaniamkulam, Kerala

ABSTRACT

Background: Fallfromheightposeasubstantialpublichealthjeopardyglobally,andareoneamongtheimportantleadingcausesofdeathduetoinjuries.DeathsduetofallfromheightarecommonintheStateofKarnatakaandcontinuetoincreaseduetomultiplereasonsbutpredominantlyduetorapidurbanizationwithmultistoriedsetups.Inordertoassessthemagnitudeofthisongoingproblem,athreeyearprospectiveautopsystudyamongdeathsduetofallfromheightwascarriedonwithregardtoitsdemographicprofile,manner,physicsandpatternofinjuriesatKIMShospitalBangalore.Results:Mostofthevictimsweremales(86%)andmajorityofthedecedentsbelongedto21-30yearagegroup.Amongthem,buildingconstructorworkers(41%)formedthehighestnumberofvictims.Themostfrequentheightoffallcausingdeathwasfound to be falls fromheights ranging between 40-50meters.Themost commonmanner of deathwasfoundtobeAccidental(55%)innature.Lastlyallcasesshowedseverevisceralandskeletalinjurieseitherindependentlyorincombination.

Keywords: Fall, Height, Autopsy, Blunt injury, head injury, skeletal injuries, visceral injuries

Corresponding author:Dr. Viswakanth BAssociateProfessor,Dept.ofForensicMedcine&Toxicology,P.KDasInstituteofMedicalSciences&Hospital,Vaniyamkulam,OttapalamPalakkadDistrict,Kerala679522EmailId:[email protected]:9744525554

INTRODUCTION

Deathsduetofallfromheight(FFH)arecommonin urban settings. In occupational settings, it is themostcommontypeofaccident.Builders,electricians,miners and painters are particularly at risk. It is alsoa major cause of personal injury, especially for thechildrenandtheelderly.Globally,FFHareasubstantialpublic health jeopardy. They account to the secondmost common cause of injury-associated mortalityaftertrafficaccidents.Fallsarealsoamajorcauseofemergencyroomvisitsandadmissionsinhospitals.Factors contributing to falls from heights include

faulty equipment, such as ladders and scaffoldstructuresandhumanfactors,suchasintoxicationandinattention.FFHdeathsare frequentlyassociatedwithavarying rangeof external and internal injuriesoftensevere, fatal and mortal. The most common regionsincludethehead,limbs,abdomen,chest,pelvisandtheneckinorderofdescent.Relativelyrareinjuriesincluderegionssuchastheretroperitoniumandgastro-intestinaltract.VirtuallythereisnoheightlimitfordeathsinFFHduetoheadinjury,whicharecommoningroundlevelfallsintheagedandinchildren.Ithasbeenfoundthatanaverageheightof10to24metersfallisrequiredforonetosustainneckinjuryandabove25metersforchestandabdominalinjuries1, 2, 3.DeathsduetoFFHarecommoninBangalore, the capital city ofKarnataka and hencea3yearprospective autopsy studywasundertaken toevaluate thedemographicprofileand injurypattern tounderstandthemagnitudeoftheproblemandtobetterevaluatethecauseofdeathfromthepatternofinjuries.

MATERIAL AND METHOD

Thestudymaterialconsistedof1503medicolegal

DOI Number: 10.5958/0973-9130.2018.00180.9


autopsies conducted in the department of forensicmedicine and toxicology, Kempegowda Institute ofMedicalSciencesandHospital,Bangalore,Karnataka,duringaperiodof3years(fromJune2015toJune2018).Ofthese,78casesweredeathsduetofallfromheight,whichwerestudied,prospectivelyafterobtainingclearance from the institutional ethical clearancecommittee.

Dataforthestudycomprisedofinquestreportsandinterviewsfromrelativesandfriends,ofthevictims.Adetailedproformaforrecordingtheparticulars,history,demographic profile and injury pattern was prepared.The information thus collected, was analyzed usingappropriate statistical tools (namely Microsoft Excel2007andIBMSPSSV.20).


Duringthestudyperiod,1503caseswerebroughtforMedicolegalpostmortemexamination,ofwhich78(5%)casesweredeathsduetoFallfromheight.

Yearwiseanalysisbetweenmid-2015tomid-2018showedhighestnumberofdeathsduetoFFHintheyear2016,whereweencountered33cases(42%)[Table1].Maximumnumberofvictims(28%)belongedtotheagegrouprangingbetween21-30years[Table2].Observingsex wise death distribution, majority of the victimswere found to bemales (86%) [Table 3].Majority ofthevictimswerebuildingconstructionworkers (41%)[Table 4]. Highest frequency of deaths due to FFHoccurredfromaHeightofmorethan50meters(38%)[Table5].MostofthedeathsduetoFFHwereAccidentalinmanner(55%)[Table6].Whileconsideringthefatalinternal injuries, Brainwas found to be injured in allcases (100%) followed by liver and lung in order ofdescent 90% and 51% respectively. Fractures of theskull, limbbonesandpelviswereobservedin90%ofthecases[Table7].

TABLE 1: Year Wise Distribution of Fall from Height Deaths [FFH]

S.NO Year No. of Deaths Percentage (%)

1. 2015 16 21

2. 2016 33 42

3. 2017 21 27

4. 2018 08 10

Total 78 100

TABLE 2: Age wise distribution of FFH Deaths

S.NO Age Group (Years) No. of Deaths Percentage (%)

1. 0-10 02 32. 11-20 10 133. 21-30 22 284. 31-40 18 235. 41-50 07 96. 51-60 13 177. >60 6 8

Total 78 100

TABLE 3: Sex wise distribution of FFH Deaths

S.NO Sex No. of Deaths Percentage (%)

1. Male 67 86

2. Female 11 14

Total 78 100

Table 4: Occupation of the Victims in FFH Cases

S.NO Occupation No. of Deaths

Percentage (%)

1. Student 14 18

2. Electrician 2 3

3. Construction worker 32 41

4. Employedinothersectors 6 8

5. Unemployed 24 31

Total 78 100

Table 5: Height of Fall (In Meters) in FFH Cases

S.NO Height (in meters) No. of Deaths Percentage

(%)

1. 5-10 1 1

2. 10-20 1 1

3. 20-30 6 8

4. 30-40 14 18

5. 40-50 26 33

6. >50 30 38

Total 78 100


Table 6: Manner of Death in FFH Cases

S.NO Manner No. of Deaths Percentage (%)

1. Accidental 43 55

2. Suicidal 34 44

3. Homicidal(Dyadicdeath) 1 1

Total 78 100

Table 7: Visceral & Skeletal injuries in FFH Deaths

S.NO Organ / Bones No. of Deaths Percentage (%)

1. Brain 78 100

2. Lung 40 51

3. Liver 70 90

4. Spleen 40 51

5. Skull Fracture 70 90

6. RibFracture 40 51

7. Limb Bone Fractures 70 90

8. PelvicFractures 70 90

DISCUSSION

In this section a comparison is made withobservation made specifically on deaths due to FFHby other researchers prior or at parallel to our study.In thepresentstudy the totalnumberofdeathsdue toFFHwere about 5%of all deaths encountered duringthe 3 year study period, which is consistent with thefindings made by Jagannatha SR et al, VenkateshaVT et al andTurgut et al 4, 5, 6. The age group in ourstudyshowedmaximumnumbersfallingwithin21-30yearswhich is consistentwith findingsmade bywiththefindingsmadebyJagannathaSRetal,VenkateshaVTet al andKiranKumaret al 4, 5, 7.However, it didnotcorrelatewiththefindingsmadebyPrathapanetal,who observed maximum number of victims in 41-50yearsagegroup8.TakingSexintoconsideration,male

death preponderancewas observed and this finding isconsistent with observation made by all researcherscomparedhereinthissection4-8.Occupationwise,weobserved highest number of deaths among buildingconstructionworkers and thisfinding is similar to thestudiesmade by Jagannatha SR et al andVenkateshaVT et al 4, 5, but it did not correlatewith thefindingsmade by Prathapan et al andTurgut et al who foundmaximumdeathsduetoFFHoccurringintreeclimbersandslipfallsamongtheelderly6, 8.TheaverageHeightoffallresultingindeathinvestigatedbyuswasfoundto be more than 50 meters which is consistent withthefindingsmade by JagannathaSR 4, but, it did notcorrelatewiththefindingsmadebyrestallresearcherscitedaboveinthissection5-8.Withregardtothemannerofdeathandinternalinjuries,FFHdeathsinourstudywere accidental in nature, and pattern or distributionor occurrence of internal organ and skeletal injuriesis similar to the studiesmade by all researchers citedaboveinthissection4-8. Intheabovediscussedsection,findingswhichdidnotcorrelatewith theobservationsmadebyotherresearcherscouldbeexplainedprobablyduetoregionalandoccupationalvariations.

CONCLUSION

While there cannot be a probable remedy forsuicidal falls or homicidal push-falls, there can beseveralremediessuggestedinordertopreventaccidentalfalls,sincetheyoutnumberthelatter.StrongandproperfencingofTerracesandbalconiesat homes,adequatesafety equipment such as helmets and safe straps forbuilding construction workers and other personnelwhoareatriskintheirrespectiveprofessionsorskillsworkingatheight.Uniformpolicyinthisregardshouldbeframedbythestateorcentralgovernmentandalsobemadecompulsorysothattheworkplaceauthoritieswillensurethesafetyofallitsemployeesifnotbywillbutbytheorderofthestate.

Ethical Committee Clearance:Obtained

Source of Funding:Nil


REFERENCES

1. Biswas G. Review of forensic medicine andtoxicology. 3rd ed. Jaypee brothers MedicalPublishers(P)Ltd.;2015:292-93.


2. EvanAN,CarolH,BoXiaetal.FallsfromHeightintheConstructionIndustry:ACriticalReviewoftheScientificLiterature.Int.J.Environ.Res.PublicHealth.2016;13(7):638.

3. ErsoyS,SonmezBM,YilmazF,etal.Analysisandinjurypaternsofwalnuttreefallsincentralanatoliaofturkey.WorldJEmergSurg.2014;9:42.

4. Jagannatha SR, Pradeep Kumar MV, NaveenKumaretal.InjuriesDueToFallFromHeight–ARetrospectiveStudy.JournalofForensicMedicine&Toxicology.2010;27(1):47-50.

5. VenkateshVT,PradeepKumarMV,JagannathaSRet al.Patternof skeletal injuries incasesof falls

from a height.Med. Sci. Law. 2007; 47(4): 330-334.

6. TurgutK,MehmetES,CemilC et al. Falls fromheight: A retrospective analysis. World J EmergMed.2018;9(1):46-50.

7. Kiran Kumar JV and SrivastavaA K. Pattern ofInjuriesinfallfromHeight.JIndianAcadForensicMed.2013;35(1):47-50.

8. Prathapan V, Umadethan B. Fall from Heights– Pattern of Injuries. International Journal ofBiomedicalResearch.2015;6(01):8-13.

TABLES

Evaluation of the Effect of Different Finish Lines and Luting Agents on Marginal Fit and Microleakage in Direct Metal

Laser Sintered Copings – An in Vitro Study

Pallavi Chavan1, Thilak Shetty2, Mahesh Mundathaje3, Shobha J Rodrigues4, Sharon Saldanha5, Umesh Pai6, Puneeth Hegde7

1Postgraduate Student, 2Professor & Guide, 3Associate Professor, 4Professor & Head, 5Associate Professor, 6Associate Professor, 7Assistant Professor, Department of Prosthodontics, Manipal College of Dental Sciences,

Mangalore, Manipal Academy of Higher Education, India

ABSTRACT

Background & Objectives:.ThepresentstudyaimedtostudytheeffectoffinishlineandlutingcementsonmarginalgapandmicroleakageincopingsfabricatedbyDirectMetalLaserSintering(DMLS)

Method: 28maxillarypremolarsweredivided in twogroupsdependinguponfinish linedesign.Co-CrcopingswerefabricatedwithDMLStechnique.Ceramiclayeringwasdonefollowedbycementationwithtwolutingagents.Thesesamplesweresectionedandmarginalgapwasmeasuredbystereomicroscopeandalsocalibratedformicroleakage.

Results: ThemeanmarginalgapvalueforcrownsfabricatedbyDMLSwas 139.73±66.06µm.ThemeanmarginalgapwasleastforsamplesinGroupB(b)105.35±67.25µmfollowedbyGroupB(a)135.71±19.66µm;GroupA(a) 142.85±71.39 µm and highest valuewas seen for GroupA(b) 175±82.28 µm. 85.7%sampleshadmicroleakage.HighestmicroleakagewasseenwithsamplesinGroupA(a)andleastinGroupB(a).Noneofthevalueswerefoundtohavestatisticalsignificancewithsignificancevaluelessthan0.05.

Conclusion: ThereisnoeffectoffinishlineorlutingcementonthemarginalgapormicroleakageonmetalceramiccrownwithcopingsfabricatedbyDMLSmethod.

Keywords: Direct Metal Laser Sintering, metal ceramic crowns, marginal gap.

INTRODUCTION

The desire to incorporate the predictable andconsistent precision provided by CAM techniquehas boosted many new manufacturing methods.Direct Metal Laser Sintering is one such computeraidedmethodwhich can produce up to 90 units perrun1. It reducesmaterialwastageand simplifiespostfabrication procedures for metal copings. DMLS

Corresponding author:Dr Shobha J RodriguesProfessor&Head,DepartmentofProsthodontics,ManipalCollegeofDentalSciences,MangaloreManipalAcademyofHigherEducation(MAHE),Email:[email protected]

requiresthreeinputs:material,energyandCADmodel2. The material used is a chrome cobalt powder-basedworkingalloy.Molybdenum,tungsten,silicon,cerium,iron,manganese and carbon are the other ingredientsused.Theyarenickelandberylliumfree.Thealloyisamixofparticlesofthesizeof3–14μm.Energyusedisahigh-poweredlaserbeam3(200WYtterbiumfiberopticlaser).Thisenergyisusedtomeltthealloypowder.Thethird input isCAD model. Themachine reads in datafromaCADdrawingandlaysdownsuccessivelayersof alloypowder and in thisway,buildsup themodelfrom a series of cross sections. DMLS is a muchcleaner and time-efficient alternative to casting. Iteliminates arduous steps of investing, de-investing,metaltrimmingandpolishing.

DOI Number: 10.5958/0973-9130.2018.00181.0


Lasersinteredcopingshaveshownhigherultimatetensile strength, 0.2% yield strength, and elasticmodulus compared to its casted counterparts4. The shearbondstrengthofDMLScopingswithporcelainhasalsoshownpromisingresults.5,6

Asuperiormarginalfitthatprovidesresistancetobiologicfailures likemicroleakage,secondarycariesandsensitivityneedstobeinvestigated

Thepurposeofthisstudywastoassessifvariationinfinishlineandlutingagentinfluencesthemarginaldiscrepancy andmicroleakage in copings fabricatedbyDMLStechnique.

Thenullhypothesiswas,therewillbenoeffectof finish lines and luting agents onmicroleakage incopingsfabricatedwithDirectMetalLaserSinteringTechnique


28MaxillaryPremolarsweredividedinto2groupsof14specimenseach.

GroupA:MetalsinteredCo-CrCopingsforcrownswith1mmdeepchamferfinishline

GroupB: MetalsinteredCo-CrCopingsforcrownswith1.5mmshoulderfinishline.

Axial reduction of 1.5mm and occlusal reduction1.5mmonnon-functionalcuspand2mmonfunctionalcuspwasmaintained.6°uniformtaperwasensuredwithacustomisedparallelingdeviceforairotor.

Impressions were made with medium body andlight body polyvinyl siloxane material (Reprosil;Dentsply caulk, USA) in special traysmade for eachsamplepriortothetoothpreparation.DieswerepouredwithscanablediestoneandweresenttoalaboratoryforscanninganddesigningusingCAD(Computer-AssistedDesigning)program.Cementthicknessof25µm,1mmabovethefinishlineandathicknessof0.3mmofeachmetalcopingweremaintained.ThedesigningdatawasthensenttotheEOSINTM270DMLSsystem.TheCo-CralloypowderwassinteredbythemachineusingYb-fibrelaser,(200W)inincrements.Ceramiclayeringwasdoneoneachcopingtoresembleamaxillarypremolar.

Eachgroupwasfurtherdividedintotwosubgroupsof7each.

Subgroup (a): Co-Cr coping cemented with self-adhesive resin cement (RelyXU200 resin cement, 3MESPE,Seefeld,Germany)

Subgroup(b):Co-CrcopingscementedwithGlassionomer luting cement (GC Fuji, GC Corporation,Japan.

Sampleswere subjected to thermocycling at 5ºCand55ºC for1000cycles inartificial saliva.24hoursafter thermocycling all the samples were de-mountedandimmersedinbasicfuchsindye0.5%concentrationfor24hours.Rootswerepaintedwithnailpaintvarnishupto1mmbelowtheCEJtopreventanydyepenetrationthroughtheroots.

Each sample was unrooted with a horizontal cut1mmbelowtheCEJandthensectionedmesio-distallythroughthecentralgroovetogivetwosectionsbuccalandlingual.Itwasassessedatmesialanddistalofeachsection,formicroleakageand marginalgap.Verticaldiscrepancywasmeasuredasaperpendiculardistancebetweenthefinishlineandcrownunder4xmagnificationlensinastereomicroscope.MicroleakagewasassessedastheamountofdyepenetrationovertheaxialwallsofthesampleandwasgradedasgivenbyTjanetal7

0-Nodyepenetration

1-Dyepenetrationupto1/3rdofaxialwall

2-Dyepenetrationupto2/3rdoftheaxialwall

3-Dyepenetrationalongthefulllengthoftheaxialwall

4-Dye penetration extending on to the occlusalsurface

Resultswereanalysedusingone-wayANOVAtestandChiSquaretest.

RESULTS

Descriptive analysis revealed 14.3% out of 28samples had score 0. The percentage of score ‘0’ ineach group according to finish line and cement typeswas28.6%forGroupA(a),14.3%forGroupA(b)andGroupB(b)and0%forGroupA(b).53.6%sampleshadscore1while17.9%hadthemaximumscoreof4.TableI reveals distribution ofmicroleakage scores for eachsubgroup.ChiSquare test revealedapvalueof0.587indicatingnosignificantinfluenceoffinishlineorluting


agentinmicroleakageofDMLScrowns.

The highest mean of 175µmwas found with thesamplesinGroupA(b)andtheleastof105.35µmwaswithGroupB(b)(GraphI).One-wayANOVArevealedthere was no statistical significance (p=0.278) in thegroupswhendifferentfinishlinesandlutingagentswereused.PostHocTukeytestappliedtocheckintergroupstatistical difference ofmarginal discrepancy, showedno significant difference.Association test ofANOVArevealed no association between marginal gap andmicroleakageinthesamples.(TableII)

Table I: Distribution of microleakage score in each group

Groups

Dyepenetration

Group A(a)

Group A(b)

Group B(a)

Group B(b) Total

score0 2 0 1 1 4

Score1 2 5 5 3 15

Score2 0 0 1 1 2

Score3 1 0 0 1 2

Score4 2 2 0 1 5

Total 7 7 7 7 28

Table II: ANOVA for association between mean marginal gap and microleakage in each group

Microleakage Scores n Mean Std.

Deviation p Value

Score0 4 143.75 88.0932

0.559

Score1 15 128.333 64.3419

Score2 2 156.25 26.5165

Score3 2 100 17.6777

Score4 5 180 73.7394

Total 28 139.732 66.0609

DISCUSSION

The present study to assess the effect of twocommonly indicated finish lines for metal ceramic

crownsandFPDsfoundthattheleastvalueformarginalgapforsampleswithdeepchamferfinishlinewas50µmandthehighestwas287µm(mean=158.92µm).Sampleswith shoulder finish lines had smaller marginal gapsthanwithchamferfinishline.ThetotalmeanmarginalgapofthecrownsmadebyDMLSinthepresentstudywas139.73±66.06µm.

AstudydonebyRidhimaetal11foundthemarginalgap in 40 metal ceramic crowns with 900 shoulder(42±4.1 µm), shoulder with 300 bevel(39± 5.2µm) ,shoulderwith450bevel(34±3.8µm),chamfer(51±5.6µm)finsih lines made by conventional casting underthermo-mechanical loading. They found the marginalgapincreasedinthefollowingorder:shoulderwith450 bevel,shoulderwith300bevel,rightangleshoulderandchamfer. The difference was found to be statisticallysignificant. Similar results have been found by Jung-Zensyu,GeraardByrne,LeonLaubMartinLand8 . Itis observed that the crownswith chamfer finish linesinitally have a better seating with less marginal gap/discrepancy,butasthecrownisseatedwithlutingagentthemarginaldiscrpancytendstoincrease.Thiscanbeexplained as the immediate adaptation at themarginsprovideslessspaceforthecementlayertoescapethusleavingagreatergap in thefinalcementedprosthesis.On the other hand crowns with shoulder finish lineshavepoorseatinginitially,howeverthisprovidegreaterspace for the cement to escape thus giving lessermarginaldiscrepancy/gapinthefinalprosthesis9.

DMLScopingsinmanystudieshaveshowngreatermarginal gap values compared to other twomethods.However,studiesbyÖrtorpetal10andHarish.Vetal.11 haveobserved somecontradicting results.TheDMLSmarginal gapswere narrower than that of casting andCAD/CAM gave thewidestmarginal gaps. A crucialfactor involved in the fabrication ofDMLS coping isscanning for CAM designing. Any object with lowreflective property gives more accurate readings. Alldies in the present study were sprayed with titaniumoxide(TiO2)toreducetheirreflectiveindices.

Themicroleakageassessment in thepresent studyshowedonly4samplesoutof28hadnomicroleakage.This is not surprising as whatever be the method offabricationorcementusedthereisalwaysagappresentbetween the crown margin and tooth. Also, basicfuchsin dye diffuses easily compared to oral fluids12. Majorityof the samples (53.6%), in thepresent study


hadanacceptablemicroleakagescoreof1.Maximummicroleakage score of 4was observedwith 17.9%ofsamples.ThesesamplesbelongedtoGroupA(a),GroupA(b)andGroupB(b).Thus,chamferfinish lineeitherwithresincementorGICpresentshighermicroleakagecompared to shoulder finish line combinedwith resincement. The combination of shoulder finish linewithresin (Group B(a)) had the least microleakage, Noneofthesevalueswereseentobestatisticallysignificant.Sample with chamfer finish line cemented with GIClutinghadthemaximummarginalgapof175µmwhilesampleshavingshoulderfinishlineandcementedwithGIC had least marginal gap of 105.35 µm. AndreePiwowarczyket al13 inhis studyobserved statisticallysignificant marginal gap with conventional GIC insamplespreparedwith chamferfinish lines.However,thepresentstudydidnothaveanystatisticalsignificanceprobablyduetothelowersamplesize.

Marginal gap and microleakage are importantparameters to judge clinical longevity of prosthesis.ADAspecifies for clinical acceptability theprosthesisshould have a marginal gap of 25 µm14. Differentauthors have mentioned different ranges of marginalgapAssifetal15statedthemeanmarginalgapiscloserto 140 μm, while Hung et al16 suggested a value of50-75μm.GulkerandBjonetal17suggestedthatupto200μm shouldbe tolerated.Themarginal gapvaluesobservedinthepresentstudywerehigherthanthevaluespresentedinpreviousliteratureonDMLScrowns.Thisprobablycanbeexplaineddue to theuseofhydraulicpressusedinthestudytoapplyauniformforceon5kgduringcementationwhichexertforceonasinglepointcontact which might have led to uneven distributionofpressurecausing inadequateflowandaccumulationoflutingagentatthemargins.Hightemperaturesusedfor ceramic veneering in PFM crowns also leads todistortioninthemetalcopingsandincreasedmarginalgapvalues18,19.Tostandardisethisparameterallsamplesinthepresentstudywereveneeredwith5ceramiclayersincluding2opaquefiringcycles.

While studying the association of marginal gapvalueswithmicroleakagethepresentstudycorroborateswithpreviousliteratureshowingnoassociationbetweenthe two. The mean marginal gap of samples havingno microleakage was higher (143.75±88.09µm) ascompared to samples which had dye penetratingthroughout the axial surface (100±17.67 µm). As

seen inTable 2 sampleswith score 4 havemaximummean marginal gap (180 ±73.73µm) followed bysampleswithscore2(156.25±26.51µm),score0,score1(128.33±64.34µm)andfinallyscore3.

The merits of the present study lie in thedetail to standardize confounding factors like thethickness of impressionmaterial, thickness of cementlayer, equalization of pressure while cementation.Thermocyclingwasdonetosimulateoralenvironmentandtomakethestudymoreclinicallyrelevant.However,thesmallsamplesize,lackofcustomizedcementationdevice, absence of a control group can be counted asdemerits.

CONCLUSION

Reviewing the results obtained in the presentstudythenullhypothesisthat,therewouldbenoeffectof finish lines and luting agents onmicroleakage andmarginal gap inmetal sintered copingswas accepted.This study thus sums up that there is no effect offinish line and luting agents on themarginal gap andmicroleakageinmetalceramiccrownsmadebyDMLSmethod.Theassociationresultsalsoshowedthatthereis no ground rule that if marginal gap is more therewillbemoremicroleakage. Althoughnotstatisticallysignificant there was a trend of shoulder finish linehavingsmallermarginalgapsthanthechamfer.Thereisstillambiguityregardingthemarginaldiscrepancyin DMLS crowns compared to casting and CAD/CAM.However,most of the literature has regardedthis discrepancy insignificant and further clinicallyacceptablestudiesarerequired.


Source of Funding :Self

REFERENCES

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2. K.VijayVenkatesh,V.VidyashreeNandini.DirectMetalLaser Sintering:ADigitisedMetalCastingTechnology.J IndianProsthodontSoc.2013 ;13:389–392.

3. A.Simchi.Directlasersinteringofmetalpowders:


Mechanism, kinetics andmicrostructural features.Materials Science and Engineering A 428 2006;148–158.

4. Yun-JungChoi,Jai-YoungKoak,Seong-JooHeo,Seong-Kyun Kim, Jin-Soo Ahn, Dong-Soo Park.Comparison of the mechanical properties andmicrostructuresoffracturedsurfaceforCo-Cralloyfabricatedbyconventionalcast,3-Dprintinglaser-sinteredandCAD/CAMmilledtechniques.KoreanAcadProsthodont2014;52:67-73.

5. Tolga Akova, Yurdanur Ucar, Alper Tukay.Comparisonof thebond strengthof laser-sinteredand cast base metal dental alloys to porcelain.DentalMaterials2008;24:1400-1404.

6. Lin Wu, Haiting Zhu, Xiuying Gai, YanyanWang. Evaluation of the mechanical propertiesand porcelain bond strength of cobalt-chromiumdentalalloyfabricatedbyselectivelasermelting.JProsthetDent2014;111:51-55.

7. AntonyTjan,DrDentetal:Marginalleakageofcastgoldcrownslutedwithanadhesiveresincement:JProsthetDent1992;67:11-15.

8. Jung-ZenSyu,Byrne,Gerard,Laub,LeonW,Land,MartinF.InfluenceofFinish-LineGeometryontheFitofCrowns.IntJProsthodont.1993;6:25-30.

9. VaishaliNemane,RavikumarSuryakanthAkulwar,Suresh Meshram. The Effect of Various FinishLine Configurations on the Marginal Seal andOcclusal Discrepancy of Cast Full Crowns AfterCementationAn InvitroStudy. JClinDiagnRes.2015;9:ZC18–ZC21.

10. Anders Örtorp, David Jönsson, Alaa Mouhsen,PerVultvonSteyern.Thefitofcobalt–chromiumthree-unit fixed dental prostheses fabricated withfour different techniques: A comparative in vitrostudy.DentalMaterials2011;27:356–363.

11. Harish V, Mohamed Ali S.A., Jagadesan N,Mohamed Ifthikar, Siva Senthil, Debasish Basak.Evaluation of Internal and Marginal Fit of TwoMetalCeramicSystem–InVitroStudy.JournalofClinicalandDiagnosticResearch.2014;8:ZC53-ZC56.

12. Isil Sener, Begum Turker, Luiz Felipe Valandro,MutluOzcan,Dr.MedDent.Marginalgap,cementthickness, and microleakage of 2 zirconia crownsystemslutedwithglass ionomerandMDP-basedcements.GenDent.2014;62:67-70.

13. AndreePiwowarczyk,Hans-ChristophLauer,JohnA. Sorensen. Microleakage of various cementingagentsforfullcastcrowns.DentalMaterials2005;21:445–453.

14. JongKyoung Park, WanSun Lee, HaeYoungKim, WoongChul Kim, and JiHwan Kim.Accuracy evaluation of metal copings fabricatedby computeraided milling and direct metal lasersintering systems. J Adv Prosthodont. 2015 ; 7:122–128.

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Transferrin (re3811647) Gene Polymorphism in Iron Deficiency Anemia in Saudi Arabia

Osama Al-Amer1, Atif Abdulwahab A Oyouni 2, Mohammed Alshehri2, Riyadh A Alzaheb3

1 Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk, Saudi Arabia, 2Department of Biology, Faculty of Sciences, University of Tabuk, Kingdom of Saudi Arabia, 3Department of Clinical Nutrition, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk, Saudi Arabia

ABSTRACT

Background:Iron-deficiencyanemia(IDA)isthecommontypeofanemia.TheWorldHealthOrganization(WHO)estimatesthatworldwide,42%ofpregnantwomen,30%ofnon-pregnantwomen(aged15to50years),47%ofpre-schoolchildren(aged0to5years),and12.7%ofmenolderthan15yearsareanemic.Iron deficiency accounts for about half the world’s anemia. Previous genomewide association studiesrevealedanumberofgeneticpolymorphismscouldbeassociatedwith iron status including: rs3811647(TF),rs7385804(TFR2),rs235756(BMP2),andrs4820268TMPRSS6.Theaimofthisstudytodeterminethe functional polymorphism (rs3811647) of transferrin (TF) gene in iron deficiency anemia in femaleuniversitystudentsinSaudiArabia.

Method:Atotalof110femaleuniversitystudentsofage18-25yearswereselected.Bloodsampleswereobtained from all participants and hematological and biochemical iron status indices were gathered.Genotyping was carried out by ARMS PCR followed by agarose gel electrophoresis, and appreciatestatisticalanalysis.

Results:Thegenotypedistributionoftransferrin(rs3811647)regioninfemaleuniversitystudentsinTabuk,SaudiArabiawere36.66%(AA),63.33(GA)and0%(GG)inirondeficientstudentscomparedto40%(AA),60%(GA)and0%(GG)innormalstudents,inwhichthereisnosignificantdifferencesinallelicdistributionbetween irondeficiencygroupandnormalgroup.However, results show transferrinpolymorphismwassignificantlyassociatedwithreducedserumironandreducedserumferritin.

Conclusion:Ourfindingsuggestthattransferrinpolymorphismissignificantlyassociatedwithdecreasedironstatus,butnotsignificantlyassociatedwithirondeficiencyanemiainSaudifemalestudentsinnorthregionofSaudiArabia.

Keywords: Iron-deficiency anemia (IDA),Transferrin (TF) gene, Anemia , TMPRSS6

Corresponding author: Dr Osama Mohammed Al-Amer, DepartmentofMedicalLaboratoryTechnology,FacultyofAppliedMedicalSciences,UniversityofTabuk,Tabuk,KingdomofSaudiArabia.Email:[email protected]

INTRODUCTION

Almosteverylivingorganismrequiresiron,whichiscontainedinallhumancellsandisvitaltonumerousmetabolicfunctions.Themostimportantamongtheseis

thetransportofoxygeninhemoglobin.Irondeficiencyisthemostgloballywidespreadnutritionaldeficiency (1),whichaffectssignificantnumbersofwomenandchildrenindevelopedcountriesandcanresultinanemia,which30%oftheworld’stotalpopulation,or2billionpeople,suffer from.This global health issue can be linked tosocio-economicproblemsbecause it can constrain thecapacity for work, thus impacting upon a country’seconomyandgrowth(WHO).Whenitisleftuntreated,irondeficiencycandevelopintoirondeficiencyanemia,a condition characterized by an insufficient red bloodcell(erythrocyte)count,orlowhemoglobinlevels.Iron

DOI Number: 10.5958/0973-9130.2018.00182.2


deficiency anemia develops when an individual hasinsufficientironintheirbody,meaningthattheycannotproduceenoughoftheproteinhemoglobin.Hemoglobinbindstooxygen,allowingredbloodcellstoprovidethebodywithoxygenatedblood.Serumferritinisregardedas themost effective test to distinguish cases of irondeficiencyfromnon-irondeficiencycases(2).AccordingtoareportbytheWorldHealthOrganization(WHO),inSaudiArabiaatotalof32.3%non-pregnantwomeninthechildbearingagerangehaveanemia(3).

The WHO has further estimated that globally,47%ofpre-schoolchildren(aged0to5years),42%ofpregnantwomen,30%ofnon-pregnantwomen(aged15to50years),and12.7%ofmenagedmorethan15yearsare anemic. Around half of all anemia cases aroundtheworldarelinkedtoIrondeficiency.TheWHOalsoreportedin2004thatirondeficiencyanemia(IDA)hadcaused 273,000 deathsworldwide,with the followingbreakdown:45%inSoutheastAsia,31%inAfrica,9%intheEasternMediterranean,7%intheAmericas,4%intheWesternPacific,and3%inEurope,with97%ofthesedeathsamonglow-andmiddle-incomecountries(4).Shilletal.(2014)foundahigherpercentageofirondeficiency anemia among female students than theirmale peers (36.7%, p<0.0001) or 63.3% of the totalpopulationwere found to have anemia. Studentswhowerenon-anemic(68.7%)werefound in thestudy tomoreregularlyconsumebreakfastthananemicstudents(41.0%),whichexplains the lattergroup’s insufficientiron intake and nutrition deficiency at breakfast timewithregardtotheirintakesofminerals,protein,vitaminC, fat, sugar, starch, and fiber (5). A study carried outusing a sample of female students found that 64 percent suffered from Iron deficiency anemia. The totalsampleofsurveyedparticipantswas268,ofwhich171were anemic. However, most anemic students couldbe categorized asmildly (45%)&moderately anemic(49%),whileonly6%wereseverelyanemic.Thisstudyrevealedthatthehighprevalenceofanemiawasduetopoordietaryhabits,andmorespecifically,wascausedby the common habit among female students to skipbreakfast(6).

A study was performed in Saudi Arabia whichexplored Iron deficiency prevalence among a sampleofgirlsaged6-12yearsinthenorthernJeddahregion.It found that theprevalenceof Irondeficiencyanemiain that group was 23%. The authors identified nosignificant association in the bodymass index (BMI),

familyincome,mother’sworkingstatus,breastfeedingstatus,orchronic illnessamongeitheranemicornon-anemicstudents.Thefoodhabitsof thestudentswereinvestigated, and insufficient iron intake was found(7). Another Saudi Arabian study aimed to determineanemia prevalence and risk factors amongwomen ofchildbearingageinthecapital,Riyadh.Eligiblefemaleparticipantswererecruitedbybeinginvitedtoprimaryhealthcarecenters(PHCCs)tocompletequestionnaires,and to have anthropometric measurements and acompletebloodcounttaken.Thestudyfoundthat40%(390)oftheparticipantshadanemia(Hb<12g/dL).Amultivariatelogisticregressionestablishedthatafamilyhistory of iron deficiency anemia (OR 2.91, 95% CI1.78–4.76),andinfrequentmeatconsumption(OR1.54,95%CI 1.15–2.05) could be associated with a higherrisk of anemia, while a higher bodymass index (OR0.95,95%CI0.92–0.97)waslinkedtoalowerriskofanemia(8).Astudywasperformedonamolecularbasisto investigate whether the TMPRSS6 polymorphismis a major genetic determinant of iron metabolismin healthy individuals, influences serum levels ofhepcidin,thehormonecontrollingironmetabolism,anderythropoiesis in chronic hemodialysis (CHD). ThisresearchaimedtomatchasampleofnormaladultswithasampleofparticipantswithCHD.Itfoundnonoticeablevariation in Serum hepcidin levels between thewiderCHD population and the controls, but higher levelswere noted in the CHD subgroup after subjects withrelative iron deficiency had been excluded. Hepcidinlevels,erythropoiesis,andanemiamanagementamongCHD patients were found to be affected by A736VTMPRSS6. This research reported that identificationoftheTMPRSS6genotypewillcontributetoimprovedanemia management (9). Recent genome-wideassociation studieshave found significant associationsbetween several genetic polymorphisms and plasmairon status, including: rs3811647 (TF), rs7385804(TFR2), rs235756 (BMP2), rs855791 (V736A) andrs4820268(TMPRSS6) (10,11). In thepresent study,wethereforeaimedtoidentifythefunctionalpolymorphism(rs3811647)of theTFgene in irondeficiencyanemiaamongasampleoffemaleuniversitystudentsenrolledatTabukUniversity,SaudiArabia.

METHOD

Study plan and data collection

Atotalof110femaleuniversitystudentsstudying


attheUniversityofTabuk,SaudiArabiaagedbetween18and26wasenrolledinthisstudy.Studentsdiagnosedwithaneatingdisorder,pregnant,breastfeeding,takingmedication or nutritional supplements were excluded.This study was approved by the Research EthicscommitteesinTabukUniversity.

Hematological parameters

WholebloodwascollectedeitherintubescontainingEDTA for hematological tests or in tubes withoutadditionalanticoagulantforbiochemicalscreening.Thehematologicaltestsincludehemoglobin(Hgb),platelets,redbloodcells(RBCs)andwhitebloodcells(WBCs)performed using a Beckman coulter LH750 machine(BeckmanCoulterInc.,Miami,FL,USA).Biochemicalscreening, include Serum iron and ferritin performedusingamodularmachine(Hitachi,UK).Accordingtothe criteria defined byWHO, iron deficiency anemiareferenced as (ferritin <15ng/ml and haemoglobin<12g/dl),irondeficiencywithoutanemiareferencedas(ferritin<15ng/mlandhaemoglobin>12g/dl).

Genotyping

Tetra-Primer Amplification Refractory MutationSystem Polymerase Chain Reaction (T-ARMS PCR)was used in this study for detection of transferrin(rs3811647)polymorphismusingexternalprimersandinternalprimersasfollowing:

Forwardouter:AATGCGAGAGAATCATGGAAGGA

Reverseouter:GATGTACCCTTACCCAGAGCC

Forwardinner(Gallele):GAGGGAGTTTACAGACAGATCG

Reverseinner(Aallele):CCCTTCCTAGATGTATAATCCTAGAT

PCRreactionwasperformedintotal25µlreactionvolumecontained50nggenomicDNA,0.4µMofeachprimer,250µMdNTP,1.5mMMgCl2and1UTaqDNApolymerase.ThePCRamplificationwasperformedwitha5minutesinitialdenaturationat95ºCfollowedby30secondsat94ºCfordenaturation,30secondsat64ºCfor

annealing, 30 seconds at 72ºC for extension andfinalextensionat72ºCfor5minutes.ThePCRreactionwasperformedfor30cycles.Productswereseparatedusing2%agarose.Productsizesarecontrol475bp,Gallele284andAallele191bp.

Statistical analysis

Statisticalsignificancewasdeterminedusingχ2testoranindependentStudent’st-testwheneverappropriateusingSPSSV.15.Datawereconsideredsignificantfor(p ≤.05).

RESULTS

Genotype distribution of transferrin (rs3811647) polymorphism

The study consisted of 110 female universitystudentsofage18-25years.Thegenotypedistributionof transferrin (rs3811647) regionwere 36.66% (AA),63.33 (GA) and 0% (GG) in iron deficient studentscompared to 40% (AA), 60% (GA) and 0% (GG) innormalstudents(Table1).Datashowedthattherewasnosignificantdifferencesinallelicdistributionbetweenirondeficiencygroupandnormalgroup(p=.374).

Genotype distribution of transferrin (rs3811647) polymorphism with respect to clinical parameters

In this study, we analyzed the distribution oftransferrin (re3811647) polymorphism to hemoglobin,iron,ferritin,RBCs,plateletsandWBCs(Table2).Datashowed that transferrin (re3811647) polymorphismis significantly associated with decreased serum iron(p=.035)anddecreasedserumferritin(p=.04),butnotwithotherparameters(hemoglobin,RBCs,plateletsandWBCs).

Association of transferrin (rs3811647) polymorphism with the iron deficiency anemia risk: The frequency distribution of transferrin (rs3811647)G/Agenotypesinanemiagroupandnormalgrouparedemonstrated inTable3.Data showed that genotypesand allele frequenciesof transferrin (rs3811647)werenot significantly different between iron deficiencyanemiagroupandnormalgroup.


Table 1: Genotype distribution of transferrin (rs3811647)

N GGN (%)

GAN (%)

AAN (%) Chi-Square DF p value

Normal 50 20(40%) 30(60%) 0(0%) 0.79 2 0.374

Irondeficiencystatus 60 22(36.7%) 38(63.3%) 0(0%)

Table 2: Genotype distribution of transferrin (rs3811647) polymorphism with respect to clinical parameters

N GG GA AA X2 DF p valueHemoglobinNormal 85 29 56 00 2.51 2 0.28Abnormal 23 12 11 00IronNormal 38 24 14 00 6.7 2 0.035Abnormal 70 26 44 00FerritinNormal 52 34 18 00 6.4 2 0.04Abnormal 56 23 33 00RBCNormal 85 29 56 00 2.51 2 0.28Abnormal 23 12 11 00PlateletsNormal 106 39 67 00 3.33 2 0.18Abnormal 02 02 00 00WBCNormal 80 29 51 00 0.08 2 0.96Abnormal 28 11 17 00

Table 3: Genotypes and allele frequencies of transferrin (rs3811647) polymorphism in normal subjects and in iron deficiency anemia group

Genotypes Normal subjects Anemia group OR (95% CI) Risk Ratio(RR) p-value

(N=50) % (N=18) %

TF-GG 20 40% 10 55.6% 1(ref.) 1(ref.)

TF-GA 30 60% 8 44.4% 0.53(0.17-1.58) 0.84(0.62-1.141) 0.25

TF-AA 00 0% 00 0% 1.95(0.036-105) 1.32(0.183-9.54) 0.78

Dominant

TF-GG 20 40% 10 55.6% 1(ref.) 1(ref.)

TF (GA+ AA) 30 60% 8 44.4% 0.53(0.17-1.58) 0.84(0.62-1.141) 0.25

Recessive

TF (GG+GA) 50 100% 18 100% 1(ref.) 1(ref.)

TF-AA 0 0% 0 0% 2.72(0.052-142.6) 1.46(0.20-10.44) 0.70

Allele

TF-G 70 70% 28 77.8% 1(ref.) 1(ref.)

TF-A 30 30% 8 22.2% 0.66(0.27-1.63) 0.90(0.73-1.11) 0.30


DISCUSSION

Previous studies have described and investigatedgenetic variants in TF in relation to their associationwith iron status (12-16). In recent years, genome-wideassociation (GWA)studieshave reporteda significantassociationbetweenSNPrs3811647 inTFandhigherserumtransferrinandtotaliron-bindingcapacity(TIBC)(17-19).Theaimofthepresentresearchwastoidentifythefunctionalpolymorphism(rs3811647)ofthetransferrin(TF) gene in iron deficiency anemia among a sampleof female university students in the Saudi Arabiancontext.Anetal.exploredtheassociationbetweenIDAriskandthegeneticvariantsfoundinthegeneswhichcontribute to iron delivery and hepcidin regulationpathways. They concluded that variant rs3811647 inTFisassociatedwithlowerlevelsofserumiron,serumtransferrin and transferrin saturation; however, thisvariantwasnotfoundtoaffectirondeficiencyortheriskofanemia(10).AnotherstudybyMcLarenetal.identifiedan association between rs3811647 SNP in TF andTIBC,but thisvariantwasnot found tobeassociatedwith othermeasures of individual iron status or case-control,whichsuggests that the study’s resultsdonotclaim that TF SNP plays a role in regulating humanironmetabolism(18).Thepresentstudyinvestigatedthegenotype distribution of TF (rs3811647) region in asample of female university students in Tabuk, SaudiArabia,thenexaminedthepotentialassociationbetweenthisSNPandtherisksofirondeficiencyandIDAamongthem.We report a significant association betweenTF(re3811647) polymorphism and both decreased serumironanddecreasedserumferritin;however,wefoundnoassociationbetweenTF(re3811647)polymorphismandlevelsofhemoglobin,RBCs,plateletsorWBCs.Neitherdid we find any association between TF (re3811647)polymorphismandIDArisk.

CONCLUSION

Our finding suggest that transferrin (rs3811647)gene polymorphism is significantly associated withdecreased iron status, but not significantly associatedwithirondeficiencyanemiainSaudipopulationinnorthregionofSaudiArabia.

Ethics approval and consent to participate

Ethical approval for the researchwas sought andobtainedfromtheUniversityofTabuk’sCommitteeofResearchEthics.

Conflict of Interest: Theauthordeclaresnoconflictofinterest.

Funding:Self-funded

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5. Shill KB, Karmakar P, Kibria MG, Das A,Rahman MA, Hossain MS, et al. Prevalenceof iron-deficiency anaemia among universitystudents in Noakhali region, Bangladesh. JHealthPopulNutr.2014;32(1):103-10.PubMedPMID: 24847599; PubMed Central PMCID:PMCPMC4089078.

6. Hassan NN. The prevalence of iron deficiencyanemia in a Saudi university students. JournalMicroscopyandultrastructure.2015;3(1):25-8.

7. GARMA.PrevalenceofIrondeficiencyanemiaamong the female children in northern part ofSaudiArabia.JKAU:MedSci.2008;15(1):55-65.

8. AlquaizAM,GadMohamedA,KhojaTA,AlsharifA,ShaikhSA,AlManeH,etal.Prevalenceofanemia and associated factors in child bearingagewomeninriyadh,saudiarabia.JNutrMetab.2013;2013:636585. doi: 10.1155/2013/636585.PubMed PMID: 24205435; PubMed CentralPMCID:PMCPMC3800602.


9. PelusiS,GirelliD,RamettaR,CampostriniN,AlfieriC,TragliaM,etal.TheA736VTMPRSS6polymorphism influences hepcidin and ironmetabolism in chronic hemodialysis patients:TMPRSS6andhepcidin inhemodialysis.BMCNephrol. 2013;14:48. doi: 10.1186/1471-2369-14-48. PubMed PMID: 23433094; PubMedCentralPMCID:PMCPMC3585892.

10. AnP,WuQ,WangH,GuanY,MuM,LiaoY,et al. TMPRSS6, but not TF, TFR2 or BMP2variants are associated with increased riskof iron-deficiency anemia. Hum Mol Genet.2012;21(9):2124-31. doi: 10.1093/hmg/dds028.PubMedPMID:22323359.

11. Danquah I, Gahutu JB, Zeile I, MusemakweriA, Mockenhaupt FP. Anaemia, iron deficiencyandacommonpolymorphismofiron-regulation,TMPRSS6 rs855791, in Rwandan children.Trop Med Int Health. 2014;19(1):117-22. doi:10.1111/tmi.12216.PubMedPMID:24175968.

12. LeePL,HoNJ,OlsonR,BeutlerE.Theeffectoftransferrin polymorphisms on iron metabolism.Blood CellsMol Dis. 1999;25(5-6):374-9. doi:10.1006/bcmd.1999.0267. PubMed PMID:10660486.

13. LeePL,HalloranC,BeutlerE.Polymorphismsin the transferrin 5’ flanking region associatedwith differences in total iron binding capacity:possibleimplicationsinironhomeostasis.BloodCellsMolDis.2001;27(2):539-48.doi:10.1006/bcmd.2001.0418.PubMedPMID:11500065.

14. LeePL,HalloranC,TrevinoR,FelittiV,BeutlerE. Human transferrin G277S mutation: a risk

factorforirondeficiencyanaemia.BrJHaematol.2001;115(2):329-33.PubMedPMID:11703331.

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Comparison Effects of Acute and Chronic Intra-peritoneal Injections of Saffron Stigma Extract and Safranal-Crocin

Mixture on Anxiety, in Mice

Mahdi Torkamani Noughabi1, Jahanshir Tavakolizadeh2, Maryam Moghimian3, Sayed-Hossein Abtahi –Eivari4

1Department of Basic Science, 2Associate Professor of Psychiatry Department, Faculty of Medicine, 3Department of Physiology, Faculty of Medicine, School of Medicine, 4Ph.D in Clinical Biochemistry,

Department of Clinical Biochemistry, Gonabad University of Medical Sciences, Gonabad, Iran

ABSTRACT

Saffronisahighlyconsumedfoodseasoningthatisimportantduetoitsanti-anxietyproperties.ThisstudyaimedatcomparingtheeffectsofacuteandchronicinjectionofsaffronstigmaextractandCrocin-Safranalmixture(CSM)ontheanxietyinmice.Inthisexperimentalstudy,56malemiceassignedtosevengroups,treatmentswereadministeredasacuteorchronicintra-peritonealinjectionsandanxietydegreeasmeasuredbytheuseofplusmaze.Resultsshowedthatacuteinjectionofsaffronstigmaextractat50and150mg/kgandCSMatall3dosessignificantlyincreasedthepercentageoftimespentintheopenarmcomparedtothecontrol.Also,saffronextractatacutedoseof50mg/kgandCSMatacutedoseof0.68mg/kgsignificantlyincreased percentage of time spent in the open arm compared to the same chronic doses. Overall, thecomparisonofsaffronextractandCSMdosesshowedthat2.04and4.08mg/kgacuteandchronicdosesofCSMsignificantlyincreasedpercentageoftimespentintheopenarmcomparedtosaffronextractat150and300mg/kg(p<0.05).Thus,itcanbeconcludedthatacuteintra-peritonealdosesofsaffronstigmaextract,inadosedependentmanner,andCSM,atalldosesapplied,hadanti-anxietyeffects.Furthermore,50mg/kgsaffronextractand4.08mg/kgCSMhadthehighestanti-anxietyeffectatacutephaseandacutedosesofsaffronextractandCSMweregenerallymoreeffectivethanchronicdosesinreducinganxiety.

Keywords: Saffron, Crocin, Safranal, Anxiety

Corresponding author:Jahanshir TavakolizadehPhDinPsychology,AssociateProfessorofPsychiatryDepartment,FacultyofMedicine,GonabadUniversityofMedicalSciences,Khorasan-e-Razavi,Gonabad,Iran

INTRODUCTION

Anxietydisorders are themost prevalent neurosiswith the estimated prevalence rate of 10-30%.1,2,3,4. Regarding the importance of reducing anxiety and itstreatmentaswellasthesideeffectsofsyntheticdrugs,researchonidentifyingeffectiveherbalmedicineswithloweradverseeffectsparticularly in laboratoryanimalmodelsiswarranted.5

Saffron(CrocussativusL),aperennialplantfromIridaceaefamily,isahighlyconsumedherbalmedicinethat isused for the treatmentofanxietyand insomniain traditional medicine.6 Safranal and Crocin are twomajor components of saffron which contribute to itspharmacological effects. Safranal is volatile, waterinsoluble and picroCrocin derived compound that isresponsible for the odor and flavor of saffron whileCrocin is soluble in water and is themain chromaticcompound of in this plant.7 Studies show that saffronextractoritsactivecomponentshavevariouseffectsoncentral nervous system improving Learning disabilityandparamnesiacausedbyethanoladministrationandneutralizing the effects of ethanol on hippocampus.8 In someempirical studiesonanimalmodels, theanti-inflammatoryandanalgesic,9,10,11anticonvulsant12,13andantidepressant14,15 effects of saffron stigma and petal

DOI Number: 10.5958/0973-9130.2018.00183.4


extracthavebeenconfirmed.Theantidepressanteffectofsaffronstigmaandpetalextracthasalsobeenconfirmedinclinical trials.16CrocinandSafranalhavealsobeeneffectivelyusedinthetreatmentofdepression.17

The results of a study revealed thatonlySafranalbutnottheCrocinhadanti-anxietyeffectsatbothlowand high doses.18Nevertheless, considering the abovementioned studies and the lack of information on thesynergisticeffectsofCrocinandSafranalandbecausethechroniceffectsofSaffronstigmaextractandCrocin-Safranal mixture (CSM) and also the comparison ofpossibleeffectsofthesecompoundsonanxietyhasnotbeeninvestigated,thisstudyaimedatinvestigatingtheeffectsofacuteandchronicinjectionofsaffronstigmaextract andCrocin-Safranalmixture on the anxiety inmalemice.


Animals

Razimalemiceweighing20–30gwereobtainedfrom a random bred colony in the animal House ofGonabadUniversityofMedicalSciences.Animalswerehoused in thecolonyroom12/12h light/darkcycleat21±2°C.Animalshadfreeaccess towaterandfood.AllanimalexperimentswerecarriedoutinaccordancewithGonabadUniversityofMedicalSciences,EthicalCommittee Acts, and This Committee approved thisprojectwithcode91/6/267.

Plantmaterial

CrocussativusL.stigmasfromGonabad,Khorasanprovince Razavi, was analysed according to the ISO3632-2: safranal, expressed as a direct reading of theabsorbance at about 330 nm, expressed as a directreadingoftheabsorbanceofcrocinatabout440nm.

Chemicals

Crocin and Safranal were obtained fromSigma Company and dissolved in normal saline atconcentrationssimilartothoseintheextract

Preparationofextracts

6 g of stigma saffron powder was macerated in800mletanol50%for72h.ThemixtureofplantandEtanolwassubsequentlycentrifuged(5min,3000rpm)andthesupernatantswereevaporatedtodrynessunderreducedpressureat40°C.Theyieldoftheextractwas

52%(w/w).

Quantification of crocin and safranal in saffronextract

Toquantifycrocinandsafranalinsaffronextraction,a modified method was used.19,20 Quantification wereperformed on a HPLC system, Agilent TechnologiesSL 1200 Series (Waldbronn, Germany) composedof a quaternary pump equipped with 152 microvacuum degasser, thermostated autosampler, columncompartmentandDADdetectorandaSymmetryC18column(250× 4.6mm,5µm,).Theinjectionof5mlofsamplewith45minutesforcrocinsusinganisocraticmobilephaseofMatanol:water(80:20%)ataflowrateof1ml/min.Theinjectionof100mlofsamplewith50minutesforsafranalandusinganisocraticmobilephaseofAcetonitrile:water(80:20%)ataflowrateof0.5ml/min.

Treatment

Malemiceweredividedinto7groupsofeighteach.MiceofgroupIwerereceived10ml/kgnormalsaline.Mice of groups II, III, IV received saffron extracts atdoses of 50, 150 and 300 mg/kg, respectively. MiceofgroupsV,VIandVIIwere receivedCSMatdoses0.68,2.04and4.08mg/kg,respectively.Allagentswereadministered intra-peritoneally. Anxiety levels weremeasured after the first injection (Acute phase).Theninjectedintodifferentgroupsonadailybasiscontinuedafter the tenth injection (Chronicphase),AnxietywasmeasuredagainbyElevatedplusMaze(EPM).

Elevatedplusmazetest

Anxiolytic activity wasmeasured using the EPMtest. This test has been widely validated to measureanxietyinrats.EPMusedweremadeofwood,21,22andconsistedoftwoopenarms(50×10×1cmeach),twoenclosedarms (50×10×50cmeach)anda centralplatform(10×10cm),arrangedinsuchawaythatthetwo arms of each type were opposite to each other.Themazewaselevated500cmabovefloorlevel.Thismodel does not have to teach and learn. Twenty fiveminutesafter injection, theanimals for5minutes inawooden box with black walls with dimensions of 40×40×30cmwas transferred to investigativeactivityincreasedanimal.Eachanimalwasplacedindividuallyinthecenterofthemaze,facingoneoftheclosearms.During the5min testperiod, thenumberofopenand


Figure 1: chromatogram of crocin (A), safranal (B) from Saffron extract; chromatogram crocin (C); chromatogram safranal (D)

Plusmazetest

Acuteintra-peritonealinjectionof50and150mg/kgsaffronextractand0.68,2.04and4.08mg/kgCrocin-Safranalmixturesignificantlyincreasedpercentageoftimespentintheopenarmcomparedtothecontrol(Figure2).Also,thecomparisonofacuteandchronicdosesshowedthatacutedosesof50mg/kgsaffronextractand0.68mg/kgCrocin-Safranalmixturesignificantlyincreasedthetimespentintheopenarmincomparisontothesamechronicdose.However,theacutedoseof300mg/kgsaffronextractsignificantlydecreasedtimespentintheopenarmcomparedtothesamechronicdoseofsaffronextract(Figure3).

Figure 2: Effects of acute and chronic intraperitoneal Different amounts of Crocus Sativus extract (CS) and Crocin–Safranal Mixture (CSM) on the percentage of time spent in the open arms entries of the elevated plus-maze test, compared with saline control. Data are expressed as mean ±SEM. (* p <0.05, ** p < 0.01,*** p < 0.001,n=8).

enclosedarmsentries,plusthetimespentinopenandenclosedarms,wasrecorded,dependingonthemethodofshooting.Increasedtimespentintheopenarmswasconsideredtoreflectananxiolyticeffect,incomparisonwith the control group. InEPM, closed arm indicatessecurity and theopenarm is indicativeof seeking, sothatitmeanslessanxietyiftheanimalspendsmoretimeintheopenarm.23,24,25.Alltestswereconductedbetween09:00and15:00.

The percent of time spent in the open arms is

calculatedaccordingtothefollowingformula:

[Time spent in theopen arms/ (Time spent in theopenarms+Timespentintheclosearms)]×100

RESULTS

Using the calibration curve, the quantification ofcrocinandsafranal ina sampleof saffronextractwasachieved about 13170 and 707 mg/kg, respectively.(Figure1)


Figure 3: Compare effects acute and chronic different amounts Crocus Sativus extract (CS) and Crocin–Safranal Mixture (CSM) on the percentage of time spent in the open arms entries of the elevated plus-maze test. Data are expressed as mean ±SEM. (* p <0.05,** p < 0.01,*** p < 0.001,n=8).

Overall,thecomparisonofdifferentdosesofsaffronextractandCrocin-Safaranalmixtureshowedthatacuteandchronicdosesof2.04and4.08mg/kgCrocin-Safranalmixturesignificantlyincreasedthepercentageoftimespentintheopenarmcomparedto150and300mg/kgsaffronextract(p<0.05)(figure4).

Figure 4: Compare effects acute and chronic Different amounts Crocus Sativus extract (CS) than Crocin–Safranal Mixture (CSM) on the percentage of time spent in the open arms entries of the elevated plus-maze test. Data are expressed as mean ±SEM. (** p < 0.01, *** p < 0.001, n=8).

DISCUSSION

Findings of the present study showed that acuteintra-peritoneal doses of saffron stigma extract, ina dose dependent manner, and CSM, at all dosescorresponding to thoseof theextract,hadanti-anxiety

effects. The comparison of acute and chronic dosesof the extract and CSM showed that CSMwasmoreeffectivethantheextractinreducinganxietyindicatingthat the anti-anxiety effects of saffron in attributabletothesecomponents.Thisfindingiscoordinationwithsimilarstudiesaboutantifear10,andAnxiolytic18effectsofsaffron.


Resultsalsoindicatedthattheanti-anxietyeffectofsaffronextractatalldosesisnotthesameasthatofCSMat thesamedoses.AlldosesofCSMhadanti-anxietyeffects but saffron extract lacked this effect at higherdosescontaininghighamountsofSafranalandCrocin.Thisfindingalongwiththosefromastudyshowinganti-anxietyeffectsforSafranalbutnottheCrocin18indicatetheprobabilityofinterferenceofothercompoundsthanCrocinfoundinsaffronextractthatmayhavepreventedanti-anxietyeffectofSafranal.Therefore,itcanbesaidthatplant extracts aremoreeffectiveat specificdosesandshouldbeconsumedprecisely.Anyway,itappearsthatanti-anxietyeffectsoflowerdosesofsaffronextractandvariousdosesofCSMisassociatedwiththereleaseofsomeneurotransmittersandsuppressionoftheothers.For instance, studies show that Safranal has agonisticeffects on GABA and benzodiazepine26 and it seemsthatSafranal,mimicsDiazepam(abenzodiazepinedrugwithprovedsedativeandanti-anxietyeffects)andexertsits sedative, relaxing and anti-anxiety effects throughinteractionwithGABA receptors present in the brainparticularlythoseinmidbrainreticularformation27andincreasesthetimeanimalspendsintheopenarm.28

CONCLUSION

The comparison of acute and chronic intra-peritonealinjectionofsaffronextractandCSMshowednochronicanti-anxietyeffectfortheextractonday10andchronicanti-anxietyeffectsonlyforthehighestdoseofCSM.Tothebestofourknowledge,thisisthefirststudycomparingchroniceffectsofsaffronextractandCSMandthereforethecomparisonofourresultswiththeotherswasnotpossible.However,itcanbesaidthatacute doses of saffron and CSMweremore effectivethan chronic ones.This canbe explainedbyprobableadaptation of receptors or decreased their irritability.However, it is possible that the time may have beencontributed and maybe the duration of chronic phaseshould have taken more than 10 days for a betterefficiencyinthisstudy.

Conflict of Interest: Theauthorsstatenoconflictofinterest.

Source of Funding: ThisworkwassupportedbyGonabad University of Medical Sciences, Gonabad,Iran[grantnumbersP.1.403].

Ethics Clearance:Ethicalmatterse.g.plagiarism,informed consent, misconduct, data fabrication and/

or falsification, double publication and/or submission,redundancy, etc. have been totally observed by theauthors.

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