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Puranik Int J Med Res Health Sci. 2014;3(3):509-513

International Journal of Medical Research

&

Health Sciences

www.ijmrhs.com Volume 3 Issue 3 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886Received: 28

thFeb 2014 Revised: 28

thApr 2014 Accepted: 1

stMay 2014

Research Article

NUTRITIONAL STATUS, SOCIO-ECONOMIC AND HYGIENIC CONDITION OF SCHOOL AGED

CHILDREN OF A VILLAGE OF PUNE DISTRICT, MAHARASHTRA

*Puranik SS

Assistant Professor, Department of Biotechnology, Modern College of Arts, Science & Commerce, Shivajinagar,

Pune, India.

*Corresponding author email:[email protected]

ABSTRACT

Introduction:The field of anthropometry encompasses a variety of human body measurements, such as weight,

height and size; including skin fold thickness, circumference, lengths, and breadths. Anthropometry is a key

component of nutritional status assessment in children and adults. Anthropometric data for children reflect general

health status, dietary adequacy and growth and development over time. The main objective of the study was to

diagnose and analyze the magnitude and causes of nutritional and health problems of the village.Method:

Anthropometric reference data of 100 children between 7-14 years of age from a small village situated 30 km

from Pune. Using this data BMI i.e. Body Mass Index was calculated which helps in determining whether an

individual is overweight or underweight. Result:The overall study helped us to find out the socioeconomic

condition, hygienic condition as well as nutritional status of children. All the anthropometric measurements of the

girls and boys in 7-14 years age group was found to be significantly normal. Conclusion: The hygienic condition

of the village was good enough and in turn BMI data shows that the socioeconomic condition of the village was

also good.

Keywords: Nutritional status, BMI, Anthropometry, socioeconomic condition.

INTRODUCTION

The work focuses on the health status of the village

children as well as their nutritional status, which

reflects the hygienic condition of the village. Themain aim of this study is to provide anthropometric

data of children.1-3

Anthropometry, the measurement

of body size, weight and proportions, is an intrinsic

part of any nutritional survey and can be an indicator

of health, development and growth. Anthropometric

values are closely related to nutrition, genetic

makeup, environmental characteristics, social and

cultural conditions, lifestyle, functional status and

health.4It is frequently used to assess nutritional status

and to study the growth and development of school-aged children and adolescents. Anthropometric

evaluation is an essential feature of geriatric

nutritional evaluation for determining malnutrition,

being overweight, obesity, muscular mass loss, fat

mass gain and adipose tissue redistribution.Socioeconomic conditions are consistent correlates of

BMI. Low Body Mass Index and high levels of under

nutrition are the major public health problems,

especially among rural underprivileged adults in

developing countries.Thus, the main objective of this

study was to establish a relationship between

nutritional statuses and the following anthropometric

parameters- weight, height and weight-height ratio.

Camps were arranged for collection of information on

the sex, age, weight and height of children from thevillage.Anthropometry provides non-invasive, easy

and cheap, but yet valuable information on nutritional

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status. Anthropometric measures of most significance

in children include: weight and height, weight-height

ratio.1-3.

Skin fold thickness at selected sites,4-6

mid

upper arm.3,6,7

Comparing anthropometric data from

children of different ages is complicated by the fact

that children are still growing (we do not expect the

height of a 5 yr to be the same as height of a 10 yr

old) Thus, height is one of the very important

components in the anthropometric data. Literature

uses height as a marker of health as Deaton (2007)

explains, “Height” is determined by genetic potential

and by net nutrition, most crucially by net nutrition in

early childhood.8-11

“Net nutrition is the difference

between food intake and the losses of activities and to

disease.”The most commonly used indices derived

from the measurement of anthropometric data are

stunting (low height for age), wasting (low weight for

height), and underweight (low weight for age) and

overweight (high/ more weight for age). Stunting is

an indicator of chronic under nutrition, the result of

prolonged food deprivation and/or disease or illness;

wasting is an indicator of acute under nutrition, the

result of more recent food deprivation or illness,

underweight is used as a composite indicator to

reflect both acute and chronic under nutrition.12

These

indices reflect distinct biological processes and their

use is necessary for determining appropriate

interventions. However, because they overlap, none is

able to provide a proper result, some children who are

stunted will also have wasting and/or be underweight;

some children who are underweight will also have

wasting and/or be stunted; and some children who

have wasting will also be stunted and/or

underweight.13-15

MATERIAL & METHOD

The numbers of camps were arranged for thecollection of Anthropometric data. The project was

approved by the Institutional Ethics Committee. The

Anthropometric measurements of 50 girls and 50

boys in range of 7-14 years of age were taken by

using standard Anthropometric instruments.Parents

were contacted through schools and signed parental

consent was obtained for children to participatein the

study. The parents were provided with an information

sheet and the study purpose was explained in their

own language by study personnel (Marathi, Hindi,and English). Participation was entirely voluntary and

patient’s data was kept confidential. In children the

most common Anthropometric indices used to

measure growth are height-for-ages, weight-for-age

and weight-for-height. Low height-for-age is

considered an indicator of shortness or stunting.

Height-for-age is the recommended indicator that best

reflects the process of failure of a child to reach linear

growth potential. Low weight-for-height for a child is

considered an indicator of thinness or wasting and is

generally associated with recent or ongoing severe

weight loss. Weight loss in children presenting low

weight-for-height is usually due to a recent illness

and/or insufficient calorie intake. Weight-for-age is

primarily a composite of weight-for-height and

height-for-age, and fails to distinguish tall, thin

children from short. Because it is influenced by both

the height of the child and the weight, it is more

difficult to interpret. The inclusion criteria for the

study was school going child, a girl or a boy of a

village, age between 7 and 14 years. Children were

excluded from the study if they were not willing to

participate and above 14 years of age.

Anthropometric measurements: - Children were

measured for height and weight without shoes and in

light clothing. Weight was measured using an

electronic digital scale and height was measured

using a height measuring board.6,7,12 BMI-for-age was

used to assess physical growth and to determine the

prevalence of overweight and underweight of the

children.

Subjects stood with their scapulae, buttocks and

heels’ resting against a wall, the neck was held in a

natural, non-stretched position, the heels were

touching each other, the toe tips formed a 45 degree

angle and the head was held straight.13-15.

Body Mass Index (BMI): -BMI is generally

considered a good indicator of not only the nutritionalstatus, but also the socioeconomic condition of a

population, especially adult populations of

developing countries. BMI was estimated by dividing

weight (kg) by square of height (m).16, 17

Individuals

were considered malnourished if their BMI was less

than 18, normal from 18-25 and overweight if more

than 25.

Descriptive statistics for all continuous variables were

presented as the mean ± SD. Group comparisons were

performed with the independent sample t test.


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Puranik

RESULTS

Table 1: Observed Anthropometri

Male subjects

Age

years

N

o.

Weight

(kg)

Height

(cm)

7 7 20.92±1.64 104±12

9 3 23.50±1.80 103±15

10 8 23.92±2.62 119±10

11 15 25.73±3.90 128±07

12 8 26.18±2.50 129±02

13 9 30.72±4.94 136±06

Table 2;Standard Anthropometric

Male subjects

Age

years

Weight

(Kg)

Height

(cm)

Wt/H

ratio(kg/c

7 22.9 121.7 0.188

9 28.1 132.2 0.212

10 31.4 137.5 0.228

11 32.2 140 0.2

12 37 147 0.251

13 40.9 153 0.267

Table 3: Levels of malnutrition anBMI (wt/ht

2) Levels of maln

Below 16 Severe level of

16 – 17 Moderate leve

17.1 – 18.5 Mid level of m

18.6 – 20 Low weight b

20.1 – 25 Normal.

25.1 – 30 First grade of

Above 30 Second grade

Comparison of the anthropometricto age and gender participating su

each age group weight were great

females while height were greater i

1,2).BMI was used to determine

overweight (Table 3).17,18

Malnutriti

24% of the population (18.5 &25.1); with 5% o

of males. (Table 3,Fig 1& Fig 2).

Int J Med Res Health S

c values of male subjects according to age.

Femal

Wt/Ht

ratio( kg/cm)

BMI N

o

Weight (kg) Heig

(cm)

0.20115 19.93±4.40 13 20.07±2.68 107±

0.22815 22.92±7.17 3 17.66±0.57 109±

0.20100 16.93±2.78 17 20.87±5.16 106±

0.20101 15.47±1.22 8 26.31±4.14 129±

0.20294 15.62±1.70 5 33.50±5.78 142±

0.22588 16.31±6.36 4 37.37±7.47 144±

values of male subjects according to age. (p<

Female

)

Diff. between

std and observedWt/Ht ratios

(p values)

Weight

(Kg)

Height

(cm)

Wt/

ratio(kg/c

16 -0.0129 21.8 120.6

55 -0.0155 28.5 132.2

36 0.02736 32.5 138.3

0.02899 33.7 142

70 0.04876 38.7 148

32 0.04144 44 150

d obesity utrition/grades of obesity No. of females

malnutrition. 7

l of malnutrition. 1

alnutrition. 7

t normal. 12

18

besity. 3

f obesity. 2

values according jects showed,for

er in males than

in females.(Table

malnutrition and

on was found in

I); with 15% of

lnourished. Data

on were normal

ales and 40% of

nd in 6% of the f females & 1 %

Fig 1: Data of female ch

511

i. 2014;3(3):509-513

e subjects

ht Wt/Ht

ratio( kg/cm)

BMI

11 0.1875 17.88±4.36

10 0.1620 15.19±4.30

14 0.1968 19.20±6.03

5 0.2039 15.53±1.78

8 0.2359 16.38±1.59

3 0.2595 17.77±3.14

.05)

subjects

t

m)

Diff. between std andobserved Wt/Ht ratios

(p values)

.1807 -0.0068

.2155 0.054

.2349 0.0381

.2373 0.0334

.2614 0.0255

.2933 0.0338

No. of males

4

0

5

17

23

1

0

ildren


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Puranik

Fig2: Data of male children

DISCUSSION

According to the 2000 Centers for

and Preventiongrowth charts, the m

who were malnourished at 7 years o

that same weight category at 5 year

the normal weight category w

according to the International Ob

(IOTF).13,14,19

However, for both

International Obesity Task Forc

underweight category showed th

While in the case of adults malnouri

at any age depending on the differ

which the villagers prevail also it

hygienic condition of the village

physical work performed by village

day life.

From a public health standpoint,

different reference criteria can

differences in prevalence estima

malnourishment. If a growth ref

adequately describe the population i

health concerns may be spuriou

decreased, leading to inappropria

action. Furthermore, when strategiereduce rates of pediatric u

malnourishment, or if studies are pl

changes in growth, the use of dif

may correspond to differences in th

changes over time. As a means

limitations inherent in the

categorizations, it would be prude

changes over time in both categorie

underweight or malnourished) and a

not rely on a single indicator. This ibe useful given that an increase

absolute BMI could take place, but


isease Control17

ajority ofchildren

f age remained in

s of age, whereas

as most stable

sity Task Force

the CDC and

references the

least stability.

shment can occur

ent conditions in

can depend on

as well as the

rs in their day to

it is clear that

reveal dramatic

tes of pediatric

rence does not

question, public

ly increased or

te (or lack of)

s are designed to derweight and

nned to examine

ferent references

ability to detect

f addressing the

relative BMI

t to express any

s (normal weight,

bsolute terms and

formation would or decrease in

not correspond to

a change in the weight c

cross BMI threshold cuto

The study has severa

prevalence estimates fro

children representative o

to 14 years. BMI wa

rather than reported hei

the weight-height ratio

taking into consideration

it may be considered to

either weight or height s

or nutritional status. Mo

anthropometric paramet

with this index. There is

index to assess childhoo

established cutoff point

children. A consistent a

underweight in children

BMI may therefore be

alternatives may be consi

CONCLUSION

Almost all the anthropo

girls in each age group

normal. The weight and

affected to a greater exte

girls. However girls sh

underweight conditions

weight, 10% girls were

were underweight. This

proper food intake

malnutrition cannot be

underweight, it may also

illness. Thus the girls a

showed the average hei

24.02 kg and average B

the anthropometric meas

found to be significant

normal weight,4% boys

boys were underweight.

and showed the avera

weight 25.40 kg, average

Thus the present data sh

the village was good en

shows that the socioecon

was also good.

512

i. 2014;3(3):509-513

ategory if individuals do not

ffs.

l strengths. It determined

m a large sample of young

f the school aged between 7

calculated from measured

hts and weights. But since

is independent of age and

weight in relation to height,

have advantages over using

ingly as an index of growth

reover, because most of the

rs had a close relationship

no internationally acceptable

malnutrition nor is there an

to define underweight in

nd pragmatic definition for

and adolescents is required,

appropriate. However, other

dered in the future.

metric measurements of the

ere found to be significantly

weight-height ratio were not

nt. This is true for almost all

owed both overweight and

. 66% girls had normal

overweight and 24% girls

may be due to the lack of

or malnutrition. However

the only factor of being

be due to certain diseases or

ged between 7-13 yrs old

ght 1.15m; average weight

MI 20.23 kg/m2. Almost all

rements of the of boys were

ly normal. 86% boys had

were overweight and 10%

The boys were 7-14 yrs old

ge height 1.23m, average

BMI 20.135 kg/m2.

w that hygienic condition of

ugh. And in turn BMI data

omic condition of the village


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513


ACKNOWLEDGEMENTS

The authors are grateful to thePrincipal, Modern

College of Arts, Science & Commerce, Shvajinagar,

Pune (India) for providing facilities for research. The

author acknowledges the financial support from the

University Grant Commission (UGC), Pune.

Conflict of interest: Nil

REFERENCES

1. Robinson M, Jelliffe DB. Interrelations between

anthropometric variables. A contribution to

nutritional anthropometry of infancy and early

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2. Samai Mohamed, Samai Hajah H, Bash-TaqiDonald A, Gage George N and Taqi Ahmed M

The Relationship between Nutritional Status and

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3. Smith DS, Brown ML. Anthropometry in

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4. Delarue J, Constans T, Malvy D, Iradignac A,Couet C, Lamisse F. Anthropometric values in an

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5. Durnin JVGA, De Bruin H, Feunekes GIJ. Skin

folds thickness; Is there a need to be very precise

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6. Marilyn D, Johnson, MS, William K, Yamanaka,

Candelaria S, Formacion MS. A comparison of

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7. Sharma B, Mitra M, Chakrabarty S and Bharati P.

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Gond – a Tribal Population in Madha Pradesh,

India. Malaysian J. Nutri. 2006:12: 147-55

8. Deaton, Angus and Jean Dreze. Food and

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9. Angus Deaton Height, health, and

development. Proceedings of the National

Academy of Sciences. 2007, 104(33): 13232-37

10. BallK, Crawford D. Socio economic status and

weight change in adults: a review. Soc Sci Med.

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11. Dean Spears.Height and cognitive achievement

among Indian children. Economics department.

Princeton University. Princeton, NJ 08540.

[email protected] 609-258-4000 April

2011.

12. Sudesh J,Saroj B and Salil S. Nutritional status of

rural preschool children of Haryana state. Indian

J Pediatr. 2000: 67: 189-96

13. Flegal KM, Ogden CL, Wei R, Kuczmarski RL,

Johnson CL. Prevalence of overweight in US

children: Comparison of US growth charts from

the Centers for disease control and Prevention

with other reference values for body mass

index.Am. J. Clin Nutr.2001;73:1086-93

14. Lavallee C.Anthropometric measurements and

growth charts for Cree children of James Bay,

from 0 to 5 years old. Arctic Med Res. 1988;47

(S1) : 204-08

15. Muntoe M, Shah CP, Badgley R, Bain HW. Birth

weight, length, head circumference and bilirubin

level in Indian newborns in the Sioux Lookout

Zone, north-western Ontario. Can Med Assoc J.

1984;131:453-56

16. Kathleen M. Ziol-Guest, Greg J. Duncan, and

Ariel Kalil. Early Childhood Poverty and Adult

Body Mass Index.Am J. of Public health.March

2009:99:3:527-32.

17. Vidmar S, Carlin J, Hesketh K, Cole

T.Standarding anthropometric measures in

children and adolscents with new functions for

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18. World Health Organization. 2006. WHO Child

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acute malnutrition in infants and children: A Jointstatement by the World Health Organization and

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tandards/weight_for length/en/index.

19. Noreen D. Willows, Melissa S. Johnson, Geoff

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514Agrawal Int J Med Res Health Sci. 2014;3(3):514-520


&

Health Scienceswww.ijmrhs.com Volume 3 Issue 3 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886Received: 20th Feb 2014 Revised: 24thMar 2014 Accepted: 28th Apr 2014Research Article

EFFECT OF REPETITIVE MCKENZIE LUMBAR SPINE EXERCISES ON CARDIOVASCULAR

SYSTEM

*Agrawal Sonal S

Assistant Professor, Department of Physiotherapy, V.S.P.M.’s College of Physiotherapy, Nagpur, Maharashtra, India

*Corresponding author email:[email protected]

ABSTRACT

Background& Purpose:McKenzie exercises for the lumbar spine, which are done repeatedly, such as flexion in

standing (FIS), extension in standing flexion in lying (FIL) & extension in lying (EIL) have been used in the

management of low back pain for over three decades. The cardiovascular effects of exercises that involve postural

stabilization, arm exercises and of exercises performed in lying are well known, but there are seldom studies

performed to assess the cardiovascular effects of these commonly used McKenzie exercises. Therefore the study

focused on evaluating the effects of 4 commonly used McKenzie exercises on the cardiovascular system.Methods:

80 subjects in the age group of 20-59 years were randomly assigned into 4 groups according to their age, such that

such that each group comprised of an equal number of subjects & equal number of males & females. Each subject

performed all the 4 exercises (FIS, EIS, FIL & EIL) for 10, 15 & 20 repetitions respectively. Heart rate, blood

pressure & rate pressure product were recorded before & after each set of repetitions & after each type of exercise. Results: Repetitive McKenzie lumbar spine exercises had cardiovascular effects in apparently healthy

subjects (both male & female). Exercises performed in lying were hemodynamically more demanding than that

performed in standing, also exercises involving flexion of the lumbar spine elicited greater cardiovascular demand

as compared to extension exercises i.e. FIL>EIL>FIS>EIS irrespective of the number of repetitions, 10, 15 or 20.

The cardiovascular demand for a given subject increased as the number of repetitions increased, for all the 4

exercises. Conclusion: McKenzie exercises when done repetitively have cardiovascular effects in healthy subjects.

Keywords: McKenzie, low back pain, cardiovascular system

INTRODUCTION

Low back pain is a condition that continues to place a

great deal of stress on the health care system of the

industrialized societies. Low back pain affects

approximately 80% of individuals in community1. It

is the second most common cause for patient visits to

physicians.1

Globally whether viewed in terms of

disability allowances, industrial injury claims, or

frequency of patients visiting physician, low back

pain is the most costly musculoskeletal condition.2

Low back pain can be extremely challenging to

prevent, diagnose and treat since its etiology is

diverse and cause often undetermined.3

Patients

suffering from low back pain as well as health care

providers who treat them are often frustrated by the

lack of progress realized during treatment &

rehabilitation programs. One reason for this may be

that treatment and rehabilitation recommendations for

low back pain vary greatly across health care

providers.4

Additionally, many of the common

treatment interventions prescribed to treat low back

pain patients have little scientific validation of their

efficacy.5

It has been suggested that several factors can

predispose people to the development of low back

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pain which includes; smoking, obesity, drug abuse,

ageing, genetic predisposition, lack of physical

conditioning, occupation involving excessive

vibrating movements or positions that involve very

little movement (i.e. sedentary occupations),

occupations that involve lifting, bending and twisting.

Also poor posture, frequency of forward bending and

loss of low back extension are predisposing factors

for low back pain.6

Many low back pain treatment and rehabilitation

protocols throughout the mid and late twentieth

century, primarily utilized passive modalities such as

bed rest, ultrasound, electrical stimulation, hot packs

and medication despite their being little validation of

their efficacy. However, one of the current treatment

interventions that utilize a more active approach to

treating and rehabilitating low back pain is McKenzie

therapy.5

Forthe last three decades, McKenzie lumbar spine

exercises are being prescribed for the management of

patients with low back pain. These comprise of

repeated lumbar flexion and extension movements as

a part of routine lumbar spine assessment and

exercise program.6, 7

Moreover,less effort is made to explain about the

cautions for increasing stress on the cardiovascular

system because of these exercises. Thus,

understanding the cardiovascular responses to

McKenzie exercises can be useful for clinicians using

these exercises fordiagnostic purpose and as an

intervention.

Aim: The aim of this study was to examine the

cardiovascular effects of four common McKenzie

exercises – lumbar spinal flexion and extension in

standing and lying, when these exercises are repeated

10, 15 and 20 times

Objectives:• To study the cardiovascular effects of 4 common

McKenzie exercises: Flexion in standing (FIS),

extension in standing (EIS), flexion in lying

(FIL)&extension in lying (EIL).

• To study the difference in the effects after 10, 15

and 20 repetitions of 4 McKenzie exercises.

• To compare the cardiovascular effects between

different exercises i.e. FIS, EIS, FIL&EIL

• To compare the cardiovascular effects of these

exercises between males and femalesMATERIAL AND METHODS

Study design:The study commenced after obtaining

permission from the head of the institution and the

ethical committee of the college. The study is a cross

sectional design, with the subject’s parameters

measured before and after the designed exercise

protocol. The independent variables - 4 types of

McKenzie exercises i.e. FIS, EIS, FIL and EIL; while

the dependent variables - heart rate, blood pressure

(both systolic and diastolic), rate pressure product.

Study setting: Out-patient department V.S.P.M.

College of Physiotherapy

Subjects: Population of 80 subjects in the age group

of 20-59 years was selected as participants for the

study as per the inclusion criteria. Each participant

performed the complete exercise protocol to examine

the cardiovascular effects of 4 common McKenzie

exercises as described earlier.

Sample size: Subjects were equally recruited

maintaining an equal number of males and females.

All the participants were subjected to the complete

exercise protocol.

Inclusion criteria:Apparently healthy and

asymptomatic subjects, age group – 20 to 59 years

According to McKenzie this age range represents

individuals at risk for pathology of the spine,

specifically postural syndrome (30 years and

younger), dysfunction syndrome (30 years and older)

and derangement syndrome (20 to 55 years)6.

Exclusion criteria: Cardiovascular conditions,

pulmonary conditions, anemia, recent

musculoskeletal injury, low back pain, intervertebral

or facet joint pathology, metabolic disorders,

smoking, any neurological deficit, cognitive disorders

Outcome measures:The main outcome measures used

were heart rate in beats per minute, blood pressure

both systolic and diastolic in mm of Hg and RPP

Pre-exercise protocol:The study purpose wasinformed to all the participants. They were made

aware of the risks and their right to terminate

participation at any time. All subjects acknowledged

their understanding of the study and their willingness

to participate by signing a written consent.

An interview was completed by positioning the

subjects in a relaxed sitting position in a firm

armchair for 5 minutes, which elicited information

about the subject’s activity and fitness levels. The

activities of subjects were rated on a 3 point scale toestablish whether the sample was homogenous

concerning activity and fitness level. The resting HR


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and BP were recorded in a relaxed sitting position in

an armchair.9,10

The arterial BP was obtained with an

aneroid sphygmomanometer applied to the left arm in

accordance with the American Heart Association

Standards.10

The resting HR was determined by palpating the left

radial arterial pulse. The pulse was counted for 30

seconds using a stop watch. The value was then

multiplied by 2 to obtain a minute rate.8

Individuals were familiarized with the patterns of the

exercises by verbal instructions, demonstration and

practice. Care was taken to see that the practice

session did not bring about any training effect to

avoid biasing of the study.

Exercise procedure was, according to standard

McKenzie protocol.11

Fig-1: McKenzie Lumbar spine exercises

Each subject performed all 4 types of above

mentioned exercises for 10, 15 and 20 repetitions

respectively in a single sitting. Subject was supposed

to return to the resting position within 30 seconds.8

The HR and BP of the subjects were then recorded.

Care was taken that the parameters were recorded

within 2 minutes.10

The RPP (Rate pressure product)

was calculated by multiplying the product of HR and

Systolic BP by 10-2.

The subjects were instructed to perform the exercises

in a continuous rhythm. The rhythm was dictated by

the therapist such that on average, each subject could

complete 20 repetitions in 1 minute.8

On each

movement, the subject reaches the maximum possible

range for all the movements and maintains the

position for one second before the next

repetition. Breath holding was not allowed during the

exercise. 15 minutes of rest period was allowed after

each set of 10, 15 & 20 repetitions of each of the 4

exercises and also 15 minutes of gap betweenchange

in the type of McKenzie exercise.

Data analysis : Descriptive statistics for the

dependent measures, including means and standard

deviations were calculated for each set of the 4

exercises i.e. Flexion in standing, extension in

standing, flexion in lying and extension in lying and

for each group i.e. 1, 2, 3, and 4.

Statistically the characteristics of the groups and the

results were compared using One- way ANOVA and

Paired and Unpaired t tests.

Statistically the characteristics of the groups and the

results were compared using One- way ANOVA and

Paired and Unpaired t tests.

A one-way analysis of variance (ANOVA) for

repeated measures was used to compare the

dependent measurements after performing all the four

exercises for 10, 15 and 20 repetitions respectively. It

was performed for both male and female subjects.

Paired t- test was used to analyze the difference in the

mean values of RPP within four types of McKenzie

exercises for 10, 15 and 20 repetitions in males.

Unpaired t- test was used to analyze the difference

between the mean RPP values of males and females

after performing four types of McKenzie exercises

for 10, 15 and 20 repetitions.

The level of significance was set at 0.05 for all thecomparisons.

RESULTS

Table 1: Mean & standard deviation for RPP

ExerciseMale Female

10 Repetition 15 Repetition 20 Repetition 10 Repetition 15 Repetition 20 Repetition

FIL 116.94±6.90 123.95±6.10 131.34±8.45 105.16±6.48 112.07±6.22 112.07±6.22

EIL 109.86±5.04 116.15±7.23 123.27±7.71 98.01±1.20 102.92±5.32 102.92±5.32

FIS 104.53±5.69 111.55±6.9 117.14±7.79 93.32±7.52 97.46±6.89 97.46±6.89

EIS 100.26±5.50 104.43±6.43 110.35±8.25 86.14±6.24 88.89±7.57 88.89±7.57

Flexion in standing (FIS), extension in standing (EIS), flexion in lying (FIL)& extension in lying (EIL).

Table 2: Comparing for the effects of different exercises in males, after applying One-Way ANOVA


9/271


ANOVA Table for Males

Variable Source df F p-value Inference

RPP after

10

repetitions

Between Exercise Groups 3

31.15537.74e-16

HighlysignificantWithin Exercise Groups 156

RPP after 15repetitions

Between Exercise Groups 3 (34.428)37.1464

< 2.2e-16 HighlysignificantWithin Exercise Groups (156)155

RPP after 20

repetitions

Between Exercise Groups 3 (38.0165)

41.5182< 2.2e-16 Highlysignificant

Within Exercise Groups (156)154,

The above Table shows that p


10/271


FIS 15 1.3468 0.09

20 1.9517 0.02*

EIS

10 1.4104 0.08

15 1.9002 0.03*

20 2.3787 0.009*

FIL10 0.3629 0.3515 0.4224 0.33

20 0.8806 0.19

EIL

10 0.4028 0.34

15 0.6745 0.25

20 0.8833 0.19

The Table shows that p values are significant i.e.

pEIL>FIS>EIS in females after any number of

repetitions.

Fig 3: Mean RPP increases such that

FIL>EIL>FIS>EIS in males whatever may be the

number of repetitions.

DISCUSSION

As a result of data analysis repetitive McKenzie

exercises for the lumbar spine elicit significant

hemodynamic stress in healthy subjects both males

and females. [pEIL>FIS>EIS) . This finding is

consistent with known physiology.15

Tommy Boonestated that cardiac output increases

when lying down versus standing

16

which isconsistent with the results of the study.

Female

0

5

10

15

20

25

30

35

40

10 15 20

Repetition

I n c r e a s e d M e a n

FIL EIL FIS EIS

Male

0

5

10

15

20

25

30

35

40

10 15 20

Repetition

I n c r e a s

e d M e a n

FIL EIL FIS EIS


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The work of a large muscle mass of the upper and

lower extremities, theabdominal muscles, and the

trunk muscles are involved in flexion in lying.11

Christensen EH, Astrand PO, in their work concluded

that volume of oxygen consumed during physical

exercise is necessarily dependent upon the load on the

muscles and also on the mass of the muscles at work.

Work with legs can bring the metabolism to a higher

level than can exercise performed by the arms.17

All

these researches confirm that there is increased

oxygen demand by the contracting muscleswhich in

turn increases the HR, BP, cardiac output and stroke

volume.11

On the other hand, EILis an exercise that involves the

workof upper extremity muscles while raising the

upper trunk against gravity.11

Several studies by Bevgard S, Freyschuss V,

Strandell T, Stenberg J, Astrand P O, Astrand I, Asit

G, John W; in their study concluded that arm exercise

in comparison with leg exercise is accompanied by a

large rise in heart rate, blood pressure, pulmonary

ventilation, and arterial lactate concentration and this

difference are attributed to more dominating

sympathetic vasoconstriction tone during arm

exercise.18

Flexion in lying, however is additionally associated

with inadvertent holding of breath and increased

intrathoracic pressure, leading to increased resistance

to blood returning to the heart and thus there is a

reflex increase in the HR and BP.11

Thus there is

increased workload on the heart during FIL as

compared to EIL, which is also in accordance with

the results of this study.

The range of motion during back extension is less

than during flexion, therefore there is presumably less

muscle work, and therefore, less work of the heart in

extension compared with flexion, in both standingand lying positions. This fact was also confirmed by

the results of the current study. (EISEIL>FIS>EISin

males as well as females and this effect is accentuated

with increasing number of repetitions.Furtherresearch is needed to elucidate factors that increase

the risk for a given patient. Electrocardiographic


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studies would help establish the effects of these

exercises on cardiac rhythm and provide a guide for

proper prescription of McKenzie exercises.

Limitation:Only non invasive outcome measures

were used for cardiovascular evaluation


REFERENCES

1. Anderson G.Epidemiological features of chronic

Low back pain. Lancet. 1999;354:581-85

2. Videman T, Battie M. A critical review of the

epidemiology of idiopathic low back pain. In:

Weinsterin J, ed. A scientific & clinical

overview. Illinois: American Academy of

orthopedic surgeons, Illinois; 1996;317-32

3. Deyo R A, Cherkin D, Cohrad D, Volinn E. Cost,controversy Crisis: Low back pain & the health

of the public. Annu. Rev. Public Health. 1991;

12: 141-56

4. Lively MW. Sports Medicine approach to low

back pain. South Med J. 2002; 95: 642-46

5. Polatin P. The functional restoration approach to

chronic low back pain Journal of musculoskeletal

medicine. 1990; 7 : 17-30

6. McKenzie RA. The lumbar Spine: Mechanical

Diagnosis & Therapy. Waikane, New Zealand:Spinal Publications. 1981; 27-80

7. Stankovic R., Johnell O. 1995; Conservative

treatment of acute low back pain. 5 years follow

up study of two methods of treatment. Spine.

1981; 20: 469-72

8. Astrand PO, Rodahl K. Textbook of Work

Physiology 3rd

ed. New York, N Y : McGraw-

Hill Inc.1986

9. Astrand I. Circulatory responses to arm exercise

in different work positions. Scand. J. Clin. Lab

Invest. 1971; 27: 293-97

10. Bevegard S, Freyschuss U, Strandell T.

Circulatory adaptation to arm & leg exercise in

supine & sitting position. J. Appl. Physiol. 1966;

1:37-46

11. Al Obaidi S., Anthony J., Dean E, Al Suwai N.

Cardiovascular Responses to Repetitive

McKenzie lumbar spine exercises; Phys. Ther.

2001; 81: 1524-33

12. Richardson D. Blood Flow responses of human

calf muscle to static contraction at various

percentages of MVC. J. Appl. Physiol: Respirat

Environ Exercise Physiol. 1981; 51: 929 – 33

13. Kispert CP. Clinical Measurements to assess

cardiopulmonary function. Phys. Ther. Dec 1987;

67: 12, 1886-90

14. Gobel FL, Nordstrom LA, Nelson RR. The rate

pressure product as an index of myocardial

oxygen consumption during exercise in patients

with angina pectoris; Circulation. 1978 ; 57: 549-

56

15. Mc Ardle WD, Katch FI, Katch VL. Essentials of

Exercise Physiology. Philadelphia, Pa: Lea &

Febiger. 1994

16. Ferreira ML, Ferreira PH, Latimer J, Herbest R,

Maher CG. Does Spinal manipulative therapy,

help people with chronic low back pain?

Australian Journal of Physiotherapy. 2003;48:

277-83

17. Astrand PO, Saltin B. Maximal oxygen uptake &

heart rate in various types of muscle activity. J.

Appl. Physiol. 1961; 16: 977-83

18. Astrand I, Asit G, John W. Circulatory responses

to arm exercise with different arm positions. J.

Appl. Physio. 1968;25:525-32

19. Landahl S, Bengtsson C, Sigurdsson JA,

Svanborg A, Svardsudd K. November 1986; Age

– Related Changes in Blood pressure.

Hypertension. 1968; 8(11): 1044 – 9


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Indira et al., Int J Med Res Health Sci. 2014;3(3):521-525


&

Health Scienceswww.ijmrhs.com Volume 3 Issue 3 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886Received: 26thFeb 2014 Revised: 28th Apr 2014 Accepted: 1st May 2014Research Article

VALVULAR HEART DISEASES AND ITS IMPACT: AN ASSESSMENT AMONG PATIENTS

ATTENDING A TERTIARY HOSPITAL IN KOLKATA

*Dey Indira1, Das Bhaskar

2, Dey Subrata

3

1Associate Professor, Department of Community Medicine, NRS Medical College, Kolkata, India

2Assistant Professor,

3Professor, Department of Cardiothoracic and Vascular Surgery, RGKar Medical College,

Kolkata, India

*Corresponding authoremail: [email protected]

ABSTRACT

Background:Valvular heart diseases(VHD) are an important cause of morbidity and mortality worldwide and

rheumatic fever still continues to be a contributing factor to VHD in the developing nations like India. This

enormous disease burden often translates into huge economic and social losses. Aims: This study was undertaken

to identify the sociodemographic characteristics of the patients with VHD, to find the frequency of different types

of valvular diseases and their etiologies and the effect of such diseases on daily living. Materials and Methods:A

hospital based observational study was carried out among the patients with VHD attending Cardiothoracic and

Vascular Surgery OPD from April,2013 to Dec,2013.Data collection was done using a predesigned and pretested

schedule after taking informed consent.Result;Out of the 108 patient’s majority were males and resided in rural

areas. Their mean age was 36.39 ± 13.88. Mitral stenosis was found to be the commonest single valve lesion and

most of the VHDs were of rheumatic origin. In 32.4% of the cases outdoor activities were completely restricted.

Out of the 62 patients working outside, 40.2% were mostly absent from their workplace.Conclusion:Mitral

stenosis of rheumatic origin was found to be the commonest type of valvular heart disease in this part. This study

reveals that valvular heart disease of rheumatic origin stillexists in our society. So preventive measures, diagnosis

and management of valvular diseases should not be neglected and we need to provide preventive services in cases

of rheumatic fever to reduce the development of VHD.

Keywords: Valvular heart diseases, rheumatic heart disease, impact assessment

INTRODUCTION

The epidemiology of valvular heart disease (VHD)

has changed dramatically over the past 50 years in

developed nations. Valvular heart diseases have a

significant contribution to morbidity and mortality

worldwide.1,2

While degenerative valvular diseases

predominates in the developed nations, rheumatic

fever and rheumatic heart disease still continues to be

a major health care concern in the developing

countries among both children and adults.

3-6

VHD isstill common and often requires intervention. In

India, rheumatic fever is endemic and remains one of

the major causes of cardiovascular disease,

accounting for nearly 25-45% of the acquired heart

disease.7,8

Moreover, important changes have occurred

regarding the presentation and treatment of the

disease over recent years and there are very few

surveys in the field of VHD as compared with other

heart diseases.9Doubt still persists regarding the

generally perceived decline in the prevalence of RHD

in India.

10-12

Inadequacy of hospital admissionstatistics and varying individual hospital admission

DOI: 10.5958/2319-5886.2014.00389.0


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522


policies greatly influence the prevalence data

obtained from these sources.7

Furthermore, research concerning the epidemiology,

pathophysiology and clinical management of VHD is

limited.Data regarding the contemporary prevalence

and natural history of VHD are required to the

economists and policy makers responsible for

healthcare planning for allocation of resources to

newer developments, such as percutaneous valve

implantation and repair.13

,14

This enormous disease burden translates into huge

economic and social losses.The potential detrimental

effect of valvular heart disease on the activities of

daily living is unknown. These patients continue to

suffer from the illness, their productivity is lost, and

imposes an economical burden on their family and

country. So, this study was undertaken to identify the

socio-demographic characteristics of the patients with

VHD, to find the frequency of different types of

valvular diseases and their etiologies and the effect of

such diseases on daily living.

MATERIALS AND METHODS

A hospital based observational study was carried out

among the patients (n=108), age of the patients varied

from 11 to 65 years of both sex with VHD attending

Cardiothoracic and Vascular Surgery OPD from

April,2013toDec 2013.This is a tertiary medical

college and hospital, catering to population referred

from all over the state of West Bengal. The centre has

cardiac catheterization laboratories and cardiac

surgical facilities as well. The study population

consisted of patients in whom VHD was ascertained

by echocardiography or patients who had undergone

any operation on a cardiac valve (percutaneous

balloon commissureotomy, valve repair, valve

replacement).Ethical clearance was obtained from the

institutional ethics committee. The purpose of the

study was briefed to the patients and their consent for

participation was obtained. A pre-designed and pre-

tested schedule consisting details regarding socio-

demographic, clinical, echocardiographic

characteristics, and treatment modalitieswas used for

data collection. The effect of the disease was assessed

by finding the difficulties in carrying out daily

activities, participation in out-door activities, number

of days absent from the workplace and monthlyexpenditure on the disease.

Statistical Analysis: Data were entered in MS Excel

and results are presented as mean and standard

deviation and percentages.

RESULTS

A total of 108 patients with valvular heart diseaseattended the Cardio Thoracic and Vascular Surgery

OPD of the tertiary hospital during the period of data

collection. The age of the patients varied from 11 to

65 years with most of the patients lying between 30 to

40 yrs of age. Only 4.6% belonged to geriatric age.

Mean age of the patients was 36.39±13.88.

Majority of the patients with VHD were male

(53.7%), belonged to Hinduism (60.2%) and attended

the OPD from rural area (62%). Most of the patients

with VHD completed middle school, but 15.7% werefound to be illiterate. A high proportion of the male

patients were farmers and almost all the females were

engaged in household activities, 7.45 of the patients

were found to be students.(Table1).

The heart valves are responsible for the transport of

blood from one chamber of the heart to another or to

a great vessel. Abnormalities of the valves may be

congenital like malformed leaflets or acquired like

valvular stenosis(stiff valves) or valvular

insufficiency (leaky valves) leading to regurgitation

of blood. Out of 108 patients attending OPD, 65.7%

were treated medically and the rest had undergone

previous cardiac interventions. Among the patients

undergoing medical treatment, 43.7% suffered from

multiple valvular disease mostly of the left while

right sided lesions were infrequent. Mitral stenosis

was found to be the commonest type of single valve

disease followed by mitral regurgitation. Valve

replacement was done in 67.6% of the operated

patients, whereas the rest underwent conservative

surgery like CMV and TVMC (FIG; 1). The valvular

heart diseases identified were predominantly of

rheumatic origin. Degenerative and congenital causes

were present in only 15% of the cases. The patients of

VHD presented with shortness of breath, weakness or

dizziness to carry out normal activities, chest

discomfort, palpitations and pedal edema.

During the study, 36.1% of the patients were in

NYHA (New York Heart Association)18

Cl I, 50.9%

in Cl II and the rest in Cl III. Major co morbidities

present among the cases were cardiovascularaccidents, lower limb ischemia and myocardial

infarction.


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Indira et al.,

The impact of VHD on activities o

also assessed among the patients.

were able to carry out their daily ind

in 32.4% of the cases outdoor

completely restricted and 7.4%

activities occasionally.Whether the

effect on the occupation of the pers

for. This was not applicable for thos

household activities. Out of the rest

that they were mostly absent from

because of the disease.(Table-2)

Table 1: Socio-demographic profil

disease patients

Characteristics Number P

AGE

11 - 20 16

21 - 30 25

31 - 40 33

41 - 50 10

51 - 60 19

> 60 5

SEX

Male 58

Female 50

RELIGION

Hindu 65

Muslim 43

RESIDENCE

Urban 41

Rural 67

EDUCATION

Illiterate 17

Primary 7

Middle school 36

Secondary 10

High secondary 19Graduate 19

OCCUPATION

Farmer 19

Household

activities

46

Industrial worker 7

Student 8

Skilled worker 4

Service 7

Others 17Total 108

Int J Med Res Health

daily living was

All the patients

oor activities, but

activities were

perform outdoor

disease had any

n was also asked

engaged only in

40.3% mentioned

their workplace

of the valvular

rcentage

14.81

23.14

30.65

9.35

17.61

4.6

53.7

46.3

60.2

39.8

38

62

15.7

6.5

33.3

9.3

17.617.6

17.6

42.6

6.5

7.4

3.7

6.5

15.7100

Fig1: Distribution of

OPD

Table 2: Impact of VHD

Can perform outdooactivities

Yes

No

Occasional

Absence from wor

place

Mostly

Occasionally

No

DISCUSSION

Present study carried o

Kolkata revealed that

disease patients were in

life with a mean age of

Survey9

carried out in a

Europe found the mean

64+ 14 yrs. This high

developed countries is

valvular diseases are mwhile in our place they

origin affecting the y

stenosis and regurgitati

commonest valvular

whereasThe Euro Heart

the most frequent type

followed by AR. The

significant, whereas righ

in both the studies.

A community based stnonagenarians of Leide

that the left sided valv

523

Sci. 2014;3(3):521-525

HD patients attending the

on daily living

r Number(108) %

65 60.2

35 32.4

8 7.4

Number(62) %

25 40.3

7 11.3

30 48.4

ut in a tertiary hospital of

ost of the valvular heart

their 2nd

, 3rd

or 4th

decade of

36.4 years. The Euro Heart

number of medical centresof

age for VHD patients to be

r age groupinvolvement in

ecause of the fact that the

inly of degenerative origin are commonly of rheumatic

unger age groups. Mitral

on were found to be the

disease in this study,

Survey9showed that AS was

of single valvular disease

multiple valve disease was

sided lesion was infrequent

dy carried out among the , The Netherlands revealed

ular diseases were in high


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524


proportions, mitral and aortic regurgitations being the

commonest valvular disease and no patient had mitral

stenosis.8

This discrepancy may be due to the fact

that aortic and mitral stenosis are characterized by

poor clinical tolerance and therefore may determine

higher hospital attendance and higher prevalence of

these heart disease in hospital based studies.

Rheumatic fever is still common in developing

countries like India. This is supported by the fact that

in 85% of cases the diseases were of rheumatic

origin, whereas Euro Survey revealed that they were

mostly degenerative.Trends in hospitalization of

cardiac cases in Cuttack 16

, population survey done in

the villages of Northern India17

and autopsy series

from Mumbai18

also revealed that Rheumatic fever &

RHD still contributes to a large number of cardiac

cases in India Diagnosis is done based on history,

clinical features and Echocardiography.

The present study revealed that in 32.4% of the cases

outdoor activities were completely restricted and

7.4% perform outdoor activities occasionally. Out of

those engaged in various employment 40.3%

mentioned that they mostly remain absent from their

workplace because of the disease. However, the

community based study carried out among the

nonagenarians of Leiden; The Netherlands found no

significant difference in daily activities between those

having the disease and others. This may be because of

the fact that they studied the population above 90

years who are engaged in very little daily activities

because of their age.

This study reveals that VHD in India is mostly of

rheumatic origin affecting the productive population

of the country. So we need to continue early detection

and treatment of rheumatic fever in the susceptible

population to reduce the occurrence of valvular heart

diseases.There is need for carrying out a population based

epidemiological study to derive the actual prevalence

of different types of VHD and their effect on daily

life because the selection of hospital may have

introduced a selection bias.

CONCLUSION

Mitral stenosis of rheumatic origin was found to be

the commonest type of valvular heart disease in this

part. This study reveals that valvular heart disease of rheumatic origin still exists in our society. So

preventive measures, diagnosis and management of

valvular diseases should not be neglected and we

need to provide preventive services in cases of

rheumatic fever to reduce the development of VHD.

ACKNOWLEDGEMENT

We would like to thank the HOD, Dept of CTVS,RGKar Medical College for allowing us to conduct

the study and all the patients who had answered our

enquiries with patience.


REFERENCES

1. Chambers JB, Shah BN,Prendergast B, Lawford

PV, McCann GP, Newby DE, Ray S et al.

Valvular heart disease: a call for global

collaborative research initiatives. Heart 2013; 99:

1797-99

2. Mohty D, Enriquez-Sarano M, Pislaru S. Valvular

heart disease in elderly adults.www.update.com/

contents/ valvular-heart-disease-in-elderford PV,

ly-adults dt.04.2.2014.

3. Jacob Jose V, Gomathi M. Declining prevalence

of Rheumatic Heart Disease in rural school

children in India: 2001-2002.Indian Heart Journal

2003; 55(2) :158-60

4. Eisenberg MJ. Rheumatic heart disease in the

developing world: prevalence, prevention andcontrol. European Heart Journal 1993;14(1):122-

28

5. Periwal KL, Gupta BK, Panwar RB, Khatri PC,

Raja S, Gupta R. Prevalence of Rheumatic Heart

disease in school children in Bikaner: An

echocardiographic study. J Assoc Physicians

India 2006; 54:279-82

6. Nobuyoshi M, Arita T, Shirai S, Hamasaki N,

Yokoi H, Iwabuchi M, Yasumoto H, Nosaka H.

Heart Disease in Asia. Percutaneous BalloonMitral Valvuloplasty. A Review. Circulation.

2009; 119: e211-19

7. Vijaylakshmi IB. Acute Rheumatic Fever:

Current Scenario in India:

www.apindia.org/pdf/medicine_update_2012/car

diology- 07.pdf.

8. Park’s Text book of Preventive and Social

Medicine. Bhanot publishers, Jabalpur. 2011;21st

ed:350-52

9. Lung B, Baron G, Butchart EG, Delahaye F,

Gohike BC, Levang OW etal. A prospective

survey of patients with valvular heart disease in


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Europe: The Euro Heart Survey on Valvular

Heart Disease. European Heart Journal 2003,

24:1231-43

10. Krishna Kumar R, Tandon R. Rheumatic fever

and rheumatic heart disease: The last 50 years.

Indian Journal of Medical Research 2013;137

(4):643-58.

11. Padmavati S. Epidemiology of cardiovascular

disease in India: I. Rheumatic Heart Disease.

Circulation.1962; 25: 703-10.

12. Faheem, Hafizullah M, Gul A, Jan H, Khan M A.

Pattern of valvular lesions in Rheumatic heart

disease. JPMI. 2007;21(2):99-103

13. Ramakrishnan, Shyam S Kothari, Rajnish Juneja,

Balram Bhargava, Anita Saxena, Vinay k Bahl.

Prevalence of rheumatic heart disease: Has it

declined in India? The National Medical Journal

of India, 2009;22(2):72-74

14. Thomas van Bemmel, Victoria Delgado, Jeroen J

Bax, Jacobijn Gussekloo, Gerard J Blauw, Rudi

G Westendorp, Eduard R Holman. Impact of

valvular heart disease on activities of daily living

of nonagenarians: the leiden 85-plus study a

population based study. BMC Geriatrics 2010,10:

17

15. Classes of Heart Failure: http:// www.heart.org/

HEARTORG/ Conditions/ HeartFailure/ About

Heart Failure/ Classes-of-Heart-Failure

_UCM_306328_Article.jsp

16. Mishra TK, Routray SN, Behera M, Pattniak UK,

Satpathy C. Has the prevalence of rheumatic

fever/ rheumatic heart disease really changed? A

hospital based study. Indian Heart J 2003;55:152-

57

17. Lalchandani A, Kumar HRP, Alam SM.

Prevalence of rheumatic heart disease in rural and

urban school children of district Kanpur(Abstr).Indian Heart J 2000;52(S):672.

18. Deshpande J, Vaideeswar P, Amonkar G,

Vasandani S. rheumatic heart disease in the past

decade: An autopsy analysis. Indian Heart J

2002;54:676-80


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SarojGoliaet al., Int J Med Res Health Sci. 2014;3(3):526-529


&

Health Sciences

www.ijmrhs.com Volume 3 Issue 3 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886Received: 5

thMar 2014 Revised: 6

thApr 2014 Accepted: 26

thMay 2014

Research Article

ISOLATION AND SPECIATIONOF ENTEROCOCCI FROM VARIOUS CLINICAL SAMPLES AND

THEIR ANTIMICROBIAL SUSCEPTIBILITY PATTERN WITH SPECIAL REFERENCE TO HIGH

LEVEL AMINOGLYCOSIDE RESISTANCE

Saroj Golia1, *Nirmala AR

2, Asha S Kamath B

2

1Professor and HOD,

2Post Graduate student, Dr B R Ambedkar Medical College,Bangalore, Karnataka, India

* Corresponding author email:[email protected]

ABSTRACT

Background and Objectives: Enterococci are important nosocomial agents and strains resistant to penicillin and

other antibiotics occur frequently. Enterococci are intrinsically resistant to cephalosporins and offer low level

resistance to aminoglycosides. In penicillin sensitive strains, synergism occurs with combination treatment with

penicillin and aminoglycoside. Serious infections caused by them are treated with penicillin and aminoglycoside

combination. But the synergistic effect is lost, when the strain develops high level aminoglycoside resistance. The

choice of drug for infections due to such strains is vancomycin. The present study was carried out to isolate and

speciate Enterococci from various clinical samples, to know the susceptibility pattern of the isolates, to determine

the High Level Aminoglycoside Resistance (HLAR) among Enterococcal isolates.Methods: A total of One

hundred Enterococcal species isolated from various clinical samples were identified by various biochemical

reactions.Antimicrobial susceptibilitytesting and HLAR were determined by Kirby- Bauer disc diffusion

method.Results: Out of 100 Enterococcal isolates, 59 were E.faecalis, 38 were E. faecium,3 were other

Enterococcal species. Among these 53 isolates showed High Level Aminoglycoside Resistance. Conclusion:

Present study shows the presence of drug resistance to most of commonly used antibiotics and HLAR is also more

in E.faecium compared to E.fecalis.

Keywords: Enterococci, High level aminoglycoside resistance.

INTRODUCTION

The Genus Enterococcus consists of Gram positive,

aerobic and facultative anaerobic organisms that are

oval in shape and may appear on smears in pairs, as

singles or short chains. E. fecalis is the most common

isolate, being associated with 80-90 % of human

Enterococcal infections.1

Enterococcus species cause urinary tract infections,

bacteremia, endocarditis, intraabdominal and pelvic

infections, wound and soft tissue infections.2

High

level aminoglycoside resistance, glycopeptides

resistance and beta lactamase production in

Enterococci causing treatment difficulties in

hospitals.3

Drug resistant Enterococci are due to indiscriminate

use of antibiotics, diabetes mellitus, prolonged

hospital stay and immunocompromised

states.3 Enterococci are intrinsically resistant to

cephalosporins and also low level aminoglycoside

resistance. Infections due to Enterococci are treated

with penicillin and aminoglycoside.This synergism is

lost if the strain develops high level aminoglycoside

resistance.4The present study was done to know theantimicrobial susceptibility including HLAR

detection in various Enterococci species.

DOI: 10.5958/2319-5886.2014.00390.7


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MATERIALS AND METHODS

The present study was done in the department of

Microbiology, Dr.B.R.Ambedkar Medical

College,Bangalore, over a period of one year and four

months from September 2012 to December 2013.A

total of 100 Enterococci isolates from various clinical

samples (urine, pus, wound swabs, blood and other

body fluids) from both OPD and IPD

(Medicine,Surgery,OBG,Paediatrics Departments)

were included in the study. Urine samples were

inoculated on Cysteine Lactose Electrolyte Deficient

(CLED) medium.5

Blood samples were processed in

blood culture bottles containing glucose broth and the

remaining clinical specimens were processed on

blood agar and MacConkey’s agar. All plates were

incubated aerobically at 37o

C for 24-48 h andexamined for microbial growth. Enterococci were

identified using standard methods.1

Based on colony

morphology, Gram staining, catalase reaction, bile

esculin test, growth in 6.5% NaCl and sugar

fermentation reactions.1

Isolates were identified by

standard biochemical tests.1

Antimicrobial sensitivity testing was done on Muller-

Hinton agar by standard disc diffusion methods as per

Clinical Laboratory StandardsInstitute (CLSI)

guidelines.6

The antibiotics tested were as follows: Penicillin

(10U), Ampicillin (10ug),Ciprofloxacin (5ug),

Vancomycin (30ug),Linezolid (30ug)and

Tetracycline (30ug).

Quality control : E. faecalis ATCC 29212 was used .

All the clinical Isolates were detected for HLAR as

per CLSI guidelines using high content Gentamicin

(120ug) and high content Streptomycin (300ug) discs.

A zone of inhibition 10mm as sensitive.6

RESULTS

Of the 100 samples, 61 were males and 39 were

females. Various Enterococcal species isolated were

E. faecalis (59), E.faecium (38), E.dispar (02) and

E.durans (01).

E.faecium isolates were more resistant to various

antibiotics-Penicillin(52%), Ampicillin (58%),

Ciprofloxacin(82%), Vancomycin

(05%),Linezolid(03%) andTetracycline(62%). E.faecaliswere resistant to

Penicillin (48%), Ampicillin (40%), Ciprofloxacin

(70%), Vancomycin (02%), Linezolid (02%) and

Tetracycline (55%).

HLAR was detected in 53% of isolates. HLAR

among E. faecium isolates (58%) were higher

than E.fecalis (48%). High level resistance to

gentamicin and streptomycin among E. fecalis strains

were 56% and 40% respectively. High level

resistance to gentamicin and streptomycin among

E.faecium strains were 68% and 48% respectively.

Combined resistance to both aminoglycosides was

slightly higher in E. faecium (58%) isolates as

compared with E. fecalis (48%).

Table 1: Details of type of specimens from which isolates were obtained

Sr.

no.

Specimen(n=100) E. faecalis(%) E.faecium(%) E.dispar

(%)

E.durans

(%)

1 Urine 38 22 01 01

2 Pus 10 08 01 -

3 Sputum 06 05 - -

4 Blood 05 03 - -

5 Total 59 38 02 01

Table 2: Resistance pattern of E.faecium

Sr.

no.

Specimen(n=38) Penicillin

(%)

Ampicillin

(%)

Ciprofloxacin

(%)

Vancomycin

(%)

Linezolid

(%)

Tetracycline

(%)

1 Urine 34 40 65 03 01 48

2 Pus 09 08 10 02 01 08

3 Sputum 05 05 04 - - 03

4 Blood 04 05 03 - 01 035 Total 52 58 82 05 03 62


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Table 3: Resistance pattern of E.faecalis

Sr.

no.

Specimen(n=59) Penicillin

(%)

Ampicillin

(%)

Ciprofloxacin

(%)

Vancomycin

(%)

Linezolid

(%)

Tetracycline

(%)

1 Urine 32 33 54 01 01 44

2 Pus 08 04 11 - 01 05

3 Sputum 04 02 02 01 - 03

4 Blood 04 01 03 - - 03

5 Total 48 40 70 02 02 55

Table 4: HLAR pattern

Sr. no. Specimen (n=100) E.faecium(%) E.fecalis(%)

1 Urine 45 38

2 Pus 08 06

3 Sputum 02 02

4 Blood 03 025 Total 58 48

DISCUSSION

Enterococci are the second most common cause of

nosocomial urinary tract and wound infections and

third most common cause of nosocomial bacteremias.

Because of their resistance to penicillin and

cephalosporins of several generations, the acquisition

of high level aminoglycoside resistance and now the

emergency of vancomycin resistance, theseorganisms are involved in serious super infections in

patients receiving broad spectrum antimicrobial

therapy.1So it is essential to know the susceptibility

pattern of these organisms.

We isolated E. faecalis more than that of E. faecium.

The same results were obtained by Mendiratta DK et

al.7,Bhat KG et al

8and Gupta et al

.9High level

aminoglycoside resistance Enterococci were first

reported in France in 1979 and then have been

isolated from all the continents.10

Our study showed E.

faecium isolates were more drug resistant compared

to E. faecalis. This is comparable to the results

reported by AnjanaTelkaretal.11

In our study majority of the Enterococcal isolates

were resistant to tetracycline, and ciprofloxacin,

which is comparable to the study conducted by

AnjanaTelkar et al.11

Overall, resistance to penicillin, ampicillin

andciprofloxacin among strains of E. faecium is high.

Linezolid showed a good sensitivity towards

Enterococci species, and this can be used as an

alternative for the vancomycin resistant Enterococci.

In our study E. faecium isolates were multi drug

resistant as compared to E.fecalis, which is

comparable to the results reported by Mendiratta et

al.7

and Bhat KG et al.8Vancomycin resistance

detected in 7% of the isolates. Similar results were

reported by Bhat KG et al.8.

In our study HLGR is more in E. faecium isolates(68%) compared to E. faecalis (56%) strains. Also

HLSR is more in E.faecium (48%) than in E.faecalis

(40%). The same results were reported by

Mendirattaetal.7

and Gupta V et al.9So high

percentages of HLAR could nullify efficacy of

combination therapy of Beta lactamase,

aminoglycosides recommended for the treatment of

serious Enterococcal infections.Karmarkaret al12

also

reported greater resistance to vancomycin among E.

faecium.

The higher antimicrobial resistance rates in the

present study may be ascribed to the source of the

isolates being from a tertiary care set up and a wider

usage of broad spectrum antibiotics.

CONCLUSION

In our study multidrug resistant and HLAR is more in

Enterococcal isolates.It is essential to screen for the

multidrug resistant and HLAR in clinical samples.So

proper antibiotic policy and hospital infection controlmeasures can be initiated to prevent the emergence of

multidrug resistant strains.


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REFERENCES

1. Winn WC Jr,Allen SD, Jande WH,

KonemanEW,Schreckenberger PC. The gram

positive cocci. Part II: streptococci, Enterococci

and the streptococcus like bacteria. In

Koneman’scolor Atlas and Text book of

Diagnostic Microbiology 6th

ed. Lippincott,

Philadelphia. 2006;672-764.

2. Parameswarappa J, Basavaraj VP, Basavaraj

CM.Isolation, identification and antibiogram of

Enterococci isolated from patients with urinary

tract infections. Ann Afr Med 2013;12:176-81.

3. LoveenaOberoi, ArunaAggarwal. Multidrug

resistant Enterocci in a rural tertiary care

hospital- A cause of concern.Journal of medical

education and research.2010;12(3):157-58

4. Ananthanarayan and Paniker’s Text book of

Microbiology.9th

edition,2013;208-18.

5. Bailey & Scott’s Diagnostic Microbiology, 12th

edition,850-855.

6. Clinical and Laboratory Standards Institute,

Performance standards for antimicrobial

susceptibilitytesting;Twenty-Third Informational

Supplement, 2013;32:M100-S23Wayne,

PA:USA:CLSI

7. Mendiratta DK, Kaur H, DeotaleV, Thamke DC,

Narang R, Narang P. Status pf high level

aminoglycoside resistant Enterococcusfaecium

and Enterococcusfaecalis in a rural hospital of

central India. Indian J Med Microbiol

2008;26:369-71.

8. Bhat KG, Paul C, Ananthakrishna NC. Drug

resistant Enterococci in a south Indian hospital.

Trop Doct 1998;28:106-7

9. Gupta V. Singla N. Antibiotic susceptibilitypattern of Enterococci. Journalof Clin and Diag

Res 2007;5:385

10. Eliopoulos GM, Moellering RC. Antimicrobial

combinations. In: Lorian V, editor. Antibiotics in

laboratory medicine.Mayland : William and

Wilkins;1996p.330-96

11. AnjanaTelkar, Baragundi. Mahesh, Raghavendra

VP, Vishwanath G, Chandrappa NR. Change in

the prevelance and antibiotic resistance of the

Enterococcal species isolated from bloodcultures.Journal of Clinical and Diagnostic

Research 2012;6:405-08

12. Karmarker MG, Gershom ES, Mehta PR.

Enterococcal infection with special reference to

phenotypic characterization & drug resistance.

Indian J Med Res 2004;119:22-25

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Radha et al., Int J Med Res Health Sci. 2014;3(3):530-534


&

Health Sciences

www.ijmrhs.com Volume 3 Issue 3 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886Received: 12th Mar 2014 Revised: 26th Apr 2014 Accepted: 17th May 2014

Research Article

REAL TIME POLYMERASE CHAIN REACTION (RT-PCR) FOR MYCOBACTERIUM

TUBERCULOSIS IN SERPIGINOUS CHOROIDITIS- A STUDY OF 29 CASES

*Radha Annamalai1, Jyotirmay Biswas

2, S Sudharshan

3, R Gayathri

4,K Lily Therese

5, Viswanathan S

6, Namitha

Bhuvaneswari7

1Associate Professor, Department of Ophthalmology, Sri Ramachandra University, Porur, Chennai,India

2Director of Uvea & Ocular Pathology Department, Sankara Nethralaya, Chennai,India

3Consultant- Department of Uvea, Sankara Nethralaya, Chennai,India4Postdoctoral fellow, &

5Senior Professor and HOD, L & T Microbiology Research Centre, Vision Research

Foundation , KNBIRVO Building 41, College Road, Chennai - 600 0066Professor of Ophthalmology, Muthukumaran Medical College, Chennai, India

7Director and Professor of Ophthalmology, Regional Institute of Ophthalmology, Chennai, India

* Corresponding author email: [email protected]

ABSTRACT

Purpose: A study of real time Polymerase Chain Reaction for Mycobacterium tuberculosis ( M. tuberculosis)

DNA in 29 cases of active serpiginous choroiditis. Design: Case control study. Methods: DNA extraction from

the aqueous humor was carried out using QIAMP DNA extraction kit. Real- time Polymerase Chain reaction (RT-

PCR) for MTB was carried out using Genosen’s Mtb complex quantitative Real time PCR kit. All patients were

also subjected to complete blood count, venereal disease research laboratory test, chest radiograph,

QuantiFERON TB Gold test on the blood and polymerase chain reaction on a sample of aqueous humor. Results:

Aqueous aspirate showed copies of mycobacterium tuberculosis DNA in one out of twenty nine cases of

serpiginous choroiditis. Direct smear and culture for mycobacteria was negative in all cases. Conclusion: RT-

PCR identifies MTB DNA in suspected latent tuberculosis in serpiginous choroiditis with high specificity.

Serpiginous choroiditis and multifocal choroiditis due to tuberculosis may resemble each other clinically but have

distinct clinical features which can be confirmed by real time polymerase chain reaction performed on the

aqueous humor The association between serpiginous choroiditis and tuberculosis would be a chance association

or if present a rare association.

Keywords: Real-time polymerase chain reaction (RT-PCR), Serpiginous choroiditis, Ampiginous choroiditis,

tuberculosis, QuantiFERON TB Gold test

INTRODUCTION

Serpiginous choroiditis is a

chronicprogressiveinflammatorydisease. It is rare,

usually bilateral but asymmetrical and is seen

between the ages of 30 and 70 years. It begins around

the optic nerve in most eyes, advancing centrifugallyby recurrences to the mid periphery in an irregular

serpentine fashion. Active serpiginous choroiditis

characterized by greyish-yellow, cream-colored

lesions at the level of retinal pigment epithelium

(RPE) with overlying retinal edema.1

In some eyes,

however, the macula is affected initially without

preceding peripapillary activity, a variant known asmacular serpiginous choroiditis.

2In addition,

occasionally patients present with involvement of

DOI: 10.5958/2319-5886.2014.00391.9


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531


peripheral retina as the primary site of affection. New

recurrent lesions occur at the border of old inactive

lesions and frequently spread to the periphery,

commonly involving a new and contiguous area of

the fundus. Various aetiologies such as

autoimmunity3, infection

4, degeneration and

vasculopathy have been assumed to cause serpiginous

choroiditis. Irreversible profound visual loss can

result due to complications such as chorioretinal

atrophy, scarring and choroidal neovascular

membranes. We performed a study on 29 eyes of 27

patients with serpiginous choroiditis with suspected

latent tuberculosis (TB) and found that in one case

Mycobacterium tuberculosis ( M .tuberculosis )DNA

was detected in aqueous humor aspirate by real-time

polymerase chain reaction (RT-PCR).

MATERIAL & METHOD

The study was conducted in a tertiary referral hospital

in India. Prior to the study ethics committee clearance

was obtained. Inclusion criteria comprised all patients

with serpiginous choroiditis and multifocal

choroiditis which were suspicious for tuberculosis.

Patients with other causes of posterior uveitis and

those where the serpiginous choroiditis was inactive

or healed were excluded from the study. The aqueous

aspirate was obtained from 29 eyes of 27 patients and

27 controls during cataract surgery. Examination was

performed on all controls using slit lamp and

biomicroscopy. They were healthy patients with no

evidence of intraocular inflammation or uveitis. An

anterior chamber tap was performed under aseptic

precautions using povidone iodine and 0.1ml of

aqueous humor sample was sent immediately to the

microbiology department. Complete blood count,

QuantiFERON TB Gold test and high resolution

chest tomography (HRCT) and polymerase chain

reaction on the aqueous humor sample were

performed in all the cases. DNA extraction from the

aqueous humor was carried out using a QIAMP DNA

extraction kit (QIAGEN, Germany). Real time

Polymerase Chain reaction (RT-PCR) for M.

tuberculosis was carried out using Genosen’s MTB

complex (Netherlands) quantitative Real time PCR

kit. RT-PCR for quantitation of MTB DNA was

carried out as a 25 µl reaction, using 12 µl of MTB

complex super mix R1, 2.5 µl of Magnesium solutionR2 and 0.5 µl of Internal control IC 1 R3 and 10 µl of

aqueous humor DNA. The amplification was carried

out at an initial denaturation at 95 º C for 10 minutes,

followed by 45 cycles of 95 º C for 15 seconds, 60 º C

for 20 seconds, 72 º C for 15 seconds. The

quantitation analysis for the internal control and M.

tuberculosis was carried out using JOE (yellow) and

FAM (green) channel. The copy number of M.

tuberculosis was expressed in copies per ml of DNA

RESULTS

Aqueous aspirate showed copies of M. tuberculosis

DNA in one out of twenty nine cases of serpiginous

choroiditis. Direct smear and culture for

mycobacteria was negative in all cases.

RT PCR was positive in one case which is

described below:

A 38 year old Asian Indian male presented to theuveitis clinic with a history of gradual diminishing

vision for one month. He was being treated with

systemic corticosteroids prescribed elsewhere. Ocular

examination revealed a best-corrected visual acuity of

6/60, N24 in the right eye and 6/6, N6 in the left eye.

Slit lamp examination revealed no aqueous cells or

flare and 1+ vitreous cell in the right eye. The left eye

was normal. Intraocular pressure was 12 mmHg in

both eyes. Fundus examination in the right eye

revealed active choroiditis with geographic borders

and a clinical diagnosis of serpiginous choroiditis was

made (Figure 1). Chest X Ray and ESR were normal.

Tuberculin skin test was negative. An anterior

chamber tap was done in the right eye and the

aspirate was subjected to direct smear, culture,

analysis by polymerase chain reaction (PCR) and RT-

PCR for M. tuberculosis genome. RT-PCR performed

on his aqueous aspirate showed 14,781 copies of M.

tuberculosis DNA (Figure 2). Direct smear and

culture for M. tuberculosis were negative. He had no

symptoms of systemic tuberculosis (TB) but

QuantiFERON TB Gold test done on his blood

sample was positive. The patient was started on

antituberculous treatment and corticosteroids under

supervision of an infectious diseases specialist.

Follow up after 2 months showed that the lesions had

resolved (Figure 3) and RT-PCR of aqueous was

negative for M. tuberculosis genome (Figure4).

Visual acuity had improved to 6/24, N12 in the right

eye. Control samples from 27 cases of anterior

chamber aspirate of patients without uveitisundergoing phacoemulsification were subjected to


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Radha et al.,

RT- PCR. All were neg

tuberculosis(Figure 5).

Fig1: Active serpiginous choroiditis

Fig 2: Positive results of real time

aspirate for M. tuberculosis

Fig 3: Resolved serpiginous choroi


tive for M.

CR of Aqueous

ditis

Fig 4:Real time PCR o tuberculosis DNA-Nega

Fig 5: Real time PC

control sample

DISCUSSION

Tuberculosis is one of

choroiditis but serpigi

autoimmune aetiology ex

with distinct clinical c

detect active replicating

and a negative anterio

indicate the response

particularly in tuberculo

fundus changes that rese

but show evidence of

532

i. 2014;3(3):530-534

f Aqueous aspirate for M.ive after 2 months

of Aqueous aspirate on

the causes of serpiginous

inous choroiditis due to

ists as an independent entity

haracteristics. RT-PCR can

TB bacilli and MTB DNA

r chamber tap result can

to treatment. Patients

is endemic areas may have

mble serpiginous choroiditis

M. tuberculosisDNA in the


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aqueous humor. A substantial contribution may be

from an underlying infection and the likelihood of

this being tuberculosis is high.

Serpiginous choroiditis in the Asian Indian

population is seen in younger individuals with three

distinct presentations that can resemble tubercular

choroiditis.5The ocular morbidity in Indian patients

with active tuberculosis was reported as 1.39% and

the most common ocular finding was bilateral healed

focal choroiditis (50%).6

Patients with evidence of

active or latent tuberculosispresent with serpiginous

like clinical features that can resemble the

autoimmune type. This has been described as

tubercular serpiginous like choroiditis.7, 8

. An atypical

picture of serpiginous choroiditis has been reported in

association with toxoplasmosis9

and herpes

virus10suggesting that aetiology of infection is indee

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