Journal of clinical and diagnostic research

Combined Left Recurrent Laryngeal Nerve and Phrenic Nerve Palsy: A Rare Presentation of Thoracic Aortic Aneurysm

Hoarseness of voice due to Vocal Cord Palsy (VCP) resulting from aortic aneurysm is a rare entity. Hoarseness due to left Recurrent Laryngeal Nerve (RLN) paralysis caused by identifiable cardiovascular disease has been described as Ortner's syndrome or Cardiovocal syndrome. Very rarely, thoracic aortic aneurysm can cause Phrenic Nerve (PN) palsy causing hemidiaphragm paralysis. But, aortic aneurysm causing both RLN and PN palsy is an extremely rare occasion. Our literature review showed only three cases of combined RLN and PN palsy due to thoracic aortic aneurysm. Here we report a 70-year-old patient having hoarseness of voice for six years for which he was on symptomatic treatment. He presented to us with cough and blood tinged sputum, left sided chest pain, loss of appetite and weakness since two months duration. Based on clinical history and chest radiograph, lung malignancy was suspected. To our surprise, Contrast Enhanced Computed Tomography (CECT) revealed partially thrombosed saccular thoracic aneurysm originating distal to origin of left subclavian artery. He was referred to the cardiothoracic vascular surgeon for surgical treatment, but was reluctant to go for surgery. He is now being followed up by cardiothoracic vascular surgery and cardiology department and his condition has remained the same.

Squamous Cell Carcinoma of Cervix with Isolated Metastasis to Ethmoidal Sinus: A Rare Occurrence

Prita Pradhan, Debasis Gochhait, Arun Kumar

Squamous Cell Carcinoma (SCC) of the cervix is a highly prevalent malignancy. Its spread and metastasis is mostly loco-regional. The occurrence of distant extra-pelvic metastases is exceedingly rare, particularly with the involvement of paranasal sinus. This case report documents an unusual presentation of a 45-year-old female diagnosed and treated for squamous cell carcinoma of cervix with metastatic deposits in the ethmoidal sinus without deposits in any intervening foci.

Lymphovascular Malformation – A Report of Two Cases

Mitakshara Sharma, Varuna Mallya, Nita Khurana, Praveen Kumar, Rajan Duggal

Congenital Vascular Malformations (CVM) represents a group of vascular anomalies that are the result of defective development of the vascular system. Lymphatic malformation consists of dilated lymphatic vessels caused by occlusion of the lymphatic drainage system due to congenital malformations or acquired causes such as the effects of trauma, infection, or surgery. Lymphaticovenous Malformation (LVM) is composed of lymphatic and venous channels. The most common sites are the neck and axilla. We report two cases of a four and a half-year-old and a seven-year-old child who presented with complaints of swelling in arm and groin respectively. A provisional diagnosis was made on radiological investigations. Excision was done and the diagnosis was confirmed on histopathology and immunohistochemistry. The cases which were presented as LVMs are rare congenital tumours and require a high index of suspicion on part of pathologist and surgeon to reach a definitive diagnosis.

Pure Primary Squamous Cell Carcinoma of Ovary – A Rare Case Report

Himsweta Srivastava, Sneha Shree, Kiran Guleria, Usha R Singh

Primary Squamous Cell Carcinoma (SCC) is a rare tumour which arises in a mature cystic teratoma, endometrioma or Brenner tumour. The pure variety arises from metaplasia of surface epithelium of ovary and it is the rarest type. For optimal management no definitive treatment protocol is available till date. Also, there is no agreement concerning the postoperative therapy-chemotherapy or radiotherapy. We present a rare case of pure primary SCC of ovary which was managed by aggressive cytoreductive surgery followed by chemotherapy.

Acinic Cell Carcinoma Papillary-Cystic Variant: Diagnostic Pitfalls in Fine Needle Aspiration Cytology

Uma Kumar

Acinic cell carcinoma is a rare tumour comprising 1%-3% of all salivary gland neoplasms. Acinic Cell Carcinoma Papillary Cystic Variant (ACC-PCV) is a distinct subtype and shows variegated appearance on cytology. It is important to differentiate it from other malignant lesions because of its poor prognosis. We describe a case of 20-year-old female with swelling on left cheek for the last four months. Fine needle aspiration was done and diagnosed as intermediate grade mucoepidermoid carcinoma on cytology. Histological study of the resected tumour showed features of ACC-PCV. We are presenting this case to illustrate the diagnostic problems encountered in cytology and important points to be kept in mind while reporting FNA of salivary gland tumours.

Complicated Hydatid Cyst of Ulna- A Rare Case Report

I V Reddy, AH Ashwin Kumar, Bheemsingh Samorekar, B Amar Babu, Anil Kumar Mettu

Although hydatidosis is not uncommon in tropical countries, still bony involvement is comparatively rare. The aetiological agent is Echinococcus granulosus, a parasite belonging to cestode group with dog as definitive host and man as incidental host. We present a case of young male, who consulted us for painless, multiple swellings in his right forearm of three years duration, with restricted wrist movements. On examination multiple non tender, soft to firm swellings were noted with restricted terminal pronation. X-rays and MRI of right forearm showed multiple lobulated soft tissue components in intermuscular, subcutaneous and cutaneous planes and the main ulnar intramedullary cystic mass extending out as extramedullary cyst through proximal ulnar cortical breach. Proximal 2/3rd radius were also affected. On surgical exploration of forearm, cystic swelling measuring 8 × 6 × 5 cm sprouting out from proximal ulnar erosion was found. Intraoperative histopathology showed multiple endocysts suggestive of hydatid cyst; hence with protective measures wound closed back in layers and six weeks of oral albendazole 400 mg daily was given. At six weeks follow-up wrist movements improved but serous discharge persisted at drain site. Patient is still under regular follow-up. Thus, a differential diagnosis of bony hydatidosis should be considered while evaluating soft tissue swellings.

Intracorneal Amphotericin B Injection in a Case of Indolent Candidal Keratitis

Jyoti Deswal, Sudesh Kumar Arya

Ocular candidiasis is one of the opportunistic infection occurring in human body. Pathogenesis wise, Candida is very virulent and slow growing organism. We report a case of 76-year-old female with left eye candidal stromal abscess, not responding to topical and oral antifungal drugs. Patient was administered intrastromal amphotericin B injection in the affected eye. Four midstromal injections were given in the areas surrounding the corneal abscess. A total of approximately 0.05 mL of amphotericin B, 5 µg per 0.1 mL, was administered. Within next four weeks, the eye became completely quiet with healed epithelial defect and corneal scarring. Intracorneal injection of amphotericin B is a safe and effective treatment option for recurrent and recalcitrant fungal infections.

Successful Outcome with Transradial Primary Percutaneous Coronary Intervention During Cardiopulmonary Resuscitation

Yashasvi Chugh, Pradhum Ram, Sunita Chugh, Sanjay Kumar Chugh

Transradial access for ST Elevation Myocardial Infarction (STEMI) has been shown to reduce mortality, major adverse cardiac events and bleeding, when compared with femoral access. Often patients with STEMIs present in the setting of cardiogenic shock and cardiac arrest. Prior published work has established the mortality benefit with early percutaneous coronary intervention in patients presenting with out of hospital cardiac arrests. However, the utility of transradial intervention in such patients is still under study. We present a case of transradial primary intervention performed during cardiopulmonary resuscitation for a patient who presented with an antero-septal MI.

Pure Primary Extragonadal Retroperitoneal Yolk Sac Tumour in a Young Child: A Case Report

Vineeth G Nair, HS Kiran, PR Shanthala

Germ Cell Tumours (GCTs) in children are uncommon, constituting approximately only 3% of all malignancies in children younger than 15 years of age. Primary extragonadal GCTs constitute only 1-5% of all GCTs and a retroperitoneal site is seen only in 4% of all extragonadal GCTs. Extragonadal GCTs arise from local transformation of primordial germ cells which have been misplaced during the migration of these cells through the midline dorsal mesentery in the fourth-sixth week of embryogenesis. GCTs in children show remarkable variability in age, site, presentation and histology. This is the case of a three-year-old male child who presented with a history of an abdominal swelling which was rapidly progressive in nature. Radiology showed a large retroperitoneal mass and lesions in the liver. Histopathology, immunohistochemistry and serum Alpha-fetoprotein (AFP) values confirmed a diagnosis of pure primary extragonadal yolk sac tumour.

Acute Ischaemic Stroke as a Manifestation of Pituitary Apoplexy in a Young Lady

Pituitary Apoplexy (PA) is defined as a clinical syndrome comprising headache, visual deficits and altered sensorium, which can result from haemorrhage or infarction of the pituitary gland. Acute ischaemic stroke following PA is very rare. We are presenting a 35-year-old young otherwise healthy lady who presented with neuro ophthalmological and vascular symptoms on a background of PA. Imaging revealed a pituitary macro adenoma with parasellar extension with internal bleed. Cerebral angiography revealed that the mass compressed the bilateral cavernous sinuses (left more than right), resulting in obliteration of the cavernous portion of the left Internal Carotid Artery (ICA). She was treated with steroids and surgical debulking of the tumour through trans-sphenoidal approach and postoperative imaging showed recanalization of the ICA with reduction of the tumour size. The histopathological diagnosis was consistent with pituitary macro adenoma. Patient improved in level of sensorium, eye movement and the patient showed almost full recovery after the operation. PA resulting in ICA occlusion is very rare. Early intervention is required for reducing mortality and morbidity and to improve quality of life.

Bilateral Testicular Metastases from Occult Primary Prostate Cancer in a Young Adult: A Rare Case Report

Vijaya Rajesh Kamble, Purvrva Mahesh Agrawal

Testicular metastases are detected incidentally in upto 4% cases after orchiectomy for Prostate Carcinoma (PCa). Most of the secondaries to testes are due to PCa, only few patients have clinically manifested metastases to bilateral testes. Metastases to bilateral testis is unusual while unilateral involvement of the testis is seen usually. We report a case of primary PCa with bilateral testicular metastases which presented with palpable mass in the right testis. A 43-year-old male patient presented with two-month history of swelling in right inguino-scrotal region. On digital rectal examination, the prostate was enlarged. The Serum Prostate-Specific Antigen (PSA) level was >100 ng/ml. Ultrasound (USG) revealed metastatic deposits in bilateral testis, however prostate was having relatively normal echo pattern. Contrast Enhanced Computed Tomography (CECT) abdomen revealed primary malignancy of prostate gland with secondary metastases in bilateral testes and metastatic lymph nodes. Transrectal biopsy from prostate and excisional biopsy of right inguinal node showed prostate gland adenocarcinoma and deposits of adenocarcinoma respectively. Patient underwent bilateral orchiectomy. Histopathology showed that bilateral testes were infiltrated by metastatic adenocarcinoma with Gleason score 8. The patient is currently on chemotherapy. This is a rare case of primary PCa with clinically manifested bilateral testicular metastases in the form of palpable mass in right testis.

Blue Finger Syndrome: An Unusual Presentation of Rheumatoid Arthritis

Robin George Manappalli, Jishnu Jayaraj

Blue Finger Syndrome (BFS) is a benign and rare condition with an idiopathic aetiology. It is characterised by an acute bluish discoloration of fingers which may be accompanied by pain. This is a case of a middle aged female who presented with painless bluish discoloration of right hand and was diagnosed to have BFS. Though BFS is idiopathic, our patient on evaluation was found to have an underlying Rheumatoid Arthritis (RA). Patients with RA are subject to Raynaud’s phenomenon; but BFS presenting in a patient with RA is a rare scenario.

An Uncommon Case of Cervical Thymopharyngeal Duct Cyst

Thymopharyngeal duct cyst is one of the most uncommon benign cervical lesions encountered in the paediatric population. Due to its rarity, it almost always escapes a correct preoperative diagnosis and is usually misdiagnosed as a branchial cyst or lymphangioma. Furthermore, although located at the neck it may present with retrosternal or mediastinal extension. In this case report here we present a case of a young boy with a right cervical mass, diagnosis of thymopharyngeal duct cyst was confirmed during histopathological examination of the excised specimen. Furthermore, preoperative ultrasonography and MRI did not detect the thin cord and the lower part of the lesion, which rendered operative treatment more demanding. Apropos to these findings, we reflect on the crucial points of awareness that affect the diagnostic and surgical process of this lesion.

Sclerosing Mediastinitis Presenting as Complete Heart Block

Reena Bharadwaj, Manoj Gopal Madakshira, Prashant Bharadwaj, Hardeep Singh Sidhu

Sclerosing Mediastinitis (SM) is a rare condition which is characterized by the presence of dense fibrosis which infiltrates and encroaches upon various structures in the mediastinal cavity. Depending on the extent and the predominant organ of involvement, the patient presents with symptomatology of dysphagia, superior vena cava compression syndrome or dyspnoea. However, the involvement of the heart is rarely seen. Aetiologies of SM are several, with infections being the most common. We discuss a case of SM involving the oesophagus, descending aorta, hilum of lungs and the heart secondary to mucormycosis in an immunocompetent male.

Detection of Compound Heterozygous Sickle Cell-b+ Thalassaemia in a Patient with Extreme Weakness, Mild Jaundice and Moderate Anaemia - A Case Report

Subhash Chandra, Mostafa Ali, Pooja Mishra, Ashok Kumar Kapoor, Yamini Jindal

A 16-year-old female complained of extreme weakness. She had moderate anaemia; her Haemoglobin (Hb) was 7.7 gm/dl. Peripheral blood smear showed few sickled red cells. Sickle cell test was positive. High-Performance Liquid Chromatography (HPLC) revealed elevated levels of HbS (38.4%) and HbF (15.7%). In addition, HbA2 concentration was 3.8% and HbA concentration was 42.1%. Results suggested a diagnosis of compound heterozygous sickle cell-ß+thalassaemia. Sickle cell test was also positive with blood of patient’s brother; Hb HPLC examination showed relatively low concentration of HbS (25.2%) suggesting a diagnosis of sickle cell trait. Chromatogram of patient’s step sister suggested a diagnosis of thalassaemia trait. Findings of this study suggested that abnormal genes were inherited in the patient from both the parents. It was interpreted that repeated haemolysis in the patient might have contributed to anaemia, weakness, rise in indirect bilirubin and jaundice. Furthermore, high level of HbF (>12%) may interfere with polymerization of sickle haemoglobin suggesting beneficial effects of HbF-inducing agents which may inhibit sickling.

Enteric Cholestatic Hepatitis with Ascites: A Rare Entity

Samarth Virmani, Rama Bhat, Raghavendra Rao, Savio Dsouza, Nitin Bhat

Typhoid fever is a very common illness in developing countries. Patients most often present with a history of fever, vomiting, anorexia, abdominal pain, etc. Rarely there is hepatic involvement due to the disease process. This is a case report of a 26-year-old male who had presented with fever, jaundice and ascites. The widal titres were found to be within normal limits (1:80) however the patient was found to have Salmonella typhi on ascitic fluid culture. The patient was treated with the appropriate antibiotics and was later discharged.

Post Stroke Psychosis Following Lesions in Basal Ganglion

Shruti Srivastava, Mukul P Agarwal, Ankur Gautam

Stroke is the second most common cause of death and fourth leading cause of disability worldwide. Post stroke behavioural manifestations are often not recognized, undiagnosed and hence remain untreated. They may even suffer from misdiagnosis of functional disorders before coming at conclusion of organic pathology. Early diagnosis and prompt treatment helps in lowering the overall morbidity related to stroke and improves quality of life of these patients with rare manifestations. Here, we report two cases of elderly female patients presenting with delusions and hallucinations subsequent to stroke, with lesions in basal ganglia detected on neuro-imaging.

Shigella sonnei Sepsis in an Infant: A Case Report

Charu Nayyar, Preeti Thakur, Vibhor Tak, Amitabh Singh

Shigella bacteraemia is a complication of gastroenteritis caused by Shigella spp. which occurs mainly in immunocompromised children. Other risk factors may include young malnourished children, patients with chronic disease, post transplant patients etc. We present a case of six-month-old infant who developed an episode of gastroenteritis caused by Shigella sonnei which was followed by septicaemia. The patient was managed well and he recovered. Shigellasonnei was isolated in both stool as well as blood culture. S. sonnei bacteraemia is a rare condition but we should always be vigilant. Blood cultures as well as stool cultures should be performed in patients presenting with acute febrile gastroenteritis, whether immunocompromised or not. This simple, early and prompt investigation may help in precise diagnosis, which will guide the clinician about appropriate intervention like antibiotic therapy and supportive care.

Influenza as a Cause of SIADH Related Hyponatremia: A Case Report

Bhavita Gaglani, Sorab Gupta, Octavio Chavez, Rueda Libardo

Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH) is one of the most common causes of hyponatremia in hospitalized patients. The distinct aetiologies and co-morbidities associated with hyponatremia pose substantial challenges in identifying and managing this disorder. Several infectious causes of SIADH are reported but hyponatremia associated with SIADH and influenza virus infection is less commonly seen. We present a case of hyponatremia associated with influenza, which was subsequently diagnosed as SIADH.

Lichenoid Dysplasia–A Case Report with a Review of Differential Diagnosis

Kumud Mittal, Mihir Jha, Roopa S. Patil, Shekhar Kapoor

Lichenoid Dysplasia (LD) is often regarded as lichen planus with dysplastic features, as it mimics lichen planus clinically and histologically. Although it has been confirmed that these two entities are entirely different with not so similar etiopathogenesis, yet the confusion still exists. The separation between the two is of utmost importance as each of them has their own prognosis and treatment plan. We report one such case, where a 51-year-old male with excessive burning sensation had similar clinical picture as that of lichen planus but was histologically diagnosed as LD.

Application of a Mixed Material Graft to Posterior Intravaginal Slingoplasty Procedure: Preliminary Pilot Series

Birol Vural, Yigit Çakiroglu, Fisun Vural, Sule Köpük Yildirim

Good anatomic outcomes have been achieved with transvaginal synthetic materials in pelvic organ prolapse, but mesh-related complications are a major health concern. Therefore, developing new synthetic or biological materials with increased tissue strength and decreased complications are major challenges. This paper presents preliminary pilot series of Posterior Intravaginal Slingoplasty (PIVS) procedure performed with mixed material graft containing both autologous tissue and a synthetic material. Six women with symptomatic Utero-Vaginal Prolapse (UVP) = stage 2 underwent the PIVS procedure. Pelvic floor symptoms were assessed with the Pelvic Organ Prolapse Quantification (POP-Q) system, Pelvic Floor Distress Inventory (PFDI), and the Pelvic Floor Impact Questionnaire (PFIQ) both before the procedure and 36 months after the surgery. There were no mesh-related complications or recurrence and all the patients had good functional and anatomic outcomes. These preliminary results are promising, but further long-term studies with a larger series are needed.

Insulin (Technique) Induced Hypoglycaemia

The most common side effect of insulin therapy is hypoglycaemia apart from weight gain. It occurs commonly due to insulin overdose, faulty injection site, technique and meal-insulin mismatch. In lean individuals even the needle size can be a contributing factor to hypoglycaemia. Here we report a case who presented with recurrent episodes of hypoglycaemia due to a combination of wrong insulin site, technique as well as needle size. On examination, he was found to have spotted dermopathy on his forearms (insulin injection site) which was consistent with intradermal insulin administration. Recently, insulin infusion through intradermal route has been found to reach the systemic circulation faster than even the conventional subcutaneous injection. This case emphasizes that hypoglycaemias can occur due to less common causes. It warrants a good clinical examination and patient education.

Pericardial Hemangioma: A Common Tumour in an Unusual Location: Case Report and Review of Literature

Overall incidence of primary cardiac tumours ranges from 0.0017% and 0.27% at autopsy. Cardiac haemangiomas are rare, and account for 2.8% of benign cardiac tumours. Pericardial haemangiomas, in particular are extremely rare. Pericardial haemangiomas are reported to present with a variety of symptoms such as dyspnea, palpitation, atypical chest pain. Other symptoms like obstruction of blood vessels, cardiac tamponade, or pericardial effusion may result due to compression of surrounding structures. Here we report a case of pericardial haemangioma in a patient who presented with breathlessness and cough.

Sinonasal Schwannoma – A Case Report

Manjusha shripad dhawle, Santosh Govind Rathod, Milind A Bhatkule, Rajan S Bindu

Schwannomas are benign peripheral nerve sheath tumours that may occur throughout the body. They rarely occur in the nasal cavity. Paranasal schawannomas are uncommon lesions, representing less than 4% of all head and neck schawannomas. Here we report a case of sinonasal schwannoma in a 35-year-old man who presented with a history of nasal blockage since two years. The mass was removed successfully without any postoperative complication and there was no recurrence within a year of follow up.

Poorly Differentiated Sertoli-Leydig Cell Tumour of Ovary with Heterologous Elements

Tapan Kumar Sahoo, Tushar Kar, Asaranti Kar, Sasmita Panda

Sertoli-Leydig Cell Tumour (SLCT) is included under sex-cord stromal tumour of testis or ovary. Ovarian pathology is an extremely rare entity constituting less than 0.5% of all ovarian neoplasms. Majority of the cases present at younger age group, i.e., 2nd and 3rd decade of life. The clinical presentation depends on either mass effect or excess hormone production. Virillization symptoms are the most common presentation and depend upon the quantity of androgen production. Most of the patients have a unilateral mass without extraovarian spread and present at stage-I. Treatment and prognosis depends on the degree of the differentiation and the stage of the disease. Here, we report a case of SLCT of the ovary in a young female. The patient initially presented with pain abdomen due to mass effect and was treated with conservative surgery followed by adjuvant chemotherapy due to the presence of poorly differentiated pathology with heterologous elements.

Psychosis in a Case of Dandy-Walker Syndrome: A Case Report

Ripu Daman Dawra, Sagar Karia, Nilesh Shah, Avinash Desousa

Dandy Walker Syndrome (DWS) is a congenital malformation with brain abnormalities, intellectual disabilities, epilepsy and visible structural changes in particular brain structures. We present here a case of psychosis in an 18-year-old male with DWS, epilepsy and intellectual disability. The purpose of this paper is to discuss the clinically relevant issues, psychopharmacological issues, neuropsychiatric manifestations and consultation liaison issues involved.

Unusually Detected Anti-M Antibody Presenting as Cross Match Incompatibility in a Female Child Diagnosed with Small Round Cell Tumour

Sheetal Anand Chandak, Aruna Vishwanath Vanikar

MNS antigen system is one of the human blood group systems. Anti-M antibody is a relatively common, naturally occurring antibody of IgM variety. Clinically significant anti-M antibody is reactive at 37°C in the anti-human globulin phase due to high thermal amplitude of IgM component or presence of IgG component. If anti-M antibody is activated at 37°C or in the anti-human globulin phase, it may cause delayed haemolytic transfusion reactions or haemolytic disease of newborn, which suggest variable clinical significance. We report a case of an unusually detected anti-M antibody presenting as cross match incompatibility in a one-year-old female child with a lump in the right lumbar region, which was later diagnosed as small round cell tumour in the right kidney.

Management of an Unusual Ectopic Eruption of Maxillary Canine

Transposition of teeth is a rare condition, with a prevalence of 0.3-0.4% in general population. They are more commonly observed in females, and may occur unilaterally/bilaterally with greater frequency of left side occurrence in unilateral transposition cases. A 17-year-old female patient reported with the chief complaint of unaesthetic smile. On clinical examination the patient was diagnosed with Angle’s class I malocclusion with an ectopically erupted maxillary left canine labial to the left central incisor with retained deciduous canine. The treatment plan decided was to extract the retained deciduous canine, level and align the ectopic canine using an R-loop. The treatment for the patient was finished in 14 months and was retained using a fixed lingual retainer in the upper and lower arches.

An Unusual Radiographic Presentation of Aneurysmal Bone Cyst of the Zygoma: A Rare Case Report

GV Murali Gopika Manoharan, Priyanka Khobre, Jayaraman Balaji, Mukesh Singh

Aneurysmal Bone Cyst (ABC) is an uncommon benign lesion affecting mainly the long bones and vertebral column. Its occurrence in the maxillofacial skeleton is rare. So far only five cases of ABC in the zygoma have been reported in the literature. Radiographic features of ABC are not pathognomonic. There can be expansion of bone and it may manifest as cystic lesion with honeycomb or soap bubble appearance.There can be perforation or destruction of cortex of the bone as well. Therefore the differential diagnosis of ABC is quite conflicting with other types of maxillary bone lesions. Here we report a case of ABC in 30-year-old female, at the left zygoma region showing periosteal reaction with sunray effect, which according to the literature is the first case reported based on location and radiographic appearance.

A Case of a Rapidly Enlarging Neck Mass with Airway Compromise

Anaplastic Thyroid Carcinoma (ATC) is one of the most lethal tumours in humans, extremely rare in occurrence and very aggressive in nature. We hereby present a rare case of ATC with airway compromise. A 66-year-old male, presented complaining of a non-tender anterior neck mass rapidly increasing in size associated with dry cough, hoarseness and voice changes. Imaging studies revealed a large heterogeneous centrally necrotic lobulated left thyroid mass with metastatic lymph nodes and rightward tracheal deviation. Core biopsy and immunohistochemistry stains revealed a profile consistent with ATC. Patient’s airway was compromised. Options for treatment and prognosis were discussed. Patient was discharged home with home hospice. A high index of suspicion for ATC is necessary in patients presenting with a rapidly enlarging neck mass. A prompt cytologic evaluation with metastatic work up is important to establish diagnosis. Due to its poor prognosis, an honest discussion regarding end-of-life issues must be initiated at diagnosis. Novel therapies toward genetic and epigenetic pathways have been developed, which is the basis of current clinical trials that are intended to improve clinical outcomes in the coming years.

An Extremely Rare Case of Small Cell Carcinoma in Submandibular Salivary Gland

Small Cell Carcinoma (SCC) of the salivary gland is a rare and aggressive tumour accounting for about less than 1% of the salivary gland tumours. Submandibular gland involvement is extremely rare. These tumours frequently present with metastasis to lymph node and distant organs. We report a case of a 30-year-old male patient who presented with a swelling on the left side of the face below the jaw and the floor of the mouth. The tumour was excised followed by histopathological evaluation and diagnosed as SCC of left submandibular gland. Immunohistochemistry was positive for pan cytokeratin, synaptophysin, chromogranin, Ki-67, CK5/6, and negative for Thyroid Transcription Factor (TTF-1) which confirmed that the tumour was SCC of submandibular salivary gland.

Large Multicystic Dysplastic Kidney Mimicking a Large Cystic Renal Neoplasm.

Priyank Yadav, Sanjoy Kumar Sureka, M S Ansari, Rahul Soni, Hira Lal

Multicystic Dysplastic Kidney (MCDK) is one of the most common renal conditions seen in paediatric population. The natural history typically involves involution and many of the patients with unilateral disease may actually never become symptomatic. The initial evaluation is usually done on Ultrasonography (USG) while cross-sectional imaging and nuclear scan are reserved for diagnostic dilemmas. Management is conservative and surgery is done for selected patients with symptomatic cysts or suspicion of neoplasm. We present an interesting case of MCDK in a nine-month-old female hypertensive child presenting with a large abdominal mass increasing in size with imaging features similar to cystic neoplasm and managed with nephrectomy.

Sturge Weber Syndrome: A Case Study

The aim of this case review was to touch upon the various clinical presentations and diagnostic features of Sturge-Weber syndrome (SWS) as seen in the dental/medical practice. Sturge-Weber syndrome is a rare congenital disorder that belongs to a group of disorders collectively known as the phakomatoses. The characteristic pathological elements of the disease include leptomeninges angioma extending out to cerebral cortex with angiomatous lesions on the same side and unilateral facial nevus that affects trigeminal nerve division. The classic oral lesions involve haemangiomatous gingival lesion limited on the same side of upper or lower jaw. An 18-year-old female patient reported to the Department of Oral Medicine and Radiology with oral manifestations of SWS. The evaluation of the patient, radiological findings as well as the management is discussed in this case report. It is important for the dental physician to be aware of the non-oral manifestations of SWS in order to identify and manage it appropriately. The challenge here is to see the oral manifestation as part of the syndrome and not as an isolated oral condition. Early diagnosis and appropriate treatment plan is imperative to prevent development of complications.

Concomitant Presence of Carcinoma of Breast in a Patient with Early-Onset Cataract: First Case Report of a Potential Association

Shahbaz Habib Faridi, Kaushal Deep Singh, Mehershree Lodhi

A recent nation-wide population based retrospective cohort study from Taiwan in 2014 suggested a propensity of developing breast cancer in young females with early-onset cataract. We report here a case of a young non-obese female who presented to us with a large lump in the right breast with skin nodules and bilateral painless progressive diminution of vision. Patient was diagnosed to be suffering from locally advanced carcinoma of right breast with axillary metastasis (Stage III B) and bilateral early-onset nuclear cataract. Patient was started on taxane and anthracycline based neoadjuvant chemotherapy and after three cycles of chemotherapy patient showed partial response (˜50% reduction of tumour mass). Patient underwent small incision cataract surgery in left eye after the first cycle of chemotherapy. However, the patient was lost before any operative intervention could be done as she died in a road traffic accident. Possible mechanism of development of breast cancer in patients with early-onset cataract is discussed. This is the first reported case of a patient of early–onset cataract developing breast cancer as well as the first reported case of concomitant presence of early-onset bilateral cataract with breast cancer.

Simultaneous Occurrence of Thyroiditis in Ectopic and Eutopic Thyroid Masquerading as Thyroglossal Cyst

Aditi Chopra, Yogendra Singh, Manju Kaushal, Anil Taneja, Bindu Kulshreshtha

Ectopic thyroid gland is a rare condition usually presenting with neck swelling or hypothyroidism. In most cases, ectopic thyroid tissue is the only functioning thyroid tissue, but it may rarely be associated with normal thyroid gland. Thyroiditis in an ectopic thyroid gland is very rare. Here, we describe a 13-year-old girl who was initially suspected, as a having a thyroglossal cyst. Thyroid functions were suggestive of thyrotoxicosis. She was diagnosed to have simultaneous occurrence of thyroiditis in the ectopic and eutopic thyroid glands. This case was exceedingly rare since this patient presented with thyrotoxicosis unlike previous reported cases who were either euthyroid or hypothyroid.

Osteoma of the Middle Turbinate Presenting with Frontal Lobe Abscess and Seizure

Ramandeep Singh Virk, Shikhar Sawhney

Osteomas are the most common benign tumours of the sinonasal tract. Even though their location in the sinuses is well known, turbinate osteomas are quite rare. We report one such case of a 26-year-old female who presented with neurological complaints of a seizure rather than nasal complaints.The cause of the seizure was found to be a small abscess in her frontal lobe, secondary to frontal sinusitis due to a bony hard nasal mass arising from the middle turbinate. She underwent endoscopic excision of the mass which was confirmed on histopathology as an osteoma. The case highlights an unusual presentation of a middle turbinate osteoma.

Cystic Sertoli-Leydig Cell Tumour in a Postmenopausal Woman with Absent Virilising Symptoms: A Diagnostic Challenge

Vidya Monappa, Saritha M Reddy, Ranjini Kudva, Muralidhar V Pai

A 60-year-old postmenopausal woman, presented with a left ovarian cystic mass with mildly elevated CA125 levels. An intraoperative frozen section showed oedematous ovarian stroma with interspersed large aggregates of spindle shaped stromal cells. Subsequently, the excised specimen was reported as Sertoli-Leydig Cell Tumour (SLCT) of intermediate differentiation. The leydig cells were identified in the imprint smears, but were misinterpreted as luteinized cells. The lack of tubular differentiated cells in frozen section had contributed to the misdiagnosis. Immunohistochemistry (IHC) played an important diagnostic role in the absence of clinical suspicion and lack of virilising features that are classically described in association with SLCTs. This case is unusual, as the tumour was seen in a postmenopausal woman in the absence of virilising symptoms. The cytomorphological features, IHC findings and the reasons for misdiagnosis are discussed in this case report.

Upper Gastrointestinal Bleeding Due to Idiopathic Oesophageal Ulceration in the Era of HAART: A Vanishing yet Pernicious Aetiology

Sofia Nigar, Tagore Sunkara, Mel A Ona, Vinaya Gaduputi, Madhavi Reddy

Oesophageal ulcers are a rare cause of upper Gastrointestinal Bleeding (GIB). In patients with Acquired Immune Deficiency Syndrome (AIDS), oesophageal diseases including oesophageal ulcers are very common. Idiopathic Oesophageal Ulcers (IOU) comprises a subgroup of oesophageal ulcers with no identifiable cause. IOU mainly present as odynophagia, retrosternal chest pain, decreased oral intake, and weight loss. Upper GIB is a rare presentation. In the era of Highly Active Anti Retroviral Therapy (HAART), with improvement in CD4 count, this entity is almost forgotten.

Leriche Syndrome: Acute Onset Painful Paraplegia of Vascular Origin with Catastrophic Consequences

Acute Aorto-Iliac Occlusive Disease (AIOD) is a rare clinical entity which when presents with buttock claudication, erectile dysfunction and absent femoral pulses is termed as Leriche syndrome. A 59-year-old male patient with past history of smoking and dyslipidaemia presented with acute onset lower back pain, paraplegia, intense lower limb pain and was initially evaluated for compressive myelopathy. On further clinical examination there were absent femoral pulses and Computed Tomography (CT) aortogram was done which confirmed the diagnosis of diffuse AIOD. Clinically, it is often challenging to differentiate between vascular or neurogenic origin of acute onset painful paraplegia. A high index of suspicion and careful clinical examination is therefore essential to avoid misdiagnosis of a major vascular event which can result in significant morbidity and mortality.

A Misdiagnosed Laryngeal Web: Treated with an Innovative Self-Made Keel

Laryngeal web is a rare congenital anomaly. Late presentation at the age of 10 years as in our case, with misleading diagnosis of asthma in a Cohen’s type III glottic web is even rarer. In cases of congenital laryngeal web the aim is to provide a patent airway and to achieve a good voice quality. Regardless of the technique used; the primary concern is recurrence. Traditionally, the treatment of choice for laryngeal web was laryngofissure with placement of a keel however; endoscopic laser excision of the web with keel placement is now the preferred technique for thin anterior glottic webs. This endoscopic technique not only requires a Lichtenberger needle carrier but also the ready-made keel, which many of the government set-ups in our country cannot provide. For an alternative to this problem, we have described an innovative, minimally invasive technique for placement of a self-made silicone keel without any sophisticated instruments.

Xanthogranulomatous Cholecystitis with Florid Ducts of Luschka: Double Trouble Mimicking Malignancy

Archana Shetty, Mudasser Rehan, V. Geethamani

Xanthogranulomatous Cholecystitis (XGC) is an uncommon inflammatory condition of gall bladder, which is often misdiagnosed as malignancy preoperatively, leading to extensive surgical resections which may not be necessary for the patient. Ducts of Luschka are a rare developmental variant of the biliary tree, which are prone to injury and bile leak during cholecystectomy. We report a case of a 52-year-old male patient who was taken up for surgery with a provisional diagnosis of chronic calculous cholecystitis. Intraoperative finding of dense adhesions, made the surgeons suspect malignancy. On histopathological examination, it was not only diagnosed as a case of XCG, but it also had florid ducts of Luschka, another rare variant needing documentation as it is a close mimicker of malignancy.

A Case Report of Rare Carcinoma Ex Pleomorphic Adenoma of Submandibular Gland and its Detailed Description

Kirti Balkrishna Buva, Ajinkya Amritrao Deshmukh, Atul A. Deshmukh

A 65-year-old female patient reported with a chief complaint of swelling in the left lower region of the jaw since two years. On clinical examination, the swelling was present on the mandibular left posterior region and measuring approximately 6.2 cm antero-posteriorly × 6.2 cm mediolaterally × 8.7 cm superioinferiorly. Initially, it was non tender but eventually it became tender. Fine needle aspiration was done to rule out any salivary gland pathology and report obtained was carcinoma ex pleomorphic adenoma. Then, excisional biopsy was taken and tissue sent for histopathology. Histopathological diagnosis was benign adenoma with carcinoma. Later serial sections of tissue were studied and came to the conclusion of carcinoma ex pleomorphic adenoma which was non invasive type and showed bizarre cells with neoplastic changes. Benign part was composed of myxomatous area with partial capsule. Neoplastic cells showed invasion into capsule and few necrotic areas were also present. Overall interpretation was favoured Non invasive carcinoma ex pleomorphic adenoma. So here, we reported a case of Carcinoma ex Pleomorphic Adenoma (CAEXPA) which is a deadly and rare variant of salivary gland malignancy.

A Unique Triad of Muscular, Vascular and Nervous Variations in Upper Limb

Multiple muscular and neurovascular anomalies in upper limb are reported continuously in medical literature because of their clinical significance. A unique case of the triad of variations was encountered during routine dissection activity. The variations observed were: 1) Accessory third head of biceps brachii; 2) High division of Brachial Artery; 3) Communication between Musculocutaneous Nerve and Median Nerve. Taken independently these variations are common but it is rare in a single cadaver. These abnormalities were found unilaterally on the right arm of the cadaver. The third head of biceps brachii was seen to be originating from the medial border and adjacent area on the anteromedial surface of the humerus at the level of insertion of coracobrachialis fusing with main muscle belly just before it forms the tendon. Additional head of biceps brachii was supplied by a branch from the Median Nerve. This branch after supplying the additional head of biceps was seen to join the Musculocutaneous Nerve. Further, a higher bifurcation of brachial artery was observed at the level of insertion of coracobrachialis. The medial division was traced distally as radial artery and the lateral division was traced as ulnar artery. The knowledge of these variations is of immense importance to correlate abnormal displacement of fractured bone segments, avoiding fatal injuries to vital structures, transradial angiography and diagnostic clinical neurophysiology.

Massive Benign Phyllodes Tumour of Breast Complicating Pregnancy

Phyllodes tumour of the breast, earlier called cystosarcomaphyllodes, is a rare fibroepithelial breast neoplasm that occurs in all age groups from adolescents to elderly. Phyllodes tumour occurring during pregnancy and associated with lactating breast is extremely rare. Giant phyllodes tumours or giant fibroadenomas are those measuring more than 10 cms in diameter and weighing more than 500 gm. Phyllodes tumour typically exhibits an exclusive intracanalicular growth pattern of fibroepithelial cells with classical, deep leaf-like stromal projections into dilated lumens from which its name “phyllodes” is derived. A 32-year-old primigravida at 38 weeks of gestation, presented with massive and heavy swelling of the left breast, growing over the last eight months. Physical examination revealed a massively enlarged left breast with palpable, firm, nodular mass measuring 10 x 20 cm and occupying whole of the left breast. A trucut biopsy demonstrated a fibroepithelial lesion suggestive of benign phyllodes tumour. Simple mastectomy was performed six days after the delivery of the baby by caesarean section. The histopathological report confirmed the diagnosis as benign phyllodes tumour with ductal hyperplasia and no atypia. We are reporting this case because of its massive size, associated with lactating breast and difficulty in histopathological differentiation from Giant fibroadenoma.

Pure Uterine Lipoma: A Common Tumour at an Uncommon Site

Although lipomas are very common tumours, pure uterine lipomas are extremely rare. Their reported incidence is 0.03-0.2%. They commonly present with symptoms similar to that due to leiomyoma except that they occur in post menopausal elderly females. We report a case of 70-year-old elderly female, who presented with third degree uterovaginal descent. A total vaginal hysterectomy was done for her. The hysterectomy specimen showed presence of a well circumscribed uterine fundal lipoma. We report this case because of its rare occurrence in the uterine fundus.

Cytological Diagnosis of Primary Cutaneous Aspergillosis Masquerading as Lipoma in a Known Case of Lepromatous Leprosy

Savitri M. Nerune, Swati Arora, Mayank Kumar

Primary cutaneous aspergillosis is a rare disease, caused by organisms like Aspergillus flavus and Aspergillus fumigatus. Fine Needle Aspiration Cytology (FNAC) is a simple and well established tool for the diagnosis of mycotic infections. We report a case of forearm swelling that presented clinically as lipoma in a known case of lepromatous leprosy. It was diagnosed as primary cutaneous aspergillosis on FNAC, which was subsequently confirmed on culture. Cutaneous aspergillosis co-existing with leprosy has rarely been reported in the literature and early diagnosis of aspergillosis in immunocompromised patients is mandatory.

Salvage Surgery for Metastatic Gall Bladder Cancer with Vanishing Liver Metastasis Following Palliative 5-Fluorouracil Metronomic Chemotherapy

Gall Bladder Cancer (GBC) is an aggressive malignancy. The prognosis of metastatic GBC is dismal. Until recently, there are no standard treatment guidelines for management of patients with metastatic GBC. But the ultimate aim of any treatment modality is to improve the overall survival with good quality of life. We hereby report a long term survivor of metastatic GBC treated with initial six cycles of gemcitabine + cisplatin combination chemotherapy, but did not show any response. In view of chemotoxicity and as a matter of physician preference patient was started on low dose weekly 5- Fluorouracil monotherapy based on a metronomic chemotherapy principle. There was complete resolution of all the liver metastasis and salvage radical cholecystectomy was done. The patient is disease free on imaging at eight months of follow up. A very few such cases have been reported in the world literature, till date. Metastatic disease must not be considered incurable as there are no objective measures to predict tumour biology. Further research on metronomic chemotherapy and tumour genetics in such patients will open a new era of individualised cancer therapy based on objective measures that will predict tumour biology.

Hemi-Chorea in a Patient with Ketotic Hyperglycemia: An Unusual Presentation

Chorea has often been associated with lesions in the basal ganglia and in the sub thalamic nucleus. It is possible for a patient with chorea-ballismus to have hyperglycemia at the initial presentation. We hereby present a case of an 81-year-old female, who was on treatment for type 2 diabetes mellitus and presented to us with sub acute onset of abnormal movements of right side of the body. She had semi purposeful, rapid and jerky movements of right upper limb and lower limb along with abnormal tongue movements. Laboratory data showed very high blood glucose levels, urine ketones were positive and pH of arterial blood was normal. MRI brain showed hyperintensities in right basal ganglia. So, hyperglycemia induced hemichorea was considered as a possibility and she was treated with insulin. These abnormal movements decreased subsequently with treatment and patient is doing better in the follow-up visits. This presentation is extremely rare, as review of literature showed similar presentations in patients with non ketotic hyperglycemia but not reported so far in diabetic ketosis.

Bilateral Primary Papillary Serous Carcinoma of the Fallopian Tube

H.K. Manjunatha, Bhargavi Mohan, V. Geethamani

Primary fallopian tube carcinoma is considered one of the rarest female genital cancers, and its bilateral occurrence is even rarer. Because of the rarity of fallopian tube carcinomas as well as the clinical presentation which simulates an ovarian cancer, a correct preoperative diagnosis of fallopian tube carcinoma is seen only in 4% of cases, and is usually first appreciated by Pathologists. We are reporting our experience of a case of bilateral primary serous carcinoma of the fallopian tube in a 36-year-old female.

Ectopic Parathyroid Adenoma Presenting as a Mediastinal Mass

Aneesha Vaidya, Mangala Gouri2, H.M Sudha, Vijaya Mysorekar, Avinash Balekudura

A parathyroid adenoma present in an ectopic site, in the anterior mediastinum, is a rare cause of persistent hyperparathyroidism. Though its occurrence in the mediastinum is unusual, existence has been noted in literature for more than a century. We describe a case of a 35-year-old male presenting with complaints of pain abdomen, clinically diagnosed as acute necrotizing pancreatitis, with raised serum calcium. Patient received symptomatic treatment for the pancreatitis which subsided. However, high levels of serum calcium persisted. Suspecting hyperparathyroidism, ultrasound neck was done, revealing apical thoracic mass. CT scan of neck revealed a large heterogeneous enhancing mass in superior mediastinum. Fine Needle Aspiration (FNA) of the mass done endoscopically was confusing as it showed features suggestive of a cystic teratoma. However, persistently raised calcium levels along with raised parathormone warranted a Technetium – 99 (Tc-99m) sestamibi scan which revealed positive uptake involving right inferior parathyroid extending to superior mediastinum. The mass was surgically excised and it was diagnosed as a parathyroid adenoma. This case helps bring to light the necessity to consider ectopic parathyroid adenoma as an important differential diagnosis in mediastinal tumour with persistent hypercalcaemia, and as a cause of hyperparathyroidism.

Parietal Wall Abscess Perforating to Transverse Colon: A Rare Presentation

Extrapulmonary tuberculosis affects an isolated organ or presents secondary to pulmonary involvement. Lymph nodes are the common sites for extrapulmonary tuberculosis. Primary extrapulmonary tuberculosis involving parietal wall is an unusual presentation. Tubercular abscess of the abdominal wall perforating to large bowel has not been reported. Here, we are reporting a very rare case of anterior abdominal wall abscess of tubercular origin in a 57-year-old female patient who presented with complaints of pain in upper abdomen for four months. CT scan and intraoperative findings revealed perforation of the abscess into transverse colon. Histopathology report confirmed the aetiology and origin of the abscess.

Bilateral Solitary Glomus Tumour of Thumb: A Case Report

Glomus tumours are benign neoplastic lesions of glomus body, a thermoregulatory apparatus of cutaneous microvasculature. These tumours can arise at any location of the body but most commonly seen in subungual region of fingers. Bilateral solitary glomus tumour of hand is a rare entity. We report a case of 54-year-old female who presented with complaints of pain in the right thumb since three years and left thumb pain since 20 years. Clinical examination revealed acute tenderness of both the thumbs. Love’s pin test and Hildreth’s test were positive. MRI revealed characteristic features of glomus tumour. Excision of both the lesions was done and proceeds forwarded to histopathology which confirmed diagnosis. Patient was symptom free immediately following surgery. No nail deformities were noticed and there was no recurrence of symptoms in one year follow up. Glomus tumours of the hand are a rare entity and often missed.

Renal Pelvis Leiomyoma- An Infrequent Clinical Case

Fernando Ugarte-y Romano, Adolfo González-Serrano, Jorge Moreno-Aranda

Renal pelvis leiomyomas are infrequent benign tumours. These tumours are more frequent in women, usually asymptomatic and difficult to distinguish from malign kidney masses. A 27-year-old female presented with an asymptomatic renal mass discovered after abdominal ultrasound during routine check-up. Percutaneous renal biopsy was performed and reported urothelial carcinoma. After open nephroureterectomy, histopathological evaluation and immunohistochemistry were positive for Smooth Muscle Actin (SMA), Ki67 <5%, and negative for cytokeratin and HMB-45. Thus, confirming the diagnosis of renal leiomyoma. The diagnosis of these infrequent tumours is often difficult and it is usually made by immunohistochemistry after surgical treatment.

Mucoepidermoid Carcinoma of Salivary Gland: Limitations and Pitfalls on FNA

Geetha Vasudevan, Arijit Bishnu, Brij Mohan Kumar Singh, Varun Kumar Singh

Mucoepidermoid Carcinoma (MEC) is the most common malignant neoplasm of salivary gland origin. However, its morphologic heterogeneity poses difficulty in interpretation. In the present series we discuss the morphologic features of MEC, limitations and pitfalls in its diagnosis on Fine Needle Aspiration Cytology (FNAC). Fourteen cases of suspected MEC were evaluated cytologically followed by histopathological examination for confirmation. A definite cytological diagnosis was rendered in nine cases; three of the remaining five were underdiagnosed as abscess, pleomorphic adenoma and mucus cyst. Of the remaining two cases, one case each of sebaceous carcinoma and sialadenitis was mislabeled as MEC on cytology. A satisfactory aspirate composed of intermediate cells, mucin secreting cells and squamous cells in a mucinous background may not be obtained in all cases of low grade MEC. High grade MEC can be classified as squamous cell carcinoma. Hence, awareness of confounding factors with clinicopathologic correlation and judicious use of frozen section can help in minimizing errors.

Intraoral Approaches for Maxillary Molar Distalization: Case Series

Devinder Preet Singh, Shefali Arora, Sumit Kumar Yadav, Neal Bharat Kedia

Correction of Class II malocclusion by distalization of maxillary molars with intraoral appliances is a non-extraction treatment approach, which has been described as an alternative to Head Gear. From the past few years, the procedures have undergone rectification to achieve treatment objective more precisely. This has been made possible by a better understanding of bone physiology, tooth movement, biomechanics and newer biomaterials. Nowadays newer distalizing appliances, like the Jones Jig, Lokar distalizer and Carrière distalizer, have been developed which have compact designs and cause minimal discomfort to the patient. Refinement in these appliances is concentrated mainly on achieving bodily movement of the molar rather than simple tipping. These appliances are also operator friendly as these are easy to insert and remove. The present case series presents the efficacy of these appliances in Class II malocclusion patients with a mean age of 16 years (age range of 15-17 years) that reported with the chief complaint of irregular upper front teeth, since non-extraction approach in correcting Class II malocclusion is gaining a lot of attention.

A Case Series of Young Patients with Completely Reversed Severe Pulmonary Hypertension

Aniketh Vijay Balegadde, Vikrant Vijan, Rajesh Thachathodiyl

Pulmonary Arterial Hypertension (PAH) is a progressive symptomatic disorder, which may ultimately lead to death if left untreated. Although majority of PAH cases are idiopathic, pulmonary hypertension resulting due to certain underlying conditions are also observed frequently. In such cases, it becomes essential to identify any potentially treatable or reversible causes for PAH. There have been significant advances in the medical management of PAH and various medicines have been approved by US Food and Drug Administration (FDA) for various stages of PAH. With these therapies, there can be varying degrees of improvement in the pulmonary artery pressures and hemodynamic profile. Therefore, physiologic reversal can and does occur, sometimes to the point of normalization. We hereby present three such cases of severe PAH in patients below 50 years of age due to various aetiologies like left heart disease, isolated unilateral absence of right pulmonary artery with hypoplastic right lung and factor V Leiden mutation associated pulmonary thromboembolism, all of whose pulmonary artery pressures are completely normalised with adequate treatment of the underlying disease and with optimised medications for PAH, ultimately leading to tapering and stoppage of PAH medications.

Unilateral Blaschkoian Lichen Planus: A Series of Cases with Review of literature

Surabhi Dayal, Priyadarshini Sahu, Poonam Verma, Ashish Amrani, Rajni Khare

A number of congenital and acquired dermatological diseases are known to follow lines of Blaschko. Lichen Planus (LP), commonly acquired inflammatory dermatosis, presents with various morphological forms but Blaschkoian variant is very less published in literature. We herein report a case series of six patients of various age groups with Blaschkoian LP, without any underlying predisposing factors. All these cases presented with asymptomatic to mildly pruritic, violaceous to hyperpigmented papules and plaques following the Blaschko lines. In all the patients, lesions responded well to topical steroids and oral antihistamines, leading to gradual resolution of lesions with post-inflammatory hyperpigmentation. Blaschkoian LP is not a rare condition and may remain under reported because of its insignificant clinical features especially the absence of pruritus. Thus, the physician should always keep this entity in mind while considering the lesions following lines of blaschko.

Role of MRI in a Series of Cases with Biceps Injuries of the Shoulder

Abhishek Dwivedi, PK Dhagat, SN Singh, Shalini Singh, Narender Yadav

Dislocation and injury of the biceps is associated with acute and chronic trauma, degenerative changes, repetitive microtrauma, or injuries associated with recurrent and neglected cases of shoulder dislocation. The cases of displaced biceps injuries are relatively rare (only 1/6th of all rotator cuff injuries). The dislocation of biceps is manifested with pain and restriction of movements. The X-ray shoulder is not of much help in this condition barring for ruling out the fractures of humerus and scapula. Ultrasound is an important tool in the dislocation and shows empty bicipital groove which raises the suspicion of the soft tissue injures. Ultrasound is a problem solving tool when the equivocal findings in MRI (Magnetic Resonance Imaging) in other muscular injuries also. MRI is the modality of choice in these conditions. The bone and anatomy is better visualised on the T1WI images and the pathology is better visualised on the PDFS (Proton Density Fat Saturation) and the STIR (Short Tau Inversion Recovery) images. The role of Non Contrast Computed Tomography (NCCT) is important in associated suspicious bony abnormalities as highlighted in the article. The biceps region is a hidden area and challenging on arthroscopy due to poor visualisation of the extra-articular tendon part. MRI study helps the orthopaedicians for better management of the hidden areas. This series highlights the role of each modality in the diagnosis and management of the biceps lesions.

Serous Microcystic Adenoma of Pancreas: A Case Series from a Tertiary Care Centre in South India

K Rajasree Varma, Saji Francis, PP Sathi, C Saikiran Reddy

Serous microcystic adenoma is a rare exocrine tumour of the cystic neoplasm of pancreas seen predominantly in the elderly population. The first patient was a 56-year-old diabetic woman with abdominal pain, constipation and loss of weight since two months. The second patient was a 73-year-old female with complaints of abdominal pain and back pain since one year. The third patient was a 72-year-old diabetic man with complaints of burning sensation in the right lumbar region since two months. Clinical and laboratory examinations were normal. The radiological examinations of the first two patients showed multiloculated cystic lesion in the pancreas and of the third patient was suggestive of islet cell tumour. The histopathological examination of the three patients showed multiple cysts of varying sizes lined by cuboidal epithelium, showing no atypia. All the three patients were diagnosed as serous microcystic adenoma of pancreas. On follow up, all three patients had no recurrence. Serous epithelial neoplasms need to be differentiated from their non-neoplastic counterparts and other neoplastic lesions with cystic changes, in view of the differences in management. Serous microcystic adenomas have excellent prognosis.

Respiratory Symptoms as Prominent Manifestation of Brucellosis: A Case Series

Brucellosis is a zoonotic infection primarily affecting the reticuoendothelial system: spleen, liver and bone marrow. Despite the fact that multisystem infection in brucellosis is usually reported, pulmonary involvement is considered to be very rare. We report four cases (three male and one female, farm workers) of pulmonary brucellosis who presented with signs and symptoms of lower respiratory infection. All of them underwent thorough clinical examination and laboratory tests before the diagnosis of pulmonary brucellosis was confirmed. All patients were hospitalized for at least eight days and given appropriate antibiotic therapy. Follow up after 12-24 months showed no lasting effects from the infection and laboratory tests were found within the normal limits.

A Speedy Yet Simple Tip to Align Imbricated Anterior Teeth

Correction of dental crowding can be achieved with several orthodontic procedures like extraction of teeth, proximal stripping etc. In contemporary orthodontic practice, resolution of incisor crowding is most commonly achieved by the use of canine lacebacks. This method takes time, requires frequent activations and taxes anchorage since it involves the “PULL” mechanics. In order to overcome these disadvantages, mostly the time factor, we devised a method of using open coil NiTi spring on 0.016” SS wire piggy backed on the 0.014” heat activated NiTi base arch wire ligated only at the canines. This method, resolved the incisor crowding in almost one third of the time taken with the use of canine lacebacks. Moreover, the result was more physiologic since light continuous force was applied with the spring and it essentially eliminated the anchorage loss since it involved “PUSH” mechanics.

Development and Validation of Health Education Tools and Evaluation Questionnaires for Improving Patient Care in Lifestyle Related Diseases

Charu Arora, Bipin Sinha, Anita Malhotra, Piyush Ranjan

Lifestyle related diseases continue to be a significant burden on the health care system. Health education is a combination of educational strategies that promote voluntary adoption of healthy lifestyle choices and dietary behaviour. The use of simple and validated education and evaluation tools is now increasing in routine clinical practice to aid health status evaluation and communication between the patient, dietitian and the health care provider. Development of effective health education materials is a systematic process which starts with setting up the goals for education, followed by literature review and focus group discussion, content selection, designing the rough draft, seeking expert comments and validation. Questionnaire development should follow a logical and structured approach. Item generation should be based on extensive literature search and target group participation. Validation by the experts makes the questionnaire more meaningful, trustworthy and applicable. Considerable effort goes into designing and testing of these tools in order to ensure that they are effective. For enhancing clinical, dietetic and educational practice, it is pertinent to learn the process of developing these tools scientifically.

Legendary Hero: Dr. G.V. Black (1836-1915)

Shruti Jain, Hemant Jain

Hypolipidaemic Effects of Gymnema sylvestre on High Fat Diet Induced Dyslipidaemia in Wistar Rats

Introduction: Hyperlipidaemia is a well known risk factor for cardiovascular diseases. Lifestyle modification can be the initial step to reduce cholesterol levels. There are various drugs which are used to control dyslipidaemia. Treatment of lipid abnormalities is a lifelong battle. Moreover, the safety and effectiveness of long term lipid lowering treatment are questionable. Gymnema Sylvestre (GS) is a well known herb with various medicinal properties. Aim: To explore the hypolipidaemic activity of GS leaves extract. Materials and Methods: Adult healthy female wistar rats, 30 in number, divided into five groups, weighing 150- 200 g were used. Dyslipidaemia was induced in rats by feeding them on high fat diet for four weeks. For the next four weeks GS extract was used as test drug while Atorvastatin was used as standard drug. Blood sample was collected for estimation of lipid profile on day 0, week 4 and week 8. Data was recorded as mean±SEM (Standard error of mean). Paired t-test and one way Analysis of Variance (ANOVA) followed by Dunnett’s post hoc test was used for comparison. A p-value <0.05 was considered statistically significant. SPSS Statistics 20 (IBM software) was used for the analysis. Results: Feeding rats with high fat diet for four weeks led to obesity and dyslipidaemia in rats. GS at both the doses (100mg/kg and 200mg/kg) significantly improved the lipid profile. Total Cholesterol (TC), Triglycerides (TG), Very Low Density Lipoprotein (VLDL) and Low Density Lipoprotein (LDL) values reduced significantly while that of High Density Lipoprotein (HDL) increased significantly. GS 200 mg/kg was found more effective than GS 100 mg/kg. GS improved the value of lipid profile significantly but the effect was found inferior to Atorvastatin. Conclusion: From the present study it can be concluded that GS possess an effective hypolipidaemic effect. Hence it can be included as an add on therapy in dyslipidaemia after further confirmatory studies.

Pharmacophore Mapping Approach for Drug Target Identification: A Chemical Synthesis and in Silico Study on Novel Thiadiazole Compounds

Introduction: Compounds containing thiadiazole moiety are cognized to possess with variety of clinical and therapeutic activity. Finding a suitable drug target for newly synthesized compounds remain a major bottle neck in current high throughout medicinal chemistry era. Aim: To effectively synthesize di substituted thiadiazole compounds and demonstrate drug target identification using an in silico pharmacophore probing approach. Moreover, we also aim to validate the suitability of identified drug target. Materials and Methods: A cost-effective and environmental friendly chemical synthesis scheme for production of di substituted thiadiazole compounds was employed. Target identification was conducted by Pharmmapper software. Validation was accomplished by performing molecular docking and further Molecular Hydrophobic Potential (MHP) analysis. Results: Pharmacophore probing base approach identified hepatocyte growth factor receptor (c-Met) as a suitable biological target for newly synthesized compounds. Binding free energy values indicate that compound 4b, 4e, 4g and 4h has tremendous potential to be further used as lead compound to design selective inhibitors of c-Met receptor. MHP data from current study supports the possibility that hydrophobic contacts might act as major factor stabilizing thiadiazole- c-Met complex. Moreover, in silico observations of current study are in absolute accordance with previously described in vitro and crystallographic analysis. Conclusion: We demonstrate that thiadiazole compounds synthesized in current investigation has high potential to act in modulation of hepatocyte growth factor receptor (c-Met) activity and thereby act as putative therapeutic agent in cancer therapy.

All Premolars with Three Roots Confirmed with Cone Beam Computed Tomography: A Rare Anatomical Variation

Tushar Krishna Yadav, Nidhi Anup Guptata, Vikesh Sisodia

Fibrolipoma of the Oral Cavity: Treatment Choice in a Case with an Unusual Location

Roberto Pippi, Marcello Santoro, Romeo Patini

Broad Thumb-Hallux Syndrome: A Diagnosis Made on Clinical Findings

An Unusual Presentation of B Cell Acute Lymphoblastic Leukaemia in a Child

Lymphangitic Pulmonary Metastasis: A Rare Finding in Gastric Carcinoma

James Benjamin Gleason, Justin Dolan, Anas Hadeh

Long Cord: A Knotty Affair

Sumita Mehta, Anshuja Singla, Shweta Sinha, Anshul Grover

Light Microscopic Features of Type II Dens Invaginatus in A Deciduous Mandibular Molar

Staged Approach for Advanced Gingival Recession: Free Gingival Autograft Followed by Coronally Advanced Flap with PRF Membrane

Sowmiya Lingeshwaran, Ramakrishnan Theyagarajan, Ambalavanan Namasivayam

Correspondence: Abnormal Nuclear Variations in Response to Radiotherapy: As a Tool in Treatment Planning and Assessment of Prognosis

Laxman Khanal

Oral Isotretinoin May Improve the Symptoms of Chronic Rhinosinusitis

Habibullah AktaS, Can Ergin, Aziz Tunç, Süha Ertugrul

Delirious State and Agitation Following Heparin Induced Stevens-Johnson Syndrome

Reza Bidaki, Sogol Ale Saeidi, Mojtaba Babaei Zarch

Hoffmann’s Syndrome- A Rare Form of Hypothyroid Myopathy

Basavaprabhu Achappa, Deepak Madi

Recognition of the Lateral Pterygoid Muscle and Plate during Ultrasound-Guided Trigeminal Nerve Block

Ke-Vin Chang, Chia-Shiang Lin, Chih-Peng Lin, Wei-Ting Wu, Levent Özçakar

Memory T Cells (CD45RO) Role and Evaluation in Pathogenesis of Lichen Planus and Lichenoid Mucositis

Mani Devi, Dhanaraj Vijayalakshmi, Kumar Dhivya, Murali Janane

Introduction: Memory T cells have the ability to survive in a quiescent state for longer periods and are responsible for the rapid responses on subsequent exposure to antigen. Analyzing memory T cells in Oral Lichen planus (OLP) and Lichenoid Mucositis (LM) suggest that these cells may play a role in the immunopathogenic mechanisms. Aim: To identify and evaluate Memory T cells in Lichen Planus (LP), Lichenoid Mucositis (LM) and Normal Mucosa (NM) using CD45RO monoclonal antibody immunohistochemically. Materials and Methods: A total of 30 cases (15 cases of OLP and 15 cases of LM) clinically and histopathologically diagnosed, and 10 cases of NM were stained for CD45RO monoclonal antibody, immunohistochemically using Biotin Streptavidin method. Staining intensity of CD45RO expression was statistically analysed using Chi-square Test. Results: The present study demonstrated a higher expression of CD45RO in connective tissue layer of OLP (53.3% intense staining) when compared to LM (20% intense staining) and no intense staining in NM. The difference in staining intensity pattern between the study groups was statistically significant (p=0.014). Conclusion: This study demonstrates a statistically significant rise in memory T cells in LP than in LM, indicating the possible different immunopathogenic mechanisms.

Neck Circumference and Leg Length as Surrogate Markers of Coronary Artery Disease - Simplifying Cardiac Risk Stratification

Ram S Kaulgud, Adhishesh Kaul, BS Arun, PB Vijayalaxmi

Introduction: Coronary angiography is the gold standard for quantification of coronary atherosclerosis. But, being invasive, it has inherent complications. Hence, we examined the accuracy of prediction of coronary angiography using simple anthropometric indices. Aim: To identify a patient friendly method to predict coronary artery disease using simple anthropometric parameters, by testing their correlation with coronary artery disease severity scoring system. Materials and Methods: We conducted a cross-sectional study on patients undergoing elective coronary angiography. A total of 48 patients were included in the study. Neck circumference and leg length of the patients were noted. The severity of coronary atherosclerosis was quantified using Jenkin’s scoring system. Mean and standard deviation for each continuous variable was calculated. The correlation between Jenkins’ score, neck circumference and leg length was tested. The data analysis was done using IBM-SPSS software. Results: Mean leg length among the study population was 88.70 cm (±2.51 cm) among males, 79.04 cm (±4.32 cm) among females and 83.66 cm (±3.26 cm) overall. Mean neck circumference was 36.87 cm (±4.37 cm) among males, 36.04 cm (±3.65 cm) among females and 36.44 cm (±3.99 cm) when combined together. There was no correlation of Jenkin’s scores with leg length. But, there was significant correlation between Jenkin’s scores and neck circumference. Conclusion: Neck circumference can be used as a simple and effective tool and is better than leg length for risk stratification of patients with coronary heart disease.

Marital Intimacy and Predictive Factors Among Infertile Women in Northern Iran

Introduction: Infertility is a stressful state that may decrease attachment between spouses. Marital intimacy is a real need in infertile women. Aim: The aim of this study was to evaluate marital intimacy and predictive factors among infertile women in Northern Iran. Materials and Methods: This cross-sectional study was conducted at Fatemeh Zahra Infertility and Reproductive Health Center of Babol Medical Sciences University in 2014. A total of 221 infertile women participated in this study. The instrument used in this research was Marital Intimacy Need Questionnaire (MINQ). Statistical analyses was performed using linear and logistic regression with p<0.05 indicating statistical significance. Results: An 88.5% of infertile women had good marital intimacy. The mean and standard deviation of the marital intimacy was 349.11±49.26 and in marital intimacy domains including: emotional (42.28±7.23), psychological (41.84±7.59), intellectual (42.56±7.46), sexual (42.90±7.41), physical (43.59±6.96), spiritual (51.61±8.06), aesthetic (42.66±6.75), and social intimacy (42.59±6.89). The highest mean of marital intimacy domains is related to spirituality in infertile women. Physical and sexual domains had the high mean in infertile women. The lowest mean in marital intimacy domains was psychological intimacy. There was a significant correlation between the domains of marital intimacy. The strongest correlation was between the physical and sexual intimacy (r=0.85). There was a significant inverse association in marital intimacy with the age difference of spouses (p<0.01), and tobacco use (p<0.02). There was a statistically significant association in the marital intimacy with husband’s occupation, and cause of infertility (p<0.02). Conclusion: Early screening and psychosocial intervention strategies suggest in the setting of female infertility to identify and prevent the predictive factors that may cause marital conflict.

Extra Articular Supracondylar Femur Fractures Managed with Locked Distal Femoral Plate or Supracondylar Nailing: A Comparative Outcome Study

SPS Gill, Ankit Mittal, Manish Raj, Pulkesh Singh, Jasveer Singh, Santosh Kumar

Introduction: Despite recent evolution in the operating techniques and surgical implants, debate continues around the choice of implant for management of distal femur fractures. High rates of complications and union difficulties continues to make them a momentous therapeutic challenge. Aim: To compare the outcome of locked compressive plating verse retrograde nailing in the management of extra articular supracondylar femur fractures. Materials and Methods: In this randomized prospective study, 42 patients with extra-articular distal femur fractures were segregated into two groups based on internal fixation with distal femoral locking plate (n=22) and retrograde nail (n=20). Clinical and radiological parameters were studied and functional evaluation was done at 18 months with KSS score. Results: A significant difference in terms of mean duration of surgery and intraoperative blood loss was discerned in favour of plating group although complication rates were equivalent between the groups. Mean duration until union was 26.5 weeks (SD=12.9; range 12 to 64 weeks) in the locked plating and 22.6 weeks (SD=13.1: range 12 to 60 weeks) in the retrograde nail group. The difference came out to be statistically insignificant. Fractures in nailed patients united earlier but the difference was not statistically significant with similar overall union rates. Functional scores too were comparable between them. We deduce that surgical planning and expertise rather than the choice of implant are more crucial for optimal results. Conclusion: Nailing proved more cumbersome intraoperatively due to escalated operating time and blood loss and successive anterior knee pain necessitating implant removal but this detriment may be offset by an inclination towards earlier union. With Less Invasive Stabilization System (LISS), technical errors are more common and less forgiving and must be overcome with proper preoperative planning and intraoperative attention to detail.

Assessment of Insulin Sensitivity and its Convalescence with Dietary Rehabilitation in Undernourished Rural West Bengal Population

Nimmy K Francis, Harpreet Singh Pawar, Anirban Mitra, Analava Mitra

Introduction: Metabolic syndrome involving diabetes is acquiring the eminence of prospective epidemic in India with dramatic rise in rural population prevalence where majority are undernourished and creates significant healthcare burden. Aim: To investigate the prevalence of the insulin resistance amongst the undernourished rural population, involving children, adolescents and adult volunteers of the West Bengal and the effect of nutritional supplementation in the parameters echoing insulin sensitivity. Materials and Methods: A prospective interventional study was carried out on 120 volunteers in three age groups; Group 1 (5-12 years), Group 2 (13-18 years) and Group 3 (19-40 years), each with 40 subjects who fulfilled the inclusion criteria, under informed consent over six months. Baseline data regarding demography, family history including parental history of diabetes, medical history, physical, activity, anthropometrical status and blood parameters echoing insulin sensitivity were obtained from volunteers. Intervention included daily nutritional supplementation with eggs and banana. After six months of food supplementation, parameters reflecting insulin sensitivity were assessed. Results: Initial low figures of fasting insulin and blood sugar levels improvised with the nutritional supplementation alongside the absence of wasting in Group 1. HOMA-IR and IRI values of the Group 2 improved from the initial figures (3.19, 2.87) to (2.204, 1.99) and that of Group 3 from (5.0, 4.52) to (4.08, 3.67) respectively over six months (p<.05). Average Fasting Blood Sugar (FBS) enhanced from 85.5±9.6 mg/dl to 78.4±7.3 mg/dl and from 90.1±10.2 mg/dl to 84.8±8.4 mg/dl in Group 2 and 3 respectively by the end of the supplementation study (p<.05). Conclusion: Six months study revealed the existence of insulin resistance and malnourishment in the selected rural population in three groups. Decrement in HOMA-IR, IRI, FBS and serum insulin alongside the improvement in the body mass, in comparison to that of initial values is evocative of restoration of insulin sensitivity with nutrition supplementation.

Early Stage Oral Submucous Fibrosis is Characterized by Increased Vascularity as Opposed to Advanced Stages

Introduction: The degree of vascularity of the diseased mucosa in Oral Submucous Fibrosis (OSMF) has always been a matter of debate with conflicting results. Knowledge of this aspect is important to understand pathogenesis of OSMF, which in future could be translated into therapeutic strategies. Aim: In the present study, attempt has been made to investigate parameters like Mean Vascular Density (MVD), Total Vascular Area (TVA) and Mean Vascular Area (MVA) using CD34 antibody. Materials and Methods: Forty five previously untreated histopathologically diagnosed cases of OSMF were retrieved from archives and fifteen age and sex matched healthy volunteers without habits were included in the control group. Sections were immunohistochemically stained for CD 34 and morphometric analysis was performed. For statistical analysis ANOVA, Kruskal Wallis test and Mann Whitney U tests were used and p-values <0.05 were considered statistically significant. Results: MVD was more in Stage I OSMF followed by Control, Stage II and Stage III with statistically significant differences (p< 0.001). Statistically significant differences were observed in the MVD between control versus Stage III OSMF. Similarly, TVA was statistically significant when compared between control versus OSMF, control versus Stage II OSMF, control versus Stage III OSMF, Stage I versus Stage II OSMF, Stage I versus Stage III OSMF, and Stage II versus Stage III OSMF. For MVA, significant differences were between control versus OSMF, control versus Stage II OSMF, control versus Stage III OSMF, Stage I versus Stage III OSMF and Stage II versus Stage III OSMF. Conclusion: Angiogenesis is seen in early stages of OSMF with decreasing trend in advanced stages. Decreased vascular areas seen in advanced stages could be attributed to the increasing fibrosis surrounding the blood vessels.

Evaluation of Surface Microhardness Following Chemical and Microwave Disinfection of Commercially Available Acrylic Resin Denture Teeth

Introduction: Denture disinfection is an indispensable procedure for preventing cross contamination and the maintenance of a healthy oral mucosa in patients rehabilitated with removable dental prosthesis. Nevertheless, they are known to cause changes in the physical and mechanical properties of denture base resins and acrylic resin denture teeth following immersion of a denture in a suitable chemical disinfectant solution or by undergoing microwave irradiation. One such mechanical property indicator for artificial tooth materials is hardness. Aim: To assess the surface hardness of acrylic resin teeth of three different commercial brands (Ivoclar, Newace, Acryrock) following chemical (2% glutaraldehyde, 1% sodium hypochlorite) and microwave disinfections. Materials and Methods: Ten specimens of each of the three commercial brands were made for control and each simulated disinfection type and stored in distilled water at room temperature for 24 hours. After water storage, specimens were immersed in 2% glutaraldehyde and 1% sodium hypochlorite (one and three cycles) at room temperature for 10 minutes. Irradiation with microwave (one and three cycles) was done in domestic microwave for three minutes with the specimens immersed in 150 ml of distilled water. The specimens were stored in distilled water at room temperature for seven days after each disinfection cycle. Vickers hardness measurements were made using a hardness indenter under a load of 50 g force for 10 seconds. Data was subjected to repeated measure two-way ANOVA test and Tukey’s test. Results: There were statistically significant differences for the variables disinfection, tooth, and cycle (p<0.05 for teeth & disinfectant interaction, p<0.05 cycle and disinfectant interaction). The mean surface hardness following one microwave disinfection cycle was lower than control, glutaraldehyde and sodium hypochlorite. Comparison among cycles revealed that microhardness was significantly decreased for three cycles of microwave disinfection. Conclusion: It was concluded that there was no significant difference in microhardness when the teeth were subjected to chemical disinfection but three cycles of microwave disinfection produced decrease in the microhardness of different types of artificial teeth.

Comparative Study of Adjuvant Temozolomide Six Cycles Versus Extended 12 Cycles in Newly Diagnosed Glioblastoma Multiforme

Introduction: Studies have shown promising survival with the use of Extended Temozolomide (E-TMZ) as compared to Conventional six cycles of Temozolomide (C-TMZ) in malignant gliomas; however, the reports are mostly limited to retrospective studies with significant bias. Aim: This study assesses the impact of six versus 12 cycles of adjuvant Temozolomide (TMZ) on Overall Survival (OS) in newly diagnosed postoperative patients of Glioblastoma Multiforme (GBM). Materials and Methods: Between January 2012 and July 2013, 40 postoperative patients of GBM between age 18-65 years and Karnofsky Performance Score (KPS) =70 were included. Patients were randomized to receive radiation (60 Gray in 30 fractions over six weeks) with concomitant TMZ (75 mg/m2/day) and adjuvant therapy with either six (C-TMZ arm) or 12 cycles (E-TMZ arm) of TMZ (150-200 mg/m2 for five days, repeated four weekly). Twenty patients were treated in each arm. Toxicity was assessed using Common Terminology Criteria for Adverse Events (CTCAE) version 3.0. OS and Progression Free Survival (PFS) were calculated from the time of diagnosis. Kaplan Meier method was used for survival analysis. A p-value of <0.05 was taken as significant and SPSS version 12.0 was used for all statistical analysis. Results: Median number of adjuvant TMZ cycles was six and 12 in C-TMZ and E-TMZ arm respectively. Overall, 5% and 15% patients respectively in C-TMZ and E-TMZ arm had haematological toxicity = 3 in grade. Median follow up in C-TMZ and E-TMZ arm were 14.65 months and 19.85 months. Median PFS was 12.8 months and 16.8 months in C-TMZ and E-TMZ arm respectively (p=0.069). Median OS was 15.4 months vs. 23.8 months in C-TMZ and E-TMZ arm respectively (p=0.044). Conclusion: Our study showed that E-TMZ is well tolerated and leads to a significant increase in PFS as well as OS in newly diagnosed patients of GBM. Further prospective randomized studies are needed to validate the findings of our study.

Efficacy of Neem Extract and Three Antimicrobial Agents Incorporated into Tissue Conditioner in Inhibiting the Growth of C. Albicans and S. Mutans

Dikshita Ray Barua, Jayaprakash Mugur Basavanna, Rana Kalappattil Varghese

Introduction: Denture stomatitis is an inflammatory condition which compromises the mucosal surface beneath dentures. The aetiology of denture stomatitis is usually multifactorial which varies from trauma from ill fitting denture to poor immune system. There are evidences that denture stomatitis is an outcome of multispecies biofilms that include Candida albicans and Streptococcus mutans. Tissue conditioners are found to be more susceptible to colonisation by micro-organisms. Aim: The purpose of this study was to compare the efficacy of neem leaf extract and three other antimicrobial agents incorporated in a tissue conditioner against both Candida albicans and Streptococcus mutans. Materials and Methods: Standard strain of Candida albicans and Streptococcus mutans were inoculated into Sabouraud Dextrose broth and Mitis-Salivarius-Bacitracin broth respectively incubated at 37°C. Tissue conditioner (Viscogel) mixed with two different concentrations of ketoconazole, nystatin and chlorhexidine diacetate (5%, 10% w/w) and neem leaf extract (7.5% w/w and 15% w/w) and control group (plain tissue conditioner) were placed into punch hole (6 mm diameter) agar plate inoculated with Candida albicans and Streptococcus mutans. A total of 216 samples were prepared for both Candida albicans and Streptococcus mutans. Mean Inhibition Diameter (MID) across each punch holes were measured in millimetres at 24 hours and seven days and data were statistically analysed using Kruskal Wallis test followed by Mann-Whitney U test. Results: Both ketoconazole and nystatin (10% w/w) showed maximum inhibition of 32 mm and mean of 31.75 followed by 15% w/w neem leaf extract with an inhibition of 21 mm and mean of 20.67 after 24 hours against Candida albicans whereas chlorhexidine diacetate (10% w/w) showed mean of 25.67 followed by chlorhexidine diacetate (5% w/w) and neem extract (15% w/w) which showed mean of 24.17 and 23.67 respectively against Streptococcus mutans. Conclusion: Neem leaf extract exhibited considerable potential to be an efficacious antimicrobial agent against both Candida albicans and Streptococcus mutans.

Efficacy of Perfusion Computed Tomography (PCT) in Differentiating High-Grade Gliomas from Low Grade Gliomas, Lymphomas, Metastases and Abscess

Introduction: Tumoural angioneogenesis and its quantification are important in predicting the tumour grade and in the management with respect to the treatment available and to assess the response to treatment and the prognosis. It also plays major role in the growth and spread of tumours. Hence, a need arises for non-invasive in vivo methods to assess tumour angioneogenesis and tumour grade at the time of presentation and for monitoring the response during treatment and follow up. In this regard Perfusion Computed Tomography (PCT) can be easily added into routine CT studies to obtain such information on lesion physiology along with its morphology. Aim: Prospective evaluation of the efficacy of PCT in differentiating high grade gliomas from low grade glioma lymphomas, metastases and abscess. Materials and Methods: Perfusion CT was performed in 68 patients (17 high-grade gliomas, 10 low-grade gliomas, 7 lymphomas, 27 metastases and 7 abscess). Perfusion parameters which include Cerebral Blood Volume (CBV), Cerebral Blood Flow (CBF), Mean Transit Time (MTT) and Time To Peak (TTP) were derived both from the lesion and the normal parenchyma and were Normalized (n) by obtaining the ratio. Statistical analysis for high grade versus low-grade gliomas, high grade gliomas versus lymphomas, metastases and abscess was performed. Results: Difference in the mean nCBV and nCBF in high grade gliomas were statistically significant from low grade gliomas with cut off of > 3.07 for nCBV and > 2.08 for nCBF yielding good sensitivity and specificity. Difference in the mean nCBV and nMTT in the lymphomas were statistically significant from high grade gliomas (p<0.05) with cut off of <3.40 for nCBV and >1.83 for nMTT yielding good sensitivity and specificity. Difference in the mean nCBV and nMTT in the metastases were statistically significant from high grade gliomas (p<0.05) with cut off of >4.95 for nCBV and >1.88 for nMTT yielding a fair sensitivity and specificity. No statistical significant difference seen among the parameters in differentiating high grade gliomas and abscess. Conclusion: Cerebral PCT greatly adds to the diagnostic accuracy when the diagnosis of a common intra-axial lesion based on morphological characters becomes uncertain.

Difference in Perception of Pregnancy Risk in Two Maternal Age Groups

Introduction: Various health risks and complications may happen during pregnancy for both the mother and her child. Women should be informed of the risk associated with their pregnancy. Aim: To compare the differences of perception of pregnancy risk of two maternal age groups of healthy nulliparous women. Materials and Methods: In an analytical, descriptive cross-sectional study, 240 nulliparous pregnant women (160 women aged 18 to 35 years as a normal age group and 80 women < 18 years as a high risk age group) were randomly selected. Women were asked to complete questionnaire which included sociodemographic characteristics, pregnancy history, perception of pregnancy risk and pregnancy related anxiety. Results: Overall, women of < 18 years (high-risk group) perceived the risks of pregnancy higher than those of 18-35 years age women (reference group). Women in high-risk group rated their risks for herself, having haemorrhaging, having a cesarean birth and dying during pregnancy to be significantly higher than reference group. There was a statistically significant relationship between maternal age and perception of pregnancy risk (p<0.003). There was also a statistically significant relationship between pregnancy related anxiety and perception of pregnancy risk (p<0.002). Conclusion: Women’s perception of pregnancy risk is different in various maternal age groups. Maternal age can be considered as one of the important factors affecting perception of pregnancy risk. By routine screening of perception of pregnancy risk during prenatal care more effective risk consulting model could be designed.

A Screening Study on Dermatoses in Pregnancy

K. Kannambal, GK Tharini

Introduction: Pregnancy produces many cutaneous changes, some of which are specifically related to pregnancy (dermatoses of pregnancy), some are modifiable by pregnancy and others that are common are named physiologic. These physiologic skin changes, usually do not impair the health of the mother or the fetus but some of them can be cosmetically significant and of importance to the dermatologist. Aim: The present study was undertaken to find out the prevalence of the physiological and pathological skin changes in pregnancy, and to correlate the prevalence of the major cutaneous changes and diseases in relation to different trimesters of pregnancy and with gravidity. Materials and Methods: A cross-sectional study was conducted during the period of August 2008 to August 2010. Ethical clearance was sought from Institutional Ethical Committee. Five hundred pregnant women were randomly selected, irrespective of the duration of pregnancy and gravidity. Detailed history and complete dermatological examination was done. Results were tabulated and analysed. Statistical analysis was done by Fisher’s exact test and Chi square test. Results: Physiological skin changes were seen in 94.8% of cases, with pigmentary changes being more common (90.8%). Specific dermatoses of pregnancy were observed in 14% of cases with pruritus gravidarum being the most common (10.4%). Prevalence of infection was found to 30.8% with fungal infection being the most common (23.8%). Exacerbations of systemic lupus erythematosus and neurofibromatosis was observed. Pigmentary changes, striae gravidarum and specific dermatoses of pregnancy were observed in statistically significant proportion in primigravidas and during third trimester. Conclusion: This study emphasizes that the prevalence of physiological skin changes (94.8%) was much higher than specific dermatoses (14%), stressing the fact that in most instances, the skin problems during pregnancy needs only reassurance. But meticulous observation and examination should be done, as pregnancy can influence many dermatological diseases and infections.

Haemostatic Disorder in Women with Unexplained Menorrhagia: A Tertiary Care Centre Experience from Northern India

Introduction: Menorrhagia is a common gynaecological problem and its cause remains unexplained in a significant proportion of females. Aim: The present study was done to diagnose a wide range of haemostatic disorders which can give rise to menorrhagia in women of adolescent, postadolescent and perimenopausal age group. Materials and Methods: A total of 1100 women presenting to gynaecological emergency with complaints of menorrhagia underwent comprehensive evaluation. After excluding local pelvic pathology and hormonal disorders as a cause of menorrhagia 104 women were included in this study. Screening investigations including bleeding time, prothrombin time, activated partial thromboplastin time, platelet count and morphology were done. The following diagnostic investigations were carried out as and when required. Platelet aggregation tests using adenosine diphosphate and ristocetin, platelets function tests, specific factor analysis as and when required. Results: Age of patients ranged from 13 years to 46 years. Eighteen patients had menorrhagia since menarche. Seven patients had family history of abnormal bleeding. Twenty three patients were found to have systemic haemostatic disorder (10 patients of Von Willebrand Disease (vWD), seven of Glanzmann-Thrombasthenia, one of Bernard- Soulier syndrome and five of immune thrombocytopenic purpura). Conclusion: From this study it is concluded that systemic haemostatic disorders are found in substantial number of women presenting with menorrhagia. Hence, after excluding organic/hormonal cause, haemostatic disorders should be considered before taking patient for invasive surgical procedures.

Immunohistochemical Expression of Human Epidermal Growth Factor Receptor 2 (HER2) and p53 in Gastric Adenocarcinoma: A Pilot Study from North India

Introduction: After the recent approval of Trastuzumab (anti-HER2 antibody) for the treatment of HER2 overexpressed Gastric Adenocarcinoma (GA), importance of HER2 testing is increasingly recognized. However, there is paucity of studies for HER2 overexpression in the Indian patients of GA. Similarly, study of p53 expression in the Indian patients of GA is infrequent. Aim: To study immunohistochemical expression of HER2 and p53 in GA biopsy samples. Materials and Methods: This was a cross-sectional observational study. The expression of HER2 and p53 by immunohistochemistry were analyzed in 50 cases of GA. The HER2 expression was scored as negative (0 and 1+), equivocal (2+), and overexpression (3+). The p53 expression was quantified as negative (0-9% tumour cells) and positive (=10% tumour cells). The intensity of p53 expression was assessed as strong and weak. Results: Mean age of the patients was 56.8±14.8 years. Male: female ratio was 2:1. Histological types of adenocarcinoma were intestinal (68%), diffuse (28%), and indeterminate (4%). HER2 overexpression and equivocal results were present in 10% cases, each. Overall, a positive expression of p53 was seen in 72% (strong and weak intensities: 66.7% and 33.3% cases, respectively). Conclusion:As compared to HER2 overexpression, a higher incidence of p53 expression was seen (10% vs.72%) in GA.

Microgap Evaluation of Novel Hydrophilic and Hydrophobic Obturating System: A Scanning Electron Microscope Study

Vibha Hegde, Laxmi Suresh Murkey

Introduction: The purpose of an endodontic obturation is to obtain a fluid tight hermetic seal of the entire root canal system. There has been an evolution of different materials and techniques to achieve this desired gap free fluid tight seal due to presence of anatomic complexity of the root canal system. Aim: To compare the microgap occurring in root canals obturated with hydrophilic versus hydrophobic systems using scanning electron microscope. Materials and Methods: Sixty extracted human single-rooted premolars were decoronated, instrumented using NiTi rotary instruments. The samples (n=20) were divided into three groups and obturated with Group A - (control group) gutta-percha with AH Plus, Group B - C-point with Smartpaste Bio and Group C - gutta-percha with guttaflow 2. The samples were split longitudinally into two halves and microgap was observed under scanning electron microscope in the apical 3 mm of the root canal. Results: Group A (control) showed a mean difference of 8.54 as compared to 5.76 in group C. Group B showed the lowest mean difference of 0.83 suggesting that the hydrophilic system (C-point/Smartpaste Bio) produced least microgap as compared to the hydrophobic groups. Conclusion: Novel hydrophilic obturating system (C-points/ Smart-paste Bio) showed better seal and least microgap as compared to gutta-percha/guttaflow 2 and gutta-percha/ AH plus which showed gap at the sealer dentin interface due to less penetration and bonding of these hydrophobic obturating system.

Photogrammetric Correlation of Face with Frontal Radiographs and Direct Measurements

Gunjan Negi, Swaroopa Ponnada, N.K.S. Aravind, Prasad Chitra

Introduction: Photogrammetry is a science of making measurements from photographs. As cephalometric analysis till date has focused mainly on skeletal relationships, photogrammetry may provide a means to reliably assess and compare soft tissue and hard tissue measurements. Aim: To compare and correlate linear measurements taken directly from subject’s faces and from standardized frontal cephalometric radiographs and to correlate them with standardized frontal facial photographs of Indian population and to obtain mean values. Materials and Methods: A cross-sectional study was conducted on 30 subjects of Indian origin. Frontal cephalograms and standardized frontal photographs were obtained from subjects in the age group of 18- 25 years. Vernier calipers were used to obtain facial measurements directly. Photographs and radiographs were uploaded and measured using Nemoceph software. Analogous cephalometric, photographic and direct measurements were compared by one-way ANOVA to assess Pearson correlation coefficients for 12 linear measurements (6 vertical, 6 horizontal). Bonferroni post-hoc test was done for pair wise comparison. Results: Among all measurements used, OR-OL (orbitale right- orbitale left) showed a high correlation r = 0.76, 0.70, 0.71. There was moderate correlation with EnR-EnL (endocanthion rt – endocanthion lt) r2 = 0.62, 0.68, 0.68. Highly significant correlation was evident with N-Sn, EnR-EnL and AgR-AgL with p<0.001. Conclusion: A statistically significant correlation was found between photographic, radiographic and direct measurements. Therefore, photogrammetry has proven to be an alternative diagnostic tool that can be used in epidemiologic studies when there is a need for a simple, basic, non-invasive and cost-effective method.

A Post-Marketing Surveillance Study to Evaluate Performance of the EXIMO™ Blood Glucose Monitoring System

Introduction: The performance of Blood Glucose Monitoring System (BGMS) is critical as the information provided by the system guide the patient or health care professional in making treatment decisions. However, besides evaluating accuracy of the BGMS in laboratory setting, it is equally important that the intended users (healthcare professionals and patients) should be able to achieve blood glucose measurements with similar level of high accuracy. Aim: To assess the performance of EXIMO™ (Meril Diagnostics Pvt. Ltd., Vapi, Gujarat, India) BGMS as per International Organization for Standardization (ISO) 15197:2013 section 8 user performance criteria. Materials and Methods: This was a non-randomized and post-marketing study conducted at a tertiary care centre of India. A total of 1005 patients with diabetes themselves performed fingertip blood glucose measurement using EXIMO™ BGMS. Immediately after capillary blood glucose measurement using the blood glucose monitoring system, venous blood sample from each patient was obtained by a trained technician which was assessed by reference laboratory method- Cobas Integra 400 plus (Roche Instrument Centre, Rotkreuz, Switzerland). All the blood glucose measurements assessed by EXIMO™ were compared with laboratory results. Performance of the system was assessed as per ISO 15197:2013 criteria using Bland-Altman plot, Parkes-Consensus Error Grid (CEG) and Surveillance Error Grid analyses (SEG). Results: A total of 1005 patients participated in the study. Average age of the patients was 44.93±14.65 years. Evaluation of capillary fingertip blood glucose measurements demonstrated that 95.82% measurements fulfilled ISO 15197:2013 section 8 user performance criteria. All the results lie within clinically non-critical zones; Zone A (99.47%; n=1000) and Zone B (0.53%; n=05) of the CEG analysis. As per SEG analysis, majority of the results fell within “no-risk” zone (risk score 0 to 0.5; 90.42%). Conclusion: The result of the study confirmed that intended users are able to obtain accurate glucose measurements when operating EXIMO™ BGMS, given only the instructions and training materials routinely provided with the system, in clinical practice.

A1 and A2 Sub-Types of Blood Group ‘A’: A Reflection of their Prevalence in North Karnataka Region

Sujata S Giriyan, Akanksha Agrawal, Richa Bajpai, Niraj Kumar Nirala

Introduction: Landsteiner ABO system of blood groups is most important for transfusion medicine and has subtypes of A Antigen, A1 and A2, upon which further groups of A and AB have been classified. Of individuals with A antigen, approximately 20% belong to A2 while rest 80% belong to A1. Anti-A1 Lectin, a cold agglutinin which destroys A1 cells is clinically significant when they react at 37°C, causing transfusion reactions. Aim: To assess the prevalence of A1 and A2 subgroups in the population. Materials and Methods: This was two year retrospective analysis of blood groups of donors coming to the blood bank of Karnataka Institute of Medical Science, Hubli, Karnataka, India. The data of the subgroups A and AB was analysed. Results: 20,864 donors were analysed. Of 5466 (26.20%) of A group, 5406 (98.90%) belonged to A1 subgroup and only 60 (1.10%) belonged to A2 subgroup. Of 1708 donors with blood group AB, 1532 (89.70%) belonged to A1B subgroup and 176 (10.30%) belonged to A2B. It was noted that A2 in AB blood-group, as A2B, was more frequent in occurrence than presence of A2 as an A blood group. Rhesus negative frequency in these subgroups was also reported. Conclusion: Having known the prevalence of A1 and A2 subgroups and incorporating them into the ABO grouping system can limit these minor, yet dangerous, transfusion incompatibilities.

Effect of Green Coffee Bean Extract on Streptococcus mutans Count: A Randomised Control Trial

Introduction: Mouth rinses have been popularly used as a supplementary oral hygiene aid. A lot of commercially available mouth rinses possess few adverse effects, which has necessitated the search for alternative and herbal mouth rinses. Aim: The aim of the study was to assess the effect of rinsing with green coffee bean extract in comparison with chlorhexidine mouthwash and sterile water on salivary Streptococcus mutans count. Materials and Methods: A randomized parallel controlled clinical trial was planned and 45 subjects aged between 18-22 years were selected. The subjects were divided into three groups (n=15 in each group): Group A: Study group: 2% Green coffee bean extract, Group B: Positive control: 0.2% Chlorhexidine (CHX), Group C: Negative control: Sterile water. Group A subjects rinsed mouth with 5 ml of 2% Green coffee bean extract for one minute. Group B subjects rinsed mouth with 5 ml 0.2% CHX mouthwash for one minute. Group C subjects rinsed mouth with 5 ml of Sterile water for one minute twice daily for two weeks. Baseline samples (Pre rinse) were collected on day 1 and post rinsing saliva samples were collected after 14 days. The samples were cultured using Mitis Salivarius Agar enriched with Bacitracin and colonies were counted using a hand held digital colony counter. The statistical analysis was done using paired t-test, One-way variance ANOVA and Post-Hoc tests. Results: The Green coffee bean extract group showed a statistical significant reduction in Streptococcus mutans colony count before and after intervention which was comparable with CHX group. Conclusion: Green coffee bean extract as a mouthwash can be explored as a safe and effective alternative to CHX mouthwash.

MRI Study on Spinal Canal Morphometry: An Indian Study

Maitreyee kar, Dipankar Bhaumik, Kaushik Ishore, Pallab Kumar Saha

Introduction: A large proportion of adults suffer from neck pain at some points of their life and show altered ranges of spinal canal morphometry in various studies. The differences in values are also seen due to genetic, hormonal and other factors too. Torg’s ratio is a widely accepted measurement to eliminate such discrepancies. The measurement of Space Available for Cord (SAC) is also gaining importance as spinal stenosis is a contributor to neck pain. Aim: (1) To examine the cervical spinal canal and spinal cord morphometric determinants in symptomatic sub-Himalayan North Bengal population and to compare the obtained data with other populations; (2) To determine whether Torg’s ratio vary with gender or not; (3) To determine SAC values in symptomatic individuals. Materials and Methods: Magnetic Resonance Imaging (MRI) based on midsagittal diameter of vertebral body, spinal canal, spinal cord and its Torg’s ratio and SAC value of the lower cervical spine (C3-C7) from 71 symptomatic adults were recorded at the Radiology Department of North Bengal Medical College and Hospital, Bengal, India. Individuals with any evidence of trauma, infection, neoplasia or any congenital anomalies related to spinal canal and below 18 years of age were excluded from the study. Results: The average diameter for vertebral body was significantly larger in males. The average diameter for spinal canal, spinal cord and values of Torg’s ratio and SAC has no significant gender difference. But the mean value of Torg’s ratio is greater in females is due to smaller vertebral body size in females. Conclusion: It is interpreted from our study that sagittal spinal canal diameter, Torg’s ratio and SAC value did not show any significant gender difference. But sagittal vertebral body’s diameter showed sexual dimorphism which influenced the mean value of Torg’s ratio.

Comparative Efficacy of Platelet Rich Plasma Injection, Corticosteroid Injection and Ultrasonic Therapy in the Treatment of Periarthritis Shoulder

Shashank Yeshwant Kothari, Venkataraman Srikumar, Neha Singh

Introduction: Periarthritis (PA) shoulder characterised by pain and restricted range of motion has a plethora of treatment options with inconclusive evidence. Platelet Rich Plasma (PRP) is an emerging treatment option and its efficacy needs to be examined and compared with other routine interventions. Aim: To assess the efficacy of PRP injection and compare it with corticosteroid injection and ultrasonic therapy in the treatment of PA shoulder. Materials and Methods: Patients with PA shoulder (n=195) were randomised to receive single injection of PRP (2 ml) or corticosteroid (80 mg of methylprednisolone) or ultrasonic therapy (seven sittings in two weeks; 1.5 W/cm2, 1 MHz, continuous mode). All participants were also advised to perform a home based 10 minute exercise therapy. The primary outcome measure was active range of motion of the shoulder. Secondary outcome measures used were Visual Analogue Scale (VAS) for pain and a shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) for function. Participants were evaluated at 0, 3, 6 and 12 weeks. Chi-square test, one way and repeated measures of ANOVA tests were used to determine significant differences. Results: PRP treatment resulted in statistically significant improvements over corticosteroid and ultrasonic therapy in active as well as passive range of motion of shoulder, VAS and QuickDASH at 12 weeks. At six weeks, PRP treatment resulted in statistically significant improvements over ultrasonic therapy in VAS and QuickDASH. No major adverse effects were observed. Conclusion: This study demonstrates that single injection of PRP is effective and better than corticosteroid injection or ultrasonic therapy in treatment of PA shoulder.

Analysis of 12 Months Clinical Outcomes Associated with Implantation of Ultrathin (60 µm) Bare Metal Stent in an Unselected Real-world Population with Coronary Artery Disease

Introduction: In the era of drug-eluting stents, Bare Metal Stent (BMS) has worked its way up to be recognized in several indications. Moreover, literature suggests that strut thickness has been directly related to the restenosis rate. Aim: We intended to evaluate the clinical performance of the ultrathin (60 µm) Flexinnium stent (Sahajanand Medical Technologies Pvt. Ltd. Surat, India) for treatment of a wide range of patients with coronary artery disease in routine clinical practice. Materials and Methods: This was an observational, non-randomized, retrospective, single-arm study carried out in real-world patients at three clinical centres of India. A total of 419 consecutive patients’ data was collected for the study, who underwent treatment for coronary lesions by implantation of Flexinnium stent, between April 2013 and December 2014. The primary endpoint of the study was Major Adverse Cardiac Events (MACE), a conglomerate of cardiac death, Myocardial Infarction (MI) (Q-wave and non-Q-wave), Target Lesion Revascularization (TLR) and Target Vessel Revascularization (TVR). Any incidence of Stent Thrombosis (ST) was also observed as safety endpoint. These endpoints were observed during in-hospital stay, at 30 days, six months and at 12 months follow up. All data were analysed using the Statistical Package for Social Sciences (SPSS; Chicago, IL, USA) program, version 15. Results: A total of 491 lesions were treated in 419 patients having mean age of 54.1 years. A total of 525 Flexinnium stents were implanted. There were 243 (58.0%) patients with hypertension. At 12 months the total incidences of MACE were 14 (3.5%). These included 9 (2.3%) cardiac deaths, 1 (0.3%) MI, 3 (0.8%) TLRs and 1 (0.3%) TVR. There was one incidence of definite ST at 12 months follow up. Conclusion: Our results demonstrate that the Flexinnium stent is associated with a low 12 months incidence of MACE in a wide range of real-world population. Long-term follow up would further confirm its clinical performance profile.

Polymorphism in the Eruption Sequence of Primary Dentition: A Cross-sectional Study

Indira Mysore Devraj, Nandlal Bhojraj, D Narayanappa

Introduction: Primary teeth have shown wide variations in their eruption time among different population. Population specific eruption ages are provided as mean with standard deviations or median ages with its percentile range. This alone will be insufficient for prediction of tooth eruption sequence because they provide no information on the frequency of sequence variation within the pairs of teeth. Norms of polymorphic variation in the eruption sequence can be more useful. Aim: This study aims at providing norms for the sequence polymorphism in primary teeth among the children of Mysore population. Materials and Methods: A cross-sectional study was designed with 1392 children, recruited from December 2015 to June 2016 by simple random sampling method. Tooth was recorded as present or absent. Across the entire possible intra quadrant tooth pair, cases of present-present, absent-absent, present-absent and absent-present and were counted and computed as percentages. Results: Sequence polymorphisms were more common in 82-84 pairs of teeth. Significant polymorphic reverse sequence was observed in 52-54 (9%), 82-84 (35%) in males and 82-84 (18%) in females. There was no polymorphism in maxillary arch in females. Conclusion: The present study provides the baseline data values for sequence variation in primary teeth eruption. To the best of investigators knowledge, there are no previous studies describing the sequence polymorphism in primary teeth in Indian population. The results of this study helps in assessment of eruption sequence problems in paediatric dentistry and in evaluation and prediction of tooth eruption sequence in individual child.

Fasting Insulin is Better Partitioned according to Family History of Type 2 Diabetes Mellitus than Post Glucose Load Insulin of Oral Glucose Tolerance Test in Young Adults

Saritha Francis, Sindhu Padinjareveedu Chandran, KK Nesheera, Jose Jacob

Introduction: Hyperinsulinemia is contributed by insulin resistance, hepatic insulin uptake, insulin secretion and rate of insulin degradation. Family history of type 2 diabetes mellitus has been reported to cause hyperinsulinemia. Aim: Correlation of fasting insulin with post glucose load Oral Glucose Tolerance Test (OGTT) insulin in young adults and their partitioning according to family history of type 2 diabetes. Materials and Methods: In this observational cross-sectional study, clinical evaluation and biochemical assays of insulin and diabetes related parameters, and secondary clinical influences on type 2 diabetes in volunteers were done for inclusion as participants (n=90) or their exclusion. Cut off levels of quantitative biochemical variables were fixed such that they included the effects of insulin resistance, but excluded other secondary clinical influences. Distribution was analysed by Shapiro-Wilk test; equality of variances by Levene’s test; Log10 transformations for conversion of groups to Gaussian distribution and for equality of variances in the groups compared. When the groups compared had Gaussian distribution and there was equality of variance, parametric methods were used. Otherwise, non parametric methods were used. Results: Fasting insulin was correlating significantly with 30, 60 and 120 minute OGTT insulin showing that hyperinsulinemia in the fasting state was related to hyperinsulinemia in the post glucose load states. When fasting and post glucose load OGTT insulin were partitioned into those without and with family history of type 2 diabetes, maximum difference was seen in fasting insulin (p<0.001), followed by 120 (p=0.001) and 60 (p= 0.002) minute OGTT insulin. The 30 minute insulin could not be partitioned (p=0.574). Conclusion: Fasting, 60 and 120 minute OGTT insulin can be partitioned according to family history of type 2 diabetes, demonstrating stratification and heterogeneity in the insulin sample. Of these, fasting insulin was better partitioned and could be used for baseline reference interval calculations.

MR Imaging of Rotator Cuff Tears: Correlation with Arthroscopy

Gururaj Sharma, Sudarshan Bhandary, Ganesh Khandige, Utkarsh Kabra

Introduction: Rotator cuff tears are quite common and can cause significant disability. Magnetic Resonance Imaging (MRI) has now emerged as the modality of choice in the preoperative evaluation of patients with rotator cuff injuries, in view of its improved inherent soft tissue contrast and resolution. Aim: To evaluate the diagnostic accuracy of routine MRI in the detection and characterisation of rotator cuff tears, by correlating the findings with arthroscopy. Materials and Methods: This prospective study was carried out between July 2014 and August 2016 at the AJ Institute of Medical Sciences, Mangalore, Karnataka, India. A total of 82 patients were diagnosed with rotator cuff injury on MRI during this period, out of which 45 patients who underwent further evaluation with arthroscopy were included in this study. The data collected was analysed for significant correlation between MRI diagnosis and arthroscopic findings using kappa statistics. The sensitivity, specificity, predictive value and accuracy of MRI for the diagnosis of full and partial thickness tears were calculated using arthroscopic findings as the reference standard. Results: There were 27 males and 18 females in this study. The youngest patient was 22 years and the oldest was 74 years. Majority of rotator cuff tears (78%) were seen in patients above the age of 40 years. MRI showed a sensitivity of 89.6%, specificity of 100%, positive predictive value of 100% and negative predictive value of 83.3% for the diagnosis of full thickness rotator cuff tears. For partial thickness tears, MRI showed a sensitivity of 100%, specificity of 86.6%, positive predictive value of 78.9% and negative predictive value of 100%. The accuracy was 93.1% for full thickness tears and 91.1% for partial thickness tears. The p-value was less than 0.01 for both full and partial thickness tears. There was good agreement between the MRI and arthroscopic findings, with kappa value of 0.85 for full thickness tears and 0.81 for partial thickness tears. Conclusion: MRI revealed high sensitivity and specificity for the diagnosis of rotator cuff tears with accuracy of 93.1% for full thickness tears and 91.1% for partial thickness tears. MRI provides useful information about the size and extent of the tear, involvement of adjacent structures, presence of muscle atrophy and tendon retraction, all of which have important therapeutic and prognostic implications.

Revisiting the Utility of Histopathological Examination of Biopsy: A Necessity in Microbiology

Introduction: Culture is the gold standard, while potassium hydroxide mount is simplest technique used for diagnosis of fungal pathogens. Histopathological examination is the only definitive means to identify certain uncultivable fungi. Aim: To analyse role of histopathological examination and potassium hydroxide (KOH) mount for diagnosing fungal infections by correlating them with culture. Materials and Methods: In this nine year retrospective study, all biopsy specimens submitted for microbiological examination were included. Histopathological examination of biopsies of cases with positive microbiological findings on either KOH mount or culture was carried out. Any discrepancy between histopathology interpretation and microbiology KOH or culture results, taking culture as the gold standard, were noted. Statistical Analysis: Open Epi software was used for statistical analysis. Comparisons between groups were made by using the chi-square test. A p-value < 0.05 was considered statistically significant. Cohen’s Kappa coefficient (?) was calculated as a measure of agreement between different variables. Results: Concurrent pathology specimen could be obtained in 70 samples positive for fungal elements in either KOH or culture. Thirty-two cases were positive for fungi in culture, of which 16 were correctly identified by histopathological examination. Histopathological examination was strongly associated with culture result. KOH mount was in good agreement with positive culture result for yeast. Eleven culture negative but KOH and histopathology positive cases included seven samples with hyphae suggestive of zygomycosis, and two cases of rhinosporidiosis. Allergic mucin was strongly associated with Aspergillus species. KOH mount and detection of allergic mucin on histopathological examination were found to be excellent complementary tools for diagnosing Aspergillus species. Necrosis was highly specific for fungal growth in culture and had good positive predictive value. Conclusion: We advocate using histopathology, culture and KOH examination in an integral manner to avoid potential lapses in patient management.

A Prospective Study of Different Methods of Inferior Turbinate Reduction

Introduction: All the functions of nasal cavities are performed through mucosa and contours of the turbinates. Hypertrophied inferior turbinate is one of the major and common causes of nasal obstruction. In these patients nasal obstruction is relieved by inferior turbinate reduction. Many procedures on turbinate reduction have been described earlier. Aim: To compare and evaluate the better method for inferior turbinate reduction among submucosal diathermy using monopolar cautery and bipolar cautery, complete turbinectomy, inj. sodium tetradecylsulphate infiltration. Materials and Methods: Eighty patients of either sex between 17-50 years of age having inferior turbinate hypertrophy were included in the study. The patients were divided into four groups with 20 patients in each group. Each group had 20 patients. Group A was subjected to submucosal diathermy using monopolar cautery, Group B to bipolar cautery, Group C to complete inferior turbinectomy and group D to injection sodium tetradecylsulphate. Patients were assessed for nasal patency and symptomatic relief, postoperative bleeding, pain, crusting and synachiae. Follow up was done on 7th day, 21st day and 3rd month postoperatively. Statistical analysis was carried out using IBM SPSS Version 20.0 for windows. Mean and standard deviations were calculated for quantitative data, for categorical variables frequencies and percentages were calculated, within the group comparisons were done with paired t-tests. Results: The mean reduction in postoperative nasal obstruction was found to be maximum with bipolar cautery when compared with the other modalities and this difference was found to be statistically significant (p<0.001). Bipolar cautery was found to be associated with minimum after effects when compared to other modalities except for postoperative pain which was found more in the patients operated by the bipolar cautery method. Conclusion: We found inferior turbinate reduction using bipolar cautery was better and safe method, when compared to monopolar cautery, complete turbinectomy and inj. sodium tetradecylsulphate, however further studies are required with larger sample size.

A Survey on Nickel Titanium Rotary Instruments and their Usage Techniques by Endodontists in India

Introduction: The preference and usage of nickel titanium rotary instruments varies from individual to individual based on their technique, experience with the rotary systems and the clinical situation. Very limited information is available to explain the adoption of changing concepts with respect to nickel titanium rotary instruments pertaining to the endodontists in India. Aim: The aim of this study was to conduct a questionnaire survey to acquire the knowledge concerning different NiTi rotary instruments and their usage techniques by endodontists in India. Materials and Methods: A Survey questionnaire was designed which consisted of 32 questions regarding designation, demographics, experience with rotary instruments, usage of different file systems, usage techniques, frequency of reuse, occurrence of file fracture, reasons and their management was distributed by hand in the national postgraduate convention and also disseminated via electronic medium to 400 and 600 endodontists respectively. Information was collected from each individual to gain insight into the experiences and beliefs of endodontists concerning the new endodontic technology of rotary NiTi instrumentation based on their clinical experience with the rotary systems. The questions were designed to ascertain the problems, patterns of use and to identify areas of perceived or potential concern regarding the rotary instruments and the data acquired was statistically evaluated using Fisher’s-exact test and the Chi-Square test. Results: Overall 63.8% (638) endodontists responded. ProTaper was one of the most commonly used file system followed by M two and ProTaper Next. There was a significant co relation between the years of experience and the file re use frequency, preparation technique, file separation, management of file separation. Conclusion: A large number of Endodontists prefer to reuse the rotary NiTi instruments. As there was an increase in the experience, the incidence of file separation reduced with increasing number of re use frequency and with experience, the management of separated file was better.

Factors Associated with Physical Inactivity among Adult Urban Population of Puducherry, India: A Population Based Cross-sectional Study

Introduction: Physical inactivity is the fourth leading cause of death worldwide. Increase in physical activity decreases the incidence of cardiovascular diseases, Type 2 diabetes, stroke, and improves psychological wellbeing. Aim: To study the level of physical inactivity among the adult population in an urban area of Puducherry in India and its associated risk factors. Materials and Methods: This cross-sectional study was conducted among 569 adult participants from an urban area of Pondicherry. The level of physical inactivity was measured by using WHO standard Global Physical Activity Questionnaire (GPAQ). Results: Overall prevalence of physical inactivity in our study was 49.7% (CI: 45.6-53.8). Among the physically active people, contribution of physical activity by work was 77.4%, leisure time activities were 11.6% and transport time was 11%. Both men and women were equally inactive {Physically inactive among women was 50% (CI:44.1-55.9)} and {Physically inactive among men was 49.5% (CI:43.8-55.2)}. Prevalence of physical inactivity was increasing with increasing age. Non tobacco users were two times more active than tobacco users {Adjusted Odds Ratio: 2.183 (1.175- 4.057)}. Employed were more active as compared to retired {Adjusted Odds Ratio: 0.412 (0.171-0.991)}, students {Adjusted Odds Ratio: 0.456 (0.196-1.060)}, house wives {Adjusted Odds Ratio: 0.757 (0.509-1.127)} and unemployed {Adjusted Odds Ratio: 0.538 (0.271-1.068)}. Non alcoholics were only 0.34 times as active as alcoholics. Conclusion: Level of physical activity was found to be insufficient among adult urban population of Puducherry. Working adult population found to be active, that too due to their work pattern. There is a need to promote leisure time and travelling time physical activity.

Elective Tracheostomy in Head and Neck Surgery: Our Experience

Introduction: Tracheostomy is commonly used to secure the airway during the immediate postoperative period in maxillofacial oncological operations. We conducted a study to review the utility of elective tracheostomy in head and neck surgery. Aim: To review the incidence of intraoperative, perioperative and postoperative complications and its management in elective tracheostomy and to analyse its utility in head and neck surgery. Materials and Methods: The study included review of 50 patients, who were treated for head and neck cancers in the Department of Oral And Maxillofacial Surgery of our centre between January 2011 to December 2014. Results: The study showed a male predilection with mean tracheostomy time of 25 minutes and operative time of 11 hours. The patients had an ICU stay of two days and elective ventilation of one day with mild tracheal secretion seen postoperatively. No other complications were noted intraoperatively or postoperatively. Conclusion: Elective tracheostomy even though an invasive tool when used properly in selected patients, can be safe and beneficial to the patients.

Knowledge and Attitude of Parents towards Avulsed Permanent Tooth of their Children and its Emergency Management in Bhopal City

Ankur jain, Parimala kulkarni, Srikant kumar, Manish jain

Introduction: Dental avulsion is a commonly reported traumatic injury causing pain, aesthetic, functional, psychological and mental impairment. Since parents are in the immediate vicinity of children in such situations, their knowledge regarding the same is of great importance. Aim: The aim of present study was to assess the level of parental knowledge and their attitude towards dental avulsion and its emergency management Materials and Methods: A 10-stemmed questionnaire was prepared for this study which was modified form of questionnaire used by Raphael and Gregory. The questionnaire consisted of two parts and was provided in both English and Hindi languages. Parents had to mark one option provided to them in multiple choice questions, which they found to be right. A written consent according to ethical guidelines was taken by all the participants before filling up the questionnaire. The survey consisted of 550 parents who accompanied their children aged between 6 to 13 years in the Department of Pedodontics and Preventive Dentistry, Peoples Dental Academy, Bhopal, Madhya Pradesh, India. Chi- square test was applied to evaluate the associations in this study. Results: Statistically it was observed that 34.5% of male participants exhibited more knowledge regarding the necessity of reimplantation of avulsed tooth in comparison to female participants. Also parents with higher educational background have showed positive response toward knowledge and attitude of emergency treatment of avulsed permanent tooth. About 25.6% of higher secondary level, 20.9% of undergraduate level, 10.9% of elementary school level and 0.4% of illiterate participants responded that reimplantation of avulsed permanent tooth is possible. Conclusion: It was concluded from the study that regardless of the age, education level or other factors, parental knowledge of tooth avulsion management was found to be very low in our society. Parents who participated in this study reported having insufficient knowledge about dental trauma and unskilled to provide emergency care to their child.

The Effect of Cavity Design on Fracture Resistance and Failure Pattern in Monolithic Zirconia Partial Coverage Restorations - An In vitro Study

Introduction: Cavity preparations of posterior teeth have been frequently associated with decreased fracture strength of the teeth. Choosing the correct indirect restoration and the cavity design when restoring the posterior teeth i.e., premolars was difficult as it involves aesthetic, biomechanical and anatomical considerations. Aim: To evaluate the fracture resistance and failure pattern of three different cavity designs restored with monolithic zirconia. Materials and Methods: Human maxillary premolars atraumatically extracted for orthodontic reasons were chosen. A total of 40 teeth were selected and divided into four groups (n=10). Group I-Sound teeth (control with no preparation). Group II-MOD Inlay, Group III-Partial Onlay, Group IV-Complete Onlay. Restorations were fabricated with monolithic partially sintered zirconia CAD (SAGEMAX- NexxZr). All the 30 samples were cemented using Multilink Automix (Ivoclar) and subjected to fracture resistance testing using Universal Testing Machine (UTM) (Instron) with a steel ball of 3.5 mm diameter at crosshead speed of 0.5 mm/minute. Stereomicroscope was used to evaluate the modes of failure of the fractured specimen. Fracture resistance was tested using parametric one way ANOVA test, unpaired t-test and Tukey test. Fracture patterns were assessed using non-parametric Chi-square test. Results: Group IV (Complete Onlay) presented highest fracture resistance and showed statistical significant difference. Group II (MOD Inlay) and Group III (Partial Onlay) showed significantly lower values than the Group I (Sound teeth). However, Groups I, II and III presented no significant difference from each other. Coming to the modes of failure, Group II (MOD Inlay) and Group III (Partial Onlay) presented mixed type of failures; Group IV (Complete Onlay) demonstrated 70% Type I failures. Conclusion: Of the three cavity designs evaluated, Complete Onlay had shown a significant increase in the fracture resistance than the Sound teeth.

Effect of 5% Chlorine Dioxide Irrigant on Micro Push Out Bond Strength of Resin Sealer to Radicular Dentin: An In Vitro Study

Introduction: Chlorine dioxide (ClO2) has been recently investigated as a possible root canal irrigant due to its broad spectrum of antimicrobial action, tissue dissolution and smear layer removal properties. Literature is scarce on the effect of chlorine dioxide irrigation on the resin sealer dentin bond strength. Aim: To compare 5% chlorine dioxide (ClO2) with or without Ethylene Diamine Tetra Acetic acid (EDTA) with 3% Sodium hypochlorite (NaOCl) and EDTA combination as endodontic irrigants on the adhesion of AH Plus sealer to radicular dentin using micro- Push out Bond Strength (µPBS) test. Materials and Methods: Forty freshly extracted central incisors were decoronated and randomly divided into four groups based on the different irrigation regimes followed during irrigation: Group I - 3% NaOCl + 17% EDTA, Group II - 5% ClO2 + 17% EDTA, Group III - 5% ClO2 and Group IV – Saline, and canal enlarged till Protaper F3. All the samples were obturated with F3 gutta-percha cones using AH Plus sealer and sectioned perpendicular to long axis to obtain 1mm thick slices from the middle and coronal portions for µPBS measurement in universal testing machine followed by assessment of failure pattern under stereomicroscope. Data was analysed using One-way analysis of variance (ANOVA), Bonferroni and t-test. Results: Bond strength values were in the following order: Group I>Group II>Group III>Group IV, with no statistically significant difference amongst experimental groups on intergroup comparison, except with saline. The µPBS values were more in coronal third than middle third in all specimens, with no statistical significant difference. Mode of failure showed mixed patterns in all experimental groups except saline. Conclusion: In the present study, the bond strength values of ClO2 were comparable with conventional NaOCl and EDTA combination and hence, ClO2 can be considered as an effective alternative endodontic irrigant.

Anti-Atherosclerotic Potential of Aqueous Extract of Cinnamomum zeylanicum Bark against Glucocorticoid Induced Atherosclerosis in Wistar Rats

IM Nagendra Nayak, Rajasekhar Chinta, Raghu Jetti

Introduction: Atherosclerosis is one of the major causes of disability of blood vessels which can result in development of many cardiovascular disorders. There is a strong association between atherosclerosis and insulin resistance and dyslipidemia. Aim: To study the anti-atherosclerotic potential of C. zeylanicum bark extract in insulin resistance associated atherosclerosis and worsened Atherogenic Index (AI) associated with dyslipidemia, which are the predominant complications of steroid diabetes in Wistar rats. Materials and Methods: A sum of 36 rats were categorized into five study groups and one plain control. In a 12 day study period, respective drug treatments were given every day throughout the study period whereas, dexamethasone dosage was started from day seven onwards. On day 12, fasting blood samples were collected and processed for lipid estimation and the determined values were also used to assess AI further. Animals were sacrificed under ether anaesthesia and the aorta was dissected away for its measurement and histopathological findings. One-way ANOVA was used to analyse the data and multiple comparison was done, interpreted based on Post-Hoc Scheffe test. Results: High dose of dexamethasone (8 mg/kg/i.p) in Dexa Control (DC) group produced significant dyslipidemia, increased risk of atherogenicity (p<0.05) and caused severe thickening (78.5% compared to Plain Control (PC) of wall of aorta. Rosiglitazone (ROSI) (8 mg/kg and 16 mg/kg) and C. zelanicum (CZE) extract treatments (500 mg/kg and 250 mg/kg) significantly prevented dyslipidemia, well maintained AI compared to dexa control (p<0.05). However, both the CZE treatments protected the aorta from atherosclerosis (40.3% and 30.2% compared to DC) and significantly prevented the dyslipidemia and reduced the risk of atherogenicity compared to ROSI treatment (p<0.05). Although, the CZE did not show difference in significance in maintaining very low density lipoprotein when compared to ROSI (p>0.05). The atherosclerotic changes were completely absent in both the CZE treatments whereas, ROSI treatments did not prevented the atherosclerosis of aorta completely as they showed moderate and mild atherosclerotic changes in the aorta. Conclusion: The aqueous extract of C. zelanicum bark exhibited marked protection against dexamethasone induced atherosclerosis and also minimized the atherogenic risk in Wistar rats.

An In vitro Comparative Evaluation of Disinfectants on Standard and Clinical Microbial Strains on Heat Cure Resins

Karuna Gajanan Pawashe, Shivsagar Tewary, Pronob Kumar Sanyal, Kumar Nilesh

Introduction: Oral cavity is colonised by numerous micro-organisms that form a biofilm on the acrylic resin. Hence, routine hygiene is essential to prevent oral mucosal inflammation and lesions. Knowledge of appropriate disinfecting agents for acrylic resins is crucial in this context. Aim: To compare and evaluate the effectiveness of four commercially available disinfectants on heat cure acrylic resin specimens contaminated with standard and clinical strains of two micro-organisms commonly inhabiting the oral microflora. Materials and Methods: Two hundred acrylic resin specimens (n=200), 10 in each group were contaminated in vitro with 1x106 cells/ml suspensions of standard and clinical strains of micro-organisms (Candida albicans and Streptococcus mutans) and were immersed in four disinfectants (1% sodium hypochlorite, 2% chlorhexidine digluconate, 2% glutaraldehyde and 3.8% sodium perborate) for 10 minutes. The control group was not subjected to any disinfection process. For collection of clinical strains, oral swab was passed over the buccal mucosa and grown on blood agar culture media. Organism confirmation was done by growing them on selective culture media. Final counts of micro-organisms per ml were performed by plating method for evaluation of microbial level reduction. Results obtained were subjected to ANOVA and Tukey’s test. Results: Standard strains of Candida albicans (C) and Streptoccocus mutans (S) subjected to various disinfectants showed varied mean Colony Forming Units per ml (CFU/ml) from <10,000 to 25,000 and <10000 to <50,000 respectively. Clinical strains and of Candida albicans (C) and Streptococcus mutans (S) subjected to various disinfectants showed varied mean CFU/ml from <10,000 to 50,000 and from 10,000 to 50,000 respectively. Control groups showed maximum mean CFU/ml (>105). All intergroup comparisons were highly significant (p<0.001; HS) and intragroup comparisons were significant (p<0.05; S) except the comparison of clinical strains of Streptococcus mutans subjected to 2% chlorhexidine digluconate and 2% glutaraldehyde which was found to be non significant (p>0.05; NS). Conclusion: Almost 1% sodium hypochlorite was found to be the most effective disinfectant for both Candida albicans and Streptococcus mutans. The least effective disinfectant being: 3.8% sodium perborate.

Effect of Motives for Food Choice on Oral Health among Primary School Children in Mangalore: An Analytical Survey

Introduction: Parents influence children’s eating behaviours by making some foods available than others and by acting as models of eating behaviour. Food selected by parents influence general and oral health of their children. Aim: Aim of this study was to assess oral health parameters among primary school children and motives for food choice among their parents in Mangalore. Materials and Methods: A total of 759 primary school children aged 5-10 years, and their parents participated in this study. Motives for food choice among parents of children were evaluated by using Food Choice Questionnaire (FCQ). Oral health status of students was assessed by using World Health Organisation (WHO) Basic Oral Health Assessment Form. Data pertaining to dietary habits and demographics was also collected. Descriptive and inferential statistics along with Pearson’s correlation and Binary logistic regression were executed for the present study and level of significance was fixed at p<0.05. Results: Caries prevalence was 10.8% and 68.9% in permanent and primary dentitions, respectively. Mean Decayed, Missing And Filled Tooth (DMFT) index scores among study subjects were 0.21±0.72 and 3.08±3.11 for permanent and primary dentitions, respectively. Increase in caries prevalence was significantly associated with decrease in total FCQ scores. FCQ domains ‘health’, ‘natural content’ and ‘weight control’ were significantly correlated with dental caries experience. FCQ also showed significant correlation with socio-economic variables. Conclusions: Overall, dental caries experience was found to be high. Parental food choice motives positively influenced dietary patterns and caries experience of their children. Caries experience was less in children whose parents reported higher scores on FCQ. Understanding the barriers, identification of risk factors for poor food choices and targeting interventions might formulate ways by which the desired behaviour can be achieved.

Diagnostic Utility of Epithelial Membrane Antigen (EMA) and Calretinin (CAL) in Effusion Cytology

Neha Nautiyal, Aparna Bhardwaj, Seema Acharya, Sanjeev Kishore, Sandip Kudesia

Introduction: Fluid cytology and subsequent utilization of immunocytology on cell block is being used commonly for increasing the diagnostic accuracy in effusion cytology. Aim: To do cytological analysis of fluids and evaluate the role of Epithelial Membrane Antigen (EMA) and Calretinin (CAL) to differentiate between reactive and malignant cell in pleural and peritoneal fluids. Materials and Methods: This was a prospective study carried out in Department of Pathology, Shri Guru Ram Rai Institue of Medical and Health Science, for a period of 18 months from January 2014 to June 2015. A total of 253 samples of pleural and peritoneal fluid were studied by May-Gruenwald-Giemsa (MGG) stain and Papanicolaou (Pap) staining. In 73 cases which were suspicious for malignancy, cell blocks were prepared and IHC was done using two immunomarkers- EMA and CAL. Results: A total of 253 cases of effusion cytology were studied out of which 73 were found positive for malignant cells. Maximum cases of malignant cells or atypical cells were seen in peritoneal fluid. A total of 34 cases were histologically positive for malignancy. All these cases showed strong membranous and cytoplasmic positivity for EMA. Most of cases also showed 2%-5% positivity for CAL. There were 38 cases categorized as atypical or reactive mesothelial cell hyperplasia. These cases showed nuclear and cytoplasmic staining for calretinin and none of these were positive for EMA, although 5 cases showed score 2-3, which was considered as negative. Conclusion: The distinction between reactive and malignant mesothelial cells in cytological specimens can be problematic. A combination of CAL and EMA may help in accurate diagnosis.

Retrospective Comparison of Estimated GFR using 2006 MDRD, 2009 CKD-EPI and Cockcroft-Gault with 24 Hour Urine Creatinine Clearance

B. Vinodh Kumar, Thuthi Mohan

Introduction: The assessment of Glomerular Filtration Rate (GFR) is essential for clinical practice in assessing kidney function, drug dosing, detecting and estimating the prognosis of Chronic Kidney Disease (CKD). The most common practical method for assessing GFR is performed with a 24 hour/timed urine collection for creatinine clearance evaluation. The estimation of eGFR by creatinine based formulae is known to be a rapid and reliable means of approximation of creatinine clearance. Aim: To compare eGFR using three commonly used Formulae {Modification of Diet in Renal Disease Study Equation (MDRD 2006), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI 2009) and Cockcroft-Gault Formula} with 24 hour creatinine clearance and to identify which amongst the 3 formulae for eGFR closely correlates with 24 hour creatinine clearance in a secondary care hospital. Materials and Methods: We retrospectively collected laboratory data requested for 24 hour creatinine clearance in the period from January 2014 to August 2016. Totally 91 laboratory request for 24 hour creatinine clearance data were obtained. The paired-t-test was used for comparison since all parameters used in the study were numerical, all patients came from same population and all had paired results. Results:The eGFR by MDRD formulae had a statistically insignificant p-value (p > 0.05) i.e., good approximation in the IInd, IIIrd, IVth and Vth stages of CKD on comparison with 24 hour creatinine clearance. The eGFR by CKD-EPI formulae had a statistically insignificant p-value (p > 0.05) in the IInd, IVth and Vth stages of CKD. The eGFR by Cockcroft-Gault Formulae had a statistically insignificant p-value (p > 0.05) in the Ist, IInd and Vth stages of CKD. Conclusion: The Creatinine based GFR estimation provides a more accurate assessment of 24 hour creatinine clearance and kidney function than measuring serum creatinine alone but have certain limitations in few clinical circumstances. No single equation will be optimal for all populations. But the result of this study showed MDRD 2006 formulae to be more accurate than CKD-EPI 2009 and Cockcroft-Gault formulae in estimating GFR, detection of CKD, drug dosing and estimating prognosis.

Clinicopathological Analysis of Glomerular Disease of Adult Onset Nephrotic Syndrome in an Indian Cohort- A Retrospective Study

Mayur Suryawanshi, Swapnil Karnik, Sanjeet Roy

Introduction: Primary glomerular disease presenting with adult onset nephrotic syndrome are a major cause of chronic renal failure worldwide. The spectrum of renal disease presenting with nephrotic syndrome has undergone a gradual change globally over the course of time. However, there still exist regional differences in the incidence of primary glomerular diseases causing adult onset nephrotic syndrome. Aim: To observe the spectrum of renal diseases presenting with adult onset nephrotic syndrome with comparative analysis of changing trends over the last five decades with regards to Western and Indian literature. Materials and Methods: Subjects included patients with age of 18-80 years presenting with nephrotic syndrome. Renal biopsies with immunofluoroscence studies were performed in all patients. Baseline clinical parameters of serum urea, creatinine, albumin, globulin, cholesterol, 24 hour urine protein and urine microscopy were recorded. Descriptive statistics was used and results were expressed as frequencies, percentages, and mean±standard deviation. Results: A total of 227 patients (72% males) were included for the study. Primary glomerular diseases formed 74.01% of total cases and majority of patients included males in the 4th decade. Minimal Change Disease (MCD) (15.8%) including its variants was the most common primary glomerular disease for adult onset of nephrotic syndrome followed by Mesangial proliferative Glomerulonephritis (MSGN) (13.2%). Membranous nephropathy and Type I Membranoproliferative Glomerulonephritis (MPGN) individually accounted for 12.3% of patients. Focal and Segmental Glomerulosclerosis (FSGS) accounted for only 11% of patients. Although, increased incidence of FSGS has been observed worldwide, there exist important regional differences in primary glomerular diseases in Indian population. MCD remains a major glomerular disease for adult onset nephrotic syndrome in different parts of India. Conclusion: Our study over three years represents important data of regional variations of primary glomerular diseases presenting with adult onset nephrotic syndrome.

Occupation Hazards – Pattern, Awareness and Preventive Measures among Welders from an Unorganized Sector in India

Introduction: Welding is an occupation associated with tremendous physical and chemical hazards. In spite of the risk involved, usage of Personal Protective Gears (PPGs) among welders in developing countries has been reported to be poor, due to their limited awareness of occupational hazards. Aim: To assess morbidity pattern, awareness of occupational hazards and usage practices of protective gears among welders. Materials and Methods: Cross-sectional study was conducted at welding sites from unorganized sector situated in and around Mangalore. A total of 155 welders chosen randomly from as many sites were interviewed at their workplace using a pilot tested structured interview schedule with both closed and open ended questions. Clinical examination of the participant and inspection of the work site was also done by the investigators. Statistical analysis used for analysis was Chi-Square test, unpaired t-test and ANOVA test. Results: Working >8 hours a day was reported by 30 (19.4%) welders. Overcrowding was present at 10.3%, ventilation status was inadequate at 6.9% and exhaust ventilation was not present at 25.9% sites. Awareness about anyone occupational health hazards associated with welding was present among 97(62.6%) welders. Periodicity of medical examination was associated with awareness of occupational hazards among welders (p=0.032). First aid kit was present at 60 (38.7%) sites. The most common morbidity over the past year was wounds 119 (76.8%). Non-usage of most essential protective gears such as face shields, masks or eye goggles was seen among 18 (11.6%) welders. Mean number of morbidities over the past one month was found to be more, in those welders doing continuous work of =6 hours (p=0.05), at sites with overcrowding (p=0.002) and at sites where >10 welders work together (p=0.031). Conclusion: The period prevalence of morbidity was high among the welders surveyed. Ignorance of health hazards associated with occupation and non-usage of protective gears was reported by number of them. Therefore, health education and safety policies need to be strengthened at welding sites.

Accessory Grooves on the Diaphragmatic Surface of the Liver: A Cadaveric Study

Satheesha B. Nayak, Ashwini Aithal Padur, Naveen Kumar, Bincy M. George

Introduction: Usually liver does not possess any grooves on its diaphragmatic surface, but there are reports on the presence of grooves on this surface. Aim: The present study was conducted to study the gross features of diaphragmatic surface of the liver and document the presence of any grooves on it and also to correlate our study with the previous studies. Materials and Methods: Ninety seven formalin embalmed livers stored in 10% formaldehyde were observed for the presence of grooves on diaphragmatic surface. Results: Fifteen (15.46%) livers had at least one groove on the diaphragmatic surface. Left lobe did not reveal the presence of any abnormal grooves. Presence of a single groove was observed in six (6.18%) livers; Double grooves were found in five (5.15%) livers; Triple grooves were found in three (3.09%) livers and four grooves were found in one (1.03%) liver. The deepest among all the grooves was measured 1.5 cm. Conclusion: The knowledge of these grooves is of importance to radiologists and surgeons during their routine procedures.

Relation between Clinical Oral Dryness Score and Denture Satisfaction among Patients’ in a Tertiary Care Centre, India

Introduction: Xerostomia is a subjective feeling of dryness commonly seen in elderly populations which impairs the quality of life. Due to loss of lubricating property of saliva the buccal mucosa, tongue and lips tend to stick leading to dry, freckled, ulcerated and sore mucosa which is of major concern to the patient to use complete denture. Aim: The aim of the study was to assess the relation between oral dryness score and denture satisfaction among elderly patients. Materials and Methods: A cross-sectional study was conducted in prosthodontics department of a dental institution. Patients wearing dentures for at least six months were invited to participate in study. Visual Analogue Scale (VAS) with scores ranging from 0-100 was used to assess patient’s satisfaction and clinical oral dryness score was assessed using the criteria described by Osailan SM et al., with scores ranging from 0-10. Data was analysed with SPSS software (version-20) and Kendall’s tau-b correlation was used to determine the relationship between mean denture satisfactions and mean clinical oral dryness scores. Results: A total of 220 participants were included in the study based on inclusion criteria. Mean dryness score of the participants was 1.8±0.6 and mean VAS-score for denture satisfaction was 74.32±21.20 for aesthetics, for chewing ability the mean score was 62.31±19.64 and for phonetics it was 67.82±30.60. Strong negative correlation between VAS-scores and oral dryness scores was observed. Conclusion: Clinical oral dryness score is one of the important factors which influence denture satisfaction. Dentist should consider in predicting prognosis.

Expression of Podoplanin in Laryngeal Squamous Cell Carcinoma and Dysplasia

Introduction: In human cancers, podoplanin expression and its correlation with tumour invasive potential raise its possible role as a diagnostic and prognostic marker for cancer. Aim: To investigate the immunohistochemical expression of podoplanin in laryngeal Squamous Cell Carcinoma (SCC) and dysplasia. Materials and Methods: This study included a total of 60 archived, formalin fixed, paraffin embedded tissue blocks of 40 cases of laryngeal SCC and 20 cases of dysplastic lesions. The samples were immunohistochemically analysed for podoplanin expression. Results: Podoplanin expression was significantly higher in laryngeal SCC (90%) than laryngeal dysplastic lesions (55%) (p-value=0.002). The expression of podoplanin was significantly increased with the higher grades of dysplasia (p-value=0.016). A significant positive correlation was detected between podoplanin expression in laryngeal SCC and depth of tumour invasion (p-value=0.035), and stage (p-value=0.026). Conclusion: The high expression of podoplanin in laryngeal SCC and its significant correlation with poor prognostic parameters recommends podoplanin as a prognostic marker in laryngeal SCC. In addition, increased podoplanin expression with higher grades of dysplasia, supports its role in malignant transformation and allows us to recommend its evaluation in premalignant lesions.

Muscle Activation Profiles and Co-Activation of Quadriceps and Hamstring Muscles around Knee Joint in Indian Primary Osteoarthritis Knee Patients

Sanjeev Kumar Sharma, Shiv Lal Yadav, U Singh, Sanjay Wadhwa

Introduction: Osteoarthritis (OA) of knee is a common joint disease. It is associated with reduced knee joint stability due to impaired quadriceps strength, pain, and an altered joint structure. There is altered muscle activation in knee OA patients, which interferes with normal load distribution around the knee and facilitates disease progression. Aim: Our primary aim was to determine activation patterns of the muscles i.e., quadriceps and hamstrings in knee OA patients during walking. We also studied co-activation of muscles around knee joint in primary OA knee patients including directed medial and lateral co-contractions. Materials and Methods: This observational study was done at Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, New Delhi, India. Forty-four patients with medial compartment primary knee OA were included in study after satisfying inclusion and exclusion criteria. All the patients were assessed for mean, peak and integrated Root Mean Square (RMS), EMG values, muscle activation patterns and co-activation of muscles around knee joint by surface Electromyography (EMG) analysis of Vastus Medialis Obliques (VMO), Vastus Lateralis (VL), Semitendinosus (SMT) and Biceps Femoris (BF) muscles during gait cycle. The EMG waveform for each muscle was amplitude normalized and time normalized to 100% of gait cycle and plotted on graph. Quantitative variables were assessed for normal distribution and accordingly mean±SD or median (range), as appropriate, was computed. Results: For primary OA knee, mean age 61±5 years, mean weight 63.7±10.1 kg, mean height 153.9±7.2 cm, and mean Body Mass Index (BMI) 26.8±3.0 kg/m² was found. The muscle activity of hamstrings (SMT muscle and BF) was increased during midstance, late stance and early swing phase of gait cycle as compared to quadriceps (VMO and VL) muscle activity respectively, suggesting co-contraction of opposing muscles around knee joint. Conclusion: Patients with knee OA walk with increased hamstring muscle activity (during late stance and early swing phase) and reduced quadriceps recruitment. Altered neuro-muscular control around knee interferes with normal load distribution and facilitates disease progression in knee joint.

How Non Consumers Differ from Consumers: A Qualitative Approach to Synthesize the Attributes of Iron Folic Acid End Users

Introduction: Anaemia continues to be a major hurdle to achieve optimum health in Indian population context. Although government continues to promote Iron Folic Acid (IFA) supplementation as one of the key strategies to combat with burden of anaemia, the expected level of IFA consumption and subsequent anaemia reduction could not be achieved. This study tries to investigate those influences, concerns, experiences and behaviour from an end user perspective through a qualitative methodology which may affect the IFA consumption ambi-directionally. Aim: To explore and understand the several aspects related with anaemia and IFA supplementation with special emphasis to reveal the contributory factors behind low level of IFA consumption at consumer end. Materials and Methods: A community based qualitative study was conducted in clusters identified through multileveled stratification from a state of central India. A conceptual construct was made in priory for this study. As the research question was related with policy, this study adapted a framework technique for making interview topic guides. Two consumers and two non consumers from each identified cluster were interviewed in depth. The data obtained through 160 in depth interviews (from 80 consumers and 80 non consumers) was utilized for thematic framework, linkage association and to typify the phenomenon. Results: Ignorance, difficult intake, meaninglessness, misconceptions and discontentment with the system were the major dimensions (sub themes) associated with discontinuation. All these sub themes were further converged into major theme of informational discontinuity. Investigators further typified the users/non users into persistent user, potential defaulters, impending defaulters and absolute non users. Conclusion: Informational gap seems to be the fundamental factor behind sub optimum IFA consumption. On a policy perspective, all the attempts should be done to instigate arise felt need’ among target groups for IFA consumption.

A Prospective Study of Adverse Drug Reactions in Patients with Bipolar Disorder in Psychiatry Outpatient Department of a Tertiary Care Hospital

Introduction: Bipolar disorder is a chronic, debilitating psychiatric disorder. Mood stabilizers and atypical antipsychotics are first line drugs for bipolar disorder. They have significant adverse effects. Aim: The study was conducted with an aim to evaluate the pattern of occurrence of Adverse Drug Reactions (ADRs) in the patients with bipolar disorder and to assess their causality, severity and preventability. Materials and Methods: A prospective and observational study - carried out in the psychiatry outpatient department of New Civil Hospital, Surat for 15 months. All patients diagnosed with bipolar disorder and receiving pharmacotherapy were included. Udvalg for Kliniske Undersøgelser (UKU) side effect rating scale and Abnormal Involuntary Movement Scale (AIMS) were used for documenting ADRs and tardive dyskinesia, respectively. Assessment of causality, severity and preventability of recorded ADRs was done using Naranjo’s algorithm and WHO-UMC scale, modified Hartwig and Seigel Scale and modified Schumock and Thornton scale, respectively. Descriptive statistics was used (percentage, mean±standard deviation) for presentation of demographics and other numerical data; Chi Square test and Fisher’s exact test were used to assess association between variables. A p-value < 0.05 was considered significant. Results: A total of 703 ADRs were recorded from 175 patients. The most common ADRs observed were asthenia (11.95%) and sedation (10.24%). Majority of ADRs were mild on assessment with UKU scale. Mood stabilizers (59.46%) were most frequently associated with ADRs and lithium was most common single drug responsible. Upon causality assessment, majority of the reactions were probable (54.77% with WHO-UMC scale, and 56.33% with Naranjo’s algorithm). The association of results between the two scales was statistically significant (p<0.001). Majority of ADRs (70.27%) were assessed as mild and 64.30% of the ADRs were not preventable. Conclusion: ADRs are a frequent occurrence in patients with bipolar disorder which are mild in most cases. Incidence of ADRs can be decreased and compliance as well as quality of life of patient can be improved by early detection and management.

Effect of Yoga on Psychological Functioning of Nursing Students: A Randomized Wait List Control Trial

Monali Devaraj Mathad, Balaram Pradhan, Rajesh K Sasidharan

Introduction: Nursing students experience considerable amount of stress to meet their professional demands. Yoga is an effective practice to reduce stress and improve psychological well being. However, improvement in psychological well being aids in stress management. Aim: To evaluate the effectiveness of eight week yoga intervention on psychological functioning of nursing students. Materials and Methods: This was a randomised Wait List Control (WLC) trial, we recruited total 100 students from Kempegowda Institute of Nursing, Bengaluru, Karnataka, India and randomized them into two groups (yoga=50 and WLC=50 students). The following instruments were used to collect the data, Freiburg Mindfulness Inventory (FMI), Self-Compassion Scale- Short Form (SCS-SF), Connor–Davidson Resilience Scale (CD-RISC), Satisfaction with Life Scale (SWLS), Jefferson Scale of Empathy HPS-Version (JSE-HPS), and Perceived Stress Scale (PSS). Data was analysed using Repeated Measures Analysis of Variance (RM-ANOVA) followed by post-hoc Bonferroni correction for all psychological variables. Results: The results of our study report that eight week yoga intervention was significantly effective in improving self compassion and mindfulness among nursing students in experimental group than compared to WLC group. Even though there were improvements in resilience, satisfaction in life and perceived stress results were not statistically significant. Conclusion: Overall, results of the present study have demonstrated impact of eight week yoga intervention on the psychological functioning of nursing students. Yoga intervention can be inculcated in the nursing education to meet demands of the profession.

Social Security Measures for Elderly Population in Delhi, India: Awareness, Utilization and Barriers

Charu Kohli, Kalika Gupta, Bratati Banerjee, Gopal Krishna Ingle

Introduction: World population of elderly is increasing at a fast pace. The number of elderly in India has increased by 54.77% in the last 15 years. A number of social security measures have been taken by Indian government. Aim:To assess awareness, utilization and barriers faced while utilizing social security schemes by elderly in a secondary care hospital situated in a rural area in Delhi, India. Materials and Methods: A cross-sectional study was conducted among 360 individuals aged 60 years and above in a secondary care hospital situated in a rural area in Delhi. A pre-tested, semi-structured schedule prepared in local language was used. Data was analysed using SPSS software (version 17.0). Chi-square test was used to observe any statistical association between categorical variables. The results were considered statistically significant if p-value was less than 0.05. Results:A majority of study subjects were females (54.2%), Hindu (89.7%), married (60.3%) and were not engaged in any occupation (82.8%). Awareness about Indira Gandhi National Old Age Pension Scheme (IGNOAPS) was present among 286 (79.4%) and Annapurna scheme in 193 (53.6%) subjects. Among 223 subjects who were below poverty line, 179 (80.3%) were aware of IGNOAPS; while, 112 (50.2%) were utilizing the scheme. There was no association of awareness with education status, occupation, religion, family type, marital status and caste (p>0.05). Corruption and tedious administrative formalities were major barriers reported. Conclusion: Awareness generation, provision of information on how to approach the concerned authority for utilizing the scheme and ease of administrative procedures should be an integral part of any social security scheme or measure. In the present study, about 79.4% of elderly were aware and 45% of the eligible subjects were utilizing pension scheme. Major barriers reported in utilization of schemes were corruption and tedious administrative procedures

Severe Puerperal Sepsis-A Simmering Menace

Sheeba Marwah, Sonam R Topden, Manjula Sharma, Ritin Mohindra, Pratima Mittal

Introduction: Even decades after the development of effective low-cost antibiotics, sepsis persists as the foremost cause of preventable maternal death worldwide. In developing countries like India, where the paramount impediment to intervention is poverty, maternal mortality due to sepsis is a continuing representation of maternal health inequality. Aim: To determine the incidence, risk factors and mortality in women presenting with puerperal sepsis in a tertiary care health facility in India. Materials and Methods: This retrospective study was carried out in VMMC and Safdarjung Hospital, New Delhi, India, from January 2016 to June 2016 in Department of Obstetrics and Gynaecology. Case records of all eligible patients of puerperal sepsis were reviewed and data were extracted regarding demographic profile, clinical profile on admission, course in hospital, management, complications and cause of mortality (in case of death). Inclusion criteria were any patient presenting either immediately after delivery or miscarriage or within 42 days of these events with fever and any of the following: pain abdomen, malodorous lochia, abdominal distention, uterine tenderness, pelvic abscess, peritonitis, mechanical or foreign body injury, any system/organ failure or shock. Exclusion criteria consisted of patients presenting with fever during pregnancy or more than 42 days after delivery or miscarriage, or patients presenting with fever due to medical conditions, wound infection, mastitis, UTI or thrombophlebitis. Data were entered in predesigned proformas and analysed. A p-value of less than 0.05 was considered significant. Results: During the study period, a total of 33 cases met the inclusion criteria. Of these, 90% were referred cases. Anaemia, prolonged labour, delivery by an untrained person and unsafe abortion were the main identifiable risk factors. Surgical management was required in 75% cases, while 70% women succumbed to their illness, mostly due to multiorgan failure. Conclusion: Maternal mortality due to maternal sepsis is very high; Lack of safe and hygienic practices for conducting delivery and abortion are important contributory factors.

Chemoresponse Assay in Head and Neck Cancer Patients: A Three-Year Follow Up

Basem T Jamal, Gregory A Grillone, Scharukh Jalisi

Introduction: The majority of patients with advanced head and neck cancer receiving chemotherapy show partial response or frank resistance. Therefore, assessing the individuals’ tumour reactivity to the eligible chemotherapeutic compounds carries the potential of personalizing the patient treatment and minimizing ineffective regimens which lead to excess toxicity and cost, treatment delays and possibly causing the tumour to be cross resistant to additional drugs. Aim: To determine the effectiveness of a phenotypic chemoresponse assay in predicting response to chemotherapy in a retrospective series of head and neck cancer patients whose tumour specimens had been tested with ChemoFx assay (Precision Theraputic Inc.). Materials and Methods: Twenty-two tumour specimens were submitted to Precision Theraputics Inc. for chemoresponse testing, all of which have been histologically confirmed as squamous cell carcinoma of the head and neck. Selection of treatment was at the discretion of the treating physician and the results of the assay were not used to determine the therapy. A portion of the patients’ solid tumour was established in primary culture, then exposed to increasing doses of different chemotherapeutic agents. The resultant cell counts in the treated wells were used to indicate the tumours’ response to the agent and based on the dose response score curve, the test was scored as “responsive,” “intermediate response,” or “non-responsive.” Results: Of the 22 tumour samples submitted, 16 (72.7%) showed adequate cell yield in cultures and subsequently underwent in vitro chemoresponse assays and are reported in this study. Of the 16 cases reviewed, 5 were excluded due to inadequate follow up. A predictable response assay was either a good response to chemotherapy in patients whose tumour specimens showed sensitivity to the chemotherapeutic agents or failure in patients whose tumours showed either intermediate response or non responsiveness to the chemotherapeutic agent/agents. Of the 11 patients reported in this study, nine showed a predictable chemoresponse assay (81.8% predictability of effective treatment). Three patients had a predictable good response and six who failed their chemotherapy regimen within six months of treatment and their chemoresponse assay showed an inadequate response to the chemotherapeutic agents they were treated with. At three years follow up, all patients who had a predictable poor response succumbed to their disease except one, whose test showed intermediate response. Conclusion: While the current report has its limitation, we conclude, based on our findings, that chemoresponse assays may be useful adjuncts in the guiding the selection of chemotherapeutic agents in patients with head and neck cancer.

Failed Back Surgery Syndrome: Evaluation with Magnetic Resonance Imaging

Introduction: Failed Back Surgery Syndrome (FBSS) is a generalized term used to describe varied spinal symptoms of patients who have had unsuccessful results after spinal surgery. The treatment of FBSS is challenging and varies from conservative management to reoperation. Imaging plays a crucial role in identifying the cause and helps to guide the appropriate therapy. Contrast enhanced Magnetic Resonance Imaging (MRI) with its superior resolution is the imaging modality of choice. Aim: To evaluate the spectrum of imaging findings on postoperative MRI in FBSS. Materials and Methods: A total of 30 postoperative symptomatic patients of FBSS were included in this cross-sectional study. Of these, 26 had undergone surgery for degenerative disc disease and four had spinal fixation surgery for spondylolisthesis or trauma. Patients were subjected to detailed clinical examination. All patients underwent MRI which was done on 1.5 Tesla scanner with standard sequences in all planes. Contrast was administered in all cases. Non Contrast Computed Tomography (NCCT) scan was done in patients with metallic implants to better delineate the placement of the implant. Patients with contraindication to MRI scanning were excluded from the study. Results: Of the total 30 cases (23 males and seven females) of FBSS that were evaluated with contrast enhanced MRI of the spine, 16 patients had recurrent/residual disc herniation, six had epidural scar tissue, three patients had recurrent disc herniation and scar tissue, two had evidence of post surgery arachnoiditis, two patients had postoperative discitis and one patient had implant mal alignment. Eight patients underwent reoperation for recurrent disc herniation and one patient for implant malalignment after imaging. Conclusion: MRI is the modality of choice for evaluating the postoperative spine. It helps to identify the cause and guide the appropriate treatment.

Comparison of Antiemetic Effectiveness of Palonosetron Versus Ondansetron in Patients on Cancer Chemotherapy: A Prospective Observational Study in South Indians

Abdul Aslam Parathoduvil, Asha Sisupapalan, Padanayil Lekshmikutty Rema

Introduction: Chemotherapy Induced Nausea and Vomiting (CINV) is the most distressing side effect of cancer chemotherapy. It can seriously produce an impact on patients quality of life. Prevention of CINV is far more effective than treatment of an established CINV. If the patient receives an optimal antiemetic regimen during the initial course of chemotherapy, the likelihood of developing emesis is greatly reduced. Although, all first generation 5HT3 antagonists demonstrate reasonable efficacy in preventing acute CINV, delayed CINV still remains a problem. Aim: To compare the effectiveness and safety of palonosetron versus ondansetron as an antiemetic agent in patients receiving cancer chemotherapy. Materials and Methods: A prospective observational study was conducted in 106 patients in each treatment arm. Study duration was 12 months from January 2013 to January 2014. Consecutive patients diagnosed with cancer satisfying inclusion criteria, who were about to receive moderately or highly emetogenic chemotherapy were enrolled into the study after getting informed written consent. Each patient received either Intravenous (IV) palonosetron 0.25 mg or ondansetron 8 mg half an hour before chemotherapy as antiemetic. Patients were followed up for a period of five days following chemotherapy. Number of episodes, severity of vomiting and nausea and antiemetic rescue given if any were recorded. The data were graded using NCI-CTCAE (VERSION 3.0). Proportion of patients with nausea and vomiting during acute (0-24 hours), delayed (24-120 hours) and overall period (0-120 hours) in both the study groups were compared. Outcome was assessed in terms of symptom control and response. Data were analysed using SPSS-16.0 statistical software (IBM). Chi-square test was used to compare the difference in clinical response. Results: Complete response during acute phase in ondansetron group was 80.2%, while for palonosetron it was 89.6%. During delayed phase, ondansetron and palonosetron produced complete response in 70.8% and 86.8% respectively. A total of 65.1% and 82.1% of subjects experienced complete response during the overall period in the ondansetron and palonosetron groups respectively. The difference in the response to antiemetic prophylaxis was statistically significant between the two groups for delayed (p-value = 0.006) and overall phase (p-value = 0.008). Conclusion: Palonosetron is clinically more efficacious than ondansetron in controlling CINV especially in delayed phase and overall period of emesis.

Effect of Single Dose Betamethasone Administration in Pregnancy on Maternal and Newborn Parameters

Komal Gaur, Barna Ganguly

Introduction: Antenatal corticosteroids play an important role in preventing Respiratory Distress Syndrome (RDS) but benefits related to time between corticosteroid administration and delivery need to be explored. Aim: To observe the effect of betamethasone administration in pregnant women at risk of preterm delivery and on foetal parameters, in terms of development of RDS. Materials and Methods: It was a prospective observational study on pregnant women at risk of preterm delivery who were administered a single dose 24 mg injection betamethasone. Outcome of 111 newborns of enrolled mothers was observed in terms of respiratory distress, Downe’s and Silverman Anderson score, need of NICU admission and ventilation. Paired t-test was used to compare means of maternal parameters before and after betamethasone. Independent sample t-test for comparison of scores for respiratory distress in neonates was used. Results: There was a significant decrease in maternal haematological parameters like mean Red Blood Cell (RBC) and mean Platelet Count (PC) whereas increase in mean Total leucocyte Count (TC) after betamethasone administration. Out of 111 newborn babies, 71 were born within 24 hours and rest were born after 24 hours of betamethasone administration. Twelve out of 71 newborns who were born within 24 hours of betamethasone administration, developed RDS. Mean Downe’s score and mean Silverman Anderson score in neonates born within 24 hours of injection administration were significantly higher than those born after 24 hours. Conclusion: Betamethasone administration affects the haematological parameters in mothers in antenatal period nearing term. A minimum of 24 hours have to elapse between corticosteroid administration and delivery of the preterm for benefits to occur.

Correlation of Prostate Gland Size and Uroflowmetry in Patients with Lower Urinary Tract Symptoms

Introduction: Benign Prostatic Hyperplasia (BPH) is a common entity among men over 40 years of age with significant disability. It is a condition that occurs when the enlarged prostate gland compresses the urethra leading to Bladder Outlet Obstruction (BOO). Aim: To correlate the size of the prostate gland and uroflowmetry parameters in patients with Lower Urinary Tract Symptoms (LUTS). Materials and Methods: One hundred and twenty randomly selected male patients, from the ages of 41 to 70 years, with LUTS, and underwent trans abdominal sonogram and uroflowmetry were included in the study. The samples were divided into three groups according to the age; Group 1: 41 to 50 years, Group 2: 51 to 60 years, Group 3: 61 to 70 years. Results: In Group 1 (41 to 50 years), there were totally 28 patients with LUTS, out of which seven patients had BPH, indicating that about 5% of patients with LUTS have BPH. In Group 2 (51-60 years) there were totally 31 patients with LUTS, out of which 10 patients had BPH, indicating that 8% of patients with LUTS have BPH. In Group 3 (61-70 years) there were totally 61 patients with LUTS, out of which 33 patients had BPH, indicating that 27% of patients with LUTS had BPH. The mean age of patients with LUTS was 60 years with mean prostate size of 45 cm3. Enlarged prostate gland was present in 41% of patients with mean Q max of 14 ml/sec and post voidal volume of 48 ml. Conclusion: This study concludes that the LUTS in older patients are mostly due to BPH leading to BOO. Also, patients with BPH in early ages can lead to increased Post voidal Residual Volume (PVR) following uroflowmetry. Thus, screening male patients with LUTS, at 40 years and above, is an ideal way to detect prostatic problems at an early stage.

Serial Changes in Complete Blood Counts in Patients with Leptospirosis: Our Experience

Deepa Sowkur Anandarama Adiga, Salony Mittal, Harini Venugopal, Sowmya Mittal

Introduction: Leptospirosis is an infectious disease caused by Leptospira interrogans. It is endemic in many parts of the world. The symptoms vary between milder forms to severe type with organ dysfunction. The disease presents with diagnostic challenge as it clinically mimics acute febrile illness due to other causes. Aim: To study serial changes in complete blood counts in patients with leptospirosis. Materials and Methods: A retrospectively collected data was prospectively studied for clinical and laboratory data of leptospirosis patients proven by raised IgM titres by ELISA on day 2 (counted from day of admission of patient to hospital) of unexplained fever. The changes in complete blood counts from admission upto the discharge of the patient were studied. SPSS version 13 (SPSS Inc. Chicago) was used for data analysis. The collected data was analysed using frequency, percentage, mean, median, standard deviation and Mann-Whitney test. A p-value less than 0.05 were considered significant. Results: Mean haemoglobin concentration showed a progressive decline (<12.5 gm/dl) from day 1 to day 7 in both mild and severe disease. Platelet counts were significantly low (p=0.002), (<1,50,000 cells/mm3) in severe disease and showed a declining trend as compared to mild disease. Total leukocyte counts were significantly higher (p=0.001), (>11,000 cells/m3) in patients with severe disease from day 4 to day 5 of the illness. Conclusion: Complete blood count is a routine test done in the monitoring of patients with leptospirosis. Declining haemoglobin, marked thrombocytopenia and a normal to high total leukocyte count will help in early detection of severe disease and thus preventing mortality by timely management.

Anatrophic Nephrolithotomy in the Management of Large Staghorn Calculi – A Single Centre Experience

Introduction: With advances in endourology, open stone surgery for staghorn calculi has markedly diminished. Anatrophic Nephrolithotomy (AN) is performed for complex staghorn stones which cannot be cleared by a reasonable number of Percutaneous Nephrolithotomy (PNL) attempts. Aim: To assess the indications and outcomes of AN in the modern era. Materials and Methods: Between April 2008 and July 2015, AN was done in 14 renal units in 13 patients. In this retrospective study, demography, stone characteristics, operative details, clearance and long term outcomes were assessed. Results: AN was performed for complex staghorn calculi involving pelvis and all calyces in 10 patients, infundibular stenosis in two patients and failed PNL in one patient. Mean (SD) in situ cold ischemia time was 47.64 (5.27) minutes. Retroperitoneal drain and double J stent were placed in all 13 patients. Median (IQR) estimated blood loss was 130 (75) ml. There was no perioperative mortality. Surgical site infection was seen in 2 patients and urosepsis in 2 patients. Drain was removed at a mean (SD) of 9.11 (6.15) days. Mean (SD) postoperative length of hospitalization was 15.44 (7.14) days. Stent removal was done in all patients between 2-8 weeks. Median (IQR) clearance was 95 (7.5%). There was no renal failure or new calculi during the follow up period {median (IQR): 1(3) years}. Conclusion: AN is effective in management of large staghorn calculi failed minimally invasive approaches and achieves 80%-100% clearance without much need for secondary interventions. Renal function is preserved and with emergence of laparoscopy and robotics, postoperative stay is minimized with expedited recovery and comparable results with open surgery.

Ultrasonographic Estimation of Endotracheal Tube Size in Paediatric Patients and its Comparison with Physical Indices Based Formulae: A Prospective Study

Jagadish G Sutagatti, Ranjana Raja, Madhuri S Kurdi

Introduction: Choosing the correct Endotracheal Tube (ETT) size is important in paediatric anaesthesia. The subglottic diameter being the narrowest diameter of the paediatric upper airway plays an important role in appropriate ETT size selection. Aim: This study was planned to determine the accuracy of Ultrasonography (USG) to assess the appropriate ETT size and compare it with physical indices based formulae. The secondary outcome was to assess the number of times the tube was changed based on air leak test for USG estimated tube size. Materials and Methods: After ethical committee approval, a prospective clinical observational study for a period of one year was conducted on 75 children (power of study 80%, confidence interval 95%) aged one to 14 years of American Society of Anaesthesiologists Physical Status (ASA) I and II undergoing elective surgery under general anaesthesia with orotracheal intubation. Parental consent was obtained. Pre-anaesthetic ultrasonography was performed on every patient at the subglottic region. The tracheal subglottic diameter was estimated to select the ETT size for cuffed and uncuffed tubes. The size estimated by USG and that based on age and height based formulae were compared with clinically used appropriate tube size. Data analysis was done using IBM Statistical Package for the Social Sciences (SPSS) version 20.0; One-way Analysis of Variance (ANOVA) and t-test for comparison were used. Results: USG predicted the appropriate ETT size (p<0.05) better than physical indices based formulae for cuffed and uncuffed tubes. The age based formula predicted the clinically used ETT size well (p=0.58) and the height based formula did not correlate with clinically used tube size (p=0.0002 – a statistically significant value). Eight patients required change of tube once. Conclusion:Ultrasonographic estimation of subglottic diameter is useful for optimal paediatric ETT size selection. USG is effective in estimating the appropriate sized ETT both for cuffed and uncuffed tubes.

MRI Evaluation of Local Extent of Carcinoma Cervix – Is Post Contrast Imaging Needed in Every Case?

Introduction: Carcinoma cervix is widely prevalent among women in developing countries. Post contrast Magnetic Resonance Imaging (MRI) utilising spin echo T1 weighted sequence with fat suppression is widely practiced as part of evaluation of carcinoma cervix. However, it is unclear if such post contrast imaging provides any additional information other than adding to the cost of imaging. Aim: To find accuracy of T1 and T2 weighted non contrast MRI protocol in comparison with post contrast spin echo T1 weighted fat suppressed imaging in evaluating the local extent of the carcinoma cervix. Materials and Methods: A prospective study was conducted in the Department of Radiodiagnosis, JJM Medical College and Hospital, Davangere, Karnataka, India, between June 2016 and December 2016. A total of 45 females with a mean age of 50.7 years with biopsy proven cervical malignancy and predetermined clinical staging underwent MRI of pelvis. Prior to the scan, 10-15 ml of lignocaine jelly was instilled into the vagina. Sagittal T2 weighted images of the pelvis were acquired to identify the plane of the uterus and cervix. Axial and coronal imaging were planned perpendicular and parallel to the plane of cervix. Post contrast fat suppressed Spin Echo T1 weighted images were also obtained. Two radiologists evaluated the non contrast and contrast enhanced MR images of all patients separately. Interobserver variability and statistical significance was calculated. Results: There was 100% agreement between the two radiologists in interpreting non contrast scans and 91.1% interobserver agreement for post contrast images. Interruption of T2 hypointense cervical stroma with or without hyperintensity in adjacent parametrium, and interruption of the hypointense inner walls of urinary bladder and rectum could be more easily and reliably identified than the extension of enhancement outside the confines of the cervix. Four patients with a clinical staging of 1b and 2a who underwent surgery showed extension into parametrium on non contrast MRI image as well as peroperatively. In patients who had not underwent surgery, both the non contrast and post contrast MRI imaging findings were in agreement with each other. Twenty out of 45 cases showed pelvic nodes which were identified on both non contrast and post contrast images. Conclusion: Routine post contrast T1 weighted imaging pro-vides no added advantage in comparison with non contrast T1 and T2 weighted imaging in evaluation of carcinoma cervix and need not be acquired routinely. However, only in selective cases with ambiguity on non contrast images, dynamic post contrast imaging may be used as a problem solving tool.

Correlation of Vascular and Inflammatory Index in Oral Pyogenic Granuloma and Periapical Granuloma – An Insight into Pathogenesis

Introduction: Angiogenesis is vital in the aetiology and pathogenesis of a number of pathological processes that include solid reactive lesions like pyogenic granuloma and chronic inflammatory disorders like periapical granuloma. Vascular Endothelial Growth Factor (VEGF) is a potent proangiogenic cytokine secreted by many cell types which present several pivotal functions in physiologic and pathologic angiogenesis. Aim: The aim of the present study was to evaluate and compare the expression of VEGF in oral Pyogenic Granuloma (PG) and Periapical Granuloma (PAG) and also to correlate with the inflammatory cell infiltrate. Materials and Methods: Paraffin embedded tissue blocks of histologically diagnosed cases of PG and PAG, 20 of each were retrieved from the archives. The cases were selected randomly to evaluate the expression of VEGF marker and to assess the Mean Vascular Count (MVC) index and inflammation by Morphological Index (MI). The results were analysed using Unpaired t-test, Mann-Whitney U test and spearman correlation coefficient-test. Results: The PG showed higher expression of VEGF when compared to PAG with no significant difference in inflammation. PG showed positive correlation and PAG showed negative correlation between inflammation and VEGF expression. Conclusion: Histologically similar PG and PAG are different not only by their clinical presentation but also by their mechanisms of formation and molecular sketch. Thereby raised expression of VEGF marker was established in PG emphasizing the fact that all histologically similar lesions need not have similar clinical course and molecular depiction.

Occurrence of COPD in Patients with Respiratory Allergy: A Clinico-Spirometric Evaluation in a Tertiary Hospital Kolkata

Sujoy Mukherjee, Goutam Banerjee, Debajyoti Das, Anil Baran Singha Mahapatra

Introduction: Smoking is established as the most important causative factor responsible for Chronic Obstructive Pulmonary Disease (COPD). Occurrence of allergy in COPD patients causes acute exacerbation of this disease, but role of allergy is not established in aetiopathogenesis of COPD. Aim: The present study was aimed at evaluation of occurrence of COPD in patients having symptoms suggestive of respiratory allergy. Materials and Methods: An observational cross-sectional study was conducted to evaluate occurrence of COPD in patients having respiratory allergic symptoms by routine spirometric screening. Five hundred and fifty urban patients aged 18-60 years (both gender) ailing from chronic respiratory symptoms like cough, wheeze and Shortness Of Breath (SOB), who were referred from OPDs of RGKMCH, Kolkata, were included in this study. After obtaining detailed clinical profile, patients were divided into two groups: subjects having additional clinical symptoms suggestive of respiratory allergy (n=260) like nasal catarrh, nasal stuffiness and sneezing and subjects with no symptoms suggestive of respiratory allergy (n=290). Thereafter, routine spirometry was carried out following recommendations of ATS/ERS (2005). Patients were then categorized based on FVC, FEV1, FEV1/FVC, FEF25-75 and PEFR percent predicted values. Results: Study revealed that 18.97% of non-allergic population was suffering from COPD whereas only 7.69% of allergic subjects had COPD. This difference was statistically highly significant (p=0.0001). Although there was no significant difference in prevalence of respiratory symptoms between these two groups. Conclusion: Present study concludes that patients with respiratory allergy may have coexistent COPD but occurrence of COPD is much less than that in patients with no respiratory allergy.

Analysis of Isocitrate Dehydrogenase -2 (IDH-2) Activity in Human Serum as a Biomarker in Chemotherapy Patients of Breast Carcinoma: A Case-Control Study

Roshni Gavel, S.P.Mishra, Seema Khanna, Rahul Khanna, Agni Gautam Shah

Introduction: Breast cancer represents a major public health problem in women worldwide. For many cancers, serum tumour markers play an important role in patient treatment and monitoring. Isocitrate dehydrogenase enzyme is also used as a biomarker for various types of cancer. Aim: The purpose of this study was to determine serum Isocitrate dehydrogenase-2 (IDH-2) enzyme activity in breast cancer patients (pre and post chemotherapy) and also correlate the changes in enzyme activity with stages of cancer and control groups. Materials and Methods: In this case-control study, histologically confirmed 40 female patients aged 28-80 years who fulfilled the criteria for diagnosis of invasive breast cancer were selected in our study groups from surgery outpatient department of SS Hospital, BHU, Varanasi, India, and 40 healthy age matched females were selected between October 2013 to July 2015. The estimation of serum IDH-2 enzyme activity in before and after two cycles of neoadjuvant chemotherapy patients was performed by spectrophotometry assay. Results: The mean serum IDH-2 activity in cases (Mean±SD) was significantly more than control group (p<0.001). The mean serum IDH-2 activity in cases was significantly decrease after neo-adjuvant chemotherapy (p=0.019). In stage II pre chemotherapy patients serum IDH-2 activity was higher than post chemotherapy (p<0.05), but in stage III the correlation between pre and post chemotherapy patients serum IDH-2 activity was not significant (p-value>0.05). Conclusion: The serum IDH-2 can be a potential biomarker in breast carcinoma and can be used for prognosis and monitoring the chemotherapy response of the patients.

Molecular Strain Typing of Clinical Isolates, Trichophyton rubrum using Non Transcribed Spacer (NTS) Region as a Molecular Marker

Introduction: Dermatophytes are a group of fungi which infect keratinized tissues and causes superficial mycoses in humans and animals. The group comprises of three major genera, Trichophyton, Microsporum and Epidermophyton. Among them Trichophyton rubrum is a predominant anthrophophilic fungi which causes chronic infections. Although, the infection is superficial and treatable, reinfection/coinfection causes inflation in the treatment cost. Identifying the source and mode of transmission is essential to prevent its transmission. Accurate discrimination is required to understand the clinical (relapse or reinfection) and epidemiological implications of the genetic heterogeneity of this species. Polymorphism in the Non Transcribed Spacer (NTS) region of ribosomal DNA (rDNA) clusters renders an effective way to discriminate strains among T. rubrum. Aim: To carry out the strain typing of the clinical isolates, Trichophyton rubrum using NTS as a molecular marker. Materials and Methods: Seventy T. rubrum clinical isolates obtained from April-2011-March 2013, from Sri Ramachandra Medical Centre, Chennai, Tamil Nadu, India, were identified by conventional phenotypic methods and included in this prospective study. The isolates were then subjected to Polymerase Chain Reaction (PCR) targeting two subrepeat elements (SREs), TRS-1 and TRS-2 of the NTS region. Results: Strain-specific polymorphism was observed in both subrepeat loci. Total, nine different strains were obtained on combining both TRS-1 and TRS-2, SREs. Conclusion: The outcome has given a strong representation for using NTS region amplification in discriminating the T. rubrum clinical isolates. The method can be adapted as a tool for conducting epidemiology and population based study in T. rubrum infections. This will help in future exploration of the epidemiology of T. rubrum.

A Stratified Analysis of Clinical Manifestations and Different Diagnostic Methods of Neurocysticercosis- Suspected Tamilian Population Residing in and Around Puducherry

Introduction: Human beings are accidental hosts for Cysticercus cellulosae showing varied clinical manifestations based on the site harbored by the parasitic cyst because of which disease profile remains unexplored at large. Besides this, diagnosis of the disease with a single conventional method is problematic due to lack of specificity and sensitivity. Aim: To assess the varied clinical manifestations and stratify based on imaging and serological methods for diagnosis of Neurocysticercosis (NCC) in our study population. Materials and Methods: A hospital-based study was carried out at Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), the tertiary care centre caters patients from Puducherry and surrounding regions of Tamil Nadu. This is a cross-sectional analysis of clinically and radiologically suspected cases of NCC (n=119) for a period of three years (2012 to 2015). The collection of detailed clinical history and imaging findings (MRI or CT) along with the lifestyle parameters was done after obtaining informed consent. Enzyme-Linked Immune-Electro Transfer Blot (EITB) was carried out for the samples collected from study subjects. Results: Based on dietary and environmental factors non-vegetarians, pork eaters, raw vegetable consumers and open-field defecation showed significant seropositivity. The clinical manifestations like seizures, blurring of vision and chronic headache with nausea followed by neck pain, cognitive deficits and movement disorder have higher seropositivity respectively. Generalized seizures were found to be more than focal seizures. While comparing the imaging and serological tests for NCC diagnosis, the positivity rate was 46.2% considering positive by both methods; but 18.5% of sero-positive cases were imaging negative, and 16% of the sero-negative cases were imaging positive. The study showed a predominance of multiple cysts (62%) in cases with cystic lesions. Conclusion: This study is first of its kind in associating varied and less commonly explored clinical manifestations with two different diagnostic measures in practice and its importance among our study settings. These manifestations must be considered as strong disease entities of NCC, which has to be suggested for differential diagnosis, and cannot be left ignored. Combinatorial diagnostic methods like serology and imaging techniques should be followed in diagnosis and assessing the disease burden.

Is the Cage an Additional Hardware in Lumbar Interbody Fusion for Low Grade Spondylolisthesis? A Prospective Study

Introduction: Lumbar interbody fusion has become the standard of care for the management of lumbar instability, where fusion is achieved using bone grafts, cages, etc. Aim: The aim of the study was to compare the outcomes of the interbody fusion using interbody cage technique and stand alone local bone graft technique. Materials and Methods: A total of 30 patients, operated for single level instability with low grade lytic and degenerative spondylolisthesis of L4-5/L5-S1, were selected and grouped into two groups: Group I (stand alone grafts) and Group II (interbody cage and graft) based on computer generated random numbers. All patients who underwent interbody fusion through conventional open posterior approach were included in the study. Data regarding the time taken for interbody fusion, formaninal height maintenance, disc height restoration, translation, functional scores (VAS,ODI) and operative complications were analysed using in both the groups was collected and a students-t test was performed to evaluate the difference. Results: The mean age of patients in Group I was 46.7 years whereas, the mean age of patients in Group II was 43.5 years with mean age of 46.7 years and 43.5 years respectively. Interbody fusion, was achieved in seven and eight months in Group I and II respectively (p>0.05). The clinical results of both groups were comparable and there was no significant difference between the two groups in VAS score (p-0.147) and ODI score (p-0.983). Radiological parameters were also comparable and there was no significant difference between the postoperative measurements of the two groups (p=0.348 for translation, p=0.310 for intervertebral disc height and p=0.135 for foraminal height). One patient in Group I had transient foot drop which recovered, while one in Group II had infection, wound was managed with wound wash and antibiotics and another patient in Group II had pseudoarthrosis. Conclusion:Lumbar interbody fusion with standalone local bone grafts is sufficient in single level low grade spondylolisthesis treated by conventional open surgery.

Detection and Differentiation of Focal Intracranial Calcifications and Chronic Microbleeds Using MRI

Rajiv Azad, Priyanka Mittal, Ankur Malhotra, Sharad Gangrade

Introduction: Differentiating calcification from chronic micro-bleeds on imaging may have important clinical implications. Aim: The present study aimed to evaluate the role and relative advantages of Magnetic Resonance Imaging (MRI) in the detection and differentiation of intracranial calcifications and chronic microbleeds. Materials and Methods: The retrospective study comprised of 100 patients having either intracranial calcifications or microhaemorrhages selected on the basis of Computerized Tomography (CT) and MRI using predefined criteria. Two independent blinded observers evaluated the images qualitatively and quantitatively. Single pixel values were taken in the circular Region of Interest (ROI) on magnitude SWI, phase Susceptibility Weighted Imaging (SWI) and Diffusion Weighted Imaging (DWI) for quantitative analysis. Results: Fifty patients with 76 focal calcifications and another 50 patients with 245 chronic microbleeds formed part of the study. Overall sensitivity of SWI in detection of calcification was 93.9% with good inter observer agreeability (k= 0.7) on phase SWI. All the chronic microbleeds were seen on SWI but there was only moderate inter observer agreeability in evaluation of signal on phase component (k= 0.5). Average pixel values of calcifications and chronic microbleeds were -312.5±187 SD and 541.9±301.7 SD respectively on phase SWI, (p=0.0001, <0.05). Conclusion: SWI can play a pivotal role in the detection of intracranial calcifications and chronic microbleeds and resolving the ambiguity in their diagnosis.

Evaluation of Histologically and Histochemically Proven Cases of Vitiligo and its Correlation with CD4+ and CD8+ Lymphocyte Counts using Flow Cytometry

Moninder Kaur, Permeet Kaur Bagga, Tejinder Kaur, Amarjit Singh

Introduction: Vitiligo is an acquired cutaneous disorder characterized by progressive and selective destruction of melanocytes from the epidermis. Autoimmunity is strongly implicated in its pathogenesis. The destruction of melanocytes has a correlation with the peripheral blood lymphocyte imbalance mainly including Cytotoxic T cells (CD8+cells) and Helper T cells (CD4+cells). The progression of vitiligo is associated with higher CD8+ counts and lower CD4+ counts thus, altering CD4+: CD8+ ratio. Aim: To evaluate the clinically suspected cases of vitiligo histopathologically and histochemically and to establish the co-relation of autoimmunity with the flow cytometric analysis of CD8+ and CD4+ lymphocyte counts. Materials and Methods: In this study, 40 patients with proven vitiligo were taken. The destruction of melanocytes was confirmed by Haematoxylin & Eosin (H & E) and by histochemical stains using Dihydroxyphenylacetic Acid (DOPA) reaction. Blood sample from these vitiligo patients and 10 control subjects was taken. Flow Cytometry was used for the determination of CD8+ and CD4+ counts in the vitiligo patients and control subjects. Then CD4+: CD8+ ratio was calculated and comparison between vitiligo patients and control subjects was done. T-test was used for the statistical analysis. Results: There was statistically significant decrease in CD4+: CD8+ ratio. CD4+: CD8+ ratio was decreased in 57.5% cases of vitiligo with increase in CD8+ counts and decreased CD4+ counts. Conclusion: It was concluded from this study that cellular immunity might have a role to play in the pathogenesis of vitiligo causing the destruction of melanocytes.

Factors Influencing Nursing Students’ Clinical Judgment: A Qualitative Directed Content Analysis in an Iranian Context

Moluk Pouralizadeh, Hamidreza Khankeh, Abbas Ebadi, Asghar Dalvandi

Introduction: Clinical judgment is necessary for clinical decision making and enhancing it in nursing students improves health care quality. Since clinical judgment is an interactive phenomenon and dependent on context and culture, it can be affected by many different factors. Aim: To understand the experiences of Iranian nursing students and teachers about the factors influencing nursing students’ clinical judgment. Materials and Methods: A qualitative study was conducted using a directed content analysis approach. In this study, purposive sampling and semi-structured interviews were applied with seven nursing students, six faculty member teachers and four clinical instructors from Guilan University of Medical Sciences, Gilan, Iran. Results: The factors influencing nursing students’ clinical judgment consisted of five main categories including thoughtful behaviour, professional ethics, use of evidence based care, the context of learning environment and individual and professional features of clinical teachers. Conclusion: Relying on the results of this research, teachers can create an appropriate educational condition and a safe psychological atmosphere, use instructional strategies strengthening deep thought processes, applying professional ethics and scientific evidence and principles to establish clinical judgment in nursing students.

Prevalence of Non Alcoholic Fatty Liver Disease and its Association with Diabetic Nephropathy in Patients with Type 2 Diabetes Mellitus

Zahra Heidari, Atiyeh Gharebaghi

Introduction: Non Alcoholic Fatty Liver Disease (NAFLD) and Type 2 Diabetes Mellitus (T2DM) are two common problems affecting global health as these two conditions can influence each other. There is very little information about the possible association between NAFLD and diabetic microvascular complications such as diabetic nephropathy. Aim: The aim of this study was to evaluate the prevalence of NAFLD in patients with T2DM and to investigate the association between NAFLD and diabetic nephropathy in these patients. Materials and Methods: This cross-sectional study was conducted on 255 patients with T2DM, with minimum age being 30 years. Hepatic ultrasonography using a 3.5 MHz probe was performed in all subjects. Fatty liver based on standard criteria was diagnosed with liver brightness, contrast between the echogenicity of the liver, kidneys and the blood vessels fading rate. Screening for microalbuminuria was performed by the preferred method, measurement of the Urine Albumin-To-Creatinine (UACR) ratio in a random spot collection. Results: In this study, 255 patients with T2DM were enrolled of which 173 (68%) were females and 82 (32%) were males. Of these 221 subjects (86.66%) had NAFLD. Diabetic nephropathy was observed among 33% of individuals, microalbuminuria among 32% and macroalbuminuria in 10% of all individuals. Duration of diabetes, Body Mass Index (BMI), hypertriglyceridemia, and HbA1c were significantly associated with incidence of NAFLD. Also, duration of diabetes and HbA1c were significantly associated with diabetic nephropathy in patients with T2DM. Conclusion: NAFLD in patients with T2DM is extremely common. NAFLD is not considered as a risk factor for diabetic nephropathy. To better understand the pathogenesis of NAFLD and its causal relationship with complications of diabetes such as diabetic nephropathy, prospective studies and long term follow up are needed.

Recurrent Optic Nerve Pilocytic Astrocytoma: A Rare Case

Pilocytic astrocytoma is a low grade glioma that affects mostly children and young adults and can occur anywhere in the central nervous system. Pilocytic astrocytoma of the optic nerve is an equally indolent subtype that is often associated with Neurofibromatosis Type I (NFI). A 40-year-old male presented with left sided axial proptosis and exposure keratopathy. MRI revealed a mass in left proximal orbit, extending posteriorly abutting the chiasma and the right optic nerve on MRI. Enucleation of the left eye along with near total excision of intracranial part of the mass was performed. Histopathology report was suggestive of pilocytic astrocytoma (WHO Grade I). Interestingly, his records showed evidence of surgery for removal of the optic nerve pilocytic astrocytoma twice (27 years and six years ago). We hereby, present an unusual case of recurrent pilocytic astrocytoma of the optic nerve in absence of NFI.

Accuracy of Diffusion Weighted Images and MR Spectroscopy in Prostate Lesions – Our Experience with Endorectal Coil on 1.5 T MRI

Devimeenal Jagannathan, Venkatraman Indiran

Introduction: Prostatic cancer is most commonly seen in individuals greater than 65 years of age. The incidence rates are constantly increasing. Aim: To assess the accuracy of the non-contrast sequences {Diffusion Weighted Imaging (DWI) and Magnetic Resonance Spectroscopy (MRS)} in the multiparametric Magnetic Resonance Imaging (mp-MRI) in identifying and differentiating benign and malignant prostate lesions using endorectal coil on 1.5 T MRI. Materials and Methods: Twenty-six patients with clinical indications for prostate lesions were evaluated using endorectal coil on 1.5 T MRI. DWI and MRS were obtained in all the lesions. Signal change on T2 weighted images, Apparent Diffusion Coefficient (ADC) values and choline + creatinine to citrate ratios (Cho+Cr/ Ci) of the lesions were obtained for all the patients. All the patients underwent Transrectal Ultrasound (TRUS) guided biopsy within one week of MRI study. Signal change on T2 weighted images, DWI and Cho+Cr/ Ci ratios were correlated with the histopathological findings using appropriate statistical analysis (Wilson score). Results: Of the 26 patients, seven had benign pathology and 19 had malignant pathology on the histopathological examination. Sensitivity and specificity (89.5% and 85.7% respectively) of the diagnosis of malignancy based on DWI were quite good. Positive and negative predictive values were also very much acceptable (94.4% and 75% respectively). Though, MRS had good sensitivity and Positive Predictive Value (PPV) (84.2% and 76.2% respectively), specificity and Negative Predictive Value (NPV) were poor (28.6% and 40% respectively). Accuracy of imaging diagnosis based on combining T2, DWI and MRS was same as that of results based on T2 signal alone (80.8%) and had higher sensitivity and lower specificity than DWI alone (94.7% and 42.9% respectively). Receiver Operating Characteristic (ROC) curves were calculated for ADC values and Cho+Cr/ Ci ratios. The Area Under the Curve (AUC) for ADC is 0.74 and for Cho+Cr/Ci is 0.70. Conclusion: Comparing the accuracy of the non-contrast sequences T2, DWI and MRS in identifying and differentiating benign and malignant lesions, giving weightage to the MRS in mp–MRI reduces the negative predictive value. The diagnosis of malignancy based on diffusion restriction was quite good and it can be the workhorse for prostate cancer detection as a shortened mp-MRI.

Smartphone, the New Learning Aid amongst Medical Students

Monika Y. Gavali, Deepak S. Khismatrao, Yogesh V Gavali, K.B. Patil

Introduction: The use of smartphone is increasing day by day for personal as well as professional purpose. They are becoming a more suitable tool for advancing education in developing countries. Mobile access to information and many applications are successfully harnessed in health care. Smartphones are also becoming popular as an effective educational tool. Aim: The present study was conducted to evaluate the use of smartphones as an educational tool amongst the medical students. The study also aimed at identifying the common medical application used by the students. Materials and Methods: It was an observational cross-sectional study carried out amongst medical students of private medical institute in India. A validated 16 point, structured, open-ended, questionnaire regarding ownership and use of smart phones was self-administered to 446 medical students. Data were analysed using SPSS and open ended questions were analysed by summative content analysis. Results: Among the study population, 96% owned a smartphone -Android based 72.4%, i phone 13.0%, Windows based Nokia phones 7% and Blackberry 3.6%. Common medical applications used by the students were Anatomy and Medical Dictionary in First MBBS; Medical Dictionary, Medscape and Google/Wikipedia in Second MBBS; and Medscape, Google/Wikipedia and Prognosis/Diagnosis in Third MBBS. More than 90% students, reported to have technological skills to use smartphones, for medical education, communication and instant access during bedside teaching. Advertently, 37.2% students felt if smartphones are used for clinical purposes, they will need to spend less time with patients. Almost 79.4% felt that smartphones should be introduced in MBBS course. Conclusion: Smartphone use amongst medical students as learning aid for various medical applications is rapidly advancing. But it will be worthwhile to study whether use of smartphones has any impact on the grades of the students before introducing them in medical schools.

Prevalence of Lung Lesions at Autopsy: A Histopathological Study

Introduction: Autopsies are carried out to establish the identity, cause of death, time of death, and ante-mortem or post-mortem nature of death. These help in establishing the cause of death and ascertain the disease process which led to death. Aim: To study the prevalence and pattern of lung diseases in medicolegal autopsies, confirmed by histopathological examination. Materials and Methods: This retrospective study was carried out in the Department of Pathology. Tissue bits from lungs, retrieved at the time of autopsy, were preserved in 10% formalin. These were processed and examined microscopically. A total of 86 cases were received during the period of study. Results: Among these 86 cases, in 4 cases (4.8%) the tissue was autolysed and in another 26 cases (30.1%) histopathology was unremarkable. Significant microscopic findings were found in 56 cases (65.1%). Wide spectrum of microscopic findings were seen, the commonest being oedema and congestion (28.5%) followed by changes in interstitium (11.9%). There were 9.5% cases of granulomatous inflammation and 5.9% cases each of acute pneumonia and emphysema. There were 1.2% cases each of Hyaline Membrane Disease (HMD), Meconium Aspiration Syndrome (MAS) and Acute Respiratory Distress Syndrome (ARDS) in the series. The series also had 1.2% cases of young adult having fungal colonies surrounded by necrosis and abscess formation. Possibility of mucormycosis was suggested in that case. Conclusion: This study highlights various lesions in lungs confirmed by histopathology, which were either incidental or direct cause of death. The short coming in present study was non receipt of whole organ or representative sample at the time of autopsy, which if overcome will set much higher standard of autopsy reporting and would be a more useful tool in understanding cause of death.

Effect of Recumbent Body Positions on Dynamic Lung Function Parameters in Healthy Young Subjects

Arvind Kumar Pal, Sunita Tiwari, Dileep Kumar Verma

Introduction: The change in body position can alter pulmonary functions parameters, therefore it is important to understand the physiological basis of these alteration. Ideally, spirometry is done in sitting position until the subject is unable to do so. Hospitalized patients often assume recumbent body positions irrespective of underlying pathology. Hence, need arises to find out best recumbent body positions for the benefit of these patients to make breathing comfortable for them. Aim: The aim of this study was to find out whether the change from the supine position to crook lying and Fowler’s position (45° dorsal elevation) causes change in spirometric parameters. Materials and Methods: The present work was carried out at Department of Physiology, King Georges Medical University, Lucknow. A total 131 apparently healthy individuals were enrolled in this cross-sectional study. Lung function was assessed using a PC-based spirometer according to American Thoracic Society guideline in the supine, crook lying and Fowler’s position (450 dorsal elevation). Results: The study consisted of 131 subjects (male 66%, female 34%), with mean age of 20.15±2.71 years and BMI 21.20±3.28 Kg/m2. Repeated measures ANOVA with post hoc Bonferroni test was used to compare the mean values between each body position. Compared with the other two positions, Fowler’s position showed significantly (p<0.05) higher values for FVC, FEV1, PEF, FEF 25-75%. Conclusion: Recumbent body position influences spirometric parameters in young healthy subjects. We demonstrated that spirometric values are higher in the Fowler’s position than in the supine or crook lying position. The results of this study will help in the selection of the best alternative position for the spirometry in bed ridden patients.

Uncovering Metabolic Syndrome among Chronic Obstructive Pulmonary Disease Patients in a Tertiary Care Hospital, India

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is known to cause various systemic problems including Metabolic Syndrome (MetS). MetS is a group of cardiovascular risk factors. By assessing MetS, one can assess the cardiovascular disease risk. There is increasing evidence of MetS in COPD patients. However, the frequency of MetS and its individual components are not still been clearly shown which is likely to vary in different population. Aim: To know the extent of association of metabolic syndrome and its components in patients with COPD. Materials and Methods: This study was designed as an analytical case control study. Ninety cases of COPD satisfying the inclusion criteria and 45 healthy volunteer subjects as controls were recruited over 18 months duration. Simple random sampling method was used to select all cases attending outdoor and indoor medicine department. All subjects (cases and controls) were matched for age, sex, occupation and socioeconomic status. Prior to participation in the study, written informed consent was taken from all subjects. All included subjects underwent a detailed history, clinical examination and laboratorial analysis. All subjects were assessed for MetS by using National Cholesterol Education Program-Third Adult Treatment Panel (NCEP ATP III) and International Diabetic Federation (IDF) criteria. Results: The present study demonstrated Metabolic Syndrome (MetS) in COPD according to NCEP ATP III and IDF criteria as 14 (15.56%) and 30 (33.33%) while there was no association of MetS with controls. The frequency of its component such as abdominal obesity, systolic blood pressure, diastolic blood pressure, elevated triglyceride, reduced HDL-C and elevated fasting glucose respectively was 71 (78.89%), 25 (26.67%), 12 (13.33%), 18 (20%), 23 (25.56%) and 17 (18.78%) respectively. Dyslipidemia was found in 36 (40%) cases of COPD including 16 (17.78%) cases of elevated LDL cholesterol. Conclusion: Our study concluded that MetS is frequent in COPD patients as compared to general population. Therefore, a comprehensive medical approach to screen all COPD patients for MetS should be done there to lower the significant risk of cardiovascular events in patients with COPD.

Clinicopathological Study of Carcinoma of the Ampulla of Vater with Special Reference to MUC1, MUC2 and MUC5AC Expression

Introduction: The ampulla of Vater consists of papilla, common channel, distal common bile duct and the distal main pancreatic duct. Ampullary carcinomas arise from two different types of mucosa, reflecting their broad histomorphological spectrum. Adenocarcinomas originating in the ampulla of Vater are classified as having either ‘Intestinal’ or ‘pancreatobiliary’ type of differentiation. Pancreatobiliary type has consistently shown a worse prognosis. Various types of mucins are distributed in normal tissues and gastrointestinal tumours. MUC1, MUC2 and MUC5AC are known to be the most important amongst all. Aim: To study clinicopathological features of different types of carcinoma of ampulla with MUC1, MUC2 and MUC5AC expression. Materials and Methods: We included 20 cases of ampullary adenocarcinoma in this study, diagnosed after radical surgery. The histopathological slides were reviewed and the tumours were classified into intestinal type, pancreatobilliary and other types. Representative block of tumours was subjected to immunohistochemical (IHC) study with MUC1, MUC2 and MUC5AC antibodies. Results were subsequently analysed. Results: Pancreaticobiliary type of ampullary carcinoma cases predominated (50%) over intestinal type (25%). Carcinomas of “other types” included one case each of mucinous carcinoma, adenosquamous carcinoma and undifferentiated carcinoma and well differentiated neuroendocrine tumours. Pancreatobiliary type of carcinomas was associated with higher tumour stage and grade and lymph node metastasis. All the pancreatobiliary type expressed MUC1 and all intestinal type carcinomas expressed MUC2. MUC 5AC expression was seen predominantly in pancreatobiliary type of ampullary carcinomas. Conclusion: Mucin markers are associated with two different subtypes of ampullary carcinomas which have different prognosis. Immunohistochemical study of mucin expression can define the different types of carcinomas of ampulla of Vater with better objective criteria.

Reliability of the Infraspinatus Test in Carpal Tunnel Syndrome: A Clinical Study

Marek A. Meder, Florian Amtage, Ruediger Lange, Michel Rijntjes

Introduction: Recently, a standardized provocation tests for the infraspinatus muscle, the Infraspinatus test (IsT), aimed at clinically confirming Carpal Tunnel Syndrome (CTS), was validated in a multiple-blind, controlled study. Aim: The present study was conducted to investigate inter-rater reliability of the IsT under conditions as they occur in daily clinical practice, since this is essential for acceptance of any new test. Materials and Methods: Two raters from different medical disciplines used the IsT in the same group of subjects at different localities and with an interval of two to four weeks. Arms with symptoms of CTS were examined and compared with a control group of arms without symptoms. Nerve conduction studies were performed in all the subjects. Statistical analysis was performed with Cohens Kappa (for inter-rater reliability) and McNemars test (for determining dependencies between arms and raters). Results: A total of 34 subjects (age 35-86 years) were investigated with the IsT by two raters in a blinded fashion. There was a high agreement between raters with a Kappa statistic of ?=0.868, when performing this new provocation test. The McNemar test did not reveal dependencies between Rater A and Rater B (p=0.6171), nor between the left and right arms of subjects (Rater A: p=0.4533, Rater B: p=0.5023). Conclusion: The new provocation test of the infraspinatus muscle is not only capable of confirming CTS, as was shown before, but is also a reliable method for use by different examiners under customary conditions.

Diabetes Mellitus in Thalassaemia Major Patients: A Report from the Southeast of Iran

Introduction: Diabetes Mellitus (DM) represents a major concern in Thalassaemia Major (TM) patients. Aim: The present study was conducted to evaluate the frequency of Impaired Fasting Glucose (IFG) and DM in TM patients in Southeast of Iran. Materials and Methods: Fasting Blood Glucose (FBS) was determined using fasting blood samples in 148 TM patients. Demographical data was collected by a questionnaire. Clinical and laboratory variables including cell blood counts, pre-transfusion Haemoglobin (Hb) level, and five-year ferritin were extracted from medical records. Statistical analysis was performed in SPSS19.0 software using chi-square, student t-test and logistic regression. Results: Females and males comprised 83 (56.1%) and 65 (43.9%) subjects respectively. The mean age and mean five-year ferritin were 17.3±6.1 year-old and 5060.6±2395 ng/ml respectively. Overall, 39 (26.4%) patients had IFG, while 13 (8.8%) were diagnosed with DM. Significant differences were identified in the mean age, volume of transfused blood per occasion, and mean five-years ferritin between the patients with IFG or DM and the patients with normal fasting glucose level. Patients with age >25-year-old had an increased risk of both IFG (OR=4.7,95% CI: 1.3-17, p=0.01) and DM (OR= 7.1, 95% CI: 1-49.2, p=0.04). In addition, splenectomized patients showed a higher risk for IFG (OR=4.3, 95% CI: 1.5-12.1, p=0.005), and ferritin value >6000 ng/ml were associated with an elevated risk of DM (OR=7, 95% CI: 0.8-60.1, p=0.07). Conclusion: Our results indicated that higher age, mean five-years ferritin, volume of blood transfused per occasion, as well as splenectomy were risk factors of IFG and DM in TM patients.

Erythrocytes and Platelets: A Critical Analysis of their Ontogenic Relationship through Automated Parameters

Deepak Kumar, Padmapriya Kasukurti, Srinivasa Murthy

Introduction: Erythrocytes and platelets share an intimate development history, due to which special interest is centered on their relationship. Mature Red Blood Cells (RBCs) and platelets show a similar physiological rhythm, and are concurrently involved in numerous pathologic states. Aim: To identify subtle relationships between various RBC and platelet parameters with an objective to analyse if a linear correlation co-exists between and among them in physiological/pathological states. Materials and Methods: A prospective analysis of 1250 EDTA blood samples was conducted. The five RBC parameters (RBC count, HCT, MCV, RDW, Hb) and four platelet parameters (platelet count, PCT, MPV, PDW) obtained from each case were statistically analysed for linear dependence. Results: A statistically significant direct linear relationship was found between RDW with platelet count and PCT. A statistically significant inverse linear relationship was noticed between the following parameters: i) HCT with platelet count and PCT; ii) MCV with platelet count and PCT; iii) Haemoglobin and platelet count. Conclusion: A linear correlation, either direct or inverse, was seen among various parallel RBC and platelet parameters.

Does Change in Thread Shape Influence the Pull Out Strength of Mini Implants? An In vitro Study

Aniruddh V. Yashwant, S. Dilip, R. Krishnaraj, K. Rav Ravi

Introduction: Mini implants form a valuable source for absolute anchorage thereby helping in achieving ideal treatment outcome. Stability of the mini implant is one of the important factors affecting the success of mini implants. Thread shape is a critical factor in the engineering design of mini implant, which affects the primary stability. Aim: To evaluate the effects of thread shape on the pull out strength of mini implants. Materials and Methods: Mini implants of five different designs in thread shape (reverse buttress, buttress, 750 joint profile with flutes, trapezoidal and trapezoidal fluted) were used with 10 screws in each group. The mini implants were loaded on to the polyurethane foam block (Sawbones pacific research lab, USA) perpendicular to the surface and the pull out strength was tested using the Instrom testing machine. The control group consisted of mini implants with reverse buttress thread shape. One-way ANOVA and Tukey post-hoc tests were used to compare the pull out strength of the mini implants within as well as between the different groups. Results: The mean in the pull out tests ranged from 13.45 N (trapezoidal) to 61 N (trapezoidal fluted). The tukey post-hoc tests showed a statistically significant difference of 34.5 N between the control group and the trapezoidal fluted group. The level of statistical significance showed p< 0.05 Conclusion: Trapezoidal fluted mini implants showed the highest pull out strength when compared to mini implants with other thread designs used in this study. Further studies with the use of Finite Element Method (FEM) and foam blocks of higher density would be required to evaluate the performance of this new thread design.

Attenuation of Haemodynamic Parameters in Response to Pneumoperitoneum during Laparoscopic Cholecystectomy: A Randomized Controlled Trial Comparing Infusions of Propofol and Dexmedetomidine

Meyong Pincho Bhutia, Arati Rai

Introduction: Effective control of sympathetic response to pneumoperitoneum is vital to avoid morbidity in patients undergoing laparoscopic surgeries. This control must be achieved without any side effects of the drugs being used as well as ensuring a raid recovery from anaesthesia in order to maximise operation theatre utility. Aim: To study the effectiveness of dexmedetomidine in attenuating the haemodynamic response to pneumoperitoneum during laparoscopic cholecystectomy (using only the maintenance dose) with that of propofol and compare time to extubation, haemodynamics on extubation, sedation score after extubation and any incidence of side effects between the two study drug. Materials and Methods: Sixty American Society of Anaesthesiologist (ASA) I and II patients undergoing laparoscopic cholecystectomy between age of 20-60 years were randomly divided into two groups of 30 patients each: Group D to receive dexmedetomidine in dose of 0.2-0.7 µg/kg/hr titrated as per clinical response and Group P to receive propofol in dose of 25-75 µg/kg/min (1.5-4.5 mg/kg/hr) titrated as per clinical response after standard anaesthetic induction. Data recording was done for changes in haemodynamic parameters, time to extubation and post extubation sedation score. Statistical analysis was done using students-test and Chi-square test with p-value of< 0.05 was considered significant. Results: Attenuation of haemodynamic parameters by dexmedetomidine during the intraoperative period even without the loading dose was comparable to that by propofol (p-value >0.05). Time to extubation was similar in both the groups (p-value >0.05). Haemodynamics on extubation was better controlled in dexmedetomidine group (p-value <0.05) while the sedation score was better in propofol group (p-value <0.05). Mean dose of dexmedetomidine and propofol used were 0.504±0.09 µg/kg/hr and 3.19±0.7 mg/kg/hr respectively. Conclusion: Dexmedetomidine in a dose of 0.2-0.7 µg/kg/hr provides a stable haemodynamics without any side effects in patients undergoing laparoscopic cholecystectomy.

The Status of Knowledge Related to the Emergency Management of Avulsed Tooth amongst the Medical Practitioners of Nagpur, Central India

Introduction: Tooth avulsion is a frequently reported traumatic injury amongst young children and whenever it occurs, the parents or teachers of those children often seek the help of Medical Practitioners to provide the first line of treatment. Therefore, the general physician’s knowledge regarding the same is an important issue to be taken into consideration. Aim: To assess the knowledge, attitude and practice of general medical practitioners of Nagpur city of Central India regarding emergency management of avulsed tooth and highlight the importance of avulsed tooth education in schools and medical colleges in order to increase the knowledge of the same among teachers, parents and general physicians. Materials and Methods: A cross-sectional survey was carried out amongst 1045 medical doctors after a comprehensive search made in Google database using the keywords ”Medical”, “doctors” “Nagpur”. Data regarding the emergency management of avulsed tooth was collected using a self administered close ended questionnaire. Results: A total of 1045 medical practitioners (718 males, 327 females) voluntarily participated in this survey. It was observed that 56.8% of the medical practitioners had no prior knowledge of management of an avulsed tooth. A 81.6% of practitioners were unaware of transport medium for an avulsed tooth whereas, more than half practitioners (64.7%) were naive about an ideal time for replantation of an avulsed tooth. A little more than one third of the practitioners (26.5%) were unacquainted about the method of holding an avulsed tooth. Conclusion: Regardless of the level of education, the general medical practitioners of Nagpur lack most of the knowledge required for the emergency management of an avulsed teeth. Keeping the in mind the present scenario, it was recommended that education regarding avulsed tooth should be incorporated in school and medical curriculum to increase awareness among parents, teachers and medical practitioners. Also, it is the responsibility of the dentist to make the society aware of this situation.

Clinical Outcome of Treatment of Diaphyseal Fractures of Humerus Treated by Titanium Elastic Nails in Adult Age Group

Introduction: Humerus shaft fracture is one of the most common injuries to the musculoskeletal system, which are managed both conservatively and surgically. There are pitfalls, advantages and disadvantages in each method. The individual fracture analysis determines the therapeutic options. Aim: To assess the clinical outcome of treatment of diaphyseal fractures of humerus treated by Titanium elastic nail in adult age group by DASH scoring. Materials and Methods: It was a prospective study of 20 cases of diaphyseal fracture of humerus admitted to Era’s Lucknow Medical College and Hospital between October 2014 and September 2015 treated with close reduction and internal fixation with titanium elastic nail. Functional outcome was evaluated using DASH scoring system and radiological outcome was evaluated by serial radiographs. The data was processed with SPSS software version 16.0 (Chicago, inc. USA) and it was summarized in proportion and percentage. Results: In our series of 20 patients, 17 were males and three were females. Most of the patients were between 30-50 years of age (mean 38 years). Most common mode of injury, side of involvement, level of fracture and fracture type were road traffic accidents (60%), right side (53.3%) and mid one third (75%), transverse (60%) respectively. So, in 65% of the patients, there was no disability of arm shoulder and hand as DASH score was within normal range and in 15% of the patients the disability was mild to moderate as scoring was slightly higher than normal and in 20% the disability was severe as the DASH score could not be calculated because of non union. Conclusion: Elastic nail fixation require very minimal soft tissue dissection and being a close reduction, the biology of the fracture is also not disturbed and the chances of nerve injury are much less and as the non union was seen in oblique and spiral fracture type hence it should be used with caution or else other alternative methods of fixation should be used.

Evaluation of Impact of Pregnancy on Oral Health Status and Oral Health Related Quality of Life among Women of Kashmir Valley- ARTICLE RETRACTED

Aasim Farooq Shah, Manu Batra, Ambrina Qureshi

Aasim Farooq Shah, Manu Batra, Ambrina Qureshi, Evaluation of Impact of Pregnancy on Oral Health Status and Oral Health Related Quality of Life among Women of Kashmir Valley (Published in Journal of Cilinical and Diagnostic Research. 2017 May: 11(5):). ZC01–ZC04 The article had to be retracted because of an error in the data. This was brought to the editorial notice, post-publication, by the authors. Due to this error, the complete analysis stands out to be wrong.

Scintigraphic Profile of Thyrotoxicosis Patients and Correlation with Biochemical and Sonological Findings

Anil Kumar AVS, Abhish Mohan, PG Kumar, Papankaj Puri

Introduction: Thyrotoxicosis is a spectrum of disorder with a rather common clinical presentation with different aetiologies. The aetiological diagnosis is important as the management differs. It is essential to accurately diagnose the cause before starting treatment. Scintigraphy of thyroid helps in differentiating accurately the various causes. USG is routinely being advocated and T3/T4 ratio has also been used. Aim: This study aims to evaluate the scintigraphic profile of thyrotoxicosis patients and to correlate biochemical and USG findings with scintigraphy. Materials and Methods: A total of 60 newly diagnosed thyrotoxicosis patients based on biochemical reports were included in the study. They underwent further evaluation with ultrasonography and 99mTc scintigraphy. Results: Of 60 patients of thyrotoxicosis, 45 cases were of Grave’s disease, 10 cases were of thyroiditis and five cases were of Toxic Multinodular Goiter (MNG). The clinical characteristics were helpful in establishing the diagnosis in only six (10%) patients who presented with classic features of Grave’s disease with ophthalmopathy. T3/T4 ratio greater than 20 was seen only in 29 (66%) patients of Grave’s disease and also in three (33.33%) of thyroiditis patients. USG had a sensitivity and specificity of 81.82% and 93.75% in diagnosing Graves’ disease and 100% and 82.4% in diagnosing thyroiditis respectively. Conclusion: Clinical findings do not help in accurately delineating aetiological diagnosis of thyrotoxicosis. Serum T3/T4 ratio when used as a criterion has marked overlap between the various conditions causing thyrotoxicosis. USG has reasonable sensitivity however, misses many cases of early Grave’s disease. Follow up scintigraphy helps in a small population with resolving thyroiditis or early Grave’s disease where the initial scintiscan is normal or inconclusive.

Adolescents Confusion in Receiving Health Services: A Qualitative Study

Nezal Azh, Fatemeh Nahidi, Giti Ozgoli, Gelayol Ardalan

Introduction: Providing health services for adolescents requires exploration of hidden factors from the perspective of adolescents, providers, and key individuals. Understanding the process of providing health services from adolescents point of view will help receiving and continuation of services. Although many studies have been conducted in Iran on adolescents health needs, few studies have dealt with provision of these services to adolescents. Aim: The present study aimed to explain the adolescents and key informants’ perception of healthcare provision. Materials and Methods:The present qualitative study was conducted according to grounded theory. Data were collected using deep semi-structured individual interviews and group discussion. Participants were selected through purposive sampling followed by theoretical sampling. Participants in present study were 65 adolescents, nine youths (19-24-year-old), and 19 parents and key people involved in providing health services. Adolescents and their parents were selected from different parts of Tehran. Data collection continued until data saturation, and was analysed using Corbin-Strauss (2008) method. Results: Issues relating to adolescents perception of the process of providing services included health concerns, society’s inappropriate behaviours, and weakness of the health services system in responding to adolescents needs, which as underlying factors contributed to adolescents confusion in receiving services and their proper coping with puberty. Conclusion: Due to lack of education on how to manage puberty by parents, schools, society, and the health system, participating adolescents from Tehran were confused about receiving information and unable to manage puberty problems. Solving this problem requires continuity of services and interaction of family, school and community.

Artificial Neural Network (ANN) Model to Predict Depression among Geriatric Population at a Slum in Kolkata, India

Arkaprabha Sau, Ishita Bhakta

Introduction: Depression is one of the most important causes of mortality and morbidity among the geriatric population. Although, the aging brain is more vulnerable to depression, it cannot be considered as physiological and an inevitable part of ageing. Various sociodemographic and morbidity factors are responsible for the depression among them. Using Artificial Neural Network (ANN) model depression can be predicted from various sociodemographic variables and co morbid conditions even at community level by the grass root level health care workers. Aim: To predict depression among geriatric population from sociodemographic and morbidity attributes using ANN. Materials and Methods: An observational descriptive study with cross-sectional design was carried out at a slum under the service area of Bagbazar Urban Health and Training Centre (UHTC) in Kolkata. Among 126 elderlies under Bagbazar UHTC, 105 were interviewed using predesigned and pretested schedule. Depression status was assessed using 30 item Geriatric Depression Scale. WEKA 3.8.0 was used to develop the ANN model and test its performance. Results: Prevalence of depression among the study population was 45.7%. Various sociodemographic variables like age, gender, literacy, living spouse, working status, personal income, family type, substance abuse and co morbid conditions like visual problem, mobility problem, hearing problem and sleeping problem were taken into consideration to develop the model. Prediction accuracy of this ANN model was 97.2%. Conclusion: Depression among geriatric population can be predicted accurately using ANN model from sociodemographic and morbidity attributes.

A Comparative Study on Clinical and Biochemical Parameters in Amlodipine and Cilnidipine Treated Hypertensive Patients

Introduction: Hypertension is a major health issue worldwide. Calcium Channel Blockers (CCBs) are the most commonly used antihypertensive agents. CCBs act on voltage-dependent calcium channels and they were categorized into two subclasses, Dihydropyridine (DHP) and non-Dihydropyridine (non-DHP) derivative. Amlodipine is a third generation L-type of DHP and Cilnidipine is a novel L/N-type of DHP CCB, both drugs have excellent pharmacological profiles with the unique actions. Aim: To study the clinical and biochemical profile in Amlodipine and Cilnidipine treated mild to moderate hypertensive patients. Materials and Methods: The present study was a cross-sectional study. A total of 140 mild to moderate hypertensive patients (HTN classified according to Joint National Committee-8 (JNC-8) HTN guideline), 70 were in Amlodipine group (Group-A), and other 70 patients were in Cilnidipine group (Group-B). Group-A receiving Tab Amlodac 5 mg/day and Group-B receiving Tab Cilacar 10 mg/day, and both the group receiving respective medications since more than six months. Patients enrolled into the study with due consideration of eligibility criteria. Demographic, clinical and biochemical parameters were noted and compared. Results: Demographic parameters are matched, there was no significant difference seen between two study groups. Systolic and Diastolic Blood Pressure (SBP and DBP) showed a significant difference (p<0.001). There was no significant difference in pulse rate between the two groups, both QT/QTc showed statistically significant difference (p<0.001). The biochemical parameters like serum creatinine, albumin, globulin, total protein, serum Na+, fractional excretion of Na+, serum osmolality, vanillyl mandelic acid, were compared between two study groups, there was no significant difference seen between the two groups. Conclusion: The Amlodipine and Cilnidipine both are equally effective antihypertensive drugs. Cilnidipine treated group showed more reduction in blood pressure than the Amlodipine treated group and there was no significant change in heart rate between the two groups. Cilnidipine group showed comparatively shortened QT/QTc interval than the Amlodipine group.

Relationship between Neutrophil-to-Lymphocyte Ratio and Stress in Multiple Sclerosis Patients

Introduction: Multiple Sclerosis (MS), a disease of autoimmunity and inflammation, is characterized by deterioration of the myelin sheath that protects the nerve fibers. The high levels of neutrophils in serum may be related to the chronic inflammation and caused by other triggers such as infections that have been associated with relapses in MS. Aim: To investigate the value of Neutrophil/Lymphocyte Ratio (NLR) as a possible marker and relationship with Depression, Anxiety and Stress (DAS) score in MS patients. Materials and Methods: A total of 60 MS patients and 60 age and sex matched healthy controls were recruited for the present study. We measured DAS score, NLR, calcium, phosphate, magnesium, chloride, alkaline phosphatase, albumin in serum levels in MS patients and in healthy controls. Results: The mean age was not significantly different in both case and control groups. The case and control groups were similar in terms of sex; however, the majority of the MS group was female. The NLR values of MS patients were significantly higher than those of the healthy controls (p=<0.001). The NLR values were also significantly (p<0.001) correlated with stress score. Conclusion: NLR could be considered as a quick, cheap, easily measurable and inflammatory marker for assessment of inflammation in MS patients. The role of NLR in MS must be explored further.

Unusual Severe Extra-Intestinal Manifestations of a Common Enteric Pathogen-Aeromonas Spp

Introduction: Aeromonas spp. are halophilic, Gram-negative bacilli. They are widely distributed in the soil and aquatic environment and have been associated with various extra-intestinal infections, such as skin and soft-tissue infections, meningitis, bacteraemia etc. The most common species associated with extra-intestinal infection is Aeromonas hydrophila. Aim: To get the overview of clinical presentations, underlying predisposing factors associated with the extra-intestinal infections caused by Aeromonas species and their antimicrobial susceptibility pattern. Materials and Methods: Extra-intestinal cases of Aeromonas spp. admitted during December 2015 to October 2016 in the tertiary care hospital of South Karnataka coastal region were analysed retrospectively. The isolates were identified by Matrix Assisted Laser Desorption Ionization Time-of-Flight (MALDI-TOF) VITEK®MS and antimicrobial susceptibility testing was performed by VITEK®2 system (bioMérieux, Inc., Durham, NC) respectively. Clinical manifestations and management of the cases were noted from the clinical records. Clinical and microbiological findings presented as mean±standard deviation, frequency and percentage. Results: We included 26 cases in this study, from whom Aeromonas spp. isolated alone or with another microorganism. Most widespread infection was Skin and Soft Tissue Infection (SSTI) (24, 92.3%). In 50% (12/24) cases, SSTI developed due to trauma. In 45.8% (11/24), underlying co-morbid conditions were present. The common site of infection was lower extremities (16/24, 66.7%) and 62.5% (15/24) of them presented with severe gangrene of the affected site. Other than SSTI, we encountered with two cases of keratitis and cholangitis respectively. A. hydrophila were frequently isolated species (23/26, 88.5%). The analysis of antimicrobial susceptibility showed, 13% isolates were Multidrug Resistant (MDR). Carbapenem resistance was also noted. Conclusion: We had isolated Aeromonas spp. from different extra-intestinal sites. Most common extra-intestinal manife-station by this organism was post-traumatic wound infection. Clinical spectrum of this infection confused the clinician with other organisms like group B Streptococcus, Clostridium spp. etc., and mislead them in empirical management. Finally with the microbiological support all the cases were treated either conservatively or in combination with surgical debridement or amputation depending on the situation.

Restricted Parenteral Antibiotics Usage Policy in a Tertiary Care Teaching Hospital in India

Introduction: The indoor hospital use of antibiotic irrationally has been a growing concern in the recent past. For the patients and providers of health care services this kind of drug consumption account for a major chunk of the budget. Aim: To assess the outcome of restriction on the use of parenteral antibiotics with respect to their utilization and monetary benefits, in a tertiary care hospital in India. Materials and Methods: Data details were collected regarding drug utilization two months before and after restriction respectively. A total 1605 patient records assessed. Drug utilization was expressed as DDD/100 patient bed days. Use of Carbapenems were restricted to culture positive cases only. Antibiotics started for patients as per clinical judgment were issued for only five days. Culture sensitivity reports verified physically on a special indent form, before every antibiotic issued thereafter. Results: Piperacillin-tazobactum (DDD/100 BD 1.72 before and 1.29 after restrictions) was the commonly used antibiotic. Considering values expressed in DDD/100 BD before and after restriction respectively, substantial decrease in consumption of antibiotics like Imipenem- Cilastin (0.22 to 0.16), meropenem (0.30 to 0.09), piperacillin-tazobactum (1.72 to 1.29), teicoplanin (0.24 to 0.05) and vancomycin (0.69 to 0.40) was observed. An increase in consumption of amoxicillin-clavulanic acid (0.90 to 1.04) and clarithromycin (0.44 to 0.55) noted, pointing to a shift in antibiotic use. Restriction decreased expenditure burden on these antibiotics by INR 1,45,911 (17.31%). Conclusion: Restriction of antibiotics cuts down consumption and benefits hospital budget immensely.

Risk Factors and Incidence of Puerperal Genital Haematomas

Shikha Rani, Meesha Verma, Dilpreet Kaur Pandher, Navneet Takkar, Anju Huria

Introduction: Puerperal genital haematomas although an uncommon entity but is elusive. This painful condition is not only distressing and dangerous to patient but is embarrassing to the obstetrician who has conducted the delivery. Aim: This study has been planned to evaluate the incidence and risk factors for puerperal genital haematomas. Materials and Methods: A case control study was done from August 2005 to August 2015, of all puerperal genital haematomas. All patients, who had undergone drainage for the puerperal genital haematoma, were enrolled as cases. Two controls were chosen for each case, who had delivered immediately after the case. All the patients were evaluated for the characteristics of haematoma and the management of the same. Cases and controls were compared for the evaluation of risk factors for puerperal genital haematoma. Results: During the study period 27,826 vaginal deliveries were performed in our institute. Thirty nine haematomas were drained during this period. Incidence of haematomas was one in 1,113 deliveries, in our institute. Among the puerperal haematomas, vulvovaginal was the most common type. Perineal pain is the most common complaint. To evaluate the risk factors, 77 controls were enrolled. Primigravida, hypertensive disease of pregnancy and coagulopathy were the significant risk factors with p-value of <0.01, 0.01 and 0.03 respectively. Episiotomy too was a risk factor with a p-value of 0.002. Conclusion: Primigravida, hypertensive disease of pregnancy, coagulopathy and episiotomy are still the most common risk factors.

Correlation between Maxillary Canine Calcification and Skeletal Maturation

Introduction: Skeletal maturation assessment has a great role in many health professions especially in Orthodontics & Dentofacial Orthopedics. Functional appliances have proved to be more effective when used at the peak of mandibular growth, rather than before. Aim: The aim of this study was to evaluate whether the calcification stages of permanent maxillary canine are useful to assess skeletal maturity. Materials and Methods: In this cross-sectional study, samples were derived from panoramic radiographs and lateral cephalograms of 300 subjects (137 males and 163 females) with their age ranging from 9 to 18 years. Dental maturity {Demirjian Index (DI)} and skeletal maturity {Cervical Stages (CS)} were assessed from radiographs. The Pearson chi-square test (?2) and Sakoda adjusted Pearson contingency coefficient (C*) were calculated to determine the correlation between DI and CS. Results: A highly significant association (C* = 0.851, p<.001for males and 0.879, p<.001 for females) was found between DI and CS. DI stage E coincided with CS2 (pre-peak of pubertal growth spurt) & DI stage F coincided with CS3 (peak of pubertal growth spurt) for all the subjects. DI stage H corresponded to CS5 and CS6 (end of peak of pubertal growth spurt). Conclusion: A highly significant association was found between DI and CS. Maxillary canine DI stages could be useful to assess skeletal maturity.

Role of Immunofluorescence in Adult Onset Nephrotic Syndrome-A Study in a Tertiary Care Centre of Western India

Sharada Rane, Prerana Mutyal, Nicholas Dcunha, Mayur Parkhi, Meenal Jadhav

Introduction: Study of renal Immunofluorescence (IF) is an ancillary but essential technique in evaluation of renal biopsies in glomerulopathies and also it enlightens on the pathogenesis of nephrotic syndrome. Aim: To determine the role of IF in evaluating definite subtyping and diagnosis of adult onset nephrotic syndrome and attempting clinicopathological correlation. Materials and Methods: A total of 52 patients of adult onset nephrotic syndrome were evaluated clinically and with pertinent investigations; and subjected to USG guided percutaneous renal biopsy which was processed and stained for light microscopy and for immunofluorescence by direct method (DIF) using antibodies against IgG, IgM, IgA and C3. Results: The predominant age group affected was 18-47 years (78.85%). Male:female ratio was 1:0.63. The most frequent glomerular lesion encountered was Focal Segmental Glomerulosclerosis (FSGS, 36.54%) followed by lupus nephritis (26.92%) and IgA nephropathy (9.62%). The most common glomerular lesion in males was FSGS and that in females was lupus nephritis. DIF was mainly coarsely granular whenever present. One case of lupus nephritis and diabetic nephropathy, showed non specific IF. It was negative in all cases of FSGS, Minimal Change Disease (MCD) and renal amyloidosis. The IF helped in differentiating eight cases that were normal on light microscopy as IgA nephropathy (n=5) and authentic MCD (n=3). It helped in endorsing 19 cases of FSGS to be a progression of MCD. It was also of help in sub-typing all cases of Membranoproliferative Glomerulonephritis (MPGN) (n=3) as MPGN-Type I. Conclusion: IF was of great help in diagnosing exact type of glomerulopathy in adult onset nephrotic syndrome and provided insight in its pathogenesis.

Effect of Menstrual Cycle Phases on Plasma Lipid and Lipoprotein Levels in Regularly Menstruating Women

Shilpi Vashishta, Sushila Gahlot, Rajni Goyal

Introduction: Physiological cyclic variability in levels of sex hormones during a menstrual cycle may possibly have an impact on lipids, lipoprotein levels and therefore on cardiovascular health status of females. Aim: To ascertain the effect of menstrual cycle phases on the levels of cardiovascular risk predictors i.e., plasma lipids and lipoproteins in healthy menstruating women. Materials and Methods: In the present study, 111 healthy regularly menstruating females aged 15-45 years were examined at two points of a menstrual cycle i.e., in the follicular phase (10th day) and in the luteal phase (22nd day) to find out the plasma levels of lipids and lipoproteins. The data were statistically analysed using paired t-test. Results: A significant decrease in the mean levels of Total Cholesterol (TC) (p=0.006), Low Density Lipoprotein Cholesterol (LDL-C) (p=0.004), TC/High Density Lipoprotein Cholesterol (HDL-C) (p=0.006), Low Density Lipoprotein Cholesterol (LDL)/HDL (p=0.01), and Triglyceride (TG)/HDL (p=0.02) was observed in the luteal phase compared to the follicular phase while TG (p=0.18), HDL-C (p=0.16). VLDL-C (p=0.17) did not show a significant difference although lower levels were observed in the luteal phase of TG and VLDL-C and higher levels for HDL-C. Conclusion: The present findings reveal high levels of oestrogen in the luteal phase compared to follicular phase of menstrual cycle. Clinicians should take menstrual cycle phase in account when inferring a women biomarker measurement in the analysis of cardiovascular diseases, particularly females possessing marginal levels. Moreover research studies should take the menstrual cycle phase in consideration which may be a confounding factor in framing and concluding studies on reproductive age group women.

Estimation of Pentraxin 3 and Porphyromonas Gingivalis Levels in Patients with Rheumatoid Arthritis and Periodontitis- An Observational Study

Introduction: Periodontal diseases are inflammatory in nature involving interplay between the bacterial plaque and the micro-organisms, with the response of the host playing a pivotal role in either attenuating or eliminating the disease. Rheumatoid Arthritis (RA) is also a chronic inflammatory disease which shares common risk factors with periodontitis. Porphyromonas Gingivalis and Pentraxin 3 (an acute inflammatory protein) have been observed to be associated with both the diseases. Aim: This study was done to determine if there was any association between Pophyromonas Gingivalis and Pentraxin 3 levels in patients with RA and Chronic Periodontitis in comparison with Healthy controls. Materials and Methods: This observational study was conducted on 90 subjects (42 Males and 48 Females) aged between 30-60 years. The subjects were selected from the out patient ward of a tertiary referral care hospital. The selected subjects were equally divided into three groups. Group I: Comprising of 30 patients with RA and chronic periodontitis who were in turn, subdivided into Group I- A (n=15) –Patients just diagnosed with RA and Group I- B (n=15) Patients under medications for more than three months. Group II: Patients with Chronic Periodontitis (n=30) and Group III: Healthy Controls (n=30) Intergroup comparison for continuous data was done by One-way analysis of variance test followed by Bonferroni’s post-hoc test. Intragroup comparison for continuous data was done by paired t-test. Results: Intergroup comparison between Group I and Group II did not show any statistical difference pertaining to the clinical parameters except for the Gingival Index (GI) which was found to be higher in Group II (Mean= 2.07) when compared to Group I (Mean=1.59). Intragroup comparison between Group IA and Group IB was statistically significant for GI, Plaque Index (PI), and Clinical Attachment Levels (CAL). Intragroup comparison between Group I-A and Group I-B showed that both Porphyromonas gingivalis and Pentraxin 3 Levels were higher in Group I- A. Conclusion: In this study, it was observed that there was a positive association between Porphyromonas gingivalis and Pentraxin 3 levels in patients with rheumatoid arthritis and periodontitis.

Quality Assessment of Family Planning Sterilization Services at Health Care Facilities: Case Record Audit

Medha Mathur, Ram Chandra Goyal, Navgeet Mathur

Introduction: Quality of sterilization services is a matter of concern in India because population control is a necessity. Family Planning Sterilization (FPS) services provided at public health care facilities need to be as per Standard Operating Procedures. Aim: To assess the quality of FPS services by audit of case records at selected health care facilities. Materials and Methods: This cross-sectional study was conducted for two and a half year duration at selected public health care facilities of central India by simple random sampling where FPS services were provided. As per the standards of Government of India, case records were audited and compliance was calculated to assess the quality of services. Results: Results of record audit were satisfactory but important criteria like previous contraceptive history and postoperative counselling were found to be deviated from standards. At Primary Health Centres (PHCs) only 89.5% and at Community Health Centres (CHCs) 58.7% of records were having details of previous contraceptive history. Other criteria like mental illness (only 70% at CHCs) assessment were also inadequate. Although informed consent was found to be having 100% compliance in all records. Conclusion: Quality of care in FPS services is the matter of concern in present scenario for better quality of services. This study may enlighten the policy makers regarding improvements needed for providing quality care.

Role of Multi Detector Computed Tomography (MDCT) in Preoperative Staging of Pancreatic Carcinoma

Soumil Singhal, Nirmal Kumar Prabhu, Pulkit Sethi, Srikanth Moorthy

Introduction: Pancreatic carcinoma is one of the leading causes of cancer related death in advanced countries and has shown rising trends in developing countries like India. Increase in the incidence has been linked to risk factors like lifestyle modification associated with increased alcohol consumption and rapid urbanization. Most patients at the time of diagnosis present with an advanced condition. Surgical resection offers the only chance for cure in them and imaging plays a crucial role in the early diagnosis of the condition. Aim:To compare the staging of pancreatic carcinoma by MDCT (Multi Detector Computed Tomography) with surgery in a preoperative setting in a tertiary referral centre in Kerala. Materials and Methods: A cross-sectional observational study was performed between November 2014 and October 2016, 25 patients (12 men, 13 women), with a mean age of 54.2 years, were evaluated. MDCT was performed using 16 slice, 64 slice and 256 slice multi detector CT machines. The gold standard for diagnosis was histopathology and operative data. All statistical analysis was done using IBM SPSS version 20.0. Validity parameters like sensitivity, specificity, accuracy and Positive Predictive Value (PPV) / Negative Predictive Value (NPV) were computed for MDCT with respect to surgery. Results: Of the 25 patients who were evaluated for surgery, 15 (60%) cases were classified as resectable tumours, 3 (12%) as borderline resectable and 7 (28%) as unresectable tumours. CT showed a sensitivity of 82.3% with a specificity of 87.5%. However, for assessing vascular invasion, CT showed sensitivity and specificity of 100% and 93.3% respectively. Three (12%) patients in the study who were classified as borderline resectable pancreatic tumours underwent surgery. Conclusion: Contrast-enhanced multiphase pancreatic imaging using MDCT plays a pivotal role in diagnosing and assessing resectability and vascular invasion of pancreatic tumours. It is very useful for determining borderline resectable tumours pre-operatively, which aids for better treatment planning.

Evaluation of Plaque pH Changes Following Consumption of Health Drinks by Children: A Pilot Study

Introduction: With increased trend among people to choose a healthy diet, there is an increased consumption of health drinks by children. Thus, it is important to know their cariogenicity. Aim: To evaluate the effect of consumption of health drinks viz., Horlicks, Boost and Complan on plaque pH in children. Materials and Methods: The study consisted of four groups: Group I (control)- 10% sucrose solution, Group II- Horlicks, Group III- Boost, Group IV- Complan. Samples of plaque from representative teeth were collected and pH was measured using an electrode outside the mouth. After baseline pH was recorded, children were given their respective drinks and were asked to consume slowly over a period of three to five minutes following swish with 20 ml of the test drink for one minute. The pH was then recorded after 10, 20, 30, 40 and 60 minutes of the post consumption period. Obtained values were subjected to one-way ANOVA test for multiple group comparison followed by Post-Hoc Tukey’s test for group wise comparison. Results: Twenty minutes after consumption of Complan and Boost, pH was decreased, but not to the critical pH value as in case of sucrose. The pH was found to be slightly increased, 20 minutes post Horlicks consumption. Post 60 minutes consumption of all the drinks including sucrose solution, the pH was increased in comparison to post 20 minutes. However, 60 minutes post consumption of Boost and Horlicks, pH increased above the baseline. Conclusion: Consumption of health drinks viz., Complan and Boost did not lower the plaque pH to the level of critical pH. Consumption of Horlicks increased the plaque pH.

Lasègue’s Sign

Surendra Umesh Kamath, Shaila Surendra Kamath

Lasègue’s sign is an interesting and important clinical sign in medicine for the last 150 years. The Lasègue test is commonly used in the physical examination of patients with low back pain. It is a test for lower lumbosacral nerve root irritation for example, due to disc prolapse. It is evident that the method of performance of this diagnostic sign varies with the physician. This article reviews the historical background and method of eliciting the sign.

Cross Sectional Observational Study Performed to See for Relation of Mallampati Score and Extended Mallampati Score with Body Mass Index

Sasha Maria Menon, Shailaja Sampangiramaiah, Megha Mathew

Introduction: There is increasing incidence of obesity worldwide. Since obese patients have an increased fatty tissue distributed in a truncal fashion, they may have an important and negative impact on the airway patency and respiratory function. Various scoring systems have been used to predict difficult airway, the most commonly used universal bedside tool is the Modified Mallampati Scoring (MMS). It was shown that the Extended Mallampati Score (EMS) predicted difficult laryngoscopy better than the MMS in the obese populations. Aim: To evaluate the association of Mallampati score and EMS in adults. Materials and Methods: This cross-sectional prospective observational study was performed on 323 subjects. The selection method included convenience sampling technique. Patient data which included name, age, sex, weight, height, Body Mass Index (BMI) and Neck Circumference (NC), Mallampati Score, and EMS were collected by two observers, anaesthesiologists. The observers noted their findings of MMS and EMS on the same patient independently. Their findings were entered independently and disclosed only during analysis. Results: There was good agreement between the observers (kappa value 0.635) for MMS and EMS. The intraobserver correlation coefficient was 0.8 for MMS (p<0.001) and 0.7 (p=0.004) for EMS which was significant. A positive correlation between sex and NC with BMI, MMS and EMS was seen. Conclusion: From this study we concluded that there was no difference between the MMS and EMS. There was interobserver agreement between MMS and EMS and a positive correlation of body mass index with MMS and EMS was seen.

Effect of Cell Phone Radiations on Orofacial Structures: A Systematic Review

Sunil Kumar Mishra, Ramesh Chowdhary, Shail Kumari, Srinivasa B Rao

Introduction: The widespread use of cell phone in recent years has raised many questions whether their use is safe to operator who is exposed to Electromagnetic Waves (EMV). Aim: To find out the effect of cell phone emitted radiations on the orofacial structures. Materials and Methods: To identify suitable literature, an electronic search was performed using Medline, Pubmed and EBSCO host database in December 2016. The search was focused on effect of cell phone on orofacial structures. Among the literature available in English, the screening of the related titles and abstracts was done, and only those articles were selected for full text reading that fulfilled the inclusion criteria. Results: The initial literature search resulted in 360 articles out of which only 24 articles fulfilled the inclusion criteria and were included in this systematic review. Conclusion: Cell phone emitted radiations had their adverse effect on salivary glands and facial nerves. Studies showed that cell phone emitted radiations had effects on oral mucosal cells and causes changes in salivary flow rate. It was still unclear that cell phone radiations cause tumours of the salivary glands.

The Impact of Oxidative Stress on Testicular Function and the Role of Antioxidants in Improving it: A Review

Nematollah Asadi, Mahmoud Bahmani, Arash Kheradmand, Mahmoud Rafieian-Kopaei

Oxidative stress is an important factor for development of male infertility because of very high rate of cell division and mitochondrial oxygen consumption in testicular tissue as well as comparably higher levels of unsaturated fatty acids in this tissue than in other tissues. Moreover, the level of oxygen pressure is low due to the weakness of testicular artery; therefore, there is a severe cell competition for oxygen. Therefore, the testicular tissue and male reproductive system are particularly susceptible to oxidative stress. On the other hand, exposure to X-ray, toxins and chemicals found in the environment as well as specific physical conditions such as varicocele can exacerbate the oxidative stress and induce apoptosis of germ cells and subsequently spermatogenesis. However, under normal conditions, the bodys capacity to produce antioxidants for inhibiting adverse effects of oxidative stress is affected by metabolic process and genetic structure. Besides that, environmental factors such as diet, pollutants, and chemicals can affect this capacity. Thus, the bodys antioxidant system alone is not able to neutralize all free radicals and prevent harmful complications of oxidative stress. Therefore, use of antioxidants and development of antioxidant therapy can break down the oxidative chain reaction and play a very significant role in increasing the bodys capacity to fight free radical-induced oxidative stress, and therefore improve the process of spermatogenesis.

Role of Vitamin E and Vitamin A in Oral Mucositis Induced by Cancer Chemo/Radiotherapy- A Meta-analysis

Introduction: Oral mucositis is known to hamper the quality of life in patients treated for oral cancer. Many pharmacological agents have been tried and tested in its management, especially vitamin supplements including A, E and their combinations. Aim: A Meta-analysis was carried out to evaluate the efficacy of vitamins individually used for prevention or treatment of oral mucositis separately for chemotherapy, concurrent chemo radiotherapy, radiotherapy and Haematopoietic Stem Cell Transplantation (HSCT) individuals. Materials and Methods: The literature study was done using PUBMED, MEDLINE, EBSCO, GOOGLE SCHOLAR and COCHRANE data bases with keywords vitamin A, vitamin E, vitamin B, vitamin C, Oral mucositis, Chemotherapy, Radiotherapy, Concurrent chemo radiotherapy and Haematopoietic stem cell transplantation individually, from the year 1980 to 2016. Only randomized controlled trials were included. The data was extracted, tabulated and was subjected to statistical analysis with CI of 95%. Results: Among 201 subjects the analysis clearly demonstrated a male predominance to females in studies where male to female ratio was given. Out of 8 studies, 2 were studies in children and remaining 6 studies concentrated on adult population. WHO and NCI-CTC criteria were followed except for one study which used customised assessment. A meta-analysis was performed regarding usage of topical medication of Vitamin E group in all three cancer treatment modalities, which showed significant reduction in oral mucositis (p < 0.001). There was reduced oral mucositis in a small group of patients with Vitamin A when compared to controls. No information on the agent used for chemotherapy, the dose of radiotherapy and the type of tumours in 4 studies. Conclusion: Topical Vitamin E had performed better on oral mucositis than Vitamin E systemic administration. Though the efficacy of topical treatment with Vitamin A showed reduction in oral mucositis, it was evaluated in a very small sample which cannot be attributed to a larger sitting.

Prevalence of Anaemia in Kerala State, Southern India - A Systematic Review

Purushothama Suseela Rakesh

Introduction: Anaemia is the most common nutritional problem affecting children, adolescents and women. A systematic review was undertaken to find out the prevalence of anaemia and to identify the trend in the prevalence of anaemia in Kerala state, Southern India. Aim: The aim of the review was to identify the prevalence of anaemia in Kerala and to comment on its trend across last 25 years. Materials and Methods: PubMed and google scholar searches and scanning of reference lists were used to identify studies. All population based studies on anaemia from Kerala, irrespective of its designs, published between Jan 1st 1990 to Dec 31st 2015 were included. Data extraction and quality assessment were carried out using structured proformas. Due to the heterogeneity of reviewed studies, meta-analysis was not done. A narrative approach was used. Results:A total of 10 studies in addition to two major survey reports- National Family Health Survey (NFHS) and District Level Household Survey (DLHS) were included in the final analysis. Prevalence of anaemia among adolescents from recent study reports was around 30% and prevalence of severe anaemia was less than 1% in all studies. Anaemia among tribal women and children were in the range of 78.3% to 96.5%. A key finding of this review was the paucity of data and inconsistency in haemoglobin estimation methods and population characteristics which made comparisons impossible. Conclusion: The current prevalence of anaemia in Kerala is unclear. Though, there are many studies and reports regarding prevalence of anaemia in the state, those results could not be combined due to non uniform haemoglobin estimation methods. Standardised prospective study of general population including subgroups will be necessary.

Critical Appraisal of Clinical Research

Azzam Al-Jundi, Salah Sakka

Evidence-based practice is the integration of individual clinical expertise with the best available external clinical evidence from systematic research and patient’s values and expectations into the decision making process for patient care. It is a fundamental skill to be able to identify and appraise the best available evidence in order to integrate it with your own clinical experience and patients values. The aim of this article is to provide a robust and simple process for assessing the credibility of articles and their value to your clinical practice.

Salient Features of a Proposed Adolescent Health Policy Draft for India

Janmejaya Samal, Ranjit Kumar Dehury

India is one of the most populous countries in the world. The adolescent population in India constitutes about one fifth of the total Indian population. Adolescent phase is a transitional phase in life and the adolescents are neither child nor adult at this stage and are full of energy, have significant drive and new ideas. The relatively lower death rate and relatively good health status of the adolescents has always been a misleading measure to adolescent health and thus given lesser priorities. In order to respond effectively to the needs of adolescent health and development, it is important to place adolescence in a life-span perspective within dynamic sociological, cultural and economic realities. For this, government of India has started a national programme known as “Rashtriya Kishor Swathya Karyakram” in 2014. However, India as a country does not have an adolescent health policy till date and hence the country requires a national adolescent health policy. The key priorities should include sexual and reproductive health, nutritional problems (both under and over nutrition), substance abuse, mental health, road traffic accidents, intentional violence and non-communicable diseases. In addition to key priorities, the policy draft should include pertinent components such as a preamble, guiding principles, coordinating agencies, monitoring and evaluation, research and documentation components.

Synchronous Primary Endometrial Carcinoma and Metastatic Malignant Melanoma in Cervical Lymph Node

Kanwardeep Tiwana, Sarita Nibhoria, Manmeet Kaur, Saloni Bansal

The occurrence of dual malignancies is not rare but concurrent occurrence of two malignancies with different histogenesis and different anatomical sites is not known. In the studies which have been conducted so far, none of them has shown the simultaneous occurrence of metastatic malignant melanoma and primary endometrial carcinoma. We report herein a case of a 42-year-old female diagnosed with metastatic malignant melanoma in cervical lymph node with unknown developing primary endometrial carcinoma within two months. No foci of primary malignant melanoma were found in uterus. Dual primary malignancy is being suggested by the presence of two malignancies in a patient with different morphological picture on histopathological examination, at anatomically distinct sites. Malignant melanoma and endometrial carcinoma, being a rare combination, prompted us to report the case.

Unusual Presentation of Atypical Infantile Pompe Disease in the Newborn Period with Left Ventricular Hypertrophy

Sanjay Kumar, Amit Kumar

Pompe disease, also known as glycogen storage disease Type II, is a lysosomal storage disorder caused by a-glucosidase deficiency. In general, the clinical spectrum varies with respect to the age of onset, residual enzyme activity and organ involvement. Infantile onset disease has two subtypes: classical and non-classical (atypical). This case report describes the case of a newborn who presented with generalized hypotonia and elevated serum enzyme levels of aspartate aminotransferase 93 IU/L, lactate dehydrogenase 888 IU/L and creatine kinase 670 µg/L. The electrocardiogram showed short PR interval with large QRS complexes with echocardiography suggesting evidence of left ventricular hypertrophy with infiltration in its walls. On the basis of the clinical signs and laboratory results, dried blood spots from the baby were tested to determine the acid a-glucosidase (GAA) activity, and the result confirmed that the GAA activity was only 1.42 units, normal range 5.5 to 29.6 units, leading to a diagnosis of Pompe disease (atypical infantile). Recognizing this disease and initiating enzyme replacement therapy in infants at the earliest can improve the quality of life of patients.

Gastric Glomus Tumour Misdiagnosed as Gastric Carcinoid: An Unfamiliar Entity with Aids to Diagnosis and Review of Literature

Tanush Vig, Mandeep Singh Bindra, Ramani Manoj Kumar, Suceena Alexander

Glomus Tumour (GT) is a rare mesenchymal tumour of the stomach with Gastrointestinal Stromal Tumour (GIST), leiomyoma and schwannoma being far more common and comprising more than 90% of all gastric mesenchymal tumours. As glomus bodies are located in the peripheral parts of the human body, these tumours are peripherally located, classically the subungual region, hands, feet and trunk. While being evaluated for renal problems, a middle aged lady was incidentally found to have a gastric tumour. This was submucosal in location and was excised by a wedge resection and reported elsewhere as carcinoid tumour. The patient came to our hospital for further management. The biopsy was reviewed here and the modified diagnosis given was GT, confirmed by panel of immunohistochemistry. Two years after regular clinical follow up the patient is free of disease or any distant metastasis. In this paper the authors discuss the potential pitfalls, differential diagnoses and diagnostic clues that help in diagnosing this gastric tumour.

Diagnostic Dilemma in a 15-Year-Old Boy with Recurrent Pneumococcal Meningitis

Recurrent bacterial meningitis is very rare phenomenon in paediatric age group. Finding the aetiology of recurrent meningitis often poses diagnostic challenge to clinicians. Among the several aetiologies, structural deficiencies at the base of skull, congenital or acquired, are readily correctable ones and hence it’s imperative to find out the location of the gap in order to surgically repair it. We report the diagnostic dilemma faced while managing a 15-year-old boy with recurrent pneumococcal meningitis. Aetiology could only be found after exclusion of immunodeficiency and performing a series of imaging studies. CT cisternogram clinched the diagnosis and patient was cured successfully. A single imaging modality, be it CT/MRI scan, although proven to be better than others according to literature, might not be sufficient while finding the cause of recurrent bacterial meningitis in an immunocompetent host.

Lip and Lower Lid Supporting Prosthetic Appliance: A Unique Approach of Treating Unilateral Facial Paralysis

Chetan Pathak, Salil Pawah, Arpit Sikri, Pushpanjali Rexwal, Prachi Aggarwal

Along with function, aesthetics plays an important role in treating partially or completely edentulous patients. Ageing, trauma, tooth loss and neuromuscular disorders have a high impact on tonicity of facial musculature, elasticity of skin as well as function of muscles. Patients affected with Bell’s palsy face functional, aesthetic as well as psychological impairment. Common problems are the partial closure of upper eyelid, sagging of lower eyelid and drooping of angle of mouth leading to facial asymmetry, along with difficulty in eating, drinking and speaking. The key to aesthetic restoration is to support and harmonize the collapsed facial musculature with the help of various prosthodontic treatment approaches. This case report attempts to focus on treating completely edentulous patient affected with Bell’s palsy with special prosthesis supporting angle of mouth and lower eyelid using novel technique.

Ebola Vaccine: How Far are we?

Rajani Sharma, Ketki Jangid, Anuradha

Ebola viruses have been identified as an emerging threat as it causes severe haemorrhagic fever in human with mortality rates ranging from 50 to 90%. In addition to being a global health concern, the virus also is considered a potential biological threat agent. As for now, no licensed vaccine is available for pre or post exposure treatment. Recent epidemic of this disease in South Africa has led to concern towards development of an effective vaccine on a priority basis. This review is an attempt to look upon current progress in the development of Ebola virus vaccines and highlights strategies that have the greatest potential for commercial development.

An Unusual Presentation of Congenital Cystoadenomatoid Malformation of Lung