Journal of clinical and diagnostic research

Lagophthalmos- A Rare Presenting Sign in a Case of Childhood Pontine Glioma

N Gayathri, G Premnath, S Kiruthika, Mano j Vasudevan, Geeta Anusha Loya

Brain stem glioma is a rare central nervous system tumour arising from glial cells which occur mostly in children. Diffuse Intrinsic Pontine Gliomas (DIPG) and Focal glioma are the two types of pontine glioma. DIPGs are highly aggressive. The clinical features are not the same in every child. It commonly has a grave prognosis as most children die within 18 months of diagnosis. Hereby, Authors present a case of 10-year-old male child complaining of watering from the left eye for four days. There was no history suggesting involvement of any other cranial nerves and there was no episode of any seizure or similar history. On examination patient was found to have left lagophthalmos. Magnetic Resonance Imaging (MRI) of brain showed features of pontine glioma with mass effect. To prevent exposure keratopathy, the child was started on lubricating drops/gel and lid taping and referred immediately to a cancer centre for further management. Patients with pontine gliomas usually complain of gait disturbance, headache, limb weakness and double vision. To Authors’ knowledge no other documented case has presented with lagophthalmos. This case is presented for the rarity of the presenting symptom and to stress the importance of picking early ophthalmic signs.

Transmigrated Mandibular Canine Guided into its Normal Position

Transmigrated mandibular canines increase treatment complexity in terms of both anchorage and biomechanical planning, posing challenges for both Orthodontists and Oral Surgeons. This case report presents the orthodontic treatment in a 12-year-old girl patient, with transmigrated and impacted mandibular right canine positioned horizontally below the apices of the mandibular incisors. The mandibular deciduous right canine was extracted followed by the traction of the transmigrated permanent canine. Eruption was properly guided, and the correct position of the tooth was orthodontically guided into its normal position in the arch. The patient’s occlusion was significantly improved with good aesthetic outcome, functional occlusion, and a stable result after 1.5 years of follow-up.

Nephrotic Syndrome: A Rare Sequelae of Varicella Zoster Infection

Nephrotic syndrome without haematuria following the sequelae of the infection is uncommon. The present case report describes nephrotic syndrome following varicella infection, without haematuria and hypertension in a 21-year-old young adult. The patient presented with four weeks history of fever, swelling of both feet and facial puffiness. General physical examination revealed vesicular lesions with skin crusts present on the face, trunk and extremities, Blood Pressure (BP)-110/70 mmHg, bilateral pedal oedema. Systemic examination was unremarkable. Laboratory data showed nephrotic range proteinuria, hypoalbuminaemia. Varicella Zoster Virus (VZV) was detected in blood through Polymerase Chain Reaction (PCR). Renal biopsy confirmed the diagnosis. Thus, viral glomerulopathies should be considered in patients following infection.

Audiological Findings in Diffused Axonal Injury Secondary to Road Traffic Accident

Mohammed Eliyas, Abishek Umashankar, G Amritha

Diffused Axonal Injury (DAI) is a form of mild Traumatic Brain Injury (TBI) that occurs when there are rapid acceleration and deceleration of the head caused by road traffic accidents. It results in the accumulation of Amyloid Precursor Protein (APP) and increased calcium that causes damage to the axonal cytoskeleton and ion channels, hence resulting in degeneration. This report is of 35 year old male patient with DAI secondary to road traffic accident, where a complete audiological test battery was done. Upon multiple Computed Tomography (CT) investigations, the third CT findings revealed a hypodensity at the level of upper brainstem. Upon audiological evaluation, the patient had a moderate sensorineural hearing loss in the left ear and a mild sensorineural hearing loss in the right ear. The speech discrimination scores were poor in both the ears, thus suggesting a presence of a Retrocochlear involvement. On administering Auditory Brainstem Response (ABR), no V peak could be visualised in both ears, thus indicating a lesion at the upper brainstem which correlated with CT findings and on administering various other test batteries, findings revealed a presence of retrocochlear involvement. This study highlights the importance of carrying out both Electrophysiological and Radiological test procedures in diagnosing DAI.

Infantile Epididymitis Presenting as Scrotal Swelling with Sinus in Paediatric Patient: A Case Report and Review of Literature

Md Mokarram Ali, Amit Kumar, Rashi, Amit Kumar Sinha, Bindey Kumar

Scrotal swelling with intermittent discharge and sinus is rare in paediatric age group. Among various differential diagnosis, Infantile Epididymitis is one possibility of scrotal swelling in infancy. Here, Authors reporting one such case of scrotal swelling in a four-year-old child which was present since three months of age. After failed initial medical management, swelling was excised which was reported as epididymitis in histopathological examination.

Pulmonary Thromboembolism in COVID-19: Initial Experience from India

Pulmonary thromboembolic complications are increasingly being recognised in Coronavirus Disease 2019 (COVID-19) infections. Most of the cases of Pulmonary Embolism (PE) are often missed in presence of non-specific symptoms. The present report is about a 90-year-old COVID-19 positive male, asymptomatic on presentation, with no prior co-morbidities who developed acute onset shortness of breath along with elevated D-dimer levels four days post admission. Subsequently, a Computed Tomography Pulmonary Angiogram (CTPA) was done which revealed segmental and sub-segmental thromboembolism in upper and middle lobar branches of right pulmonary artery along with bilateral lower lobe ground-glass opacities consistent with COVID-19 pneumonia. As the patient was haemodynamically stable, he was managed conservatively on low molecular weight heparin and subsequently discharged on oral anti-coagulants. This report highlights the need for prompt evaluation of symptoms such as dyspnoea in COVID-19 patients and to rule out thromboembolic complications in them. In resource limited countries such as India with most of the COVID-19 centres having limited access to CT scans, triaging patients based on clinical suspicion and serially rising D-dimer levels may help identify those with thromboembolic complications.

Giant Intermuscular Thenar Lipoma: A Case Report and Literature Review

Prabhakar Ulaganathan

Lipoma is the most common benign tumour in hand. Lipoma in hand of size more than 5 cm is classified as Giant Lipoma. Lipoma of larger sizes is rare in hand because of accessibility and lesser subcutaneous tissues. Large lipoma interferes in the hand functions. Lipoma in dominant hand is usually noted early and gets operated. This case is of 65 year old female patient who reported with the swelling in right hand for past 25 years. The size of the lipoma was big and asymptomatic till the presentation. The swelling was investigated and surgically removed which was diagnosed histopatholoically as Intermuscular Thenar Lipoma.

Cutaneous Horn of Prepucial Skin on Pre-existing Lichen Sclerosus in a Young Male: A Rare Presentation

Amit Kumar Singh, Nitin Kumar Agarwal, Dev Kumar Sao

Cutaneous horn of penis is rare. Cutaneous horns are generally found over sun exposed areas of body after fifth decade of life. Penile horns are hyperkeratotic lesions which are secondary to chronic irritation. Hereby, the author reports a case of a young male with cutaneous horn over phimotic prepucial skin with lichen sclerosus which was successfully treated by circumcision.

Bifurcation Disease: The Role of Proximal Optimisation Technique

Bhupesh Shah, Nishit Sardava, Nikita Chaturvedi

Bifurcation lesions are both complex and challenging coronary lesion subsets in terms of lower procedural success and increased rates of long-term adverse cardiac events. Here described is a challenging case of a bifurcation lesion in a 60-year-old diabetic female with multi-vessel coronary artery disease. She presented with chest pain associated with perspiration, chest discomfort and mild breathlessness. In view of the diagnosis of acute coronary syndrome, all diseased vessels were stented and kissing balloon and Proximal Optimisation Techniques (POT) were performed yielding excellent results. This case emphasises the importance of POT, kissing balloon, and re-POT techniques in bifurcation intervention procedures that have been proven to facilitate success in such procedures. Moreover, interventional cardiologists should be familiar with all bifurcation techniques.

Epitheloid Angiosarcoma of Liver: A Hanging Tumour

Primary Epitheloid Angiosarcoma (EA) of liver is an aggressive malignant tumour with poor prognosis irrespective of aggressive surgical resection with or without adjuvant therapy. It constitutes for 0.1-2% of primary malignant tumours of liver and is seen commonly in sixth or seventh decade of life, with male preponderance. It can be asymptomatic or may present with nonspecific symptoms. Lack of pathognomonic features on serological, biochemical and radiological tests, makes it even difficult for an early diagnosis. Despite early surgical removal, EA has very high recurrence rate. Chemotherapy agents (paclitaxel, bevacizumab) and immunomodulators (mTOR inhibitors) have shown some survival benefit and reduction in recurrence rates in recent years as adjuvant therapy. To the best of our knowledge, a hanging morphological variant of EA of liver has not been reported yet in literature. We report a case of incidentally diagnosed aggressive, hanging variant of EA of liver. Despite early surgical resection and adjuvant, after chemotherapy patient had survival of less than eight months since first presentation.

Pelvic Congestion Syndrome Presenting with Massive Pulmonary Embolism

Mullusoge Mariappa Harsha, Megha Sharma, Ankit Kumar Sahu

Pelvic Congestion Syndrome (PCS) causes chronic pelvic pain due to incompetent, dilated pelvic veins. Inferior Vena Cava (IVC) thrombosis can either be a cause or effect of PCS. Pulmonary embolism in such a setting is rare with only a few reported cases till date. A heightened awareness and clinical suspicion for the specific symptomatology and associated findings are necessary to prevent catastrophe. This report is about a rare case in a young multiparous female with overlooked chronic pelvic pain, due to PCS presenting with breathlessness and hypotension. On evaluation, her echocardiogram revealed dilated right sided chambers, large thrombus in IVC and right pulmonary artery. Troponin was elevated. Computed Tomography (CT) scan confirmed massive pulmonary embolism along with presence of dilated pelvic plexus and dilated right ovarian vein. Patient was successfully treated with systemic thrombolysis followed by oral anticoagulation.

Perioperative Sedation and Sympatholysis Due to Tizanidine

Situ, Girish Kumar Singh, Hari Haran Gnaneswaran

Tizanidine is a short acting central muscle relaxant. It has agonist activity at noradrenergic alpha 2 receptors and inhibits the excitatory (presynaptic) motor neurons at both the spinal and supraspinal levels. Its action is through central alpha 2 receptors agonism. Tizanidine is a Food and Drug Administration (FDA) approved drug for reducing muscle tone in spastic conditions like spastic quadriparesis, multiple sclerosis, spinal cord injury and so on. Working knowledge of this kind of drugs are rarely used in the clinical practice which is useful for the anaesthesiologists to manage cases in the perioperative period. Here Authors reported the perioperative effects of Tizanidine in a patient with clitoral mass excision under general anaesthesia. All preoperative investigations were found with in normal limits. Patient was on tizanidine preoperatively for spastic quadriparesis. Intraoperatively, there were no significant fluctuations of Blood Pressure (BP) and Heart Rate (HR) even laryngoscopic response blunted. Postoperatively patient was calm and drowsy. This perioperative sympatholysis and sedation was due to tizanidine.

Left Planum Sphenoidale Transitional Meningioma -Simpson Grade-1

Planum sphenoidale meningiomas are rare slow growing tumours that impair cognition and lead to behavioural changes. Other common presentations of this condition include persistent headache followed by vision diminution. Dismissing cognitive impairment and behavioural changes as part of dementia, depression or aging might lead to loss of opportunity to treatment. The common symptoms manifested in sphenoid (spheno-orbital) wing meningioma is bulging of the eyes which may be painless, visual impairment and ocular paresis. Headache is also a common symptom, in addition to ptosis. Variants of the clinical syndrome include the following: Eye swelling and hearing loss, optic atropy, Kennedy syndrome and mental changes. Patient had severe headache for which he went for the eye checkup, where the loss of vision in the left eye was confirmed, through the field test. The MRI confirmed the tumour presence. Though the diagnosis was informed it took one year to convince the patient for the surgery. Hence, the author wishes to emphasise the role of tumour support systems. Physician’s serve as patients’ first point of entry into the health care system and as the continuing focal point for all necessary health care services along with their team they play a vital role in convincing patients from postdiagnosis to surgery and recovery.

Cavernous Sinus Metastasis from Carcinoma of Buccal Mucosa- A Rare Case Report and Review of Literature

Sambit S Nanda, Ayushi Patni, Ajeet K Gandhi, Madhup Rastogi, Satyajeet Rath

Distant metastasis from Head and Neck Squamous Cell Carcinomas (HNSCC) is uncommon, Cavernous Sinus (CS) metastasis being very rare. Infrequent presentation and misdiagnosis makes it a difficult entity to identify and treat. Hereby, Authors present a rare case of 47 year old male of CS metastasis from postoperative carcinoma of buccal mucosa. The patient was a histopathologically proven case of poorly differentiated Squamous Cell Carcinoma (SCC) of left buccal mucosa for which he underwent definitive surgery. During adjuvant Radiotherapy (RT) he developed severe headache, diplopia and ptosis. ¹⁸Fluorodeoxy-Glucose-Positron Emission TomographyComputed Tomography (¹⁸FDG PET-CT) revealed an FDG avid lesion in left CS suggestive of CS metastasis. In view of local recurrence and CS metastasis palliative RT was given. Patient responded well to palliative RT but succumbed to the disease within months. CS metastasis has poor prognosis with limited treatment options which include palliative RT, either External Beam Radiotherapy (EBRT) or radiosurgery to CS. Chemotherapy for disseminated disease has limited benefits due to lesser penetration of the blood brain barrier.

Cutaneous Sarcoidosis- A Report of Two Intriguing Cases

R Mathumathy, S Murugan, S Adikrishnan, R Sivayogana

Sarcoidosis is an inflammatory disease which leads to formation of noncaseating granuloma in the affected organs like lungs, lymph nodes and less commonly the skin. Cutaneous sarcoidosis occurs in about 20-35% of individuals with systemic sarcoidosis. Skin involvement serves as an early marker and may be the presenting sign of systemic sarcoidosis. Wide variety of morphological forms of cutaneous sarcoidosis is known to occur simulating several other dermatoses. Isolated skin involvement is very rare. Histopathological examination and special stains plays an important role in ruling out other granulomatous conditions like cutaneous tuberculosis, leprosy, foreign body granuloma and granuloma annulare from sarcoidosis. Corticosteroids remain the main cornerstone in the treatment of cutaneous sarcoidosis. Here, the authors reported two interesting cases of cutaneous sarcoidosis without systemic involvement, of which one presented as micropapular sarcoidosis and the other was mimicking lupus vulgaris. Both of them responded well to corticosteroid treatment and are in regular monitoring for development of systemic symptoms. Informed consent was obtained was obtained from both the patients.

Necrosis of Anterior Wall of Stomach Presenting as Pneumoperitoneum in Neonates- Report of Two Cases with Review of Literature

Necrotising enterocolitis is a common disease that affects low birth weight and preterm babies. Mostly small intestine and large intestine develop necrosis sparing stomach and duodenum. Necrosis involving the anterior wall of stomach and sparing other parts of Gastrointestinal (GI) tract is a rare entity, but can present in neonates with massive pneumoperitoneum. Though the exact aetiology is not known, it may be related to perinatal hypoxia. Case report of two preterm low birth weight babies who presented with pneumoperitoneum on day three of life had an area of anterior gastric wall necrosis with perforation peritonitis. The rest of GI tract was healthy. After excision of necrotic tissue, suture repair of viable stomach and feeding jejunostomy was done in both cases. These two neonates survived with intensive neonatal ICU care and gradual jejunostomy feeding. Gastric wall necrosis with perforation peritonitis is a rare entity in neonates with high mortality. Tip of nasogastric tube lying outside stomach shadow can give clue to the diagnosis. Survival can be improved by early surgery, good neonatal Intensive Care Unit (ICU) care and gradual jejunostomy feeding.

An Atypical Meningioma Presenting at an Unusual Site

Meningiomas are tumours that originate from the arachnoid cells (meningocytes) and the majority are benign grade I tumours according to World Health Organisation (WHO). Chordoid meningioma is an uncommon variant of meningioma and corresponds to grade II tumour in WHO classification of tumours of the Nervous System 2016, because of its more aggressive behaviour and increased likelihood of recurrence. These meningiomas may appear extracranially (i.e. head and neck region, sinonasal tract, ear, temporal bone, scalp etc) in only 2% cases. The histopathological and immunohistochemical evaluation is usually diagnostic. Here, we present a case of Chordoid meningioma in a 32-year-old patient who presented with complaints of nasal obstruction clinically suspected to be due to nasal polyp.

Mediastinal Actinomycosis: A Rare Mediastinal Pseudotumour

Aishwarya Dubey, Ajay Lanjewar, Babaji Ghewade, Diti Gandhasiri

Actinomycosis, once fairly common and often catastrophic, has now become an occasional infection in the era of antibiotics. The infection is caused by a branching Gram-positive, facultative anaerobic microorganism Actinomycetes. Various forms of the diseases in decreasing order of their frequency include cervico-facial form, abdomino-pelvic form and thoracic form. The thoracic involvement occurs in approximately 15% of all cases of actinomycosis. The disease presents with nonspecific signs and symptoms and therefore establishment of a definitive diagnosis with clinical and radiological investigations is difficult. The clinical and radiological picture mimics a number of other pulmonary conditions like cancer, tuberculosis, lung abscess and pneumonia. To reach at a definitive diagnosis one needs to have a high degree of suspicion and carry out histopathological studies in order to look for colonies of Actinomycetes as well as sulphur granules which are pathognomic for the infection. Here is a case of a 48-year-old diabetic male presenting with complaints of pain and swelling of neck, fever, dysphagia, dyspnea and cough with a mediastinal tumour like appearance on chest radiography. The patient underwent various noninvasive and invasive diagnostic modalities that included Contrast Enhanced Computed Tomography (CECT), Ultrasonography (USG) of thorax and histopathological examination of the cervical lymph nodes (level 2 and 3). The disease process was initially thought to be tubercular or malignant in origin which later turned out to be an actinomycotic lesion which was confirmed on the histopathological study of the lymph node specimen, that responded to antibiotics over a period of few months.

Myeloma Cast Nephropathy Manifesting only as Unexplained Acute Renal Failure

Sarojini Raman, Nikunj Kishore Rout

Multiple Myeloma (MM) is characterised by clonal B cell proliferation affecting elderly age group and involving various organ systems namely haematological, renal and skeletal system. Kidney may be affected in 50% of cases of MM. Though, Chronic Kidney Disease (CKD) is usually seen in MM, unusual presentations have been documented. The present case is of a 50-year-old female with complains of breathlessness and vague generalised symptoms. Routine tests showed blood urea level of 90 mg/dL and serum creatinine of 8.3 mg/dL. Further investigations revealed 24 hour protein level 48.5 gm/day, Erythrocyte Sedimentation Rate (ESR)-126 mm/1st hour, cast nephropathy in renal biopsy. Immunohistochemical (IHC) study on renal biopsy revealed kappa light chain deposits in tubules, raised kappa light chains (3280.00 mg/L) in serum Free Light Chain (FLC) assay and MM in bone marrow aspiration and biopsy study. So, MM should be considered in differential diagnosis in elderly patients presenting with acute severe renal failure.

Large Duodenal Gastrointestinal Stromal Tumour Invading the Pancreas- A Masquerader for Pancreatic Head Mass

Priyanka Gopinath Ghodekar, Aniruddha V Bhosale, Dinesh K Zirpe, Bipin B Vibhute

Gastrointestinal Stromal Tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract commonly arising from stomach and small intestine. Duodenal GISTs are rare. Though uncommon, GISTs can arise from the omentum, mesentery, gallbladder as well as retroperitoneum and are defined as Extra GISTs (EGIST). Authors have reported a case of large GIST arising from the second part of the duodenum and mimicking the large pancreatic head mass in a 34-year-old female patient presented with abdominal pain and vomitings. The Contrast Enhanced Computed Tomography (CECT) revealed a large enhancing mass in the pancreatico-duodenal groove not separated from pancreatic head. Whipple’s surgery was performed. Histopathology and Immuno-histochemistry report revealed the duodenal GIST with pancreatic infiltration with high risk for metastases according to mitotic index and size. Sometimes large duodenal GISTs can make the diagnosis difficult radiologically due to invasion of pancreatic head and mimic as primary pancreatic head tumour.

Clinical Nature and Treatment with Sclerotherapy of Pyogenic Granuloma: A Case Series

Jigna S Shah, Anand Patel, Nutan Lunagariya

Pyogenic granuloma is a misnomer, as in reality it arises in response to various irritating factors such as low-grade local irritation or hormonal factors, traumatic injury as well as presented as inflammatory hyperplasia that is not related to infection. Oral pyogenic granuloma is a lobulated or smooth exophytic lesion with pedunculated or sometimes sessile base, haemorrhagic in tendency. Although excisional surgery is the treatment of choice for it, some other treatment protocols such as laser therapy, sclerotherapy with 3% polidocanol, cryotherapy and steroid therapy have also been proposed. Here, Authors present a case series of gingival as well as extra gingival pyogenic granulomas which were diagnosed and treated by various therapies i.e., surgical excision, Carbon Dioxide (CO2 ) laser therapy and sclerotherapy. Regression period of lesion with different therapies was evaluated in detail. Maximum patients were female in the age group of 26-50 years in present case series. Almost all cases of pyogenic granuloma had typical clinical characteristic without bony alteration. Amongst all therapies sclerotherapy had the biggest advantage of less regression period for any case of pyogenic granuloma i.e., 7-8 days only.

Rods and Rings Antinuclear Antibody Pattern in Non Hepatitis C Patients: A Series of Five Cases with Review of Literature

Antinuclear Antibody (ANA) is commonly found in various Autoimmune Diseases (AD) and their pattern help in narrowing down the differential diagnosis. International Consensus on ANA Pattern (ICAP) has recently introduced Rods and Rings (RR) pattern in their reporting guideline. Since its first identification, it has been considered to be exclusively associated with hepatitis C and its associated treatment {Ribavirin/Interferon-α (INF-α)}. However, later on, a few reports have described its association with other diseases and even in healthy population. In the present series, out of 25,242 clinical samples, five cases of RR-ANA pattern in non hepatitis patients were found and they were further investigated for their disease associations. We are documenting association of RR-ANA pattern with amoebiasis, hepatitis B, idiopathic thrombocytopenic purpura, Rheumatoid Arthritis (RA) and undifferentiated connective tissue disease. Documentation of such reports may help in better understanding of pathobiology and clinical relevance of this pattern.

Baclofen Induced Encephalopathy in Patients with Chronic Kidney Disease

Alok Kumar, Dorchhom Khrime, Nitin Bansal, Saurabh Agarwal, Utkarsh Sharma

Hiccups are manifestation of uremic syndrome. Baclofen had been used in uremic hiccups, but its usage has been described in literature with development of neurotoxicity in patients with renal failure. The case series reports three patients of Chronic Kidney Disease (CKD) that were on haemodialysis. All of them had intractable hiccups, for which Baclofen was administered. They developed encephalopathy within 24-48 hours of ingestion of Baclofen. The drug was discontinued and the patients improved within 36-48 hours. They were finally discharged with no residual neurological deficit.

Challenges in Delivering Optimal Healthcare to COVID-19 Patients: Focus on Delhi, India

Kaushik Bharati, Aarti Garg, Sunanda Das

INTRODUCTION The public health scenario in India is grim. It is an open secret that India doesn’t spend adequate public money on healthcare. Interestingly, the public sector health expenditure is only 25%, compared to 75% in case of the private sector. In case of other countries, the public sector bears 50% of the total health expenditure. The Government of India’s healthcare budget is deplorable, which currently stands at a meagre 1.15-1.5% of the Gross Domestic Product (GDP). In stark contrast, the United States health budget accounts for 18% of the GDP. Looking at the National Health Profile of India (2018), it is clearly evident that the per capita expenditure on healthcare is only USD 100 (after adjusting for purchasing power parity). In comparison, the US spends a staggering USD 10,224 per capita on healthcare annually. This dismal health spending in India has led to a severely weakened health system that is literally crippled and incapacitated (1). When the current COVID-19 crisis is superimposed on the already fragile health infrastructure, one can easily imagine the immense strain that has been put on the health system as a whole. This is reflected in the available statistics for India on the prevailing pandemic. At the time of writing (28 August 2020; 11.00 AM IST), the total number of cases and deaths in India were 3,325,971 and 61,529 respectively. The corresponding figures for Delhi were 150,027 and 4,369 respectively. Importantly, Delhi is currently the sixth worst affected state in India, following Maharashtra, Tamil Nadu, Andhra Pradesh, Karnataka, and Uttar Pradesh (2). DELHI GOVERNMENT’S STRATEGY FOR TACKLING COVID-19 The Delhi Government has planned a 5-pronged approach (3) to tackle the COVID-19 crisis in Delhi, which are briefly highlighted below: • Ramping-up bed capacity: The number of beds dedicated to COVID-19 patients have been ramped-up in Delhi over the past two months. In this initiative, banquet halls, hotels and private nursing homes are being acquired to boost the bed capacity in the National Capital. These include 11,000 beds in 80 banquet halls, 4,000 beds in 40 hotels, and 5,000 beds in private nursing homes (4). In this regard, 117 private hospitals have been instructed to reserve 20% of beds for COVID-19 patients (6). Additionally, 500 railway coaches have also been allocated to the Delhi Government by the Central Government, which has added a further 8,000 beds (6). Besides these, the Central Government and Delhi Government have jointly inaugurated the Sardar Patel COVID Care Centre and Hospital at the Radha Soami Satsang Beas, Chhatarpur, New Delhi on 27 June 2020. This COVID-19 centre is the world’s largest, with a bed capacity of 10,000 (7). However, since almost 78% of beds dedicated to COVID-19 patients are currently lying vacant (8), the Delhi Government is thinking of delinking the hotels from the hospitals (9). • Testing and isolation: Currently, large-scale COVID-19 testing is being carried out across Delhi. Delhi is currently conducting the third-highest number of tests in the country, only after Assam and Andhra Pradesh. The exact number is 7,210 tests per million per day (10). Moreover, around 600,000 test kits have been acquired by the Delhi Government so that testing is not hampered (3). • Serosurvey and screening: A comprehensive house-tohouse serological survey is being conducted in Delhi, which has a target sample size of 20,000. This will help to screen for potentially infected COVID-19 patients, as well as develop a better understanding of recent and past infections by measuring the levels of IgM and IgG antibodies, respectively (3). • Oximeters, oxygen and oxygen concentrators: One of the cardinal features of COVID-19 is a sudden drop in blood oxygen levels. Hence, close monitoring of the oxygen level of blood is crucial for preventing breathing problems. For this purpose, pulse-oximeters are vital, which are being supplied by the Delhi Government to all home quarantined COVID-19 patients (11). Also, oxygen cylinders can be ordered by home quarantined COVID-19 patients via telephone, in order to increase convenience and efficiency (12). The Delhi Government has procured 4,000 oxygen concentrators in order to ensure that sufficient oxygen cylinders are available (13). • Plasma therapy: Administration of plasma from cured convalescent patients have shown significant benefit in saving the lives of active COVID-19 patients. The Lok Nayak Jai Prakash (LNJP) Hospital in New Delhi has reported a reduction in the death rate by more than 50%. Other hospitals in Delhi that are conducting plasma therapy trials include the All India Institute of Medical Sciences (AIIMS), Ram Manohar Lohia (RML) Hospital and five prominent private hospitals (14). CHALLENGES IN HEALTHCARE DELIVERY Disparities in Healthcare Personnel in India (15) Of the various categories of healthcare professionals in India, doctors and nurses make up 39.6% and 30.5% respectively, of the total health workforce. Of all the doctors, 77.2% are allopathic, while 22.8% fall under the category of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy), which constitute the traditional systems of Indian medicine. There are significant disparities in the distribution of healthcare professionals across the country. The majority of healthcare professionals prefer to work in urban areas, with an urban to rural ratio of 1.45:1. In fact, it is quite surprising that of all health workers, 59.2% work in urban areas, where only 27.8% of the population resides, while 40.8% work in rural areas, where the majority (72.2%) of the population resides. There are also large variations in doctor density across India. For example, the high-income state of Punjab has 2.6 times higher doctor density than Bihar, which belongs to the low-income strata. The urban-rural divide is also evident in the educational attainments of the doctors. Many doctors do not hold the requisite degree (MBBS) for practicing allopathic medicine. In fact, one third of so-called doctors (quacks) are only educated till the secondary level. This lack of medical qualification is particularly rampant in rural areas. Whereas in urban areas, 58% of doctors have a medical degree, in rural areas this value is only 19%. Severe Shortage of Doctors and Nurses in India (16) The Centre for Disease Dynamics, Economics and Policy (CDDEP), which is a non-profit organisation based in Washington, USA, has recently conducted a study assessing the shortage of key healthcare personnel in India. Alarmingly, the study found that in India, there is only one government doctor for every 10,189 people, as opposed to the World Health Organisation (WHO) recommended doctor to patient ratio of 1:1,000. This translates into a deficit of approximately 600,000 doctors in India. The nurse to patient ratio is equally appalling at 1:483, which translates into a shortage of two million nurses. Putting these statistics into perspective with reference to the COVID-19 pandemic, the already low number of doctors and nurses could become even lower, as many of these key frontline health personnel are becoming infected by the virus, thereby putting them out of action. Shortfall of Doctors and Paramedical Staff in Delhi As per data published by the National Capital Region Planning Board (NCRPB), the total number of doctors in the National Capital is 3,594 (Government: 777; Private: 2,817). The total number of paramedical staff (including nurses) in the National Capital is 23,634 (Government: 11,469; Private: 12,165) (17). Therefore, the current doctor to patient ratio (doctors: 3,594; confirmed COVID-19 patients: 150,027) is 1:42. However, it must be kept in mind that not all doctors can be allocated solely for treating COVID-19 patients, as a certain proportion will need to be reserved for treating regular inpatients. Hence, the above doctor to patient ratio is likely to increase drastically. High Cost of Hospital Beds- Hidden Expenses The Association of Healthcare Providers of India (AHPI) has indicated that a super speciality private hospital in India spends approximately 28-32% of its operational budget on maintaining a bed, which amounts to INR 15,000 to 25,000 per day. In contrast, the cost of maintaining a bed in a tertiary care government hospital is INR 9,000 to 17,000 per day (18). Some of the hidden recurring costs that contribute to the overall expenditure for running a hospital bed are briefly highlighted below (19),(20): Employee and staff salaries: Besides salaries for key medical personnel, such as doctors and nurses, salaries for other employees also need to be allocated. These include hospital administrative staff, ward boys, pharmacists, pathology/Xray technicians, receptionists, clerks, security personnel, and sweepers, among others. • Building maintenance and utilities: These include premiums for hospital insurance, electrical installations, electricity/water bills, annual maintenance charges for high-end equipment, and fire safety. • Medical equipment: These form a large chunk of the expenses and include various types of fixed equipment, such as monitors, scanners/imagers, surgical instruments, operation theatre equipment and other associated paraphernalia. • Diagnostics and therapeutics: These include costs towards diagnostics involving pathological and biochemical investigations, X-rays, CT scans, MRI, as well as medications and other associated therapeutics. • Supplies for staff and patients: These include uniforms, aprons, surgical scrub suits, patient’s gowns, and footwear, to name a few. • Housekeeping, linen and laundry: Linen, such as blankets, bedsheets and pillow covers will need to be provided to all patients, which will require regular washing. Hence, an in-house laundry will be required. It is these and other housekeeping expenses that are often overlooked. • Power backup: Hospitals require 24-hour power supply, which require powerful generator sets, the running costs of which don’t usually come to notice. • Biomedical waste disposal: Disposal of hospital waste often require substantial investment, as huge amounts of biomedical waste is generated daily. These expenses also largely go unnoticed. Logistical Problems Installing and running a bed in a hotel, banquet hall or railway carriage is not the same as setting-up a bed in a hospital. The major problem associated with treatment of patients outside a hospital setting is associated with logistical issues, including the following: • Patient transfer: Transfer of patients in critical condition toand-from these facilities will be a major problem, considering the fact that there are only about 817 general and 206 trauma ambulances (Government and Private combined) in the National Capital (17). Again, similar to doctors (discussed under ‘shortfall of doctors and paramedical staff in Delhi’), not all ambulances will be available exclusively for COVID-19 patients. • Care of critical cases: Since transfer of patients may not always be possible, as indicated above, essential medical facilities, such as ICUs need to be installed. Also, emergency equipment, such as ventilators should be available. And of course, adequate designated medical staff will need to be at hand. • Patient monitoring: Regular rounds by doctors will take up an enormous amount of time. If we take the simplistic doctor to patient ratio of 1:42 (discussed under ‘shortfall of doctors and paramedical staff in Delhi’) and if a doctor devotes just 10 minutes per patient, then for 42 patients, the time required for one round will be 420 minutes or 7 hours. This will deduct a huge amount of time out of a standard 8-hour shift, leaving almost no time for emergency medical treatments. Therefore, more doctors will be required- the question is, where will they come from? • Diagnostic testing:Sending/tracking samples for testing could prove to be a logistical nightmare. Although rapid diagnostic kits that measure IgM and IgG levels could be used at the PointOf-Care (POC), these tests only provide information about past infection and not current infection. For detecting current infection, the Polymerase Chain Reaction (PCR) test is currently the only option, which can only be carried out in a specialised lab, and therefore, the samples need to be physically transferred to these facilities. • Oxygen supply: Supplying oxygen will be a huge problem in these facilities, unlike hospitals, where piped oxygen is available round-the-clock. Hence, supply of oxygen cylinders will require dedicated personnel. Moreover, one cylinder will need to be kept on standby while the other goes for refilling. Sickness of Key Healthcare Personnel A major factor that needs to be taken into consideration is- what will happen when key health personnel like doctors and nurses become infected and fall sick? In this regard, between March and June 2020, at least 1,200 doctors and nurses have tested positive for COVID-19 in Delhi (21). A simple calculation will show the loss of work-hours due to sickness for these frontline health staff. Since 1,200 doctors and nurses tested positive, they would all need to be quarantined for at least 14 days for observation. Taking 8 hours to be the duration of a standard work shift, the total work-hours lost is a staggering 134,400 hours (1,200×14×8=134,400 hours). Moreover, if some of them become seriously ill, they will need to be hospitalised, which will lead to more loss of work-hours. The million-dollar question is- who will replace this deficit of doctors and nurses? CONCLUSION(S) Delivering optimal healthcare to COVID-19 patients amidst the ongoing pandemic is indeed a challenge for healthcare professionals, especially in an overcrowded and congested metropolitan city like Delhi. There are multiple impacting factors that hinder adequate healthcare delivery, which have been discussed above. From a holistic standpoint, the root cause for the lack of pandemic preparedness in India is the chronic underinvestment in healthcare, which can be traced back to the time of independence, over seven decades ago. So, the current rush to tackle the pandemic on a war-footing could be looked upon as a stop-gap arrangement. However, ending on an optimistic note, it must be mentioned that Delhi is fighting back impressively and slowly but surely, turning the tide.

Comparative Evaluation of Modified Endodontic Sealers’ Penetration Following Sonic Activation of Irrigants: A Scanning Electron Microscope Study

Introduction: When sealer is adapted well to the root canal wall, there is less tendency for microleakage and strength of root canal is enhanced. Therefore, it is important for the sealer to possess good tubular penetration depth and adaptation to dentinal walls. Aim: To compare the effects of sonic activation of 5.25% Sodium Hypochlorite (NaOCl) and incorporation of Zinc Oxide (ZnO) nanoparticles in AH Plus sealer on tubular sealer penetration. Materials and Methods: Forty extracted human mandibular premolars with a single root canal were used for this invitro study from October 2019 to January 2020. All teeth were prepared upto F3 with Pro Taper Universal rotary system. Teeth were randomly divided into four groups of 10 teeth each. Group I (control) included teeth obturated using AH plus sealer, Group II: teeth obturated using AH plus sealer incorporated with ZnO nanoparticles, Group III: teeth prepared along with sonic activation of the irrigant followed by obturation using AH plus sealer and Group IV: teeth prepared along with sonic activation of the irrigants followed by obturation with AH plus sealer incorporated with ZnO nanoparticles. Irrigation was achieved with 5.25% sodium hypochlorite. The canals were dried and obturated using respective sealers and single gutta percha cones. After storage at 37°C and 100% humidity, the roots were split into two halves and sealer penetration in the dentinal tubules was examined by using scanning electron microscope. The values obtained were statistically analysed using Oneway Analysis of Variance (ANOVA) with significant p-value less than 0.05. Results: In all the groups, sealer penetrated into the dentinal tubules. There was enhanced tubular sealer penetration (289.57±59.43 µm) after sonic activation of the irrigant (group 3) followed by that on addition of ZnO nanoparticles to the sealers (group 2) (278.21±71.24 µm) and the least was seen in the control group (group 1) (211.5±66.33 µm). The combined effect of both i.e., use of sonic activation of irrigant followed by obturation using modified sealer with gutta percha (group 4) (318.64±88.27 µm) showed greatest tubular sealer penetration depth. Conclusion: Incorporation of nanoparticles aids in improving sealer penetration which is further enhanced in case of sonic activation during irrigation.

Association of Nerve Conduction Velocity with Total Body Fat Mass and Body Mass Index in Type 2 Diabetes Mellitus

Faique Rahman, Anwar Hasan Siddiqui, Sangeeta Singhal, Hamid Ashraf, Ahmad Faraz

Introduction: There is a close association between obesity and type 2 diabetes as well as its complications. Obesity related changes in nerve conduction assume paramount importance in diabetic patients where the nerve functions are already compromised by other metabolic derangements. Aim: To study any existing correlation of the Nerve Conduction Velocity (NCV) with the Total Body Fat Mass (TBFM) and Body Mass Index (BMI) and to identify which is a better predictor of NCV impairment in type 2 diabetics. Materials and Methods: A prospective, cross-sectional study was conducted during April 2018-January 2019 in 90 patients with confirmed diagnosis of Diabetes type 2 of recent onset or not more than 8 years and age between 30 to 60 years. NCV was measured in both upper and lower limbs. Median, ulnar, and posterior tibial nerves were selected for motor nerve conduction study and median, Ulnar and sural nerves were selected for sensory nerve conduction study. Bioelectric Impedance Analysis (BIA) was used to find the TBFM. The correlation of TBFM and BMI with the NCV was assessed by using Pearson’s coefficient of linear correlation. Results: Both BMI and TBFM showed negative correlation with the motor and sensory NCV of both sides of the body. BMI had a significant negative correlation with conduction velocity of two sensory nerve viz., right median (r=-0.388) and left sural (r=-0.356) and two motor nerves viz., right median (r=-0.483) and right posterior tibial (r=-0.305) only. However, the TBFM showed a significant negative correlation with the motor conduction velocity of four motor viz., right median (r=-0.602), right posterior tibial (r=-0.455), left median (r=-0.483) and left posterior tibial (r=-0.288) and four sensory nerves viz., right median (r=-0.411), right sural (r=-0.435), left median (r=-0.461) and left sural (r=-0.408). Conclusion: TBFM as assessed by BIA analysis shows a stronger correlation with the NCV as compared to the BMI and should be used clinically along with electrophysiological studies for the risk factor stratification of diabetic peripheral neuropathy in type 2 diabetes patients.

Application of Haematological Indices in the Diagnosis of Swine Influenza Infection in Adults

Introduction: The differential diagnoses of patients hospitalised for Influenza-Like Illness (ILI) due to swine influenza virus vs other pathogens are challenging. Aim: To evaluate haematological indices such as lymphocyte (LYM), platelet (PLT), Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), and Lymphocyte multiplied by Platelet Count (LYM×PLT) as potential indicators to discriminate swine influenza virus infection from another ILI in Adults. Materials and Methods: This study was conducted among 332 patients, admitted with ILI from January 2019 to December 2019. Complete Blood Count (CBC) and Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) to detect swine influenza virus from throat/nasal swab were performed in each patient. Based on results, patients were divided into swine influenza-positive and swine influenza-negative groups. ANOVA test was used to compare different groups. The diagnostic values of the haematological indices in swine influenza infection were evaluated, using the ROC curve. p-value <0.05 was considered statistically significant. Results: The haematological indices in patients with swine influenza-positive were significantly different as compared to swine influenza-negative and healthy control groups. Additionally, among all the haematological indices, NLR showed the highest diagnostic value with the Area Under the Curve (AUC) of 0.511 with the best sensitivity and specificity of 55.1% and 48.1%, respectively, if the swine influenza-negative group was used as a reference. Whereas, using controls as a reference, the AUC of NLR was 1.0 with the best sensitivity and specificity of 100% each. The best sensitivity and specificity of PLR was 46.1% and 46.9%, if the swine influenza-negative group was used as a reference. Conclusion: Combination of the NLR values more than 3.09 and the PLR values more than 130.53 may indicate swine influenza infection in adults. NLR and PLR value can be used to ascertain, whether the patient who presented as ILI, is infected with Swine Influenza.

A Comparative Study of Central Corneal Thickness and Endothelial Cell Density after Phacoemulsification by ‘Phaco-chop’ and ‘Divide and Conquer’ Techniques

Madhumita Prasad, V Sachin Daigavane

Introduction: Phacoemulsification was introduced by Kelman in 1967. It is one of the most important innovations in ophthalmology. This has now been accepted as gold standard surgical procedure for management of cataract. Divide and conquer technique, described by Gimbel, was the first nucleofractis cracking technique developed. Phoc-chop technique was presented by Kunihiro Nagahara in 1993 at the meeting of America Society of Cataract and Refractive Surgery. Aim: To compare the Central Corneal Thickness (CCT) and endothelial cell density after phacoemulsification by ‘phacochop’ and ‘divide and conquer’ techniques. Materials and Methods: The study included 100 patients divided into two groups, each including 50 patients; Group A, where Divide and Conquer was performed, and in Group B Phacochop was performed. The mean Absolute PhacoTime (APT), mean Endothelial Cell Count (ECC), mean Endothelial Cell Loss (ECL), corneal thickness and the visual acuity were reported in the two groups both preoperative and postoperative. Results: The mean APT in group A was 27.12±10.15 seconds, and in group B was 16.58±5.11 seconds (p=0.0001). The mean ECC at sixth week postoperative in group A was 2102. 14 cells/ mm² and in group B it was 2365.38 cells/mm² (p=0.003). There was statistically significant ECL following sixth week postoperatively 16.22% in divide and conquer group and 8.51% in phaco-chop group (p-value=0.0001). A significant increase in the CCT was observed at the immediate postoperative week among the two studied groups; 3.16% in group A and 2.34% in group B, which was statistically significant. The postoperative CCT pachymetry values were returned to near preoperative values at one and a half months postoperative. Conclusion: The phaco-chop technique utilises less phaco time and energy without significant effect on the final surgical outcome. Significant and equal ECL occurs after the two studied techniques. APT and nuclear grade have a positive correlation with higher ECL. CCT increases significantly and equally postoperatively following the two techniques.

Comparison of Two Doses of Chloroprocaine for Spinal Anaesthesia in Brachytherapy Procedures: A Randomised Clinical Study

Shashidhar Gowdra Sugandarajappa, N Sneha, Namrata Ranganath

Introduction: Subarachnoid block is a widely used anaesthetic technique for lower abdominal and lower limb surgeries. Commonly used local anaesthetics are with longer duration of action and delayed recovery. Chloroprocaine is good choice for day care procedures because of its reliable action, faster resolution of block and earlier discharge time. Aim: To compare the minimum effective dose of chloroprocaine for spinal anaesthesia in brachytherapy. Materials and Methods: A total of 140 carcinoma cervix patients of ASA class I and II of age group 18 to 60 years were randomly divided into two groups of 70 each. They were posted for elective brachytherapy procedure under subarachnoid block. Group A patients received 2 mL of chloroprocaine (20 mg) and Group B patients received 3 mL of chloroprocaine (30 mg). Parameters like onset of sensory and motor blocks, maximum level of sensory block, time for two segment regression, duration of block and haemodynamic parameters were studied for the duration of procedure. Data were analysed using SAS 9.2, SPSS 15.0 software version. Descriptive and inferential statistical analysis was carried out. Results on continuous measurements are presented as mean±SD (min-max) and results on categorical measurements are presented in number (%). Significance was assessed at 5% level of significance. Results: Patients in both the groups were comparable with respect to the demographic characteristics. There were statistically significant differences in time for onset of motor blockade, duration of motor and sensory blockade, time for two segment regression which were shorter in chloroprocaine 20 mg (group A) compared to chloroprocaine 30 mg (group B). Haemodynamic variations and incidence of side-effects were similar in both groups. Conclusion: Subarachnoid 2-chloroprocaine (30 mg) provides adequate duration and density of spinal anaesthesia for brachytherapy procedures as compared with 20 mg 2-chloroprocaine.

Paediatric Malignant Blue Cell Tumours- A Practical Pathological and Immunohistochemical Study in Duhok, Iraq

Intisar Salim Pity, Shilan Ameen Younus

Introduction: Malignant Blue Cell Tumours (MBCTs) are common heterogeneous tumours among paediatric age group. Their heterogeneity is reflected in their therapeutic and prognostic diversity. Mere morphology is not enough to differentiate them. Immunohistochemistry is a key tool for identification of small blue cell tumours that lack evidence of lineage differentiation on the ground of light microscopic morphology. Aim: To identify the immunohistochemical identity of paediatric MBCTs in Duhok, Iraq. Materials and Methods: This was a cross-sectional study performed on 120 cancers reported morphologically as MBCTs over 11-year period, from January 2009 to December 2019. Clinical data and histomorphologic acumen were considered and integrated with the immunohistochemical findings. Applying autostainer, immunohistochemistry was performed using monoclonal or polyclonal antibodies. Results: Lymphoma/leukaemia topped the diagnostic list 36 (30%) formed the commonest category, followed by Ewing’s/Primitive Neuro Ectodermal Tumour (PNET) 29 (24.2%), Neuroblastoma 16 (13.3%), Wilm’s tumour 11 (9.2%), Rhabdomyosarcoma 9 (7.5%) and Medulloblastoma 7 (5.8%). The remainders comprised Retinoblastoma (3.4%), Glioblastoma and Ependymoma (2.5% each). Hepatoblastoma and Astroblastoma formed the least frequent tumours (0.8% each). These tumours were more frequently located in the soft tissue (30%) followed by brain (14.2%), bone (10%), Lymph Node (LN) (9.2%) and kidney (10%). Conclusion: Integration of clinical data and histomorphologic acumen helped much for categorisation of MBCTs. Application of immunohistochemistry in this study has shown a significant improvement in the diagnostic accuracy of paediatric MBCTs. Loss of some differentiation antigens and aberrant expression of some markers often necessitate the use of panels of antibodies and, even molecular testing to target the task.

Effectiveness of Planned Teaching Program on Knowledge Regarding Management of Leukaemia among Leukaemia Patients

Madhavi Madhukar Narayane , Savita Bansiram Pohekar

Introduction: Leukaemia is a blood cancer which affect the bone marrow. The cells of leukaemia or abnormal cells continue to grow and divide, resulting in the normal blood cells being crowded out. Thus, planned teaching on leukaemia management among patients with leukaemia would improve their health and mold them into a healthy quality of life. Aim: To determine the effectiveness of planned teaching program on management of leukaemia among leukaemia patients. Materials and Methods: The interventional one group pretest and post-test study design with a Quantitative research approach was used. The present study was carried out in selected hospitals of Nagpur from January 2017 to March 2017. The sample size was 60. Validated pre-tested pre-designed structured questionnaires were used. Data collected were entered into the Microsoft Excel sheet. The statistical analysis was done using SPSS software. Frequencies and percentages were presented for categorical variables. Reliability analysis was done by the Guttman split-half coefficient and was found to be 0.90. Results: The pre-test findings show that 23 (38.33%) had a poor level of knowledge score, 31 (51.67%) had average knowledge and 06 (10%) of them had good knowledge and no one of them had found a very good level of knowledge. After planned teaching in the post-test, 12 (20%) had a good knowledge score and 48 (80%) had very good knowledge, showing an increase in the knowledge score, post-test. The Mean score value of the pre-test was 07.57 and the post-test was 21.13 (p-value is 0.001), Hence it indicates that planned teaching was effective. There was a significant association between knowledge scores of leukaemia patients with respect to education of leukaemia patients (p-value 0.014 i.e. <0.05) and area of residence (p-value 0.047 i.e. <0.05). Conclusion: The study showed that the leukaemia management education was successful in improving the awareness about management of leukaemia and thus helps them to understand the nature and management of the disease as well as to take the required measures to avoid complications.

Experiences of Cancer Patients on their Visit to Cancer Outpatient Department: A Qualitative Study from a Regional Hospital in Mauritius

Introduction: Cancer care studies suggest that being diagnosed with cancer, the patients and their families face various hardships such as financial crisis, increased mental stress, difficulty in managing their relationships and routine lifestyle activities. Moreover, psycho-oncological studies also describe the intense distress and disbelief experienced by patients on their initial diagnosis. The role of cancer care needs to be understood as well as implemented in cancer treatment, thus further enriching the insights of the treating oncologist about their patient’s state of mind. This ultimately allows for the betterment of treatment compliance. Aim: To study the experience of cancer patients on their visit to the cancer clinic and the emotional turmoil after diagnosis and throughout treatment. Materials and Methods: A descriptive phenomenological qualitative study was designed and conducted from August to September 2019 at the Oncology Department of Victoria Hospital, Mauritius. Participation in the study was voluntary, and written consent was taken from each of the study participants. The data was collected on an in-depth one on one interview basis and was recorded, and the purposive sampling technique was used for collecting the data. Results: Out of 12 patients, the male/female ratio equated to 5:7, these patients were from the ages of 23 to 70 years and the mean age of the participants was 48.2 years. A total of 25 different codes were generated in the study, seven main themes were established there from (Motivational factors, Psychological factors, Society, Message for others, Awareness about the disease, Economic factors and Perception towards the healthcare environment). Conclusion: The main implication that emerged from this study is the notion of the lateral views of informal caregivers, family members and medical professionals, towards the patient’s feelings and emotional reactions in respect to their experience of cancer. It has been noted that the positivity of the caregiver corresponds directly to positive outcomes in the cancer treatment whilst simultaneously decreasing the psychological ramifications of the process.

Local Side Effects of Inhaled Budesonide in Asthmatic Children- A Cross-sectional Study

Aditi Tiwari, Satnam Kaur, Rani Gera

Introduction: There is scarcity of Paediatric literature regarding local side effects of Inhaled Corticosteroids (ICSs) and available paediatric literature on the subject is old and has shown variable prevalence of these side effects varying from none to 60%. Aim: To evaluate local side effects of inhaled Budesonide in asthmatic children of ≤12 years. Materials and Methods: In this cross-sectional study, 250 asthmatic children attending Paediatric chest clinic of a tertiary care hospital and taking inhaled Budesonide for at least three months were evaluated for occurrence of local side effects during preceding one month. Local side effects (dysphonia, sore throat, cough during inhalation, thirsty feeling after inhalation, oral ulcers) experienced in preceding month were asked for and clinical evaluation for oral thrush, perioral dermatitis and tongue hypertrophy was done at the time of assessment. Information was collected regarding potential risk factors associated with occurrence of these side effects. Chi-square test was used to study the association between qualitative variables. Univariate and multivariate logistic regression were used to study the association between local side effects and potential factors associated with their occurrence. Results: About 250 asthmatic children aged ≤12 years (64 children <6 years, 186 children ≥6 years) taking inhaled budesonide via pressurised Metered Dose Inhaler (pMDI) were evaluated. Almost half (48.8%) of the enrolled children experienced at least one local side effect, either daily or frequently, in the preceding month. Though majority experienced a single side effect, 21% experienced two or more side effects. Thirsty feeling after inhalation was the most common reported side effect experienced by 31.2% children followed by cough during inhalation, sore throat and dysphonia which were experienced by 25.2%, 17% and 8% children, respectively. Perioral dermatitis was found in only one patient while none of the patients had tongue hypertrophy or oral thrush. On univariate logistic regression, thirsty feeling after inhalation was associated with older age (≥6 years) and higher dose of Budesonide (>400 μg/day). Cough during inhalation was found to be associated with older age, higher dose of Budesonide, poor compliance to treatment and incorrect technique of taking pMDI and sore throat was associated with poor compliance and incorrect technique. However, on multivariate logistic regression, only cough during inhalation was found to be associated with higher dose of Budesonide and poor compliance to treatment. Conclusion: Local side effects are common in asthmatic children using ICSs and should be routinely assessed during follow-up as a part of comprehensive asthma management plan.

Correlation between the Findings of Magnetic Resonance Imaging Shoulder and Shoulder Arthroscopy

Introduction: Shoulder pain is a significant cause of decreased functional activity of an individual. The overall prevalence of shoulder pain is 16-26%, which makes it the third most common cause among musculoskeletal complaints. The cause of pain in the shoulder is often difficult to evaluate, and diagnosis is usually ambiguous because physical findings are poorly reproducible. The diagnosis therefore, requires multiple imaging modalities. Therapeutic arthroscopy is “the current gold standard” for diagnosing shoulder pathologies, however the procedure is invasive, needs hospitalisation and anaesthesia. Aim: To correlate the findings of Magnetic Resonance Imaging (MRI) shoulder with the findings of shoulder arthroscopy and subsequently determine sensitivity, specificity and accuracy of MRI in diagnosing shoulder pathologies. Materials and Methods: Forty two patients suffering from chronic shoulder pain for a period of more than six weeks, having symptoms of instability, clinical signs of tear or impingement, or functional limitation of the affected shoulder were included in this study. The patients included were in the age group of 18-80 years. Subsequently, MRI followed by arthroscopy of the shoulder was done and the findings of MRI were compared to that of arthroscopy using kappa statistics. Results: In this study along with rotator cuff tear (26 patients), subacromial bursitis (26 patients), was the other most common shoulder pathology. The sensitivity of MRI in detecting shoulder pathologies varied from poor (0.28) for Superior Labrum Anterior Posterior (SLAP) lesion to very good (0.88) for Bankart’s tear and (0.8) for synovial chondromatosis to excellent for rotator cuff tears (0.92). Although sensitivity of MRI was variable for different shoulder pathologies, specificity was comparatively high in detecting all of the above shoulder pathologies. The accuracy of MRI was highest (0.95) in diagnosing synovial chondromatosis, followed by bankart’s lesion (0.92), and rotator cuff tear (0.88). Conclusion: MRI is a very useful and effective tool in diagnosing various shoulder pathologies with exception of SLAP tears where its sensitivity diminishes significantly.

Nutritional Status of One to Five-Year-Old Children in Rural Haryana: A Community Based Study

Narottam Samdarshi, Amrit Virk, Parmal Saini, Vikrant Prabhakar

Introduction: Under-nutrition remains one of the major causes of morbidity and premature mortality among one to five-yearold children in India. WHO recommended indicators used in the past for assessment of under-nutrition are overlapping and do not provide a comprehensive estimate of the under-nourished in the community. Aim: To assess prevalence of under-nutrition among one to five-year-old children of rural Haryana, using conventional indices and Composite Index of Anthropometric Failure (CIAF) and compare the estimated results. Materials and Methods: A community based cross sectional study was conducted on 1032 children, one to five-year-old (477 boys; 555 girls), in rural field practice area of Department of Community Medicine, AMCH, Shahabad (M), Haryana from January to December 2019. House to house visits were conducted to collect information from the child’s mother/ primary caregiver using a semi-structured questionnaire followed by anthropometric assessment of the children. The WHO recommended conventional indicators of under-nutrition (stunting, wasting and underweight) as well as the CIAF were used to evaluate the nutritional status of the children following standard procedures. Z-scores were computed separately for boys and girls. Categorical data was presented as percentages (%) and Pearson’s Chi-square test was used to evaluate differences between groups for categorised variables. The p-value <0.05 was considered significant. Results: Our study results revealed 21.5% children as underweight, 30.2% children as stunted and 8.9% children as wasted according to WHO recommended indices. The prevalence of under-nutrition in studied children according to CIAF was found to be 43.7%. Of the studied children, 56.3% of children reported no failure (Group A), 4.1% reported wasting only (Group B), 2.3% reported wasting and underweight (Group C), (4.2%) reported wasting, stunting and underweight (Group D), 7.6% reported stunting and underweight (Group E), 18.4% reported stunting only (Group F) while 7.1% reported underweight only (Group Y). Conclusion: CIAF may be a better indicator of nutritional status in one to five-year-old children. The apparent advantage lies in the fact that it reveals a comprehensive picture of the severity of the actual burden of under-nutrition in a population.

Prediction of Mortality in Sepsis using Rapid Emergency Medicine Score: A Cohort Study

Introduction: Organ dysfunction due to sepsis is manifested as acute rise of 2 points in quick Sequential Organ Failure Assessment (qSOFA) score from baseline, which is assessed by: 1) Systolic Blood Pressure (SBP) ≤100 mmHg; 2) Respiration Rate (RR) ≥22/min; 3) altered mentation, each having one point. For timely and specific management, an early diagnosis and stratification of severity of the sepsis is important. To predict the outcome of sepsis many scoring systems like SOFA, Acute Physiology and Chronic Health Evaluation II (APACHE II), Rapid Emergency Medicine Score (REMS), Mortality Prediction Model (MPM) have been developed. REMS is simple and feasible scoring system comprising of simple variables like, age in years, Pulse Rate (PR), RR, Mean Arterial Pressure (MAP), Glasgow Coma Scale (GCS) and SpO₂ estimation. Aim: The aim of the study was to evaluate the efficacy of REMS score and to validate its utility in patients with sepsis to predict mortality. Materials and Methods: This was an observational, cohort study conducted in the Department of Medicine of SCB Medical College and Hospital, Cuttack. A total of 100 patients of sepsis admitted to medical wards and Intensive Care Unit (ICU) of Medicine department were included in the study. Vital parameters like PR, SBP, RR, GCS, SpO₂ were noted. REMS score was calculated for patients with sepsis and septic shock, among survivors and non survivors. Primary outcome was either death or discharged. The observed data was statistically analysed for utility of REMS score in predicting mortality, which is the secondary outcome of the study. Student’s t-test and Mann-Whitney U test were used for comparing normally and non-normally distributed data respectively. Univariate and multivariate logistic regression was done for all parameters in REMS. Results: The average age of the patients was 49 years (SD 14.5) with males and females almost equally distributed. Major source of infection were pneumonia (24%) followed by urinary tract infections (19%). REMS score was calculated on the day of admission of all 100 patients. It clearly distinguished survivors from non survivors (p<0.001). The median value of REMS among non survivors was 9 (7-10), which was highly significant compared to survivors; median value of REMS among survivors was 3.5 (2-5). REMS score was high among patients with septic shock than patients with sepsis {median REMS: 9 (7-10.5) vs. 4 (2-5.75); p<0.001}. All the variables in REMS were significantly associated with mortality, however with multivariate analysis only the RR was independent predictor of mortality. REMS at cut-off score 7 has sensitivity of 87.5%, specificity of 88.2%, Positive Predictive Value (PPV) of 70%, Negative Predictive Value (NPV) of 95.7%, and accuracy of REMS was 88%. Conclusion: REMS score showed a significant difference among survivors and non survivors with higher score predicting higher mortality. Hence, REMS is a valid scoring system that can be used in resource limited emergency departments to predict the mortality in patients with sepsis and septic shock.

Histopathological Spectrum of Lesions in Lungs on Post-mortem Specimen in a Tertiary Centre of Bastar Region- A Retrospective Study

Introduction: Lungs are the major organ involved in a number of infectious, inflammatory and occupational disease, secondarily involved in almost all form of terminal disease. So many people around the world suffer from preventable Lung disease. Many a times it has been found that when gross pathology could not help to evaluate cause of death, histopathology provide the valuable information. Aim: To study the spectrum of histopathological finding in lung autopsy and the incidental findings identified during histopathological examination gain a prime importance in academic and research purpose. Materials and Methods: This was a retrospective study done in the Department of Pathology, Lt B.R.K.M G.M.C, Bastar, Chhattisgarh, India, over a period of 10 years i.e., from January 2010 to December 2019. The study consisted of Lung specimens (474 cases) from medico-legal autopsies, irrespective of their age and sex, received during this period. Gross and Microscopic features were documented, and diagnosis was made. The results were analysed based on gross findings and the histopathological examination. Results: Among 474 cases studied during period of 10 years, maximum cases were seen in 30-39 (141 cases) years of age group. Males were more commonly affected 345 (73%) as compared to Females 129 (27%). Pathological findings of Lung were seen in 441 cases, of which Pulmonary Oedema with Congestion was found in 352 cases, along with Intra-alveolar Haemorrhage in 41 cases, Bronchopneumonia in 14 cases, Lobar Pneumonia in 11 cases, seven cases of Tuberculosis, Interstitial Pneumonia in seven cases, Vegetative material in three cases, Emphysema in three cases, Aspiration pnuemonitis in two cases and one case of Chronic Bronchitis. Conclusion: Autopsy study of lung specimens gives valuable information, improves clinical diagnosis and provides diagnostic setup for better clinical assessment. Histopathological examination proves to be the great diagnostic tool in the identification of lung lesions which were incidental finding or direct cause of death. Limitation was non-availability of large specimens, detailed clinical history and autolysis of the organ.

Arginase and Procalcitonin: Promising Biomarkers for Early Diagnosis of Sepsis

Shruti Rahul Mulgund, Subodhini Anant Abhang

Introduction: Sepsis remains a major cause of death in critically ill patients in Indian population because of high susceptibility towards infectious diseases in the world. Procalcitonin (PCT) is a well-studied marker in foreign countries but needs to be established in Indian population. In the last few years, importance of Arginase as a marker of immunity has also increased exceptionally, because this enzyme is essentially involved in different inflammatory processes. Keeping these facts in mind PCT and Arginase were evaluated for their utility as markers to diagnose sepsis. Aim: To evaluate Arginase and PCT as biomarkers for early diagnosis of sepsis. Materials and Methods: Hundred adult patients (age >18 years) with Systemic Inflammatory Response Syndrome (SIRS) attending BJ Medical College which is affiliated with Sassoon General Hospital (Pune, Maharashtra, India) during May 2012- July 2015 were incorporated in the study. Age n sex-matched of 100 samples healthy controls were also collected. Arginase was estimated by Roman and Ray method and PCT by Enzyme-linked Immunosorbent Assay Kit (ELISA) method. Unpaired t-test was done to compare the mean biomarker levels between the cases and controls. The Area Under Curve (AUC) was calculated using Receiver Operating Curve (ROC). All the data analysis was set at 95% Confidence Interval (CI) and value p<0.05 are statistically significant. Data analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. Results: In the study, a significant increase was observed in the levels of arginase (p<0.01) and PCT (p<0.01) in cases as compared to controls. ROC curves were plotted to find out the cut-offs of arginase (4.6 IU/L) and PCT (0.04 ng/mL) to check the diagnostic efficacy of both the biomarkers. Conclusion: Serum PCT and arginase offers a high level of accuracy than other currently available tests and hence can be helpful in the management of sepsis. In addition to this apart from high sensitivity and specificity arginase estimation is cost effective as compared to PCT.

Comparative Evaluation of Cytotoxicity of 0.12% and 0.2% Chlorhexidine, 2% Povidone Iodine, 3% Hydrogen Peroxide and 0.9% Normal Saline Solutions on Fibroblasts- An Invitro Study

Sruthy Madhusudanan, Ambili Renjith

Introduction: Periodontitis is initiated by plaque microbes and modified by systemic and environmental factors. Treatment of periodontitis primarily focuses on plaque control by mechanical and chemical means. Chlorhexidine (CHX) mouthwash is considered as the ‘gold standard’ chemical plaque control agent. But studies have demonstrated cytotoxic effects of CHX. However, there is limited evidence available regarding the cytotoxicity of other commonly used postoperative mouthwashes. Aim: To evaluate cytotoxicity of commonly used postoperative mouthwashes (CHX- 0.12% and 0.2%, 2% povidone iodine, 3% hydrogen peroxide and 0.9% normal saline solutions) using MTT assay on fibroblast cells and to identify the least cytotoxic agent. Materials and Methods: The study was an invitro study conducted at Department of Periodontics, PMS College of Dental Sciences and Research, Vattapara, Thiruvananthapuram in association with Biogenix research centre Poojapura in January 2018. The cytotoxic effects of CHX -0.12% and 0.2%, Povidone iodine 2%, 3% hydrogen peroxide and 0.9% normal saline solution on L929 fibroblast cells were observed using inverted phase contrast microscope and images were recorded for all the groups. Cytotoxic evaluation was done by MTT {3,(4,5- dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide} assay. Optical Density (OD) was measured and percentage of cell viability for each mouthwash was calculated. Statistical Analysis was carried out using analysis of variance (ANOVA). Intergroup comparison was done using Post hoc analysis (Tukey HSD). The p-value <0.05 was considered to be statistically significant. SPSS software version 22.0 IBM, Chicago, IL. was used. Results: Cell viability percentages were highest for normal saline (87.11%) followed by 2% povidone iodine (73.71%), 0.12% and 0.2% CHX (24.9% and 24.56%) and the least for 3% hydrogen peroxide (23.82%). Post hoc analysis showed significant difference for all the reagents compared to control (p<0.001) except normal saline (p=0.658). The difference between povidone iodine and normal saline was not significant (p=0.433). Comparison of both concentrations of CHX (0.2% and 0.12%) and povidone iodine 2% w/v was significantly different with p<0.001, but not with hydrogen peroxide (3%) (p=0.899). The comparison between povidone iodine 2% and hydrogen peroxide (3%) was significantly different (p<0.001). Microscopic findings of CHX and hydrogen peroxide treated cells included cell shrinkage, condensed nuclei, membrane blebbing and apoptotic bodies. Changes in cellular morphology were not observed in cells treated with povidone iodine and normal saline solution. Conclusion: Both 0.12% and 0.2% CHX and 3% hydrogen peroxide were found to have significant cytotoxic effects when compared to other mouthwashes. The findings of this study preclude the use of 0.12% and 0.2% CHX and 3% hydrogen peroxide as postoperative mouth rinses due to their possible cytotoxic effects. A 2% povidone iodine and normal saline solution can be considered as excellent alternatives as they were found to be least cytotoxic on fibroblast cells.

Effectiveness of Health Promotional Strategies on Quality of Life among Spouse of Alcoholics in Selected Communities of Dakshina Kannada District, India

PJ Shiji, Neetha Kamath, Supriya Hegde

Introduction: Alcoholism is a major problem in developing countries like India. Alcoholism affects not only the individual but also his family and the society. Spouses of alcoholics are among those who suffer the maximum consequences of alcoholism and its effects. Aim: To find the effect of health promotional strategies (Yoga and Health education) on Quality of Life (QOL) of the spouse of alcoholics. Materials and Methods: Quasi experimental pre-test post-test control design was adopted. A total of 330 men were administeredthe Alcohol Use Disorders Identification Test (AUDIT) tool to screen for alcoholics through house to house survey, of which 279 men who scored in the range of 8-15 AUDIT score were considered as alcoholics. Their spouses were selected as study participants (who met the sampling criteria) and subjects were randomly allocated to intervention group (132) and control group (147) through simple randomised sampling. The data was gathered by using WHOQOLBREF tool to assess the QOL; initially pre-test QOL was assessed, followed by individual health education (45 minutes) and yoga (15 minutes) once a week for 3 consecutive weeks and post-test was done during fourth week for intervention (127) and control groups (142). There were five dropouts in post-test from each group due to health problems, migration and no cooperation from the family for the intervention. Independent t-test was performed by using SPSS version 18.0 to determine effectiveness of health promotion strategies on QOL scores between the intervention and control group and chi-square test was used to find the association between post-intervention QOL scores and selected demographic variable at p<0.05 level of significance. Results: QOL scores in all four domains in the intervention group showed that there was an increase before and after the interventions. On comparing the mean differences between QOL scores post-test in intervention and control group, calculated t-value was (34.04) and the difference was highly statistically significant at p<0.001** showing that health promotional strategies were effective in improving QOL among spouse of alcoholics. There was a significant association between post-test intervention QOL scores of subjects and selected variables such as primary decision maker (p=0.002*) of the family and history of domestic violence (p=0.030*). Conclusion: The study findings suggest that adopting health promotional strategies such as yoga can help the spouses of alcoholics to improve their QOL.

Impact of Hospital Acquired Infection and Antibiotic Resistance Awareness Campaign on Knowledge Attitude and Practices of Medical Undergraduates in a Tertiary Care Teaching Hospital, India

Introduction: Healthcare professionals have an important role in tackling the growing menace of Hospital Acquired Infections (HAI) and Antibiotic Resistance (ABR). Regular trainings imparted early in career can result in better understanding of these crucial issues. Aim: To identify the baseline Knowledge Attitude and Practices (KAP) of 5th semester MBBS undergraduate students of a University Medical College in Rajasthan, India, and to determine the changes in these parameters after the implementation of a vigorous “HAI and ABR Awareness campaign”. Materials and Methods: This prospective interventional study involved 86, 5th semester MBBS undergraduate students. The study instrument was a preformed pretested 30 item selfadministered questionnaire. The study intervention included a series of lectures, role plays, poster competition; and an audiovisual quiz. The performance of individual participants before and after the intervention was then statistically analysed with Microsoft Excel and software Statistical Package for the Social Sciences (SPSS) version 20. Results: The pre-intervention overall KAP score of each student was found to be poor in 17.4%, average in 61.6%, and excellent in 20.9% in study participants. Post-intervention grades were found to be poor, average, and excellent in 1.1%, 8.14%, and 90.7% study participants, respectively. A statistically significant decrease in the percentage of students with poor grade and a significant increase in those with excellent grade were observed. Conclusion: There is a need for suitable amendments in current MBBS curriculum to include modules which comprehensively address the core issues of ABR, HAIs and Antimicrobial Stewardship (AMS). This would help to bring out attitude and behavioural changes in students at the very grass-root level.

Comparative Study of FOXC1 Expression in Selective Odontogenic Cysts and Tumours

Thanit Prasitsak, Chaidan Intapa

Introduction: Many studies have indicated that Forkhead Box C1 (FOXC1) is highly expressed in a various malignant neoplasms and its over expression is associated with tumour development, progression and metastasis. However, the role of FOXC1 in odontogenic lesions remains to be elucidated. Aim: This study aimed to investigate FOXC1 expression in selective Odontogenic Cysts (OC) and Odontogenic Tumours (OT). Materials and Methods: A descriptive study on OC and OT was performed on oral biopsy specimens at Faculty of Dentistry, Naresuan University, Phitsanulok, Thailand, between January 2009 and December 2016. Institute of Cancer Research (ICR) mouse were used as study animal. Immunohistochemical reaction was performed using antibody against FOXC1 in 23 formalin-fixed and paraffin-embedded tissues of eight Ameloblastoma (AM), one Adenomatoid Odontogenic Tumour (AOT), seven Odontogenic Keratocyst (OKC), five Dentigerous Cyst (DC), two Calcifying Odontogenic Cyst (COC) and three mouse embryonic head at Embryonic Day (E)14. The expression level of FOXC1 was evaluated using semi-quantitative analysis. Results: Immunoreactivity of FOXC1 was not detected in the epithelial lining of OKC, DC and COC but it was identified in the epithelial compartment of AM and AOT. Overall, semi-quantitative analysis demonstrated moderate staining of FOXC1 and staining score was 4.13 in AM and 5 in AOT. In addition, FOXC1 was not detected in normal tooth bud of mouse including both enamel organ and condensing ectomesenchyme. Conclusion: Expression of FOXC1 may contribute in tumouriogenesis of OT whereas it is may not be related with normal odontogenesis.

Prothrombotic State and Cardiovascular Risk in Hyperuricaemic Individuals: Does Hyperglycaemia Play a Role? A Case-control Study

Shilpa Bhardwaj, Ashok Ahirwar, Bhawesh Mishra, Gaurav Singla, Anju Jain

Introduction: The role of Hyperuricaemia (HU) in pathogenesis of cardiovascular disorders is debated. A number of hypothetical mechanisms that link HU to increased cardiovascular risk are researched. Aim: To evaluate the hypercoagulable state and cardiovascular risk in diabetic hyperuricaemics, nondiabetic hyperuricaemics in comparison to healthy controls, and to analyse whether chronic hyperglycaemia has a causal role in HU associated cardiovascular risk. Materials and Methods: A case-control study was conducted in which 60 known hyperuricaemic cases and 30 healthy controls were included in the study. Cases were further divided into nondiabetic hyperuricaemic and diabetic-hyperuricaemic subgroups. Routine blood biochemistry including high sensitivity C-Reactive Protein (hs-CRP), Plasminogen Activator Inhibitor-1 (PAI-1) and lipid profile was performed to assess endothelial function and hypercoagulability. Data were expressed as Mean±SEM. Results: Levels of hs-CRP and PAI-1 were significantly higher in diabetic hyperuricaemics (p<0.001) and nondiabetic hyperuricaemics (p<0.001) compared to controls. The difference was not significant between the hyperuricaemic subgroups. Serum Uric Acid (UA) levels showed a significantly positive correlation with hs-CRP (r=0.554, p<0.001) and PAI-1 (r=0.525, p=0.003) levels among the cases. Association between UA and glucose was not significant in diabetic hyperuricaemics (r=0.270, p=0.15). Conclusion: HU is associated with endothelial dysfunction and prothrombotic state leading to increased cardiovascular risk. Hyperglycaemia does not have a direct causal role in HU associated cardiovascular risk.

Seroprevalence of Scrub Typhus among Pyrexia of Unknown Origin Patients: A Study from Tertiary Care Hospital in Eastern Odisha, India

Shreekant Tiwari, Monalisah Nanda

Introduction: Scrub typhus is a fatal rickettsial infection. It is caused by mite-borne bacterium Orientia tsutsugamushi which is transmitted by the bite of mite larvae called chiggers. It usually presents with acute febrile illness. Clinicians usually do not consider it as differential diagnosis as it is still an unknown entity. Aim: To assess the seroprevalence of scrub typhus among the pyrexia of unknown cases in Eastern part of Odisha, India. Materials and Methods: This was a cross-sectional study involving 260 serum samples obtained from clinically suspected cases of scrub typhus. Detection of antibodies was done on the samples by Immunochromatography (ICT) and IgM ELISA (Enzyme Linked Immunosorbent Assay). Samples were also processed for dengue fever, malaria, typhoid and leptospirosis which are the other causes of febrile illness in this region and excluded from the study once they come positive. Among these febrile cases which were excluded from study, malaria was predominant (44%) followed by typhoid (34.4%), dengue (15%) and leptospirosis (6.45%). Descriptive statistical analysis was applied to evaluate the results. Results: Out of 260 clinical samples, 74 (28.46%) were positive by IgM ELISA. There was good correlation (98.6%) between ICT and IgM ELISA. Fever was the most common clinical symptom followed by abdominal pain. Pathognomonic feature such as eschar was seen in one patient only. Scrub typhus should be considered as one of the differential diagnosis of Pyrexia of Unknown Origin (PUO) cases, along with dengue fever, malaria typhoid and leptospirosis. Conclusion: IgM ELISA is simple, rapid and economical test and should be used as reference diagnostic test for the diagnosis of scrub typhus.

Clinical and Sero Immunological Profile of Scrub Typhus in Bengaluru, Southern India

JV Shwetha, Sneha K Chunchanur, R Ambica

Introduction: Scrub typhus is a common but neglected cause of Acute Febrile Illness (AFI) in India. Under diagnosis of this severe disease with protean manifestations, can negatively influence the treatment and outcome. Early laboratory diagnosis by appropriate means is therefore important. In addition, as antigenically diverse variants of Orientia tsutsugamushi (O.tsutsugamushi) are known to exist and evolve, information regarding the strain types is also crucial. Aim: To know the clinical spectrum, laboratory diagnosis by different modalities, outcome and strain variation of scrub typhus in Southern India. Materials and Methods: A prospective cross-sectional study was conducted in a Tertiary Care Hospital in Bengaluru, Southern India from June 2015 to May 2017. Hundred clinically suspected cases of scrub typhus (rickettsioses) were enrolled. Serum and EDTA (Ethylenediaminetetraacetic acid) blood samples were subjected to serodiagnosis for scrub typhus and Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP) respectively. Strain characterisation was done by Microimmunofluorescence (MIF), PCR-RFLP and phylogenetic analysis. Patients were followed-up for four weeks. Data was entered in Microsoft Excel spreadsheet and analysed using Statistical Package for the Social Sciences (SPSS) software. Results: Laboratory evidence of scrub typhus was showed by 38% of the cases. Seropositivity was more in comparison to PCR. Paediatric preponderance and seasonal trend was evident. Strain typing showed presence of different strain types, with no correlation between clinical features and strain types. PCR-RFLP results correlated well with phylogeny, while MIF results did not match. All the patients responded to doxycycline, except for 12% who succumbed. Conclusion: Different strain types of O. tsutsugamushi are known to cause scrub typhus in Southern India. PCR-RFLP can be a useful preliminary tool for strain typing in resource poor settings, where phylogenetic analysis is not possible. Early diagnosis and treatment helps in improved outcome.

Comparison of Unidirectional and Bidirectional Barbed Suture in Vaginal Cuff Closure during Total Laparoscopic Hysterectomy- A Randomised Controlled Trial

Neethu Selvest, Murali Subbaiah, Dilip Kumar Maurya, Gowri Dorairajan

Introduction: Laparoscopic hysterectomy is increasingly replacing abdominal hysterectomy in many countries. The advantages of laparoscopic approach include short postoperative recovery time and hospitalisation time. However, vaginal cuff closure during laparoscopic hysterectomy can be challenging, especially for beginners. Barbed sutures have been found to be superior to conventional sutures for vaginal cuff closure during laparoscopic hysterectomy in several studies. However, studies comparing different barbed sutures are lacking. Aim: To compare vaginal cuff closure time, operative time and complications between unidirectional and bidirectional barbed suture during Total Laparoscopic Hysterectomy (TLH). Materials and Methods: A randomised, controlled clinical trial was conducted from November 2017 to March 2019, in a Medical College in Puducherry, India that involved 46 women, who underwent TLH for benign pathology. After TLH, vaginal cuff closure method was randomised to unidirectional barbed suture or bidirectional barbed suture. The vaginal cuff closure time, total operative time and complications were recorded. The patients were evaluated postoperatively at 4 weeks after the surgery and by phone interview at 6 months. The comparison between the continuous variables was done with independent Students t-test or Mann-Whitney U Test and categorical variables with Chi-square or fisher-exact test. A p-value of <0.05 was considered as statistically significant. Results: The mean time taken for vaginal cuff closure by unidirectional barbed suture group was 6.8±1.6 minutes and bidirectional barbed suture was 11.3±1.46 minutes (p<0.001). The mean operative time in the unidirectional barbed suture group was 139±48.3 minutes and in the bidirectional barbed suture group was 150.6±42.7 minutes (p=0.39). The frequency of postoperative complications such as bleeding, infection and cuff dehiscence were not statistically significant between the two groups. Conclusion: Vaginal cuff closure time using unidirectional barbed suture is significantly less when compared to bidirectional barbed suture during TLH.

Role of Non-invasive Imaging in Characterisation of Soft Tissue Vascular Anomalies: Comparison of Ultrasound with Contrast-Enhanced Magnetic Resonance Imaging

Introduction: Soft tissue vascular anomalies present a diagnostic challenge. In these anomalies, imaging is crucial for therapeutic planning and improvement of prognosis. Ultrasound (US) and Contrast-Enhanced Magnetic Resonance Imaging (CEMRI) are both widely utilised and are valuable imaging modalities, both having distinct advantages and limitations in evaluation of such lesions. Aim: To evaluate soft tissue vascular anomalies using US and CEMRI and assess their agreement in characterisation of these lesions. Materials and Methods: The prospective study included 75 patients with vascular anomalies evaluated by means of US and CEMRI: 71 underwent both US and MRI, three underwent US alone, and one patient underwent MRI alone. Patients of all ages were included. Lesions were characterised based on imaging findings and vascular perfusion characteristics. Histopathological evaluation was done in all patients. Receiver Operating Characteristic (ROC) analysis was used for differentiating data. The agreement of US and CEMRI with histopathological diagnosis were assessed using kappa statistics. Results: Among the soft tissue vascular anomalies, 17 were haemangiomas, 55 were vascular malformations and 3 were other vascular tumours. Majority of the lesions were venous malformations (n=26; 34.66%). A cut-off value of 17.5 cm/sec of peak venous velocity using colour Doppler showed 100% sensitivity in differentiating Arterio-Venous Malformations (AVM) from haemangiomas using ROC curves. Agreement expressed as kappa was 0.884 (95% CI 0.794-0.973) for US and 0.923 (95% CI 0.850-0.996) for CEMRI demonstrating near perfect agreement with histopathology in both. Conclusion: The findings of this study indicate that both US and CEMRI are accurate in detection and characterisation of soft tissue vascular anomalies showing comparable level of agreement. US may be the preferred imaging modality as it is widely available, relatively inexpensive and non-invasive. Contrast enhanced MRI may be reserved as a complementary technique in cases wherein lesion categorisation or extent is ambiguous during diagnosis.

Clinical Profile and One Year Outcome of Atrial Fibrillation- A Prospective Cohort Study

Praveen Satheesan, Veena Felix, Alummoottil George Koshy

Introduction: Atrial Fibrillation (AF) is the most common arrhythmia in clinical practice and imposes a great burden on health care resources. There is limited data regarding the impact of AF in our population. Aim: To estimate the mortality and Major adverse Cardiovascular events {(MACE)- Acute Coronary Syndrome (ACS), Stroke, Cardiac death} in AF patients in a tertiary care centre in South India. Materials and Methods: This prospective cohort study included all patients >18 years with newly diagnosed or previously documented evidence of AF in Electrocardiography (ECG). Transient reversible causes and critically ill patients were excluded. Total of 346 patients were recruited and prospectively, followed-up at 1, 3, 6 and 12 months for development of MACE, anticoagulation status, Prothrombin Time (PT), International Normalised Ratio (INR) and major bleeding events. Baseline data including clinical parameters, comorbidities and appropriate investigations such as ECG and Echocardiogram (ECHO) parameters were collected with a structured questionnaire and analysed at one year using appropriate statistical tests. Results: Average age was 60.5 years (SD 11.5 years) and majority (74.6%) were between 50-75 years. Females were more (59.5% vs 40.5%). Most common AF risk factor was Hypertension (44.5%) followed by Rheumatic Heart Disease (RHD) in 27.2% of AF patients. AF was classified as permanent in 42.2%, persistent in 23.1% and paroxysmal in 34.7%. Valvular AF was present in 26.6% and non-valvular AF in 73.4%. At one year, 17 patients were lost to follow-up. CHA₂ DS₂ VASc score of ≥2 was present in 65.1%. During one year follow-up the MACE rate was 26.7% (ischemic stroke in 9.4%, ACS in 2.7% and cardiac mortality in 14.6 %). Mean time in Therapeutic Range (TTR) was 28.12%. TTR >60% (good control) was present in only 9.2%. Conclusion: AF continues to be a significant arrhythmia causing substantial morbidity and mortality. Non-valvular AF was thrice as common as valvular AF. Though 3/4th of the patients were on oral anticoagulants, <10% had their INR under good control which contributed to the higher events. To improve the outcomes in AF patients, treatment of risk factors and optimal anticoagulation plays a crucial role.

Predictive Value of the New Inflammatory Score Based on C-reactive Protein to Albumin Ratio on Serious Postoperative Complications after Curative Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

Ümit Mercan, Ogün Ersen, Cemil Yüksel, Ali Ekrem Ünal

Introduction: The CRP/Albumin Ratio (CAR) which has been shown to be closely related to the results in septic patients has been found to be also associated with postoperative and long-term outcomes in patients with malignant diagnosis. Although the prognostic value of CAR in many gastrointestinal cancers has been determined, studies on pancreatic cancer are limited. Aim: To evaluate the predictive value of CAR on serious postoperative complications after curative pancreaticoduodenectomy for pancreatic cancer. Materials and Methods: One hundred eighty seven patients that underwent curative resection for pancreatic cancer between January 2010 and January 2020 were included in the study. The optimal cut-off level of the CAR was calculated as 0.22. Patients were divided into two groups as below and above this value. Clinicopathological and postoperative variables were compared between the groups. Results: In univariate and multivariate analysis, modified Glasgow Prognostic Score (mGPS) (OR: 3.67. %95 CI: 2.31~5.82. p=0.028), CAR (OR: 8.02 %95 CI: 3.45~21.62. p=0.001>), lymph node status (OR: 1.54. %95 CI: 0.41~3.39. p=0.042) and TNM stage (OR: 3.92. %95 CI: 1.56~10.08. p= 0.005) were found to be independent risk factors for serious postoperative complications. Conclusion: Based on these data, CAR, which can be easily measured from preoperative biochemical results in each patient, may be an independent and significant predictor of postoperative serious complications and poor outcomes after pancreaticoduodenectomy in patients with pancreatic cancer.

Detection of Toxoplasma gondii by Loop-mediated Isothermal Amplification in Blood and Urine Samples from Women in Saudi Arabia

Introduction: Toxoplasmosis is the disease which is caused by the protozoan parasite Toxoplasma gondii (T. gondii)?i, which has the ability to infect all warm-blooded animals. Several molecular techniques for the diagnosis of Toxoplasma gondii includes normal and Real Time Polymerase Chain Reaction (RT-PCR), and gene sequencing. Aim: To apply Loop-Mediated Isothermal Amplification (LAMP) for the diagnosis of T. gondii infections in urine and blood samples from female population in Saudi Arabia. Materials and Methods: In this cross-sectional study, genomic DNA was extracted from 22 blood and urine samples (11 each), two LAMP assays based on B1 and Surface Antigen 2 (SAG2) genes of T. gondii was performed. Conventional PCR was done for the LAMP product followed by sequencing to confirm the specificity of LAMP method. Statistical Package for the Social Sciences (SPSS) version 20.0 was used to summarise continuous and categorical variables. Results: From 22 samples, 17 samples were LAMP positive in both urine and blood samples, four were negative in blood and positive in urine samples, and one was positive in blood and negative in urine. Sequencing of PCR product confirm the specificity of the method used. Conclusion: LAMP detection of T. gondii DNA is an appropriate, sensitive and specific method for diagnosis of toxoplasmosis from urine and blood specimens in humans.

Magnetic Resonance Imaging Evaluation of Cerebral Microbleeds: A Comparative Analysis of Susceptibility Weighted Imaging and T2* Gradient Recalled Echo Sequences

Abhinav Juneja, Rajiv Azad, Ankur Malhotra
Introduction: Cerebral Microbleeds (CMBs) are increasingly recognised as an important predictor of small vessel disease and cannot be detected on routine Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) sequences. Aim: This study was aimed at evaluating CMBs on MRI and to compare the sensitivity of SWI and T2* GRE sequences in detection of these microbleeds. In addition, we also sought to evaluate association between topography (size, number and location) of CMBs and various risk factors. Materials and Methods: This Prospective observational analytical study comprised of 67 patients with CMBs who were evaluated with Siemens 1.5 Tesla MRI machine. T2*-weighted gradient recalled echo sequence and Susceptibility-Weighted Imaging (SWI) were taken in all the patients in addition to routine MRI sequences. Two observers blinded to clinical information, independently interpreted the T2*GRE and SWI sequences. Both observers recorded the topographical details of CMBs which included presence, number, size and location and their association with various risk factors (hypertension, diabetes, smoking and hyperlipidemia). Inter-rater agreement for the number of CMBs on SWI and on T2*GRE was calculated using Cohen’s Kappa (?) as measure of agreement. Intra-Class Correlation Coefficient (ICC) for reliability index in test-retest, intra-rater and interrater reliability was also analysed. The intra-rater reliabilities of each rater were compared. The Correlations between CMBs and risk factors was performed with Pearson’s correlation Coefficient (r). The p-value <0.05 was considered statistically significant. Results: The SWI with its Reverse Phase (RP) detected more number of CMBs as compared to T2*GRE. Majority of the subjects (71.6%) had more than 5 CMBs. CMBs ≥5 mm had a strong correlation with both hypertension and diabetes as compared to CMBs <5 mm. There was a higher frequency of patients with lobar CMBs (89.6%) followed by the deep location (70.1%). An almost perfect agreement was found between both observers for number of CMBs on RP SWI with ‘κ’ value of 0.97a (0.96-0.98) in contrast to a weak agreement on RP T2*GRE with κ=0.52a (0.40-0.64). For SWI, an almost perfect reliability was found (ICC=0.998) as compared to a moderate reliability on T2*GRE (ICC=0.6826). An excellent reliability was seen for size of CMBs <5 mm on RP SWI (ICC 0.998). Conclusion: SWI offered greater reliability and sensitivity for CMB detection as compared to the T2*GRE sequence and is presently the gold standard sequence of MRI for quantifying CMBs. The burden of CMBs may further indicate inappropriately treated hypertension and diabetes.

Can Study of Variations in Platelet Indices in Adult Thrombocytopenias Help to Differentiate the Underlying Mechanism? A Prospective Study

HV Shubha, Archana Shetty, TG Vivek, Vijaya Chowdappa
Introduction: Thrombocytopenia (TCP) is defined as a platelet count below 1,50,000 per microliter. This fall can be attributed to increased destruction, decreased production in bone marrow and pooling of platelets. A good knowledge of the cause and clinical course of the underlying pathology as reflected by the platelet indices contributes to the better management of TCP. With the advent of automation in haematology, these indices are now available from the routinely used blood cell counters in the laboratory. Aim: To determine if studying the variation in platelet indices helps to identify the aetiology of TCP. Materials and Methods: This study was a prospective study conducted in the haematology wing of our central diagnostics attached to a medical college in Bangalore, Karnataka, India over a period of three months from June 2019 to August 2019. A total of 598 cases of adult TCPs were encountered, out of which 505 cases met the inclusion criteria and were categorised into three groups, namely- Hyperdestructive (Group 1), Hypoproductive (Group 2) and Abnormal pooling (Group 3). Variation of platelet indices {Platelet count, Plateletcrit (PCT), Mean Platelet Volume (MPV), Platelet Distribution Width (PDW)} were studied not only between the groups but also with the severity of TCPs. Data was analysed using the software Statistical Package for Social Sciences (SPSS) program version 20 and tested for statistical significance using one-way Analysis of Variance (ANOVA) test. A p-value of <0.05 was considered as statistically significant. Results: Of the 505 cases a majority fell under Group 1- 420 cases (83%). A higher value of MPV (11.870±1.3) and PDW (15.63±3.4) were seen in Group 1 compared to Groups 2 and 3. There was also significant variation among the platelet indices (PCT, MPV, PDW) with the severity of TCPs. Conclusion: Platelet counts along with a good knowledge on interpretation of platelet parameters obtained by automated analysers play a pivotal role in determining the aetiology of TCPs, thereby, providing better initial patient management.

Measurement of Main Pulmonary Artery Diameter and its Ratio with Ascending Aorta in Indian Population by Multi-detector Computed Tomography
Introduction: An increase in Pulmonary Artery (PA) pressure is associated with an increase in its diameter. Hence, it is necessary to know the normal range of Main Pulmonary Artery Diameter (MPAD). An attempt has been made to know the same among the Indian population. Aim: To determine the normal range of reference values for diameter of Main Pulmonary Artery (MPA) and its relation with Ascending Aorta (AA) in Indian population. Materials and Methods: A prospective cross-sectional study was conducted between October 2018 and September 2019 ((380 males, 120 females) between the age of 30-65 years). Data from the contrast CT scans of thorax of 500 subjects such as those patients with cough under evaluation, suspected lung nodule, chest wall lesions, primary or secondaries in the lung, etc., who visited the Department of Radio-diagnosis, in the medical college of South India were analysed. We further defined healthy population as those who were free from chronic cardiopulmonary illness in particular with regard to present study, which would affect the diameter of great vessels including that of PA and aorta. MPA and ascending aortic diameters were measured at the level of pulmonary artery bifurcation, viewed at fixed mediastinal window settings. Statistical Package for Social Sciences (SPSS) version 20. Inferential statistics like Unpaired-t test was used to test the significant difference for variables between the two groups (Males and Females). The level of significance was set at 5%. Results: The MPADs of whole population ranged between 15.6 mm to 31.6 mm, with mean diameter of 23.08±2.81 mm. Correlation between age and MPAD was statistically significant (p-value <0.001), while sex-specific MPAD was not significant. The mean AA diameter was 27.15±2.6 mm. The mean AA diameter in males was 27.76±3.2 mm, and 26.67±2.0 mm in females with statistical significance (p-value 0.001) between the groups. The diameter ratio of MPA to AA was 0.85. Conclusion: In present study, the normal ranges of diameter of PA and its ratio with AA were defined among Indians. The diameter ratio of MPA to AA appears to be more important, as it tends to normalise the effects of anthropomorphic factors.

Infected Non Union of Tibia Managed by Limb Reconstruction System- A Prospective Cohort Study
Introduction: Infected non union of Tibia is one of the most commonly faced problem in both compound as well as closed fractures of Tibia, treated surgically. Few patients also present with gap at the fracture site which may be either due to bone loss during trauma or due to debridement of dead bone during previous surgeries. Treatment of infected non union is always challenging with unpredictable outcomes. Limb Reconstruction System (LRS) is one of the systems available to treat this complex situation. Aim: To evaluate the role of LRS in treatment of infected non union of Tibia in terms of union time, total duration of fixator applied and Visual Analouge Score (VAS). Materials and Methods: Twenty one patients of infected gap, non union of tibia were included in the study and were treated with debridement, resection of dead bone and application of LRS and segment transport. The results were evaluated in terms of union time, total duration of fixator applied and VAS. Bony and functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. SPSS statistics 24.0 was used for analysis. Mean, median and mode were used to describe continuous variable. Results: Out of 21 patients, 19 were males and two were females. The mean age of patients was 29.43±14.07 years. The mean limb length discrepancy was 23.3 mm (range, 15-40 mm). The mean duration from injury to LRS application was 7.9 months (range, 6-12 months). Mean duration of follow-up was 29.5 months (range, 16-50 months). Average union time was 44 weeks and average fixator time was 11.2 months. Bony and function results were good and excellent in 90% cases. Conclusion: The use of monolateral rail external fixator LRS is an effective method for the treatment of infected non union of tibia augmented with a fibular strut graft. This provides good results in terms of bony union, subsidence of infection and functional results.

Nurses’ Experiences of Managing Cardiopulmonary Resuscitation: A Qualitative Study

Nahid Dehghan Nayeri, Mojtaba Senmar, Amir Ghobadi
Introduction: Cardiac arrest is one of the leading causes of death. Nurses are often the first members of the healthcare teams to deal with these patients. The management of how nurses performing resuscitation has drawn a lot of attention. Aim: The present study was conducted with an aim of determining nurses’ experiences of managing Cardiopulmonary Resuscitation (CPR). Materials and Methods: This qualitative study was conducted using the content analysis approach. Fourteen nurses with different positions and active roles in the CPR were selected purposefully. Data were collected through semi-structured interviews from July to December 2019. Data were analysed based on the Graneheim and Lundman’s approach. Guba and Lincoln’s trustworthiness criteria were used to obtain the trustworthiness of data. Results: Fourteen Nurses, with mean age of 32.14±4.34 years and mean work experience of 9.78±4.50 years were included in the study. Four main categories and fourteen subcategories were recognised in the questionnaire, including the role of human resources (fluctuation of coordination and cooperation, capability and motivation), management of procedures (cardiac massage, shock, airway, drug therapy, and vascular access), role of context and structure (equipment and physical space, contextual factors, and losing time) and the role of law and ethics (guideline, reporting and evaluation, and power of conscience). Conclusion: This study showed that nurses face various challenges and limitations at the beginning, during and after resuscitation in the management of CPR. Therefore, nurses’ ability to manage and execute this process should be enhanced.

Detection of Rifampicin Resistance among Patients with Tuberculosis using GeneXpert MTB/RIF Assay: A Retrospective Study
Introduction: Tuberculosis (TB) remains one of the major cause of death worldwide, and the leading causes of mortality in developing countries like India. Smear microscopy has certain limits as it requires 10,000 bacilli/mL for positivity, culture methods takes longer turnaround time of around 6-8 weeks. The recent advancement like Genexpert Mycobacterium tuberculosis/Rifampicin (MTB/RIF) Assay, which has more accuracy and analysis where it detects MTB and RIF resistance in smear negative including immunosuppressive patients even with a volume of 138 cfu (colony forming units)/mL in less than two hours. World Health Organisation (WHO) also recommended new Cartridge Based Nucleic Acid Amplification Test (CB-NAAT) on 2010 and named as GeneXpert system for diagnosis of TB. Aim: To evaluate the patterns of RIF Resistance by GeneXpert as a Rapid and primary screening test in TB patients. Materials and Methods: Both pulmonary and extra pulmonary samples were subjected to AFB (Acid Fast Bacilli) smear microscopy before being tested for GeneXpert MTB/RIF Assay. MTB detected samples were further tested at National Institute for Research in Tuberculosis (NIRT) to confirm RIF resistance and to find out associated resistance to Isoniazid and other second line drugs like fluroquinolones, kanamycin, capreomycin and amikacin. All statistical analysis were performed using Statistical Package for the Social Sciences (SPSS) version 15.0. Results: A total of 8140 samples were tested for CB-NAAT, MTB was not detected in 4414 samples, MTB detected and RIF Sensitive in 3554 samples, MTB detected and RIF resistance in 172 samples. Among these RIF Resistant samples 97% were retreatment patients and the primary drug resistance was less common. HIV/TB co-infected contributes to 1% of resistance and there was no gender preponderance. RIF mono-resistance was found in majority of patients. Conclusion: Genexpert has higher specificity for early detection of RIF resistance as a surrogate marker of MDR-TB to initiate early treatment and prevent transmission of Multi Drug Resistance (MDR) strains.

Detection of Drug Susceptible and Resistant Viridans Streptococci spp., Staphylococcus Aureus, Klebsiella Pneumoniae and E.coli in Complete Denture Patients and Visualisation using Scanning Electron Microscopy

Leoney Andonissamy, Suma Karthigeyan, Seyed Asharaf Ali
Introduction: The bacteria colonising the oral cavity and the dentures acquire drug resistance due to frequent usage of antibiotics systemically and application of mouth rinses and denture disinfectants locally. These multidrug resistant bacteria pose potential threat to the health of the patient as infections caused by them do not respond to conventional antibiotics. Aim: The present study aims at detecting the drug resistant bacteria in patients who wear complete dentures. Materials and Methods: The study is a descriptive study and follows laboratory invitro study design involving 30 complete denture patients. Swabs were collected from their oral cavity as well as complete denture surfaces. Antibiotic sensitivity tests were performed for the following bacteriae namely Viridans streptococci species, Staphylococcus aureus, Klebsiella pneumoniae and E.coli. Isolation of the bacteria were done by means of selective media and subjected to biochemical tests. The 16S rRNA sequencing was done to ascertain the microorganisms by which 20 isolates of each of the selective bacteria were obtained. The bacteria were classified as sensitive, intermediate sensitive and resistant based on antibiotic sensitivity tests. Those isolates which exhibited MultiDrug Resistance (MDR) were visualised using SEM. Results: Viridans streptococci spp. (40%) and Staphylococcus aureus (25%) isolates were resistant to Amoxiclavulinic acid and Methicilin, whereas Klebsiella pneumoniae (30%) and (30%) E.coli isolates were most resistant to Cefotaxime and Doxicilin. Conclusion: Drug resistant bacteria have been identified from complete dentures and oral cavity in the present study. Antibiotic sensitivity tests, 16S rRNA sequencing and SEM are vital investigative tools to detect and to visualise drug resistant bacteria. Cell density, Extracellular Polymeric Substances (EPS) and capsule could be important factors for providing drug resistance.

Influence of Motivation on Academic Progression of Students: A Cross-sectional Study

Ahmad K Alnemare
Introduction: Motivation plays a vital role in learning and is a great enabler as it functions on multiple dimensions and paves way to conquer impediments in the path of success. An attempt has been made through this study to scrutinize the convictions related to motivation and the deployment of strategies in the learning process of students. Aim: To find the relation if any, between academic achievement and the motivation level with the students of College of Medicine, Majmaah University, Majmaah, Saudi Arabia. Materials and Methods: The cross-sectional study was carried out among pre-medical and medical students of Majmaah University. Academic Motivation Scale (AMS) questionnaire was distributed to 250 students who were selected based on simple random sampling. There were 233 students who participated in the study out of which there were 147 males and 86 females who completed the questionnaire. Motivation of student towards education was assessed in three domains, namely Intrinsic, Extrinsic and Amotivation. After ethical approval from institutional review board, questionnaire was distributed and results recorded in Statistical Package for the Social Sciences (SPSS) version 25. Qualitative variables were represented with frequencies and percentages and quantitative variables with mean and standard deviation. Student’s t-test and Analysis of Variance (ANOVA) were applied to compare the means. Results: Comparison of motivational scores between students in different years showed no significant difference in the mean scores across all dimensions of motivation except Extrinsic MotivationRegulation. The mean score of 2^nd year students was 16.63 and it increased over the years. The mean score at 6^th year was 22.03 and it decreased during internship with mean score of 20.58. Conclusion: The study of various stimulators which affect the learning experience of the student provides good insight on motivation and its influence on academic performances.

Effect of Isotretinoin on Thyroid Function Test in Acne Patients

Amruta Morey, Bhushan Madke, Adarshlata Singh
Introduction: With the rising popularity of Isotretinoin for acne vulgaris treatment, the interest in knowing the effect of oral Isotretinoin on endocrine function and the metabolic processes has increased considerably. Aim: To study the effect of Isotretinoin on serum thyroid hormone levels in acne patients and to study side effects of Isotretinoin, if any. Materials and Methods: In this interventional from September 2018-August 2019, using purposive method, 30 patients (Twenty males and Ten females) between age group 15-30 years-old having grade 3 (20 patients) and 4 (10 patients) acne vulgaris (according to standard system of grading) were enrolled and were started on oral capsule Isotretinoin 0.5 mg/kg/day for at least three months. A baseline thyroid profile which includes serum Triiodothyronine (T3), serum Thyroxine (T4) and Thyroid Stimulating Hormone (TSH) was performed on all subjects before and after three months of continued treatment. p-value <0.05 was considered as significant. Results: After three months of continuous oral Isotretinoin administration, it was observed that serum T3 and T4 values were raised while serum TSH was slightly reduced as compared to baseline values but the difference was not statistically significant. It was also observed that lip cheilitis was the most common side effect manifesting in 28 out of 30 patients. Conclusion: In the study, minor alteration in thyroid profile was observed but the difference was statistically not significant. Thus, it can be concluded that Isotretinoin can be safely given upto three months without any disturbance in thyroid function tests.

Analysis of WHONET Surveillance Data of Antimicrobial Sensitivity of Uropathogens in a Tertiary Care Hospital: An Indicator to Empirical Antimicrobial Treatment for Urinary Tract Infection

Vandana A Agarwal, Gopal Nandlal Agrawal, Bhavana Bazare, Sunanda Zodpey
Introduction: Urinary Tract Infections (UTIs) are among the most common bacterial infections. A regular surveillance of local aetiology and susceptibility profile could support the most effective empirical treatment. WHONET (World Health Organisation Network) is free software developed since 1989 by the WHO Collaborating Centre for Surveillance of Antimicrobial Resistance. Aim: Analysis of WHONET surveillance data was undertaken to know the aetiological profile of uropathogens and their antimicrobial susceptibility pattern to formulate an empirical treatment policy in a tertiary care hospital. Materials and Methods: The present study was retrospective and cross-sectional study. Uropathogens and their antimicrobial susceptibility from a tertiary care hospital during July 2018 to June 2019 were studied. For analysis, the software WHONET 5.6 version was used. An inclusion criterion was uropathogens with significant growth of one pathogen and only the first isolate of a given species encountered in case there were repeat samples from the same patient. Chi-square test was used to compare percentages and p-value <0.05 was considered as statistically significant. Results: Of the 1152 non-duplicate uropathogens, Enterobacteriaceae was the causative agent in 75% cases, E. coli accounting for more than two third of the cases. Gram positive cocci and Non-fermenters were isolated in 13% and 10% cases respectively. S. aureus, E. faecalis and Enterobacteriaceae showed high sensitivity to nitrofurantoin. Conclusion: For uropathogens, nitrofurantoin can be the drug of choice for empirical treatment of UTI. However, in serious hospitalised patients with UTI, additional parenteral administration of piperacillin-tazobactam may be considered.

Correlation of Maternal BMI with Foetal Liver Blood Flow and Neonatal Adiposity in Normal Pregnancies and Pregnancies Complicated by Gestational Diabetes Mellitus and Foetal Growth Restriction

Sumtira Bachani, Vatsla Dadhwal, Vanamail Perumal
Introduction: The foetus exhibits a wide array of structural and functional adaptations in response to intrauterine conditions, towards protection of vital organs and maintaining the supply of essential nutrients. When oxygen is limited, foetal adaptations prioritise brain growth, irrespective of whether other essential nutrients are limited or not. The hypothesis for this study was that fatty acid synthesis occurs in foetal liver therefore if adaptive changes occur in the hepatic and umbilical flow it will affect fat deposition which will manifest as neonatal adiposity. Aim: Correlation of maternal Basal Metabolic Index (BMI) with Foetal liver blood flow and neonatal adiposity in normal pregnancies and pregnancies complicated by Gestational Diabetes Mellitus (GDM) and Foetal Growth Restriction (FGR). Materials and Methods: An observational pilot study was carried out in a tertiary care referral hospital of Northern India. Antenatal women were recruited in three groups of singleton uncomplicated pregnancies (40), Women with GDM (31) and women with FGR (29). Maternal characteristics including prepregnancy BMI and obstetric ultrasound doppler study were recorded at 35 weeks gestation. The time-averaged maximum velocity (TAMX) was calculated for Umbilical Vein (UV) and Ductus Venosus (DV) as (Vmax) UV and (Vmax) DV. Blood flow (Q) was calculated as Q=h×(D/2)2 ×p×TAMX. The neonatal biometry and Skin Fold Thickness (SFT) was measured. Statistical techniques used were t-tests for analyses of dichotomous outcomes, Pearson’s correlation (r) and multivariate regression. Results: In mothers with higher DV shunting neonatal adiposity was significantly lower in the FGR group. In the uncomplicated group about 46% of variation in adiposity was explained by all the study variables and overall regression equation was statistically significant (p=0.004). Conclusion: Mothers with low BMI and normal umbilical and middle cerebral doppler flow had higher foetal hepatic flow to improve substrate deposition. DV shunting was significantly higher in hypoxic foetuses with reduced hepatic flow.

Impact of Nutritional Status and Vitamin D Levels in Children with Febrile Seizure from a Suburban Tertiary Hospital in Tamil Nadu, India
Introduction: Febrile seizure is one of the most common paediatric emergencies encountered in a paediatric practice. There have been studies done with regards to iron deficiency anaemia and family history and chances of a child developing febrile seizure. Many studies state that vitamin D has a role in development of brain and seizure activity. Aim: To find the association between Vitamin D levels and febrile seizures in children and assessing the nutritional status of children with febrile seizures. Materials and Methods: Fifty consecutive children (developmentally normal), between ages of 9-60 months, presenting with febrile seizures to the Paediatric Department, from February 2019 to January 2020, were enrolled. Antenatal history regarding birth order, maternal weight gain, antenatal check-ups, antenatal supplements and medical problems in mother if any, were noted. Birth history, birth weight, breast feeding, complimentary feeding and present diet history were noted. The height and weight were documented. Skin colour was noted based on Fitzpatrick scale. Vitamin D levels were classified as deficient if blood levels were <10 IU; insufficient if between 10-30 IU and sufficient, if the levels were >30 IU. Collected data were analysed and compared using Sigma Plot 13 and Chi-square test was done and a p-value <0.05 was considered as statistically significant. Results: Vitamin D insufficiency was prevalent in 68% of children. The dark skin, reduced time spent outdoors, clothing habits and diet and antenatal factors contribute to this vitamin D insufficiency. A 58% of children had Height for Age Z (HAZ) score less than -1SD and 62% of children had Weight for Age Z (WAZ) score less than -1SD. On correlating the Complete Blood Count (CBC) values with iron deficiency, it was found that 56% of children with febrile seizure had anaemia based on Red-cell Distribution Width (RDW) value >14.5. Febrile seizure was less common in summer (16%). Conclusion: A 68% of children had vitamin D insufficiency. A 56% of children had low iron based on RDW. The nutritional status of children was poor as assessed by HAZ and WAZ scores.

Prevalence of Clinical Artesunate Resistance among Cases of Complicated Malaria in Southern Odisha, India

Sindhusuta Das, Sanghamitra Padhi
Introduction: Drug resistant malaria represents the most challenging health problem worldwide. The major threat to malaria control is the increasing incidence of complicated and drug-resistant cases. Aim: To determine the prevalence of clinical artesunate resistance among complicated malaria cases by invivo method. Materials and Methods: The study included 241 patients with complicated malaria, which showed trophozoites of malarial parasite Plasmodium in the blood smear. They were administered with artesunate monotherapy. They were then followed-up for clinical response to therapy and quantification of parasitaemia levels on day 1, day 2, day 3, day 7, day 14 and day 28. Clinical examination included core body temperature recording, assessment of associated complications like vomiting, altered sensorium, anaemia, bleeding tendencies and investigation of renal parameters, liver function test and hypoglycaemia. Results: Out of 241 complicated malaria cases showing malarial parasite in peripheral blood smear, 204 cases were of Plasmodium falciparum, 32 cases were of Plasmodium vivax and five were cases of mixed Plasmodium falciparum and Plasmodium vivax infection. Among the 241 malaria positive cases, the most commonly associated complication was severe anaemia in 87 (36.1%) cases. All the 32 cases of Plasmodium vivax malaria and the five cases of mixed infection responded and recovered after administration of artesunate monotherapy. But among the 204 cases of Plasmodium falciparum, clinical artesunate resistance was detected in 6 (2.94%) cases and the rest 198 (97.06%) cases were sensitive to artesunate monotherapy. Conclusion:Clinical artesunate resistance was noticed in 2.94% cases of Plasmodium falciparum malaria. Hence, continuous monitoring of antimalarial therapy is required, especially in complicated cases of Plasmodium falciparum malaria, to prevent the emergence of artesunate resistance.

Factors Enhancing Drug-induced Hepatotoxicity among Thai Patients with TB

Santisith Khiewkhern, Jirarat Ruetrakul, Wisit Thongkum, Naree Areeruk
Introduction: Drug-Induced Hepatotoxicity (DIH) is usually found in patients with Tuberculosis (TB) who have received the standard anti-TB treatment due to the specific drugs in the standard regimen as well as other factors. Hepatotoxicity is the main cause of drug discontinuation and influences drug resistance and fulminant hepatitis in patients with TB. Aim: This study aims to assess the factors enhancing DIH in patients with TB who received the standard anti-TB regiment in Phichit Hospital, Thailand. Materials and Methods: A retrospective study was used to examine factors that enhanced DIH in 327 new patients with TB who received the standard anti-TB treatment at the TB-clinic in Phichit Hospital from October 1st, 2016 to September 30th, 2018. Data was collected from medical and laboratory records at the TB clinic. The univariate and multivariate logistic regression were used to assess factors enhancing DIH in patients with TB, reported using an Adjusted Odd Ratio (AOR) of 95% CI and a p-value of <0.05. Results: The results of this study confirmed that malnutrition was positively associated with increased risk of DIH development {AOR 4.40 (1.26 to 12.26), p=0.01}. In addition, an age of >60 years was associated with an increased risk of DIH development {AOR 2.87 (95% CI 1.16 to 7.14), p=0.02}. Conclusion: For TB patients, being over 60-year-old and malnutrition are significant factors related to DIH. Therefore, the new patients with TB should receive the screening for present chronic liver disease, including AST and ALT whenever feasible, and nutritional assessment should be done for elderly patients before start of anti-TB treatment.

Contemporary Concepts and Techniques of Teaching Posterior Palatal Seal among Dental Colleges of Karnataka: A Cross-sectional Survey
Introduction: Since literature provides various schools of thought to achieve Posterior Palatal Seal (PPS) in a maxillary denture, it becomes essential to know the techniques dominating in our curriculum presently. Aim: To determine the prevalence of concepts and also the need for standardisation in establishing PPS among dental colleges of Karnataka. Materials and Methods: A descriptive survey was conducted among teaching faculty of Department of Prosthodontics with varied teaching experience across the dental colleges of Karnataka. A pre-tested questionnaire containing ten close ended questions was distributed to 230 faculty members with MDS qualification in Prosthodontics via e-mail. The faculty responses were divided into three groups based on teaching experience: Group 1 (2-7 years), Group 2 (7-12 years) and Group 3 with more than 12 years of teaching experience. The Chi-Square Goodness of Fit test was used to compare the overall differences in the responses by the study participants; and Independent ChiSquare test to compare the differences in the responses based on teaching experience of the study participants. A value of p<0.05 was considered as statistically significant. Results: The most common method taught for locating vibrating line was Phonation-Nose Blowing-Fovea Palatini (46.0%). Twoline concept of vibrating line was taught (77%) more commonly, where the termination of maxillary denture is on posterior vibrating line (58%). Currently, Boucher’s conventional method without master cast scoring (63%) was the most favoured method to record the seal. This was true mainly with Group 1 (81.9%) and Group 2 (66.7%). In contrast, Group 3 faculty largely advocated Boucher’s conventional technique along with master cast scoring (70%). Overall most of the faculty members (66.5%) did not make the students score the postpalatal area. This was mainly seen in faculty belonging to Group 1 (81.9%) and Group 2 (69.7%). Bulk of Group 3 faculty (75%) taught scoring of the master cast. A large portion of the faculty (60.0%) recommended standardisation in the methods of teaching PPS which was mainly backed by Group 2 (77.3%) and Group 1 (61.7%). Conclusion: This survey indicates that among dental colleges of Karnataka, a majority of faculty of Prosthodontics prefer Boucher’s conventional method without master cast scoring (63%) to achieve maxillary PPS. Nevertheless, teaching concepts differed based on faculty experience. It is emphasised that teaching methods should be standardised and include unambiguous techniques.

Clinico-Aetiological Profile of Patients with Vertigo: A Cross-sectional Observational Study
Introduction: Nearly 5-10 percent of patients seen in general OPD, and between 10-20 percent of patients seen by ENT specialists and neurologists are those with complaints pertaining to vertigo and dis-equilibrium. The standard definition of vertigo states it to be an illusion of motion particularly rotatory sensation. Overlapping symptoms and terms such as dizziness, light headedness, giddiness and pre-syncope make it challenging to achieve a proper diagnosis. Aim: To study the clinical profile and revisit the various aetiological factors for vertigo in patients with actual sensation of rotatory motion seen in contemporary Otolaryngology practice. Materials and Methods: The present study was a cross-sectional observational study carried out over a period of 12 months in the Department of Otorhinolaryngology at a tertiary care centre. One-hundred and ten cases complaining of the sense of rotation of either head or their surroundings with at least a single episode in preceding one month were included. Comprehensive otological and vestibular evaluation was done. Each patient was subjected to thorough clinical vestibular and laboratory tests. Subjects with known cervical spine disease, neurological disorders and cardiac ailments were excluded. Statistical analysis was done and Chi-square test was applied. Results: The mean age of patients in the study was 49.75 years with a male to female ratio of 1:1. Majority of the patients (90%) presented with acute onset of vertigo. The total duration of symptoms most commonly observed ranged between one week to one month. Nearly, all patients had intermittent character of vertigo. The duration of each episode in most of the patients ranged between 1 minute to 10 minutes. Maximum patients (90.9%) were observed with intensity of vertigo as mild and moderate type (Level II and III SVVSLCRE). Positional variation was observed in 64.5% of the patients. The most common aetiological diagnosis deduced from the study was benign paroxysmal positional vertigo (30.4%) followed by orthostatic hypotension (17.9%) and Meniere’s disease (13.4%). Conclusion: The most common aetiological factor of vertigo was found to be benign paroxysmal positional vertigo, which can be effectively treated by performing Epley’s maneuver. Orthostatic hypotension has been observed as an important cause liable to be missed by otologists. The management of vertigo must be directed by a meticulous work up of aetiologies and should not be treated under a blanket regimen.

Gestational Diabetes Mellitus and its Relation to Pre-pregnancy Body Mass Index

Veena Thamban, Kavana G Venkatappa
Introduction: Obesity mediates a systemic inflammatory response in our body which includes insulin resistance and glucose dysregulation. Increased Body Mass Index (BMI) associated with Gestational Diabetes Mellitus (GDM) leads to a state of insulin resistance additive to insulin resistance of GDM. Aim: To assess the relationship between GDM and prepregnancy BMI. Materials and Methods: This case-control study enrolled 64 women with GDM and 64 without GDM, attending antenatal care clinic at a Tertiary Care Hospital, after obtaining their informed consent. Obstetric history, pre-pregnancy BMI and Oral Glucose Tolerance Test (OGTT) values were noted. Diabetes in Pregnancy Study Group in India (DIPSI) criterion was used for diagnosing GDM. The BMI was categorised according to World Health Organisation (WHO) criterion. Data obtained was statistically analysed. Results: Out of 44, 41 (93.2%) women with GDM had prepregnancy BMI ≥25 kg/m² (overweight and obese) compared to 3 (6.8%) in controls (χ² value=50.01, p≤0.001). Mean±SD of pre-pregnancy BMI in women with GDM was significantly higher (26.38±2.74 kg/m² ) compared to controls i.e., 22.26±1.54 kg/m² (unpaired t-test: p≤0.001). Conclusion: GDM was found to be significantly associated with pre-pregnancy BMI. Appropriate interventions and risk factor modifications are recommended to prevent GDM and its complications.

Prevalence of Injuries in National Level Kabaddi Players in India- A Cross-sectional Survey

Sajjan Pal, Saurabh Kumar, Ankush Sharma, Shalu Thariwal
Introduction: Kabaddi is a contact sport and national game of India and is widely played in all regions of India. In the recent past decade, it has been grown in popularity at the national level or the international level also. It is a highly strategic game that involves rapid forceful movements of the body, thus, injuries are inevitable in this field. Aim: To record the prevalence of injuries in the past and present, in terms of various body parts and to record awareness and access of physiotherapy in Indian Kabaddi players. Materials and Methods: A cross-sectional survey of 80 professional national-level male Kabaddi players (mean age=21.65) presenting with various sports-related injuries were identified in the 1^st All India Inter-University Kabaddi Tournament (2014-2015) held in Punjabi University, Patiala. Samples were selected by a convenient random sampling technique and scheduled questionnaire was the tool for data collection with three domains: demographic features, the present and past injuries, awareness and access of physiotherapy. Data was analysed using Microsoft excel and SPSS 20. Results: It was found that out of 80 players, the prevalence of present injury was 42.5% (N=34) and 62.5% (N=50) of injury was recorded in the past 2 years. In the upper limb, the most common injured location was shoulder (21.25%) followed by the arm (5%). In the lower limb, knee (21.25%) was the most commonly injured site followed by the ankle (13.75%) while lower back (14.25%) constituted most of the injuries in the trunk. It was found that only 53.75% (N=41) of players had awareness about physiotherapy and 23 (67.65%) players out of 34 players have chosen physiotherapy as treatment at the time of data collection. Conclusion: As kabaddi is a highly combative sport in nature, so athletes are more prone to get injured. More epidemiology studies are needed in Indian context to known the biomechanics of injuries.

Subclinical Atherosclerosis and Atherogenic Index of Plasma in Lichen Planus PatientsA Comparative Cross-sectional Study

A Ramesh, P Deepavarshini
Introduction: Lichen Planus (LP) is an idiopathic and chronic inflammatory disease that affects the skin and the mucous membranes, and studies have proven its association with increased risk for Cardiovascular (CV) diseases. Subclinical atherosclerosis and Atherogenic Index of Plasma (AIP) are strong predictors of CV risk. Aim: The primary aim of this study was the evaluation of Common Carotid artery mean Intima-Media wall Thickness (CIMT) and AIP which are predictors of CV risk in patients with LP. Materials and Methods: Fifty patients with LP and fifty age, gender and Body Mass Index (BMI) matched healthy controls (from the general population without the disease) were included in the study. CIMT was measured using ultrasound. Lipid profile was calculated by biochemical analysis. AIP was calculated from lipid profile using validated formula. Data was analysed using SPSS version 16.0 software. Results: Compared to healthy controls, patients had significantly higher CIMT. A 28% of patients had subclinical atherosclerosis compared to 2% of controls (p<0.001). Dyslipidemia was detected in 42% of patients and only 10% of controls (p<0.001). AIP was significantly elevated in LP patients compared to controls (p<0.001). A 36% of patients had high CV risk according to AIP versus 8% of controls. The 80% of controls had low CV risk versus 48% of patients (p<0.001). Conclusion: LP patients were found to have increased CV risk. CIMT, lipid profile and AIP can serve as important diagnostic markers of CV risk. Educating the patients about such a risk will enable them to follow lifestyle modifications so as to prevent further complications and morbidity

Impact of Anticoagulation Clinic Intervention on Patient Centred Outcomes in a Tertiary Care Hospital
Introduction: Vitamin K Antagonists (VKAs) have been in use for more than 50 years. They have remained as mainstay therapy in the prevention of thromboembolic events in atrial fibrillation, mechanical heart valves and venous thromboembolism. Despite many years of clinical experience with VKAs, the quality of anticoagulation achieved in routine clinical practice is suboptimal. Aim: To study the effects of structured Anticoagulation Clinic (ACC) interventions on patient centred outcomes in subjects taking VKAs. Materials and Methods: A retrospective study was conducted among patients taking VKAs enrolled in ACC. A total of 169 patients receiving VKAs for at least six months with 4 INR (International Normalised Ratio) values and completed 12 months of follow-up were analysed. Anticoagulation related quality measures like Time in the Therapeutic Range (TTR), Percentage of International Normalised Ratios in the therapeutic Range (PINRR) and clinical outcomes like stroke, systemic embolic events and bleeding was analysed at the time of enrolment and compared with those during ACC care. Results: Among 352 patients enrolled in ACC, 169 patients were eligible for analysis. The mean age of the study population was 55.62±13.77 years. Atrial fibrillation (59%) was the most common indication for VKA therapy. Hypertension (66.3%) was the most common co-morbidity. Mean TTRs were significantly higher in the ACC care when compared with the pre-ACC care at 12 months follow-up (77.58±8.85% vs 51.01±16.7%, p<0.0001). There was a significant improvement in TTRs as early as three months of ACC intervention (73.18±13.56%). At the time of enrolment, 21.9% of patients had individual TTRs (i-TTR) >70% which increased to 70.4% at 12 months of follow-up. INR testing was done more frequently in ACC care. Adverse clinical events were higher in pre-ACC care than ACC care (4.7% vs 2.4%, p>0.05). Major bleeding and thromboembolic events were higher in pre-ACC care than ACC care (1.8% vs. 0.6% and 2.4% vs. 0.6% respectively). Conclusion: ACC services helps in achieving better quality of anticoagulation control as measured by time in therapeutic range translating into better clinical outcomes.

Single Dose Prophylactic Antibiotic in Caesarean Delivery and its Effect on Maternal Infectious Morbidity: A Prospective Observational Study
Introduction: Caesarean delivery is the most common surgery performed in obstetrics. Antibiotics have revolutionised the surgical practise in this era. But multidrug resistance is a challenging issue in day to day practise. So, antibiotics have to be administered judiciously at the appropriate time with respect to surgery. Aim: To determine whether the administration of single dose injection ceftriaxone 1 gm intravenously prior to skin incision was superior to administration at the time of cord clamping for prevention of post-caesarean maternal infection. Materials and Methods: A prospective observational study was conducted in BLDE (DU) Shri BM Patil Medical College and Research Centre, Vijayapura, Karnataka, India. Patients undergoing caesarean sections for singleton term pregnancies both elective and emergency with intact membranes were included in study during one-year period. Alternatively, group A received 1 gm injection ceftriaxone intravenously 60 minutes before skin incision and group B received at the time of cord clamping during surgery. Chi-square (?2 ) test was used for association between two categorical variables. Results: Incidence of obstetric complications such as nausea (0.5% vs 0.0%) and wound infections (6.6% vs 4.1%) were more in patients who received a single dose of ceftriaxone at cord clamping than patients receiving the same antibiotic, preoperatively whereas, incidence of postoperative fever was more in group A (4.1%) than group B (3.3%) which was although not significant but is an important finding in this study. Conclusion: Administration of single dose antibiotic either preoperatively or at the time of cord clamping was not statistically significant in reducing the incidence of wound infections.

Comparative Evaluation of Three Skin Closure Materials- A Microbiological Pilot Study

Kalpa Pandya, S Pradeep, Rajendra B Prasad, SM Sharma, Veena Shetty
Introduction: The goal of a skin closure technique is to precisely approximate the wound edges without tension for sufficient time, to allow healing to take place. The presence of a suture in surgical wounds has been found to increase the tissue’s susceptibility to infection. Increased microbial colonisation in a particular area results in higher risk of infection. There are limited studies investigating the presence and the type of microbial colonisation with respect to different skin closure techniques, especially metal staples. Aim: To compare and analyse microbial colonisation and wound complications in association with the use of surgical staples, nylon and polypropylene suture material; and to compare and analyse the incidence of wound complications in association with these three materials. Materials and Methods: A cross-sectional study was conducted on 60 patients, of which 20 underwent closure by prolene, 20 by nylon and 20 by metal staples. The prolene sutures, nylon sutures and staples were removed on 8th to 14th day postoperatively. The removed suture fragments and the staples were inoculated aerobically in suitable culture media according to the standard methodology to look for microbial growth. The results were derived using repeated measures ANOVA and Chisquare test. Results: A total of 70% of the patients from prolene group were found to have bacterial growth on microbial colonisation, whereas 30% did not show any growth. In the nylon group, 50% of the patients demonstrated bacterial growth whereas the rest of the 50% showed no growth. In the staples group 95% of the patients did not show any bacterial growth on culture media and only 5% showed positive bacterial growth. All of these differences were highly statistically significant (p<0.001). The most common colonising bacteria was Staphylococcus aureus followed by Klebsiella spp followed by Pseudomonas aeruginosa. Conclusion: The findings of this study suggested that prolene was most prone to bacterial colonisation followed by nylon and staples. The most common micro-organisms found were Staphylococcus aureus, Pseudomonas aeruginosa and Klebsiella spp.

Diagnostic Yield of Medical Thoracoscopy in Undiagnosed Exudative Pleural Effusion- A Tertiary Centre Experience from Aligarh Muslim University, Uttar Pradesh, India
Introduction: Pleural effusions are one of the most common entities encountered by pulmonologists worldwide which have a very long list of causes. Initial workup of these patients begins with a chest X-ray and percutaneous or Ultrasound (USG) guided thoracocentesis followed by biochemical and cytological evaluation of the fluid to ascertain the cause of effusion. A 20 to 25% of cases remain undiagnosed even after thoracocentesis and closed pleural biopsy. Medical Thoracoscopy is emerging as a safe diagnostic procedure in these patients. Aim: To detect the diagnostic yield of medical thoracoscopy in cases of undiagnosed exudative lymphocytic pleural effusion and to study the complications associated with it. Materials and Methods: This was a prospective observational study, carried out in the Department of Pulmonary Medicine, JN Medical College and hospital, Aligarh Muslim University (AMU), Aligarh, Uttar Pradesh, India, from August 2016 to August 2018. Undiagnosed exudative pleural effusion was defined as pleural effusion with Adenosine Deaminase (ADA) levels less than 70 IU/L and negative pleural fluid cytology for malignancy. Thoracoscopic examination of the pleural space using flexi-rigid thoracoscopy was done and biopsy was taken from suspected areas and the tissue obtained, was send for histopathological examination. The results were presented as mean±SD (Standard Deviation) or percentage. Differences in categorical data were compared using the chi-square test or the Fisher-exact test. A p-value of <0.05 was considered statistically significant. Results: Fifty patients underwent thoracoscopy for undiagnosed pleural effusion. Most common gross thoracoscopy finding was nodules which was seen in 23 patients. Malignancy was the most common histopathological finding, seen in 22 patients. Minor complications were seen in five patients. A final diagnosis could be made in 41 patients; the diagnostic yield was 82%. Conclusion: Medical thoracoscopy should be performed in all patients in which radiological and pleural fluid examinations could not lead to a definitive diagnosis as it has high sensitivity and a very low rate of complications.

Efficacy of Different Reagents to Prepare Transparent Tooth Model for Three Dimensional View of the Root Canal System- An Invitro Study

Monika Tomar, Nitin Mirdha, Bobbin Gill, Manish Sundesha, Swarneet Kakpure
Introduction: There are certain common as well as atypical characteristics in the root canal anatomy of each tooth. Simultaneous understanding of both can be the key to successful endodontics. Various methods have been used till date for visualisation of root canal morphology with variable success rates like magnification, radiography, CBCT, digital imaging and clearing. Clearing technique provides a three-dimensional view of the root canal anatomy from outsidewhile maintaining the original form and relationship of canals as minimal instrumentation is required in the procedure. It is a simple and inexpensive technique which involves decalcification of tooth structure, dehydration in alcohol and clearing by immersing in clearing agents. Aim: This study aimed to evaluate the efficacy of two decalcifying agents (nitric acid and trichloroacetic acid) and two clearing agents (methyl salicylate and eugenol) in the preparation of transparent tooth model for viewing the root canal system. Materials and Methods: The in-vitro research study from August 2, 2019 to August 27, 2019 included 40 freshly extracted teeth (18 maxillary and 22 mandibular) which were randomly divided in two groups (n=20); group A (decalcification done in 5% nitric acid) and group B (decalcification done in 10% trichloroacetic acid). Then, the teeth were dehydrated in isopropyl alcohol. Each group was subdivided in two subgroups depending on the clearing agent used (methyl salicylate or eugenol). Afterwards they were graded for transparency and haziness criteria, and data analysis was done using chi-square test, value of significance at p<0.05. Results: The results showed that nitric acid took lesser time for decalcification than trichloroacetic acid. The subgroup 1 (NA/ MS) showed better transparency level in 90% of the samples when compared with other subgroups; however the results were not significant with p-value 0.121. Haziness was present in all samples. The subgroup 4 (TCA/E) showed 100% haziness which was statistically significant among all the subgroups with p-value 0.002. Methyl salicylate showed better transparency, less haziness and good root canal morphology when compared with eugenol. Conclusion: Nitric acid when used in combination with methyl salicylate prepared the best transparent tooth model. Trichloroacetic acid showed average transparency and haziness was present in almost all the samples irrespective of the clearing agents used.

Serum Magnesium Levels among Pregnant Women with and without Complications: A Cross-sectional Study

Santhini Gopalakrishnan Sethulekshmi, S Sumathy, Banani Dutta
Introduction: Pregnancy is a period that is characterised by remarkable physiological changes which are needed to support the growing fetus. Micronutrients play a crucial role in the maintenance of pregnancy. Among the micronutrients, magnesium has got ample amount of clinical relevance to pregnancy. Magnesium deficiency has been associated with reproductive risk during pregnancy such as anaemia, preeclampsia, eclampsia, fetal growth retardation, preterm labour, low intrauterine growth rate and leg cramps. Aim: To find out whether there was significant difference in the magnesium levels among pregnant women with and without pregnancy related complications and also to find out whether the magnesium levels differed significantly among the three trimesters. Materials and Methods: This was a cross-sectional study done among 240 pregnant patients from different trimesters attending the Obstetrics and Gynaecology Outpatient Department. Out of them 164 women had complications like pre-eclampsia, Gestational Diabetes Mellitus, leg cramps and history of abortions. Demographic details were obtained from all the women. BMI was calculated for each subject using the formula BMI=weight(kg)/height(m2 ). Haemoglobin was assessed in all samples using cyanmethaemoglobin method. Magnesium levels were analysed in the all samples using automated analyser in the Biochemistry laboratory. Student’s t-test was used to compare the levels of magnesium among the groups with and without complications. ANOVA test was used to compare the three trimesters. Results: The pregnant women were divided into three groups based on the different trimesters in which the samples were taken. Magnesium levels among the women in the first trimester were (2.96±0.83) second trimester (2.99±1.48) and third trimester (3.05±1.48) respectively. Women with previous abortions were found to have less magnesium levels (2.71) compared to women without a history of abortion (3.11) and value was found to be statistically significant (p<0.007) and magnesium levels among vegetarians (2.45) were lower than non vegetarians (3.08) and it was found to be statistical significant (p<0.013). There was no significant difference in the magnesium levels among pregnant women with complications and those without complications. Conclusion: The study shows the importance of maintaining the magnesium levels among pregnant women. There was no difference in the magnesium levels among the three trimesters. Study also points out the influence of parity, diet and occupation of pregnant women on the levels of magnesium.

Comparative Analysis of Alzheimer Questionnaire and Montreal Cognitive Assessment Tool for Cognitive Impairment Screening among the Elderly Population
Introduction: Alzheimer Questionnaire (AQ) and Montreal Cognitive Assessment (MoCA) are tools for assessment of cognitive impairment. MoCA is a common tool for screening of cognitive impairment but it requires trained personnel. AQ questionnaire is informant-based, simple and less time consuming with or without the involvement of trained personnel. Aim: To estimate the prevalence of cognitive impairment and to find out the accuracy of AQ compared to MoCA in Cognitive Impairment screening among elderly population in an urban area of West Bengal. Materials and Methods: The Prospective cross-sectional study was conducted in urban field practice area of All India Institute of Hygiene and Public Health, Kolkata among 140 randomly selected elderly population from June to September 2019. Accuracy of AQ with MoCA tool as gold standard in screening cognitive impairment was analysed by Cohen’s Kappa, Receiver Operating Characteristics (ROC) Curve, Spearman rho Coefficient along with sensitivity, specificity, predictive values and likelihood ratio was obtained. Results: Prevalence of cognitive impairment using MoCA and AQ was 40% (95% CI=31.8-48.6) and 36.4% (95% CI=28.5- 45.0), respectively. AQ and MoCA showed good agreement (Cohen’s kappa, ?=0.834; 95% CI=0.739-0.928). The AQ and MoCA showed a strong negative correlation (spearman’s Rho=-0.709; 95%CI=0.764-0.884, p-value <0.001). Considering MoCA as gold standard, AQ showed sensitivity of 85.7% (95% CI=74.2-92.6), specificity of 96.4% (95% CI=89.9-98.7) for cognitive impairment screening and the Positive predictive value of this tool was 94.1% (95% CI=84.0-97.9%). The Youden index of 0.821 showed highest sum of sensitivity and specificity of AQ tool at 4.5 score to anticipate cognitive impairment. Conclusion: AQ is equally effective as MoCA to screen cognitive impairment among elderly at the community level. AQ can be used even by grass root level health workers without involvement of trained personnel. So, community level screening of elderly for cognitive dysfunction can be made even in resource poor settings. Early identification and referral of elderly with cognitive dysfunction will help them in better living.

Is there a Relationship between Combined Oral Contraceptive Use and Intrauterine Device Use with Abnormal Smear Results and Cervical Atypia?

Selçuk Kaplan
Introduction: The relationship between the use of contraceptive method and the presence of Human Papilloma Virus (HPV) persistent infection and precancerous cervical lesions has not been fully established. Aim: To investigate the frequency of cervical atypia and risk factors affecting it in women using Combined Oral Contraceptive (COC) and Copper-Intrauterine Device Use (Cu-IUD). Materials and Methods: A retrospective study was conducted in a tertiary centre between 2017 to 2019, involving 835 patients using Cu-IUD and 538 patients using COC. Age, obstetric data, high-risk HPV type positivity, education level, location, occupation, Body Mass Index (BMI), smoking, cervical cytology results and colposcopic biopsy results were noted for each group. Statistical Package for the Social Sciences (SPSS) version 22.0 program was used to analyse the data. Pearson chi-square test and multivariate binary logistic regression test were performed. Model compatibility was good in binary logistics test (omnibus test p<0.001). The p<0.05 value was considered statistically significant. Results: The frequency of Cervical Intraepithelial Neoplasia l (CIN l) lesions increased in women using Cu-IUD (p=0.038), while the frequency of CIN II+ lesions increased in COC users. The use of COC increased the risk of CIN II+ (p=0.014). High-risk HPV type positivity was common in those using COC (p<0.05). In addition, age group 40-51 years, education level being primary, being multiparous, urban location, high risk HPV positivity were other risk factors for the presence of cervical atypia (p<0.05). Conclusion:The risk of CIN I increased in those using Cu-IUD, while the risk of CIN II+ increased in those using COC.

Identification of a Rothia mucilaginosa Strain in a Clinical Specimen Based on PCR-Sequencing with Mycobacterium hsp65 Primers

Kai Ling Chin, Maria E Sarmiento, Zainal Arifin Mustapha, Armando Acosta
Introduction: Tuberculosis (TB) is one of the top 10 causes of death worldwide. Xpert Mycobacterium tuberculosis (MTB)/Rifampicin (RIF) has been recommended by World Health Organisation (WHO) to diagnose TB, while hsp65-Polymerase Chain Reaction (PCR) has been used for mycobacteria identification. Aim: To report a false positive result (Rothia mucilaginosa) using hsp65-PCR for detection of mycobacteria in a clinical specimen. Materials and Methods: A sputum sample from a 58-year-old, male, suspected-TB patient was studied by Xpert MTB/RIF and hsp65-PCR. The amplified hsp65-PCR product was sequenced and analysed using bioinformatics for bacterial identification and primer specificity. Results: Xpert MTB/RIF showed a negative result, while hsp65-PCR was positive, suggested the presence of Pulmonary Non-Tuberculous Mycobacterial (PNTM) Infection. The analysis of the sequencing result of the amplified hsp65-PCR fragment showed 98% similarity to Rothia mucilaginosa, a member of the normal flora of the human oropharynx and upper respiratory tract, which may cause pneumonia. Further analysis showed that the mycobacteria hsp65 primers used have high percentage of similarity with Rothia mucilaginosa gene sequence, resulting in non-specific detection. Conclusion: This study showed the possibility of false positive results in clinical specimens using PCR-hsp65 primers considered specific for mycobacteria, therefore, this test should be used in clinical samples with caution and it is suggested the need of its further re-optimisation.

Introduction of Mini-clinical Evaluation Exercise for the Formative Assessment of Postgraduates in the General Surgery Discipline

Kailash Charokar, Anil Kapoor
Introduction: The common practice prevalent in most of the Postgraduate (PG) teaching institutes is that while the PGs are clinically evaluating the patients for the traditional long case, they are mostly not directly observed by the faculty. The presentation of the case by PGs is the main focus of assessment. Workplace Based Assessment (WPBA) tools assess the clinical competence of students at the ‘does’ level of Miller’s pyramid, while they perform in a real setting. Aim: To assess the feasibility, acceptability and effectiveness of Mini-Clinical Evaluation Exercises (Mini-CEX) for the PGs in Surgery. Materials and Methods: This educational intervention study was conducted in the General Surgery Department, over a period of one year. Sixteen PGs of 1st, 2nd, and 3rd-year residency participated in the study, and 13 faculty as assessors. The MiniCEX was conducted and the abim.org proforma was used to record the observations by the faculty. The perceptions of the PGs and faculty were obtained at the end of the study using a predesigned validated feedback questionnaire. The change in the level of acquisition of clinical skills of the PGs was evaluated using the group mean, median and rank. The Friedman test was applied to calculate the statistical significance at p<0.05 using Statistical Package for the Social Sciences (SPSS) version 20. Results: A total of 124 Mini-CEX encounters were conducted over a period of one year. The mean satisfaction score for the Mini-CEX encounters was 7.3±0.88 and 6±0.89 on the global rating (0-9) among the PGs and faculty respectively. While 14 PGs (87.5%) accepted that Mini-CEX was easy to conduct as compared to the traditional long case. Ten faculty (76.5%) accepted that it was feasible to conduct with the prevailing professional workload. Twelve PGs perceived that Mini-CEX was an effective tool for improving clinical skills. Statistically significant (p-value <0.05) improvement was found in the competencies of medical interviewing, physical examination, counseling skills, and professionalism. Conclusion: Mini-CEX was acceptable to the PGs and faculty. It was found to be an effective and formative assessment tool for learning clinical skills in a supportive workplace-based environment for clinical skills improvements.

Role of Different Volumes and Dilutions of Intraperitoneal Lignocaine Instillation on Postoperative Morbidity Following Laparoscopic Cholecystectomy

Varun Kumar Singh, Sofia Batool, Babita Chettri, Kumar Nishant, Wali Ahmad
Introduction: Even though Laparoscopic Cholecystectomy (LC) is far less traumatic compared to open cholecystectomy, it is still associated with considerable postoperative pain. Apart from routine analgesics, several attempts have been made to establish intraperitoneal analgesia as a useful perioperative pain relief modality. Aim: To determine the optimal concentration (or dilution) and volume of intraperitoneal lignocaine among three preparations of 100 mg lignocaine for postoperative analgesia after LC. Materials and Methods:Study was designed as a randomised controlled, double blinded study. Patients undergoing elective LC for symptomatic cholelithiasis were included in the study. Patients (n=105) were randomised into three groups. Group A received 5 mL 2% lignocaine in 5 mL normal saline (100 mg/10 mL=10 mL solution of 1% lignocaine). Group B received 5 mL 2% lignocaine in 100 mL of normal saline (100 mg/100 mL=100 mL solution of 0.1% lignocaine). Group C received 5 mL 2% lignocaine in 500 mL normal saline (100 mg/500 mL=500 mL solution of 0.02% lignocaine). Three groups were compared for postoperative pain using Visual Analog Score (VAS), requirement of rescue analgesia, nausea and vomiting, vital parameters (heart rate, respiratory rate, mean arterial pressure, transcutaneous saturation) and hospital stay. Analysis of Variance (ANOVA) was used to compare mean and χ² test was used to compare categorical data. Results: The mean VAS of group B (100 mg lignocaine in 100 mL of normal saline) was significantly lower than the overall mean VAS at different postoperative time intervals, and consistently lower than those of groups A and C. The study found a consistent (r=0.15 to 0.33) and significant (p<0.05 at alltime intervals) positive correlation between pain and duration of surgery. Demand for rescue analgesia was significantly higher in group A. Pulse rate was least in all postoperative time and significantly lower at 4th hour. The difference in mean arterial pressures, respiratory rate and transcutaneous saturation among the three groups was not significant statistically. Nausea and vomiting were uncommon. Conclusion: The study concluded that for a total dose of 100 mg lignocaine, 100 mL solution is more effective compared to 10 mL or 500 mL solution.

Efficacy and Safety of Rituximab in Immunobullous Diseases: A Retrospective Study from a Tertiary Care Centre of Nepal

Sudip Parajuli, Jyoti Vidhan, Dinesh Binod Pokhrel, Upama Paudel
Introduction: Rituximab is effective and safe treatment of immunobullous disorders. There are variations in doses of drugs used in different studies and uncertainties on when to use it along with use of adjuvant therapies. Efficacy and safety of this drug has not been described in Nepalese population till date. Dermatologists have hesitation in starting this drug in immunobullous diseases because of lack of data on efficacy and safety. Aim: To assess the efficacy and side effects of Rituximab therapy in treating immunobullous disorders in Nepalese patients. Materials and Methods: This was a retrospective study of patients with immunobullous diseases treated with Rituximab in Dermatological ward of Tribhuvan University Teaching Hospital, Kathmandu, Nepal from May 2018 to August 2019. Data were analysed for duration of disease and treatment received before Rituximab therapy, duration of steroid used before Rituximab, adverse effects due to prolonged steroid use, time to remission from 1st Rituximab pulse, duration of remission, relapse, duration of steroid and adjuvant drug used post 1st pulse and adverse effects associated with Rituximab. SPSS version 20 was used for data entry and descriptive statistics was used for analysis of the data. Results: Nine patients (Pemphigus Vulgaris-8 (PV-8), Bullous Pemphigoid-1 (BP-1) were treated with Rituximab. Seven were treated for refractory disease not controlled by conventional therapy and two received Rituximab as first-line therapy. The patients were under follow-up for 15-60 weeks (mean 31.89±15.62 weeks). Out of these nine patients, eight were free of lesions in one to eight weeks (mean 5.125±2 weeks) of first pulse. One patient with Oral Pemphigus had persistence of old lesions, however there were no new cutaneous lesions after first pulse. Adverse effects were seen in four patients that included infusion reaction in one and infection in three. There was relapse in one patient at last follow-up. Conclusion: Rituximab is efficacious and is safe in treating immunobullous disorders in Nepalese Population..

Self-gratification Habits among Children Under Five Years of Age: A Prospective Cohort Study
Introduction: Self-gratification or masturbation is a normal sexual behaviour; however, masturbation in childhood is less commonly addressed in literature. Aim: To describe the clinical profile of the children diagnosed with self-gratification condition. Materials and Methods: This prospective cohort study recruited all cases diagnosed to have the self-gratification condition presenting to the outpatient clinic in the Department of Paediatric Medicine, Burdwan Medical College, Burdwan, West Bengal, India during the period- January 2014 to December 2019. Diagnosis was made from history, home videotapes and sometimes by direct observation of the act during hospital stay. All relevant data pertaining to demographic characteristics, clinical presentation, investigations and treatment were collected in case sheets and were analysed by simple descriptive statistics. Results: Fifty-four patients were diagnosed to have the condition. Among them, 29 (53.70%) were girls and 25 (46.30%) were boys. The mean age at first symptoms was 20.98±9.31 months (range 3 months to 3 years 4 months). The average age at diagnosis was 26.16±11.35 months (varied from 4 months to 3 years 11 months). The mean frequency of events was 10.31±5.10 times per week, and the mean duration was 9.83±5.98 minutes. Events occurred mostly when children were left alone and bored (n=34, 62.97%). Usual presentations were: rocking in prone position (n=24, 44.44%), intermittent dystonic posturing of the crossed legs (n=23, 42.59%), direct genital manipulation (n=3, 5.56%) and others (n=4, 7.40%)). Two children had been previously misdiagnosed as having definite epilepsy. In 51 cases (94.44%) home videos were available which served as invaluable tools allowing confident diagnosis. Results of urine and stool examination were normal. MRI and EEG performed on two children with suspected epilepsy were reported normal, and antiepileptic drugs were stopped in both. Sixteen children (29.63%) were sent for behavioural therapy and all of them responded well in next one year. Conclusion: Gratification habits are not uncommon in children and should be considered in the differential diagnosis of epilepsy and other paroxysmal events in early childhood. Home video recording of these actions can be a very influential mean to help in diagnosis and to avoid needless investigations and treatments.

Cross-cultural Adaptation and Validation of Professional Scale in Iranian Nurses
Introduction: Professionalism is a fundamental concept in nursing. Today’s society needs nurses who are able to accept and fulfill their professional roles. Specially, nurses of the Intensive Care Unit (ICU) are one of the most sensitive parts of the hospital and their behaviour is very important. In order to measure their caring professionalism and the leveling of this process, there are instruments used in Iranian culture. Aim: This study was aimed to cross-culturally adapt and validate the Hall’s Professionalism Scale (HPS) in clinical setting for Iranian nurses of ICU. Materials and Methods: Methodological study was carried out with 300 nurses of ICU in Iran. The criteria for selection of the participants was limited to the nurses who worked full time in ICU of the mentioned hospitals, were available and interested to respond to data collection instrument. The cross-cultural adaptation of the Professionalism Scale was performed according to international standards, and its validation was carried out to be used in the Iran context by means of factor analysis and Cronbach’s alpha as a measure of internal consistency. Results: All nurses who participated in the study worked in ICU with average working experience of 6.77±5.99 years and their mean age was 34.03±10.3 years. The results of the factor analysis revealed six factors including factor 1 (the scope of the Professional Association as reference) with a specific amount of 14.04, factor 2 (believing in the continuing competency) with a specific amount of 14.42, factor 3 (believing in self-regulation) 16.06, factor 4 (sense of commitment to the profession) has a special amount of 11.56, factor 5 (independence) with a special amount of 16.81, and factor 6 (believing in serving society) with a specific amount of 14.02. The correlation coefficient of Cronbach’s alpha was used to determine the internal correlation of the instrument, which was 0.89 for all items. Conclusion: This study showed that the translated version of the “Nursing Professionalism Scale” is a useful instrument for helping nurses and nursing authorities to understand the concept of professionalism and its impact on improving the clinical status of nurses, patients and organisations, and even clinical education of nursing students.

Comparison of Morphine and Clonidine as Adjuncts to Bupivacaine in Spinal Anaesthesia- A Double Blind Randomised Control Trial
Introduction: Spinal anaesthesia is a preferred choice for infraumbilical surgery. Various drugs have been added intrathecally to augment analgesia in the postoperative period. Morphine an opiate was among the first to be introduced. More recently the alpha-2 agonist Clonidine. Aim: To compare Clonidine and Morphine as adjuncts to bupivacaine in spinal anaesthesia on the quality of the block, the duration of postoperative analgesia, haemodynamic changes and complication. Materials and Methods: In this randomised double blind controlled study, one hundred patients between age 20-40 years of age and American Society of Anaesthesiologists (ASA) physical status 1 and 2 undergoing lower limb Orthopaedic procedures were studied to compare the effect of preservative free morphine (100 mcg) (Group BM) and clonidine (30 mcg) (Group BC) as an adjunct to 0.5% bupivacaine in spinal anaesthesia. Group BM received a mixture of 2.6 mL (13 mg) of hyperbaric bupivacaine (0.5%) with 0.1 mL of preservative free Morphine and 0.1 mL 0.9% saline. Group BC received a mixture of 2.6 mL (13 mg) of hyperbaric bupivacaine (0.5%) with 0.2 mL of clonidine (30 mcg). Total volume of solution in both the groups was 2.8 mL. The groups were compared for the onset and duration of sensory and motor blockade. Duration of analgesia, Sedation, Haemodynamic variations viz., Pulse rate, blood pressure and complications. Data obtained was analysed using Student t-test, Pearson chi-square test and ANOVA as appropriate. Results: Onset of sensory block was faster and duration of the sensory as well as motor block was more after addition of Clonidine (30 µg) to bupivacaine in spinal anaesthesia. The duration of postoperative analgesia was significantly prolonged to 10-13 hours in patients receiving Bupivacaine and morphine combination as compared to 6-8 hours noted in patients receiving Bupivacaine and Clonidine only. Incidence of hypotension, bradycardia, shivering, nausea and vomiting was not statistically significant. None of the patients in both groups showed any other side effects like respiratory depression, hypoxia, excessive sedation or any other spinal consequences. Conclusion: Clonidine improves the quality of spinal anaesthesia in terms of faster onset of sensory block and longer duration of sensory as well as motor block compared to morphine, when added as an adjunct. However, the duration of postoperative analgesia was prolonged more with the addition of Morphine compared to Clonidine.

Estimation of Glycated Haemoglobin by Nephelometry, Ion Exchange Resin and High Performance Liquid Chromatography: A Cross-sectional Study
Introduction: Diabetes mellitus cases are continually rising all over the world. Glycated haemoglobin (HbA1c) used as a diagnostic test to measure long-term average glycaemic control in diabetic patients. Aim: To assess the precision and reproducibility of the Ion Exchange Column Chromatography Resin (IECR) method and nephelometry in comparison to High-Performance Liquid Chromatography (HPLC) with respect to the estimation of HbA1c. Materials and Methods: A cross-sectional comparative study was conducted on 50 blood samples, collected from the diabetic subjects at the Department of Biochemistry and their HbA1c values were estimated by HPLC based BioRad D-10, nephelometry and IECR techniques. HPLC was used as a gold standard method, to evaluate the sensitivity and specificity of nephelometry and IECR techniques. Data were expressed as mean±standard deviation and intraclass Correlation Coefficient and Pearson correlation were calculated. Results: The mean age of the study subjects was 53.06±7.67 years. The mean plasma HbA1c levels were 8.16±2.9, 7.62±2.5 and 7.84±2.5 and mean estimated Average Glucose (eAG) was 187.00±84.4, 172.0±76.8, and 289.46±199.9 by HPLC, Nephelometry and IECR, respectively. Compared with HPLC, nephelometry had excellent correlation (r-value 0.925); p<0.001) and IECR (r-value 0.869; p<0.001). Conclusion: Nephelometry and IECR both had better performance and showed a greater concordance with gold standard HPLC. Therefore, nephelometry and IECR can be used as an alternative assay for HbA1c estimation.

Complications and Recurrence after Pterygium Excision using Mitomycin C Eye Drops versus Sutureless and Glue Free Conjunctival Autograft: A Comparative Study

Prachi Shukla, Suman Bhartiya
Introduction: Recurrence is the most common problem with pterygium excision. Various adjunctive methods have been described to decrease the recurrence rate of pterygium. Mitomycin C (MMC) and limbal Conjunctival Autograft (CAG) are most commonly used methods to reduce its recurrence. Aim: To compare the recurrence rate of pterygium and the complications with MMC eyedrops after bare sclera pterygium excision versus sutureless and glue free CAG. Materials and Methods: Total 104 eyes were divided into two groups (A and B) of 52 eyes each. Group A patients underwent bare sclera excision of pterygium followed by 0.01% MMC eye drops BD (twice a day) for five days and Group B patients had sutureless and glue free CAG using oozing blood as tissue adhesive after pterygium excision. The patients were followed-up postoperatively on day 1, day 3, day 7, one month, three months, six months and one year. All the patients were examined for recurrence and complications. Statistical analysis was done by using Statistical Package for the Social Sciences (SPSS) version 16 and student’s t-test was applied for comparison. Results: A total of 104 eyes of 92 patients were divided into two groups (A and B) of 52 each. The mean age of Group A was around 45 year and group B was around 43 years and the difference was statistically insignificant (p>0.05). Total three patients had recurrence in one year of follow-up in group A, out of which first case appeared before the end of 1^st month, second before the completion of 3^rd month and the third case at the last follow-up. In group B only one case presented with recurrence at 6^th month follow-up. The difference between the recurrences in both the groups was statistically insignificant (p>0.05). Short term complications were observed in five patients in group A. One patient had corneal thinning; one had scleral thinning, two patients presented with avascular sclera and one patient with granuloma. In group B, 18 patients with graft retraction, eight with graft oedema, five with sub-conjunctival graft haemorrhage and one with granuloma were observed. All these complications resolved by the time. Long term complications were not observed in any patient of both the groups. Conclusion: This study concluded that the use of MMC eye drops (0.01%) BD or glue free and sutureless CAG after pterygium excision is safe and effective treatment modalities for pterygium.

Correlation of CAT, CCQ and mMRC Scores in Patients of COPD with Exacerbation and after Treatment
Introduction: Chronic Obstructive Pulmonary Disease (COPD), a globally prevalent disease holds a huge stake among all pulmonary patients being admitted throughout the year. Various disease specific and health related quality of life questionnaires such as the Constructed Response Question (CRQ) and St. George’s Respiratory Questionnaire (SGRQ) are readily available, although, attributing to their complex structure, they can’t be used in a widespread manner. Some new scores like COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ) were developed to ease-off this dilemma. However, there is a need to justify usage of these patient-friendly simplified scores by objectifying their inter-score reliability and correlation with disease severity and progression using statistical analysis. Aim: To analyse efficacious use of CAT, CCQ score and modified Medical Research Council (mMRC) scale in assessing health status of COPD with exacerbation. Additionally, it was also targeted to assess the inter-score correlation and reliability. Materials and Methods: A total of 180 confirmed cases of COPD with exacerbation were included in this study and subjected to requisite biochemical parameters, assessment scores at their admission, after 1 week and then after 4-6 week (at stabilisation) and spirometry. 136 patients were followed-up to 4-6 weeks and studied. Quantitative and qualitative variables thus obtained were compared statistically to find out correlation, if any. A p-value of <0.05 was considered significant. Results: Mean difference between CAT score at exacerbation and at 1 week and CAT score at exacerbation and at 4-6 weeks were statistically significant. The changes in CCQ scores from exacerbation to 1 week and 6 weeks were also found to be statistically significant. Similar pattern was also observed in assessing timescale variability of mMRC score. There was good correlation between CAT, CCQ and mMRC scores at exacerbation, 1 week and it continually intensified as patients progressed towards a more stable state (4-6 weeks). Similar pattern was also observed with significant progressive positive correlation between change in CAT, CCQ and mMRC scores from exacerbation to 1 week and from exacerbation to 4-6 weeks. Conclusion: These score have a high correlative reliability when used to assess health status among various stages of disease from exacerbation towards a stable state. Similarly, correlation between change of individual score from exacerbation towards recovery state was also high.

Assessment of Knowledge, Attitude and Practice Regarding COVID-19 Pandemic among Health Care Professionals: A Cross-sectional Study

Ambika Sharma, Mali Ram Aswal, Rahul Gupta
Introduction: Health care professionals are at greater risk of acquiring and subsequently transmitting Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection to their patients, families and colleagues. It is of utmost importance for them to have a knowledge about this Coronavirus Disease (COVID-19) and hence be in a position to practice infection prevention and control. Aim: To assess the Knowledge, Attitude and Practice (KAP) among health care professionals regarding the COVID-19 pandemic. Materials and Methods: This is a descriptive, cross-sectional study and was conducted in the month of April, 2020, among doctors and nurses. Total 164 health care professionals from the medical college hospital were included in the study. A 53-item survey questionnaire was developed to assess KAP among the health care professionals. Data analysis was done by using Epi info 7.2.1.0 version. Chi-square test was used to analyse variables as appropriate. A p-value of <0.05 was taken to be statistically significant. Results: A total of 164 responses were collected and analysed. Doctors comprised 43.9% of the total study subjects while remaining 56.1% were nurses. Male to female ratio of the study subjects was 2:1. Fifty-eight percent informed that they had received training about infection control. In the present study, common source of information about COVID-19 was the internet, social media and television followed by newspaper, government sources and radio. Most of the Health Care Workers (HCWs) were aware of the mode of transmission of infection and common preventive measures. Incubation period was known to 95% of respondents. Only 48.9% of nurses thought that the mild form of disease was most common. Almost all believed that washing hands and wearing mask were important preventive measures. Around 60% of HCWs assumed that they knew the steps for wearing and removing Personal Protective Equipment (PPE), but very few could remember the exact sequence. Most of them felt that the disease was dangerous, however only 31% were scared to do hospital work. Both nurses and doctors practiced high levels of hand hygiene, cough hygiene and wearing face masks at the workplace. Conclusion: This study highlights the level of existing KAP of COVID-19 among health care professionals. There is an urgent need to focus on training for correct use of PPE which can safeguard HCWs from contracting COVID-19.

A Protocol of Case Control Study of Childhood Trauma and Alexithymia in Persons with Alcohol Dependence Syndrome

Ajinkya Sureshrao Ghogare, Pradeep Shriram Patil, Ganpatlal Kodarbhai Vankar
Introduction: Psychological trauma may occur when an individual suffers from serious loss or his/her life is under serious threat. If such traumatic experience is failed to be resolved, it may lead to drug misuse including alcohol dependence. Early childhood trauma may predispose an individual to mental health issues, including development of alcohol dependence later in life. Childhood trauma includes various forms like emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. Those who experience and suffer from earlylife trauma may consume alcohol to cope with trauma related symptoms. In general, onset of trauma precedes onset of alcohol dependence. Childhood trauma can act as preceding factor for alexithymia. Childhood emotional abuse might be a risk factor for alexithymia among inpatient alcohol dependents. Aim: Present synopsis aims at finding out relationship between childhood trauma and alexithymia in persons diagnosed with Alcohol Dependence Syndrome (ADS). Materials and Methods: The study would be a case control study. It will be conducted at tertiary healthcare centre from central rural India. Study participants will be selected from psychiatry inpatients with diagnosis of ADS. The study will include total 110 persons of which 55 will belong to “case” group and 55 will belong to “control” group, both including persons between age group of 18-45 years who fulfill International Classification of Mental and Behavioural Disorders 10th revision Diagnostic Criteria for Research (ICD 10 DCR) and diagnostic criteria for ADS. Conclusion: The study expect to find significant relationship between childhood traumatic experiences and alexithymia among the persons with ADS.

Novel Coronavirus Infection: A Review on Haematological Markers of Disease Severity

Angela Ogechukwu Ugwu, Theresa Ukamaka Nwagha
The Corornavirus Disease (COVID-19) virus infection has a wide range of presentation- asymptomatic, mild, severe and critical forms that often lead to death from respiratory failure. There is a strong relationship between the severity of COVID-19 infection and some haematological parameters. Patients often present with lymphocytopenia at diagnosis despite having a normal total white cell count. The degree of lymphocytopenia could predict the progression to pneumonia and subsequent need for ventilator support due to respiratory failure. Apart from lymphocytopenia, thrombocytopenia has been linked with increased severity of COVID-19 symptoms. The lymphocyte-platelet ratio has been found to a better marker for disease severity than isolated lymphocytopenia or thrombocytopenia. COVID-19 patients have been found to be at increased risk of Venous Thromboembolism (VTE). There is elevation of D-dimers, abnormalities of the Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT) among hospitalised COVID-19 patients. This has necessitated the use of prophylactic anticoagulation even in the early phases of the infection.

An Integrated Approach to Deal with Mental Health Issues of Children and Adolescent during COVID-19 Pandemic

Mousumi Sethy, Reshmi Mishra
The pandemic caused by COVID-19 has left few countries untouched. It is a far-reaching implication on humankind, with children and adolescents, being no exception. Although the prevalence and fatality are negligible among children, a possible impact on their psychological and mental health cannot be disregarded. The unprecedented change in the way of living is bound to be having some psychological consequences on children and adolescents. The experiences gathered in childhood and adolescence are known to contribute to shaping the physical, emotional, and social well-being in adult life. Children are highly susceptible to environmental stressors. The present situation has the potential of adversely affecting the physical and mental well-being of children. To save the children from the long term consequences of this pandemic, a holistic approach integrating biological, psychological, social and spiritual methods of enhancing mental health have become essential. A concerted effort of government, Non Government Organisations (NGOs), parents, teachers, schools, psychologists, counselors and physicians are required to deal with the mental health issues of children and adolescents. This paper discusses the possible role of these agencies in the holistic intervention of this crisis.

Plant Based Diet- A Therapeutic Riposte to Emerging Zoonotic Infections

Praveen Jodalli, Amitha Basheer, Aradhana Nagarsekar, Ridhima Gaunkar, KM Ramya
Emerging zoonotic infectious diseases like swine influenza, avian influenza and Ebola have caused massive human suffering, social upheaval and economic damage across countries and continents. There is increasing evidence that humanity’s overexploitation of nature is one of the major factors responsible for the spread. Recently, mankind is traversing a hard-pandemic time due to COVID-19 outbreak which appears to be a brutal killer. When humans infringe wild adobes for food production, it generates opportunities for infectious pathogens to leap to livestock and humans. It is the time to begin brooding about more radical measures to handle the root of this crisis. A resilient food system that puts less stress on the environment would reduce the outbreak of Emerging Infectious Diseases (EID) by reducing contact between humans and wild animals thereby restoring biodiversity. World Health Organisation (WHO) advises avoidance/judicious use of animal meat consumption during or after every outbreak. It is clearly evident that a balanced, healthy plant-based diet can help to control pandemics/epidemics not only by preventing the transmission but also by strengthening the immune system of individuals to combat the infection. This paper throws light on how the human diet is directly or indirectly linked to the emergence, spread and prognosis of various infectious diseases.

COVID-19: How the Radiology Department Should Combat this Global Pandemic

Tanvi Modi, Mitusha Verma, Gauri Ahuja, Deepak Patkar
The impact of the global pandemic due to novel Coronavirus Disease (nCOVID-19) has been braced by all medical subspecialties, including the radiology department. As Computerised Tomography (CT) of the chest as well as radiographs gain more and more importance in diagnosing, following up and prognosticating this respiratory infection, it becomes essential to have set protocols in place regarding imaging, disinfection and departmental workflow to ensure smooth functioning and protection of patients and health care workers. We have formulated the “AMMO” protocol as a guide to smooth functioning of the radiology department, which enumerates the steps to be taken for organisation of patient workload, organising equipment, disinfection protocols, maintaining the health and safety of radiology healthcare workers along with timely and accurate reporting. By combining the established guidelines and the knowledge gained from our experience at a dedicated COVID-19 hospital, this article aims to provide a reference in the management of radiology departments during this pandemic.

Basic Reproduction Number (R naught) and Case Fatality Rate of COVID-19: A Conceptual Approach

Bhavna Sahni, Arvind Kumar Yadav, Kiran Bala, Pabitra Kumar Jena, Dinesh Kumar
Pandemics are an exceptional form of disaster which wreak havoc on physical, psychological, social and fiscal well-being of the entire populace. In the past decade alone, outbreaks of infectious diseases like Severe Acute Respiratory Syndrome (SARS), swine flu, Middle East Respiratory Syndrome (MERS), Ebola and the Zika virus resulted in significant upheaval, globally. Listing the key events in a time frame is of utmost importance in understanding the progression of the pandemic so as to map the natural history and plan targeted interventions. Research into dynamics of disease transmission and severity are important to public health preparedness. In the present communication, evolution of SARS-CoV-2 and public health concepts such as R naught (R₀) and Case Fatality Rate (CFR) of SARS-CoV-2 in comparison with other recent epidemics of coronaviruses have been summarised, along with presumable scenarios relevant to the pandemic in an attempt to disseminate succinct, consolidated, uncomplicated, specific and scientifically accurate information.

Inventive Methods Used to Study and Control Thermal Necrosis: A Review

Rajesh V Dahibhate, Santosh B Jaju, Rajendra I Sarode
Orthopedic surgeries use screw and plate fixations. Bone drilling is performed for smooth and minimum damage to bone surface during screw insertion. Bone drilling creates a hole with circular cross-section. This process involves cutting and material removal with a helical drill tool. Heat is generated at the drilling site due to cutting, shearing of bone material by drill tool and friction between drill tool and bone surface. Previous research studies found that if temperature at drilling site reaches 47°C and remains the same for one minute, irreversible cell damage i.e. thermal necrosis can occur. Thermal necrosis causes ring sequestrum around the pin; this leads to a vicious cycle involving secondary infection, discharge and pin loosening. This postoperative complication can only be rectified by removal of pin and sequestrum, curettage of the tract and pin replacement and so thermal necrosis- the root cause must be avoided and attended very seriously. To avoid thermal necrosis, postoperative complications and delay in patient rehabilitation, researchers are studying bone drilling in detail. In this review paper, a discussion is made on different innovative methods that are turning points in the study of thermal necrosis and the latest technologically improved equipment devised by researchers. These inventive methods have used experimental set ups, software-based simulations and training programs. The author also conducted experiments on female goat rib bone and based on these observations an improved drilling machine is suggested.

Utility of TP53 in Breast Carcinoma Immunophenotypes

Ria Jaggi, Samarth Shukla, Sourya Acharya, Sunita Vagha
Breast cancer is a heterogeneous disease and has significant variability in presentation, treatment response, and prognosis. The management of carcinoma breast is currently based on immunophenotypes and Tumour Nodes Metastasis (TNM) staging. The aim of the study is to review the literature and to look for treatment guidelines of carcinoma breast, the role of immunophenotypes in treatment of carcinoma breast, TP53 mutation in breast cancer, and the relationship of TP53 mutation with immunophenotypes, histological grade, efficacy of chemotherapy, and BRCA (Breast Cancer gene) mutation. Pubmed database was researched and a total of 510 articles were analysed. A total of one meta-analysis, one randomised controlled trial, one literature review, nine prospective studies, and three retrospective studies were included for further analysis. It was observed that TP53 mutation is associated with poor overall survival. It was also found to be inversely associated with the Estrogen Receptor (ER) status and so it was seen more commonly in basal type and HER2/neu enriched breast cancer. There is a need for further studies to establish the definite association between TP53 and immunophenotypes so that TP53 alone can be used as a guide for management in carcinoma breast at low resource centres.

Systemic Shortcomings in Medical Education System of India: A Review with Radical Solutions

Sundip Charmode, Shelja Sharma, Suryakanta Seth, Subodh Kumar, Vivek Mishra
India leads the world in the number of registered medical institutions and produces the largest number of medical doctors in the world. Notwithstanding this, India struggles for the concerns of poor quality of medical education, incompetent medical workforces, and insignificant research contribution to the world which is due to the malfunctioning of Indian regulatory bodies. Many Authors (domestic and foreign) have written extensively on the prevailing deficiencies of the medical education system of India in the last decade but essentially failed in offering effective and realistic solutions for the deficiencies cited by them. The present study undertakes a detailed review of the articles published in the last decade that critically analyses the various aspects of the medical education system of India. The objective of this article is to present the deficiencies in the medical education system in the country supported by statistical facts and figures to provide a framework to enable a better understanding of the complexity of the medical education system in India. This article also attempts to present effective solutions for the same as publicised by the regulatory and governing bodies of medical education and health care system of India thereby providing insight into the future directions in revolutionising it.

Literature Review on Development and Validation of Quality of Life Tool among Chemotherapy Patients

Virendra Kumar Jain, Anil Sharma
Introduction: Cancer is the second commonest explanation for death subsequent to heart diseases and it represented 8.8 million deaths worldwide during 2015. Quality of Life (QOL) is all about personal satisfaction, degree or the standard to which an individual, gathering of individuals or community people can appreciates the significant inclination and experience of life like physically, mentally, socially, etc. Aim: To identify the existing tools or instrument for QOL among chemotherapy patients. Materials and Methods: A systematic review of literature for QOL tool among chemotherapy patients was conducted. Electronic databases were looked: Pubmed, proquest, PsycINFC Scopus, Cumulative Index to Nursing and Allied Health Literature (CINHAL). Results: Researcher found 673 research papers from electronic data base: from that 353 articles were excluded bases on exclusion criteria. So total retrieved articles were 320 among all 51 duplicate articles, 88 No full text available, 58 not relevant and 47 abstracts were excluded. Final retrieved articles were 76; among them 38 full articles were excluded based on inclusion criteria. Finally, according to 38 studies, out of 14 investigations utilised European Organisation for the Research and Treatment of Cancer (EORTC QOL-C 30) survey, four studies used the Health Related Quality Of Life (HRQOL) tool, four studies used World Health Organisation Quality of Life-BREF (WHOQOLBREF) is a self-report questionnaire which assesses 4 domains of quality of life (QOL): physical health, psychological health, social relationships, and environment, Twelve studies used self administered questionnaire, four studies used other method like face to face validity, Functional Assessment of Cancer Therapy (FACT) etc. The most-normally utilised instrument was a QOL tool for use in universal clinical preliminaries in oncology having a place with EORTC QOL C-30 survey, HRQOL tool and WHO BREF tool. Conclusion: In this review study variety of instruments has been used by the researcher that explores the QOL of chemotherapy patients. The significance of psychometric properties of the instruments and its effect on discoveries rising up out of various examinations, it appears to be fundamental that more thought be paid to the validity and reliability of tool before conducting the research studies. Literature suggested that the analysts contribute enough consideration regarding the choice of standard instruments and organise the instruments validity and reliability of their outlook explores. Finding of study suggested that tools along with ideal psychometrics properties which were good with the socio-cultural setting of particular country

Novel COVID-19 Global Outbreak and a Need for Proactive Dental Care

Prachi Gupta, Abhinav Garg, Lovejeet Ahuja
The global pandemic Novel Coronavirus Disease (COVID-19), which originated in Wuhan, has affected the countries worldwide and has been declared as a public health emergency by World Health Organisation. Because of the exclusive features of dental healthcare set-ups, risk of cross-contamination is greater between patients and dental personnel due to high chances of getting in contact with suspected or asymptomatic COVID-19 patients. Preventive measures are essential to be taken for prevention of furthermore spread of nosocomial infection. The present article provides a brief overview on COVID-19 in dental settings and recommended protocols for screening/assessment, patient management and precautions for dental health care professionals.

Composition of the Oral Microbiome in Patients with Coronary Artery Disease

Thangam Menon, Supraja Kalyanaraman, Seethalakshmi Srinivasan
Introduction: Distinct microbial communities reside in the oral cavity and the composition of the oral microbiota has important implications for human health and disease. Identification of bacterial flora of the microbiome is done by metagenomic analysis of 16S ribosomal RNA sequences. Aim: The aim of this study was to characterise the human microbiome in patients with Coronary Artery Disease (CAD) in comparison with the normal human microbiome. Materials and Methods: A pilot study was carried out in tertiary hospital, Chennai. Oral mouthwash samples collected from nine patients with CAD were selected, with one control group. They were studied by metagenomic analysis of V3-V4 region of 16SrRNA gene sequences.. Sequencing of the variable V3 and V4 regions was done using Illumina platform. Results: The six major phyla, Firmicutes, Bacteroidetes, Proteobacteria, Actinobacteria, Spirochaetes, and Fusobacteria contained 99% of the taxa in all the samples analysed. Conclusion: Diversity of the microbiome in patients with CAD was similar to the normal human microbiome.

GeneXpert MTB/RIF Based Detection of Rifampicin Resistance and Common Mutations in rpoB Gene of Mycobacterium Tuberculosis in Tribal Population of District Anuppur, Madhya Pradesh, India

Poonam Sharma, Rambir Singh
Introduction: Tuberculosis (TB) caused by Mycobacterium tuberculosis (MTB) continues to be one of the most significant causes of death in the developing countries. Development of Multi Drug Resistance (MDR) and Extremely Drug Resistance (XDR) strains of MTB has been recognised as a major threat. Rapid diagnosis along with drug sensitivity analysis is the prerequisite for effective treatment of TB, especially in rural and remote location settings. Aim: The goal of this study was to investigate the Rifampicin Resistance (RR) using GeneXpert MTB/Rifampicin (RIF) in tribal patients suffering from Pulmonary Tuberculosis (PTB) in District Anuppur, Madhya Pradesh, India. Materials and Methods: Sputum samples were obtained from 413 patients with symptoms of PTB, who visited District Hospital, Anuppur from April 2017- April 2018. Based on clinical symptoms and chest X-ray, GeneXpert MTB/RIF assay was performed for the confirmation of TB and detection of RR. The data was analysed and expressed in percentage. Results: Out of 413 samples, 104 (25.18%) were diagnosed with PTB. Out of 104 TB positive samples, RR was detected in 7(6.73%) samples. The most common mutations conferring RR were located in the region of Probe B (71.42%), followed by Probe C (14.28%) and Probe E (14.28%), while no mutations were found in the region of Probe A and Probe D. Conclusion: Possibly, this is the first report of RR and probe mutational analysis from this tribal region of India. High rate of mutation at Probe B locus may be the chief reason for RR development. Gene sequencing may be carried for understanding the higher rates of mutations at probe B locus

Revisiting Integration: A Proposed Framework in the Light of Competency-Based Medical Education in Indian Context

Tripti K Srivastava Waghmare, Archana Dhok, Lalitbhushan S Waghmare
The manuscript reviews various methods of Integration (Temporal co-ordination, Sharing, Nesting and Co-relation) as recommended in the revised curriculum of Undergraduate Competency Based Medical Education (CBME) from 2019 academic session onwards. A brief description of these methods and recommended frameworks for planning such integration sessions are suggested. Medical colleges can plan and place integration of contents across various phases of curriculum on the basis of suggested frameworks, depending on factors like the targeted areas of integration, views and experience of teachers, organisational structure and course outcomes.

Journal of clinical and diagnostic research

Lagophthalmos- A Rare Presenting Sign in a Case of Childhood Pontine Glioma

Transmigrated Mandibular Canine Guided into its Normal Position

Nephrotic Syndrome: A Rare Sequelae of Varicella Zoster Infection

Audiological Findings in Diffused Axonal Injury Secondary to Road Traffic Accident

Infantile Epididymitis Presenting as Scrotal Swelling with Sinus in Paediatric Patient: A Case Report and Review of Literature

Pulmonary Thromboembolism in COVID-19: Initial Experience from India

Giant Intermuscular Thenar Lipoma: A Case Report and Literature Review

Cutaneous Horn of Prepucial Skin on Pre-existing Lichen Sclerosus in a Young Male: A Rare Presentation

Bifurcation Disease: The Role of Proximal Optimisation Technique

Epitheloid Angiosarcoma of Liver: A Hanging Tumour

Pelvic Congestion Syndrome Presenting with Massive Pulmonary Embolism

Perioperative Sedation and Sympatholysis Due to Tizanidine

Left Planum Sphenoidale Transitional Meningioma -Simpson Grade-1

Cavernous Sinus Metastasis from Carcinoma of Buccal Mucosa- A Rare Case Report and Review of Literature

Cutaneous Sarcoidosis- A Report of Two Intriguing Cases

Necrosis of Anterior Wall of Stomach Presenting as Pneumoperitoneum in Neonates- Report of Two Cases with Review of Literature

An Atypical Meningioma Presenting at an Unusual Site

Mediastinal Actinomycosis: A Rare Mediastinal Pseudotumour

Myeloma Cast Nephropathy Manifesting only as Unexplained Acute Renal Failure

Large Duodenal Gastrointestinal Stromal Tumour Invading the Pancreas- A Masquerader for Pancreatic Head Mass

Clinical Nature and Treatment with Sclerotherapy of Pyogenic Granuloma: A Case Series

Rods and Rings Antinuclear Antibody Pattern in Non Hepatitis C Patients: A Series of Five Cases with Review of Literature

Baclofen Induced Encephalopathy in Patients with Chronic Kidney Disease

Challenges in Delivering Optimal Healthcare to COVID-19 Patients: Focus on Delhi, India

Comparative Evaluation of Modified Endodontic Sealers’ Penetration Following Sonic Activation of Irrigants: A Scanning Electron Microscope Study

Association of Nerve Conduction Velocity with Total Body Fat Mass and Body Mass Index in Type 2 Diabetes Mellitus

Application of Haematological Indices in the Diagnosis of Swine Influenza Infection in Adults

A Comparative Study of Central Corneal Thickness and Endothelial Cell Density after Phacoemulsification by ‘Phaco-chop’ and ‘Divide and Conquer’ Techniques

Comparison of Two Doses of Chloroprocaine for Spinal Anaesthesia in Brachytherapy Procedures: A Randomised Clinical Study

Paediatric Malignant Blue Cell Tumours- A Practical Pathological and Immunohistochemical Study in Duhok, Iraq

Effectiveness of Planned Teaching Program on Knowledge Regarding Management of Leukaemia among Leukaemia Patients

Experiences of Cancer Patients on their Visit to Cancer Outpatient Department: A Qualitative Study from a Regional Hospital in Mauritius

Local Side Effects of Inhaled Budesonide in Asthmatic Children- A Cross-sectional Study

Correlation between the Findings of Magnetic Resonance Imaging Shoulder and Shoulder Arthroscopy

Nutritional Status of One to Five-Year-Old Children in Rural Haryana: A Community Based Study

Prediction of Mortality in Sepsis using Rapid Emergency Medicine Score: A Cohort Study

Histopathological Spectrum of Lesions in Lungs on Post-mortem Specimen in a Tertiary Centre of Bastar Region- A Retrospective Study

Arginase and Procalcitonin: Promising Biomarkers for Early Diagnosis of Sepsis

Comparative Evaluation of Cytotoxicity of 0.12% and 0.2% Chlorhexidine, 2% Povidone Iodine, 3% Hydrogen Peroxide and 0.9% Normal Saline Solutions on Fibroblasts- An Invitro Study

Effectiveness of Health Promotional Strategies on Quality of Life among Spouse of Alcoholics in Selected Communities of Dakshina Kannada District, India

Impact of Hospital Acquired Infection and Antibiotic Resistance Awareness Campaign on Knowledge Attitude and Practices of Medical Undergraduates in a Tertiary Care Teaching Hospital, India

Comparative Study of FOXC1 Expression in Selective Odontogenic Cysts and Tumours

Prothrombotic State and Cardiovascular Risk in Hyperuricaemic Individuals: Does Hyperglycaemia Play a Role? A Case-control Study

Seroprevalence of Scrub Typhus among Pyrexia of Unknown Origin Patients: A Study from Tertiary Care Hospital in Eastern Odisha, India

Clinical and Sero Immunological Profile of Scrub Typhus in Bengaluru, Southern India

Comparison of Unidirectional and Bidirectional Barbed Suture in Vaginal Cuff Closure during Total Laparoscopic Hysterectomy- A Randomised Controlled Trial

Role of Non-invasive Imaging in Characterisation of Soft Tissue Vascular Anomalies: Comparison of Ultrasound with Contrast-Enhanced Magnetic Resonance Imaging

Clinical Profile and One Year Outcome of Atrial Fibrillation- A Prospective Cohort Study

Predictive Value of the New Inflammatory Score Based on C-reactive Protein to Albumin Ratio on Serious Postoperative Complications after Curative Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

Detection of Toxoplasma gondii by Loop-mediated Isothermal Amplification in Blood and Urine Samples from Women in Saudi Arabia

Magnetic Resonance Imaging Evaluation of Cerebral Microbleeds: A Comparative Analysis of Susceptibility Weighted Imaging and T2* Gradient Recalled Echo Sequences

Can Study of Variations in Platelet Indices in Adult Thrombocytopenias Help to Differentiate the Underlying Mechanism? A Prospective Study

Measurement of Main Pulmonary Artery Diameter and its Ratio with Ascending Aorta in Indian Population by Multi-detector Computed Tomography

Infected Non Union of Tibia Managed by Limb Reconstruction System- A Prospective Cohort Study

Nurses’ Experiences of Managing Cardiopulmonary Resuscitation: A Qualitative Study

Detection of Rifampicin Resistance among Patients with Tuberculosis using GeneXpert MTB/RIF Assay: A Retrospective Study

Detection of Drug Susceptible and Resistant Viridans Streptococci spp., Staphylococcus Aureus, Klebsiella Pneumoniae and E.coli in Complete Denture Patients and Visualisation using Scanning Electron Microscopy

Influence of Motivation on Academic Progression of Students: A Cross-sectional Study

Effect of Isotretinoin on Thyroid Function Test in Acne Patients

Analysis of WHONET Surveillance Data of Antimicrobial Sensitivity of Uropathogens in a Tertiary Care Hospital: An Indicator to Empirical Antimicrobial Treatment for Urinary Tract Infection

Correlation of Maternal BMI with Foetal Liver Blood Flow and Neonatal Adiposity in Normal Pregnancies and Pregnancies Complicated by Gestational Diabetes Mellitus and Foetal Growth Restriction

Impact of Nutritional Status and Vitamin D Levels in Children with Febrile Seizure from a Suburban Tertiary Hospital in Tamil Nadu, India

Prevalence of Clinical Artesunate Resistance among Cases of Complicated Malaria in Southern Odisha, India

Factors Enhancing Drug-induced Hepatotoxicity among Thai Patients with TB

Contemporary Concepts and Techniques of Teaching Posterior Palatal Seal among Dental Colleges of Karnataka: A Cross-sectional Survey

Clinico-Aetiological Profile of Patients with Vertigo: A Cross-sectional Observational Study

Gestational Diabetes Mellitus and its Relation to Pre-pregnancy Body Mass Index

Prevalence of Injuries in National Level Kabaddi Players in India- A Cross-sectional Survey

Subclinical Atherosclerosis and Atherogenic Index of Plasma in Lichen Planus PatientsA Comparative Cross-sectional Study

Impact of Anticoagulation Clinic Intervention on Patient Centred Outcomes in a Tertiary Care Hospital

Single Dose Prophylactic Antibiotic in Caesarean Delivery and its Effect on Maternal Infectious Morbidity: A Prospective Observational Study

Comparative Evaluation of Three Skin Closure Materials- A Microbiological Pilot Study

Diagnostic Yield of Medical Thoracoscopy in Undiagnosed Exudative Pleural Effusion- A Tertiary Centre Experience from Aligarh Muslim University, Uttar Pradesh, India

Efficacy of Different Reagents to Prepare Transparent Tooth Model for Three Dimensional View of the Root Canal System- An Invitro Study

Serum Magnesium Levels among Pregnant Women with and without Complications: A Cross-sectional Study

Comparative Analysis of Alzheimer Questionnaire and Montreal Cognitive Assessment Tool for Cognitive Impairment Screening among the Elderly Population

Is there a Relationship between Combined Oral Contraceptive Use and Intrauterine Device Use with Abnormal Smear Results and Cervical Atypia?

Identification of a Rothia mucilaginosa Strain in a Clinical Specimen Based on PCR-Sequencing with Mycobacterium hsp65 Primers

Introduction of Mini-clinical Evaluation Exercise for the Formative Assessment of Postgraduates in the General Surgery Discipline