Journal of clinical and diagnostic research

Management of Bilateral Dental Agenesis with Aesthetic Rehabilitation by Groper's Appliance- A Six-year Follow-up

Zohra Jabin, Pooja Dudeja, Krishan Dudeja

Tooth agenesis is the most clearly recognised dental anomaly in humans. Tooth agenesis may be single or multiple and may involve single or both arches. However, agenesis of permanent tooth is more commonly seen than primary tooth agenesis. Various studies reported 2.6-11.3% incidence of missing permanent teeth, out of which 0.4-0.9% occurs in the primary dentition and most commonly lateral incisors are involved. Women are usually more affected and the male-to-female ratio is about 2:3. The clinical features evident in children with missing teeth are compromised growth of alveolar ridge, speech discrepancies and reduced lower facial height resulting in deep bite. Missing anterior compromises aesthetics and affects the psychological and social well being of the child. Absence of teeth results in speech defects and unbalanced jaw growth which predisposes the patient to dental malocclusion. Thus, the condition requires careful treatment planning and subsequent management. Limited treatment options are available for the management of this condition due to child’s tender age and co-operation levels. Among these Groper’s appliance presents a promising treatment modality. This appliance has proven to be compliant functionally as well as aesthetically. Agenesis of multiple anterior teeth in both the arches and involving primary as well as permanent dentition is a rare presentation and literature shows paucity of data pertaining to this anomaly. Thus, there is a need for the documentation of such cases in literature. The author reported a case of nonsyndromic bilateral agenesis of primary and permanent interiors in a healthy three-year-old Indian male patient and a brief overview on its clinical implications and management.

Collagenofibrotic Glomerulopathy: A Rare Diagnosis and Seldom Thought of Differential for Nodular Glomerular Mesangial Expansion

Anisha Manocha, Pallav Gupta

Collagenofibrotic glomerulopathy, a very rare glomerular disease, characterised by abnormal deposition of Type III collagen in the mesangium and subendothelial space. This disease may have an indolent course clinically but is capable of finally progressing to end stage renal failure. Thus, it is imperative for clinicians and pathologists to be mindful of this entity due to its rarity, nonspecific presenting signs and symptoms and varied differentials on histopathology which must be ruled out. A definite diagnosis depends on the awareness of this entity, a high index of suspicion and confirmation by immunohistochemistry and electron microscopy. Here, the present authors report a case of a 41-year-old hypertensive female who came with persistent pedal oedema and proteinuria. The biopsy showed nodular expansion of the mesangium by a homogenous, Congo red negative, eosinophilic material. A diagnosis of Collagenofibrotic glomerulopathy was confirmed on immunohistochemistry and electron microscopy.

Partially Treated Typhoid fever Leading to Inevitable Abortion: A Case Report

Ashima Jain Vidyarthi, Namita Jaggi, Deepa Maheshwari

Typhoid fever continues to be a major public health problem in developing countries especially due to the challenging infrastructure and sanitation facilities. Many cases of abortions due to untreated Salmonella infection have been reported. The present report is about a 25-year-old female who was inadequately treated for typhoid fever with suboptimal doses of oral ampicillin leading to inevitable abortion despite the infection being cleared from blood. Salmonella typhi was isolated from products of conception. The patient was treated with Ceftriaxone injections and has been found to be fine on follow-up visits. Typhoid during pregnancy needs to be treated with higher doses and preferably intravenous antibiotics instead of oral due to the increased volume of distribution and reduced tissue penetration of antibiotics in such patients.

Story of Dying Inferior Vana Cava and Saviour Azygous- Inferior Vana Cava Thrombosis and Azygous Continuity in Deceased Donor Liver Transplant

Aniruddha Bhosale, Priyanka Ghodekar, Manoj Raut, Dinesh Zirpe, Bipin Vibhute

Liver transplantation is the only solution or treatment of decompensated chronic liver disease and it becomes more difficult when there is shortage of organ donor leading to mortality. Here an unusual case of decompensated chronic liver disease with Hepatocellular Carcinoma (HCC) is reported who underwent a Deceased Donor Liver Transplant (DDLT). Intraoperatively patient was found to have a new onset Inferior Vana Cava (IVC) thrombosis, which posed technical difficulty in caval anastomosis and risk of thrombus propagation with standard techniques. Patient also had azygous continuity, where azygous vein was tortuous and was draining entire abdominal, pelvic and lower limb venous return into systemic circulation. Hence, piggyback reconstruction was used; the native vena cava was ligated infra hepatically and allowed azygous to remain sole drainage. This reduced risk of future thrombus propagation into IVC, also eliminated risk of unhealthy vascular anastomosis. There are very few case reports regarding azygous continuity in liver transplant surgery. As per the literature search this is the first case such reconstruction in setting of DDLT from India.

Actinomyces turicensis causing Urinary Tract Infection in Nephrotic Syndrome PatientA Case Report

D Sarumathi, Pallam Gopichand, Kapil Sejpal, PS Priyamvada, Jharna Mandal

Urinary Tract Infections (UTI) are one of the most common bacterial infections which accounts for significant cost to health care and it is one of the important cause of bacteremia. Escherichia coli remain the most common causative agent followed by Klebsiella pneumoniae, Proteus mirabilis and Enterococcus species. Actinomyces turicensis (A. turicensis) belongs to the family Actinomycetaceae. It is a rare pathogen and an infrequent cause of UTI. The author highlights one such case of a 42-year-old male with history of Nephrotic Syndrome (NS) presented with complaints of fever, dysuria and loose stools for three days. He was on treatment with corticosteroids for a long time. A. turicensis was isolated from urine of this patient as a single pathogen on culture and was found to be sensitive to ampicillin, ciprofloxacin, co-trimoxazole and nitrofurantoin. The patient responded well to metronidazole and ampicillin and was discharged. The pathogenic importance of this organism cannot be undermined and should not be ignored in such cases who are on corticosteroids or any immunosuppressive drugs.

Asymptomatic Migration of Intrauterine Device into the Abdominal Cavity

Atef Mejri, Khaoula Arfaoui, Emna Trigui, Badreddine Aloui

The Intrauterine Device (IUD) is one of the most used and effective contraceptive means worldwide due to its anti-conceptual and anti-nesting action. Although IUD use offers the benefits of being affordable, long lasting, highly effective, and reversible. However, like any foreign body, it can expose to certain complications, sometimes, with very serious consequences. Migration is the rarest but most feared complication. The frequency of uterine perforation ranges from 0.05 to 13 per 1000 insertions. It can be announced by pelvic pain, and in the majority of cases reported; this accident does not lead to major complications and remains clinically silent. The clinical presentation varies depending on the final ectopic site of the device. We report the case of an IUD migration into the peritoneal cavity 10 years after its insertion in a 41-year-old patient whose only complaint was epigastric pain. The clinical examination did not reveal lower abdominal tenderness. Apart from a lipase rate, which was around ten times the normal level, other ordinary blood tests did not show any abnormalities. The diagnosis was made fortuitously based on the subsequent CT scan findings that were part of the routine staging of the acute lithiasic pancreatitis, the underlying cause of the described pain. Acute pancreatitis was staged B and the patient had a successful surgical retrieval of the IUD with a good outcome.

Retention of Foetal Bone Fragments: A Cause of Secondary Infertility

Olatunji Okikiola Lawal, Oluwasomidoyin Bello, Gbolahan Oladele Obajimi

Foetal bone retention is a rare cause of infertility. They act as barriers within the endometrial cavity like an intrauterine device. Nonspecific clinical symptoms such as abnormal uterine bleeding, pelvic pain, vaginal discharge and dysmenorrhea may be present in some patients. Here, the present author reports a case of a 31-year-old female who presented with secondary infertility and a history of recurrent brownish vaginal discharge following voluntary termination of pregnancy 16 years earlier. Ultrasonography was suggestive of bone retention and further evaluation with hysteroscopy confirmed the diagnosis. She had successful removal of bone fragments and she was pregnant 6 months post-removal of bone fragments.

Detection of rare targetable EGFR variant in Metastatic Non-small Cell Lung Carcinoma by next Generation Sequencing: A Case Report

Single gene assays for variants in Epidermal Growth Factor Receptor (EGFR) demonstrate actionable and sensitising mutations in majority of the cases. However, the emergence of next generation sequencing platforms has facilitated the detection of newer variants in the already known drivers of lung carcinomas, which may be clinically actionable. Mutations in exons 18 to 21 of EGFR are widely characterised in literature, and rare unusual mutations in these regions are constantly being demonstrated recently. This report describes a rare exon 18 insertion variant in EGFR gene in a 61-year-old patient of non-small cell lung carcinoma, which is potentially actionable, thus highlighting the need of next generation sequencing based platforms in this era of precision medicine.

Haemospermia- A Disorder of Male Sexual Health

Dwijesh Kumar Panda

The testicular involvement with lymphatic filariasis caused by Wuchereria bancrofti (95%) is common in the endemic zone of Odisha in India. Haemospermia is the presence of blood in ejaculation. It is relatively uncommon and may affect one in every 5,000 individuals. Blood in semen can be frightening, but the condition is usually benign. A case of haemospermia was presented with the complaint of pain and discomfort in the perineum for the last five years. Trans Rectal Ultrasonography (TRUS) did not reveal any pathology. The Contrast-Enhanced Magnetic Resonance Imaging (CE-MRI) showed haemorrhage in the left seminal vesicles. The serum Prostate-Specific Antigen (PSA) test was within the reference range and carcinoma of the prostate was ruled out. The positive monoclonal circulating adult filarial antigen test (OG₄C₃) confirmed the diagnosis. The patient was given anti-filarial treatment for six months. Blood in the semen disappeared, but sexual asthenia persisted.

Severe COVID-19 Infection While on Long Standing Therapy with Hydroxychloroquine

Kartik Ramakrishna, Gaston Habib, Japjot Chahal, Dragos Manta, Pratishtha Gupta

The Coronavirus Disease 2019 (COVID-19) pandemic has placed a large demand on healthcare resources worldwide. Hydroxychloroquine is reported as an agent with potential benefit in prophylaxis and treatment and is being used for both. The authors hereby present the case of 63-year-old male patient with myasthenia gravis and 22-year-old female patient with mixed connective tissue disease, both on chronic therapy with hydroxychloroquine, who were admitted to intensive care with severe Acute Respiratory Distress Syndrome (ARDS) and COVID-19 infection. The patients had typical symptoms of fever, cough and dyspnea with lymphopenia on blood investigations. They were intubated and mechanically ventilated, requiring paralytics and proning, with subsequent dramatic improvement in oxygenation noted. This is the first report to describe the development of SARS-CoV-2 infection in patients already on hydroxychloroquine and demonstrates the need for robust clinical studies before we can recommend its use for routine prophylaxis in healthcare workers or exposed patient contacts.

Ocular Surface Squamous Neoplasia: Monotherapy with Mitomycin C

Manu Sharma

Ocular Surface Squamous Neoplasia (OSSN) is a neoplasm of ocular surface present in the interpalpebral area having feeder vessel. It is more common in middle age group and present as a mass lesion or chronic ocular irritation. Treatment is chemo reduction, surgical excision, cryotherapy and excision with adjuvant chemotherapy. There is high rate of recurrence in OSSN. Here, a case of 79-year-old female patient with painless mass over conjunctiva and cornea was presented. The mass was whitish, shiny and placoid extending from 9 o’clock to 5 o’clock position covering half of the corneal surface with feeder vessel. Gelatinous or leucoplakic OSSN was managed with chemoreduction and monotherapy with mitomycin C. No recurrence was reported during more than 2 years follow-up at the peripheral health institution.

Imaging Findings of Inferior Vena Cava Web Associated with Primary Budd Chiari Syndrome- A Case Report in Elderly Male

Budd Chiari Syndrome (BCS) is characterised by obstruction of hepatic venous outflow and Inferior Vena Cava (IVC) causing portal hypertension. The gold standard imaging for such a case is Contrast Enhanced Computed Tomography (CECT). The conventional treatment of BCS involves systemic thrombolysis, surgical shunt (transjugular intrahepatic portosystemic shunt) or IVC venoplasty with stenting with or without hepatic venoplasty. A case of 60-year-old male who presented with complaints of 3 months history of right loin pain and nocturia, who was later diagnosed with BCS with IVC web is presented. The clinical history was atypical whilst the Imaging findings of multiple venous collaterals on CECT abdomen and echogenic IVC thrombus traced till Right Atrium (RA) on longitudinal grey scale Ultrasonogram (USG) aided in diagnosis. The percutaneous interventional procedure of IVC venoplasty with stenting was done and patient recovered with good prognosis.

Intrascrotal Solitary Neurofibroma

Abhishek Gupta, Suhas N Jajoo

Solitary Neurofibroma of the scrotum is a rare benign tumour, particularly when it is not associated with neurofibromatosis Type I, hence, less number of cases have been reported in the English literature. Hereby the authors report a case of intrascrotal solitary neurofibroma in a 45-year-old male who was admitted to the hospital with a 2 year history of a painless swelling. With a preoperative diagnosis of soft tissue tumour, exploration was performed. The pathological diagnosis of the lesion was neurofibroma of scrotum. Although a relatively rare disease, intrascrotal solitary neurofibroma should be considered in the differential diagnosis of scrotal swellings.

Use of Vaginal Flaps and Pubovaginal Sling in Urethral Reconstruction

Kishan K Raj, Prateek Ramdev, Ashwin P Shekar

The delayed or prolonged second stage of labour occurs when the foetal head exert pressure against the anterior vaginal wall and it results in ischemia and necrosis of bladder base and urethra. The ischaemic injury can result in Vesicovaginal Fistula (VVF) and Urethrovaginal Fistula (UVF). Most of the time it is related to Stress Urinary Incontinence (SUI) because of wearing out of sphincter mechanism. The index case is of a 43-year-old female who presented with total incontinence. Patient had previously undergone transvaginal fistula closure for UVF resulting from obstructed labour. On evaluation she was found to have UVF and SUI. She underwent simultaneous urethral reconstruction and pubovaginal sling surgery for SUI. Patient is currently continent and has satisfactory voiding. Simultaneous pubovaginal sling along with urethral reconstruction is a safe and feasible procedure in managing such patients.

Solitary Prostatic Urethral Carcinoma: Cryptic cause of Acute Urinary Retention

Acute Urinary Retention (AUR) caused by urological malignancy is a rare event, even in elderly. A solitary prostatic urethral Transitional Cell Carcinoma (TCC) causing retention of urine is even rarer. Hereby, a case of 60-year-old non-smoker, with sudden onset of AUR was reported. Detailed clinical examination, biochemical and radiological investigations were not conclusive. Cystoscopy revealed a solitary papillary prostatic urethral growth projecting from base probably causing urinary retention. Histopathology confirmed it as a low grade urothelial carcinoma. Patient voided well after complete transurethral resection. Hence, an urothelial malignancy can have varied presentation, and appropriate histological diagnosis with cross-sectional imaging and regular follow-up with cystoscopy is mandatory.

Secondary Vesical Calculus caused by Transmigration of Intrauterine Device: A Case Report

Akshay Bahadur, Yanshul Rathi, Om Yadav

Intrauterine Contraceptive Device (IUCDs) are among the popular methods having results comparable to tubal ligation contraception method among the women. Some; not common but serious complications by its insertion may be encountered in the clinical practice like uterine perforation which may lead to its migration to adjacent organs which in turn leads to bladder stone formation being one among them. An uncommon case of a 45-year-old female patient presented with a stone formation around a migrating intrauterine device (Copper-T). The lady presented with a 4-year history of irritative voiding symptoms and occasional terminal haematuria for which she received treatment from time to time but her symptoms persisted. She had a history of a Copper-T inserted 18 years ago in one of the primary health centre in Punjab. She also gave history of tubal ligation 3 years after the insertion of Copper-T. Her X-ray Kidney Uretere and Bladder (KUB) showed a large radio-opaque vesical calculus with a part of T loop IUCD protruding through it. Ultrasonogram of the pelvis revealed a bladder calculus. Suprapubic cystolithotomy was performed and a vesical calculus with embedded Copper-T was retrieved. The post-operative period was uneventful. Awareness about proper insertion of intrauterine device through trained persons, its time of insertion (chances of uterine perforation being more during puerperium), proper counselling in patients going for IUCD insertion (the significance of missing thread) and the use of newer contraceptive device causing less complication is overemphasised in the present case report.

Diagnostic Challenges in Adenomyoepithelioma of the Breast: A Rare Case Report

Zachariah Chowdhury, Yookarin Khonglah

Adenomyoepithelioma (AME) is an uncommon tumour of breast, which is common in middle aged and older adults (>60 years). It is characterised by dual differentiation of cells into luminal as well as myoepithelial cells. Herein we report a case of a 22- year-old female who presented with a solitary swelling in the upper outer quadrant of the left breast, diagnosed as fibrocystic breast disease on Fine Needle Aspiration Cytology (FNAC). Excisional biopsy and histopathologic examination showed features suggestive of AME, which was confirmed on Immunohistochemistry (IHC) staining. On retrospective review of the cytology slides, a biphasic appearance was discerned; the myoepithelial cells probably having been masked by the cystic degeneration. AMEs are generally benign. However, in view of substantial reports of local recurrences, malignant transformations and metastases, accurate distinction of this lesion is crucial. Here, the authors report this rare case, to emphasise the importance of considering this entity in the differential diagnosis of a focal solid lesion in the breast, and to underline the accompanying diagnostic pitfalls.

Bartonella Endocarditis: A Case Series from Chennai, India

Bartonella spp. are Gram-negative haemotropic bacteria transmitted by arthropod vectors. They are considered as important aetiologic agents of Blood Culture Negative Endocarditis (BCNE). The diagnosis of Bartonella endocarditis is often challenging because of its non-specific clinical presentation and difficulty in isolating the microorganism in culture using standard microbiological techniques as it is an intracellular bacterium. A combination of serological and molecular methods will aid in a comprehensive diagnosis of this condition. This study reports a series of four Bartonella endocarditis cases diagnosed in Chennai, Tamil Nadu, India. All of them were known Rheumatic Heart Disease (RHD) patients. The common valves affected in the patients were mitral and aortic valves. Three out of four cases showed presence of valvular vegetation in echocardiogram. One patient had a history of close contact with cats. Specific real time Polymerase Chain Reaction (PCR) targeting 16S-23S rRNA spacer region of Bartonella spp. was positive in three cases. Serology using Indirect Immunofluorescence Assay (IFA) was positive in one case. Western blot test was performed on serum samples of all four cases and Bartonella henselae was identified as the aetiological agent in one case. Extra cardiac complications were observed in three cases. Antibiotic treatment was successful in three out of four cases. One patient died due to acute renal failure.

Gospels of a Pandemic- A Metaphysical Commentary on the Current COVID-19 Crisis

Sourya Acharya, Samarth Shukla, Neema Acharya

The entire human race is now going through an extremely rough patch. The SARS-CoV-2 is ravaging us in and out, ripping through our bodies and souls. Fighting is the core of survival and the fitter will win. Optimism flies high and yes! Human will be the ultimate winner but maybe the entire human race will be fatigued enough to celebrate the triumph. It’s now the call of Nature that “Lessons are to be learned”. The “Big–Bang” which created our Universe happened from Quantum fluctuations. The realm of our visible Universe contains within it: uncountable galaxies, stars, nebulae, black holes and dark matter. We are the luckiest to be in the Goldilock’s zone (habitat zone) that has enabled us to grow in a habitable atmosphere!! As per Einstein, the eternal macrocosm is disciplined by the theory of relativity; the cosmic law of causality and determinism. But there evolves the hidden paradoxical truth, the truth of duality, uncertainty and indeterminism of Quantum Physics that fiercely contradicts causality and epitomise duality. This is the essence of “Quantum superposition”- the simultaneity of wave and particle, life and death. This war between the theoretical and particle physicists will go on till, we achieve the eternal wisdom, “The Quantum Gravity” which would be the Final equation of triumph. Ultimately, from relativity to quantum all are the play of Eternal Physics. Alas! The same search will continue in our science, the “Science of Medicine”. It’s the same play of biophysics from Epidemiology to Molecular genetics! The disease will be there, its behavioural epidemiology will predictably swing in the fabrics of agent, host and environment akin to “The special theory of Relativity”. It will live and die out expectantly, but; here enters the villain…our enemy won’t succumb to every fight! It’s not that moron as we thought. It was and is still there preparing itself at its molecular level. Those quantum molecular mutations are indeed quantum fluctuations which would create a big bang. That would ravage our epidemiologic prejudices. The human race has been shattered by several pandemics since time immemorial. But this is something different. The warnings had come earlier in form of SARS and MERS. The corona virus was adamant, and why not? After all, it prepared itself with great discipline for that ultimate divinely scientific weapon, “the mutational fluctuations” and the power for zoonotic spillover or species jumping. And now it waited for the right moment, the moment of human indiscipline. It is indeed not important how it attacked; whether by directly infecting us from bats, through an intermediate mammal (Malayan pangolin) or maybe from a point source laboratory; but yes, what is worth important is it struck back with a vengeance with new preparedness and rest is history. It is high time we the supreme race (are we?) start to respect Nature and learn our lessons. The first gospel: is not to tamper with the laws of natural discipline and to realise that maybe, we aren’t the smartest of species. Though, the viruses out there are quantum sized, but they possess and are poised with the greatest power of Genetic diversity. They have the capability of mutagenic shifts and drifts that would destroy any human weapon (medicines/vaccines). They have been here on this planet millions of years before us. They have experienced the evolution and thrived through eternal cataclysms. They have influenced evolution of life. Even we, the newest of species carry their fossils in our genomes as reminders of past epidemics that our ancestors survived. The second gospel: makes us realise how our activities have been the genesis of emergence of new pathogenic disease causing viruses. Our selfish overwhelming greed has no boundaries; it is limitless and is encroaching and disturbing other natural habitats. We with our activities are warming up the atmosphere and its temperature. This is giving a chance to certain species to expand their old habitat and encounter new hosts. And by the virtue of our so called advancements, we are subjecting ourselves to those close dangerous encounters. The unknown enemy is out there powerful enough to wipe us out. The irony is our great minds already know all this!! Maybe it’s the wisdom paradox, “Glorified wisdom with a nucleus of utter ignorance and foolishness”. The third gospel: would be to leave behind all our pseudo egoism, petty politics, selfish cruel barbarism, racism, religious bigotries, terrorism, wars (with due respect to the devil inside), and focus and concentrate our economy on mending and maintaining the natural laws which we have tampered with, and destroyed. It is necessary to propel research in those directions that would strengthen us as a smart species in reality. Agents will remain through eternity (any doubts?), they will continue to prepare themselves for greater encounters and of course, they are superior to us as species. They will continue to mutate in their respective quantum physical realms and jump through species and attack us with greater vigour. Maybe greater Pandemics are waiting to cast their spells!! Intermediate hosts will remain as innocent bystanders; they will always respect the laws of Nature and will be at the mercy of their masters (agents). It is on us, how we play with the environment so that the delicate fabric of Epidemiology would pave way to promote Euthenics. Our future is filled with uncertainties. Actually, the human race is thriving in a trance of superposition (alive and dead at the same time!). From relativity to Quantum mechanics and from epidemiology to molecular genetics. Nature has written its own Gospels. Respect it or perish in the Apocalypse!! Others are here to stay. We won’t be here to learn from History, for we will be history.

Anecdote from Editors Desk Anecdote 6- A Curious Case of Ethical Misconduct

Mainak Dutta

Few weeks back I was invited to review a case report (article A) by the Editorial team of Journal of Clinical and Diagnostic Research (JCDR). It was an international submission that dealt with cochlear implant candidacy in two children with relatively uncommon clinical situations of bilateral cochlear dysplasia associated with multiple dysplasia/hypoplasia/aplasia of the vestibular system, vestibulo-cochlear nerve and facial nerve. These are known challenges for a cochlear implant surgical team regarding decision-making and the surgical procedure itself, and thus the article promised an interesting read. While midway in the review process, I received another e-mail from JCDR requesting me to review a second article (article B) which, according to the Editorial Assistant who seemed little alarmed and confused, had the same authors as in article A, and had some overlapping imaging and clinical description. I accepted the review request and went on to review and compare both the articles simultaneously. Both the articles were de-identified by the journal while being sent to me. While reviewing, the Magnetic Resonance (MR) and Computed Tomography (CT) images attracted my attention, not because they were novel or revealed something exceptional, but they appeared to be forged. The quality and print of the images in both the papers were highly suspicious. Most of the MRI and CT images, including the three-dimensional reconstruction of the vestibular system, appeared to be reprints of scanned or photocopied versions of the original, probably from some old-edition textbooks. The use of superimposed symbols (arrows) used by the authors were in contrast with the “in-built” annotations already there in the original version of the photographs. One of the “in-built” annotations even included Latin terminologies (“aplasia n. cochlearis” for cochlear nerve aplasia), something that modern medical literature seldom, if ever, uses. However, a plagiarism check using a freely available tool of the text of article A revealed a “100% unique” result. But, on careful plagiarism check of article B and subsequent cross-analysis of the suspicious highlighted results, it could be ultimately concluded that article B is an almost facsimile of another paper (article C) published one year back in a different journal, from the same geographic region, and in all possibilities, from the same group of authors. Almost, because article C had a different Title and Abstract, but from the Key words onwards, there was little to differentiate the two papers (B and C) in the overall presentation. Article B described three patients, all of whom were the same as in article C (with some alteration in the text), and one of them, a 4.5-year-old boy with spina bifida aperta, was also included in article A. This child had been described in all the three articles. The text of article A was cleverly edited such that it escaped the plagiarism check. The MRI and CT images overlapped as necessary in the three articles, and were identical in all respects, including the annotations, making them a curious example of unabashed permutation and combination of textual and photographic documentation across submissions. The journal that published article C was open-access (OA), and was in its first year of publication. The article was poorly edited, as evident from the printer’s devil in the Title, and the imaging fraud went undetected, questioning the rigor of the review and Editorial process. A search in the updated Beall’s list revealed the publisher to be a predator one (1). The review process of the two articles for JCDR opened up a Pandora’s box that exposed several facets of ethical misconduct in medical literature. It is evident that the two articles A and B have been submitted simultaneously for review, and were independently copied from article C (one a verbatim copy, the other in essence). While the former constitutes duplicate submission, the latter is a clear example of self-plagiarism. The white paper published by iThenticate® on the ethics of self-plagiarism defines it as “a type of plagiarism in which the writer republishes a work in its entirety or reuses portions of a previously written text while authoring a new work” (2). Thus this could be the ideal example of “literary theft” both in entirety and in portions. One may argue: how can one steal his/her own copyrighted property? Here lies the deep malady in the authors’ misunderstanding of the OA policy, and the ethics associated with its legal implications. The concept of being OA presently rules the medical publishing industry. It has its own set of merits, discussing details of which is beyond the scope of this Editorial. In short, in the OA policy, “the author(s) and right holder(s) of such contributions grant(s) to all users a free, irrevocable, worldwide, right of access to, and a license to copy, use, distribute, transmit and display the work publicly and to make and distribute derivative works, in any digital medium for any responsible purpose, subject to proper attribution of authorship…..” (3). The system is mediated through the many licenses of the Creative Commons, the common minimum of which simplifies the application as “This license lets others distribute, remix, adapt, and build upon your work, even commercially, as long as they credit you for the original creation.” (4) Here, “others” may involve the authors themselves, but the reference list in either of the articles A or B never acknowledges article C as a source material. The authors need to understand that mere holding the copyright as allowed in the OA publication model does not authorise them to reproduce their work without proper citation (self-citation, that is to say), and claim it as fresh and novel. Furthermore, irrespective of whether the authors retain the copyright, there is a palpable difference between the maximum extent of credited material that can be borrowed within the “fair use” allowance (2), and “self-plagiarism” as laid down by the Chicago Manual of Style. It states: “one should never quote more than a few contiguous paragraphs or stanzas at a time or let the quotations, even scattered, begin to overshadow the quoter’s own material” (6). By such standards, which perhaps are more ethical than legal, these three articles under discussion are blatant examples of self-plagiarism and violation of the principles of OA policy. And misconducts like these cannot be unforced. Lack of awareness should not be an excuse when senior faculty members are involved as contributing authors, especially in today’s era of easy access of information through the worldwide web. Had not the authors submitted article B prior to the end of the Editorial review of article A, it would have been very difficult to detect the duplicate submission and the act of plagiarism, as the text in article A was quite cleverly crafted, if not the imaging photographs. Checking plagiarism of the photographs is not easy, and the reviewer has to count on his/her intuition and experience for such practice. At the end of the day, the authors’ intent and integrity need to be questioned behind such deliberate practices of ethical misconduct. At the same time, the market of the predator journals is gaining foothold in medical publishing under the veil of being OA. And the two seem to be made for each other, lead a symbiotic relationship, and together pamper research malpractices that mislead the scientific and user community with fabricated, unoriginal and erroneous outcome. Choosing a predator journal is the easiest avenue to get published with minimal effort that helps the authors meet publication deadlines with the hope of career advancement. These journals demand exorbitant article processing charges citing the inherent advantages of being OA, with minimal, if any, Editorial processing. Not only are the principles of OA in its wider perspectives get defeated in the process, many young researchers fall prey to this system, getting lured and wooed by the florid promises of “quick review” (?) and “immediate publication”. And the rest, generally the senior ones, knowingly participate in this fraudulent system with study outcomes that do not exist at all. The three articles I discussed here serve as a suitable example for this, where, with the photographic documentations copied and forged, there should be every reason to believe that the clinical events presented did never exist! The OA journal where article C was published did not reveal any information regarding the Creative Commons licence policy neither in its website nor in the article pages. The result is the unholy nexus between the two corrupt ideas, and the defeat of the research ethics and the science of medicine. JCDR takes a strict stance on such malpractices. Articles submitted in this journal undergoes careful pre-review screening, and are subjected to rigorous, double-blinded peer review. Any ethical issues are noted, and serious malpractices are severely dealt with. Not only are such articles summarily rejected without further processing, the authors are not allowed to let go with impunity. They are blacklisted and prevented from further submissions in the journal. It has always been our effort to bring genuine research data to our readers, and this anecdote Editorial series puts forward some examples on one of the many ways we do it.

Rare Cause of Hemifacial Spasm: Diagnosed on Magnetic Resonance Imaging

Madhurima Sharma, Munish Dev

A 36-year-old hypertensive male presented with involuntary twitching involving left side of face for last 3 days. On neurological examination, left hemifacial spasm was present. Rest of neurological examination including cranial nerve examination was within normal limits. Patient underwent Magnetic Resonance Imaging (MRI) of brain with angiography of intracranial vessels. On T2 weighted images, prominent flow void of basilar artery was seen causing indentation upon anterior aspect of pons with resultant deformation [Table/Fig-1a,b]. Pons and medulla however showed normal signal intensity. Sampling Perfection with Application optimized Contrasts using different flip angle Evolution (SPACE) sequence and 3D Time of Flight (TOF) MR angiography showed dilated and tortuous bilateral vertebral arteries and basilar artery. Basilar artery measured ~6.2 mm in maximum caliber and showed abnormal lateral course (slightly lateral to clival margin) with presence of high bifurcation at the level of third ventricle [Table/Fig-1c,d]. Right vertebral artery was elongated and seen crossing the midline towards left side. Left vertebral artery was also tortuous and more lateral in course resulting in displacement of left facial nerve with compression upon root exit zone (Table/Fig 2). Right 7^th, 8^th nerve complex was normal. Bilateral 5^th, 9^th and 10^th nerves were normal in their intracranial course and morphology. Based upon these findings, a diagnosis of vertebrobasilar dolichoectasia, causing compression upon left facial nerve was made. Patient was offered option of botulinum toxin injection for symptomatic relief. However, patient refused the injection and was lost to follow-up. Hemifacial spasm is characterised by involuntary tonic-clonic contractions of muscles supplied by facial nerve. It can result from compression of ipsilateral facial nerve by a vascular loop or cerebellopontine angle mass (1). Facial nerve has its nucleus in pons with nerve fibers exiting from inferior border of pons. Nerve root entry or exit zone is the transition point from central to peripheral myelin and is most susceptible for vascular compression [2,3]. It is postulated that pulsatile compression by the vessel produced demyelination at root entry zone of the nerve leading to abnormal transmission of impulses (4). Direct compression of facial nerve by dilated vertebral artery is rare, accounting for 0.7% cases of hemifacial spasm in a previous study (6). Vertebrobasilar Dolichoectasia (VBD) is characterised by abnormal dilatation, elongation and tortuosity of vertebrobasilar system (6). Diagnosis of VBD is made when basilar artery measures ~4.5 mm in maximum caliber (typically measured at the level of mid-pons on axial images), lies lateral to clival margin and shows high bifurcation above the level of floor of third ventricle (6). Patients with VBD are often elderly hypertensive males predominant left sided involvement (2). In the present case, manifestation of VBD at a younger age could be seen. A congenital vascular anomaly is thought to be responsible for dolichoectasia in these cases (7). In most of the cases VBD remains asymptomatic and is detected as incidental finding. Symptomatic cases of VBD can present with ischemic stroke, intraparenchymal, subarachnoid haemorrhage or compressive symptoms due to mass effect on adjacent brainstem and cranial nerves (6). Treatment of hemifacial spasm due to VBD can be medical or surgical. Medical treatment consists of botulinum toxin injection, which provides symptomatic relief with effect lasting 4-6 months (8). Surgical treatment consisting of microvascular decompression is the definitive treatment. However, it carries the risk of hearing impairment and facial nerve palsy (9). REFERENCES (1) Abdel Hamid M, John K, Rizvi T, Huff N. Hemifacial spasm due to vertebrobasilar (1)dolichoectasia: A case report. Radiology Case Reports. 2015;10(4):65-67. (2) Aga P, Parashari U, Parihar A, Yadav R, Singh R, Kohli N. Simultaneous involvement of fifth and seventh nerves by vertebrobasilar dolichoectasia presenting as painful tic convulsif-Demonstrated by MR imaging. Neurology India. 2010;58(1):163. (3) Woolfall P, Coulthard A. Pictorial review: Trigeminal nerve: Anatomy and pathology. Br J Radiol. 2001;74(881):458-67. (4) Smoker WR, MJ Price, WD Keyes, JJ Corbett, LR Gentry. High-resolution computed tomography of basilar artery. AJNR. 1986;7(1):55-60. (6) Han IB, Chang JH, Chang JW, Huh R, Chung SS. unusual causes and presentations of hemifacial spasm. Neurosurgery. 2009;65(1):130-37. (6) Samim M, Goldstein A, Schindler J, Johnson MH. Multimodality imaging of vertebrobasilar dolichoectasia: Clinical presentations and imaging spectrum. Radiographics. 2016;36(4):1129-46. (7) Hegedus K. Ectasia of basilar artery with special reference to possible pathogenesis. Surg Neurol. 1985;24(4):463-69. (8) Czyz CN, Burns JA, Petrie TP, Watkins JR, Cahill KV, Foster JA. Long-term botulinum toxin treatment of benign essential blepharospasm, hemifacial spasm, and Meige syndrome. Am J Ophthalmol. 2013;156(1):173e-177.e2. (9) Mikami T, Minamida Y, Akiyama Y, Wanibuchi, M, Sugino T, Houkin K, et al Microvascular decompression for hemifacial spasm associated with the vertebral artery. Neurosurg Rev. 2013;36(2):303-09.

Correspondence: Knee Effusion with Peripheral Eosinophilia: A Need to Rule out Idiopathic Eosinophilic Synovitis

Sharat Agarwal, Manika Agarwal

Dear Editor, At the outset, I would like to congratulate the authors of the article entitled-‘Knee Effusion with Peripheral Eosinophilia: A Need to Rule out Idiopathic Eosinophilic Synovitis’ published in JCDR (1). However, I regret to mention that the workup mentioned in this article is highly inadequate, before one can come to a definitive diagnosis of eosinophilic synovitis. I would like to highlight that it is very crucial to rule out history of ‘milk allergy’, which has been ascertained by finding increased IgG anti milk levels, IgG milk-circulating immune complexes and in vitro T-cell sensitivity to milk as mentioned in the literature (2). It is must to undertake skin testing for commonly available allergens related to eosinophilia (house dust, Acaridae, feathers, kapok upholstery, ragweed, trees, grasses, pollens, weeds, dog and cat hair, Alternaria, Horrnodendrum). Laboratory testing has to include, in addition to what was undertaken by the author, blood chemistry profile; circulating IgG, IgA, IgM, and IgE; VDRL; antistreptolysin 0 (ASO); with subspecificity assays for antibodies to native DNA (anti-nDNA), Sm, RNP, SS-Pi, SS-B, Scl-70, PM-1, centromere, nucleole; and organ-specific autoantibodies (3). Also, nephelometric assays of C3 and C4; microbiology studies of blood and stool samples for parasites especially Taenia solium as Indian subcontinent is endemic for this infection; serology for HBV and HCV should be included (4). Minor eosinophilia, in the range of 1-10%, can occasionally be found in haemorrhagic fluids and in the presence of systemic diseases, such as rheumatoid arthritis, rheumatic fever, hypereosinophilic syndrome, parasitic disease and probably many others. Eosinophilic synovitis has been found in patients with systemic and local parasitic infections, in cancer patients with articular and extraarticular cancerous involvement who received previous radiotherapy and/or chemotherapy, and in patients submitted to air or contrast knee arthrography. In the existing clinical scenario, it is must to rule out low grade septic (pyogenic) arthritis, tubercular arthritis and Juvenile Monoarticular Synovitis (JRA) before finally labelling this condition; so, this essentially warrants the synovial histopathological confirmation (6). Moreover, it is very important to rule out ‘gout’, the incidence of which is increasing even though we may agree that the patient was a teenager as various hereditary enzyme linked hyperuricaemic conditions can cause early age hyperuricemia (6). Finally, it is must to document ‘eosinophilic infiltration of synovium”, which has to be confirmed with Fine Needle Aspiration Cytology (FNAC) or arthroscopic and open biopsy, before coming to a conclusion. Besides, the elevated levels and assessment of IgE in synovial fluid has not been undertaken in this particular case (7). As far as management of this condition is concerned, it is better to avoid the use of ‘Aspirin’ as it causes ‘Widal Syndrome’ (8) and also Ibuprofen (9). They have the potential to cause eosinophilia; the author has managed the condition with ‘Ibuprofen’. Last is the issue regarding the follow-up of such patients. It is well mentioned in the literature and an established dictum that “Eosinophilic disorders are chronic conditions that require long term treatment for the prevention of clinical manifestations. Morbidity and mortality for many eosinophilic disorders remain high, so they need constant regular monitoring even after initial remission” (10).

Correspondence: Association of Serum Uric Acid Level with the Severity of Brain Injury and Patient’s Outcome in Severe Traumatic Brain Injury

Takahiko Nagamine

Dear Editor, Uric Acid (UA) has validated its neuroprotective role in damaged brain. However, the relationship between serum UA levels and the severity of brain damage is controversial. I read with great interest the article “Association of Serum UA Level with the Severity of Brain Injury and Patient’s Outcome in Severe Traumatic Brain Injury” by Hatefi M et al., (1). They showed a strong relationship between UA levels and patients’ outcomes in Traumatic Brain Injury (TBI). I recently experienced a coma patient with TBI who showed low UA and sodium levels, which may indicate an excess excretion or consumption of UA and sodium is a risk factor for the severity of TBI. A 69-year-old male was admitted to the hospital because of head injury after a fall during clearing work. On arrival, his consciousness was clear. Radiological examination revealed traumatic subarachnoid haemorrhage and subdural haemorrhage. On the 4^th hospital day, his became comatose, serum sodium and UA levels dropped to 115 mEq/L and 3.2 mg/dL, respectively. His plasma osmolality was 228 mOsm/kg H₂0, whereas urine osmolality was 476 mOsm/kg H₂0. The serum antidiuretic hormone concentration was detected as 1.5 pg/mL despite severe hyponatremia. His serum sodium level was increased to 122 mEq/L with 3% hypertonic saline drip at 20~30 mL/hour, resulted in slightly improving consciousness. His serum sodium and UA levels remained low even after adequate sodium infusion. Thus, fludrocortisone (0.1 mg/day) was stared considering the possibility of Central Sault Wasting Syndrome (CSWS). This resulted in the improvement in sodium and UA levels. On the 21^st hospital day, he recovered completely and was discharged with sodium and UA levels of 138 mEq/L and 6.8 mg/dL, respectively. The clinical course of the patient is illustrated in (Table/Fig 1). TBI brings oxidative stress due to the structural and biochemical changes in the brain. UA is involved in almost 70% of the free radical scavenging reactions in the human. Thus, UA levels may influence the clinical course of TBI. Hatefi M et al., showed a significant positive linear relationship between increase in serum UA levels and improvement in the levels of consciousness in TBI patients (1). In agreement with their report, the index patient showed low UA levels during unconsciousness and his condition improved as his UA levels were increased. Intriguingly, UA levels were related to sodium levels in the patient (Table/Fig 1). Brain damage interferes with normal neuroendocrine function and sympathetic nervous system of hypothalamus and pituitary, which could influence laboratory data such as serum sodium and UA levels (2). CSWS brings an excess excretion of sodium and UA, although precise pathophysiology remains unclear. Since UA has numerous antioxidant properties including scavenging of free radicals, low UA levels could be related to poor outcomes in TBI patients. However, Liu H et al., indicated that UA levels were significantly lower in TBI patients that had a good outcome, and low serum UA level was an independent predictor of good outcome after TBI (3). This contradicting report may be due to the difference of time for blood sampling. Following TBI, active antioxidant defence in the brain could result in consumption of UA in the serum, and thus, recovery from a decreased serum UA should be predictive of good clinical recovery. In conclusion, the serum UA level is important in TBI patients as Dr. Hatefi M mentioned because UA could act to attenuate neuronal loss in numerous TBI animal models. Therefore, further clinical studies are warranted to elucidate the effect of serum UA and sodium levels on TBI patients’ outcomes.

Biochemical Markers of Ascitic Fluid to Differentiate Ovarian Cancer from Liver Cirrhosis Patients

Introduction: The pathological accumulation of abdominal fluid (ascites) is due to multiple causes often associated either with peritoneal and non-peritoneal diseases. The differential diagnosis of the above patients is made by biochemical, cytological and imagological methods. Aim: The present study was conducted in serum and ascitic fluid to estimate the levels of Cholesterol, Triglycerides, SATG and SACG along with SAAG to differentiate ascitic patients of ovarian cancer from liver cirrhosis. Materials and Methods: The present prospective crosssectional study was carried out between December 2016 and June 2019 in the Department of Gastroenterology, Osmania General Hospital, Hyderabad, Telangana, India. A total of 375 ascitic patients, (230 patients with liver cirrhosis, 145 ovarian cancer) and 150 age and sex-matched healthy volunteers (hospital working staff and patient’s attendant) were enrolled in this study. Serum and ascitic fluid concentrations of Total proteins Total Proteins (TP), Albumin (ALB), Cholesterol (CHOL) and Triglycerides (TG) were measured by standard methods using the autoanalyzer. Serum Ascitic Albumin Gradient (SAAG), Serum Ascitic Cholesterol Gradient (SACG) and Serum Ascitic Triglycerides Gradient (SATG) were derived by the calculation method. The statistical analysis was conducted by one-way ANOVA; SPSS (version 22). A p-value <0.05 was considered statistically significant. Results: Significantly increased levels of ascitic fluid TP, ALB, CHOL, and TG were observed in ovarian cancer patients when compared to the ascitic fluid of liver cirrhosis (p<0.001). Ascitic fluid total proteins, albumin and SAAG showed the highest diagnostic efficiency (99%) with a sensitivity of (100%) and specificity of 99%. Ascitic fluid CHOL and SATG were also found the highest diagnostic efficiency 95%; 87%; Sensitivity of 93%; 84%. The Area under the curve of CHOL and SATG strongly indicated the diagnostic efficiency of 0.984 and 0.945, respectively. Conclusion: The present study suggested ascitic fluid cholesterol and SATG were found to be the more sensitive parameters that would be used as an additional biomarker along with the SAAG for screening and differential diagnosis of ovarian cancer, to that of liver cirrhosis.

Use of Salivary Alpha Amylase to Evaluate Dental Stress in Children during their First and Subsequent Visits: A Pilot Study

S Sruthi, Deepa Gurunathan

Introduction: Dental anxiety is very frequent among population of many countries. It is assessed with a noninvasive biomarker, Salivary alpha amylase. Assessment of dental anxiety or stress can be a vital part of children management during treatment as it affects the children behaviour. Aim: To evaluate acute psychological stress undergone by children during their first visit and subsequent dental visit using salivary biomarker of stress namely salivary alpha amylase. Materials and Methods: This cross-sectional study was conducted in Department of Paediatric and Preventive Dentistry, Saveetha Dental College, Chennai, Tamil Nadu, India. Twenty children were selected for the study. To measure anxiety, the child’s parent completed Modified Dental Anxiety Scale (MDAS). Unstimulated whole salivary samples were collected from 20 children in their first dental visit and in their second visit. Salivary alpha amylase concentrations were obtained using an automatic analyser and assay kits from Roche. Paired t-test was used to compare the two study groups (new and returning patients). Results: Moderate and severe anxiety was present in seven and twelve children out of twenty new patients. Six children had moderate anxiety while no one reported severe anxiety among returning children. Salivary alpha amylase levels were higher in children in their first dental visit (61.29±4.51) compared to their second visit (45.56±3.58). Conclusion: Children during their first dental visit experienced higher levels of stress compared to subsequent visit.

Efficacy of Tramadol Hydrochloride as Local Anaesthetic and Analgesic Agent for Extraction of Maxillary Teeth

U Siva Kalyan, NVV Satya Bhushan, KC Chiang, D Aparna, T Sunil

Introduction: To make the extraction experience pain-free administering local anaesthesia before dental extraction is standard protocol worldwide. Over the years, the concept of local anaesthesia and anaesthetic agents has evolved. Apart from conventional esters and amides, opioids have also shown the local anaesthetic property. In circumstances, where the patients are allergic to esters and amides or when they are unavailable or unobtainable the need for an alternative local anaesthetic agent arises. Aim: To assess the efficacy of 1 mL of 50 mg tramadol hydrochloride as a local anaesthetic agent when given as buccal infiltration for extraction of maxillary teeth. Also, assess its analgesic effect. Materials and Methods: A prospective, non-randomised, nonblinded study was done from October 2017 to August 2019 in 90 patients who required extraction of maxillary teeth. A 1 mL of 50 mg tramadol hydrochloride was given via buccal infiltration as a local anaesthetic-agent and its efficacy was evaluated by assessing the onset of action, peak effect, the intensity of pain during extraction, duration of anaesthesia and postoperative analgesic intake. No palatal injection was given. The data was analysed using SPSS v. 20. Descriptive statistics were represented in percentages. Statistical tests used were unpaired t-test and chi-square test. The level of significance was considered to be statistically significant when the p-value was =0.05. Results: A 1 mL of 50 mg tramadol hydrochloride, when given as a buccal infiltration has been effective in providing local anaesthesia for extraction of maxillary teeth. It also provides a good postoperative analgesia within the first 24 hours postextraction. It was noted that patients undergoing extraction of posterior maxillary teeth experienced more pain when compared to those undergoing extraction of anterior maxillary teeth with a significant p value of <0.001. Conclusion: Tramadol hydrochloride was good in first 24 hours of post-extraction as analgesic. Buccal infiltration of tramadol hydrochloride was an effective local anaesthesia for extraction of anterior maxillary teeth.

Factors Affecting Patient Compliance to Physician Advice among Lebanese Internet Users

Introduction: Patient compliance to physicians’ advice is pivotal for successful management of disease and in improving health care outcome. Aim: To identify the factors that affect medical compliance to physicians’ advice among Lebanese internet users. Materials and Methods: This descriptive cross-sectional study was conducted by interviewing randomly-selected adults Lebanese internet users who visited a physician at least once in the past three months. A pre-tested, pre-structured questionnaire was applied comprising of six parts: (1) personal information; (2) patient’s compliance; (3) perceived information asymmetry; (4) patient-physician concordance; (5) internet health information quality; and (6) physician quality. Descriptive statistics were computed as means/standard deviations (±SD) for continuous variables and as frequencies for categorical variables. The independent sample t-test or ANOVA was used to compare means of scales between groups and Pearson’s correlation was used to determine the degree of correlation between continuous variables. Results: The mean age of the participants was 28.54±12 and the majority had secondary school education (53%), unmarried (64.5%), had a non-medical educational background (64.6%). Results showed that the level of education, patient-physician concordance and communication, and physicians’ empathy and competence were significantly associated with patient compliance with medical advice. Primary educated Lebanese patients exhibited the highest compliance score (29.80±3.53). Interestingly, perceived information asymmetry and internet health information quality had no significant impact on patients’ compliance. Conclusion: This study demonstrated that patients’ compliance is affected by the level of education, patient-physician concordance, physician’s competence and empathy, and communication between the patients and the physicians themselves. Henceforth, it is recommended that physicians should focus on improving their communication and professional skills rather than worrying about patients acquiring health information through the internet.

Evaluation of the Prevalence of Giardia Infection in People Referred to the Laboratories of Ilam City, Iran

Soghra Viesy, Jahangir Abdi, Zahra Rezaei, Jalil Feizi

Introduction: Giardiasis is one of the most important health problems around the world and its prevalence has been reported in various regions. Furthermore, it causes long-term digestive disorders and can spread rapidly if there is no hygiene. Aim: To investigate the prevalence of Giardia lamblia in people referred to laboratories of Ilam, Iran, and to provide strategies for prevention. Materials and Methods: This descriptive cross-sectional study was conducted on 1000 stool specimens in Ilam labs in 2017. These were randomly collected from the laboratories along with demographic information. Subsequently, all samples were examined microscopically by using saline and iodine mount on grease-free slides. Furthermore, suspect specimens were examined using trichrome staining. Finally, the results were analysed using statistical software SPSS 20. The data were then compared with the Chi-square test. Results: The results revealed that 84 (8.4%) of 1,000 samples were infected with the Giardia parasite. The frequency of the giardiasis in the age group of 20-30 years was higher than in other age groups and in males it was more as compared to females. Conclusion: The present study revealed that despite improving public health, Giardiasis is still a health problem. There are some useful strategies for reducing Giardia infection, for instance: proper planning, public health education, and providing safe drinking water.

Subjective Global Assessment and Quality of Life in Hemodialysis Patients- A Clinical Observational Study

Introduction: Malnutrition is a prevalent problem in patients undergoing haemodialysis. Malnutrition is strongly associated with increased morbidity and mortality in these patients. Early detection and intervention is the key to prevent significant morbidity and mortality. Aim: To assess the nutritional status of Maintenance Haemodialysis (MHD) patients by anthropometry, biochemical measurements, Subjective Global Assessment (SGA), Malnutrition Inflammation Score (MIS). Also, to assess the correlation between SGA, MIS and WHO SF 36 scores which measures the Health Related Quality of Life (HRQOL). Materials and Methods: This was a clinical observational study which included 60 stable maintenance haemodialysis patients. The patients who were on haemodialysis for atleast 3 months and who fulfilled the inclusion criteria were selected randomly and studied over a period from January 2017 to January 2019. They underwent nutritional status assessment by anthropometry i.e., Body Mass Index (BMI), Mid Arm Circumference (MAC), triceps Skin-Fold Thickness (SFT) and biochemical tests i.e., S.creatinine, S. albumin, S.cholestrol, S.total iron binding capacity (TIBC), S.ferritin, S.transferrin saturation. All the patients were subjected to SGA, MIS and SF 36 questionnaires. They were divided into 3 groups based on SGA scores: well nourished, mild to moderately malnourished and moderate to severely malnourished. Biochemical tests, anthropometric parameters, MIS scores were compared between these three groups using Analysis of variance (ANOVA) test to find out if there was any significant difference. Pearson’s correlation was performed to find the degree of correlation between SGA, MIS and WHO SF 36 scores. The p-value less than 0.05 were considered significant. Results: In the present study, 55% were diabetics and 86.7% were hypertensive. 53.3% of the patients had a dialysis vintage of <30 months (Mean±SD: 44.33±38.52). Based on SGA scores, 20% were in well-nourished group, 63.3% of patients were in mild to moderate malnourished group and 16.7% were in moderate to severely malnourished group. Patients who were moderate to severely malnourished had significantly lesser anthropometric measurements compared to other groups. (p-value for BMI=0.001, MAC=<0.001, TSF=0.003). While studying Biochemical parameters we found that those with moderate to severe malnourishment had significantly lesser S.albumin (p-value=0.001), S.cholestrol (p-value=0.038), S.creatinine (p-value=0.005), S. transferrin (p-value=0.047) saturation. There was no significant difference with respect to S.ferritin (p-value=0.993) and TIBC (p-value=0.921). Those with moderate to severe malnourishment had higher MIS scores (p=<0.001). All quality of life aspects, physical and mental component summary and total scores (except bodily pain) had a significant difference with SGA and MIS parameters (p<0.001). All the quality of life parameters (except bodily pain) had a significant negative correlation with SGA and MIS scores. Overall (Total) SF 36 scores also had a significant negative correlation with SGA (r=-0.785) and MIS scores (r=-0.604). Conclusion: MIS, SGA and HRQOL SF 36 are cost-effective, simple to use, bedside and readily available tools for nutritional assessment of MHD patients. Patients with poor nutrition have a poor physical and mental quality of life. Hence, it becomes important for us to identify such patients and intervene earlier, in order to improve their quality of life and also reduce morbidity which in turn helps in reducing mortality. This can be effectively carried out by using these simple and cost-effective questionnaires across all MHD units on a periodic basis to monitor their progress towards achieving better health goals.

Changes in Macular Oedema by Optical Coherence Tomography in Patients Receiving Intravitreal Bevacizumab: A Retrospective Observational Hospital Based Study

Ajit K Joshi, Nimisha Lahkar, Paurnima U Bodhankar, Abhinandan N Patil

Introduction:Collection of fluid in the macula is called macular oedema. It is a manifestation of various pathologies, main being diabetic retinopathy. Since the burden of the disease is immense and can cause blindness, its early detection and treatment are of utmost necessity. Optical Coherence Tomography (OCT) is a fast, efficacious and easy diagnostic tool for detecting macular oedema at the earliest and hence is used widely now. Intravitreal Injection Bevacizumab (IVB) is an anti Vascular Endothelial Growth Factor (anti-VEGF) agent effective in the treatment of macular oedema and is cost effective compared to its contemporaries. Aim: To study the clinical effectiveness of IVB as measured by Spectral Domain-Optical Coherence Tomography (SD-OCT) changes in macular thickness in patients with macular oedema. Materials and Methods: This was a retrospective analysis of 32 eyes of 30 patients with macular oedema due to various retinal pathologies that underwent IVB and followed-up for a period of minimum 6 months. The outcomes were measured on SD-OCT at baseline then at one month, three months and six months. Morphological changes were also analysed through the OCT pictures. Paired t-test and chi-square test were used for statistical analysis. Results: The Central Foveal Thickness (CFT) reduced from 445.28±155.87 µm at baseline to 334.44±100.42 µm at one month which was statistically significant (p<0.001) and the Parafoveal Thickness (PFT) reduced from 452.70±131.95 µm at baseline to 353.09±100.92 µm at one month which was also statistically significant (p<0.001). This decrease in macular oedema continued at three months and six months follow-up. The improvement in visual acuity was also significant from baseline to one month and six months follow-up. Sixteen eyes (50%) received a second injection and 9 (28.12%) eyes received a third injection as well. None of the patients showed serious ocular and systemic side-effects of the drug in the present study. Along with the retinal thickness, morphological changes in OCT biomarkers namely cystoid spaces, Hyper-Reflective Foci (HRF), Serous Macular Detachment (SMD) and Ellipsoid Zones (EZ) were also analysed at baseline then at one, three and six months follow-up. Conclusion: IVB has promising morphometric and functional outcomes in macular oedema of various retinal pathologies as a primary treatment modality in real world scenario.

Mean Platelet Volume and Salivary C-Reactive Protein Levels among Smokers with Chronic Periodontitis: A Pilot Study

Introduction: Periodontitis is a chronic inflammatory disease with smoking as a major risk factor. Previous studies have shown that elevated number of platelets, platelet activation and Mean Platelet Volume (MPV) are the important indicator of platelet activity which can be used as an inflammatory marker in severe Periodontitis. It is known that smokers are more prone for periodontal breakdown, however, there have been no studies among smokers with chronic periodontitis assessing MPV as an inflammatory marker. Aim: To assess and correlate MPV and salivary C-Reactive Protein (CRP) levels among smokers with Chronic Periodontitis. Materials and Methods: This was an observational study comparing four groups: Group A-Smokers with Chronic Periodontitis (n=25), Group B-Smokers without Chronic Periodontitis (n=25), Group C-Nonsmokers with Chronic Periodontitis (n=25) and Group D-Nonsmokers without Chronic Periodontitis (n=25). Plaque Index (PI), Gingival Index (GI), Probing Depth (PD) and Clinical Attachment Levels (CAL) were recorded. Fasting venous blood sample (2 mL) and unstimulated saliva sample (2 mL) was collected and assessed for MPV and salivary CRP respectively in a fully automated analyser. These variables were analysed using one-way ANOVA and independent sample t-test to test for statistically significant difference between the groups. The correlation between MPV and salivary CRP levels was assessed using Karl Pearson’s product moment correlation co-efficient. Statistical significance as fixed at p≤0.05. Results: MPV was found to be highest in group B (11.12±0.72), followed by group D (10.44±0.35), group A (10.06±0.53) and group C (9.89±0.53). A statistically significant difference was noted between all the groups (p<0.05) except between group A and C (p=0.269). Salivary CRP levels were increased in group A and B than group C and D. A significant negative association was observed between MPV and salivary CRP (r=0.762, p=0.001) in smokers with periodontitis (p<0.05). Conclusion: MPV was decreased and negatively correlated to salivary CRP among smokers with chronic periodontitis and further studies must be done to confirm this finding.

Comparative Evaluation of Flexural and Impact Strength of Different Commercially Available High Impact Denture Base Materials: An In Vitro Study

Introduction: Acrylic resin is the most common material used for the prosthodontic and orthodontic removable appliances. Many brands have come up with High impact resins to overcome its inherent drawbacks of relatively poor resistance to impact and flexural forces, which might affect lifespan of the denture. Now-a-days, use of the high impact denture base materials is very common and hence, clinicians should be aware of the properties of high impact denture base materials available in market. Aim: To evaluate and compare the impact strength and flexural strength of different brands of high impact denture base materials. Materials and Methods: The present study was a comparative in-vitro study carried out in Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India from January 2017 to August 2017. Three high impact denture base materials used in the study were TRIPLEX (Ivoclar, Vivadent, Liechtenstin), LUCITONE 199 (Dentsply International Inc. Degu Dent GmbH Hanau, Germany) and DENTEK (SP Dental, India). Flexural and impact strengths of these three brands of high impact denture base materials were evaluated and analysed statistically using One-way analysis of variance (ANOVA) test with the help of SPSS version 21.0© software (IBM Corporation, Armonk, NY, USA). Results: The mean impact strength values of three groups showed that Group III (DENTEK) (8.45 KJ/mm²) had the highest mean impact strength value followed by Group I (TRIPLEX), (8.19 KJ/mm²) and Group II (LUCITONE 199) (5.43 KJ/mm²). The difference between Groups III and I was insignificant but the difference was significant between Group III and Group II as well as between Group I and Group II. Group II showed highest mean flexural strength (103.45 Mpa) followed by Group I (95.95 Mpa) and Group III (86.22 Mpa). But difference was statistically insignificant among the three groups for flexural strength. Conclusion: The study concluded that highest impact strength recorded was with DENTEK followed by TRIPLEX and LUCITONE. The highest flexural strength recorded was with LUCITONE followed by TRIPLEX and DENTEK.

Pattern of Physiologic Root Resorption in Deciduous Teeth at Different Stages

Prashanth Murthy, Nandlal Bhojraj, Usha Hegde

Introduction: Pattern of physiologic resorption represents the path of eruption of permanent teeth. It is essential to have thorough knowledge of normal pattern of resorption, so as to identify the deviation from normal which would help in early diagnosis and treatment planning. Aim: To assess the pattern, surfaces and extent of physiologic root resorption in deciduous incisors, canines and molars at different stages of root resorption. Materials and Methods: An observational study was conducted to understand the pattern of physiologic root resorption in the extracted deciduous teeth from June 2015 to December 2017. A total of 138 extracted deciduous incisors, canines and molars were included in the study. Remaining Root Length (RRL) was determined for all the teeth based on the standardised photographs. The teeth were divided into 4 groups with 3 subgroups each, based on the percentage of RRL. The measurements made on the photographs from buccal/ labial, mesial, distal and lingual/palatal aspects of each group were used for assessing the pattern of resorption. Descriptive statistics, Frequency distribution and ANOVA were applied to identify the pattern of resorption and to compare the changes occurring within groups. Results: ANOVA indicated that incisors began with resorption on the lingual aspects having least mean length of 10.43 mm in stage 1 which further progressed to involve all the surfaces. The mean length of remaining root for stage 3 was significantly different across different surfaces with a p-value 0.0015 while it was insignificant in stages 1 and 2. The mean length of resorption for canines in stage 2 was significantly different across different surface with a p-value 0.0453 using repeated measures of ANOVA. The mean length was least for lingual surface of the root. Maxillary molars showed that distobuccal pattern and palatal of resorption more evident. The mean length of resorption for maxillary molar in stage 1 was significantly different across different surfaces with a p-value 0.0232. Similarly, mandibular molars indicated that distal root resorbed much earlier than the mesial root with all the 10 samples showing this pattern in stage 1 and 2. The mean length of resorption for mandibular molar in stage 1 and stage 2 was significantly different between two surfaces with a p-value 0.0005 and <0.0001, respectively. Conclusion: All the deciduous teeth do not follow a similar pattern of resorption. This study describes a definite pattern of resorption of deciduous teeth in different stages of resorption which could be identified as most common pattern of resorption and any deviation thus can be observed and used for early diagnosis of abnormal pattern of resorption.

Assessment of Age-related Cataract using Scheimpflug Imaging System and its Correlation with Phacoemulsification Parameters

Introduction:Phacoemulsification has become the preferred treatment for cataract removal throughout the world. Therefore, it is important to assess cataract preoperatively which could lead to a better organised and customised operative plan. Aim: To evaluate correlation of age-related cataract using Scheimpflug imaging system (Pentacam) with parameters employed during phacoemulsification. Materials and Methods:This was a prospective study conducted between February 2016 and July 2017 in the Department of Ophthalmology, Government Medical College, Amritsar, India. Hundred patients (100 eyes) with age-related cataract were enrolled in the study to assess cataract using Scheimpflug imaging (Pentacam) before surgery. Intraoperative parameters during phacoemulsification (ultrasonic power employed and time for which power was employed within the eye) were noted. Correlation of parameters of Scheimpflug imaging system i.e., Nuclear Lens Density (NLD), Average Lens Density (ALD) and Pentacam Nuclear Staging (PNS) score with phaco power and time used during surgery, were analysed using Pearson correlation analysis (r) and regression analysis. Statistical analysis of postoperative complications was done using student t-test. SPSS Version 17 software was used and p-value of <0.05 was considered statistically significant. Results: There were 55 males and 45 females. Parameters of Scheimpflug imaging system i.e., NLD, ALD and PNS score showed a positive correlation with phaco power (r=0.712; p<0.001, r=0.530; p<0.001, r=0.624; p<0.001 respectively, overall r=0.733) and time (r=0.842; p<0.00, r=0.653; p<0.001, r=0.679; p<0.001 respectively, overall r=0.852). Conclusion: Preoperative evaluation of age-related cataract using Scheimpflug imaging system aptly predicted the parameters employed during phacoemulsification.

Intrathecal Administration of Fentanyl with Hyperbaric Bupivacaine either a Mixture or Sequentially in Elective Caesarean Section: A Randomised Single Blind Study

Anita Kanwariya, Chanda Khatri, Sarita Janweja

Introduction: Effect of adjuvant drug’s density on local anaesthetic agent’s movement in CSF has not been studied extensively which may affect the onset, level and quality of spinal anaesthesia. Aim: To compare intrathecal fentanyl with hyperbaric bupivacaine as either a mixture or sequentially in elective caesarean section under spinal anaesthesia. Materials and Methods: A randomised, controlled, comparative study was done on 160 parturients scheduled for elective caesarean section from December 2018 to March 2019. Parturients were randomly allocated into two groups M and S, each having 80 parturients. Group M parturients received 7.5 mg bupivacaine heavy (0.5%) premixed with 25 µg fentanyl in the same syringe as spinal anaesthetic agents. Group S parturient received 25 µg fentanyl in the first syringe and 7.5 mg bupivacaine 0.5% in the second syringe without barbotage. Both groups were compared for block characteristics, haemodynamic changes, duration of analgesia (primary outcome) and fetal outcome, side effects (secondary outcome). Statistical analysis was done using unpaired t-test, chi square test, Fisher-exact test. The level of significance was taken as p-value <0.05. Results: Hypotension was recorded in 30 patients (37.50%) in group M and 18 patients (22.5%) in group S without significant difference. However, early hypotension at 3 minutes and 6 minutes was significantly higher in group M than group S. No significant difference of onset time of sensory, motor block was found between the groups. Time to reach the highest level of sensory and motor block was higher in group M (p<0.05). Duration of motor block and time of 1st dose of analgesic required (p<0.0001) were significantly higher in group S. Conclusion: Two syringe techniques of fentanyl and hyperbaric bupivacaine provide better quality of sensory block without incidence of hypotension and provide prolonged post-operative analgesia as compared to one syringe technique.

Role of Dual Energy CT Scan in Evaluation of the Chemical Composition of Renal Stones

Introduction: For appropriate management of renal stone knowing its composition is important. Laboratory chemical analysis of the stones involves sophisticated techniques. Dual Energy Computed Tomography (DECT) has emerged as a viable option that can be helpful in determining the composition of urinary stones with precision. Aim: To determine the composition of renal stones with DECT. Materials and Methods: Patient aged 20-70 years, diagnosed for renal calculi and scheduled to undergo surgical extraction of stones were included in the study from November 2016 to May 2018. After the characterisation of the calculus via DECT, surgical extraction was done. The chemical composition of the stones was determined by laboratory analysis and was compared with the findings of DECT. The statistical analysis was done using Statistical Package for Social Sciences (SPSS) Version 21.0. P<0.05 was taken as significant. Results: A total of 100 patients with mean age of 41.15±10.08 years were analysed in the study. Majority of cases (55%) had stone size in 6-10 mm range and the mean stone size was 10.15±6.36 mm. Mean number of stones was 4.17±1.55 with maximum subjects having multiple stones (96%). According to chemical analysis, most common renal stone was hydroxyapatite (32%) followed by cystine (30%), uric acid (28%), mixed stones (7%) and oxalic acid (3%), respectively. DECT showed that maximum number of stones were hydroxyapatite (36%) followed by cystine (34%) and uric acid (30%), respectively. DECT did not identify any stone as oxalic acid or mixed type. The level of agreement between DECT and chemical analysis was excellent for uric acid (K=0.951); cystine (K=0.908) and hydroxyapatite stones (K=0.889). Conclusion: Barring the mixed stones and oxalic acid stones, DECT characterisation of the chemical composition of the renal stones (uric acid, cystine and hydroxyapatite) was excellent. The high precision of DECT can better help in determining the management plan for renal stones and reduce the unnecessary burden of surgical intervention.

Percutaneous Tracheostomy using Combined Griggs and Ciaglia Technique with Fibreoptic Guidance- A Prospective Observational Study

Introduction: Percutaneous Tracheostomy (PCT) is a bed side procedure, done by the anesthesiologists in critically ill, patients. In the study centre, Fibre Optic Bronchoscopy (FOB) guided combined Griggs {Guidewire Forceps Dilatation (GWFD)} technique and Ciaglia’s single dilatation technique had been adopted, to make the procedure shorter and safer. Aim: To evaluate the ease of insertion, timing of the procedure and complications when combining Griggs and Ciaglia technique for performing PCT under fiberoptic guidance. Materials and Methods: This was a prospective observational study, done in 250 patients in whom the combined Griggs and Ciaglia technique were used to perform PCT, under Fiberoptic Bronchoscopy guidance. Results: The mean duration of the procedure was 2.4±0.8 minutes. There was no complication due to the procedure per se. The mean bleeding volume was less than 10 mL. No voice changes or breathing difficulty present after 8 weeks of procedure. Conclusion: By combining Griggs and Ciaglia technique, the procedure could be done in less than 3 minutes, the tapered dilator and the tracheostomy tube could be inserted in the 1^st attempt, without any difficulty. The procedure-related complications occurred rarely. The complications were nil in the perioperative period.

Outpatient High-Dose Urokinase Lock: A Quick Answer to Blocked Tunneled Cuffed Catheters

Introduction: Tunneled Cuffed Catheters (TCC) in haemodialysis are often lost to thrombotic complications. Thrombolytic agents like urokinase are used for thrombolysis of blocked catheters. Inpatient administration of such thrombolytic agents is problematic and expensive for patients and increases burden on hospitals. Aim: To evaluate the efficay and safety of high-dose urokinase lock used for thrombolysis of TCCs on outpatient basis and whether thromolysed catheters achieve adequete survival. Materials and Methods: Catheters inserted over a 12-month period, starting September 2017 were followed prospectively (n=183 TCCs). Catheter dysfunction was defined as inability to aspirate blood from any one port or blood-flow of <250 mL/ min or high arterial/venous pressures. Non-mechanical or non-positional flow-dysfunction was treated with urokinase lock (50,000 units/port) with 5000 U/mL of heparin, total lock volume equal to the catheter dead volume. The solution was kept for 24 hours. Patency rates, need for repeat locks and overall survival was evaluated. Kaplan-meier survival analysis and binary logistic regression was done to evaluate survival and factors associated with need for urokinase rescue. Results: There were 57 episodes of flow-dysfunction during the 16-month follow-up period (n=159 TCCs, as rest were lost to follow-up). Flow improved in 48 (84.2%) and was completely restored in 41 (71.9%) cases. Seventeen (29.8%) cases needed repeat locks. Twenty-two catheters were lost to flow-related dysfunction. Overall survival of catheters needing urokinase rescue was non-inferior to catheters not needing such intervention (p=0.78). No prelock coagulopathy or postlock bleeding episodes were seen. Conclusion: Urokinase lock protocol has high efficacy and safety. It allows acceptable survival of TCCs developing thrombotic dysfunction.

Factors Leading to Early Preterm Premature Rupture of Membranes in a Tertiary Care Centre in Eastern India: A Prospective Study

Manisha Sahu, Ritimukta Panda, Sasmita Das

Introduction: Rupture of fetal membranes before completion of 37 weeks of gestation is called Preterm Premature Rupture of Membranes (PPROM), seen in 3% of all deliveries. PPROM occurring before 34 weeks are called early PPROM, and after 34 weeks are late PPROM. Risk of morbidity and mortality are more among the early preterm deliveries. It also increases the financial burden for the parents and society. A mother with premature rupture of membranes is at risk of developing chorioamnionitis, abruption, increased surgical intervention and postpartum endometritis. Neonates are at risk of respiratory distress syndrome, sepsis, intraventricular haemorrhage, necrotising enterocolitis and death. Aim: To evaluate the incidence, the clinical characteristics, factors leading to early PPROM (<34 weeks) in a tertiary care centre in Eastern India. Materials and Methods: It was a hospital based prospective cross-sectional study and was conducted over of period of 2 years. The patients presented with a history of PPROM at gestational age <34 weeks, admitted in the Department of Obstetrics and Gynaecology, Institute of Medical Sciences and Sum Hospital, Bhubaneswar, India. Factors leading to early PPROM, like association of anaemia, urogenital tract infection, threatened abortion in present pregnancy and history of PPROM, miscarriage in previous pregnancy were primary outcome and, admission to Neonatal Intensive Care Unit (NICU) and neonatal sepsis as secondary outcome were measured and analysed by SPSS v25 using proportion and chi-square test. Results: A total of 92 patients were analysed out of 108. Incidence of early PPROM was 3.08%. Maximum number of patients were in the age group 26-30 years, and primigravida accounted for 52.20%. Risk factors identified for early PPROM were history of PPROM in previous pregnancy, seen in 20 (21.7%) pregnancy, 28.30% patients had history of one or more previous abortions, 10.9% (n=10) had threatened miscarriage in index pregnancy, 26 (28.3%) had urinary complaints, 21 (22.8%) had leucorrhea. Positive urine cultures were seen in 19 (20.7%), with E. coli being the most common isolated organism. Anaemia was seen in 55 (60%), other associated conditions were hypothyroidism in 12 (13%), gestational diabetes mellitus 9 (9.7%), hypertensive disorders in 4 (4.3%), uterine myomas and polycystic ovarian syndrome in 3 (3.2%) patients in each category. High rate of neonatal sepsis was observed in patients with positive urine cultures, but no association with positive high vaginal swab cultures. About 77 (83.7%) babies were admitted to the NICU. Conclusion: History of PPROM in previous pregnancy and anaemia, urogenital tract infections in present pregnancy has association with premature rupture of membranes. The finding of the study suggests early identification and treatment of these factors can reduce the incidence of PPROM.

Effect of Three Different Polishing Systems on Surface Texture of Nanofilled Composite- A Profilometric Study

Introduction: Improper finishing and polishing of composite resins always present a problem to dental practitioner. Advances in composite resin materials and the instruments used for finishing and polishing has revolutionised the art of aesthetic dentistry. This study utilises surface texture of composite resin as a quality of finishing and polishing achieved by polishing systems. Aim: To evaluate the surface texture of nanofilled composite resin (Filtek Z350XT) polished by Sof-Lex XT, Enhance and PoGo, KerrHawe and OptiDisc polishing systems. Materials and Methods: In this invitro experimental study, three polishing systems were tested for surface texture of a nanofilled composite resin (Filtek Z350XT, USA). A total of 66 specimens (2 cm in diameter and 2 cm in height) were prepared from acrylic mold. Circular cavity measuring 8 mm in diameter and 3 mm in depth were prepared in each specimen. All the cavities were filled with nanofilled composite resin. The filled specimens were divided into 3 groups of 22 each and polished by Sof-Lex XT, Enhance and PoGo, KerrHawe and OptiDisc respectively. The surface roughness was measured by surface profilometer. Data was analysed by using ANOVA test between treatment groups. Results: The surface roughness (Ra) was less for the Sof-Lex XT group (0.35±0.09) as compared to Enhance and PoGo (0.56±0.14), KerrHawe and OptiDisc groups (0.59±0.15). One-way ANOVA test revealed p≤0.05 which was statistically significant. Conclusion: The Sof-Lex XT system was found to be more effective as compared to other two systems.

Prevalence of Musculoskeletal Pain and its Correlation with Ergonomics among Dental Students and Practitioners of Karad- A Questionnaire Based Study

Jai Abooj, Siddhartha Varma, Girish Suragimath, Sameer Zope, Apurva Kale

Introduction: Musculoskeletal Disorder (MSD) is an ordeal for dental professionals, as they work for long hours in astatic and discomfited posture. Aim: To assess the prevalence of musculoskeletal pain and its co-relation with ergonomics among dental students and private practitioners in Karad. Materials and Methods: The study population filled a questionnaire related to socio-demographic information, musculoskeletal pain arising from professional practice and ergonomics. Group 1 consisted of 53 private practitioners and group 2 consisted of 47 postgraduate students and interns. Results: A total of 79.25% and 59.57% of participants from group 1 and 2, respectively experienced musculoskeletal pain, with neck being commonly affected and lower extremities being least. Musculoskeletal pain was found to be significantly associated with working hours (p=0.001) and poor ergonomics. Conclusion: MSD is prevalent among dental students and practitioners of Karad. Awareness of proper ergonomics and preventive measures and its application is required for its management.

Comparison of Incidence of Postoperative Sore Throat after Nebulisation with Ketamine, Lignocaine and Magnesium Sulphate- A Randomised Controlled Trial

Ranjana, Anu Sharma, Manjit Singh, J Rajitha

Introduction: Recent advances in anaesthesia ensures better postoperative outcome. Postoperative Sore Throat (POST) is prevalent in patients after tracheal intubation, leading to significant discomfort thereby increasing the length of hospital stay. Aim: To compare the efficacy of preoperative nebulisation with ketamine, lignocaine and magnesium sulphate for attenuating risk of POST at different time intervals. Materials and Methods: Total of 120 patients were randomly divided into four groups of 30 each, and were preoperatively nebulised with 50 mg Ketamine (group A), 40 mg of 4% Lignocaine (group B), 225 mg of Magnesium Sulphate (group C) and distilled water (group D). POST score was recorded at 0, 2, 4, 6, 8, 12 and 24 hour postoperatively using four point scale. The analysis was done by student’s t-test and chi-square test. The p<0.05 was considered statistically significant. Results: The overall incidence of POST was 37.5% (45/120). In Group A, the incidence of POST was observed to be 13% (4/30). In Group B, the incidence was 43% (13/30), in Group C it was 36% (11/30), and in group D it was 56% (17/30). On intergroup comparison of incidence and severity, a statistically significant difference was observed at 4^th and 6^th hour (p<0.05). Conclusion: Preoperative nebulisation with all the three drugs ketamine, magnesium sulphate and lignocaine is a simple and effective way to reduce the incidence of Sore Throat (ST) in patients undergoing tracheal intubations under General Anaesthesia (GA). The maximum reduction in POST was seen with ketamine followed by magnesium sulphate and then lignocaine.

Comparison of Efficacy Between Conventional Excisional Technique and Ligasure® for Haemorrhoids- An Observational Study

Sanjog Sharma, Poorna Chandra Thejeswi, Shivananda Prabhu

Introduction: Ligasure® is a new modern device used in a variety of surgery, with demonstrable advantages over conventional hand-tying technique. Aim: To compare the use of the Ligasure® device and conventional excisional technique in the treatment of prolapsing haemorrhoids (grade III and IV) and compare the postoperative complications of each in a prospective randomised controlled study. Materials and Methods: A prospective study was conducted on 66 patients from November 2012 to September 2014, admitted to hospitals attached to Kasturba Medical College, Mangalore. The patients were divided using convenient sampling into two groups of 33 patients each having Grade III and IV haemorrhoids and were operated using conventional excisional technique and Ligasure®. Postoperative pain, bleeding, urinary retention, faecal incontinence, number of days to return to work and complications was assessed and analysed using SPSS v18 and independent sample t-test. Results: Ligasure® was statistically superior for postoperative pain 12 hours after surgery (6.34 vs 6.97), at 1st bowel movement (5.43 vs 6.03) and 1 week (3.57 vs 4.54). One patient had faecal incontinence which resolved within one day of surgery. One patient had anal stenosis 2 weeks postsurgery which resolved by conservative means. The number of days for the patient to be pain-free was better for Ligasure® (7.9 vs 11.1 days). Patient in Ligasure® group also had lower use of analgesic days (6.34 vs 10.51 days), had fewer patients postoperative bleeding (12 vs 23 patients) and the patient returned faster to work (9.97 vs 12.94). Conclusion: Ligasure® haemorrhoidectomy, demonstrated reduced postoperative pain, use of analgesic, postoperative bleed and the patient returned faster to work

Correlation of Admission Time Blood Glucose, Left Ventricular Function and Regional Wall Motion Index with Occurrence of In-hospital Major Adverse Cardiac Events in Acute Coronary Syndrome

Swathi Gurursamy, Arunprasath Palamalai, Lokesh Shanmugam, Kalaimani Sivamani

Introduction: Admission time hyperglycaemia is associated with larger infarct size and increased inflammatory process in patients with Acute Coronary Syndrome (ACS). Patients with severe and moderate Left Ventricular (LV) dysfunction are more likely to have triple vessel disease. Admission blood glucose along with conventional Echocardiography (Echo) is a cost-effective and easily feasible method compared to N-terminal proB-type natriuretic peptide (NT-proBNP) in predicting Major Adverse Cardiac Events (MACE) in ACS. Aim: To study the correlation of admission time blood glucose, LV systolic function and Regional Wall Motion Index (RWMI) with in-hospital MACE in patients with ACS. Materials and Methods: This was a cross-sectional study which included 100 patients with ACS. Blood samples were taken immediately after admission for plasma blood glucose levels and 2D echo was done within 24 hours to assess LV systolic function and RWMI. All the 100 patients were observed for in-hospital MACE events like cardiac arrhythmias, cardiogenic shock, Congestive Cardiac Failure (CCF), LV dysfunction, recurrent angina and death. Chi-square test was carried out to look for statistical significance between clinical and demographic parameters. Results: The mean age was 55.4±11.2 years. The incidence of admission time hyperglycaemia was significant in patients with history of Diabetes Mellitus (DM). A total of 55 patients (87.3%) with history of diabetes and 12 patients (32.4%) patients with no previous history of diabetes had admission time hyperglycaemia and five patients had stress hyperglycaemia. There was statistically significant correlation of admission time hyperglycaemia with LV systolic dysfunction (p-value=0.02) and CCF (p-value=0.02). RWMI had statistically significant correlation with LV systolic dysfunction (p-value <0.001), CCF (p-value=0.008) and recurrent angina (p-value=0.02). There was statistically significant correlation of LV systolic function with recurrent angina (p-value=0.04) and death (p-value=0.005). Conclusion: RWMI and poor LV systolic function can predict the occurrence of in-hospital MACE in patients with ACS. In addition to echocardiography, raised blood glucose levels at the time of admission have a positive predictive outcome with higher incidence of MACE.

Outcome of Intralesional Bleomycin on Cystic Lymphangioma of Major Salivary Glands

Ankur Bhatnagar, Eti Sthapak, Basant Kumar, Vijai Datta Upadhyaya

Introduction: Cystic Lymphangioma (CL) commonly involves head and neck region and axilla. Involvement of other sites like salivary glands is very rare. This study was done to assess the role of bleomycin sclerotherapy in salivary gland CL with relevant review of literature. Aim:To assess the outcome of intralesional bleomycin as sclerotherapy in CL of major salivary glands. Materials and Methods: This was an retrospective observational study, done in Department of Paediatric surgery and Plastic surgery from July 2013 to July 2017. All diagnosed cases of pure CL involving major salivary glands were included, where as those with venous or arterial component were excluded from the study. Patients having previous surgery or other treatment modalities were also excluded. Primary mode of treatment of CL at present center was sclerotherapy using aqueous bleomycin. As per our protocol sclerotheray was done under sedation for paediatric patients using dopler ultrasound. Relevant demographic and clinical data of all seven patients was collected in structured proforma and results were analysed. Results:Out of seven cases, four patient’s lesion responded well in a single session, two patients reported unfavourable response even after second session hence, were managed surgically and one patient responded partially after first session and managed surgically later on. Conclusion:Cystic lymphangioma should be included in the differential diagnosis of cystic lesion of parotid and submandibular gland though its involvement is rare. Bleomycin sclerotherapy can be used as a safe and low cost treatment modality for the management of this rare entity.

Study of Obstructive Sleep Apnea in Obese Patients with Type 2 Diabetes Mellitus

GN Srivastava, Mrityunjay Sharma, SK Singh

Introduction: Obstructive Sleep Apnea (OSA), characterised by repetitive episodes of breathing cessation due to upper airway collapse is associated with significant morbidity and mortality. Type 2 Diabetes Mellitus (T2DM) and OSA are two common, chronic conditions that are associated with each other, in a bidirectional relationship and both share common risk factor obesity. Aim: To study the prevalence of OSA in obese patients with T2DM. Materials and Methods: Unattended polysomnography was performed in 50 obese (BMI >30 Kg/m2 ) and T2DM patients (symptoms of diabetes plus random blood glucose concentration ≥200 mg/dL and/or fasting plasma glucose ≥126 mg/dL, and/ or Haemoglobin A1c (HbA1c) ≥6.5%, and/or 2-hour plasma glucose ≥200 mg/dL). Descriptive statistical methods were used such as computing percentage, mean, standard deviation and correlations. Results: Over 88% (N=44) of participants i.e., 64% male (N=32) and 24% female (N=12) with obesity and T2DM (Mean HbA1c 8.87±1.88) had OSA with an Apnea-Hypopnea Index (AHI) ≥5 events/h. The mean AHI was 33.57±24.88 events/h in males and 24.33±18.75 events/h in females. A total of 32% (N=16) of the participants had mild OSA (AHI 5-14), 26% (N=13) had moderate OSA (AHI 15-30), and 30% had severe OSA (AHI ≥30) (N=15). 28 out of 34 class I obese (BMI- 30-34.99 kg/m2 ) with T2DM, 12 out of 12 class II obese (BMI- 35-39.99 kg/m2 ) with T2DM and 4 out of 4 class III obese (BMI≥40 kg/m2 ) and T2DM patients had OSA (p-value=0.001). Conclusion: There was an exceedingly high prevalence of undiagnosed OSA in obese patients with T2DM.

Antibiotic Impregnated Nailing in Compound Fractures of Tibia- A Prospective Study

Kamal Kumar Arora, Priti Chaudhary, Rajesh Kapila

Introduction: Antibiotic nails are taking over the traditional method of fixation of open fractures of tibia now and are becoming a treatment of choice for Gustilo Type I, II and IIIA fractures. They not only hasten the bone union as a single step procedure, but also decrease the systemic side effects of parenteral antibiotics postoperatively. These nails elute the antibiotic exactly in right doses where it is needed to combat the infection and prevent a possible delayed union or hostile environment in Gustilo type I, II and IIIA compound tibial fractures. Aim: To study the clinical and radiological outcome of antibiotic impregnated Intramedullary (IM) nailing in compound tibial fractures. Materials and Methods: Twenty five adults having compound tibial shaft fractures of Gustilo Type I and Type II and IIIA were treated with antibiotic impregnated IM nails to evaluate the outcome. Data collection, compilation, and analysis performed using microsoft excel 2007. Results: Results were excellent to good in 92% (Lysholm’s scale). Partial weight bearing commenced at 5.44 weeks and full weight bearing after 10.48 weeks of operation on an average. Radiological union achieved in 12 to 18 weeks (average 15.55 weeks) in all AO (Arbeitsgemeinschaft für Osteosynthesefragen, German for “Association for the Study of Internal Fixation”) group A, group B fractures with Gustilo type I injury. Complex (AO group C), while Gustilo type II took 12 to 22 weeks (average 16.69 weeks). One Gustilo type IIIA fracture showed delayed union (beyond 22 weeks). There was minimal incidence of infection [overall 24% (20% in type II- superficial in 12% and deep in 8% cases; 4% in type IIIA-deep)]. One Gustilo type IIIA fracture showed infection along the deeper tissue planes. Conclusion: Antibiotic impregnated nails can be a trustworthy alternative single stage treatment modality, obviating the need of multiple procedures to achieve the bony union in open fractures of tibia.

An Analysis of Treatment and Prognosis of Spinal Tuberculosis: A Prospective Study done in Tertiary Care Centre

Shubhendu Gupta, Harsh Pratap Shishodia, Varun Singh

Introduction: In cases of skeletal Tuberculosis (TB), spinal TB is considered to be the most hazardous. Early treatment of spinal TB brings somewhat fine projections as well. Aim: To evaluate the treatment and prognosis of patients with spinal TB. Materials and Methods: The study involved patients with spinal TB from the period of 2017 to 2019. The total of 67 patients were included and follow-ups were made during the entire period of healing. Patients diagnosed with spinal TB and had not previously received anti-TB therapy and debridement or radical decompression surgery were included. A paired t-test was used to compare the pre-treatment and post-treatment clinical data. A p-value <0.05 was considered statistically significant. Results: The male patients comprised of the 62.7% of the total sample size. At the final follow-up, the Visual Analogue Scale (VAS) score significantly improved from 5.99±2.11 preoperatively to 1.90±4.81 postoperatively (0<0.05), the Cobb angle significantly decreased from 16.84±6.42 preoperatively to 3.86±2.26 postoperatively (0<0.05). The Erythrocyte Sedimentation Rate (ESR) significantly decreased from 45.26±12.26 preoperatively to 9.91±6.48 postoperatively (0<0.05), and C-Reactive Protein (CRP) also significantly decreased from 49.22±42.31 to 9.84±11.53. Conclusion: Quick treatment and diagnosis of spinal TB are essential to prevent permanent neurological disability and to minimise spinal deformity.

Evaluation of N-Terminal pro B-Type Natriuretic Peptide (NT-proBNP) Levels with Co-morbidity Factors as a Threshold Concept of Heart Dysfunction Progress

Rana Majeed Hameed, Rasha Alsafi, Haider H Sallum, Mohammed F Alqanbar

Introduction: Ischemic Heart Diseases (IHD) is one of the most common causes of death worldwide. Myocardial impairment is an imbalance between coronary blood flow and myocardial needs which result in circulatory changes. Cardiovascular Disease (CVDs) (including IHD and hypertensive heart disease) accounts for 31% of total world mortality; it has been estimated that 17.9 million people died from CVDs in 2016. IHD alone is the cause of 7.2 million deaths equalling to 12.6% of the total (World Health Organisation, 2017). Aim: To examine the N-Terminal proB-type Natriuretic Peptide (NT-proBNP) levels and their association with some co-morbidity factors in the IHD patients. Materials and Methods: The present case control study comprises a group of 90 subject with IHD which were selected from Cardiac Care Unit (CCU), Al Hussein Teaching Medical City, Kerbala, Iraq. Quantitative determination of the biochemical markers was performed; Chemiluminescence Immunoassay (CLIA) was used for serum NT-proBNP levels. Significant differences in continuous variables among the parameters were confirmed through analytical statistical tests (ANOVA). Results: Mean NT-proBNP levels in male patients with IHD (mean age 53.76 year) were 249.89 pg/mL as compared to 62.35 pg/mL in control subjects. Increased level of NT-proBNP was independently associated significantly with patients being hypertensive, having insulin resistance and smoking with p-values <0.01. Conclusion: Patients with elevated NT-proBNP levels may be a good indicator for the severity of heart diseases, but many offending agents might interfere with the progress of such cases. Offending factors should be kept under consideration while evaluating the correlation of NT-proBNP level and history of these patients.

Prevalence and Socio-demographic Determinants of Tobacco Use in Rohtak City, Haryana, India

Sneh Kumari, RB Jain, Bharti Chawla, Sumit Chawla, Seema Sharma

Introduction: Tobacco use is a modifiable risk factor of noncommunicable diseases. It is the leading cause of mortality and morbidity worldwide directly or indirectly. There is a need to study the various factors associated with tobacco use. Aim: Present study was carried out to determine the prevalence and socio-demographic determinants of tobacco use in urban area (Rohtak city) of Haryana, India. Materials and Methods: The present study was a community based observational study with cross-sectional design. It was conducted among 15-64 years aged individuals in Rohtak city of Haryana, India, from September 2013 to October 2014. For the purpose of Integrated Child Development Services (ICDS) scheme, Rohtak city was divided into eight different circles. Multistage random sampling was carried out including all the anganwadi centres located in these eight different circles. From each circle, two anganwadi centres were selected randomly. From each anganwadi, 90 individuals of 15-64 years age group (subdivided into five sub age groups) were selected by taking 18 individuals (9 males and 9 females) of each age bracket by systematic random sampling. Thus, a sample size of 1440 was included in the study. Results: The overall prevalence of current tobacco use was found to be 23.6% (tobacco-smoking: 22.8%; tobacco-smokeless: 3%) and it was found to be higher among males as 46.3% (tobacco-smoking: 44.6%; tobacco-smokeless: 6%) than 1% in females (tobacco-smoking: 1%; tobacco-smokeless: 0%). The overall prevalence of current smoking was highest among married (25.4%) followed by unmarried (15.5%) and widowed (9.5%). While observing the association with educational status, it was seen higher in graduates and above (13.7%) as compared to illiterates (8.3%). It was highest in those who had business as occupation (59.5%) and lowest in those who had no occupation (4.3%). The prevalence of current smoking was highest among lower socio-economic status (32.1%) followed by lower-middle (24.4%), upper-lower (23.6%), upper-middle (22.0%), and upper socio-economic status (0.0%). Conclusion: Present study highlighted that males are indulged in tobacco use at an early age and more frequent as compared to females. As tobacco use is an important risk factor for noncommunicable diseases, so more strict rules and regulations should be implemented for prevention of development of such unhealthy habits in the people of the country

Comparison of Mental Health and Foetal Attachment in Adolescent and Non-adolescent Pregnancies

Maryam Ghorbani, Afsaneh Keramat, Shahrbanoo Goli, Elieh Abasi, Narges Eskandari

Introduction: During adolescence, many physical and mental changes occur. According to evidence, adolescents begin their first sexual activity in younger age and do not use contraceptive methods. Therefore, unwanted pregnancies are more common in this group. The incidence of disorders such as depression, poverty, abuse, neglect and insecure mother to infant attachment are higher in such pregnancies. Aim: To compare the mental health state and maternal to foetal attachment of adolescent and non adolescent mothers. Materials and Methods: This was a descriptive-comparative study. Total 285 participants were considered and divided in two groups: adolescent (women aged 19 years or younger, n=145) and non-adolescent (women aged 20 years and older, n=140). General Health Questionnaire (GHQ-28) was used for assessing mental health; Cranleys Maternal-Foetal Attachment Scale (MFAS) was used to collect data about mother to infant attachment. Descriptive statistical methods, chi-square, t-test and Mann-Whitney U test were used for data analysis. Results: No significant difference was found between two groups in terms of mental health score (p=0.23), while results of this study indicated a significant difference in terms of foetal attachment between the two groups of participants (p=0.002). Conclusion: Mother-foetal attachment score was low among pregnant adolescent. More studies must be done about this global concern to find suitable intervention.

Spirituality and Abstinence Self-efficacy in Patients with Alcohol Dependence Syndrome

Dinesh Panati, Ramya Keerthi Paradesi, Vinay Kumar Sayeli, Swetha Panati

Introduction: Spirituality and self-efficacy are the concepts related to health, which plays a protective role in maintaining abstinence as well as predicts response to treatment in alcohol dependence patients. Aim: To determine the correlation between Spirituality and Abstinence self-efficacy among patients with alcohol dependence syndrome. Materials and Methods: An observational study was conducted on 50 patients with DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-4^th edition) for diagnosis of alcohol dependence syndrome. They were recruited from the de-addiction unit of psychiatry ward at a tertiary care centre. Subjects were assessed for spirituality and abstinence self-efficacy using The Functional Assessment of Chronic Illness Therapy-Spiritual well-being scale (FACIT Sp-12) {12 indicates total number of items in FACIT Sp questionnaire, which consists of three subscales (Meaning, Peace and Faith subscales) of four questions each} and Alcohol Abstinence Self-Efficacy (AASE) scale. Mean and standard deviation for continuous variables and frequency counts for discrete variables were obtained. Pearson’s correlation coefficient (r) was used to determine the correlation. Results: The current study demonstrated that the subjects had more spiritual belief in meaning and faith components and less belief in peace component of the FACIT Sp-12. AASE scale showed high efficacy (Total score=78.2±17.2) to remain abstinent. There was a significant positive correlation among two spiritual variables meaning (r-value=0.799) and faith (r-value=0.825) with negative effect, social and positive behaviour, physical and other concerns, craving and urges. There was a negative correlation (r-value=-0.026) with peace component in spiritual well-being and AASE scale. Conclusion: Spiritual belief and AASE were found to be high in index study. Also, spiritual variables (meaning and faith) had a positive correlation with ASSE, which suggests that patients with high spiritual belief had a better capability to remain abstinent from alcohol and good long term recovery than others.

Validity and Reliability of Persian Version of the Patient-Doctor Relationship Questionnaire among Iranian Population in Primary Care

Mohammadreza Maleki, Mehran Alijanzadeh, Hamid Porasghari

Introduction: Patient-Doctor Relationship (PDR) as recognised by the patients is one of the significant concepts in primary care. In this regard, PDR Questionnaire (PDRQ-9) shows a brief measure of the treatment dimension in primary care. Aim: The present research aimed at the evaluation of the reliability and validity of the Persian version of the PDRQ-9 among Iranian population. Materials and Methods: The research included 208 patients referred to the primary health centers. The study was conducted in Tehran between March and May 2019. The participants completed a 9-item questionnaire. Principal Components Analysis (PCA) and then a varimax rotation were utilised for assessing the PDRQ-9 factor structure. Then exploratory and confirmatory factor analyses were used to assess the scale construct validity. In addition, Cronbach’s alpha coefficient and construction reliability were employed to evaluate reliability of the questionnaire. Results: Outputs obtained from PCA and considering the meaning of the research items, we could identify a one-factor solution that explained 68.01% of the variance. Moreover, a Confirmatory Factor Analysis (CFA) approved the acceptability of one domain structure of PDRQ-9. In addition, goodness of fit indicators demonstrated reasonable fitness with the full model. Furthermore, Cronbach’s alpha and construct reliability were found to be higher than 0.70. Conclusion: It has been found that the Persian version of PDRQ-9 possesses a one-factor structure and reasonable reliability and validity in primary care.

Depression and Anxiety among Adult Patients with Type II Diabetes Mellitus- A Descriptive Study in Urban North Karnataka

Priyanshu Jain, Deepti M Kadeangadi

Introduction: Diabetes Mellitus (DM) and its complications are the leading cardinal threats to public health. They are leading to a potential epidemic in India with more than 69 million diabetic individuals currently diagnosed with the disease. Depression is a common psychiatric syndrome leading to an increase in co-morbidities affecting over 300 million people worldwide. Anxiety is another form of psychiatric disorder chronically affecting the day-to-day life of over 264 million people worldwide. Very few studies have been conducted that report the prevalence of anxiety and depression among diabetic individuals in India. Aim: To assess Type II DM patients for psychological problems like depression and anxiety. Materials and Methods: This was a cross-sectional study which was conducted at Urban Health Centre (UHC) for a period of two months. One hundred and twenty six individual diagnosed with Type II DM for a year were recruited as study participants (18-60 years of age). All the study participants were interviewed personally by the investigator at the UHC or their residence and the purpose of the study was explained to the participants in detail before asking them to participate. The ‘Hospital Anxiety Depression Scale’ (HADS) was used to assess the levels of anxiety, depression and the factors associated with it by standard scoring system. Results: Type II DM patients had 30.2% of depression and 31.8% had anxiety; depression was prevalent in illiterate (p=0.006), lower socio-economic class (p=0.034), sleep-deprived (p<0.001) and in those complaining of reduced appetite (p=0.001). Conclusion: Among the sleep deprived and reduced appetite cases, anxiety levels were significantly high indicating several factors playing a role in development of psychological problems.

Comparative Evaluation of Microleakage of Three Different Generation Dentin Bonding Agents and Resin Modified Glass Ionomer Cement: An In Vitro Study

Introduction: In order to ensure that there is no occurrence of recurrent caries, post-operative sensitivity and marginal staining, it is important that the material used for restorative purposes achieves good seal with the adjacent tooth structure and causes minimal microleakage. Numerous studies have been conducted to evaluate microleakage of different adhesive systems but none of the materials used, showed complete reduction in microleakage. As no adhesive systems were found to eliminate microleakage at dentin margins, use of a resinmodified glass ionomer as a base can be recommended. Aim: To evaluate microleakage of three different bonding agents and compared with resin modified glass ionomer at coronal and apical margins of class V restorations. Materials and Methods: For this in-vitro study done in February 2019, total sixty extracted human upper premolars were selected and randomly divided into four groups of 15 teeth each (30 cavity preparations). Class V cavity preparations were done on buccal and lingual surfaces with occlusal margins in enamel and gingival margins in cementum. In 3 experimental groups, cavities were treated with Adper Single-Bond 2, Adper SE Plus and Adper Easy One as dentin bonding agents. Cavities were restored with composite. Fourth experimental group was restored with resin modified glass ionomer cement (Vitremer). All specimens were thermocycled, stained with methylene blue dye and sectioned to evaluate dye penetration. Statistical analysis was done using Kruskall Wallis test and Mann-Whitney test with significant p-value <0.05 and result was expressed through sum of ranks. Results: At enamel margins, Adper Single Bond (mean±SD 0.57±0.73) 2 and Vitremer (0.43±0.63) showed the lowest mean leakage. Adper Easy One (1.83±1.15) showed highest mean leakage. At cementum margins, Vitremer showed lowest mean leakage (mean±SD 0.47±0.63) and Adper Single Bond (2.97±1.22) 2 showed highest mean leakage. Conclusion: It can be concluded that in comparison with the dentin bonding agents used in this study Vitremer has a better sealing ability at both coronal (enamel) and apical (dentin/ cementum) margins

Retracted: 2016 Dec:10(12): RC14-RC17

Mohit J Jain, Kinjal J Mavani, A Comprehensive Study of Internal Distraction Plating, an Alternative Method for Distal Radius Fractures (Published in Journal of Clinical and Diagnostic Research. 2016 Dec, 10(12): RC14-RC17 ) The article had to be retracted to avoid any future misinterpretation of clinical knowledge because of the fallacies in the data. This unintentional error was brought to the editorial notice, post-publication by the authors.

Effect of Neural Mobilisation Versus Nerve and Tendon Gliding Exercises in Carpal Tunnel Syndrome: A Randomised Clinical Trial

Shlesha Maulik Vaidya, Darshana Nariya

Introduction: Neural mobilisation versus nerve and tendon gliding exercises are a treatment technique that may improve symptoms related to Carpal Tunnel Syndrome (CTS). Aim: To find whether the neural mobilisation and nerve and tendon gliding exercises are effective or not on pain and functional status in individuals diagnosed with CTS and to find which treatment technique is more effective. Materials and Methods: In this randomised clinical trial, Sixty hands diagnosed with mild to moderate CTS clinically as well as electrophysiologically were selected from Physiotherapy OutPatient Department of the Shree Krishna Hospital, Karamsad from October 2014 to April 2015 and randomly assigned into 2 groups. Group A was given Ultrasound, Neural mobilisation and night splinting. Group B was given Ultrasound, nerve and tendon gliding exercises and night splinting. Assessments were done prior and at the end of twelve sessions for all treatment of both the groups. The subjects were assessed in terms of Symptom Severity Scale and Functional Severity Scale as subjective outcome measures. Objective outcome measures comprised of Grip strength, Pinch strength and two point discrimination. Normalcy of data was checked through Kolmogorov-Smirnov test. Baseline homogeneity for outcome measures was established by unpaired t-test. Paired t-test was used for intra-group analysis and unpaired t-test was used for inter-group analysis and p-value was set at less than 0.05. Statistical power was set at 0.80. Results: All the outcome measures in intra-group analysis for both the groups showed significant improvements. Intergroup analysis proved that neural mobilisation is more effective in terms of reduction of symptom severity, improvement in functional status, grip strength and pinch strength than nerve and tendon gliding exercises except two point discrimination (p<0.05). Conclusion: Neural mobilisation and nerve and tendon gliding exercises are effective in treating CTS and reducing associated disability. Neural mobilisation is more effective than nerve and tendon gliding exercises in terms of improvement.

Comparative Evaluation of the Efficacy of Arthroscopic Bankart Repair and Modified Boytchev Technique for Surgical Correction of Recurrent Dislocations of Shoulder

Pratik Mundhara, Arnab Karmakar, Dibyendu Biswas

Introduction: Recurrent shoulder dislocation can be tackled by many ways. In Modified Boytchev procedure rerouting the tip of coracoid process with conjoint tendon is done under subscapularis. Arthroscopic Bankart repair involves reattaching the over stretched or torn labrum and capsule with suture anchors. The evidence regarding the relative effectiveness of modified boytchev vs arthroscopic bankart repair remains unclear. Aim: To study the efficacy and functional outcomes of modified Boytchev vs arthroscopic Bankart repair in recurrent shoulder dislocation. Materials and Methods: This Hospital based prospective observational study was carried out in the Department of Orthopaedic Surgery, SSKM Hospital and IPGME&R, Kolkata, West Bengal, India during the period of 20 months between January 2015 and August 2016. Total 30 cases were included of which 15 cases were treated by modified boytchev technique and 15 cases were treated by arthroscopic repair of bankart lesion. Results: Out of 15 patients in arthroscopic group, 2 (13.4%) had recurrence, one had apprehension and one had mild subluxation. Out of 15 patients in modified boytchev group only 1 (6.7%) had recurrence with positive apprehension. The comparison of the final external rotation showed a significant difference between the two groups (p-value-0.006). The mean final external rotation was higher in the arthroscopic bankart group with 71.6 degrees as compared to 63.733 degrees in the modified boytchev group. The comparison of the final Constant Murley Scores (CMS) between the two groups also came out to be very significant (p-value 0.036) with the arthroscopic bankart group having a mean of 90.2667 as compared to modified boytchev group having a mean of 83.6667. There were 9 excellent (60%), 4 good (26.7%), 1 fair (6.7%) and 1 poor (6.7%) CMS grading in arthroscopic bankart group. In modified boytchev group there were 6 excellent (40%), 6 good (40%), 3 fair (20%) and 0 poor CMS grading. Conclusion: In the present study, the rate of infection was more in modified boytchev technique due to it being an open procedure, the postoperative external rotation was less and CMS were lower when compared to arthroscopic bankart repair; but it had a lower rate of recurrence when compared to arthroscopic group. Modified boytchev technique still provided the patients a reasonable function and stable shoulder at low cost when compared to the costly and technically demanding arthroscopic surgery.

A Retrospective Analysis of Plasma Viral Load in Cases of Immunological Failure in HIV Patients on HAART from Central India: How Close are We to the 90-90-90 Target?

Introduction: Anti-Retroviral Therapy (ART) initiation in patients leads to increase in CD4 counts and decrease in the Plasma Viral Load (PVL). However, some patients fail to achieve a significant increase in CD4 count despite undetectable PVL. In spite of complete viral suppression, patients have immunological failure; this is referred as “immunological discordance”. This study is a retrospective analysis of PVL in cases of immunological failure in Human Immunodeficiency Virus (HIV) patients and aims to find out the rate of discordance and associated co-morbid conditions. Aim: To carry out a retrospective analysis of PVL in HIV patients with immunological failure on ART in a tertiary health care centre in Nagpur, Maharashtra, India. Materials and Methods: This study was carried out at the ART centre in Government Medical College and Hospital, Nagpur, Maharashtra, India. Patients (>16 years of age) of immunological failure (458) who started second-line ART during the period 2012-2017 were included in the study. The data was coded using MS-Excel 2013 and statistical softwares OpenEpi (Version 3.01) and STATA (Version 10.1-2011, Texas, USA) were used for analysis. Results: The most common co-existing condition seen was tuberculosis. Risk of low (<100) baseline CD4 count was almost three times higher in males. Risk of immunological failure {in those with greater than 100 cell decrease after six months of Highly Active Antiretroviral Therapy (HAART)} was higher in those with low baseline CD4 counts (0-200 cells/mm³) (OR-1.39). The rate of discordance was 17.82%. The number of patients of immunological failure decreased when ART was initiated at higher CD4 counts. Conclusion: Discordance was seen in patients of immunological failure, thus, PVL assay must be done before second line ART initiation to avoid unnecessary switching of regimen. Early initiation of ART can lead to a better prognosis, thus helping us reach closer to the 90-90-90 target.

Comparative Evaluation of Rapid Polymyxin Nordmann-Poirel Test and VITEK-2 for Colistin Resistance in Escherichia coli and Klebsiella pneumoniae

Introduction: Escherichia coli (E.coli) and Klebsiella pneumoniae (K.pneumoniae) are the most common organisms isolated from clinical specimens. Increasing Multi-Drug Resistance (MDR) in these Gram-negative organisms has caused considerable therapeutic challenges in clinical practice. This has recently revived interest in Colistin as a remedial option. The increasing use of colistin entails the provision of rapid and reliable methods for colistin susceptibility testing. Aim: To evaluate the performance of rapid polymyxin Nordmann-Poirel (NP) test and VITEK-2 for detection of colistin resistance. Materials and Methods: Two methods of colistin susceptibility testing, VITEK-2 and Rapid polymyxin NP test were compared on 310 isolates of E.coli and K.pneumoniae obtained from various clinical samples such as blood, urine, sputum, pus and endotracheal aspirates. Kappa analysis was done to evaluate the percentage agreement between Vitek-2 and Rapid Polymyxin NP tests. Results: Out of 310 isolates, 232 were E.coli and 78 were K.pneumoniae. The results of both the methods were consistent in (237/310) 76.45% cases and non-consistent in (73/310) 23.55% cases. Kappa analysis revealed that the strength of agreement between the two test was considered moderate (kappa=0.412, confidence interval: from 0.312 to 0.513). Conclusion: Rapid polymyxin NP test when compared to VITEK-2 was simple, rapid and cost-effective. Thus, it can be used in laboratories for screening of polymyxin resistance in carbapenemase-producing Gram-negative bacteria as recommended by CLSI (Clinical Laboratory Standard Institute).

Effect of Olanzapine on Metabolic Syndrome- A One Year Follow-up Study

KJ Samyukta, D Shivson, Suvarna Jyothi Kantipudi

Introduction: Patients with schizophrenia have increased risk of cardiovascular mortality and this is partly attributed to antipsychotics. Olanzapine, one of first line antipsychotic for the management of schizophrenia is associated with Metabolic syndrome (MetS). There is paucity of follow-up studies on course of metabolic parameters with Olanzapine. Aim: To understand the effect of Olanzapine on weight, Fasting blood glucose, Triglycerides (TG), High Density Lipoprotein (HDL), and Waist Circumference (WC) in patients with schizophrenia. Materials and Methods: This was a prospective observational study where metabolic parameters of patients with schizophrenia were assessed prior to initiation of olanzapine and after one year. Physical health [Blood Pressure (BP), WC, Weight] and laboratory indices (fasting blood sugar, HDL and TG) were evaluated and compared. The association between qualitative variables were assessed using chi-square test and differences in metabolic parameters before and after olanzapine was assessed using paired t-test. Results: The prevalence of MetS before initiation of olanzapine was 15.4% which increased to 56.9% in one year as per Adult Treatment Protocol of the National Cholesterol Education Program (NCEP ATP III) criteria. There was statistically significant difference in weight, fasting blood glucose, TG, HDL and WC at the end of one year when compared to baseline (p-value <0.05). Conclusion: Olanzapine has high propensity to derange metabolic parameters in patients with schizophrenia. Close monitoring and lifestyle modification is advised to prevent adverse metabolic effects of olanzapine.

Early Detection of Multi-drug Resistant Tuberculosis and Mutations in Mycobacterium tuberculosis isolates using Line Probe Assay from a Tertiary Care Centre in Northern India

Introduction: Early detection and drug susceptibility analysis of Mycobacterium tuberculosis (MTB) in the shortest possible time has been the driving force for research that aims to bridge the gap between detection and treatment. In this regard Line Probe Assays (LPA) were commissioned in 2008 by World Health Organisation (WHO) as an addition in the long list of diagnostic tools for MTB. Aim: To assess the utility of LPA for the detection of Multi Drug Resistant Tuberculosis (MDR-TB) and to find out the most common mutations associated with it. Materials and Methods: This cross-sectional prospective study was carried out in the Department of Microbiology, Government Medical College, Srinagar, Jammu and Kashmir, India; for a period of 18 months from November 2016 till May 2018. Two hundred and fifty two smear positive sputum samples and 100 randomly selected smear negative samples were subjected to LPA and cultured on Loweinstein Jensen (LJ) medium. MTB was confirmed taking into account colony morphology on LJ medium, Ziehl-Neelson (ZN) staining and Nitrate reductase assay. LPA was performed as per the directions of the manufacturer. McNemar χ² test was used for statistical hypothesis testing and data was analysed using OpenEpi version 3. Results: Of the 252 smear positive sputum samples, growth on LJ was seen in 238 (94.4%) samples whereas LPA was positive for 241 (95.6%) samples. Of the 100 smear negative samples growth of MTB was seen in seven samples whereas five were positive by LPA. Sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) for smear positive and negative samples was 100%, 78.6%, 98.9%, 100% and 71.4%, 100%, 100%, 97.9%, respectively. Diagnostic accuracy of the test was 98.6%. One sample showed low level Isoniazid (INH) mono-resistance whereas two samples were hetero-resistant to INH that corresponded to C15T mutation. One sample was resistant to Rifampicin (RIF) that represents a mutation in 531 codon of rpoB gene. Average detection time of MTB on LJ medium was 31.5 days whereas for LPA it was 3.8 days. Conclusion: LPA due to its rapid turnaround time and high sensitivity and specificity for the detection and susceptibility testing of MTB directly from smear-positive sputum samples can significantly aid in the diagnosis, treatment, and management of MDR-TB. However, LPA cannot completely replace phenotypic culture methods, as the performance of this test is still low for sputum smear negative cases.

Role of Staphylococcus epidermidis Virulence Factors in Adhesion to Intravascular Cannulae

Introduction: The adhesion of bacteria to implanted devices in the human body is a major risk factor that can affect the long-term success of these devices. Staphylococcus epidermidis (S. epidermidis) have few virulence factors which have been identified and reported including autolysin (AtlE), Polysaccharide Intercellular Adhesin (PIA), Fibrinogen Binding Protein (SdrG) and Lipase enzymes (GehC and GehD). These virulence factors play an important role in the pathogenesis of S. epidermidis. Aim: To investigate the role of some of the virulence factors of S. epidermidis in the adhesion to three different types of intravascular cannulae used in hospitals. Materials and Methods: Three different types of most commonly used intravascular cannulae in hospitals were tested in this study. Polytetrafluoroethylene (PTFE), Siliconized Polytetrafluoroethylene (SPTFE) and Vialon cannulae were incubated with different S. epidermidis strains, including the mutant strains that were deficient in a specific virulence factor, each separately. The virulence factors tested with each strain were AltE, PIA, SdrG and Lipase enzymes (GehC and GehD). The number of detached bacteria were determined by plating serial dilutions on agar plates. Experiments were repeated and expressed as means and standard deviations with at least three experiments. Results were computed and analysed using Statistical Package for Social Sciences (SPSS) version-20 program. Tabulated values were compared with a student’s t-test. Statistical significance was defined as p<0.05. Results: All three types of intravascular cannulae showed significant reduction in adhesion by means of cfu/mL with the mutant strains deficient in adhesion factors when compared to the wild strains. The reduction in the percentages of adhesion of AtlE-strain when compared to wild type strain were 35% for PTFE, 38% for SPTFE and 48% for Vialon cannula. This was statistically significant. PTFE (p-value=0.005), SPTFE (p-value=0.02), and Vialon (p-value=0.001). Likewise, all three types of cannulae showed reduction that was statistically significant except for one mutant strain which was deficient in GehC lipase. However, GehD lipase showed statistically significant reduction in adhesion of bacterial colonies similar to mutant strains for PIA and SdrG indicating a role of these virulence factors in the process of adhesion to biomaterials. Conclusion: The virulence factors of S. epidermidis; AtlE, PIA, SdrG and Lipase GehD, play an important role in the adhesion to intravascular cannulae. Further researches are needed to investigate the involvement of other virulence factors in order to understand and prevent such mechanism.

Effect of Treadmill Test According to Bruce Protocol Stage 1 on Left Ventricular Diastolic Function in Patients with Exertional Dyspnea and Normal Left Ventricular Function

Jayanta Saha, Satyendra Nath Dutta, Kuntal Bhattacharyya

Introduction: Diastolic dysfunction, detected commonly by echocardiography is the fore-runner of Heart Failure (HF) with preserved Ejection Fraction (HFpEF) in future. Exercise stress by Treadmill Test (TMT) followed by echocardiography can unmask sub-clinical diastolic dysfunction. Aim: To estimate the proportion of patients with unexplained exertional dyspnea that had sub-clinical diastolic dysfunction and to find out the factors associated with it. Materials and Methods: This institution-based cross-sectional study, included participants with history of unexplained exertional dyspnea having normal baseline electrocardiogram and echocardiogram (N=106). Patients having serious co-morbidities like azotemia, decompensated liver disease, malignancy and also individuals who did not give consent were excluded. Included individuals were subjected to exercise stress by TMT Bruce protocol stage 1. Postexercise echocardiography was done to find out proportion of patients showing diastolic dysfunction in postexercise echocardiogram. Factors associated with unmasking of sub-clinical diastolic dysfunction were assessed by logistic regression analysis. Results: Postexercise echocardiography revealed diastolic dysfunction in 33 individuals (31.13%). On multivariate analysis, diabetes and hypothyroidism were significant predictors of exercise-induced diastolic dysfunction. The appearance of diastolic dysfunction was due to changes in mitral inflow E/A ratio and pulmonary vein systolic flow/diastolic flow (S/D) ratio in postexercise echocardiogram. Conclusion: Exercise stress can unmask sub-clinical diastolic dysfunction in significant number of patients.

Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Phenotypic Screening and Sensitivity of Microbiological Profile

Introduction: An upper respiratory tract infection which can be either due to increased airway bacterial load or emergence of new bacterial strain is the most common cause of Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD). Other factors responsible for exacerbation include viral infections, pollution and other unidentified pathogens. Aim: To evaluate the local pattern of bacterial and fungal isolates from patients diagnosed with AECOPD and forming an antibiogram of the hospital. Materials and Methods: A total of 200 clinically diagnosed cases of AECOPD of age =40 years were included in the study. Sputum sample was obtained from the patients and processed according to standard lab procedures. Statistical analysis was done by using Statistical Package for Social Sciences (SPSS) version-20. The test applied in the current study was modified chi-square used for comparison of proportion to analyse statistical significance for antibiotic sensitivity. The p-value <0.05 was considered statistically significant. Results: The prevalence of AECOPD was more common in the age group of 50-60 years (49.5%) with ratio between male and female of 2.8:1. Among gram negative isolates the most common was Klebsiella sp. (21.6%) followed by Pseudomonas aeruginosa (20.7%), Moraxella catarrhalis (16.5%), E.coli (7.6%), and Citrobacter sp. (7.0%). Among gram positive isolates the most common was Staphylococcus aureus (13.3%) followed by Streptococcus pneumoniae (9.5%), Enterococcus sp. (1.9%) and Coagulase negative Staphylococcus (1.9%). Gram negative and gram positive isolates were found sensitive to commonly used antimicrobials, fungal growth was seen in only 49 (24.5%) patients out of which 37 (75.5%) patients had Candida sp. and 12 (24.5%) patients had Aspergillus sp. and were sensitive to commonly used antifungals. Conclusion: Antibiogram helps in forming correct treatment protocol avoiding unnecessary use of antibiotics preventing drug resistance, decrease mortality and morbidity.

Diagnosis of Celiac Disease using Fuzzy Logic Probabilistic System in North-Indian Patients

Sunny Thukral, Jatinder Singh Bal

Introduction: Fuzzy logic is gaining popularity with predictive healthcare applications in the field of medicine. It is consistently being used in recognising various chronic diseases with optimum accuracy. Fuzzy logic is also supposed to be a beneficial tool to diagnose celiac disease with approximate reasoning. Aim: To design a fuzzy logic inference system to predict celiac disease based on individual symptoms in North-Indian patients. Materials and Methods: The study was conducted in Punjab, Northern India, on 700 individuals using a questionnaire stratagem. SPSS software was used for the analysis of celiac data. The fuzzy logic system was implemented in Python software with 6 inputs and 1 fuzzy output parameter to determine the probability level of celiac disease. Results: The fuzzy logic system produced 98.8% accuracy, 98.5% sensitivity and 98.39% specificity with minimal error rate. The prevalence of celiac disease obtained a 1:19 ratio from the survey in Punjab with 134 celiac patients. Conclusion: Fuzzy logic yields better results in terms of sensitivity and specificity in comparison with other existing disease probabilistic systems. Hence, the fuzzy system is a fruitful tool for celiac disease disclosure without any painful testing strategy.

Drug Utilisation Study in Paediatric Patients with Acute Exacerbation of Bronchial Asthma Hospitalised in a Tertiary Care Teaching Hospital

Sukhmeen Kaur, Bhagya M Sattigeri

Introduction: Bronchial asthma is a heterogenous disease in children. It often leads to acute exacerbations resulting in increased Emergency Department (ED) visits, hospital admissions and school absenteeism among them. Irrational prescribing practices are quite prevalent among children. This highlights the importance of Drug Utilisation Studies (DUS) that are essential to investigate the pattern of drug use, thereby ensuring cost-effective health care and rational use of drugs. Aim: To evaluate drug utilisation pattern for the treatment of acute asthma exacerbations in children hospitalised in a tertiary care teaching hospital. Materials and Methods: This cross-sectional, observational study was conducted in the in-patient, Department of Paediatrics for a period from December 2017 to March 2019. A total of 30 children aged 1-17 years of either sex hospitalised for acute asthma exacerbations were enrolled in the study. Parameters like demographic profile and pattern of drug use were assessed. The collected data was presented as percentages, SD and mean. Results: Results revealed that most commonly affected age group was 1-5 years (43.33% of total subjects) with female predominance. 13.33% children presented a positive family history of asthma. To manage acute exacerbations of asthma, all the patients received anti-asthmatic drug combinations and inhalational route was preferred. Corticosteroids and Short Acting ß2 Agonists (SABA) were the most commonly prescribed drug classes. SABA (Levosalbutamol) was prescribed mainly through inhaled route (66.66%). 90% children received inhaled budesonide while IV Hydrocortisone was used in 86.66% cases of exacerbation. Combination of inhaled SABA + Ipratropium bromide was given in 36.66% patients. Montelukast was prescribed in 33.33% children as an add-on therapy. Average duration of hospital stay for the present episode was 3.96±1.04 days. Average number of drugs per prescription was 10.13. None of the drug was prescribed by generic name and antibiotics were used in 96.66% patients. Conclusion: The observed drug utilisation pattern in the present study does not completely comply with the recommendations of standard treatment guidelines for asthma. High prescribing of antibiotics, polypharmacy and prescribing by brands are issues that need to addressed which will ensure rational use of drugs in future.

Evaluation of Salivary Gland Lesions by Real Time Sonoelastography: Diagnostic Efficacy and Comparative Analysis with Conventional Sonography

Introduction: Bronchial asthma is a heterogenous disease in children. It often leads to acute exacerbations resulting in increased Emergency Department (ED) visits, hospital admissions and school absenteeism among them. Irrational prescribing practices are quite prevalent among children. This highlights the importance of Drug Utilisation Studies (DUS) that are essential to investigate the pattern of drug use, thereby ensuring cost-effective health care and rational use of drugs. Aim: To evaluate drug utilisation pattern for the treatment of acute asthma exacerbations in children hospitalised in a tertiary care teaching hospital. Materials and Methods: This cross-sectional, observational study was conducted in the in-patient, Department of Paediatrics for a period from December 2017 to March 2019. A total of 30 children aged 1-17 years of either sex hospitalised for acute asthma exacerbations were enrolled in the study. Parameters like demographic profile and pattern of drug use were assessed. The collected data was presented as percentages, Standard Deviation (SD) and mean. Results: Results revealed that most commonly affected age group was 1-5 years (43.33% of total subjects) with female predominance. 13.33% children presented a positive family history of asthma. To manage acute exacerbations of asthma, all the patients received anti-asthmatic drug combinations and inhalational route was preferred. Corticosteroids and Short Acting ß2 Agonists (SABA) were the most commonly prescribed drug classes. SABA (Levosalbutamol) was prescribed mainly through inhaled route (66.66%). 90% children received inhaled budesonide while IV Hydrocortisone was used in 86.66% cases of exacerbation. Combination of inhaled SABA + Ipratropium bromide was given in 36.66% patients. Montelukast was prescribed in 33.33% children as an add-on therapy. Average duration of hospital stay for the present episode was 3.96±1.04 days. Average number of drugs per prescription was 10.13. None of the drug was prescribed by generic name and antibiotics were used in 96.66% patients. Conclusion: The observed drug utilisation pattern in the present study does not completely comply with the recommendations of standard treatment guidelines for asthma. High prescribing of antibiotics, polypharmacy and prescribing by brands are issues that need to addressed which will ensure rational use of drugs in future.

Study on Students' Perceptions for Online Zoom-app based Flipped Class Sessions on Anatomy Organised during the Lockdown Period of COVID-19 Epoch

Hironmoy Roy, Kuntala Ray, Satyajit Saha, Asis Kumar Ghosal

Introduction: In the present situation of containment for COVID19 epoch, the physical classroom sessions in medical colleges were suspended by different Government advisories. Faculties have been guided by the university as well as institution to carry on the online teaching to the medical students. As the students were not present physically, so flipped class model has been implemented using the Zoom cloud app for teaching Anatomy. Aim: To explore the perception of undergraduate students of Anatomy regarding online Zoom-app based flipped class sessions and to obtain the suggestions for improvement of such classes organised during the lockdown period of COVID-19. Materials and Methods: Ten gross Anatomy topics and 10 histology slides (total 15 sessions; one session for each gross anatomy topics and five sessions covering two slides for each day) were discussed in flipped class mode. For each session, the text materials were served to the students two days before. On the third day, face to face interactive classes were undertaken using the Zoom platform; for the entire 199 students of Anatomy. After completion of one month, students’ perceptions were obtained by semi-structured questionnaire made with Google form. Results: Although the department has organised almost daily Zoom sessions with pre-shared study material; in flipped classroom mode, but majority of the students opined for maximum three days per week Zoom sessions instead of every day’s classes. Total 92% preferred the current strategy of advanced sharing of study material instead of concurrent sharing of text. Almost 93.5% students felt the study material helpful to them, 79% students found the Zoom sessions helpful for their doubt clearance. Strikingly, 40% students confessed that they failed to keep up with the progress of the classes in daily mode. There was a mixed reaction for continuing such mode of teaching in the post-lockdown era. The network connectivity became a broad issue as constrain to almost all of them to participate in online discussion platform. Conclusion: As the students and teachers were new in the online mode of teaching; so students feedbacks were felt need for future planning. The students had an opinion to lessen the number of classes so that they can cope up with the study material. However, majority of them wanted to move back to their classrooms rather than remain in the online mode of learning

Comparison of MPI and APACHE II in the Prognosis of Perforating Peritonitis

Introduction: Peritonitis is an important surgical emergency that a surgeon has to face. Reproducible scoring systems that allow a surgeon to determine the severity of peritonitis are essential to prognosticate the patient. Aim: To evaluate effectiveness of Mannheim Peritonitis Index (MPI) in comparison to Acute Physiology and Chronic Health Evaluation (APACHE) II in assessing prognosis of patients with perforation Peritonitis. Materials and Methods: In this prospective observational study from November 2015 till March 2017, 63 patients above 18 years of age presenting with perforation peritonitis were included. APACHE II and MPI scoring systems were calculated in all the patients in order to assess their individual risk of morbidity and mortality. The outcome variables studied were: Postoperative wound infection, wound dehiscence, anastomotic leak, respiratory complications, duration of hospital stay, need of ventilator support and mortality. The inferences were drawn with the use of statistical software package SPSS v22.0. The tests used were ANOVA, Chi-square analysis and t-test. The p value <0.05 was taken as significant. Results: Out of total subjects of 63, Mean age of male subjects was 37.4 years and female subjects was 38.5 years. The mean APACHE II score of 63 patients was 11.2±8.1 with range of 0 to 35 and the mean MPI score was 26.9±7.2 with range of 6 to 39. APACHE II was able to predict postoperative respiratory complications (p<0.001), postoperative need for ventilatory support (p<0.001), hospital stay duration (p-value <0.05) level and mortality (p-value 0.003) while MPI was able to predict postoperative respiratory complications (p<0.001), postoperative need for ventilatory support (p<0.001) and mortality (p-value 0.025). Neither APACHE II nor MPI could predict postoperative anastomotic leak, postoperative wound infection, and postoperative wound dehiscence. Conclusion: MPI is a useful and simple method to determine outcome in patients with peritonitis and is comparable to APACHE II in assessing the prognosis in perforation peritonitis. It can be used in place of APACHE II score in prognosticating patients of perforation peritonitis.

A Literature Review to Analyse the Outcome of Myofascial Release for Myofascial Pain Syndrome

Anjali Suresh, SG Sudhan

Myofascial Pain Syndrome (MPS) is one of the most common causes of muscle pain. MPS is characterised by the presence of trigger points that form a taut band in the muscle. The aim of this review was to evaluate the literature related to MPS and to analyse the outcome of Myofascial Release (MFR) Techniques for various musculoskeletal conditions from published articles. Online search engines such as MEDLINE, PubMed, Google scholar and Physiotherapy Evidence Database (PEDro) were searched. There were no limitations for dates applied to the review article. Sixteen articles were selected with the terms MFR techniques used. The data were tabulated according to the type of study, number of participants in the study, the condition being treated, treatment given, outcome measures, and results. This literature review found mixed responses to the outcomes of MFR techniques. These contrasting results reveal the need for future research. This may help researchers to conduct Randomised Controlled Trials (RCT) using MFR and further develop protocols to enhance better interpretations and the need for evidence-based information.

The Emergence of Novel SARS-CoV-2 (COVID-19) a Triple Reassortant Corona Virus Immunogenicity and Reactogenicity in Human

Presently, the emergence of a novel human corona virus, Severe Acute Respiratory Syndrome (SARS)-CoV-2, has lead to a global health concern. It causes severe respiratory tract infections in humans. WHO on March 11, 2020, declared COVID-19 (Corona Virus) as a pandemic. There have been more than 3,842,000 confirmed COVID-19 cases in the world. The reports have shown sharp increase in the number of infections reported in recent days from Italy, Iran, South Korea, Spain, Germany, United States, and other parts of the world, with the most dramatic increase recorded in China where more than 80,000 cases were reported in a very short duration. Neither potential medication nor vaccines are available in the market and the virus can manifest itself both symptomatically and asymptomatically in the human system.

Pharmaco-Invasive Approach to Acute Coronary Syndrome with Acute Thrombotic Occlusion: A Tough Enemy to Conquer

Rutvik Trivedi

Acute occlusion of a Saphenous Vein Graft (SVG) is commonly associated with extensive atherosclerotic and thrombotic burden, which increases the risk of distal embolisation and no reflow and thus myocardial infarction and death. To decrease the risk of distal embolisation, embolic protection devices are used. This case report is about two elderly patients admitted with Acute Coronary Syndrome (ACS) due to acute thrombotic SVG occlusion that was recanalized through the complementary nature of two strategies.