ISSN: 2348-4438 International Journal of Medical Science ...Dr.Arvind Sharma(Community Medicine, Rajasthan University of Health Sciences, Jaipur), Dr.Reshu Gupta (Physiology, Rajasthan

International Journal of Medical Science and Education

Internationally

Indexed,

Peer Reviewed,

Multi-specialty

Medical Journal

.

AN OFFICIAL PUBLICATION

OF THE

ASSOCIATION OF

SCIENTIFIC AND

MEDICAL EDUCATION

(ASME)

Vol. 01 / Issue 01/ Jan-March 2014

Frequency: Quarterly

Language: English

www.ijmse.com

ISSN: 2348-4438

International Journal of Medical Science

and Education (IJMSE)

Editor –in – Chief

Dr.Narendra K.Chauhan,

Prof. and Specialist Anaesthesia

Mafraq hospital, Abu Dhabi.UAE

Member Editorial Board

Dr.Soon Hyuck Lee,

Korea University ,Korea

Dr.Yoshihiko K, MD,Japan

Dr.Siswanto S, Department of Public

Health, University of Brawijaya, Indonesia

Dr.Mazen Khalil Ali, Consultant

Psychiatrist King Hamad University

Hospital, Kingdom of Bahrain

Dr.Vidhya Sgar D,USA

Dr.Mohammed Nahidh, Department of

Orthodontics. College of Dentistry,

University of Baghdad.

Dr. Amupitan I., Department Of

Orthopedics and Trauma, Jos University

Teaching Hospital, Jos, Nigeria

Dr. S. Chandramohan ,( Public Health) ,

Saudi Electronic University, Saudi Arabia.

Dr.Rajkumar Patil, (Community Medicine) ,MG

University, Pudduchery

Dr.S.S.Surana ,(Pathology),Pacific University,

Udaipur

Dr.A.P.Gupta,(Peadiatrics),Pacific

University,Udaipur

Dr.Pratibha Vyas ,(Otolaryngology), MG

University, Jaipur,

Dr.Jaya Chaudhary, ( Obstetrics and

Ganecology) MG University, Jaipur,India

Dr.Sanjeev Chaudhary, (Forensic Medicine)

Geetanjali University ,Udaipur

Dr. Pooja S.K. Rai,(Biochemistry) L.T.M.C &

Hospital, Sion, Mumbai

Dr.Pavan Singhal, (Otolaryngology), SMS

MC,Jaipur

Member Editorial Management Board

Dr.Arvind Yadav (Pharmacology, Geetanjali University, Udaipur)

Dr.Arvind Sharma(Community Medicine, Rajasthan University of Health Sciences, Jaipur),

Dr.Reshu Gupta (Physiology, Rajasthan University of Health Sciences, Jaipur)

Associate Editor-Dr.J.Ahuja, Address all correspondence regarding articles, subscription to and advertisement in this journal to Dr. J.

Ahuja Associate Professor,(Biochemistry), RUHS, Jaipur-302018(India) Editorial office: H.N.22,

SAMA 1, Mohmmad Bin Zayed City Abu Dhabi, United Arab Emirates.-2951. Administrative

Office:Association For Scientific And Medical Education, 35/23, Rajat Path

Road,Mansrovar,Jaipur,Raj,India.Email:[email protected] or [email protected]

Phone:+91-9680010844

Accessible on Internet at website www.ijmse.com .

An official publication of the

Association of Scientific and Medical Education

mailto:[email protected]


http://www.ijmse.com/

General information

About IJMSE International Journal of Medical Science

and Education (IJMSE) is one of the

popular quarterly international Medical

Science journals. IJMSE is a peer

reviewed journal which is available

online and in print format as well.

IJMSE, a broad-based open access, was

founded on two key tenets: Firstly, to

publish the most exciting researches with

respect to the subjects of our functional

Journals. Secondly, to provide a rapid

turn-around time possible for reviewing

and publishing, and to disseminate the

articles freely for teaching and reference

purposes.

indexed/abstracted in: Wiki

CSP, getCited, Journal Index, Academic

Keys, Research Bible, Pubicon Science

Index, Directory of Research Journal

Indexing, Advance Science Index, Cite

Factor, International Committee of

Medical Journal Editors, Scientific Index

service.

Aim: IJMSE is an answer to the wishes

and desires of many researchers and

teachers in developing nations who lack

free access to quality materials online.

This Journal opts to bring panacea to this

problem, and to encourage research

development. It aims to disseminate

knowledge; provide a learned reference

in the field; and establish channels of

communication between academic and

research experts, policy makers and

executives in industry, commerce and

investment institutions

Scope: IJMSE follows stringent

guidelines to select the manuscripts on

the basis of its originality, importance,

timeliness, accessibility, grace and

astonishing conclusions.

The journal publishes original research

article from Medical science which also

includes some untouched areas like

Health and Hospital Management,

Biodiversity & Conservation,

Occupational and Environmental

sciences, Medical education and ethics

etc.

Mission Statement: Our mission is to contribute to the

progress and application of scientific

discoveries, by providing free access to

research information online without

financial, legal or technical barriers.

IJMSE is dedicated to promote high

quality research work in the field of

health and allied sciences.

About the editors: IJMSE editorial

board members are renowned,

experienced medical educationist whose

expert and have fair contribution in the

field of Medical Science. Editors are

selected from different countries and

every year editorial team is updated. All

editorial decisions are made by a team of

full-time journal management

professionals.

IJMSE Award for Best Article: IJMSE editorial team selects one 'Best

Article' in every issue for award among

published articles.

IJMSE is official publication of Association

of Scientific And Medical Education.

Editorial office

H.N.22, SAMA 1, 307501

2951 Mohmmad Bin Zayed City Abu Dhabi,

United Arab Emirates.

Administrative Office: Association For Scientific And Medical

Education, 35/23, Rajat Path Road,

Mansrovar,Jaipur,Raj,India. www.ijmse.com


Executive Council 2014-15

President Dr.Rajkumar Patil,

(Community Medicine) ,MG University,

Pudduchery

Vice-President Dr.Pavan Singhal,

(Otolaryngology), SMS MC, Jaipur

Secretary Dr.Arvind Yadav (Pharmacology, Geetanjali

University, Udaipur)

Treasurer Dr. J. Ahuja Associate

Professor,(Biochemistry), RUHS,

Joint-Secretary (head quarter) Dr. Sunil Gupta,(Biochemistry)

RUHS, Jaipur

Joint-Secretary (out station) Dr. Ashish Sharma ,(Biochemistry)

Geetanjali University,Udaipur

Executive Members

Dr. S. Chandramohan ,( Public Health) , Saudi Electronic University, Saudi Arabia.

Dr.S.S.Surana ,Pathology,Pacific University, Udaipur

Dr.A.P.Gupta,Peadiatrics,Pacific University,Udaipur

Dr.Sanjeev Chaudhary, (Forensic Medicine) Geetanjali University ,Udaipur

Dr. Pooja S.K. Rai,(Biochemistry) L.T.M.C & Hospital, Sion, Mumbai

Dr.Soon Hyuck Lee, Korea University ,Korea

Dr.Yoshihiko K, MD,Japan

Dr.Siswanto S, Department of Public Health, University of Brawijaya, Indonesia.

Dr.Mazen Khalil Ali, Consultant Psychiatrist King Hamad University Hospital, Kingdom of

Bahrain

Association of Scientific And

Medical Education (ASME)

ISSN WXYZ-ABCD

Vol.01 / Issue 01 / Nov 2013

Publication Ethics and Publication Malpractice

Statement The publication of an article in a peer reviewed journal is an essential model for our journal

"International Journal of Medical science and Education". It is necessary to agree upon standards of expected ethical behaviour for all parties involved in the

act of publishing: the author, the journal editor, the peer reviewer and the publisher. Our ethic statements are based on COPE’s Best Practice Guidelines for Journal Editors.

Publication decisions The editor of the GR is responsible for deciding which of the articles submitted to the journal should

be published. The editor may be guided by the policies of the journal's editorial board and constrained by such

legal requirements as shall then be in force regarding libel, copyright infringement and plagiarism. The editor may confer with other editors or reviewers in making this decision.

Fair play An editor at any time evaluate manuscripts for their intellectual content without regard to race,

gender, sexual orientation, religious belief, ethnic origin, citizenship, or political philosophy of the authors.

Confidentiality The editor and any editorial staff must not disclose any information about a submitted manuscript to

anyone other than the corresponding author, reviewers, potential reviewers, other editorial advisers, and the publisher, as appropriate.

Disclosure and conflicts of interest Unpublished materials disclosed in a submitted manuscript must not be used in an editor's own

research without the express written consent of the author.

Duties of Reviewers Contribution to Editorial Decisions

Peer review assists the editor in making editorial decisions and through the editorial communications with the author may also assist the author in improving the paper.

Promptness Any selected referee who feels unqualified to review the research reported in a manuscript or knows

that its prompt review will be impossible should notify the editor and excuse himself from the review process.

Confidentiality Any manuscripts received for review must be treated as confidential documents. They must not be

shown to or discussed with others except as authorized by the editor.

Standards of Objectivity Reviews should be conducted objectively. Personal criticism of the author is inappropriate. Referees

should express their views clearly with supporting arguments.

Acknowledgement of Sources Reviewers should identify relevant published work that has not been cited by the authors. Any

statement that an observation, derivation, or argument had been previously reported should be accompanied by the relevant citation. A reviewer should also call to the editor's attention any substantial similarity or overlap between the manuscript under consideration and any other

published paper of which they have personal knowledge.

Disclosure and Conflict of Interest Privileged information or ideas obtained through peer review must be kept confidential and not

used for personal advantage. Reviewers should not consider manuscripts in which they have conflicts of interest resulting from competitive, collaborative, or other relationships or connections

with any of the authors, companies, or institutions connected to the papers.

Duties of Authors

Reporting standards Authors of reports of original research should present an accurate account of the work performed as well as an objective discussion of its significance. Underlying data should be represented accurately

in the paper. A paper should contain sufficient detail and references to permit others to replicate the work. Fraudulent or knowingly inaccurate statements constitute unethical behavior and are

unacceptable.

Data Access and Retention Authors are asked to provide the raw data in connection with a paper for editorial review, and

should be prepared to provide public access to such data (consistent with the ALPSP-STM Statement on Data and Databases), if practicable, and should in any event be prepared to retain such data for a

reasonable time after publication.

Originality and Plagiarism The authors should ensure that they have written entirely original works, and if the authors have

used the work and/or words of others that this has been appropriately cited or quoted.

Multiple, Redundant or Concurrent Publication An author should not in general publish manuscripts describing essentially the same research in

more than one journal or primary publication. Submitting the same manuscript to more than one journal concurrently constitutes unethical publishing behaviour and is unacceptable.

Acknowledgement of Sources Proper acknowledgment of the work of others must always be given. Authors should cite publications that have been influential in determining the nature of the reported work.

Authorship of the Paper Authorship should be limited to those who have made a significant contribution to the conception,

design, execution, or interpretation of the reported study. All those who have made significant contributions should be listed as co-authors. Where there are others who have participated in certain substantive aspects of the research project, they should be acknowledged or listed as

contributors. The corresponding author should ensure that all appropriate co-authors and no inappropriate co-

authors are included on the paper, and that all co-authors have seen and approved the final version of the paper and have agreed to its submission for publication.

Hazards and Human or Animal Subjects If the work involves chemicals, procedures or equipment that have any unusual hazards inherent in

their use, the author must clearly identify these in the manuscript.

Disclosure and Conflicts of Interest All authors should disclose in their manuscript any financial or other substantive conflict of interest that might be construed to influence the results or interpretation of their manuscript. All sources of

financial support for the project should be disclosed.

Fundamental errors in published works When an author discovers a significant error or inaccuracy in his/her own published work, it is the

author’s obligation to promptly notify the journal editor or publisher and cooperate with the editor to retract or correct the paper.

References Committee on Publication Ethics (COPE). (2011, March 7). Code of Conduct and Best-Practice

Guidelines for Journal Editors. Retrieved from http://publicationethics.org/files/Code_of_conduct_for_journal_editors_Mar11.pdf

http://publicationethics.org/files/Code_of_conduct_for_journal_editors_Mar11.pdf

Index

S.N. Title Authors Page

No.

0 Author information Editorial Board i-x

1 Chronic sclerosing sialadenitis

masquerading as salivary gland

tumour

Dr.Prashant Sharma,Dr.Riru

Mehta,Dr.Sanjeev K.Agrawal,

Dr.P.M.Parihar

1-7

2 Lymphangiomyomatosis - A Rare

Interstitial Lung Disease (ILD)

Dr. Rishi Kumar Sharma, Dr. Gaurav

Chhabra , Dr. S.K.Luhadia

8-11

3 Aetiology and presentation of

neonatal septicaemia at tertiary care

Hospital of southern Rajasthan

Dr.Deepandra Garg,Dr.Neha Agrawal 12-20

4 Ormeloxifene: Boon to

perimenopausal Dysfunctional

Uterine Bleeding (DUB) women in

avoiding hysterectomies

Dr. S. Fayyaz Shahab, Dr. Shailesh Jain,

Dr. Jyoti Jain,Dr.Ujjwala Jain,

21-29

5 The study of socioeconomic factor

affecting breast feeding practice

among family of rural area of

Jaipur

Dr. Veerbhan Singh, Dr. Archana Paliwal,

Dr. Indu Mohan, Dr. S. L. Bhardwaj

,Dr.Ram Chandra Choudhary , Dr.

Bhupendra Nath Sharma

30-38

6 The study of the organisms

colonizing trachea in mechanically

ventilated patients admitted in the

Intensive Care Unit (ICU)

Dr.Trilok Patil

39-48

7 Electrolytes imbalance in

traumatic brain injury patients

Dr. Sanjay K.Gupta, Dr. Jitendra Ahuja,

Dr. Arvind Sharma

49-56

International Journal of Medical Science and Education (IJMSE)

Vol.01 / Issue 01 / Jan-March 2014

ISSN WXYZ-ABCD

Vol.01 / Issue 01 / Nov 2013

International Journal of Medical Science and Education pISSN- 2348 4438 eISSN-2349- 3208

Published by Association for Scientific and Medical Education (ASME)

Page I Vol.1; Issue: 1;Jan-March 2014

http://www.ijmse.com

We provide good quality content for researchers and health care professionals so we don’t

accept plagiarised (Copy and paste) manuscript. Kindly check your article before

submission to our journal for faster processing

Authors Instructions:

Please go through the following instructions

that help you in your manuscript preparation

and feel free to contact us for any queries.

All the manuscripts will be subjected

to RAPID peer review process and those of

high quality (which are not previously

published and are not under consideration

for publication by another journal) would be

published without any delay in

subsequent issue. All articles must be

submitted along with covering letter

(model covering letter) by email

attachment only

to [email protected] or

[email protected] .

Authors are encouraged to suggest the

names and give official email addresses of

three potential referees/reviewers of your

choice while submitting their articles (Not

compulsory). We are looking forward to

your submissions.

Editorial Policy:

Authors should prepare their manuscripts

submitted to the journal exactly according to

the instructions given here. Manuscripts

which do not follow the format and style of

the journal may be returned to the authors

for revision or rejected. The journal reserves

the right to make any further formatting

changes and language corrections necessary

in a manuscript accepted for publication so

that it conforms to the formatting

requirements of the journal. Manuscripts and

figures are not returned to the authors, not

even upon rejection of the paper. Each

submitted article will be reviewed by at

least three peer reviewers and authors will

be asked to do modifications/ corrections, if

required. It is the responsibility of the

corresponding author to ensure that the

galley proofs are to be returned without

delay with correction (if any). The

authors are responsible for the contents

appeared in their published manuscripts.

Open access policy:

www.ijmse.com publishes peer-reviewed

scholarly journals indexed with most

international A&I databases. The journal

provides immediate free access to the full

text of articles in PDF format. The open

access policy of the journal aims at

increasing the visibility and accessibility of

the published content and thus providing the

desirable research impact.

Authorship Criteria

Authorship credit should be based only on

substantial contributions to: 1. Concept and

design of study or acquisition of data or

analysis and interpretation of data;

2. Drafting the article or revising it critically

for important intellectual content; and

3. Each contributor should have participated

sufficiently in the work to take public

responsibility for appropriate portions of the

content of the manuscript. The order of

naming the contributors should be based on

the relative contribution of the contributor






Page II Vol.1; Issue: 1;Jan-March 2014


towards the study and writing the

manuscript. Once submitted, the order

cannot be changed without written consent

of all the contributors. 4. Corresponding

author should check his /her e-mail

regularly.

Guarantor

One or more author should take

responsibility for the integrity of the work

from the inception to the publishing of the

article. This author will be designated as the

guarantor.

Manuscript Style

Manuscripts must follow the International

Committee of Medical Journal Editors’

revised “Uniform Requirements for

Manuscripts to be submitted to Biomedical

Journals: Writing and Editing for

Biomedical Publication”. (See

http://www.ICMJE.org/)

Preparation of manuscript:

Title:

The title of the article should be

approximately 10-15 words (this may be

changed with the authors’ approval).

Authors

The full names, qualifications, affiliations,

details of position/place of work of all

authors should be listed at the beginning of

the article. E-mail id of corresponding

author is must. Your Manuscript should be

typed, double-spaced on standard-sized –

paper (8.5" x 11") with 1" margins on all

sides. You should use 12 pt Times New

Roman fonts. Authors should take care over

the fonts which are used in the document,

including fonts within graphics. Fonts

should be restricted to Times New Roman,

Symbol and Zapf Dingbats.

Title: Should be in Title Case; the first

character in each word in the title has to be

capitalized. A research paper typically

should include in the following order

Abstract

Keywords

Introduction

Materials and Methods

Ethics

Statistics

Results

Discussion

Conclusion

Acknowledgements (If any)

References

Figure legends

Tables

Appendices (if necessary)

Abbreviations (if necessary)

Abstract – Limit of 250 Words

A brief summary of the research should

include a brief introduction, a description of

the hypothesis tested, the approach used to

test the hypothesis, the results seen and the

conclusions of the work. It can be a

structured abstract like Introduction/

Background, Materials and methods,

Results, Conclusion(s).

http://www.icmje.org/



Page III Vol.1; Issue: 1;Jan-March 2014


Key words

Please, write no more than six keywords.

Write specific keywords. They should be

written left aligned, arranged alphabetically

in 12pt Times Roman, and the line must

begin with the words Keywords boldfaced.

Introduction

Description of the research area, pertinent

background information, and the hypotheses

tested in the study should be included under

this section. The introduction should

provide sufficient background information

such that a scientifically literate reader can

understand and appreciate the experiments

to be described. The introduction MUST

include in-text citations including references

to pertinent reviews and primary scientific

literature. The specific aims of the project

should be identified along with a rationale

for the specific experiments and other work

performed.

Materials and Methods

Materials and/or subjects utilized in the

study as well as the procedures undertaken

to complete the work. The methods should

be described in sufficient detail such that

they could be repeated by a competent

researcher. Please include the company

sources for all uncommon reagents (kits,

drugs, etc). Illustrations and/or tables may

be helpful in describing complex equipment

or elaborate procedures. The statistical tool

used to analyze the data should be

mentioned. All procedures involving

experimental animals or human subjects

must accompany with statement on

necessary ethical approval from appropriate

ethics committee.

Ethical Considerations

In all experimental and studies on human or

animals, authors must state whether formal

approval from an Institutional Review Board

or Ethics Committee was obtained. In the

absence of such committee, the Declaration

of Helsinki (click here) guidelines must be

followed and be clearly stated in the

Methods section of the manuscript. All

studies on human subjects must include a

statement that the subjects gave informed

consent. Patient anonymity should be

preserved. Photographs need to be cropped

to prevent human subjects being recognized.

Experiments involving animals must be

demonstrated to be ethically acceptable and

should conform to national guidelines for

animal usage in research.

Statistics

Whenever possible, quantify findings and

present them with appropriate indicators of

measurement error or uncertainty. Report

losses to observation resulting from

conditions, such as dropouts from a clinical

trial, include a general description of

methods in the Methods section. While

summarizing the data in the Results section,

specify the statistical methods used to

analyse them. Avoid non-technical uses of

technical terms in statistics. Define

statistical terms, abbreviations, and most

symbols.

Results

Data acquired from the research with

appropriate statistical analysis described in

the methods section should be included in

this section. The results section should

describe the rational for each experiment,

http://www.wma.net/en/30publications/10policies/b3/17c.pdf



Page IV Vol.1; Issue: 1;Jan-March 2014


the results obtained and its significance.

Results should be organized into figures and

tables with descriptive captions.

The captions, although brief, should tell the

reader the method used, explain any

abbreviations included in the figure, and

should end with a statement as to the

conclusion of the figure. Qualitative as well

as quantitative results should be included if

applicable.

Discussion

This section should relate the results section

to current understanding of the scientific

problems being investigated in the field.

Description of relevant references to other

work/s in the field should be included here.

This section also allows you to discuss the

significance of your results - i.e. does the

data support the hypotheses you set out to

test?

Conclusion

This section should end with new

answers/questions that arise as a result of

your work.

Tables and Figures

Tables:

Tables should be self-explanatory and

should not duplicate textual material.

Tables with more than 12 columns and

25 rows are not acceptable.

Number tables, in Arabic numerals,

consecutively in the order of their first

citation in the text and supply a brief

title for each.

Use only horizontal rules for the tables

to separate the column headings.

Place explanatory matter in footnotes,

not in the heading.

Explain in footnotes all non-standard

abbreviations that are used in each

table.

Obtain permission for all fully

borrowed, adapted, and modified

tables and provide a credit line in the

footnote.

For footnotes use the following

symbols in this sequence: *, †, ‡, §, ||,¶

, **, ††, ‡‡

Tables with their legends should be

provided at the end of the text after the

references. The tables along with their

number place in the text. An example

follows for ready reference:

Table 1: PK parameters as calculated for enalapril in different groups

Parameter

value

Group Ib Group IIb Group IIIb Literature

Cmax

(ng/ml)

91±8.55* 96.60±9.29 95.00±7.32 69±37

tmax (hrs) 4.34±0.50 3.70±0.4 3.85±0.23 NA†

*: Normalized to therapeutic dose of 10mg; †: Data not available



Page V Vol.1; Issue: 1;Jan-March 2014


Figures:

The maximum number of figures should be

limited to four

Upload the images in JPEG format. The file

size should be within 4 MB in size while

uploading.

Figures should be numbered consecutively

according to the order in which they have

been first cited in the text.

Labels, numbers, and symbols should be

clear and of uniform size. The lettering for

figures should be large enough to be legible

width of printed column. Use only

horizontal rules for the tables; to separate

the column headings. No vertical rules

should that all columns and rows are

aligned.

Symbols, arrows, or letters used in

photomicrographs should contrast with the

background and should be marked neatly

with overlay and not by pen.

Titles and detailed explanations should be

written in the legends for illustrations, and

not on the illustrations themselves.

Send digital X-rays, digital images of

histopathology slides, where feasible.

If photographs of individuals are used,

authors should take written permission to

use the photograph.

If a figure has been published elsewhere,

acknowledge the original source and submit

written permission from the copyright a

credit line should appear in the legend for

such figures.

If the uploaded images are not of

printable quality, the publisher office

may request for higher resolution

images which can be sent at the time of

acceptance of the manuscript. Ensure

that the image has minimum resolution

of 300 dpi or 1800 x 1600 pixels.

The Journal reserves the right to crop, rotate,

reduce, or enlarge the photographs to an

acceptable size.

Acknowledgements – Limit of 100 Words

Page layout & styles

Page size Letter Portrait 8 ½ X 11

Margins All Margins, 1 inch

Page numbers Numbered at bottom right

Footer / Headers None

Title 14 pt Times New Roman, bold, centered.



Page VI Vol.1; Issue: 1;Jan-March 2014


Author and co-

authors

12 pt Times New Roman centered, bold - author and all co-authors names in

one line. The corresponding author should include an asterisk*.

Authors affiliation 12 pt Times New roman centered - giving each authors' affiliation (i.e.

Department/Organization/Address/Place/Country/email). Followed by

single line spacing.

Author for

Correspondence:

10pt Times New roman centered - giving a valid e-mail of the

corresponding (main) author is a must.

Abstract 12 pt Times New roman, full justification Normal - maximum 250 words

Text 12 pt Times New roman, full justification – 1.5 line spacing between

paragraphs. No indentation

Headings and

numbering

Major headings (ABSTRACT, KEYWORDS, INTRODUCTION,

MATERIALS AND METHODS, RESULTS, DISCUSSION,

ACKNOWLEDGEMENTS, REFERENCES, FIGURE LEGENDS,

TABLE/S) in upper case left-justified, 12 pt bold, Intermediate headings

should be in italics, sentence case, left justified, 12 pt

Tables To be incorporated at the end of Manuscript

Correct

“Table 1: CRP levels in different grades of obesity………”

Incorrect

“Table No. 1: CRP levels in different grades of obesity………”

Figures /Graphs Figures may be embedded in your word document but they should be

created with a program that allows you to save them as gif, jpg or tiff

format.

For any figures or other materials directly extracted from previously

published materials, you must have written permission from the publisher of

that material for reprint use. A copy of that permission release must be

submitted with your article.

It is the individual author's responsibility to attain this permission.

To be incorporated at the end of the manuscript with proper labelling

Correct



Page VII Vol.1; Issue: 1;Jan-March 2014


“Figure 1: CRP levels in different grades of obesity………”

Incorrect

“Figure No. 1: CRP levels in different grades of obesity………”

Graphs To be included from excel, it should be editable.

Non – editable graphs will not be accepted.

References

References should be numbered

consecutively in the order in which they are

first mentioned in the text (not in alphabetic

order). Citations of literature within the text

must be presented in numerical order and

should be set in small brackets, for instance,

(1, 12).The cited literatures are also

collected in numerical order at the end of the

manuscript under the heading “References”.

References cited only in tables or figure

legends should be numbered in accordance

with the sequence established by the first

identification in the text of the particular

table or figure. Use the style of the examples

below, which are based on the formats used

by the NLM in Index Medicus. (Click here)

The titles of journals should be abbreviated

according to the style used in Index

Medicus. Use complete name of the journal

for non-indexed journals. Avoid using

abstracts as references.

Information from manuscripts submitted but

not accepted should be cited in the text as

"unpublished observations" with written

permission from the source. Avoid citing a

"personal communication" unless it provides

essential information not available from a

public source, in which case the name of the

person and date of communication should be

cited in parentheses in the text.

The commonly cited types of references are

shown here, for other types of references

such as newspaper items please refer to

ICMJE Guidelines (http://www.icmje.org or

http://www.nlm.nih.gov/bsd/uniform_requir

ements.html).

Articles in Journals

Standard journal article (for up to six

authors): Shukla N, Husain N, Agarwal GG,

Husain M. Utility of cysticercus fasciolaris

antigen in Dot ELISA for the diagnosis of

neurocysticercosis. Indian J Med Sci 2008;

62: 222-7.

Standard journal article (for more than six

authors): List the first six contributors

followed by et al.

Nozari Y, Hashemlu A, Hatmi ZN,

Sheikhvatan M, Iravani A, Bazdar A, et al.

Outcome of coronary artery bypass grafting

in patients without major risk factors and

patients with at least one major risk factor

for coronary artery disease. Indian J Med Sci

2007; 61: 547-54

http://www2.bg.am.poznan.pl/czasopisma/medicus/med_I.htm

http://www.icmje.org/

http://www.nlm.nih.gov/bsd/uniform_requirements.html

http://www.nlm.nih.gov/bsd/uniform_requirements.html



Page VIII Vol.1; Issue: 1;Jan-March 2014


Volume with supplement: Shen HM, Zhang

QF. Risk assessment of nickel

carcinogenicity and occupational lung

cancer. Environ Health Perspect 1994; 102

Suppl 1:275-82.

Issue with supplement: Payne DK, Sullivan

MD, Massie MJ. Women's psychological

reactions to breast cancer. Semin Oncol

1996; 23(1, Suppl 2):89-97.

Books and Other Monographs

Personal author(s): Ringsven MK, Bond D.

Gerontology and leadership skills for nurses.

2nd ed. Albany (NY): Delmar Publishers;

1996.

Editor(s), compiler(s) as author: Norman IJ,

Redfern SJ, editors. Mental health care for

elderly people. New York: Churchill

Livingstone; 1996.

Chapter in a book: Phillips SJ, Whisnant JP.

Hypertension and stroke. In: Laragh JH,

Brenner BM, editors. Hypertension:

pathophysiology, diagnosis, and

management. 2nd ed. New York: Raven

Press; 1995. pp. 465-78.

Electronic Sources as reference

Journal article on the Internet

Abood S. Quality improvement initiative in

nursing homes: the ANA acts in an advisory

role. Am J Nurs [serial on the Internet].

2002 Jun [cited 2002 Aug 12]; 102(6):

[about 3p.]. Available from:

http://www.nursingworld.org/AJN/2002/jun

e/Wawatch.htm

Monograph on the Internet

Foley KM, Gelband H, editors. Improving

palliative care for cancer [monograph on the

Internet]. Washington: National Academy

Press; 2001 [cited 2002 Jul 9]. Available

from:

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Homepage/Web site

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New York: Association of Cancer Online

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http://www.cancer-pain.org/.

Part of a homepage/Web site

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on the Internet]. Chicago: The Association;

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assn.org/ama/pub/category/1736.html

Dissertation

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Role of antibiotic resistance [dissertation].

St. Louis (MO): Washington Univ.; 2002.

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CHRONIC SCLEROSING SIALADENITIS MASQUERADING AS

SALIVARY GLAND TUMOUR

Dr. Prashant Sharma1*

, Dr. Ritu Mehta2, Dr. Sanjeev K.Agrawal

1, Dr.P.M.Parihar

3

1Assistant professor, Dept. of Surgery, Geetanjali Medical College and Hospital, Udaipur

(Rajasthan)

2Associate professor, Dept. of Radiology, Geetanjali Medical College and Hospital, Udaipur

(Rajasthan)

3Assistant professor, Dept. of Pathology, Geetanjali Medical College and Hospital, Udaipur

(Rajasthan)

* Email id of corresponding author : [email protected]

Received: 26/09/2013 Revised: 11/10/2013 Accepted: 17/10/2013

Abstract:

Küttner described 4 cases of chronic sclerosing sialadenitis (CSS) of submandibular gland in

1896 and defined it as a chronic inflammatory salivary gland disease. Although chronic

sclerosing sialadenitis is an inflammatory lesion of the salivary glands but sometime mimics

malignant masses of salivary glands. We reported a 35-year-old male with a neck swelling of

chronic sclerosing sialadenitis which was initially diagnosed as malignancy.

Keywords: chronic sclerosing sialadenitis, sialoliths, submandibular gland, salivary glands.

INTRODUCTION:

The mass of salivary glands may result from

a benign inflammatory process, which is

known as Chronic sclerosing sialadenitis

(CSS) or Kuttner’s tumour (KT).Sometime

these masses may present as stony hard

tumour and masquerade as malignant lesion.

It affects mainly the submandibular gland

but some cases of parotid glands are also

reported. (1, 2)

The histological characteristics of chronic

sclerosing sialadenitis are ductal squamous

metaplasia, periductal fibrosis, dense

lymphoplasmocytic infiltration, loss of the

acini, sclerosis of the salivary gland and

sialoliths in salivary ducts. (3, 4)Because

CSS appear as a hard mass, it usually

assumes an immense clinical doubt of a

malignant neoplasm. In recent years, fine-

needle aspiration cytological (FNAC)

Case History






examination and needle biopsy have been

used. It is more safer, comparatively trouble-

free with quick result and economical

techniques to confirm salivary gland

lesions.(5,6) The assistance of CT scan in

FNAC is also very valuable in correct

diagnosis of salivary gland masses. We

report the CT scan appearance and CT scan

guided FNAC features of an adult with CSS

of the unilateral submandibular gland.

CASE REPORT:

A 35 –year-old male was referred to

oncology outpatient department. He

observed the neck mass 2 years ago. On

examination there was hard, bimanual

palpable mass at level Ib on right upper neck

and it seemed to be attached to underlying

structures. Small Lymph node were palpable

at right level II and III and also at left level

Ib and II in neck. Small nodule was noted at

right Floor of Mouth (FOM). Any other

related events were not found in the

patient’s medical history. He reported no

other symptoms or complaints. His facial

nerve function was intact. Patient came with

FNAC report which revealed an impression

of malignant lesion. Malignancy of

Unknown Origin was predicted as probable

diagnosis because report of malignant

lesion. Identification of primary and

secondary and further management of both

were planned. CT scan showed mildly

enlarged right submandibular gland with

heterogeneous enhancement and

architecture, suggestive of sialadenitis along

with calculi in the submandibular duct.

Figure 1:CT scan image (transverse view)

shows that Right submandibular duct was

mildly dilated and there were two calcified

calculi measuring 8 mm and 9 mm in the

proximal part of duct and at the distal end.

(Black arrows).

Figure 2:CT scan image (transverse view) of

the head shows Right submandibular gland

mass located within the neck. (white

arrows).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216182/figure/f1-mjms-17-4-057/






Figure 3

FNAC: A CT scan guided fine-needle

aspiration cytological (FNAC) examination

was performed. Cytology revealed

occasional acinar clusters with inflammatory

cells against a dense necrotic background.

No pathologic nodes were identified

(Figures 3).

Figure 4

Histopathological examination:

Gross features: The specimen collected for

pathological examination measured 5x4x1.8

cm. External surface was unremarkable, and

its cut surface revealed lobulated pale tan

tissue. The whole tissue sample was

submitted for pathological examination.

Salivary duct also received that measured

3cm in length, dilated and one end with a

calculus. (Figure 4)

Microscopy: For microscopic examination,

multiple sections studied from salivary

gland reveal preserved lobular architecture.

There was dense lymphoplasmocytic

infiltrate, surrounding the duct and acini

with accompanying periductal fibrosis. The

salivary acini proximal to obstructed and

dilated ducts were atrophic. Reactive

lymphoid follicles were seen. There was

varying degree of fibrosis surrounding the

lobules. Dilated larger duct revealed

squamous metaplasia. Two adjunct lymph

node revealed reactive hyperplasia. (Figure

5). (Figure 6). Malignant cells were not

found, and the chronic sclerosing

sialadenitis was diagnosed.

Figure 5: Histology of the salivary gland

tissue showing chronic sclerosing

sialadenitis (Küttner’s tumour) fibrosis and

few residual ducts and foci of lymphocytic









infiltrate often with germinal centres.

(Haematoxylin and Eosin).

Figure 6:Histology showing the salivary

gland residue embedded in collagenised

fibrous tissue and dense lymphoplasmocytic

infiltration. (Haematoxylin and eosin, 100 x

magnifications)

DISCUSSION:

CSS is a benign disease that results from

different causes. In recent years some

etiological processes have been suggested

by authors to define underlying pathology of

CSS, for instance salivary gland stones,

secretory abnormality with ductal stasis of

saliva, infections, ductal diorders and an

autoimmune pathology.(7,8) Seifert et al

showed that the findings of CSS were

analogous to obstructive sialadenitis. (9)

However, the obstructive sialadenitis or

sialolithiasis could not explain the

mechanisms of the inflammatory process

clearly. Immunologic pathogenesis of CSS

was explained by some researchers. There

was a close connection between the T cell-

lymphocyte with plasmacytic infiltrate,

surrounding the duct and acini with

accompanying periductal fibrosis, equally

with the persistent presence of monoclonal

and oligoclonal cytotoxic T cells and their

relevant histopathological features. Tiemann

et al concluded that intraductal

inflammatory chemo-attractant may elicit an

immune process and histological changes in

CSS. (10) Geyer JT et al also showed other

immunological markers in CSS.

Immunohistochemical staining shows

abundant IgG4 and IgG positive cells. The

IgG4/IgG ratio is high compared to other

inflammatory diseases of the salivary

glands. (11)

Mucous plugs and salivary stones are

reported in 29% to 83% of cases of CSS.

(12) In this case, two sialoliths were found

which may be a cause of dilation of right

submandibular duct. Salivary gland stones

may obstruct salivary discharge or

accumulation of secretions. A hypothesis of

obstructive electrolyte sialadenitis, is given

by Seifert and Donath .(13) They postulated

that secretion abnormality makes mucous

plug that obstructs the small ducts,

obliteration further cause inflammatory

reaction, parenchymal and ductal atrophy,

periductal fibrosis, and an immune reaction

towards the duct system. Benign differential

diagnosis of CSS include simple chronic

sialadenitis, granulomatous sialadenitis,

necrotising sialometaplasia, sialolithiasis, an

inflammatory pseudotumour, radiation

effects and benign lymphoepithelial lesions.

Another common cause of CSS of the

salivary glands is associated to rheumatoid

arthritis, which is also explained the immune

pathogenesis.(14) The malignant differential





diagnosis includes extra nodal marginal

zone B-cell lymphoma of MALT,

fibrohistiocytic tumours, Kimura's

disease,sclerosing lymphoma, sarcoidosis

and neoplasms of the salivary glands. CSS

have a very good prognosis as this disorder

has benign lesions that are not liable to

recurrence. No reports were found to

support the view that this condition may be

causative factor for malignancy. (15)

The disease mimics true neoplasm and

sometimes difficult to distinguish clinically.

(16) Radiological imaging is frequently used

for the primary examination to assess the

character of salivary gland mass. For the

detection of focal salivary masses,

sonography has a sensitivity of 100% and an

accuracy of nearly 100% compared with

92% and 87% by palpation.(17)

MRI is also a sensitive tool for diagnosis of

CSS. In MRI, signal intensity ratios for T2

weighted and STIR images, ADC values and

patterns of enhancement may help to

distinguish Kuttner’s tumours from benign

submandibular gland tumours, but not from

malignant tumours. Although the intensities,

ADC values and enhanced patterns of

Kuttner’s tumours were similar to those of

malignant tumours, but there were some

morphological differences.(18)

Repeat FNAC may provide a cytological

diagnosis in cases where the initial diagnosis

is not clear, although cytology should be

used in combination with other

investigations of salivary tumours, including

image-guided biopsy examination where

appropriate. Ideally salivary gland FNAC

should be interpreted by a specialist

pathologist. (19)

CONCLUSION:

Kuttner tumour should be kept in mind

during the differential diagnosis of any firm

to hard swelling of salivary gland as it is

rare swelling of salivary glands that

clinically masquerade as malignancy. Early

and correct diagnosis is essential for the

planning of management. FNAC is good

tool but the sensitivity will be increased if it

is image guided and repeat FNAC also give

a correct diagnosis in case of any confusion.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved

by the institutional ethics committee

REFERENCES:

1. Williams HK, Connor R, Edmondson H.

Chronic sclerosing sialadenitis of the

submandibular and parotid glands: a report

of a case and review of the literature. Oral

Surg Oral Med Oral Pathol Oral Radiol

Endod 2000; 89:720–723.

2. Seifert G. Tumour-like lesions of the

salivary glands. The new WHO

classification. Pathol Res Pract.

1992;188(7):836–846.

3. Räsänen O, Jokinen K, Dammert K.

Sclerosing inflammation of the

submandibular salivary gland (Küttner

tumour): A progressive plasmacellular





ductitis. Acta Otolaryngol. 1972;74(4):297–

301.

4. Chan JK. Kuttner tumor (chronic

sclerosing sialadenitis) of the submandibular

gland: an underrecognized entity. Adv Anat

Pathol 1998; 5:239–251.

5. Stewart CJ, MacKenzie K, McGarry GW,

Mowat A.Fine-needle aspiration cytology of

salivary gland: a review of 341 cases. Diagn

Cytopathol 2000; 22:139–146.

6.Nanda K D, Mehta A, Nanda J. Fine-

needle aspiration cytology: a reliable tool in

the diagnosis of salivary gland lesions. J

Oral Pathol Med 2012; 41: 106–112

7. Chan JK. Kuttner tumor (chronic

sclerosing sialadenitis) of the submandibular

gland: an underrecognized entity. Adv Anat

Pathol 1998; 5:239–251.

8. Yoshihara T, Kanda T, Yaku Y, Kaneko

T. Chronic sialadenitis of the submandibular

gland (so-called Kuttner tumor). Auris

Nasus Larynx 1983; 10:117–123.

9. Seifert G, Miehike A, Haubrich J, Chilla

R, Stell PM. Diseases of the Salivary

Glands: Pathology, Diagnosis, Treatment,

Facial Nerve Surgery.Stuttgart, Germany:

Georg Thieme Verlag; 1986.

10. Tiemann M, Teymoortash A, Schrader

C, Werner JA, Parwaresch R, Seifert G, et

al. Chronic sclerosing sialadenitis of the

submandibular gland is mainly due to a T

lymphocyte immune reaction. Mod Pathol.

2002;15(8):845–852.

11. Geyer JT, Ferry JA, Harris NL, Stone

JH, Zukerberg LR, Lauwers GY, Pilch BZ,

Deshpande V. 2010. Chronic sclerosing

sialadenitis (Küttner tumor) is an IgG4-

associated disease. Am J Surg Pathol. 2010

Feb;34(2):202-10.

12. Harrison JD, Epivatianos A, Bhatia SN.

Role of microliths in the aetiology of

chronic submandibular sialadenitis: A clinic-

pathological investigation of 154 cases.

Histopathology. 1997;31(3):237–251.

13. Seifert G, Donath K. On the

pathogenesis of the Küttner tumor of the

submandibular gland: Analysis of 349 cases

with sialadenitis of the submandibular gland.

HNO. 1977;25(3):81–92.

14. Kuroshima C, Hirokawa K. Age-related

increase of focal lymphocytic infiltration in

the human submandibular glands. J Oral

Pathol. 1986;15(3):172–178.

15. Agale SV, Momin YA, Agale VG.

Kuttner tumor: a report of an

underdiagnosed entity. J Assoc Physicians

India. 2010; 58: 694-5.

16. Roh JL, Kim JM. Küttner’s tumour:

Unusual presentation with bilateral

involvement of the lacrimal and

submandibular glands. Act Oto Laryngol

2005; 125: 792-796

17. Gritzmann N. Sonography of salivary

glands. AJR Am J Roentgenol 1989;

153:161–166.





18. A Abu, K Motoori,S Yamamoto, T

Hanazawa,Y Nagai, K Kaneoya, and H Ito,

MRI of chronic sclerosing sialoadenitis. The

British Journal of Radiology. 2008; 81: 531–

536.

19.Brennan PA, Davies B, Poller D, Mead

Z, Bayne D, Puxeddu R, Oeppen RS.Fine

needle aspiration cytology (FNAC) of

salivary gland tumours: Repeat aspiration

provides further information in cases with an

unclear initial cytological diagnosis. Br J

Oral Maxillofac Surg. 2010;48(1):26-9.





LYMPHANGIOMYOMATOSIS - A RARE INTERSTITIAL LUNG DISEASE (ILD)

Dr. Rishi Kumar Sharma1, Dr. Gaurav Chhabra

1, Dr. S.K.Luhadia

2

1. Assistant professor, Dept. of TB and Respiratory diseases, Geetanjali Medical College and

Hospital, Udaipur

2. Professor, Dept. of TB and Respiratory diseases, Geetanjali Medical College and Hospital,

Udaipur

*Email id of corresponding author: [email protected]

Received: 20/08/2013 Revised: 12/10/2013 Accepted:28/10/2013

Abstract:

We report a case of a 26 years old Female with Lymphangiomyomatosis , a rare multi system

disorder. Clinical history was sudden onset of chest pain and was operated for Left Renal

Angiomyolipoma 4 years back. Her Chest X-Ray showed Left sided Pneumothorax. Her CT

Thorax was suggestive of bilateral diffuse well defined cystic shadows distributed all over lung

fields surrounded by normal Lung Parenchyma along with Left Pneumothorax, distinguishing

features for pulmonary Lymphangioleiomyomatosis. Lymphangioleiomyomatosis is under

diagnosed by clinicians, so awareness of this disorder may be helpful to reduce morbidity and

mortality.

Keywords: Lymphangioleiomyomatosis, Pneumothorax, Renal Angiomyolipoma CT-Thorax

INTRODUCTION:

Lymphangiomyomatosis (LAM) is a

unusual multifocal origin disease which

typically involves lung, kidney and lymph

and may be associated with the tuberous

sclerosis (TS).(1) Commonly it affects

women of reproductive age group with

incidence of 1:400,000 . (2,3) Proliferation

of abnormal smooth muscle causing

obstruction of venules and lymphatics which

further carry doggedness of dilated

lymphatics. (4) There are two types of

presentation of lymphangiomyomatosis in

the chest. In initial phase, immature muscle

cells are proliferating in such a way that they

cover alveolar walls, bronchioles, pleura and

vessels, including lymphatic routes. In the

later stages cystic lesions appears in lung

with more proliferation of muscle cells

throughout the lung.(5)

HISTORY

A 26 yrs. old female came to the TB and

Chest Diseases OPD with complaints of

Chest pain Left side for last 2 days. It was

sudden in onset and not associated with

Palpitation / sweating / Shortness of

Breathing (SOB). Her Chest X-Ray was

suggestive of left sided Pneumothorax. Inter

Case History






Costal Tube Drainage (ICTD) was done and

lung expanded. Chest tube was removed

after 4 days and Patient remained

asymptomatic for next 1 year. After 1 year,

she again developed left sided chest pain.

Chest X-Ray was suggestive of

Pneumothorax left side. Again ICTD was

done and lung expanded. This time, her past

medical records were reviewed and it was

found that she was operated for Left Renal

Angiomyolipoma four years back. Her CT

Thorax was suggestive of well defined

cystic shadows distributed all over lung

fields surrounded by normal Lung

Parenchyma along with Left Pneumothorax.

Hence a diagnosis of Lymphangi-

omyomatosis was made as the patient was a

young female in reproductive age group

with past history left renal

Angiomyolipoma.

DISCUSSION

LAM is a rare disorder exclusively found in

young females mainly between 30 and 49

years of age. It is characterized by abnormal

proliferation of smooth muscle cells around

pulmonary lymphatics, vessels and small

bronchi.(5) Clinically patient presents with

Chest pain, SOB, cough or Hemoptysis.

Patient may develop Chylothorax or

Pneumothorax. 1/3rd

of patients may have

Renal Angiomyolipoma.(6) lymphangio-

leiomyomatosis is two types, one is sporadic

and another is combined with tuberous

sclerosis. Mutation in tumour suppressor

genes on chromosome 9 (9q34) and on

chromosome 16 (16p13.3) are root cause of

this. (7)

Figure No.1 CT scan Thorax

Figure No .2 Chest X-Ray

Lymphangioleiomyomatosis commonly

creates confusion with asthma, emphysema

or pulmonary fibrosis. The diagnosis is

made mainly on clinical findings and CT

Thorax. A high-resolution CT scan can be

very helpful in diagnosis of

lymphangioleiomyomatosis correctly. (8)

Rarely Lung Biopsy is required. The most

common pulmonary function defects in





LAM are airflow obstruction and decreased

lung diffusion capacity. With the disease

progression, lung functions begin to decline

with an average monthly rate of 7–9 mL of

FEV1. Airflow obstruction was showed in

about 60% of patients of LAM. This loss is

caused by cystic destruction of lung

parenchyma. (8, 9) Proliferating smooth

muscle cell were from unknown origin and

showed metastatic properties.Benign kidney

tumours (angiomyolipoma) are also

associated with 60% of cases of LAM.(10)

The classic presentation of

lymphangioleiomyomatosis is

pneumothorax or chylothorax. Reccuent

pneumothorax may suggest about the

diagnosis of LAM as in this case and

pneumothorax is managed by chemical or

surgical pleurodesis (10)

Main Differential Diagnosis include Langer-

han’s cell Histiocytosis. Lymphangio-

leiomyomatosis is managed by supportive

treatment such as bronchodilator therapy,

pulmonary rehabilitation, treatment of

anxiety, oxygen therapy and eventually lung

transplantation. Clinician should be careful

about prescribing any medication which

contain estrogen (An estrogen-MMP-driven

process play a role in the destruction of lung

parenchyma and may responsible for this

condition among women).(11) Treatment

options include Medroxy-progesterone

acetate ,Tamoxifen , Gonadotropin releasing

hormone agonists , Doxycycline and

Sirolimus with varying results. In some

cases Oophorectomy or Lung transplantation

is indicated.(12 ,13)

CONCLUSION

Lymphangioleiomyomatosis sometimes

under diagnosed by clinicians, awareness of

this disorder may be helpful to reduce

morbidity and mortality. Early and correct

diagnosis of LAM through CT scan of

women with TSC and who come with

pneumothorax or nonspecific respiratory

symptoms makes it possible to start proper

treatment before permanent lung changes

take place.





REFERENCES

1. Sullivan EJ: Lymphangioleiomyomatosis:

a review. Chest 1998; 114:1689-1703.

2.Abbott GF, Rosado-de-christenson ML,

Frazier AA et-al. From the archives of the

AFIP: lymphangioleiomyomatosis:

radiologic-pathologic correlation.

Radiographics. 25 (3): 803-28.

doi:10.1148/rg.253055006

3. Johnson SR, Cordier JF, Lazor R et-al.

European Respiratory Society guidelines for

the diagnosis and management of

lymphangioleiomyomatosis. Eur. Respir. J.

2010;35 (1): 14-26.

doi:10.1183/09031936.00076209

4.Angelo M. Taveira–DaSilva, Gustavo

Pacheco–Rodriguez, Joel Moss.

The Natural History of

Lymphangioleiomyomatosis: Markers of

Severity, Rate of Progression and Prognosis.

http://dx.doi.org/10.1148/rg.253055006

http://dx.doi.org/10.1183/09031936.00076209





Lymphat Res Biol. 2010 March; 8(1): 9–19.

doi: 10.1089/lrb.2009.0024

5.B. Corrin, A. A. Liebow, and P. J.

Friedman. Pulmonary

lymphangiomyomatosis. A review. Am J

Pathol. 1975 May; 79(2): 348–382.

6.O’Callaghan FJ, Noakes MJ, Martyn CN,

Osborne JP. An epidemiological study of

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7.Curatolo P, Bombardieri R, Jozwiak S.

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8.Schmithorst VJ. Altes TA. Young LR, et

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11.

10.Cohen MM. Pollock-BarZiv S, Johnson

S. Emerging clinical picture of

lymphangioleiomyomatosis. Thorax

2005;60:875-9.

11.Glassberg MK, Elliot SJ, Fritz J,

Catanuto P, Potier M, Donahue R, Stetler-

Stevenson W, Karl M. Activation of the

estrogen receptor contributes to the

progression of pulmonary

lymphangioleiomyomatosis via matrix

metalloproteinase-induced cell invasiveness.

J Clin Endocrinol Metab. 2008

May;93(5):1625-33. doi: 10.1210/jc.2007-

1283. Epub 2008 Feb 19.

12. Elizabeth P. Henske and Francis X.

McCormack.Lymphangioleiomyomatosis —

a wolf in sheep’s clothing. J Clin Invest.

2012;122(11):3807–3816.

doi:10.1172/JCI58709.

13.Lymphangioleiomyomatosis (LAM):

Treatment

http://www.nationaljewish.org/healthinfo/

conditions/lam/ treatment.

http://www.ncbi.nlm.nih.gov/pubmed/19304711

http://www.nationaljewish.org/healthinfo/





AETIOLOGY AND PRESENTATION OF NEONATAL SEPTICAEMIA AT TERTIARY

CARE HOSPITAL OF SOUTHERN RAJASTHAN

Dr.Deepandra Garg1*

, Dr.Neha Agrawal2

1 Associate professor, Dept. of Peadiatrics, Geetanjali Medical College and Hospital, Udaipur

(Rajasthan)

2 Resident Dept. of Radiology, JLN Medical College and Hospital, Ajmer (Rajasthan)

*Email id of corresponding author: [email protected]

Received: 22/09/2013 Revised: 15/10/2013 Accepted:27/10/2013

Abstract:

Objective: Sepsis is the one of the common cause of neonatal mortality. The aetiology of

neonatal sepsis has variations according to the various customs and practices in the perinatal and

neonatal period and geographical area. This study was designed to analysis the magnitude and

aetiological characteristics of neonatal sepsis. Martial and Methods: This descriptive study

included 35 full-term neonates of birth weight >2.5 kg admitted in Nursery Balchikitsalaya RNT

Medical College, Udaipur (Lodger and intramural). The study was carried out during the month

of March to May of year 2006. A structured Performa was used to collect the information for the

baseline characteristics like age, gender, birth weight, gestational age, mode of delivery of the

neonate and age of onset of illness. Results: Out of 35 full-term neonates with neonatal sepsis

were included in the study by consecutive sampling. The most common bacteria grown was

coagulase negative staphylococcus (CONS) (28.57%) followed by coagulase positive

staphylococcus (21.42%) and streptococcus fecalis (14.28%). Other organism grown in blood

culture are --hemolytic streptococci in one case (7.14%), Klebsiella in one case (7.14%),

proteus in one case (7.14%), and E. coli in one case (7.14%).lastly one case of blood culture

showed Candida albicans. Conclusion: Most common organisms were coagulase negative

staphylococcus (CONS) (28.57%) followed by coagulase positive staphylococcus (21.42%)

Keywords: Neonatal sepsis, Sensitivity and resistance, Antibiotics, organisms

INTRODUCTION:

Neonatal sepsis is a common cause of neo-

natal morbidity and mortality worldwide.

(1)It contributes to 6 million deaths per year

and nearly accounts for 40% of deaths in

first weeks of life. Its incidence in developed

countries varies from 1-10/1000 live births,

where as it is 3 times more common in

India. (2) Newborn is a relatively

compromised host who is unable to localize

the infection and bacterial sepsis can

Original Research Article






frequently involve vital organs including

meninges. Sepsis neonatrum is the

completely curable life-threatening disease

of the newborn. Prompt institution of

specific anti-bacterial therapy can be life

saving and can reduce neonatal morbidly

and mortality up to a large extent.

The exact reason is unknown but

geographical, socioeconomic, seasonal and

prevalent use of various antibiotics may play

an important role. (3, 4) Most infants with

suspected sepsis recover with supportive

care (with or without initiation of

antimicrobial therapy). The paediatrician

faces three challenges: (5) early recognition

of neonates with a high probability of sepsis

quickly and starting antimicrobial therapy;

(6) differentiate “high-risk” healthy-

appearing infants or infants with clinical

signs who do not require treatment; and (7)

are stopping the therapy once sepsis is

consider not expected.

Bacterial organisms causing neonatal sepsis

in developed countries and developing

countries are different. Information about

Incidence and prevalence of bacteria

responsible for neonatal septicaemia is very

crucial for management of this

simultaneously there have been an increase

in antibiotic resistance over the past two

decades which is due to mutant forms of

common bacteria, overuse, or under use or

inappropriate use of broad spectrum

antibiotics and poor infection control in

maternity and neonatal units. (8, 9)

This study was designed to determine

clinical presentation and bacteriological

spectrum to develop new preventive

strategies at department of Neonatology,

RNT Medical College and Hospital,

Udaipur.

MATERIALS AND METHODS

A total of 35 full-term neonates of birth

weight >2.5 kg admitted in Nursery

Balchikitsalaya RNT Medical College,

Udaipur (Lodger and intramural) were

included.The study was carried out during

the month of March to May of year 2006.

Inclusion criteria were :

Symptoms and signs suggestive of

septicemia with positive sepsis screen.(10)

Exclusion Criteria

1. Neonates with birth asphyxia (APGAR

score <5 at 5 minutes).

2. Neonates with Meconium aspiration

syndrome.

3. Neonates who had previously received

antibiotics in any form.

4. Patient undergoing surgery or major

chromosomal / congenital

malformation.

5. Neonates <1.5 kg and gestational age

<28 weeks.

Methods

After the first clinical suspicion of

infection, blood was taken for blood

culture, blood cell count with differential

and quantitative CRP and micro ESR.

Antibiotic therapy with a standard

regimen of Ampicillin/Cefotaxim and

Gentamycin/Amikacin was started in all

neonates with suspension of septicemia.

Sepsis screen was done on the time of

admission i.e. 0 hours and then again at

4th

day i.e. after 72 hours and again on





8th

day i.e. 168 hours and if sepsis screen

is not negative on 8th

day then again on

14th

day.

Antibiotics were stopped whenever CRP

levels are <10mg/L.

The neonates were also evaluated

clinically daily.

Blood Culture

It is considered gold standard for infection.

Skin is cleaned for 30 seconds with sprite

(70% methylated ethyl alcohol).Under

aseptic precautions, 1 ml blood added to

unvented culture bottle containing 5-10 ml

liquid enriched tryptic Soya broth. Blood

culture incubated for 72 hours before being

considered negative. The good yield of

culture can be attributed to the fact that

blood culture were taken in micro culture

broth tubes in 1:10 dilution. Special small

test tubes containing 5-10 ml of glucose

broth were used and a small amount of

sample i.e. 0.5-10 ml (10 to 20 drops) blood

was sufficient for analysis. These sample

containing bottles were immediately sent to

laboratory and if it was not possible, they

were not kept in refrigerator and stored at

room temperature.

RESULTS

In present study 35 full-term neonates of

birth weight >2.5 kg were included who

suffered from septicemia, confirmed by

clinical examination, different blood tests

and blood culture. Out of which 25 (71.4%)

were male and 10 (28.6%) were female

neonates.

18 cases (51.43%) were of early onset type

(<72 hrs) and 17 cases (48.57%) were late

onset type (>72 hrs). Further, 5 cases

(27.78%) expired in early onset group and

one case (5.26%) expired in late onset

group. This is statistically significant

(p<0.05). More than three forth (77%) were

delivered outside the hospital i.e. lodger and

23% were intramural. Mortality statistics

showed that death was also more in lodger

group i.e. 5 cases (18.57%) as compared to

intramural 1 (12.5%).

History of >3 per vaginal examination was

the commonest maternal risk factor for

neonatal septicemia. Considering the

presence of maternal risk factors and

occurrence of neonatal septicaemia showing

that history of >3 per vaginal examination

was the most important risk factor for

developing neonatal septicaemia. It was

present in 42.85% of cases followed by

PROM >12 hrs in 12 cases (34.28%).

A look at the data regarding vital signs and

clinical features on admission table 1

revealed that refusal to feed was commonest

presenting symptoms (100%) and poor

sucking /swallowing was commonest sign

(85.7%). Fever (22.8%), icterus (25.7%) and

sclerama (8.5%) were other signs and

symptoms. This indicates that refusal to feed

is most important and earliest symptom to

suspect neonatal septicaemia and it should

not be ignored and every child of refusal to





Table No. 1 Signs & symptoms on Admission

S.No. Signs No. of patients Percentage

1 Fever on admission 8 22.8%

2 Icterus on admission 9 25.7%

3 Cyanosis on admission 7 20.0%

4 Sclerema on admission 3 8.5%

5 Hepatomegaly on admission (>2cm

BCM)

7 20.0%

6 Splenomegaly on admission 6 17.14%

7 Perfusion poor (i.e. CRT > 3 sec.) 8 22.8%

S.No. Symptoms No. of cases %

1 Fever 8 22.8%

2 Not well 9 25.7%

3 Refusal to feed 35 100%

4 Convulsion 5 14.2%

5 GIT symptoms 16 45.7%

6 RS symptoms 18 51.4%

7 CVS symptoms 9 25.7%

8 CNS symptoms 14 40.0%

9 Hematological symptoms 11 31.4%

10 Others symptoms 6 17.1%

feed should have a detailed clinical and

laboratory evaluation so that early diagnosis

of neonatal septicaemia can be made and

treated.

Table 1 also shows that commonest systemic

complaint was related to respiratory systems

(51.4%) in the form of (grunting, nasal

flaring, retraction) followed by

gastrointestinal system (45.7%), central

nervous system (40.0%) and haematological

(31.4%).

Among GI manifestations of neonatal

septicaemia, the commonest symptom was

abdominal distension (56.25%) followed by

hepatomegaly >2cm. BCM (43.75%),

vomiting (37.25%) and diarrhoea

(12.5%).The commonest GIT symptom was

abdominal Distention.

The commonest systemic complaints were

related to respiratory system in the form of

dyspnea (Grunting, nasal flaring and

retraction).

The commonest CVS Manifestation of

septicemia was poor perfusion (CRT >3

sec.) It support the fact that neonatal

septicemia has rapid downhill course and if

not timely diagnosed and managed, may

leads to irreversible stage of septic shock

and fulminate outcome.

The commonest CNS manifestation of

septicemia is lethargy. (85.7%) followed by

abnormal moro (42.9%), seizures (35.7%)

and high pitch/ inconsolable cry

(28.6%).The jaundice (81.8%) was

commonest hematological manifestation of





neonatal septicemia followed by pallor

(54.5%) and splenomegaly (84.5%).

The blood culture were positive in 14 cases

(40%) and were negative in 21 (60%) cases.

21.4% deaths were in culture positive and

14.35% in culture negative group

respectively. The regression analysis

revealed statistically significant correlation

between mortality and culture positivity.

The most common bacteria grown was

coagulase negative staphylococcus (CONS)

(28.57%) followed by coagulase positive

staphylococcus (21.42%) and streptococcus

fecalis (14.28%).

Other organism grown in blood

culture are -hemolytic streptococci in one

case (7.14%), Klebsiella in one case

(7.14%), proteus in one case (7.14%), and E.

coli in one case (7.14%).lastly one case of

blood culture showed Candida albicans. Out

of all culture positive cases, only one case

was Candida albicans positive, remaining 13

cases tested positive for various bacterial

pathogens.

Table No. 2 Organisms Isolated from Blood Culture

Organisms No. of cases %

Coagulase –ve staphylococcus (CONS) 4 28.57%

Coagulase +ve staphylococcus 3 21.42%

Streptococcus fecalis (gr. D. streptococcus) 2 14.28%

- Hemolytic streptococcus 1 7.14%

Klebsiella sp. 1 7.14%

Proteus 1 7.14%

E. coli. 1 7.14%

Candida albicans 1 7.14%

DISCUSSION

Neonatal sepsis is a common cause for

admission to neonatal units in developing

countries. It is also increase Neonatal

Mortality Rate in developed as well as in

developing countries.(11, 12)

A total of 35 term neonates (wt >2-5kg)

lodger and intramural were included in the

study, out of which 25 (71.4%) were male &

10 (28.6%) were female neonates (Table

No. 1).The male to female ratio being 2.5:1;

our results are equivalent with the other

studies (11, 12). The mortality was highest 5

(20%) in male group & 1 (12.5%) was in

female group. A high male prevalence in

neonatal septicemia may be correlated well

to the X- linked immunoregulatory gene

factor which makes male infants are more

prone to infection, disease and death. (13)

18 cases (51.43%) were of early onset type

(<72 hrs) and 17 cases (48.57%) were late

onset type (>72 hrs). Further, 5 cases

(27.78%) expired in early onset group and

one case (5.26%) expired in late onset

group. This is statistically significant

(p<0.05). This indicates that early onset

septicemia carried a poor prognosis. An

another study by F Motara et al showed

different results that neonatal septisemia was

more prevalent in late onset group but CK

Shaw et al study from Nepal showed same

results as our study ,this may be because of

geographical differences or other factor,

which may differs in developing and

developed countries.(14,15) Early onset and





late onset Neonatal sepsis have different risk

factors. The Maternal fever with or without

chorioamnionitis and the maternal genital

flora are primarily implicated in early onset

septicaemia (first week) while the duration

of hospital stay with or without invasive

procedures and invasive strains of organisms

colonizing after birth may give results in late

onset ticaemia (onset > 7 days).Immature

immune system of the neonate and the

opportunity of infectious agent to spread

infection may ensnare the compromised

neonate. (16)

More than three forth (77%) were delivered

outside the hospital i.e. lodger and 23%

were intramural. Mortality statistics showed

that death was also more in lodger group i.e.

5 cases (18.57%) as compared to intramural

1 (12.5%). Results were similar with CK

Shaw etal study. (15) Early onset sepsis is

also correlated well with leaking per

vaginum > 24 hours and unclean methods of

per-vaginal examination (home deliveries).

In case of the intramural sepsis, the data for

the high vaginal swab and amniotic

membrane cultures was inconsistent due to

lack of reports and hence was not taken into

account. This may be a lacuna in the study.

Nosocomial sepsis results from invasion of

the hospital flora colonizing the skin and

indwelling catheters of the neonate. This is

reflected in our analysis as prolonged

hospital stay, exchange transfusions,

invasive ventilation and major surgery were

most frequently associated with nosocomial

sepsis cases. Recycling of catheters/ tubes,

maintaining stock solutions and the use of

multi-dose vials of antibiotics are other

potential sources which commonly escape

notice! (17).

history of >3 per vaginal examination was

the most important risk factor for developing

neonatal septicemia. It was present in

42.85% of cases followed by PROM >12 hrs

in 12 cases (34.28%). This revealed the fact

that frequent per vaginal examination is

associated with more chance of neonatal

septicaemia, which is also well suggested by

Belady PH et al study. (18) By reducing per

vaginal examination and proper cleaning of

perineum before per vaginal examination

can deduce the hazards of infection to the

newborn significantly.

A look at the data regarding vital signs and

clinical features on admission table 6 and 7

revealed that refusal to feed was commonest

presenting symptoms (100%) and poor

sucking /swallowing was commonest sign

(85.7%). Fever (22.8%), icterus (25.7%) and

sclerama (8.5%) were other signs and

symptoms. This indicates that refusal to feed

is most important and earliest symptom to

suspect neonatal septicemia and it should

not be ignored and every child of refusal to

feed should have a detailed clinical and

laboratory evaluation so that early diagnosis

of neonatal septicemia can be made and

treated. Table 1 shows system wise

manifestation of neonatal septicaemia. It

revealed that commonest systemic complaint

was related to respiratory systems (51.4%)

in the form of (grunting, nasal flaring,

retraction) followed by gastrointestinal

system (45.7%), central nervous system

(40.0%) and haematological (31.4%)The

clinical presentation was somehow similar

to the study done in Nepal. (15) It may be





because same geographical and cultural

habits of India and Nepal.

The commonest Gastrointestinal symptom

was abdominal distention (56.25%)

followed by hepatomegaly >2cm. BCM

(43.75%), vomiting (37.25%) and diarrhea

(12.5%).poor perfusion i.e. CRT >3 sec was

chief cardiovascular manifestation. It

support the fact that neonatal septicemia has

rapid downhill course and if not timely

diagnosed and managed, may leads to

irreversible stage of septic shock and

fulminate outcome.

The commonest CNS manifestation of

septicemia is lethargy. (85.7%) followed by

abnormal moro (42.9%), seizures (35.7%)

and high pitch/ inconsolable cry

(28.6%).Jaundice (81.8%) was commonest

hematological manifestation of neonatal

septicemia followed by pallor (54.5%) and

splenomegaly (84.5%).

Table 2 shows that blood culture were

positive in 14 cases (40%) and were

negative in 21 (60%) cases. About 21.4%

deaths were in culture positive and 14.35%

in culture negative group respectively. The

regression analysis revealed statistically

significant correlation between mortality and

culture positivity. Different studies showed a

culture positive rate ranging from 41.6 to

46.2.(19,20) which equivalent to our study.

The most common bacteria grown was


(28.57%) followed by coagulase positive

staphylococcus (21.42%) and streptococcus

fecalis (14.28%). Although these results

may be of equivocal significance, reflecting

either contamination or true bacteremia, but

because all 4 cases (28.57%) of blood

culture growing coagulase negative

staphylococci were also accompanied by an

increase of CRP to >10 mg/L. So that the

predominance of coagulase negative

staphylococci (CONS) in this study is

probably true and not caused by

contamination. A study from Port Harcourt

showed Klebsiella pneumonia as commonest

organism. (19) An another study done in

Pakistan showed most common pathogen in

sepsis was Enterobactor (48%).(21)

Other organism grown in blood culture are

-hemolytic streptococci in one case

(7.14%), Klebsiella in one case (7.14%),

proteus in one case (7.14%), and E. coli in

one case (7.14%).

Table 2 is showing an interesting

observation that one case of blood culture

showed Candida albicans and delayed

fungal culture after 14 days. The

explanations offered by microbiologists

were a risk of contamination or probably

rampant use of broad spectrum antibiotics in

NICU which predispose newborn to

fungemia. Some other study also observed

Candida as etiological factor of neonatal

septicaemia.(22)

CONCLUSION

The causative microbes of neonatal sepsis

varies with the time and differs in different

regions it may be due to changes in cultural

taboos in different regions and awareness

about hygiene and availability of health

resources. Most common organisms were


(28.57%) in this study. Judicious and

prudent use of antibiotics should be





implemented to avoid unnecessary bacterial

resistance.

Information in relation to the etiology and

clinical presentation of neonatal sepsis in

India are limited. This study provide the data

about neonatal sepsis of the south Rajasthan

region but imperative future research is

needed, including high disease burden area

where there is a lack of data. For the

strengthening of Health system the planning

of organized and combined research using

same criteria is recommended to observe

neonatal sepsis etiology, Clinical feature and

record antimicrobial sensitivity patterns.

Precise etiological data and knowledge of

clinical features are helping in Neonatal

sepsis prevention and management, which

further make a significant improvement in

the community Health. Achievement of

Millennium Development Goal 4 is very

crucial for India. It may possible by the

early identification and treatment of the

infecting organism to reduce neonatal

mortality rates.





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Philadelphia Saunders 2004; p 623-640.

2. Singh M; Care of the newborn; 6th

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3. Aurangzeb B, Hameed A. Neonatal sepsis

in hospital born babies: Bacterial isolates

and antibiotic susceptibility patterns. J Coll

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4. Haque KN, Khan MA, Kerry S,

Stephenson J, Woods G.Pattern of culture-

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organization. Pediatrics. 1999;103(1, suppl

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6.Polin RA, St Geme JW III. Neonatal

sepsis. Adv Pediatr Infect Dis. 1992;7:25–61

7. Riley LE, Celi AC, Onderdonk AB, et al.

Association of epidural-related fever and

noninfectious inflammation in term labor.

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8. Kapoor L, Randhawa VS, Deb M.

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septicemia in a pediatric care hospital in

Delhi. J Commun Dis 2005; 37: 227-32.

9.Tom-Revzon C. Strategic use of

antibiotics in the neonatal intensive care

unit. J Perinat Neonatal Nurs. 2004 Jul-

Sep;18(3):241-58.

10. Rhiskesh Thakre. Neonatal sepsis

screen. Pediatrics Today 2005 VIII No. 3,

174-176.

11.YR Khinchi AK, Satish Yadav. Profile of

Neonatal sepsis. Journal of college of





Medical Sciences-Nepal. 2010; Vol.6( No-

2):p1-6.

12. Rekha Sriram IJBMR. Correlation of

blood culture results with the sepsis score

and the sepsis screen in the diagnosis of

neonatal septicemia. BioMedSciDirect

publications; 2011. p. 360-8.

13. Sharma M, Goel N, Chaudhary U,

Aggarwal R, Arora DR. Bacteraemia in

children. Indian J Pediatr.

2002;69(12):1029-32.

14.F.Motara F,BallotDE,Perovic O.

Epidemiology of neonatal sepsis at

Johannesburg hospital.The south African

Journal of Epidemiology and

infection.2005;20(3)90-93

15. Shaw CK, Shaw P, Malla T, Malla

K.K.The clinical spectrum and outcome of

neonatal sepsis in a neonatal intensive care

unit at a tertiary care hospital in western

Nepal: January 2000 to December 2005 – A

retrospective study. Eastern Journal of

Medicine 17 (2012) 119-125

16. Oddie S, Embleton ND. Risk factors for

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sepsis: case-control study. BMJ 2002 10;

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17. Singh M, Paul VK, Deorari AK, et al.

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neonatal mortality. Indian J Pediatr 1988;

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Ormeloxifene: Boon to perimenopausal Dysfunctional Uterine Bleeding

(DUB) women in avoiding hysterectomies

Dr. S. Fayyaz Shahab

1*, Dr. Shailesh Jain

2, Dr. Jyoti Jain

2,Dr.Ujjwala Jain

2

1 Senior Consultant, Santokba Durlabhji Memorial Hospital, Jaipur

2 Senior Resident, RNT Medical College, Udaipur


Received: 20/09/2013 Revised: 25/10/2013 Accepted: 12/11/2013

Abstract:

Aim and objective: To observe effect of ormeloxifene for treatment of perimenopausal

Dysfunctional Uterine Bleeding (DUB) women and follow up in terms of avoiding

hysterectomies and to compare ormeloxifene with norethisterone in terms of relief of symptoms,

patient acceptability and complications. Material and Methods: 300 cases of DUB from two

hospitals who have completed child bearing and are between 40-55 years were given

Ormeloxifene and Norethisterone during period January 2009 to December 2012 (3

years).Ormeloxifene group (n=150) received 60 mg twice weekly for 12 weeks followed by once

weekly for 3 months initially. Norethisterone (n=150) group received 5mg twice a day for 12

days in every cycle for 6 months. Results: 123(82%) women in the ormeloxifene administered

patients and 45(30%) of norethisterone group had marked relief of symptoms with significant

reduction of blood clots, reduction of Pictorial Blood Assessment Chart (PBAC) scores (

=25.36,P value=0.0001, extremely significant). Side effects/complications included amenorrhea

(=0.614, P value=0.433, not significant), irregular periods (=0.614, P value=0.1102, not

significant). 54(36%) of ormeloxifene group and 36(24%) had bout of bleeding after treatment

was stopped (=1.190, P value=0.2752, not significant). Dosage schedule of ormeloxifene

administration facilitated compliance and acceptability. Conclusion: Ormeloxifene has better

compliance and acceptability with marked relief in symptoms. Women who underwent

hysterectomy after treatment were significantly less in ormeloxifene group. Though the study

size is small, it highlights the role of ormeloxifene in reducing menorrhagia and avoiding surgery

in perimenopausal women with proper follow up.

Keywords: ormeloxifene , hysterectomy.

INTRODUCTION:

Hysterectomy is a major surgical procedure

that has some risks and benefits, and affect

a overall health of woman by changing the

hormonal balance for the whole life.

Because of this, hysterectomy is normally

preferred as a last option to treat certain

complicated uterine/reproductive system







disorders. Such conditions include, but are

not limited to:

uterine, cervical, ovarian, endometrium

cancers or some benign tumors,

like uterine fibroids that do not respond

to more conservative treatment options.

Severe and intractable endome-

triosis (growth of the uterine lining

outside the uterine cavity) and/

or adenomyosis

Chronic pelvic pain, when medicinal or

other surgical options have been failed.

Postpartum to eliminate either a

complicated case of placenta praevia or

placenta percreta , as well as a last

choice in case of excessive obstetrical

haemorrhage.

Several forms of vaginal prolapse.

But in recent scenario, hysterectomy is well

performed in non-indicated cases as well as

in cases for which other forms of treatment

is available. Major reasons for these are:

Cost effectiveness of hysterectomy

Less requirement of follow up if done

for benign reason

Women think that quality of life will be

better when they will get rid of their

menorrhagia

Cancer phobia

Other forms of treatment are not

discussed with patient

Other forms of treatment require follow

up and are costly

Most common indications for

hysterectomies worldwide are menorrhagia,

fibroid uterus and prolapse but there is

alarming increase for indications like

chronic pelvic pain, pelvic inflammatory

disease and asymptomatic fibroids.(1)

Though there is lesser incidence of

hysterectomies in developing countries in

comparison to developed countries but it

seems the tip of iceberg due to under

reporting of cases. There are extrapolated

statistics used for calculation of the

incidence.

Incidence in various regions:

Approximately 600,000 hysterectomies are

performed annually in the United States and

an estimated 20 million U.S. women have

had a hysterectomy (2). During 2000–2004

the overall hysterectomy rate for United

States female civilian residents was 5.4 per

1,000 women (3). During this time period,

the overall rate of hysterectomy decreased

slightly(4,5). Hysterectomy rates were

highest in women aged 40–44 years.

According to the National Center for Health

Statistics, of the 617,000 hysterectomies

performed in 2004, 73% also involved the

surgical removal of the ovaries. In the

United States, 1/3 of women can be

expected to have a hysterectomy by age

60. There are currently an estimated 22

million people in the United States who

have undergone this procedure. An average

of 622,000 hysterectomies a year has been

performed for the past decade. In the UK, 1





in 5 women are likely to have a

hysterectomy by the age of 60, and ovaries

are removed in about 20% of

hysterectomies. The total number of

hysterectomies performed in UK NHS

hospitals in 2011/2012 is 56,976. Of this, at

least 35,396 are abdominal

hysterectomies and at least 18,154

are vaginal hysterectomies. In developing

countries, a lower rate (4-6%) has been

reported.

To avoid irrational hysterectomies, we

considered the role of Ormeloxifene which

is effective as well as economic in

perimenopausal DUB women in avoiding

hysterectomies.

Ormeloxifene is a SERM, or

selective estrogen receptor modulator. In

some parts of the body, its action is

estrogenic (e.g., bones), in other parts of the

body, its action is anti-estrogenic

(e.g., uterus, breasts) It causes an

asynchrony in the menstrual cycle

between ovulation and the development of

the uterine lining.

MATERIAL AND METHODS:

300 cases of DUB (Dysfunctional uterine

bleeding) from two hospitals who have

completed child bearing and are between 40-

55 years were given Ormeloxifene and

Norethisterone during period January 2009

to December 2012 (3 years). Ormeloxifene

group (n=150) received 60 mg twice weekly

Fig.1

Ormeloxifene molecule

for 12 weeks followed by once weekly for 3

months initially. Norethisterone (n=150)

group received 5mg twice a day for 12 days

in every cycle for 6 months. Before starting

therapy, ultrasound, hysteroscopy and

endometrium sampling for histopathology

was done and repeated at the end of follow

up. Initial evaluation was done and systemic

diseases, diabetes, liver disorders, thyroid

disorders, coagulation disorders were ruled

out. A detailed gynecological examination

excluded any uterine pathology.

Endometrial thickness and transvaginal

sonography was carried out every three

months to study the response of the

endometrium to the drug. The side effects

and complications of the drug ormeloxifene

were noted and reliefs of symptoms, patient

compliance were compared with

norethisterone. All patients were followed

till 6 months. The side effects and

complications of drug Ormeloxifene were

noted and relief of symptoms and patient

acceptability were compared with

Norethisterone. Women who were

benefitted with ormeloxifene continued the





same. Women who required hysterectomy

despite of treatment were observed. Chi

square test was applied and P value

Calculated.

RESULTS:

123(82%) women in the ormeloxifene

administered patients and 45(30%) of

norethisterone group had marked relief of

symptoms with significant reduction of

blood clots, reduction of Pictorial Blood

Assessment Chart (PBAC) scores (= 80.208,

p value < 0.001, highly significant). The

pretreatment median PBAC score was 423

(range 169-835) in ormeloxifene group and

410 in norethisterone group. Median PBAC

reduced to 85 (range 0-730) and 25(range 0-

310) at 3 and 6 months in case of

ormeloxifene group whereas in

norethisterone group, it reduced to 123

(range 0-730) and 45(range 0-310) at 3 and

6 months, respectively. During the 36-month

study period, 20 women from ormeloxifene

group underwent hysterectomy and 7 were

lost to follow up. In norethisterone group, 40

women underwent hysterectomy, 40 women

resorted to other treatment (other than

ormeloxifene) and 15 were lost to follow up.

Side effects/complications included

amenorrhea ( =6.284, p value 0.0122(<0.05)

significant), irregular periods ( = 3.038 p

value 0.0813(>0.05), Not significant.

54(36%) of ormeloxifene group and

36(24%) had bout of bleeding after

treatment was stopped ( =4.587 p value

0.0322(<0.05) significant). 8(5.3%) women

in each group suffered from stress urinary

incontinence ( =0.000, p value 1.000 (>0.05)

not significant). Dosage schedule of

ormeloxifene administration facilitated

compliance and acceptability.

DISCUSSION:

A medical management is the first line of

therapy for dysfunctional uterine bleeding.

The agents that have been used to treat

menorrhagia include iron, cyclooxygenase

inhibitors, desmopressin, antifibrinolytics,

gonadotropin-releasing hormone agonists,

androgens, combined oral contraceptives,

and progestins (6,7) . Progestins can be

administered systemically or locally and

they may be given cyclically or

continuously. The increased use of effective

medical therapies has the potential to reduce

the number of surgical procedures, such as

endometrial ablation and hysterectomy.

Dysfunctional uterine bleeding is the

diagnosis in a majority of the cases of

menorrhagia. The symptom of menorrhagia

accounts for a significant proportion of the

referrals to gynecologists. There is no

hormonal defect in dysfunctional uterine

bleeding; however, disturbances in the

endometrial mediators have been noted. A

majority of the cases are associated with

ovulatory cycles when the cycle control is

not an issue, and they can thus be treated

with non-hormonal methods such as

prostaglandin synthetase inhibitors and

antifibrinolytics. Those patients with

anovulatory cycles may benefit from an

exogenous control of the pattern of bleeding

by the use of hormonal preparations. When

an effective contraception is also required,

the uses of either a combined oral

contraceptive or the levonorgestrel releasing





Intrauterine System (IUS) are the suitable

choices.

In our study, significant reduction in PBAC

Score was seen similar to other studies (8,9).

Ormeloxifene has better compliance and

acceptability as symptoms are reduced to

great extent (10). In comparison to

norethisterone, it provided better

symptomatic relief. Women who underwent

hysterectomy in ormeloxifene group were

almost half of that of norethisterone group.

Acceptability can be seen as none of the

women resorted to other methods and were

satisfied with ormeloxifene. Amenorrhea

was seen in 19 women in ormeloxifene

group and 6 women in other one which was

significant. These women acquired

menopause as they were in climacteric

phase. Irregular bleeding was seen in both

the groups but it was not significant. Only

significant problem seen with ormeloxifene

is heavy bout of bleeding when shifting the

dose from 60 mg twice weekly to once

weekly at 12 weeks. Heavy bout was seen

between 3-6 months also in ormeloxifene

group. Stress urinary incontinence was seen

in equal number of women in both the

groups and was insignificant. Study by

kriplani et al showed similar results(8).

CONCLUSION:

Ormeloxifene has better compliance and

acceptability with marked relief in

symptoms. Irregular bleeding and

amenorrhoea was seen more with

norethisterone group. Though bout of

bleeding was observed in some patients with

ormeloxifene, it was not significant. Women

who underwent hysterectomy after treatment

were significantly less in ormeloxifene

group. Though the study size is small, it

highlights the role of ormeloxifene in

reducing menorrhagia and avoiding surgery

in perimenopausal women with proper

follow up.





REFERENCES:

1. Deeksha Pandey, Kriti Sehgal, Aashish

Saxena, Shripad Hebbar, Jayaram

Nambiar, and Rajeshwari G. Bhat, “An

Audit of Indications, Complications, and

Justification of Hysterectomies at a

Teaching Hospital in India,”

International Journal of Reproductive

Medicine, vol. 2014, Article ID 279273,

6 pages, 2014. doi:10.1155/2014/27927

2. Wu, JM; Wechter, ME; Geller, EJ;

Nguyen, TV; Visco, AG (2007).

"Hysterectomy rates in the United

States,

2003". ObstetGynecol 110 (5):1091–5.

doi:10.1097/01.AOG.0000285997.38553

.4b. PMID 17978124.

3. Masters, Coco (2006-07-01). "Are

Hysterectomies Too Common?". TIME

Magazine. Retrieved 2007-07-17.

4. "Hysterectomy rates falling:

report". CBC News. 2010-05-27.

Retrieved 2010-05-28.

http://en.wikipedia.org/wiki/Digital_object_identifier

http://dx.doi.org/10.1097%2F01.AOG.0000285997.38553.4b

http://dx.doi.org/10.1097%2F01.AOG.0000285997.38553.4b

http://en.wikipedia.org/wiki/PubMed_Identifier

http://www.ncbi.nlm.nih.gov/pubmed/17978124





5. "Hysterectomy". National Women’s

Health Information Center. 2006-07-01.

Retrieved 2007-06-07.

6. Dhananjay BS, Sunil Kumar Nanda

“The Role of Sevista in the Management

of Dysfunctional Uterine Bleeding” J

Clin Diagn Res. 2013 January; 7(1):

132–134.

7. Porteous A, Prentice A. The medical

management of dysfunctional uterine

bleeding. Reviews in Gynaecological

Practice. 2003;3(2):81–84.

8. Lal J. “Clinical pharmacokinetics and

interaction of centchroman—a mini

review.”Contraception. 2010;81(4):275–

80.

9. Kriplani A, Kulshrestha V, Agarwal N.

“The efficacy and safety of ormeloxifene

in the management of menorrhagia: a

pilot study” J. Obstet.

Gynaecol.2009;35(4):746–52.

10. Irvine GA, Cameron IT. The medical

management of dysfunctional uterine

bleeding. Baillieres Best Pract Res Clin

Obstet Gynaecol. 1999;13(2):189–202.

11. Shelly W, Draper MW, Krishnan V,

Wong M, Jaffe RB. The selective

estrogen receptor modulators: an update

on the recent clinical findings. Obstet

Gynecol Surv.2008;63(3):163–81.

Table 1. Showing symptomatic relief (Reduction of PBAC scores) in two groups

Ormeloxifene Group

(n=150)

Norethisterone group

(n=150)

Symptomatic relief present

(reduction of PBAC scores)

123(82% ) 45(30%)

Symptomatic relief not present 27(18%) 105(70%)

*Chi square value 80.208, p value <0.001(highly significant)

Table 2. Showing number of women who underwent hysterectomy in two groups

Ormeloxifene Group

(n=150)


(n=150)

Finally Underwent

hysterectomy

20(13.3%) 40(26.7%)

Resorted to other treatment and

were satisfied

none 40 (26.7%)

Lost to follow up 7 (4.7%) 15 (10%)





Table 3. Showing women with amenorrhea in two groups

Ormeloxifene Group (n=150) Norethisterone group (n=150)

Amenorrhea present 19(12.7%) 6(4%)

Amenorrhea absent 131(87.3%) 144(96%)

Chi square value 6.284, p value 0.0122(<0.05) significant

Table 4. Showing women with irregular bleeding in two groups

Ormeloxifene Group (n=150) Norethisterone group (n=150)

Irregular bleeding

present

23(15.3%) 36(24%)

Irregular bleeding absent 127(84.6%) 114(76%)

* Chi square value 3.038 p value 0.0813(>0.05) Not significant

Table 5.showing women with heavy bout of bleeding in two groups

Ormeloxifene Group

(n=150)


(n=150)

Heavy bout of bleeding

present

54 (36%) 36 (24%)

Heavy bout of bleeding

absent

96(64%) 114(76%)

* Chi square value 4.587 p value 0.0322(<0.05) significant

Table 6.showing stress urinary incontinence in two groups

Ormeloxifene Group

(n=150)


(n=150)

Stress urinary incontinence present 8(5.3%) 8(5.3%)

Stress urinary incontinence Absent 142(94.6%) 142(94.6%)

*Chi square value 0.000 p value 1.000 (>0.05) not significant





Table 7.showing women in two groups with statistical analysis

Ormeloxifene

Group

(n=150)

Norethisterone

group(n=150)

Chi

square

value

P value Remarks

Symptomatic

relief(reduction of

PBAC scores)

123(82% ) 45(30%) 80.208 <0.001 Highly

significant

Amenorrhea 19(12.7%) 6(4%) 6.284 0.0122(<0.05) Significant

Irregular bleeding 23(15.3%) 36(24%) 3.038 0.0813(>0.05) Not

significant

Heavy bout of

bleeding

54 (36%) 36 (24%) 4.587 0.0322(<0.05) Significant

Stress urinary

incontinence

8(5.3%) 8(5.3%) 0.000 1.000(>0.05) Not

significant

Figure no.1

Figure no.2 showing women in Ormeloxifene Group with statistical analysis





Figure no.3 showing women in Norethisterone group with statistical analysis

ormeloxifene group

Symptomatic relief(reduction of PBAC scores)

amenorrea

iregular bleeding

heavy bout of bleeding

stress urinary incontinence

norethisterone group

Symptomatic relief(reduction of PBAC scores)

amenorrea

iregular bleeding

heavy bout of bleeding

stress urinary incontinence





THE STUDY OF SOCIOECONOMIC FACTOR AFFECTING BREAST FEEDING

PRACTICE AMONG FAMILY OF RURAL AREA OF JAIPUR

Dr. Veerbhan Singh1*

, Dr. Archana Paliwal1, Dr. Indu Mohan

1, Dr. S. L. Bhardwaj

2 ,Dr.

Ram Chandra Choudhary 3

, Dr. Bhupendra Nath Sharma4

1. Resident, Department of Community Medicine, Mahatma Gandhi Medical College and

Hospital Jaipur (Rajasthan)

2. Associate Professor, Department of Community Medicine, Mahatma Gandhi Medical

College and Hospital Jaipur (Rajasthan)

3. Professor, Department of Community Medicine, Mahatma Gandhi Medical College and

Hospital Jaipur (Rajasthan

4. Professor and Head, Department of Community Medicine, Mahatma Gandhi Medical

College and Hospital Jaipur (Rajasthan) * Email id of corresponding author : [email protected]

Received:12/09/2013 Revised: 11/10/2013 Accepted: 12/12/2013

Abstract:

Objectives: To study the socio-economic factors influencing initiation and duration of breast

feeding. Material and methods: A cross-sectional prevalence based study was conducted on

400 mothers and their infants residing in the rural area of Jaipur within six months (Jan13 to

June-13). Information was collected and analyzed on occupation, socio-economic status, literacy

status and type of work, type of family, residential environment, life-style. Information regarding

infant’s anthropometric measurements, feeding practices, weaning and immunization status are

also obtained. Results: According to socioeconomic classification, maximum mothers belongs to

class III 155(38.75%), followed by 81(20.25%) mothers from socio-economic class V,

73(18.25%) mothers were from socio-economic class IV, 49(12.25%) were from socio-economic

class II and 42(10.5%) mothers were from socio-economic class VI. Literacy wise,148(37%)

mothers were illiterate, 95(23.75%) mothers were educated up to primary level followed by

74(18.5%) educated up to middle, 45(11.25%) educated up to secondary level, 16 (4%) mothers

educated up to higher secondary and rest 22(5.5%) mothers were graduate and above.

Conclusion: Multiple health problems was encountered in the survey area dominated by twin

problems of malnutrition along with infective diseases which are associated with socioeconomic

factors like mothers illiteracy, mother working conditions, family income and socioeconomic

status. Looking forth on these matters socioeconomic status is an important factor affecting the

care of infants in terms breast feeding, weaning and personal hygiene.

Keywords: socio-economic factors, breast feeding practice, occupation, literacy status

INTRODUCTION:

Age, sex and inheritance are non modifiable

factors that affect human health. The views

of family members is also an important

factor for affecting health of new born and

his mother , but these views are influenced







by socioeconomic determinants of health,

cultures and experiences.

Socioeconomic determinants of health such

as income, education and working

environment have an immediate pertaining

to health. (1,2) Those with very low

socioeconomic status as an example, often

having limited resources and deficiency of

good foodstuff, inadequate housing

condition (Kchha Ghar) and safe drinking

water, which can cause negative effect on

their health.(3) On the another side , those

who have enough earnings and good

occupation are less vulnerable for health

issues. The care and health of newborn and

lactating mother is also affected by such

socioeconomic factors.

Human breast milk, nature great gift is best

for newborn compare to anything made by

human being with advanced technology.

Human breast milk is a complete food which

is available at the no cost and an effective

way to provide protection with a caring

environment. (4)

The American academy of paediatrics

(AAP) and WHO strongly advocate

breastfeeding has the preferred feeding for

all infants. The success of breastfeeding

initiation and continuation depend on

multiple factor such as education about

breastfeeding, hospital breastfeeding

practices and policies, routine and timely

follow up care, family and social support.(5)

In India, breastfeeding is a universal

practice. Most mothers in India continue

breastfeeding up to 2 years or even beyond it

which is highly beneficial for child survival

and adequate growth. (5) UNICEF and

WHO launched, Baby friendly hospital

Initiative (BFHI) in 1992 and subsequently

world health assembly (WHA54: 2; 18) in

May, 2001 adopted the resolution to approve

exclusive breastfeeding for first 6 month. (6,

7) Baby friendly hospital initiative (BFHI),

recommends that infant should be only

breastfed for first 6 month.

Early breastfeeding postpartum establish

proper feeding and a close mother-child

relationship known as “bonding”. Under

normal condition, a mother secretes about

450 to 600 ml of milk daily with 1.1gm of

protein per 100ml. The energy value of

human milk is 70kcals per 100ml which is

sufficient to meet all the nutritional needs of

newborn. (8)

The report furthermore said over 12 present

of Indian mothers nourished their newborns

with bottled milk which affect bonding

between Mather and their child and their

wellbeing. The report recommends to make

a policy for child feeding practices with

main emphasis on awareness for nutrition

for lactating mother and counselling to

improve this situation.(9)

Inspite of vigorous promotional activities

large number of newborn, infants are still

deprived of Colostrums and exclusive breast

milk. The present study was undertaken with

a view to assess socioeconomic factors

affecting breast feeding practices among the

mothers of rural area of Jaipur and to

determine impact of feeding on growth and

development.

MATERIAL AND METHODS:





A cross-sectional prevalence based study

was conducted on 400 mothers and their

infants residing in the rural area (Vatika

village) in Jaipur district which is a rural

health training Centre (R.H.T.C) of the

Department of Community Medicine,

Mahatma Gandhi medical college and

attached group of hospitals within six

months (Jan13 to June-13). Permission to

conduct study was under taken prior to

commencement from the organization

ethical committee of the college.

Information was collected and analyzed on

occupation, socio-economic status, literacy

status and type of work. Information

regarding infant’s anthropometric

measurements, feeding practices, weaning

and immunization status are also obtained.

Pretested structured Performa questionnaire

was used. Door to door survey was

undertaken.Each respondent was explained,

the purpose of the study prior to the

administration of tools of data collection and

informed consent was obtained prior to

interview. Respondent were assured of the

confidentiality of the information. A

structured pretested Proforma containing

two schedules were used. Instrument used

were infantometer, Salter hanging weighing

machine, steel non –stretchable tape.

Literacy: Criteria as defined in GOI,

registrar general census scale were used.

Illiterate: Those mothers who cannot

read and write in any language. Those

who can only read not write were also

considered illiterate.

Literate: Those who can read and write

in any language. Formal education up to

Primary, Middle, Secondary, Higher

secondary, Graduate and Post Graduate.

Occupation: Occupation was classified as-

Housewife- those who are working in

house only.

Labourer- those who are working on

daily wages.

Farmer- working on farms or owning

agriculture land and dependent on its

produce.

Service- those who were working in

public and private sector part time or full

time both.

Business- running her own business.

Gainful employment- employment of her

own from which the woman is earning

Socio-economic Status: Socio-economic

status was determined as per the

classification devised by B.G. Prasad on the

per capita income of the family. The

modified classification for the year 2008

was used for determining the socio-

economic status of mothers under survey.

(10)

RESULTS

Maximum mothers belongs to class III

155(38.75%), followed by 81(20.25%)

mothers from socio-economic class V,

73(18.25%) mothers were from socio-





Economic class IV, 49(12.25%) were from

socio-economic class II and 42(10.5%)

mothers were from socio-economic class VI.

No mother belong to class I .

Table 1.Distribution of study population according to their socio-economic status

Socio-Economic Status Total Percentage (%)

I 0 0

II 49 12.25

III 155 38.75

IV 73 18.25

V 81 20.25

VI 42 10.5

Total 400 100

Table 2.Distribution of Study Population According to Literacy Status of Mothers and

their breast feeding in relation with literacy status of mother

Literacy Status No % On Demand Schedule EBF % BF+S %

Illiterate 148 37 136 (91.82%) 12 (8.11%) 98 46.23 50 26.60

Primary 95 23.75 82 (86.32%) 13 (13.68) 46 21.70 49 26.06

Middle 74 18.5 69 (93.24%) 5 (6.76%) 36 16.98 38 20.21

Secondary 45 11.25 44 (97.78%) 1 (2.22%) 17 8.02 28 14.89

Higher Secondary 16 4 14 (87.50%) 2 (12.50%) 7 3.30 9 4.79

Graduate and Above 22 5.5 20 (90.91%) 2 (9.09%) 8 3.77 14 7.45

Total 400 100 365 35 212 100 188 100

The above table no. 2 shows that 148(37%)

mothers were illiterate, 95(23.75%) mothers

were educated up to primary level followed

74(18.5%) educated up to middle,

45(11.25%) educated up to secondary level,

16 (4%) mothers educated up to higher

secondary and rest 22(5.5%) mothers were

graduate and above.

Out of 400 infants 365 were on demand out

of which 136(91.82%) were illiterate

followed by 82(86.32%) are primary school,

69(93.24%) were middle school, 44

(97.78%) were secondary, 20 (90.91%) were

graduate and above and rest 14(87.50%) are

higher secondary. Out of 400 mothers

212(53%) mothers Exclusive breast feed

their infants and rest 188(47%) mothers

have given Supplementary food along with

the breast feed. Out of 400 infants 212 were

on EBF of which, mothers of 98(46.23%)

were illiterate followed by 46(21.70%) are

primary school, 36(16.98%) were middle

school, 17(8.02%) are secondary, 8(3.77%)

mothers are graduate and above and rest

7(3.30%) are higher secondary.





Table 3. Distribution of Study Population of Infant by feeding pattern according to the

working status of mothers

χ2 64.413 df 1 p 0.0001

Among 400 infants 212 were EBF of which

mothers of 160(75.47%) infants were house

wife and 52(24.53%) were working, the

relation is being statistically significant.

DISCUSSION

In the present study breastfeeding practices,

feeding pattern, health status and

immunization of infants was assessed in

rural area of Vatika (rural health training

centre of MGMCH). Study was completed

in six months (January 2013-june2013). A

total of 400 infants were included in the

study. In our study 37% mother were

illiterate, 23.75% mothers were educated up

to primary, 18.5% up to middle, 11.25%

educated up to secondary level and <10%

were educated up to higher secondary and

above. Uttekar BP et al also observed in

their study in Rajasthan that majority of

Janany Surksha Yojana beneficiaries were

illiterate (68%) or had studied only up to

primary and middle level (22%), <10% had

studied above secondary level.(11)

In our study there is an inverse relationship

between literacy level of mothers and

practice of giving prelacteal. There were

none of mother who was graduate or above

given prelacteal feed, but more than 90%

illiterate mothers were given prelacteal feed

this association proved statistically

significant. Devang Raval et al reported in

his study Illiterate mother (85.2%) practices

more prelacteal feeding than literate mother

(50.9%), majority of literate mother (49.1%)

compare to illiterate mothers (14.8%) had

started breastfeeding within one hours. (12)

Dinesh Kumar et al reported illiterate just

literate mothers who delivered at home were

found at significantly higher risk of delay in

initiation of breastfeeding analysis. (13)

Yadvenankar et al reported that only 25%

mothers who have studied up to the college

level have practiced breastfeeding.(14)

Wadde et al observed that out of 306

mothers enrolled in the study 66.01% were

illiterate, very less no of illiterate mothers

followed exclusive breast feeding as

compared to literate mothers.(15)

Bhardwaj et al reported that all of them

(100%) were illiterate. (16)

Roy et al

observed in his study 81.6% were literate

(17) D.K. Taneja et al in their study 59.4%

Occupation EBF % BF+S %

House Wife 227 160 75.47 67 35.64

Working 173 52 24.53 121 64.36

Total 400 212 100.00 188 100





had primary and higher level of educations.

(18) Syed E. Mahmood et al observed in his

study that 69.9% were illiterate.(19) Neeraj

Mohan Srivastava concluded in their study

neonates born to mothers with no formal

education, fathers with no formal

education.(20)

Malireddy Radhika et al in his study shows

that out of 214 mothers who were

questioned about their education status 27

mothers were illiterates, 39 mothers had

primary schooling, 105 mothers had high

school education, 23 mothers had secondary

education, and 20 mothers were graduates.

(21)

In the developing world, now improving

health systems and resources by making new

strategy, maternal education level is very

important for using and understanding

government policies which further affects

health status of mothers and their infants and

children. It is very essential for India to

achieve the ultimate target of education that

is the universal primary education to

upgrading education to higher levels. The

Socioeconomic factors associated with

health of mother such as environmental

hygiene and sanitation, household food

security, poverty and illiteracy, all together

are impinging on aetiology of low birth

weight and Intra uterine growth

retardation(IUGR).(22)

The maximum mothers (38.75%) were from

socio-economic class III followed by

20.25% of socio-economic class V. Singh A,

Arora AK (2007) observed in their study of

changing profile of pregnant women in rural

north India that most of their study

population was from lower middle or middle

class. (23)Gogoi G and Ahmed FU showed

that majority (57%) of their study population

belonged to upper- lower socio-economic

class. (24)

Wadde et al (2012) Exclusive breast feeding

was less prevalent in mothers of lower

socioeconomic status than the upper one.

(15) Syed E. Mahmood et al 97.5% belong

to lower socioeconomic class. (19)

A study was conducted in Kolkata by Roy et

al showed that maximum ( 41.67%) of the

children belonged to families whose below

poverty line which is per capita income per

month was less than Rs 500.(17) Maximum

mothers belonging to socio economic class

VI (97.62%) are giving prelacteal feed

followed by mothers belongs to

socioeconomic class II (77.55%),followed

by class III(64.52%).Prelacteal feed given to

93% infants in case of Muslims family,

while it is 58.49% in case of Hindu families.

In present study 56.75% mothers were house

wives, and rest were working. 61.81% of

total mothers were doing moderate level of

daily physical activity followed by 34.67%

heavy worker and 3.52% mother had light

work Similar observation are found in study

of Sima Roy et al where 69.15% mothers

were housewives.(17) But in other study of

Syed E. Mahmood et al there were 99.1%

were housewife, also Venkatesh RR

observed in their study in urban slums of

Devangare city, Karnataka that 88% women

were house wives and only 12 % were

working in the unorganized sectors.(19,25)





There was significant association between

occupation and feeding pattern of infant in

developing countries like India, women are

responsible for a wide range of household

work and child care duties as well as work

outside the home. These women are also the

women at high risk for poor birth

outcome.Bhardwaj et al showed around

seven percent (7.77%) mothers were

working. (16)Roy et al revealed 69.15%

were housewives. (17)

In present study, breast feeding mainly

practiced was on demand 365(91.25%), as

compare to on schedule in 35 (8.75%) cases.

Similar finding were observed by Wadde et

al in his study that shows 90.52% mothers

followed demand feeding. (15) In study of

Bhardwaj et al, Demand breast feeding was

practiced by all mothers. (16) Nitin Joseph

et al Demand feeding was practiced by

87.1% mothers.(26) In the present study

out of 148 illiterate mothers, 136(91.82%)

were given on demand breast feeding, as

compare to mothers educated up to primary

level who were given on demand breast

feeding in 86.32%.

In present study there are significant

association between literacy level of mother

and practice of exclusive breastfeeding also

there is significant association between

occupation of mother and practice of

exclusive breastfeeding but there is no any

significant association between socio

economic status and religion of mothers.

CONCLUSION

Multiple health problems was encountered

in the survey area dominated by twin

problems of malnutrition along with

infective diseases which are associated with

mothers illiteracy, mother working

conditions, wrong feeding practices, delayed

weaning practices, poor personal hygiene of

children and socioeconomic status.

Our study revealed that the recommendation

of six months exclusive breastfeeding is not

properly implemented in the rural area of

Jaipur. This is showing that the policy

implementation at field level still require

some changes to combat its failure. Looking

forth on these matters following suggestions

are recommended, so as to improve health of

infants to some extent. Health and nutrition

programmes, as well other programmes

dealing with women and children should

mainstream breastfeeding counselling and

support interventions, to help women to

succeed both in early (within an hour) and

exclusive breastfeeding (for the first six

months of life).But these programmes will

become more successful when more focus

on to improve socioeconomic determinant of

health. This will not only reduce the burden

on the health systems to treat sick newborn

babies, but also has the potential to make

our children grow well and have sound

development.









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Social Determinants of Health: The Solid

Facts. 2nd Edition.

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What Determines Health. Retrieved on

January 4, 2008, from http://www.phac-

aspc.gc.ca/ph-

sp/phdd/determinants/#determinants

3. World Health Organization. (2007).

Achieving health equity: from root causes to

fair outcomes. Interim Statement.

Commission on Social Determinants of

Health.

4. Guha's Neonatology: Principles and

Practice" 3rd edition, 2 volume set. Editor

Deepak Guha. Publisher: M/s. Jaypee

Brothers Medical Publishers (P) Ltd., New

Delhi,India. Pages 16-20.

5. Nicolas Stellter, Jatinder Bhatia, Anjali

parish,Virginia. A. Stallings. ‘Feeding

Healthy infants, children and Adolescents,

In: Nelson textbook of paediatrics 9th

Edition, Vol-1, Part 1-IXVI: Published by

Elsevier, adevisian of Reed Elsevier India

PVT Limited

6.Gupta A, Mathur GP, Jindal T, Dadhich

JP. Breastfeeding. BPNI Technical Info

Series-2, 2003

7.WHO/UNICEF Protection, promotion and

supporting breastfeeding—The special role

of maternity services. Geneva: WHO;1989

8.K. Park, Park’ Text Book Of Preventive

And Social Medicine; Publisher Edition

22,2013

9.Prokerala news India lags behind in breast

feeding practices: reports; Thursday Dec 6,

2012; original article

10.Agarwal AK, Social Classification: the

need to update in the present scenario,

Indian journal of community medicine

(Serial online) 2008 [Cited on Jan 26th 211]

; 33:50-51

11.Uttekar BP, Barge S, Khan W,

Deshpande Y, Uttekar V, Sharma J et al.

Assessment of ASHA and JSY in Rajasthan.

2007,

12.DevangRaval, D. V. JankarM. P. Singh

A. Study of breast. feeding practices.

Among Infants living In slums Of

Bhavnagar city, Gujarat, India. Health line

2011; 2 ( 2)

13. 45. KumarDinesh,Agarwal

Neeraj,SwamiHM Socio-demographic

correlates of breast-feeding in urban slums

of Chandigarh; ORIGINAL

CONTRIBUTIONS; : 2006 ; : 60 ; Issue :

11; PP : 461-466

14. IM C Yadavannavar and 2Shailaja S

Patil Socio cultural factors affecting breast

feeding practices and decisions in rural

women Volume-1, Issue-2 June-Aug :2011.

15.WaddeSatish K.1*, YadavVallabh

B.2Determinants of Exclusive Breast

Feeding in a Rural Community of

Maharashtra. International Journal of Recent





Trends in Science And Technology, 2012

issue1, Volume 4.

16.BharadwajS.L,Rathore M.S andPaliwal

A. A Study of Breast Feeding and Neonatal

Care Practices in Some Ethnic Communites

in Periurban Slum at Jaipur Rajasthan,

Anthropologist,2012 14 (5): 459-465

17.Sima Roy, AparajitaDasgupta and Bobby

Pal. IndJou Com Med.2009;34/4:362-363

18.D.k. Taneja, RenukaSaha,

PratibhaDabas, V.P. Gautam, Y. Tripaty, M.

Mehara. I.J.C.M. 2003-07 – 2003-

09;Vol.28, No.3:

19.Syed E. Mahmood, AnuragSrivastava,

Ved P. Shrotriya, Payal Mishra. Infant

feeding practices in the rural population of

north India. J of family and Com-

Med;19:2:130-135

20.Neeraj Mohan Srivastava , Shally

Awasthi. Breastfeeding practices for

newborns among urban poor in Lucknow,

northern India: A prospective follow-up

study. Clinical Epidemiology and Global

Health. 2013; 1-9.

21.Malireddy Radhika, Sekhar K. Chandra,

Deotale P.G. Knowledge, attitude, practice

regarding breast feeding practiceamong

mothers attending AlluriSita Rama Raju

Academy of Medical Sciences, Eluru,

Andhra Pradesh .Indian Journal of Public

Health Research andDevelopment : 2012, :

3, ( 2) 76-79

22.Barker DJP. Mothers, babies and health

in later life.Pub Edinburgh: Churchill

Livingstone; 1998

23.Singh A, Arora AK.The Changing Profile

of Pregnant Women and Quality of

Antenatal Care in Rural North India. Indian

Journal of Community Medicine, 2007

;32(2):136

24.Gogoi G, Ahmed FU. Effect of Maternal

Nutritional Status on the Birth Weight

Among Women of Tea Tribe in Dibrugarh

District. Indian Journal of Community

Medicine, 2007 Apr;32(2):120-122.

25.Venkatesh RR Safe Motherhood Status in

urban slums of Devanger city. Indian J. of

Comm. Med (2005), Jan-Mar:31(4):230

26.Nitin Joseph, B. Unnikrishnan,

VijayaA.Naik,N.SMahantsheeti, M.D.

Mallapur, ShashidharM.Kotian, Maria

Nelliyanil. Infant Rearing Practices in south

India: A Longitudinal Study. J of Family

Medicine and Primary Care. 2013; 2:37-43.





THE STUDY OF THE ORGANISMS COLONIZING TRACHEA IN MECHANICALLY

VENTILATED PATIENTS ADMITTED IN THE INTENSIVE CARE UNIT (ICU)

Dr.Trilok Patil*

Associate Professor, Department of Microbiology, Geetanjali Medical College, Udaipur


Received:12/09/2013 Revised: 17/10/2013 Accepted:21/11/2013

Abstract:

Objectives: To isolate and identify the organisms colonizing trachea in mechanically ventilated

patients admitted in the Intensive Care Unit (ICU). Methods: The present study was conducted

on 265 patients were admitted in the ICU during from July 2004 to June 2005 in Government

Medical College & Hospital, Aurangabad (Maharashtra). A total of 100 patients on mechanical

ventilation with intubation tube fulfilling the inclusion criteria were followed-up prospectively.

The patterns of tracheal colonization were studied in these patients. Patients were followed-up

twice a week on day 4 and day 7. The antibiotic sensitivity testing of the isolated organisms were

carried on Mueller-Hinton Agar (MHA). Results: In all total 361 isolates of organisms were

identified from the 229 processed samples of endotracheal aspirates (EA) of mechanical

ventilation. Pseudomonas aeruginosa was the most commonly isolated organism, present in 135

(37.4%), followed by Klebsiella pneumonia in 103 (28.5%),Staphylococcus epidermidis in 53

(14.7%), Staphylococcus aureus in 10 (4.36%)among the 229 positive culture samples.The

isolation rate of Pseudomonas aeruginosa increased with the duration of ventilation from 18.5%

on day 1 to 46.7 % on day 7. Conclusion: One aspect been proven beyond doubt is that, the

microorganisms, either exogenous or endogenous, colonize the normally sterile trachea of

mechanically ventilated patients before the development of VAP. Nevertheless, the optimal

management of patients with VAP requires collaboration amongst critical care specialists and

microbiologists.

Keywords: Ventilation-associated pneumonia, endotracheal aspirates, mechanical ventilation,

Microorganisms.

INTRODUCTION:

The hospital while fulfilling its role as a

health care institute, sometimes presents its

patients with the unwanted gifts of Hospital-

acquired infections (HAI).The common HAI

are respiratory tract infection, urinary tract

infection, blood-stream infection, and skin

and surgical-site infections.(1,2)







According to the surveillance data from the

National Nosocomial Infections Surveill-

ance (NNIS) system of the Centers for

Disease Control and Prevention (CDC),

‘Hospital acquired pneumonia (HAP) or

Nosocomial pneumonia’ is the most

common infection in the intensive care units

(ICUs).(3,4)

Hospital acquired pneumonia (HAP) is more

frequent in intubated patients with

mechanical ventilation (MV).(5)

The

incidence of HAP varies from 9 to 78 %,

depending on the severity of illness, type of

patients studied, the techniques & criteria

used to diagnose the pneumonia.(6)

Hospital-acquired pneumonia is the most

common nosocomial infection reported

among mechanically ventilated patients

admitted in the ICU, where it is labeled as

‘Ventilation-associated pneumonia’ (VAP),

with estimated prevalence ranging from 10

to 65.(7)The mortality rate in VAP ranges

from 24% to 80% in several studies with 2

to 10 fold higher risk of death in ICU-

ventilated patients.(8,9)

Various organisms have been implicated in

the colonization and causation of a VAP. It

is possible that various organisms are

introduced into the trachea through different

routes.(10) To label the presence of

organisms in the trachea as ‘colonization’ or

‘pneumonia’ is not a very simple task.(11)

In ICU patients, especially those who are

intubated, the signs of pneumonia are

relatively subtle, and thus the diagnosis

often is relatively complex. (12) However,

no single criterion has been specifically

diagnostic for VAP. (13) Since the Accurate

data on etiologic agents and the

epidemiology of ventilator-associated

pneumonia are limited by the lack of a

“gold-standard” for diagnosis.(14)

Laboratory investigations of microbial cause

are important because in the absence of such

identification of organisms, antibiotic

therapy may not be optimal. Clinicians need

to adapt the treatment recommendations and

preventive measures to their respective

institutes, as the routes of infection and

agents causing pneumonia vary considerably

among health-care facilities.(15)

Therefore, knowledge about the commonest

etiological pathogens colonizing trachea in

mechanically ventilated patients, developing

into VAP at the institute level by

prospective study will definitely be useful in

formulating the optimal management of the

patients.

MATERIALS AND METHODS

The present study was conducted in 5-

bedded Intensive Care Unit (ICU),

Government Medical College & Hospital,

Aurangabad (Maharashtra). The study

period extended from July 2004 to June

2005. A total of 265 patients were admitted

in the ICU during the study period.

Patients with more than 48 hours of

mechanical ventilation (MV) with

endotracheal tube were included in the

study. Patients on mechanical ventilation for

48 hours or less or who developed

pneumonia within 48 hours of MV were

excluded from the study. Exclusion criteria

were severe immunosuppression (organ





transplantation, AIDS) and evidence of

pulmonary infection or suspicion of gross

aspiration at admission.All the patients were

given antibiotic prophylaxis with

administration of gentamicin. A total of 100

patients on mechanical ventilation with

intubation tube fulfilling the inclusion

criteria were followed-up prospectively.

Informed consent was obtained from the

patient or the nearest relative of the patient.

The patterns of tracheal colonization were

studied in these patients.

Major complaints, underlying disease,

indication for intubation, general & systemic

examination, and results of routine

investigations with X-ray chest reporting

were noted. Patients receiving antibiotics

with its duration of administration was also

recorded. Patients were followed-up twice a

week on day 4 and day 7. During the follow-

up visits, special note about the duration of

Mechanical Ventilation (MV), CBC, X-ray

chest, rise in temperature and extra

pulmonary focus, if any was noted.

The antibiotic sensitivity testing of the

isolated organisms were carried on Mueller-

Hinton Agar (MHA), by modified Kirby-

Bauer disc-diffusion method, using 0.5

McFarland as the turbidity standard as per

NCCLS guidelines. (16)

RESULTS

During the one-year study period, from July

2004 to June 2005, a total of 265 patients

were admitted in the medical ICU. Out of

which 100 patients mechanically ventilated

(MV) with intubation tube for more than 48

hours were included in the study to evaluate

the pattern of tracheal colonization and

development of VAP. The study group

comprised of 64 males and 36 female

patients.

The study group comprised of wide range of

age, the youngest being a seven-year old

female and the oldest an 80 years female.

The maximum numbers of patients were

clustered in the age group of 21-30 years,

consisting 26% of the patients. The mean

age of patients was 30.7 years.

The tracheal aspirates were followed on

days 1, 4 and 7 to evaluate the incidence of

tracheal colonization and development of

VAP. However, on day 5, total 3 patients

were extubated since they showed signs of

recovery. These 3 patients, one each with

OPP, GBS and ARF did not yield any

organism either on day 1 or day 4 of

intubation.

During the study, 1 patient died on fourth

day and 2 patients died each on day 5 and

day 6.

In all total 361 isolates of organisms were

identified from the 229 processed samples of

endotracheal aspirates (EA) from 100

patients up to the seventh day of mechanical

ventilation.

Average number of isolates per EA sample

was 1.58. The mean colonization rate was

3.61 strains per patient. Mean colonization

rate was obtained by dividing the total

number of organisms isolated by the total

number of patients studied.





Table 1 : Microorganisms Isolated from Endotracheal Aspirates

Table 2 : Day Wise Isolation of Organisms.

ORGANISM DAY 1 DAY 4 DAY 7

No. % No. % No. %

P. aeruginosa (135) 25 18.5 47 34.8 63 46.7

Kl. pneumoniae (103) 19 18.4 38 36.9 46 44.7

S. epidermidis (53) 08 15.1 22 41.5 23 43.4

E. coli (49) 07 14.3 20 40.8 22 44.9

S. aureus (10) 06 60 02 20 02 20

P.mirabilis (04) 00 0 01 25 03 75

S. pyogenes (04) 01 25 02 50 01 25

S.pneumoniae (03) 01 33.3 01 33.3 01 33.3

Total Isolates (361) 67 18.6 133 36.8 161 44.6

Out of the total 100 patients studied,

colonization with Gram-negative organisms

occurred in 87 patients (i.e. 87

%).Pseudomonas aeruginosa was the most

ORGANISM NO. OF ISOLATES Percentage %

Pseudomonas aeruginosa 135 37.4

Klebsiella pneumoniae 103 28.5

Staphylococcus epidermidis 53 14.7

Escherichia coli 49 13.6

Staphylococcus aureus 10 2.8

Proteus mirabilis 04 1.1

Streptococcus pyogenes 04 1.1

Streptococcus pneumoniae 03 0.9

TOTAL 361 100





commonly isolated organism, present in 135

(37.4%), followed by Klebsiella

pneumoniae, isolated in 103 (28.5%) of the

229 positive culture samples. The total

Gram-negative organisms isolated were 291

(80.6%), while Gram-positive organisms

accounted to be 70 (19.4%).

Staphylococcus epidermidis

accounted for 53 (14.7%) among the 229

positive culture samples. Out of total 10

Staphylococcus aureus, 4 were methicillin

resistant Staphylococcus aureus (MRSA),

while 6 were methicillin sensitive

Staphylococcus aureus (MSSA).

Pseudomonas aeruginosa was the

most commonly isolated organism among

all other organisms throughout the duration

of mechanical ventilation (MV).

Pseudomonas aeruginosa

predominated with 37.3%, 35.3% and 39.1%

isolates in the endotracheal aspirates (EA)

processed on days 1, 4 and 7 respectively.

Total number of isolates increased

with the duration of mechanical ventilation

(MV) from 18.6% on day 1 to 44.6% on day

7.The isolation rate of Pseudomonas

aeruginosa increased with the duration of

ventilation from 18.5% on day 1 to 46.7 %

on day 7. Similarly, isolation rate of

Klebsiella pneumoniae increased with the

duration of ventilation from 18.4% on day 1

to 44.7 % on day 7.

Significant increase in isolation of

coagulase negative Staphylococcus

epidermidis (CONS) was seen from 15.1 %

on day 1 to 43.4% on day 7. Although,

Staphylococcus aureus showed decrease in

the isolation rate from 60% on day 1 to 40%

on day 7, developed resistance to β-lactams.

Two isolates each on day 4 & 7 of

Staphylococcus aureus were MRSA.

DISCUSSION

Mechanical ventilation is indicated to

combat the fatal outcome of respiratory

failure due to various causes like central

nervous system dysfunction as a result of

poisoning, drug intoxication, paralytic

diseases, head injuries and many others.

Ventilation-associated pneumonia (VAP) is

the commonest complication in patients

mechanically ventilated with endotracheal

intubation tube. A wide range of

microorganisms causes the potential

problem of VAP. (17) The associated large

bulk of morbidity and mortality makes its

early diagnosis and appropriate treatment,

the right of the patient.

Various studies have studied the pattern of

tracheal colonization and shown that over a

period of time, the micro-organisms

gradually colonize the trachea. Potentially

pathogenic organisms, mostly Gram-

negative bacteria, rapidly colonize airways

of critically ill patients.(17) The organism

colonizing the trachea depends on the

source, either oropharynx or stomach, the

length of hospital stay with duration of

mechanical ventilation and the various

associated risk factors.(11)

In the present study, colonization occurred

in 97 patients out of the total 100 patients

studied. Hence, total colonization rate was





found to be 97%. In a study by Ewig et al

the trachea was initially colonized by 83%

of the organisms causing VAP, whereas de

Latorre et al, reported 83.3% colonization

rate in their studies.(17,18)

In the present study, in almost all 57 patients

developing VAP, the infecting organism had

colonized the trachea. Delclaux et al in a

study showed that in 66% of the episodes of

VAP, the infecting organism had colonized

the trachea. (19)

In the present study, the tracheal

aspirates were followed up on days 1, 4 and

7 of intubation to evaluate the colonizing

organisms causing VAP. Johanson et al

found only 22% of their patients to be

colonized on the first day. However, they

studied only Enterobacteriaceae and

Pseudomonas species.(20) Niederman et al

also found only 22% of their patients

colonized within the first three days of

intubation. This low value could be

explained by the fact that they studied only

enteric Gram-negative bacilli. (21) Both this

studies also neglected the Gram-positive

organisms, which tend to colonize the

trachea early during ventilation.

Francisco J de Latorre et al found that 80%

of the patients mechanically ventilated had

their trachea colonized on day 1.(18) In our

study, on day 1, i.e. within first 24 hours of

intubation, out of the total 100 endotracheal

aspirates, 47 showed growth on culture

indicating the early tracheal colonization

rate of 47%, which increased drastically to

97.83% on day 7 of mechanical ventilation.

The result of our study relates well to the

study carried out by Bonten et al 116

where

they found 96.1% of the patients, previously

colonized by the organisms.(22)

Schwartz et al found the similar trend. 75%

of their patients colonized on day 1

increased to 95% by the end of day 4 and

subsequently to 98.6% at the end of week of

intubation. (23) Niederman et al also

showed a similar trend. The frequency of

colonization increased over duration with

only 22% of the subjects being colonized at

the start of MV to 78% at the end of the

week.(21)

Similarly, of the total 122 isolates

responsible for VAP, Pseudomonas

aeruginosa emerged as the most common

pathogen with 41% followed by Klebsiella

pneumoniae 26.2%. Of the total isolated

organisms developing VAP, only 25.4%

were isolated on day 4 which dramatically

increased to 74.6% on day 5 of MV.

Merchant et al 72

found that Pseudomonas

aeruginosa made upto 44% of the total

isolates, followed by Klebsiella spp. (34%)

and Escherichia coli (9%).(24)

A large-scale study conducted in 107

ICUs in Europe demonstrated, a crude

pneumonia rate observed was 9%.(25) The

low incidence of VAP in these studies could

be due to greater specificity of criteria for

diagnosis, clinical criteria and quantitative

culture of PSB.

Distribution of microorganisms responsible

for the VAP differs according to the

population studied

(surgical/medical/trauma), the duration of

hospital / ICU stay, duration of mechanical





ventilation (MV) and the diagnostic method

used.(10)

Salata et al found Gram-negative bacilli in

62% of their pathogens incriminated in the

development of VAP.(26), whereas Ewig et

al reported 54% colonization rate due to

Gram-negative bacteria in their studies.(17,)

In the present study, out of the total 100

patients studied, colonization with Gram-

negative organisms occurred in 87 % of the

patients. The total Gram-negative organisms

isolated were 291 (80.6%), while Gram-

positive organisms accounted to be 70

(19.4%) out of the total 361 isolates

identified.

The Gram-negative organisms showed

increased in the colonization rate with

duration of mechanical ventilation (MV)

from 76.1% on day 1 to 83.2% to day 7.

The more percentage isolation of Gram-

negative organisms colonizing trachea may

be due to higher isolation rate of

Pseudomonas aeruginosa and Klebsiella

pneumoniae among the Gram-negative

bacteria, which in turn might be due to more

mean duration of MV (13 days) and prior

broad-spectrum antibiotics to every patient.

Niederman et al isolated Pseudomonas

aeruginosa and enteric Gram-negative

bacilli in 73.3% if their tracheal

aspirates.(21) Craven et al

studied 233

patients and found predominance of Gram-

negative bacilli, which were detected in 61%

of the patients developing VAP.(27) Baker

et al showed that Gram-negative bacilli

accounted for 63% of the isolates causing

VAP.(28)

Johanson W G et al found Klebsiella

pneumoniae to be the most common

organism isolated from the respiratory tract,

but not all of their patients were

intubated.(20)

In the present study, total 361 isolates were

isolated from 97 patients colonizing the

trachea of the 100 patients studied. Out of

these 361, total 122 isolates were

responsible for VAP. Pseudomonas

aeruginosa was the most commonly isolated

organism 40% (50 of the 122), followed by

Klebsiella pneumoniae 26.2% (32 of the

122), of the 229 positive culture samples

throughout the duration of MV.

In the present study, E.coli was found as

12.3% of the isolates, while Proteus spp.

even after colonizing the trachea of MV

patients did not develop VAP. Trouillet et al

found E.coli in 3.3% and Proteus spp. in

2.9% of their isolates obtained from VAP

patients.(14)

In the present study, MRSA accounted for

3.3%, while Streptococcus pyogenes and

Streptococcus pneumoniae each were 0.8%

of the total isolates. Trouillet et al 24

found

CONS and Streptococcus species in 1.6%

and 13.9% of their samples respectively,

from patients of VAP. In our study,

Staphylococcus epidermidis accounted for

53 (14.7%). (14)

The decrease in the isolation of Gram-

positive organisms could be attributable to

effect of prophylactic antibiotic treatment,





which might have caused the disappearance

of the sensitive strains and also the

colonization by the Gram-negative bacteria

with increase in the duration of MV.

CONCLUSION

Thus, to conclude with ventilation-

associated pneumonia (VAP), a common

complication of mechanical intubation in the

ICU, caused by a wide range of

microorganisms with increasing resistance

to empirically administered antibiotics,

adding on to the large bulk of morbidity and

mortality makes its accurate diagnosis and

adequate treatment, the patients right

towards the health care providers.

One aspect been proven beyond doubt is

that, the microorganisms, either exogenous

or endogenous, colonize the normally sterile

trachea of mechanically ventilated patients

before the development of VAP.

The need of hospital infection control should

be entrenched with stress on personal

cleanliness and hygiene to eliminate the

sources of infection and cease the spread of

microorganisms.

Nevertheless, the optimal management of

patients with VAP requires collaboration

amongst critical care specialists and

microbiologists. This will help not only in

the early recognition and management of

individual VAP cases, but also may lead to

early recognition of any outbreaks.





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ELECTROLYTES IMBALANCE IN TRAUMATIC BRAIN INJURY PATIENTS

Dr. Sanjay K.Gupta1*, Dr. Jitendra Ahuja

2, Dr. Arvind Sharma

3

1.Associate Professor (Surgery) and consultant neurosurgeon, Geetanjali Medical College and

Hospital, Udaipur, India.

2.Associate Professor (Biochemistry), Geetanjali Medical College and Hospital, Udaipur, India.

3.Assistant professor (Community Medicine), Jhalawar Medical college, Jhalawar, Rajasthan,

India

*Email id of corresponding author- [email protected]

Received:13/02/2013 Revised: 18/10/2013 Accepted:22/11/2013

Abstract:

Objectives: The role of electrolyte imbalance is being delineated in severe cranial trauma and is

an essential investigation for its therapeutic managements. This study is designed to uncover the

prevalence of electrolyte imbalance in traumatic brain injury (TBI) patients. Material and

Methods: 50 consecutive patients with head injury and 50 trauma patients without clinical and

radiological evidence of head injury were admitted to the emergency service of Geetanjali

Medical College, Udaipur during 2 month period. We measured serum level of Magnesium,

phosphorus, calcium, potassium and sodium and calculate APACHE score for prognosis at

admission. We compared all electrolyte values in two groups taking head injury patient as case

and trauma patient without head injury as control. Results: Different Electrolyte levels at

admission in group 1 vs. group 2 were as follows (mean ±SD): Na levels were 138.85±5.68 vs.

140.62±5.89 in groups 1 and 2, respectively. K levels were not very significant between both

groups group 1 vs group 2 (4.23±0.62 mmol/L vs. 4.384±0.54mmol/L; (p, .20). Phosphorus

2.971 ±0.91 vs. 3.48±0.91 (p, .01). Mg, 2.1086±0.44 vs. 2.96±0.68 (p, .01). Ca levels were

8.17±0.74 vs. 8.68±1.12mg/dl for groups 1 and group 2, respectively (p=0.008). Conclusion:

We conclude that patients with brain injury are at a high risk for the development of electrolyte

imbalance including hyponatremia, hypocalemia, hypophosphatemia as well as hypokalemia and

(to a lesser degree) Hypomagnesemia.

Keywords: Traumatic Brain Injury, hyponatremia, hypocalcaemia, hypophosphatemia,

Hypomagnesemia.

INTRODUCTION:

India is passing through the triple epidemic

of communicable, non communicable and

injuries, due to epidemiological and

demographic transition. (1) Among injuries,







traumatic brain injury (TBI) is among the

most significant one manifesting high

morbidity and mortality. The consequences

of TBI results in disability with lifelong

financial, medical, emotional, family

trauma.TBI is a foremost important cause of

death and disability entire the world (2) and

is the leading cause of brain damage in

children and young adults.(3)

Patient with TBI have a high risk of

developing different type of electrolyte

imbalance, at the time of admission and

duration of their ICU stay. It will affect

treatment and outcome of patient.

Magnesium (Mg) is engaged in so many

biomedical important enzymatic reactions as

a cofactor and it is also well correlated with

control of the sodium/potassium (Na/K)

transport across membranes by activating

the Na-K ATPase pump. (4,5)

Magnesium has been called "nature's

physiological calcium channel blocker"

because it appears to regulate the

intracellular flow of calcium ions and

hypocalcemia is also related with low levels

of Mg. Previous studies showed a strong

correlation between

Hypomagnesemia and some disorders like

ischemic heart disease, hypertension,

coronary vasoconstriction, transient

ischemic attacks, cardiac arrhythmias,

sudden death, preeclampsia-eclampsia,

strokes, seizures, neuromuscular irritability,

and diabetes (1–7).

Phosphate (P) is a major intracellular anion

and play important role in maintaining

muscle tone (7, 8). Hypophosphatemia has

been shown to be associated with muscle

weakness, including weakness of respiratory

muscles. (9, 10)

Hyponatremia and correction of

hyponatremia are clinically significant in

neurology as a fast declining serum sodium

concentration as well as rapid correction of

chronic hyponatremia may lead to

neurological symptoms .(11, 12 )

K is found in high concentration in cell with

comparatively low extracellular

concentration levels. Small Changes in K

ions can severely affect nerve conduction,

heart rhythm and muscle contraction. (13)

Calcium is involved in nerve conduction,

skeletal and cardiac muscle contractions

therefore hypocalcemia may be involved in

pathology of some clinical disorders like

neuromuscular irritability, muscle spasms,

seizures, delayed ventricular repolarization,

and cardiac failure. (14)

Cerebral injury can lead to electrolyte

imbalance which may prove critical for

survival of patients. There are different

mechanisms to explain electrolyte imbalance

in TBI patients. Cerebral injury can cause

polyuresis through the syndrome of

inappropriate antidiuretic hormone secretion

and cerebral salt loss.

Patients with cerebral trauma are commonly

managed with mannitol, which can promote

polyuresis. Thus, polyuresis is a possible

source of loss of different electrolytes in

severe head injury patients.





The role of electrolyte imbalance is being

delineated in severe cranial trauma and may

be essential investigations for its therapeutic

managements. This study is designed to

uncover the prevalence of electrolyte

imbalance in traumatic brain injury (TBI)

patients.

MATERIAL AND METHOD

50 consecutive patients with head injury and

50 trauma patients without head injury were

admitted to the emergency service of

Geetanjali Medical College, Udaipur during

2 month period. We measured serum level

of Magnesium, phosphorus, calcium,

potassium and sodium and calculate

APACHE score for prognosis at admission.

We compared all electrolyte values in two

groups we took head injury patient as case

(GROUP 1) and orthopaedic trauma patient

without head injury as control (GROUP 2).

RESULTS

Mean age in group 1 was 37.78 (range, 15–

73) year. There were 2 females and 48 males

in the study. Road traffic accident was mode

of injury in 34 and fall from height in

16.According to type injury there were 15

patients had Subdural haemorrhage (SDH),

8 patients with Intracranial haemorrhage

(ICH) , 27 patients with contusion.

According to site of lesion of 16 patients had

lesion frontal temporal region, 14 frontal, 2

temporal, 1crebellum, and 1cerbral injury

and 8 patients with no any abnormality in

brain.

The average Glass comma scale (GCS) in

group 1 was 6.44 and the average apache

score was 13.07 at admission to our hospital.

Five patients in group 1 used medication

that can be associated with loss of Mg

and/or P (diuretics). No pre-existing risk

factors for electrolyte loss were present in

the other patients in group 1. The average

age in group 2 was 33.30 yrs (range, 15–65).

The average GCS in group 2 was 13.0 and

the average apache score is 4.82 at

admission to our hospital. None of the

patients in group 2 used medication

associated with electrolyte disorders. There

were 7 females and 43 males in the study.

Road traffic accident was mode of injury in

37, slip in bathroom in 5 and fighting in 8

patents.

Different Electrolyte levels at admission in

group 1 vs. group 2 were as follows (mean

±SD): Sodium (Na), Potassium (K),

Calcium (Cl), Calcium (Ca) and Phosphorus

(P) level.

Na levels were 138.85±5.68 vs.

140.62±5.89 in groups 1 and 2, respectively.

Seventeen of 50 patients in Group 1 had Na

levels of 135mmol/L or lower vs. 10/50 in

group 2 (p= 0.177) and hypernatremia (Na

level more than 145 mmol/L) 7/50 in group

1 vs. 11/50 in group 2 (p=0.435).

K levels were not very significant between

both groups group 1 vs group 2 (4.23±0.62

mmol/L vs. 4.384±0.54 mmol/L; p, 0.20).

Moderate hypokalemia (K levels below 3.6

mmol/L) was present in 10/50 patients in

group 1 vs. 2/50 patients in group 2 (p,

0.031). Severe hypokalemia (K levels equal





or lower than 3.0) was present in 1/50

patients in group 1 vs. 0/50 patients in group

2 (p, 1.00). Hyperkalemia K level (greater

than 5.1 mmol/L) 6 patients in group 1 vs.

9/50 patients in group 2 (p 0, 575) .

Phosphorus level was 2.971 ±0.91 vs.

3.48±0.91 (p, .01). In group 1, 28/50

patients had P levels, less than 2.7 mg/dl vs.

7/50 patients in group 2(p=0.0001) and p

level greater than 4.5 (hyperphosphatemia)

in group 1, 3/50 patients (p, .01) vs. 10/50

patients in group 2(p=0.074).

Mg level, 2.1086±0.44 vs. 2.96±0.68 (p,

.01). None of the patients had low Mg level

in both groups, in group 1, 3/50 patients had

Mg levels, more than 2.6 mg/dl

(hypermagnesemia) vs. 32/50 patients in

group 2 (p=0.0001).

Ca levels were 8.17±0.74 vs.

8.68±1.12mg/dl for groups 1 and group 2,

respectively (p=0.008). Hypocalcaemiaca

level (less than 8.5 mg/dl) was present 32

out of 50 patients in group 1 vs. 17 out of 50

in group 2 (p=0.005)and hypercalcaemia

(Ca level more than 10.5mg/dl) 0/50 and

4/50 in group 1 vs. group 2

respectively(p=0.126).

Saline infusion (NaCl, 0.9%) was given 15

patients and of Na 0.45%/glucose 2.5% in

five patients in group 1. Average volume

infused was 899 ml in group 1 before ICU

admission. Three patients had also received

blood transfusions of the patients in group

1.Fluid resuscitation in group 2 consisted of

infusion of saline (NaCl, 0.9%) in 18

patients and of Na 0.45%/glucose 2.5%in

seven patients. Average volume infused

before ICU admission was 976 ml. Five

patients had also received blood transfusions

of the patients in group 2, The difference in

volume infused between groups 1 and 2 was

not significant. No hypertonic saline was

used in our head injury patients.

Urine production in both groups before

admission was measured using a Foley

catheter. The average residual urine volume

was 902 ml in group 1 vs. 767 ml in group2

(p, = 0.0152) upon insertion of the catheter.

APACHE II scores were significantly higher

in group 1 than in group 2 (9.28±5.07 vs.

5.12±2.42), reflecting differences in GCS as

well as other factors, such as tachycardia

and tachycardic arrhythmias, episodes of

low or high blood pressure, and electrolyte

disorders (high Na levels and low K) present

and blood counts in group 1. There were no

differences in the presence of chronic

diseases between groups 1 and 2.

DISCUSSION

Our results clearly demonstrate that patients

with severe head injury are at a high risk for

the development of hyponatremia, hypopho-

sphatemia, hypokalemia, hypocalcemia and

hypormagnesemia, when cerebral injury is

present in compared to other group while in

other orthopaedic injury patients (group 2)

developed hyponatremia, hperphosphatemia,

hypermagnesemia, hyperkalemia and some

extend to hypocalcemia.

Hyponatremia may develop as a result of

syndrome of inappropriate secretion of

antidiuretic hormone characterized by

dilutional hyponatremia or cerebral salt-





wasting syndrome featured by natriuresis in

head injury patients. Brain natriuretic

peptide (BNP) activities may also

responsible for hyponatremia. (15) Brain

natriuretic peptide is an effective diuretic,

natriuretic, vasodilating agent, and an

inhibitor of the secretion of aldosterone,

renin, and vasopressin. Patients with

subarachnoid hemorrhage or hemorrhage at

the base of the brain or in the third ventricle

are most commonly show enhanced BNP

level. (16-17)

Diabetes insipidus, have hypothalamic-

pituitary dysfunction, particularly growth

hormone deficiency, ACTH, TSH and

gonadotrophin deficiency and diabetes

insipidus that commonly could be caused of

hypernatremia. (18)

Patients with severe head injury are at high

risk for the development of hypokalemia.

Low potassium levels in these patients might

be due to an increase in their urinary loss,

caused by neurologic trauma. Patients with

severe head injury are at risk for developing

polyuresis. Through a variety of

mechanisms has worked in polyuresis like

the syndrome of inappropriate antidiuretic

hormone secretion, cerebral salt loss.

Hypomagnesemia was associated with

hypokalemia in most patients. As outlined in

our introduction, hypomagnesemia and, to a

lesser degree, hypophosphatemia are

associated with various forms of cardiac

arrhythmia. (19) Causes of

hypomagnesemia include protein-calorie

malnutrition, intravenous administration of

Mg-free fluids and total parenteral nutrition,

as well as diarrhoea and steatorrhea, short

bowel syndrome, and continuous nasogastric

suctioning. Many of these factors may be

present simultaneously in brain injury

patients. Trauma patients are frequently

treated with antibiotics, often including

aminoglycosides. Thus, as with

hypomagnesaemia, a combination of many

factors may put brain injury patients at risk

for hypophosphatemia. Polyuresis induced

by cerebral injury increases this risk even

further, as demonstrated by the results of our

study. The process through which patients

with severe head injury could be put

endangered for the development of

electrolyte disturbance is uncertain.(20-21)

A shift of electrolytes from the extracellular

to the intracellular compartment may have

taken place; electrolyte loss through

induction of polyuresis by cerebral injury

may also have played a role. Residual urine

volume was higher in group 1 than in group

2; however, the time period in which urine

volumes were formed in group 1 is

unknown, because we were unable to

determine the last time that the patients had

urinated before the occurrence of head

injury.

In addition, spontaneous urine loss could

have occurred in group 1 patients at the

scene of their accident; this would lead to an

underestimation of residual urine levels.

Although this does not establish that

polyuresis was the cause of electrolyte

deficiencies in group 1, it seems likely that

high urine production and renal excretion of

electrolytes contributed to the occurrence of

electrolyte disorders. It is difficult to





determine to what extent outcome in our

patients was affected by the presence of

electrolyte disorders. (22-23)

Na and K are measured routinely at

admission in all patients, including those

with cerebral injury. However, Ca, Mg and

P are not measured on a routine basis;

therefore, deficiencies in levels of these

electrolytes are likely to remain undetected

for a longer period of time.

We feel that intensivist and others physician

who are treating patients with severe head

injuries should be aware of this potential

problem and that levels of Ca, Mg and P

should be measured on a routine basis in all

patients with severe head injury.

CONCLUSION

We conclude that patients with brain injury

are at a high risk for the development of

hyponatremia, hypocalcemia, hypocalcemia

and hypophosphatemia as well as

hypokalemia and (to a lesser degree)

Hypomagnesemia.

Increased urinary loss appears to be one of

the factors contributing to electrolyte

depletion; other, as yet unknown factors,

induced by neurologic trauma may also play

a role. Levels of Mg and P, as well as K, Na

and Ca, should be determined frequently in

these patients, and if necessary, adequate

supplementation should be initiated

promptly.





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Table 1: Various group parameters & their association

PARAMETER Group 1

(N=50)

Group 2

(N=50)

t- value p-value

Glass Comma Score 9.46±3.77 12.92±1.70 5.916 < 0.0001

APACHE SCORE II 9.28±5.07 5.12±2.42 5.236 < 0.0001

Age 37.78±15.11 33±13.72

MAP 98.39±16.9 92.13±9.8 3.6932 0.0004

Heart Rate 84.26±22.60 79.94±15.95 1.1043 0.2722

Respiratory Rate 20.44±3.79 19.44±2.71 1.5177 0.1323

Oxygenation 97.31±2.17 97.28±1.34 0.0832 0.9339

Arterial PH 7.42±0.09 7.45±0.09 1.6667 0.0988

Serum Na 138.85±5.68 140.62±5.89 1.5296 0.1293

Serum K 4.23±0.62 4.384±0.54 1.29 0.2001

Serum Cl 105.88±6.87 106.96±7.41 0.7558 0.4516

Serum Ca 8.17±0.74 8.68±1.12 2.6864 0.0085

Serum P 2.971 ±0.91 3.48±0.91 2.7967 0.0062

Serum Mg 2.1086±0.44 2.96±0.68 7.4330 < 0.0001

Random Blood Sugar 134.58±27.40 131.3±26.01 0.6139 0.5407

Serum Creatinin 0.73±0.17 0.69±0.16 1.2116 0.2286

Hemoglobin 12.76±2.03 12.352±2.06 0.9975 0.3210

Pack Cell Volume (PCV) 36.28±5.63 35.2±5.54 0.9668 0.3360

Total Leucocytes Count (TLC) 13433±4419 12036±3769 1.7008 0.0922

Platelet Count 2.27±0.78 2.26±0.61 0.0714 0.9432

Urine Volume 902±277.85 767.2±267.57 2.4711 0.0152

Fluid Volume 899±280.11 976±272.62 1.3930 0.1668

Association for Scientific and Medical Education (ASME)

International Journal of Medical Science and Education (IJMSE) is an official publication of

Association for Scientific and Medical Education (ASME). The Association for Scientific

and Medical Education is the professional organisation, working nationally and

internationally, for all those involved in medical education – the education and training of

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ISSN: 2348-4438 International Journal of Medical Science ...Dr.Arvind Sharma(Community Medicine, Rajasthan University of Health Sciences, Jaipur), Dr.Reshu Gupta (Physiology, Rajasthan

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