Journal of clinical and diagnostic research

Immune Thrombocytopenia causing Abnormal Uterine Bleeding in an Adolescent Girl having Co-Existent Type-1 Neurofibromatosis- Is it an Association or Coincidence?

Charu Sharma, Shavina Bansal, Shashank Shekhar, Manisha Jhirwal, Payal Patwa

Immune Thrombocytopenia (ITP) is an autoimmune disorder characterised by a low circulating platelet count. ITP is caused by destruction of antibody-sensitised platelets in the reticuloendothelial system. Majority of the patients with ITP remain asymptomatic or develop only purpura, petechiae or epistaxis (83%) but few, very rarely, may present with abnormal uterine bleeding. On the other hand, Neurofibromatosis is an autosomal dominant disorder which can present with either precocious puberty or delayed puberty. This case report highlights a case of a 14-year-old female who presented with heavy menstrual bleeding as a presenting symptom of ITP and was co-incidentally also diagnosed as Neurofibromatosis type 1 (NF-1) during work-up of ITP for multiple hyperpigmented macules (Cafè-au-lait spots) noticed on her neck, forearm and back and the presence of Lisch nodules in iris. She was managed with steroids, oral contraceptive pills, iron and multivitamin tablets.

A Case of Disseminated Extensively Drug Resistant Extrapulmonary Tuberculosis

Diti V Gandhasiri, Tilak M Dhamgaye, Ulhas Jadhav, Babaji Ghewade

Tuberculosis (TB) strains with drug resistance are more difficult to treat than drug susceptible ones and jeopardise global progress towards the targets set by the World Health Organisation’s End TB Strategy. Although disseminated TB is well known as an opportunistic infection in HIV infected individuals, it is uncommon in HIV negative individuals. The present case is a rare case of Extensively Drug Resistant (XDR)-TB in disseminated TB involving the extrapulmonary sites in an immunocompetent adult. We report a case of a young man who has disseminated TB involving pleura and peritoneum. Prior to this, he had taken category II anti-TB treatment with no satisfactory response. Drug sensitivity test of pleural fluid revealed resistance to quinolones, kanamycin, isoniazid and rifampicin. Patient was administered second line anti-TB therapy with remarkable response. Therefore, this case highlights the importance of investigating aggressively for Drug Resistance (DR) in suspected cases of extrapulmonary TB.

Spontaneous Haemoperitoneum in Pregnancy- A Diagnostic Challenge

Niranjan Mayadeo, Anusha Devalla

Spontaneous haemoperitoneum in pregnancy is an extremely rare condition that poses a diagnostic dilemma for the obstetrician. The authors here present a case of 23-year-old primigravida presenting at 34-weeks with acute pain in abdomen masquerading as clinical chorioamnionitis secondary to prolonged rupture of membranes. Abdomen palpation revealed uterine tenderness and pathological cardiotocography tracings suggesting the need for immediate delivery of the foetus by emergency caesarean section. Intraoperatively, there was haemoperitoneum (800 mL) and bleeding superficial uterine serosal veins on the posterior surface of uterus seen on exploration. The patient was successfully managed with favourable maternal and fetal outcome.

Metastatic Carcinoma to Breast from Renal Cell Carcinoma- A Rare Case Report with Unusual Cytology

Neelam Sood, Shikha Chopra

Metastatic carcinoma to breast is an uncommon entity compared to the primary breast malignancies. Renal Cell Carcinoma (RCC) metastasising to breast is very rare as it commonly metastasises to lung, liver or bone. An accurate diagnosis of Secondary Tumour is must, since the prognosis and treatment differs between primary and secondary tumours. Here, the authors present the case of a 55-year-old female patient who presented with lump in right breast measuring 5×4 cm. Mammographic findings showed relatively well-defined round irregular marginated heterogenous radioopaque mass in outer lower quadrant, Breast Imaging Reporting and Data System (BIRADS- IV B). Fine Needle Aspiration Cytology (FNAC) showed atypical cells arranged in cohesive clusters with focal papillary architecture, entangled in eosinophilic stroma and cellular stromal fragments. The cells were small with ill-defined cell borders, granular to focal vacuolated cytoplasm, mild anisocytosis and indistinct nucleoli. Stain for mucin was negative. The differential diagnosis offered were primary breast carcinoma with possibility of metaplastic carcinoma and metastatic carcinoma. A trucut biopsy showed fibrocellular stroma, islands of cells with clear cytoplasm separated by thin fibrous septa. Immunohistochemical (IHC) for pancytokeratin (panCK), CD10 and vimentin were positive and Estrogen Receptor (ER), Progesterone Receptors (PR), Human epidermal growth factor receptor 2 (HER2) were negative and the diagnosis of metastatic RCC was made. The cytology case reports in the literature have shown characteristic cytomorphological features composed of cells with abundant, finely vacuolated cytoplasm, moderate pleomorphism and prominent nucleoli. This case is unusual as it was predominated by small cells with granular cytoplasm. Therefore, it was concluded that trucut biopsy is mandatory for breast lump in patient with RCC since the cytological features on FNAC might not always be characteristic.

A Rare Case of Dengue Fever Complicated by Hepatitis and Pancreatitis: Expanded Dengue Syndrome

Tridip Kumar Das , Sagar Kanta

Dengue is a vector borne disease which is one of the major public health problems caused by dengue virus which has 4 serotypes (DENV 1-4) and the vector being Aedes mosquito which has varied clinical manifestations. This report is about a previously healthy 32-year-old male patient that complained of fever, pain abdomen and jaundice for 1 week. On investigation, the patient tested positive for dengue NS1 antigen with raised liver enzymes. As the disease progressed, the pain of abdomen aggravated, radiating to the back and developed constipation with raised serum amylase and lipase. The patient was treated for both acute hepatitis and pancreatitis accordingly and responded to the treatment and gradually improved. Hence, it was thought that common dengue should be ruled out as a cause of Acute Hepatitis or Pancreatitis, depending on the incidence of dengue in that area.

A Case Report on Aesthetic Rehabilitation of Midline Diastema- An Insight into Perio-Restorative Interrelationship

Archie Khera, Vidhi Kiran Bhalla, Rajeev Ranjan, Daya Shankar

Aesthetic restorative procedures have gained immense popularity in the recent years. Midline diastemas have been commonly reported by a majority of patients due to poor aesthetic appeal. Various treatment modalities are available and cases have to be managed differently depending on the aetiological factors. Also, the selection of an appropriate restorative option is imperative to providing a pleasing smile. Conservative treatments that provide a solution to aesthetic problems and fulfil the patient’s expectations should always be the first therapeutic option. Ceramic veneers are capable of providing an accurate replica of the natural teeth along with good colour stability and periodontal biocompatibility. Soft tissues play a vital role in creating a harmonious and aesthetic result between the restorations, hard tissues and surrounding gingiva. Therefore, periodontal treatments such as crown lengthening and frenectomy are essential for creating an ideal soft tissue form corresponding to the tooth proportions. Management of large anterior interdental spaces requires a comprehensive treatment planning and often, a multidisciplinary approach is essential from a team of restorative dentists and periodontists to focus on the aetiological factors, patient needs, aesthetics and achieve stable long-term clinical results. The present case report discussed the satisfactory management of a wide anterior maxillary midline diastema in a 30-year-old female using a conservative perio-restorative approach with ceramic veneers after frenectomy and aesthetic crown lengthening procedure without any orthodontic intervention. The success of the present case was determined by a proper diagnosis of the underlying aetiology, treatment planning, use of ceramic veneers and total-etch adhesive technique.

Displaced Root of 3^rd Maxillary Molar Tooth into Infratemporal Fossa- Role of 3D CT Scan

Sanjay M Khaladkar, B Nagi Reddy

The displaced molar tooth is an unexpected and uncommon intraoperative complication of tooth extraction. Its prompt and early identification and management is crucial, as this may reduce the patient morbidity. Orthopantomogram (OPG) has limitations because of extensive anatomical superimposition of various structures. A 36-year-old female patient was referred for Computed Tomography (CT) of maxillofacial region with 3D CT scan for severe pain and swelling in right cheek region with inability to open mouth for 4 days following the dental intervention in outside dental clinic. CT scan of maxillofacial region showed bony defect in the right 3^rd maxillary alveolus with multiple small bony fragments. Small fragment of molar tooth was displaced into the right infratemporal fossa and was impinging on right lateral pterygoid muscle with surrounding ill-defined soft tissue infiltrates in right retroantral fat. CT Face with 3D reconstruction helps in accurate localisation and gives appropriate anatomical detail in case of displaced molar tooth into infratemporal fossa. Thus, a detailed radiological investigation and documenting the relations of the displaced tooth or fragment with adjacent structures provides crucial information for proper surgical planning and avoiding possible complications.

Mass-Querade: Spontaneous Intramural Oesophageal Haematoma Following Thrombolysis in the Setting of Myocardial Infarction

Spontaneous Intramural Oesophageal Haematoma (IEH) is a rare oesophageal emergency. This report describes the case of a 70-year-old diabetic male, who presented with chest pain and was started on thrombolysis as Electrocardiography (ECG) showed ST elevation Myocardial Infarction (MI). As the patient developed gum bleeding and neck swelling, thrombolysis was stopped. Computed Tomography (CT) showed a non-enhancing mediastinal mass, causing significant extrinsic compression of the distal trachea and a diagnosis of IEH, possibly secondary to thrombolysis was made. Although IEH generally resolves spontaneously with conservative management, the patient remained poorly ventilated despite intubation and expired due to cardiac arrest following failure of resuscitative efforts, eight days after the initial thrombolysis. Several cases of uncomplicated IEH where complete recovery was achieved with conservative treatment are reported in literature; however, there are fewer reports on the poorer outcomes in patients with multiple co-morbidities and co-existent clinical complications.

Failure of three Recommended Regimens to Treat a Case of Gastritis Caused by Helicobacter pylori

Musa Basheer Mansour, Sara Elsheikh Ahmedana

Helicobacter pylori (H. pylori) is a gram-negative pathogen that leads to chronic bacterial infection. Approximately, 50% of the world’s population is affecting even though the precise route of transmission is not known. Up to 90% of people infected with H. pylori never experience symptoms or complications and the majority remains asymptomatic. Treatment failure can occur and physician must deal with case as recommended by guidelines. This report describes the management of a man with gastritis caused by H. pylori that was failed to the three recommended regimens. The patient was initially (first visit) diagnosed as a case of stomach pain (irritation) due to spicy/chilly food. Then the patient was followed regularly up to six visits approximately for 25 weeks with clinical and laboratory assessment provided by medical prescription of recommended regimens. This paper has been reported to describe an unexpected beneficial response to treatment, report unlabeled or unapproved uses of medication and show a positive personal impact despite, the lack of advanced medical facility.

Safe Motherhood after Cardiopulmonary Resuscitation in a Term Pregnancy with Eclampsia: A Maternal Near Miss

Ruby Bhatia, Rohan Bhatia, Vartika Pathak, Sunita Mor, Surbhi Gupta

Cardiac arrest in a term pregnancy is rare with a survival rate of 15-20% and mortality rate as high as 42%. Eclampsia, amniotic fluid embolism, haemorrhagic shock, sepsis, pulmonary thromboembolic events, and anaesthetic complications are significant causes of cardiac arrest. We report a rarest case of a young 26-year-old unbooked primigravida, 38+4 weeks gestation with eclampsia, HELLP syndrome, thrombocytopenia with sudden cardiac arrest-A Maternal Near Miss. Prompt resuscitation with obstetric, and anaesthetist specialist team, paved the journey to safe motherhood. An emergency Lower Segment Caesarean Section (LSCS) immediately after Cardiopulmonary Resuscitation (CPR) was performed. Ventilator support was continued for 72 hours. Successful CPR and immediate caesarean section paved the way to safe motherhood with discharge of healthy mother and baby on 12th post LSCS day. With increasing trends towards high-risk pregnancy and maternal near miss cases, a thorough knowledge in the management of cardiac arrest in pregnancy with advanced resuscitation skills among obstetricians, anaesthetists, and nursing staff is need of the millennium. Repeated simulation learning and mock drills in CPR in pregnancy should be advocated.

Multidisciplinary Approach to Prosthetic Rehabilitation of Traumatically Lost Mandibular Anterior Teeth using Onlay Graft, Laser and Dental Implants: A Case Report

Rizwana Mallick, Mohammad Faisal, Madhuri Alankar Sawai, Vanshika Jain

Traumatic injuries are a primary cause of anterior tooth loss and associated soft and hard tissues damage. Management of lost teeth necessitates a multidisciplinary approach. While the simplest approach in such cases remains that of a Removable Partial Denture (RPD), problems with support and retention can often lead to functional limitations and patient discomfort. Further, patients generally prefer to have a fixed solution over a removable prosthesis. Conventional bridgework also does not provide with suitable replacement in patients with large edentulous spans, thereby, leaving dental implants as the only predictable rehabilitation option. Dental implants present with their own limitations in terms of need for sufficient bone volume for optimum biomechanical foundation for implant placement, adequate space between present teeth and vestibule depth to avoid impingement of the placed implant. This present report illustrates a case of 24-year-old male patient who experienced Road Traffic Accident (RTA) leading to multiple injuries and loss of permanent mandibular anterior teeth. Being dissatisfied with his current removable prosthesis, implantbased treatment was planned. Various clinical findings indicated towards need for onlay grafting and laser assisted periodontal surgery. Thus, a staged multidisciplinary approach was adopted. Postoperative clinical and radiographic findings showed clinically successful treatment. The patient too was satisfied with prosthesis functionality and achieved aesthetics.

Stuck in the Middle! A Case of Repeated Foreign Body Impaction in Oesophagus

P Kiranmayi, Y Radha Krishna

Oesophageal foreign body impaction is usually seen in children as well as in adults with varying aetiologies. It is an emergencysituation requiring proper evaluation and prompt treatment because of the possible complications like oesophageal perforation,mediastinitis and aspiration. Here, the report presented an interesting case of repeated foreign body impaction in the loweroesophagus of an elderly male. A 76-year-old male patient came to the Emergency Department in a Tertiary Care Center withchest pain and obstruction in the passage of food which had begun several hours prior to visit after having a chicken meal. Thepatient had presented with similar complaints in the past on three different occasions. The clinical examination was normal. Asa part of the treatment, urgent upper gastrointestinal endoscopy was performed by using olympus flexible video endoscopeunder general anaesthesia, which showed meal impaction in distal oesophagus. The impaction was removed successfully withcombination of rat tooth forceps and endoscopic snare. Later on after successful retrieval during his subsequent visit in view of hisrepeated foreign body impaction, further evaluations including High-Resolution Manometry (HRM) were performed which revealedmultiple oesophageal spasms during the passage of food, with premature peristalasis and thereby, it was diagnosed as DiffuseOesophageal Spasm (DES). The patient was given nitrates and kept on calcium channel blockers for long term medication. DES isan uncommon cause of dysphagia, for which oesophageal manometry is the gold standard procedure. Presence of synchronouscontractions in a minimum of twenty for one hundredth of wet swallows (constituting 20%), alternating with normal motility patternsis a diagnostic criteria for DES on manometry. HRM has been a significant improvement in the accuracy of describing the variousmotility disorders of oesophagus.

Ayurvedic Management of Subepithelial Vocal Cord Cyst: A Case Study

Sundara Raman, S Aswathy Krishna, BN Ashwini, K Sivabalaji

Vocal fold cysts, otherwise called as vocal cord cyst, are benign masses formed on the membranous vocal folds. Present lineof treatment in contemporary medical science is surgery followed by supplementary voice therapy. There are high chances ofrecurrence of the cyst after surgical excision. This report deals with a single case which was effectively managed with ayurvedicintervention. A 38-year-old female patient presented with hoarseness of voice, difficulty to produce high pitch notes, variationsin pitch while talking. Rigid endoscopy was done and there was presence of solitary subepithelial vocal fold cyst in the middle oflarynx. Treatment was done with Amapachana with Swasamrutam capsule and gorochanadi, two tablets twice daily after food. Snehapana with Varanadighrita + Guggulutikthaka ghrita in arohana matra for 4 days; Abhyanga and bashpasweda for 1 day;Virechana with TrivrtChurna 20 gm given at 7 am; Nasya with Anuthaila for 7 days; Matravasti with Sahacharadi Mezhukupakam60 mL for 5 days. The hoarseness of voice and voice clarity improved on completion of the treatment. A repeat endoscopy showedthat the cyst was no longer present. Subepithelial vocal cord cyst can be effectively managed with ayurvedic intervention principlesof amapachana, agnideepana and ojovardhana.

Ovarian Burkitt´s Lymphoma in a Four-Year-Old Girl: A Rare Case

Godfrey Mutakha, Yuvane Maiyo, Grace Mudi, Anisa Mburu, Peter Itsura

Burkitt´s Lymphoma (BL) is one of the most common paediatric cancers in Sub-Saharan Africa. It is a high-grade lymphoma associated with Epstein Barr Virus (EBV) and malaria infections as co-factors. It may occur as an abdominal tumour with ovarian involvement in a few cases. Previous incidences range between 0.5% to 1.5% of all ovarian neoplasm and are involved in 19% of all adnexal lymphomas. Its occurrence is often among those aged between 6-62 years but very rare among four-year-old girls. This study describes a case of ovarian BL in a four-year-old girl presenting with difficulty in breathing, abdominal pain and distension. The lymphoma had spread to several sites within a short duration. This case represents a great challenge in paediatric oncology management as to when medical or surgical treatment should be considered. Significant laboratory findings were elevated serum Cancer Antigen (CA) 125 and Lactate Dehydrogenase (LDH). Furthermore, flow cytometry, histopathology and immunohistochemistry were confirmed as BL. The child completed chemotherapy and is on remission. Despite its rarity in children, this tumour should be treated aggressively to improve long-term survival.

Nd:YAG Capsulotomy Induced Pupillary Block Glaucoma- A Rare Case Report

K Stephen Sudhakar, G Premnath, KR Vignitha, Minnu Lekshmi, DP Shinisha

A 70-year-old female reported with complaints of defective vision in both eyes. Ophthalmological examination of both eyes revealed well-centred Posterior Chamber Intraocular Lens (PCIOL), thin membranous Posterior Capsular Opacification (PCO) with no signs of inflammation, myopic fundus and normal Intraocular Pressure (IOP). She had history of uneventful cataract surgery in both eyes four years back and was on treatment for diabetes mellitus and chronic obstructive pulmonary disease. PCO was managed with Nd: YAG capsulotomy in both eyes. After ten hours, patient reported back with severe headache, right-sided periorbital pain and profound diminution of vision. Examination revealed corneal oedema, shallow Anterior Chamber (AC) and raised IOP in her right eye. Patient was admitted and treated with parenteral and local IOP lowering agents and cycloplegic agents. Once the IOP was lowered and cornea cleared, slit lamp examination revealed vitreous blocking the pupil resulting in secondary angle closure which was confirmed by Anterior Segment Optical Coherence Tomography (AS-OCT). Nd:YAG LASER peripheral iridotomy was done to relieve the pupillary block. This is presented as a rare case of pupillary block following Nd:YAG capsulotomy in the presence of well-centred PCIOL.

Long-Term Stability of Root Coverage of Restored Roots: A 18-Year Follow-up Case Report

Khalid S Al-Hamdan

Tooth sensitivity is a major concern following gingival recession. Stable long-term results are necessary for the management of this condition. Here, we present a case report with the aim of validating the utilisation of a connective tissue graft to replace a restorative material over the root surface for a long term. A 36-year-old female patient presented with the chief complaint of sensitivity in her lower right (#43) and left (#33) canines, which were previously restored with a composite restoration. The recession type defect was Miller’s Class II. The old restoration was removed and replaced with a connective tissue graft, accompanied by a double-papilla flap. The case was followed-up for 18 years, and the results were stable during the follow-up period, with a highly satisfied patient. Based on these results, it can be reported that a connective tissue graft has highly predictable results and can be used for previously restored root surfaces. In addition, the connective tissue graft provides more stable results than does the use of a restorative material over root surfaces.

Endodontic Retreatment of a Mandibular Second Premolar with Four Roots and Four Canals: A Case Report

Girish Nanjannawar, Saquib Mulla, Divya Gupta, Sharad Kamat

It is a well-recognised fact that incomplete cleaning, shaping and obturation of root canals will lead to endodontic failure. Mandibular second premolars usually have a single root and a single root canal. The presence of four separate roots and four root canals is quite rare. Hence, a comprehensive knowledge about the normal canal configuration along with its variations becomes an indispensable pre-requisite to achieve the success of endodontic treatment. Authors hereby present a case of a 26-year-old male patient and describe its succesful treatment of the mandibular second premolar with four roots and four root canals. The clinical implications of this paper aim at establishing an accurate diagnosis of the root canal system using diagnostic aids such as angulated radiographs and making use of advanced endodontic instruments for successful retreatment of endodontic therapy (C+ files and NiTi rotary endodontic instruments).

Myomectomy with Gelatin Sponge in Myoma Bed- A Video Presentation

Manidip Pal, Soma Bandyopadhyay, Ranita Roy Chwodhury

Authors hereby present a case 23-year-old female of myomectomy with vasopressin and gelatine sponge which obviated the need of blood transfusion. Myomectomy was done in an infertile woman for a 20 weeks gravid uterus size type 5 anterior solitary fibroid under spinal anaesthesia. About 60 mL of diluted vasopressin (10 units in 100 mL normal saline) was injected in the incision area. Incision was made with electrocautery. Myoma capsule was separated by blunt dissection and with the help of myoma screw fibroid was enucleated. Closure of myoma-bed was started with polyglactin 1-0. First knot was applied in one angle. Then, gelatin absorbable sponge {AbGel, size (8×5×1 cm) each, Sri Gopal Krishna Labs Pvt., Ltd., Mumbai, India} was applied over myomabed, followed by continuous simple suture to obliterate the dead space. The bite on the bed side wall started from above, went to the bottom of the bed and traversed to other side wall just above the gelatin sponge, then from bottom went above and pulled-up. After completion of the first layer, second layer was given in same way as myoma-bed depth was still more. Serosa was closed by continuous simple suture and here also a small piece of gelatine sponge was inserted in one area. So, myoma-bed got obliterated. Altogether 1 and ?rd sponge was needed. Bleeding stopped by combined action- mechanical compression of suture and clotting action of gelatin sponge. On contact with bleeding surface, the sponge absorbed platelets. These platelets get damaged, once they come in contact with the walls of myriad of interstices of sponge. Thus, thromboplastin gets released from platelets which initiate coagulation cascades and clot formation (1). Blood loss was about 80 mL. No blood transfusion was given. On 6 month follow-up, patient is doing well [Video: Myomectomy]. Myomectomy is an age-old operation. But, haemorrhage is always a big concern to the gynaecologist. Many techniques have been described to prevent this complication. Diluted vasopressin local infiltration eases the operation by keeping the operative field blood free. In a RCT, vasopressin 20 units diluted with 20 mL normal saline was injected intramyometrially during myomectomy. Vasopressin group had 66% reduced blood loss (2). Preoperative uterine artery embolisation with absorbable gelatin sponge resulted in very less blood loss during myomectomy (3). Gelatin-thrombin matrix (liquid form) topical application during open myomectomy reduced the intraoperative bleeding and transfusion rates (4). In present case we have applied gelatin sponge directly over the bleeding myoma bed to achieve haemostasis and result was good. Gelatin sponge is very cheap and easily available and it is completely absorbed within 4-6 weeks (1). Same technique can be applied for laparoscopic and robotic myomectomy. Gelatin sponge topical application on myoma bed could be a good cost effective option to achieve haemostasis during myomectomy, especially for resource poor country.

Intra-articular Mass of the Knee by Gout Tophus: A Case Report

Naoki Ishida, Ivan Sekiguchi

Gout is a relatively common condition in the population today. With progressing of the treatment of the hyperuricaemia, the case of producing a tophus decreases year by year. On the other hand people who are leaved without treatment is increasing, and severe cases are also seen. Intra-articular tophus is rare, but some cases have been reported in the knee. In this, a case of 33-year-old man who had an intra-articular mass of the knee by gout tophus, causing the limitation of the range of motion is reported. The patient didn’t improve with conservative treatment, so he had to undergo surgery. After arthroscopic excision of the tumour, the patient was symptom free. There had been no recurrence of symptoms at the 2-year follow-up.

Testicular Lymphoma: A Rare Entity

Soumya Mondal, Eeshansh Khare, Dilip Kumar Pal

Testicular malignancy in old age men should be thoroughly studied because of low rate of incidence. Incidence of testicular lymphomas have been shown to be nearly 9% among all testicular malignancies and 1-2% of all lymphomas found in human body. The most common hisopathological pattern among lymphomas is B-cell type and of these diffuse large B-cell subtype is commonest; however, less commonly, Burkitt’s lymphoma, anaplastic lymphoma or Hodgkin’s lymphoma may primarily involve the testis. Testicular lymphoma is rare whether as a primary or as a secondary origin. Diffuse Large B-Cell Lymphomas (DLBCL) is the most common histopathological type if primary in origin; however aggressive patterns like, Burkitt’s lymphoma, are more common when there is secondary involvement of testis. Stage of the lymphoma (Ann Arbor staging) determines the prognosis of the disease. Other prognostic factors include presence of B symptoms and International Prognostic Index (IPI) score, involvement of spermatic cord and other testis. Immunohistochemistry should be done after histopathological diagnosis for effective treatment of variants of testicular lymphoma. High inguinal orchiectomy along with chemotherapy with or without radiotherapy is current treatment of choice for these tumours. In this article, the case of testicular lymphoma is presented in a 61-year-old male patient, clinical presentation, investigations and surgical and chemotherapeutic management with discussion with respect to previous clinical studies. In this case report, patient presented with swelling of left scrotum for which he underwent the radiological and biochemical investigations. He was further planned for frozen section biopsy. The histopathological and immunohistochemical analysis was suggestive of DLBCL, as final diagnosis.

A Rare Case of Adult-onset Best Disease

Siddharam S Janti, Shinisha Damodaran Paul, Stephen Sudhakar Karunakaran

Best disease also known as Vitelliform macular dystrophy, classically presents with defective central vision. Macula which is responsible for the central vision and colour perception is affected. Individuals affected by Best disease, initially have normal vision followed by decrease in central visual acuity as well as metamorphopsia. The case presented a 49-years-old female with complaints of progressive and painless defective Vision of her Left Eye (LE) with previous history of Diabetes. A well circumscribed single greyish lesion of size 0.5DD was noted in the macula, which was conformed to be Best disease.

Brugada-like ECG Pattern in COVID-19 Infection

The Brugada-like Electrocardiogram (ECG) pattern is a transient condition which may be induced by number of conditions. In this case reported, a 53-year-old Iranian male patient, presented with seven-day history of fever, chills, headache and shortness of breath. At the time of presentation to the Emergency Department (ED), the patient was febrile with tachycardia, tachypnea, and oxygen (O₂ ) saturation 75%. The chest radiograph showed a bilateral infiltration and positive result of Real Time Polymerase Chain Reaction (RT-PCR) confirmed the diagnosis of COVID-19 infection. He received kaletra, hydroxychloroquine, azithromycin, antibiotics, and Intravenous Immunoglobulin (IVIG). The patients was intubated and underwent mechanical ventilation because of no improvement on the O₂ saturation level. Fever subsided on seventh day and hydroxychloroquine was stopped on fifth day. On the sixth day of hospital stay, ECG showed sinus tachycardia. Troponin-I- high sensitive was within normal range and Transthoracic Echocardiography (TTE) showed normal Ejection Fraction (EF). On 10^th day, type I Brugada-ECG pattern presented and regular ECG monitoring was recommended. Finally, after 11-day hospital stay, the patient died due to bradycardia and asystole despite Cardiopulmonary Resuscitation (CPR). Thus, physicians should consider Brugada-ECG pattern in the pre-cordial leads (V1 to V3) of ECG among patients with COVID-19 infection beside regular QT interval monitoring.

Plasma Cell Rich Osteomyelitis: A Rare Entity

Prakhar Maheshwari, Rajesh Kumar Maheshwari, Anuradha Kusum, Digvijay Agarwal

Plasma cell rich osteomyelitis is a rare finding characterised by a plethora of plasma cells localised in the affected bone without the typical clinical features of infection. It usually affects the metaphysis of long bones with a radiological appearance as a dense thickening of bone without sequestrum formation. We present an atypical case of plasma cell osteomyelitis with a lesion in the metaphysis as well as the diaphysis of the humerus without sclerosis but with sequestrum formation. An 11-year-old girl was brought to OutPatient Department (OPD) with complaints of post-traumatic pain and swelling at left shoulder and proximal arm since one and a half months with aggravation of symptoms since last 10 days. Patient had also been treated for Urinary Tract Infection (UTI) by a paediatrician who prescribed antibiotics and antipyretics because of which fever subsided but the pain persisted. The x-ray of left shoulder with arm revealed a fracture of surgical neck of humerus with cortical irregularity noted in the midshaft of humerus along with lamellated periosteal reaction suggestive of post-traumatic osteomyelitis with a pathological fracture. Clinicoradiologic diagnosis of pathological fracture of left neck of humerus was made with an underlying neoplastic or infective aetiology. An open biopsy was taken from left proximal humerus. Histopathological examination showed plasma cells in sheets having abundant basophilic cytoplasm, round to eccentric nuclei and perinuclear hoff along with lymphocytes and few polymorphs with surrounding area showing fibrosis, oedema and hyperemia. A diagnosis of chronic plasma cell osteomyelitis was rendered, which is an uncommon condition without specific clinical findings and an ambigious cause. Histopathology is the definitive tool for obtaining an accurate diagnosis and we strongly recommend a meticulous histopathological examination correlated with clinicoradiological description for a correct diagnosis in order to avoid an increased frequency of diagnosis of neoplastic plasma cell lesion as well as for advocating the correct treatment. This case is discussed for presentation of plasma cell osteomyelitis and also to report a case of chronic primary plasma cell rich osteomyelitis with atypical clinical features.

Dental Implant for a Patient with Narcolepsy: A Case Report

Hani Mawardi, Yasser Mahfouz, Siraj Dakhil, Mohammed Zahran, Lena Elbadawi

Narcolepsy is a neurological disorder characterised by cataplexy, sleep paralysis and excessive daytime sleepiness. The literature on dental managements of patients with narcolepsy is lacking with no set guidelines for dental practitioners. A 31-year-old female presented to the dental office with a dull pain related to the maxillary left lateral incisor with Grade 2 mobility and isolated 8 mm periodontal pocket. In addition, there was loss of buccal gingiva with radiographic changes suggestive of caries and fractured crown. The patient had a history of narcolepsy with cataplexy and hypertension controlled with bisoprolol and desvenlafaxine in addition to clonazepam 1 mg/day as needed to prevent episodes of cataplexy. Patient was asked to take 2 mg clonazepam and 600 mg ibuprofen one hour before procedure. The maxillary left lateral incisor was extracted atraumatically and an immediate implant combined with allogenic bone graft and collagen membrane was placed. The procedure was uneventful, and patient left conscious and stable. After three months, the implant was restored with porcelain fused-to-metal crown and followed-up for six months without any complications. This is the first case describing a narcolepsy patient who successfully received a dental implant without developing a cataplexy episode. Clonazepam prophylaxis may be considered prior to dental procedures for similar situations.

Salmonella Newport Gastroenteritis in an Adult- A Rare Case Report

Poornima Baby, Aishwarya Babu

Salmonella Newport is a major cause of food-borne infection which occurs due to consumption of contaminated food items. Stool sample from a suspected case of enteric fever was received in the Central Microbiology Laboratory of a tertiary care teaching hospital in Southern India. The bacterial isolate was identified on the basis of Gram Staining, cultural characteristics and biochemical reactions as Salmonella species. Agglutination for serotyping was done and it was found to be agglutinable by only Polyvalent O antiserum. For further speciation, the isolate was sent to the National Institute of Cholera and Enteric Diseases (NICED), Kolkata, West Bengal, India and was identified as Salmonella enterica serotype Newport. The patient responded well to ciprofloxacin therapy. As the diagnosis of Non-Typhoidal Salmonellosis (NTS) is often challenging, patients with suspected Salmonella infections are usually given empirical antibiotic therapy which can cause an increase in drug resistant NTS.

Myroides causing Catheter Associated Urinary Tract Infection in Diabetic Patients: An Emerging Multidrug Resistant "Superbug"

Kalpana Chauhan, Priyanka Chaturvedi, Ravi Pratap Singh, Anita Pandey

Myroidesis a nonfermentative, gram-negative rod shaped bacterium which is an emerging multidrug resistant pathogen causing many serious hospital acquired infections like Catheter Associated Urinary Tract Infection (CAUTI). The authors report a case series (four cases) of CAUTI caused by Myroides species which was resistant to all tested antibiotics (ticarcillin-clavulanic acid, piperacillin-tazobactam, ceftazidime, cefepime, aztreonam, cefoperazonesulbactam, imipenem, meropenem, amikacin, gentamycin ciprofloxacin, levofloxacin, colistin, tigecycline) and sensitive only to minocycline (minimum inhibitory concentration <1 µg/mL), in long-standing Diabetic Mellitus Type II patients. All the four patients were successfully treated with minocycline. Present cases highlight the importance of Myroides as a pathogen in Urinary Tract Infection (UTI) in diabetic patients, especially in nosocomial settings which clinicians should keep in mind.

Neurological Insights of Scrub Typhus: A Case Series

Puneet Saxena, Deepak Chadha, Rishika Goyal

Scrub typhus is a rickettsial disease caused by gram-negative coccobacilli and transmitted through the bite of larval stage of mite. The disease is notable in the Asia-Pacific belt with few sporadic and epidemic cases reported from India as well. The disease is well-identified from North-Western part of Rajasthan that are the areas with dense vegetation. The clinical scenario ranges from acute febrile illness to multiple-organ dysfunction by virtue of haematogenous seedling. This case series highlights the neurological manifestations of scrub typhus that are diverse and life-threatening but holding dearth of literature to convoy appropriately timed diagnosis and treatment.

Demyelinating Pseudotumours Presenting as Space Occupying Lesions Mimicking Brain Tumours- A Histopathologic Assessment of Seven Cases

B Deepthi, Somasekhar Pothula

Demyelinating lesions which present as solitary contrast-enhancing masses pose a diagnostic challenge for both radiologists and surgical neuropathologists and can mimic a number of intracranial space occupying lesions either neoplastic/inflammatory. Herein, a series of seven cases with particular emphasis on histopathological and immunohistochemical characterisation of these lesions was presented. The seven cases of Tumefactive Demyelinating Lesions (TDLs) diagnosed on histopathology include three males and four females with age ranging from 10 to 58 years (median-25 years) chiefly presenting with focal neurological deficits. Radiologically, the lesions were predominantly localised in the temporo-parietal region. Histologically, the lesions were well-demarcated, hypercellular with infiltration by foamy macrophages and reactive astrocytes. In addition, Creutzfeldt astrocytes and granular mitoses were seen. Additional special stains for myelin (Luxol fast blue), demonstrated focal, sharply marginated loss of myelin, and Immunohistochemistry (IHC) with Neurofilament (NF) for axons showed relative preservation of axons in areas of myelin loss. IHC with Glial Fibrillary Acidic Protein (GFAP) highlighted the fibrillary processes of the reactive astrocytes and the cytoplasm of the Creutzfeldt cells. Knowledge of the characteristic features such as welldemarcated lesions with histological characterisation by large number of macrophages, including Creutzfeldt astrocytes, granular mitoses and perivascular inflammation should raise index of suspicion and prompt pathologist to do additional myelin stains and IHC to confirm demyelination and preservation of intact axons thereby, differentiating from neoplasms and other non-neoplastic inflammatory lesions.

Intra-abdominal Abscesses by Burkholderia cepacia in Poorly Controlled Diabetes Mellitus: A Case Series

Aditya Dhanawat, Partisha Gupta, Lalatendu Mohanty, Guncha Maheshwari

Burkholderia is a gram-negative bacillus causing infections in immunocompromised patients. It is commonly seen in the tropics and is known to mimic tuberculosis clinically. Six patients were reviewed who were admitted in our hospital between July 2018 to June 2019 after obtaining their consent. All the six patients were uncontrolled diabetics with HbA1c levels between 8.2-13.9% who presented with fever more than 2 weeks and had abdominal symptoms like vomiting, abdominal pain or loss of appetite. Some also had respiratory symptoms like cough, chest pain and breathlessness. All of them had leucocytosis (neutrophilic). Mild transaminitis was also observed. CT abdomen revealed presence of multiple hepatic and splenic abscesses in all the patients. Chest X-ray revealed bilateral pneumonia in five patients. Burkholderia cepacia was found in the blood of four patients, sputum of one patient and splenic pus aspirate of one patient. Four patients were treated with meropenem and rest with ceftazidime. All of them responded well to treatment and became asymptomatic. Ultrasonography abdomen at follow-up was negative for any intra-abdominal abscesses. They were also put on long term oral co-trimoxazole. The clinical presentation of Burkholderia closely mimics tuberculosis as it predominantly affects immunocompromised and causes a long-duration multi-systemic illness. There has been several case series of intra-abdominal abscesses caused by Burkholderia pseudomallei but infections by Burkholderia cepacia in the abdomen is a rare finding. The diagnosis of burkholderia is often delayed due to its inconspicuous nature, lack of clinical suspicion and often mimicking tuberculosis clinically

“Pravara Tent”- An Innovative Protective Device to Control Aerosol in Dental Clinics during the COVID-19 Pandemic

Many dental procedures use modern devices like an air rotor and ultrasonic scaler, which generate aerosols and droplets. The dental procedures cannot be performed without the above devices. The ways commonly available today to control aerosols are suction, saliva ejectors, but it does little to control aerosols. The expensive filters like HEPA (high-efficiency particulate air) are available but they are not easily available in rural set-up and economical for everyone. There are many diseases, for example- severe acute respiratory syndrome, tuberculosis, influenza and viral infections, which spread through droplets, so management of the infection control procedures for aerosols is mandatory in dental clinics. A novel human coronavirus-that is, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) also can be transferred through droplets and splatter. The COVID-19 pandemic has led to the manufacturing of novel devices to protect the dentist from the risk of transmission. The “Pravara tent” (the name Pravara was given to the tent by the authors as it was invented at the place called Pravara) is one of the examples of a protective (box) device, which can be used to control aerosols generated from air rotor and an ultrasonic scaler to reduce transmission of diseases between clinicians, and the patients. So, this tent is a simple, modified, and economical innovative protective device working with high efficacy by creating a barrier between patient and dentist to minimise aerosols during dental procedures.

Optimisation of the Method of Stem Cells Mediated Tissue Remodelling in Diabetic Wound Healing

Raid Saleem Al-Baradie

Introduction: Incomplete, slow or limited wound healing is one of the major disabling events accompanying diabetic patients. At the present time, there is no effective treatments which enable efficient wound healing in diabetic patients. Aim: To optimise the method of loading of Human Mesenchymal Stem Cells (MSC) with S-Allyl Cysteine (SAC) from aged garlic extract and invitro optimisation of the delivery process, attachment and optimisation of stem cells and loaded stem cells to the fibroin matrix in induction of wound recovery completion in a model of diabetic wound healing. Materials and Methods: It was a preclinical invitro model which employed the anti-inflammatory and anti-bacterial properties of fibroin matrix after populating them with drug-loaded human MSCs. This combination allowed slow and sustained release of the active substance into the wound and with the stem cells, promoted tissue remodelling thereby, inducing enhanced wound recovery in diabetic model. Results: Mixture of SAC and N-Acetylcysteine (NAC) was most effective. S-Allyl Mercaptocysteine (SAMC) protected angiogenesis and showed tube formation in the presence of advanced glycation end-products. Protection against oxidative stress and apoptosis-Propidium Iodide (PI) staining shows protective effects of the cysteine compounds particularly SAC and SAMC. Conclusion: Present study results provide possibilities of utilising tissue-engineered fibroin matrix with drug loaded human MSC as a potential therapeutic technique, due to its beneficial effects in terms of cell attachment and bioactive factor loading, for diabetic wound healing.

Endoscopic Removal of a Migrated Fragment of Wire used for Intermaxillary Fixation in Surgical Treatment of Mandibular Fracture

Toshinori Iwai, Satomi Sugiyama, Toshiyuki Koizumi, Makoto Hirota, Kenji Mitsudo

A 63-year-old woman fell and hit the right side of the mandible directly on the floor, and visited our department with right side of the lower jaw pain and intraoral bleeding as the chief complaint. She had no present and past significant medical and dental histories. She had trismus. Intraoral examination showed malocclusion (imperfect positioning of the teeth when the jaws are closed) and intraoral bleeding from the fractured site. Panoramic radiograph showed a fracture of the right posterior body of the mandible and the root fracture of the right second molar. Therefore, she underwent open reduction and internal fixation of the mandibular fracture under general anaesthesia. An intraoral incision was made along the ascending ramus and cervical gingiva of the right second molar, and vertical gingival incision was made at the mesial aspect of the mandibular second molar. The second molar was removed after the flap elevation, and six 2.0 mm diameter intermaxillary fixation screws (Dual-Top Auto Screw II^®, Jeil Medical Corporation, Seoul, Korea) were used for intraoperative intermaxillary fixation. After the bone reduction and intermaxillary fixation with wires, two plates fixation was performed with 2.0 mm fixation system (Universal Mandible^®, Stryker, Tuttlingen, Germany). The 0.3 mm diameter steel wires were cut and removed, and the wound was closed with resorbable suture (VICRYL^®). Surgical time was 172 min. The next day, panoramic radiograph and computed tomography revealed a wire fragment below the right inferior border of the mandible (Table/Fig 1). Therefore, she underwent removal of the wire fragment under general anaesthesia. Because the wire fragment was small (6 mm length), the removal was performed using a 30-degree, 4-mm-diameter endoscope with tissue retractor (Karl Storz, Tuttlingen, Germany) (Table/Fig 2). An intraoral incision was made along the ascending ramus and cervical gingiva of the right second molar, and vertical gingival incision was made at the mesial aspect of the mandibular second molar. This incision was opened during second surgery by suture removal. The sutures were removed and intraoral wound was opened. After the retractor was inserted into the wound, the endoscope was inserted intraorally and blindly in the surgical space, and additional space-making was performed by the tissue retractor of the endoscope. The small wire fragment was identified on the lateral side of the right inferior border under endoscopic guidance (Table/Fig 3), and removed completely using a long mosquito forceps (FOUR MEDICS, Tokyo, Japan) without the use of 3D C-arm prepared (Table/Fig 4). The wound was closed with resorbable suture (VICRYL^®). Furthermore, refixation of plates was performed due to insufficient plate fixation in the initial surgery. Panoramic radiograph after second surgery showed no wire fragment (Table/Fig 5). The patient was discharged 7 days after first surgery. Foreign bodies are sometimes migrated in the tissues in head and neck by trauma [1-3], but iatrogenic foreign bodies, such as broken needles or instruments, teeth, roots, and dental implants are also reported [4-8]. Foreign body removal is challenging for the complexity of the approach and the proximity to vital anatomical structures such as nerves and vessels (3), and blind exploration is often time-consuming and sometimes futile (4). Therefore, preoperative localisation and intraoperative identification of foreign bodies are required. Foreign bodies retained in the head and neck region may cause complications including infection such as sinusitis or meningitis, pain, fistula, metal relevant poisoning, or cancer (1). Several methods have been used to detect and localise foreign bodies, such as radiograph, computed tomography, magnetic resonance imaging, ultrasonography (4), C-arm fluoroscopy [4-6], navigation system [1,2,4,7], endoscope [1-3,8]. Preoperative imaging methods cannot allow intraoperative identification of foreign bodies. Intraoperative ultrasonography cannot show foreign bodies migrated in deep tissues. Navigation systems help identify the location of foreign bodies three-dimensionally and intraoperatively, but the intraoperative displacement of foreign bodies migrated in the soft tissues makes the identification difficult. Although C-arm fluoroscopy has radiation exposure, it can provide real-time twodimensional image. Especially, 3D C-arm allows not only planar images but also 3D images as CT. Because endoscope can provide good illumination, clear and magnified visualisation of the surgical field, it is used for removal of foreign body in deep regions, such as condylar process (3) and maxillary sinus (8). Although the intraoral approach without a visible scar and facial nerve injury has restricted surgical field and difficult access, even small foreign bodies can be identified under endoscopic guidance. In the present case, a small wire fragment remained on the lateral side of the right inferior border, could be removed easily by magnified visualisation of the endoscope, without the use of 3D C-arm prepared.

Umbilical Deposit in Metastatic Breast Cancer

Anju Anna Abraham, TM Anoop, P Rona Joseph, Steffi Chacko

Sister Mary Joseph nodule or Sister Mary Joseph Sign refers to a palpable umbilical nodule as a result of metastasis from disseminated malignancy. It is a rare finding and is a sign of advanced stage of malignancy. Gastrointestinal malignancies and gynaecologic malignancies account for most cases of umbilical deposit. Here, the authors describe a case of disseminated metastatic breast cancer with umbilical metastases as Sister Mary Joseph nodule. A 59-year-old postmenopausal lady presented with progressive abdominal distension and exertional breathlessness of two months duration. The patient had history of triple negative breast cancer treated in December 2017 with neoadjuvant chemotherapy, Modified Radical Mastectomy and adjuvant radiation. Clinical examination revealed enlarged right axillary lymph node, distended abdomen with pelvic mass, ascites and an infected pea sized umbilical lesion clinically suggestive of Sister Mary Joseph nodule (Table/Fig 1). A Computer Tomography of abdomen and pelvis showed an umbilical deposit with size of 3.4×3.3 cm (Table/Fig 2) along with moderate ascites, multiple peritoneal and omental deposits. A bulky uterus with mass like enhancement in endometrial cavity and Peritoneal and Omental Deposits (POD) deposits were also noted. Metastatic evaluation with Computer Tomography of Chest, Abdomen and Pelvis also revealed mediastinal lymphadenopathy, lung and liver metastases. Right axillary lymph node biopsy showed metastatic adenocarcinoma. Immunohistochemistry revealed negative staining for estrogen, progesterone and Her 2/Neu receptors. Final diagnosis of disseminated metastatic breast cancer with umbilical deposit was considered. Patient received palliative chemotherapy with single agent carboplatin for six cycles. Evaluation done 3 weeks after sixth cycle of palliative chemotherapy with CT scan, showed progressive increase in size of peritoneal deposits, ascites and lung metastasis. Patient opted for follow-up with supportive care thereafter. The first umbilical metastasis was described by Storer in 1864. Sir Hamilton Bailey coined the term “Sister Mary Joseph nodule” as this sign was first identified by Sister Mary Joseph who was a surgical assistant to Dr William James Mayo, in patients being prepared for surgery in 1928 (1). The nodules are typically firm and irregular, located at dermal, subcutaneous or peritoneal level. They may be sometimes painful, ulcerate or fistulise, with a serous, purulent or bloody discharge. Commonly encountered primary tumours associated with umbilical metastasis include stomach, ovary, colorectal and pancreas (2). The presence of an umbilical metastasis indicates a poor prognosis and is a sign of disseminated malignancy (3). The differential diagnosis of umbilical nodule is Sister Mary Joseph nodule, umbilical granuloma, umbilical hernia, endometriosis, omphaliths and keloid (4). Sister Mary Joseph nodule is associated with evidence of disseminated malignancy especially with gastric and genitourinary malignancies [5,6]. Umbilical endometriosis usually occurs in reproductive age group with bleeding from umbilcal nodule during menstruation [7,8]. Omphaliths are formed due to poor personal hygiene which results in accumulation of sebum and exfoliated skin within the umbilicus (9). Umbilical keloids usually have a history of trauma or umbilical piercing (10). Umbilical hernia may be congenital or postsurgical in origin. This article highlights the importance of keeping Sister Mary Joseph nodule in the differential diagnoses for umbilical hernia. Though rare, breast metastasis may present as umbilical hernia.

Impact of COVID-19 on Medical Education in India: A Student’s Perspective

Prabal Saha, Lekha Saha

Dear Editor, Coronavirus Disease (COVID-19) is caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). COVID-19 is so called because it was first reported on 31 December 2019 from Wuhan, the Capital City of Central China’s Hubei Province. It was first identified in a cluster of atypical pneumonia cases of unknown cause. These patients exhibited severe respiratory symptoms, including Acute Respiratory Distress Syndrome (ARDS) (1). Subsequently, COVID-19 spread across the globe and affected more than 213 countries and territories. As of 18 June 2020, the World Health Organisation (WHO) reported 8,242,999 cases and 445,535 deaths globally, which still continues to rise. At the same time point, there were 366,946 confirmed cases and 12,237 deaths in India (2). On 24 March, the Government of India under Prime Minister Narendra Modi, ordered a nationwide lockdown for 21 days to combat the spread of coronavirus and was further extended till 30th May 2020 (3). This had a huge impact on health, economy, society and educational system. Since SARS-CoV-2 is highly contagious, most educational institutions have cancelled or postponed all academic activities, conferences and workshops or other important events which involve large gatherings. Career of medical students is affected to huge extent as compared to their peers from other non-medical courses because of the sudden interruption in their academics. Theory and practical curriculum have been suspended and all assessments withheld indefinitely. It has led to lots of uncertainties among students both because of the enigma surrounding the natural history of the disease and sudden disruption of all teaching and other educational activities. Due to suspension of clinical sessions, the required clinical skills may not be developed up to the mark for practicing medicine. There is tremendous fear and depression among medical students who are the frontline workers in future for such a devastating pandemic (4). In this scenario, the following steps should be taken to mitigate their apprehensions: 1. There should be immediate psychological counselling and support for all medical students through telemedicine or with the help of other technologies. 2. Awareness should be created about COVID-19 and measures should be taken to prevent transmission of SARS-CoV-2 among medical students and shield them from rumors and misinformation. 3. Social media platforms should be utilised by students and faculty, which will make them feel that they are connected, even though they are away from college. 4. Classes should be resumed through online teaching platforms, which will be an effective alternative to conventional academic activities during the COVID-19 crisis. These measures can alleviate the stress and anxiety of students and can also simultaneously reduce the risk of transmission of the disease among them. Web-based online classes will help them cope with the lost clinical hours and lagging syllabus which is already a huge loss for a medical student.

Perception of Students towards Newer Teaching Methods in Medical Education

Motilal Chandu Tayade

Dear Editor While I came across a published research article by Ramya C et al., on the perception of students towards newer teaching methods in medical education in your esteemed journal, found relevant and fruitful message contained in the article (1). I thank the authors and editors of JCDR for covering such a wonderful topic. Authors concluded that medical educators need to constantly change their teaching methodologies in order to effectively hold the attention of students (1). Different learning environments and methodologies can surely help in better retention rather than traditional teaching patterns. When molecular changes occur at neuronal levels due to learning stimulations, these various sites get amplified, processed and transformed. The human brain processes information in complex networks of nerve cells (2). The cells communicate and excite one another through special connections, called synapses. There are a number of learning styles like visual, aural, verbal, physical, logical, social and solitary, etc. Kolb stated that “Learning is the process whereby knowledge is created through the transformation of experience” (3). New brain cells connections formed by learning process, represent and store new knowledge or information. Growth factors, specialised neurotransmitters are responsible for formation as well as strength of these connections. These growth factors can be enhanced by regular specialised training of the brain. Only active learning process can be responsible for changes in our neural connections (2). Now-a-days medical students face increasing pressure due to huge competition and changing expectations from community. This may be due to wide exposure towards technology and information flood. Ramya C et al., introduced the effectiveness of three different tools viz., Crossword Puzzle, Mind Maps and e-learning (1). Specialised graphical forms are used to record ideas as well as information in mind mapping techniques. These are used very effectively to understand and grasp complicated topics. The visually encoded information is more easily retained than auditory encoded information. In mind mapping, visually encoded information is linked with a topic on which students can focus easily. It is also observed that students can learn better with project-based learning than traditional classroom learning. The use of a crossword puzzle in regular learning makes the environment relaxing and friendly facilitating active learning. This direct involvement in learning is responsible for a positive outcome (4). The objective behind writing the letter was to highlight the basic neurophysiological scientific aspects associated with the results of Ramya C et al., (1).

Malignant Gastric Neoplasms: A Clinicopathological Study with Special Reference to Serum CA125 Level with Peritoneal Dissemination

Ankita Pranab Mandal, Adahra Patricia Beso, Mou Das, Rama Saha

Introduction: Gastric cancer is a malignant tumour with a fifth position amid all cancers and its mortality rate is third globally. The most common distant mode of metastasis is Peritoneal Dissemination (PD). There is a positive correlation between serum Cancer Antigen 125 (CA125) level and PD in cases of malignant gastric neoplasm. Aim: To study the demographic features, the macroscopic and microscopic features of malignant gastric neoplasm and the relation of serum CA125 level with PD in cases of gastric cancer. Materials and Methods: This cross-sectional observational study was conducted for two years from January, 2018 to January, 2020 on 120 cases at Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal (India). Detailed history taking, clinical examination, routine investigation was done. Peripheral blood sample for CA125 assay was collected. PD was identified through Ultrasonography (USG) or Computed Tomography (CT) or intraoperatively during open surgery. The gastrectomy specimens were sent for gross examination, staging and histopathology. Microsoft excel 2016 and SPSS 18 was used. Chi-square test was used for the comparison between the groups. A p-value of <0.05 was considered significant. The sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were used for elective assessment. Results: This study comprised 120 cases with mean age of presentation as 54.3 years and male: female ratio of 2.3:1. Fifty cases (41.6%) were identified as tubular (solid)-poorly differentiated adenocarcinoma with 59 cases (49.2%) of stage IIIA and 52 cases (43.3%) of stage IV. The sensitivity and specificity of CA125 was 81.8% and 85.7%. The PPV and NPV were 56.2% and 95.4%. Conclusion: Early detection of peritoneal disease will help the clinicians to stratify the treatment of gastric cancers. Higher sensitivity suggests that preoperative serum CA125 is a promising tool to predict PD which aids in subsequent alternative mode of treatment, lesser morbidity and better survival of patients.

Risk Stratification of Patients with Gastrointestinal Stromal Tumours by Histopathological and Immunuhistochemical Analysis

Prathima Shivaji Rao, Manikya Manjunath

Introduction: Gastrointestinal Stromal Tumours (GISTs) are the most common mesenchymal tumours of the alimentary canal. Interstitial cells of Cajal are believed to be the cell of origin of GIST which regulates gastrointestinal peristalsis. GISTs encompass a clinicopathologically distinctive, but heterogenous group of neoplasms with reference to their origin, cellular differentiation and prognosis. Aim: The aim of this study was to analyse the histopathological and immunohistochemical characteristics of GIST. Materials and Methods: A hospital-based cross-sectional study of 108 cases of GIST were studied over a period of three years from January, 2017 to December, 2019 in Department of Pathology, Vydehi Institute of Medical Sciences and Research Institute (VIMS&RC), Bangalore. Patient’s demographic data like age and gender were collected. Tumour characteristics like site, size and number of lesions were analysed. Histopathological and immunohistochemistry for Desmin, CD117 and DOG-1 were analysed for significant association with risk groups. Risk stratification according to the Fletcher's risk classification, the cases were divided was divided into very low, low, intermediate and high risk groups. The master chart of collected data was prepared in Excel sheet. Chi-square test with Yates correction was used to calculate p-value to ascertain statistical significance. The master chart of collected data was prepared in Excel sheet. Descriptive statistical analysis was presented in the form of tables, figures and diagrams wherever necessary using Epi info 07 statistical software package. Results: The mean age of the patients was 55.6±14.4 years. Males (55.6%/60 cases) were commonly affected than females (44.4%/48 cases). Small intestine was the commonest location (44.4%/48 cases). Tumour size ranged from 1.5 cm to 25 cm with a mean of 9.1 cm. Microscopic findings revealed that spindle cell type was the most common (86.1%/93 cases). Majority of the cases belonged to high risk category. Multifocality, necrosis, tumour size and >5 mitosis/50 High Power Field (HPF) showed significant association with high risk category tumours (p-value 0.033, 0.016, 0.004 and <0.001, respectively). Immunohistochemical staining showed positivity for CD 117 (83.3%/90 cases), DOG-1 (88.9%/96 cases) and 108 cases/100% negativity for desmin. Conclusion: This study found significant association of high risk groups with tumour size, multifocality, necrosis and mitosis >5/50 HPF. Risk categorisation of GIST remains important. A combination of CD117 and DOG-1 will be more useful in diagnosing GIST rather than using them alone.

Relationship between Maternal and Perinatal Outcome with High Vaginal Swab Culture: A Cross-sectional Study

Charu Mahajan, Devyani Misra, Mariyam Faruqi, Rajkumar Mishra

Introduction: Most of the pregnancies progress normally but unfortunately, few are prone to developing complications. Some antenatal and intra-partum conditions place the mother and the developing foetus or both at risk for complications and infections which undoubtedly play a major role in the same. Vaginal microbiome composition changes during pregnancy. This change is believed to inhibit pathogen growth through secretion of bacteriocins such as lactic acid that maintain acidic pH. Disturbed vaginal environment is associated with complications of pregnancy. Aim: To find the relationship between the microbiological study of High Vaginal Swab (HVS) in pregnancy at term with the maternal and foetal outcome. Materials and Methods: This cross-sectional study was conducted on 200 women who underwent vaginal swab culture during routine prenatal check-up from July 2019 to January 2020, in a hospital in Lucknow, Uttar Pradesh, India. The maternal and perinatal outcome and their relation with microbiological study of HVS were studied. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 11.5. Chi-square test was used for comparison of data for statistical significance. For descriptive statistics percentage, mean and Standard Deviation (SD) was calculated. Results: E.coli (18%) was the most common organism isolated from HVS cultures in this study. Maternal complications, rate of Lower Segment Caesarean Section (LSCS), low APGAR scores (Appearance, Pulse, Grimace, Activity and Respiration), need for neonatal resuscitation and Neonatal Intensive Care Unit (NICU) admission were more in the culture positive group. Conclusion: The study suggests that the abnormal vaginal microbiota is associated with adverse pregnancy outcomes. HVS cultures are simple and non-invasive screening tool which should be used as a routine procedure in all antenatal patients for preventing complications and improving the foeto-maternal outcome.

Comparison of Clinicopathological Profile of Oral Squamous Cell Carcinoma between Younger and Older Indian Adults

Introduction: The relative incidence of Oral Squamous Cell Carcinoma (OSCC) seems to be increasing in young subjects and there is still no consensus regarding its pathogenesis, clinicopathological characteristics and prognosis in this population. Aim: The study aimed at evaluating the clinicopathological features of OSCC in younger patients and to determine any characteristic specific to this population in contrast to the older subjects. Materials and Methods: This was a single centre prospective study, conducted on 187 radical resection specimens of OSCC, between April 2015 and April 2020, at MS Ramaiah Medical College and Hospitals, Bengaluru. Of the study population 18.7% were young patients (≤40 years) and 81.3% were older patients. The clinical features and tumour characteristics were evaluated and the tumours were staged according to American Joint Committee on Cancer (AJCC) staging system. The characteristics in young patients (≤40 years) were compared to those of older patients. SPSS Version 18.0 software was used for statistical analysis. Chi-square test was used to determine any significant difference in the categorical variables. Results: Of the 187 patients, included in the study, 18.7%were young with a mean age of 36.8 years and male: female ratio of 1.3:1. Risk factor usage was present in 85.7% and family history of OSCC was present in 5.7% of the patients. Buccal mucosa was the commonest tumour site (54.3%) (significant p-value 0.031). Most patients presented at advanced TNM (Tumour Node Metastasis) stage (77.2%) and lymph node metastasis, extranodal extension and Worst Pattern Of Invasion (WOPI) were respectively present in 40%, 14.2% and 8.6% of the cases. Conclusion: Family antecedent of OSCC was higher in the young patients. Risk factor exposure and tumour characteristics like commonest anatomic site, morphology, differentiation and perineural invasion are relatively similar between the two age groups. Lymphovascular invasion, extranodal extension, WOPI, lymph node metastasis and presentation at advanced TNM stage were relatively more frequent, though not statistically significant, in the young suggesting a possibility of OSCC being more biologically aggressive in this population.

Reliability of the Flexible Ruler in Measuring Lumbar Lordosis among Children

Introduction: Postural alignment is commonly assessed, and the abnormal postures are associated with musculoskeletal disorders. There are different methods for screening spinal column anomalies. The flexible ruler provides a safe, portable, inexpensive and non-invasive way to measure the spinal curvature in clinical and larger population. Aim: To determine the intra-rater and inter-rater reliability of flexible ruler in measuring lumbar lordosis among children. Materials and Methods: In this cross-sectional study 81 school children that fulfilled the criteria were recruited with age ranging from 9 to 15 years. Youdas method in standing position was adopted. By using flexible ruler, measurement was taken and without altering the shape of the lumbar curve it was traced in a graph sheet. By using straight ruler, line L and H were drawn by following deep point method. Lumbar lordosis angle was calculated by using the formula, ?=4Arctan 2H/L. Intra-rater reliability: Four measurements were taken by evaluator 1 with a gap of one minute between first 2 measurements and 3 minutes rest then other 2 measurements were taken with a gap of one minute between each. The average of first two and the last two measurements were considered as measurements 1 and 2. Inter rater reliability: Two measurements were taken by evaluator 2 by adapting the same procedure. The averages of two measurements were considered as measurement for evaluator 2. This value was correlated with the value of measurement 1 of evaluator 1. The data was analysed using Intra Class Correlation coefficient (ICC) test. Results: The results showed high intra-rater reliability (ICC-0.991; p<0.001) for lumbar lordosis angle by flexible ruler and poor inter-rater reliability (ICC-0.241; p=0.11) for lumbar lordosis angle by flexible ruler. Conclusion: The flexible ruler has shown only intra-rater reliability and additional studies are required to prove inter-rater reliability in measuring lumbar lordosis among children.

An In-vitro Study to Determine the Sealing Ability of Biodentine when used as a Class II Restorative Material

Deebah Choudhary

Introduction: Microleakage is a major setback to restorative dentistry. Leakage at the tooth/restoration interface may lead to numerous problems like postoperative sensitivity, recurrent caries, marginal sealing and later total failure of restoration. Aim: To determine the sealing ability (microleakage) of a new hydraulic calcium silicate cement (Biodentine) as a base material and a bulk filling material. Materials and Methods: An in-vitro study was conducted with ten freshly extracted maxillary molars from March 2019 to June 2019. Standardised Class II cavities were prepared on mesial and distal proximal surfaces. The twenty prepared samples were randomly divided into two groups (n=10)- G1 (Biodentine™ group) and G2 (Biodentine™ + Tetric N-Ceram group). The samples were subjected to thermocycling, followed by 1% methylene blue dye immersion. They were subsequently sectioned both buccolingually and mesiodistally in order to separate to proximal restorations (mesial and distal) and appreciate the amount of dye penetration at tooth/restoration interface respectively. Microleakage was evaluated by observing the samples under a stereomicroscope (30x). The data obtained was analysed using one-way ANOVA test and compared using Post-hoc test. p-value <0.05 to be considered significant. Results: Biodentine showed no significant difference between the sealing ability as a bulk filling and a base material. Group G2 (0.35) indicated comparatively less microleakage as compared to Group G1 (0.6) but the difference in microleakages in both groups was insignificant (p-value 0.083467). Conclusion: BiodentineTM exhibits microleakage when used as a bulk filling material and as a dentin substitute in Class II cavities since there is no significant difference in both the groups.

Variation in Facial Index and Nasal Index in Western Maharashtrian Males- An Anthropometric Study

Laxmi Prashant Nivale, Achleshwar Gandotra, RR Karambalekar

Introduction: Facial anthropometry had proved its great importance in the field of facial reconstructive surgery as well as in the field of forensic science. Specific face types and nose types provides us important information about specific types of races. Aim: To study the morphometric variation in facial index and nasal index as well as different types of faces and types of noses in the Western Maharashtrian males. Materials and Methods: An observational study was carried out in the five cities- Sangli, Kolhapur, Islampur, Karad and Satara of Western Maharashtra, India. Total 535 male students of different colleges between the age group of 18-20 years were selected and measurements were taken with the help of Digital Vernier Calliper in the sitting position after due approval from Institutional Ethical Committees and informed consent. The methodology adopted for the measurements was taken from the guidelines given by Farkas LG in his book-“Anthropometric facial proportions in Medicine”. Results: The mean facial index of Western Maharashtrian males was 89.51 with standard deviation 4.26 and dominant face type was leptoprosopic which was 46.73% and rare type of face was hypereuriprosopic which was 0.19%. Mean nasal index of Western Maharashtrian males was 72.84 with standard deviation 6.86 and dominant nose type was mesorrhine which was 63.74%. Conclusion: Certain facial and nasal features are common in particular racial group. Its detection can be helpful in reconstructive facial surgeries.

Dose Volume Relationship in Estimating Cardiac Doses in Breast Cancer Radiotherapy

Introduction: Radiation therapy is an integral part of adjuvant treatment for breast cancer which reduces local recurrence and significantly increases survival. But, radiation therapy also has the propensity to increase cardiac morbidity and mortality due to dose received by the heart which is more in left-sided breast cancer. Mean Heart dose and Maximum Heart Distance (MHD) are two parameters to study dose received by the heart. Aim: The purpose of this study was to determine individual doses received by the heart and to correlate MHD with the mean heart dose received by heart in carcinoma breast patients receiving radiotherapy. Materials and Methods: Ninety patients of histologically proven carcinoma breast who attended the Department of Radiotherapy, Acharya Harihar Regional Cancer, Cuttack from January 2017 to January 2019 were selected for a prospective observational study. All patients were treated with 3D Conformal Radiotherapy technique using free breathing multi slice Computed Tomography (CT) scans to contour target and vital organs. Parallel opposed tangential treatment plans were generated for each patient. Individual dose received by the heart and MHD was assessed for each case. SPSS version 21 used for statistical analysis. The Spearman’s Rho test was used for correlation of MHD with Mean heart dose. The Mann-Whitney U test was used for comparing mean of MHD in left-sided and right-sided breast cancer. The Independent t-test was used for comparing means of Mean heart dose in left-sided and right-sided breast cancer. A p-value <0.05 was considered as statistically significant. Results: The Mean Heart Dose was 4.63 Gy for left-sided breast carcinoma patients and 0.846 Gy for right-sided breast cancer and there was a significant difference (p<0.001). Mean MHD for left-sided breast cancer was 2.974 cm while for right-sided it was 0.017 cm, the difference was statistically significant (p-value <0.001). MHD also correlated positively with Mean Heart Dose with correlation coefficient of 0.849 and p-value <0.001. Conclusion: MHD and Mean Heart dose were significantly higher in left-sided breast cancer receiving radiotherapy. MHD was also found to be positively related to Mean Heart dose and therefore found to be an important predictor of cardiac dose. For right-sided breast carcinoma receiving radiotherapy, free breathing technique using 3-Dimensional Conformal Radiotherapy (3DCRT) will suffice in terms of cardiac dose.

Effectiveness of Dry Needling and Low-Level Laser Therapy in Nonspecific Low Back Pain

Introduction: Musculoskeletal spinal disorders are an immense problem in industrialised societies resulting in tremendous personal and economic costs. Younger adults (30 to 60-yearold) are more likely to experience Low Back Pain (LBP) from the disc space or from back muscle strain or other soft tissue strain. Experiencing it earlier in life may lead to recurrent and chronic LBP in adulthood. Dry Needling (DN) which are utilised to treat low back torment in current patterns. Low Level Laser Treatment (LLLT) is utilised to treat LBP by concentrating on the trigger focuses. Aim: To identify the effectiveness of DN and LLLT in the management of selected outcome variables among patients with nonspecific LBP. Materials and Methods: The Quasi experimental study was conducted among a total of 30 subjects who met the inclusion criteria. The subjects were divided into 15 each as group A (DN) and group B (LLLT). The Numerical Pain Distress Scale (NPDS), Quebec Back Pain Disability Scale (QBPDS) and lumbar flexion range of motion were assessed, before and after two weeks of intervention program to identify the effectiveness. Data analysis was done through SPSS and graph pad, using paired t-test and independent t-test. Results: Both groups have shown improvement after two weeks of intervention treatment program. Both groups showed significant difference in relieving pain, reducing disability and improving lumbar range of motion on nonspecific LBP individually. However, there was no significant difference found between the groups, thus null hypothesis was accepted and rejecting the alternate hypothesis. Conclusion: Both the techniques are equally effective in reducing the pain, disability level and improving range of motion individually after two weeks of intervention.

Cervical Cancer Screening Behind Bars: A Woman’s Right

Sumita Mehta, Anshuja Singla, Payal Jadaun

Introduction: Cervical cancer is the fourth most common cancer in women across the globe. Women prisoners are a vulnerable population, so timely provision of screening programs is of utmost importance in this population. Aim: To screen female prisoners for cervical cancer using visual inspection with acetic acid method. Materials and Methods: This was a cross-sectional study conducted on women inmates in one of the largest prisons of North India. A total of 181 women prisoners aged 18 and older were interviewed using a questionnaire. After an informed consent, women were screened using Visual Inspection with Acetic acid (VIA). Results: Majority of the women (74.03%) were between 21 to 40 years. Ninety-one women (50.2%) were illiterate. Majority of the women (123) had between one and three pregnancies. Majority (43) used condoms as a birth control method. Thirtyeight women (20.9%) had multiple partners. Among 181 women who were screened for cervical cancer, 22.6% were VIA positive. Conclusion: Women prisoners are at a high risk of cervical cancer because of increased prevalence of risk factors in them. Screening and intervention programs must be in place to ensure organisation of health services within the prison environment so that screening, diagnosis and treatment for cervical carcinoma can be provided at early stages with improved prognosis.

Comparison of Enamel Demineralisation Scores between Passive Self-Ligation Brackets and Conventional Ligation Brackets in Patients Undergoing Orthodontic Treatment- A Laser Fluorescence Study

Akriti Tiwari, Ravindra Kumar Jain

Introduction: Enamel demineralisation is often seen in patients undergoing fixed orthodontic treatment because appliances create retentive areas around the brackets leading to food debris accumulation. The method of ligation is also an additional factor in causing plaque accumulation leading to demineralisation around the brackets. Aim: The present study aims to compare enamel demineralisation around self-ligation brackets and conventional ligation brackets at the 3rd month and 12th month of orthodontic treatment using laser fluorescence. Materials and Methods: The present prospective study aims to compare enamel demineralisation around self-ligation brackets (Damon 3mx) and conventional ligation brackets (Gemini 3M) at the 3rd month and 12th month of orthodontic treatment using laser fluorescence. Nineteen subjects who were scheduled for fixed orthodontic treatment were selected for the study and were divided into two groups that is conventional ligation and passive self-ligation. Diagnodent (DD) was used to take enamel demineralisation scores at the time of bonding (T0), 3 months (T1) and 12 months (T2) into treatment. All statistical analysis was performed using IBM SPSS version 20. Chi-square test was performed to find the gender association, One-way ANOVA test was carried out to evaluate the difference of DD scores at time period T0, T1 and T2 in self-ligation group and conventional ligation group and Independent t-test was carried out to evaluate the difference of DD scores between self-ligation brackets and conventional ligation at T0, T1 and T2. Results: One-way ANOVA test reported that in conventional ligation groups there was a statistically significant difference in the mean DD scores between T0 and T1, T0 and T2 (p<0.05). Similarly, in the self-ligation group, a statistically significant difference was observed in the mean DD score between T0 and T1, T0 and T2 (p<0.05). Independent t-test to evaluate the difference of mean DD scores between self-ligation brackets and conventional ligation at T2 was found to be statistically non-significant (p>0.05). No gender association was noted. Conclusion: The method of ligation did not influence enamel demineralisation around orthodontic brackets.

Prognostic Significance of Number of Lymph Nodes Harvested in Patients with Node Negative Antral Gastric Adenocarcinoma Undergoing Laparoscopic Curative Resection

Ümit Mercan, Ogün Eren, Cemil Yüksel, Salim Demirci

Introduction: The most important parameters affecting patient prognosis in gastric cancer are the T stage and regional lymph node invasion. Although it is known that lymph node positive patients have poor long-term survival and recurrence and metastasis rates are higher than patients with lymph node negative, recurrence and metastasis may also develop in lymph node negative patients. Studies have found that the most likely causes of this situation are micrometastases which cannot be detected in routine pathological examination and the inability to remove a sufficient number of lymph nodes. There is no clear consensus regarding the number of lymph nodes to be removed and there are very few studies in the literature on this subject. Aim: To determine the effect of the number of lymph nodes harvested in laparoscopically resected, lymph node negative, early stage antral gastric adenocarcinoma on patient prognosis. Materials and Methods: A retrospective study was conducted from January 2015 to January 2020 in which 62 patients with pT1N0, pT2N0 and pT3N0 tumour located in gastric antrum were included. Distal gastrectomy, partial omentectomy and lymph node dissection were performed to all patients. The number of lymph nodes harvested were determined from pathology reports. The patients were divided into two groups according to the number of lymph nodes as below 15 or above 15, clinicopathological variables, overall and disease-free survival rates were compared between these two groups. X2 or Fisher-Exact test and Student-T or Mann-Whitney U test were used for comparing clinicopathological variables and Kaplan-Meier survival curves and Cox regression model for survival analysis. All p-values less than 0.05 were considered statistically significant. Results: It has been found that the mean overall survival in groups with lymph node removal ≥ and <15 was 55.07±2.28 (95% CI: 50.60 ~ 59.55) months and 34.80±4.26 (95% CI: 26.43 ~ 43.17) months and mean disease-free survival was 59.43±1.10 (95% CI: 57.26 ~ 61.59) months and 27.85±4.19 (95% CI: 19.63 ~ 36.07) months, respectively. The difference was statistically significant (p=0.001, p=0.002). Conclusion: Present study concludes that removal of a minimum of 15 lymph nodes in radical gastrectomy and lymphadenectomy is effective on overall and disease-free survival, regardless of the T stage. In addition, removal of 15 or more lymph nodes can provide more accurate and appropriate staging and affect patients’ decision to be directed towards adjuvant therapy

Effect of Ethyl Chloride Spray versus Ice Pack Application on Pain Perception in Patients Undergoing Radial Arterial Puncture: A Randomised Controlled Trial

Harjot Dhami, Suresh K Sharma, Rakesh Sharma, Shiv K Mudgal, Gaurav Jain

Introduction: Radial Arterial Puncture (AP) is much needed procedure in critical care setting but pain associated during AP makes patients anxious and stressed. Aim: To evaluate the efficacy of ethyl chloride spray versus ice pack application in decreasing pain during puncture of radial artery for Arterial Blood Gas (ABG) analysis. Materials and Methods: A randomised controlled parallel group design study was conducted in a tertiary care hospital in critical care units among 60 participants during November 2018 to December 2018. Seventy-two participants were initially recruited for this study who had to undergo ABG analysis out of them 12 were excluded and finally 60 participants were randomly allocated to ethyl chloride spray group (n=30) and ice pack application group (n=30). The assigned treatment was given just prior to radial AP. The primary outcome variable was to assess the level of pain score, which participants experienced during AP and measured by pain numerical rating scale while secondary outcome variable was incidence of haematoma within two hours after procedure. Data were presented in frequency, percentages, chi-square, Mann-Whitney U and Fisher’s-exact test. The statistical computer package, IBM Statistical Package for the Social Sciences (SPSS 23.0) was used for statistical analysis. Results: The mean pain score was 2.5±1.2 in the ethyl chloride group and 3.1±1.8 in ice pack application group (p=0.113); while incidence of haematoma was significantly high in ice pack application group as compared to ethyl chloride group (33.3% vs. 6.66%; p=0.01). Conclusion: Ethyl chloride spray and ice pack application have no significant difference in reducing pain intensity due to radial AP.

Effect of Training Program to Improve Observational Skills of Psychiatric Nursing Students

Atallah Khalaf Alenezi

Introduction: Training program is believed to enhance nursing students’ knowledge and performance in observational skills, which can be an essential factor in their future practice as nurses working in a psychiatric institution. Aim: This study aimed to assess the effect of training program for psychiatric nursing students to improve their observational skills. Materials and Methods: This study used an interventional design. The study sample included 80 nursing students undergoing clinicalpractice in psychiatric nursing during 2019-20 (10months). The tools used for data collection were questionnaire to assess nursing student’s knowledge and an observational checklist to measure the performance. Percentage distribution, chi-square, and correlation coefficient were used to determine influence of training program on nursing students. Results: The training program imparted to students was effective as indicated by a highly significant difference between pre/post-training programs in all items of psychiatric nursing students’ knowledge. Furthermore, a highly significant difference between pre/post-training programs in all elements of students’ observational rating scale was also evident. Conclusion: The training program improved nursing students’ knowledge and performance. Particularly, their observational skills have brought confidence in their exposure and boast their ability in caring for their patients.

Cancer Knowledge, Attitude and Protective Behaviour in High-School Students: A Cross-sectional Analytical Study in East Azerbaijan, Iran

Roya Dolatkhah, Keivan Fakhari Dehkharghani

Introduction: Providing and enhancing knowledge, attitude, delivering and conduction of evidence based information and beliefs about all aspects of cancer in adolescent life period are so important. Aim: The study aimed to evaluate and investigate the main information regarding knowledge, attitude and protective behaviour on high-school student of Tabriz City, East Azerbaijan, North West of Iran. Materials and Methods: This study was performed as a cross-sectional analytical research study, during the 2017 Sep-2018 June academic year, in randomly selected high-schools. Questionnaire was designed and implemented which included socio-demographic information and 65 questions with three answers from disagree, agree, completely agree, and each answer was given from 1 to 3 marks. Question were about the knowledge (n=20; 0-20 poor, 21-40 moderate, 41-60 good), attitude (n=20; 0-20 poor, 21-40 moderate, 41-60 good) and protective behaviour (n=25; Protective Behaviour: 0-25 poor, 26-50 moderate, 51-75 good) regarding cancer. The response options designed as Likert scales and each variable scored from worst to best status and the total scores as 0-40 (very poor), 41-80 (poor), 81-120 (moderate), 121-160 (good) and 161-195 (very good). Results: Overall 471 students participated in this survey, between 14-19 years with mean age of 16.79 years. The total mean score of knowledge, attitude and protective behaviour was 136.05 (±SD 3.24) which was considered as good. Total scores was significantly higher in better Socio-Demographic Status (SDS), students with moderate SDS had 3.85 times and students with good SDS had about 2 times higher total scores. Total scores were twice among16-17 year-old group than younger students (OR=1.97; 95% CI: 1.03-3.76, p=0.04). Conclusion: The results indicated better levels of knowledge, attitude and protective behaviour regarding cancer in high-school students. SDS had significantly impact on the total knowledge levels.

Diagnostic Efficacy of Fine Needle Aspiration Cytology and Cell Block Technique in Thyroid Lesions: A Hospital-based Study

Usha Kiran Raina, Jyotsna Suri, Subash Bhardwaj, Bhavna Sahni

Introduction: Fine Needle Aspiration Cytology (FNAC) and Cell Block are very commonly used initial tests for triaging thyroid lesions and play a pivotal role in deciding subsequent clinical management of thyroid nodules. In most cases, after excision, the diagnosis remains unchanged, but at times discordance does occur when benign lesions are reported on FNAC and cell blocks are found to be malignant on final histopathology and vice-versa. Aim: To assess the diagnostic efficacy of both FNAC and Cell Block technique in the evaluation of thyroid lesions by comparing their respective results with final histopathological diagnosis (after excision) in case of malignancies and clinicoradiological follow-up in benign cases. Materials and Methods: An observational hospital-based study was conducted in the Department of Pathology in a Tertiary Care Teaching Institute from 1st November, 2016 to 31st October, 2017. A total of 100 cases of thyroid masses were subjected to both FNAC and Cell Block and the diagnostic efficacy of both the techniques was assessed using MedCalc Statistical Software. Results: Mean age of the patients was 42.75±15.75 years with a range of 12-75 years. Females constituted 88% of the sample with male to female ratio of 1:7.3. 88% lesions were benign, 8% were malignant and 4% suspicious of malignancy on conventional smears in comparison to cell block which showed 90% benign, 8% malignant and 2% suspicious lesions. The validity of FNAC in terms of sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and accuracy was found to be 100%, 95.65%, 66.67%, 100.00% and 96.00% respectively, whereas for cell blocks these statistics were 100%, 97.83%, 80%, 100% and 98% respectively. Conclusion: Cell block improved the overall diagnostic accuracy of FNAC when used as an adjunct leading to 100% diagnostic yield. The results of this study also establish that FNAC and Cell blocks are sensitive, specific, and accurate as preliminary diagnostic tests for evaluation of patients with thyroid swellings. Moreover, their combined use can reduce the diagnostic errors and to improve the overall reporting efficacy. It is thus advised to perform cell block for each case of FNAC in thyroid lesions.

Clinical Significance of Serum Sodium Levels in Liver Cirrhosis: A Cross-sectional Observational Study

Sandeep Reddy Nareddy, Akshatha Rao Aroor, Archana Bhat

Introduction: Hyponatremia is a dominant feature and is of primary concern in liver cirrhosis. It is an important prognostic factor for the severity and complications of liver cirrhosis associated with poor survival. The issue of hyponatremia in liver cirrhosis has been the subject of intense debate within the scientific community. Aim: To determine the association of serum sodium levels with the severity and complications of liver cirrhosis. Materials and Methods: This observational, cross-sectional study included all adult patients diagnosed with liver cirrhosis, admitted in single tertiary care centre from December 2016 to April 2018. Their serum sodium levels was estimated on admission and correlated with Child Pugh Score and complications of cirrhosis. Statistical analysis was done by ChiSquare test, Fisher's-exact test and Odds Ratio (OR) estimation. Results: A total of 95 patients were enrolled in the study. Majority were in the age group of 41-50 years (35.8%) with a mean age of 48.38±11.8 (mean±SD). There was a male preponderance (91 patients, 96.8%). Hyponatremia (≤130 meq/L) was noted in 33 patients (34.7%). Among the patients with hyponatremia, 29 (87.9%) belonged to Child Pugh C. The association of hyponatremia with Child Pugh C was highly significant (OR 3.987; CI 1.240-12.818; p=0.029). A positive correlation was found between low sodium levels (≤130 meq/L) and complications such as spontaneous bacterial peritonitis (OR 4.667; CI 1.538-14.164; p=0.004) and hepatorenal syndrome (OR 5.357; CI 0.979-29.327; p=0.034). Conclusion: Low sodium levels in cirrhosis has a positive correlation with the disease severity, hepatorenal syndrome and spontaneous bacterial peritonitis.

Enhancing Knowledge of Women on Urinary Incontinence- A Pre and Post Interventional Study

BS Suchithra, Fatima Dsilva, TP Rajeev

Introduction: Urinary Incontinence (UI) is highly prevalent among women and has a significant impact on physical and psychological health. Several women fail to seek help or treatment as this problem is a cause of significant embarrassment among women. UI is an important social problem that affects more than 50% of postmenopausal women. Aim: To explore awareness level amongst women about UI and determine the effectiveness of an educational intervention to commensurate their awareness towards the same. Materials and Methods: A descriptive study design was adopted. Postmenopausal rural women of the community in Mangalore were selected by the door to door household survey from April 2018 till March 2019. Data was collected from 60 women using demographic performa and structured knowledge questionnaire on UI. Results: The response rate for the questionnaire was 100%. In the pretest, 53 (88%) women had poor knowledge, and 7 (12%) had average knowledge regarding UI. In the post-test, knowledge of women enhanced amongst 52 (87%) of women; however, 8 (13%) women were in the poor knowledge category. The mean pretest knowledge score ( χ=5.38) had significantly enhanced in the post-test ( X=11.73, p<0.001). Conclusion: Women have limited access to information and knowledge regarding UI. Nurses play a significant role in promoting targeted awareness in the community towards this condition. The present study created awareness among women and encouraged them to seek timely help for a better Quality of Life (QoL).

Agreement between the Radiological Diagnosis of Mullerian Duct Anomalies on 3 Tesla MRI and Clinical Diagnosis

Adarsh Kibballi Madhukeshwar, Hadi Hassan, Smitha B Rao

Introduction: Mullerian Duct Anomalies (MDAs) are developmental abnormalities of paramesonephric ducts. MDAs usually present with reproductive issues. Aim: To determine the agreement between the Magnetic Resonance Imaging (MRI) findings of MDAs with clinical diagnosis. Materials and Methods: Retrospective observational study was done where the MRI abdomen and pelvis imaged using 3 Tesla (T) MRI during the period of two years (May 2018 till April 2020) were reviewed. The American Society for Reproductive Medicine classification was used for classifying MDAs. Clinical details (clinical symptoms, findings from pelvic examination, imaging modalities other than MRI, surgeries/procedures like laparoscopy, laparotomy, hysteroscopy, etc) were obtained by reviewing the case records and agreement between radiological and clinical diagnosis was observed using Kappa statistics. Results: Out of 1,054 female MRIs of abdomen and pelvis screened during the study period about 36 patients were found to have MDAs. Thirty six MRIs were included for the final analysis and three were excluded because of no consensus in diagnosis. Prevalence of MDA was 3.13% and mean age of the study participants was 24.76 (±5.52) years. The minimum and maximum ages were 15 years and 36 years respectively. Most common symptom of MDAs was repeated miscarriage (36.36%) followed by dysmenorrhea (30.30%). For evaluation of the uterus, there was agreement in 27 out of 33 patients and disagreement in 6 out of 33. Reporting was done by two radiologists. The radiological diagnosis was made first and the cases with MDAs were checked for clinical diagnosis. Excellent agreement was observed between the radiological and clinical diagnosis with kappa value of 0.80. Retrospective image analysis was done to specify the disagreements and the causes were found to be lack of specific criterion for conditions like arcuate uterus, presence of associated complex and less known pathological conditions and not acquiring thinner volume sections in certain cases having thin septa. Conclusion: Among female patients who were diagnosed with MDAs, excellent agreement was observed between the radiological and clinical diagnosis. Few pitfalls were noted which needs to be addressed while making a diagnosis of MDAs in MRI.

Minimally Invasive Percutaneous Plate Osteosynthesis: A Blessing for Notorious Distal Tibia Fractures

Manjunath Daragad, Shrihari L Kulkarni, Sunil Mannual, Sachin Kumar

Introduction: Fractures of distal tibia are difficult to treat as they are high energy fractures, associated with extremely damaged soft tissues, poor vascularity, high incidence of compound injuries, skin complications following surgery and comminution of the metaphysis and articular surface makes anatomical reduction difficult. A mechanically stable osteosynthesis can be obtained with minimum dissection and surgical trauma by Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO). In this technique fracture is reduced indirectly, and is fixed with Locking Compression Plate (LCP). Aim: To assess functional and radiological outcomes of distal tibial fractures managed by MIPPO using LCP. Materials and Methods: In this cross-sectional study, 25 patients with distal tibia fractures were operated by LCP using MIPPO technique. Patients were followed-up at regular intervals for about one year. They were assessed clinically, functionally and with radiologically for fracture union. Functional assessment was done using American Orthopaedic Foot and Ankle Society Score (AOFAS) scoring system. Radiological outcome was evaluated using the Radiological Union Scale in Tibia Fracture (RUST) to assess union. Data was analysed using paired t-test. The chosen level of significance was p-value <0.05. Statistical Package for the Social Sciences (SPSS) version 21 was used for analysis. Results: Males were more commonly affected with Road Traffic Accident (RTA) being the most common mode of injury. All fractures healed with good functional outcome. Mean union time was 20 weeks. Mean AOFAS score at the end of one year was 88.83 (SD 5.65) and mean RUST score was 11.58 (SD 0.72) at the end of one-year follow-up, indicating good outcome. There was one case of superficial infection which was managed with antibiotics, one patient had implant failure. Conclusion: LCP using MIPPO offers biological advantage by preserving periosteal blood supply, which is particularly critical with distal tibia or pilon injury. Thus, fractures heal rapidly with very few complications.

Comparison of Efficacy of Alginate Filler Dressings with Conventional Saline Dressings for Cavity Wounds in Diabetic Foot Ulcer- A Prospective Cohort Study

Introduction: Diabetic foot ulcers are associated with 25% of patients with Diabetes Mellitus (DM). These diabetic foot ulcers if not given appropriate care at the right time can lead to amputations and poor quality of life. Alginate dressings are newer and help in faster healing of cavity wounds in diabetic foot ulcer. Aim: To compare the advantages of alginate dressings over conventional saline dressings in cavity wounds of diabetic foot ulcer patients. Materials and Methods: A single centre prospective longitudinal cohort study was conducted on 88 patients with diabetic foot ulcers randomising equally into two groups containing 44 patients in each group in a tertiary care hospital. The wounds of all patients included in the study were thoroughly debrided and initial assessment was done using the Pressure Ulcer Scale for Healing (PUSH) scoring system. The patients were started on alginate dressings in one group and saline dressings in other group and were assessed after two and four weeks. The reduction in the surface area of the wound, reduction in the exudate amount, type of the tissue over the ulcer and reduction in the bacterial load (wound cultures) of the ulcers were studied. The statistical analysis were done using Statistical Package for the Social Sciences (SPSS) software version 21. The statistics were done using independent sample tests (Levene’s test for equality of variances and t-test for equality of means), Mann-Whitney test and Wilcoxon test. Results: The results of wound assessment before dressings, at two weeks and at the end of four weeks are as follows: The mean (SD) reduction in wound surface area was 9.07 (1.634) to 6.89 (1.434) to 4.68 (1.272) for alginate group and 9.25 (2.059) to 8.00 (1.905) to 6.50 (1.650) for saline group. The mean (SD) reduction of the exudate amount was 2.02 (0.505) to 1.09 (0.473) to 0.14 (0.347) for alginate group and 1.98 (0.590) to 1.43 (0.625) to 0.75 (0.615) for the saline group. The mean (SD) for tissue type of cavity wounds assessed via PUSH scoring was reduced from 2.30 (0.701) to 0.16 (0.370) for the alginate group in comparison to 2.32 (0.740) to 0.77 (0.743) for the saline group at the end of four weeks. On evaluation of the wound cultures; 6 out of 44 patients (13.6%) were culture positive in the alginate group while 30 out of 44 patients (68.2%) were culture positive from the saline group at the end of four weeks. All the above results were statistically significant with a p-value of 0.001. Conclusion: Alginates dressings are superior to saline dressings in terms of reduction in the size of the ulcer and control of microbial activity in diabetic foot. Alginate absorbs large amount of exudates and fill in irregular shaped cavities which are ideal in treating cavity wounds in diabetic foot syndrome.

Comparison of Fatty Meal, Drotaverine and Hyoscine for Duodenal Anti-motility and Cannulation During ERCP- A Randomised Controlled Trial

S Vadivel Kumaran, Rajesh Nanda Amarnath, Mohammed Ali, T Pugazhendhi

Introduction: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a technically demanding procedure that requires considerable amount of training to be performed safely. Successful cannulation of the ducts depends on the expertise of the endoscopist. Conventionally, cannulation is facilitated with the help of smooth muscle relaxants like Hyoscine-N-butyl bromide or Drotaverine which impair duodenal contractions and facilitate sphincter of oddi relaxation. Aim: To compare the effect of Fatty meal versus Drotaverine hydrochloride versus Hyoscine-N-butyl bromide on duodenal contraction rate, ease of identification of the papillary orifice, time for cannulation, and adverse effects of agents used on haemodynamic parameters. Materials and Methods: The study was conducted at Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai,Tamil Nadu, India, where 60 patients admitted for ERCP with normal appearing ampulla, were taken-up for the study. Patients were subjected randomly into the three groups viz., Hyoscine group, Drotaverine group and Fatty meal group. In Fatty meal group, 200 mL of semi skimmed milk (1.7% fat) was given orally one hour prior to the procedure to allow for gastric emptying. A 20 mg of intravenous Hyoscine-N-butyl bromide and 40 mg of intravenous Drotaverine hydrochloride were administered 15 minutes before procedure in Hyoscine and Drotaverine group, respectively. Statistical analysis was done by Chi-square test and Analysis of Variance (ANOVA) test and using Statistical Package for the Social Sciences (SPSS) 16.0 version software. A p-value <0.05 was considered significant. Results: The difference in duodenal motility, cannulation time and success of the procedure did not show a statistically significant p-value between the three groups. The identification of ampulla was easy with the fatty meal group. The statistical analysis for intraprocedural change in pulse rate and Blood Pressure (BP) variation showed a significant p-value for Hyoscine group compared to the other two groups. The change in pulse rate for Hyoscine vs. Drotaverine vs. Fatty meal group during the procedure was 51.5±12.8 vs. 24.2±8.4 vs. 24.4±8.8 per minute, respectively. The variation in BP during the procedure was 18.3/15.7±7.7/9.0 mmHg vs. 9.0/8.7±5.7/5.6 mmHg vs. 10.4/8.6±4.6/3.3 mmHg for Hyoscine vs. Drotaverine vs. Fatty meal group respectively. Conclusion: Fatty meal is not inferior to the conventionally used Hyoscine-N-butyl bromide or Drotaverine for its anti-motility effect on the duodenum during ERCP. The cannulation time is no different within the groups. Fatty meal, the action of which is physiological may be used as a suitable alternative to antispasmodic pharmacological agents which have potential adverse effects.

Comparison of Insulin Resistance in Lean and Obese Adults with Type 2 Diabetes Mellitus- A Cross-sectional Study

Introduction: Insulin Resistance (IR) can develop into type 2 diabetes mellitus and is closely associated with obesity. However, the non-obese population has also shown a predisposition to the risk of IR due to genetics. Aim: To assess the relationship between IR and obesity in Type 2 Diabetes Mellitus (T2DM) by comparing the proportion of subjects with IR in lean and obese T2DM and to identify the factors predicting IR in T2DM. Materials and Methods: A cross-sectional, hospital-based study was done at Department of Medicine of RL Jalappa hospital, Kolar, Karnataka on 106 T2DM patients aged >18 years. The study population was grouped into lean (BMI<19kg/ m² ) and obese adults (BMI >30 kg/m² ). IR was calculated using Homeostasis Model Assessment-Insulin Resistance (HOMA-IR) and was considered as primary outcome variable. Obesity was considered as primary explanatory variable. Age, Gender, fasting insulin, C-peptide, Fasting Blood Sugar, Glycated haemoglobin (GHB or HbA1c) were the other explanatory variables. Descriptive analysis was carried out using mean and standard deviation for quantitative variables, frequency and proportion for categorical variables. Chi-square test was used to test statistical significance between the groups. Univariate logistic regression analysis was done to identify the predictors of IR. IBM Statistical Package for Social Sciences (SPSS) version 22 was used for statistical analysis. The p-value <0.05 was considered to be statistically significant. Results: The 106 subjects involved in the study had a mean age of 53.88±9.21 years. 44 subjects (41.5%) had IR. Obese to lean diabetic patients were in the ratio of 1:4. The proportion of obese diabetic subjects was (n=84, 79.2%) whereas lean diabetics were (n=22, 20.8%). The proportion of obese diabetic subjects with IR was 38.1% while the proportion of lean diabetic subjects with IR was 54.55%, but this difference was statistically not significant (p=0.163). On univariate logistic regression analysis, fasting insulin (odds ratio of 2.442 with 95% CI of 1.665 to 3.851, p<0.001^**) and C-peptide (odds ratio of 1.446 with 95% CI of 1.123, p=0.004) were statistically significant factors attributing to IR. Conclusion: There was no significant relationship between IR and obesity. IR was independently associated with Fasting insulin levels and C-peptide levels.

Occupational Health and Safety Problems, Health Literacy, Mental Health and Quality of life among Public Work Division Workers in the Northeast of Thailand - A Cross-sectional Study

Parichat Wongwarissara, Natnapa Padchasuwan, Wongsa Laohasiriwong

Introduction: Public Work Division is a local government organisation in Thailand. The workers of the Public Work Division are vulnerable to Occupational Health and Safety (OHS) problems. Those who could cope with various hazards should be able to maintain their good Quality of Life (QOL). Aim: To determine the OHS problems, level of Health Literacy (HL), mental health status, QOL and its association among Public Work Division workers of Local Government Organisations in the Northeast of Thailand. Materials and Methods: A cross-sectional study was conducted among 823 participants recruited by using multistage random sampling from Public Work Division of Local Administration Organisations in eight provinces of the Northeast of Thailand. A self-administered structured questionnaire was administered to assess OHS problems, HL, mental health and QOL. Multiple logistic regression was used to determine the association between mental health, HL, OHS problems and QOL when controlling other covariates. Results: More than half of the workers were male (71.20%) with the mean age of 39.38 years (±9.64). Almost one-third of the workers had high level of ergonomic OHS (32.20%), 39.49% had high level of depression and 60.51% had interactive level of HL. Only 32.32% had good QOL. The multivariable analysis indicated factors that were significantly associated with good QOL of participants. These factors were critical level of HL on self-management skills (adj. OR=5.57; 95% CI: 3.46-8.94), critical level of HL on media literacy skills (adj. OR=3.29; 95% CI: 1.92-5.63), moderate depression (adj. OR=2.56; 95% CI: 1.68-3.91), mild depression (adj. OR=5.05; 95% CI: 3.23-7.78) and low-to-moderate ergonomic problems (adj. OR=1.42; 95% CI: 1.01-2.09) when controlling the effect of other covariates. Conclusion: Less than one-third of public work division workers had good QOL. HL, depression, OHS problems had influence on QOL.

Relationship of Acute ST-Elevation Myocardial Infarction with hs-CRP and Serum Iron Profile in Southern India: A Cross-sectional Study

Introduction: Cardiovascular diseases are a major cause of mortality. The role of Iron in oxidative myocardial damage remains controversial with multiple studies showing positive and negative correlations. Systemic inflammation is also an important factor in Myocardial Infarction (MI) with high sensitive C-Reactive Protein (hs-CRP) being an important marker. Aim: To investigate the relationship of serum iron and hs-CRP in patients diagnosed with ST-segment Elevation Myocardial Infarction (STEMI) and its role as prognostic indicators. Materials and Methods: A cross-sectional hospital-based study was conducted in which 45 patients were enrolled over a period of two months. Primary variables studied were STEMI and site of infarction as confirmed on echocardiography, hospital stay and patient outcome. Secondary variables were serum iron, hs-CRP, Total Iron Binding Capacity (TIBC), ferritin. Statistical analysis was done using IBM Statistical Package for the Social Sciences (SPSS) software version 20. Mann-Whitney U test, Kruskal Wallis test, ANOVA and Spearman’s rank correlation was used. Results: Iron profile was significantly altered in the various types of MI. Serum iron values lower than 61 mg/dL had a sensitivity of 89% and high Negative Predictive Value (NPV) (95%) for the prediction of mortality in patients. It was seen that significantly lower Unbound Iron Binding Capacity (UIBC) values were seen in patients who died than the survivor group. Low Transferrin Saturation (TS), serum iron, TIBC were associated with a longer hospital stay. About 42 patients showed hs-CRP levels above 0.3 mg/L. High hs-CRP and ferritin values were associated with a prolonged hospital stay. Conclusion: In patients with acute STEMI, serum iron and hs-CRP are shown to be important predictors of morbidity and mortality. Regular iron supplementation with a six monthly hs-CRP monitoring is recommended. Further research shows screening capability is needed.

The Effect of Omega-3 Fatty Acids Supplementation on the Improvement of Metabolic Syndrome in Patients with Ischemic Heart Disease: A Double-blind, Randomised, Placebo-controlled Trial

Introduction: Metabolic syndrome is a set of metabolic abnormalities that increase the risk of cardiovascular disease. Omega-3 fatty acids may play a role in improving metabolic syndrome by affecting endothelial status. Aim: To study the effect of omega-3 fatty acids on metabolic syndrome in patients with cardiac ischemia. Materials and Methods: This was a 12-weeks, double-blind, randomised, placebo-controlled trial. Ninety patients with a history of cardiac ischemia and metabolic syndrome were randomly divided into intervention (n=45) and placebo (n=45) groups. In the end, 86 people completed the study. The intervention group consumed daily Omega-3 capsules containing 1000 mg fish oil, 180 mg EPA and 120 mg DHA. The placebo group took gelatin-containing capsules. Serum triglycerides, Fasting Blood Sugar (FBS), cholesterol, Low-Density Lipoprotein (LDL), High-Density Lipoprotein (HDL) were measured at baseline and the end of the study and weight, waist circumference, Body Mass Index (BMI) were measured at baseline, middle and end of the study. Independent t-test was used for comparing the baseline and mean changes. The variables that measured in three times were compared using repeated measurement test between two groups. Paired t-test was performed to compare within group differences. Results: Serum triglyceride, FBS, weight and systolic blood pressure decreased and serum HDL increased compared to the placebo group. There were no significant changes in serum cholesterol, LDL, BMI, waist circumference and diastolic blood pressure after omega-3 administration. Conclusion: Omega-3 supplementation for 12 weeks improves some of the indicators of metabolic syndrome in individuals with ischemic heart disease. (IRCT Code: IRCT20190819044563N1).

Role of Serum Osteopontin as a Biomarker in the Diagnosis of Alcoholic Liver Disease

Sanjiv Kumar Bansal, Arpita Suri, Naveen Kumar Singh

Introduction: Alcohol consumption is a major cause of liver disease worldwide. The amount of alcohol ingested is the most important risk factor for the development of Alcoholic Liver Disease (ALD). Osteopontin (OPN) is an extracellular matrix protein that is markedly up-regulated in patients with ALD. Aim: To determine the best predictor of ALD among Serum Aspartate Transaminase (AST)/Alanine Transaminase (ALT) ratio, Alkaline Phosphatase (ALP), Gamma Glutamyl Transferase (GGT) and serum OPN. Materials and Methods: Clinically diagnosed cases of ALD (N=60) with alcohol consumption ≥100 gm/day, for more than eight years and age and gender matched healthy controls (N=60) were recruited for the study. Estimation of AST, ALT, ALP and GGT were assayed by standard photometric methods in auto analyser ERBA-XL (EM-200) and plasma OPN was estimated by using commercial kit based on Enzyme-Linked Immunosorbent Assay (ELISA). Receiver Operator Characteristic (ROC) curve analysis was done to establish the best predictor of ALD among the markers. Results: The parameters of the liver function tests such as AST, ALT, ALP were significantly increased in the cases (p<0.001) as compared to controls. In the study, there was a significant increase in the level of OPN and GGT in the patients with ALD (p<0.001) as compared to controls. OPN showed significant positive correlations with AST (r=0.76, p<0.001), ALT (r=0.64, p<0.001), ALP (r=0.68, p<0.001). Upon ROC analysis, OPN had the maximum area (0.998) under curve as compared to GGT and AST/ALT ratio. Conclusion: OPN is a better predictor of ALD as compared to GGT and AST/ALT ratio.

Serum Fluorescence of Advanced Glycation End Products: A Potential Screening Tool to Distinguish Between Diabetic Patients with and without Microvascular Complications

Sadaf Ali, Nivedita L Rao

Introduction: Enhanced formation and accumulation of Fluorescent Advanced Glycation End products (F-AGEs) in diabetes mellitus have been linked to increased risk of developing the associated vascular complications. Aim: To evaluate the potential of serum fluorescence levels of F-AGEs as screening tools to distinguish between type 2 diabetic patients with and without microvascular complications such as retinopathy, neuropathy. Materials and Methods: This cross-sectional study was conducted between June 2016 and June 2017, included 95 type 2 diabetic patients with more than 1 year of diabetes duration. Fasting blood glucose, glycated haemoglobin and total protein levels were estimated by automated methods. Serum F-AGEs were estimated by using a simple spectrofluorometric method. Microvascular complications due to diabetes mellitus were studied in each patient from medical records data on fundus examination for retinopathy and touch, vibration sensation detection for neuropathy. Diabetic patients were categorised into two groups as those without microvascular complications and those with microvascular complications-retinopathy and neuropathy. Statistical tests used for comparisons between groups were chi-square test for gender distribution, independent t-test for other parameters and Pearson’s correlations. The p-value <0.05 indicated significant difference between variables. Results: Mean age of the population was 55.1±5.3 years. Diabetic patients with microvascular complications (n=26) in the form of retinopathy, neuropathy had significantly higher levels of serum F-AGEs with mean 7.4±1.8 AU/g protein compared with diabetic patients without complications with mean value 1.5±0.7 AU/g protein (p<0.01). Conclusion: Two categories of serum fluorescent AGE values, without overlap, could be distinguished between diabetic patients with and without complications. Measurement of serum F-AGEs products has the potential to emerge as a simple, valuable screening tool to distinguish between diabetic patients with and without microvascular complications.

Assessment of Psychomotor Skill using Mentally Guided Imagery and Physical Practice in Medical Interns- An Interventional Study

S Anu, N Uwaraja, R Somaskandan, R Vairapraveena, K Jeyashree, VB Ranjith

Introduction: Mentally Guided Imagery (MGI) has successfully been applied in sports for skill acquisition and performance enhancement. Despite the fact that athletes often use mental imagery as a part of their preparation, it has not been extensively explored as a learning technique in medical education. Few studies had highlighted mental imagery as a way to review and practice surgical skills efficiently. The present study aimed to assess the efficiency of intubation skills acquired through mental imagery in medical interns. Aim: To assess and compare the effect of Guided mental imagery and physical practice using mannequins on intubation technique among 40 medical Interns after seven days of training. Materials and Methods: The study was conducted in the Department of Emergency Medicine, Velammal Medical College and Hospital, Madurai over a period of seven days. Forty house surgeons were randomly divided into two groups. Group A (n=20) practiced MGI on intubation technique and Group B (n=20) practiced on mannequins one hour everyday for seven days. The performance of the students was assessed using a graded Objective Structured Clinical Examination (OSCE). Results: Results of Group A and Group B were analysed and compared statistically using paired and unpaired t-test. Though there was significant difference between the pre and post values in the MGI group (p<0.001), there was no statistically significant difference (p=0.216) in the post-intervention scores between the Mentally Guided Imagery (MGI) and physical practice group. Conclusion: Guided mental imagery was as effective as additional physical practice for medical students learning to perform intubation.

Changes in Sleep Across Different Phases of Life of Medical Students and Impact of Home Confinement on Sleep during COVID-19 Lockdown

Shailesh Kumar, Jitendra Mahour, Ravikant Arjariya, Jaidev Singh

Introduction: Sleep is indispensable. The sleep habits changes with age and is influenced by external factors. The nationwide enforcement of complete lockdown lead to home confinement of all the students as classes in colleges were suspended on orders of the Government of India. Aim: To find out changes in the sleep pattern and quality in different phases of life of the students namely from school days, to college days and during the period of home confinement during COVID-19 pandemic. Materials and Methods: A questionnaire in the form of online form was shared with the students of MBBS first year in four Government medical colleges of Madhya Pradesh during nationwide lockdown on 1^st May, 2020. The information about sleep pattern, usual bed time, average duration of sleep, sleep quality and student’s perception about adequate sleep during college days and during lockdown period was recorded. The statistical analysis was done by Wilcoxon signed rank test, and Chi-square test. The satisfaction with sleep quality was recorded on a five point Likert’s scale as very dissatisfied, dissatisfied, neither satisfied nor dissatisfied, satisfied and very satisfied. Results: A total 760 students participated in the present study. During usual college days among all participants, majority 373 (49.1%) of them had night owl type of sleep pattern. Maximum number of students 358 (47.10%) had morning lark type of sleep pattern during school days. The highest percentage of students 271 (35.7%) with no fixed pattern of sleep was observed during the period of home confinement due to lockdown. A total of 383 (50.4%) students reported that their average duration of night sleep during usual college days was six to seven hours per day. A total of 698 (91.8%) students reported that they are able to take adequate sleep at home during lockdown period. A statistically significant association was found between sleep pattern during college days and gender of participants (p-value <0.01). Wilcoxon signed rank test results showed statistically significant (p<0.001) change in number of students whose bed time changed during college days as compared to school days and during lockdown as compared to bed time during college days. Conclusion: In majority of the participants, sleep pattern changed to night owl type during college days from morning lark type during school days. The home confinement in lockdown period due to global viral pandemic has positively impacted sleep of students in terms of bed time, sleep quality and quantity.

Evaluation of Nurses’ Workload in the Intensive Care Unit, Neonatal Intensive Care Unit and Coronary Care Unit: An Analytical Study

Maryam Azadi, Jalil Azimian, Maryam Mafi, Farnoosh Rashvand

Introduction: The workload on nurses can have adverse effects on the patient, nurse and healthcare system such as reduced quality of care, increased risk of nursing errors, reduced patient satisfaction, increased nurse anxiety, increased nursing job stress, increased risk of infection, increase in the length of hospital stay and increased risk of death. Aim: The present study was designed and conducted to compare nurses' workload in the Intensive Care Unit (ICU), Neonatal Intensive Care Unit (NICU), and Coronary Care Units (CCU). Materials and Methods: The present study is a cross sectional analytical study that was conducted in the ICU, NICU and CCU of educational hospitals affiliated to Qazvin University of Medical Sciences. The convenience sampling method was used. A nursing activity score was used to assess nurses’ workload. The total score in this instrument is between zero and 178. Data were analysed using SPSS 16. Pearson correlation coefficient, chi-square, independent t-test, one-way analysis of variance was used. Results: The mean score of the total workload in nurses was 104.19±25.18. Regarding the primary purpose of the study, the results of the present study showed that the mean score of nurses' workload was significantly higher in nurses working in the NICU than nurses working in the ICU and CCU (p<0.05). Among the demographic variables, only the marital status was significantly associated with nurses' workload, that married nurses experienced more workload in some shifts (p<0.05). Conclusion: Nurses working in NICUs experienced a higher level of workload compared to the nurses in ICU and CCU. Due to the high workload of nurses in the NICU and the complications that this can cause for neonatal patients and nurses, it is necessary to pay more attention to the distribution of nurses in these wards.

Pattern of Physical Activity among Undergraduate Medical Students: A Multicentric Cross-sectional Study Across Bihar, India

Neha Chaudhary, Shradha Mishra, Manish Kumar, Yamini Sharma, Shamshad Ahmad

Introduction: Inspite of the fact that the medical students have a greater awareness about a healthy lifestyle; their academic stress to perform well may poorly affect their pattern of physical activity and thus, compromise their overall health. Aim: To assess the level of physical activity among undergraduate medical students studying in various institutions across the state of Bihar and to evaluate the Metabolic Equivalent Task (MET) score so as to measure the intensity of physical activity performed by the participants. Materials and Methods: This was a cross-sectional study conducted among the undergraduate students, studying in different medical colleges across Bihar, India. An Online Google Form was created using a short version of the International Physical Activity Questionnaire (IPAQ). The collected data was analysed using Stata (Version 13) software. Results were presented as frequencies, mean and standard deviation. Chi-square test was applied to test for significant association at 0.05 level of significance. To identify the predictors of physical activity, multiple logistic regression analysis of the data was done. Results: A total of 1200 students participated in the study. Among these, 64.3% were males and 35.7% were females. More than half of the participants (57.6%) were aged <21 years. Majority of the participants (67.7%) had normal weight followed by overweight/obese (22.8%). Approximately, half of the participants (54.4%) reported availability of gym in their campus and only 26.7% of the participants were following regular routine of physical exercise. Maximum students under the study were residing in the hostel (89.4%); who were reaching college mainly by walking (74.8%), {OR=17.5 (12.9-23.5)}. On multivariate analysis; Body Mass Index (BMI), age, having an availability of gym in the campus and following a regular routine of physical exercise were found to be significant predictors of physical activity. Conclusion: In present study, the majority were sufficiently physically active. However, the low physical activity was observed among the overweight/obese participants is a distressing fact which may reflect the need to integrate the physical education electives in the curriculum.

BAP 65 and DECAF scores in Predicting Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Prospective Observational Study

Sashideep Reddy Telukutla, TA Vidya, SK Nellaiappa Ganesan

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is the fourth most common cause of mortality in the world. Acute Exacerbation of COPD (AECOPD) is a common entity to the emergency room of physician. It also contributes to the morbidity and mortality of the disease. Since multiple factors influence the outcomes of AECOPD, many prognostic indices incorporating various parameters have been proposed. BAP 65 {Blood Urea Nitrogen (BUN), Altered mental status, Pulse rate and age >65 years} and Dyspnoea grade, Eosinopenia, Consolidation, Acidemia and Atrial fibrillation (DECAF) are two which are commonly used. Head-to-head comparisons of these scores in their ability to correctly predict outcomes will aid the clinician in decision-making. Aim: To evaluate the performance of BAP 65 and DECAF scores in accurately predicting need for mechanical ventilation and mortality in patients with AECOPD. Materials and Methods: In this prospective observational study, 170 patients presenting with AECOPD to the emergency department were recruited consecutively. All patients were clinically examined and all variables for the calculation of the two scores were documented at baseline. Routine neurological examination was used to determine altered sensorium at admission. Following this, all patients underwent appropriate investigations including chest X-ray, Electrocardiogram (ECG) and arterial blood gas estimation. BAP 65 and DECAF scores were recorded and patients were followed till death or improvement. The results were analysed using Statistical Package for the Social Sciences (SPSS) software version 23. Student’s t-test, Mann-Whitney test and Chi-square test were used depending on the type of variables. Receiver Operating Characteristic (ROC) analysis was done and Area Under the Curve (AUC) was determined. A p-value <0.5 was deemed to be significant for all tests. Results: Out of 170 patients, 48 required non-invasive ventilation and 30 required invasive ventilation and 23 (13.5%) expired. Mortality correlated significantly with age, median years of COPD, smoking pack years and hospitalisations in the past one year and also with lower haemoglobin and higher total leucocyte counts and BUN values. Both BAP 65 and DECAF scores correlated with need for mechanical ventilation and mortality. Area Under Receiver Operator Characteristic Curves (AUROC) predicting mortality was 0.712 for BAP 65 and 0.965 for DECAF scores. AUROC predicting need for ventilation was 0.583 for BAP 65 and 0.791 for DECAF scores. DECAF showed sensitivity of 78.26%, specificity of 95.92%, Positive Predictive Value (PPV) of 75%, Negative Predictive Value (NPV) of 96.58%, with an accuracy of 87.09% in predicting mortality. In predicting need for mechanical ventilation, DECAF had sensitivity of 32.14%, specificity of 94.74%, PPV of 75%, NPV of 73.97% with an accuracy of 63.44%. DECAF showed a higher positive predictive value for both outcomes. Conclusion: History and basic clinical examination provide a lot of data to formulate prognosis in AECOPD. In resource-poor settings, BAP 65 can be used while DECAF can be used where arterial blood gas analysis is readily available, since both have proven to correlate with outcomes.

Assessment of Corneal Endothelium among Diabetic Patients in a Multispecialty Hospital in Tamil Nadu

Introduction: Corneal damage is the common issue affecting 70% of diabetic patients. Diabetic cornea has functional abnormalities such as decreased corneal Endothelial Cell Density (ECD), thicker corneas with increased endothelial permeability, lesser corneal sensitivity, and elevated corneal auto-fluorescence. Aim: To study the corneal endothelial characteristics among diabetic patients and to identify the factors associated with endothelial damage and compare the corneal changes based on the duration of diabetes mellitus and glycaemic control. Materials and Methods: The hospital based cross-sectional study was conducted in 155 patients (100 diabetic and 55 control) from 24th September 2016 to 29th March 2018. The corneal endothelial morphological features were evaluated using a non-contact EM-3000 specular microscope. The morphological characteristics of endothelial cell like the ECD, Coefficient of Variation (CV), Central Corneal Thickness (CCT), and percentage of hexagonal cells were compared between diabetic patients and the control population. Age, gender, blood pressure, duration of diabetes, fasting and Postprandial Blood Sugar (PPBS) HbA1c value, blood urea, and serum creatinine, Intra Ocular Pressure (IOP) were also recorded, and the endothelial cell characteristics were compared between the diabetic groups according to the duration (< or = 3 years) and HbA1c% (< or = 7%). An independent t-test was performed to compare the means of endothelial characteristics between study subjects and the control group and also between duration of diabetes and HbA1C levels. A p-value of less than 0.05 was considered statistically significant. The data were analysed using a SPSS statistical program. Results: Baseline characteristics like Fasting Blood Sugar (FBS), PPBS, HbA1c, Systolic and Diastolic Blood Pressure (SBP and DBP) were significantly higher in diabetic group than control. A significant difference in corneal thickness (p=0.01) and hexagonality (p<0.001) were also observed between both the groups. The diabetic group showed a reduction in cell density and a higher coefficient variation of cell size however the differences were not statistically significant, There was no significant difference in the ECD, CCT, CV, and hexagonality irrespective to HbA1c level and duration of diabetes. Conclusion: Patients with diabetes had a significant increase in corneal thickness, and a higher frequency of pleomorphism compared to control subjects. In terms of ECD and co-efficient variation, no difference was observed between groups.

A Randomised Clinical Radiological Study using Platelet Rich Fibrin and MTA in Pulpotomy of First Permanent Immature Molars

Introduction: Maintaining a vital pulp of immature permanent teeth is an essential and important requirement for dentin formation. Every effort must be made to preserve the vitality of teeth with incomplete apices to maintain the physiological apex generation process as much as possible. Pulpotomy is considered as one of the successful procedures to maintain this process in immature teeth. Aim: To evaluate the treatment success of pulpotomy of first immature molars with irreversible pulpitis using Platelet-Rich Fibrin (PRF) or Mineral Trioxide Aggregate (MTA) and monitoring the teeth for one year. Materials and Methods: A randomised clinical and radiological double-blinded evaluation was conducted in the Department of Paediatric Dentistry at Damascus University, Damascus, Syria. The research sample consisted of 24 first permanent immature molars in 20 children between age group of 6-8 years. Each of them had at least one first permanent immature molar with irreversible pulpitis. The research sample was randomly divided into two equal groups according to the treatment method: 1) pulpotomy with PRF; and 2) pulpotomy using MTA. Treatment were evaluated through periodic reviews and clinical and radiological examinations of the treated teeth by three specialists to assess treatment success. The treatment outcome was determined in terms of success or failure during two study periods (after six months and after one year). McNemar’s and Chi-square tests were applied using IBM SPSS version 20.0. The significance level was set at p-value <0.05. Results: Chi-square test showed that there were no statistically significant differences in the treatment success or failure between the treatment groups after six months and one year follow-up, p>0.05. After analysing the results statistically using McNemar’s test, it was observed that the treatment success rate after one year (50%, n=6) was lesser than that after six months (100%, n=12) in the MTA treatment group (p=0.031). In the treatment group using PRF, no significant difference (p=0.125) was observed in the success or failure of treatment between the two studied time periods (after six months and one year). Overall, the success rate of MTA was slightly higher than the success rate of PRF at the two study time periods (after six months and one year), the difference however was not statistically significant. Conclusion: Performing first immature molar pulpotomy using MTA had a slightly higher success rate than PRF pulpotomy.

Intravitreal Bevacizumab Alone Versus Combined Bevacizumab and Macular Grid Laser Photocoagulation in Diffuse Diabetic Macular Oedema

Fawaz Al Sarireh, Hamzeh Mohammad Alrawashdeh, Khalid Al Zubi, Khalil Al Salem

Introduction: Diabetes Mellitus (DM) is a common disease with multiple systemic complications. Diabetic macular oedema is the main threat to vision in patients with diabetic retinopathy, which results from the increased permeability of the inner and outer blood-retinal barrier. Macular argon laser photocoagulation was the only treatment of diabetic macular oedema in the past. Now-a-days, both intravitreal anti-Vascular Endothelial Growth Factor (VEGF) and macular grid laser photocoagulation are used in the management of diffuse and focal Diabetic Macular Oedema (DME). Aim: To assess the changes in both visual acuity and Central Macular Thickness (CMT) in patients with DME after intravitreal injection of bevacizumab only or in combination with macular grid laser treatment. Materials and Methods: A prospective longitudinal cohort study included 89 eyes of 52 patients with DME, who were categorised into two interventional groups. The first group received only intravitreal bevacizumab for the first three months, then Pro Re Nata (PRN), while the second group received intravitreal bevacizumab, similar to the first group, in addition to macular grid laser treatment two weeks after the initial injection. Participants were followed-up at 12 months, and the visual acuity, CMT, and the total number of injections were documented. Patients were followed-up but data was gathered on baseline and at the 12^th month were compared. Results: In comparison to the initial presentation, a significant decrease in CMT was noticed in both groups (163.47±83.60 μm vs. 126.45±52.45 μm, respectively). Moreover, a significant improvement in visual acuity of both groups (p<0.023 and p<0.016, respectively) and significantly fewer injections being required in the second group were noticed. Conclusion: Combining intravitreal bevacizumab with macular grid laser treatment can lead to stabilisation and improvement of visual acuity with a smaller number of injections which was statistically significant.

Effectiveness of Dexmedetomidine vs Ketamine in Paediatric Patients Undergoing MRI

Introduction: Magnetic Resonance Imaging (MRI) is not painful, but frightening especially in children leading to movement and artefacts causing prolongation of the procedure. Though analgesia is not required, but being a noisy suite, deep sedation is a prerequisite for it. Dexmedetomidine (DEX) and Ketamine both anaesthetic drugs can achieve the sedation in the children but never had been compared. Aim: To compare the effect of DEX and Ketamine in paediatric patients undergoing MRI under sedation. Materials and Methods: This was a cross-sectional study carried out from August 2017 to July 2018 included 74 patients. All patients were separated into Group K for Ketamine (loading dose of 1 mg/kg, intravenous over 10 min followed by infusion of 10-15 mcg/kg/min) and Group D for DEX (loading dose of 1 mcg/kg over 10 min followed by infusion of DEX at 0.2-0.7 mcg/kg/h). Ramsay sedation score of five was considered as onset of sedation. Midazolam 0.1 mg/kg IV was decided as rescue sedation. Unpaired t-test was applied for the continuous variables. Results: Sixty-one patients were analysed, 31 in Group K, and 30 in Group D. The onset time for sedation in Group K was 6.30±1.32 minutes and 12.20±SD=2.01 minutes in Group D which was significantly shorter in Group K (p=0.001). However, the time to Modified Aldrete Score of 10/10 was higher in Group K (21.10±1.84 minutes) vs (13.73±1.89 minutes) in Group D which is statistically significant. (Mean±SD; p=0.001). No adverse events were reported in both the groups. Conclusion: Ketamine and DEX can both be used for MRI sedation in children successfully without any adverse effects. The onset of sedation is faster in Ketamine, but discharge and recovery are significantly delayed with Ketamine as compared

Different Risk Factors Associated with Persistence or Regression of Squamous Intraepithelial Lesions of Cervix under Rural Conditions in India

Jata Shanker Misra, Anand Narian Srivastava, Shivani Singh

Introduction: In many Human Papilloma Virus (HPV) negative women, the Squamous Intraepithelial Lesions (SIL) of cervix often show persistence or progression of the lesion on followup which shows involvement of other risk factors of carcinoma cervix. Aim: The aim of the study was to evaluate the different risk factors of cervical cancer in persistent, progressed and regressed cases of SIL to identify the prominent ones among them. Materials and Methods: The study had been of a screening type for early detection of cervical cancer and it was done in the women population of west Lucknow, Uttar Pradesh, India (May, 2013-February, 2020). Cervical smears were collected in 2949 women attending the camps whose cytological examination revealed 498 cases of SIL and follow-up was available in 254 of them done through home visits after 1-4 years. Persistence of SIL was seen in 60 women on follow-up while in the remaining 194, the SIL had regressed to normal. The percentage of different risk factors seen with the persistence or regression of SIL was studied. Results: Among the different risk factors identified, prominent were of young age between 16-30 years with vaginal discharge and their percentage were insignificantly higher with persistence of SIL than in the regression group. Multiparity was also highly associated with both persistence and regression of SIL. The erosion of cervix was significantly associated with SIL persistence while associated inflammation was insignificantly higher in persistent than in the regression group. The percentage of all these factors except erosion of cervix was found higher in HPV- positive than in the HPV negative women. Conclusion: It appears that all the identified risk factors are present both in persistent and regression group but their percentage is higher with persistence of SIL. Hence, presence of any of these factors in these two groups should be viewed with caution to rule out any progression/recurrence of SIL.

A Cross-sectional Study to Determine the Relationship between Various Anthropometric Indices and Depth of Spinal Needle Insertion in Indian Patients undergoing Elective Surgeries under Spinal Anaesthesia

Anish H Dave, Rajendra D Patel, Mansi U Vaidya, Nirav M Kotak

Introduction: The estimation of Depth from Skin to Subarachnoid Space (DSS) may be helpful in selecting the appropriate length of the spinal needle before insertion and decrease the chances of accidental dural puncture. Aim: To determine the usefulness of previously suggested formulae and to derive mathematical formulae to predict DSS for the Indian population. Materials and Methods: After approval from the Institutional Ethics Committee, 700 American Society of Anaesthesiologists (ASA) Physical Status I and II patients were recruited from August 2017 to July 2018. Patients of either sex in the age group of 18-65 years, undergoing elective surgeries under spinal anaesthesia were included in this cross-sectional study. DSS was measured after Sub Arachnoid Block (SAB) and it was compared with various formula-based predicted DSS. Multivariate regression analysis was done to evaluate the influence of anthropometric indices on DSS and formulae were derived for the Indian population. p<0.05 was considered significant. Results: Final data analysis was performed on 685 patients. SAB was successful in first attempt in 624 (91.09%) patients, second attempt in 47 (6.86) patients and third attempt in 11 (1.60) patients. There was a failure of SAB in 3 (0.43%) in total analysed subjects. The measured mean DSS was 4.60±0.602 cm. DSS in adult males (4.60±0.5818 cm) was comparable with DSS in adult females (4.61±0.6377 cm). Formula for predicting DSS in the overall population was DSS (cm)=0.8+0.16×BMI. Formulae were also derived based on other variables like weight, Weight-to-Height Ratio (WHR) and Waist Circumference (WC). The strength of correlation between the anthropometric indices and DSS is BMI>WHR>Weight>WC>Height in decreasing order. DSS correlates best with Body Mass Index (BMI) and WHR. Conclusion: The proposed formulae based on BMI can be used to predict the DSS. It would help in the selection of appropriately sized spinal needle which in turn would reduce the number of attempts and incidence of failure and complications in patients.

Quality Indicators for Error Minimisation in Histopathology: Experience at a Tertiary Care Centre

Sheenam Azad, Pooja Sharma Kala

Introduction: Quality Indicators (QI) are parameters defined by Quality Management System (QMS) in a laboratory to assess and monitor quality of results generated. A regular and periodic review of these QI also help improves the quality of laboratory results. These QI are often underutilised or less commonly followed-up in histopathology laboratory/Surgical Pathology. Aim: This study was conducted with the aim to evaluate QI and their role in improving the quality in histopathology. Materials and Methods: This cross-sectional study was conducted in histopathology laboratory of a tertiary care hospital and teaching institute located in Dehradun, Uttarakhand, India from January 2016 to June 2018. A set of nine QI were evaluated biannually and the data was analysed using ANOVA test followed by Post-hoc Tukey test. Results: During the study period, number of unacceptable samples (QI-1) was zero. Number of errors at registration and/or accession (QI-2) was five (0.05% with respect to total number of specimens). Completeness of equipment (QI-3) and performance in External Quality Assurance Programs (EQAP) (QI-4) were satisfactory throughout. Number of amended reports (QI-5) was three (0.03%). There were two (0.02%) complains/negative feedbacks from users (QI-7). QI-8 (laboratory safety and environment) and QI-9 (effectiveness of document control system) were maintained during the study period. Turn Around Time (TAT) (QI-6) as a QI which was deranged mostly (4.5%). Reasons for delayed TAT were further analysed. It was found that pre analytical factors were commonest and statistically significant reasons behind the delayed TAT as compared to analytical and postanalytical ones. Root cause analysis and future preventive actions were undertaken, accordingly to improve the quality. Conclusion: Periodical review of QI helps in understanding the flaws in the analytic cycle and appropriate actions undertaken accordingly helps in improving the quality in histopathology.

Association between Triglyceride Glucose Index and Insulin Resistance among Thai Obese Adolescents

Thidarat Somdee, Udomsak Mahaweerawat, Chatchada Mahaweerawat, Suneerat Yangyuen

Introduction: Global adolescence obesity is considered as the risk factor associated with the development of Insulin Resistance (IR). And, Triglyceride Glucose (TyG) index has been used as an alternative tool to estimate IR. Thailand has also encountered the same trend especially the adolescence obesity risk is increasing because of malconsumption behaviour. Aim: The aim of this study was to assess the association between the TyG index and IR among Thai adolescents. Materials and Methods: This cross-sectional study was carried out on 300 obese adolescents selected from the Obesity Outpatient Clinic of Mahasarakham Provincial Public Health Office during 2009 to 2013. Anthropometric and IR risk factors were measured. The TyG index was calculated as in {fasting Triglycerides (TG) (mg/dL)×fasting blood sugar (mg/dL)}/2, while IR was estimated by Homeostasis Model Assessment for Insulin Resistance (HOMA-IR). Data were analysed by using a multiple logistics regression at 0.05 level of significance running with STATA version 13.0 software. Results: All subjects were divided into tertile groups based on the TyG index to analyse statistically significant differences (p<0.05). ANOVA revealed that there were significant differences in IR risk factors (Basal Metabolic Index, Fasting Blood Sugar level, and Triglyceride level) among the groups. Both TyG index and HOMA-IR level were statistically highly significant among the tertiles (p<0.001). Multiple logistic regression analysis revealed that TyG index can be used as an association factor for IR, in a fully adjusted model after adjusting BMI and Tricep thickness (3.06; 95% CI 1.780, 5.170; p<0.001). Conclusion: The results of the TyG index were significantly associated with IR in thai obese adolescents hence, supporting the use of TyG index as a surrogate marker for IR.

Validation of Modified Paediatric Triage Score in a Tertiary Care Hospital

Bandya Sahoo, Reshmi Mishra, Mukesh Kumar Jain, Sibabratta Patnaik

Introduction: The global burden of paediatric mortality is high and majority of the deaths are preventable by providing timely access to specialised emergency care. An appropriate triage in a busy emergency department can identify the sickest patient for early intervention. Aim: To develop a simple score based on physical variables alone and assess its validation so as to predict Intensive Care Unit (ICU) admission. Materials and Methods: This prospective hospital based study included 936 children, aged 1 month to 18 years. Baseline demographic data along with clinical variables were noted in a pre-designed proforma at the time of admission. A scoring system was developed based on severity of various clinical variables i.e., heart rate, respiratory rate, respiratory effort, Oxygen Saturation (SpO₂ ), Capillary Refill Time (CFT), temperature, level of consciousness and behaviour. The outcome i.e., admission to ward or Pediatric Intensive Care Unit (PICU) of the patient was correlated with the study variables and total score. An association of modified PETS with the PICU admission was done using Chi-square test. A p-value of <0.01 was considered as statistically significant. Results: The modified Paediatric Triage Score (PETS) which is developed based on eight physical variables, is reliable in discriminating the children with ward and ICU admission. A score of =6 leads to 14.8 times higher risk of getting admitted to ICU as compared to a child with score of <6. A cut-off of ≥6 for modified PETS score has a sensitivity of 79.6% and specificity of 79.2% in predicting ICU admission. Conclusion: This simple clinically developed scoring system based on physical variables alone with an optimal cut-off of ≥6 can predict severity of illness and need for PICU admission in Emergency Department with acceptable validity and can serve as a potentially excellent screening tool.

Spontaneous Versus Medical Induction of Labour in Previous One Caesarean Term Patients: A Prospective Analytical Study

Nupur Mittal, Pragya Shree, Neelam Swaroop, Soniya Vishwakarma

Introduction: The rate of Caesarean Section (CS) either primary or repeat has significantly increased worldwide over the time. Trial of Labour After Caesarean (TOLAC) is an important strategy to limit the number of repeat CS. TOLAC either spontaneous or induced offers both benefits and risks to the mother and neonate. Aim: To determine the risks and benefits of inducing labour with Prostaglandin Gel (PGE₂ ) in women with previous one CS and to compare it with patients who developed spontaneous labour in terms of fetal and maternal outcome. Materials and Methods: A prospective interventional study was conducted over a period of one year from June 2017 to May 2018. A total of 322 pregnant patients with previous one CS who fulfill the eligibility criteria for TOLAC were enrolled and divided into two groups. Of these 74 patients were induced with PGE₂ gel (study group) and 248 experienced spontaneous labour. Data were analysed via Chi-square test and unpaired t-test using analytical tool pack of Microsoft excel (version-10.0)-2010 home edition. Results: In study group and control group, 51 (68.9%) and 191 (77.01%) women respectively delivered vaginally either spontaneous or assisted, but the difference was not statistically significant. Two cases in the study group had laparotomy for uterine rupture with favourable feto-maternal outcome. Vaginal Birth After Caesarean (VBAC) rate was significantly more in women who had history of prior vaginal delivery (p=0.0024). TOLAC was successful in 242 women while CS was done in 80 women. Mean BMI in women with successful TOLAC was significantly lower than in women with unsuccessful TOLAC (23.42±2.07 versus 26.08±3.07, p=0.0001). With an interpregnancy interval of 25-36 months, 45.1% in study group and 47.6% in control group delivered vaginally. Conclusion: For women with previous one CS, TOLAC is a reasonable option as compared to planned repeat Caesarean. In these women with continuous supervision, PGE₂ is as safe and effective as spontaneous labour in achieving vaginal birth after Caesarean.

Impact of Efflux Pump Inhibitor Carbonyl-Cyanide M-Chlorophenylhydrazone in Multidrug Resistant Acinetobacter Species Isolates from Sterile Body Fluids

Introduction: Antimicrobial resistance of Acinetobacter baumannii (A. baumannii) are rapidly emerging, becoming non-responsive to most of the commonly prescribed antibiotics and leaving us with few treatment options and galloping treatment costs. Aim: To study the effect of Efflux Pump Inhibitor (EPI) Carbonyl Cyanide 3-Chlorophenylhydrazone (CCCP) on Multidrug Resistance (MDR) A. baumannii isolates from different sterile body fluids. Materials and Methods: A total of 40 Acinetobacter species isolates from different sterile body fluids i.e., Cerebrospinal Fluid (CSF), ascitic fluid, pleural fluid, and peritoneal fluid were collected and identified by Matrix Assisted Laser Desorption/Ionisation-Time Of Flight (MALDI-TOF), Biomerieux, France. Minimum Inhibitory Concentration (MIC) of A. baumannii was determined by automated VITEK-2 Antimicrobial Susceptibility Testing (AST) system (Biomerieux, France). In addition, MIC of the isolates, grown on Mueller-Hinton Agar (MHA) plate with 15 μg/mL with EPI CCCP (Sigma Aldrich, US) was determined. For Tigecycline, MIC was determined by Broth Microdilution (BMD) method. Results: Out of 40 isolates, 34 (85%) were A. baumannii and 6 (15%) were Acinetobacter junii. Most of the Acinetobacter spps were MDR and only susceptible to few antibiotics. Most effective antibiotic was Tigecycline 25 (73.52%) followed by Co-trimoxazole 10 (29.41%). Similarly, Out of 40 isolates, 2 to 64 folds reductions in MIC was observed due to CCCP in 10 (25%) isolates for various antibiotics. Likewise, for Tigecycline, 2 to 4 folds reductions in MIC value (One strain changed from intermediate to sensitive) was observed by VITEK-2 AST which corroborated with reduction in MIC by BMD after addition of CCCP. Conclusion: MDR A. baumannii are spreading rapidly. There is the need to overcome the antimicrobial resistance by investigating resistance inhibiting substance that will help to restore antimicrobial susceptibility and bringing back the existing antibiotics in prescription.

Clinical Correlates of Rapid Eyeball Movement Sleep Behaviour Disorder with Clomipramine: A Case Control Study

Abhinav Pandey, Achyut Kumar Pandey, Malvika Pandey, Mona Srivastava

Introduction: Antidepressants have been implicated in causing Rapid eyeball movement sleep Behaviour Disorder (RBD). While Selective Serotonin Reuptake Inhibitor (SSRI) and Serotonin Norepinephrine Reuptake Inhibitors (SNRI) are more frequently implicated, Tricyclic Antidepressants (TCA) have been less studied. Aim: To characterise the clinical correlates of RBD on Clomipramine and to compare these parameters with those who didn’t develop RBD on treatment with clomipramine. Materials and Methods: It was a case control study in which participants who were on clomipramine and had developed RBD were studied, and a comparison was made with those participants who were on clomipramine but didn't develop RBD. All the assessments were done in a single sitting. Patients who were on clomipramine, for any reason, were screened for presence of sleep disorder. Detailed interview was done for diagnosis and Statistical Manual of Mental Disorders (DSM-5) diagnosis of RBD to form the case group. From the group of participants, who didn’t meet the criteria for RBD, every 7th case was included to form the control group (NRBD group). Both the groups were interviewed for socio-demographic and clinical profile and Mini International Neuropsychiatric Interview (MINI Version 5) was applied for International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) of diagnosis of psychiatric disorders. Chi-square and Independent t-test were used to make the group comparisons. Pearson 's coefficient was used for correlation analysis. Results: A total of 164 participants, on clomipramine, were evaluated for presence of RBD, which was found in 20 and were included in the RBD group and 20 participants, were included in the NRBD group. Mean age of the participants in RBD group was 36.650±7.882 years. Mean duration of RBD development was 16.4 days (Range: 3-40 days). In comparison to the NRBD group, in the RBD group mean dosages (p=0.016), and mean duration of treatment (p=0.026) with clomipramine was significantly higher. Correlational analysis showed that duration of development of RBD correlated negatively with age (r=-0.479, p=0.034) and dosage of clomipramine (r=-0.095, p=0.690). Conclusion: RBD has higher prevalence and younger age of onset with clomipramine usage than earlier reported. Higher dosage increases the chance of developing RBD. Clinicians should be alert for identifying and managing RBD in all patients on antidepressants.

Knowledge, Attitude, and Practices Regarding Maxillofacial Defects and their Prosthetic Rehabilitation among Dental Undergraduate Students in Belagavi District- A Cross-sectional Study

S Shreya, Ramesh P Nayakar

Introduction: Maxillofacial defects are facial disfigurements resulting from congenital abnormalities, surgical resection of tumours, trauma, or a combination of these. The resulting deformity often leads to a difficult path of recovery with lifelong consequences, causing both physical disability and mental distress. Prosthetic rehabilitation is not only a solution to cover the physical deficit, but also a way to improve function as well as the quality of life for such patients. However, the knowledge amongst undergraduate dental health professionals about the same has been at sparse. Aim: To evaluate the knowledge, attitude, and practices regarding maxillofacial defects and their prosthetic rehabilitation amongst dental undergraduate students. Materials and Methods: A cross-sectional survey was conducted between January 2020 and June 2020, amidst the third year, fourth year undergraduate students, and interns of Belagavi city, Karnataka, India. The data was collected using a 16-item custom designed proforma, comprising of questions evaluating student’s basic knowledge about the diagnosis, treatment procedures, and treatment planning of maxillofacial defects and their prosthetic rehabilitation. Statistical analysis was done using Chi-square test in each group, using SPSS version 22 p-value <0.05 to be considered significant. Results: A total of 286 participants answered the questionnaire, of which 117 (40.9%) were interns, 116 (40.6%) were third year students, and 53 (18.5%) were fourth year students. 279 (97.6%) participants had an understanding regarding maxillofacial defects. Of those who had witnessed cases, only 18.2% had observed more than three cases (p-value <0.001). Out of respondents with treatment understanding, 184 (64.3%) answered that it required a multidisciplinary approach (p-value <0.001). 197 (68.9%) of the respondents felt that silicone was the most commonly used material (p<0.003). 165 (57.7%) answered that waxes were the most commonly used impression material (p-value <0.001). Out of the respondents awared about treatment modalities, 120 (42%) respondents majority answered that CAD-CAM would contribute the most to maxillofacial rehabilitation. Conclusion: Comprehensive understanding and clinical application of prosthodontic rehabilitation of maxillofacial defects among undergraduate students was found to be lacking. This awareness should be initiated at an early stage of the clinical training for undergraduate training programme, as it will help to understand the basic aspects involved in the prosthodontic rehabilitation of maxillofacial defects.

Association between Body Mass Index and Cognitive Functions in Medical Students

Introduction: There is a widespread prevalence of obesity and growing evidence suggests its possible adverse effect on cognitive functions. Hence, it is important to study the relationship between Body Mass Index (BMI) and Cognitive Functions. Aim: The aim of this study was to find out the association between BMI and cognitive functions in medical students. The present study also determined whether there are any gender based difference of association of BMI and cognitive functions. Materials and Methods: A cross-sectional study was done at Cognitive function test Laboratory of Dr. Vasantrao Pawar Medical College, Hospital and Research Centre, Nashik between July and December 2016. Study was done on randomly selected medical undergraduate students (50 male and 50 females) of 18-25 years age group. Height and weight were recorded and subjects were divided into 3 groups based on BMI (in kg/m² ) as: Underweight (BMI <18.5 kg/m² ), Normal weight (BMI 18.5- 25 kg/m² ) and Overweight (BMI >25 kg/m² ). In all the above BMI groups, four domains of cognitive functions were assessed i.e., attention, perception, executive functions and working memory using Visual and Auditory Reaction Time (VRT and ART) and Go/No-Go VRT and ART; Fast Counting (FC); Eriksen Flanker Test (EFT) and Stroop Test (ST) and Visual Forward (VFDS) and Backward Digit Span (VBDS) test, respectively. The data was statistically analysed and different cognitive function tests were compared in various categories of BMI (viz., underweight, normal and overweight) using ANOVA and Tukey HSD tests. Gender based association of BMI and cognitive functions were also assessed. The data was analysed statistically using SPSS version 16.0 and p-value <0.05 was considered to be significant. Results: On comparing the cognitive functions with BMI, it was found that when whole study population was considered, the difference in time taken by subjects of different BMI categories to give response in VBDS test was found to be statistically significant (p=0.007). When the gender differences were analysed, it was found that in males, the time taken to give response to stimuli with interference (ST) in various BMI categories was statistically significant (p=0.004) and in females, the time taken to give response in VBDS test in various BMI categories was found to be statistically significant (p=0.024). The correlation between the reciprocal of time taken to give response in ST and VBDS and BMI was a weak positive correlation (0.3 < r < 0.5). Conclusion: A weak positive correlation was found between BMI and reciprocal of time taken to give response to stimulus with interference in males and BMI and reciprocal of time taken to give response in VBDS Test in Females.

Membranoproliferative Glomerulonephritis- A Disease or a Pattern of Injury?

Introduction: Pre-Eclampsia (PE) is the common multisystem disorder which complicates the pregnancies 3-8% and a major cause of morbidity and mortality throughout the world. Aim: To determine the correlation of placental growth factor with PE in mid trimester of pregnancy at Liaquat University of Medical and Health Sciences Jamshoro. Materials and Methods: This Case-Control study was performed at Pathology Department with Department of Obstetrics and Gynaecology, Liaquat University of Medical and Health Sciences (LUMHS) Jamshoro/Hyderabad, during 12 months, from 6th February, 2017 to 5^th February 2018. Pregnant women with mid trimester were enrolled in the study. Group A included females with PE, while Group B were normotensive females of same gestation. Their blood sample were collected and stored at -80°. Level of placental growth factor was measured on Elecsys system. Data was analysed via Statistical Package for the Social Sciences (SPSS) version 20. Results: Total 384 PE females were selected and 50 females without hypertension were studied as control. Mean age of patients was 27.46±3.91 years. No significant variance was seen between mean of gestational age of patients and normal pregnant females; p-value 0.346. Mean of placental growth factor was insignificantly decreased 35.21±31.68 pg/mL among patients in contrast to normal women as 47.23±56.13 pg/mL, p=0.081. A negative correlation was found between blood pressure and placental growth factor, r-values -0.004 and -0.001, respectively. Conclusion: It was concluded that serum placental growth factor was the poor marker for PE, as it showed weak negative correlation with PE.

Comparative Evaluation of Chitosan Nanoparticles, Silver Diamine Fluoride and Acidulated Phosphate Fluoride Gel on Microhardness of Artificial Carious Lesions Created on Extracted Teeth

Introduction: Dental caries is a multifactorial microbial infectious disease characterised by demineralisation of the inorganic and destruction of the organic substance of the tooth. To combat dental caries the application of nanotechnology includes the inhibition of formation of biofilm and regulating the balance of demineralisation-remineralisation processes, ensuring a possible mechanism that can aid in prevention and treatment of tooth decay. Initial caries progression may be prevented by suitable surface treatment, by applying surface remineralising agents. Aim:To evaluate and compare the efficacy of remineralising potential of Acidulated Phosphate Fluoride (APF) gel, Chitosan nanoparticles and Silver Diamine Fluoride (SDF) on microhardness of artificial carious lesions created on extracted teeth. Materials and Methods: This was an in-vitro experimental study associated with Krishna Institute of Medical Sciences, Karad conducted during a period of two months (October and November 2019) at Mechanical Department of Rajarambapu Institute of Technology, Islampur, Maharashtra. The total sample size was 30 premolar teeth. In this in-vitro study, test materials Chitosan nanoparticles, Silver Diamine Fluoride (SDF) and Acidulated Phosphate Fluoride gel (APF) varnishes were manipulated and applied (10 in each group) in accordance with manufacturer’s instructions. Artificial carious lesions were created in the enamel. This was achieved by suspending the teeth in an artificial caries system. Baseline microhardness was then recorded using Vickers Hardness Test and varnish application was carried out. Samples were then placed separately in a demineralisation solution for three hours. Thereafter, samples were placed in a remineralisation solution. Any change in microhardness was determined by evaluating the Vickers Hardness Test at the end of 28 days. The data was then recorded, tabulated and statistically analysed using KruskalWallis Test and Wilcoxon Signed Test for inter and intra groups comparisons to find out if there was a significant difference. Results: All the three varnishes i.e., Chitosan nanoparticle, silver diamine fluoride and APF gel in intragroup comparison after intervention showed significant differences with Chitosan nanoparticle showing the highest increase in microhardness with p-value of 0.001 followed by SDF with p-value of 0.005 and APF gel with p-value of 0.005. Conclusion: All the three varnishes increased enamel microhardness significantly. Chitosan nanoparticle showed highest increase in remineralisation followed by SDF and APF gel. Hence, varnish application is a good method in remineralising the tooth.

A Study of Significance of Poorly Differentiated Clusters in Colorectal Carcinomas: Association with Histopathological Prognostic Factors

Shailja Maurya, Sapna Patel, Harish Srikantegowda

Introduction: Colorectal Cancer (CRC) is the third most common cancer worldwide with prevalence rate of 47 million per five years and 1.8 million new cases per year. Routinely differentiation-based histologic grading of CRC is used, but its clinical impact is limited by insufficient prognostic value, inter-observer variability and the difficulty of its application to specific CRC's like mucinous, micropapillary, signet ring cell and medullary carcinomas. To overcome this, Poorly Differentiated Cluster (PDC) based grading have been proposed recently in 2012 by Ueno H et al., PDC is defined as a solid cancer cell nest comprising ≥5 cancer cells, lacking a gland-like structure. Aim: To compare PDC based grading with conventional World Health Organisation (WHO) grading in resected specimens of colorectal adenocarcinomas and to evaluate the relationship of PDC grading with known prognostic histopathological parameters. Materials and Methods: The present study was a descriptive study done duration of three years and two months in the Department of Pathology, JSS Medical College and Hospital, Mysuru, Karnataka, India. A total of 60 CRC cases were studied. WHO grading was done according to eighth edition, 2018 of the American Joint Committee on Cancer (AJCC) staging system. Haematoxylin and Eosin (H&E) stained slides were studied by two pathologists and looked for inter-observer variability by k statistics. Finally, both pathologists arrived at a consensus and was subjected for PDC grading and correlated with other prognostic histological markers. The comparison of data was done by Pearson 's Chi-square test and t-test. The p-values <0.05 were considered statistically significant. Fleiss-Cohen 's weighted k statistics was used for the assessment of interobserver variability in tumour grading. Results: There was significant association between PDC grading and WHO grading with k-value of 0.852 and p-value of 0.001. The maximum cases on PDC grading were of G-II type-29 (48.3%) followed by G-III-25 (41.7%) and G-I-6 (10%). There was increase in G-II and G-III carcinomas, as mucinous adenocarcinoma and signet ring cell carcinomas were also graded with PDC which was not possible with current WHO grading system. Conclusion: Present study findings suggest that PDC grading is more reproducible and provides better prognostic stratification as it is less subjective than the conventional WHO grading.

Level of Stress among Final Year Dental Students while Performing Paediatric Dentistry Procedures in Riyadh City- A Cross-sectional Study

Introduction: Dentistry is considered a stressful profession. Stress is defined as a state of mental or emotional strain or tension resulting from adverse or demanding circumstances. In particular to paediatric dentistry, dental student’s anxiety and stress level is elevated to the peak as managing a child in the dental chair is a great challenge for any dentist. Aim: To evaluate self-reported levels of stress of dental students about performing different procedures in paediatric dentistry in Riyadh city. Materials and Methods: A cross-sectional survey was conducted among final year dental students in seven different dental schools in Riyadh city. The final questionnaire was used following literature review of similar studies, focus group and piloting stage. The questionnaire addressed upon stress of performing treatment on a child patient and the future specialty preference for final year dental students. Descriptive analysis was done using Microsoft Excel. The statistical analysis were performed using Statistical Package for the Social Sciences (SPSS) (Version 22.0. Armonk, NY: IBM Corp.) and conducted at a Confidence Interval (CI) of 95%, and a significance level of 0.05. Internal consistency of the questionnaire was assessed by calculating Cronbach’s alpha. The level of significance was set at p-value <0.05. Results: The study included 176 participants of which 92 males and 84 females. A 43.8% of the dental students are not stressed of having the patient 's guardian in the clinic during the time of treatment, some are little confident in using the non-pharmacological management approaches for uncooperative child. A 54% of the students are quite stressed when performing dental treatment for preschool children. Conclusion: The current study revealed that both genders show some similarity in their answers, with the majority having no or little stress providing paediatric treatment. Dental students in Saudi Arabia were more stressed when performing pain stimulating procedures on preschool children.

Potential Risk of Developing Peripheral Neuropathy in Heavy Motor Vehicle Driving: A Cross-sectional Study

Kashif Ali, Gaurav Sharma, Nadeem Raza, Aliya Mufti

Introduction: There is a growing concern regarding increasing road traffic accidents due to overburdened drivers, which also affect their general health. Drivers maintain the extreme position of arm, forearm, and legs which during distant journeys may put increased constraint on nerves passing in forearm and legs in addition to the vibrations transmission i.e., Hand Arm Vibration Syndrome (HAVS) and Foot Transmitted Vibration (FTV). Aim: To find out if chronic repeated movements at wrist and foot along with vibration transmitted from steering wheel and pedals influence the nerve conduction parameters and to find out which nerves are more prone to neurological conduction defects. Materials and Methods: A cross-sectional study was conducted over a period of two years in Neurophysiology Lab, Department of Physiology, JN Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India. Mean peak sensory and motor latency, mean motor and sensory Nerve Conduction Velocity (NCV), Sensory Nerve Action Potential (SNAP) and Compound Muscle Action Potential (CMAP) of median, ulnar and common peroneal nerve in Professional Heavy Vehicle Drivers (PHVD) was compared with non-drivers using Medicaid System’s (Electromyography) EMG/ (Nerve Conduction Velocity) NCV equipment with Neuroperfect Software. Student’s unpaired t-test was used to assess the significance of difference in nerve conduction study findings. Results: Heavy vehicle drivers showed slow Sensory Nerve Conduction Velocity (SNCV) (drivers: 51.40±3.30, non-drivers: 53.66±3.60 in right hand p-value 0.0001) and (drivers: 52.51±3.78, non-drivers: 53.87±3.61 in left hand p-value=0.0145) and increase in sensory latency (drivers: 3.71±0.72, nondrivers: 2.89±0.56 in right hand p-value<0.0001 and drivers: 3.4±0.81 non-drivers: 2.76±0.70 in left hand p-value <0.0001) of median nerve. Ulnar nerve sensory latency was prolonged (drivers: 2.98±0.52, non-drivers: 2.76±0.42 in right hand p-value 0.0021 and drivers: 2.97±0.42, non-drivers: 2.80±0.65 in left hand p-value 0.0386) and sural nerve sensory latency was prolonged (drivers: 3.05±0.55, non-drivers: 2.78±0.54 in right leg p-value=0.0011 and drivers: 2.92±0.45, non-drivers: 2.69±0.40 in left leg p-value 0.0004). There was no significant difference in Motor Nerve Conduction Velocity (MNCV), motor latency, SNAP and CMAP of median, ulnar and common peroneal nerve among heavy vehicle drivers in comparison to non-drivers. Conclusion: We conclude that pressure and vibrations transmitted at hand and foot along with repeated movements at forearm wrist and pedals leads to more neurological conduction defects in median nerve than in ulnar and sural nerve. Flexibility in delivery time, incorporating judicious breaks in duty, better ergonomics design may help in improving work conditions of drivers.

A Pilot Study to Evaluate HEMA based Desensitising Agent and 980 nm Diode Laser in Dentinal Hypersensitivity

Anupama Ahirwar, Anuj Bhargava, Sanjesh Kumar Meena

Introduction: Dentinal Hypersensitivity (DH) presents as a short, intense pain emanating from exposed dentinal tubules. Many studies have concluded that mechanical, chemical or both factors increase the frequency of DH. Sealing of exposed dentinal tubule can be achieved with the use of Dental adhesives, restorations, Desensitising Agents (DA) and Lasers, each having their own mechanism of action. Aim: This clinical study was done to evaluate the efficacy of Hydroxy Methacrylate (HEMA) based DA and 980 nm diode laser in the treatment of DH. Materials and Methods: This two-arm parallel design split-mouth study was conducted on 30 adult patients attending the Dental Outpatient Clinic of Gandhi Medical College, Bhopal during the year December 2018 to January 2020 with clinically diagnosed high cervical DH (Charlie=3) occurring bilaterally in maxillary canine teeth. Scoring of baseline and postoperative DH was done utilising using Modified U.S. Public Health Service Criteria for DH Assessment. After recording the pretreatment baseline scores, mouth of each sample subject was divided bilaterally using split-mouth technique into Group A and Group B. The left side of patient’s mouth was designated as Group A in which a 10 W Diode Laser (980 nm) was used and right side of the patient’s mouth was classified as Group B, in which Shield Active (HEMA based) DA was used. The sensitivity score for both the groups was assessed immediately after application, after 24 hours, after seven days and after 21 days. Statistical Analysis was done by using Statistical Package for Social Sciences (SPSS) software version 22.0. Student’s t-test and repeated measures of ANOVA Test were applied. The p-value of less than 0.05 was considered statistically significant. Results: There was a statistically highly significant difference in sensitivity scores between both groups immediately after treatment p=0.038, after 24 hours, seven days and after 21 days. (p<0.001) depicting high efficacy of Diode lasers over DA. Repeated Measure of ANOVA was applied to find difference in mean score from baseline to 21 days. Immediately after application the results in Group A compared to baseline were statistically highly significant (p<0.001) and statistically significant in Group B (p<0.05). However, overall difference after 21 days compared to baseline were not significant in any group (p>0.05) depicting that the effect of both the desensitising therapies were not significant beyond 21 days in both the groups. Conclusion: Within the limits of this study, it can be concluded that both HEMA based DA and 980 nm diode laser were effective desensitisation treatment modalities for achieving immediate reduction of high cervical dentin hypersensitivity from baseline. Further, 980 nm Diode laser was found to be more efficacious and effective treatment option than HEMA based DA for treatment of DH.

Incidence of Cirrhotic Cardiomyopathy among Hundred Patients of Tamil Nadu, India- A Cross-sectional Study

AK Koushik, P Ganesh, S Shanmuganathan

Introduction: Cardiac dysfunction in cirrhosis may affect quality of life, prognosis and also may aggravate the course in patients undergoing invasive procedures such as surgery, insertion of a Transjugular Intrahepatic Portosystemic Shunts (TIPS), and liver transplantation. Aim: To evaluate the association of cardiomyopathy in cirrhotic patients of Tamil Nadu region in India. Materials and Methods: This cross-sectional study included 100 diagnosed cirrhotic patients. The patient’s cardiac status was obtained from Electrocardiography (ECG) and echocardiography. Liver profile was obtained from biochemical assays and ultrasonography of abdomen. The patients were classified as per cirrhosis grading system, Child Toucotte Pugh (CTP) scoring. The association was analysed using frequency analysis, percentage analysis and Chi-square test. Results: Prolonged QTc (>0.44 sec) was seen in 35% of the study population (p-value-0.014). A 10% of patients had systolic dysfunction and 25% showed diastolic dysfunction. Also, these patients showed positive troponin T and elevated Brain Natriuretic Peptide (BNP). The incidence of cardiomyopathy in cirrhotic patients was 28% in this study. Conclusion: This study established 28% incidence of cardiomyopathy in cirrhotic patients. This association may further be evaluated in larger study samples to provide a better prognosis and quality of life in cirrhotic patients treated with liver transplantation or other surgical procedures.

Evaluation of Outcome Measures of Hysteroscopy Polypectomy in Women with Abnormal Uterine Bleeding

Introduction: The most common causes of Abnormal Uterine Bleeding (AUB) in women of reproductive age are uterine polyps. Operative hysteroscopy is the management of choice to remove polyp. However, the certainty of the treatment remains to be examined. Aim: To investigate the outcome of hysteroscopy polypectomy in women with AUB. Materials and Methods: This was a cross-sectional study on the samples of women with AUB who underwent a hysteroscopy polypectomy. Patients were assessed pre and postoperatively and were asked to respond to a number of outcome measures including duration of monthly cycle, menstruation cycle, heavy menstrual bleeding, the number of pads used in day and night and improvement of inter-menstrual bleeding, postcoital bleeding, and limited activity. Pre-and postsurgery data were compared using Wilcoxon and McNemar tests. Results: In all, 83 patients were entered into the study. The mean age of participants was 41.8 (±8.37) years. The most common preoperative complaint was heavy menstrual bleeding (n=63, 76%) followed by intermenstrual bleeding (n=40, 48%). There were significant differences between preoperative and postoperative symptoms (p-values <0.05). Perceived complete recovery (n=54, 65%), partial recovery (n=13, 15.7%) and satisfaction (n=66, 79.5%) were high after hysteroscopy. Conclusion: AUB due to polyp might be improved with hysteroscopy. Further investigations are needed to confirm the results and to study on co-existence of other causes of AUB after hysteroscopy polypectomy

Prospective Study on Histopathological Spectrum of Upper Gastrointestinal Tract Lesions in a Teaching Hospital of Southern India

Eslavath Aruna, V Kalyan Chakravarthy

Introduction: The Upper Gastrointestinal Tract (UGIT) disorders are quite common in routine clinical practice and have high degree of morbidity and mortality. They can be studied by collecting tissue sample by way of fiberoptic endoscope and by subjecting the tissue to histopathological examination. Aim: To study the spectrum of histopathological lesions of UGIT lesions by endoscopy. Materials and Methods: This was a prospective observational study done in the Department of Pathology at PSIMS, Chinna Avutapalli, Andhra Pradesh, India, over a period of one year from March 2019 to February 2020 on 160 endoscopic biopsies. All UGIT endoscopic biopsies received were examined histopathologically. The data was entered into excel sheets and percentages and ratios were calculated. Results: Lesions of UGIT were more common in the age groups of 31 to 50 years and the male to female ratio was 1.9:1. The patient age ranged from 20 years to 78 years. Stomach was the common site for UGIT endoscopic biopsies i.e., 80 (50%) followed by oesophagus 50 (31.2%) and then duodenum 30 (18.7%). At all three sites, non-neoplastic lesions predominated over neoplastic lesions. The gastric malignancies were more common in antral and pyloric regions. Conclusion: Males in the fourth and fifth decades are more prone for UGIT lesions with predominance of chronic non-specific inflammatory conditions as compared to neoplastic conditions. Malignancy within the stomach, more commonly affects the antrum and pylorus. Malignant lesions are very rare in duodenum.

Co-expression of 16S rRNA Methyltransferase and Carbapenemase in Multidrug Resistant Gram Negative Bacteria

Introduction: The drug resistance caused by bacteria has complicated the fight against the infectious diseases and recovery of the patients from the diseases. Multiple mode of drug resistant mechanisms including epigenetic and enzymatic mode have been involved in the genesis of drug resistance leaving only fewer antibiotics for the treatment. Studies has shown the presence of 16S methyltransferase which is associated with carbapenem drug resistance. Early detection of different multimode of bacterial drug resistance helps in reducing the dissemination rate and treatment failures. Aim: To detect the genes related to the methylation mode of bacterial drug resistant mechanism including armA (aminoglycoside resistance methylase), rmtA, rmtB, rmtC and rmtD (rmt-RNA methyltrasferase) as well as genes OXA-48 (Oxacillinase), VIM (Verona intergron metallo-β lactamase) and KPC (Klebsiella pneumoniae carbapenemase) in the production of carbapenemases and also to identify the co-expression of these genes in the gram negative bacterial isolates. Materials and Methods: Prospective study was conducted through application of multiplex Polymerase Chain Reaction (PCR) for detection of 16S methyltransferase genes including armA, rmtA, rmtB, rmtC and rmtD and carbpenemase VIM, KPC and OXA-48 genes, respectively. A total of 200 multidrug resistant gram negative bacilli were evaluated for presence of these genes. The antibiotic sensitivity was evaluated using Kirby-Bauer disc diffusion method. Results: The gram negative bacteria which were isolated includes Acinetobacter spp. 20, E.coli-85, Klebsiella spp.-55 and Pseudomonas aeruginosa-40 from several specimens such as urine, endotracheal tube-secretion, wound swab, sputum, pus etc. A total of 121 (61%) of the bacterial isolates were resistant to either gentamicin or amikacin and netilimycin and 50 (25%) bacterial isolates were resistant to either imipenem or carbapenem. A total of 48 (24%) isolates were resistant to both aminoglycosides and carbapenems. The 16S methyltransferase genes including armA gene was detected in 16 isolates, rmtB in 15 isolates, rmtC in 10 isolates and rmtD detected in 13 isolates The carbapenem genes detected including VIM in 20 isolates, OXA-48 in 25 isolates and KPC was detected in 13 bacterial isolates. Co-expression of both methyltransferase and carbapenemase were detected in nine isolates. Conclusion: The presence of multiple mode of bacterial drug resistance mechanisms including epigenetic and enzymatic modes have been found to be associated with resistance to different classes of antibiotics. The application of multiplex PCR helps in detection of multiple genes involved in bacterial drug resistance and helps in prevention of rapid spread of bacterial drug resistance and prevention of overuse of antibiotics.

Clinical and Radiological Profile of Trigeminal Neuralgia- A Retrospective Study

Roy Thomas

Introduction: Trigeminal neuralgia is described as severe, stabbing unilateral pain along the distribution of trigeminal nerve branches. The three subtypes include- Classical, secondary and idiopathic. Aim: To study the clinical profile, presentation and radiological imaging features in trigeminal neuralgia patients. Materials and Methods: This cross-sectional study included outpatient medical records of 60 trigeminal neuralgia patients between June 2015 to June 2020 (five years) in a Tertiary care Medical College Hospital. Various parameters studied were: (a) Age; (b) Gender; (c) Dental treatment; (d) Pain severity; (e) Trigger factors; (f) Side and branch involved; (g) Sensory abnormalities; (h) MRI. Data was entered in Microsoft excel and analysed using SPSS statistical software 20.0. Chi-square test was used for categorical variables. Results: Among the 60 patients studied, the common demographic and clinical features were as follows: 34 were females (56.7%); 36 with right side presentation (60%); 25 had maxillary nerve division distribution (41.7%); 57 patients experienced shock/lancinating pain (95%); and 40 had numeric pain severity scale of 4-6 (66.7%). Classical Trigeminal Neuralgia was the most common subtype seen in 31 patients (51.7%). Involvement of dual divisions (maxillary and mandibular), absence of trigger factors and presence of hypoesthesia were more suggestive of Secondary Trigeminal Neuralgia (p<0.05). Based on MRI imaging, 31 (51.7%) showed neurovascular compression with atrophy or displacement of trigeminal nerve root. Only 5 (8.4%) had secondary causes (schwannoma, meningioma, demyelination, infarct). Conclusion: The key clinical features of trigeminal neuralgia include female preponderance, right side presentation, maxillary nerve division distribution, shock/lancinating pain with touch and breeze as common trigger factors. As some of them had a previous dental treatment or procedure, dentists need to be aware of this entity. Certain clinical features would help to differentiate the secondary from classic and idiopathic neuralgia subtype.

Histological Study of Placental Changes in Low Birth Weight Neonates in a Tertiary Care Hospital

Geethapriya Govindarajan, Shivashekar Ganapathy, Muthu Sudalaimuthu

Introduction: Low Birth Weight (LBW) in the newborn is a major health problem in our country and across the world. Identifying the pathological changes in placenta can help in understanding the pathogenesis of LBW babies. Aim: To compare histological changes in placenta of LBW baby and normal birth weight baby and to find out the maternal risk factors associated with LBW baby. Materials and Methods: A case-control study was done on a total of 140 samples which were collected in the study period of August 2017-August 2019 in SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India, with 70 placentas from LBW delivery and 70 placentas from normal birth weight delivery. Placentas from preterm delivery were excluded from this study. Histological changes in placenta were assessed in both the groups. Statistical analysis was done with Statistical Package for the Social Sciences (SPSS) version 17. Independent sample Student’s t-test and Chi-square test were used for comparison between two groups. Results: Histological changes like chorioamnionitis, syncitial knots, calcification, Perivillous Fibrin Deposition (PVFD), stromal fibrosis and basement membrane thickening were observed more frequently in placentas from LBW delivery. The commonest histological finding in present study was villous stromal fibrosis in 58 cases (82.9%) followed by excessive syncytial knots in 57 cases (81.4%). In this study, anaemia was the commonest maternal risk factor associated with LBW baby. Conclusion: The structure of placenta has strong relationship with the pregnancy outcome. There are few significant histological changes in placenta of LBW neonates. These changes have an impact in the development of the baby. Study about these changes provides a scope for prevention of certain morbidities in subsequent pregnancies.

Clinical Presentation and Management of Mastalgia: A Cohort Study

TG Raghu

Introduction: Recurring mastalgia, non-cyclical mastalgia and non-specific extra-mammary pain are usually categorised as breast pain. Aim: To determine the most usual aetiology of mastalgia and its response to management modalities like topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), bromocriptine and danazol. Materials and Methods: This cohort study was conducted amongst 130 reproductive women within 21 years to 50 years of age group, with breast pain as a chief complaint, in the General Surgery Department from June 2004 to December 2005. General and local clinical assessment was performed as per the proforma. Patients’ past records associated with breast pain were noted in the Out Patient Department (OPD). Patients underwent a comprehensive quantifiable assessment. Patients with flagrant lumps in the breast and lumps discovered with ultrasound or mammography, underwent Fine Needle Aspiration Cytology (FNAC). Results: Amongst the total 130 patients, 41 (31.54%) were in age group of 21-30 years, 72 (55.38%) were in 31-40 years of age group and 17 (13.08%) were in 41-50 years of age group. The most frequent complaint was pain in the breast region which was seen in 92 patients comprising 70.77%, followed by pain with lump in 29 cases comprising 22.31 percent and pain with discharge in 9 patients comprising approximately 6.92%. Cyclic mastalgia was recorded in 22, 44 and 1 patients, non-cyclical mastalgia in 19, 27 and 6 patients and non-specific extra mammary pain in 0, 1 and 10 patients; in the age group of 21-30, 31-40 and 41-50 years respectively. Conclusion: From the present study it is concluded that danazol, followed by bromocriptine and topical NSAIDs were effective in management of mastalgia. Their advantages in relieving symptoms must be balanced against their potential for unfavourable consequences.

Demographic Profile of Patients with Bilateral Mature Cataract: A Cross-sectional Study from Central India

Lipi Chakrabarty

Introduction: In India, cataract is responsible for 50-80% of the bilateral blindness in the country. With government funded and private hospitals offering cataract surgeries, patients still report late with advanced bilateral cataract. There is scarcity of local data about the profile of late presenters of cataract and its associated factors. Aim: To study the socio-demographic profile of patients with bilateral mature and hypermature cataracts and to evaluate reasons for delayed presentation at the Ophthalmology Department of a medical college hospital in rural Chhattisgarh, India. Materials and Methods: A cross-sectional, observational study was carried out at Durg, Chhattisgarh, India over a period of 12 months from October 2018 to September 2019. The study comprised 48 consecutive and consenting adult patients of bilateral mature and hypermature cataracts reporting to the Outpatient Ophthalmology Department of a medical college included by convenience sampling. All patients were subjected to detailed history taking and ocular examination. Sociodemographic details and reasons for delay in reporting were obtained with a face-to-face interview. Descriptive data analysis was conducted and reported as mean, standard deviation, frequencies and percentage. Results: The mean age of patients was 68.45±7.4 years. About 29 (60.42%) patients were females, 70.83% patients were unemployed or retired. About 87.5% patients stated having systemic co-morbidities. Lack of awareness, old age, systemic ailments, want of assistance and fear of surgery were the prime factors revealed for the delayed presentation to the hospital. Conclusion: Female sex, rural territory, low socio-economic status and lower literacy rates were associated with patients seeking delayed medical attention for cataract. Educational efforts and improvement in accessibility to health centres appear vital to overcome the hurdles in the way of timely presentation of cataract.

Correlation between Cardiac Biomarkers and Right Ventricular Dysfunction in Acute Inferior Wall Myocardial Infarction with and without Right Ventricular Myocardial Infarction

Introduction: Right Ventricular Myocardial Infarction (RVMI) along with inferior wall left ventricular (LV) dysfunction or Inferior Wall Myocardial Infarction (IWMI) is found in 30-50% of the cases. Isolated Right Ventricular (RV) dysfunction or infarction is rare except in iatrogenic (interventional) procedures. RVMI is being more commonly diagnosed retrospectively in the era of primary angioplasty, when these patients post procedure fail to improve satisfactorily as compared to isolated IWMI patients. Clues to identify early RV involvement in acute IWMI patients will help in better management and less morbidity in this group of patients. Aim: The study was undertaken to search for any correlation between cardiac biomarkers {Troponin I (Trop I), Creatinine Kinase-MB (CK-MB), Brain Natriuretic Peptide (BNP)} and RV involvement using echocardiographic parameters in inferior Acute Myocardial Infarction (AMI), with and without associated RVMI, in patients who underwent primary Percutaneous Coronary Intervention (PCI). Materials and Methods: This was a cross-sectional study, conducted from September 2018 to August 2019, in the Cardiology Department of ABVIMS and Dr. Ram Manohar Hospital. A total of 294 patients, presenting with acute IWMI, were included in the study. Samples for Trop-I, CK-MB and BNP were taken immediately after admission. One hundred and thirty two patients had an associated RVMI. Two-dimensional Echocardiography was done within the first 12 hours of admission. Electrocardiography and Echocardiographic assessments were used to determine RV involvement. Comparison was done first between patients with and without RV involvement, followed by comparison among groups for quantitative parameters, especially biomarkers, for finding correlation between biomarker levels and echocardiographic parameters (both RV and LV functions). Results: Patients presenting with IWMI with an associated RVMI had increased LV E/E’ ratio. Also, as predicted, they had a low Tricuspid Annulus Plane Systolic Excursion (TAPSE) and a low RV fractional area change, as well, due to stunning of right ventricle in the acute phase. In the group with higher BNP levels (≥400 pg/mL), the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/E’) was increased; on the other hand LV ejection fraction and TAPSE were decreased. There was negative correlation between RSm (RV systolic wave), TAPSE and BNP levels. BNP, Trop I and CK-MB levels showed a positive correlation with E/E’ at higher levels. Hypotension was more in patients presenting with RVMI, but it did not reach statistical significance. The mortality was 4.5% in the inferior Myocardial Infarction (MI) with RV involvement group versus 1.8% in isolated inferior MI group (during hospital stay). Conclusion: In acute Inferior wall MI, higher levels of BNP, CK-MB, Trop I, alone or in combination, might be used for prediction of RV involvement. BNP levels ≥400 pg/mL, Trop I levels ≥1.1 ng/mL, and CK-MB levels ≥4.5 ng/mL, along with hypotension and higher E/E’ ratio were observed in such cases and were associated with RV dysfunction and increased mortality.

An Observational Study of Stroke and its Outcomes in a Tertiary Care Hospital

Amruth Gujjar, Rekha Walwekar, AN Dattatri

Introduction: Incidence of stroke is higher in developing countries than in developed countries. India shows prevalence of Cerebrovascular Disease (CVD) in the range of 52 to 843/100,000 population. Stroke causes 9% deaths around the world. The basic principle of managing stroke includes making an accurate diagnosis, choosing the effective drugs and dose for the stroke type. Aim: To analyse the outcomes of pharmacotherapy of stroke based on characteristics and clinical presentation of patients admitted to hospital and to know the adverse effect of drugs used. Materials and Methods: This cohort study was conducted with Department of Medicine and Neurology at Karnataka Institute of Medical Sciences, Hubballi from January 2015 to December 2015. After clearance from Institutional Ethics Committee, 162 cases were selected based on the inclusion and exclusion criteria. The clinical history, in examination modified Rankin score (mRS) at admission, discharge and on follow-up were recorded. The criteria for selecting the drugs, frequency, dosing, duration and change in drug therapy were recorded. The efficacy of drug therapy was assessed by clinical improvement. The adverse events were assessed and recorded. The patients were followed-up at three and six months. The data were entered after defining the variables in SPSS (version 16) from case record form. Descriptive statistics were used to summarise baseline data. Results: Of the 162 patients, 155 completed the six months follow-up. The median age of patients was 60 years for ischaemic and 55 years for haemorrhagic stroke. More males were admitted with strokes {108 (69.67%)} compared to females {47 (30.32%)}; 130 (83.87%) patients had ischaemic strokes, 16 (10.30%) haemorrhagic stroke {15 (9.67%) were intracerebral haemorrhage + 1 (0.63 %) patient had a subarachnoid haemorrhage}, 9 (5.8%) had Transient Ischaemic Attack (TIA). The modified Rankin score calculated for the patients was statistically significant between admission and discharge (1.29, p-value 0.0035), and that between three months and six months (0.9, p-value 0.003) of follow-up. Total 93% of 121 patients with ischaemic stroke received antiplatelet therapy. Amlodipine was the most commonly prescribed antihypertensive. Conclusion: Pharmacotherapy of stroke in the study was evidence-based and satisfactory. However, patients showed reduced compliance to all medications. Clinical presentation and type of stroke were important predictors of morbidity and mortality at the end of six months.

Correlation of Placental Growth Factor with Pre-Eclampsia during Mid Trimester of Pregnancy: A Case Control Study at Liaquat University of Medical and Health Sciences, Pakistan

Gastrointestinal and Extra-Gastrointestinal Stromal Tumours: A Clinicopathological and Immunohistochemical (c-KIT) Study

Parasappa Joteppa Yaranal, N Prasanna, Anantharao Shankar Anand

Introduction: Gastrointestinal Stromal Tumour (GIST) is one of the most common mesenchymal tumours of GIT. They have been proved to be arising from the smooth muscle pacemaker interstitial cells of Cajal, these cells are involved in gut motility and peristaltic movements. They can also rarely arise outside the Gastrointestinal Tract (GIT) from retroperitoneum, mesentery and omentum called as Extragastrointestinal Stromal Tumor (EGIST). Single best defining feature of GIST is positivity for Cytoplasmic Tyrosine Kinase (c-KIT). Aim:The aim of the study was to analyse clinicopathological features and c-KIT expression in both gastrointestinal and EGISTs. Materials and Methods: This was a retrospective observational (cohort) study; over a period of two years from January 2018 to December 2019, done at Navodaya Medical College and Hospital, Raichur, Karnataka, which comprised of 12 cases of GIST. All the cases were a resected specimens and thorough evaluation of clinical, imaging and histopathological studies were done and forwarded for immunohistochemistry for c-KIT expression. Results: Age of cases ranged from 04-70 years, mean age being 50.6 years and male to female ratio 2:1. Presenting symptoms of most of GIST were pain abdomen, diarrhea and few with vomiting whereas, rectosigmoid GISTs (2 cases and one with metastasis to liver) were associated with pain abdomen, bleeding per rectum and constipation. One case of retroperitoneal (extraintestinal) GIST was asymptomatic and other presented with pain in the right hip due to secondaries and one benign gastric serosal GIST was associated with gastric adenocarcinoma. The CT scan in two of malignant GISTs, confirmed metastasis and c-KIT study was negative in these 2 malignant GISTs. Conclusion: This study reaffirms importance of CD117 in diagnosis of GIST and EGIST, however, the negativity of CD117 does not rule out GIST, which requires thorough clinicoradiological and pathological correlation.

Surgical Outcome of Levator Resection in Congenital Ptosis with Poor Levator Function at a Tertiary Care Centre

Sonali Vinay Kumar, Sanjay Dhar, HS Trehan

Introduction: Treatment of congenital ptosis is challenging as results are unpredictable. The ideal surgical technique which gives optimal cosmetic outcome without complications is still evolving. Tarso-frontalis sling operation is the preferred standard of care when levator action is poor but it has high rate of complications. Hence, supramaximal levator resection has been advocated over the past two decades as an alternative treatment modality. Aim: To assess the effectiveness of supramaximal levator resection in patients with unilateral simple congenital ptosis, having poor levator action (≤4 mm). Materials and Methods: A longitudinal interventional study was conducted over a period of six months. Fifteen patients, during the study period, underwent supramaximal levator resection under General Anesthesia (GA) after taking informed consent from next of kin. All patients were evaluated on day one, one week, one, three and six months after surgery. Surgical outcome measures were change in margin reflex distance-1, vertical palpebral fissure height and inter-eyelid difference of margin reflex distance. Success was defined as margin reflex distance-1 (MRD-1) ≥3 mm and inter-eyelid difference of MRD-1 between 0.5 and 1 mm. Results: There were 10 females (60%) and 5 males (40%) in the study group. The mean age group at the time of ptosis surgery was 5.73±0.55 years (range from 03 and 11 years). A good surgical outcome was obtained in 12 (80%) patients. In 02 (13.3%) patients under-correction was noted which did not need further intervention as visual axis was clear. Upper lid swelling occurred in one patient (6.6%) which was treated with anti-inflammatory medications. Conclusion: Supramaximal levator resection may be considered in all cases of unilateral ptosis patients with poor levator action as this procedure yields good surgical outcomes.

Ergonomic Consideration of Ultrasound Guided Transversus Abdominis Plane Block between Experienced and Novice Anaesthesiologists

Subbulakshmi Sundaram, Dhakshinamoorthy, Srinivasan, Ashok Swaminathan

Introduction: Ergonomics is the science of interaction between human and working environment. The growing use of Ultrasound (US) in regional anaesthesia has created the need to consider ergonomic aspects relevant to regional anaesthesia. Aim: To analyse ergonomic consideration of Ultrasound-guided (USG) Transversus Abdominis Plane block (TAP) between experienced and novice anaesthesiologists for Inguinal Hernia Repair. Materials and Methods: A prospective observational study was conducted where 10 experienced (E) (performed >20 TAP block procedures) and 11 novice (N) (performed at least 5 TAP block procedures) anaesthesiologists participated. The study included 21 patients of ASA I and II posted for inguinal hernia repair under spinal anaesthesia. USG TAP block was given after the completion of surgical procedure. Patient, operator and environmental factors were observed and measured using a measuring scale and photographs and goniometer. Results: Performance of USG TAP block was ergonomically suboptimal and varied among the operators. A 7E and 2N performed the procedure in sitting position and others in standing position, which was statistically significant (p=0.03) adjustment of tables were done by 7E and 2N operators, the difference statistically significant (p=0.03). A 2E and 8N flexed their back and 7E kept their neck flexed less than 20° and 9N kept their neck flexed more than 20° which was statistically significant (p=0.001). Only 10E and 5N kept Ultrasound machine in front in line and others were not, which was statistically significant (p=0.012). There was no significant difference between the groups in terms of side of the block performed, location of the procedure, position of assistants and trolleys in relation to operator during the procedure. Conclusion: It was found that the performance of USG TAP block was ergonomically sub-optimal in the setting described. compared to novice, experienced operators performed better. Inclusion of ergonomic concepts in academic training

An Evaluation on Full Coverage Crown Preparation: An Institutional Analysis

Introduction: Undergraduate (UG) dental students are trained for fixed prosthodontics course clinically in teaching institutions during the clinical years. However, there is a lack of objective data on the quality of fixed prostheses preparations done by UG students on their patients for academic and clinical staff. Aim: To evaluate the full-coverage crown preparations performed by UG dental students in the university clinical teaching programme. Materials and Methods: This study was a clinical audit done in the Faculty of Dentistry, Universiti Sains Islam, Malaysia (USIM) from April to July 2018. The demographic and clinical data were collected from the patients’ notes and included relevant information of patients such as age, gender and others. Full-coverage crowns were analysed and crown preparation assessments were done using specific criteria and standards. The descriptive data were measured in frequency and percentage for categorical variables and mean and standard deviation for continuous data. Results: A total of 31 patients fitted with 45 units of full-coverage crowns were analysed. The mean age of patients treated by fifth year dental students was 40.5 (±14.16) years. A 51% Porcelain Fused to Metal (PFM) crown provided to the patients. On the whole, UG undergoing the dentistry programme in the institution scored the lowest (51%) on proximal reduction and the highest (97.7%) on producing smooth and continuous preparation. Conclusion: Majority of the crowns prepared by students have acceptable preparation except in proximal reduction and cervical margin preparation that can be improved upon and emphasised further during the teaching and learning sessions.

Radiodensity of Various Dental Biomaterials for Endodontics: The Role of Particle Size

Introduction: The thickness threshold for detecting endodontic biomaterials depends on many factors, such as the nature of the radiopacifier and the particle size. Aim: The aim of this study was to determine the effect of thickness on radiodensity of various endodontic biomaterials; and evaluate the impact of radiopacifier particle size on radiodensity. Materials and Methods: This in-vitro study was conducted between August 2018 to December 2019. The study was divided in two parts, in first part, Six endodontic biomaterials (AH26, EndoSequence, Endoseal Mineral Trioxide Aggregate (MTA), Nano-MTA, Endocem Zr, and MTA without radiopacifier) were selected and evaluated in different thicknesses, in second part, MTA mixed with Bismuth oxide 10 µm, 200 µm, 120 nm (Groups 1-3), and Zirconium oxide 5 μm, 1 μm and 20 nm (Groups 4-6) were placed in frames with 1 mm, 0.5 mm, 0.2 mm, 0.1 mm thicknesses to evaluate the radiopacity. Results: The mean radiodensity was significantly different among various thickness (p<0.001) and materials (p<0.001). The changes of the radiodensity in various thickness from one material to the other were not uniform (interaction p-value <0.001). A 1 mm thickness had highest radiodensity (206.6±83.99), followed by 0.5 mm (68.9±24.6), 0.2 mm (17.9±4.9), and 0.1 mm thick material had least radiodensity (11.97±4.37). Materials of AH26 (99.1±103.2), Nano MTA (97.4±104.9), Endoseal MTA (87.86±101.4), Endosequence BC sealer (85.5±93.87) and Endocem Zr (71.88±77.67) were significantly different from the control group (16.38±10.85). The size of particles played important role in radiodensity (p<0.001). The radiodensity of Fine GIII (100 nm) material (112.68±108.47) was significantly higher than other materials: Thin GII (200 nm) (100.9±102.4), Fine GVI (20-40 nm) (99.7±95.1), Coarse GI (10 μm) (76.66±74.75), Thin GV (1~3 µm) (63.19±67.3), Coarse GIV (5 µm) (49.66±51.59) and MTA without Radiopaque Agent GVII (100%) (23.67±19.68). The effect of the thickness on radiodensity was different for each biomaterial, with significant differences from the control group. Conclusion: One of the readily available methods for increasing radiodensity is to increase the amount of radiopacifier, which might compromise the physical properties of the material. Fine particle radiopacifier (120 nm) with 1 mm thickness has significantly higher radiodensity than any other biomaterials in this study. Within the limitations of the current study, it can be concluded that the radiopacifier particle size has a significant impact on the level of radiodensity of dental biomaterials. Finding the optimum distribution, size, and geometry of radiopacifier particles within the same fraction rate can enhance the radiodensity.

Evaluation of Effectiveness of COVID-19 Training and Assessment of Anxiety among Nurses of a Tertiary Health Care Centre during the Corona Virus PandemicAn Experimental Study

Introduction: The Corona Virus Disease 2019 (COVID-19) is spreading rapidly and has become a source of various challenges and pressure for the healthcare workers specially the nursing staff. As the nurses are exposed to environments with huge amount of physical as well as psychological stress, their anxiety issues have been on the rise. Thus, an elaborate knowledge about the COVID-19 is essential for the staff nurses to manage this situation. Aim: To assess the anxiety levels in nurses and to find out the effectiveness of training provided to the nurses regarding information on COVID-19. Materials and Methods: This experimental study was conducted in the Department of Community Medicine of a medical college in Central India from 21st May to 30th May 2020. In all, 232 nurses were present during the training, organised to provide the information on COVID-19. Corona virus Anxiety scale (CAS) was used to calculate anxiety score of all the participants. Mean scores of pre-test and post-test were calculated. Significance was found out using Mann-Whitney's U-test. Results: The mean age (±SD) of the study participants was found to be 38.95 (±4.5) years. The mean pre-test and post-test scores of all the participants were found to be 6.7586 (±3.08SD) and 13.5517 (±3.27 SD) respectively. The difference between the means was observed to be (p-value <0.001). Around 38.3% of the nurses had dysfunctional anxiety (CAS score more than 9), 52.1% were found to be working on the frontline (outpatient departments, wards and laboratory services specifically dedicated to COVID-19). Conclusion: This study was found to be effective in gaining knowledge and practice pertaining to COVID-19 training. This study also revealed the level of anxiety among the nurses during the ongoing pandemic. Thus, a proper counselling of the nurses is required for their mental stability and for an efficient execution of healthcare duties.

D-dimer: A Marker of Severity in COVID-19

Introduction: The ever-growing number of COVID-19 patients stresses upon the need to identify effective yet readily available predictors of disease severity to ensure better clinical outcomes. D-dimer is a fibrin specific degradation product derived by enzymatic action of plasmin on factor XIIIa cross-linked fibrin. It serves as an ideal marker for activation of coagulation and fibrinolytic pathways. Identification of coagulopathy as an important complication in COVID-19 patients has brought to focus D-dimer as a possible predictor of clinical severity in patients. Aim: In this study, we analysed the role of D-dimer levels in assessing the clinical severity of the COVID-19 patients. Materials and Methods: We enrolled 217 in-patients of Tirunelveli Medical College in this single centre observational study and classified them into asymptomatic, mild, moderate and severe according to "Clinical Management Protocol: COVID 19", by the Ministry of Health and Family Welfare and Director General of Health Services. D-dimer was estimated in the separated plasma, using latex based assay using semi-automated coagulation analyser. Data were presented as percentages for categorical variables and median±Inter Quartile Range (IQR) for continuous variables. Chi-square test was used to compare the D-dimer values between symptomatic and asymptomatic groups. A value of p<0.05 was considered statistically significant. Results: Among the 217 cases, 88.9% were asymptomatic cases, 8.8% presented with mild clinical severity and 2.3% had moderate clinical presentation. In our study population, the Mean±SD and Median±IQR of D-dimer values (in ng/mL) were 223.4±230.6 and 157.0±187.7, respectively. The mean D-dimer value was found to increase as the category of our study group ascended from asymptomatic patients to mild and moderate clinical cases. It was noted that 91.1% of the cases who had D-dimer values <500 ng/mL were asymptomatic. Also, the odds of patients with high levels of D-dimer being clinically symptomatic was 5.5 times more than the odds of patients with D-dimer levels <500 ng/mL. Conclusion: Elevation of D-dimer levels associated with the severity of clinical course of patients infected with SARS CoV-2 when compared to patients with mild or asymptomatic clinical presentations.

Prevalence of Fracture of Forearm Bones in Obese and Non-obese Children: A Cross-sectional Study

SP Akshatha, JB Santhosha

Introduction: Through much history of mankind, the overt manifestation of bodyweight gain in children and adults have been considered as a sign of personal health and family wealth and an indicator of the economic prosperity of the society. As developing societies are industrialised and urbanised, the standards of living continued to rise; obesity and weight gain began to pose a growing threat to the health of the citizens. Aim: To determine the prevalence of forearm bones fracture in obese and non-obese children between age group of 2-15 years. Materials and Methods: A cross-sectional study was conducted in the Department of Orthopaedics and Paediatrics at Dr BC Roy Post Graduate Institute of Paediatric Science, Kolkata, West Bengal, India from September 2017 to October 2018. Children were classified into obese and non-obese group according to Body Mass Index (BMI). Calculation of BMI was done by the formula BMI=weight (kg)/{height(m)}² . Obese children were determined by the BMI percentile by plotting the BMI number on the appropriate Centers for Diseases Control and Prevention (CDC) BMI-for-age growth chart. Doubtful cases classification was confirmed by the paediatric surgeon. Injury mechanism was graded into three trauma kinetics (direct trauma, slow motion trauma and high motion trauma). The validated paediatric Physical Activity Questionnaire (PAQ-A and PAQ-C) were used to grade the average daily activities during the week prior to trauma. Statistical analysis was done by using the Chi-square test and p-value of <0.05 was considered to be statistically significant. Results: Total 583 children were treated during the study period in the hospital including both Outpatient Department (OPD) and Emergency Department. About 433 children were excluded due to below age two years, refracture, chronic illness, and major congenital malformation. Among them only 150 patients met the criteria of present study. Out of 150 children, 69 (46%) were found obese and non-obese were 81 (54%). The distribution by gender was the same in obese group which had 26 (37.68%) female and 43 (62.32%) male, in non-obese group 34 (41.97%) female and 47 (58.03%) male. It was observed that both bones fracture of forearm in obese children was more at risk than non-obese children, p-value of <0.5 which was statistically significant. Conclusion: Present study shows higher prevalence of forearm bone fracture in obese children than non-obese children. Obesity and other certain factors might have been significant risk factor for fracture required for operation. Both radius-ulna fracture in obese were found significant.

Faculties Perception on Anatomy Teaching and Assessment in Lockdown and Post-lockdown New Normal Phase

Hironmoy Roy, Kuntala Ray, Abhijit Bhakta

Introduction: For last five-six months in the Corona Virus Disease (COVID-19) lockdown period the Phase 1 MBBS students were being taught Anatomy theory as well as demonstration topics in online mode. Faculties were new to the mode initially, but gradually they coped up for online teaching. Now, in coming near future, institutes will resume with physical class activities and examinations will be held in departments; in the 'new normal period' even when the COVID cases are increasing day-by-day. Aim: This study was an endeavour to explore faculties' perception in Anatomy teaching and assessment in online teaching and side by side their opinion for planning to resume class and assessment in new normal phase. Materials and Methods: For this amongst the faculties of Anatomy of West Bengal, posted in 17 different medical teaching institutes; included in the Whatsapp group of Anatomical Society of India West Bengal (WB) Chapter; this cross-sectional study was carried on by an online survey using a pre-tested pre-designed structured questionnaire upon 14 questions regarding their perception of online class-cum-assessments as practiced as well as their perception for future post-unlock class sessions and assessment methods; assuring anonymity; with encouragement and support from Anatomical Society of India WB chapter. Out of total 199 faculties 163 responded in time and their responses was tabulated. Results: From the response of 163 faculties, it came out that all faculties taught 'abdomen', 'head and neck', 'neuroanatomy' parts as well as some parts of histology and embryology. Google classroom was most favoured teaching platform followed by Zoom meeting application. Majority (84.6%) of the faculties used to take lecture classes by sharing Power Point Presentation (PPT) during class hours; and 46% used to share the pre-recorded demonstration video of the parts. Only 5% of them felt that by this mode full competency could be achieved for the students. Questions sharing followed by answers writingscan-mail was the most favoured (88.9%) mode of theory assessments; although 57% faculties used Multiple Choice Questions (MCQs) for assessment. In the 'new-normal phase' when the college and classes will resume, faculties like to have demonstration classes with ‘mini-group’ and lecture topics to be covered solely in online mode. For theory assessment, MCQs was mostly opted (63.8%) supplemented by cameraobserved Objective Structured Practical Examination (OSPE) in the practical portion (50.3%). Conclusion: This study not only provides the experience shared by faculties in conducting the online teaching of Anatomy in the lockdown phases, but also provides insight in planning of the classes and examinations in the post-lockdown COVID-19 times which can be presented as recommendation to the university, which is yet to plan out the examination in 'new normal' era.

To Assess the Utility of BASNEF Model on the Quality of Life among Peri-menopausal Women

Vishranti Bhagwan Giri, Vaishali Taksande

Introduction: Post-menopausal health issues has always been given attention, while only few people are aware the health issues associated with peri-menopause. Symptoms include tremendous fluctuations in hormone levels, irregularities in the menstrual cycle, vasomotor and psychological issues. Aim: The present study is aimed to assess the utility of Belief, Attitude, Subjective Norms, Enabling Factors (BASNEF) model to improve quality of life among perimenopausal women in the rural community setting and to compare the quality of life before and after intervention, the association between the selected demographic variables and the quality of life in the experimental and control groups will be assessed. Materials and Methods: The present interventional analytical quasi-experimental study will be conducted on study population from Vidarbha region of Maharashtra. In this study, two stage cluster sampling technique will be used to select the study participants. Age group of perimenopausal women will be 40- 55 years. Study participants will be screened as per inclusion/ exclusion criteria and divided into two groups. One group will receive intervention of BASNEF model while another group will be control group. The BASNEF intervention will be divided into five phases for five days, follow-up visits will be conducted at first and third month of phase four. During intervention period and further up to three months, an educational pamphlet based on care during menopause will be provided to the participants and contact number will be provided to ask any doubts during this period. Primary outcome includes assessment of the utility of BASNEF model on quality of life among perimenopausal women. Secondary outcome includes increase in knowledge, change in belief and attitude, to know participation of subjective norms and to make aware about enabling factors. Conclusion: The conclusion will be drawn from the result will be published in peer reviewed journal.

A New Phase of Healthcare: COVID-19 and Medical Advancements

Oshin Puri, Vyas Kumar Rathaur, Nitish Pathania, Monika Pathania

Corona Virus Disease (COVID-19) was, declared a global pandemic by the World Health Organisation (WHO) on 11th March 2020, which has posed innumerable challenges for the medical fraternity. To overcome these obstacles healthcare professionals, engineers and industries like robotics, Artificial Intelligence (AI), 3 Dimension (3D) printing etc., are coming up with innovations that can assist them in administering critical care to COVID patients, restart health services for non-COVID patients, combat the spread of the disease, restart elective services and above all protect themselves while treating others. This article is a narrative review of the developments in the field of robotics and AI, improvements in ventilators and critical care facilities, measures taken to spread awareness and the need of such innovations, their benefits and effectiveness in relation to the current scenario. Articles regarding advancements during COVID months of March-May 2020 were searched on the internet and references giving medical evidence of the suitability of these innovations were added from PubMed and Google Scholar search engines, wherever necessary. Knowing the need and principles of such medical innovations which can help in improving the current practices or replace them with even better technologies are the need of the hour.

Nonoperative Strategies to Manage Pain in Osteoarthritis during COVID-19 Pandemic

Corona Virus Disease (COVID-19) has resulted in restriction of face-to-face consultations and mechanisms to access health care. Oesteoarthritis (OA) is one of the most common forms of musculoskeletal disease encountered and a leading cause of painful disability in adults and elderly. The assessment of the challenges and strategies encountered in the nonoperative management of OA of knee care during the COVID-19 pandemic was done. A comprehensive review of the literature using suitable keywords such as 'COVID-19', 'OA', 'OA knee', 'knee joint' on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in May 2020 on developments and guidance during the current COVID-19 pandemic. The management of OA has been hampered by COVID-19 pandemic lock down with subsequent suspension of elective surgeries. Nonoperative complementary therapy has been evaluated with National Institute for Health and Care Excellence (NICE) recommendations to guide management. Conservative strategies including judicial use of analgesia as recommended by NICE, supportive orthosis, patient education and advice using remote telecommunication consultations play an important role in the nonoperative management of OA till elective surgery can safely resume.

Tackling Worm Infestations with a Multifactorial Approach in the 21^st century: An Indian Perspective

Krunal Dalal, Sandeep Lahiry, Yashpal Chugh, Alap Gandhi, Bhavesh Kotak

Soil-Transmitted Helminths (STH) or geohelminths are an important cause of morbidity worldwide. A large proportion of the infection burden occurs in India, including STH infections due to roundworms (Ascaris lumbricoides), whipworms (Trichuris trichura) and hookworms (Necator americanus or Ancyclostoma duodenale). Apart from direct health impacts, they are also implicated in anaemia, nutritional deficiencies and delayed cognitive development in children. They also have been shown to have detrimental impact on economic development and future income earning potential. The current global strategy on STH control is through increased utilisation of Preventive Chemotherapy (PC) for at-risk population, comprising mainly pre-school and school age children. This is crucial for India, as there can be significant proportion of untreated subjects in the community, who may act as a reservoir of infection for treated subjects to get re-infected. Additionally, inculcating healthy behaviour modifications and adopting WASH interventions meant a major shift in social and cultural norms in many societies. Overall, the multifaceted nature of STH control in India requires concerted efforts and significant mobilisation of human and financial resources. In this regard, several recent initiatives including Swachh Bharat Abhiyan, Nirmal Gram Puraskar, Water Sanitation and Hygiene (WASH) interventions, Clean India: Clean schools etc., have brought a positive change, apart from the provision of deworming for morbidity control through National Deworming Day. In this paper, authors have narrated major initiatives in recent years that are expected to bring a lasting solution to the problem of STH infection in India.

Management and Therapeutic Options for COVID-19: A Review

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the causative organism for Coronavirus Disease 2019 (COVID-19), originated in Wuhan, China and has now spread to most parts of the world. A pandemic of this magnitude has not been witnessed in more than 100 years since the Spanish flu in 1918. The major challenge for scientists and doctors worldwide has been to find a therapeutic intervention to prevent the spread and development of this disease. As more research is being done, the pathophysiology of COVID-19 has been explained, although no effective therapy has been found. Multiple drugs and therapies are under trials and a few have shown inconclusive results. The attempts have ranged from repurposing drugs to trying to develop new vaccines. Formulation of guidelines pose another challenge to the government and international agencies owing to the lack of data. These agencies have constantly released and updated guidelines based on new research and growing knowledge. In this review, we aim to compare and bring out the different international guidelines for management of COVID-19, along with a review of tried therapeutic interventions and their primitive results. The COVID-19 has been a major global health crisis that is overpowering most heath care systems and multiple agencies and research teams are trying to limit and manage this spread. Currently no effective treatment is available and guidelines differ regarding the drugs that can be used, which are mostly off-label.

Euthanasia: Past, Present and Future

Shantanu Ajay Phatak, Ajay Gajanan Phatak

In a landmark decision, the Supreme Court of India has provided a legal recognition to ‘passive euthanasia’ in March 2018. In May 2018, David Goodall, an Australian scientist ended his life through Physician Assisted Death in a Swiss clinic at the age of 104 for old age rather than terminal illness. These two events sparked a fresh debate regarding euthanasia and the proponents and opponents of euthanasia argued voraciously for and against it albeit the central theme remained same- ‘the dignity of human life’. This monograph elaborates on the philosophy and popular terminology of euthanasia. It also deliberates on the socio-cultural differences in the conceptualisation of euthanasia and an unbiased critique of the pros and cons of euthanasia with the intention to redress the balance. The monograph finally discusses the current scenario and future directions related to euthanasia.

Lessons Learnt in the Journey of Bioethics... In Verse

Manoj Goyal

Ethics is a discipline of philosophy which guides on the notions of good and bad, right and wrong. Bioethics is the application of ethics to the field of medicine and healthcare. My journey in bioethics started with a workshop in India and the journey progressed with training in a postgraduate diploma in Bioethics from PSG Institute of Medical Sciences and Research, Coimbatore, India. I was exposed to various topics/aspects of bioethics; medicine as a profession, history and evolution of bioethics, theories of moral reasoning, professionalism and ethics, law and ethics, autonomy, privacy and confidentiality, communication in health care, pharmaceutical industry and physician, research ethics, beginning of life issues, end of life issues, organ donation and transplantation. During this journey, I have learnt tremendous lessons, which are significant not only for my professional role, but in personal life as well. The following monograph is a reflective narrative of my journey in bioethics. Reflecting on my journey, I have attempted to capture my learning and the essence of certain topics/aspects of bioethics in the form of a rhyme. The purpose of writing this reflective narrative and rhyme is multifold. One is to develop the deeper understanding of my learning, going by the maxim given by John Dewey that “We do not learn from experience...we learn from reflecting on experience.” Second is to invite the readers to engage with the creative expression of some aspects/lessons of bioethics. Third, the rhyme can also be used by the medical teachers to sensitise their students on bioethics and on reflective writing. Along the journey, I internalised that medicine is a vocation, not just a profession. It can be best put in the words by Sir William Osler “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head”. When, I learnt about the history and evolution of the codes of ethics and principles of ethics, I found that the history of mankind is quite painful with a number of instances when moral principles were violated (1). While, learning about the history, I understood the hidden warning in the words of George Santayana “those who don’t learn from the history are doomed to repeat the mistakes of it” and realised that whatever we possess today, the mankind has paid the price for it! I learnt about the theories of moral reasoning with the help of classical scenarios; Heinz dilemma (2) and Run way trolley (3). Doctrine of double effect (4) was understood with the help of another real case scenario of conjoined twin children “Mary and Jody Siamese twins,” in which one child had to be sacrificed in order to save another [4,5]. It was a tricky case where certain principles of ethics; beneficence and non-maleficence were in conflict with each other. In such situations, doctrine of double effect (4) helps in resolving such conflicts. It is fundamental to understand that the Health Care Professionals (HCP) owe fiduciary duty to their patients and their relation with them rests on loyalty and trust. A fiduciary duty is an obligation to act in the best interest of another party. The law and ethics are inseparable; the law sets minimum standards of what must be done, whereas ethics set highest standards of what ought to be done. I learnt about the first systematic use of the informed consent by Major Walter Reed for yellow fever experiments during Spanish American war (6). Respect of patient’s autonomy is of paramount importance; it is important to note that many cases of litigation are due to errors in informed consent. Therapeutic privilege is a privilege of withholding information from the patient when the physician believes that the disclosure may have an adverse effect on the patient’s condition or health. Empathetic communication and compassionate care are essential for better health outcomes. The protocols (7) for communicating the medical errors and bad news are of little value if the communication lacks empathy. It is known that the prescribing behaviour of a physician is influenced by the promotional strategies and tricks played by the pharmaceutical companies, which leads to conflict of interest situations. However, a solid foundation of ethical principles will usher the way forward for HCPs. Consequentialism and deontology (8) are theories of morality, which consider the “ends” and “means” respectively, to determine the morality of action. While, performing research studies, a researcher may find himself in dilemma as whether to put the science first or the participants, so, in these situations following the basic principles, guidelines and law will help. Further, I learnt the ethical aspects related to beginning of life, organ donation and transplantation. It was very painfully realised that in spite of the so-called technological advancements, societal progress, with the laws in place, female feticide is still prevalent in some parts of the world. Medicine an art or science, a profession or a vocation, at the outset this was contemplated Atrocities of Nazis, deception of Tuskegee, sacrifice of mankind, Hippocratic oath…. We all were acquainted Heinz dilemma, Run way trolley, Mary and Jody’s separation triggered a number of dilemmas with a profound effect Deontology, Principlism, Consequentialism…answered many of them and then came the rescue with the doctrine of Double Effect. Fiduciary’s duty is resting on honesty, loyalty and trust For a doctor in relation with his patient being professional is a must Law and ethics are integral to each other and have a natural intimacy Civil, Criminal liabilities, knowledge of law is must but it is full of intricacy Informed consent was first attempted by Major Walter Reed Respecting patient’s autonomy is utmost hence for informed consent every HCP* should pay heed Respecting privacy and truthful disclosure are essential but it is also of good knowledge HCP may withhold information in patient’s best interest in exceptional instance under the principle of therapeutic privilege Breaking bad news and communicating medical errors are challenging and are my dislikes Empathy and compassion are imperative to practice the protocols of CONES and SPIKES Gifting authorship, free lunches to foreign tours, pharma industry will play all the tricks But following the principle of ethics a fiduciary can annul all the gimmicks I am often in doubt that in research whether its consequentialism or deontology which is right Adherence to guidelines and law will protect the participants, and hold their rights and dignity upright I am a zygote on day first, my heart beats on thirty first and I become a soul on one forty first Natural, ART** or surrogate, I am a blessing from the heavenly abode, at times I am not of preferred gender then this blessing becomes a curse and I end up in dust As I sense my end, I want to cry out loud ...so that you can hear me Maa*** I know you are aware, but helpless...but where else do I share my pain Maa Life and death with dignity is a human right But euthanasia/physician assisted suicide can be a slippery slope hence its indication should be water tight There is a special part (organ) of me that will help someone to live I will do something, by which, even after death I will find a way to live Medicine is a life calling.... Ethics is a way of life It is a soul of science ...as it deals with humane side of medicine and human life Let’s promise that the price paid by the mankind will not go in vain We will practice ethics and make it count time and again...! Footnotes: *HCP: Health care professional, **ART: Artificial reproductive technology ***Maa: means Mother in Hindi language Disclaimer/disclosure: The author does not claim the topics and the rhyme to narrate the complete picture of bioethics. The rhyme is neither meant to be prescriptive nor an absolute interpretation of ethical principles. Some words may seem crude, since they have been used for creative expression and rhyming. In the narration the pronouns “I” and ‘We” have been used to deliver the perspective in first person, with hope that the readers would relate better and would go in self-reflection! The expression “Do you hear me Ma” is inspired from another poem (9). Acknowledgement I wish to thank the teachers and mentors who have shared their wisdom, and the students who accompanied me during this journey.

The Poor and the Pandemic: COVID-19

Arati Raut, Ruchira Ankar, Sheetal Sakharkar

COVID-19 was proven to be a pandemic in early 2020 by the World Health Organisation (WHO). At present, 213 countries have been affected by the COVID-19 pandemic. In the history of global pandemics, COVID-19 has had a major impact on society as it has killed humans, spread human suffering and uprooted the lives of the people. Across the globe, there are 18,705,096 confirmed cases, 11,922,692 recovered cases, 704,385 deaths, and 6,078,019 active cases as of, 5 August 2020. It has affected the world’s economic, social and political status. Poor people belonging to the lower strata of society face more difficulties during pandemics. They are unable to secure their daily bread as well as other basic needs. The impact of COVID-19 on the poor and the role of society have been addressed.