Journal of clinical and diagnostic research

Mammary Analogue Secretory Carcinoma- A Salivary Gland Neoplasm: Case Report of an Exceptionally Rare Tumour

Shailaja Shukla, Anamika Kashyap, Shuchita Sharma, Lubaba Kamal

Mammary Analogue Secretory Carcinoma (MASC) is a rare salivary gland tumour. It clinically presents as a painless mass in the parotid gland affecting mainly males. A 17-year-old male presented with 18 month history of a painless swelling of left parotid region. Physical examination showed a 3×3 cm, firm, non tender mass in the left parotid region. FNAC diagnosis of mucoepidermoid carcinoma was made. Final diagnosis of MASC was made on the basis of characteristic histopathology and immunohistochemistry. This tumour is considered as a low-grade carcinoma with a potential for high-grade transformation.

Non Lactational Breast Abscess due to Actinomyces odontolyticus: First Case Report from Asia

Dinoop Korol Ponnambath, MS Priyadharshini, Appalaraju Boppe

Actinomycosis is a chronic infection caused by the aerotolerant anaerobe, Actinomyces spp., characterised by the formation of abscess, draining sinuses and tissue fibrosis. Primary actinomycosis of the breast is a rare clinical presentation. We describe a rare case of breast abscess due to Actinomyces odontolyticus in a 53-year-old premenopausal woman with invasive papillary carcinoma of breast. The organism was isolated from the breast abscess and the identity was confirmed using VITEK® 2 and Matrix Assisted Laser Desorption/Ionisation-Time of Flight (MALDI-TOF). The patient was managed with modified radical mastectomy and amoxicillin-clavulanic acid for six weeks. The patient recovered completely with no recurrence on follow up visits.

Early Childhood Caries: A Case Report of an Extensive Rehabilitation

Gabriela Maltz Goldenfum, Sofia Conte Dallagnol, Jonas De Almeida Rodrigues

Early Childhood Caries (ECC) can be defined as the presence of one or more carious lesions, cavitated or not, in children up to five years of age. Presence of bacterial plaque, poor oral hygiene, frequency and time of consumption of beverages containing sugar are among the risk factors. Unfortunately, ECC has a major impact on the child's quality of life, causing pain, early tooth loss, malnutrition, delayed growth and development, difficulty in chewing, speech problems, general health disorders and psychological problems. This paper presents a case report of a 3-year-old male patient, diagnosed with ECC and describes the therapeutic approach that ranges from effective measures to control caries activity, rehabilitative and restorative treatment, to changing of the eating habits and oral hygiene of the child.

Papillary Renal Cell Carcinoma Presenting as a Perinephric Abscess

Vinod Kumar, Sushant Nanavati, Luis Carlos Ortiz, Fnu Komal, Monisha Singhal

Typically, Renal Cell Carcinoma (RCC) presents with distinguishing features of flank pain, abdominal palpable mass and haematuria. Other clinical symptoms include weight loss, anorexia and metastasis to the lungs. In rare instances, patients may present with infected renal mass that may be underlying malignancy. Herein, we report a case of a 65-year-old, African American man presenting with flank pain and fever suspected of a renal abscess and eventually diagnosed with Papillary RCC (pRCC) type II requiring radical nephrectomy and initiating adjuvant tyrosine kinase inhibitor (sunitinib).

Basal Cell Adenoma Arising in the Minor Salivary Gland of the Hard Palate

Tatsuo Okui, Soichiro Ibaragi, Keisuke Nakano, Yukiko Fujii, Akira Sasaki

Basal Cell Adenoma (BCA) is an extremely rare benign salivary gland tumour that usually arises in the parotid gland. The incidence of BCA is 1%-3% of all salivary gland tumours. Here, we report an extremely rare case of BCA arising in the minor salivary gland of the hard palate of a young man.

Nasopharyngeal Carcinoma: A Deceptive Presentation as Deep Neck Space Abscess

Raghul Sekar, Vignesh Karunakaran, Arun Alexander

The presentation of Nasopharyngeal Carcinoma (NPC) can be clandestine and deceptive. The NPC presenting as a deep neck space infection with airway compromise and intracranial extension is a rare occurrence. We report a case of 60-year-old male presenting with headache followed by right sided neck swelling with breathing difficulty with a Computed Tomography (CT) scan revealing a collection in deep neck space and destructive mass in the nasopharynx. We discuss the varied presentation of NPC from a trivial headache till life threatening stridor and furthermore review the literature emphasising on the same.

Autoimmune Haemolytic Anaemia: An Unusual Manifestation of Kawasaki Disease

Aashish Gupta, Rahi Raza, Ayush Manchanda, Jacob Puliyel

Intravenous Immunoglobulin (IVIg) can cause Autoimmune Haemolytic Anaemia (AIHA) in some patients. There are many reports of AIHA developing in children with Kawasaki Disease (KD) after they were treated with IVIg. However, AIHA is seldom reported at the onset of KD, prior to the treatment with IVIg. Here, we report a case of a 10-month-old infant, who developed AIHA alongside the manifestations of KD. Treatment with IVIg resulted in the resolution of symptoms of both KD and AIHA. We also present a review of the literature on similar findings. This suggests that AIHA may be an uncommon manifestation of KD; or that KD and AIHA may both be stimulated, in susceptible persons, by some common agent.

Cerebral Microbleeds with Posterior Reversible Encephalopathy Syndrome: A Rare complication in Acute Lymphoblastic Leukaemia

Aravind Yogabalan, Karthick Udupa

Cerebral microbleeds are a rare entity usually seen in hypertensive microangiopathy or amyloid angiopathy. Its occurrence in Acute Lymphoblastic Leukaemia (ALL) has not been reported so far. Clinicians while treating patients should be aware of such complications for timely diagnosis and management. This is a case report on 19-year-old male, who was on treatment for ALL, under induction phase of the Berlin-Frankfurt-Munster-95 (BFM-95) regimen, who developed one episode of generalised tonic-clonic seizures. The MRI brain in T2 sequence showed hyperintense lesions in the white matter of occipital region, suggestive of Posterior Reversible Encephalopathy Syndrome (PRES). Susceptibility Weighted Imaging (SWI) showed multifocal areas of blooming in bilateral cerebral hemispheres suggestive of microbleeds. The fibrinogen level was very low strongly suggestive of L-Asparaginase induced microbleeds. The patient was treated with antiepileptic and cryoprecipitate transfusion to maintain fibrinogen levels and further doses of L-Asparaginase were withheld. He recovered without any neurological sequelae.

Transarterial Embolisation of Post-traumatic Uterine AVM-Uterus Salvaging Minimally Invasive Treatment Option

Udit Chauhan, Jaya Chaturvedi, Mohit Tayal

Uterine Arterio-Venous Malformations (AVM) are uncommon cause of uncontrolled uterine bleeding. The incidence of their occurrence is rare and is mostly associated with trauma following Dilatation and Curettage (D&C). Their recognition is important as they could lead to life threatening haemorrhage and death. Diagnosis includes a high index of suspicion coupled with modalities like colour Doppler and MRI. Hysterectomy was the main stay of treatment in the past, but in current scenario, angioembolisation is considered as the best treatment option, since most of the patients are in the young reproductive age group. Authors present a case of post D&C uterine AVM in a young female who presented with persistent uterine bleeding and was successfully treated with angioembolisation using Poly Vinyl Alcohol (PVA) particles and gel foam. We also wish to highlight important diagnostic features of uterine AVM along with available treatment options.

Neurodynamic Technique for Functional Ankle Instability: A Case Report

Vinodhkumar Ramalingam, Viswanath Sundar, Saju Joseph

Athletes who encounter repeated Functional Ankle Instability (FAI), exhibit excessive foot inversion during the various phases of gait than non-injured ankle. In gait, heel strike to toe off inversion ankle movement of the foot is controlled by eccentric function of the peroneus muscle, which stabilizes the ankle joint. As such, the purpose of this study was to investigate the response of biomechanical characteristics during gait cycle by applying neurodynamic exercise technique. An athlete with repeated FAI was checked for dynamic balance (Y-balance) and knee range of motion (using a electro-goniometer). To test the peroneal longus muscle activity and gait parameters, synchronisation of Surface Electromyography (sEMG) (Noraxon Myo-Muscle) was done with an instrumented myo-pressure treadmill in both injured and non-injured leg. Six-week post intervention measurements exhibited significant improvement in dynamic balance, knee range of motion, pain score, efficient peroneal muscle response and gait parameters. This ascertains the effect of neurodynamic technique..

Carcinosarcoma Gallbladder: A Rare Variety of Gallbladder Malignancy

Koustav Jana, Amit Kumar Das, Suman Saha, Ranajoy Ghosh, Sukanta Ray

Gallbladder malignancy is frequently found in Indian population. Most of them are adenocarcinoma variety whereas carcinosarcoma variety is quite rare. It is typically characterised by presence of both epithelial and mesenchymal components. The prognosis of this variety is poorer because of its aggressive nature and delayed diagnosis. Here we report a case of Carcinosarcoma of Gallbladder (CSGB) in a 40-year-old lady presenting to us with features of acute cholecystitis and gallbladder mass. She was treated with radical cholecystectomy, bile duct excision and Roux-en-Y Hepaticojejunostomy (RYHJ). Histopathological examinations reveal pleomorphic spindle cells as well as epitheloid cell. In postoperative period she received adjuvant chemotherapy. Despite all these treatment she developed recurrence at seven months follow up.

Rhino-Orbital-Cerebral Mucormycosis Causing Orbital Apex Syndrome and Blindness

Mucormycosis is a potentially fatal fungal infection caused by a group of molds called mucormycetes. Rhino-Orbital-Cerebral Mucormycosis (ROCM) represents nearly half of all cases. This is the case of a 46-year-old female recently diagnosed with leukaemia and was started on chemotherapy. After initiating chemotherapy, she complained of headache, blurring of vision in the right eye and nasal discharge. Examinations revealed orbital apex syndrome. MRI disclosed an inflammation affecting the right orbit, ethmoid sinus and the frontal lobe. Ethmoidectomy was performed and biopsies confirmed mucormycosis. After that, symptoms persisted and complete loss of vision in her right eye occurred. Right orbital exenteration was required. The response was noticed over the subsequent weeks until she became asymptomatic. Five weeks after initially being diagnosed with leukaemia, she entered remission and was discharged on oral itraconazole and oral retinoic acid. Later, she remained in complete remission. In conclusion, early suspicion and diagnosis especially in immunocompromised patients with early aggressive treatment can be life saving.

Gastric Tuberculous Ulcer Perforation Presenting as Acute Peritonitis

Koch’s bacillus infection is a rare cause of gastric ulcer. Gastric perforation associated with tuberculosis is extremely rarely presented as generalised peritonitis. A 39-year-old patient presented with epigastralgia with fever for one week. The physical examination found a generalised abdominal defense. Computed tomography evoked the diagnosis of perforated duodenal ulcer. The patient was operated and a suture excision of a perforated gastric ulcer was performed. The mesentery contained multiple lymph nodes. The small intestine was uniformly carded. The histopathological examination showed a gastric tuberculous ulcer. Acute peritonititis complicating tuberculous duodenal ulcer should be evoked especially in endemic area. Clinical history, abdominal CT scan results, and intraoperative exploration should suggest this diagnosis with therapeutic implications.

Granular Cell Tumour of Breast-An Enigmatic Entity-Case Report with Emphasis on Role of Frozen Section

Pooja Jain, Geetha Vasudevan, Padmapriya Jaiprakash, Stanley Mathew

Granular Cell Tumour (GCT) is a rare tumour involving the breast, pre- and intraoperative diagnosis of which plays an important role in deciding the treatment. Recognition of this usually benign tumour is important, since clinical (irregular and firm), radiological (ill defined or spiculated lesion without microcalcifications) and gross findings often mimic carcinoma. We report a case of a GCT of the breast mimicking carcinoma clinically and on mammography. The diagnosis was made by frozen section, confirmed by histological examination and immunohistochemistry (IHC). We emphasise the role of frozen section and intraoperative diagnosis in guiding treatment and preventing radical surgery. The clinico-radiological, histopathological and therapeutic aspects of this rare tumour, are also discussed.

A Rare Case of Primary Leiomyosarcoma of the Ovary

Vishwanath, Neetha M Vyas, Shreeja Goripally, Supriya Rai

Ovarian leiomyosarcoma is a very rare tumour representing less than 1% of all ovarian tumours. Primary sarcoma of ovary is about 3% of all ovarian tumours. Fibrosarcoma, chondrosarcoma, angiosarcoma, rhabdomyosarcoma and leiomyosarcoma have been reported. They have an aggressive behaviour and poor prognosis. Till date less than 100 cases have been reported. Because of their rarity, there is no case series to establish definitive treatment guidelines. Even the type of adjuvant therapy which could be beneficial has not yet been established. We present a case of ovarian leiomyosarcoma in which patient underwent total abdominal hysterectomy with bilateral salphingo-ophorectomy, pelvic lymphadenectomy and omental biopsy. Microscopy and Immunohistochemistry (IHC) established the diagnosis.

Primary Intraarticular and Extraarticular Synovial Chondromatosis at Foot and Ankle: A Case Report and Review of Literature

Raghavendra S Kembhavi, Boblee James

Synovial chondromatosis is a benign condition in which the synovial tissue undergoes metaplastic changes into cartilagenous or osteocartilagenous bodies within joints, bursae or tendon sheaths. Knee, hip, shoulder, elbow are the commonly involved joints whereas foot and ankle joints are rare joints to be involved. They are classified into primary or secondary form depending on whether disease develops in apparently normal joint or in a pre-existent pathology like arthritis. Synovial chondromatosis can be intraarticular or extraarticular or combined. Here we report about a 52-year-old female presented with the history of mild swelling over right ankle associated with painful and terminal restriction of movement at ankle joint. She was operated with open excision of loose bodies and synovectomy. Postoperative histopathological examination confirmed the diagnosis of synovial chondromatosis without cellular atypia. Twelve months postoperative, patient was asymptomatic with no signs of recurrence.

Common Trunk Arising from Ansa Cervicalis Innervating Strap Muscles along with Sternocleidomastoid: A Case Report

Binita Chaudhary, Prabhas Ranjan Tripathy, Manisha Rajanand Gaikwad

The infrahyoid muscles (omohyoid, sternohyoid, sternothyroid and thyrohyoid) are innervated by Ansa Cervicalis (AC) and are involved in movement of hyoid bone, thyroid cartilage during vocalisation and swallowing. Though variations in the formation and looping pattern of AC are reported in the literature, here we present a rare branching pattern of AC. During routine undergraduate dissection class, we have come across a rare variant of AC which has clinical significance. On the left side of the neck a common trunk was found to be arising from the loop of AC which trifurcated to supply inferior belly of omohyoid, sternohyoid and sternothyroid. This trunk was also providing a branch to sternocleidomastoid. Surgeons should keep such variation in mind while operating in the carotid region. If accidently during surgery or stab wound in the neck, this common trunk is cut, the function of inferior belly of omohyoid, sternohyoid and sternothyroid will be compromised leading to difficulty in deglutition and voice production. In unilateral vocal cord paralysis, artificially created anastomosis between AC and recurrent laryngeal nerve gives excellent to normal result in affected vocal cord. In thyroid surgery, recurrent laryngeal nerve is injured leading to vocal fold paralysis. To restore the nerve supply to the larynx in such cases neurorrhaphy (end to end anastomosis) between AC and recurrent laryngeal nerve is the choice of treatment.

Sibling Screening of a Case of Pyroglutamic Aciduria Resulting in Normal Development- A Case Report

Nalini Bhaskaranand, Saritha U Kamath

Pyroglutamic aciduria is a condition usually associated with metabolic acidosis and increased excretion of pyroglutamic acid in urine. It occurs due to metabolic defect in ?-glutamyl cycle. Here we report a case of 5-month-old male baby presented with respiratory symptoms who had a history of two months age sibling death due to pyroglutamic aciduria which was diagnosed by Gas Chromatography Mass Spectrometry (GCMS). Analysis of urine for organic acid by GCMS in the present baby also showed increased excretion of pyroglutamic acid. Hence in the present baby history of sibling death due to pyroglutamic aciduria led to the early diagnosis. Proper medication and timely management during fever and cold resulted in normal development.

Aortopulmonary Window: Case Report of Survival in Untreated Adult Patient

Neha Nischal, Sakshi Arya, Ruchi Gupta, Nayna Goyal, Sunil Kumar Puri

Aortopulmonary window is a rare congenital communication between ascending aorta and main pulmonary artery. The condition carries poor prognosis in absence of early corrective surgery. Few case reports exist in literature where adult survival is seen in untreated patients. We present such a case of a 27-year-old male who had developed irreversible pulmonary hypertension secondary to aortopulmonary window and is thus being managed medically.

Excision of Masson’s Haemangioma Following Suspected Liposarcoma on Imaging

Jayan George, Duncan Meikle, Andrew Whitfield, Susan Hill

Lipomas are commonly seen in general practice. Lipomas of large size should be investigated for the possibility of a soft tissue sarcoma. Intravascular papillary endothelial hyperplasia (Masson’s haemangioma) is a benign non-neoplastic vascular lesion that can mimic soft tissue sarcomas and can lead to an incorrect diagnosis. We report a case of a 60-year-old male artist who had an 8×8 cm swelling of his left mid-scapular region, without history of injury or trauma. Ultrasound and Magnetic Resonance Imaging (MRI) were suggestive of a lipoma or a liposarcoma. Tissue biopsy revealed fibrous tissue with a dense capillary network suspicious of a vasoformative lesion. The patient was discussed in the sarcoma multidisciplinary team and a surgical excision was decided. At the time of wide local excision, a haematoma and thrombosed veins were seen. Histology revealed a Masson’s haemangioma.

The Iron Man

The clinical presentation of haemochromatosis is usually complex and differs from patient to patient. We present one such complex case of primary haemochromatosis in a 35-year-old man with congestive heart failure and non-sustained ventricular tachycardia. He was a known case of diabetes, was infertile after nine years of marriage, and displayed haepatomegaly with increased homogenous attenuation of liver. His serum iron levels (347 µg/dL) and serum ferritin levels (2169 ng/mL) were very high, which made us call him an ‘Iron Man’. Liver biopsy and genetic testing confirmed the diagnosis of primary haemochromatosis. With regular phlebotomies, along with treatments for secondary complications, his symptoms improved gradually and the patient is doing well for past 11 years.

Rituximab Therapy in Pulmonary Alveolar Proteinosis: A Rare Case Report

Fatemeh Aghaei Meybodi, Salar Khazani Fard, Mojtaba Babaei Zarch, Mostafa Babai

Pulmonary Alveolar Proteinosis (PAP) is a rare disorder characterised by accumulation of surfactant in alveoli due to impaired surfactant clearance. Although, whole lung lavage is the standard treatment of PAP, rituximab has also been introduced as a therapeutic option for PAP. A 49-year-old female patient, a known case of PAP, came to the outpatient clinic complaining of exacerbation of dyspnoea. The patient was treated with rituximab four times in a year. Finally, the clinical status and spirometry tests showed improvement. Although, the main treatment for PAP is whole lung lavage, other therapeutic options may be useful too. According to the prior case reports and the present one, rituximab can be useful in treatment of PAP.

Ectopic Ureter Causing Hydrometra in a Case of Cervical Dysgenesis with Vaginal Agenesis

Cervical agenesis or dysgenesis is the defect of vertical fusion of the mullerian duct and the urogenital sinus. The reported incidence is 0.01% in general population. Up to 53% of patients with mullerian agenesis have concomitant congenital malformations and hence these patients should be thoroughly evaluated for the same. We report a case of cervical dysgenesis with ectopically located right ureter in the uterus. This patient had cervical obstruction with absent vagina. Conservative surgical approach was adopted. Cervical reconstruction with cervicovaginal anastomosis with the neovagina was done. The ectopically located ureter was cut and reimplanted into the bladder. Hence in patients with cervical agenesis or dysgenesis radicle approach like hysterectomy should be adopted only in case of failure of conservative surgery. Thus giving the patient a chance for healthy reproductive life and prevent premature ovarian failure.

Extramedullary Plasmacytoma Presenting as Lung Cancer

Gajanan S Gaude, Avya Bansal

Extramedullary Plasmacytoma (EMP) is a rare plasma cell tumour without any other systemic characteristics of multiple myeloma. They are commonly observed in tissues of the upper aerodigestive tract and are extremely rare tumours. Herein, we report an extremely unusual presentation of EMP as endobronchial mass without any bone involvement.

Pseudomonas monteilii an Emerging Pathogen in Meningoencephalitis

Varsha Gupta, Shiwani Sharma, Lipika Singhal, Ranu Soni, Jagdish Chander

Pseudomonas monteilii (P. monteilii) is a gram negative, rod shaped, nonsporing, motile, non-fermenting bacterium belonging to family Pseudomonadaceae. It is a known environmental contaminant, has been seen as an emerging opportunistic pathogen and is closely related to Pseudomonas putida. We isolated this organism from a young immunocompetent patient with meningoencephalitis, who despite of treatment had a fatal outcome.

A Difficult Case in Clinical Practice: Combined Polycythaemia Vera and Protein S Deficiency in a Patient with both Thrombotic and Bleeding Complications

Polycythemia Vera (PV) is a chronic myeloproliferative disorder which is characterised by a high risk of developing arterial as well as venous thromboembolic complications like deep vein thrombosis, stroke, cortical vein thrombosis and rarely acute Myocardial Infarction (MI). PV has a risk rate of major thrombosis as high as 50%. Bleeding, thrombotic, and vascular complications are the major causes of morbidity and mortality, occurring in 40 to 60% of these patients. MI with heart failure is the most common cause of death in these patients. Congenital Protein S deficiency is an autosomal dominant disease. Venous thrombosis develops in 60-80% of patients who are heterozygous for Protein S deficiency. Hereditary Protein S deficiency is a well known risk factor not only for venous thrombosis but also for arterial thrombosis including MI and stroke. However, association of Protein S deficiency with arterial thrombosis is less appreciated. Very rarely, we find all the varied thrombotic complications in one patient. We hereby present a case who had varied thrombotic presentations due to underlying polycythemia with Protein S deficiency.

Granulomatosis with Polyangiitis Presenting as a Diagnostic Challenge: A Report of two Cases with Literature Review

Jahnvi Dhar, Alpana Meena, Mradul Kumar Daga, Sunita Aggarwal

Vasculitis is defined as a clinicopathological entity characterised by inflammation and destruction of the wall of the blood vessel. Granulomatosis with Polyangiitis (GPA), earlier commonly known as Wegener Granulomatosis (WG) is a primary vasculitic pathology, which is a systemic disease with myriads of clinical presentations. It is an uncommon disease presenting with the triad of involvement of upper and lower respiratory tracts along with renal involvement in the form of glomerulonephritis. However, isolated organ involvement as a first clinical presentation without a chronic course of the disease culminating into a diagnosis of GPA is very uncommon and only isolated case reports are available in literature. Here, we describe two case reports of GPA, one of a young girl who presented with chest pain and suddenly developed necrotising scleritis with loss of vision and the second a middle aged female who presented with sudden onset breathlessness without haemoptysis and deranged Kidney Function Test (KFT) which diagnosed it as Pulmonary Renal Syndrome (PRS) {Diffuse Alveolar Haemorrhage (DAH)}. In both the cases, a strong clinical suspicion of vasculitis led to the diagnosis of GPA. These two case reports highlight the importance of timely intervention which resulted in a fruitful outcome for both the patients.

Root Canal Treatment of Three Rooted Maxillary First and Second Premolar using CBCT: A Case Report

Parul Mour Agarwal, Sonali Taneja

A discrete knowledge of the innate anatomy of a tooth is imperative for favourable endodontic treatment. Meticulous understanding of tooth morphology, judicious study of angled radiographs, emphasis on access cavity modifications and thorough exploration of the pulpal floor under magnification are important factors that contribute to successful treatment outcome. The present case report outlines the diagnostic approach and endodontic management of maxillary 1st and 2nd premolar with three root canals, each treated with the aid of operating microscope and Cone-Beam Computed Tomography (CBCT) image.

Abdominal Aggressive Fibromatosis: Diagnostic and Therapeutic Features

Desmoid tumours are rare soft tissue tumours developed from myofibroblasts. They usually infiltrate into adjacent muscle bundles and are characterised by the absence of metastatic potential. However, a high local aggressiveness is seen with a high rate of recurrence after surgical excision. We hereby attempt to present a series of patients with desmoid tumours and review treatment options and management strategies. Ten tumours occurred in the abdominal wall, five in the mesentery, and one was presacral tumour. The mean diameter of the tumour was 6 cm (range, 2.3-40 cm). Associated Familial Adenomatous Polyposis (FAP) was found in five patients. The margin of surgical resection was healthy in five patients. During follow up period, two patients returned with recurrence of tumours.

Dengue Co-infections-An Emerging Entity during the Outbreak

Prasan Kumar Panda, Srikant Mohta, Naveet Wig, Manish Soneja

Viral infections predispose a patient for super added infections and it is important to know the spectrum to suspect them. We analysed 98 cases of dengue fever who were presented at a tertiary care hospital; of which 12 were associated with co-infections. Bacterial infections were the most common type of co-infections (50%; n=6). Viral co-infections were present in 25% patients (n=3) and included hepatitis A, hepatitis B, and chikungunya. The remaining co-infections included parasitic and fungal co-infections. Severe dengue was seen in 83.3% cases (n=10). Amongst the organ involvement, the liver was maximally involved followed by deranged haematological parameters. Mortality was seen in 25% cases (n=3). Few unique co-infections caused by organisms like Ascaris and Aspergillus were identified. There is a possibility of bilateral increase in the severity of few co-infections. Prolonged fever (=5 days) and severe organ dysfunction should alert the physician to actively look for co-infections.

Congenital Midline Cervical Cleft –Clinical and Pathological Review of Three Cases

Anjireddy Kallam, M Anantha Satyanarayana

We are presenting three rare cases of Congenital Midline Cervical Cleft (CMCC). All are treated by excision and Z-plasty. Embryology, clinical appearance, histopathology and treatment have been discussed with review of the available literature.

Process of Developing of Community Based Medical Education Programme Curriculum in Puducherry, India

Kalaiselvan Ganapathy, Amol R Dongre

We have developed, implemented and evaluated context specific Community Based Medical Education (CBME) programme. The present CBME programme was developed and implemented in villages served by the Rural Health Training Centre (RHTC) of the Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital (SMVMCH), Puducherry, India. It was a programme development and evaluation design consisted of feedback from students, group interview with small group tutors and Focus Group Discussion (FGD) with community members. Five batches consisting of 629 medical students over a period of five years were exposed to the CBME programme. The following steps were used in the process of curriculum development: Need for a CBME programme: It was observed that students had difficulty in relating health problems with social, economic and environmental conditions. Medical Council of India (MCI) envisions the curriculum to be an active process, student-centred and addressing the needs of the community. Development of expected outcomes: We reviewed previously published needs-assessment survey and FGD findings from local community. It was followed by Delphi study with experts. Plan for teaching and learning: In a selected village, students were allotted three to four families for family study and each small group of students were supervised by trained small group tutors. Feedback to students and faculty reflections: Students were given feedback on their assignments. It was followed by reflections by small group tutors to further improve the teaching programme. Team formation and training: We formed a team consisting of faculty, post-graduates in community medicine, medical interns, medical social workers and active members of ‘gram-panchayat’ for implementation and supervision. Evaluation: Students perceived improved ability to identify health problems and relate them with social, economic and environmental conditions. They learned to interact with local community on common health issues. Community members felt that students could sensitise them to various environmental issues such as mosquito breeding places, stagnation water and waste disposal.

Role of Ascorbic Acid in Ameliorating Testicular Tissue Damage Induced by Testicular Torsion and Detorsion: An Animal Model Study

Anu Vinod Ranade, Yogesh Tripathi, CV Raghuveer, Rajalakshmi Rai

Introduction: Testicular torsion-detorsion induced tissue damage, in neonates or adolescents may hamper fertility potential in their future life. Ascorbic acid being a water-soluble antioxidant has a number of antioxidant properties and is the most important antioxidant in human plasma. Aim: To evaluate the potential role of ascorbic acid in ameliorating testicular tissue damage induced by testicular torsion and detorsion in wistar rats. Materials and Methods: Forty male albino wistar rats were randomly divided into four groups. Group I served as normal control while Group II underwent Sham operation. Animals of Group III underwent testicular torsion and detorsion without any treatment while animals of Group IV were pretreated with ascorbic acid for 30 days, followed by 3 hours of testicular torsion and one hour detorsion. In the animals that underwent testicular torsion the testis appeared devitalised and a mild testicular oedema was observed. On detorsion, there was a slight further increase in oedema beside reactive hyperaemia. Other than this no complications were seen in the rats during the observation period. All the animals were sacrificed 1 hour after the experimental procedure, and testicular tissue sample was collected and evaluated for Seminiferous Tubular Diameter (STD), Seminiferous Epithelial Height (SEH), tubular necrosis, tissue lipid peroxidation, tissue glutathione and superoxide dismutase levels. Statistical analysis was done using SPSS package version II. The analysis of multiple group variation was done by ANOVA. Intergroup comparison was done by post-hoc (LSD) test. Results: Animals of Group III showed a decrease in STD and SHE compared to Groups I and II. A four-fold increase in lipid peroxidation was observed in these animals (Group III). Superoxide dismutase and tissue glutathione levels were considerably reduced in these animals. Whereas, animals of Group IV showed merely 25% of seminiferous tubular necrosis with no significant decrease in their STD and SEH. A significant reduction in lipid peroxidation was also observed in these animals with antioxidants showing near to normal value compared to their untreated controls. Conclusion: Results of the present study display that pretreatment with ascorbic acid offers salvaging effect on the testicular torsion-detorsion induced injury in rats.

Craniovertebral Junction Compression due to Posterior C1 Arch in Morquio Syndrome: A Diagnostic Dilemma

Basharath Husseni Khan, Ajit Singh, Girish Menon, Tom Devasia

Pressure Bandaging for Fingers Using Finger Crepe: An Economic and Effective Method

Manoj Bachhav, Raghav Shrotriya, Vinita Puri

A Modified Approach for Ultrasound-guided Lumbar Facet Joint Injection: Caudal-to-Cranial Technique

Ke-Vin Chang, Wei-TingWu

Correspondence: Modulation of Lung Function by Increased Nitric Oxide Production

Anirban Mandal, Puneet Kaur Sahi

Hypocalcaemia Following Transfusion of a Small Volume of Red Blood Cell Concentrate: An Unusual Case

Lalita Jyotsana Prakhya, Shivali Sehgal, Priti Chatterjee

Correlation of Personality Traits with Happiness among University Students

Arash Ziapour, Alireza Khatony, Faranak Jafari, Neda Kianipour

Introduction: Nowadays, happiness has changed into one of the indices of development in society. The significance of happiness doubles when it comes to lively strata of university students. Aim: The present study was aimed to investigate the relationship between the five-factor model of personality traits and happiness among the students of Kermanshah University of Medical Sciences, Kermanshah, Iran in 2015. Materials and Methods: In this descriptive-correlational study, 350 students of Kermanshah University of Medical Sciences were selected through stratified random sampling. For data collection, a demographic questionnaire, the revised NEO Personality Inventory (NEO PI-R) and Oxford Happiness Inventory (OHI) were used. Data were analysed through descriptive statistics (percentage, mean, and standard deviation) and inferential statistics (the Pearson product-moment correlation coefficient and multiple regression analysis). Further, the SPSS statistics software V.21 was utilised for data analysis. Results: The results of correlation analyses demonstrated that there was a significant positive relationship between happiness (p<0.001) and each of the personality trait dimensions of extraversion (p<0.001, r=0.594), agreeableness (p<0.001, r=0.431), neuroticism (p<0.001, r=0.368), conscientiousness (p<0.001, r=0.351), and openness to experience (p<0.001, r=0.151). Additionally, the results of regression analysis showed that aside from openness to experience, the other four dimensions of personality traits could significantly predict the changes of happiness (p<0.001). Conclusion: To extend happiness among university students, the personality traits can be adjusted to some extent. Therefore, if the extension of happiness is high on the lists of managers, it can be influenced in different ways, and the personality traits can be developed with the help of various management techniques.

Initial Experience with Grafalon as Induction Agent in Kidney Transplantation

Divyesh Engineer, Himanshu Patel, Vivek Kute, Pankaj Shah

Introduction: Renal transplantation is ideal modality of Renal Replacement Therapy (RRT) as it is cost effective and associated with quality of life. Induction immunosuppression is an immunosuppressive therapy given at the time of transplantation to reduce risk of acute rejection. Induction agents include lymphocyte depleting antibodies and Interleukin-2 (IL2) receptor antagonists. Commonly used lymphocyte depleting antibodies are ‘Thymoglobulin’ and ‘Grafalon’. There is no study with Grafalon as induction agent in renal transplantation from India, as until recently it was unavailable in India. Current study is the first report from India, of Grafalon use as an induction agent in renal transplantation. Aim: The aim of the present study was, to study safety and efficacy of ‘Grafalon’ as induction agent in kidney transplantation. Materials and Methods: This was a single center study of 11 patients who have received Grafalon as induction agent for renal transplantation. All received steroid pulse and Grafalon 4 mg/kg as induction. Maintenance immunosuppression consisted of prednisolone, tacrolimus and mycophenolate sodium. Results: Four patients (36.3%; 95% Confidence Interval (CI), 8 to 65%) developed biopsy proven acute rejection. Three patients had combined acute T-cell and acute antibody mediated rejection and one had acute T-cell mediated rejection. One patient died due to rhinocerebral mucormycosis and one graft was lost due to graft thrombosis. Two patients got urinary tract infection, one with wound infection and another one developed cytomegalovirus syndrome. Cost of Grafalon induction (4 mg/kg) was higher compared to Thymoglobulin (1.5 mg/kg). Conclusion: Induction with Grafalon was associated with high rate of acute rejection, at the dosage used in the present study. So, cannot be recommended in clinical practice at this dose.

Treat the Patient Not the Image: Non-operative Management of High Grade Solid Organ Injuries in Abdominal Trauma

Ameet Kumar, Sumesh Kaistha

Introduction: Trauma is a modern day epidemic. Abdominal trauma is the most common cause of trauma-related death that is preventable. Non operative Management (NOM) is increasingly being done in Blunt Abdominal Trauma (BAT). However, for high grade injuries, the risk of failure of NOM has been shown to be higher. Aim: To assess the feasibility and success rate of NOM in abdominal trauma with high grade solid organ injury. Materials and Methods: The present study was a retrospective review of a prospectively maintained database at a Tertiary Care Centre. 17 blunt trauma abdomen cases with high grade solid organ Injuries over a period of four and a half years without peritoneal signs or persistent haemodynamic instability after initial resuscitation were included. Data was analysed using online statistical software (graphpad). Results: Of the 17 cases with high grade injuries, two had contrast extravasation on imaging. Predominant organ involved was spleen in 11 (64.8%), liver in 10 (58.8%) and pancreas in one patient, respectively. NOM was successful in 100% of patients. Three patients had rebleeding and all were successfully managed non-operatively. There was no mortality. Conclusion: The NOM is feasible and safe even in high grade injuries in BAT. This decision is based on a sound clinical judgment and should be attempted at centers with facilities for critical care, interventional radiology and adequate blood bank facilities. The patient condition and not the grade of injury on imaging should dictate the line of management.

Efficacy of Electroconvulsive Therapy in Various Psychiatric Disorders: A Hospital Based Longitudinal Follow-up Study

Yuman Kawoos, Irfan Ahmad Shah, Yasir H Rather, Zaid A Wani, Waris A Zarger

Introduction: Electroconvulsive Therapy (ECT) is one of the neurobiological therapies available for the treatment of various psychiatric disorders especially those resistant to pharmacotherapy or, where a rapid response is needed. Aim: To study the response of patients with different psychiatric disorders to ECT and study the relationship between seizure duration and response. Materials and Methods: It was a longitudinal study where a total of 40 patients were studied. Patients aged =12 years, who were resistant to pharmacotherapy or, having conditions where rapid response was warranted like suicidality or catatonia were included in our study as cases. A written informed consent was taken from all patients or their caretakers wherever necessary. Scales for assessment of various disorders were applied before and after treatment. Results: Majority of the patients 37.5% were in the age-group of 38-47 years followed by 22.5% in 28-37 years. Only 5% of patients were aged >60 years. Males were slightly higher in number as compared to females (21:19). Affective disorders formed the major group of the patients (75%) followed by schizophrenia (10%), obsessive compulsive disorder (10%) and mental retardation (5%). Overall, 75% of patients showed >50% response to ECT with maximum response seen in affective disorders. No significant relation was seen between seizure duration and response to ECT. Conclusion: ECT is very effective for treating various psychiatric disorders especially affective disorders. ECT is life saving in conditions like catatonia and suicidality.

Sysmex XN1000 versus Manual Method in Leukopenic Blood Samples

Divya Pursnani, Surekha B Hippargi

Introduction: Complete Blood Cell (CBC) and` differential leukocyte tests are one of the most common haematology laboratory investigations. Immature Granulocytes (IGs) form a part of extended leukocyte differential count and is considered as a promising tool for screening and early detection of bacteraemia. Differential leukocyte analysis provides information regarding the underlying pathologic process. Manual method of performing these counts is labor-intensive, time-consuming especially in leukopenic blood samples, lacks reproducibility and objectivity and therefore suffers from increased inter observer variation. Automated counts provided by the haematology analysers on the other hand are supposed to be more precise, objective and help to reduce the Turnaround Time (TAT). Aim: Comparison of Differential Leukocyte Count (DLC) and IG flagging by automated haematology analyser XN1000 with findings of manual method in leukopenic blood samples. Materials and Methods: The study included 346 patients considering the inclusion and exclusion criteria. CBC analysis was done using Sysmex XN1000. All leukopenic samples enumerated by the analyser were included and peripheral smears were made for each of them. Manual counts were correlated with cell counter counts. Statistical analysis was done using linear regression and correlation analysis. Mean counts were compared using Student's t-test. Pearson’s correlation coefficient and regression analysis was used for correlation studies. Bland-Altman plot analysis was also performed to compare the two measurement techniques. Results: Correlation coefficient for neutrophils, lymphocytes, eosinophils, monocytes and basophils proportional counts were 0.998, 0.992, 0.996, 0.771 and 0.570 respectively; and for absolute counts 0.999, 0.994, 0.996, 0.825 and 0.585 respectively. IG proportional and absolute counts correlation coefficients were 0.898 and 0.908 respectively. Sensitivity was 97.30%, specificity 91.91% and efficiency 92.49% for IG flagging. Conclusion: Strong positive correlation was observed between automated and manual neutrophil, lymphocyte, eosinophil, monocyte and IGs proportional and absolute counts. Basophil showed moderate degree of correlation for both proportional and absolute counts. IG flagging by Sysmex XN1000 showed high sensitivity, specificity and efficiency.Thus, automation seems to be a suitable, reliable and practical option for leukopenic blood samples keeping in view the results obtained by this analyser.

Perceptions of Patients and Physicians Regarding Need for Taking Ayurveda Therapy

Introduction: Globally there is great awareness about complementary health systems and its integration. Ayurveda is nowadays being increasingly preferred by patients; however, reasons for patients need to attend ayurveda Outpatient Department (OPD) and the approach of allopathic physicians towards ayurveda is minimally highlighted. Aim: To assess needs of patients attending ayurvedic OPD in an allopathic setup and to assess the clinical needs of physicians practicing allopathy for conditions which are not adequately treated by allopathy. Materials and Methods: A cross-sectional study among 300 patients attending ayurveda OPD and 50 allopathic physicians of a tertiary care hospital was undertaken after Institutional Ethics Committee permission. Separate questionnaires for patients and physicians related to needs of ayurveda were validated for content and administered to patients and physicians after receiving their due consent. Data entered in MS Excel 2010, responses were coded and analysed. Descriptive statistics was expressed in terms of actual numbers, mean±standard deviation, frequency and percentage. A p-value <0.05 was considered statistically significant. Student’s unpaired t-test was used to compare the scores of Visual Analogue Scale (VAS) and parametric data. Categorical variables were compared using chi-square test. Results: The level of satisfaction to ayurveda therapy by VAS score was 7.67±1.58. Females patients were more satisfied with ayurveda than males. About 77 patients had taken Ayurveda medicine for maintaining good health and 71 feel it does not have any adverse effects. About 90.75% patients taking Allopathy had discontinued treatment before they visited ayurveda OPD. The percentages of patients attending ayurveda OPD and the percentage of physician’s that feel the need to develop ayurveda treatment were similar and matching for diseases which included arthritis, diabetes mellitus, backache, irritable bowel syndrome, malignancy, hypertension, alopecia, obesity, piles, viral hepatitis, degenerative spinal disease and migraine were common. Conclusion: The most common clinical condition for which both patients and physicians preferred ayurveda was for osteoarthritis. There is need for developing scientifically validated therapies for conditions wherein allopathy treatment is inadequate.

Assessing the Changes in Cariogram Generated Risk Profiles following the use of Casein Phosphopeptide-Amorphous Calcium Phosphate Chewing Gums

Introduction: Caries risk assessment is an essential element in the prevention of the disease. Targeted preventive strategies customised for each individual is economically beneficial and rational. Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP) is the preferred anticariogenic agent among non fluoridated preventive agents. Aim: To assess the changes in cariogram generated risk profiles following the use of CPP-ACP chewing gums. Materials and Methods: This longitudinal study was conducted at Sri Venkateswara Dental College and Hospital, Tamil Nadu, India, for a period of 14 days, January, 2017. CPP-ACP chewing gums were distributed to a group of 10 healthy individuals of the age group 18-25 years. They were instructed to use the gums for a period of 14 days. Details required for constructing a cariogram were obtained via questionnaires, interview, oral examination and salivary analysis. Two cariograms were constructed for each individual using the details collected before and after usage of the gums. The percentage change in each sector was tabulated and interpreted. Results: There was a visible increase in the percentage of chances to avoid caries sector (green colour) in all cariograms. The percentage increase ranged from 3-24%. A significant reduction of the susceptibility sector (light blue colour) with difference ranging from 3-12% and bacteria sector (red colour) with difference range from 3-8% was seen. Circumstances and diet sectors (yellow and dark blue colours) showed negligible changes. Conclusion: The CPP-ACP is an effective preventive intervention that can alter the cariogram of an individual by increasing the green colour sector area.

Evaluation of Efficacy and Safety of Epalrestat (150 mg) Compared to Epalrestat (50 mg) in Patients Suffering from Diabetic Peripheral Neuropathy

Sachin Devendrarao Shende, Mirza Shiraz Baig, Sudhakar Madhukar Doifode

Introduction: Epalrestat is currently the only Aldose Reductase Inhibitor (ARI) approved to treat symptoms of Diabetic Peripheral Neuropathy (DPN). The efficacy and safety of Epalrestat 50 mg TDS have been established in clinical practice, however compliance is challenging. Aim: To evaluate efficacy and safety of Epalrestat Sustained Release (SR) (150 mg) compared to Epalrestat Immediate Release (IR) (50 mg) in patients suffering from DPN. Materials and Methods: A total of 100 patients with DPN were enrolled in the study, after fulfilling the inclusion and exclusion criteria into two groups of fifty each. Each patient received tablet Epalrestat SR 150 mg once daily or Epalrestat IR 50 mg thrice daily orally for 12 weeks were follow-up at the end of 4, 8, and 12 weeks for evaluation. Primary outcome measure was percent change in Modified Neuropathy Disability Score (MNDS) in both groups from baseline. Secondary outcomes were mean change in pain intensity, numbness in Upper Limb (UL); Lower Limb (LL), cramping and dizziness on VAS score in both groups from baseline. Statistical analysis was done using Student’s paired and unpaired t-test, Fisher’s-exact-test, and repeated measures ANOVA test. Results: Epalrestat SR treatment showed clinically significant improvements in MNDS Score and symptoms of neuropathy when compared with Epalrestat IR tablet. Mean MNDS in Epalrestat SR group was reduced to 6.38, 4.28, 1.86 after 4, 8 and 12 weeks of treatment respectively (p<0.001). At the end of 12 weeks, mean pain severity was reduced to 1.68 in Epalrestat SR group and 2.68 in Epalrestat IR group respectively on VAS (p<0.0001). UL numbness was reduced to 0.54 in Epalrestat SR group and to 1.14 in Epalrestat IR group after 12 weeks of treatment which was statistically significant. Similar statistically significant decline was observed in numbness of LL at the end of 12 weeks of treatment (Epalrestat SR: 1.46 and Epalrestat IR: 2.12). Cramping and dizziness also showed improvement in both Epalrestat groups (p>0.05). The most common reported adverse events were headache, diarrhoea and vomiting. Conclusion: Epalrestat SR is a better alternative to Epalrestat IR in the treatment of DPN.

Ahmed Glaucoma Valve in Refractory Glaucoma: A Retrospective Study

Suresh Kumar, Sahil Thakur, Madhu Sharma

Introduction: Ahmed Glaucoma Valve (AGV) is a modality to surgically manage patients of glaucoma who are refractory to conventional intraocular pressure lowering drugs. Aim: To evaluate the success rate and safety profile of AVG in patients of refractory glaucoma. Materials and Methods: This study is a retrospective review of 30 eyes with refractory glaucoma that were implanted AGV over a period from January 2012 to November 2014. The collected data was analysed using SPSS Version 21.0, ANOVA and Kaplan-Meier survival analysis to evaluate surgical success and rate of complications. Results: The AGV reduced the preoperative mean Intraocular Pressure (IOP) of 33.47±6.19 mmHg to 12.36±3.55 mmHg at last follow up after surgery (p-value=0.001). The dependency on anti-glaucoma drugs decreased from 2.43±1.1 to 1.1±0.5 at the last follow up visit (p-value=0.65). AGV implantation was successful in 90% eyes at 12 months (n=30), 86.7% at 24 months (n=26) and 70% eyes at 36 months (n=21). Complications requiring intervention were found in seven (23.33%) eyes. Conclusion: Ahmed Glaucoma Valve is a reliable and safe alternative for IOP control in patients with refractory glaucoma.

Misdiagnosis: How Uncommonly Common is it?

Mahak C Jain, Uma B Dixit

Introduction: General dentists may be the first dental practitioners to see children with dental problems. ‘Misdiagnosis’ of certain commonly occurring dental conditions in children by general dentists may lead to failure of treatment in children. There are a few studies that have evaluated either knowledge or practices of general dentists regarding specific conditions in children. However, we found a lacunae in studies that evaluate diagnostic ability of the dentists. Aim: To evaluate the diagnostic skills and treatment acumen of general dentists related to caries and its consequences, dental injuries, and certain common as well as rare conditions in children. Materials and Methods: The present study was a cross-sectional survey based study that included 55 general dentists treating children in their practices. Selected general dentists were asked to fill a questionnaire which included 15 questions with photographs, and complete description of history and clinical and/or radiographic findings of most commonly seen conditions in children. Options were provided for the diagnosis or treatment of each condition. Collected data were subjected to descriptive statistics and percentages of correct answers were obtained. Pearson’s correlation coefficient was calculated to evaluate correlation between two continuous variables. Results: None of the participants could answer all 15 questions correctly. Number of correct answers given by general dentists ranged from 4 to 13, average score of correct answers being 9. Number of years in practice did not have significant association with diagnostic skills and treatment acumen of the general dentists (r=-0.0022). Conclusion: General dentists did not demonstrate sufficient diagnostic skills or treatment acumen of commonly seen oral conditions in children.

Effect of Mycobacterium tuberculosis Lineage, Drug Resistance and HIV Status on the Outcome of Patients with Tuberculous Meningitis

Introduction: Tuberculous Meningitis (TBM) is a devastating disease with high morbidity and mortality. Resistance to anti tubercular drugs, strain variation among M. tuberculosis and HIV status of the host are important factors governing the disease progression in pulmonary tuberculosis and data regarding TBM is lacking. The geographical variations present in these factors necessitate local epidemiological studies. Aim: The present study was conducted to assess the influence of drug resistance and lineage on the outcome of HIV positive and negative cases of TBM. Materials and Methods: Genotypic profiling using 24-loci Mycobacterial Interspersed Repetitive Units-Variable Number of Tandem Repeats (MIRU-VNTR) analysis was retrospectively conducted on 70 (8 HIV positive patients, 62 HIV negative patients) Cerebrospinal Fluid (CSF) culture isolates of M. tuberculosis processed in the Mycobacteriology laboratory of PGIMER during January 2010-December 2015. Drug susceptibility was performed phenotypically by 1% proportion method and genotypically by rpoB and katG gene sequencing. Results: Total 4 (5.7%) out of 70 isolates of M. tuberculosis were multidrug resistant and were associated with higher mortality than the drug sensitive ones. Among the different lineages, the Beijing genotype was uniformly associated with drug resistance and mortality. All HIV positive patients had a poor outcome, irrespective of drug resistance and lineage. Conclusion: Multidrug resistance lineage of M. tuberculosis and HIV status are important determinants of mortality in patients of TBM. Targeting these factors can contribute to a favourable outcome.

Assessment of Internet Addiction among Undergraduate Medical Students: A Cross-Sectional Study in a Medical College of Kolkata

Santanu Ghosh, Supantha Chatterjee

Introduction: Internet use is an important activity of the young generation for academic learning, for maintaining social relationship and for entertainment. Sometimes, internet use by students reaches an exaggerated stage to call it an addiction because it jeopardises their psychological stability. Aim: The present study was conducted among undergraduate medical students to assess the pattern of internet use to classify levels of internet addiction and to find out possible associated factors related to internet addiction. Materials and Methods: This descriptive, cross-sectional study was conducted among the undergraduate students of 1st and 3rd semester batches of College of Medicine and Sagore Dutta Hospital (CMSDH), Kamarhati, West Bengal, India, from November to December, 2015. The relevant data were collected by complete enumeration. The Young’s Internet Addiction Test (IAT) questionnaire was used. Final population size was 155, out of 203 students. Data were analysed using SPSS version 20.0. Proportion and chi-square test were used wherever applicable. Results: Two participants were found to have severe internet addiction whereas 54.2% had mild to moderate addiction. Factors such as male gender, average duration of internet use per day and amount of money spent by them for internet use were found to be significantly associated with internet addiction. Other factors like religion, place of permanent residence, place of present stay, occupation of parents, educational status of parents, socioeconomic status were not significant statistically. Conclusion: Internet addiction has become a vital problem for medical students. Students should be counselled about the hazard of internet addiction. Duration of internet use must be restricted by parents and authorities. Parents should also delimit amount of pocket money for their childrens and should also monitor the monthly income and expenditure pattern of them.

Arm Function and Quality of Life Among Patients after Mastectomy

Anu Thomas, Kanmani Job

Introduction: For many women with breast cancer, mastectomy is a common form of treatment which has an indirect effect on female beauty, sexuality and feminity. Also, the patients suffer severe arm and shoulder morbidity post surgery which affects their quality of life. Aim: To determine the arm function and quality of life among patients after mastectomy and find correlation between these two aspects. Materials and Methods: A quantitative descriptive correlational design with non probability convenience sampling technique was used to collect data from 60 post mastectomy women. The setting used for the study was Gynaecological Oncology OPD at Amrita Institute of Medical Sciences (AIMS), Kochi, Kerala, India. Data collection was done from November 2016 to December 2016. A standardised Quality of Life-Breast Cancer Patient Version (QOL-BCV) questionnaire and DASH (Disability of Arm Shoulder Hand) tool was used for the assessment along with a structured questionnaire to assess sociodemographic and clinical data. Karl Pearson correlation test was used for data analysis. Results: The study result showed that majority of the patients 48 (80%) had good arm function with less disability. Quality of life of 21 (35%) patients was high and 39 (65%) patients had moderate quality of life. There was a significant correlation found between disability score and quality of life (r=-0.802) and with all the domains of quality of life {physical (r=-0.771), psychological (r=-0.695), social (r=-0.746) and spiritual (r=-0.500)}. Also a significant association was found between arm function and the clinical variables like oedema (p=0.006) and radiation therapy (p=0.017). Conclusion: Arm disability influences quality of life of patients after mastectomy. The results of this study will help to improve actions to reduce arm disabilities such as lymphoedema as early as possible, through proper assessment and post mastectomy exercises, including special care for patients undergoing radiation therapy. This will improve the quality of life of post mastectomy patients.

Grading and Study of Biological Markers in Ductal Carcinoma in situ and Concurrent Infiltrating Ductal Carcinoma of Breast

Lovely George, Muktha Ramesh Pai

Introduction: Breast cancer is the most common cancer in women. Breast cancer has surpassed cervical cancer and is now the leading cause of cancer death; however, cervical cancer still remains common in rural areas. Aim: To assess the architectural pattern, nuclear grade, presence and absence of necrosis of Infiltrating Duct Carcinoma (IDC) and concurrent Ductal Carcinoma in situ (DCIS) and to correlate the biological markers of the two. Materials and Methods: The present study was carried out in the Department of Pathology, Father Muller Medical College, Mangaluru, Karnataka, India from January 2011 to February 2013. The mastectomy and lumpectomy specimens received in the histopathology laboratory were studied for the presence of IDC and concurrent DCIS. Haematoxylin and Eosin (H&E) staining for histological diagnosis and IHC analysis for ER, PR and Her-2/neu was carried out. All the data were analysed using SSPS software version 13.0. Results: This study included total 60 cases of IDC (NOS) with concurrent DCIS. The mean age of patients was 48.6 years (SD ±11.21). Most common anatomic location was in the left breast. Majority of tumours were Grade 2 followed by Grade 3. The grades of the IDC and coexisting DCIS were concordant in 66.66% cases and 33.33% cases showed discordance. Also, 98.33% of cases showed similar expression of ER, PR and Her2/neu in both the components. Statistically, a strong correlation was seen in the grades, ER, PR and Her2/neu expression of IDC and DCIS (p<0.001). Conclusion: We found that to a great extent, it is possible to predict the biological behaviour of one component when that of the other is known and this may help in planning patient management when only DCIS is present.

Qualitative Evaluation of ‘BIPP Dressing’ for Intraoral Mucosal Defect

Arun Paul Charlu, Saurabh Kumar, Rabin Chacko

Introduction: Various biologic and non biologic graft materials are considered in the past as Intraoral wound dressing material. While autografts have issues related to donor site morbidity, allografts like collagen have limited intraoral usage due to allergenicity and ease of adaptability to the mucosal defect. Bismuth sub-nitrate Iodoform Paraffin Paste (BIPP) dressing is prepared by impregnating sterile gauze with a paste containing one part bismuth sub-nitrate, two parts iodoform, one part sterile liquid paraffin by weight. BIPP is well known for its antiseptic and astringent properties, henceforth serves as a good wound dressing material preventing infection and wound contractures. Its use in intraoral mucosal defects though widely acknowledged has rarely been evaluated. Aim: The aim of this study was to assess the qualitative properties of BIPPs as an intraoral wound dressing material. Materials and Methods: A total of 10 patients with oral precancerous lesions of the oral mucosa were included in this study. After excision of the oral lesions, BIPP pack was used to cover the defects that were too large to close primarily. Before use, sterile BIPP gauze was cut into a suitable shape of the defect and was placed directly on the wound and stabilised using vicryl sutures. The dressing was removed after two weeks of the operation. The effectiveness and usefulness of the BIPP dressing was evaluated by scoring the following parameters in the intraoperative and postoperative periods: operability, haemostatic status, pain relief, feeding situation, epithelialisation, scar contracture, and safety. Results: Out of the 10 patients, in six patients BIPP was used for the buccal mucosal defect, in two patients for labial mucosal defect and in one patient each for tongue and palatal defect. In all the patients the raw wound post resection were covered with BIPP pack and stabilised with vicryl sutures. Postoperatively there was no adverse event, there was no discomfort and all the patients tolerated the BIPP dressing. Conclusion: BIPP use in covering the defect, post soft tissue resection of the intraoral precancerous lesion has given a satisfactory result in the present study.

Modulatory Role of Mucuna pruriens against Aluminium Fluoride Induced Neuronal and Behavioural Alterations in Rats

Vanishri S Nayak, Nitesh Kumar, Antony Sylvan DSouza, Sunil S Nayak, KSR Pai

Introduction: Aluminium Fluoride (AlF3) intake produces oxidative stress resulting in brain damage. Although Mucuna pruriens (Velvet bean) is commonly used in ayurvedic system of medicine for different neurological disorders, its usefulness in oxidative stress induced behavioural and neuronal damage has received little attention. Aim: This study was conducted to evaluate the neuroprotective role of Mucuna pruriens against AIF3 induced behavioural and neuronal changes in rats. Materials and Methods: Thirty six male Wistar albino rats were divided into six groups as: I-Normal saline; II-AIF3; III-25 mg/kg Quercetin and AlF3; IV, V and VI received 50, 100 and 200 mg/kg Mucuna pruriens methanolic extract and AlF3 (600 ppm). Extract was given for 10 days followed by AlF3 treatment for next seven days. Behavioural parameters were assessed such as T-maze test, actophotometer, and rotarod followed by histopathological studies. Results: A reduction in the locomotor activity, spatial learning and motor coordination was observed in the animals of Group II which reversed when treated with Mucuna pruriens. The histopathological studies of hippocampal CA1 region also showed the neuroprotective role of this plant. Conclusion: This study suggests the potential neuroprotective ability of Mucuna pruriens against the change in behaviour and neuronal damage which occurred due to induction of AIF3.

Left Ventricular Systolic Dysfunction among Hypertensive Subjects

Anugya Aparajita Behera, Suresh Kumar Behera, Dipti Mohapatra, Arati Mohanty

Introduction: Hypertension has been established as one of the most significant causes of heart failure. Left ventricular function is a useful measure in the assessment and prognostication of heart disease. Aim: To determine the prevalence of Left Ventricular Systolic Dysfunction (LVSD) in hypertensive patients and assess the echocardiographic characteristics associated with LVSD. Materials and Methods: After obtaining informed consent, 650 eligible adults of age =18 years attending cardiology OPD diagnosed to have essential hypertension with or without medication were included in the study. Using a predesigned structured questionnaire, details of demographic characteristics and echocardiographic data were obtained from the study participants. Results: The prevalence of LVSD was 136 (20.9%) in the study population {mild LVSD 78 (12%), moderate LVSD 40 (6.2%), severe LVSD 18 (2.8%)}. In Analysis of Variance (ANOVA), variables such as blood pressure, body surface area, size of left atrium and ventricle, relative wall thickness, stroke volume, left ventricular mass index, diastolic function, ejection fraction, fractional shortening were significantly associated with moderate-severe LVSD. Conclusion: Higher prevalence of LVSD among hypertensive subjects in this study advocates for use of echocardiography as part of routine evaluation in hypertensive patients.

Competency in Home Blood Pressure Monitoring and Effect of Training Program on Competency

Introduction: Blood Pressure (BP) measurement is the basis of diagnosis and treatment of hypertension. Automatic BP monitors are available for self-measurement of BP at home and it helps in adaptation of treatment strategy. However, proper measurement procedures are of paramount importance for credible BP readings. Aim: To ascertain the level of competency in Home Blood Pressure Monitoring (HBPM) among patients and their family members (i.e., operators) and to find the effect of a simple educational program on improvement in the competency in HBPM. Materials and Methods: A cross-sectional survey was conducted with patients or their family members who measure BP at home. Procedure of HBPM, as practiced by the participants was observed by the surveyor physician and competency was scored on 17 item survey questionnaire. Then, an educational tool was used to educate the participants. Summative assessment was conducted after the training program by another session of HBPM. The data was tested statistically by chi-square and paired t-test with a=0.05. Results: A total of 125 respondents of mean age 34.51±12.32 years participated in the survey. Among 17 items, overall competency score in HBPM before training program was 4.63±4.59. The competency score (16.31±2.53) significantly (p<0.001) increased after the training. Conclusion: The HBPM procedure, as followed by patients or their family members is grossly deficient in accordance with standard protocol. This deficiency can be improved with simple educational program.

Critical Evaluation of various Sonologic Parameters of Early Foetal Growth Discrepancies in Predicting Adverse Pregnancy Outcomes

Shripad Hebbar, Lavanya Rai, Zara Ali

Introduction: It is well established that adverse perinatal outcomes such as Small for Gestational Age (SGA), preterm delivery, and pre-eclampsia are associated with higher incidence of neonatal complications and death. Evidence suggests that these adverse outcomes may have their origins dating back to early pregnancy growth discrepancies. Aim: To establish an association between early fetal growth discrepancies and occurrence of adverse obstetric outcomes such as pre-eclampsia and SGA. Materials and Methods: This is a prospective observational study done in the Department of Obstetrics and Gynaecology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India, between Jan 2015 to May 2016 involving 314 pregnant women, using Crown Rump Length (CRL) measurements at the time of early anomaly (11-14 week scan). Pregnancies with congenital and chromosomal defects, multifetal gestation and non viable foetuses were excluded from the study. The biometric parameters mainly Biparietal Diameter (BPD), Head Circumference (HC), Abdominal Circumference (AC), Femur Length (FL), and Estimated Foetal Weight (EFW) at the time of targeted organ scan (between 18 to 20 weeks) were recorded and reverse calculations were done to convert these parameters to corresponding GA based on published regression formulae. The GA at the time of targeted scan was also calculated based upon the first trimester CRL values. The growth discrepancy was calculated by deducting CRL based GA from biometrically estimated GA for each individual growth parameters. Fisher’s-exact test was used to compare the means of biometric lags in SGA vs. Appropriate for Gestational Age (AGA) fetuses and also in Pre-eclampsia vs. normotensive groups. For each biometric parameter, the best cut-off for discrepancy value was determined using Receiver Operator Characteristic (ROC) analysis along with their diagnostic ability to predict occurrence of SGA in terms of sensitivity, specificity, positive and negative likelihood ratio with their 95% confidence intervals. The Area Under Curve (AUC) and z-test statistics were taken into account to decide the best parameter to predict adverse outcome. A p-value of <0.05 was considered statistically significant. Results: Out of 314 women studied, 62 (19.7%) delivered an SGA neonate, and 30 (9.5%) had pre-eclampsia. All biometric parameters of SGA babies showed growth lag compared to AGA babies which was statistically significant (BPD p<0.001, HC p<0.001, AC p<0.001, FL p<0.01, and EFW p<0.001). However, we could not establish similar associations between early growth discrepancies and onset of pre-eclampsia. Conclusion: Models of second trimester growth discrepancies can be used to predict SGA babies. Earlier anticipation of adverse perinatal outcome may add to quality of antenatal care and timely delivery to prevent late stillbirths associated with SGA.

Sociodemographic and Clinical Variables related to Panic Disorder with and without Agoraphobia

Neha Salhotra, Debajyoti Bhattacharyya, Jag Mohan Wadhawan, Prateek Yadav

Introduction: Panic Disorder (PD) is characterised by sudden episodic attacks of anxiety that are extremely disabling for the patients. It is usually associated with agoraphobia and several other psychiatric comorbid disorders. These not only tend to escalate the severity of primary illness however, also worsen the long term prognosis. An association has also been noticed between presence of stress and severity of PD. In the current study we have tried to include as many factors as possible that affect common and disabling illness like PD. Aim: To compare the severity of illness in the patients of PD with and without agoraphobia, and to further find the association, if any, of psychiatric comorbidities and stress on the severity of symptoms in these two groups. Materials and Methods: A cross-sectional observational study was carried out in a tertiary care psychiatry centre, from November 2013 to January 2015. Patients between 18 and 65 years with PD were divided into two groups PD (Panic Disorder without Agoraphobia) and PDAG (Panic Disorder with Agoraphobia) which were compared for difference in severity of anxiety {Panic Disorder Severity Scale (PDSS) and Hamilton Rating Scale for Anxiety (HAM-A) were used}, presence of comorbidity and stress, and their effect on severity of symptoms. SPSS 22.0 was used for all statistical analyses. Continuous variables were presented on mean, Standard Deviation (SD) or median if data is unevenly distributed. Categorical variables were expressed as frequencies and percentages. The comparison of normally distributed continuous variables between groups has been performed using ANOVA. Nominal categorical data between groups were compared using chi-squared test or fisher’s exact test as appropriate. Non-normal distribution continuous variables have been compared using Kruskal-Wallis test. For all statistical tests a p-value of less than 0.05 has been taken to indicate significant difference. Results: Mean PDSS and HAM-A scores were higher in PDAG group (21.30±3.46 and 23.37±2.91) than in PD group (13.50±4.1 and 18.50±5.070). 43 (71.67%) of the total patients (60) suffered from another psychiatric disorder. Comorbidity was higher in PDAG group with more than 83.3% (n=25) suffering from another mental health condition apart from PD. Depression was the most common comorbidity while Generalised Anxiety Disorder (GAD), alcohol use disorder and Obsessive Compulsive Disorder (OCD) were others. Almost all individuals reported, some stress rated on Perceived Stress Scale (PSS). In individuals experiencing stress, panic and anxiety symptoms were found to be more severe. Conclusion: There was significant difference in the two groups in terms of severity of symptoms as measured on corresponding scale for PD (PDSS score of 21.3 in PDAG, 13.5 in PD group; p=0.035), presence of comorbidity (83.3% in PDAG group, 60% in PD group) and stress {all individual in PDAG group (n=30) reported moderate to high stress levels}. Presence of agoraphobia; comorbid psychiatric disorders and stress were associated with more severe illness, increased severity of panic and other anxiety symptoms.

Determinants of Job Satisfaction amongst Medical Officers of Primary Health Centre in Anand District, Gujarat, India

Deepak B Sharma, Utkarsh M Shah, Rakesh Patel, Vidushi Gupta, Uday Shankar Singh

Introduction: Dissatisfaction with job is invariably linked with decreased work performance. Discontent provider is more likely to face difficulty in caring for his patients and provide quality medical care. Thus, provider dissatisfaction results in patient dissatisfaction which deleteriously affects health outcomes. Aim: The study was undertaken with the objective of finding determinants of job satisfaction amongst Primary Health Centre (PHC) doctors in Anand, Gujarat, India. Materials and Methods: The present cross-sectional analytical study was conducted amongst 50 PHC Medical Officers (MO), MBBS and Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homeopathy (AYUSH) of Anand, Gujarat, India. Self-administered questionnaire method was used to obtain the responses from the participants. Job satisfaction was seen in four different heads/dimensions like “Workload”, “Relationships with Staff”, “Personal Difficulties” and “Availability of Infrastructure”. Some questions were in Likert scale and some questions were of dichotomous type. All the individual heads were summated to get a final score. Total scores ranged from 6-36. Categorical analysis of all the individual variables was also done. Face validity and consensual validity, and content validity of the questionnaire was checked. The data entry was done in excel and analysed using SPSS version 15.0. Qualitative as well as quantitative analysis was done. Mann-Whitney U test, and chisquare test were applied and values were calculated. Fisher’s exact test was also applied. Results: Out of total 50 MO, 33 (66.0%) were MBBS doctors and the rest were BAMS and BHMS doctors. Overall job satisfaction score was found to be significantly different amongst two groups (p=0.037). The two groups (MBBS and AYUSH) were statistically different in the workload scores (p=0.008). Conclusion: Overall job satisfaction scores were poor amongst PHC doctors. It was observed that doctors were unsatisfied on account of facilities in terms of good infrastructure, support services, good human relations, and personal conflicts. If we want sustainable development at primary healthcare level, job satisfaction is must, as doctors are providers of health services and they must be satisfied so that they can provide best of the services to a large number of rural beneficiaries.

Lower Facial Morphometrics in Children upon the Eruption of First Permanent Molars

Seema Deshmukh, Bhojraj Nandlal

Introduction: Transition from primary to early mixed dentition brings about various changes in the occlusion and facial appearance. After complete eruption of primary teeth, the occlusion seems to be relatively stable till eruption of first permanent molars. Transition from primary to early mixed dentition is characterised by increase in the vertical dimensions, increase in the arch perimeter, and increase in the intercanine width. However, skeletal changes characterising the first transitional phase are not completely explored. With more emphasis on early diagnosis and treatment planning, it is essential to have a thorough knowledge of the complete developmental changes that can be considered during diagnosis and deciding the treatment needs. Aim: To determine the developmental changes in the lower facial dimensions upon the eruption of first permanent molar. Materials and Methods: A longitudinal prospective study was planned to study developmental changes in the lower facial dimensions. Lateral cephalometric radiographs of 46 children with primary dentition (Mean age 5.5 years) were taken. The sample comprised of 27 males and 19 females. All the subjects had complete primary dentition with normal occlusion and well balanced facial proportions. The lateral cephalometric radiographs were repeated on the same subjects after a period of two years. Cephalometric analysis was done using Nemoceph software (version 10.4.2). The data was compiled and the following statistical analysis tests were performed: descriptive statistics, Paired t-test, Benjamin and Hochberg multiple testing correction and unpaired t-test. Results: Among primary and early mixed dentition, males exhibited larger dimensions than females. However, all the variables were not statistically significant. There was significant increase in the dimensions upon the eruption of first permanent molars. However, mandibular inclination, jaw relationship and gonial angle decreased during this transition phase. Conclusion: Eruption of first permanent molars contributes significantly towards the changes in the lower craniofacial dimensions. Initial signs of mandibular rotations and displacement correspond with the eruption of first permanent molars.

Plasma Omentin-1 Level and its Relationship with Insulin Resistance in Obese Prediabetics

Introduction: Omentin-1 is an adipokine expressed, predominantly in visceral fat and has insulin sensitising effects. However, its levels in obese prediabetics have not been evaluated so far in India. Aim: To evaluate plasma levels of omentin-1 in obese prediabetic, obese normoglycaemic and healthy individuals and to explore correlation of omentin-1 with measures of obesity and insulin resistance. Materials and Methods: The present case control study was conducted on 150 males from medical OPD of hospital. Based on anthropometrical measurements and Oral Glucose Tolerance Test (OGTT) with 75 g of anhydrous glucose, three groups of 50 males each (20-50 years) were selected. Group-1 included healthy controls, Group-2 obese normoglycaemic and Group-3 obese prediabetic subjects. Fasting and postprandial plasma glucose, HbA1c, fasting serum insulin, plasma omentin-1 and lipid profile was investigated. Insulin resistance was calculated by Homeostatic Model of Insulin Resistance (HOMA-IR). Statistical analysis was carried out by SPSS statistics software using one-way ANOVA followed by Tukey’s test at 5% level. Pearson’s correlation coefficient was used for calculation of association of variables. Results: We found that plasma omentin-1 levels were decreased significantly in obese prediabetics (228.7±13.4 ng/mL) compared to obese normoglycaemic (298.4±79.8 ng/mL) and healthy control (408.0±98.9 ng/mL) (p<0.05). Fasting insulin levels were higher in obese prediabetics (11.2±3.20 µU/mL) compared to obese normoglycaemic (8.4±4.78 µU/mL) and healthy controls (5.5±2.90 µU/mL). Obese prediabetics had altered lipid profile. HOMA-IR was higher in obese prediabetics, compared to other two groups. Plasma omentin-1 levels showed negative and significant correlation with HOMA-IR (p<0.05). Conclusion: Concentration of plasma omentin-1 decreased and insulin resistance increased in obese prediabetics compared to obese normoglycaemics and healthy controls. As omentin-1 increases sensitivity to insulin, its decreased levels may be responsible for impaired glucose homeostasis in obese prediabetics.

Perception of School Teachers towards Inclusive Education System in Jodhpur City, Rajasthan, India

Kriti Mishra, V Siddharth, Pankaj Bhardwaj, Abhay Elhence, Divesh Jalan

Introduction: Many disabled children receive rehabilitation but they find it difficult to get school admission. For successful inclusion, teacher’s attitudes and their perception towards disabled children play a crucial role. Aim: To explore teacher’s perception towards inclusive education in Jodhpur city, Rajasthan, India and to describe factors contributing to this perception. Materials and Methods: A cross-sectional study was conducted over a period of three months. Two schools {1 Government (G) and 1 Private (P)} were selected from 30 randomly selected wards (total number of school, n=60) and four teachers were targeted randomly from each school (n=240). A 64 item scale; combination of Cochran’s 20 items STATIC Survey and Littrell’s 40-item survey with additional four demographic questions related to experience and pre-service and professional development training was used. Results: In total, 240 teachers were recruited. Of these, 172 teachers (G=49/120, P=120/120) responded; three forms were excluded due to incomplete information. Hence, 169 forms were analysed. An average score of ‘attitude construct’ (item 5-24) was 61 where as ‘principal support construct’ (Item 25-64) was 150. Most of the teachers neither had pre-service training (n=133, 79 %) nor post-professional training (n=109, 65%) for inclusive education. Teacher’s attitude construct showed negligible correlation with year of teaching certification (Rho=0.178, p-value=0.034) and experience of having disabled students in classrooms (Rho=0.198, p-value=0.010); and low positive correlation with pre-service training (Rho=0.379, p-value<0.001) and post professional training for inclusive education (Rho=0.445, p-value<0.001). Principal support construct showed negligible correlation with all four factors. Conclusion: The current study showed a tendency of positive attitude for inclusive education among teachers in urban schools of Jodhpur, India. This positive perception with professional training and incentives from school authorities can support practical implementation of inclusive education.

Knowledge, Stress and Coping Patterns of Grandmothers in Child-rearing Practices

Reena M D’Silva, Ansuya, V Vinish

Introduction: Grandmothers are an essential part of the extended family. In modern culture, grandparents frequently have a direct role in the care of grandchildren. Grandmothers have a powerful and prominent role within the family and usually when the mother is working the grandmothers takes charge of child-rearing. Aim: To assess the knowledge, stress and coping patterns of grandmothers involved in child-rearing practices of children of employed mothers in selected areas of Udupi district, Karnataka, India. Materials and Methods: The present descriptive study was conducted in Udupi taluk of Udupi district. Villages of Udupi taluk were selected randomly and the samples were selected by purposive sampling techniques. A total of 300 grandmothers involved in child-rearing practices of children of employed mothers were assessed with the help of a structured questionnaire. Results: The result showed that grandmothers had average knowledge, moderate stress and high coping in regard to child-rearing practices. A statistically significant association was found between knowledge score and selected variables such as educational status (?2=13.768, p=0.022), family income (?2=14.363, p=0.016) and previous work experience (?2=15.77, p<0.001). A statistically significant association was also found between levels of stress score with family income (?2=17.028, p=0.005). There was a negative correlation between the stress and coping and there was a weak positive correlation between the knowledge and the coping patterns of grandmothers. Conclusion: Caring for a grandchild may be stressful for grandmothers. The study suggests that when the grandmothers take care of grandchildren their views should also be considered as it may reduce stress among them and helps to lead a positive life.

Diagnosis of Acute Appendicitis using Modified Alvarado Score and Abdominal Ultrasound

Aabhas Mishra, Sukumar Santosh Kumar, Anamika Sinha

Introduction: Acute Appendicitis (AA) requires prompt surgery to prevent complications, and the diagnosis is mostly based on clinical features where scoring systems like Modified Alvarado Score (MAS) have been found to be helpful. However, as clinical findings tend to be subjective, Abdominal Ultrasound (AUS) can be used to add some objectivity to the diagnosis of AA. Aim: The aim of the present study was to assess the effectiveness of MAS and AUS in diagnosing AA. Materials and Methods: The present study was designed as a study of Diagnostic Accuracy and was carried out using STARD guidelines at a Tertiary Care Teaching Hospital in India. Prospective collection of data of 100 consecutive patients (70 male and 30 female) who were taken up for Emergency appendectomy for AA during the period from April 2009 to April 2011 was done. Patients with complicated Appendicitis, e.g., perforation-peritonitis, abscess; appendicular lump and pregnant women were excluded. Sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), Likelihood Ratios (LR+ and LR-), Diagnostic Odds Ratio (DOR) and Negative Appendectomy Rate (NAR) were calculated for MAS and AUS by standard statistical calculators. Results: The present study included 70 males and 30 females belonging to various ages ranging from 11-62 years. Majority of patients (42%) were in their third decade of life. A total of 76% of patients who underwent surgery for AA had MAS of =7. All the 24% remaining patients had MAS of 4-6. Overall AUS revealed inflamed appendix in 67% cases, while in the rest, either the appendix could not be visualised or was reported as normal. Sensitivity, specificity, PPV, NPV, LR+, LR-, DOR and NAR of MAS and AUS were 81.61%, 61.54%, 93.42%, 33.33%, 2.12, 0.30, 7.10, 6.58%; and 71.26%, 61.54%, 92.54%, 24.24%, 1.85, 0.47, 3.97, 7.46% respectively. Between the sexes, diagnostic parameters of MAS were slightly better in males. In contrast, in females the parameters of AUS fared marginally better. AUS had much better diagnostic accuracy in diagnosing AA in MAS <7, when compared to MAS =7. Conclusion: The MAS is a good diagnostic tool for AA and should be adequate in uncomplicated AA, if score is =7. In those patients where the score is 4-6, AUS should be added to aid in early diagnosis and prompt surgical management of AA. The AUS is also recommended in female patients with suspected AA.

Comparative Analysis of Body Fat Measurement Methods in School Children of Central India

Introduction: Considering the prevalence of metabolic disorders, especially in south asian people, a rapid, economical, easy and reliable method of assessment of body fat for mass screening, is the need of the hour. Aim: The aim of the present study was to derive the population and gender specific prediction equations for Body Fat percentage (BF%) in Central Indian children and compare with that, derived from published equation by Shaikh, and obtained by Bioelectric Impedance Analysis (BIA), separately for boys and girls. Materials and Methods: It was a randomised cross sectional school based study. A total of 15 schools were randomly selected from Central India to cater the sample of 2304 children (1005 girls) of age 8-16 years. Anthropometric and Skinfold Thickness (SFT) measurements were done. The BF% was assessed by BIA. Gender specific prediction equations were derived using SFT and Mid Arm Circumference (MAC) measured and regressed on BF%. This prediction equation was compared with BF% values by BIA and with Shaikh prediction equation by Bland-Altman Analysis. Results: Shaikh’s equation underpredicts BF% than BIA with mean bias of 4.59 and Limits of Agreement (LOA) 16.69-7.49. On comparison between BF% in boys by BIA and present prediction equation showed minimum bias of 0.019 with LOA 14.79 and -14.75. In girls Shaikh’s equation overpredicts BF% than BIA with mean bias of -3.09 and LOA 12.02 and - 18.21. The present equations for girls overpredicted BF% than BIA with a bias of -13.23. Conclusion: The BF% measured in children by BIA method and present prediction equations tend to either underpredict or overpredict. New prediction equations are hereby presented using SFT, MAC and age in months, which provides excellent estimates of BF% in boys of central India because of least bias. The BF% (boys) =17.09267+(-0.10016)*A+0.535823*M+0.443805*T+0.468107*SS. The BF% (girls)=17.96293+(-0.07976)*A+0.385465*M+0.497878*T+0.58131*SS.

Prepulse Modulation of Auditory Startle Reflex with Different Stimulus Onset Asynchronies

Nikhilesh Singh, Richa Gupta, Sanjay Kumar Sood

Introduction: Startle reflex is measured by delivering a sensory stimulus and measuring eyelid closure in human beings to investigate the neurophysiology of information processing. However, the characteristics of startle reflex can be modified by weaker prepulse. Since this modification is increasingly being associated with various psychiatric disorders, it is worth exploring the prepulse modification of startle reflex. Aim: The aim of the present study was to explore the differential modulatory effect of auditory stimulus onset asynchronies on startle response magnitude as well as latency. Materials and Methods: The study was conducted on 30 healthy right handed male subjects aged 18-40 years. Auditory prepulse was delivered binaurally which was followed by startle stimuli. The startle reflex was recorded from orbicularis oculi muscle by electromyography. Inter stimulus interval was varied in different trials from 30 ms to 1000 ms. The startle reflex from different trials were later analysed for response latency and magnitude. Results: The results of the present study show that latency of the response was not different with different Stimulus Onset Synchronies (SOA’s). However, the magnitude of the response was inhibited with SOAs 60 ms, 120 ms and 250 ms while facilitated with SOA 1000 ms when compared to baseline. SOAs 30 ms and 500 ms had no effect on the response. Conclusion: Differential response to different prepulse to pulse inter stimulus interval implies that temporal presentation of stimuli is very important for priority coding. Very small SOA’s are important for priority coding of the stimulus. However, with much larger SOA’s, the first stimulus serves as an orienting response for the next stimulus.

Cervical Osteophytes: A Missed Cause in Dysphagia?

Introduction: Dysphagia is a common symptom seen in patients in ENT OPD. Gastro-oesophageal reflux, foreign body, mass lesions being the known common causes. Cervical spondylosis with large osteophytes is one of the causes of dysphagia, which can be easily diagnosed even with limited facilities available but it is less discussed in younger age group. Aim: To evaluate the clinical importance and significance of cervical osteophytes as a cause of dysphagia. Materials and Methods: Seventy patients of either sex, between the age group of 25-59 years, with dysphagia were evaluated with complete history and clinical examination followed by upper gastrointestinal endoscopy. All common causes of dysphagia were ruled out. Patients were evaluated with a digital X-ray of cervical spine in lateral view. The results were analysed statistically using chi-square test and Fischer’s-exact test. Results: Out of 70 patients evaluated, 40 (57.1%) were female patients and 30 (42.9%) male patients. About 21 (30%) patients were found to have cervical spine osteophytes. Conclusion: After ruling out common causes, anterior cervical osteophytes should be remembered as one of the causes of dysphagia by the otorhinolaryngologists for effective management.

Hyperferritinemia in Dengue Fever-Correlation between Serum Ferritin and Thrombocytopenia

S Jyothi Visalakshy, Selva Saravanan Saminathan, Sandeep Surendran, MGK Pillai

Introduction: Dengue fever is a widely prevalent viral infection in the tropical countries. Many patients with dengue fever are known to have severe cytopenias and the mechanism for the same is not known. Macrophage Activation Syndrome (MAS) is a life threatening complication that is known to be triggered by viral infections. This study attempts to examine the possibility of MAS as an underlying cause of cytopenias in dengue fever. Hyperferritinemia which is an important diagnostic criteria for MAS is known to occur in dengue fever also. Aim: The primary objective of the study was to assess the correlation between ferritin levels and mean platelet drop among patients admitted with dengue fever. Secondary objective was to do a subgroup analysis and compare the patients treated according to WHO standard protocols in dengue fever with those who were also given steroids and compare outcomes. Materials and Methods: This was a retrospective study done over a period of 18 months. Patients with dengue fever who satisfied the criteria for MAS were selected and the mean change in platelet count between the time of admission and 48 hours later was calculated. This was compared with the ferritin levels. Subgroup analysis was also done and the groups were correlated on two important clinical outcomes-the mean platelet drop and length of stay in hospital. Results: Total of 26 patients were enrolled in the study (n=26), of whom 18 (69.2%) were male. Pearson’s correlation coefficient (-0.231) was calculated to compare Ferritin levels with mean platelet drop and it showed that there was no correlation. There was no difference between the two groups with respect to mean platelet drop (p=0.08) and length of stay (p=0.443) in hospital. Conclusion: Hence, it can be concluded that hyperferritinemia does not correlate with the severity of platelet drop. There was no significant change in outcomes in patients with dengue fever associated MAS who were treated with steroids or with only standard treatment protocol.

The Effect of Saliva Contamination on Shear Bond Strength of Two Universal Bonding Agents-An in vitro Study

Anuja Sanjay Kulkarni, Sharad Kokate, Vibha Hegde, Ushaina Fanibunda

Introduction: Universal bonding agents are prevalent in dentistry today. The effects of both salivary contamination and subsequent decontamination protocols on these adhesives have not been studied extensively. Aim: To evaluate the effect of saliva contamination and decontamination on bond strength of two universal adhesive systems. Materials and Methods: This in vitro study was conducted in the Department of Conservative Dentistry and Endodontics, YMT Dental College and Hospital, Navi Mumbai, Maharashtra, India. Ninety permanent teeth mounted in acrylic were randomly divided into two groups based on the adhesives used; Group I- Single Bond Universal (SBU) (3M ESPE) and Group II-Tetric ®N-Bond Universal (Ivoclar Vivadent). They were further divided into three subgroups (n=15): subgroup-1) Control; subgroup-2) Contamination; subgroup-3) Decontamination (Water rinse and reapplication). After composite application, the samples were subjected to Shear Bond Strength (SBS) testing with universal testing machine. Modes of failure were examined using a stereomicroscope. Statistical analysis was carried out using one-way ANOVA test and Tukeys HSD test (p<0.05). Results: Highest mean SBS was observed in subgroup-1 whereas lowest mean SBS was seen in subgroup-2. There was statistical increase in mean SBS values in subgroup-3. The mean SBS values of Group II were statistically higher than those in Group I (p<0.05). The mode of failure was mainly adhesive. Conclusion: The SBS of universal adhesives to dentin is decreased by salivary contamination. Water rinsing and reapplication of the bonding agent improves the bond strength significantly.

Care Seeking Behaviour of Families for their Sick Infants and Factors Impeding to their Early Care Seeking in Rural Part of Central India

Vani Mittal, Tushar Jagzape, Priyanka Sachdeva

Introduction: India is still among the high Infant Mortality Rate (IMR) countries (44 per 1000 live births in the year 2012). Of the deaths, 33% is accounted by pneumonia, diarrhoea and malaria. This can be prevented if timely treatment is provided. Thus healthcare seeking behaviour is important and plays a central role for disease prevention, identification of danger signs and treatment for the well-being not only of the individual child, but also the community. Aim: To assess the parents’ knowledge about danger signs of illness in infants, care seeking behaviour and gender differences in it and also to identify factors impeding early care seeking. Materials and Methods: This was a two month community based observational study conducted during May-June 2014 with the help of a self-designed, prevalidated questionnaire with face to face interview of 303 mothers in villages of central India. Percentages of mothers aware of various childhood diseases and their healthcare seeking behaviour were calculated and chi-square test was used to assess gender differences in healthcare seeking. Results: About 97.6% (296) of mothers were aware of diarrhoeal diseases. Awareness about pneumonia, convulsion and jaundice was 47.8% (145), 43.8% (133) and 41.2% (125) respectively. Only 16.5% (86) and 15.8% (48) were aware of malnutrition and anaemia. A 86 (29.05%) of those aware of diarrhoeal disease were unaware of any complications related to diarrhoea. This figure was 33% (100) and 18.1% (55) for febrile and respiratory illness respectively. Private practitioners for 181 (59.7%), Public health facility for 108 (35.6%) and traditional healers for 14 (4.7%) were the preferred health facilities. For 46.8% (142), qualification of doctor was not important. For male infant 95 (52.4%) preferred private health facility as against 38 (31.1%) for female (p<0.001). Cost of treatment among 114 (37.6%), distance of health care facility among 91 (30.03%), unavailability of doctors among 90 (29.7%), lack of easy transport among 76 (25.08%) were the hindrances. Conclusion:Awareness about malnutrition, anaemia and danger signs of common illnesses were poor. Local private practitioners were the preferred medical support. There were gender differences in choosing the healthcare facility. Financial constraints and poor connectivity were barriers for early care seeking.

Correlation of Paediatric Trauma Score, Revised Trauma Score and Injury Severity Score with Length of Hospital Stay in Paediatric Trauma Patients

Geeta Ghag, Abhijit Jagdale

Introduction: Hospital stay is an important aspect of the medical care and most of the times medical professionals face this question at the very beginning when patient is advised indoor treatment. The role of Revised Trauma Score (RTS) and Paediatric Trauma Score (PTS) for initial screening of the trauma patients is very well established. However, there is a lack off data available on the correlation between hospital stay and different score in pediatric trauma patients. Aim: The aim of the present study was to find which trauma score is better for prediction of length of hospital stay in paediatric trauma patients. Materials and Methods: A prospective, observational study conductived from January 2013 to December 2013, including Children less than 12 years with history of trauma and who required admission. Patients with burns, drowning, physical abuse were excluded. Data regarding demographics, vital parameters, Glasgow Coma Scale (GCS), laboratory parameters, number of days required for full recovery were recorded on case record proforma. Rapid respiratory rate of infant and toddler age group were adjusted before calculation of RTS. Revised Abbreviated injury score was used to calculate Injury Severity Score (ISS). The RTS, PTS were calculated based on parameters at admission. ISS was calculated after primary examination, radiological investigations and intraoperative findings. Results: Mean ISS, RTS and PTS for 0-2 days of hospital admission was {(6.19±2.84), (7.59±0.41), (10.60±1.38)}, for 3-4 days it was {(6.72±3.40), (7.58±0.54), (11.03±1.42)} and for =5 days it was {(11.19±4.68), (7.69±0.54), (10.67±1.53)} respectively. Conclusion: Length of hospital stay does not depend on physiological parameters on admission. There is a positive correlation between ISS and length of hospital stay. The ISS is a better predictor of length of hospital stay than PTS and RTS.

Speckle Tracking Echocardiography in the Diagnosis of Subclinical Left Ventricular Systolic Dysfunction in Hypertensive Patients

Introduction: The early diagnosis of subclinical left ventricular systolic dysfunction in hypertensive patients is of crucial importance to prevent further adverse events and the onset of tissue and organ complications. Aim: To determine a high-risk group on the basis of subclinical Left Ventricular (LV) systolic dysfunction using Speckle Tracking Echocardiography (STE). Materials and Methods: This was a case-control study comparing 80 patients with hypertension (HTN, mild, moderate and severe) with preserved Ejection Fraction (EF) with or without Diastolic Dysfunction (DD) to 70 healthy volunteers. We defined subclinical LV systolic dysfunction as a reduced global longitudinal strain (GLS) <-20%, determined by Two Dimensional-STE (2D-STE). The statistical analysis was performed using unpaired t-test to assess categorical data, chisquare test for proportions, Pearson’s coefficient for strength of correlation and multiple regressions for continuous variables and their association with age and gender. Inter-and intraobserver variability were assessed using intraclass correlation coefficient. The significance level was set at p<0.05. Results: Significant differences in EF between HTN and the controls were not found. The GLS showed normal values in the controls and non-significant changes in patients with mild HTN without DD (p=0.840). A stepwise reduction of the GLS, which is dependent on the severity of HTN and DD was observed. The more severe the HTN and DD respectively, the more significant was the reduction of the GLS (p<0.001). In patients with HTN and reduced GLS, increased Body Mass Index (BMI) (p<0.001), Left Atrial Volume Index (LAVI) (p<0.001) and Left Ventricular Mass Index (LVMI) (p<0.001), reduced Sm (p=0.01) and Mitral Annular Plane Systolic Excursion (MAPSE) (p=0.02) were found. A moderate negative correlation between GLS and BMI (r=- 0.52; p<0.001) as well as GLS and LVMI (r=-0.61; p<0.001) were observed. A moderate positive correlation between GLS and EF (r=0.48; p=0.03), and GLS and Sm (r=0.56; p=0.01), as well as strong positive correlation between GLS and MAPSE were also found (r=0.756; p=0.003). These findings were observed mainly in patients with HTN and DD. Conclusion: The 2D-STE GLS provides an excellent opportunity for an early diagnosis of the subclinical LV systolic dysfunction in patients with HTN. In contrast to EF, GLS gives the real concept for the minimal changes in LV longitudinal mechanics, mainly in subjects with already developed DD. These findings corresponded to a higher risk of adverse CV events, and give a strong evidence to augment the antihypertensive treatment, control of the risk factors and lifestyle changes.

Neutrophil Gelatinase-associated Lipocalin, Cystatin C and Matrix Metalloproteinase-9 as Possible Biomarkers in Early Detection of Acute Kidney Injury after Cardiac Surgery

Introduction: Acute Kidney Injury (AKI) often occurs after open heart surgery. Today, serum creatinine is used as an indicator for identifying AKI; however, creatinine is unreliable due to delay in its elevation. Therefore, more reliable markers are required for early diagnosis of AKI. Aim: To measure the changes in Neutrophil Gelatinase-Associated Lipocalin (NGAL) and Cystatin C (Cys C) levels and Matrix Metallo Proteinase 9 (MMP-9) activity in serum of patients who underwent cardiac surgery. Materials and Methods: The present descriptive study was conducted from September to October 2015 among patients referred to Cardiovascular Surgery Center at Shahid Modarres Hospital in Tehran, Iran. Urine and serum sample from 29 candidates for cardiac surgery were collected at 6 and 12 hours after surgery. On the basis of increase in serum creatinine, the patients were divided into two groups; AKI and control group. AKI group had at least 50% increase in serum creatinine; those with less than 50% increase were considered as control group. Urine NGAL and Cys C concentrations were measured using ELISA; MMP-9 activity was determined using gel zymography. Results: The results showed an increase in Cys C concentration in AKI group compared to control group after 6 and 12 hours of surgery. The comparison of Cys C concentration in AKI group between 6 and 12 hours after surgery showed no significant difference. The comparison of NGAL at 12 hours after surgery between control and AKI groups showed no significant difference. The MMP-9 activity showed a decreasing trend in AKI group compared to control group at 12 hours after surgery. Decrease in MMP-9 activity in AKI group at 6 hours after surgery was statistically different from after 12 hours of surgery. Conclusion: Present results provide evidence that Cys C and MMP-9 can be better reliable markers for early detection of AKI as compared to serum creatinine, after cardiac surgery. NGAL did not show higher sensitivity compared to creatinine in these patients. Therefore, Cys C and MMP-9 can be suggested as biomarkers for early detection of AKI after cardiac surgery.

Electroencephalographic Correlates of Brain Adaptations to Medical School Academic Challenges-A Pilot Study

Introduction: A relatively specific quantitative Electroencephalogram (qEEG) signature is shown to be indicative of working memory deficits in low performing high school students. Previous studies have shown that Theta/Beta (T/B) ratio measured by qEEG is an indicator of poor Attention Control (AC) and that high T/B ratio may be diagnostic of attention deficit disorders. Aim: This study tests the hypothesis that high T/B ratio measured by qEEG may be associated with low academic performance in a medical school curriculum. Materials and Methods: Nine healthy male volunteers were subjected to 5-10 minutes of qEEG measurements at 19 electrode sites, under Eyes-Open (EO) and Eyes-Closed (EC) conditions. The qEEG measurements were performed for three days before each of the first two block examinations, covering standard first semester integrated basic science courses. Mean±Standard Deviations (SD) of the amplitudes, expressed in µV, and of the mode frequency in each of four standard bandwidths (delta, theta, alpha, beta), expressed in hertz, were measured. T/B ratio was then computed. Results: Mean theta and beta amplitudes increased significantly and T/B ratio decreased significantly for both the EO and EC conditions. Dominant (mode) theta frequency also increased. Overall inter and intra-hemispheric theta and beta band coherences increased for both the EO and EC conditions between the Block 1 and Block 2 exams; theta intra-hemispheric coherence was significant only for the EC condition. Correlations between Human Structure and Function (HSF) Block 2 exam scores and overall inter and intra-hemispheric coherences were significant for the beta bandwidth under the EC condition only. Conclusion: These findings suggest that high T/B ratio, a qEEG indicator of AC, may be associated with low academic performance. Future studies including a larger number of subjects should be done to determine whether these findings are gender-specific and whether lowering the T/B ratio is a predictor of medical school performance and other academic challenges.

Efficacy of Systemic Administration of Alpha Lipoic Acid and Scaling and Root Planning in Patients with Chronic Periodontitis and Type 2 Diabetes Mellitus-A Randomised Controlled Trial

Introduction: Both diabetes and periodontitis are globally rampant diseases with common risk factors. Current evidence points to a bidirectional inter-relationship between diabetes and periodontitis and it has been hypothesised that inflammation, lipids and adipokines may mediate this relationship. Resistin is an adipokine whose levels are elevated in patients with insulin resistance. Oxidative stress has a pivotal role to play in the progression of both the diseases, and antioxidants like Alpha Lipoic Acid (ALA) and Non Surgical Periodontal Therapy (NSPT) may improve the disease outcome. Aim:To evaluate the effect of systemic administration of ALA as an adjunct to Scaling and Root Planing (SRP) on serum resistin levels and Glycated Haemoglobin (HbA1c) in patients with chronic periodontitis and type 2 diabetes mellitus. Materials and Methods: This study was a randomised interventional single blinded clinical trial conducted on 40 patients, 18 males and 22 females, aged between 35 and 60 years. Subjects with type 2 diabetes and chronic periodontal disease were recruited in the study. The samples were equally divided into groups A and B. A total of 20 patients in group A were administered ALA systemically, 600 mg thrice a day for three months after SRP, whereas 20 patients in group B underwent SRP only. Clinical parameters like Gingival Index (GI), Probing Pocket Depth (PPD), and Clinical Attachment Levels (CAL) as well as the HbA1c and serum resistin levels were measured at baseline and three months after NSPT. Intragroup comparison was done by paired t-test for continuous data and Wilcoxon signed rank test for score data and intergroup comparison was done by unpaired t-test for continuous data and Mann Whitney U test for score data. Data was analysed by Statistical Package for Social Sciences (SPSS) version 22.0. Results: Both group A (test) and group B (control) showed significant improvement in relation to clinical parameters, as well as HbA1c and serum resistin levels, however when an intergroup comparison was made, patients in group A showed statistically significant results over group B. Conclusion: ALA systemically administered after NSPT in the test group proved to be efficacious in improving the clinical parameters as well as in reducing the levels of serum resistin and HbA1c.

Analysis of Adolescent Idiopathic Thoracic Scoliosis Treated with Posterior Instrumentation and Fusion: Our Experience

Abhinandan Reddy Mallepally, Raju Sreenivasan Iyengar, Chandra Sekhar Patnala

Introduction: At present gold standard surgical treatment for progressive idiopathic scoliosis is posterior instrumentation and fusion though there is considerable amount of debate over usage of pedicle screws for their safety in scoliosis surgery on the amount of correction achieved using them and also the need for shorter fusion. Pedicle screw construct gives a three column fixation with better control and enhanced three dimensional corrections, in coronal and sagittal plane. Aim: To assess the clinical, radiological and pulmonary function results after treating patients with posterior instrumentation using pedicle screws and hooks and to assess the complications. Materials and Methods: This was a retrospective observational study of 41 Adolescent Idiopathic thoracic Scoliosis (AIS) patients treated with posterior instrumentation and posterior spinal fusion. A t-test to compare preoperative and immediate postoperative Cobbs angle was used. SRS 30 functional scoring system was used to measure the outcome of surgical treatment. Results: There were 16 males and 25 female patients with age ranged from 11 years to 19 years with average of 13.5 years. The mean preoperative scoliosis is 59°±15°. The mean preoperative kyphosis was 25°. The mean postoperative scoliosis is 17°±10° (72% reduction). The mean postoperative scoliosis at two years follow-up was 19°±9° (68% reduction). Correction loss was 30 (14.8%). The mean preoperative FVC was 90.6. The mean preoperative FEV1 was 86.67. The mean preoperative TLC was 97.8. The mean postoperative FVC was 86.2 (p=0.3125). The mean postoperative FEV1 was 85 (p=0.5660). The mean postoperative TLC was 100 (p=0.6671). Thoracoplasty was carried out in 24 patients. Conclusion: Posterior instrumentation using pedicle screw with or without proximal hook constructs offer improved primary and secondary curve correction in idiopathic scoliosis and with limited fusion of motion segments. Insertion of screws in every single vertebra is not necessary as a satisfactory multidimensional radiological correction and a high long-term patient’s satisfaction can be achieved with a low implant density.

Study of Insomnia, Day Time Sleepiness and Sleep Quality among South Indian Nurses

Yogita Khade, Swikruti Behera, Parvathi R, Sowmya Korradi

Introduction: Good quality and adequate sleep is important for good cognitive, psychological and physical health. Nurses who work closely with patients need to have sound mental and physical health for proper health care delivery. Aim: To evaluate the incidence of insomnia, day time sleepiness and sleep quality among South Indian nurses. Materials and Methods: The present cross-sectional study was conducted at NRI Medical College, Vishakhapatnam, Andhra Pradesh, India and Vijaya Hospital, Belgaum, Karnataka, India during the period of August to December 2016. One hundred and ninety nurses were included in the study. Among 190 nurses, 42 were males and 148 were females. Three questionnaires namely, Epworth Sleepiness Scale (ESS), Regensburg Insomnia Scale (RIS) and Pittsburgh Sleep Quality Index (PSQI) were included in the study. These questionnaires were distributed among the nurses and the questions were explained to them in their local language. Measures of central tendency, dispersion and chi-square tests were used for analysis of the data. Results: Significant higher values of sleep disorders were found. On analysis the PSQI and RIS scoring were significant whereas ESS scoring was found to be insignificant. In the present study 77 (40.5%) out of 190 nurses were found to be suffering from insomnia. 88 (46.31%) nurses had poor sleep quality and 48 (25.26%) nurses were suffering from daytime sleepiness whereas 30 (15.78%) of nurses had borderline daytime sleepiness. The highest number of cases was seen in nurses having one to three years of experience. Conclusion: The present study suggests that a large fraction of South Indian nurses were found to be suffering from insomnia and poor sleep quality. Adequate number of nursing staff, shorter shift durations and meticulously planned night shifts are needed to improve the sleep health and well being of nurses which in turn will result in better and more efficient patient care.

Impact of Counselling Services in Stress Reduction among First Year MBBS Students

Abraham Jobby, Angela Viswasom

Introduction: Medical education being a highly competitive field is known to be quite stressful. Stress hinders the efficiency of many medical students. It has a negative influence on their academic performance as well as their physical health. Aim: To observe the baseline stress level of first year medical students and to assess the effect of counselling and mentoring programme on these stress levels. Materials and Methods: An experimental study (pre and post-test without control) was conducted during November to December 2015 amongst the first year medical students of the Travancore Medical College, Kollam, Kerala, India. Ninety-eight first year medical students were divided into 10 batches and were assigned to a teaching faculty of the basic specialities (mentor). Personal interaction and counselling was conducted by the teaching faculty with technical assistance from the psychiatry department. General stress relieving techniques were taught to students through two counselling programmes in four batches, each within a gap of one month. Standardised peer reviewed, pre validated stress assessing questionnaires (pre-test and post-test) were administered to the students who consented and attended all sessions. Results: It was identified that around 74 out of 98 (75.5%) of the students were experiencing stress at the beginning of the study and this reduced to 69 out of 98 (70.4%) after implementation of the programme in a time period of one month. This shows that counselling programmes were effective in reducing both baseline stress and academic stress amongst first year medical students. Conclusion: Assessment of stress and conduct of stress management programmes are necessary for improving the academic performance and Quality Of Life (QOL) of medical students. Stress relieving techniques should also be practiced to reduce stress in medical education.

Comparison of Physiological Changes between Transperitoneal and Retroperitoneal Approach for Urologic Laparoscopic Surgery

Introduction: Laparoscopy is increasingly being performed for urologic surgeries either through transperitoneal or retroperitoneal approach. While physiological changes during transperitoneal surgeries have been extensively studied, very few studies have explored the effect of retroperitoneal laparoscopy. Aim: To compare physiological changes that occurred when urologic laparoscopic surgeries were carried out through either transperitoneal or retroperitoneal approach in lateral positions. Primary outcome was respiratory changes and haemodynamic changes were considered secondary outcome. Materials and Methods: This single centre prospective non randomised human study was conducted in 46 healthy individuals undergoing elective urologic laparoscopic surgeries at Dr. H.L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India, from January 2017 to July 2017 and patients were divided into two groups according to the surgical approach used: 1) Transperitoneal (Trans) group; and 2) Retroperitoneal (Retro) group. Compliance, Peak Inspiratory Pressure (PIP), Minute Ventilation (MV), Heart Rate (HR) and Mean Arterial Pressure (MAP) were monitored at defined time interval. Arterial blood gases were also measured to compare Partial Pressure of Arterial Oxygen/Fraction of Inspired Oxygen (PaO2/FiO2) ratio. Chi-square and t-test were used for statistical comparison between the two groups. A p-value<0.05 was considered significant. Results: PaO2/FiO2 ratio improved in Trans (from 395.45±128.35 to 439.88±87.77) and decreased in Retro group (from 399.29±57.6 to 349.72±97.89) at the end of pneumoperitoneum with significant statistical difference between the two groups. Compliance decreased to 37% of baseline (from 33.03 to 20.99 mL/cm H2O in Trans group and from 37.02 to 23.23 mL/cm H2O in Retro group) and PIP increased to 45% from baseline (from 18.43 to 26.13 cm H2O in Trans group and from 17.91 to 25.86 cm H2O in Retro group) in both the groups without any statistical difference. The HR remained higher in Trans group as compared to Retro group during the insufflation period. The MAP remained higher than baseline during pneumoperitoneum in both the groups. Statistical comparison of HR and MAP between the two groups was insignificant. Conclusion: Respiratory and haemodynamic parameters remain stable and are comparable between the two approaches. Larger studies are required to validate this results.

Clinical Study for Efficacy of Different Diagnostic Tools for the Diagnosis of Acute Appendicitis

Introduction: Acute Appendicitis (AA) is one of the most common causes of surgical abdominal pain and can be confused with other diseases due to atypical presentations of the disease. So, to aid in the diagnosis the various scoring systems and radiochemical investigations are in use such as Modified Alvarado Score (MAS), Ultrasonography (USG) of abdomen, Computed Tomography (CT) scan of abdomen and serum bilirubin levels. Aim: To study the diagnostic efficacy of MAS, USG of abdomen, CT scan of abdomen and serum bilirubin level for the diagnosis of AA. Materials and Methods: This was a prospective observational study conducted in the North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India. A total of 72 patients with the clinical diagnosis of AA participated in the study. The patients were subjected to MAS, USG of abdomen; serum bilirubin level and Contrast-Enhanced Computed Tomography (CECT) scan on admission. Sensitivity, specificity, positive predictive value and negative predictive value for each test were found. Final diagnosis was confirmed histopathologically. Descriptive statistics data were calculated using SPSS version 22.0. Results: Sensitivity was highest for USG 42 (80.77%) out of 52. Specificity was highest for CT scan 18 (90%) out of 20, when target sign was found positive in the patient and also in cases of serum bilirubin 18 (90%) out of 20 when the patient had perforated appendicitis. Otherwise the overall diagnostic accuracy of USG was the highest 47 (65.28%) of 72. Conclusion: Diagnosis of AA is still challenging as the overall sensitivity or specificity of scoring system as well as radiochemical analysis is still very poor.

Factors Affecting Adequacy of Prenatal Care in Suburban Women of Southeast Iran: A Cross-sectional Study

Introduction: Prenatal and delivery care should be considered as a priority for women and societys health. Residents of the suburbs are among the groups who do not have enough access to such services. Aim: The present study aimed to determine the pregnancy care as well as factors affecting adequacy of prenatal care for suburban women in Southeast Iran. Materials and Methods: This cross-sectional study was conducted from July 2016 to December 2016. A total of 384 women were evaluated by a single stage cluster random sampling. Inclusion criteria included women living in Zahedan suburbs areas and women in their reproductive ages who gave birth. Exclusion criteria was the history of diseases affecting pregnancy and multiple pregnancies. Safe motherhood questionnaire was completed by face to face interview in order to gather data. The questionnaire includes items for assessing prenatal and delivery care. Descriptive, chi-square and Spearmans correlation coefficient tests were used to analyse data. SPSS version 20.0 software was used for analyses. A p-value <0.05 was considered significant. Results: A total of 372 (96.9%) of subjects received prenatal care however 189 (50.8%) of them received inadequate care. There was a statistically significant relationship between adequate care and women’s education level (p-value=0.009), marriage age (p-value =0.001), husbands education (p-value=0.05), husband’s employment status (p=0.01), age in the first pregnancy (p-value=0.003), the time intervals among pregnancies (p-value=0.04), place of receiving care (p-value=0.004) and health care provider (p-value=0.006). Conclusion: We found that most of suburban women did not receive adequate prenatal care, although, free health services were available for these mothers. Individual, familial features, care provider and place of receiving services were found effective for the quality and productivity of such services.

Factors Affecting Medical Equipment Maintenance Management: A Systematic Review

Rona Bahreini, Leila Doshmangir, Ali Imani

Introduction: The medical equipment maintenance management has a pivotal issue for the safety and costs of medical devices. We need a comprehensive assessment tool that covers all aspects of medical equipment maintenance management in hospitals. In this regard, identification of influential factors is essential. Aim: The aim of the present systematic review was to extract the factors affecting the medical equipment maintenance management. Materials and Methods: We conducted a comprehensive search in databases including OVID, PubMed, ProQuest, Scopus, Embase, Science Direct and web of science without any time limitation until October 2015. The result was updated in June 2017. Inclusion criteria were all studies related to medical equipment maintenance management and mentioning at least one factor that affects this process. Two independent reviewers checked the research process, screening of articles and quality assessment. Quality of the studies was assessed by QASP and STROBE checklist. Results: A total of 29 articles were included in this study. All the included articles were in English language. Finally, 89 factors were identified that affect the medical equipment maintenance management. Five of the factors were found related to resource item, 12 factors related to service, four factors related to education, 15 of these factors related to quality control, 19 factors related to inspection, 12 factors related to information bank and 22 factors were dedicated to management. Conclusion: Influential factors (management, resources, information bank, inspection, quality control, education and service) are implicated in decision-making in support of selection, purchase, repair and maintenance of medical equipment, especially for capital equipment managers and medical engineers in hospitals and also for assessment of this process. Identification and classification of influential factors can be of help for raising critical alerts about equipments more prone to maintenance problems.

Is there a Correlation between Micronutrients and Cognitive Status: An Exploratory Study of Senile Dementia of Alzheimer’s Type

Introduction: Alzheimer disease is a multifarious neurodegenerative disorder which is a leading cause of dementia in late adult life. It is characterised by deposition of intracellular neurofibrillary tangles and extracellular amyloidal protein which contributes to senile plaques. Studies suggested that vitamin B12 (cobalamin) and folate (folic acid) deficiency in the elderly are most common. These micronutrients are crucial for proper brain function and play an important role in mental and emotional health. Aim: To evaluate the level of homocysteine, folate, vitamin B12 and vitamin D in the serum of the patient suffering from Senile Dementia of Alzheimer’s Type (SDAT). Materials and Methods: The study was an open label, crosssectional and comparative analysis. There were 110 patients suffering from SDAT taken as sample. Study included elderly patient aged 60-75 years and the duration of the study was 17 months (December 2014 to May 2016). The Group 1 (n=110, case) included patients whose age between 60-75 year given Treatment As Usual (TAU) and they were supplemented with oral vitamin B12 and folate during the treatment and Group 2 (n=55, control) included patients whose age between 60-75 year given TAU i.e., without any supplementation. The study was done by Competitive, sandwich Enzyme-linked Immune Sorbent Assay (ELISA) to assess the serum level of homocysteine, folate, vitamin B12 and vitamin D in patients suffering from SDAT (as cases) and healthy individual (as control). The statistical analysis was done by Student’s t-test. The data were expressed as mean±SD, p<0.05 was considered significant and mean±SD, p<0.001 was highly significant. Results: The mean serum homocysteine level was higher in cases (11.65±8) nm/mL as compared to controls (6.27±6.77) nm/mL. The mean value of serum homocysteine was found significant in cases as compared to controls (p<0.001). The serum folate (17.59±22.74 ng/mL/26.65±27.26 ng/mL), vitamin B12 (1.27±1.61 ng/mL/1.44±0.75 ng/mL) and vitamin D (21.01±34.68 ng/mL/42.74±70.49 ng/mL) level was lower in cases as compared to controls. The mean value of folate, vitamin B12and vitamin D was found to be not significant in cases as compared to controls (p>0.05). Conclusion: This study concluded that higher serum homocysteine levels, lower vitamin D, vitamin B12 and folate levels are risk factor for the SDAT.

Daily Life Challenges in an Earthquake Disaster Situation in Older Adults: A Qualitative Study in Iran

Introduction: Understanding the challenges of daily life in older adults after a disaster is a necessary precondition to manage the consequences of disasters in this vulnerable group. Aim: The purpose of this study was to explore the challenges of daily life of older adults after an earthquake in Iran. Materials and Methods: This qualitative study was conducted using a content analysis approach. A purposeful sampling method with maximum diversity was applied until reaching data saturation. In total, 18 older adults, four experts and four caregivers participated in the study. Data were collected using in-depth and semi-structured interviews. Data analysis was done with an inductive approach and with the help of the recommended principles. Results: By analysing 564 primary codes, three main categories: losses, ageism and disruption in usual routine life were extracted from the experiences of older adults. Each of these categories included several subcategories, which were categorized according to their significant characteristics. Conclusion: Clarifying the challenges in the daily lives of the older adults after disasters can help to create an age sensitive approach for recovery and thus, more effectively addressing their needs. Based on the findings of the research, it is recommended that further research is needed to investigate the life processes in older adults after disasters and to extract their experiences in different contexts.

Quality of Life Among Geriatric Population in an Urban Area of Tripura, India

Anjan Datta, Kaushik Nag, Nabarun Karmakar, Kaushik Tripura

Introduction: With the increase in proportion of geriatric population, assessment of their Quality of Life (QOL) is also a major concern in developing countries like India. Aim: The aim of the present study was to assess different domains of QOL and associated sociodemographic factors among geriatric population. Materials and Methods: The present community based crosssectional study was conducted among geriatric population residing in Dukli municipal area of Agartala, Tripura, India for a period of two months (August 2016-September 2016). The study was conducted among 76 randomly selected individuals (19 individuals from each of four different para) from Dukli area, using Lot Quality Assurance Sampling (LQAS) technique. Data were collected using predesigned, structured WHOQOL-BREF questionnaire format after meaningful translation into local language (Bengali) and analysed using computer software SPSS version 20.0. Results: The mean QOL scores were maximum in Social Relationship domain (60.03±11.73), followed by Environment domain (55.30±8.88). Majority of the study participants were found to have poor QOL in all four domains [50 (65.8%) in Physical Health domain, 43 (56.6%) in Psychological, 44 (57.9%) in Social Relationship and 56 (73.7%) in Environment domain]. Significant difference was found in Psychological domain score among different socioeconomic class (p-value=0.019) and marital status (p-value=0.004). Again Environment domain of QOL was found better in lower socioeconomic class (p-value<0.05). Conclusion: Overall poor QOL was reflected among the urban geriatric population in this study and improvement in personal relationships, social support etc., for the elderly females were found to be important to improve their QOL. Economic stability by means of various self-help groups and self-employment schemes for the elderly by government is of utmost importance especially for the lower class population in urban areas to improve their QOL.

Role of Low Density Lipoprotein Cholesterol in Progression of Diabetic Retinopathy

Introduction: Various cross-sectional studies indicate that dyslipidemia and increased activity of enzyme Aldose Reductase (ALDR-2) are associated with the establishment of Diabetic Retinopathy (DR). However, it remains unclear that among dyslipidemia and ALDR-2 activity, which is more important for the progression of DR from nonproliferative to the proliferative stage. Aim: The present study was designed to explore the role of dyslipidemia and ALDR-2 activity in the progression of DR. Materials and Methods: Two hundred subjects were involved in this cross-sectional study, 150 subjects had Type 2 diabetes while 50 had No Diabetes and No Retinopathy (NDNR) and acted as controls. On the basis of fundus examination, diabetic subjects were further divided equally into those having: No Retinopathy (DNR), Non-Proliferative DR (NPDR), and Proliferative DR (PDR). Fasting lipid profile, ALDR-2 level, fasting and postprandial blood sugar were measured using a standard protocol. Data were analysed using both descriptive and inferential statistics using unpaired t-test. Results: ALDR-2 level was significantly (p-value=0.0001) higher in NPDR than DNR. Low-Density Lipoprotein Cholesterol (LDL-C) was significantly (p-value=0.0235) higher in PDR than NPDR. Fasting Blood Sugar (FBS), Postprandial Blood Sugar (PPS), and LDL-C were significantly higher in DNR than NDNR while high-density lipoprotein cholesterol was significantly lower in DNR than NDNR group. Conclusion: Persistent hyperglycaemia causes an increased ALDR-2 activity that has a significant role in the establishment of DR. However, dyslipidemia is more important as a risk factor for progression of NPDR to PDR. Hypolipidemic drug as an adjunctive therapy could prevent the progression of DR from NPDR to PDR.

Echocardiography in Transfusion Dependent Beta Thalassaemia Major Egyptian Children: Correlation with Thyroid Function Status and Ferritin Level

Hanan Mahmoud Fayed, Eman Ahmed Abdel Mawgood, Heba Mohammed Qubaisy

Introduction: Iron-mediated cardiomyopathy is leading cause of death in ß-thalassaemia (ßTM). Thyroid dysfunction maybe associated with cardiac dysfunctions. Early detection of cardiac-function impairment can help in preventing further cardiac damage by modifying disease progression and treatment. Aim: To assess cardiac function and echocardiography indices in transfusion dependent ßTM children in Qena, Egypt and correlate findings with thyroid status and serum ferritin levels. Materials and Methods: This was a case-control study conducted on 40 transfusion dependent ßTM cases aged from 6-12 years who were on regular follow-up in outpatient paediatric clinic in Qena university hospital between January 2016 and December 2016. Fifteen, age and sex-matched healthy children were included as a control group to investigate Left Ventricle (LV) diastolic and systolic function using echocardiography, and correlate findings with serum Thyroid Stimulating Hormone (TSH), free thyroxine (FT4), and serum ferritin. SPSS version 22 used for data analysis and Pearson correlation was used to explore the relationship between quantitative variables. All statistical tests were two tailed, and a p-value below 0.05 was considered statistically significant. Results: In children with ßTM had a mean age 9.51 years (SD±3.26), (n=10, 25%) had hypothyroidism; primary (n=1, 2.5%), subclinical (n=5, 12.5%) and central (n=4, 10%). Cases had Left Ventricular Ejection Fraction percentage (LVEF%) of 67.68±7.04, ferritin level of 2617±1866 vs. 118±43 in control; (p-value=<0.001), Left Ventricular Dimensions at the End of Systole (LVESD) 40.63±6.17 vs. 36.53±4.82 in control; (p-value=0.025) and Left Ventricular Dimensions at the End of Diastole (LVEDD) was 25.40±4.83 vs. 22.60±3.54 in control; (p-value=0.046). Cases with impaired thyroid function had higher ferritin and lower EF%. Cases displayed left ventricular diastolic restrictive pattern with preserved left ventricular systolic function in echocardiogram. FT4 showed a negative correlation with TSH and myocardial performance index (LV Tei) while ferritin showed a positive correlation with TSH, LVEDD and LVESD. Conclusion: Periodic evaluation of thyroid and cardiac functions and thyroxine replacement maybe considered in cases with iron overload, subclinical hypothyroidism and poor response to chelation therapy.

Mastoid Air Cell System: Hounsfield Density by Multislice Computed Tomography

Introduction: Multislice Computed Tomography (MCT) is the main radiographic examination to evaluate mastoid air cell system. Hounsfield Unit density (HU), determined by MCT is useful to evaluate mastoid pneumatization, but HU values in different genders, right/left mastoid sides, as well as their association with age have not been studied yet. Aim: To evaluate the difference in Hounsfield density values between genders as well as between right and left sides, and also to correlate HU with age. Materials and Methods: A total of 102 skull MCT examinations that included mastoid process of temporal bone were evaluated (47 from male and 55 from female patients). The HU was measured at mastoid cavity applying exclusively axial slices in a standardized region of interest. All statistical analyses were performed at a level of significance of 5%, using IBM SPSS Statistics 17, SPSS®, Inc, Chicago, IL. Linear regression was used to determine the relationship between age and HU; Non-parametric tests were performed to evaluate differences between right and left sides, as well as between genders. Results: No statistical significant differences was observed between left and right sides HU values (p-value=0.676) nor between male and female (p-value=0.155), according to Mann-Whitney test. Age was not correlated with HU values (p-value=0.06). Conclusion: Within the limitations of the present investigation, we concluded that the Mastoid Air Cells System (MACS) HU values do not vary among male and female individuals and left-right sides. Age is advocated to be associated with the volume of mastoid pneumatization, but it may not be related to differences in HU values.

Impact of Duration and Control of Diabetes Mellitus on Anterior Segment Parameters in Indian Eyes

Gnaneswaran Premnath, Chokkalingam Shankar

Introduction: Patients with diabetes mellitus are prone to develop angle closure resulting in glaucoma which is one of the leading causes of blindness. Aim: The aim of the present study was to find the impact of diabetes mellitus on anterior segment parameters in relation to the duration of the disease and glycaemic control. Materials and Methods: A total of 100 consecutive diabetic patients aged 40 years and above were included in the present observational cross sectional study. After obtaining informed consent, complete ocular and medical history was taken, followed by clinical evaluation. Relevant laboratory investigations were carried out. Anterior Chamber Depth (ACD) was measured with IOL Master. Central Corneal Thickness (CCT) and Lens Thickness (LT) were measured using A-Scan Biometry and Ultrasound Pachymetry respectively. SAS 9.2 was used for analysis. Microsoft Word and Excel were used to generate graphs, tables etc. Significance was assessed at 5% level of significance. Results: A total of 100 patient’s eyes were studied. Group analyses in terms of duration of diabetes and glycaemic control were done. Patients with diabetes more than five years duration and poor control of the disease had lower mean ACD (p=0.056 and p<0.0001 respectively), high mean CCT (p=0.0094 and p=0.022 respectively) and high LT (p<0.0001). Conclusion: The present study showed that diabetic patients with more than five years duration and poor glycaemic control had shallower anterior chamber, thicker central cornea and thicker lens than that of those who had diabetes less than five years duration and good glycaemic control.

Effect of Multimedia Information on Preoperative Anxiety Levels of Patients Posted for Surgery under Subarachnoid Block

Anupama Pandey, Gaurav Chopra, Yashwant Singh Payal

Introduction: Preoperative anxiety is associated with problems such as difficult venous access, jaw relaxation and coughing during induction of anaesthesia, autonomic fluctuations and increased anaesthesia requirements. It has also been correlated with increased pain, nausea and vomiting in the postoperative period, prolonged recovery and increased risk of infection. Most patients experience preoperative anxiety which is a major concern before surgery and it has been suggested that the reduction in preoperative anxiety levels might be associated with better surgical outcomes, shorten hospital stay and minimise lifestyle disruptions. Aim: The aim of the present study was to assess the pre and post procedure anxiety level of the patient undergoing surgery under spinal anaesthesia, after being shown a video of how the procedure is performed and to assess the ease of the anaesthesiologist performing the Subarachnoid Block (SAB). Materials and Methods: The present study included 100 patients divided in two groups. One group who had a face-to-face interview with the anaesthesiologist and the other group were shown a audio-visual video of the procedure, posted for elective surgery under SAB. The anxiety levels of the patients was evaluated using Visual Analogue Scale (VAS) scores, State-Trait Anxiety Inventory (STAI) questionnaire and the satisfaction level of the anaesthesiologist using Likert’s scale. The postoperative anxiety values were assessed when the patients were shifted to recovery room. The statistical tests used were Student’s t-test for continuous data, chi-square test for categorical variables. One-way repeated ANOVA to analyse the significance. Results: The VAS scores in between Group 1 and Group 2 showed that the pre-intervention, pre-procedure and post-procedure were statistically not significant. The pre-intervention VAS score was 3.23±0.92 in Group 1 and 2.78±0.82 in Group 2 (p-value=0.4), the pre-procedure VAS score was 3.04±0.84 in Group 1 and 2.67±0.76 in Group 2 (p-value=0.6), the post-procedure VAS score was 3.84±0.96 in Group 1 and 2.88±0.9 in Group 2 (p-value=0.5). The state anxiety between the pre-intervention, pre-procedure and post-procedure in Group 1 and Group 2 the data was statistically significant (p=0.01 and p=0.02). The trait anxiety between pre-intervention, pre-procedure and post-procedure in Group 1 and Group 2 showed that the data was statistically significant (p=0.03 and p=0.01) respectively. The Likert’s score which was assessed by the anaesthesiologist performing the block, there was statistically highly significant difference present between the groups (p=0.00). Conclusion: Educating the patient is important for helping in reducing the fear and anxiety of patient, face-to-face interview is a good way of providing information to the patient but multimedia information is better as patients are more receptive to audio-visual information.

If ‘Express’ is to ‘Say’, then ‘Believe’ is to What? Development of an Aristotelian Styled Analogical Reasoning Task for Indian Adolescents

Jayashree Sunil Bhat, Sudhin Karuppali

Introduction: Analogical reasoning skills are a cognitive linguistic mechanism that develops with age. This development is manifested in the language abilities exhibited by children and adolescents. There are only a handful of standardised language tasks available to assess analogical skills in typically developing adolescents in India. Aim: The present research attempts to develop an analogical reasoning task to assess language in Indian adolescents. Materials and Methods: The research followed a two-stage cluster random sampling design with a total of 432 participants between 10-16 years of age allocated based on age and standard. The participants were recruited from English-medium schools based on a selection criterion. The development of the task followed three stages: Stage I comprised of construction of the task along with pilot studies; Stage II included the administration of the developed task; Stage III focused on establishing test validity and reliability measures. The mean and SD of the scores of the task of the adolescents (typical and language disordered) were calculated. The test-retest reliability of the items was measured using Kappa statistics. Intra-class correlation coefficient was done to determine the agreement between the total scores of the task. Mann Whitney Test was done for the items and total scores of each age group. ROC analysis was performed to determine the sensitivity and specificity. Results: Significant results were obtained when the typically developing and age matched adolescents with language disorders were compared using Mann-Whitney test. ROC analysis revealed a moderate-high sensitivity and low-moderate specificity. Conclusion: The developed task is a criterion and norm-referenced test which can be used to determine language disordered adolescents.

Effects of Continuous Care Model on Blood Pressure in Patients with Type II Diabetes

Milad Borji, Asma Tarjoman, Reza Seymohammadi, Ebrahim Salimi, Masoumeh Otaghi

Introduction: One of the main problems encountered by type II diabetes patients is high Blood Pressure (BP). Continuous care is the standard process of making effective, mutual, and continuous relationships between patients and nurses as healthcare providers. Continuous Care Model (CCM) can help the nurses in identifying needs, problems, and sensitisations of the patients and encourage them to maintain and enhance their health status. Aim: This study aimed to investigate the effects of CCM on the BP trends of patients with type II diabetes in Ilam city. Materials and Methods: This quasi-experimental research was conducted in 80 patients with type II diabetes. Subjects were selected using cluster sampling method and then were randomly divided into intervention and control groups. Interventions based on the CCM were in the form of training sessions that were conducted for three weeks. Consequently, continuous care consultations, control, and assessment were conducted for nine weeks. A questionnaire on demographic characteristics and a BP recording device was used to collect the data obtained before intervention and 1-3 months after intervention. Then, descriptive and inferential tests (ANOVA, repeated measures, chi-square) were used for data analysis. Results: Findings revealed that the mean BP (measured in mmHg) scores of the CCM (systolic, 133.22±3.98; diastolic, 86.00±2.96) and control groups (systolic, 133.65±2.10; diastolic 84.62±2.72) before intervention were not significant (p>0.05); however, after intervention, a significant difference was observed between the mean BP (measured in mmHg) scores of the CCM (systolic, 127.52±3.13; diastolic, 80.75±1.97) and control groups (systolic, 133.65±2.25; diastolic, 83.87±2.12) (p<0.05). Conclusion: CCM is suggested to be effective in managing the BP and can be applied to improve the health behaviour in patients with type II diabetes.

From Potpourri to Percipience: Developing Problem Solving Skills in Medical Students through a Computer Assisted Active Learning Strategy

Maya Roche, Ronald Aloysius Roche, Akshatha Ganesh Nayak, Shashikiran Umakanth

Introduction: Problem solving skills are of utmost importance to medical students who in the future would depend on them for diagnosing a case. However, there are very few avenues to develop problem solving skills in the preclinical years. Generally, case scenarios are used by medical schools to develop these skills during Problem Based Learning (PBL) or Case Based Learning (CBL) sessions. Aim: To build problem-solving skills by using analysis, reasoning and application. The experiment tests a novel digital mode to achieve these objectives. Materials and Methods: This was a prospective cross-sectional study, conducted at Melaka Manipal Medical College (MMMC), Manipal Academy of Higher Education, Manipal, India, spanning over four months. MBBS students (n=81), in the first year of their curriculum, took part in the activity. Seven case scenarios were designed using PowerPoint 2013. Each case scenario was divided into case title, case history, clinical findings, investigations and treatment. The content and construct validity of the case scenarios was carried out by a clinician and changes were affected accordingly. The slides were placed in random order, forming a ‘potpourri’ and presented to the students through a Local Area Network (LAN) in the digital laboratory. They were asked to sort the slides and give a diagnosis for each case. Using google forms a questionnaire was prepared and this was used to collect feedback from students. Results: Majority of students (85%) scored more than 72% marks in the activity. Marks obtained in arranging the slides did not correlate with marks obtained in diagnosis of the case. However, it is important to note that all students who got the diagnosis right had full marks in arranging the slides. The present study required students to recall and relate the facts which they had learnt during their entire year, apply it to the case and give a diagnosis which 74% of them found challenging. Though, most of the time they succeeded in bringing order to the ‘potpourri’, their success in achieving percipience was limited. Conclusion: This novel experiment in using case scenarios on a digital platform offers many possibilities for testing and building skills essential for clinical practice. The fact that the activity was much appreciated by students, bolsters the faculty’s resolve to plan many more such innovations.

Middle Ear Risk Index Scores as a Predictor for Hearing Threshold after Tympanoplasty in Patients with Chronic Suppurative Otitis Media

Rina Hayati, Tengku Siti Hajar Haryuna

Introduction: One of the main purposes of tympanoplasty is to improve hearing. Middle Ear Risk Index (MERI) Scores can be use to predict the average success in the procedure of the middle ear reconstruction. Aim: To assess the change in hearing threshold after tympanoplasty, based on the assessment of MERI Scores. Materials and Methods: An observational assessment was done on 21 patients with Chronic Suppurative Otitis Media (CSOM) who underwent tympanoplasty. Pure tone audiometry was done before and 12 weeks after tympanoplasty an MERI Scores were assessed before and during the operation. Change in hearing after tympanoplasty statistically was analyzed by using Willcoxon test. Correlation between hearing threshold and MERI Scores was analyzed by using Spearman’s Coefficient Correlation. Results: Hearing threshold after tympanoplasty was much better in the subjects with no otorrhea, subtotal perforation type, no cholesteatoma and granulation, complete ossicular chain, who had never been operated and did not smoke. There was a significant negative correlation between MERI Scores as the predictor of hearing threshold which indicated that the lower the MERI Scores were, the better the improvement of hearing threshold after tympanoplasty (p=0.039; r=-0.453). Conclusion: MERI Scores could be used as a measuring instrument to assess the prognosis of hearing threshold after tympanoplasty.

Comparative Study of Endothelial Cell Loss after Phacoemulsification in Different Anterior Chamber Depth Groups

Meghna Solanki, Gargi Verma, Ankur Kumar, Kishor Kumar

Introduction: Corneal decompensation is a rare but potentially vision-threatening complication after phacoemulsification surgery. The evaluation of risk factors for perioperative endothelial cell loss provides important information in preserving these cells from the mechanical and thermal damage that can occur during phacoemulsification. Aim: To assess and compare endothelial cell loss after phacoemulsification in three different Anterior Chamber Depth (ACD) groups. Materials and Methods: The study was a hospital based comparative type of observational study, which comprised of 90 patients who were further divided into 3 groups (30 in each group) according to ACD. The patients underwent phacoemulsification surgery with Intraocular Lens (IOL) implantation. Endothelial cell loss was calculated by measuring the percentage decrease in endothelial cell density of the central cornea. Results: The percentage of mean endothelial cell loss was significantly higher in shallow ACD groups as compared to groups with deep ACD at each follow up (Day 1, 1st week, 1 month and 3 months), which was statistically significant. Conclusion: Eyes with shallow ACD is associated with an increased endothelial cell loss than eyes with deep ACD.

First Outbreak of Dengue in Jorhat District of Assam

Introduction: Dengue Virus (DENV) infection is an important human arboviral infection. Though it is endemic in several parts of India, there has been no reported outbreak from Jorhat district of Assam, India. Aim: To present a comprehensive picture of the first outbreak of dengue fever that occurred in Jorhat (Assam, India) and its adjoining districts from July to December 2016. Materials and Methods: Serum samples from 289 clinically suspected cases of dengue fever were sent to Microbiology laboratory of Jorhat Medical College and hospital for serological confirmation of the diagnosis. All the samples were tested for DENV specific IgM antibodies and DENV-Non Structural protein 1 Antigen (NS1Ag) by ELISA. Results: Out of the 289 clinically suspected cases of dengue, 114 (39.45%) were positive for DENV infection. Amongst the seropositive cases, NS1Ag was positive in 80 (27.7%) and IgM antibody was positive in 72 (24.9%) cases. Both NS1Ag and IgM antibody were positive in 38 (13.1%) cases. Adults (n=109; 95.61%) are more commonly affected than children (n=5; 4.39%). Male preponderance was noticed with a male:female ratio of 2.8:1. The maximum number of positive cases was reported in September (n=35; 30.71%) and occurred equally in rural (n=46; 40.4%) and urban areas (n=68; 59.6%). Fever was the most common presenting symptom followed by headache. Conclusion: Involvement of mainly the young adult population, male predominance and presence of rural dengue cases was seen during the outbreak. Majority of the cases presented with dengue fever without severe manifestations. Vector control measures and increased public awareness is the need of the hour to prevent further spread and complications of the disease in subsequent years.

The Effect of Peer Education on Treating Pain in Patients for Burn Debridement

Bita Kamranfar, Mohammad Heidari, Sara Shahbazi, Mansour Ghafourifard

Introduction: Debridement is a daily care for burn patients that can cause severe pain due to skin damage. Pain is one of the primary side effects of burn wounds and relieving pain is a basic need for all patients. Aim: To investigate the impact of peer education on the pain level of patients for burn debridement. Materials and Methods: This clinical trial conducted from January 2014 to March 2015, consisted of 60 patients who were to undergo burn debridement. The patients in the control group received routine training regarding the methods to reduce pain and the patients in the intervention group were trained by their peers under the supervision of the researcher. Pain severity was re-evaluated in both the groups on that day after training. The data collection tool was the demographic information questionnaire and a Visual Analogue Pain Scale (VAS). Data were analysed using SPSS software (version 18) and descriptive-analytical tests. Results: The mean score of pain severity at the beginning of burn debridement was 6.35±2.10 in the intervention group and 5.30±1.85 in the control group. After the peer education, the mean score of pain severity was 3.30±1.78 and 4.20±1.23 in the intervention and control group, respectively (p-value=0.02). Conclusion: Peer education can significantly reduce the severity of pain associated with burn debridement. The use of non pharmacological effective techniques, such as peer education can be beneficial in relieving pain and preventing its exacerbation

Effect of Opioids on Oral Health Status among Institutionalised Drug Addicts in a District of Rajasthan, India

Introduction: According to the World Health Organisation survey, 2004, opioid is one of the most common forms of drug used by drug abusers in India. The total number of registered opium abusers in India is estimated to be 1.4 million. The state in India with the maximum consumption of opium is seen in Punjab and Rajasthan when compared to the other states. Aim: To assess the oral health status and related practices of opium drug users in Sri Ganganagar, Rajasthan, India. Materials and Methods: The present cross-sectional study was conducted on 577 institutionalised adult male, drug addicts from across Rajasthan and Punjab. Comparison was made with duration of addiction to investigate any differences in oral health status. A standardised, pre-validated questionnaire was used to collect data on tooth brushing and its frequency, duration of drug abuse and oral complication like dry mouth, burning mouth, taste impairment and eating difficulty along with clinical examination to record Oral Hygiene Index-Simplified (OHI-S), Community Periodontal Index (CPI), and Decayed Missing Filled Surface (DMFS) index. The statistical significant analysis was done by t-test, Chi-square and level of significance was set at p<0.05. Multiple linear regression model was used to find out the association between duration of addiction and CPI, OHI-S and DMFS score. Results: The mean age of the patients was 38.2±11.89 years. Maximum addiction was seen in the age group of 18-24 years (n=158, 27.4%). Significantly higher mean scores of OHI-S, CPI, Decayed Missing Filled Teeth (DMFT) and DMFS score were reported among the patient on drug abuse of opioids for more than five years. Around half of the patients reported brushing their teeth at least once. Multiple linear regression model showed very high DMFS score which were associated with longer duration of drug addiction and no tooth brushing. Conclusion: The present study demonstrates poor oral health behaviour, worse periodontal health and higher caries experience among opium abusers, it is important to develop a specialised awareness protocol towards oral healthcare for the societies where such drug dependency is widespread.

Dental Anxiety in Children: A Review of the Contributing Factors

Amerah A Alasmari, Ghadah S Aldossari, Mohammed S Aldossary

Dental anxiety is a challenge faced by the dental professionals while treating young children. Many factors have been reported as contributing factors that influence and affect the level of dental anxiety in children. Being familiar with these factors would facilitate behaviour management in anxious children. This article reviews the contributing factors that have been investigated in the literature.

Role of Thrombopoietin in the Diagnosis of Ovarian Cancer: A Brief Review

Amar Ranjan, Rajani Anand, Iffat Jamal, Amrendra Kumar, Ritesh Kumar

Ovarian Cancer (OC) is the most fatal condition among all gynaecologic malignancies. The survival rate of early and advance stage of OC is 80-90% and 15-20% respectively. This data constitutes the need of a novel biomarker for early diagnosis, which may distinguish malignant tumours from benign ovarian cysts. Presently in practice there are three screening techniques: bimanual pelvic examination, serum Cancer Antigen (CA) 125 and transvaginal ultrasound. Bimanual pelvic examination can detect only 1 in 10,000 ovarian cancers in women presenting to the clinic. CA 125 is raised in 80% of cases of ovarian carcinoma; however, if the carcinoma is limited to ovary, the raised value is seen only in 50% of women. It is mainly useful in postmenopausal women. Ultrasonography also lacks specificity and sensitivity, apart from being costly as a screening test. Studies are going on for search of a biomarker, which may complement CA 125. Most common among these are Human Epididymis Protein 4 (HE4), Thrombopoietin (TPO), CA19-9, human kallikrein 10, human kallikrein 6, osteopontin, claudin 3, DF3 (murine monoclonal antibody), vascular endothelial growth factor, MUC1, mesothelin etc. In 2008, FDA approved the use of HE4 assay for monitoring of progressive disease in patients with epithelial ovarian cancer. Similarly TPO also holds the promise of being a biomarker to complement CA125 and many studies are indeed available to support the association of TPO and OC. In this review article we have summarised and analysed such studies.

ESC 2016 Heart Failure Guidelines: A Consensus Document from Indian Experts for Adaptation in India

Heart Failure (HF) in chronic setting is an important cardiac cause of morbidity and mortality. HF burden in India is expected to increase because of increasing risk factors especially hypertension and Coronary Artery Disease (CAD). Treatment of HF in India has been as per recommendations from international guidelines. There are no guidelines for management of HF in India. Recently, European Society of Cardiology guidelines on management of HF were released. To understand the new evidence and new recommendations and to apply these in management of HF in India, experts from across the country provided consensus for adaptation of these ESC guideline recommendations in Indian setting. This article provides the consensus opinion from Indian experts on recommendations of ESC guideline for diagnosis and treatment of HF for adaptation in India.

Implications of Postprandial Hyperglycaemia and Role of Voglibose in Type 2 Diabetes Mellitus

S R Pattanaik, Parag Shah, Abu Baker, Navin Sinha, Neeraj Kumar, Onkar C Swami

Type 2 Diabetes Mellitus (T2DM) is a chronic disease which requires treatment to prevent further complications. The Diabetes Epidemiology: Collaborative analysis of Diagnostic criteria in Europe (DECODE) study and diabetic intervention study demonstrated that high Postprandial Glucose (PPG) increased the mortality and cardiovascular complications. Voglibose, an ?-glucosidase inhibitor, controls PPG level and have cardiovascular benefits. Objective of this article was to review postprandial hyperglycaemia and clinical evidences of voglibose in management of PPG in T2DM patients, its role in prediabetic condition and cardiovascular benefits. Extensive search work was conducted on Google, Google scholar and PubMed from January, 1990 to May, 2017. Studies relevant to pharmacology, efficacy and safety of voglibose were included in the article. Voglibose significantly reduces the PPG level in T2DM patients compared to other antidiabetic drugs. Superior control on PPG contributes to cardioprotective action. Beyond PPG regulation, voglibose has an effective role on prediabetic condition. Weak absorption of voglibose through intestine make it a drug of choice in elderly patients or in hepatic impairment and mild to moderate renal function impairments when other anti-diabetic agents are contraindicated. Clinical studies on voglibose, highlighted its role to control PPG level in T2DM patients and its cardiovascular benefits.

Gender Bias in Autism Spectrum Disorders- A Review

Autism Spectrum Disorders (ASDs) have been one of the baffling mysteries of human mind. It is known that ASDs have a significant male predominance. Moreover, the differences between male and female brain that have been explored by many researchers point towards the role of hormones specifically steroid sex hormones during the developmental stages in functional development and coordination in brain structures. There is an abundance of receptors for steroid hormones such as testosterone, oestrogen, progesterone in brain. We have reviewed several research papers that indicate the involvement of steroid hormones acting through various pathways that affect cognitive, linguistic, social and emotional circuits which may culminate in manifestation of ASDs and the observed gender bias. These observations may also hold the key for a possible treatment or prevention of these types of disorders.

Recent Changes in Health Status of Women in Bihar through National Family Health Survey Window

Rahul Singh, Alok

Bihar is one of the states of India having lowest health profile. The accessibility of health facility is very poor and due to dire poverty, people are becoming malnourished. The main objective of this study was to assess the change in health status of women in Bihar through various indicators and compare this with corresponding changes at national level based on NFHS-3 and 4 fact sheets. The selected indicators are divided into three dimensions: nutritional status, maternal health care status and some determinants of women’s health. The indicators which were compared under the dimension of nutritional status include BMI, obesity and anaemic status of women in pregnancy and reproductive span period. Under the dimension of maternal health care status, the indicators which were compared includes antenatal care, consumption of iron-folic acid during pregnancy, postnatal care, neonatal tetanus, institutional births, birth assisted by health personnel, birth delivered by caesarean section under private and public health facility both. Whereas under the dimension of some determinant of women’s health: women’s literacy, child marriage, HIV/AIDS knowledge, uses of contraceptive method and tobacco consumption were compared. Almost all indicators showed some improvement during the reference period except percentage of overweight women and caesarean delivery which have increased to double between the reference period and utilisation of any contraception method which have decreased both at Bihar and national level. There is a need to spread health education for equitable health development and development policies should be framed in accordance with factors prevailing with in the locality.

Advances in Tumour Biomarkers for Screening, Diagnosis and Management of Ovarian Malignancies

Naina Kumar, Amit Kant Singh

Ovarian cancer is one of most deadly malignancies in women, accounting for 1,52,000 deaths annually worldwide. Most ovarian malignancies are diagnosed at advanced stages when they have already metastasised to distant sites. Many researches are still under way to find means of detecting this malignancy at an early stage, so as to improve overall survival rates associated with it. One such way is use of serum biomarkers, which can help to some extent in detecting these cancers at an early stage as well as to follow-up patients during chemotherapy, after surgery and for detection of recurrent/persistent disease. Present review throws light on some of these novel biomarkers that help in detection and follow-up of women with ovarian cancers.

Exudative Pharyngitis by Corynebacterium pseudodiphtheriticum-A Diagnostic Challenge during Diphtheria Epidemic

Kalpana George, Sohanlal Thiruvoth, Sheena Krishnan, Geetha Raveendran

Corynebacterium pseudodiphtheriticum is a common commensal of the upper respiratory tract which can mimic mild diphtheria clinically and can be a challenge for treating physicians, especially in the setting of a diphtheria epidemic. We report eight cases of pharyngitis caused by macrolide resistant Corynebacterium pseudodiphtheriticum.

Continuity of Care Following Intraoperative Cardiac Arrest due to Thymoglobulin^®-induced Anaphylaxis

Rabbit anti-thymocyte globulin (Thymoglobulin®, Sanofi-Aventis, Quebec, Canada) a purified gamma immune globulin obtained from the serum of rabbits immunised against human thymocytes, is widely used as an immunosuppressant agent to prevent acute rejection during solid organ transplantation. Anaphylaxis after first-time exposure to the drug is rare, but may be associated with devastating consequences. We present the case of a patient undergoing renal transplantation who developed intraoperative cardiac arrest due to severe allergic reaction immediately after initiation of Thymoglobulin® intravenous infusion. The patient was successfully resuscitated, but developed chronic chest pain from left-sided rib fractures sustained during chest compressions, and was evaluated by the same senior staff anaesthesiologist as an outpatient in the pain clinic. A high level of suspicion from anaesthesia providers is paramount in the diagnosis and management of intraoperative drug-induced severe allergic reactions, furthermore there is an opportunity for continued care of these patients by anaesthesia providers beyond the return of spontaneous circulation.

Left-sided Gastroschisis with Skeletal Deformities

Gastroschisis is a full thickness congenital defect in the abdominal wall. It has strong association with young maternal age of first para first gesta and usually in premature male babies. Though the pathogenesis is unclear, vascular insult during embryonic period is the most accepted theory. Variable length of intestine and occasionally parts of other abdominal organs are herniated outside the abdominal wall with no covering membrane or sac. It is commonly associated with gastrointestinal anomalies but extraintestinal anomalies are rare. An early preterm male neonate of 25-year-old first para first gesta mother without significant antenatal events exhibited left-sided gastroschisis with evisceration of both small and large intestine with stomach. He had absent digits of left foot except a single appendage, Congenital Talipes Equino Varus (CTEV) on right foot and pelvic deformity. Early identification of this defect by improving antenatal care and ultrasound examination helps to identify high risk patients in order to choose a specialised centre to optimise their outcome.