TCMS – Vol 2 – Issue 4 (2022) – PISRT https://old.pisrt.org Sat, 25 Mar 2023 16:03:08 +0000 en-US hourly 1 https://wordpress.org/?v=6.7 Awareness, acceptance and hesitancy regarding human papilloma virus vaccine among nursing students of a rural medical college of Maharashtra https://old.pisrt.org/psr-press/journals/tcms-vol-2-issue-4-2022/awareness-acceptance-and-hesitancy-regarding-human-papilloma-virus-vaccine-among-nursing-students-of-a-rural-medical-college-of-maharashtra/ Sat, 31 Dec 2022 22:48:05 +0000 https://old.pisrt.org/?p=7025
TCMS-Vol. 2 (2022), Issue 4, pp. 32 - 38 Open Access Full-Text PDF
Aitalwad Deepmala, Jogdand Mohini, Mali Sandeep, Aghav Shridhar and Amar Raj
Abstract: Introduction: Human papillomavirus causes many diseases like genital warts, sexual transmitted diseases; cervical cancer. Human papilloma virus vaccine is available for adolescent girls. Though it is effective its use has not increased. Therefore, the current study is designed to determine the awareness, acceptance and hesitancy among nursing students.
Objectives: To study awareness about HPV vaccine and to assess the acceptability and hesitancy regarding HPV vaccine.
Materials and Methods: A cross-sectional study conducted among first year to last year nursing students studying in a rural medical college, Ambajogai. A pretested self-administered structured questionnaire was used for collecting data. Information regarding sociodemographic characteristics, awareness, acceptability, willingness to take the vaccine and spreading information to community were interviewed and recorded. Study period was from 1st July 2022 to 31st August 2022. Results: Out of 180 students, study carried among 169 those who gave consent and presented at time of study. Among them 27% were 15- 20 years of age group and 73% were in the age group 20-25 years. Most of them belongs to middle (43.7%) and upper middle (36.6%) socioeconomic class. Out of total participants 22.5% were males and 77.5 %were females. 7.7% were married and 92.3% were unmarried. 27.8% were heard about HPV and HPV vaccine. Conclusion: This study has indicated that very few participants were aware about HPV vaccine. Hesitancy can be reduced by providing proper knowledge about safety and side effects of HPV vaccine.
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Trends in Clinical and Medical Sciences

Awareness, acceptance and hesitancy regarding human papilloma virus vaccine among nursing students of a rural medical college of Maharashtra

Aitalwad Deepmala\(^{1}\), Jogdand Mohini\(^{1}\), Mali Sandeep\(^{1}\), Aghav Shridhar\(^{1,*}\) and Amar Raj\(^1\)
\(^{1}\) Department of Community Medicine, S.R.T.R. Government Medical College, Ambajogai, Maharashtra, India.
Correspondence should be addressed to Aghav Shridhar at shridharaghav95@gmail.com

Abstract

Introduction: Human papillomavirus causes many diseases like genital warts, sexual transmitted diseases; cervical cancer. Human papilloma virus vaccine is available for adolescent girls. Though it is effective its use has not increased. Therefore, the current study is designed to determine the awareness, acceptance and hesitancy among nursing students.
Objectives: To study awareness about HPV vaccine and to assess the acceptability and hesitancy regarding HPV vaccine.
Materials and Methods: A cross-sectional study conducted among first year to last year nursing students studying in a rural medical college, Ambajogai. A pretested self-administered structured questionnaire was used for collecting data. Information regarding sociodemographic characteristics, awareness, acceptability, willingness to take the vaccine and spreading information to community were interviewed and recorded. Study period was from 1st July 2022 to 31st August 2022.
Results: Out of 180 students, study carried among 169 those who gave consent and presented at time of study. Among them 27% were 15- 20 years of age group and 73% were in the age group 20-25 years. Most of them belongs to middle (43.7%) and upper middle (36.6%) socioeconomic class. Out of total participants 22.5% were males and 77.5 %were females. 7.7% were married and 92.3% were unmarried. 27.8% were heard about HPV and HPV vaccine.
Conclusion: This study has indicated that very few participants were aware about HPV vaccine. Hesitancy can be reduced by providing proper knowledge about safety and side effects of HPV vaccine.

Keywords:

HPV; Vaccination; Acceptance; Hesitancy.
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Study of hemoglobin levels among pregnant women in different trimesters at a tertiary hospital https://old.pisrt.org/psr-press/journals/tcms-vol-2-issue-4-2022/study-of-hemoglobin-levels-among-pregnant-women-in-different-trimesters-at-a-tertiary-hospital/ Fri, 30 Dec 2022 19:44:28 +0000 https://old.pisrt.org/?p=6965
TCMS-Vol. 2 (2022), Issue 4, pp. 26 - 31 Open Access Full-Text PDF
Sradhamoni Kumbang, Archana Khanikar, Rumi Konwar and Siddhartha Sankar Konwar
Abstract: Background: Pregnancy increases the demand for nutrients and hemoglobin. Besides these, physiological changes in blood parameters also occurs during pregnancy. Anemia in pregnancy is a serious condition contributing to increased maternal and fetal morbidity and mortality. Present study has been undertaken with the knowledge of hemoglobin values and its distribution in different trimesters of pregnancy. Material and Methods: Present study was single-center, prospective, comparative, parallel-group, observational study, conducted in pregnant women attended the ANC OPD or admitted in antenatal ward and sixty healthy non-pregnant women of same age group. Results: The mean hemoglobin value was \(12.23\pm1.32 gm\) % throughout pregnancy. In control group the mean value was \(12.59 \pm 2.50 gm\)%. Statistically significant variation was observed between control and each trimester of pregnancy \((p<0.05)\). Significant difference observed between 1st and 2nd trimester \((p < 0.05)\) and 2nd and 3rd trimester \((p < 0.05)\). When compared between 1st and 3rd trimester, difference was not significant \((p>0.05)\) Hemoglobin values are lower in pregnant cases as compared to non-pregnant subjects \((p<0.05)\). Lowest hemoglobin value is observed in 2nd trimester in maximum number of cases. Mean hemoglobin level was found lower in pregnant women with gravidity more than 1 as compared to primigravidae. Conclusion: A significant association was observed between hemoglobin level and trimester of pregnancy. High occurrence of low hemoglobin level in pregnant women was found belonging to lower socioeconomic class. Maternal hemoglobin value decreases with increase in gestational age. ]]>

Trends in Clinical and Medical Sciences

Study of hemoglobin levels among pregnant women in different trimesters at a tertiary hospital

Sradhamoni Kumbang\(^{1}\), Archana Khanikar\(^{1}\), Rumi Konwar\(^{1}\) and Siddhartha Sankar Konwar\(^{1,*}\)
\(^{1}\) Department of Physiology, Assam Medical College, Dibrugarh, Assam, India.
Correspondence should be addressed to Siddhartha Sankar Konwar at sskonwar@gmail.com

Abstract

Background: Pregnancy increases the demand for nutrients and hemoglobin. Besides these, physiological changes in blood parameters also occurs during pregnancy. Anemia in pregnancy is a serious condition contributing to increased maternal and fetal morbidity and mortality. Present study has been undertaken with the knowledge of hemoglobin values and its distribution in different trimesters of pregnancy.
Material and Methods: Present study was single-center, prospective, comparative, parallel-group, observational study, conducted in pregnant women attended the ANC OPD or admitted in antenatal ward and sixty healthy non-pregnant women of same age group.
Results: The mean hemoglobin value was \(12.23\pm1.32 gm\) % throughout pregnancy. In control group the mean value was \(12.59 \pm 2.50 gm\)%. Statistically significant variation was observed between control and each trimester of pregnancy \((p<0.05)\). Significant difference observed between 1st and 2nd trimester \((p < 0.05)\) and 2nd and 3rd trimester \((p < 0.05)\). When compared between 1st and 3rd trimester, difference was not significant \((p>0.05)\) Hemoglobin values are lower in pregnant cases as compared to non-pregnant subjects \((p<0.05)\). Lowest hemoglobin value is observed in 2nd trimester in maximum number of cases. Mean hemoglobin level was found lower in pregnant women with gravidity more than 1 as compared to primigravidae.
Conclusion: A significant association was observed between hemoglobin level and trimester of pregnancy. High occurrence of low hemoglobin level in pregnant women was found belonging to lower socioeconomic class. Maternal hemoglobin value decreases with increase in gestational age.

Keywords:

Hemoglobin level; Pregnancy; Trimester of pregnancy; Anemia.

1. Introduction

It has been known to mankind from ancient times that blood is the essence of life. Blood is a special type of connective tissue [1] which plays a vital role in our body as it helps in maintaining a series of physiological needs, the most important being the exchange of respiratory gases: oxygen and carbon dioxide.

The oxygen carrying capacity of blood is due to the presence of hemoglobin, the iron containing metalloprotein [2] inside the red blood cells or erythrocytes. Oxygen carried by hemoglobin is one of the vital mechanisms by which tissue survives. The level of hemoglobin in blood is dependent on nutrients, especially Iron, Folic Acid and Amino Acids [3] which are required for hemoglobin synthesis. The importance of hemoglobin lies in the fact that deficiency of hemoglobin leads to a condition known as anaemia, which can be caused by either too few red blood cells or too little hemoglobin in the cells [4], i.e., qualitative and quantitative reduction of hemoglobin and red blood cells in the circulation in relation to age and sex of the individual.

Pregnancy increases the demand for nutrients, hemoglobin. Besides these, physiological changes in blood parameters also occurs during pregnancy. Factors leading to anemia in obstetric cases are multiparity and blood loss in antepartum, intrapartum and postpartum period. Lactation, malnutrition and malabsorption are the additional factors. Anemia in pregnancy is a serious condition contributing to increased maternal and fetal morbidity and mortality [5].

The hemoglobin level in different trimesters have not been studied extensively in this part of the country. So the present study has been undertaken with a view that knowledge of hemoglobin values and its distribution in different trimesters of pregnancy in the study population will prove useful towards management of pregnant mother.

2. Material and methods

Present study was single-center, prospective, comparative, parallel-group, observational study, conducted in department of Physiology, Assam Medical College and Hospital, Dibrugarh, India. Study duration was of 1 year (September 2009 to August 2010). Study approval was obtained from institutional ethical committee.

Inclusion criteria

  • Patients attended the Outpatient Department of Obstetrics and Gynaecology or admitted in antenatal ward (for routine antenatal check up) without having other ailment, Willing to participate in present study.

Exclusion Criteria

  • Those subjects with medical illness like Diabetes, renal diseases, heart or lung disease.
  • Cases with prevailing illness or disease which is documented.

Study was explained to patients in local language & written consent was taken for participation & study. One hundred eighty (180) pregnant women, sixty (60) from each trimester of pregnancy belonging to the age group of 20-40 years and sixty (60) healthy non-pregnant women of same age group were taken as control. Details of cases & controls such as socio-demographic profile, obstetric history, antenatal care history, clinical history (complaints, past medical/surgical history), examination findings, laboratory reports were noted in case record proforma.

Hemoglobin Estimation was done by Cyanmethaemoglobin Method, 2 ml of venous blood is collected using EDTA as anticoagulant, 20 microliter of blood is then added to 5 ml of cyanide Ferricyanide solution. It is mixed thoroughly inverting the tube several times. After that the tube is allowed to stand at room temperature for 10 minutes for completion of the reaction then optical density of the solution is measured in a photoelectric colorimeter using a 540 nm filter and taking a reagent solution as black. The value of hemoglobin in gram percent is obtained with the help of standard table and curve prepared from Hemoglobin standard obtained from a reputed commercial firm.

Data was collected and compiled using Microsoft Excel, analysed using SPSS 23.0 version. Frequency, percentage, means and standard deviations (SD) was calculated for the continuous variables, while ratios and proportions were calculated for the categorical variables. Difference of proportions between qualitative variables were tested using chi- square test or Fisher exact test as applicable. P value less than 0.5 was considered as statistically significant.

3. Results

The study was carried out in 240 subjects out of which 60 being non-pregnant control and the remaining 180 in three different trimesters of pregnant (60 in each trimester). The mean hemoglobin value was 12.23 \(\pm\) 1.32 gm % throughout pregnancy.

Table 1. Comparison of hemoglobin in different trimesters of pregnancy.
Trimesters
1st 2nd 2nd 3rd 3rd 1st
Range 8.4-16.2 9.4-13.5 9.4-13.5 11.2-13.3 11.2-13.3 8.4-16.2
Mean  \(\pm\) SD Hemoglobin (gm%) 12.58  \(\pm\) 2.01 11.91 \(\pm\) 0.83 11.91 \(\pm\) 0.83 12.20 \(\pm\) 0.55 12.20 \(\pm\) 0.55 12.58 \(\pm\) 2.01
p Value < 0.05 < 0.05 > 0.05
In the 1st trimester of pregnancy, the range was from 8.4-16.2gm%. The mean value was 12.58 \(\pm\)2.01 gm%. In the 2nd trimester of pregnancy the range was from 9.4-13.5gm%. The mean value was 11.91 \(\pm\)0.83 gm %. In 3rd trimester of pregnancy the range was from 11.2-13.3 gm%. The mean value was 12.20 \(\pm\)0.55 gm%. Significant difference observed between 1st and 2nd trimester (\(p < \) 0.05) and 2nd and 3rd trimester (\(p < \) 0.05). When compared between 1st and 3rd trimester, difference was not significant (\(p>\)0.05), see Table 1.
Table 2. Comparison of mean hemoglobin of pregnant and control.
Pregnant women (\(n=\)180) Control (\(n =\) 60) p value
Mean Hemoglobin \(\pm\) SD (gm%) 12.23 \(\pm\) 1.32 12.59 \(\pm\) 2.50 < 0.05
From Table 2, it can be observed that the mean hemoglobin value was 12.23 \(\pm\) 1.32 gm % throughout pregnancy. In control group the mean value was 12.59 \(\pm\) 2.50 gm%. Statistically significant variation was observed between control and each trimester of pregnancy (\(p< \)0.05).
Table 3. Age wise distribution and hemoglobin in cases and controls.
Trimesters
1st Control 2nd Control 3rd Control
Range 8.4-16.2 7.2-16.8 9.4-13.5 7.2-16.8 11.2-13.3 7.2-16.8
Mean \(\pm\) SD Hemoglobin (gm%) 12.58 \(\pm\) 2.01 12.59 \(\pm\) 2.50 11.91 \(\pm\) 0.83 12.59 \(\pm\) 2.50 12.20 \(\pm\) 0.55 12.59 \(\pm\) 2.50
p Value <0.05 <0.05 <0.05
Table 3 shows that the Hemoglobin values are lower in pregnant cases as compared to non-pregnant subjects (\(p< \)0.05). Lowest hemoglobin value is observed in 2nd trimester in maximum number of cases.
Table 4.Gravidity wise distribution of hemoglobin level in different trimesters of pregnancy .
No. 1st Trimeste 2nd Trimeste 3rd Trimeste control
No. Mean \(\pm\) SD Hb (gm%) No. Mean \(\pm\) SD Hb (gm%) No. Mean \(\pm\) SD Hb (gm%) No. Mean \(\pm\) SD Hb (gm%)
20-25 8 12.58 \(\pm\) 2 8 11.44 \(\pm\) 0.83 12 12.09 \(\pm\) 0.60 10 12.36 \(\pm\) 2.69
26-30 25 12.84 \(\pm\) 2.11 25 11.87 \(\pm\) 0.76 23 12.32 \(\pm\) 0.55 24 12.85 \(\pm\) 2.70
31-35 21 12.38 \(\pm\) 2.09 20 12.21 \(\pm\) 0.76 19 12.15 \(\pm\) 0.53 18 12.56 \(\pm\) 2.64
It was observed from Table 4 that maximum number of cases belong to 26 to 30 years of age range. Out of 180 pregnant women 25 in the 1st and 2nd trimester each and 23 in the 3rd trimester of pregnancy. Mean hemoglobin values was 12.84 gm%, 11.87 gm% and 12.32 gm% in 1st, 2nd and 3rd trimester respectively in the same age range, i.e., 26-30 years. Age wise distribution was found to be statistically not significant.
Table 5. Gravidity wise distribution of hemoglobin level in different trimesters of pregnancy.
Gravida First Trimester Second Trimester Third ester Control
No. of cases (%) Mean \(\pm\) SD Hb (gm%) No. of cases (%) Mean \(\pm\) SD Hb (gm%) No. of cases (%) Mean \(\pm\) SD Hb (gm%) (%)
1 25
(41.67 %)
13.81\(\pm\)
1.85
26
(43.33 %)
12.24\(\pm\)
0.72
24
(40 %)
12.73\(\pm\)
0.22
75
(41.67 %)
2 9
(15 %)
12.42 \(\pm\)
2.09
14
(23.33 %)
11.49\(\pm\)
0.86
9
(15 %)
12.27\(\pm\)
0.05
32
(17.78 %)
3 11
(18.33 %)
11.95 \(\pm\)
1.50
8
(13.33 %)
11.61\(\pm\)
1.13
12
(20 %)
11.92\(\pm\)
0.26
31
(17.22 %)
4 13
(21.67 %)
11.03 \(\pm\)
1.21
10
(16.67 %)
11.78\(\pm\)
0.47
12
(20 %)
11.85\(\pm\)
0.20
35
(19.44 %)
Table 5 shows that the maximum number of cases were primigravidae comprising 41.67% of total cases. Mean hemoglobin value of 13.81 gm% and SD was 1.85, 12.24 gm% and SD 0.72 and 12.73 gm% and SD 0.22 in the 1st, 2nd and 3rd trimester respectively. It was observed that there was progressive decrease in mean hemoglobin level in pregnant women with increasing number of gravidity. Mean hemoglobin level was found lower in pregnant women with gravidity more than 1 as compared to primigravidae.
Table 6. Distribution of hemoglobin in different socio-economic class in pregnancy .
Socioeconomic Class No of cases Mean Hbgm (%) SD(\(\pm\))
Upper 0 - -
Upper Middle 10 13.04 1.52
Lower Middle 76 12.38 1.40
Upper Lower 59 12.11 1.34
Lower 35 11.87 1.26
It was observed from Table 6 that maximum number of cases (76 out of 180) belongs to lower middle strata of socioeconomic class as per Kuppuswamy's classification. There was not a single case from high socio-economic strata. In lower socioeconomic group mean hemoglobin level was found lower as compared to higher economic group.
Table 7. Distribution of hemoglobin according to dietary habit.
CASES Mean \(\pm\) SD Hb (gm%) CONTROL Mean \(\pm\) SD Hb (gm%) P Value
Vegetarian 12.30 \(\pm\) 1.22 12.53 \(\pm\) 2.59 \textgreater 0.05
Non vegetarian 12.21 \(\pm\) 1.63 12.89 \(\pm\) 2.16
It is observed from Table 7 that mean hemoglobin value in vegetarian was 12.30 gm%, SD 1.22 and 12.53 gm% and SD 2.59 in cases and control respectively. For non-vegetarian the values was 12.21 gm% and SD 1.63 and 12.89 gm%, SD 2.16. This variation in mean hemoglobin value in non-vegetarian is statistically not significant (\(p>\)0.05).

4. Discussion

Anaemia in pregnancy is an important preventable cause of maternal and perinatal morbidity and mortality. Pathological anaemia of pregnancy is mainly due to nutritional deficiency and among them iron deficiency anaemia is most common.

There are marked physiological changes in the composition of the blood in healthy pregnancy, mainly to combat the risk of hemorrhage at delivery. Plasma volume and red cell mass increases by 50% and 18.25% respectively, resulting in dilutional decrease in hemoglobin concentration called the physiological anaemia of pregnancy maximum at 32 weeks of gestation. WHO has recommended a cut off value of 11 gm/dl in 1st and 3rd trimester and 10.5 in 2nd trimester to define anaemia during pregnancy.

In India incidence of anaemia [6] during pregnancy ranges from 40-90%. In India, out of pregnant population of 22 million women [7] it affects 13 million pregnant women. About 0.5 million women die annually in India7 as a result of pregnancy and its complications. Anemia is the leading contribution to this high maternal mortality rate. Maternal consequences of anemia include cardiovascular symptoms, reduced physical and mental performance, reduced immune function and increased risk for blood transfusion in the postpartum period.

A detailed compilation of prevalence of anemia in women published by Brabin [8] estimated that maternal mortality ranges is 27 per 100,000 live births in India. Fetal consequences of iron deficiency anemia are an increased risk of growth retardation, premature birth, intra uterine death, amnion rupture and infection.

Women often become anemic during pregnancy because the demands for iron and other vitamins is increased. The mother must increase her production of red cells and in addition the fetus and placenta need their own supply of iron, which can only be obtained from the mother. In order to have enough red cells for the fetus, the body starts to produce more red cells and plasma.

In normal pregnancy there is a gradual and progressive fall in hemoglobin level up till the 32nd to 36th week [9] after which the level shows a gradual rise up till term. This initial fall in hemoglobin concentration has been attributed to the greater increase in plasma volume compared to increase in red cell volume. This phenomenon is known as physiological anemia of pregnancy.

Anemia may be pathological in some conditions when there is inability to meet the extra nutritional demands for hemoglobin synthesis during pregnancy. Some workers consider the fall in hemoglobin as a part of physiological anemia to be abnormal and have shown that some, if not all of this fall can be prevented by providing hematinic supplements. Deleterious effects occurs in mother as well as baby as a result of anaemia, which is multifactorial in our community.

In the present study, the mean hemoglobin concentration was 12.23 \(\pm\) 1.32 gm% throughout gestation. The results show that hemoglobin level falls progressively as the period of gestation progresses uptil 2nd trimester followed by slight rise up to term but still lower than 1st trimester. It was also seen that maximum number of cases had their lowest hemoglobin level in 2nd trimester of pregnancy. This is probably due to increasing requirements of iron and other nutritional factors for hemoglobin synthesis as the pregnancy progresses coupled with the fact that iron stores are exhausted in most women in the 2nd trimester. Moreover, maximum physiological hemodilution occurs in the 2nd trimester further exaggerating the condition.

It was observed that this trend of mean hemoglobin values of the present study was comparable with figures obtained by a number of researchers, see for example [10,11,12,13] in which the authors found a progressive fall in mean hemoglobin level from 1st trimester through the 3rdtrimester, but mean hemoglobin values were lower in the present study in comparison to study by other researchers.

Another study done by Iyenger et al., [6] obtained similar finding but mean hemoglobin values were comparatively higher than our study. This difference in hemoglobin values from the present study is probably due to varying no of cases, higher socio-economic and better nutritional status, higher level of education, health care delivery system of the place, and difference in race and ethnicity of the study population.

Another finding of the present study was that hemoglobin values of pregnant women were lower when compared to that of non-pregnant counterpart who had mean hemoglobin value of 12.59 gm%. This finding is correlated with study done by Knight et al., [11] who observed 79-82% variation of hemoglobin value from the non-pregnant status during 3 trimesters of pregnancy. This data is also consistent with findings of study done by Pulokka et al., [14] who observed that mean hemoglobin value is lower in pregnant women even if iron supplements are given during pregnancy. The possible explanation could be higher nutritional need for increased metabolic demand of pregnancy period as compared to non-pregnant group.

In the present study, it was observed that there was progressive decrease in mean hemoglobin level in pregnant women with increasing number of gravidity. On analysis of hemoglobin distribution according to parity it was observed that high parity rate is inversely related to hemoglobin level in pregnant women. This finding of the present study is consistent with the findings of previous studies done by a number of authors, see [10, 12, 15]. This finding is due to exhaustion of nutritional factors which depletes progressively with childbearing and may be due to previous illness and complications related to previous pregnancies.

In the present study, mean hemoglobin values were higher in vegetarian but statistically not significant. Conflicting results are observed in other studies which is probably due to the fact that in the present study vegetarian group belonged to higher socio-economic class as compared to non-vegetarian. In this part of the country proper study that described the pattern of hemoglobin concentration among pregnant women has not been done extensively.

The findings of the present study was parallel with the established relation between hemoglobin and trimester of pregnancy. Limitation of the study was that prevalence of Anaemia was not assessed in pregnant group and the their values were obtained in a wide range. As per WHO guidelines hemoglobin level of \(< 11\) gm% during 1st and 3rd trimester and \(< 10.5\) gm% in 2nd trimester of pregnancy is considered as anaemia. In the present study, a few cases had hemoglobin level in the range of anaemia as per WHO criteria. But to confirm anaemia further investigations were not performed among the study group. In this part of the country proper study that described the pattern of hemoglobin concentration among pregnant women has not been studied extensively.

Socioeconomic and demographic characteristics of a pregnant women have potential influence on hemoglobin distribution and other hematological changes during pregnancy. High frequency of low hemoglobin level in this study group reflects inadequate access to antenatal care, low socioeconomic background and nutritional deficiency and other socio-cultural behaviour of the women.

A knowledge of these hematological values and trends in the study population group would prove useful towards management of pregnant mothers and planning of maternal health services. A comprehensive community based intervention with iron supplementation, helminth treatment and increase in knowledge regarding information, education and communication through effective strategies, to improve the hematological status of pregnant women in each trimester, is needed.

5. Conclusion

A significant association was observed between hemoglobin level and trimester of pregnancy. High occurrence of low hemoglobin level in pregnant women was found belonging to lower socioeconomic class. Maternal hemoglobin value decreases with increase in gestational age. Distribution pattern of hemoglobin in pregnant women in this part of the country which is lower than that of non-pregnant counterparts correlates with the finding of studies in other parts of India.

Author Contributions:

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest:

"The authors declare no conflict of interest."

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COVID 19 associated mucormycosis: A curse in pandemic https://old.pisrt.org/psr-press/journals/tcms-vol-2-issue-4-2022/covid-19-associated-mucormycosis-a-curse-in-pandemic/ Fri, 30 Dec 2022 19:32:58 +0000 https://old.pisrt.org/?p=6963
TCMS-Vol. 2 (2022), Issue 4, pp. 18 - 25 Open Access Full-Text PDF
Dhruvika Rathva, Mayursinh Dodia, Atisha Modi and Saudhan Desai
Abstract: Aims: Mucormycosis is an acute invasive fungal infection which is rare, opportunistic and can potentially cause fatal complications. This study aimed to evaluate demographic data, disease presentation, medical &/or topical, surgical treatment. Material and methods: Total twenty five patients with mucormycosis treated at tertiary care hospital in Gujarat during three months duration from May to July 2021. After detailed history thorough Ear, Nose and throat examination was performed. Along with local examination, ophthalmologic and neurologic examination performed in every case. After Functional endoscopic sinus surgery, tissue sent for histopathologic examination. Results: Twenty five patients diagnosed with Mucormycosis, 18(72%) patients were males and 7(28%) were females. All 25(100%) had past history of COVID 19 infection and Diabetes Mellitus. Out of 25, 23(92%) patients were treated with intravenous or oral steroids and 2(8%) patients were not treated with any steroids. MRI paranasal sinuses with orbit with brain cuts performed for all 25 patients after suspicion of mucormycosis. 12(48%) patients had Sinonasal involvement, 11(44%) were Rhino-orbital involvement, and 2(8%) had Rhino palatal involvement. All 25(100%) patients were given Injection Amphotericin B for 3-4 weeks according to response. 6(24%) Patients were also given Oral Posaconazole. We performed Functional endoscopic sinus surgery in 23(92%) patients. In two (8%) cases Sinus surgery performed along with Maxillectomy. All 25(100%) cases on histopathology confirmed of Mucormycosis. Conclusion: Prognostic factors we observed in our study were involvement of rhino-orbito-cerebral disease shows poor prognosis. Good Diabetes control showed early recovery. Early identification and early treatment improves prognosis as well as survival rates. ]]>

Trends in Clinical and Medical Sciences

COVID 19 associated mucormycosis: A curse in pandemic

Dhruvika Rathva\(^{1}\), Mayursinh Dodia\(^{1}\), Atisha Modi\(^{1}\) and Saudhan Desai\(^{2,*}\)
\(^{1}\) Department of Otorhinolaryngology, Parul Institute of Medical Sciences and Research, Parul University, Vadodara, Gujarat, India.
\(^2\) Department of Ophthalmology, Parul Institute of Medical Sciences and Research, Parul university, Vadodara, Gujarat, India.
Correspondence should be addressed to Saudhan Desai at drsaudhandesai@gmail.com

Abstract

Aims: Mucormycosis is an acute invasive fungal infection which is rare, opportunistic and can potentially cause fatal complications. This study aimed to evaluate demographic data, disease presentation, medical &/or topical, surgical treatment.
Material and methods: Total twenty five patients with mucormycosis treated at tertiary care hospital in Gujarat during three months duration from May to July 2021. After detailed history thorough Ear, Nose and throat examination was performed. Along with local examination, ophthalmologic and neurologic examination performed in every case. After Functional endoscopic sinus surgery, tissue sent for histopathologic examination.
Results: Twenty five patients diagnosed with Mucormycosis, 18(72%) patients were males and 7(28%) were females. All 25(100%) had past history of COVID 19 infection and Diabetes Mellitus. Out of 25, 23(92%) patients were treated with intravenous or oral steroids and 2(8%) patients were not treated with any steroids. MRI paranasal sinuses with orbit with brain cuts performed for all 25 patients after suspicion of mucormycosis. 12(48%) patients had Sinonasal involvement, 11(44%) were Rhino-orbital involvement, and 2(8%) had Rhino palatal involvement. All 25(100%) patients were given Injection Amphotericin B for 3-4 weeks according to response. 6(24%) Patients were also given Oral Posaconazole. We performed Functional endoscopic sinus surgery in 23(92%) patients. In two (8%) cases Sinus surgery performed along with Maxillectomy. All 25(100%) cases on histopathology confirmed of Mucormycosis.
Conclusion: Prognostic factors we observed in our study were involvement of rhino-orbito-cerebral disease shows poor prognosis. Good Diabetes control showed early recovery. Early identification and early treatment improves prognosis as well as survival rates.

Keywords:

Antifungal therapy; Amphotericin B; Endoscopic surgery; Mucormycosis.

1. Introduction

Sinonasal mucormycosis is an acute invasive fungal infection which is rare, opportunistic and potentially fatal, that mostly occurs in immunocompromised patients[1]. Such immunocompromised patients are those with diabetes mellitus, prolonged corticosteroid therapy, solid organ transplant recipients, neutropenia and haematological malignancies[2]. Coronavirus disease (COVID-19), attributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a global pandemic by the World Health Organisation(WHO) in March 2020[3].

In recent years, it was observed a surge regarding the incidence of mucormycosis infection; extracted evidence from multiple published epidemiological studies revealed a pooled prevalence of Coronavirus disease 2019 (COVID-19)-associated mucormycosis 50 times higher than before the pandemic era.The proposed mechanism of pathogenesis consists of inhalation of fungal spores from air that determine the colonization of respiratory mucosa at the level of the nasal cavity and paranasal sinuses and rapid spread to surround-ing structures, facilitated by its angio-invasive properties.Based on the anatomical region where mucormycosis has developed, it can be classified into rhino-orbito-cerebral, gastrointestinal, pulmonary, renal, cutaneous, disseminated. Other rare sites include ear, parotid gland, heart, lymph nodes, and bones.

This disease is caused by saprophytic and opportunistic fungi of class Phycomycetes, order mucorales, family mucoraceae belonging to genus mucor and rhizopus[4]. The fungus is angioinvasive and causes thrombosis of vessels, with consequent black necrosis of nasal and sinus tissue. Surgery, antifungals- intravenous along with topical therapy remains the main treatment options.

Untreated of severe cases of Mucormycosis can lead to cavernous sinus thrombosis, periorbital destruction, palatine ulcers, osteomyelitis, disseminated infection and eventually death.

2. Material and methods

Total twenty eight patients with suspected mucormycosis treated at tertiary care hospital in Gujarat during three months duration from May to July 2021. Out of which total 25 cases has been included in this study. Two patients died due to complications related to COVID 19 infection and also complications of mucormycosis, of these one patient had histopathologically proven Rhino-orbito-cerebral mucormycosis and other had radiologically suspected Pulmonary mucormycosis. Third patient had radiologically suspected Sinonasal mucormycosis but clinically and histopathologically turn out to be negative, so patient treated as Rhinosinusitis case.

So, after excluding above mentioned three cases, in this study total 25 patients were analysed. After detailed history thorough Ear, Nose and throat examination was performed. All patients were also evaluated by ophthalmologists and Infectious disease specialist. Along with local examination, ophthalmologic and neurologic examination performed in every case. All routine blood investigations were done, see Figures 1,2 and 3.

Figure 1. Case of right side periorbital oedema at presentation.

Figure 2. Figure showing palatal involvement.

Figure 3. Intraoperative finding of palatal involvement of another case.

In our all cases MRI paranasal sinuses with orbit with brain done for confirmation of clinical suspicion of mucormycosis, extent of disease, intaorbital or intracranial involvement, CT scan of Paranasal sinuses to check extent of disease and 3D CT Face for palate involved cases done. Diagnostic Nasal Endoscopy was done, Tissue sent for Potassium hydroxide(KOH) examination. After Functional endoscopic sinus surgery, tissue sent for histopathologic examination. Treatment included multitherapy consisting of surgical debridement, control of blood sugar and injectable and/or oral Antifungal drugs after KOH or histopathological confirmation. Main antifungal given in all cases was Injectable Amphotericin B(1mg/kg/day) for 2-3 weeks, in few cases oral Posaconazole (800mg per day) for 4-6 weeks/ injectable Liposomal Amphotericin B for 2-3 weeks also given. Every alternate day renal function and serum electrolytes were monitored. Nasal endoscopy with local debridement done on alternate day with gelfoam soaked in Amphotericin B kept locally at surgically debrided area in few cases. Follow up was done every weekly for 3 weeks and then every month for 3 months.

3. Results

Twenty five patients diagnosed with Mucormycosis, 18(72%) patients were males and 7(28%) were females, see Table 1. Of all 25 cases Mean Age group 53 years $\pm$11standard deviation. All 25(100%) had past history of COVID 19 infection, But when came with mucormycosis related complaints, all patients RTPCR came negative. (Two patients diagnosed of mucormycosis on same presentation with COVID 19 with positive RTPCR report, but both expired during COVID 19 treatment, so excluded from study.) Clinical presentation observed in our cases was Nasal Obstruction 22 (88%), Nasal Discharge 2 (8%), Facial Pain 18 (72%), Facial Swelling 5 (20%), Vision Loss 1 (4%), Headache 21 (84%), Toothache 2 (8%), Periorbital Edema 7 (28%), see Table 2. All 25(100%) patients were also suffering from Diabetes Mellitus. Among 25 cases 8(32%) patients took treatment at Home in form of medications and home isolation for COVID 19 infection(one patient took oxygen therapy at home), one(4%) patient got admitted to hospital and stay was for less than 1 week. 16(64%) patients had COVID 19 related treatment at hospital with stay of 1-2 week. Total 18(72%) patients had to take Oxygen therapy for COVID 19 treatment, 7(28%) patients did not require O2 therapy. Out of 25, 23(92%) patients were treated with intravenous or oral steroids (Methyle presdnisolone/dexamethasone) and 2(8%) patients were not treated with any steroids. 14(56%) were given antiviral medications during COVID 19 treatment in form of Injection Remdesivir, 11(44%) patients did not require same. MRI paranasal sinuses with orbit with brain cuts performed for all 25 patients after suspicion of mucormycosis. 12(48%) patients had Sinonasal involvenment, 11(44%) were Rhino-orbital involvement, and 2(8%) had Rhino palatal involvement, see Table 3. All 25(100%) patients were given Injection Amphotericin B for 3-4 weeks according to response. 6(24%) Patients were also given Oral Posaconazole. We performed Functional endoscopic sinus surgery in 23(92%) patients. In two (8%) cases Sinus surgery performed along with Maxillectomy, see Table 4. All 25(100%) cases on histopathology confirmed of Mucormycosis. In case of Rhino orbital Mucormycosis 5(45%) patients were given retobulbar Amphotericin B injection on alternate day basis, for 2 weeks by Ophthalmologists, see Table 5. Advantages of performing surgery in mucormycosis cases are given in Table 6.
Table 1. Associated comorbidities.
Comorbidity Male Females Total
Diabetes 18 7 25 (100%)
Hypertension 5 4 9 (36%)
Table 2. Clinical presentation.
Symptoms : Patient No. (%)
Nasal Obstruction 22 (88%)
Nasal Discharge 2 (8%)
Facial Pain 18 (72%)
Facial Swelling 5 (20%)
Vision Loss 1 (4%)
Headache 21 (84%)
Toothache 2 (8%)
Periorbital Edema 7 (28%)
Table 3. Disease extension based on MRI Findings.
MRI fnding Patient No. (%)
Sinonasal 12 (48%)
Rhino Orbital 11 ( 44%)
Rhino Palatal 2 (8%)
Table 4. Treatment outcome.
Surgical : Patient No. (%)
FESS 23 (92%)
FESS + locally kept Amphotericin soaked gelfoam 5(20%)
FESS + Maxillectomy 2 (8%)
FESS + Retrobulbar Amphotericin Inj. 5 (20%)
Table 5. Treatment outcome.
Medical: Patient No. (%)
Inj Amphotericin B 25 (100%)
Oral Posaconazle 6 (24%)
Table 6. Advantages of performing surgery in mucormycosis cases.
i. Better penetration of Antifungal medications
ii. Slows down disease progression and restricts the extent allowing time for bone marrow regeneration
iii. Reduces the fungal load which reduces load on recovering neutrophils
iv. Provides a specimen for histopathology

4. Discussion

Along with increase in the novel coronavirus (COVID - 19) cases, number of opportunistic fungal infections appears to be raised. Globally, several cases of mucormycosis have been observed in patients with COVID-19, the term being used is COVID-19 associated mucormycosis (CAM). Mucormycosis has been declared an epidemic in several Indian states and has been classified as a notifiable disease. Early diagnosis and prompt initiation of treatment is crucial as the condition can progress rapidly with fatal outcome. The etiology of the sudden rise of mucormycosis in India appears to be multifactorial in nature with several hypothesis linking mucormycosis to severe Covid-19 patients who are immune compromised and/or have associated co-morbidities. For example, diabetes, which is a known risk factor for Covid, is also found to be strongly associated with risk of mucormycosis. According to the WHO[5], about 1.5 million deaths were attributed to diabetes globally, and its prevalence is increasing rapidly in low- and middle-income countries. India, home to over 77 million diabetics, has the second highest number of diabetics in the world next to China[6] and that the prevalence of diabetes in India is on the rapid rise[7].

In our study majority of patients were a male, which is similar to study by Pal et al.,[8]. We observed that all our cases were related to COVID-19 infection, majority of patients had suffered from disease. So Mucormycosis linked with it. Our all cases had associated diabetes mellitus, observed in all 25(100%) cases. Hyperglycemia, as seen in patients with uncontrolled diabetes mellitus, leads to phagocyte dysfunction, impaired chemotaxis and defective intracellular killing by oxidative and non-oxidative mechanisms[9]. Although data on the degree of glycemic control were infrequently reported across all the included studies, it is expected that COVID-19 might have further worsened the glucose profile of the patients with diabetes, thereby further predisposing them to mucormycosis. SARS-CoV-2 can infect and replicate in the human islet cells, leading to $\beta$-cell damage and reduced endogenous insulin secretion. Besides, the plethora of cytokines, as seen in patients with COVID-19, can lead to worsening of insulin resistance.% with COVID-19, can lead to worsening of insulin resistance.

Usually elevated in patients with severe COVID-19, interleukin-6 (IL-6) causes insulin resistance by impairing the phosphorylation of insulin receptor and insulin receptor substrate-1[10].

The use of glucocorticoids is a known risk factor for the development of mucormycosis[11]. Glucocorticoid-induced immunosuppression, hyperglycaemia and lymphopenia predispose to the pathogenesis of mucormycosis. The rampant use of glucocorticoids in patients with COVID-19 has undoubtedly contributed to the upsurge in the number of cases of CAM. Another indirect association between the concomitant surge in COVID-19 and mucormycosis is the dissemination of fungal spores via water used in oxygen humidifiers. Indeed, hospital water is a potential reservoir for fungi including Mucorales[12]. After such study found, in our hospital we used distilled water in oxygen humidifiers in COVID affected patients. We could not find out its actual relation in occurrence of post COVID-19 mucormycosis, due to lack of proper follow up of cases that were treated with only oxygen therapy for COVID 19 infections.

The 1950 Smith and Krichner criteria[13] for the clinical diagnosis of mucormycosis are still considered to be gold standard and include: \begin{description}

  • [(i)] Black, necrotic turbinate's easily mistaken for dried, crusted blood,
  • [(ii)]Blood-tinged nasal discharge and facial pain, both on the same side,
  • [(iii)]Soft peri-orbital or peri-nasal swelling with discoloration and induration,
  • [(iv)]Ptosis of the eyelid, proptosis of the eyeball and complete ophthalmoplegia and,
  • [(v)] Multiple cranial nerve palsies unrelated to documented lesions.
  • \end{description} In our study 72% cases had facial pain, 8% cases had blood stained nasal discharge and 28% cases had periorbital oedema. It can be correlated with Krichner criteria. All cases black necrotic tissues confirmed on nasal endoscopy. Imaging helps in diagnosis of Mucormycosis to evaluate the extent of disease plays a crucial role in early diagnosis and timely intervention. CT scan demonstrates nodular mucosal thickening with absence of fluid levels and hyperdense content leading to erosions of bony sinus walls.MRI provides better evaluation of intracranial and soft tissue involvement, skull base invasion, perineural spread and vascular obstruction. MRI demonstrates variable signal intensity depending on the sinus contents, due to iron and manganese in the fungal elements[14]. MRI contrast study shows invasion of orbital soft tissues, skull base infiltration, perineural spread, intracranial complications and vascular obstruction involving internal carotid artery.T2 slow flow can suggest internal carotid artery invasion by the fungus.In all our cases MRI imaging- MRI paranasal sinuses with orbit with brain cuts was done.

    In our study 12(48%) patients had Sinonasal involvement, 11(44%) had Rhino-orbital involvement, and 2(8%) had Rhino palatal involvement. These findings are similar to study by Abha et al.,[15], where most common sino-nasal disease involvement followed by rhino-orbital disease. In all our cases we performed Functional endoscopic sinus surgery. Advantages described in Table \ref{tab5}. In case of palatal involvement, after maxillectomy obturator was given to cover defect & to prevent nasal regurgitation.

    Despite recent tremendous advancements in sinus surgery, invasive fungal sinusitis still has a high mortality rate. So, many researchers have recommended sinus surgery/debridement and long-term antifungal treatment. These might cause severe morbidity and complications, so some treatment techniques have been modified in order to gain better clinical outcomes. Direct introduction of amphotericin B to the sinus cavity is one of the options which we followed. We did it in 5(20%) cases, which showed better outcome. Those patients had early recovery. After surgery, local area packed with gelfoam soaked in Amphotericin B(50mg vial of Amphotericin B diluted in 10ml of sterile water). This method helps in reducing density of fungal spores. Many researchers have used topical treatment, but well designed, controlled studies are needed to evaluate patients responses to this type of treatment.

    All 25 patients treated with Injectable Amphotericin B, with dose of 1 mg/kg/day or Liposomal Amphotericin B 3-5mg/kg/day for 2-3 weeks. Liposomal or conventional injection usage, decided on basis of availability, cost and comorbidities of patients. Amphotericin B acts by binding to ergosterol in the cell membrane of fungi. After binding with ergosterol, it causes the formation of ion channels leading to loss of protons and monovalent cations, which results in depolarization and concentration-dependent cell killing. Additionally, amphotericin B also produces oxidative damage to the cells with the formation of free radicals and subsequently increased membrane permeability. Amphotericin B also has a stimulatory effect on phagocytic cells, which assists in fungal infection clearance.The half-life of amphotericin B is from 24 hours to 15 days.

    Infusion related reactions occur in few cases. Such reactions can be rigor, chills, fever, headache, nausea, malaise or generalised rashes. Reactions can be avoided or minimized by premedication with aspirin or ibuprofen or by adding 25mg of hydrocortisone to the infusion directly[13]. We did not notice any kind of infusion related reactions in our patients receiving Injection Amphotericin B. Oral Posaconazole(800mg per day) can be used for salvage treatment in patients who are intolerant to Amphotericin B. It can also be used as a step down therapy after initial control of the disease with Amphotericin B. We used oral Posaconazole in 6(24%) cases after initial control with Injection Amphotericin B. Oral Isavuconazole also being better option, but not used in any case due to unavailability.

    Hyperbaric oxygen has been used as an adjunct to the current therapeutic approach of aggressive surgical debridement, Amphotericin B therapy and control of underlying predisposing conditions. Although studies have shown that hyperbaric oxygen exerts a fungistatic effect, its most important effect is to aid neovascularization with subsequent healing in poorly perfused acidotic and hypoxicbut viable tissue. Hyperbaric oxygen therapy for mucormycosis should consist of exposure to 100% oxygen for 90 min to 2 hour at pressures of 2.0-2.5 atmospheres with one or two exposures daily for a total of 40 treatments. Reported toxicities of hyperbaric oxygen include teratogenicity and, rarely, pulmonary or CNS side-effects. Although hyperbaric oxygen is offered by only a few medical facilities, it may be warranted in patients who appear to be deteriorating despite maximal surgical and medical therapy[16]. Though we did not treat any case of mucormycosis with Hyperbaric oxygen therapy.

    Antifungal therapy started only after KOH or histopathological confirmed cases of Mucor. On histopathology, the fungal hyphae seen as broad, ribbon like, irregular and aseptate with branching at right angle. On KOH also broad, aseptate hyphae seen.

    To note, our study has few limitations. 25 cases in this study can be considered as small sample size. This disease seen rarely in past but post COVID 19 era rapid surge was seen. High cost treatment is one of factor for less number of patients. Being an observational study there is no control group to evaluate differences.

    5. Key message

    • Mucormycosis is a rare and occasionally fatal opportunistic infection that affects immunocompromised patients. Most patients who encounter mucormycosis are diabetic with uncontrolled diabetes. Occurrence of many cases of mucormycosis was a curse in already bad situation of COVID 19 infection, which lead to significant morbidity.
    • In the COVID-19 era, the rate of mucormycosis seems to be increasing, and the earlier the presentation to hospitals, the better the outcome. Early surgical debridement and antifungal therapy is must for treatment. Use of steroids in COVID 19 related cases was like walking on double edge sword. So, A standard dose recommended by the World Health Organization based on the RECOVERY trial that is 6 mg of dexamethasone once daily for no more than 7-10 days should be strictly adhered to and lower doses should be considered in immunocompromised or diabetic patients.
    • Prognostic factors we observed in our study were; involvement of rhino-orbito-cerebral disease shows poor prognosis. Good Diabetes control showed early recovery. Early identification and early treatment improves prognosis as well as survival rates.
    • Disclosure of potential conflicts of interest: All authors declare that they have no conflicts of interest.
    • Informed Consent: Informed consent was obtained from all individual participants included in the study. Additional informed consent was obtained from one participant whose identifying information is included in this article.
    • Sources of funding: None
    • Ethical approval: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional ethics committee and with the 1964 Helsinki declaration.

    Author Contributions:

    All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

    Conflicts of Interest:

    "The authors declare no conflict of interest."

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    Pap smear: Are we choosing wisely? An observational study of clinicopathologic variables of patients undergoing Pap smear examination https://old.pisrt.org/psr-press/journals/tcms-vol-2-issue-4-2022/pap-smear-are-we-choosing-wisely-an-observational-study-of-clinicopathologic-variables-of-patients-undergoing-pap-smear-examination/ Fri, 30 Dec 2022 19:20:39 +0000 https://old.pisrt.org/?p=6959
    TCMS-Vol. 2 (2022), Issue 4, pp. 12 - 17 Open Access Full-Text PDF
    Vani Swapnil Garde
    Abstract: Background: Cervical cancer is a major cause of mortality in women. Pap smear is a screening test used in the screening of cervical cancer. There are well defined guidelines regarding its use. It should be offered to all sexually active women between the ages of 30-65 years, irrespective of whether or not they are symptomatic. Moreover, those women who have undergone hysterectomy for reasons other than cervical cancer or precancerous lesions, do not require this test. Materials and methods: We undertook an observational study to describe the age, presenting complaint, previous history of hysterectomy and reason for hysterectomy in women undergoing Pap smear testing in a private super speciality hospital in Central India in the past 3 years. Objectives: The objective of this study was to examine how closely the aforementioned guidelines were being followed, so as to deduce how wisely were we choosing the women to whom the test was being offered. Results: This study found that a significant proportion of tests were being offered to women who did not need them. And more importantly, we were missing the opportunity to screen women who presented with non gynaecologic complaints in our hospital.
    Conclusion: Hence we present the findings of this study to reassert the role of Pap smear as a screening test, the primary goal of which is to identify high grade precancerous lesions of the cervix; and to sensitizesensitise specialist physicians other than gynaecologists to offer Pap smear to women presenting with complaints unrelated to the genitourinary tract: so that we can choose wisely as to who should and who should not get the test.
    ]]>

    Trends in Clinical and Medical Sciences

    Pap smear: Are we choosing wisely? An observational study of clinicopathologic variables of patients undergoing Pap smear examination

    Vani Swapnil Garde
    LN Medical College and Research Centre, Kolar Rd, Sarvadharam C Sector, Shirdipuram, Sarvadharam, Bhopal, Madhya Pradesh 462042, India; vanisgarde@gmail.com

    Abstract

    Background: Cervical cancer is a major cause of mortality in women. Pap smear is a screening test used in the screening of cervical cancer. There are well defined guidelines regarding its use. It should be offered to all sexually active women between the ages of 30-65 years, irrespective of whether or not they are symptomatic. Moreover, those women who have undergone hysterectomy for reasons other than cervical cancer or precancerous lesions, do not require this test.
    Materials and methods: We undertook an observational study to describe the age, presenting complaint, previous history of hysterectomy and reason for hysterectomy in women undergoing Pap smear testing in a private super speciality hospital in Central India in the past 3 years.
    Objectives: The objective of this study was to examine how closely the aforementioned guidelines were being followed, so as to deduce how wisely were we choosing the women to whom the test was being offered.
    Results: This study found that a significant proportion of tests were being offered to women who did not need them. And more importantly, we were missing the opportunity to screen women who presented with non gynaecologic complaints in our hospital.
    Conclusion: Hence we present the findings of this study to reassert the role of Pap smear as a screening test, the primary goal of which is to identify high grade precancerous lesions of the cervix; and to sensitizesensitise specialist physicians other than gynaecologists to offer Pap smear to women presenting with complaints unrelated to the genitourinary tract: so that we can choose wisely as to who should and who should not get the test.

    Keywords:

    Cervical cancer; Choosing wisely; HPV; Pap smear; Patient anxiety; Screening; Screening guidelines; Unnecessary cost; Unnecessary testing.

    1. Introduction

    As per Globocan 2020, 6,04,100 new cases of cervical cancer were detected globally in 2020 and 3,41,831 deaths were attributed to this malignancy. In India, cervical cancer accounted for 9.4% of all cancers and 18.3%(1,23,907) of new cases in 2020: making it the third most common cancer incidence wise in the Indian population. It was also the second most common cause of cancer death in the Indianpopulation [1] Department of Health Research has released a Health Technology Assessment for early diagnosis of cervical cancer. There is sufficient evidence that suggests that screening leads to a reduction in the occurrence of cervical cancer cases with a decrease in cancer deaths [2].

    The Papanicolaou test (abbreviated as Pap test, also known as Pap smear, cervical smear) is a method of cervical cancer screening. The test was independently invented in the 1920s by Georgios Papanikolaou and Aurel Babe? and named after Papanikolaou. The primary goal of cervical cancer screening is to identify precancerous lesions caused by Human Papilloma Virus (HPV) so they can be removed to prevent invasive cancers from developing. A secondary goal is to find cervical cancers at an early stage, when they can usually be treated successfully. Abnormal findings are often followed up by more sensitive diagnostic procedures and, if warranted, interventions that aim to prevent progression to cervical cancer.

    Choosing Wisely is an initiative of the ABIM (American Board of Internal Medicine) Foundation that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures [3].The campaign identifies over 500 tests and procedures and encourages doctors and patients to discuss, research, and possibly get second opinions, before proceeding with them.

    The Choosing Wisely Pap Test patient resource web page [4] states:

    Pap tests usually don't help low-risk women

    Many women have a very low risk for cervical cancer.
    • Cervical cancer is rare in women younger than 21, even if they are sexually active. Abnormal cells in younger women usually return to normal without treatment.
    • Cervical cancer is rare in women over 65 who have had regular Pap tests with normal results.
    • Pap tests are not useful for women who have had their cervix removed during a hysterectomy, unless the hysterectomy was done because there were cancer or pre-cancer cells in the cervix.

    Pap tests can have risks

    A Pap test can be uncomfortable and cause a little bleeding. The test may show something that does not look normal but would go away on its own. Abnormal results cause anxiety. And they can lead to repeat Pap tests and follow-up treatment that you may not need.

    The tests cost money

    A Pap test is done during a pelvic exam. Although costs vary across the country and even from practice to practice, any money spent on an unnecessary test is money wasted.

    So, when do I need a Pap test

    That depends on your age, your medical history, and your risks.
    • Ages 21 to 30: You should have a Pap test every three years. Cervical cancer takes 10 to 20 years to develop, so you don't need the test each year. You do not need a Pap test before age 21, even if you are sexually active.
    • Ages 30 to 65: The new guidelines from the American Cancer Society and others say that you can have the Pap test every five years as long as you have a test for the human papillomavirus, or HPV, at the same time. HPV is a sexually transmitted infection that can cause cervical cancer.
    • Age 65 or older: You do not need Pap tests if your recent ones have been normal. If you have risk factors for cervical cancer, ask your doctor how often you need a Pap test. Risk factors include: pre-cancer cells in your cervix, a history of cervical cancer, or a weak immune system."
    The Operational Framework-Common Cancers published by Ministry of Health and Family Welfare(MOHFW), Government of India states that women ages 30-65 years should be screened for cervical cancer using Visual Inspection with Acetic Acid(VIA) once every 5 years [4].

    2. Material and methods

    Study design: Descriptive Observational study.

    Inclusion criteria

    I collected data regarding age, presenting complaint , and interpretation of Pap smears of women undergoing Pap smear examination in a private superspeciality hospital in Central India in the past 3 years. I also recorded whether those women undergoing Pap smear had a previous history of hysterectomy, and if yes, then whether hysterectomy was performed because there was invasive cancer or precancerous lesion in the cervix. All the data was collected from the investigation request form sent along with the Pap smear slides.

    Exclusion criteria

    Those subjects whose investigation request form sent along with the Pap smear slides lacked the details regarding age, presenting complaint, history of hysterectomy, and reason for hysterectomy were not included in this study. The age of the study participants was recorded in years and subjects were categorized into age groups as follows:
    1. \(<\)21,
    2. 21-29,
    3. 30-65,
    4. \(>\)65.
    The presenting complaints of the study participants were grouped under the following categories:
    1. Screening: where there was no complaint, Pap smear was done as a screening procedure (in asymptomatic subjects).
    2. Abdominal pain (as reported by the patient).
    3. AUB(abnormal uterine bleeding): including menorrhagia, irregular bleeding in women of reproductive age group, post coital bleeding, post menopausal bleeding. (as reported by the patient).
    4. Leucorrhoea: thick whitish or yellowish colour discharge from the vagina. (as reported by the patient).
    5. Prolapse:the uterus slipped down into or protruding out of the vagina(as reported by the gynaecologist).
    6. Erosion: red, inflamed patch surrounding the external is(as reported by the gynaecologist).
    7. Fibroid: benign neoplasm of smooth muscle in the uterus (as reported by the gynaecologist).
    8. Cervicitis: Any redness on cervix, discharge, blood on vagina or cervix.(as reported by the gynaecologist).
    9. UTI: urinary tract infection, an infection in any part of urinary system-kidneys, ureters, bladder and urethra.(as reported by the gynaecologist).
    10. Other: including polyp, infertility, vaginitis, ovarian cyst, ovarian cancer.
    The subjects undergoing Pap smear and having a history of hysterectomy were categorized as:
    1. Hysterectomy Not done,
    2. Hysterectomy done.
    The reasons for hysterectomy in those who had a history of hysterectomy and were undergoing Pap smear testing were categorized as:
    1. Invasive cancer/precancerous lesion (including LSIL, HSIL, AGC),
    2. other.
    All the smears we received were made by conventional method and stained using Biolab Rapid Pap kit. The Bethesda system for reporting cervical Pap smears was used to interpret the Pap smears received. The smears were categorized into the following diagnostic categories;
    1. NILM: Negative for Intraepithelial Lesion or Malignancy.
    2. Inadequate: A conventional smear broken (shattered) beyond repair; there was deemed to be a poor or scanty squamous epithelial component to the cervical smear (less than 8,000 to 12,000 well preserved, well visualized squamous cells on a conventional smear); blood, inflammatory cells, lubricant, thick clumps of cells, air-drying artefact or poorly fixed cells hindered the accurate interpretation of the sample.
    3. ASCUS: Atypical Squamous Cells of Undetermined Significance.
    4. LSIL: Low-grade Squamous Intraepithelial Lesion.
    5. ASC-H: Atypical Squamous Cells, Cannot Rule Out High Grade Squamous Intra-epithelial Lesion.
    6. HSIL: How-grade Squamous Intraepithelial Lesion.
    7. SCC: Squamous Cell Carcinoma.
    8. AGC: Atypical Glandular Cells.
    I then compared the observations of this study with the Choosing Wisely patient resources for Pap smear [4], and MOHFW guidelines [5].

    3. Results

    Out of a total of 1878 request forms for Pap smear test received in the past 3 years, only 1005 carried all the required data pertaining to age, presenting complaint, previous history of hysterectomy, and the diagnosis of cancer or precancerous lesion in those who had had a hysterectomy. The age distribution (Table 1) of subjects undergoing Pap smear examination was as follows: The frequency of distribution of various presenting complaint (Table 2) of women undergoing Pap smear was as follows: The number of subjects undergoing Pap smear and having History of hysterectomy (Table3) was as follows The reason for hysterectomy in those who had a history of hysterectomy and were undergoing Pap smear testing (Table 4) was as follows: The frequency of distribution of various interpretations (Table 5) on Pap smear was as follows:
    Table 1. Age distribution of subjects undergoing Pap smear examination.
    Age Number Percent
    <21 3 0.3
    21-29 124 12.3
    30-65 859 85.5
    <65 19 1.9
    Total 1005 100
    Table 2. frequency of distribution of various presenting complaint of women undergoing Pap smear .
    Presenting complaint Number Percent
    Screening 230 22.9
    Abdominal pain 225 22.5
    AUB 160 15.9
    Leucorrhoea 115 11.5
    Prolapse 92 9.2
    Erosion 56 5.5
    Fibroid 30 2.9
    Cervicitis 27 2.7
    UTI 26 2.6
    Other 44 4.3
    Total 1005 100
    Table 3. number of subjects undergoing Pap smear and having History of hysterectomy.
    Hysterectomy Number Percent
    Not done 992 98.7
    done 13 1.3
    Total 1005 100
    Table 4. Reason for hysterectomy in those who had a history of hysterectomy and were undergoing Pap smear testing.
    Reason for hysterectomy Number Percent
    Invasive cancer/precancerous lesion 1 7.7
    Other 12 92.3
    Total 13 100
    Table 1. Age distribution of subjects undergoing Pap smear examination.
    Interpretation Number Percent
    NILM 873 86.8
    Inadequate 91 9.1
    ASCUS 16 1.6
    LSIL 14 1.4
    HSIL 7 0.7
    SCC 3 0.3
    AGC 1 0.1
    ASC-H 0 0.0
    Total 1005 100

    4. Discussion

    As per the Choosing Wisely patient resources for Pap smear [4], women less than 21 years of age do not need to be screened for cervical cancer, as they are at a very low risk for developing it. In this study only 3 subjects (0.3%) were falling in this age group. The majority (983(97.8%)) were conforming to the age of screening recommended by Choosing Wisely. However, 19 subjects(1.9%) were aged greater than 65 years. In this older age group there was no record of previous Pap smear done, and hence a Pap smear done in them was still justified as per the Choosing Wisely guidelines.

    However, the Choosing Wisely guidelines differ from those of MOHFW, Government of India [4], which recommend starting screening every 5 years from the age of 30 years and continuing upto 65 years of age. As per these guidelines 127(12.6%) of the study subjects were less than 30 years of age and did not require screening.

    Pap smear is a screening test for cervical cancer.

    A screening test is defined as "the search for unrecognized disease or defect by means of rapidly applied tests or examinations or other procedures in apparently healthy individuals" [6]. Opportunistic screening relies on screening patients for common diseases unrelated to their presenting complaint. In this study 230 subjects (22.9%) were apparently healthy(had no presenting complaint), the majority (775(77.1%)) presented with some genitourinary complaint. In a country like India where awareness regarding Pap screening among the population is limited, and social and cultural attitudes are limiting factors, this kind of opportunistic screening might be justified. However, all those subjects who presented with a complaint were primarily managed by a gynaecologist, none of the subjects in this study were primarily managed by a specialist other than a gynaecologist. From this observation it can be deduced that gynaecologists, who are trained in obtaining Pap smear and are also sensitized to the cause of cervical cancer screening are more likely to screen their patients opportunistically for the same as compared to other specialist physicians. This highlights the need to sensitize specialist physicians other than gynaecologists to opportunistically screen their patients for cervical cancer.

    Also notable in this study was that 115 subjects (11.5%) presented with leucorrhoea (white discharge from vagina), this figure closely correlating with the proportion of Pap smears interpreted as "Inadequate"(91 smears,9.1%). Out of the 91 smears interpreted as Inadequate in our study, 83 were due to dense inflammatory infiltrate obscuring the nuclear details of the cervical cells on the slide. This highlights the need for treating clinically apparent causes for leucorrhoea prior to taking the Pap smear. The "Inadequate" interpretation leads to repeat testing and patient anxiety. Though an argument can be made against this that a Pap smear might be helpful in finding out the cause of vaginal discharge (sexually transmitted infections such as Trichomoniasis, bacterial vaginosis, gonorrhoea, candida), detecting infectious agents is not the primary goal of Pap smear, the primary goal of Pap smear is to identify precancerous lesions caused by Human Papilloma Virus (HPV) so they can be removed to prevent invasive cancers from developing. Also, not treating the infection prior to Pap smear can lead to a higher rate of false negatives due to obscuring inflammation, as well as higher rate of false positives due to reactive changes induced by the inflammation being misinterpreted as cervical cells suspicious for precancerous lesion. This again leads to unnecessary patient anxiety and extra costs of repeated testing, follow up diagnostictesting or unnecessary therapy.

    In this study, 12 subjects had undergone a previous hysterectomy for causes other than invasive cancer or precancerous lesions. This again was not justified as per the Choosing Wisely guidelines [4].

    I do acknowledge the fact that this was a small study, involving the experience from a single institute, and that it might not be appropriate to extrapolate these observations to the population at large. Given that this study was conducted at a private institute, where the patients were capable of paying higher costs for healthcare(and thus had access to purportedly better healthcare), and were also more literate than the general population (thus more capable of making informed decisions for themselves), is all the more reason to ponder: Pap smear: are we choosing wisely?

    Author Contributions:

    All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

    Conflicts of Interest:

    "The authors declare no conflict of interest."

    References

    1. Cancer Today [Internet]. Global Cancer Observatory. Accessed at 18 November 2022.
    2. Strategies for cervical cancer screening in India [Internet]. Accessed on 18 November 2022.
    3. Choosing wisely [Internet]. Choosing Wisely: Promoting conversations between providers and patients. Accessed on 18 November 2022.
    4. Foundation ABIM. Pap Tests: Choosing wisely [Internet]. Choosing Wisely: Promoting conversations between providers and patients. Accessed on 18 November 2022.
    5. Operational framework: management of common cancers. New Delhi, India: Government of India Ministry of Health and Family Welfare; 2016.
    6. Park, K. (2005). Park's textbook of preventive and social medicine. Preventive Medicine in Obstet, Paediatrics and Geriatrics
    ]]>
    A clinico-pathological study of colonic biopsies https://old.pisrt.org/psr-press/journals/tcms-vol-2-issue-4-2022/a-clinico-pathological-study-of-colonic-biopsies/ Fri, 30 Dec 2022 19:07:51 +0000 https://old.pisrt.org/?p=6956
    TCMS-Vol. 2 (2022), Issue 4, pp. 8 - 11 Open Access Full-Text PDF
    Alka Dixit Vats and Anubhav Garg
    Abstract: Background: To assess clinico-pathological study of colonic biopsies. Materials and methods: One hundred ten colonic biopsies obtained from Gastroenterology department were collected in 10% neutral buffered formalin processed and embedded with the mucosal surface being uppermost. 4\(\mu\) thick serial sections were prepared and stained with H&E. Detailed study of the sections was done under light microscope and diagnosis rendered accordingly. Result: Age group 11-20 years had 8, 21-30 years had 22, 31-40 years had 40, 41-50 years had 24 and >50 years had 16 cases. The difference was non- significant (\(P> 0.05\)). Most common clinical features were constipation seen in 36, bleeding PR in 28, bleeding PR weakness in 17, diarrhea in 16 and diarrhea \(+\) pain abdomen \(+\) weakness in 14 patients. The difference was non-significant (\(P> 0.05\)). Non-neoplastic lesions were 74. These were as non-specific colitis in 22, ulcerative colitis in 16, acute inflammation in 14, hyperplastic polyp in 10, inflammatory polyp in 6, retention polyp in 4 and endometriosis in 2 cases. Neoplastic benign lesions were 25. Benign spindle cell lesion was in 3, tubular adenoma in 15, villous adenoma in 5 and tubulovillous adenoma in 2 cases. Neoplastic malignant lesions were well differentiated adenocarcinoma seen in 4, moderately differentiated adenocarcinoma in 6, poorly differentiated adenocarcinoma in 2 and signet ring cell carcinoma in 1 case. Conclusion: Colonoscopy is a simple and a safe procedure. It helps in assessing the lesions clinically and confirming histopathologicaly through guided biopsy. Colonoscopic biopsies also play a key role not only in diagnosis, but also in follow up and treatment. ]]>

    Trends in Clinical and Medical Sciences

    A clinico-pathological study of colonic biopsies

    Alka Dixit Vats\(^{1}\) and Anubhav Garg(^{1,*}\)
    \(^{1}\) Department of Pathology, Rama Medical College Hospital & Research Centre, Hapur, Uttar Pradesh, India.
    Correspondence should be addressed to Anubhav Garg at dr.anubhavgarg@gmail.com

    Abstract

    Background: To assess clinico-pathological study of colonic biopsies.
    Materials and methods: One hundred ten colonic biopsies obtained from Gastroenterology department were collected in 10% neutral buffered formalin processed and embedded with the mucosal surface being uppermost. 4\(\mu\) thick serial sections were prepared and stained with H&E. Detailed study of the sections was done under light microscope and diagnosis rendered accordingly.
    Result: Age group 11-20 years had 8, 21-30 years had 22, 31-40 years had 40, 41-50 years had 24 and >50 years had 16 cases. The difference was non- significant (\(P> 0.05\)). Most common clinical features were constipation seen in 36, bleeding PR in 28, bleeding PR weakness in 17, diarrhea in 16 and diarrhea \(+\) pain abdomen \(+\) weakness in 14 patients. The difference was non-significant (\(P> 0.05\)). Non-neoplastic lesions were 74. These were as non-specific colitis in 22, ulcerative colitis in 16, acute inflammation in 14, hyperplastic polyp in 10, inflammatory polyp in 6, retention polyp in 4 and endometriosis in 2 cases. Neoplastic benign lesions were 25. Benign spindle cell lesion was in 3, tubular adenoma in 15, villous adenoma in 5 and tubulovillous adenoma in 2 cases. Neoplastic malignant lesions were well differentiated adenocarcinoma seen in 4, moderately differentiated adenocarcinoma in 6, poorly differentiated adenocarcinoma in 2 and signet ring cell carcinoma in 1 case.
    Conclusion: Colonoscopy is a simple and a safe procedure. It helps in assessing the lesions clinically and confirming histopathologicaly through guided biopsy. Colonoscopic biopsies also play a key role not only in diagnosis, but also in follow up and treatment.

    Keywords:

    Gastroenterology; Colonoscopy; Biopsy.

    1. Introduction

    A variety of inflammatory and neoplastic disorders affect the lower gastrointestinal tract, with differing clinical outcomes and management. These conditions encompass a spectrum of acute and chronic conditions [1]. Colon is the primary site for various non neoplastic and neoplastic diseases. The spectrum of colonic lesions ranges from congenital diseases, infections, inflammatory conditions, vascular diseases, polyps and colorectal tumours. Colorectal carcinoma is one of the leading cause of morbidity and mortality with an overall cancer incidence rate of 9% [2].

    The development of flexible endoscopes has led to the increase in the examination and mucosal biopsy evaluation of all portions of large intestine and rectum [3]. Another rapidly evolving technique is the Virtual colonoscopy, in which data from computed tomography are used to generate both two-dimensional and three-dimensional displays of the colon and rectum [4]. Vining introduced virtual colonoscopy in 1994 to maintain the desirable features of colonoscopy of ease of lesion detection while avoiding the undesirable features of colonoscopy of test invasiveness, patient discomfort, need for sedation, analgesia and test risks [5].

    Colonic mucosal biopsies procured from colonoscopy plays a crucial role in specific diagnosis of patients with Inflammatory Bowel disease and early detection of colonic epithelial tumours. Histopathological interpretation of colonic mucosal biopsies when correlated with clinical finding helps in definitive diagnosis and early treatment of patients with colonic lesions [6]. Considering this, we performed clinico-pathological study of colonic biopsies.

    2. Materials and methods

    A sum total of one hundred ten colonic biopsies obtained from Gastroenterology department were selected for the study. Ethical clearance was obtained before starting the study. Inclusion criteria was all the colonoscopic biopsies taken from terminal ileum to rectum, received in the Department of Pathology. Exclusion criteria was poorly fixed/unfixed specimens.

    After obtaining tissues, all colonoscopic biopsy specimens were collected in 10% neutral buffered formalin processed and embedded with the mucosal surface being uppermost. 4 \(\mu \) thick serial sections were prepared and stained with H &E. Detailed study of the sections was done under light microscope and diagnosis rendered accordingly. Results were tabulated and assessed statistically. P value less than 0.05 was considered significant.

    3. Results

    Age group 11-20 years had 8, 21-30 years had 22, 31-40 years had 40, 41-50 years had 24 and >50 years had 16 cases. The difference was non- significant (\(P> 0.05\)) [Table 1].

    Most common clinical features were constipation seen in 36, bleeding PR in 28, bleeding PR weakness in 17, diarrhea in 16 and diarrhea + pain abdomen + weakness in 14 patients. The difference was non- significant (\(P> 0.05\)) [Table 2].

    Table 1. Distribution of patients based on age group.
    Age group (years) Number P value
    11-20 8 0.82
    21-30 22
    31-40 40
    41-50 24
    <50 16
    Table 2. Assessment of clinical profile.
    Clinical profile Number P value
    Constipation 36 0.72
    Bleeding PR 28
    Bleeding PR weakness 17
    Diarrhea 16
    Diarrhea + Pain abdomen + weakness 14
    Table 3. Distribution of non-neoplastic and neoplastic lesions.
    Parameters Variables Number P value
    Non-neoplastic
    (74)
    Non-specifc colitis 22 0.05
    Ulcerative colitis 16
    Acute inflammation 14
    Hyperplastic polyp 10
    Inflammatory polyp 6
    Retention polyp 4
    Endometriosis 2
    Neoplastic benign
    (25)
    Benign spindle cell lesion 3 0.02
    Tubular Adenoma 15
    Villous Adenoma 5
    Tubulovillous Adenoma 2
    Neoplastic Malignant
    (13)
    Well differentiated adenocarcinoma 4 0.04
    Moderately differentiated Adenocarcinoma 6
    Poorly differentiated Adenocarcinoma 2
    Signet ring cell Carcinoma 1

    Figure 1. Distribution of non-neoplastic and neoplastic lesions.

    Non-neoplastic lesions were 74. These were as non-specific colitis in 22, ulcerative colitis in 16, acute inflammation in 14, hyperplastic polyp in 10, inflammatory polyp in 6, retention polyp in 4 and endometriosis in 2 cases. Neoplastic benign lesions were 25. Benign spindle cell lesion was in 3, tubular adenoma in 15, villous adenoma in 5 and tubulovillous adenoma in 2 cases. Neoplastic malignant lesions were well differentiated adenocarcinoma seen in 4, moderately differentiated adenocarcinoma in 6, poorly differentiated adenocarcinoma in 2 and signet ring cell carcinoma in 1 case. The difference was significant ( \(P< 0.05 \)) [Table 3, Figure 1].

    4. Discussion

    Large intestine is affected by a long array of non-neoplastic and neoplastic lesions. Development of flexible fibreoptic sigmoidoscopy and colonoscopy revolutionized the diagnosis and management of colorectal diseases, for the reason that the procedure is safe with no serious complications [7, 8]. Application of therapeutic colonoscopy like colonoscopic polypectomy has replaced the open surgical procedure to a great extent [9, 10]. We performed clinico-pathological study of colonic biopsies.

    Our results showed that age group 11-20 years had 8, 21-30 years had 22, 31-40 years had 40, 41-50 years had 24 and >50 years had 16 cases. Chandrakumari et al., [11] correlated histopathological spectrum of colonic mucosal biopsies with clinical findings. Out of 250 colonoscopic biopsies, 152 were non-neoplastic and 98 were neoplastic. Non neoplastic lesions were found to affect the colon most commonly. Most of the cases with non-neoplastic lesions presented with colicky abdominal pain, diarrhea and constipation. Among neoplastic lesions, 44 cases were benign and 54 cases were malignant. Majority of cases with neoplastic lesions presented with bleeding per rectum and constipation.

    Our results showed that most common clinical features were constipation seen in 36, bleeding PR in 28, bleeding PR weakness in 17, diarrhea in 16 and diarrhea + pain abdomen + weakness in 14 patients. Makaju et al., [12] performed correlation between clinical and histopathological diagnosis of colorectal diseases. Analyses of 95 cases of colonoscopic biopsies were done. The most common clinical diagnosis was polyp in 49 cases (51.57%) and the common histopathological diagnosis was non-neoplastic polyps 31 (32.63%). There was no correlation in cases for suspected infectious colitis, microscopic colitis and hemorrhoids.

    We observed that non-neoplastic lesions were 74. These were as non-specific colitis in 22, ulcerative colitis in 16, acute inflammation in 14, hyperplastic polyp in 10, inflammatory polyp in 6, retention polyp in 4 and endometriosis in 2 cases. Neoplastic benign lesions were 25. Benign spindle cell lesion was in 3, tubular adenoma in 15, villous adenoma in 5 and tubulovillous adenoma in 2 cases. Neoplastic malignant lesions were well differentiated adenocarcinoma seen in 4, moderately differentiated adenocarcinoma in 6, poorly differentiated adenocarcinoma in 2 and signet ring cell carcinoma in 1 case. Bhagyalakshmi et al., [13] evaluated normal and abnormal mucosal colonoscopic biopsy in the contribution of differential diagnosis in chronic diarrhea patients. Out of 104 biopsies evaluated, specific diagnoses were 41 (39.42%) and nonspecific diagnoses were 63 (60.57%). This study showed male preponderance (67% of cases) with average age of 40.5 years (6-84 years), remaining 33% female cases had average age 45 years (16-65 years). Out of 41 specific histological diagnoses made, majority of them were malignancies seen in the age group of 51-60 years and inflammatory bowel disease seen in the age group of 30-40 years.

    Karve et al., [14] in their study a total of 159 colonoscopic biopsies were studied. Out of them, 68 (42.8%) were non neoplastic, 23 (14.4%) were benign lesions and 68 (42.8%) were malignant lesions. Among the 68 non neoplastic lesions, 32 cases were non-specific colitis, 11 cases ulcerative colitis, 5 cases juvenile polyps, 5 cases hyperplastic polyps, 4 cases SRUS, 3 cases granulomatous inflammation, 3 cases retention polyp, 2 cases Crohn's disease and one case each of acute inflammation, inflammatory polyp and endometriosis. Out of the 23 benign cases, 18were tubular adenomas (78.3%); 3 were villous adenomas (13%); 1 case of tubulovillous adenoma (4.3%) and 1 case of benign spindle cell lesion (4.3%). Out of 68 malignant lesions, 24 cases (35.3%) were well differentiated adenocarcinoma, 25 cases (36.8%) were moderately differentiated adenocarcinoma, 9 cases (13.2%) were poorly differentiated, 8 cases (11.8%) were mucin secreting adenocarcinoma and 2 cases (2.9%) were signet ring cell carcinoma.

    5. Conclusion

    Authors found that colonoscopy is a simple and a safe procedure. It helps in assessing the lesions clinically and confirming histopathologicaly through guided biopsy. Colonoscopic biopsies also play a key role not only in diagnosis, but also in follow up and treatment.

    Author Contributions:

    All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

    Conflicts of Interest:

    "The authors declare no conflict of interest."

    References

    1. Patel, Y., Pettigrew, N. M., Grahame, G. R., & Bernstein, C. N. (1997). The diagnostic yield of lower endoscopy plus biopsy in nonbloody diarrhea. Gastrointestinal Endoscopy, 46(4), 338-343. [Google Scholor]
    2. Schmitt Jr, M. G., Wu, W. C., Geenen, J. E., & Hogan, W. J. (1975). Diagnostic colonoscopy: an assessment of the clinical indications. Gastroenterology, 69(3), 765-769. [Google Scholor]
    3. Kolhe, H. S., Mahore, S. D., Patil, S. S., & Patil, R. N. (2014). To study the endoscopic colonic biopsies of patients presenting with chronic watery diarrhea or constipation with special emphasis on microscopic colitis. IOSR Journal of Dental and Medical Sciences, 13(12), 84-88. [Google Scholor]
    4. Sood, A., Midha, V., Sood, N., Bhatia, A. S., & Avasthi, G. (2003). Incidence and prevalence of ulcerative colitis in Punjab, North India. Gut, 52(11), 1587-1590. [Google Scholor]
    5. Azad, S., Sood, N., & Sood, A. (2011). Biological and histological parameters as predictors of relapse in ulcerative colitis: a prospective study. Saudi Journal of Gastroenterology, 17(3), 194-198. [Google Scholor]
    6. Qayyum, A., & Sawan, A. S. (2009). Profile of colonic biopsies in King Abdul Aziz University Hospital, Jeddah. The Journal of the Pakistan Medical Association, 59(9), 608-611. [Google Scholor]
    7. Paudel, S. M. R., & Sharma, V. K. (2007). Ulcerative colitis is it the clinical problem in Nepal? Post-Graduate Medical Journal of NAMS, 7(2), 1-6. [Google Scholor]
    8. Rajbhandari, M., Karmacharya, A., Khanal, K., Dhakal, P., & Shrestha, R. (2013). Histomorphological profile of colonoscopic biopsies and pattern of colorectal carcinoma in Kavre district. Kathmandu University Medical Journal, 11(3), 196-200. [Google Scholor]
    9. Pandey, M. S., Pandey, A., & Dombale, V. D. (2016). Histomorphological profile of colonoscopic biopsies-a two year study in a tertiary care hospital in South India. International Journal of Science and Research, 5(2), 1513-1518. [Google Scholor]
    10. Badmapriya, D., & Kumar, V. S. (2011). Profile of ulcerative colitis in south indian region: karaikal. International Journal of Pharmacy and Biological Scinces, 1(2), 47-51. [Google Scholor]
    11. Roka, K., Indu, K. C., Jha, S. M., Subedi, R. C., & Adhikari, A. (2022). Pattern of lower Gastrointestinal diseases on colonoscopy and histopathological examination in a Ttertiary care center of Nepal. Medical Journal of Shree Birendra Hospital, 21(1), 87-92. [Google Scholor]
    12. Makaju, R., Amatya, M., Sharma, S., Dhakal, R., Bhandari, S., Shrestha, S., ... & Malla, B. (2017). Clinico-pathological correlation of colorectal diseases by colonoscopy and biopsy. Kathmandu University Medical Journal, 58(2), 173-178. [Google Scholor]
    13. Bhagyalakshmi, A., Venkatalakshmi, A., Praveen, L., & Sunilkumar, K. (2016). Clinico-pathological study of colonoscopic biopsies in patients with chronic diarrhea. Journal Research Medical Sciences, 4(7), 2738-2744. [Google Scholor]
    14. Karve, S. H., Vidya, K., Shivarudrappa, A. S., & Prakash, C. J. (2015). The Spectrum of colonic lesions: A Clinico-pathological study of colonic biopsies. Indian Journal of Pathology and Oncology, 2(4), 189-209. [Google Scholor]
    ]]>
    Major bacteriological isolates and their antimicrobial susceptibility trends in ICU of a tertiary care hospital: A prospective observational study https://old.pisrt.org/psr-press/journals/tcms-vol-2-issue-4-2022/major-bacteriological-isolates-and-their-antimicrobial-susceptibility-trends-in-icu-of-a-tertiary-care-hospital-a-prospective-observational-study/ Fri, 30 Dec 2022 18:36:09 +0000 https://old.pisrt.org/?p=6953
    TCMS-Vol. 2 (2022), Issue 4, pp. 1 - 7 Open Access Full-Text PDF
    Kirti Ahuja, Prateek, Meena Singh, Anil Kumar Verma, Pranav Bansal and Sanjay.
    Abstract:Bacterial bloodstream infections are important causes of morbidity and mortality, globally. The aim of the present study was to determine the bacterial profile of bloodstream infections and their antibiotic susceptibility pattern among the patients admitted to ICU at a tertiary care hospital.This prospective study was conducted over a period of eighteen months. Inclusion criteria comprised of patients admitted to ICU who belonged to either gender and were in the age group of 15-60 years. Over the course of study, 30 out of total 140 blood culture samples were identified to be culture positive (18 GNB and 11GPB). The most common Gram-positive isolate was Staphylococcus spp (26%) while Escherichia coli was the most common gram negative isolate (36%).Escherichia coli expressed highest resistance to all the drugs but sensitivity to Meropenemand Polymyxin B was 72% and 90%, respectively. High degree of resistance was noted to cephalosporins and piperacillin -tazobactam, among all the groups. The study indicated high level of antimicrobial resistance among Gram negative bacilli, esp E.Coli and justifies the need for antimicrobial stewardship to prevent development of further resistance. ]]>

    Trends in Clinical and Medical Sciences

    Major bacteriological isolates and their antimicrobial susceptibility trends in ICU of a tertiary care hospital: A prospective observational study

    Kirti Ahuja\(^{1}\), Prateek\(^{1}\), Meena Singh\(^{1}\), Anil Kumar Verma\(^{2,*}\), Pranav Bansal\(^{1}\) and Sanjay\(^{3}\)
    \(^{1}\) Department of Anaesthesiology, Govt Medical College for Women, Khanpur Kalan, Sonepat, India.
    \(^{2}\) Department of Anaesthesia, GSVM Medical College Kanpur UP India.
    \(^{3}\) Department of Orthpaedics, N.C. Medical College, Israna, Panipat, India.
    Correspondence should be addressed to Anil Kumar Verma at kirtiahuja2812@gmail.com

    Abstract

    Bacterial bloodstream infections are important causes of morbidity and mortality, globally. The aim of the present study was to determine the bacterial profile of bloodstream infections and their antibiotic susceptibility pattern among the patients admitted to ICU at a tertiary care hospital.This prospective study was conducted over a period of eighteen months. Inclusion criteria comprised of patients admitted to ICU who belonged to either gender and were in the age group of 15-60 years. Over the course of study, 30 out of total 140 blood culture samples were identified to be culture positive (18 GNB and 11GPB). The most common Gram-positive isolate was Staphylococcus spp (26%) while Escherichia coli was the most common gram negative isolate (36%).Escherichia coli expressed highest resistance to all the drugs but sensitivity to Meropenemand Polymyxin B was 72% and 90%, respectively. High degree of resistance was noted to cephalosporins and piperacillin -tazobactam, among all the groups. The study indicated high level of antimicrobial resistance among Gram negative bacilli, esp E.Coli and justifies the need for antimicrobial stewardship to prevent development of further resistance.

    Keywords:

    Antibiotic susceptibility; Gram negative bacilli; Antimicrobial resistance; Bloodstream infections; Antibiogram.

    1. Introduction

    Bloodstream infection is one of the principal causes of morbidity and mortality in the intensive care unit. Critical care patients are often associated with an increasing number of invasive devices and monitors that make them five to seven-fold more susceptible to acquisition of nosocomial infection as compared to general inpatients in the hospital [1, 2]. The Surviving sepsis campaign guidelines, ever since its inception, have emphasised the initiation of antibacterial therapy within the first hour of presentation to the hospital for better/improved survival [3]. But, the institution of an inappropriate empirical antimicrobial therapy has been associated with a five-fold reduction in survival. Rapid and accurate identification of bacterial species in the blood is, therefore, of paramount importance [4].

    Since, microbiological culture results are not available until after 24 to 72 hours, the initial therapy for infection is often empirical and guided by the clinical presentation. Broad-spectrum antimicrobial agents are generally started initially with the intent to cover most pathogens commonly associated with specific clinical syndromes. Nonetheless, the irrational and inappropriate usage of antibiotics has resulted in rising trend of resistant organisms especially in critical care settings [5, 6]. Therefore, once the identity of the etiologic pathogen and the antimicrobial susceptibility data are available, every attempt should be made to narrow down the antibiotic spectrum. This is a critical component of antibiotic therapy through which a reduction in the cost, toxicity and development of antimicrobial resistance in the community can be accomplished.

    The micro-organisms and their antibiotic susceptibility pattern vary among different healthcare facilities and geographical areas. The antibiograms provide a summary of in vitro activity of antimicrobials of an institution or geographical area. So, the decisions regarding initial antimicrobial therapy should be based on the institution's specific antibiograms. Clinicians must choose empirical antibiotic therapy aimed at both maximizing outcomes and minimizing the emergence of resistance. With blood culture being one of the most reliable investigations for bacterial isolation and detection, we designed the present study to determine the bacterial profile of bloodstream infections (BSI) and their antibiotic susceptibility patterns among the clinically diagnosed cases of sepsis in patients presenting to our surgical intensive care unit (ICU) to direct the antibiotic treatment of hospital acquired infections in the ICU.

    2. Materials and methods

    After approval from institutional ethical committee, this prospective study was conducted over a period of eighteen months in the 6- bedded surgical ICU of a tertiary care hospital. All patients of either sex between the age of 15-60 years, admitted to the ICU during the study period were included. Patients shifted to ICU for monitoring during postoperative period, mortality within 24 hours of admission and patients transferred to another speciality team were excluded. Written informed consent was obtained from either the patient or relatives of the included patients. The blood culture sample of these patients were collected when the patient presented with any two of the following four features,alongwitha suspected source of infection i.e. temperature>38$^{o}$C or< 36$^{o}$C, heart rate >90 beats/min, respiratory rate >24/min and Total leucocyte counts >12000/cu mm or < 4000/cu mm.

    Collection of blood sample for blood culture was done using standard aseptic techniques. 10 ml of blood specimen was collected and inoculated into brain heart infusion (BHI) broth at the blood to broth ratio of 1:10. After incubation at 37$^{o}$C for 24 and 48hours, blind subcultures were made on Macconkey agar and blood agar plates (Hi Media Laboratories, India). After 24 hrs of aerobic incubation at 37$^{o}$C, the plates were observed for bacterial growth. Identification of significant isolates and their antimicrobial susceptibility tests was carried out as per Clinical and Laboratory Standards Institute (CLSI) guidelines, 2012 [7]. Antimicrobial sensitivity patterns of isolated organisms were identified by Kirby Bauer's disc diffusion method on Mueller Hinton Agar media [8]. Interpretations of antibiotic susceptibility results were made according to the guidelines of interpretative zone diameters of CLSI [7]. Antibiotics that were tested in this study include Amoxycillin-sulbactam, Cefuroxime, ceftriaxone,cefoperazone-sulbactum,cefipime,cefazolin,ceftazidime,piperacillin-tazobactum,imepenem, meropenem, linezolid, clarithromycin, azithromycin, clindamycin, norfloxacin, ofloxacin, levofloxacin, sparfloxacin, gentamycin, amikacin, tobramycin, netilmycin, tigecycline, nitrofurantion, colistin, polymyxin-B, and vancomycin.

    3. Data collection and analysis

    Standard descriptive statistics were calculated for categorical (in percentage) and continuous variables (median and interquartile range). Prevalence rate was calculated for the numbers of positive cases of examined subjects. Antibiogram, which provides the percentage of isolates that are susceptible to an antibiotic, was constructed according to consensus guidelines from the Clinical Laboratory Standards Institute.

    4. Results

    A total of 140 blood samples of the patients with suspectedbacteraemia, admitted to the critical care unit were sent for processing of blood culture to the department of Microbiology. The median age of the patients in our study was 31.9 years (range 23.5-44.5 years), while 65% were male.Ninety five (67.86%) patients were admitted secondary to traumatic brain injury while forty five (32.14%) patients were postoperative cases. Figure \ref{f1} shows that out of the 140 blood cultures sent during the study period, 30 (21.43%) were positive for significant growth of pathogen suggesting bloodstream infection (BSI). In this, 29(96.67%) were bacterial and 1(3.33%) was fungal (candida nonalbicans). Among the bacterial isolates, Gram negative bacteria (GNB)(60%) were the leading pathogenic agents with E. coli (11cultures, 36.67%) being the most common followed by Klebsiella species (4 cultures, 13.3%), and Acinetobacter species (2 cultures, 6.67%).Gram positive bacteria (GPB) were isolated in 36% of the samples, wherein staphylococcus aureus (8 cultures, 26.67%) was the main pathogen followed by streptococcus (2 cultures, 6.675%).

    Figure 1. Organisms in Bloodstream infection.

    Among, GNB isolates, Escherichia coli showed a higher level of resistance to penicillins, cephalosporins, fluoroquinolones and aminoglycosides while it was most sensitive to polymixinB (90%) followed by tigecyclin and colistin (81%each), see Table 1. Carbapenems showed sensitivity of 77% whereas $\beta$-lactam and $\beta$-lactamase inhibitor piperacillin-tazobactum was only 45% sensitive. Klebsiella was 100% resistant to penicillins and a few cephalosporins (cefipime, ceftazidime, Cefuroxime) with very low sensitivity for the other cephalosporins, piperacillin-tazobactum (25%) and colistin (33%). The sensitivity for imipenem, tigecyclin and polymixin B was 100%. The isolated Acinetobacter also showed 100% sensitivity to Carbapenems, tigecycline and polymixin B. The sensitivity to colistin, most of the fluoroquinolones except levofloxacin (75%) and aminoglycosides was 50%. A high degree of resistance to cephalosporins was seen (0-25%), see Figure 2.

    Figure 2. Antibiogram of gram negative bacteria in blood.

    In GPB isolates, Staphylococcus aureus showed low sensitivity towards penicillins, cephalosporins (8-36%) and macrolides (31-37%). Piperacillin-tazobactum (42%) and clindamycin (43%) too had a lower sensitivity profile. The sensitivity was variable for aminoglycosides (50-75%) and fluroquinolones, maximum being 75% and 81% for levofloxacin and ofloxacin, respectively. However, it was highly sensitive to Carbapenems (85-92%), tigecycline (83%), linezolid (81%) with 100% sensitivity only to vancomycin.Steptococcus was found to be 100% sensitive to imipenem, tigecycline and linezolid, apart from vancomycin. It showed more sensitivity to aminoglycosides (50-75%) compared to fluroquinolones (50%) or clindamycin (50%). However, the resistance to penicillins and cephalosporins was 100%, showing sensitivity only to cefoperazone-sulbactum (50%). High level of resistance was also noted for piperacillin-tazobactum (75%), see Figure 3.

    Figure 3. Antibiogram of gram positive bacteria in blood.

    Table 1. Antimicrobial susceptibility of major bacterial isolates in blood.
    Amoxyclav Piperacillintazo Amoxysulbactamm Cefazolin Cefuroxime Ceftrixone Cefoperazone+Sulbactum Ceftazidime Cefpime Imepenem Meropenam Norfloxacin Ofloxacin Levofloxacin ciprofloxacin Gentamycin Amikacin tobramycin netilmycin Tigecycline nitrofurantion Colistin Polymyxin-B Vancomycin Linezolid Clindamycin Azithromycin Clarithromycin
    E.coli(11) 18 45 22 13 18 22 27 18 27 77 72 18 18 36 36 22 18 18 27 81 31 81 90
    Staphylococcus aureus(8) 25 42 21 8 37 25 36 28 35 85 92 13 81 75 44 50 62 57 75 83 60 100 81 43 31 37
    Klebsiella(4) 0 25 0 12 0 12 25 0 0 100 87 0 75 62 37 12 37 25 50 100 37 33 100
    Streptococcus spp(2) 0 25 0 0 0 0 50 0 0 100 75 0 50 50 50 50 50 75 75 100 50 100 100 50
    Acinetobacter(2) 0 25 0 0 0 25 25 25 0 100 100 50 50 75 50 25 50 50 25 100 50 50 100

    5. Discussion

    Nosocomial infections cause significant morbidity and mortality in patients admitted to ICUs worldwide. Antibiotics form a considerable portion of the immense economic burden borne by these patients [5]. However, inappropriate use of antibiotics may lead to antimicrobial resistance causing increasing mortality and healthcare costs. This study was undertaken to study the spectrum of the bacterial isolates causing blood stream infection in ICU patients and their antibiotic susceptibility pattern which could guide the formulation of antibiogram and future antibiotic policy.The Blood culture positivity rate in our study was observed to be 21.43% which was similar to the studies conducted by Alam et al., and others [10, 11, 12]. Though these were lower than the incidence observed by Parihar et al., and others [13,14, 15, 16, 17]. But, these blood culture rates were however higher as compared to a few other studies where the blood culture positive rates ranged only from 9.94% - 11.2% [18, 19, 20]. These differences in the positivity rates may be due to the difference in methodology used for blood culture, the study design, nature of patient population, epidemiological difference in etiological agents, geographical differences and differences in the infection control policies [19, 20, 21].

    In our study, 60% of the infections were caused by GNBand36.67% of the infection was due to GPB. This finding was comparable to most of the studies from India and other developing countries, where Gram-negative bacteria have been reported to be the most common cause of bacteraemia in hospitalized patients [21, 22, 23]. In contrast, Arora et al., [11] and Shrestha et al., [17] have reported gram positive bacterial dominance in blood stream infections. Escherichia coli (36.67%) was the predominant Gram-negative isolate in our study, followed by Klebsiella (13.33%). These findings are in concordance with findings of Gupta et al., [23]. However, some other studies have isolated Pseudomonas and Acinetobacter predominantly [24]. This may be due to different antibiotic prescription policies. In GPB isolates, Staphylococcus aureus (26.67%) formed the majority followed by Streptococcus (6.67%). Similar findings were reported by Gupta et al., and Parihar et al., [23, 13], that Candida was seen in 3.33% of positive blood culture and all were non albicans Candida species.

    Antibiotic resistance is a major concern in ICU worldwide and especially in India. Critical care areas are the major foci of antimicrobial resistance in hospitals [1]25,26}. Overuse of antibiotics is the leading cause of selection pressure on organisms and thereby, antimicrobial resistance [1]27}.

    All the three major GNB isolates; E.coli, Klebsiella and Acinetobacter showed high degree of resistance to penicillins, cephalosporins and piperacillin-tazobactum. Susceptibility to levofloxacin, ofloxacin, amikacin and netilmycin ranged from intermediate to high in Klebsiella and Acinetobacter while E coli showed high resistance. Similar findings were noted by Parajuli et al., [17]. The increasing resistance to Colistin is a troublesome finding as it further decreases the antimicrobials available in our armamentarium for treatment of infections, especially multidrug resistant variants. On the positive side, all the three GNB isolates demonstrated higher susceptibility to Carbapenems, tigecycline and polymixin B. This is in contrast to studies [24, 25, 26, 27, 28, 29], which showed high level of resistance to Carbapenems. The low resistance to Carbapenems in our study could be attributed in part to the practice of administering the Carbapenems as infusions in our institute which has shown to limit the resistance to these antibiotics.

    Both GPBisolates, staphylococcus and streptococcus showed high resistance to penicillins, cephalosporins and macrolides. The sensitivity for aminoglycosides, clindamycin and fluoroquinolones was intermediate with higher sensitivity noted to ofloxacin and levofloxacin. However, the sensitivity to Carbapenems, tigecyclin, linezolid and vancomycin was as high as upto100%. The high degree of resistance to $\beta$-lactams, most cephalosporins, and increasing resistance to fluoroquinolones and aminoglycosides among both GPB and GNB in our study was also established in many other studies, see [11, 27, 28, 29]. This is probably because these are the most frequently prescribed antibiotics in developing nations. Another frequently observedissue in developing nations is the easy availability of antibiotics as over the counter preparations.

    6. Conclusion

    Gram negative bacterial isolates are the most common organism found in our study followed by gram positive bacteria. E coli being the predominant organism followed by staphylococcus aureus, Klebsiella, streptococcus and Acinetobacter.Antibiogramdepicts gram negative organism have maximum sensitivity towards polymyxin followed by Carbapenems and piperacillin-tazobactum in decreasing order and gram positive bacteria have maximum sensitivity to vancomycin and linezolid followed by Carbapenems, piperacillin-tazobactum.Appropriate and targeted antimicrobial therapy initiated early can be life-saving. However, the high prevalence of multidrug resistance microbes highlight our limited treatment options. Proper antimicrobial stewardship can be a step forward towards antimicrobial resistance containment. Routine surveillance to know the local epidemiology and baseline resistance of the pathogens for formulation of local antibiogram and hospital antibiotic policy will go a long way in combating growing antimicrobial resistance and curtailing rising costs in critical care.

    Author Contributions:

    All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

    Conflicts of Interest:

    "The authors declare no conflict of interest."

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