Wednesday, August 26, 2015

 Low energy helium neon laser in the prevention of oral Mucositis

Introduction:

Effectiveness of cancer therapies designed to improve cure rates and to extend survival time, including chemotherapy and radiotherapy is tempered by side effects that may become life threatening. Oral complications are one such side effect category and include chemotherapy and radiation therapy related stomatitis (oral mucositis) and associated pain, xerostomia and oral infection.1

Stomatitis (oral mucositis) is an inflammation of the mucous membranes of the oral cavity and oropharynx characterized by tissue erythema, edema, and atrophy often progressing to ulceration. The clinical significance of  radiation therapy related stomatitis is widely recognized.1Stomatitis is virtually universal when radiation therapy includes the oropharyngeal area, with the severity dependent upon the type of ionizing radiation, volume of irradiatd tissue, dose per day, cumulative dose and duration of radiation therapy.


Radiation therapy for head and neck cancers has a range of sequelae in the oral cavity. This includes caries, mucositis, trismus, xerostomia, osteoradionecrosis and secondary oral and fungal infections.2

Radiotherapy-induced oral mucositis represents a therapeutic challenge frequently encountered in cancer patients. This side effect causes significant morbidity and may delay the treatment plan, as well as increase therapeutic expenses.3

Side effects of radiation therapy to the head and neck may be noted as early as the first week.4 A syndrome of pain, swelling and tenderness after irradiation of major salivary lands begin a few after small doses of radiation are given. The pain may be severe.5 Severe reduction in the volume of saliva and the alteration of its composition may cause serious complications. Dryness of mouth and difficulty in swallowing and mastication are common The changes in salivary flow, volume and viscosity may be related to vascular damages to the salivary glands and may persist for years. The recovery of a normal production of saliva will depend on the characteristics of each patient and the salivary gland irradiated percentage. Many investigators have observed, however that within hours of low dose radiation therapy, dryness of mouth and the elevation of serum amylase develop.5
The xerostomia appears soon after the beginning of the RT, becoming more evident after 20Gy doses. Initially, the saliva becomes thicker and its elimination rate decreases6
This xerostomia may be irreversible, although there is a tendency of recovering up to 50% of the initial salivary volume, if both the irradiated parotid volume and the final irradiation dose remain in the lowest possible values(7-11).
Research findings to date based upon animal, human and most notably cellular studies have enhanced the establishment of low intensity laser treatment  as an effective means of biostimulation for the wound healing process. The most popular laser in studies on cell irradiation to date has been the helium – neon laser with a wavelength of 632.8nm. Using embryonic foreskin fibroblasts and adult human skin fibroblasts , Boulton and Marshall (1986) reported an increase in cell proliferation following irradiation with a He-Ne laser.  Lyons et al 1987 have found out that laser irradiation stimulates the production of collagen by fibroblasts, which in turn is an important component of scar tissue formation. Myofibroblasts are modified fibroblasts that are directly involved in granulation tissue contraction. A study by Pourreau Schneider et al (1990) found that He-Ne laser irradiation of fibroblasts transforms the cells into myofibroblasts , which the author suggests may set into motion the acceleration of the wound healing process which is typically observed in clinical practice after He-Ne laser treatment12.

            Iijima K et al observed that repeated irradiation with low power He-Ne laser is an effective and safe therapy for post herpetic neuralgia. They have irradiated 18 patients with severe postherpetic neuralgia. The efficacy of low power He-Ne laser was evaluated using a four grade estimation visual analog scale and modified McGill pain questionnaire after every 10 of as many as 50 irradiations. The efficacy rate using a four grade estimation at the end of 50 treatments was 94.4%. VAS decreased from 6.2 before irradiation therapy to 3.6 after 50 treatments.13

Maiya GA, Sagar MS & Fernandes Donald has reported that low energy He-Ne laser was effective in preventing and treating oral mucositis among head and neck cancer patients receiving radiotherapy.  The patients with carcinoma of oral cavity with stages II-IV a being uniformly treated with curative total tumour dose of 66 Gy in 33 fractions over 6 wk were selected for the study. The patients were divided based on computer generated randomisation into laser (study group) and control groups with 25 patients in each group. Both study and control groups were comparable in terms of site of the lesion, stage of the cancer and histology. The study group patients were treated with He-Ne laser (wavelength 632.8 nm and output of 10mW) and control group patients were given oral analgesics, local application of anaesthetics, 0.9 per cent saline and povidine wash during
the course of radiotherapy. All patients tolerated the laser treatment without any adverse effect or reactions. The result showed a significant difference in pain and mucositis 

Use of the low-energy helium-neon laser (LEL) appears to be a simple atraumatic technique for the prevention and treatment of mucositis of various origins. Preliminary findings, and significant results obtained for chemotherapy-induced mucositis in a previous phase III study, prompted a randomized multicenter double-blind trial to evaluate LEL in the prevention of acute radiation-induced stomatitis. Irradiation by LEL corresponds to local application of a high-photon-density monochromatic light source. Activation of epithelial healing for LEL-treated surfaces, the most commonly recognized effect, has been confirmed by numerous in vitro studies. The mechanism of action at a molecular and enzymatic level is presently being studied. From September 1994 to March 1998, 30 patients were randomized. Technical specification: 60 mW (25 mW at Reims, 1 patient), He-Ne, wavelength 632.8 nm. The trial was open to patients with carcinoma of the oropharynx, hypopharynx and oral cavity, treated by radiotherapy alone (65 Gy at a rate of 2 Gy/fraction, 5 fractions per week) without prior surgery or concomitant chemotherapy. The malignant tumor had to be located outside the tested laser application areas (9 points): posterior third of the internal surfaces of the cheeks, soft palate and anterior tonsillar pillars. Patients were randomized to LEL or placebo light treatment, starting on the first day of radiotherapy and before each session. The treatment time (t) for each application point was given by the equation : t (s)=energy (J/cm2)2surface (cm2)/Power (W). Objective assessment of the degree of mucositis was recorded weekly by a physician blinded to the type of treatment, using the WHO scale for grading of mucositis and a segmented visual analogue scale for pain evaluation. Protocol feasibility and compliance were excellent. Grade 3 mucositis occured with a frequency of 35.2% without LEL and of 7.6% with LEL

Carlos et al has conducted a study to verify if the use of InGaAIP laser with 685 nm wave length can reduce the xerostomy incidence, the oral mucositis severity and the pain related to mucositis in patients with head and neck cancer submitted to radiotherapy.
Sixty patients presenting head and neck carcinoma were submitted to radiotherapy with daily doses of 1.8 to 2.0 Gy and a final dose of 45 to 72 Gy. The salivary volume was evaluated in the first and fifteenth days, at the end of the treatment and after 15 and 30 days. The oral mucositis was evaluated on a weekly basis. Twenty-nine patients were submitted to radiotherapy without laser and 31 were submitted to radiotherapy and laser with daily doses of 2 joules/cm² in predetermined areas of the oral mucosa and the parotid and submandibular glands. In the group submitted to radiotherapy and laser the incidence of mucositis (p < 0.001) and pain (p < 0.016) was significantly lower and the salivary volume (p < 0.001) was kept higher during and after the treatment.
The group of patients submitted to radiotherapy and laser had lower incidence of xerostomy, oral mucositis and pain when compared to the group treated with radioteraphy without laser, producing statistically significant results.
Need for the study:
Helium neon laser and its ability to improve salivary flow is not studied yet. There are not many studies done on helium neon lasers and the degree of salivary flow which helps to prevent oral mucositis in India. Although nurses are taking care of such patients every day, nurse’s role is hidden within. Keeping all these in mind, the researcher has decided to undertake this study collaborating different categories of personnel.
Purpose of the study:
            The overall purpose of the study is to test whether helium neon laser increases the salivary flow which is already reduced due to the effect of radiotherapy. If the salivary flow increases with helium neon laser it will help to considerably reduce oral pain and oral mucositis. In further studies, the mechanism of action of increase in salivary flow can be studied.
Assumptions:
The researcher assumes that
  1. helium neon laser increases salivary flow
  2. Helium neon laser will reduce the incidence of oral mucositis and oral pain.
  3. Patients will willingly participate in the study.

Problem statement:

A study to determine the effectiveness of low energy helium neon laser in the prevention of oral complications of cancer therapy among cancer patients admitted to a selected hospital in India.

Objectives:

  1. To determine the incidence of oral mucositis among patients undergoing radiation therapy.
  2. To assess the severity of oral mucositis among patients undergoing radiation therapy as measured by mucositis grading scale.
  3. To correlate the dose of radiation and the severity of oral mucositis.
  4. To find out the effectiveness of low energy helium neon laser in reducing the severity of oral mucositis among patients undergoing radiation therapy   as measured by mucositis grading scale.
  5. To determine the incidence of oral pain among patients undergoing radiation therapy.
  6. To assess the severity of oral pain among patients undergoing radiation therapy as measured by visual analog scale.
  7. To correlate the dose of radiation and the severity of oral pain.
  8. To determine the effectiveness of low energy helium neon laser in reducing the severity of oral pain among patients undergoing radiation therapy   as measured by visual analog scale.
  9. To determine the incidence of salivary dysfunction among patients undergoing radiation therapy.
  10. To assess the severity of salivary dysfunction among patients undergoing radiation therapy as measured un stimulated salivary flow
  11. To correlate the dose of radiation and the severity of salivary dysfunction.
  12. To determine the effectiveness of low energy helium neon laser in reducing the severity of salivary dysfunction among patients undergoing radiation therapy   as measured by un stimulated salivary flow
  13. To determine the association between oral complications of cancer therapy and selected demographic variables ;age, gender, associated chronic illnesses

Definition of terms:
Oral complications of cancer therapy
In this study oral complications of cancer therapy refers to salivary dysfunction, oral pain and the development of oral mucositis following   radiotherapy.
Cancer therapy
In this study, cancer therapy refers to radiotherapy used to treat head and neck cancer patients.
Cancer
In this study, cancer refers to cancers of the head and neck region.

Variables:
Dependent variable:  Helium neon laser therapy of 632.8nm wavelength
Independent variables: Oral mucositis, oral pain, salivary dysfunction.
Selected demographic variables: age, gender, associated chronic illnesses
Hypotheses:

  1. There will be significant difference in the severity of oral mucositis among patients undergoing radiation therapy who are treated with low energy helium neon laser and  not treated with helium neon laser as measured by mucositis grading scale at 0.05 level of significance.

  1. There will be significant difference in the severity of oral pain among patients undergoing radiation therapy who are treated with low energy helium neon laser and   not   treated with helium neon laser as measured by mucositis grading scale at 0.05 level of significance.

  1. There will be significant difference in the severity of salivary dysfunction among patients undergoing radiation therapy who are treated with low energy helium neon laser and not treated with helium neon laser as measured by mucositis grading scale at 0.05 level of significance.

Research methodology:
Research approach: The study uses survey approach and evaluative approach.
Research design:  Experimental.
Population: Head and Neck Cancer patients undergoing radiotherapy.
Sample size:100
Sampling techniquePurposive sampling.
Sampling criteria:
The study was performed in a group of
  1. Voluntary patients aged above 21 years,
  2.  Bearing head and neck carcinomas and not submitted to previous RT in the affected region.
  3.  Patients whose the irradiation fields include the salivary glands.
  4. The patients with hospital numbers bearing odd numbers will be denominated "control", receiving RT without laser
  5. Patients with hospital numbers bearing even numbers will be submitted to RT and laser therapy.
Exclusion criteria:
Head and neck cancer patients who receive combination treatment.
Data collection instruments:
Patient profile, oral mucositis grading scale, visual analog scale for pain, Scale to assess the salivary flow.
Ethical considerations
Plan for data analysis: t test, chi – square, anova, odds ratio and path analysis for relationship
Work plan
Conceptual framework:

This study incorporates the quality caring model developed by Deffy J.The Quality-Caring Model exposes and demonstrates the value of nursing within the evidence-based practice milieu of modern health care. It favors a process, or way of being, that challenges modernist conventions and highlights the power of relationships. By reaffirming the nature of nursing's work as relationship-centered, the blended model describes the 2 dominant relationships that comprise professional encounters. Relationships characterized by caring are theorized to influence positive outcomes for patients/families, health care providers, and health care systems.

References:

  1. Devita VT Jr. Oral complications. In: Cancer: principles and practice of oncology. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001; 2523 – 2533, 2881–2888.  
  2. Berger. M. Ann, Zlotolow. M. Ian. Oral manifestations and complications of cancer therapy. In:Principles and practice of paliative care and supportive oncology. 2nd ed. Philadelphia, PA: Lippincot Williams & Wilkins, 2002; 282 – 298.
  3. Kostler JW. Hejna M. Wensel C. & Zeilinzki CC. Oral mucositis complicating chemotherapy/radiotherapy CA A cancer journal for clinicians. 2001; 51:290-315
  4. Oral Complications of Cancer Therapies: Diagnosis, Prevention, and Treatment. NIH Consens Statement 1989 Apr 17-19;7(7):1-11.
  5. Fajardo LF, Berthrong M,  Anderson RE.Salivary glands In: Fajardo LF, Bertrong M, Anderson RE, editors,Radiation pathology.Minnesota:  Oxford University Press. 2001. 265 – 270.
  6. Semba SE, Mealy BL, Hallmon WW. The head and neck radiotherapy patient: Part 1 – oral manifestations of radiation therapy. Compend Contin Educ Dent 1994;15:252 – 260.CROSS REFERENCE FROM  Carlos de oliviera. Low level laser therapy in the prevention of radiation therapy induced xerstomia and oral mucositis.
  7. Chao KS, Deasy Jo, Markmon J et al, A prospective study of salivary function sparing in patients with head and neck cancers receiving intensity modulated or three dimensional radiation therapy: initial results. Int J Radiat Oncol Biol Phys 2001; 49:907 – 916. 
  8. Burlage FR, Coppes RP, Meertens H et al. Parotid and submandibular/sublingual salivary flow during high dose radiotherapy. Radiother Oncol 2001;61: 271 – 274 
  9. Roesnik JM, Moerland MA, Batterman JJ, et al. Quantitative dose volume respose analysis of changes in parotid gland function after radiotherapy in the head and neck region. Int J Radiat Oncol Biol Phys 2001; 51: 938 – 946. 
  10. Maes A, Weltens C, Flamen P, et al. Preservation of parotid function with uncomplicated conformal radiotherapy. Radiother Oncol 2002;63:203 – 211. 
  11. Cheng VST, Downs J, Herbert D, Aramany M. The function of the parotid gland following radiation therapy for head and neck cancer. Int J Radiat Oncol Biol Phys1981; 7:253–258. 
  12. Baxter GD. Therapeutic lasers theory & practice. Churchill Livingstone. Edinburgh. 1994; 89 – 182.
  13. Iijima K,Shimoyama N,Shimoyama M, & Mizuguchi T. Evaluation of analgesic effect of low power He-Ne laser on postherpetic neuralgia using VAS and modified MC Gill pain questionnaire. J Clin Laser Med Sug. 1991 Apr;9(2):121-6.
  14. Maiya AG, Sagar MS & Fernandes D. Effect of low level helium neon laser therapy in the prevention and treatment of radiation induced mucositis in head and neck cancer patients. Indian J Med Res 124, October 2006, pp 399-402
  15. R. J. Bensadoun et al.Low energy helium neon laser in the prevention of radiation induced oral mucositis. Supportive care in cancer.7(4).June, 1999.
  16. Oliveira et al. Low level laser therapy in the prevention of radiotherapy induced xerostomia and oral mucositis. Radiologia Brasileria. 39(2). Mar/Apr. 2006.
Pressure of Education on the Students

Pressure of Education on Students
Oh! Baby, My beautiful Baby! Your touch softens my heart
Your smile lights up my life
I will wait for the day when you can look at my face and smile at me.
I promise to take care of you as the most precious gem in my life.
Did you get confuse that I am starting on a poem? This is not a poem. These are the thoughts every mother, every father feels when they look at their new-borns.
New born grows into infant, then to toddler and our “beautiful baby” starts going to school. Our expectations about the baby start to grow.
Why can’t he draw a full circle when his friends can do?
Why is she so shy in dancing when her friends are dancing?
Why are his grades low, when his friends score better?
A lot of Pressure on the Students are Exerted by Parents
Anxieties grow for the parents. We start pressurising our “beautiful baby”. Extra coaching, tuition classes, home tutoring and the list goes on to make our “beautiful baby” come first among his friends .
Our “beautiful baby” is sent for coaching from seventh standard onwards for a seat in the country’s prestigious institutions probably because we could not get one.He is sent for medical entrance examination (which he has to appear after 12th standard) coaching from eighth standard onwards to make him a doctor probably because we could not become one.
Day after day we dream about our “beautiful baby” winning accolades.

But are we on the right track?

This thought came to my mind after reading an article about students’ suicides in some of the prestigious educational institutions in India which was featured in a weekly magazine.
There are quite a good number of suicides happening in these premier institutions where the best brains of the country are admitted. Parental pressure is pointed out as one of the significant reasons for this.Some students reported that they had to stop all kinds of extracurricular activities from class 8 onwards to attend the coaching classes for the entrance examination of these institutes. In India, you will find such coaching centres at every nook and corner of the country.

Parents need to Train Children on Life Skills

We, parents forget to train our children on life skills. They fail to cope up with the pressures of a professional school, land up in adjustment problems in college and hostel, and end up in love failures, because we trained them to be just MCQ monsters. After a very strict atmosphere at home, till 12th standard, when they go to hostels and stay on their own, they are getting access to many things to which they may indulge in by compulsion and more often than not by choice.
Unnecessary expectations from parents force the children to keep unachievable goals and deadlines for themselves and when they fail to keep up with parents’ aspirations, tragedy starts.


Procedure for glutathione estimation

Glutathione is tripeptide, L-γ-glutamyl-L-cysteinylglycine present in high concentrations in most cell types. It is most powerful and naturally occurring antioxidant making it critically important in eliminating detoxification and free radicals. In breast cancer, the GSH concentration is twice more compared to normal patients.


1.810 ml of distilled water is added to 0.2 ml of the haemolysate.  0.01 ml of lysate is added to 3 ml of ferricyanide-cyanide reagent for hemoglobin estimation, and 3 ml of precipitating solution is added to the remaining haemolysate. After standing for 10 minutes, the mixture is filtered through a medium or coarse grade of filter paper. One milliliter of filtrate is added to 4 ml of 0.3 M Na2 HPO4 solutions in a cuvette with a critical volume of 10 ml or less. It is read at 412 nm against a blank prepared by adding one ml of distilled water to 4 ml of 0.3 M Na2 HPO4. Optical density reading is taken after 0.5 ml of DTNB is added to the blank cuvette and the cuvette containing filtrate