Journal of clinical and diagnostic research

Recurrent Vaginal Cuff Dehiscence in a Treated Case of Carcinoma Cervix

Sunesh Kumar, Seema Singhal, Yamini Kansal, Dayanand Sharma

Vaginal Cuff Dehiscence (VCD) is partial or total separation of anterior and posterior vaginal cuff layers. We report a case of recurrent vault cuff dehiscence in a patient of cervical carcinoma. A 60-year-old treated case of carcinoma cervix post surgery and radiotherapy was found to have vault dehiscence and intestinal prolapse second time during a routine speculum examination. She underwent an emergency laparotomy and closure of vault. Vaginal Cuff Dehiscence with Evisceration (VCDE) is a rare but potentially fatal complication following hysterectomy. Postoperative infection, poor technique, hematoma, coitus before healing, radiotherapy, corticosteroid therapy are the risk factors. Radiotherapy leads to progressive obliterative endarteritis and resultant tissue hypoxia. There is paucity of literature regarding the best management of VCD, but early corrective intervention is necessary. Patients and the treating physicians should be made aware of this possibility especially those receiving adjuvant radiation or cases of robotic or laparoscopic hysterectomies.

Mycobacterium fortuitum Infection at Umbilical Hernioplasty Site

Bharti Chogtu, Daliparty Vasudev Malik, Rahul Magazine, Vishnu Prasad Shenoy

Non Tuberculous Mycobacteria (NTM) are a group of rapidly growing mycobacteria and are generally considered to be of low virulence. Of late, there has been an increase in incidence of infections due to these organisms. Among them, Mycobacterium fortuitum, M. chelonae and M. abscessus are the common species which have been identified. Though they are occasionally implicated in pulmonary infections, NTM are very commonly associated with cutaneous infections, especially surgical site infections. Identification of NTM infection at such sites should be suspected when there is delayed healing of the wound. Histopathological Examination (HPE) of the wound site may reveal a classical picture of granulomas, epithelioid cells and giant cells which may lead to a suspicion of tuberculosis. It is important to perform mycobacterial culture and sensitivity testing of the wound tissue as this helps to differentiate tuberculous and non tuberculous infections. Here, we present a case of a patient who underwent mesh hernioplasty for umbilical hernia and was diagnosed with M. fortuitum infection at the site of umbilical hernioplasty.

Bilateral Persistent Hyperplastic Primary Vitreous - A Rare Case Report

Rashmi Kumari, Bhawesh Chandra Saha

Persistent Hyperplastic Primary Vitreous (PHPV), now-a-days referred to as Persistent Fetal Vasculature (PFV), is a rare congenital anomaly of the eye that typically presents unilaterally with white pupillary reflex and microphthalmia without systemic associations. Bilateral presentations are rare. Here we report a case of 15-year-old male with bilateral PFV without leucokoria who was misdiagnosed as congenital esotropia with amblyopia, treated for refractive errors and referred to higher centre for squint corrections. The diagnosis of PFV was made easily on slit lamp examination with dilated pupil due to media clarity. Findings were confirmed by colour doppler ultrasonography of the eyes. This case warrants essential screening of the posterior segment of all children with deviated eyes to ensure earliest detection of such pathologies.

Axial Torsion of Meckel’s Diverticulum: A Rare Case Report

Meckel's Diverticulum (MD) is the most common congenital anomaly of gastrointestinal tract, occurring in 2% of the population. It is a true diverticulum and histologically all four intestinal layers are present within MD. There are various complications related to a Meckel’s diverticulum, including haemorrhage, intestinal obstruction, inflammation and perforation. Axial torsion followed by gangrene of MD is the rarest of the complications that have been reported. The exact mechanism for torsion is unclear. Preoperative diagnosis of torsion of MD is difficult and often confused with appendicitis as pain is usually localized to right lower quadrant. Radiological investigations do not provide much help in diagnosis. We report a case of axial torsion of MD presenting as acute abdomen in an 11-year-old female patient. The diagnostic laparoscopy was performed. Confirmatory diagnosis and further surgical management was done by exploratory laparotomy under general anaesthesia.

Right Pulmonary Venous Atresia: A Rare Cause for Recurrent Unilateral Pneumonia

Prashant P. Patil

Recurrent unilateral pneumonia poses a diagnostic dilemma for all paediatricians. Isolated pulmonary venous atresia is an uncommon entity, which presents with recurrent unilateral pulmonary infections, dyspnoea on exertion and haemoptysis. It is associated with significant mortality and morbidity. Owing to rarity of condition, there may be some difficulties in the diagnosis and therapy. Pulmonary angiography is the investigation of choice. However, the current multislice CT scanners may obviate the need for pulmonary angiography. We report a two-year-old child with this rare congenital malformation and discuss diagnostic modalities and management options.

Tiny Creature in Oral Cavity: A Case Report

Cheena Singh, M Parvathi Devi, Kamal Sagar

Oral cavity is nidus of much pathology. Some may arise due to altered eating habits such as meat, uncooked food etc. The parasitic infections arising from ingesting uncooked pork (larva of pork tapeworm) called as cysticercosis and being undiagnosed lead to “diagnostic dilemma”. Herein we report a case of cysticercosis involving the right dorsum of tongue along with review of literature.

Dengue Stings the Eye!

Sumana J Kamath, Madhurima K Nayak, Ruchi Gour, Neha Singh

Dengue is a vector borne viral fever and has varied ocular affections. We report two cases of Dengue Associated Maculopathy (DAM). The first patient was a 22-year-old lady with dengue fever, presented with diminution of vision in the left eye with best corrected visual acuity of 20/40. Fundus revealed soft exudates and streak haemorrhages at the macula in the left eye. Optical Coherence Tomography (OCT) showed cystoid macular oedema. She recovered completely within four days. The second patient was a 33-year-old lady with dengue, with blurred vision in the left eye and with a visual acuity of 20/80. Fundus examination in the left eye revealed elevated fovea with a yellow well circumscribed lesion with surrounding striations. OCT showed features suggestive of foveolitis. She improved spontaneously over the next 21 days to a visual acuity of 20/20p. DAM is usually a selflimiting condition with favourable prognosis. This report highlights the importance of anticipating visual morbidity in patients with dengue and a thorough evaluation and follow-up in spite of its benign behaviour. Also, this report highlights the importance of OCT in differentiating various presentations of DAM.

Delayed Tension Pneumothorax – Identification and Treatment in Traumatic Bronchial Injury: An Interesting Presentation

Amit Gupta, Amulya Rattan, Sunil Kumar, Vinita Rathi

A 13-year-old girl, who did not receive any treatment for few hours following Road Traffic Injury (RTI), reported to the Casualty Department and found to have patent airway with clinically normal C spine, air-hunger (RR 42/minute), trachea deviated to left, distended neck veins and absent breath sounds on the right side. The chest X-ray she carried, done immediately after the injury, showed right sided tension pneumothorax. She was put on oxygen at 11 L/minute and an Intercostal chest tube drainage (ICD) was inserted on right side. Her oxygen saturation (40%) failed to improve. ICD bag showed continuous bubbling and air entry remained absent on the right side. An urgent right thoracotomy was done which revealed right main bronchus tear; the tear was repaired using interrupted Prolene® sutures. Patient recovered well and was discharged 10 days later in a stable condition.

Thalassaemia Trait with Gaucher Disease: A Diagnostic Dilemma

Gaucher Disease is an autosomal recessive disease caused by the accumulation of glucocerebrosidase due to deficiency in lysosomal glucocerebrosidase. Thalassaemia trait is asymptomatic and is usually an incidental diagnosis. Both thalassaemia and Gaucher disease can have similar haematologic manifestations and hence, their coexistence causes diagnostic dilemma. Our patient presented at one-and-a-half years with weakness, pallor, failure to thrive and massive hepatosplenomegaly. Clinical examination and history pointed to a lipid storage disease. Peripheral smear revealed microcytic hypochromic cells and nucleated red cells with haemolytic blood picture. Thalassaemia trait was indicated on haemoglobin variant analysis using High Performance Liquid Chromatography. Liver biopsy, bone marrow aspirate and therapeutic splenectomy revealed Gaucher-like cells. Type 1 Gaucher disease can be clinically asymptomatic as well as present with massive liver and spleen enlargement and involvement of bone marrow. Anaemia, splenomegaly and thrombocytopenia are the usual presentations at diagnosis, similar to the haemoglobinopathies. Gaucher-like cells with normal beta-glucocerebrosidase (pseudo-Gaucher cells) are seen in thalassaemia, leukaemia, mycobacterial infections and myeloma. Gaucher disease coexisting with thalassaemia trait is uncommon. We report the occurrence of thalassaemia trait and Gaucher disease in a child, which resulted in confusion regarding the haematological diagnosis. This report highlights the necessity of independent establishment of the diagnosis in every patient so that appropriate management decisions are taken.

Non-Catheter Related Perioperative Superior Vena Cava Syndrome Following Surgical VSD Closure-Role of Transesophageal Echocardiography

Tanveer Singh Kundra, Divya Gopal, Manasa Dhananjaya

Unintentional iatrogenic surgical complications can complicate the operative and postoperative courses of paediatric cardiac surgery patients. Unless recognized and treated early, it’s possible, these complications may lead to a prolonged hospital stay, increased treatment cost, morbidity, and even death. Ventricular Septal Defect (VSD) is the most common congenital heart defect in children, occurring in 50% of all children with congenital heart disease and in 20% as an isolated lesion. Herein, we discuss the development of Superior Vena Cava (SVC) syndrome following surgical repair of VSD in a nine-month-old child. Early clinical diagnosis, immediate confirmation with Transthoracic Echocardiography (TTE) and surgical re-exploration led to a good outcome in this patient. If, however, we could have performed an intraoperative Trans Esophageal Echocardiography (TEE), this complication could have been recognized, even before shifting from the operating room.

Autoimmune Pancreatitis Type II: First Report from India

Gunjan Desai, Prasad Pande, Chandralekha Tampi, Prasad Wagle

Autoimmune Pancreatitis (AIP) presents in two forms - Type I or lymphoplasmacytic sclerosing pancreatitis and Type II or idiopathic ducto-centric pancreatitis (IDCP). AIP II is rare in south Asia and, especially so, in India. Most patients have either Idiopathic Chronic Pancreatitis (ICP) or alcohol related chronic pancreatitis. AIP Type I has been described in India. We herein report a patient who had features of ICP on imaging, for whom surgery was performed to relieve chronic pancreatic pain. However, the pathologic features revealed AIP Type II or IDCP.

Epididymal Cystic Lymphangioma Presenting as Scrotal Swelling in a Post Surgery Case of Carcinoma Rectum- A Case Report

Mohammad Haroon, Yashmin Nisha, Kashif Iqubal

Cystic lymphangiomas are usually congenital malformations of draining lymphatic channels with most common sites including neck, axilla, mediastinum and retroperitoneum. Occurrence of lymphangiomas in scrotum or inguinal region is a rare entity and epididymal origin of these lesions is even more infrequent. We herein report a case of epididymal lymphangioma detected on USG, which developed after surgical abdominal lymph nodal dissection in an adult patient of carcinoma rectum presenting as painless scrotal swelling.

Carbamazepine Induced Thrombocytopenia

Antiepileptic Drugs (AEDs) are commonly associated with haematological disorders, including anaemia, thrombocytopenia, neutropenia and even bone marrow failure. Fatal disorders like aplastic anaemia are uncommon. On exploring through the literature, older AEDs are more associated with haematological alterations than newer AEDs, and careful monitoring is warranted especially with phenytoin, carbamazepine and valproate. The exact cause of these alterations is not established, though immune mechanisms and pharmacology of individual drugs are the proposed mechanisms, a further research along this path is underway. Of worth mentioning here, this predilection of older AEDs towards haematological disorders is pronounced in children compared to adults. We present here a case of congenital heart disease with history of brain abscess and seizures, on carbamazepine who presented to our hospital with toothache. Routine screening prior to tooth extraction revealed thrombocytopenia. Further evaluation revealed the association of carbamazepine and thrombocytopenia, which mandated discontinuation of drug and switching patient to alternative AED.

Successful Management of Urosepsis with Ceftriaxone+Sulbactam+EDTA: A Case Report of Penem Sparing Approach

Amit Bery, Candy Sodhi, Rishu Bhanot

Over the past decade, the Anti-Microbial Resistance (AMR) among members of Enterobacteriaceae family is on rise mainly due to rapid spread of strains producing Extended-Spectrum Beta-Lactamases (ESBLs) and Metallo Beta-Lactamases (MBLs). Hence, the choice of drugs available for these resistant strains is diminishing and their treatment is becoming more challenging. This is a case of complicated Urinary Tract Infection (cUTI) due to ESBL producing E. coli leading to septic shock which was successfully managed with Antibiotic Adjuvant Entity (AAE), a combination of ceftriaxone+sulbactam+EDTA.

Prenatal Screening for Rare Co-Inheritance of HbE and ß-Thalassaemia Traits in Western India

Parth S Shah, Hari Shankar P Ray, Ketan K Vaghasia, Sandip C Shah, Mandava V Rao

The mutations in Haemoglobin Beta (HBB) gene, bring about less or no production of Hb ß- chain synthesis in affected cases, leading from minor to major types depending on haematological indices. In compound heterozygotic conditions, two traits are involved, in which one parent has HbE trait and the other has ß-thalassaemia carrier (trait). Here, we report a family of Rajasthan, West India which had a proband (son) having HbE/ ß- thalassaemia a co-inherited compound heterozygosity as revealed by DNA sequencing. It also contained upper levels of HbE with altered Hb and red cell indices showing asymptomatic to symptomatic state requiring blood transfusion periodically. The parents and Chorionic Villus Sampling (CVS) were HbE and ß- thalassaemia traits only. Such case is rare in Western India and we recommend this family for genetic counseling and genetic testing before they want reproductive choices in future for better management in a society.

Non Traumatic Fracture of Pedunculated Osteochondroma: Conservative Management of a Rare Case

Ahmet Senel, Erhan Sukur, Huseyin Nevzat Topcu

Fracture of a pedunculated osteochondroma is a rare complication for which surgical treatment is usually advocated. In this report, we present the functional and radiological outcomes of a case of a conservatively treated fracture of a pedunculated osteochondroma. A 26-year-old man with no history of trauma presented with acute onset of left knee pain, oedema, and limited range of motion. Radiological assessment revealed a fracture of a pedunculated osteochondroma. It was treated conservatively with an elastic bandage and non-steroidal anti-inflammatory drugs, and union was achieved by the 12-week follow-up, with no complications. Although surgical treatment is usually advocated for a pedunculated osteochondroma fracture, conservative treatment should be the first approach to avoid complications of surgical intervention.

Papillary Renal Cell Carcinoma with Tubercular Paraaortic Lymphadenopathy: A Blessing in Disguise

Bhavna Sharma, Purnima Malhotra, Minakshi Bhardwaj

Incidental Renal Cell Carcinoma (RCC) can be found in a tubercular kidney; however, the vice versa i.e., finding tubercular lymphadenopathy after radical nephrectomy for cancer is exceptionally rare. To the best of our knowledge, only two cases of coexistent renal cell carcinoma and tubercular paraaortic lymphadenopathy have been reported till date. Out of these, only one case was of papillary renal cell carcinoma. We hereby, report a rare case of papillary renal cell carcinoma with coexisting paraaortic tubercular lymphadenopathy, which was upstaged based on radiology findings. This case highlights the importance of considering the possibility of tuberculosis in cancer-associated lymphadenopathy. This can prevent unnecessary lymphnode dissection and inappropriate clinical upstaging in renal cancer patients.

Hyperparathyroidism during Pregnancy- A Diagnostic and Therapeutic Challenge

Richa Sharma, Bhanupriya, Vishnu Bhartiya, Kiran Guleria, Amita Suneja

Primary Hyperparathyroidism (PHP) is a rare event in pregnancy; Maternal complications in PHP patients can be as high as 67%. It can be overlooked easily because of many similar complaints shared by hyperparathyroidism and pregnancy such as nausea and vomiting, gastritis, bone aches, easy fatigability. Hypercalcemic crisis can develop resulting in coma and death. Neonatal effects are tetany and death in about 80% of cases. We report a case, of an antenatal woman at 30 weeks gestation with complains of painful swelling in left lower jaw and below right knee, pain over right hip joint and frequent episodes of gastritis. She was finally diagnosed to have primary hyperparathyroidism and brown tumour due to parathyroid adenoma. The baby was kept in Neonatal Intensive Care Unit (NICU) for three weeks, in view of prematurity with respiratory distress and later developed sepsis with DIC. The patient’s signs and symptoms regressed after parathyroid surgery and the baby was healthy at the time of discharge. This case highlights the progressive deterioration of the patient because of lack of awareness of this disease process and its impact on maternal and foetal morbidity.

Sodium Valproate Induced Alopecia: A Case Series

Sereen Rose Thomson, Vinay Mamulpet, Shalini Adiga

Drug induced alopecia may range from a barely detectable shedding to an irreversible baldness. Alopecia associated with valproate is a dose-dependent and reversible side effect. We hereby report, three cases of alopecia that occurred in patients who received sodium valproate for various neurological conditions. In all three cases, long term exposure of valproate therapy led to the development of alopecia which eventually resolved after dose reduction or discontinuation. The Naranjo’s causality assessment scale indicated valproate as the probable cause of the alopecia in all our patients.

Autoimmune Haemolytic Anaemia-A Spectrum of Presentation in Children

Amitabh Singh, Anirban Mandal, Ankita Patel, Sataroopa Mishra

Autoimmune Haemolytic Anaemias (AIHAs) are rare in children. They can be either a primary disease or secondary to/triggered by a host of other clinical conditions. We present five interesting cases of paediatric AIHA associated with infections (viral, bacterial and atypical) and autoimmune diseases {Systemic Lupus Erythematosus (SLE) and Autoimmune Hepatitis (AIH)}. The H1N1 influenza associated AIHA responded to oseltamivir and Intravenous Immunognobulin (IvIg) while the cases secondary to Mycoplasma pneumoniae and pneumococcal bacteraemia required only treatment of the primary infection. AIHA with SLE responded well to corticosteroid therapy but the patient with AIH and AIHA succumbed to severe liver failure. Rest of the four cases with good response to therapy did not have any recurrence/relapse of AIHA during their follow up periods.

Safety Assessment of Human Bone Marrow-derived Mesenchymal Stromal Cells Transplantation in Wistar Rats

Ashwini P Aithal, Laxminarayana Kurady Bairy, Raviraja N Seetharam

Introduction: Bone Marrow-derived Mesenchymal Stromal Cells (BM-MSCs) are multipotent stem cells isolated from adult human bone marrow. Properties of MSCs make them potentially ideal candidates for regenerative medicine. The preclinical data available in the literature regarding the safety assessment of MSCs at different dosage group is scanty. Aim: To evaluate the safety of BM-MSCs transplantation in Wistar rats. Materials and Methods: Eighteen adult female Wistar rats were used in the study. They were randomly divided into normal control, low dose MSCs and high dose MSCs groups. Low dose group received 3.25 million BM-MSCs/kg body weight; high dose group received 9.75 million BM-MSCs/kg body weight intravenously. Body weight, food and water intake of each rat were measured statistically using SPSS version 16.0; animals were observed for changes in behaviour, general clinical signs, presence of any abnormal response, mortality for thirty days. Results: Repeated measures ANOVA indicated a significant increase in body weight, food, and water intake of all animals at all weeks of the study period compared to week zero (p<0.05). Between the low dose and high dose MSCs group, increase in absolute body weight was seen at the end of the 30th day which was statistically significant (p=0.01). There was no significant difference in body weights, food and water intake in MSCs group when compared to normal control. All the animals survived for the entire duration of the study. Further, there was no change in the behaviour of the animals, no adverse clinical signs or complications following the MSCs treatment. Conclusion: Results indicate that administration of BM-MSCs is safe when given by a slow intravenous infusion as it did not alter the food and water intake behaviour of the animals and did not have any negative effect on its body weight.

Brugada Syndrome with Spontaneous Fluctuation in ECG Pattern

Abhishek Goyal, Varun Loomba, Naved Aslam, Bishav Mohan, Gurpreet Singh Wander

A Boy with a Congenital Sagittal Fissure of the Glans Penis Representing an Abortive Isolated Urethral Duplication

Bilateral Conjunctival Rhinosporidiosis in a Paediatric Patient

Charudutt Kalamkar, Amrita Mukherjee

A Three Year Analysis of Systemic Comorbidities in Cataract Operated Patients in India

Parthasarathi Sathyan, Padma Sathyan

Gastroenteritis In Pregnancy: Relevance and Remedy

Sumita Mehta, Ritu Khatuja, Menka Verma, Anshul Grover

Statistical Significance is Prerequisite in Study

Himel Mondal, Shaikat Mondal

Validity of Simplified Ankylosing Spondylitis Disease Activity Scores (SASDAS) in Indian Ankylosing Spondylitis Patients

Nagma Bansal, Lalit Duggal, Neeraj Jain

Introduction: Ankylosing Spondylitis Disease Activity Score (ASDAS) is a complex score for monitoring disease activity in Ankylosing Spondylitis (AS). Aim: To develop a simplified version of the ASDAS. Materials and Methods: Consenting 254 AS patients (modified New York and/or Assessment in Ankylosing Spondylitis 2009 criteria) were recruited. Sociodemographic data and disease characteristics such as Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), and AS Quality of Life (ASQoL), Erythrocyte Sedimentation Rate (ESR), and C-Reactive Protein (CRP) were collected. Simplified ASDAS (SASDAS) was calculated as the simple sum of patient global assessment, back pain (BASDAI question no.2), peripheral pain and swelling (BASDAI question no.3), morning stiffness (BASDAI question no.6), and either ESR in mm/hour (for SASDAS-ESR) or CRP in mg/L (for SASDAS-CRP); this sum was divided by 10 to obtain the final score. Results: Most patients (224/254; 88.19%) were males with the median age of 30 years. SASDAS-ESR and SASDAS-CRP showed good correlation with ASDAS-ESR and ASDAS-CRP respectively (r2=0.78 and 0.58 respectively; p-value<0.0001). SASDAS-ESR showed good correlation with CRP (r=0.50) and is fairly correlated with backpain (r=0.19), morning stiffness (r=0.21) and peripheral pain (r=0.21); SASDAS-CRP showed good correlation with BASFI (r=0.32), and ESR (r=0.55) (all p-value<0.0001). Using established ASDAS cut-off values, corresponding cut-off points between ‘inactive’, ‘moderate’, ‘high’, and ‘very high’ disease activities (with optimum sensitivity and specificity) were 1.83, 2.45 and 4.45 for SASDAS-ESR, and 0.79, 1.50, and 3.26 for SASDAS-CRP. Both the SASDAS scores showed good correlation with BASDAI. Conclusion: SASDAS-ESR and SASDAS-CRP are reliable, easy-to-calculate scores for disease activity assessment in Asian Indian AS patients; which can be used in daily clinical practice

Association between Vascular Endothelial Markers and Carotid Intima-Media Thickness in Children and Adolescents with Type 1 Diabetes Mellitus

Noushin Rostampour, Kiavash Fekri, Elham Hashemi-Dehkordi, Mahdieh Obodiat

Introduction: Type 1 Diabetes Mellitus (T1DM) is one of the important risk factor for cardiovascular disease. Endothelial dysfunction and increased Carotid Intima-Media Thickness (CIMT) result in cardiovascular complications. Vascular Cell Adhesion Molecule-1 (VCAM-1) and Intercellular Adhesion Molecule-1 (ICAM-1) are two adhesion molecules that are markers of early atherosclerosis and play a significant role in developing atherosclerosis. Aim: To evaluate CIMT and its association with the levels of ICAM-1 and VCAM-1 in children and adolescents with T1DM. Materials and Methods: In this descriptive, cross-sectional study conducted between April 2013 and September 2014, 29 children aged 7-20 years with T1DM for at least two years and 29 age and sex-matched, healthy individuals were evaluated. Plasma level of ICAM-1 and VCAM-1 was measured by ELISA, and CIMT via Doppler ultrasound was also assessed. The data were analysed by t-test and Pearson’s correlation coefficient in SPSS 16.0 (p=0.05). Results: Independent t-test indicated that there is a significant difference in ICAM-1 level between the patients and controls (p<0.001). Further, CIMT was significantly higher in diabetic subject (p<0.001). CIMT was not significantly associated with the level of VCAM-1 and ICAM-1 in the patients (p>0.5). Conclusion: ICAM-1 and VCAM-1 were not associated with CIMT but, CIMT and level of ICAM-1 were significantly, higher in diabetic patients, and therefore could be used as useful tools for identification of early atherosclerosis in children and adolescents with T1DM.

Pre-microRNA Gene Polymorphisms and Risk of Cervical Squamous Cell Carcinoma

Introduction: MicroRNAs (miRNAs) are short (~22 nucleotides) regulatory RNAs that can modulate gene expression and are aberrantly expressed in many diseases, including cancer. It has been suggested that, the presence of single nucleotide polymorphisms in precursor miRNAs (pre-miRNAs) can alter miRNA processing, expression and binding to target mRNA and represents another type of genetic variability, that can contribute to the susceptibility of human cancers. Aim: The present study investigated the genetic variants in pre-miRNAs (hsa-miRNA-196a2 rs11614913 C/T, hsa-miRNA-499 rs3746444 T/C and hsa-miRNA-146a rs2910164 G/C) for their role in cervical cancer susceptibility. Materials and Methods: The study comprised 164 controls and 184 patients of cervical cancer. The genotypic frequency of miRNA polymorphisms were determined by using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay. Logistic regression was used for statistical analysis using SPSS Software version 15.0. Results: Hsa-miRNA-499 rs3746444 T/C polymorphism showed a statistically significant association with considerable risk for cervical cancer at genotypes (CC, p=0.001, OR=4.801) and variant allele (p<0.001, OR=2.307). MiRNA 146a and miRNA 196a2 polymorphisms showed no association with cervical cancer. However, interaction of miRNA polymorphisms with smoking habit showed higher risk of cervical cancer with miRNA 196a2 polymorphism in patients with smoking but no significant modification in the risk of cervical cancer was seen for other polymorphisms. Conclusion: The results of the present study demonstrate that, miRNA 499 T/C polymorphism is significantly associated with genetic susceptibility to cervical cancer and may have a role in its pathogenesis.

Awareness of Patients Rights among Inpatients of a Tertiary Care Teaching Hospital– A Cross-sectional Study

Upasana Agrawal, Brayal C D’Souza, Arun Mavaji Seetharam

Introduction: The rights of a patient are a set of rules of conduct which govern the interaction between the patients' and healthcare professionals. Every patient has a right to be informed about their rights and also the responsibility of the healthcare provider. Aim: To assess awareness among inpatient about patients' rights at an academic accredited hospital. Materials and Methods: A questionnaire based cross-sectional study was carried out among 350 patients admitted to the wards of a Tertiary Care Teaching Hospital. A 21-point questionnaire was developed based on standards of the National Accreditation Board for Hospitals and Healthcare Providers (NABH) and patients' charter of rights and validated. This charter of rights is also displayed in the hospital for patient’s awareness. Frequencies and percentages were depicted. Chi-square test was used for statistical analysis. Results: Positive awareness among the patients ranged from 28% to 97.4%. Females were more aware of their rights than males for 11 out of the 21 patient rights items. Younger adults were more aware than any other age group participants. Participants who were admitted to wards of higher categories (deluxe rooms) had high degree of awareness about patients’ rights and education. Patients from urban areas and higher educational status were more aware than patients coming from rural areas. Conclusion: The study concludes that effective measures should be taken to improve the overall awareness not only among patients but also among different stakeholders in the healthcare delivery system. Readability of the patients' rights charter with good readability score, developing and distributing patient education materials in simple language about the rights and responsibilities to the patient and their family/relatives during their stay in the hospital or at the time of registration. Continuing nursing and medical education in medical teaching institutions and hospitals should focus on patients' rights and its importance, its need for awareness and its consequences should be taught to students and hospital staff. Patient Right Committee in the hospital should be established for supervision monitoring and observance of patients’ rights.

Radiological Manifestations of Pulmonary Tuberculosis - A Comparative Study between Immunocompromised and Immunocompetent Patients

Manoj Mathur, Rajesh K Badhan, Sudesh Kumari, Navkiran Kaur, Saryu Gupta

Introduction: Pulmonary tuberculosis has atypical radiological manifestations in patients with underlying immunocompromised disease like diabetes and human immunodeficient virus infection. Computed tomography has important role in such patients for early diagnosis of disease and management to minimize complication. Aim: To evaluate and compare the computed tomography chest features of pulmonary tuberculosis in between immunocompromised patients and immunocompetent patients. Materials and Methods: This cross-sectional study was conducted in the hospital on newly diagnosed 60 pulmonary tuberculosis patients of which 30 patients had no underlying disease (Immunocompetent Group) and 30 patients had diabetes mellitus or were human immunodeficiency virus seropositive (Immunocompromised Group). CT scan of chest were evaluated for each patient. Results: In immunocompetent patients, 36.7% had radiologically atypical presentation,90% had nodular opacities, 73.3% had consolidation, 23.3% had lymphadenopathy, 60% had cavitation and cavitatory lesion were single in 94.4% patients. Isolated upper lung field were involved in 60% patients. In immunocompromised patients 76.7% had radiologically atypical presentation, 66.7% had nodular opacities, 46.7% had consolidation, 63.3% had lymphadenopathy, 20% had cavitation and cavitatory lesions were multiple in 60% patients. Isolated lower lung field were involved in 23.3% patients. Conclusion: We concluded that immunocompromised patients have more atypical involvement of lung fields, higher prevalence of lymphadenopathy as compared to immunocompetent patients. Diabetic patients have multiple cavitatory lesions as compared to non-diabetic patients. HIV seropositive patients have more prevalence of lymphadenopathy as compared to HIV seronegative patients.

Rapid and Accurate Diagnosis of Acute Pyogenic Meningitis Due to Streptococcus Pneumoniae, Haemophilus influenzae Type b and Neisseria meningitidis Using A Multiplex PCR Assay

Introduction: Acute bacterial meningitis is one of the major causes of morbidity and mortality in children and geriatric population, especially in developing countries. Methods of identification are standard culture and other phenotypic tests in many resource poor settings. Aim: To use molecular methods for the improvement of aetiological diagnosis of acute pyogenic meningitis in patients. Materials and Methods: CSF samples of 125 patients were included for the study. Gram staining and culture were performed according to standard procedures. Antigen was detected using commercial latex agglutination test kit. Multiplex PCR was performed using previously published primers and protocols. Fischer’s exact test was used for finding association between presence of the disease and clinical/biochemical parameters, considering two tailed p<0.05 as statistically significant. Sensitivity, specificity, positive and negative predictive values were calculated using Graphpad QuicCalc software. Results: A total of 39 cases (31.2%) were confirmed to be of acute pyogenic meningitis based on biochemical methods. Only 10/39 was positive for the three organisms tested. Multiplex PCR was able to detect one additional isolate each of Streptococcus pneumoniae and Haemophilus influenzae type b. When compared with multiplex PCR as the gold standard, culture and latex agglutination tests had same sensitivity (80%), specificity (100%), PPV (100%) and NPV (97.8%), whereas Gram stain had poor sensitivity (40%) and good specificity (95.6%). Detection rates were higher in multiplex PCR for the two organisms Streptococcus pneumoniae and Haemophilus influenzae type b. Conclusion: Multiplex PCR was more sensitive than culture or antigen detection, and employing this assay can significantly increase the speed and accuracy of identification of the pathogen.

Therapeutic Efficacy of Ozone Injection into the Knee for the Osteoarthritis Patient along with Oral Celecoxib and Glucosamine

XU Feng, Li Beiping

Introduction: Suffering from osteoarthritis is prevalent among elderly patients so the use of intra-articular injection of medical ozone may well be the effective way to relieve their pain. Aim: To evaluate the effect of intra-articular injection of medical ozone given into the knee of the osteoarthritis patients, and to compare it with taking celecoxib and glucosamine orally. Materials and Methods: In the present study, 76 patients suffering from osteoarthritis were randomly assigned into two groups. In the ozone group, 20 ml ozone-oxygen mixture gas concentration of 20 µg/ml was injected into knee articular cavity and each patient took oral celecoxib and glucosamine hydrochloride. Patients in control group only took the celecoxib and glucosamine hydrochloride orally. Pain score and Lysholm knee score were measured prior to the injection (pretreatment) and at one, three, six weeks after the beginning of the treatment (posttreatment). Results: After the treatment, the pain intensity and function significantly improved in the two groups compared with the pretreatment (p<0.05). In the ozone group, three weeks after intervention, the pain score improved significantly when compared with the control group (p<0.05). After the treatment, the lysholm scores increased significantly (p<0.05), but in the ozone group, it improved faster. Conclusion: Intra-articular injection of ozone plus oral celecoxib and glucosamine could significantly decrease pain intensity in patients with mild to moderate Knee Osteoarthritis (KOA), and improve their functional status early than oral celecoxib and glucosamine only.

Variation in Morphometry of Vastus Medialis Muscle

Hina B Rajput, Sangeeta J Rajani, Vasant H Vaniya

Introduction: The Vastus Medialis (VM) muscle divides into two parts, proximal Vastus Medialis Longus (VML) and distal Vastus Medialis Obliquus (VMO). The VMO originates from the tendon of adductor magnus and insert into the medial border of patella and these fibers are nearly horizontal. It exerts medial force vector to counter the lateral force vector of Vastus Lateralis (VL) hence the VM presents a biomechanical advantage over the VL. The functional importance of VML and VMO is well explained but the anatomical evidence of separate identity of VMO is lacking. Aim: To determine muscle fiber angles and lengths of VML and VMO, to find out the distinct nerve supply and fascial plane between VML and VMO and to evaluate VM insertion in relation to patella. Materials and Methods: Thirty intact lower limbs (right-15 and left- 15) from 15 donated cadavers with an age 60 years and above were dissected. Lengths and angles of VML, VMO superior (VMOs) and VMO inferior (VMOi) were measured. The fascial plane and the femoral nerve and its branches supplying VM were dissected and terminal branches were traced in each section with the blunt dissection. All parameters were recorded and statistical analysis was done using one-way ANOVA. Results: The VMO took origin from the adductor magnus muscle and attached to the patella. VMOi was present in 83.33% cases (25 limbs), and inserted to the medial border of patella. The percentages of VML, VMOs and VMOi lengths compared to total VM length were 65.54±4.84, 25.23±4.20 and 9.22±2.17 respectively. The fiber angles ranged for VML, VMOs and VMOi were between 18 to 32, 30 to 46 and 46 to 56 degrees respectively. There were significant differences among all groups (p=0.001). These two parts were not separated by distinct fascial plane and no separate nerve supply was observed but the richest nerve supply to VMO was noted. Conclusion: The present study conclude that VMO is having obtuse angle, horizontal fibers and richest nerve supply as compared to proximal part which make it functionally as a separate entity but not anatomically.

A Comparative Study of High Sensitivity C-Reactive Protein and Metabolic Variables in Type 2 Diabetes Mellitus with and without Nephropathy

Abid K Shaheer, Jithesh K Tharayil, Parvathi W Krishna

Introduction: Diabetic nephropathy is a serious chronic complication of Type 2 Diabetes Mellitus (T2DM) which impairs the quality of life, leading to increased morbidity and mortality. The high sensitivity C-reactive protein (hs-CRP) is an acute phase reactant which acts as a non-specific systemic marker of inflammation. Aim: To find out the relationship between serum hs-CRP and metabolic variables in Type 2 diabetic patients with and without nephropathy. Materials and Methods: The study group consists of 96 subjects that include non-diabetic healthy controls, Type 2 diabetic patients without any complications and patients with diabetic nephropathy. The study group was composed of both genders, aged 31-70 years, who reported after 10-12 hours overnight fasting; then, venous blood and fresh urine samples were collected, in the morning from all the study subjects. Data were analysed using Statistical Package for the Social Sciences (SPSS). Independent t-test was used to compare between the groups and Chi square test was used to find out the relationship between serum hs-CRP and metabolic variables. Results: The results showed a significantly (p<0.05) increasing trend of serum hs-CRP with the degree of microalbumin excretion and the severity of nephropathy in Type 2 diabetic patients. The result showed a significant (p<0.05) relationship between hs-CRP and the metabolic variables like Fasting Blood Glucose (FBG), Post Prandial Blood Glucose (PPBG), Total Cholesterol (TC), Triglycerides (TG), LDL-Cholesterol (LDL-C), TC:HDL-Cholesterol (HDL-C) ratio and estimated Glomerular Filtration Rate (eGFR) and no significance (p>0.05) between hs-CRP and HDL-Cholesterol in both diabetic and diabetic nephropathy subjects. Conclusion: Hs-CRP was strongly associated with the metabolic variables and predictors of cardiovascular risk in Type 2 diabetes mellitus with and without nephropathy. The hs-CRP might be considered as a predictor or illness indicator for the development of nephropathy and cardiovascular risk in Type 2 diabetic patients.

Cirrhosis of Liver and Diabetes Mellitus: The Diabolic Duo?

Introduction: Cirrhosis of the liver and diabetes mellitus are two chronic illnesses with significant impact on the quality of life. Studies from different part of the world have shown the combination to be associated with higher incidence of complications of cirrhosis and reduced survival. However, data on the impact of pre-cirrhotic and post-cirrhotic diabetes on cirrhosis is minimal. Aim: The aim of the study was to determine the complications of cirrhosis patients with and without co-existent DM and to compare the relation between cirrhosis patients with antecedent DM and hepatogenous DM. Materials and Methods: This was a prospective study conducted at a tertiary care hospital in Kerala, India, over a period of three years. Cirrhosis patients with and without diabetes, along with subcategorization as antecedent/hepatogenous diabetes, were studied for various complications and outcome including death. Chi-square and Mann-whitney tests were used for comparing data. Results: Patients with cirrhosis and diabetes had higher incidence of gall stones (27.6% versus 13.2%; p=0.008) and urinary infection (29.3% versus 7.5%; p=<0.001). Incidence of hepatocellular carcinoma and mortality were similar between the groups. Patients with antecedent diabetes and hepatogenous diabetes were similar with respect to complications and mortality. Child-Turcotte-Pugh (CTP) score, Model for End stage Liver Disease (MELD) score, urinary tract and respiratory infections and duration of cirrhosis were independent predictors of mortality in patients with cirrhosis. Conclusion: Coexistent diabetes mellitus increases the incidence of complications and hospitalizations in cirrhosis patients but without impact on mortality rates. There is no significant morbidity or mortality difference between cirrhotics with antecedent diabetes and hepatogenous diabetes.

Imaging Findings of Solid Pseudopapillary Neoplasms of the Pancreas on Multiphasic Multidetector CT Scan – A Single Institute Experience from Southern India

Introduction: Solid Pseudopapillary Neoplasms (SPN) are uncommon pancreatic tumours and are slow growing with uncertain malignant potential, showing female preponderance. Postoperative prognosis is good and metastasis is rare. Aim: To summarise the imaging and pathological features of seven cases of SPN in three years period, from January 2013 to January 2016. Materials and Methods: In this retrospective study the imaging features of seven cases on triphasic multidetector Computed Tomogram (CT), a 16-slice scanner, were reviewed along with CT-guided Fine Needle Aspiration Cytology (FNAC) and histopathological examination. Statistics were expressed in terms of percentiles. Results: All cases were female patients with an age range of 13-35 years (mean: 23.3 years). On CT assessment, the size of the tumours varied from 2.5-14 cm (mean: 5.3 cm). All these tumours were well capsulated and round to oval in shape. In four out of seven cases, the tumour was located in the tail of pancreas. All the solid enhancing portions showed moderate enhancement of at least 20-30 HU compared to unenhanced scan, on the other hand the cystic parts remained unenhanced with <5 HU variation in comparison to the plain scan. Histopathological examination exhibited characteristic poorly cohesive cuboidal cells arranged in papillaroid pattern having fine nuclear chromatin with nuclear grooves. Conclusion: Solid pseudopapillary neoplasm is a high diagnostic possibility in case of a young female having pancreatic mass and needs to be evaluated with triphasic contrast enhanced CT scan, followed by FNAC and or histopathological examination.

Estimation of Correlation between Chronological Age, Skeletal Age and Dental Age in Children- A Cross-sectional Study

Introduction: In the modern era, identification and determination of age is imperative for diversity of reasons that include disputed birth records, premature delivery, legal issues and for validation of birth certificate for school admissions, adoption, marriage, job and immigration. Several growth assessment parameters like bone age, dental age and the combination of both have been applied for different population with variable outcomes. It has been well documented that the chronological age does not necessarily correlate with the maturational status of a child. Hence, efforts were made to determine a child’s developmental age by using dental age (calcification of teeth) and skeletal age (skeletal maturation). Aim: The present study was aimed to correlate the chronological age, dental age and skeletal age in children from Southeastern region of Andhra Pradesh, India. Materials and Methods: Out of the total 900 screened children, only 100 subjects between age groups of 6-14 years with a mean age of 11.3±2.63 for males and 10.77±2.24 for females were selected for the study. Dental age was calculated by Demirjian method and skeletal age by modified Middle Phalanx of left hand third finger (MP3) method. Pearson's and Spearman's correlation tests were done to estimate the correlation between chronological, dental, and skeletal ages among study population. Results: There was a significant positive correlation between chronological age, dental age and all stages of MP3 among males. Similar results were observed in females, except for a non-significant moderate correlation between chronological age and dental age in the H stage of the MP3 region. Conclusion: The results of the present study revealed correlation with statistical significance (p<0.05) between chronological, dental and skeletal ages among all the subjects (48 males and 52 females) and females attained maturity earlier than males in the present study population.

An In vitro Study to Compare the Effect of Different Types of Tea with Chlorhexidine on Streptococcus mutans

Dona Elizabeth George, Roshan Shetty, Pooja J Shetty, Leslie Allan Gomes

Introduction: Tea is the second most commonly consumed beverage in the world after water. The leaf and bud of the plant Camellia sinensis produces tea. The different forms of tea are ‘non-fermented’ green tea, ‘semi-fermented’ oolong tea and ‘fermented’ black tea according to the manufacturing process. Streptococcus mutans is the main causative organism in dental caries and plaque formation. Aim: The present study was undertaken to determine the antibacterial effectiveness of aqueous and ethanol extracts of green tea, black tea and oolong tea against S. mutans in comparison with 0.2% chlorhexidine. Materials and Methods: An in vitro study was conducted to compare the effectiveness of aqueous and ethanol extracts of green tea, black tea and oolong tea with 0.2% chlorhexidine against S. mutans. Chlorhexidine 0.2% commercially available as mouthwash was used as such for comparison. The antimicrobial activity was determined using agar well diffusion method. About 50 µl of the aqueous and ethanol extracts of tea and 0.2% chlorhexidine were inoculated into the wells prepared on blood agar plates smeared with S. mutans. The agar plates were incubated for 24 hours after which the diameter of the zone of inhibition was measured. Analysis of Variance (ANOVA) followed by Tukey's post hoc test were used for statistical analysis. Results: The mean zone of inhibition of the aqueous extracts of green tea, black tea, oolong tea and chlorhexidine was found to be 16.33 mm, 10.33 mm, 19.66 mm and 22 mm respectively. The mean zone of inhibition of the ethanol extracts of green tea, black tea, oolong tea and chlorhexidine was found to be 14 mm, 9 mm, 20.66 mm and 22 mm respectively. The study result state that the inhibitory effect of chlorhexidine is almost similar to that of oolong tea followed by green tea and black tea. Conclusion: From the present study, it can be concluded that the aqueous and ethanol extracts of oolong tea showed highest antimicrobial activity compared to green tea and black tea.

Role of HER-2/neu in Premalignant and Malignant Lesions of Uterine Cervix

Introduction: In light of literature and controversy that exists in various cervical lesions, this prospective study was designed to explore the expression of Human Epidermal Growth Factor Receptor-2 (HER-2/neu) in the cervical lesions and its correlation with the histopathological grade and type of tumour. Immunohistochemistry (IHC) was performed to evaluate HER-2/neu expression as it is the most reliable method of detecting overexpression of HER-2/neu. Aim: To assess the role of HER-2/neu expression in premalignant and malignant lesions of uterine cervix. Materials and Methods: Seventy cases of premalignant and malignant cervical lesions received in our department from January 2015 to December 2016, were included in study and Polyclonal Rabbit Anti-Human c-erbB-2 oncoprotein from DAKO was used. Standard streptovidin-biotin peroxidase method of IHC was followed. A golden brown membrane and cytoplasmic staining was taken as a positive reaction and intensity of expression was graded according to the 2014 ASCO/CAP guidelines for HER-2/neu reporting. Results: Out of total 70 cases, HER-2/neu expression scores were 0 in 64.3% {23 cases of Cervical Intraepithelial Neoplasia (CIN) and 22 of Squamous Cell Carcinoma (SCC)}, +1 in 22.9%, (04 cases of CIN and 12 of SCC) +2 in 10% (06 cases of SCC and 01 of adenosquamous carcinoma) and +3 in 2.9% (02 cases of adenocarcinoma) cases. HER-2/neu overexpression rate was significantly higher in malignant (48.8%) as compared to pre malignant (14.8%) cases (p=0.004) and expression scores were higher (+2 and +3) in 20.9% of malignant cases as compared to none of pre malignant cases (p=0.020). Significant higher HER-2/neu scores are seen (+2 and +3) in all the adenocarcinoma cases as compared to 15% cases of SCC (p<0.001). Among malignant cases, HER-2/neu expression was statistically significantly higher in {Moderately Differentiated (MD) + Poorly Differentiated (PD)} 59.09% as compared to {Well Differentiated (WD)} 38.09% cases (p=0.090). Conclusion: Study shows that expression of HER-2/neu is relatively lower in cervical lesions. However, the results of our study show that with shift from well to poorly differentiated lesions; the HER-2/neu expression rate shows an incremental trend.

Characterization of Vancomycin Resistant Enterococci in Hospitalized Patients and Role of Gut Colonization

Introduction: Enterococci are part of the normal intestinal flora and have been recognized as important human pathogens. Vancomycin Resistant Enterococci (VRE) are global threat as this resistance is transmissible and also poses a challenge for infection control. Aim: This study was undertaken to study phenotypic and genotypic characteristics of VRE from clinically significant infections among hospitalized patients and their association with gut colonization. Materials and Methods: Clinically significant isolates of enterococci (n=250) were studied. Species confirmation was done by Polymerase Chain Reaction (PCR). Minimum Inhibitory Concentration (MIC) for vancomycin was determined by E-test. PCR for VanA, VanB and VanC1 gene was done for genotypic characterization. MIC for teicoplanin, linezolid, tigecycline, daptomycin and quinupristin-dalfopristin was determined by E test. Patients with VRE infection were screened for gut colonization using vancomycin screen agar (6 µg/mL). Continuous data was analysed using the Student’s t-test. Categorical data was assessed using Pearson’s Chi-square test. A value of p = 0.05 was considered statistically significant. Results: There was good correlation between the phenotypic and genotypic methods used for species identification and detection of vancomycin resistance. E. faecium (162, 64.8%) was most common followed by E. faecalis (82, 32.84%) and E. gallinarum (6, 2.4%). Overall higher resistance was observed among E. faecium. Vancomycin MIC = 2 µg/mL was noted in 63 (25.2%) isolates. Fifty seven isolates showed presence of vanA and vanC1 was detected in six isolates of E. gallinarum. Isolates with VanB genotype was not detected in the present study. MIC50 (µg/mL) for teicoplanin, linezolid, tigecycline, daptomycin and quinupristin-dalfopristrin was 24, 0.75, 0.064, 2 and 0.064 respectively. Resistance to linezolid (1, 1.6%) and tigecycline (2, 3.2%) was rare. Majority (33/47, 70.2%) patients with clinically significant VRE infection showed gut colonization. Conclusion: Vancomycin resistance among enterococci is emerging. Emergence of tigecycline and linezolid resistance is also posing a challenge for clinicians. Thus, further investigations are warranted to control vancomycin resistance among pathogens.

Risk Factors for Kidney Stones in Rural Puducherry: Case-Control Study

Amol R Dongre, M Rajalakshmi, Pradeep R Deshmukh, MR Thirunavukarasu, Ravi Kumar

Introduction: Renal stone is a distressing chronic condition which is getting common across the world. The rigorous evidence on multiple risk factors of kidney stone from a single study is limited. Aim: To find out the social and dietary risk factors responsible for the occurrence of kidney stone in a local community in rural Puducherry, India. Materials and Methods: It was a hospital-based unmatched case-control study. Based on existing information, a sample of 70 cases and 140 controls was calculated and considered adequate. The exposure information on recent cases was uniformly collected by interview and review of radiologic records and exposure information for controls was collected through interviews. Associations between the occurrence of renal stone as a dependent variable and multiple independent variables such as age, sex, socioeconomic status, type of family, religion, the source of drinking water and dietary practices were studied by using multiple logistic regression analysis. Results: We found associations of occurrence of kidney stone with genetic predisposition (OR:16.98, CI;3.02-95.25), less frequency of urine per day (OR:5.95, CI;1.03-34.19) and dietary habit of eating red meat once a week (OR:32.28, CI; 9.7-143.2) and even once a month (OR:5.20, CI;1.44-18.77). Conclusion: The risk of kidney stone was found high among those who had genetic predisposition, less frequency of urination per day and those who consumed red meat once a month or more. Patients and local community should be educated to reduce the red meat consumption and increase the consumption of water and fluid, especially during the hot climates.

Analysis of Patient’s Satisfaction with Phlebotomy Services in NABH Accredited Neuropsychiatric Hospital: An Effective Tool for Improvement

Anshu Gupta, Tanima Dwivedi, Sadhana, Raju Chaudhary

Introduction: Patients satisfaction is the need of the hour and one of the most important quality indicators in the laboratory medicine. Aim: To assess the patient’s satisfaction with phlebotomy services in a neuropsychiatric hospital by a structured questionnaire with grading scale also identify the problems causing dissatisfactions and to undertake necessary Corrective and Preventative Action (CAPA). Materials and Methods: Total 1200 patients were randomly selected over a period of two months (June and July 2016). A structured self designed questionnaire (feedback form) was devised in both Hindi and English languages containing ten questions with a grading scale for each question. It also included suggestions from the users. All the selected patients or their attendants filled up this questionnaire. At the same time, they were also interviewed by phlebotomy staff. A statistical analysis was conducted using SPSS version 16.0 software and Likert scale. Results: A total of 94% of the patients were satisfied with the phlebotomy services. Almost 30.0% patients found the phlebotomy services to be very good, but the majority of them (40.5%) found it to be good and another 23.5% found it to be satisfactory while, 4% found the services to be poor and 2% found it to be very poor. The highest rate of satisfaction (4.21) was noted in case of parameter-ease to find collection sample room and lowest rate of satisfaction (3.92) was scored by the parameter-staff’s wearing proper uniform. Depending upon the deficient areas some corrective actions were suggested such as strict compliance of personal protective equipments, regular training to improve technical skill, knowledge and behaviour with emphasis on cleanliness of work area. Conclusion: Even though the overall patient’s satisfaction was high, there were areas which needed our attention such as waiting time for phlebotomy procedure, lack of proper sitting arrangement, techniques of sample collection, knowledge of universal precautions etc. Appropriate corrective and preventive actions were taken to solve the problems. Thereby, feedback proved effective in maintenance and improvement of phlebotomy services.

Comparative Evaluation of Antiplaque Efficacy of Coconut Oil Pulling and a Placebo, Among Dental College Students: A Randomized Controlled Trial

Introduction: Oil pulling, has been extensively used as traditional Indian folk remedy since many years to prevent dental diseases and for strengthening teeth and gums. Aim: To compare and evaluate antiplaque efficacy of coconut oil pulling with a placebo among dental students, in Hyderabad city of India. Materials and Methods: A randomized controlled study was carried out among 40 dental students. Out of 40, 20 subjects were randomly assigned to study group and other 20 to control group. Subjects in the study group were given the coconut oil and control group a placebo, and advised to rinse for 10 minutes, once daily in the morning for a period of seven days. Plaque levels were assessed on day zero, third and seventh day using Turesky-Gilmore-Glickman Modification of the Quigley-Hein Plaque Index (1970) for both the groups. Results: The mean plaque scores showed a significant difference at baseline, third day and seventh day among both study (p<0.001) and control groups (p<0.001). Group wise comparison revealed, though the mean plaque scores were low among study group on third day and seventh day on comparison with the control group, significant difference was noticed only on the seventh day. Furthermore, the mean percentage reduction of plaque scores were also significant only on the seventh day with a high mean plaque reduction among study groups (p<0.001). Conclusion: Oil pulling is effective in controlling plaque levels.

Global Search Trends of Oral Problems using Google Trends from 2004 to 2016: An Exploratory Analysis

Introduction: Oral diseases are pandemic cause of morbidity with widespread geographic distribution. This technology based era has brought about easy knowledge transfer than traditional dependency on information obtained from family doctors. Hence, harvesting this system of trends can aid in oral disease quantification. Aim: To conduct an exploratory analysis of the changes in internet search volumes of oral diseases by using Google Trends© (GT©). Materials and Methods: GT© were utilized to provide real world facts based on search terms related to categories, interest by region and interest over time. Time period chosen was from January 2004 to December 2016. Five different search terms were explored and compared based on the highest relative search volumes along with comma separated value files to obtain an insight into highest search traffic. Results: The search volume measured over the time span noted the term “Dental caries” to be the most searched in Japan, “Gingivitis” in Jordan, “Oral Cancer” in Taiwan, “No Teeth” in Australia, “HIV symptoms” in Zimbabwe, “Broken Teeth” in United Kingdom, “Cleft palate” in Philippines, “Toothache” in Indonesia and the comparison of top five searched terms provided the “Gingivitis” with highest search volume. Conclusion: The results from the present study offers an insight into a competent tool that can analyse and compare oral diseases over time. The trend research platform can be used on emerging diseases and their drift in geographic population with great acumen. This tool can be utilized in forecasting, modulating marketing strategies and planning disability limitation techniques.

The Association between Periodontal Status, Serum Lipid Levels, Lipoprotein Associated Phosholipase A2 (Lp-PLA2) in Chronic Periodontitis Subjects and Healthy Controls

Bittu Saira Koshy, Jaideep Mahendra

Introduction: Lipoprotein associated phospholipase A2 (Lp-PLA2) has been explored as a potential biomarker for Cardiovascular Disease (CVD). The human Lp-PLA2 is a serine-dependent, Ca2+- independent enzyme. It gives way to oxidised free fatty acids and lysophosphatidyl choline by hydrolysing oxidised phospholipids, that leads to smooth muscle cell apoptosis, inflammatory cell chemotaxis and endothelial cell dysfunction in CVD. Owing to its role in inflammation, it may influence the development and progression of periodontitis as well. Aim: To compare the demographic variables, Gingival Index(GI), Bleeding On Probing (BOP) , Probing Pocket Depth (PPD), and Clinical Attachment Level (CAL) with serum lipid profile and Lp-PLA2 level in Chronic Periodontitis (CP) subjects. Materials and Methods: A total of 75 subjects were selected and divided into three groups; based on the inclusion and exclusion criteria: Group I - 25 subjects with severe generalized CP with CAL = 5 mm in more than 30% of sites. Group II - 25 subjects with moderate generalized CD with clinical CAL 3 mm-4 mm in more than 30% of sites. Group III- 25 systemically and periodontally healthy volunteers who served as control. Clinical parameters such as Plaque Index (PI), BOP, Probing Depth (PD) and CAL , lipid profile such as Total Cholesterol (TC), Triglyceride (TG), High density Lipoprotein (HDL), Low Density Lipoprotein (LDL), Very Low Density Lipoprotein (VLDL) as well as Lp-PLA2 were assessed. One-way ANOVA and Tukey's Post-hoc test were used for data analysis. Results: Age was higher in Group I and II when compared to Group III. Group II showed a significant correlation between PI and LDL. In Group III, lower PI was significantly correlated with high HDL and low LDL and BOP was positively correlated with TG and HDL. A significant association of Lp-PLA2 was found to be higher with increase in the TG and VLDL level in Group I and Group II when compared to Group III. Conclusion: The study concluded that Lp-PLA2, TG and VLDL already being a predictor biomarker for atherosclerotic disease can be an inflammatory marker for periodontitis.

To Evaluate the Correlation Between Skeletal and Dental Parameters to the Amount of Crowding in Class II Div. 1 Malocclusions

Shivani Singh, G. Shivaprakash

Introduction: Crowding of teeth is one of the most common problem that motivates the patient to seek orthodontic treatment. Determination of etiology of crowding could have a significant effect on treatment planning and prognosis of Class II malocclusion. Aim: Aim of this study was to evaluate the relationship of skeletal and dental parameters to amount of dental crowding in patients with Class II Divison 1 (div.1) malocclusion. Materials and Methods: Pretreatment lateral cephalograms and dental casts of 60 patients with skeletal Class II malocclusion were collected for the study. The sample was divided into two groups according to severity of pretreatment mandibular crowding. Group I consisted of cases with crowding =3 mm and Group II with crowding <3 mm. Lateral cephalograms for each patient was manually traced and skeletal parameters (effective maxillary and mandibular length, mandibular plane angle, Y Axis, lower anterior face height) and dental parameters (axial inclination of lower incisor, inclination of lower incisor to mandibular plane, interincisal angle) were measured. Unpaired t-test was used for intergroup comparison and relationship between different measurements was investigated using Pearson correlation coefficient. Results: Among the skeletal parameters measured, only effective mandibular length exhibited statistically significant difference between the two groups. No statistically significant difference was found between the two groups for any of the dental parameters. Significant inverse correlation was found between mandibular crowding and effective mandibular length. Conclusion: Subjects with Class II div.1 malocclusion and moderate to severe mandibular crowding have significantly smaller effective mandibular base length than subjects with the same malocclusion and slight mandibular crowding.

Micronucleus Assay: An Early Diagnostic Tool to Assess Genotoxic Changes in Patients with Tobacco Use, Oral Leukoplakia and Oral Submucous Fibrosis

Moulshree Kohli, Puneet Ahuja, Monica Mehendiratta, Mohit Sharma, Jahnobi Dutta

Introduction: Micronuclei (MNi) are acentric chromatid or chromosome fragments produced via genetic damage through genotoxic agents contained in tobacco and betel nut. Evidently, the various Oral Potentially Malignant Disorders (OPMDs) like oral lichen Planus, oral leukoplakia and Oral Submucous Fibrosis (OSMF) demonstrate MNi, as a substantiation of genetic damage. As these changes can be easily appreciated in oral exfoliated cells, an exfoliated cell based MNi assay might be utilized as handy and non invasive biomonitoring tool for gauging the genetic damage and hence the propensity for malignant transformation in OPMDs. To this end, MNi are definitely easier to evaluate when compared to chromosome aberrations. Aim: To compare the MNi frequency in normal mucosa, in individuals using various tobacco forms without oral leukoplakia, individuals using various tobacco forms with oral leukoplakia, and areca nut chewers with OSMF, using three different stains. Materials and Methods: Oral exfoliated cells from 50 cases of normal mucosa (Group I), 50 cases of tobacco chewing people without Oral Leukoplakia (Group II), 50 cases of people with Oral Leukoplakia (Group III) and 50 cases of areca nut chewers with OSMF (Group IV) were taken. MNi frequencies were compared in these groups using three different stains i.e., Papanicolaou (PAP) stain, May Grunwald Giemsa (MGG) stain and Feulgen stain. The data between cases (Group II, III and IV) and control groups (Group I) was analyzed by Kruskal-Wallis Test. The comparison between two independent groups was done by Mann-Whitney U test and interstain comparison between cases and control was done by Wilcoxon Signed Rank Test and the individual p-value was obtained. Results: A significant increase in the count was observed during transition of normal mucosa to OPMDs. The best stain for detecting MNi was PAP stain followed by MGG stain and Feulgen stain. Conclusion: The higher mean MNi count for PAP stain and MGG stain could be attributed to nonspecific staining. Further study using a larger sample size on quantitative assessment of MNi count in various OPMDs is warranted.

Evaluation of Tumour Associated Macrophages and Angiogenesis in Ameloblastoma

Introduction: Ameloblastoma is a locally invasive odontogenic neoplasm that has a high recurrence rate. The invasion of adjacent tissue is supported by angiogenesis stimulated by Tumour-Associated Macrophages (TAMs). TAMs are macrophages modified in the milieu of the tumour microenvironment and have very weak or no ability to present antigens. Thus, there is collaboration between the tumour and the tumour microenvironment to maintain tumour enlargement. TAMs exist as the classically activated M1 macrophages that possess antitumour activity and the otherwise activated M2 macrophages that support tumour invasion and metastasis. Aim: To investigate the relative expression and topography of TAMs and CD34 in ameloblastoma in order to assess their affiliation and effect on tumour growth. Materials and Methods: Forty-six Formalin Fixed Paraffin Embedded (FFPE) blocks of ameloblastoma were processed for Abcam Mouse monoclonal Anti-CCR7 antibody, Abcam Rabbit polyclonal Anti-CD206 antibody and Dako Mouse monoclonal Anti-CD34 antibody QBEnd-10. Cytoplasmic/membrane brown staining was taken as positive for all antibodies. The relative percentage of TAMs was classified as: <5%, 5-25%, 25-50% and >50%. TAMs related Microvessel Density (MVD) was evaluated as the mean of the three-recorded values. Cases with no CD34+ vessels adjacent to the TAMs region had MVD score of 0. Simple descriptive statistics was applied. Results: Macrophages adjacent to peri-tumour islands were marked by CD206 and CCR7 and we noted negligible intra-tumour presence of positive macrophages. The percentage of positive CCR7 immune cells was greater than that for CD206 in 38 (82.6%) cases, approximately equal to CD206 in 6 (13%) cases, and the CD206 expression was more than CCR7 in only 2 (4.3%) cases. In 34 (73.9%) cases, the area of MVD did not overlap with the region of TAMs but in 4 (8.7%) cases (where MVD overlapped TAM1), the average MVD score was 20. Conclusion: The relative percentage of TAM1 exceeds TAM2 in peri-tumoural areas of ameloblastoma, conferring anti-angiogenic and hence anti-tumour activity on the tumour.

Nagging Presence of Clostridium difficile Associated Diarrhoea in North India

Introduction: Clostridium Difficile Associated Diarrhoea (CDAD) is a significant cause of morbidity in hospitalised patients worldwide. The data on clinical epidemiology of this disease in Indian subcontinent is scarce. Aim: To evaluate the risk factors and clinical course of patients with CDAD. Materials and Methods: A cross-sectional study was planned at our tertiary care centre, All India Institute of Medical Sciences, whereby, all patients who had nosocomial diarrhea between 2010 and 2014 were included in the study. Their clinical and laboratory profile were recorded using structured questionnaire and their stool samples were subjected to ELISA for detection of toxins A and B (Premier toxins A and B). Those patients who had toxins A and B in their stool samples were diagnosed as CDAD. The clinical and laboratory profile of CDAD patients were further analysed. Results: A total of 791 patients with nosocomial diarrhea were included in this study. CDAD was diagnosed in a total of 48 patients (6%). The year wise breakdown of the positive patients is as follows: 7/135 (5.2%), 4/156 (2.6%), 5/141 (3.5%), 9/193 (4.7%) and 23/166 (13.8%) respectively. A total of 16/48 (34%) of CDAD cases belonged to the age group of 51-60 years. Malignancy (n=15, 31.25%) was the most common underlying pathological condition. All the patients had a history of antibiotic intake. Most common antibiotic used in the patients of CDAD was third generation cephalosporins (n=27, 56.25%). The use of clindamycin, carbapenems and colistin increased in the year 2014. Mean duration of hospital stay was 9.8 days. Diarrhoea was associated with fever in 50% of the patients while abdominal pain was seen in 39.6% of the patients. Conclusion: The control of Clostridium difficile infection suffers from the rampant use of higher antibiotics. There is a need for proper implementation of antimicrobial stewardship programmes and better hospital infection control to stop the transmission of this nagging bug.

Paediatric Peripheral Primitive Neuroectodermal Tumour – A Clinico–Pathological Study from Southern India

Introduction: Primitive Neuroectodermal Tumour (PNET)/Ewing Sarcomas (ES) are aggressive childhood malignancies with neuroectodermal differentiation. Aim: To study the clinical presentation, morphology, Immunohistochemistry (IHC), management and outcome of all the cases of paediatric pPNET/ES reported in our tertiary care centre over a period of six years. Materials and Methods: This was a retrospective study conducted at Sri Ramachandra Medical College and Research Institute, Chennai, India. All biopsy proven cases of peripheral PNET/ES, in patients less than 18 years of age for a period of six years were included in this study. The corresponding clinical details regarding initial presentation, treatment and follow up were retrieved from the case files and analysed. Survival rate was calculated and Kaplan-Meier survival curve was plotted. Results: We describe eleven cases of paediatric peripheral PNET/ES. The mean age at presentation was 94.08 (±58.27) months with a male/female ratio of 1.2:1. About 27.3% cases, all male with a mean age of 140 months at presentation, had distant metastasis during initial diagnosis. Biopsy showed small round blue cell morphology on light microscopy. IHC revealed strong membranous staining for CD99 in all cases. All children were treated with neo-adjuvant chemotherapy and then surgery, followed by radiotherapy if indicated. The cases were followed up for a mean duration of 20.82 months (ranging from one to 66 months). Nine children are doing well on follow up (81.8% survival rate). Two cases with metastasis at initial presentation died. Patients with metastatic disease exhibited a mean duration of survival of 9.66 (±7.24) months and those with localized disease exhibited a mean duration of survival of 25 (±22.88) months. Conclusion: Metastasis at diagnosis is the single most important factor affecting prognosis. This was reflected in the present study where cases with metastasis exhibited a short mean duration of survival when compared to localized disease. It is likely that many cases of PNET/ES were not accurately identified in the past as IHC plays a vital role in the diagnosis of these small round blue cell tumours. IHC in adjunct with molecular studies has improved diagnostic accuracy. Multidisciplinary management and good supportive care when the lesion is localized has lead to improved survival.

Radiological Biometric Study of Metatarsals and Phalanges

Shrish Patil, G H Hanumantharaya, Suresh P Desai, Madhumati Nidoni

Introduction: Several diseases affect the forefoot bones. Relative dimensions of the forefoot bones are important considerations for preoperative and postoperative assessment of surgeries. The choice of a particular surgery over another can also be made if the surgeon knows the length to which a bone needs to be lengthened or shortened in comparison to other bones of the forefoot. Aim: To measure the dimensions of the metatarsals and phalanges on standardized radiographs and to determine possible correlations amongst them. Materials and Methods: A cross-sectional prospective study was conducted on 60 volunteer participants of either sex. The dimensions of metatarsals and phalanges were measured on standardized radiographs of both feet in 60 healthy adults. The mean, range and standard deviation were calculated. Correlation analysis was done to assess the association between the variables. Results: The first metatarsal was the shortest (56.42±4.41 mm in males and 50.09±3.06 mm in females) and widest of all metatarsals (13.7±1.00 mm in males and 11.7±0.91 mm in females). The first proximal phalanx was the longest (28.0±2.40 mm in males and 25.8±2.21 mm in females) and the fifth distal phalanx (5.2±1.33 mm in males and 4.4±1.03 mm in females) was the shortest of all phalanges. A strong correlation (p<0.001) exists amongst the lengths of metatarsals, proximal phalanges and middle phalanges, within their own groups. Conclusion: Correlation of the lengths and widths of the forefoot bones amongst themselves and between types can be calculated mathematically utilising standardized radiographs. This helps in assessment of forefoot disorders, choose an appropriate surgical technique and postoperative evaluation.

Effects of Organophosphorus Pesticides on Cardiorespiratory Parameters among the Farmers

Introduction: Indiscriminate use and improper handling of synthetic pesticides in agriculture have resulted in serious problems such as asthma, wheeze and chronic bronchitis among the farmers. Though number of studies have been done on pesticide exposure and its effect on cardiorespiratory parameters in Northern India, only few studies were done in Southern India, thus this study was chosen. Aim: To find the cardiorespiratory changes in farm workers exposed to organophosphorus pesticides. Materials and Methods: Peak Expiratory Flow Rate (PEFR), blood pressure, pulse rate were measured among 35 farm workers of Palayam and Naduveerpattu village of Cuddalore district and 35 age, sex, BMI matched controls were taken from urban area and the same parameters were measured in both groups from 10 am-12 am in the morning. History of use of personal protective equipments like face mask, eye mask, special clothes, shoes, hat, history of respiratory symptoms and hygienic work practices was also obtained from the farmers. Chi-square test was used to analyse the qualitative data. All values were expressed as Mean±SD. Students unpaired t-test was used to compare PEFR between two groups and to compare the duration of exposure and PEFR using GRAPH PAD PRISM. The p<0.05 was considered to be statistically significant. Results: There was a significant decrease in PEFR among the farmers (p<0.001) compared to the controls. On comparing the duration of exposure of pesticide and the PEFR values by unpaired Students t-test, there was a significant difference with p-value of 0.03. Blood Pressure did not show any significant difference between the two groups. But the pulse rate was significantly decreased among the farmers (p<0.001) which could be due to their regular physical activity. About 71% of the farmers used personal protective equipments. Conclusion: Thus, chronic exposure to organophosphorus pesticides has an impact on PEFR among the farmers.

The Association between Prolonged Jaundice and TATA Box Dinucleotide Repeats in Gilbert’s Syndrome

Introduction: Jaundice is a common condition during the neonatal period. Prolonged jaundice occurs in a large number of breastfed infants, considering the impact of genetic factors on the incidence of jaundice. Aim: To determine the association between prolonged jaundice and TATA box dinucleotide repeats in Gilbert’s Syndrome (GS). Materials and Methods: In this case-control study, the case group consisted of 51 neonates with jaundice, aged more than two weeks with indirect bilirubin level higher than 10 mg/dl. Acute diseases, mother’s use of phenobarbital and other medications were the exclusion criteria. The control group consisted of 54 newborns without jaundice. The two groups were matched in terms of age and sex. TATA box polymorphisms in the promoter region of UGT1A1 gene were evaluated using Polymerase Chain Reaction (PCR) in order to determine TATA box dinucleotide repeats. Results: Overall, 64.7% and 50% of subjects in the case and control groups were male, respectively (p=0.168). The mean age of neonates in the case and control groups was 20.1±7.1days and 18.8±4.1 days, respectively. The distribution of Gilbert genome was not significantly different between the two groups. In the case group, 13.7% of the subjects were homozygous, 37.3% were heterozygous and 49% were normal. In the control group, 7.4% of the participants were homozygous, 35.2% were heterozygous and 57.4% were normal. Conclusion: The results of this study showed an association between TATA box polymorphism and prolonged jaundice in neonates which revealed that TATA box polymorphism is an important risk to increase and extend icterus.

Pattern of Isolated Fatal Mechanical Injury in Homicidal Deaths: A Cross-Sectional Study

Kiran Kumar Patnaik1, Sudeepa Das2, Sachidananda Mohanty3, Hemanta Panigrahi4

Introduction: Homicide is the death of one human being as a result of conduct of another. Multiple assaults on the body are seen in 70% cases, which indicate determination on the part of the accused to end the life of the victim. Aim: To identify the pattern, distribution and means of inflicting fatal isolated mechanical injury on the body in cases of homicide. Materials and Methods: This cross-sectional study was conducted on total 728 homicide deaths, out of which 63 cases had an isolated fatal mechanical injury over the body and the rest 665 cases had multiple injuries. The data collected from the study sample were recorded in a case record form and was analysed using Graphpad Prism 5.0. Results: Homicidal deaths occurring due to an isolated bodily injury were 8.65%. Most of the victims (82%) were males. Those in the age group more than 60 years and less than 10 years together constituted 38% of the cases having isolated fatal homicidal injury. Sharp cutting weapons were used in most of the cases (46.03%) followed by use of hard and blunt weapon in 20.63%. The most common site of isolated injury causing homicide was head (41.26%) followed by the neck in 31.74%. The least common site of injury was the groin/scrotum (7.93%). The leading mode of death was coma (38.09%) followed by haemorrhagic shock in 34.92%. Conclusion: Victims of homicidal deaths with isolated bodily injury showed a distinct pattern in comparison to deaths due to homicide with multiple injuries, which can be an indicator of the degree of aggression, magnitude of violence and the determination or intention of the assailant to kill.

In vitro Evaluation of Resin Infiltrant Penetration into White Spot Lesions of Deciduous Molars

Introduction: Caries Infiltration is a recent microinvasive restorative technique that permits treatment of non-cavitated demineralized lesions, known as White Spot Lesions (WSL). Aim: To evaluate the extent of penetration of a commercially available resin caries-infiltrant into natural WSL occurring in deciduous tooth enamel. Materials and Methods: Deciduous molars with natural WSL on any smooth surface were selected and sectioned into halves to yield equal control and experimental groups. Therefore, 25 samples in the control group were untreated whereas 25 samples in the experimental group were treated with caries-infiltrant according to the manufacturer’s instructions. Samples were then evaluated under cross-polarized light microscope. Lesion Depth (LD) and Penetration Depth (PD) of the caries-infiltrant were measured quantitatively and descriptive statistics were calculated. Results: Mean LD (standard deviation) for all samples (n=50) was 367(±182) µm. Caries-infiltrant demonstrated varying depths of resin penetration into the natural white spot lesions of deciduous molars. Mean PD (standard deviation) was 352 (± 141) µm. Conclusion: Resin-infiltrants can deeply and predictably penetrate enamel porosities in natural WSL in deciduous molars and impede lesion progression and prevent cavitation.

A Comparison of Clinicopathological Differences in Oral Squamous Cell Carcinoma in Patients Below and Above 40 Years of Age

Supriya Nikita Kapila, Srikant Natarajan, Karen Boaz

Introduction: Recent times have revealed an increase in incidence of Oral Squamous Cell Carcinoma (OSCC) in young adults including those who lack association with typical risk factors such as tobacco. There are reported variations in clinical behaviour of tumours in young and older individuals. Aim: Present study evaluated differences in clinicopathological characteristics between two groups of OSCC, below and above 40 years of age. Materials and Methods: An analytical study was performed on two groups of OSCC patients, below and above 40 years of age. Clinicopathological parameters of site distribution, type of habit, histological grade, nodal metastasis, margin status, mitotic index and Argyrophilic Nucleolar Organizing Regions (AgNOR) count were compared. Chi-square test and Students t- test were applied for statistical analysis. Results: Present study revealed that mean AgNOR count was significantly higher in older group (6.38) than younger group (4.27). However, no significant differences were noted in site distribution, tobacco habit, histological grade, mitotic index, nodal metastasis and status of resected surgical margins between the two age groups. A trend for increased metastasis and poor histological differentiation was also observed in the older and younger age group respectively. Most common site was buccal mucosa followed by tongue in both groups. Conclusion: Reasons for documented variability in tumour characteristics between young and older patients are currently unclear. Difference in AgNOR count found in present study is suggestive of variability in proliferative and ploidy characteristics between different age groups and supports the hypothesis of genetic and epigenetic influences in development of oral cancer.

Possible Role of Bcl-2 Expression in Metastatic and Non Metastatic Oral Squamous Cell Carcinoma

Introduction: Oral carcinoma is a global health problem. India accounts for one-third of world burden with high prevalence rate of 2.5 million and mortality rate of 5.5 lacs per year. Oral carcinogenesis is a multistage process that frequently involves invasion and metastasis that needs early detection and treatment to improve the overall quality of life. The ability of Oral Squamous Cell Carcinoma (OSCC) to metastasize to lymph nodes does not always show a relationship with clinical staging. A spectrum of molecular mechanisms is involved in carcinogenesis, where defect in the regulation of apoptosis is assumed to contribute to the pathogenesis and progression of cancer. Apoptosis regulatory genes include the antiapoptotic protein such as B-cell lymphoma-2 (Bcl-2) gene that might be used as a molecular marker to evaluate the biological behaviour of oral cancer. Aim: To evaluate and correlate the Bcl-2 expression in OSCC patients with lymphnode metastasis and without metastasis. Materials and Methods: The study comprised of 30 samples, 15 cases of metastatic and 15 non-metastatic primary OSCC. All the cases were stained for routine Hematoxylin and Eosin (H&E), and Bcl-2 antibody by immunohistochemistry. The H&E stained sections were evaluated for Lymphocytic Infiltrate (LI) and Pattern Of Invasion (POI). Bcl-2 stained sections were evaluated for staining intensity and distribution. The differences between the groups were statistically analysed using chi-square test. Results: The histopathological parameters, LI and POI did not show any statistical difference between the study groups. Expression of Bcl-2 in OSCC was 33.3% among the study groups, where metastatic group showed a positive expression of 13.3% and 20% in non-metastatic OSCC that did not show statistically significance among the study groups. Conclusion: There was no significant difference in the expression of Bcl-2 between the study groups. Apoptosis is regulated by interaction among the Bcl-2 gene family. Hence, evaluation of Bcl-2 along with other apoptotic regulating proteins could define the role in pathogenesis and prognosis of metastatic and non-metastatic OSCC.

Clinical Evaluation of Quality of Obturation and Instrumentation Time using Two Modified Rotary File Systems with Manual Instrumentation in Primary Teeth

Lavanya Govindaraju, Ganesh Jeevanandan, EMG Subramanian

Introduction: Pulp therapy in primary teeth has been performed using various instrumentation techniques. However, the conventional instrumentation technique used for root canal preparation in primary teeth is hand instrumentation. Various Nickel-Titanium (Ni-Ti) instruments are available to perform efficient root canal preparation in primary teeth. These Ni-Ti instruments has been designed to aid in better root canal preparation in permanent teeth but are rarely used in primary teeth. It is necessary to assess the feasibility of using these adult rotary files with a modified sequence in primary teeth. Aim: To compare the quality of obturation and instrumentation time during root canal preparation using hand files and modified rotary file systems in primary molars. Materials and Methods: Forty-five primary mandibular molars were randomly assigned to three experimental groups (n=15). Group I was instrumented using k-hand files, Group II with S2 ProTaper universal file and Group III with 0.25 tip 4% taper K3 rotary file. Standardized digital radiographs were taken before and after root canal instrumentation. Root canal preparation time was also recorded. Statistical analysis of the obtained data was done using SPSS Software version 17.0. An intergroup comparison of the instrumentation time and the quality of obturation was done using ANOVA and Chi-square test with the level of significance set at 0.05. Results: No significant differences were noted with regard to the quality of obturation (p=0.791). However, a statistically significant difference was noted in the instrumentation time between the three groups (p<0.05). ProTaper rotary system had significantly lesser instrumentation time when compared to that of K3 rotary system and hand file system. Conclusion: The hand files, S2 ProTaper Universal and K3 0.25 tip 4% taper files systems performed similarly with respect to the quality of obturation. There was a significant difference in instrumentation time with manual instrumentation compared to the modified rotary file systems in primary teeth.

SEM Evaluation of Enamel Surface Changes and Enamel Microhardness around Orthodontic Brackets after Application of CO2 Laser, Er,Cr:YSGG Laser and Fluoride Varnish: An In vivo Study

Tarundeep Kaur, Tulika Tripathi, Priyank Rai, Anup Kanase

Introduction: One of the most undesirable consequences of orthodontic treatment is occurrence of enamel demineralization around orthodontic brackets. Numerous in vitro studies have reported the prevention of enamel demineralization by surface treatment with lasers and fluoride varnish. Aim: To evaluate the changes on the enamel surface and microhardness around orthodontic brackets after surface treatment by CO2 laser, Er,Cr:YSGG laser and fluoride varnish in vivo. Materials and Methods: A double blind interventional study was carried out on 100 premolars which were equally divided into five groups, out of which one was the control group (Group 0). The intervention groups (Group I to IV) comprised of patients requiring fixed orthodontic treatment with all 4 first premolars extraction. Brackets were bonded on all 80 premolars which were to be extracted. Enamel surface treatment of Groups I, II and III was done by CO2 laser, Er,Cr:YSGG laser and 5% sodium fluoride varnish respectively and Group IV did not receive any surface treatment. A modified T-loop was ligated to the bracket and after two months, the premolars were extracted. Surface changes were evaluated by Scanning Electron Microscopic (SEM) and microhardness testing. Comparison of mean microhardness between all the groups was assessed using post-hoc test with Bonferroni correction. Results: Group I showed a melted enamel appearance with fine cracks and fissures while Group II showed a glossy, homogenous enamel surface with well coalesced enamel rods. Group III showed slight areas of erosions and Group IV presented areas of stripped enamel. Significant difference was observed between the mean microhardness (VHN) of Group I, Group II, Group III, Group IV and Group 0 with p<0.001. A significant difference of p<0.001 was observed while comparing Group I vs II,III,IV,0 and Group II vs III,IV,0. However, difference while comparing Group III vs IV was p=0.005 and difference between the mean microhardness of Group 0 vs Group III was non significant. Conclusion: Surface treatment with Er,Cr:YSGG laser causes a positive alteration of the enamel surface increasing its ability to resist demineralization with optimum microhardness as compared to CO2 laser and sodium fluoride varnish.

Oxidative Stress in the Development of Genetic Generalised Epilepsy: An Observational Study in Southern Indian Population

D.K.V. Prasad, U. Satyanarayana, Uzma Shaheen, T. Surya Prabha, Anjana Munshi

Introduction: Oxidative stress resulting from excessive generation of Reactive Oxygen Species (ROS) plays a significant role in neurodegeneration associated with seizures/epilepsy. Aim: To evaluate oxidative stress markers and antioxidant enzymes in Genetic Generalised Epilepsy (GGE) and to know the extent of oxidative stress induced by Anti-Epileptic Drugs (AEDs) with the time duration of treatment. Materials and Methods: In this case-control study, 310 GGE patients (male:female=203:107), who were on AED treatment (n=235) and 75 untreated patients (male:female=49:26) along with 310 age and sex matched healthy controls were recruited. Oxidative stress markers such as Nitric Oxide (NO), Malondialdehyde (MDA) and antioxidant enzyme activities namely Superoxide Dismutase (SOD), Glutathione Peroxidase (GPx) and Catalase (CAT) were measured spectrophotometrically. Results: Significantly higher levels of serum NO, MDA and low levels of plasma Total Antioxidant Capacity (TAC) were found in patients as compared to controls (p<0.001) whereas erythrocyte SOD, CAT and GPx activities were found to be significantly low in patients when compared to the control group (p<0.001). Statistically significant higher levels of NO, MDA and lower levels of SOD, CAT and TAC were observed in patients subgroup, who were on AEDs for more than >5 years compared to other groups (= 1 year and 1-= 5 years) (p=0.02, p=0.01, p=0.001, p=0.01 and p=0.05 respectively). Further, significant increase in the levels of NO, MDA and decreased activities of SOD, CAT were found in treated patients compared to untreated patients (p<0.05) denoting that additional oxidative stress induced by AEDs which results in seizure recurrence and drug intractability. Conclusion: Our study demonstrated that GGE patients have additional oxidative stress due to AEDs and decreased antioxidant enzyme activities causing an imbalance between oxidant and antioxidant status, which might contribute to the pathogenesis of GGE.

Serum Uric Acid in Chronic Obstructive Pulmonary Disease: A Hospital Based Case Control Study

Introduction: Airway inflammation and imbalance between oxidant/anti-oxidant mechanisms are postulated to play a major role in the pathogenesis and exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Previous studies on the role of serum Uric Acid (UA) in COPD subjects have been both confounding and inconclusive. Aim: To measure the serum UA levels among COPD subjects and to correlate with different stages of the disease. Materials and Methods: The study included 39 stable COPD subjects (21 males, 18 females; 13 smokers, 26 nonsmokers; age group; 40 to 60 years) and compared with 46 control subjects from the general population. Serum UA levels were measured by enzymatic colorimetric assay in fully automated analyser (Cobas Integra 400+, Roche, Germany) using commercially available kits from Roche. This was further correlated with duration and severity of COPD {determined as per Global Initiative for Obstructive Lung Disease (GOLD) criteria}. Results: The mean age of COPD and control subjects was 62.97±11.30 and 48.76±12.71 years, respectively (p<0.001). COPD cases had significantly higher level of UA compared to control subjects (4.85±1.67 vs. 2.32±0.93 mg/dl, respectively, p<0.001). Female subjects with COPD had higher levels of UA compared to their male counterparts (5.15±1.89 vs. 4.59±1.45 mg/dl, respectively, p=0.3). Similar insignificant (p=0.56) trend was also observed among control subjects. Hyperuricaemia correlated significantly (p< 0.05) with advance duration (= 10 years) of COPD; whereas, statistically insignificant trend was observed for GOLD stage 3/4 versus stage 1/2 disease. Nonsmokers were having higher uric acid level than smokers. Alcohol intake did not affect the level of uric acid in COPD cases (p=0.79). Conclusion: Serum uric acid is a simple, cost effective biochemical test which may be useful in risk stratification of subjects with newly diagnosed chronic obstructive pulmonary disease. Hyperuricaemia is associated with advance duration and stage of COPD.

Diagnosis of Acute Q Fever by Detection of Coxiella burnetii DNA using Real-Time PCR, Employing a Commercial Genesig Easy Kit

Jothimani Pradeep, Selvaraj Stephen, Stanley Ambroise, Dhandapany Gunasekaran

Introduction: Query (Q) fever is an important zoonosis and a cause of concern for humans, due to the potential bioterrorism threat posed by the causative agent, Coxiella burnetii. Because of the danger of contracting the illness, isolation attempts are seldom made. Serological and molecular diagnostic tests are the main option. Aim: To study the prevalence of acute Q fever in Puducherry and surrounding districts of Tamil Nadu, India, employing a new commercial Real-Time Polymerase Chain Reaction (PCR) kit and confirming it by the gold standard Immunofluorescence Assay (IFA). Materials and Methods: Acute phase blood samples from 72 consecutive febrile patients and 24 healthy individuals were included in this prospective study. DNA was extracted from the buffy coats and preserved at -80°C. Detection of C. burnetii was carried out employing a commercial Real-Time PCR kit. Serum samples were tested for IgM (Phase I+II) and IgG (Phase I+II) by QM-120 and QG-120, Coxiella burnetii IFA Fuller Laboratories, California, USA. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated keeping IFA as the reference. Results: Presumptive diagnosis of acute Q fever was made in two febrile patients by the Genesig Easy kit (2.78%). In addition to these two PCR positive cases, one more patient was positive for both Phase II IgM and Phase II IgG antibodies by the gold standard IFA. All 24 healthy controls were negative for Q fever by both PCR and IFA. The sensitivity, specificity, NPV and PPV for Genesig Easy kit PCR were: 66.67%, 100%, 100% and 98.57 % respectively against IFA as the reference. Conclusion: The true prevalence of Q fever in India and other developing countries is poorly understood, owing to the difficulties in the diagnosis of this infection. Since molecular diagnostic tests have good specificity and are mandated for confirmation of single acute samples, validation of commercial Q fever PCR kits is the need of the hour. Genesig Easy kit in our hands was found to be reliable with the moderate sensitivity and high specificity. Performing both PCR (with acute specimens) and IFA (with paired sera) would be ideal for Q fever diagnosis.

Use of Multi-Response Format Test in the Assessment of Medical Students Critical Thinking Ability

Introduction: To evaluate students critical thinking skills effectively, change in assessment practices is must. The assessment of a student’s ability to think critically is a constant challenge, and yet there is considerable debate on the best assessment method. There is evidence that the intrinsic nature of open and closed-ended response questions is to measure separate cognitive abilities. Aim: To assess critical thinking ability of medical students by using multi-response format of assessment. Materials and Methods: A cross-sectional study was conducted on a group of 159 undergraduate third-year medical students. All the participants completed the California Critical Thinking Skills Test (CCTST) consisting of 34 multiple-choice questions to measure general critical thinking skills and a researcher-developed test that combines open and closed-ended questions. A researcher-developed 48-question exam, consisting of 8 short-answers and 5 essay questions, 19 Multiple-Choice Questions (MCQ), and 16 True-False (TF) questions, was used to measure critical thinking skills. Correlation analyses were performed using Pearsons coefficient to explore the association between the total scores of tests and subtests. Results: One hundred and fifty-nine students participated in this study. The sample comprised 81 females (51%) and 78 males (49%) with an age range of 20±2.8 years (mean 21.2 years). The response rate was 64.1%. A significant positive correlation was found between types of questions and critical thinking scores, of which the correlations of MCQ (r=0.82) and essay questions (r=0.77) were strongest. The significant positive correlations between multi-response format test and CCTST’s subscales were seen in analysis, evaluation, inference and inductive reasoning. Unlike CCTST subscales, multi-response format test have weak correlation with CCTST total score (r=0.45, p=0.06). Conclusion: This study highlights the importance of considering multi-response format test in the assessment of critical thinking abilities of medical students by using both open and closed-ended response questions.

Awareness of Presbyopia among Rural Female Population in North Karnataka

Introduction: Presbyopia is an age related loss of lens accommodation resulting in inability to read and/write or to do near work. Though literacy level may be low in rural female population of South India, but household works like sewing, sorting grains and operating mobile phones must be difficult due to presbyopia. Aim: To determine the awareness of presbyopia in rural females; also, to determine the knowledge levels regarding presbyopia, spectacle coverage and reasons for not wearing spectacles. Materials and Methods: A hospital based cross-sectional study was conducted at SDM College of Medical Sciences, Dharwad, Karnataka, India, on 1000 female subjects of age group 35 years and above coming from rural area (around Dharwad). They were examined and open-ended questionnaire was used to record subject’s awareness and knowledge about presbyopia and their responses were analysed. Results: More than 2/3rd of 1000 (66.7%) subjects were not aware about presbyopia. More than 50% subjects had difficulty in cleaning grains, threading needles and reading fine newspaper print. About 86.5% thought presbyopia is age related and 92.2% thought it could be treated with spectacles. In spite of high prevalence, almost 98% of the population were not willing to wear glasses among which majority (60.2%) felt that spectacles were difficult to be maintained while working. In the present study, no statistical significance between literacy and awareness was noted (p=0.46). Conclusion: High prevalence of presbyopia was seen with majority of them uncorrected due to lack of awareness or unwillingness to wear glasses. We need to provide better health education regarding presbyopia among both literate and illiterate individuals. Thus, there is a need to create awareness and to provide affordable, accessible and compatible optical services to the affected population.

A Study of Correlation of Neck Circumference with Framingham Risk Score as a Predictor of Coronary Artery Disease

Anand K Koppad, Ram S Kaulgud, BS Arun

Introduction: It has been observed that metabolic syndrome is risk factor for Coronary Artery Disease (CAD) and exerts its effects through fat deposition and vascular aging. CAD has been acknowledged as a leading cause of death. In earlier studies, the metabolic risk has been estimated by Framingham risk score. Recent studies have shown that Neck Circumference (NC) has a good correlation with other traditional anthropometric measurements and can be used as marker of obesity. It also correlates with Framingham risk score, which is slightly more sophisticated measure of CAD risk. Aim: To assess the risk of CAD in a subject based on NC and to correlate the NC to Framingham risk score. Materials and Methods: The present cross-sectional study, done at Karnataka Institute of Medical Sciences, Hubli, Karnataka, India, includes 100 subjects. The study duration was of one year from 1st January 2015 to 31st December 2015. Anthropometric indices Body Mass Index (BMI) and NC were correlated with 10 year CAD risk as calculated by Framingham risk score. The correlation between BMI, NC, vascular age and Framingham risk score was calculated using Karl Pearson’s correlation method. Results: NC has a strong correlation with 10 year CAD risk (p=0.001). NC was significantly greater in males as compared to females (p=0.001). Males had greater risk of cardiovascular disease as reflected by higher 10 year Framingham risk score (p=0.0035). Conclusion: NC gives simple and easy prediction of CAD risk and is more reliable than traditional risk markers like BMI. NC correlates positively with 10 year Framingham risk score.

Prediction of Delivery in Women with Threatening Preterm Labour using Phosphorylated Insulin-Like Growth Factor Binding Protein-1 and Cervical Length using Transvaginal Ultrasound

Amrita Kumari, Vandana Saini, P.K. Jain, Mamta Gupta

Introduction: Preterm delivery remains a challenge in Obstetrics as it is responsible for significant cause of perinatal morbidity and mortality. At present there is no standard test for prediction of preterm labour for timely referral to a center with NICU facilities. Aim: To evaluate the effectiveness of the cervical phosphorylated insulin like growth factor binding protein-1(phIGFBP-1), cervical length measurement and combination of phIGFBP-1 with cervical length for Predicting Preterm Labour (PTL). Materials and Methods: It was a observational prospective study done from January 2014 to April 2015 in Department of Obstetrics and Gynaecology, NDMC Medical College and Hindu Rao Hospital, Delhi, India. A total of 100 women with singleton pregnancy, between 24 and 36 weeks of gestation with complaint of uterine contractions were randomly selected. These women were subjected to detect phIGFBP-1 in cervical secretions and cervical length measurement by Transvaginal Sonography (TVS). Result of the test, cervical length and time lapse between test and delivery was noted and the results were analysed. The cervical length less than 25 mm was used as a cut off point for predicting pre-term delivery. Data was analysed using SPSS software version 20.0. Results: The Negative Predictive Value (NPV) of phIGFBP-1 and cervical length was similar (95.2% vs 94.05%) respectively for prediction of preterm labour within one week of admission and 93.92% vs 94.80% at 37 weeks of gestational age. Combined test had higher NPV of 96.38% at 34 weeks of gestation and 94% within two days of admission. Positive Predictive Value (PPV) was low for both the test and combining the two-test did not have any advantage as far as PPV was concerned. Receiver Operating Characteristic (ROC) curve showed that the combined test had a superior result in predicting PTL compared to either phIGFBP-1 or cervical length. The combined test had steepest ROC curve at < 34 weeks of gestation (AUC-0.83 with 95% CI). Conclusion: The phIGFBP-1 test and cervical length have an almost equivalent ability to predict preterm delivery independently. The combined use of phIGFBP-1 and TVS for cervical length shows an increase in efficacy in predicting preterm labour.

Prevalence of Chronic Morbidity and Sociodemographic Profile of Police Personnel – A Study from Gujarat

Kishankumar Maheshkumar Bhatia, Niraj Pandit

Introduction: The police personnel are special group of population that work for minimum 12 hours a day. They are at risk of various types of chronic morbidities. Aim: To determine the socio-demographic, chronic morbidity and health profile of police personnel of Vadodara district. Materials and Methods: It was a cross-sectional study conducted on the police force of Vadodara district, Gujarat, India. The present study was the outcome of health checkup camp for police personnel. Total 982 police personnel participated in the aforementioned study. Information regarding the socio-demographic profile, addiction to alcohol drinking, tobacco chewing or smoking, diagnosed chronic morbidities, BMI, blood sugar and history of exercise and yoga was collected. Data collected was entered into Microsoft Excel 2007 and analysed by using Epi-Info 7. Statistical methods used included frequencies and proportions for categorical data while range, mean and standard deviation were calculated for continuous data. For bivariate analysis, Chi-square test was used. Results: In the study population, 95.10% were males. The prevalence of chronic morbidity, hypertension and diabetes were 9.5%, 5% and 2.6% respectively. About 47.05% had normal BMI and mean BMI was 24. The study revealed that 7.64% police personnel had the habit of smoking, 3.16% consumed alcohol whereas 24.03% consumed tobacco products. It was found that 138 (14.05%) were active in sports and 304 (30.95%) were actively involved in exercise while 44 (4.48%) were involved in yoga. Conclusion: The prevalence of hypertension (5%) and diabetes (2.6%) were low as compared to the general population (NFHS-4). This can be attributed to health consciousness prevalent among the population. A substantial number of study population were involved in sports, exercise and yoga.

Effect of Rocker Soled Shoe Design on Walking Economy in Females with Pes Planus

Introduction: The energy cost is increased during walking in pes planus condition whereas, energy cost during walking using rocker bottom shoes is debatable. Aim: To determine the walking economy with rocker soled shoes, when compared with bare feet walking in females with pes planus over treadmill. Materials and Methods: Seventeen collegiate flat footed females aged 18-25 years were recruited in accordance with inclusion and exclusion criteria. Subjects were asked to walk barefooted and with rocker soled shoes on treadmill for four minutes at a speed of 3.8 km/hour. Oxygen consumption (VO2) was measured directly using PowerLab 8/35 data acquisition system with Lab Chart Pro (AD Instruments, Australia) one minute before walking, four minutes during walking and one minute after walking. Rating of Perceived Exertion (RPE) was taken after termination of walking. Results: VO2 during barefoot walking was significantly lower than rocker soled shoe walking during four-five minutes (p<0.001) and during recovery (p=0.04). RPE is significantly lower during barefoot walking than rocker soled shoe walking (p<0.001) over treadmill. Conclusion: Oxygen consumption and RPE were increased during walking with rocker soled shoe design in comparison to bare feet walking over treadmill at same speed.

An Evaluation of Dental Crowding in Relation to the Mesiodistal Crown Widths and Arch Dimensions in Southern Indian Population

Partha Jyoti Das, Winniecia Dkhar, Abhimanyu Pradhan

Introduction: With the advancement in imaging technology, 3D dental computed tomography plays a very significant role in orthodontic treatment and diagnosis. Aim:To evaluate dental crowding in relation to the mesiodistal crown widths and arch dimensions and also to determine the differences of dental crowding among males and females, in Southern Indian population. Materials and Methods: A total of 132 subjects were divided into two groups: crowded and non-crowded, each comprising 66 subjects (33 males and 33 females), aged between 15 and 35 years, who were referred for computed tomography scan of brain to the radiology department, were selected. During the scan both the jaws were included in the image. The 2D images were converted to 3D images using volume rendering software. By using measurement tool, individual and collective mesiodistal crown widths of canine, first and second premolar and first molar and arch perimeter of both the maxillary and mandibular jaws were measured. Results: When both the gender were considered, the mesiodistal crown widths and arch perimeter were statistically significant for dental crowding in both mandibular jaw (p-value=0.001 for both mesiodistal crown width and arch perimeter) and maxillary jaw (p-value=0.016 for mesiodistal crown width and 0.002 for arch perimeter). However, when analysed separately, in males the mesiodistal crown widths and arch perimeter were statistically significant for dental crowding in both mandibular jaw (p-value=0.001 for mesiodistal crown width and 0.002 for arch perimeter) and maxillary jaw (p-value=0.002 for mesiodistal crown width and 0.001 for arch perimeter) but in females it was not statistically significant in any jaw (p-value=0.7 for mesiodistal crown width and 0.06 for arch perimeter in mandibular jaw and p-value=0.2 for mesiodistal crown width and 0.9 for arch perimeter for maxillary jaw). The crowded group had larger tooth size and smaller arch perimeter. Conclusion: This study concluded that in males, both the factors i.e., mesiodistal crown width and arch dimensions contributed to dental crowding and the crowded dentition had larger mesiodistal tooth size and smaller arch dimensions; whereas, in females both the factors were not responsible for crowding in Southern Indian population.

Comparison of Microbiological Flora in the External Auditory Canal of Normal Ear and an Ear with Acute Otitis Externa

Introduction: Acute Otitis Externa (AOE) is also known as swimmer’s ear. Investigations initiated during World War II firmly established the role of bacteria in the aetiology of Acute Otitis Externa. Aim: To culture the microbiological flora of the normal ear and compare it with the flora causing AOE and to know the role of normal ear canal flora and anaerobes in the aetiology. Materials and Methods: A prospective observational study was conducted on 64 patients clinically diagnosed with unilateral AOE. Ear swabs were taken from both the ears. Microbiological flora was studied considering diseased ear as test ear and the normal ear as the control. Aerobic and anaerobic cultures were done. Severity of the disease was assessed by subjective and objective scores. Effect of topical treatment with ichthammol glycerine pack was assessed after 48 hours and scores were calculated again. Patients with scores < 4 after pack removal were started on systemic antibiotics and were assessed after seven days of antibiotics course. Data was analysed using Paired t-test, Wilcoxon signed ranks test and Chi-square test. A p-value < 0.05 was considered significant. Results: Pseudomonas aeruginosa (33%) was the most common bacteria cultured from the ear followed by Methicillin Resistant Staphylococcus aureus (MRSA) (18%). Patients with anaerobic organism in the test ear had severe symptoms and needed systemic antibiotic therapy. Conclusion: Most of the cases may respond to empirical antibiotic therapy. In cases with severe symptoms and the ones refractory to empirical treatment, a culture from the ear canal will not be a tax on the patient. This helps in giving a better understanding about the disease, causative organisms and helps in avoiding the use of inappropriate antibiotics that usually result in developing resistant strains of bacteria.

Aspects of Evolving Genito Urinary Tuberculosis-A Profile of Genito Urinary Tuberculosis (GUTB) in 110 Patients

Introduction: Genito Urinary Tuberculosis (GUTB) is a widespread disease seen in urology practice. The true incidence and prevalence of GUTB is difficult to estimate because a large number of patients remain asymptomatic. Aim: To recognize typical and atypical clinical and radiological features of tuberculosis and to emphasize the need for diagnosing GUTB early. Materials and Methods: This was a retrospective study conducted in 110 cases of GUTB diagnosed and treated in two teaching institutions over a period of three years, from July 2002 to June 2005. A detailed history, thorough clinical examination, urine examination, culture for tubercle bacillus, imaging studies, cystoscopy and histological and serological examination were done to arrive at a diagnosis. Results: Fifty six patients (51%) were in the age group of 21-40 years. The male: female ratio was 1.4: 1. Loin pain was the most common symptom observed in 27% of the patients. Intravenous Urogram (IVU) revealed non-visulalised kidney in 25 patients (23%), hydronephrosis or hydrouretero nephrosis in 34 patients (31%) and distortion, cavitation or scarring of the calyces in 16 patients (14.5%). Five of them had thimble bladder. In 14 patients, IVU appeared normal. About 28 patients (25%) were treated conservatively with anti tuberculosis therapy. Twenty one of them (19%) underwent Nephrectomy and 10 patients had reconstructive procedures. Conclusion: A peculiarity of most of our patients was a late presentation with advanced disease. Most patients were asymptomatic or ignorant. Slow but continuous infection causes a destruction of renal parenchyma and the healing process leads to renal parenchymal loss. If identified early and treated appropriately, GUTB is a curable condition.

Comparison of Pain Relief from Different Intravenous Doses of Ketorolac after Reduction of Mandibular Fractures

Introduction: Pain is an unpleasant feeling due to tissue destruction, which disturbs an individual’s daily routines even at its lowest levels. The majority of surgeons and anaesthesiologists are increasingly trying to administer non-opioid analgesics because excessive use of opioids after surgery results in patient dissatisfaction. Aim: To evaluate the analgesic effect of intravenous injection of different doses of ketorolac at different intervals in patients undergoing surgery for unilateral fractures of the mandible. Materials and Methods: In the present randomized clinical trial (March 2016 to January 2017, in Tabriz Imam Reza Treatment/Educational Center), 50 patients were assigned to five groups with simple randomization method. In Group 1 and 2, immediately before the induction of general anaesthesia 30 and 60 mg of ketorolac and in Group 3 and 4, immediately before termination of surgery 30 and 60 mg of ketorolac was injected intravenously. In Group 5, ketorolac was not administered. After each patient regained complete consciousness, the severity of pain was determined using VAS up to 24 hours at baseline and at 2, 4, 6, 12 and 24-hours intervals. The total dose of the opioid analgesic agent (morphine-pethidine) and the time for the first request for an analgesic agent were recorded for each patient and their means were compared in each group with suitable statistical tests. Results: The patients in Group 5 and 4 exhibited the highest and lowest mean pain scores (5.03±0.9 and 3.5±1), respectively. ANOVA for repeated measures and post-hoc Tukey tests showed significant differences only between Group 3 and 5 (p=0.002) and Group 4 and 5 (p=0.001), with no significant differences between the other groups (p>0.005). The highest dose of the analgesic agent was in Group 5 (5.3±1.4 mg) and the lowest dose was recorded in Group 4 (1.6±0.6 mg). Patients in the control group received significantly higher doses compared to the other groups (p<0.05). The patients in Group 1 and 2 received higher doses of analgesics compared to Group 3 and 4 (p<0.05). The longest time for the request for the first dose of analgesic agent after surgery was 73.4±12.03 minutes in Group 4. The patients in the control group had requested analgesics after surgery at a significantly shorter time compared to the patients in all the study groups (p<0.05). The patients in Group 1 and 2 had requested analgesics at a shorter time after surgery compared to the subjects in Group 3 and 4 (p<0.05). Conclusion: Intravenous administration of 30 and 60 mg of ketorolac, immediately before termination of surgery, decreases the pain severity and the need for opioid analgesics after surgery.

Assessment of Pulp Oxygen Saturation Levels by Pulse Oximetry for Pulpal Diseases –A Diagnostic Study

Bander Anusha, Koppolu Madhusudhana, Suneel Kumar Chinni, Yelloji Paramesh

Introduction: Diagnosis of pulpal inflammation is a key to endodontics. Pulse oximetry is a true vitality testing device which relies on oxygen saturation levels of pulp and helps in diagnosis of different pulpal conditions. Aim: The aim of the study was to analyse oxygen saturation levels of different pulpally inflamed teeth by using pulse oximetry. Materials and Methods: Hundred patients were included in the study and categorized into five groups based on pulpal status of the test tooth by using heat test and cold test. Twenty patients were recruited in each of the experimental groups i.e., Reversible Pulpitis (RP), Irreversible Pulpitis (IP), Pulpal Necrosis (PN), Positive Control (PC, healthy teeth), and Negative Control (NC, endodontically treated teeth). Oxygen saturation levels of all the groups were measured along with each patient index finger oxygen saturation readings. Results were analysed by using ANOVA and Tukey HSD tests. Results: The mean oxygen saturation levels of RP, IP, PN, PC and NC were 85.4%, 81.6%, 70.7%, 94.6% and 0 respectively. There was significant difference in the oxygen saturation levels between all the groups. Conclusion: Pulse oximeter is an effective tool in diagnosing different pulpal pathologies especially PN which was interpreted inaccurately by thermal tests.

Does Azithromycin and Cetirizine Combination Given for Upper Respiratory Tract Infections has any Significant Effect on QTc?

Kishor Kumar Rajasekaran, Jayakumar Jeganathan, Pavan Manibettu Raghuram

Introduction: Azithromycin usage in patients with baseline cardiovascular risk is associated with increased risk of cardiovascular mortality, following which Food and Drug Administration (FDA) issued a black box warning regarding safety of azithromycin in patients with cardiovascular morbidity particularly with prolonged QTc. Cetirizine is a second generation anti histaminic and is found to be commonly used for Upper Respiratory Tract Infections (URIs) along with azithromycin on outpatient basis. Whether, usage of these two drugs in combination confers a similar risk, is unknown. Aim: To assess the effect on QTc among patients treated with azithromycin and cetirizine combination for upper respiratory tract infection. Materials and Methods: We conducted a prospective longitudinal study from August 2014 to July 2016. The study was done on 45 patients above 18 years of age without any cardiovascular morbidity in whom azithromycin and cetirizine were prescribed for upper respiratory tract infections. We compared the QTc on day 1 and day 4. Data was analysed using Student’s paired t-test. Results: During three days of azithromycin and cetirizine for upper respiratory tract infections, we observed that on day 4 there was significant increase in QTc in 43 patients (95.6%) as compared with the QTc on day 1. We also observed that in 8 (17.8%) out of 45 patients, QTc on day 4 crossed the upper limit of normal {430 milliseconds (ms)}, but this was not statistically significant. However, analysing these eight patients, we obtained the baseline QTc of 377.50 ms above which if prescribed, this combination of drugs have a chance of prolonging the QTc above 430 ms with a sensitivity of 87.5% and specificity of 40.5%. Conclusion: During three days treatment with azithromycin and cetirizine, there was significant change in QTc between day 1 and day 4. Patients with baseline QTc greater than 377.5 ms were at risk of QTc prolongation above 430 ms on day 4.

Comparison of Gingival Biotype between different Genders based on Measurement of Dentopapillary Complex

Introduction: Clinical and aesthetic outcomes after periodontal or implant surgical procedures are determined by anatomical and morphological characteristics of the gingiva like width of keratinized gingiva, thickness of gingiva and alveolar bone. Therefore, the knowledge of gingival biotype plays an important role in modifying the dental therapeutic procedures for the desired outcome and predictability. Aim: The aim of the present study was to assess and compare the gingival biotype among genders by clinical, photographic and radiographic parameters. Materials and Methods: A total of 800 subjects (400 males and 400 females) were considered for the study. Width of keratinized gingiva (GW), transparency of the periodontal probe through the sulcus (TRAN) were assessed clinically; Crown Width/ Crown Length ratio (CW/CL) and Papillary Height (PH) were assessed photographically; Gingival Thickness (GT1, GT2, GT3) and Alveolar bone Thickness (AT1, AT2, AT3) were assessed radiographically. The obtained data was correlated to compare the gingival biotype between males and females. The collected data was statistically analysed using Pearson correlation coefficient (r) with the corresponding 95% confidence interval. Results: The TRAN at GT1, GT2 and GT3 as well as at AT1, AT2 and AT3 showed a very strong positive correlation in males (r>0.8) as compared to females (r<0.8). A very strong positive correlation was observed between GT1, GT2, GT3 and AT1, AT2, AT3 in males (r>0.9) as compared to females (r<0.7). Conclusion: There are definite differences in the gingival biotype among different genders with predominance of a thin gingival biotype with reduced alveolar bone thickness in females as compared to males.

Study of Left Ventricular Mass and Its Determinants on Echocardiography

Introduction: Increased Left Ventricular Mass (LVM) is an independent risk factor for cardiovascular morbidity and mortality. Aim: This study was done to find the prevalence and determinants of LVM in the Northern Indian population. Materials and Methods: A prospective cross-sectional observational study was carried out in a tertiary care centre in Himachal Pradesh, India and the study population included all consecutive patients fulfilling the inclusion criteria attending cardiology OPD on seeking medical attention with various symptoms for dyslipidaemia, hypertension but not on medication over a period of one year. Focused history was taken; physical examination and investigations were done. Data collected was analysed using Epi-info software version 3.5.1. We calculated means of LVM index for categorical variables i.e., sex, tobacco consumption, alcohol consumption and sedentary lifestyle etc., and also calculated p-values as test of significance for mean difference across the exposure variable groups. The Pearson correlation coefficient was calculated and 2 tailed significance at p< 0.05 was taken as statistically significant. Results: Mean age of study population was 42.30±9.8 years and 62.9% were males. The mean LVM index was significantly higher in men than in women 77.7 ± 11.4 vs.71.3 ± 15.7 (p-value <0.01). Strong positive correlation was observed between increased waist hip ratio and increased Left Ventricular Mass Index (LVMI). The Pearson correlation coefficient was 36.77 and it was statistically significant with p-value 0.04. Conclusion: We found positive and independent correlation of increased LVMI with increased Waist Hip Ratio (WHR). A positive independent correlation was also observed with higher fasting blood sugar levels.

Immunohistochemical Expression of Cyclo-oxygenase 2 and Liver X Receptor-a in Acne Vulgaris

Introduction: Acne Vulgaris (AV) is a common inflammatory disease of pilosebaceous units. Liver X Receptor-a (LXR-a) is a ligand activated transcription factor. It controls transcription of genes involved in lipid and fatty acid synthesis. Cyclo-oxygenase 2 (COX2) is a rate limiting enzyme in prostaglandin synthesis. It plays important role in inflammation. Aim: To evaluate the immunohistochemical expression of LXR-a and COX2 in acne vulgaris skin biopsies to explore their possible pathogenic role in this disease. Materials and Methods: Sixty five subjects were included (45 cases with AV and 20 age and gender-matched healthy controls). Skin biopsies were taken from lesional and perilesional skin of cases and from site-matched areas of control subjects. The evaluation of LXR-a and COX2 was done using immunohistochemical technique. Data were collected, tabulated and statistically analysed using a personal computer with “(SPSS) version 11” program. Chi-square test was used to study the association between qualitative variables. Mann–Whitney test was used for comparison between quantitative variables. Student’s t-test was used for comparison between two groups having quantitative variables. Spearman’s coefficient was used to study the correlation between two different variables. Differences were considered statistically significant with p<0.05. Results: COX2 was upregulated in lesional skin compared with peilesional and control skin both in epidermis and pilosebaceous units (p<0.001 for all). Higher epidermal COX2% was significantly associated with papulopustular acne (p=0.009) and higher acne score (p=0.018). Higher pilosebaceous units COX2% was significantly associated with papulopustular acne (p=0.04). LXR-a was upregulated in lesional skin compared with peilesional and control skin both in epidermis and pilosebaceous units (p<0.001 for all). Higher LXR-a % in epidermis and pilosebaceous units was significantly associated with papulopustular acne (p=0.01 for both) and higher acne score (p=0.03 for both). Significant positive correlation was detected between COX2% and LXR-a % in epidermis (p=0.001, r=0.87) and pilosebaceous units (p=0.001, r=0.65). Conclusion: Both LXR-a and COX-2 play a role in the pathogenesis of acne vulgaris through their effects on cellular proliferation, inflammation and lipid synthesis. Research for new therapeutic modalities based on their inhibition is needed. More understanding of the interaction between LXR-a, COX2 and acne lesions may lead to effective interference, possibly directed toward specific cell types or steps within inflammatory pathways.

Comparative Study of the Effect of Dexmedetomidine Vs. Fentanyl on Haemodynamic Response in Patients Undergoing Elective Laparoscopic Surgery

Jayshree P Vaswani, Debasis Debata, Varsha Vyas, Surekha Pattil

Introduction: Dexmedetomidine and fentanyl, both have sedative and analgesic effects. They are often used as adjunct during anaesthesia to attenuate pressor response during tracheal intubation. Limited study has been done comparing the effect of both drugs on haemodynamic response in patients undergoing laparoscopic surgery. Aim: The study was designed to compare the effect of dexmedetomidine Vs fentanyl on haemodynamic response to tracheal intubation, following pneumoperitoneum and intraoperative period in patients undergoing laparoscopic surgery. Materials and Methods: Sixty patients of age group 18-60 years of either sex, classified as American Society of Anaesthesiologist (ASA) Grade I and II undergoing elective laparoscopy surgery were randomly allocated to one of the two groups (Group-D) and (Group F) of 30 each. Group D received dexmedetomidine and Group F received fentanyl. Patients received intravenous 0.5 µg/kg of the study drug as loading dose over 10 minutes prior to intubation followed by 0.2-0.7 µg/kg/hr as infusion till surgery was over. In operating room parameters like Heart Rate (HR), Respiratory Rate (RR), Systolic Blood Pressure (SBP), Mean Arterial Pressure (MAP), SpO2, EtCO2 were recorded 10 minutes after infusion of drug i.e., dexmedetomidine or fentanyl. The said parameters were again recorded after injection of induction drugs, after intubation, five minutes after intubation, just after pneumoperitoneum, and 5,10,15,30,45 and 60 minutes after pneumoperitoneum, five minutes after release of pneumoperitoneum, five and 10 minutes after extubation. Results: Dexmedetomidine significantly attenuates stress response at intubation with lesser increase in HR (5% Vs 18%), SBP (9% Vs 19%) and DBP (3% Vs 15%), MAP (2% Vs 15%) as compared to fentanyl (p<0.05). Throughout intraoperative period of pneumoperitoneum Group D showed significant fall in HR, SBP, DBP, MAP from baseline value at all points of time intervals whereas it remained constantly high above baseline value in Group F (p-value <0.05). Conclusion: Dexmedetomidine when compared to fentanyl causes greater attenuation of stress response to tracheal intubation, following pneumoperitoneum and in intraoperative period resulting in greater reduction of HR, SBP, DBP, MAP than that of fentanyl, thus causing better haemodynamic stability in patients undergoing elective laparoscopic surgery.

Assessment of Palliative Care Awareness among Undergraduate Healthcare Students

Rajaragupathy Sujatha, Karthikeyan Jayagowri

Introduction: Palliative care knowledge is being given meager importance in the curriculum of medical and other allied medical sciences. It is vital that all health care practitioners including medical, pharmacy, physiotherapy and nursing are aware and apply the best principles of palliative care. Aim: To assess the awareness of palliative care among undergraduate students of medical, nursing, pharmacy and physiotherapy. Materials and Methods: The study population included total of 200 students. Among 200 students, 50 were from each of the colleges of medicine, nursing, pharmacy and physiotherapy. After obtaining informed consent, questionnaire was given. The questionnaire contained the sociodemographic profile and 35 statements under nine groups, for which the respondents were expected to answer one out of the three options (Yes, No, Don’t know). The groups of statements deal with palliative care definition, its philosophy, communication issues, non-pain symptoms, medications use and context of application of palliative care. Results: It was found that less than 20% of nursing students were unaware of palliative care. Among the undergraduates of college of pharmacy, more than 50% had no knowledge of palliative care. More than 80% of physiotherapy, nursing and medical students agree that death should occur without any pain or symptoms. The need of palliative care was well understood by more than 70% of students of physiotherapy, pharmacy, nursing and medical colleges. Conclusion: Basic knowledge about palliative care was inadequate among the undergraduate students related to healthcare.

Clinical Efficacy and Safety on Combining 20% Trichloroacetic Acid Peel with Topical 5% Ascorbic Acid for Melasma

Surabhi Dayal, Priyadarshini Sahu, Manoj Yadav, VK Jain

Introduction: Trichloroacetic Acid (TCA) is a versatile peeling agent for treatment of melasma. However, Post-Inflammatory Hyperpigmentation (PIH) is reported to be the most common side-effect associated with TCA peel. Topical Ascorbic Acid (AA) due to its effect as antioxidant and tyrosinase inhibitor helps to prevent PIH and maintains the response. Aim: To assess the clinical efficacy, safety and reduction in Melasma Quality of Life (MELASQOL) on combining 20% TCA peel with 5% ascorbic acid cream in epidermal melasma. Materials and Methods: This study was conducted in the Department of Dermatology, Pt. Bhagwat Dayal Sharma University of Health Sciences, Rohtak. This was an open labelled prospective randomized study in which 60 patients of epidermal melasma were enrolled for 12 weeks. Patients were divided into two groups: Combination group received 20% TCA peel every two weeks with once daily 5% ascorbic acid cream and Control group received only 20% TCA peel. Melasma Area Severity Index (MASI) was used for evaluating clinical improvement of melasma. Improvement in Quality Of Life (QoL) was assessed by MELASQOL scale in both groups. Adverse effects were evaluated at each visit. All statistical analysis was carried out with SPSS 20th version. The difference in change in mean MASI scoring and MELASQOL scores between the two groups were analysed using Mann-Whitney test. The side effects between the two groups were compared using Chi-square test. Results: The combination group demonstrated a statistically significant improvement in MASI, percentage decrease in MASI and quality of life as compared to control group after treatment. At the baseline there was no statistically significant difference in MASI between the two groups (i.e., MASI in combination group and control group were 23.55±4.61 and 23.613±4.088 respectively). However, it was statistically significant at the end of therapy (i.e., MASI in combination group was 9.50±5.31 and in control group was 15.10±4.44). When the results were analysed in terms of percentage decrease in MASI from baseline, there was statistically significant difference in combination group (i.e., 10.87±4.11) as compared to control group (i.e., 6.3±1.97) after 2nd week of therapy. When the mean MELASQOL scores were compared between the two groups at the end of therapy (i.e., 12 weeks), it was found to be statistically significantly lower in combination group (16.60±8.03) as compared to control group (25.90±8.17). Minor adverse effects like post peel erythema, pruritus, burning and stinging sensation were observed in some of the patients, which didn’t necessitate termination of the therapy. Conclusion: Combination of 20% TCA peel with topical 5% ascorbic acid is a highly effective, safe and promising therapeutic option in treatment of melasma which significantly improves the QoL

Evaluation of Effect of Irrigants with or without Surfactant on Root Canal Transportation by Cone Beam Computed Tomography–An In vitro Study

Introduction: Maintenance of original canal anatomy with proper disinfection is our primary goal to achieve during root canal instrumentation. Surfactants are added to irrigating solution to promote deeper penetration into dentinal tubules. Aim: The aim of this study was to evaluate the influence of addition of surfactants to Sodium Hypochlorite (NaOCl) and Ethylenediaminetetraacetic Acid (EDTA) on transportation of root canal. Materials and Methods: Fifty human mandibular molars with mesial root curvatures of 10° – 40° were selected and embedded in silicone impression material to simulate mandibular arch form to facilitate imaging process and maintain reproducibility of images. Before instrumentation, root canals were scanned by using Cone Beam Computed Tomography (CBCT) imaging (Carestream, India). The canals were then prepared with the ProTaper Next (PTN) system (Dentsply Maillefer, Ballaigues, Switzerland), using one of the following irrigation regimens during the instrumentation and were divided into five groups based on irrigation regimens followed: G1 (n=10)-irrigation with saline solution(control); G2 (n=10)-irrigation with 2.5% NaOCl; G3 (n=10)-irrigation with 2.5% NaOCl added with surfactant; G4 (n=10)-irrigation with 17% EDTA; G5 (n=10)-irrigation with 17% EDTA added with surfactant. Post-instrumentation scans were obtained with similar parameters and position as pre-instrumentation scans by CBCT imaging. Transportation of the root canals were then analysed at three cross-sectional planes of pre-instrumentation and post-instrumentation images at 2 mm, 5 mm, 8 mm from the apical end of the root. The data was statistically analyzed using Analysis of Variance (ANOVA) and Tukey post hoc test (p<0.05). Results: The mean transportation values were higher in G5. Transportation in G3 and G5 was not significantly different compared to G2 and G4 respectively (p<0.05). Conclusion: Instrumentation using irrigating solutions added with surfactant like 1% cetrimide maintained the canal curvature well.

Evaluation of the Efficacy of G32 (Commercially Available Ayurvedic Preparation) in Reducing Halitosis – A Randomized Controlled Trial

Introduction: Oral malodour is a social malady affecting people of all the age groups. Effective management of oral malodour is the key to improve the quality of life of such people. Aim: To evaluate the effectiveness of ayurvedic medication, G32 in controlling oral malodour and comparing the effects with Chlorhexidine (CHX). Materials and Methods: This was a single blind randomized controlled trial with parallel study design conducted at a hospital in the city of Udupi in Southern India. A total of 40 patients suffering with oral malodour, aged 17-35 years, were included in this trial. After inclusion into the study, the subjects were examined twice, with a one-week interval between both examinations. Volatile Sulphur Compounds (VSCs), gingival, plaque and tongue coating scores were assessed at both examinations. Subjects were randomly allocated to G32 group – ayurvedic formulation (intervention group) and Chx group (control group), and were provided with the respective formulations enough to be used twice daily for a period of one week. The difference between the mean scores of VSCs, plaque, and gingivitis and tongue coating were compared within the intervention and control groups, respectively, using paired t-test. Results: Both test and control groups showed a significant reduction in VSCs, plaque and gingivitis levels. The percentage reductions in VSCs, plaque and gingivitis were found to be similar among the two groups. There was no significant difference between the preintervention and postintervention scores in both the groups. Conclusion: G32, an ayurvedic medication, can be an effective tool to deal with oral malodour.

Effect of Mobile Phone Usage on Nickel Ions Release and pH of Saliva in Patients Undergoing Fixed Orthodontic Treatment

Even though, the incidence of Mitral Stenosis (MS) has reduced grossly, it still remains a health problem in developing countries and is the most common rheumatic valvular lesion encountered in pregnant patients. The already compromised cardiac status of a pregnant female deteriorates further by the presence of MS. So, pregnancy is a common situation during which untreated and frequently poorly tolerated MS are first diagnosed. Percutaneous Balloon Mitral Valvuloplasty (BMV) may be life saving in such a setting and a multidisciplinary approach in the management reduces the mortality and morbidity during the procedure. Anaesthetic management of such a procedure has hardly ever been reported. We report a case of a 23-year-old woman presenting at 28 weeks gestation with severe MS and severe pulmonary hypertension (52 mmHg) who underwent successful percutaneous BMV under monitored anaesthesia Care. The anaesthetic considerations in such situations are being discussed.

A Three Month Comparative Evaluation of the Effect of Different Surface Treatment Agents on the Surface Integrity and Softness of Acrylic based Soft Liner: An In vivo Study

Harekrishna Jayendra Raval, Neerja Mahajan, Y. G. Naveen, Rajesh Sethuraman

Introduction: Acrylic based soft liners are cost effective, yet are inferior in durability as compared to silicone based liners. Hence, this study was conducted to evaluate if the softness and surface integrity of acrylic based soft liner can be maintained by using different surface treatment agents. Aim: To comparatively evaluate the effects of Varnish, Monopoly and Kregard surface treatment agents on the surface integrity and softness of acrylic based soft liner at baseline, at one month and after three months. Materials and Methods: A total of 37 participants who required conventional maxillary dentures were selected according to the determined inclusion and exclusion criteria of the study. In the maxillary denture on the denture bearing surface, eight palatal recesses (5 mm x 3 mm) were made and filled with acrylic based soft liner (Permasoft). The soft liners in these recesses were given surface treatment and divided as control (uncoated), Varnish, Monopoly and Kregard groups. The hardness and surface integrity were evaluated with Shore A Durometer and Scanning Electron Microscope (SEM) respectively at baseline, one month and three months interval. Surface integrity between groups was compared using Kruskal-Wallis test. Intergroup comparison for hardness was done using ANOVA and Tukey’s HSD post-hoc tests. Results: Amongst all the groups tested, surface integrity was maintained in the Kregard group, as compared to control, Varnish and Monopoly groups for all three time intervals (p< 0.001). Kregard treated samples also demonstrated significantly higher softness at all the time intervals (p<0.001). Conclusion: Surface treatment with Kregard demonstrated better surface integrity and softness at all the time intervals.

Biosynthesis, Characterization and Antibacterial Efficacy of Silver Nanoparticles Derived from Endophytic Fungi against P. gingivalis

Introduction: Microbial resistance to existing antimicrobial agents in periodontal therapy is a growing problem. Therefore, there is a need for development of new antimicrobial agents. Aim: To biosynthesize and characterize Silver Nanoparticles (AgNPs) using endophytic fungi and to evaluate the antibacterial efficacy against P. gingivalis. Materials and Methods: Cut leaf segments of Withania Somnifera (Ashwagandha) were used to isolate the fungi. Fresh cultures of fungi were inoculated in Erlenmeyer flask of 100 ml Malt Glucose Yeast Peptone (MGYP) broth and incubated at 29ºC for 72 hours for the biomass to grow. Biomass was filtered and cell free fungal filtrate was used further. Biosynthesized AgNPs were characterized by visual observation, Ultraviolet-Visible (UV-Vis) spectrophotometer, Transmission Electron Microscopy (TEM), Selected Area Electron Diffraction Analysis (SAED) and Fourier Transform Infrared Spectroscopy (FTIR). Antibacterial efficacy was evaluated by agar diffusion method measuring the zone of inhibition. The study groups included different concentrations of AgNPs: A (20 µl), B (40 µl), C (60 µl), D (80 µl) and E (100 µl) of AgNPs, F (0.2% CHX), G (2% CHX), H (Ampicillin) and I (sterile distilled water). The data collected for inhibition zones were statistically analysed using One-way Anova followed by Tukey post-hoc multiple comparison tests. Results: The fungi were identified as Fusarium semitectum. Characterization studies showed the colour change from colourless to reddish brown; U-V spectrum showed peak 420 nm, TEM revealed the particles spherical in shape and 10-20 nm in size. FTIR analysis revealed the presence of functional groups. AgNPs 80 µl and 100 µl showed mean zone of inhibition 17.33 and 18 mm against P. gingivalis. CHX (0.2%) 17.85 and CHX (2%) 19.97 mm, Ampicillin 20.5 mm and no zone for sterile distilled water. Conclusion: Biosynthesized AgNPs showed efficient antibacterial efficacy against P. gingivalis hence, creates a new horizon in periodontal therapy.

Morphological and Morphometric Study of Coronary Sinus in North Indian Population

Beegum Zabina, Rajan Kumar Singla, Ravi Kant Sharma, Neelam Bala

Introduction: Coronary sinus (CS) is the largest vein draining the blood from heart. It is a muscular tube of about 2 cm to 3 cm length and 1 cm in caliber. It has become a clinically important structure through its role in providing access for different cardiac procedures viz., biventricular pacing, arrhythmia ablation and for deployment of an array of cardiac devices. Aim: To study the location, shape, length and width of CS including its left atrial muscular coverage in 50 cadaveric hearts. Materials and Methods: The present study comprised of 50 adult human apparently normal formalin fixed cadaveric hearts belonging to either sex obtained from the Department of Anatomy, Government Medical College, Amritsar, India. Location and shape of CS were noted, external and internal lengths of the CS were measured with the help of a thread and Vernier caliper. Width of CS was measured at three levels; at the beginning, at the point of entry of Middle Cardiac Vein (MCV) and at termination in right atrium. The walls of CS were examined to note whether they were covered by the muscles of left atrium or not. Descriptive analysis was done to calculate range, mean and Standard Deviation (SD) by using Statistical Package for Social Science (SPSS) 17.0. Results: CS was located in the posterior atrioventricular sulcus in 98%. Two shapes; funnel in 82% and tubular/cylindrical in 18% were observed. External length of coronary sinus ranged from 20.5 mm to 58.78 mm (mean 38.22±8.6 mm) and internal length ranged from 16.28 mm to 49.6 mm (mean 34.48±8.9 mm). Maximum width of coronary sinus was at its termination (9.61±2.6 mm) and it was covered by muscles of left atrium in 96% of hearts. Conclusion: CS is a constant structure in cardiac venous anatomy but its location, shape, length and width are variable. Knowing these variations can help cardiac surgeons especially during cardiac resynchronization therapy, ablation and defibrillation.

Diagnostic Approach to Viral Acute Encephalitis Syndrome (AES) in Paediatric Age Group: A Study from New Delhi

Shipra Goel, Anita Chakravarti, Mukta Mantan, Surinder Kumar, Md. Anzar Ashraf

Introduction: Acute Encephalitis Syndrome has heralded the emergence of multiple virulent pathogens, which may result in severe morbidity and mortality. In India, encephalitis is not notified and there has been a dearth of analysis for trends in encephalitis death rates and causation. A downward trend has been observed in encephalitis deaths, due to ‘known’ causes, which can be largely explained by improvement in diagnostic, treatment, and prevention methods. There is still a very high proportion of encephalitis deaths in developing countries, where the aetiological diagnosis of the pathogen is not established and thus, lies the importance of monitoring encephalitis morbidity and mortality with a view to improve pathogen diagnosis and identify emerging infectious diseases. Aim: To formulate a diagnostic approach to viral acute encephalitis syndrome in paediatric age group. Materials and Methods: A cross-sectional study including 50 paediatric patients, clinically diagnosed with acute encephalitis syndrome using WHO criteria was conducted. The CSF of all the patients was evaluated to diagnose the aetiology for viral pathogens. ELISA was used for diagnosing Japanese encephalitis and dengue encephalitis; and multiplex real time PCR was used for detecting HSV-1, HSV-2, Varicella zoster virus, Mumps virus, Enterovirus and Parechovirus. Results: Confirmed diagnosis was established in 11 (22%) of 50 cases. A confirmed or probable viral agent of encephalitis was found in 7 (14%), bacterial agent was found in 2 (4%), noninfectious aetiology was found in 2 (4%). Fatal outcome was independently associated with patient age. Conclusion: Despite extensive testing, the aetiologies of more than three fourth of the cases remains elusive. Nevertheless the result from the present study may be useful for future design of early diagnosis and treatment of the disease. New strategies for pathogen identification and continued analysis of clinical features and case histories should help us improve our ability to diagnose, treat and prevent encephalitis.

Relationship Between Trunk Control and Balance in Children with Spastic Cerebral Palsy: A Cross-Sectional Study

Sivatejaa Panibatla, Vijaya Kumar, Amitesh Narayan

Introduction: Trunk control is impaired in children with Cerebral Palsy (CP) thus influencing their functional balance. However, there is a paucity of literature determining the relationship between trunk control and balance in children with CP. Aim: To find the relationship between trunk control and balance by means of Trunk Control Measurement Scale (TCMS) and Paediatric Balance Scale (PBS). Materials and Methods: Twenty four children {age range 8-14 years, Gross Motor Function Classification System (GMFCS) Level I-III} with spastic CP were recruited and evaluated using TCMS and PBS. The results were expressed as summary measures median (M) and Inter-Quartile Range (IQR). The correlation of TCMS and PBS were done using Spearman’s correlation coefficient. A p-value <0.05 was considered statistically significant. Results: The children obtained a median score of 52 out of 58 on the TCMS and 50 out of 56 on PBS. There was a significantly strong correlation with rs=0.77 and p<0.01. A strong correlation (p<0.01) was seen between static, dynamic and total components of TCMS and PBS. The median scores of TCMS and PBS had a strong correlation for boys with rs=0.74 and very strong correlation for girls with rs=0.84. Based on the type of spastic CP, diplegics had a very strong correlation with rs=0.85. While based on GMFCS levels, Level II and Level III had a very strong correlation (For level II rs=0.81 and level III rs=0.86) and weak correlation for level I (rs=0.27). Conclusion: Based on gender, topography and severity of the motor impairment both trunk control and balance are impaired to a different degree in children with CP. The findings of this study showed a high positive correlation between trunk control and balance in children with spastic CP.

Effect of Cellular Mobile Phone Use and Cetrizine on Hand-Eye Coordination and Visual Acuity

Introduction: Cellular mobile phones are a major cause of distraction especially while driving. The aggressive and inappropriate use of cellular mobile phones has increased the risk of accidents. Similar alerts are available in literature for certain substances and drugs (e.g. second generation anti H1 drug –Cetirizine) which also derange psychomotor performance and parameters of alertness. Aim: This study measured variations in hand-eye coordination and visual acuity due to use of cellular mobile phone in comparison to that of commonly used antihistaminic drug viz., single dose Cetirizine 10 mg. Materials and Methods: It was a single blind, single dose, interventional study, 100 healthy human volunteers divided into two groups. Baseline readings of all volunteers were noted. Group-I (n=50) was Cetirizine group (10mg orally stat), Group –II (n=50) Cellular mobile phone user group. Alertness was tested on hand– steadiness tester (Reaction Time Index = RTI) and on Flicker–fusion apparatus (visual acuity - Critical Flicker Fusion Frequency per second= CFFF/sec). Baseline readings of all volunteers were noted before intervention. Baseline was compared with readings at three hour post-intervention and was analysed by paired t-test. Inter-group comparison of parameters was also done and was analysed by unpaired t-test. Results: The baseline RTI (95.46±41.74, 85.11±39.05) and CFF low and high (40.07±9.970, 40.76±9.309 and 40.42±9.035, 40.48±9.863) respectively, in Cetirizine group and Mobile user group were comparable. The RTI increased significantly (116.4±51.46, 102.8±49.26) in both the groups after intervention. However, there is no significant change in CFF intensity from baseline in either group post-intervention. Conclusion: Concurrent use of mobile phone while performing tasks, showed significant impairment of hand–steadiness which was comparable to that produced by single dose Cetirizine 10 mg and this may be one of the factors contributing to their close association with road traffic accidents.

The Effect of Soy Isoflavones on the Menopause Rating Scale Scoring in Perimenopausal and Postmenopausal Women: A Pilot Study

Marya Ahsan, Ayaz Khurram Mallick

Introduction: Menopause is associated with many unpleasant symptoms which vary in different phases of menopausal transition. Although, Hormone Replacement Therapy (HRT) is considered the most effective mode of treatment for these symptoms, its use is associated with increased risk of breast cancer, endometrial cancer and thromboembolic events. Soy isoflavones are being widely used as a safer alternative to HRT, even though scientific evidence of their efficacy is poor or lacking. Aim: To study the effect of soy isoflavone supplementation on the menopausal symptoms in perimenopausal and postmenopausal women. Materials and Methods: An observational pilot study was done involving 29 perimenopausal and 21 postmenopausal women prescribed 100 mg soy isoflavones for 12 weeks. Menopause Rating Scale (MRS) questionnaire was administered to the patients before starting soy isoflavone therapy and at the end of treatment. Responses were analysed using Statistical Package for Social Sciences (SPSS) software 23.0. Results: Total score of both the groups were comparable at baseline. Among perimenopausal women highest score was given to symptoms of psychological domain. Urogenital symptoms were the worst among postmenopausal women. After 12 weeks of treatment, total scores improved significantly by 19.55% and 12.62% in the perimenopausal and postmenopausal women respectively. The greatest improvement was seen in scores of hot flashes for both the groups and the least improvement was shown by symptoms of urogenital subscale. Conclusion: Soy isoflavone improves the MRS score among both the perimenopausal and postmenopausal women. As they are most effective for somatic and psychological symptoms, their use could be beneficial during perimenopause.

Correlation of Trace Elements in Patients of Chronic Liver Disease with Respect to Child- Turcotte- Pugh Scoring System

Introduction: Zinc, copper, manganese and magnesium are essential trace elements whose role in chronic liver disease and its complications is not clear. Aim: To study the concentration of these elements in patients with Chronic Liver Disease (CLD) with respect to Child-Torcotte-Pugh (CTP) scoring. Materials and Methods: This was an observational study carried out in the Department of Medicine, JSS Hospital, Mysore, India, between October 2013 and October 2015. A total of 75 patients with cirrhosis were prospectively enrolled. Severity of liver disease was assessed based on CTP score and patients were grouped into Class A, B and C. Routine investigations were done and following trace elements were assessed in all-zinc, copper, manganese and magnesium. Results: The serum concentrations of zinc decreased with severity of liver disease, and the mean difference between different severity classes was statistically significant (p<0.001). There was a significant negative correlation between zinc and CTP Score (r= -0.439; p<0.001). Copper concentration was increased in patients with more severe cirrhosis and mean level difference of copper among the CTP groups were statistically significant (p<0.001). Moreover, copper showed significant positive correlation with CTP Score (r=0.385; p<0.001). The serum levels of manganese were significantly higher in patients with CTP C class in comparison to patients with CTP A and B class (p<0.05); Manganese showed significant positive correlation with CTP Score (r=0.271; p= 0.019). The concentrations of magnesium did not differ significantly between CTP class with the mean level difference not statistically significant. Conclusion: Increasing liver dysfunction alters the metabolism of trace elements towards excess of copper and deficiency of zinc.

Intravenous Fluid Administration and the Survival of Pre hospital Resuscitated out of Hospital Cardiac Arrest Patients in Thailand

Introduction: Out of Hospital Cardiac Arrest (OHCA) is a leading cause of death worldwide. The Emergency Medical Service (EMS) provides early care to critical OHCA patients. Pre hospital intervention has been improving OHCA survival rate, however it is still unclear for the recommendation of routine infusion of Intravenous (IV) fluids during cardiac arrest resuscitation. Aim: This study aimed to determine whether IV fluid administration was associated with increasing survival of resuscitated OHCA patients and to assess the survival rate of resuscitated OHCA patients. Materials and Methods: This cross-sectional analytical study was conducted among 33,006 resuscitated OHCA patients who received emergency medical service in Thailand. Data set from the EMS Registry of the OHCA patients who received Advanced Life Support (ALS) and Cardiopulmonary Resuscitation (CPR) during January 2011 to December 2015 was enrolled as per inclusion criteria. Data were analysed by using both descriptive statistic and multiple logistic regression. Results: The result indicated that 27,270 OHCA patients (82.62%:95%CI=82.121-83.030%) survived until they reached hospital. In addition, after adjusting for effect modifiers and covariates, it was found that adult (=18 years) with IV fluid administration were more likely to survive (adjusted OR=4.389; 95% CI: 3.911-4.744) when compared to children (<18 years) with IV fluid administration (adjusted OR =2.952; 95% CI: 2.040-4.273). Other factors associated with OHCA patients’ survival were female gender (adjusted OR =1.151; 95% CI: 1.067-1.241), response time per minutes (adjusted OR =0.993; 95% CI: 0.989-0.997), scene time per minutes (adjusted OR=0.948; 95% CI: 0.944-0.952) and transport time per minutes (adjusted OR=0.973, 95%CI: 0.968-0.978). Conclusion: This study revealed that IV fluid administration was significantly associated with survival of OHCA patients while controlled other covariates including female gender, response time, scene time and transport time. Therefore, it is recommended that the IV fluid administration should be medicated for resuscitated OHCA patients.

Change in Bone Mineral Density and Role of Vitamin D and Calcium Supplementation During Treatment of First Episode Nephrotic Syndrome

Introduction: Nephrotic Syndrome (NS) is one of the common illnesses in childhood. Oral glucocorticoids are mainstay of treatment, which are known to cause various short term and long term adverse effects including osteoporosis. Children with first episode and infrequent relapsing NS are not prescribed Calcium (Ca) and Vitamin D (VitD) supplements routinely. Aim: To observe change in Bone Mineral Density (BMD) in children during first episode of NS and role of VitD and Ca supplementation during the treatment of first episode of NS. Materials and Methods: A double blind randomized control trial was conducted in Department of Paediatrics at a tertiary care center in New Delhi, India, from October 2011 to March 2013. Three groups were made, each having sample size of 20. Group A (intervention group) consisted of first episode NS patients who received steroids along with VitD and Ca supplements. Group B (placebo group) had children with first episode of NS treated with steroids and placebo. Biochemical tests and BMD assessment were done at start and after three months of steroid treatment. Groupwise differences in BMD, VitD, Ca, Phosphate (PO4) and Alkaline Phosphatase (ALP) were assessed at baseline and after three months through Analysis Of Variance (ANOVA). Linear regression models for repeated measures were used to test the association between different variables and BMD and also between various study groups. Results: Among study population, Group B had significant decrease in VitD levels (28.85±5.52 ng/dl to 14.22±1.36 ng/dl) than to Group A (23.59±6.08 ng/dl to 13.27±1.35 ng/dl) after three months of steroid treatment. Similarly BMD decreased significantly in Group B (-0.033g/cm2) as compared to Group A (0.001g/cm2) showing significant decrease in VitD and BMD in children with first episode of NS after three months of steroid treatment whereas use of VitD and Ca supplements improves the deficit. Conclusion: Ca and VitD supplement should be used during treatment of first episode of NS, but further studies are required to ascertain the adequate dose for the same.

Students’ Perception and Attitude on Methods of Anatomy Teaching in a Medical College of West Bengal, India

Raktim Bandyopadhyay, Romy Biswas

Introduction: Incorporating newer teaching aids over traditional one in Anatomy has been challenging both for the teachers and the learners. Different educational strategies are being used for teaching of Anatomy. Aim: To elicit the perception and attitude toward teaching approaches in the Anatomy curriculum among first year medical students. Materials and Methods: A cross-sectional, descriptive study was undertaken with the help of predesigned, pre-tested questionnaire to elicit knowledge in four domains of classroom teaching which were: a) gross anatomical structure; b) organ identification; c) topography; and d) radiological anatomy and self-assessment of acquired skills in respective fields among 114 first year students. Results: A total of 57% of students opined good in gross structure of anatomy. A 60.5% of students preferred chalk and board method and 33.3% with LCD projector. Regarding acquiring knowledge, 72.8% of medical students gathered knowledge in gross anatomical structure domain whereas 58.8% in radiological anatomy. The overall mean score of attitude of the students regarding incorporating newer techniques in Anatomy teaching is 14.17±2.26. Conclusion: The perception of Anatomy teaching and attitude among medicos have been studied and opinion from them had thrown light for incorporation of newer techniques in their teaching curriculum.

Association of Glycated Haemoglobin and Serum Apolipoproteins with Diabetic Retinopathy: An Indian Overview

Bhasker Mukherjee, Sandeep Shankar, Rehan Ahmed, Kanchan Singh, Kapil Bhatia

Introduction: India is presently facing an epidemic of diabetes mellitus and the risks of chronic complications from the disease are associated with the duration of the disease as well as the degree of hyperglycaemia. Diabetic retinopathy is a known microvascular complication of diabetes mellitus and is the most common cause of blindness in the western countries. Apolipoproteins are the protein component of lipoproteins. Apart from acting as structural proteins, they also act as cofactors to various enzymes. Aim: To measure the levels of serum apolipoproteins and glycated haemoglobin in cases of diabetic retinopathy and to assess their association with the stages of diabetic retinopathy. Material and Methods: The 135 diabetic cases [with (110) and without (125) retinopathy] attending the Ophthalmology OPD of this tertiary care hospital were included in the present study. Following retinoscopy, the patients were classified as Non-Proliferative Diabetic Retinopathy (NPDR) (n=75) and Proliferative Diabetic Retinopathy (PDR) (n=35). The controls (n=100) were age and sex matched patients who did not have diabetes. The cases and controls were assessed for HbA1c, total cholesterol, triglycerides, HDL cholesterol, Apo A-I and Apo B-100. Results: The HbA1c was found to be higher in diabetics without retinopathy (7.02%) as compared to controls (5.58%) (p<0.05) and the highest value was seen in the mild NPDR group (8.82%). The mean value of Apo A-I was found to be lowest in the diabetics without retinopathy at 88 mg/dl and the highest in severe NPDR at 167 mg/dL. The mean value of Apo B-100 was found to be highest in severe NPDR at 114 mg/dL. The mean value of HDL cholesterol was lowest in moderate NPDR at 36.6 mg/dl. Total cholesterol was highest in severe NPDR at 280.88mg/dl while triglyceride was highest in severe NPDR at 286.4mg/dl. Conclusion: In our study, the level of HbA1c was found to range from 5.58% in non-diabetic to 8.82% in mild NPDR. There was a clear association between Apo B-100 and total cholesterol, triglycerides with the highest value of each parameter seen in the severe NPDR group. There was a discordance noted in the levels of HDL and Apo A-I in various groups. Apo B-100 values may be of value in prognosis of diabetic retinopathy as higher values may result in progression of the disease. Further studies involving Lp(a) and homocysteine may be required in cases of diabetic retinopathy.

In Vitro Anti-Cariogenic Plaque Effects of Essential Oils Extracted from Culinary Herbs

Kornsit Wiwattanarattanabut, Suwan Choonharuangdej, Theerathavaj Srithavaj

Introduction: Cariogenic bacteria including mutans streptococci and lactobacilli are partly but significantly involved in dental caries development. An effective prevention strategy against dental caries is to decrease the accumulation of this microbiota either in planktonic or in biofilm form. Aim: To examine the antimicrobial and anti-plaque effects of some culinary herbs (spices), so the herbs are plausibly used as alternative and effective herbal plaque control supplements to promote good oral health. Materials and Methods: Essential oils extracted from sweet basil (Ocimum basilicum), cinnamon bark (Cinnamomum zeylanicum), sweet fennel (Foeniculum vulgare), kaffir lime (Citrus hystrix), black pepper (Piper nigrum), peppermint (Mentha piperita), and spearmint (Mentha spicata) were primarily examined for their antimicrobial activities against the cariogenic bacteria (Streptococcus mutans KPSK2 and Lactobacillus casei) using the agar disk diffusion and broth microdilution methods, respectively. These essential oils were then analysed for anti-plaque effects (retardation of S. mutans biofilm formation and reduction of the in vitro established biofilm). This experimental study was performed at the Department of Oral Microbiology, Faculty of Dentistry, Mahidol University during June 2015 till August 2016. Results: All selected essential oils showed different degrees of antimicrobial activity against the planktonic form of both cariogenic bacteria. Cinnamon bark essential oil expressed the strongest inhibitory effect against S. mutans {MIC of 0.08% (v/v)} and L. casei {MIC of 0.16% (v/v)}, whereas the weakest effect was found in kaffir lime essential oil {MIC values of 2.5% and 5.0% (v/v) for S. mutans and L. casei, respectively}. Up to 80% of S. mutans biofilm was retarded to form on the substratum primed with these spice essential oils, especially cinnamon oil. The preventive effect of these oils was in dose- and exposure time-dependent manners. For reductive effect against the 24-hour pre-established S. mutans biofilm, at least 50% of the biofilm mass was reduced when the biofilm was treated with each essential oil at the MIC for an hour. The reductive effect against the in vitro established S. mutans biofilm of these culinary herb essential oils only depended on the exposure time. Conclusion: Cinnamon and sweet basil essential oils with impressive in vitro anti-cariogenic bacteria and antiplaque effects may be proposed as alternative and effective supplements to promote oral health status.

Isolation of the Rare Opportunistic Yeast Saprochaete capitata from Clinical Samples-Experience from a Tertiary Care Hospital in Southern India and a Brief Review of the Literature

Introduction: Saprochaete capitata (Teleomorph: Magnusiomyces capitatus) is a ubiquitous yeast found in environmental sources such as soil, water, air, plants and dairy products. It is also a part of the normal microbial flora in humans. The yeast is being increasingly reported as an opportunistic pathogen, especially in patients in the haemato-oncology setting, the infection being often mistakenly diagnosed as invasive candidiasis. Aim: To review the epidemiological, clinical and microbiological features of six patients admitted in our hospital over a period of 10 years (from January 2007 to December 2016), from whom Saprochaete capitata was isolated. Materials and Methods: A retrospective study was conducted and the epidemiological, clinical, imaging and microbiological data of the six patients were collected and analysed. Results: The age of the six patients ranged from 19 years to 65 years with a median age of 53 years. There were two males and four females. In three out of the six patients, the isolation of S. capitata was considered clinically significant as the yeast was isolated repeatedly from blood and/or respiratory specimens and the clinical features could not be explained by any other alternative diagnosis. Haematological malignancy was the underlying disease in three out of the six patients while one patient was on triple immunosuppression following renal transplantation four years back. Three out of the six patients had severe neutropenia with Absolute Neutrophil Count (ANC) = 500 at the time of isolation of S. capitata. Two patients with clinical features of fungal sepsis received antifungal therapy with Amphotericin B but succumbed within a short period of starting the therapy. The post renal transplant patient who presented with pneumonia recovered after treatment with a combination of Amphotericin B and Voriconazole. Conclusion: Awareness regarding the epidemiological, clinical and microbiological aspects of invasive infections caused by S. capitata is essential for early recognition and appropriate management.

Comparison of Different Dosing Protocols of Anti-Snake Venom (ASV) in Snake Bite Cases

BR Daswani, AS Chandanwale, DB Kadam, BB Ghongane, VS Ghorpade, HC Manu

Introduction: Considering the cost of Anti-Snake Venom (ASV) and irregularity in its supply, there is often a need to curtail doses of ASV, despite guidelines for management of snake bite. During June 2013 to Sept 2013, when ASV was in short supply, our institutional committee reviewed the overall hospital statistics of snake bite cases as well as scientific literature and formulated a working modified protocol that used low dose of ASV in snake bite cases. Aim: To retrospectively analyse and compare the modified ASV protocol versus conventional ASV protocol with respect to outcome, number of ASV vials required, duration of stay in the hospital/ ICU, and additional supportive interventions needed. Materials and Methods: This was a retrospective study conducted at a tertiary care teaching hospital, Maharashtra, India. Hospital records of inpatients admitted for snake bite during June 2013 to September 2013 (since introduction of the modified protocol) as well as during June 2012 to September 2012, (when patients received conventional protocol-historical controls) were retrospectively analysed to assess the number of ASV vials received by the patients during the stay, need for supportive therapy, duration of stay and outcome of the patients. Results: There was a significant reduction in average number of ASV vials per patient, required vide the modified protocol compared to their historical controls (10.74+0.95 Vs 28.17+2.75 p<0.001). There was no significant difference in outcome, need for dialysis, fresh frozen plasma requirement, need for ICU stay and duration of hospitalization of snake bite patients. Yet, the average cost of management of each patient reduced by approximately 11974.41 INR per treated patient, based on the requirement of ASV. Conclusion: The modified ASV protocol used in this study is more cost effective as compared to the conventional protocol, deserves prospective evaluation and may be followed at least during prime time of scarcity of ASV.

Clinical Evaluation of Efficacy and Performance of All-Poly Tibial Freedom® Total Knee System for Treating Osteoarthritis Patients: Three-Year Follow Up Study

Avatar Singh, Kanwar Kulwinder Singh

Introduction: Advancement in technology in terms of design and building materials has made Total Knee Replacement (TKR) a highly effective, safe, and predictable orthopedic procedure. Aim: To review the clinical outcomes for efficacy and performance of Freedom Total Knee System for the management of Osteoarthritis (OA), at a minimum of three years follow up. Materials and Methods: For this retrospective, post-marketing study, clinical data of patients treated with Freedom Total Knee System was retrieved from the clinical records after approval from the Institutional Ethics Committee . All the patients above the age of 18 years who completed at least three years after TKR were observed for the study purpose. Patients treated for OA were included while the patients who received the implant for treatment of rheumatoid arthritis and traumatic injury were excluded. Factors such as aseptic loosening, implant failure, and need for revision surgery were observed to evaluate implant performance. Cases were recruited for clinical assessment of primary efficacy endpoint in terms of post-surgery maximun range of motion. Secondary efficacy endpoint was to determine the clinical and social quality of life as per the American Knee Society Score (AKSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and stiffness scores. Results: A total of 158 patients who had 191 TKR were observed for performance. The mean age of the patients was 67.67 years; mean BMI was 28.97±3.33, and the group comprised of 43% men and 57% women. Telephonic follow up at three years of 158 patients identified that none of them required revision surgery or had aseptic loosening suggesting excellent performance. Final clinical follow up at three years was available for only 35 patients (41 knee implants). The range of motion significantly improved from preoperative 104°±5.67° (range, 85°-119°) to 119.8°±11.05° (98°-123°) at follow-up (p<0.05). There was a significant improvement in clinical and functional AKSS score and WOMAC score at follow-up. Conclusion: The evaluation of Freedom Total Knee System for TKR in treating OA, at a minimum of three years follow up showed excellent outcomes in terms of performance, range of motion, reduced postoperative stiffness and pain, and improved functionality.

Hand-Held Dynamometer is a Reliable Tool to Measure Trunk Muscle Strength in Chronic Stroke

Suruliraj Karthikbabu, Mahabala Chakrapani

Introduction: Patients with chronic stroke show atypical coordination of trunk movement and they find difficulty during bed mobility and transfer skills due to weakness of trunk muscles. Routine bedside clinical examination fails to quantify the trunk muscle strength in patients with stroke. Handheld dynamometer is widely administered to quantify the strength of extremities, but its reliability on testing the trunk muscles strength is limited. Aim: This study aimed at examining the reliability of hand-held dynamometer to quantify the strength of trunk muscle groups in chronic stroke. Materials and Methods: This reliability study was conducted in outpatient clinical settings. Patients with chronic stroke aged between 30 and 80 years and an ambulatory capacity of 10-meter distance volunteered in the study. The strength of trunk flexors, extensors, rotators towards most and least affected sides and bilateral lateral flexors was examined by break test using hand-held dynamometer and the isometric strength was reported in pounds (lb.). These tests were carried out by two physical therapists independently at two time points and the assessment procedure was standardized. Pearson’s correlation test was conducted to observe the reliability of dynamometer strength testing i.e., internal consistency of the measure and intra-class correlation coefficient (r). Results: Of the 85 study participants, 51 of them had most trunk involvement on the left side and 34 had it on the right side. This study showed an excellent intra-rater (0.88-0.98) and inter-rater (0.84-0.96) reliability of trunk muscle strength testing using hand-held dynamometer. Conclusion: Hand-held dynamometer showed excellent intra and inter tester reliability to quantify the trunk muscle strength in patients with chronic stroke. So this tool can easily be administered in clinical and rehabilitation settings for diagnostic and prognostic purposes.

Benign Lesions on Screening Mammography: Increasing Diagnostic Confidence in a Hitherto Unscreened Population

Piyush Joshi, Rohit Sharma

Introduction: Screening mammography is used for detection of breast cancer and is interpreted using the Breast Image Reporting and Data System (BIRADS) convention. It is not routinely offered to women in countries which do not have a national screening programme resulting in a challenge for the radiologist who has to interpret these in the absence of previous mammograms. b# Aim: To analyse benign and probably benign lesions in screening mammograms in a hitherto unscreened population and suggest protocols to increase diagnostic confidence. Materials and Methods: Screening mammograms of 362 asymptomatic women in the age range of 40 to 60 years carried out over a two year period were retrospectively analysed. Patients of breast cancer and those who had palpable lumps were excluded from the study. All images were analysed in standard Mediolateral Oblique (MLO) and Craniocaudal (CC) projections with additional views wherever necessary. Corroborative ultrasound had been carried out wherever indicated in the opinion of the interpreting radiologist. The mammograms were finally classified according to the BIRADS convention. Results: Of the total number of 362 women screened, most of whom did not have any previous mammogram, 162 were reported as BIRADS I, 179 as BIRADS II and 18 as BIRADS III. The mammograms reported as BIRADS II had various findings including dystrophic calcification/ macrocalcification, vascular calcification, simple cysts and fibroadenomas. Only 26 (16.5%) of the BIRADS I mammograms had undergone further evaluation with Ultrasound (US) due to dense breasts or asymmetrical involution of breast tissue whereas 76 (42.5%) of the BIRADS II mammograms had undergone further evaluation with US to characterize lesions like cysts and fibroadenomas, but occasionally also for benign clustered calcification. Of BIRADS III mammograms, 12 (66.6%) had required US correlation to exclude a mass in cases with dense breasts. The increased likelihood of ultrasound corroboration in BIRADS II and BIRADS III was analysed using the Chi square test and was statistically significant. Conclusion: In the absence of previous screening mammograms, a small number of BIRADS I mammograms and a significant number of BIRADS II and BIRADS III mammograms undergo a corroborative US examination. The addition of supplemental US to the evaluation of these lesions increase diagnostic confidence and lesion characterization in a population which is not subject to routine screening.

Expression of p16INK4A Protein in Cervical Intraepithelial Neoplasia and Invasive Carcinoma of Uterine Cervix

Vatsala Kishore, Anuradha G. Patil

Introduction: Cervical cancer still ranks as the most frequent cancer among women in India. Infection with Human Papilloma Virus (HPV) results in precancerous lesions and invasive cervical cancer. Interaction of HPV oncogenic proteins with cellular regulatory proteins leads to upregulation of p16INK4A, a cyclin dependent kinase inhibitor. Therefore, p16INK4A overexpression is a surrogate biomarker of HPV infection making it useful in evaluating HPV associated premalignant and malignant lesions of gynaecological tract. Aim: This study was conducted to evaluate the usefulness of p16INK4A as a biomarker in dysplastic and malignant alteration of cervical epithelium. Materials and Methods: A total of 57 specimens diagnosed histopathologically as cervical dysplasia or malignancy were included in this prospective study of two year duration. Immunohistochemical (IHC) study of p16INK4A expression was performed on normal cervical tissue samples, Cervical Intraepithelial Neoplasia (CIN) 1, CIN 2, CIN 3, squamous cell carcinoma, adenocarcinoma. Expression was scored by two methods. One was simple positive versus negative p16INK4A staining and the other method was a semi-quantitative IHC scoring (0 to 8 points) according to the intensity of staining and the proportion of stained cells. The collected data was entered in excel sheet and analysed using Statistical Package For Social Science (SPSS) 16.0 software and the descriptive statistics, Chi-square test. The p-value of <0.05 was considered statistically significant. Results: Nuclear and/or cytoplasmic p16INK4A immunoreactivity was absent in normal cervical tissue, while immunopositivity was 25% in CIN 1, 50% in CIN 2, 75% in CIN 3, 75% and 100% in squamous cell carcinoma and adenocarcinoma respectively. All normal cervical samples had low scores (0 to 2 points), while number of cases with high scores was proportional to the degree of cervical dysplasia or invasive carcinoma. p16INK4A immunostaining with higher expression (score>5) was observed in 75% cases of carcinoma cervix. Conclusion: IHC expression of p16INK4A is related to degree of histological dysplasia and malignancy, suggesting its prognostic and predictive value in the management of cervical cancers.

Does Vitamin D Supplementation Improve Glycaemic Control In Children With Type 1 Diabetes Mellitus? – A Randomized Controlled Trial

Introduction: Vitamin D endocrine system is a potential immune system modulator and has been implicated in the pathogenesis of several autoimmune diseases including Type 1 Diabetes Mellitus (T1DM). Studies have demonstrated an inverse risk relationship between T1DM and Vitamin D levels and also, shown a reduced risk of the disease with its supplementation. Aim: To evaluate the role of Vitamin D as an adjuvant in improving glycaemic control and residual pancreatic beta-cell function. Primary outcome was the mean change in HbA1c levels over a period of six months. Materials and Methods: This double-blinded randomized controlled trial was done in a tertiary care hospital, Southern India and included 52 children aged 1-18 years with T1DM, with 26 participants each in the intervention and standard of care arm. Oral Vitamin D therapy was administered once a month for six months in addition to insulin in intervention arm while only insulin was continued for other arm. Plasma HbA1c, serum 25-Hydroxy vitamin D (25OHD), insulin dose and C-peptide were measured at baseline and repeated after 6 months. Results: Prevalence of Vitamin D deficiency was as high as 63.5% i.e., 33 of total 52 children with T1DM. The mean C-peptide levels were significantly high in intervention arm as compared to standard of care after six months. However, there was no significant difference in HbA1c, and insulin requirement at six months between the two groups. No adverse events due to Vitamin D therapy were noted. Conclusion: Oral Vitamin D may serve as an adjuvant to insulin therapy for children with T1DM by augmenting residual beta-cell function and improving insulin secretion. However, a significant decrease in HbA1c level and requirement for exogenous insulin was not achieved in our study.

Factors Affecting Post Caesarean Pain Intensity among Women in the Northern Peninsular of Malaysia

Introduction: Caesarean section (CS) rate has increased considerably during the past years, accounting for 15% to 25% of births. During post-CS period, moderate to severe postoperative pain is a regularly reported problem. Ideally, the intensity of postoperative pain should be predicted so as to customize analgesia. Aim: To document the CS rate, assess the pain intensity and preoperative factors that may predict post caesarean pain among women in the Obstetric unit of a Hospital Pulau Pinang in Malaysia. Materials and Methods: A retrospective chart review of 400 caesarean deliveries was conducted between January 2013 and June 2014. The study encompassed patient’s demographic data and obstetrics data. The overall pain scores since the time of surgery (2, 4, 8, 12, 24 and 48 hours postoperatively at rest and while moving) were assessed by visual analogue scale (VAS). The data were analyzed by using SPSS software (version 21.0 for Windows). Results: The results demonstrate that within a 48 hours postoperative period, the average pain at rest and while moving was 0.40±0.013 and 0.83±0.017 (VAS score), respectively. Logistic regression identified that a higher BMI (=30) (OR 1.056; 95% CI=1.003 to 1.113, p=0.04), an increase in operation time (> 60 minutes) (OR 1.009; 95% CI=1.000 to 1.018, p=0.049), Single women (OR 11.597; 95% CI=1.382 to 97.320, p=0.024), blood group type O (OR 1.857; 95% CI=0.543 to 2.040, p = 0.001) and general anesthesia (OR 3.689; 95% CI=1.653 to 8.232, p=0.001) were found to be independent predictors for postcaesarean pain intensity. Conclusion: This study concluded that CS rate is 28% among women in the obstetric unit of a Hospital Pulau Pinang and the pain experienced by the study participants was mild. Moreover, the predictive factors for pain intensity may aid in identifying patients at greater risk for postoperative pain. This study concluded that the predictive methods proposed may aid in identifying patients at greater risk for postoperative pain.

Medical Education Terminologies: Do These Really Percolate to the Level of Medical Students? A Survey

Arunita Jagzape, Tushar Jagzape, Swanand Pathak

Introduction: In Medical Education Technology, many terminologies are embodied in faculty training programs; used by teachers in daily practice like learning objectives, curriculum, and domains, formative and summative assessments. The awareness and knowledge of students regarding these terminologies, is questionable. Aim:To assess the awareness and knowledge of the students of all phases of MBBS - regarding terminologies in medical education. Materials and Methods: The study was questionnaire based survey at a private medical college in rural setting. Participants were the students from first, second, third Part I and third part II MBBS. Sample size included 175, 161,150 and 162 participants of first, second, third Part I and third Part II MBBS respectively. The questionnaire included 10 closed and one open ended questions which included the themes in educational spiral like: learning objectives, teaching-learning and assessment. Statistical data analysis was done by using descriptive and inferential statistics (Chi-square test) and p<0.05 was considered as level of significance. Qualitative data was analysed using coding and categorization. Results: Percentage of students participated for first, second, third Part I and third Part II MBBS were 87.5%, 80.09%, 93.16% and 90% respectively. The students were aware of some terms like learning objectives, its importance, curriculum; but knowledge component was missing. For some terms like cognitive, psychomotor, affective domain, simulation, formative, summative assessment; awareness as well as knowledge was missing. The methods suggested by students regarding the terminologies ranged from explanation of importance of these terms to its application. Conclusion: Efforts should be made in the direction to increase the awareness and knowledge of the basic terminologies used in medical education technology.

Audit of Organic Acidurias from a Single Centre: Clinical and Metabolic Profile at Presentation with Long Term Outcome

Seema Pavaman Sindgikar, Krithika Damodar Shenoy, Nutan Kamath, Rathika Shenoy

Introduction: Organic Acidurias (OA) accounts between 10% and 40% of confirmed Inborn Errors of Metabolism (IEM) in India. With prompt recognition and management, better survival but adverse neurodevelopmental outcome is reported. Aim: To study the clinical and metabolic presentation, management with immediate and long term outcome of symptomatic children with confirmed OA. Materials and Methods: Hospital based study of symptomatic children diagnosed to have OA between 2003 and 2009 and the survivors followed up over next five years. Diagnosis was based on clinical and metabolic presentation and confirmed by spectrometry analyses of urine and blood. Management, immediate outcome, compliance to treatment and recurrence of crises were documented. Neurodevelopmental outcome was assessed in follow up. Mean with Standard Error (Mean ± SE) and frequencies with percentages were calculated. Results: Of 72 cases suspected to have IEM, 38 (52.8%) were confirmed of (IEM), and out of which 15 (39.5%) had OA. Methyl malonic acidemia, multiple carboxylase deficiency and Propionic Acidemia (PA) constituted the largest proportion. Neurodevelopmental issues (73.3%) and metabolic crisis (53.3%) were common presenting features. Mean ± SE of ammonia was 639.0±424.1 µg/dl and lactate was 33.6±4.9 mg/dl. Mean pH, bicarbonate, and anion gap was 7.27±0.07, 14.1±2.3 and 17.9±2.3 respectively. Management was protocol based. Death was reported in two cases of PA; other morbidities were seen in five. Recurrent crisis (46.7%) complicated the follow up in survivors. Spasticity, extrapyramidal movement disorder, intellectual subnormality, autism spectrum, attention deficit hyperactivity disorder and sensory neural deafness were seen amongst survivors, in spite of compliance to therapy. Conclusion: OA is part of differential diagnosis in sick children and treatment needs to be prompt and specific. Prognosis is guarded even with long term cofactor supplementation in the symptomatic.

Effect of 12 Weeks of Yoga Therapy on Quality of Life and Indian Diabetes Risk Score in Normotensive Indian Young Adult Prediabetics and Diabetics: Randomized Control Trial

Introduction: India has become the epicentre for diabetes, a stress-related disorder affecting the working skills and day-to-day lifestyle management of younger population. Most of the studies have reported the effect of yoga on improving Quality of Life (QoL) in diabetic patients with other comorbidities. Till date, no randomized control trial reports are available to show the effect of yoga therapy on QoL and Indian Diabetes Risk Score (IDRS) in normotensive prediabetic and diabetic young individuals. Aim: To determine the effect of 12 weeks of yoga therapy on QoL and IDRS among normotensive prediabetic and diabetic young Indian adults. Materials and Methods: A randomized control trial was conducted in Endocrinology Outpatient Department (OPD). Normotensive participants (n=310) aged 18-45 years were divided into healthy controls (n=62), prediabetics (n=124) and diabetics (n=124). Study group subjects were randomly assigned to Group II (n=62, prediabetes-standard treatment), Group III (n=62, prediabetes-standard treatment + yoga therapy), Group IV (n=62, diabetes-standard treatment) and Group V (n=62, diabetes-standard treatment + yoga therapy). Flanagan QoL scale, IDRS questionnaire, Fasting Plasma Glucose (FPG) and insulin were assessed pre and post 12 weeks of intervention. Statistical analysis was done using Student’s paired t-test and one-way ANOVA. Results: Pre-post intervention analysis showed significant improvement in QoL scale with p<0.01 in Group II and Group IV; p<0.001 in Group III and Group V respectively. There was significant reduction in IDRS in Group II (p<0.05); p<0.001 in Group III, Group IV and Group V respectively. Significant difference (p<0.001) in QoL scale and IDRS were found when study groups with standard treatment along with yoga therapy were compared to standard treatment alone. Conclusion: Yoga therapy along with standard treatment for 12 weeks improved QoL and attenuated the diabetes risk among Indian prediabetics and diabetics compared to standard treatment alone.

The Effect of Ramadan Fasting on Biochemical Parameters in Healthy Thai Subjects

Sara Ongsara, Sakulrat Boonpol, Nussaree Prompalad, Nutjaree Jeenduang

Introduction: Although, the effect of Ramadan fasting on the risks for Cardiovascular Disease (CVD) has been reported in several studies, the results were inconsistent. In addition, the effect of Ramadan fasting on biochemical parameters in Thai subjects has not been evaluated. Aim: The aim of this study was to investigate the effect of Ramadan fasting on anthropometry, blood pressure, Fasting Blood Glucose (FBG), lipid profiles, and body composition in healthy Thai subjects. Materials and Methods: A total of 65 healthy subjects (21 men and 44 women) aged between 19-24 years were randomly recruited. Anthropometry, blood pressure, FBG, Total Cholesterol (TC), Triglyceride (TG), High Density Lipoprotein-Cholesterol (HDL-C), Low Density Lipoprotein-Cholesterol (LDL-C), and body composition were measured before Ramadan, end of Ramadan and after one month of Ramadan. Results: There were no changes in anthropometry, blood pressure, lipid profiles and body composition in both genders before Ramadan, end of Ramadan and after one month of Ramadan. Nevertheless, FBG levels were significantly increased after one month of Ramadan compared with baseline (5.09±0.50 versus 4.83±0.38 mmol/L, p=0.016, respectively) in women. Conclusion: The Ramadan fasting did not affect the lipid, anthropometric and body composition in healthy Thai subjects. However, the increased FBG levels after one month of Ramadan were observed in women. To improve the favourable biochemical parameters after Ramadan fasting, the lifestyle modifications such as, increased intake of healthy diets and increased physical activity should be recommended.

Opportunistic Microorganisms in Oral Cavity According to Treatment Status in Head and Neck Cancer Patients

Priyanka Soni, Rajendra Singh Parihar, Laxman Kumar Soni

Introduction: Cancer patients receiving chemotherapy and/ or radiation therapy are prone to many predisposing factors like immunosuppression, imbalance in the oral flora, hyposalivation and local tissue damage. Therefore, considered to be at higher risk for oral bacterial and fungal infection than the general population. Aim: To study oropharyngeal flora in head and neck cancer patients under treatment and to correlate their incidence according with Chemotherapy cycles and Radiochemotherapy. Materials and Methods: Total 110 patients were selected for study, those were further divided into two groups, group I under Chemotherapy (CT) – 55 patients and group II under Radiochemotherapy (RCT) – 55 patients and 50 healthy individuals were taken as control. Saliva sample was collected from control and study group and inoculated on Blood agar, MacConkey agar and Sabouraud’s Dextrose Agar (SDA). The identification of bacterial and fungal isolates was done by standard microbiological methods and result was calculated according to cycles of Chemotherapy and Radiochemotherapy combined. Significant differences between patients were tested using the Chi-square test or Fisher’s exact test. A p-value less than 0.05 was considered as statistically significant. Result: There were 149 culture isolates from 110 patient in which Gram Negative Bacilli (GNB) found in 63.6%, Candida spp. in 50%, Staphylococcus aureus in 8% and Normal commensal of oral cavity in 13.6% patients in study group and this was higher than control group and this difference was statistically significant in relation to all isolates individually. Relatively more microorganism were isolated during RCT (56%) in compare to CT alone (44%), among GNB- Pseudomonas (27.7%,32.3%) and Klebsiella (25%,29.4%) were most frequently isolated during CT, RCT respectively. Candida spp. were more commonly isolated from patient on RCT (63.6%) than CT (36.3%) when compared to control group (20%) among which C. tropicalis was more prevalent species. Both GNB & Candida spp. were more commonly isolated in later chemotherapy cycles (CT4, CT5 CT6). Conclusion: Colonisation of Gram negative bacilli & Candida spp. is directly related to number of chemotherapy cycles and combined cancer therapy. Hence, prophylactic medication for these two organisms should be incorporated along with cancer therapy.

Serum Vitamin D Level as a Risk Factor for Female Genital Tuberculosis (FGTB)

Introduction: Vitamin D is now known to be essential to Mycobacterium tuberculosis containment and killing through activation of 25-hydroxyvitamin-D receptors (VDRs) present on all immune cells or obtained from dietary food stuffs as either vitamin D3 or vegetable vitamin D2 (also known as ergocalciferol). Aim: To evaluate the association of serum vitamin D level between the Female Genital Tuberculosis (FGTB) cases and healthy controls. Materials and Methods: Total 120 cases and 120 controls enrolled for the study following inclusion and exclusion criteria. Detailed clinical history was taken from each subjects. Total of 3 ml of the blood was collected in EDTA vial from each subject (case and control). Quantification of serum vitamin D level was measured by active human vitamin D ELISA kit using an ELISA reader. Statistical analysis was done using Statistical Package for Social Science (SPSS) version 21.0. A p-value <0.05 was considered as significant. Results: A total of 120 confirmed FGTB cases and 120 healthy control enrolled for study. Out of 120 women 97.5%, 10.0%, 3.3%, 3.3% were detected positive for M. tuberculosis respectively. Comparing the mean demographic value of age and BMI were (29.03±3.127, 28.03±3.00) and (22.92±3.33, 24.15±3.97) respectively with the p=0.012* and p=0.010* found to be significant among cases and controls. The mean serum vitamin D level was 14.96±8.81 in cases and 23.00±8.83 in controls with p-value<0.001. There was a significant positive association found in low serum vitamin D level among FGTB cases than controls. Conclusion: Vitamin D is important for normal immune cell function, as well as regression of FGTB disease. FGTB may be controlled by regulating the serum vitamin D level concentration. This study suggests that, vitamin D deficiency and BMI is strongly associated with the progression of active FGTB disease which alters the expression of antimicrobial peptide and lead to the persistence of TB infection.Therefore, serum vitamin D level may play an important role in treatment of FGTB.

Detection of blaCTX-M Extended Spectrum Betalactamase Producing Salmonella enterica Serotype Typhi in a Tertiary Care Centre

Aishwarya Ramachandran, Mariappan Shanthi, Uma Sekar

Introduction: Infections caused by Salmonella are an important public health threat in tropical and subtropical countries. Due to the emergence of resistance to ampicillin, chloramphenicol and trimethoprim/sulfamethoxazole (multidrug resistant salmonellae) in the late 1980s, fluoroquinolones and extended spectrum cephalosporins became the drugs of choice. Resistance to cefotaxime and ceftriaxone due to the production of Extended Spectrum Beta-Lactamase (ESBL) and reduced susceptibility to ciprofloxacin have emerged resulting in treatment failure. The Cefotaximase (CTX-M) type ESBLs are the most widespread beta lactamase among Enterobacteriaceae including salmonellae. Aim: To detect the presence of blaCTX-M in salmonellae causing human infections. Detection of qnr genes to identify the coexistence of blaCTX-M and qnr gene. Materials and Methods: The study included 103 consecutive, non-repetitive salmonellae isolated from clinical specimens obtained from July 2015- June 2016 which were identified up to species level by conventional/automated methods. Susceptibility to various classes of antimicrobial agents was determined by disc diffusion method. Minimum Inhibitory Concentration (MIC) to cefotaxime and ceftriaxone was determined by agar dilution method. The results were interpreted in accordance with Clinical & Laboratory Standard Institute (CLSI) (guidelines 2015. Detection of the ESBL phenotype was performed by the combined disk method. Polymerase Chain Reaction (PCR) amplification of all isolates was performed using group specific primers to characterize the presence of blaCTX-M, qnrA, qnrB and qnrS. Result: Of the 103 study isolates two isolates of Salmonella typhi were resistant to cefotaxime and ceftriaxone and had a MIC of 128µg/ml. PCR amplification and sequencing detected the presence of blaCTX-M-15 in these two isolates. These two isolates exhibited resistance to ciprofloxacin in vitro but qnr gene was not detected in these isolates. Conclusion: Resistance to third generation cephalosporins among salmonellae is a cause for concern as it may lead to treatment failure. It is imperative to continuously monitor the susceptibility pattern as enteric fever is endemic in India.

Pleiotropic Effects of Losartan in Hypertensive Patients with Dyslipidemia

Sivakumar Sivasubramaniam, Banupriya Kumarasamy

Introduction: In essential hypertension, the comorbidity of dyslipidemia is very common. In addition to hypertension, dyslipidemia is linked to cardiovascular disease, stroke and decline in renal function. Unlike other angiotensin receptor blockers, Losartan has been claimed to have unique pleiotropic property and thereby decreasing the risk of future cardiovascular complications. Aim: The present study was done to assess on the pleiotropic effect of losartan in newly diagnosed hypertensive patients with dyslipidemia. Materials and Methods: Fifty four hypertensive patients with dyslipidemia who fulfilled the eligible criteria and were willing to give informed consent were included in the study after getting Institutional Ethical Committee (IEC) approval. All the study participants were given tab. Losartan 50mg once daily for four weeks. At the end of 1st, 2nd, 3rd and 4th week, blood pressure control and compliance were monitored. At the end of 4th week all the baseline laboratory parameters like renal function test, liver function test, lipid prolife and random blood sugar were performed. The EQ-5D questionnaires were completed at two points during the study: at the patient’s initial visit before enrollment in the study and after 4 weeks of Losartan therapy. Appropriate statistical methods were used to analyse the results. The primary endpoint was reduction in blood pressure and improvement in lipid profile and improvement in quality of life score from baseline after 4 weeks of losartan therapy Results: Four patients were withdrawn due to non-compliance and totally 50 patients completed the study. The mean systolic blood pressure was reduced from 154.54 mm Hg to 138.16 mm Hg with p<0.0001 and the mean diastolic blood pressure was reduced from 91.56 mm Hg to 82.44 mm Hg with p<0.0001. There was a significant reduction in the mean total cholesterol from 189.52 to 180.46 mg/dl, mean LDL from 110.50 to 101.32 mg/dl and mean triglygeride from 135.68 to 127.70 mg/dl with p<0.0001. Improvements in anxiety and depression, as well as other dimensions in the QOL questionnaire, paralleled with improvement of the clinical picture. Conclusion: Based on the results of this study, Losartan is safe and effective in treating hypertensive patients with dyslipidemia in addition to its antihypertensive effect and it also has benefits of reducing serum glucose, lipid levels; and improvement in the quality of life.

A Correlative Study between Platelet Count, Mean Platelet Volume and Red Cell Distribution Width with the Disease Severity Index in Psoriasis Patients

Introduction: Platelet activation is presumed to play an important role in the immunoinflammatory reactions. Several recent studies on a variety of inflammatory disorders have used Mean Platelet Volume (MPV) as a marker for platelet activation. Aim: To determine the relationship between haematological parameters and disease severity index in psoriasis patients. Materials and Methods: A Case control study was carried out on 50 psoriatic patients and 50 healthy control subjects. Ten haematologic parameters were compared between patients and control subjects. These parameters were also correlated in patients with PASI (Psoriasis Area and Severity Index) score. The data was statistically analysed using IBM SPSS software (Version 21). Spearman Rank Correlation was used to find the correlation between PASI and haematological parameters. Results: When all the patients were considered together, mean values for MPV, Platelet Count (PLT) and Red Cell Distribution Width (RDW) were significantly different between the two groups (Control and Patients). While MPV and RDW were raised, PLT was reduced in patients of both sexes when compared with controls. In Male patients the MPV and RDW showed statistically significant correlation with Psoriasis Area And Severity Index (PASI) (MPV <0.01; RDW<0.05), whereas PLT though reduced in both sexes when compared with controls, it showed significance in female patients alone (p <0.01). Conclusion: The mean values for MPV and RDW were higher and mean platelet values were lower in patients than controls. The MPV values in male patients and Platelet counts in female patients showed strong positive and negative correlation respectively with the PASI score. It can be concluded that rising MPV and decreasing PLT could be good indicators of disease severity and progression. These indicators could also help in assessing the treatment course of the disease.

Evaluation of Maternal and Perinatal Outcomes of Induction in Borderline Oligohydramnios at Term

Setu Rathod, Sunil Kumar Samal

Introduction: Oligohydramnios is described as decreased amniotic fluid volume relative to gestational age. Semiquantitatively it is described using the Amniotic Fluid Index (AFI) which is calculated by adding the depth in centimetres of the largest vertical pocket in each of four equal uterine quadrants. AFI less than or equal to 5 cm is defined as oligohydramnios. A Borderline Oligohydramnios (BO) is defined as AFI 5.1-8 cm. Aim: To assess the maternal and perinatal outcome of induction in borderline oligohydramnios cases at term. Materials and Methods: This is a retrospective observational study done from December 2015 to November 2016 in Mahatma Gandhi Medical College and Research Institute, Puducherry, India. Fifty cases of BO with AFI 5.1 cm - 8 cm taken as case and another 50 cases of Normal Liquor (NL) with AFI 8.1 cm - 18 cm taken as control. Data was collected and analysed by SPSS software version 20.0 For qualitative data, the ?2-test or Fisher’s-exact test were used and for continuous variables, the t-test was used. Results: Cases and controls were matched in baseline parameters. More number of cases were found with meconium stained liquor during labour which is statistically significant (p<0.05). Otherwise there were no statistical significant difference between cases and controls in maternal and perinatal outcome. Conclusion: Induction of labour in cases with BO cases compared to those with NL at term did not show very statistically significant difference in terms of induction to delivery interval and neonatal outcome.

Emergency Peripartum Hysterectomy: A 14-Year Experience at a Tertiary Care Centre in India

S Tahmina, Mary Daniel, Preetha Gunasegaran

Introduction: Emergency Peripartum Hysterectomy (EPH), although relatively infrequent in present day obstetrics, is a life-saving procedure in the event of a massive postpartum haemorrhage. Aim: To assess incidence, risk factors, indications and complications of peripartum hysterectomies at a tertiary care teaching hospital in India. Materials and Methods: A retrospective study was conducted at a 650-bedded tertiary care medical teaching hospital in Southern India. All emergency peripartum hysterectomies performed between February 2002 and December 2015 at a tertiary care teaching hospital, were included in the study. Demographic characteristics, risk factors, antepartum, intrapartum and post-partum events, need for blood transfusion, length of stay in intensive care unit and postoperative complications were noted. Data was entered in Microsoft Excel spreadsheet and analysed using SPSS software version 22.0. For categorical variables, data was compiled as frequency and percent. For continuous variables, data was calculated as mean±SD. Results: Among 16,473 deliveries in the study period, 12 emergency peripartum hysterectomies were undertaken, the incidence being 0.073%. Women were aged 20 to 40 years (mean 30.25 years). Majority (83%) were multiparous women. Atonic postpartum haemorrhage was the most common (58%) indication for hysterectomy. About 67% of hysterectomies performed were subtotal hysterectomies. One half of them had a previous caesarean section. Two patients had bilateral internal iliac artery embolization for ongoing haemorrhage. All patients required intensive care and blood transfusion. Two patients did not survive even after hysterectomy. Conclusion: Atonic postpartum haemorrhage was the most common reason for performing an emergency peripartum hysterectomy. Women with previous caesarean section are at increased risk, both due to atonic and traumatic postpartum haemorrhage. Regular departmental audits are needed to formulate appropriate protocols to decrease mortality and near-miss events like EPH. Stringent protocols should be instituted for managing obstetric haemorrhage. Although EPH is life-saving, early intervention by a senior obstetrician well versed with conservative procedures may avoid morbidity associated with EPH.

Role of Sonographic Gray-Scale Pattern Recognition in the Diagnosis of Adnexal Masses

Jyothi Shetty, Grishma Reddy, Deeksha Pandey

Introduction: Characterization of adnexal masses as benign or malignant is of utmost importance for optimal management and prognostication. Ultrasound examination plays an important role in the differentiation of adnexal masses. Various sonographic characteristics have been recognised to differentiate benign and malignant adnexal masses. Subjective evaluation of gray-scale ultrasound images by an experienced ultrasound examiner to discriminate adnexal masses is known as “pattern recognition”. Aim: To access the efficacy of pattern recognition at predicting an accurate histological diagnosis of adnexal masses. Materials and Methods: All adnexal masses diagnosed clinically or during screening sonography were included in the study (n=136). Sonographic pattern recognition was performed and documented with specific diagnosis whenever feasible. Risk of Malignancy Index 3 (RMI3) score was also calculated. Results were compared with the gold standard histology. Chi-square test was used to assess the significance of the results and a p-value <0.05 was considered statistically significant. Results: In the final cohort of 136 women, on pattern recognition, 91 were suspected to have benign adnexal masses and 45 were reported as malignant adnexal masses. However, on final histo-pathology, 94 patients had benign tumours and 42 patients had malignant disease. The benign group pattern recognition could render a specific diagnosis in 85.7% as compared to RMI3 pattern recognition conferred a sensitivity of 95.2% (RMI3 78.6%), with a slight compromise in the specificity (94.7% versus 96.8%). Conclusion: Pattern recognition is a sensitive and specific sonographic tool in discriminating benign and malignant adnexal masses. Moreover, it is also useful in differentiating various benign adnexal masses.

Comparative Evaluation of Ropivacaine and Fentanyl Versus Ropivacaine and Fentanyl with Clonidine for Postoperative Epidural Analgesia in Total Knee Replacement Surgery

Introduction: Clonidine an alpha 2 adrenoceptor agonist possesses analgesic properties and has been used as an adjuvant in epidural analgesia. The addition of clonidine to other analgesics may result in enhanced analgesia through additive mechanisms or synergistic mechanisms. The enhanced analgesia may lead to a decrease in the dosage of analgesic drugs along with reduction of side effects. Aim: The purpose of this study was to evaluate the effect of adding clonidine to epidural ropivacaine and fentanyl mixture in terms of quality of analgesia and side effects in patients of total knee replacement surgery. Materials and Methods: A prospective randomised double blind study was conducted on 60 patients of ASA physical status I, II and III who underwent unilateral total knee replacement surgery under combined spinal epidural anaesthesia. Patients were divided into two Groups A and B randomly. Postoperatively Group A received continuous epidural infusion of ropivacaine 2 mg.ml -1 and fentanyl 2 µg.ml -1 along with clonidine 2 µg.ml-1 in the range of 3-7 ml.hr-1 while Group B received the ropivacaine and fentanyl epidural solution. The postoperative VAS scores, haemodynamic parameters, motor block, sedation, nausea, vomiting and any other significant side effects were noted. The two groups were compared with student's t-test, Pearson’s Chi square test and t-test using SPSS statistical software. Results: Visual analog scale scores were lower in Group A (3.38) than in Group B (3.72). The average infusion rate was lower in Group A (4.7 ± 0.7 ml.hr -1) than in Group B (5.5 ± 0.7 ml.hr-1). Patients in Group A required less dosage of rescue pain medication Paracetamol (1g i.v.), diastolic pressure and heart rate were lower in Group A. The groups were comparable in terms of sedation, motor block and nausea vomiting. Conclusion: Clonidine added to a ropivacaine and fentanyl mixture augmented the postoperative epidural analgesia without significant side effects.

Prediction of Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) after Thoracic Surgery- The Role of Estimated GFR

Shibani Padhy, Prachi kar, Gopinath Ramachandran

Introducton: Little is known about the prognostic utility of preoperative estimated GFR (eGFR) on perioperative Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) in apparently lower risk patients undergoing moderate risk surgeries like thoracotomy. Aim: The current study sought to identify a clinically relevant cut-off value of eGFR for identifying thoracotomy patients at higher risk for MACCE. Materials and Methods: Between July 2012 and July 2016, 436 consecutive patients were retrospectively studied after elective thoracotomy in a single institution. Patients were classified into six groups according to the calculated Chronic Kidney Disease Epidemiology Collaboration equations (CKD-EPI) eGFR (ml min -11.73 m -2): Stage 1, eGFR >90; Stage 2, eGFR=60–89.9; Stage 3a, eGFR=45–59.9; Stage 3b, eGFR=30–44.9; Stage 4, eGFR=15–29.9; Stage 5, eGFR <15. All the eGFR groups were analysed for perioperative MACCE, length of hospital stay, and mortality. Results: The incidence of perioperative MACCE in our study was 4.24%. The mean eGFR in our study as calculated by the CKD-EPI equation was 83 ml min-11.73 m-2. With the exception of nonfatal cardiac arrest which was not seen in any patient, the incidence of all MACCE increased with progressively worsening preoperative eGFR. It was seen by logistic regression analysis that the occurrence of any perioperative MACCE increased significantly with worsening eGFR (p<0.001). The increase in MACCE was particularly marked from Stage 3b onwards to the later stages (OR 1.9 in 3a vs. 3.6 in 3b). The two mortalities observed in the study were in Stages 4 and 5 with no deaths seen in the better eGFR subgroups. There was also an increased length of hospital stay with declining eGFR. Conclusion: Preoperative eGFR is a predictor of perioperative MACCE in homogenous moderate risk elective surgical population like thoracic surgeries. There is an inverse relationship between eGFR and MACCE, particularly manifested at eGFR values <45 ml/min/1.73. Routine use of preoperative eGFR for cardiovascular and cerebrovascular risk assessment in patients undergoing moderate risk surgeries like thoracotomy would be beneficial.

Clinico-Aetiological Study of Severe and Very Severe Pneumonia in Two Months to Five Years Children in a Tertiary Health Care Centre in Odisha, India

Introduction: Pneumonia is a major cause of mortality under fiveyear-old children. In spite of recent advances in management, there is paucity of data on clinical, aetiological profile of severe and very severe pneumonia among under five-year-old children in developing countries. Aim: To determine the clinico-aetiological factors of severe and very severe pneumonia and its outcome in children aged two -months to five-years in a tertiary health care centre in Odisha, India. Materials and Methods: This was a prospective observational study. All the patients between two-months to five-years age admitted to SCB Medical College, Cuttack, Odisha, India, were screened for features of severe and very severe pneumonia based on WHO diagnostic criteria, over a one year period. Out of 10300 patients admitted to our hospital during the study period; 141 cases were included in the study. Their clinical parameters were recorded and were followed up till discharge or death. Continous variables were analyzed using Student t-test or Mann-Whitney U test whereas categorical data were analyzed using Pearson Chi square test or Fischer Exact test. Results: Out of 141 patients included in the study, cough, tachypnea and chest retractions were present in 100% cases while fever in 97.1% (137) cases. In 17% (24) cases, bacterial pathogen was isolated. Most common organism being Staphylococcus aureus 8.51% (12) followed by Streptococcus pneumonie 6.4% (9). Higher mortality 11.34% (16) was found among patients presenting after three days of illness (p=0.048). About 17% (24) patients developed complications. Common complications were sepsis 5.6% (8), CCF 4.2% (6) and empyema 4.2% (6). Higher mortality 22 (15.6%) was observed in very severe pneumonia group (p=0.003). Conclusion: The incidence of severe and very severe pneumonia was higher in infancy. Rainy and winter season were associated with higher incidence of disease. Bottle feeding practice and smoking were significantly associated with more severe disease. Death rate was high among patients admitted to hospital after three days of onset of illness, so early referral is indicated for better outcome.

Clinicopathological Characteristics and Outcomes of Diffuse Crescentic Glomerulonephritis - A Single Center Experience from Southern India

Introduction: Diffuse Crescentic glomerulonephritis (CrGN) is characterized by rapidly progressive renal failure and has grave prognosis. There is significant regional and temporal variation in aetiology, prevalence and prognosis of diffuse crescentic glomerulonephritis (CrGN) with limited data available in adult Indian population. Aim: This study aims to identify the aetiology, clinico-pathological features and outcomes of diffuse CrGN in south Indian population. Materials and Methods: In this retrospective study, clinical records of all adults (>18 years) over a 5-year period (2010-2014) with a histopathological diagnosis of diffuse CrGN (>50% crescents) were reviewed. Clinical, serological, biochemical and histopathological data were collected. Follow-up data at six months including renal outcome and mortality were studied. Data was analysed using SPSS version 15. Results: There were 29 cases of diffuse CrGN accounting for an incidence of 2.9% among 1016 non-transplant kidney biopsies. The most common cause was pauci-immune crescentic GN. The median creatinine at admission was 7.2 mg/dl {(interquartile range (IR) 3.3 - 10.4)} and 75.9% of patients required haemodialysis at admission. Complete/partial recovery was seen in 34.5%. At the end of six months 31% were dialysis dependent and the mortality was 27.6%. On univariate analysis, the significant predictors of renal loss and mortality were oliguria (p=0.02), requirement of haemodialysis and serum creatinine (p=0.001) at admission (>5.5mg/dl) (p=0.003). Histopathological features did not influence the outcome in our study. Conclusion: In our cohort, the most common cause for diffuse CrGN is pauci-immune CrGN. Diffuse CrGN carries a poor prognosis. Patients with pauci-immune and AntiGBM disease have worst prognosis compared to immune complex CrGN. The presence of oliguria, high serum creatinine and requirement of haemodialysis at admission are associated with poor outcomes.

Recurrent Aphthous Stomatitis: An Assessment of Antioxidant Levels in Plasma and Saliva

J S Jesija, Saraswathi Gopal, Hugh P Skiel

Introduction: Recurrent Aphthous Stomatitis (RAS) is a common oral mucosal disorder that affects 20% of the population worldwide. Factors such as trauma, stress, genetic, hypersensitivity, nutrition, immune disturbance, and hormonal imbalance may disturb the oxidant and antioxidant balance of an organism, and precipitate RAS, but the relationships are poorly understood. Aim: The purpose of this study was to evaluate the antioxidant status in plasma and saliva of patients with RAS. Materials and Methods: Forty patients with RAS and forty healthy individuals were included in the study. The levels of antioxidants such as Superoxide Dismutase (SOD), Glutathione Peroxidase (GSHPx) Catalase (CAT) and Uric Acid (UA) were measured in plasma and saliva. Statistical analysis was performed to compare the two groups using independent t-test and ANOVA. Results: Decreased SOD levels were observed in plasma amongst RAS patients (p < 0.03) whereas, increased levels were observed in their saliva (p < 0.001) compared to the control group. A significant difference (p < 0.001) was noticed in GSHPx levels: RAS patients exhibited higher levels in plasma but decreased in saliva compared to the control group. CAT activities and UA levels in saliva (p = 0.015 and p < 0.001 respectively) were observed to be significantly higher in RAS patients. Within the RAS group elevated plasma SOD level (p < 0.006) was found in patients with major ulcers whereas, an increased plasma UA (p < 0.01) level was observed in patients with minor ulcers. Conclusion: The non-equilibrium antioxidant levels observed in both plasma and saliva indicate the antioxidant status of the body is disturbed in patients with RAS.

Fracture Resistance of Endodontically Treated Teeth Restored with Biodentine, Resin Modified GIC and Hybrid Composite Resin as a Core Material

Introduction: The restoration of a severely damaged tooth usually needs a post and core as a part of treatment procedure to provide a corono - radicular stabilization. Biodentine is a class of dental material which possess high mechanical properties with excellent biocompatibility and bioactive behaviour. The sealing ability coupled with optimum physical properties could make Biodentine an excellent option as a core material. Aim: The aim of the study was to determine the fracture resistance of Biodentine as a core material in comparison with resin modified glass ionomer and composite resin. Materials and Methods: Freshly extracted 30 human permanent maxillary central incisors were selected. After endodontic treatment followed by post space preparation and luting of Glass fibre post (Reforpost, Angelus), the samples were divided in to three groups based on the type of core material. The core build-up used in Group I was Biodentine (Septodont, France), Group II was Resin-Modified Glass Ionomer Cement (GC, Japan) and Group III was Hybrid Composite Resin (TeEconom plus, Ivoclar vivadent). The specimens were subjected to fracture toughness using Universal testing machine (1474, Zwick/Roell, Germany) and results were compared using One-way analysis of variance with Tukey’s Post hoc test. Results: The results showed that there was significant difference between groups in terms of fracture load. Also, composite resin exhibited highest mean fracture load (1039.9 N), whereas teeth restored with Biodentine demonstrated the lowest mean fracture load (176.66 N). Resin modified glass ionomer exhibited intermediate fracture load (612.07 N). The primary mode of failure in Group I and Group II was favourable (100%) while unfavourable fracture was seen in Group III (30%). Conclusion: Biodentine, does not satisfy the requirements to be used as an ideal core material. The uses of RMGIC’s as a core build-up material should be limited to non-stress bearing areas. Composite resin is still the best core build-up material owing to its high fracture resistance and bonding to tooth.

Protective effects of Ethanolic Extract of Emblica officinalis (amla) on Cardiovascular Pathophysiology of Rats, Fed with High Fat Diet

Introduction: Dietary high fat alters lipid profile and possibly induce sympatho-vagal imbalance. Emblica officinalis is found to be potential antioxidant and possibly counteract hyperlipidemia induced lipid peroxidation. Aim: To assess Ethanolic extract of Emblica Officinalis (EEO) as lipid lowering and cardiovascular protective agent against high dietary fat supplemented to experimental rats. Further to study a comparative analysis between EEO and atorvastatin on hyperlipidemia and cardiovascular integrity. Materials and Methods: EEO was prepared and phytochemical analysis was done. Rats were divided into five groups, having six rats in each group as following; Group I-control (20% fat); Group II (+ EEO 100 mg/kg body wt); Group III (fed with high fat diet; 30% fat); Group IV (fed with high fat diet; 30% fat + EEO 100 mg/kg body wt) and Group V (fed with high fat diet; 30% fat + atorvastatin 4 mg/kg body wt). The treatments were continued for 21 days. Gravimetric parameters and electrophysiological parameters {Heart Rate (HR), sympatho-vagal balance} were recorded and lipid profiles of all the groups were measured. ANOVA, correlation and multiple regressions were done for analysis of data. Results: Significant alteration in serum lipid profile was observed in rats fed with high dietary fat but supplementation of EEO was found to be reversible. Electrophysiological evaluation revealed altered HR and sympatho-vagal balance in high dietary fat fed rats (Group III) which indicate cardiac autonomic malfunctions which were found to be improved in Emblica officinalis supplemented group of rats (Group IV). Further, analysis has shown significant negative correlation between HDL/LDL and sympatho-vagal balance in all groups of rats which clearly indicate a role of dietary fat on sympatho-vagal balance. These results further corroborated with findings of histopathological study on myocardium and elastic artery. Conclusion: Observations from the study indicate a beneficial role of ethanolic extract of Emblica officinalis (amla) on dyslipidemia and cardiac autonomic functions in rats treated with high fat diet.

Vitamin D Levels and Associations in Indian Patients with Primary Sjögren’s Syndrome

Introduction: Vitamin D is a steroid hormone belonging to the class of secosteroids with myriad immune functions and has been implicated in aetiopathogenesis of various autoimmune diseases. Although, there have been various studies showing the association of vitamin D in rheumatoid arthritis and lupus in different populations, there have been limited studies on vitamin D and primary Sjögren's Syndrome (pSS). There are no studies on association of vitamin D and pSS from any tropical country including Indian subcontinent. Aim: The purpose of the study was to look for any association between 25-hydroxyvitamin D (25(OH)D) levels and disease manifestations in Indian patients with pSS. Materials and Methods: This is a retrospective cross-sectional study done at a tertiary teaching hospital in southern India in 235 patients with pSS. Patients satisfying the American European Consensus Group (AECG) or American College of Rheumatology (ACR) 2012 for pSS between 2008 and 2015 were included if baseline 25(OH)D levels using electrochemiluminescence were available in hospital’s laboratory record, 25(OH)D <20 ng/ml,20-30 ng/ml and >30 ng/ml was defined as deficiency, insufficiency and normal, respectively. Clinical laboratory data and disease activity scoring by EULAR Sjögren's syndrome disease activity index (ESSDAI) were retrieved retrospectively. Latitude corresponding to residence of each patient and the season of performing the assay were recorded. Chi-square statistics was done to find associations between categorized 25(OH)D and outcomes and was reported as odds ratio(95% confidence interval). Results: Mean 25(OH)D for 235 patients with pSS was 19.98(12.55)ng/ml. A vitamin D deficiency, insufficiency and sufficiency was seen in 141(60%), 60(25.5%) and 34.0(14.5%), respectively. No association was noted between latitude or season of performing assay and the levels. pSS with 25(OH)D =30ng/ml had more than two fold risk of higher grading on lip biopsy as well as Rheumatoid Factor (RF) positivity. However, low 25(OH)D seemed to be associated with lower ESSDAI and less pulmonary involvement. Conclusion: Prevalence of 25(OH)D deficiency in Indian patients with pSS was comparable to that of general Indian population. Low 25(OH)D level =30ng/ml was associated with higher odds for RF positivity and positive grading on lip biopsy. Surprisingly, low 25(OH)D was associated with lower ESSDAI score.

Impact of Nano Hydroxyapatite, Nano Silver Fluoride and Sodium Fluoride Varnish on Primary Teeth Enamel Remineralization: An In Vitro Study

Ali Nozari, Shabnam Ajami, Azade Rafiei, Elmira Niazi

Introduction: Dental caries is still prevailing worldwide, although different anti caries products have been introduced. Each remineralizing agent has its own shortcomings. Therefore, looking for new agents to have benefits of previous ones with lesser side effects is worthwhile. Aim: To determine the remineralization ability of NaF varnish, nano-Hydroxyapatite Serum (n-HAP) and Nano Silver Fluoride (NSF) on enamel of primary anterior teeth. Materials and Methods: Incipient caries were induced in primary sound anterior teeth by storing each specimen in demineralization solution for 72 hours. Then they were randomly divided into four groups of 15 samples each: (1) NaF varnish; (2) n-HAP repairing serum; (3) NSF and (4) no treatment (control). Surface Microhardness (SMH) was assessed with Vickers micro hardness tester before and after demineralization and after 10 days of pH-cycling. A total of 12 random specimens from groups 1 to 4 (3 random samples of each group) were examined by Atomic Force Microscopy (AFM). The SMH values were analysed with one-way and repeated measures ANOVA. Level of significance was set at p=0.05. Results: Post lesion SMH values significantly decreased in all groups (p<0.001). Post treatment SMH values significantly increased in comparison to post lesion ones (p<0.001) except for control group which was not different statistically (p=0.86). The highest SMH values were observed in NSF group (mean 222.90 ± 28.79). Statistically significant differences were shown between all groups (p<0.05). However, NaF varnish and n-HAP groups were not statistically different (p=0.165). AFM images demonstrated protective layers in all treated groups. Conclusion: The results of this in vitro study suggest that NSF could have the greatest remineralization efficacy. NaF varnish and n-HAP serum were similar in remineralizing initial caries. Future clinical studies are recommended for selection of the most appropriate remineralizing agent in primary teeth.

Correlation of Pregnancy Associated Plasma Protein A and Zinc with Calculated Risk Ratio of Dual Test

Introduction: First trimester screening by dual test is the most preferred method of antenatal screening. The detection rate of foetal aneuploidy using dual test is 95%. This test uses maternal serum free ß human Chorionic Gonadotropin (free ß hCG) and Pregnancy Associated Plasma Protein A (PAPP-A) along with maternal demographic and foetal sonographic indices to calculate risk for foetal aneuploidy. PAPP-A is a zinc binding metalloproteinase which is also responsible for placental development and foetal growth. So, zinc might also have some role in first trimester screening. No studies are available substantiating the role of zinc in first trimester screening. Aim: To measure and correlate maternal serum zinc with PAPP-A and calculated risk ratio of first trimester screening. Materials and Methods: PAPP-A and zinc were measured from the serum of 84 pregnant women aged 20-40 years in 11th-13th weeks+6 days of gestation who underwent dual test during their antenatal check-up. Risk calculation was done using Screening Software for Downs Windows Lab (SSDWL). Results: Maternal serum PAPP-A showed a significant positive correlation with maternal serum zinc (p-value <0.001). Maternal serum PAPP-A and zinc both showed a significant positive correlation with calculated risk ratio (p-value<0.01). Conclusion: As PAPP-A is a zinc binding metalloproteinase, zinc showed significant pattern of correlation with aneuploidy risk as shown by PAPP-A. So there could be a possible role for serum zinc in first trimester of screening.

Controversies in Serotonin Syndrome Diagnosis and Management: A Review

Over the past few years, Serotonin Syndrome (SS) has become a significant clinical concern. Over the last decade or so, United States saw a surge in antidepressant use. SS characteristically presents as the triad of altered mental status, autonomic dysfunction and neuromuscular excitation. Symptoms vary from patient to patient with mild cases presenting with subacute symptoms and severe cases progressing rapidly to death. Due to the protean manifestations of the syndrome along with non-specific prodromal, SS can easily be misdiagnosed if not carefully assessed. In severe cases, SS can be mistaken as neuroleptic malignant syndrome while mild cases are mostly misattributed to other causes such as flu. SS is a clinical diagnosis and therefore, requires a thorough review of medications and physical examination. Given the protean nature of this toxicologic syndrome various criteria were defined which includes Sternbach’s, Radomski and Hunter’s criterian. Keeping in mind the wide symptoms of serotonin syndrome from being barely perceptible to lethal emphasis there is a need to treat the syndrome on urgent basis. Mainstay for treatment of serotonin syndrome is to discontinue the offending drug. Improvement is seen in most patients within 24 hours.

Management of Paediatric Oral Ranula: A Systematic Review

Saraniya Packiri, Deepa Gurunathan, Kathiravan Selvarasu

Introduction: Ranula is mucous extravasation cyst that occurs in the floor of the mouth. There are various methods of management of paediatric oral ranula each of which has their own advantage and disadvantage. Aim: The aim of this paper was to systematically review the available literature on the management of paediatric oral ranula. Materials and Methods: A total of 64 articles were retrieved by electronic search. Based on the preset inclusion and exclusion criteria, a total of 21 articles were retrieved for full text analysis. The following characteristics were assessed from the retrieved articles: author, year of publication, study design, sample size, intervention, adverse effects and follow up period. Results: The included studies consisted of the following study design: Seven articles were prospective clinical study, four articles were retrospective review, five articles were case series and five articles were case report. The mode of care varied from surgical excision to drug administration and lasers. Conclusion: The data obtained from the review, display a lack of high quality study, with proper sample size and adequate follow up period. Further, randomized clinical trials are required to help the clinicians devise a best treatment approach for the management of paediatric oral ranula.

Bite Force Recording Devices - A Review

Tarun Prakash Verma, Kanteshwari Iranagouda Kumathalli, Vinay Jain, Rajesh Kumar

In dental research, bite force serves as a valuable parameter to evaluate the efficacy of masticatory system. A variety of devices with different design and working principle have been used to record bite force, but no single device is capable to record all the required forces. One may find it difficult to choose a device that will fulfil the purpose of recording bite force for research. So, the present review aims to report and compare the wide range of devices and will help in describing their uses for recording bite force.

Posterior Dislocation of Subtalar Joint without Associated Fracture: A Case Report and Review of Literature

Sahil Gaba, Arvind Kumar, Vivek Trikha, Saubhik Das, Prabhat Agrawal

Posterior subtalar dislocation is an exceedingly rare entity. Clinically, the appearance of the foot can simulate a complex fracture dislocation. It is important to recognize that not all posterior subtalar dislocations are true posterior dislocations. We report a true posterior subtalar dislocation in a 34-year-old female, managed promptly with closed reduction and resulting in an excellent functional outcome. A chronic dislocation or an irreducible dislocation may need open reduction.

A Case of Keratomycosis Caused by Fusarium Solani at Rural Tertiary Care Center

Keratomycosis is defined as invasive infection of corneal stroma caused by variety of fungi. Most of these cases occur in agricultural workers with history of corneal trauma with vegetative matter contaminated by fungi. Fusarium species which causes keratomycosis receives occasional mention in literature. We report a case of a 27-year-old male, farmer by occupation presented with complains of foreign body sensation, itching and discharge from the right eye and developed white patch on cornea which was progressed gradually to size of diameter of pea which was later diagnosed as keratitis caused by Fusarium species.

Approach to a Pregnant Woman with Anti D + Anti C Reactivity Pattern: A Diagnostic Conundrum

Preeti Rai, Geetika Sharma, Deeksha Singh, Jyoti Garg

The Rhesus G antigen is present on all RBCs that are C+ and also on most D+ RBCs. Due to this co-distribution of G with either C or D antigen, it mimics a reactivity pattern of anti C + anti D on Indirect Antiglobulin Test (IAT), though the role of Anti G in causing Hemolytic Disease of Newborn (HDN) is controversial. The differentiation of anti D, anti C, and anti G is essential particularly in pregnant females. We hereby report a rare case of anti G with anti D and anti C in a pregnant woman with emphasis on approach to identify anti D+C+G and its implications.

Locally Aggressive Primary Intraosseous Paraganglioma of Sacrum

Parampalli Srinivas Srilatha, Lakshmi Rao

Primary Intraosseous Paraganglioma (PGL) of sacrum is highly uncommon. Few of the spinal PGL reported were mostly intradural mass. Paraganglionic tissue is usually not present in the bone. So far, only seven cases of primary intraosseous sacral PGL have been reported in the literature. There are no dependable prognostic histological features to differentiate benign from malignant PGL. The only unequivocal criterion for malignancy is metastasis to an organ where paraganglionic tissue is normally not present. However, an aggressive nature can be identified histologically by loss of architecture, decreased or absent sustentacular cells and Ki-67 index of >3%. We report a case of an elderly male who was admitted with complaints of swelling in the lower back with associated radiating pain and difficulty in sitting of two months duration. A diagnosis of sacral chordoma was made on Magnetic Resonance Imaging (MRI). No other mass was detected elsewhere in his body. The patient underwent surgical excision followed by radiotherapy. On histopathology and immunohistochemistry, a diagnosis of locally aggressive primary intraosseous PGL of sacrum was rendered. Hence, when evaluating a lytic sacral mass, PGL has to be considered as a differential diagnosis.

Heterotopic Prostate at Autopsy- An Unusual Mass at the Dome of the Urinary Bladder

Shital Munde, Gwendolyn Fernandes, Priyanka Phadnis

Heterotopic prostate in the dome of the urinary bladder is extremely rare and difficult to diagnose. It is often mistaken for neoplastic masses and histopathological examination is warranted for diagnosis. We report an autopsy case of an ectopic prostate at the dome of the bladder which mimicked a neoplasm on gross pathology.

An Alpha Fetoprotein Producing Gastric Tumor with Yolk Sac, Hepatoid and Papillary Adenocarcinoma Components

Archana Lakshmanan, Ann Kurian, Annapurneswari Subramanyan, Ayyappan Srinivasan

Alpha Fetoprotein (AFP) producing gastric carcinomas are very rare and have unique clinicopathological features and an extremely poor prognosis. Here, we report a case of AFP producing gastric carcinoma with three distinct histomorphologic patterns such as yolk sac like, hepatoid, tubular and papillary adenocarcinoma components. The uniqueness of this case is absence of metastases and associated findings such as fundic gland polyposis with varying degrees of dysplasia, gastric and duodenal well differentiated neuroendocrine tumour and rectal ganglioneuroma. The patient is symptom free as of two and half year’s postoperative period. AFP producing gastric tumours although rare, need to be identified as it is known to carry poor prognosis.

Anaesthetic Considerations for Balloon Mitral Valvuloplasty in Pregnant Patient with Severe Mitral Stenosis: A Case Report and Review of Literature

Hemlata, Puneet Goyal, Satyendra Tewari, Arindam Chatterjee

Even though, the incidence of Mitral Stenosis (MS) has reduced grossly, it still remains a health problem in developing countries and is the most common rheumatic valvular lesion encountered in pregnant patients. The already compromised cardiac status of a pregnant female deteriorates further by the presence of MS. So, pregnancy is a common situation during which untreated and frequently poorly tolerated MS are first diagnosed. Percutaneous Balloon Mitral Valvuloplasty (BMV) may be life saving in such a setting and a multidisciplinary approach in the management reduces the mortality and morbidity during the procedure. Anaesthetic management of such a procedure has hardly ever been reported. We report a case of a 23-year-old woman presenting at 28 weeks gestation with severe MS and severe pulmonary hypertension 52 mmHg who underwent successful percutaneous BMV under monitored anaesthesia Care. The anaesthetic considerations in such situations are being discussed.

Testicular and Epididymal Metastasis from Prostate Carcinoma: A Rare Manifestation of Common Disease

Jayesh Mittal, L. N. Dorairajan, R. Manikandan, Bhawanan A. Bade, Amit Mishra

Carcinoma prostate secondary metastasis to testicle and epididymis is rare. We report a case of metastatic carcinoma prostate in which testicular and epididymal metastasis were diagnosed incidentally in bilateral orchiectomy specimen. Testicular and para testicular structure should be properly evaluated for accurate staging of carcinoma prostate. Epididymis should always be included in bilateral orchidectomy specimen.

A Diagnostic Surprise For A Right Iliac Fossa Mass - A Perforated Ileal Gastrointestinal Stromal Tumour

J Sanjay Prakash, Anita Samraj, G Sabarish Kumar, R Vijai

Gastrointestinal Stromal Tumours (GISTs) are tumours of the gut found mostly in stomach and small intestine. The complications are Gastrointestinal (GI) bleeding, obstruction, pain and rarely perforation. We are reporting an abnormal presentation of GIST masquerading as an acute abdomen with Right Iliac Fossa (RIF) mass in 60-year-old lady. Contrast Enhanced Computed Tomography (CECT) of abdomen revealed a peripherally enhancing encapsulated abscess in RIF in close contact with base of caecum and adjacent peritonitis suggesting caecal perforation. On laparotomy, a gangrenous perforated ileal GIST was identified along the antimesenteric border of ileum. Pathological examination confirmed the tumour to be a GIST of spindle cell type further reiterated by immunohistochemistry. Our case report emphasizes, GIST as a rare and unusual differential diagnosis of RIF mass, and to have high degree of clinical suspicion when a similar situation is encountered in an emergency scenario, keeping in mind the poor outcome due to delay in appropriate management of the disease.

Primary Adenocarcinoma of the Bulbomembranous Urethra in a 33-Year-Old Male Patient

Rupesh Gupta, Sweta Gupta, Supriya Basu, Priyatosh Dey, Imran Ahmad Khan

Primary Urethral Carcinoma (PUC) is considered as a rare tumour, accounts for less than 1% of all malignancies and an incidence rate of four cases per million patients. Incidence increases with the patient’s age and most commonly present in seventh decades. Urothelial carcinoma is the most common type (76%) of the PUC, adenocarcinoma accounts for less than 5% of the PUC. No definitive protocol for tumour management for urethral adenocarcinoma has been described in the literature due to lack of prospective study and scarcity of the cases. Treatment usually depends on the site and stage of the tumour. We hereby report a case of 33-year-old male patient with urethral adenocarcinoma of bulbomembranous urethra spread to the prostatic urethra and left side inguinal lymph node. He was treated through multimodal therapy with surgery plus adjuvant chemotherapy.

Combined Thrombophilia in a Young Male Presenting as Life Threatening Pulmonary Embolism

Akshyaya Pradhan, Ayush Shukla, Mili Jain, Anupam Mehrotra, Rishi Sethi

Combined hereditary thrombophilia is an uncommon entity associated with higher risk of early onset thrombosis. We report a case of 39-year-old male with combined deficiency of natural anticoagulants (protein C, S and anti thrombin) along with hyper homocystenemia and factor V Leiden mutation, presenting with life threatening bilateral pulmonary embolism. The clinical implications of combined thrombophilia are also discussed.

Two Episodes of Trigeminocardiac Reflex During a Pan facial Fracture Surgery, a Rare Phenomenon – Case Report and Review of Literature

Trigeminocardiac reflex is a sudden physiologic response due to mechanical manipulation of any of the branches of trigeminal nerve. Trigeminocardiac reflex occurs due to pressure effect or stretching of trigeminal nerve which causes fall in blood pressure and decrease in heart rate. In this reflex arc, the trigeminal nerve serves as afferent pathway and vagus nerve, which is cardio inhibitory in nature, serves as efferent pathway. Trigeminocardiac reflex during maxillofacial trauma surgery is not a common phenomenon. The present case report describes a case of 40-year-old male patient, diagnosed with pan facial fracture in which two episodes of trigemino cardiac reflex were seen intraoperatively during fracture reduction and fixation of left zygomaticomaxillary complex fracture and inferior orbital rim fracture. Intraoperative management of trigeminocardiac reflex was done by withholding the stimulus and administration of atropine.

Epituberculosis Revisited: Case Report and Review

Primary pulmonary tuberculosis can involve regional lymph nodes which may resolve spontaneously or on treatment; or they may enlarge causing extrinsic bronchial compression; or cause endobronchial inflammation and ulceration; or a node may erode through the bronchial wall with extrusion of caseous materials into the bronchial tree, causing focal or lobar pneumonia. This erosion is seen radiologically as hilar lymphadenopathy, with atelectasis and consolidation and described as “epituberculosis”. It is more common in infants than older children. We hereby describe the case of a 13-year-old child with right hilar lymphadenopathy and right upper lobe consolidation on chest x-ray. We demonstrated by fibreoptic bronchoscopy that this epituberculosis resulted from perforation of a lymph node and discharge of caseous material into the upper lobe bronchus with resultant endobronchial obstruction. Thus a tuberculous ruptured lymph node may lead to clinical and radiological worsening, but this does not indicate development of drug resistance in these patients and they respond well to the same treatment regimen.

Rapunzel Syndrome

A bezoar refers to a mass of undigestible foreign material found in the gastrointestinal tract, mainly stomach. The second most common bezoar is the trichobezoar, which usually occurs in the young psychiatric female patients with history of trichotillomania and trichophagia. This is a case report of a 12 -year-old female patient came with complaints of diffuse abdominal pain, vomiting, and constipation. Ultrasound, Barium X-ray and Computed Tomography scan were done, which suggested trichobezoar. Thus, trichobezoar should be considered as differential diagnosis of abdominal pain in young female patients with associated psychiatric complaints. A review is presented here, as a high index of suspicion for better diagnostic facilities which can help in timely diagnosis and intervention, to prevent further complications like intestinal obstruction, perforation and mortality in such children.

An Aggressive Primary Retroperitoneal Diffuse Large B-Cell Lymphoma Mimicking a Pancreatic Neoplasm, Presenting as Duodenal Stenosis

Diffuse Large B-Cell Lymphoma (DLBCL) is the most common histological subtype of Non-Hodgkin’s Lymphoma (NHL). Primary retroperitoneal DLBCL is uncommon and has seldom been reported. Extrinsic compression of the duodenum due to lesions originating from the retroperitoneum is also rare. We present a case of a 39-year-old man who presented with inability to tolerate oral intake, abdominal pain, an upper abdominal mass and postprandial bilious vomiting caused by a large DLBCL arising from the retroperitoneum causing extrinsic compression of the duodenum. The cause of compression was initially presumed to be a neoplasm arising from the uncinate process of the pancreas or duodenum because of its proximity to the uncinate process and apparent widening of the C loop of duodenum. Repeat Computed Tomography (CT) scans were obtained because of the rapid increase in the size of the mass, normal levels of tumour markers such as Cancer Antigen (CA) 19-9, Carcinoembryonic Antigen (CEA) and no evidence of jaundice in spite of the large size of the mass. It revealed encasement of the uncinate process of pancreas with no involvement of parenchyma of the pancreas, thereby mimicking a pancreatic tumour. The neoplastic lymphoid cells were positive for Leukocyte Common Antigen (LCA), Cluster of Differentiation (CD)20, CD10, B-cell Lymphoma 2 (Bcl-2) and were negative for Creatine Kinase (CK), CD23, CD30, Anaplastic Lymphoma Kinase (ALK) and cyclin D1, D3 and D5. The Ki67 proliferative index was greater than 95%. Retroperitoneal DLBCL although rare should be considered in cases of duodenal obstruction.

Categorization and Management of Various Types of C-Shaped Canals: Two Case Reports

Sherin Jose Chockattu, B. S. Deepak

Guillain-Barre Syndrome with Falciparum Malaria and Scrub Typhus Mixed Infection-An Unusual Combination

Rahul Sai Gangula, Weena Stanley, Arunsheshu Vandanapu, M Mukhyaprana Prabhu

Guillain-Barre Syndrome is very rare in parasitic and rickettsial infection. Here we report a case of Plasmodium falciparum and scrub typhus mixed infection, presented with quadriparesis. Clinical, Serological, CSF analysis and Nerve Conduction Studies were consistent with Acute Inflammatory Demyelinating Polyneuropathy (variant of GBS). After administration of antimalarials and antibiotics for the mixed infection, patient gradually improved.

Congenital Lobar Emphysema: Anaesthetic Challenges and Review of Literature

Suman Saini, Smita Prakash, Meera Rajeev, K.KGirdhar

Congenital Lobar Emphysema (CLE) is a developmental anomaly, characterized by hyperinflation of one or more pulmonary lobes. It presents in infancy with variable degree of respiratory distress due to compression atelectasis. It is most often associated with mediastinal shift with subsequent hypoxia. CLE poses a diagnostic and therapeutic dilemma. We report a case of five-month-old infant of CLE requiring left lobectomy, who was previously being treated for pneumonia which was unresponsive to medical therapy. Anaesthetic challenges experienced during the case and a brief review of literature is presented.

Anaesthetic Management in Transoral Endoscopic Thyroidectomy

Rajendra D Patel, Nisha Gowani, Manali Nadkarni, Sameer Rege, Priti Devalkar

Young females undergoing thyroid surgery are apprehensive about the surgical scar. This leads to the introduction of Transoral Endoscopic Thyroidectomy (TOET). TOET is gaining popularity for its minimally invasive and cosmetically sound approach to perform thyroidectomies in young patients. The surgical site being the mouth orifice poses a challenge to the anaesthesiologist to secure a definitive airway. The case report is that of a young female undergoing TOET for whom we have successfully performed nasal intubation with a North Pole ivory Endotracheal Tube (ET).

Primary Adenocarcinoma of the Fallopian Tube: A Rare Entity

Ankita Singh, Sudha Prasad, Ashok Kumar, Renu Tanwar

Primary fallopian tube carcinoma is an uncommon gynaecologic malignancy usually seen in postmenopausal females. We present a case of a 66-year-old postmenopausal female who presented with complaint of blood mixed vaginal discharge on and off for past one month. Workup of the patient revealed no abnormality other than presence of atypical squamous cells on Papanicolaou (PAP) smear. MRI showed mildly bulky cervix with around 4cc fluid in endometrial cavity. As the patient remained symptomatic and fluid in endometrial cavity persisted, total abdominal hysterectomy with bilateral salpingo-oophorectomy was done. On histopathological examination, fimbrial end of left tube had features of poorly differentiated papillary serous adenocarcinoma. Postoperatively, she was given chemotherapy and is doing well with more than 3 years of follow up. This case highlights the importance of high suspicion in postmenopausal women with bleeding per vaginum, where there is little to suggest clinically or radiologically.

Anorectal Melanoma: An Unusual Cause of Rectal Bleeding

Uma Kumar, Udita Singhal

Anorectum is a rare site for primary melanoma. It is an aggressive cancer with poor prognosis. The diagnosis is often delayed due to non-specific signs and symptoms. Clinically, it is often misdiagnosed as hemorrhoids. The cytological diagnosis can be challenging especially when melanin pigment is sparse or absent. Herein, we present a rare case of anorectal melanoma which was initially misdiagnosed as hemorrhoids. A final correct diagnosis was made on cytology when later on the patient developed inguinal metastasis.

Foreign Body Aspiration: An Unusual Presentation and Outcome

Surabhi Jaggi, Anuj Kumar, Kranti Garg, Deepak Aggarwal, Reetu Kundu

Foreign body aspiration mostly presents as acute emergency with cough, choking and dyspnoea. Rarely aspiration of foreign body may be the underlying cause in patients presenting with long term symptomatologies. Here is a case of 60-year-old male who came for surgical management of cholelithiasis. During his workup, X-ray chest revealed right paracardiac opacity. Fibre-optic bronchoscopy showed a mass lesion in right main bronchus. It was taken out of the airways by flexible bronchoscope but could not be retrieved. Subsequent chest radiographs showed marked improvement.

Spontaneous Renal Artery Thrombosis Successfully Intervened with Drug Eluting Stent: A Primary Renal Artery Angioplasty

Basant Kumar, Savita Kumari

Renal artery thrombosis is a rare medical emergency and needs to be diagnosed early and treated urgently to prevent irreversible renal injury. We report a case of 35-year-old male, who presented with the total thrombotic occlusion of right renal artery and was managed with percutaneous transluminal angioplasty with a drug eluting stent.

Syndrome of Inappropriate Secretion of Antidiuretic Hormone Preceding Guillain-Barré Syndrome

Joe James, James Jose

Guillain–Barré Syndrome (GBS) is an inflammatory polyradiculoneuropathy which is known to produce syndrome of inappropriate Secretion of Antidiuretic Hormone (SIADH). However, the hyponatremia is usually seen after the onset of weakness. Here, we report a case of SIADH that presented with hyponatremic seizures which preceded the onset of GBS by ten days.

Intraductal Tubulopapillary Neoplasm: A New Entity in the Spectrum of Pancreatic Intraductal Neoplasms

Houcine Maghrebi, Amin Makni, Rami Rhaeim, Alia Zehani, Zoubeir Bensafta

Intraductal Tubulopapillary Neoplasms (ITPN) is a rare and new entity defined as an intraductal, grossly visible, tubule-forming epithelial neoplasm with high- grade dysplasia and ductal differentiation without overt production of mucin. Its clinical presentation can be varied, which makes the diagnosis quite challenging. In this report, we present a case of pancreatic ITPN and review the published work to learn clinicopathological, radiological features and treatment strategies of this recently proposed pancreatic neoplasm.

Minerals in Pregnancy and Lactation: A Review Article

Samira Khayat, Hamed Fanaei, Abdolhakim Ghanbarzehi

Micronutrients (include vitamins and minerals) are essential for normal function, growth and development. Minerals have important effects on the health of the mother and foetus. But biological mechanisms of minerals are not completely understood. Micronutrient deficiency during pregnancy can lead to anaemia, hypertension, obstetric complications and even maternal death and in foetus lead to a fail in growth and development. Mineral deficiency during pregnancy, particularly exist in developing countries. During pregnancy due to the increased demands caused by physiological changes, deficiency is exaggerated and as a result its complications occur. Thus, ensuring to receive enough macronutrients and micronutrients before and during pregnancy, is important. Nevertheless, there are controversies regarding administrating supplements. There are not enough studies about some of the minerals and the challenges remain. Regarding the importance of minerals in pregnancy and lactation, in this review we will analyze the role of them in pregnancy and lactation.

Clinical Utility of Blood Cell Histogram Interpretation

E.T. Arun Thomas, S. Bhagya, Abdul Majeed

An automated haematology analyser provides blood cell histograms by plotting the sizes of different blood cells on X-axis and their relative number on Y-axis. Histogram interpretation needs careful analysis of Red Blood Cell (RBC), White Blood Cell (WBC) and platelet distribution curves. Histogram analysis is often a neglected part of the automated haemogram which if interpreted well, has significant potential to provide diagnostically relevant information even before higher level investigations are ordered.

A Novel Technique of Fabricating a Modified Removable Provisional Prosthesis over an Autologous Bone Grafted Maxillary Anterior Edentulous Segment Prior to Implant Placement

Leoney Andonissamy, N. Sri Vidhya

Implant dentistry has provided a lot of surgical as well as prosthetic techniques for improving the success of the implants. The surgical technique commonly followed now prior to implant placement is bone grafting procedure. One of the commonest techniques is the use of autologous block graft harvested from mandibular chin region. However, interference in healing as well as excessive bone resorption due to the use of removable provisional prosthesis over the bone grafted region has been commonly observed/reported. Hence now-a-days, fixed provisional prosthesis is preferred over removable provisional prosthesis for the added advantages of superior aesthetics and patient acceptance. This article highlights a new technique of fabricating removable provisional prosthesis, which is superior in aesthetics and strength, consumes less chair time and exerts zero pressure onto the grafted site.

Diagnosis of Lafora Disease by Skin Biopsy

Prasath Sathiah, Debasis Gochhait, Priyadarshini Dehuri, Hema Subramanian

Large Vulvar Haematoma of Traumatic Origin

Dimitrios Papoutsis, Hope K Haefner

Chilli Sign: Pathognomonic Sign for Ruling Out Sacral Agenesis on Foetal MRI

Vikas K Yadav, Madhavi Nori

Universal Presence of blaNDM-1 Gene in Carbapenem-Resistant Gram-Negative Bacilli in an Indian Hospital in 2015

Biswaroop Chatterjee, Naresh Khanduri, Barnali Kakati, Aarti Kotwal

Correspondence: Correlation of Salivary pH, Incidence of Dental Caries and Periodontal Status in Diabetes Mellitus Patients: A Cross-Sectional Study

Parisa Piroozmand, Mahdieh-Sadat Moosavi, Khatereh Akbari

Making Nutrition Management Scientific, Objective and Simple with the Help of Technology

Sanjith Saseedharan, Edwin Joseph Pathrose

Nutrition management is one of the cornerstones of care in the management of hospitalized patients, especially, for those who are critically ill. Significant numbers of hospitalized patients have alteration in appetite and the function of the gastrointestinal tract. Calculating the caloric goal, prescribed proteins to be delivered in a finite amount of water at a certain rate is the need of the hour and it becomes a daunting task to complete daily. With the help of technology such tasks can be completed easily and accurately. This suggestion based software called as “iNutriMon” helps to screen out the patients which are at risk of malnutrition, formulate a plan, monitor and manage enteral nutrition of patients by calculating calories, proteins and water intake as per the patient requirement.

Correction: 2015 April: 9(4): FC09-FC12

Harminder Singh, Ritu Bala, Kamalpreet Kaur, Efficacy and Tolerability of Levosulpiride, Domperidone and Metoclopramide in Patients with Non-Ulcer Functional Dyspepsia: A Comparative Analysis. (Published in Journal of Cilinical and Diagnostic Research. 2015 April: 9(4)): FC09-FC12. There was a spelling error in the title as well as few minor typographical errors in the Text.