Journal of clinical and diagnostic research

The Changing Teacher-Disciple (Guru-Shishya) Equation in Modern Times

Sunanda Das, Arti Garg, Hemant Jain

Guidelines for authorship have been outlined by various international bodies like Committee on Publication Ethics (COPE) and International Committee of Medical Journal Editors (ICMJE). However, instances do arise where these guidelines fail to resolve authorship conflict. A common example is when an article based on a thesis/PhD work, is submitted with the name of the guide or the student (principal investigator) missing from the authors’ list. It is expected that the guide as well as the principal investigator are among the authors in thesis articles. On the contrary, a displeased guide may choose to publish the thesis, omitting the student’s name, stating that the student did not work hard enough to gain authorship. The student might also consider not providing authorship to the guide believing that the guide did not appropriately ‘guide’ him during the research. After completion of the degree, the student might lose interest in publishing his work. The guide therefore may decide to unilaterally publish the thesis for dissemination of knowledge. However, the fact that the student has actually collected the data cannot be denied. The true contribution of the student or the guide in the thesis work as well as the manuscript preparation, to merit them as authors, remains debatable. In this paper we present a series of cases where we had to face student and guide authorship issues. Further we discuss the literature on such issues and the steps that were taken by the editorial for resolution of these disputes.

Adult Solid Hepatic Mesenchymal Hamartoma Masquerading as Malignancy

Gunjan Desai, Prasad Pande, Chandralekha Tampi, Dattaprasanna Kulkarni

Solid Hepatic Mesenchymal Hamartoma (HMH) rarely occurs in adults. We report two cases of solid adult HMH. A 62-year-old female with right upper abdominal pain on Computed Tomography (CT) scan revealed a well defined heterogeneously enhancing solid mass lesion in segment VII of liver along with non-enhancing central necrotic areas. Percutaneous biopsy and intraoperative frozen section were inconclusive and conventional right hepatectomy was done. Final histopathology was solid HMH. Another 63-year-old female with right upper abdominal pain had cirrhotic liver, choledocholithiases, cholelithiases, mild ascites and a right lobe lesion with calcifications on CT scan. Ultrasound guided biopsy showed fibrocollagenous tissue. She was operated for a right hepatectomy and choledochoduodenostomy. Final histopathology revealed solid HMH. Though solid adult HMH is rare, it should be considered in differential diagnosis of solid/cystic/focal or multifocal liver lesions and surgical resection to negative margins is the treatment of choice.

Leiomyoma of Testis –Rare Benign Mimicker of Testicular Malignancy

Asif Baliyan, Harshi Dhingra, Ranjeev Bhagat

Leiomyomas are benign tumours that originate from any organ containing smooth muscles. The testis is an extremely rare site. We report a case of testicular leiomyoma in a 50-year-old. Testis-associated leiomyomas are a benign and rare disease presenting as a painless, slowly-growing mass. Only histological examination with immunohistochemistry can validate the diagnosis.

Basidiobolomycosis - A Rare and Underdiagnosed Fungal Infection Mimicking Eosinophilic Colitis

Basidiobolomycosis is a rare fungal disorder mostly restricted to the arid regions of US and the middle-eastern countries. We report an unusual case of this rare infection of the colon in a 45-year immunocompetent male with a rare fungus Basidiobolus ranarum managed successfully with surgery and antifungals. To the best of our knowledge, this is the first case of gastrointestinal infection with B. ranarum in an immunocompetent individual, reported from India.

An Unusual Presentation of Metanephric Adenofibroma: A Rare Case Report

Kiran Agarwal, Jyoti Garg, Gunjan Mahajan, Partap Singh Yadav, Divya Manohar

Metanephric adenofibroma is a rare renal neoplasm with only a few case reports in literature. In majority of cases, it is asymptomatic. However, it may present with haematuria, polycythemia or hypertension. Radiologically, it is indistinguishable from other solid renal tumours. Definitive diagnosis can only be made on the basis of histopathology. It is a benign neoplasm and requires only surgical excision with no need for chemotherapy. Involvement of urinary bladder and presentation as bladder mass has never been reported. In this case report, we present a case of metanephric adenofibroma in a two-year-old male child manifesting with haematuria and urinary bladder mass.

Diagnostic Dilemma of Cytology in Salivary Gland Neoplasm: Case Report of a Rare Diagnosis with Brief Review of Literature

Aruna Chhikara, Preeti Rai, Manjula Jain, Brijnandan Gupta, Sunil Kumar

Carcinoma ex Pleomorphic Adenoma (Ca ex PA) is a rare malignancy accounting for 3.6% of all salivary gland neoplasms. Malignant component of Ca ex PA is most often adenocarcinoma, Not Otherwise Specified (NOS). Myoepithelial carcinoma is a rare subtype of Ca ex PA. We present a case of myoepithelial Ca ex PA, firstly, due to its low prevelance and secondly, due to the frequent diagnostic conundrum it poses to the clinicians and pathologists.

Idiopathic Systemic Capillary Leak Syndrome: A Diagnostic Challenge and Its Management

Idiopathic Systemic Capillary Leak Syndrome (ISCLS) is a fatal disorder characterised by recurrent episodes of hypotension, hypoalbuminemia and haemoconcentration. It is a rare disease, under-reported partly because of unawareness of treating physician. Here is a description of a 30 year old male presenting with history of fever, generalized oedema progressing to hypovolemic shock and multi organ dysfunction. His laboratory studies showed haemoconcentration, hypoalbuminemia and monoclonal gammopathy with negative bacteriological cultures. After excluding other probable etiologies he was diagnosed to have ISCLS. He was managed successfully with intravenous methylprednisolone, theophylline and other supportive measures. He has been put on prophylactic oral theophylline for one year.

Multidisciplinary Clinical Management of Paraneoplastic Pemphigus – A Case Report

Sadaksharam Jayachandran, M Preethi

Paraneoplastic pemphigus is a rare immunobullous disorder commonly associated with lymphoproliferative neoplasms and less commonly in carcinomas with a poor prognosis. The neoplasms produce autoantibodies that react with members of plakin family to produce a suprabasilar split and varied clinical presentations in the skin and mucous membrane. Oral erosions are the first manifestation most resistant to treatment and persist even after the underlying tumour has been resected or treated. We report here a rare case of paraneoplastic pemphigus with an underlying squamous cell carcinoma of the oesophagus that constitutes only 8% of the neoplasms associated with this condition. It was successfully managed by a multidisciplinary approach involving the Departments of Dermatology, Surgical Oncology and Oral Medicine. The oral erosions were resistant to treatment however, a patient-tailored treatment was advocated using professionally administered debridement with hydrogen peroxide diluted with hypotonic saline, high potency topical steroids, analgesic oral rinses and topical anaesthetics with systemically administered immunomodulators. Hence, management of such cases exhibiting systemic and oral manifestations require a multidisciplinary team approach to improve the quality of life of the patients.

Spindle Cell Liposarcoma – A Rare Tumour Occurring at a Rare Site?

Varuna Mallya, Nita Khurana, N.S. Hadke

Lipomatous tumours are the most common type of soft tissue neoplasms with liposarcomas being the most common soft tissue sarcomas. Spindle cell liposarcoma is the most recent addition to this group and is characterized by a lipocytic and spindled component both showing atypia. Lipoblasts with their characteristic scalloped nuclei are found in the spindled areas. These tumours show CD34 positivity. Arising in the head and neck and soft tissues of the extremities, this tumour was described for the first time in 1994. Very few cases are reported in the literature. The present case emphasizes the fact that this tumour should be considered as a possible diagnosis in tissues histologically showing a good admixture of adipocytic and spindled cells.

Delayed Repair of Infected Ruptured Patellar Tendon using Suture Anchors

Himanshu Kataria, Lakshay Goel, Sahil Gaba, Jatin Prakash, Arvind Kumar

Patellar tendon rupture are rare injuries that are easily missed in acute phases if careful clinical examination is not carried out. The delayed condition is further difficult to treat and augmentation of end to end repair is generally required. However, literature presents no such case of delayed presentation with presence of infection. We here present one such case of delayed presentation of patellar tendon rupture at three weeks in a 52-year-old male patient. Usual techniques were not sufficient to allow early rehabilitation. Technique of suture anchors was planned for repair after thorough debridement. After this intervention, patient was put on aggressive rehabilitation protocol and he gained excellent range of motion. Patient was followed for one year and he showed no loss of movement or signs of infection. We thus recommend using anchor suture repair of patellar tendon that provides a stable and rigid fixation with possibility of early active rehabilitation even in delayed setting.

Subcutaneous Cyst due to Medicopsis romeroi in a Diabetic Lepromatous Leprosy Patient: An Interesting Case Report and Review from India

Medicopsis romeroi (M. romeroi) (syn. Pyrenochaeta romeroi) is a rare melanized fungus causing subcutaneous/localized invasive phaeohyphomycosis in immunocompromised patients. We present a rare case of subcutaneous phaeohypho-mycotic cyst caused by M.romeroi in a diabetic male with lepromatous leprosy. Molecular identification was performed by sequencing of Internal Transcribed Spacer (ITS) region and D1/D2 region of Large Ribosomal Subunit (LSU).

Leprosy in Pregnancy: Obstetric Diligence is the Key

Rupali Bhatia, Sumita Mehta, Anshul Grover, Swati Dubey

Leprosy in pregnancy is a rarely encountered event. Out of the 2000 patients detected of leprosy annually, two to three are pregnant women and majority of them are diagnosed in the third trimester. We, hereby, report a case of borderline tuberculoid leprosy with Type I lepromatous reaction in a 26-year-old pregnant woman in early second trimester with a large raised red coloured lesion over the forehead and six other small lesions involving the trunk and limbs with reduced sensory perception over involved skin. Occurrence of leprosy in an obstetric patient belonging to low prevalence area of India is infrequent especially in the post elimination era. However, we do need to have a high index of suspicion in lesions suggestive of the disease.a

Anaesthetic Considerations in Patients of Takayasu Arteritis and Blunting of Stress Response to Intubation by Dexmedetomidine Infusion “A Report of two Cases”

Deepak Dwivedi, Kiran Sheshadri, Abhijit Karmarkar, Arijit Ray, Swayam Tara

Takayasu arteritis is an entity resulting in pan-endarteritis. It involves the principal arteries resulting in ischaemia and persistent hypertension. Hypertension affects the anaesthetic management where the principal goal is to control the haemodynamic stability during the induction and for the entire course of anaesthesia preventing damage to the end organs. We present two cases, one paediatric with hypertension refractory to medical management posted for nephrectomy and one adult patient posted for diagnostic hysterolaparoscopy. Both the cases were administered dexmedetomidine, an alpha 2 agonist during the pre-induction period. Sympatholysis caused by infusion dexmedetomidine was effectively utilized in both the cases hence, pre-induction infusion of dexmedetomidine can be utilized to obtund the haemodynamic response to intubation.

Surgical Removal of Fractured Endodontic Instrument Extending Beyond the Periapex of Mesiobuccal Root of Maxillary Second Molar through the Maxillary Sinus

Kiezhekke Veedu Sheethi, Kitu Sheoran, Thakur Veerandar Singh

Procedural accidents during endodontic treatment often complicate the overall treatment plan of the patient. One of the most frequently encountered procedural accidents is fracture of endodontic instrument. Removal of fractured instrument from root canal is often a difficult procedure especially, when the fractured instrument extends beyond apex. This case report presents the management of a case involving the surgical removal of a broken endodontic file from the periapical region of the mesiobuccal root of a maxillary second molar.

Pancreatic Head Hydatid Cyst Masquerading Cystic Pancreatic Neoplasm in a Young Female

Neeraj Wadhwa, Udit chauhan, Sachin Agrawal, Neha Nischal, Sunil Kumar Puri

Hydatid Cyst (HC) disease is a zoonotic infection caused by larval stage of Echinococcus granulosus. The disease poses an important public health hazard not only because it is endemic to many parts of the world but also because of migration and travel related spread. HC may develop in almost any part of the body, most commonly found in the liver, followed in frequency by the lung, kidney, brain and bone. Involvement of other organs is rare. In this case report, we describe a rare occurrence i.e., primary HC of pancreas along with review of literature and possible differential diagnosis. Pancreatic HC disease may be associated with complications such as jaundice, cholangitis, and pancreatitis which develop as a result of fistulization of the cyst content into pancreato-biliary ducts or external compression of those ducts by the cyst. Pancreatic HC may mimick pseudocyst or cystic neoplasm of pancreas such as cystadenoma, intraductal papillary mucinous neoplasm, cystic islet cell tumour etc.

A Successful Outcome of Pregnancy in Hepatic Haemangioma: An Account of a Perplexing Case

Harsha Shailesh Gaikwad, Sheeba Marwah

Liver haemangiomas are described to be the most frequent benign liver tumours, and are mostly incidental detections in asymptomatic individuals. Giant lesions can develop symptoms, and are associated with complications. Female sex hormones, particularly estrogen, are believed to influence haemangioma development and progression. The optimal management of giant haemangiomas during gravidity is inadequately illustrated in literature so far. Diagnosis of a symptomatic giant haemangioma during pregnancy presents a quandary for the clinicians; besides, the safety of conservative management during pregnancy has not been comprehensively investigated. Consensus on the indications for surgical resection of asymptomatic lesions is also lacking at present. Thus, we present a case of a giant hepatic haemangioma diagnosed during pregnancy, where in timely detection and close observation, could successfully diffuse an otherwise a ticking bomb to explode; and also review the literature, with an aim of alleviating the bewilderment on management of haemangioma in pregnancy that might exist in the mind of budding gynecologists.

Amyand´s Hernia – Vermiform Appendix in an Inguinal Hernia: A Rare Finding

Prakash Kumar Sahoo, Suman Saurav Rout, Abhijit Samal

A variety of surprises may spring up when the sac is opened in an inguinal hernia. Omentum, bowel diverticulum, ovary, fallopian tube, urinary bladder, large bowel, Meckel’s diverticulum or foreign bodies being the varied contents of a hernia sac. The presence of vermiform appendix in the hernia sac in an inguinal hernia is a rare finding. This condition has been named as “Amyand’s Hernia” in the honour of an English surgeon, Claudius Amyand. A diagnosis preoperatively is difficult and is most often made intraoperatively. We report here a 52-year-old patient who presented with acute intestinal obstruction due to an obstructed right sided inguinal hernia. A diagnosis of Amyand’s hernia was confirmed when on exploration appendix along with a part of ascending colon was found to be content of the sac along with a few loops of small bowel. The contents were reduced after checking the viability and Bassini’s repair was done. The patient had an uneventful postoperative period.

Multiple Cutaneous Tuberculous Abscess: A Case Report

Rahul Suna, Ramu Duttaluri

Cutaneous tuberculosis is a relatively rare form of extrapulmonary tuberculosis. It usually manifests secondary to haematogenous spread or from an underlying focus of infection. We report a case of multiple tuberculous abscesses without any primary focus. A 26-year-old female, presented with polyarthalgia since four months and multiple abscesses over the body since three months. No response was seen after taking various courses of antibiotics and analgesics, which was misdiagnosed as bacterial abscesses. Skin biopsy showed multiple epitheloid cell granulomas with multinucleated giant cells suggestive of tuberculosis. After treating the patient with antitubercular therapy, complete resolution of the lesions occurred within four weeks. Tuberculosis with unusual presentations is common in endemic countries like India. A high index of suspicion with regard to cutaneous tuberculosis presenting as multiple abscess and nodule without any underlying lesion is essential.

Stenotrophomonas maltophilia mimicking Klebsiella on Chromogenic Media

Vivek Hada, Kumar Saurabh, Vibhor Tak, Anuradha Sharma, Vijaya Lakshmi Nag

Chromogenic media are being used now-a-days for identification of many microorganisms in the clinical microbiology laboratories. They are being used for screening purposes especially in case of urine cultures, environmental surveillance and also for detection of multidrug-resistant organisms like Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE) and Carbapenem-resistant Enterobactericeae (CRE) etc. Organisms produce specific colour due to digestion of chromogenic substrates present in the medium. Thus the Organisms are identified on basis of colour production. These media are specific in detecting common pathogens which are isolated. But they can give different results when uncommon organisms are encountered. In this case report the uncommon organism that is Stenotrophomonas maltophilia produced colour similar to Klebsiella spp. on chromogenic media.

Unilateral Foot Drop: An Unusual Presentation of a more Common Disease

Rameshwar Nath Chaurasia, Abhishek Pathak, Vijay Nath Mishra, Deepika Joshi

An isolated and unilateral foot drop due to intracranial lesion is quite rare. Presenting herein a case of a 14-year-old female who complained of inability to wear and hold slipper in her left foot. Detailed neurological examination revealed left foot dorsiflexion which had 1/5 muscle power along with brisk left ankle reflex. Magnetic resonance imaging of the brain revealed multiple conglomerate inflammatory granulomas in cerebrum and cerebellum, larger one in right parasagittal region with perifocal oedema. Magnetic resonance spectrum was suggestive of tuberculoma. Her chest X-ray chest revealed milliary shadowing. She was put on anti-tubercular drugs, steroid and a prophylactic anti-epileptic drug. The dorsiflexion improved to grade 4/5 after three weeks of treatment. The motor homunculus for foot is located in parasagittal area. Therefore, in patients with foot drop, we must keep high index of suspicion for parasagittal lesions, so that prompt diagnosis and early management can be done to prevent complications and improve the quality of life of patient.

Primary Multidrug-Resistant Extrapulmonary Tuberculosis Presenting as Empyema Necessitans in an Immuno-competent Young Girl

Jyoti Bajpai, Surya Kant, Ajay Kumar Verma

Empyema Necessitans (EN) is a variant of empyema that extends to extrapleural space and can affect chest wall too. Although, tuberculosis is the most common cause of EN, primary multidrug resistant TB presenting as EN is rare. Despite the ominous upward trend of drug resistant pulmonary tuberculosis prevalence globally, only sparse reports of extrapulmonary involvement by drug resistant mycobacteria have been documented in literature. Uptill now, culture has been the gold standard for diagnosis of TB. However, the availability of simple and rapid molecular tests has made the diagnosis of extrapulmonary forms of TB possible with high sensitivity and specificity. Here, we report a case of primary Multidrug-Resistant (MDR) extrapulmonary tuberculosis presenting as EN in an immuno-competent young girl.

Interesting Cystic Lesions of Pancreas in Septuagenarians

Biggs Saravanan Ramachandran, Maria Jacob

Intraductal papillary mucinous neoplasms are rare pancreatic tumours which can mimic more common diagnoses like pancreatic pseudocysts or pancreatic mass. Here we describe two of our cases who presented with abdominal pain and weight loss and were diagnosed to have Intraductal Papillary Mucinous Neoplasm (IPMN) after Endoscopic Ultrasound-guided Fine Needle Aspiration (EUS FNA) which was crucial in clinching the diagnosis.

Clitoral Leiomyoma with Condyloma Accuminata in Young Female: A Rare Case Report

Taru Gupta, Deepika, Sangeeta Gupta

Leiomyomas are benign tumours of the smooth muscle. They occur predominantly during the reproductive age especially in females. Clitoral leiomyoma is a rare tumour and is usually asymptomatic but can present as a local growth with urinary complaints. MRI has a very high detection rate in the diagnosis as well as differentiation of benign from malignant. Here we are reporting a rare case of 22-year-old sexually active female of clitoral mass diagnosed as case of clitoral leiomyoma (rare location) with localised condyloma accuminata.

Degenerated Cystic Uterine Myoma Mimicking Postpartum Haemoperitonium

Servet GenÇdal1, Hüseyin AydoGmuS2, serpil Aydogmus, Zafer Kolsuz, Sefa KelekÇi

Haemoperitoneum due to spontaneous haemorrhage of intraleiomyoma is a very rare complication of uterine myoma. Acute complications of uterine myoma are seldom seen, but it may be fatal. We hereby report case of a female, who presented with abdominal pain and distension, postpratum, found to have degenerated cystic uterine myoma, mimicking postpartum haemoperitonium.

Periodontally Accelerated Osteogenic Orthodontics (PAOO) Assisted Management of Palatally Impacted Canine with Five Years Follow Up

R Navaneethan, KK Shantha Sundari, K Ambika

Periodontally Accelerated Osteogenic Orthodontics (PAOO), a patented technique by the Wilcko brothers has become very popular in reducing the treatment time in Orthodontics. A 17-year-old male patient presented to the Department with a Class I skeletal and a Class I dental pattern with bilateral canine impactions. The canine impaction was buccal on the right side (13) and palatal on the left side (23). The initial treatment plan was to disimpact 13 with a piggy back wire and 23 using the K9 spring respectively and it did not involve the PAOO Technique. However, six months into treatment, the patient stopped reporting for his regular appointments and reported after a time interval of one and a half years to continue his treatment. At the time of his return, considerable bone loss around the region of 23 was noticed on radiographs. The PAOO technique was therefore, carried out to augment bone around 23 as well as reduce the time for treatment.

Protocol for Dental Management in a Patient with Glucose- 6-Phosphate Dehydrogenase Deficiency

Glucose-6-Phosphate Dehydrogenase (G6PD) enzyme deficiency is the most common inherited genetic disorder affecting RBCs in humans. The disorder is characterised by inability of RBC to maintain a balanced redox state when challenged by oxidative stresses like drugs, infections and certain food substances leading to severe haemolytic anaemia which complicates any therapeutic management in these patients. This article reports on a successful endodontic management of a 36-year-old class III G6PD deficient male patient with deep carious lesion in left mandibular first molar tooth (36). Considering there is no protocol precedence in dental literature, in consultation with the physician/haemotologist a three step protocol for safe and efficient dental management is proposed.

Inguinal Hernia as an Initial Presentation of Pseudomyxoma Peritonei

Biswajit Dey, Gourav Kaushal, Prita Pradhan, Pampa Ch Toi, Biju Pottakkat

Pseudomyxoma Peritonei (PMP) is characterized by presence of abundant extracellular mucin in the peritoneum. Preoperative diagnosis of pseudomyxoma peritonei is difficult due to its varied presentation. We report a case of pseudomyxoma peritonei in a 64-year-old male, who initially presented with right inguinal hernia and then with recurrence as left inguino-scrotal hernia. A debulking surgery including subtotal colectomy, cholecystectomy and splenectomy along with peritonectomy was performed. The left inguino-scrotal hernia was reduced and a left inguinal hernioplasty was performed. This case is reported to highlight that pseudomyxoma peritonei can present as inguinal hernia and therefore, a thorough examination of the hernial contents for mucin should be done.

Supratentorial Haemangioblastoma without Von Hippel-Lindau Disease – A Rare Case Report with Review of Literature

Salman Tehran Shaikh, Chandrashekhar Eknath Deopujari

Haemangioblastomas are slow-growing, benign and vascular neoplasms of the central nervous system. They are usually infratentorial, occurring either sporadically in approximately 67% of cases or as a manifestation of Von Hippel-Lindau (VHL) disease in approximately 33% of cases. They were first described by Von Hippel in 1895. Haemangioblastoma in the supratentorial compartment is an infrequent occurrence. Only 58 cases of supratentorial haemangioblastoma without Von Hippel-Lindau disease have been reported from 1902 to 2015. This case discusses a left basifrontal supratentorial haemangioblastoma occurring in a young female who presented with headache and blurring of vision without manifestations of VHL disease. Its benign nature and prognosis merited surgical excision as the treatment of choice.

Haemolytic Disease of Foetus and Newborn (HDFN) due to Anti c with Previous Fatal HDFN in Two Other Siblings

Evarisalin Marbaniang, Debdutta Bhattacharya, Steward Kshiar

Haemolytic Disease of Foetus and Newborn (HDFN) or Haemolytic Disease of Newborn (HDN) has been known to occur mostly as a result of Rh-isoimmunisation. However, HDFN due to minor antigens of the Rh system have also been reported. Anti-c causes severe HDN after anti D. Here, we report a case of HDN due to anti-c and we want to emphasise the importance of routine antibody screening as part of the antenatal services for all pregnant woman so as to prevent hazardous complications for the baby.

Anomalous Muscles Encountered in the Carpal Tunnel: A Report of Two Cases

Laxminarayan Bhandari, Michelle Palazzo

Anomalous muscles are infrequently encountered in carpal tunnel surgery. They are challenging to identify and may mislead the surgeon by obscuring normal anatomy. Hence knowledge of their presence is essential. We report two cases of anomalous muscle encountered in the carpal tunnel during surgery. First case consisted of an anomalous muscle seen in carpal tunnel release surgery. The muscle had proximal tendinous origin at wrist and distal tendinous insertion on index finger. In the second case, we incidentally encountered an anomalous muscle, which originated from the distal end of radius, travelled through the carpal tunnel and fused with the flexor digitorum superficialis of the small finger. Through this case report we have discussed the current concepts regarding anomalous muscle in the carpal tunnel and its management.

Extra-Nasopharyngeal Angiofibroma in a Pre-Pubertal Child

Subhro Ganguly, Surendra H Gawarle, Prashant N Keche

Nasopharyngeal Angiofibromas (NA) are benign fibro-vascular tumours, predominantly occurring in the region around sphenopalatine foramen of adolescent males. Angiofibromas arising outside nasopharynx are termed as Extra-Nasopharyngeal Angiofibromas (ENA) which often gets misdiagnosed because of its rarity and atypical clinical and biological behaviour. We present a case of angiofibroma of nasal septum in a seven-year-old boy presenting with two months history of left nasal obstruction and occasional nasal bleeding. CECT revealed a contrast enhanced soft tissue mass in left nasal cavity with no extension into the sinuses and nasopharynx. The mass was completely removed by lateral rhinotomy approach and a follow up of ten months showed no recurrence. Histopathology and immunohistochemistry confirmed the diagnosis of angiofibroma. The age of the patient and the location of the tumour make the case exceptionally rare. We conclude that ENA must be taken into consideration in differential diagnosis of unilateral vascular nasal mass, and nasal septum should be taken into account as a potential, yet exceptional site for the tumour. Furthermore the age and gender of the patient should not be given utmost importance for diagnosis of angiofibromas.

Ceftriaxone Induced Hypersensitivity Reactions Following Intradermal Skin Test: Case Series

Sereen Rose Thomson, Balaji Ommurugan, Navin Patil

The incidence of cephalosporin induced hypersensitivity reactions in non-penicillin allergic patients is about 1.7% and in penicillin allergic patients it is about 3-5%. Infact, cephalosporins are considered as the first choice in penicillin allergic patients who need antibiotic therapy intraoperatively. Prompt identification of patients with beta-lactam allergy would lead to an improved utilization of antibiotics and reduced occurrence of resistant strains. We hereby attempt to present a series of cases where ceftriaxone has been implicated in the manifestation of various hypersensitivity reactions. We have also tried to highlight some of the errors, risk factors and other drugs that precipitate a hypersensitivity reaction.

Non Iodine Avid Bone Metastasis from Differentiated Thyroid Cancer: A Case Series

Differentiated Thyroid Carcinoma (DTC) constitute up to 90 per cent of all thyroid malignancy. The overall prognosis of patients with DTC is good, but when bone metastases are present, the overall survival at 10 years ranges from 13 to 21%. Treatment of metastatic thyroid cancer that are non iodine avid offers a surgical challenge. This paper reviews a series of three cases of DTCs with bone metastasis treated by surgery.

The Inflated Urobag Technique for Accessing the Pelvicalyceal System during Prone Percutaneous Nephrolithotomy in a Ptotic Kidney

Percutaneous Nephrolithotomy (PCNL) is a common endourologic procedure done for removal of renal stones. The most important initial step involves making a safe puncture into the pelvicalyceal system, and establishing an access tract into pelvicalyceal system. This is a crucial step in the success of the PCNL. Though the procedure is relatively simple and straight forward, in conditions like hyper-mobile kidney or ptotic kidney, the pelvicalyceal system is abnormally oriented and the kidneys are excessively mobile making the puncture of pelvicalyceal system difficult. Till date there is no established technique to overcome this problem. The technique of resolving this problem involved placing an air filled urobag beneath the patient in the prone position on the ipsilateral side of abdomen. This technique of placing an inflated urobag called as “The inflated urobag” technique is a simple one, which relocates the kidney and hence the pelvicalyceal system to normal anatomical position, making the initial puncture easier. This also prevents excessive mobility of the kidney during puncture and dilatation of the tract. This technique, which is not described earlier, is extremely useful in the puncture and dilatation during prone PCNL in ptotic and hyper-mobile kidneys. We here in describe our experience in 15 cases of PCNL in ptotic or hypermobile kidney.

Large Ulcerated Oral Focal Mucinosis: A Rare Case Report

Perineural cyst: An Unusual Cause of Radiating Low Backache in Children

Basudev Biswal, Amit Kumar Satapathy, Samarendra Mahapatro, Rashmi Ranjan Das

Additional Virtual Reality Sitting Balance Training Using XBox Kinect™ in Patients with Neurological Disorders: A Pilot Study

Xina Henry Quadros, Sanjana Rao, Senthil Kumaran Dharmaraj

Introduction: Sitting balance is a prerequisite to upper extremity function, standing and walking, which is affected in various neurological diseases. It is important to attain a good level of sitting balance before one can proceed to standing. In recent years, virtual reality game training has gained a widespread application. Aim: This pilot study aimed to examine the role of additional virtual reality sitting balance training using a commercial interactive virtual reality system- Xbox Kinect™ in patients with neurological disorders. Materials and Methods: Four patients with sitting balance impairments following neurological disorders received two weeks of virtual reality based therapy along with the conventional physiotherapy. Sitting balance was evaluated using FIST (Function In Sitting Test) scores at baseline, one week and after two weeks of intervention. Results: All four patients showed clinically significant improvement in FIST score between the pre and post intervention. Percentage of improvement in FIST score was approximately 27% with a minimum change of 10 points in the FIST score Minimal Clinically Important Difference (MCID=6.5). Conclusion: Additional virtual reality training may improve sitting balance control in neurological patients with balance impairments. It can be used as an adjunct in routine neurorehabilitation.

Validation of Self-Reported Hearing Loss Among Multi-Ethnic Community Dwelling older Adults in Malaysia

Introduction: Little is known about the prevalence of hearing loss and the usefulness of self-report hearing loss among older adults in Malaysia. Aim: We conducted a population-based study to investigate the prevalence of self-reported hearing problem and its relationship with audiometric hearing thresholds in older adults in Selangor, Malaysia. We also investigated demographic factors that were associated with the self-reported hearing loss. Materials and Methods: The participants were recruited from Selangor using a multi-stage clustered sampling involving 324 participants aged between 60 to 88-year-old (68.3±5.9 years). All participants underwent a face-to-face interview and pure tone audiometry. Self-reported hearing loss was obtained using three questions. Results: The prevalence of self-reported hearing problems was 53.4%. This prevalence did not differ significantly among age group, gender, race and education level (p>0.05). Univariate and logistic regression analyses found that tinnitus and Pure Tone Average (PTA) of at least moderate hearing loss at 0.5 kHz to 4 kHz contributed significantly to the likelihood of self-reported hearing problem. Participants with tinnitus and participants with PTA at least moderate hearing loss at 0.5 kHz to 4 kHz were twice as likely to report hearing problem than their counterparts. The questions yielded poor sensitivity in identifying at least mild loss and moderate sensitivity for at least moderate hearing loss. Conclusion: The present study highlights the need for a more effective self-report inventory or audiometry instrument that is less sensitive to background noise to better estimate hearing loss prevalence among adults in Malaysia.

Co-Testing of Cervical Screening Tests in Detection of High Grade Cervical Intraepithelial Neoplasia

Smita Asthana, Satyanarayana Labani, Pushpa Sodhani, Sanjay Gupta

Introduction: Co-testing performance for detection of high grade Cervical Intraepithelial Neoplasia (CIN) has not been adequately addressed from Low Resource Countries (LRCs). Where isolated tests do not have adequate performance, further explorations are recommended. Aim: To evaluate the co-testing of conventional cervical screening tests such as Papanicolaou (Pap) and Visual Inspection Cervix with Acetic Acid (VIA), with care HPV on Cervical Samples (CHPV) or on Vaginal Samples (VHPV) in the detection of high grade CIN. Materials and Methods: The cross-sectional study was conducted on ever married women of age 30 to 59 years in a rural community of Dadri. Women were screened by CHPV, VHPV, and Pap and VIA methods. Confirmation of screen positives was done by histology. Sensitivity, Specificity and likelihood ratios of different combinations of test determined to evaluate the performance. Results: Total eligible women, 66.2% (5032/7604) responded for screening. Analysis was performed on 4658, after excluding those who did not complete all screenings. Co-testing of CHPV (OR=246) or VHPV (OR=278) with Pap had highest association. Positive likelihood ratios of CHPV and VHPV with Pap in CIN II+ detection rates were 13.0 and 11.8 and in CIN III+ the detection rates were 18.0 and 16.0 respectively. Higher sensitivities and specificities were observed in co-testing for CIN III+ detection as against CIN II+ lesions. Conclusion: Choice of co-testing in a pair of tests for detection of high grade CIN is likely to depend on whether screening is targeted for developed or low resource country. VIA in isolation might not yield optimal results for LRCs.

Evaluation of Clinical Parameters to Distinguish Mucinous Cystic Neoplasms from Serous Cystic Neoplasms of Pancreas- A Retrospective Study

Introduction: Pancreatic cystic neoplasms represent approximately 15% of all pancreatic tumours. Serous Cystic Neoplasm (SCN) is a benign lesion, and observation instead of surgical resection is suggested as first line treatment. Mucinous Cystic Neoplasm (MCN) has malignant potential and surgical resection has been considered the first line treatment. The preoperative distinction between SCN and MCN is important due to their completely different treatment strategies. Aim: This study was aimed to find clinical parameters for distinguishing between mucinous and serous cystic neoplasms of pancreas. Materials and Methods: From 1992 to 2010 at Chang Gung Memorial Hospital, Linkou, Taiwan and from 1988 to 2014 at Chang Gung Memorial Hospital, Keelung, Taiwan 141 patients underwent pancreatic tumour resection for pathologically proven SCN or MCN. The demographic data, characteristics and biochemistry data were reviewed and analysed. Results: In our study cohort, the levels of Aspartate Transaminase (AST) (p=0.009), Alanine Transaminase (ALT) (p=0.032), albumin (p=0.043) and Alkaline Phosphatase (ALP) (p<0.001) were all higher in the SCN group (p<0.001). Patients in the MCN group were noted to have relatively larger tumours (mean size of 8.11±4.72 cm vs. 6.05±3.58 cm, p=0.022). The SCNs were located predominantly in the head of the pancreas whereas the MCNs were predominantly located in the tail and body (p<0.001). After a logistic regression analysis, the independent factors that helped to distinguish SCN from benign MCN include the serum ALP level and the tumour location. We further applied a Receiver Operating Characteristic (ROC) curve to determine the cut-off value of ALP. The Area Under the Curve (AUC) for ALP was 0.762. The cut-off value for ALP was 61.5 U/L. We also found that when the ALP level was >61.5 U/L in the case of a proximally located pancreatic cystic neoplasm, SCN was indicated (84.2% specificity and 94.1% negative predictive value), but otherwise, MCN may be implicated. Conclusion: Preoperatively, SCN and benign MCN are not easily distinguishable from each other. However, a combination of the tumour location and the preoperative ALP level may provide some diagnostic benefit.

Effects of Frequent Glove Change on Outcomes of Orthopaedic Surgical Procedures - A Multicenter Study on Surgical Gloves

Introduction: Intact surgical gloves are a barrier to microorganisms migration between surgical team members and the patient. The surgical gloves are changed at various junctures but the effects of changing gloves during surgical procedures on various surgical parameters or clinical outcomes are not established. Aim: To determine rationale of glove change during orthopaedic procedures, differences amongst surgical parameters with and without changing the surgical gloves and whether frequent glove change affected surgical parameters or clinical outcomes. Materials and Methods: A prospective multicenter study conducted at three centers from January 2014 to January 2016. A 250 patients were divided into 2 groups (n=125 each) in Group 1, surgical team operated with regular changing of gloves. In Group 2, only 1 set of double gloves were worn throughout the procedure. Surgical parameters or clinical outcomes were assessed for both the groups. Statistical analyses included the median, mode, range, Interquartile Range (IQR) and sample standard deviation (s) and independent-samples t-test. Bacterial counts were expressed as median with (IQR). Results: Surgical Timing Difference was 10 (S.D.- 4.2) minutes more in Group-1 (<0.05), Surgical Cost was higher in Group-1 by Rs.150-450 (<0.05). Outer glove micro-perforation rate was 5.85% and 8.15% in group-1 and 2 respectively with no inner glove perforation or Surgical Site Infections. Outer glove micro perforations were proportional to duration of surgery; operations lasting 120-210 and 61-120 minutes had 66.6% and 37.2% micro perforation rates respectively (p<0.05). Conclusion: Under standard operating conditions, procedures performed without glove change are shorter and cost effective than procedures performed with regular glove change with similar surgical and functional results. Judicious use of surgical gloves is a patient and environment friendly option, thereby reducing the hospital’s biomedical waste load.

Domestic Violence against Women – An Unsolved Issue: A Community Based Study in an Urban Slum of Kolkata, India

Jayita Pal , Tanjib Hassan Mullick , Shamshad Ahmad , Ashish Kumar Yadav

Introduction: Domestic Violence against women is still an unsolved issue in India, though, it is an important public health problem contributing to physical, mental illness and low quality of life. Aim: The study was undertaken with the aim to estimate the prevalence of domestic violence against ever married women in an urban slum and the associated factors contributing to it. Materials and Methods: A community-based cross-sectional study had been conducted among 430 ever married women of reproductive age group, selected using a systematic random sampling technique in an urban slum of Kolkata. Interviews were conducted using pre-designed, pre-tested semi structured schedule regarding their socio-demographic characteristics, violence experienced by the subjects in their lifetime, type of violence (physical, emotional and sexual violence) and the person responsible for the same. Data were entered and analysed using SPSS 20.0 version. Results: The overall prevalence of any form of violence in the study population as a whole was (59.3%). The prevalence of physical, emotional, sexual violence was 61.6%, 84.3%and 58.8%, respectively. The occurrence of the event was reported by only 33.1% of the victims. Multivariate analysis revealed violence was higher among women belonging to families with low per capita income (< Rs 3138 per month), with higher spousal age difference (>6 years), low educational background of husband, not able to bear a male child, unemployment amongst both the spouses, leave the household on any pretext without prior permission from husband and where the wives did not attend household activities properly. Conclusion: The prevalence of domestic violence in urban slum of Kolkata was high which is an alarming public health problem which needs to be addressed at the earliest through awareness programmes and empowerment of women.

Factors Influencing Mothers to Initiate Early Complementary Feeding in Darjeeling, West Bengal

Introduction: More than half of the infants are started on complementary feed before six months. Perception of Inadequate Milk supply (PIM) remains one of the most frequent causes of early institution of complementary feeding. Perception of Inadequate Weight Gain (PIWG), may also influence a mother’s decision to start early complementary feeding which may be a consequence of PIM. Aim: To find the proportion of early complementary feeding and to compare predictive models in identifying mothers who are more likely to initiate early complementary feeds. Materials and Methods: A descriptive epidemiological study with cross-sectional design was carried out for three months between May-July 2013 among 99 mother-child dyads, with children in the 6-24 months age group, residing in Matigara block of West Bengal. Data were collected regarding infant feeding practices and prevalence of early complementary feeding was calculated. Logistic regression was done using SPSS Version 20.0 with the predictor variables classified under three constructs of socio-demography, health system related factors and mothers perceptions; and models were constructed using one, two or all three constructs. Results: The proportion of early complementary feeding was 30.3%. In univariate analysis, none of the variables were found to be statistically significant. However, on multivariate analysis, Model (with all variables) was found to be statistically significant. The best Area Under Curve (AUC) was found with the inclusion of the socio-demography, health system related factors and mothers’ perception. Conclusion: The perception of the mother regarding adequacy of her milk production and regarding the child’s weight gain are the most important predictors of early initiation of complementary feeding. All counselling activities for the mother should therefore be designed in a way as to address these issues.

Evaluation of Prevalence and Causes of Acute Kidney Injury and its Effect on Short Time Mortality in Intensive Care Unit Patients

Ali Momeni, Fereidun Khaje Ali, Bahareh Behvandi, Foruzan Ganji

Introduction: Hospital mortality of Intensive Care Unit (ICU) patients has shown correlation with severity of the Acute Kidney Injury (AKI). There are a few studies regarding short term or long term morbidity and mortality of the ICU patients after hospital discharge. Aim: The aim of the study was to evaluate predisposing factors, in hospital mortality and six months followup of the ICU admitted patients in two general hospitals. Materials and Methods: This prospective descriptive study was carried out on 520 ICU admitted patients, in Hajar and Kashani Hospitals, Shahrekord, Iran. The patients were evaluated for causes of hospital admission and inpatient and outpatient mortalities three and six months after discharge. Data were collected and analyzed by SPSS version 19.0 through Spearman’s and Pearson’s correlation tests. Results: Of 520 patients under study, 350 were male and others were female. Mean age of the patients was 55.06±23.3 years. During ICU admission, AKI developed in 147 (28.2%) patients. Based on RIFLE criteria, in the patients with AKI, prevalence of risk, injury and failure were 51 (35%), 44 (30%) and 52 (35%) patients respectively. In the patients older than 65, AKI was more common (p=0.03). In the patients with AKI compared to other patients, serum sodium (Na), Potassium (K), was higher but haemoglobin and platelet were significantly lower. During ICU admission 91 (17.5%) patients died, out of which 56 (38%) cases had AKI and 35 (9.3%) had not (p<0.001). Among dead patients, prevalence of risk, injury and failure were 16%, 30.3% and 53.5% respectively. Among the alive patients, after hospital discharge, 3 months survival were 55.1%, 54.9%, 46.8% and 68.9% in risk, injury, failure and non AKI groups respectively (p=0.002), however six months survival of the AKI patients were 54.7%, 46.3% and 24.9% in risk, injury and failure patients comparing to 69.2% in non AKI patients respectively (p=0.001). Conclusion: The study showed that inpatient mortality and short term survival of the ICU admitted patients had correlation with severity of AKI, based on RIFLE criteria. So, proper prophylaxis and treatment methods for prevention of AKI are very important and critical in these patients.

Mast Cell Density in Oral Lesions using Metachromatic Stains: A Comparative Study

Introduction: Mast Cells (MCs) are bone marrow derived granular cells, distributed throughout the body near blood vessels, nerves and subepithelial areas. MC granules stain by basic dyes but are most readily demonstrated by metachromatic dyes such as toluidine blue and azure A. Aim: This study focuses on evaluating and comparing the count of MCs by identification and staining of these cells by azure A with toluidine blue as a control, in normal oral mucosa and in various other oral pathologies. Materials and Methods: Five cases each of Normal Oral Mucosa (NOM), Inflammatory Fibrous Hyperplasia (IFH), Oral Pyogenic Granuloma (OPG), Oral Lichen Planus (OLP) and Oral Squamous Cell Carcinoma (OSCC) were stained with 1% toluidine blue and azure A. Results: Mean MC count was higher in all four lesions when compared to normal oral mucosa with both stains. OLP exhibited the maximum amount of mean MC count when compared to other pathologies under study. With all four lesions, toluidine blue exhibited higher number of MC density (count/high power field) compared to azure A. Conclusion: Higher count of MCs was noticed in all four lesions indicating a possible role of MCs in their pathogenesis either directly or indirectly. Also, the number of degranulated MCs was more in OLP followed by OSCC, IFH and OPG.

Screening of Pregnant Women for Anti-Toxoplasma Antibodies and their Newborn for Vertical Transmission

Introduction: Toxoplasmosis is a world-wide protozoan-zoonosis caused by Toxoplasma gondii (T. gondii). Primary infections during pregnancy may result in miscarriages, still births, and congenital malformations in the new born. Studies on vertical transmission of toxoplasmosis from India are lacking. Aim: To estimate the seroprevalence of antibodies to T. gondii among pregnant women from the rural population of Kolar and to document vertical transmissions, if any. Materials and Methods: Anti-Toxoplasma IgG levels were estimated among 251 women admitted for labour at a tertiary care hospital in Kolar, Karnataka, between December 2014 and October 2016, by enzyme linked immunosorbent assay (ELISA). Demographic, socio-economic, and obstetrical data along with exposure to risk factors among the participants were recorded. Two hundred and fifty one cord blood samples of the newborns of the above mothers were tested for anti-Toxoplasma IgM antibodies by µ capture ELISA. The validity of an IgM positive reaction was evaluated. The differences in proportions were analysed by the Chi-square test and the differences in means were analysed by the unpaired t-test. A p-value of <0.05 was considered significant. Results: IgG antibodies to T. gondii could be detected in 53 (21.1%) of the mothers tested; the titres ranged between 35 IU/ml – 350 IU/ml. Mothers from lower socio-economic strata had significantly higher prevalence as compared to mothers from middle classes. The seropositivity was not significantly associated with gravid status, literacy, occupation, exposure to cats, consumption of raw meat, salad, or drinking untreated water, gestational age, previous history of abortion or the mode of delivery. Cord blood samples from 5 (2 %) of the newborns gave positive IgM reactions, but they were interpreted as false positives as there was no evidence of infection in their respective mothers or the baby lacked antibodies on follow up. Conclusions: About one fifth of the pregnant women in Kolar region, possess anti-Toxoplasma IgG antibodies and are immune to toxoplasmosis. The rest, constituting a large proportion, are susceptible and run the risk of infection during pregnancy. Routine screening of women for Toxoplasma infections during pregnancy and screening of newborns for congenital toxoplasmosis are recommended.

Efficacy and Safety Evaluation of Myostaal Forte, a Polyherbal Formulation, in Treatment of Knee Osteoarthritis: A Randomised Controlled Pilot Study

Introduction: Myostaal Forte, a proprietary poly-herbal formulation, is mixture of nine herbal plant extracts which possess analgesic, anti-inflammatory and chondroprotective properties. Aim: A prospective, randomised, active controlled, 2-arm, parallel group, assessor blind study was planned to evaluate clinical efficacy and safety of Myostaal Forte in patients of knee osteoarthritis. Materials and Methods: Idiopathic knee osteoarthritis cases as per American College of Rheumatology (ACR) clinical criteria were screened and recruited. A total of sixty patients were assigned to receive Myostaal Forte TDS (n=30) or Paracetamol 650 mg TDS (n=30) for six weeks. Naproxen was rescue analgesia. Modified Western Ontario and McMaster Universities Arthritis Index (WOMAC), Visual Analogue Scale (VAS), global assessment scores determined by orthopaedic physician at baseline, two, four, six weeks and telephonically at eight weeks. Safety was assessed through laboratory investigations at baseline and six weeks, adverse events and tolerability. Data were expressed as Mean±SD and analysed by Chi-square and unpaired t-test. p<0.05 was considered significant. Results: Myostaal Forte and Paracetamol showed significant reduction in osteoarthritis disease activity. Myostaal Forte produced significant improvement compared to Paracetamol, in the pain, stiffness and physical function from baseline to eight weeks (p<0.05). Significant reduction in WOMAC pain score was seen within two weeks in Myostaal Forte group (p<0.05), but not in Paracetamol group. From baseline to two weeks, the pain severity reduced in 8/8 patients in Myostaal Forte group, whereas in 4/8 patients in Paracetamol group. After treatment cessation at six weeks, symptomatic relief was sustained over two weeks in Myostaal Forte group, whereas in Paracetamol, relapse of pain and physical disability occurred within two weeks (p>0.05). No significant adverse events, changes in the laboratory parameters and excellent compliance to treatment were seen in both the groups. Conclusion: Earlier onset analgesic effect with sustained chondroprotection after treatment cessation makes Myostaal Forte, a safe and effective alternative for treatment of knee osteoarthritis.

Awareness and Referral Patterns of Diabetic Retinopathy: A Hospital Based Study

Aditi Dubey, Prafulla K. Maharana, Ashish Chauhan, Vaibhav Ingle

Introduction: Diabetic Retinopathy (DR) has emerged as an important cause of ocular morbidity and blindness in past 20 years. About one fifth of known diabetics are projected to have DR in their lifetime. Thus awareness about DR is an important determinant in reducing the burden of blindness due to DR. Aim: To identify the factors that accounts for poor awareness about DR among patients with Diabetes Mellitus (DM). Materials and Methods: Three hundred thirty cases of DM who were undergoing screening for the first time were subjected to questionnaire to assess their awareness about DR. On the basis of awareness about visual blurring caused by diabetes the cases were divided into two groups, Group I included aware cases and Group II unaware cases. Various factors were then compared between these two groups like demographic profile, literacy level, Socioeconomic Class (SEC), family history, type and duration of DM. All cases were under treatment for DM and majority was on oral hypoglycaemic agents. Results: The study included 330 cases undergoing retinal screening for the first time. The mean age of the study group was 52.8±11.3 years with 54.5% male and 45.5% female cases. Overall, 226 cases (68.5%) were aware that DM could lead to visual impairment (Group I) and 104 (31.5%) cases were unaware of the condition (Group II). Awareness was more in male patients (54.5%), with positive family history (23%), with higher educational qualification (70%) and those belonging to a high SEC (55.8%). The rate of referral by the first contact physician for routine DR screening was 21.2%. The source of information for most of the cases was print media. Conclusion: Literacy and SEC are important factors for awareness of DR. Practice pattern among primary care physician also affects the awareness of DR.

Comparison of Posterior Capsular Opacification with Hydrophilic and Hydrophobic Acrylic Posterior Chamber Intraocular Lens after Cataract Surgery

Abhay Karman Khurana, Anuradha Raj, Harsh Bahadur

Introduction: Posterior Capsule Opacification (PCO) is a type of membrane formation composed from pearls, fibrotic and Soemmering’s rings on the posterior capsule. It is a multifactorial physiological consequence of cataract surgery with Posterior Chamber Intraocular Lens (PCIOL). Aim: To evaluate the difference in the incidence of PCO between hydrophilic and hydrophobic acrylic Intraocular Lens (IOL). Materials and Methods: This observational study was conducted over a period of 12 months and patients attending Department of Ophthalmology were incorporated in the study. A total of 112 eyes of 106 patients with age related cataract were included in the study. Patients were divided into two groups, group I had 55 eyes which underwent cataract surgery with hydrophilic PCIOL and group II had 57 eyes which underwent cataract surgery with hydrophobic PCIOL. PCO analysis was done on subsequent follow-ups, at one month, three months and six months with the help of retroilluminated images taken with slit lamp guided anterior segment photography. Results: PCO grade 2 was seen to be most common among both Group I {31 (56.4%)} and Group II {38 (66.7%)} eyes. PCO grade 3 was seen among 20 (36.4%) eyes in group I and 10 (17.5%) eyes in group II which was 2.7 times more in group I as compared to group II. PCO grade 3 was also found to be more prevalent among young patients, diabetics and in patients with immature cataracts. Conclusion:The incidence of PCO is higher with the hydrophilic IOL. However, the increased incidence of PCO is also attributed to young age of patient, presence of diabetes mellitus and immature cataract grade. These are factors known to be associated with higher incidence of PCO.

Randomized Controlled Trial Comparing Open, Conventional, and Single Port Laparoscopic Appendectomy

Introduction: Open appendectomy took decades to evolve to establish itself as the treatment for appendicitis. Then came the era of laparoscopy, which unlike in case of cholecystectomy, faced quite resistance and still has not become the treatment of choice. What followed was the reduction in the size and number of ports. Single port laparoscopic appendectomy and Natural Orifice Transluminal Endoscopic Surgery (NOTES) were the further developments. Aim: To evaluate the status of appendectomy in patients with simple appendicitis through the three approaches: Open Appendectomy i.e. OA, Conventional Laparoscopy Appendectomy i.e. CLA and Single Port Laparoscopic Appendectomy (SPLA)/Incision Approach. Materials and Methods: The study was designed as a double blinded randomised controlled trial and included the patients aged 12-50 years who had simple uncomplicated appendicitis and underwent appendectomy over a duration of 18 months. Results: Mean age of patients was 31.27, 27.4 and 27.64 years and female to male ratio was 1.14, 1.5 and 1.33 for OA, CLA and SPLA arm, respectively. Overall duration of presentation was two days and most of the patients were under BMI of 25. The appendix was the first visualized organ in less than half of the total patients and a little over half had adhesions. The most common location of the appendix was paracaecal followed by pelvic. There were very few intraoperative complications like bleeding from appendicular artery and spillage from appendix in one patient who underwent OA. Mean duration of surgery was 65.18 minutes (SPLA>CLA>OA). Surgery took less time in patients with BMI<25 (SPLA>CLA>OA). CLA took substantially less time (49.5 minutes) in patients with BMI=25 (CLA>OA>SPLA). Pain was significantly higher in minimal invasive procedures compared to OA in immediate postoperative period, which settled 4th hour onwards and remained on higher side for patients who underwent OA. Three fourth patients were able to accept orally after six hours. Wound infection rate was low (OA>CLA=SPLA). Patients who underwent OA stayed in hospital for a longer time and resumed their duty much later compared to minimal invasive arm. Scar assessment score and overall satisfaction were not much different among the patients with simple appendicitis of three arms. Cost of treatment was significantly higher for SPLA compared to other treatment arms. Conclusion: In patients with simple uncomplicated appendicitis, OA, CLA and SPLA do not differ much in outcome especially in lean and thin patients.

Assessment of Degree of Difficulty in Laparoscopic Cholecystectomy using Intraoperative Scoring System

Navin Kumar, Shantanu Kumar Sahu, Karamjot Singh Bedi

Introduction: Laparoscopic cholecystectomy is one of the most commonly performed minimally invasive surgery. But in every patient, there are different types of difficulties in performing laparoscopic cholecystectomy and outcome may be different according to the difficulties. Aim: To assess and grade the degree of difficulty in laparoscopic cholecystectomy and their postoperative outcome using intraoperative scoring system devised. Materials and Methods: One hundred three consecutive patients who underwent elective laparoscopic cholecystectomy at Himalayan Institute of Medical Sciences, were included in the study. Inclusion criteria was all the cases of elective laparoscopic cholecystectomy and exclusion criteria was cases in which directly open cholecystectomy was performed. Intraoperative findings were assessed on the basis of five key aspects which includes: 1) Gallbladder appearance and amount of adhesions; 2) Degree of distension/ contraction of the gallbladder; 3) Ease of access; 4) Local/septic complications; and 5) Time taken to identify the cystic artery and duct. Results: Total 103 patients of laparoscopic cholecystectomy were included in this study. The severity score was between 2-4 in 63 (61.16%) patients and between 5-7 in 20 (19.41%) patients. Mild to moderate degree of difficulty was encountered in 80 (77.66%), severe degree in 20 (19.41%) and extreme degree of difficulty in 03 (2.91%) patients in performing cholecystectomy and conversion to open surgery were done in 08 (7.76%) patients with score between 6 to 8. Conclusion: This scoring system is useful and reliable. If the intraoperative severity score is more, the severity of cholecystitis increases and then it is more difficult to perform laparoscopic cholecystectomy.

Study of Faculty Viewpoints on Challenges and Factors Influencing Curriculum Development/Revision

Deepa Bhat, K Pushpalatha, Praveen Kulkarni

Introduction: Curriculum Development (CD) is an on-going process and not just a product. It must be responsive to changing values and expectations in education if it has to remain useful. Aim: To investigate the perspectives of educators on challenges and factors affecting the curriculum development/revision in health profession education courses. Materials and Methods: Mixed method approach was used for data collection. The faculties involved in curriculum development/revision were administered structured validated questionnaire (n=8), in depth interviews (n=3) and focus group discussion (n=3). Rigor was ensured through triangulation of data. The questionnaire data was analysed using descriptive statistics. Results: Faculties opined that 87.5% of courses are running successfully, 75% developed curriculum as team, 50% expressed that all stake holders were involved and 75% CD process did not turn out to be an organised approach. Needs assessment was not done in every course and some faculties did not have prior experience in CD. Time allotted was just sufficient and planning was fair. The allocation of finance and resources were just adequate. Team work and cooperation followed by qualified expert panel were the leading facilitating factors whereas lack of awareness on steps involved in CD and infrastructure were the significant hindering contributors. About 87.5% expressed their concern that addition of new courses affected their basic course they had to teach. Global requirements were not taken into account in several courses but reasonable number of courses was adequately monitored. Conclusion: Formal training of faculty in CD must be made mandatory in any health profession education. Understanding the facilitating and hindering factors with systematic monitoring of each step would impact the outcome of a program.

Assessment of Efficacy of Transforaminal Epidural Steroid Injection for Management of Low Back Pain with Unilateral Radiculopathy in Industrial Workers: A Randomized Control Trial

Piyali Mondal, Subrata Goswami, Subhadeep Basak

Introduction: Disability related to chronic Low Back Pain (LBP) is a multi-factorial phenomenon, associated with high social and health costs, with a prevalence ranging from 11 to 76%. Significant and long-lasting pain relief can be achieved with transforaminal epidural steroid injection. Surgery is indicated for those patients with progressive neurological deficits or severe LBP refractory to conservative measures. Aim: To evaluate the efficacy of transforaminal epidural steroid injection through pelvic angle measurement, pain and disability measurements in patients with LBP and radiculopathy. Materials and Methods: This prospective randomized controlled study was conducted in Department of Pain in ESI institute of pain management for the industrial workers at Kolkata, India between October 2015 and September 2016. Sixty patients aged between 18 to 60 years, who attended pain clinic with complaints of LBP with unilateral radiculopathy due to lumber disc herniation were included in this trial. Patients were divided into 2 groups (30 patients in each group); Group I: Test group received single transforaminal epidural steroid injection with deposteroid (20 mg) and 0.25% bupivacaine (total 2 ml) together with oral medications and exercises at day 0. Group II: Control group received only medications and exercises on day 0/visit 1. Each patient was followed up for one month at visit 2. Each patient was assessed with Numeric Rating Scale (NRS) for pain intensity and modified Oswestry Disability Index (ODI) for measurement for disability and pelvic angle measurement on affected side. Results: During study period, 60 confirmed patients were included in the analysis. NRS for pain intensity measurement between visit 1(V1) and 2 (V2), showed significant improvement (p-value is < 0.001) in group I. ODI scores between 2 visits showed better outcome in group I. Pelvic angle measurement of affected limb on second visit in both groups as compared to first visit, showed significant improvement, but changes are more evident in group I than group II. Conclusion: Transforaminal epidural injection not only decreases pain and disability due to pain significantly but also decreases pelvic angulations significantly after one month in lumber disc herniation with unilateral radiculopathy.

Menstrual Disorders from Puberty to Early Adult Age: A Cross-Sectional Survey

Krupa Hitesh Shah, Anjum Afsha, Jyoti Bali, Shashikala Bhat

Introduction: A female encounters various menstrual disorders from puberty to menopause. We evaluated menstrual disturbances in post-menarche age and young adult age. Aim: To know the prevalence and impact of menstrual abnormalities at early adolescent and young adult age and to evaluate course of disorders identified at early adolescent age. Materials and Methods: A cross-sectional survey was carried out through self-administered questionnaire on 367 consented students at Melaka Manipal Medical College at Manipal, during December 2015- April 2016. Data were analysed by Statistical Package for the Social Sciences (SPSS) 16.0 software. Results: Prevalence and pattern of menstrual disorders at early adolescent and at young adult age were noted. The mean age of menarche was 12.1 ±1.1 years. Menorrhagia was the most frequent (14.7% and 11.7%) and polymenorrhea (7.6 % and 6%) was least frequent menstrual disorder at adolescent age and young adult age respectively. Resolution of pubertal menstrual disorders was observed in all disorders, but noticed highest in oligomenorrhea (91%), (p-value <0.05). Prevalence of menstrual related disorder like dysmenorrhea was 88.7% at adolescent age and 67.6% at the young adult age. It was statistically significant reduction. Hindrance in academic performance and social behavior was noted more at young adult age, which was in 23.9% and 46.7% respectively (p-value <0.05). Conclusion: The most prevalent menstrual abnormality was menorrhagia at the early adolescent and the young adult age. Associated the most prevalent menstrual related symptoms were dysmenorrhea at early adolescent age, and premenstrual symptom at the young adult age. The study demonstrates the natural course (decreasing prevalence) of all menstrual disorders from early adolescent to young adult age.

Predictive Role of Proteinuria in Urinary Tract Infection

Introduction: Urine culture is considered as holy grail in diagnosis of Urinary Tract Infection (UTI). However, the significance of preliminary urinalysis cannot be neglected. Aim: To evaluate proteinuria as a predictor of UTI. Materials and Methods: This study was conducted at the Department of Microbiology, Dr. Baba Saheb Ambedkar Hospital, New Delhi, India, over a period of three months (April 2015 to June 2015). Urine specimens from clinically suspected cases of UTI were analysed microscopically for pyuria and by reagent strip test for albuminuria. The results were correlated with urine culture findings. Antimicrobial resistance for various antimicrobials was compared among proteinuria positive and negative cases. Statistical analysis was done by Fisher’sexact test and p-value was calculated. A p-value =0.05 was considered significant. Results: A total of 369 urine samples received for both routine microscopy and culture, out of which 73 were proteinuria positive. Out of these 73 samples, 32 were culture positive while 41 were culture negative. Among culture positive, 62.5% patients were symptomatic (20/32) while 37.5% were asymptomatic (12/32). Their age ranged from five months to 83 years. Male to female ratio was 1:1.5. Association between culture positivity and proteinuria was statistically significant (p<0.001) with 43.8% positive predictive value. Pyuria was observed in 42.5% cases. Out of 296 proteinuria negative samples, 36 were culture positive. ß-lactam antibiotic resistance among proteinuria positive cases and chloramphenicol resistance among proteinuria negative cases was significantly high. Conclusion: Proteinuria as a urinalysis parameter may have good predictive power combined with the clinical presentation to diagnose UTI.

Platelet Indices and Basic Coagulation Profile of Type 2 Diabetic Patients undergoing Haemodialysis in Rural Population

H. Pahim, Supreetha Megalamane

Introduction: Diabetes mellitus is rapidly growing and almost becoming epidemic, with currently 285 million people with diabetes worldwide. Chronic Kidney Disease (CKD) is evolving to be an important global disease, with diabetes playing a pivotal role behind this rapid outburst of CKD incidence. Aim: To evaluate platelet indices and to study the coagulation profile in haemodialysis patients having Type 2 diabetes with CKD and diabetic patients without CKD. Materials and Methods: This prospective study was conducted from March to December 2016 for 10 months. Two groups of patients were recruited. The first group (study group) consisted of 80 patients clinically diagnosed as CKD with Type 2 diabetes who were on haemodialysis treatment. The second group (controls) consisted of 80 cases diagnosed with Type 2 diabetes but without CKD, coming for routine checkups. Results: Male predominance was seen in both groups. The red blood cells and leukocyte counts were within the reference values and showed no statistical difference between the groups. Haemoglobin was slightly lowered in study group than controls. Although, platelet counts were similar between the groups, there was an increased in Mean Platelet Volume (MPV) in study group 9.84±2.28% and controls 6.59±1.69% with p-value 0.002 significant. Also, increased PDW in patient’s 17.93±2.79% and controls 15.15±1.39% with p-value 0.005 significant. Prothrombin Time (PT) and Activated Thromboplastin Time (APTT) both were increased in patients. Conclusion: Our study concluded that platelet indices play a crucial role in patients having diabetes with CKD. Basic coagulation profile aids in predicting the long term complications in such patients. Haemodialysis, in these patients have more advantageous effect with few preventable factors, which can be overcome with monitoring platelet indices and coagulation profile.

Exposure Keratopathy: Prophylaxis and Impact of Eye Care Education Programme in ICU Patients

Wasea Narmawala, Harsha Chetan Jani

Introduction: Sedated and ventilated patients are more prone to develop exposure keratopathy. Eye care is gaining emphasis as a part of critical care for its prevention. Aim: To study the impact of education programme among ICU staff to prevent exposure keratopathy in Intensive Care Unit (ICU) patients at a tertiary care hospital. Materials and Methods: This prospective study was conducted on the patients admitted in Medicine, Surgical and Paediatric ICU at a tertiary care hospital. The medical staff were educated for the effects of sedation and ventilation on eyes. Patients were taken from all ICUs at different time periods before and after training. The pre training group consisted of 89 patients from October 2014 to February 2015 whereas the post training group had 57 patients from April 2015 to August 2015. Patients' demographic details along with lid position, conjunctiva and corneal examination were recorded and analysed. Results: The incidence of exposure keratopathy was 40% in total 146 patients included in the present study. The incidence of exposure keratopathy decreased from 44% to 33% after the eye care training given to the ICU staff. The maximum incidence of exposure keratopathy was found in Paediatric ICU i.e., 60%. The risk factors like lid position, conjuctival oedema, sedation level and poor outcome of patient were associated with the development of exposure keratopathy. Conclusion: The training given to the staff of ICUs reduced the incidence of exposure keratopathy by 10%. Thus the importance of an eye care algorithm is highlighted.

Role of Papanicolaou Smear in the Diagnosis of Pathologic Flora in Asymptomatic Patients in Rural Health Care Set-Up

Siona Sabu, Deepak M. Nayak, Suma Nair, Ranjitha Shetty

Introduction: The infections of female genital tract, especially the cervix are asymptomatic in presentation and pose a diagnostic challenge. Vaginal infections can lead to cytoplasmic and nuclear abnormalities in the epithelial cells. Additionally, these infections could augur an inflammatory response of varying nature. The most common flora include Candida albicans, Gardnerella vaginalis, Trichomonas vaginalis, Human Papilloma Virus (HPV), Human Herpes Virus (HHV) and Actinomyces sp. Aim: This study seeks to measure the role of Papanicolaou smear in detection of pathologic flora: Candida albicans, Gardnerella vaginalis, Trichomonas vaginalis, HPV, HHV and Actinomyces; in a rural health care set up amongst women in the reproductive and menopausal age group. Materials and Methods: A retrospective study of cervical smears by Papanicolaou method, over a 14 month period was carried out in a tertiary care centre including a total number of 150 patients. Results: Of the total of 150 samples examined, Candida species was the most frequently detected (8.7%) followed by Trichomonas vaginalis (5.3%) and Gardnerella vaginalis species (4.7%). HPV-induced changes were noted in a mere 2% of cases. Actinomyces species was noted in less than 1% of cases. Conclusion: The Papanicolaou test for examining cervical smear has definite uses in detecting vaginal microorganisms. Apart from detection of the usual pathogenic flora, the test has utility in defining the degree of inflammation and additional reparative changes.

Morphometric and Histological Study of Osteophytes in Human Cadaveric Lumbar Vertebrae

Ashwini Aithal Padur, Naveen Kumar, Swamy Ravindra Shanthakumar, Arijit Bishnu

Introduction: Osteophytes are bony outgrowth on the vertebral column. Its prevalence in the lumbar region and clinical importance mandates to conduct a detailed study of lumbar osteophytes in the cadaveric vertebral column. Aim: The present study was conducted to study the detailed features of lumbar osteophytes and document its prevalence, morphometric and histological structure. Materials and Methods: This was an observational study in which frequency of occurrence of lumbar osteophytes was studied in 40 cadaveric vertebral columns over a period of four years. The lumbar part of the vertebral columns was dissected and examined meticulously. The occurrence of lumbar osteophytes with their vertebral levels and morphometric measurements were recorded. A small excision of the osteophyte was processed histologically to study its microscopic details using routine Haematoxylin & Eosin stain. Results: Lumbar osteophytes were present in 4 specimens (10%). They were mostly found on the right side of the vertebral bodies. Histopathological examination of the osteophytes revealed degenerative osteophytic cartilage and fibrillation overlying the trabecular bone enclosing fatty marrow spaces containing haematopoietic elements. Conclusion: Lumbar osteophytes were found in 10% of the specimens studied and it is assumed that these cadaveric reports deserve further attention given their potential clinical implications. Knowledge regarding occurrence and incidence of osteophytes is essential for management of common degenerative changes of the vertebral column.

Modification of First-line Antiretroviral Therapy in Treatment-naive, HIV Positive Patients

Introduction: Modification of initial Antiretroviral Therapy (ART) program is an important issue in HIV infected patients as the number of ART regimens available is limited. Hence, there is a need to understand the factors that affect modification and therefore, the durability of the initial antiretroviral regimen. Aim: To study the type of modification of first line ART in treatment-naive HIV positive patients and factors influencing it. Materials and Methods: A retrospective observational study was carried out in the HIV clinic of a tertiary care hospital, using data obtained from the case records of the subjects who were initiated on ART between January 2012 to December 2014. Data on patient baseline characteristics, proportion of patients who required modification, type and time of modification was collected. The determinants of time to modification were analysed using Chi-square test. Binomial logistic regression was utilized to assess independent risk factors for change in regimen. Results: Out of 200 case records analysed, 54 patients had to undergo a modification in their initial regimen. The mean age of patients was 44.68 ± 11.31 years. Majority of the patients were males. The most common reason for modification was Adverse Drug Reactions (ADRs) (79.63%) followed by treatment failure (9.25%). In 85.18% cases, modification involved substitution. Occurrence of ADRs and non-tenofovir based first-line regimens were associated with higher likelihood of substitution in regimen (p<0.05). The median time (IQR) to modification was 173 (152.25, 293.50) days. Conclusion: ADRs and the use of non-tenofovir based regimens resulted in significantly higher rates of modification of antiretroviral therapy. There should be monitoring of patients on ART to detect ADRs at the earliest and to obtain increased use of single tablet containing tenofovir based regimen to improve durability of first line regimens.

Effectiveness and Safety of Heparinized Saline versus Normal Saline in Maintaining Patency of Peripheral Intravenous Locks in Neonates at a Tertiary Care Hospital

Introduction: Heparinized saline is usually used as a regular flush solution to prevent occlusion of peripheral intravenous locks in neonates but the risks associated with the use of heparin cannot be ignored in these patients. Aim: To assess and compare the efficacy and safety of Heparinized Saline (HS) and Normal Saline (NS) flush solution in neonates. Materials and Methods: A prospective study was conducted for a period of 12 months using 1 unit/ml HS and NS 0.9% solution. The mean number of catheters removed due to nonelective reasons was calculated to evaluate the effectiveness of flushing solutions. To evaluate the safety, the reason for catheter removal was noted and platelet nadir was used to assess the thrombocytopenia. Poisson regression, Pearson Chi-square test and stratified analysis were conducted. Results: Data were analysed from 100 neonates. We found no significant difference between HS and NS flushes in neonates in maintaining the patency of 24 gauge peripheral intravenous locks {rate ratio= 1.12, p-value =0.584}. Gestational age, body weight and site of insertion did not significantly affect the patency. The reasons for removal of catheter were similar in both the groups and majority were due to non-elective reasons. HS group reported more cases of thrombocytopenia that was attributed to sepsis. Conclusion: Standard NS can be considered as an alternative flush in neonates as both the solutions were found to be equally efficacious and safe in our patient group. Factors like gestational age, body weight and site of insertion did not significantly affect the patency.

Effect of Maternal Diet Diversity and Physical Activity on Neonatal Birth Weight: A Study from Urban Slums of Mumbai

Komal Manerkar, Devaki Gokhale

Introduction: India has the highest prevalence of low birth weight babies. Geographical variation and level of physical activity can influence diet diversity and maternal nutritional status which in turn influences the birth weight of the neonate. Mumbai is a large city comprising of slums in suburbs depicting diet diversity amongst populations. Aim: To study the maternal diet diversity, physical activity and its effect on birth weight of the neonates in urban slums of Mumbai. Materials and Methods: A six month follow-up study was carried out in three maternity homes representing different geographical areas of Western, Central and Southern Mumbai. A total number of 131 pregnant women were selected using simple random sampling. Final sample size was n=121 after follow-up loss of 9 and 1 miscarriage. Maternal anthropometric, socio-demographic, physical activity and diet diversity data was collected using structured questionnaires through personal interview after taking written informed consent. Birth weight of the neonate was recorded. Chi-Square, Correlation, ANOVA was used to test the significance. A p-value of <0.05 was considered to be significant. Results: Nineteen (15.7%) were low birth weight (LBW) infants, 102 (84.3%) had normal weight. There was a significant association between place of Antenatal Clinic (ANC) visit and diet diversity score and its subsequent effect on birth weight (p<0.05). Geographic variation had an impact on diet diversity scores which in turn affected the birth weight of neonates. Women who delivered low birth weight babies were more involved in household domestic activities (p<0.05) compared to those women who delivered normal weight babies. Conclusion: Diet diversity and physical activity influence the birth weight of neonates across different geographic locations. Despite of ample interventions available to prevent maternal malnutrition, the incidence of LBW was not decreased. Thus, this issue needs to be addressed at the national level to curb the problem of low birth weight especially among the urban slums that are rapidly encroaching.

Raman Microspectrometry: An Alternative Method of Age Estimation from Dentin and Cementum

Introduction: Raman spectroscopy is simple, quick, sensitive and non destructive form of tissue examination that provides vital data about the structure, molecular composition and interactions within a sample. The human hard tissues like teeth and bone are able to resist decay for long even after other tissues are lost, thus have valuable forensic importance. Aim: To ascertain the known age of the teeth by analysing dentin and cementum using Raman microspectrometry and assess the accuracy of age estimation by comparison of dentin with cementum. Materials and Methods: The sound permanent extracted tooth specimens (40) of age ranging between 12-74 years were collected and sectioned longitudinally and different dentinal and cemental areas were analysed by Raman microspectrometry. The spectra of dentin and cementum were used as predictors of age estimation. For each sample, ratios were obtained for dentin and cementum areas, and Pearson’s correlation coefficient was calculated. Ratios, which had a correlation coefficient greater than 0.40 were used for further statistical analysis. This led to selection of ratios only for dentin areas, and it allowed us to develop a regression formula. Partial Least Square (PLS) regression method was used for computing our model. Results: A significant correlation was observed between the actual chronological age and predicted age of the individual using dentinal areas of the tooth. A closest to the estimated result was achieved, with an error of three years between predicted and actual chorological age. Conclusion: Raman microspectrometry may be considered as an alternative to the conventional method of age estimation and contribute to the identification of individuals.

Nutritional Intake in Low Body Mass Index (BMI) Males with Type 1 Diabetes and Fibrocalcific Pancreatic Diabetes: What are the Unmet Needs? A Cross-Sectional Study from a South Indian Tertiary Care Hospital

Introduction: There is paucity of data on the nutritional intake in low Body Mass Index (BMI) Asian Indians with diabetes. Aim: To study the difference in the nutrient intake pattern in low-BMI Type 1 Diabetes Mellitus (T1DM) and Fibrocalcific Pancreatic Diabetes (FCPD) patients. Materials and Methods: This cross-sectional study consisted of T1DM (n=40) and FCPD (n=20) male patients with similar BMI. Nutritional data was collected using the 24 hour recall method and food diaries. Fasting blood samples were analysed for lipid profile, serum creatinine, glycosylated haemoglobin, albumin, calcium and vitamin D. Stool samples were analysed for pancreatic elastase. Percentage analysis, Independent sample t-test and Pearson coefficient correlation were used to analyse the data. A p-value<0.05 was considered as statistically significant. Results: The FCPD patients, on biochemical analysis, had significantly lower vitamin D levels compared to the T1DM group (p=0.035). However, haemoglobin, triglycerides, low density lipoproteins, creatinine, albumin and calcium were similar between the groups. In the nutrient data, FCPD patients had a significant higher intake of fat (p=0.039), fibre (p<0.001), calcium (p=0.047), phosphorous (p=0.035), and niacin (p=0.001) and calories from fat (p=0.047). The T1DM group had a significantly higher intake of thiamine (p=0.047) and carbohydrates (p=0.014). Conclusion: T1DM and FCPD groups have similar dietary pattern deficit in fibre, calories, macronutrients and micronutrients. Malabsorption and poor glycaemic control in FCPD patients can be attributed to a higher dietary fat intake. A balanced diet can ensure better glycaemic control.

Normative Values of Physical Fitness Test in the Elderly: A Community Based Study in an Urban Population in Northeast India

Prasanta Kumar Bhattacharya, Kuldeep Deka, Aakash Roy, Hiranya Saikia

Introduction: Physical inactivity exposes elderly people to higher risk of diseases. Assessing their functional fitness using fitness assessment tools like Senior Fitness Test (SFT) is helpful in geriatric care. Determination of normative values of SFT increases its interpretability of interindividual and intergroup performances scores and usefulness. Aim: To determine normative values of SFT in geriatric population in an urban community setting. Materials and Methods: A community based prospective study in 400 elderly participants (284 men, 116 women), aged =65 years, selected by multistage random sampling from 60 municipal wards of Guwahati city in Northeast India. Descriptive statistics, percentiles, univariate Analysis of Variance (ANOVA) and Bonferroni correction methods were used. A p-value <0.05 was considered significant. Results: Mean ages in males and females were 69.80±3.82 and 67.25±2.57 years. Mean height, weight and BMI in males and females respectively were 165.61±5.36 cm and 161.03±7.93 cm; 63.63±5.99 kg and 55.54±6.74 kg; 23.2±2.03 kg/m2 and 21.5±3.42 kg/m2. Males aged 65-69 years had highest BMI (23.4±2.11 kg/m2) while those =80 had lowest (21.8±1.30 kg/m2). Females aged 70-74 years had highest BMI (23.3±3.50 kg/m2) while 65-69 years (21.3±3.39 kg/m2) had lowest. ‘Arm-curl’ test showed maximum values in 70-79 year and 65-69 year age-groups in males and females respectively (11.4±3.89; 14.5±4.63). In ‘chair-stand’ test, maximum values were in 65-69 year for both sexes (males=15.2±4.64; females=13.6±4.26 respectively). In ‘back-scratch’ and ‘chair-sit and reach’ tests, maximum values were found in age-groups 70-74 and 65-69 in males and females respectively (10.5±9.11 and 13.4±8.91; 9.8±7.28 and -8.4±6.92). In ‘8-foot up-and-go’ test, maximum time to perform in males and females were in =80 and 75-79 year groups respectively (13.9±4.11; 20.3±0). In both sexes, maximum values of ‘2-minute step up’ test was found in 65-69 year age groups (male=67.4±21.9; female=62.7±16.9). In both sexes, changes of performance scores with age were observed in all tests, with maximum changes observed in ‘back-scratch’ test (male=131.4%, female= 157%). Conclusion: The normative values obtained for SFT of each test score can be applied in aged population of similar settings to assess physical fitness.

Apolipoproteins an Early and Better Diagnostic Marker for Diabetic Retinopathy

Introduction: Diabetic Retinopathy (DR) is one of the most common microvascular complications of diabetes and is the leading cause of blindness and visual impairment worldwide. Dyslipidemia is the major biochemical alteration in diabetes mellitus. Some studies have shown that traditional serum lipids are positively associated with the risk of DR whereas other studies have not consistently shown similar associations. Aim: To compare the association of DR with the serum levels of Apo- A1, Apo B, Apo B/Apo-A1 ratio and with traditional lipid profile in Type 2 Diabetes Mellitus (T2D) patients. Materials and Methods: The present study was a case-control study carried out with 100 T2D patients in ophthalmology department, Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry from June 2016- December 2016. Fasting blood sugar and post-prandial blood sugar were estimated by GODPOD method and HbA1C by turbidimetric method. Serum lipid profile was assessed by autoanalyser. Serum Apo-A1 and Apo-B were measured using fully automated nephelometry. Apo-B/A1 ratio was calculated. Retinopathy was graded from the digital retinal photographs according to Early Treatment of Diabetic Retinopathy Study (ETDRS) criteria. Results: Serum Apo-A1 was significantly decreased with severity of DR levels (p<0.001). Increasing levels of Apo B (p<0.001) and Apo B-to-Apo-A1 ratio (p<0.001) were found and strongly associated with severity of DR. HDL cholesterol levels were inversely associated with the severity of DR (p<0.05). Triglyceride level was significantly associated with the increased incidence and severity of DR in T2D patients and not LDL or total cholesterol. Conclusion: There is strong association between serum apolipoproteins (Apo-A1, Apo B, and the ApoB/Apo-A1 ratio) and the progression and severity of DR in T2D patients than traditional lipids. Although apolipoprotein measurements have not been widely used in clinical practice, considering its protective mechanism further studies are needed to unravel the underlying mechanism in order to decrease the prevalence and to offer comprehensive eye care.

Study on Serum Lipoprotein Profile of Exclusive Breast Fed, Mixed Fed and Formula Fed Preterm Infants

Vineet Jaiswal, Anita Mehta, Komal Prasad Kushwaha

Introduction: Breast feeding is protective for atherosclerotic cardiovascular disease, obesity, Diabetes Mellitus (DM) and hypertension. Serum lipoprotein is principal risk factor for atherosclerosis. There is growing evidence that risk of Coronary Heart Disease (CHD) begins to emerge from infancy. Lipoprotein level is affected by different feeding pattern during infancy. Aim: To compare serum lipoprotein profile of exclusively breast fed, mixed fed and formula fed preterm infant. Materials and Methods: A total of two fifty preterm newborn were recruited at birth and divided into three groups. Group A were Exclusively Breast Fed (EBF), Group B were Mixed Fed (MF) and Group C were Formula/bovine milk Fed (FF) infants. Preterm newborns with severe sepsis, hypoglycemia, Hypoxic Ischemic Encephalopathy (HIE) stage II and III, meconium stained amniotic fluid, pathological jaundice, Hyaline Membrane Disease (HMD), less than 28 weeks gestation, with major congenital anomaly and infants born to mothers with DM, gestational diabetes, hypertension, pre-eclampsia, eclampsia or on long term medications were excluded from the study. Lipoprotein profile estimation was done at four weeks and again at 16 weeks of age. Results: At four weeks of age, Total Cholesterol (TC), Triglyceride (TG), Low Density Lipoprotein (LDL) and Very Low Density Lipoprotein (VLDL) were higher in EBF infants as compared to MF and FF infants. For TC, difference was significant between EBF vs. MF (p<0.001), EBF vs. FF (p<0.001) and MF vs. FF (p=0.005) infants. At 16 weeks also, TC and HDL were higher in EBF infants as compared to MF and FF infants. For TC, this difference was significant between EBF vs. MF (p<0.001) and EBF vs. FF (p<0.001) infants. When infants were followed up to 16 weeks of age, TC and LDL level fell significantly (p<0.001) in EBF and MF group, a significant (p<0.05) rise for TC was seen in FF group. At 16 weeks of age, there was no significant rise in HDL in EBF infants, but significant fall was seen in MF (p=0.0001) and in FF (p=0.001) infants. Conclusion: Breastfeeding, even MF is beneficial in preterm infants as compared to FF in terms of lipoprotein profile which is protective for atherosclerosis.

Assessment of Anxiety and Depression among Dental Practitioners-An Exploratory Cross-sectional Study

Introduction: Dentists face a great deal of professional stress, in the dental school as well as in clinical practice. Their personal, as well as professional lives, get affected negatively by the stress and poor mental health. Aim: To assess the prevalence of anxiety and depression among dentists practicing in Ghaziabad city of Uttar Pradesh, India. Materials and Methods: A cross-sectional study was carried out among 242 registered dentists in Ghaziabad city. Data regarding demographic, work-related characteristic, lifestyle and self-reported physical and mental status was collected. Mental status was measured through prevalidated questionnaire Zung Self-Rating Anxiety Scale (SAS) and the Zung Self- Rating Depression Scale (SDS). Data were analysed using Statistical Package for Social Sciences (SPSS) 16.0 (SPSS Inc., Chicago, IL, USA) and descriptive statistics and Pearson Chi-square test were used (p< 0.05). Results: Of the 242 dentists, only one dentist did not respond to the questionnaire thus generating the response rate of 99.5%. The prevalence of anxiety and depression among dentist was found to be 44.4% and 36.9% respectively. Almost all sociodemographic (except gender), work-related characteristics (except frequency of conflicts and working hours per week), lifestyle were significantly associated with anxiety symptoms (p< 0.05) and demographic characteristics like marital status, years of experience, lifestyle, income per month, additional source of income were significantly also associated with depression (p< 0.05). Conclusion: Dentists are prone to stress which leads to further anxiety and depression. Stress coping strategies should be included in dental education curriculum to tackle these forms of tensions which indirectly improves their professional abilities and personal life.

Efficacy of Calendula officinalis Extract (Marigold Flower) as an Antimicrobial Agent against Oral Microbes: An Invitro Study in Comparison with Chlorhexidine Digluconate

Introduction: Calendula officinalis is a member of the family Asteraceae containing flavonoids, and essential oils etc. It is known to be effective against certain gram negative and gram positive clinical pathogens. Incorporating natural plant extracts into periodontal antiinfective therapy is a wise alternative in light of rampant antibiotic resistance amongst periodontal pathogens. Aim: To assess the antimicrobial efficacy of C.officinalis against five oral microbes, as compared to gold standard chlorhexidine digluconate. Materials and Methods: The inhibitory action of the two test agents, chlorhexidine digluconate 0.2% and C.officinalis raw extract was assessed using tests to determine minimum inhibitory concentration, minimum bactericidal concentration, and inhibition zones using agar diffusion method. Time kill curve method was used to assess the time in which drug was inhibitive against five oral microbes namely, A.actinomycetemcomitans, P.gingivalis, P.intermedia, F.nucelatum and S.mutans. Results: P.gingivalis and P.intermedia were sensitive to C.officinalis, while F.nucleatum and A.actinomycetemcomitans exhibited reduced sensitivity. C.officinalis was highly effective against S.mutans (3.12 µg/mL), its inhibitory concentration close to that of chlorhexidine digluconate 0.2% (6.25 µg/mL). C.officinalis took longer than chlorhexidine digluconate 0.2% to exhibit lethality against all the organisms that it inhibited. Chlorhexidine exhibited immediate lethality (zero minute) against S.mutans while it inhibited the other microbes at 5 minutes. A.actinomycetemcomitans and P.intermedia were inhibited by C.officinalis at 30 minutes, S.mutans at 10 minutes. F.nucleatum was inhibited by C.officinalis at 2 hours and no inhibition of P.gingivalis by C.officinalis was observed. Conclusion: C.officinalis showed antimicrobial efficacy against most organisms tested, yet its efficacy was not on par with chlorhexidine digluconate 0.2%. However, its performance could still be used as evidence to spur on further human clinical trials, in patients undergoing phase I or IV therapies.

Estimation of Height from Arm Span in 6-11 Years Children in Odisha, India

Snigdha Prava Mishra, Himel Mondal, Shaikat Mondal

Introduction: Standing height is an important anthropometric parameter to track longitudinal growth, to estimate body fatness and to calculate energy requirement. Measurement of height may be difficult in children who cannot stand. Aim: To establish regression equation for estimation of height from arm span in children. To check comparative relevancy of this equation with fixed height-to-arm span ratio (HAR) for estimation of height. Materials and Methods: A cross-sectional study was conducted with 6-11 years school children (n=1465, Boys=774, Girls=691) in state of Odisha, India. Height was measured by portable stadiometer and arm span was measured by fiberglass measuring tape to nearest 0.1 cm. Pearson correlation and regression analysis was carried out between height and arm span data. p<0.05 (two tail) was considered statistically significant. Results: Mean height and arm span in boys (124.16±8.74 cm and 125.57±10.43 cm respectively) was significantly more (p<0.001) than height and arm span in girls (121.18±10.37 cm and 121.50±11.68 cm respectively). Mean HAR was 0.9942±0.0279. Correlation between height and arm span in boys was r = 0.94 (p<0.001) and in girls was r = 0.96 (p<0.001). Overall correlation coefficient was r = 0.95 (p<0.001). Regression equation for estimation of height from arm span was established: Height (cm) = 0.8192 * arm span (cm) + 21.46. Conclusion: Height in children of 6-11 years showed strong positive correlation with arm span. Regression equation established from this study can be used to estimate height from arm span. This estimation is more reliable than estimation of height from HAR.

Clinical Profile of Tubercular Empyema with Special Reference to Diagnostic Role of Cartridge Based Nucleic Acid Amplification test (CBNAAT)

Subhasis Mukherjee, Shabana Begum, Somenath Kundu, Subhra Mitra

Introduction: Tuberculosis is continuing to be a significant burden in the developing world and tubercular empyema thoracis still remains a common entity with significant morbidity and mortality. Clinical course of tubercular empyema is often accompanied by bronchopleural fistula, concomitant pulmonary tuberculosis and unfavourable outcome. Aim: A prospective study was conducted to assess the clinical presentation of tubercular empyema with special emphasis on evaluating diagnostic role of Cartridge Based Nucleic Acid Amplification Test (CBNAAT) and outcome issues. Materials and Methods: A prospective study was carried out consisting of adult cases of tubercular empyema admitted in the department of Respiratory Medicine in a teaching hospital in eastern India over a period of 18 months. Tubercular empyema cases were analysed on the basis of clinicoradiological features, diagnostic challenges with special interest on role of newer molecular diagnostic test like CBNAAT, management and outcome issues. Results: A total of 40 cases of tubercular empyema were encountered during the study period. Tubercular empyema frequently affected young population (mean age 31.5 years) with a male preponderance (72.5%). Thirty five (87.5%) patients had a duration of illness of more than one month on presentation. There was frequent accompaniment of concomitant pulmonary tuberculosis (60%) and bronchopleural fistula (42.5%). Sputum smear for acid fast bacilli (55%) and CBNAAT (57.5%) were positive in good number of cases. Pleural fluid smear for acid fast bacilli and CBNAAT yield were also very high (72.5% and 92.5% respectively). Pleural fluid CBNAAT had a sensitivity of 92.5% (95% CI: 79.61-98.43) and specificity of 100% (95% CI: 93.51-100) in diagnosis of tubercular empyema. Mean duration of Intercostal tube drainage was 45.6 days and eighteen patients needed decortication. Conclusion: Tubercular empyema is a disease affecting the young population most commonly, has a chronicity in clinical course and is commonly complicated by presence of associated pulmonary tuberculosis, bronchopleural fistula and unfavourable outcome. Pleural fluid and sputum CBNAAT have good yield in diagnosis.

Role of Aspirin in Patients with Bladder Cancer Receiving Intravesical Bacillus Calmette-Guerin: A Prospective, Observational Study

Introduction: High-Risk Non-Muscle Invasive Bladder Cancers (HR NMIBC) are prone to recur and progress even with intravesical Bacillus Calmette-Guerin (BCG) therapy. Aim: To investigate the role of aspirin in prevention of early recurrence and progression in patients with HR NMIBC receiving intravesical BCG. Materials and Methods: This was a prospective, single centre, observational study that included patients with HR NMIBC {Ta, T1 or Carcinoma in situ (CIS)} from February 2015 to January 2017. Patients were screened for eligibility based on clinical, radiological and risk factor profile assessment, history of treatment with aspirin and medical records. Eligible patients were grouped into Group 1 and Group 2 based on aspirin (for minimum of three months) or non-aspirin consumption respectively. Both groups received similar induction, maintenance and intravesical BCG therapy; according to Southwest Oncology Group (SWOG) protocol. Follow up cystoscopy was done every three months for up to two years. Results: A total of 152 patients were screened and 103 patients were included in the study (Group 1, n=15; Group 2, n=88). Binary progression analysis revealed that focality was the only significant predictor variable for the recurrence (OR, 5.064; p=0.001). Aspirin intake was not related to stage (p=0.595), grade (p=0.558), recurrence (p=0.508) and progression (p=0.621) of the tumour. Kaplan-Meier analysis showed that 12-month recurrence (64.2% versus 64.7%, p=0.566) and progression free survival rate (66.7% versus 57.3%, p=0.640) were same in both groups. Conclusion: Results showed that aspirin does not affect the recurrence and progression of HR NMIBC in patients receiving BCG therapy.

Hypovitaminosis D is Associated with Gestational Diabetes Mellitus

Introduction: Vitamin D deficiency has been shown to cause expression of insulin gene resulting in high insulin synthesis and secretion. It also decreases insulin resistance, thus affecting abnormal glucose metabolism and diabetes. Aim: To estimate total 25-hydroxy vitamin D levels in pregnant women and to find its association with Gestational Diabetes Mellitus (GDM). Materials and Methods: Fifty-four antenatal women were randomly enrolled at 24-28 weeks gestation after conforming to exclusion criteria. Serum vitamin D, two-hour 75 grams glucose and postprandial plasma glucose levels were estimated in all women at the time of enrollment. GDM was diagnosed with plasma glucose level >140 mg/dL (Group A). Rest of the women constituted Group B or control group. They were followed up till delivery. Vitamin D status and fetomaternal outcome was evaluated. Results: Hypovitaminosis D was found in 93% of women. There were 38.8% women (n=21) in GDM group compared to 61.2% (n=33) in control group. Vitamin D was significantly low in Group A than B (p-value 0.004). None of the women in Group A had vitamin D levels of 10 ng/mL and above compared to 37.2% in Group B. Severe vitamin D deficient women (levels <5 ng/mL) had a risk ratio of 5.647 for developing GDM. A negative correlation was observed between vitamin D levels and plasma glucose levels. Conclusion: Hypovitaminosis D was associated with development of GDM.

Comparison of Toxicities Associated with Concomitant Boost and Conventional Fractionated Radiotherapy Regimen in Oral and Oropharyngeal Cancers

Introduction: The prevalence of Head and Neck Cancers (HNC) is very high in the Indian subcontinent. Radiotherapy is an essential modality in the management of HNC. Aim: The aim of the present study was to compare toxicities of two radiotherapy fractionation regimen (conventional fractionation and concomitant boost technique) for the management of HNC. Materials and Methods: A total of 60 patients (n=30 in each arm) were assigned to receive either conventional fractionation or concomitant boost radiotherapy. Toxicities were analysed weekly during the treatment, and one and three month after treatment completion. The radiation therapy oncology group acute radiation morbidity scoring system was used to document the severity. Toxicities assessed were mucositis, skin reactions, dysphagia and xerostomia. Statistical analysis was done by the online Graphpad software using Chi-square test. A value of p<0.05 was considered significant. Results: Overall mean age of the patients was 47.35 years (range 23-70 years). There was a male preponderance in both groups (Group A=73.33%, Group B= 76.6%). Most common primary sub site in Group A was tongue (33.3%) and in Group B was buccal mucosa (50%). On statistical analysis of toxicity comparison during and post treatment completion, no significant difference in toxicity was found between the two arms in terms of mucositis (p=1), skin reactions (p=0.6404), dysphagia (p=0.7906) and xerostomia (p=0.1066). Conclusion: The concomitant boost technique resulted in no statistically significant difference in toxicity as compared to the conventional fractionation with the added advantage of reduced overall treatment time. This may be a favourable schedule for high volume centers.

Comparison of Aorta-sacral Promontory Distance with Age and BMI in Female Patients Undergoing CT

Sneha Mary Varghese, Suresh Sukumar, Abhimanyu Pradhan

Introduction: Sacral colpopexy is the gold standard procedure for pelvic organ prolapse. During sacral colpopexy, various complications such as haemorrhage can occur. Careful dissection of presacral space is essential to minimize complications. Aim: The aim of the study was to compare patient age and Body Mass Index (BMI) with Computed Tomography (CT) measured aortosacral promontory distance. Materials and Methods: From 172 samples data such as age and BMI of female patients aged 18 years and above was collected. Study was performed on patients who underwent Contrast Enhanced Computed Tomography (CECT) scans of abdomen. The obtained data was statistically analyzed using Pearson’s correlation test and Multiple linear regression. Results: The mean age was 56.5 years (range 18-95) and Mean body mass index was 23.25 (range 10.8-35.7). Increase in age is correlated with decrease in Aortosacral Promontory distance (APT) {Pearson’s correlation coefficient (r) is -0.795 between age and APT, p<0.01}, but there is no correlation between BMI and APT (Pearson’s correlation coefficient (r) is - 0.005 between BMI and APT, p>0.01). According to CT measurements aortopromontary distance is decreased in elderly female patients, but no significant changes in BMI and APT. Conclusion: The study showed that as age increases, APT decreases and there is no significant changes in relation to BMI. Therefore, during abdominal sacral colpopexy, the surgeon should be careful and consider the aortopromontary distance in the elder female patients while performing dissection.

HER2 and Helicobacter pylori Status in Resected Gastric Cancers: A Pathological Study of a Gastroenterological Issue

Introduction: Human epidermal growth factor receptor 2 (HER2)/neu is a critical target for gastric carcinoma treatment utilizing trastuzumab. Helicobacter pylori is a well known causative agent of gastric carcinoma. Aim: To study association of HER2/neu expression with the presence of H. pylori infection in resected carcinoma stomach patients. Materials and Methods: A cross-sectional study of 85 gastrectomies received in the department from January 2010 to September 2014 was done. HER2/neu was studied using Immunohistochemistry (IHC) and Giemsa stain was used to detect presence of H. pylori. Chi-square test and Fisher’s exact test were used, to test the correlation between the various parameters. A p-value <0.05 was considered significant. Results: Our study population included 67 (78.8%) males, and 18 (21.2%) females, ranging from 22 to 84 years, mean 57.68±12.12 years. HER-2 expression, graded from 0 to 3± was correlated with location, histologic type, grade, local invasion, metastasis to lymph nodes, TNM tumour staging and H. pylori infection, graded from 0 to 3+ using Giemsa stain. HER2/neu 3+ was observed in intestinal type of gastric cancer (5/55, 9%) only. Scores 2+ and 3+ were more common in H. pylori-negative patients (5/26, 19.2%) than H. pylori-positive patients (4/59, 6.8%) (p=0.02). TNM stage, extent of local invasion and lymph node metastasis in intestinal gastric carcinomas correlated significantly with HER2/neu expression. H. pylori was present in 59 (69.4%) and absent in 26 (30.6%). Conclusion: H. pylori-negative gastric cancer showed significant immunophenotypic HER2/neu overexpression i.e., H. pylori might protect against HER2 overexpression that correlated significantly with higher TNM stages of intestinal-type gastric cancer. In contrast, H. pylori infection correlated significantly with Lymph-Vascular Invasion (LVI) but was pN1/2+, thereby diminishing prognostic importance. H. pylori induced intestinal metaplasia was not significantly associated with intestinal-type gastric cancer.

Three Years Experience of Third Year Undergraduate Medical Students in Different Teaching Learning Methods: A Qualitative Study

Introduction: India is a second largest populous country producing more than sixty thousand doctors every year. Still in India research on teaching learning methods are subtle. To improve the quality of knowledge and skills of medical students, there is a need to analyse the existing teaching learning methods as well as innovating new methods. Aim: To compare the three years experience of third year MBBS (Bachelor of Medicine and Bachelor of Surgery) students in three different teaching learning methods (Tutorials, Integrated Teaching sessions and Routine Lectures). Materials and Methods: Qualitative study was carried out among 60 third year MBBS students in medical college in south India. A semi-structured questionnaire was developed, with the help of literature review and is distributed among 66 students. Six participants excluded due to incomplete information. Questionnaire consisted of totally 16 questions. For the first ten questions answers were captured in Likert scale of one to five (one-poor; five- excellent). Eleventh to sixteenth questions were asked as an open-ended question to mention some positive and negative things about each method. Questions with Likert scale were analysed using Kruskal Wallis H Test and the open ended questions were analysed by thematic analysis. Results: Overall mean rank for Tutorial was 129.03 followed by Integrated Teaching (mean rank 86.33) and Routine Lecture (mean rank 56.14). Students gave better scores for Tutorials in areas such as easily understandable, better attention span and students involvement in the session. Students gave better scoring for Integrated Teaching in areas such as well organized, integration with other departments, ideal usage of audio visual aids and providing detailed information to the students. Drawbacks of Integrated Teaching were failure to attract the students, prolonged sessions (long duration), boring and minimal involvement of students. Lecture classes on the other hand purely depend upon the ability of the faculty. Conclusion: In three years of students experience, when comparing to Routine Lecture and Integrated Teaching, Tutorial was considered as the best teaching learning method by students because of involvement of students, easily understandable, focussed and increased student teachers interaction.

The Role of Job Performance on Career Success and Self-esteem of Staff

Introduction: Human resources are the most valuable assets to any organisation, identifying factors that affect job performance of these resources has become increasingly important. Aim: To determine the relationship between self-esteem and success with job performance in the staff of the Shahrekord University of Medical Sciences (SKUMS) Headquarters, Shahrekord, Iran. Materials and Methods: This descriptive-analytical (correlational) study, based on structural equation modeling, was conducted in 2015. The study population included 240 of the staff of SKUMS Headquarters, Shahrekord, Iran. From these people, 86 were selected by simple random sampling. A questionnaire of demographic characteristics, Paterson job performance, Radsyp career success and Eysenck selfesteem questionnaire were used to evaluate the concepts of job performance, success and self-esteem. The data were analysed using Statistical Package for the Social Sciences (SPSS) version 23.0. Results: A total of 86 out of which 49 were female (57%) and 37 (43%) male, with a mean age of 39.85±7.6 (range 24-55) years. There was no significant relationship between demographic characteristics and job performance, career success and selfesteem. Self-esteem could be predicted positively and career success could be predicted negatively. Job performance and selfesteem had a significant positive correlation relationship (p<0.05). Conclusion: According to the direct relationship between job performance and self-esteem in this study, officials can improve job performance of staff through supporting them and reinforcing their self-esteem and thus providing career success.

Comparison of Normal Resident Flora on the Face of Medical Students who use and who do not use Cosmetics

Udayalaxmi Jeppu, Harsimran Kaur, Shashidhar Kotian

Introduction: Normal flora of the skin plays a beneficial role in preventing the pathogenic organisms from colonizing the skin and causing infection. It is possible that the facial cosmetics may cause a change in the normal flora disrupting its protective function. Aim: To find out the effect of cosmetics, those that are applied on to the face on resident normal flora of the face. Materials and Methods:This was a cross-sectional study involving medical students aged 19 to 25 years, of whom 42 were regular cosmetic users and another 42 were non cosmetic users. Swabs were taken from the face of the subjects after a face wash with soap and water and eluted in 1 ml sterile peptone water. Tenfold dilutions of the sample were made and 100 µl of the diluted sample was spread over the surface of Trypticase soy agar, Mac Conkey’s agar and blood agar. The colonies were counted and also identified. Statistical evaluation was done by Chi-square test using SPSS version 16. Results: We isolated Coagulase Negative Staphylococci (CoNS), Micrococcus spp. and methicillin sensitive S.aureus, non-fermenting oxidase negative gram negative bacilli and diphtheroids from both the groups. We found that most of the students who were regular cosmetic users 22 (52.38%) yielded negligent growth in comparison with non-cosmetic users (16, 38%). CoNS was less frequently isolated from regular cosmetic users 10 (23.8%) in comparison with those who do not use cosmetics 17 (40.47%). Conclusion: It is possible that regular use of cosmetics does reduce the normal flora but further studies with larger sample size are required to prove and confirm this finding.

Sudden and Unexpected Deaths among Women of Reproductive age – Qualitative Analysis of Risk Factors

Kiran Kumar Patnaik, Hemanta Panigrahi, Sudeepa Das, Sachidananda Mohanty

Introduction: Unnatural deaths in women of reproductive age (range 12-49 years) have a serious psychological and social impact on the family and community. Women of reproductive age comprise a vulnerable section of the society as they are confronted with menstrual and pregnancy related stress factors in addition to the stressors prevalent in the general population. Aim: To analyse the socio-epidemiological and medico-legal factors involved in unnatural deaths among women of reproductive age. Materials and Methods: This cross-sectional study was conducted on 1379 unnatural deaths of women of reproductive age subjected to medico-legal autopsy during a period of five years. Information was based on documents submitted by police at the time of autopsy and postmortem reports. Various demographic and medico-legal parameters were studied in detail. Results: Unnatural deaths among women of reproductive age were 1415 (25.2%) cases of total autopsy. Road traffic accidents with 684 (49.6%) cases followed by poisoning in 157 (11.3%), hanging in 133 (9.6%), burn in 114 (8.2%) and railway injuries in 108 (7.8%) cases were the leading causes of death. Nature of death was accidental in 877 (63.6%) cases followed by suicide in 434 (31.5%) cases and homicide in 68 (4.9%) cases. Dowry related deaths accounted for 247 (22.7%) deaths. Poisoning in 152 (35%) cases followed by hanging in 133 (30.6%) and burn in 71 (16.4%) cases respectively were the most common methods of suicide. Strangulation or smothering with 33 (48.5%) cases was preferred method of homicide. Road traffic and railway injuries in 727 (82.8%) cases constituted the bulk of accidental deaths. Married women with 1087 (78.9%) cases and housewives in 917 (66.5%) cases from combined families in 829 (60.1%) cases from rural background in 875 (63.5%) cases with low socioeconomic in 912 (66.1%) cases and poor education in 739 (53.6%) cases were the most vulnerable victims. Conclusion: There is a strong association of various socio-epidemiological and medico-legal factors with respect to unnatural deaths among women of reproductive age group. To bring down the incidences of such deaths, multipronged preventive measures have been suggested.

A 3-D Finite Element Analytical Study to Evaluate the Effects of Newer Variable Implant Thread Pattern in Different Bone Densities

Abhijeet Ramchandra Kore, Shobha Abhijeet Kore

Introduction: Success of dental implant treatment depends on number of patient related and procedure dependent parameters. Various studies have shown that bone quality and implant design are two important factors in the success of dental implant treatment. Today, many implant systems are coming up with variable thread patterns. There is not much literature available on the effects of such variable thread patterns within different bone densities. Aim: The study was conducted to evaluate the effect of two different implant thread patterns in two different bone densities using three dimensional finite element analyses. Materials and Methods: A three-dimensional finite element model of a mandibular section of bone and an implant was developed. 4.2x12 mm screw type dental implants with two different thread designs (buttress thread design and variable thread design) and a metal ceramic crown using Co-Cr and feldspathic porcelain were modelled. The model was developed with finite element software and two types of bone qualities were prepared (D2 and D4). A load of 450 N was applied in a vertical direction and in an oblique direction to the central fossa, buccal cusp and distal fossa of the mandibular first molar crown. Results: For the variable thread design, von Mises stresses developed within bone were 109.89 MPa and 257.46 MPa for vertical and oblique loading respectively, in D2 type of bone. While in D4, the stresses were 243.91 MPa and 371.81 MPa for vertical and oblique loading respectively. Similarly, for buttress thread design, stresses were 113.51 MPa and 176.14 MPa for vertical and oblique loading respectively in D2 type of bone; while in D4 type of bone the stresses were 290.99 MPa and 481.27 MPa respectively within the bone. Conclusion: The results of the present study showed that the von Mises stresses were more in D4 type of bone as compared to D2 type of bone for both, the variable and buttress thread designs. The study also compared the two thread designs. Less stresses were seen with the variable thread pattern than in the buttress thread pattern particularly in D4 type of bone.

Drug Utilisation Pattern and Adverse Events in Patients with Chronic Kidney Disease Undergoing Maintenance Haemodialysis at a Tertiary Care Hospital of Odisha

Introduction: The number of patients receiving renal replacement therapy in the form of dialysis or transplant has been increasing in recent years. Increased frequency of monitoring due to complex therapeutic regimen and inappropriate use of drugs may lead to increased Adverse Events (AEs), hospital stay, cost of treatment as well as increased morbidity and mortality. Aim: To analyse utilisation pattern of drugs and AEs in Chronic Kidney Disease (CKD) patients undergoing maintenance haemodialysis. Materials and Methods: This prospective, observational study was conducted in the Department of Pharmacology in collaboration with Department of Nephrology, SCB Medical College and Hospital, Cuttack, from 1st June to 31st December, 2015. Demographic, clinical and medicine details were collected from patients’ case sheet, matched with nursing case records and tabulated in a predesigned case study form. The data were analysed in a descriptive manner using percentage calculation and Spearman´s correlation, multiple logistic regression using trial version SPSS v24. Results: A total number of 115 cases were included in this study. Average number of drugs used, per prescription was 12.8 during the dialysis and non-dialysis days. Most frequently used drugs were antihypertensives, 25% dextrose and heparin (before dialysis and on dialysis days) were prescribed to all patients followed by haematinics in 90.43% of the patients and proton pump inhibitors were prescribed in 70.43% of the patients. Among 1472 drugs prescribed, 40.96% of the drugs were prescribed in generic name. It was observed that 72.62% of the prescribed drugs were from National List of Essential Medicine. AEs were observed with varying severity in all the patients. Frequently observed AEs as per the laboratory investigations were hyperphosphataemia, hyponatraemia, metabolic acidosis, hyperkalemia, hypoglycaemia, hypocalcaemia and hypokalemia. AEs were statistically significant with age group >45 years (p<0.001). Conclusion: This study provides an insight regarding utilisation pattern of a wide variety of drug classes in CKD patients undergoing maintenance haemodialysis in a tertiary care teaching hospital setting and suggests a possible improvement in medicine practices among patients suffering from CKD which may probably affect adherence patterns positively. Certain areas like potential drug interactions, adverse drug reactions and adherence are required to be explored further.

Is Local Surgical Site Infiltration as Efficacious as Epidural Analgesia in Laparoscopic Low Anterior Resection?

Jyothi Avula, Gigi Varghese, Tunny Sebastian, Mark Ranjan Jesudason

Introduction: Role of epidural analgesia in laparoscopic surgery is questionable. There is paucity of data comparing local surgical site infiltration with epidural analgesia in laparoscopic colorectal resections. Aim: To evaluate the efficacy and feasibility of local surgical site infiltration versus epidural analgesia in laparoscopic low anterior resection done for adenocarcinoma of the rectum. Materials and Methods: This retrospective cohort study was done on 37 patients who had undergone laparoscopic low anterior resection at a single institution from January 2014 to March 2016. Patients were divided into two cohorts; Infiltration group (n=23) and Epidural group (n=14). Baseline characteristics and postoperative outcomes like number of patients requiring opioid rescue analgesia, incidence of urinary tract infection, postoperative hospital stay and overall morbidity were compared. Statistical analysis was done using SPSS software version 16.0. Mann-Whitney U test, Fischer’s-exact test and Pearson Chi-square test were used to test the significance wherever necessary. Results: The number of patients requiring rescue opioid analgesia within the first 48 hours following surgery were 5 (35.7%) in the epidural group versus 4 (17.4%) in the infiltration group (p=0.255). The incidence of urinary tract infection at the index admission was 2 (14.3%) in the epidural group versus 2 (8.7%) in the infiltration group (p=0.625). Overall morbidity calculated using Clavien Dindo classification was 8 (57.14%) and 14 (60.8%) respectively in epidural and infiltration group (p=0.836). The median (interquartile range) postoperative hospital stay for the epidural group was nine days (5-13 days) and for the infiltration group was eight days (5-15 days). Conclusion: Surgical site infiltration is a simple technique comparable to epidural analgesia for immediate postoperative pain control in terms of efficacy and feasibility in laparoscopic low anterior resections.

A Prospective Study to Compare the Functional and Aesthetic Outcomes with and without Primary Bone Grafting in Facial Fractures

Introduction: Open Reduction and Internal Fixation (ORIF) has been the gold standard in treatment of facial fractures. Bone grafts have been used to correct bone defects in face. Many studies assessing outcomes of ORIF and primary bone grafting separately have been published in literature. Aim: A prospective study to compare the functional and aesthetic outcomes with and without primary bone grafting in facial fractures. Materials and Methods: Thirty patients, admitted between January 2012 and December 2013, were divided into two groups. Group 1 patients underwent ORIF with primary bone grafting and in group 2, only ORIF was done. Clinical and functional, photographic and radiological assessments were done after one month and three months. Results: Mean value of vertical dystopia in groups 1 and 2 after three months postoperatively were 1.25mm and 0.67mm. Mean value of enophthalmos in groups 1 and 2 after three months postoperatively were 0.5mm and 1mm. Thus, vertical dystopia was corrected better without bone grafts and enophthalmos corrected better with bone grafts. Photographic assessment revealed no statistical difference between the two groups. Postoperatively, in upper face fractures, both groups had similar number of patients in grades 1 and 2. Only one patient from group 2 of midface fractures ended up with grade 3 asymmetry. Radiologically, in upper face fractures, group 2 had more mean projection, height and breadth deficits (1.28mm, 2.57mm and 2.42mm) when compared to group 1 (0.67mm, 1.50mm and 0.50mm). The mean projection and height deficits were statistically better in group 1. In midface fractures, mean zygomatic complex projection and height deficits were more in group 2 (1.88mm and 0.63mm) than group 1 (0.78mm and 0.44mm). The mean zygomatic complex projection was statistically better in group1. Postoperative complications were lesser with the bone graft group. Conclusion: Judicious use of bone grafts in comminuted facial and orbital floor fractures primarily can give better functional and aesthetic outcomes.

Self-Reported Behaviour about Internet Addiction among Medical and Paramedical Students

Akila Ganesh, D Pragya Kumari, N Ramsudarsan, M Rajkumar, S Shyam, SK Balaji

Introduction: Internet has become an essential tool in day to day life. It has become an important and convenient mode for networking and information exchange. Excessive use of internet adversely affects an individual’s physical, mental and social health along with academic performance. Aim: The present study aimed at determining the prevalence of internet addiction among undergraduate and postgraduate medical and paramedical students and also the effect of internet on gender. Materials and Methods: This was a questionnaire based, cross-sectional study carried out among 1011 medical and paramedical undergraduate and postgraduate students of Sri Ramachandra University, Chennai. A questionnaire consisting of two components; basic demographic information of the participants and Modified Young’s Internet Addiction Test (IAT) was used to gather data. The normal users were categorized as non-addicts and mild, moderate and severe users were categorized as addicts. Descriptive statistics was calculated in terms of frequency and percentage. Inferential statistics was calculated using Chi-Square test. Results: According to the findings, most of the students were mild internet addicts 590 (58.40%) followed by moderate addicts 239 (23.60%), normal users 171 (16.90%) and severe addicts 11 (1.10%). Prevalence of internet addiction was outnumbered by medical 112 (91.10%) students among all the other medical and paramedical specialties. Conclusion: Internet addiction has become an emerging problem among the professional students, which has educational, physical and mental impact on student’s life. So, it is necessary to understand the importance of prevention of internet addiction, which is essential for promoting safe and healthy use of the internet.

Meningococcal Carriage among College Freshmen in Kashmir, North India- A Single Centre Study

Introduction: Data on the community carriage of meningococci in developing countries are sparse. Knowledge about the same would help identify demographic and socio-behavioural risk factors, the need for infection control strategies and the composition of the relevant serogroup for locally effective meningococcal vaccine. Aim: To assess the meningococcal carriage and the major serotypes among fresh college hostellers. Materials and Methods: Charcoal-impregnated nasopharyngeal swabs were collected from 274 consenting fresh college recruits (first year students residing in the college hostel) and plated on to Thayer-Martin medium. Oxidase-positive diplococci were taken as presumptive Neisseria species. DNA was extracted from the isolates and Sanger sequencing was performed on the amplified PCR product. Blast analysis of all sequenced samples was performed against the retrieved Neisseria meningitidis sequences from whole NCBI-nr/nt database and within the dataset. Phylogentic analysis was done by Mega-6 professional package comparing published sequences of serogroups against the detected Neisseria meningitidis. Results: Ten (3.6%) samples grew oxidase-positive diplococci suggestive of Neisseria. On molecular testing and sequence analysis, 4 samples were found to be N.meningitidis, one (Neisseria spp) had close similarity to N.meningitidis and the others included N.perflava (n= 3), N.pharyngis (n=1) and N. flavescens (n=1). N.meningitidis isolates on blast and phylogenetic analysis bore molecular homology to serogroup B. Conclusion: Nasal carriage of N. meningitis (serogroup B) was found in about 1.5% (n=4) of the fresh college recruits in the present study. Close proximity amongst the hostellers is likely to result in transmission and such preventive strategies for infection control are desirable. Further, studies of similar kind are mandated to determine the appropriate serogroups required for inclusion in the vaccine.

Probiotics in the Prevention of Antibiotic Associated Diarrhoea in a Tertiary Teaching Hospital in Pokhara: A Prospective Study

Sahisnuta Basnet, Eva Gauchan, Sudhir Adhikari, Brijesh Sathian

Introduction: Diarrhoea is an undesirable side effect when treating common infections in children with antibiotics. Though studies have shown the effectiveness of probiotics in preventing antibiotic associated diarrhoea, and there is no documented research in Nepal regarding this issue. Aim: The objective of this study was to observe the efficacy of probiotics for the prevention of antibiotic associated diarrhoea when co-administered with an oral antibiotic in children with respiratory tract infections who attended the outpatient department in Manipal Teaching Hospital, Pokhara, Nepal. Materials and Methods: A prospective interventional study was conducted from January 2016 to October 2016 in which 174 children attending the outpatient department in Manipal Teaching Hospital, Pokhara, Nepal and requiring antibiotics for respiratory tract infection were enrolled using convenient sampling method. Eighty-seven of the subjects received standard antibiotic treatment with amoxicillin and clavulanate (control group) and another 87 children received the same antibiotic which was prescribed along with probiotics (probiotic group). Result: Out of the 174 eligible children enrolled in the study, diarrhoea occurred in 11/87 (12.6%) of the patients in the control group and in 1/87 (1.1%) patient in the probiotic group {relative risk, 12.45, 95% CI(1.57,98.67)}. The co-administration of probiotic with amoxicillin and clavulanate significantly decreased the incidence of diarrhoea in the probiotic group (p= 0.003). Conclusion: Co-administration of probiotics in children receiving oral amoxicillin and clavulanic acid reduces the risk of diarrhoea.

A Prospective Study of Routine Screening of Hypothyroidism in Antenatal Patients and their Outcome with Levothyroxine Treatment

Manisha Sahu, Sasmita Das, Pradip Kumar Panigrahi, Saumya Nanda

Introduction: Pregnancy with hypothyroidism is associated with significant maternal, fetal and neonatal complications. Early diagnosis and treatment can effectively reduce such complications. Aim: To find out the complications that can be prevented or reduced in severity in adequately treated hypothyroid pregnant women. Materials and Methods: Pregnant women attending obstetrics’ OPD upto 20 weeks were screened with serum Thyroid Stimulating Hormone (TSH) and free Thyroxine FT4 .Those having Subclinical Hypothyroidism (SCH), Overt Hypothyroidism (OH) and pre pregnant women with hypothyroid were treated with levothyroxine as per consulting with endocrine unit. They were followed up till delivery and any adverse outcomes were documented such as Pregnancy Induced Hypertension (PIH), Pre Eclamptic Toxemia (PET), Abruption, Preterm Premature Rupture Of Membranes (PPROM), Low Birth Weight (LBW), oligohydramnios, Gestational Diabetes Mellitus (GDM), abortion, Intra Uterine Death (IUD), mode of delivery and Neonatal Intensive Care Unit (NICU) admission were compared with similar complications documented among normal pregnant women excluding the treated hypothyroid during a period of one year study. Untreated or late trimester diagnosed hypothyroidism were excluded from study group. Results: Incidence of PIH, GDM, Oligohydramnios, PPROM, NICU admissions and caesarean section were higher among hypothyroid pregnant women though adequately treated than the control pregnant women. But incidence of LBW baby is less and no one had developed PET, Eclampsia or abruption among treated group. Comparing between SCH and OH incidence of PIH is almost equal in both while association of GDM is more in OH. A p-value for PIH, GDM, Oligohydramnios, PPROM developed in hypothyroid pregnant ladies which were calculated by Yates corrected Chi-Square and Fisher’s-exact test from open epic version 3.03a. A p-value is significant (<0.001) for PIH, GDM, PPROM and oligohydramnios but insignificant for LBW. Conclusion: Severe form of PIH (PET and Eclampsia), IUD and Abruptio placentae can be prevented in adequately treated pregnant hypothyroid women and all pregnant women with SCH and OH must screen for GDM even if there is no other risk factors for GDM.

Functional Evaluation of Barrel Vault Tibial Osteotomy for Medial Compartmental Osteoarthritis of the Knee

Introduction: Degenerative changes in articular cartilage of diarthrodial joints and subsequent new bone formation at articular margin are caused due to aging. This leads to osteoarthritis. Most commonly affected joint is the knee. High tibial osteotomy is one of the treatments of isolated osteoarthritis of medial tibiofemoral compartment of knee. Aim: To evaluate functional outcome of barrel vault tibial osteotomy in management of osteoarthritis of knee. Materials and Methods: The present prospective study was conducted in Poona Hospital and Research Centre, between May 2012 and May 2015. Fifty patients of either sex in age group 45 to 60 years with suspicion of medial compartmental osteoarthritis knee and out of these who were ready to participate were included in the study. Arthroscopy of knee was performed to confirm the diagnosis of osteoarthritis knee and to exclude the diagnosis of lateral compartmental osteoarthritis knee. Patients were treated with barrel vault tibial osteotomy. Postoperatively, patients were evaluated by HKA angle, Knee Society Score, Visual Analogue Scale to measure the outcome. Fisher’s-exact test, paired t-test and ANOVA test were used to study the statistical significance. Results: There was significant improvement (p < 0.001) in mean HKA angle, knee score (from 48.10 preoperatively to 86.14 postoperatively), mean functional score (from 58.60 preoperatively to 93.40 postoperatively) postoperatively at six month follow up. There was significant difference between mean HKA angle, mean functional score and mean range of motion with respect to functional outcome. In all 47/50 (94%) patients had excellent or good functional outcome. Relief of patellofemoral symptoms were because of Maquet effect. Conclusion: Barrel vault tibial osteotomy in the management of medial compartmental osteoarthritis of the knee is useful in patients between 45 and 60 years of age.

Subclinical Anal Sphincter Injuries Following Instrumental Delivery–A Physiological Analysis: A Pilot Study

Introduction: Obstetric Anal Sphincter Injuries (OASIS) has been reported in up to 25% patients and occult OASIS has been reported in up to 1.2%. Instrumental delivery has been considered a risk factor for OASIS. Aim: To compare the anal sphincter functions as assessed by Anorectal Manometry (ARM) in asymptomatic patients following instrument delivery with those of patients who underwent Lower Segment Caesarian Section (LSCS) after six months of delivery. Materials and Methods: Seventeen women who had instrumental delivery and thirteen who underwent elective cesarean section were recruited. Evaluation included a detailed history and physical examination, administration of the Cleveland Clinic Questionnaire and ARM to record the basal pressure, squeeze pressure, anorectal sensation and balloon expulsion time. Categorical variables were compared using the Chi-square test. All calculations were done using the software SPSS 21.0. Results: We found statistically significant lower basal (34+3.4 vs 60+2.3 mm hg, p<0.05) and squeeze pressures (56+4.1 vs 76+5.2 mm hg, p<0.05), and higher balloon expulsion time (58+2.9 s vs 19+1.8 seconds, p<0.05) in women with instrument delivery compared to LSCS. The rectal sensation was comparable in both the groups. Conclusion: Persistent subtle anal sphincter dysfunctions are common following instrument delivery compared to LSCS. The role of identifying these and preventing future incontinence in such women needs to be assessed in future studies.

Altered Adaptive Cellular Immune Function in a Group of Egyptian Children with Autism

Introduction: There is a growing evidence of immune system alteration in children with Autism Spectrum Disorder (ASD). These changes may include higher levels of pro-inflammatory cytokines in plasma, Cerebrospinal Fluid (CSF) and brain cells. Aim: To evaluate the imbalance of the immune system in autism through correlating some immunological markers (C3, C4, CD4, IL12 and IL17) with severity of ASD. Materials and Methods: The current case-control study included 120 subjects, 60 autistic children and 60 healthy control obtained from the Clinical Genetics Clinic, National Research Centre, Egypt from the period between December 2014 to December 2016. All candidates were subjected to full clinical evaluation in addition to ElectroEncephaloGraphy (EEG), hearing test and estimation of interleukins (IL12- IL17), C3-C4, CD4 levels in blood samples. Independent t-test, Chi-square test or McNemar test were used to analyse the data. Results: The levels of IL12 (27.47 ±7.15) and IL17 (1630.46±310.42) were significantly higher, (p= 0.026, 0.005) respectively, while levels of CD4 were significantly lower (37.93± 3.25), (p<0.001) in autistic children compared to controls; however, there was no significant difference in C3 and C4 between the two groups. High statistically significant difference between autistic children with moderate and severe ASD in CD4 levels were seen, (p=0.018). Conclusion: Autistic children may suffer from immunological dysfunction. Further efforts should be exerted to find out the relation between immune imbalance and the progression of ASD.

Myomectomy During Cesarean Section: Seven Years’ Experience

Introduction: The incidence of myomas during pregnancy is reported as 1.6-10.7% depending on gestational age. Increased rates of Caesarean Section (CS) together with advanced maternal age bring the decision for caesarean myomectomy (myomectomy during caesarean section) into question. Aim: To compare the obstetric features and clinical outcomes of pregnant women with uterine leiomyoma who had myomectomy together with caesarean section to those who had caesarean section only. Materials and Methods: A retrospective study was performed on a total of 50 pregnant women with myoma that underwent caesarean section in the Obstetrics and Gynaecology Department of Trakya University Medical Faculty between 2007 and 2014. Obstetric history, operative details and type, size and location of leiomyoma were noted and compared. Data were analysed using the IBM Statistical Package for Social Sciences version 17.0 (SPSS Inc., Chicago, IL, USA). Parametric tests were applied to data with normal distribution and non-parametric tests were applied to data without normal distribution. Results: Two groups displayed similar features in terms of age, parity, gestational weeks, type and location of leiomyomas. Notably, average size of leiomyomas was larger (p=0.03) and duration of operation was significantly longer in patients that underwent caesarean myomectomy (72.69±26.73 minutes vs. 56.25±6.64 minutes) (p=0.003). Duration of hospitalisation and preoperative/postoperative values for haemoglobin and hematocrit levels did not show any clinically significant difference (p >0.05). Conclusion: Our results demonstrate that caesarean myomectomy is a safe and effective procedure in especially cases with large uterine leiomyomas.

Does Late Presentation of Displaced Supracondylar Humerus Fracture in Children Influence Outcomes of Surgery?

Introduction: Displaced Supracondylar Humerus Fracture (SCHF) in children is usually treated with percutaneous pinning on emergency basis in fresh cases. Though there are spectrum of modalities treatment reported, still paucity of literature available to compare between cross versus lateral pinning in late presented cases with massive swelling and poor soft tissue condition. Aim: To compare the efficacy and safety of percutaneous medial-lateral cross Kirschner wire (K-wire) and two lateral K-wire fixation in treatment of displaced SCHF in children. Materials and Methods: We retrospectively reviewed the functional and radiological result of treatment in 58 children (aged 2-12 years) with displaced SCHF presented more than two days duration after injury. Among 58 patients, (n=31) treated with cross K-wire (Group A) and (n=27) treated two lateral K-wire fixation (Group B). Statistical analysis of different variables was performed using SPSS software (version 20.0; SPSS, Chicago, Illinois). A p-value of <0.05 was considered to be statistically significant. Results: Both the group were similar in terms of mean demographic variables. Mean delay of presentation was 4.07 days and 4.87 days in Group A versus Group B respectively. In Group A, three patient had iatrogenic ulnar nerve injury. There were also no significant differences (p>0.05) between groups with respect to the Baumann angle, change in the Baumann angle, Flynn grade, carrying angle, elbow range of motion, return to function, or complications. Conclusion: Although both the technique appears to be equally effective in term of stability and outcomes. But lateral pinning has a definite edge over cross pinning in respect to reduced incidence of iatrogenic ulnar nerve injury, especially in late presenters with severe swelling and poor soft tissue conditions.

Clinical Outcome of Non-occlusive Versus Occlusive Dressing in Postoperative Sutured Wounds

Dinesh Kumar, Amol Daniel

Introduction: The main objective of dressing wounds is to prevent wound infections. Successful wound management depends on an understanding of the healing process combined with knowledge of the properties of the various dressings available. Wounds can heal primarily, secondarily, or by delayed primary closure. The method of dressing includes occlusive and non-occlusive dressing. Aim: To evaluate the clinical outcome of non-occlusive versus occlusive dressings in postoperative sutured wounds. Materials and Methods: This was a prospective study done on 298 patients over a period of one and half years from 1st January 2012 to 30th June 2013. All elective inpatients with sutured wounds in the Department of General Surgery requiring local wound care postoperatively were included in this study. The patients were divided into two groups according to the type of dressing used i.e., occlusive or non-occlusive. The results obtained were statistically analysed by student t-test and Chi-square test. Results: In our study, we found that wound infection and wound dehiscence were noted more in non-occlusive dressing group as compared to occlusive dressing group. We also found that mean cost of dressing, frequency of dressing changes, the pain during dressing change, mean duration of hospital stay for non-occlusive dressing was more than occlusive dressing. Conclusion: After a careful review of current study on wound management and type of dressing, it is evident that occlusive dressing had better clinical outcomes as compared to non-occlusive dressing.

Gene Therapy Applications in Dentistry: A Review

Gene therapy involves transfer of new genetic material or manipulation of the existing material for the purpose of treating human disease. It involves transfer of genetic material – ex vivo and in vivo and may conceivably revolutionize clinical practice in the coming years. Although progress has chiefly been in the medical domain, research has moved to various dental conditions as well. This review is presented to highlight various applications of gene therapy in dentistry in the areas such as salivary gland disorders, chronic pain, DNA vaccines, bone repair, implantology, head and neck cancer, orthodontic therapy, periodontal repair and tooth regrowth.

All About Dowels - A Review Part II Considerations After Cementation

Zishan Dangra, Mahesh Gandhewar

The present review summarizes the published literature examining cementation of the dowel and factors related to it. The peer reviewed English language literature was reviewed from the period 1990 to 2015. Articles were searched in Pubmed/Medline for the relevant terms. Additional manual searches of some dental journals were also carried out. The original key terms resulted in 228 articles. After applying inclusion criteria, 64 articles remained to be included in part II of this review. Article search indicates that most published literature on dowels are in the form of in vitro analysis. Literature on prefabricated dowel systems far exceeds than the custom cast dowel and newer fibre dowels. Clinical evidence is not sufficient and cannot be used to inform practice confidently. However, within the limitations of this review it is suggested that adhesive fixation is preferred in case of short dowel. Dowel width should be as small as possible. A ferrule of 2 mm has to be provided. Composites have proven to be a good core material provided that adequate tooth structure remained for bonding. Dowel should be inserted if endodontically treated tooth is to be used as abutment for removable partial dentures.

Clinical and Radiographic Outcome of Herbal Medicine Versus Standard Pulpotomy Medicaments in Primary Molars: A Systematic Review

Divya Subramanyam, Sujatha Somasundaram

Introduction: Various medicaments has been used for many years as a pulpotomy medicament that has its own advantages and disadvantages. Recently, there has been the use of herbal medicine as a pulpotomy medicament due to its good antibacterial effect and least complications compared to standard chemically synthesized pulpotomy medicaments. Aim: The aim of this systematic review was to analyse the existing literature on the effectiveness of herbal medicine compared to standard pulpotomy medicaments in primary molars. Materials and Methods: Information was collected from Electronic databases (PubMed, Cochrane Library, LILACS, Google scholar, Science Direct and SIGLE) and hand search was also done in International Journal of Paediatric Dentistry (September 2011-March 2016), Journal of clinical Paediatric Dentistry (September 2011–March 2016) and International Journal of Current Research and Academic Review (September 2013- March 2016). Only those articles which met the inclusion criteria were selected. Literature abstracts and full text articles were analysed in this review. Results: A total of six articles were included in this systematic review. All were randomized clinical trials which evaluated the clinical and radiographic success or outcomes of herbal medicine such as allium sativum, ankaferd blood stopper, elaegnus angustifolia, propolis compared with standard pulpotomy medicaments in primary teeth. The overall clinical and radiographic outcomes were not significantly different in all the studies. All the included studies recorded high risk of bias. There is lack of strong evidence to support the use of herbal medicine to replace standard pulpotomy medicaments. Conclusion: There seems to be a lacunae of strong and long term evidence to support the use of herbal medicines. Therefore, more quality randomized controlled trials with long term follow up, to evaluate the clinical success of herbal medicine to replace the gold standard agents of conventional pulpotomy is required.

Marine-Derived Bioactive Peptides with Pharmacological Activities- A Review

Sana Rabiei, Mehdi Nikoo, Masoud Rezaei, Mahmoud RaFIeian Kopaei

Some nutritional factors are related to chronic disease. In response to increased concern regarding nutrition and health, the functional and nutraceuticals food markets have been developed. During food digestion, proteins are hydrolyzed and a wide range of peptides are formed. Some of these peptides have special structures which permit them to confer particular biological functions. Marine animals which involve more than half of the world biological varieties are a wide source of bioactive proteins and peptides. Marine derived peptides show various physiologic functions such as anti-oxidant, antimicrobial, anti-cancer, Angiotensin-1-Converting Enzyme (ACE) glucosidase and a-amylase inhibitory effects in vitro. Before application of marine bioactive peptides as nutraceuticals or functional food ingredients, their efficacy should be approved through pre-clinical animal and then clinical studies. The aim of this study was to review the studies conducted on the pharmacological effect of marine bioactive peptides in animal models and humans.

A Review of Measures against Increasing Temperature and Climate Change for the Safeguard of Workers in India

Ranjit Kumar Dehury , Parthsarathi Dehury

Severe heat causes various health related problems among the workers in India. Working under hot and humid environment damages health of workers especially the agriculture labourers, construction workers, rickshaw pullers, venders, brick kiln workers and daily wage labourers. High humidity and high temperature can leads to heat stress even in 38oC temperature. The damage might be temporary, like heat related injuries to permanent like, critical heat stroke. Sometimes, it leads to occupational hazards which is irreversible in nature. Despite these serious issues, there is minimal preparation which exposes the workers to serious conditions. This paper evaluates various consequences of climate change and increasing temperature on the workers. Various databases like PubMed, Scopus and Google Scholar have been enquired to bring evidences across industry and places. The effects of heat and temperature were thematically arranged to understand the seriousness of the issues. Suggestions and way forwards are also discussed for the solution for workers and sustainability of various sectors depending on labourers working under the heat of sun. The paper suggests the requirement of creating a heat combating environment by coordinating among various government departments and agencies for the welfare of the workers. The industrial workers have to be provided with sufficient measures by various industries as per the governing laws. The agriculture and brick kiln workers have to work in mild heat and with sufficient protection to avoid consequences. The government need to monitor the unorganised sectors for protection of workers by law enforcing organs.

A Review of Abstracting and Indexing Services for Biomedical Journals

Sarita Bhardwaj, Arun Bhardwaj

The days are gone when the researchers used to go to library to look for the articles of their choice. With the introduction of electronic era, searching an article online has become easier. This has been possible due to the availability of various Abstracting and Indexing (A & I) services in the world. Of more than 400 online A & I services available, only a few like Google and Thomson Reuters cover all disciplines. Most A & I services cover just one discipline allowing them to cover their area in more depth. There are many databases and indexing services for biomedical journals, most important ones being PubMed/Medline, Scopus, and Web of Science (ISI). This article gives a review of various databases and indexes available for dental journals in the world.

Defusing a Time Bomb – Embolization of a Uterine Arteriovenous Malformation with Venous Aneurysms

Uterine Arteriovenous Malformation (AVM) is a rare disease and is usually an acquired disorder which can remain asymptomatic or cause life-threatening bleeding. Prompt diagnosis and management in the appropriate clinical setting is crucial. Imaging can diagnose and sometimes predict the possibility of future severe bleeds. Embolization is the mainstay of treatment, however should be performed using proper techniques of selective embolization avoiding physiological blood vessels supplying normal structures.

Monteggia Type 1 Fracture Equivalent with Concomitant Ipsilateral Distal Radius and Ulna Fracture in an Adult: A Rare Case Report

Shankarlinga S Sajjan, Atmananda S Hegde, Rajendra Annappa, Sharan Mallya

Monteggia fracture comprises of 5% to 10% of all forearm fractures. It represents severe forearm injuries which require operative intervention. We report a unique case of Monteggia variant in female patient aged 67-year-old presenting a fracture of proximal ulna and radial neck along with ipsilateral fracture of distal ulna and radius at its metaphyseal end, which cannot be classified under Monteggia fracture and its equivalents occurring in adults. We managed this case using dorsal approach surgically and patient had good functional result at the end of six months.