Table of Contents : Journal of clinical and diagnostic research : 2013 - May - 7

Hyperprolactinaemia and its Comparision with Hypothyroidism in Primary Infertile Women

Sunita Turankar, Kanchan Sonone, Avinash Turankar Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Aim and Objective: To study the serum prolactin levels and the serum TSH in primary infertile females. Material and Method: In this study, we investigated thirty women who were diagnosed cases of primary infertility, who attended the Biochemistry Department, Sir JJ Group of Hospitals, Mumbai, India, for hormonal evaluations. Thirty fertile women with similar ages were enrolled as the controls. The status of the thyroid dysfunction and the levels of serum prolactin were reviewed in infertile women and in the controls. The serum Prolactin and the thyroid stimulating hormone levels were measured by using Siemens kits in IMMULITE 1000 chemiluminescence immunoassays. Results: In our study, the serum prolactin levels in the infertile group were found to be high as compared to those in the control group and they were highly significant (p<0.0001). The serum TSH levels in the infertile group were found to be high, as compared to those of control group and they were highly significant (p<0.0001). Conclusion: There is a higher incidence of hyperprolactinaemia in infertile patients. There is also a greater propensity for thyroid disorders in infertile women than in the fertile ones. The incidence of hypothyroidism in the hyperprolactinaemic subjects in the study population was found to be highly signifi-cant than the normal controls.

Effect of Alcohol Withdrawl on Glutathione S-transferase, Total Antioxidant Capacity and Amylase in Blood and Saliva of Alcohol-Dependent Males

Neethumol Peter, Kevin J. Chiramel, Shivashankara A.R. Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Introduction: Alcohol biomarkers help in the early detection of alcoholism and its complications. There is a paucity of studies in India on the salivary markers of systemic diseases in general and on salivary alcohol biomarkers in particular. Objectives: The present study was aimed at assessing the effect of alcohol withdrawal on the antioxidants and amylase in blood and saliva, and at finding the correlation between the blood and the salivary parameters in alcoholics. Methods: Sixty alcohol-dependent males who were in the age group of 30 – 70 years, who were admitted to the Deaddiction Centre for alcohol withdrawal treatment for one month, were the subjects of this study; age-matched healthy individuals were the controls. In the blood and saliva samples, the activities of Glutathione S-Transferase (GST) and amylase and the Total Antioxidant Capacity (TAC) were assayed. Results: The alcohol-dependent subjects showed significantly lower GST and amylase activities and the TAC in blood and saliva as compared to those in the controls (P<0.001). The alcohol withdrawal caused a significant increase in the GST and amylase activities and the TAC to near-control values. In the alcohol-dependent subjects, there was a significant correlation between the values in blood and saliva with respect to GST and TAC. Conclusions: Alcoholism causes an impaired antioxidant capacity and a decreased secretion of amylase, which is ameliorated due to the alcohol withdrawal regimen . The strong correlation between blood and saliva with respect to the antioxidants suggests the potential future use of saliva as a laboratory tool in clinical medicine.

Evaluation of HS-CRP and Lipid Profile in COPD

Anup N. Nillawar, Kedar B. Joshi, Sandip Bharat Patil, Jayshree S. Bardapurkar, Suhas J. Bardapurkar Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Introduction: COPD is a major public health problem. More than 50 % of the patients of COPD die because of some cardiovascular event. Traditionally, the risk of CVD is assessed by the presence of dyslipidaemia. Recently, HS-CRP has emerged as a novel risk factor for the CVD assessment. In this study, we assessed the patients of COPD for CVD with HS-CRP and lipid indicators. Material and Methods: Forty Five diagnosed patients of COPD and 45 age, sex, and BMI matched healthy controls were enrolled for the study after the institutional ethical committee’s clearance was obtained. The fasting serum samples of the study subjects were evaluated for the lipid profile and HS-CRP. Results: There was no statistical difference in the lipid profile in the two groups, while HS-CRP was significantly raised in the COPD patients. On applying kappa statistics, we found a poor agreement between the lipid parameters and HS-CRP in estimating the risk for CVD. This underlines the independent importance of HS-CRP in the CVD assessment of COPD patients. Discussion: GOLD has described COPD as a systemic chronic inflammatory disease which involves the lung and the distant organs by the emissary of the systemic inflammation, which is also an antecedent to cardiovascular diseases. COPD is a systemic inflammatory disease which is underlined by this study. But the derangement of the lipid indicators is not statistically significant. This suggests the addition of HS-CRP in the assessment of the COPD patients for CVD. This further needs to be ascertained in a large prospective model. Conclusion: COPD is systemic inflammatory disease, but there is hardly any derangement of the lipid indicators.

The Clinical Assessment of Ischaemia Modified Albumin and Troponin I in the Early Diagnosis of the Acute Coronary Syndrome

Sangita M. Patil, M.P. Banker, Ramchandra K. Padalkar, Abhijit P. Pathak, Sonali S. Bhagat, Rahul A. Ghone, Anjali S. Phatake Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background: An early identification of the patients with the Acute Coronary Syndrome (ACS) is of prime importance, due to the associated very high mortality. Only about 22% of the patients who present at the emergency cardiology care centres with chest pain, have coronary disease. Ischaemia modified albumin has already been licensed by the US Food and Drug Administration for the diagnosis of suspected myocardial ischaemia. Aim: The goal of the present study was to assess the diagnostic value of serum ischaemia modified albumin and to compare it with sensitive cardiac troponin I in patients with the acute coronary syndromes like unstable angina and acute myocardial infarction. Methods: A diagnostic case control study was conducted on 102 patients who presented to the Emergency Department within 6 hrs of having acute chest pain and on 110 healthy age and sex matched volunteers who formed the control group. The serum Ischaemia Modified Albumin level was estimated by the albumin cobalt binding test by using a digital spectrophotometer, while Troponin I was measured by doing an immunofluroscence assay. A receiver operating characteristic curve was established for ischaemia modified albumin, to determine the cut-off point. The sensitivity and the specificity of ischaemia modified albumin and troponin I for the detection of acute coronary syndromes, were analyzed. The results of ischaemia modified albumin and troponin I alone and in combination, were correlated. Results: The ischaemia modified albumin (p<0.05) and the troponin I (p<0.001) concentrations were significantly higher in acute myocardial infarction and in unstable angina than in the healthy controls. The sensitivity and the specificity of ischaemia modified albumin for the detection of acute coronary syndromes was 88% and 93% as compared to 87% and 75% respectively for troponin I. The combined use of ischaemia modified albumin and troponin I significantly enhanced the sensitivity to 96%. The area which was under the Receiver Operating Characteristic (ROC) curve of ischaemia modified albumin in acute coronary syndromes was 0.90. Conclusion: Ischaemia modified albumin is a useful biochemical marker for the early diagnosis of acute coronary syndrome. The combined use of ischaemia modified albumin and cardiac troponin I enhances the sensitivity and specificity. Hence, a combination of ischaemia modified albumin and cardiac troponin I can be used as a more precise diagnostic marker for Acute Coronary Syndrome.

Blood Arsenic and Cadmium Concentrations in End-Stage Renal Disease Patients who were on Maintenance Haemodialysis

Subha Palaneeswari M, P.M. Abraham Sam Rajan, Santhi Silambanan, Jothimalar Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background: In India, there is a rising burden of chronic diseases like hypertension and diabetes. It has been estimated that 25-40% of these patients are likely to develop chronic kidney disease (CKD), with a significant percentage requiring renal replacement therapy. Haemodialysis is the most common method which is used to treat advanced and permanent kidney failure. Derangements in the metabolism of several toxic and trace elements such as antimony, arsenic cadmium, molybdenum, nickel, and selenium have been reported for several decades in patients with chronically reduced renal functions. Overall, the available literature suggests that the blood levels of some elements such as cadmium, chromium, fluorine, iodine, lead, or vanadium are high in end-stage renal disease (ESRD). Aim and Objectives: Our aim was to study the levels of blood arsenic and cadmium in ESRD patients who were on maintenance haemodialysis (MHD), and to study whether there was any relationship between their concentrations and the duration of the MHD. Methods: The blood lead levels were determined in 50 healthy subjects with normal renal functions and in 50 patients with ESRD, who were on MHD. None of them had any history of smoking or any industrial exposure. Results: The results of the study revealed that the blood arsenic and cadmium concentrations were higher in the ESRD patients who were on MHD than in the healthy adults. The blood arsenic and cadmium concentrations were found to increase with the duration of the MHD. Conclusion: The mild increase in the blood arsenic and cadmium concentrations, with an increase in the duration of the MHD in the study population, may be viewed in the wider context, that a prolonged exposure to arsenic and cadmium, even at low levels, may result in renal damage and/or progression of an already existing CKD.

The Association of Serum Osteocalcin with the Bone Mineral Density in Post Menopausal Women

KalaiSelvi VS, Prabhu K, Mani Ramesh, Vathsala Venkatesan Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background: The markers of bone remodelling, such as serum osteocalcin, may be used to assess osteoporosis and to predict the fracture risk in elderly persons, especially in women. The bone mineral density which reflects the bone mass and strength, also predicts osteoporotic related hip fractures. So, this work highlights the association between the bone turnover and the bone mass and strength. Aim: To assess the association between the biochemical markers of bone remodeling and osteocalcin with the bone mineral density in non osteoporotic and osteoporotic women among post menopausal subjects. Materials and Methods: Sixty postmenopausal women whose ages ranged from 55-65 years included in this study, were further divided into group 1 (thirty non osteoporotic subjects) and group 2 (thirty osteoporotic subjects). For all the subjects, serum osteocalcin was measured by ELISA. BMD was measured by the Dual Energy X- Ray Absorptiometry (DXA) scan. The women with osteoporosis were diagnosed, based on the T- score of the bone mineral density, by the DXA scan. The Student’s “t” test was performed between the variables of both the groups and a correlation test was also performed between osteocalcin and BMD by using SPSS. Results: A negative correlation was found between the osteocalcin level and the bone mineral density in post menopausal women. The mean values of both serum osteocalcin and BMD between the osteoporotic and the non osteoporotic subjects were statistically significant. Conclusion: An increased bone turnover coincides with the trabecular deterioration in osteoporotic women of the post menopausal age group. A combination of biochemical markers and BMD may be a better predictor of the fracture risk than when it was assessed by either alone. The biochemical markers of the bone turnover cannot be a substitute for the serial BMD measurement, but they may be useful when they are considered in conjunction with the BMD measurement.

The Prospect of Serum Magnesium and an Electrolyte Panel as an Adjuvant Cardiac Biomarker in the Management of Acute Myocardial Infarction

Ramesh Ramasamy, Sathish Babu Murugaiyan, Niranjan Gopal, Rachel Shalini Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background: Ischemic heart disease accounts 12.2% deaths worldwide. Serum magnesium (Mg+) status is often ignored in Acute Myocardial Infarction (AMI). Studies showed alterations in the levels of serum electrolytes including magnesium in AMI. Aim: To evaluate serum Mg+ and other electrolytes as adjuvant markers in the diagnosis of AMI. Design and Settings: Case control study was conducted in South Indian male population with AMI within six hours of onset of symptoms. Patients and Methods: Study includes sixty patients with AMI and 100 controls. Serum electrolytes were estimated using electrolyte analyzer. Data were compared by using student‘t’ test. ROC was drawn to find out optimum cutoff for diagnosing AMI. Pearson’s correlation was done to see the association among the markers. Results: Serum Ca, Mg, K and Na electrolytes were significantly lower (‘p’<0.001) in AMI. Ca:Mg, K:Mg, and Na:K ratios were significantly higher when compared to controls (‘p’<0.001). There was significant correlation of serum Mg levels with other cardiac markers (Total CK, CK–Mb, Troponin –T) of AMI (‘p’ <0.05).ROC analysis of Na:Mg (40.9), Ca:Mg (3.43) and K:Mg (2.74) ratios showed optimum cutoffs in diagnosis of AMI. Conclusion: Serum Mg, Ca:mg, K:mg and Na:K ratios could be useful adjuvant markers in diagnosis of AMI.

Assessment of the Effects of Pranayama/Alternate Nostril Breathing on the Parasympathetic Nervous System in Young Adults

Anant Narayan Sinha, Desh Deepak , Vimal Singh Gusain Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background and Aim: Pranayama, the art of breath control, is considered to be the heart of yogic exercises. The present study was performed with the aim of evaluating the effect of Pranayama/Alternate Nostril Breathing (A.N.B.) on the parasympathetic nervous system in healthy young adult males. Methods: A comparative account of the expiratioin: inspiration ratio (E:I ratio) and the orthostatic tolerance test (30:15 ratio) at the basal level, at the start of the study and after the practice of A.N.B for 5 minutes and following a training period of 6 weeks. Result and Conclusion: This study showed that the parasympathetic tone was enhanced appreciably in the participants. The observations of this study suggest that the yogic exercise of A.N.B. influences the parasympathetic nervous system significantly.

ECG Changes in Smokers and Non Smokers-A Comparative Study

M.R. Renuka Devi, T. Arvind, P. Sai Kumar Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Introduction: Tobacco consumption is the single most cause of the preventable deaths globally. Tobacco is consumed in the form of cigarettes. It contains nicotine which causes physical and psychological dependencies. Cigarette smoking increases the blood coagulability. Nicotine facilitates conduction block, re-entry and it increases the vulnerability to ventricular fibrillation. Hence, Nicotine and other components of cigarette can produce profound changes in the heart, which can be assessed by doing an ECG, which is the , cheapest and the most reliable method for assessing cardiovascular abnormalities. Aim: To compare the ECG changes between smokers and non- smokers. Materials: 88 healthy male volunteers who were in the age group of 18-30 years, who attended the outpatients department of SBMCH were recruited for the study. Among the volunteers, 44 were smokers as per the ICD-10 criteria for substance abuse and the rest of the 44 were non-smoker subjects without any systemic illnesses and a drug and alcohol intake. Methods: After a thorough examination, all the subjects were asked to abstain from smoking and caffeine beverages, 2 hours prior to the taking of the ECG recording. The ECG was recorded in the lab of the Department of Physiology of SBMCH. The following parameters were assessed, namely, the heart rate, the p- wave, the PR interval and the QRS complex. The QTc (corrected QT interval) was calculated by using Bazet’s formula. The QT interval, the ST segment and the T wave duration were evaluated in seconds. The results which were obtained were statistically analyzed by using the Students ‘t’ test. Results: The analysis showed that QTc interval was shortened and that the QRS complex duration was widened in the smokers, although the values did not show any statistical significance. The heart rate was increased in the smokers, which was statistically significant. The RR interval, the QT interval and the ST segment were shortened in the smokers as compared to those in the non smokers, which was highly significant statistically. Conclusion: All the above changes in our study were either a result of the acute effects or the chronic effects of smoking, which led to cardiovascular disorders which could be easily identified by the wave duration in electrocardiography. This may be used by physicians as a tool for counselling the smokers to stop smoking as early as possible. Smoking even a single cigarette can increase the risk of sudden cardiac deaths.

The Serum C Peptide Levels Among the Offsprings of the People with Type 2 Diabetes

Gaurav Kumar, Jayballabh Kumar, Farhan Ahmad Khan, Devesh Kumar, Kiran Malik Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background: Insulin Resistance (IR) is a condition in which the cells of the body become resistant to the effect of insulin , that is, the normal response to a given amount of insulin is reduced. As a result, levels of insulin are needed in order for insulin to produce its effect. The incidence of diabetes in the offsprings of diabetic couples was more than the incidence of diabetes in the offsprings, of whom only a single parent was diabetic. Aims and Objectives: This study was done to assess the prevalence of insulin resistance in the offsprings of diabetic patients. Material and Methods: The present, cross sectional study conducted in the Teerthanker Mahaveer Medical College and Research Centre, Moradabad, U.P., india. The offsprings of diabetic subjects attended the General Medicine OPD and the Diabetic Clinic and they were also admitted in the indoor wards of the Department of Medicine. The study material consisted of 53 (35 males and 18 females) live offsprings of diabetics from 28 families. Results: The mean c-peptide level in the offsprings of biparental diabetics was significantly higher than that in the offsprings of monoparental diabetics (p<0.01) and in the offsprings of non-diabetics (p<0.01). The frequency of the high c-peptide level was 38.1% in the offsprings of biparental diabetics, it was 21.1% in the offsprings of monoparental diabetics and it was 7.7% in the offsprings of non-diabetics. Conclusion: This study revealed that during the young ages of the offsprings of biparental diabetics, insulin resistance was common and that insulin resistance was more common in the obese, female offsprings of biparental diabetics.

Domestic Microwave Versus Conventional Tissue Processing: A Quantitative and Qualitative Analysis

Bhuvanamha Devi R., Subhashree A.R., P.J. Parameaswari, B.O. Parijatham Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background: Microwave irradiation has been tried as a replacement for the conventional tissue processing technique in histopathology laboratories for quite some time. Studies have shown that Domestic Microwave Tissue Processing (DMWTP) provides a faster delivery of the tissue sections with a morphology which is similar to that which is seen Conventional Tissue Processing (CTP). But many laboratories still confine the domestic microwave tissue processing method only to the handle selected specimens, for which urgent reports are needed. One of the probable reasons is that, understanding about the number of tissue sections which can be processed using a microwave oven at a time, with the appropriate quality, still remains unclear. Aim: The aim of this study was to quantitatively analyze the optimum number of samples that a domestic microwave could process at a time, as well as to qualitatively analyze the morphological outcome of those tissue sections with that of conventional processing. Materials and Methods: This study was approved by the research and ethical committee of Sree Balaji Medical College and Hospital. A total of 135 paired tissue sections were included in the study. Ten tissue sections (which are mentioned hereafter as A10) were processed in a domestic microwave and their paired 10 tissues were processed by a conventional method. Subsequently, the number of tissues which was to be processed was increased to B15, C20, D25, E30 and F35, after ascertaining that the morphological qualities of the previously processed tissue sections were satisfactory. Sections of 4 µm thickness were taken and they were stained by the Haematoxylin and Eosin method. The slides of the tissues which were processed by the microwave method and the conventional method were randomly numbered, for a blind study, which were independently evaluated by two observers. The qualities of slides were assessed, based on 4 parameters: the cytoplasmic details, the nuclear details, the tissue architecture and the staining characteristics. The statistical analysis was done by using SPSS 15.0. Results: The morphological outcomes (quality) of the DMWTPs were comparable to that of the CTPs, when the sample load (quantity) in the microwave oven was up to 25 samples. Conclusion: Domestic microwave processing can be effectively used in laboratories with a maximum sample size of 25 samples per load. This has the advantage of being rapid, with its morphological quality being identical to that of conventional processing.

E-Cadherin Expression: A Diagnostic Utility for Differentiating Breast Carcinomas with Ductal and Lobular Morphologies

Kanthilatha Pai, Poornima Baliga, Bishwo Lal Shrestha Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Objectives: The objective of this study was to evaluate the diagnostic utility of the E-Cadherin (EC) expression in differentiating between an infiltrating ductal carcinoma (IDC) and an infiltrating lobular carcinoma (ILC), the two most common forms of invasive breast carcinomas. Methods: The authors evaluated the E-Cadherin expression by doing immunohistochemistical studies of all the cases of invasive lobular carcinomas (ILC) which were diagnosed in the pathology laboratory during a 3 year period and they compared the expression of E-Cadherin in an equal number of invasive ductal carcinomas (IDC) of the breast. Results: A moderate to strong inter-membranous E-Cadherin expression on immunohistochemistry was seen in all the cases of IDC, while only 1 case of ILC showed a moderate E-Cadherin expression. Hence, the E-cadherin expression can be reliably used as a marker to differentiate IDC and ILC. However, an aberrant cytoplasmic expression of E-Cadherin may be seen in some cases of ILC, which should be interpreted with caution.

Application of WHONET in the Antimicrobial Resistance Surveillance of Uropathogens: A First User Experience from Nepal

A.N. Ghosh, D.R. Bhatta, M.T. Ansari, H.K. Tiwari, J.P. Mathuria, A.Gaur, H.S. Supram, S. Gokhale Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Introduction: WHONET is a freely downloadable, Windows-based database software which is used for the management and analysis of microbiology data, with a special focus on the analysis of antimicrobial susceptibility test results. Urinary Tract Infections (UTI) are a common medical problem and they are responsible for notable morbidity among young and sexually active women. Objectives: The major objective of this study was the utilization and application of the WHONET program for the Antimicrobial Resistance (AMR) surveillance of uropathogens. Methods: A total of 3209 urine samples were collected from patients who visited Manipal Teaching Hospital with a clinical suspicion of UTI, during December 2010 to July 2011. The isolation and characterization of the isolates were done by conventional methods. Antimicrobial Susceptibility Testing (AST) was performed by Kirby Bauer’s disc diffusion method. The data entry and analysis were done by using the WHONET 5.6 software. Results: Out of the 3209 specimens, 497 bacterial isolates were obtained and they were subjected to AST. Escherichia coli (66.2%) was the commonest bacterial isolate, followed by Enterococcus species (9.3%), Staphylococcus aureus (5.0%), and Klebsiella pneumoniae (4.2%). Among the gram-negative enteric bacilli, a high prevalence of resistance was observed against ampicillin and ciprofloxacin. The gram negative nonfermenters exhibited a high degree of resistance to ceftazidime. Staphylococcus species. showed a moderately high resistance to co-trimoxazole. One isolate was Vancomycin Resistant Enterococci (VRE). Conclusion: This study, a first of its kind which was done in Nepal, was carried out by using the WHONET software to monitor, analyze and share the antimicrobial susceptibility data at various levels. This study was also aimed at building a surveillance network in Nepal, with the National Public Health Laboratory, Nepal, acting as a nodal centre. This would help in the formulation of antibiotic policies and in identifying hospital and community outbreaks at the nodal centre, as well as in sharing information with the clinicians at the local level.

The Bacterial biofilms in Dialysis Water systems and the Effect of the sub Inhibitory Concentrations of chlorine on them

Ethel Suman, Benji Varghese, Neethu Joseph, Kumari Nisha, M. Shashidhar Kotian Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Introduction: The presence of bacteria in the form of biofilms poses a problem in the fluid pathways of haemodialysis plants and procedures which are aimed to detach and neutralize biofilms are necessary to improve the patient safety and the quality of the healthcare. The present study was therefore aimed at isolating the organisms which colonized dialysis water systems as biofilms, as well as to study the effect of the sub inhibitory concentrations of chlorine on the biofilms which were produced by these isolates. Methods: Swabs were used to collect the biofilms which were produced on the internal surface of the dialysis tubing from the dialysis units. This study was conducted at the Department of Microbiology, Kasturba Medical College (KMC), Mangalore, India. The cultures were performed on MacConkey’s agar and blood agar. The organisms which were isolated were identified and antibiotic sensitivity tests were performed. The biofilm production was done by the microtitre plate method of O’Toole and Kolter. The biofilm production was also studied in the presence of sub inhibitory concentrations of chlorine. Results: Acinetobacter spp and Pseudomonas aeruginosa were the two predominant organisms which colonized the dialysis water systems as biofilms. The sub inhibitory concentrations of chlorine did not bring about any decrease in the biofilm production by the isolates. On the contrary, there was an increase in the biofilm production. Conclusion: Our study highlighted the importance of using appropriate methods to improve the quality of the water in dialysis units. This in turn, may help in reducing the biofilm formation in the water systems of dialysis units and thus, contribute to the prevention of hospital acquired infections in the patients who need haemodialysis.

A Study on the Acute Kidney Injury in Snake Bite Victims in A Tertiary Care Centre

Harshavardhan L, Lokesh A J, Tejeshwari H L, Halesha B R, Siddharama S Metri Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Introduction: Snake bite is a common medical emergency and an occupational hazard, more so in tropical India, where farming is a major source of employment. Viper bites are more common than other poisonous snakebites in humans. The World Health Organization has estimated that there are approximately 1,25,000 deaths among 2,50,000 poisonous snake bites worldwide every year, of which India accounts for 10,000 deaths. Acute kidney Injury (AKI) is an important consequence of a snake bite and its proper supportive management after the anti-venom administration is of utmost importance, for a good patient outcome. Aims and Objectives: 1. To assess the risk factors and the prognostic factors in snake-bite induced Acute Kidney Injury. 2. To determine the outcome of snake bite patients with AKI in a tertiary care centre in Karnataka, India. Methodology: This prospective study was carried out at Vijaynagar Institute of Medical Sciences, Bellary, Karnataka, India. This institute is a referral government hospital in north Karnataka, India. Study Design: This was a prospective and descriptive type of study. Results: A total of 246 cases of venomous snakebite were included in this study, who were admitted in the hospital from November 2007 to October 2008. Among the AKI and the non-AKI patients, Illiteracy was more among the patients who suffered from AKI (75%). In our study, among all the patients (both AKI and non-AKI patients), viper bite was the commonest and it was seen in 31(91.6%) cases among the AKI patients and in 142 (67.6%) cases among the non-AKI patients. In our study, a majority of the patients who developed AKI had initially visited traditional healers before visiting our hospital, which was found to be statistically significant. In the present study, disseminated intravascular coagulation (DIC) and intravascular haemolysis were found to be predominant among the AKI patients. The “Bite to Needle” time was significantly more in the patients who developed AKI as compared to that in those who developed non-AKI. Out of 36 patients who suffered from AKI, 28 (77.7%) patients survived. Among them, 27(96.7%) patients developed cellulitis, 25(89.5%) had regional lymphadenopathy, 22(81.2%) were bitten at their lower limbs, and 6 (23.8%) patients developed bleeding manifestations. Conclusion: This study concludes that acute kidney injury occurs in 14.6% of the victims of snake bite. The common manifestations include cellulitis, bleeding manifestations and gangrene at the site of the bite.

Self Care Activities, Diabetic Distress and other Factors which Affected the Glycaemic Control in a Tertiary Care Teaching Hospital in South India

Sasi Sekhar TVD, Madhavi Kodali, Kalyan Chakravarthy Burra, Baby Shalini Muppala, Parvathi Gutta, Murali Krishna Bethanbhatla Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background: Interventions which were made to promote a better self-management have produced improvements in the glycaemic control in patients with Diabetes mellitus. An improved glycaemic control is known to prevent the long term complications. Method: This study was conducted at the Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, which is a rural tertiary health care centre. 546 patients were included in our study and they were assessed for the glycaemic control (HbA1c), diabetes distress (DDs), and self care activities. Results: Of the total 546 patients, 49% had a poor glycaemic control, as was indicated by HbA1c levels of >7%. The factors which are significantly associated with a poor glycaemic control are age (p=0.03 ), sex (p= 0.0415), literacy (p=0.0422), duration of the disease (p=0.0006), diabetic distress (p=0.0001) and self care activities like diet ( p=0.0001), medication (p=0.0001) and exercise (p=0.0001), whereas there was no significant effect of the BM I (p=0.094) on the glycaemic control. Conclusion: This study revealed the factors that could predict the glycaemic control in the diabetic patients who attended our tertiary care teaching hospital. The barriers that prevent these patients from meeting their goals must be explored, to improve their health outcomes.

Biomechanics of Climbing Coconut Trees and its Implications in Ankle Foot Morphology- A Video Sequence analysis

Bincy M. George, Arunachalam Kumar, Muddanna S. Rao Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Introduction: Few studies regarding foot changes and health of professional coconut tree climbers of south India are reported. Medical emergencies are very common, especially due to accidental fall from coconut trees, while on job. Objective of the present study is to analyze the altered biomechanics of lower limb joints used by the coconut tree climbers. Method: Videographs of tree climbing each from a total of 30 male volunteers, all between 30-55 years, engaged in coconut tree climbing profession were collected. Results: The data revealed the coconut tree climbers are using abnormal rages of foot and lower limb joint motions. Conclusion: This study establishes an occupationally induced form of altered biomechanics, which leads to professional health hazards.

The Clinicopathologic Manifestations of Plasmodium Vivax Malaria in Children: A Growing Menace

Prasun Bhattacharjee, Suparna Dubey, Vijay Kumar Gupta, Prerana Agarwal, Mathura Prasad Mahato Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Context: Today, India faces increasing morbidity and mortality due to malaria, which is a global health burden. Plasmodium vivax which was once considered to have a benign course, is now being increasingly associated with complicated malaria. Studies which have been done on the increasing virulence of P. Vivax in children, are exceptionally rare. Aims:This study has addressed some of the hitherto unanswered questions, such as: • This study has tried to explore the wide spectrum of severe illnesses which are associated with P.vivax malaria in children. • Other co-morbid conditions, which include a co-infection with P.falciparum, have been excluded with great care, to assess the increased virulence of P. Vivax. • The present study was focused on the paediatric population with a large sample size of 168 subjects. Settings and Design: This was an observational retrospective analysis on the clinicopathologic manifestations of the paediatric cases which were admitted with severe malaria due to a mono-infection with Plasmodium vivax, in a tertiary-care centre in the national capital region, India. Methods and Material: The diagnosis of the mono-infection with P. Vivax malaria was established by making peripheral blood films (PBFs) and by doing rapid diagnostic tests. The severe forms of malaria were categorized as per the World Health Organization guidelines and the clinical and laboratory findings in these cases of complicated malaria were studied. Statistics: A descriptive statistical analysis was done by using the SPSS software and an Excel worksheet. Results: This comprehensive study revealed a multisystem involvement. Abdominal manifestations were observed in 75(45.8%) cases (which included hepatosplenomegaly, hepatomegaly, splenomegaly and ascites) and hepatic dysfunction and jaundice were observed in 28(16.7%) cases. The haematological tests showed moderate to severe anaemia in 151(89.9%) cases and thrombocytopaenia in 138(82.1%) cases. Petechiae were noted in 45(26.8%) cases and a gross bleeding was noted in 9(5.3%) cases. The respiratory findings which included tachypnoea, pleural effusions and ARDS were observed in 22(13.1%) cases. Renal dysfunction was noted clinically in 20(11.9%) cases and biochemically in 16(9.5%) cases. Shock was observed in 7(4.1%) cases, cerebral malaria was observed in 10(5.9%) cases and hypoglycaemia was observed in 5(3%) cases. Multi-organ dysfunction was detected in 11(6.54%) cases. The complications were more severe in the younger children (0-5 years). Conclusions: A mono-infection with P. Vivax may lead to severe malaria and this increased virulence has resulted in the changing picture of P. Vivax malaria, leading to a spectrum of complications which are similar to those which are traditionally associated with P. Falciparum.

‘Single Dose MgSo4 Regimen’ for Eclampsia – A Safe Motherhood Initiative

Joshi Suyajna D, Veerendrakumar CM Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Objectives: To determine the efficacy and the safety of the single dose MgSo4 (‘VIMS’) regimen in treating eclamptic seizures and their effect on the maternal and foetal outcomes. Methods: A prospective, observational study was conducted in the period from 2003 to 2007. 513 eclamptic women who were admitted to the Dept of OBG, VIMS, Bellary, received single doses of 4g diluted 50% Mgso4 intravenously, with simultaneous 4g 50% MgSo4 intramuscularly. The recurrent seizures, maternal mortality and the perinatal mortality were measured. Results: 9.16% of recurrence (11.66%-16.49%), 3.3% of maternal mortality (1.8%-4.9%) and 24.8 % ( 21.1%-28.7%) of perinatal mortality were observed. The statistical analysis was done by using confidence intervals, standard deviations, means and the Standard normal “Z” test. Conclusion: The single dose MgSo4 regimen is effective and safe in controlling eclamptic convulsions. The ‘VIMS’ regimen can be used at First Referral Units, before shifting the patients to tertiary care centres. This approach has special implications in the developing countries, especially at the primary care level, where the standard obstetric care is not widely available.

Target Scan-The Experience at Saveetha Medical College

Navamani Hephzibah Kirubamani, M.R Meenatshi Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Introduction: The identification of foetal anomalies in utero is important . The prenatal detection of such abnormalities, often aids in planning the appropriate obstetrical management. Objectives: To evaluate the antenatal prevalence of the major congenital anomalies and the malformation patterns which were seen in low risk patients of our hospital population. Study Design: This was a cross-sectional and an observational study. Settings: This study was done in the Radiology and Obstetrics Department of Saveetha Medical College. Duration: It extended from June 2012 to Aug 2012. Sample size: It was done on 250 patients. Results: The incidence of foetal anomalies in our study was 2.97%. The mean maternal/mean gestational age at diagnosis was 24.5years /20 weeks. Among the 250 cases, five cases had lethal anomalies and two cases had non lethal anomalies. The lethal anomalies were cystic hygroma, body stalk anomaly, multicystic kidney, non immune hydrops and a Dandy Walker variant. All of the patients were primi gravida, without any risk factors. Two non lethal anomalies which were found were a duplication cyst in the foetal abdomen and a single umbilical artery. Foetal kartotyping and foetal autopsies were done in two cases. The parents of the offsprings with the lethal anomalies were counseled and they decided to go for termination of the pregnancies. It was offered to them. For the non- lethal cases, complete postnatal work ups were done by the paediatrician. Conclusion: The sonographic demonstration of a lethal foetal anomalies is mandatory, which may dramatically alter the obstetrical management and it also aids in the parental preparation. Future Scope: In our study, all the non compatible with life anomalies were seen in the young primi without any risk factors and hence, the environmental cause has to be studied.

The Role of Fibrin Glue in the Treatment of High and Low Fistulas in Ano

Atul Mishra, Sheerin Shah, Amandeep Singh Nar, Ashvind Bawa Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Aim: The aim of this study was to assess the outcome of fibrin glue in high and low anal fistulas. Methods: A prospective, non-randomized trial was carried out on 30 patients who were diagnosed to have fistulas in ano. They were evaluated by categorizing them into high (with the internal opening above the anorectal ring)(14/30) and low anal fistulas (with the internal opening below the anorectal ring)(16/30). The fibrin glue was instilled in their anal tracts. The character of the anal tract, whether it was single or multiple and primary or recurrent, was analyzed. The outcome in terms of a postoperative discharge (failure), the incidence of a postoperative perianal pain/abscess and the glue reaction, was noted at 1 week, 1 month, 3 months and 6 months. A success was defined as the absence of any discharge at 6 months. Results: Fourteen patients with high anal fistulas and 16 with low anal fistulas (with a mean age of 48.5yrs) were treated with fibrin glue. 19 patients had primary tracts (7- high group and 12- low group) and 11 had recurrent tracts (7- high group and 4- low group). 20 fistulas were single tracted (8- high and 12- low) and ten were multiple tracted (6- high and 4-low). The success rate at 6 months was 57.14% in the high group and it was 81.25% in the low group. The failure rate was 85.71% in the recurrent high fistula group as compared to 25% in the recurrent low fistula group (p=0.049). 25% of the single tracted high fistulas failed to heal as compared to a 100% healing rate in the single low fistulas group (p=0.90). Conclusion: This procedure is thus, superior to the conventional surgical treatment, in terms of the patient comfort, an undisturbed sphincter function, a reduced overall hospital stay, wound pain and the complications and adverse reactions. It showed the best results in the primary, single tracted and the low anal fistulas.

The Perforation-Operation time Interval: an Important Mortality Indicator in Peptic Ulcer Perforation

Sushama Surapaneni, Rajkumar S, Vijaya bhaskar Reddy A. Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Objective: To find out the significance of the Perforation-Operation Interval (POI) with respect to an early prognosis, in patients with peritonitis which is caused by peptic ulcer perforation. Study Design: Case series. Place and Duration of the Study: Department of General Surgery, Konaseema Institute of Medical Sciences and RF Amalapuram, Andhra Pradesh, India from 2008-2011. Materials and Method: This study included 150 patients with generalized peritonitis, who were diagnosed to have Perforated Peptic Ulcers (PPUs). The diagnosis of the PPUs was established on the basis of the history , the clinical examination and the radiological findings. The perforation-operation interval was calculated from the time of onset of the symptoms like severe abdominal pain or vomiting till the time the patient was operated. Result: Out of the 150 patients 134 were males and 16 were females, with a male : female ratio of 9:1. Their ages ranged between 25-70 years. Out of the 150 patients, 65 patients (43.3%) presented within 24 hours of the onset of severe abdominal pain (Group A), 27 patients (18%) presented between 24-48 hours of the onset of severe abdominal pain (Group B) and 58 patients (38.6%) presented after 48 hours. There was no mortality in Group A and the morbidity was more in Group B and Group C. There were 15 deaths in Group C. Conclusion: The problem of peptic ulcer perforation with its complication, can be decreased by decreasing the perforation –operation time interval, which as per our study, appeared to be the single most important mortality and morbidity indicator in peptic ulcer perforation.

A Qualitative Assessment of The Small Group Teaching at Hawler College of Medicine

Abubakir M. Saleh, Namir G. Al-Tawil, Nazar P. Shabila, Tariq S. Al-Hadithi Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Context: Although the medical schools in Iraq recently started to increasingly use the small group teaching approach, only little is known about the students’ perceptions toward this approach. Therefore, the aim of this study was to assess small group teaching as a method of teaching at Hawler College of Medicine, from the students’ perspectives. Setting: This study was a qualitative study which was based on six focus group discussions which involved a sample of students from the three last years at the Hawler College of Medicine. A topic guide was used to lead the discussions and it covered questions on the positive aspects and the problems of small group teaching in the college, in addition to recommendations for its improvement. The qualitative data analysis involved a content analysis, followed by a thematic analysis. Results: The participants were generally happy with the application of the small group teaching approach and they recognized many positive aspects which were related to this experience, which included, increasing the focus on the study subjects, enhancing the student-teacher interaction, building a better student-teacher relationship, encouraging the students’ attendance, providing a better opportunity to apply a student-centered learning, enhancing a more efficient use of time and assisting in a better understanding of the subjects. The main problems which were faced, included a poor infrastructure and teaching facilities, problems which were related to examinations and the mark distribution, an improper syllabus preparation and problems which were related to the teachers’ commitments and performances. The main suggestions which were put forth to improve this system, included, changing the assessment system with the focus more on the end of the course assessment, the students’ involvement in the curriculum design, improving the infrastructure and teaching facilities and a better organization and management of the system. Conclusions: The concept of the small group teaching approach was well received by the students and many positive aspects of this approach have been highlighted. However, this experience witnessed many problems and faced different challenges that need better preparation, organization of the resources and the orientation of students and teachers, for insuring its success.

Perforator Plus Fasciocutaneous Flaps in the Reconstruction of Post-Burn Flexion Contractures of the Knee Joint
Madhumita Gupta, Ashwin A. Pai, Ravi R. Setty, Raghavendra Sawarappa, Bijay Kumar Majumdar, Tibar Banerjee, Aditya Kanoi, Abhimanyu Bhattacharya Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background: A post-burn flexion contracture of the knee joint is a disabling condition which interferes with an upright posture and a bipedal locomotion. Islanded perforator flaps have been used to resurface the tissue defect which is produced as a result of the contracture release. Despite their various advantages, they are limited by an increased tendency to undergo venous congestion. Perforator-plus flaps can be used to overcome this limitation, while retaining the merits of the islanded perforator flaps. Methods: Ninteen patients with post flame burn flexion contractures of the knee joints underwent surgical releases and coverages by various local fasciocutaneous perforator-plus flaps. The patients were followed up for 6 months and the various aspects of the functional and the aesthetic rehabilitations were assessed. Results: All the local fasciocutaneous perforator-plus flaps resurfaced the tissue defect over popliteal fossa with good colour and texture match and maintenance of the contour. None of the flaps had any significant early or delayed complications (which included venous congestions) which necessitated reoperations. All the patients were satisfied with the functional and aesthetic outcomes. Conclusion: Local fasciocutaneous perforator-plus flaps can be considered as one of the primary treatment modalities for the surgical release and reconstruction of post burn flexion contractures of the knee.

Household Salt Iodine Content Estimation with the Use of Rapid Test Kits and Iodometric Titration Methods
Ashwini Kumar Nepal, Prem Raj Shakya, Basanta Gelal, Madhab Lamsal, David A Brodie, Nirmal Baral Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background: Universal salt iodization remains the best strategy for controlling iodine deficiency disorders in Nepal. Aims: This study was designed to study the salt types and the household salt iodine content of school aged children in the hilly and the plain districts of eastern Nepal. Material and Methods: This cross-sectional study was carried out on school children of seven randomly chosen schools from four districts, namely, Sunsari, Dhankuta, Sankhuwasabha and Tehrathum of eastern Nepal. The school children were requested to bring two teaspoonfuls (approx. 12-15 g) of the salt which was consumed in their households, in a tightly sealed plastic pouch. The salt types were categorized, and the salt iodine content was estimated by using rapid test kits and iodometric titrations. The association of the salt iodine content of the different districts were tested by using the Chi-square test. The sensitivity, specificity, positive predictive values, and negative predictive values of the rapid test kits were compared with the iodometric titrations. Results: Our study showed that mean±SD values of the salt iodine content in the four districts, namely, Sunsari, Dhankuta, Sankhuwasabha and Tehrathum were 34.2±17.9, 33.2±14.5, 27.4±15.1 and 48.4±15.6 parts per million (ppm). There were 270 (38.2%) households which consumed crystal salt and 437(61.8%) of the households consumed packet salts. Conclusions: Our study recommends a regular monitoring of the salt iodization programs in these regions. More families should be made aware of the need to ensure that each individual consumes iodized salt.

To Study The Incidence of Heterotopic Ossification After Anterior Cruciate Ligament Reconstruction
Bhaskara Bhandary, Sudeep Shetty, Vinay V. Bangera, Yogaprakash R., Mohammed Shabir Kassim, Karan Alva, Sudarshan Bhandary Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Introduction: Previous studies have enumerated the advantages of an arthroscopic Anterior Cruciate Ligament (ACL) reconstruction with the use of a Bone Patellar Tendon Bone (BPTB) graft. Complications are extremely rare in such surgeries and one such known complication, which is an extra-articular heterotophic ossification at the femoral tunnel site, is rarely seen only in few patients. Aim: To evaluate the incidence of heterotrophic ossifications at the femoral tunnel site and the efficacy of the preventive measures which were undertaken, in patients who had undergone ACL reconstructions with the use of bone patellar tendon bone grafts. Material and Methods: A total of 285 patients who had ACL tears within a duration of six years, were evaluated prospectively for the incidence of heterotrophic ossifications after they underwent arthroscopic reconstructions with the use of bone patellar tendon bone grafts by the double incision technique. The effect of the efficacy of various preventive measures on the incidence of the heterotophic ossifications post surgery was also studied. Results: The observed incidence of the heterotophic ossifications was 2.58% in patients whom preventive measures were not used. In contrast, an incidence of 1.54% of similar complications was recorded, after preventive measures were undertaken. Our results showed that heterotophic ossifications after arthroscopic reconstructions with the use of bone patellar tendon bone grafts were a rare complication and that their incidence could be further reduced if preventive measures were taken. Conclusion: The heterotophic ossification is a rare complication after an ACL reconstruction is done with the use of a bone patellar tendon bone graft by the double incision technique. Its incidence reduces significantly after preventive measures are undertaken.

Rigid Nasal Endoscopy in the Diagnosis and Treatment of Epistaxis
Vinay Kumar M.V., Raghavendra Prasad K.U., Belure Gowda P.R., Manohar S.R., Chennaveerappa P.K. Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Background and Objectives: Epistaxis is one of the common symptoms encountered in the Otorhinolaryngology department. Many times the cause for epistaxis is not found on anterior and posterior rhinoscopy. The present study was undertaken to assess the role of rigid nasal endoscope in the diagnosis and treatment of epistaxis, where normal anterior and posterior rhinoscopy did not reveal any specific finding. Methods: Fifty patients with epistaxis were studied using rigid nasal endoscope under local anaesthesia. Patients who were above 15 years with nasal bleeding and who were willing for rigid nasal endoscopy were included in the study. Patients less than 15 years were not included in the study because nasal endoscopy was difficult in them under local anaesthesia. Only those patients in whom, the cause for epistaxis could not be made out on anterior and posterior rhinoscopy were chosen for the study, this was done in order to remove the bias for nasal endoscopy. Results: The use of the nasal endoscope allowed diagnosis of bleeding points and treating them directly. Epistaxis was more in male patients especially in the 3rd and after the 5th decade. On endoscopic examination,the bleeding points were identified as coming from the crevices of the lateral nasal wall, posterior spur on the septum, posterior deviation of the septum with ulcer, congested polyps, enlarged and congested adenoids, scabs or crusts in the crevices of the lateral nasal wall and angiofibroma. Endoscope also helps in the treatment of epistaxis, which includes endoscopic selective nasal packing using gelfoam, endoscopic cautery or diathermy and endoscopic polypectomy. Other patients with adenoids, scabs and crusts and angiofibroma were managed on their merits. Interpretation and Conclusion: Nasal endoscopy helps not only in the localisation of the bleeding point but also in the treatment of those bleeding areas that are situated in the posterior and lateral part of the nose.

The Flexor Indicis Profundus - Its Morphology and Clinical Significance
Prathap Kumar J, Padmalatha K, Prakash B S, Radhika P M, Ramesh B R Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X The knowledge on the anatomical variations of the deep flexor muscles is important due to its evolutionary significance. The flexor digitorum profundus is the deep flexor muscle of the forearm. It is a composite muscle with a dual nerve supply. The medial half of muscle is supplied by the ulnar nerve, and lateral half of the muscle is supplied by the anterior interosseous nerve, a branch of the median nerve. It flexes the distal phalanges of the medial four digits. In the present case, we observed the presence of extensive cleavage of belly and tendon of flexor digitorum profundus to form flexor indicis profundus on the right side in an adult male cadaver. Flexor indicis profundus muscle is an example of progressive type of variation and it is usually asymptomatic, but it may cause compression of the anterior interosseous nerve, which can lead to compression neuropathy. If it is enlarged, it may simulate a ganglion.

Metaplastic Ossification in a Juvenile Rectal Polyp: A Rare Histological Finding
Monika Garg, Jasveen Kaur, Samridhi Bindroo, Anuradha Sharma, Nanak Chand Mahajan Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X An osseous metaplasia is a phenomenon which has been described in a wide variety of tissue types with respect to both neoplastic and non-neoplastic conditions. However, an osseous metaplasia is exceedingly rare in colonic polyps. We are herein representing a case of osseous metaplasia in a juvenile rectal polyp in a six year old boy, with review of the literature on the suggested mechanisms of its aetiology.

Primary Urachal Mucinous Adenocarcinoma of the Urinary Bladder
Iqbal Singh, Ravi Prasad Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Urinary bladder cancer is the second most frequent tumour of the genitourinary tract with bladder adenocarcinoma comprising for about 0.5-2% of all malignant bladder tumours. Other primary sites for such tumours include rectum, stomach, endometrium, breast, prostate, seminal vesicles and ovaries. Such non-urothelial bladder tumours with intramural bladder tumour growth may delay the onset of symptoms which may lead to a delay in the diagnosis and thereby adversely affecting the prognosis as compared to urothelial bladder tumours. Traditionally bladder adenocarcinomas were believed to be resistant to both chemotherapy and radiotherapy, but recent advancements have shown encouraging responses with adjuvant chemotherapy and radiotherapy. We present here a case of primary urachal mucinous adenocarcinoma of the urinary bladder highlighting their relative rarity of occurrence and the difficulties encountered in diagnosing primary bladder mucinous adenocarcinoma.

Vivax Malaria Presenting with Myelitis: A Rare Complication
Avijit Moulick, Somnath Maitra, Biswanath Sharma Sarkar, Anirban Jana, Sujoy Sarkar Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Neurological complications may occur with the Plasmodium falciparum infection. However, the association of neurological manifestations with vivax malaria remains doubtful. Of late, there are isolated case reports/studies which have implicated P. vivax in the pathogenesis of severe malaria which is characterized by the features of different organ dysfunctions, which were previously thought to be caused by P. falciparum alone. Though several case studies have mentioned the association of the P. vivax infection with cerebral malaria, a causal correlation has yet to be established. Dorsal cord myelitis (which leads to paraplegia) during the febrile illness, is rarely described in association with vivax malaria, though there are reports on the Post Malaria Neurological Syndrome (PMNS) and acute disseminated encephalomyelitis following vivax malaria. We are reporting a case of P. Vivax malaria which presented with myelitis, which responded well to the antimalarial treatment.

Haematemesis: An Uncommon Presenting Symptom of Plasmodium Falciparum Malaria
Peter George, Narasimha Hegde Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Plasmodium falciparum malaria with complications is a challenge for the clinicians worldwide, especially when it presents with rare manifestations. Haematological abnormalities and coagulopathy are the well documented complications in malaria. Rarely does malaria present with bleeding. We are reporting a 20 years old man who presented with haematemesis as the presenting symptom of falciparum malaria. In the review of literature, there are reports of haematemesis in malaria, but none of it as a presenting symptom.

An Impacted Denture in the Oesophagus- An Endoscopic or A Surgical Emergency-A Case Report
Parvinder Singh, Amritpal Singh, Puneet Kant, B. Zonunsanga, Amarjit Singh Kuka Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Accidentally swallowed dentures can lead to severe complications in the gastrointestinal tract. Therefore, an early detection and an effective therapeutic management are important. In the era of advanced endoscopy, though the primary treatment of an impacted foreign body in the oesophagus is an endoscopic removal, a primary surgical treatment is advised for dentures with sharp hooks. Also, a prolonged impaction of dentures with sharp hooks leads to an increase in the complication rates. We are reporting a case of accidentally swallowed denture. After the diagnosis of an impacted denture was made, upper GI endoscopy revealed that an endoscopic removal was not feasible and thus, a late surgical removal was performed in the form of a transhiatal oesophagectomy and reconstruction. This case highlights the importance of an early and preferred treatment in the form of a controlled surgical intervention as compared to an endoscopic extraction for patients with impacted dentures with sharp hooks.

Livedoid Vasculopathy and Mononeuritis Multiplex, with a Fulminant Hepatic Failure which was caused by Herpes Simplex Hepatitis: A Case Report
Sathish Pai B, Kanthilatha Pai Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Livedoid vasculopathy with mononeuritis multiplex is a rare association. We are presenting a case of an unusual association of livedoid vasculopathy with mononeuritis multiplex, who developed fulminant hepatic failure which was secondary to Herpes simplex virus (HSV) hepatitis, while she was on treatment with immunosuppressants. Her skin biopsy and immunofluorescence studies showed the features of vasculitis. A biopsy from the sural nerve showed the features of chronic vasculitis.

A Rare Case of Craniofacial Morphology with Absent Face and Neck Structures, with Its Review
Lokadolalu Chandracharya Prasanna, Kumar M.R. Bhat,, Antony Sylvan D’Souza Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X The development of the head and the face requires an intimate interaction between two mesenchymal populations, a paraxial mesoderm and neural crest cells for the morphogenesis of the musculoskeletal components of the calvaria, the face and the branchial regions. The disruptions in these interactions can cause foetal fatalities or congenital craniofacial anomalies. We are describing a rarest case with a craniofacial malformation, who was born with complete absence of the facial skeleton and the neck structures, a set of well developed ears in their normal locations and eyelids at the junction between the head and the thorax.

Primary Genito-Urinary Tuberculosis with Bilateral Urolithiasis and Renal Failure-An Unusual Case
Sandeep Gupta, Santhosh R, Kangjam Sholay Meitei, Sinam Rajendra Singh Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Urolithiasis leading to renal failure is a very common occurrence. But if the patient is co-infected with genitourinary tuberculosis, then it becomes all the more unusual and challenging, especially if the patient is immunocompetent. This patient, who presented to us with bilateral urolithiasis and features of renal failure, underwent left nephrectomy after thorough investigations. The biopsy revealed features of renal tuberculosis. The patient was put on anti-tubercular therapy (ATT) and later, he underwent right ureteroscopic lithotripsy. He completed his course of ATT and is on regular follow-up. His serum creatinine also stabilised with regular hemodialysis. The main aim of this case report is to bring to light this unusual and interesting presentation of bilateral urolithiasis with genito-urinary TB presenting as renal failure, which was successfully managed.

Primary Bilateral Fallopian Tube Carcinoma The Report of a Single Case with Review of the Literature
Prajna Hariprasad, Hariprasad S., Teerthanath Srinivas, Jayrama Shetty K. Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Primary fallopian tube carcinoma is an extremely uncommon neoplasm of the female genital tract. Primary Fallopian Tube Carcinoma (PFTC) has a clinical and a histological resemblance to Epithelial Ovarian Cancer (EOC). We are reporting a case of PFTC in a 55 year old tubectomized, postmenopausal woman with the non-specific complaints of a watery vaginal discharge and lower abdominal pain. The clinical and radiological findings suggested a bilateral tubo-ovarian abscess. On laprotomy, a bilateral fallopian tube tumour was seen, with a focal extension to the surface of the right ovary from the right fallopian tube. Total abdominal hysterectomy, bilateral adnexectomy andomentectomy, along with excision of the draining lymph nodes, was done. The histopathological examination revealed a bilateral papillary serous carcinoma of the fallopian tube. The patient was treated with adjuvant chemotherapy with Paclitaxel. There was no evidence of any recurrence, after 2 years of regular follow up. The clinical signs and symptoms of fallopian tube neoplasms are usually non-specific. The primary treatment remains a surgical resection, followed by adjuvant chemotherapy or radiation. The prognosis is poor, although long-term survivors have been reported.

Perineal Bull Gore with Urinary Bladder Perforation and Pneumoperitoneum
Santhosh R, Arun Kumar Barad, Hemanth Sureshwara Ghalige, Sridartha K, Birkumar Sharma M Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Animal related injuries are frequently reported in India and other countries, where bulls are used for sporting events as well as in places where farming and livestock rearing is practised. The presentation is, many times, atypical and misleading as well. They have unique mechanics of injury. The patterns of the injury are reviewed. An intra-peritoneal urinary bladder injury which is caused by a perineal bull gore with a pneumoperitoneum is unusual and it has not been reported in the literature which was reviewed. We are reporting a successfully treated 25 years old male patient from the slopes of the southern district of Manipur, India, who had presented 40 hours after he was injured. The identification and prompt exploration, keeping in mind the mechanics of bull goring, helps the surgeons to adequately deal such atypical injuries, for optimal outcomes.

Misplaced Intrauterine Contraceptive Devices: Common Errors: Uncommon Complications
Vishwas Johri, Kailash C Vyas Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Contraception is essential in a developing country like India. Intrauterine Contraceptive Devices (IUCDs) are amongst the most frequently used methods of contraception. The patients with misplaced IUCDs may present with pregnancies or ‘lost strings’ or they may remain asymptomatic.

The Associations of Nuchal Translucency and Fetal Abnormalities: Significance and Implications
Shaista Salman Guraya Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X This review of literature describes the first-trimester nuchal translucency (NT) which forms the basis of new form of screening which can lead to a significant improvement in detection of congenital anomalies as compared to second trimester screening programs, the so called genetic-sonogram. A growing body of evidence-based studies has demonstrated that fetal NT can be a powerful prenatal screening tool and combined with first trimester serum markers, it can be incredibly promising in near future. It should be expressed as Multiple of median (MoM) and maintained and monitored like any laboratory analyte. The aim of this review was to investigate the different hypotheses on the aetiology of increased NT. Using a computerized database (PubMed), articles on the aetiology of first-trimester NT were retrieved. Furthermore, the cited references of the retrieved articles were used to find additional articles. Based on ultrasonography, the associations of increased NT fetuses are described in relation with Down syndrome, Cardiac anomalies, and a diverse range of other anomalies. The review concludes that first trimester NT ultrasound has the potential to be used as an important tool for the detection of various congenital abnormalities and an early management can be implemented to reduce the mental trauma of expecting mothers by proper counseling and early diagnosis. For the precise measurements, it should be implemented in a meticulous and coherent manner.

The Role of Colour Doppler Ultrasonography in the Diagnosis of Fascial Space Infections - A Cross Sectional Study
Aarthi Nisha V., Parthiban J., Santana N., Giridhar A.G, Yashoda Devi B.k., Sujatha Reddy S., Rakesh N. Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Aims and Objectives: (1) To evaluate the role of ultrasonography with colour Doppler in the diagnosis of fascial space infections, (2) To determine the nature, size and extent of the odontogenic infections which involve the primary and secondary fascial spaces of the maxilla and the mandible (3) To evaluate the sensitivity of ultrasonography in determining whether the inflammatory process is in a stage of cellulitis or abscess and to thus determine the appropriate time for a surgical intervention during the course of the infection and to correlate the clinical and radiographic findings with the ultrasonographic findings and (4) to determine the treatment plan. Methodology: Thirty four patients with odontogenic infections which involved the superficial and the deep fascial spaces of the head and neck were subjected to ultrasonographic examinations over the suspected area in the transverse and axial directions to determine the stage of the infection, its anatomic location and the treatment plan. Results: Ultrasonography showed 95.7% sensitivity and 100% specificity as compared to the clinical and radiographic diagnoses and it proved to be an effective investigation modality in the diagnosis of fascial space infections. Conclusion: The addition of ultrasonography to the clinical and radiographic examinations provides a high sensitivity and a specificity and it also increases the accuracy of the diagnosis of odontogenic space infections.

The Aesthetic Management of a 180 Degree Rotated Maxillary Central Incisor With Two Root Canals- A Case Report
Shweta Jain, Praful Narang, Rohit Sharma, Vijay Agarwal Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X The success of the root canal treatment is based on a thorough knowledge of the normal tooth, the root and the root canal morphology, which include variations. Tooth rotation is a common finding in the premolar-molar region, but a 180 degree rotation of the maxillary central incisor is extremely rare and it has not documented anywhere in the dental literature. This case report describes the aesthetic correction of a maxillary central incisor with a 180 degree rotation and two root canals.

Molecular Predictors in the Early Diagnosis of Oral Cancer
S. Rajkumari, J. Sathiyajeeva, C. Santhosh Kumar, P. M. Sunil, B. Thayumanavan Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Human beings are being subjected to a variety of disease processes, a majority of which can be cured. However, cancer remains an endangering disease that affects various body parts. Though cancers can be prevented by various therapeutic modalities, the patient survival and the prognosis are questionable, as they are detected at very late stages. The aim of improving the prognosis lies in an early detection of the cancer, which can be brought about by an analysis of the changes in the cellular biomolecules.

Mystery Inside the Tooth: The Dental Pulp Stem Cells
K.M.K. Masthan, S. Leena Sankari, N. Aravindha Babu, T. Gopalakrishnan Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Stem cells are distinguished by their ability to differentiate into different types of cells in the body and to self-replicate. During the recent years, stem cells have been used extensively in the field of medicine for the repair and regeneration of defective tissues and organs. However, the knowledge on the stem cell technology is increasing quickly in all medical disciplines and it dictates the need for new protective approaches in all fields, which include reparative dentistry. Stem cell therapy constitutes a common challenge for dentists as well as for biotechnologists. The aim of this study was to review the knowledge which was related to stem cells and to consider the possibility of use of stem cell populations and their technology in the future clinical applications, to cure diseases like Parkinsonism, Juvenile diabetes, certain forms of cancer, spinal injuries and heart problems.

Dental Considerations In Pregnancy-A Critical Review on The Oral Care
Hemalatha VT, Manigandan T, Sarumathi T, Aarthi Nisha V, Amudhan A Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Pregnancy is a dynamic physiological state which is evidenced by several transient changes. These can develop as various physical signs and symptoms that can affect the patients health, percep - tions and interactions with others in the environment. The patients may not always understand the relevance of the adaptations of their bodies to the health of their foetuses. A gestational woman requires various levels of support throughout this time, such as medical monitoring or intervention, preventive care and physical and emotional assistance. The dental management of pregnant patients requires special at - tention. Dentists, for example, may delay certain elective proce - dures so that they coincide with the periods of pregnancy which are devoted to maturation versus organogenesis. At other times, the dental care professionals need to alter their normal pharma - cological armamentarium to address the patients’ needs versus the foetal demands. Applying the basics of preventive dentistry at the primary level will broaden the scope of the prenatal care. Den - tists should encourage all the patients of the childbearing ages to seek oral health counseling and examinations as soon as they learn that they are pregnant. This article has reviewed some of the physiologic changes and the oral pathologies which are associated with pregnancy, and how these alterations can affect the dental care of the patient.

Fibrous Dysplasia and Central Giant Cell Granuloma: A Report of Hybrid Lesion with its Review and Hypotheticated Pathogenesis
Saritha Kurra, Sreenatha Reddy D., Sumanth Gunupati, Srikanth K., Srinath Reddy M. Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Benign fibro–osseous lesions (BFOLS) of the jaws are a wide array of lesions that actually represent distinct phases of a single benign morphological process. These lesions share certain histopathological features which are in common with giant cell containing lesions, which include central giant cell granulomas (CGCGs). The association of BFOLS and CGCG has to be critically evaluated, pertaining to their clinical, radiologic and histologic features. Many pathologists diagnose these types of lesions, considering only one of the prominent features. Eventually, surgeons end up treating these lesions inadequately. This ambiguity may be because of very small number of cases have been reported in the literature, with uncertain clinical, radiologic and histologic features. We are reporting a case of fibrous dysplasia (FD) which was associated with a central giant cell granuloma (CGCG) and discussing the hypothetical pathogenesis of giant cells.

The Crouzan Syndrome-A Case Report
Manu Prasad, Ashwini S. Shetty, Manjula Shantaram Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X The Crouzon syndrome is a genetic disorder which is known as the brachial arch syndrome. It is an autosomal dominant disorder which is one of a rare group of syndromes which is characterized by cranio synostosis or a premature closing of the cranial sutures. The major features are brachiocephaly, occular proptosis, an under developed maxilla, mid face hypoplasia, a rare cleft lip or palate, hypodontia (some teeth missing) and crowding of teeth. Due to the maxillary hypoplasia, the Crouzon syndrome patients generally have a considerable permanent underbite and they subsequently cannot chew by using their incisors. We have presented in this article, a case of the Crouzon syndrome which was seen in a girl who was aged six years, with similar symptoms and the multidisciplinary approach which has to be followed in managing the case.

Chvostek’s and Trousseau’s signs in a Case of Hypoparathyroidism
Mohammad R. Mohebbi, Kurt A. Rosenkrans, Michael J. Jung Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X Downoad full video from below link : Download full video

An ‘Open–Ishihara-Book’ Case of What Lies Beneath
Samuel George Parker, Jonathan Costello Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X

The Role of the Total Cholesterol Level in the Assessment of the Severity of Myocardial Infarction
S. Venkata Rao, Mahendra Gandhe, S.Indira, P. Srilakshmi, Kalyan Goswami Journal of clinical and diagnostic research : 2013 - May - 7:0973-709X