issn: 2348-4438 international journal of medical science ...dr.arvind sharma(community medicine,...
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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
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
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
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
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Published by Association for Scientific and Medical Education (ASME)
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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).
International Journal of Medical Science and Education pISSN- 2348 4438 eISSN-2349- 3208
Published by Association for Scientific and Medical Education (ASME)
Page III Vol.1; Issue: 1;Jan-March 2014
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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,
International Journal of Medical Science and Education pISSN- 2348 4438 eISSN-2349- 3208
Published by Association for Scientific and Medical Education (ASME)
Page IV Vol.1; Issue: 1;Jan-March 2014
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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
International Journal of Medical Science and Education pISSN- 2348 4438 eISSN-2349- 3208
Published by Association for Scientific and Medical Education (ASME)
Page V Vol.1; Issue: 1;Jan-March 2014
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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.
International Journal of Medical Science and Education pISSN- 2348 4438 eISSN-2349- 3208
Published by Association for Scientific and Medical Education (ASME)
Page VI Vol.1; Issue: 1;Jan-March 2014
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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
International Journal of Medical Science and Education pISSN- 2348 4438 eISSN-2349- 3208
Published by Association for Scientific and Medical Education (ASME)
Page VII Vol.1; Issue: 1;Jan-March 2014
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“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.
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authors): List the first six contributors
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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
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1996; 23(1, Suppl 2):89-97.
Books and Other Monographs
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Gerontology and leadership skills for nurses.
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Redfern SJ, editors. Mental health care for
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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:
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Monograph on the Internet
Foley KM, Gelband H, editors. Improving
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Internet]. Washington: National Academy
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Homepage/Web site
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http://www.cancer-pain.org/.
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2002 Aug 12]. AMA Office of Group
Practice Liaison; [about 2 screens].
Available from: http://www.ama-
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Dissertation
Susan MK. Hospital acquired infections:
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
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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).
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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
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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
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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
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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.
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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.
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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
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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
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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.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved
by the institutional ethics committee
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.
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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
renal pathology in tuberous sclerosis
complex. BJU Int. 2004;94:853–7.
7.Curatolo P, Bombardieri R, Jozwiak S.
Tuberous sclerosis. Lancet. 2008;372:657–
68.
8.Schmithorst VJ. Altes TA. Young LR, et
al. Automated algorithm for quantifying the
extent of cystic change on volumetric chest
CT: Initial results in lymphangioleio-
myomatosis. AJR Am J Roentgenol.
2009;192:1037–1044. [PubMed]
9.Ryu J, Moss J, Beck G, et al. The NHLBI
lymphangioleiomyomatosis registry:
characteristics of 230 patients at enrollment.
Am J Respir Crit Care Med 2006;173:105-
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.
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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
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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
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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
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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
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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
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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
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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
coagulase negative staphylococcus (CONS)
(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
coagulase negative staphylococcus (CONS)
(28.57%) in this study. Judicious and
prudent use of antibiotics should be
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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.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved
by the institutional ethics committee
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Intraamniotic infections and premature
rupture of membranes. Clin Perinatol. 1997
Mar;24(1):43-57.
19. West and Peterside: Sensitivity pattern
among bacterial isolates in neonatal
septicaemia in Port Harcourt. Annals of
Clinical Microbiology and Antimicrobials
2012 11:7.
20.Desai KJ,Malek SS. Neonatal
Septicemia: Bacterial Isolates & Their
Antibiotics Susceptibility Patterns.NJIRM
2010; Vol. 1(3);12-15
21. Rizvi F., Afzal M., Khan A, and Wahid
S. Bacterial Sensitivity in Neonatal Sepsis.
Journal of Islamabad Medical & Dental
College (IM&DC); 1211(1):1-5
22.Bode-Thomas F, Ikeh EI, Pam SD,
Ejeliogu EU. Current aetiology of neonatal
sepsis in Jos University Teaching Hospital.
Niger J Med 2004; 13: 130-5.
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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
* Email id of corresponding author : [email protected]
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
Original Research Article
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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
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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
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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
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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.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved
by the institutional ethics committee
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.
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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)
Norethisterone group
(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%)
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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)
Norethisterone group
(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)
Norethisterone group
(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
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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
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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
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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 socio- economic
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
Original Research Article
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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:
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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-
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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.
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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
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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)
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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 socio- economic 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.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved
by the institutional ethics committee
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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
* Email id of corresponding author : [email protected]
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)
Original Research Article
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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
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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.
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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
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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
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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
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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,
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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.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved
by the institutional ethics committee
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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,
Original Research Article
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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.
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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
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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-
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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
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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.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved
by the institutional ethics committee
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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
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