Journal of clinical and diagnostic research

Morganella Morganii- A case of an Emerging Hurdle in the Journey of Septic Wound Healing

Bhavna Pate, Supriya Meshram, Gargi Mudey

Morganella morganii is a facultative gram-negative anaerobe present in the human gastrointestinal system as normal flora. Clinically, the organism is significant when it manifests as an opportunistic pathogenic infection elsewhere in the body. Morganella morganii (M. morganii) is a gram-negative bacillus found in the environment and among normal human intestinal flora. It is a well-known cause of urinary tract infections, wound infections, sepsis and other extraintestinal infections. It is also considered an opportunistic pathogen and has been known to occur in both community-acquired and nosocomial infections. The present case report depicts the outcome of wound healing in a 65-year-old, non diabetic, non hypertension male who had a history of a life-threatening necrotising soft-tissue infection in the right lower limb, which resulted in an infected ulcer due to M. morganii as the responsible pathogen. After proper diagnosis of the aetiologic pathogen as M. morganii, following pus and tissue culture and sensitivity tests from the infected wound, and after appropriate management with local wound care and antibiotics, there was early recovery, less morbidity, and an improved quality of life.

A Case of Atypical Neurofibromatous Neoplasm of Uncertain Biologic Potential: Unravelling the Enigma

Apoorva Pande, Samarth Shukla, Sourya Acharya, Pravin Gadkari, Milind Pande

Neurofibromatoses are a group of genetic disorders that cause tumours to form on the nerve tissue. These tumours can progress to more proliferative lesions and can also eventually become malignant, giving rise to a Malignant Peripheral Nerve Sheath Tumour (MPNST). The authors describe a rare case involving a 27-year-old female who presented with swelling on the left forearm in the surgery Outpatient Department (OPD). The swelling measured 6×5 cm and was noted on the left upper forearm. The overlying skin appeared normal, with no evident pulsations. Notably, a scar mark indicative of a previous surgery for a similar swelling was observed at the same site. The patient reported that the previous swelling was operated 2 years ago. Magnetic Resonance Imaging (MRI) findings indicated fusiform swelling in the mid-forearm, possibly originating from the ulnar nerve with significant involvement of the adjacent structures. This case underscores the complexity and diagnostic challenges associated with such swellings, necessitating thorough examination and ongoing monitoring for timely intervention. This case highlights the importance of thorough clinical evaluation, histopathological examination, and molecular analysis in accurately characterising such tumours, guiding clinical management decisions, and ensuring optimal patient outcomes. The diagnostic evaluation and analysis of such swellings contribute invaluable information regarding their proliferation rate and propensity for malignant progression. This comprehensive understanding aids clinicians in tailoring management approaches that prioritise minimal invasiveness while effectively addressing the potential for malignancy, thus optimising patient care.

Systemic Lupus Erythematosus with Concurrent Thrombotic Thrombocytopenic Purpura: A Case Report of Diagnostic Challenges and Management Approaches

Thrombotic Thrombocytopenic Purpura (TTP) is a thrombotic microangiopathy in which decreased activity of the von Willebrand Factor (vWF) multimer-cleaving protease ADAMTS13 leads to microvascular thrombosis. This condition can manifest as a pentad of symptoms that includes fever, thrombocytopenia, Microangiopathic Haemolytic Anemia (MAHA), renal disease and neurological disease. Authors hereby, detail the case of a 29-year-old female with a rare combination of TTP and Systemic Lupus Erythematosus (SLE), which presents challenges in diagnosis, clinical progression and therapeutic response. The patient had an unusual presentation of a ruptured ovarian cyst with haemoperitoneum, which was surgically treated with emergency laparotomy. This patient also presented with a malar rash, confusion, thrombocytopenia and haematuria, raising suspicion for SLE, which was confirmed with positive autoantibodies. Continued neurological deterioration led to subdural haemorrhage with generalised tonic-clonic seizures and refractory severe thrombocytopenia, treatment with intravenous methylprednisolone, suggesting an underlying haematological condition. Clinical findings, including schistocytes on peripheral smear, elevated lactate dehydrogenase and indirect bilirubin, prompted investigation for ADAMTS13 activity.

Effect of Pulmonary Rehabilitation on Dyspnoea, Functional Capacity and Thoracic Excursion in Chronic Obstructive Pulmonary Disease: A Case Report

Priyanka K Chilhate, Lajwanti Lalwani (Adwani)

Chronic Obstructive Pulmonary Disease (COPD) is a top cause of death. It is a lung disease that gets worse over time and includes emphysema and chronic bronchitis, causing blocked airflow. Hospitalisations, mortality and exacerbations of COPD are all increased by poor air quality. Significant occupational dosages include excessive pesticide exposure and home air pollution from burning coal, wood, animal dung and crop residues. Besides medical treatments, pulmonary rehabilitation is crucial for patient recovery from hospital to home. This study focuses on a 67-year-old man who visited a respiratory clinic with breathing problems for the past 15 days and chest pain for the past week. He also had a yellowish cough and occasional fever in the last week. With a 5-year history of COPD, he used an inhaler twice daily. His symptoms worsened in winter but stayed the same throughout the day. A chest X-ray confirmed a flare-up of COPD. A two-week pulmonary rehab plan with physical therapy was recommended. Before starting treatment, a baseline assessment was done, including measures like Modified Medical Research Council (mMRC) grading for breathlessness, 6-Minute Walk Distance (6MWD) and chest movement. Following the completion of the instructed pulmonary rehabilitation, significant improvements in dyspnoea grading, 6MWD, and thoracic were found. The findings imply that when modified to each patient’s specific requirements and capabilities, an organised pulmonary rehabilitation program can have an important beneficial therapeutic impact on those suffering from Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD).

Early Bilateral Corneal Ectasia after Photorefractive Keratectomy with Non Identifiable Preoperative Risk Factor: A Case Report

Farhan Khashim Alswailmi, Mujeeb Ur Rehman Parrey

Corneal ectasia following Photorefractive Keratectomy (PRK) remains a relatively rare but significant complication; however, its onset can range from a few weeks to many years. This case report presents the earliest known onset of bilateral corneal ectasia after PRK in the absence of predictable preoperative risk factors. A 21-year-old male with stable refraction and no family history of keratoconus underwent an uneventful PRK for myopic astigmatism. Despite normal preoperative corneal tomography, bilateral ectasia was diagnosed within one week after surgery. This case emphasises the potential for rapid onset of corneal ectasia following PRK and highlights the importance of patient counseling regarding this early complication.

Primary Orbital Marginal Zone B-cell Lymphoma: A Rare Case Report

Orbital Lymphomas (OL) account for 1 to 2% of Non Hodgkin Lymphomas (NHLs) and 2 to 11% of all orbital tumours. The most common primary OL is low-grade marginal zone B-cell lymphoma. This is a case of primary orbital NHL mimicking an orbital pseudotumour. A 67-year-old male presented with a swollen right eye associated with lacrimation for two months. On examination, there was right eye proptosis. Thyroid, liver and renal function tests were within normal limits. Contrast Enhanced Computed Tomography (CECT) revealed a homogenously enhancing intraconal mass measuring 4.1×3.2×2.8 cm, with features favouring a benign aetiology. Cytosmears revealed features suggestive of inflammatory pseudotumour of the orbit. Histopathological findings suggested low-grade NHL. Immunohistochemistry (IHC) showed positivity for CD20, CD79a, PAX5, and Bcl2, and negativity for CD3, CD5, CD10, CD23, Bcl6, and Cyclin-D1. Hence, a final diagnosis of marginal zone B-cell lymphoma was rendered. Detailed clinical and radiological evaluations did not reveal lymphadenopathy anywhere else or any other focus of tumour, indicating the primary origin of this tumour in the orbit. Primary NHL of the orbit is rare. It can occur in the orbit without any systemic features. It must be diagnosed early and can be treated with surgery and chemotherapy.

Graves’ Disease Presenting with Headache: An Unusual Association

Headache is a common presenting complaint seen in the general population, with varying causes. However, headache as a primary symptom of thyroid disorders, specifically hyperthyroidism, is not routinely observed. Hyperthyroidism due to Graves’ disease presents with typical symptoms such as hyperactivity, palpitations, fatigue and weight loss and can be associated with signs such as tachycardia, tremors and ophthalmopathy. Studies have not shown any definitive association between headache and Graves’ disease. Authors hereby, describe a case of a middle-aged female patient who presented with severe bouts of headache. She was using Non Steroidal Anti-Inflammatory Drugs (NSAIDs) and other medications for pain relief, but they had no long-lasting effect. An initial diagnosis of primary headache was made after ruling out other pathologies based on blood investigations, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI) studies. Despite starting appropriate therapy, the patient continued to experience persistent headache and tachycardia. Further evaluation revealed hyperthyroidism, which was managed using antithyroid drugs. This, in turn, led to the resolution of her main complaint, which was headache. She required no further pain medication and was symptom-free.

Massive Haemopericardium in a Case of Aortic Infective Endocarditis

Sonali Agarwal, Asmita Samal, Sai Yagnam Hareeswar

The prototypic lesion of Infective Endocarditis (IE), known as vegetation, is a mass of platelets, fibrin, microorganisms and scant inflammatory cells. IE can involve heart valves, low-pressure areas of an intracardiac defect, mural endocardium damaged by aberrant jets of blood or foreign bodies, or intracardiac devices. A similar process involving arteriovenous shunts, a patent ductus arteriosus, or a coarctation of the aorta is called infective endarteritis. Hereby, the authors present a case of 50-year-old female, known case of chronic kidney disease, presented to the Emergency Department with a history of fever, dry cough and chest pain for 10 days, along with acute onset breathlessness. Upon urgent clinical examination and investigation, she was found to have a massive haemopericardium causing cardiac tamponade and vegetation on the aortic valve cusp. Pericardiocentesis was performed immediately on an emergency basis and one liter of blood was drained from the pericardial sac. The pericardial fluid and blood were sent for culture to further evaluate the suspected IE. Enterococcus raffinosus was isolated from three blood culture sets sent half an hour apart. Appropriate antibiotics were initiated and the patient was discharged after two weeks of intravenous antibiotics. The enterococcus species is a known pathogen that can cause IE, but Enterococcus raffinosus is not a common organism found in endocarditis. It has previously been implicated as a colonic pathogen. The present case highlights the swift detection and diagnosis of a rare organism responsible for causing IE.

Cardiac Failure Secondary to Idiopathic Hypoparathyroidism: A Case Report

Mansi Harale, Sreevidya Yekkaluru, Anita Basvaraj

Hypoparathyroidism causes low calcium levels due to insufficient Parathyroid Hormone (PTH). This can lead to cardiovascular issues, including arrhythmias and rarely, hypocalcaemic cardiac failure. In cardiac failure, calcium dysregulation impairs contractility and increases myocardial stress. Hypoparathyroidism-induced hypocalcaemic cardiac failure is an exceptionally rare cause of heart failure, often unresponsive to standard treatments. This report highlights a case of a young female with undiagnosed idiopathic hypoparathyroidism who developed acute cardiac complications postoperatively after an appendectomy. Sixteen hours postsurgery, she experienced sudden onset breathlessness, with her oxygen saturation dropping to 50%. A chest X-ray showed bilateral homogeneous opacities consistent with pulmonary oedema. She was intubated, placed on invasive mechanical ventilation, and required pressor support before being transferred to the medicine unit. Initial Electrocardiography (ECG) findings were unremarkable. On the second day, carpal spasm was observed, prompting serum calcium testing, which revealed significantly low levels, as did serum PTH. Subsequent ECG demonstrated changes associated with hypocalcaemia, including a short PR interval and prolonged QT interval. Echocardiography indicated left ventricular hypokinesia with an ejection fraction of 25-30%, although cardiac enzymes were normal. N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels were elevated, and arterial blood gas analysis showed metabolic alkalosis and hypokalemia. The hypocalcaemia was aggravated by metabolic alkalosis due to gastric drainage. A diagnosis of heart failure secondary to hypocalcaemia from idiopathic hypoparathyroidism was established after excluding other aetiologies. Treatment focusing on heart failure management and calcium correction led to significant clinical improvement, and the patient was successfully extubated. This case highlights the importance of measuring serum calcium in all patients presenting with heart failure, as hypocalcaemia is a treatable cause. A comprehensive evaluation of endocrine and metabolic factors is essential in young patients with unexplained heart failure for accurate diagnosis and effective management.

Management of Diabetic Ketoacidosis Complicated by Invasive Systemic Candidiasis in Type 1 Diabetic Patient: A Case Report

Diabetic Ketoacidosis (DKA) is a severe metabolic complication commonly associated with Type 1 Diabetes Mellitus (T1DM), characterised by hyperglycaemia, metabolic acidosis and ketonaemia, leading to significant morbidity and mortality if not promptly treated. Invasive systemic fungal candidiasis, caused by Candida species, is a critical opportunistic infection that can complicate DKA. This case report discusses a patient with type 1 diabetes who developed DKA, which was subsequently complicated by invasive systemic fungal candidiasis and multiorgan dysfunction. A 19-year-old female patient presented with complaints of vomiting, dyspnoea on exertion, swelling of the vagina, and left hypochondriac pain for two days. The patient had T1DM for two years and had missed her insulin doses, after which she developed DKA along with a vaginal Bartholin’s cyst that tested positive for fungi. She went into sepsis and septic shock. Subsequently, this developed into Multiple Organ Dysfunction Syndrome (MODS) after initially presenting as a local illness and then spreading to systemic invasive fungal candidiasis. The patient ultimately succumbed to the illness following a protracted stay in the Intensive Care Unit (ICU), despite receiving larger doses of antibiotics and antifungals, undergoing tracheostomy and mechanical ventilation, and having returned of spontaneous circulation, repeated Cardiopulmonary Resuscitation (CPR) cycles, as well as support from inotropic agents and vasopressors. This case highlights the necessity of early diagnosis and intervention with prompt action to prevent delayed diagnosis and complications that may arise. Serum 1,3 Beta-D-Glucan was positive, while Galactomannan was negative. Blood cultures were positive for Klebsiella pneumoniae. A vaginal swab culture from the Bartholin cyst revealed Candida albicans with pseudohyphae and budding yeast cells.

Genetic Counselling and Prenatal Diagnosis in a Case of Harlequin Ichthyosis: A Novel ABCA12 Gene Mutation

Shreya Singh, Bhagyesh Sapkale, Dhruba Chandi, Kamlesh Chaudhari

Hereditary diseases are disorders that mainly result from mutations or changes in Deoxyribonulciec Acid (DNA), Ribonucleic Acid (RNA), or chromosomes, which impact the overall and physical welfare of an individual. One such severe inherited skin disease is Harlequin Ichthyosis (HI), which is characterised by the rigid and thick formation of diamond-shaped scales on the skin. It occurs due to a mutation in the ABCA12 gene, which plays a central role in the formation of the outermost layer of the skin. Hereby, the authors present a case of a 29-year-old female presented herself at Acharya Vinoba Bhave Rural Hospital (AVBRH) for hereditary counselling. She was 38 weeks pregnant and had no other chief complaints; however, she wanted proper counselling for the pregnancy due to the death of her previous children. In her prior pregnancy, the neonate was diagnosed with HI and exhibited all the manifestations of grossly thick, inelastic skin, which posed a high risk for life-threatening complications, including infections, fluid loss, and episodes of acute respiratory intolerance. The neonate was born at 40 weeks of gestation. Other initial diagnostic methods, such as amniocentesis, Chorionic Villus Sampling (CVS), and pre-implantation genetic diagnosis during In-vitro Fertilisation (IVF) for genetic disorders, were utilised. These prenatal testing techniques facilitate genetic screening methods in managing hereditary ailments such as HI in present case. Genetic testing revealed that both parents carried a heterozygous deletion in the ABCA12 gene, indicating a 25% chance of having another affected child. Early identification of the disease and its treatment will enable neonates to have the best quality of life possible.

Malunited Distal End Radius with Garden Spade Deformity and Distal Radioulnar Synostosis: A Case Report of a Quirky Wrist

Distal end radius fractures are the most common type of wrist fracture and a significant complication associated with these injuries is malunion, which can lead to deformities that adversely affect the normal biomechanics of the wrist joint. Failing to address this malunion may result in chronic pain, a reduced range of motion and early-onset arthritis of the wrist joint. Therefore, it is essential to correct this malunion surgically, as doing so can greatly enhance functional outcomes for patients and improve their overall quality of life. Hereby authors report a rare case of a malunited distal end radius fracture with garden spade deformity and distal radioulnar synostosis. Upon presentation, the patient had a fixed wrist flexion deformity of 40° and a fixed pronation deformity of 20°. The patient was managed with corrective osteotomy of the malunited distal end radius, distal ulna excision and resection of the distal radioulnar synostosis. The preoperative measured volar tilt angle of 49.3° was corrected to 18.6°. At one year follow-up, the patient’s QUICK DASH score improved from 50% (severe disability) to 11.4% (minimal disability) and the modified Mayo wrist score improved from a score of 35 (poor) to 80 (good).

Unilateral Obturator Hernia in an Elderly Male: A Case Report

Praveen K Sharma, P Evangeline Christina, S Sharmeela, Amogh Diwakar

Obturator Hernia (OH) is a rare type of pelvic hernia in which abdominal contents protrude through the obturator canal. This condition can lead to bowel obstruction, gangrene, or ischaemia, all of which pose significant risks and can be life-threatening. OH predominantly affects elderly, thin females and often remains asymptomatic until there is compression of the obturator nerve. As a result, OH should be considered in the differential diagnosis of intestinal blockages of unknown origin. For preoperative diagnosis, Computed Tomography (CT) is regarded as the optimal imaging modality. However, Ultrasonography (USG) may sometimes misidentify it as a femoral or inguinal hernia. Due to its non specific symptoms and clinical presentations, early preoperative identification of OH can be challenging. Hereby, the authors present a case of OH in an 80-year-old male patient with biopsy-proven prostate carcinoma who reported burning sensations and difficulty in micturition over the past month. His medical history included insulin-managed diabetes and extensive alcohol consumption. Physical examination revealed a non tender swelling on the medial aspect of the right upper thigh, prompting imaging studies that included a Kidney, Ureter, and Bladder (KUB) radiograph and a CT-KUB. The radiograph showed a radiolucent area in the right obturator canal, while the CT confirmed the diagnosis, revealing a herniated sac within the obturator externus muscle, measuring 61×109×89 mm, with associated bone remodelling of the pubic symphysis and mild prostatomegaly. Despite understanding the risks, the patient has not yet undergone surgery due to his age and co-morbidities. The present case underscores the need for heightened awareness of OH in elderly males, especially those with significant medical histories, as early recognition and intervention are crucial to preventing serious complications.

Management of Fournier’s Gangrene by Indigenous Ayurveda: A Case Report

Mansi Nakum, Devyani Dasar, Naveen Singh, Dhruv Modi, Krishna Shinde

Fournier’s gangrene is a severe necrotising fasciitis affecting the perianal, genital and perineal regions. This rapidly progressing and potentially fatal condition involves a polymicrobial infection, causing extensive tissue necrosis. Predominantly affecting middle-aged to older adults, Fournier’s gangrene presents with acute pain, swelling and redness, often accompanied by systemic symptoms like fever and tachycardia. Other risk factors include immunosuppression, chronic alcohol consumption, peripheral vascular disease, and cancer, although cases without known risk factors also occur. Diagnosis is based on clinical suspicion and confirmed through imaging tests such as ultrasound, Computed Tomography (CT), or Magnetic Resonance Imaging (MRI), which reveal soft-tissue gas or fluid collections. Laboratory tests, including blood cultures and inflammatory markers, are crucial for assessing severity and guiding treatment. Immediate and aggressive management is essential, typically involving surgical debridement, broad-spectrum antibiotics, and sometimes reconstructive surgery. Intensive supportive care is often required due to the rapid progression and risk of septic shock. In Ayurveda, Fournier’s gangrene may be related to a condition called Kotha described in ancient texts, with treatment involving surgical excision (Chedana karma), wound care (Shodhana karma), and healing promotion (Ropana karma). A case report of a 68-year-old male patient highlighted the successful integration of Ayurvedic principles and modern medical interventions, resulting in complete recovery without complications. The patient’s treatment included surgical debridement, the use of Ayurvedic medications for wound cleansing and healing, and antibiotics. Regular follow-up and careful wound management were crucial in achieving full recovery, demonstrating the potential efficacy of combining traditional and contemporary medical approaches in managing Fournier’s gangrene.

Unusual Presentation of Legionella as an Acute Flaccid Quadriparesis in a Case of Guillain-Barre Syndrome

Guillain-Barré Syndrome (GBS) is a rare polyradiculoneuropathy of the peripheral nerves and, occasionally, the cranial nerves, causing dysfunction, segmental demyelination, and/or axonal degeneration. GBS is considered an autoimmune disease because the body’s own immune system attacks its own tissues. There is a strong association between GBS and preceding acute infectious illness. Aetiology is unknown in most cases. GBS has been less commonly reported in association with Legionella. Furthermore, unusual GBS-related clinical signs might lead to confusion and incorrect diagnoses, like transverse myelitis, spinal cord compression, stroke, infections, myasthenia, and periodic paralysis. To establish the diagnosis of GBS, patient history, electrophysiological assessments, neurological evaluations, and Cerebrospinal Fluid (CSF) analyses are equally important. Hereby, the authors present a case report of 75-year-old male patient who presented with a history of fever spikes and diarrhoea 10 days prior, followed by the acute onset of ascending paralysis and hypertension. A systemic examination revealed right eye ptosis, loss of power in the bilateral lower limbs, areflexia, and diminished sensory function. Further evaluation through nerve conduction studies showed findings suggestive of demyelinating axonal sensory-motor polyneuropathy involving all four limbs. Based on the clinical suspicion of an acute infectious illness history followed by ascending paralysis, the patient was investigated for the cause of GBS, which was found to be Legionella. The patient was treated with plasmapheresis and physiotherapy and is now on regular follow-up.

A Resource-limited Approach for Stabilising Paediatric Femoral Neck Fracture: A Case Report

Paediatric Femoral Neck Fracture (PFNF) is rare, and its repair is challenging for orthopaedists. Surgical treatment should be performed, as soon as, possible with anatomical repair to avoid postoperative complications, including Avascular Head Necrosis (AVN) and bone deformity. In the present case scenario, a 14-year-old male patient presented to the Orthopaedic Emergency Department with hip pain and an inability to bear weight or move his right lower extremity. He arrived at the hospital at night and was examined immediately. The patient reported a fall from the second floor two days prior. Due to the unavailability of some necessary surgical instruments at the time of the emergency surgery, orthopaedic surgeons adopted a new procedure for treating a PFNF. The fracture reduction was maintained under general anaesthesia, and the incision site was properly sterilised before using a 3 mm Kirschner wire (K-wire). The 3 mm K-wire was removed before compressing the fracture site with screws. The wires were cut to a length that allows them to be bent over the femoral shaft and secured to the shaft using ligature wires. This is a modification of the Wagner technique, which involves passing the ligature wire around the femoral shaft.

Ketogenic Diet for Seizure Management in Glucose Transporter Type 1 Deficiency Syndrome: A Case Report

Soma Basu, Ranjith Kumar Manokaran, Arambakkam Janardhanam Hemamalini

Glucose transporter Type 1 (GLUT1) deficiency syndrome is a rare genetic disorder impairing glucose transport across the blood-brain barrier, leading to reduced brain glucose availability and neurological symptoms, including epilepsy. The Ketogenic Diet (KD), high in fat and low in carbohydrates, induces ketosis, providing ketone bodies as an alternative brain fuel bypassing GLUT1 transport. This compensates for glucose deficiency, stabilising neuronal activity and reducing seizure frequency in GLUT1 deficiency. This case is of a 10-year-old girl with GLUT1 deficiency syndrome, developmental delay, SLC2A1 gene mutation and refractory epilepsy with 2-3 weekly seizures despite multiple Antiseizure Medications (ASMs). A South Indian-style KD, using traditional household ingredients, was initiated as medical nutrition therapy. Remarkable improvements were observed, a 50% reduction in seizures within one month, 80% reduction by three months and complete seizure freedom by the fourth month. Developmental progress accompanied seizure control and the diet was well-tolerated, maintaining stable nutritional status. This case highlights the efficacy of a culturally tailored KD in managing GLUT1 deficiency, emphasising its potential as a form of therapeutic treatment. Ongoing parental support and supervision were critical for ensuring dietary adherence and optimising outcomes.

An Unusual Bilateral Membranous Variant of Triplicate Pitted Pectoralis Major Muscle: A Case Report

Surraj Susai, Mrudula Chandrupatla, Ansumaan Nayak, Deepika Gandicherla

The variations in the attachments of the pectoralis major not only affect its function but also reflect on its ability to be used as flaps. Membranous origins of this muscle not only add to its stress but also contribute to its inherent tears. The present report unravels the membranous as well as variant tri-muscular origins of this muscle bilaterally, with implications for its role in reconstructive procedures. Although varied classifications of this muscle exist in the literature, the present case finding is unique due to the gaps of separation that were found between the strata of this muscle, which is quite a rare phenomenon. Variations in the membranous and triplicate origins of the pectoralis major are indeed rare findings that warrant the need for larger, separate morphological typing studies in order to delineate its intricate patterns. Membranous variants of the pectoralis major are prone to shearing stress and internal tears, which pose threats to flap reconstruction procedures involving this muscle; thus, the present case report represents a significant finding.

Management of Difficult Airway in Mentally Challenged Patient with TAScope and Fiberoptic Intubation: A Case Report

Pooja Arpan Shah, Arpit Shah, Tejash Sharma, Sara Mary Thomas

Managing a difficult airway is a very challenging task for practicing anaesthesiologists in day-to-day life. Addressing a difficult airway in patients with intellectual disabilities is even more challenging and requires a stepwise approach for management. The authors hereby report a case of a 26-year-old male patient, with intellectual disabilities who has a history of ankylosing spondylitis and was scheduled for an open gastrojejunostomy. The patient presented with a mouth opening of only 1.5 cm and grade IV extension, which restricted movements at the atlanto-occipital joint and resulted in a short neck. The most challenging aspect of the present case was the patient’s intellectual disability, which made it difficult to employ awake intubation techniques. Video laryngoscopy was not feasible due to the limited mouth opening and retrognathia. The authors planned for tracheal intubation using The Anaesthetist Society Scope (TAScope) and considered fiberoptic intubation as a second option. After a failed attempt at intubation under Intravenous (i.v.) anaesthesia with TAScope, fiberoptic intubation was successfully performed, albeit with difficulty. In conclusion, fiberoptic intubation is considered the gold standard for managing difficult airways.

Leptospirosis with a Rare Presentation of Acute Multiple Cerebral Infarcts: A Case Report

Reshmi R Kurup, TJ Ramya, M Rama Devi, M Revathi, C Ramesh Kumar

Leptospirosis is a zoonotic disease that can manifest as an asymptomatic infection or as a fulminant, fatal illness. According to published literature, neurological manifestations can be observed in 10-15% of cases. Here is a case of a 65-year-old female patient who presented with a history of fever lasting six days, followed by seizures and loss of consciousness. Leptospira IgM was found to be positive, and Magnetic Resonance Imaging (MRI) of the brain showed multiple acute cerebral infarcts. The patient was treated with intravenous antibiotics, antiepileptics and other symptomatic treatments. During her hospital stay, the patient improved symptomatically. Neurological manifestations of leptospirosis may result from immune-mediated reactions, leading to cerebral arteritis. This makes it a potential differential diagnosis for fever with acute cerebrovascular accidents in tropical and endemic regions.

Rare Presentation of Organophosphorus Poisoning Induced Diabetes Insipidus: A Case Report

Vignessh Raveekumaran, V Shyam Kumaran, Sethuraj Selvaraj, KS Chenthil

Organophosphorus Compounds (OPC) are widely used insecticides that pose significant health risks following intentional or accidental consumption. The effects of organophosphates on the central nervous system include irritability, restlessness, disorientation and confusion, which can progress to generalised seizures, status epilepticus and brain damage. Diabetes insipidus is a rare and unusual complication of organophosphorus poisoning. In this case study, a patient with organophosphate poisoning who was admitted to the Emergency Department (ED) with an alleged history of exposure to the OPC Chlorpyrifos 1.5% is presented. Upon admission, her Glasgow Coma Scale (GCS) score was 7/15 and she exhibited anisocoria (right pupil 4 mm and left pupil 2 mm) with sluggishly reacting pupils to light. She was immediately started on an atropine infusion, but later developed tachycardia and seizures, which were treated appropriately. Her electrolytes were abnormal, revealing hypernatremia (serum Na+ 182 mEq/L) and she was treated to reduce this condition. Additionally, the patient was monitored for urine output, which measured 250-350 mL/hr, with a serum osmolality of 379 mOsm/kg and a urine spot sodium of 243 mEq/L. Based on these findings, she was diagnosed with diabetes insipidus and started on desmopressin. However, her GCS showed no improvement and eventually decreased to 2T/15, indicating a poor prognosis. In conclusion, this case study suggests that diabetes insipidus is a rare transient complication of OPC poisoning. This idiosyncratic effect is uncommon and physicians should be aware of such complications and treat them accordingly.

A Case Report on Paramedian Forehead Flap: A Treatment Approach for Basal Cell Carcinoma of Nose

Tanmay Chaudhari, Ruchir Dashora, Vinod Shinde, Mayur Ingale

Non melanoma Skin Cancers affect only about 1-2% of Indians, but they account for more than one-third of skin cancers in the white population. A total of 75% of all non melanoma skin cancers are Basal Cell Carcinomas (BCCs), the most prevalent type of skin cancer globally. Risk factors include middle or old age, fair skin (Fitzpatrick skin type I or II), immunosuppression and Ultraviolet (UV) radiation. While it can be extremely disfiguring, it is rarely fatal. Currently, the cornerstones of BCC treatment are tumour excision, Electrodesiccation and Curettage (EDC), cryosurgery, and Mohs micrographic surgery. The paramedian forehead flap is a local cutaneous flap that can be used for nasal reconstruction. Hereby, authors report a case of an 82-year-old male patient who presented with the classical findings of an ulcer on the dorsum of the nose, which was diagnosed as BCC based on typical clinical features and histopathological examination. The patient underwent surgical resection of the lesion with paramedian forehead flap reconstruction. The paramedian forehead flap is an extremely effective tool for nasal reconstruction. Using paramedian forehead flaps, it is possible to achieve stunning functional and aesthetic outcomes in cases of BCC of the nose with considerable technical expertise and knowledge.

Unveiling Kartagener’s Syndrome in a Young Male: A Case Report

Kartagener's Syndrome (KS) is a rare genetic condition that affects the cilia. It is characterised by a situs inversus triad, chronic sinusitis, and bronchiectasis, distinguishing it from other diseases. This disease leads to impairment of ciliary movement, which leads to recurrent respiratory infections, infertility, and infections associated with the ears, nose, and throat. The authors present a rare case of a 29-year-old male who presented to the hospital with complaints of high-grade fever associated with chills, cold and coughs with expectoration for five days. On further inquiry, he revealed that he has been suffering from recurrent sinusitis and lower and upper respiratory tract infections. He had been admitted in private hospitals for pneumonia 5-6 times. Clinical examination revealed consolidation features, and investigations revealed features of KS and consolidation. These symptoms were treated per conventional guidelines, and the patient was discharged. This case report highlights the importance of suspecting atypical syndromes when a patient presents with recurrent respiratory tract infections.

A Rare Case of Artery of Percheron Infarction: Diagnostic Challenges and Management

The Artery of Percheron (AOP) is a rare anatomical variant in the posterior circulation, where a single arterial trunk supplies both the paramedian thalami and the rostral midbrain bilaterally. Infarction of the AOP can result in altered mental status, memory deficits and vertical gaze palsy. However, early diagnosis remains challenging, as initial Computed Tomography (CT) scans often fail to detect subtle ischaemic changes. This underscores the critical need for the early use of advanced imaging techniques, particularly Magnetic Resonance Imaging (MRI), to improve diagnostic accuracy and expedite management. In this case, a 66-year-old male presented with sudden-onset severe drowsiness and unresponsiveness. Initial CT imaging did not reveal abnormalities, delaying diagnosis and ruling out thrombolytic therapy, which is most effective within 4.5 hours of symptom onset. Subsequent MRI identified bilateral thalamic and left midbrain infarction consistent with AOP occlusion. Management focused on supportive care, secondary stroke prevention with antiplatelet therapy, and rehabilitation. Despite the delayed intervention, the patient demonstrated gradual neurological improvement, highlighting the importance of tailored care in rare ischaemic stroke subtypes. Early identification and treatment remain essential for optimising outcomes and minimising long-term deficits. This case emphasises the importance of advanced imaging for diagnosing AOP infarction, a condition often missed on early CT scans, and highlights the challenge of timely diagnosis in ischaemic stroke management.

Vocal Cord Paralysis in Association with CHARGE Syndrome: A Case Report

Akansha Sisodia, RJ Meshram, Sagar Karotkar

CHARGE (Coloboma, Heart defects, Atresia choanae (also known as choanal atresia), growth Retardation, Genital abnormalities and Ear abnormalities) Syndrome (CS) is a rare genetic disorder characterised by distinct physical and developmental abnormalities. This report presents a case of a seven-day-old male infant who exhibited respiratory distress, noisy breathing and feeding difficulties, was subsequently diagnosed with CS due to a pathogenic variant in the CHD7 gene. The infant exhibited vocal cord paralysis, bilateral profound hearing loss and other characteristic features of CS. Multidisciplinary management included Continuous Positive Airway Pressure (CPAP), antibiotics, laparoscopic gastrostomy, fundoplication and treatment for heart failure. Comprehensive evaluation and genetic testing confirmed the diagnosis of CS, underscoring the need for a multidisciplinary approach to managing associated conditions. This case highlights the importance of early recognition and management of CS. Furthermore, this case report contributes to the existing literature by emphasising the unique clinical manifestations and challenges associated with CS. Early diagnosis and management of this condition can significantly impact the quality of life and outcomes for affected individuals. This report underscores the importance of prompt recognition and referral to specialised care teams for optimal management of CS.

Incidental Case of Pelvic Haemangiopericytoma: A Clinical Diagnostic Challenge and Clinicopathological Overview

Haemangiopericytoma is a rare vascular tumour. Given its unusual presentation, location, and the clinical diagnostic challenges it poses, hereby, the authors present a case report of a 38-year-old female sought medical attention in the Outpatient Department (OPD) due to pain in her lower abdomen. A pelvic mass was identified in the right adnexa, pushing the uterus to the left. The patient underwent excision of the pelvic mass, considering leiomyoma as a differential diagnosis. A preoperative large mass, approximately 15×20×15 cm in size, was found between the bladder and uterus, adherent to the broad ligament. Subsequently, mass excision was performed along with total abdominal hysterectomy and bilateral salpingo-oophorectomy. The intraoperative and postoperative periods were uneventful. The histopathological report confirmed the diagnosis of haemangiopericytoma. The patient declined radiotherapy and lost to follow-up; later, she succumbed to distant metastasis to the bone and brain four years after treatment. The tumour of the pericyte cells is called haemangiopericytoma. It is considered one of the rarest types of tumours in the pelvis. Most of these tumours are asymptomatic; if they are symptomatic, it is usually due to the compression of adjacent structures or paraneoplastic effects. Computed Tomography (CT) is relevant in establishing the diagnosis, but histopathological examination is confirmatory. The preferred treatment option comprises surgery; at times, preoperative embolisation is necessary to control bleeding. Some literature has highlighted the role of radiotherapy in adjuvant settings to enhance local control. However, the ideal treatment option remains debatable. Surgery is the preferred course of treatment, occasionally following preoperative embolisation of the mass vascularisation. Surgical resection with clear margins and total removal of the tumour offers survival rates of upto 70 to 80% at five and ten years, respectively. The present case is of interest because of its location, rarity, and size.

Successful Management of Angiodysplasia of Colon by Transarterial Embolisation: A Case Report

Angiodysplasia is a common cause of lower Gastrointestinal (GI) bleeding, particularly in elderly patients. It can range from asymptomatic or occult bleeding to moderate or severe bleeding that leads to haemodynamic instability. The diagnosis of angiodysplasia should be considered among the differential diagnosis in cases of intermittent GI bleeding when no other significant cause is identified. Various treatment modalities are described for management; among them, endovascular management with embolisation is one of the most effective and safe approaches, especially in high surgical risk patients. Hereby, authors present present a case of splenic flexure colon angiodysplasia in 54-year-old male patient, that led to haemodynamic compromise, which was successfully treated via minimally invasive transarterial endovascular embolisation without the need for surgical intervention. In haemodynamically unstable patients, angiography is a suitable approach because it not only demonstrates bleeding points but also offers a minimally invasive therapeutic endovascular intervention in the same sitting.

Application of Leech Therapy in Alleviating Residual Limb Pain Following Distal Foot Digit Amputation: A Case Report

Yogesh Yadav, Sheetal Asutkar

Residual Limb Pain (RLP) poses a significant challenge in post-amputation care and often necessitates multimodal pain management. Here, a 55-year-old male patient with RLP was managed with Jalaukavacharan (leech therapy). The patient had previously undergone amputation of the terminal fingers and toes of the right foot and had inadequate pain relief with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), prompting him to seek Ayurvedic treatment. Leech therapy was administered daily to the amputated area for seven days, and follow-up assessment was conducted on day 14 using the Visual Analog Scale (VAS). The patient’s VAS pain scores decreased significantly, from 8/10 at baseline to 0 on day 14, underscoring the potential of Jalaukavacharan as an effective complementary approach for pain reduction in RLP. The clinical implication of this case lies in demonstrating the feasibility and impact of Jalaukavacharan for managing persistent post-amputation pain, offering an alternative that aligns with the patient’s comfort and preferences. This report contributes to the limited evidence supporting Ayurvedic treatments in pain management and underscores the need for further studies with larger sample sizes to evaluate its broader applicability and effectiveness.

Co-existence of Untreated Chronic Lymphocytic Leukaemia and Acute Myeloid Leukaemia: A Rare Case of Synchronous Dual Haematological Malignancy

Renu Sukumaran, Rekha A Nair, AV Jayasudha, MT Sugeeth

The occurrence of Acute Myeloid Leukaemia (AML) or Myelodysplastic Syndrome (MDS) in patients with Chronic Lymphocytic Leukaemia (CLL) is rare. In most of the reported cases, AML occurs after treatment of CLL with cytotoxic drugs suggesting that AML may be a secondary leukaemia (therapy-related AML). AML or MDS occurring in untreated CLL patients is extremely rare with isolated case reports. Herein, we report the case of a 74-year-old male patient who was diagnosed four months back to have chronic B cell lymphoproliferative disorder, from an outside centre. The patient did not receive any treatment. Because of intermittent fever and increased fatigability, he came to our centre. Peripheral blood smear and bone marrow studies showed a dual population of atypical cells-one population of large immature cells with opened-up chromatin, prominent nucleoli, and another population of small atypical lymphocytes with clumped chromatin. Around 10% of immature cells showed Myeloperoxidase (MPO) positivity. Flow cytometric analysis also showed two separate populations of cells. The immunophenotype of one population was compatible with AML, with monocytic differentiation, and the second population showed features of CLL. A diagnosis of co-existent CLL and AML was given. The awareness of the co-existence of dual haematological malignancy, thorough morphological evaluation, and flow cytometric immunophenotyping will lead to accurate diagnosis of these combined malignancies.

Management of Hepatitis B with Siddha Medicine: A Case Report

Hepatitis B is a viral disease that causes acute and chronic liver diseases. The Hepatitis B Virus (HBV) infects more than 300 million people worldwide, and over 686 billion people die every year due to its consequences. Present case is of a 59-year-old male patient with positive Hepatitis B envelope Antigen (HBeAg) and a remarkably high viral load of HBV Deoxyribonucleic Acid (DNA) presented as a previously diagnosed case of chronic hepatitis. He came to the Outpatient Department (OPD) Siddha Clinical Research Unit (SCRU) with complaints of loss of appetite, abdominal discomfort, malaise and constipation. Based on his symptoms, supported by blood investigation reports and Siddha parameters, internal medicines such as Elathy Chooranam, Silasatthu Parpam, Ayabringaraaja Karppam, Saanthachandrodaya Maathirai, Keezhanelli Maathirai, and Nilavembu Kudineer were prescribed. The effects of the treatment modalities were monitored during follow-up with routine blood examinations. After six months of treatment, the HBV viral load reduced from 203,000,000 IU/mL to 125.89 IU/mL, and HBeAg became non reactive. The reported case had a prospective follow-up for six months and was found to be free of all clinical symptoms. It is evident that Siddha medicine shows a decrease in the level of HBV DNA viral load, delays the hepatocyte damage caused by the HBV, and has proved to have no side-effects at a lower cost. Since this study was based on a single case, further randomised controlled clinical trials need to be conducted with a larger population.

A Case of Atypical Actinomycosis: A Diagnostic Conundrum in Lower Limb Pathology

Somya Goel, Raju Shinde, Khushbu Vaidya, Ashish Jivani

Actinomycosis is a rare bacterial infection known for its chronic, indolent course and diverse clinical presentations. Diagnosis can be more challenging without sinus formation, as there may be fewer visible signs to suggest actinomycosis. Actinomycosis typically lacks specific radiologic findings and presents with indolent and non specific symptoms. The present is a case of a 35-year-old female with no associated co-morbidities. Over 1.5 years, she developed a progressively enlarging swelling over her left lateral malleolus, accompanied by pain exacerbated by walking. The absence of classic inflammatory signs, draining sinus tracts, or localised tenderness negates the suspicion of an infective etiology. Radiological investigations revealed a soft-tissue tumour, prompting an excisional biopsy. Histopathological analysis confirmed the diagnosis of actinomycosis, highlighting the importance of recognising rare entities with unusual clinical presentations. The present case underscores the diagnostic challenge posed by atypical presentations of actinomycosis and emphasises the necessity of maintaining a broad differential diagnosis to ensure timely recognition and appropriate management of this elusive condition.

Invasive Pneumococcal Disease in Children: A Case Series on Clinical Profile, Serotypes and Antibiotic Resistance from Southern India

Nimmy Paul, Nirmal Babu, Balaji Veeraraghavan, Chitra C Nath, KV Unnikrishnan

Invasive Pneumococcal Disease (IPD) is defined as the isolation of pneumococci from normally sterile sites, including blood, cerebrospinal fluid, pleural fluid, ascitic fluid and synovial fluid. Despite widespread vaccination, IPD continues to be a major public health concern worldwide. Studying antibiotic resistance in the context of emerging serotypes and vaccines for IPD is crucial for optimising clinical management, guiding vaccine strategies and forming public health policies. By understanding the interplay between serotype dynamics, antibiotic resistance and vaccination, researchers and healthcare professionals can better mitigate the impact of pneumococcal disease on global health. In this case series, the authors describe the clinical profile, serotypes and antibiotic resistance of five cases of IPD in the paediatric age group. All five children exhibited severe signs of IPD, such as meningitis or septicaemia. The serotypes identified were 15C (2 cases), 6B, 19F and 23F. All five cases were sensitive to chloramphenicol, vancomycin, linezolid and levofloxacin. All cases were resistant to penicillin, and only one case was sensitive to erythromycin; all others were resistant. Cefotaxime was sensitive in three cases and intermediate in two cases. Cotrimoxazole was resistant in three cases, sensitive in one and intermediate in another case. The currently available Pneumococcal Conjugate Vaccine (PCV) offer substantial protection against IPD, but the occurrence of severe IPD cases, such as meningitis and septicaemia, necessitates the introduction of newer vaccines with broader coverage, such as PCV 15 and PCV 20.

CT Peritoneography for Identifying the Complications of Peritoneal Dialysis: A Case Series

P Prathiba Rajalakshmi, K Srinivasan, K Jagdish, Hemanth Sudarsanam, G Murugan

Peritoneal Dialysis (PD) is a commonly used method of renal replacement therapy for End-stage Renal Disease (ESRD), along with Haemodialysis (HD) and renal transplantation. However, various complications may develop early or late in the course of PD, causing patient morbidity, compromising the success of PD, and necessitating a change to HD. Imaging plays a crucial role in the diagnosis and management of PD-related complications, of which Computed Tomography (CT) peritoneography has proven to be an effective modality, allowing for elaborate visualisation of the peritoneal anatomy and the demonstration of small leaks and hernias. The authors hereby report a case series of three patients (41-year-old male, 62-year-old female and 31-year-old male) with PD-related complications, including abdominal wall, pericatheter and peritoneopleural leaks, highlighting the role of CT peritoneography in identifying them.

Peripartum Cardiomyopathy: A Case Series about the Conundrum of Anaesthetic Management

Mamta Jain, Lisa Barman, Anish Kumar Singh, Shilpa Popli, Teena Bansal

Peripartum Cardiomyopathy (PPCM) is a rare, potentially life-threatening condition characterised by left ventricular dysfunction and heart failure, occurring in the last month of pregnancy or within five months of delivery. Anaesthetic management of PPCM poses significant challenges due to compromised cardiac function, necessitating careful planning and individualised strategies to optimise patient outcomes. This case series presents three patients with PPCM, highlighting the complexities of anaesthetic management. Multidisciplinary collaboration between anaesthesiologists, cardiologists and obstetricians was crucial in developing and implementing effective management plans. Present cases demonstrate the importance of a tailored approach to anaesthetic management, emphasising the need for close monitoring and prompt intervention to address haemodynamic instability. This series aims to contribute to the limited literature on anaesthetic management of PPCM, providing valuable insights into the challenges and opportunities for optimising patient care. By sharing this experiences and lessons learned, we hope to inform and improve the management of PPCM in the perioperative period.

Arm Wrestling and Humeral Fractures: A Case Series

Humeral shaft fractures are common injuries seen in the increasingly popular sport of arm wrestling. They occur due to a combination of axial load and twisting forces on a fixed elbow. Hereby, the authors present a case series of four cases of humeral shaft fractures, all of which presented within an hour of injury. Two of the four patients had oblique fractures, one had a spiral fracture, and one had a comminuted fracture. Additionally, one of the patients had an associated radial nerve injury immediately following the injury. All were managed with fixation by plating, and the radial nerve injury was treated with dynamic splinting. On follow-up, all four patients showed radiological and clinical signs of union, and radial nerve function returned to normal. These fractures occurred at the junction of the middle and distal thirds of the humeral shaft, a site that carries the risk of injuring the radial nerve due to its course. Therefore, the present case series aimed to determine the mechanism of injury, identify the type of fractures and associated nerve injuries seen in such cases, compared these findings with available literature, and ascertain the clinical outcomes of managing such injuries.

Challenges and Outcome of Infected Non Union of Bones using Masquelet Technique: A Case Series

Shivam Sahu, V Venkataram, Jomon De Joseph, KR Ganesh Krishnan

Infected non union of bones poses a significant challenge for orthopaedic surgeons due to the complexity of the problem, which includes bone necrosis, segmental bone loss, sinus tract formation, fracture instability, and scar adhesion of soft tissues. Bone infections remain a prevalent complication following fracture fixation. Effective management involves a multi-step approach, including debridement, soft tissue reconstruction, and bone stabilisation. The induced membrane technique, a two-stage process, has been successfully used to treat bone defects in both the upper and lower extremities. Here, four cases of infected non union treated using the Masquelet technique at various locations are presented. This technique involves a two-stage approach, where an induced membrane forms around a cement spacer, leading to the successful resolution of infection and bone union. Challenges encountered in these cases included recalcitrant infection, complex deformities, sclerotic bone ends, large bone gaps, shortening, and joint stiffness. Co-morbid factors such as smoking, diabetes, and hypovitaminosis D also influenced treatment choices and duration. All four cases treated with the Masquelet technique showed successful resolution of osteomyelitis, osseous union, and improvement in functional outcomes. Follow-up assessments revealed an average Visual Analogue Scale (VAS) improvement from 30 to 7.5, complete eradication of infection, and an average Lawton-Brody instrumental activities of daily living scale improvement from 13/23 to 21/23, with complete union of bone achieved in all four cases. Hence, it was concluded that the Masquelet technique is an effective approach for treating infected non union of bones, leading to the successful resolution of infection and bone union. Patience and perseverance are essential for achieving optimal outcomes.

Unveiling the Spectrum: Case Series on Congenital Diaphragmatic Hernia Variations in Second Trimester Foetal Autopsies

Suganya Saminathan, AK Manicka Vasuki, Amudha Govindarajan

Congenital Diaphragmatic Hernia (CDH) is a developmental defect characterised by abnormal diaphragm formation, leading to the herniation of abdominal contents into the thoracic cavity. CDH occurs in approximately 1 in 2,500 live births and can significantly affect pulmonary development and overall foetal health. The present series aimed to document the spectrum of presentations observed in second-trimester autopsies, which may aid in understanding the variability of the condition and its implications for foetal outcomes. Presentations of CDH were observed in three foetuses with gestational ages ranging from 14 to 28 weeks. Among the three CDH cases discussed, each presented a different type: one was bilateral CDH, one was left-sided CDH and one was right-sided CDH. The first specimen exhibited bilateral CDH of Bochdalek’s type on the right, with an absent hemi-diaphragm on the left. The foetus had massive herniation of abdominal contents into the right-side of the thoracic cavity, resulting in a significant mediastinal shift to the left. The second specimen displayed left-sided Bochdalek’s type of CDH, which was associated with herniation of the intestinal loops into the left-side of the thoracic cavity, resulting in a mediastinal shift to the right. The third specimen presented right-sided Morgagnian type of CDH, where only a small portion of the left lobe of the liver had herniated into the thoracic cavity and there was no mediastinal shift. The variability in presentations of CDH in the present case series underscores the complexity of the condition. Factors influencing outcomes include the timing of the hernia diagnosis, the degree of lung hypoplasia and the presence of associated anomalies. The identification of CDH through ultrasound allows for better prenatal counseling and management strategies for affected pregnancies.

Insights into Management of Smooth Muscle Tumours with Uncertain Malignant Potential: A Case Series

Amey Chugh, Janvi Patel, Varshini Vadithala, Prashansa Gupta

Smooth Muscle Tumours with Uncertain Malignant Potential (STUMPs) represent a rare and diagnostically challenging category within uterine neoplasms. These tumours exhibit biological features similar to both benign leiomyomas and malignant leiomyosarcomas, complicating diagnosis and management. STUMPs are characterised by their potential for unpredictable clinical behaviour, including local recurrence and, in rare cases, metastasis, necessitating careful postoperative monitoring. Classifying uterine mesenchymal tumours is difficult due to significant overlap with terms such as atypical leiomyoma, atypical leiomyoma with low risk of recurrence, and atypical leiomyoma with low malignant potential. Despite their infrequent occurrence, STUMPs have garnered increasing attention due to their ambiguous nature and the clinical implications they pose. Diagnostic criteria and management strategies for STUMPs remain areas of active research and debate within gynaecological pathology and oncology. The present case series was aimed to contribute to the existing body of literature by presenting three cases of female patients (aged 38-year-old, 34-year-old and 47-year-old) of large uterine leiomyomas that were later diagnosed as STUMPs postoperatively following hysterectomy. Each case underscores the complexities involved in diagnosing and managing these tumours, emphasising the importance of multidisciplinary collaboration and long-term follow-up in optimising patient outcomes.

Transient Neonatal Hyperparathyroidism Unfolding a Noteworthy Cause: A Series of Four Cases

AO Vinitha, VH Sankar, Rahul Aswathy, Karun Arjun, T Alex Sherrin

Transient Neonatal Hyperparathyroidism (TNHP) is an abnormal bone disorder caused by impaired maternal-foetal calcium transport across the placenta, leading to inadequate foetal bone mineralisation. It is caused by mutations in the gene encoding the Transient Receptor Potential Channel, Subfamily V, Member 6 (TRPV6), which is involved in maternal-to-foetal calcium transport. The TRPV6 mutation results in hypocalcaemia in the foetus, leading to skeletal deformities such as narrow chest walls, multiple rib fractures, bowing of long bones, and generalised osteopenia. Babies are usually born with respiratory distress that requires ventilatory support due to a pliable chest wall. The skeletal abnormalities closely resemble those of osteogenesis imperfecta, skeletal dysplasias and congenital rickets. All four cases described in this series presented with clinical features of undermineralisation of bone and chest wall deformities resembling congenital rickets or osteogenesis imperfecta. One case of suspected osteogenesis imperfecta was found to have a homozygous variant in the TRPV6 gene upon genetic testing. The other three cases presented with respiratory distress after birth and had homozygous variants in the same gene (TRPV6). In newborns, similar clinical presentations coupled with the presence of hyperparathyroidism should raise suspicion of TNHP. Genetic studies may reveal homozygous or compound heterozygous variants in the TRPV6 gene. There will be significant clinical improvement with treatment using oral calcium, as the intestinal transport of calcium becomes effective after birth. Early identification of this transient condition is helpful for timely management.

A Rare Presentation of Keratoderma Blennorrhagicum: Images in Medicine

Pankaj Yadav, Vaishali Kuchewar, Devesh Nagpure, Madhvi Jain

Keratoderma Blennorrhagicum (KB) is a rare dermatologic manifestation commonly associated with reactive arthritis, particularly Reiter’s syndrome (1). Reiter’s syndrome is an autoimmune disorder that develops in response to an infection, commonly in the intestines, urinary tract, or genital area. It is characterised by a triad of symptoms: arthritis, conjunctivitis, and urethritis. Characterised by hyperkeratotic skin lesions, it poses diagnostic challenges due to its rarity and resemblance to other dermatoses (2),(3). This is a unique case of KB in a 48-year-old male with a history of a recent genitourinary infection. A 48-year-old male presented with multiple hyperkeratotic lesions that were yellowish with a waxy texture on the lower limbs and lower back for the past three months. The patient also complained of itching and pain, with no discharge from the lesions. He had a known case of Reiter’s syndrome for the last 10 years, for which he was taking oral corticosteroids (Tab Prednisolone 10 mg once a day) and Non Steroidal Anti-Inflammatory Drugs (NSAIDs) (Tab Diclofenac 50 mg as needed). Physical examination revealed thickened, yellowish plaques with underlying erythema. The lesions measured 13×4 cm on both lower limbs and 10×6 cm on both knee joints, were well-demarcated, and some were coalescing into larger areas of hyperkeratosis (Table/Fig 1). Notably, the patient also exhibited intermittent symptoms of arthritis in the knees and lower back over the past 4-5 days, alongside urethritis for six months. There was no significant family history or co-morbidities like diabetes and hypertension. Laboratory investigations showed elevated inflammatory markers, including an Erythrocyte Sedimentation Rate (ESR) of 130 mm/hour and positive C-reactive Protein (CRP), supporting the diagnosis of reactive arthritis, pustular psoriasis, psoriasis vulgaris, lichen amyloidosis, and erythrodermic psoriasis. Based on the clinical presentation, laboratory findings, and the patient’s known case of Reiter’s disease, the cutaneous lesions were diagnosed as KB. The clinical image of KB in present patient demonstrates characteristic features: multiple, well-defined hyperkeratotic plaques primarily affecting both lower limbs. The lesions appear yellowish with a waxy texture, and small pustules can be observed within the plaques, indicative of ongoing inflammation. The surrounding skin is erythematous, further highlighting the inflammatory nature of the condition. These lesions are typically symmetrically distributed, and their size can range from a few millimeters to several centimeters in diameter. The patient was treated as described in (Table/Fig 2). Follow-up and outcomes: The patient was monitored regularly over a three-month period. Significant improvement was noted within one month, with a resolution of the lesions (Table/Fig 3). By the end of the treatment period, the lesions had completely resolved, and no recurrence was observed. The patient reported overall well-being and was satisfied with the treatment outcome. The KB is a crucial dermatologic sign of reactive arthritis. Although the skin lesions are similar in appearance to psoriasis, they have distinct clinical correlations with systemic symptoms such as urethritis, conjunctivitis, and arthritis. Based on the clinical presentation, laboratory findings, and the patient’s known case of Reiter’s disease, the cutaneous lesions were diagnosed as KB. The study conducted by Dhakad U et al., discusses a 15-year-old male patient who presented with hyperkeratotic lesions on the palms and soles, along with joint pain (4). The case underscores the importance of recognising Keratoderma Blisters (KDB) as a manifestation of systemic inflammation. Timely intervention, including antibiotics and anti-inflammatory treatment, led to significant improvement (4). Another study conducted by Games et al., describes a 26-year-old female patient with KDB associated with reactive arthritis. The patient exhibited hyperkeratotic skin lesions on the soles and palms, characteristic of KDB, alongside joint involvement. Treatment with NSAIDs and Disease-modifying Antirheumatic Drugs (DMARDs) led to significant improvement in both skin and joint symptoms (5). Management typically includes systemic NSAIDs and DMARDs. Early recognition and appropriate management are essential to address both the cutaneous and systemic manifestations effectively.

Acanthosis Nigricans: A Rare Presentation in a Patient with Hypothyroidism and Metabolic Syndrome

Rucha Sawant, Pranav Chaudhari, Sourya Acharya, Roma Chavhan

A 38-year-old male came to the Medicine Outpatient Department (OPD) with complaints of easy fatigability for four months. He had no other significant history. Upon general examination, his Body Mass Index (BMI) was 33.2 kg/m², and his waist circumference was 142 cm. The patient was diffusely hyperpigmented; upon examining his neck region, a dark, velvety hyperkeratotic plaque suggested Acanthosis Nigricans (AN) (Table/Fig 1). His axillary region showed similar pigmentation (Table/Fig 2)a,b. Upon further examination, the patient also had facial suffusion, hoarseness of voice, coarse skin and brittle hair (Table/Fig 3). Upon examination, his blood pressure was 138/92 mmHg. On neurological examination, he displayed delayed relaxation of the ankle reflex [Video-1]. His cardiovascular, respiratory, and abdominal examinations were within normal limits. When the case was further investigated, his lipid profile was deranged, with increased triglycerides at 288 mg/dL (<150 mg/dL) and decreased High-density Lipid (HDL) at 30 mg/dL (>40 mg/dL). His fasting and postprandial blood sugars were within the normal range, ruling out diabetes mellitus as a contributing factor for AN. He was diagnosed with Metabolic Syndrome (MS) based on the National Cholesterol Education Program (NCEP) - Adult Treatment Panel (ATP) III criteria (1). His thyroid profile showed an elevated Thyroid stimulating Hormone (TSH) of 78 μIU/mL (0.4-4.68 μIU/mL), with free T3 at 1.7 pg/mL (2.76-5.26 pg/mL) and free T4 at 0.2 ng/mL (0.77-2.18 ng/mL), suggestive of overt hypothyroidism. The patient was started on levothyroxine 100 mcg once a day, advised dietary and lifestyle modifications, and instructed to follow-up in a month. Despite a lack of significant change in BMI (32.9 kg/m2), after one month, the patient experienced positive results from treatment. His fatigue levels became minimal, and thyroid function tests demonstrated improvement, with TSH reaching 60 μIU/mL (0.4-4.68 μIU/mL), free T3 reaching 2.6 pg/mL (2.76-5.26 pg/mL), and free T4 reaching 1 ng/mL (0.77-2.18 ng/mL). These findings suggest the need for continued monitoring and potential treatment adjustments for optimal outcomes.

Dejerine-Roussy Syndrome: Understanding Chronic Thalamic Pain

Saket S Toshniwal, Jiwan Kinkar, Yatika Chadha, Sourya Acharya, Sunil Kumar

A 50-year-old male, known to be hypertensive and non compliant with medications, with a significant past history of stroke three months ago, presented to the hospital with chief complaints of persistent burning sensations in his left arm and leg, as well as his entire face. He also reported episodes of sharp shooting pain in these regions lasting for a few seconds. Additionally, he complained of increased sensitivity to touch and intolerance to any painful stimuli, experiencing pain even upon touch, which caused significant discomfort and led to feelings of depression. These complaints have been present since he had a stroke three months ago, and they have gradually progressed to a stage where the pain has become intolerable. A Magnetic Resonance Imaging (MRI) of the brain performed at the time of the stroke showed a lesion in the ventroposterior lateral thalamic region, leading to the diagnosis of the debilitating condition known as Dejerine-Roussy syndrome, as shown in (Table/Fig 1)a-d. The patient was started on anticonvulsant drug therapy (tablet pregabalin 75 mg once at night) for the management of his neuropathic pain, along with a tricyclic antidepressant (tablet amitriptyline 10 mg once at night), and was asked to follow-up after a week. On the follow-up after seven days, the patient reported no significant relief in pain. Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) (tablet duloxetine 60 mg once daily) were added to his treatment. Subsequent follow-ups showed a reduction in the intensity of his pain, but it was still persistent, disrupting his day-to-day activities and causing mental frustration. Rehabilitation was further advised for functional improvement and the emotional well-being of the patient. The rehabilitation process, along with ongoing pain management, was initiated by educating the patient about this debilitating disorder, its prognosis, and all available treatment options such as physiotherapy, psychotherapy, as well as various invasive and non invasive non pharmacological treatments like deep brain stimulation, repetitive transcranial magnetic stimulation, motor cortex stimulation, and transcutaneous electrical nerve stimulation. In this patient, physiotherapy and psychotherapy were initiated to address the emotional stress associated with this disorder. Desensitisation therapy was also started by identifying various triggers of the patient’s pain stimuli and implementing gradual exposure therapy to painful stimuli in a controlled environment where the patient feels safe and supported, along with relaxation techniques such as deep breathing and progressive muscle relaxation. This minimal stimulus was progressively increased to more intense stimuli to help the patient adapt and desensitise to painful triggers, and the patient was advised to practice these techniques at home. Regular follow-up, along with a multidisciplinary approach involving healthcare professionals such as physical therapists, occupational therapists, pain specialists, psychologists and social workers, was crucial in managing the patient. Although the pain persisted with decreasing intensity in further follow-ups, the patient became acclimated and coped well with his disorder.

Thoracic Calcinosis Cutis in a Case of Dermatomyositis

Souvik Sarkar, Babaji Ghewade

A 42-year-old man presented at the outpatient department with a two-month history of cough accompanied by mucoid expectoration, as well as a gradual onset of breathlessness rated at Modified Medical Research Council (MMRC) Grade 1 to 2 over the past five years, progressing to Grade 3 in the last two months. Additionally, he reported intermittent joint pain, loss of appetite, and a progressive weight loss of approximately 20 kilograms over the course of five years. The cough tended to worsen in the mornings but improved throughout the rest of the day. He experienced stiffness in the small joints of his hands, which persisted throughout the day. He also mentioned a previous occurrence of maculopapular rash, a month earlier to the onset of respiratory symptoms, on his hands and face, although no lesions were currently present. Despite seeking treatment in the past including irregular use of both allopathic and ayurvedic medicines, his symptoms had not been alleviated. He denied any seasonal variation in symptoms, allergies, comorbidities, or past known diseases and reported being a non-smoker. Upon examination, the patient was found to be underweight with a Body Mass Index (BMI) of 17 kg/m2. Vital signs were within normal limits, with a pulse rate of 82/min, blood pressure of 130/80 mmHg, respiratory rate of 22 breaths/min, and oxygen saturation of 94% on room air. Auscultation revealed bilateral crackles in the infrascapular, infra-axillary, and mammary areas. No other significant abnormalities were noted. Blood tests revealed elevated Lactate Dehyrogenase (LDH) levels (300 U/L), while Antinuclear Antibody (ANA) test was negative. Serum calcium, phosphorous, and creatine phosphokinase levels were within normal range. All other serological panels with respect to connective tissue, autoimmune diseases, HIV, Hepatitis-B and Hepatitis-C were negative. Chest X-ray showed bilateral patchy infiltrates in the lower and mid-zones with blunting of the costophrenic angles and bilateral linear subcutaneous calcifications in the thoracic wall and proximal part of the upper limbs (Table/Fig 1). Spirometry revealed a restrictive pattern with Forced Vital Capacity at 64% of the predicted value. High-Resolution Computed Tomography (HRCT) of the thorax demonstrated peripheral, bilateral lower lobe subpleural reticular shadows and septal thickening, with additional findings of ground glass opacities, predominantly in the right middle and lower lobes. Fascial calcifications were noted along the posterolateral chest wall (Table/Fig 2). Abdominal and pelvic CT scans showed no significant abnormalities besides soft-tissue and muscle calcifications. X-rays of bilateral femurs showed soft-tissue calcifications. The above-mentioned radiological scans did not show any evidence suggestive of malignancy. Echocardiography results were within normal limits. Skin biopsy confirmed Dermatomyositis (DM), showing lymphocytic infiltrate with mucin deposition in the reticular dermis, mild irregular epidermal hyperplasia, and smudged dermo-epidermal junction. Magnetic Resonance Imaging (MRI) of the thighs and pelvis revealed muscle signal alterations and intermuscular fluid. Subsequent therapy with oral prednisolone, methotrexate, and hydroxychloroquine showed no improvement, leading to initiation of Mycophenolate Mofetil (MMF) at 1 g/day, resulting in reduced joint pain and symptom frequency. The patient was discharged on maintenance therapy with MMF, which led to symptomatic improvement, and he remained stable at the one-month follow-up. DM, an autoimmune inflammatory disease affecting skin and muscles, is characterised by progressive symmetrical proximal muscle weakness and a typical skin rash, varying in intensity. Systemic manifestations often involve the pulmonary and gastrointestinal systems, and there’s some association with internal malignancy too (1). Calcinosis cutis is a persistent condition characterised by the accumulation of insoluble calcium deposits in the skin and subcutaneous tissue. This condition affects 20-40% of individuals with Juvenile Dermatomyositis (JDM) (2),(3) and up to 20% of those with adult DM. Currently, there are no universally effective treatments for calcinosis; however, immunosuppressive therapies might be used to prevent its development and progression (4),(5),(6).

Clinical Images of Basal Cell Carcinoma of Occipital Region and Right Ear Lobe in an Adult Male: Common Yet Uncommon

Prastuti P Dhande, Sheetal Asutkar, Shubham Bobade

A 75-year-old male patient, a farmer residing in a rural area, presented to the outpatient department with primary complaints of a localised swelling over the right side of the occipital region and right earlobe posteriorly. The swelling has been present for 12 months, has gradually increased in size and is not associated with pain. The patient had no family history of similar symptoms, no history of prior surgical intervention, and no significant medical history. Upon inspection, the swelling was found to be nodulocystic, well-circumscribed, and scaly, measuring about 6×6 cm in size with warmth, blanching erythema, dilated vessels, and scabs over the surface (Table/Fig 1)a. The smaller swelling present on the right earlobe posteriorly measuring around 1×1 cm was also found to be nodulocystic (Table/Fig 1)b. There was no lymphadenopathy present over the neck. The diagnosis was Basal Cell Carcinoma (BCC)- rodent ulcer which was confirmed by ultrasonography-guided Fine Needle Aspiration Cytology (FNAC) reports which stated that smears showed small baseloid cells mostly in monomorphy, background showing haemorrhagic material suggesting BCC. The patient was shifted to the oncology department where 5 fluorouracil (5-FU) topical ointment (1) therapy was administered to the patient; however, a poor prognosis was observed. BCC is the most prevalent form of skin cancer globally (2). Many countries exclude BCC data from cancer registries because of its relatively low mortality rate. However, analysis of insurance records and official statistics in the United States estimates that BCC incidence reaches 4.3 million cases annually (3). This epidemiological trend is anticipated to continue in the near future, driven by improved diagnosis and an increasingly ageing population with a history of Ultraviolet (UV) exposure (2),(3),(4). The risk of developing a BCC is consequently due to a complex interplay of environmental, phenotypic, and genetic factors. BCC primarily manifests in four distinct types: nodulo-ulcerative, pigmented, morpheaform, and superficial (5). The incidence of BCC rises significantly after the age of 40 years. However, recent trends show a growing number of cases among younger individuals, especially women, due to increased UV exposure from both sunlight and artificial sources (6). The patched/hedgehog intracellular signalling pathway regulates cell proliferation, and its persistent activation plays a role in the development of BCC. The most common mutations involve inactivating changes in the Patched-1 gene (PTCH1) and activating changes in SMO (smoothened receptors), leading to abnormal activation of the Hedgehog pathway and subsequent tumour development (7). Diagnosis of BCC can be done in various ways like inspection is the first process for diagnosis of BCC followed by dermoscopy with confirmation by biopsy and histopathologic examination. Histologically, BCC is characterised by the proliferation of uniform basaloid cells with hyperchromatic nuclei and minimal, poorly defined cytoplasm, along with peripheral palisading and retraction artefacts. Although basaloid cells resemble epidermal basal cells in appearance, they function more like follicular germinative cells (8),(9). The differential diagnosis of BCC includes Squamous Cell Carcinoma (SCC), malignant melanoma, psoriasis, solar keratosis, and molluscum contagiosum (10). Nodular BCC might be mistaken for trichoblastoma or trichoepithelioma, while superficial BCC can resemble inflammatory dermatoses like psoriasis and eczema. Morphea-like BCC may be mistaken for a morphea plaque or a scar. In these situations, histopathological examination is essential for confirming the diagnosis of BCC. Current evidence indicates that surgical approaches remain the gold standard for treating BCC, with Mohs micrographic surgery primarily reserved for high-risk lesions. For selected primary low-risk lesions, alternative treatments such as Photodynamic Therapy (PDT), cryotherapy, topical imiquimod, and 5-FU may be appropriate. Radiotherapy is a viable non-surgical option, particularly for older patients (11),(12). This procedure involves removing a thin margin of tissue circumferentially around and beneath the clinical margins of a skin tumour. Electric cauterisation and curettage are performed in lesions that are <5 cm in greatest diameter. PDT is a newer modality, in the tumour cells are first sensitised with methyl-amino levulinate and then irradiated with a light of 630 nm wavelengths (13). Even though large-sized BCCs are extremely rare, they can still be diagnosed accurately and treated effectively with surgical procedures similar to those used to treat smaller-sized carcinomas.

Letter to the Editor, on “Effect of Anaemia on Cognitive Ability in Female Dental Undergraduate Students: A Cross-sectional Study”

Madhuri Abhay Jagtap, Anita Deepak Deshmukh

Dear Sir, I read the original article “Effect of Anaemia on Cognitive Ability in Female Dental Undergraduate Students,” a cross-sectional study by Qairunnisa S et al., (1). I found this article very interesting and potentially helpful in improving the cognitive ability of students. However, there are a few questions that need to be addressed: A) In this study, 50 students were found to have mild anaemia (Hb: 10.408±0.84 gm/dL) and 50 students had normal Hb (Hb: 12.718±0.65 gm/dL). As there are various important factors, other than anaemia, that affect cognitive ability, if the anaemic students had received appropriate treatment based on the type of anaemia, and if their cognitive function were reassessed using these tests (the digit symbol substitution test, letter cancellation test, and Stroop test), it could have been confirmed that anaemia causes a decrease in cognitive ability. B) One of the important factors that affect cognitive ability is basic intelligence. Because of its general nature, intelligence integrates cognitive functions such as perception, attention, memory, language and planning (2). Various studies have proven that Sleep Deprivation (SD) can significantly affect cognitive ability. The decrease in attention and working memory due to SD is well established. Vigilance is especially impaired, but a decline is also observed in several other attentional tasks. These include measures of auditory and visuospatial attention, serial addition and subtraction tasks, and different reaction time tasks (3). In some studies, it has been shown that mental stress and the personality of the individual also affect cognitive ability. The total effect, which is a combination of the direct effect of stress and the indirect effect of personality, indicates that stress is negatively associated with total/crystallised cognition (4). C) Now a days, the incidence of addictions or drug abuse has increased, and various studies have proven that people with Substance Use Disorders (SUDs) have moderate deficits in memory, attention, executive functions and decision-making (5). Therefore, factors such as addictions or psychological problems should also be excluded when studying the effect of anaemia on cognitive ability. Response to Reviewer A) We agree with your valuable comment. As this was a student Short Term Project (STS) funded by ICMR, we were restricted by a time limit, and we submitted a research proposal with limited parameters that were approved. Unfortunately, we were unable to extend it. However, we did recommend conducting an awareness program on anaemia for dental students after the report submission. B) Thank you for your patient review and for going through many research articles that support and enhance our work analysis from different perspectives. As the author concludes, that intelligence integrates cognitive functions, which are also reliable measures. We agree with this point and appreciate the valuable references quoted, which can be used to extend our work in long-term research. C) As a female student in India, especially in Tamil Nadu, we can confidently say that in the village where our college is located, substance abuse is rare and stigmatised. Women in our community are often discouraged from indulging in any form of substance use and are instead encouraged to focus on education, family and social responsibilities. The cultural and social norms in the village prioritise tradition and modesty, making it unlikely for women to engage in substance abuse. However, we are aware that this might not be the case in other parts of the country or in different social circles, and we believe it is essential to address the growing concern of substance abuse among Indian youth. Thanks.

Capecitabine-induced Hand-foot Syndrome with Hyperpigmentation on Oral Mucosa and Nails: A Rare Entity

Suprit Malali, Sourya Acharya

Dear Editor, We present two cases of Capecitabine-induced Hand-Foot Syndrome (HFS), hyperpigmentation on the oral mucosa, and nails. Case 1 A 28-year-old female, previously diagnosed with stage 4 left-sided inflammatory breast cancer, along with metastases to the right breast and skeletal sites one year ago, as confirmed by trucut biopsy and Positron Emission Tomography scan (PET), presented to our clinic with complaints of fatigue and generalised weakness persisting for the last month. The patient does not report any co-morbidities. Further clinical assessment and investigation are warranted to address the current symptoms and determine the appropriate course of management for the underlying cancer and associated symptoms. She received four cycles of injectable capecitabine and cyclophosphamide and later was shifted to oral chemotherapy with the same drugs for the last six months. All routine investigations such as complete blood count, liver function test, kidney function test, coagulation profile, and random blood sugar were within normal limits. The chest X-ray was normal. The Electrocardiogram (ECG) was suggestive of normal sinus rhythm. Upon examination, vitals were normal, and hyperpigmented patches and macules with blackish to grey colour were seen in the oral mucosa, gingival mucosa, teeth, palmar and dorsal aspects of hands, and plantar and dorsal aspects of the foot (Table/Fig 1)a-d,(Table/Fig 2)a-d. Case 2 A 60-year-old female presented to our emergency department with complaints of breathlessness (without aggravating or relieving factors), cough with expectoration, and low-grade fever for the past five days. She was a known case of adenocarcinoma of the esophagus and had received nine cycles of chemotherapy with capecitabine and cisplatin. During examination, the patient exhibited an SpO₂ level of 90% in ambient temperature conditions, while all other vital signs remained within normal ranges. Chest auscultation revealed bilateral fine crepitations. No abnormalities were detected in other organ systems. All routine investigations were performed. The leukocyte count was raised (15,400 cells/cu mm), while liver function tests, kidney function tests, and random blood sugars were within normal limits. The chest X-ray suggested bilateral scattered haziness (Table/Fig 3). The ECG showed normal sinus rhythm. On local examination, it was noticed that the patient had hyperpigmented lesions on the nails of her hands (Table/Fig 4)a,b. Capecitabine is an oral chemotherapy drug frequently used to treat metastatic breast cancer and is also recommended as a first-line treatment for gastrointestinal malignancies. As a prodrug, it is rapidly absorbed by the liver and converted to 5-fluorouracil (5-FU) by the abundantly expressed thymidine phosphorylase enzyme in tumour tissue. Hand-foot syndrome (HFS) is a side-effect of capecitabine characterised by skin hyperpigmentation, hyperkeratosis, and palmar-plantar desquamation (1),(2). The pathophysiology of oral mucosal hyperpigmentation caused by capecitabine is poorly understood and underreported in the literature. Additionally, earlier research has questioned whether hyperpigmentation of the oral mucosa is merely another symptom of HFS or if it exhibits a distinct behaviour (1),(3). The purpose of the letter is to report a case of oral mucosal hyperpigmentation in a cancer patient who had been treated with oral capecitabine as an antineoplastic therapy. The cause of capecitabine-induced nail changes is unknown, but immunosuppression and subsequent nail bed colonisation, disruption and change of the nail plate, loss of adhesion between the nail plate and nail with subungual oedema, as well as erosive and inflammatory processes, may all play a role in causing melanonychia (4),(5). One extremely uncommon side-effect of capecitabine is hyperpigmentation of the oral mucosa and nails (1). It is still unknown if it is a component of an early HFS manifestation or if it exists independently. We present a case of oral mucosal and nail hyperpigmentation that occurred prior to the clinical diagnosis of HFS and may be an early indicator of this condition. Capecitabine-induced hyperpigmentation of the hands and feet is a widely recognised and well-documented side-effect (1). However, the occurrence of capecitabine-induced hyperpigmentation affecting the oral mucosa and nails is considered rare and distinctive. Understanding this uncommon manifestation is crucial as it enables early identification of the side-effect. Such awareness is valuable in facilitating timely intervention, potentially leading to a modification of the chemotherapy drug if deemed feasible. Therefore, having knowledge of this unique aspect of capecitabine-induced hyperpigmentation is significant for healthcare professionals involved in cancer treatment.

Efficacy of Intrathecal 0.75% Hyperbaric Ropivacaine versus 0.5% Hyperbaric Bupivacaine for Elective Inguinal and Perineal Surgery: A Randomised Double-blinded Clinical Study

Bhavini Shah, Dipanjali Mahanta

Introduction: Ropivacaine, an amide local anaesthesia, often considered safer alternative to bupivacaine. Bupivacaine, a longer-acting agent that provides dense motor blockade, is known to carry a higher risk of re-entrant arrhythmias and cardiac depression with accidental intravascular injection. The shorter duration of action, coupled with profound sensory block and comparatively less side-effects, makes ropivacaine useful in tackling cases of day care surgery. Aim: To compare the efficacy of hyperbaric ropivacaine versus bupivacaine for elective inguinal and perineal surgery under spinal anaesthesia in terms of time of sensory and motor block, time taken to reach peak T8 level sensory block, total duration of both sensory and motor block, time of first micturition, and any associated side-effects. Materials and Methods: The present randomised double-blind clinical study, was carried out in the Department of Anaesthesia, Dr. D. Y Patil Medical College, Hospital and Research Centre (tertiary healthcare centre), Pune, Maharashtra, India, from March 2023 to August 2023. Study involved 30 patients aged 18-60, classified as American Society of Anaesthesiologists (ASA) grade I and II. Patients were randomly assigned to group RH (receiving hyperbaric ropivacaine) or group BH (receiving hyperbaric bupivacaine). The study assessed for onset and duration of sensory block at T-8 dermatome. The study also assessed motor block onset and duration using modified Bromage scale, observing postoperative micturition, intraoperative haemodynamic changes and adverse effects. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 16.0, with a p-value of <0.05 considered significant. Results: Demographic profile in terms of age {Mean±Standard Deviation (SD) in group RH: 42.93±14.73 years vs group BH: 39.06±11.94 years), gender distribution, type of surgery performed and its duration (group RH: 85.67±39.5 minutes vs group BH: 98.4±32.8 minutes) was not significant. The onset of sensory block (2.09±0.69 min) and motor block (3.52±0.66 min), the time taken to reach T8 level (3.40±0.93 min), was faster in the hyperbaric ropivacaine group. Similarly, the duration of motor block (261.93±73.21 min), time taken for the recession of the sensory block to S2 (351.4±66.78 min), and the recession of the motor block to Bromage scale 0 (291.93±64.93 min) were faster in ropivacaine group. The time taken for the passage of first micturition post-subarachnoid block was earlier (338.73±31.29 min) in ropivacaine group. Conclusion: A 0.75% hyperbaric ropivacaine is more efficacious, with faster onset of sensory and motor blockade, relatively quick recovery profile, and an earlier time of first micturition in comparison to 0.5% hyperbaric bupivacaine.

Dexmedetomidine versus Dexamethasone as Perineural Adjuvants in Supraclavicular Brachial Plexus Block: An Interventional Study

Introduction: Supraclavicular block is a common regional anaesthetic technique for upper limb surgeries. Adjuvants like dexamethasone and dexmedetomidine can enhance the block’s efficacy and prolong the duration of anaesthesia and analgesia. Aim: To compare the effects of perineural dexamethasone versus perineural dexmedetomidine added to a local anaesthetic mixture in supraclavicular brachial plexus block for upper limb surgeries. Materials and Methods: This interventional study was conducted in the Department of Anaesthesiology at Dhiraj Hospital, Vadodara, Gujarat, India from October 2023 to April 2024 on 80 patients with American Society of Anaesthesiologists (ASA) physical status I and II, aged 18 to 65 years, scheduled for surgery under supraclavicular brachial plexus block. Patients were allocated into two groups of 40 patients each. Group 1 received 12 mL of 0.2% lignocaine with adrenaline and 13 mL of 0.5% bupivacaine along with dexmedetomidine 50 mcg. Group 2 received the same local anaesthetic mixture with dexamethasone 8 mg (2 mL). The onset and duration of sensory and motor blocks, haemodynamic changes {variations in pulse, blood pressure, and oxygen saturation (SpO₂)}, duration of rescue analgesia, side-effects, and complications were evaluated. Chi-square test and t-test were applied for statistical evaluation. Results: Group 1 had a significantly lower average age (35.38±9.03 years) compared to Group 2 (46.40±13.12 years) (p=0.000039). Group 1 had a slower onset of sensory and motor blockade compared to Group 2 (14.38±2.19 minutes vs. 13.00±1.89 minutes, p=0.0036; 16.20±2.14 minutes vs. 15.70±1.99 minutes). Group 2 also showed significantly longer durations for motor blockade (918.75±65.80 minutes vs. 632.60±23.09 minutes, p=3.10×10-44), postoperative analgesia (1051.00±90.18 minutes vs. 811.12±17.23 minutes, p=1.00×10-28), and time for rescue analgesia (1116.75±93.96 minutes vs. 826.50±13.92 minutes, p=2.40×10-32). Haemodynamics and SpO2 were comparable between the two groups. Conclusion: Dexamethasone, as an adjuvant to a local anaesthetic mixture in supraclavicular brachial plexus block, provided excellent quality of postoperative analgesia with minimal side-effects. However, the incidence of hypotension and bradycardia was higher with dexmedetomidine, which could be managed with routine clinical measures.

Preparation of Nutmeg Gel and Evaluation of its Efficacy as Local Drug Delivery in Stage II Grade A Periodontitis Patients: A Prospective Interventional Study

Vazeeha Afrin Syed, AS Pavithra, Arvina Rajasekar, Rajeshkumar Shanmugam

Introduction: Periodontitis is defined as a chronic inflammatory disease caused by specific microbes, which triggers the production of inflammatory mediators. This process leads to the loss of tissue structure and function. Nutmeg has been found to consist of a number of chemical components that have been linked to antioxidant, health promoting, and disease-prevention activity. Aim: To prepare nutmeg gel and to assess its anti-inflammatory, antioxidant, and cytotoxic activities, and its effectiveness as a locally delivered drug in the management of stage II grade A periodontitis. Materials and Methods: The present study was conducted in Department of Periodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai, Tamil Nadu, India. A 30 mg nutmeg gel was prepared and subjected to anti-inflammatory, antioxidant, and cytotoxic assays. Followed by in-vitro analysis, 40 patients with stage II grade A periodontitis patients who reported between June 2023 and September 2023 to the Department of Periodontology were enrolled. A total of 20 patients were subjected to Scaling and Root Planing (SRP) alone (Group A - Control), and the remaining 20 patients were subjected to SRP + placement of 0.3% nutmeg gel (Group B - Test). Probing Depth (PD) and Clinical Attachment Level (CAL) were recorded at baseline and after three months. The data were analysed for statistical significance using Statistical Package for the Social Sciences (SPSS) software, version 23.0. Intergroup and intragroup comparison was done using independent t-test and paired t-test, respectively, with a p-value <0.05 considered statistically significant. Results: In vitro analysis revealed that the anti-inflammatory and antioxidant activity of nutmeg gel was comparable to the control. Also, the survival rate of nauplii fell within acceptable ranges. Followed by in-vivo analysis, in-vivo analysis was done. A total of 13 females and seven males with a mean age of 29.45±3.98 years were treated with SRP (Group A), and eight females and 12 males with a mean age of 28±3.22 years were treated with SRP along with 0.3% nutmeg gel (Group B). PD and CAL showed significant reduction from baseline to three months in test and control groups and was statistically significant (p<0.05). On intergroup comparison in terms of PD and CAL statistically significant difference was present (p<0.05) at the end of three months, favouring Group B. Conclusion: The developed nutmeg gel was found to be effective when used in addition to SRP as a Local Drug (LD) among patients with stage II grade A periodontitis.

Comparison of Hyperbaric 0.5% Levobupivacaine and Hyperbaric 0.75% Ropivacaine for Intrathecal Use in Infraumbilical Surgeries: A Randomised Clinical Study

Tejash H Sharma, Jagrati Jain, Priya Kishnani, Richa Tailor, Sara Mary Thomas

Introduction: Ropivacaine is a long-acting amide local anaesthetic agent and the pure S (-) enantiomer of propivacaine. It has been readily available as an isobaric solution for a long time. Recently, a hyperbaric solution has become available in the Indian market. Levobupivacaine is the pure S-enantiomer of bupivacaine, which is safer than racemic bupivacaine in regional anaesthesia. It has less affinity and strength of depressant effects on myocardial and Central Nervous System (CNS) vital centers in pharmacodynamic studies, along with a superior pharmacokinetic profile. Aim: To compare the sensory and motor blockade, time of two-segment regression, time for rescue analgesia, haemodynamic effects and sedative effects between hyperbaric 0.5% levobupivacaine and hyperbaric 0.75% ropivacaine. Materials and Methods: This prospective, double-blinded and randomised clinical study was conducted in the Department of Anaesthesiology, Shrimati Bhikhiben Kanjibhai Shah Medical Institute and Research Centre (a tertiary care institute), Sumandeep Vidyapeeth Deemed to be University, Piparia, Vadodara, Gujarat, India, from September 2023 to July 2024, with a sample size of 40 patients. Patients with American Society of Anaesthesiologists (ASA) I/II status were randomly allocated into two equal groups of 20 each. Group-R received 0.75% hyperbaric ropivacaine 3.5 mL+0.1 mL normal saline (total 3.6 mL) and Group-L received 0.5% hyperbaric levobupivacaine 3.5 mL+0.1 mL normal saline (total 3.6 mL). Data were recorded using MS Excel and analysed using Statistical Package for Social Sciences (SPSS version 22.0) software. The Student’s t-test was used for data comparison regarding the onset and duration of sensory and motor blockade, time of two-segment regression, time for rescue analgesia, haemodynamic stability and sedative effects between the study groups. Results: The mean age for Group-R was 45.00±7.1 years and Group-L 51.95±8.03 years. onset of sensory blockade at the T10 level and the onset of motor blockade in Group-R were slower than in Group-L (p-value <0.05). The time to two-segment regression was significantly faster in Group-R than in Group-L (p-value <0.05). The duration of sensory and motor blockade, as well as the time for rescue analgesia, was significantly prolonged in Group-L compared to Group-R (p-value <0.05). The sedative effects, arterial oxygen saturation (SpO2) and respiratory rate were comparable in both groups. Intraoperatively, haemodynamics were more stable in Group-R compared to Group-L. Conclusion: The present study implies that in haemodynamically unstable patients, 0.75% hyperbaric ropivacaine can provide a less complicated neuraxial blockade. In contrast, levobupivacaine offers a superior effect in terms of the duration of blockade and analgesia. This makes levobupivacaine useful for longer-duration surgeries, while ropivacaine is more suitable for shorter-duration procedures.

Assessment of Birth Preparedness and Complication Readiness among Pregnant Women: A Cross-sectional Study

T Elamathi, K Ananthi, Rimi Singh

Introduction: Maternal deaths are a significant cause of death in women in the 15-49 years of age group, and they make up a larger proportion of all causes of death in the rural areas of poorer states, compared to other regions of India. Birth Preparedness and Complication Readiness (BPACR) is an overarching program to improve the use and effectiveness of maternal and newborn health services, based on the premise that preparing for birth and being ready for complications reduces all three phases of delays in receiving services. Aim: To assess the level of BPACR among pregnant women. Materials and Methods: This was a cross-sectional study conducted among 360 antenatal women admitted at Indira Gandhi Medical College and Research Institute, Puducherry, India, over three months. A modified Johns Hopkins Program for International Education in Gynaecology and Obstetrics (JHPIEGO) questionnaire was used for data collection. BPACR steps include arranging a mode of transport, saving money for pregnancy and childbirth, identifying an institute for delivery and arranging a blood donor. Among these participants, those who followed ≤2 practices were considered less prepared, and more were considered well prepared. The Chi-square test was used to demonstrate the difference between study subject characteristics, and the level of significance set at p≤0.05. Results: Of the 360 participants, 49 (13.6%) had good knowledge about antenatal danger signs, and a significant association was observed with educational status (p-value=0.023), occupational status (p-value=0.072), and number of Antenatal Care (ANC) visits (p-value=0.046). A good knowledge of childbirth danger signs was seen in 19 women, with a significant association observed with education (p-value <0.001), working women (p-value=0.014). Conclusion: This study revealed that a very small portion of the participants had good knowledge of obstetrical danger signs. Hence, more effort needs to be employed to educate women and motivate them about the importance of regular ANC visits and create awareness about the complications.

Effect of Different Doses of Intrathecal Nalbuphine as Adjuvant to Hyperbaric Bupivacaine on Characteristics of Subarachnoid Block in Pelvic and Lower Limb Orthopaedic Surgeries: A Randomised Clinical Study

Anupama Kumari, Shraddha Jogani, Nilesh Shah, Sara Mary Thomas

Introduction: Hyperbaric bupivacaine 0.5% is most commonly used amide local anaesthetic drug in spinal anaesthesia. Various additives have been used as an adjuvant to hyperbaric bupivacaine 0.5% to modify its anaesthetic properties. Nalbuphine, a mix opioid with high efficacy kappa receptors agonism has also been used as an adjuvant to hyperbaric bupivacaine 0.5% at different doses. Aim: To compare and discover the effective dose of nalbuphine as adjuvant in subarachnoid block with hyperbaric bupivacaine in pelvic and lower limb orthopaedic surgeries in terms of onset and duration of sensory and motor block along with postoperative analgesia duration. Materials and Methods: This randomised clinical study was conducted in the Department of Anaesthesia, Shrimati Bhikhiben Kanjibhai Shah Medical Institute and Research Centre (SBKS MIRC), Piparia, Vadodara, Gujarat, India over a period of 18 months from February 2023 to August 2024 on 80 patients belonging to 20-60 years of age, American Soceity of Anaesthesiology (ASA) Grade I or II, of either gender undergoing elective pelvic and orthopaedic surgeries. Patients were randomly divided into two groups having 40 patients each. Group A received hyperbaric bupivacaine 12.5 mg+0.4 mg nalbuphine (total 3 mL) and Group B received hyperbaric bupivacaine 12.5 mg + 0.8 mg nalbuphine (total 3 mL). Sensory and motor block characteristics like their onset time, time to achieve highest sensory level, time to achieve bromage 3, time of two segment regression, duration of sensory and motor block, duration of postoperative analgesia and time for requirement of first rescue analgesia dose were observed and assessed. Haemodynamic parameters along with intraoperative and postoperative side-effects were also observed. Results: Both the study groups had similar demographics and haemodynamic parameters. Time of two segment regression of sensory block was significantly longer in Group B (135.25±11.49 min) than A (120.95±16.98 min) with statistically significant prolonged duration of sensory block in Group B (228.25±21.91 min) than A (206.75±15.21 min) (p<0.0001). Postoperative analgesia was also prolonged in Group B (294.75±19.15 min) than A (226.19±14.78 min) without significant increase the incidence of side-effects (p≥0.05). Conclusion: Study concluded that 0.8 mg nalbuphine as an adjuvant to 0.5% hyperbaric bupivacaine in subarachnoid block is more effective dose as it provides prolonged duration of sensory block and postoperative analgesia with good haemodynamic stability and minimal side-effects.

Comparative Evaluation of Intra-articular Ozone and Steroid Treatments in Patients with Coxarthrosis under Ultrasound Guidance: A Retrospective Study

Introduction: Osteoarthritis (OA) is the most common degenerative joint disease characterised by the loss of articular cartilage and synovial inflammation. This condition causes stiffness and swelling in the joint, as well as pain, loss of movement and disability. When performed under Ultrasound Guidance (USG), steroid treatments offer several advantages. On the other hand, ozone therapy accelerates anabolic mechanisms, provides vascularisation of cartilage and bone, and slows down the degenerative process. Additionally, it affects inhibitory cytokines, antioxidant enzymes, and neo-angiogenesis. Aim: To evaluate and compare the effectiveness of USG intra-articular ozone therapy versus corticosteroid injections in managing hip OA (coxarthrosis) in patients who have not responded to conventional treatments. Materials and Methods: A retrospective comparative study was conducted at Ankara Training and Research Hospital, Ankara, Altindag, Turkey, from August 2021 to August 2022. Patients unresponsive to conventional treatments were divided into two groups: Group A (n=30) received intra-articular steroid (triamcinolone acetonide), and Group B (n=23) received three weekly ozone sessions (200 μg/20 mL), both under USG. Clinical outcomes were assessed using the Visual Analog Scale (VAS) for pain and the Harris Hip Score (HHS) for functional status, both pre- and post-treatment. Monthly analgesic use was monitored before treatment and at the 1st week, 1st month, 3rd month and 6th month. Statistical analysis were conducted using Unpaired t-tests and Chi-square tests. A p-value <0.05 was considered statistically significant. Results: A total of 53 patients (mean age 63.23±10.50 years) participated in the study. Analgesic needs decreased in both groups, with no significant differences observed in the 1st week, 1st month, 3rd month, and 6th month (p-value=0.139, p-value=0.724, p-value=0.391, p-value=0.546). The most notable improvement occurred one month post-treatment, particularly in low-stage coxarthrosis. Increases in HHS scores and decreases in VAS values for stages 2-3 were statistically significant in both groups (p-value <0.001). Conclusion: The effectiveness of steroid and ozone therapy for coxarthrosis varies by disease stage. Both treatments are more effective in the early stages, while ozone is ineffective and steroids offer limited benefits in advanced stages. Thus, treatment planning should consider the disease stage, and alternative strategies should be explored for advanced cases. Clinicians should prioritise early intervention and seek alternative options for better patient outcomes.

Effectiveness of Ai Chi as Aquatic Intervention for Balance Impairments in Community-dwelling Older Adults in India: A Randomised Controlled Study

Purnima Singh, Pratap Chandra Sarma

Introduction: Balance impairment is a significant concern for older adults in India and worldwide, as it increases the risk of falls and affects quality of life. Aquatic therapy, particularly Ai Chi, which is not a widely popular intervention in India, offers a low-impact approach to improving balance. Aim: To investigate the effectiveness of Ai Chi in improving balance among community-dwelling older adults compared to conventional aquatic therapy. Materials and Methods: This randomised controlled trial investigated the effectiveness of Ai Chi compared to Conventional aquatic therapy (Control group) in improving balance among community-dwelling older adults. Thirty participants aged 60 and above with balance impairments were randomly assigned to either the Ai Chi or control group. Both groups received 40-minute aquatic therapy sessions three times a week for eight weeks. Balance was assessed using the Berg Balance Scale (BBS), Timed Up and Go Test (TUGT), and Dynamic Gait Index (DGI) before (P1), after four weeks (P2), and after eight weeks of intervention (P3). An Independent t-test was used for between-group analyses, and a Dependent t-test was used for within-group analysis. A Bonferroni test was applied to analyse differences between groups. Results: The participants had a mean age of 72 years, ranging from 65 to 80 years. The mean baseline scores for the BBS, TUGT, and DGI were 39.06, 13.33, and 14.13, respectively. After four weeks of intervention, the mean scores improved to 42.03, 11.73, and 15.69 for the BBS, TUGT, and DGI, respectively. Following the eighth week of intervention, the mean scores further improved to 46.23, 10.66, and 16.23 for the BBS, TUGT, and DGI, respectively. There were significant differences between the pretest and post-test 1 (MD=3.80, p-value=0.005), post-test 1 and post-test 2 (MD=4.8, p-value <0.001), and between the pretest and post-test 2 (MD=8.608, p-value <0.001). These analyses indicated that measures of static and dynamic balance improved consistently in both the groups. A post-hoc analysis of BBS scores showed both short-term and long-term improvements in the Ai Chi group compared to the control group. Conclusion: The study concluded that Ai Chi is an effective and enjoyable intervention for enhancing balance and potentially reducing the risk of falls and improving overall quality of life in older adults.

A Retrospective Descriptive Study on Caesarean Isthmocele: A Delayed and Under-recognised Complication of Caesarean Section

Maneesha Shrivastava, Varuna Pathak, Sushruta Shrivastava

Introduction: A caesarean scar defect (isthmocele) is an indentation that represents myometrial discontinuity in the anterior uterine wall, with the base communicating with the uterine cavity at the site of a previous caesarean section scar. It has been linked to a variety of gynaecological symptoms, including abnormal uterine bleeding and secondary infertility. Aim: To describe the demographic characteristics, clinical presentation, management and outcomes in patients with Caesarean Scar Defect (CSD). Materials and Methods: A retrospective cohort analysis was conducted in the Department of Obstetrics and Gynaecology, Gastrocare Hospital (tertiary care centre), Bhopal, Madhya Pradesh, India, from February 2020 to February 2023. Data were collected from the hospital records of 43 patients who presented with CSD. The recorded variables included demographic details, clinical presentations, prior treatments, diagnostic interventions, types of surgical procedures performed and patient outcomes. Descriptive statistics, such as means, standard deviations and frequencies, were used to summarise patient characteristics and outcomes. All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) software version 29.0 software. Results: The majority of the women were in the age group of 30-40 years. Out of 43 patients, eight presented with Abnormal Uterine Bleeding (AUB), three had secondary infertility, and 32 presented with Caesarean Scar Ectopic Pregnancy (CSEP) and its complications. All cases were managed either by hysteroscopy or laparoscopy, based on the Residual Myometrium Thickness (RMT). Conclusion: Transvaginal Sonography (TVS) is an effective tool for diagnosing CSD and CSEP. Surgical management can be guided by the RMT as determined by TVS.

Prevalence of Edentulism, Associated Factors, Perceived Treatment Needs and Barriers for Dental Care among the Elderly in a Rural Area of Puducherry, India: A Community-based Mixed-method Study

Introduction: Edentulism is a significant cause of poor oral health among the elderly in India. It affects their quality of life, particularly in terms of nutrition, phonetics and aesthetics. Most studies assessing edentulism in India are hospital-based, which may not provide an accurate representation of the general population. Therefore, community-based studies are essential to accurately estimate the prevalence of edentulism and enable the planning of specific strategies to promote oral health. Aim: To estimate the prevalence of partial and complete edentulism, identify the associated factors, assess the treatment needs and evaluate the perceived barriers influencing the treatment needs of the affected population. Materials and Methods: This was a community-based, mixed-method study conducted in Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India. The study was carried out over six months from May 2017 to October 2017 and included 328 elderly individuals aged 60 years and above. A pretested semi-structured proforma was used to collect data. Quantitative data on the extent of partial and complete edentulism and treatment needs were collected, while perceived barriers to seeking treatment were assessed qualitatively through in-depth interviews. Data analysis was performed using Statistical Package for Social Sciences (SPSS) software version 22.0, with a p-value of <0.05 considered statistically significant. Results: The mean age of the participants was 71.4±7.6 years. The overall prevalence of edentulism was found to be 297 (90.5%) (95% CI=86.7%-93.2%). Of these, partial edentulism was found in 253 (13.4%) (95% CI=72.1%-81.4%), while 13.4% (95% CI=10.1%-17.7%) were completely edentulous. Out of the 297 edentate subjects, 65 (22%) participants reported a perceived need for dental treatment, while 232 (78%) did not perceive a need. Similarly, 285 (96%) participants were professionally determined to need dental treatment and 12 (4%) did not require dental treatment. Age, gender and tobacco use had a statistically significant association with edentulism (p-value <0.05). About 227 (76.4%) of the edentate subjects reported difficulty in chewing. The striking findings revealed a low level of denture use among the participants, with only 20 (6.7%) of the 297 edentulous individuals using dentures. The most common perceived barriers to treatment were a lack of awareness regarding oral health, unaffordability and a lack of social support. Conclusion: The study found a high prevalence of edentulism among the elderly, with significant disparities between perceived and actual needs for prosthetic treatment. Only a small proportion of participants use dentures or seek dental care, emphasising the importance of targeted interventions to raise oral health awareness, reduce treatment costs and provide social support. Policymakers should prioritise oral health promotion programs for the elderly in order to bridge these gaps and improve their quality of life.

Efficacy of Levobupivacaine versus Ropivacaine for Tonsillar Pillar Block in Patients Undergoing Tonsillectomy: A Randomised Clinical Trial

Vishnu Sadanandan, Antony John Charles, Srinivasan Parthasarathy

Introduction: Tonsillectomy, one of the most frequent otorhinolaryngologic procedures, causes considerable pain and dysphagia in the postoperative period. As previously stated, preoperative local anaesthetic infiltration contributes to the reduction of pain during and after the surgical operation, as well as the use of postoperative analgesics. The measurement of pain intensity commonly used is the Numerical Rating Scale (NRS). Aim: To compare levobupivacaine and ropivacaine for post-tonsillectomy analgesia. Materials and Methods: This hospital-based randomised double-blinded clinical trial was conducted at Mahatma Gandhi Medical College and Research Institute, Puducherry, India, between March 2023 and February 2024 on 60 American Society of Anaesthesiologists (ASA) physical status Class I and II patients aged between 7 and 25 years undergoing elective tonsillectomy under general anaesthesia. Patients were randomly allocated to either the Levobupivacaine group (Group L, n=30) or the Ropivacaine group (Group R, n=30). Pain intensity in the postoperative period was measured at 15 minutes, 1 hour, 4 hours, 12 hours, and 24 hours after surgery using the NRS. Rescue analgesia was administered if the patient’s pain rating exceeded five. All continuous variables were reported as mean and Standard Deviation (SD), while categorical variables were compared using the Chi-square test or Fisher’s-exact test with Yates correction, wherever necessary. Results: The sample comprised 30 patients in each group. The mean ages of the participants were 16.86 and 17.55 years, respectively. The preoperative and intraoperative values of Heart Rate (HR), Systolic Blood Pressure (SBP), and Diastolic Blood Pressure (DBP) were comparatively lower in the ropivacaine group. The difference between the groups was statistically insignificant. Pain scores were significantly lower in the Ropivacaine group compared to the Levobupivacaine group at 15 minutes (p-value=0.004), one hour (p-value <0.001), four hours (p-value=0.027), and 12 hours (p-value <0.001) postoperatively. By 24 hours, pain scores were similar. The need for rescue analgesia was lower in the ropivacaine group, suggesting that the duration of analgesia was longer in this group. There were no significant side-effects in either of the groups. Conclusion: The results of the study showed that patients who received ropivacaine had better postoperative pain control than those who received levobupivacaine in paediatric tonsillectomy patients. Compared to the levobupivacaine group, patients administered ropivacaine experienced reduced pain intensity at different time points and utilised fewer rescue analgesics, illustrating a prolonged and superior quality of analgesia.

Dermoscopic Patterns of Facial Melanoses in Adult Patients: A Cross-sectional Study

Introduction: Facial melanoses encompass a heterogeneous group of diseases characterised by altered pigmentation on the face, including melasma, lentigines, freckles, Lichen Planus Pigmentosus (LPP), actinic lichen planus, periorbital hyperpigmentation, nevus of Ota, nevus of Hori, Riehl’s melanosis and Postinflammatory Hyperpigmentation (PIH). Dermoscopy is a non invasive and reliable tool for the direct visualisation of skin pigmentation and early diagnosis due to its distinctive dermoscopic patterns. Aim: To evaluate various patterns of dermoscopy in disorders of facial melanoses. Materials and Methods: A cross-sectional study was conducted at the Konaseema Institute of Medical Sciences and Research Foundation in Amalapuram, Andhra Pradesh, India, over a period of 20 months, involving patients attending the Dermatology, Venereology, Leprosy (DVL) Outpatient Department (OPD). The study included both sexes aged over 18 years with clinical evidence of facial pigmentation. Clinical and dermoscopic examinations were performed using a contact polarised DE-3100 dermoscope attached to a smartphone. Data were analysed using Statistical Package for the Social Sciences (SPSS) version 23.0. Results: A total of 114 subjects with facial melanosis were included in the study, with the majority of patients in the age group of 31-40 years (42, 36.8%), followed by 41-50 years (33, 29%) and a female predominance (82, 71.93%). The pigment network was present in 87.7% of the cases and absent in 12.3%. The most common dermoscopic pattern observed was reticular observed in 46 (40.4%), followed by reticulo-globular in 23 (20.2%). The most common non melanocytic feature identified was arciform structures seen in 42 (36.8%), followed by crista cutis and sulcus cutis in 17 (14.9%). Vascular structures such as telangiectasia were seen in 36 (31.6%) patients, while arborising vessels were observed in 1 (0.9%) patient. Conclusion: In this study, the most commonly reported condition was melasma, followed by facial acanthosis. Different pigmentary conditions exhibit specific pigment patterns, networks and special features on dermoscopy, which aid in their diagnosis. This study emphasises the importance of pigmentoscopy in facial melanosis and its significant role in assessing prognosis, treatment response and follow-up.

Comparing Minor Connector Castability of Printed Cast Partial Dentures to Conventional Cast Partial Dentures: An In-vitro Study

Meghna Budati, Suresh Venugopalan

Introduction: Partial denture prostheses are used to restore missing teeth and oral function, with minor connectors playing a crucial role in the denture framework. Traditionally, Cast Partial Dentures (CPD) are made using wax patterns and metal casting; however, this process can sometimes result in issues such as porosity or distortion. Advances in digital dentistry have introduced 3D printing, which offers a new method for creating denture frameworks with greater precision. However, the impact of 3D printing on the castability of minor connectors compared to conventional methods remains underexplored. Aim: To compare the minor connector castability of manually CPDs to Direct Metal Laser Sintering (DMLS) printed partial dentures. Key objectives include assessing the minor connector castability between the two groups, manual and DMLS, before and after wax-up and casting. Materials and Methods: This in-vitro study was conducted in the Department of Prosthodontics at Saveetha Dental College, Chennai, Tamil Nadu, India from July 2023 to December 2023. A total of 10 samples were included and divided into two groups. Group 1 consisted of five samples of manually CPDs, while group 2 included five samples of DMLS printed partial dentures. A standardised casting procedure was followed for both the manually cast and DMLS printed partial dentures to evaluate their minor connector castability. The two groups were compared for wax-up and casting. To assess castability, the number of lattice framework holes in each connector was counted after wax-up and fabrication. Statistical analysis was performed using a statistical software program Statistical Package for Social Sciences (SPSS) version 23.0. The Wilcoxon signed-rank test, a non parametric test, was used, with statistical significance set at p<0.05. Results: Comparisons between the groups revealed a statistically significant difference in the medians of manual wax-up (p=0.25) and casting compared to DMLS (p=0.317) design and printing. The DMLS group demonstrated superior accuracy compared to manual casting. Conclusion: The present study demonstrates that the Removable Partial Denture (RPD) frameworks designed and produced by DMLS exhibit better castability compared to manual wax-up and casting.

Comparative Evaluation of the Effectiveness of Manual and Electric Toothbrushes in Blind Children: A Randomised Controlled Trial

PS Thanalakshme, R Ramesh

Introduction: Plaque removal is vital for preventing gingivitis and periodontitis, while maintaining oral hygiene is crucial for overall health. Blind children face unique challenges in oral care due to their reliance on touch rather than visual cues, which makes proper brushing difficult. Although research is limited, electric toothbrushes have been proposed as a solution to help blind children remove plaque more effectively by compensating for their reduced ability to visually monitor their brushing technique. Further studies are needed to confirm their benefits. Aim: To evaluate the effectiveness of manual and electric toothbrushes in promoting better oral hygiene in visually impaired children in Palayamkottai, Tirunelveli District. Materials and Methods: A randomised controlled clinical trial conducted at a high school for the blind in Palayamkottai, Tirunelveli district, Tamil Nadu, India on 120 blind chidren aged 6-12 years. The study participants was divided into Group 1, the manual toothbrush group, received a standard soft-bristle manual toothbrush (Colgate Sanxiao Co., Ltd., No. 8 Gaolujie Road, Guang Ling District, Yangzhou, 225111). In Group 2, the electric toothbrush group, participants were provided with a MINISO electric toothbrush with soft silicone bristles. Key parameters- Plaque Index (PI), Patient Hygiene Performance (PHP) index, Decayed, Missing, and Filled Teeth (DMFT) index, and Ayesha’s Oddbods Dental Anxiety Scale (AODAS) were measured at baseline, three months, and six months. Descriptive statistics were used to summarise demographic and clinical data. Repeated measures Analysis of Variance (ANOVA) were used to analyse the changes in the PI, PHP Index, and DMFT indices, as well as anxiety levels over time. A paired t-test was used to compare oral health outcomes and anxiety levels between the two groups. Results: Over the course of six months, the study showed that manual toothbrushes were superior to electronic toothbrushes in enhancing oral health in blind children. The PI (2.4±5.04 to 0.39±0.49), PHP Index (2.24±0.65 to 0.45±0.50), and DMFT Index (2.45±0.50 to 0.53±0.54) all significantly decreased in Group 1 (manual), while Group 2 (electric) exhibited less noticeable changes. Furthermore, compared to Group 2 (32.7±5.3 to 11.7±3.7), dental anxiety decreased more in Group 1 (32.8±5.3 to 7.9±3.2). Conclusion: In present study, manual toothbrushes outperformed electronic toothbrushes in enhancing oral health in blind children. Better gingival health and plaque clearance may have been facilitated by the tactile input of manual brushing. For blind children to maintain good oral health, it is advised to follow consistent oral hygiene practices and customise therapies.

Role of Proliferative Marker (Ki-67) and ER, PR in Cervical Epithelial Lesions with Clinicopathological Association: A Cross-sectional Study

Introduction: Cervical cancer is the fourth most common cancer affecting women worldwide, following breast, colorectal and lung cancer. India contributes 28% of the cervical cancer mortality burden, with 87,090 deaths due to cervical cancer, making it the second most populous country in the world. Oestrogen Receptors (ER) are located not only in the tissues of the female reproductive tract and breast but also in diverse tissues such as bone, brain, liver, colon, skin and salivary glands. Ki-67 is a nuclear protein expressed during all active phases of the cell cycle and is absent in the G0 phase, making it a potent biomarker of cellular proliferation. Aim: To study the clinicopathological spectrum of cervical epithelial lesions and their association with cell proliferation (Ki-67) and ER and Progesterone Receptor (PR) status. Materials and Methods: This was a single-institution-based cross-sectional study in which a total of 202 cases of cervical epithelial lesions diagnosed from May 2022 to May 2024 at the Institute of Post Graduate Medical Education and Research and SSKM Hospital, Kolkata, West Bengal, India were studied. Clinical and demographic data were associated with histological findings. Immunohistochemical staining with Ki-67, ER and PR antibodies was performed and the Ki-67 labelling index and ER and PR status were assessed respectively. Based on the assessment, a master chart was prepared for patients belonging to different age groups with certain medical complaints, and data were organised into tables. Statistical analysis was conducted using Microsoft Excel and Statistical Package for the Social Sciences (SPSS) version 23.0 software. Results: In this study, 202 patients were evaluated. The patient age ranged from 18 to 68 years, with a mean age of 40.78±10.13 years. Cervical epithelial lesions were most prevalent in the age group of 31 to 50 years (66.8%). Among the 202 cases, 108 (53.5%) were non neoplastic, 10 cases (5.0%) were benign neoplastic, and 84 cases (41.6%) were malignant neoplastic lesions. The difference in proliferative rates, as indicated by the Ki-67 labelling index, between benign neoplasms and malignant neoplasms was statistically significant (p-value <0.001). There was no significant association between the levels of ER and the nature of the lesions in the patients (non neoplastic and neoplastic) (p-value=0.08). Additionally, there was no significant association between the levels of PR and the nature of the lesions in the patients (p-value=0.25). Conclusion: Malignant neoplasms exhibit a significantly higher proliferative rate than benign neoplasms and non neoplastic lesions. No significant association between ER and PR status and the nature of the lesions was found in the study, although the mean ER score and mean PR score of adenocarcinomas were significantly higher than those of Squamous Cell Carcinoma (SCC) and Cervical Intraepithelial Neoplasia (CIN).

Test-retest Reliability of Balance Error Scoring System in Individuals with Osteoarthritis Knee: A Cross-sectional Study

Introduction: Osteoarthritis (OA) of the knee is a degenerative joint disease that leads to changes not only in the articular cavity but also in the ligaments, tendons and muscles. These structures play an important role in human balance, which is important for daily activities. Due to the degeneration of ligaments, tendons and muscles, OA of the knee results in balance impairment. Aim: To evaluate the test-retest reliability of the Balance Error Scoring System (BESS) in patients with OA of the knee. Materials and Methods: This cross-sectional study was conducted at Department of Physiotherapy, MMIPR, MMDU, Ambala, Haryana, India, from March 2023 to April 2024. A total of 20 participants were recruited for the study and balance was evaluated using BESS on a firm surface, first in double limb stance, then in single limb stance and finally in tandem stance, both with eyes open and closed. A single rater conducted the same process twice on a foam surface. Descriptive statistics were used to represent the demographic characteristics of the participants. Reliability was examined using both Intraclass Correlation Coefficients (ICCs) and Cronbach’s alpha was executed to check internal consistency. Results: The mean age of the participants in the present study was 49.4±10.6 years and the Body Mass Index (BMI) was 26.2±4.2. Both males 9 (45%) and females 11 (55%) were recruited for the present study. When comparing the demographic characteristics between males and females using an independent t-test, it revealed that no significant difference exists between them. The reliability analysis demonstrated excellent reliability for all parameters of BESS (ICC: 0.9). Cronbach’s alpha for all parameters was also 0.9. The limits of agreement plotted with the Bland-Altman plot indicated an excellent level of agreement, as the maximum scores fell within the 95% Confidence Interval (CI). Conclusion: Based on the findings of the present study, the authors can conclude that BESS is a reliable tool for balance assessment in patients with OA of the knee.

Cord Direct Antiglobulin Test for Predicting the Need for Phototherapy in Neonates with ABO Incompatibility: A Prospective Cohort Study

Introduction: The Direct Antiglobulin Test (DAT) is a screening technique used to detect Immunoglobulin G (IgG) antierythrocyte antibodies on foetal Red Blood Cells (RBCs). Universal bilirubin screening decreases the incidence of severe hyperbilirubinemia. The diagnostic efficacy of DAT in cases of ABO incompatibility is not well established, in contrast to Rh incompatibility. Aim: To evaluate the diagnostic ability of routine cord blood DAT in neonates ≥35 weeks of gestation with ABO incompatibility in predicting the requirement for phototherapy. Additionally, to compare the diagnostic ability between two methods of DAT estimation, namely the semiagglutination gel method and the conventional tube method. Materials and Methods: This prospective cohort study was conducted from September 2022 to March 2024 at SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India. Following the acquisition of informed consent, cord blood samples were collected from 934 neonates delivered after 35 weeks of completed gestation to mothers with O blood type. In cases of ABO incompatibility (523 neonates), DAT was performed using both the manual tube method and the automated semiagglutination gel method in the blood bank. Serum bilirubin levels, complete blood counts with peripheral smear analysis and reticulocyte counts were performed on day 3 or earlier, as clinically indicated. The neonates were treated in accordance with the American Academy of Paediatrics (AAP) 2004 recommendations on phototherapy. Babies were monitored for jaundice until 14 days of age. Results: Out of 3,092 eligible deliveries, 523 babies with ABO incompatibility were enrolled. The baseline characteristics were comparable. Bilirubin levels in DAT-positive and DAT-negative neonates were 14.60±3.58 mg% and 13.18±3.16 mg% (p-value <0.001), respectively. The adjusted odds ratio of positive DAT for both methods in predicting the requirement for phototherapy was 3.21 (95% CI 2.1-5.8). The sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of the tube method were 37.5%, 85.16%, 2.53, and 0.73, respectively, while for the gel method they were 37.08%, 86.57%, 2.76, and 0.73, respectively. Conclusion: In cases of ABO incompatibility, neonates with positive cord DAT had higher odds of requiring phototherapy; however, a high negative likelihood ratio indicates that additional factors may be involved in hyperbilirubinemia that necessitate phototherapy.

Intrathecal Clonidine versus Dexmedetomidine as Adjuvants to Hyperbaric Ropivacaine in Lower Limb Orthopaedic Surgeries: A Randomised Clinical Study

Priya Kishnani, Aiman Monaf, Kalpesh Patil, Jatin Patel, Sara Mary Thomas

Introduction: Subarachnoid block is the most chosen mode for orthopaedic surgeries in lower limb. Adjuvants such as opioids and α2 agonists are often added intrathecally to improve or prolong the anaesthetic and analgesic effects. Ropivacaine, a novel local anaesthetic agent, is widely accepted as it has better safety profile as compared to bupivacaine and lignocaine. Aim: To compare clonidine and dexmedetomidine as adjuvants to hyperbaric ropivacaine given intrathecally in lower limb orthopaedic surgeries, focusing on haemodynamic changes, sedation, duration of analgesia, and sensory and motor blockades. Materials and Methods: This randomised clinical study was conducted in a teritary care facility at the Operation Theatre (OT) complex in the Department of Anaesthesiology at Dhiraj Hospital, Smt. Bhikhiben Kanjibhai Shah Medical Institute and Research Centre (SBKS and MIRC), Piparia, Waghodia, Vadodara, Gujarat, India. The study duration was 18 months, with a total sample size of 60 patients, comprising of 30 patients in each group. Group RC30 (Ropivacaine+Clonidine) was given 3.5 mL of 0.75% hyperbaric ropivacaine with 30 μg of clonidine, while Group RD5 (Ropivacaine + Dexmedetomidine) was given 3.5 mL of 0.75% hyperbaric ropivacaine along with 5 μg of dexmedetomidine, intrathecally. Results were assessed by comparing the onset and duration of sensory and motor blockade. The absolute and effective analgesia durations were also compared and side-effects and complications along with haemodynamic changes were analysed. Data was analysed using Statistical Package of Social Sciences (SPSS) Software version 26.0. Mean and Standard Deviation (SD) were derived for continuous variables and t-test or Analysis of Variance (ANOVA) was used to evaluate relationship between them, proportions for categorical variables and the Chi-square test was used for categorical variables. Results: The mean for age in Group RD5 was 39.43±10.6 years and Group RC30 was 41.43±13.65 years. The time to S2 regression was longer in Group RD5 (136.10±8.10 min) compared to Group RC30 (102.67±7.69 min) (p<0.0001). Longer duration of sensory and motor blockade was seen in Group RD5 (312.53±23.22 min, 381.40±30.01 min) as compared to Group RC30 (279.90±29.64 min, 321.63±38.82 min) (p<0.0001, respectively). Group RD5 also required fewer analgesic interventions in the first 24 hours. Absolute and effective analgesia was found longer in Group RD5 as compared to Group RC30 (p=0.0006, p=0.0022, respectively). Conclusion: Dexmedetomidine offers superior postoperative analgesia compared to clonidine but is associated with a higher incidence of bradycardia and hypotension, both of which are manageable with standard interventions.

Confocal Microscopy for Detection of Intracellular Bacteria in Urine Samples of patients Suspected with Urinary Tract Infection: A Cross-sectional Observational Study

Introduction: Uropathogenic bacteria like Escherichia coli (UPEC) and Pseudomonas are the most common agents of Urinary Tract Infection (UTI). Recently, the ability of UPEC to invade urothelial cells and to form Intracellular Bacterial Communities (IBCs) has been described which can be missed out during routine diagnosis and can lead to recurrent infection despite antibiotic treatment. Aim: To study the presence of ICB in exfoliated urothelial cells using confocal microscopy. Materials and Methods: A cross-sectional observational study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India for detection of Isolated Intracellular Bacteria (IIB) and IBC. The study done for detection of IIB/IBC in urine samples suspected with UTI between January 2022 to December 2022. Four hundred ninety-five urine samples collected from women of age group 18-50 years visited at Central laboratory for suspected diagnosis of UTI. Urine samples were screened for detection of Gram-negative intracellular bacteria by using light microscopy. Urine samples showing intracellular gram-negative bacteria by Gram staining were further processed for fluorescence confocal microscopy followed by conventional culture and virulence detection by multiplex Polymerase Chain Reaction (PCR). Formation of biofilm ability was assessed by tube method. Quantitative data presented as mean and Standard Deviation (SD) while qualitative variables expressed as frequency (percentage). Results: Ninety-two Gram negative urine samples were processed for fluorescence staining and culture, out of that 24 were processed for virulence gene detection. Mean age of women was 36.2±9.5 years and 74 (80.4%) had fever, 19 (20.7%) had burning sensation and 16 (17.4%) had frequent micturition. Confocal microscopy examination showed 23 (25.0%) samples which were IIB and 11 (12.0%) were IBC. While the culture report showed 23 (25.0%) were E. coli, 29 (31.5%) were polymicrobial flora and 29 (31.05%) were negative for culture. Interestingly, out of 29 culture negative samples 9 (3.1%) were detected with IIB and IBC by confocal microscopy. Prevalence of virulent genes like iutA was higher 12 (50.0%). Conclusion: This study highlighted the importance of confocal microscopy for diagnosis of IIB/IBC which was missed by urine culture. Unrecognised bacterial colonisation might be maintained through intracellular reservoir. Hence diagnosis of IIB/IBC is crucial for the management of recurrent UTI and precise antibiotic therapy to avoid antibiotic resistance.

Efficacy of 5μg and 10μg Dexmedetomidine as Adjuvants to 3 mL 0.5% Hyperbaric Bupivacaine in Pelvic and Lower Limb Orthopaedic Surgeries: A Randomised Clinical Study

Introduction: Low-dose bupivacaine used in spinal anaesthesia results in speedy recovery. For lower limb orthopaedic surgeries, to provide sufficient anaesthesia and prolong postoperative analgesia in a less cumbersome way, author can add potent adjuvants like dexmedetomidine (an alpha-2 adrenergic receptor agonist) in effective and safer doses intrathecally. Aim: To compare the effects of intrathecal 5 μg dexmedetomidine versus 10 μg dexmedetomidine as adjuvants to 3 mL of 0.5% hyperbaric bupivacaine in pelvic and lower limb orthopaedic surgeries. Materials and Methods: This randomised clinical and single-blind study study was conducted at the Operation Theatre (OT) complex of Dheeraj Hospital, SBKS, and MIRC, Sumandeep Vidyapeeth, Vadodara, Gujarat, India in the Department of Anaesthesia over a period of 18 months, from September 2022 to March 2024 and total of 82 patients scheduled for lower limb and pelvic orthopaedic surgery who were to receive spinal anaesthesia were divided into Group D1 and D2. Group D1 (n=41) received 3 mL of bupivacaine (0.5% heavy) with 5 μg dexmedetomidine, totaling 3.1 mL, while group D2 (n=41) received 3 mL of bupivacaine (0.5% heavy) with 10 μg dexmedetomidine, also totaling 3.1 mL intrathecally. The onset and duration of sensory and motor blockade, as well as the duration of analgesia, were noted, along with the monitoring of haemodynamic parameters and any side effects. All observed data were analysed using statistical tests such as the unpaired t-test and Chi-square test. A p-value <0.05 was considered statistically significant. Results: Demographic data were comparable in both groups and were non significant (p-value >0.05). The onset of sensory block was earlier in group D2 (2.01±0.12 min) than in group D1 (2.87±0.36 min) (p-value <0.05). The onset of motor block was also earlier in group D2 (2.63±0.26 min) compared to group D1 (3.36±0.43 min). The duration of sensory block was longer in group D2 (457.46±32.85 min) than in group D1 (318.02±32.27 min). The duration of motor block was also longer in group D2 (396.17±36.13 min) than in group D1 (257.37±25.02 min) (p-value <0.05). The duration of analgesia and the time until the need for the first rescue analgesia was significantly longer in group D2 (364.29±43.64 min) compared to group D1 (219.51±23.39 min). Conclusion: Intrathecal bupivacaine with dexmedetomidine at a dose of 10 μg results in an earlier onset and longer duration of sensory and motor block compared to a dose of 5 μg. The duration of postoperative analgesia was longer, and the time until the need for the first rescue analgesia was extended with the 10 μg dosage. No significant side effects were observed in either group.

Factors Determining the Yield of Lymph Nodes in Colorectal Carcinoma: A Cross-sectional Study from a Tertiary Care Hospital, Manipal, Karnataka India

Sinduja Raghuraman, Vidya Monappa, Kanthilatha Pai, Balaji Karunakaran

Introduction: Colorectal Cancer (CRC) is one of the leading causes of mortality worldwide. Adequate and appropriate treatment depends on accurate histopathological staging. The current College of American Pathologists (CAP) guidelines emphasise sampling 12 Lymph Nodes (LNs) for adequate staging; however, there are situations where this ‘magic number’ is not achieved. Aim: To determine whether a higher Lymph Node Yield (LNY) is associated with tumour upstaging (N status). Materials and Methods: This cross-sectional study was conducted at Kasturba Medical College, Manipal, Karnataka, India and included total 60 resected cases of CRC diagnosed from June 2018 to May 2019 and staged according to Tumour Node Metastasis (TNM), American Joint Cancer Committee (AJCC) 8th edition. The following parameters were analysed: age, sex, type of surgery, excised specimen length, tumour laterality, tumour size, histological grade, Lymph Node (LN) status, Lymphovascular Invasion (LVI), and stage. Statistical analysis: The Student’s t-test (unpaired t-test) was used to determine the level of significance for different parameters. Chi-square and Fisher’s-exact tests were employed in the analysis of nominal variables. Results: A statistically significant value (p<0.05) was obtained from a total of 60 cases with various parameters, including mean age (M=64 years, F=63 years), an average tumour size of 7 cm in greatest dimension, hemicolectomy as the most commonly performed type of surgery, and an average excised specimen length of 36 cm. Stage III and G1 tumours were the most common types. Conclusion: Despite the fact that numerous authors have expressed opinions on the number of LNs sampled, both surgeons and pathologists can improve outcomes by standardising surgical techniques and dedicating more time to these procedures. Various modifiable and non modifiable factors play a significant role in the sampling of LNs. The primary aim of the study was achieved, as findings indicate a possible chance of tumour upstaging when the LNY exceeds 12. Thus, it is crucial for pathologists to sample an adequate number of LNs for appropriate patient management.

Efficacy of Intrathecal vs Intravenous Route of Magnesium Sulphate as an Adjuvant with 0.75% Hyperbaric Ropivacaine to Augment Quality of Spinal Anaesthesia in Lower Limb Surgeries: A Randomised Clinical Trial

Sivateja Doddipatla, Sanjaya Kumar Behera, Amrita Panda

Introduction: Subarachnoid block is commonly used for lower limb surgeries but has a limited duration. Adjuvants like Magnesium Sulphate (MgSO₄) are added to extend analgesia. Ropivacaine is a highly protein-bound amide local anaesthetic that is structurally similar to bupivacine. The present study compared intravenous versus intrathecal MgSO₄ combined with 0.75% hyperbaric ropivacaine to enhance spinal anaesthesia in lower limb surgeries. Aim: To compare the efficacy of MgSO₄ as an adjuvant administered via the intrathecal versus intravenous route, in conjunction with 0.75% hyperbaric ropivacaine, to augment the quality of spinal anaesthesia in lower limb surgeries. Materials and Methods: A prospective randomised clinical trial was conducted in the Department of Anaesthesiology, Pradyumna Bal Memorial Hospital, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India, from August 2022 to July 2024. A total of 166 patients undergoing elective lower limb surgery were randomly assigned to two groups. Group IT received 3 mL of 0.75% hyperbaric ropivacaine with 50 mg of intrathecal MgSO₄, while group IV received intravenous MgSO₄ (50 mg/kg bolus, 15 mg/kg/h infusion) alongside intrathecal ropivacaine. The time taken for the onset of sensory and motor block was evaluated as the primary objective, whereas the duration of the block, along with haemodynamic parameters and postoperative VAS scores, was assessed as secondary objectives. The statistical analysis was performed using the Mann-Whitney U test and Chi-square test. Results: Of total study participants, there were 59 (73.8%) males and 21 (26.3%) females in group IT, and 54 (67.5%) males and 26 (32.5%) females in group IV. The onset of motor block was faster in group IV (95 seconds) than in group IT (205 seconds), and the onset of sensory block was quicker in group IV (150 seconds) compared to group IT (360 seconds), with both results yielding p-value <0.001. The duration of motor block was longer in group IV (240 minutes) compared to group IT (160 minutes), as was the duration of sensory block (300 minutes versus 240 minutes); p-value <0.001. Conclusion: Intravenous MgSO₄ combined with subarachnoid block shortened the onset time of the block, prolonged the duration of sensory block, reduced postoperative pain, and caused minimal haemodynamic instability, making it an effective adjunct for spinal anaesthesia.

Effect of Individual Cognitive Stimulation Therapy on Dementia and Quality of Life in Older Adults: A Quasi-experimental Study

Pooja Motar Sublok, Mrunali Kerkar, Shivani Patil, Bhairavi Ugale

Introduction: Dementia is a chronic neurocognitive disorder that causes a decline in cognitive functions. As the global prevalence of dementia rises, non pharmacological therapies, such as Cognitive Stimulation (CS), have shown promise in preserving cognitive function and improving Quality of Life (QoL). Individual Cognitive Stimulation Therapy (iCST) offers an alternative intervention for those unable to participate in group therapies, often involving caregivers as facilitators. Aim: To evaluate the effect of iCST on dementia in older adults and its impact on individual QoL. Materials and Methods: This quasi-experimental trial, a pre-post study design was conducted in Marathwada, Aurangabad, Maharashtra, India, from September 26, 2023 to February 21, 2024. A total of 34 study participants, aged ≥60 years with mild to moderate dementia {Global Clinical Dementia Rating (CDR) score=1 or 2}, were included. Participants received iCST three times a week, with each session lasting 45 minutes, over a period of five weeks. After the completion of therapy, changes were noted using the Clinical Dementia Rating (CDR) scale and the Older People’s Quality Of Life (OPQoL) questionnaire. Data were analysed using the Shapiro-Wilk test and the dependent t-test. Results: The results were statistically significant with respect to both measures. The mean difference of the CDR Scale and the OPQoL questionnaire score was 0.97±1.28 and 10.79±5.31, respectively which showed a statistically highly significant difference with a p-value <0.001. Conclusion: The iCST program has shown efficacy in alleviating dementia symptoms and enhancing the QoL for individuals with mild to moderate dementia.

Radiological and Inflammatory Markers Predicting the Spontaneous Transit of Mid and Lower Ureteric Stones: A Prospective Observational Study

Souvik Chatterjee, Indra Prakash Mandal, Debansu Sarkar

Introduction: Almost 75-90% of ureteric stones pass out spontaneously without any active intervention. Stones that do not pass out can be treated with Extracorporeal Shock Wave Lithotripsy (ESWL) or Ureteroscopic Lithotripsy (URSL). Certain radiological and inflammatory factors can be used to foresee the spontaneous passage of stones. Aim: To determine the factors predicting the spontaneous transit of mid and lower ureteric stones and to assess the outcome of expectant management of stones. Materials and Methods: A prospective observational study was carried out in the Department of Urology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India, from December 2022 to November 2023. All patients attending Urology Outpatient Department (OPD) and Emergency Department of a tertiary care hospital with ureteric colic due to mid and lower ureteric stones were considered for the study. A total of 108 patients meeting inclusion criteria were included in the study. Among them, four patients were lost to follow-up and another two patients had to be excluded as they developed urosepsis with acute pyelonephritis. Hence, data was collected from 102 patients. Stone identification was done using X-ray Kidney Ureter Bladder (KUB), Ultrasonography (USG) KUB and Non Contrast Computed Tomography (NCCT) KUB. Patients were followed-up after every two weeks with repeat reports. The patients were followed-up till they spontaneously passed the stone or till four weeks. Confirmation of stone passage was done with NCCT KUB. The radiological factors that were taken into consideration were included stone volume, stone position, stone density, side of presentation, proximal ureteral diameter, Ureteral Wall Thickness (UWT), Tissue Rim Sign (TRS), Perinephric Fat Stranding (PFS) and degree of hydronephrosis. The inflammatory factors studied included C-reactive Protein (CRP), White Blood Cell (WBC)/Total Leucocyte Count (TLC), Neutrophil Percentage (NP) and procalcitonin. The patients were divided into two groups: those who spontaneously passed the stone (SP) and those who did not (SNP). The non parametric Mann-Whitney U test and independent t-test were used to compare continuous variables, while Fisher’s exact test or the Chi-square test was used to compare categorical variables. Univariate and multivariate analyses were performed to identify predictors for stone passage. Results: Of the 102 participating patients, 67 (65.7%) passed the stone spontaneously. The mean age of the total population was 34.9±9.7 years. The presence of hydronephrosis, PFS and TRS were all found to be associated with failure of spontaneous passage of ureteric calculi (p-value<0.001). High CRP, leucocyte count and procalcitonin were associated with a lower spontaneous passage of stones. Increased CRP (SP 3.13±1.76 vs SNP 8.56±7.02, p-value <0.0001) and procalcitonin (SP 0.13±0.02 ng/mL vs SNP 0.22±0.14 ng/mL, p-value=0.001) were significantly associated with non passage of ureteric stones. On multivariate analysis, only stone size (p-value=0.028), procalcitonin (p-value=0.003) and stone level (p-value=0.026) were found to be significantly related to spontaneous stone passage. Conclusion: Inflammatory markers and radiological variables were found to predict the spontaneous transit of mid and lower ureteric stones.

Efficacy of Laparoscopic versus Open Donor Nephrectomy in the Living Kidney Donor: A Retrospective Cohort Study

Sashikant Asabe, Shivam Singh, Sunil Mhaske, Vilas P Sabale

Introduction: Renal transplantation is the optimal treatment for End-stage Renal Disease (ESRD), with living donor nephrectomy providing significant advantages over deceased donor renal transplantation. The present study compares the safety and efficacy of Laparoscopic Donor Nephrectomy (LDN) versus Open Donor Nephrectomy (ODN) in living kidney donors. Aim: To evaluate the efficacy of laparoscopic versus ODN. Materials and Methods: This retrospective cohort study was conducted in the Department of Urology at Dr. D. Y. Patil Medical College, Pune, Maharashtra, India, over a period of two years, from May 2022 to May 2024 involved 60 living kidney donors who underwent either LDN (30 patients) or ODN (30 patients). Data were collected from medical records, including demographic information, surgical details, and postoperative outcomes. Primary outcomes assessed included mean operative time, warm ischaemia time, amount of intraoperative blood loss, conversion rates to open surgery, and intra- as well as postoperative complications and difficulties encountered. Secondary outcomes included length of hospital stay, postoperative pain, recipient graft function, and donor renal function at the time of discharge. Quality of life was measured using a validated questionnaire at six months post-surgery. Data were analysed using the Student’s t-test and Chi-square test with Statistical Packages of Social Sciences (SPSS) version 22.0, considering p<0.05 as statistically significant. Results: The mean age of the LDN and ODN patients was 50.10±10.69 years 50.17±7.88 years, respectively. Most patients were aged 51-60 years (40%) and predominantly female (65%). The ODN had a shorter mean operative time (186.50±27.04 vs. 256.23±25.53 minutes, p<0.001) and lower warm ischaemia time (3.30±1.36 vs. 9.10±3.82 minutes, p<0.001) compared to LDN. However, ODN resulted in greater blood loss (89.67±36.99 vs. 61.16±15.68 mL, p<0.001) and longer hospital stays (4.60±0.77 vs. 3.50±0.63 days, p<0.001). Peri- and postoperative complications were more frequent in ODN (n=8 Grade 1; n=1 Grade 3 complication). At six months, LDN donors reported better quality of life scores in physical function (85.0 vs. 78.0, p=0.02), vitality (78.0 vs. 70.0, p<0.05), social functioning (82.0 vs. 75.0, p=0.012), and mental health (80.0 vs. 73.0, p=0.006). Conclusion: The LDN offers superior surgical outcomes and quality of life for living kidney donors, promoting its continued use in renal transplantation. However, additional studies are necessary to validate these findings across various populations and clinical environments, especially in novice surgical centres.

Characterisation of Adrenal Masses with Contrast Enhanced Computed Tomography- Adrenal Protocol: A Cross-sectional Study

Introduction: Adrenal masses are increasingly identified due to advancements in cross-sectional imaging. Radiology is critical in differentiating benign from malignant adrenal lesions, aiding in appropriate clinical management. Adrenal masses can arise from primary neoplasms, metastasis, hemorrhage, or hormonal stimulation, with adenomas and metastasis being the most common types. Characterising these masses is essential, as malignancy in adrenal lesions may indicate incurable primary disease, while benign lesions allow for curative treatment approaches. Aim: To assess the accuracy of the Contrast Enhanced Computed Tomography (CECT) washout study in characterising adrenal masses as benign or malignant. Materials and Methods: A hospital-based cross-sectional study was conducted at the Department of Radiodiagnosis, Gauhati Medical College and Hospital, Guwahati, Assam, India from August 2022 to December 2023 on 50 patients with 53 adrenal masses. Patients underwent CECT using a Philips brilliance iCT 256-slice machine. Adrenal masses with non enhanced attenuation values over 10 Hounsfield Units (HU) were evaluated through Absolute Percentage Washout (APW) and Relative Percentage Washout (RPW) criteria. APW and RPW thresholds of 60% and 40%, respectively, were used to classify masses as adenomas. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) software version 21.0. Continuous variables were expressed as mean±SD, and an Independent t-test was used for comparison. Categorical variables were expressed in terms of frequency and percentage, and variables were compared using the Chi-square test. Parameters between adenomas (benign adrenal masses) and non adenomas (malignant adrenal masses) were compared, with significance set at p-value <0.05. Results: A total of 53 adrenal masses were evaluated in 50 patients (29 males and 21 females) with a mean age of 53.02±13.98 years (range: 27-77 years). After Histopathological Examination (HPE), it was determined that 24 of the masses were adrenal adenomas, i.e., benign adrenal masses, whereas the remaining 29 masses were classified as non adenomas, i.e., malignant adrenal masses. Malignant lesions were significantly larger than benign adenomas (p-value=0.026) and showed lower APW and RPW values. Using a 60% APW threshold, the sensitivity and specificity for differentiating adenomas were 89.6% and 95.8%, respectively. The RPW method with a 40% cut-off yielded a sensitivity of 86.2% and specificity of 91.7. Conclusion: The CECT washout studies demonstrate high accuracy in characterising adrenal masses, with APW and RPW showing robust sensitivity and specificity.

Effect of Aerobic Training on Anxiety, Activities of Daily Living and Visual Motor Skills Performance in Children with Autism: A Randomised Controlled Trial

Anju Dhingra, Aarti Gupta, Aditi

Introduction: The prevalence of Autism Spectrum Disorder (ASD) has significantly increased over the past 20 years. Characterised by impairments in communication skills and the presence of stereotypical behaviours, individuals with ASD often experience difficulties in performing Activities of Daily Living (ADLs), abnormalities in visual processing and anxiety disorders. Structured exercise programs can serve as an effective complementary therapy for individuals with ASD by reducing symptoms and maximising abilities. Aim: To study the effect of aerobic exercise on anxiety, ADLs and visual motor skills performance in children with mild to moderate ASD. Materials and Methods: This randomised controlled trial was conducted at the SGT Medical College Hospital and Research Institute in Gurugram, Haryana and Holy Heart Special School in Dwarka Mor, Delhi, India from January 2023 to May 2023. Thirty-eight children aged between 7 and 13 years with mild to moderate ASD who met the selection criteria were included and randomly assigned to two groups. Group A (n=19) received aerobic training, while Group B (n=19), the control group, received an ASD awareness lecture along with other students to help them understand this disorder, which may decrease anxiety and improve the performance of children with ASD. Data were collected at baseline and at the end of the 8th week of the study. The outcome measures used were the Screen for Child Anxiety Related Disorders (SCARED), the Functional Independence Measure (FIM) and the mirror drawing apparatus. Data were statistically analysed using the Shapiro-Wilk normality test and the Mann-Whitney test. Results: Group A and Group B had respective median ages of 11 (8-13) years and 8 (7-12) years, with a similar gender distribution (F=1, M=18) in both groups. There was a significant reduction in the SCARED scores in Group A compared to Group B (p-value=0.004) after aerobic exercises. FIM scores were significantly higher in Group A than in Group B after the aerobic exercise intervention (p-value=0.009). Similarly, in Group A, the amount of time needed to draw the figure and the errors made with both the right and left hands decreased significantly for the mirror drawing score following aerobic exercises, indicating improvements in anxiety, ADLs and visual motor skills after the treatment. Conclusion: The results indicated that incorporating aerobic activities for children with mild to moderate autism improves ADLs, visual motor abilities and reduces anxiety.

Evaluation of Ergonomic Risk Factors and Pinch Strength in Goldsmith Workers: A Cross-sectional Study

Minal Dhairya Bhavsar, Bhavana Rajesh Gadhavi, Yagna Unmesh Shukla

Introduction: Gold ornament making industries are small scale widespread industries. India is the largest exporter of gems and jewellery. Goldsmith work is highly repetitive and strenuous job which may lead to Musculoskeletal Disorders (MSD) among workers. In the work, the worker uses tools such as cables, screwdrivers, scissors, cutters, pliers etc., for various gripping tasks. Such repetitive movements while working impair the pinch strength of the goldsmith, which is one of the MSDs. Aim: To evaluate the risk of MSDs and pinch strength in goldsmith workers. Materials and Methods: This observational cross-sectional study was conducted from jewellery workers from different areas of Ahmedabad, Gujarat, India, on March 2024 to July 2024, which comprised of 300 male participants. Study was affiliated with government physiotherapy college and government spine institute, civil hospital Ahmedabad, Gujarat, India. Rapid Upper Limb Assessment (RULA) was used to assess the stress of workers for all predominant postures by scoring them according to their severity of stress. The average working posture of the goldsmiths at their working condition were analysed by the RULA method. This was carried out with the digital photography. Baseline hydraulic pinch gauze was used to measure pinch strength. Pinch strength was tested using a standardised position given by American Society of Hand Therapists. Measurements were taken alternately between two hands. Descriptive statistics, including mean and standard deviation, were calculated for pinch strength data based on age group and hand dominance. To compare pinch strength between goldsmith workers and the normal values in the Gujarati population for both hands, the Mann-Whitney U test was performed. Results: The RULA analysis indicates that a significant majority of goldsmith workers are at risk for MSDs due to their adoption of awkward postures during daily work processes, with 44.3% (133 subjects) classified as low-risk suggesting that changes may be needed, 53.7% (161 subjects) categorised as medium-risk indicating a need for further investigation and prompt interventions and 2% (6 subjects) found to be at high-risk, which requires immediate changes, while none of the workers were at negligible risk level. Result of this study showed that tip to tip pinch strength, key pinch strength and three jaw chuck strength values were reduced in goldsmith workers as compared to normal values of population. Furthermore, there was a significant difference between all three types of pinch strength of goldsmith workers and normal values (p-value <0.05). Conclusion: From the observation and analysis of the result it was concluded that health of the goldsmiths were highly affected by the improper body posture and workload. Therefore, it is necessary to undertake ergonomic interventions in designing goldsmith workers workstation. Based on the results, the high-risk factors lead to significant decrease in pinch strength of goldsmith workers.

Preoperative Gargling with Magnesium Sulphate versus Lignocaine on Postoperative Sore Throat in Patients Undergoing Surgery under General Anaesthesia: A Randomised Clinical Study

Jatin Patel, Yashvi Samir Patwa, Pooja Shah, Rajsi Shah, Sara Mary Thomas

Introduction: Patients frequently experience throat pain after undergoing surgical procedures that require tracheal tube insertion, leading to patient discomfort. Various methods are employed to prevent Postoperative Sore Throat (POST), including preoperative gargling with Magnesium Sulphate and Lignocaine. These agents act through different mechanisms, with potential implications for intraoperative haemodynamic stability. Aim: To compare the effectiveness of preoperative gargling with Magnesium Sulphate (20 mg/kg) versus Lignocaine (4 mg/kg of 2%) in reducing POST and to assess the influence of these agents on intraoperative haemodynamic parameters. Materials and Methods: In this randomised, double-blinded prospective clinical study at tertiary care centre Dhiraj Hospital, Department of Anaesthesiology, Smt. Bhikhiben Kanjibhai Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth Deemed to be University, Gujarat, India, from October 2022 to November 2023, 70 adult patients {ages 18-65 years, American Society of Anaesthesiologists (ASA) I and II} undergoing surgery under general anaesthesia with endotracheal intubation were enrolled. They were randomly assigned to two groups of 35 each: Group M (Magnesium Sulphate, 20 mg/kg in 20 mL of 5% dextrose solution) and Group L (Lignocaine, 4 mg/kg of 2% Lignocaine in 20 mL sterile water). Both groups gargled for 30 seconds, 15 minutes prior to induction. Demographic data, haemodynamic parameters, and POST scores were compared across different time points intraoperatively (5, 15, 30, 45, 60, 90, 120 minutes) and postoperatively (0, 1, 2, 4, 6, 8, 12, and 24 hours). Statistical analysis was performed using an unpaired Student’s t-test for numerical data and a Chi-square test for categorical data. Paired t-tests were used for comparisons within groups. Results: Both Magnesium Sulphate and Lignocaine significantly reduced the incidence of POST (p-value <0.05). However, Magnesium Sulphate was found to be more effective than Lignocaine in preventing POST (p-value <0.05). Additionally, Magnesium Sulphate was associated with better haemodynamic stability, as assessed by intraoperative blood pressure and heart rate measurements. No significant differences in adverse events were noted between the groups. Conclusion: Preoperative gargling with Magnesium Sulphate was more effective than Lignocaine in reducing POST and contributed to better haemodynamic stability during surgery. These findings suggest that Magnesium Sulphate may be a superior option for reducing postoperative discomfort and improving patient outcomes in surgeries requiring general anaesthesia with tracheal intubation.

Knowledge of Physical Medicine and Rehabilitation among Medical Graduates in Kolkata, India: A Cross-sectional Study

Mausumi Sen, Shuvankar Mukherjee, Sukanta Majumdar, Tanmoy Naskar, Swapan Mishra

Introduction: With the changing demographics and increasing burden of chronic diseases and their consequences, there is increasing need for rehabilitation care. But unfortunately there is lack of knowledge and awareness about Physical Medicine and Rehabilitation (PMR) among healthcare professionals including Indian Medical Graduates (IMG) and medical students. Aim: To evaluate the basic knowledge and perception regarding PMR among IMGs at a Medical College in Kolkata, India. Materials and Methods: This cross-sectional study was conducted among interns posted at the Department of PMR, Calcutta National Medical College, Kolkata, West Bengal, India from May 2023 to April 2024. Altogether 165 out of total 200 interns of the current batch filled up an anonymous, pretested, predesigned, structured questionnaire. Prior ethical clearance was obtained from Institutional Ethics Committee. The questionnaire had 20 items, of which 15 were about knowledge pertaining to different aspects of PMR and two questions on the participant’s opinion regarding inclusion of PMR in undergraduate medical curriculum and PMR as a good option for pursuing a postgraduate course in future. The remaining three items are on participant’s age, sex and sources of knowledge regarding PMR. Data were analysed using Statistical Package for the Social Sciences (SPSS) version 20.0. Chi-square test was used to compare between male and female participants regarding their opinion about inclusion of PMR in undergraduate medical curriculum and their willingness to pursue PMR as a postgraduate course in future, at 5% significance level. Results: The study showed that 75.2% (124/165) of the participants had correct knowledge about the full form of “PMR”. But only 27.9% (46/165) could correctly identify “physiatrist” as the team leader of the rehabilitation team. Eighty three percent (137/165) of them were knowledgeable about the level of prevention, the term “rehabilitation” represented. However, only 30.3% (50/165) and 31.5% (52/165) knew the meaning of “disability” and “handicap” respectively. It was observed that 34.5% (57/165) were aware about when to start rehabilitation for any clinical condition. About 33.9% (56/165) had the correct idea that PMR interventions can improve Quality of Life (QOL). Majority was found to be unsure about inclusion of PMR in undergraduate curriculum and whether to pursue PMR in post postgraduate course. Conclusion: There was gross lack of knowledge regarding PMR among the participating interns.

Oral Surgical Site Infections and Wound Healing Associated with Silk Fibroin Sutures versus Alternative Suture Materials: A Systematic Review

Introduction: Delayed or improper wound healing can lead to Surgical Site Infections (SSIs), which are associated with increased mortality, morbidity, readmission rates and healthcare costs. Dental sutures are routinely used to close wounds, promote haemostasis and prevent infection. Although non absorbable sutures are preferred for promoting wound healing and preventing infection, Silk Fibroin (SF) sutures are still used due to their affordability and favourable properties. However, their multifilament structure makes them susceptible to higher bacterial adherence. Aim: To compare the effectiveness of SF sutures in reducing SSIs and promoting wound healing with other suture materials used in dental procedures. Materials and Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 checklist. PubMed, University of Toronto libraries and the Web of Science (WoS) were searched using specific keywords until January 4, 2025. Data were extracted and a risk of bias assessment was performed using the Risk of Bias 2 (RoB 2) and Risk of Bias In Non randomised Studies - of Interventions (ROBINS-I) tools. Nine studies were included. Results: The study demonstrated that non resorbable multifilament SF sutures show high microbial adherence and prolonged wound closure time compared to other materials, due to their multifilament and braided structure. However, significant infections were rarely reported. Results regarding bleeding, pain and swelling varied across studies and were mostly non significant on day 7. Conclusion: Antiseptic or antibiotic coatings on SF sutures can reduce bacterial adherence and lower the risk of infection, especially given their significantly higher adherence compared to other sutures.

Association of Lipid Profile with the Severity of Diabetic Retinopathy: A Cross-sectional Study

T Shakthiya, Arul Senghor, Radha Annamalai, Leena Chand, Teena Koshy

Introduction: Diabetic Retinopathy (DR) is a microvascular complication of diabetes that damages the retina and is the primary cause of irreversible vision loss among young adults of working age worldwide. It is important to understand the risk factors, such as dyslipidemia, as they have been linked to the pathogenesis and progression of this microvascular disease. Aim: To assess the association of lipid profiles with the severity of DR. Materials and Methods: This cross-sectional study included 150 participants of both genders with type 2 diabetes, aged 35-80 years, attending the Retina Clinic at the Outpatient Department (OPD) of Ophthalmology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India, between December 2021 and December 2022. The Early Treatment Diabetic Retinopathy Scale (ETDRS) was used to grade the severity of DR. Results: The mean age of diabetic patients with Non Proliferative Diabetic Retinopathy (NPDR) was 53.28±8.56 years, while the mean age of those without DR was 54.35±7.79 years, with p=0.3. The mean Fasting Blood Sugar (FBS) was significantly higher in patients with NPDR than in those without DR (199.76±65.47 vs. 177.69±62.75, p<0.031*). Similarly, the mean HbA1c level was higher in patients with DR compared to those without (9.77±2.27 vs. 8.71±1.97, p=0.002*). A statistically significant association was found between the level of Low-density Lipoprotein (LDL) cholesterol and severe NPDR (p=0.03*), but no correlation was found between Fasting Blood Sugar (FBS) and Glycated Haemoglobin (HbA1c) with the lipid profile among type 2 diabetes patients with NPDR and those without DR. Conclusion: A significant association was found between blood glucose, HbA1c, and the duration of diabetes in patients with NPDR and those without DR. Additionally, when NPDR is subcategorised as mild, moderate, and severe, a statistical increase in LDL cholesterol in severe NPDR was observed.

Effect of Lignocaine Infiltration versus Intravenous Dexmedetomidine on Haemodynamic Response during Skull Pin Holder Application for Craniotomy: A Prospective Interventional Study

P Shajla, Rashmi Ravindran, KT Shafna, S Minu

Introduction: The use of a skull pin holder during craniotomy is a painful procedure that induces haemodynamic changes. This may lead to raised intracranial pressure, brain bulging, or intracranial haemorrhage. Effectively managing these stress responses is very important, as they may increase morbidity and mortality in neurosurgical patients. Aim: To compare the effects of lignocaine infiltration and intravenous dexmedetomidine on the haemodynamic stress response to skull pin holder application during craniotomy. Materials and Methods: This prospective interventional study was conducted on 122 patients over a period from June 2020 to June 2021 in the Neurosurgery operation theatre of Government Medical College, Kozhikode, Kerala, India, a tertiary care teaching centre. Patients were divided into two groups: Group-L received 3 mL of 2% lignocaine with 1 in 200,000 adrenaline at each premarked pin site, while Group-D received intravenous dexmedetomidine at a dose of 0.5 mcg/kg over 10 minutes before the induction of general anaesthesia. Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP) and Mean Arterial Pressure (MAP) were recorded at baseline, after induction, post-intubation, pre-pin application and at intervals of 1, 2, 3, 4, 5, 10 and 15 minutes post pin application. Stata version 14.2 was used for data analysis. Statistical comparison between the groups was conducted using the independent t-test and Chi-square test. Results: There was no statistically significant difference in HR and blood pressure between the groups immediately after skull pin application. However, Group-D exhibited a significant reduction in HR at 10 and 15 minutes (p<0.001) post pin application compared to Group-L. Additionally, a statistically significant reduction in SBP, DBP and MAP was observed among the groups at 5, 10 and 15 minutes post pin application, with a greater reduction in Group-D. Conclusion: Intravenous dexmedetomidine at a dose of 0.5 mcg/kg was as effective as lignocaine infiltration at the premarked pin site in reducing the haemodynamic stress response to the application of the skull pin holder. Dexmedetomidine at this dosage also showed a greater reduction in HR and blood pressure after five minutes post pin application and did not require any additional pharmacological measures.

Effectiveness of Radiofrequency Ablation of Genicular Nerves in the Treatment of Chronic Knee Pain due to Degenerative Osteoarthritis: A Prospective Interventional Study

Introduction: Radiofrequency Ablation (RFA) has a long history dating back to 1931, with applications in treating various pain conditions. Given its established efficacy in managing spinal facet joint pain and its emerging popularity in treating arthritic knee pain through Genicular Nerve RFA (GNRFA), it is essential to investigate the effectiveness of traditional RFA in alleviating knee pain due to degenerative Osteoarthritis (OA) in patients with advanced OA who are not candidates for Total Knee Arthroplasty (TKA). Aim: To evaluate the effectiveness of RFA of genicular nerves in reducing chronic knee pain due to degenerative OA. Materials and Methods: This prospective interventional study was conducted at the Department of Orthopaedic Surgery, JSS Medical College, Mysore, Karnataka, India over a period of one year from July 2022 to June 2023. A total of 38 patients with chronic knee pain resulting from degenerative OA underwent RFA of genicular nerves, with assessments conducted at four time points: baseline, one month, three months and six months postprocedure. The evaluations utilised the Numerical Rating Scale (NRS) to measure pain levels, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to evaluate functional outcomes, and monitored analgesic usage to track pain management, providing a comprehensive understanding of the treatment’s effectiveness in alleviating chronic knee pain. The Friedman test was used to study the effectiveness of RFA of genicular nerves in reducing knee pain due to degenerative OA, and the pairwise Wilcoxon test with Bonferroni correction was used to compare statistical significance between different pairs. A p-value of <0.05 was considered statistically significant. Results: Substantial reductions were noted in pain levels, both at rest and during movement, as evidenced by significant reductions (p-value <0.001) in NRS scores, alongside improvements in WOMAC scores and decreased analgesic usage at all follow-up assessments compared to baseline (p-value <0.05). Conclusion: The study found that GNRFA significantly reduces pain and improves function in patients with chronic knee OA. This minimally invasive procedure is a safe, effective and cost-efficient treatment option for OA patients who rely heavily on analgesics, are unsuitable for surgery, or experience persistent pain after Total Knee Replacement (TKR).

Correlating Pain and Thermal Changes in Inflammatory Periapical and Periodontal Lesions using Visual Analogue Scale and Infrared Thermography: A Prospective Observational Study

Ranjjith Ravichandar, Jagat Reddy, Sivasankari Thirunavukarasu

Introduction: The diagnosis of inflammatory periapical lesions remains a challenge, as it typically requires invasive testing methods that might adversely affect individuals. With the modern imaging modality of infrared thermography, the mapping and analysis of the exact temperature of the affected inflammatory site can be performed due to its non invasive and non ionising properties. Aim: To measure and compare the thermal levels (°C) and to correlate them with pain using the Visual Analogue Scale (VAS) score in patients with inflammatory periapical and periodontal lesions using infrared thermography. Materials and Methods: The present prospective observational study was conducted in the Department of Oral Medicine and Radiology, Indira Gandhi Institute of Dental Sciences, Puducherry, India, from October 2022 to April 2023. Study included a total of 60 patients diagnosed with inflammatory lesions such as apical periodontitis, periapical abscess, periodontal abscess and endo-perio lesions. Thermal levels (°C) were measured at baseline, on the 3rd day and on the 5th day of follow-up using the FLIR ONE® Pro thermal device. Pain was assessed using the VAS score at baseline and on the 5th day of follow-up. The comparison of thermal changes in inflammatory lesions was statistically analysed using repeated measures of Analysis of Variance (ANOVA) and its correlation with pain using the VAS score was analysed using the Spearman’s correlation test. Results: There were 30 males and 30 females, and mean±Standard Deviation (SD) age of study participants was 39.87±13.17 years. The mean thermal levels (°C) at baseline, on the 3rd day and on the 5th day of follow-up for dental caries with apical periodontitis were 35.38, 34.38 and 33.21; for periapical abscess, they were 36.41, 35.04 and 33.89; for periodontal abscess, they were 35.61, 34.13 and 33.44; and for endo-perio lesions, they were 34.86, 34.07 and 33.23, respectively. A significant difference was observed in the thermal levels among the different odontogenic lesions on all three days (p-value <0.05). The correlation coefficients between the thermal levels (°C) and VAS scores at baseline and on the 5th day were 0.119 and -0.043, respectively, which were not statistically significant (p-values=0.366 and 0.743, respectively). Conclusion: The present study was conducted to measure and compare the thermal levels of inflammatory lesions and the results showed a gradual decrease in thermal levels during follow-up. Hence, infrared thermography can be a useful diagnostic tool for temperature mapping in the identification of inflammatory lesions such as apical periodontitis, periapical abscess, periodontal abscess and endo-perio lesions.

Effect of Retro Walking Combined with Lagos Neuropathy Protocol on Balance and Spatiotemporal Parameters of Gait among Patients with Diabetic Neuropathy: A Prospective Interventional Study

Supriya Kumari, Kalidasan Varathan

Introduction: Diabetic Peripheral Neuropathy (DPN) clinically manifests as a sensorimotor disturbance that leads to complications in gait alteration and balance impairment. Balance and locomotion are the most critical aspects of an individual’s independence. Aim: To assess the effect of Retro walking with Lagos Neuropathy Protocol (LNP) on balance and spatiotemporal parameters of gait among patients with Diabetic neuropathy. Materials and Methods: The present prospective interventional Study was conducted in the Outpatient Department (OPD), Krupanidhi College of Physiotherapy, Bengaluru, Karnataka, India, from October 2022 to June 2023. The sample size was 60 individuals, 30 in each group (experimental and control group). Group 1, the control group, received the conventional LNP. Group 2, the experimental group, received the LNP combined with backward walking. The interventions were given to the patients four times/week for eight weeks. Subjects were assessed at the initial stage and following the end of the intervention. The parameters assessed were balance and spatiotemporal parameters of gait, in which balance was assessed by using the Mini Balance Evaluation Systems Test (Mini-BESTest) and gait speed using a 10 m walk test; other gait parameters cadence, step length, and stride length were measured individually using a stopwatch and inch tape. The statistical software used was Statistical Package for the Social Sciences (SPSS) software version 29.0, and the tests included were paired t-tests and independent t-tests for data analysis. Result: The mean±Standard Deviation (SD) age of the experimental group participants was 51±3.24 years, and the control group was 50.87±3.12 years. A significant improvement was seen in cadence, step length, stride length, gait speed, and balance in the control and experimental group (p-value<0.001)Greater improvement was found in the experimental group when compared with the control group in all the outcome measures. Significant improvement was seen in all parameters in the experimental group when compared to the control group at post-test (p-value <0.05). Conclusion: The study concluded that the LNP combined with backward walking had a significant positive effect on balance and spatiotemporal determinants of gait than the LNP alone among DPN patients.

Factors Influencing Anxiety among Patients in a Dental Setting: A Cross-sectional Study

Introduction: Dental Anxiety (DA) is a well-known obstacle that influences how patients behave and feel about receiving dental care. The Modified Dental Anxiety Scale (MDAS) is a widely used instrument for evaluating DA in patients attending dental clinics. Aim: To determine the variables affecting DA in patients at a private dentistry college in Jeddah. Materials and Methods: A cross-sectional study was conducted at Department of Preventive Dental Sciences, Ibn Sina National College for Medical Studies, Jeddah, Makkah, Saudi Arabia, from December 2023 to March 2024. A self-reported questionnaire was used as the data collection tool. The study comprised a total of 346 participants, with responses collected electronically via Google Docs. Participants were categorised into three groups—low, moderate and high DA—based on established risk indicators. The analysis of responses employed descriptive statistics, presented as mean±standard deviation. Associations between variables were assessed using the Chi-square test, with a p-value of less than 0.05 considered statistically significant. Results: Among participants aged 18 to 30 years, 73 individuals (54.1%) reported low anxiety levels, 56 individuals (41.5%) reported moderate anxiety and 6 individuals (4.4%) reported high anxiety levels. In the cohort of participants older than 30 years, 84 individuals (39.8%) exhibited low anxiety, 103 individuals (48.8%) exhibited moderate anxiety and 24 individuals (11.4%) exhibited high anxiety levels. Examining gender differences, 58 males (58%) reported low levels of anxiety, while 8 males (8%) reported high levels. Comparatively, 99 females (40.2%) reported low anxiety and 22 females (8.9%) reported high anxiety levels. Although a majority of participants indicated low levels of anxiety, among postgraduate individuals, 6 (26.1%) reported high anxiety levels. Participants were also queried regarding their prior dental visits and of those who responded affirmatively, 157 individuals (45.4%) reported low anxiety, 159 individuals (45.9%) reported moderate anxiety and 30 individuals (8.6%) reported high anxiety. Conclusion: The findings of the present study indicate that DA is significantly influenced by various factors, including age, gender, occupation, self-perceived oral healthcare and prior dental visit experiences. Addressing these variables may enhance the effectiveness of strategies aimed at mitigating DA among patients visiting dental clinics.

Comparison of Retinal Thickness in Diabetic Patients with Healthy Controls: A Cross-sectional Study

Saroj Chaudhary, Manjinder Kaur, Lipa Monhanty, Naren Kurmi

Introduction: Diabetes Mellitus (DM) is a metabolic disorder characterised by chronic hyperglycaemia, leading to systemic complications such as Diabetic Retinopathy (DR). The impact of DM on retinal thickness is of particular interest, as it can serve as an early indicator of DR progression. Aim: To assess variations in retinal thickness among diabetic patients without systemic involvement and also to correlate retinal thickness with the duration of diabetes and Glycated haemoglobin (HbA1c) levels. Materials and Methods: This cross-sectional study was conducted in the Department of Physiology at Geetanjali Medical College and Hospital, a tertiary care centre, from January 2023 to April 2024. A total of 120 participants were included, with 60 individuals in the diabetic group (group D) and 60 in the healthy control group (group N). Group D consisted of participants with a diabetes duration of 1.5-10 years and HbA1c levels above 6.5%, while those with systemic or ocular complications of diabetes were excluded. Retinal thickness was measured using Optical Coherence Tomography (OCT), and HbA1c levels were recorded. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 20.0, employing independent samples t-tests and correlation analysis. Results: The study included 60 participants in each group, with group N (Control) and group D (Diabetic) having a mean age of 38.67±5.38 years and 48.17±8.76 years, respectively, with the latter being significantly older. The gender distribution varied, with group N having a higher male-to-female ratio (51 males and 9 females) compared to group D (39 males and 21 females). The diabetic group exhibited significantly reduced retinal thickness compared to the controls, with mean values of 190.88±22.33 μm in the right eye and 188.02±19.58 μm in the left eye. In contrast, the control group had mean values of 206.02±21.29 μm in the right eye and 210.33±18.14 μm in the left eye (p-value<0.001). Correlation analysis showed no significant associations between HbA1c levels, duration of diabetes and retinal thickness. Conclusion: This study highlights significant reductions in retinal thickness among diabetic patients compared to healthy controls. The lack of correlation with HbA1c levels and diabetes duration suggests the need for further investigation into additional factors influencing retinal changes in DM.

Antimicrobial Susceptibility Patterns of Haemophilus influenzae and Streptococcus pneumoniae in Respiratory Tract Infections: A Retrospective Observational Real-world Database Study in India

Introduction: Antimicrobial Resistance (AMR) presents a major worldwide challenge to public health, leading to significant levels of illness and death in India. The rise in antibiotic prescriptions during the pandemic raised concerns over the possible increase in antibiotic resistance and the risk of AMR. Aim: To investigate the real-world antibiotic susceptibility patterns of Haemophilus influenzae and Streptococcus pneumoniae to various antibiotics using diagnostic laboratory-based Antibiotic Sensitivity Testing (AST) data from India. Materials and Methods: This was a retrospective, observational, real-world database study that included 1,351 diagnostic AST records of the most common respiratory specimens collected from all ages between January 2017 and July 2022. Diagnostic AST records were collected across four accredited diagnostic laboratories in India, selected through an exhaustive Quality Control (QC) process validated by microbiology experts. The susceptibility patterns of H. influenzae and S. pneumoniae to amoxicillin-clavulanic acid, azithromycin, levofloxacin, cefixime, cefpodoxime and cefuroxime were evaluated using quantitative analysis {mean ± standard deviation, median (range) for age, frequency and proportions; and Odds Ratios (OR) comparing the susceptibility patterns of amoxicillin-clavulanic acid with other antibiotics} and reported as per the standard AST results as % Sensitive, % Intermediate and % Resistant. Results: Of the 1,351 diagnostic AST records included in the analysis, 1,257 (93.0%) were from adults (≥18 years). Most H. influenzae {566/608 (93.1%)} and S. pneumoniae {554/743 (74.6%)} isolates were from sputum samples. Most isolates of S. pneumoniae {227 (95.8%)} and H. influenzae {86 (88.7%)} were susceptible to amoxicillin-clavulanic acid. Susceptibility to amoxicillin-clavulanic acid was higher compared to most of the antibiotics evaluated. S. pneumoniae also showed high susceptibility to second-generation {cefuroxime: 87.4% (n=111)} and third-generation cephalosporins {cefixime: 91.3% (n=115), cefpodoxime: 97.5% (n=119)}. The susceptibility patterns of both organisms remained consistent during the pre- and post Coronavirus Disease-2019 (COVID-19) pandemic periods, except for H. influenzae to cefixime {94.0% (n=252) to 63.7% (n=137)}. Conclusion: The overall susceptibility patterns of H. influenzae and S. pneumoniae to the selected antibiotics varied over the 5-year study period. The susceptibility of both organisms to amoxicillin-clavulanic acid remained high with some fluctuations. This data also guides clinicians in making evidence-based decisions for managing Respiratory Tract Infections (RTIs).

A Cohort Study on the Aspartate Aminotransferase and Alanine Aminotransferase Ratio (De Ritis Ratio) as a Reliable Marker of Outcome in Patients with Acute Ischemic Stroke

Introduction: Functional prognosis after an Acute Ischaemic Stroke (AIS) has been linked to two blood enzymes: Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT). The metabolic effects of AST and ALT in decreasing blood glutamate levels may account for this association. Aim: To establish a correlation between AIS, its severity and mortality with their De Ritis ratio (AST/ALT). Materials and Methods: In this hospital-based prospective cohort study conducted at the Department of Medicine at Acharya Vinoba Bhave Rural Teaching Hospital, Wardha, Maharashtra, India, 100 AIS patients were enrolled from December 2020 to December 2022. The parameters used in this study included the Aspartate Aminotransferase/Alanine Transaminase Ratio (AAR), AST, ALT, age, Body Mass Index (BMI) and hypertension. The patients were categorised into four subgroups according to AAR quartiles. The National Institutes of Health Stroke Scale (NIHSS) score was calculated at admission and the modified Rankin Scale (mRS) score was assessed at a 3-month follow-up period. Univariate and multivariate non conditional logistic regression models were employed to assess the relationship between AAR quartiles and outcomes among AIS patients. An association of the De Ritis ratio with these scores was evaluated. Microsoft Office Excel was used for data entry and Statistical Package for the Social Sciences (SPSS) version 28.0 was used for analysis. Results: In the patients’ demographic information, including their past medical history and co-morbidities, 94.0% of the patients were aged ≥40 years, with a mean age of 58.16±13.44 years. The anthropometric measurements (BMI=23.89±2.42 kg/m²) and blood indices of all patients were compared and highlighted in the baseline characteristics. There was a significant association between disease severity, as per the NIHSS score and the De Ritis ratio (p=0.038). Disease severity increased significantly with the De Ritis ratio. Additionally, there was a significant association between the outcome 3 months after discharge (mRS score) and the ratio of AST to ALT (p=0.043). Notably, 42.9% of deaths occurred in patients with a De Ritis ratio >1.45. Patients with higher NIHSS and mRS scores were significantly associated with an elevated De Ritis ratio. Conclusion: The De Ritis ratio (AST/ALT) relates to the severity of stroke (NIHSS score), poor outcomes (mRS score) and mortality. The value of the De Ritis ratio can be used as a reliable assessment tool for the prognosis of patients with AIS. The De Ritis ratio can serve as a non invasive and cost-effective tool for assessing AIS, differentiating stroke severity and predicting mortality.

Assessment of Educational Environment and its Association with Burnout and Mental Health among the Dental Students of Majmaah University: A Pilot Study

Mohamed Helmy Salama

Introduction: The educational environment is crucial to the well-being of students, particularly in high-stress fields like dentistry, where academic and clinical pressures can significantly affect mental health. In Saudi Arabia, the high prevalence of psychological distress among dental students necessitates an understanding of the underlying causes. Aim: To analyse dental students’ perceptions of their educational environment in the College of Dentistry, Saudi Arabia and its impact on mental health, particularly anxiety and burnout. Materials and Methods: This pilot study was conducted in September 2024, involving 50 undergraduate dental students from College of Dentistry, Majmaah University, Al Majmaah, Riyadh, Saudi Arabia. The Dundee Ready Education Environment Measure (DREEM) questionnaire assessed the perception of the educational environment. The Generalised Anxiety Disorder (GAD-7) scale and Maslach’s Burnout Inventory-Student Survey (MBI-SS) measured levels of anxiety and burnout. Statistical data were analysed using Statistical Package for Social Sciences (SPSS) version 29.0, with stratification based on gender and residence. One-way Analysis of Variance (ANOVA) and linear regression were applied to evaluate the relationship between the study variables. A p-value of <0.05 was considered significant. Results: The average age of the participants was 22.96±2.9 years (range: 19-26 years). The overall mean DREEM score was 124.82/200, with Students’ Perception of Teachers (SPT) scoring the highest (71.59%). Female students had a significantly more positive perception of teachers than male students. No significant correlation was found between Professional Efficacy (PE) and GAD-7 scores (r=0.257), but other parameters, such as scores for DREEM domains, MBI dimensions and GAD-7, showed significant positive correlations. All the DREEM domains significantly predicted anxiety and burnout levels. Conclusion: Overall, the undergraduate dental students of Majmaah University, Saudi Arabia, had a generally favourable perception of their educational environment. However, addressing emotional stressors and enhancing peer relationships, curriculum design and the academic atmosphere may help reduce burnout and anxiety.

Determine the Correlation Coefficient between the Plethysmographic Variability Index and Pulse Pressure Variation as a Marker for Intravascular Volume Status in Non Laparoscopic Abdominal Surgery: A Cross-sectional Study

D Harsha, Amit Singh, Praveen Kumar, Vikram Singh Rathore

Introduction: Precise evaluations of intravascular fluid status are crucial for managing haemodynamically unstable patients and for perioperative treatment. Assessing a patient’s response to fluid resuscitation is a vital and challenging aspect of intraoperative care. Aim: To study the correlation of the Plethysmographic Variability Index (PVI) and Pulse Pressure Variation (PPV) for prediction of fluid responsiveness in non laparoscopic abdominal surgery patients. Materials and Methods: This was a cross-sectional observational study conducted at Base Hospital Delhi Cantt, India after obtaining approval from the ethical committee and written informed consent. A total of 55 American Society of Anaesthesiologists (ASA) I/II patients of any gender, aged between 18-60 years, who were undergoing major surgery requiring invasive arterial pressure monitoring, were included in the study. The surgery was carried out using standard general endotracheal anaesthesia along with muscle relaxation and intermittent positive pressure ventilation. The PPV and PVI were measured using the Masimo Rainbow set pulse co-oximetry. Measurements were taken five minutes before a fluid bolus and then at five-minute intervals after the fluid bolus, up to 30 minutes. The Pearson correlation coefficient, Bland-Altman plot, independent sample Student’s t-test and Chi-square test were used to test statistical significance. A p-value of <0.05 was considered statistically significant. Results: In the group of 55 patients, there were 31 females and 24 males, with age (Mean±SD) of 42.62±13.25 years for fluid responders and 47.07±13.12 years for non responders. Among them, 13 were identified as fluid responders based on a PPV >13, and 22 were identified based on a PVI >12.5. There were no significant variations in mean Heart Rate (HR) and Mean Arterial Pressure (MAP) between fluid responders and non responders (p-value >0.05). Age, gender and Haemoglobin (Hb) levels were comparable in fluid responders and non responders (p-value >0.05). A statistically significant positive correlation was observed between PPV and PVI at 0, 5 and 15 minutes. The difference in PPV between fluid responders and non responders was significant at all time points (p-value <0.001). The area under the Receiver Operating Characteristics (ROC) curve for fluid responsiveness by PVI was 0.625 (95% CI: 0.453-0.797). The sensitivity and specificity of PVI were 53.85% and 64.29%, respectively. Conclusion: Fluid responders and non responders showed a positive correlation between PPV and PVI. The PVI is a highly effective tool for guiding perioperative fluid management.

Effect of a Single Dose of Metoclopramide on Gastric Volume in Fasting Diabetic Patients Measured using Ultrasonography: A Randomised Controlled Trial

Shwetha K Mudalagirigowda, Madhu Srinivasaiah, Jyothi Bramhachar

Introduction: Diabetic patients have delayed gastric emptying time and even if adequately fasted before elective surgery, are found to have increased Gastric Volume (GV) compared to non diabetic patients. Increased GV poses them with an increased risk of aspiration during general anaesthesia. Metoclopramide is an Food and Drug Administration (FDA)-approved drug for diabetic induced gastroparesis which is given orally for a long duration unless there are any side-effects. Its intravenous use as a single dose in diabetic patients to increase gastric motility is not studied. With the use of portable ultrasound, the estimation of GV has become very easy and reliable compared to older techniques. Aim: To evaluate the effect of metoclopramide on GV in diabetic patients using Ultrasonography (USG). Materials and Methods: This prospective randomised double-blinded study was conducted in the Department of Anaesthesiology, Chandramma Dayanand Sagar Institute of Medical Education and Research (a tertiary care centre), Bengaluru, Karnataka, India between March 2023 and March 2024. A total of 60 diabetic patients posted for elective surgeries who had fasted for more than eight hours were enrolled in the present study to receive either injection Metoclopramide (group M) or Injection normal saline (group N). Ultrasonography was done in both supine and right lateral position to calculate the antral diameters (antero-posterior and cranio-caudal) before and after 30 minutes of giving the drug. The Cross-sectional Area (CSA) and the GV were calculated and compared. Independent sample t-test and Mann Whitney U test were performed to compare the mean and median values of GV between the groups. The p-value <0.05 was considered statistically significant. Results: The demographic parameters, the baseline CSA and the GV in both groups were similar. After the intervention, the GV was significantly less in group M than in group N in the right lateral position post intervention (p=0.0103). On intragroup comparison, a significant decrease in CSA and GVs was seen in the right lateral position after intervention in the study group (p<0.05). However, in the control group, there was a slight increase in the diameters and CSA but it was not significant statistically in both supine and right lateral positions. Conclusion: A single dose of intravenous metoclopramide drug accelerated gastric emptying in diabetic patients as compared to the placebo group.

Assessment of Diagnostic Accuracy of Nuclear Matrix Protein 22 versus Urine Cytology for Detecting Bladder Cancer keeping Cystoscopy and Biopsy as Gold Standard: A Cross-sectional Study

Santosh Kumar, Kunal Mehra, Neeraj Suhas

Introduction: Bladder cancer is a common urological malignancy that requires early and accurate detection for effective treatment and improved patient outcomes. Traditional urine cytology is effective for high-grade tumours but has limited sensitivity for low-grade cancers. Aim: To compare the sensitivity and specificity of the Nuclear Matrix Protein 22 (NMP22) test and urine cytology for bladder cancer detection, using cystoscopy and biopsy as the gold standard. Materials and Methods: This cross-sectional validation study was conducted at the Vydehi Institute of Medical Sciences and Research Centre in Bengaluru, Karnataka, India from August 2023 to August 2024, involving 42 patients with Transitional Cell Carcinoma (TCC). Urine samples were analysed using ALERE NMP22® and cytology, with cystoscopy and biopsy serving as the gold standard for diagnosing bladder cancer. Contingency tables were created to calculate sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), and diagnostic accuracy of NMP22 and urine cytology, using cystoscopy/biopsy as the gold standard. Results: The mean age of the study population was 56 years, with the mean age among males and females being 58.5 years and 51.3 years, respectively. NMP22 outperformed urine cytology in diagnosing bladder cancer, with a sensitivity of 76.32% (32/42) versus 31.58% (13/41), and both tests had 100% specificity and PPV. NMP22’s NPV was 30.77%, compared to 13.33% for cytology. Overall accuracy for NMP22 was 78.57% (33/42), while the accuracy for cytology was 38.10% (16/42). Conclusion: The NMP22 is more sensitive than urine cytology for detecting bladder cancer. While cytology remains valuable for its specificity and confirmatory role, NMP22 offers a superior diagnostic option, particularly for the early detection of aggressive tumours. Future research should explore combining NMP22 with other diagnostic methods to further enhance early detection and improve patient outcomes.

Comparative Analysis of 3D Printing, Computer Aided Design and Milling and Conventional Fabrication Techniques on Fracture Resistance of Interim Restorations: A Systematic Review and Meta-analysis

Banashree Sankeshwari, Aditi Kanitkar, Channaveer Pattanshetti, Aneesh Kanitkar

Introduction: The fracture resistance of interim restorative materials is important for success of dental restorations. Various fabrication methods have been employed to create provisional restorative materials, but impact of these methods on fracture resistance remains unclear. Understanding the influence of different fabrication techniques of interim restorative materials on fracture resistance is essential for optimising clinical outcomes, patient satisfaction, and overall dental treatment success. Aim: To compare the effect of different fabrication techniques on fracture resistance of interim restorations. Materials and Methods: A systematic search was conducted in electronic databases, which included PubMed, Scopus, and Corrections: Web of Science (WoS), to identify relevant studies published. Studies were included if they met the following criteria: Investigate the fracture resistance of provisional restorative materials, compare different fabrication techniques, published in English and peer-reviewed articles. Studies were excluded if they do not meet these criteria or are not available in full text. The quality of included studies was assessed using a validated tool modified Consolidated Standards Of Reporting Trials (CONSORT) checklist. A meta-analysis was performed to quantitatively analyse the effect of different fabrication techniques on the fracture resistance of provisional restorative materials. Subgroup analyses and sensitivity analyses was conducted if necessary. Results: The initial search yielded 254 potential articles. After removing duplicates and conducting a thorough screening of titles, abstracts, and full texts, 17 articles met the inclusion criteria for the study which were included for qualitative analysis. Data were extracted regarding the authors' details, the journals and years of publication, different fabrication methods and materials and evaluation of fracture resistance. The result revealed that there was no statistically significant difference for fracture resistance between Computer Aided Design and Computer Aided Manufacturing (CAD-CAM) and 3D-printed interim restorations {Mean difference=50.72 (95% CI=143.55, 244.99)} whereas there was statistically significant difference between CAD-CAM and conventional restorations {mean difference=282.58 (-411.59, -153.47)} and 3D printed and conventional interim restorations {Mean difference=169.75 (95% CI= 353.68, 14.17)}. The p-value is not significant but there is difference seen. Conclusion: Polymethyl Methacrylate (PMMA) CAD/CAM milled interim restorations demonstrated the highest fracture resistance among the groups compared in the study. This finding highlights the superior durability and strength of CAD/CAM milling technology, particularly when using PMMA as the material for fabricating provisional restorations. The precise and controlled nature of the milling process ensures a strong, reliable restoration with high fracture resistance, making it the ideal choice for many clinical situations. A 3D-printing was shown to be a stronger and more reliable manufacturing method for interim restorations when compared to traditional conventional techniques (such as indirect methods). Although 3D-printed restorations exhibited lower fracture resistance than CAD/CAM milled restorations, they still offer a significant advantage over conventional techniques in terms of strength and reliability. This suggests that 3D-printing can be a viable alternative, especially when CAD/CAM milling is not available or feasible.

Intubating Conditions and First Pass Success Rate with Low Dose Rocuronium during Rapid Sequence Intubation: A Cross-sectional Study

Introduction: Emergency Rapid Sequence Intubation (RSI) aims to reduce complications such as pulmonary aspiration, prolonged intubation with hypoxia and the occurrence of a crash airway, while making rapid intubation safer and easier. Rocuronium, a non depolarising muscle relaxant with a prolonged neuromuscular blockade, was used to create “Modified RSI.” The first-pass success rates of rocuronium in the Indian population have not been extensively studied. Therefore, investigations in adult patients are essential to link it to an anticipated troublesome airway. Aim: To determine the first-pass success rates in patients needing RSI and to investigate whether paralysis with a low dosage of rocuronium provides clinically acceptable intubating conditions. Materials and Methods: A cross-sectional study was carried out involving all adult patients admitted to the Department of Emergency Medicine, Amala Institute of Medical Sciences, Thrissur, Kerala, India, from March 2021 to November 2022, who required emergent intubation. The vital signs of every adult patient who arrived at the ED were monitored and categorised appropriately. Basic resuscitation techniques were administered to unstable patients. Informed consent was obtained and patients who met the inclusion and exclusion criteria were grouped. Data were gathered using a standard data collection form. The arithmetic mean, standard deviation, or median value were used to convey quantitative data, whereas proportions were used to express qualitative factors. Fisher’s-exact test was employed to test associations between qualitative factors, while the t-test was used to examine the relationship between qualitative and quantitative data. Results: The mean age of the study participants was 64.30±14.49 years. A low dose of rocuronium (0.3 mg/kg) produced the best intubation conditions. Fisher’s exact test indicated that patients with good/easy intubating conditions had a failure rate of 5% and 8.1% at 60 and 90 seconds, respectively, while patients with challenging intubation settings had a failure rate of 100% at both time points. With a p-value of <0.001, the association between the intubating conditions at 60 and 90 seconds and the success rate of intubation on the first attempt was determined to be statistically significant. Conclusion: The present study concluded that a dose of 0.3 mg/kg of rocuronium produced satisfactory laryngeal relaxation, increasing the success rate of intubation on the first attempt.

Comparative Efficacy of Formoterol Combined with Glycopyrronium versus Budesonide in Managing Chronic Obstructive Pulmonary Disease: A Randomised Clinical Trial

Madhav Mahawar, Keertivardhan D Kulkarni, BK Likhitha

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a leading global health issue, often resulting from prolonged exposure to harmful particles or gases. The 2022 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest using combinations of Long-acting Beta Agonist plus Inhaled Corticosteroid (LABA+ICS), Long-acting Beta Agonist plus Long-Acting Muscarinic Antagonist (LABA+LAMA) or LAMA for treatment, but do not specify which combination is most effective. Studies have shown mixed results regarding the superiority of LABA+ICS over LABA+LAMA, with some suggesting better outcomes for LABA+ICS, while others report similar or even better efficacy for LABA+LAMA. Aim: To compare the effects of Formoterol+Glycopyrronium (LABA+LAMA) versus Formoterol+Budesonide (LABA+ICS) in COPD patients by evaluating changes in spirometry, 6-minute walk test performance, side-effects and Quality Of Life (QOL). Materials and Methods: This double-blinded Randomised Clinical Trial (RCT) included 70 COPD patients visiting the Department of Respiratory Medicine at BLDE (Deemed to be University) Shri BM Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka, India. The study compared two treatment regimens: LABA+LAMA (Formoterol+Glycopyrronium) FM-GP group and LABA+ICS (Formoterol+Budesonide) FM-PD group. The study’s sample size was 70 patients, with 35 in each group. Inclusion criteria included patients aged over 40, of either sex and willing to provide informed consent. Several tools were used to assess the severity and prognosis of COPD, including spirometry, the Six-minute Walk Test (6MWT), the Body Mass Index, Airflow Obstruction, Dyspnoea and Exercise Capacity (BODE) index, the COPD Assessment Test (CAT), the Clinical COPD Questionnaire (CCQ) and the modified Medical Research Council (mMRC) scale. Follow-up assessments took place after three months. The data were analysed using Statistical Package for the Social Sciences (SPSS) version 20.0 and the results are presented as mean±SD, median, interquartile range and percentages. Results: The mean age was 64.41 years in the FM-BD group and 64.75 years in the FM-GP group, respectively. In a study of 70 COPD patients, both the Formoterol-Budesonide (FM-BD) and Formoterol-Glycopyrronium (FM-GP) groups showed improvements in various parameters over three months. The FM-GP group exhibited a significant improvement in predicted Forced Expiratory Volume in One Second (FEV1) (p=0.001) and a more substantial reduction in the BODE index (p=0.04). Both groups showed significant improvements in mMRC scores, with the FM-GP group showing a slightly better outcome (p=0.019). The FM-BD group had more adverse effects and hospitalisations, including higher rates of exacerbations and Intensive Care Unit (ICU) admissions. Conclusion: The FM-GP group showed significant improvement in mMRC and BODE Index and reduced adverse effects and rates of exacerbations compared to the FM-BD group. The mean change in post-bronchodilator FEV1 was significant in the FM-BD group compared to the FM-GP group.

Assessment of Coronary Artery Disease Risk Factors and its Knowledge among Perimenopausal Women: A Questionnaire-based Cross-sectional Study from Mangaluru, Karnataka, India

Janet Prima Miranda, Prabha Adhikari, Binsha Pappachan

Introduction: Assessing knowledge of Coronary Artery Disease (CAD) and identifying its risk factors is crucial because Cardiovascular Disease (CVD) remains the leading cause of death in women, particularly as they age. During perimenopause, declining oestrogen, changes in cholesterol, weight gain and insulin resistance increase the risk of CAD. Raising awareness and identifying risks early enables healthcare providers to promote heart-healthy behaviours, reduce modifiable risks and improve long-term outcomes. Aim: To assess the knowledge of CAD risk factors and identify the specific risk factors among perimenopausal women. Materials and Methods: The study used a cross-sectional research design targeting non healthcare worker women aged 45 to 55 years. Ninety-two women in the perimenopausal period were selected through purposive sampling. The study was conducted at a private medical college hospital in Karnataka, India from January 2023 to July 2024. Knowledge regarding CAD prevention was assessed using a structured knowledge questionnaire. The risk factors for CAD were evaluated using various parameters: biophysical, biochemical and lifestyle. Descriptive statistics were used to analyse the data, including frequency, percentage, mean and standard deviation. Data processing and statistical analysis were conducted using Statistical Package for the Social Sciences (SPSS) software version 27.0. Results: The mean age of the participants was 47.60±2.45 years. Of the participants, 46 (50%) had completed secondary schooling prerequisites and all had their monthly household income was less than Rs. 25,000. Few women reported having diabetes (12, 13%), hypertension (8, 8.7%), or high cholesterol (3, 3.3%). Nearly all of them (91, 98.9%) reported having less than eight hours of uninterrupted sleep. Most women (90, 97.82%) had inadequate knowledge of preventing CAD risk factors. The CAD risk factors included low High Density Lipoprotein (HDL) (28, 30.43%) and borderline high triglyceride (23, 25%), elevated blood pressure (16, 17.4%), overweight (57, 62%), with larger Waist Circumference (WC) (68, 73.91%) and Waist-Hip Ratios (WHR) (51, 55.43%). Lifestyle risk factors present in perimenopausal women included low Physical Activity (PA) (41, 44.6%), moderate stress (91, 98.9%) and unhealthy dietary practices (33, 35.87%). Conclusion: The study found that there was low knowledge among perimenopausal women regarding CAD risk factors. Overweight, stress, physical inactivity, elevated WHR, low HDL and high LDL were prevalent. These findings emphasise the need for targeted interventions to reduce CAD risk.

Evaluating the Efficacy of Cueing Strategies versus Walking Aids in Parkinson’s Disease: An Interventional Study

Sharki Rawat, Jyoti Balyan, Sonia

Introduction: Parkinson’s Disease (PD) is a neurodegenerative disorder that affects both motor and non motor brain pathways. It is the world’s second most common neurodegenerative illness, with an increasing incidence. The PD results in slow movement, tremors, involuntary movements, difficulty walking, and imbalance. The focus of physical therapy treatment is to improve balance, postural stability, and walking. The use of walking aids promotes stability, and cues help individuals with PD improve their stride. External cues provide temporal or spatial inputs related to the initiation and cessation of motor activities. Aim: To evaluate the effectiveness of cueing strategies and walking aids in patients with PD and their impact on gait and balance. Materials and Methods: The interventional study was carried out at Adarsh Chander Medicare Centre, Rohtak, Haryana, India for six weeks, from March 2023 to May 2023. The participants were divided into two groups, A and B, with 30 participants in each group. Participants in Group A were trained with walking aids, while those in Group B were trained with cueing strategies. Pre- and post-training assessments were conducted using the Unified Parkinson’s Disease Rating Scale (UPDRS), the Berg Balance Scale (BBS), and a measuring tape to evaluate step length, stride length, balance, and gait. Data analysis was performed using Statistical Package for Social Sciences (SPSS) version 20.0. Mean values were compared using a t-test (for two groups). A p-value of less than 0.05 was considered statistically significant. Results: The mean age of Group A was 67.60±4.80 years, while the mean age of Group B was 69.40±5.63 years. The pretraining UPDRS reading for Group A was 152.43±12.55, while for Group B, it was 153.00±15.14 (p=0.87). The post-training reading for Group A was 144.27±12.43, and for Group B, it was 140.43±15.07 (p=0.28). The pre-training BBS reading for Group A was 28.20±5.68, and for Group B, it was 28.17±4.72 (p=0.98). Post-training, Group A had a reading of 32.63±5.76, and Group B had 38.80±4.35 (p=0.01). There was also a significant improvement in step and stride lengths in Group B compared to Group A. Conclusion: There was a notable enhancement in balance and gait among individuals who engaged in an exercise program across both groups. However, the group that underwent exercise training with cueing strategies exhibited more favorable outcomes compared to the group that solely used walking aids. Therefore, exercise training incorporating cueing strategies may present a promising treatment approach for individuals with PD.

Effect of Sensory Integration Therapy on Attention Span and Gross Motor Skills in Children with Down Syndrome: A Quasi-experimental Study

Introduction: Down Syndrome (DS) is the most widely recognised intrinsic chromosomal problem that is related with mental retardation. Attention and motor abilities are negatively impacted by intellectual disability. One approach to dealing with the intellectual disability is Sensory Integration Therapy (SIT). Aim: To find out the effect of SIT on attention span and gross motor skills in children with DS. Materials and Methods: The present quasi-experimental study was conducted in various special schools in Rohtak, Haryana, India and at College of Physiotherapy, Pt. BD Sharma PGIMS, Rohtak, Haryana, India, between November 2022 and August 2023. A total of 40 patients were equally divided into two groups: an experimental group (n=20), comprising children with DS and control group (n=20), comprising normal children. Only DS children were provided with 10 sessions (over 5 week) of SIT. Evaluations were done at pretreatment, post-treatment and one month after the post-treatment evaluation in experimental group, while only pretreatment evaluations were conducted in control group. Attention span was measured using Stroop colour and Word Test and gross motor skills were measures with the help of {Gross Motor Function Measure 88 (GMFM-88)}. The data was analysed with the help of independent t-test (for between-group analysis) and repeated measures Analysis of Variance (ANOVA) (for within-group analysis). Results: The mean age of the experimental and control group was 10.30±1.976 years and 10.40±1.273 years, respectively. Both groups had 13 males and seven females. The independent t-test showed a significant difference (p<0.001 and p<0.001) between the attention span and gross motor skills) between the experimental group (71.90±5.22) and control group (118.25±0.786). Repeated measures ANOVA also indicated significant difference (p<0.001 and p<0.001) of attention span between the pretreatment, post-treatment and follow-up values of experimental group (71.90±5.22, 77.40±4.871, 74.45±4.839). Conclusion: The SIT helps in improving the attention span and gross motor skills of children with DS.

Virtual Reality for Hemiplegic Patients in Transforming Gait Recovery: An Experimental Study

Abha Khisty, Zafar Azeem, Tushar Palekar

Introduction: Stroke-induced gait disability is the most common neurological condition that leads to long-term disability. Therefore, it is essential to address the factors contributing to this disability factors to improve overall quality of life of stroke survivors. Despite extensive literature, hemiplegic gait rehabilitation remains a significant challenge for practicing physiotherapists. A comprehensive treatment plan customised for various deviations in temporal and spatial variables is crucial. Aim: To examine the add-on effect of Virtual Reality Training (VRT) combined with weight-bearing exercises on spatial parameters of gait, such as step width and step length, and temporal variables, including Center of Gravity (COG) sway velocity, reaction time, movement velocity and Limits of Stability (LOS). Materials and Methods: This experimental study was conducted at Dr. D. Y. Patil College of Physiotherapy, Pimpri, Pune, Maharashtra, India. A six-week, pre-post experimental study was carried out on 30 ambulatory hemiplegic patients aged 25 to 60 years, with an episodes of a stroke at least 12 weeks, with spasticity of Modified Ashworth Scale (MAS) <2, Postural Assessment Scale for Stroke (PASS) score less than 30, and normal cognition were included in the study. Patients with any contractures, peripheral artery diseases, history of cardiac failures or epilepsy, or any neurological surgeries were excluded. The study duration was from June 2024 to August 2024. Spatial and temporal variables of gait assessed by the Neurocom Balance Master, were primary outcome measures. Statistical analysis was done using IBM Statistical Package for the Social Sciences (SPSS) software version 27.0, with paired and unpaired t-tests used to test the statistically significant difference. Results: After a six-week intervention, a reduction in movement velocity during a heel strike from 1.2°/sec to 0.9°/second (p-value=0.02) was found, suggesting improved reciprocal control of agonist-antagonist muscle coordination. Other parameters for COG sway velocity, step width, and step length improved from 0.15 sec to 0.8 sec (p-value=0.04), from 25.8 cm to 15.2 cm (p-value=0.04), and from 29.7 cm to 32.5 cm (p-value=0.03), respectively. Measures of LOS in anteroposterior sway were reduced from 5°/second to 3.3°/second (p-value=0.02). Conclusion: The findings suggest that VRT combined with weight-bearing exercises can effectively adjunct traditional rehabilitation methods, aiding spatial and temporal variable gait issues in hemiplegic patients. Authors recommend adding VRT combined with weight-bearing exercises to manage post-stroke circumduction gait problems first-line.

Prevalence of Occupational Burnout among Resident Doctors at a Tertiary Care Centre in Kerala, India during the COVID-19 Pandemic: A Cross-sectional Study

Jaziya Jabeen, Indu K Gopi, PR Varghese, EL Presthiena Lofi, Jerry Earali

Introduction: Burnout is a psychological syndrome resulting from a prolonged response to persistent job stress, characterised by overwhelming physical and mental exhaustion and a lack of accomplishment, which leads to decreased professional efficacy. With rising violence, medical errors and workplace demands, evaluating the prevalence of burnout and its associated factors has become increasingly important. Aim: To assess the prevalence of occupational burnout in resident doctors at a tertiary care centre in India during the pandemic era. Materials and Methods: A cross-sectional study was conducted at a tertiary healthcare institute in Central Kerala, India among 114 resident doctors. The survey consisted of three parts, including demographic data, a validated 19-item questionnaire known as The Copenhagen Burnout Inventory (CBI), which contains questions on burnout divided into three scales—personal, work-related and patient-related—and a checklist of possible factors contributing to burnout identified through an extensive literature search. The data was analysed using IBM Statistical Package for the Social Sciences (SPSS) version 25.0. Results: More than 75 residents (65.8%) experienced moderate burnout, with 51 (44.7%) reporting high personal burnout, 72 (63.2%) experiencing moderate work-related burnout, and 48 (42.1%) reporting moderate patient-related burnout. Feelings of loneliness, a lack of an adequate support system, discrimination or harassment in the workplace, specialties causing excessive workloads and a lack of confidence in dealing with patients correlated with work-related, patient-related, and total burnout (p-value <0.05). The pressure of malpractice suits was associated with high personal burnout (p-value=0.027). Additionally, work-related responsibilities at home, lack of control, lengthy work hours and frequent call duties showed significant work-related burnout (p-value <0.05), while frequent call duties were linked to high patient-related burnout (p-value=0.036). Conclusion: The prevalence of burnout in various domains—personal, work-related and patient-related—was found to be substantial, with approximately 65.8% of respondents reporting moderate total burnout. Various factors such as negative life events, work hours, experience, lack of an adequate support system, frequent call duties, patient deaths, discrimination faced in the workplace and many others were identified in this study.

Association between Obesity and Psychiatric Co-morbidities: A Cross-sectional Study

Sathyaseelan Manivel, BS Suganya Priyadharshini, Frederick Eugene

Introduction: Obesity is a global epidemic associated with significant physical, economic and psychological costs. It has a bidirectional relationship with various psychiatric disorders. However, the evidence regarding the strength, direction and moderating factors of this relationship remains inconsistent and inconclusive. Aim: To examine the association between different grades of obesity and psychiatric disorders, as well as, to evaluate their impact on quality of life. Materials and Methods: The present cross-sectional study was conducted in the Departments of Medicine and Endocrinology, PSG Institute of Medical Sciences and Research (a tertiary care centre), Peelamedu, Coimbatore, South India, between January 2019 and June 2020, among stable inpatients. A total of 195 participants with a Body Mass Index (BMI) ≥25 kg/m², aged between 18 years and 65 years, of all genders, were included. The participants were initially categorised into two groups: overweight and obese. The obese group was further subdivided into three classes: obese-I, obese-II and obese-III. Participants were required to have the ability to read and write in Tamil or English. The prevalence of various psychiatric disorders and quality of life was assessed using the Mini-International Neuropsychiatric Interview (M.I.N.I.) 5.0 and the World Health Organisation Quality of Life-Brief (WHOQoL-BREF) tools. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 21.0. Results: Of the total participants, majority, 114 (58.5%) were aged from 31-45 years. Males comprised 116 (59.5%) and females were 79 (40.5%) of the study participants. Among the 195 participants, depressive episodes were present in 1 (1%) of the overweight group and 7 (8.8%) of the obese-I group. The prevalence of dysthymia was 3 (3%) in the overweight group, 15 (18.8%) in the obese-I group, and 2 (15.4%) in the obese-II group. Panic disorder was observed in 1 (1%) of the overweight group, 3 (3.8%) of the obese-I group, 2 (15.4%) of the obese-II group, and 1 (33.3%) of the obese-III group. Lifetime limited symptoms of panic attacks were reported by 5 (5.1%) participants in the overweight group and 14 (17.5%) in the obese-I group. Pair-wise group analysis revealed a significant association with the diagnosis of dysthymia. Quality of life was found to be poor across all four domains: physical health, psychological well-being, environmental factors and social relationships. Conclusion: The present study demonstrates a significant association between obesity and psychiatric disorders, particularly dysthymia, anxiety, and substance use disorders. Obesity negatively impacts quality of life across physical, psychological, social, and environmental domains. Further longitudinal studies are needed to explore the causal relationships and underlying mechanisms between obesity and psychiatric co-morbidities.

Evaluation of the Shear Bond Strength of Orthodontic Adhesive Incorporated with Titanium Dioxide Nanoparticle: An In-vitro Study

M Ashfaq Ahmed, S Sumalatha, N Narendran, G Dinesh Nandakumar, A Agasthiya

Introduction: White Spot Lesions (WSL) are a common problem in orthodontic treatment due to improper oral hygiene maintenance and plaque accumulation, which reduce the bond strength of the appliance. To address this issue, various bonding materials have been introduced over time to enhance the bond strength of adhesives. Recently, different kinds of nanoparticles have been added to composite resins with the goal of enhancing bonding efficiency without affecting bond strength. Aim: To evaluate the shear bond strength of Titanium Dioxide (TiO₂) nanoparticle-incorporated orthodontic adhesive. Materials and Methods: The present in-vitro study was conducted in the Department of Orthodontics and Dentofacial Orthopaedics, Best Dental Science College, Madurai, Tamil Nadu, India, between July 2022 and December 2023. Study included 60 samples of extracted human maxillary first premolar teeth. The samples were equally divided into two groups. In group 1, brackets were bonded with conventional composite, and in group 2, brackets were bonded with TiO₂ nanocomposite. The shear bond strength for each group was determined using a universal testing machine, and Adhesive Remnant Index (ARI) scores were also assessed. Statistical analysis was conducted using the Student t-test and Chi-square test to evaluate the differences between the groups. Results: The results of the study showed that the bond strength was significantly higher for the TiO₂ nanocomposite group with mean±Standard Deviation (SD) of 14.3±1.21 MPa than for the conventional composite group with mean±SD of 12.9±1.05 MPa. This indicates that the TiO₂ nanocomposite had significantly better bond strength than the conventional composite by 1.4 MPa (p-value=0.045). However, the ARI scores between the two groups were statistically not significant (p-value=0.682). Conclusion: In conclusion, incorporating TiO₂ into the conventional composite significantly enhanced the bond strength of the composite.

Effect of Aerobic and Foot Intrinsic Muscle Strength Training on Plantar Pressures and Spatiotemporal Gait Parameters in Type 2 Diabetes Mellitus: A Randomised Controlled Study

Shashikumar Channmgere Govindappa

Introduction: Type 2 Diabetes Mellitus (T2DM) is associated with microvascular and macrovascular complications. Among all the complications, foot complications are mostly caused due to altered plantar pressures, spatiotemporal gait parameters, balance deficits and impaired proprioception, which often results in fall-related injuries in such patients. Aim: To analyse the effect of aerobic exercises on plantar pressures and spatiotemporal gait parameters in T2DM patients. Materials and Methods: A randomised controlled study was conducted in Hail General Hospital and King Khalid Hospital in Hail City, Saudi Arabia from September 2023 to June 2024. A total of 140 patients with uncontrolled T2DM diagnosed aged between 30 and 65 years were assessed for peripheral neuropathy, both with and without clinical signs based on the Michigan Neuropathy Screening Instrument Index (MNSI). The control group received standard medical care (Antidiabetic medications prescribed by a physician and a Diabetic diet prescribed by a Nutrition Therapist), and the experimental group received identical aerobic exercise and specific intrinsic foot muscle exercise along with standard care, three times a week for three months. A descriptive analysis was conducted to determine the mean, standard deviation, and normality of the variables. The Mann-Whitney U test was applied for intergroup comparison. A p-value <0.05 was considered statistically significant. Results: A statistically significant reduction in the average plantar pressure, forefoot both left and right and right hindfoot pressure in the intervention group was observed compared to the control group. These reductions were significant at the p-value <0.001 level. In addition, significant improvements were observed in the spatiotemporal gait parameters, including step duration, gait cycle duration and double stance duration with p-value <0.001. Conclusion: This study indicates that intrinsic foot muscle exercises and standard aerobic exercises may have an additive effect in improving function and reducing plantar pressure in patients with diabetes.

Evaluation of Coagulation Profile and Transfusion Support in Pre-eclampsia Patients: A Cross-sectional Study

Introduction: Pre-eclampsia (PE) is an obstetric disorder characterised by high morbidity and mortality rates, yet it lacks a definitive etiology. The PE syndrome involves platelet activation, dysfunction and increased adherence, along with microangiopathic haemolysis. Consequently, coagulation and fibrinolytic status serve as good predictors for the onset and clinical severity of PE. Anticipating these coagulation disturbances in patients with PE can help prevent significant maternal morbidity and mortality. The need for blood components in PE typically arises in cases of thrombocytopenia and platelet dysfunction at the time of caesarean delivery, concomitant placental abruption, acute fatty liver disease, or dilutional coagulopathy resulting from major haemorrhage. Aim: To evaluate the coagulation profile and transfusion support in patients with PE. Materials and Methods: A prospective cross-sectional study was conducted at the Department of Transfusion Medicine, Institute of Obstetrics and Gynaecology (IOG), Chennai, Tamil Nadu, India, over a period of one year, from August 2017 to July 2018. The study included 30 normotensive pregnant women as controls (Group 1) and 50 pregnant women with PE as cases (Group 2). The cases were categorised as PE with severe features (n=22) and PE without severe features (n=28), according to American College of Obstetricians and Gynecologists (ACOG) Guidelines on Hypertension in Pregnancy. The platelet indices and coagulation parameters of the PE cases were compared with those of the normotensive pregnant women, as there is no standard reference available for our normotensive pregnant population. These parameters were observed initially at mid-pregnancy (24 to 27 weeks) and at late pregnancy (37 to 40 weeks) or at the time of admission for delivery, whichever was earlier, in both cases and controls. The collected data were analysed using IBM Statistical Package for Social Sciences (SPSS) Statistics software version 23.0. Results: The mean values of Platelet Count (PLC), Mean Platelet Volume (MPV) and Platelet Distribution Width (PDW) in late pregnancy for normal pregnant women (n=30) were 289.6±79.56, 10.12±0.83 and 13.28±1.78, respectively. The mean values of PLC, MPV and PDW in late pregnancy for PE cases with severe features were 184.05±74.08, 11.65±1.44 and 15.14±2.06, respectively. Statistical significance was obtained for PLC, MPV and PDW between the normal pregnant group (n=30) and the PE with severe features group (n=22), with p-values of less than 0.001, 0.0001 and 0.006, respectively. The mean values of Activated Partial Thromboplastin Time (APTT), Thromboplastin Time (TT) and Serum Fibrinogen (SF) in normal pregnancy were 24.6±7.5, 13.08±1.24 and 349.47±102.94, respectively. The mean values of APTT, TT and Serum fibrinogen for PE with severe features were 32.15±9.6, 14.74±1.15 and 235.09±76.52, respectively. There was a significant prolongation of APTT and TT, along with a significant decrease in Serum fibrinogen in PE with severe features when compared to the controls, with p-values of 0.001, 0.000 and 0.000, respectively. Conclusion: The evaluation of the coagulation profile in PE patients revealed a significant association between altered coagulation profiles and the severity of PE cases in late pregnancy. However, these parameters can only serve as indirect predictors, alongside the severity of symptoms of PE, in determining the need for prophylactic transfusion support.

Impact of Dental Treatment under General Anaesthesia on Oral Health-related Quality of Life, Weight and Oral Hygiene Measures in Children: A Quasi-experimental Study

Khlood Baghlaf, Haneen Baty, Ibtesam Alzain, Akram Qutob, Medhat Abdulla

Introduction: Dental treatment for children who cannot be controlled by standard behaviour management strategies or who are unable to endure more advanced pharmaceutical approaches is challenging. Dental treatment under General Anaesthesia (GA) is suitable for these uncooperative children. There is a gap in the literature regarding whether dental treatment under GA is associated with changes in weight and oral hygiene measures. Aim: To evaluate children’s Oral Health-related Quality of Life (OHRQoL) and the changes in weight, dental history, dental pain, and oral hygiene measures after dental treatment under GA. Materials and Methods: The present pretest-post-test quasi-experimental study involving children aged 3-6 years scheduled for dental treatment under GA was conducted in the Department of Paediatric Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia, from September 2022 to December 2023. A convenience sampling method was used, with a total of 93 children participating. A validated measure was employed to assess OHRQoL. Additionally, weight, dental history, dental pain and oral hygiene measures were assessed before and after dental treatment under GA. A follow-up visit was scheduled six weeks after the GA. Data were entered and analysed using Statistical Package for Social Sciences (SPSS) software version 22.0 Statistics for Windows. Results: The mean±Standard Deviation (SD) age of the children in the current study was 4.88±1.06 years. The findings showed a significant improvement in OHRQoL after dental treatment under GA. The mean±SD score of the total OHRQoL before dental treatment was 15.73±10.2. The mean±SD score after GA was 6.64±8.52 (p-value <0.001). The mean±SD weight of the children before GA was 16.72±3.17, and six weeks after dental treatment under GA, the mean±SD weight was 16.99±3.73, with no statistically significant difference (p-value=0.21). The findings also indicated an improvement in oral hygiene practices among children after dental treatment under GA. Conclusion: Dental treatment under GA improves OHRQoL in children. No significant difference was found concerning weight change after six weeks of dental treatment. An improvement in oral hygiene practices was observed following dental treatment under GA.

Effectiveness of Tranexamic Acid to Prevent Blood Loss in Patients Undergoing Hip Arthroplasty: A Randomised Controlled Study

Introduction: The safe and efficient Intravenous (i.v.) administration of Tranexamic Acid (TXA) has been shown to reduce blood loss and transfusion requirements following total hip replacement. However, its effectiveness in hip arthroplasty for femoral neck fractures remains a subject of debate to date. Aim: To evaluate the effects of TXA in patients undergoing hip arthroplasty to prevent blood loss. Materials and Methods: The present prospective, double-blinded, randomised controlled study was conducted in in the Department of Orthopaedics, SRM Medical College Hospital and Research Institute (a tertiary care facility), Chengalpattu, Tamil Nadu, India, between August 2023 and January 2024. Study involved 138 participants with hip fractures classified into a TXA group (group A) and a placebo group (group B). The selected participants were monitored for blood loss, haemoglobin levels and blood transfusion volume. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) software version 21.0, with t-tests and chi-square tests employed to compare participant characteristics. Results: In the present study, 69 of the 138 individuals received TXA in the interventional group, while 69 received a placebo in the control group. The mean±Standard Deviation (SD) age was 44.6±17.6 years in the interventional group and 48.5±16.4 years in the control group. Postoperatively, the interventional group exhibited a smaller decline in haemoglobin levels (12 g/dL vs. 11.0 g/dL). TXA significantly reduced transfusion volume (p-value <0.001). Additionally, blood loss was lower in patients receiving TXA (p-value <0.001). Conclusion: Treatment for hip fractures with TXA showed a tendency towards reduced blood loss and transfusions, as well as, a shortened total duration of surgery among the study participants. This indicates that TXA is safe and efficient in minimising blood loss during surgery.

Efficacy of Murivenna Tail Gudapurana and Yashtimadhu Ghrita Gudapurana in the Postoperative Pain Management of Haemorrhoids and Fissure in-ano: A Research Protocol for a Randomised Controlled Trial

Ayushi Chandrakant Gautam, Sheetal Gajanan Asutkar

Introduction: Lifestyle diseases resulting from sedentary work, stress, poor sleep, and unhealthy eating habits have led to an increase in anorectal disorders, such as anal fissures, fistulas, haemorrhoids, and abscesses. Haemorrhoids, which are dilated veins in the anal canal, are influenced by factors like prolonged sitting, straining, and pregnancy. Treatment options for haemorrhoids range from laxatives to surgical procedures. In Southern India, Murivenna Tail is commonly used for its anti-inflammatory and analgesic properties, aiding in wound healing and postoperative pain management. Need of the study: Surgical procedures for fissure-in-ano, such as Lord’s anal dilatation and lateral internal sphincterotomy, as well as haemorrhoid surgeries including various types of haemorrhoidectomy, can be extremely painful and typically require analgesics for pain management. However, traditional pain relief medications often come with side-effects, including diarrhoea, nausea, vomiting, skin rashes, headaches, mood swings, dependency, and overall dissatisfaction. Murivenna Tail, known for its anti-inflammatory and analgesic properties, presents a cost-effective and readily accessible alternative for managing postoperative pain following fissure and haemorrhoid surgeries. Preclinical studies have shown its potential to reduce inflammation, indicating it could serve as a viable alternative to conventional medications for postoperative pain relief. Aim: To compare the efficacy of Murivenna Tail against Yashitimadhu Ghrita in managing postoperative pain associated with haemorrhoids and fissure-in-ano. Materials and Methods: A randomised controlled trial will be conducted at the Mahatma Gandhi Ayurveda College Hospital and Research Centre (MGACHRC) in Salod, Maharashtra, India, from January 2024 to June 2025. The study will include 72 participants who will provide written informed consent. They will be divided into four groups, with 18 subjects in each group. The treatments administered will be 20 mL of Murivenna Tila and Yashtimadhu Ghrita Gudapuarana, given twice a day for 14 days each. To assess the effectiveness of the four treatment groups Analysis of Variance (ANOVA) will be applied to compare mean scores if the data meet the criteria for normality and homogeneity of variance; otherwise, the Kruskal-Wallis test will be applied.

Disease-Free Overall Survival in Patients Operated for Poorly Differentiated Squamous Cell Carcinoma: A Research Protocol for a Retrospective Cohort Study

Bhawna Banga, Rajanikanth Kambala, Nitin Bhola

Introduction: Oral cavity cancer is the leading cause of cancer-related death. Squamous Cell Carcinoma (SCC) is the most common malignant tumour of the oral cavity. The degree of differentiation of Oral Squamous Cell Carcinoma (OSCC) has been related to several clinical features and outcomes, including prognosis. In OSCC with inferior tumour histological classifications, there is a substantial correlation between the likelihood of developing recurrence and distant metastasis after therapy and Extracapsular Spread (ECS) and perineural invasion of the main tumour. Need of the Study: Studying the Disease-Free Overall Survival (DFOS) postsurgery will help analyse and improve the efficacy of surgical intervention in controlling the disease and improving treatment strategies leading to better prognosis postsurgery in Poorly Differentiated Squamous Cell Carcinoma (PDSCC). Aim: To analyse the effects of surgical intervention (with or without adjuvant radiation or chemotherapy) in poorly differentiated OSCC patients by studying and analysing the DFOS postsurgery. Materials and Methods: An retrospective cohort study will be conducted in the Department of Oral and Maxillofacial Surgery at Sharad Pawar Dental College and Hospital, Wardha, Maharashtra, India from December 2024 to December 2025. The study will include 45 subjects who underwent surgical removal of lesions between January 2016 and January 2019 at Siddharth Gupta Memorial Cancer Hospital, AVBRH, Sawangi Wardha, Maharashtra, India. Medical records will be reviewed, and telephonic interviews will be conducted. Patients who have not had any follow-up appointments after five years will be contacted to confirm their survival. Subsequently, further clinical and radiological tests will determine the DFOS rate and the variables impacting long-term survival. The Kaplan Meiyer test will be applied to assess the long-term survival rate and factors that influence DFOS. Pearson/Spearman correlation test will be applied to assess the correlation between TNM staging and overall survival rate and a p-value of <0.05 will be considered statistically significant.

Efficacy of Low-level Laser Therapy on Motor Recovery, Functional Independence and Quality of Life among Individuals with Incomplete Spinal Cord Injury: A Protocol for Randomised Controlled Trial

Divya Rathore, Jasobanta Sethi, Chitra Kataria

Introduction: A complete or incomplete Spinal Cord Injury (SCI) reduces a person’s Quality of Life (QoL) by producing persistent neurological deficiencies from the disruption of nerve impulses that result in the loss of motor and sensory function. For these people, functional recovery and QoL enhancement are the main goals of rehabilitation. Even with advancement in the treatment of spinal cord injuries, many people still struggle with motor function deficits and functional independence, which significantly lowers their QoL and limits their capacity for independent living. Need of the study: Low-Level Laser Therapy (LLLT) has numerous advantages, including preventing tissue and cell death, promoting injury healing and repair, reducing pain, oedema, and inflammation, promoting cell division and even apoptosis. LLLT has been shown to provide neuroprotection through a variety of outcomes, including cell regeneration, stimulation of Schwann cell growth, reduction of spasticity, improvement of function, reduction of nitric oxide levels and upregulation of the cytokine Interleukin 10 (IL-10) proving that LLLT provides neuroprotection. It is expected that LLLT will stimulate the cell growth while inhibiting the inflammation and other secondary changes after SCI. Aim: To analyse the efficacy of LLLT for motor recovery, functional independence and QoL among incomplete SCI patients. Materials and Methods: The present study will be a single blind, prospective, parallel group, randomised controlled trial recruiting 104 patients with incomplete SCI and will be allocated through block randomisation into two groups as per the inclusion and exclusion criteria. The duration of the study will be from 1st June 2023 to 28th February 2025. Control group will be treated with placebo LLLT and conventional therapy whereas experimental group will be treated with LLLT and conventional therapy for three times per week for four weeks. The performance of the participants will be assessed using amplitude-based lower extremity surface Electromyography (EMG) on lower extremity key muscles, Lower Extremity Motor Score (LEMS-ASIA), Spinal Cord Independence Measure (SCIM-III), Quality of Life (WHOQOL-BREF) at baseline and at the end of fourth week postintervention.

Evaluation of Standard Market Preparation Tablet (Tentex Forte) and Vrishya Gutika in the Management of Klaibya (Erectile Dysfunction): Research Protocol for a Randomised Controlled Trial

Abhishek Patil, Sourabh Deshmukh, Trupti Thakre

Introduction: Klaibya is a sexual dysfunction characterised by various symptoms, including Ling Shaithilya (penis shrinkage) and Mlan Shishna (penis weakening). It refers to a man’s inability to engage in sexual acts satisfactorily, leaving the female partner either partially or completely unsatisfied. The Charak Samhita mentions Vajikaran (aphrodisiac) Yoga as a remedy for Klaibya. Need of the Study: Common modern medications used to treat Klaibya include Cialis, Viagra, Levitra and Stendra. However, these drugs can lead to several side-effects, such as headaches, body aches, gastrointestinal disturbances, dizziness, vision changes, flushing, nasal congestion and in some cases, priapism (an erection lasting longer than four hours) and sudden changes in hearing. On the other hand, Vrishya Gutika, an herbal formulation mentioned in the Charak Samhita, includes ingredients like Vidarikand Swaras, Tugaksheeri Churna, Sharkara Churna, Ikshurak Churna (Kokilaksha), Pippali Churna, and Kappikacchu Beej Churna, along with cow ghee, cow milk, and honey-all known for their aphrodisiac properties. Aim: To conduct a comparative evaluation of the efficacy of Vrishya Gutika and Tablet Tentex Forte in the management of Klaibya (Erectile Dysfunction). Materials and Methods: A single-blinded, randomised controlled trial will be conducted at the Kayachikitsa outpatient and inpatient departments of Mahatma Gandhi Ayurved College, Hospital, and Research Centre in Salod (H), Wardha, Maharashtra, India from March 2023 to February 2025. Two groups will be formed, each consisting of 30 subjects. Group A will serve as the control group and will receive a standard market preparation (Tentex Forte)-two tablets twice daily. Group B, the trial group, will receive Vrishya Gutika-four tablets twice daily, both for 30 days. The effectiveness of the interventions will be evaluated using a validated questionnaire. The paired t-test will be employed to assess subjective parameters within the same group, while the unpaired t-test will be used for intergroup comparisons, establishing a significance level of <0.05.

Evaluation of the Immunomodulatory Effect of an Organometallic Formulation of Laghumalini Vasant by using Cell Culture: A Research Protocol

Anita Wanjari, Bharat Rathi, Amit Naik

Introduction: The immune system serves as the body’s defence mechanism and aids in maintaining homeostasis by defending against infections and foreign bodies. Immunomodulation, either through stimulation or suppression, is useful in disease prevention. During Coronavirus Disease-2019 (COVID-19) pandemic, significant immunity and preventive measures were considered of prime importance. Need of the Study: During the pandemic, an organometallic formulation, Laghumalini Vasant (LMV), was prescribed by AYUSH advisory to control mild to moderate fever. Under the Indian system of medicine, it is recommended for pyrexia, diarrhoea, piles, ophthalmic diseases and diabetes mellitus. While many review articles claim that LMV is an immunomodulator, this has not been evident. LMV is rich in zinc. Hence, it might affect immunity. Considering this, the study is undertaken to assess the immunomodulatory effect of LMV through cell line experiments. The LMV will be assessed for Immunoglobulin G (IgG), Immunoglobulin M (IgM), Adenosine Deaminase (ADA) and Cytokinase. If evidence of the immunomodulatory effect is generated, this drug could be prescribed to patients for immunomodulation. Aim: To evaluate the immunomodulatory effect of the organometallic formulation, LMV, using cell culture. Materials and Methods: An in-vitro experimental study will be conducted at Central India Institute of Medical Sciences (CIIMS), Nagpur, Maharashtra, India from November 2024 to January 2026. The immunomodulatory effect will be assessed by Lipopolysaccharide (LPS) and Phytohemagglutinin (PHA)-induced immune deregulation in the cell culture model system via assays for IgG, IgM, ADA and Interleukins. Statistical analysis will be performed using MedCalc software (version 10). Each experiment will be carried out in triplicate and repeated three times to ensure data reliability. Results will be expressed as Mean±SD. The experimental and the control group will be compared using a t-test. A p-value <0.05 will be considered statistically significant.

Therapeutic Evaluation of Antidiabetic and Antihypertensive Therapy versus Antidiabetic, Antihypertensive and Statins Therapy in the Management of Type 2 Diabetes Mellitus Patients with Hypertension: A Pragmatic Clinical Trial

Smruti Besekar, Sangita Jogdand, Satyawan Singh Patel, Raju Shinde, Sunil Kumar

Introduction: India is grappling with a growing occurrence of Type 2 Diabetes Mellitus (T2DM) and its related conditions, including hypertension and dyslipidaemia, with Cardiovascular Diseases (CVD) being the primary cause of morbidity and mortality. Statins, primarily used for hypercholesterolaemia and CVD prevention, have demonstrated potential in lowering Blood Pressure (BP) through mechanisms that are independent of cholesterol reduction. Need of the study: Most evidence regarding the effect of statins on BP comes from controlled trial settings, which may not fully reflect real-world scenarios. Additionally, many clinical studies do not compare different therapeutic approaches to evaluate their impact on patients with T2DM and hypertension. This study aims to address this gap by assessing and comparing the effects of different therapies in a more realistic clinical context. Aim: To assess the real-world effectiveness of adding a statin to an antihypertensive drug compared to an antihypertensive drug alone in patients with T2DM and hypertension. Materials and Methods: This pragmatic clinical trial will be conducted across three centres from August 2024 to August 2025 in Maharashtra: one tertiary care hospital and two multispecialty private hospitals, namely Shalinitai Meghe Hospital and Research Centre, Nagpur; Hrudaya Cardiac and Vascular Care Centre, Nagpur; and Shri Sai Multispeciality Hospital, Amravati, Maharashtra, India. The study will enroll a minimum of 300 patients who are newly diagnosed with T2DM and hypertension. Patients will be divided into two groups based on the prescriptions given by physicians: Group 1: Antidiabetic drug+Antihypertensive drug+Statins; Group 2: Antidiabetic drug+Antihypertensive drug. Their effects will be assessed on BP, blood sugar and lipid level parameters. Statistical analyses will include linear regression, multiple regression and quantile regression to evaluate the significance of statin therapy on BP control. A p-value <0.05 will be considered statistically significant.

Comparison of Oxytocin versus Carbetocin in Reducing Intraoperative Bleeding during Caesarean Section: A Research Protocol for Randomised Controlled Trial planned in a Tertiary Care Hospital in Central India

Vinit Sunil Dhanure, Nikhil Bhalerao

Introduction: Caesarean Section (CS) is a common obstetric procedure associated with the risk of intraoperative bleeding, necessitating the use of uterotonic agents such as oxytocin and carbetocin to reduce blood loss. Need of the Study: Given the clinical significance of intraoperative bleeding during CS and the potential implications for maternal outcomes, there is a need for well-designed comparative studies. Therefore, the present study was planned to address this gap in the literature by comparing the efficacy of oxytocin and carbetocin in reducing intraoperative bleeding during CS. Aim: To evaluate and compare the effectiveness of oxytocin versus carbetocin in reducing intraoperative bleeding during caesarean sections. Materials and Methods: A prospective, randomised, double-blind controlled trial will be conducted at the Department of Anaesthesiology, Jawaharlal Nehru Medical College (JNMC), Datta Meghe Institute of Higher Education and Research, Sawangi (M), Wardha, Maharashtra, India from October 2024 to March 2026. One hundred female patients aged 18-35 years with American Society of Anaesthesiologists (ASA) grade I and II, scheduled for CS under spinal anaesthesia, will be included in the study and divided into the oxytocin and carbetocin groups during CS. The amount of blood loss exceeding 1000 mL during CS, haemodynamic changes, the requirement for vasopressors and antifibrinolytics and the duration of surgery will be assessed between the two groups. Statistical analysis will be conducted using experimental and inferential statistics, including the Chi-square test, Student’s paired and unpaired t-tests and Tukey test, with a significance level set at p<0.05.

Postoperative Outcomes of Modified Carnoy’s Solution versus 5-Fluorouracil for Chemical Cauterisation following Enucleation and Peripheral Ostectomy in Patients with Odontogenic Keratocyst: A Research Protocol

Nidhi Vijay Kumar Bodiwala, Nitin Bhola

Introduction: An Odontogenic Keratocyst (OKC) is always a topic of debate due to its distinct biological behaviour to recur after surgical procedure. Also, it has an odyssey cyst-tumour-cyst from 1956 to 2005 to 2017. For this reason, number of treatment modalities was cited in the literature. Modified Carnoy’s Solution (MCS) is commonly used due to its effectiveness, while 5FU, an antimetabolite used in cancer treatment, presents a newer approach. Need of the study: The varying Recurrence Rate (RR) and postoperative complications associated with different treatment modalities for OKC. While MCS is a commonly used adjuvant therapy due to its effectiveness, and bone resection minimises recurrence but leads to severe functional and aesthetic issues, there is limited data comparing the efficacy of MCS to newer agents like 5-Fluorouracil (5FU) in reducing recurrence. Evaluating the effectiveness of 5FU, a promising chemotherapeutic agent, could potentially offer a less invasive and equally effective treatment option for reducing recurrence and improving patient outcomes in OKC management. Aim: To compare and evaluate the postoperative outcomes, specifically the RR, of MCS vs 5FU used for chemical cauterisation following enucleation and peripheral ostectomy in patients with OKC. Materials and Methods: An experimental in-vivo study will be conducted in the Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Datta Meghe Institute of Higher Education and Research (DMIHER), Sawangi (M), Wardha, Maharashtra, India, from April 2023 to March 2024. The approach involves categorising 12 histologically proven cases of OKC into two groups according to distinct adjunct techniques used (six patients in each group). Group A includes subjects treated with MCS. Group B includes subjects with 5FU. Postoperative outcomes will be evaluated and compared among the groups. The data will be analysed and compared using Student's t-test and Mann-Whitney U test. It will be used at a 5% level of significance (p-value ≤0.05).

Correlation of Platelet Indices with Severity of Gastroesophageal Varices in Patients of Liver Cirrhosis: A Research Protocol

Parav Tantia, Sourya Acharya

Introduction: In India, liver cirrhosis is a significant public health concern, contributing to 2.95% of total deaths. Cirrhosis is the advanced stage of ongoing liver fibrosis, which poses substantial global health challenges due to its fatal consequences, such as gastroesophageal varices. Need of the study: Gastroesophageal varices are a potentially lethal complication of liver cirrhosis. The severity of these varices directly impacts the prognosis of the patient. Gastroesophageal varices are major contributors to both mortality and morbidity on a global scale. While various parameters have been explored to predict the progression and severity of these varices, platelet indices have not been extensively studied in cirrhosis patients with gastroesophageal varices in India. Aim: To study the association and correlation of platelet indices with the severity of gastroesophageal varices in patients with liver cirrhosis. Materials and Methods: A cross-sectional study will be conducted in the Medicine OPD/IPD of Acharya Vinoba Bhave Rural Hospital (AVBRH), Wardha, Maharashtra, India from May 2023 to May 2025, involving 64 patients who meet the inclusion and exclusion criteria. Patients fulfilling the selection criteria will be informed about the study procedure in their native language. The diagnosis of liver cirrhosis will be established based on the patient’s detailed history, physical examination, laboratory tests, and ultrasound scan. Upon enrollment, a detailed history will be taken, and parameters will be recorded in a specifically designed proforma. Initial parameters will include age, gender, weight, co-morbidities (such as Diabetes Mellitus (DM), Hypertension (HTN), Heart Failure (HF), Cardiovascular Disease (CVS), Chronic Obstructive Pulmonary Disease (COPD), kidney failure, liver failure, and malignant conditions), and the aetiology of cirrhosis. Platelet count and indices-Mean Platelet Volume (MPV), Platelet Distribution Width (PDW), and Plateletcrit (PCT)-will be assessed. The categorical and continuous variables will be represented as frequency (percentage) and mean (standard deviation, SD). The Chi-square test and Independent sample t-test will be used to evaluate the association between various categorical variables and continuous variables. The Pearson correlation test will be used to assess any correlation between platelet indices and oesophageal varices, with a significance level set at <0.05.

Comparing the Institution-based Supervision and Tele-based Supervision for Task-oriented Exercises on Upper Limb Motor Performance and Functional Ability among Stroke Patients: A Research Protocol

Neha, Subhasish Chatterjee

Introduction: Rehabilitation is a vital part of recovery for stroke patients, presenting a complex intervention that requires collaboration among patients, caregivers and the rehabilitation team. Telerehabilitation has emerged as a promising alternative to standard outpatient and home-care rehabilitation, offering advantages such as minimal travel barriers, flexible exercise schedules and the integration of skills into daily activities. Need of the study: The technologies that can be used for telerehabilitation range from inexpensive internet-based solutions, virtual reality, and robotic systems to more costly telephones and mobile phones, which are present in most homes. Physiotherapists have been suggested as being in the best position to help stroke victims transition from the hospital to their homes. However, there has been significant international professional resistance to using telerehabilitation-based services, based on the belief that the lack of in-person care may result in worse outcomes. Nevertheless, research on numerous chronic health disorders demonstrates that telerehabilitation strategies can effectively enhance results. There is a dearth of literature comparing tele-based supervision for task-oriented exercises with institution-based supervision for task-oriented exercises. Thus, the need for this study is to identify a cost-effective method for rehabilitation in stroke patients. Aim: To compare the effect of institution-based supervision and tele-based supervision for task-oriented exercises on upper limb motor performance and functional ability among stroke patients. Materials and Methods: A two-group pretest-post-test randomised clinical trial will be conducted in recognised hospitals in Mullana and Panipat, using purposive sampling from December 2022 to December 2024. A total of 62 male and female patients, aged 45-75 years, who have experienced their first ischaemic or haemorrhagic stroke within the last six months and have scores ranging from 26 to 56 on the Fugl-Meyer Assessment for Upper Extremity (FMA-UE), mild to moderate spasticity (less than 2 on the Modified Ashworth Scale (MAS), >24 on the Mini-mental State Examination (MMSE), and stages II and III of the Brunnstrom score will be included in the study. Group B will receive institution-based supervision for task-oriented exercises, whereas Group A will receive tele-based supervision for live sessions. Both groups will perform task-oriented exercises for 30 minutes, three days a week for eight weeks. There will be a 30-second break before switching tasks. Outcome measures, including the Fugl-Meyer Assessment for Upper Extremity (FMA UE) and the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES), will be assessed at baseline, the 4th week, and the 8th week of intervention, respectively. Repeated measures of Analysis of Variance (ANOVA) or the Friedman test will be chosen based on normality to find differences within the groups at baseline, the 4th week, and the 8th week (completion). A paired t-test or Wilcoxon signed-rank test will be applied to identify differences between the groups for pre-post intervention changes in outcome measures. An Independent t-test or Mann-Whitney U-test will be applied based on normality to compare the changes in mean values of the outcome measures between Group A and Group B at baseline, the 4th week, and the 8th week of intervention. The level of statistical significance will be set at alpha=0.05.

Remineralising Effects of L-arginine Fluoride Mouthwash versus Sodium Fluoride Mouthwash: A Protocol of an In-vitro Study

Anjori Ajinkya Raut, Punit Ratnakar Fulzele

Introduction: Preventing dental caries and maintaining oral health are important for children’s quality of life, as they profoundly impact overall well being, self-esteem and long-term health outcomes. Despite breakthroughs in preventive dentistry, oral infections and tooth decay remain common among children, highlighting the need for novel and efficient preventive interventions. Although fluoride is a proven preventive measure against tooth decay, L-arginine, a naturally occurring amino acid, has shown promising results in enhancing remineralisation and has gained interest due to its role in maintaining oral health. The combination of L-arginine and fluoride in mouthwash may improve dental health. Need of the Study: L-arginine fluoride is utilised in oral care products such as varnishes and toothpastes; however, there are no studies examining the efficacy of L-arginine fluoride as a mouthwash. Aim: To assess the remineralising activity of L-arginine fluoride mouthwash compared to sodium fluoride mouthwash. Materials and Methods: The present in-vitro study will be conducted in the Department of Paediatric and Preventive Dentistry, Sharad Pawar Dental College, Wardha, Maharashtra, India from September 2024 to December 2025. Forty-two teeth with no white spot lesions or caries will be included, while teeth with lesions, fractures, or wear will be excluded from the study. The teeth will be randomly divided into six groups with different concentrations of L-arginine fluoride, and a control group with sodium fluoride will also be evaluated. The teeth will be assessed for Ca/P ratio using Scanning Electron Microscopy with Energy Dispersive X-ray (SEM-EDX), mineral density using micro-Computed Tomography (micro-CT), and for mineral gain and remineralisation using a specific formula. The data will be statistically analysed using Statistical Package for Social Sciences (SPSS) software version 22.0; a two-way Analysis of Variance (ANOVA) with Bonferroni post-hoc test, a one-way ANOVA with Student-Newman-Keuls (SNK) test, and Kruskal-Wallis one-way ANOVA will be used. A p-value of <0.05 will be considered statistically significant.

Comparative Evaluation of Functional Outcomes in High Condylar Fractures Treated with Closed Methods with and without Temporomandibular Joint Arthrocentesis: A Research Protocol for a Randomised Controlled Trial

Sachindra Dubey, Nitin Bhola, Anchal Agarwal

Introduction: Temporomandibular Disorders (TMD) encompass a range of conditions affecting the joint and surrounding structures, often resulting in pain, restricted movement, and dysfunction. Arthrocentesis involves the insertion of a single needle into the joint space, allowing for irrigation, lavage, and aspiration of the joint. The present procedure aims to alleviate symptoms, improve joint function, and promote healing by removing inflammatory mediators, debris, and adhesions from the joint space. Need of the study: Arthrocentesis offers several advantages over traditional techniques, including reduced trauma, quicker recovery times, and a decreased risk of complications. It has emerged as a valuable tool in the multidisciplinary approach to managing TMDs, offering patients a minimally invasive option to relieve their symptoms and restore jaw function. Hence, the present study will present the utility of arthrocentesis as an adjunct procedure to closed reduction in high condylar fractures, improving the functionality of the condyle, providing pain relief, increasing mouth opening and bite force, stabilising bilateral occlusion, and normalising excursive movements. Aim: To compare and evaluate the efficacy of closed reduction with or without arthrocentesis in patients with high condylar fractures regarding functional outcomes. Materials and Methods: A randomised controlled trial will be conducted at Siddharth Gupta Memorial Cancer Hospital, Sawangi, Wardha, Maharashtra, India, from September 2024 to May 2026, involving 10 patients. The protocol includes examining patients with suspected high condylar fractures, taking detailed case histories, performing clinical examinations focusing on the Temporomandibular Joint (TMJ), and recording preoperative measurements of mouth opening and pain levels using a Visual Analogue Scale (VAS). Patients with suspected fractures will undergo radiographic examinations, and those meeting the inclusion criteria will be included in the study after providing informed consent. Arthrocentesis will be performed using a specialised needle with two lumens, inlet and outlet bevels, and a silicone stopper for maximal insertion depth. Statistical analysis will be conducted using descriptive and inferential statistics, specifically the Chi-square test and Student’s paired and Unpaired t-tests, with p-value<0.05 considered significant.

The Reconstruction of Tympanic Membrane Perforations using Various Biomaterials: A Narrative Review

Prasad Trimbakrao Deshmukh, Farhat Qamruddin Khan, Sagar Shankarrao Gaurkar

Tympanic Membrane Perforations (TMP), resulting from trauma or infections, can result in auditory impairment and recurring infections. Conventional surgical techniques, such as tympanoplasty, employ autologous grafts such fascia and cartilage; however, these approaches can be invasive, result in scarring and are subject to limitations including graft rejection and increased costs. Biomaterials such as Hyaluronic Acid (HA), collagen and gelatin sponges are being explored for Tympanic Membrane (TM) repair to resolve these issues. HA, recognised for its function in tissue regeneration, has demonstrated efficacy in facilitating TM healing by cell proliferation and revascularisation. Techniques such as HA fat graft myringoplasty have attained success rates of up to 92.7%. Collagen, another crucial biomaterial, promotes fibroblast proliferation and aids in the restoration of the TM’s fibrous layer. Repairs utilising collagen have exhibited success rates between 66.7% and 92%, contingent upon the extent of the perforation. Gelatin sponges, commonly utilised as scaffolds in the healing process, offer structural support and mitigate inflammation. These biomaterials have substantial advantages, including diminished surgical complications, expedited healing period and minimised scarring, rendering them advantageous substitutes for conventional grafts. Biomaterials are particularly advantageous in situations where autologous tissue grafting is impractical, offering effective and novel techniques for TM restoration. The review discusses advancements in the treatment of TMPs employing biomaterials.

Cutting-edge Strategies for Scaling Down Pain in Orthopaedic Surgery: A Comprehensive Review

OR Jeff Walter Rajadurai, CS Likhit, Shailesh Kumar, P Dinesh Kanna

Postoperative musculoskeletal pain is a significant challenge in orthopaedic surgery, leading to discomfort, restricted mobility and delayed recovery. Effective pain management strategies are crucial for optimising patient outcomes, reducing opioid reliance and enhancing recovery. The present review examines recent advancements in pain management techniques, focusing on multimodal analgesia, regional anaesthesia and non pharmacological interventions. The findings highlight the efficacy of multimodal analgesia, which integrates pharmacological approaches such as opioids, Non Steroidal Anti-inflammatory Drugs (NSAIDs), and N-Methyl-D-Aspartate (NMDA) antagonists with non pharmacological methods like Radiofrequency (RF) ablation, Transcutaneous Electrical Nerve Stimulation (TENS) and Spinal Cord Stimulation (SCS). Innovations such as oliceridine offer effective opioid alternatives with fewer side-effects. Regional anaesthesia techniques, particularly nerve blocks, demonstrate significant potential in reducing opioid consumption and promoting recovery. The integration of these strategies has significantly advanced postoperative care, reducing opioid dependence and improving pain management. Ongoing research is essential to further optimise these approaches, ensuring their safety and enhancing patient quality of life.

Magnetic Resonance Cholangiopancreatography in Identifying both Typical and Unusual Variations of Intrahepatic Bile Ducts: A Pictorial Review

Understanding the internal and external liver anatomy is crucial for planning procedures such as liver transplantation, resection, laparoscopic surgeries, complex biliary reconstruction and radiological interventions in the biliary tree. This pictorial review aims to provide a comprehensive visual portrayal of both common and uncommon patterns of biliary tree anatomy in Magnetic Resonance Cholangiopancreatography (MRCP), along with a review of the literature describing the prevalence. The most typical pattern of Right Hepatic Duct (RHD) branching was found in approximately 50-70% of cases, whereas the most common variant involved the Right Posterior Sectoral Duct (RPSD) opening into the Left Hepatic Duct (LHD), followed by a trifurcation pattern. On the left side, in approximately three quarters of cases, the common trunk of the segment II and III ducts joined the segment IV duct, representing the most frequent LHD branching pattern. Cystic duct variations were observed, with the right lateral insertion being the most common in this review. Many complex cases of aberrant and accessory bile ducts were also noted. MRCP serves as a non invasive imaging method to visualise biliary duct morphology, reducing the risk of iatrogenic injuries during hepatobiliary procedures and surgery.

Strategies for Managing Odontogenic Infections in Expectant Mothers: A Narrative Review

Abhishek Rupani, Raj Kumar, Priya Yadav, Garima Singh, Stuti Ketan Shah

Odontogenic infections, which originate from dental issues, can spread to fascial spaces in the head and neck, posing serious health risks. In pregnant patients, these infections are particularly challenging due to pregnancy-related physiological changes and the need to protect both the mother and the foetus. This narrative review elaborates on strategies for managing these infections in pregnant patients, highlighting the importance of a multidisciplinary approach involving Dental Professionals, Obstetricians, and Anaesthesiologists. Pregnancy induces changes such as altered immune function and increased vascularity, which can worsen the severity of infections and complicate treatment. The article discusses how these changes affect infection progression and treatment, stressing the need for early diagnosis to prevent severe complications like airway obstruction. Management strategies must balance effective infection control with foetal safety. This involves the careful selection of antibiotics, avoiding those that are contraindicated in pregnancy, and considering minimally invasive surgical techniques and local anaesthesia. Imaging is also addressed, with a preference for low-radiation methods or alternatives like ultrasound to reduce foetal exposure while ensuring accurate diagnosis. The article emphasises the importance of personalised treatment plans based on the stage of pregnancy, infection severity, and patient health. Close monitoring and follow-up care are crucial to managing potential complications during treatment. In conclusion, managing odontogenic infections in pregnant patients requires a careful, multidisciplinary approach to prioritise the health of both mother and foetus. The article offers a comprehensive overview of best practices, advocating for early intervention and tailored management to effectively safeguard both lives.

Role of Artificial Intelligence in Delivering Anaesthesia: A Communication

Prachi P Deshmukh, Vivek Chakole

Anaesthesia is one of the vital branches of contemporary medicine, ensuring the possibility of painless surgical and diagnostic procedures. Previously, anaesthesia management was based on the estimation and titration of the doses of administered anaesthetic agents by an anaesthetist. Nonetheless, with advancements in medical sciences, Artificial Intelligence (AI) has found its way into the practice of anaesthesia (1). AI can play a critical role in improving anaesthetic administration through better decision-making systems, enhanced patient outcomes and improved overall organisational efficiency in clinical settings (2). This communication aims to highlight the advances in the use of AI in anaesthesia, the existing issues and future directions.

Sociogenomics: Gene-environment Interactions in Enamel Defects

Ramya Sekar, Sindhu Subramani, Dharshini Devi, Monisha Prasad, Kavitha Bottu

Sociogenomics, an interdisciplinary field at the intersection of genomics and social sciences, offers a unique lens to understand the complex interplay between genetic predispositions and social/environmental influences on human health. While hypomineralisation has traditionally been studied from a biological standpoint, recent advancements in sociogenomics shed light on the significance of social determinants in shaping its impact. Sociogenomic approaches advocate for an integrative perspective, acknowledging the contribution of social determinants in modulating the expression and severity of hypomineralisation. The present short communication explores the emerging connections between sociogenomics and dental hypomineralisation.

Deep Vein Thrombosis and Pulmonary Embolism Secondary to Thrombophilic Disorder: A Case Report

Iron Deficiency Anaemia (IDA) is a prevalent nutritional deficiency and a common haematological disorder characterised by low iron levels, which lead to reduced haemoglobin production, fatigue, pallor and diminished oxygen delivery. IDA increases the risk of venous thromboembolism by causing thrombocytosis, venous stasis and hypercoagulability. Although iron deficiency is a rare risk factor, recognising it as a significant risk factor can help prevent pulmonary thromboembolism if detected early and treated. The most common inherited thrombophilias—such as Factor V Leiden mutation, prothrombin G20210A mutation and deficiencies in protein C, protein S and antithrombin III—are a group of genetic conditions that predispose individuals to thrombotic events by influencing various factors involved in the coagulation cascade. Deep Vein Thrombosis (DVT) is a common condition that is part of venous thromboembolism disorders and represents the third most common cause of death from cardiovascular disease, following heart attacks and strokes. Authors hereby, report a rare and complicated case involving a 44-year-old male patient who experienced Pulmonary Embolism (PE), DVT, IDA and underlying abnormalities in two key anticoagulant proteins: Protein C and Protein S. Anticoagulation with low molecular weight heparin was initiated to treat the PE and DVT. Based on the patient’s thrombophilia profile, a newer oral anticoagulant, rivaroxaban, was prescribed as a long-term anticoagulant.

The Hidden Aftermath: A Case of Late-stage Bronchial Stenosis Post-tuberculosis

Swapnil Deshmukh, Vasu Agarwal

Tuberculosis (TB) is a major health problem globally. Post-tuberculous pulmonary complications can manifest years after the initial infection, often presenting as unexpected and severe respiratory symptoms. This case report illustrates a unique presentation of late-onset post-tuberculous bronchial stenosis in a 36-year-old female who experienced acute chest pain and subsequent lung collapse. Despite a 15-year asymptomatic period following TB treatment, the patient developed significant airway obstruction due to fibrotic changes in the bronchial wall. This case underscores the importance of considering late-onset complications in patients with a history of TB, even in the absence of recent symptoms. In present case, the history and clinical profile led to a prompt diagnosis with appropriate management to alleviate the patient’s symptoms.

Design, Development and Implementation of iALERTS (Informatics Analytics for Long-term Evaluation and Repercussions Tracking of SARS-CoV-2 Infection): A Research Protocol

Krishna Mohan Surapaneni, Manmohan Singhal, Ashish Joshi

Introduction: The global pandemic caused by SARS-CoV-2 has led to significant morbidity and mortality, with many survivors experiencing long-term sequelae known as Post Acute Sequelae of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection (PASC) or “long Coronavirus Disease (COVID).” Addressing the healthcare challenges posed by PASC requires an innovative approach to monitoring and management. Need of the study: Traditional systems are often under-equipped to monitor and manage these prolonged effects comprehensively. An alert system is crucial for filling this gap, offering a data-driven approach to track, analyse, and manage the long-term repercussions of SARS-CoV-2 infection. Aim: To design, develop, and implement an informatics decision support tool that leverages data analytics to track and analyse the long-term effects of COVID-19, facilitating early identification and management of PASC. Materials and Methods: A quasi-experimental study will be conducted at Panimalar Medical College Hospital and Research Institute (PMCHRI), Chennai, Tamil Nadu, India, from December 2023 to December 2024. Primary data will be collected through a predictive survey tool from patients who have recovered from COVID-19, in addition to secondary data from hospital records, to develop a clinical decision support system. This platform employs machine learning algorithms to predict the likelihood of PASC development among Coronavirus Disease-19 (COVID-19) survivors. The project involves three phases: the creation of the predictive survey tool, the development of the iALERTS platform (Informatics Analytics for Long-term Evaluation and Repercussions Tracking of SARS-CoV-2 infection), and the implementation and evaluation of the system in clinical settings. Evaluation metrics will include user satisfaction, predictive accuracy, and the impact on clinical decision-making and patient outcomes. Statistical analysis will be conducted using multivariable regression models to identify predictors of PASC and to evaluate the association between SARS-CoV-2 infection characteristics and long-term outcomes. A p-value of <0.05 will be considered statistically significant for all analyses.