Journal of clinical and diagnostic research

A Rare Case of de novo Mucoepidermoid Carcinoma of Parapharyngeal Space: Excision by Mandibular Swing

Abhishek Bhardwaj, Neena Chaudhary, Shashank Gupta, Para Chaudhary

Mucoepidermoid carcinoma of Parapharyngeal Space (PPS) not originating from parotid is a very rare finding. Tumours of PPS represent a formidable challenge to the surgeon in view of preoperative assessment and appropriate surgical approach. We present a clinical case of a mucoepidermoid carcinoma in the PPS in a 62-year-old female who presented to a tertiary care hospital with complaints of throat pain and difficulty in swallowing for duration of one month. Left parapharyngeal bulge was present on clinical examination and Computed Tomography (CT) revealed homogeneous non enhancing mass occupying left PPS. Intraoral fine needle aspiration cytology revealed features suggestive of mucoepidermoid carcinoma. Tumour was excised in toto using mandibular swing technique. It was a well encapsulated, dumb-bell shaped tumour separate from parotid with no invasion of surrounding tissue. Histopathology was consistent with low grade mucoepidermoid carcinoma. Patient was in follow up for past two years without any local recurrence or distant metastasis.

“Head Over Heels” Position of Duodenum–A Unique Congenital Anomaly

Satheesha B Nayak, Sudarshan Surendran, Prakashchandra Shetty, Surekha D Shetty

Knowledge of congenital anomalies of duodenum and biliary apparatus is useful in radiological diagnosis and surgical procedures of upper abdominal region. We present concurrent variations of duodenum, bile duct and coeliac trunk in this report. The first part of the duodenum descended downwards in front of the head of the pancreas. At the lower end of the head of the pancreas, it ascended upwards along the right border of the head of the pancreas until the first lumbar vertebra. At the level of first lumbar vertebra, it continued to the left as its third part. The third and fourth part passes behind the head, neck and the body of the pancreas (and also behind superior mesenteric vessels). On the left side of the second lumbar vertebra, the duodenum continued as jejunum at the duodenojejunal flexure. The common bile duct coursed down in front of the head of the pancreas, being surrounded by a few pancreatic acini in the lower part of its course. It terminated at the hepatopancreatic ampulla, which opened into the first part of the duodenum. The coeliac trunk passed through the body of the pancreas before it divide into its terminal branches.

Recurrent Branchial Cleft Cyst with Symptomatic Cervical Oesophageal Diverticulum in Adult -An Interesting Presentation of Incomplete Branchial Cleft Cyst Excision

Jmv Amarjothi, Anbalagan Amudhan, D Bennet, L Anand, Ol Naganath Babu

Branchial cysts are congenital cystic lesions of the neck, presenting in childhood. Complete surgical excision is the treatment of choice for these lesions. Recurrence of branchial cysts after incomplete excision is fraught with complications due to the second surgery and the complications of the recurrent cyst per se. Here we present a case of recurrent branchial cyst presenting, after a decade, with a full thickness traction diverticulum of the upper cervical oesophagus necessitating excision of the cyst with the diverticulum. This case report emphasises on the pitfalls of incomplete excision at the index surgery and the long-term complications of recurrence.

Spindle Cell Lipoma of the Arm: A Case Report with Review of Literature

Spindle cell lipomas are rare benign tumours of adipocytes. They are usually found in middle aged to elderly males. There are a number of differential diagnoses for this lesion. Treatment is excision with no recurrence. Here we report a case of a firm non tender swelling of the arm which after excision was diagnosed as Spindle Cell Lipoma (SCL). We discuss the case and a review of the literature for a deeper understanding of this tumour.

Acute Amoebic Appendicitis: A Rare Case Report

Manjari Kishore, Devender Singh Chauhan, Seema Rahar, Shashikant Singh

Acute appendicitis is a common cause of acute pain abdomen. Amoebic infestation is still a rare cause of acute appendicitis. Herein, we report a rare case of amoebic appendicitis in a young female, who presented to emergency department with pain abdomen, fever and vomiting along with rebound tenderness. Laboratory investigation revealed leukocytosis and mild eosinophilia. Histopathological examination showed numerous trophozoites of Entamoeba histolytica in the ulcerated mucosa of the appendix. The present case report aim to highlight this rare cause of appendicitis which should be treated appropriately to prevent further complication.

Refractory Thrombotic Thrombocytopenic Purpura: A Case Report

Mohammed Shafi Abdulsalam, Venkateshwaran Radhakrishnan, Prabu Pandurangan

Thrombotic thrombocytopenic purpura is a thrombotic microangiopathy. Clinical manifestations occur due to decreased perfusion to the internal organs. Usually it responds to pulse steroids and plasma exchange. Various therapies are available for refractory cases which respond to N-Acetyl cysteine, cyclosporin, rituximab, bortezomib and caplacizumab. We report a case of refractory Thrombotic Thrombocytopenic Purpura (TTP) in a 29-years-old female showed improvement with the use of rituximab (anti-CD 20 monoclonal antibody), who presented with history of fever and one episode of seizure.

A Rare Case of Amphotericin B Resistant Cryptococcal Meningitis in a HIV Non-reactive Immunocompetent Patient

Cryptococcus meningitis is the most common opportunistic fungal infection in immunocompromised individuals and rarely occurs in HIV non-reactive people. Fever, headache, altered sensorium and neck stiffness are the usual presenting features of meningitis and common causative agents are of viral, mycobacterial and mostly bacterial origin in an immunocompetent host. However, fungal infection should be considered amongst the differentials. Knowledge of geographical distribution and a high degree of clinical suspicion are important for an early diagnosis, institution of early treatment and ultimately preventing lethal complications. We hereby report a case of amphotericin B resistant cryptococcal meningitis in a HIV non-reactive immunocompetent individual.

Multiple Fractures in a Patient with Disseminated Cysticercosis-Orthopaedic Implications

Shyamasunder N Bhat, Nishanth Ampar, CJ Joseph, Brij Mohan Kumar Singh

Cysticercosis is a parasitic infection caused by the larval form of pork tapeworm, Taenia solium. Disseminated cysticercosis is an unusual manifestation of cysticercosis which has been reported in endemic areas. Only a few cases of disseminated cysticercosis have been reported worldwide, to date in literature. Herein, we present an incidental finding of disseminated cysticercosis in a middle-aged male who had presented to us with multiple fractures following a road traffic accident.

Acute Visual Loss as the Presenting Feature of Metastatic Upper Gastrointestinal Cancer-A Rare Case Report

Choroidal metastases are the most frequent intraocular tumours in adults. Primary tumour sites include lungs in men (68%) and breasts in women (40%). Gastrointestinal cancer is the origin in only 2% of the cases, occurring in women. Only 30% of patients present to the ophthalmologist with no previous history of cancer. We hereby report the case of a 41-year-old female with no relevant medical history, complaining of sudden-onset blurred vision in the right eye (OD: hand motion), since one day and 20/25 vision in the left eye (OS) due to bilateral, multifocal choroidal metastatic disease. Systemic treatment with carboplatin and paclitaxel was started and the patient refused to undergo orbital External Beam Radiotherapy (EBRT). A follow up of four weeks recorded the rapid progression of bilateral exudative retinal detachment, increase in size of choroidal lesions, visual acuity decline (OD: Light perception, OS: Count fingers, at her last visit), as well as appearance and worsening of systemic symptoms. This represents a relevant example of a serious underlying multiorgan disease diagnosed after an ophthalmologic examination. Our report highlights the importance of including the differential diagnosis of uveal metastases in patients with suspicious posterior segment lesions despite the absence of systemic symptoms.

Systemic Lupus Erythematosus Presenting as Macrophage Activation Syndrome

Satyabrata Guru, Anupama Behera, Nishant Debta, Rajesh Kumar

Macrophage Activation Syndrome (MAS), a potentially life threatening condition belongs to acquired cause of Hemophagocytic lymphohistiocytosis (HLH) group of diseases more often found in children than adults. It presents as familial forms or acquired forms that include infectious aetiologies notably viral, malignancies, drugs and autoimmune diseases. Its association with several systemic autoimmune disease includes commonly systemic Juvenile Idiopathic Arthritis (sJIA), adult-onset Still's disease and rarely with Systemic Lupus Erythematosus (SLE), rheumatoid arthritis and dermatomyositis. It is a heterogeneous presentation of systemic and laboratory findings characterised by abnormal immune activation and inflammation warrants early diagnosis and prompt treatment. Herein we report a rare case of 15-year-old female who presented with fever of two months duration, who was later diagnosed to be having MAS with SLE. Despite the rarity MAS can be initial presenter in SLE and should be searched in the background of fever and features of SLE. Initiation of treatment with pulse methylprednisolone and follow up with oral hydroxychloroquine, cyclosporine and steroids had a favourable outcome.

Neuropathic Shoulder Joint Associated with Syrinx and Chiari Malformation Type I Clinically Masquerading as Malignancy - A Case Report

Ruchi Gupta, Kishore Kunal, Subhash Kumar, Neetu Sinha, Abhishek Anand

We report a rare case of 40-years-old male patient who presented with right shoulder joint swelling and reduced range of motion since one and half month. Subsequent X-ray and Magnetic Resonance Imaging (MRI) revealed completely resorbed humeral head, extensive intra-articular debris, joint effusion and thickened synovium. MRI of whole spine showed long segment syrinx, pointed peg of tonsils with tonsillar ectopia and basilar invagination. Diagnosis of atrophic type of Neuropathic shoulder joint secondary to syrinx and Chiari malformation was made.

Coinfection by Salmonella and Leptospira Presenting as Subacute Intestinal Obstruction with Colitis: A Diagnostic Dilemma

ARTI NEGI, NIDHI TEJAN, CHINMOY SAHU, TAPANKUMAR NIRODCHAND DHOLE

Coinfection with Salmonella and Leptospira is a rare entity even in regions where both pathogens are endemic. As clinical features are nonspecific and overlapping, it is very difficult to differentiate between these two infections. However, many cases of coinfections of leptospirosis and scrub typhus; dengue and Leptospirosis, typhoid and dengue have been reported but coinfections by Salmonella and Leptospira have been reported rarely. Clinically they should be suspected in endemic areas and here we are presenting such a case. A 30-year-old female presented with chief complaints of loose stools for 10 days, high grade fever and jaundice for three days. CT enterography showed mildly enlarged liver and features of small bowel obstruction. Blood culture was sterile. No improvement was seen with empirical antibiotics. Widal titers were very high and IgM antibodies for Leptospira was positive by Enzyme-Linked Immune Sorbent Assay (ELISA) test in third week of illness. She was started on ceftriaxone 1 gm Intravenous (IV) twice a day as both the infections respond excellently to ceftriaxone. Over next couple of days her conditions improved and she was discharged in stable condition. This case highlights the need for optimal use of microbiological laboratory services and timely intervention to reach a final diagnosis.

Bite of a Mite: A Case of Human Otoacariasis caused by Cosmoglyphus Species (Acari: Acaridae)

Shekhar Pal, Vikrant Negi, Ravindra Singh Bisht, Deepak Juyal

Otoacariasis or parasitic otitis, is the infestation of the ear with ticks/mites and is a common condition in the livestock and domestic animals. Although, less common, cases of human otoacariasis caused by mites can be occupational in origin and ear being in permanent contact with biotic elements of the biosphere is one of the commonest organs predisposed for various microorganisms to settle in. The local lesions observed in otitis such as skin congestion, increased vascular permeability and raised temperature creates favourable conditions for their development. We here describe a unique case of human otoacariasis caused by mixed aetiology–mites, fungi and bacteria in a 45-year-old female, a grain dealer by profession. To the best of our knowledge this is the first report of human otoacariasis by Cosmoglyphus (Acari: Acaridae) species.

Burkholderia pseudomallei: Liver Abscess in a Diabetic Patient from Western India

In Indian subcontinent, liver abscesses are often caused by amoebic and gram-negative organisms. Burkholderia pseudomallei (B. pseudomallei) is an emerging pathogen in India. The spectrum of disease caused by B. pseudomallei is variable and liver abscesses are an infrequent presentation. We report a case of isolated liver abscess caused by B. pseudomallei in a 72-year-old diabetic male patient, who was referred from Goa. Patient was treated with pigtail drainage of abscess and injection ceftazidime was given during stay in hospital. Patient was discharged on co-trimoxazole and doxycycline. The repeated culture after prolonged therapy showed markedly reduced colonies with similar antibiotic pattern and patient was treated successfully. It is important that pus aspirates from liver abscesses are worked up for microbiological culture and prompt treatment is initiated in case of melioidosis which is an emerging infection in India.

Hemangiopericytoma: A Rare Mass Arising in the Kidney

Hemangiopericytoma, a tumour arising from pericytes is an unusually rare kidney neoplasm. It is difficult to establish a preoperative diagnosis. Here, we present a case report of a 47-year-old gentleman who presented with haematuria and underwent left radical nephrectomy as preoperative imaging was suggestive of Renal Cell Carcinoma (RCC). The final histopathological diagnosis was hemangiopericytoma of the left kidney.

Anomalous High Transverse Course of Brachiocephalic Trunk and its Clinical Significance: A Rare Case Report

Manisha R Gaikwad, Krishna S Patil, Amit P Tirpude, Naina S Wakode

The branching pattern and the course of brachiocephalic trunk in relation to the trachea, thyroid gland has profound surgical importance. Any alteration in the normal course of the brachiocephalic trunk, if accidently ruptured during emergency tracheostomy or thyroid surgeries may lead to haemorrhage. Hence, anomalous course of vessels in the neck and thorax should be kept in mind to prevent iatrogenic injury to abnormal vessels. We present a case with a variable course of brachiocephalic trunk passing left to right transversely crossing trachea in a formalin fixed female cadaver. In this case report, brachiocephalic trunk had its origin from the arch of aorta to the left of trachea corresponding to the left margin of manubrium sterni. Then, it ascended along the left margin of trachea up to the lower border of the left lobe of thyroid gland taking a sharp bend of approximately 90° to hook around and cross the trachea transversely to the right side along the inferior margin of the right lobe of thyroid gland. Knowledge of the variable rather transverse course of the brachiocephalic trunk appears to be important in various surgical approaches such as tracheostomies, thyroidectomies and mediastinoscopies.

Cutaneous Ischaemia Following Terlipressin Therapy for Hepatorenal Syndrome

Aneesh Basheer, Dayanandan Yoganandan, Meera Baby John, Prem Kumar Guna

Hepatorenal Syndrome (HRS) is a potentially fatal complication of hepatic failure and portal hypertension. Among the various treatments available including octreotide, midodrine and albumin, the current standard of care for stable patients is terlipressin along with albumin. Although, terlipressin is considered safer than its parent molecule vasopressin, there have been reports of ischaemic side effects related to vasoconstrictor effects such as myocardial and mesenteric ischaemia. Cutaneous ischaemia has been reported in as few as 20 cases to date. We report the case of a gentleman who developed ischaemic skin lesions due to peripheral vasoconstriction following terlipressin thereapy for HRS and rapid reversal on discontinuing the drug. This and other similar cases highlight the need for larger studies exploring ischaemic side effects of terlipressin as well as close monitoring of patients for early detection of this side effect.

Tubercular Retropharyngeal Abscess in Early Infancy - Rare Presentation of a Common Infection: A Case Report

Divya Gupta, Ishwar Singh, Gaurav Jareda, Divya Vaid, Purodha Prasad

Retropharyngeal abscesses in children are acute-infectious and non tubercular in nature. We present a rare case of tubercular retropharyngeal abscess presenting in early infancy. Patient was born to a mother who was diagnosed within four weeks of delivery with tubercular meningitis. Within six weeks of being born, the child developed fever and tubercular lymphadenopathy, possibly a manifestation of latent tubercular hematogenous infection transmitted to the child from mother in utero.

Pitfalls in Diagnosing Seropositive Rheumatoid Arthritis: Haematologic Malignancy Presenting as an Autoimmune Disease

Carcinomatous Polyarthritis (CP) is defined as the development of arthritis in association with a malignancy but distinct from that associated with metastasis or direct invasion. It can occur before, with, or after onset of malignancy or with treatment. CP usually affects large joints and is negative for Anti Citrullinated Protein Antibodies (ACPA). CP is rarely if ever considered in the differential diagnosis of a case of symmetric polyarthritis with ACPA positivity. Presence of autoimmune disease related antibodies further obscures the diagnosis. We present a case of a young lady with symmetrical inflammatory polyarthritis with positive ACPA who was found to have haematological malignancy. This is one of the very few cases of CP of small joints with ACPA positivity reported worldwide and highlights the need to be vigilant for red flags while evaluating any case presenting with rheumatologic symptoms.

Resistant Widespread Facial Impetigo in a Healthy Infant with Atopic Dermatitis

Atopic Dermatitis (AD) or eczema is a chronic and relapsing, itchy skin inflammatory condition in infancy and childhood. The diagnosis is based on pruritus and an eczematous dermatitis with typical presentation. A five-month-old infant who was suffering from itches and eczema since three months, was diagnosed with AD. After clinical diagnosis of AD, the condition seemed to be superimposed by a bacterial infection, an empirical treatment of antibiotic (oral cephalexin) was started. However, the patient showed no improvement. As per the hospital protocol, he received clindamycin, to which the lesions responded and totally resolved. The AD in our case was reported due to severe facial impetigo with an unusual feature that it resembled a primary immunodeficiency. However, in our case, the patient had an intact immune system and did not have any transient hypogammaglobulinemia.

Hydrochlorothiazide Sensitised Acetazolamide induced Bilateral Angle Closure Glaucoma with Choroidal Detachment after Cataract Surgery

Chitaranjan Mishra, T Sundar, Srinivas Sanjeev, Naresh Babu, Ramasamy Kim

Sulfonamide (Sulfa) derived medications causing bilateral secondary angle closure glaucoma with choroidal effusion is a known but rare clinical entity. Both acetazolamide and hydrochlorothiazide belong to sulfonamide group of drugs and have been separately reported in literature causing secondary angle closure glaucoma. However, administration of both these drugs causing this side effect in the same patient has not been reported previously. We report a case of 58-year-old male patient with hypertension and diabetes who developed bilateral angle closure glaucoma with choroidal detachment after administration of oral acetazolamide tablets during routine cataract surgery. The possible role of hydrochlorothiazide, a systemic antihypertensive, which the patient was on for three years, potentiating the adverse effect of acetazolamide is postulated since both these drugs are reported to cause this clinical entity. The patient was managed successfully with conservative antiglaucoma measures and cessation of the offending drugs. Hence, in all cases of secondary angle closure glaucoma, a thorough review of drugs of the patient is warranted. Identification of sulfa drugs and their discontinuation will result in prompt recovery of symptoms. Refraction, gonioscopy, fundoscopy and Ultrasonography (USG) B-scan will help in diagnosis and documentation of the clinical presentations.

MR Imaging in Idiopathic Inflammatory Polymyositis: Case Report and Review of Literature

Pratiksha Yadav, Ashim Wokhlu

Idiopathic Inflammatory Myopathies (IIM) are a group of rare autoimmune disorders which present clinically with proximal muscle weakness. Diagnosis of IIM involves clinical history, pathological investigation, imaging studies and histologic examination. It shows muscle weakness on Electromyography (EMG) and increased level of muscle enzymes. MRI is very useful to demonstrate the soft tissue and muscle changes in the IIM. MRI of whole body, especially peripheral limbs show typical findings which help in diagnosis, extent and severity of disease as well as follow up. We report a case of 31-year-old male who came with a complaint of muscle weakness since six months. The level of Creatinine Phosphokinase (CPK) was high. MRI of both upper and lower limbs showed diffuse symmetrical altered signal intensities involving the muscles of both upper and lower limbs. Biopsy was advised which was positive for idiopathic inflammatory polymyositis.

Prolonged Remission and Good Quality of Life with Maintenance Chemotherapy in Recurrent Ewing’s Sarcoma

Priyanka Sreelatha, Wesley Mannirathil Jose

Ewing’s sarcoma is an aggressive tumour of bone commonly affecting individuals in 10-20 years of age group. Older age and metastatic disease has an overall poor outcome. We are reporting a case of a 37-year-old lady with Ewing’s sarcoma who was initially diagnosed with localised disease involving C5-7 vertebral bodies. She received conventional treatment. She relapsed three years later with metastatic disease and was treated with salvage treatment followed by high dose chemotherapy and autologous stem cell transplant. She had a second relapse with lung metastasis after 28 months. She was treated with gemcitabine and docetaxel and she achieved complete remission again. She is on maintenance chemotherapy with cyclophosphamide and etoposide and continues to be in remission on maintenance treatment.

Scanning Electron Microscopic Analysis of the Screw Threads of Loosened and Fractured Abutments: A Case Report

Leblebicioglu Kurtulus Ikbal, Kuru Emel, Canakci Gulfesan

Fracture and loosening of the implant can pose a serious impact as the fractured segment remaining inside the implant may prevent it from functioning efficiently. The harmony between the implant supported prosthesis and implant could be disrupted, leading to failure of the upper structure. Fistula formation and soft tissue inflammation are frequently associated with loose abutment screws. This case report involved an evaluation of the screw threads of a loosened abutment compared with those of a fractured abutment removed from the same patient by Scanning Electron Microscopy (SEM). According to the results of the SEM analysis, deformities in the screw threads of the loosened abutment were evaluated, and whether a loosened abutment should be rescrewed was considered. In this case report an unused abutment screw, broken screw, and loosened abutment screw were analysed by SEM. In the loosened abutment screw, the thread was deformed in the concavities to a greater extent, than in the convexities. The metal structure appeared strained without any cracks. In the fractured abutment screw, the metal structure in the convexities appeared strained with small cracks present at grain boundaries. Crack growth appeared to be related to the high number of crack coalescence events. A significant difference was observed between screw threads with abutment loosening and screw threads without abutment loosening. Therefore, a loosened abutment should not be rescrewed because it increases the risk of abutment fracture.

Digital Gangrene in Association with Retinoblastoma

We report a 5-year old boy, diagnosed with Retinoblastoma (RB) in the right eye and subsequently developed digital gangrene as a result of Raynaud’s phenomenon. Color Doppler ultrasound showed occlusion of radial and ulnar arteries of the left upper limb. Antinuclear Antibody, Antiphospholipid Antibody (APLA) and rheumatoid factors were negative. The patient was treated with low molecular weight heparin (enoxaparin), nifedipine, and analgesics. Raynaud’s syndrome and digital gangrene constitute a rare paraneoplastic process, which was not reported with retinoblastoma earlier.

Duplicated RCA with Anomalous Origin of Left Circumflex Artery: A Rare Case Report

Coronary artery anomalies are found in around 1-2% of patients undergoing coronary angiography. Uncovering of more coronary anomalies has increased with increase in awareness and easy availability of non invasive Computed Tomography Coronary Angiography (CTCA). We present a rare case of a 64-year-old female with a history of atypical chest pain and mild ST depression ECG changes who underwent CTCA. The present case revealed unusual findings of an anomalous origin of the Left Circumflex Coronary artery (LCx) from the proximal Right Coronary Artery (RCA) with duplicated right coronary artery after arising as a common trunk from right coronary cusp. In the present case report we attempted to highlight the rarity of this coronary anomaly.

Right Hilar Mass Diagnosed by Endobronchial Ultrasound Guided Transvascular Needle Aspiration

Asmita Anilkumar Mehta, Arvind Perathur

The Endo Bronchial Ultrasound–guided Transbronchial Needle Aspiration (EBUSTBNA) for diagnosis and staging of benign and malignant thoracic diseases is the standard of care nowadays. The complications associated with it are rare and minor. We report one case of a 47-year-old male, was evaluated by his primary care physician for complaints of cough, chest pain on right side and episodic dyspnea of one month duration. He was a non smoker and chef by occupation. He denied any history of fever, chills, sputum production, wheezing, or haemoptysis. Chest radiograph showed right lower zone mass. Computed tomography (CT) of the chest revealed well defined a 3×4 centimeter tumorous lesion arising from the right middle lobe bronchus. Fiberoptic bronchoscopy was normal. Endobronchial Ultrasound (EBUS) revealed 2.3×3.3 cm hypoechoic lesion at station 12R lying adjacent to a branch of right inferior pulmonary artery. We examined the pulmonary artery segment using color flow Doppler enhancement. It showed no blood flow over the mass. We next deployed the biopsy needle to its full length into the mass, traversing the near and far walls of the pulmonary artery branch in the process. Rapid on site evaluation by a cytopathologist revealed diagnosis of spindle cell neoplasm. In present case, we did EBUSTBNA of a right hilar mass traversing the pulmonary artery. There was no vascular injury in the current procedure and with the small diameter needle and real-time guidance such procedures can be performed safely.

Near Fatal Anaphylactoid Reaction Due to Bupivacaine Spinal Anaesthesia

Shruti Singh, Prashant Kumar Singh

Cardiorespiratory collapse in perioperative scenario-a dreaded occurrence, can have multiple aetiologies. Among them hypersensitivity reactions although rare, contribute significantly to patient mortality. The incidence of hypersensitivity reactions during anaesthesia have been reported to a range from 1 in 4000 to 1 in 25,000. Latex gloves and skeletal muscle relaxants are quite renowned in causing allergic reactions during perioperative period. The needle points less towards local anaesthetics, due to the rarity of such reports in literature. Also, the use of amide linked local anaesthetics for spinal anaesthesia reduces the chances of any such allergies occurring. Here, we report a case of severe anaphylactoid reaction occurring due to Bupivacaine given as a spinal anaesthetic. The extreme rarity of such reports implicating Bupivacaine as the causative agent for perioperative hypersensitivity puts this case in sharp focus. Preventing any such future episodes that are detrimental to a patient’s well-being require awareness and skill on the part of the whole team. Exploring all questionable causative agents; however, less likely or farfetched therefore becomes important.

Paraurethral Leiomyoma in a Young Female: A Case Report

Rohan Surendrakumar Batra, Jaynil A Bagawade, Phanindra Mohan Deka

Leiomyomas are benign tumours which originate in the smooth muscle rest cells. The origin of the tumour in the paraurethral region is rare. Herein, we describe a case of a 30-year-old female patient with a mass at the paraurethral region which turned out to be leiomyoma. Paraurethral leiomyoma make up only approximately 5% of urethral tumours. This case depicts the presentation and subsequent management of the patient with paraurethral leiomyoma.

Insulin Antibody-induced Diabetic Ketoacidosis in an Elderly Type 2 Diabetic Ameliorated with Prednisolone

Yuko Matsumoto, Hodaka Yamada, Masafumi Kakei, San E Ishikawa, Kazuo Hara

In the patients who are treated with insulin, the synthesis of insulin antibodies occasionally induce difficulty in glycaemic management. Insulin antibodies are now being closely examined in the context of diabetes treatment. Although, human insulin analogues are supposed to be less antigenic; however, insulin antibodies may mimic severe insulin resistance or blood glucose brittleness in some cases. We hereby report the case of an 82-year-old male with insulin-treated Type 2 diabetes admitted to our hospital and diagnosed with diabetic ketoacidosis and acute pancreatitis. His levels of insulin antibodies and binding rate was very high. Intravenous insulin infusion and gabexate mesilate were administered. The acute pancreatitis improved but ketoacidosis re-emerged during insulin infusion. After administration of 30 mg prednisolone, infusion with insulin detemir was discontinued. On the day of discharge, his glycaemic control was good and the patient was prescribed low dose prednisolone, 8 U/day of insulin detemir, and 150 mg of miglitol. Therefore, severe immuno-insulin resistance can cause diabetic ketoacidosis and steroid might be an useful therapeutic target for insulin antibody-induced diabetic ketoacidosis.

Unilateral Pulmonary Aplasia with Dextroposition of Heart: A Case Report

‘Pulmonary Aplasia’ is a rare condition where there is absence of unilateral or bilateral lung tissue with a rudimentary bronchus which separates it from the similar looking ‘Pulmonary Agenesis’. The aetiology is not completely understood, though a defect in chromosome number two is often associated. Failure of development of primary lung bud leads to aplasia/agenesis. It is often associated with other anomalies involving skeletal, cardiovascular, genitourinary and gastrointestinal system. We present a case of right sided pulmonary aplasia with dextroposition/levorotation of heart in a 10-month-old female child.

Correspondence: Comparison of Central Corneal Thickness using Anterior Segment Optical Coherence Tomography Versus Ultrasound Pachymetry

Maddalena De Bernardo, Nicola Rosa

An Unusual Case of ABO Discrepancy: Lessons Learnt

Vandana Puri, Shivali Sehgal, Maria Khatoon, Geetika Sharma, Sarita Deorari

Correspondence: Shigella sonnei Sepsis in an Infant: A Case Report

Anirban Mandal, Puneet Kaur Sahi

Physical and Psychological Dependence of Smokeless and Smoked Tobacco

Introduction: Worldwide tobacco usage is considered to be the most pervasive addictive behaviour, which eventually leads to physical and psychological dependence on nicotine. Aim: The present study was conducted to measure the physical and psychological dependence of smoked and smokeless tobacco. Materials and Methods: It was a questionnaire based survey in which 500 smokeless and 500 smoking forms of tobacco users participated. A standard questionnaire format of modified Fagerstrom Test for Nicotine Dependence (mFTND) for physical dependence and American psychiatric association scale for psychological dependence was given to each subject to answer. The total score was calculated for each subject which evaluated the physical and psychological dependence on smoked and smokeless tobacco. Descriptive analysis was done to check the prevalence of physical and psychological dependence. Chi-squared test was used to assess associations of age, gender and education is study subjects. Results: The study data revealed that the tobacco chewing habit was more common in males than in females. According to mFTND score for smokeless tobacco users, 16.3% males and 6.7% females and for smoked tobacco users, 35.65% males and 50% females were highly dependent. On using American psychological scale for nicotine dependence for smokeless tobacco users, 66.42% males and 56.17% females were psychologically dependent whereas for smoked tobacco 16.59% males were dependent on smoked tobacco. Conclusion: Our study findings relate to both, the prevalence of smoking and smokeless nicotine dependence. We found that the rate of nicotine dependence was higher in males than in females. The prevalence of nicotine dependence was also higher in subjects with lower education.

Prognostic Value of Epidermal Growth Factor Receptor in Colorectal Carcinoma

Anamika Sinha, Sukumar Santosh Kumar

Introduction: Colorectal carcinoma is a common malignancy with a worldwide distribution. AJCC tumour staging is the single most important prognostic indicator which is also used for selecting cases for postoperative adjuvant therapy. However, a considerable number of curatively treated colon cancer patients ultimately develop disease recurrence prompting the need to identify additional prognostic markers. Extensive research into the biology of colorectal cancer has identified some molecular markers such as Epidermal Growth Factor Receptor (EGFR) which, in addition to providing an insight into the carcinogenesis of colorectal carcinoma, also provide prognostic information. Aim: To evaluate the prognostic value of expression of EGFR in colorectal carcinoma by correlating it with established prognostic markers such as grade and stage of the tumour. Materials and Methods: Retrospective cohort study of 100 cases of colorectal carcinoma who underwent radical surgery at a large tertiary care hospital was done. Relevant clinical data of the cases was collected from medical records. Histopathologic evaluation of tumour grade, depth of invasion, number of lymph nodes involved and pathologic stage was done. Immunohistochemistry (IHC) was performed for assessment of EGFR expression, which was categorised as positive if >1% of the tumour cells showed EGFR immune-specific membranous brown staining. Expression of EGFR was correlated with the tumour site, histological grade and the pathologic stage by chi-squared test (?2). Values were considered significant at p<0.05. Results: Among the stage I and stage II tumours, 18% and 31%, respectively, were positive for EGFR, while among the stage III and stage IV tumours, 74% and 80%, respectively, were positive for EGFR. A highly positive and significant correlation (p<0.01), along with a linear association was noted between the pathologic stage and the EGFR expression of the tumours. No significant association was noted between either the expression of EGFR and the histological grade (p=0.51) or the expression of EGFR and the site of tumour (p=0.10). Conclusion: Epidermal growth factor receptor, due to its strong correlation with the pathologic stage of colorectal carcinoma, can be of prognostic significance. This may have a role in selecting those patients who are at high risk for disease progression and therefore are likely to benefit from adjuvant therapy.

Neck Circumference: An Alternative Tool for Screening Cardiovascular Risk among Adults

Introduction: Upper body obesity has been attributed to increased cardiovascular risk in various studies. Measuring the Neck Circumference (NC) is an easy and inexpensive method to determine the upper body obesity. Aim: To correlate NC with Waist to Hip ratio (W:H ratio) and to find critical cut off points for NC for the screening cardiovascular risk among adults. Materials and Methods: A community based cross-sectional study was conducted among apparently healthy adults in field practice area of a tertiary care hospital in Maharashtra, India. A predesigned and pretested questionnaire was used and following the standard guidelines Waist Circumference (WC), Hip Circumference (HC) and NC were measured. Necessary permissions were sought before the start of the study. Indian standard cut off for W:H ratio was used to classify the cardiovascular risk among the study subjects. Statistical analysis: Epi info 7.1 and Statistical Package for the Social Sciences (SPSS) version 20.00 was used for analysis. Chi square test (For proportions), independent t-test (For mean), Pearson’s correlation coefficient and Receiver Operating Characteristic (ROC) analysis was done. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated. Results: Total of 300 study subjects were recruited in the present study . There were equal number of males (n=150) and females (n=150) with the average age of the study population as 44.70±20.24 years. The Pearson’s correlation coefficient between NC and W:H ratio was 0.42 and 0.33 among males and females respectively. Based on receiver operating curve analysis for NC, cut off of 32.5 cm among females and 35.5 cm among males was defined as best critical cut off to screen the adults for cardiovascular risk. Conclusion: A significant association was observed between NC and W:H ratio (p<0.001). NC can be used as a fair test to screen cardiovascular risk among adults.

The Effects of Rheumatoid Arthritis in Hearing Loss: Preliminary Report

Muhammad Edy Syahputra Nasution, Tengku Siti Hajar Haryuna

Introduction: Rheumatoid Arthritis (RA) is a chronic inflammation that can cause systemic manifestations. Auditory system can also be affected by this disease. Sensorineural and conductive hearing loss have been reported but the results remain controversial. Aim: The aim of this study was to find out the correlation between RA and hearing loss. Materials and Methods: This cross-sectional, analytical, and prospective study included 19 subjects with RA and 19 subjects with other joints disease as comparison from January to June 2015. Pure tone audiometry and tympanometry examinations were conducted for all subjects. Pearson Chi-square test was used to analyse the correlation between RA and hearing impairment as well as the correlation between diseases duration, Erythrocyte Sedimentation Rate (ESR), and platelet count; and hearing threshold. Independent samples t-test was used to analyse the difference in mean of air and bone conduction thresholds, air-bone gap values, as well as hearing thresholds in both groups. Results: Hearing impairment was 78.9% in RA group and 21.1% in comparison group (p<0.05). Sensorineural hearing loss was the most common finding in RA (52.6%). There were significant correlations of disease duration and ESR with hearing loss degree in RA (p<0.05). The significant difference was obtained in air-bone gap values at 500 Hz to 4000 Hz (p<0.05). Conclusion: Rheumatoid arthritis can cause hearing loss.

Cranial Neuroimaging in Infantile Tremor Syndrome: The Road Ahead

Introduction: Infantile Tremor Syndrome (ITS) is a self-limiting clinical state of unknown aetiology characterised by tremors, anaemia, pigmentary skin disease, regression of mental development and hypotonia of muscles in a plump looking child, mostly reported from Indian subcontinent. Aim: To analyse the role of cranial neuroimaging in identifying aetiology of ITS patients. Materials and Methods: This observational cross-sectional study done at Department of Paediatrics, RD Gardi Medical College, Ujjain, Madhya Pradesh, India, was conducted during the period of April 2013 to August 2014. Ten patients admitted with clinically diagnosed ITS were studied. Patient profiles, history, anthropometric measurements, general and systemic examination along with cranial neuroimaging were also studied. Results: Out of ten ITS patients, four were males and six females. Mothers of all children were vegetarian and Hindu by religion. Severe wasting was present in four patients whereas three had moderate wasting. On cranial neuroimaging non specific cerebral atrophy of different grades was observed in all cases except one and cerebellar atrophy in one case of ITS. Reduced thickness of corpus callosum was observed in six patients and nine children had prominence of Sylvian sulcus. Out of the four children with severe wasting three had evidence of cerebral atrophy; moreover, all the three patients having moderate wasting had evidence of cerebral atrophy. Conclusion: Different grades of cerebral atrophy, ventricular enhancement along with corpus callosum thinning have been the key findings in ITS patients. Findings support nutritional deficiencies as most probable aetiology.

Gender Determination of an Individual by Scapula using Multi Detector Computed Tomography Scan in Dakshina Kannada Population-A Forensic Study

Manna Debnath, Rahul P Kotian, Dolly Sharma

Introduction: Gender is the most vital segment of the biological characteristics which can be evaluated from the skeleton because of the marked sexual dimorphism of bone segments. The bone examined in present study is scapula. Multi Detector Computed Tomography (MDCT) scan was used to study the scapula which provides 3D volume rendering images with good measurement accuracy. Aim: To determine the gender of an individual by scapula using MDCT scan in Dakshina Kannada population. Materials and Methods: Bilateral scapular images (right and left) were acquired from 186 patients (93 males and 93 females) and different parameters {Longitudinal Scapular Length (LSL), Transverse Scapular Length (TSL), Oblique Scapular Length (OSL)} were measured and evaluated. Mean and standard deviation of both scapular measurements were calculated and compared. The data were analysed using Multivariate Analysis of Variance (MANOVA) and discriminant function analysis. Results: Scapular measurements showed statistically significant difference between two mean vector groups i.e., female and male groups (p<0.001). Transverse left scapula contributed much separation with highest accuracy compare to other measurements. The final result of discriminative analysis showed the ability of the scapula to identify gender with an overall accuracy of 93.5%. Conclusion: In the present study transverse left scapular length contributed much separation with highest accuracy compared to other measurements. Scapular estimations can be useful to determine gender in Dakshina Kannada Population.

Comparison of Induction Characteristics of two Anaesthetic Agents: Etomidate-lipuro and Propofol for Day Care Surgery

Introduction: Induction of anaesthesia is the most critical stage of anaesthesia. Thus, an induction agent with less side effect should be used. Aim: To compare the newer formulation of Etomidate in lipid formulation (Etomidate-lipuro) and propofol-lignocaine admixture in patients undergoing day care gynaecological surgery. Materials and Methods: Hundred ASA I and II patients in the age group 18-60 years, scheduled for dilatation and curettage procedure were randomly allocated to receive either Etomidate-lipuro 0.2 mg/kg or propofol 2 mg/kg. Both groups received intravenous midazolam 0.05 mg/kg and fentanyl 2 µg/kg as premedication. After induction with the desired agent titrated to Response Entropy (RE) 40, the time to achieve values to 40 (RE 40 time) were measured. Heart Rate (HR), Mean Arterial Pressures (MAP) were recorded at baseline, at induction and every minute for 15 minutes. Incidence of pain at injection site, myoclonus, apnea and thrombophlebitis were observed. Statistical analysis was done using Chi-square test and Student unpaired t-test. Results: Haemodynamic parameters (HR and MAP) were well maintained with etomidate. There was a significant decline in HR and MAP with propofol as compared to etomidate (p<0.001). Onset of anaesthesia (Time to achieve RE 40) was 81.22±2.79 s and 77.60±230 s in propofol and Etomidate-lipuro respectively (p<0.001). The incidence of pain was more with propofol-lidocaine admixture (40%) as compared to no pain with etomidate (p<0.05). None of the patients had myoclonus and postoperative thrombophlebitis in our study. Incidence of postoperative nausea was high with etomidate use (22%) than with propofol (14%) but statistically insignificant (p>0.05). None of the patient in our study had vomiting. Incidence of apnoea was higher with propofol (58%) as compared to etomidate (14%) (p<0.001). Conclusion: Etomidate-lipuro can be a valuable induction agent due to its haemodynamic stability and lesser side effect profile for day care surgery.

A Correlation Study on Apolipoprotein Ratio and Malondialdehyde in Patients with Type 2 Diabetes Mellitus

Ayaz Khurram Mallick, Marya Ahsan

Introduction: Type 2 Diabetes Mellitus (DM) is associated with hyperglycemia, dyslipidemia and oxidative stress. Oxidative damage, indicated by elevated levels of Malondialdehyde (MDA), plays a vital role in development of Coronary Artery Disease (CAD) in diabetics. Although reduction of Low Density Lipoprotein (LDL) is identified as the primary target for therapy in dyslipidemic patients by National Cholesterol Education Programme (NCEP), the levels of LDL may not be elevated in diabetic patients. Moreover, many studies have shown that apolipoprotein B100 and A1 (Apo B100 and Apo A1),which are the corresponding protein components of LDL and High Density Lipoproteins (HDL) respectively, are more sensitive markers for screening of CAD. Aim: To determine the concentration of Apo A1 and Apo B100 along with serum MDA in patients with type 2 DM and study the correlation between them. Materials and Methods: A case-control study was done on 75, type 2 diabetic patients and 75 healthy controls. Fasting plasma glucose, glycated hemoglobin, fasting lipid profile along with Apo A1, Apo B100 and MDA as a marker for lipid peroxidation were determined, compared and analyzed using Statistical Package for Social Sciences (SPSS) version 23.0. Results: Diabetic patients had a significantly higher levels of serum triglyceride, Apo B100 and MDA along with significantly lower levels of HDL and Apo A1. The Apo B100/Apo A1 ratio was also higher in diabetic cases which showed a strong positive correlation with HbA1c (r=0.515) and MDA (r=0.819). The levels of total cholesterol and LDL were comparable in both the groups. Conclusion: Diabetes mellitus is associated with dyslipidemia and oxidative stress. Poor glycemic control is associated with an increased oxidative damage which contributes to development of microvascular complication. Hence, Apo A1, Apo B100 and serum MDA may be included as additional parameters in the management of DM as they could help in early diagnosis and prevention of CAD.

Clinicopathological Diversity of Pancytopenia: A Series of 400 Cases

Introduction: Pancytopenia is characterised by decreased haemoglobin, Packed Cell Volume (PCV), Total Leukocyte Count (TLC) and Platelet Count (PC). Variety of haematological disorders can present with pancytopenia and hence, it has an extensive differential diagnosis. The clinical presentation is based on the severity of pancytopenia as well as its aetiology that warrants a systematic approach to identify the cause of pancytopenia. Aim: To evaluate the clinicopathological characteristics of various causes of pancytopenia. Materials and Methods: A total of 400 cases presenting with pancytopenia were clinically assessed, and the haematological investigations were collected from the haematology unit of Department of Pathology, from January 2010 to December 2016. The clinical data of the patients was obtained and the haematological findings were analysed. Bone marrow aspiration (200/400 cases) and biopsy (77/400 cases) were evaluated. Data was analysed using SPSS 22.0 version. The test of significance was performed by chi-square test. A p-value <0.05 was considered of statistical significant. Results: Among the 400 cases, malaria was the most common cause for pancytopenia (n=108, 27%), followed by megaloblastic anaemia (n=93, 23.25%). Other causes included hypersplenism, liver disease, retroviral disease, acute leukaemia, hypoplastic marrow, sepsis, myelodysplastic syndrome, lymphoma, myelofibrosis, and certain infections. Rare causes such as fanconi anaemia, tuberculosis and mucolipidosis were also encountered. The most common symptom with which the patients presented was weakness and easy fatigability (n=337, 84.3%) and pallor was the most common physical sign (n=400, 100%). Conclusion: Pancytopenia is a commonly encountered entity in outpatient clinics which has got a wide variety of differential diagnosis. In certain diseases, pancytopenia is transient and uncomplicated; however, it can be a presenting feature of a life threatening disease as well. Therefore, a systematic approach in evaluating the underlying cause of pancytopenia is essential to plan and implement the timely intervention.

Health-related Quality of Life among University Students: The Role of Demographic Variables

Arash Ziapour, Neda Kianipour

Introduction: Quality of life is seen as a broad concept pertaining to the sense of well-being and satisfaction in life. The physical and mental health of the students directly correlate with the health and future of the society. Aim: The present study aimed to investigate the effect of factors associated with quality of life on health promotion among students at Kermanshah University of Medical Sciences. Materials and Methods: In this descriptive study, 453 students of Kermanshah University of Medical Sciences were selected through stratified random sampling in the academic year 2015-2016. For data collection, a demographic questionnaire and the SF-36 questionnaire were used. Data were analysed through the descriptive statistics (percentage, mean, and standard deviation) and inferential statistics (Kolmogorov–Smirnov test, independent t-test, and ANOVA). Further, the SPSS Statistics 21 Software was utilised for data analysis. Results: The results of the present study showed that the mean and SD of the total score for health-related quality of life of students was measured to be 2.55±0.40. The results also indicated that quality of life significantly correlated with gender, age, marital status, education, faculty, and residence (p<0.001). Conclusion: Considering the results of the present study and the desire of the students for a better quality of life, there is a necessity to introduce programs in universities to improve the quality of life. Also, more attention should be paid towards students’ health and quality of life during their education.

C-reactive Protein as a Diagnostic Marker of Bacterial Infection in Febrile Children

Bandya Sahoo, Bhaskar Thakur, Mukesh Kumar Jain, Reshmi Mishra

Introduction: Evaluation of febrile infants and children without focus possess a great clinical concern. Although several biochemical indices indicate diagnosis towards bacterial agents, combining low cost and easily performed haematological parameters could reasonably predict the presence of Bacterial Infection (BI). Aim: To assess the value of C-reactive Protein (CRP) alone and in conjunction with total White Blood Cell (WBC) count and Absolute Neutrophil Count (ANC) in predicting bacterial infection in febrile children. Materials and Methods: A prospective study was conducted in the Department of Paediatrics of a tertiary care hospital among children aged 1 month to 14 years admitted with fever for >24 hours. Data were collected from 97 consecutive children in whom CRP and total blood count was advised at admission. These data were analysed to predict the presence of BI by investigating the diagnostic performance of CRP, WBC and ANC using standard statistical software Stata version 13.1. Results: BI was diagnosed in 41 children. Sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), Diagnostic Accuracy (DA) of CRP for BI among the febrile infants were 83%, 75.0%, 71%, 86% and 78% respectively. The sensitivity and specificity were 61% and 98% when all the three parameters CRP, WBC and ANC were positive and were 95% and 45% when any of these parameters was positive. Conclusion: A definitive cut-off value of 1.2 mg/L for CRP is a reasonably good predictor of BI among febrile children. However, addition of other laboratory parameters (total leukocyte count and ANC may enhance clinicians’ ability to discriminate bacterial from non BIs.

Clinicobiochemical Difference of Patients Presenting with Dengue and Chikungunya during Post-Monsoon Season

Introduction: India plays host to a number of vector-borne diseases, including dengue and chikungunya. Both diseases demonstrate a synchronised peak, and present with similar findings. An early accurate distinction between them is valuable for effective treatment and prevention of complications. Currently used diagnostic methods estimate either antibodies or antigens; the former are absent in the first week of disease, and testing for the latter is expensive. Aim: To compare clinical profiles (history, examination) and laboratory parameters of patients with dengue fever and chikungunya fever. Materials and Methods: Pre-diagnosed patients of dengue (50) and chikungunya (50) were studied to elicit patterns in clinical, haematological and biochemical profiles which may be used for differentiation. The time taken for resolution of symptoms, and complications, were studied prospectively. The data were analysed using Z-test. Results: In both the diseases, patients present with short pyrexia (<1 week). The study found abdominal pain and bleeding significantly (p-value <0.001) more common in dengue than in chikungunya. It was discovered that joint pain and swelling was significantly (p-value <0.05) more common in chikungunya. Furthermore, leukopenia (<4000 WBCs/cumm) as well as moderate (50,000-100,000 platelets/microL) and severe (<50,000 platelets/microL) thrombocytopenia was significant for dengue. Milder (up to 3 times) SGOT and SGPT elevations were significant for chikungunya, whereas larger (>3 times) elevations were significant for dengue. Conclusion: It may be concluded that the two diseases, despite their synchronised peak during post-monsoon season, and overlapping presenting symptoms, can be distinguished on the basis of clinical profiles of the patients, and a few basic laboratory tests. On studying a larger sample size, the presence of these associations could be determined with more certainty.

Utility of Sonographic Parameters in Prediction of Obesity and their Correlation with Body Mass Index

Introduction: Obesity has become widely prevalent in the world with a desperate need to search the population at risk for complications of obesity for timely intervention. Ultrasonography (USG) has been previously used to measure the Subcutaneous Abdominal Fat Thickness (SAFT); however, its role has not been adequately defined. Aim: To establish the role of USG as a quantitative measure of obesity by measurement of SAFT and Skin Thickness (ST). Materials and Methods: The study was done on a total of 406 patients. Body Mass Index (BMI) was calculated for all the patients who were categorised into four pre defined BMI based subgroups. The patients then underwent USG measurement of SAFT and ST. Statistical analysis with intergroup comparison was done using one-way ANOVA test. Results: Of the total, 146 patients had BMI=25 kg/m2 and belonged to the obese category. Mean values of SAFT and ST showed statistically significant results. Box and whiskers plots for all the variables showed least overlapping of the Interquartile Range (IQR) for SAFT. SAFT showed significantly higher median value for the overweight and obese categories. SAFT showed highest area under the curve with 79% sensitivity and 72% specificity for prediction of obesity (BMI=30 kg/m2) at a value of 18.65 mm. SAFT showed the strongest correlation with increasing BMI. Conclusion: The findings of the present study showed that USG is an excellent modality for the measurement of SAFT and ST which may be useful in future epidemiological studies. Addition of these sonographic parameters may significantly enhance the prediction and categorisation of adiposity over other anthropometric variables like BMI.

Estimation of Total Time Duration and Comfort Equation of Three Different Appliances used to Manage the Condition of Single Tooth Developing Anterior Crossbite in Children

Introduction: Single tooth anterior dental crossbite is a major aesthetic and functional concern to the parents during the early stages of dental development with evident incidence rate during the early mixed dentition period. Though several treatment modalities exist on the dental management of these patients with developing single tooth anterior crossbite, earlier literature has shown variation among dentists in management of such cases. Aim: The purpose of this study was to evaluate and compare the total time duration and comfort equation of three different appliances used to manage the condition of single tooth developing anterior crossbite in children at Mogappair, Chennai, Tamil Nadu, India, using a semi structured printed questionnaire. Materials and Methods: A total number of 30 patients was divided into three groups. 10 patients in each group had underwent treatment with fixed, removable and myofunctional appliances. The inter visit comfort assessment questionnaire in printed format containing five questions was given to all the parents at their first and last visit during their child’s dental treatment, at the waiting area of the department, inside the college campus. Chi-square test was used to analyse the data. Results: Of the total patients (n=30), the time duration for correcting single tooth developing anterior crossbite by fixed appliance was 11 days, removable appliance was 15 days and myofunctional appliance was 21 days. Comfort equation was found to be better in fixed appliance when compared with removable and myofunctional appliance. Conclusion: Several treatment modalities are available for the management of single tooth developing anterior crossbite. Based on the results of this study, the author suggest’s that further research is still needed with larger sample size in estimating the time duration and comfort equation used to manage single tooth developing anterior crossbite for providing effective paediatric dental care.

Platelet Rich Plasma as a Boon for Osteoarthritic Knees- A Prospective Observational Study

Introduction: Knee pain is a leading cause of disability and the most prevalent form in the world. It is associated with tissue inflammation, physical disability and imbalanced homeostasis in cartilage. As the number of people with age greater than 35 years increases, so does the prevalence of knee pain and the need for cost effective treatment and care. A treatment strategy is needed which takes into account the underlying physiology of degenerative joint disease, but it should also consider the different age ranges and their needs in different population. Aim: To assess the clinical and functional benefits associated with the use of intra-articular Platelet Rich Plasma (PRP) in treatment of patients with knee pain of primary Osteoarthritis (OA). Materials and Methods: A prospective observational study of 50 patients visiting the outpatient department from 1st January 2013 to 31st December 2015 with Kellgren and Lawrence Grade 1 and 2 OA knees were evaluated with the Western Ontario and McMaster Universities Arthritis Index (WOMAC) before the treatment and at 1, 3 and 9 months after the PRP intra-articular treatment. Results: Statistically significant improvements in WOMAC scores were noted in all the evaluated measures in all patients. Conclusion: A minimum of two intra-articular injections of PRP is an effective treatment for mild to moderate osteoarthritis of knees.

Practice of Intravenous to Oral Conversion of Antibiotics and its Influence on Length of Stay at a Tertiary Care Hospital: A Prospective Study

Introduction: Several studies have demonstrated the efficacy and safety of switching from intravenous to oral antibiotics in clinically stable patients. Early switch from Intravenous (IV) to Per Oral (PO) could be one of the factors that influence the Length of Hospital Stay (LOHS). Aim: To evaluate the practice of switch from intravenous to oral antibiotics and its impact on the LOHS at a tertiary care hospital. Materials and Methods: A prospective observational study was conducted over a period of six months from November 2015 to April 2016. The practice of conversion from IV to PO antibiotic therapy was assessed according to predefined criteria for clinical stability. Clinical end points such as day of IV to PO switch, LOHS and duration of antibiotic therapy were assessed. Results: Results reveal that 43.68% of antibiotics were converted from IV to oral formulation while 56.32% of antibiotic courses were not converted from IV to oral. Out of all IV to oral conversions, sequential therapy was more commonly used than switch and step-down therapy. LOHS for patients had significantly (p<0.05) decreased following IV to oral conversion of antibiotics in comparison to LOHS for patients with non conversion of antibiotics from IV to oral formulation. Day of conversion was more delayed in switch therapy than two other modes of conversion. Conclusion: Timely switching of antibiotics from IV to oral therapy could reduce the length of hospitalisation for patients.

Effectiveness of Tranexamic Acid for Reducing Postpartum Blood Loss in the First Two Hours after Vaginal Delivery: A Randomised Controlled Trial

Anuchat Sujita, Srisuda Songthamwat, Metha Songthamwat

Introduction: Postpartum Haemorrhage (PPH) is the leading direct cause of maternal death worldwide, especially in developing countries. Fibrinolysis is an important process in bleeding during the third stage of labour. Tranexamic acid (TA) is used to reduce the fibrinolysis process which might reduce the blood loss after delivery. Aim: To study the effectiveness of intravenous TA for reducing postpartum blood loss in the first two hours after vaginal delivery. Materials and Methods: A prospective double blinded Randomised Controlled Trial (RCT) was performed. The participants were randomly allocated to receive either an intravenous infusion of TA (n=75) or a placebo (n=75) after delivery of the anterior shoulder. A prophylactic intramuscular injection of 10 units of oxytocin was used in both groups. Blood loss was directly measured using a collective bag combined with a gravimetric of gauzes and diapers during the first two hours postpartum. The means of blood loss of both groups were compared. The prevalence of PPH (>500 ml) and severe PPH (>1,000 ml) in both groups were analysed. Statistical analysis were performed using Stata13 (Stata Corp, College Station, TX). A p-value below 0.05 was considered statistically significant. Results: Seventy two participants in the TA group and 69 participants in the placebo group completed this study. Mean blood loss in the first two hours for the TA group was not significantly different from the placebo group (226.59±114.66 ml versus 234.05±142.41 ml, p=0.73). Adjusted mean difference was 4.61 ml (95% CI: -48.25 to 39.02). The frequency of PPH was one case in the TA group and three cases in the placebo group (one case was severe PPH). Only one woman had a mild side effect (nausea) and no episode of thrombosis occurred in the women who received TA. Conclusion: In normal delivery, the addition of TA did not reduce the amount of postpartum blood loss in the first two hours compared with prophylaxis oxytocin only.

Factors that Predict the Response to Treatment in Carpal Tunnel Syndrome

Ankur Munjal

Introduction: Carpal tunnel release is a very common surgery and most people do very well after the surgery but some pre-existing conditions can have a negative impact on the outcome of the surgery. Our current knowledge about the impact of these conditions on the outcome of carpal tunnel release is incomplete. Aim: To find out the various factors that could affect the outcome of the carpal tunnel release. Materials and Methods: The present study was a retrospective analysis of the patients who underwent open carpal tunnel decompression and the study evaluates the effect of pre-existing factors like age, sex, duration of symptoms, BMI, Nerve Conduction Studies (NCS), alcohol, smoking status and comorbid conditions like diabetes, depression and fibromyalgia on the outcome of surgery. Chi-square analysis was carried out to find out the relationship between the final outcome and each variable. A p-value <0.05 was considered as significant. Results: Age, sex, duration of symptoms, BMI, NCS, alcohol and smoking status and comorbid conditions like diabetes, and depression were not found to be associated with the outcome. Fibromyalgia was found to be significantly associated with poor outcome. Conclusion: Carpal tunnel release consistently gives good outcomes and must be offered to the patients who have failed conservative treatment, irrespective of the factors like age, sex, duration of symptoms, BMI, NCS, diabetes, and depression. Patients with fibromyalgia must be warned pre-operatively about the possibility of inferior results following the surgery.

Comparative Analysis of Dexmedetomidine and Propofol Based Sedation Regimens on Anaesthetic Requirements in Cardiac Surgery with On-pump Cardiopulmonary Bypass

Sheikh Ahmad Tufail, Nadeem Ahmad, Nihida Akhter

Introduction: Dexmedetomidine is a selective a2-agonist that has been successfully used as an anaesthetic adjuvant in cardiac surgery. Aim: To evaluate the effect of dexmedetomidine on intraoperative requirements of isoflurane and opioids for maintenance of anaesthesia during On-pump cardiac surgery and compare the anaesthesia sparing effect with that of propofol. Materials and Methods: This was a randomised, double blind observational study. Morphine consumption and minimum alveolar concentration of isoflurane was compared among 60 patients planned for elective open heart surgeries who were randomised to receive either dexmedetomidine (1 µg/kg bolus over 10 minutes followed by infusion of 0.2 to 0.6 µg/kg/hour) or propofol (0.25-1 mg/kg/hour) throughout the intraoperative period till skin closure. The drug infusions were titrated to target Bispectral Index (BIS) score of 40-60. BIS scores and minimum alveolar concentration of isoflurane were recorded at predetermined intervals during surgery. Total dose of morphine used was also recorded. Statistical analysis was carried out using analysis of variance, Chi-square test, Student’s t-test and Mann–Whitney U test. Results: BIS scores were significantly lower in dexmedetomidine group (p<0.05). Total dose of morphine and minimum alveolar concentration of isoflurane were significantly lower in dexmedetomidine group (p<0.05). Conclusion: From the results we concluded that intraoperatively administered dexmedetomidine during On-pump cardiac surgery has specific analgesic properties and decreases intraoperative anaesthetic requirement. Thus, dexmedetomidine has significant opioid and anaesthetic sparing property.

Morbidity Audit of Women Beedi Workers in an Urban Fringe of West Bengal, India

Gandhari Basu, Deblina Sarkar, Ranabir Pal, Suman Kumar Roy, Raju Dasgupta

Introduction: Literature has reported morbidity profiles for beedi workers in different parts of India. West Bengal is a place with a good number of beedi workers and only few number of studies have attempted to assess their overall morbidity. Aim: To find out the overall health status and presence of any morbidity among the beedi workers included in the study. Materials and Methods: This cross-sectional survey was conducted among beedi workers from November 2016 to January 2017 in Kalyani, West Bengal. A predesigned, semi structured proforma was used to collect data on sociodemographic profile, awareness of hazards, systemic symptoms along with general and anthropometric examination. For measuring weight and Blood Pressure (BP), calibrated weighing scale and aneroid sphygmomanometer was used. Statistical analysis was done with SPSS Version 16.0. Chi-square value, odd’s ratio, confidence interval was calculated for determining association. Results: A total of 103 women participated with mean (±SE) age of 38.69 (±8.53) years. Literacy status was low; worked an average five hours a day, more than half (n=59,57.28%) started beedi consuming in the age range 15 to 25 years. One-third were in this job for more than 20 years. The proportions of most of the morbidities were quite high. Eye and musculoskeletal system related hazards were most common. Pallor was present in 20 (19.41%) workers. Two-third, (n=68) had more than normal BP and more than half were overweight. The association between the increase in BP and Body Mass Index (BMI) with increasing age of the workers was found to significant (p-value <0.05). Conclusion: The study concludes that the health of the female workforce in an unorganised beedi industry is an important public health issue with worsened scenario of health related hazards.

Mobile Phone and its Effect on Foetal Cardiotocography Pattern

Zaheera Saadia, Robina Farrukh

Introduction: Mobile phones have become a part and parcel of our every day’s life. As they operate by creating an electromagnetic field therefore, there are concerns for their safety while using in pregnancy. Aim: The aim of the present study was to study the differences in Foetal Heart Rate (FHR) pattern between women without mobile phone and then after using mobile phone. Materials and Methods: The present study was conducted as an interventional study at the Department of Obstetrics and Gynecology, Sir Ganga Ram Hospital, Lahore, Pakistan. First the women underwent Cardiotocography (CTG) without mobile phone (controls) and then exposed to mobile phone in calling mode (served as cases) for 10 minutes. The variables measured for CTG were base line FHR, beat to beat variability, accelerations and decelerations. Multivariate Analysis of Variance (MANOVA) was used to evaluate the research question. Results: Participants with mobile phones had significantly lower acceleration scores (M=1.330, SD=0.560) as compared to those without a mobile phone (M=1.590, SD=0.551). Additionally, participants with mobile phones had significantly lower variability scores (M=2.522, SD=0.503) as compared to those without a mobile phone (M=2.725, SD=0.450). Conclusion: Use of mobile phone affects the FHR tracing CTG.

Reliability and Validity of the Indian (Telugu) Version of the Shoulder Pain and Disability Index

Introduction: The Shoulder Pain and Disability Index (SPADI) is one of the most commonly used shoulder specific self report questionnaires that is available to evaluate patients with shoulder pathology but it has not been adapted in Telugu version. Aim: The aim of the present study was to translate, culturally adapt, and validate the Telugu version of the SPADI. Materials and Methods: Based on the cross cultural adaptation guidelines stated by the American Association of Orthopaedic Surgeons (AAOS) outcome committee, cross cultural adaptation and psychometric testing of SPADI was conducted at the Outpatient Physiotherapy Department of the Susruta Institute of Physical Medicine and Rehabilitation, Hyderabad, India. The test-retest reliability was quantified using the Intraclass Correlation Coefficient (ICC) and Cronbach’s alpha was calculated to assess internal consistency of the Telugu questionnaire. Results: The reliability of the total Telugu SPADI and its subsets (Intraclass correlation coefficient >0.96) were found to be higher than that of the English SPADI and the German SPADI in this population. Conclusion: The cross culturally adapted version of the English SPADI into a regional Indian language (Telugu) is easy to use and is a reliable and valid tool for measuring shoulder pain and disability in the Telugu speaking population.

Prevalence of Osteopenia and Osteoporosis in Orthopaedic Outpatients in Southern India

Jojin Jose Chitten, Boblee James

Introduction: Osteoporosis is a common metabolic bone disorder yet, it is underdiagnosed and undertreated in clinical settings. Many studies have shown that, as part of the treatment of fragility fractures, early osteoporosis screening by orthopaedic surgeon, can lead to better management. Even better would be if orthopaedic surgeons could prevent these fragility fractures by routine Bone Mineral Density (BMD) screening in indicated patients to diagnose it early and treat them before fracture occurs. Aim: To find out the age-related prevalence of osteopenia and osteoporosis in patients who attend orthopaedic outpatient clinics in southern India, using quantitative calcaneal ultrasound . Materials and Methods: This was a multicentric cross-sectional study conducted between January 2017 to September 2017 in seven centres in the union territory of Puducherry and one centre in the state of Tamil Nadu. The patients were divided into young (<35 years), middle age (36-55 years) and elderly (>55 years) groups and screened using quantitative calcaneal ultrasound and then BMD was grouped as normal, osteopenia and osteoporosis according to WHO T-score criteria. Statistical analysis were done using SPSS version 23.0. Analysis were carried out at 5% level of significance and p <0.05 (2-sided) was considered statistically significant. Results: The overall prevalence of osteopenia and osteoporosis in present study were found to be (48.4%) and (6.6%) respectively in all the age groups. Women had more prevalence of osteoporosis (9.3%), while men had only (3.5%). But osteopenia was more prevalent in men (51.2%) than women (45.9%). The main finding of the present study was the high prevalence of osteopenia in the middle age group (35-55 years) men and women; (54%) in men and (51%) in women. In the present study even (39%) of men and (34%) women in the young age group were found to be osteopenic while (1%) of men and (3%) of women in the same age group were osteoporotic. Conclusion: We found a high prevalence of osteopenia in the age group of 35-55 years. Hence, we recommend extending routine screening for BMD in middle aged orthopaedic outpatients. And the common understanding that low BMD is mainly a disease of the elderly needs to be reconsidered.

A Magnetic Resonance Study and Demonstration of the Spectrum of Diverse Aetiologies for Trigeminal Neuralgia

Introduction: Intractable hemifacial pain or twitching can be an incapacitating disorder caused by trigeminal neuralgia. The aetiologies for trigeminal neuralgia are numerous and the most frequent cause is a neurovascular compression. However, there are other less common aetiologies which need to be assessed. Magnetic Resonance Imaging (MRI) with dedicated cranial nerve sequences remains the modality of choice in diagnosing and establishing a cause for this condition. Aim: This study aims in showing that all trigeminal neuralgias are not secondary to neurovascular compression and other unusual causes needs to be looked for and assessed during an MRI examination. Materials and Methods: This was a cross-sectional observational study conducted at the Saveetha Medical College and Hospital, Chennai, India (from September 2015 to August 2017). This study included 70 patients presenting with clinical symptoms of unilateral trigeminal neuralgia. The MRI was done using a 1.5 Tesla, Philips multiva system. A high resolution 3D T2 DRIVE or 3D bFFE cranial nerve sequences were performed in addition to the routine Magnetic Resonance (MR) sequences. Patients with known dental issues which could cause the pain, and patients with intracranial tumours were excluded from the study. Results: Out of the 70 patients, we found that the majority (53) had a neurovascular compression, which ranged from a simple indentation by a tortuous Superior Cerebellar Artery (SCA) to full blown vertebrobasilar dolichoectasia. Out of the remaining cases, six were found to be secondary to benign intracranial hypertension with prominent Meckel’s caves. There were two cases who had an unusual finding of “Trigeminal pontine sign”, which were post infective (postherpetic being the most probable cause). Conclusion: By tailoring the MRI protocol in present study, and based on the clinical presentation, we can conclude that in most cases of clinically diagnosed trigeminal neuralgia, it could be possible to demonstrate a probable cause and consequently aid the clinician for appropriate management, and to select only the deserving cases for microvascular decompression.

Assessment of the Consequences of Dental Caries on the Body Mass Index in Children using the Pufa Index

Nikita Vinod Dandekar, J Jasmin Winnier, Uma B Dixit

Introduction: Dental caries continues to exert a significant influence on children’s overall health and the effect of untreated dental caries impacts dental health more than the presence of caries itself. Aim: To investigate the effect of consequences of untreated dental caries on Body Mass Index (BMI) in children using PUFA/pufa index (pulp involvement, ulceration, fistula, and abscess). Materials and Methods: A total of 400 school children aged 5-12 years were divided into two groups-5 to 8 years (Group 1) and 9 to 12 years (Group 2). Selected children were examined for the presence or absence of pulpal involvement, ulceration, fistula and abscess using the PUFA/pufa index, and further subdivided into with PUFA/pufa> 0 and PUFA/pufa =0. Children’s BMI score was calculated using weight in kg and height in meters. BMI scores for children with PUFA/pufa=0 and PUFA/pufa>0 were compared with independent t-test. Correlation between BMI scores and PUFA/pufa score was analysed by using Pearson’s correlation coefficient for both age groups. Results: Mean BMI score of children with PUFA/pufa>0 in both the age groups (14.69 and 14.93) was significantly lesser than the BMI score of children with PUFA/pufa=0 (21.69 and 22.57), (p<0.001). Correlation between BMI and PUFA/pufa score was highly significant in the Group 1 (r=-0.345) whereas, that in the Group 2 was significant (r=-0.234). Conclusion: Children with the consequences of longstanding dental caries had significantly negative effect on BMI. This negative effect was higher in younger children as compared to the older age group.

Influence of BMI on Cardiac Output and Peripheral Blood Flow in Young Adult Males

Sumit Garg, Shitij Arora, Jawahar Lal Agarwal

Introduction: Obesity is increasing at an alarming rate in young population which has a direct effect on their cardiovascular health resulting in development of hypertension, dyslipidaemia and peripheral vascular diseases at an early stage of life. Aim: To determine association of BMI with cardiac output and peripheral blood flow in young adult males. Materials and Methods: The study was a cross-sectional study done in Department of Physiology, Saraswathi Institute of Medical Sciences, Hapur, Uttar Pradesh, India, between August to September 2015 under ICMR STS project. A total of 90 males with age 17-25 years with no history of smoking, alcoholism, diabetes mellitus, hypertension, cardiovascular or respiratory diseases were enrolled. BMI (kg/m2) was calculated and equal numbers of subjects were categorised into three groups according to BMI (South Asian Standards). Non obese (BMI <22.9 kg/m2), Overweight (BMI between 23-24.9 kg/m2) and Obese (BMI =25 kg/m2). Cardiac output and peripheral blood flow of forearm and calf were measured using Non Invasive Continuous Cardiac Output and Peripheral Blood Flow Monitor (NIVOMON) series. The data were analysed statistically by using one-way ANOVA test. Results: Cardiac output was significantly more in obese group compared to overweight and normal BMI group (5.7±0.43 vs. 5.26±0.54 vs. 4.95±0.65 L/min, p<0.01). Forearm and calf blood flow of both limbs were significantly less in obese group compared to overweight and normal (p<0.01). Conclusion: Obese subjects have increased cardiac output which may lead to cardiac complications like left ventricular hypertrophy and high output cardiac failure in future. Inspite of increased cardiac output, peripheral blood flow was decreased in obese subjects which may be due to endothelial dysfunction and accelerated atherosclerotic vasoconstriction which may result in peripheral artery disease in future.

A Morphological and Morphometric Study on Meniscofemoral Ligaments of Knee Joint and its Variations

Prerana Aggarwal, Anwesa Pal, Asis Kumar Ghosal, Indra Datta, Biswarup Banerjee

Introduction: There are two Meniscofemoral Ligaments (MFLs) in the knee joint, anterior Meniscofemoral Ligament (aMFL) and posterior Meniscofemoral Ligament (pMFL) named according to their position relative to Posterior Cruciate Ligament (PCL). Aim: To describe the frequency of occurrence of MFLs and their anatomical variations along with variations in their size in adult cadaveric knees. Materials and Methods: A total of 38 cadaveric knees belonging to both genders and age ranging from 40-65 years were dissected in the Department of Anatomy IPGMER, Kolkata, India over a period of two years (May 2015 to April 2017). After treating the cadavers with 10% formalin, posterior capsulotomy was done to expose the interior of the knee joint followed by anterior capsulotomy. MFLs (anterior and posterior) were identified in relation to PCL. Their frequency, size and anatomy were noted along with the variations, data analysis was done using SPSS version 23.0, compared with other studies and inference was drawn. Results: At least one MFL was present in every knee joint dissected. Both aMFL and pMFL were present in 10 (26.3%) joints, only aMFL in 4 joints (10.5%) and only pMFL in 24 joints (63.2%). An accessory band was found in 8 (21.05%) joints (2 with only aMFL and 6 with only pMFL). Mean age of subjects with both aMFL and pMFL was 45.40±3.14 years, those with either of the ligaments was 56.86±5.27 years. Mean length of aMFL and pMFL was 25.74±1.98 mm and 31.63±4.87 mm respectively. Mean length of pMFL in males and females was 33.08±3.15 mm and 28.99±6.35 mm respectively. Mean width of pMFL at lateral end was 5.97±0.96 and 5.13±1.25 in males and females respectively. Therefore, pMFL was found to be more prevalent and longer than aMFL, also pMFL in males was longer and broader at lateral end than in females. Conclusion: Presence of at least one MFL in each knee joint, variations in anatomy in the form of presence of accessory bands and in size suggest the importance of identifying and differentiating these ligaments from the surrounding structures during radiological and arthroscopic examination for correct diagnosis and treatment. Presence of either MFLs in older subjects and both in younger subjects suggests degeneration of these ligaments with the advancement of age.

Comparative Evaluation of Neem, Aloevera, Chlorhexidine and Calcium Hydroxide as an Intracanal Medicament against E. faecalis-An in vitro Study

Chandrashekar Shikaripura Kusuma, Vinutha Manjunath, Paras Mull Gehlot

Introduction: Microorganisms play a fundamental role in the aetiology of pulp and periapical diseases. Their control and elimination are important during endodontic treatment. Intracanal medicaments help in reducing the bacteria remaining after root canal preparation and can provide a favourable environment for periapical tissue repair. Aim: To determine the antimicrobial activity of neem extract, aloevera and calcium hydroxide in comparison with 2% Chlorhexidine on Enterococcus faecalis (E. faecalis) infected root canal dentin at two different depths (200 µm and 400 µm) and at three intervals of time (day 1, 3 and 5). Materials and Methods: A total of 90 extracted single rooted human premolar teeth were selected for the study and infected for 21 days with E. faecalis. Samples were divided into five groups: Group I (2% chlorhexidine); Group II (neem); Group III (calcium hydroxide); Group IV (aloevera); and Group V (saline). The remaining vital bacterial population was assessed at the end of 1, 3 and 5 days. Gates glidden drills were used to obtain dentin shavings at two depths (200 µm and 400 µm) and the total number of Colony Forming Units (CFUs) were determined following culture. The data were statistically analysed using ANOVA and Scheffe’s multiple comparison test (p<0.05). Results: Chlorhexidine produced better antimicrobial efficacy followed by neem and calcium hydroxide. Aloevera showed the least antimicrobial activity. There was statistical significant difference between the experimental groups, neem showing highest antimicrobial activity and aloevera the least at 200 µm and 400 µm depth. Conclusion: Among the natural intracanal medicaments, neem consistently showed good inhibition up to five days, with aloevera showing minimal antimicrobial activity.

Antiretroviral Therapy under the National Program: Experience of a Single Large Centre in Southern India

Introduction: The National Aids Control Organization (NACO) has been providing free Antiretroviral Therapy (ART) in India since 2004. Several concerns exist regarding functional outcome, possible low rates of treatment adherence, treatment failure, mortality and high drug toxicity with the provision of large scale free ART. Aim: This study was done to evaluate the outcomes of ability to return to work, lost to follow up rates, treatment failure and drug toxicity requiring regimen change from the ART centre located in Christian Medical College, Vellore, Tamil Nadu, India, which is a large tertiary care centre attached to an academic Infectious Disease and medical unit in Southern India. Materials and Methods: A prospective longitudinal follow up study on patients enrolled in the NACO ART centre at a large tertiary care hospital in Southern India between April 2008 and April 2012 were followed up for a minimum of two years. Outcomes assessed were WHO clinical stage and functional status at the end of the follow up period, rate of lost to follow up, failure of ART, mortality rate and drug toxicity requiring change of regimen. Results: There were 963 patients included in the study with a mean follow up period of 39.78 months (SD 11.34). At the end of the follow up period, 914 (94.9%) of the patients were asymptomatic (WHO clinical stage 1T) and 92.3% of all patients on treatment were able to return to work after ART initiation. We found low rates of lost to follow up (3.2%), drug toxicity and mortality (5.8%) compared to data from other centres in India. A total of 136 adverse events were recorded, the most common being Zidovudine induced anaemia (7.2%). There was also a very low rate of treatment failure in our cohort. Conclusion: This data shows the overall success of the program and the feasibility of having low rates of lost to follow up because of rigorous methods used in follow up of patients and support offered by attachment to an academic infectious disease unit.

A Five Year Analysis of Sudden Death Cases at a Tertiary Care Hospital in South India–A Postmortem Study

Hajra K Mehdi, Kalyani Raju, CV Raghuveer

Introduction: Sudden Death (SD) is defined by WHO as death within 24 hours from the onset of symptoms. Cardiac causes form most of the cases and acute myocardial infarction is the common cause of mortality. There is limited data in Indian literature. Aim: To study and analyse the different morphological features of SDs at postmortem examination. Materials and Methods: The present retrospective cross-sectional study was conducted in Sri Devaraj Urs Medical College, Karnataka, India. All autopsy cases of SD from 1 July 2012 to 30 June 2017 were collected from the archives of Pathology, Forensic Medicine and Toxicology Department. The sociodemographic data of each case was noted. The autopsied specimens were examined grossly and the histomorphological findings were noted. Results: In five years, 11 cases underwent autopsy for SD. Only 10 (91%) out of 11 cases were males. Mean age of the cases was 44.36 years (standard deviation, 4.35). In 9 (81%) cases SD was attributed to cardiac causes. Only 1 (9.09%) case had a hepatic cause. One case (9.09%) had no demonstrable cardiac or non cardiac pathology. Out of the 9 cardiac cases, atheromatous plaque was seen in 5 (55.5%) cases ranging from American Heart Association (AHA) Grade 2 to Grade 5. Myocardial infarction was seen in 2 (22.2%) out of 9 cases. Intraventricular thrombus was seen in 3 (33.3%) out of 9 cases. Out of 9 cardiac cases, pulmonary congestion was seen in 2 (22.2%) cases. Conclusion: Cardiac factors are the major cause of SD. Awareness regarding preventive measures and affordable interventions should be made available by the health authorities.

Expression of COX-2 in Carcinoma Breast

Ashish Sharma, Nisha Marwah, Padam Parmar, Rajeev Sen

Introduction: Early detection of breast cancer with chemoprevention is needed to decrease cancer related mortality at an early stage. The role of Cyclooxygenase-2 (COX-2) in carcinogenesis and tumour progression has been a subject of interest in breast cancer. Aim: To study the spectrum of COX-2 expression in normal breast tissue, Ductal Carcinoma In Situ (DCIS) and invasive breast cancer. Materials and Methods: Fifty cases of primary breast cancer undergoing radical or modified radical mastectomy constituted the study group. Histopathological diagnosis was established on routine Haematoxylin and Eosin (H&E) stain and various histologic prognostic parameters were assessed. Immunohistochemical profile of the tumour was assessed by subjecting one section each from a representative block of tumour to ER, PR, HER2/neu and COX-2. Immunohistochemical Score (IHS) of COX-2 was calculated by combining an estimate of the percentage of immunoreactive cells (quantity score) with an estimate of the staining intensity (staining intensity score). The results obtained were interpreted and correlated statistically. When the data was qualitative, a chi-square test was used to assess the association. Correlation of COX-2 IHS with clinicopathological parameters and different areas was calculated by Spearman rank correlation (rs). The significance of correlation was evaluated by using critical values table for Spearman’s coefficient of correlation. Results: COX-2 IHS was negative in (n=17, 34%) and moderately positive in (n=33, 66%) of the tumour cases examined. Among normal breast tissues, negative and moderate positivity was seen in (n=14, 28%) and (n=36, 72%) of the cases respectively. Amongst the 23 cases with DCIS component, (n=20, 86%) of the cases revealed moderately positive COX-2 IHS. COX-2 expression was correlated within normal breast tissue, DCIS component and invasive areas, as paired samples. Paired areas examined for COX-2 expression with group of normal-invasive, normal-DCIS and tumour-DCIS and all the three components together. Correlation of COX-2 expression among the paired areas examined was statistically significant. Conclusion: Based on present results, COX-2 exerts autocrine and paracrine effects and is involved in early breast cancer carcinogenesis. Inhibition of COX-2 may represent a potential target for preventing breast cancer oncogenesis.

Clinical Value of Stone Radiodensity and Size in Predicting the Outcome of Extracorporeal Shockwave Lithotripsy in Renal Stones

Heshmatollah Sofimajidpour, Hooshmand Sofimajidpour

Introduction: The success rate of Extracorporeal Shockwave Lithotripsy (ESWL) depends on multiple factors. A major cause of ESWL failure is an undesirable stone composition. Aim: The aim of this study was to evaluate the usefulness of measuring renal calculi attenuation values on unenhanced computerised tomography images as a predictor of the outcome of ESWL in patients with a single renal stone of 7-20 mm, located in the renal pelvis. Materials and Methods: This retrospective study was conducted on 151 patients with renal stone of 7-20 mm within the renal pelvis who were referred to the Tohid Hospital, Sanandaj, Iran during the time period between May 2011 and May 2015. Patients with a single stone of 7-20 mm located in the renal pelvis were included in this study. Patients with elevated creatinine levels (more than 2 mg/dL), single kidney, obstructed kidney stones more than 20 mm and stones elsewhere in the collecting system were excluded from the study. For all patients Non-Contrast Computerised Tomography (NCCT) and ESWL was performed. Stone density, stone size and stone free rate were measured. Successful treatment of renal stones was defined as those patients who were stone free or were asymptomatic i.e., clinically insignificant residual fragments =4 mm in diameter, as measured by KUB X-ray and sonograhy three months after ESWL. The patients were further analysed by dividing them into six groups according to the stone density. All ESWLs were undertaken by STORZ SLK Lithotripter with fragmentation performed under fluoroscopic guidance. Data were analysed using SPSS statistical software version 18.0 and Chi-square test was also used. Results: The results showed that the ESWL success rate in patients with small stone size and high stone radiodensity was (n=10, 52.6%), while in patients with large stone size and high stone radiodensity it was (n=4, 36.4%). There was a significant difference between the success rate of lithotripsy and stone radiodensity (p-value=0.0002). Conclusion: The findings of the present study showed that stone radiodensity and stone size were useful parameters to predict the outcome of ESWL. We found a direct relation between the stone radiodensity and ESWL success rate. In addition, the results of our study showed that ESWL success rate in patients with small stone size (7-14 mm) was clinically remarkable. Considering these two parameters in conjunction with other stone parameters to select appropriate procedure is suggested.

Thyroid Disorders in Pregnancy: An Exploratory Study

Jyochnamayi Panda, Aparajita Maji, Jayanti Mishra, Magna Manjareeka

Introduction: Thyroid disorders, mostly hypothyroidism, being one of the common diseases during pregnancy, if untreated, affect the neuro-psycho development of neonates. Many factors influence thyroid function tests in pregnancy; ethnic variations or different environmental conditions being one of them. Aim: This study was done to find the prevalence of overt hypothyroidism, subclinical hypothyroidism, overt hyperthyroidism and subclinical hyperthyroidism in the pregnant women in all trimesters. Materials and Methods: The present cross-sectional study was carried out by the Department of Obstetrics and Gynaecology and the Department of Physiology over a period of one year. Pregnant women who consented; with uncomplicated singleton pregnancy attending the antenatal check up for first time at antenatal OPD were included for the study. Blood samples for the estimation of FT4 and TSH were collected during a specific time period of the day. Serum FT4 and TSH estimation were done using an electro-chemiluminescent immunoassay technique. Results: Amongst the total 505 enrolled pregnant ladies 428 were included in the study. There were (n=278, 65.0%), (n=146, 34.1%) and (n=4, 0.9%) women in their first trimester, second trimester and third trimester respectively. With TSH cut off at 2.5mIU/L, prevalence of subclinical hypothyroidism was (n=159, 37.15%) and overt hypothyroidism was (n=48, 11.21%). Prevalence of subclinical hypothyroidism was (n=13, 3.04%) when TSH cut off 4.5mIU/L was considered. There was no significant difference in prevalence of subclinical hypothyroidism or overt hypothyroidism in pregnant ladies in different trimesters. Prevalence of subclinical hypothyroidism and overt hypothyroidism was lesser in women in primi gravida than women in multi gravida. There were no women with subclinical hyperthyroidism or overt hyperthyroidism. Conclusion: Hypothyroidism is more prevalent among the thyroid disorders during pregnancy. Prevalence of subclinical and overt hypothyroidism is more in multiparous pregnant women, irrespective of their trimesters.

Radiological Assessment of Idiopathic Club Foot Treated with Ponseti Technique

Rohit K Shankar, Prem Kotian, Rajendra Annappa, Premjit Sujir, Varghese Joe

Introduction: Idiopathic club foot is primarily treated by Ponseti technique of serial manipulation and casting. Ponseti recommended evaluation of club foot by palpation, but it is subjective, dependent on clinical experience and limited by inter-observer variability. Aim: To assess the deformities and amount of correction achieved after the treatment using radiographs obtained before and after treatment. Materials and Methods: A non-randomized, interventional study was done among patients with idiopathic club foot treated by Ponseti method. Radiographs including the anteroposterior and lateral projections in maximum dorsiflexion of foot were taken at presentation and after completion of treatment. Five parameters, i.e., the Anteroposterior (TCA-AP) and Lateral Talo-Calcaneal Angle (TCA-LT), Anteroposterior Talo-First Metatarsal Angle (TMT-AP), Lateral Tibio-Calcaneal Angle (TiC-LT) and Talo-Calcaneal Index (TCI) were measured and analysed. The Students paired t-test was used to compare the variables before and after treatment and a p-value of less than 0.05 was considered significant. Results: There was a statistically significant improvement in the mean values of the five parameters after treatment when compared with the values on presentation. The Anteroposterior Talo-Calcaneal Angle (TCA-AP) before treatment had a mean value of 21.4 and after treatment had a mean value of 33.82° (p-value <0.05). The TMT-AP had a mean value of 29.07° & 2.14° following treatment (p-value <0.05). The TCA-LT had a mean of 18.05° prior to treatment & 34° after correction (p-value <0.05). The TCI had a mean of 39.41° before treatment & 67.82° after treatment (p-value<0.05). The TiC-LT at presentation had a mean value of 102.95° & 64.31 after treatment (p-value <0.05). Conclusion: Analytical radiology of club foot is a reliable method of evaluation of the treatment and tends to be more objective and critical when multiple parameters are considered.

Molecular Characterisation of Fungi from Mycotic Keratitis and Invasive Infections and Comparison with Conventional Methods

Introduction: Fungi can cause systemic or localised infections in human beings, among which mycotic keratitis and Invasive Fungal Infections (IFIs) are very important, which can lead to severe complications and fatal consequences. In some instances, fungal culture isolates may not be identified accurately on the basis of morphology and microscopy. In those cases, molecular characterisation of isolates becomes more helpful in identification, which is essential for providing appropriate antifungal therapy and avoiding bad prognosis. Aim: To identify the fungi collected from patients of mycotic keratitis and IFIs (diagnosed by conventional methods) using molecular methods and to compare the results with the results of conventional methods of identification. Materials and Methods: In the present prospective study, fungal culture isolates were taken from 24 keratomycosis and seven IFIs patients (diagnosed by conventional methods) reporting to the OPD and wards of AIIMS Hospital, Delhi, India (March 2016 to March 2017). Isolates were further subcultured for DNA isolation and amplification for the variable ITS1 and ITS2 regions, and processed for nucleotide sequencing. The obtained sequences for ITS1 and ITS2 regions were searched for homology with NCBI-BLAST program. Results of molecular diagnosis at species level were compared with the conventional methods. Results: Conventional methods could identify Fusarium spp., Alternaria spp., Bipolaris spp., Cladosporium spp., Penicillium spp., Rhizopus spp., up to genus level only, which could be further identified up to species level by molecular methods. Phenotypically identified isolates of Acremonium spp. was identified as Simplicillium spp., Alternaria spp. as Chaetomium globosum, Mucor spp. as Rhizopus oryzae by molecular methods. Conclusion: As prognosis and therapy varies among different genera of fungi and in some cases from species to species, correct species level identification is important; hence, molecular methods may be complemented to traditional methods. Identification of rare fungal isolates is also important in clinical mycology, so that they will not be discarded as contaminants, which is possible using molecular techniques.

Clinical Profile, Evaluation and Management of Gallstone Disease in Children in a Rural Referral Tertiary Centre

Gaurav Gupta, Balija Satyasree, Sangeeta Gupta, Vishrut Narang, Prateek Sharda

Introduction: Cholelithiasis or gallstone disease is primarily a disease of adults. Recently, there has been a global increase in the incidence in children resulting in an increased number of cholecystectomies both by open technique as well as by laparoscopy at a very young age. Aim: To study the epidemiology and to evaluate the management options and outcomes of cholelithiasis in children from a rural background. Materials and Methods: A prospective study was done on 30 children diagnosed with cholelithiasis in a tertiary care medical college and hospital from April 2014 to April 2016. The data was analysed and evaluated for clinical presentation and management outcomes. Observations were made on the type of surgery (open/laparoscopic cholecystectomy), economical aspects, morbidity and mortality in these patients by descriptive statistics. Results: Amongst the 30 children, males were more commonly affected than females. Children taking a mixed diet (vegetarian and non-vegetarian) had a greater tendency to form gallstones. Laparoscopic cholecystectomy was performed in (n=24, 80%) of cases while (n=6, 20%) cases underwent open cholecystectomy. Mixed stones were common with an incidence of (n=20, 66.6%) while cholesterol stones and pigment stones had an equal incidence of 16.7% in the persent study. No intraperitoneal drainage was done and there were no early or late complications in the present study. Conclusion: Laparoscopic cholecystectomy is a safe, economical and efficacious procedure. It does not have significant morbidity and there is no surgery related mortality.

Yoga Based Lifestyle Program in Improving Quality of Life after Coronary Artery Bypass Graft Surgery: A Randomised Controlled Trial

Introduction: The Quality of Life (QOL) after Coronary Artery Bypass Grafting (CABG) is an important contributor to morbidity and mortality. The addition of Yoga Based Lifestyle Program (YLSP) to conventional cardiac rehabilitation has found useful and effective in improving ejection fraction and reducing risk factor profiles. Aim: The aim of the present study was to evaluate the effect of add-on YLSP to conventional post-CABG rehabilitation and to compare the changes of QOL. Materials and Methods: A total of 300 patients posted for elective CABG at Narayana Hrudayalaya Super Specialty Hospital, Bengaluru, India were randomised into two groups (150 each) i.e., Conventional Lifestyle Program (CLSP) and YLSP. Data on CLSP (95) and YLSP (102) was available for analysis at one year follow up. The YLSP Group practiced integrated yoga module including Yama, Niyama, Anasa, Pranayama and Meditation as an add-on to conventional lifestyle advice. Assessments were done before and one year after CABG on World Health Organization Quality of Life- Brief form questionnaire (WHOQOLBREF) with four domains viz., ‘Physical Health’, ‘Mental Health’, ‘Social relationships’ and ‘Environmental health’. As the data was not normally distributed, the non-parametric tests viz., Mann-Whitney Test and Wilcoxon signed ranks test for between group and within group comparisons were applied. Results: In YLSP group, significant (p<0.001; Wilcoxon’s test) improvements were found within group after one year in all domains of WHOQOL-BREF, while there was significant improvement (p<0.05; Wilcoxon’s test) only in the Social health domain, in the control (CLSP) group. There was significant differences between groups (p<0.05; Mann-Whitney test) in all domains with better improvement in the YLSP Group. Conclusion: Addition of integrated yoga program to conventional post-CABG rehabilitation leads to better improvement in all domains of quality of life after coronary artery bypass surgery.

Comparison of Body Mass Index Percentile with Two Different Types of Skeletal Maturity Indicators: An Observational Study

Introduction: Skeletal maturational status is widely used in actively growing patients to determine the timing and modalities of orthodontic treatment. Previous investigations have found obese children to have an advanced skeletal age. Aim: To compare and correlate Body Mass Index (BMI) percentile with two different types of skeletal maturity indicators: Cervical Vertebral Maturity Indicators (CVMI) and hand wrist radiographic method (SMI) in orthodontic patients. Materials and Methods: This observational study was drawn from the subjects registered for orthodontic treatment between January 2011 to December 2015 at Narayana Dental College, Nellore, Andhra Pradesh. A sample of 250 subjects (137 males, 113 females) aged between 7-19 years with different stages of skeletal maturation were selected from the existing treatment records. The total subjects were segregated into four groups, correlating BMI percentile stages with that of CVMI and SMI. Analysis of the data is done by SPSS software. Spearman's correlation coefficient test to assess the correlation between BMI percentile Groups and skeletal maturity indicators. Results: The median distribution in case of obese groups was found to be centred around Stage 3 of SMI, Stage 3 and Stage 4 of CVMI indicating early skeletal maturity. There was a significant correlation between the CVMI and SMI in each of the BMI percentile Groups. Conclusion: There was a significant relationship between weight status as defined by BMI percentile and skeletal maturation stages. However, the difference in strength of correlation of BMI in relation to SMI and CVMI is not significant.

Study of Soluble Transferrin Receptor/Log Ferritin Ratio as a Determinant of Body Iron in Young Healthy Non Pregnant Females

Introduction: Iron deficiency is the most common nutritional deficiency which affects young females in India. A battery of diagnostic tests is available these days which can diagnose this condition. However, to arrive at a particular marker which can tell about the iron status of healthy and non anaemic females becomes more promising as timely preventive interventions may be started. Aim: To determine the role of soluble Transferrin Receptor (sTfR) and index based on it in determining the body iron status in young non anaemic females. Materials and Methods: We undertook a cross-sectional study and recruited 200 female students (in the age group of 18-22 years) of SGT University; who volunteered to participate. Only those with haemoglobin (Hb)>12 gm/dL upon screening were included in the study. Blood samples were taken from the participants and routine haematological parameters were measured i.e., haematocrit, Mean Corpuscular Volume (MCV), Mean Corpuscular Haemoglobin Concentration (MCHC), Mean Corpuscular Haemoglobin (MCH), platelet count, red cell count and Total Leukocyte Count (TLC) to rule out anaemia and inflammation. Further we measured the iron markers like serum ferritin, transferrrin, iron, Total Iron Binding Capacity (TIBC) and Transferrin Saturation (TSAT) and sTfR along with the calculation of a ratio i.e., sTfR/log ferritin ratio (R/F ratio). This ratio was correlated with the traditional iron markers using Pearson’s correlation coefficients. Receiver Operating Characteristic (ROC) curve was used to arrive at the desired sensitivity and specificity for a particular test at a particular cut off level. Results: The sTfR/log ferritin (R/F ratio) had better discriminative power compared to sTfR or serum ferritin alone to distinguish between iron deficient and non iron deficient population. It had the best combination of sensitivity and specificity at a cut off value of 1.575 derived from ROC (AUC 0.9809) and identified 108/200 (54%) subjects to be iron deficient with a good sensitivity (98.18) and specificity (87.5%). Conclusion: Significant numbers of healthy females were found to be iron deficient and therefore accurate analysis of iron status will aid in undertaking timely preventive intervention. R/F ratio at a cut off value of 1.575 can become a good screening test in bringing forth such individuals and providing an insight towards their body iron status.

Morbidity Pattern of Patients Attending a Primary Healthcare Facility in an Urban Slum of Chandigarh, India

Rajesh Kumar, Navdeep Kaur, Manju Pilania

Introduction: The knowledge of morbidity pattern at primary healthcare level plays a key role to plan resources for a community efficiently. Poor living conditions in slums along with the effect of urbanisation makes them peculiar to study. Aim: To study the morbidity pattern of patients who attended a primary healthcare facility in an urban slum of Chandigarh, India. Materials and Methods: Secondary data analysis of outpatients of a primary healthcare facility in a slum area of Chandigarh, India was done. The sample size of the study was 16,483 morbidity for the year 2016. Diseases were categorised according to organ system of the body. Descriptive statistics were used to present the results. Pearson’s Chi-square test was used to determine the difference between proportions. Results: In this study, a total of 14,153 patients who suffered from 16,483 total morbidity attended the outpatient department of urban primary care facility. Most common morbidity reported was due to respiratory diseases (6214,37.7%) followed by gastrointestinal (2056,12.5%) and cardiovascular diseases (1253,7.6%). Total morbidity of females (62.2%) was higher than males. Proportion of morbidity was higher in females, except injury, which was predominant in males. In reproductive and urinary tract infections, nutritional disorders, musculoskeletal and cardiovascular diseases groups, morbidity in females constituted more than 80% of total in each group. Communicable Diseases (CDs) constituted approximately two-third of the morbidity while Non Communicable Diseases (NCDs) contributed one-fifth of the disease burden. Seasonal pattern of morbidity showed higher cases in the months of July to October with a peak in September. Conclusion: Predominantly, slum dwellers are still facing burden of CD. Morbidity pattern at a primary care level facility is a valuable tool for program managers and policy makers to plan services at grass root level in fast growing urban areas in India.

Video Assisted Thoracoscopic Surgery Emerging as a Primary Treatment for Empyema Thoracis

Bhagavan C Balagopal, Harsha Goutham, Lohit Shetty Raju

Introduction: The current treatments of empyema include tube thoracostomy with or without the instillation of fibrinolytics, Video Assisted Thoracoscopic Surgery (VATS), and an open thoracotomy with decortication. Success has been reported for all of these techniques. VATS has been suggested as the best method because of decreased length of stay and least postoperative morbidity. Conversion to Open Thoracotomy for Decortication (OD) is more frequent in the setting of complex, chronic empyema. Aim: To determine the indications, its efficacy, postoperative pain (VAS/CHEOPS), for VATS in the management of empyema. Materials and Methods: This was a prospective study conducted in Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India, for a period of 24 months from October 2011 to October 2013. A total of 37 cases (21 paediatric cases and 16 adult cases) were studied. Based on the duration of symptoms the patients were divided into three clinical stages of empyema. Depending on the radiological findings (CT Scan/USG Thorax), 19 patients were subjected to primary VATS. The rest of the patients (n=18) who did not respond to ICD tube thoracostomy were subjected to VATS later. VATS debridement or decortication was attempted according to intraoperative findings. If successful debridement/decortication was not possible then conversion to open thoracotomy was done. In all patients who underwent surgery ICD tube was inserted postoperatively. Results: VATS was successful in 30 (81%) cases and conversion to open thoracotomy was done in 7 (19%). VATS decortication was successfully and effectively done in seven patients. All the stages of empyema were effectively treated through VATS. Conversion to thoracotomy was done because of dense fibrous strands and thickened pleura, which were unable to be managed by VATS. VATS lead to earlier recovery, reduced hospital stay and less morbidity. Stage III empyema was found statistical significant for VAS scores on postoperative day 1 {F(1,24)=26.14, p<0.001} and day 7 {F(1,24)=28.09, p<0.001} in VATS group compared to thoracotomy group using one way ANOVA. Decortication done by both methods (VATS/thorocostomy) gave similar degree of postoperative radiological and functional improvements. Most of the pleural fluid culture yielded Pneumococcus and Staphylococcus aeurus. Five patients (17%) had complications after VATS i.e., uncomplicated pleural effusion, surgical site infection. Conclusion: The VATS is a safe, efficacious and feasible procedure which can be done in all the stages of empyema. Early primary VATS should be performed in patients with Stage I empyema with multiloculations. Open thoracotomy should be reserved when VATS fails. However, the VATS approach gives less pain and greater patient acceptance.

Compliance to Antihypertensive Therapy and its Predictors: A Cross-sectional Study in Western Coastal Region of India

Amrita Sarkar, Naresh R Makwana, Pradeep Pithadia, Dipesh V Parmar

Introduction: Hypertension (HTN) is a chronic Cardiovascular Disease (CVD) characterised by persistently raised Blood Pressure (BP >140/90 mmHg), leading to various complications and currently causing the highest mortality, worldwide. The risks of morbidity and mortality related to HTN can be diminished by proper compliance to pharmacotherapy. Aim: To assess the compliance to treatment of HTN and to study its correlation with various sociodemographic variables, presence of other comorbidities, BP control, duration of disease and knowledge about duration of continuation of antihypertensives. Materials and Methods: A cross-sectional study was conducted in a district of Gujarat, India for a period of one year. A sample size of 400 was calculated. Hypertensive patients attending Non Communicable Disease (NCD) clinics at the tertiary care hospital and Community Health Centres (CHCs) of Jamnagar district, Gujarat, India selected by simple random sampling, formed the study population. Data were collected from patients using a predesigned, pretested and semistructured questionnaire. The data were analysed by MedCalc 10.4.8.0 software applying Chi-square test. Results: The rate of treatment compliance observed was 359 (89.8%). Among the non compliant patients, 28 (68.3%) had poor compliance whereas 13 (31.7%) had discontinued the treatment. Compliance to treatment showed highly significant association (p<0.001) with age, type of family, educational status, socioeconomic status, locality of residence, health insurance status and knowledge about hypertensive treatment. Patients with improper knowledge about treatment were more likely to be non compliant. It was observed the duration of illness was inversely proportional to the treatment compliance and this was statistically significant (p<0.05). Significant statistical association (p<0.05) was also observed between marital status and occupation of the patient and compliance. The other reasons of non compliance were forgetfulness, financial reasons and it was also observed that patients did not like to carry their medications when away from home. It was observed that only 10 (24.4%) of the non compliant patients had controlled BP as compared to 150 (41.9%) in the compliant patients. Conclusion: The findings of the study suggest measures should be taken for proper awareness among patients regarding HTN, its treatment and complications. Log book maintenance and other measures for checking compliance should be adopted.

Protein Creatinine Index: An Alternative for Screening Nephropathy in Hypertensives

Akif Ahsan, Arsalan Moinuddin, Anwar Hasan Siddiqui, Sana Alam, Aquil Ahmad

Introduction: The 24-hour urinary protein estimation is the gold standard for detecting proteinuria and nephropathy in hypertensives. But, it’s a time-consuming and inconvenient process. Aim: The aim of the present study was to analyse the utility of urinary Protein Creatinine Index (PCI) as an alternative approach to predict nephropathy in hypertensives. Materials and Methods: Urinary PCI and 24-hour urinary protein was estimated in 300 hypertensive and 100 control subjects and various diagnostic parameters of urinary PCI, at different cut offs, was assessed using Receiver Operating Characteristic (ROC) curve. Results: At cut off 1200, urinary PCI predicts nephropathy with 81.6% sensitivity, 78.5% specificity, 79.52% accuracy and Youden’s index of 0.60, and can be considered as a reasonable diagnostic alternative. Similarly, at cut off 300 and 200, urinary PCI can be used to predict proteinuria >300 mg and >150 mg. At cut off 800, urinary PCI can prognosticate nephropathy with 95.3% sensitivity, 96.33% negative predictive rate and negative likelihood ratio of 0.08. Conclusion: The PCI can diagnose nephropathy and proteinuria, in hypertensives, with good accuracy and can be used as an alternative for 24-hour urinary protein estimation. At the very least, urinary PCI (cut off 800) can be safely used as a screening tool for predicting nephropathy in hypertensives.

To Assess Functional Outcome for Intra-Articular and Extra-Articular Distal Femur Fracture in Patients using Retrograde Nailing or Locked Compression Plating

Saumya Agarwal, Shailesh Udapudi, Srinath Gupta

Introduction: Distal femur fractures are one of the most common fractures encountered in high velocity trauma which are associated with high morbidity and mortality. The incidence of distal femoral fractures is approximately 37 per 100000 person per year. Fixation of intra-articular fractures is a challenge even to most experienced surgeons. The ideal treatment plan of intra-articular distal femur fracture is still open for debate. Aim: The aim of the present study was to determine the best functional outcome for distal third femur fracture treated by closed/open reduction using retrograde nailing or locked compression plating in respect to knee-flexion, early mobilisation and fracture union. Materials and Methods: A prospective study was carried out at KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India, in which 40 patients with age >18 years were operated with either Retrograde nailing (20) or locked compression plating (20) for intra-articular and extra-articular distal femur fractures (July 2015 to June 2017). Patients with Grade 1 and 2 fractures (Gustillo-Anderson classification), who were medically fit, both males and females in the age group of 18 years and above were included in the study. Exclusion criteria included, patients having pathological fractures, who were not fit for surgery, was not willing for surgery, lost in follow up and distal femoral fractures with neurovascular compromise. We use chi-square test and fisher’s exact test to find the p-value. Results: Patients who underwent retrograde nailing, showed average radiological union time of 14.6 weeks, average full weight bearing time of 12.4 weeks, average knee flexion of 113.4 degree with an extensor lag of 3 degree. Patients who underwent locked compression plating showed average radiological union time of 16.2 weeks, average full weight bearing time of 14.4 weeks, average knee flexion 106.3 degree with an extensor lag of 4.5 degree. According to Modified Neer’s criteria 70% excellent results were found in Retrograde nailing and 65% excellent results were found in Locked compression plating. Conclusion: Retrograde nailing is a good fixation system for fractures of distal femur with better outcome in terms of range of movements, early mobilisation, less operative time and blood loss.

Factors Affecting Medication Errors from the Perspective of Nursing Staff

Masoumeh Shohani, Hamed Tavan

Introduction: Medication administration is a key responsibility of nurses. If this duty is not properly accomplished, it can cause serious threats to the health and safety of patients. Aim: To explore factors affecting the frequency of medication errors from the perspective of nurses in educational hospitals of Ilam, Iran. Materials and Methods: The present descriptive analytical study was conducted on 120 nurses randomly selected from teaching hospitals of Ilam. A two part standard questionnaire was used. Its first part was on the participants demographic information. The second part consisted of three domains including 11 questions on the factors associated with nursing, seven questions on the factors associated with wards, and four questions on the factors associated with nursing management. Data analysis was performed using the SPSS software, version 19.0. The significant p-value was considered less than 0.05. A total of 120 completely filled questionnaires were obtained and this formed the study data. Results: The participants included 50 (42%) males and 70 (58%) females. In all the three domains, the most frequent factors resulting in the incidence of medication errors included: occupational fatigue exhaustion (58.5%), nurses personal neglect (56%), heavy workload in wards (65.6%), and inadequate staffing and high nurse/patient ratios (69.7%), respectively. Conclusion: Fatigue, personal carelessness, heavy workload, inadequate staffing and high nurse/patient ratios are the important and effective factors causing medication errors. Reducing the number of nurse's shifts during the month and increasing the number of personnel per shift are recommended.

Prevalence of Anaemia and Metabolic Syndrome and their Relationship among Postmenopausal Women in Rural West Bengal, India

Soumi Srimani, Piupita Das, Debnath Chaudhuri

Introduction: Metabolic Syndrome (MS) is becoming pandemic very fast. Anaemia continues to be one of the most significant public health issues. Anaemia is often found with the presence of MS, though the pathophysiological theory is mostly unclear. Aim: To determine the prevalence of anaemia and MS and also to find out the relation between anaemia and MS and its components among rural postmenopausal women of West Bengal, India. Materials and Methods: This study was conducted among 509 postmenopausal women, selected randomly from 30 villages of Singur block, West Bengal, India. Ethical clearance was obtained and informed written consent was obtained prior to the study. Haemoglobin (Hb), Fasting Blood Glucose (FBG), serum Triglycerides (TG), High Density Lipoprotein-Cholesterol (HDL-C), Blood Pressure (BP) and Waist Circumference (WC) were measured. MS was defined as per International Diabetes Federation (IDF), 2005 (for Asian-Indians) criteria. Spearman’s correlation coefficient (rho) was calculated using SPSS software, version 20.0. A p-value <0.05 was considered as statistically significant. Results: Prevalence of mild, moderate and severe anaemia among the postmenopausal women was 20.8%, 35.8% and 2.2%, respectively. Prevalence of MS among the studied population was 38.1%. Among the postmenopausal women suffering from anaemia (n=299), 35.1% were having MS. About 60.2%, 30.1%, 36.1%, 38.8% and 61.9% of them had WC =80 cm, FBG =100 mg/dL, TG =150 mg/dL, HDL-C <50 mg/dL and BP =130/85 mmHg. Statistically significant positive correlation was found between Hb level and MS (rho=0.09, p<0.05), WC (rho=0.11, p<0.05) and systolic blood pressure (rho=0.10, p>0.05). Significant negative correlation was observed between Hb level with FBG (rho=-0.11, p<0.05) and HDL-C (rho=-0.12, p<0.05). Conclusion: High prevalence of anaemia and MS was observed among the postmenopausal women of Singur, West Bengal, India. Significant correlation existed between anaemia and MS as well as most of the components of MS among studied population indicating a possible coexistence of anaemia and MS.

Baseline NT-ProBNP Level as a Risk Predictor of Contrast Induced-Acute Kidney Injury in Acute Coronary Syndrome Patients Undergoing Primary Angioplasty

Introduction: Contrast Induced Acute Kidney Injury (CI-AKI) is a common complication of invasive cardiovascular procedures. A three-fold higher risk of developing CI-AKI has been observed in patients with Acute Coronary Syndrome (ACS) who undergo Percutaneous Coronary Intervention (PCI). Several risk score models reflecting the cumulative risk of several peri-procedural predictors, such as the Mehran CIN score and Battle Management Command and Control (BMC2) CIN score, have been established and proven. Recent data suggest that baseline NT-proBNP may help to identify ST-Elevation Mycardial Infraction (STEMI) patients at risk for CI-AKI after primary PCI. Aim: The aim of the present was to prognosticate ACS patients treated with Primary PCI for the risk of developing CI-AKI by correlating it with pre procedural NT-proBNP levels. Materials and Methods: The present study was a prospective cross-sectional observational study, involving 150 patients with ACS undergoing PCI at Kasturba Medical College, Manipal, Karnataka, India (January 2016 to December 2016). Patients with ACS (STEMI and NSTEMI) who underwent primary PCI were included in the study. Pre-existing renal derangement, acute left ventricular failure and cardiogenic shock patients were excluded from the present study. Continuous variables were described as mean±standard deviation and compared by using the t-test or Wilcoxon rank-sum test. Categorical variables are described in terms of frequency and percentage and compared using the Chi-square or Fisher exact test. The Receiver Operating Characteristic (ROC) curves, paired sample t-test and independent t-test were applied for further analysis. Results: A total of 150 patients (mean age, 63.03±9.07 years and 64.3% male) were included in the study. Among the study 22 (14.6%) patients developed CI-AKI. The value of NT-proBNP at presentation was significantly higher in patients who developed CI-AKI compared to those who did not (p<0.001). A cut off value of NT-proBNP of =2320 pg/mL as measured on admission has 90.9% sensitivity and 81.5% specificity in predicting CI-AKI. Conclusion: Higher Baseline NT-proBNP levels (with a cut off value of 2620.46 pg/mL) can predict the development of CI-AKI after Percutaneous Transluminal Coronary Angioplasty (PTCA) in patient with ACS.

Abdominal Emergency Surgery in the Elderly: How to Predict Mortality?

Introduction: Elderly patients are exposed to high mortality rate in emergency surgery. Aim: The aim of the present study was to identify the factors which predict mortality among elderly patients =70 years, operated for an abdominal emergency. Materials and Methods: In the present study, a case-control study including patients of age group 70 years and older, operated for abdominal emergency in the Emergency Surgery Department between January 2008 and December 2013. The present study, compared 70-year-old patients who died after having undergone urgent abdominal surgery. Death Group (DG) including 50 consecutive patients with a Control Group (CG) including 50 patients. A consecutive list of all patients (291) of age group 70 years and older was established according to the admission registry of the emergency surgery department. A numeric code was assigned to each patient. All the 50 patients in CG were randomly selected from this list. The predictive mortality factors were analysed in a multivariate the study. The contribution of scores and indexes was also evaluated. Results: The risk factors which were identified in the univariate analyses were delay in hospital admission =48 hours, impaired general condition, dehydration, haemodynamic or respiratory preoperative instability, delay in surgical treatment =24 hours, laparotomy procedures, peritonitis, mesenteric ischaemia or gastrointestinal metastases diagnosed during surgery, complications, the need for Intensive Care Unit (ICU) stay, and finally the use of intubation. American Society of Anesthesiologist (ASA) score, Charlson index and Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) were also predictive of mortality. In the multivariate analyses, delay in surgical treatment =24 hours, laparotomy procedures and the need of ICU stay were independent predictors of mortality. Conclusion: In the elderly, the delay of surgery =24 hours, the laparotomy procedure and ICU stay are independent predictors of mortality. The scores and the indexes are objective and reliable evidences. This visibility of the evolution of patients; undergone emergency surgery would adapt the management, target a sub population more exposed and provide the patients with the most enlightened information possible.

Ex vivo Evaluation of the Erosive Effect of Acid Tea Widely Consumed in Brazil

Introduction: Dental erosion is defined as the pathological, irreversible, chronic, and localised loss of dental enamel by prolonged acid action and often without bacterial involvement. Aim: To evaluate ex vivo, the erosive potential of widely consumed teas in Brazil by measuring the pH, titratable acidity of beverages and the roughness and surface microhardness of dental enamel before and after erosive challenges. Materials and Methods: Thirty human maxillary third molars, extracted for clinical reasons and obtained from Human Teeth Bank of the Dental School from 8th May 2017 to 18th May 2017 (Federal University of Juiz de Fora), were used to perform erosive cycles, which were exposed to Morinda citrifolia, Uncaria tomentosa, Caesalpinia ferrea, Schizolobium amazonicum, Schinus aroeira teas and 1% citric acid. The samples were immersed in the solutions for two minute, five times a day, at intervals of two hours for four days. Between the erosive cycles, the specimens remained in artificial saliva. Statistical analyses were performed using the IBM SPSS statistics 22.0 software. The accepted significance was set has p-value <0.05. Results: The mean pH of the five samples ranged from 3.55 to 5.55 and all the herbal teas tested showed significant buffering capacity. The results suggested that all acid teas in the study have an erosive potential. The microhardness ranged from 34.12 to 46.98, and no significant difference was observed between groups in relation to the control group (1% citric acid). The roughness results for M. citrifolia and U. tomentosa teas were similar to those of the control group. Conclusion: The analysis of the data allows for the conclusion that all the teas present with acid pH and presence of ions capable of interacting with the dental surface and causing loss of dental tissue, reducing the microhardness of the enamel. Thus, there is a need to be careful in consuming such beverages.

Molecular Imprints of Bacteria in Oxalate Containing Kidney Stone: A Preliminary Report

Introduction: Most of the world’s part, including India comes under stone belt area, where incidences and frequency of kidney stone are high. Presence and diversity of bacteria inside the Calcium-Oxalate (CaOx) stones and its role in kidney stone formation is poorly studied. Aim: To report the presence and diversity of bacteria in CaOx kidney stones. Materials and Methods: The present retrospective study conducted in National Centre for Cell Science, Maharashtra, India (November 2012 to November 2015). A total of 120 kidney stone samples from 24 subjects (having symptomatic recurrent kidney stone episodes) had been collected from a retrospective study. These were subjected to Fourier Transformation Infrared (FTIR) spectral analysis. Bacterial diversity inside the kidney stone nidus anticipated with making gene library clones and sequencing of 16S rRNA gene as a molecular marker. Results: The FTIR spectral analysis revealed that the stones were of pure CaOx in nature. Successful clone library preparation for 16S rRNA gene confirmed the bacterial imprints in the kidney stones. The present analysis indicate that the microbes present in stones are diverse in origin. Bacillus was found to be the major genus whiles the other five genera viz., Acinetobacter, Enterococcus, Leucobacter, Prolinoborus, and Streptococcus as diversity prospects in CaOx stone nidus. Conclusion: The present study report the presence of bacteria inside the nidus of CaOx stones through the molecular approach; which may help urologist to understand that bacteria can be associated with formation of CaOx stones. Further, we suggest that these bacteria may be associated with recurrent episodes of stones; hence, underscores the need for use of suitable antibacterial therapy along with surgical procedures to remove them.

Spink1 Mutation in Idiopathic Recurrent Acute Pancreatitis-Pilot Study

Introduction: Recurrent Acute Pancreatitis (RAP) and Chronic Pancreatitis (CP) are labeled as idiopathic when no identifiable factors are found. The identification of genetic mutations associated with pancreatitis have provided opportunities for identifying patients at risk for idiopathic pancreatitis. Aim: The aim of the present study was to study the clinical profile and prevalence of SPINK1 mutation in idiopathic RAP. Materials and Methods: The present study was a prospective observational study of idiopathic RAP patients at a tertiary care hospital. DNA was isolated from blood obtained from patients and genotyping of SPINK1 mutation was studied. Results: A total of 17 patients with idiopathic RAP were included. Their mean age was 22.29±9.7 years, 14 (82%) were male, 7 (41.7%) had SPINK1 mutation. Patients with SPINK1 mutations had more frequent acute episodes of pancreatitis. Conclusion: SPINK1 mutation patients have more frequent acute episodes of pancreatitis and nearly 7 (41.7%) had SPINK1 mutations in the so called idiopathic RAP. Genetic testing in idiopathic pancreatitis might have role in future. Multicenter studies are further required to confirm the role of genetic testing in RAP.

Assessing the Impact of a Structured Tuberculosis Training Activity on the Knowledge and Attitude of Community Volunteers

Janmejaya Samal, Ranjit Kumar Dehury

Introduction: With the paucity of health workforce for Tuberculosis (TB) in India a cadre of trained community volunteers can effectively contribute to the prevention and control of TB in a particular community. Aim: The aim of this study was to assess the impact of a structured TB training activity on the knowledge and attitude including post training appraisal of activities among the Community Volunteers (CVs). Materials and Methods: A two days structured training was imparted to a group of 10 preselected CVs and the knowledge and attitude was assessed with the help of pre-test and post-test questionnaire. The post training appraisal of activities was carried out after a period of three months since the CVs were placed on job in the community. Data analysis was carried out using Statistical Package for Social Sciences (SPSS) version-16.0 and p-value of <0.05 was considered significant. Students t-test was applied to test the significance of knowledge and attitude improvement in the group before and after the training. Results: Highly significant (p=0.0042) impact was observed in knowledge segment however the same was not the case with attitude segment (p= 0.0676). The mean knowledge and attitude score was 9.20 (SD=2.97) and 12.70 (SD=1.42), respectively for pre-test and the mean knowledge and attitude score was 3.00 (SD=0.94) and 2.10 (SD=0.74), respectively for post-test. Out of the 10 CVs trained, eight CVs were placed on job for different types of community level activities. A total of 5633 households were reached by the CVs for creating awareness on TB and 648 sputum samples were collected from TB suspects and transported to the nearest Designated Microscopic Centres (DMCs). A total of 45 TB cases were diagnosed and put on treatment over a period of three months, post training. Conclusion: The level of improvement shows that the CVs could effectively be utilised in the community for TB control and support activities. In addition, the training appears to be influencing the CVs positively on their roles and responsibilities.

Association of Circulating Insulin-like Growth Factors and IGF Binding Protein with Early Cases of Cancer Cervix

Praveen Sablania, Montosh Chakraborty, Debajit Bagchi

Introduction: Insulin-like Growth Factor (IGF) signaling pathway has important roles in regulating cellular proliferation, apoptosis, differentiation and transformation. IGF-axis is implicated in pathogenesis of several common cancers including cancer cervix and its pre cancer stage. Aim: To measure the circulating levels of IGF-I, IGF-II and IGFBP-3 and evaluate their association with early stages of cancer cervix. Materials and Methods: The present case-control study consisted of 29 histologically proven cases of early cancer cervix (FIGO Stage I and II) and 37 age matched cytologically proven normal healthy controls. The study was conducted in Department of Biochemistry, Maulana Azad Medical College, Delhi, India from May 2004-April 2007. Peripheral blood was drawn in a heparinized vial and plasma was separated by centrifugation and stored at -80°C till analysis. Concentration of IGF-I, IGF-II and IGFBP-3 was measured using commercially available ELISA kit (DRG Diagnostics) in units of ng/mL. Statistical analysis was done using SPSS statistics (V21.0) and Microsoft excel software, viz. Student-t-test for comparison of significant mean, binary logistic regression was used to measure Odds Ratios (OR). Bio-Effective Mitogen (BEM) was calculated as (IGF-I in nM+IGF-II in nM+100)–(90% IGFBP-3 in nM) and mitogenic index as BEM/10% IGFBP-3 in nM. Results: Plasma levels of IGF-I were significantly decreased (p<0.01) while IGF-II levels were not significantly different between cases and controls (p=0.12). IGFBP-3 levels were decreased significantly in cases than controls (p<0.01). Mitogenic index was significantly increased in cases as compared to controls (p=0.01). OR for cancer cervix was calculated based on distribution of 50th percentile in control group and OR (95% CI) was 3.5 (1.04-11.73); p=0.04. Conclusion: Circulating IGF-I, IGF-II and IGFBP-3 are in a dynamic relationship; hence, mitogenic index was educed from these factors. We found mitogenic index to be associated with cancer cervix in concordance to the cognizant role of IGFs and their binding proteins.

Effect of Occupational Noise Exposure on Sleep among Workers of Textile Industry

Spinal Anaesthesia for Lower Abdominal Surgery: Levobupivacaine versus Racemic Bupivacaine

Roma Tejaskumar Kalaria, Mahendra Ramkrishna Upadhyay

Introduction: Levobupivacaine is the pure S (-) enantiomer part of racemic mixture of bupivacaine. It is said to have local anaesthetic properties similar to racemic bupivacaine but with less cardiac toxicity. Aim: The aim of this study was to compare the efficacy and safety of these two local anaesthetic agents in patients undergoing lower abdominal surgery under spinal anaesthesia. Materials and Methods: One hundred and four American Society of Anaesthesiologists Physical Status Grade I-II patients undergoing inguinal hernioplasty or hydrocele excision were randomized to receive an intrathecal injection of one of two types of local anaesthetic solutions. Group L patients (n=52) received 3 mL (15 mg) of isobaric levobupivacaine while Group B patients (n=52) received 3 mL (15 mg) of isobaric bupivacaine. Onset of sensory block at L1, peak sensory level attained and time taken for it, two segment regression time from highest sensory level, time for regression back up to L1 level, onset and intensity of motor block, time to attain maximum motor block and its duration were recorded. Vital parameters and adverse effects in relation to spinal anaesthesia were also observed. Quantitative data were presented as mean and standard deviation (mean±Sd) and intergroup data were analysed by unpaired t-test. Results: The two groups were comparable to each other with respect to sensory block characteristics (p>0.05). Time to attain maximum Bromage grade was significantly faster in Group B (8.03±1.91) compared to group L (10.06±1.38); (p<0.0001). There was no statistically significant difference in other motor block characteristics, vital parameters and perioperative complications between the two groups (p>0.05). Conclusion: Thus, isobaric levobupivacaine (0.5%) appears to be a good alternative to isobaric bupivacaine (0.5%) in spinal anaesthesia for inguinal hernioplasty and hydrocele excision.

A Study on Immediate Effect of Cold Abdominal Pack on Blood Glucose Level and Cardiovascular Functions in Patients with Type 2 Diabetes Mellitus

Suvith V Das, A Mooventhan, NK Manjunath

Introduction: Diabetes mellitus is one of the metabolic disorders which is characterised by chronic hyperglycaemia due to insulin resistance or deficiency or both. Though a hydrotherapy text reported the use of Cold Abdominal Pack (CAP) for various metabolic disorders, there is a lack of scientific evidence for the use of CAP in a metabolic disorder like Type 2 Diabetes Mellitus (T2DM). Aim: To evaluate the immediate effect of CAP on blood glucose level and cardiovascular functions in patients with T2DM. Materials and Methods: In this prospective single group pre-test and post-test study, a total of 20 male T2DM subjects with the mean age of 51.75±7.71 years were recruited from June 2016 to December 2016. Study was conducted in SVYASA University, Bengaluru, Karnataka, India. All the subjects underwent CAP for 20 minutes. Assessments were taken before and immediately after the intervention using standard methods. Statistical analysis was performed using Students paired samples t-test with the use of Statistical Package for the Social Sciences (SPSS), version 16.0. Results: Results of this study showed a significant reduction in random blood glucose level (p=0.011), pulse rate/heart rate (p=0.028), systolic blood pressure (p=0.023), mean arterial pressure (p=0.010), rate pressure product (p=0.006), and double product (p=0.003) compared to its respective pre-test and no such significant changes were observed in diastolic blood pressure (p=0.095) and pulse pressure (p=0.306). Conclusion: Results of this study suggest that 20 minutes of CAP might be effective in improving blood glucose level and cardiovascular functions of patients with T2DM.

Role of Hypomagnesaemia in Acute Kidney Injury

Ventakarakesh Chintala, Venkataraya M Prabhu, Manaswitha Boyanagari, Ajay N Bhat

Introduction: Acute Kidney Injury (AKI) is a common problem with various causes and consequences like electrolyte disturbances in the form of hypocalcaemia, hypokalemia, hyperkalemia depending on the phase. Serum magnesium concentration of <1.5 meq/L is defined as hypomagnesaemia and is one of the common electrolyte abnormality. Serum magnesium levels are not routinely done in AKI cases. Aim: The aim of our study was to assess the role of hypomagnesaemia as a risk factor for non recovery of AKI. Materials and Methods: A cross-sectional study was conducted between July 2014 and August 2015 with a sample of 100 patients. The decrease in magnesium <1.5 meq/L was defined as hypomagnesaemia. AKI was defined as per KDIGO criteria. Day 1, day 3 and day 6 magnesium levels were measured. Results: Prevalence of hypomagnesaemia was 69%, 43% and 27% on day 1, day 3 and day 6 respectively. It was observed that hypomagnesaemia on day 1 was significantly associated with recovery of AKI (p=0.004). Conclusion: Prevalence of hypomagnesaemia was significantly higher in AKI patients and hypomagnesaemia on day 1 was associated with recovery. However, magnesium levels on day 3 and day 6 had no significant correlation with the renal function in AKI.

Dental Pulp Stem Cells from Natal Teeth: Isolation and Morphological Study

Introduction: Stem cells have a remarkable capacity for self-regeneration and have the potential to originate different types of cells and tissue. There is a significant occurrence of natal teeth in newborn babies and usually the treatment consists of surgical removal. Aim: To isolate and extensively characterise stem cells derived from human natal dental pulp. For this characterisation, proliferation capacity, ultrastructural morphological evaluation and trace elements were utilised. Materials and Methods: The study was carried out in the oral pathology laboratory during 2016. Cells from the pulp of two natal teeth were isolated through the explant technique and separated with a STRO-1 marker. The colony forming units, cell proliferation and cell viability after plating and the growth curve were analysed. The cells were morphologically analysed through Scanning Electron Microscopy (SEM) and the trace elements were analysed using Energy Dispersive Spectroscopy (EDS). Results: The predominant cellular morphology, observed in the stem cells separated with the STRO-1 biological marker, was fibroblastic. The study of trace elements using EDS detected chlorine, sodium and sulfur. Conclusion: Natal teeth extracted for medical reasons could be an opportunity for everyone to preserve stem cells, permitting their use in future experimental studies.

Serum Vascular Endothelial Growth Factor and Aging: Study among Urban Population of Vijayapur, Karnataka, India

Jyoti P Khodnapur, Manjunatha R Aithala, Kusal K Das

Introduction: It is known that angiogenesis delays in aging. Vascular Endothelial Growth Factor (VEGF) is the most potent angiogenic factor. But the influence of aging on VEGF is still unclear among healthy population. Aim: To determine the relationship between aging and VEGF among different age groups in both male and female subjects of Vijayapur city, Karnataka, India. Materials and Methods: The present cross-sectional study conducted in Sri B.M. Patil Medical College (October 2016 to April 2017) on 196 healthy subjects male (n= 98) and female (n=98) subjects (20-95 years) were randomly selected among general population of Vijayapur city, Karnataka, India. Subjects were divided into six group: Group I (20-29 years), II (30-39 years), III (40-49 years), IV (50-59 years), V (60-69 years) and VI (>70 years). Anthropometric and physiological parameters like height (cms), weight (kg), Body Mass Index (BMI in kg/m2), Body Surface Area (BSA in m2), Pulse Rate (PR in bpm) and Blood Pressure (BP) were assessed. The VEGF was assessed by Enzyme-Linked Immunosorbent Assay (ELISA) method. Statistical analysis was done by using one-way ANOVA followed by post-hoc t-test and unpaired t-test by using SPSS software. Results: Group I to Group VI showed significant (p<0.001) steady increase of VEGF in both male and female subjects. There was significant difference (p<0.001) of VEGF between male and female subjects. Conclusion: Aging alters serum VEGF and causes vascular dysfunction. Females are greater protected against age related alteration of vascular pathophysiology due to greater VEGF concentration as compared to male counterparts.

Effect of Folic Acid Supplementation and/or its Absence on Body Weight of Wistar Rats in Pregnancy and in their Offspring

Introduction: Foetal birth weight is the best predictor of pregnancy outcome as the growth restriction has been associated with high morbidity and mortality. The need of Folic Acid (FA) supplementation is essential during the period of pregnancy to prevent untoward effects on pregnancy related complication in mother and to prevent birth defects in foetus. Aim: To compare the effects of FA supplementation and FA absent diets during the pregnancy on maternal and their offspring body weight. Materials and Methods: This was a prospective study comprising of 18 Wistar albino rats procured from the Animal house, Manipal Academy of Higher Education, Karnataka, India (January 2017 to June 2017), after the Institutional Ethical Committee clearance. Rats were randomly divided into three groups and given different diets: Control group with normal diet, group with FA supplementation diet, and group with FA absent diet (with added succinyl sulfathiazole) for five weeks. Later the female adult Wistar rats could mate with male rats of their own strain and allowed the female to complete their pregnancy. After the delivery, delivered pups were counted for each rat and gross malformation in each pup were noted. Immediately after the delivery, all the pups born to each rat were weighed individually in digital weighing machine. The statistical data were analysed using SPSS version 6.0. Results: Among the pregnant dams the body weight gain was observed more in control group with an average weight of 40.56 gm, followed by diet with absent FA (32 gm) and least in rats fed with FA supplementation diets (31 gm). Average number of pups born to pregnant dams fed with FA supplementation, FA absent diet, and in normal diet was found to be 8, 8, and 9 respectively. Regarding the birth weight of pups born to pregnant dams fed with FA supplementation the average weight was found to be 6.01-5.09 gm, with normal diet it was 5.51-5.08 gm, and least weight was observed in pups born with FA absent diet (4.74-3.31 gm). Conclusion: The present study concluded that the FA status in pregnancy is inversely proportional to the prenatal death in pups but in offspring’s born to mothers fed with FA supplementation, average body weight was more than those born to mothers fed with FA absent diet and with control groups. However, this needs further confirmation as the tests were done on limited samples.

Incidence of Neurobrucellosis from Central India: A Hospital Based Study

Introduction: Despite being a rare complication, neurobrucellosis can be a major cause of neurological morbidity and mortality if not adequately diagnosed and treated. Aim: In the present study, we report utility of antibody based immunoassay protocol for diagnosis and incidence of neurobrucellosis in suspected cases with neurological complications in our hospital. Materials and Methods: This was a prospective cohort study conducted in Central India Institute of Medical Sciences, Nagpur, Maharashtra, India (April 2015 to March 2016). A total of 60 suspected participants with neurological abnormality were prospectively recruited and screened for the disease using commercially available IgG and IgM antibody detection kits. Conventional tests like Standard Tube Agglutination Test (STAT) and Rose Bengal Test (RBT), Brucella culture were also performed to compare positivity rates of evaluated tests in Cerebrospinal Fluid (CSF). Clinical characteristics were summarised in terms of percentages for categorical variables, i.e., age groups, gender, signs and symptoms. All statistical analysis was carried out using MedCalc software version 10.1.2.0. Results: A total of 13 patients showed IgG positivity against Brucella while 7 cases were positive for IgM antibody out of 60 screened cases. The sensitivity and specificity of both IgG and IgM assay was aroud 100%, 82% and 100%, 83% respectively. About 6 (10%) cases showed positivity for both IgG and IgM antibodies. About 9 (64%) out of 14 IgG/IgM positive cases showed positivity in STAT, while 8 (57%) cases showed agglutination in RBT. Only 1 (1.3%) patient showed culture positivity and was positive for IgM, STAT and RBT. Among neurological complications, meningitis was a major complication observed in 7 (50%) of IgG/IgM positive cases whereas hydrocephalus was found in 6 (43%) instances. Conclusion: Doctors should take the likelihood of neurobrucellosis in the patients exhibiting high risk for brucellosis with unexplained neurological behaviour. Diagnosis of neurobrucellosis using an Enzyme-linked Immunosorbent Assay (ELISA) based detection assay showed good sensitivity and specificity and therefore should be used as adjunct tests with other convential assays for rapid screening and treatment initiation in neurobrucellosis cases.

Health Related Quality of Life of Urban Young Adults Misusing Analgesics Participating in a Controlled, Cross-sectional Study in East Sikkim, North East India

Deepanjana Dass, Sunil Kumar Pandey

Introduction: A great deal of interest exists in assessing the health related Quality of Life (QoL) as an important aspect of treatment effectiveness with prescription drug misuse. The SF-36 Health Survey is a self-report measure assessing subjective health status along with physical and mental health domains. Aim: To evaluate how analgesic misuse affects both physical and emotional QoL in an urban area of Sikkim in a young adult population (15-40 years of age) of either sex. Materials and Methods: This study was a cross-sectional general population survey. Proposed study site included an urban area in East Sikkim. A pre-devised questionnaire of SF-36 was administered to 700 subjects. Data were statistically analysed using Statistical Package for Social Sciences software version 20.0. Results: Significant difference among analgesic misusers and non misusers in measures like general health (?2=17.197, df=2, p<0.001), compared to one year ago, health condition now (?2=8.379, df=2, p=0.015), emotional health-depression (?2=13.811, df=2, p=0.001), emotional health-full of life (?2=8.998, df=2, p=0.011), emotional health-felt dumped (?2=6.065, df=2, p=0.048), emotional health-energy (?2=13.190, df=2, p=0.001), emotional health-worn out (?2=6.325, df=2, p=0.042) was found. Conclusion: This study could identify a subset of participants in their youth with current pain and several measures of low QoL in emotional domain like depression, full of life, energy; felt dumped, worn out in the past four weeks in subjects misusing analgesics. Low QoL also identifies possibility of future onset of mental and psychiatric impairments.

Profile of Cerebral Visual Impairment in Children with Cerebral Palsy at a Tertiary Care Referral Center in Southern India

Smitha Jasper, Swetha Sara Philip

Introduction: Cerebral Visual Impairment (CVI) is a complex cognitive-perceptual dysfunction with wide spectrum of clinical manifestations. Perinatal insults like hypoxic ischaemic encephalopathy and neonatal hypoglycaemia are common aetiologies for neurological disorders like Cerebral Palsy (CP) and CVI. Currently there are no published data describing the features of CVI in CP from the Indian subcontinent. Aim: To describe the characteristics of CVI in children with CP at a tertiary care referral center in southern India. Materials and Methods: This was a cross-sectional study of children below the age of 18 years, referred to the CVI clinic of a tertiary care teaching hospital in southern India from March 2011-Feb 2012. All children attending the clinic underwent a complete neuro-ophthalmology examination including functional vision assessment. They were classified into: 1) absent CVI; 2) probable CVI; and 3) definite CVI depending on the clinical examination. Results: A total of 341 children, M:F=1.8:1, age range 3 months-17 years were included in the study. Around 69% (n=236) of the referral had CP with 96% (n=227) having spastic form of CP. Definite CVI was seen in 50% (n=119) of children with CP. In children with CP and definite CVI history of neonatal and perinatal insults was more common and the most common clinical diagnosis was seizure disorder in 52% (n=143) of children. Exotropia, temporal pallor of optic disc, inability to recognise face, impaired visual attention and lower field defect were the common clinical findings. Neuroimaging of children with CP and definite CVI showed occipital gliosis in 51% (n=31) of cases. Conclusion: In our study, CVI was prevalent in children with CP. A detailed neuro-ophthalmological evaluation is a must in all children with special needs and it is important to be aware of the factors that contribute to CVI and initiate habilitative strategies early to improve their quality of life.

Aetiology, Diagnosis and Clinical Characteristics of Nephrocalcinosis

Introduction: Nephrocalcinosis (NC) is the increased deposition of calcium in the renal parenchyma due to different aetiologies. Aim: The present study aimed to investigate the aetiology of NC and its effect on renal function and growth in children. Materials and Methods: In the present study, 25 children diagnosed with NC between 1999 and 2016 were retrospectively analysed. Relevant demographic, clinical and laboratory data were extracted from patients’ records. Results: The median (range) age at diagnosis was 9 (3-84) months. The leading cause of NC was distal Renal Tubular Acidosis (dRTA) in 16 (64%), followed by Idiopathic Hypercalciuria (IH) in 2 (8%) children. Clinical manifestations were failure to thrive in 8 (32%), polyuria and polydipsia in 5 (20%), haematuria and renal colic in 2 (8%), urinary tract infection in 7 (28%) and in 3 (12%) cases, NC was found accidentally during routine checkup. Chronic renal insufficiency developed in two patients with dRTA and in one with hyperoxaluria. The degree of NC worsened in 3 (23%) patients, remained the same in 7 (54%) and improved in 3 (23%) patients. However, the effect of nephrocalcinosis grade change on renal function and growth was not significant. Conclusion: It is not the degree of NC rather the underlying cause and the age at diagnosis that affects the growth and renal function of children.

Gender Specific Knee Replacement -Do Indian Females Need It

V Senthil Jayapal, Karthick Anand, Saravanan Ananda Kumar

Introduction: Total knee replacement is a revolutionary procedure aimed at relieving pain improving knee function and the quality of life, Indian women are more prone for osteoarthritis and recent researches have led on to manufacturing implants specific to their anatomy to achieve the above mentioned goals. Aim: The study aimed at analysing whether these modifications in the newly designed gender specific implants translate to any additional significant improvement in functional outcome in comparison to the commonly used traditional knee implants. Materials and Methods: It was a prospective comparative study done in 30 knees of 30 women patients aged between 55-70 years in GV Hospital, Trichy, India between July 2011- January 2013. A total of 15 patients (Group B) had Zimmer Legacy Posterior Stabilized (LPS) knee implant and the other 15 (Group A) had Zimmer gender specific knee implants. Patients were followed up for 24 months post surgery, preoperative and postoperative data were recorded according to the knee society scoring system. All the patients were operated by standard anterior midline incision by a single surgeon and underwent the same postoperative protocol. Results: The average age in Group A was 59.93 and in group B was 59.4. The mean preoperative Knee Score (KS) and Functional Score (FS) was 50.2 and 49.3 in Group A and B respectively. The range of motion increased following surgery in all patients but there was no statistically significant difference noted between the two groups. The postoperative KS and FS were assessed at 6 weeks, 3 months, 6 months, 12 months and 24 months and statistical significance using Student’s t-test, on SPSS 13.0 (SPSS Inc., Chicago, Illinois) was done during each follow-up. There was no statistical significant difference in KS and FS between the groups at the end of 24 months. Conclusion: Based on the results of our study we found no significant advantage of using gender specific implants oriented to female knees. Our study shows the goal of the design of the gender-specific high-flexion knee prosthesis has not been achieved.

Tadalafil versus Papaverine in Pharmaco Penile Duplex Ultrasonography-A Comparative Study

Introduction: ‘Erectile Dysfunction’ (ED) traditionally defined as inability to achieve and/or maintain an erection for satisfactory sexual intercourse. It can affect men of all age groups, but prevalence increases with age. Aim: The aim of the present study was to assess whether oral Tadalafil is as useful as injectable Papaverine in the evaluation of men with ED. Materials and Methods: Pharmaco penile duplex ultrasonography was done using a linear broadband phased array transducer (7–12 MHz) on an E-Saote MyLab 60 ultrasound-colour Doppler system on 36 patients over a period of two years. Visual grading score for erection, cavernosal artery diameter, Peak Systolic Velocity (PSV), End Diastolic Velocity (EDV), Resistive Index (RI) and Acceleration Time (AT) were obtained in all patients following administration of oral Tadalafil and intracavernosal injection of Papaverine in one week gap. All the data was analysed using SPSS software version 22.0 (SPSS Inc., Armonk, NY, USA). Results: In Tadalafil mode, visual grading for erectile response was E1 in four patients, E2 in eight patients, E3 in seven patients, E4 in two patients and E5 in 15 patients. In Papaverine mode, visual grading for erectile response was E1 in three patients, E2 in seven patients, E3 in five patients, E4 in two patients and E5 in 19 patients. In Tadalafil mode, a total of 17 patients showed evidence of arterial insufficiency and two patients showed evidence of venous insufficiency. In Papaverine mode, a total of 12 patients showed evidence of arterial insufficiency, two patients showed evidence of venous insufficiency and one patient showed indeterminate results. Conclusion: In the present study, oral Tadalafil contributed significantly in the evaluation of ED and showed statistically significant results similar to intracavernosal injection of Papaverine.

Amnion and Chorion Membranes in the Treatment of Gingival Recession and their Effect on Gingival Biotype: A Clinical and Ultrasonographic Study

Introduction: Treatment of gingival recession defects should aim at addressing both the biological and aesthetic demands. The chances of relapse are minimised if periodontal therapy fulfils the main goal to attain complete root coverage and an increase in the thickness of the keratinised tissue. Aim: To clinically evaluate and compare the efficacy of amnion and chorion membranes in the treatment of gingival recession as root coverage procedures. Further to assess their effect on the gingival biotype. Materials and Methods: Twenty sites in 10 patients with gingival recession defects were selected. These sites were divided into two groups as Group A sites (coronally advanced flap along with the placement of amnion membrane) and Group B sites (coronally advanced flap along with the placement of chorion membrane) according to the treatment modality received. All the subjected sites were assessed for clinical parameters like plaque index, gingival index, probing pocket depth, relative clinical attachment level, position of the gingival margin and the gingival thickness measured by manual and ultrasonographic methods; pre and postoperatively at different intervals. For the intragroup comparisons, ‘paired t test’ was used and for intergroup comparisons, ‘independent t test’ was applied. Pearson's coefficient correlation was used for correlation of gingival thickness measured by manual and ultrasonographic methods. For the intragroup comparisons, ‘paired t-test was used and for intergroup comparisons independent t-test was applied. A statistical significance p-value was considerd <0.05. Results: A significant reduction in the plaque index and gingival index scores was seen but statistically no significant difference between the probing pocket depth measured at baseline to six months postoperatively, were observed for both the groups. Amnion group (Group A) showed statistically significant mean gain in relative clinical attachment (p-value=0.01*) and highly significant mean reduction in position of gingival margin (p-value=0.001*) at six months. Chorion group (Group B) showed statistically highly significant mean gain in the relative clinical attachment level (p-value=0.001*) and significant mean reduction in the position of gingival margin (p-value =0.03*) in six months. Both the groups showed statistically high significant mean increase in the gingival thickness measured by both manual and ultrasonographic methods, after six months postoperatively. An improvement in clinical parameters was observed in both the groups but the difference was not statistically significant. Conclusion: The various clinical parameters suggest that both amnion and chorion membranes are biocompatible and safe to use without causing any inadvertent tissue response or antigenic reaction and thus can be used in the treatment of gingival recession defects and to augment the gingival biotype.

Effect of Surface Treating Fibre Posts on Shear Bond Strength of Composite Resin-An In vitro Study

Introduction: Fibre-reinforced post is a common choice for restoring endodontically treated teeth which are badly broken. To improve the retention of post, surface treatments are performed to modify the surface structure and to enhance the adhesion of fibre post and resin cement. Aim: To evaluate and compare the effect of three different surface treatment protocols on Fibre-Reinforced Composite (FRC) post to increase the bond strength between FRC post and dual cure adhesive resin luting agent using Universal Testing Machine (UTM). Materials and Methods: Sixty four radiopaque fibre-reinforced posts were selected. The samples were divided into two groups of glass fiber (Group A) and carbon fiber (Group B) each (n=32) embedded into acrylic resin which were sub-divided into four groups each [I-no surface treatment, II-ethyl alcohol and silanization, III-hydrogen peroxide and silanization, IV-sand blasting and silanization (n=8)]. A customised metal ring was placed around the exposed fibre post surfaces after surface treatment. The dual cure adhesive resin cement was loaded in the ring and polymerised with halogen polymerising light. Observations were then statistically analysed using (One-way ANOVA) to evaluate the mean difference among four groups and Tukey’s Post-Hoc test to determine inter group comparisons. Results: Statistically significant difference was found among all groups with sub-group IV of A and B i.e., both carbon and glass fibre posts treated with sand blasting and silanization showing significantly higher value (p<0.05) compared to all other groups and glass fibre posts showed significantly higher value than carbon fibre posts. Conclusion: Sand blasting followed by silanization is the most effective surface treatment than other treatments done for improving the bond strength of resin cement to the fibre post surface.

Dental Treatment Experiences of Patients with Hearing Impairment in Southern Saudi Arabia: A Questionnaire Based Study

Asmaa Assaf Alshehri, Rafi Ahmed Togoo, Tasneem S Ain

Introduction: It is quite difficult for people with impaired hearing to interact with people who can hear. This situation is more grave while receiving dental or medical treatment as the health professionals might be unaware about the special modes of communication causing deleterious effect on the oral health of patients with impaired hearing. Aim: To assess the dental treatment experiences of patients with impaired hearing in Southern Saudi Arabia. Materials and Methods: A cross-sectional study was conducted among patients in the age range of 18 to 45 years, subjects with impaired hearing in Southern Saudi Arabia for a period of three months from April 2017 to June 2017. All those subjects who had only hearing impairment and who gave the consent of participation in the study were included and all those who had other disabilities or systemic diseases and who were not willing to participate in the study were excluded from it. A self-administered questionnaire was distributed among the study subjects with impaired hearing at their centres. The duly filled questionnaires were collected the next day from the respondents. The data was analysed statistically using SPSS version 17.0. Descriptive analysis and Chi-square tests were used. Statistical significance was set at p-value = 0.05. Results: About (n=120, 77.9%) respondents had visited the general dentists for their or their child’s dental treatment (n=31, 20.1%), while (n=3, 1.9%) of the respondents had not visited any dentist for treatment. The difference between the responses was found to be statistically significant (p-value =0.001). Majority (n=72, 46.8%) of the respondents encountered difficulties during their appointment with the dentists. About (n=111, 72.1%) of the respondents reported that they were not asked about their preferred way of communication by the assisting dental staff, before the start of treatment. Only (n=43, 27.9%) of the respondents were being enquired about the same. The difference between the responses was statistically significant (p-value =0.001). Conclusion: Majority of the respondents encountered difficulties during their appointment with the dentists. A major proportion of the respondents rated their dental visit experience as “very unpleasant’ and while others rated it as being unpleasant. The dentists should be aware of the modes of communication while dealing with patients with impaired hearing so that they could avail the health services easily.

Assessing the Clinical Applicability of Population Specific Bolton’s Norms

Shweta Airan, Rekha Sharma, Sonal Chowdhary

Introduction: Bolton’s norms are an essential parameter used in orthodontic diagnosis to evaluate the tooth size discrepancy. However, these norms have been established for Caucasian population and population variations necessitates the evaluation of these norms on Haryana population. Aim: The aim of the present study was to determine Bolton’s ratios for Haryana population, compare them with original Bolton’s ratios and determine the clinical significance of these differences. Materials and Methods: The study sample consisted of study casts of 100 subjects in the age range of 18-25 years, all belonging to Haryana population, having a full complement of teeth with Angle’s Class I molar and canine relationship, proper intercuspation, normal overjet and overbite and minimal crowding and spacing. Tooth dimensions were measured using digital vernier caliper (accurate to 0.01 mm) and Bolton’s anterior and overall ratio was calculated. Unpaired t-test was used to determine statistical differences between sexes and Single sum t-test was used to determine difference between population groups. Results: Bolton’s anterior and overall ratio norms for Haryana population sample were found to be 77.89+0.23% and 91.45+1.77% respectively. Statistically significant differences were found in the anterior ratio of Haryana population and Bolton’s original values but both anterior and overall ratio of Haryana population lie well within the 1 standard deviation of original Bolton’s norms. Conclusion: Clinical relevance of differences in Bolton’s norms established for Haryana population was not found in spite of statistically significant differences from original Bolton’s norms. Hence, original Bolton’s norms for anterior and overall ratio can be used for Haryana population.

Inheritance of Hypertrichosis Pinnae Auris-A Review of Literature

Neha Baryah, Kewal Krishan, Sanjeev Puri, Tanuj Kanchan

Hypertrichosis is an excessive growth of hair on a particular area of the body which is abnormal for the age, sex or race of an individual. The presence of the excessive coarse black hair on the auricle of the human ear is referred to as hypertrichosis pinnae auris or hairy ears. The condition is primarily restricted to older men and occasionally observed in females. According to the available literature, hypertrichosis pinnae auris is a Y-linked character. A number of studies have shown that the inheritance of the trait is from father to the son, any exceptions can be attributed to the lack of penetrance of the gene or crossing over from Y to X chromosome. A few researchers have suggested the probability of it being inherited in an autosomal manner. The mode of inheritance of the trait thus, remains controversial as to whether it is Y-linked or autosomal or perhaps both. The present article reviews various available studies on hypertrichosis pinnae auris in different populations of the world. It further deliberates on different aspects of the modes of inheritance of hypertrichosis pinnae auris and discusses the contradictions in its inheritance. The understanding of this area of research is significant for studying morphological variations and their genetic basis, sex differences among individuals and populations together with intergroup differences involving anthropology, anatomy, comparative morphology, personal identification and human genetics.

Dentists’ Prescription Patterns of Non-Steroidal Anti-inflammatory Drugs and Antibiotics: A Systematic Review

Gholamreza Sepehri, Sasan Sepehri, Molook Torabi Parizi, Mahmoud Reza Dehghani

Introduction: Non-Steroidal Anti-inflammatory Drugs (NSAIDs) and antibiotics are the most commonly prescribed drugs by the dentists; however, the prescription patterns, as well as the inappropriate use vary among dentists in different countries. Aim: This systematic review was done to evaluate the dentists’ prescription patterns for antibiotics and NSAIDs, using electronic databases. Materials and Methods: Dentists’ prescription pattern of NSAIDs and antibiotics were searched by two sets of independent reviewers from January 2000 to December 2016, using PubMED, MEDLINE and Scopus databases sources of published original/ review articles in English language published from January 2000 to December 2016, using NSAIDs, non-opioid analgesics, opioid analgesics, antimicrobials, antibiotics, dentists and prescription patterns as the key word search terms. The main outcomes included the type of antibiotic drug category, most frequently prescribed antibiotics and the prescription pattern of NSAIDs by dentists. Results: A total number of 145 studies were identified by our databases search, and finally 28 articles met our inclusion criteria. Our results showed that 24 out of 28 published studies which had the inclusion criteria for this study reported the antibiotic prescription pattern by dentists and the ß-lactam antibiotics were the most frequently prescribed antibacterial drug category followed by metronidazole and macrolides. Amoxicillin (23 out of 24 studies) and amoxicillin/clavulanic acid (15 out of 24 studies) were the most frequently prescribed antibacterial in most countries. Our results showed that ibuprofen was the most frequent NSAID drug (6 out of 7 studies) and oxycodone, hydrocodone were the most frequently opioid drugs (2 out of 3 studies) prescribed by dentists. Conclusion: Our results showed different prescription pattern of NSAIDs and antibacterial drugs by dentists in different countries; however, amoxicillin and amoxicillin/clavulanic acid, metronidazole and macrolides were the most common prescribed antibacterial drugs and ibuprofen as the most frequently NSAIDs used by dentists. The empirical use of amoxicillin/ clavulanic acid in some countries could be an evidence for inappropriate use of antibiotics by dentists.

Remimazolam (CNS 7056): an Emerging Sedative and General Anaesthetic

Sumit Bansal, Shubha Singhal

Remimazolam is a newer drug in the field of anaesthesia. It combines the properties of midazolam and remifentanil. As the name indicates, midazolam is the parent compound of remimazolam which incorporates the pharmacokinetic properties of remifentanil. Remimazolam is an ultra short acting anaesthetic agent/sedative which rapidly shows its effect after injection and also wears off expeditiously after cessation. Therefore, remimazolam’s dosage can be ideally controlled. Since it acts on benzodiazepine receptors, availability of specific antagonist (flumazenil) further adds to its safety in case of overdose.

Novel Methods and Regulation on Electronic Data Collection in Clinical Trials

Syed Mujtaba Hussain Naqvi, Suyog C Mehta, Akhilesh D Sharma

The data collection is a pivotal part of clinical studies and impacts how the data is managed and analysed and the outcome of the clinical research besides contributing to the cost and duration of the clinical studies. Paper based method is a common method for clinical research data collection, because of certain advantages of paper over computer based approaches. The use of multicenter trials with centers across the globe strongly benefits from electronic data systems for the effective management in the collection and transfer of data. Online data collection utilises internet to enter data from the clinical study site to a central database. Novel convenient handheld devices are used in clinical research to record and process data especially in field studies and self reporting data collection processes. Personal Digital Assistants (PDA) and tablet personal computers (Tablet PC) allow real time data collection at the point of care in clinical studies. There are technical issues which need to be considered in Electronic Data Capture (EDC). The Indian Good Clinical Practice (GCP) gives guidelines on electronic data collection and Food and Drug Administration (FDA) describes the regulation in 21 Code of Federal Regulations (CFR) regarding electronic data collection.

Attitude of Patients towards Euthanasia Attending Neurology Clinic: A Pilot Study in Iran

Payam Saadat, Reza Golpour, Seyede Fatemeh Shafaie

Introduction: Due to the recent progress in medical and technological knowledge, the attitude towards death has changed. Euthanasia is another concept that has acquired attention in the recent decades. Aim: To compare the attitude toward euthanasia among dying patients, relatives of dying patients, depressed patients and non depressed patients, at a neurological clinic in Babol, Iran. Materials and Methods: The present pilot cross-sectional study was conducted in October 2014 at the neurological diseases clinic affiliated to Babol University of Medical Sciences, Mazandaran, Iran. Four groups of subjects participated in the study (16 in each group): dying patients, relatives of dying patients, patients with depressive disorders and non depressed patients. In order to assess the willingness of participants toward euthanasia, a researcher-made questionnaire was designed based on the objectives of the study. Due to the lack of reliable and valid questionnaires on euthanasia in Iran, the researchers tailored a questionnaire in accordance with Iranian culture and cognitive aspects of euthanasia and related literature. Questions were devised and given to three specialists for expert opinion. After minor revisions, validity and reliability of the questions were calculated. After data collection, statistical analysis was performed by SPSS version 16 and ANOVA test. Results: Of the total 64 participants, 34 were female and 30 were male (mean age=55±4.7 years). The mean euthanasia score for men was slightly higher (9.33±2.6) than women (9.03±2.8). There was no significant difference between gender and euthanasia score (p=0.66). Also, there was no significant difference between the mean euthanasia score of four study groups (p=0.28). Conclusion: According to the findings of our study, there was no significant difference between attitude towards euthanasia among depressed and dying patients versus other patients (relatives of dying patients, non depressed patients).

A Retrospective Analysis of ‘Slip-and-Fall’ Injuries Among Inpatients at a Tertiary Care Hospital, Karnataka, India

Nachiket Gudi, Reshmi B Nair, Myron Anthony Godinho, Basavraj Hadpad

Introduction: The reported cases of ‘Slip-And-Fall’ (SAF) injuries among inpatients are increasing at an alarming rate, causing increased morbidity and mortality, productivity losses, financial losses, and raising questions about the healthcare facility’s capacity to provide safe patient care. Moreover, the lack of studies on SAF injuries in Indian healthcare settings impedes attempts to identify and prevent such inpatient injuries in the future. Aim: To the documented causes of SAF injuries and identify the contextual factors related to the injuries. Materials and Methods: A retrospective study conducted in Kasturba Hospital, Karnataka, India, analysis (data from July 31st 2000 to July 31st 2015) of 61 case reports was carried out. A checklist was developed according to the objectives which consisted the time, outcome, area and the root cause of SAF injuries in the study setting. Results: In the present study, out of 61, 28 cases were reported to have occurred in the wards, 21 cases occurred between 7:30 pm and 7:30 am, no noticeable injuries were the outcome in (36%) of the reported cases. Conclusion: The present study concludes by providing recommendations for reducing SAF injuries in hospitals, and for improving the quality of reporting in SAF injury reports.

Treatment of Plaque Psoriasis by 308 nm Excimer Light in Egyptian Patients

Introduction: Psoriasis is a chronic skin condition that demonstrates a high burden and an impaired quality of life. The role of excimer light therapy and its modes of action are not completely understood in the treatment of psoriasis. Aim: To evaluate the clinical efficacy and safety of Monochromatic Excimer Light (MEL) in the treatment of psoriasis. Materials and Methods: Ninety Egyptian psoriasis patients with plaque-type psoriasis were treated with MEL twice a week, for a total of 24 sessions or until complete improvement. The Psoriasis Severity Index (PSI) was assessed for each patient. Results: At the final visit, 96/360 (26.67%) patches of psoriasis showed complete clearance, 75/360 (20.83%) patches achieved more than 75% improvement, 132/360 (36.67%) patches achieved 51-75% improvement and 57/360 (15.83%) patches achieved 26-50% improvement. The best result occurred on the trunk followed by lower limbs, upper limbs, palms and soles than the scalp. There was inverse statistical correlation between the percentage of improvement and skin phototype and no correlation with patient’s age, sex or duration of disease. Side effects reported were erythema in 45 patches, post inflammatory hyperpigmentation in 102 patches, perilesional skin was covered by protective sheet, so no side effect occurred. No recurrence was observed six months after treatment. Conclusion: The clinical data indicate that 308 nm excimer light is safe and effective in the treatment of psoriasis and the outcome of treatment is affected by skin phototype and site of the disease. Post inflammatory hyperpigmentation was the most common side effect.

Mesenchymal Lesion in an Adolescent Girl-A Rare Case Report

Rhabdomyosarcoma (RMS) comprises 3% of all childhood malignancy. Commonly it involves head and neck, extremity and genitourinary systems. Pure primary RMS of breast is a rare malignacy. Here, we present a case of adolescent girl presented with breast lump which was initially treated as benign lesion with excision. Again she presented with recurrent mass which was operated and microscopically showed features of small blue round cell tumour which has lead to many diagnostic confusions both clinically and histopathologically. Immunohistochemistry (IHC) with strong nuclear myogenin positivity in >50% of tumour cells confirms the diagnosis of primary mammary RMS. Postoperative period was uneventful.

Synchronous Neuroendocrine Tumour of Small Intestine in a Case of Squamous Cell Carcinoma Cervix – An Incidental Finding

Anamika Kashyap, Shailaja Shukla, Priyanka Banga

Multiple Primary Cancers (MPCs) are defined as two or more malignancies in a single individual without any relationship between cancers. Neuroendocrine carcinoma is a relatively rare tumour and its coexistence with other primary cancers is being increasingly recognised. Sometimes, the patients may present with the symptoms related to the other primary cancer (often described as second primary malignancy) which are usually more aggressive and the concurrent Neuroendocrine Tumour (NET) may be detected later. We present a case of a 60-year-old female presenting with haematuria due to bladder involvement by carcinoma cervix. The coexistence of small intestinal NET was co incidentally established. The second primary malignancy in NET can occur even many years later and can be multiple involving different organs. Therefore, patients with NET should be thoroughly evaluated with regular follow up.

Complete Spontaneous Resolution of Complex Renal Cyst: A Case Study

Arun Kumar Maurya, Dilip Kumar Pal

Renal cysts are the lesion which can bother to patient, treating nephrologists and urologist. Spectrum of presentation ranges from benign to malignant, familial to sporadic. In this case, we present a young 34-year-old female who initially came with a large renal cyst in her left kidney of Bosniak category IIF. Patient was then planned for regular follow up. Subsequent imaging revealed complete regression of the renal cyst.

Pulmonary Embolism Following Varicella Infection

A S Sandhya, Brijesh Prajapat

Venous Thromboembolism (VTE) post varicella infection is a rare complication owing to vascular endothelial damage, accelerated atherosclerosis and antibody-mediated hypercoagulable state. Pulmonary Embolism (PE) is a life threatening condition presented with sudden onset dyspnoea and refractory hypoxemia. We report a case of post varicella extensive thrombotic complication which involved deep veins of lower limbs and pulmonary vasculature.

Sever’s Disease in a Patient Receiving Growth Hormone with no Causative Relation

Erdal Kurnaz, Senay Savas-Erdeve, Zehra Aycan, Semra Çetinkaya

Growth Hormone (GH) shows its main effect on bones and muscle tissues. There are reports of orthopaedic complications including carpal tunnel syndrome, Legg-Calve-Perthe’s disease, scoliosis, and slipped capital femoral epiphysis with GH use in the literature, except for calcaneal apophysitis (Sever’s disease). We hereby present the case of a 13-year-old male who was treated with GH for GH deficiency and developed Sever’s disease in the first year of treatment.

Root Coverage of Class III Recession using Free Gingival Graft using Novel Root Coverage Esthetic Score

A variety of regenerative procedures has been used for the correction of gingival recession defects. However, root coverage can be quite challenging in cases of deep and wide Miller’s class III recession defects. Free Gingival Graft (FGG) technique has been the most preferred choice of treatment in cases of an inadequate width of attached gingiva. But currently, due to various drawbacks of FGG, and versatility of connective tissue grafts and other new techniques, FGG’s status as the most sought-after procedure in periodontal plastic surgeries has been eluded. The present case highlights a case of class III gingival recession which was successfully treated with this technique with postoperative evaluation using RES scores.

Cholesterol Management in Indians: Should We Treat the Targets or Treat the Risk?

Clinical evidence on relationship between cholesterol and Cardiovascular Disease (CVD) has highlighted the importance of all lipid components in the pathogenesis of CVD, thereby generating the concepts of “target”. Low Density Lipoprotein Cholesterol (LDL-C) and Non High Density Lipoprotein Cholesterol (non HDL-C) have been identified as the main “targets” in the guidelines for lipid management. For the corresponding targets, different “target goals” have been defined in most guidelines according to the levels of risk, to guide the lipid management and to minimise CV events. In the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guideline abandoned the target goal. This caused confusion among physicians. Recent trials like Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) have brought back into focus the concept of LDL hypothesis. Subsequent guidelines for dyslipidaemia management have retained the target goal based approach. In India, there is a high prevalence of dyslipidaemia and many patients do not achieve their lipid target goals. In this article, we have reviewed the evidence base used by different guidelines on lipid targets along with newer studies; in order to bring clarity to the dyslipidaemia management approach of Indian physicians.

Lipofibromatous Hamartoma of Median Nerve with Classical Radiological Features

Surya Nandan Prasad, Madhuri Kumari, Raghunandan Prasad, Hira Lal

Outcomes of Mechanically Ventilated Critically Ill Geriatric Patients in Intensive Care Unit

Mariam Zaidi, Djouhar Belgaid

Correspondence: Application of CAD-CAM for Fabrication of Metal-free Band and Loop Space Maintainer

Niraj Gokhale, Parin Shah, Shivayogi M Hugar, Divyata Kohli