Journal of clinical and diagnostic research

A Rare Presentaion of Adrenocortical Carcinoma

Introduction: Orthodontic treatment with fixed appliances especially during the retraction stage makes it challenging to maintain the oral hygiene. Attachments used, such as elastic chains, loops and springs, result in changes in the oral environment due to the accumulation of plaque and increase in the levels of bacterial count mainly Streptococcus mutans and Lactobacilli species. Aim: To determine the prevalence of oral microbial flora during orthodontic space closure. Materials and Methods:This was a cross-sectional pilot study conducted during the month of December 2019 which consisted of eight patients who were randomly selected among the age group of 18-25 years. Mean and SD of age in Males (4) and Females (4) were 22±2.16 years and 22.25±1.70 years, respectively and had reported to the Department of Orthodontics of a private dental college, Saveetha Dental College. In each patient, after 6-8 months of orthodontic treatment, plaque samples were collected only once around the orthodontic brackets at the cervical aspect of the maxillary lateral incisor, maxillary premolar, mandibular canine, mandibular premolar in 1st, 2nd, 3rd, and 4^th quadrant respectively, by the method of cotton swabbing for the evaluation of micro flora. Independent paired t-test and One-way ANOVA with Post-hoc Tukey HSD test were done to estimate the prevalence of microorganisms at different sites. Results: Independent paired t-test showed highly significant differences in the levels of Streptococcus mutans when compared to Lactobacillus (p<0.001) with mean values of 4.8±2.5 and 23.1±9.2 for Streptococcus and Lactobacillus, respectively. One-way ANOVA with Post-hoc Turkey HSD analysis showed significant difference at the region of maxillary lateral incisor compared to other sites whereas Lactobacilli showed no significant differences between the various sites tested (p-value<0.001). Kappa statistics was performed which revealed an inter examiner reliability of 0.91. Conclusion: During orthodontic space closure, bacterial count of Streptococcus mutans showed a statistically significant difference between different sites (maxillary lateral incisor, mandibular canines, maxillary and mandibular premolars) with highest being the maxillary incisor region followed by that of mandibular canines. However, the incidence of Lactobacillus acidophilus did not show any difference between the various sites evaluated.

A Curious Case of Acute Pancreatitis in Pregnancy

Karan Rajgopal Kalani, Vaishali Kathuria, Sanjay Pandit, Dharam Pal Bhadoria

Hypercalcaemia is rare in pregnancy and is under diagnosed owing to its non-specific presentation which is frequently attributed to the pregnancy itself. Severe hypercalcaemia presents a therapeutic challenge, especially during pregnancy. The present case of a 26-year-old primigravida who presented with acute pancreatitis is described here. The pancreatitis was found to be secondary to parathyroid adenoma- induced hypercalcaemia. After initial conservative medical management with subcutaneous and intranasal calcitonin, she underwent a small-incision adenoma excision. This unusual cause and presentation of hypercalcaemia and its management is reviewed thereof.

Second New Primary PNET of Kidney in a Treated Case of Carcinoma Breast: A Case Report

Primitive Neuroectodermal Tumour (PNET) is a member of small round cell “Blue tumour” family. The overall incidence of PNET is <1%. PNET of kidney is uncommon and was first reported in 1975. Since the first report around 150 cases have been published in medical literature. It exhibits highly aggressive behaviour. It usually affects young adults and has a male predominance of 3:1. Only six cases of PNET of kidney have been reported in older patients and PNET of kidney as a second new primary has rarely been reported, only three cases of renal PNET with history of an earlier or synchronous primary cancer were reported in literature from the USA, Germany and China. We are reporting a case of renal PNET in a 48-year-old female who has been treated for right breast cancer by surgery, adjuvant chemotherapy and radiotherapy three years (July 2015) prior to diagnosis of PNET of left kidney. Upon diagnosis, patient underwent left nephrectomy. Postoperatively, patient was started on Ewing’s Family of Tumors (EFT) 2001 protocol. Patient completed induction therapy followed by radiation to tumour bed with concurrent weekly single agent vincristine and was planned for maintenance chemotherapy. After one cycle of maintenance chemotherapy patient developed severe febrile pancytopenia and was admitted in the ICU, even after aggressive medical line of management, patient could not be revived. Although, the patient tolerated the treatment protocol for breast malignancy well and the primary was under control but after three years, with the diagnosis of a very rare second new primary PNET of left kidney which has a very aggressive nature and poor prognosis, the patient could not tolerate the multimodality treatment which was required. To the best of our knowledge, this case report is very rare.

An Interesting Case of Rhino-Orbito-Cerebral Mucormycosis: A Case Report

R Minnu Lekshmi, Stephen Sudhakar, S Rajasekharan

Fungal infections are the most challenging problems in an immunocompromised individual. Mucormycosis is a life-threatening fungal infection with rapid progression and high mortality in immunocompromised individuals. A case of 58-year-old female, with uncontrolled diabetes is with five days history of headache, fever, and acute onset drooping of the eyelid. The initial vision was normal which dropped to PL in the following days, with ophthalmoplegia and dilated nonreactive pupil in the right eye. Fundus and IOP were normal on presentation. MRI and MRV brain showed subtle ethmoidal cysts. CT-PNS showed mild ethmoidal thickening and cyst. Diagnostic nasal endoscopy showed unhealthy mucosa with no lesion suggesting eschar. A provisional diagnosis of orbital mucormycosis was made. The patient was started on antibiotics and IV Amphotericin B but she went on to further neurological complications. Despite treatment, she developed necrotising eschars in eyelid for which debridement was done. Further, exenteration was advised and patient developed septicaemia, however he died. The culture from debrided tissue showed growth of mucor. The objective of presenting this particular case is to emphasise the importance of considering mucormycosis as diagnosis despite subtle radiological and endoscopic findings in symptomatic immunocompromised patients. Early diagnosis and aggressive management improve better chances for survival.

Unidentical Double Trouble- A Rare Case Report

Collision tumours are relatively rare entities and are thus, not well recognised. Collision tumour can be defined as two coexisting but histologically different malignancies involving the same organ or adjacent organ with an equivocal intermediate transitional zone between them. Collision tumours of the lung and oesophagus are very rare. Such cases are diagnosed by Computerised Tomogram (CT) Scan or Chest X-Ray for complaint of dysphagia. Definitive diagnosis is made by tissue biopsy. Here, a 66-year-old male is admitted for evaluation of an anterior mediastinal mass. Radiology revealed an anterior mediastinal mass extending in to the left hilar region and upper lobe of right lung anteriorly and in to the lower end of oesophagus posteriorly. Biopsy was performed. Microscopically, transbronchial biopsy revealed a cellular lesion, composed of round-to-oval cells with streaming nucleus, positive for Immunohistochemistry (IHC) markers, CD-56 and Synaptophysin pertaining to a diagnosis of small cell carcinoma. Biopsy of the oesophageal growth shows nest of dysplastic squamous epithelium which infiltrates into underlying muscularis propria showing features of a squamous cell carcinoma. Multiple fragments of squamous epithelium are also seen with necrotic tissue in vicinity and acute inflammatory exudate. Few cells show multinucleation, molding and margination of chromatin, showing the characteristic morphological features of Herpes oesophagitis. The patient was administered platinum-based Chemotherpy

An Unusual Presentation of Leiomyosarcoma Posing a Diagnostic Dilemma: A Case Report

Smita Singh, Kusha Sharma, Vipan Kumar, Partap Yadav

Leiomyosarcoma (LMS) is a malignant tumour of smooth muscle origin commonly seen in genital and gastrointestinal location. However, its presence in the head and neck region in a young child is extremely rare. Authors present a unique case of LMS in a one year and five-month-old child who presented with a painless mass in the right temporal region of the head. Histopathological examination revealed a highly cellular tumour arranged in intersecting fascicles of spindle cells with brisk mitotic activity and interspersed areas of necrosis. On Immunohistochemistry (IHC), the tumour cells were positive for Smooth Muscle Actin (SMA), Desmin and Vimentin and negative for S100 and Myogenin. A diagnosis of LMS was thus, made. Head and neck sarcoma is a broad entity encompassing plethora of differentials with closely overlapping morphological features which renders them diagnostically challenging, this can be resolved by employing various immunohistochemical stains readily available in all laboratories. This case highlights the combined role played by histopathology and immunohistochemistry in arriving at the correct diagnosis. To the best of our knowledge, this is the first case of LMS reported in the temporal region of head and is distinct with respect to its rare incidence, location and age at presentation. LMS at this site may masquerade as deceptively benign painless mass and may not be suspected initially, however one should bear in mind that these are moderate-to-high grade tumours and any delay in management may portend poor prognosis. Timely and aggressive surgical management is thus, the mainstay of treatment and critical to patient survival.

Salvage of Failed Endovascular Management of Internal Carotid Artery Injury during Endoscopic Endonasal Pituitary Surgery

Chandra Veer Singh, Shraddha Jain, Sagar Gourkar, Sandeep Iratwar

Rupture of Internal Carotid Artery (ICA) during trans-sphenoidal surgery can have high morbidity, as it results in altered mental status, stroke or cranial nerve palsies or is fatal for the patient as well. Hereby, Authors describe a case of 23-year-old female who underwent trans-sphenoidal surgery for recurrent pituitary macroadenoma. Removal of the pituitary tumour under general anaesthesia resulted in a bleeding pseudoaneurysm. Distal access catheter across the bleeding pseudoaneurysmal segment of right ICA was made and embolisation of the bleeding pseudoaneurysmal segment was done by placing stent graft. Then check angiogram was performed, which showed that significant embolisation was not achieved. Since, stent graft was unsuccessful to control bleeding, a decision was taken to perform neck dissection to clamp and control the ICA in the neck. Part of the procedure was to harvest a part of vastus lateralis muscle (1 cm × 0.5 cm), crushing it and mixing it with alternating layers of fibrin sealant. This mixture was put over the injured site for better clotting effect. The patient tolerated the procedure well, was shifted to the Intensive Care Unit and vitals were stable thereafter. There are very few instances in published literature which describe the repair of injured ICA using muscle and fibrin sealant. The present case highlights the importance of executing urgent and innovative techniques to control bleeding ICA.

Giant Phyllodes Tumour in a Postmenopausal Woman: A Case Report

Kalaivani Vinayagam , C Satish , Abhishek Chaturvedi

Phyllodes Tumours (PT) of the breast are uncommon fibroepithelial lesions accounting for less than 1% of breast tumours. These tumours commonly occur in females during the fourth and fifth decade of life. They have a morphological resemblance to the intracanalicular fibroadenoma. Their median size is around 4 cm, however if the size is more than 10 cm it’s called a giant phyllodes tumour accounting to less than 10% of phyllodes tumours. Clinically and histologically, they are difficult to be differentiated from fibroadenoma and a wide local excision is the mainstay of treatment. Hereby, Authors are reporting a case of giant phyllodes tumour in a 56-year-old post-menopausal female patient. She presented with a lump of 27×20 cm of two years duration occupying the entire left breast. Since,the lump had rapidly increased in size in the last six months of presentation, a clinical diagnosis of giant phyllodes tumour with malignant transformation was the provisional diagnosis. She underwent simple mastectomy with splitthickness skin graft. The final histopathology was reported as borderline phyllodes tumour and the patient was on a regular followup since the last 10 months.

Anatomical Variations of the Axillary Artery in a Human Cadaver: A Case Report

Martin G Rosario , Monica E Mathis , Paige D Chambers

Anatomical variations are deviations from the standard structures and morphologies of bodily arrangements, a phenomenon commonly seen in arteries and nerves. A typical axillary artery extends from the outer border of the first rib to the lower edge of the teres major before the pectoralis minor divides the axillary artery into three parts. Within existing research, several variations have been seen in the branching of the axillary artery, particularly among the second and third divisions. This case report examines and describes the anatomical differences of the second and third division of the axillary artery in a 64-year-old Caucasian female; variations were found in the second division of the axillary artery, two thoracoacromial arteries, as well as the absence of the stemming lateral thoracic artery. Within the third division of the axillary artery, the subscapular artery supplying the latissimus dorsi (two branches), subscapularis (circumflex scapular artery), and the serratus anterior (two branches) muscles were identified and distally, the axillary artery bisected into the brachial and accessory brachial arteries. A genetic mutation, environmental factors, and embryological malformations are among the hypotheses associated with these anatomical variations. From a clinical standpoint, these variations may not produce impairment though the knowledge of an individual's distinctive arrangements would aid in preventing unnecessary complications that could arise during particular interventions.

Pulsatile Proptosis, Secondary to Carotid Cavernous Sinus Fistula- A Case Report

Archana Thool, Neha Bajpayee, Rashmi Laxman Ramani

Aetiology behind unilateral proptosis can run from benign to life-threatening condition. Carotico Cavernous Sinus Fistula (CCF) is abnormal communication between Internal Carotid Artery (ICA) alone or its branches and cavernous sinus. This was a case of a 32-year-old female presented with unilateral proptosis, diminution of vision in right eye, diplopia and unilateral headache towards right side. On ocular examination, right eye had pulsating proptosis, severe chemosis, relative afferent papillary defect, restricted ocular movements in all gazes and left eye was normal. There was no history of trauma, hypertension, diabetes mellitus, cardiovascular abnormality. Common causes of unilateral proptosis are carotid cavernous sinus fistula, orbital pseudotumour, orbital cellulitis, cavernous sinus thrombosis, or intraorbital neoplasms. Radiological investigations like Computed Tomography (CT)/Magnetic Resonance Imaging (MRI) imaging and CT/MR Angiography (MRA) is necessary to rule out the cause for proptosis. Patient presented to Ophthalmology Outpatient Department (OPD) with concern of reduced vision, redness and proptosis. Hence, MRA was advised to this patient which was suggestive of right ICA- cavernous sinus fistula. Cavernous sinus fistula can be traumatic or spontaneous and delay in diagnosis may lead to poor visual outcome

Acute Presentation of Amiodarone Toxicity with Pleural Involvement

Amiodarone is a frequently prescribed anti-arrhythmic drug which is used to treat ventricular and supraventricular tachyarrhythmia. Although it has excellent efficacy in controlling or preventing common arrhythmias, it is potentially associated with a variety of adverse effects, the most serious of these being pulmonary toxicity. Amiodarone-associated toxicities are usually seen in solid organs like lung, spleen and thyroid due to extension of its pharmacokinetic properties. The presentation is often subacute. Acute presentation with pleural involvement is distinctly uncommon in amiodarone toxicity and can pose diagnostic challenges. Here the case presented is of a 67 year old female with multiple co-morbidities on amiodarone therapy, who presented with massive pleural effusion and respiratory failure. Typical radiological findings along with exclusion of alternate causes with appropriate tests led to a diagnosis of amiodarone toxicity involving lung parenchyma, pleura, liver and other organs. She responded to withdrawal of drug, steroid therapy and supportive care.

Transitional Cell Carcinoma in Pelvis of a Double Moiety Kidney- A Rare Presentation

Debansu Sarkar, Bikram Haldar, Dilip Kumar Pal

Neoplasia of the renal pelvis in duplex kidneys is extremely rare, especially in complete renal ureteral duplex cases. A 46-year-old aged male patient had presented with intermittent haematuria for the last seven months. A mildly enhancing well-defined, lobulated mass arising from the pelvis of lower moiety of right kidney was found on evaluation. Confirmatory findings of a renal pelvic malignancy couldn’t be obtained. Infective condition like pyelonephritis couldn’t be excluded. To clear the diagnostic dilemma, flexible ureteroscopy was done which revealed the renal pelvic malignancy. Right lap assisted radical nephroureterectomy was done. Histopathology was suggestive of transitional cell carcinoma. The increased incidence of chronic infection, obstruction and stone formation may be instrumental in producing a higher incidence of renal pelvic tumours in patients with anomalous kidney. Diagnosing a neoplasia originating from a duplex kidney is difficult and often a multiple battery of investigations like intravenous pyelogram, ultrasonography and rigid ureteroscopy may not be useful. Considering the fact that tumour recurrence is high in the ureteric stump after local resection, a total nephroureterectomy seems to be a better treatment choice. Flexible ureteroscope might be the saviour in such doubtful clinical situations to confirm our diagnosis beyond doubt. Partial nephrectomy cannot be recommended unless long-term follow-up reports of such cases are available.

An Unusual Case of Dengue Fever with Necrotising Pneumonia

Nazeem Fathima, Balamma Sujatha, Shami RP Kumar, S Rajesh

Concurrent bacteremia in patients with dengue fever is rarely reported. Two and a half-year-old female child with fever, cough and cold for six days presented to Emergency Room (ER) with tachypnea, tachycardia and hepatomegaly. Investigations revealed dengue fever. Respiratory symptoms probed us to investigate the case further. High-Resolution Computed Tomography (HRCT) thorax showed moderate pleural effusion with collapse consolidation of left lung and a thin walled cavity with septations and fluid in left upper lobe. Child was treated with injection meropenem and vancomycin successfully.

Complex Arteriovenous Malformation in a Kidney with Multiple Renal Arteries: A Case Report

J Sanjay Prakash, T Mathisekaran, Nitesh Jain, Pritam Chatterjee, Sandeep Bafna

The abnormal communications between arteries and veins outside the capillary level are called Arteriovenous Malformation (AVM). A 25-year-old known hypertensive on irregular medications, presented with acute stroke (Computed Tomography (CT) brain revealed left putamen haemorrhage). On evaluation, all routine investigations were normal except for microscopic haematuria. Ultrasound (USG) KUB showed right AVM and on further evaluation with 320 slice Contrast Enhanced Computed Tomography (CECT) abdomen with angiogram and 3D reconstruction revealed right kidney supplied by three renal arteries. The second renal artery was dilated (1.1 cm diameter) and communicates directly with aneurysmally dilated right renal vein (2.9 cm diameter). Digital Subtraction Angiography (DSA) with angioembolisation was done four days’ postadmission. Large second renal artery with a direct Arteriovenous Fistula (AVF) draining into the renal vein with aneurysmal venous sacs was occluded with 16 mm, 12 mm and 10 mm coils. Complete obliteration of fistula was confirmed. Then the inferior most third renal artery was accessed and angiogram revealed RAVM with multiple feeders shunting into the venous sacs and it was occluded with 40% glue. Postoperative day one USG showed thrombosed venous aneurysmal sacs and occlusion of the arterial fistulae. He was discharged at four weeks with antihypertensive and antiseizure medications. During the follow-up there was no loss in the function of the kidney and micro or macroscopic haematuria was not detected.

A Case of Pseudoepitheliomatous Keratotic and Micaceous Balanitis with Verrucous Carcinoma

Yu-hua Yang, Ren-he Chen, Ru-zhi Zhang

Pseudoepitheliomatous Keratotic and Micaceous Balanitis (PKMB) is a rare chronic inflammatory disease characterised by hardened, hyperkeratotic plaques on the glans of the penis of older men. Although PKMB is described as benign, there is growing evidence that it has the potential to become cancerous. authors hereby report a case of 55 year old male who was initially characterised by white sclerosis and atrophy at the glans. Without treatment, verrucous keratinising organisms appeared after two years and were misdiagnosed as viral warts. The patient received four cryotherapy treatment with liquid nitrogen, which completely removed the warts, but the rash recurred about two months after cryotherapy. The patient received histopathological examinations which showed obvious hyperkeratosis with incomplete keratosis in the epidermis, papilloma-like and pseudoepithelioma-like hyperplasia appeared in the spinous layer, flattening of rete ridges, squeezing growth into the dermis, disordered arrangement of basal cells and frequent mitoses. A few squamous masses were seen in the dermis and the formation of squamous fossa could be seen. There were more lymphocyte infiltrations in the superficial layer of the dermis and around blood vessels. After being diagnosed with PKMB with verrucous carcinoma, the patient finally chose to undergo surgery in the Urology Department of another hospital. Unfortunately, we lost the follow-up. Our case supports the view that PKMB can develop into a malignant disease, which suggests that early detection, treatment and follow-up of the disease are essential.

Rieger’s Anomaly without Posterior Embryotoxon: A Rare Presentation

Shrinkhal, Mood Mahesh, Ajai Agrawal, Ramanuj Samanta, Anupam Singh

Rieger’s anomaly is a rare congenital ocular defect with autosomal dominant inheritance, characterised by dysgenesis of the anterior segment. Ocular features of typical Reiger’s anomaly include a prominent anteriorly displaced Schwalbe's line (posterior embryotoxon), iris stromal hypoplasia, corectopia, and glaucoma. An atypical presentation of Rieger’s anomaly is described in the current case report. A 26-year-old female presented with diminution of vision in right eye and mild photophobia in both eyes, since childhood. On examination, it was recognised as an atypical isolated case of Rieger’s anomaly with several classical features including segmental full thickness iris defect and ectropion uveae. This was associated with total cataract in right eye and persistent pupillary membrane in left eye, without posterior embryotoxon and glaucoma. There were no other associated ocular or systemic anomalies. Patient was operated for cataract surgery in right eye under guarded visual prognosis. The postoperative visual acuity was 3/60, signifying pre-existing amblyopia. The patient was kept on close follow-up for the development of glaucoma. This is a rare case of Anterior Segment Dysgenesis (ASD) manifesting as atypical Rieger’s anomaly without posterior embryotoxon and any systemic association, signifying the fact that posterior embryotoxon is not an essential diagnostic criterion.

Primary Thyroid Lymphoma in an Adult Male: A Rare Presentation

Poonam Dambhare-Wasnik, Ashish Kumar Gupta

Primary Thyroid Lymphoma (PTL) is a rare entity prevalent in middle to old aged females. They are predominantly B-cell Non-Hodgkin’s Lymphoma (NHL), among which Diffuse Large B-Cell Lymphoma (DLBCL) is the most common subtype. Here, we describe a case of PTL in a male patient which is extremely rare. He presented with a swelling over anterior aspect of neck and dysphagia since 2 months. Fine Needle Aspiration Cytology (FNAC) of thyroid swelling and following immunocytochemistry showed B-cell NHL. Histopathological and Immunohistochemical (IHC) examination was also done thereafter on right hemithyroidectomy specimen, which revealed a nongerminal center type of DLBCL. Histopathological examination revealed an antecedent chronic lymphocytic thyroiditis in this patient. With this case we noticed that early diagnosis of thyroid lymphoma can be possible with FNAC. However, false negative diagnosis can occur on non-representative aspiration sample. Besides this, it is challenging for a pathologist to subtype the lymphoma on cytology smear. Hence, histopathological examination along with Immunohistochemistry (IHC) is imperative for accurate diagnosis of PTL. The patient had received three cycles of chemotherapy and follow-up of 11 months was uneventful.

Port Site Metastasis following Laparoscopic Excision of Ovarian Carcinosarcoma

Anju Singh, Avir Sarkar, Rimpi Singla, Nalini Gupta, Bhavana Rai

Port site metastasis is a rare complication and carcinosarcoma is itself a rare malignant tumour of the ovary. We report a case of an ovarian carcinosarcoma which was retrospectively diagnosed from the metastasis which developed at the specimen retrieval port site of primary laparoscopic surgery. A 48-year-old nulliparous lady underwent laparoscopic cystectomy previously for endometrioma. Six months postlaparoscopy, she developed pain and palpable mass at the trochar site. Fine needle aspiration biopsy showed metastatic adenocarcinoma of ovarian origin confirmed by immunohistochemistry. Six cycles of chemotherapy followed by total hysterectomy, resection of the mass and attached tubal segment, opposite salpingo-oophorectomy and omentectomy was done. Post-surgery, patient was followed-up with three chemotherapy sessions. Final histopathological report showed carcinosarcoma of ovary at port site with omental deposit.

Tubercular Iliopsoas Abscess: A Rare Case Report

Sunil Kumar Patanaik, Chaitali Pattanayak, Vartika Srivastava, Sougata Sarkar

A psoas (or iliopsoas) abscess is an accumulation of pus in the region of iliopsoas muscle compartment. In regions where Mycobacterium tuberculosis is endemic, this is a frequent cause of psoas abscess. When an inguinal mass in a patient with a psoas abscess is painless, tuberculosis is a more likely cause than a bacterial infection. Here, the author report a rare case of psoas abscess of tubercular origin in a 31-year-old patient who presented with back pain and limping, with features of inflammation. Diagnosis was done based on history, physical examination, ultrasonography, microbiological investigation and Contrast-Enhanced Computed Tomography (CECT) scan of abdomen which revealed a large psoas abscess caused by M. tuberculosis. Patient was diagnosed with a psoas abscess due to Mycobacterium tuberculosi with secondary infection and treated empirically with Directly Observed Treatment Short-Course (DOTS) category I and antibiotics. He presented again with a chest abscess due to Multidrug-Resistant (MDR) tuberculosis.

Point Mutations in Muscle Segment Homeobox 1 (MSX1) Gene in an Individual with Mandibular Retrognathia: A Case Report

Malocclusion is an orofacial anomaly that manifests in the form of misaligned dental arches. Mandibular retrognathia is a type of malocclusion, characterised by defective mandibular bone growth. Muscle Segment Homeobox (MSX) gene family, plays an essential role during embryonic development by coordinating processes that decide the patterning and morphogenesis of tissues. Expression of MSX1 and MSX2 genes in the maxilla, mandible and the mesenchymal cells of cephalic neural crest strongly suggest their role in craniofacial development. Here, point mutations (T8I, P11S and A68V) in the coding region of MSX1 gene in a 20-yearold male patient with severe mandibular retrognathia was reported. To date, there has been no report on the association of MSX genes with mandibular anomalies. Evaluating, the significance of these novel mutations through functional studies in animal models will lead to a better understanding of the role of MSX genes in mandibular morphogenesis.

Co-existing Tubercular Pleural Effusion and Visceral Larva Migrans in a Patient with Hypereosinophilia: A Rare Case

Taranpreet Kaur, Nitin Kumar Bansal, Kuldeep Goyal, Jaykrat Chaudhary

Eosinophilic pleural effusions accounts for 5-16% of all the cases of pleural effusion. Here the authors present a case of 21 years old male patient, with right-sided chest pain in whom peripheral blood eosinophilia along with eosinophilic pleural effusion were found after a series of relevant investigations and two causative factors were found for same i.e., Visceral Larva Migrans (VLM) and tubercular pleural effusion. Both of them individually can cause hypereosinophilia, but presence of them together makes this case rare and interesting.

Heat Intolerance and Hyperhidrosis as the only Presenting Manifestations of Acromegaly: A Case Report

TN Kamalesh, HA Vijaya Sarathy, NT Sreedevi

Acromegaly is a state of Growth Hormone (GH) excess characterised by coarse facial features, acral enlargement, hyperhidrosis, headache, visual disturbances and visceromegaly. The most common cause of acromegaly is pituitary adenoma. The average delay between onset of symptoms and diagnosis is about six years in acromegaly owing to its subtle clinical features at the disease onset. Early diagnosis is important to reduce the morbidities and mortality associated with acromegaly. Familiarisation of physicians with the signs and symptoms of the disease is an effective strategy for the early diagnosis of acromegaly. Here, the authors report a case of 38year-old female patient. After proper clinical examination, history and series of relevant investigations, the serum GH level was estimated and was found to be elevated (40 ng/mL). GH secreting pituitary macroadenoma presenting with heat intolerance and hyperhidrosis without the classical manifestations of acromegaly.

Clinical Improvement with Pirfenidone in Section Two Patients of COVID-19

Pirfenidone has been approved for the treatment of idiopathic pulmonary fibrosis due to its anti-fibrotic activity. It has been shown to have anti-inflammatory and antioxidant properties apart from being an anti-fibrotic agent. Cytokine storm, severe inflammation and oxidative stress leading to acute respiratory distress syndrome and multiorgan failure are factors causing mortality in patients of COVID-19. This article reports two cases of 35 years and 60-year-old male patients of COVID-19, those were diagnosed by real time Polymerase Chain Reaction (PCR) using nasopharyngeal samples. They were started on pirfenidone 400 mg BD, later increased to 600 mg TDS along with empirical antibiotics, dexamethasone, supplemental oxygen and non-invasive ventilator support. Both the patients improved and were discharged. Both the patients were followed by telemedicine after one week, did not require oxygen at rest and were comfortable at rest in contrast to earlier complaints. Thus, the authors conclude that pirfenidone can be a possible cure for COVID-19 patients, larger trials are required to confirm its efficacy.

Pulmonary Nocardiosis in Immunocompetent Patient: A Rare Case Report

Kusum V Shah, Saket Kumar, Yash Rana, Arti D Shah

Pulmonary nocardiosis is a rare bacterial infection that may lead to severe disease in immunodeficient patients and usually not so common in immunocompetent patients. The report is about a 57-year-old male with Norcardiosis. His sputum and Bronchial Alveolar Lavage (BAL) were negative for acid-fast bacilli. Nocardia species was isolated in BAL culture. He was started on Trimethoprim/ Sulfamethoxazole and Clarithromycin, which was later continued for six months.

Elusive Presentations of Female Genital Tuberculosis: A Case Series

Arpita De, Nidhi Gupta, Abhinav Jain, Reva Tripathi

The Ministry of Health and Family Welfare has made a target of eliminating tuberculosis by 2025 under the National Tuberculosis Elimination Plan (NTEP). For this, it is important to identify cases, notify and treat them effectively. This case series is on women with unique presentations of the Female Genital Tract TB (FGTB). It further explores the diagnostic and treatment modalities of such cases. The cases include four women with atypical presentations- a young nulliparous woman with repeated episodes of pyometra, a woman with tubo-ovarian mass and chronic fever and two women with adnexal masses mimicking dermoid and endometriosis, respectively. The diagnosis was based on the unique presentations, exclusion of other diseases and on the operative findings. One should target to get a tissue based diagnosis. Now the government has advised Cartridge-Based Nucleic Acid Amplification Test (CBNAAT), for all samples of FGTB, to get an accurate estimation of drug resistance. It can be used in very interior areas, gives a result within the same day and also gives sensitivity results to the antitubercular drugs. CBNAAT may give incorrect results with small specimens. That makes clinical judgement by specialists very important. The antitubercular regime has changed and there are no separate regimes for relapses or treatment failures. It is now therapy with daily intake of rifampicin, isoniazid, pyrazinamide and ethambutol for two months and rifampicin, isoniazid and ethambutol for four months. For all cases of FGTB, a working definition should be given and notification should be done by the Nikshay online portal. Future structured studies are required to investigate the sensitivity and specificity of different tissues for CBNAAT in different clinical scenarios of genital Tuberculosis (TB).

Primary Small Cell Neuroendocrine Carcinoma of Urinary Bladder: Case Series of a Rare Entity

Noushad Aryadan, Sithara Aravind, Akhil Suresh, Sangeetha Keloth Nayanar

10.7860/JCDR/2020/46493.14362 Date of Submission: Aug 27, 2020 Date of Peer Review: Oct 01, 2020 Date of Acceptance: Oct 30, 2020 Date of Publishing: Dec 15, 2020 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was informed consent obtained from the subjects involved in the study? Yes • For any images presented appropriate consent has been obtained from the subjects. NA PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: Sep 05, 2020 • Manual Googling: Oct 21, 2020 • iThenticate Software: Dec 12, 2020 (12%) ETYMOLOGY: Author Origin

Haemangioma of Cavernous Sinus- A Case Series

Neeraj Jain, Mohit Bhargava, Sunil Kumar Puri

Extra-axial cavernous sinus haemangioma are rare extra-axial parasellar lesions. These are non-neoplastic lesions, but can behave in a manner like that of neoplastic lesions as their slow growth with progressive enlargement of thin-walled vascular channels may result in extrinsic compression on adjacent retro-orbital neural structures. It is important to diagnose these lesions preoperatively as surgery in these lesions is often complicated by incomplete removal, severe intraoperative haemorrhage and significant operative morbidity and mortality. A parasellar lesion showing homogeneous markedly increased signal on T2 or proton density weighted images with progressive centripetal "filling-in" with contrast on dynamic Magnetic Resonance Imaging (MRI) should suggest the diagnosis. We are presenting three interesting cases of cavernous sinus haemangioma.

COVID-19 Patients Encountered by a General Surgeon: Seven Unique Scenarios

With rising demand of surgical interventions post-lockdown due to Coronavirus Infectious Disease (COVID)-19, surgeons all over the country have restarted their surgical practice. To increase caution and safety, seven scenarios in which surgeons in a Tertiary Care Centre in North India encountered COVID-19 patients during lockdown are being highlighted in the present case series. The main aim was to encourage prompt recognition and isolation of positive patients along with establishment of a clear institutional protocol for surgical practice to keep our system resilient and useful for the population we serve. Clinical and radiological records of eleven patients admitted from 22.3.2020 to 31.5.2020 (period of lockdown) in a Tertiary Care Hospital in India were studied separately and concluded consensually by two surgeons and seven unique scenarios in which a surgeon may encounter a COVID-19 patient were identified. First was the COVID-19 positive patient with concurrent symptomatic surgical pathology, second was COVID-19 positive patient incidentally diagnosed with additional surgical pathology and third was a solely surgical patient mimicking COVID19 positive symptomatology. Fourth was a COVID-19 negative surgical patient acquiring nosocomial COVID-19 infection, fifth was COVID-19 positive surgical patient with false negative COVID-19 test report, sixth was COVID-19 suspected by intraoperative unusual intestinal findings and then, getting postoperative COVID-19 test positive for the patient and last was COVID-19 patients requiring elective surgical procedures

CBCT Assisted Endodontic Management of Teeth for Aberrant Roots: Case Series

Cone Beam Computed Tomography (CBCT) is a radiographic imaging technique which provides accurate, high-quality, threeDimensional (3D) images of various parts of head and neck. They deliver images with a spatial resolution of teeth required for diagnosis, treatment planning and postoperative evaluation. The aim of this case series is to describe the importance of determining the root canal morphology with the help of CBCT. This case series presents the endodontic management of a three rooted maxillary first premolar, maxillary first molar with single palatal root and three canals and mandibular first molar with five canals using CBCT. The axial images from CBCT show Gulabivwala K Type I (3-1) canal pattern in distal root of mandibular first molar (36) and palatal root of maxillary first molar (26) according to Al-Quadah Awawdeh showed Type XXII (3-2-1) canal configuration. Biomechanical preparations of all the teeth were done with hand as well as rotary file systems and lateral compaction obturation technique was used. With the advancing technology in imaging, there are possibilities to detect and treat a number of variations particularly in posterior teeth leading to successful endodontic treatment.

Telemedicine: A Paradigm Shift in Healthcare in the wake of COVID-19 in India

Ria Saha, Vinoth Gnana Chellaiyan

The COVID-19 pandemic has severely affected the delivery of essential healthcare services in India. The massive disruption of the routine healthcare services had been circumvented to a certain extent with the application of telemedicine. In the wake of the COVID-19 pandemic, the Government of India has issued regulatory guidelines and approved Registered Medical Practitioners (RMP) to adopt the usage of teleconsultation service which can be real-time or asynchronous to minimise the risk of disease transmission. The commentary provides an in-depth review of the regulatory guidelines implemented by the Government of India and discusses the inherent structural and fundamental challenges associated with its wide scale adoption, accessibility, and utilisation. Though the Government of India had issued national guidelines to promote safe and effective usage of telemedicine practice, there remains certain primary structural, technical and institutional challenges regarding expansion of uninterrupted services to periurban and rural peripheral health facilities and its nationwide sustainability. The article demands the attention of the policymakers and relevant stakeholders to identify the inherent bottlenecks intrinsic to the guidelines and amend the regulatory framework accordingly to ensure its long-term sustainability.

Endoscopically-Assisted Intraoral Resection of Compound Odontoma Arising from the Inferomedial Surface of the Mandibular Ramus using Piezosurgery

Toshinori Iwai, Satomi Sugiyama, Hiroaki Kitajima, Makoto Hirota, Kenji Mitsudo

A 45-year-old woman presented with left submandibular discomfort for several years. There was no history of the mandibular trauma or previous medical and family history including Gardner’s syndrome. Although several dental treatments including dental restorations and periodontal therapy were performed, the right lower wisdom tooth was missing by nature. An about 5-mm-diameter painless hard mass was identified by palpation in the inferomedial mandibular ramus, and was immobile. She had no difficulty of swallowing, discharge from the overlying normal skin, facial asymmetry, and regional lymphadenopathy. A left lower second molar was vital. Computed Tomography (CT) showed a hyperdense, well-circumscribed, pedunculated mass attached to the inferomedial surface of the mandibular ramus, measuring 6.7×5.1×7.6 mm (Table/Fig 1). The radiological diagnosis was peripheral osteoma, because CT values of the lesion were similar to bone. Informed consent was obtained for surgery, but she refused an extraoral approach. Therefore, as a minimally invasive surgery, she underwent endoscopically-assisted intraoral resection of the peripheral osteoma using piezosurgery (Mectron Medical Technology, Carasco, Italy) under general anaesthesia. The lingual crevicular incision was made on the gingiva from the lateral incisor to the second molar, with extension to the retromolar area for relief of the flap. The mucoperiosteal flap was elevated to the mylohyoid muscle region. The mylohyoid muscle attachment was incised, and further elevation in the medial surface of the mandible was performed. The bony lesion which intruded into the soft tissue was exposed by the incision of the periosteum and soft tissue, and then the projected bone along the mylohyoid line was removed to improve access to the bony lesion using a rotary bur of AESCULAP® (B.Braun, Melsungen, Germany). A 30-degree, 4-mm-diameter endoscope with tissue retractor (Karl Storz, Tuttlingen, Germany) was inserted into the surgical space, and the bony lesion was resected safely using piezosurgery under endoscopic guidance (Table/Fig 2). After the complete removal, the bone surface was removed smoothly. The specimen was a hard bony lesion (Table/Fig 3). Surgical time was 58 minutes. She was discharged on the first day after surgery. The histopathological diagnosis was compound odontoma, because the specimen showed dentin and cementum (Table/Fig 4). The postoperative course was uneventful without palsy of the mental and lingual nerve, and there was no recurrence two years after surgery. Odontomas are slow-growing odontogenic tumours which are made of tissues which comprise the teeth like enamel, dentine, cementum, and pulp tissue. They are commonly clinically asymptomatic, and often associated with tooth eruption disturbances for intraosseous lesions. Peripheral (extraosseous) odontomas are extremely rare, and some might be erupted (1). In the present case, because CT showed a pedunculated mass was located at the inferomedial surface of the mandibular ramus and CT values of the homogeneous lesion were almost similar to cortical bone hence, a provisional diagnosis of osteoma was made. As a differential diagnosis of peripheral bony lesions such as exostoses, osteochondroma, osteoblastoma, and ossifying fibroma, odontoma also should be considered. Although the treatment of odontoma is surgical resection, the selection of an appropriate surgical approach should be made on an individual basis after considering the size, shape, and origin of the tumour. Because extraoral approaches have a risk of facial nerve injury and visible scar, an intraoral approach as a minimally invasive surgery should be performed as much as possible. However, limited surgical access, poor visualisation, and potential injury of vital structures make the intraoral approach difficult. An endoscope can provide good illumination and visualisation in a deep and limited surgical field. In the oral and maxillofacial region, endoscopically-assisted intraoral surgery has been performed for Yesplate fixation of subcondylar fracture, removal of an impacted tooth, cyst, tumour and foreign body. Especially, surgical access to the medial side of the mandibular ramus is limited and challenging. But, Yaslikaya S et al., reported endoscopic transoral resection of pharyngeal osteoma arising from the medial ramus to preserve the temporomandibular joint function and to minimise complications and the patient’s aesthetic concerns (2). The osteoma could be resected intraorally without an external scar using endoscopic assistance. Piezosurgery (piezoelectric bone surgery) is a novel technique that uses ultrasonic microvibrations to cut bone tissue. Comparing with rotary instruments, piezosurgery can provide more favorable bone healing, soft tissue protection, optimal visibility in the surgical field [3-5]. In oral and maxillofacial region, piezosurgery is used for various bone surgery such as sinus floor elevation, bone graft harvesting, orthognathic surgery [3-5]. The use of both endoscope and piezosurgery can allow even more minimally invasive surgery in the oral and maxillofacial region. Ochiai S et al., reported endoscopic-assisted intraoral resection of peripheral osteoma on the inferolateral border of the mandibular angle using piezosurgery, and the osteoma was resected easily and safely (3). In the present case, odontoma arising from the inferomedial surface of the mandibular ramus could be resected in an intraoral approach safely and accurately without injury of the marginal mandibular branch of the facial nerve and facial artery by use of piezosurgery and endoscope.

How to Avoid Pre-analytical Errors in Arterial Blood Collection for Blood Gas Analysis

Prabhat Kumar Nigam

Arterial Blood Gas (ABG) analysis is a necessary test in patients admitted in Intensive Care Unit (ICU)/Intensive Coronary Care Unit (ICCU) for diagnostic and therapeutic purposes. However, many times the results of ABG analysis are not satisfactory and this is mostly due to errors at preanalytical level. The preanalytical phase includes identification of the patient, blood collection, labelling, storage and transportation of the blood samples. Though some articles on this topic have been published [1-9], this letter tried to make it simple and stepwise so that a quick glance of it would refresh the preanalytical issues associated with arterial blood collection. Here are a few tips to avoid/minimise pre-analytical errors in arterial blood collection for blood gas analysis based on clinically-approved guidelines: 1. Identification of the patient: Identity the patient by name, age and bed number and match with the requisition form to ensure the blood collection of the desired patient [1-8]. 2. Prepare the patient [1-8]: • Explain the patient about the test to make the patient comfortable mentally and physically as the pain and anxiety may induce hyperventilation resulting in spuriously reduced pCO₂. • Let the patient relax and rest for about 3-5 minutes, if he/she is without any pulmonary disease. • Let the patient relax and rest for 20-30 minutes, if he/she has Chronic Obstructive Pulmonary Disease (COPD) or there have any ventilatory changes been done (administration of oxygen and mechanical ventilation may affect measured values). 3. Blood collection [1,2]: a. From Radial Artery • To perform the modified Allen test to ensure adequate collateral circulation from ulnar artery (to ensure the patency of the radial artery, ulnar artery and palmer arches in case of any damage to the artery during the procedure). • Use of short-beveled needle helps to position the needle correctly and to avoid the risk of puncturing the opposite arterial wall. • Use of pre-heparinised syringe reduces the chance of blood clots (blood clots affect the measured parameters as well as damage the analyser). • Use of dry electrolyte-balanced heparinised syringe reduces the risk of electrolyte bias and sample dilution (the calcium binding property of heparin reduces the ionised calcium concentration and hence, may give falsely low-ionised calcium). • Use of self-filling syringe avoids hitting a vein (The Gold Standard sample for blood gas testing is arterial blood). • Puncture the artery at 45° with bevel facing up to minimise trauma to the blood vessel. • Insert the needle slowly to minimise arterial spasm. • Avoid the re-direction of the needle to prevent nerve damage. • If the artery is punctured correctly, a blood flash appears and then, allow the syringe to fill to appropriate level without pulling the piston. Alternatively, preset the syringe plunger to the desired volume before the arterial puncture and allow the syringe to fill to the desired level. • Filling the syringe with correct amount of blood is important [1-9] • In pre-filled liquid heparinized or ‘in-house’ heparinised syringe (prepared from therapeutic heparin, though not recommended) the blood volume should be 20 times the dead space of the syringe (a 2 mL syringe has a dead space of about 0.1 mL so, 2 mL blood will be required. Likewise, the 1 mL syringe would require 1 mL blood). The dead space of syringe is the volume of liquid remaining in the hub and the needle after completely emptying the syringe. It varies with the size of syringe and the needle. • Underfilling the heparinised syringe may give erroneous results due to dilution and chemical effects (excess of heparin may cause erroneously low pCO₂ and bicarbonate). • The dry electrolyte-balanced heparinised syringe also requires correct amount of blood as underfilling may give erroneous results. • Expel the air bubble quickly if any, by taping the sides of the syringe to allow them to go to the top of the syringe for expulsion and it is better to use syringe with a tip cap that is vented for safe removal of air bubbles (air bubble, if not expelled, may result in spurious elevation or drop of invitro pO₂ depending on the initial arterial pO₂ of the sample and that of the ambient air in a time-dependent manner) [1-9]. • Cap the syringe with syringe cap (not the needle cap) properly to prevent the leakage of gases and mix the blood by gentle inversions and rolling between the palms of hands to ensure the proper mixing of blood with the heparin (mixing is important to prevent microclots which may block the analyser and prevent analysis. However, vigorous mixing may result in haemolysis causing false elevation of potassium results). • If syringe cap is not available then, after removing the air bubbles insert the tip of the needle in a bung to prevent the leakage of gas and blood during transport (do not bend the needle which is a common practice because it doesn’t prevent the leakage completely and it may cause needle stick). b. From Indwelling Catheter • To prevent the contamination of the blood sample with flush solution, at least three times the dead volume of the catheter (as given on catheter package) should be drawn and discarded before drawing the sample for ABG using a new syringe dilution of blood sample with flush solution may affect the blood gas and electrolyte parameters giving erroneous results. (Dead volume of catheter is the volume of residual fluid between the sampling point and the blood stream) [4,5]. 4. Label the syringe with patient’s identification details, date and time of blood collection using a waterproof marker pen (writing patient’s identification details with waterproof marker pen is important when the blood sample syringe is to be kept in ice-water slurry). 5. Transport the sample to the laboratory immediately as it should be analysed within 15-20 minutes [1-9]: • If it is not possible to send the sample immediately then, keep the sample in a container with ice water slurry (not with ice alone which may result in haemolysis) to reduce cellular metabolism (the invitro blood cells metabolism which may consume oxygen and generate carbon dioxide resulting in spurious pO₂, pCO₂ and pH values) but it should be analysed within an hour because plastic syringes are partially permeable to gases and the permeability increases at lower temperature. • Samples with high leukocyte or platelet counts and for shunt analysis need to be analysed within five minutes (to avoid the effect of invitro cellular metabolism on blood gas parameters). Common Sources of Preanalytical Errors • Incorrect identification of the patient • Patient not stabilised and relaxed before the procedure • Haemolysis- Due to use of too fine needle and vigorous shaking of the blood sample • Clotting- Due to incorrect amount of heparin and inadequate mixing • Sample dilution- Due to under-filling of syringe • Air bubbles- If not expelled before capping the syringe • Venous blood contamination- Due to use of long bevel needle and piercing the artery with an incorrect angle. • Leakage from syringe- Due to improper sealing of the syringe • Delayed measurement

Sleep Disorders in Patients with Juvenile Idiopathic Arthritis as Characterised by Sleep Disturbance Scale for Children

Priyanka Kumari, Neha Mehra, Kalpana Panda, Somdipa Pal, Tribhuvan Pal Yadav

Introduction: Sleep disorders negatively impact a child’s quality of life, behaviour and cognitive function. Sleep disturbances have not been widely studied in patients with Juvenile Idiopathic Arthritis (JIA) especially using the Sleep Disturbance Scale for Children (SDSC). Aim: To characterise sleep disorders in JIA patients by using SDSC and determine its correlation with pain and disease activity. Materials and Methods: In this cohort study, 30 patients each of active JIA and age and sex matched controls (age 6-15 years) were administered SDSC at enrollment and after six months of treatment (in JIA patients). The study duration was from November 2017 to March 2019. Pain severity and disease activity were assessed at baseline and after six month by Visual Analogue Scale (VAS) for pain and Juvenile Arthritis Disease Activity Score-27 (JADAS-27). Data at baseline between patients and controls were compared by unpaired t-test and between six months and baseline by paired t-test. Categorical variables were analysed by Chi-square test or Fisher’s-exact test and correlation by Spearman correlation. Results: Total SDSC score was higher in JIA patients at baseline (45.67±9.13 vs. 28.5±1.17) and decreased significantly after six months (29.73±3.17). Disorders of Initiating and Maintaining Sleep (DIMS), excessive somnolence, hyperhidrosis, arousal and sleep-wake transition were observed in 29, 18, 4, 1 and 2 patients, respectively. After six months excessive somnolence and hyperhidrosis were found in one patient each. Significant positive correlation was observed between total SDSC score, VAS for pain and JADAS-27 score. Conclusion: SDSC scores revealed significant sleep disturbances in patients with JIA and a positive correlation with pain severity and disease activity.

Alternatives to Viral Transport Medium for use in SARS-CoV-2 Sample Preparation

Introduction: As the world struggles to manage and move forward from the clinical effects of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the ability to test for viral genomic RNA in patient samples is critical. Currently, the development and performance of SARS-CoV-2 clinical tests is impaired by a diminished supply chain of reagents needed for the tests, compelling labs to seek alternative, readily-available reagents as substitutes. Aim: To evaluate the suitability of Phosphate-Buffered Saline (PBS) and RNAlater™ as substitutes for sample transport media, to preserve the fidelity of viral RNA for use in a SARS-CoV-2 RT-PCR assay. Materials and Methods: This molecular study was conducted in Dayton, Ohio (USA) using synthetic materials and de-identified remnant patient specimens. Simulated standard clinical laboratory storage conditions were used, including prolonged storage up to 72 hours at 2-8°C and a freeze/thaw cycle. PCR amplification performance was measured for PBS and RNAlater ™ against transport medium as a reference using purified viral RNA. Performance differences were determined using repeated-measures two-way ANOVA with a 5% false discovery rate. Results: Results indicate that both solutions were suitable for testing viral RNA in the short term, but the viral RNA stored in PBS began to degrade after just 24 hours at 2-8°C. In contrast, RNAlater™ preserved the viral RNA out to 72 hours when stored at 2-8°C, with no statistically significant decrease in the detection limits compared to freshly-prepared viral RNA dilutions. A single freeze/thaw cycle raised the lower limit of detection for RNAlater™-preserved viral RNA slightly. Conclusion: The current (as of April 2020) CDC sample guidelines permit the use of PBS, but have not published data to support this claim. These results offer an alternative to the transport options outlined in many Emergency Use Authorisations (EUA) currently authorised for use in diagnostic testing and may be used for possible long-term storage solutions for studies investigating SARS-CoV-2.

Intrusion Effects on Maxillary Anteriors using Mini Implant Anchorage and K-Sir Loop in Subjects with Deep Overbite- A Cohort Study

Purva Verma, Ravindra Kumar Jain

Introduction: Various options to treat deep bites nonsurgically involve extrusion of posterior teeth or intrusion of anterior teeth. Intrusion of anterior teeth is required in patients with excessive incisal display and to correct deep bite in adult patients when extrusion of posterior teeth is not desirable. Aim: To compare the rate of intrusion and dento-alveolar effects on maxillary anterior teeth by Kalra-Simultaneous Intrusion and Retraction loop (K-SIR loop) and Mini implant anchorage in subjects with deep overbite. Materials and Methods: This prospective cohort study included 12 patients with Class I or Class II Div 1 malocclusion having an overbite and overjet of >4 mm treated with therapeutic extractions of upper first premolars. Group A included six subjects treated using orthodontic Mini implants, while Group B had six subjects treated with K-SIR loop. Lateral cephalograms were taken before intrusion and retraction (T1) and at the end of six months (T2) into intrusion and retraction. Independent t-test and paired t-test was done for intergroup and intragroup comparison respectively. Results: The rate of intrusion was 0.38 mm/month and 0.31 mm/ month for Group A and Group B, respectively. The amount of intrusion was significantly more in Temporary Anchorage Devices (TAD) group (p-value <0.01). Conclusion: In the TAD group, rate and amount of intrusion was significantly higher. There is no difference in vertical control between the two modalities statistically significant amount of molar extrusion was seen with the K-SIR loop group.

Student Assessment in Pharmacology: A Prospective Observational Study

Introduction: The assessment of student is an important step to check learning in medical education. Conventional Oral Viva Voce (COVV) is an important assessment tool but have certain demerits like more subjectivity, gender bias. So, COVV should be modified to make it proper assessment tool in second year MBBS students as per new curriculum in medical education. Aim: To develop and assess Structured Oral Viva Voce (SOVV) and compare with COVV in second year MBBS students. Materials and Methods: A prospective observational study was done in the second year medical undergraduate students of fourth semester at GMERS Medical College and Civil Hospital, Sola, Ahmedabad, Gujarat, India. Viva cards for SOVV were developed and was validated by the experts. Teachers and students were sensitised for SOVV. A total 116 students participated and were randomly assigned to four groups: Group A, Group B, Group C and Group D for viva voce in between four examiners. Group A and B were assessed by SOVV and Group C and D were assessed by COVV then groups were crossed over. In SOVV part, students picked up one viva card consisting of nine questions of different level and had to give answers in 10 minutes. Students and faculties perception were taken by perception questionnaires. Data were analysed by Microsoft Excel and Graph Pad Instate 3 (version 3.06). Results: In SOVV, mean marks given by all examiners having uniformity, while in COVV, there was significant difference in mean marks given by examiners, mainly examiner A (7.66±1.86) and examiner D (10.01±2.08), (p<0.05). About 100% of faculty and 83.62% students agreed that SOVV is a better method than COVV. Conclusion: Based on study results and feedback from students in this college set-up, SOVV in pharmacology brings uniformity in viva process, increases objectivity and removes inter-examiner variability.

Nephroprotective Impact of Adjuvant Yoga Therapy on DiabetesA Randomised Controlled Trial

Rajasekar Balaji, Meena Ramanathan, Ananda Balayogi Bhavanani

Introduction: Recent studies have provided abundant evidence about benefits of yoga in various chronic disorders. Diabetes Mellitus (DM) is a group of metabolic diseases characterised by chronic hyperglycaemia and renal complications of the disease are especially notable. It is estimated that 10% to 40% cases of Type 2 DM (T2DM) eventually end up having kidney failure. Yoga therapy may help to prevent progression of kidney damage in diabetic patients. Aim: To evaluate the effect of adjuvant yoga therapy on renal profile in diabetic patients. Materials and Methods: This single blind Randomised Controlled Trial (RCT) was designed as an interdisciplinary collaborative work between Centre for Yoga Therapy, Education and Research (CYTER) and Department of Endocrinology of Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India. A total of 72 diabetic patients with HbA1c, more than 7% were recruited and pre study evaluation of Fasting Blood Sugar (FBS), Postprandial Blood Sugar (PPBS), HbA1c, blood urea and serum creatinine were done. They were then randomised into control group (n=36) who received only standard medical management and yoga group (n=36) who received yoga therapy thrice weekly for 4 months along with standard medical management. Poststudy evaluation of all parameters was done at end of study period and data were analysed by Student's paired and unpaired t-test for intra and intergroup comparisons. Results: Postinterventional comparisons revealed statistically significant reductions (p<0.001) in all glycaemic and renal parameters in the group receiving yoga therapy when compared with control group who didn’t receive the yoga intervention. Intragroup comparisons revealed significant reduction of all parameters in yoga group. Conclusion: It is concluded from the present RCT that yoga has a definite role as an adjuvant therapy as it enhances standard medical care and hence, can be recommended in routine clinical management of diabetes to prevent progression into complications that are part of the natural history of the disease.

Prevalence of Posterior Segment Disease in Subjects Screened for Cataract- A Retrospective Study

Gayatri Ravulaparthi, Sravanthi Singarapu, Sathya Vattikonda, Gogineni Sahitya

Introduction: Glaucoma, retinal vein occlusion and diabetic retinopathy are the common posterior segment diseases affecting the eye and need to be specifically looked for in the community by Intra Ocular Pressure (IOP) measurement and a dilated fundus examination. Cataract screening alone in eye camps might not be adequate to prevent and treat these causes of blindness. Aim: To establish the need for routine screening of posterior segment diseases at primary and secondary eye care level by estimating the prevalence of this diseases in patients presenting with cataract in order to prevent avoidable blindness. Materials and Methods: This was a retrospective observational study conducted at Tertiary Care Hospital comprising of 1109 subjects who were screened for cataract and underwent cataract surgery, at screening camps from semi urban and rural localities in and around Hyderabad city between October 2018-March 2019. All subjects underwent detailed ophthalmic evaluation including visual acuity assessment, applanation tonometry, slit lamp examination and dilated fundus examination. Prevalence of blindness and moderate to severe visual impairment caused by posterior segment disease among these patients was analysed. Percentage distribution of the data was calculated mathematically. Results: Of the 1109 subjects, posterior segment diseases causing blindness was seen in 0.63%, severe visual impairment in 0.99% and moderate visual impairment in 3.78%. Glaucomatous optic neuropathy was the most common posterior segment disease followed by retinal vein occlusion and diabetic retinopathy in that order. Diabetes Mellitus (DM) and Hypertension (HTN) were associated with increased risk of glaucoma. Conclusion: Routine screening for posterior segment disease is recommended with the use of portable fundus cameras in the elderly population along with IOP measurement using hand held portable tonometer in screening camps in order to reduce the burden of avoidable blindness. Monitoring of life style diseases like HTN and DM at the time of cataract screening is needed for primary prevention of most of these diseases of the eye.

A Study to Assess the Effectiveness of the Jigsaw Reading Technique in Improving the Reading Skills among High School Children

Introduction: Jigsaw Reading Technique is one kind of cooperative learning strategy which allows dividing the students in a group to improve reading skills by giving tasks (like reading paragraph) to them. In Jigsaw learning method, students are assigned to a small group that composes different level of skills like a piece of Jigsaw puzzle. Aim: To determine the effectiveness of the Jigsaw Reading Technique in improving reading skills among high school children. Materials and Methods: The interventional study design was a post-test control group study with a quantitative research approach. A simple random sampling method was used to collect the data. The present study was carried out in the selected school of Tah Kelapur district. Yavatmal. The sample size was 60. Validated structured questionnaires were used. Data were collected. The software used in the analysis was SPSS 24.0. Descriptive Statistics and Frequency distribution and comparison were presented for categorical variables. Results: The findings show that assessing the reading skills in the experimental and control group was divided into five categories skimming, scanning, awareness about synonyms and antonyms, deduce the meaning of unfamiliar words from the text, infer mood and author's attitude or tone. The experimental group was reading with a positive attitude. The mean reading score of the control group was 2.36, the experimental group was 12.43 (p-value=0.001), the calculated t-value is 40. Therefore, the jigsaw reading ability score among high school students is statistically interpreted to have been successful. There was no significant association between reading skill scores among high school students concerning the control group and experimental with any other demographic variables. Conclusion: The comparison of the high school students’ reading skill scores shows a significant difference between the control group and experimental group, that is after the completion of this study, it is revealed that assessment of jigsaw reading technique in improving reading skills among high school children is effective.

Comparison of LJ Medium and BACTEC MGIT 960 Culture System for the Diagnosis of Tuberculosis

Pinki Kumari, Jiwesh Kumar Thakur, Prashant Kumar, Rakesh Kumar, Deval Parekh

Introduction: Sputum negative pulmonary Tuberculosis (TB) is a major public health problem. So, the emergence of new techniques for a more precise and rapid microbiological identification of Mycobacterium tuberculosis in clinical samples is of great importance to improve the management of TB. Aim: To determine and compare the sensitivity and turnaround time for Mycobacterium tuberculosis detection by the BACTEC Mycobacteria Growth Indicator Tube (MGIT) 960 system, Lowenstein Jensen (LJ) medium and Ziehl-Neelsen (ZN) staining. Materials and Methods: An Institution based, observational, cross-sectional study was conducted at Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India, from July 2013-March 2016. Sputum, pericardial fluid, pleural fluid, peritoneal fluid, pus and endometrial tissue samples were collected from 80 patients of suspected TB cases. All were Acid-Fast stained by ZN staining method and cultured on solid culture LJ medium and on liquid medium (MGIT). Data was analysed using Statistical Package for the Social Sciences (SPSS) software, Version 20.0 (SPSS Inc, Chicago, IL, USA). Fisher's-Exact test was used to show association of categorical variables. Non-parametric Mann-Whitney U test was used to show median difference of non-normally distributed continuous variables of two groups. Results: Out of the 80 samples, 41 cases were positive by either of the all methods. The positive specimen for ZN staining, LJ media and MGIT were 21, 29 and 41 cases respectively. The mean Time To Detection (TTD) was shorter for MGIT system than LJ media. Both LJ medium and MGIT 960 detected all cases of sputum smear positive cases and in addition significantly higher number than ZN stain in sputum smear negative cases. MGIT 960 detected significantly higher number of cases of sputum negative cases than LJ Media. The mean TTD was also significantly shorter in case of smear positive cases than the smear negative cases by both the solid and liquid culture mediums. Conclusion: The use of liquid media (MGIT) is more accurate and rapid method for the diagnosis of TB. The combination of more than one method is also highly recommended for rapid detection and early treatment of TB.

Evaluation of Marginal Adaptation and Wear Resistance of Nanohybrid and Alkasite Restorative Resins

Introduction: Polymerisation shrinkage stresses developed during curing of adhesive resin cements may cause debonding at the margins of cavity leading to microgap formation with secondary caries and consequently restorative failure. Thus, a restoration should have good marginal integrity and wear resistance to obtain high success with clinical longevity. Aim: To compare the influence of thermo-mechanical stresses on marginal quality and wear of class II Mesio-Occluso-Distal (MOD) restorations filled with Solare Sculpt or Cention N. Materials and Methods: An in vitro study was conducted at GITAM Dental College and Hospital, Visakhapatnam on 80 human extracted mandibular molars by preparing mesioocclusal-distal class two cavities that restored either with Solare Sculpt or Cention N resin composites. Baseline evaluations were recorded for marginal gaps (in µm) through Scanning Electron Microscope (SEM), and the weights of the samples were recorded by an electronic balancing instrument to measure the amount of wear (in grams). Following thermo-mechanical cyclic loading, all the restored teeth were evaluated again to record the same parameters. The statistical analysis was done using Statistical Package for the Social Sciences (SPSS) programme for windows version 22.0 (IBM, NY) software. An independent t-test for intergroup comparison and a dependent t-test for intragroup comparisons were done to analyse the tested parameters with the significance level established at (p≤0.05). Results: In intergroup comparison, no difference in marginal adaptation was observed before thermo-mechanical loading between two materials with a p-value of 0.3625, but after thermomechanical loading Cention N exhibited significantly superior marginal adaptation with a p-value of 0.0374. Both the materials have shown a significant difference in the marginal adaptation after thermo-mechanical loading in the intragroup comparison with Cention N (0.0002) and Solare sculpt (0.0001) p-values. The wear rate was not different statistically between the materials with a p-value of 0.7144 before thermo-mechanical loading and 0.2285 after thermo-mechanical loading. Conclusion: Marginal adaptation of Cention N was superior to Solare Sculp

Impact of Simulated Gastric Acid on Surface Roughness and Frictional Resistance of Orthodontic Archwires: An In vitro Study

Laila Baidas, Huda Alkawari, Nada Alshihah, Ghaida Almashaan, Haya Alwaalan

Introduction: Acid regurgitation caused by gastro-oesophageal reflux disease can lead to decreases in intraoral pH below the critical pH for orthodontic appliances. Exposure of brackets and archwires to such acidic environments causes changes in the surface properties that affect the frictional forces generated during orthodontic sliding mechanics and reduce the clinical efficacy of the wires. Aim: This in vitro study aimed to determine the effects of simulated gastric acid with pH 1.2 and pH 4 on the surface topography, surface roughness, and frictional resistance properties of different types of orthodontic archwires. Materials and Methods: A comparative in vitro study evaluated a total of 135 samples of three commercially available archwires: Stainless Steel (SS), nickel titanium, and beta-titanium (n=45/ group). Each archwire was divided into three subgroups (n=15) according to different pH solutions: distilled water (control; pH 6.7), pH 4, and pH 1.2. The samples in the two acidic pH subgroups were immersed in the respective solution for two minutes, rinsed with distilled water, and stored in distilled water at 37°C. The procedure was repeated 6 times a day for nine days with 24-hours interval in between each cycle. The surface topography of the wires was examined by scanning electron microscopy, while the surface roughness was inspected by noncontact surface profilometry. Finally, the frictional resistance was measured by a universal testing machine. Oneway ANOVA and a Tukey’s post-hoc test were used for analysis, with values of p=0.05 considered significant. Results: The results showed an increase in surface roughness of the SS (p<0.001) and beta-titanium (p=0.003) wires as the acidity of the solution increased. The SS wires showed the lowest frictional resistance in pH 1.2 solution among the wires used (p=0.005). No correlation was found between surface roughness and frictional resistance in this study. Conclusion:Increased acidity condition significantly affects the surface roughness of beta-titanium and SS wires, and has no effect on the frictional behaviour of the orthodontic wires expects in the SS wires. Thus, because the surface properties of the archwires can be affected by acidity in the oral cavity, it is recommended to change the orthodontic wires regularly throughout orthodontic treatment, especially in patients with gastro-oesophageal reflux disease.

Comparative Study of Clinicopathologic Features of Apocrine Carcinoma of Breast with Invasive Breast Carcinoma of No Special Type- A Tertiary Care Centre Experience

Sunanda Nayak, Snigdha Rani Nahak, Kailash Chandra Agrawal

Introduction: Apocrine Carcinoma (AC) of breast is a rare breast cancer comprising only 0.3-1.0% of all breast cancers. Microscopically, Invasive Duct Carcinoma of No Special Type (IDC-NST) and AC have similar architecture, but they differ in cell morphology. Immunohistochemistry for both the tumour types is also different. Aim: This study was undertaken to know the incidence of AC and analyse them with respect to different clinicopathological features and compare them with that of IDC-NST. Materials and Methods: This was an observational study conducted in Department of Pathology, Veer Surendra Sai Institute of Medical Science and Research, Burla from March 2010 to February 2019. Patients diagnosed as invasive breast carcinoma were taken as study group. Breast cancer in male patients and female patients taking neoadjuvant chemotherapy were excluded from study group. Clinical features, pathological features and immunohistochemical findings of IDC-NST and AC were studied and statistical data were analysed by SPSS version 23.0 for windows. Comparison of data was done by using Pearson’s Chi-square test. Results having p-value <0.05 were accepted as significant. Results: During the 10 years, 05 cases of AC and 560 cases of IDC-NST were found. Mean age of presentation of AC was 59.5 years and that of IDC-NST was 50.4 years. Most cases of AC and IDC-NST presented with breast lump of size >5 cm. Low grade (grade 1) carcinoma was seen in 20% of AC. Immunohistochemistry showed 3 (60%) cases of AC as triple negative, whereas 213 (38.2%) of IDC-NST were triple negative. All the cases of AC were Gross Cystic Disease Fluid Protein (GCDFP-15) and CK-7 positive. Conclusion: AC is a rare category of breast cancer. Although prognosis of AC and IDC are almost similar, correct diagnosis of AC is important as antiandrogenic therapy can be given to Androgen Receptor (AR) positive AC cases.

Evaluation of Antimicrobial Efficacy of Pudina (Menthaarvenis), Tulsi (Ocimumtenuiflorum) and Curry Leaves (Murrayakoenigii) on Streptococcus mutans by Modified Direct Contact Test- An In vitro Study

Introduction: Dental caries is a pandemic disease caused by Streptococcus mutans. Numerous preventive strategies have been developed to prevent dental caries with modern medicines. Recently, there has been a shift from use of modern medicines to herbal ayurvedic preparations which are easily available and cause least possible side effects but have not been tested against S. mutans. Aim: To evaluate antimicrobial value of Pudina, Tulsi and Curry leaves against S. mutans by modified direct contact test. Materials and Methods: This in vitro study used finely powdered form of Pudina, Tulsi and Curry leaves extracts (Hakim Chi Chi Pharmacy, Surat, India) without any added preservatives. The test microorganism S. mutans was isolated from human saliva using mitis salivarius agar. The Minimum Inhibition Concentration (MIC) was determined using agar well diffusion for Group 1 (Tulsi), Group 2 (Pudina), Group 3 (Curry leaves) and Group 4 (Chlorhexidine). Using this MIC, modified Direct Contact Test was performed for specific evaluation of the antimicrobial efficacy of each product. Chlorhexidine (0.2%) was used as a positive control for the comparison of each product. The results of modified direct contact test were subjected to ANOVA Test and Tukey's Test using SPSS software version 23.0 which showed that when compared against chlorhexidine, the antimicrobial efficacy against S. mutans in decreasing order was of curry leaves, tulsi and pudina and the result of the study was significant. Results: Curry leaves showed higher antimicrobial efficacy than tulsi and pudina when compared against chlorhexidine (control) and the results were statistically significant (p<0.05). Conclusion: Curry leaf extract shows promising antimicrobial property against S. mutans and can be recommended for caries control with further investigations.

Lipid Profile as a Nutritional Status Marker in Tuberculosis

Vaishnavi Sandip Salunkhe, Vinayak Wamanrao Patil, Pooja Rai

Introduction: Tuberculosis (TB) is a global health problem. India has the highest cases in the world and accounts for nearly one fifth of global cases. TB is a chronic disease and in long term leads to malnutrition. Lipids are important constituents in the body that determine the nutritional status and immune function. Aim: To study lipid profile as a nutritional status marker in pulmonary TB. Materials and Methods: Fifty patients of pulmonary TB and fifty healthy subjects in age group of 18-60 years were included for study. The lipid profile was analysed to assess the nutritional status of the patients. Unpaired t-test was used to study the significance of study parameters in cases and controls group. The p-value of <0.05 was considered to be statistically significant. Results: Out of 100 subjects 63% were males 37% were females. Significant decreased levels of total cholesterol, Triglycerides, High Density Lipoprotein-Cholesterol (HDL), Very Low Density Lipoprotein-Cholesterol (VLDL), Low Density LipoproteinCholesterol (LDL) were seen in cases as compared to controls. Conclusion: In this study, it was observed that lipid profile could play a significant role as a biochemical marker of nutritional status in pulmonary TB patients. Thus, knowledge of these levels can help in providing a proper balanced diet to these patients which can ultimately help in better quality treatment.

Development of a Regression Model to Determine Tooth Size Dimensions from Finger Nail Beds- An Innovative Approach

Introduction: Teeth selection is a crucial step and reflects the aesthetic quality of complete dentures and the prime responsibility to ensure their selection with maximum precision lies with the dentist. The anterior teeth reflect the overall aesthetic value of the denture, and hence the need to individualise maxillary anterior teeth was recognised, and the study was undertaken to find an alternative method of teeth selection. Aim: To establish an alternate/additional method of teeth selection for edentulous patients using extraoral landmarks. Materials and Methods: This observational cross-sectional study was conducted in School of Dental Sciences, Krishna Institute of Medical Sciences “Deemed To Be University”, Karad, Maharashtra for a time period of three months (AprilJune 2015). Dimensions of 402 maxillary central and lateral incisors were measured using a vernier caliper. The superior point selected was the gingival zenith of the teeth and the inferior point was the mid-point of the incisal edge. A line connecting these points determined the teeth length. Similarly, width was determined by marking the midpoint of the proximal surfaces and line connecting them. The points considered for recording the dimensions of the finger nail bed were the midpoints of the mesial and lateral surfaces of the nail bed and mid-points of the superior and inferior edges of the nail bed, respectively. The dimensions of maxillary right central incisor were correlated with the dimensions of right nail bed of index, ring and little finger. Similar procedure was followed for the left central incisor; left and right lateral incisors, respectively. The recorded data were statistically analysed using SPSS version 20 to find out Pearson’s correlation coefficient (r) between dimensions of maxillary incisors and finger nail beds. Further regression equation was derived to determine dimensions of maxillary incisors (dependent variable) from dimensions of nail beds (independent variables) for variables with significant correlations. The p-value less than or equal to 0.05 was taken significant. Results: In males, the central incisor length significantly correlated with little finger nail bed width (p=0.01*). The lateral incisor length had significant correlation with index finger nail bed width (p=0.03*), and little finger nail bed width (p=0.02*). The lateral incisor width had significant correlation with index finger nail bed width (p=0.01*). In females, the lateral incisor width had significant correlation with index finger nail bed width (p=0.01*) and ring finger nail bed length (p=0.002*). Further using the correlations for significant variables, regression formulae were developed. Conclusion: The regression model developed for male and female patients can be used to determine the dimensions of lateral incisor width in females, and central incisor length, lateral incisor length and width in males from the dimensions of index, ring and little fingers. The model stands true as a potential method of teeth selection for edentulous patients.

Peripheral Artery Disease in Patients Presenting with Acute Coronary Syndrome in Hill Population of Northern India

Introduction: Acute Coronary Syndrome (ACS) and Peripheral Artery Disease (PAD) represent the serious presentations of the atherosclerotic disease spectrum. PAD due to atherosclerotic disease can lead to significant morbidity and mortality with significant medical and economic burden. Aim: To study the prevalence of PAD in patients presenting with ACS in the Hill population of Northern India. Materials and Methods: Patients presenting with ACS, with acute chest pain, Electrocardiogram (ECG) changes and elevated troponins were enrolled in the study. The presence of PAD was assessed with MESI Ankle Branchial Measuring Device (MESI ABPI MD® Slovenia EU) system which uses plethysmographic sensors with an inbuilt software that automatically calculates ABI with accuracy. Patients with ABI <0.91 were further evaluated by Computed Tomography (CT) Angiography of lower limb vessels. Results: A total of 288 patients were included in the study. There were 238 (82.6%) males and 50 (17.4%) females. Majority of patients had hypertension (214, 74.3%) as the risk factor. ST-Elevation Myocardial Infarction (STEMI) was seen in 197 (68.4%) and Non-ST Elevation Myocardial Infarction (NSTEMI) in 91 (31.6%). Coronary angiography was done in 240 patients. Single vessel disease was seen in 135 (56.2%), double vessel disease in 69 (28.8%) and triple vessel disease in 36 (15%) cases. Out of overall 288 patients 9 (3.12%) had borderline ABI (ABI- >0.9 and =1.0) and 4 (1.38%) had abnormal ABI (ABI <0.9). CT angiography of 3 out of 4 patients with ABI <0.9 showed significant atherosclerosis of lower limb vessels. Conclusion: There was very low prevalence of PAD with ACS in this study population.

Brucellosis, Unravelling an Enigma: Eight Years of Experience from a Tertiary Care Hospital in Central Kerala, India

M Ardra, Chithra Valsan, KA Sathiavathy

Introduction: Various emerging and re-emerging infectious diseases have made the existence of mankind in this world a great challenge. In the midst of these havocs, some important diseases has undermined in the dark. Brucellosis is an endemic zoonotic disease in most of the developing world and it has farreaching and deleterious effects on humans and animals alike. In humans, brucellosis shows a variety of non-specific clinical signs. To recognise and diagnose this neglected but debilitating disease, the awareness and alertness of medical personnel has to be enhanced. Aim: To determine the prevalence of brucellosis in Tertiary Care Hospital. Materials and Methods: A retrospective study was conducted from June 2011 to May 2019, all culture proven cases of human brucellosis admitted in a Tertiary Care Hospital in central Kerala, India were reviewed. Demographic data, clinical presentations, laboratory parameters, treatment and outcomes of the same were analysed in Microsoft excel sheets as percentages. Results: Of the 12 culture proven Brucella cases, 11 presented as Pyrexia of Unknown Origin (PUO) cases and one was a soft tissue infection. Eleven patients had history of either consumption of unpasteurised milk products or had contact with animals before the symptoms developed. A 75% cases were imported cases from middle-east countries. In one case the route of entry was by close personal contact probably sexual transmission. All the patients complained of fever and malaise (100%), while low backache and arthralgia was noted in 83%. Most common clinical and laboratory findings associated with brucellosis were hepatosplenomegaly (41.7%) and anaemia (66.6%). Oral doxycycline for six weeks combined with either aminoglycoside or rifampicin was used for treatment. There was no death or relapses noted. Conclusion: This study emphasises the close collaboration of an alert clinician and an experienced microbiologist to correctly diagnose and treat an infection with multiple presentations as brucellosis, in endemic areas also.

Use of Ertapenem as a Marker for Detection of Carbapenem Resistance for Enterobacteriaceae

Introduction: Detection of carbapenem resistance in the clinical microbiology laboratory is challenging. Production of carbapenemase enzymes remains the most important mechanism among Carbapenem Resistant Enterobacteriaceae (CRE). Ertapenem has been found as a sensitive marker for detecting CRE, especially the non-carbapenemase producing CRE. However, limited literature is available discussing its specificity and sensitivity in comparison to gold standard tests. Aim: To compare the ability of the ertapenem disc diffusion test with other confirmatory tests i.e., Epsilometer test (E test), Carbapenemase Nordmann-Poirel (CNP) test, and Polymerase Chain Reaction (PCR) for CRE identification. Materials and Methods: Seventy six phenotypically confirmed Enterobacteriaceae isolates were tested for carbapenem resistance. Ertapenem susceptibility was compared with imipenem, meropenem, and doripenem disc individually and in combination to determine its sensitivity. Further, it was compared with the E test, CNP test, and PCR to find the concordance of the result. Data were analysed by statistical software using Chisquare test with p-value <0.05 as significant. Results: Ertapenem disc independently was able to detect maximum resistant isolates (64/76) in comparison to other individual carbapenem discs or their combinations. Among the four carbapenem discs, the result of the ertapenem disc showed maximum concordance with its corresponding E test. The sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) of the Ertapenem disc compared to the gold standard tests (CNP and PCR) were 89.7%, 62.5%, 95.3%, and 41.7%, respectively. Conclusion: Disc diffusion test using ertapenem disc was observed as a sensitive marker for detecting CRE. The result of the ertapenem disc diffusion test was observed less discordant with E test, CNP test, and PCR in comparison to other carbapenem discs.

Narrowband Ultraviolet B Phototherapy versus Excimer Laser in the Treatment of Vitiligo: A Retrospective Analysis

Esmaeel Alsayed Mohamed, Nisha V Parmar, Amani Al Falasi

Introduction: Vitiligo is an acquired autoimmune disorder of depigmentation with a global prevalence of 1%. Phototherapy with Narrowband Ultraviolet B (NBUVB) light and excimer laser are both FDA approved treatments for vitiligo. Studies comparing the two modalities are few in patients with different skin colors. Aim: To compare the efficacy and safety of NBUVB versus excimer laser in vitiligo in terms of re-pigmentation achieved during treatment and side effects. Materials and Methods: This study was a retrospective chart review of vitiligo patients attending the phototherapy unit from January 2016 to August 2018. Patient profiles including age, gender, site and extent of vitiligo, type of phototherapy treatment (NBUVB vs excimer laser), sessions per week, sessions required for onset of repigmentation, sites of repigmentation, and side effects were noted. Qualitative variables were analysed using Chi-square test. Quantitative variables were analysed using mean and Standard Deviation (SD). A p-value of <0.05 was considered statistically significant. Results: A total of 146 patients aged 4-70 years were included. Ninety-six patients received excimer laser and 50 patients were on NBUVB. Initial repigmentation occurred after a mean±SD of 28.91±16.61 sessions in the NBUVB group and 24.26±17.57 sessions in the excimer laser group. The difference was not statistically significant (p=0.18). Repigmentation occurred faster on the face followed by the trunk in both groups. Side effects were higher with excimer laser compared to NBUVB (90.6% versus 76%) and the difference was statistically significant (p=0.017). Side effects were, however, mild and did not warrant treatment discontinuation. Conclusion: Number of sessions required for onset of repigmentation was similar in both groups. Side effects, although more frequent with excimer laser, were mild and required dose reduction rather than discontinuation of treatment.

Propofol vs Sevoflurane in General and Cognitive Recovery from Anaesthesia in Day Care Surgery- A Randomised Clinical Trial

Introduction: Rapid emergence from anaesthesia and postoperative recovery of cognitive function is one of the most important requirements of a day care surgery. Propofol is a nearideal intravenous anaesthetic agent for day care surgeries due to its pharmacological properties. Similarly, amongst inhalational anaesthetic agents, sevoflurane is the preferred agent due to low blood-gas solubility. Aim: To evaluate sevoflurane and propofol for general and psychomotor recovery profile in day care anaesthesia techniques. Materials and Methods: This randomised clinical trial was conducted at GGS Medical College and Hospital, Faridkot, Punjab after getting approval by Institutional Ethical Committee. A total of 70 American society of Anaesthesiologists’ (ASA) Grade I and II patients aged 18-60 years, scheduled to undergo elective day care surgery under general anaesthesia were enrolled. In group A (n=35) anaesthesia was induced with propofol 2 mg/kg intravenously and maintained with variable-rate propofol infusion. In group B (n=35) anaesthesia was induced with sevoflurane 8% and maintained with sevoflurane. In both the groups general {mean time to remove Laryngeal Mask Airway (LMA), emergence, time to responds to commands, mean orientation time} and psychomotor recovery profile was evaluated using unpaired student’s t-test and Chi-square test. Results: Mean Time to remove LMA in Group B was earlier being 5.30 ±1.23 minutes vs 8.65 ±2.40 minutes in group A (p<0.001). Mean emergence time in Group B was 5.83 ±1.23 minutes and in Group A was 8.87±2.42 minutes (p<0.001). Time to respond to commands in Group B was 6.81 ±1.39 minutes and in Group A was 10.01 ±2.52 minutes (p<0.001). Mean Orientation time in Group B was 7.15 ±1.53 minutes and in Group A was 10.76±2.61 minutes (p<0.001). Psychomotor recovery was also faster with sevoflurane as compared to propofol. Conclusion: Both sevoflurane and propofol are useful agents for day care surgery. Sevoflurane provides a rapid return of psychomotor and cognitive ability as compared to propofol.

Prevalence of Iron Deficiency Anaemia among the Reproductive Age Group Women Attending the Unani Hospital, Bangalore, Karnataka, India

Mazharul Islam, Atiya Khan, Arish Mohammad Khan Sherwani

Introduction: Iron Deficiency Anaemia (IDA) is the most widespread micronutrient deficiency. Globally, nearly two billion people are affected by anaemia. This disease most often affects children, women of child-bearing age, and pregnant women. Nearly half of the pregnant women in the world are estimated to be anaemic. Its prevalence varies according to region and socio-economic conditions. The majority of those who are anaemic live in developing countries where the problem is exacerbated by limited access to inadequate resources and appropriate treatment. Aim: To find out the prevalence of IDA in the reproductive age group women and its associated factors. Materials and Methods: This hospital based, cross-sectional study was conducted among 400 females, of age group 15- 49 years. After obtaining the written informed consent, eligible subjects were inquired about socio-demographic variables, socio-economic status, anthropometric measurements and risk factors. Required investigations were done. All the information was recorded on the semi-structured schedule form. Chisquare/Fisher’s-exact test was used to find the significance of study parameters on categorical scale between two or more groups. Results: Prevalence of IDA was found to be 42% (168/400). Prevalence of IDA was significant with habitat (p=0.0180), exercise (p=0.0004), amount of blood loss during menstruation (p<0.0001), duration of flow during menstruation, (p=0.0020), consumption of fish (p=0.0002), consumption of legumes (p=0.002), consumption of green leafy vegetable (p<0.0001). Conclusion: Results confirmed an increased prevalence of IDA in women of reproductive age group.

Collaboration between Paediatrician and Orthopaedician in Management of Congenitial Talipes Equino Varus by Ponseti Method

JB Santhosha, SP Akshatha

Introduction: Congenital Talipes Equino Varus (CTEV) or Clubfoot is one of the commonest orthopaedic problems observed in infants. Deformity involving in utero malalignment of calcaneo-talar-navicular complex of the foot is known as CTEV. Due to lack of treatment capacity and less knowledge about "Appearance, Pulse, Grimace, Activity, and Respiration." (APGAR) Score in low income countries, CTEV end up with neglected clubfoot deformity (untreated children >2 years). About 1-2/1000 live births is the estimated incidence of idiopathic clubfoot. Aim: To assess the clinical profile and efficacy of Ponseti technique in the management and treatment of CTEV by Paediatrician and Orthopaedician collaboration. Materials and Methods: The observational study was conducted at AdiChunchanagiri Institute of Medical Sciences (AIMS). The data was recorded in a standard predesigned proforma which contained all details of patients like name, age, sex, parent details, address, family history, pregnancy and delivery details of mother, any prior treatment taken for clubfoot and examination details of spine, hips, upper and lower limbs with both feet and also other systems for associated clinical problems. The parents of the patients visiting Paediatric Out Patient’s Department (OPD) with CTEV were informed regarding the deformity and were sent to Orthopaedic Department. In Orthopaedic Department, after counselling of the parents regarding the ponseti method, all patients were treated and managed. All patients were followed over a two year period and assessed for any deformities which were subsequently managed surgically. All the data was documented, statistically analysed using suitable statistical methods. Results: Total 53 patients had 81 idiopathic CTEV or Clubfoot between the period of three years from 2015 to 2018. The age of patients varied upto one year after birth. Among 53 patients, 38 (72%) were males and 15 (28%) were females. Out of 53 infants, 35 had one clubfoot and 23 had bilateral clubfoot (total 81 clubfoot in 53 infants). The mean age of initial presentation to treatment was 3.5 weeks, 11 out of 53 infants came in 1st week of life. Out of 53 infants, 21,14,6,5,4,2 were followed-up for 7-12 months, 13-18 months, 0-6 months, 25-30 months, 19- 24 months and 31-36 months, respectively. Out of 81 clubfoot; 76 (93.83%) had achieved near normal correction, five clubfoot (6.17%) required posteromedial soft tissue release, 67 foot (82.71%) had undergone percuteneoustenotomy and nine foot (11.11%) got corrected without tenotomy. Conclusion: CTEV or clubfoot is treated very safely and effectively by using ponseti method. It is rapidly decreasing the necessity of extensive surgery. This method should be encouraged to be set as the gold standard treatment of congenital clubfoot or CTEV by national efforts.

Comparative Evaluation of Postoperative Pain after using Open Ended, Closed Ended Endodontic Needles and Endoactivator during Final Root Canal Irrigation Procedure: A Randomised Controlled Trial

Sucharita Vishwakarma, Arvind Shenoy

Introduction: Apart from manual activation methods of irrigants during final irrigation procedure, multiple irrigant activation devices have been introduced which can influence the postoperative pain. Aim: To evaluate postoperative pain after final irrigation with open and closed-ended endodontic needles and Endoactivator during root canal treatment. Materials and Methods: This randomised controlled trial was conducted in Department of Conservative Dentistry and Endodontics, Bapuji Dental College and Hospital, Davangere, from June 2018 to August 2018. Total of 75 symptomatic irreversible pulpitis patients were randomly assigned into three groups. In group EN-1, final irrigation protocol was performed with 30-gauge notched tip needle (Pac-Dent, India), group EN-2 using side-vented, closed 30-gauge needle (Max-i-Probe, Dentsply, USA) and in group EA using Endoactivator (Dentsply, USA). Pain using Visual Analog Scale (VAS) was evaluated at 8, 24 and 48 hours. Participants were prescribed Non-steroidal Anti-Inflammatory Drugs (NSAIDs) as an escape medication. Comparison between the three groups at each time interval was done using Kruskal Wallis test followed by Mann-Whitney U test as post-hoc test. Change in VAS score over different time intervals (8, 24 and 48 hours) in each group was compared using Kruskal Wallis test and Mann-Whitney U test. The p-value less than 0.05 was considered statistically significant. SPSS version 20 was used for statistical analysis. Results: Mann-Whitney U test revealed significant difference between EN-1 and EN-2 (p=0.002) and between EN-1 and EA (p<0.001) at 8-hour time interval; between EN-1 and EA (p=0.002) at 24 hour time interval and between EN-1 and EN-2 (p=0.01) as well as between EN-1 and EA (p=0.002) at 48 hour time. MannWhitney U test showed significant difference (p<0.05) in number of NSAIDs taken at 8 hour between EN-1 and EA (p=0.04) and between EN-2 and EA (p=0.01); at 8-24 hour between EN-1 and EA and between EN-1 and EN-2 (p<0.001); at 24-48 hour between EN-1 and EA and between EN-1 and EN-2 (p<0.001). Conclusion: Number of NSAIDS taken by patients was significantly higher in open-ended needle irrigation group compared to side-vented needle and Endoactivator group in all the three time intervals along with postoperative pain. Thus, during final irrigant activation, application of Endoactivator or side-vented needle can be more beneficial in decreasing the incidence of postendodontic pain.

Demographic and Clinical Status of COVID-19 Patients in a Tertiary Care Hospital in Chengalpattu District, Tamil Nadu: An Observational Study

P Getrude Banumathi, S Sujatha, A Arul Murugan

Introduction: The ongoing outbreak of the coronavirus disease 2019 (COVID-19) infection has posed significant threats to international health and economy. On 30th January 2020, the World Health Organisation (WHO) declared it to be a Public Health Emergency of International Concern. Despite exponential rise of COVID-19 cases, there are limited studies on COVID-19, so an observational study to assess the demographic and clinical status of COVID-19 patients at a Tertiary Care Centre was conducted. Aim: To study the demographic and clinical status of COVID-19 patients in a tertiary care hospital in Chengalpattu district. To assess the co-morbid status and its influence on the outcome among the study population. To find the doubling rate and weekly trend of COVID-19 cases. Materials and Methods: A cross-sectional study was conducted in Chengalpattu Medical College Hospital, Chengalpattu district among the COVID-19 patients during April to June 2020. By non-probability sampling technique (convenient sampling), all the COVID-19 patients (n=3028) admitted in the institution during the study period were included. A semi-structured questionnaire was administered to collect the data. The questionnaire had three sections A, B, and C. Section A dealt with sociodemographic details, Section B with symptom status and co-morbidity status and section C with COVID test results. Ethical clearance was obtained from the Institutional Ethics Committee. Data was entered in MS Excel and analysis was done using SPSS Software. Results: In this study, there were 1932 (64%) males and 1096 (36%) females; 1489 (49%) were affected in the age group of 21-40 years, which was the most commonly affected group; 704 (23%) were in the age group above 50 years; 2574 (85%) of cases were from urban areas of Chengalpattu district; 1145 (38%) were found to be symptomatic, fever being the pre-dominant symptom 753 (66%); 712 (24%) of the patients were associated with co-morbid conditions, the most common being diabetes mellitus 391 (55%); mean duration of stay was found to be 9.21±3.26 days; doubling rate was found to be 18.91 days; the overall swab positivity rate was 14.56%; the overall case fatality rate was 2.47%; 3028 (59%) of the district cases were treated in the institution. Conclusion: This study found that the patients aged >50 years with co-morbidity are at a higher risk of mortality than others. The present work predicts that the number of cases double in 19 days. Hence, strict containment measures are recommended to lengthen the doubling rate.

Variability in Insight Before and After Treatment in Patients with Schizophrenia

Introduction: An important component in the management of schizophrenia is insight. Schizophrenia patients that lack insight have poor clinical outcomes. Chronic patients of chronic schizophrenia lacking insight more often require hospitalisation than those recognising their illness. Poor insight is a good indicator of poor compliance and can predict the prognosis of any psychiatric patient including schizophrenia. Aim: This study was aimed at contrasting the gain in insight after treatment among various sub-groups of patients with schizophrenia. Materials and Methods: A cross-sectional study was conducted at the Acharya Vinobha Bhave Rural Hospital, Wradha, Maharashtra. The sample size was collected for a period of 1 year, during which all the patients admitted to the psychiatry ward were screened, of which 100 eligible patients with schizophrenia were identified using prespecified inclusion and exclusion criteria. Patients of both sexes aged above 18 years and attendants that provided consent were included in the study. The Schedule for Assessment of Insight Scale (SAI) was used to determine the patient’s level of insight. The proportion of patients with distinct socio-demographic characteristics, clinical profile, psychiatric diagnosis and SAI scores were calculated. A paired t-test was used for elaborating the results. The p-value <0.05 was considered significant. Results: The changes in insight scores from the time of admission (4.15) to the time of discharge (9.28) were statistically significant and similar in both males and females and also results are statistically significant according to marital status. Significant improvement was seen in patients irrespective of their employment status or their educational status. Conclusion: This study showed that the insight changes as the patient improves during the hospital stay. This study highlights that poor insight is commonly seen in psychotic patients and the treatment considerably improves their insight.

Study to Assess the Prescription Pattern and Quality of Life in Osteoarthritis Patients at a Tertiary Care Hospital

Introduction: Osteoarthritis (OA) often called wear and tear arthritis is a chronic progressive musculoskeletal joint disease with multifactorial aetiology, affecting millions of people around the world. It is one of the leading causes of morbidity, having major impact on Quality of Life (QoL) of the patient with substantial economic and social burden. OA can have a negative impact on health related QoL and psychological wellbeing of the individual. Aim: To evaluate the prescribing trends of drugs in the management of OA in a tertiary care teaching hospital and to assess the effect of pharmacotherapy on QoL of OA patients in terms of subjective and functional status using Western Ontario and McMaster Universities Arthritis index scale (WOMAC)- modified Centre for Rheumatic Disease (CRD) Pune version OA patients. Materials and Methods: Prospective observational study conducted among the OA patients in Orthopaedic Department over the period of one year between November 2014-December 2015. Adult patients of either gender diagnosed with OA for minimum period of three months were enrolled for the study. Out of 285 eligible patients, drug therapy of 256 patients’ data were analysed and they were given treatment by the treating orthopaedician. All the patients were asked to personally complete the WOMAC index scale during their first visit. They were followed-up for one month of pharmacotherapy in order to assess change in the WOMAC index scale. Data were analysed using Statistical Package for the Social Sciences (SPSS) software 16.0 version. The p-value <0.05 was considered statistically significant. Results: Among 256 patients who completed the study, the most frequently prescribed drug class was NSAIDs (82.1%). Acelofenac with Paracetamol combination (117) and Diclofenac monotherapy (44) were most commonly prescribed. Statistically significant reduction in the WOMAC (pain, stiffness and physical function) score was observed in the follow-up visit when compared to first visit (p<0.0001) after one month of pharmacotherapy in patients taking Diclofenac and Aceclofenac with Paracetamol combination. Conclusion: This study highlighted the significant improvement in QoL and significant reduction in WOMAC scores with Aceclofenac-Paracetamol combination and Diclofenac monotherapy in OA patients.

Co-morbidities of Nocturia among Adults: A Cross-sectional Study in Southern India

Susamma Varughese, TP Rajeev, Devina E Rodrigues

Introduction: Night urination severely impacts the quality of life among adults. Coexisting factors such as age, obesity, diabetes, hypertension, cardiac diseases, UTI, asthma, anxiety, and depression are significantly related when voiding episodes exceed two per night. However, understanding its associated factors are essential aspects in the management of Nocturia. Aim: The aim of the study was to determine the association of nocturia with selected demographic variables, co-morbidities, and the precipitating factors among adults with voiding episodes two or more times and adults who void only once at night. Materials and Methods: A descriptive cross-sectional design was carried out among 420 adults of age 35-65 years with voiding over two times (Group I) and 206 adults of age 35- 65 years who voided only once (Group II) a night. The data was collected from two selected hospitals of Mangalore between January 2018 and June 2019. The written permission was taken from the concerned authority, after obtaining the informed consent from the subjects. The baseline proforma was assessed by the researcher using structured interview schedule and the questionnaire on co-morbidity and precipitating factors such as regular intake of alcoholism, smoking, consumption of coffee, spicy food, anxiety, urinate before bedtime, use of diuretics, day time frequency, underwent surgeries was filled by the subjects. The data was analysed using frequency, percentage, Chi-square test, and logistic regression statistics by Statistical Package for the Social Sciences (SPSS) Version 16. Results: The study observed that the risk of nocturia was significantly higher among Group I subjects with Urinary Tract Infection (UTI), constipation, hypertension, and on medication for various diseases compared with Group II. The precipitating factors of nocturia revealed that Group I subjects who regularly took coffee, spicy food, had anxiety, daytime frequency, and had undergone various surgeries showed significant difference associated with increased risk of nocturia compared with Group II. Conclusion: The study findings demonstrate that nocturia is strongly associated with multiple co-morbidities and precipitating factors. These results therefore provide evidence to establish the primary and secondary preventive strategies among adults with nocturia.

Bacteriological Profile of Pyoderma Cases Attending the Dermatology Department in a Tertiary Care Hospital

DOI: 10.7860/JCDR/2020/46943.14338 Date of Submission: Sep 28, 2020 Date of Peer Review: Oct 19, 2020 Date of Acceptance: Nov 20, 2020 Date of Publishing: Dec 15, 2020 AUTHOR DECLARATION: • Financial or Other Competing Interests: As declared above • Was Ethics Committee Approval obtained for this study? Yes • Was informed consent obtained from the subjects involved in the study? Yes • For any images presented appropriate consent has been obtained from the subjects. NA PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: Sep 29, 2020 • Manual Googling: Nov 19, 2020 • iThenticate Software: Dec 07, 2020 (15%) ETYMOLOGY: Author Origin

Evaluation of Perception and Awareness of Dental Injuries among Sports Children Aged 6-18 Years and their Coaches during Contact Sports

Introduction: Dental injuries are the most common form of orofacial injury suffered during sports participation. This injury can be severe, affecting appearance, voice, and ability to eat. Reputation of contact sports activities is growing day-by-day so the function of dental specialists has turn out to be extra essentials to prevent dental and orofacial injuries. Aim: To evaluate perception and awareness of dental injury in sports children and their coaches during contact sports. Materials and Methods: A cross-sectional study was conducted between August 2019 to October 2019 at three sports complexes in Vadodara, Gujarat. A structured questionnaire was used to assess the perception and awareness of oral injuries sustained during sports activities. Self-administered questionnaire with 20 closed ended questions for coaches and 18 closed ended questions for children were constructed with multiple choice or Yes-No format. Total of 50 coaches and 240 children were included in the study. Results: Most common sustained injury occurred on the face (41.7%), followed by lip/tongue/cheek injury (22.9%), teeth fracture (10.4%) and teeth avulsion (7.5%). Among all participants, 66 (27.5%) sports children and 27 (54.0%) coaches knew that it was possible to re-implant the teeth. A total of 118 (49.2%) sports children were aware that mouthguard can prevent dental injuries and 31(86%) coaches had advised children to use mouthguards while playing contact sports. Conclusion: The knowledge related to sports injury is poor and under-usage of protective devices requires education and motivation.

Serum Procalcitonin as a Diagnostic Marker for Systemic Inflammatory Response Syndrome in Intensive Care Unit Patients

Rama Mishra Ramapriya, Pallavi Prakash

Introduction: Early assessment of Systemic Inflammatory Response Syndrome (SIRS) through various biomarkers like Procalcitonin (PCT), C-reactive Protein (CRP), Interleukin-1 (IL-1) etc., is crucial to manage the outcome of patients. Levels of PCT concerning its likelihood to distinguish patients with SIRS and non-SIRS and the possibility to predict mortality in patients with sepsis has been variable. Aim: To investigate the role of PCT in early diagnosis of sepsis in patients admitted to Intensive Care Unit (ICU). Materials and Methods: In this prospective observational study, 136 patients hospitalised in ICU at Vydehi Institute of Medical Sciences and Research Centre, Bangalore, Karnataka, India, between July 2019 to June 2020 were evaluated and PCT was analysed using Finecare™ PCT rapid test. Receiver Operating Characteristic (ROC) curve analysis and multiple logistic regression was carried out to detect the association of predictive PCT value with its outcomes. Results: PCT showed the best predictive value in the diagnosis of SIRS at 1.68 ng/mL (Area Under Curve (AUC)-0.87; p<0.05) having Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of 90.43% and 73.81% respectively. Multiple logistic regression model adjusted for age, weight, and duration of stay to predict the outcome of SIRS, positive blood culture and fatality case rate derived a significant association of PCT with Odds Ratio (OR) being 1.23 (1.11-2.31), 1.06 (1.01-1.98) and 1.76 (1.08-2.14) respectively. Conclusion: Early identification and treatment for sepsis significantly affects mortality. It appears that consecutive measurements of biomarkers could be valuable, but further prospective studies are important to characterise the role of PCT as a prognostic marker in sepsis and severe sepsis.

Clinical Manifestation and Diagnostic Approach Towards ‘TORCH Test’: A Knowledge, Attitude and Practice Study

Introduction: 'TORCH Test' (Toxoplasmosis, Rubella Cytomegalovirus, Herpes simplex) is usually requisitioned in females having ‘Bad Obstetrics History (BOH)’ or those who are suspicious of ‘intrauterine infection’ or for neonates having congenital malformation. However, the understanding of the test is lacking amongst the practitioners. Hence, this Knowledge Attitude and Practice (KAP) study was conducted to access the knowledge of resident doctors about the correct way of requesting TORCH test. Aim: To assess the understanding, clinical manifestation and diagnostic approach towards TORCH test amongst the Resident Doctors. Materials and Methods:Four groups of questions were put to Resident Doctors from Obstetrics and Gynecology (ObG), Paediatrics (Paeds) and Microbiology Department to assess their understanding of TORCH test. The questionnaire having 30 questions was divided in four groups A, B, C and D. Group A (Q. 1-4) about the fundamental of TORCH infection; Group B (Q. 5-8) brief clinical manifestation; Group C (Q. 9-12) indication of TORCH test i.e., when torch test should be requested and Group D (Q. 13-30) result interpretation of TORCH profile. Results: Questions as to the full form of TORCH test were correctly answered by almost all participants. As far as questions as to Clinical Manifestation, residents of ObG (72.3%) were more accurate in predicting than that of Paeds residents (48%). Amongst Microbiology residents only 5.2% of them were able to gave correct answers. When questions as to when the TORCH test is to be recommended were asked, only 30.7% residents of Paeds, 59% of ObG and 10.5% of Microbiology were aware about it. Interpretation of the test results amongst the participants was also not that up to the mark as only 36.1% in Paeds, 67.6% in ObG and 29.8% in Microbiology residents were correctly able to predict. To sum up, understanding, clinical manifestation and diagnostic approach towards TORCH test is better amongst the ObG residents (67.7%) as compared to that of the Microbiology Residents (26.7%) and Paeds Residents (42%). Conclusion: It can be understood that since the clinical branch residents of ObG and Paeds are not that thoroughly acquainted with the TORCH test understanding and complete clinical information is necessary. Therefore, it is apparent that the same is being not requisitioned in cases where pregnant women or infants have non-descript illnesses where testing is not necessary at all. It is, therefore, highly recommended that regular seminars and teaching activities are conducted by the concerned respective departments in order to impart TORCH test understanding and complete clinical information regarding it.

Study to Evaluate HER2-neu Expression in Different Histopathological Grades of Prostatic Carcinoma in a Tertiary Care Centre, Bareilly

Surbhi Bansal, Hema Pant, Tanu Agrawal, Piyush Kumar, Pradeep Mehdiratta

Introduction: Prostate cancer is the second most common neoplasm among men around the world. Two routinely used immunocytochemical markers for prostatic epithelium are Prostatic Acid Phosphatase (PAP) and Prostatic Specific Antigen (PSA). Various other markers like Prostate-Specific Membrane Antigen (PSMA), androgen and progesterone receptors, HER2- neu, low molecular weight keratin, etc., are also used. HER2-neu overexpression has been implicated in tumorigenesis and has been correlated with a poor prognosis for patients with breast cancer, ovarian cancer, and gastric cancer. Use of Trastuzumab for the treatment of breast carcinoma has improved prognosis in HER2-neu positive cases. Recent studies have suggested the correlation of HER2-neu overexpression with higher grades of prostate cancer. Aim: To study HER2-neu expression in different histopathological grades of prostatic carcinoma. Materials and Methods: A prospective study was carried out on 41 histopathologically proven cases of prostatic carcinoma in Pathology Department of SRMSIMS, Bareilly over a period of one year and six months (November 2017 to April 2019). Gleason grading and HER2-neu Immunohistochemistry was applied on every case and then correlated. Statistical tests were applied, statistical software Statistical Package for the Social Sciences (SPSS) version 21. Results: A 92.7% (38/41) cases were reported as Prostatic Adenocarcinoma of Non-Mucinous type. Total of 42.5% (17/40) were grouped under Grade group 5, 27.5% (11/40) cases under Grade group 3 and 10% (4/40) under Grade groups 1,2 and 4 each. Out of total, 14.6% (6/41) cases were considered as positive and 80.5% (33/41) cases were considered as negative for HER2-neu expression and 4.9% (2/41) cases were considered as equivocal (Fluorescence In Situ Hybridization (FISH) conformation required). In cases with positive HER2-neu expression, mean group grade was calculated to be 4.83±0.40 and in patients with negative HER2-neu expression, it was 3.38±1.40 (it was calculated to find correlation between group grade and HER2-neu expression). There was a significant statistical difference (p=0.00003668) found between the Gleason Group Grade in HER2-neu positive and negative patients as HER2-neu positivity is seen in higher group grades. One case was reported as neuroendocrine carcinoma in which Gleason grading was not done. Conclusion: Compared to low Gleason Group Grade carcinoma, higher percentage of HER2-neu expression was seen in high Gleason Group grade carcinoma

Exploring the Unexplored: Circulating Micromegakaryocytes in Chronic Myelogenous Leukaemia

Pallavi Sinha, Sarika Singh, Lity Dhar, Sunita Aggarwal

Introduction: Chronic Myeloid Leukaemia (CML) is a clonal haematopoietic stem cell disorder characterised by balanced chromosomal translocation called the Philadelphia chromosome. It is clinically divided into Chronic Phase (CP), Accelerated Phase (AP), and Blast Crisis (BC). Disease is seen associated with leukocytosis and myeloid bulge in the peripheral smear. Sighting of circulating Micromegakaryocytes in peripheral smear in CML, is a known entity but long forgotten and a finding not well explored to depend on. They are dysplastic, small megakaryocytes with increased nuclear to cytoplasmic ratio and hypolobated nuclei, at times seen with pinching off platelets though being dysplastic. Besides CML, micromegakaryocytes are also observed in myelodysplasia, and other myeloid neoplasms. Aim: To assess the frequency of Circulating Micromegakaryocytes in CML in North Indian population and to observe its correlation with clinical staging. Materials and Methods: This cross-sectional study was conducted in the Department of Pathology, Maulana Azad Medical College, Delhi, from July 2017-July 2018. Forty-five newly diagnosed cases of CML, with median age being 37 years, were included in the study. Of these 22 were males and 23 females. Micromegakaryocytes were identified on peripheral smear stained by Giemsa and by CD61 immunostaining. Statistical analysis was performed using SPSS software version 24. Pearson Chi-square was used to calculate p-value. The p-value <0.05 was considered statistically significant. Correlation was calculated as Pearson correlation coefficient formula. Results: Micromegakayocytes were found in 37 (82%) cases, out of which 20 (54%) were in CP, 8 (22%) in AP and 9 (24%) in BC. Anaemia was present in 42 (93%) cases. Mean value of micromegakaryocytes were highest in BC (2.6) and lowest in CP (0.57). There was significant positive correlation of micromegakaryocytes with bone marrow fibrosis (p=0.01). There was no significant correlation of micromegakaryocytes with splenomegaly (p=0.41) and basophil count (p=0.79). Conclusion: Micromegakaryocytes and cytoplasmic fragments of micromegakaryocytes are found in CML in Indian population. There was significant correlation of circulating megakaryocytes with progressive phase and marrow fibrosis. However, study on large number of subjects is needed for better correlation.

N-Terminal Pro-Brain Natriuretic Peptide Levels in Patients Presenting with Acute Breathlessness in Emergency Department

Arun Bahulikar, Sunil Patel, Deepak Sadashiv Phalgune

Introduction: Breathlessness is one of the most common symptoms in patients presenting to the emergency department. Differentiating Congestive Heart Failure (CHF) from other causes of dyspnea is of extreme importance. N-Terminal proBrain Natriuretic Peptide (NT-proBNP) levels may be valuable for the diagnosis of Heart Failure (HF) in patients with acute breathlessness when used in combination with other clinical information. Aim: To find the utility of NT-proBNP levels in patients presenting with acute breathlessness. Materials and Methods: This cross-sectional study was conducted on 255 patients presenting with acute breathlessness. Details of clinical history, clinical examination, laboratory tests, Electrocardiogram (ECG), X-ray chest, and 2D echocardiogram were collected from each patient. A 5 mL sample of peripheral venous blood was taken from the patients for the quantitative determination of NT-proBNP levels. Mann-Whitney U test was used to compare medians of continuous variables. Sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and accuracy were determined for NT-proBNP levels. Results: The mean age of the patients was 58.9 years. The median NT-proBNP level was significantly higher in patients who had HF compared to respiratory failure and Hyperventilation Syndrome (HVS). The sensitivity and specificity of NT-proBNP level >450 pg/mL was 76.9% and 90.0%, respectively for patients <50 years of age. The sensitivity and specificity of NTproBNP level >900 pg/mL was 82.9% and 92.3%, respectively for patients 50-75 years of age. The sensitivity and specificity of NT-proBNP level >1800 pg/mL was 61.5% and 100.0%, respectively for patients >75 years of age. Conclusion: NT-proBNP measurement is a useful biochemical tool for the emergency room physician in the rapid and reliable diagnosis of HF in patients with acute breathlessness.

Comparative Evaluation of Fracture Resistance of Root Dentin Treated with Calendula Officinalis L. and Calcium Hydroxide as Intracanal Medicaments- An In vitro Study

NJ Nagaraj, N Ravikumar, S Mahalaxmi, S Pallavi

Introduction: Intracanal Medicaments (ICMs) play a major role in disinfection of root canal system. The use of interappointment ICM during endodontic treatment may affect the mechanical properties of dentin which results in decreased fracture resistance of teeth. The use of synthetic medicament is associated with many limitations such as antibiotic overdose, side effects and cytotoxic reactions. In order to overcome this, recent research has been directed towards herbal ICMs with better efficacy and lesser side effects. Aim: To evaluate the effect of a novel herbal ICM Calendula officinalis L. (CO) on fracture resistance of root dentin in comparison to Calcium Hydroxide (CH). Materials and Methods: This in vitro study was conducted in the Department of Conservative Dentistry and Endodontics, SRM Dental College and Hospital, Ramapuram, Chennai, Tamil Nadu. Thirty freshly extracted single rooted human premolar teeth were selected for the in vitro study and randomly assigned into three groups: Group 1: No medication (Control group) (n=10), Group 2: CH (n=10), Group 3: CO (n=10). The samples were decoronated and biomechanical preparation was done followed by placement of respective ICMs in the root canal space, sealed with glass ionomer cement and immersed in saline for a storage period of 7 and 14 days. Each group was subdivided into 5 teeth, depending on the storage period. After each storage period, ICMs were removed and samples were subjected to fracture resistance test using universal testing machine. Data were analysed using One-way Anova followed by Tukey HSD post-hoc test with level of statistical significance set at p<0.05. Results: On evaluation of compressive strength, CO group showed more fracture resistance compared to CH group on 7^th day and no statistical significant differences were seen between CO and CH groups on 14^th day. Conclusion: CO can be efficiently used as an alternative to CH because of its low toxicity and increased resistance to fracture.

Study of Pattern of Histopathological Lesions in Nephrectomy Cases in Southern Rajasthan

Introduction: The kidney is one of the most highly differentiated organs in the body, affected by various disease processes, some resulting in permanent damage leading to surgical removal of the organ i.e., nephrectomy. Patterns of the indications for nephrectomy vary in different age groups, geographical locations and time periods. Nephrectomy is a common procedure in urological practice done for various conditions like calculi, chronic pylelonephritis, malignancy, obstruction, injury etc., with wide range of morbidity and mortality. Aim: The aim of this study was to study the pattern of histopathological lesions in nephrectomy cases in Southern Rajasthan. Materials and Methods: This study was conducted in the Department of Pathology, Geetanjali Medical College and Hospital (GMCH), Udaipur, Rajasthan. It was a cross-sectional study performed on 121 patients, from January 2015 to March 2020 in which patient’s detail such as age, sex, gross and microscopic findings were retrieved and reviewed. Data was tabulated and analysed. Results: A total of 121 specimens of nephrectomy were included in the study. Among 121 nephrectomy cases, higher incidence was observed in 6^th and 3^rd decade of life with approximately equal preponderance of male and female; 0.98:1. Out of 121 cases 88 (72.7%) were non-neoplastic and 33 (22.27%) were neoplastic. Conclusion: Benign conditions of kidney are the leading cause of End Stage Renal Disease (ESRD) in the developing world. In our country, there are an increased number of ESRD which require dialysis and transplantation. This study has been performed to know the different causes of nephrectomy in a tertiary care center of India.

A Cadaveric Study on Lumbar Spinous Process Fusion: Risk Factor for Wrong Level Spinal Surgeries

Priyanka N Sharma, Manoj M Kulkarni, AR Gandotra

Introduction: The fusion of Lumbar Spinous Processes (LSP) of adjacent vertebrae may lead to errors in determining the correct spinal level. This may result in wrong level spinal surgeries around the lumbar region. Aim: To determine the prevalence of fusion between adjacent LSP. Materials and Methods: This study was a prospective observational study done in the Department of Anatomy, Smt. B.K. Shah Medical Institute and Research Centre, Vadodara, Gujarat, India. The present study had examined the lumbar spines in 30 formalin preserved cadavers. The fusion between the LSP of adjacent vertebrae was recorded after the removal of soft tissue from L1 to S1 vertebrae. Results: The present study found the fusion between the adjacent LSP in 11 (36.67%) cadavers (08 males; 03 females). The fusion between the adjacent LSP, from L4 to S1 vertebrae, was found in 10% of cadavers and was the most common pattern. The fusion between the adjacent LSP was more common in males (53.3%) compared to females (20%). Conclusion: The occurrence of fusion between the adjacent LSP is not uncommon.

Pharmacokinetics, Biodistribution and Toxicity Studies for Nanocarrier of Antitubercular Agent- Rifabutin

Swapnil Patil, Surendra Gattani, Pradip Nirbhavane, Kiran Patil, Amit Kumar Pal

Introduction: Rifabutin (RFB) is a lipophilic, semi-synthetic antibiotic given for the treatment of atypical mycobacterial infections along with drug susceptible tuberculosis infections. The major challenges in its usage include low oral bioavailability (~20%) mainly due to its low solubility and extensive first pass metabolism. Aim: The present study aims to explore the pharmacokinetics, biodistribution and toxicity of nanocarrier of RFB. Materials and Methods: An experimental animal study was carried out in Institute for Industrial Research and Toxicology, Ghaziabad, Uttar Pradesh, India. RFB nanocarriers were formulated by using solvent diffusion evaporation method with minor modifications and characterised for its physicochemical properties by using various techniques like Field Emission Scanning Electron Microscopy (FESEM), Dynamic Light Scattering (DLS) method, High-Performance Liquid Chromatography (HPLC), X-ray Diffractometry (XRD), in-vitro release study etc. Further nanocarriers were also studied for in-vivo analysis using pharmacokinetics, biodistribution and toxicity studies. GraphPad Prism Software (Version 5.02) was used for the statistical analysis. Results: Nanocarriers of RFB were developed and evaluated for its safety and efficacy. The results of evaluation of nanocarrier for physical and chemical attributes revealed that its particle size obtained was 305-325 nm with low Poly Dispersity Index (PDI) of 0.26-0.36 and the high drug encapsulation efficiency (62.45- 70.15%). The nanocarrier formulation showed a sustained release pattern in Simulated Intestinal Fluid (SIF) upto 48 hours and in Physiological Buffer System (PBS) upto 7 days. The invivo study showed that the nano-lipoidal drug has significant higher T_max and C_max plasma value with higher t_1/2(h) values in comparison to plain drug. Moreover, the slow elimination rate (Kel) resulted in significant (p<0.001) prolonged half-life (t_1/2), which was many fold higher than the plain drug. No significant change was observed in haematological and liver enzyme profile of rats in plain drug and drug with nano-lipoidal carrier. Nanocarriers showed that there was an increase cell survival rate in MTT assay as compared to normal drug. Conclusion: By using nanotechnology based formulations, dose and dosing frequency of drug administration can be reduced. Thus, RFB drug can be administered in more efficacious manner reducing its toxic side effects, which ultimately improves patient compliance.

Readiness to Send Children Back to School in the COVID-19 Pandemic: Maternal Perception and Preferences

Ann Aronu, Chinawa Awoer, Nduagubam Obinna, Ossai Edmund Ndudi, Chinawa Josephat

Introduction: Whether children should go back to school amidst the Coronavirus Disease 2019 (COVID-19) menace, is currently a burning issue. The perception of parents on their children returning to school varies. This may be due to discrepancies in the learning methods available to the children at home, as well as the child’s exposure to the vices and abuse of the internet. Aim: To determine the maternal perception and preferences with regard to their readiness to send their children back to school in the COVID-19 Pandemic. Materials and Methods: This was a cross-sectional study undertaken in a tertiary health institution in South East Nigeria. Systematic random sampling technique was used to select mothers who presented in the three units of children outpatient department in the hospital. A pre-tested intervieweradministered questionnaire was used to collect information from the respondents. Chi-square test and multivariate analysis using binary logistic regression were used in the analysis. The level of statistical significance was determined by a p-value of <0.05. Results: The mean age of the respondents was 40.1±12.3 years and the highest proportion (33.2%) were in the age group 30-39 years. Majority of them (78.5%) were married. Majority of the respondents (56.7%) were willing to allow children return to school. The major reason for not allowing children return to school was their distrust in the schools’ preventive measures (80.6%). Predictors of willingness of mothers to allow children return to school included being <30 years, {Adjusted Odds Ratios (AOR)=0.3, 95% Confidence Interval (CI): 0.2- 0.7}, being married, (AOR=0.4, 95% CI: 0.2-0.7) and having poor knowledge of preventive practices against COVID-19, (AOR=2.8, 95% CI: 1.7-4.8). Conclusion: Majority of mothers preferred that children should return to school. The younger age group and the married women were more likely to allow children go back to school. The respondents who had poor knowledge of preventive practices were also more eager that children should return to school.

Vitamin D Status in Mothers and their Newborns at a Tertiary Care Centre in Mumbai: A Cross-sectional Study

Avinash L Sangle, Amol P Jaybhaye, Ravindra Y Chittal, Deepak Ugra

Introduction: Indian population has a paradoxically high prevalence of vitamin D deficiency. Maternal vitamin D levels are related to outcomes of pregnancy for mother and foetus. To understand the need for screening and appropriate management decisions, data is needed from various regions of India to explore the magnitude of the problem. Aim: To evaluate the vitamin D levels in pregnant mothers and their newborns at a hospital catering to the affluent population in Mumbai. Materials and Methods: A cross-sectional study was conducted from August to December 2012. A 100 women of Indian origin, between 20-45 years of age and their newborns who were delivered at the Lilavati Hospital and Research Centre in Mumbai were included. Determination of 25 hydroxy (OH) vitamin D, serum calcium, albumin concentration was done in mothers just before delivery and newborns venous cord blood at the time of delivery. Pearson's correlation test was used for determining relation between maternal and newborns vitamin D levels and Chi-square test for association of maternal vitamin D levels with their sun exposure and newborns birth weight. Results: The distribution of serum 25 (OH) vitamin D status in mothers was 75 deficient (75%), 13 insufficient (13%) and 12 sufficient (12%). Mean serum 25 (OH) vitamin D in mothers was 15.09 ng/mL. The distribution of serum 25 (OH) vitamin D levels in newborns were 78 deficient (78%), 13 insufficient (13%) and 9 sufficient (9%). Mean serum 25 (OH) vitamin D in neonates was 13.82 ng/mL. There was strong correlation between maternal and newborns serum 25 (OH) vitamin D levels with a Pearson correlation coefficient value of 0.94 and the p-value of <0.001. Conclusion: There was a high prevalence of vitamin D deficiency in pregnant mothers associated with hypovitaminosis D in newborns in this hospital-based study catering to affluent population from Mumbai.

A Longitudinal Study on Comparison of Haematocrit, Glasgow Score and Computed Tomography Abdomen as Prognostic Markers in Assessment of Severity in Acute Pancreatitis

Introduction: Acute Pancreatitis (AP) can present from a mild self-limiting process that requires only supportive care to severe disease that can cause multiple Organ Failure (OF) and high mortality. It is therefore important to identify such patients at increased risk of OF and mortality at the earliest. Aim: To evaluate and compare the efficacy of three prognostic markers namely Haematocrit, Glasgow scoring and Computed Tomography (CT) abdomen in assessing the severity of AP. Materials and Methods: A prospective longitudinal study was done on 120 patients diagnosed with AP, over a period of 18 months. Haematocrit was done at admission and at 48 hours. A fall in haematocrit of more than 10% was considered sensitive. Modified Glasgow score was assessed at admission and after 48 hours. Other variables include blood glucose level, white blood count, blood urea nitrogen, serum calcium, partial oxygen pressure (PaO2), decrease in haematocrit, serum Lactate Dehydrogenase (LDH), serum aspartate aminotransferase (AST) and serum albumin. A score of ≥3 was considered sensitive. CT of abdomen was done at 72 hours and a Computed Tomography Severity Index (CTSI) score of ≥4 was considered sensitive. The results of each prognostic marker were graphed and compared to assess Length of Hospital Stay (LOHS), need for Intensive Care Unit Admission (ICUA), OF and mortality. Results: The mean LOHS was six days. Haematocrit was sensitive in 23 of 79 patients that stayed in hospital for >6 days. Modified Glasgow scores were sensitive in 35 of 79 patients. CT of abdomen was sensitive in 59 out of 79 patients. Total 29 of 120 patients were admitted in the ICU, out of which difference in haematocrit was sensitive in 14 patients, Modified Glasgow coma score of ≥3 was seen in 14 patients and CTSI scores were sensitive in 22 patients. Twelve out of 120 patients developed OF. All 12 patients showed a sensitive Modified Glasgow scores of ≥3 and CTSI ≥4, whereas only five patients were sensitive for fall in haematocrit. Five patients died during the study. All five patients were sensitive for fall in haematocrit Glasgow coma scores and CT abdomen. Among the prognostic markers, haematocrit showed 100% sensitivity, specificity and Positive Predictive Value (PPV) than the other prognostic markers making haematocrit the better prognostic marker. Conclusion: CT of abdomen is a reliable prognostic marker in terms of assessment of LOHS, need for Intensive Care Unit (ICU) care and mortality. Modified Glasgow score is accurate in assessing OF. Haematocrit is specific in assessing the need for ICU care and mortality.

Ultrasound Guided Paramedian versus Landmark Guided Midline Technique for Spinal Anaesthesia- A Randomised Clinical Trial

Anil Kumar, Preeti Thakur, Rama Wason

Introduction: Spinal anaesthesia has been traditionally performed using landmark guided technique. Ultrasound helps in identifying the insertion point, depth, as well as angle of the needle advancement by visualisation of the neuraxial structures, thus, increasing the probability of successful dural puncture. Aim: To compare the success rates of dural puncture at first attempt between Preprocedural Ultrasound (PUS) guided paramedian and landmark guided midline approach in spinal anaesthesia. Materials and Methods: This was a randomised clinical study, conducted at a Tertiary Care Hospital during May 2017-December 2018. Patients (n=110) undergoing lower limb orthopaedic surgery were randomly allocated into group US (PUS guided with paramedian approach) and group LM (landmark guided with midline approach), with 55 patients each. Number of attempts and passes, procedure time, any complication, periprocedural pain and patient satisfaction were noted. The correlation between quality of ultrasound view and success rate was also analysed using Fisher's-exact test. Results: The success rate of dural puncture at first attempt was 89.09% in US group versus 76.36% in LM group, p>0.05. Total number of needle insertion attempts (1.31±0.63 in group LM, 1.11±0.31 in group US, p>0.05) were comparable. Total procedure time was higher (11.96±1.55 minutes) in US group as compared to LM group (3.26±0.68 minutes), p<0.001. Periprocedural pain score was significantly lower in US group with p<0.01. The patient satisfaction score was comparable in the two groups, p>0.05. Correlation between the quality of parasagittal oblique view and success rate of dural puncture was good, p<0.01. Conclusion: PUS guided paramedian approach does not significantly increase the success rate at first attempt as compared to midline landmark guided approach.

Correlation of Anaemia and Restless Legs Syndrome in Elderly: A Cross-sectional Study

Abhijit Agrawal, Jahnabi Bhagawati, Sunil Kumar

Introduction: Restless Legs Syndrome (RLS) also known as Willis Ekbom Disease (WED) which manifests as a neurologic disorder among patients with anaemia, particularly with iron deficiency anaemia. Aim: To find the association of anaemia with RLS in the elderly population. Materials and Methods: In this cross-sectional study, 100 patients of age ≥60 years were enrolled and categorised into mild, moderate, and severe anaemia as per World Health Organisation (WHO) criteria. Every participant was enquired about RLS via a questionnaire based on the International RLS Study Group Rating Scale (IRLSSGRS) for its Severity and for the diagnosis (Essential clinical criteria for the diagnosis of RLS). Results: The study showed that patients with anaemia had a statistically significant correlation with RLS (p=0.04) and severity of RLS (p=0.032). Serum ferritin levels too showed a statistically significant correlation with RLS (p=0.032). Conclusion: Patients with severe anaemia and lower serum ferritin levels were more prone to RLS and had more RLS severity.

The Impact of Fasting on Metabolic and Anthropometric Parameters in Type II Diabetic Patients: A Prospective Observational Study

Introduction: Fasting has certain effects on metabolic and anthropometric parameters in diabetic patients. It is therefore, necessary for patients to receive proper instructions about their physical activities, eating habits, blood glucose monitoring and medications. Aim: To investigate the effects of fasting on metabolic and anthropometric indices in type II diabetic patients. Materials and Methods: This prospective observational study was performed during Ramadan 2018. The study population consisted of 40 type II diabetic patients (33 females and 7 males) who wished to fast. They started to follow given instructions on their physical activity, eating habits, blood glucose monitoring, and medications before Ramadan. Anthropometric variables were measured pre and post-Ramadan. Fasting Blood/Plasma Glucose (FBG/FPG), Glucose 2 Hour Postprandial (2h PPG), glycosylated haemoglobin (HbA1c), and the lipids profile were assessed before and after Ramadan. FPG and 2h PPG were also evaluated on the fifteenth day of Ramadan. Data were presented as mean±SD. Paired t-test was employed and a p-value of <0.05 was considered statistically significant. Results: After completion of the study, anthropometric variables of patients, including weight (74.9±12.7 vs. 73.0±13.1 kg, p<0.001), BMI (29.9±5.2 vs. 29.0±5.1 kg/m2 , p=0.042), waist circumference (106.2±11.8 vs. 105.3±11.6 cm, p<0.001), conicity index (9.94±0.96 vs 9.80±0.99, p=0.085), systolic blood pressure (118.5±10.6 vs. 113.8±9.4 mmHg, p=0.018), Diastolic blood pressure (72.0±7.9 vs. 68.3±7.0 mmHg, p=0.02) and FPG (125.1±27.4 vs. 105.2±21.4 mg/dL, p<0.001) decreased significantly. However, serum triglyceride increased significantly (127.5±45.5 vs. 166.5±53.5 mg/dL, p<0.001) after fasting compared to pre-Ramadan measurements. Changes in other variables were not statistically significant. Conclusion: The results of this study indicate that fasting had beneficial effect on fasting blood glucose level and anthropometric parameters in type II diabetic patients.

Effectiveness of Ultrasonography and Fluoroscopy as a Therapeutic Imaging Modality in the Management of Lumbar Facet Arthropathy: A Prospective Interventional Study

Rachit Gulati, Ushnish Mukherjee, Sandeep Kumar Gupt, Pankaj Kumar Mandal

Introduction: Lumbar zygopophyseal joint arthropathy is one of the most common causes of low back pain in adults. Historically, C-arm/Fluoroscopy has served as an image guidance tool in intra-articular facet joint injections, however, now ultrasound guidance is also a viable option. Aim: To compare ultrasonography (USG) and fluoroscopy as therapeutic imaging modalities on the basis of time taken for intervention, Visual Analogue Score (VAS) for pain and Oswestry Disability Index (ODI) at 2, 4 and 12 weeks. Materials and Methods: It was a prospective interventional study done with 62 patients who satisfied the inclusion and exclusion criteria and randomly allocated into two groups. Groups were compared on the basis of time taken for intervention, VAS for pain and ODI at 2, 4 and 12 weeks. Independent sample student t-test/Mann-Whitney U test was applied. Confidence Interval (CI) was taken as 95% and p-value <0.05 was considered as statistically significant. Results: Ultrasound group had mean age of 37.75 years (range, 23-55 years) while that of Fluoroscopy group was 40.05 years (range, 20-54 years). Ultrasonography group was quicker by about 135 seconds (2 minutes and 15 seconds) which was statistically significant but there was statistically no difference between the two groups in terms of VAS and ODI at 2 weeks (p=0.107 and 0.893, respectively), 4 weeks (p=0.383 and 0.408, respectively) and 12 weeks (p=0.343 and 0.777, respectively) at 95% CI. Conclusion: Both groups showed significant improvement in pain and disability after 2, 4 and 12 weeks however there were no significant differences in pain and functional improvement between USG guided transverse view and fluoroscopy guided intra-articular lumbar facet joint injection. Therefore, USG guided transverse approach is quicker, feasible and minimises exposure of radiation to patient as well as interventionist.

Lung: Another Victim of the Silent killer Diabetes- A Cross-sectional Study

Tirthankar Mukherjee, SR Sneha, NS Vinayaka

Introduction: Diabetes is a multisystem disorder with well known complications involving various organs in the body. The presence of abundant connective tissue and microvasculature raises the possibility that lung may also be affected in diabetes. Aim: To evaluate the pulmonary function parameters in patients with diabetes mellitus and to determine their correlation with glycaemic control, duration of diabetes and other microvascular complications. Materials and Methods: This is a cross-sectional study done between September 2018 and March 2019. A total of 300 type 2 diabetic patients, aged 30-70 years, with duration of diabetes more than 1 year, were included in the study. Thorough history was taken regarding the duration of diabetes and symptoms of the complications. All of them were evaluated for diabetic microangiopathies: nephropathy (by 24 hour urinary protein excretion), retinopathy (by direct ophthalmoscopy) and neuropathy (by clinical examination). Glycosylated Haemoglobin (HbA1c) was measured as an indicator of glycaemic control. Spirometry and single breath diffusion capacity for carbon monoxide were performed on all the subjects. Pulmonary Function Test (PFT) parameters of each subject were compared with the normal values. Unpaired t-test and one-way analysis of variance (ANOVA) were used. Correlation and regression studies were used to find out the strength of association between Diffusing Capacity of the Lungs for Carbon Monoxide (DLCO) and the following: the duration of disease, HbA1c and presence of other microvascular complications. Results: Pulmonary function parameters like Forced Expiratory Volume in first second (FEV1), Forced Vital Capacity (FVC), Peak Expiratory Forced Rate (PEFR) and DLCO were below the normal values in 53% of diabetic patients included in the study. Majority of them had a restrictive ventilation pattern. The diffusion capacity corrected for Alveolar Volume (VA) as measured by DLCO/VA was significantly reduced in those with longer duration of diabetes and in those with other microvascular complications. However, the poor lung functions had no correlation with the HbA1C values. Conclusion: This study demonstrated that lungs are indeed affected in patients with type 2 diabetes. The presence of extrapulmonary microangiopathy and duration of the disease may predict the incidence and the severity of the lung function abnormality.

Clinical Characteristics of Pigment Dispersion Syndrome and Pigmentary Glaucoma Patients: A Cross-sectional Study

Introduction: Pigmentary Glaucoma (PG) and Pigment Dispersion Syndrome (PDS) are two different spectrums of a single disease. Since the disease is seen in younger population and is rapidly progressive blinding disease, therefore early diagnosis and treatment will reduce the burden of the disease and improve the quality of life. Aim: To evaluate clinical characteristics of PDS and PG patients in eastern part of Uttar Pradesh. Materials and Methods: This was a two years (1st January 2018 to 31st December 2019) hospital-based retrospective cross-sectional study of patients who attended the glaucoma clinic. Diagnosis of PDS was made when they had normal optic disc, normal visual field {with or without increased Intra Ocular Pressure (IOP)} and at least two of the following three signs were found clinically: Krukenberg spindle, homogenous moderate-to-heavy (≥Spaeth 2+) Trabecular Meshwork (TM) pigmentation, and any degree of zonular and/or lenticular pigment granule dusting. Patients with PDS were diagnosed with PG, if they had two or more of the following findings: initial IOP >21 mmHg, glaucomatous optic nerve damage or glaucomatous visual field loss. Various parameters such as influence of demographics, IOP, Best-Corrected Visual Acuity (BCVA), Central Corneal Thickness (CCT), Mean Deviation (MD), Visual Field Index (VFI %), spherical equivalent and clinical finding of anterior segment of study patients were analysed. Mean, standard deviation and percentage were calculated using GraphPad Instat version 3.0. Results: Among 40 patients, nine eyes of the six patients had myopia of -0.5D or greater, with mean refractive error of -3.55±4.72 spherical equivalent. The average baseline IOP in study patients (PDS+PG), was 30.21±11.42 mmHg. Twenty four (60%) patients, either in one or both eyes had glaucoma, secondary to PDS at the initial diagnosis. Thirty three (82.5%) patients had Krukenberg spindles. Homogeneous TM pigmentation was seen in all patients. Typical spoke-like radial Iris Transillumination Defects (ITDs) were not observed in any of the patients except in one patient, who had isolated short slitlike trans-illumination defects in iris crypts. Conclusion: PDS patients with normal optic disc and visual field and raised IOP, should be started prophylactic treatment and needs to be monitored more closely. Thus, the finding of PDS in Indians should alert the ophthalmologist to look for glaucoma during the initial examination.

Caregiver Burden for Patients Diagnosed with Parkinson’s Disease: A Cross-sectional Study from Southern India

Arun Kurupath, Praveen Arathil, Rahul Bansal

Introduction: Parkinson's Disease (PD) is a progressive neurodegenerative disorder where the individual over time needs more and more assistance from their caregivers to carry on their life and that causes increasing burden on the caregiver. The burden for the caregiver is affecting them physically, mentally and also on a socioeconomic level. Aim: To examine the factors related to caregiver burden in caregivers of Parkinson's patients. Materials and Methods: This was a cross-sectional study conducted in Parkinson's clinic of a Tertiary Care Hospital of Kochi, on 100 Parkinsonism patients and their respective caregivers. Patients were assessed using the Unified PD Rating Scale (UPDRS), Hoehn and Yahr Scale (H&Y) and Mini-Mental State Examination (MMSE). Caregivers were assessed using Zerit’s Caregiver Burden inventory (CBI). Semi structured questionnaire was administered for socio-demographic details. Non parametric tests were done to examine the correlation among various variables. Results: Among the patients and caregivers, mean age was 70.65±7.30 and 67.31±8.56, respectively. Among the patient’s majority were males (n=74) while among caregivers, majority were females (n=73). Mean duration of disease was 6.79±2.68 years, mean caregiver burden score was 65.05±21.79, mean UPDRS score was 21.89±8.74 and had significant positive correlation with caregiver burden. Mean MMSE score was 17.19±4.91. The disease duration and UPDRS score had a significant positive correlation with caregiver burden score. MMSE score had significant negative correlation with caregiver burden score. Conclusion: This study concludes that a patient's Parkinsonism related disability accounts for majority of caregiver burden. An early identification of factors contributing to stress in caregivers will help to avoid its persistency leading to a better insight in the caregiving role and thus in-patient care.

Risk Factors of Drug Resistance among Tuberculosis Patients of Prakasam District, Andhra Pradesh, India

P Sudha Kumari , M Siva Durga Prasad Nayak , Usha Devi , Susmita , S Sushma

Introduction: India is leading in the burden of Tuberculosis (TB) according to the new report of the World Health Organisation (WHO) on the disease. Multi-Drug Resistant TB (MDR-TB) cases have been increasing in India. About half of the world’s MDR-TB cases are present in India. Aim: To assess the incidence of drug resistant TB in Prakasam district, Andhra Pradesh, India, in the second quarter of the year 2019 and to determine the risk factors that are responsible to develop drug resistance to anti-tubercular drugs in the study population. Materials and Methods: A Community based cross-sectional study was conducted from April 1^stto June 30^th in Prakasam district, Andhra Pradesh. All the registered drug resistant TB cases in Prakasam district who gave consent during the study period were taken as sample. The diagnosed drug resistant TB patients were interviewed and proportions of different variables were calculated and chi-square test was used to test significance of results. Results: Out of 209 TB patients, 88 patients were having drug resistant TB in Prakasam district. Prevalence of Drug resistant TB in Prakasam district was calculated as 5.64 per one lac population. In the second quarter of the year 2019-2020, i.e., from April 1st to June 30th, 88 new cases were identified. Incidence of Drug resistant TB in Prakasam district was calculated as 2.38 per one lac population. Male persons (76%), having the age 20-40 years (42%), 40-60 (38.7%) belonging to middle class (45.5%) and migrating for work (85%) are at more risk of developing drug resistant TB. Most of the patients are developing drug resistant TB directly (70.5%) which is an alarming signal. The rifampicin resistant patients were also developing psychological complications (22). Drug toxicity was observed in 55% of the cases. Conclusion: Incidence of drug resistant TB was more in male persons, above 20 years of age, belonging to middle class socio-economic status and migrating for work. Most of the patients developed drug resistant TB directly without previous history of TB. Drug toxicity was observed in half of the cases. Psychological complications were observed in rifampicin resistant patients. Surveillance activity should be addressed properly to combat the risk factors.

Efficacy of Tramadol and Fentanyl when used Intrathecally for Prevention of Shivering in Endoscopic Urosurgical Cases- A Randomised Control Trial

Introduction: Shivering is an undesired complication seen perioperatively with incidence of 40 to 70% under spinal anaesthesia. This further increases in patients undergoing endoscopic urosurgical procedures where huge amount of cold irrigating solution is used. Aim: To compare the anti-shivering effect of intrathecal tramadol with intrathecal fentanyl given as an additive in spinal anaesthesia in endoscopic urosurgical cases. Materials and Methods: It was a randomised control study. Total 105 patients of American Society of Anaesthesiologists (ASA) grade I and II posted for various endoscopic urosurgeries were included in the study and divided into three groups by computerised randomisation. Group T received injection bupivacaine 0.5% heavy 15 to 20 mg (3 to 4 mL) plus 20 mg (0.4 mL) tramadol in spinal anaesthesia, Group F received injection bupivacaine 0.5% heavy 15 to 20 mg (3 to 4 mL) plus 25 microgram (0.5 mL) fentanyl in spinal anaesthesia and Group C received injection bupivacaine 0.5% heavy 15 to 20 mg (3 to 4 mL) plus 0.5 mL normal saline. Incidence and grade of shivering was recorded in each group. The data was analysed using statistical package SPSS version 21.0. Mean and SD were calculated for the quantitative variables. Analysis of variance test was used to compare the means of three groups with respect to each of the parameters. Results: Significant difference was observed among three groups in respect of incidence of shivering intraoperatively and postoperatively both. Least incidence of shivering was observed in tramadol intraoperatively with a p-value <0.05. Also, tramadol group had least shivering postoperatively with a p-value <0.05. Also, the grade of shivering in control group was significantly higher (p-value <0.05) than that of both group F and group T. There was no statistically significant difference among the three groups in respect of sedative score, itching, nausea, vomiting and respiratory depression (p-value >0.05). Conclusion: Intrathecal tramadol is more effective than intrathecal fentanyl in prevention of shivering in patients undergoing endoscopic urological surgeries and also has low side effect profile.

Oxidative Stress in Preterm Neonates: An Analysis of Oxidative Stress Biomarkers and Antioxidant Profiles

Shobha S Pajai, Apurva P Bezalwar

Introduction: Oxidative stress is a complex event determined genetically and induced by an in- utero stressor. Oxidants are composed of reactive free radicals like Reactive Oxygen Species (ROS) and Reactive Nitrogen Species (RNS) which are manifested by several macromolecules of lipid, protein and DNA, causing deleterious effects in several organs. Antioxidant defense mechanism and its ability to be induced by hyperoxia is relatively impaired in preterm neonates. Aim: To study oxidative stress and antioxidants in preterm neonates. Materials and Methods: This study is an observational analytical study, which included preterm babies (25 males and 20 females) delivered vaginally from October 2012 to October 2013. Cord blood was collected in citrate bulbs immediately after vaginal delivery and stored at 4°C until processed. Malondialdehyde (MDA), Nitrates, Vitamin C and Vitamin E, levels were measured in cord blood. Statistical z-test was applied. Results: High levels of oxidative stress biomarkers like MDA and Nitrites along with decreased levels of antioxidants, Vitamin C and Vitamin E in preterm neonates was observed. MDA and Nitrates levels were significantly higher in males (p<0.05) than females. Vitamin C and Vitamin E levels were not significant (p>0.05) in both. Conclusion: This study results may conclude that preterm neonates have more oxidative stress especially in males affecting their life survival.

Percutaneous Nephrolithotomy in Horseshoe Kidneys: A Cross-sectional Study

Shanawaz Alam, Darshil Shah, Neelakandan, Velmurugan, Chandru, K Natarajan

Introduction: Horseshoe Kidneys (HSK) are the most common congenital fusion of the kidneys. After the reports of Wickham and Kellet in 1981 and Clayman in 1983, percutaneous extraction of stones in HSKs has been widely adopted. In this era of advancement of Retrograde Intra Renal Surgery (RIRS), Percutaneous Nephrolithotomy (PCNL) still holds strong position for HSK stone management, due to HSK vascular and pelvicalyceal anatomy. Aim: To evaluate PCNL in managing large HSK stone disease in the form of stone free rate and to assess procedure related complication between October 2016 to March 2020. Materials and Methods: A retrosepective cross-sectional study was conducted between October 2016 to March 2020, in total of 18 patients (21 renal units) underwent PCNL for stone disease in HSK. Stone size >1.5 cm, failed Extra-Corporeal Shockwave Lithotripsy (ESWL) and recurrent stones were included in the study. Results: Mean age of the patients was 40.67±7.87 years, 12 were male and 6 were female. Three patients had stones in both renal units. The mean stone size was 22.19±7.43 (12.00-46.00) mm. Twelve units had stone in the pelvis (57.1%), 6 unit in upper calyx (28.6%). One unit (4.8%) had stone in isthmus and 3 units (14.3%) had staghorn calculi. Access site was upper calyx in majority 76.2% of the cases, 23.8% required additional puncture most commonly through middle calyx. Total 8 patients had postoperative complications, fever being the most common (19%). Complete clearance was obtained in 85.7%, while 14.3% had residual calculi for which ancillary procedures were performed. Conclusion: PCNL can be recommended as the first line of management in the treatment of HSKs with large stone burden, considering its higher clearance rate and minimal complications.

Prevalence and Factors Associated with Wound Colonisation by Staphylococcus Species at Tertiary Care Hospital: A Cross-sectional Study

J Lakhani Sucheta, Hatkar Sunil, J Lakhani Som

Introduction: The Staphylococcus species do not directly cause infection but invade an already existing wound and causing extensive tissue necrosis and enlarging an already existing wound. The human host factor plays a major role in the pathogenesis by making a suitable environment for pathogens, like diabetic mellitus, hypertension, and so on. The emergence of methicillin resistant strains worsens the clinical output and very few therapeutic alternatives are left to treat such infections. Aim: The present study was attempted to see the relation of Staphylococcus species with host factors among wound infections. Materials and Methods: The specimens taken from various types of wound infection were screened for Staphylococcus species as per standard microbiological guidelines. The clinical history of the patients were taken from the ‘patient’s case record form’ and Medical Record Department (MRD) section. The data was statistically analysed, p-value ≤0.05 was considered significant. Results: A total of 421 Staphylococcus species were isolated from various clinical samples, out of which 159 (37.7%) were isolated from wound infections. Of which 142 (89.3%) were S.aureus and 17 (10.7%) were S.epidermidis. Diabetic mellitus 29 (18.2%) and hypertension 11 (7%) were found to be a major host factor facilitating the infection. Methicillin Resistant Staphylococcus aureus (MRSA) was 100 (62.9%) while Methicillin Resistant Staphylococcus epidermidis (MRSE) was not found in the single strain. Inducible clindamycin resistant strains among wound infection were found to be 58 (36.5%). Conclusion: Staphylococcal wound infections should be carefully treated to prevent microbial spread especially in immune-compromised patients, better patient recovery, and reducing healthcare costs.

Evaluation of Cardiac Biomarkers in Dengue Myocarditis in a Tertiary Care Hospital in Eastern India

Introduction: Dengue, a vector borne viral infection transmitted by Aedes mosquito has recently become a major public health concern in the tropical regions of the world. In addition to the two major life threatening complications- Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS), a variety of cardiac complications have been recognised, the most common being myocarditis. Aim: To study and compare the quantity of different cardiac biomarkers in patients of Dengue Fever with and without myocarditis. Materials and Methods: This was a hospital-based retrospective observational study done in a Tertiary Care Hospital, Kolkata, West Bengal, India from June 2019 to November 2019. Dengue patients with diagnosed myocarditis on day 7 of fever based on electro and echocardiogram changes of left ventricular ejection fraction less than 50% were considered as cases (n=41). Age and sex matched dengue patients with normal electro and echocardiogram changes were considered as control (n=43). After obtaining Institutional Ethics Committee Clearance, laboratory data were collected from samples coded and assayed for markers of acute cardiac myocyte damage such as total Creatine Kinase (CK), CK-Muscle Brain (CK-MB), Troponin T (Trop T) and cardiac failure biomarker N-Terminal pro Brain Natriuretic Peptide (NT-proBNP). Statistical analysis of the data was performed using Statistical Package for Social Sciences (SPSS 20). Results: Cardiac biomarkers CK, CK-MB, Trop T and NT-proBNP levels in cases were higher compared to controls (p-value <0.05). Trop T and NT-proBNP were positively correlated to each other (r-value: 0.44). Trop T changes could also predict significantly the rise in NT-proBNP in circulation (p<0.05). Conclusion: It reconfirmed the need of routine monitoring of cardiac biomarkers in conjunction with other cardiac function tests in early diagnosis and or management of myocarditis, a severe complication of Dengue Viral Infection (DENV).

Pulse Oximetry Understanding and Application: A Survey on Nursing Staff

Introduction: Pulse Oximetry (PO) is widely used for the noninvasive detection of hypoxemia, particularly in the perioperative setting. Research regarding the perioperative assessment of nursing knowledge of PO continues to evolve. Prior evaluations have identified relative knowledge deficits among nurses regarding physiologic principles, data interpretation, and clinical application. Such deficits need identification and targeted education to prevent perioperative patient mismanagement. Aim: To assess nursing knowledge of PO in perioperative and critical care settings of a single center in the United States and to analyse identified knowledge deficits. Materials and Methods: A cross-sectional questionnaire study was conducted in Post Anaesthesia Care Unit (PACU) and Medical Respiratory ICU (MRICU) among 150 participants. The validated questionnaire on surveying PO principle consisted of 21 true/false and 3 open-ended questions. Univariate analysis of nursing Total Knowledge Score (TKS), years of clinical experience, and current practice settings was performed. Significance was set at p<0.05. Results: A total of 51 questionnaires were completed, with a 34% response rate. The mean TKS for the true/false questionnaire was 16.4±2.0. There was no significant difference in TKS between PACU and MRICU nurses (16.5±1.7 vs. 16.2±2.5, respectively, p=0.27). Ninety-eight percent of all nurses scored >50% correct while 13.7% scored >90% (p=0.19 and p=0.74, respectively). The lowest percentages of correct responses (<50%) were seen in questions 3 and 16, which pertained to physiologic principles of PO. There was no significant difference in scoring percentiles between MRICU and PACU nurses, nor was there significant difference in TKS based on clinical experience. Conclusion: The mean TKS of nurses in the study was higher than the mean TKS of nurses in reference studies. There was no significant difference in TKS between PACU and MRICU nurses. Furthermore, clinical experience did not correlate with TKS scores. The authors believe analysing these knowledge deficits may offer educational opportunities in initial and continuing nursing education as well as routine postgraduate assessments.

SARS-Coronavirus Disease-19 and Comorbidities: A Systematic Review

Mythri Shankar, KR Nishanth

Introduction: Coronavirus-19 (COVID-19) pandemic is evolving rapidly worldwide. It has led to a worldwide research to identify the people who are at more risk for developing the infection, increasing severity and mortality. Aim: The aim of this systematic review was to evaluate the risk of some of the common and major comorbidities on the outcome of the disease. Materials and Methods: A literature search was conducted using EMBASE, PUBMED, Web of science, SCOPUS and Cochrane database. Medical Subject Headings (MeSH) used were "COVID-19" or "SARS CoV 2" or "Coronavirus disease 19" and "Comorbidities" or "Risk factors". Individual risk factors were also used as keywords such as "Diabetes", Hypertension", "Obesity", "Chronic kidney disease", "Elderly", "Cardiovascular disease", "Lung disorders" and "Malignancy". Two researchers conducted the search independently. Results: After extensive search, 57 articles were shortlisted for complete review. It was found that patients with comorbidities had more severe disease than those without comorbidities. Patients with more number of comorbidities had more severe disease than patients with single comorbidity. Initial reports suggested that elderly were at more risk than the younger population. The most common comorbidity was hypertension followed by diabetes and obesity. Conclusion: A meticulous triage of patients should be carried out after acquiring proper medical history because this will help to identify patients who are at an increased risk of poor outcome of the infection. Also, they should be given more aggressive treatment upon diagnosis of infection.

Knowledge, Attitude and Practice of Research among Undergraduate Medical Students in India

Maulin Dhiren Mehta, Jayant Patharkar, Ervilla Dass

Introduction: "The detailed process of gathering information or detailed study to discover and understand new information that would initiate, modify or terminate present understanding" is the definition of research. Research is very important in every field to generate new information in particular subject. Aim: To evaluate Knowledge, Attitude and Practice (KAP) of research in undergraduate medical students in a medical college, India. Materials and Methods: It was a questionnaire based crosssectional study. Total 150 students from first, second and third year MBBS from the medical college participated voluntarily. Percentages of students were taken for statistical analysis. Results: Out of 150 students, total 143 (95.43%) students had basic understanding about research. Total 139 (92.7%) students knew about both the research study designs that is observational and experimental. Only 59 (41.3%) students knew that randomised controlled trial is not an observational study. Only 62 (42.8%) students knew that meta-analysis type of studies can generate highest level of evidence. Total 88 (58.66%) students were willing to conduct the research. Lack of time (88 students, 60.7%) and lack of guidance (86 students, 59.3%) were two major hurdles for conducting research study. Total 8 (5.3%) students were currently conducting research out of 150. Conclusion: As per the study, in-depth knowledge required to conduct research is not upto the mark among undergraduate medical students. They are willing to conduct research but their major limitations are time and guidance during undergraduate tenure. By including research methodology as subject in undergraduate medical curriculum, medical students can be inspired to conduct research efficiently. Those who are practicing research are getting favourable outcome from it.

Aerobic Bacteriological Profile and Antimicrobial Susceptibility Pattern of the Isolates from Pyogenic Infections done in a Tertiary Care Hospital: A Retrospective Analysis

J Gunasekaran, K Deepika, A Dhanasekaran

Introduction: Pyogenic infections are characterised by acute and chronic inflammation with exudate formation. It is a serious threat leading to sepsis with gram positive organism being the major cause. The source of infection could be either endogenous or exogenous. There is a recent change in the spectrum with gram negatives being the most common cause than the gram positives. Aim: To analyse the aerobic organisms involved in causing the various pyogenic infections with their current susceptibility pattern. Materials and Methods: A retrospective analysis of 750 culture positive pus and wound swabs received in the Department of Microbiology from various departments of the hospital between June 2018-June 2019 was done and data was recorded. Results: Out of 942 total samples analysed, 750 were culture positive with gram negative being 508 and gram positive being 242. The predominant organism of pyogenic infection was Pseudomonas aeruginosa. Among gram positive, the most common organism was Methicillin-Resistant Staphylococcus aureus (MRSA). Pyogenic infections were predominant in males and monomicrobial was common over polymicrobial infections. Extended Spectrum Beta Lactamases (ESBL) was seen highest in Escherichia coli at the rate of 47.8% and Multi-Drug Resistance (MDR) was high among Klebsiella species and non-fermenting Gram Negative Bacilli (GNB) other than Pseudomonas spp and Acinetobacter spp. Conclusion: There is a changing trend with gram negative organisms being the commonest cause of pyogenic infections as evidenced across India. Spurious use of drugs would help in reducing the spread of drug resistant isolates. Antibiotic policy formulation would help in empiric therapy with reduction in infection rates.

Application of Sigma Metrics for Evaluating the Analytical Performance of Thyroid Profile and Cortisol in Clinical Biochemistry Laboratory

Smita Natvarbhai Vasava, Roshni Gokaldas Sadaria

Introduction: Now-a-days quality is the key aspect of clinical laboratory services. The six sigma metrics is an important quality measurement method for evaluating the performance of the clinical laboratory. Aim: To assess the analytical performance of clinical biochemistry laboratory by utilising thyroid profile and cortisol parameters from Internal Quality Control (IQC) data and to calculate sigma values. Materials and Methods: Study was conducted at Clinical Biochemistry Laboratory, Dhiraj General Hospital, Piparia, Gujarat, India. Retrospectively, IQC data of thyroid profile and cortisol were utilised for six subsequent months (July to December 2019). Coefficient of Variation (CV%) and bias were calculated from IQC data, from that the sigma values were calculated. The sigma values <3, >3 and >6 were indicated by poor performance procedure, good performance and world class performance, respectively. Results: The sigma values were estimated by calculating mean of six months. The mean sigma value of Thyroid Stimulating Hormone (TSH) and Cortisol were >3 for six months which indicated the good performance. However, sigma value of Triiodothyronine (T3), Tetraiodothyronine (T4) were found to be <3 which indicated poor performance. Conclusion: Six sigma methodology applications for thyroid profile and cortisol was evaluated, it was generally found as good. While T3 and T4 parameters showed low sigma values which requires detailed root cause analysis of analytical process. With the help of six sigma methodology, in clinical biochemistry laboratories, an appropriate Quality Control (QC) programming should be done for each parameter. To maintain six sigma levels is challenging to quality management personnel of laboratory, but it will be helpful to improve quality level in the clinical laboratories.

Possible Drug-Drug Interactions of Hydroxychloroquine with Concomitant Medications in Prophylaxis and Treatment of COVID-19: Multiple Standard Software Based Assessment

P Ansuman Abhisek, Shweta Supriya Pradhan

Introduction: It is a crucial time for the medical community to cope up with novel Coronavirus Disease 2019 (COVID-19). The empirical evidence for the effectiveness of Hydroxychloroquine (HCQ) in COVID-19 is currently very limited. So in this context, it is very important to counter Drug-Drug Interactions (DDIs). Aim: To assess, compare and compile DDIs of HCQ with other medications and their risk management. Software databases like Lexicomp, drugs.com DDI checker and Medscape DDI checker were utilised to obtain various spectrum of DDIs. Materials and Methods: The study was undertaken in Department of Pharmacology from 31st March 2020 to 30th April 2020, in a Tertiary Care Teaching Hospital in Eastern India. This was an observational, software-based study. Lexicomp® drug Interactions software was the baseline software, used to access the details of DDIs of HCQ like severity, adverse effects, types of DDIs, risk management of DDIs and their reliability. Drugs. com and Medscape interaction checkers were used to compare details of DDIs obtained from Lexicomp. Spearman’s rank order correlation and reliability (cohen’s kappa) of the data obtained from the three software programs were analysed. Results: Total number of DDIs of HCQ with individual drugs were found to be 279. Among these DDIs of individual drugs, maximum had risk rating of C (66.66%). The adverse effect that was maximum reported in Lexicomp was changes in glycaemic control whereas Medscape and drugs.com software programs showed QT prolongation. Considering Lexicomp as standard, the correlation with Medscape and Drugs.com interaction checker software programs were -0.257 (weakly negative) and -0.359 (moderately negative), respectively. When Medscape and drugs.com were compared, both showed strong positive correlation (r=0.716). Cohen’s kappa between Lexicomp and Medscape, Lexicomp and drugs.com, Medscape and drugs. com were 0.011 (slightly reliable), 0.004 (poorly reliable), 0.568 (moderately reliable), respectively. Conclusion: There is a need to improve knowledge and awareness amongst the treating physicians and the healthcare professionals of HCQ related DDIs in the higher risk cases especially related to COVID-19 or for prophylaxis and/or other. It was observed that Lexicomp software is better in assessing DDIs of HCQ as compared to other two software programs.

Knowledge, Attitude and Practices on COVID-19 among Patients Attending a Private Dental College in Jeddah

Introduction: The close proximity to the patient's oropharyngeal region and also involved aerosol production presents a potential high risk for the transmission of disease across patients and dental health practitioners. This requires dentists and patients to be aware of the risks of contracting coronavirus from the patient's perspective when they seek dental treatment. Aim: To assess the knowledge, attitude and practices of the patients toward the dental visits during the pandemic crisis. Materials and Methods: The present study was a cross-sectional questionnaire-based study conducted in IBN Sina National College, Jeddah, Saudi Arabia from 6th July, 2020 to 24^th July 2020. All the patients who had visited the dental clinics attached to the dental college were sent online google docs form with a consent through WhatsApp. Questions were divided into 2 sections, one section related to demographic data of participants like age, gender, education level, frequency of dental visits and the other section related to patients’ perspective with regards to the coronavirus infection in the dental set up. The results were analysed using SPSS version 23. Results: The questionnaire was sent to all the patients online and all of them had responded to the survey. Majority of the patients {1757 (80.9%)} have knowledge about the COVID-19 disease signs, symptoms, transmission and complications. Among these respondents 6.6% (144) had routinely visited a dentist, 8.8% (192) had sometimes visited a dentist and only 0.3% (7) visited a dentist only once and they generally try to avoid visiting a dentist. Conclusion: At a clinical level, education is limited only to the patients who approach the dentists. At a community level, government, dental colleges and dentists have to take several measures in educating the public in equipping them with health promotional materials. Community-based online programs should be planned and implemented by different levels of administration.

Protocol for a Systematic Review of Mobile Phone Technology for Managing Side Effects of Chemotherapy in Cancer Patients: A Research Protocol

Uppu Praveen, M Manickavasagam, SJ Nalini

Introduction: Mobile phone technology is an evolving trend in the medical field for rendering health-related care services to the needy. Chemotherapy is one of the cancer treatments which leads to certain side effects. These side effects can be managed well with the help of mobile phones, which became an essential thing in our life in recent decades. Aim: To identify the efficacy of using mobile phone technology for managing side effects associated with chemotherapy and improvement in quality of life. Materials and Methods: A systematic review will be conducted on randomised control trials and non-randomised control trials. In this review, Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) will be followed and a literature search will be conducted in PubMed-Medline, CINHAL Cochrane Library, Scopus, Science Direct, Ovid, J-Gate, and Trip databases. The literature search for this systematic review will be done on studies published between 2007 and 2019. The quality of the study will be assessed by the JBI clinical appraisal checklist for Randomised Controlled Trials (RCTs) and Non-Randomised Controlled Trials (Non-RCTs). Studies will be included based on predetermined inclusive criteria like studies published in the English language, with keywords like cancer patients, smartphone/android applications, chemotherapy, quality of life. Results: A descriptive synthesis of the findings of the selected studies will be carried out which will be presented in a narrative summary with statistical findings incorporated. Conclusion: This review will provide up-to-date evidence to support or oppose the hypothesis that mobile phone technology plays an effective role in managing side effects associated with chemotherapy and improve the quality of life of cancer patients.

Dental Caries Prevalence among Diabetics Acrylic Partial Denture Wearer’s- A Review

Introduction: Dental caries is one of the most common oral health conditions affecting 60-90% of the population. The progression of dental caries results in tooth loss if not treated properly. Tooth loss will presumably cause functional impairment which might ultimately affect the quality of life. Removable partial denture is one of the most widely accepted means of tooth replacement. It had been noticed that removable partial dentures increased the likelihood of new or recurrent caries on remaining adjacent natural teeth. Diabetes mellitus is the most routinely encountered disease among various systemic diseases. Studies revealed that dental caries has been more prevalent and even severe in diabetic patients than nondiabetics. Aim: To assess the effect of Acrylic Removable Partial Dentures (RPD) and diabetes in prevalence of dental caries. Materials and Methods: This study was carried out in JSSDCH, JSSAHER, Mysuru, Karnataka in the year July 2017. The duration of conducting literature search was from July 2017 to Dec 2019. Individuals participating in the study should be partially edentulous and aged between 18-64 years either diabetic or nondiabetic. 69 articles were identified from searching electronic data base (Pubmed, Cochrane, Google scholar) and manual searching from July 2017 to December 2019. 19 articles were excluded following an initial screening. 50 articles were included for the further review. Scientific evidence supporting the hypothesis of the study 10 articles where five articles were review and five articles were original research. The main outcome of intervention involved both methodology and assessment tools applied by investigator to assess the effect of RPD and diabetes in terms of prevalence of dental caries. Results: Studies had shown that RPD wearers shows high caries prevalence as compared to nonwearers, Diabetic patients reported high caries prevalence compared to nondiabetic patients. This literature review states that RPD and Diabetes had an impact on prevalence of dental caries. Conclusion: The conclusion from this present review would indicates that good metabolic control in diabetic patients, periodic monitoring of the removable partial denture, oral hygiene, good RPD design framework, following post-insertion instruction of the RPD, following regular recall visits contributes towards prevention of plaque favouring inhibition of caries prevalence among diabetic and nondiabetic patients wearing RPD.

Human Exposure to Lead, Mechanism of Toxicity and Treatment Strategy- A Review

KS Sridevi Sangeetha, S Umamaheswari

Lead is one of the earliest metals discovered by humans. It has a number of unique properties such as softness, high malleability, ductility, low melting point, resistance to corrosion and low cost. This has made its widespread usage in different industrial sectors, which in turn has led to its manifold occurrence in free form in biological systems and the inert environment. Over the last few decades, with the adverse effects of lead coming to the forefront, nations across the world have started to recognise lead toxicity. This review covers the history behind the usage of lead, sources of lead exposure, absorption, distribution and excretion of lead, toxic signs and symptoms of lead toxicity and methods to evaluate the lead levels and the current treatment regimen. This also covers the details of current research work going on in the area of herbal remedies against lead induced liver damage.

COVID-19 Pandemic: Mental Health and Coping Strategies

Sajjan Pal, Sheetal Kalra, Shilpa Jain

The world has been facing a global threat from the past few months from Coronavirus Disease 2019 (COVID-19). There has been a significant increase in morbidity and mortality due to this ongoing pandemic which is creating a global challenge. This pandemic is having a profound effect on all aspects of society especially the physical and mental health of the people. There has been a rising concern about the mental health of normal population, COVID-19 patients, Healthcare Workers (HCW) or doctors, children and the elderly population. Recent research has reported symptoms of anxiety, depression and other symptoms of psychological distress among these populations. The main purpose of this review was to focus on various mental health issues and the coping strategies during the COVID-19 pandemic period.

Teledentistry Applications: Potential Dental Care Facilitator amidst a Pandemic

Shubham Datta, Deborah Sybil, Vanshika Jain

This article illustrates the various accessible Teledentistry Applications (Apps), available on Google play store and Apple app store for android and iOS software, respectively, which can facilitate dental care amidst global health crisis such as pandemics, specifically the current COVID-19 pandemic. Online searches, according to set criteria, were conducted on Google search engine using the WorldWideWeb and Google play store. Search yielded 499 applications of which, 478 were excluded to include a total of 21 applications. Each included app was reviewed for downloads, user ratings, customer support and key features. Teledentistry in the form of mobile or web based application is a viable option for continuing dental services during periods of lockdown. Effective use of the existing apps requires increased patient awareness and dentist acceptance. Newer and efficient apps are required to facilitate comprehensive care in a hospital based dental practice

Physiological Role of Leptin: A Bird’s Eye View

Dipika P Baria, Tejas J Shah, Shruti V Brahmbhatt

Since its discovery over fifteen years ago, Leptin remains the cornerstone for researchers because of its important role in central control of energy metabolism. Apart from role in energy metabolism, researchers have identified some newer but important roles of leptin in various areas like neuroendocrine function and regulation of metabolism-immune system interplay. Recently, recombinant human leptin emerged as a therapeutic intervention in various disorders. In this review, we highlighted important biology and physiology of leptin, its association with several disorders, and therapeutic interventions involving leptin.

Impact of COVID-19 Pandemic on Management of Head and Neck Malignancy

Amit Kumar Gupta, Annanya Soni, Abhishek Dubey

With an increasing number of COVID-19 cases and a lack of definitive treatment, there is an increasing burden on already stressed health care sector in India. The patients that require medical and surgical intervention need to be triaged and provided with adequate treatment. India has a major chunk of head and neck malignancy in the world attributable to tobacco use. These patients when diagnosed early have a fair survival rate. Health personnels bear the responsibility to provide early and adequate treatment to these patients and at the same time, need to follow all measures to contain the spread of the virus. The present review highlights the various issues and newer guidelines in the management of head and neck malignancy patients during the COVID pandemic. The current review aims to present a comprehensive outlook of the updated evidence base available from PUBMED and other search engines. In India, treatment of head and neck malignancy patients are severely affected at this time of COVID-19, due to the long waiting period, delayed diagnosis, limited dedicated centres for head and neck cancer. The pandemic had diverted resources and manpower leading to potentially poor outcome of the head and neck malignancy patients. Triage policy, safety precautions for health care staff is the need of the hour and should be imbibed in regular practice.

Impact of COVID-19 Pandemic on Urology Practice: Review of Literature

Mohammad Shazib Faridi, Jasim Khan, Hemant Goel, Rajeev Sood

Coronavirus Disease (COVID-19) pandemic is a challenge to the healthcare system including urology which is big and formidable. The present scenario has changed the health preferences to emergency and essential services only. Reallocation of healthcare providers, wards and equipments resulted in suspension of all outpatient and elective activities to select only non-deferrable and critical procedures. Consequently, all health care workers including urologists must abide by the recommendations when dealing with the COVID-19 patients. This pandemic has also disrupted the training and education programs of urology residents also. Subsequently, in this review article, authors have discussed the influence of COVID-19 on urological practice. Authors have also reviewed the recommendations on triaging of urology procedures (emergent and non-emergent), office based urological procedures, oncologic surgeries, paediatric urology, urology-pathology interaction and economic burden on healthcare system during COVID-19 pandemic.

COVID-19: An Epidemiological Puzzle

Subrata Baidya, Debosmita Paul, Purvita Chowdhury

A cluster of pneumonia cases of unknown aetiology was reported from Wuhan, Hubei province of China on 31st December, 2019. The World Health Organisation (WHO) declared the outbreak a Public Health Emergency of International Concern (PHEIC) on 30th January, 2020. Thereafter, it has spread through China and reached the level of a pandemic expanding to 210 countries with 77.9M confirmed cases and 1.71M deaths as per Corona virus Disease (COVID-19) situation report issued by WHO based on data received upto 23rd December, 2020. A number of questions remain unanswered regarding pathogen-associated variables for amplification dynamics, host environment and agent interaction. This short communication makes an effort to compile the information gathered from published articles of renowned journals and newsletters to explore the epidemiological characteristics of COVID-19. Hereby in this article, authors have tried to assemble the epidemiological lacunae created by the novel characteristics of the SARS-CoV-2 (Severe Acute Respiratory Syndrome-Corona Virus-2) which presently pose a rather puzzling transmission dynamics of COVID-19 that still remain unanswered.

Multiple Keratocyst Glimpses Falx Cerebri and Bifid Rib- A Case of Gorlin-Goltz Syndrome

Vrushali Baburao Zamare, Rahul Bhowate, Vidya Lohe, Mrunal Meshram

Multiple Odontogenic keratocysts with multi-organ abnormalities are a feature of Gorlin-Goltz Syndrome (GGS) which is an autosomal dominant inherited disorder. The most common oral manifestation of GGS is odontogenic keratocyst. Early diagnosis of GGS without cutaneous manifestations is important as this syndrome has basal cell carcinoma as one of its major criteria. This paper includes a case report of a 24-year-old female who reported with swelling and pus discharge in lower right posterior region. The swelling was clinico-radiologically diagnosed as odontogenic keratocyst on a panoramic radiograph which revealed the presence of multiple cystic lesions in symphysis, parasymphysis, and bilateral maxillary region. Postero-Anterior (PA) chest showed bifid ribs and PA skull showed calcification of falxcerebri. Histopathological diagnosis confirmed the Odontogenic keratocyst. Ultrasonography (USG) abdomen revealed a simple ovarian cyst on the right side. Clinical examination findings and radiological imaging evaluation with histopathological examination of cystic lesion confirms Gorlin-Goltz. Surgical enucleation of the keratocyst, peripheral ostectomy followed by bone graft substitute, and primary closure under General Anaesthesia (GA) were done in the Department of Oral and Maxillofacial Surgery. Follow-up healing was uneventful after one month.

Role of Serum Amyloid A Protein in Various Diseases with Special Reference to Periodontal and Periapical Inflammation- A Review

Serum Amyloid A (SAA) is an Acute-Phase Protein (APP) produced as an innate nonspecific response to any tissue damage. Hence, it plays a significant role in chronic inflammatory diseases. In particular, SAA levels increase dramatically in chronic periodontitis and chronic apical periodontitis. Recent studies suggest this role of SAA in the pathogenesis of various diseases, including chronic periodontitis and chronic apical periodontitis. Thus, the focus of this review is to sum up the current understanding of the role of SAA in health and disease and to elaborate on possible mechanisms by which SAA could play a role in the pathogenesis of chronic periodontitis and chronic apical periodontitis.