REVIEW ARTICLE J Pub Health Med Res Central Sterile · PDF fileCentral Sterile Supply...

Central Sterile Supply Department: Need Of The Hour.

Abstract: Central Sterile Supply Department(CSSD) is a service unit in a hospital that processes, issues, and controls the sterile stores supply to all departments of the hospital. The essentials of this department are correct design, appropriate equipments, skillful operators and a unidirectional work flow. The CSSD should have four zones – 1) The unclean and washing area, 2) The assembly and packing area, 3) The sterilization area and 4) The sterile area. Each of these has equipments in place in order to perform specific functions towards sterilization of articles for immediate use in patient care. All The hospitals should establish an adequate CSSD set-up and adopt strict quality control processes with the latest technology to mitigate hospital acquired infections.

Key words: Central Sterile Supply Department, Hospital Acquired Infections, Sterilization.

1 2Asima Banu , Subhas G.T. ,

1Associate professor, Dept. of Microbiology, Bowring and Lady Curzon Hospitals, Bangalore Medical College and Research Institute2 Professor, Department of Neurology, Bangalore Medical College and Research Institute

Introduction :

Central sterile supply department( CSSD) is a service unit in a hospital that processes, issues, and controls the sterile stores supply to all departments of the hospital. It can be defined as that service, with in the hospital, catering for the sterile supplies to all departments , both to specialized units as well as general wards and OPDs(Bhattacharjee definition). The last few years have witnessed an

[1]increasing interest in organizing sterilization . The purpose of such a CSSD is to provide all the departments of a hospital with guaranteed sterile equipment ready and available for immediate use in patient care – a step towards the prevention of hospital acquired

[2]infections(HAI) .

Ideally, CSSD is an independent department with facilities to receive, clean, pack, disinfect, sterilizes, store and distribute instruments as per well-delineated protocols. The essentials of this department are correct design, appropriate equipments, skilful operators and

[2]proper work flow The history of CSSD starts in 1928 when American College Of Surgeons introduced the word CSSD.In1955 the Cambridge Military Hospital established Regular CSSD in United Kingdom. In India, Safdarjang Hospital New Delhi, established the first CSSD in 1965..

The planning of a CSSD has to be steered by committee including representatives of departments of administration, infection control, anaesthesia, microbiology, nursing and housekeeping drawing upon their knowledge and experience. The committee is required to meet monthly even during the running of a fully functional CSSD in order to discuss new procedures or alternations to existing procedures in the light of new knowledge and breakthroughs.

J Pub Health Med ResREVIEW ARTICLE

The objectives of the department are:

§ To provide sterilized material from a central department where sterilizing practice is conducted under conditions, which are controlled, thereby contributing to a reduction in the incidence of hospital infection.

§ To take some of the work of the Nursing staff so that they can devote more time to their patients.

§ To avoid duplication of costly equipment's, which may be infrequently used.

§ To maintain record of effectiveness of cleaning, disinfection and sterilization process.

§ To monitor and enforce controls necessary to prevent cross infection according to infection control policy.

§ To maintain an inventory of supplies and equipment.

§ To stay updated regarding developments in the field in the interest of efficiency, economy, accuracy and provision of better patient care.

§ To provide a safe environment for the patients and staff.

Designing of A CSSD:

The workload in a CSSD varies from hospital to hospital. The size and location usually depends on the number of the hospitals the CSSD will serve as well as the number of beds and the future expansion of the hospital. However 6 to 10 square feet per bed is recommended as an area of requirement for the CSSD. It should be located as close as possible to the major user areas such as Operation theatres, Accidents and Emergency department and wards.

The CSSD layout should be designed for a unidirectional flow. The CSSD should have four zones

2013;1(2):25-30

for a smooth work flow.

1. The unclean and washing area

2. The assembly and packing area

3. The sterilization area

4. The sterile area

The Layout

1. Entrance lobby

2. Reception and Cleaning room

3. Glove room

4. Work room (Preparation and assembling of packs)

5. Sterilisation room

6. Sterile store room

7. Nurses/Managers room

8. Staff changing room

Workflow in the CSSD

Receipt: The material that is to be sterilized coming from various departments arrives in the reception area using stainless steel trolleys via a dedicated elevator.

Cleaning: This function means cleaning of the used equipments/materials, rubber and plastic goods either manually or by machines eg., washer-disinfector, ultrasonic cleaner, jet glove washing machines and dryers.(FIG-1) This function may also include cleaning of the delivery trolleys..The common items handled by the CSSD stores are syringes and needles, Procedure sets which includes Lumbar puncture , sternal puncture , venesection , paracentesis .aspiration, catheterization ,tracheotomy ,suturing ,dressing , biopsy , incision & drainage ,aortography cardiac resuscitation , gloves, I.V.Fluids, treatment Trays, O.T Instruments, O.T. Linen, infusion Fluids for Renal Dialysis and at times linen from wards etc.

Assembly and Packing: It includes checking of glass items for breakages, needles and instruments for sharpness and breakages, assembling of the equipment after washing and drying, making appropriate sets for use by various departments and packaging along with sealing either manually or using a machine before sterilization. Adequate documentation and labeling of each pack should be done and records should be maintained.(FIG 2 & 3)

Sterilisation: It renders materials sterile for quality patient care. It is achieved by steam sterilizers working at specified cycles of temperature and duration to attain adequate sterility assurance level (SAL). .Advantage of steam sterilizers are rapid heating & penetration of loads,destruction of all forms of microbial life and no

residual toxicity.Different types of Autolaving machines that can be used are

1. Downward Displacement

2. Vacuum Assisted.

3. Pulsed Steam Dilution .

The capacity of the sterilizer is based on the load and the number of cycles per day. The load is calculated by estimating litres to each procedure and converting it into a standard unit i.e st.u(1 st.u = 54L). This value is then divided by the number of cycles that will be run per day to obtain a value of st.u/cycle. The capacity of the sterilizer is then selected based on the value obtained. It is better to have 2 sterilizers in case of breakdowns.(FIG-4)

Additionally an ethylene oxide sterilizer can be included in a separate compartment of this area in order to sterilize heat sensitive instruments.(FIG-5)

Storage: The function includes storage of sterilized materials where space is also provided for storing distribution trolleys. Sterile store maintains inventory of all types of sterile packs. At the end of the path of the treated material a computer terminal should be provided in order to manage delivery of materials and transport documentation.(FIG-6)

Issue and Distribution: The function entails issue of the sterilized packages, dressings, linen, instruments and disposables to various departments of the hospitals[3,4]

Process of sterilization:

The items to be sterilized at the Central Sterile Supply Department are washed (with detergent or chemical as applicable), sorted in the washing area. linen from wards and OT are to be sent directly to the laundry for cleaning. The laundry washed linen are to be received , packed and forwarded to the CSSD for sterilization.

The CSSD technicians or trained nurses shall receive the unsterile packs, inspect them to check the status of the item (torn, punctured, cracked etc) and place them at the unsterile packs storing platform. Entry must be made in CSSD receipts register including date, time, type of instruments in the pack, ward, its source, procedure used for, and case infected or not, name and signature of person handing over, and name and signature of person receiving it.

The autoclave indicator is pasted in the packs by the CSSD technician and the packs are taken to the main sterilizing area where the sterilizing units are placed .The CSSD technician places the unsterile packs under appropriate temperature and pressure specifications in the sterilizing units. The temperature, pressure

Asima Banu, et al, Central Sterile supply Department – Need of the hour. 2013;1(2):31-35

J Pub Health Med Res 2013;1(2):1-5

FLOW PROCESS IN CSSD

specifications and accordingly the temperature period are for Normal Sterilization, temperature of 121*C at 15 lb for 20 minutes, and for Rapid Sterilization , 140*C at 20 lb for 15 minutes. At the end of the sterilization the packs are removed from the sterilizing units, the autoclave indicators are checked to confirm adequate sterilization of the packs, and incase the sterilization is not adequate the process is to be repeated. A material is pronounced sterile if it achieves 99.99% kill of bacterial spores. Packs which are adequately sterilized are stored in the sterile storage area. If the sterile packs are torn, if it has been opened, they are wet, etc, and then the whole process is to be repeated again.

In case the packs which are sterilized in the CSSD and issued to the departments remains un utilized in the respective user departments for a period of 72 hours , the same are returned to the CSSD department for re-sterilization. Registers to be maintained in the CSSD are CSSD receipt register, CSSD issue Register, Equipment Maintenance Record register and Equipment Calibration Register.

Maintenance of the equipments are to be done as per the annual maintenance contract (AMC) entered into with the vendor of the respective CSSD equipments. All details in these regard are maintained by the Maintenance Department of the hospital.

All equipments used in the department are to be appropriately calibrated at periodic intervals to ascertain

whether they are performing at the expected level and a record of the same is documented in the department as well as with the concerned case workers working in the administration.

Indent For Setting Up An Ideal Cssd:

1. Washer disinfector with accessories - The washer should perform pre-rinsing, cleaning, post-rinsing, thermal disinfection, final rinsing and drying phases. Validated programs are secured by access code. Detergents and rinse agents should be automatically dispensed during the cycle.

2. Steam Sterilizers - The sterilizer should meet the relevant standards. The chamber and doors should be made of solid, high quality 316L Stainless steel. The chamber should be jacketed to ensure the temperature uniformity in chamber. The chamber floor is slightly sloped towards an internal drain to facilitate drainage. A stainless steel mesh strainer should be provided to protect the drain port from blockage by debris. The chamber is mounted on a stainless steel framework with height adjustable feet.

The internal surface should be electro-chemically treated for high quality smooth finish to facilitate cleaning. The resultant surface should be polished to less than 0.8 ìm fineness to protect against corrosion. The internal corners should be rounded off to facilitate efficient cleaning. The sterilizer jacket and door should be completely insulated with mineral rock wool to keep the autoclave



cool on the outside. The insulation should be completely encased in a rigid removable sheet housing. The jacket should be made of 316L quality stainless steel. The chamber should have a warranty for 10 years. The sterilizer should have inbuilt steam generator of adequate capacity. It should be mounted under the sterilizer chamber & should be made of 316 quality stainless steel. The steam generator should have insulation of thick chloride free mineral rock wool with rigid aluminum sheet housing. It should have a built in thermostat, pressure safety valve & water level glass gauge inspection device visible from service area. The heating element, not less than 36KW should also be made of stainless steel. It should also have the automatic blow down valve & degassing system for feed water to steam generator. To make the sterilization process faster the capacity of the heating element should not be less than 36 KW.

3. Ultrasonic cleaner (optional) - The units should be a compact free-standing bench model, with a built-in tank manufactured from high-quality (316) stainless steel and a solid-state generator that sends ultrasonic (approx 42,000 cycles per second) impulses through wash water containing detergent and electrical heating; microprocessor controlled display with memory time and temperature functions. The electrical energy should be transformed into sound waves by transducers, fixed to the bottom of the tank. The tank should be made of solid stainless steel (316).

The ultrasonic cleaner should have a display and control which could be easily seen and placed above any liquid for safety and reliability. It should have digital read out timer and temperature setting (up to +69° C (temperature adjustable from 20 to 69 °C) monitoring.-

4. Heat Sealing Machine - Rotary heat sealers should provide validated sealing of sterilization bags and clear-view pouches (paper/plastic laminate). These through feed-type sealers should be microprocessor-controlled for highest capacity and ease of operation. The rotary heat sealer should give documentation of process parameters via an integrated printer and could be integrated with documentation system. The ergonomically design should be tilted forward for increased user convenience and space saving installation.

5. Inspection tables, lamps, cleaning equipment, interior water treatment facilities

6. Table top sterilizer with accessories - Table Top Sterilizers should be equipped with B-process as per latest international standards

7. Ethylene Oxide Sterilizer (optional)- Ethylene oxide sterilizer is defined as equipment which uses ethylene oxide as a biocide to destroy bacteria, viruses, fungi and other unwanted organisms. Ethylene oxide is used in sterilization of items that are heat and moisture sensitive. The ETO gas sterilizer should be fully automatic type for sterilization of heat sensitive goods such as anesthetic tubing and endoscopes.

8. Documentation labeller

9. Process challenge devices

10. Water treatment plant

11. All necessary furniture required for the facility

An alarming rate of hospital acquired infections (HAI) in Indian hospitals has highlighted the importance of CSSD. Despite all measures and advancements in technology, hospital acquired infections remain a challenge in healthcare scenario today. The hospitals are required to establish an adequate CSSD set-up and adopt strict quality control processes with the latest technology to mitigate hospital acquired infections. Hence the concept of infection control by FLORENCE NIGHTINGALE who said"No Stronger Condemnation of any hospital or ward could be pronounced than the simple fact that zymotic disease has originated in it or that such disease attack other patients than those brought-in with ''. stands true for generations of healthcare to come.

Acknowledgement :

We are thankful to Medovation Products, Bangalore for their valuable technical inputs.

References :1. Welch JD. The Organization of Central Supply Departments. J Clin Path.

1961; 14: 69-75

2. Allison VD. Hospital Central Sterile Supply Depts.. BMJ. 1960: 772-778

3. Gardner JF and Peel MM. Introduction to Sterilization, Disinfection and Infection control, Second Edition. Melbourne, Churchill Livingstone. 1991

4. Ayeliffe GAJ et al Control of Hospital Infection: A Practical Handbook. Third Edition. London, Chapman Hall. 1992.



FIG 6- Sterile area with storage racks.FIG 5- ETO Steriliser and Flash sterilisers.

Funding: Declared noneConflict of intereset: Declared none

How to Cite this article :Asima Banu, Subhas G.T. Central Sterile supply Department – Need of the hour.J Pub Health Med Res, 2013;1(2):31-35

FIG 2-Packing and assembly area- Clean Area FIG 4- Steriisation Area having two fully automatic steam sterilisers

FIG 1- The washing and disinfection area with fully automatic washer disinfector.

FIG 3-Linen inspection and storage room.

Asima Banu, et al, Central Sterile supply Department – Need of the hour.


Abstract :

The mucocele of the Appendix is an uncommon cystic lesion characterised by distension of the appendiceal lumen with mucus. The incidence ranges from 0.3% to 0.7% of all appendectomied specimens.

Objective: We report here the demographic, clinical, radiologic, histopathologic, preoperative and postoperative findings and outcome of patients of mucocele of the appendix diagnosed on histopathologic examination.

Methods:

We retrospectively analysed the hospital records of all the patients whose appendectomy was done and had a histopathological diagnosis of mucocele of the appendix. Cases were collected from Bider institute of medical sciences medical college and private nursing homes,hospitals and private pathology labarotories in Bider.

Results:

A total of 885 patients with the preoperative diagnosis of appendicitis were admitted and surgically treated in our centre from September 2007 to September 2012. 13 (1.47%) patients were diagnosed to have mucocele of the appendix on histopathologic examination. Average age of presentation was 53yrs (range 17yrs - 85yrs). 6(46.15%) patients were male and 7 (53.85%) were female with M: F ratio 0.86:1. The most common presentation was right lower quadrant pain in 7 (53.85%) patients. 2(15.38) patients presented with generalised abdominal pain, distension of abdomen and loss of appetite while 4(30.77%) patients were asymptomatic. In preoperative ultrasonographic examination, appendiceal cystic masses were diagnosed in 7 (53.85%) patients. Histopathologic examination revealed simple mucocele in 7 (53.85%) patients, mucinous cystadenoma in 5 (38.46%) and mucinous cystadenocarcinoma in 1(7.69%) patient. Two patients of mucinous cystadenoma were diagnosed with complication of pseudomyxoma peritonei. No mortality was noted in any of the patient postoperatively and on follow up.

Conclusion :

Mucocele of the appendix is a rare disease and is usually diagnosed on histopathologic examination of Appendectomied specimens. As there is potential for malignant transformation and pseudomyxoma peritonei due to rupture of the mucocele, extensive preoperative evaluation and thorough intraoperative gastrointestinal, ovarian & peritoneal examination is required.

Key Words: Appendix, mucocele, mucinous cystadenoma.

Mucocele of the Appendix : A 5 YearsRetrospective Study

1 2 3 4Rajesh Patil , Narain V.N. , Veerendra Patil , Soumya Patil1 Associate Prof, Dept of Pathology,MRMC,Gulbarga,

2 Asst. Prof., Dept of Pathology, Bidar Institute of Medical Science3 Associate Prof, Dept of medicine, Belgaum Institute of Medical Science, Belgaum

4 PG Student, Dept of OBG,MRMC,Gulbarga

Introduction:1Appendiceal mucocele, first described by Rokitansky ;

refers to localised or diffuse dilatation of appendiceal lumen by an abnormal accumulation of mucus. It represents 0.3%-0.7% of appendiceal pathology and 8%

2of appendiceal tumors . Its frequency is higher in females 3(M: F = 1: 4) and in people older than 50 yrs of age .

Mucocele of appendix are difficult to diagnose despite

extensive preoperative evaluation. Patients are often asymptomatic and lesions are usually discovered incidentally intraoperatively or postoperatively during

3histopathological examination .

Others may present as acute appendicitis or as acute or chronic non specific abdominal pain with or without vomiting. Mucoceles of appendix can be divided into

4three categories :

1. Simple or Retention mucocele resulting from obstruction of appendiceal outflow and characterised by normal or hyperplastic epithelium with mild luminal dilatation upto 1.0 cm. These constitute 5 – 25% of mucoceles.

J Pub Health Med Res 2013;1(2):1-5ORIGINAL ARTICLE

Address for Correspondance :

Dr. Rajesh Patil, MD,

Associate Prof, Dept of Pathology,MRMC, GULBARGA. email : [email protected]

2. Mucinous cystadenoma – Most common form accounting for 63- 84% cases of mucoceles. These exhibit epithelial villous adenomatous changes with some degree of epithelial atypia and characterized by marked distension of lumen (upto 6.0 cm.). The neoplastic epithelium is similar to that seen in villous adenomas and adenomatous polyps.

3. Mucinous cystadenocarcinoma – representing 11-20% of cases. These show glandular stromal invasion and / or presence of epithelial cells in peritoneal implants. The neoplastic epithelium is similar to that seen in adenocarcinoma of colon. Mucinous cystadenoma and mucinous cystadenocarcinoma may rupture producing fatal entity pseudomyxoma peritonei.

Method :

This was a unicentric retrospective study; patients with the diagnosis of Appendiceal mucocele were searched from the hospital and private pathology laborotory records. These patients were evaluated for age, sex, symptom duration, major complaint, ultrasonographic and computed tomographic findings, surgical procedures performed, histopathologic diagnosis, complications if any and their follow up outcomes.

Inclusion Criteria: All cases diagnosed as Appendiceal mucocele on Histological examination were included.

Exclusion Critera: Cases suspected as Appendiceal mucocele on ultrasonography or/ and computed tomography but not proved on histological examination were excluded.

Results: A total of 885 patients with the preoperative diagnosis of appendicitis were admitted and surgically treated in Bider area from September 2007 to September 2012. Out of them 13 (1.47%) patients were diagnosed to have mucocele of the appendix on histopathologic examination.

Clinical features: Average age of the patients in years was 53 yrs (range 17yrs – 85yrs). 6 (46.15%) patients were male and 7 (53.85%) were female with M:F ratio 0.86:1. The duration of the symptoms was varied from 1 day to 2 months, with a median of 6 days. Right lower quadrant abdominal pain was the most common complaint in 7 (53.85%) patients while 2 (15.38%) patients were admitted with complaints of generalised abdominal pain and loss of appetite. These 2 patients were females and had distension of abdomen with mild to moderate ascites.

Investigations: Appendiceal mucocele was detected incidentally in 4 (30.77%) patients. Laboratory investigations showed leucocytosis in 8 (61.54%)

patients with increased absolute neutrophils count. All other routine biochemical and haematological parameters were within normal limits.

Preoperative ultrasonographic examination of the patients revealed appendiceal cystic mass (mucocele) with variable internal echogenicity in 7 (53.85%) patients, while free fluid was found in abdomen in 2 of these 7 patients. Abdominal CT examination was done in 4 (30.77%) patients; 2 patients were reported as having appendiceal cystic tumoral mass containing mural calcification. Peritoneal fluid was tapped from 2 patients who had ascitis, and was reported as pseudomyxoma peritonei / mucinous tumor in view of presence of clusters of epithelial cells and stromal fragments in mucinous background.

Appendiceal cystic mass was appreciated by the surgeons in 10 (76.92%) patients during intraoperative exploration, out of which 2 patients who had ascitis were found to have dense mucinous deposits on appendix, omentum, uterine, ovarian and peritoneal surfaces.

Histopathological examination: Appendix was ruptured in both of these cases. 11 (84.62%) patients were treated by appendectomy. In 2 patients who had ruptured mucocele with diffuse pseudomyxoma peritonei, caecectomy with omenectomy was performed. As both these patients were postmenopausal females and dense mucinous deposits were present on uterine and ovarian surface, total abdominal hysterectomy with bilateral salpingo-oophorectomy was also done. Both these patients were given early postoperative chemotherapy.

Histopathologic examination revealed simple mucocele in 7 (53.85%) patients, mucinous cystadenoma in 5 (38.46 %) patients, and mucinous cystadenocarcinoma in 1 (7.69%) patient. In the 7 patients with preoperative ultrasonographic diagnosis of appendiceal cystic masses (mucocele), histopathologic examination showed simple mucocele in 3 patients and mucinous cystadenoma in 4 patients. In 1 patient diagnosed as mucinous cystadenocarcinoma, right colectomy was done subsequently. No peritoneal or adjacent organ involvement was seen in this patient and no lymph node metastasis was seen.

In both the patients with pseudomyxoma peritonei, ruptured primary mucinous cystadenoma of appendix was diagnosed on histopathology examination. Pools of mucin were also seen on the surface of ovaries, uterus, peritoneum and omentum with very few benign looking epithelial cells. Ovarian tumor was ruled out in both these patients.

Rajesh Patil et al, Mucocele of the Appendix : A 5 Years Retrospective Study


No postoperative morbidity or mortality occurred. Average postoperative length of hospital stay was 4.6 (2–10) days. At postoperative follow up of two patients of pseudomyxoma peritonei and one patient of mucinous cystadenocarcinoma ; physical examination, abdominal sonography, carcino-embryonic antigen (CEA) and other laboratory investigations were done twice a year. No tumor was detected in any of the cases on follow up for two years. Long term follow up is required to access the final outcome.

Discussion:

Present study showed much higher incidence of appendiceal mucocele (1.47%) in appendectomied specimens as compared to 0.3 – 0.6% reported in

2,5previous studies . However increased incidence (2.01%) of appendiceal mucocele from some tertiary health care

6centres has also been reported . Female preponderance was seen in our study with M:F ratio 0.86 : 1, which is much lower as compared to reported in some previous

3,5studies . However some recent reports show a male predominance (2:1), suggesting that the gender

7distribution of appendiceal mucoceles is changing . Average age of presentation was 53 years which was in

3,5concordance to that reported previously that is more than 50yrs of age. In our study 7 (53.85%) patients presented with right lower quadrant abdominal pain while 2 (15.38%) with generalised abdominal pain, abdominal distension & loss of appetite. In remaining 4 (30.77%) patients, Appendiceal mucocele was an incidental finding. In a study done by Muthukumaran

7Rangarajan et al , out of 9 patients, 6 (66.67 %) presented with pain localised to right lower quadrant of abdomen

5while 2 (22.22 %) with palpable mass. S. Yakan et al reported right lower quadrant abdominal pain in 8 (89%) and generalised abdominal pain in 1(11%) out of 9 patients.

Our study revealed leucocytosis in 8 (61.54%) out of 13 5patients. In a similar study by S. Yakan et al , leucocytosis

was seen in 5 (55.56%) out of 9 patients. In our study preoperative ultrasonographic examination showed appendiceal cystic mass (mucocele) in 7 (53.85%) patients, while free fluid was found in abdomen in 2(15.38%) patients.

Abdominal CT examination was done in 4 (30.77%) patients; 2 (15.38%) patients were reported as having appendiceal cystic tumoral mass containing mural

8calcification. Kemal Karakaya et al reported in their study that USG and CT examination showed appendiceal cystic mass with peripheral enhancement in 3 (60% ) out

of 5 patients, free fluid in 1(20%) patient and in one patient CT / USG was not done.

7In the study of Muthukumaran Rangarajan et al , USG was able to diagnose cystic appendiceal mass in 6 (66.67 %) patients and CT revealed mucocele in 2(22.22%) out

5of 9 cases. While in the study of S. Yakan et al , appendiceal cystic mass was diagnosed in 4 (44.5%) patients on USG and in 1 (11%) patient on CT examination.

Simple appendectomy was done in 10(76.92%) patients in present study, in 2(15.38 %) patients caecectomy and in 1 (7.69%) patient hemicolectomy was done. In the

5study of S.Yakan et al , appendectomy was done in 6 (67%) and right hemicolectomy in 2(22%) patients.

8Kemal Karakaya et al have reported simple appendectomy in 3(60 %) and caecectomy in 2 (40% ) patients. Present study revealed higher incidence of simple retention mucocele as compared with previous studies. Histopathologic examination showed simple mucocele in 7(53.85%), mucinous cystadenoma in 5 (38.46 %) patients and mucinous cystadenocarcinoma in

51 (7.69%) patient. S Yakan et al have reported simple mucocele in 2(22%), mucinous cystadenoma in 4(45%) and mucinous cystadenocarcinoma in 3(33%) cases.

8Kemal karakaya et al have reported four cases of mucinous cystadenoma and one case of simple mucocele.

Different theories had been postulated in literature about 9mucocele origin. The first, postulated by Neeslund , is

mechanical and starts from an obstacle (diverticulitis, inflammation, polyps) at the base of appendix, which gives an accumulation of mucus inside the appendix, increasing volume and consequently causing rupture.

Another theory is nervous; hyperincretion of mucus and muscular paralysis could cause the changement of

9appendix in a cyst . According to Higa classification we know retention cysts, caused by mucin accumulation and dilations due to hyperproduction of mucus by an

10appendicular benign or malignant neoplasia . In this last condition it is important to specify the nature of the malignancy because gelatinous mass cells have an autonomic growth maintaining function of mucus

11secretion .

USG, CT and colonoscopic examinations can facilitate 12-15preoperative diagnosis of appendiceal mucocele .

Ultrasound is the first line diagnostic modality for patients with acute abdominal pain or mass.

Different sonographic findings of appendiceal mucocele 16-18and acute appendicitis have been described . Outer

diameter of appendix 15mm or more in USG examination



has been described as the threshold for the diagnosis of appendiceal mucocele with a sensitivity of 83% and a

16specificity of 92% , while for acute appendicitis it has

19been established as 6mm .

USG examination revealed appendiceal cystic mass in 7 of our patients. CT is the modality of the choice in cases of appendiceal mucocele because of its ability to detect the anatomic location of mass and tissue characteristics. Mural curvilinear calcification aids considerably in the

20diagnosis but occurs in less than 50% cases . USG and CT findings are not specific and the differential diagnosis should be established with other pathologies such as carcinoid, lymphoma, mesenteric cysts and ovarian

2,21masses .

Fine needle aspiration of the appendiceal mucocele is generally avoided because of fear that puncture of a distended viscus will lead to localized or diffuse

17pseudomyxoma peritonei . Colonoscopy in patients with abdominal pain is a useful tool for determination of

22,23mucocele .

Generally an elevation of the orifice of the appendix is seen. A yellowish mucous discharge would be visible from appendiceal orifice during colonoscopy. 'Volcano sign' is appendiceal orifice in the centre of a firm mound covered by normal mucosa or lipoma like submucosal mass. Colonoscopy is also important for the diagnosis of synchronous and metachronous colon tumor.

Elevated CEA levels have been described in neoplastic 24mucoceles The spontaneous and surgery induced

complications of appendiceal mucocele include intestinal 21 13,25obstruction, intussusceptions , intestinal bleeding ,

15 26fistula formation and volvulus .

The worst complication is pseudomyxoma peritonei. The preoperative diagnosis that distinguishes appendiceal mucocele from acute appendicitis is essential for the best choice of surgical approach (open Vs laproscopic) to prevent peritoneal dissemination of mucin producing

16,27epithelial cells and perform the appropriate surgery . It was thought that only mucinous cystadenocarcinomas

3lead to pseudomyxoma peritonei . However other authors believe pseudomyxoma peritonei can complicate either ben ign o r mal ignan t mucoce les , a l though pseudomyxoma peritonei from the former would carry a

10,28,29better prognosis .

No reports of lymphatic or hematogenous spread of mucinous cystadenocarcinoma are found in the literature. Most acknowledge that pseudomyxoma peritonei predominantly originates in the appendix in men and increasingly evidence suggests a similar site of origin in

30,31females .

In women synchronous ovarian and appendiceal disease is common, and Pseudomyxoma peritonei appears more prevalent. However immunohistochemistry and molecular genetics techniques support the hypothesis that in the majority of women, the ovarian tumor is metastatic from a perforated appendiceal mucinous

32- 35tumor .

Concomitant cases of appendiceal mucocele and colon adenocarcinoma have been described with an incidence

10,28,36of 19.5% - 21.4% . In our study no such concomitance was noted. The progression of mucinous cystadenoma to mucinous cystadenocarcinoma has not been proved yet, but it is suggested.

37 Dhage– Ivatury and Sugarbaker have suggested simple appendectomy as the choice of treatment for patients with benign mucocele that has negative margins of resection and without perforation. No long term follow up is needed for these patients. In patients having perforated mucocele with positive margins of resection and negative appendiceal lymph nodes, caecectomy / cytoreductive surgery (CRS) / Heated intraperitoneal chemotherapy (HIIC) and early postoperative intraperitoneal chemotherapy (EPIC) should be performed.

Long term follow–up is also obligatory in these patients. The 5- year survival rate for simple or benign neoplastic mucocele after appendectomy ranges from 91% to 100% , but recurrences as pseudomyxoma peritonei and metachronic colonic neoplasms causing mortality can be

3,38,39seen .

Cystadenocarcinoma without peritoneal or adjacent organ involvement also show good outcome after surgical resection, but if it progresses to pseudomyxoma peritonei, 5 yr survival is 25%, with most deaths

40attributed to intestinal obstruction and renal failure .

Conclusion: Appendiceal mucocele is a relatively uncommon pathology seen in people older than 50 yrs of age with female preponderance. Surgical treatment of appendiceal mucocele is mandatory because of the potential for malignant transformation and pseudomyxoma peritonei due to rupture of the mucocele itself. Preoperative suspicion and diagnosis of appendiceal mucocele are important.

Appendiceal mucocele should be considered in patients presenting as right lower quadrant abdominal pain or diffuse abdominal pain. Ultrasonography and computed tomography are useful tools for the diagnosis of appendiceal mucocele. Accurate preoperative diagnosis is a major component for optimal management, to minimize intraoperative and post operative



complications. Extreme care must be taken while handling the tissue during operation. Intraoperative exploration of the entire gastrointestinal tract and ovaries in females should be done. All gross peritoneal implants should be removed and examined for presence of epithelial atypia for diagnostic and prognostic purposes.

References :1. Rokitansky CF. A manual of pathological anatomy. Philadelphia (PA) : Blanchard & Lea; 1855. P 89.2. Ruiz-Tovar J, Teruel DG, Castiñeiras VM, Dehesa AS, Quindós PL, Molina EM. Mucocele of the appendix. World J Surg. 2007; 31: 542-548.3. Aho AJ, Heinonen R, Lauren P. Benign and malignant mucocele of the appendix. Acta Chir Scand. 1973; 139 (4) : 392-400.4. Qizilbash AH. Mucoceles of the appendix. Their relationship to hyperplastic polyps, mucinous cystadenomas and cystadenocarcinomas. Arch Pathol Lab Med. 1975; 99: 548– 555.5. Yakan S, Caliskan C, Uguz A, Korkut MA, Coker A. A retrospective study on mucocele of the appendix presented with acute abdomen and acute appendicitis. Hong Kong J Emerg Med 2011; 18 : 144 - 149.6. Karakaya K, Barut F, Emre AU, Ulcan HB, Cakmak GK, Irkorucu O, Tascilar O, Ustundag Y, Comert M. Appendiceal Mucocele : Case reports and review of current literature. World J Gastroenterol 2008; 14 (14) : 2280 – 2283.7. Muthukumaran Rangarajan, Chinnusamy Palanivelu, Alfie Jose Kavalakat, Ramakrishnan Parthasarathi. Laparoscopic appendectomy for mucocele of the appendix : report of 8 cases. Indian J Gastenterol. 2006; 25 : 256 – 57.8. Kemal Karakaya, Figen Barut, Ali Ugur Emre, Hamdi Bulent Ucan, Guldeniz Karadeniz Cakmak, Oktay Irkorucu, Oge Tascilar, Yucel Ustundag, Mustufa comert. Appendiceal Mucocele : Case reports and review of current literature. World J Gastroenterol. 2008 April 14; 14 (14) : 2280 – 83.9. Alberti P, Bonera A, Antoci G e Bianchi P. II mucocele appendicolare. Min Chir. 1993; 48: 865-870.10. Higa E, Rosai J, Pizzim Bono CA, Wise L. Mucosal hyperplasia, mucinous cystadenoma and mucinous cystadenocarcinoma of appendix. A re-evaluation of appendiceal mucocele. Cancer. 1973; 32:1525-1541.11. Woodruff R, Mac Donald JR. Benign and malignant cystic tumors of the appendix. Surg Gynecol Obstet.1950; 71: 750-753.12. Pitiakoudis M, Tsaroucha AK, Mimidis K, Polychronidis A, Minipoulos G, Simipolous C. Mucocele of the appendix : a report of five cases. Tech Coloproctol. 2004 ; 8 : 109 – 112.13. Qualia CM, Drugas GT, Jones LT, Rossi TM. Colonoscopic diagnosis of an appendiceal mucocele. J Pediatr Gastroenterol Nutr. 2007; 45 : 145 – 146.14. Minagawa M, Ishikawa H, Date K, Kosugi S, Hatakeyama K, Endo K, Kimura K, Fukuda F. Mucus outflow from the appendiceal orifice due to an appendiceal mucocele. Gastrointest Endosc. 2001; 53: 493.15. Nakao A, Sato S, Nakashima A, Nabeyama A, Tanaka N. Appendiceal mucocele of mucinous cystadenocarcinoma with a cutaneous fistula. J Int Med Res. 2002; 30 : 452 - 456.16. Lein WC, Huang SP, Chi CL, Liu KL, Lin MT, Lai TI, Liu YP, Wang HP. Appendiceal outer diameter as an indicator for differentiating appendiceal mucocele from appendicitis. Am J Emerg Med. 2006; 24: 801 – 805.17. Pickhardt PJ, Levy AD, Rohrmann CA Jr, Kende AI. Primary neoplasms of the appendix : radiologic spectrum of disease with pathologic correlation. Radiographics. 2003; 23 : 645 – 662.18. Sasaki K, Ishida H, Komatsuda T, Suzuki T, Konno K, Ohtaka M, Sato M, Ishida J, Sakai T, Watanabe S. Appendiceal mucocele : sonographic findings. Abdom Imaging. 2003; 28: 15 – 18.

Funding: Declared noneConflict of interest: Declared none

19. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology. 2000; 215 : 337 – 348.20. Madved D, Mindelzum R, Jeffrey RB Jr. Mucocele of the appendix : Imaging finding. AJR Am J Roentgenol. 1992 ; 159 : 69 -72.21. Cois A, Pisanu A, Pilloni L, Uccheddu A. Intussusception of the appendix by mucinous cystadenoma. Report of a case with an unusual clinical presentation. Chir Ital. 2006; 58 : 909 – 910.22. Zanati SA, Martin JA, Baker JP, Streutker CJ, Marcon NE. Colonoscopic diagnosis of mucocele of the appendix. Gastrointest Endosc. 2005; 62 : 452 – 456.23. Watanabe T, Yoshikawa I, Kihara Y, Kume K, Otsuki M. Appendiceal mucocele. Gastrointest Endosc. 2003; 58 : 909 – 910.24. Soweid AM, Clarkston WK, Andrus CH, Janney CG. Diagnosis and management of appendiceal mucoceles. Dig Dis. 1998; 16(3) : 183 – 186.25. Lakatos PL, Gyori G, Halasz J, Fuszek P, Papp J, Jaray B, Lukovich P, Lakatos L. Mucocele of the appendix : an unusual cause of lower abdominal pain in a patient with ulcerative colitis. A case report and review of literature. World J Gastroenterol. 2005 ; 11 : 457 – 459.26. Rudloff U, Malhotra S. Volvulus of an appendiceal mucocele : report of a case. Surg Today. 2007; 37 : 514 – 517.27. Gonzalez Moreno S, Shmookler BM, Sugarbaker PH. Appendiceal mucocele. Contraindication to laproscopic appendectomy. Surg Endosc. 1998; 12: 1177 – 1179.28. Kim SH, Lim HK, Lee WJ, Lim JH, Byun JY. Mucocele of the appendix: ultrasonographic and CT findings. Abdominal imaging. 1998; 23: 292 - 296.29. Balthazar EJ, Megibow AJ, Gordon RB, Whelan CA, Hulnick D. Computed Tomography of the abnormal appendix. J Comput Assist Tomogr. 1988; 12: 595 – 601.30. Mukherjee A, Parvaiz A, Cecil TD, Moran BJ. Pseudomyxoma Peritonei usually originates from the appendix: a review of the evidence. Eur J Gynaecol Oncol. 2004; 25: 411-414.31. Sherer DM, Abulafia O, Eliakim R. Pseudomyxoma Peritonei: a review of current literature. Gynaecol Obstet Invest. 2001; 51: 73-80.32. Ronnett BM, Shmookler BM, Diener – West M, Sugarbaker PH, Kurman RJ. Immunohistochemical evidence supporting the appendiceal origin of pseudomyxoma peritonei in women. Int J Gynecol Pathol. 1997; 16: 1-9.33. Szych C, Staebier A, Connolly DC, Wu R, Cho KR, Ronnett BM. Molecular genetic evidence supporting the clonality and appendiceal origin of pseudomyxoma peritonei in women. Am J Pathol. 1999; 154: 1849-1855.34. Chuaqui RF, Zhuang Z, Emmert – Buck MR, Bryant BR, Nogales F, Tavassoli FA, Merino MJ. Genetic analysis of synchronous mucinous tumors of the ovary and appendix. Hum Pathol. 1996; 27: 165 -171.35. Guerrieri C, Franlund B, Fristedt S, Gillooley JF, Boeryd B. Mucinous tumors of the vermiform appendix and ovary, and pseudomyxoma peritonei; histogenetic implications of cytokeratin 7 expression. Hum Pathol. 1997; 28: 1039 – 1045.36. Fujiwara T, Hizuta A, Iwagaki H, et al. Appendiceal mucocele with concomitant colonic cancer. Report of two cases. Dis Colon Rectum. 1996; 39: 232 – 236.37. Dhage – Ivatury S, Sugarbaker PH. Update on the surgical approach to mucocele of the appendix. J Am Coll Surg. 2006; 202 : 680 -684.38. Carr NJ, McCarthy WF, Sobin LH. Epithelial non- carcinoid tumors and tumor like lesions of the appendix. A clinicopathological study of 184 patients with a multivariate analysis of prognostic factors. Cancer. 1995; 75: 757 – 768.39. Smith JW, Kemeny N, Caldwell C, Banner P, Sigurdson E, Huvos A. Pseudomyxoma peritonei of appendiceal origin. The Memorial – Sloan Kettering Cancer Center experience. Cancer. 1992; 70 (2) : 396 – 401.40. Isaac KL, Warshauer DM. Mucocele of the appendix : computed tomographic, endoscopic and pathologic correlation. Am J Gastroenterol. 1992; 87 (6) : 787 – 789.

How to Cite this article :Rajesh Patil, Narain V. Nimbal, Veerendra Patil, Soumya Patil. Mucocele of the Appendix - A 5 Years Retrospective Study. J Pub Health Med Res2013;1(2):1-5



Anaesthetic Management of a Patient with poor Cardiac Reserve, Posted for Intrascrotal Surgery using Spermatic Cord Block.

Abstract :

Neuraxial block though most rampently employed anaesthetic procedure has a number of physiological sequel. These physiological changes may be more significant in patients with poor cardiac reserve. We present the anaesthetic management of patient with poor cardiac reserve posted for intrascrotal surgery.

Keywords: Intrascrotal surgery, spermatic cord block, poor cardiac reserve.

1 2 3Dheeraj R. Patel , Arun kumar Ajjappa , Priyanka S .

1 2 3 Asst. prof., Professor & Head, Post graduate, Dept. of Anaesthesiology,

S. S. Institute of Medical Sciences & Research Centre, Davangere.


Introduction:

In 2000 Rodgers and colleagues published an extensive meta-analysis showing reduction in post operative mortality & morbidity with neuraxial anaesthesia1. Peripheral nerve blocks & local anaesthesia have very few cardiovascular / pulmonary side effects 1.Regional anaesthesia in the form of single shot major conduction block has been advocated as ideal anesthesia for ambulatory surgery2. Regional anaesthesia would provide excellent post-operative analgesia & thus reduce the need for opioids & risk of nausea2. We describe the anaesthetic management of a 65 year old male with post CABG status & hydrocele posted for sac excision.

Case Report:

Patient aged 65 year was posted for hydrocele sac excision. Known case of Ischemic heart disease(IHD) & hypertension. He gave history of CABG 4 years back.

Anaesthetic Management of Case: Started from preoperative evaluation. The patient was on following medication

T. ATROVASTATIN 10mg, T. CLOPIDOGREL 150mg,

T. ASPIRIN 75mg & T. METOPROLOL 25mg.

Patient was thoroughly evaluated with basic (CBC, RFT, LFT) and cardiac (ECG, ECHO) evaluation. Investigation revealed Hb 13.2g%,platelet of 1.63 lac , Differential WBC count was normal, RFT, LFT & Serum electrolytes were normal . Cardiologist opinion was sought. ECG showed T? avL, v5- v6.

ECHO: IHD, RWMA(regional wall motion abnormality)+, moderate LV dysfunction, LVEF(left ventricle ejection fraction) 35%, trivial MR(mitral regurgitation), no PAH(pulmonary artery hypertension).

Following advice were given:

To continue antihypertensive drugs & to withhold anticoagulation drugs for 7 days prior to surgery.

Patient preanaesthetic evaluation was done keeping in mind with above investigation and instructions. Patient and patient's attenders were counselled. On the night prior of surgery T. ALPRAZOLAM 0.25 mg & T. PANTOPRAZOLE 40 mg was adviced.

It was decided to proceed with regional anaesthesia in the form of spermatic cord block since both neuraxial and general anaesthesia(GA) were relatively contraindicated

On the day of surgery, patient was shifted to operation theatre, monitors were connected ( ECG , NIBP, Pulse oximetry ) base line readings were recorded. 18G cannula was inserted into vein on dorsum of left hand and was started on Ringers Lactate.

Patient was positioned for spermatic cord block( supine ), area was painted and draped.

Technique of spermatic cord block:

Spermatic cord was palpated 1cm below and medial to pubic tubercle ( felt as cord like structure between thumb & index finger) local anaesthetic (containing 1% lignocaine with 0.25% bupvacaine) was taken in 10 ml syringe with 26 G hypodermic needle.

The needle was advanced into the spermatic cord which was stabilized between thumb & index finger of non – dominant hand. Upon entry the syringe was aspirated to rule out any intravascular placement of needle.

On negative aspiration local anaesthetic was injected into the cord structure which was confirmed by sense of enlargement of spermatic cord structure between the thumb and index finger.

To ensure adequate block 2-3 passes were made in the cord at slightly different angles, injecting 3-4 ml each time.

CASE REPORT


Dheeraj R. Patel,Asst. Prof, Dept of Anaethsiology, SSIMS&RC, Davangere

After about 10-15 min adequate block was achieved.

Further the skin and subcutaneous tissue at the site of incision was infiltrated.

Discussion:

Intrascortal procedures under regional block (spermatic cord) can be used in patients where neuraxial block / GA are unsuitable as in our case : patient with low cardiac reserves, thus overcoming the complication that may occur during neuraxial block / GA)

The genital branch of genitofemoral nerve & terminal branch of ilioingunial nerve innervate together the sensory part of scrotal content. After emergence through external ring of inguinal canal both nerves are found inside spermatic cord either on top / under cremastric fascia3 . At their emergence they are readily available for spermatic cord block.

Dr. Dheeraj R. Patel ct al, Management of poor Cardiac Reserve, Posted for Intrascrotal Surgery using Spermatic Cord block.

The skin and subcutaneous tissue at site of incision are infiltrated. This is necessary because scrotal skin receives sensory fibres from pudendal nerve & perineal branch of posterior cutaneous nerve of thigh.

Conclusion:

Spermatic cord block is a simple, safe and effective technique which can be practiced for intrascrotal surgery particularly in patient considered unfit for neuraxial / G.A.

References:1. Kettner SC, Wilschke H and Marhofer P. Does regional anaesthesia really improve the outcome ? Br J Anaesth. 2011;107(s1):190-195.

2. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia. Anesth Analg 2005;101:1634-42.

3. Wipli M, Birkhauser F, Luyet C, Grief R, Thalmann G and Eichenberger U. Ultrasound- guided spermatic cord block for scrotal surgery. Br J Anaesth. 2011;106(2):255-9

How to Cite this article :

Dheeraj R. Patel, Arun kumar Ajjappa, Priyanka S. Anaesthetic Management of a patient with poor Cardiac Reserve, posted for Intrascrotal Surgery using Spermatic Cord Block. J Pub Health Med Res. 2013;1(2):6-7



Experimental Evaluation of antidiabetic activity ofSwertia Chirata – Aqueous Extract.

Abstract

Aims : The present study evaluates the antidiabetic activity of Swertia chirata (aqueous extract) on the blood glucose level of streptozotocin induced diabetic rat models.

Objectives : i) To study the antidiabetic activity of aqueous extract of Swertia chirata in streptozotocin induced diabetes in albino rats. ii) To compare the antidiabetic activity of Swertia chirata extracts with that of standard drug glibenclamide used in the treatment of type 2 diabetes mellitus.

Materials and Methods: In the present study 24 male albino wistar rats divided into 4 groups with 6 animals were taken. One group as control was given normal saline for 21 days daily. Other 3 groups were induced diabetes. Standard and test groups were fed with glibenclamide (0.5mg/kg) and aqueous extract (200mg/kg) daily for 21 days respectively.

Statistical Analysis: The results were analysed with ANOVA and comparison with standard, test and control groups done by post hoc tukeys test. p<0.001 was considered highly significant.

Key Words: antidiabetic activity, Swertia chirata, aqueous extract, Glibenclamide.

1 2Kavitha K.N , Dattatri A.N .

1 2 Tutor, Professor and Head, Department of Pharmacology, KIMS, Hubli

Introduction

Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of

1hyperglycemias Depending on the aetiology of the DM, factors contributing to hyperglycaemia include reduced insulin secretion, Decreased glucose utilisation,

1increased glucose production . DM is the leading cause of end- stage renal disease, non traumatic lower extremity amputations and adult blindness and predisposes to cardiovascular diseases. Currently the number of cases of diabetes worldwide is estimated to be around 150 million. This number is predicted to double by 2025, with the greatest number of cases being expected in China and India. India has now been declared by WHO as the

2,3,4'diabetes capital of the world' .

The currently used hypoglycaemic drugs in the treatment of diabetes are not completely effective and are associated with adverse effects both in the short and long

4run .The antihyperglycemic effects of the antidiabetic plants are attributed to their ability to increase insulin output from the pancreas or inhibit intestinal absorption of glucose or some other process. Several herbs have been tried in various studies to prevent or delay type2 diabetes. Aegle marmelose, Aloe vera, Artemisia pallens, Coccinia

indica, Swertia chirayita and many others have been 5,6,7

shown to have antidiabetic activity .

Among the different species of Swertia, Swertia chirata is considered for its medicinal properties as antihelminthic, antipyretic, hypoglycaemic and antifungal property. So this study is undertaken to evaluate the antidiabetic activity of aqueous extract Swertia chirata in streptozotocin induced diabetes in rats.

Aims : The present study evaluates the antidiabetic activity of Swertia chirata (aqueous extract) on the blood glucose level of streptozotocin induced diabetic rat models.

Objectives: i) To study the antidiabetic activity of aqueous extract of Swertia chirata in streptozotocin induced diabetes in albino rats. ii) To compare the antidiabetic activity of Swertia chirata extracts with that of standard drug glibenclamide used in the treatment of type 2 diabetes mellitus.

Epidemiology : Diabetes mellitus is pandemic in both developed and developing countries. Worldwide the prevalence of diabetes mellitus is estimated to be 2.8%

2and is set to rise to 4.4% by 2030 . In India alone the prevalence of diabetes is expected to increase from 42

4million to 69.9 million by 2025 .In developed countries as U.S.A , about 5-10 % of all diabetics have type 1 DM. Geographic variations also alter the incidence of Type 1 DM and Type 2 DM.

I. Type 1 diabetes due to â-cell destruction, usually leads to absolute insulin deficiency. Type 2 diabetes may


Kavita K.N, MD,

Tutor, Dept of Pharmacology,KIMS, Hubli.


range from predominantly insulin resistance with relative insulin deficiency to a predominantly insulin secretory defect with insulin resistance.

Swertia Chirata

This plant belongs to Gentianaceae family. It is a medicinal plant indigenous to temperate Himalaya. This plant is known by an array of names, for example chiravata (Urdu), Nelabevu (Kannada), Shirattakuchi (Tamil), Nelavembu (Telugu).The trade name is

8Chiretta .The plant is a native of temperate Himalayas, found at an altitude of 1200-1300 m from Kashmir to Bhutan and in the Khasi hills at 1200-1500 m. It can be grown in sub temperate regions, at altitudes 1500-2100 m. The genus Swertia consists of annual and perennial

19herbs. Its medicinal properties, antihelminthic ,

21,24 18hypoglycaemic and antipyretic , are attributed to its active principles amarogentin ,swerchirin and swertiamarin. Its secondary metabolites xanthones, seco-iridoid glycoside, triterpenoid alkaloid & hexane fraction

16also contribute to its medicinal properties . It is also used

18in the dyspepsia and diarrhoea . Three main phytochemicals mangiferin, amarogentin, and swertiamarin were identified in aqueous and 12% ethanolic extracts of all plant parts. Mangiferin is reported to possess considerable hypoglycaemic property and also shows suppressive effects on blood lipid profiles

25in diabetes .

MATERIALS AND METHODS

This Study was conducted at the Department of Pharmacology, Karnataka Institute of Medical Sciences, Hubli, after approval from Institutional Animal Ethics Committee.

Materials:

Animals: The animals used in the present experimental work were healthy albino rats of Wistar strain of male sex weighing between 150-250 g .The animals were maintained under standard laboratory conditions with free access to food and water . Each group consisted of randomly selected six animals.

2) Drugs :

2.1) Streptozotocin(STZ): After weighing the required quantity of STZ powder fresh STZ solution was prepared in 0.1M sodium citrate buffer of pH 4.5. STZ was administered at a dose of 50-60 mg/kg by intraperitoneal

12route . STZ was purchased from Sisco Research Lab, Ahmedabad.

2.2) Sodium citrate buffer: Composition of 100 ml of 0.1M citrate buffer of pH 4.5.

2.3) Glibenclamide: In this study glibenclamide was taken as the standard drug at a dose of 0.5 mg/kg b.w. by oral route and results were compared with test drug. Glibenclamide powder dosage form was purchased from Bangalore (Aventis Pharma).

2.4) Test drug (Swertia Chirata): Swertia chirata extracts-aqueous extract at a dose of 200 mg/kg b.w. by oral administration was used. Swertia chirata extract was procured from Department of Rasayanashastra, Ayurveda Mahavidyalaya; Bengeri, Hubli.

2.5) Glucometer: The Glucometer used was Accu-Chek- TM

Active, Roche Group, Germany for measuring blood glucose.

Methods:

Inclusion Criteria: Animals weighing 150-250 g and healthy male rats with normal behaviour & activity. Exclusion Criteria: Animals weighing <150 g and >250 g and female rats.

In the present study, diabetes was chemically induced by streptozotocin (STZ) which produced permanent hyperglycaemia in rats. Blood glucose levels were measured by glucometer. A total of 24 animals were used for the study .They were divided into 4 groups of 6 animals each. Out of 24 rats, only 18 rats were induced diabetes.

Induction of Diabetes:54After an 18hrs fasting, diabetes was induced in 18 rats

by intra-peritoneal (i.p.) injection of streptozotocin (STZ) dissolved in 0.1 M sodium citrate buffer (pH 4.5) at

12a dose of 50-60 mg/kg b.w . Animals were observed for first 24 hrs following the injection of STZ for any evidence of allergic reactions, behavioural changes and convulsions. Animals were fed with 5% glucose solution

14to overcome the STZ induced hypoglycaemia . No untoward reaction was observed in any animal.

After 72 hrs of STZ induction, blood glucose levels were recorded. Only those animals whose blood glucose levels were between 200-300 mg/dl with glycosuria were selected for the study and were divided into 6 groups as

33follows . Animals not given STZ were considered as non-diabetic or normal control group.

SWERTIA CHIRATA AQUEOUS EXTRACT:

Normal control group (A-1)

This group of animals received 0.5 ml of normal saline daily for 21 days by oral route. Blood glucose levels were recorded before the administration of normal saline on

rd th th stday 0 at 9 am, then on 3 , 7 , 14 & 21 day at 9 a.m.


Kavitha K.N. et al, Experimental Evaluation of Antidiabetic activity of Swertia Chirata – Aqueous Extract.

Diabetic control group (A-2) - The blood glucose levels of this group were recorded at 9 am on day 0 before administering normal saline. Later the animals were fed with 0.5 ml of normal saline daily orally for 21 days. The animals were observed for evidence of any behavioural changes, hyperglycaemia and convulsions. Aqueous extract test group (A-3) - The blood glucose levels of this group were recorded at 9 am on day 0 before the administration of the test drug. Then the aqueous extract at a dose of 200 mg/kg b.w. were fed to all animals orally for 21 days daily. The blood glucose levels were recorded on

rd th th st3 , 7 , 14 and 21 day. The animals were observed for any evidence of hypoglycaemia and convulsions. Glibenclamide standard group (A-4) - The blood glucose levels of this group were recorded at 9 am on day 0

before the administration of glibenclamide. Later the animals were fed with glibenclamide at a dose of 0.5 mg/kg b.w. daily orally in the morning for 21 days. Their

rd th th stblood glucose levels were recorded on 3 , 7 , 14 and 21 day. They were observed carefully for evidence of hypoglycaemia and convulsions.

Statistical Analysis: The results have been statistically analyzed for significance by using one way analysis of variance (ANOVA) for multiple group comparisons followed by Post Hoc Tukey's Test. p<0.001 was considered highly significant.

Table-1, Mean ± SD values of blood glucose levels in different groups of rats treated with Aqueous Extract of Swertia chirata 0n Days 0, 3, 7, 14, 21.

GROUPS day0 day3 day7 day14 day21

A1 66.33 72.33 67.50 69.00 60.00±7.50 ±4.13 ±5.36 ±8.833 ±5.18

A2 285.17 285.83 294.50 296.17 296.17±12.75 ±7.17 ±14.61 ±10.80 ±12.11

A3 264.67 163.70 105.67 78.20 85.80±24.43 ±31.80 ±8.57 ±25.50 ±31.70

A4 246.50 142.00 109.83 89.33 73.17±20.83 ±14.21 ±12.91 ±11.86 ±8.01

A1vsA2,A1vsA3,A1vsA4 p< 0.001 p< 0.001 p< 0.001 p> 0.05 p> 0.05

ANOVA-Analysis of Variance

p< 0.0001 Highly Significant, p> 0.05 Not Significant

Bar Diagram-2: Mean Blood Glucose Levels in Different Groups Of rats treated with

Aqueous Extract of Swertia chirata On Days 0, 3, 7, 14, 21. B

L

O

O

D

G

L

U

C

O

S

E

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2

B

L

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Line diagram-2: Mean Blood Glucose Levels in Different Groups of rats treated with Aqueous

Extract of Swertia chirata on Days 0, 3, 7, 14,

Line diagram-2: Shows comparison of mean blood glucose levels between normal control, diabetic control, standard and test groups in aqueous extract treated rats which are recorded in the fixed intervals as detailed in Table 2. It indicates that the test drug (A3) has antidiabetic activity but less when compared to the standard group (A4). Thus an analysis of results shows that aqueous extract group (A3) of Swertia chirata have significant antidiabetic activity in comparison to respective control groups (A1,A2),but less marked antidiabetic activity when compared to the respective standard glibenclamide groups (A4).

Discussion

In this study, the hypoglycaemic (antidiabetic) activity of aqueous extract of Swertia chirata has been evaluated & its efficacy had been compared with that of standard oral hypoglycaemic drug glibenclamide. Study done by

16Susanna Phoboo et al had shown that aqueous extract of Swertia chirata has antidiabetic activity and is probably due to the active principle mangiferin, present in the stem of the plant.

Mangiferin has several modes of action viz

i) Direct stimulation of â cells to release insulin

ii) May be due to reduced intestinal absorption of 32

glucose .

iii) Enhances glycolytic enzymes which stimulates glycogenesis in the liver and thereby contributes to

33reduction of blood glucose .

iv) Inhibiting á-glucosidase & other enzymes as 30maltase, sucrase, isomaltase & aldose reductase .

29v) Enhances peripheral utilization of glucose .

29vi) Increases hepatic and muscle glycogen content , 30promotes â cell repair and regeneration .

vii) Exerts insulin like action by reducing the glycated 30

haemoglobin levels .

viii) Also inhibits dipeptidyl peptidase IV mediated degradation of glucagon like peptide-1(GLP-1) &

33increases GLP-1 .

Swertiamarin found in roots, inflorescence & leaf mixture accounts for antidiabetic activity of aqueous extract of Swertia chirata. Amarogentin present in all

28plant parts also contributes to the antidiabetic activity .

Study done by Joshi and Dhawan had also showed the 8

antidiabetic activity of Swertia chirata . Studies done by Singh AP had shown that swerchirin, xanthone of Swertia

9chirata had antidiabetic activity .

. Saxena et al had demonstrated the blood sugar lowering effect of swerchirin found in aqueous extract of Swertia chirata extract in streptozotocin treated rats. Swerchirin acts by stimulating insulin release from islets of

29Langerhans .

. Arya Renu et al have demonstrated the antidiabetic activity of its hexane fraction of Swertia chirata which

28has active principle swerchirin .

. Sekar et al had shown that the main principle swerchirin of Swertia chirata induced a significant fall in blood sugar in albino rats and more effective in regulating blood sugar levels when compared to the regular drug

28tolbutamide .



. swerchirin (a xanthone isolated from hexane fraction of the plant) showed significant blood sugar lowering effect in fasted, glucose loaded & tolbutamide pre-treated albino

34rats .

. Studies done by Bajpai et al has confirmed observation that swerchirin from hexane fraction of Swertia chirata

28had antidiabetic activity .

The present study has several limitations. The study has been carried out only in one species of animal i.e. rats and needs to be extended to other animals as well. Only the fasting blood glucose was estimated in this study which does not give a clear picture about the effect of Swertia chirata on other parameters of diabetes mellitus. No attempt has been made to establish exact mechanism of antidiabetic activity and â cell pathology. In order to establish the exact mechanism of antidiabetic activity further investigations are also required to standardize the composition of extracts of Swertia chirata.

Conclusion - At the end of the study it can be concluded that

·Swertia chirata extract – aqueous extract at a dose of 200 mg/kg body weight, has exhibited antidiabetic activity in streptozotocin induced diabetes in rats.

·These extracts exhibited less marked antidiabetic activity when compared to standard drug glibenclamide in streptozotocin induced diabetes in rats.

However extensive studies have to be undertaken to establish this activity in animal models as well as human subjects. Further investigations are also required to standardize the composition of extracts.Results have shown that Swertia chirata has significant antidiabetic activity which is statistically significant as compared to control groups but has less marked antidiabetic activity when compared to the standard drug glibenclamide. Thus, this study concludes that aqueous extract of Swertia chirata possess significant antidiabetic activity.

References:1) Powers AC .Diabetes mellitus .In: Fauci AS, Braunwald E, Kasper DL,

Hauser SL, Longo DL, Jameson JL, et al, editors. Harrison's Principles thof Internal Medicine.17 ed. Newyork. McGraw hill. 2008;Vol 2: p.

2275.2) Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of

Diabetes: Estimates for yr 2000 & for yr 2030.Diabetes Care 2004;27(5):p.1047-53.

3) Ponnambalam R, Pavithra VS. What we need to about diabetes mellitus. The Asian J of Diabetology. June 2007; 9 (2):p17-21.

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thPharmacology. 4 ed . Kolkata .Ghosh SK Hilton and company ;2008: p 31

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brothers medical publishers pvt Ltd; 2009:p.593.15) Joshi P, Dhawan V. Swertia Chirayita- An overview. Curr sci 2005

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Quantification of major Phytochemicals of Swertia Chirayita. A medicinal plant from Nepal. Ecoprint 2010; 17: p.59-68.

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Asymptomatic Pulmonary Hydatid CystManifesting In Post-partum Period

Abstract: The fact that Hydatid cyst is a parasitosis occurring secondary to Echinococcus granulosus has been [1]known since Hippocratic times .

In India, the disease is endemic due to various sociocultural practices. The lung is a known site for the hydatid cyst [2]

and when it is present, usually the disease presents subsequent to secondary infections .We report a case of hydatid cyst, localized to the right lower lobe of the lung. Patient was asymptomatic for an unknown duration but became symptomatic after a normal vaginal delivery, which is a rare presentation.

Keywords: pulmonary hydatid cyst, post-partum pulmonary hydatid cyst, hemoptysis.

Introduction :

Hydatid disease is caused by the tapeworm Echinococcus granulosus and E multilocularis. Nearly 66% of the cases of hydatid cyst, present with cystic lesion in the liver and

[7]5-15% in lung .Via systemic circulation approximately 10 to 15% may reach other organs including the cardiac chambers, interventricular septum and the pericardium

[3],[4],[5](0.02-2%) . Most cases remain asymptomatic, but pulmonary involvement of the disease presents with

[8]cough, hemoptysis, chest pain and breathlessness . Chest radiographs and CT scan helped to localize and characterize the lesion.

Case Report :th

A 28 year lady presented on 12 post-partum day with the complaints of cough, fever and breathlessness. Breathlessness was insidious in onset and progressive in nature, starting from the day of delivery. Cough is associated with pain bilaterally in the lower thoracic region, with small amount of blood tinged expectoration. Patient and her family members are laborers by occupation and also rear sheep.

On examination the patient appears to be on respiratory distress with usage of accessory respiratory muscles. On auscultation there are decreased breath sounds on right side. Crepitation is appreciated on the base of the right lung.

Chest radiograph showed a round partially filled cavitary lesion in right lower zone. Lateral view confirmed the position of the cyst as the posterior aspect of the right lower lobe.

PA chest radiograph showing partially filled cavitary lesion in the lower lobe of the right lung. The lesion was confirmed to be posterior segment of lower lobe on the right lung.

CT thorax revealed cavitary lesion in the right lower lobe along with basal wavy floating membranes.

Contrast enhanced CT scan done in the axial plain shows cavitatry lesion with multiple floating membranes within cavity in the posterior segment of the right lower lobe.

Patient was started on oral Albendazole at dose of 15 mg/kg/day and was referred to CTV surgeon for surgical intervention.

Intra-operative photograph showing pulmonary hydatid

J Pub Health Med Res 2013;1(2):13-14CASE REPORT

1 2 4Kishan Ashok Bhagwat , Dhruva Rajagopal , Sangeeta , Venugopal1,2, 3,4

Department of Radiology, S. S. M.S.R.C, Davangere, GH, Harapanahalli

3

cyst. A large hydatid cyst was extracted with multiple collapsed cyst within it (insight).

Discussion:

Hydatid disease is caused by the tapeworm Echinococcus granulosus and E multilocularis. The life cycle involves primary and the intermediate mammalian hosts. Dogs are the usual primary host and the intermediate host is usually a sheep or cow but sometimes human. In the intestine the eggs hatch and the embryo cross the intestinal mucosa, enters into blood vessel and lymphatic system. Wherever the embryo settles, it forms a hydatid cyst.

Hemoptysis in adults is most often caused by tuberculosis, bronchiectasis and trauma or bronchogenic carcinoma. Parasitic etiology is very rare. Small cysts are usually asymptomatic in hydatid disease. Coughing, chest pain and breathlessness are the common presenting symptoms. Hemoptysis as a presenting symptom is common in adult series, although massive hemoptysis is rare. The mechanism of hemoptysis may be due to pressure erosion of a bronchus or an obstructive effect with bronchial infection or like in our case, it could be rupture of the hydatid cyst into the bronchial tree due to intra-partal pressure. The underlying etiology for hemoptysis may be unknown in 20% of cases, but in cases with pulmonary hydatidosis, the clinical and radiological picture is so unique that it can be easily identified despite

[6]its rarity .

The cyst was large and was communicating with the bronchus on the right side, the right lower lobe was dissected and the cyst was excised.

Patient was discharged with a prophylactic course of Albendazole at a dose of 15mg/kg/day.

Conclusion:

This case report suggests that when a post-partum women presents with hemoptysis, zoonotic infections, especially hydatid disease of the lung, should always be considered alongside other common causes of massive hemoptysis. The raise in intra-abdominal pressure can cause rupture of an asymptomatic lower lobe hydatid cyst and can lead to hemoptysis.

References:

[1] Papadimitriou J. Surgical treatment of hydatid disease of the lung. Surgery 1969; 66: 488– 491.

[2] Boussetta K, Siala N, Brini I, Aloui N et al. The hydatid cyst of the lung in children: 54 cases. Tunis Med. 2005 Jan; - 83(1): 24-7.

[3] BeggsI (1985). The radiology of hydatid disease. AJR 1, 639-648

[4] Cantoni S, Frola C, Gatto R, Loria F, Terzi MI et al (1993). Hydatid cyst of interventricular septum of heart, MR findings. AJR 161: 753-754

[5] Alper H, Yunten R, Sener NR (1995). Intramural hydatid cysts of pulmonary arteries: CT and MR findings. Eur J Radiology, 666-668

[6] Bharti S, Bharti B: Hydatid disease of the lung – unusual cause of hemoptysis.

[7] Indian Pediatr 2002, 39:1062-1063.[7]D Chattarjee, Echinococcus granulosus, Textbook of parasitology, 12th edition, Calcutta, India, Chatterjee Medical Publishers, April 1980: 121-127[8]

Antony S. Fauc[et al] Harrison's Principles of Internal Medicine, 17th edition: McGraw -Hill, Inc., 2005;1:1272-77.

Asymptomatic Pulmonary Hydatid Cyst Manifesting In Post-partum Period

How to Cite this article :Experimental Evaluation of antidiabetic activity of Swertia Chirata – Aqueous Extract.J Pub Health Med Res, 2013;1(2):13-14



Brest feeding practices in Bellary, Karnataka,A hospital based study.

1 2 3Vandana Hiregoudar , Hemagiri K. , Gangadhar Goud T

1 2 Postgraduate, Associate Professor,

3 Professor, Dept of Community Medicine, VIMS, Bellary

ABSTRACT

Background: Breast feeding in India is a universal phenomenon, with a large number of communities the practices very vastly because of different socio-cultural practices. The current study was designed to know the level of knowledge and to assess the correct feeding practices among postnatal mothers.

Materials and Methods: A hospital based cross-sectional study was done in postnatal wards of Vijayanagara Institute of Medical Sciences, Bellary, Karnataka. Mothers were interviewed to collect information about the baseline socio-demographic and obstetric characters of mothers and also consisted the questions to know the level of knowledge. To assess the position of the baby and attachment of baby to mothers, they were observed while breast feeding, if they had already fed the baby then they were observed during the next feed.

Results: A total of 240 mothers were interviewed during the study period. 102 (42.5%) mothers had the correct knowledge about initiation of breast feeding within an hour, however only 96 (40.0%) mothers had initiated breast feeding within a hour. About 220 (91.7%) of mothers knew about colostrums feeding but 234 (97.5%) of mothers add actually fed their babies with colostrum. By adopted scoring system 156 (65%) of mothers with babies had correct position while feeding and 136 (56.6%) of babies had correct attachment to their mothers.

Conclusion: The study emphasizes on imparting a correct knowledge regarding importance of breast feeding to mothers especially during ANC's .Regarding breast feeding practices mothers should be observed while feeding and should be corrected with demonstration.

Introduction

Breast milk is the unique gift from mother to the baby, and best start for the life. Mother's milk is a complete food with all the essential nutrients that are necessary for the growth and development of the baby for the first few months of life. Breast milk provides a considerable protection against not only diarrheal diseases but also against respiratory infections. It also promotes a bonding

1between mother and baby.

As a whole breast feeding is associated with a wide spectrum of health benefits to the mother and baby, social and economic benefits to the community, and reducing child morbidity and mortality. Understanding the importance of breast milk WHO and UNICEF advocates

2exclusive breast feeding.

The beneficial effects of breast feeding depend on breastfeeding initiation, its duration and the age at which

3weaning was started.

According to NFHS survey only 23.5% of newborn babies were put on breast feeding within an hour of birth and 37% initiated breast feeding within one and 43% of

4mothers had not given any pre lacteal feed .

In India breast feeding is universal phenomenon. However the reasons for existing child malnutrition and mortality may be the poor knowledge and incorrect practices. The practices of breast feeding are mainly

3influenced by social, cultural and other related factors.

Breastfeeding practices vary among different regions and communities. In India they are influenced by socio-economic factors, cultural background, psychological status, religious values and literacy rate. For the effective breast feeding the correct practices like proper positioning of baby to the mother and attachment of child

5to the mother's breast play a crutial role.

So, the current study was designed to know the level of knowledge and to assess the correct feeding practices among postnatal mothers.


Hemagiri K.Associate Prof, Dept. of Community Medicine, VIMS,Bellary- 583104, KarnatakaPh. : 0984549468(M), 08392-235204. Fax : 08392-235202.email : [email protected]


Materials and Methods

A hospital based cross-sectional study was done in postnatal wards of Vijayanagara Institute of Medical Sciences, Bellary, Karnataka.

A total of 240 mothers who delivered normally and by LSCS both preterm and term gestation were interviewed during the study period from February to April 2013 both were included.

Mothers were interviewed after obtaining a informed consent using a pretested, semi structured and validated questionnaire was used to collect information about the baseline socio-demographic and obstetric characters of mothers and also consisted the questions to know the level of knowledge. To assess the position of the baby and attachment of baby to mothers, they were observed while breast feeding, if they had already fed the baby then they were observed during the next feed using WHO-

6BREAST feed form.

For assessing the knowledge arbitrary scoring method was used. The arbitrary grading system was also used to assess the position and attachment, out of 4 criteria mothers were grouped in to correct position and

7good attachment if they fulfilled 3 criteria.

Variables Frequency Percentage (%)

1. Age in years

<20 70 29.2

20-25 122 50.8

>25 48 20

2. Education

Illiterate 86 35.8

Primary 70 29.2

High School & above 84 35

3. Occupation

Housewife 134 55.8

Unskilled & others 106 44.2

4. Religion

Hindu 192 80

Muslim & others 48 20

5. Type of family

Nuclear 68 28.3

Joint 172 71.7

6. Modified B.G. Prasad

classification

Class-III 63 26.33

Class-IV 97 40.4

Class-V 80 33.3

Table: 2 Obstetric profile of mothers

Variables Frequency Percentage (%)

1. Para

1 104 43.3

2 100 41.7

3 36 15

2. No. of ANC’s taken

<3 84 35

>3 156 65

3. Place of ANC taken

PHC 42 17.5

CHC 18 7.5

District hospital 94 39.2

Private hospital 86 35.8

4. Home visits done byhealth worker

Yes 134 55.8

No 106 44.2

5. Mode of delivery

Normal 112 46.7

LSCS 128 53.3

Table no:3 Knowledge about breast feeding among mothers

Factors Correctanswer

1. Time of initiation of breast feeding 096 (40%)

2. Prelactel feeding should not be given 146 (60.8%)

3. Colostrum feeding should be done 220 (91.7%)

4. Exclusive breast feeding should be

done for 6 months 202 (84.2%)

5. Knowledge about demand feeding 180 (75%)

Vandana Hiregoudar et al, Brest Feeding parctices in Bellary, Karnataka, A hospital based study.

A database was created in MS Excel and analysed using SPSS 16 version. Variables presented as percentages and chi-square test was used as test of significance.

Table:1 Socio-demographic profile of mothers


Table 4: Socio-demographic variables with breast feeding practices

Variables Early initiation

(n=96) not given(n=126) position (n=156) attachment (n=136)

1.Age in years

<20 24 (34.3%) 66 (94.3%) 50 (71.4%) 36 (51.4%)

20-25 54 (44.3%) 106 (86.9%) 70 (57.3%) 72 (59.0%)

25-30 18 (37.5%) 44 (91.7%) 36 (75%) 28 (58.3%)

2.001 (p=0.368) 2.839 (p=0.236) 6.498(p=0.039) 1.111 (p=0.574)

2.Education

Illiterate 46 (53.5%) 84 (97.7%) 60 (69.7%) 40 (46.5%)

Primary 24 (34.3%) 60 (85.7%) 36 (51.4%) 46 (65.7%)

High School 26 (31.0%) 72 (85.7%) 60 (71.4%) 50 (59.5%)

10.337 (p=0.006) 8.771(p=0.112) 8.052 (p=0.018) 6.225 (p=0.045)

3.Occupation

Housewife 44 (32.8%) 116 (86.6%) 94 (70.1%) 72 (53.7%)

Unskilled 52 (49.1%) 100 (94.3%) 62 (58.4%) 64 (60.3%)

6.488 (p=0.110) 3.973 (p=0.046) 3.356 (p=0.685) 1.065 (p=0.302)

4.Religion

Hindu 68 (35.4%) 180 (93.8%) 126 (65.6%) 108 (56.2%)

Muslim 28 (58.3%) 36 (75.0%) 30 (62.5%) 28 (58.3%)

8.403 (p=0.004) 15 (0.000) 0.165 (p=0.685) 0.068 (p=0.794)

5.Type of family

Nuclear 28 (41.2%) 64 (94.1%) 44 (64.7%) 34 (50%)

Joint 68 (39.5%) 152 (88.4%) 112 (65.1%) 102 (59.3%)

0.005 (p=0.815) 1.788 (p=0.181) 0.004 (p=0.952) 1.717 (p=0.190)

6.Monthly family income

Class-III 24 (38.1%) 57 (90.5% 37 (58.7%) 51 (80.9%)

Class-IV 34 (35.1%) 84 (86.6%) 73 (75.2%) 47 (48.4%)

Class-V 38 (47.5%) 75 (93.8%) 46 (57.5%) 38 (47.5%)

Prelacteal feeding Correct Correct



Variables Early initiation

(n=96) given(n=126) (n=156) (n=136)

1. Para

1 38 (36.5%) 100 (96.2%) 66 (63.4%) 54 (51.9%)

2 44 (44.0%) 88 (88.0%) 66 (66.0%) 64 (64.0%)

3 14 (38.9%) 28 (77.8%) 24 (66.6%) 18 (50.0%)

1.204 (p=0.548) 10.796 (0.005%) 0.196 (0.907) 3.795 (p=0.150)

2. No. of ANC’s taken

<3 46 (54.8%) 78 (92.9%) 58 (69.0%) 42 (50.0%)

>3 50 (32.1%) 138 (88.5%) 98 (62.8%) 94 (60.2%)

11.734(p=0.001) 1.172 (p=0.279) 0.931 (p=0.335) 2.339 (0.126)

3. Place of ANC taken

PHC 10 (23.8%) 42 (100%) 22 (52.3%) 28 (66.6%)

CHC 6 (33.3%) 16 (88.9%) 06 (33.3%) 06 (33.3%)

District hospital 36 (38.3%) 80 (85.1%) 68 (72.3%) 62 (65.9%)

Private hospital 44 (51.2%) 78 (90.7%) 60 (69.7%) 40 (46.5%)

9.499 (p=0.023) 7.239 (p=0.065) 13.959 (p=0.003) 12.617 (p=0.006)

4. Home visits done by

health worker

Yes 60 (44.8%) 120 (89.6%) 88 (65.6%) 70 (52.2%)

No 36 (34.0%) 96 (90.6%) 68(64.1%) 68(64.1%)

2.884 (p=0.089) 0.068 (p=0.795) 0.060 (p=0.806) 2.422 (p=0.120

5.Mode of delivery

Normal 40 (35.7%) 108 (96.4%) 88 (78.5%) 86 (76.7%)

LSCS 56 (43.8%) 108 (84.4%) 68 (53.1%) 52 (40.6%)

1.607 (p=0.205) 9.643 (p=0.002) 17.002 (p=0.000) 8.964 (p=0.003)

Prelacteal feeding not Correct position Correct attachment

Table no 5: Obstetric variables with breast feeding practices

Results:

A total of 240 mothers were interviewed during the study period. The age of the mothers ranged between 15 to 35 and 122(50.8%) being in the age group 20-25.The majority of mothers were illiterates 86 (35.8%) and were housewives 134 (55.8%) by occupation. Most of the mothers 192 (80%) were hindu by religion and were from joint family 172 (71.7%).Most of the mothers 97 (40.4%) belong to class-4 according modified B.G.Prasad classification.

About 104 (43.3%) mothers were primipara.156 (65%) mothers had more than 3 ANCs 94 (39.2%) had taken antenatal checkups at district hospital, 86 (35.8%) from private hospital. For 134 (55.8%) mothers had got home visits done by health workers.128 (53.3%) mothers had delivered by LSCS and 112 (46.7%) had delivered normally.

In our study 102 (42.5%) mothers had the correct knowledge about initiation of breast feeding within an

hour, however only 96 (40.0%) mothers had initiated breast feeding within an hour. About 46 (53.5%) of illiterate mothers, 28 (58.3%) of mothers of muslim community had had done early initiation.46 (54.8%) of mothers who had less than three ANCs and 44(51.2 %) mothers who had availed there ANCs from private hospital had done practiced initiation correctly. About 60 % mothers had given the correct answer about prelacteal feeding but in practice only 116 (48.3%) of mothers had not given any prelacteal feed to newborns. About 97% of illiterate mothers, 94.3% of unskilled laborers and 93.8% of hindu mothers had not given any prelacteal feeding which were statistically significant.96.2% of primi paras and 96.4% of mothers who delivered normally had not given any prelacteal feeding and proved statistically significant. The commonest prelacteal feeds used were honey and sugar water.

About 220 (91.7%) of mothers knew about colostrums feeding but 234 (97.5%) of mothers add actually fed their

2013;1(2):13-14Vandana Hiregoudar et al, Brest Feeding parctices in Bellary, Karnataka, A hospital based study.


babies with colostrum.180 (75%) of mothers knew about demand feeding and 202 (84.2%) of mothers had given correct answer about exclusive breast feeding for 6 months.

By adopted scoring system 156 (65%) of mothers with babies had correct position while feeding and 136 (56.6%) of babies had correct attachment to their mothers. A correct position was observed in greater proportion 36 (75 %) of mothers in the age group of 20-25 and 60 (69.7%) of mothers who were illiterates which were proved statistically significant.68 (72.3%) of mothers who had done there antenatal checkups at district hospital.88 (56.4%) mothers who had delivered normally.

Discussion:

A correct knowledge about breast feeding is the right of the mother. All the mothers in our study had at least one ANC and one home visit by health worker but only 40% of mothers knew about early initiation of breast feeding, but in a similar study done by Maheshwari Ekambaram et al 90% of mothers knew about early initiation large amount of this difference may be attributed to the failure on the part of our health care facilities to impart correct knowledge. However similar findings were observed in

8other aspects of breast feeding.

In our study about 91.7% of mothers knew about colostrum feeding which was similar to studies done in

9other parts of India i.e 75%-90%.

In our study 40% of mothers had done early initiation of breast feeding. In a study done by M C Yadavannavar et al only 23.3% mothers had done early initiation, the larger number of early initiation in our study may be because of our study set up which was hospital and who will be under

10constant support and observation from hospital staff. but studies done in various parts show early initiation from 16

11to 54.5%.

Our study setting being a tertiary care hospital but also only 48.3% mothers had not given any prelacteal feed to their babies. A large proportion of unskilled and other occupation mothers and mothers from hindu community had not given any prelacteal feed. We observed a positive association between no prelacteal feed to primiparas and mothers who delivered normally.

97% of mothers had fed the babies with colostrums however in a study done by M C Yadavannavar et al only

35% of mothers had given colosrtum, but 81.6% mothers had fed the babies with colostrum in a study done by

11Tiwari et al in north India.

About 65% of mothers had the correct position of babies while feeding and increasing age of the mother was positively associated, a similar finding was observed in a study done by Gupta et al Mothers from the claas-5 socio-economic income group and multiparous women had good attachment but there was no statistically significance. In a study done by Gupat et al. Mothers who had their ANCs in private hospital and district hospital had better position and mother delivered normally which

12were proved statistically significant.

56.6% of mothers had a correct attachment with their babies. A statistically significant association was observed between mothers from high income families and mothers who had delivered normally.

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stBhanot publishers,21 edition 2011 page no 4962. World Health Organization. Evidence for the ten steps to successful

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AM,et al.Evidence for protection against infant deaths from infectious diseases in Brazil Lancet 1987:2:319-322

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9. Agarwal S, Srivastava K, Sethi V. Maternal & New-born Care Practices Among the Urban Poor in Indore, India: Gaps, Reasons and Possible Program Options. Urban Health Resource Center, New Delhi. 2007.

10. M.C. Yadavannavar, Shailaja S Patil : Socio cultural factors affecting breast feeding practices and decisions in rural women: International Journal of Plant, Animal and Environmental Sciences :2011:Vol 1:Issue2:46-50

11. Tiwari V, Singh A. Knowledge, attitude and practice regarding breastfeeding in an urban area of Fazidabad district (U.P). Indian J Prev Soc Med 2007; 38(1): 18-22.

12. Gupta M,Aggarwal AK.Feasibility study of IMNCI Guidelines on effective breast feeding in rural area of North India.Indain J Community Med 2008:33:201-3

4. Child Feeding Practices and Nutritional Status of Children NFHS-3 report 2005-06,p-10

This Work attributed to: Dept of Community Medicine & MCH, VIMS, Bellary.

2013;1(2):13-14

How to Cite this article :Vandana Hiregoudar, Hemagiri K., T. Gangadhar Goud. Brest Feeding parctices in Bellary, Karnataka, A hospital based study.J Pub Health Med Res, 2013;1(2):6-7

Disclaimers: none



MR Imaging of Lipohaemarthrosis in Knee Joint1 2 3Kishan Ashok Bhagwat , Dhruva Rajagopal , Ramesh S. Desai

1Assistant Professor, 2 Post Graduate, 3 Professor & Head

Department of Radiology, S. S. M.S.R.C, DavangereAbstract:

Joint effusion constitutes a common post-traumatic finding. However presence of lipohaemarthrosis is indicator of intra-articular extension of fracture. Though a trivial finding, joint effusion in knee joint speaks of many secrets.

Aims: To determine the relationship between intra-articular extension of the fracture and presence of lipohaemarthrosis.

Methods: MR Images of 150 knee joints were reviewed retrospectively. MRI performed for patients with history of trauma were included and others were excluded. Each case was reviewed for presence of lipohaemarthrosis with associated intra-articular fracture. Presence of statistically significant association was confirmed.

Result: Out of 150 cases, 11 cases had intra-articular fracture with associated lipohaemarthrosis.

Keywords: knee joint effusion, lipohaemarthrosis, intra-articular fracture.

Introduction:Joint effusions constitute a common finding after sports injuries. They can be an indirect trauma sign on conventional X-rays in case of intra-articular fractures, which is especially helpful if the cleft between the fragments is not visible.However, the constitution and therefore the diagnostic value of joint effusions vary. Serous or sanguineous effusions alone tend to be non-specific, whereas lipohaemarthrosis, the presence of lipid material and blood, is very accurate for an intra-articular fracture penetrating the cartilaginous parts of the joint. In this study we are attempting to establish the relationship between lipohaemarthrosis in the knee joint with presence of intra-articular extension of the fracture. Materials and method:MR Images of 150 knee joints were reviewed retrospectively. Knee MRI done for patients with trauma was included and others were excluded. Each case was reviewed for presence of lipohaemarthrosis with associated intra-articular fracture. Lipohaemarthrosis was evaluated on axial and sagittal sections of proton density images as well as T2 weighted images done on GE SIGNA-HDxt 1.5 tesla MR imaging system. Corresponding sections were also reviewed on T2WI with fast spin echo sequences. Presence of associated intra-articular extension of the fracture was also seen in most of the cases. Results:A m i d s t 1 5 0 K e e n M R I , 1 0 p a t i e n t s h a d lipohaemarthrosis in which 8 patients had infra-articular extension of the fracture. 1 patient had infra-articular extension of the fracture but there was no lipohaemarthrosis.

On applying chi square test, statistical significance was

confirmed between Lipohaemarthrosis and intra-articular extension of the fracture (p value=0.001).Sensitivity of the lipohaemarthrosis in detection of intra-articular fracture is 88.8%, specificity- 98.6%, positive predictive value- 80% and negative predictive value is 99.3%.Lipohaemarthrosis showed and efficiency of 98% in detecting intra-articular extension of fracture.Discussion:Lipohaemarthrosis results from the extrusion of fat and blood from bone marrow into the joint space after an intra-articular fracture. This was first described by Kling in

11929 . Lipohaemarthrosis is more common in knee fractures, especially those affecting the tibial plateau, but it has also been described in shoulder, elbow, and hip

2-4fractures .Three bands can normally be distinguished: As the fat floats on the associated blood, the top band constitutes fatty material. The following band below is composed of serum and serous joint effusion. The cellular parts of the blood, i.e., erythrocytes and leukocytes,

5sediment due to gravity and form the lowest band .

Fig 1: Axial proton density MR image. A double-fluid level is visible. Note the low signal intensity of the highest layer, which is c o m p a r a b l e t o su r round ing f a t t y tissue. A high-intensity band fol lows and consists of serum. Cellular parts of blood have sedimented and display an intermediate signal.

J Pub Health Med Res 2013;1(2):13-14Original Article

Fig 2: Sagittal T2 weighted MR images. A characteristic three-layered appearance with varied signal intensities are seen in the knee joint. Fracture of the upper end of the tibia is noted with extension of the fracture line to the articular surface.

Serous or sanguineous effusions alone tend to be non-specific, whereas lipohaemarthrosis, the presence of lipid material and blood, is very accurate for an intra-articular

6fracture penetrating the cartilaginous parts of the joint .

7Lipohaemarthrosis can be found in approximately 40% of all intra-articular fractures of the knee and evolves at

8the latest 3 h after the trauma ; however, gravity and a certain time of rest are needed to depict the characteristic

double fluid-fluid layer, which is characteristic of 9, 10

lipohaemarthrosis .

Conclusion:

With this study we conclude that there is a strong association between the presence of lipohaemarthrosis and intra-articular extension of the fracture. Presence of lipohaemarthrosis should make a radiologist over conscious and should look for associated intra-articular fracture

REFRENCES :1. Kling DH. Fat in traumatic effusions of knee joint. Am J Surg 1929;

6:71–74.2. Arger PH, Oberkircher PE, Miller WT. Lipohemar- throsis. Am J

Roentgenol Radium Ther Nucl Med 1974; 121:97–1003. Lugo-Olivieri CH, Scott WW Jr, Zerhouni EA. Fluid–fluid levels in

injured knees: do they always represent lipohemarthrosis? Radiology 1996; 198:499–502

4. Bianchi S, Zwass A, Abdelwahab IF, Ricci G, Ret- tagliata F, Olivieri M. Sonographic evaluation of lipohemarthrosis: clinical and in vitro study. J Ultra- sound Med 1995; 14:279–282

5. Kier R, McCarthy SM (1990) Lipohemarthrosis of the knee: MR imaging. J Comput Assist Tomogr 14:395-396

6. Lee JH, Weissman BN, Nikpoor N, Aliabadi P, Sosman JL (1989) Lipohemarthrosis of the knee: a review of recent experiences. Radiology 173:189-191

7. Colletti P, Greenberg H, Terk MR (1996) MR findings in patients with acute tibial plateau fractures. Comput Med Imaging Graph 20:89-94

8. Bianchi S, Zwass A, Abdelwahab IF, Ricci G, Rettagliata F, Olivieri M (1995) Sonographic evaluation of lipohemarthrosis: clinical and in vitro study. J Ultrasound Med 14:279-282

9. Hart R, Campbell MR (2002) Digital radiography in space. Aviat Space Environ Med 73:601-606

10. Ryu KN, Jaovisidha S, De Maeseneer M, Jacobson J, Sartoris DJ, Resnick D (1997) Evolving stages of lipohemarthrosis of the knee. Sequential magnetic resonance imaging findings in cadavers with clinical correlation. Invest Radiol 32:7-11.

Kishan Ashok Bhagwat et al, MR Imaging of Lipohaemarthrosis in Knee Joint

How to Cite this article :Kishan Ashok Bhagwat, Dhruva Rajagopal, Ramesh S Desai. MR Imaging of Lipohaemarthrosis in Knee JointJ Pub Health Med Res, 2013;1(2):20-21



Prevalence of Helicobacter Pylori among rural school children of 5-12 year Age Group

ABSTRACT

Background: Helicobacter pylori is a bacterium that is commonly found in the stomach and is usually contracted during childhood. It is more common in the developing countries than in developed countries. The prevalence of H. pylori infection is stated to be as high as 80% in the developing countries.

Objectives: The present study was planned to investigate the prevalence of H. pylori among school children with low socio-economic status of the rural areas of Jagalur, Davangere.

Methods: A cross-sectional study was conducted among 5-12 year old rural school children. A total of 484 children 13 13

participated in the study. H. pylori was diagnosed by means of Carbon-Urea Breath Test ( C-UBT).

Results: The prevalence of H. pylori infection was 13.2%.

Conclusion: The prevalence of H. pylori infection is inversely related to socio-economic and developmental status. Those living in developing countries or crowded, unsanitary conditions are most likely to contract the bacterium, which is passed from person to person.

Key words: Helicobacter pylori, Urea Breath Test

1 2 3 UmaKiran , Vinod Kumar C.S , Suneeta Kalasurmath

1Research Scholar, Bharathiar University, Coimbatore.2Associate Professor, Department of Microbiology, S.S. Institute of Medical Sciences and Research Centre, Davangere.

3Associate Professor, Department of Physiology, S.S. Institute of Medical Sciences and Research Centre, Davangere.

Introduction

The vast majority of people infected with H. pylori infection have no symptoms and will never develop problems. H. pylori is probably spread by consuming food or water contaminated with faecal matter. H. pylori causes changes to the stomach and duodenum. The bacteria invade the protective tissue that lines the stomach. This leads to the release of certain enzymes and toxins. These may directly or indirectly injure cells of the stomach or duodenum, causing chronic inflammation in

1their walls .

Factors predisposing to H. pylori infection in children 2,3

were low socioeconomic status . H. pylori infection is 1

greater among those living in crowded dwellings . McCallion et al. showed that the association between social class and H. pylori becomes insignificant after adjustment for household density and bed-sharing between a child and an adult. This finding suggests that with regard to the acquisition of H. pylori infection, social class was acting as a proxy measure for conditions and practices within the household that increase the transmission of the organism from infected to uninfected

4subjects . Improvements in the standards of living have

5resulted in a marked reduction in H. pylori transmission .

J Pub Health Med Res 2013;1(2):22-24SHORT ARTICLE


UmaKiranResearch Scholar, Bharathiar University, Coimbatore.

In developing countries, most children are infected with H. pylori before age 10.

As many as half of the world's population is infected with H. pylori, but most people will never experience any symptoms. The infection penetrate in childhood and continues lifelong. During its course, the disease can have several manifestations including acute gastritis, chronic atrophic gastritis, intestinal metaplasia, dysplasia growth

6,7failure, malnutrition and finally cancer .

The aim of the study was to evaluate the prevalence of H. pylori infection among 5-12 year age group rural school children who belong to low socio-economic status.

Materials And Methods

Ethical clearance: Ethical clearance was obtained from the Bharathiar University, R & D centre, Coimbatore. Informed written consent was taken from all students and their guardians for interview and sample collection.

Type of study: A school based cross sectional study, deals with the investigation of prevalence of H. pylori infection in children between the ages of 5-12 years.

Study area: Three schools from three different villages of Jagalur taluk, Davangere district, Karnataka were selected.

Sample size: A school based cross sectional study was conducted through a pretested, semi structured interview schedule in rural areas of Davangere. A total of

484 samples between the age group of 5-12 years participated in the study.

Inclusion and exclusion criteria: The rural school cater to low socio-economic group of population. Children with an obvious cause of blood loss, such as active or recent gastro intestinal hemorrhage, epistaxis were excluded. Other exclusion criteria were the presence of chronic diseases, hematologic diseases, motor mental retardation, celiac disease, recent antibiotic or antacid use and malabsorption syndromes. The age of children was ascertained by questioning them and later confirmed from school registers in case of any discrepancy between the two, the date in the school register was taken as a accurate. Age in completed years was taken for analysis.

Urea breath test (UBT): The 13C-UBT was performed as described by Ohare et al. after at least a 2 hour fast, 100 mg 13C- urea was administered with 100 ml of water. Breath samples were collected before and 20 minutes after ingestion. The ratios of 13C- to 12C in the baseline sample and the sample obtained after 20 minutes were determined by a mass spectrometer (ABCA – G; Europe Scientific of the baseline, Crewe, UK). An excess value of 2.5ä (subtraction of the baseline value from that of the 20 minute sample) was considered positive for the infection.

Because fasting for at least 6 hours was required the 13C- UBT was performed in the morning of the day following the interview.

Results :

Demographic characteristics: Children were categorized into four groups based on the age group. 112 (23.1) children from 5-6y, 121 (25.0) from 7-8y, 125 (25.8) from 9-10y and 126 (26.1) from 11-12y children. Participation of boys was 48.8% (236) and that of girls were 51.2% (248).

Out of 484 children studied, 64 (13.2) was found positive for H. pylori infection (Fig 1). Among these 19 (17.0) was positive in 5-6y age group, 16 (13.0) in 7-8y, 17 (14.0) in 9-10y and 12 (10.0) in11-12y age group was found positive for H. pylori infection (Fig 50). There was no significant difference of H. pylori positivity among different age groups (Table 1).

Discussion

The stomach is protected from its own gastric juice by a thick layer of mucus that covers the stomach lining. H. pylori take advantage of this protection by living in the mucus lining.

According to the U.S. Centers for Disease Control and Prevention (CDC), more than half of the world's population is infected with H. pylori, which is acquired

8almost always within the first five years of life , making it

9the most widespread infection in the world . Actual infection rates vary from nation to nation; the developing countries has much higher infection rates (90%) than the

1,2,10,11developed countries (1.2% - 12%) .

Studies point towards a relation between the low socio-12

economic status and the high rate of H. pylori infection . Herberth et al reported a prevalence of 6.5% among

13school children in Germany . Improving the living conditions lowers the rate of infection. The decrease in the rate of infection of H. pylori in Southern China from 1993 to 2003 was attributed to an improvement in the

14socio-economic conditions . In the middle east countries like Turkey, the prevalence was 44% in children and in

15,16other studies, the prevalence was upto 89% . Prevalence of H. pylori infection appears to be higher in Africa, Mexico, South America and Central America, which reaches 70% - 90% of the population, most likely

17due to socio-economic factor . The lower rate of infection in the west (Western Europe, North America, Australia) is largely attributed to higher standards and

18widespread use of antibiotics .

The prevalence of H. pylori was 13.2% in the present study. Several studies have shown that H. pylori infection

19,20,21,22in childhood is associated with growth faltering . However, these studies are confounded by the coexistence of variables such as poor socioeconomic status, which may contribute to both the development of malnutrition and the early H. pylori colonization. Therefore, H. pylori and growth faltering may be mere associations rather than cause and effect.

Conclusion

There is a conspicuous paucity of similar reports in populations with high prevalence of H. pylori. We speculate that strains of H. pylori and its colonizing behavoiur, host factors and environmental factors may be involved in the development of infection. Recently it has been suggested that H. pylori infection may affect metabolism of iron in healthy humans.

Fig 1: Prevalence of H. pylori positivity

2013;1(2):22-24Uma Kiran et al, Prevalence of Helicobacter Pylori among rural school children of 5-12 Year age group


8. Suerbaum, S., and Michetti, P. 2002. Helicobacter pylori infection. N Engl Med 347: 1175 – 86.

9. Pounder, RE, and Ng, D. 1995. The prevalence of Helicobacter pylori infection in different countries. Aliment Pharmacol Ther 9(2): 33 – 9.

10. Rothenbacher, D., Bode, G., Berg, G., Gommel, R., Gonser, T., Alder, G., and et al. 1998. Prevalence and determinants of Helicobacter pylori infection in preschool children: A population based study from Germany. Int J Epidemiol 27: 135 – 41.

11. Mourad-Baars, P.E., Verspaget, H.W., Mertens, B.J., and Luisa Merain, M. 2007. Low prevalence of Helicobacter pylori infection in young children in the Netherlands. Eur J Gastroenterol Hepatol 19: 213 – 6.

12. Perez-Perez, G.I., Rothenbacheri, D., and Brenne,r H. 2004. Epidemiology of Helicobacter pylori infection. Helicobacter 9: 1 – 6.

13. Herbarth, O., Krumbiegel, P., Fritz, G.J., Richter, M., Schlink, U., Muller, D.M., and et al. 2001. Helicobacter pylori prevalences and risk factors among school beginners in a German urban center and its rural county. Environ Health Perspect 109: 573 – 7.

14. Chen, J., Bu, XL., Wang, Q.Y., Hu, P.J., and Chen, M.H. 2007. Decreasing Seroprevalence of Helicobacter pylori Infection during 1993-2003 in Guangzhou, Southern China. Helicobacter 12: 164 – 9.

15. Malaty, H.M., and Nyren, O. 2003. Epidemiology of Helicobacter pylori Infection. Helicobacter 8: 8 – 12.

16. Novis, B.H., Gabay, G., and Nafatli, T. 1998. Helicobacter pylori: The Middle East scenario. Yale J Bio Med 71: 135 – 41.

17. Howden, C.W., and Hunt, R.H. 1998. Guidelines for the management of Helicobacter pylori infection. Ad Hoc Committee on Practice Parameters of the American College of Gastroenterology. Am J Gastroenterol 93: 2330 – 8.

18. Malaty, H.M. 2007. Epidemiology of Helicobacter pylori infection. Best Pract Res Clin Gastroenterol 21(2): 205 – 14.

19. Perri, F., Pastore, M., Leandro, G., Clemente, R., Ghoos, Y., Peeters, M., and et al. 1997. Helicobacter pylori infection and growth delay in older children. Arch Dis Child 77: 46 – 9.

20. Worst, D.J., Otto, B.R., and deGraaff, J. 1995. Iron-repressible outer membrane proteins of Helicobacter pylori involved in heme uptake. Infect Immun 63: 4161 – 5.

21. Thomas, J.E., Dale, A., Bunn, J.E., Harding, M., Coward, W.A., Cole, T.J., and et al. 2004. Early Helicobacter pylori colonization: The association with growth faltering in the Gambia. Arch Dis Child 89: 1149 – 54.

22. Mera, R.M., Correa, P., Fonthan, E.E., Reina, J.C., Pradilla, A., Alzate, A.,and et al. 2006. Effects of a new Helicobacter pylori infection on height and weight in Colombian children. Ann Epidemiol 16: 347 – 51.

2013;1(2):22-24Uma Kiran et al, Prevalence of Helicobacter Pylori among rural school children of 5-12 Year age group


REFERENCES

1. Wizla-Derambure, N., Michaud, L., Ategbo, S., Vincent, P., Ganga-Zandzou, S., Turck, D., and et al. 2001. Familial and community environmental risk factors for Helicobacter pylori infection in children and adolescents. J Pediatr Gastroenterol Nutr 33: 58 – 63.

2. Opekun, A.R., Gilger, M.A., Denyes, S.M., Nirken, M.H., Philip, S.P., Osato, M.S., and et al. 2000. Helicobacter pylori infection in children of Texas. J Pediatr Gastroenterol Nutr 31: 405 – 10.

3. Ndip, R.N., Malange, A.E., Akoachere, J.F., MacKay, W.G., Titanji, V.P., and Weaver, L.T. 2004. Helicobacter pylori antigens in faeces of asymptomatic children in the Buea and Limbe health districts of Cameroon: A pilot study. Trop Med Int Health 9: 1036 – 40.

4. McCallion, W.A., Murray, L.J., Bailie, A.G., Dalzel,l A.M., O'Reilly, O.J., and Bamford, K.B. 1996. Helicobacter pylori in children: Relation with current household living conditions. Gut 39: 18 – 21.

5. Tkachenko, M., Zhannat, N.Z., Erman, L.V., Blashenkova, E.L., Isachenko, S.V., Isachenko, O.B., et al. 2007. Dramatic changes in the prevalence of Helicobacter pylori infection during childhood: A 10 year follow-up study in Russia. J Peditr Gastroenterol Nutr 45: 428 – 32.

6. Akcam, M., Ozdem, S., Yilmaz, A., Gultekin, M., and Artan, R. 2007. Serum ferritin, vitamin B folate and zinc levels in children infected (12),

with Helicobacter pylori. Dig Dis Sci 52: 405 – 10.

7. Windle, H.J., Kelleher, D., and Crabtree, J.E. 2007. Childhood Helicobacter pylori infection and growth impairment in developing countries: a vicious cycle? Pediatrics 119: e754 – 759.

How to Cite this article :UmaKiran, Vinod Kumar C.S., Suneeta Kalasurmath. Prevalence of Helicobacter Pylori among rural school children of 5-12 Year age group. J Pub Health Med Res, 2013;1(2):22-24

Age H. pylori positivity n (%)

5-6y 19 (17.0)

7-8y 16 (13.0)

9-10y 17 (14.0)

11-12y 12 (10.0)

Total 64 (13.2)2X =1.6, P=0.65 NS 3 d.f

Table 1: Prevalence of H. pylori infection among 5-12y children


Case controlled Clinical study of Prophylaxis with a single dose of cefepime for caesarean section.

Paper Abstract : Background . The incidence of caesarean section is on the rise world wide. Post caesarean infection is a very serious morbity and calls for considerable manpower ,time and financial burden on the society. Again with the inadvartment use of antibiotics many drug resistant microbial have emerged.This is of very serious concern while managing a post caesarean wound infection.Attempts have been made to bring down such infections by taking all aseptic precautios and use of minimal possible yet effective dose of prophylactic antibiotics in sch circumstances.with this background current study was conducted. Objectives : The concept of prophylactic antibiotics has gained wide acceptance as the commonest complication associated with surgery is post-operative infection.The fourth generation cephalosporins namely cefepime and cefpirome are stable to hydrolysis by plasmid encoded -lactamases (TEM-1; TEM-2; SHV-1), cefepime is a poor inducer of and relatively resistant to some extended spectrum -lactamases. It is thus active against many enterobacteriaceae that are resistant to other cephalosporins. Against the fastidious gram – negative bacteria (H.influenzae, Neisseria gonorrhoeae, Neisseria meningitidis) cefepime has comparable or greater in vitro activity than cefotaxime. Given I v . Cefepime has slightly greater activity than cefpirome against gram-ve bacteria. They both exhibit a low level of cross resistance with third generation cephalosporins and offer a low potential for induction of bacterial resistance.In this study the effectiveness of single dose of cefepime prophylaxis in caesarean section has been studied and compared to that of ampicillin, gentamicin and metronidazole for 5 days post-operatively with regard to post-operative morbidity, cost of the treatment, hospital stay and side effects.Methodology: Two hundred cases were selected among the pregnant women who underwent emergency caesarean section or elective caesarean section at OBG Department at Bapuji Hospital, Chigateri General Hospital and Women and Children Hospital, Davangere during the study period August 2011 to June 2013. Out of that hundred cases were taken as study group and hundred were taken as control group, by simple random sampling (Lottery method).This is a cross sectional study comparing the drug efficacy of prophylactic single dose injection of cefepime given intravenously immediately after clamping the umbilical cord during caesarean section with the control group of injection Ampicillin, + Gentamicin, Metronidazole given routinely for 5 days post operatively in prevention of post-operative infection. Injection cefepime was given IV immediately after clamping the umbilical cord during caesarean section to prevent the masking of neonatal sepsis. For Study group : Injection cefepime 1 gm IV as a single dose given immediately after clamping the umbilical cord during caesarean section. And for Control group Inj Ampicillin + Inj Gentamicin +Inj Metronidazole. Which is practiced routinely by some physicians. In the post operative period we saw for Temperature of 100.40 F (or more 24 hours after surgery.),Wound infection.Foul smelling lochia. Urinary tract infection. Respiratory tract infection. Oral temperature record, Post-operative routine investigations. Blood culture was to be sent if fever in any patient lasted for >96 hours (4days) and, in case of wound infection, culture swabs were taken and sent to laboratory. Vaginal swab was sent for culture in suspected cases of endometritis, and febrile morbidity total count, differential count and ESR was done. Wound was inspected as per wound infection score on 3rd and 4th post operative day and after removal of sutures on 5th day.. comparison between study and control group regarding all the above criteria was done by chi-square test where frequency variables were involved and student 't' test where continous variables were involved. Result : The majority of cases were Emergency sections,the major indication being foetal distress followed by previous section with CPD. The post operative morbity in study group with prophylaxis was statically low w (12%)

Shivamurthy. H M***, Jyotsna R Himgire**, Amrutha K*, Giridhar**** Professor In OBG, JJMMC, Davanagere, Karnataka

** Asst Professor, Bidar Inst. of Medical Sciences, Bidar, Karnataka.*Post Graduates in OBG JJMMC, Davanagere.


Introduction :

The greatest effort of modern antibiotic therapy is its 1influence on evolution of modern surgery Caesarean

section is one of the commonest forms of surgery performed in modern days; though there is decline in perinatal morbidity and mortality; maternal morbidity is

1on the rise due to bacterial infection.

The commonest complication associated with surgery being post-operative wound infection, hence the concept

1,2of prophylactic antibiotics has gained wide acceptance.

In addition to patient discomfort and morbidity associated with wound sepsis; there are consequences involving nursing time and increased costs that are more

3easily quantified.

Therefore antibiotics should be present at the site of possible contamination at the time bacteria are introduced

1so as to prevent infection.

Thus prophylactic antibiotics defined as short term "use of antibiotics for the prevention of infection in the absence of clinical signs and symptoms of infection"

4,5came into consideration.

Various analysis have shown decreased wound infection and improved physical and psychological well being given appropriate prophylactic antibiotics compared with

2that of untreated or placebo groups.

The concept of antimicrobial prophylaxis for caesarean 2,6

section has now gained wide acceptance. Most clinical trials have shown the efficacy of antimicrobials not only in preventing endometritis but also in reducing wound

7infection.

The choice of prophylactic antibiotics involves several criteria; including the spectra of activity, the likelihood of encountering virulent bacteria at surgery; the population incidence of post-operative infections, complications

3without prophylaxis; cost and potential toxicities.

Morbidity due to urinary tract infections, febrile episodes and respiratory tract infections were also noted in the

4,8post-operative period.

Hence attempts have been made to bring down such infections by taking all aseptic precautios and use of minimal possible yet effective dose of prophylactic antibiotics in such circumstances.with this background current study was conducted.

Cephalosporium acremonium, the first source of the cephalosporins, was isolated in 1948, by Brotzu from the Sardinian sea coast. Crude cultures of this fungus were found to inhibit staphylococcus aureus in vitro and to cure staphylococcal and typhoid infections in humans.

Culture fluid in which the Sardinian fungus was cultivated were found to contain three distinct antibiotics, which were named cephalosporin P,N and C. With the isolation of the active nucleus of cephalosporin C, (7-aminocephalosporanic acid) and with the addition of side chains, semisynthetic compounds with antibacterial activity very much greater than that of the parent

10,11substance were produced.

The fourth generation cephalosporins namely cefepime and cefpirome are stable to hydrolysis by plasmid encoded -lactamases (TEM-1; TEM-2; SHV-1), cefepime is a poor inducer of and relatively resistant to some extended spectrum -lactamases. It is thus active against many enterobacteriaceae that are resistant to other cephalosporins.

Against the fastidious gram – negative bacteria (H.influenzae, Neisseria gonorrhoeae, Neisseria meningitidis) cefepime has comparable or greater in vitro activity than cefotaxime. Given I v . Cefepime has slightly greater activity than cefpirome against gram-ve bacteria.

They both exhibit a low level of cross resistance with third generation cephalosporins and offer a low potential for induction of bacterial resistance.

If an antibiotic is injected IV just prior to the incision, it is effective in preventing wound infections. Timing in critical prophylaxis is only appropriate when there has been no preoperative contamination or established

9infection.

Shivamurthy H.M. et al, Case controlled Clinical study of Prophylaxis with a single dose of cefepime for caesarean section


when compared to control group (32%) .there was need for additional drug administration in control group (25%) The majority wound complications observed were Purulent discharge and wound gaping .More wound morbidity seen in emergency sections.Conclusion : Single dose cefepime prophylaxis was cost effective, easy to prepare and administer, has significantly reduced post-operative morbidity, reduced the hospital stay of the patients ,has no major side effects and can be widely applied in routine practice. Keywords : Prophylaxis, caesarean section, cefepime, fourth generation cephalosporin


Shivamurthy H.M.# 4006/1, 17th Main, 6th Cross, M C C "B" Block(extended), Kuvempu Nagar, Davangere 577004, STATE KARNATAKACell No : 8971724225 E mail : [email protected]

In this study the effectiveness of single dose of cefepime prophylaxis in caesarean section has been studied and compared to that of ampicillin, gentamicin and metronidazole for 5 days post-operatively with regard to post-operative morbidity, cost of the treatment, hospital stay and side effects.

Materials and methods .

Two hundred cases were selected among the pregnant women who underwent emergency caesarean section or elective caesarean section at hospitals attached to J J M Medical college, Davangere during the study period August 2011 to June 2013. Out of that hundred cases were taken as study group and hundred were taken as control group, by simple random sampling (Lottery method).

Inclusion criteria :

All the women who underwent cesarean section :

1) Primigravida and Multigravida

2) With term gestation

3) With membranes intact

4) With membranes ruptured with in 6 hours.

5) Afebrile

6) Not on any antibiotics

7) Elective / emergency caesarean section.

Exclusion criteria :

1) Hypersensitivity to any cephalosporin or penicillin group of drugs.

2) Antibiotic treatment within two weeks prior to surgery

3) Presence of chorioamnionitis which is defined as presence of documented rupture of membranes with fever.

04) Temperature > 100.4 F.

5) Uterine tenderness or maternal tachycardia > 100 beats/ min.

6) Foul smelling amniotic fluid.

7) Leaking per vaginum for more than 6 hours

8) Prolonged labour more than 24 hours

9) Any other infection if present

This is a cross sectional study comparing the drug efficacy of prophylactic single dose injection of cefepime given intravenously immediately after clamping the umbilical cord during caesarean section with the control group of injection Ampicillin, + Gentamicin, Metronidazole given routinely for 5 days post operatively in prevention of post-operative infection.

Injection cefepime was given IV immediately after clamping the umbilical cord during caesarean section to prevent the masking of neonatal sepsis.

Dosage schedule :

·Study group : Injection cefepime 1 gm IV as a single dose immediately after clamping the umbilical cord during caesarean section.

th·Control group : Injection Ampicillin – 500 mg IV 8 thhourly + Injection Gentamicin – 80 mg IV/IM 12

thhourly +Injection Metronidazole 500 mg IV 8 hourly

For 48 hours post operatively and switched over to oral Ampicillin and Metronidazole with injection Gentamicin for next 3 days.

We have looked for following parameters during post operative period.

01) Temperature of 100.4 F or more 24 hours after surgery.

2) Wound infection.

3) Foul smelling lochia.

4) Urinary tract infection.

5) Respiratory tract infection.

In clinical examination, patient's general condition, pulse rate, temperature, blood pressure, cardio-vascular system, respiratory system, foul smelling lochia were studied. Follow up of patients was done according to the following criteria.

·Oral temperature record was maintained 6 hourly.

·Post-operative routine investigations - urine culture was sent on the morning following removal of catheter.

·Blood culture was to be sent if fever in any patient lasted for >96 hours (4days), in case of wound infection, culture swabs were taken and sent to laboratory.

·Vaginal swab was sent for culture in suspected cases of endometritis, in cases of febrile morbidity total count, differential count and ESR was done.

·Wound was inspected as per wound infection score on rd th3 and 4 post operative day and after removal of

thsutures on 5 day.

th·The patient was discharged on 6 post-operative day if no infection was present.

·Comparison between study and control group regarding all the above criteria was done by chi-square test where frequency variables were involved and student 't' test where continous variables were involved.

Statistical analysis :

·Results are expressed as Mean SD Range and number and percentages.



·Student's t-test was used for comparing means of two groups. Chisquare test was used for analyzing categorical data.

·A P-value of 0.05 or less was considered for statistical significance.

·Chi-square test,

Results and Discussion

Table 1 showing Type of LSCS done

Types of LSCS Study (n = 100) Control (n = 100)

Elective 18(18%) 20(20%)

Emergency 82(82%) 80(80%)

It was observed that majority of caesarean section done were emergency both in study and control group

Table 2 showing Indications for caesarean sectionStudy

Indication group group

(n = 100) (n = 100)

1. Foetal distress 46 (46%) 45(45%)

2. Previous LSCS with CPD 10 8

Not willing for VBAC 2 2

Gestational hypertension 1 -

Oblique lie 1 -

Breech presentation 1 1

Threatened scar rupture 1 2

3. Previous 2 LSCS 4 4

4. Mid pelvic contraction 1 -

5. Major degree CPD 5 2

6. PE with CPD 1 -

7. Brow presentation 3 2

8. Primi with breech presentation 6 5

9. Oblique lie 1 -

10. Face presentation 1 2

11. Transverse lie 1 4

12. Placenta praevia 3 2

13. Abruptio placente 3 2

14. Imminent eclampsia 2 3

15. Oligohydramnios 3 4

16. Precious pregnancy 1 -

17. Failed induction 2 3

18. PPROM with unfavourable cervix 1 1

19. PROM - 1

20. Twins 1 -

21. Deep transverse arrest 1 1

22. Failure to progress - 4

23. Cord prolapse - 2

Control

The numbers also show the percent as the total number taken were 100 both in study and control group.

It is evident by the table that majority of the cases had indication of foetal distress, study group (46%) and control group(45%) followed by

Previous lscs with cpd,study group(10%) control group(8%).

Table 3 Showing the Wound infection score used in the study

Wound characteristics Proportion of wound infected (%)

0 < 20 20-39 40-59 60-79 > 80

Serous exudates 0 1 2 3 4 5

Erythema (>5mm from the edge of the incision) 0 1 2 3 4 5

Purulent exudates 0 2 4 6 8 10

Separation of deep tissue 0 2 4 6 8 10

Form the table it is clear that purulent exudate and wound separation were found in > 80% of the cases of wound infection.

Table 4 : showing Morbidity patterns in study and control groups

Type of LSCS Study group Control group (n = 12) (%) (n = 32) (%)

Elective 2 (11.1 %) 7 (35 %)

Emergency 10 (12.2 %) 25 (20 %)

From the table it can be seen that the morbity was more in emergency caesarean section group, study group with 12.2% and control group with 20%, highlighting the advantage of use Prophylactic antibiotic.

Table 5 : Wound infection score

Wound infection Study group Control groupscore (n=100) (n=100)

0 96(96%) 87(87%)

2 2(2%) 3(3%)

4 – 12 - 8(8%)

20 2(2%) 2(2%)

The table shows clearly shows that lesser wound score was seen in both study group (96%) and control group (87%), however the control group had more number of subjects (8%) in the higher score range of 4-12, and the sudy group did not show that trend.

Table 6 : showing the Comparison of morbidity indices in both groups

Study Group Control Group (n = 12) (n = 32)

Morbidity No. of Percent No. of Percentcases -age cases age

1) Urinary tract infection 4 4(30%) 6 6(18.7%)

2) Wound infection 4 4(30%) 13 13(40%)

3) Foul smelling lochia(endometritis) - - 4 4(12%)

4) RTI 4 4(30%) 6 6(18.7%)

5) Only fever - - 3 3(9.37%)

From the table it is clear that post operative morbidity was more in control group 32 (32%), as compared to only 12(12%) in study group.

Also it is clear that wound infection was the commonest morbidity in control group (40%).

Table 7 : Showing Additional drugs given

Groups No. of cases additional drugs given

Study 10%

Control 25%2

(X = 7.79, P < 0.01),

From the table it can be seen that more number of subjects (25%) in the control grouop required additional antibiotics to manage post operative morbidity.



Disscussion :

Puerpereal infection remains the common problem of any surgery in pregnancy. Prevention of infection is far more practical than treatment when they are established.

Advances in surgery and sophisticated life-saving procedures make it essential to pay particular attention to the prevention of infection. Previously, the use of prophylactic antibiotics in surgery was controversial for some time. But various studies have clearly proved that there is a definitive role of prophylactic antibiotics in surgery (like Parulekar et al, Chelmow et al)1,2. The primary aim of perioperative antibiotic is to reduce the infection and thereby reduce morbidity and mortality.

Study by Parulekar et al (2001)1 had included both elective and emergency caesarean section in their studies, whereas studies by Chelmow et al (2004)7, Ahmed et al (2004)7 and Baqratu et al (2002)14 included only elective caesarean section in their studies.

Faro et al (1990)15, Eliot et al (1986)16, Kristensen et al (1990)17 and Mansue et al (1989)18 had included only emergency caesarean section in their studies.

In our study, both emergency and elective caesarean sections have been included.

Inclusion and exclusion criteria of this present study were similar to Parulekar et al (2001)1.

This is a cross-sectional study comparing the drug efficacy of prophylactic single dose of Cefepime given intravenously immediately after clamping the umbilical cord during caesarean section with control group of Ampicillin+ Gentamicin, Metronidazole given routinely for 5 days postoperatively.

In all the previous studies the timing of antibiotic prophylaxis was after the clamping of umbilical cord.

In this study, Cefepime had been used for single dose antibiotic prophylaxis whereas other studies used various different antibiotics as their study drug.

In this study, the regimen for control group was Ampicillin+ Gentamicin, Metronidazole given routinely for 5 days postoperatively.

Whereas the regime for control group was different in different studies varying from no drug to multiple drugs in different routes.

We have looked for following parameters during postoperative period and compared with other studies available in world literature- febrile morbidity, urinary tract infections, endometritis, wound infection and overall postoperative morbidity.

All the studies including the present study showed single dose to be more efficacious in prevention of febrile morbidity, except in the study by Saltzman (1986) which showed better results with multiple doses antibiotic therapy compared to the single dose prophylaxis.The percentage of urinary tract infections was calculated and compared with other studies.13

The rate of post partum endometritis in study group when compared to control group in different studies showed significant difference in most of the studies.

This present study also showed statistically significant difference of incidence of endometritis (p <0.05) between two groups.

Incidence of wound infection in both study and control groups have been studied and compared with other available studies.

In the present study wound infection was significantly low (Chi-square test=5.21, p value<0.05) in the study group.

Respiratory tract infection was compared in both study group and control group.

In the present study, difference of Respiratory tract infection in both groups is not statistically significantly (Chi-square test=0.42, p value is 0.52).

In the present study, the difference of overall morbidity between the two groups is statistically significant (p value is<0.05); whereas in Von Mandach study there was no statistically significant difference.12

The cost effectiveness of the treatment in both groups was compared. Single dose antibiotic has been found to be more economic. In an economic review by Chelmow (2004) revealed a significant reduction in overall cost of treatment (30$) in the study group7.

Prophylactic single dose Cefepime has better postoperative outcome as compared to routine antibiotic therapy probably due to its administration in the per-operative period and its broader spectrum of action.

Febrile morbidity, urinary tract infection, endometritis, wound infection as also overall postoperative morbidity showed promising results.

It also reduces the hospital stay and thus reducing the financial burden on health care system.

Injection Cefepime did not produce any significant side effects in this study group.

This study failed to identify side effects of this drug probably due to small sample size.



This study should be continued, as large sample size will help to give a statistically significant difference between two groups in respect to overall postoperative morbidity and side effects of the drug. The post operative infections in both study and control groups required administration of other antibiotics by oral or intravenous route namely Ciprofloxacin, Norfloxacin, 2nd dose of Cefepime, injection Amikacin

These additional drugs were given in 10% of cases in the study group and 25% of cases in the control group. (P < 0.01) which is statistically significant.

Second dose of cefepime had to the repeated in two cases in the study group.

Conclusion

Single dose cefepime prophylaxis has shown many advantages over the control group as follows;

Cefepime significantly reduced post-operative morbidity. Cefepime prophylaxis was more cost effective. Cefepime reduced the hospital stay of the patients.

Cefepime has no major side effects. It was easy to prepare and administer than multiple doses of antibiotics. Thus it is concluded that the single dose cefepime prophylaxis in caesarean section can be widely applied in routine practice.

References1. Parulekar P, Kumar S, Awasthi RT, Tarneja P. A single dose of

cefotaxime- as a prophylaxis during caesarean section. J Obstet Gynaecol Ind 2001. Sept/Oct; 51(5):118-121.

2. Chelmow D, Hennesy M, Evantash EG. Prophylactic antibiotics for non-laboring patients with intact membranes undergoing caesarean delivery: an economic analysis. Am J Obstet Gynaecol 2004;191:1661-1665.

3. Owen J. Wound complications after caesarean section. COG 1994;37(4):842-855.

4. Turano A. Antibiotic prophylaxis for surgical infections. Am J Surg 1992;164(4A Suppl):1S.

5. Agarwal NR, Coomar DR. Single dose cefotaxime prophylaxis in caesarean section. J Obstet Gynaecol Ind 1993;43(5):752-755.

6. Ahmad ET, Mirghani OA, Gerais AS, Adam I. Ceftriaxone versus ampicillin/ cloxacillin as antibiotic prophylaxis in elective caesarean section. East Mediterr Health J 2004;10(3):277-288.

7. Baqratu JS, Moodley J, Kleinschmidt I, Zawilski W. A randomized controlled trial of antibiotic prophylaxis in elective caesarean section. Brit J Obstet Gynecol 2002;109(12):1423-1423.

8. Faro S, Martens MG, Hammill HA, Riddle G, Tortolero G. Antibiotic prophylaxis; is there a difference? Am J Obstet Gynecol 1990;162(4):900-907.

9. Eliott JP, Flaherty JF. Comparison of lavage or intravenous antibiotic at caesarean section. Obstet Gynecol 1986;67(1):29-32.

10. Kristensen GB, Beiter EC, Mather O. Single dose cefuroxime prophylaxis in non-elective caesarean section. Acta Obstet Gynecol Scand 1990;69(6):497-500.

11. Mansue GB, Tomaselli F. Antibiotic prophylaxis in non-elective caesarean section with single dose imipenem versus multiple dose cefotaxime. Riv Eur Sci Med Farmacol 1989;1(1):65-68.

12. Von Mandach U, Huch R, Malinverni R, Huch A. Ceftriaxone (single dose) versus cefoxitin (multiple doses): success and failure of antibiotic prophylaxis in 1052 caesarean sections. J Perinat Med 1993;21(5):385-397.

13. Saltzman DH, Eron LJ, Taumala RE, Protomastro LJ, Sites JG. Single dose antibiotic prophylaxis in high risk patients undergoing caesarean section-A comparative trial. J Reprod Med 1986;31(8):709-712.

14. Baqratu JS, Moodley J, Kleinschmidt I, Zawilski W. A randomized controlled trial of antibiotic prophylaxis in elective caesarean section. Brit J Obstet Gynecol 2002;109(12):1423-1423.

15. Faro S. Antibiotic prophylaxis. Obstet Gynecol Clin North Am 1989;16(2):279-289.

16. Eliott JP, Flaherty JF. Comparison of lavage or intravenous antibiotic at caesarean section. Obstet Gynecol 1986;67(1):29-32.

17. Kristensen GB, Beiter EC, Mather O. Single dose cefuroxime prophylaxis in non-elective caesarean section. Acta Obstet Gynecol Scand 1990;69(6):497-500.

18. Mansue GB, Tomaselli F. Antibiotic prophylaxis in non-elective caesarean section with single dose imipenem versus multiple dose cefotaxime. Riv Eur Sci Med Farmacol 1989;1(1):65-68.



How to Cite this article :Shivamurthy H.M., Jyotsna R. Himgire, Amrutha K, Giridhar. Case controlled Clinical study of Prophylaxis with a single dose of cefepime for caesarean section. J Pub Health Med Res, 2013;1(2):25-30


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