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Amrita Journal of Medicine


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Prevalence of Dermatological Problems in Indian Geriatric Population

Myxoedema Madness Case Report

Percentage Comparison and Evaluation of Curve of Spee and Overbite Among Class II division 1 and Class I Malocclusion Group

Factors Determining Immediate Mortality In Hospitalised Patients Suffering Cardio pulmonary Arrest – Observations From A Tertiary Care Center

Treatment Outcomes of Bicondylar Tibial Plateau Fractures by Hybrid Fixator and with open Reduction and Internal Fixation

Sajana Krishna, Jacob Thomas, Vinitha Varghese, Gopikrishnan Anjaneyan, Soumya Jagadeesan

Salini Nair, P C Kesavankutty Nayar, Chithra Venkateswaran

Ruby Raj, Namitha Ramesh, Krishnan K V, Sapna Varma N K

Bharath Prasad S, Ajith V, Arunkumar, K Kru-panidhi, Nandu Mohan, Vishnu Manohar, Naveen Mohan, Sreekrishnan T P, Gireesh Kumar K P

Editorial Board

CONTENTS

Faizal Ali A A, Mohammed Ashraf

Vol. 13, NO: 1Jan - Mar 2017, Page 1 - 44

Original Article

18 Comparison of 3% Hypertonic Saline with 20% Mannitol on Water - Electrolyte Balance and Brain Relaxation During Elective Supratentorial Tumour SurgeriesRakesh Rajagopal, S Gokuldas

Perceptions of Students Towards a Change of Pattern in the Otorhinolaryngology (ENT) Question Paper Unnikrishnan K Menon, Joe Joseph

42 Primary Urachal Mucinous Adenocarcinoma of the Urinary Bladder

Jeena V Chimmen, C S Sakunthala Bai, S Shenoy MS, Tanya S Ponnatt

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Editorial Board

Patrons

Swami Amrita Swaroopananda Puri Dr. Prem Nair Dr. P Prathapan Nair

Chief Editor

Dr. Harish Kumar

Editorial Board Members

Dr. Anand Kumar Dr. Sudhindran Dr. Unnikrishnan K Menon Dr. Ramakrishna P Venugopal Dr. Sasidharan Dr. Sheela Nampoothri Dr. Sanjeev K Singh Dr. D M Vasudevan Dr. C Jayakumar

Publicity Officer

Mrs. Gita Rajagopal

Design & Artwork

Sivaprasad U

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

Vol. 13, NO: 1Jan - Mar 2017, Page 1 - 44

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Amrita Journal of Medicine Vol. 13, NO: 1Jan - Mar 2017, Page 1 - 44


Sajana Krishna, Jacob Thomas, Vinitha Varghese, Gopikrishnan Anjaneyan, Soumya Jagadeesan

ABSTRACTBackground: Aging is a gradual process that results in the changes in appearance and functions. These changes are due to both intrinsic factors and extrinsic factors especially UV radiation. Females additionally have their hormonal changes at menopause. It occurs basically at a cellular level and reflects both genetic programme and environmental damage.

Aim: To assess the prevalence of dermatological problems in the geriatric population and effects of external factors on their development.

Methods: A prospective cohort study was carried out on 250 people aged above 65 years who were attending the Dermatology OPD.

Results: The most common symptom was pruritus seen in 177 (70.8%) patients. Xerosis was present in 61.2% of patients. Aging changes included fine wrinkling in 58.4% patients, dyspigmentation in 68%, senile lentigines in 30.4%, senile comedones in 30.4%, sebaceous hyperplasia in 19.6% and idiopathic guttate hypomelanosis in 33.6% of population. The most common systemic diseases found were hypertension(48.4%) and diabetes mellitus.

Conclusion: In our study the commonest geriatric age group was 65-70 years with a male preponderance. Pruritus was the most common complaint present, followed by dryness of skin. Common aging skin changes included xerosis, wrinkling, pig-mentatary disorders, sebaceous hyperplasia, senile lentigines, senile comedones and IGH. Systematic hypertension was the commonest systemic disease followed by diabetes mellitus in the geriatric population.

Key words: geriatric,dermatoses,ageing,environment.

INTRODUCTION

Dept. of Dermatology, AIMS, Amrita University, Kochi, India.

ORGINAL ARTICLE

Aging in the skin is a gradual process that results in changes in appearance and functions. These changes are due to both intrinsic factors and effects of a num-ber of environmental damages. Aging can be biolog-ical aging and chronological aging and also has two distinct types called intrinsic and extrinsic aging out of which intrinsic can be caused by cellular senescence whereas extrinsic is caused by external factors like UV rays, smoking and environmental pollutants. Our study therefore deals with the prevalence of dermatological problems related to old age and the statistical associa-tion with different environmental insults, drug use and smoking.

METHODS The study was carried out on 250 patients, aged above 65 years attending the Dermatology OPD from December 2012 to March 2014. A detailed drug his-tory was collected and systemic examination was performed. Skin, hair, nails, oral and genital mucosa was examined. Routine blood and urine investiga-tions and blood sugar were done. Other tests like ESR, LFT, blood urea, serum creatinine, lipid profile, serum electrolytes, thyroid profile, and stool for occult blood were done when required. Dermatological procedures included scrapings and nail clipping for fungal infec-

tion, Patch test, skin prick test, skin biopsy, pus for cul-ture and sensitivity.To test the statistical significance of the results Chi-square test was applied. Microsoft excel 2007 was used for the statistical analysis in our study.

Table 1- showing aging changes in 250 patients.

Thinning

No.of patients

58.4146

Aging change Percentage (%)

Wrinkling

54.4136

Dyspigmentation 68170

36.190.25Rough thick skin

34.987.25Deep furrows

53.2133Freckles

30.476

Comedones

Sebaceous hyperplasia

Senile purpura

Senile lentigines

IGH

30.476

19.649

26.466

33.684

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RESULTS A total of 250 patients (67.6% males and 36.4% fe-males) of 65-89 years were examined. Maximum num-ber of patients belonged to age group 65-70 years (52.4%), followed by 71-75 years (24.8%). The most common symptom was pruritus complained by 177 (70.8%) patients. Association of pruritus with xerosis, diabetes mellitus,atopy,anaemia,systemic hyperten-sion especially on treatment with ACE inhibitors and diuretics was noted (p< 0.05). 61.2% patients had xerosis which was associated with systemic hypertension especially on ACE inhibi-tors (p0.039 ) and diuretics (p0.006), atopy (p0.03) and smoking (p0.024).Aging changes noticed are shown in table 1. The most common dermatitis was asteatotic ecze-ma (26.8%). Out of 67 patients with asteatotic ecze-ma,40.3% were atopics (P <0.001). Twentythree (41.1%) of them were smokers( P0.01). Contact der-matitis was seen in 12% patients, stasis eczema in 6% and seborrhoeic dermatitis in 4.8%.

Different skin infections seen are shown in table 2. In our study, 20(8%) cases of psoriasis (12 males and 8 females) and 13 (5.2%) cases of lichen planus (8 males and 5 females) were seen. There were two cases of oral lichen planus and one case of pustular psoriasis. Nine(3.6%) cases of Bullous pemphigoid and 7(2.8%) cases of pemphigus vulgaris were seen.There were 23(9.2%) cases of vitiligo and melasma. Twelve(4.8%) cases of lichen simplex chronicus, 2 cases of delusional parasitosis, one case of prurigo nodularis and dermatitis neglecta were observed. Seborrheic keratosis,acrochordons and cherry angio-mas were seen in 42.4%,34.4% and 32.8% cases re-spectively.

Premalignant conditions included one case each of Bowens disease and leukoplakia. Malignant condi-tions were one case each of malignant melanoma, ba-sal cell carcinoma, angiosarcoma, mycosis fungiodes and squamous cell carcinoma.

Only 2 cases of lichenoid drug eruption and DRESS syndrome and one case each of TEN and fixed drug eruption were seen during this period.

Xanthelasma was seen in 53 patients (21%) of which 21(36.2%) had dyslipidaemia (p0.003).

Fissuring of feet was seen in 62(24.8%) patients of which 36 (31.6%) had diabetes mellitus (P0.034). Mil-ia was seen in 12.8%. Out of 22(8.8%) cases of angu-lar chelitis, 9 (20%) were alcoholics ( p0.008). In this study, keloid was seen in 1.6% patients.

Of the 14 cases of urticaria,10 (10.4%) were hyper-tensives on ACE inhibitors.

Nail changes observed are shown in fig 1.

Subungual hyperkeratosis was seen more in males (20.7%) than females (P value < 0.05). Paronychia

Onychomycosis

No.of patients

16.441

Disease Percentage (%)

Dermatophytosis

16.441

Intertrigo 15.639

11.629Folliculitis

9.223Mucosal candidiasis

7.218Warts

6.817

Cellulitis

Furunculosis

615

Table 2 - showing different skin infections observed.

Luster

Paronychia

Brittle Nails

Subungual Hyper Keratosis

Logitudinal Ridging

Brittileness

Cuticle Loss

Fig 1- showing different nail changes

70.80% 11.2

0%

73.20%

20.70%

47.60%

50.4

0%

57.60%


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DISCUSSION We tried to find the prevalence of dermatological problems in geriatric population and the possible risk factors in our part of the country. A total of 250 pa-tients were studied. Male: female ratio was 2.08:1 and this male preponderance was observed by others also1.

Pruritus The most common symptom complained by patients was pruritus in 177 (70.8%) patients.In other studies it was 54%,37%,39%2,3,4,5 In our study,pruritus was associated with xerosis, diabetes mellitus, atopy, ane-mia, systemic hypertension on angiotensin converting enzyme inhibitors and on diuretics (P <0.05). But no significant association of pruritus was observed with dyslipidaemia on statins, CLD/CKD or hypothyroid-ism. Durai et al6 found pruritus in 49.6% patients, of which 29.8% was associated with xerosis.Association of pruritus with ACE inhibitors was reported in other studies also7. Association of pruritus with anemia8 and diabetes mellitus9 are reported.

Discussion on skin changes to aging Xerosis was present in 61.2% of our patients. Other studies also showed similar results3,10,11. In our study, there was significant association of xerosis with sys-temic hypertension especially on ACE inhibitors (p 0.039), diuretics (p 0.006), atopy (p0.03) and smok-ing (p 0.024). A positive association of xerosis with atopy12 and diuretic are reported13. Fine wrinkling and thinning were seen in 58.4 and 54.4% patients which was less compared to observations by Durai and Thappa(100%) while other studies showed wrin-kling in 95.5%, 95.6%and 94%. Pigmentary changes was seen in 68% patients in our study though only 13% reported by others. In our study rough thick skin and deep furrows on face was observed in 36.1% and 34.9% which were much higher than prevalence re-ported by others. This could be attributed to the in-creased exposure to sun due to lack of knowledge and usage of protective sunscreens in our study popula-tion. In our study 53.2% of population had freckles, higher than 4.8% reported by Durai et al. Idiopathic

Guttate Hypomelanosis was seen in 33.6% of popu-lation. IGH was more common in males (33.5%) than females (23.5%) (P 0.02). Senile lentigines were found in 30.4% in our study, higher than the12% reported by Durai and 10% by Grover but lower than 51% found by others. Senile comedones were found in 30.4% of our patients which is higher than reported by other ob-servers5,6. Senile purpura was seen in 26.4% in our study while other studies showed 9%, 1%, 11.9%3,4,5. In our study, there was a statistically significant asso-ciation of smoking with deep furrows, thick rough skin (P 0.001), IGH (P0.03) and senile purpura (P 0.049) comparable to findings of Durai6,7 and Kennedy15. Se-baceous hyperplasia was seen in 19.6% patients in our study while others reported 17% and 1.6%6,10.

Dermatitis In our study, the most common dermatitis was as-teatotic eczema (26.8%) which was more common in males (33.1%) than females (13.6%) (P 0.02). Other studies had incidence of eczema in 24.2%, 31.2% patients 16,18. Contact dermatitis was seen in 12% patients (M 14.2% F 7.4%). This could be due to increased exposure of men to more allergens. In our study, stasis eczema was seen in 6% and sebor-rhoeic dermatitis in 4.8% patients. Out of 67 patients with asteatotic eczema, 27 (40.3%) were atopics (P <0.001) and 23(41.1%)were smokers (P 0.01). Lee et al15 postulated that exposure to cigarette smoking may contribute cumulatively to development of atopic dermatitis. Out of15 cases of stasis eczema,11(45.8%) had varicose veins (P 0.001). It was also seen that out of the 69 hypertensives on ACE inhibitors and 41 on diuretics,asteatotic eczema was present in 27(40.3%) and 23(34.3%) patients respectively. Ivanov and Fe-dotov16 who noticed 24.8% of eczema patients had hypertension emphasized that the detected specificity of eczema in the presence of hypertension indicate a certain relationship between these diseases involving manifest abnormalities in the skin micro circulatory bed.

Infections Intertrigo, onychomycosis and folliculitis were seen more in females(P<0.05). Patange and Fernandez re-ported infective dermatoses in 34.5% of the total der-matoses3. Association of intertrigo and mucosal can-didiasis with diabetes mellitus (P< 0.05)was observed in our study, comparable to results by Timshina and Thappa17. In our study there were 9 cases of pediculo-sis capitis and 4 cases of scabies(1.6%). Papulosqamous disorder: In our study,20(8%) cases of psoriasis (12 males and 8 females), 13 cases of li-chen planus (8 male and 5 females)two cases of oral lichen planus and one case of pustular psoriasis were seen. Higher prevalence of psoriasis reported in some studies18.

was seen in 11.2% patients and was more in fe-males (19.8%) as compared to males (7.1%). Fortyone (73.2%) cases with brittle nails had statistically signifi-cant association with smoking (P value <0.001). In our study, greying of hair was seen in 94% cas-es and patterned baldness in 72% cases.Prevalence of patterned baldness was more in males (76.3%) than females (63%)(P 0.04). Male pattern baldness was seen in 89.1% of smokers and 70.2% of non-smokers and this difference is significant (P 0.012). The most common systemic disease was hyperten-sion in 48.4% of 250 patients, followed by diabetes mellitus (45.6%).

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CONCLUSION In our study the maximum number of geriatric patients belonged to 65-70 years of age with a male preponder-ance. Hypertension was the most common systemic disease followed by diabetes mellitus in the geriatric population. Pruritus was the most common present-ing complaint followed by dryness of skin. Common aging associated skin changes included xerosis, wrin-kling, dyspigmentation, sebaceous hyperplasia, senile lentigines, senile comedones and IGH. Smoking was a significant risk factor for aging changes like deep furrows, thick rough skin, senile purpura and IGH. Most common dermatitis was asteatotic eczema. Most common infections included dermatophytosis, onych-omycosis, intertrigo followed by folliculitis, mucosal candidiasis, warts, furunculosis and cellulitis. Most common benign tumour was seborrheic keratosis. This study showed a significant association between fissure feet and diabetes, angular chelitis and alcoholism and xanthelasma and dyslipidemia. Most common nail changes included loss of luster,cuticle loss,brittleness and longitudinal ridging. Smoking was found to be a risk factor for developing brittle nails among elderly. Common hair changes included graying and patterned alopecia. Male pattern alopecia was significantly asso-ciated with smoking. As there is proportional increase in the geriatric population, it is imperative for the clini-cian to have a better understanding of the prevalence

Nail changes In our study, most common nail changes included loss of lustre (70.8%), cuticle loss (57.6%), brittleness (50.4%) and longitudinal ridging (47.6%). Other stud-ies also showed similar results. Paronychia was seen in 19.8% females and 7.1% males. Female preponderance reported by others also is26 probably due to frequent contact with water and detergents. 41(73%) cases with brittle nails had signifi-cant association with smoking (P0.001). Similar associ-ations were reported by Gequelim27. Of the 20 psoriasis patients 11(55%) had nail pitting (P <0.001) and 9(45%) had subungual hyperkeratosis ( P 0.001).

Hair changes In our study, graying was seen in 94% cases and patterned baldness in 72% cases. Patterned baldness was seen more in males(76.3%) than females (63%) (P0.04). In our study,prevalence of patterned baldness in male was 89% in smokers and 70.2% non smokers and this difference is statistically significant (P 0.012). These results were comparable to other studies28. The most common systemic disease was hypertension in 48.4% followed by diabetes mellitus (45.6%). Hy-pertension was detected in 40%,27% and 31.5% in other studies while diabetes mellitus was observed in 29.5% and 18% in other studies.

Xanthelasma was seen in 21% patients in our study.This is higher than in other studies -1%, 1.4% 18,19. Out of 53 cases of xanthelasma, 21(36.2%) had dyslipidae-mia (p0.003) which was comparable to study by Jain et al19.

Vesiculobullous Prevalence of immune blistering diseases in our pa-tients was same as in other studies.

Psycho cutaneous disorders Prevalence of psycho cutaneous disorders were also same as in other places7.

Benign tumor Prevalence of seborrheic keratosis (40-50%), acro-chordons (30-50%), cherry angiomas (30-60%) was almost similar in our study and other studies.

Premalignant and malignant conditions Prevalence of premalignant and malignant skin con-ditions were very low. The lower prevalence of skin tumours in our region could be due to type IV and V skin types.

Disorders of pigmentation Prevalence of vitiligo was 92%. Others observed 8% and 19%. One study showed 1.57% prevalence. Our prevalence of melasma was 9%, while in other studies it was5% and 2.4% Melasma was more common in females (23.5%) than males (2.4%)(P0.001).

Adverse drug reactions Incidence was very low in this part of the world.

Miscellaneous dermatological conditions Fissuring of feet was seen in 24 – 62% patients in our study and in other studies. Out of 62 cases with fissuring feet 31.6% were diabetics(p 0.034). Oe M et al found superficial fissures on feet in 9% of dia betic patients.

In our study, milia was seen in 15.6%. Others re-ported 2.2% ,2%18,20.Acanthosis nigricans was seen in 38 patients (females 26% males 10%)(p0.002). Female preponderance is observed in other studies21. Melanocytic nevi was seen in 13% in our study, as compared to 27% by Grover2, 32% Patange and 46.3% by Beauregard.

In our study of total 22(9%) cases of angular cheli-tis, 9(20%) were alcoholics (P 0.008). Other studies reported 5 and 2.9% prevalence22,23. Rifkind have24 re-ported an association between angular chelitis and al-coholism similar to our study. We found that out of the 14 cases of urticaria, 10(10.4%) were hypertensives on ACE inhibitors. A similar association was reported in other studies. Keloids were seen in 1.6% patients comparable to reports by Lio YH25. In our study mac-ular amyloidosis was seen in 1.6% patients whereas Grover found in 3.5%.


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REFERENCES1. Rajan, Irudaya S. Population Ageing and Health in India. Back-

ground Paper Series 1. vi,37 p., July 2006 [ISBN 81-89042-44-0]

2. Grover S, Narasimhalu C. A clinical study of skin changes in geriatric population. Indian J Venereol Leprol 2009; 75: 305-6.

3. Patange VS, Fernandez RJ. A study of geriatric dermatoses. In-dian J Dermatol Venerol Leprol 1995; 61: 206-8.

4. Nair PA, Bodiwala N, Arora TH, Patel S, Vora R. A Study of Getriatric Dermatosis at a Rural Hospital, Gujarat. Journal of The Indian Academy of Geriatrics 2013; 9(1): 15-9

5. A Sahoo, PC Singh, S Pattnaik, RK Panigrahi. Geriatric Derma-tosis in southern Orissa. Indian J Dermatol 2000; 45(2): 66-8.

6. 6. Durai PC, Thappa DM, Kumari R, Malathi M. Aging in elder-ly: Chronological versus photoaging. Indian J Dermatol 2012; 57: 343-52.

7. Stecklings UM, Artuc M, Wollschlager T, Wiehstutz S, Henz BM. Angiotensin- converting enzyme inhibitors as inducers of adverse cutaneous reactions. Acta Derm Venerol 2001 Oct-Nov; 81(5): 321-5.

8. Lewiecki EM, Rahman F Pruritus. A manifestation of iron defi-ciency. JAMA. 1976 Nov 15; 236(20): 2319-20.

9. Berger TG et al. Pruritus in the older patient: a clinical review.JAMA 2013; 310(22):2443-50.

10. Darjani, Golchai J et al. Skin disorders among elderly patients in an referral center in Northern Iran 2011. Dermatology re-search and practise 2013; articla ID 193205, 4 pages.

11. Tindall JP, Smith JG Jr. Skin lesions of the aged and their associ-ation with internal changes. JAMA 1963; 186: 1039-42.

12. Paul C et al. Prevalence and risk factors for xerosis in the el-derly: a cross sectional epidemiological study in primary care. Dermatology 2011; 223.3: 260-5.

13. Chu W, Reddy M. Dry skin in the elderly: complexities of a common problem. Clinics in dermatology 29.1(2011): 37-42.

14. Kennedy C et al. Effects of smoking and sun on aging skin. Jour-nal of Investigative Dermatology 2003; 120: 548-54.

15. Lee CH et al. Lifetime exposure to cigarette smoking and the development of adult onset atopic dermatitis. Britiish Journal of Dermatology 2011; 164(3): 483-9.

16. Ivanov SV, Fedotov VP. Clinico-epidemiologic characteristics of eczema in patients with arterial hypertension. Vestn Derma-tol Venerol 1989; (9): 31-5.

17. Timshina DK, Thappa DM, Agrawal A. A clinical study of der-matoses in diabetes to establish its markers. Indian J Dermatol 2012; 57: 20-5.

18. Raveendra L. A clinical study of geriatric dermatoses. Our Der-matol Online. 2014; 5(3): 235-9.

19. Jain A, Goyal P, Nigam PK, Gurbaksh H, Sharma RC. Xanthe-lesma Palpebrarum- clinical and biochemical profile in a ter-tiiary care hospital of Delhi. Indian J Clin Biochem 2007; 22: 151-3.

20. Puri N. A study of pathogenesis of acanthosis nigricans and its clinical implications. Indian J Dermatol. 2011 Nov- Dec; 56(6): 678-83.

21. Mujica v, Rivera H, Carrero M. Prevalence of oral soft tissue lesions in an elderly Venezuelan population. Med Oral Patol Oral Cir B ucal. 2008 May 1; 13(5): E270-4.

22. Espinoza I, Rojas R, Aranda W, Gamonal J. Prevalence of oral mucosal lesions in the elderly people in Santiago, Chile. Jour-nal of Oral Pathology and Medicine. 2003; 32: 571-5.

23. Rifkind JB. What should I look for when treating an alcoholic patient (current or recovered) in my office? J Can Dent Assoc 2011; 77: b114.

24. Liao YH, Chen KH, Tseng MP, Sun CC. Pattern of skin diseases in a geriatric patient group in Taiwan. A 7 year survey from the outpatient clinic of a university medical center. Dermatology. 2001; 203: 308-13.

25. Guha PK, Panja SK. Clinicomicrobiological study of chronic paronychia. Indian J Dermatol Venereol Leprol 1992; 58: 73-6.

26. Gequelim GC et al. Preception of brittle nails in dermatologic patients: a cross sectional study. An bras de dermatol. 2013; 88(6): 1022-5.

27. Su, Lin-Hui, Tonu Hsiu-His chen. Association of androgenetic alopecia with smoking and its prevalence among Asian men: a community-based survey. Archives of dermatology 2007; 143(11): 1401-06.

and pathophysiology of geriatric skin disorders and their specific management, which differ from that of adult population. Hence more epidemiologic studies concerning dermatologic problems in the geriatric population are needed to help them age gracefully and to live the process of senescence with dignity.

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Percentage Comparison and Evaluation of Curve of Spee and Overbite Among Class II division 1 and Class I

Malocclusion GroupRuby Raj*, Namitha Ramesh**, Krishnan K V*, Sapna Varma N K*

ABSTRACTBackground: Exaggerated curve of Spee is frequently observed in dental malocclusions with deep overbites. Such excessive curve of Spee alters the muscle imbalance, ultimately leading to the improper functional occlusion. It has been proposed that an imbalance between the anterior and the posterior components of occlusal force can cause the lower incisors to overerupt, the premolars to infraerupt, and the lower molars to be mesially inclined.

Objectives: To compare percentage difference in the depth of curve of Spee and overbite between Class I and Class II division 1 malocclusion group. The influence of gender was also investigated.

Method: 100 diagnostic casts of untreated subjects 50 males and 50 females aged 18-25 years were selected from Department of Orthodontics and Dentofacial Orthopaedics.The samples were further divided into 4 groups and the depth of curve of Spee and overbite was measured with a vernier caliper.

Results: There was a 60% increase in curve of spee in Class II div 1 than Class I group and a 44% increase in overbite in Class II division 1 than Class I group .The mean value of curve of Spee and overbite was increased in class II division I group.

Conclusion: The curve of Spee and the overbite was greater in Class II division 1 malocclusion group than Class I malocclusion group. There was no difference between genders within all the groups.

Keywords: Curve of Spee, Class I malocclusion, Class II division 1 malocclusion, Overbite.

*Dept. of Orthodontics and Dentofacial Orthopedics, AIMS, Amrita University, Kochi, India. **Mahe Institute of Dental Sciences & Hospital,Pallor, Mahe.

INTRODUCTION Occlusal curvature is a naturally occurring phenom-enon in the human dentition.The curve of Spee had been first described by Ferdinand Graf von Spee in 1890. He found a line of occlusion in the fossils of mammals and humans. He used skulls with abraded teeth to define a line of occlusion1. This line lies on a cylinder that was tangent to the anterior border of the condyle, the occlusal surface of the second molar and the incisal edges of the mandibular incisors. Spee was located at the center of this cylinder in the mid orbital plane so that it had a radius of 6.5 to 7.0 cm2,3. It had been suggested that the curve of Spee has a biomechanical function during food processing by increasing the crush-shear ratio between the posteri-or teeth and the efficiency of occlusal forces during mastication4,5. Recently, the curve of Spee and leve-ling of this curve has been related to incisor overbite, lower arch circumference, lower incisor proclination, and craniofacial morphology6,7. A deep curve of Spee was usually associated with an increased overbite. And therefore the orthodontic correction of the overbite, reffered to as deep overbite often involves leveling the curve of Spee by anterior intrusion, posterior extrusion or a combination of these actions. Lower incisor pro-clination had been used in some cases to decrease the relative vertical overlap of the lower incisors by the

upper incisors8. Leveling of the curve of Spee was a routine pro-cedure in orthodontic practice. Clinicians have been concerned for some time with the degree of reduction in arch circumference that accompanies leveling be-cause this could lead to incisor protrusion9. On the other hand, Andrews10 mentioned that there was a nat-ural tendency for deepening of the Curve of Spee with time because the lower jaw’s downward and forward growth was faster and longer than that of the upper jaw. This causes the lower anteriors which are con-fined by the upper anteriors and lips to be forced back and up, resulting in crowded lower anteriors and or a deeper overbite and deeper Curve of Spee. Previous studies suggested that the Curve of Spee might be related to the position and inclination of the upper and lower incisors and the overbite. Therefore, the determination of this relationship might be useful to assess the feasibility of leveling the Curve of Spee by orthodontic therapy. The primary aim of this study was to find the per-centage increase of curve of Spee and overbite among Class I and Class II division 1 malocclusion group and the secondary aim was to compare the different depths of Curve of Spee in class I malocclusion and Class II division 1 malocclusion group and also to compare the overbite among the same groups and to assess whether it can be of use as a diagnostic parameter in evaluating prognosis.

ORGINAL ARTICLE

8


Materials and methods Pretreatment study casts of 100 subjects based on the inclusion criteria were selected .The sample consisted of subjects of Class I malocclusion (male=25 and fe-male= 25)and subjects of Class II division 1malocclu-sion (male=25 and female=25) . The inclusion criteria included subjects with full complement of teeth with all teeth in occlusion upto second molar with an age range of 18-25 years and had no history of orthodontic treatment. The crowding was quantified using Little’s Irregularity Index11. This was done by using a digital vernier caliper. The Little’s irregularity index had been used as scoring method of incisor crowding and this involves measurement of lin-er displacement (labio -lingually) of anatomic contact points of each mandibular incisor from the adjacent tooth. In this study mild crowding cases ( Little’s Irreg-ularity Index =0-6mm) were accepted .The exclusion criteria included subjects with gross crowding(Little’s Irregularity Index=6-10mm), anterior or lateral cross bites, cast restorations or cuspal coverages, rotations and craniofacial disorders like cleft palate.

Measurement of curve of Spee on study cast The depth of curve of Spee was measured as the perpendicular dis-tance between the deepest cusp tip and a flat plane that was laid on the top of the mandibular dental cast, touching the incisal edges of the central incisors and the distal cusp tips of the most posterior teeth in the lower arch. The measurement was made on both the right and left side of the dental arch and the mean value of these two measure-ments was used as the depth of curve of Spee12(Figure 1)

Measurement of overbite The overbite was measured as the vertical distance (in millime-ters) between the incisal edges of the maxillary central incisor and the incisal edge of the mandibular central incisor13.

RESULTS The results stated that there was a 60% increase in curve of spee in Class II divison 1 than Class I malocclusion group and a 44% increase in overbite in Class II di-vison 1 than Class I malocclusion

Fig1:Measurement of curve of spee on a study model.

No of tributaries 3 Mean ± SD P Value

MalesClass I

Class II div 1

Class I

Class II div 1 2.02± 0.37

0.001***1.58 ± 0.24

2.01 ± 0.50

1.71 ± 0.280.001***Females

No of tributaries 3 Mean ± SD P Value

MalesClass I

Class II div 1

Class I

Class II div 1 2.02± 0.37

0.001***1.58 ± 0.24

2.01 ± 0.50

1.71 ± 0.280.001***Females

Comparison of Curve of Spee

group.The mean value for depth of curve of Spee was more in class II division 1 malocclusion groups when compared to class I malocclusion group. There was no significant difference among males and females of the same group. The mean depth of curve of Spee and overbite is given below

P-value: NS>0.05:nonsignificant;*<0.05: significant ; **<0.01:moder-ately significant; ***<0.001:highly significant.

P-value: NS>0.05:nonsignificant;*<0.05: significant ; **<0.01:moder-ately significant; ***<0.001:highly significant.

Comparison of overbite

Table 1: Intraobserver comparison of mean ± SD of values of curve of Spee

Table 2. Intraobserver comparison of mean ± SD of values of overbite

Groups

Groups

9


Data was analysed using IBM SPSS Statistics20. Descriptive statistics in-cluding mean and standard deviation values were calculated for all varia-bles. To test the statistical significance in the difference in mean value of curve of spee between class I and class II division 1 for males and females stu-dents t test had been applied depend-ing upon distribution of values of vari-ables. To test the statistical significance in the mean value of overbite Mann –Whitney Test had been applied. The percentage increase of curve of Spee among class I and class II division 1 malocclusion group had been analysed using Fisher’s Exact Test and the per-centage increase of overbites among class I and class II division 1 malocclu-sion group had been analysed using Chi –square Test.

STATISTICAL ANALYSIS

In this study, attempt was made to separate the sample according to

DISCUSSION

Curve of Spee

P Value

Class I

Normal n=(%)

45

41

Above normal n=(%)

5

90.001***

ClassII division 1

Groups

Table 3: Percentage difference of curve of Spee among Class I and Class II division 1 malocclusion group.P value=0.001:highly significant***

Curve of Spee

P Value

Class I

Normal n=(%)

17

10

Above normal n=(%)

33

50

0.001***ClassII division 1

Groups

Table 4: Percentile difference of overbite among Class I and Class II division 1 maloc-clusion group

P value=0.001:highly significant***

ClassI0.00

ClassII ClassI ClassII

0.50

2.502.00

1.50

1.00

Male Female

1.582.01

1.712.02

ClassI0.00

ClassII ClassI ClassII

1.00

5.00

4.00

3.00

2.00

Male Female

gender, type of malocclusion and in an age range of (18-25years) to evaluate the variables more precisely. The measurement of curve of spee was done and the average of the distance on right and left side was taken as the depth of curve of Spee14. Subjects were taken who had the age range between 18-25years to exclude any growth effects since the depth remained constant during adulthood as compared to flat curve in decidu-ous and maximum deepening in adolescent dentition. Marshall et al15and Farella et al6 also mentioned that the homogenous dental wear could be the reason for the maintanence of curve of Spee in adulthood.

The results obtained in this study indicated that there were no significant differences in any of the variables between two genders for both groups. These results were similar to that of studies conducted by Braun and Schmidt16 They had compared non–growing white males and Females with class I and class II division-1malocclusion and had reported that the depth of the curve of Spee was the same for men and women based on the contact points between the mandibular teeth taken from lateral cephalometric radiographs. Cartor and McNamara17 reported that there was no differ-ence in the overbite and curve of Spee between males and females when measured from pretreatment study models. HuiXu18 et al also stated that there was no sig-nificant difference in curve of Spee between Japanese men and women.

As expected, subjects with class II division 1 had

Graph 1-Comparison of the mean changes in the depth of curve of Spee between Class 1 malocclusion group (M+F) and Class II div I malocclusion group (M+F).

Graph 2 - Comparison of the mean changes in overbite between Class I malocclusion group (M+F) and Class II division 1 malocclusion group (M+F)

4.04

2.29

4.13 2.46

Graph 1: Mean Distribution of Curve of spee in Gender

Graph 1: Mean Distribution of Curve of Overbite in Gender

Percentage Comparison and Evaluation of Curve of Spee and Overbite Among Class II division 1 and Class I Malocclusion Group.

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CONCLUSION• There was a 60% increase in curve of spee in Class

II divison 1 than Class I malocclusion group.• The mean value of depth of curve of Spee was

larger in class II division 1malocclusion group than class I group .

• There was no significant differences in the curve of Spee between males and females in the same malocclusion group.

• There was no significance in the depth of curve of Spee between the right and left side of the man-dibular arch.

• There was a 44% increase in overbite in Class II divison 1 than Class I malocclusion group.

• There was a significant increase in overbite in class II division 1 group than class I malocclusion group.

• The variation in depth of curve of Spee influences the overbite .

• There was no significant difference in overbite among males and females in the same malocclu-sion group.

REFERENCESlarger curve of Spee than the subjects with Class I mal-occlusion with mild significance. Within each occlu-sion group, both males and females had similar dimen-sions. Our result were very similar to those of Stalay et al19. The males and females of class II division 1 group had larger mean values than males and females of class I group and also there was a significant difference in the curve of Spee among the class I and class II division 1group . Usually a deep curve of Spee was associated with an increased over-bite. Bernstein et al 20 showed that orthodontic correction of the class II division 1 cases often involves leveling the curve of Spee either by an-terior intrusion, posterior extrusion or a combination. This indicates that the curve of Spee was more deep-er in class II division 1 samples than class I occlusion sample. Also, Shannon and Nanda21 showed that the class II division 1 occlusions had significantly deeper curve of Spee measurement than did class I occlusion. Our findings were greatly differed from that Braun and Schmidt16 who reported that the curve of Spee was found to be identical for class I and class II occlusions. The variation in depth of curve of spee has influence in overbite relation. An increase in curve of spee was seen in deep bite cases and a decrease/negative spee was seen in open bite cases22. Therefore an increased spee was a common feature of patients undergoing or-thodontic treatment, hence the evaluation of the depth of curve of spee was an critical point in treatment plan-ning23 Apart from previous studies, the uniqueness of this study is that it reflects a percentage prevalence of curve of Spee and overbite among class II division 1 and class I malocclusion groups .

1. Imtiaz Ahmed, Rozina Nazir. Influence of malocclusion on the depth of curve of Spee. J Pak Med Assoc. Vol 61. No 11. No-vember 2011.

2. Spee FG ,Biendenbach MA, Hotz M,Hitchcock HP. The gliding path of the mandible along the skull. J Am Dent As-soc.1980;100:670-5.

3. Hitchcock HP. The curve of Spee in Stone Age man. Am J Or-thod 1983;84,248-53.

4. Osborn JW. Relationship between the mandibular condyle and the occlusal plane during hominid evolution: some of its effects on jaw mechanics. Am J Phys Anthropol. 1987;73:193–207.

5. Baragar FA, Osborn JW. Efficiency as a predictor of human jaw design in the sagittal plane. J Biomech. 1987;20:447–57.

6. Farella M, Michelotti A, van Eijden TMGJ, Martina R. The curve of Spee and craniofacial morphology: a multiple regression analysis. Eur J Oral Sci. 2002;110:277–81.

7. Orthlieb JD. The curve of Spee: Under-standing the sagittal or-ganization of mandibular teeth. Cranio. 1997; 15: 333–40 .

8. Al Qabandi AK, Sadowsky C,BeGole EA. A comparison of the effects of rectangular and round arch wires in leveling the curve of Spee. Am J Orthod Dentofacial Orthop. 1999;116:522–9.

9. Proffit WR, Epker BN. Treatment planning for dentofacial de-formities. In: Bell W, Proffit R, eds. Surgical Corrections of Den-tofacial Deformities. Philadelphia, Penn: WB Saunders; 1980: 167 .

10. Andrews LF. The six keys to normal occlusion. Am J Orthod. 1972;62:296–309.

11. Robert M .Little. The Irregularity Index: A quantitative score of mandibular anterior alignment.Am.J.Orthod.1975;68,554-63.

12. Baydas B ,Yavuz I, Atasar l N, Ceylan T, Dagsuyu I.Investi-gation of the Changes in the Positions of Upper and Lower Incisors, Overjet, Overbite, and Irregularity Index in Sub-jects with Different Depths of Curve of Spee. Angle Orthod 2003;74:349–55.

13. Warren A ,Bishara S .Comparison of dental arch measurements in the primary dentition between contemporary and histological samples .Am J Orthod Dentofacial Orthop 2001;119(3):211-5.

14. Nanda Surinder K .The developmental baswas of occlusion and malocclusion .Chicago Quintessence Publishing Compa-ny.1983;244-58.

15. Marshall SD ,Caspersen M, Hardinger RR .Fransiscus RG ,aqui-line SA,Southard TE .Development of the curve of Spee .Am J Orthod Dentofacial Orthop 2008,134,344-52.

16. Braun ML, Schmidt WG. Cephalometric appraisal of the curve of Spee in class I and class II division 1 occlusion for males and females. Am J Orthod. 1956; 42: 255–78.

17. Cartar GA, McNamara JA. Longitudinal dental arch changes in adults. Am J Orthod Dentofacial Orthop. 1998; 114; 88–99.

18. Hui X, Suzuki T, Muronoi M, Ooya K.An evaluation of the curve of Spee in the maxilla and mandible of human per-ma-nent healthy dentitions. Prosth Dent J. 2004; 92(6): 536–9.

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19. Staley RN, Stuntz WR, Peterson LC. A comparison of arch widths in adults with normal occlusion and adult with class II division 1 malocclusion. Am J Orthod. 1985; 88(2): 163–9.

20. Bernstein RL, Preston CB, Lampasso J. Leveling the curve of Spee with a continuous arch wire technique: A long term ceph-alometric study. Am J Orthod Dentofacial Orthop. 2007; 131: 363–71 .

21. Shannon KR, Nanda RS. Changes in the curve of Spee with

treatment and at 2 years post treatment. Am J Orthod Dentofa-cial Orthop. 2004; 125(5): 589–96.

22. Prerna Raja Batham.Curve of spee and its relationship with Dentoskeletal Morphology. J Ind Orthod Soc 2013;47(3) 128-34.

23. Ilknur Veli. Curve of Spee and its relationship to vertical erup-tion of teeth among different malocclusion groups. Am J Orth-od Dentofacial Orthop;2015;147:305-12.

Percentage Comparison and Evaluation of Curve of Spee and Overbite Among Class II division 1 and Class I Malocclusion Group.

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Perceptions of Students Towards a Change of Pattern in the Otorhinolaryngology (ENT) Question Paper

Unnikrishnan K Menon*, Joe Joseph**

ABSTRACTBackground: As a precursor to a potential change of pattern of question paper to bring it in alignment with KUHS recommen-dations, this project was planned to study the perceptions of towards the new pattern. A qualitative study using focus group discussions (FGDs) was considered for this purpose.

Objectives: To study perceptions of students about a changed question paper pattern. Ultimately, to formulate evidence for a change in question paper pattern at the University level.

Method: Voluntary participants from the Third year exam-going batch of students at AIMS, Kochi, were administered a trial ex-amination with the new pattern of question paper, followed by FGDs. The resultant interview data were analysed qualitatively. The faculty were given a feedback questionnaire regarding the question paper.

Results: The students had an overall positive perception towards the new pattern, but with preference for the status quo of two structured essay questions (SEQs), and a willingness to change to the one-mark questions of the new pattern. Reasons for these were clearly elucidated from the emergent themes derived from the FGDs.

Conclusions: Qualitative analysis, via focus group discussions, has proved useful to study student perceptions. The present study has brought to light interesting aspects of students’ motivations for and expectations from a summative theory examina-tion, along with their perceptions towards a new pattern.

INTRODUCTION Assessment and evaluation are integral aspects of the teaching-learning process. Apart from the obvious use of grading and certification of the learner, assessment helps in feedback for both teacher and learner. It has been shown that assessment techniques can be used to motivate students1. Needless to say, it has a significant role in medical education too. Studies have reported the importance of designing suitable assessment meth-ods in this field2. Written (theory) examination is one method that has stood the test of time. Van der Vleuten has stated that “written examinations are at the ‘heart of the hidden curriculum3”. Medical students, like all other learners, adapt learning methods to suit the ex-amination question patterns. Scouller has compared students’ preparation for multiple choice questions with assignment essays; he found that they are “more likely to employ surface learning approaches in the MCQ examination context and to perceive MCQ ex-aminations as assessing knowledge-based (lower levels of) intellectual processing4”. Despite this, it is discon-certing to note that curriculum-planners and teachers hardly give due importance to how the students feel about these assessment modalities. This is evident in the inadequate literature on this specific topic. Questionnaires are the most commonly used tools to study response patterns of individuals or groups. How-ever, something as subjective as ‘perceptions’ may not be amenable to objective quantification. Herein lies the relevance of qualitative research, of which focus group discussion (FGD) is one method.

*Dept. of ENT, **Dept. of Public Health Dentistry, AIMS, Amrita University, Kochi, India.

The present study looks at the perceptions of stu-dents about a change in question paper pattern, using FGD as the tool. Ultimately, these perceptions could be used to effect a change in the curriculum via the examination control division (ECD) of the University. The principal researcher is a member of the medical education unit in the Institution.

OBJECTIVESPrimary To study perceptions of students about a changed question paper pattern.

Secondary To formulate evidence for a change in question paper pattern at the University level.

REVIEW OF LITERATURE There is no doubting the fact that students are the big-gest stakeholders in any assessment paradigm. Hence, there is a need to understand their attitudes towards the assessment system. An entire literature review of this subject was done by Katrien Struyven, Filip Dochy and Steven Janssens. They looked at various studies on assessment patterns in higher education5. They men-tion in their concluding remarks that “assessment pro-cedures that are perceived to be ‘inappropriate’ ones tend to encourage surface approaches to learning.” This underlines the need for studies into perceptions of medical students about assessment methods. Two studies can be quoted in this context. Zeidner, M. (1987) reported a definite preference of students for multiple choice (MCQ) type over Essay type questions6 Birenbaum, M., & Feldman, R. A. (1998) looked at this

ORGINAL ARTICLE

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in greater detail and found that good, confident learn-ers chose Essay type over MCQs while poor learners and those low on confidence preferred MCQs over structured essay questions (SEQs)7. Another study by Lindblom-Ylänne and Lonka K. discusses the “prob-lems that arise in a traditional medical curriculum, par-ticularly concerning traditional assessment practices”8. A relevant study from Singapore analysed data ob-tained via questionnaire and face-to-face interviews to study students’ perception of change in the Singapore education system. It concluded that “the implication for education leaders is that it is important to under-stand student perception of change because they are the ultimate beneficiary of change”9. Not withstanding the above, overall, there is a pau-city of literature in the specific domain of student per-ceptions of question paper patterns. The present study has been an effort at correcting this. Qualitative or quantitative method? That was the next consideration for the study. Creswell in his text about design frameworks, has advised a qualitative ap-proach if the study is done to understand either ‘a new topic or a topic that has never been addressed with a certain group of people’10. The present study clearly fell in the latter category. Regarding the use of focus group discussions (FGDs), there is a comprehensive guide to this aspect in a chapter in the ‘Handbook of Mixed Methods in Social and Behavioural Research’11 A recent Indian study has reported the use of FGD to look at student perceptions12. Another has used FGDs to study the perceptions of undergraduate MBBS stu-dents about a specific posting13.

METHODStudy Design Qualitative study using focus group discussion (FGD) was conducted with the students. Setting This study was conducted in a AIMS. The MBBS undergraduate student strength is 100 per batch. Third year (phase III) includes ENT, Ophthalmology and Community Medicine. The final examination (summa-tive assessment) is in January every year. The existing question paper pattern in the study set-ting consists of two sections (A & B), each of 20 marks, with one full question of 10 marks (not always SEQ or MEQ type) and 5 short notes of 2 marks each. The new pattern has only 1 ‘full question’ which is an MEQ, followed by 4 more main questions containing short answer questions with differential marking, including a set of four 1-mark questions. The trial paper creat-ed consisted of high percentage of clinical questions. The students were being exposed to such a pattern of theory question paper for the first time.Participants and Sampling The students scheduled to appear for the final ex-amination of third year in January, 2016 took part

in the study. Participant recruitment was through purposive sam-pling, using convenience and homogenous types. The students were informed well in advance of the plan for this study, excluding specific details and purpose. They were informed that it would be a ‘trial exami-nation’, which could be considered as preparation for their summative assessment examination. They were assured that the marks would not be counted or used in any way towards final assessment scores. They were also informed that it was voluntary. Accordingly, a to-tal of seventy-three (73) students offered to participate. After the trial question paper was administered, care was taken to include variety of levels of performers amongst the students. Undoubtedly, voluntarism was also an important factor. Accordingly, thirty-six (36) participants were finalized. For the groups’ formation, the main aspect considered was to ensure good group dynamics. Hence, the chosen participants were al-lowed to form the groups, while ensuring not more than ten in each group. Thus, a total of five focus groups (5 FGs) were formed.Procedure After discussion in the department, and getting per-mission from the medical college principal and exami-nation control division (ECD), the project proposal was placed before the ethics committee for approval. Eth-ics clearance was obtained from the Institutional Ethics Committee. The focus group discussion module was created with the guidance of faculty from community medicine de-partment, conversant with this method. Specific the-ory question paper, as per the new pattern, was set, with an accent on more clinical (application-type) questions. The participating students were taken into confidence, regarding the trial paper, and the need for their participation in a group discussion. Informed con-sent was taken for the latter. The trial question paper was administered to the study population as a ‘mock exam’, about two weeks before their scheduled model examination. At the end of the examination, the study purpose was introduced by the PI. Another faculty (Head of Dept. of Public Health Den-tistry in the same Institution) was identified, who had undergone training in qualitative research. He was inducted as the co-moderator, after briefly explaining about the study. Over the next few days, the FGDs were conducted in the appropriate method. The time and venue were chosen to suit the participants’ convenience, ensuring no disruption of academic or clinical work. Written informed consent was obtained from participants af-ter explaining the purpose and process of the study. Following introductions, the moderator informed the guidelines of conduct of the discussion. Stress was placed on the need for free flowing discussion, avoiding


14


the remaining four. Active overall participation was ensured. The moderator maintained handwritten field notes of relevant quotes as well as non-verbal cues. The co-moderator helped to oversee the preparations (and later for triangulation of analysis). Audio record-ing of the FGDs was done, using hand-held mikes and recording device, manned by experienced AV staff. The recordings were labelled and saved in a separate hard drive.

direct communication with the moderator. A semi structured discussion guide was prepared with prede-fined themes. Each theme was introduced by the mod-erator and the group was encouraged to discuss freely about the same. These themes helped to maintain con-tinuity and an element of uniformity between groups. The time limit was set at approximately one hour. All the themes were quite well covered within this time. An assistant contributed to making sociograms; two for each FGD, one for themes 1 and 2, and another for

Overall theme

Advantages & disadvantages

Topics coverage

Time adequacy

Comparison

Self-satisfaction

Whether better or worse than previous sessional ENT papers, and/or Ophthalmology and Community Medicine patterns

Suggestions & recommendations

Aspects that were good and bad about this pattern, in whichever way the students perceived

Whether this pattern covered / can potentially cover more topics, as compared to existing pattern

Whether this new pattern can be easily completed in two hours

To get an idea about the sense of satisfaction, in terms of not only obtaining marks, perceived by the students after answering this different pattern

Students’ final feedback about this new pattern, as regards continuation with or without modifications

Information sought

FINDINGSSTUDENT FGDS

Analysis Transcription of each FGD was done verbatim, typed into separate Word files. Next, all the transcripts were re-grouped theme-wise. Thus, the five FGD transcripts were redeveloped into six theme transcripts. For con-tent analysis with the predefined themes, a validated method was used14. Colour coding was used such that common points in favour or against were highlighted with the same colour. Next, all the coloured (coded) words and text were assembled into a separate Word file and labelled. Thus, a ‘coding tree’ was created. This was refined by cross-checking between the groups (axial coding), to ensure accuracy and conciseness. Patterns and trends relating to the predefined themes, and keeping the research question in mind, were not-ed and verified. Quotations, which best represented relevant aspects under each theme, were chosen. Tone and nonverbal communication were checked from the field notes. Finally, the emergent themes (inductive analysis) were summarised. For the purpose of reliability, a copy of the tran-scripts was assigned to the co-moderator, to apply his coding process. The results were checked for similari-ties and points of disagreement, if any.

Theme 1 Many of the students compared this question paper pattern favourably with its prior counterpart. The main factors cited were “clinical questions” and “to the point”. The points against related to “overly practical/clinical questions”, “only 1 structured essay question (SEQ)” and “compulsory diagram question”.

Theme 2 This theme was intended as the mainstay of this study. There were lively discussions and debates amongst in-dividual members in all the FGDs. Most of these relat-ed to three aspects of the new pattern, namely: Only one structured essay question (SEQ) [Q. I]Compulsory diagram question [Q. III]One mark question [Q. V]With regard to Q. I, nearly half the students were of the opinion that the existing pattern, with 2 SEQs, was better. The SEQs, in the ENT question paper, usually represent a major topic. And, the usual trend is that the latter number less than ten. Hence, the student can ensure a passing score by studying these. Regarding

15


the question of drawing diagrams, it was interesting to note that there was at least one in each group who detested it. The mental block against being “forced to draw” was evident. Q. V proved to be the ‘twist in the end’, from the point of view of the research question. Although this was a new pattern for them in ENT, they were exposed to it in Ophthalmology, and few other subjects in earlier Phases. A large majority were en-thusiastic in their support for this pattern. Whether this stemmed from the very specific questions asked in this paper, needing clear-cut one word or one sentence an-swers, is a moot point.

Theme 3 A significant majority agreed that this pattern made for good coverage of all topics in ENT.

Theme 4 This theme reached saturation point very quickly. There was hardly any debate; nearly all agreed that the allotted time of two hours was sufficient (as was the case with the existing pattern).

Theme 5 For this theme, the students were specifically asked to consider the satisfaction of not only getting good marks, but also the sense of having answered a dif-ferent type of question paper. Once again, there was considerable debate, with the more than half of them expressing satisfaction.

Theme 6 In this concluding theme, the students were asked to give their ‘final verdict’, in terms of recommending a change to this pattern, and to make any related sugges-tions. It was a mixed bag all through the groups. The enthusiastic ones, always willing for change, whole-heartedly endorsed this pattern, and the clinical nature of questions. At the other end of the spectrum, there were the few totally opposed to change, with the most common argument being against only 1 SEQ. Amongst those who supported the pattern change, majority wanted it only for ENT or, at the most, for Ophthal-mology.

Summary of emergent themes• Only 1 SEQ/MEQ: Most of the students were not

in favour of this change in the new pattern

• More clinical-oriented questions: Almost equal support and opposition for this type of questions (not necessarily related to the pattern)

• Compulsory diagram question (Q. III): Many were strongly against this question, very few in support

• One mark question (Q. V): Majority of students in support, provided questions suitably well-framed

• Need to change to this pattern: More in favour, very few definitely against

DISCUSSION The study threw up largely expected results. Howev-er, the FGDs helped in understanding student mind-sets and perceptions towards examinations and success in them. Specifically, they did not mind a permanent change in the question paper pattern, provided ade-quate preparation was given in the formative examina-tions. That was a fair point. Structured or modified essay questions found favour with most of the students in the study. In the present pattern in ENT, the SEQs represent the ‘safety cush-ion’ of representing two of the few major topics. The loss of one such cushion expectedly did not find much favour. This opinion was seen amongst students of dif-ferent achievement levels; not just the ‘good, confident learner’ as noted in the earlier quoted study.8 Here too, the students had a fair point. It was encouraging to note the level of enthusiasm for the more challenging one-mark questions, with some even recognising its discriminatory potential. The notion of getting a feel of how a doctor has to tackle patients and their problems was appreciated by these students. The finer points such as need for parity with a central University pattern, need for a slightly different study pattern, advantages of differential marking and the lack of suitability of such a pattern in final Phase subjects all emerged from the FGDs. Possible causes for concern were the student’s style of studying for a summative examination and the level of importance attached to marks as the sole determinant of satisfaction. From the FGDs, it became clear that for many, reading from the textbook, especially the ‘important topics’, in the last month or so prior to the exam, was the preferred mode of preparation. The re-sultant success in terms of gaining the required marks seemed to be the only desired end-point. And, their views about ‘expected pattern and questions’ were skewed accordingly. The lack of sense of all-round un-derstanding of the subject, especially the applied as-pects, does raise questions about the nature of theory examination patterns and questions. A Singaporean study looked at the students’ percep-tion of computer-based versus pen-and-paper testing, using an online survey. Majority preferred the former, except for MEQs15. A qualitative study of medical students’ perceptions of teaching was reported in BMJ16. Another study utilised the students’ perceptions as a tool for explaining the strengths and weaknesses of two new assessment forms in problem-based learning and the learning environment in which they are em-bedded17. Literature search did not throw up any study quite the same as the present one. Hence, no direct com-parisons can be drawn. Many studies, cited above, are


16


broadly of the same nature. All of them underline the importance of taking into consideration the perception of students towards the teaching, learning and assessment processes.

CONCLUSIONS• Qualitative analysis, via focus group discussions,

has proved to be a very useful tool to study student perceptions.

• The present study has brought to light interesting aspects of students’ motivations for and expecta-tions from a summative theory examination.

• Preference for the status quo of two SEQs, and a willingness to change to the one-mark questions of the new pattern was perceived.

• Similar studies would be useful to understand stu-dents’ and also patients’ perceptions.

Recommendations• To consider suitable change in the ENT theory pa-

per, including the present 2 modified essay ques-tions (MEQs), with introduction of the one-mark questions of the KUHS pattern.

• One-mark question to be necessarily on applica-tion type.

• To ensure adequate questions on clinical aspects.

Limitations• Only one qualitative method (FGD) was used.

Validity and reliability would have been more if mixed methodology used.

• Convenience sampling and voluntary nature of participation could have compromised a truly rep-resentative sample.

• Limited experience of research team.

REFERENCES1. Kniveton BH. Student Perceptions of Assessment Methods. As-

sessment & Evaluation in Higher Education; 1996:21(3), 229-37.

2. Chandratilake M, Davis M, Ponnamperuma G. Evaluating and designing assessments for medical education: the utility formu-

la. The Internet Journal of Medical Education;2010:1(1), 1-17.

3. Van der Vleuten CP. The assessment of professional compe-tence: developments, research and practical implications. Ad-vances in Health Sciences Education;1996:1(1), 41-67.

4. Scouller K. The influence of assessment method on students’ learning approaches: Multiple choice question examina-tion versus assignment essay. Higher Education. 1998 Jun 1;35(4):453-72.

5. Struyven K, Dochy F, Janssens S. Students’ perceptions about evaluation and assessment in higher education: a review. As-sessment & Evaluation in Higher Education;2005:30(4), 331–47.

6. Zeidner, M. Essay versus multiple-choice type classroom ex-ams: The student’s perspective. The Journal of Educational Re-search;1987:80(6), 352-8.

7. Birenbaum, M., Feldman, R A. Relationships between learning patterns and attitudes towards two assessment formats. Educa-tional Research;1998:40(1), 90-8.

8. Lindblom-Ylänne S, Lonka K. Students’ perceptions of assess-ment practices in a traditional medical curriculum. Advances in Health Sciences Education;2001:6(2), 121-40.

9. Ng PT. Students’ perception of change in the Singapore educa-tion system. Educational Research for Policy and Practice. 2004 Jan 1;3(1):77-92.

10. Creswell JW. Research design: Qualitative, quantitative, and mixed methods approaches. Sage publications; 2013 Mar 14.

11. Kemper, EA., Stringfield S., Teddlie, C. Mixed Methods Sam-pling Strategies in Social science Research in Tashakkori, A. & Teddlie, C. (Eds.) Handbook of Mixed Methods in Social and Behavioural Research, Sage, Thousand Oaks. Chapter Data Collection Strategies in Mixed Methods Research.2003.

12. Arati SP, Tripti S. Students’ perception about the Formative As-sessment examinations. JHSE; 2014:1(1).

13. Rahman SP, Sankarapandian V, David KV, Christopher P. Per-ceptions of Medical Students about Family Medicine Rotation in India: A Pilot Study. Journal of Contemporary Medical Edu-cation. 2015;3(2):77-81.

14. Krueger RA, Casey MA. Focus groups: A practical guide for applied research. Sage publications; 2014 Jul 25.

15. Lim EC, Ong BK, Wilder-Smith EP, Seet RC. Computer-based versus pen-and-paper testing: Students’ perception. AN-NALS-ACADEMY OF MEDICINE SINGAPORE. 2006 Sep 1;35(9):599.

16. Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ per-ceptions of teaching. BMJ. 2004 Sep 30;329(7469):770-3.

17. Segers M, Dochy F. New assessment forms in problem-based learning: the value-added of the students’ perspective. Studies in higher education. 2001 Oct 1;26(3):327-43.

17


Comparison of 3% Hypertonic Saline with 20% Mannitol onWater - Electrolyte Balance and Brain Relaxation During Elective Supratentorial Tumour Surgeries

Rakesh Rajagopal, S Gokuldas

ABSTRACTBack ground: Hyperosmolar therapy is used for brain relaxation during supratentorial surgeries. Mannitol has been tradi tionally used to reduce the intracranial pressure1. This double blinded randomised control study compared the effectiveness of 3% hypertonic saline and two different doses of 20% mannitol during elective supratentorial tumour surgery as a brain relaxant and also compared the water-electrolyte abnormalities that occurred in these patients.

Methods: Cerebral relaxation and water electrolyte balance after intravenous administration of 3% hypertonic saline [ HTS] and 0.5gm/Kgm and 0.75gm/Kgm of 20% mannitol were evaluated in 120 adult patients divided into 3 groups.

The estimation of dural tension and cerebral relaxation was assessed immediately after opening the dura10. At 0, 30, 60, 120 and 180 minutes and at extubation or 6 hours (whichever was earlier) after study agent infusion, haemodynamic variables, core temperature, ET CO2, pH, lactate, sodium, potassium and osmolarity were recorded.

Results: 120 patients enrolled in the study were divided into 3 groups of forty patients each (HTS group, 0.5M group, 0.75M group). Brain relaxation was significantly better in the HTS group compared with the M groups (p=0.018). Two patients in the HTS group, 4 patients in the 0.75 group and 9 patients in 0.5 M group required the administration of additional hyperosmotic agents for brain relaxation (P=0.051). Even though mannitol is a known diuretic there was no significant difference in urine output between the 3 groups (average1231 ml HTS, 1527ml 0.75 M, 1336 ml 0.5M; P=0.16). Compared with mannitol, HTS caused an increase in serum sodium concentration and a decrease in serum potassium concentration over time (P<0.001) Os-molarity was higher in the HTS group (312.63 +/- 4.823 mOsm/L) when compared with the 0.75 M group (305.25 +/- 4.289 mOsm/L) and 298.45 +/- 3.471 mOsm/L in 0.5 M group (P<0.001).

Conclusion: In this study, we observed that during elective supratentorial surgeries 1] 3% hypertonic saline was a better brain relaxant than 20% mannitol 2] With 20% mannitol brain relaxation was better with a higher a higher dose than a lower dose. Even though mannitol is a diuretic we did not find any difference in urine output between the groups. Sodium was higher in the HTS group but it was less than the maximum recommended rise of 12 meq/24 hours. Hyperkalemia was found after mannitol administration but it did not rise to dangerous levels.

Key Words: Hypertonic saline, mannitol, supratentorial tumours, osmolarity, electrolyte balance, lactate.

INTRODUCTION Raised intracranial pressure [ICP] and brain edema reduces cerebral perfusion pressure and cause second-ary brain injury. Neuroanaesthetists uses various meth-ods to control ICP and prevent secondary brain injury during surgery. The commonly used pharmacological method is hyperosmolar therapy The intravenous ad-ministration of hyper osmolar agents produces an os-molar gradient, drawing water across the blood brain gradient. This leads to a decrease in interstitial and in-tra cellular volume thereby causing a decrease in ICP and producing brain relaxation. Mannitol has been traditionally used for brain relaxation in neurosurgery1. It is associated with adverse effects such as intra vas-cular volume depletion, hypotension, hemolysis, renal insufficiency, hyperkalemia, rebound rise in ICP and pulmonary edema2. In this study we used 0.5gm/Kgm and 0.75 gm/Kgm of 20 % mannitol on two different groups to compare the effects. HTS was mainly used as a rescue agent for controlling refractory cerebral edema in neuro surgical patients.

Dept. of Anaesthesiology, AIMS, Amrita Vishwa Vidyapeetham, Kochi.

It produces reduction in ICP without producing a de-crease in serum osmolarity or serum sodium. Although hypertonic saline has potential side effects like subdur-al haemorrhage and central pontine myelinolysis, it has gained renewed interest as an alternative therapy3. There are few clinical trials using hypertonic saline for reducing ICP and brain edema19,20,21. Hypertonic saline is found to be as efficient as mannitol in controlling ICP and reducing the brain bulk intraoperatively4. In our study we used 3 ml/Kgm of 3 % saline as infusion.

Objective The primary objective of our study was to find out whether there is any difference in cerebral relaxation when different doses of 20% mannitol and 3% hyper-tonic saline were used in patients undergoing elective supratentorial tumour surgeries. The secondary objec-tive was to find the acute changes in osmolarity, pH, lactate, serum sodium and potassium values during the period of action of drugs administered.

Methods This double blinded random controlled study was conducted on patients who underwent elective

ORGINAL ARTICLE

18


Anesthetic management Patients in all the three groups received general anaesthesia. All the patients were induced with in-tra venous midazolam 2 mg, glycopyrrolate 0.2 mg, fentanyl (2 mcg/kg) and propofol 2mgm/Kgm. Vecu-ronium 0.1mgm/kgm was the muscle relaxant used for intubation. Arterial blood pressure [ABP] and cen-tral venous pressure [CVP] were monitored in addition to standard monitoring. Anaesthetic maintenance in-cluded isoflurane [ MAC 1] in air - oxygen combined with intravenous infusion of fentanyl at 1-2mcg/kg/hr and atracurium at 0.3-0.6 mg/kg/hr . Patients were kept normocarbic [ PaCO2 35 - 40 mm of Hg]. Hae-modynamic variables like heart rate and arterial blood pressure were kept within +/- 20% of baseline val-ues. Hypotension was treated using intravenous fluid/ blood and /or a vasopressor. Intravenous fluid man-aged according to urine output, CVP and blood loss. The transfusion of blood was guided by clinical indi-cators, assessed blood loss and a haemoglobin of less

RESULTS The study was conducted on 120 patients divided into 3 groups . There was no significant difference in the demographic profile between the three groups of patients (Table1). The hemodynamic parameters,

supratentorial tumour surgery at Amrita Institute of Medical Sciences, Kochi, a tertiary care centre in India during the period December 2012 to November 2014.The study was conducted after getting approval from the ethics committee of the hospital. Each patient was explained about the study and informed consent was taken before enrolling to the study group. The study population was randomly divided into three groups who received hyperosmolar therapy during surgery. The three groups were1 HTS group who received3 ml of 3%saline, 2] 0.5M group who received 0.5 gm/Kg bodyweight of 20% Mannitol and 3] 0.75M group who had received 0.75gm/kg bodyweight of 20% Mannitol.

Exclusion criteria We excluded patients below 18years and over 65 years of age and those with symptoms of raised ICP and low GCS[less than 13]. Patients with serum sodi-um less than 130 or more than 150 meq/l and patients who received hyperosmolar therapy upto 24hrs before surgery were also excluded. ASA 4 and 5 patients and patients who had metabolic abnormality that affect the hydro electrolytic balance like diabetes insipidus, syndrome of inappropriate antidiuretic hormone and cerebral salt wasting syndrome were not included in the study.

After randomization using sealed envelopes, a sin-gle intravenous bolus dose of either 0.5 g/kg or 0.75 g/kg of 20% mannitol or 3 ml/kg of 3 % hypertonic saline was administered at the onset of periosteal inci-sion through a central line over a period of 15 minutes. The surgeons and anaesthesiologists were blind about the identity of the agents used. All patients received 8 mg of intra venous dexamethasone and antiepileptic on the day of surgery as this was the normal practice in our institute.

than 10 mg/dL.Estimation of dural tension and cerebral swelling Immediately after opening the dura, the degree of brain relaxation was assessed using a 4- point scale of “perfectly relaxed” (1), “satisfactorily relaxed “(2), “firm brain”(3) and “bulging brain”(4)10.When the surgeons were not satisfied with the degree of brain relaxation another bolus of the study fluid was administered. The parameters like hemodynamic variables (HR, MAP and CVP), core temperature, ETCO2, PaO2, PaCO2, lactate and pH, serum electrolytes (sodium, potassium) and osmolarity [all from ABG] were record-ed at 0 minute (i.e. just before the administration of hy-perosmotic agent – baseline), 30 minutes, 60 minutes, 120 minutes, 180 minutes and at 6 hours or extubation (whichever was earlier) after study agent infusion.Statistical analysis With 95% confidence and 80% power the mini-mum sample size was computed to be 110 in each group. Due to time constraints and limited availability of patients, we have restricted the sample size to 120 patients with 40 patients in each group. Percentage of patients with cerebral relaxation char-acterized as relaxed/ firm in the three groups [ 0.5M, 0.75 M and HTS] were noted. Mean change with standard deviation in parameters (sodium, potassium, lactate, pH, osmolarity and urine output) were com-puted in the above three groups To test the statistical significance of the difference in percentages of cases-- perfectly relaxed/ satisfactori-ly relaxed/ firm brain/ bulging brain among the above three groups, additional doses of study agent given and the urine output among the three groups record-ed -- Chi-square test was applied. To test the statistical significance of the difference in the mean changes at different periods of time in the parameters (sodium, po-tassium, lactate, pH and osmolarity) between the three groups, analysis of variance (ANOVA) with Bonferro-ni correction was applied. In statistics, the Bonferroni correction is a method used to counteract the problem of multiple comparisons. To test the homogeneity of variances, Levene’s test was carried out. To test the statistical significance of the difference in the mean changes at different periods of time in the parameters (sodium, potassium, lactate, pH and osmo-larity) within a group, students T test was applied. The data obtained was processed using IBM SPSS Statistics version 20.0. A P value ≤ 0.05 was required to be sta-tistically significant.

19


PaCO2, ETCO2 and temperature levels were not signif-icantly different between the groups. The brain relaxa-tion scores observed were either satisfactorily relaxed or firm brain in all the groups. There was no perfectly relaxed or bulging brain observed in any of the three groups. The relaxed/ firm brain observed in the HTS group was 32 and 8 patients respectively, whereas in the 0.75M group it was 27 and 13 and 0.5 M it was 20 each respectively(Table 2). Brain relaxation was signif-icantly better in the HTS group compared with the M groups (p=0.018). Two patients in the HTS group, 4 patients in the 0.75M group and 9 patients in 0.5 M group required the administration of additional hyper-osmotic agents for brain relaxation (P=0.051)( Table 2). Even though mannitol is a known diuretic there was no significant difference in urine output between the 3 groups (average1231 ml HTS, 1527ml 0.75 M, 1336 ml 0.5M; P=0.16) (Table 2). Compared with mannitol,

HTS caused an increase in serum sodium concentration and a decrease in serum potassium concentration over time (P<0.001, Figures. 2, 3). Serum potassium levels were found to increasewith mannitol administration and decrease with hypertonic saline. Osmolarity was higher in the HTS group (312.63 +/- 4.823 mOsm/L) when compared with the 0.75 M group (305.25 +/- 4.289 mOsm/L) and 0.5 M group [ 298.45 +/- 3.471 mOsm/L, (P<0.001)] [Figure 1]. In our study there was statistically significant change in lactate levels in both mannitol group and hypertonic saline group over time. When compared with each other statistically sig-nificant changes were observed at 120 minutes, 180 minutes and 6 hours after administering the respective hyperosmotic agent [Figure 4]. There were no signif-icant differences in pH levels between the 3 groups (Table 3)[figure 5].

0.75 g/kgMannitol

3% Hypertonic saline0.5 g/kgMannitol

0.74

46.55+/-12.704 46.00+/- 13.27846.80+/-12.17

63.05+/-8.1868

25/15

0.96

P value

Age (years)

64.5 +/- 8.3113

22/18 22/18

62.4+/-7.5644

Male/ Females

Weight (kg) 0.49

0.75 g/kgMannitol

3% Hypertonic saline0.5 g/kgMannitol

0.051

27/13 32/820/20

1527.5+/-813.89

4/36

0.018

P value

Cerebral relaxation Relaxed/ firm

1336.25+/-635.58

9/31 2/38

1231.25 +/-627.43

Additional Agent requirement

Urine output 0.1618

0.75 g/kgMannitol

3% Hypertonic saline

0.5 g/kgMannitol

<0.001

305.25+/-4.289 312.63 +/- 4.823

4.200+/-0.2230

130.95+/-1.811

<0.001

P value

Sodium

Osmolarity

2.043 +/- 0.6437

144.43+/-3.029

3.723 +/-0.2567

1.675+/-0.3815

Potassium

Lactate

pH

298.45+/-3.471

134.88+/-2.483

4.153+/-0.2112

1.555 +/-0.3351

7.4115+/- 0.0408 7.4072 +/- 0.02864 7.4160+/-0.05138

<0.001

0.182

0.640

Table 1: Patient Characteristics.

Table 2: Cerebral Relaxation and Urine output

Table 3: Arterial blood gas parameters at 30 minutes post infusion of study agent.

Comparison of 3% Hypertonic Saline with 20% Mannitol onWater - Electrolyte Balance and Brain Relaxation During Elective

Supratentorial Tumour Surgeries

20


275280285290295300305310315

120

125

130

135

140

145

150

Base line 30 Min 60 Min 120 Min 180 Min End of surgery/6h

Time

Osm

olar

ity

Osmolarity


Time

Sodi

um

Sodium

3.43.53.63.7

3.83.9

44.14.2

4.3


Time

Potta

ssiu

m

Pottassium

0.5g/ kg MANNITOL0.75g/ kg MANNITOL35% HYPERTONIC SALINE



fig 1: Variations in osmolarity among the three groups over a period of time.

fig 2: Variations in serum sodium among the three groups over a period of time.

fig 3: Variations in potassium among the three groups over a period of time.

21


DISCUSSION Osmotically active agents are used to reduce the intracranial pressure and cerebral edema in neuro surgical patients. In our study, patients who received 3% HTS were found to have a better relaxed brain (80%) than the patients who received mannitol (0.75 M-67.5% 0.5 M 50%). The studies of Wu et al9 and Dostal et al11. also showed similar results. We ob-served an increase in osmolarity 30 minutes after the administration of HTS infusion (312.63 mOsm/L).This is significantly higher than the osmolarity in mannitol groups (0.75 M-305.25 mOsm/L , 0.5 M-298.45mOs-m/L) . Hypertonic saline has a higher osmotic reflection coefficient than mannitol (1.0 and 0.9 respectively). This result in a lower solute leakage with HTS and a

rise in serum osmolarity9. The higher osmotic gradi-ent increases brain water extraction into the intravas-cular space and produces better brain relaxation with hypertonic saline compared to mannitol. Among the mannitol groups the 0.75M group has recorded better cerebral relaxation (67.5% vs. 50% respectively) and higher rise in serum osmolarity (305.25 mOsm/L vs. 298.45 mOsm/L respectively) when compared with 0.5 M group. Higher doses of mannitol result in a dose-related increase in serum osmolarity and a cor-responding decrease in brain water content leading to better brain relaxation13. The study of Quentin et al12 also showed similar results. Patients in HTS group recorded a rise in serum sodi-um levels (144.43 mmol/L), 30 minutes after adminis-tration of the intravenous agent where as the mannitol

0.5

1

1.5

2

2.5

3


Time

Lact

ate

0

Lactate

7.4

7.405

7.41

7.415

7.42

7.425


Time

PH

7.395

PH



fig 4: Variations in lactate among the three groups over a period of time.

fig 5: Variations in pH among the three groups over a period of time



22


REFERENCES

The study showed 3% HTS provided better brain relaxation than 20% mannitol during elective su-pratentorial tumour surgeries. The administration of 3% hypertonic saline resulted in higher sodium and osmolarity levels than 20% mannitol . Among the mannitol groups better brain relaxation was obtained with 0.75 M than 0.5 M group. Though mannitol is a diuretic we could not find any statistically significant difference in urine output between the groups. Po-tassium was significantly high in the mannitol groups compared to hypertonic saline group. Though serum lactate was significantly high in all the groups over a period of time there was no significant change in pH.

This study shows 3% hypertonic saline is better than mannitol for supra tentorial surgeriesin reducing brain edema. If mannitol is being used it is better to use 0.75 gms/Kgm of 20% mannitol as it provided better brain relaxation than 0.5 gm/Kgm of 20% mannitol.

This study looked only the immediate effects of both agents but not any sequelae and other factors affecting neurological outcome in the patient groups.

CONCLUSION

Limitations There were few limitations to this study. The major limitation was the 4- point scale10 assessment of brain relaxation . This is a subjective assessment and the ad-ditional dose requirement is based on this. Pre-opera-tive factors that might affect brain relaxation like the size of the tumour, peritumoral edema8, midline shift,

groups showed a decrease in serum sodium level (130.95 mmol/L in 0.75 M and 134.88mmol/L in 0.5 M). The rise in sodium in the HTS group may be due to the decreased solute leak. Hypernatremia stimulates the release of antidiuretic hormone which increases the reabsorption of water from the distal convoluted and collecting tubules of kidneys18 leading to a decrease in urine output. Mannitol administration results in an initial increase in osmolarity with fluid shift towards the intra vascular compartment producing dilutional hyponatremia. Similar observations were seen in the studies of Wu et al9, Rozet et al10 and Gemma et al5. In this study potassium levels were increased in M groups and decreased in HTS group. Hyperkalemia after high doses of mannitol administration has been reported,6 [Manninen et al7 ] but the exact mechanism of this phenomenon is unknown. The probable causes are 1] potassium efflux from intra cellular fluid as a result of hyperosmolar condition14 . 2] crenation and hemolysis of RBCs and 3] dilution of extra cellular fluid with a decrease in bicarbonate leading to metabolic acidosis. HTS infusion produces hyperchloremic acidosis. The development of hypo-kalemia with HTS is a compensatory mechanism to maintain electrical neutrality15,16. Studies of Wu et al 9 and Rozet et al 10 showed an increase in lactate levels when mannitol was used and no change with hypertonic saline. In this study there was statistically significant change in lactate levels ob-served at 120 minutes, 180 minutes and 6 hours after administration of the respective hyperosmolar agent. The negative fluid balance induced by mannitol sug-gests that the increase in lactate concentration may be secondary to effective hypovolemia. There was no significant change in pH between the groups or within a group over a period of time. Patients in the present study remained haemodynamically stable without sig-nificant changes in heart rate or blood pressure. Serum sodium levels should not be not be correct-ed more than 8-10 mEq/day17. In this study, we ob-served a mean increase in serum sodium levels of 7.40 mmol/L at thirty minutes, and 5.62 mmol/ L at sixty minutes after intravenous administration of 3% hyper-tonic saline. Severe hypernatremia can disrupt the blood brain barrier and can lead to subdural haemorrhage. Rapid increase in serum sodium level [ > 12 meq/ 24 hrs] can rarely lead to central pontine myelinolysis.

the position of the head and body were not included in the study. Patients with symptoms and signs of raised intracranial pressure were excluded but it may be pos-sible to have some patients with altered intracranial compliance. The values of electrolytes, lactate, pH and osmolality were taken from ABG values which may be slightly different from serum values.

1. Kofke WA, Stiefel M. Monitoring and intraoperative manage-ment of elevated intracranial pressure and decompressive cra-niectomy. AnesthesiolClin, 2007 Sep; 25(3):579-603.

2. Ziai WC, Toung TJ, Bharadwaj A. Hypertonic saline: First-line therapy for cerebral edema? J Neuro Sci 2007 Oct 15; 261(1-2):157-66.

3. De Vivo P, Del Gaudio A, Ciritella P et al. Hypertonic saline solution: a safe alternative to mannitol 18% in neurosurgery. Minerva Anesthesiol, 2001 Sep; 67(9): 603-11.

4. Bentsen G, Breivik H, Lundar T, Stubhaug A. Hypertonic saline (7.2%) in 6% hydroxyethyl starch reduces intracranial pressure and improves hemodynamics in a placebo-controlled study in-volving stable patients with subarachnoid haemorrhage. Crit Care Med 2006;34:2912-7.

5. Gemma M, Cozzi S, Tommasino C, Mungo M, CalviMR, Cipri-ani A, Garancini MP. 7.5 % hypertonic saline versus 20% man-nitol during elective neurosurgical supratentorial procedures J NeurosurgAnesthesiol, 1997 Oct; 9(4):329-34.

6. Hiroto K, Hara T, Hosoi S, Sasaki Y, Hara Y, Adachi T: Two cas-es of hyperkalemia after administration of hypertonic mannitol during craniotomy. J Anaesth 2005; 19(1): 75-7.

7. Manninen PH, Lam AM, Gelb AW, Brown SC. The effect of high dose mannitol on serum and urine electrolytes and osmo-lality in neurosurgical patients. Can J Anaesth 1987 Sep; 34(5): 442-6.

8. Toung TJ, Hurn PD, Traystman RJ, Bhardwaj A. Global brain

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water increases after experimental focal cerebral ischemia: ef-fect of hypertonic saline. Crit Care Med 2002 Mar; 30(3):644-9.

9. Wu CT, Chen LC, Kuo CP, Ju DT, Borel CO, Cherng CH, Wong CS. A Comparison of 3% Hypertonic saline and Mannitol for Brain Relaxation During Elective Supratentori-al Brain Tumor surgery, Anesthesia Analgesia March 2010 Mar1;110(3):903-7.

10. Rozet I, Tontisirin N, Muangman S, Vavilala MS, Souter MJ, Lee LA, Kincaid S, Britt GW, Lam AM. Effect of equiosmolar solutions of mannitol versus hypertonic saline on intraopera-tive brain relaxation and electrolyte balance. Anaesthesiolo-gy. 2007 Nov; 107(5):697-704.

11. Dostal P, Dostalova V, Schereiberova J, Tyll T, Habalova J, Cerny V, Rehak S, Cesak T. A Comparison of Equivolume, Equiosmolar Solutions of Hypertonic Saline and Mannitol for Brain relaxation in Patients Undergoing Elective Intracranial Tumor Surgery: A Randomized Clinical Trial. J NeurosurgAn-esthesiol. 2015 Jan; 27(1): 51-6.

12. Quentin C, Charbonneau S, Moumdjian R, Lallo A, Bouthilier A, Fourneir-Gosselin MP, Bojanowski M, Ruel M, Sylvestre MP, and Girard F. A Comparison of Two Doses of Manni-tol on Brain Relaxation during Supratentorial Brain Tumour Craniotomy: A Randomized Trial. Anesthesia Analgesia. April 2013; 116(4): 862-8.

13. Sorani MD, Morabito D, Rosenthal G, Giacomini KM, Manley GT. Characterizing the dose-response relationship between mannitol and intracranial pressure in traumatic brain injury patients using a high frequency physiological data collection system. J Neurotrauma 2008 Apr; 25(4):291-8.

14. Makoff DL, da Silva JA, Rosenbaum BJ, Levy SE, Maxwell MH: Hypertonic expansion: Acid-base and electrolyte changes. Am J Physiol 1970 Apr; 218(4):1201-7.

15. Moon PF, Kramer GC. Hypertonic saline-dextran resuscitation from hemorrhagic shock induces transient mixed acidosis. Crit Care Med 1995 Feb;23(2):323-31.

16. Bruegger D, Bauer A, Rehm M, Niklas M, Jacob M, Irlbeck M, Becker BF, Christ F. Effect of hypertonic saline dextran on ac-id-base balance in patients undergoing surgery of abdominal, aortic aneurysm. Crit Care Med 2005 Mar; 33(3):556-63.

17. Mortazavi MM, Romeo AK, Deep A, Griessenaur CJ, Shoja MM, Tubbs RS, Fisher W. Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis-A re-view. J Neurosurg 2012 Jan; 116(1):210-21.

18. Burl T, Robertson G. Pathophysiology of Water Metabolism. Philadelphia: Saunders, 2000. 84-88.

19. Schwarz S, Schwab S, Bertram M, Aschoff A, Hacke W. Effects of hypertonic saline hydroxyethyl starch solution and manni-tol in patients with increased intracranial pressure after stroke. Stroke. 1998;29:1550–5.

20. Vialet R, Albanese J, Thomachot L, Antonini F, Bourgouin A, Al-liez B, Martin C.Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory post traumatic in-tracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol. Crit Care Med. 2003;31:1683–7.

21. Francony G, Fauvage B, Falcon D, Canet C, Dilou H, Lavagne P, Jacquot C, Payen JF. Equimolar doses of mannitol and hyper-tonic saline in the treatment of increased intracranial pressure. Crit Care Med.2008;36:795–800.



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Amrita Journal of Medicine Vol.13, NO: 1Jan - Mar 2017, Page 1 - 44

Factors Determining Immediate Mortality In Hospitalised Patients Suffering Cardiopulmonary Arrest – Observations

From A Tertiary Care CenterBharath Prasad S, Ajith V, Arunkumar, K Krupanidhi, Nandu Mohan, Vishnu

Manohar, Naveen Mohan, Sreekrishnan T P, Gireesh Kumar K P

ABSTRACTEach year, cardiac arrest claims more than 3.7 million lives worldwide. Burden of cardiac arrests on developing countries are unknown due to limited data recorded and lack of major studies.

Objective: Evaluation of the significance of intra-arrest parameters in determining immediate mortality for hospitalized patients suffering cardio-pulmonary arrest.

Method of Study: Prospective cross-sectional study of adult patients undergoing active resuscitation following a cardiac arrest episode in our hospital was taken. Out of hospital arrests and arrests in individuals with age<18years was not taken into ac-count. Data was collected by ‘code blue’ teams and ICU duty doctors. Statistical analysis was done to estimate mortality and to identify pre-arrest factors of mortality.

Results: Of the total 140cases, there were 76 (54.28%) males and 64 (45.72%) females. Mean age was 57.6 ± 13.5 years; 52.14% were in < 60 years group while >60 years had 45.72%. ICU admissions were 41.43%, 15% were in ER and pro-cedure rooms, 20% in monitored rooms & rest in general ward beds. Analysis showed significant mortality in General wards & ICU. Common presenting rhythm in our study was asystole 42.86% followed by PEA 35%. Asystole rhythm had 71.7% mortality, while VT/VF had 100% survival. The mean resuscitation duration was 24.4 ± 13.5minutes and resuscitation for >20minutes was found to have 62.8% mortality. Our study had 47.86% arrests during day time shifts while night shifts had 52.14% arrests, 50.7% mortality present for cardiac arrests during night time.

Conclusion: Immediate mortality following cardiac arrest for hospitalized patients was 35%. The independent factors responsi-ble for immediate mortality were: Age >60years, Time of cardiac arrest and PEA as presenting rhythm.

Key Words: Cardiopulmonary arrest, Hospitalized patients, Mortality factors.

INTRODUCTION

Dept. of Emergency Medicine, AIMS, Amrita University, Kochi, India.

Cardiopulmonary resuscitation (CPR) is widely prac-ticed since the clinical use of closed chest massage was first reported in 19601. Each year, cardiac arrest claims more than 424,000 lives in the United States, 300,000 lives in Europe, and upwards of 3.7 million lives worldwide2. Geographically there is a great im-balance in the statistical figures available about the burden of cardiac arrest on a global scale; practically almost all published literature about this condition is from the developed world.

Studies from the 1990s have noted hospital CPR dis-charge rates ranging from 13 to 14%3. Studies of CPR among hospitalized patients revealed survival to dis-charge ranging from 6% in cancer patients in the USA to as high as 43% in monitored bed patients in Sweden4

Using data from 14, 720 in-hospital cardiac arrests in the national registry of cardiopulmonary resuscitation (NRCPR), Peberdy et al5. reported overall survival to hospital discharge rate of 17%. Recently Nadkarni et al6 analyzed years of NRCPR data and compared the survival outcomes in adults after cardiac arrest using survival to discharge ratio as primary outcome, they

found a survival rate of 18% for adults after pulseless cardiac arrests. Even though there are multiple stud-ies conducted about survival post-resuscitation, there are wide variations regarding the outcomes of those studies regarding role of advanced age, mechanically ventilated patients, and location of arrest in mortality7,8

Multiple reasons are given for these variations, differ-ences in inclusion/exclusion criteria, differences in the setting in which the CPR was performed & problems with definitions of common variables.

Even though outcomes after in-hospital & pre-hospi-tal cardiac arrest resuscitations have been studied well in developed countries, there is only limited data on the outcomes of in-hospital cardiac arrest from coun-tries like India. Differences in resources for utilization & prevalent disease pattern in developing countries are likely to have an impact on the eventual outcome of CPR.(10-12) Despite considerably difference in health care delivery pattern & diseases, Indian healthcare sys-tem currently rely on data that is overwhelmingly from developed nations. We aim to estimate the pre-arrest factors that account for significant immediate mortality following cardiac arrest in hospitalized patients.

ORGINAL ARTICLE

25


Table 1

< 60years

Frequencyn (%)

Mortalityn (%)

ARREST VARIABLES WITH FREQUENCIES & STATISTICAL ANALYSIS

11 (15.3)<0.001

38 (55.3)

76 (54.28) 27 (35.5)

64 (45.72) 22 (34.4)

12 (17.9)

37 (50.7)

Multivariate Analysis(OR, p-value)

<0.001

58 (41.43) 29 (50)

<0.001

Category

Day Time

Time of Arrest

Location of Arrest

Age

72 (51.42)

68 (48.57)

Gender

Male

Female

67 (47.86)

73 (52.14)

ICU

21 (15) 4 (19)

28 (20) 2 (7.1)

33 (23.57)

2 (7.1)

ER & Procedure Room

Monitored Beds

79 (56.43)

14 (42.4)

28 (20) 0.003

33 (23.57) 14 (42.4)

Time to Start CPR

< 1 minute

1-2 minutes

>2 minutes

60 (42.86) 43 (71.7)

7.88 (1.49 – 41.63)p - 0.015

Presenting Rhythm

Asystole

General Beds

33 (41.8)

> 60years

15.13 (2.12 – 108.27)p - 0.007

0.515

Night Time

8.51 (1.49 – 48.69)p - 0.016

PEA

VT

VF

49 (35)

21 (15)

10 (7.14)

6 (12.2)

0 (0)

0 (0)

<0.001

Duration Of CPR

< 10minutes

10-20 minutes

> 20minutes

37 (26.42)

25 (17.86)

78 (55.72)

0 (0)

0 (0)

49 (62.8)

P-value

Factors Determining Immediate Mortality In Hospitalized Patients Suffering Cardiopulmonary Arrest – Observations From A Tertiary Care Center

26


To identify significant intra-arrest risk factors causing immediate mortality in hospitalized patients suffering cardio-pulmonary arrest.

OBJECTIVES

METHOD OF STUDY A prospective cross-sectional study was conducted in our tertiary care hospital which has more than 1000 total beds & 200 acute care beds. The hospital had a ‘Code Blue Team’ for managing cardiac arrests happen-ing outside of acute care settings & procedural rooms. Cardiac arrest was defined as per AHA guidelines; by the absence of a detectable pulse (pulselessness) in an unresponsive patient. Any of such cases was informed to ‘Code Blue Team’ which consists of Anaesthesiolo-gists and Emergency medicine doctors with staff nurs-es, all of them well trained in 2010 ACLS guidelines by AHA. Inclusion criteria for the study were hospitalized patients who underwent active resuscitation efforts fol-lowing cardiac arrest; in case of patients having multi-ple cardiac arrests during current admission, only the

RESULTS

Of the 140 individuals in our study group, there were 76 (54.28%) males and 64 (45.72%) females. Youngest patient was 31years old while the oldest was 89years. The mean age of the group was found to be 57.6 ± 13.5 years. For the statistical analysis purposes they were dived into two groups of age : < 60years & > 60years. 73 (52.14%) people in < 60years group while the other had 64 (45.72%). Gender was not found to be statistically significant for mortality [Table 1]. On calculation, Mean age for mortality was 62.8 ± 5.23years and for survival was 54.76 ± 15.66years. Mann-Whitney U Test was applied to calculate P-val-ue. Mean age was found significant for immediate mortality. [Table 2] Of the total 140 cases, 41.43% were admitted in ICUs, 15% were in ER and procedure rooms, 20% in monitored rooms & rest in general ward beds [Table 1][Graph 1]. Association showed significant factor for

mortality in General wards & ICU. We looked for variations in mortality for cardiac arrests occurring during day & night duty times. And in our study 47.86% arrests occurred during day time while night shifts had 52.14% arrests. On association, 50.7% mortality was estimated for cardiac arrests dur-ing night time and time of arrest was found to be a significant independent factor for immediate mortality. Time to start resuscitation codes in each of the above admission areas where: < 1minute in ICUs, ER & pro-cedure rooms 56.43%, 1-2minutes in monitored single beds 20% & 2-3 minutes in general beds 23.57 [Table 1]. Association showed it as a significant factor for im-mediate mortality. The most common presenting rhythm during cardi-ac arrest was asystole 42.86% followed by PEA 35%; while shockable rhythms VT 15% & VF 7.14% were not seen as frequently as former [Table 1]. Asystole rhythm had 71.7% mortality, while VT & VF had 100%

first episode was taken into study. The exclusion cri-teria were: age less than 18yrs, out of hospital cardiac arrests or en-route cardiac arrests treated by Emergen-cy Medical Services (EMS), patients opted for Do Not Resuscitate order (DNR), patients or by-standers who refused to give consent. Initial assessment was done at the site of arrest, where the team recorded time of arrest, time to start code, pre-senting rhythm, duration of code. Immediate survival was defined as the restoration of spontaneous circula-tion (ROSC) for more than 20 min. Percentage of mor-tality in cardiac arrest cases was computed and tabu-lated under Immediate Mortality, Mortality within 24 hours and Mortality before discharge. To compare two categorical variables, Chi square test was used to find statistical significance and if any expected cells has<5 frequencies then Fisher’s Exact Test was applied. For data that follows heterogeneity Mann-Whitney U Test was applied to calculate P-value. P-value of<0.05 was considered to be statistically significant. Statistical anal-ysis was done using IBM SPSS Statistics 20.

Mean age & immediate outcome

N Meanoutcome

49

Std. Deviation P-valuecategory

AgeMortality 62.80

Table 2 : Mean hospital stay was higher for the control group.

Survival 91 15.661<0.001

54.765.236

Mean age & immediate outcome

N Meanoutcome

49

Std. Deviation P-valuecategory

AgeMortality 35.3061

Table 3 : Comparison between

Survival 91 12.87061<0.001

18.51655.89917

27


20 %13 and it has remained stable in the last 25 years. Most studies regarding cardiac arrest outcome was focussed only on intra-arrest variables; studies that have considered pre-arrest varia-bles have generally suffered low accu-racy and/or incomplete validation.

Age was a statistically significant predictor for immediate mortality in our study. Age group >60 years had 55.9% immediate mortality in com-parison to Age <60years which had 15.3%, these are similar to those de-scribed by Schneider AP II et al14. Age has been described as a significant fac-tor for mortality by many studies15 but contradicted in some newer studies16.

0 5 10 15 20 25 30 35 40 45 50

ICU

ER & Operation Room

Monitored beds

General beds21.21

36.3614

25

7.14

4.7642.865

19.04

10.3427.59

50

25

Immediate Mortality %

Mortality Within 24 hours %

Mortality Before discharge %

Graph 1: Location of Arrest & Prevalance of Mortality

Percentage of Mortality

0

1020

3040506070

35.14

64

36

62.82

37.18

<10 minutes >20 minutes10-20 minutes

Immediate Mortality %

Mortality Within 24 hours %

Mortality Before discharge %

Graph 2: Duration of Resuscitation & Prevalance of Mortality

DISCUSSION The incidence of IHCA is not just a measure of the burden of illness; it is also a measure of the institution-al response for prevention of IHCA. IHCA outcomes serve as a more refined measure of institutional read-iness and effectiveness in the treatment of IHCA. In case of IHCAs, despite the availability of qualified life support immediately, the outcome of IHCA remains poor. Survival to discharge after IHCA rarely exceeds

survival. Presenting rhythm was a significant factor for immediate mortality while PEA as a presenting rhythm was an independent factor for mortality. The mean resuscitation duration in our study was 24.4 ± 13.5minutes, while for statistical purposes they were grouped into three categories. [Table 1][Graph 2]Resuscitation for >20minutes was found to have 62.8% mortality & thus duration of resuscitation was

found to be a significant factor for immediate mortal-ity. For mortality mean duration of resuscitation was found to be 35.3 ± 5.9minutes, while for survival it was 18.5 ± 12.9minutes [Table 3]. Mean resuscitation duration is a statistically significant predictor for imme-diate mortality. Of the total 140 subjects, 49 (35%) didn’t survive resuscitation and had immediate mortality.

Reason for the contradiction can be due to the increase in Do Not Resuscitate orders for those with poor prog-nosis and elderly patients. In our study 76 males & 64 females were there with respective mortality of 35.5% & 34.4%. We didn’t find gender as a significant factor for immediate outcome5,6.

Data showed increased mortality for patients ad-mitted in non-monitored general wards (42.4%) than monitored wards (7.1%). Our immediate mortality for


28


CONCLUSION Immediate mortality following cardiac arrest for hos-pitalized patients was 35%. The independent factors responsible for immediate mortality were identified by multivariate analysis [Table 10]; the most significant factors according to Odds Ratio were: Age >60years, Time of cardiac arrest and PEA as presenting rhythm

Outcome of cardiac resuscitation in this single-ter-tiary care hospital from a developing country showed a mortality rate comparable to the developed countries.

Our study resuscitation duration more than 20 min-utes showed 62.8% immediate mortality and was a sig-nificant factor for immediate outcome. Our final mod-el on multivariate analysis failed to show resuscitation duration as an independent factor for mortality. This finding is supported by many other studies also, but a few of them reported the variable to be an independ-ent predictor of outcome as well7,27-29. A shorter resus-citation duration was associated with a higher rate of survival to discharge: this point makes intuitive sense. Schultz et al27 found a direct relationship between du-ration of resuscitation and subsequent mortality. Coo- per and Cade29 reported that the most important factor affecting the survival rate was a resuscitation duration less than 20 minutes. Our data showed a mean dura-tion of resuscitation for mortality as 35.3 ± 5.9minutes and for survival it was 18.5 ± 12.9minutes.

resuscitations done in Emergency department & pro-cedure rooms was only 19%; this contradicts with the values reported in other studies17,18. The reason those studies reported a huge mortality rate close to 80% may be due to the high incidences of OHCAs which were treated on the way to hospital. While some of the newer studies conducted shows similar picture to ours19. Our ICU mortality was 50%, presumably due to greater severity of illness in the people admitted there and also may have more multiple co-existing condi-tions than those admitted in other parts of the hospi-tal. Location of arrest was significant factor on univar-iate analysis but when other factors were controlled it failed to show as an independent factor for mortality on multivariate analysis.

Mortality was high (50.7%) for cardiac arrests happen-ing during night shifts than during day time (17.9%). Other studies also have shown similar effect on the outcome of cardiac arrest with better survival among patients who experienced cardiac arrest during morn-ing or evening shifts20-23.Rakićetal21 & Brindley et al23. suggested that it could be because of the increase in the number of un-witnessed arrests in the night which would also explain the increased incidence of cardiac arrests at night shift we found in our study. Cardiac arrests during night were an independent predictor of mortality as well (OR 8.51 [1.49-48.69]).

In our study 42.4% mortality was seen in patients for whom CPR was started >2minutes after recognised cardiac arrest. This difference in time to initiate resus-citation is due to: (a) Failure to identify cardiac arrest following distress call and (b) Arrival of code team to the place of distress to start resuscitation. Kinney et al24. reported that survival to discharge is improved if a cardiac arrest team arrives in less than 3 minutes. Although faster arrival times are critical in survival, the expertise, skills & ability to work as an efficient team are of utmost importance for the diverse scenarios as-sociated with cardiac arrests. Even though it was sig-nificant for immediate outcome, when other relevant variables were controlled for multivariate analysis, it was no longer associated with outcome.

It is observed that VF/VT as the initial rhythm has a better outcome than PEA/Asystole rhythms; this has been reported in numerous studies7,25-27. Nadkarni et al7 reported 23% prevalence of ventricular fibrillation or ventricular tachycardia, and asystole and PEA prev-alence of 35% and 32%, respectively and in our study we had VT/VF of 22.14%, PEA of 35% & Asystole of 42.86% prevalence in adults. Findings in our study also concur to above reports; 71.7% immediate mor-tality was seen in patients having asystole. On multi-variate analysis, rhythm PEA showed significance for mortality (OR 7.88 [1.49-41.63]).

LIMITATIONS There were a few limitations to our study which pre-vent us from extrapolating the results to general popu-lation. Sample population in our study was regional in nature and so results may not reflect to the whole pop-ulation. A prolonged study period could have helped to grasp the trends in the topic and improvement due to interventions. All pre-arrest parameters could not be assessed due to technical reasons and loss of data. Lack of proper post-resuscitation briefings or documen-tation protocols caused some loss of sample subjects.

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cardiac massage. JAMA 1960; 173: 1064-7.

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3. Ebell MH, Becker LA, Barry HC, et al. Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis. J Gen Intern Med 1998; 13: 805-16.

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5. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary re-suscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resusci-tation. Resuscitation 2003; 58: 297-308.

6. Nadkarni VM, Larkin GL, Peberdy MA, et al. First document-ed rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 2006; 295: 50-7.

7. Rosendberg M, Wang C, Hoffman-Wilde S. Results of cardio-pulmonary resuscitation. Arch Intern Med 1993;153:1370-5.

8. Tresch DD, Heudebert G, Kutty K. Cardiopulmonary resuscita-tion in elderly patients hospitalized in the 1990s: a favorable outcome. J Am Geriatr Soc 1994;42:137-41.

9. Herlitz J, Bang A, Aune S etal (2001) Characteristics and out-come among patients suffering in-hospital cardiac arrest in mon-itored and non-monitored areas. Resuscitation 48(2):125–35

10. Hajbaghery MA, Mousavi G, Akbari H (2005) Factors influenc-ing survival after in-hospital cardiopulmonary resuscitation. Resuscitation 66(3):317–21

11. Pembeci K, Yildrim A, Turan E et al (2006) Assessment of the success of cardiopulmonary resuscitation attempts performed in a Turkish university hospital. Resuscitation 68(2):221–9

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13. Brindley PG, Markland DM,Mayers I, Kutsogiannis DJ. Predic-tors of survival following in-hospital adult cardiopulmonary resuscitation. Cmaj 2002;167:343–8.

14. Schneider AP II, Nelson DJ, Brown DD. In-hospital cardiopul-monary resuscitation: a 30-year review. J Am Board Fam Pract. 1993;6:91-101

15. Burns R, Graney MJ, Nichols LO. Prediction of in-hos-pital cardiopulmonary arrest outcome. Arch Intern Med. 1989;149:1318-21.

16. Ravakhah K, Khalafi K, Bathory T, Wang HC. Advanced cardiac life support events in a community hospital and their outcome: evaluation of actual arrests. Resuscitation. 1998;36:95-9.

17. Gray WA, Capone RJ, Most AS. Unsuccessful emergency med-ical resuscitation: are continued efforts in emergency depart-ment justified? N Engl J Med. 1991;325:1393-8.

18. Ozcan V, Demircan C, Engindenizi Z, Turanoglu G, Ozdemir F, Ocak O, Cebicci H, Akgoz S. Analysis of the outcomes of cardiopulmonary resuscitation in an emergency department. Acta Cardiol. 2005 Dec;60(6):581-7.

19. Dumot JA, Burval DJ, Sprung J, Waters JH, Mraovic B, Karafa MT, Mascha J, Bourke DL. Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of

“limited” resuscitations. Arch Intern Med. 2001;161:1751–8.

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21. RakićD,RumboldtZ,CarevićVetal(2005)In-hospitalcardiacarrest and resuscitation outcomes: rationale for sudden cardiac death approach. Croat Med J 46(6):907–12.

22. Marcu CB, Juhasz D, Donohue TJ (2005) Circadian variation and outcome of in-hospital cardiopulmonary resuscitation. Conn Med 59(7):389–93

23. Brindley PG, Markland DM, Mayers I et al (2002) Predictors of survival following in-hospital adult cardiopulmonary resuscita-tion. CMAJ 167(4):343–8

24. Kinney KG, Boyd SYN, Simpson DE. Guidelines for appropri-ate in-hospital emergency team time management: the Brooke Army Medical Center approach. Resuscitation. 2004;60:33-38.

25. Neumar RW, Nolan JP, Adrie C, Aibiki M, Berg RA, Bottiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT Jr., Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Vanden Hoek T. Post-car-diac arrest syndrome: epidemiology, pathophysiology, treat-ment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Re-suscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Re-suscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovas-cular Surgery and Anesthesia; the Council on Cardiopulmo-nary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation. 2008;118: 2452–83.

26. Merchant RM, Yang L, Becker LB, Berg RA, Nadkarni V, Nich-ol G, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med 2011;39:2401-6.

27. Schultz SC, Cullinane DC, Pasquale MD, Magnant C, Evans SRT. Predicting in-hospital mortality during cardiopulmonary resuscitation. Resuscitation. 1996;33:13-7.

28. Varon J, Fromm RE Jr. In-hospital resuscitation among the el-derly: substantial survival to hospital discharge. Am J Emerg Med. 1996;14: 130-2.

29. Cooper S, Cade J. Predicting survival, in-hospital cardiac ar-rests: resuscitation survival variables and training effectiveness. Resuscitation. 1997;35:17-22.


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Faizal Ali A A, Mohammed Ashraf

ABSTRACTBackground: High energy bicondylar tibial fractures are conventionally being treated by open reduction and internal fixation (ORIF). There are very few studies comparing the efficacy of ORIF with the relatively new treatment option using hybrid fixator.

Aim: To compare the treatment outcomes of ORIF and hybrid fixator in Schatzker types 5 and 6 of proximal tibial fractures.

Methods: A prospective study was conducted in 20 patients each from both groups. The patients were followed up at 3 months, 6 months and one year postoperatively. Assessment was done using Rasmussen’s WOMAC scores.

Results: The hybrid fixator group had lesser blood loss and hospitalisation compared to the ORIF group which was statistically significant.

Conclusions: Both ORIF and hybrid circular fixator were comparable in terms of functional and anatomical outcomes. The circular fixator seems to be marginally more efficacious in fractures with extensive soft tissue injury.

INTRODUCTION Tibial condylar fractures are especially challenging to the orthopaedic surgeons because of their number, variety, complexity, different concepts of management and associated injuries. As proximal tibia gives attach-ment to the various elements of knee stabilizers, alter-ation of anatomy caused by injury results in functional impairment1. Bicondylar fractures are less common among the tibial fractures and are more difficult to treat2. The com-plex fracture and the soft tissue injury result in greater complication rates after open reduction and internal fixation (ORIF). This used to be popular in earlier days, but now more and more reports of successful treatment with external fixation are coming out3,4. Stability is more with internal fixation but there is always the risk of wound breakdown with extensive soft tissue injury. As the detrimental effects of excessive dissection of the tenuous soft-tissue envelope and devascularisation of the osseous fragments became apparent, a number of alternative methods of treatment have been popu-larized including percutaneous reduction and circular frame stabilization, minimally invasive techniques and implants, and temporary external fixation followed by delayed definitive surgery5,6,7. The advantage of cir-cular frame fixation includes minimal soft tissue dis-ruption. Early reports by Stainer et.al reported good or excellent results in his cases 8. The main compli-cation associated with hybrid fixator seems to be pin tract infection. However, there remains doubt as to the articular reduction with circular fixation and a direct comparison with standard reduction techniques has to be performed9, 10, 11. Honkonen described poor results when associat-ed with a varus misalignment of greater than 5 de-grees, a valgus tilt of more than 10 degrees, articular

Dept. of Orthopaedics, , T D Medical College, Alleppey, Kerala.

ORGINAL ARTICLE

displacement in excess of 4 mm and more than 10 mm of condylar widening12. So, the indications for hybrid external fixation would be Schatzker V and VI tibial plateau fractures, significant metaphseal comminu-tion with or without diaphyseal extension, soft tissue issues of compartment syndrome, open fractures etc. The disadvantages include the need for constant pin care site and the risk of septic arthritis13,14. This allows early joint mobilization, cartilage regeneration and joint remodelling, which decreases the risk of joint stiffness3. The commercially available fixators are ex-pensive and so we have utilized a modified version by using an Ilizarov ring with a monolateral external fixator system. There are only few direct comparisons of the two op-erative approaches. Taking all these facts into consid-eration, a study was carried out to compare the func-tional outcomes between open reduction with internal fixation and hybrid external fixator in terms of mode of injury, fracture pattern, complications encountered and associated injuries.

ObjectivesPrimary: To compare the Rasmussen’s score of patients presenting with bicondylar tibial fractures at three months, six months and one year after hybrid exter-nal fixation with that of open reduction and internal fixation.Secondary: To compare the functional outcome of open reduction with internal fixation and hybrid exter-nal fixator in tibial bicondylar fractures.

Materials and methodsStudy design: A prospective, open labelled parallel group study in which standard open reduction and in-ternal fixation was compared with percutaneous and/or limited open fixation and application of a hybrid fixator for displaced bicondylar tibial plateau fractures (Schatzker types V and VI)(10, 15). Forty patients who

31


satisfied the inclusion criteria during the study period from November 2012- November 2013 were included in the study.

Inclusion criteria The presence of a bicondylar tibial plateau fracture Schatzker type V or VI planned for surgery Patient’s age over 18 years and the ability to walk with-out assistance before injury

Exclusion criteria Polytrauma patients with tibial plateau fractures re-quiring prolonged ICU care.

Data collection All cases of tibial plateau fractures presenting to the casualty who satisfied the inclusion criteria were in-cluded in the study. Appropriate management of the associated injuries was done by the concerned speci-alities. Once the patient was stabilised, relevant X-rays were taken (Fig-1, 2). CT scan was taken for all tibial plateau fractures16,17. Patients with compartment syn-drome diagnosed clinically underwent emergency fasciotomy followed by the definitive surgery. The de-cision on the surgical procedure was made on an al-ternating basis. All the patients who underwent either ORIF or hybrid fixation were observed for the outcome at three, six and twelve months. Patients who under-went ORIF did so with a standard AO buttress plate (Fig- 3). Following internal fixation, patients were mo-bilised (non-weight bearing) with crutches for 6 weeks. Partial weight bearing was commenced, progressing to full weight bearing by 3 months. The hybrid fixation was done under spinal or gener-al anaesthesia. The fragments were aligned by simple manual traction. The condylar fragments were com-pressed with a large tenaculum forceps or a pelvic reduction forceps and fixed with 6.5 mm cannulated screws or the long 3.5-mm screws from the pelvic sets depending on the size of the fragment. Failure to reduce the articular fragments or the presence of arti-

cular depression often necessitated an open reduction through a small antero-medial or an antero-lateral ap-proach to elevate the articular surface. Two 1.8-mm wires were introduced in the safe zone, 15 mm from the joint line. The minimal angle in between the two oblique wires was 60 degrees respecting the anatom-ic constraints. The ring was attached and the wires were tensioned. The meta diaphyseal alignment was corrected, and two Schantz pins were inserted at the diaphysis. The Schantz pins were connected to the ex-ternal fixator bar, which was then coupled to the ring using the external fixator clamp (Fig- 4, 5). The align-ment was again checked under fluoroscopy in both the standard anteroposterior and the lateral planes. All patients were instructed on fixator care and taught to do daily pin sites cleansing with Povidone Iodine solution. They were started on passive range of motion exercise on the third post operative day and active mo-tion by first week. Non weight bearing was initiated at 6–8 weeks, followed by partial weight bearing ambu-lation depending on the amount of callus formation. Full weight bearing was given after removal of the fix-ator. Serial radiographs in AP and lateral planes were Fig 1: Schatzker type V fracture

Fig 2: Schatzker type VI

Fig 3: Open reduction and internal fixation with plate


32


performed at 3 months, 6 months, and 1 year post op-eratively.

Follow up Pre-operative, post-operative and most recent radi-ographs for each patient were analysed to assess the anatomical outcome using Rasmussen’s system of grading(Fig- 6). This rating system evaluated joint de-pression, condylar widening and varus or valgus angu-lation. Postoperative reductions with less than 3mm of residual joint depression on anteroposterior or lateral views were considered acceptable. Postoperative re-ductions with more than 5mm of residual joint depres-sion on anteroposterior or lateral views were rated as poor.

During follow-up, the patients were assessed in terms of range of motion, fracture union clinically and radio-logically, any hardware-related complications like wire breakage, clamp failures, surgical site infections, osteo-myelitis, and complications related to the surgery like nerve injury from inadvertent pin placement (Figs- 7, 8, 9, 10, 11, 12). Follow-up radiographs were used to detect post-traumatic osteoarthritis. Osteoarthritis was recorded if there was progressive obliteration of joint space, osteophyte formation and subchondral sclerosis at six months or at one year. Functional and anatom-ical scores according to Rassmussen and the WOMAC (Western Ontario and McMaster Universities) Index of Osteoarthritis were assessed at 3 months, 6 months and 1 year 9, 18, 19, 20, 21 (Tables- 1, 2, 3).

Fig 4: Hybrid fixator

Fig 5: Same fracture after hybrid fixator

Fig 6: Postoperative X- ray at one year after ORIF

Fig 7: Extension of the knee joint at one year post ORIF

Fig 8: Flexion post ORIF at one year

Fig 9: Status post hybrid fixator, follow- up X- Ray at 3 months.

33


Statistical analysis Data was analyzed using computer software, Statis-tical Package for Social Sciences (SPSS) version 16 for Windows. To elucidate the associations and compar-isons between different parameters, Chi square (2)test, Student’s t test and Analysis of variance (One Way ANOVA) were used. A two-tailed probability of value, < 0.05 was considered significant.

Outcome of the study Outcome variables included the clinical complica-tions, functional analysis using Rasmussen’s score and The WOMAC Index of Osteoarthritis9, 18, 19, 20, 21.

Ethical issues Though the proposed study included an invasive procedure, no major ethical issues were expected. The study was cleared by Ethics committee and was intended for publication later on, maintaining the pri-vacy and confidentiality of the study participants.

Conflict of interests if any There was no additional burden imposed on the pa-tient through this study. There was no financial support for the study from any external agencies. There was no conflict of interests in this study.

Observation and Results All the patients in the ORIF group had a closed inju-ry compared to 90% of patients from hybrid fixation group (Table- 4). 5% from ORIF group and 15% from hybrid fixator group had soft tissue injury. Comminut-ed fracture was seen in 85% of ORIF group and 95% of hybrid fixator group. Both groups had displacement in X- Rays in all cases. In ORIF group, there was ex-tension into the shaft in 50% of cases and in hybrid fixator group extension into the shaft was present in 65% of cases. While all patients in the ORIF group had concomitant fibular fracture, only 85% from the hybrid fixator group had fibular fracture. 50% from the ORIF group had type 5 and the rest 50% had a type 6 bicondylar tibial fracture. In the hybrid fixator group it was 30% and 70% respectively. Both group had equal incidence of postoperative complications in the form of infection which was not statistically significant. The mean duration of hospital stay and the average blood loss were significantly less in the hybrid fixator group (P value less than 0.001) (Table- 5). Duration of hospital stay in days was found to be extremely high for ORIF group nearing two weeks (13.5 days) where as in Hybrid fixator group, it was only one week (6.75 days). Similarly, average blood loss was high with 498.5ml in ORIF group against 222 ml in hybrid group. At 3 months of follow up, the WOMAC score, which was measured in terms of pain, stiffness, and physical function, showed a mean score of 55.5 against a max-imum score of 68. The mean Rasmussen anatomical score was 17.1 for the hybrid group. The mean de-pression score was 5.5. Condylar widening was 5.8 mm which fall between the good and excellent range.

Fig10: Status post hybrid fixator(R) leg on follow up. Standing posture at 3 months

Fig 11: Status post hybrid fixator– (R) leg lying down position at 3 months

Fig 12: Status post hybrid fixator – limb extension at 3 months


34


A. Depression Not Present < 5mm 6 to 10mm > 10 mm

B. Condylar widening Not Present < 5mm 6 to 10mm > 10 mm

C. Angulation (valgus/varus)

Not Present < 10 degrees 10 to 20 degrees > 20 degrees

Sum (minimum)

Points

6

Excellent Good Fair poor

5

420

6420

4 2 0

4 2

6

6420

6

6

18

4 2 0

0

012 6

Table 3: Rasmussen’s anatomical grading

4

A. Subjective Complaints a. Pain No Pain Occasional ache, Bad weather pain Stabbing pain in certain position

Afternoon pain, Intense, Constant pain around the knee after activity

Night pain at rest

b. Walking Capacity Normal walking capacity(In relation to age)Walking outdoors at least one hour Short walks outdoors > 15 minutesWalking indoors only Wheel chair / Bedridden

Points

Acceptable Percentage

6

excellent Good Fair poor

B. Clinical Signs a.Extension Normal Lack of extension (0 to 10 degrees) Lack of extension > 10 degrees

b. Total range of motionAt least 140At least 120At least 90At least 60At least 300

c. Stability Normal stability in extension and 20 degrees of flexion

Abnormal Instability 20 degrees of flexion instability in extension< 10 degreesinstability in extension >10 degrees

Sum (minimum)

54

20

64210

4 2 05

4 2 16

4 2 26

4 2 15

4 2 25

20 10 627

6

5

42

0

6

421

6

5

2

Table 2: Rasmussen’s functional grading

35


ORIF% Hybrid%

100Closed injury

Soft tissue injury

Comminuted fracture

Fracture extension into shaftFracture fibula

Schatzker Type 5

Schatzker Type 6

Post op complications

5

85

50

100

50

50

10

90

15

95

65

85

30

70

10

Table 4: Comparison between the groups in terms of fracture, soft tissue injury, concomitant fracture etc.

Mean + SDGroup

14.633

13.50 4.15ORIF

498.506.75

6.541 < 0.001

p valuet testParameters

Duration of Hospital Stay (Days)

Average Blood Loss (ml)

ORIFHybrid Fixator

Hybrid Fixator 222.00

2.0280.6125.36

< 0.001

Table 5: Note the lesser blood loss and decreased hospitalisation for the hybrid fixator group

3 months 6 months One yearScore

Rasmussen’s functional score

19.75

17.3

44.55

22.5522.4

16.7

44.3

16.7

43.8

Rasmussen’s anatomical score

WOMAC score

Table 6: Functional and anatomical scores of ORIF during post op

3 months 6 months One yearScore

Rasmussen’s functional score

19

17.1

44.05

22.2522.15

16.25

44.05

16.25

43.6

Rasmussen’s anatomical score

WOMAC score

Table 7: Showing the various scores of hybrid fixator at 3, 6 and 12 months post op


DISCUSSION High energy trauma is considered as a major cause of poor results in the treatment of tibial plateau fractures. Mahadeva et al, comparing external to internal fixation, concluded that hybrid external fixation possesses theoretical advantages in terms of the soft tissues protection; however the benefit over internal fixation is modest as far as ac-curacy of reduction is concerned22. The evidence of osteoarthritis in the form of progressive obliteration of joint space, osteophyte formation and subchondral sclerosis has been recorded in stud-ies of longer duration 2, 5. In a study by Chan et.al., 26% from the hybrid group and 29% from the ORIF group developed radiological evidence of osteoarthritis2.Our study did not show any radiological evidence after twelve months and the patients need further follow up for this. Postoperative infection was seen in 10% of both groups in our study. Pin

The angulation was 5.8 which was good to excellent. Patients had good fracture reduction at the end of three

months (Tables- 6, 7). The mean pain score was 3.8 in the hybrid fixator group at the end of three months. The mean extension was 3.8 in the fixator group. The mean range of move-ment was 3.8. The mean stability was 5.8. The mean walking capacity was 1.85. The Rasmussen functional grading was 19 which was graded as good and accept-able. So, at three months, the quality of fracture reduc-tion was good (Fig- 13). At six months, the mean WOMAC score was 44.05 in the hybrid fixator group. The mean Rasmussen’s anatomical score was 16.25. The mean Rasmussen’s functional score was 22.15. The various parameters showed a good anatomical reduction and functional improvement (Fig- 14) (Table- 6, 7). At one year postoperative period also, the WOMAC score and Rasmussen’s scores were similar (Fig- 15). There was no radiological evidence of osteoarthritis during the study period.

36


tract infection was the most common complication. In Chan’s study, infection was more common in the hy-brid group (26%) than in the ORIF group (19%). Our infection rate is comparable to the study by Babis et al23. Duration of hospital stay in days was found to be significantly prolonged for ORIF group and so was the average blood loss. Our observations were sim-ilar to other studies conducted by Chan, Hisham etc2, 3, 6. In the postoperative period, there was no statistically significant difference between WOMAC score and Rasmussen’s scores24 (Tables- 6, 7). There was no radiological evidence of osteoarthritis during

PainRasmussen functional Grading

Depression

Condylar widening

Angulasion valgus/ varus Rasmussen Anatomical Score

WOMAC:Pain

WOMAC: StiffnessWOMAC: Physical Function

0 1 2 3 4 5

ORIFHybirs Fixator

Pain

WOMAC physical function

Angulasion

Depression

StabilityExtension

Condylar wedening

0 5 15 25 40 45

ORIFHybirs Fixator

10 20 30 35

fig 14 : WOMAC and Rasmus-sen’s scores at six months postop

WOMAC Pain

WOMAC physical function

Angulasion

Depression

StabilityPain

0 5 15 25

ORIFHybirs Fixator

10 20 30

fig 15: Scores at one year postop-erative period

fig 13: Various scores at 3 months post op

the study period. In Rasmussen’s anatomical score though, there were significant changes in terms of depression, angulation and condylar widening at six months (Fig- 13, 14, 15). In the first year significant changes continued to be seen in terms of depression and angular variation but there was no condylar widening. Overall, there was good anatomical re-duction and functional improvement in both groups (Fig- 16, 17, 18). One point to be noticed here was the comparable results despite the hybrid fixator having a worse clinical scenario with more number of open injuries, soft tissue injury and complicated fractures.

37


LIMITATIONS The study period was not sufficient to know the long term results. The main drawback of the present study was the non-randomised design, and the rela-tively small number of cases. The author acknowledg-es that a longer follow-up period would be preferred to further detect the development of osteoarthritis. A prospective study of a modern fine-wire external fixa-tor and a minimally invasive plating system would also be a useful addition to the literature.

CONCLUSIONSMinimally invasive reduction of fracture followed by hybrid fixator has been suggested as an alternative to open reduction and internal fixation in Schatzker type V and VI proximal tibial fractures with the aim to reduce surgical morbidity. In our study, both tech-niques- ORIF and hybrid fixator provided a reasonable quality of fracture reduction. Closed reduction and ap-plication of a hybrid fixator resulted in shorter hospital stay and lesser blood loss than ORIF. Hybrid fixator resulted in fewer and less severe complications, fast-er return of function, and similar or superior clinical outcomes when compared with ORIF. These benefits were obtained without compromising on the quality of fracture reduction.We feel closed reduction with hybrid fixator is margin-ally superior to ORIF and should be considered in the treatment of difficult to treat proximal tibial fractures. A long term study is required to know the effects of both techniques on the development of osteoarthritis.

REFERENCES1. Type VI Plateau Frx - Wheeless’ Textbook of Orthopaedics

www.wheelessonline.com/ortho/type_vi_plateau_frx Mar 20, 2015.

2. Chan CC, Keating J. Comparison of Outcomes of Operatively Treated Bicondylar Tibial Plateau Fractures by External Fixation and Internal Fixation. UKMalaysian Orthopaedic Journal2012 Vol 6 No 1

3. Hisam MA, Nidzwani MM, Shaharuddin AR, Azmi B, Moha-mad H S. Modified hybrid fixator for high-energy Schatzker V and VI tibial plateau fractures. Strat Traum Limb Recon (2011) 6:21–26

4. Musahl V, et al. New trends and techniques in open reduction and internal fixation of fractures of tibial plateau. J Bone Joint Surg (Br) 2009; 91-B: 426-33.

5. Canadian Orthopaedic Trauma Society. Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Results of a multicenter, prospective, randomized clinical trial. J Bone Joint Surg Am. 2006; 88: 2613– 23.

6. Apley A.G: Fractures of the tibial plateau. Orthop. Clinic.North Am. 10:61, 1979.

7. Kumar A, Whittle AP. Treatment of complex (Schatzker Type

VI) fractures of the plateau with circular wire external fixation: retrospective case review. J Orthop Trauma. 2000; 14: 339-44.

8. Stainer DT, Schenk R, Staggers B, Aurori K, Aurori B, Behrens FF. Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study. J Orthop Trauma. 1994; 8:455-61.

9. Rasmussen DS. Tibial condylar fractures, Impairment of knee joint stability as an indication of surgical treatment. JBJS 1973; 55: 1331.

10. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture, the Toronto experience: 1968-1 975. CIin Orthop 1979; 138: 94-104.

11. Dias JJ, Strung AM, Finaly DB. Computerized Axial Tomogra-phy for tibial plateau fractures. J Bone Joint Surg 1987; 69(b): 84-8.

12. Honkonen SE. Indications for surgical treatment of condyle fractures. Clin Orthop 1994; 320: 199-205.

13. Dendrinos GK, Kontos S, Katsenis D, Dalas K. Treatment of high-energy tibial plateau fracture by the llizarov circular exter-nal tibial plateau fixator. JBJS 1996; 78(B): 710-7.

14. McLaurin TM (2005) Hybrid ring external fixation in the treat-ment of complex tibial plateau fractures. Tech Knee Surg. 4:226–36

15. Schatzker, J.: Tibial Plateau Fractures.In Browner,Jupiter, Levine, andTrafton(edts): Skeletal Trauma,p.1745.Philadel-phia, W.B. Saunders,1993.

16. Moore, T.M., and Harvey,J.P., Jr.: Roentgenographic measure-ment of Tibial-Plateau Depression due to Fracture. J Bone Joint Surg.56A:155,1974.

17. Dias, J.J., Stirling, A.M., Finlay,D.B., and Gregg, R.J.: Comput-erised Axial Tomography for Tibial Plateau Fractures. J. Bone Joint Surg., 69B: 84,1987.

18. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of womac: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988; 15:183340.

19. Dieppe PA. Recommended methodology for assessing the pro-gression of osteoarthritis of the hip and knee joints. Osteoar-thritis Cartilage 1995; 3: 737.

20. Bellamy N. Womac osteoarthritis index, http://www. auscan.org/womac/index.htm (21 Feb 2012, date last accessed).

21. Lequesne M. Indices of severity and disease activity for osteo-arthritis. Seminars in Arthritis and Rheumatism. 1991; 20 (sup-plement 2): 48-54.

22. Mahadeva D, Costa ML, Gafrey A: Open reduction and inter-nal fixation versus hybrid fixation for bicondylar/severe tibial plateau fractures: a systematic review of the literature. Arch Orthop Trauma Surg 2008, 128:1169-75

23. George C Babis, Dimitrios S Evangelopoulos, Panagiotis Kon-tovazenitis,et al. High energy tibial plateau fractures treated with hybrid external fixation. Journal of Orthopaedic Surgery and Research 2011, 6:35 http://www.josr-online.com/con-tent/6/1/35

24. C. Dall’Oca , T. Maluta, F. Lavini et al. Tibial plateau fractures: compared outcomes between ARIF and ORIF. Strategies in Trauma and Limb Reconstruction November 2012, Volume 7, p 163-75.


38


Myxoedema Madness Salini Nair, P C Kesavankutty Nayar, Chithra Venkateswaran

ABSTRACTMyxoedema madness is a very rare but established entity1. A psychotic patient having hypothyroid features should always be evaluated regarding the same1.

INTRODUCTION

Dept. of Psychiatry, AIMS, Amrita University, Kochi, India.

The prevalence of overt, or clinical, hypothyroidism is approximately 2 percent in women and less than 0.1 percent in men2. Subclinical hypothyroidism also pre-dominates in women, occurring in approximately 7.5 percent of women and 3 percent in men2. Hypothy-roidism is traditionally defined as deficient thyroidal production of thyroid hormone3.

Hypothyroidism ranges from very mild cases to very severe cases in which the danger exists to slide down into a life-threatening myxoedema coma3.

Hypothyroidism is thus a graded phenomenon, in which the first stage of subclinical hypothyroidism may progress via mild hypothyroidism towards overt hypothyroidism3.

The most common cause of hypothyroidism is de-struction of the thyroid gland by disease or as a con-sequence of vigorous ablative therapies to control thy-rotoxicosis3. Primary hypothyroidism may also result from inefficient hormone synthesis caused by inherited biosynthetic defects, a deficient supply of iodine, or inhibition of hormonogenesis by various drugs and chemicals3. In such instances, hypothyroidism is typ-ically associated with thyroid gland enlargement (goi-trous hypothyroidism)3.

Psychiatric symptoms include depressed mood, ap-athy, impaired memory and concentration2. Psychotic symptoms, including paranoid ideas, misidentifica-tion, visual and auditory hallucinations, and thought disorder, were originally thought to be common and described as myxedema madness, but likely occur in less than 5 percent of all patients with hypothyroidism and tend to emerge after the onset of physical symp-toms2. Myxoedema madness is an acute or chronic organic brain syndrome occurring in cases of severe hypothyroidism2. An array of psychotic symptoms, in-cluding delusions, visual and auditory hallucinations, paranoia, and thought disorders, have been reported

secondary to hypothyroidism4. Severe hypothyroid-ism, especially in the elderly, may present with confu-sion or even coma5.

Myxoedema coma is very rare: hypothermia is often present and the patient may have severe cardiac fail-ure, pericardial effusions, hypoventilation, hypogly-caemia and hyponatraemia5.

Severe hypothyroidism also leads to several cardio-vascular effects including bradycardia, decreased myo-cardial contractility, a low cardiac output and hypoten-sion5. All of these cardiac changes are reversible with thyroid hormone replacement5.

Respiratory depression can lead to hypoventilation and respiratory acidosis5. Ventilatory support is need-ed in some patients, and full recovery from respiratory depression can take up to three to six months following treatment5. The involvement of many organ systems necessitates managing myxoedema coma patients in an intensive care setting5.

The mortality rates may be as high as 25–60% even with best possible treatment7. Recent developments in brain imaging techniques provide novel insights in the relationship between hypothyroidism and mood dis-orders3.

CASE REPORT A 46 year old lady presented with symptoms of low mood, suspicious behaviour, reduced sleep and re-duced intake of food of 6 months duration. Patient also had gradual onset of difficulty in walking over the past 3 years, and as a result was unable to go for work, which then progressively increased over the past 6 months. Patient was brought to outpatient department of psychiatry and was admitted for further evalua-tion. Physical examination revealed non-pitting oede-ma, hoarseness of voice, puffiness of face, paucity of speech and psychomotor activity was decreased. Neu-rological examination revealed delayed deep tendon reflexes, power was reduced on b/l upper and lower limb. On mental status examination, patient had poor eye contact, low tone rough voice with a paucity of

CASE REPORT

39

Amrita Journal of MedicineMyxoedema Madness

DISCUSSION In our study, it was observed that the patient had in-itially presented with depressive symptomatology and paranoid delusions. In a study conducted by the Committee of the Clini-cal society of London, the study noted 109 patients of myxoedema and reported that “delusions and halluci-nations occur in nearly half of the cases mainly with advanced disease”1. In another study by Westphal et al, it was observed that patients with hypothyroidism presented with rare manifestations, and the initiation of thyroid hormone therapy resulted in significant improvement of the pre-senting symptoms8. Asher reiterated the relationship between psychosis and hypothyroidism in 1949 and added the terminol-ogy “myxoedema madness” to the literature6. Since that time, numerous case reports have continued to explore and report on the diverse physical and psy-chiatric consequences of hypothyroidism6. Although Asher’s study of 14 patients and resulting description of myxoedema madness has been often cited as a typ-ical example of psychosis secondary to hypothyroid-ism, subsequent case reports have revealed considera-ble variation in clinical psychotic presentations2. In a study by Ghasem et al, a patient presenting with behavioural changes and hypothyroidism was treated with a combination of antipsychotics and levothyox-ine2. They illustrated the importance of ascertaining the thyroid status in patients presenting with psychosis and behavioural changes and the need to consider hy-pothyroidism in the differential diagnosis of new onset psychosis2.

The range of physical and psychiatric presentations

speech. She was oriented to time, place and person. Patient was guarded and depressive features and par-anoid delusions were reported. Suicidal wishes were not reported and her affect was apathetic. Patient was started on low dose mirtazapine, olanzapine. Clonaze-pam was added for her complaints of insomnia.

Detailed evaluation revealed laboratory values of a TSH level of more than 1oo µU/ml (reference range: 0.50–5.00 µU/mL), thyroxine (T4) level of less than 0.4 (reference range: 4.5–10.9 µg/dL) and total triidothyro-nine (T3)level of 1.98 (reference range: 60–181 ng/dL). Her parathyroid hormone level was 302.2 pg/mL (ref-erence range -15.0 -68.0pg/mL). As the initial calcium level of the patient was borderline high, work-up of vitamin D and parathyroid hormone was done, in view of hypercalcemia. Initial calcium level was 13mg/dl and repeat value was found to be 8.3mg/dl, initial vi-tamin D level was 2ng/ml when repeated later on, was found to be 64.95ng/ml, phosphorous level was found to be 5mg/dl and repeat value was later found to be 3.34mg/dl. Neurology department evaluated her and advised further investigations, of which nerve conduc-tion study (NCV) revealed evidence of carpal tunnel syndrome. They advised to continue thyroxine supple-mentation and supportive therapy.

General blood profile revealed that patient was anae-mic with a haemoglobin value of 7.4 g/dl. Patient’s family members report that patient was found to be anaemic 3 years back but had refused treatment. Pe-ripheral smear showed microcytic hypo chromic anae-mia. General medicine department evaluated the pa-tient and oral iron supplementation was given. One pint packed cell blood transfusion was given as the haemoglobin value decreased again. Her vitamin D3 level was found to be 3.12 on evaluation. Patient was started on thyroxine 50µg after consultation from the endocrine department of our hospital, which was later increased to 75µg, after electrocardiogram and chest x-ray were found to be normal.

Further on the 14th day her saturation dropped to 83 in room air, maintaining at 90 with 5 litres of O2. Her pulse rate was around 96 beats per minute. Her blood pressure recording was 180/110mmHg, which then dropped to 140/90mmHg. Periorbital oedema was present. Hyperthermia+ and peripheries were cold. Patient was diagnosed with myxodema coma. Patient was shifted to ICU and then put on ventilator support, with consent from family members. Echocar-diography showed evidence of mild pericardial effu-sion. Repeat investigations showed TSH value more than 100µU/ml, T4 value of 0.54µg/dL and T3 value of 1.18ng/dL.

Patient developed seizures while intubated and was started on parenteral phenytoin, levipil, topiramate,

midazolam and hydrocortisone. Electroencephalo-gram showed evidence of epileptiform seizures. Tra-cheostomy was done at a later stage. TSH values then dropped to 1.5 µU/ml and T4 of 1.61 µg/dL. Thyrox-ine supplementation was given orally in view of high TSH value with a maximum dose of 150 µg/day and minimum dose of 50 µg/day, dosage was modified ac-cording to response. Patient was then slowly tapered off parenteral medications and oral antiepileptics were gradually introduced. Patient spent a total of 47 days in ICU, under Neurology department and was then later shifted out to Physical Medicine department for reha-bilitation. Thus in our case patient had initially pre-sented with psychiatric manifestations and was found to have an organic background suggestive of organic psychosis which improved with symptomatic treat-ment. Initially hyponatraemia and hypercalcemia was diagnosed, possibly dehydration-induced hyponatrae-mia, which later came down to normal levels. Repeat sodium level was 137mEq/l and repeat calcium level was 8.3mg/dl.

40


REFERENCES1. A Case Report on Myxedema Madness: Curable Psychosis -

Nimesh Parikh, Prateek Sharma, and Chirag Parmar Indian J Psychol Med. 2014 Jan-Mar; 36(1): 80–81. doi: 10.4103/0253-7176.127260.

2. Delusional type psychosis associated with hypothyroidism: A case report Ghasem Dastjerdi Procedia - Social and Behavioral Sciences 84 ( 2013 ) 1050 – 2.

3. Adult Hypothyroidism Department of Endocrinology Wilmar

M.Wiersinga, M.D. Department of Endocrinology December 12, 2013.

4. Hypothyroidism: An Important Diagnostic Consideration for the Psychiatrist: Kristi R. Estabrook, MD and Thomas W. Hein-rich July 11, 2013, Bipolar Disorder, Metabolic Disorders, Mood Disorders, Psychopharmacology, Schizophrenia Psy-chotic Features, Special Reports.

5. Myxoedema Coma: A Very Rare Presentation of Severe Hypo-thyroidism Mohamed Abdusalam Lklouk Journal of medical cases Volume 4, Number 11, November 2013, pages 715-8.

6. Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited Thomas W. Heinrich, M.D. and Garth Grahm, M.D Prim Care Companion J Clin Psychiatry. 2003; 5(6): 260–6.

7. Myxedema Coma: A New Look into an Old Crisis Vivek Mathew, Raiz Ahmad Misgar, Sujoy Ghosh,* Pradip Mukho-padhyay, Pradip Roychowdhury, Kaushik Pandit, Satinath Mukhopadhyay, and Subhankar Chowdhury J Thyroid Res. 2011; 2011: 493462. doi: 10.4061/2011/49362.

8. Unusual presentations of hypothyroidism: Westphal SA. Am J Med Sci. 1997;314:333–7.

and their potential subtle manifestations make hypo-thyroidism a diagnosis that is easy to miss2. Behaviour-al changes may occur in the absence of the classical physical signs and symptoms of the disorder2.

Since psychiatric complaints may be one of the ear-liest manifestations of hypothyroidism, they are often misdiagnosed as functional psychiatric disorders, rath-er than a psychiatric disorder due to a general medical condition2. This confusion leads to delayed treatment and a high likelihood of increased morbidity2.

41


Primary Urachal Mucinous Adenocarcinoma of the Urinary Bladder

Jeena V Chimmen*, C S Sakunthala Bhai*, S Shenoy MS**, Tanya S Ponnatt*

ABSTRACTPrimary urachal mucinous adenocarcinomas are rare and aggressive neoplasms that arises from the urachus, a vestigial mus-culofibrous band that extends from the dome of the bladder to the umbilicus. They account for only 0.5 – 2% of all the bladder tumours. The advanced stage at presentation due to the delayed onset of symptoms results in poor prognosis. We report a case of a 57 year old gentleman with primary urachal mucinous adenocarcinoma; to increase the awareness of this aggressive but clinically silent neoplasm with dismal prognosis.

Key words: Urachus, adenocarcinoma, bladder.

CASE REPORT A 57yr old man presented with haematuria of one month duration. Physical, urological and rectal exami-nation was unremarkable. Blood routine and Renal function tests were normal. Computed tomography of abdomen showed solid ex-travesical mass extending into the dome and anterior wall of the urinary bladder suggestive of urachal car-cinoma. Cystoscopic biopsy from the mass confirmed urachal adenocarcinoma. Colonoscopy was done to exclude primary colonic malignancy. Patient underwent partial cystectomy with en-bloc ex-cision of the urachal growth. Gross specimen revealed bladder mucosa with an ulcerated polypoidal grey white growth with mucinous areas (m) 4.2x3.8x3.4cm extending into the urachus. Histopathology showed a malignant tumor with neoplastic cells arranged in glandular pattern and in groups separated by pools of extracellular mucin. Moderate nuclear atypia and mi-totic figures were seen. Final diagnosis was urachal mucinous adenocarcinoma invading the muscle layer and the mucosa of the bladder. Patient was referred to medical oncology for further treatment.

*Dept. of Pathology, **Dept. of Urology, Jubilee Mission Medical College and Research Institute, Thrissur.

CASE REPORT

Fig 1. Partial cystectomy with en-bloc urachectomy specimen showing bladder mucosa with an ulcerated growth extending to urachus.

Fig 2. Cut surface showing grey white tumor with mucinous areas.

Fig 3. Urachal Mucinous Adenocarcinoma showing tumor cells infiltrating the bladder wall. Haematoxylin and Eosin 4x.

Fig 4. Urachal Mucinous Adencoarcinoma with groups of tumor cells surrounded by extracelluar mucin H&E 10x.

42


DISCUSSION The urachus is a thick tube like structure, that is formed in the embryo as the allantois involutes. It ex-tends from the bladder dome to the umbilicus. Rem-nants of allantois are usually seen in the dome of blad-der and rarely in the anterior and posterior bladder wall1 Neoplasm arising from such remnants are usu-ally adenocarcinoma2,3. Urachal tumors are rare and aggressive cancers of bladder which were originally described by Hue and Jacquin in 1863. They account

for only 0.5% of all bladder malignancies and 20-40% of primary bladder adenocarcinomas4,5,6. Hematuria is the most common presenting symptom in about 90% of patients7.

Most urachal adenocarcinomas have enteric features and are mucinous. Some may have signet ring cell component8.

MD Anderson Cancer Centre MDACC suggested 5 criteria for the diagnosis of urachal cancers (Table-1)

Fig 5. Urachal Adenocarcinoma . H&E 40x Fig 6 . Urachal adenocarcinoma with overlying normal urothelium

The MD Anderson Cancer center criteria for the Diagnosis of urachal cancer

Main Criteria :• Location in the bladder dome or elsewhere in the midline of the bladder• sharp demarcation between tumour and normal surface epithelium

Supportive criteria :• Enteric type histology• Absence of urothelial dysplasia• Absence of cystitis cystica or cystitis glandularis transitioning to tumour• Absence of primary adenocarcinoma of another orgin

Staging systems for urachal cancers

I

II

III

IIIA

IIIB

IIIC

IIID

IV

IVA

IVB

Stage 1984: Sheldon et al11 2006: Ashley et al11

Confined to urachal mucosa

Invasion Confined to urachus

-

Extension to bladder

Extension to Abdominal wall

Extension to Peritoneum

Extension to other Viscera

-

Metastatic to lymph nodes

Metastatic to Distant sites

Confined to urachas and bladder

Extension beyond muscularis of urachas and/or bladder

Metastatic to regional lymph nodes

Metastatic to nonregional lymph nodes/distant sites

Table 1

Table 2

43


CONCLUSION

The criteria include midline location of the tumor, a sharp demarcation between the tumor and normal surface epithelium, an enteric histology, the absence of urothelial dysplasia, cystitis cystica or cystitis glan-dularis transitioning to the tumor and the absence of a primary adenocarcinoma of another origin9. All of the criteria were satisfied in our reported case.Immunohistochemistry may help the distinction be-tween the primary and secondary carcinoma. In pri-mary adenocarcinoma of the bladder CK 7 and CK 20 are positive in contrast with colonic adenocarcinoma that express only CK 207.

Two systems have been proposed for staging urachal cancer. In the first system by Sheldon and colleagues in 198410, early stage urachal cancers are localised to the urachal mucosa while late stage disease involves the local structures such as bladder, abdominal wall or peritoneum and metastasis to regional lymphnodes or distant sites. The mayo clinic recently proposed a more simplified system11 Table 2But none of them are validated. Partial cystectomy with en-bloc urachectomy upto the umbilicus is the treatment of choice as, urachal tumors can occur anywhere along the urachus in-cluding the umbilicus. Unlike other cancers there is currently no adjuvant chemotherapy regime for treat-ment of Urachal cancers, but it has been used in some studies12,13,14 with variable efficacy.

Primary urachal adenocaricnoma in addition to be-ing a rare and aggressive tumor is also known to pose significant diagnostic challenges. Further studies are warranted for better treatment strategies and better outcome Competing interests : None declared

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