Journal of clinical and diagnostic research

Unusual and Unique Variant Branches of Lateral Cord of Brachial Plexus and its Clinical Implications- A Cadaveric Study

Profile of Kidney Histopathology in Cases of Burns - Particular Emphasis on Acridine Orange Fluorescence Study and to Explore its Forensic Utility

Bharat V. Bhetariya, Nandini J. Desai, B.D. Gupta, Pratik N. Patel

Introduction: The major cause of death in the burn patients includes multiple organ failure and infection but, sometimes the exact cause of death in many fatally burned patients is difficult to detect. Many times in medico-legal post-mortem examinations in cases of burns, histopathological examination of organs is requested. Aim: The aim was to study various histopathological changes in kidneys in the post-mortem cases of burns, by using routine Haematoxylin and Eosin stain (H&E stain), special Periodic and Schiff’s Stain (PAS) stain, to study the role of acridine orange fluorescence study, to explore the forensic utility of this microscopic study and to find out the relationship between duration of survival and histopathological changes observed. Materials and Methods: An experimental longitudinal prospective study from October 2010 to September 2012. Total 32 cases of death due to burns were autopsied at mortuary, the Department of Forensic Medicine and Toxicology in our hospital. Bilateral kidneys were removed and preserved in 10% formalin solution. These were forwarded to Department of Pathology for histopathological examination. Routine microscopic examination by H&E stain as well as PAS stain and fluorescence study by acridine orange stain were done in all cases. Results: It was observed that in 21 (65.63%) cases gross findings in kidneys were normal, in 06 (18.75%) were grossly pale and in 05 (15.62%) heavy & congested. Sections taken from kidneys and studied by H&E stain showed overlapping histopathological changes in all cases. In 26 (81.25%) cases, changes of Acute Tubular Necrosis (ATN) while in remaining 06 (18.75%), changes of cloudy swelling were observed. The sections stained by acridine orange and observed under fluorescent microscope were lightly positive in 15 (46.88%), brightly positive in 08 (25.00%) whereas, negative in 09 (28.12%). Conclusion: Microscopy by various methods helps in getting specific lesions in kidney due to burns. However, it does not add any new tool to resolve any forensic issues of burns. Therefore, microscopy (including florescent), if done would be redundant.

Association Between Serum B12 and Serum Homocysteine Levels in Diabetic Patients on Metformin

Twinkal R. Upadhyay, Nitin Kothari, Hitesh Shah

Introduction: Type-2 Diabetes Mellitus (T2DM) and metformin both can lower serum B12 (s.B12). Raised serum Homocysteine (s.Hcy) is considered as an early marker of B12 deficiency. Aim: The study aimed to check whether homocysteine levels are more sensitive indicator of s. B12 deficiency or not among diabetics using metformin. Materials and Methods: Mean s.B12 and s.Hcy levels of 30 cases (diabetics on metformin <5years) were compared with 30 diabetic controls not on metformin and 31 nondiabetic controls and statistically analysed by ANOVA and post-hoc tests. Results: No significant differences in either s.B12 mean or s.Hcy mean were found between cases and diabetic controls. s.B12 mean did not differ significantly but s.Hcy mean was significantly higher among nondiabetics as compared to diabetic control. s. B12 level of Nondiabetic group was in borderline category while mean s. B12 levels of cases and diabetic control groups was in normal category but nearer to the lower cut off. Mean s.Hcy values in all the groups were high. Pearson correlation showed strong association between s.B12 and s.Hcy in all the groups. Additionally equation based on linear regression was derived to calculate either of the s.B12 or s.Hcy. On Receiver Operative Characteristic (ROC) curve, area under curve value was 0.842 for the value of s.Hcy. Conclusion: In this study neither metformin nor T2DM could be identified as a cause for s.B12 lowering and raised s.Hcy in the scenario of low normal levels of s.B12 (<300pmol/L). If B12 deficiency recognized early using s. Hcy, consequences due to B12 deficiency can be prevented or delayed among nondiabetics as well as among diabetics and metformin users.

Atypical Lymphocytes and Cellular Cannibalism: A Phenomenon, First of its Kind to be Discovered in Chronic Periapical Lesions

Ketki P Kalele, Kaustubh P. Patil, Abhishek Singh Nayyar, Rutuparna S Sasane

Introduction: Lymphocytes are often termed to be isomorphic, having a monotonous light microscopic appearance. Morphological aspects of lymphocytes in tissue sections thereby are not routinely taken notice of as their morphology seems to vary only in case of lymphoid malignancies, hematological malignancies apart from certain viral infections. Atypical lymphocytes are the lymphocytes with unusual shape, size or overall structure. These are more commonly known as reactive lymphocytes. The unusual histomorphological feature of these cells include larger size than normal lymphocytes; in some cells the size exceeds even 30 microns. The large size is the result of antigenic stimulation of the cell. Alongwith these, the other rare feature which is recently coming under light is “Cellular Cannibalism” which is defined as a large cell enclosing a slightly smaller one within its cytoplasm. Previously, this feature was noted only in cases of malignant tumors. Aim: The objectives of this study were to determine the proportion of atypical lymphocytes in chronic periapical granulomas and cysts; to determine the proportionate cellular cannibalism in these periapical lesions. Materials and Methods: This was a descriptive, observational study conducted in the Department of Oral Medicine and Radiology and Oral Pathology and Microbiology. Haematoxylin and eosin stained 30 slides of chronic periapical granulomas and 20 slides of cysts reported in the year 2014-15 and the clinical proformas of the patients were retrieved from the files of the Department of Oral Medicine and Radiology and Oral Pathology and Microbiology. These slides were evaluated by 3 experts from the specialization of Oral Pathology and Microbiology to determine the presence of atypical lymphocytes and cellular cannibalism under high power magnification (400X). Results: Out of the 30 slides of chronic periapical granulomas, about 12 slides (40%) revealed presence of atypical lymphocytes. In case of slides of chronic periapical cysts, however, only 4 out of the 20 slides (20%) examined histopathologically showed presence of atypical lymphocytes. An interesting feature of cellular cannibalism was noted in tissues with atypical cells. Cannibalistic cells were present in 12 out of the 30 slides of chronic periapical granulomas (40%). None of the cysts, however, revealed cannibalistic cells (0%). Conclusion: In the present study, we have quoted our observations on the unique cellular composition that was seen in histopathological sections of chronic periapical lesions. As also it was noted that those cases in which atypical cells & cellular cannibalism was evident the lesion clinically showed size more than 5cm. The question arises that whether presence of atypical cells from the tissue sections in these lesions denotes an aggressive clinical behavior and should be given a due consideration in deciding the treatment protocols for such cases to provide an optimum patient care.

Morphometric Study of Anterior Clinoid Process and Optic Strut and the Ossification of Carotico-Clinoid Ligament with their Clinical Importance

Introduction: Knowledge about the ossification of the Carotico-Clinoid Foramen (CCF), as it forms a potential site for compression of the internal carotid artery may be beneficial for neurosurgeons and radiologists. Aim: To obtain a detailed knowledge of morphometry of Anterior Clinoid Process (ACP) and Optic Strot (OS) and the type of ossification of CCF which would be necessary to increase the success of surgeries related to the cavernous sinus and internal carotid artery. Materials and Methods: Parameters such as the length of ACP from its base to the tip, the width at its base and the distance between the tip of ACP to optic strut were measured in mm using digital calipers. SPSS version 17 was used for the statistical analysis. Paired t-test was applied to compare between right and left sides. Presence of carotico-clinoid foramen was observed and was classified as incomplete, contact form or complete. Results: The average length of ACP ranged from 12 to 15mm on right side and 11 to 16mm on the left side. Paired t-test was applied to compare the means between the right and left sides. The width of ACP varied between right and left sides and this difference was statistically significant (p<0.05). Out of 12 CCF observed, the commonest type was incomplete (N=7) followed by complete (N=3) and contact form (N=2). Conclusion: Considering the immense anatomical surgical and radiological importance of morphology of ACP, OS and CCF, this study highlighted the detailed morphometry of these structures. The study also has explained the sexual dimorphism in their morphology.

A Clinical Study to Examine the Effect of Complete Denture on Head Posture/Craniovertical Angle

Introduction: Edentulous patients show some significant changes in ridge relationship caused by resorption of alveolar ridge. The changes are characterized by an upward rotation of mandible, increase in mandibular prognathism that ultimately results in change of natural head posture. Aim: This clinical study was planned to know the effect of complete denture on head posture in different age groups of Indian completely edentulous population, after placement of complete denture at various time intervals. Materials and Methods: The sample consisted of completely edentulous patients without previous experience of the dentures. They were divided into 2 age groups: Group A (45-60) and Group B (61-75). During placement of complete denture craniovertical angle was measured with the help of custom made ruler protector device. Readings were taken before denture placement, immediately after denture placement, 30 minutes, 24 hours and 30 days after dentures placement. Results: The results of this study indicated that in most of the patients (90%) despite their age, change in head posture (extension) occurred immediately after the denture placement. Thereafter reading remains same for measurement at 30 minutes and 24 hours of denture placement. However after 30 days, observation revealed that all the patients showed reduced craniovertical angle (flexion). Even though the values of craniovertical angle remain higher than its baseline in both groups, significant changes were noticed only in Group A. Conclusion: Findings revealed that head posture was significantly altered by the placement of dentures in completely edentulous patients. Within the time interval of 30 minutes and 24 hours extension of head posture remained constant with slight variation. Although after 30 days, changes remained significant for group ‘A’, but no significant changes were observed in the subjects of group ‘B’.

Prevalence of Dental Caries among School Children in Chennai, Based on ICDAS II

Ponnudurai Arangannal, Sunil Kumar Mahadev, Jeevarathan Jayaprakash

Introduction: Dental caries is a common dental disease, which occurs during childhood and continues to be a major public health problem. The prevalence of dental caries was associated with oral hygiene practice, sugar consumption and implementation of the preventive oral health program. Aim: The purpose of this study was to assess the prevalence of dental caries in school children aged between 6-14 years using the International Caries Detection and Assessment System (ICDAS II). Materials and Methods: The study population consisted of 2796 school children living in Pallikkaranai, Chennai, India and studying in government recognized schools. Each student was examined by a single examiner using ICDAS system under natural light during normal school hours. Results: The prevalence of dental caries was 68.8% in the total surveyed population. The gender-wise prevalence of dental caries shows, females to have slightly higher prevalence than male. The prevalence of dental caries at the age group of 6 years was 57%, seven year 67%, eight year 63%, nine year 74%, 10 year 76%, 11 year 74%, 12 year 69%, 13 year 71%, and 14 year 69%. The distribution of CARS (Caries associated with Sealants and Restorations) in the surveyed population was only 1.4% Conclusion: The distribution of non-cavitated/early enamel lesions was higher in the studied population and indicated a requirement of a sustained dental health preventive program targeting specific segments of the population.

Evaluation of the Symptom of Constipation in Indian Patients

Gautam Ray

Introduction: The exact prevalence of constipation in India is unknown. To know this, first it has to be properly defined based on stool frequency and form (as in western definition) in Indian patients, data on which is scarce. There may be difference with the western definition also. Aim: To determine the stool frequency and form in patients consulting doctor for the complaint of constipation and compare these with the Western definition of constipation. Materials and Methods: This was a prospective cross-sectional study on 331 consecutive patients seeking medical advice for their complaint of constipation. They were administered a questionnaire containing Rome III criteria points of functional constipation and constipation predominant irritable bowel syndrome and the Bristol stool chart to report their predominant stool form. Organic bowel diseases were excluded by further history taking, physical examination and appropriate investigations. The data on stool frequency and form thus obtained were compared with the existing Indian population data. Results: A total of 65% patients were above 60 years of age. The predominant stool types were 1-3 according to Bristol stool form scale present in 93.8% patients and conformed to Asian criteria of constipation by stool form. Only 67.9% patients passed Bristol Stool Scale (BSS) type 1 and 2 stool which is the western definition. 51.5% reported a frequency of 3-4 motions/week, 19.8% had normal stool frequency by Indian standard (i.e. at least 1 motion/day) and only 35.4% had constipation by Western criteria (less than 3 motions/week). Hence subjective feeling varied widely from observed rate and Western definition was invalid in about twothird of patients. Feeling of incomplete evacuation was universal and this was referred to as constipation by patients. Functional constipation was diagnosed in 69.1% (of whom most were elderly with co-morbidities) and constipation predominant irritable bowel syndrome in 13.8% by Indian standard. Only 2.1% had colonic cancer. Conclusion: A stool frequency of <5 motions/week appears more appropriate in Indian definition of constipation where the subjective feeling of incomplete evacuation should also be given due weightage. Asian criteria based on stool form holds true in India.

Heavy Metal Contamination in Groundwater around Industrial Estate vs Residential Areas in Coimbatore, India

K. Mohankumar, V. Hariharan, N. Prasada Rao

Introduction: Water is the vital resource, necessary for all aspects of human and ecosystem survival and health. Depending on the quality, bore water may be used for human consumption, irrigation purposes and livestock watering. The quality of bore water can vary widely depending on the quality of ground water that is its source. Pollutants are being added to the ground water system through human and natural processes. Solid waste from industrial units is being dumped near the factories, which react with percolating rainwater and reaches the ground water. The percolating water picks up a large number of heavy metals and reaches the aquifer system and contaminates the ground water. The usage of the contaminated bore water causes the diseases. Mercury, Arsenic and Cadmium are used or released by many industries. Aim: This study was conducted to investigate the pollution of bore water in the industrial region (Kurichi Industrial Cluster) of Coimbatore, in the state of Tamilnadu, India. Materials and Methods: Four samples were taken from residential areas around Kurichi Industrial Cluster and analysed to find the concentrations of Mercury, Arsenic and Cadmium. Four more samples were taken from other residential regions far from the industrial estate and served as control. Samples were analysed using Atomic absorption spectrophotometry method. Results: We found that the ground water of the areas surrounding the industrial cluster does not contain significant amount of those metals. Instead, Heavy metal contamination of ground water were observed in some residential areas of coimbatore. Conclusion: The regulatory measures to contain and prevent ground water contamination by industries undertaken by Tamilnadu pollution control board may have lead to absence of heavy metal contamination in Kurichi Industrial cluster, Coimbatore, India.

Effect of Vitamin C Supplementation on Blood Lead Level, Oxidative Stress and Antioxidant Status of Battery Manufacturing Workers of Western Maharashtra, India

Introduction: The high blood lead level induces oxidative stress and alters the antioxidant status of battery manufacturing workers. Supplementation of vitamin C is beneficial to reduce the oxidative stress and to improve the antioxidant status of these workers. Aim: The main aim of this study was to observe the changes in blood lead levels, oxidative stress i.e. serum lipid peroxide and antioxidant status parameters such as erythrocyte superoxide dismutase and catalase and serum nitrite after the vitamin C supplementation in battery manufacturing workers. Materials and Methods: This study included 36 battery manufacturing workers from Western Maharashtra, India, having age between 20-60 years. All study group subjects were provided vitamin C tablets (500 mg/day for one month) and a blood sample of 10 ml each was drawn by puncturing the anterior cubital vein before and after vitamin C supplementation. The biochemical parameters were estimated by using the standard methods. Results: Blood lead levels were not significantly altered, however, serum lipid peroxide (p<0.001, -15.56%) and serum nitrite (p<0.001, -21.37%) levels showed significant decrease and antioxidant status parameters such as erythrocyte superoxide dismutase (p<0.001, 38.02%) and catalase (p<0.001, 32.36%) revealed significant increase in battery manufacturing workers after the supplementation of vitamin C. Conclusion: One month vitamin C supplementation in battery manufacturing workers is not beneficial to decrease the blood lead levels. However, it is helpful to reduce the lipid peroxidation and nitrite formation and enhances the erythrocytes superoxide dismutase and catalase activity.

Effect of ACP-CPP Chewing Gum and Natural Chewable Products on Plaque pH, Calcium and Phosphate Concentration

Introduction: Numerous epidemiological studies have documented dental caries as the major public health problems throughout the world. It is gradually increasing in the underdeveloped and developing countries especially in children due to increasing popularity of refined sugars. Aim: The aim of the study was to evaluate the effect of natural chewable products (Tulsi, sesame seeds, fennel seeds, coconut) and ACP-CPP chewing gum on plaque pH, calcium and phosphate concentration. Materials and Methods: A randomized controlled trial, with a cross-over study design, was conducted. Ten subjects aged 15-17 years who agreed to refrain from oral hygiene practice for 48 hours prior to the sample collection were selected for the study. The baseline plaque pH, calcium and phosphate was measured and repeated after 5 and 30 minutes. It was ensured that each study participant was subjected to all the products making an effective sample of ten subjects per product. The data was statistically analysed. Results: The mean pH in all the study groups increased after 5 minutes and 30 minutes compared to baseline, except for coconut group at 30 minutes and fennel group at 5 minutes. Highest increase in plaque calcium concentration was found in fennel group followed by recaldent and sesame, respectively. Whereas, the highest increase in plaque phosphate was found in recaldent group followed by sesame group and fennel group respectively. Conclusion: Plant products can be effective, inexpensive, easily accessible methods of maintaining oral health. Further studies are recommended to confirm long term effects.

Friction between Archwire of Different Sizes, Cross Section, Alloy and Brackets Ligated with Different Brands of Low Friction Elastic Ligatures- An Invitro Study

Introduction: Friction in orthodontic treatment does exist and is thought to reduce the efficiency of orthodontic appliances during sliding mechanics. During sliding mechanics, a friction force is produced at the bracket archwire-ligature unit which tends to counteract the applied force and in turn resists the desired movement. Aim: The aim of this invitro study was to determine the friction between archwire of different sizes, cross section, alloy and brackets ligated with different brands of low friction elastic ligatures. Materials and Methods: An 0.022-in slot, 10 stainless steel brackets and various orthodontic archwires which were ligated with low-friction ligatures and subjected to evaluate frictional resistance i.e. static friction and dynamic friction. The archwires of 0.014” and 0.016” nickel titanium (NiTi), 0.016 × 0.022” stainless steel (SS), 0.017 × 0.025” NiTi, 0.017 × 0.025” SS, 0.017 × 0.025” titanium molybdenum alloy (TMA), 0.019 × 0.025” SS were used. Each bracket/archwire combination was evaluated 10 times at room temperature of 27 ± 2ºC. The study groups included Group I of conventional round shape module with reduced friction coating i.e. super slick and synergy and Group II contained figure of “8” shape module i.e. Octavia ties and Slide ligature. Result: The mean static friction force and dynamic friction force for all 7 types of wires was lower in Group II (C, D) combined compared to Group I (A, B) and the difference was statistically very highly significant (p<0.001). Conclusion: Super slick and synergy can be used in the initial and final phase of treatment when full engagement of archwire in the bracket slot is necessary for proper tip and torque expression. Slide and Octavia ties modules can be used in the premolar brackets during en mass retraction when using friction mechanics.

A Comparative and a Qualitative Analysis of Patient’s Motivations, Expectations and Satisfaction with Dental Implants

Introduction: Dental Implants are the norm of today’s prosthetic and restorative dentistry but, is it the answer for edentulism that can affect both individual’s appearance and functioning, therefore having an impact on the psychological and the social well being of the person is an ongoing quest. Also, patient’s beliefs and personal expectations for dental implants vary, which may influence the treatment outcome, thus emphasizing the importance of a good clinician–patient communication. Hence in this study a qualitative analysis was carried out with an earnest attempt to gain an insight into patient’s motivations, personal expectations, satisfaction and impact of clinician’s motivation for implant maintenance. Aim: To learn about patient’s expectations and their level of satisfaction from dental implants. To know the impact of clinician’s instructions and motivation for implant maintenance, with the patient’s level of understanding and compare the level of motivation for implant maintenance and care provided by a dentist with Bachelor’s degree to a dentist with a Master’s degree. Materials and Methods: A 30 systemically healthy patients who had undergone implant treatment (aged 25-65 years) were considered and divided into two groups: Group A: 15 patients in whom implant placement was done by a dentist with Bachelor’s degree (24 years, 18 years in general and implant practice respectively) and Group B: 15 patients in whom implant placement was done by a dentist with a Master’s degree (Periodontics; 20 years,17 years in general and implant practice respectively). A qualitative analysis with the help of appropriate questionnaires comprising of multiple choice questions specifically designed for this purpose and few open ended questions was carried out with an earnest attempt to gain an insight into patient’s motivations, personal expectations, satisfaction and impact of clinician’s motivation for implant maintenance. Results: Patients motivations for seeking implants and their expectations of treatment differed. Dental implants had met the patient’s pre-treatment expectations and they were satisfied. Variations in the knowledge on the maintenance of the implants by the patients and the kind of maintenance care provided by the dentists varied between the two groups. Conclusion: In regard to the patient’s compliance towards dental implants, a clinician must ensure that patients understand the different demands.

A Custom Made Intrinsic Silicone Shade Guide for Indian Population

K.V. Anitha, Mohammed Behanam, S.C. Ahila, J. Brintha Jei

Introduction: Replication of natural skin colour in maxillofacial prosthesis has been traditionally done using trial and error method, as concrete shade guides are unavailable till date. Hence a novel custom made intrinsic silicone shade guide has been attempted for Indian population. Aim: Reconstruction of maxillofacial defects is challenging, as achieving an aesthetic result is not always easy. A concoction of a novel intrinsic silicone shade guide was contemplated for the study and its reproducibility in clinical practice was analysed. Materials and Methods: Medical grade room temperature vulcanising silicone was used for the fabrication of shade tabs. The shade guide consisted of three main groups I, II and III which were divided based upon the hues yellow, red and blue respectively. Five distinct intrinsic pigments were added in definite proportions to subdivide each group of different values from lighter to darker shades. A total number of 15 circular shade tabs comprised the guide. To validate the usage of the guide, visual assessment of colour matching was done by four investigators to investigate the consent of perfect colour correspondence. Data was statistically analysed using kappa coefficients. Results: The kappa values were found to be 0.47 to 0.78 for yellow based group I, 0.13 to 0.65 for red based group II, and 0.07 to 0.36 for blue based group III. This revealed that the shade tabs of yellow and red based hues matched well and showed a statistically good colour matching. Conclusion: This intrinsic silicone shade guide can be effectively utilised for fabrication of maxillofacial prosthesis with silicone in Indian population. A transparent colour formula with definite proportioning of intrinsic pigments is provided for obtaining an aesthetic match to skin tone.

Chronic Periodontitis in Type 2 Diabetes Mellitus: Oxidative Stress as a Common Factor in Periodontal Tissue Injury

Introduction: The prevalence of periodontitis is significantly higher among people with poorly controlled diabetes mellitus. Majority of tissue destruction in periodontitis is considered to be the result of an aberrant inflammatory/immune response to microbial plaque and involve prolonged release of reactive oxygen species (ROS). There is increased evidence for compromised antioxidant capacity in periodontal tissues and fluids which may be an added factor for tissue damage in periodontitis. Aim: To study the possible role of Reactive oxygen species (ROS) and antioxidant status in blood among chronic periodontitis patients with and without Type 2 Diabetes mellitus. Materials and Methods: The study comprised of total 100 subjects among which 25 were normal healthy controls, 25 were gingivitis patients, 25 were chronic periodontitis patients (CP) and 25 were having chronic periodontitis with type 2 diabetes (CP with DM). ROS levels were determined as MDA (Malondialdehyde) and antioxidant status as plasma total antioxidant capacity (TAC), vitamin C and erythrocyte Superoxide dismutase (SOD) and catalase activity. Results: There was significant increase in MDA levels in all the patient groups compared with healthy controls (p<0.05). The decrease in TAC, Vitamin C and SOD levels among CP with DM patients as compared to controls was highly significant (p<0.01). There was a positive correlation between the probing pocket depth and MDA levels among periodontitis patients with diabetes (r=0.566, p=0.003). Conclusion: There is increased oxidative stress in chronic periodontitis with and without type 2 diabetes indicating a common factor involvement in tissue damage. More severe tissue destruction in periodontitis is associated with excessive ROS generation which is positively correlated in type 2 diabetic subjects.

Role of Frequency Doubled Nd: Yag Laser in Treatment of Corneal Neovascularisation

Jitendra Kumar, Aakanksha Gehra, Naveen Sirohi

Introduction: Cornea is the outermost transparent coat of eye along with sclera, for which its avascularity is essential for maintaining its transparency to have normal visual acuity. Corneal neovascularization is characterized by the invasion of new blood vessels into the cornea from the limbus interfering with corneal transparency, resulting in reduction in visual acuity. It also increases the risk of graft rejection. So their being a dire need to treat corneal neovascularisation, with laser photocoagulation being an effective means of treating it. Aim: To evaluate the efficacy and safety of frequency doubled Nd:Yag laser photocoagulation in treatment of corneal neovascularisation. Materials and Methods: A single centre prospective study was carried out on patients attending the outpatient department of ophthalmology in Maharani Laxmi Bai Medical College, Jhansi. Forty eyes of 40 patients having corneal neovascularisation with quiescent eyes satisfying the inclusion criteria were selected and treated with laser. The efficacy of the procedure was noted in terms of area of corneal neovascularisation, status of treated vessels, area of corneal opacity, visual acuity. The above parameters of selected patients were recorded before treatment and subsequent follow up visits at 1 week, 1 month, 2 month and 3 month after laser. Paired t-test was used to calculate the p-value. Results: There was a statistically significant difference in the percentage mean area of corneal neovascularisation with a pre laser value of 31.93% to 17.62% after 3 months of laser treatment (p-value<0.0001). The percentage mean area of corneal opacity decreased from 30.75% to 23.74% (p<0.0001). Out of 185 corneal vessels, 99( 53.51%) vessels were completely occluded,17(9.18%) vessels were partially occluded and 69(37.29%) vessels were recanalised at the end of 3 months after laser treatment. Conclusion: Frequency doubled Nd:Yag laser is an effective and safe method for the treatment of corneal neovascularisation.

Delayed Diagnosis of Left-Sided Diaphragmatic Hernia in an Elderly Adult with no History of Trauma

Diaphragmatic Hernia (DH) is the herniation of abdominal contents into the thorax through a rent in the diaphragm. Acquired DH most commonly occurs following a blunt or penetrating trauma to the abdomen with former being common than the later. Very rarely DH can be spontaneous and be asymptomatic until it’s very extensive. A 78-year-old presented with breathlessness and chest pain of one month duration. There was dull note to percussion and absent breath sounds in left lower zone. Auscultation revealed bowel sounds in left infra-axillary and mammary area. Electrocardiogram and laboratory data suggested acute myocardial infarction. Coronary angiogram showed a triple vessel disease. Roentgenogram was simulating pneumonic consolidation but presence of air shadows was the thing against pneumonic consolidation. CT imaging of the thorax revealed an extensive left diaphragmatic hernia with viscera and left kidney as its contents. He was initially taken up for CABG and surgery for diaphragmatic hernia was planned at a later date. This case is important for its extensive nature and for its rarity as acquired DH rarely occurs spontaneously. Chest roentgenogram must be read cautiously in all such cases to look for this entity. Auscultation for bowel sounds in the thorax is a diagnostic clue.

Analysis of Intraoperative and Postoperative Complications in Pseudoexfoliation Eyes Undergoing Cataract Surgery

BC. Hemalatha, Sathyendranath B Shetty

Introduction: Pseudoexfoliation (PXE) is a genetically inherited condition affecting usually seen in those aged over 50 years. Surgical management of cataract in patients with PXE pose a challenge due to associated changes in ocular structures. Aim: To study the challenges in the management of cataract in patients with PXE. Materials and Methods: This was an interventional study conducted in the Ophthalmology Department of MS Ramaiah Medical College and Memorial Hospital, Bangalore from June 2012 to September 2014. All patients admitted for cataract surgery during this period who were diagnosed as cataract associated with PXE above 50 years of age belonging to either sex were included in the study. All patients underwent cataract surgery with intraocular lens implantation. Depending on type of cataract both small incision and phacoemulsification operations were conducted. Intraoperative and postoperative complications were studied. The patients were reviewed up to 6 weeks postoperatively. Results: A total of 50 eyes of 50 patients diagnosed as cataract with PXE underwent cataract surgery. Of which 40 eyes (80%) underwent small incision cataract surgery whereas, 10 (20%) underwent phacoemusification. Corneal thinning ( <535 microns) was noted in majority of the cases (41 cases). Preoperatively there were 3 cases of zonular weakness. Pseudo exfoliation with glaucoma was seen in 5 cases. Intraoperative complications encountered during surgery were; zonular dialysis in 3 cases, posterior capsular tear in 2 cases, out of these 5 cases vitreous loss was seen in 3 cases. Postoperative complications were corneal odema in 17 cases, of which endothelium de-compensated in one case, while early posterior capsular opacification was seen in 6 cases. Final best corrected visual acuity was between 6/6-6/12 in 39(78%) eyes, 6/18 -6/36 in 6(12%) cases; 6/60 to less in 5(10%) cases. Conclusion: Cataract surgery in eyes with PXE has higher incidence of intraoperative and postoperative complications. A complete preoperative workup helps reduce intraoperative complications and maximises the postoperative results. As corneal thinning is more common a pre-operative pachymetry is desirable to prevent underdiagnoses of glaucoma.

Protection Provided by Hepatitis B Vaccine in Adult Population of Chaharmahal and Bakhtiari Province, Iran in 2013

Masoumeh Moezzi, Reza Imani

Introduction: Hepatitis B vaccination has been integrated into National Expanded Program on Immunization in Iran since the year 1993 and young adult national vaccination project was done in 2008. So we have three subpopulations with vaccination coverage for hepatitis B and different antibody levels. Consisting of Subpopulation 1 born after 1993, subpopulation 2 born between 1989 and 1993 and receiving vaccination under adult national project, and subpopulation 3 born prior to the year 1989. Aim: The present study was conducted to investigate community protection by hepatitis B vaccine in adult population in an accessible population in Iran and compare vaccination coverage, HBs Ab level, and its effective titration among the three above-mentioned subpopulations. Materials and Methods: This cross-sectional study was done on a 3000-individual adult population from all seven counties of Chaharmahal and Bakhtiari province enrolled by clustering. After obtaining written consent and filling out a questionnaire of demographic data and history of hepatitis B vaccination by trained interviewers, necessary blood sample was taken and HBs Ab titration was checked. The data were analysed by chi-square in SPSS 19. The level of significance was considered as 0.05 and effective Ab titration as = 10. Results: The mean age of the participants was 38.4±16.3 years. Of the participants 48.2% had effective titration. For vaccination coverage, 77.4% were unvaccinated, 20% completely vaccinated, and 2.6% incompletely vaccinated with a significant association with effective titration (p<0.001). Eighty six percent of the subpopulation 1 and 79% of the subpopulation 2 were completely vaccinated, with a significant difference in effective titration between them (p<0.001). Vaccination coverage was higher in men and the single but equal in cities and villages. The effective titration was significantly associated with being married and residence place (p=0.003). There was a significant association between effective titration and the time at vaccination (p<0.001). Conclusion: Protection provided by hepatitis B vaccine in adult population is relatively suitable especially in the youth population; however, catch-up programs of the groups exposed to risk are recommended.

Morphometric Study of Clavicular Facet of Coracoclavicular Joint in Adult Indian Population

Sushant Swaroop Das, Anita Mahajan, Neelam Vasudeva

Introduction: Anthropologists have used Coracoclavicular Joint (CCJ), a non-metric anatomical variant in population, as a marker for population migration from prehistoric times to present. Aim: The aim of this osteological study was to determine the incidence and morphometry of articular facet of CCJ on conoid tubercle of clavicle in Indian population, as Indian studies are scanty and incomplete. Materials and Methods: The study was done on 144 adult human clavicles (76 right and 68 left; 93 males and 51 females) collected from osteology museum in Department of Anatomy, Maulana Azad Medical College, New Delhi, India. The presence of articular facet on the conoid tubercle was determined and Maximum Antero-Posterior (MAPD) and maximum transverse diameter (MTD) was measured by digital vernier calliper. The incidence was compared on the basis of sex, side and with other osteological studies in the world. Statistical analysis was done using the Chi-Square test for nominal categorical data and student’s t-test for normally distributed continuous variables in Microsoft Excel 2007 to assess the relationship between the examined variables. Results: Articular facet on conoid tubercle was found in 8 cases (5.6%). Seven (9.2%) were present on the right side and one (1.5%) on the left side. Seven cases (7.5%) were present in males and one case (2%) was found in females. The facets were generally oval, with MAPD and MTD of 12.28 and 17.17 mm respectively. A significant side variation was present with right sided facet being more common. The left sided facet was more transversely elongated than right. In males, the facets were more elongated antero-posteriorly than in females. Conclusion: The Indian population showed an incidence of 5.6%, which was comparable to other ethnic groups in world population. The morphometric and side differences could be attributed to the occupational factors and range of movements associated with the CCJ. The CCJ should be borne in mind as a differential diagnosis for thoracic outlet syndrome and in general for shoulder pain.

Comparative Study of Permeatal Sandwich Tympanoplasty and Postaural Underlay Technique

Namit Kant Singh, Prakash Shankarrao Nagpure, Manish Yadav, Sushil Chavan

Introduction: Tympanoplasty is the most common operation performed by an Otolaryngologist right from the period of residency. During the last hundred years various modifications in this surgical technique have come up because of continued efforts made by otologists all over the world to achieve the best surgical outcome. Aim: To compare the graft take up and complications associated with the Permeatal Sandwich Tympanoplasty performed with the use of Otoendoscope and traditional Postaural Underlay technique of Tympanoplasty from 1st September 2014 to 30th August 2015. Materials and Methods: Patients attending the ENT OPD, suffering from Chronic Suppurative Otitis Media (CSOM) were selected on the basis of type of perforation and their workup was done to assess the candidature for tympanoplasty. Results: A total of 100 patients were included in the study and the overall graft take was 92.3% in cases of Permeatal Sandwich technique as compared to 64.58% in the case of postaural underlay technique, with a majority of the failures in the large central perforation group rendering a p = 0.021 for patients operated for Large perforations, p = 0.036 for moderate perforations and p = 0.476 for small perforations. The overall p = 0.000649 which is highly significant. On comparing the complications there were only 2 cases in Permeatal Sandwich Technique compared to 25 cases in Postaural Underlay technique rendering a highly significant p-value 0f 0.000000348. There was a difference in hearing improvement with majority of the cases improving to the range of 16-25 dB in Permeatal Sandwich technique compared to 26-45 dB in Postaural Underlay technique. Conclusion: Permeatal Sandwich technique produce much better results when compared with Postaural approach in terms of graft take up, complications and hearing improvement.

Basic Risk Factors Awareness in Non-Communicable Diseases (BRAND) Study Among People Visiting Tertiary Care Centre in Mysuru, Karnataka

Thippeswamy Thippeswamy, Prathima Chikkegowda

Introduction: Non Communicable Diseases (NCDs) are the major causes of mortality and morbidity globally. Awareness about NCDs and their risk factors has an important role in prevention and management strategies of these NCDs. Aim: 1) To assess the awareness of risk factors contributing to NCDs among the patients visiting tertiary care hospital in Mysuru district; 2) To compare the difference in awareness of risk factors for NCDs among the urban and rural patients with/ without NCD visiting the tertiary care hospital. Materials and Methods: A cross- sectional study was conducted in a tertiary care centre- JSS Hospital, Mysuru, Karnataka from March 2013 – August 2013. The patients visiting Medicine OPD during the period were the study subjects. The subjects were allocated into 4 groups: Urban without any NCD, Urban with atleast one NCD, rural without NCD, rural with atleast one NCD. A pretested questionnaire regarding awareness of risk factors for NCDs was used in the study and frequency and proportions were used to analyse the data. Results: A total of 400 subjects, 100 subjects in each group were included in the study. Out of these subjects about 65% of the urban group and 42% of the rural group subjects were aware of the NCDs and their risk factors. Least awareness was observed among the rural subjects without any NCDs (35%). Conclusion: The awareness of risk factors of NCDs and knowledge regarding prevention of NCDs was not satisfactory. The results highlighted the need and scope for health education and interventions to improve the awareness about NCDs and their risk factors.

Level of Satisfaction Among People Living with HIV (PLHIV) Attending the HIV Clinic of Tertiary Care Center in Southern India

Introduction: Patient satisfaction is an important issue for the health care sector. Hospitals routinely collect patient satisfaction data so that they can improve the quality of their services. There is a dearth of research in the field of satisfaction among people living with HIV (PLHIV) in India. Aim: The aim of our study was to determine the level of satisfaction among PLHIV attending the HIV clinic of tertiary health centre in Southern India. Materials and Methods: This descriptive cross-sectional study was done in the HIV clinic attached to Kasturba Medical College (KMC) Hospital, Mangalore, India from August 2012 - August 2013. PLHIV of age more than 18 years were included. During the study period 422 consecutive patients who consented for the study were enrolled. To determine patient satisfaction towards healthcare service, we used the Short Form Patient Satisfaction Questionnaire (PSQ-18). Data was analysed using SPSS Version 11.5 statistical software. Results: A total of 422 patients were included in the study out of whom 253(60%) were males and 169(40%) were females. Mean age of the patients was 37.08±7.2 years. The median CD4 count was 345 cells/mm3 (IQR 245-451.2). The mean score for general satisfaction was 4.43±0.48, for technical quality 4.77±0.26, for interpersonal manner 4.59±0.4, for communication 4.64±0.42, for financial aspects 3.20±0.78), for accessibility and convenience 4.50±0.72 and for time spent with the doctor was 4.59±0.45. Subscale scores for general satisfaction, technical quality, accessibility, interpersonal manner, finance and communication were higher in females when compared to males which were found to be statistically significant. Younger PLHIV (= 35 years) had significantly higher scores in technical quality, interpersonal manner and time spent with the doctor when compared to older PLHIV. Conclusion: Patient satisfaction was highest for technical quality and it was lowest for financial aspects. If hospitals wish to improve the quality of health services they should give priority to decreasing costs and improving accessibility.

Hot Climate and Perioperative Outcome in Trauma Patients

Bhawna Gupta, Parshotam Lal Gautam, Sunil Katyal, Nikhil Gautam

Introduction: Extreme hot climatic conditions constitute a major public health threat. Recent studies have shown higher rate of perioperative complications during hot weather. Although a lot of researches have been carried out to evaluate effect of hot climatic conditions and its correlation with other medical conditions, but very little has been studied in trauma patients. Aim: To evaluate the impact of hot climatic conditions on perioperative morbidity in trauma patients. Materials and Methods: We enrolled 100 trauma patients scheduled for surgery after approval by the Hospital and University Ethical Committee. Patients were grouped as Control Group (C) when outdoor temperature ranged in comfortable zone i.e., 20-290C and Study Group (S) when outdoor temperature ranged 400C or more. Patients living in regular air conditioned atmosphere (more than 18 hours per day) and with co-morbid conditions or on drugs interfering with temperature regulation were excluded. Student's t-test, z-test and chi-square tests were used for statistical analysis. Results: Both groups were comparable in terms of demographics, age (control group C=38.2±12.93 years and in group S= 40.14 ± 15.98 years), sex, socioeconomic status and type of surgery. Mean Trauma Index Score (TIS) were 6.20±1.56 and 5.80±1.31 respectively. All patients were of low risk as per Shoe Maker’s risk criteria. Post Anaesthesia Care Unit (PACU) stay was similar. Mean duration of hospital stay was 12.16 ± 8.50 days in group C and 10.98 ± 6.90 days in group S (p-value 0.21). 20% patients in group C whereas 54% in group S had complications (p= 0.009). There was a higher incidence of infections as well as respiratory distress in group S. On multiple logistic regression analysis peak environmental temperature was found to be the single independent risk factor for predicting perioperative morbidity. Conclusion: High ambient temperature adversely affects the outcome of surgery even in low risk young trauma patients belonging to American Society of Anaesthesia (ASA) physical status I and II categories. So we opine that it may be probably helpful to either postpone non-emergency surgery till fair adaptation is achieved in air conditioned environment of hospital or be cautious for complications to reduce the heat related perioperative morbidity in days of heat waves.

The Er/Ki-67 Proportion in Breast Tumours - An Immunohistochemical Study

Rachna, M K Rai

Introduction: Breast tumours are classified as benign, proliferative and invasive tumours. Estrogen hormone influences the proliferative activity and progression of the tumour. Estrogen Receptor (ER) status and proliferative index (Ki 67) are important histopathological factors in the development and prognosis of these tumours. Aim: The present study was aimed to evaluate the variations in ER and Ki-67 expression in three broad categories of breast lesions namely benign breast disease, proliferative breast disease and malignant breast disease. Materials and Methods: ER% and Ki-67% was evaluated on the histopathological tissues of 15 patients each of benign, proliferative and invasive breast tumours. The ER+/ Ki-67+ ratio was calculated and the variation of expression between the three categories was analyzed using student's t-test. Pearson’s coefficient of correlation was used to correlate ER and Ki-67 positivity within each category. Results: The mean ER+/Ki-67+ in benign, proliferative and invasive tumours was 0.81, 0.87 and 1.42 respectively. A statistically significant difference in ER+/Ki-67+ proportions was observed between proliferative breast disease category and malignant breast disease category and also between benign breast disease category and malignant breast disease category (p<0.05). However, no significant difference was observed in benign breast disease category and proliferative breast disease category (p>0.05). A significant correlation was observed in proliferative breast disease and malignant breast disease categories. However, no significant correlation was observed in benign breast disease category Conclusion: ER+/Ki-67+ ratio is an important determinant of the invasive breast cancer and can be used to differentiate invasive cancers from benign and proliferative breast tumours.

Evaluation of NS1 Antigen Detection for Early Diagnosis of Dengue in a Tertiary Hospital in Southern India

Introduction: Dengue is a mosquito-borne disease affecting mainly tropical and subtropical regions of the world. The early diagnosis of dengue is required for identifying an epidemic and also for implementing effective vector control measures. Aim: To evaluate NS1 antigen assay as an alternative to RT-PCR for the early diagnosis of Dengue. Materials and Methods: A comparative study was conducted to evaluate NS1 antigen assay in clinically suspected dengue cases admitted to JIPMER hospital from January to November 2011. Serum samples were tested for NS1 antigen, IgM and IgG antibodies by ELISA and RT-PCR. Results: Out of total 112 clinically suspected dengue, 94 were laboratory-confirmed dengue cases (positive by one or more of the following tests - IgM ELISA, NS1 antigen ELISA and RT-PCR). NS1 was detectable from day 1 to day 12 of fever. The positive detection rate of NS1 antigen ELISA, RT-PCR and IgM ELISA were 80.9%, 68.1% and 47.9% respectively. NS1 antigen ELISA was evaluated using RT-PCR as the reference standard and showed a sensitivity of 96.8%, specificity of 53.3%, positive predictive value of 81.6% and negative predictive value of 88.9% with a likelihood ratio of 2.1 by Fisher’s-exact test. The combination of NS1 and IgM had the highest sensitivity of 97.8%. DEN-3 was the serotype identified by RT-PCR for 24 randomly selected samples. NS1 antigen detection had the highest sensitivity in the early stages while IgM detection was more sensitive in the later half of the illness. Conclusion: Both NS1 and RT-PCR are useful for early dengue diagnosis, although in terms of cost, ease of performance and rapidity, NS1 is superior to RT-PCR. NS1 in combination with IgM assay offers the most sensitive and cost-effective diagnostic modality for dengue.

Wispy Prosthesis: A Novel Method in Denture Weight Reduction

Introduction: Stability and retention of the denture becomes at stake with the increase in weight of the denture prosthesis. As a consequence, different materials and methods have been introduced to overcome these issues but denture weight reduction still remains to be a cumbersome and strenuous procedure. Aim: To introduce a novel technique for the fabrication of denture prosthesis where in the weight of the denture will not affect the retention and stability of the denture. Materials and Methods: Four groups with a sample size of 10 each, were included where in one group was control and other three were study groups. The control group samples were made completely solid and the study group samples were packed with materials like bean balls, cellulose balls and polyacrylic fibers. The weight of all the samples of each study group was measured and compared with the control group. The observations were analyzed statistically by paired t-test. Results: It was observed that the bean balls group produced a weight reduction of 31.3%, cellulose balls group 27.4% and polyacrylic fibers group 24.5% when compared to that of the control group. Conclusion: This novel technique will eliminate the problems that were associated in creating hollowness and at the same time will reduce the weight of the prosthesis and among all the study groups, bean balls group were found to reduce maximum weight of the prosthesis.

Comparative Efficacy of Intrathecal Bupivacaine Alone and Combination of Bupivacaine with Clonidine in Spinal Anaesthesia

Ajay Wahi, Amanjot K. Singh, Kartik Syal, Ajay Sood, Jyoti Pathania

Introduction: Clonidine is an a2 agonist agent that has been used as an adjuvant to local anaesthetics in regional anaesthesia. Aim: This study compared two combinations of bupivacaine and clonidine with bupivacaine alone for surgeries below the level of umbilicus in spinal anaesthesia. Materials and Methods: We conducted a randomized double blind study on 90 patients of ASA I and ASA II aged 20-60 years, 30 in each group, undergoing surgery below the level of umbilicus in spinal anaesthesia. For intrathecal block, Group 1 received bupivacaine hydrochloride 12.5mg (2.5ml) in 8% dextrose (0.5% sensorcaine heavy) + 1ml (150mg) of preservative free clonidine. Group 2 received bupivacaine hydrochloride 12.5mg (2.5ml) in dextrose (0.5% sensorcaine heavy) + 0.5ml (75mg) of preservative free clonidine + 0.5ml of normal saline to make the volumes of all the groups same. Group 3 received bupivacaine hydrochloride 2.5ml in 8% dextrose (0.5% sensorcaine heavy) + 1ml of normal saline to make the volumes of all the groups same. Heart rate, NIBP, oxygen saturation and respiratory rate were monitored. The onset and duration of sensory block, the highest dermatomal level of sensory block, motor block, time to complete motor block recovery and duration of spinal anaesthesia were recorded. Statistical Analysis: The data of the study was recorded in the record chart and results were evaluated using statistical tests (ANOVA test, post-hoc turkey hsd test, paired t-test and chi-square test). Results: Demographic data, the incidence and duration of bradycardia were comparable amongst the groups. The duration of sensory and motor block were greatest in group 1, followed by group 2 and group 3 (p <0.01). Decrease in the systolic blood pressure of group 2 and group 3 was noted as compared to group 1. No significant sedation or respiratory depression was observed in any group. Conclusion: Addition of clonidine to bupivacaine intrathecally is although a reliable method to prolong spinal anaesthesia but close monitoring for hypotension is desirable.

Effect of Silybin on Lipid Profile in Hypercholesterolaemic Rats

Senthil Gobalakrishnan, Sylvia Santhakumari Asirvatham, Venkatraman Janarthanam

Introduction: Hyperlipidemia is a major cause of atherosclerosis and atherosclerosis associated conditions, such as Coronary Heart Disease (CHD), ischaemic cerebrovascular disease and peripheral vascular disease. Though there are hypolipidemic drugs available, the search for a more efficacious hypo lipidemic agent was always going on. Aim: To study the effect of Silybin on lipid profile in Hypercholesterolaemic rats. Materials and Methods: After grant of permission from animal ethics committee, the animals were divided into four groups of eight each (normal control, Experimental control with High cholesterol diet, High cholesterol diet + Silybin 300mg, High cholesterol diet + Silybin 600mg). At the end of 60 days the animals in all the groups were subjected to overnight fasting followed by plasma and liver biochemical analyses. Statistical Analysis: The data were analysed by ANNOVA followed by Duncan’s multi range test and the value of p=0.05 was used as the criterion for statistical significance. Results: The rats fed on high cholesterol diet showed significant increase in serum total cholesterol, Triglycerides, LDL-C and VLDL-C. Treatment with Silybin significantly decreased serum total cholesterol (24%), Triglycerides (21%), LDL-C (24%) in a dose dependent manner. Rats treated with Silybin (300 and 600 mg/kg) showed significant increase in hepatic HDL –C and decrease in other lipid profiles. Conclusion: Treatment with Silybin significantly decreased both serum and hepatic total cholesterol, triglycerides, VLDL-C, LDL-C and increased HDL-C at both doses.

Clinico-Histopathological Spectrum of Infectious Granulomatous Dermatoses in Western India- A Representative Study from Mumbai

Introduction: Infectious Granulomatous Dermatoses (IGDS) have various aetiological factors with a considerable overlap in the histopathological and clinical features, thus posing a diagnostic dilemma for dermatologists and pathologists. Aim: We aimed at determining the histopathological profile of IGDS correlating it with clinical features with an attempt to find the aetiology. Materials and Methods: In a cross-sectional study conducted in a tertiary referral center of Mumbai over two years, out of 1872 skin biopsies received, 239 histopathologically diagnosed cases of IGDS were studied for histopathological features of granuloma. A clinico-histopathological correlation was attempted. Chi-square test was used for comparison of proportions of different groups. Results: Leprosy (211 cases) and tuberculosis (28 cases) were the commonest histopathologically diagnosed IGDS. Leprosy spectrum included BT (30.33% cases), followed by TT (21.32%), BL and LL and 21.79% cases of lepra reactions. Skin TB biopsies on histopathology showed lupus vulgaris (53.85% cases), scrofuloderma (15.38%), TBVC and papulonecrotic tuberculid (11.54% each). In leprosy maximum clinico-pathological agreement was seen at tuberculoid pole (TT 72.7% and BT 56.6%). Among tuberculosis cases, scrofuloderma (100%) and lupus vulgaris (53.8%) showed maximum agreement. Conclusion: Leprosy and skin TB are the commonest IGDS in Mumbai region though difficult to diagnose and subcategorize with certainty during initial stages. Histopathology plays the important role to elucidate the dilemma. This being a single center study, more such studies with a larger sample size are recommended to get more elaborate data and regional prevalence of these IGDS for a better overall approach to prevention, treatment and control.

Study of the Clinical Outcome between Traumatic and Degenerative (non-traumatic) Meniscal Tears after Arthroscopic Surgery: A 4-Years Follow-up Study

Nietiayurk Aminake Ghislain, Ji-Nan Wei, Yong -Gang Li

Introduction: The meniscus is a biconcave fibrocartilage in the knee joint interpose between the femoral condyles and tibial plateau; the meniscus has functions in load bearing, load transmission, shock absorption joint stability, joint lubrication, and joint congruity. Aim: The aim of this study is to provide orthopeadic surgeon a base of reference in the choice of the optimal course of management for meniscal tears. Materials and Methods: One hundred and seventeen patients met the criteria of inclusion for the present study. Patients were divided in two groups T and NT according to the presence of distinct previous traumatic events to the knees. Two subgroups were formed in each groups T and NT respectively at a mean follow up of 1 and 4 years. Postoperative clinical outcome were assessed using Lysholm scores and Rand SF-36 survey. Results: One hundred and seventeen patients were included in the present study with 60(51.28%) patients in the traumatic group and 57(48.71%) in the degenerative group. 95(81.19%) patients in total were satisfied with their health status at end of follow up. The mean value of Lysholm scores at 1 year were respectively 85.25±8.78 for traumatic group and 86.38±12.14 for non-traumatic group and at 4 years were respectively 92.63±7.31 for traumatic group and 72.90±20.77 for non-traumatic group. According to Rand SF-36 health, traumatic group showed better improvements compare to non-traumatic group between 1 and 4 years after arthroscopic meniscus surgery. Conclusion: A total of 95(81.19%) patients in total were satisfied with their health status at follow up, however, we found that arthroscopy as a treatment for meniscal tear have a relatively better mid-term clinical outcome for traumatic meniscal tears compare to non-traumatic/degenerative meniscal tears.

Cotoneaster: A Safe and Easy Way to Reduce Neonatal Jaundice

Mahmoud Rafieian-kopaei, Abolfazl Khoshdel, Soleiman Kheiri, Rabin Shemian

Introduction: Consumption of cotoneaster may reduce neonatal jaundice. Aim: Hence this study was undertaken to determine the effect of mothers’ cotoneaster consumption on treatment of their neonates’ jaundice. Materials and Methods: In this randomized clinical trial study, 120 neonates with jaundice referred to a hospital in southwest Iran were enrolled by nonprobability sampling and divided randomly into four groups. In the first group both mothers and neonates received cotoneaster; in the second group only mothers; in the third group only neonates; and in the fourth group the neonates received distilled water as placebo. Phototherapy was done under the same condition for all neonates. Results: The reduction of bilirubin was significantly higher in treatment groups compared to control group (p<0.05). Bilirubin in the group of neonates whose mothers consumed cotoneaster was less compared to control group at 24 and 36 hours (p<0.05) and the highest reduction in bilirubin was observed in the first group. The mean duration of hospitalization was longer for the control group (p<0.05). Conclusion: Consumption of cotoneaster by both mothers and neonates caused a decrease in neonatal jaundice more rapidly compared to other groups and decreased the duration of hospitalization. Cotoneaster consumption by mothers, neonates, or both may be useful in treatment of neonatal jaundice.

Correlation of a-Lipoic Acid and S. Glutathione Level with Free Radical Excess in Tobacco Consumers

Suman Sharma, Manjinder Kaur, M.L. Suhalka, Chanchal Shrivastav

Introduction: Tobacco consumption is a serious health hazard and most important avoidable cause of death worldwide. Tobacco is recognized as lethal toxin, ripping off 7-11 minutes of human life with each cigarette through harmful compounds and inducing free radical synthesis and a high rate of lipid peroxidation. These free radicals are scavenged by the endogenous antioxidants viz. S. Glutathione (S.GSH) and S.a-Lipoic acid (S. a-LA), thus preventing the endothelial damage. Aim: The present study was designed with an aim to find out the lipid peroxidative stress through S. Malondialdehyde (S.MDA) and its correlation with antioxidant levels like S. Glutathione (S. GSH) and S. a- Lipoic acid (S. a- LA) among tobacco users (in both smokers and chewers). Materials and Methods: A case control cross-sectional study was carried out in the Department of Physiology among 200 subjects; aged 18-50 years of both sexes which were chosen randomly from institutional campus and healthy volunteers. The subjects were broadly divided into two groups (A & B); group A comprised of tobacco users (n=150) with history of smoking cigarette/biddies and chewing tobacco daily, for at least one year and group B had controls (non tobacco users) (n=50). S. MDA, S.GSH and S. a-LA levels were estimated by standardized methods. The data was analysed by unpaired student t-test and Pearson’s correlation coefficient (r) for finding the correlation between antioxidants and S.MDA in group-A and group-B. Results: The present study reports the significantly higher (p<0.0001) levels of S.MDA and lower (p<0.0001) levels of S.GSH and S. a-LA in tobacco users as compared to nontobacco users. The observed value of S.MDA was (2.72±0.87, 1.39±0.47) nmol/ml, S. a-LA was (9.94±5.96, 14.24 ± 4.34) µg/ml and S.GSH was (23.24±7.04, 32.82±2.95) mg/dl respectively in group-A and group-B. A significant (p<0.01) strong negative correlation was observed between S. MDA and antioxidants (S.GSH and S. a-LA) with a Pearson co-efficient of r=-0.619, r= -0.625 respectively, in group A. Conclusion: The decreased level of S. a-LA and S. GSH, in our study clearly indicates potential risk of cellular damage in tobacco users due to lipid peroxidation. Hence, the present study recommends supplementation of S. a-LA and Vitamin C in tobacco users to prevent this damage whereas quitting this evil habit will be the best available option.

The Efficacy of Three Learning Methods Collaborative, Context-Based Learning and Traditional, on Learning, Attitude and Behaviour of Undergraduate Nursing Students: Integrating Theory and Practice

Ali Hasanpour-Dehkordi, Kamal Solati

Introduction: Communication skills training, responsibility, respect, and self-awareness are important indexes of changing learning behaviours in modern approaches. Aim: The aim of this study was to investigate the efficacy of three learning approaches, collaborative, context-based learning (CBL), and traditional, on learning, attitude, and behaviour of undergraduate nursing students. Materials and Methods: This study was a clinical trial with pretest and post-test of control group. The participants were senior nursing students. The samples were randomly assigned to three groups; CBL, collaborative, and traditional. To gather data a standard questionnaire of students’ behaviour and attitude was administered prior to and after the intervention. Also, the rate of learning was investigated by a researcher-developed questionnaire prior to and after the intervention in the three groups. Results: In CBL and collaborative training groups, the mean score of behaviour and attitude increased after the intervention. But no significant association was obtained between the mean scores of behaviour and attitude prior to and after the intervention in the traditional group. However, the mean learning score increased significantly in the CBL, collaborative, and traditional groups after the study in comparison to before the study. Conclusion: Both CBL and collaborative approaches were useful in terms of increased respect, self-awareness, self-evaluation, communication skills and responsibility as well as increased motivation and learning score in comparison to traditional method.

Antiproliferative and Apoptotic Effect of Curcumin and TRAIL (TNF Related Apoptosis inducing Ligand) in Chronic Myeloid Leukaemic Cells

Introduction: Curcumin, traditionally utilized as a flavouring zest as a part of Indian cooking, has been accounted to decrease the proliferation potential of most cancer cells. Apoptosis is a mechanism by which most anticancer therapies including chemotherapy, radiation and antihormonal therapy kill tumour/cancer cells. Novel agents that may sensitize drug-resistant tumour cells for induction of apoptosis by customary treatments could lead to the regression and improved prognosis of the refractory disease. Indeed, chemotherapeutic agents have been shown to sensitize cancer cells to killing by death ligands such as tumour necrosis factor-a. Aim: To investigate cytotoxicity and apoptotic effect of curcumin in chronic myeloid leukaemic cell line KCL-22. Materials and Methods: In present study, different doses of curcumin (10,25,50,75,100µM) and tumour necrosis factor–related apoptosis-inducing ligand (TRAIL) (25,50 µM) alone and combine regimen were exposed to myeloid leukaemic cell KCL-22. The cell viability was monitored by MTT assay, apoptotic activity by binding of Annexin V-FITC using fluorescence microscopy and cell cycle check points by flow cytometry. Results: Cytotoxic assay revealed that curcumin and TRAIL induced both dose and time-dependent decrease in cell viability. Significant cell cytotoxicity was seen in combine regimen of both curcumin and TRAIL at 48 h of exposure. Cells treated with curcumin and TRAIL was arrested at the S phase, as revealed by flow cytometric analysis. Subtoxic concentrations of the curcumin-TRAIL combination induced strong apoptotic response in KCL-22 cells as demonstrated by the binding of Annexin V-FITC. Conclusion: Our study conclude that curcumin inhibits the cancer cell growth by inducing apoptosis and enhance the therapeutic potential of TRAIL which recommends that both curcumin alone or in combination with TRAIL might be useful for leukaemic prevention and better therapeutic responses.

Complications in Advanced Diabetics in a Tertiary Care Centre: A Retrospective Registry-Based Study

Ankush, Amit Dias, Edwin Gomes, Ankush Dessai

Introduction: Diabetes is a major public health problem in our country and complications of diabetes are a major cause of morbidity and mortality. There is a need to quantify the complications in order to improve our strategies for prevention and management. Aim: To measure the prevalence of complications in type 2 diabetics following up at a tertiary care centre and to study its association with the socio-demographic and clinical parameters. Materials and Methods: A retrospective record based study was conducted on 3261 type 2 diabetic patients on insulin therapy, recorded in the diabetic registry maintained at Goa Medical College from Aug 2009 to May 2012. Data on anthropometric measurements, demographic characteristics, complications and other details were extracted from these records. Results: Out of the 3261 patients 1025 (31.4%) had macrovascular complications and 1122 (34.4%) had at least one microvascular complication. The prevalence of peripheral vascular disease, coronary artery disease and stroke were 6.7%, 21.3% and 6.6% respectively and were significantly higher in males. The prevalence of diabetic retinopathy, nephropathy and neuropathy were 16.7%, 16.5% and 16.3% respectively with diabetic nephropathy being significantly higher in males. Trend analysis showed significant association of rising prevalence of all complications with age (p<0.05). Duration of diabetes also showed significantly positive trend for all complications (p<0.05) except stroke. Conclusion: The study presents the prevalence of diabetic complications in patients reporting to a tertiary hospital in Goa. Coronary artery disease was found to be the most common complication. As age and duration of diabetes were found to be significantly associated, efforts should be made towards promoting earlier diagnosis of diabetes so as to improve management and decrease the chances of complications.

Evaluation of the Quality of Obturation with Obtura at Different Sizes of Apical Preparation Through Microleakage Testing

Introduction: Obturation of the root canal system is required to prevent recontamination of the root canal after cleaning and shaping procedures and to seal the root canal completely, both the apical and coronal avenues of potential leakage and to maintain the disinfected status. Aim: The aim of this study was to determine the microleakage by dye leakage method at 1mm, 3mm and 5mm short of the apex with different sizes of apical preparation, obturated by Obtura. Materials and Methods: Sixty freshly extracted human single rooted teeth were randomly distributed into six equal groups. Group I (control group) was obturated by lateral compaction technique. Group II to VI were experimental groups (apical preparations done upto ISO sizes 20, 30, 40, 50 and 60 respectively), obturated by Obtura technique. After storing the samples at 100% humidity for seven days and one day in 2% methylene blue, the roots of the teeth were sectioned at 3mm short of the apex. They were observed under stereomicroscope at 20X magnification and the images were analysed for microleakage using the scoring criteria. The data obtained were analysed by One-way ANOVA followed by Tukey pair-wise multiple comparison test and p = 0.05 was considered as the level of significance. Results: The lowest mean microleakage score was seen in Group VI (0) and the highest mean leakage score was seen in Group II (1.5). There was statistically significant difference between Group II and Group V (p = 0.044), Group II and Group VI (p = 0.013). There was no significant difference between all the other groups (p> 0.05). Conclusion: Comparison of microleakage between different groups from ISO sizes 20-60 recommends a minimum apical preparation of ISO size 30.

Recasting Disaster Recovery Strategy at Dental Workplace in Combating Crisis – A Questionnaire Study

Introduction: The number of reported natural and human-made disasters continues to rise worldwide. Disasters occur every day somewhere in the world with dramatic impact on individuals, families and communities. Aim: This study was designed to measure the knowledge, attitude and practices regarding disaster management among academicians and practitioners in Ghaziabad city. Materials and Methods: A cross-sectional study was conducted among 487 dentists. A questionnaire (15 items) measuring knowledge, attitude and practice was distributed manually to the participating dentists and data was analysed using SPSS software, version 19.0 and student t-test was performed to assess the differences. Results: There was statistically significant relation between knowledge and attitude in relation to qualification degree, career prospective and years of experience (p <0.05). Conclusion: Dentists form an important part of the health care community and thus there is a need to harvest the services of wide distribution of dentists practicing in our country.

The Study of Gonadal Hormonal Abnormalities and Sexual Dysfunction in HIV Positive Females: An Exploratory Study

Introduction: Every endocrine gland has been reported to be affected at varying rates in HIV. HIV is a highly stigmatized chronic disease with a substantial co-occurrence of mental and sexual health problems; however the sexual health problems in women have not been extensively studied. Aim: To study the gonadal hormonal abnormalities and sexual dysfunction in HIV positive female patients and its possible association. Materials and Methods: This descriptive/exploratory study was conducted in the Department of General Medicine at a tertiary care hospital from September 2013 to August 2015. The study group included 50 diagnosed HIV-positive patients. They were also subjected to specific questions regarding sexual dysfunction by female counselors using female sexual function index. Visits of the subjects were scheduled independent of the menstrual cycle. Hormonal levels (free testosterone, FSH, LH) were measured. Results: Out of 50 patients, 26 patients in our study had sexual dysfunction (52%). Patients with age group between 30-39 years had the maximum sexual dysfunction compared to the other groups (<0.001). Patients with a CD4 count between 200 and 499 had the maximum sexual dysfunction (<0.02). Mean duration of HIV in the study was 30 months in sexual dysfunction group which was significant (p<0.005). Hormonal levels were found to be in normal range. All the study patients reported desire, arousal and lubrication problems whereas orgasm and satisfaction problems were noted in 60% patients with pain reported in 52%. Conclusion: We identified that although the hormonal levels were in the normal range, they were comparatively in the lower range in the dysfunction group than the non-dysfunctional group. Both free testosterone and FSH levels were low indicating involvement of the pituitary rather than the gonads. We also conclude that duration of HIV and also level of CD4 count is related to sexual dysfunction.

Validation of Selection Criteria for Active Surveillance in Prostate Cancer

Saif Elamin, Nikita Rajiv Bhatt, Niall F. Davis, Paul Sweeney

Introduction: Considerable Proportion of Prostate Cancer (PCa) patients suitable for Active Surveillance (AS) harbour aggressive disease at surgical histopathology. Identification of truly indolent prostate cancer at diagnosis is difficult. Aim: Of this study was to evaluate the accuracy of current AS protocols in identifying low risk PCa by comparing the histopathology at biopsy and surgery. Materials and Methods: A retrospective study was performed on all patients who underwent Radical Prostatectomy (RP) between 2008 and 2012. We identified patients who fulfilled inclusion criteria of five different established AS protocols. Histopathology at biopsy was compared with final surgical histopathology to identify upgrading or upstaging of disease. The biochemical recurrence rate in the cohort was also determined. Results: A total of 59 patients (24%) met criteria of at least one protocol. Sixteen patients (28%) were eligible for AS based on all studied criteria. Overall 24 patients (40.6%) were upgraded in their final histopathology while 12 patients (20%) upstaged from their original TRUS biopsy. Two patients (3%) had PSA failure, both had salvage radiotherapy Conclusion: There is considerable discrepency in current AS selection criteria which makes it necessary to introduce novel markers to identify indolent disease as a part of AS protocol for PCa.

A Comparison of the Effectiveness of Oral Midazolam –N2o Versus Oral Ketamine – N2o in Pediatric Patients–An in–Vivo Study

Introduction: Most children are casual and moderately agreeable in the dental treatment environment, however some of them show practices that upset the professional and make the protected conveyance of worthy treatment extremely troublesome. For such cases dental practitioner utilizes behavior management techniques. At the point when behavioral administration procedures come up short, some type of pharmacologic sedation or anesthesia may be an important and vital option. Dental sedation is a strategy in which the utilization of a medication or drugs produce(s) a condition of depression of the central sensory system empowering treatment to be completed during which verbal contact with the patient is kept up all through the time of sedation. Aim: This study was designed to evaluate and compare the effectiveness of oral midazolam and oral ketamine in combination with N2O-O2 in children undergoing dental treatment. Materials and Methods: This study involved a sample of 30 pediatric dental patients (age range is 3-9 years), whose selection criteria included ASA I & II health status, cooperative but apprehensive behavior and a need for multiple dental extractions. The patients were assigned to receive oral midazolam on their first visit and on the follow up visit they received oral ketamine. Nitrous oxide (30%) was used during each sedation visit. Physiological parameters like Respiratory Rate (RR), pulse rate, and oxygen saturation were evaluated for each procedure, followed by the use of modified Bender Visual Motor Gestalt Test to evaluate psychomotor effects. Data were analyzed using Independent sample student t –test. Results: Analysis of the data showed statistically no significant difference (p >0.05) on comparison of effectiveness of oral midazolam-N2O with oral ketamine-N2O when pulse rate, oxygen saturation and respiratory rate were taken into consideration. Psychomotor performance was found to be marginally better with oral midazolam-N2O compared to oral ketamine-N2O. Conclusion: Both the drugs were effective in reducing the patient anxiety while undergoing dental extractions. Though the t-test results were not statistically significant with respect to physiological parameters. Oral midazolam-N2O showed marginally better results compared to oral ketamine-N2O with respect to psychomotor effects.

Marquardt’s Facial Golden Decagon Mask and Its Fitness with South Indian Facial Traits

Introduction: The mathematical ratio of 1:1.618 which is famously known as golden ratio seems to appear recurrently in beautiful things in nature as well as in other things that are seen as beautiful. Dr. Marquardt developed a facial golden mask that contains and includes all of the one-dimensional and two-dimensional geometric golden elements formed from the golden ratio and he claimed that beauty is universal, beautiful faces conforms to the facial golden mask regardless of sex and race. Aim: The purpose of this study was to evaluate the goodness of fit of the golden facial mask with the South Indian facial traits. Materials and Methods: A total of 150 subjects (75 males &75 females) with attractive faces were selected with cephalometric orthodontic standards of a skeletal class I relation. The facial aesthetics was confirmed by the aesthetic evaluation of the frontal photographs of the subjects by a panel of ten evaluators including five orthodontists and five maxillofacial surgeons. The well-proportioned photographs were superimposed with the Golden mask along the reference lines, to evaluate the goodness of fit. Results: South Indian males and females invariably show a wider inter-zygomatic and inter-gonial width than the golden mask. Most of the South Indian females and males show decreased mid-facial height compared to the golden mask, while the total facial height is more or less equal to the golden mask. Conclusion: Ethnic or individual discrepancies cannot be totally ignored as in our study the mask did not fit exactly with the South Indian facial traits but, the beauty ratios came closer to those of the mask. To overcome this difficulty, there is a need to develop variants of golden facial mask for different ethnic groups.

Papillary Height and its Relation with Interproximal Distances and Cementoenamel Junction in Subjects with Chronic Periodontitis. A Cross-Sectional Study

Nishi Tanwar, Satish Chander Narula, Rajender Kumar Sharma, Shikha Tewari

Introduction: Presence of intact interdental papilla is considered as an essential component of aesthetic dentistry. Loss or absence of interdental papilla creates black triangles which are unpleasing. Aim: The purpose of the present study was to determine relation of interproximal distances and cementoenamel junction with the classification of interdental papilla recession after surgical exposure in chronic periodontitis patients. Materials and Methods: This cross-sectional, single masked study group involved 198 interdental papillae in 50 chronic periodontitis patients subjected to open flap debridement. The subjects were divided into three groups according to loss of height of interdental papillae: Class I papilla, Class II papilla, Class III papilla. The interproximal distances included vertical and horizontal distance. The vertical distance was measured from apical point of the contact area to alveolar crest; horizontal distance was measured between roots at the alveolar crest. Distance from mid buccal cementoenamel junction to apical point of the contact area was also measured. Results: The vertical distance was found to be significantly affecting all the classes of loss of papillary height (p<0.05). Significantly positive correlation was found between vertical distance and buccal cementoenamel junction (p<0.05). On applying multiple linear regressions vertical distance was found to be strongest determinant of loss of papillary height. Conclusion: Although interproximal distances and cementoenamel junction affect the height of interdental papilla, other factors influencing the existence of interdental papilla should also be taken into consideration for treatment planning to achieve better aesthetics.

Evaluation of Vacuum Assisted Closure Therapy for Soft Tissue Injury in Open Musculoskeletal Trauma

Introduction: The application of controlled levels of negative or sub atmospheric pressure for a prolonged period of time on a wound had shown to accelerate removal of excess fluid and promote hyperaemia, which eventually promote wound healing. Aim: The study was conducted with the aim to evaluate the effectiveness of Vacuum Assisted Closure (VAC) therapy for soft tissue injury in open musculoskeletal trauma. Materials and Methods: Twenty cases of complex musculoskeletal wound involving different parts of body were included in this progressive randomized study. In patients, aggressive debridement was done before the application of VAC therapy. Controlled negative pressure was uniformly applied to the wound. Dressings were changed after every 4 to 5 days. The evaluation of results included healing rate of the wound, eradication of infection, complication rate, and number of secondary procedures. Results: VAC therapy over the wound was administered for an average of 20.4 days ±6.72 days (range 14 to 42 days). There was decrease in wound size attained by VAC therapy ranged from 2.6 to 24.4cm², with an average reduction of 10.55 cm². Three wounds were infected at the start of VAC therapy. However, all patients were cleared of bacterial infection by the end of VAC therapy. Conclusion: VAC therapy using negative pressure promote Wound healing by increasing local capillary perfusion and increased rate of granulation tissue formation, decreases the duration of wound healing and requires fewer painful dressing change.

Human Chorionic Gonadotropine in Cul-de-sac Fluid in Tubal Ectopic Pregnacy; A New Diagnostic Approach

Ayse Karahasanoglu, Isil Uzun, Mucize Ozdemir, Fehmi Yazicioglu

Application of Radial Basis Function Network Tool for Correlation of CD4+ Count with Plasma Viral Load in HIV-Seropositive Individuals

Arnaw Kishore, Sumana M. Neelambike

Introduction: Human Immunodeficiency Virus (HIV) infects and cripples the immune system of the body. The two important marker CD4+T cells and Plasma viral load are crucial not only in understanding the disease progression but also in starting the antiretroviral therapy. A lot of research is going on in understanding the dynamic nature of HIV. Aim: To find the correlation between CD4+ count and Plasma Viral Load (PVL) measured by two different technologies; with the help of correlation technique in conjunction with the three dimensional HIV model with a purpose of establishing a mathematical model between the CD4+ cells and PVL using a sinusoidal function as well as Radial Basis Function (RBF) neural network. Materials and Methods: Plasma Viral Load were determined by two different methods viz Exavir CavidiTM and Abbott Real time HIV-1 assay and then they were correlated with the CD4+ count with the help of computational intelligence in predicting viral load. Results: It was found that there exists a positive correlation between the CD4+ cells and viral loads. A correlation value of 0.4082 and 0.3652 was observed between CD4+ cells and viral measured using Exavir CavidiTM and Abbott Real time HIV-1 assay respectively. Conclusion: The existence of positive correlation had helped us to understand the nature and dynamic of the existence of HIV and how the CD4 + and PVL act.

Ascitic Fluid High Sensitive C-Reactive Protein (hs-CRP). A Prognostic Marker in Cirrhosis with Spontaneous Bacterial Peritonitis

Nakul Kadam, Sourya Acharya, Samarth Shukla, Kriti Gupta

Introduction: C-Reactive Protein (CRP) is an acute phase reactant. Its level increases in the presence of acute or chronic inflammation and infections. High sensitive CRP (hs-CRP) is more sensitive than CRP as an inflammatory marker. High sensitive CRP has been known to be elevated in chronic liver diseases and Spontaneous Bacterial Peritonitis (SBP). Aim: The aim of the study was to establish the role of ascitic fluid high sensitive C-reactive protein (hs –CRP) as a prognostic indicator in patients with SBP. Materials and Methods: A total of 100 patients with decompensated cirrhosis admitted in medicine ward and ICU were included, of which 50 patients of acute bacterial peritonitis were used as study group and 50 patients of sterile ascites were used as control group. Hs-CRP level of cases and controls were estimated. SBP cases were treated with its standard recommended antibiotic therapy and hs-CRP level was again estimated after 5 days of antibiotic therapy or at the time of discharge. Results: The mean level of hs-CRP before antibiotic therapy of the patients with SBP was significantly higher than that of the patients without spontaneous bacterial peritonitis (t98=17.72; p=0.0001). The mean level of hs-CRP at 5th day or discharge after initiation of antibiotic therapy was significantly lower than that of level of hs-CRP before initiation of antibiotic therapy (p<0.05). The mean hs-CRP of the cases with poor outcome (death and prolonged hospital stay) was significantly higher than others. Conclusion: Ascitic fluid hs-CRP level can be considered as a surrogate prognostic marker in cases of Cirrhosis with SBP.

Optimal Dose of Intrathecal Dexmedetomidine in Lower Abdominal Surgeries in Average Indian Adult

Shagufta Naaz, Jahanara Bandey, Erum Ozair, Adil Asghar

Background: Dexmedetomidine, a selective alpha2 adrenoceptor agonist, has been used as adjuvant to spinal anaesthesia. Aim: To find out the optimum dose of dexmedetomidine to be used in lower abdomen surgery intrathecally. Materials and Methods: This was a randomized, controlled, double blinded study which included adult ASA I and II patients. They were allocated into five groups (n=20). Patients allergic to drugs to be used in the study and those with co-existing neurological disorders, coagulopathies, cardiac diseases, obesity and hypertension were excluded. Groups were designed as 2.5ml hyperbaric bupivacaine with 0.5ml saline (Control) or 0.5ml dexmedetomidine: 5mcg (D1), 10mcg (D2), 15 mcg (D3) and 20mcg (D4). Data were collected for 10 point VRS for pain, Bromage motor block, Ramsay sedation score, haemodynamics, time of first rescue analgesia (TRA) and any adverse effects and groups were analysed using one way analysis of variance (ANOVA) by SPSS16.0 (p-value <0.05 significant). Results: The mean duration of analgesia and need of first rescue analgesics are 201.5±29.1 mins in control group but in D1 group 259.1±15.2 mins, D2 310.7±48.1mins, D3 540.3±51.6 mins and D4 702.4±52 mins. p=0.003. The mean highest VRS score along with analgesic requirements were significantly reduced in dexemeditomidine groups, but D3 and D4 had hypotension which needed correction. Conclusion: Weighing the prolongation of anesthesia and analgesia and side effects we conclude that 10 mcg of dexmedetomidine is optimum intrathecal dose.

ESBL and MBL in Cefepime Resistant Pseudomonas aeruginosa: An Update from a Rural Area in Northern India

Aarti Kotwal, Debasis Biswas, Barnali Kakati, Malvika Singh

Strangulated Groin Hernia Repair: A New Approach for All

Introduction: The available classical approaches for Groin hernia are multiple. The change of approach with change of incision is needed with these approaches when the bowel is gangrenous. Aim: To evaluate the efficacy and safety of a new approach for all Strangulated Groin hernias (inguinal, femoral and obturator), in terms of change of approach/complications. Materials and Methods: It was conducted in surgical unit-2 of MGM Hospital, Kakatiya Medical College Warangal, Telangana State, India, from Nov 2000 to Oct 2010. Total 52 patients operated with classical approach were compared with 52 patients operated present new approach. All the cases (52+52) were with gangrenous bowel which required resection and end to end anastomosis of bowel. All the cases (52+52) were managed with mesh repair and the results were analysed. Results: In classical approach: Three cases required laparotomy (5.7%). Twelve cases required change of approach with change of incision (23%). Eight cases developed wound infection after mesh repair (15%). Four cases required removal of mesh (7.6%). Two Cases developed recurrence (3.8%). In present new approach: No laparotomy (0%), no change of incision (0%), no removal of mesh (0%) and no recurrence(0%). Only 2 cases (3.8%) developed wound infection at lateral part of incision ie. p<0.05. Conclusion: This new approach for all - gives a best approach for strangulated groin hernias as it is easy to follow. It obviates the change of incision and need for a laparotomy. It further retains normal anatomy, prevents contamination of the inguinal canal and permits a mesh repair leading to decreasing the chances of recurrence.

Comparison of Antigen Detection and Nested PCR in CSF Samples of HIV Positive and Negative Patients with Suspected Cryptococcal Meningitis in a Tertiary Care Hospital

Sunita Kumari, Rajesh Kumar Verma, Dharmendra Prasad Singh, Ramakant Yadav

Introduction: The cases of cryptococcal meningitis and other forms of cryptococcosis have increased in recent time and the present scenario of the condition with significant morbidity and mortality is actually posing a serious threat to the community, so an early and prompt diagnosis is necessary to prevent serious complications and thus improving the overall disease outcome. Aim: Comparison of diagnostic efficacy of nested Polymerase Chain Reaction (PCR) with Latex Agglutination Test (LAT) in the Cerebro Spinal Fluid (CSF) samples of the cases of meningitis in HIV positive and negative cases. Materials and Methods: We have compared the diagnostic efficacy of Latex Agglutination Test (LAT) with nested Polymerase Chain Reaction (PCR) in 200 Cerebrospinal Fluid (CSF) samples, including 14 HIV positive also, in the cases of suspected cryptococcal meningitis. Nested PCR was done in all cases reporting positive by LAT and results were then compared with that of India ink and culture on Sabouraud Dextrose Agar (SDA), and the isolates were further identified by urease, nitrate and sugar assimilation tests. Results: Of the 200 cases, including 14 HIV positive, LAT was positive in 46 cases while 154 were negative. Out of these 46 LAT positive cases, nested PCR was positive in 40 cases only, while culture and India ink was positive in 38 and 33 cases respectively. Majority of the cases, 30 (65.2%) were between age group 21-50 years, while 2 (4.3%) in 0-20, and 14 (30.4%) in 51-80 years age group. Conclusion: Although negative staining like India ink and nigrosin are most widely used techniques, but these suffer with subjective error. Rapid method like LAT is available but it always has the scope of false positive and negative results. In such cases nested PCR can help in establishing final diagnosis.

A Study of Prescription Pattern of Neutraceuticals, Knowledge of the Patients and Cost in a Tertiary Care Hospital

Siddharth Gosavi, Mangala Subramanian, Rajendra Reddy, Bharath L. Shet

Introduction: Neutraceuticals are increasingly becoming a part of diet in a health-conscious society. People have changed their outlook towards neutraceuticals because of varying lifestyle diseases and they see the need to improve their physical and mental health. Aim: To study the prescription pattern by doctors, knowledge of patients, cost for patients and patient satisfaction regarding neutraceuticals. Materials and Methods: Total of 120 patients were included in the study after obtaining written informed consent. The patients were interviewed and the prescriptions and bills were scrutinized. The data was gathered based on a structured pretested questionnaire comprising of socio-demographic variables, their knowledge of neutraceuticals and history of regular usage, reason for their use, total cost for a month on neutraceuticals alone. The data was analysed using tests of proportions and percentages. Results: Vitamins were prescribed maximum in Internal Medicine (51%), Orthopaedics (43%) and Surgery (37%). Minerals were prescribed maximum in Obstetrics and Gynaecology (30%). 66% of the patients were aware about neutraceuticals. The awareness was maximum in medicine department (70%) and least in surgery department (63.3%). The study showed that the average amount that the patients spent was Rs 357.45 per month on neutraceuticals alone, maximum was Rs 557 in orthopaedics and minimum was Rs 219 in medicine respectively. A 61.6% of the patients expressed their satisfaction after taking the neutraceuticals. However, 12.45% of the patients were dissatisfied even after taking the neutraceuticals. Conclusion: Neutraceuticals are being increasingly perceived as beneficial to health and are being continuously used in the treatment of various diseases. Therefore, it is imperative that a doctor educates the public and creates an awareness of the required amount of neutraceuticals that can be safely used. The future of neutraceuticals is bright and can transform healthcare in a developing country like India which utilizes a large number of natural compounds.

Assessment and Evaluation of Quality of Life (OHRQoL) of Patients with Dental Implants Using the Oral Health Impact Profile (OHIP-14) - A Clinical Study

Bader K AlZarea

Introduction: Peri-implant tissue health is a requisite for success of dental implant therapy. Plaque accumulation leads to initiation of gingivitis around natural teeth and peri-implantitis around dental implants. Peri-implantitis around dental implants may result in implant placement failure. For obtaining long-term success, timely assessment of dental implant site is mandatory. Aim: To assess and evaluate Quality of Life (OHRQoL) of individuals with dental implants using the Oral Health Impact Profile (OHIP-14). Materials and Methods: Total 92 patients were evaluated for assessment of the health of peri-implant tissues by recording, Plaque Index (PI), Probing Pocket Depth (PD), Bleeding On Probing (BOP) and Probing Attachment Level (PAL) as compared to contra-lateral natural teeth (control). In the same patients Quality of Life Assessment was done by utilizing Oral Health Impact Profile Index (OHIP-14). Results: The mean plaque index around natural teeth was more compared to implants and it was statistically significant. Other three dimensions mean bleeding on probing; mean probing attachment level and mean pocket depth around both natural teeth and implant surfaces was found to be not statistically significant. OHIP-14 revealed that patients with dental implants were satisfied with their Oral Health-Related Quality of Life (OHRQoL). Conclusion: Similar inflammatory conditions are present around both natural teeth and implant prostheses as suggested by results of mean plaque index, mean bleeding on probing, mean pocket depth and mean probing attachment level, hence reinforcing the periodontal health maintenance both prior to and after incorporation of dental implants. Influence of implant prostheses on patient’s oral health related quality of life (as depicted by OHIP-14) and patients’ perceptions and expectations may guide the clinician in providing the best implant services.

Effect of Probiotic Dietary Intervention on Calcium and Haematological Parameters in Geriatrics

Introduction: Probiotics are live microorganisms which when administered in adequate amounts confer a health benefit on the host. Sufficient calcium intake has been reported to support bone growth and prevent bone loss during the ageing process. Aim: To determine the effect of Lactobacillus helveticus MTCC 5463 probiotic dietary intervention on serum calcium & haematological parameters in geriatric population. Materials and Methods: Healthy volunteers with age ranging from 64-74 years were recruited from the nearby residential areas in and around Anand, Gujarat. Study duration was from 2012 to 2015. Of the 112 subjects initially enrolled in the trial, 36 withdrew before the intervention because of not matching with criterias. Of the 76 participants, 5 subjects (4%) under test group and 12 subjects (11%) under placebo left the study. We had 59 subjects who successfully completed a double blind cross over trial. Probiotic fermented milk products (in form of “Lassi”) was prepared by supplementing toned milk with honey and fermenting with probiotic Lactobacillus helveticus MTCC 5463 and Streptococcus thermophilus MTCC 5460. The final product had at least 108 CFU/ml of viable Lactobacillus helveticus MTCC 5463 at the time of feeding. During feeding period, 200 ml of fermented product containing the test strain to one group and a similar product but without the test strain as placebo were fed regularly at the time of breakfast in morning for 4 weeks. Subjects of each group were given a washout period of 4 weeks before they were crossed over and included to the other group. The study was approved by institutional ethics committee. Results: The socio-demographic and clinical profiles were similar at baseline. The mean (SD) calcium level improved significantly in test {9.36 (0.45) vs 8.45 (0.61), p<0.001}. No significant effect was observed with respect to haemoglobin & haematological parameters. Conclusion: The well-documented probiotic Lactobacillus helveticus MTCC 5463 confirmed increase in serum calcium level but no effect on haematological parameters when administered to geriatrics.

Vision Screening of School Children by Teachers as a Community Based Strategy to Address the Challenges of Childhood Blindness

Introduction: Early detection and treatment of vision problems in children is imperative to meet the challenges of childhood blindness. Considering the problems of inequitable distribution of trained manpower and limited access of quality eye care services to majority of our population, innovative community based strategies like ‘Teachers training in vision screening’ need to be developed for effective utilization of the available human resources. Aim: To evaluate the effectiveness of introducing teachers as the first level vision screeners. Materials and Methods: Teacher training programs were conducted for school teachers to educate them about childhood ocular disorders and the importance of their early detection. Teachers from government and semi-government schools located in Ludhiana were given training in vision screening. These teachers then conducted vision screening of children in their schools. Subsequently an ophthalmology team visited these schools for re-evaluation of children identified with low vision. Refraction was performed for all children identified with refractive errors and spectacles were prescribed. Children requiring further evaluation were referred to the base hospital. The project was done in two phases. True positives, false positives, true negatives and false negatives were calculated for evaluation. Results: In phase 1, teachers from 166 schools underwent training in vision screening. The teachers screened 30,205 children and reported eye problems in 4523 (14.97%) children. Subsequently, the ophthalmology team examined 4150 children and confirmed eye problems in 2137 children. Thus, the teachers were able to correctly identify eye problems (true positives) in 47.25% children. Also, only 13.69% children had to be examined by the ophthalmology team, thus reducing their work load. Similarly, in phase 2, 46.22% children were correctly identified to have eye problems (true positives) by the teachers. By random sampling, 95.65% children were correctly identified as normal (true negatives) by the teachers. Conclusion: Considering the high true negative rates and reasonably good true positive rates and the wider coverage provided by the program, vision screening in schools by teachers is an effective method of identifying children with low vision. This strategy is also valuable in reducing the workload of the eye care staff.

A Study on the Correlation of Pertrochanteric Osteoporotic Fracture Severity with the Severity of Osteoporosis

Introduction: Osteoporosis is a metabolic bone disease caused by progressive bone loss. It is characterized by low Bone Mineral Density (BMD) and structural deterioration of bone tissue leading to bone fragility and increased risk of fractures. When classifying a fracture, high reliability and validity are crucial for successful treatment. Furthermore, a classification system should include severity, method of treatment, and prognosis for any given fracture. Since it is known that treatment significantly influences prognosis, a classification system claiming to include both would be desirable. Since there is no such classification system, which includes both the fracture type and the osteoporosis severity, we tried to find a correlation between fracture severity and osteoporosis severity. Aim: The aim of the study was to evaluate whether the AO/ASIF fracture classification system, which indicates the severity of fractures, has any relationship with the bone mineral status in patients with primary osteoporosis. We hypothesized that fracture severity and severity of osteoporosis should show some correlation. Materials and Methods: An observational analytical study was conducted over a period of one year during which 49 patients were included in the study at HIMS, SRH University, Dehradun. The osteoporosis status of all the included patients with a pertrochanteric fracture was documented using a DEXA scan and T-Score (BMD) was calculated. All patients had a trivial trauma. All the fractures were classified as per AO/ASIF classification. Pearson Correlation between BMD and fracture type was calculated. Statistical Analysis used: Data was entered on Microsoft Office Excel version 2007 and Interpretation and analysis of obtained data was done using summary statistics. Pearson Correlation between BMD and fracture type was calculated using the SPSS software version 22.0. Results: The average age of the patients included in the study was 71.2 years and the average bone mineral density was -4.9.The correlation between BMD and fracture type was calculated and the r–values obtained was 0.180, which showed low a correlation and p-value was 0.215, which was insignificant. Conclusion: Statistically the pertrochanteric fracture configuration as per AO Classification does not correlate with the osteoporosis severity of the patient.

Effect of Red Yeast Rice and Coconut, Rice Bran or Sunflower Oil Combination in Rats on Hypercholesterolemic Diet

Sumitra Govindarajan, Kishore Vellingiri

Introduction: Dietary supplements provide a novel population based health approach for treating hyperlipidemias. Red yeast rice is known to have lipid lowering effects. Combination of red yeast rice with various oils is taken by different population around the world. Aim: In this present work, we aimed to compare the effects of red yeast rice with different oil (coconut, rice bran and sunflower oil) supplementations on lipid levels and oxidative stress in rats fed on hypercholesterolemic diet. Materials and Methods: A Randomized controlled study was conducted on 28 male Sprague Dawley rats. It included 4 arms-Control arm (hypercholesterolemic diet), Test arm A (hypercholesterolemic diet +Red yeast rice + Rice bran oil), arm B (hypercholesterolemic diet +Red yeast rice + Coconut oil) and arm C (hypercholesterolemic diet +Red yeast rice + Sunflower oil). At the end of one month, serum cholesterol, triglycerides, MDA and paraoxonase was measured. The mean values of analytes between the different groups were compared using student ‘t-’ test. Results: The rats fed with red yeast rice and rice bran oil combination showed significantly lower levels of serum cholesterol, triglycerides and MDA when compared to the controls. The serum paraoxonase levels were significantly higher in this group when compared to the controls. The rats fed with red yeast rice and coconut oil combination showed significantly lower serum cholesterol and MDA levels when compared to the controls. The mean triglyceride and paraoxonase levels did not show any statistically significant difference from the controls. The rats on red yeast rice and sunflower oil combination did not show any statistically significant difference in the lipid levels and oxidative stress parameters. Conclusion: The food combination which had best outcome in preventing the development of hyperlipidemia and oxidative stress in rats fed with hypercholesterolemic diet was red yeast rice and rice bran oil. Combining red yeast rice with coconut oil and sunflower oil gave suboptimal benefits.

Metabolic Syndrome among Secondary School Teachers: Exploring the Ignored Dimension of School Health Programme

Shashikala Narayanappa, Renuka Manjunath, Praveen Kulkarni

Introduction: The rising trend of obesity, insulin resistance, metabolic abnormalities, pro atherogenic factors are important determinants of both the non-communicable diseases and metabolic syndrome. Employees especially school teachers have chronic stress which predisposes them to metabolic syndrome (MS). Thus, increasing the possibility of premature mortality due to CVD and T2DM and escalating the health care cost is affecting their families. Aim: To assess the prevalence and the risk factors influencing metabolic syndrome among secondary school teachers. Materials and Methods: A cross-sectional study among secondary school teachers of Mysore city. A self administered, pretested and structured questionnaire based on the WHO Steps Approach for NCD evaluation. Data was analysed in SPSS version 20, chi-square test for categorical variables and t-test for continuous variable was applied along with logistic regression analysis to determine the independent predictors of MS. Results: The prevalence of MS was 115 (38.3%). It increased from 6 (14.3%) in 21-30 years to 40(56.3%) in > 50 years age group. However, 144(48.0%) had = two risk factors, 121(40.3%) had = 3 risk factors and 7(2.3%) had all the five risk factor. Conclusion: All components of MS were statistically significant in their association with the metabolic syndrome disease complex. The School health programme can be utilised as an opportunity to screen the teachers and provide primary preventive care.

Diabetes Mellitus has no Significant Influence on the Prevalence of Antenatal Asymptomatic Bacteriuria

Nissi Priya Mekapogu, Swarnalatha Gundela, Renuka Devi Avula

Introduction: Diabetes is a known risk factor for asymptomatic bacteriuria (ASB). However, the influence of diabetes on antenatal ASB was previously not addressed. Aim: The prevalence of ASB, effect of risk factors and type of isolates and susceptibility patterns were studied in diabetic pregnancy. M aterials and Methods: A total of 311 pregnant women were recruited for this study of which 103 were diabetic and 208 non-diabetic. A clean catch midstream urine samples were collected and cultured. The isolates were identified and antibiotic sensitivity was studied. The data was analysed by Chi-square test. Results: The prevalence of ASB in diabetic pregnancy was 38.83% (40/103; 95% CI: 23.73 - 53.94) and in non-diabetic pregnancy was 37.98% (79/208; CI: 27.28- 48.68). The odds ratio was not significant 1.0225 (95% CU: 0.65 – 1.599; p=0.922) and associated factors such as age and gestational period had no effect. The major isolates were Escherichia coli (25.0%), Staphylococcus aureus (22.5%), Coagulase negative staphylococci (CONS) (20.00%), and Klebsiella pneumonia (20.00%) in diabetic pregnancy and CONS (31.7%), E.coli (24.0%) and K.pneumonia (16.5%) in non-diabetic pregnancy. The isolates of diabetic pregnancy showed highest susceptibility to nitrofurantoin (56.4%), gentamicin (38.5%) and cotrimoxazole (38.5%) whereas that of non-diabetic pregnancy to gentamicin (43.0%), azithromycin (32.9%) and norfloxacin (30.4). There was no significant (p<0.05) difference in the type and susceptibly of the isolates between diabetic and non-diabetic pregnancy. Conclusion: Diabetes has no significant influence on the prevalence of ASB in diabetic pregnancy both in terms of isolates and antibiotic susceptibility pattern.

Utility of Cell-Block of Bronchial Washings in Diagnosis of Lung Cancer- A Comparative Analysis with Conventional Smear Cytology

Uday C Kakodkar, Rohit Vadala, Suresh Mandrekar

Introduction: Bronchoscopy is a safe & effective means of diagnosing bronchogenic carcinoma with a varying diagnostic yield of different bronchoscopic procedures. Cell-Block (CB) preparation of cytology specimen has been shown to increase the diagnostic yield further. To the authors’ knowledge, the diagnostic value of CB as an adjunct to conventional smear cytology (CS) of bronchial washing specimens in the detection of bronchogenic carcinoma has not been well evaluated. Aim: The present study was aimed to evaluate the diagnostic utility of CB of bronchial washings when compared with CS. Materials and Methods: A total of 104 patients of suspected bronchogenic carcinoma were subjected to bronchoscopy as per British Thoracic Society (BTS) protocol. Bronchial biopsy, brushings and washings were collected. Smears were prepared immediately of bronchial washings and another aliquot was subjected to CB preparation and further processing by paraffin embedding and H&E staining. Results: Out of 104 patients, 92 were diagnosed by bronchoscopy with a cumulative diagnostic yield of all sampling techniques being 88.46%. Yield of CB of bronchial washings (44.23%) was higher than Bronchial washings – conventional smears (36.53%). CB detected additional 8 cases of malignancy where corresponding bronchial washings-conventional smears were negative. Exclusive diagnosis by CB was obtained in 2 cases. Brushings and biopsy confirmed malignancy in 49.03% and 57.69% cases. Conclusion: CB of bronchial washings had a higher yield as compared to corresponding conventional smears. Increase in yield was also noted when CB of bronchial washings was combined with biopsy and compared to bronchial washings- conventional smears combined with biopsy. In limited resource settings, CB preparation is a simple method that increases diagnostic yield of flexible bronchoscopy, is cost effective & hence can be routinely used. The immunohistochemical and molecular studies are possible with CB only, which is a distinct advantage over conventional smears of bronchial washings.

Retention of Implant Supported Metal Crowns Cemented with Different Luting Agents: A Comparative Invitro Study

Roohi Kapoor, Kavipal Singh, Simrat Kaur, Aman Arora

Introduction: To overcome limitations of screw-retained prostheses, cement-retained prostheses have become the restoration of choice now a days. Selection of the cement hence becomes very critical to maintain retrievability of the prostheses. Aim: The purpose of this study was to assess and compare the retention of base metal crowns cemented to implant abutments with five different luting cements. Materials and Methods: Ten implant analogs were secured in five epoxy resin casts perpendicular to the plane of cast in right first molar and left first molar region and implant abutments were screwed. Total of 100 metal copings were fabricated and cemented. The cements used were zinc phosphate, resin modified glass ionomer cement, resin cement, non-eugenol acrylic based temporary implant cement & non-eugenol temporary resin cement implant cement. Samples were subjected to a pull-out test using an Instron universal testing machine at a crosshead speed of 0.5mm/min. The load required to de-cement each coping was recorded and mean values for each group calculated and put to statistical analysis. Results: The results showed that resin cement has the highest retention value 581.075N followed by zinc phosphate luting cement 529.48N, resin modified glass ionomer cement 338.095 N, non-eugenol acrylic based temporary implant cement 249.045 N and non-eugenol temporary resin implant cement 140.49N. Conclusion: Within the limitations of study, it was concluded that non-eugenol acrylic based temporary implant cement and non-eugenol temporary resin implant cement allow for easy retrievability of the prosthesis in case of any failure in future. These are suitable for cement retained implant restorations. The results provide a possible preliminary ranking of luting agents based on their ability to retain an implant-supported prosthesis and facilitate easy retrieval.

Is Reactive Dengue NS1Antigen Test a Warning Call for Hospital Admissions?

Introduction: Dengue fever is a major public health problem worldwide. The 2011 revised World Health Organization (WHO) guidelines have emphasized on early diagnosis and intervention to reduce the case fatality rate due to dengue fever. Rapid diagnostic tests like NS1 antigen assays have improved the detection of cases in early clinical phase of illness but its role as a predictor of severe dengue infection is not very clear. Aim: To evaluate the utility of NS1 Ag assay as an early diagnostic marker and predictor of severe dengue infection. Materials and Methods: All children (0-12 years of age) diagnosed and confirmed with dengue fever at a tertiary care hospital in Puducherry between 01st August 2012 and 31st July 2015 were reviewed retrospectively from hospital case records as per the revised WHO guidelines for dengue fever. The diagnosis was confirmed by NS1antigen-based ELISA test or dengue serology for IgM and IgG antibodies and the data were analysed using SPSS 16.0 statistical software. After collecting all the data, all the variables were summarised by descriptive statistics. Categorical variables were expressed as frequencies and percentages, and then analysed by the ?2 test or fishers exact test, where appropriate. Significance was taken at p-value< 0.05. Results: Among the 261 confirmed cases of dengue fever non-severe dengue and severe dengue infection was seen in 60.9% and 39.1% respectively. The mean age of presentation was 6.9 years and M:F ratio was 1.2:1. NS1 Ag was positive in 217 cases (83.1%) and among them non-severe dengue and severe dengue was seen in 65.9% and 34.1% cases respectively. A total of 44 cases (16.9%) were negative for NS1 Ag assay and positive for IgM MAC ELISA and among them 16 children (36.4%) had non-severe dengue infection where as 28 children (63.6%) had severe dengue infection. Secondary infection with (MAC-ELISA IgG) was seen in 17 cases (6.5%). NS1Ag assay was predominantly positive in acute phase sera, where as IgM/IgG MAC ELISA was predominantly positive in convalescent phase sera. There were six deaths (2.3%) and the common causes of poor outcome were multiorgan failure, encephalopathy and refractory shock. Conclusion: NS1 Ag assay is a useful early diagnostic marker for dengue fever but cannot be used as an early predictor of severe dengue infection. The criteria for admission in hospitals of cases of dengue fever should be based on clinical warning signs rather than positive NS1 Antigen test.

Tumour-Associated Tissue Eosinophilia in Oral Squamous Cell Carcinoma- A Boon or a Bane?

Introduction: The infiltration of tumour stroma by eosinophils, Tumour-Associated Tissue Eosinophilia (TATE) is known to modulate the evolution of Oral Squamous Cell Carcinoma (OSCC). Identification of eosinophils in the inflammatory stroma has been proven to be an important factor in prognostication of malignant tumours including cancers of mouth, oesophagus, larynx, pharynx, breast, lung, intestine and genitourinary tract. Aim: Our study aimed to assess the role of TATE as a prognosticator in OSCC as visualized by Haematoxylin and Eosin (H&E) and congo red staining. Materials and Methods: Thirty histologically-proven cases of OSCC were retrieved from the archives of Department of Oral Pathology, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka, India. Two serial sections of 4µm thickness were made and subjected to routine staining with H&E and modified congo red staining, where eosinophil granules stained red and nuclei stained blue. In 40x magnification, 10 HPF at invasive tumour front were assessed for counting eosinophils by placing a 49 square grid (measuring 0.0289 sq mm). Statistical Analysis: The TATE was compared with the prognosticators using Mann-Whitney U-test. The grades of carcinoma were correlated with TATE using Kruskal-Wallis test followed by Post-hoc Bonferronis correction. Agreement of the number of eosinophils counted in the two staining techniques (H&E and Congo red) in OSCC was achieved using interclass correlation coefficient, and Friedman’s test. A value of p< 0.05 was considered statistically significant. Results: Our results showed that tissue eosinophil counts were higher in well-differentiated cases of OSCC, cases with lymph node involvement, decreased survival, without margin involvement and in cases that did not recur. H&E stain showed significantly better visualization of eosinophils resulting in higher eosinophil counts than when seen with Congo red (p=0.008). Conclusion: Thus, TATE can be used as a surrogate marker in prediction of survival and recurrence in OSCC. H&E proved to be a better stain for evaluation of eosinophils.

Comparison Between Biofilm Production, Phospholipase and Haemolytic Activity of Different Species of Candida Isolated from Dental Caries Lesions in Children

J. Udayalaxmi, Neetha Shenoy

Introduction: C.albicans is the most commonly isolated fungal pathogen in the oral cavity, but isolation of non-albicans Candida is increasing in recent years. We wish to demonstrate the virulence factors of Candida spp. isolated from the dental caries lesion of the children as presence of virulence factors determines the pathogenic potential of any microorganism. Aim: To compare biofilm production, phospholipase and haemolytic activity of C.albicans with that of non-albicans species of Candida isolated from dental caries lesions of children to evaluate the role of non- albicans species of Candida in formation of dental caries. Materials and Methods: Oral swabs were collected from caries lesion of 100 school children of age 5-10 years with dental caries. Candida isolates were tested for biofilm production, phospholipase and haemolytic activity. Statistical analysis was done by Chi-Square test and Mann-Whitney U test wherever applicable using SPSS version 11.5. Results: Out of the 100 children with dental caries 37 were positive for Candida by smear or culture and 31 by culture. C.albicans was the most prevalent isolate followed by C.krusei, C.tropicalis and C.albicans. Out of 21 C.albicans isolates, 10 (47.6%) showed phospholipase activity and 18 (85.71%) produced biofilm. Of the 10 non-albicans strains, 5 (50%) showed phospholipase activity and 6 (60%) produced biofilm. All isolates of Candida produced haemolysin (100%). Conclusion: There was no statistically relevant difference between the virulence factor production by C.albicans and non-albicans species of Candida. In other words, our study shows that both C.albicans and non-albicans species of Candida isolated from caries lesions of the children, produce these virulence factors. So we can say that non-albicans species of Candida also are involved in caries formation.

Dating of Early Subdural Haematoma: A Correlative Clinico-Radiological Study

Murali Gundu Rao, Dalbir Singh, Niranjan Khandelwal, Suresh Kumar Sharma

Introduction: Determination of post-traumatic interval remains one of the foremost important goals of any forensic investigation related to human crimes. The estimation of time since injury in cases of subdural haemorrhage has been studied only by a few investigators on the histological and radiological front. Aim: The purpose of this study was to determine the post-traumatic interval of Subdural Haemorrhage (SDH) based on Hounsfield Unit measurements (HU) on Computed Tomography (CT) in surviving victims of head injury. Materials and Methods: The study included a total of 100 cases of closed head injury with subdural haemorrhage. The Post-traumatic Time Interval (PTI) varied from 0.5 hours to a maximum of 249 hours, with a mean of 54.2 hours. Results: Statistically significant results were obtained between the HU measurements of the SDH and the post-traumatic intervals and were found to be statistically significant. A rough attempt was made to determine the effect of haematoma volume on attenuation and was found out to be statistically insignificant. Conclusion: The density of the subdural haematoma decreases with increase in the post-traumatic interval that concurs with the limited number of studies being conducted in the past. We concluded that further sorting of cases could be done according to its age with additional research and uniformity in the methodology.

Comparative Evaluation of Antimicrobial Effect of Three Endodontic Sealers with and Without Antibiotics – An In–vitro Study

Introduction: Root canal sealers with good sealing ability and antimicrobial activity are desired to entomb the surviving microorganisms. Aim: Aim of the present study is to evaluate the antimicrobial effect of different sealers mixed with antibiotics. Materials and Methods: Sixty extracted premolars were taken and were cut coronally & apically such that 7mm of tooth specimen was prepared. They were sterilized by autoclaving, inoculated with E.faecalis and incubated for three weeks. The specimens were divided into six groups of 10 each. Group 1 – ZnOE , Group 2 – ZnOE +TAM, Group 3 – Apexit Plus, Group 4 – Apexit Plus +TAM, Group 5 – AH Plus, Group 6 – AH Plus + TAM. Bacterial growth in the each specimen was calculated before & after sealer application and noted as initial & final colony count. Antimicrobial effect of each sealer was measured by calculating the Percentage Reduction in Colony Count (%RCC). One way analysis of variance and post hoc tests were used for statistical analysis. Results: ZnOE + TAM group showed maximum antibacterial effect among the sealers tested and AH Plus sealer showed least antimicrobial effect. Conclusion: When the sealers were mixed with triple antibiotic mixture the antimicrobial effect was increased significantly.

Collapsing Glomerulopathy: A Single Centre Clinicopathologic Study of Seven Years

Introduction: Collapsing Glomerulopathy (CG) is recognized as distinct pattern of proliferative parenchymal injury with poor response to empirical therapy. Aim: A single center retrospective study was carried out to find out clinicopathological features of idiopathic CG. Materials and Methods: A total of 3335 native renal biopsies were analyzed retrospectively which were performed from 2008 to 2014 with emphasis on clinicopathological correlation and histopathological presentation. Results: Idiopathic CG constituted 0.75% incidence (25 out of 3335 biopsies) of all biopsies, adults constituting major study part with 88%. The duration of the symptoms at the time of biopsy was 34.12±26.09 days and 35±22.91 days respectively in adults and children. Hypertension was noted in 9(40.9%) and oliguria in 8(36.4%) in adults. Urinalysis revealed microscopic haematuria 12(54.5%) in adults. Nephrotic range proteinuria was reported in 10 (45.5%) adult patients. Glomerular collapse with hyperplasia/ hypertrophy of podocytes was seen in 4.54±3.11 glomeruli. Tubular microcystic dilation was seen in 16(64%) patients. Tubular atrophy involving mild (t1) in 15(60%), moderate (t2) in 4(16%) and severe (t3) in 6(24%) patients. Interstitial fibrosis was mild (i1) in 17(68%), moderate (i2) in 2(8%) and severe (i3) in 6(24%) patients. Conclusion: Idiopathic CG is a morphological pattern of grave podocyte injury with poor prognosis. However, there are chances of remission/ recovery if the tubular atrophy and interstitial fibrosis are of grades = t1 i1

Impact of Mode of Curriculum on Knowledge and Attitudes of Medical Students towards Health Research

Introduction: Equipping students with skills in medical research should be an integral part of medical education systems. This study is designed to gauge the difference in knowledge and attitudes towards health research between two sets of undergraduate medical students; those enrolled in the new Problem Based Learning (PBL) education system versus those of the conventional Lecture Based Learning (LBL) curricula. Materials and Methods: From the 4th and 5th years of medical university students, 90 participants were recruited from the Aga Khan University (PBL group) and Dow University of Health Sciences (LBL group) and were presented with structured and pre-validated questionnaire. Responses obtained for knowledge and attitudes of each group were recorded on a scale and graduated in percentages to be compared statistically for differences to identify the effectiveness of each curriculum. Results: The score on the knowledge scale for the PBL group was found to be 44.77% against the 31.55% of the LBL students (p-value<0.001). Furthermore, the mean attitude score of AKU students was 72.22% as opposed to the 56.11% of the DUHS participants (p-value<0.001). Conclusion: The PBL group achieved significantly higher scores in all aspects than the LBL group, showing healthier attitudes towards health science research along with better knowledge. Hence, the apparent positive influence of PBL curricula on attitudes towards research may be helpful in improving research output of medical students in Pakistan.

The Effect of Combined Antenatal and Postnatal Counselling on Postpartum Modern Contraceptive Use: Prospective Case-Control Study in Kocaeli, Turkey

Fisun Vural, Birol Vural, Yigit Cakiroglu

Introduction: The integration of family planning education into obstetric care has been suggested to increase postpartum contraception use. However, ideal time and type of counseling is controversial. There is no prospective study about combining prenatal and postnatal education on the postpartum modern contraceptive use (PPMC). Aim: This study was aimed to explore the effects of the addition of postpartum contraceptive counselling to antenatal education on PPMC. Materials and Methods: Family planning counselling was given to all participating patients throughout antenatal care (ANC) via brief communications. After delivery, the women were categorised into two age-matched groups with a 1:1 allocation ratio in the order of the birth date. No further intervention was performed for Group I (n: 98). Women in Group II (n: 102) received further contraceptive education at six weeks after hospital discharge. Six months after delivery, PPMC was compared between the two groups. Results: PPMC was similar between Group I and II (p>0.05). Previous contraceptive experiences, obstetric care service intensity and partner's support were the factors related to postnatal contraceptive use. Logistic regression analysis showed that PPMC was independent of confounding factors in each group. Conclusion: The addition of postnatal counseling to antenatal one did not further increase PPMC. The results of this study suggested that family planning counseling should be provided antenatally.

Contrast Enhanced Computed Tomographic Study on the Prevalence of Duodenal Diverticulum in Indian Population

Introduction: Duodenal diverticulum (DD) is the second most common diverticulum, yet its incidence varies widely from 1–22% based on the mode of investigation. Computed Tomography (CT) of abdomen is the preferred modality to diagnose acute abdomen including those of complications of DD. Moreover, the prevalence of DD in Indian population is not yet been studied using CT. Aim: The current study aim to look for the prevalence of DD in Indian population using Contrast Enhanced Computed Tomography (CECT) abdomen. Materials and Methods: A retrospective study was done to assess the presence of DD using the CECT abdomen of 565 patients. The number, size, location, wall thickness and the contents of the diverticulum were noted. The data obtained was analysed using SPSS version 17.0. The mean, percentage of frequency of each variable and the association of DD with pancreatitis, cholelithiasis and colonic diverticulum were also looked for. Frequencies and percentages were calculated for all categorical variables. Spearman’s rho correlation was done for age, diameter and content of DD. Results: The prevalence of DD in Indian population was 8.3% with the mean diameter of 17.13mm+7.26. The prevalence increased with age with no sex predilection. 89.3% were solitary and 10.64% were multiple. It was predominantly seen in the second part of duodenum (90.38%) and juxtapapillary type was the commonest. As the diameter of DD increased, fluid became its content. No significant association was observed between the presence of DD with pancreatitis, cholelithiasis or colonic diverticulum. A case of periampullary carcinoma arising from DD, a rare entity is being reported in this study. Conclusion: The prevalence of DD in Indian population is high compared to western population. DD has been attributed to the cases of acute abdomen and fluid alone as a content of DD with an incidence of 1.92% can be mistaken for a cystic neoplasm of pancreas. Rarely, a periampullary carcinoma can also arise from the wall of the pre-existing DD. This knowledge should be emphasised upon by the radiologist, surgeons and gastroenterologist who will be dealing with cases of acute abdomen and periampullary carcinoma.

Study of Life Events and Personality Dimensions in Generalized Anxiety Disorder

A. Sri Sennath J Arul
Introduction: Life events, recognized as stressors, due to their unanticipated nature, can cause psychiatric illness. Also there is some line of continuity between neurotic illness and antecedent personality traits. Aim: To study generalized anxiety disorder in relation to Life events and personality dimensions. Materials and Methods: Certain hypotheses were tested in two groups, namely 30 Generalized Anxiety Disorder patients (GAD) and 30 matched controls, by utilizing assessment tools. These include: GAD patients experience more undesirable Life events than normal; GAD patients with high level of anxiety experience more undesirable Life events; Neuroticism is related to the severity of anxiety; Extroverts experience more anxiety; Level of anxiety in females is higher; GAD patients with higher education level experience more anxiety, while those with lower education level somatize more. The group differences were examined using Chi-Square test, Student t-test and ANOVA. Pearson’s Correlation Co-efficient was used to find the correlation between anxiety and the undesirable Life events. The level of statistical significance was set at p<0.05. Results: GAD patients experienced significantly more undesirable Life events than the matched controls. Patients with high level of anxiety experienced more undesirable Life events, with the coefficient of correlation being quite high. A significant association between Neuroticism scale and GAD was observed. Conclusion: The study suggests a possible causative link between the undesirable Life events and GAD; and a significant association between Neuroticism dimension and the anxiety disorder. Role of environmental stressors and personality traits in treatment outcome among GAD patients awaits further, prospective studies.

Comparison of the Effects of Varicocelectomy and Oral L-carnitine on Sperm Parameters in Infertile Men with Varicocele

Heshmatollah Sofimajidpour, Ebrahim Ghaderi, Omid Ganji
Background: Varicocele is defined as dilated and twisted veins of the pampiniform plexus in the spermatic cord. It is the most common cause of male infertility. There are various medical and surgical procedures for the treatment of this disease. Aim: This study was aimed to compare the effects of oral administration of L-Carnitine and varicocelectomy on spermogram parameters. Materials and Methods: This study was conducted as a double blind clinical trial without randomization. Inclusion criteria were, all married infertile men with varicocele. Patients chose their treatment personally and spermogram was carried out for all patients before and after the third and sixth months of treatment. Then, the sperm parameters of the two groups were compared using repeated measures ANOVA. Results: In our study, trend of sperm count in the surgery group changed from 22 to 28.61 million (vs 34.6 to 45.37 in L-Carnitine group), motility changed from 21.74 to 35.38 percent (vs 33.9 to 47.48 in L-Carnitine group), normal sperm morphology changed from 46.25 to 60 percent (vs 56.61 to 69.7 in L-Carnitine group) and volume of semen changed from 3.5 to 4.17 cc (vs 2.95 to 4.33 in L-Carnitine group). These values were not statistically different between the two groups. Conclusion: Based on the results of this study, we can say that medicinal treatment by administration of oral L-Carnitine is as effective as varicocelectomy in improving semen parameters and can be used as an alternative to surgery for varicocele grade II.

Macrodystrophia Lipomatosa of the Toe: A Rare Case Report

Alagar Raja Durairaj, Surya Rao Rao Venkata Mahipathy
Macrodystrophia lipomatosa is a rare congenital hamartoma presenting as a localized or generalized gigantism of a limb or digit manifesting from infancy to late adulthood. It is a progressive enlargement of the soft tissue components, especially fibrofatty tissue. The patient presents to us because of cosmetic reasons or mechanical issues secondary to degenerative joint disease, or features of neurovascular compression due to large osteophytes. Here, we present a case of this anomaly of the left second toe with complaints of difficulty in walking and wearing shoes, for which toe reduction surgery with partial amputation was done.

Optimum Concentration of Caudal Ropivacaine & Clonidine - A Satisfactory Analgesic Solution for Paediatric Infraumbilical Surgery Pain
Introduction: Ropivacaine is amide local anaesthetic pure S(-)enantiomer of bupivacaine. Its duration of analgesia is similar to that of Bupivacaine (in equivalent doses) but the motor block is slower in onset, less intense, shorter in duration for a given level of sensory block with lesser cardiac side effects but addition of an adjuvant like clonidine which is an imidazoline derivative has been studied for its sedative, anxiolytic and analgesic properties. Aim: This study was aimed to show the optimum concentrations of Ropivacaine and Clonidine to maximize analgesia without side effects by evaluating its safety and efficacy. Materials and Methods: Sixty children aged 2-10 years of ASA grade 1, scheduled to undergo infraumbilical surgeries were randomly allocated to Group A & Group B of 30 each. Group A received 0.2% Ropivacaine with normal saline and Group B received 0.2% Ropivacaine and preservative free Clonidine 1µg/kg, the total volume of solution being 1ml/kg haemodynamic changes were monitored intraoperatively and haemodynamic parameters along with motor blockade, pain score and sedation score were assessed postoperatively. Statistical analysis: Done with unpaired student t and Mann-Whitney test. Results: The groups were comparable regarding demographic characterstics. The mean duration of analgesia was prolonged in group B (12+2.22 hours) than in group A (6.53+1.16 hours) with p-value <0.001 leading to less rescue analgesia in former group. None of the children in the groups had a pain score of = 4 at the end of 2 hours. A 6.6% and 60% of group A children had score of = 4 at the end of 4th & 6th hour respectively. None in Group B had a score of = 4. At the end of 8th hour, only 6.6% of the children in Group B had a pain score of = 4 whereas it was 33.33% in Group A which is statistically significant. No bradycardia or hypotension and no significant sedation. Conclusion: Combination of Ropivacaine and Clonidine in the concentration used (0.2% ropivacaine and 1µg/kg of clonidine) can be optimal for postoperative analgesia in paediatric population.

Spatio-Temporal Pattern of Breast Cancer - Case Study of Southern Karnataka, India
Introduction: Spatio-ecological study of disease provides a framework to study the interaction of genetic, environmental, social, cultural and behavioural factors on people’s health. The occurrence and interaction of these factors are different in different places, giving rise to distinct geographic or spatial variation. Diseases like breast cancer have variation both spatially and temporally. Public health practitioners can use Geographic Information System (GIS) as a visualization tool to effectively present geographic phenomenon and depict it in maps that might remain otherwise undiscovered in tabular form. Aim: To demonstrate how GIS can be used to understand and communicate breast cancer data through spatial visualization techniques. Objectives: (i) To visualize the Spatial Distribution of Breast cancer incidences by a point map. (ii) To visualize the Temporal distribution of breast cancer incidences by thematic maps for the study period of 2007 -2011. Materials and Methods: Total 1090 breast cancer case records collected for the year 2007-2012 were segregated taluk wise for the 29 taluks and geocoded using the address of the patient, creating a point map. ArcGIS 10.2 software was used to prepare thematic map of breast cancer cases. The taluk wise aggregated breast cancer incidence from the year 2007 to 2011 was then attributed into polygon map representing taluks (Base Map).Natural break data classification technique was used to classify the breast cancer incidence data and breast cancer incidences were classified as low, moderate, high and very high. Results: Spatial distribution of breast cancer incidences using thematic mapping methods high incidences were reported in MY_ T24 (Hunsur), MY_ T25 (KR Nagar), MY_27 (Nanjangud), CH_T1 (Chamrajnagar) and CH-T2 (Gundlupet). Temporal maps prepared for the study from 2007 to 2011 showed that Mysore Taluk had very high Incidence level and the same was observed throughout the study period. The taluks which have high and moderate intensities seem to be fluctuating. However, 25 taluks do not fall into very high category during the study period. Taluks such Gundlupet (CH_T2), K R Nagar (MY_T25), Kollegal (CH_T3) have been observed to enter high intensity category during the year 2011 from moderate intensity. It is also observed that Nanjangud (MY_T27) is in high intensity category throughout the study period which might be due to its proximity to Mysore urban. Conclusion: Analysis of Breast Cancer in southern Karnataka using GIS has revealed that urban areas of Mysore has the highest risk of breast cancer and the temporal trends reveal that even rural areas with moderate risk are moving towards high risk areas.

Effect of Communication Skills Training on the Burnout of Nurses: A Cross-Sectional Study
Introduction: One of the factors influencing the burnout of nurses is their difficult and complicated relations with patients and other members of the medical team. Therefore, it is necessary that nurses to be trained on communication skills. Aim: The present research aims to study the effect of communication skills training on the burnout of nurses. Materials and Methods: The present research was an experimental study using pretest-posttest method. The subjects included 60 nurses working in Khatamolanbia Hospital in Iranshahr, Sistan and Baluchestan Province, Iran. The subjects were randomly divided into two groups. The required data and information were collected using Jackson and Maslach Burnout Inventory which was filled out by subjects in three steps including before the intervention, at the end of the second session, and one month after the intervention. The intervention included training on communication skills which was carried out for the intervention group as a 2-day workshop for 8 hours within a week. Results: The findings showed that the mean score of frequency and intensity of burnout in the intervention group before the intervention, at the end of the intervention, and one month after the intervention was 39.3±6.2 and 61.1±8.0, 37.5±4.6 and 58.8±7.6, and 34.2±4.4 and 54.6±7.0, respectively. These changes suggest a significant decreasing trend (p=0.01). On the other hand, mean scores of burnout in the control group showed no significant difference in three steps (p<0.05). Conclusion: Since communication skills training is an effective and inexpensive way for reducing the burnout among nurses, it is recommended that this approach to be taken into account by managers in order to reduce the burnout among nurses and improve the quality of healthcare services provided by them.

Invitro Evaluation of Fluoride Release from Hydroxyapatite Reinforced Glass Ionomer with or without Protective Coating

Shilpi Tiwari, Bhojraj Nandlal
Introduction: Glass Ionomer Cement (GIC) is well known for its fluoride releasing property but has its own drawbacks of poor mechanical properties, sensitivity to initial desiccation and moisture contamination. To overcome these, search led to the reinforcement of hydroxyapatite and application of surface coating agent but their effect on fluoride release is still not clear. Aim: To evaluate and compare the release of fluoride from Hydroxyapatite Reinforced Glass Ionomer (HA-GIC) with and without protective coating. Materials and Methods: Specimens were prepared as follows- Eight percent by weight conventional glass ionomer was replaced by hydroxyapatite powder (HA) and an indigenous product was prepared (HA-GIC). This powder was mixed with liquid of conventional GIC and allowed to set, then G coat plus coating agent was applied in surface coated group and light cured. Fluoride release of the sample was measured every 24 hrs for seven days and weekly from 7th to 21st day using combination ion selective electrode. Results: Mean values clearly reveal a significant decrease in the fluoride release from day 1 to day 21 for both the groups. Results of repeated measure ANOVA revealed statistically significant difference between two groups (p <0.001). Conclusion: Coating the hydroxyapatite reinforced glass ionomer will allow for slow and steady release of fluoride for a long period of time into oral environment.

Management of Chronic Periodontitis Using Chlorhexidine Chip and Diode Laser-A Clinical Study
Introduction: The use of adjuncts like chlorhexidine local delivery and diode laser decontamination have been found to improve the clinical outcomes of scaling and root planing in non-surgical periodontal therapy in patients with chronic periodontitis. Aim: To evaluate the effects of diode laser and chlorhexidine chip as adjuncts to scaling and root planing in the management of chronic periodontitis. The objective is to evaluate the outcome of chlorhexidine chip and diode laser as adjuncts to scaling and root planing on clinical parameters like Plaque Index, Gingival Index, probing pocket depth and clinical attachment level. Study and Design: Department of Periodontics. Randomized clinical trial with split mouth design. Materials and Methods: Fifteen chronic periodontitis patients having a probing pocket depth of 5mm-7mm on at least one interproximal site in each quadrant of the mouth were included in the study. After initial treatment, four sites in each patient were randomly subjected to scaling and root planing (control), chlorhexidine chip application (CHX chip group), diode laser (810 nm) decontamination (Diode laser group) or combination of both (Diode laser and chip group). Plaque Index (PI), Gingival Index (GI), probing pocket depth (PPD) and clinical attachment level (CAL) were assessed at baseline, one month and three months. Statistical analysis: Results were statistically analysed using paired T test, one-way ANOVA, Tukey’s HSD test and repeated measure ANOVA. Results: Post-treatment, the test and control sites showed a statistically significant reduction in PI, GI, PPD, and CAL. After three months, a mean PPD reduction of 1.47±0.52 mm in control group, 1.40±0.83 mm in diode laser group, 2.67±0.62 mm in CHX group, and 2.80± 0.77 mm in combination group was seen. The mean gain in CAL were 1.47±0.52 mm in the control group, 1.40±0.83 mm in diode laser group, 2.67± 0.49 mm in CHX group and 2.67± 0.82 mm in combination group respectively. The differences in PPD reduction and CAL gain between control group and CHX chip and combination groups were statistically significant (p<0.05) at three months, whereas, the diode laser group did not show any significant difference from the control group. Conclusion: Chlorhexidine local delivery alone or in combination with diode laser decontamination is effective in reducing probing pocket depth and improving clinical attachment levels when used as adjuncts to scaling and root planing in non-surgical periodontal therapy of patients with chronic periodontitis.

Quantitative Assessment of Tumor Associated Macrophages in Head and Neck Squamous Cell Carcinoma Using CD68 Marker: An Immunohistochemical Study
Introduction: Oral Squamous Cell Carcinoma (OSCC) is one of the most prevalent cancers in India. Clear evidence regarding inflammation being an etiological factor of cancer was found only in the last few decades. A major inflammatory component in the tumor tissue is Tumor-Associated Macrophages (TAMs). The CD68 antibody is a marker for staining TAMs. Aim: The aim of this study is to quantify the macrophage count in healthy oral mucosa and OSCC and comparing TAMs in different histopathological grades of OSCC immunohistochemically. Materials and Methods: Thirty archival specimens of OSCC patients and 10 healthy biopsy samples were collected. Immunohistochemical staining was done using a CD68 marker. Statistical analysis was done using Kruskal-Wallis ANOVA and Mann-Whitney U test. Results: Comparing CD68 expression in various study groups showed a significant difference (p=0.000). The pair-wise analysis showed different grades of OSCC, which differed significantly for CD68 expression from the normal oral mucosa. Conclusion: The most significant cells present in tumor stroma are TAMs, which remain in close proximity to neoplastic cells and interact with them via several chemical mediators, which may serve to increase the invasiveness of the malignant epithelium. Dense infiltration of TAMs adjacent to tumor cells and islands vividly implies their role in tumor progression.

Prevalence of Attention-Deficit Hyperactivity Disorder in Students and Needs Modification of Mental Health Services in Shahrekord, Iran in 2013

Parvin Safavi, Forouzan Ganji, Atenasadat Bidad
Introduction and Objectives: In view of the complications of Attention-Deficit Hyperactivity Disorder (ADHD) and significance of its treatment, the present study was aimed to investigate the prevalence of ADHD among elementary school students of Shahrekord and to assess the obstacles preventing patients from accessing mental health services. Materials and Methods: In this cross-sectional study, 631 eligible students were selected from elementary school students in Shahrekord County, Iran. Multi-stage stratified random sampling was adopted. Demographic data were gathered and Child Symptom Inventory-4 for parents and teachers was filled out for each student. The students with suspected ADHD were identified, and examined for the association among mental health help-seeking steps. Obstacles to mental health help-seeking were assessed. Results: ADHD prevalence was derived 17.3% and higher among male students (p=0.025). ADHD prevalence was associated with parents’ education and occupation. The evaluation and diagnosis rates were significantly associated with gender (p=0.002 and 0.005, respectively). The most prevalent obstacles facing access to mental health services were those relevant to feeling no need (86%), negative expectations of treatment (78%) and mental health system (64%). Conclusion: ADHD was highly prevalent among elementary school students. Identifying the patients and examining the existing obstacles of access to mental health system seems necessary.

Correlation of Retinal Nerve Fiber Layer Thickness and Axial Length on Fourier Domain Optical Coherence Tomography

Abhinav Dhami, Renu Dhasmana, R.C. Nagpal
Introduction: The assessment of the peripapillary Retinal Nerve Fiber Layer (RNFL) thickness has been an important tool for evaluating and diagnosing glaucoma and its progression. Literature suggests that myopic eyes are at an increased risk for developing glaucoma. This study gives an insight into the relationship of RNFL thickness to the axial length in normal population. Aim: To correlate the RNFL thickness and the axial length in normal individuals with Fourier domain Optical Coherence Tomography (OCT). Materials and Methods: In the current study, 298 eyes of 149 normal individuals (10 years or older) with or without refractive error were recruited. The RNFL thickness was measured using Optovue (RTVue) three-dimensional Fourier domain OCT. Results: We observed an inverse relationship between average RNFL thickness and increasing axial length(p=0.003). Maximum RNFL thickness was seen in the Infero-Temporal (IT) quadrant and minimum in the Supero-Nasal (SN) quadrant. RNFL thickness did not show any tendency to decline with age using the Pearsons correlation (r=0.07). Females had an increased RNFL thickness in the Supero-Temporal (ST) and Infero-Nasal (IN) quadrant (p-value 0.046 and 0.02) in comparison to males. There was a statistically significant thinning in Ganglion Cell Complex (GCC) with increasing axial length (p-value 0.000) Conclusion: The current study suggests that the average RNFL thickness does not decrease with age. The RNFL and GCC thickness shows an inverse correlation with axial length of the eyeball hence observations have to be carefully interpreted in myopic eyes. Clinicians need to keep the anatomical variations in RNFL for better patient management.

Brucellosis in Occupationally Exposed Groups

Smita S. Mangalgi, Annapurna G. Sajjan, Shivajirao T. Mohite, Shivali Gajul
Introduction: In India, high incidence of human brucellosis may be expected, as the conditions conducive for human brucellosis exist. Limited studies have been undertaken on human brucellosis especially in occupationally-exposed groups. Aim: To estimate prevalence of anti-brucellar antibodies, evaluate the clinical manifestations, risk factors and Knowledge, Attitude and Practices (KAP) levels about brucellosis among occupationally exposed groups. Materials and Methods: Blood samples were collected from 2337 occupationally exposed individuals. The serum samples were screened for the presence of anti-brucellar antibodies by Rose Bengal Plate Test (RBPT), Serum Agglutination Test (SAT) and 2-Mercaptoethanol test (2-ME). Clinical manifestations, risk factors and KAP levels were evaluated by personal interview using a structured questionnaire. Results: Seroprevalence of brucellosis by RBPT, SAT and 2-ME test was 9.46%, 4.45% and 3.64 % respectively. Clinical symptoms resembling brucellosis were seen in 91 subjects. The major risk factors were animal exposure in veterinarians and abattoirs, both animal exposure and raw milk ingestion in farmers and shepherds, exposure to raw milk and its ingestion in dairy workers and exposure to Brucella culture in laboratory workers. Except laboratory workers, few veterinarians and dairy workers none had heard about brucellosis. KAP levels regarding brucellosis were too poor in all the groups except laboratory workers. Conclusion: Brucellosis most of the times was missed or misdiagnosed. Regular screenings for brucellosis and awareness programmes to increase KAP levels are necessary to control brucellosis in occupationally exposed groups.

Effect of Green and White Tea Pretreatment on Remineralization of Demineralized Dentin by CPP-ACFP- An Invitro Microhardness Analysis

Poornima Jose, Kavitha Sanjeev, Mahalaxmi Sekar
Introduction: Mechanical performance of dentine is of major significance for the overall function of the teeth. Remineralization of carious dentine is the ultimate goal in re-establishing the functionality of the affected tissue so as to regain and maintain the mechanical properties of dentine. Functional remineralization of the affected dentin involves stabilization of both inorganic and organic component, but Caesin Phosphopeptide Amorphous Calcium Flurophosphate (CPP-ACFP) stabilizes only inorganic content. Hence to stabilize organic content and to bring in functional remineralization the use of anticollagenolytic and antielastastic agent was considered for this study. Aim: To assess and compare the remineralization of artificial carious dentin pre treated with white and green tea, before and after application of CPP-ACFP using microhardness test. Null hypothesis was that both teas did not have any effect on remineralization potential of CPP ACFP. Materials and Methods: Forty specimens were subjected to artificial caries lesions and were randomly divided into 4 groups based on the application of tea extract followed by CPP-ACFP (groups A & B) and CPP-ACFP followed by tea extracts (groups C & D). All the specimens were subjected to two pH cycling regimen. The specimens were subjected to Vickers microhardness test to obtain the microhardness values. The values were statistically analysed using one-way ANOVA and multiple comparisons with Tukey’s HSD procedure. Results: After the 1st and 2nd pH cycling in groups A and B, Group B showed significant increase in microhardness values (35.79± 3.12 VHN). But after the pH cycling regimen in groups C and D, microhardness values increased in 1st pH cycling (50.03± 3.64 VHN); (50.03±3.64 VHN), respectively but decreased during the 2nd pH cycling, (33.94±6.45 VHN); (33.11±6.11 VHN) respectively with the level of significance <0.05. Conclusion: The results of this study rejects the hypothesis tested and showed that both the tea extracts increased the microharness values when used prior to the application of remineralizing agent. However, white tea showed better results indicating stabilization of collagen in dentine resulting in functional remineralization.

β-Thalassaemia and its Co-existence with Haemoglobin E and Haemoglobin S in Upper Assam Region of North Eastern India: A Hospital Based Study
Introduction: ß-Thalassaemias are common genetic disorders in the Indian subcontinent and its status has not been well studied in the Upper Assam region of North Eastern India. Aim: The aim of the study was to show the prevalence of ß- thalassaemias and its co-existence with Haemoglobin E and Haemoglobin S in the Upper Assam region of North Eastern India. Materials and Methods: A total of 1200 anaemic patients were investigated for ß- thalassaemias. Complete Blood Count (CBC) and High Performance Liquid Chromatography (HPLC) were done for screening. Results: Out of 1200 patients screened, 5.83% ß-thalassaemia trait, 2.33% compound Hb E/ß-Thalassaemia, 1.33% ß-thalassaemia major and 0.42% compound Hb S/ß- thalassaemia were detected. A high incidence of thalassaemia is found among the people of Upper Assam region of North Eastern India. Conclusion: The only way to prevent the disease is carrier detection and awareness among the people about it.

Antibacterial Activity and Fluoride Release of Glass-Ionomer Cement, Compomer and Zirconia Reinforced Glass-Ionomer Cement
Introduction: The cariostatic property of glass ionomer cement (GIC) stems from its ability to release fluoride into the oral environment. Recently, zirconia reinforced GIC has been launched which promises the protective benefits of glass ionomer while completely eliminating the hazard of mercury. Aim: To evaluate invitro antibacterial activity and fluoride release from two conventional glass ionomer cements (GC II and GC IX), compomer (Compoglass) and a zirconia reinforced glass ionomer cement (Zirconomer). Materials and Methods: The antibacterial activity of the cement specimens was evaluated against Streptococcus mutans using the agar inhibition test. Zone of inhibition on Mueller-Hinton agar plates was measured after 48 hours. The fluoride release from the cement specimens in ppm were measured at day 1, 7, 14 and 21 using a fluoride ion selective electrode. Data was analysed using one-way and two-way analysis of variance (ANOVA) followed by LSD post-hoc test. A p-value <0.05 was considered statistically significant. Results: Statistically significant largest zone of inhibition was observed with Zirconomer. Also, significant differences were seen in fluoride release of different materials. At all the time intervals maximum fluoride release was observed with Zirconomer and minimum with Compoglass. Conclusion: This invitro investigation has revealed that zirconia reinforced GIC (Zirconomer) had maximum antibacterial activity against S.mutans and fluoride release.

Demystifying the Enigma of Smoking – An Observational Comparative Study on Tobacco Smoking
Introduction: Smoking is a hazardous habit which causes definite changes in the oral cavity, consequently there exist changes in the mucosa when subjected to smoking. Palatal mucosa is first to be affected. The present study determines the palatal status in reverse smokers and conventional smokers. Aim: To study and compare the clinical, cytological and histopathological changes in palatal mucosa among reverse and conventional smokers. Materials and Methods: Study sample was categorized into two groups. Group 1 comprised of 20 subjects with the habit of reverse smoking and Group 2 comprised of 20 subjects with the habit of conventional smoking. Initially, clinical appearance of the palatal mucosa was recorded, followed by a cytological smear and biopsy of the involved area among all the subjects. The findings were studied clinically, the specimens were analysed cytologically and histopathologically, and compared among the two groups. Results: The severity of clinical changes of the palatal mucosa among reverse smokers was statistically significant when compared to those of conventional smokers. There was no statistically significant difference observed in cytological staging between the groups with a p-value of 0.35. The histopathological changes in both the groups showed a significant difference with a p-value of 0.02. A significant positive correlation was observed between the clinical appearance, and cytological, histopathological changes. Conclusion: Profound clinically aggressive changes were observed in group I compared to group II. Severity of dysplastic changes have been detected in few subjects through histopathological examination irrespective of no prominent clinical and cytological changes observed among the two groups.

Effect of Mindfulness Meditation on Perceived Stress Scores and Autonomic Function Tests of Pregnant Indian Women

Shobitha Muthukrishnan, Reena Jain, Sangeeta kohli, Swaraj Batra
Introduction: Various pregnancy complications like hypertension, preeclampsia have been strongly correlated with maternal stress. One of the connecting links between pregnancy complications and maternal stress is mind-body intervention which can be part of Complementary and Alternative Medicine (CAM). Biologic measures of stress during pregnancy may get reduced by such interventions. Aim: To evaluate the effect of Mindfulness meditation on perceived stress scores and autonomic function tests of pregnant Indian women. Materials and Methods: Pregnant Indian women of 12 weeks gestation were randomised to two treatment groups: Test group with Mindfulness meditation and control group with their usual obstetric care. The effect of Mindfulness meditation on perceived stress scores and cardiac sympathetic functions and parasympathetic functions (Heart rate variation with respiration, lying to standing ratio, standing to lying ratio and respiratory rate) were evaluated on pregnant Indian women. Results: There was a significant decrease in perceived stress scores, a significant decrease of blood pressure response to cold pressor test and a significant increase in heart rate variability in the test group (p< 0.05, significant) which indicates that mindfulness meditation is a powerful modulator of the sympathetic nervous system and can thereby reduce the day-to-day perceived stress in pregnant women. Conclusion: The results of this study suggest that mindfulness meditation improves parasympathetic functions in pregnant women and is a powerful modulator of the sympathetic nervous system during pregnancy.

Ischaemic Markers in Acute Hepatic Injury
Introduction: Hepatic injury of varied aetiology may progress to Acute Liver Failure (ALF). Compromised microcirculation is thought to be a deciding factor of hepatic hypoxia may be involved in disease progression that needs early detection. Ischaemia markers like serum Ischaemia- modified albumin (IMA), ALT-LDH ratio and ALT-LDH index have been suggested for its detection at early stage. Aim: To find out the association of Ischaemia markers like serum IMA, ALT-LDH ratio and ALT-LDH index in acute hepatic injury cases. Materials and Methods: Forty one diagnosed acute liver injury cases of varied aetiology admitted in Department of Medicine, and Gastroenterology of SCB Medical College, Cuttack were enrolled in the study along with 30 age and sex matched healthy controls. Blood collected at time of admission and at time of discharge (1st day and 7th day) were evaluated for FPG, RFT, LFT, Serum Albumin along with serum LDH, IMA, PT-INR and platelet count. Result: Serum bilirubin, hepatic enzymes, IMA, PT-INR was more markedly raised in cases than controls on the 1st day of admission. ALT-LDH ratio and index were significantly low in complicated cases. However, on responding to treatment the ALT-LDH index on 7th day registered a rise in comparison to the 1st day, while serum IMA revealed an insignificant decline showing improvement in hepatic hypoxia. ALT-LDH ratio remains more or less same on response to treatment. Conclusion: Serum IMA and ALT-LDH Index reveals association with disease process in Acute Hepatic Injury cases both clinically and biochemically and can be used as supportive parameters for the diagnosis of disease process.

Time Dependent Effect of a Denture Cleanser on the Sorption and Solubility of Four Soft Liners-An Invitro Study

Swathi Sudhapalli, SruthiKeerthi Sudhapalli
Introduction: Soft liner materials, when used with ill fitting dentures, are constantly kept in a wet environment of either saliva or denture cleanser that affects their sorption and solubility. These inturn have detrimental effect on other properties. Aim: To evaluate the influence of different exposure times of a commonly used denture cleanser on sorption and solubility of four soft liners. Materials and Methods: Metal disc was fabricated to make the mould space for soft liner samples. Four materials were used, long term and short term acrylic liners; long term and short term silicone liners. Each of these were divided into four groups: first control group– all liners were kept in artificial saliva for entire period of study. Second group- liners were immersed daily in cleanser for 1 hour and then transferred to artificial saliva for rest of the day. Similarly samples of third and fourth groups were immersed in cleanser for 4 and 8 hours respectively and transferred to artificial saliva. Sorption and solubility tests were conducted and statistical analysis done. S tatistical Analysis: One-way ANOVA followed by Post-hoc Tukey’s test for pair wise comparisons was done. Significance was set at the probability level of p < 0.05. Results: Solubility values of all groups were higher than the quoted ADA specifications. Conclusion: Overall, silicones performed better than acrylics. Long term silicone was most stable. Short term acrylic was most unstable. The 8 hour immersion in denture cleanser caused significantly high sorption and solubility.

Efficacy of Magnesium Sulphate as an Adjunct to Ropivacaine in Local Infiltration for Postoperative Pain Following Lower Segment Caesarean Section
Introduction: Intravenous and peri-articular magnesium has been shown to reduce perioperative analgesic consumption. With this background, subcutaneous infiltration was hypothesized to potentiate the subcutaneous infiltration of local anaesthetic agent. Aim: To comparatively evaluate the efficacy of magnesium sulphate as an adjunct to ropivacaine in local infiltration for postoperative pain following lower segment cesarean section. Materials and Methods: Sixty parturients undergoing cesarean delivery were randomized to either group A or B in a double blinded manner. After uterine and muscle closure but before skin closure, Group A was administered local subcutaneous wound infiltration of Injection (Inj) ropivacaine 0.75% 150 milligram (mg) or 20 millilitres(ml) whereas, group B patients were given a local subcutaneous wound infiltration of Inj magnesium sulphate 750 mg (1.5 ml of Inj 50% Magnesium sulphate) added to Inj ropivacaine 0.75% (18.5 ml) making a total volume of 20 ml. In postoperative period, Heart rate (HR), Mean Arterial Pressure (MAP),Visual Analogue Score (VAS), supplemental analgesic consumption and timing of each subsequent analgesic was noted for the initial 24 hours. Results: There was no difference in the timings for the requirement of first Intravenous (IV) rescue analgesic among both the groups (p=0.279). However, the need for 2nd and 3rd doses of rescue analgesics was significantly later in group B and the difference was statistically significant with p-value of 0.034 and 0.031 respectively. The number of patients who were administered 2nd, 3rd and 4th doses of rescue analgesics was significantly greater in group A as compared to group B. None of the patients in group B needed more than 4 doses of rescue analgesia while in group A, 5 patients were administered a rescue analgesic for 5th time. The cumulative analgesic requirement in the initial 24 hours was also greater in group A as compared to group B and the difference was statistically significant (p =0.01). The incidence of adverse effects was similar in both the groups. Conclusion: Subcutaneous infiltration of magnesium along with local anaesthetic prolongs the analgesic efficacy of local anaesthetic and is not associated with any significant adverse effects.

To Evaluate the Efficacy of an Innovative Irrigant on Smear Layer Removal – SEM Analysis

Mensudar Rathakrishnan, Vridhachalam Ganapathy Sukumaran, Arunajatesan Subbiya
Introduction: The goal of endodontic therapy is to completely eliminate the microorganisms and the smear layer from the root canal in order to provide a good seal of the root filling materials. Aim: The aim of this study was to find a viable alternative irrigant, which is easily available with less erosion and clinically acceptable smear layer removal by comparing the efficacy of EDTA and commercially available super-oxidized water, named Oxum, as a final rinse on smear layer removal and erosion in relation to coronal, middle and apical thirds of radicular dentin using Scanning Electron Microscope (SEM) analysis. Materials and Methods: Freshly extracted 30 human lower second premolar teeth with straight roots and type I canal anatomy were selected. The root canals were cleaned and shaped using Universal Protaper Rotary System. Irrigation was performed with 1 ml of 2.5% of NaOCl solution after each instrument change. The final irrigation (5 ml) sequence was as follows: Group I- 17% EDTA, Group II – OXUM, and Group III - 0.9% saline (control) for one minute. Then, the root canals were finally irrigated with 5ml of distilled water to remove any precipitate. The roots were then gently split into two halves using a chisel and subjected to SEM analysis. Results: The SEM photomicrographs were evaluated by two independent examiners and Mann Whitney results showed that there was no statistically significant difference between the two examiners. Non-parametric statistical analysis of all experimental groups showed significant difference between coronal, middle and apical third for smear layer removal with p-value<0.05. For erosion, in group II (oxum) showed statistically significant difference between coronal, middle and apical third and it showed significantly less dentine erosion when compared to EDTA. Conclusion: Within the limitations of the present study, Oxum the commercially available super-oxidized water proved to be equally effective in smear layer removal with less erosion when compared to EDTA.

Association between Hyperglycaemia with Neurological Outcomes Following Severe Head Trauma

Javaher Khajavikhan, Aminolah Vasigh, Taleb Kokhazade, Ali Khani
Introduction: Head Trauma (HT) is a major cause of death, disability and important public health problem. HT is also the main cause of hyperglycaemia that can increase mortality. Aim: The aim of this study was to assess the correlation between hyperglycaemia with neurological outcomes following severe Traumatic Brain Injury (TBI). Materials and Methods: This is a descriptive and correlation study that was carried out at the Imam Khomeini Hospital affiliated with Ilam University of Medical Sciences, Ilam, IR, during March 2014–March 2015 on patients with severe TBI. Data were collected from the patient records on mortality, Intensive Care Unit (ICU) length of stay, hospital length of stay, admission GCS score, Injury Severity Score (ISS), mechanical ventilation, Ventilation Associated Pneumonia (VAP) and Acute Respiratory Distress Syndrome (ARDS). Random Blood Sugar (RBS) level on admission was recorded. Patients with diabetes mellitus (to minimize the overlap between acute stress hyperglycaemia and diabetic hyperglycaemia) were excluded. Results: About 34(40%) of patients were admitted with hyperglycaemia (RBS = 200 mg/dl) over the study period. The mortality rate, length of ICU stay, hospital stay, ISS and VAP & ARDS in patients with RBS levels = 200 mg was significantly higher than patients with RBS levels below = 200mg (p<0.05, p<0.001). A significant correlation was found between RBS with GCS arrival, length of ICU stay, length of hospital stay, ISS, mechanical ventilation and VAP & ARDS (p<0.05, p< 0.001). RBS is a predicate factor for ISS (p <0.05, OR : 1.36), GCS (p <0.001, OR : 1.69), mechanical ventilation (p< 0.05, OR : 1.27), VAP & ARDS (p <0.001, OR : 1.68), length of ICU stay (p <0.001, OR : 1.87) and length of hospital stay (p <0.05, OR : 1.24). Conclusion: Hyperglycaemia after severe TBI (RBS = 200) is associated with poor outcome. It can be a predictive factor for mortality rate, ICU stay, GCS arrival, VAP & RDS, hospital stay and ISS. Management of hyperglycaemia with insulin protocol in cases with value >200mg/dl, is critical in improving the outcome of patients with TBI.

Evaluation of Clinical Diagnosis of Fetal Distress and Perinatal Outcome in a Low Resource Nigerian Setting
Introduction: Fetal distress has been shown to contribute to the increasing caesarean section rate. There has been controversy on the usefulness of clinical diagnosis of fetal distress using only the intermittent counting of the fetal heart rate and/or passage of meconium-stained liquor. Aim: To evaluate the clinical diagnosis of fetal distress and the perinatal outcome. Materials and Methods: This was a retrospective study in which the case records of the patients, who were diagnosed of fetal distress at Federal Teaching Hospital, Abakaliki, Nigeria, from January 1, 2008 to December 31, 2014, were collated. The statistical analysis was done using the Statistical Package for Social Sciences version 17 software (SPSS Inc., Chicago IL,USA). Results: Out of the 15,640 deliveries carried out within the study period, 3,761 (24.05%) deliveries were through caesarean section. A total of 326 (8.9%) of the 3,761 caesarean sections were due to fetal distress within the study period. More so, a total of 227 (70.9%) babies were born with = 7 Apgar score at the 1st minute of delivery. The perinatal mortality rate was 31.25 per 1000 deliveries. Though birth asphyxia was recorded more on babies of mothers that had fresh meconium-stained liquor and whose decision-intervention interval was more than 30 minutes when compared with those without any of the two conditions, there was no statistical significant difference between them. Conclusion: The clinical diagnosis of fetal distress is accurate in 29.1% of the cases. However, it has led to an unnecessary caesarean section in the remaining 70.9% of the parturients. In order to reduce this high trend of unnecessary caesarean sections due to clinical diagnosis of fetal distress in this environment, antepartum fetal assessment with non-stress test or biophysical profile and intrapartum use of continuous electronic fetal monitoring should be used to confirm or refute the fetal distress before any surgical intervention. Fetal blood sampling and fetal pulse oximetry should be performed in event of non- re-assuring or abnormal cardiotocography.

Effect of Massage Therapy on Duration of Labour: A Randomized Controlled Trial

Nahid Bolbol-Haghighi, Seyedeh Zahra Masoumi, Farideh Kazemi
Introduction: Massage is an old technique that is widely used in childbirth and can decrease the childbirth pain by reducing the adrenaline and noradrenaline and increasing the endorphins and oxytocin and reduce the childbirth duration by increasing the uterine contractions. Therefore, Aim:This study is aimed to evaluate the effect of massage therapy on the duration of labour. Materials and Methods: The present study was performed as randomized controlled clinical trial method on 100 pregnant women referred to maternity ward in Fatemieh Hospital, Shahroud. Subjects with inclusion criteria and who were interested to participate in the study were placed in one of the test or control groups based on pre-specified sequence. Questionnaires were completed in several stages. Data analysis was conducted using chi-square test, Fisher’s exact test, independent t-test, Mann-Whitney test and multivariate linear regression in SPSS-21software. In data analysis, p < 0.05 was considered significant. Results: The results of multivariate linear regression showed that the duration of the first and second stage labour in the massage receiving group is significantly decreased compared to the test group (p= 0.004 and p= 0.02, respectively). In addition, the Apgar scores at minutes 1 and 5 in test group is significantly increased compared to control group (p <0.0001). Conclusion: The findings of this study showed that massage therapy during labour will lead to shortening of the first and second stage labour duration and improve Apgar scores at the first and fifth minutes. By shortening the duration of labour, pregnant women tend to have more normal vaginal delivery.

Role of Dynamic Contrast-Enhanced Magnetic Resonance Imaging in Staging of Bladder Cancer

Elham Rabie, Fariborz Faeghi, Mohammad-Hossein Izadpanahi, Mohammad-Ali Dayani
Introduction: Dynamic Contrast Enhanced (DCE)-Magnetic Resonance Imaging (MRI) is a useful technique in which rapid enhancement of tumour by uptake of the contrast agent compared to bladder wall. Aim: To evaluate the accuracy of dynamic gadolinium-enhanced MRI in staging of bladder cancer through differentiating superficial tumours from invasive tumours and organ-confined tumours from non-organ-confined tumours. In addition, the benefits of DCE-MRI in diagnosis of tumour progression steps were investigated. Materials and Methods: This was a quasi-experimental study in which 45 patients (95.55% men and 4.45% women) were enrolled. Patients with confirmed transitional cell carcinoma by histopathology findings were imaged using 1.5 Tesla MRI systems. Pathology results were considered as the standard reference. Tumour stage was determined by imaging findings and compared with pathologic findings after radical cystectomy. Data were analysed by SPSS version 16 and the level of significance in all tests was considered p<0.001. Results: The most common stage that was seen in pathology and MRI findings was T3b. Kappa agreement coefficient between MRI and pathology was 0.7 (p<0.001). The accuracy of MRI in differentiating superficial tumours (=T1) from invasive tumours (= T2a), and organ-confined tumours (=T2b) from non-organ-confined tumours (=T3b) was 0.97 and 0.84, respectively. The overall accuracy of MRI was 0.77 (p<0.001). Totally, 10 cases of disagreement between MRI and pathological staging were found, eight (80%) of which were overestimated and two cases (20%) underestimated. MRI detection rate was 0% in stage Ta, 100% in stage T1, 66.7% in stage T2, 86.7% in stage T3, and 100% in stage T4. The sensitivity and specificity of MRI in differentiating superficial tumours from invasive tumours were 0.97 and 1, respectively, and in differentiating organ-confined tumours from non-organ-confined tumours were 0.94 and 0.77, respectively. The Spearman s correlation coefficient between the signal enhancement slope of time-intensity curves and tumour stages was 0.88 (p<0.001). Conclusion: Gadolinium-enhanced MRI is an appropriate and useful modality with a high accuracy in determining the stage of the bladder cancer. In addition, this method shows extension and progression of tumour and tumour invasion depth.

Assessment of Rationality of Fixed Dose Combinations Approved in CDSCO List

Krunal Dalal, Barna Ganguly, Alpa Gor
Introduction: Fixed Dose Combination (FDC) is highly popular in the Indian pharmaceutical market and has been particularly flourishing in the last few years. Though rationality status is not clear, the pharmaceutical industry has been manufacturing and marketing FDCs. Aim: To assess rationality of FDCs enlisted in CDSCO list and marketing in India according to pharmacokinetic (FD) and pharmacodynamic (FD) reasoning and WHO rationality criteria. Materials and Methods: In this study, 264 FDCs marketed in India from 2009 to 2014 from CDSCO list 2014 were included. Assessment was done on the basis of following parameters: 1) Year and system of FDC; 2) Dosage form; 3) Number of Active Pharmacological Ingredient (API); 4) Schedule of FDC; 5) The presence of the FDC and its ingredients in the WHO Essential Medicine List 2013 and National Essential Medicine List, India 2011; 6) FD and PK parameters of APIs of combination; 7) PK and PD interaction; 8) Safety parameters of ingredients in combination. Descriptive statistics in terms of frequency counts and percentages were used for variables. Results: Out of total 264 FDCs selected, maximum number of combinations (112) were approved in 2010. System wise selection showed 51 (19.31%) FDCs were from cardiovascular system followed by 46 (17.42%) from pain/musculoskeletal system. Oral dosage form was found to be maximum with 200 (75.75%) combinations. According to schedules, 154 (58.33%) combinations were categorized under schedule H. There were 210 (79.54%) FDCs that had two API which was found to be maximum, whereas, only 3 (1.13%) combinations had 5 API. We could find possible PK and PD interactions in between API of 10 (3.78%) and 73 (27.65%) combinations respectively on basis of standard textbooks and references. Similarly dose reduction in API was seen in 58 (21.96%) FDCs. There were 123 (46.59%) FDCs had chances of increased ADRs due to its API. Out of 264 combinations, 52 combinations were rational (6-9), 75 combinations were semi-rational (3-<6) and 137 combinations were found to be irrational (0<3). Conclusion: We could reveal that majority of combinations approved in last six years were found to be semi-rational and irrational. It is important to carry out detailed study in this area to establish the fact and increase rationality of combinations.

Prevalence and Characteristic of Headache in Dental Professionals: A Questionnaire Based Survey
Introduction: Medical and dental streams in today’s date are considered highly demanding and stressful educational environments. Dental professionals, students and faculty, encounter great deal of stress in form of academic stress and job performance. Headache is a major and common neurological problem and is the main reason for decreased work performance, absenteeism and behavioral disturbances in dental professionals. Aim: In current scenario of increasing stressful conditions in dental professionals, the present study was carried out with an aim to assess the prevalence and characteristic of headache in dental professionals in Udaipur, India. Materials and Methods: A cross-sectional questionnaire based study was conducted in a private dental teaching hospital in Udaipur. The undergraduate, postgraduate dental students and faculty members, who gave consent, were included in the study. Information regarding the reason for headache and its various parameters was collected. Statistical analysis was done using SPSS version 22 and descriptive statistics was used to compare the results obtained. Results: The headache was found to be prevalent in 87.1% of the subjects included in the study. Females (91.9%) were more frequently affected by headaches than males (87.1%). Conclusion: It can be concluded from the present study that headache was the main cause of absenteeism at school and work, mood and behavioral changes and inappropriate work actions.

Role of Optical Coherence Tomography in Assessing Anterior Chamber Angles
Introduction: Gonioscopy is the gold standard in assessing anterior chamber angles. However, interobserver variations are common and there is a need for reliable objective method of assessment. Aim: To compare the anterior chamber angle by gonioscopy and Spectral Domain Optical Coherence Tomography (SD-OCT) in individuals with shallow anterior chamber. Materials and Methods: This comparative observational study was conducted in a rural tertiary multi-speciality teaching hospital. A total of 101 eyes of 54 patients with shallow anterior chamber on slit lamp evaluation were included. Anterior chamber angle was graded by gonioscopy using the shaffer grading system. Angles were also assessed by SD-OCT with Trabecular Iris Angle (TIA) and Angle Opening Distance (AOD). Chi-square test, sensitivity, specificity, positive and negative predictive value to find correlation between OCT parameters and gonioscopy grading. Results: Females represented 72.7%. The mean age was 53.93 ±8.24 years and mean anterior chamber depth was 2.47 ± 0.152 mm. Shaffer grade = 2 were identified in 95(94%) superior, 42(41.5%) inferior, 65(64.3%) nasal and 57(56.4%) temporal quadrants. Cut-off values of TIA = 22° and AOD = 290 µm were taken as narrow angles on SD-OCT. TIA of = 22° were found in 88(92.6%) nasal and 87(87%) temporal angles. AOD of = 290 µm was found in 73(76.8%) nasal and 83(83%) temporal quadrants. Sensitivity in detecting narrow angles was 90.7% and 82.2% for TIA and AOD, while specificity was 11.7% and 23.4%, respectively. Conclusion: Individuals were found to have narrow angles more with SD-OCT. Sensitivity was high and specificity was low in detecting narrow angles compared to gonioscopy, making it an unreliable tool for screening.

Study of Imaging Pattern in Bone Marrow Oedema in MRI in Recent Knee Injuries and its Correlation with Type of Knee Injury
Introduction: The knee is a major weight bearing joint that provides mobility and stability during physical activity as well as balance while standing. If the knee is exposed to forces beyond its physiologic range, risk of injury to bone or soft tissue structures increases. A thorough understanding of knee injury patterns and their mechanisms may help in achieving more accurate assessment of injuries. Aim: To identify imaging pattern in bone marrow oedema and to correlate the pattern of bone marrow oedema retrospectively with type of knee injury from clinical history. Materials and Methods: A cross-sectional study was done on all patients referred to Krishna Hospital, Karad for MRI knee with history of recent (< 6 weeks) knee injury. Study was conducted between May 2014 to September 2015 with a sample size of 200 patients. Plain radiograph of knee was done in all patients and they were scanned using 1.5 Tesla Seimens Avanto (Tim + Dot) with Tx/Rx 15 channel knee coil # Tim. Results: Among the 200 cases, bone marrow contusion was noted in 138 cases (69%) and absent contusion in 62 cases (31%). Bone marrow contusion showed five patterns (according to Sanders classification) i.e., Clip injury in 39 cases (28.3%), Pivot shift injury in 78 cases (56.5%), Dashboard injury in eight cases (5.8%), Hyperextension injury in four cases (2.9%), Lateral patellar dislocation in three cases (2.2%). In six cases (4.3%) no pattern of bone marrow contusion could be explained and was categorized as unclassified pattern. Conclusion: Pivot shift pattern is most common contusion pattern and the most common type/mode of sports related injury. By analysing bone marrow contusion pattern, type/mode can be determined in most of the cases. By applying a biomechanical approach in MR interpretation, it is possible to detect lesions like ligament rupture and osseous contusion, to predict subtle but it might overlook important abnormalities.

The Role of Fibular Fixation in Distal Tibial Fractures
Introduction: Lower tibial extra-articular fractures of lower tibial extra-articular bone, treated with Minimally Invasive Percutaneous plate osteosynthesis (MIPPO) may have certain advantages, though the modiality is technically demanding. Aim: To assess the results of distal tibial fractures treated with minimally invasive plate osteosynthesis utilizing precontoured dital medial tibial locking plates without fibular fracture fixation. Material and Methods: The study was conducted during the period from june 2009 to june 2011. A series of 30 patients (22 men and 8 women) with concurrent distal tibia and fibula fractures who underwent minimally plate osteosynthesis utilizing precontoured distal tibial medial locking plates without fibular fracture fixation have been reviewed after surgery. 14 fractures were type A1, 6 type A2, and 4 type A3. Open Grade II fracture were 4 and Open Grade IIIA fracture is2. Results: The mean follow-up duration was 2 years. The mean time to bone union was 20 weeks. No patient had shortening, hardware breakdown, or deep-seated infection. Out of 30 patients, 24 had excellent results, 6 had good results. Four patients had palpable screws, two patient had blisters which subsidized with conservative treatment. This minimally invasive technique for treatment of distal tibial fractures proved to be a feasible and worthwhile method of stabilization. Conclusion: It appears from our study that fibula fixation is not required in non-syndesmotic distal metaphyseal extra articular fractures when fixed by locking plate using minimal invasive techniques.

Ruptured, Intracranial Dermoid Cyst - A Visual Diagnosis?

Dominik Heger, Fabian Scheer, Reimer Andresen
Dermoid cysts are a very rare entity of intracranial tumours. The traumatic or non-traumatic rupture of the cyst wall is a serious complication that can be treated surgically or conservatively depending on the clinical symptoms. However, more common entities have to be considered as a differential diagnosis. We report on a female patient who was admitted with complaints of significant, prolonged headache and diffuse pain. Analysis of her blood and cerebrospinal fluid indicated no clear pathology. A CT examination of the head revealed a ruptured dermoid cyst adjacent to the left sphenoidal bone. An additional MRI was conducted to confirm the CT findings and rule out an intracranial ischemia or vasospasms. A conservative therapy was scheduled and the patient recovered well. Using current imaging techniques, especially magnetic resonance imaging, it is possible to identify a ruptured dermoid cyst by its pathognomonic signal behavior and rule out potentially life threatening complications.

Thoracic Endometriosis Syndrome: A Veritable Pandora’s Box

Sobha S. Nair, Jayashree Nayar
Thoracic endometriosis syndrome is a rare disorder characterised by the presence of functioning endometrial tissue in pleura, lung parenchyma, airways, and/or encompasses mainly four clinical entities–catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and lung nodules. The cases were studied retrospectively by reviewing the records at Amrita Institute of Medical Sciences, for duration of five years i.e., form March 2010-2014 and analysed for the clinical presentation and management of thoracic endometriosis syndrome. Catamenial breathlessness was the main symptom. Pneumothorax and pleural effusion were the findings on investigations. Histopathology report of endometriosis was present in three cases (50%). Conditions with excess oestrogen like endometriosis, fibroid, adenomyosis were diagnosed in these patients by pelvic scan. After the initial supportive treatment with hormones, pleurodesis, hysterectomy and lung decortication were the treatment modalities. Two cases that had multiple recurrences were diagnosed as disseminated TES. They underwent combined treatment of surgery and hormones.

Intrinsic Obstetric Palsy: Case Report and Literature Review

Rashida Hakeem, Cliff Neppe
Maternal neurological injuries may be intrinsic to the labour and delivery process or may result directly or indirectly from obstetric or anaesthetic intervention. This intrinsic obstetric palsy is a rare complication of labour but can have devastating impact on a previously healthy mother. A 23-year-old gravida1, para0 who had epidural for labour analgesia, was augmented for slow progress and had a normal vaginal delivery. She was diagnosed post delivery with intrinsic obstetric palsy involving several peripheral nerves and lumbosacral nerve roots with a guarded prognosis. In this article we have discussed the risk factors and mechanisms of intrinsic obstetric palsy and proposed further investigation into the potential protective role of ambulatory analgesia i.e. CSE (Combined Spinal Epidural) or LDI (Low Dose Infusion).

Diffuse Large B–Cell Lymphoma of Maxilla – A Case Report of Late Relapse
Diffuse Large B Cell Lymphomas (DLBCL) encompasses a heterogeneous group of tumors that together constitute the commonest of all Non Hodgkin Lymphoma (NHL) and the proclivity of DLBCL to oral cavity is unknown. They mostly arise from soft tissues as asymptomatic lesions, mostly without ‘B’ symptoms and involvement of jaw bones is uncommon. Most studies and case reports of oral DLBCL’s are based on, manifestation of primary extra-nodal disease or a component of a disseminated disease process involving regional lymph nodes. Many investigators have proposed that patients with this cell type who maintain a complete response for 24 consecutive months are cured because late relapses seldom occur. With advances in treatment modalities, many patients with NHL become long-term survivors and the risk of relapses or second tumors are of growing concern. We present a case of DLBCL which relapsed after five years of initial lesion in a 41 year old female patient and presented as a nonspecific bilateral anterior maxillary radiolucency. DLBCL usually express pan-B markers with small percentage expressing T-cell markers. Few rare cases of DLBCL have shown CD3 expression, which is a most sensitive T-cell marker which was focally expressed in the present case.

Leukaemic Transformation of Multiple Myeloma in Post Chemotherapy Remission Phase

Palak Agarwal, Prachi Nayak, Premala Anthony Singh, Bal Krishna Mishra
Plasma cell leukaemia is diagnosed when plasma cells are >20% in the peripheral blood. Plasma cell leukaemia may be present at the time of diagnosis (primary plasma cell leukaemia) or may evolve from multiple myeloma (secondary plasma cell leukaemia). We report case of a 62-year-old male who was diagnosed with multiple myeloma. He was treated with combination of prednisolone, melphalan and thalidomide. After 6 years he had Worsening of symptoms and also developed a scalp swelling. The swelling was diagnosed as plasmacytoma on fine needle aspiration cytology and confirmed on histopathology. Complete haemogram showed-Haemoglobin - 8g/dl, Total Leucocyte Count – 4300/µl, Differential leucocyte count - Neutrophil-40%, Lymphocyte-28%, Eosinophil-01%, Monocyte-10%, Atypical cells-21%, Platelet count- 1.5 lacs/µl. Peripheral blood showed rouleaux formation and plasma cells. Serum protein electrophoresis revealed an M spike (3.26 g/dl). So, patient was diagnosed as secondary plasma cell leukaemia. Weekly bortezomib and dexamethasone combination chemotherapy was given to the patient. Patient is on monthly follow up. Here we present a detailed case history of this patient.

Antibiotic Adjuvant Therapy for Multi-Drug Resistant Carbapenemases Producing Klebsiella pneumoniae Associated Sepsis: A Case Study

Robin Gupta
Rising resistance and spread of K. pneumoniae strains, create great concerns in treating sepsis patients due to high incidence of mortality and morbidity. The current study is a case of a 20-year-old male with sepsis and bilateral lung lesions infected with Multi-Drug Resistant (MDR) carbapenemase producing K. pneumoniae (KPC) showing resistance to carbapenem and polymyxin. Based on sensitivity report, patient was put on antibiotic adjuvant: Elores (ceftriaxone, sulbactam, disodium edetate) along with fluconazole for 10 days. Elores was instituted with remarkable recovery and patient was discharged.

Massive Intrabile Duct Invasion Caused by a Fatal Progression of Colonic Adenocarcinoma: Abdominal Computed Tomography Findings and Cholangiography Correlation
In this report, we present an unusual case of jaundice in a patient with advanced colorectal cancer due to intraductal tumour invasion of the intra- and extrahepatic biliary tree. This complication proved to be fatal despite aggressive therapeutic management. A correct diagnosis of this type of involvement was achieved by a combination of diagnostic and therapeutic cholangiography. Despite adequate biliary decompression, the patient died from liver failure and biliary sepsis.

Thoracic Endometriosis Syndrome: A Veritable Pandora’s Box

Dukhabandhu Naik, K Felix Jebasingh, Nihal Thomas
Adrenal crisis is a potential life threatening complication. The common causes of adrenal crisis are infections, surgical stress and abrupt cessation of steroid medications. Endocrine causes like Graves’ disease with thyrotoxicosis is one of the less common causes of an adrenal crisis. We report a 42-year-old female who presented with recurrent episodes of adrenal crisis due to delayed diagnosis of thyrotoxicosis. She was initially treated with Carbimazole followed by Radio-iodine ablation and currently she is euthyroid. Her adrenal insufficiency was initially treated with hydrocortisone during the time of adrenal crisis followed by Prednisolone 5 mg once daily in the morning along with fludrocortisone 50 mcg once daily. This case highlights the need for high index of suspicion and less common causes like thyrotoxicosis should be ruled out in patients with adrenal crisis.

A Rare Case of Mayer-Rokitansky-Kuster-Hauser Syndrome Presenting with Acute Psychosis

Kamal Nath, Bhanita Boro, Subrata Naskar
The psychiatric co-morbidities in female population with mullerian agenesis is an area with limited research. This is probably due to the fact that when those patients are diagnosed not much attention or information is given for long term psychiatric follow-up. Owing to their inability to bear children, these subjects often become socially harassed. Thus these constant stressors may lead to development of psychopathology in future. Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a congenital abnormality with absence of uterus, cervix and vagina, but normal secondary sexual characteristics and external genitalia and occurs in every 1 out of 4000-10,000 females. There is also limited literature on the probable common chromosomal aetiology for both psychosis and MRKH patients. We, present here a case of MRKH syndrome, whose initial presentation was psychosis only. In this respect, we also highlight the much neglected need of appropriate psychiatric screening and provision of psychiatric care in this population.

Successful Treatment of a Large Pelvic Abscess Using Intraluminal VAC: A Case Report

Abbas Aras, Sebahattin Celik, Remzi Kiziltan, Özkan Yilmaz, Çetin Kotan
The most feared complication of the surgical treatment of rectal cancer is anastomotic leakage, which is related to high rates of mortality and morbidity. Here, we present a patient who could not be treated with surgical drainage but treated by intraluminal Vacuum Associated Closure (VAC). A 34-year-old male patient was treated for rectal cancer by low anterior resection, colorectal anastomosis, and diverting ileostomy following neoadjuvant CRT. The patient reported with a postoperative anastomotic disruption and a large pelvic abscess. Due to the continuation of foul-smell drainage inspite of perianal incision and drainage, intraluminal VAC was applied and the pelvic abscess and the foul-smell were successfully treated. The presence of an adequate anal sphincter tonus is a disadvantage in anastomotic leakage, since it prevents the emptying of the intestinal content and also precludes the drainage of the pelvic abscess. The endoluminal application of VAC, similar to the results of application of VAC in open wounds, has been demonstrated to decrease fibrin and necrotic tissue in the pelvic cavity and increase granulation tissue. VAC, which has long been used in the treatment of open wounds, is a promising method in the treatment of large pelvic abscesses due to anastomotic leakage following rectum resection.

Anastomotic Leakage in a Patient with Acute Intestinal Obstruction Secondary to Appendiceal and Ileal Endometriosis: A Case Report

Ilker Murat Arer, Hakan Yabanoglu, Bermal Hasbay
Endometriosis is a commonly encountered problem in women of reproductive age. It usually causes chronic abdominal pain. However, it rarely causes complications such as intestinal obstruction. The most commonly performed procedure for these patients is bowel resection and anastomosis. Unless it is complicated with anastomotic leakage. We present a 39-year-old woman presented with intestinal obstruction due to appendiceal and ileal endometriosis complicated with anastomotic leakage after surgery.

Bowel Herniation Through 5mm Port Site: An Unusual Complication

Shibumon Mundunadackal Madhavan, Vamsi Krishna Potunru, Alfred Joseph Augustine
Trocar site herniation is a rare complication following laparoscopic surgery. We report a case of small bowel herniation through 5mm port site following laparoscopic myomectomy. A 36-year-old lady underwent laparoscopic myomectomy. On the fourth postoperative day she developed features of intestinal obstruction. Further evaluation with CT scan showed herniation of a loop of small bowel through the 5mm port site in right iliac fossa. Surgical exploration of the port site revealed a herniated loop of viable small bowel. The enlarged facial defect was closed after reduction of the bowel. Patient recovered uneventfully. Bowel herniation through 5mm port site is a rare complication which requires prompt diagnosis and immediate treatment to avoid morbidity.

Primary Inverted Papilloma of Middle Ear and Mastoid: A Rare Case Report

Jyotiman Nath, Bibhuti Das
Inverted papilloma or Schneiderian papilloma arising primarily from middle ear and mastoid is a very rare entity. It is a benign and locally aggressive condition, with increased risk of recurrence and malignant transformation. Surgery is the primary treatment. Radiation therapy should be considered in case of malignant transformation, recurrent or inoperable disease. Here we are reporting a case of recurrent inverted papilloma with dysplastic changes arising from mastoid cavity in a 60-year-old male. The patient was treated with surgery followed by radiotherapy.

An Unusual Lesser Sac Collection Causing Gastric Outlet Obstruction with Coincidental Occurrence of Leriche`s Syndrome: A Case Report

Anand Singla, Darshanjeet Singh Walia, Rishabhpreet Kaur
Gastric outlet obstruction in adults is usually caused by pyloric stenosis secondary to peptic ulcer disease or malignancy. However, there are few other causes such as a foreign body and external compression due to pseudocyst pancreas. We present a rare aetiology of a large collection of pus in the lesser sac in our patient causing gastric outlet obstruction. A perforated peptic ulcer was suspected in our patient who had symptoms of sudden onset pain in epigastric region which was referred to back. This was followed by pain in upper abdomen, vomiting, constipation and fever for which patient was being managed conservatively before being referred to us. The CECT didn`t show any leakage of contrast to the lesser sac making the possibility of healed perforation likely as all other causes were ruled out at the time of presentation to our hospital. The CECT scan ruled out other causes of gastric outlet obstruction with normal wall thickness of the stomach and duodenum along with normal looking liver, pancreas and no lymphadenopathy. The liver function tests and serum amylase were within normal limits. Along with this, there was another unrelated rare coincidental finding of aortoiliac occlusive disease termed as Leriche`s syndrome. Ultrasound guided percutaneous drainage was done following which the patient`s obstruction was relieved and patient was referred to the department of vascular surgery for the mangement of aortoiliac occlusive disease.

Appearances are Deceptive – Passing a Nasogastric Tube does Not Always Rule Out Oesophageal Atresia

Manish Kumar, Niranjan Thomas
Oesophageal atresia/trachea-Oesophageal fistula is commonly diagnosed in the newborn period by inability to pass a nasogastric tube (NGT). We present the instance of a newborn baby where the diagnosis of oesophageal atresia was delayed because of an apparent successful passage of nasogastric tube to the stomach. Failure to reinsert the NGT raised the suspicion of oesophageal atresia which was confirmed by contrast study showing blind upper oesophageal pouch.

The Arid Melancholy- Netherton Syndrome With Protein Energy Malnutrition

Sonia Pramod Jain, Pramod Ajit Jain, Neha Pandey
Netherton Syndrome (NS) is a rare autosomal recessive hereditary ichthyosiform disease with a classical triad comprising of an ichthyosiform dermatosis, hair shaft abnormalities and atopic diathesis. There is a mutation in a gene named Serine Protease Inhibitor Kazal type-5 (SPINK5); a new type of serine protease inhibitor involved in the regulation of skin barrier formation and immunity. Skin manifestations include, Ichthyosis Linearis Circumflexa (ILC), polycyclic and serpiginous, erythematous plaques with characteristic migratory, double-edged scale at the margins, or Congenital Ichthyosiform Erythroderma (CIE). Most of the patients have elevated immunoglobulin class E (IgE) and show atopic manifestations. Hair shaft abnormalities like pili torti and/or trichorrhexis nodosa, trichorrhexis invaginata, are seen. Here, we report a rare case of Netherton Syndrome having ILC and trichorrhexis nodosa with protein energy malnutrition in a five-year-old school going girl. She belonged to a poor socio-economic background and was worried about her physical appearance due to her skin lesions, causing psychosocial morbidity to her.

Treatment of Resistant Cyclophosphamide Induced Haemorrhagic Cystitis: Review of Literature and Three Case Reports

Turgay Ebiloglu, Engin Kaya, Sercan Yilmaz, Gökhan Özgür, Yusuf Kibar
Haemorrhagic Cystitis (HC) is defined as diffuse inflammatory bladder bleeding due to many aetiologies. Massive HC often arises from anticancer chemotherapy or radiotherapy for the treatment of pelvic malignancies. Phosphamides are the anti-cancer drugs used for treating breast cancer, B-cell lymphoma, leukemia, rheumatoid arthritis and systemic lupus erythaematosis by cross-linking strands of DNA and preventing the cell division. They are also used in bone marrow transplantation for prevention of Graft Versus Host Disease (GVHD). Hepatic metabolism of phosphamide forms acrolein, and acrolein makes ulceration, haemorrhage, edema and necrosis of the urothelium during its excretion by the urine. Infectious causes of HC in immunocomprimesed patients are adenovirus, BK polyoma-virus (BK), JC virus, and Cytomegalovirus (CMV). The present article attempts to make a review of literature for the treatment of intractable HC and report three cases with HC.

Ainhum - A Rare Case Report
The term ‘AINHUM’ is derived from the African word meaning ‘to saw or cut’. True ainhum otherwise called dactylolysis spontanea is a condition involving soft tissue or digits with constricting rings commonly presenting in fifth toes, usually bilateral. It is to be differentiated from Pseudo-ainhum that occurs secondary to some hereditary and nonhereditary diseases that lead to annular constriction of digits. We report a rare case of true ainhum involving the left fourth toe only. It is a very rare case and a very few were reported worldwide. The highest incidence of ainhum has been reported in South Africa and South America. It is rarely reported in India. Ainhum when diagnosed and treated in early stages can be prevented from progressing to mutilating deformities.

Behavioural Variant Frontotemporal Dementia with Bilateral Insular Hypometabolism: A Case Report

Ananya Mahapatra, Mamta Sood, Roshan Bhad, Manjari Tripapathi
Fronto-Temporal Dementia (FTD) is a cluster of syndromes, characterized by progressive deterioration of cognition, language and/or behavioural changes associated with degeneration of the frontal and temporal lobes. A 53-year-old man was admitted with a history of gradually progressive behavioural disturbances, disinhibition, unprovoked anger outbursts, apathy, disorganised behaviour and impaired self-care. A clinical diagnosis of Fronto temporal Dementia (behavioural variant) was made. Extensive investigations found no abnormality except in FDG-PET scan of the brain which revealed hypo metabolism in bilateral anterior insular region. Insula is an important brain area implicated in emotional awareness and behaviour control. Hypo metabolism in insular region in the absence of any structural neuroimaging findings, in a case of behavioural variant of Fronto-temporal dementia suggest that, it might be one of the earliest neurobiological changes occurring in this disorder.

A Novel Technique To Correct Multiplanar Maxillary Hypoplasia

Sibu Sajjan Simon, Arun Paul Charlu , Rabin Kurudamannil Chacko, Saurabh Kumar
Dental malocclusion and facial deformity are frequent observations in patients with clefts of the orofacial region. These patients have a low self perception secondary to their aesthetic appearance. Cleft palate patients are further affected in their speech and oral function with direct impediment to their quality of life. Early identification and treatment in cleft lip and palate patients may directly enhance their overall well being and productivity with sustainable prognosis when managed by skilled and evidence informed operators. We present a successful case management of a patient with a cleft palate and dentofacial deformity with a past surgical history, treated with an anterior maxillary advancement osteotomy, stabilized with an interpositional non vascular iliac bone graft. The posterior open bite was corrected using overlay full coverage crowns. Both these techniques are rarely reported in the literature. The procedure positively improved the quality of life in our patient with regards to her aesthetics, speech and function. This treatment approach could be considered in similar cases to achieve predictable outcomes.

Male Breast Abscess Secondary to Actinomycosis: A Case Report

Shavitri A Mahendiran, A. Jill Leibman, Adam S. Kommehl
Primary breast actinomycosis is a rare condition that has been previously reported in the female breast. Male breast infection is uncommon and most often associated with trauma to the skin or predisposing conditions like diabetes. We report the first case to our knowledge of primary breast actinomycosis in the male breast caused by Actinomycesneuii (A. neuii), a rare strain of Actinomyces. Mammography demonstrated periareolar skin thickening with a mottled pattern. Sonography showed multiple small cystic structures. Definitive diagnosis was made by culture of the nipple discharge.

An Unusual Case of Hcv Negative Cryoglobulinemia Presenting as Symmetrical Peripheral Gangrene
Cryoglobulins are monoclonal or polyclonal immunoglobulins that undergo reversible precipitation at low temperatures. Cryoglobulinemia is associated with HCV infection in more than 90% cases, the remaining 10% being called as Essential Cryoglobulinemia which is generally associated with a severe course and suboptimal response to conventional therapies. As the digital vessels are more prone to colder temperatures, hyperviscosity in those vessels can initiate local thrombosis and may manifest as ischemic ulceration and gangrene. We report here a very unusual case of HCV negative cryoglobulinemic vasculitis presenting as symmetrical peripheral gangrene of fingers and toes.

Pulmonary Toxicity of Bleomycin – A Case Series from a Tertiary Care Center in Southern India
Hodgkin’s lymphoma is one of the curable cancers and the standard treatment regimen involves combination chemotherapy involving bleomycin. One of the fatal side effect of bleomycin is pulmonary toxicity. Here we present three cases of Hodgkin’s lymphoma treated with ABVD chemotherapy who had pulmonary toxicity. All three developed bleomycin induced pulmonary toxicity in the form of pulmonary fibrosis during treatment of the disease. Mode of treatment, severity of the condition and the treatment outcome varied among the three.Two recovered following treatment and one patient died due to irreversible pulmonary damage. Causality assessment using Naranjo’s scale gave a score of 7 for case one and three and a score of 6 for case two, both indicating the adverse drug reaction to be a probable bleomycin induced Lung fibrosis.

Non Aggressive Mandibular Osteoblastoma– A Rare Maxillofacial Entity
Benign osteoblastoma is a very rare, bone tumour occurring in the facial region. These lesions are most frequently seen in long bones. They are characterised by proliferation of compact or cancellous bone. The lesion is usually asymptomatic until it causes significant facial asymmetry or displacement of the teeth if present in the alveolar region. The clinical appearance of osteoblastoma is very similar to peripheral ossifying fibroma or any fibro-osseous lesion. The tumour is characterised by bone formation along with the presence of numerous osteoblasts. This case report describes the presence of a bony hard mass in the right side of mandible of a 27-year-old female patient with the chief complaint of a painless growth since past 10 years. The growth slowly increased in size displacing the teeth associated with it. The patient also complained of difficulty in speech and mastication.

Parathyroid Adenoma Associated with Granulomatous Inflammation: A Curious Cause of Hypercalcaemia

Hena Paul Singh, Vikram Narang, Neena Sood, Harpreet Puri
Primary Hyperparathyroidism (PHPT) due to solitary parathyroid adenoma followed by parathyroid hyperplasia and carcinoma are the most frequent cause of hypercalcaemia. The most common granulomatous disorders causing hypercalcaemia are sarcoidosis and tuberculosis. We have reported a case where unexplained granulomas were seen along with parathyroid adenoma.

A Rare Case of Angiofibroma Arising from Inferior Turbinate in a Female

Gautam Bir Singh, Shilpi Agarwal, Rubeena Arora, Pankaj Doloi, Deepak Kumar
A rare case of extranasopharyngeal angiofibroma arising from the inferior turbinate in a young female of 28 years is presented. The case is discussed in light of scant contemporary literature on the cited subject. This clinical record highlights the distinct clinical nature of Extranasopharyngeal angiofibroma (ENA) and importance of Immunohistochemistry in diagnosis of such lesions. With this case we report a rare clinical entity which presented in an extremely rare manner.

Biphasic Effect of Rifampicin on Bilirubin- A Case Report

Manigandan Gopi, Mandalam Subramanian Seshadri
Drug induced hepatitis is a major problem which a physician encounters in his clinical practice. In view of increasing incidence of tuberculosis in our country a large number of infected individuals are started on Antituberculous (ATT) drugs and rifampicin is invariably part of the regimen. One of the major adverse effects of ATT drugs is drug- induced hepatitis which is characterized by elevation of liver enzymes and bilirubin. Hepatotoxicity is usually idiosyncratic or dose-dependent. Rifampicin causes transient elevation of transaminases in 10-20 percent of individuals and this does not warrant dose adjustments of the drug. Rarely rifampicin can lead to severe hepatitis with hyperbilirubinaemia and marked elevations of SGOT and SGPT and in some patients this can be fatal. The exact mechanism of Rifampicin induced hepatotoxicity is not known but it is postulated to be due to idiosyncratic reaction to rifampicin metabolites which may be directly toxic or induce an immunologically mediated liver injury. Rarely rifampicin may cause hyperbilirubinaemia without enzyme elevation. Here we report a patient with bilateral pulmonary tuberculosis who developed transient severe indirect hyperbilirubinaemia on rifampicin. On review of relevant literature we find that rifampicin can have a biphasic effect on bilirubin, an initial increase in indirect bilirubin and later normalization of bilirubin. We have reported this case because of its rarity in clinical practice.

Candidal Vertebral Osteomyelitis in the Midst of Renal Disorders
Vertebral osteomyelitis also known as discitis/pyogenic spondylitis refers to inflammation of the vertebral disc space. It is commonly seen in men and adults more than 50 years of age. Fungal osteomyelitis is a rare scenario compared to its bacterial counterpart. Spinal epidural abscess is a dangerous complication associated with vertebral osteomyelitis. Here, we report two cases of vertebral osteomyelitis caused by Candida tropicalis in patients with renal disorders (stage 5 chronic kidney disease and nephropathy). One of the case discussed here presented with spinal epidural abscess. Both the patients were started on antifungal therapy. One patient responded to treatment while the other was lost to follow up.

Paragonimiasis in a Child from Assam, India

Jashbeer S. Roy, Partha Pratim Das, Amrit Kr Borah, Jayanta Kr Das
Paragonimiasis or lung fluke infection is one of the neglected tropical parasitic disease which is found worldwide. Several endemic foci have been discovered in the Northeast India. Pulmonary paragonimiasis presenting with haemoptysis is generally mistaken for pulmonary tuberculosis. Herein, we present a case of pulmonary paragonimiasis, which initially presented with haemoptysis and remained undiagnosed for two years. The patient was treated with Praziquantel 25mg/kg thrice daily for two days along with the supportive care. Subsequently, on follow up after three months the patient had improved with no fever and cough.

Scrub Typhus Presenting with Bilateral Lateral Rectus Palsy in A Female

Tony Ete, Jaya Mishra, Bhupen Barman, Sumantro Mondal, Rondeep Kumar Nath Sivam
Scrub typhus, a rickettsial disease is endemic in several parts of India usually presenting with acute symptoms. Fever, maculopapular rash, eschar, history of tick exposure and supportive diagnostic tests usually leads to diagnosis. Scrub typhus should be included in the differential diagnosis in occasions when a patient presents with fever with or without eschar and isolated cranial nerve palsy. Here we are reporting a case of Scrub typhus who presented with fever and altered sensorium of short duration, eschar formation and bilateral lateral rectus palsy. Patient was treated with doxycycline with complete reversal of neurodeficit.

Blue Cell Tumour at Unusual Site: Retropritoneal Ewings Sarcoma

Anita P Javalgi, Mahesh H Karigoudar, Katatyayani Palur
Ewing’s sarcoma is a highly malignant tumour of osseous or non-osseous origin, tremed as extra-skeletal Ewings sarcoma if arising from soft tissue. It is rare occurrence tumor most commonly occurring in paravertebral area, chest wall, head & neck and retroperitoneum. Reporting an interesting case of retroperitoneal Ewing’s sarcoma in 39 years old female. Patient had complains of abdominal discomfort & vague pain since 2 months, following weakness in lower limb and loss of weight. On detail history and examination she was further referred to detail pathological and radiological investigations. Haematological profile, renal function test and liver function test were in normal limits. USG abdomen was normal, MRI showed a mass in pelvis retroperitoneum measuring 10x10cms, bilateral ovaries and tubes were normal. Because of retroperitoneal nature of tumor and suspicion of uterine sarcoma, laparotomy was performed. The large retroperitoneal mass adherent to posterior of uterus was excised and send for histopathological diagnosis. On gross and microscopy examination the diagnosis of blue cell tumor with PAS positivity, possibility of extraskeletal Ewing’s sarcoma/primitive neuro-ectodermal tumor was made which was further confirmed by immunohistochemistry, positive for S100,Vementin and CD99 and negative for desmin and CK. Confirmed diagnosis help in accurate management and improves survival rate.

Intravenous Immunoglobulin Responsive Persistent Thrombocytopenia after Dengue Haemorrhagic Fever

Prabhat kumar, Riyaz Charaniya, Anindya Ghosh, Ratnakar Sahoo
Dengue outbreak is common in Indian subcontinent and causes significant morbidity and mortality. Year 2015 has witnessed yet another Dengue epidemic in northern India and the number of cases this year is maximum in a decade. Dengue infection is a viral disease and there are 4 different serotypes DENV1, DENV2, DENV3 and DENV4. This year DENV2 and DENV4 have been isolated from most of the patients. Thrombocytopenia is hallmark of dengue infection and generally recovers within ten days of onset of symptoms. We report a case of dengue haemorrhagic fever in which thrombocytopenia persisted for almost a month and improved after Intravenous immunoglobulin (IVIG) administration. This is the first case where IVIG has been successfully used for treating persisting thrombocytopenia after dengue infection.

A Rare Presentation of Two Cases of Metallic Intrascleral Foreign Body Entry through Upper Eyelid

Satish C Shitole, Rakesh K Barot, Rakesh Shah, Nupur Bhagat
Ocular injury secondary to foreign body remains an important cause of ocular morbidity with or without blindness in working population. Intraocular foreign body may have varied clinical presentation. Initially it may look an apparently normal eye followed by obvious ocular symptoms depending upon its location and degree of inflammation. It can result in partial or full thickness penetration of sclera with or without involvement of posterior segment. We hereby present two cases of metallic intrascleral foreign body entry through upper lid in young carpenters following hammer and chisel injury. In case 1, Intrascleral location of foreign body was confirmed with X ray orbit and B scan ultrasonography while in case 2 the diagnosis of intrascleral foreign body was missed at the first visit to ophthalmology clinic Both the patients underwent exploratory surgeries where intrascleral metallic foreign bodies were found without ocular penetration. An intrascleral foreign body may be missed due to small penetrating scleral wound covered by a large subconjunctival haemorrhage accompanied by minimal or no signs of inflammation and failure on part of treating ophthalmologist to suspect an intrascleral foreign body. To establish a diagnosis of intraocular particularly intrascleral foreign body, careful history taking and clinical examination along with use of imaging studies are mandatory steps which help in successful management and good visual outcome. These cases highlight the importance of considering a presumptive diagnosis of retained intrascleral foreign body in every patient with a history of penetrating ocular trauma through lid or a visible wound/scar on the lid.

A Unique Presentation of Primary Intestinal MALT Lymphoma as Multiple Lymphomatous Polyposis

Seetu Palo, Dayananda S. Biligi
Multiple lymphomatous polyposis is considered to be a rare condition, with most of the cases being extranodal counterpart of mantle cell lymphomas. We report a rare case of multiple lymphomatous polyposis of the gastrointestinal tract in which the patient presented with abdominal pain and bloody diarrhea. Computer tomography of the abdomen showed circumferential wall thickening with intramural mass involving caecum & ascending colon with enlarged pericolonic lymph nodes. The patient underwent right hemicolectomy. Immunohistologic findings were characteristic of MALT lymphoma. Microscopic examination of polypoidal masses and mesenteric lymph nodes revealed infiltration by pleomorphic, atypical lymphoid cells which were CD20 positive and negative for CD3, CD10, Cyclin D1. Lymphoepithelial lesions were also noted. Careful endoscopic evaluation and histopathological review along with an immunohistochemical panel is extremely useful for accurately diagnosing such cases and avoiding unnecessary surgery and inappropriate therapy.

Combined Arterial and Venous Thrombosis in Ulcerative Colitis- A Rare Vascular Manifestation

Harpreet Singh, Pranav Ish, Richa Dewan, S Anuradha, Sumeet Singla
Combined arterial and venous thrombosis in patients with ulcerative colitis is a rare extra vascular manifestation, which motivated the current report. Increased coagulability is a recognised feature of ulcerative colitis with frequency increasing during flares. We report the case of a 42-year-old lady who was a diagnosed case of ulcerative colitis, currently in remission. She presented with swelling followed by discolouration of left lower limb which later was diagnosed as deep venous thrombosis combined with femoral and popliteal artery thrombosis. This led to wet gangrene of the limb, sepsis, septic shock and death despite aggressive management with heparin infusion, ionotropes, and parenteral antibiotics therapy.

Benign Lymphoepithelial Cyst of the Parotid in HIV Negative Patient
Benign lymphoepithelial cysts are slow growing tumours commonly seen in HIV positive adults. It is rare to find them in non HIV individuals. In this article we discuss an uncommon presentation of a parotid swelling occurring in a 49-year-old non HIV male, which was diagnosed as benign lymphoepithelial cyst. The various investigative modalities and treatment options are outlined in this article.

Adult Rhabdomyosarcoma of Ethmoid Sinus Recurring as an Orbital Mass

Bahram Eshraghi, Kambiz Ameli, Pasha Anvari
Alveolar rhabdomyosarcoma (RMS) is a primitive, malignant, round cell neoplasm derived from mesenchymal tissue that exhibits partial skeletal muscle differentiation. We describe a rare case of alveolar RMS of ethmoid sinus, recurring as an orbital mass. A 23-year-old man with the chief complaint of anosmia and mild proptosis was diagnosed with RMS of the left ethmoid sinus and orbit following an endoscopic biopsy of the mass. He was treated with chemotherapy and radiotherapy. At 12 months after diagnosis, while still on maintenance chemotherapy, he presented to our eye hospital with a large medial canthal mass and lateral globe displacement. Orbital computed tomography revealed an extraconal mass in the medial orbit of the left eye, extending posteriorly and compressing the medial rectus muscle. Notably, the ethmoid sinus was clear. Incisional biopsy was performed and the recurrence of alveolar RMS was confirmed. Alveolar RMS of the ethmoid sinus may recur as an orbital mass, even if the sinus where it originated is clear at the time of recurrence.

A Rare Case of Haemoperitoneum in Pregnancy

Divya Narayanan Kutty, M.P. Kanchana
Haemoperitoneum in pregnancy is a rare, but potentially fatal condition. Primary hepatocellular carcinoma (HCC) in pregnancy is also very uncommon. Primary hepatocellular carcinoma occuring in a pregnant lady and presenting with massive haemoperitoneum is, to the best of our knowledge, the first case to be reported in world literature. Here we present a case of 32-year-old female who had no typical risk factors for HCC; was in nineteenth week of gestation presented with abdominal pain. Following a spontaneous expulsion of a dead and macerated foetus, she developed massive haemoperitoneum due to rupture of a liver mass. This caused a great diagnostic challenge for us to differentiate between the benign Hepatocellular Adenoma (HA) and well differentiated HCC because of the age and typical clinical presentation favouring HA and the histopathological features favouring more for HCC. Diagnosis of HCC was confirmed based on the immunohistochemical findings. The differential diagnosis between HA and well differentiated HCC is very difficult and sometimes impossible especially when it occurs in young females and in pregnancy.

Isolated Right Ventricular Infarction Mimicking Anterior ST-Segment Elevation

Onur Baydar, Veysel Oktay, Ugur Coskun, Ahmet Yildiz, Tevfik Gurmen
Acute coronary syndromes in patients with presence of ST-segment elevation in the anterior precordial leads indicates left anterior descending coronary artery occlusion. However, anterior ST-segment elevation has also been described in right ventricular myocardial infarction and is thought to be due to right coronary artery (RCA) occlusion. We present a rare case of isolated RVMI presenting with anterior ST-segment elevation due to proximal occlusion of a right coronary artery that was treated by primary coronary angioplasty. Primary coronary angioplasty and stenting of this artery was performed resulting in resolution of the chest pain and ST- segment elevation.

Idiopathic Pulmonary Fibrosis and Myasthenia Gravis: An Unusual Association

Bharti Chogtu, Daliparty Vasudev Malik, Rahul Magazine
Idiopathic Pulmonary Fibrosis (IPF) is a chronic fibrosing lung condition with high morbidity and mortality, accounting for about 25% of the cases of interstitial lung diseases. It usually has a progressive course resulting in death due to respiratory failure. Myasthenia Gravis (MG) is an autoimmune neuromuscular disease, caused by antibody mediated activity against acetylcholine receptor at the neuromuscular junction. It is characterized by fluctuating muscle weakness and fatigue. Extensive literature search did not reveal any case report of an association between these two conditions. Here we present a case of a patient with IPF who also developed MG. The diagnosis of IPF was based on High Resolution Computed Tomography (HRCT) of the lung and that of MG was based on clinical criteria and electrophysiological testing. The case was successfully managed.

A Case of Pleuroparenchymal Metastasis: Rare Aetiology
A phyllodes tumour is a malignancy of both mesenchymal and epithelial origin affecting the breast. The malignant course of this breast tumour causing lung metastasis is rare. Here we report a treated case of borderline phyllodes tumour that presented with pleuroparenchymal metastasis. Our case highlights the possibility of recurrence of borderline phyllodes tumour as pleuroparenchymal metastasis even after a long disease free interval.

Unusual Finding in the Inguinal Canal: Abdominal Tuberculosis Presenting as Inguinal Hernia

Priya Dhandore, Narendra Narayan Hombalkar, Mohd Hamid Shafique Ahmed
Abnormal findings in the inguinal canal during Herniotomy are not very rare for a paediatric surgeon. These abnormal findings may range from opposite gender sex organ (e.g. uterus and fallopian tube during orchidopexy) to unexpected malignancy (e.g. Rhabdomyosarcoma) to the abnormal embryological development (Splenogonadal fusion). Though abdominal tuberculosis is common, abdominal tuberculosis presenting as an inguinal hernia is exceedingly uncommon. We report an unusual case of abdominal tuberculosis presenting as inguinal hernia.

Ileo-Colic Burkitt Lymphoma in a Young Adult Female- A Case Report

Mima Maychet B. Sangma, Simon D Dasiah, Aju James Ashok
Burkitt’s lymphoma is an uncommon and aggressive type of Non-Hodgkins lymphoma and is one of the fastest growing cancer tumour in humans; growth fraction close to 100%. We report a case of a young adult female presented with acute pain abdomen with ileo-caecal mass. On clinical presentation, initial diagnosis was acute appendicitis with lump formation. Ultrasound reported as diffuse inflammatory changes and later CECT was done which reported as Gastro-Intestinal Stromal Tumour (GIST). On laparotomy, a huge hard mass was found on ileo-caecal region and right hemicolectomy was done. Diagnosis was confirmed as Non-Hodgkins Burkitt’s Lymphoma by HPE and immunohistochemistry testing. So, careful workup is the key to initiate early treatment. This patient had complete remission after the right hemicolectomy followed by multiagent chemotherapy.

Fine Needle Aspiration Cytology Diagnosis of an Urachal Adenocarcinoma
Urachal Carcinoma (UC) is a rare malignancy of urinary bladder. It is usually found in adults in advanced stages because the tumour often grows outside the bladder without producing clinical symptoms. Most of the cases are mucinous, intestinal or signet ring cell adenocarcinoma and the diagnosis is usually made on biopsy. Radiographic images of this tumour may show characteristic features with a midline solid or cystic mass in the anterior wall of bladder associated with small calcification, which is considered as a pathognomonic sign for the diagnosis of UC. We report a case of UC in an adult, whose radiographic images suggested an urachal tumour and Fine Needle Aspiration (FNA) cytology revealed an adenocarcinoma. Laparoscopic partial cystectomy with umbilectomy and pelvic node dissection was done without further histopathological confirmation. Surgical intervention of UC on the basis of FNA diagnosis has not been reported in the literature.

Gynaecological Perspective of Schwannoma: A Rare Pelvic Tumour
Schwannomas are benign tumours that arise from Schwann cells of nerve fibres. They commonly occur in the head, neck, mediastinum and extremities but pelvic occurrence is rare. We report a rare case of retroperitoneal tumour with Gynaec presentation. A 26-year-old parous woman was admitted with abdominal mass, pain abdomen, painful menstruation and painful coitus for one year. Abdominal examination revealed firm mass filling the lower abdomen with restricted mobility. On bimanual examination cervix was hitched against pubic symphysis. Mass felt through anterior and left adnexa not tender, uterus felt close to the mass about 8-10 weeks size, right adnexa free. USG revealed broad ligament fibroid with cystic right ovary. Hence myomectomy was planned, but intraoperatively it was found that the mass was filling the pelvis close to bulky uterus with cystic right ovary. After informed consent while proceeding with hysterectomy, necrotic, yellow colour material came out from the capsule like structure of the mass which was close to lower part of posterior wall of uterus. Mass was removed except which was adherent to deeper structure left behind. Histopathological examination revealed Schwannoma undergoing cystic degeneration. Since Schwannoma was mostly diagnosed incidentally, high degree suspicion is necessary for diagnosis.

Vagal Schwannoma: A Rare Parapharyngeal Tumour
Among the parapharyngeal tumours, salivary gland tumours are the commonest, followed by schwannomas, which are slow growing benign tumours. Half of the parapharyngeal schwannomas originate from the vagus. Complete surgical excision is the treatment of choice. We hereby present two cases of parapharyngeal schwannomas, one which had presented as an intraoral mass and the other as a swelling in the neck. The first case, a 57-year-old female patient complained of a slowly increasing swelling in the left side of the throat since 3 months, associated with pain and dysphagia. In the Contrast Enhanced CT scan of the neck, a well-defined cystic lesion with central enhancing solid components (4cm X 4.5cm X 3cm) was seen in the left parapharyngeal region. The second case, a 39-year-old male patient complained of a painless, gradually increasing swelling below the lobule of the right ear since one month. Examination revealed a solitary, nontender, firm and mobile swelling of 2cm X 2cm below the lobule of the right ear. In Contrast Enhanced CT scan of the neck, an enhancing lesion was seen involving the right parapharyngeal space, post-styloid compartment. Both the patients underwent trans-cervical surgical excision. Vagal nerve schwannoma is rare. The majority of the cases present with a slow growing neck swelling without neurological deficit. Complete surgical excision of the tumour is important to prevent recurrence.

Fibrofascitis – An Enigma for the Dentist: A Case Report

Kriti Shrivastava, Giridhar Naidu, Manas Gupta, Neha Singh
Fibromyalgia is a chronic syndrome that causes widespread musculoskeletal pain and stiffness throughout the connective tissues that support and move the bones and joints. Pain and localized tender points occur in the muscles, particularly those that support the neck, spine, shoulders, and hips. Moreover the disorder includes fatigue, depression, sleep disturbances and constipation. A combination of treatments including medications, patient education, physical therapy and counseling are usually recommended. Here, we present a case report of fibromyalgia and the treatment given to the patient, a combination of dental and orthopedic treatment.

Spindle Cell Carcinoma of Nasal Cavity- A Case Report

Priyank Mistry, Abhishek Mittal, Tapan Nagpal
Spindle Cell Carcinoma (SpCC), also known as Sarcomatoid Carcinoma, is a rare and peculiar biphasic malignant neoplasm that occurs mainly in the upper aero-digestive tract, mostly in larynx. SCC accounts for 3% of all squamous cell carcinomas (SCCs) in the head and neck region. It is a rare variant of SCC which shows spindled or pleomorphic tumour cells simulating a true sarcoma. We present a case report of SpCC nasal cavity in a 50-year-old female patient, presented with intermittent epistaxis from left nasal cavity. On physical examination, the patient had an ulcero-exophytic type of mass in the left nasal cavity and a smooth bulge on the left side of anterior hard palate. Patient underwent excision of nasal mass along with partial palatectomy by facial degloving approach and reconstruction of palate with naso-labial flap. The postoperative histopathological report showed SCC. Surgery forms the mainstay of treatment. Radiotherapy and Chemotherapy is warranted in order to improve treatment results. As only few cases have been reported, we report a case of this rare entity to contribute for better understanding and awareness of this rare malignancy.

Perforated Gastric Gangrene without Pneumothorax in an Adult Bochdalek Hernia due to Volvulus
Bochdalek hernia is the most frequent congenital diaphragmatic hernia which occurs due to a defect in the posterior attachment of the diaphragm when there is a failure of closure of the pleuroperitoneal membrane in utero. It rarely presents for the first time in adults. We report one such case of a 23-year-old male patient who presented with an acute abdomen. Chest X-ray showed air under diaphragm and he was taken up for an emergency laparotomy. Intraoperatively an organoaxial volvulus of the stomach was found in a bochdaleks hernia with a focal gangrene of the stomach fundus with perforation and peritonitis. However, there was no breach of pleural cavity. A sleeve resection of the gangrenous portion of the stomach was performed and the diaphragmatic defect was repaired. Patient made an uneventful postoperative recovery. Gastric gangrene with perforation as a manifestation of the adult bochdalek hernia is indeed rare. A concomitant pneumothorax occurs along with this condition which requires an intercostal drainage tube prior to the laparotomy. We report this case for its unique presentation without pneumothorax.

Uterine Fibroid (Leiomyoma) with Acute Urinary Retention: A Case Series
Uterine leiomyomas are an extremely rare cause of acute urinary retention in women. The delay in diagnosing uterine leiomyomas presenting with acute urinary retention further complicates the management. The rarity of the condition makes it difficult to plan either prospective or retrospective trials. Hence, most of the evidence comes from case reports or series. We report a case series of acute urinary retention in women with uterine leiomyomas and discuss the pathophysiology, diagnosis and management options.

Capillary Hemangioma of the Fallopian Tube

Richa Katiyar, Shashikant C.U. Patne, Shreekant Bharti, Madhu Jain
Neoplastic lesions of the fallopian tube are rarely seen by surgical pathologists. Haemangioma of the fallopian tube is an extremely rare benign neoplasm. A 30-year-old lady with polymenorrhea and dysmenorrhea underwent hysterectomy and bilateral salpingo-oophorectomy. Her left fallopian tube showed a 2mm sized solid nodule in the wall. Histopathological examination revealed a well-defined vascular lesion in the left fallopian tube, consistent with capillary haemangioma. The vascular endothelium was highlighted by CD34 immunostaining. Our literature review has identified 10 cases of cavernous haemangioma of the fallopian tube. To the best of our knowledge, we report the first ever case of capillary haemangioma of the fallopian tube. This is also the smallest detected haemangioma in the fallopian tube.

An Interesting Case of Penetrating Craniofacial Trauma Involving a Wooden Stick
Penetrating craniofacial trauma, although uncommon, has a high potential for death or catastrophic consequences from head injury or vital neurovascular injuries. The foreign body may cause significant challenge, especially when it is a large one. Airway obstruction, vascular injuries, intracranial communication, ocular injury and injuries to any other adjacent vital structures when involved may change the treatment objectives from simple foreign body retrieval to a comprehensive multidisciplinary approach to stabilize the patient. Retrieval of foreign bodies may be challenging because of many factors including the size of the object, its site, and the surrounding anatomical structures. Accurate localization of the foreign body before removal is essential in craniofacial region. We present a case of penetrating craniofacial trauma from a wooden stick, with an in situ foreign body, that was managed by emergency surgical exploration in general anaesthesia and retrieval of foreign body in Toto under antibiotic coverage and tetanus prophylaxis.

Sebaceous Gland Carcinoma of Eyelid- A Tarnished Masquerade

Bijnya Birajita Panda, Sucheta Parija, Susanta Pujahari, Jyotiranjan Mallick
Malignant tumours of the face are usually seen in the periocular region, mainly on eyelids most commonly in the inferior eyelid, medial canthus and superior eyelid, respectively. The prime treatment for eyelid malignant tumours is the total excision of the lesion with frozen section control or by Mohs Micrographic surgery. The postoperative defects should be reconstructed judicially taking care that the near normal anatomical and functional recovery is achieved. The Cutler-Beard flap procedure, a good alternative in the reconstruction of superior near-total eyelid defects resulted in good restoration of anatomy and function in our patient. We report a case of an eyelid growth persisting for 2 year duration mimicking a chalazion. Clinically the eyelid mass had malignant features and hence was planned for wide excision with frozen section of margins. After confirming the tumour free margins, we performed reconstruction of the eyelid defect with Cutler Beard flap procedure. She was followed up for one year which showed no local recurrence or regional/distant metastases.

Microfilariae, a Common Parasite in an Unusual Site: A Case Report with Literature Review

C.S. Rohini Dhanya, H.T. Jayaprakash
Filariasis is common in tropical countries. Wuchereria bancrofti is the most common parasite which causes lymphatic filariasis in India. This paper reports the finding of microfilariae in cervicovaginal smear of a 61-year-old post menopausal woman with a brief review of literature. There are limited numbers of reports describing the presence of microfilariae in the cervicovaginal smears and even rarely as an incidental finding. It is very important to keep in mind and screen for microfilariae in the non-endemic areas also.

Umbilical Sepsis Caused by Multidrug Resistant Strain of Kocuria kristinae in a New Born: A Case Report

Umadevi Sivaraman, Pramodhini Subramanian, Kalaivani Ramakrishnan, K.S Seetha
Kocuria species were placed previously under the genus Micrococcus, are skin and oropharynx commensals in mammals, including man. A rare bacteria, Kocuria kristinae isolated from a new born with umbilical sepsis. Identification and antibiotic susceptibility was done by Vitek 2 compact system (Biomerieux). The isolate was sensitive to higher antibiotics like vancomycin, teicoplanin and linezolid. As this new pathogen resembles coagulase negative staphylococcus, it should not be misidentified.

Inflammatory Myofibroblastic Tumour of Thyroid with its Prominent Spindle Cell Pattern: A Rare Case Report

S. Marylilly, T. Subachitra, V. Ramya
Inflammatory myofibroblastic tumour of thyroid is very rare. Only 18 cases reported so far. Here we report a case of Inflammatory myofibroblastic tumour with its prominent spindle cell (fibrohistiocytic) pattern in a 61-year-old male patient. The dominant histological pattern in our case was myofibroblastic in contrast to prominent lymphoplasmocytic pattern in other previously reported cases. The tumour was strongly positive for vimentin, Anaplastic lymphoma kinase and showed focal positivity for Smooth Muscle Actin. The patient was treated with total thyroidectomy and he is comfortable after surgery.

Budd- Chiari Syndrome as an Initial Manifestation of Systemic Lupus Erythematosus

Jayabal Pandiaraja, Arumugam sathyaseelan
Budd- Chiari syndrome is caused by obstruction of hepatic venous outflow. There are numerous causes for Budd-Chiari syndrome. One of the causes is systemic lupus erythematosus due to antiphospholipid antibodies. Only few cases have reported Budd-Chiari syndrome as an initial manifestation of systemic lupus erythematosus (SLE). This is a case report of Budd-Chiari syndrome due to SLE.

Congenital Absence of Internal Carotid Artery with Rare Type of Intercavernous Anastamosis and Ruptured Cerebral Aneurysm

Anand Alurkar, Lakshmi Sudha Prasanna Karanam, Sagar Oak, Smita kori
Congenital absence of Internal Carotid Artery (ICA) is a rare anomaly seen in <0.01% of the population. Various collateral circulations develop in these cases to maintain adequate cerebral perfusion. High incidence of aneurysms is reported in these cases. Complete evaluation is required to detect other abnormalities usually seen in these patients. We report a case of congenital absence of right ICA in a 39-year-old female who presented with Subarachnoid Haemorrhage (SAH) and had a Middle Cerebral Artery Aneurysm (MCA). The right MCA got supply from the intercavernous communication from the left internal carotid artery. Skull base Computed Tomogram (CT) confirmed the congenital absence of right ICA. She underwent successful surgical clipping for the aneurysm. The high incidence of aneurysms, collateral circulations, embryological development and postulated mechanisms of this anomaly were discussed. The exact aetiology behind the absence of ICA remains unclear. It is important to differentiate this condition from acquired stenosis/occlusion due to atherosclerosis and carotid dissection. Recognising the anomaly is important and gains even more significance during surgical planning in cases of direct aneurysm clipping, carotid endarterectomy and transphenoidal surgeries.

Acute Urinary Retention due to Primary Pelvic Hydatid Cyst: A Rare Case Report and Literature Review
Causes of urinary retention in old men include benign prostatic hyperplasia, prostatitis, prostate cancer, Scarring of the urethra or bladder neck as a result of injury or surgery, use of certain medicines particularly NSAIDs and opioid analgesics, constipation and neurogenic bladder. When the above common causes are not quite obvious by clinical examination and relevant investigations, then it is necessary to think of other rare diseases. It is with the above in our mind that a case of bladder outflow obstruction due to a large primary retrovesical hydatid cyst is herein reported in a 58-year-old man. Ultrasonography (USG) and Contrast Enhanced Computed Tomography (CECT) scan of the abdomen and pelvis of the patient revealed a large, multilocular, nonenhancing, cystic lesion in the rectovesical pouch having typical cartwheel appearance without any other intraabdominal organ involvement. These typical radiological characteristics led us to suspect the presence of a hydatid cyst. He underwent exploratory laparotomy where cystopericycstectomy was done. Pre-operative and post-operative albendazole prophylaxis was also given. In conclusion, hydatid cyst should always be considered in the differential diagnosis of pelvic cystic masses, specially in endemic regions.

Giant Placental Chorangioma: A Rare Case Report

Nidhi Kataria, Amarjit Singh, Preet Kamal Bedi
Chorangioma is a nontrophoblastic benign vascular tumour of the placenta, arising from the primitive chorionic mesenchyme. The clinical significance is related to the size of the tumours. Small chorangiomas, with a frequency of about 1%, are often asymptomatic. On the contrary, giant chorangiomas, greater than 5 cm in diameter, are rare tumours, with prevalence ranging from 1:9,000 to 1:50,000, and often associated with a variety of pregnancy complications and a poor perinatal outcome. We report a case of 26-year-old female who presented to us at 36 weeks of gestation with pain in the lower abdomen. Ultrasonograpy revealed polyhydramnios and a vascular tumour on the surface of placenta. Proper conservative antenatal management was done and a full term healthy baby was delievered. Histopathological examination of the extracted mass confirmed the diagnosis of chorangioma. The novelty of this report lies in the presence of large nontrophoblastic vascular placental tumour and the absence of any fetal complications. We emphasise the need of regular and timely antenatal management to diagnose and treat the complications of chorangioma at an early stage.

Familial Constitutional Rearrangement of Chromosomes 4 & 8: Phenotypically Normal Mother and Abnormal Progeny

Fulesh Kunwar, Sonal R. Bakshi
Balanced chromosome translocations carriers mostly do not have recognizable phenotypic expression but may have more risk of recurrent spontaneous abortions &/or children with serious birth defects due to unbalanced chromosome complements. Unbalanced chromosomal rearrangements have variable clinical expression and are rare. We present here a case report of three siblings affected with intellectual disability and minor dysmorphic features of face and limbs, born to a non-consanguineous couple in which mother had 5 abortions. The constitutional chromosome analysis revealed balanced translocation t (4;8) in mother and all the three siblings were karyotypically normal. Chromosomal microarray in one of the probands revealed partial monosomy 8pter-p23 and a partial trisomy 4pter-p16. Phenotypic features were recorded in 3 probands using Human Phenotype Ontology terms to query web-based tool Phenomizer. The harmonized description using globally accepted ontology is very important especially in case of rare genetic conditions and the heterogeneous phenotypes which make it even more challenging. The prevalence of sub-microscopic unbalanced translocations may be under-reported due to lesser use of molecular genetic analysis. The familial expression of abnormal phenotypes including intellectual disability make the individuals candidate for molecular genetic analysis and phenotyping to help defer the status of idiopathic mental retardation and identify sub-entity of genetic condition.

Concurrent Infections of Conidiobolus Coronatus with Disseminated Tuberculosis Presenting as Bilateral Orbital Cellulitis

Deepa John, Aparna Irodi, Joy Sarojini Michael
Zygomycetes species contains two orders of organisms that infect humans, namely Mucorales and Entomophthorales. Entomophthorales cause chronic infection in immunocompetent patients, invading subcutaneous tissues but are non-angioinvasive. This includes Basidiobolus ranarum, Conidiobolus incongruus and Conidiobolus coronatus. We report a case of disseminated tuberculosis with Conidiobolus coronatus infection presenting as orbital cellulitis in an adolescent.

Sinister Splenic Artery Pseudoaneursym: A Rare Case of Unidentified Aetiology
Splenic Artery Pseudoaneurysms (SAP) are very rare. Giant SAPs are those which are more than 5 cm in diameter and are rarer. SAPs are usually caused by pancreatitis, trauma, surgery or other iatrogenic interventions, vasculitis, local infective or inflammatory processes. We report the successful surgical management of a giant SAP of unidentified aetiology. This case report highlights the significance that this entity may present atypically and hence, early recognition and aggressive management may be life saving.

Massive Broad Ligament Cellular Leiomyoma with Cystic Change: A Diagnostic Dilemma

Preeti Sharma, Sufian Zaheer, Amit Kumar Yadav, Ashish Kumar Mandal
Leiomyomas are known to arise from uterus, but rarely from broad ligament. Further, cellular leiomyoma of broad ligament is the least common variant reported in literature. The diagnostic dilemma arises when leiomyomas undergo degenerative changes. This poses both clinical and radiological difficulty in differentiating with an ovarian tumour. We present an unusual case of a huge broad ligament mass measuring 29x19x09cm, mimicking an ovarian tumour both clinically and radiologically. Histopathology revealed cellular leiomyoma of broad ligament with cystic and myxoid degeneration hereby being the second case reported in literature.This case is being presented not only because of the rare incidence but also due to its diagnostic confusion with ovarian malignancy on clinical evaluation and radiological findings.

Thoracic Endometriosis-A Rare Cause of Haemoptysis

Seema Alwadhi, Supreethi Kohli, Bhupendra Chaudhary, Kirti Gehlot
Thoracic endometriosis is a rare condition and occurs in females of reproductive age due to the presence of active endometrial tissue in tracheobronchial tree, lung parenchyma and lung pleura. A typical history of haemoptysis during menstrual periods and strong suspicion of the disease entity is important for the diagnosis and management of the case. Diagnosis of the disease is usually delayed. Serial CT thorax during menstrual period and in non-menstrual period supports the diagnosis. We present here a case of catamenial haemoptysis. The diagnosis was missed initially but later a detailed clinical history revealed the same. Serial computed tomography of thorax taken during menstrual and after menstrual period supported the diagnosis. Though bronchoscopy was able to reveal hyperemic tissue in the tracheobronchial tree, bronchial washing was inconclusive. The patient was treated successfully with danazol.

Innovative Application of a Microlaryngeal Surgery Tube for difficult Airway Management in a Case of Down’s Syndrome
An 11-year-old male child, known case of down’s syndrome with congenital oesophageal stricture was posted for oesophageal dilatation. Preoperative airway assessment revealed a high arched palate, receding mandible and Mallampati Score of 2. During surgery, after loss of consciousness which was described as loss of eyelash reflex and adequate jaw relaxation, direct laryngoscopy and endotracheal intubation was attempted with a cuffed endotracheal tube number 5.0mm ID (internal diameter). The endotracheal tube could not be negotiated smoothly, so 5.0mm ID uncuffed endotracheal tube was used which passed through easily, but on auscultation revealed a significant leak. Later, intubation via a Micro Laryngeal Surgery (MLS) cuffed tube 4.0mm ID was attempted. The MLS tube advanced smoothly and there was no associated leak on positive pressure ventilation. Thus by innovative thinking and avant-garde reasoning, a definitive airway device could be positioned with no other suitable alternative at hand.

Radiographic Assessment of Bone Formation Using rhBMP2 at Maxillary Periapical Surgical Defects: A Case Series

M.Siva Kumar, M.Hari Kumar, K.Vishalakshi, H.Sabitha
Periapical cysts are the most common inflammatory odontogenic cysts arising from untreated dental caries with pulp necrosis and periapical infection. The choice of treatment is often influenced by various factors like size, extension of the lesion, proximity to vital structures, systemic condition and compliance of the patient too. The treatment protocol for management of periapical cysts is still under discussion and options vary from conservative treatment by means of endodontic technique to surgical treatment like decompression or a marsupialisation or even to enucleation. Large bony defect secondary to periapical surgery compromising the tooth integrity often requires bone graft to enhance bone formation and thus restoring function at the earliest. The present case series included 10 patients who had established periapical pathology secondary to history of trauma on upper anterior teeth as well patients with history of carious teeth with an apparent failure in root canal therapy. All ten patients were treated with cyst enucleation and apiceotomy along with 1.4cc Recombinant Human Bone Morphogenetic Protein-2 soaked Absorbable Collagen Sponge implantation at surgical defect. Radiographs and clinical examinations were done upto 3 months to evaluate healing. Radiographic and clinical assessments revealed bone regeneration and restoration of the maxillary surgical defects in all 10 patients. No evidence of graft failure was noted. The Recombinant Human Bone Morphogenetic Protein-2 soaked Absorbable Collagen Sponge carrier is thus proved to be a viable option for the treatment of maxillary periapical surgical defects.

Role of Orthodontics in Forensic Odontology- A Social Responsibility

Giridhar Reddy, Vinay P Reddy, Meenakshi Sharma, Monika Aggarwal
Orthodontics like any other specialty has much to offer law enforcement in the detection and solution of crime or in civil proceedings. Forensic odontology often requires an interdisciplinary approach towards dentistry for the purpose of proper diagnosis of cases. In cases where the forensic odontologist has to establish a person’s identity, an orthodontist can be of great help at times. Teeth, with their anatomic/physiologic variations and therapy such as orthodontic treatment, restorations and prosthesis may record information that remains throughout life and beyond. The teeth may also be used as weapons for defense or offense and as such may leave information about the identity of the biter at the time of crime. Forensic odontology also plays an important role in the recognition of crime and abuse among people of all ages. Orthodontists like all other dental professionals can play a major role by maintaining proper dental records and thus providing important or vital information or clues to the legal authorities in order to help them in their search.

Pulmonary Aspergillosis: What CT can Offer Before it is too Late!

Akhila Prasad, Kshitij Agarwal, Desh Deepak, Swapndeep Singh Atwal
Aspergillus is a large genus of saprophytic fungi which are present everywhere in the environment. However, in persons with underlying weakened immune response this innocent bystander can cause fatal illness if timely diagnosis and management is not done. Chest infection is the most common infection caused by Aspergillus in human beings. Radiological investigations particularly Computed Tomography (CT) provides the easiest, rapid and decision making information where tissue diagnosis and culture may be difficult and time-consuming. This article explores the crucial role of CT and offers a bird’s eye view of all the radiological patterns encountered in pulmonary aspergillosis viewed in the context of the immune derangement associated with it.

Screening and Diagnosis of Gestational Diabetes Mellitus, Where Do We Stand

P. Reddi Rani, Jasmina Begum
Gestational Diabetes Mellitus (GDM) is defined as any glucose intolerance with the onset or first recognition during pregnancy. This definition helps for diagnosis of unrecognized pre-existing Diabetes also. Hyperglycemia in pregnancy is associated with adverse maternal and prenatal outcome. It is important to screen, diagnose and treat Hyperglycemia in pregnancy to prevent an adverse outcome. There is no international consensus regarding timing of screening method and the optimal cut-off points for diagnosis and intervention of GDM. DIPSI recommends non-fasting Oral Glucose Tolerance Test (OGTT) with 75g of glucose with a cut-off of = 140 mg/dl after 2-hours, whereas WHO (1999) recommends a fasting OGTT after 75g glucose with a cut-off plasma glucose of = 140 mg/dl after 2-hour. The recommendations by ADA/IADPSG for screening women at risk of diabetes is as follows, for first and subsequent trimester at 24-28 weeks a criteria of diagnosis of GDM is made by 75 g OGTT and fasting 5.1mmol/l, 1 hour 10.0mmol/l, 2 hour 8.5mmol/l by universal glucose tolerance testing. Critics of these criteria state that it causes over diagnosis of GDM and unnecessary interventions, the controversy however continues. The ACOG still prefer a 2 step procedure, GCT with 50g glucose non-fasting if value > 7.8mmol/l followed by 3-hour OGTT for confirmation of diagnosis. In conclusion based on Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study as mild degree of dysglycemia are associated with adverse outcome and high prevalence of Type II DM to have international consensus It recommends IADPSG criteria, though controversy exists. The IADPSG criteria is the only outcome based criteria, it has the ability to diagnose and treat GDM earlier, thereby reducing the fetal and maternal complications associated with GDM. This one step method has an advantage of simplicity in execution, more patient friendly, accurate in diagnosis and close to international consensus. Keeping in the mind the diversity and variability of Indian population, judging international criteria may not be conclusive, thus further comparative studies are required on different diagnostic criteria in relation to adverse pregnancy outcomes.

LongoVital- An Imminent Therapeutic Modality: An Unseen Drug Review with Advanced Features and Hypothesis

Ruchika Khanna, Nisha Dua, Anand Kumar, Ruchit Khanna, Pyare Mohan Lal Khanna
Herbal medication still happens to be the backbone of the major world’s population essentially because of the assumption that these drugs are free of any side effects and easily available. LongoVital (LV) is a herbal preparation with documented immune-modulatory and immune-stimulatory effects in man. Various studies conducted to date, have shown LV to have prolonged and beneficial impact in the treatment of orofacial diseases, when administered in recommended daily doses. With its combined antimicrobial and immunostimulatory effects, LV can be regarded as an emerging therapeutic modality in the treatment of orofacial diseases.

Fundamental Ethical Issues in Unnecessary Surgical Procedures

Motilal Chandu Tayade, Shashank D. Dalvi
In clinical practice performing any surgical procedure is inconsistent because all surgical procedures carry definitely some degree of risk. Worldwide every year millions of patients go under knife, but many of them are enduring great pain and shelling out thousands and dollars for surgeries they don’t really need. This review work was planned with an intention to focus attention towards it with reporting cited evidences of unnecessary surgical operations and discuss ethical issues concern with it. In present review the references search included standard citations Google scholar, MEDLINE and PUBMED. We also used Google search engine for screening various news concern with highlighting this topic in community and online media. For articles we go through more than 60 articles from worldwide and 12 news media views from Google search in last one year. We used following quotes for their search-unnecessary surgeries, second opinion, ethical issues in unnecessary surgeries. Geographical variations were also kept in view. Our intension was highlighting ethical issues concern with unnecessary surgical operations. Henceforth we excluded such work that does not concern with ethical issues. Unnecessary surgery is that which is medically unjustifiable when the risks and costs are more than the likely therapeutic benefits or relief to the patient based on the patient’s lifestyle requirements. To avoid or minimize such interventions basic seeding of ethics in curriculum and strict laws will definitely helpful in clinical practice. In conclusion, our aim was to highlight this major issue and underline need of competency based medical bioethics education in Indian scenario.

Anogenital Pruritus – An Overview

Murugan Swamiappan
Anogenital pruritus is defined as intense itching, acute or chronic, affecting the anal, perianal, perineal and genital skin, which is a dominant problem in the course of various cutaneous and systemic conditions. It is one of the common, extremely annoying symptom for which patients attend the Dermatology Outpatient Department (OPD). Anogenital skin is highly sensitive to soaps, perfumes, clothing and superficial trauma and it is more prone for itchy dermatoses as a result of warmth, friction, lack of aeration, sweating and occlusive inner garments. Anogenital pruritus is associated with a wide spectrum of diseases which includes localized infections, infestations, inflammatory dermatoses, allergic and irritant conditions, anorectal diseases, systemic causes, nutritional disorders, psychological and when the cause cannot be found out it is often termed idiopathic. Patients are highly reluctant in consulting the physician for anogenital itch in the early stage, they usually present at a later stage with either atypical manifestations or depigmentation and lichenification, secondary to constant scratching. They often resort to over the counter topical agents, particularly combination products which contain topical steroids. The irrational use of such products results in complications like skin atrophy, striae, incognito etc. A proper clinical history, clinical examination, investigations like scrapping for fungus and itch mite, skin biopsy, patch test and relevant blood investigations to rule out systemic conditions should be carried out, when needed, to arrive at an accurate diagnosis, before treating the patient.

Effect of Morinda citrifolia (Noni) Fruit Juice on High Fat Diet Induced Dyslipidemia in Rats

Ahsan Shoeb1, M.C. Alwar, Preethi J. Shenoy, P. Gokul
Introduction: The medicinal value of Morinda citrifolia L. (commonly known as Noni) has been explored in ancient folk remedies with a wide range of therapeutic utility, including antibacterial, antiviral, antifungal, antitumour, analgesic, hypotensive, anti-inflammatory and immune enhancing effects. Aim: The present study was designed to evaluate the effects of Noni fruit juice on serum lipid profile in high fat diet induced murine model of dyslipidemia. Materials and Methods: Hyperlipidemia was induced by feeding a cholesterol rich high fat diet for 45 days in wistar albino rats of either sex (n=8). Noni fruit juice administered at 50mg/kg/day and 100mg/kg/day, per oral, was compared with the standard drug Atorvastatin (10mg/kg/day, oral) fed for the latter 30 days. The blood samples were then sent for complete blood lipid profile, after 30 days of treatment. The data presented as mean ± SEM was analyzed using one-way ANOVA followed by Tukey’s post-hoc test. The p <0.05 was considered as statistically significant. Results: The Noni fruit juice treated group showed a significant decrease in the total cholesterol, triglycerides and very low density lipoprotein - Cholesterol at both the doses when compared to the disease control (p<0.05). However, the decrease in the TC (102.75±9.79 mg/dL) and LDL-C (47.87±7.47 mg/dL) levels observed with the noni fruit juice at the 50mg/kg dose employed, failed to show a statistical significance when compared to atorvastatin. Conclusion: The present study provides evidence for the hypolipidemic activity of Noni fruit juice in high fat diet induced hyperlipidemia in rats.

Implication of Renal Aquaporin-3 in Fructose-Induced Metabolic Syndrome and Melatonin Protection

Suzy Fayez Ewida, Dalia Rifaat Al-Sharaky
Introduction: Metabolic Syndrome (MetS) can be induced by ingestion of large amounts of fructose as a consequence of oxidative stress and dyslipidemia. Aim: We investigated the possible protective effects of melatonin administration on MetS induced in fructose-fed rats with special focus on the role of renal aquaporin-3 (AQP-3). Materials and Methods: Thirty rats were randomly divided into three groups; control, fructose, and fructose plus melatonin. MetS was induced by fructose rich diet and melatonin was injected at a dose of 5 mg/kg dissolved in 1% ethanol in normal saline. After the end of the 6-week experimental period, body weight and fat accretion were assessed. Invasive blood pressure and vascular reactivity were evaluated. Serum lipid profile, glucose, insulin levels, insulin resistance, malondialdehyde (MDA) and uric acid were measured, also underwent renal AQP-3 immunohistochemistry. Results: Fructose consumption significantly increased fat accretion, systolic blood pressure, serum lipids, insulin levels and insulin resistance, confirming successful establishment of the MetS model. Also serum MDA, uric acid and renal AQP-3 expression increased compared to the control group. Melatonin supplementation significantly decreased the previously measured parameters compared to fructose group. Conclusion: Increased AQP-3 expression may be implicated in fructose induced MetS. Melatonin protective effect against metabolic consensus and vascular affection may be linked to its antioxidant and lipid lowering effect with reduced renal AQP-3 expression.

Evaluation of Protein Kinase Cß and Pparpar ? Activity in Diabetic Rats Supplemented with Momordica charantia
Introduction: The present study was taken up to compare and evaluate the effect of Momordica charantia supplementation with pioglitazone on PKC-ß and PPAR-? activity in kidneys of diabetic rats. The hypoglycaemic and lipid lowering effect of Momordica charantia were screened in laboratory animal model and its potency was compared with a Thiazolidinedione (TZD) group antidiabetic drug like pioglitazone. Materials and Methods: Adult healthy albino rats of Wistar strain aged 3-4months, weighing between 170-250gm of either sex were divided into 4 groups; Group 1 (normal controls), Group 2 (diabetic controls), Group 3 (diabetic rats treated with pioglitazone) and Group 4 (diabetic rats treated with bitter melon juice). Type 1 Diabetes was induced in rats by intraperitoneal injection of streptozotocin at a dose of 55 mg/kg body weight, following which glucose levels were estimated by Accu chek- active glucometer on day 0, 7, 14, 21 and 28 days to assess the efficacy of Bitter Melon Juice (BMJ) and pioglitazone. After 28 days of treatment, the rats were sacrificed and blood collected from abdominal vena cava was used for estimation of triglycerides by Glycerol 3 phosphate oxidase phenol aminophenazone method and cholesterol by Cholestrol oxidase phenol aminophenazone method. PKC-ß and PPAR-? were estimated in the dissected kidneys by using double sandwich ELISA based kits on an automated plate reader. Results: BMJ significantly reduced blood glucose levels in group 4 as compared to diabetic controls (p<0.001). Total cholesterol and triglycerides were significantly reduced in both group 3 and 4. In Group 4, there was reduction in PKC-ß levels, when compared to Group 3(p=0.004). PPAR-? levels were increased in both Group 3 and 4, when compared to Group 2. Conclusion: The results suggest that BMJ has hypoglycaemic and lipid lowering effect in diabetic animal models. BMJ increases PPAR-? activity and decreases PKC-ß activity in kidneys of diabetic rats, thereby preventing the complications of diabetes mellitus. Fresh BMJ mimics action of pioglitazone belonging to TZD group thus showing a potential for further research in identifying the active molecules responsible for glucose and lipid lowering action.

Impact of Seasonal Variant Temperatures and Laboratory Room Ambient Temperature on Mortality of Rats with Ischemic Brain Injury
Introduction: A popular rat model for hypoperfusion ischemic brain injury is bilateral common carotid artery occlusion (BCCAO). BCCAO surgery when performed in varying geographical locations and during different seasons of the year is reported to have variable mortality rates. Studies have also documented the diminishing influence of Ketamine-Xylazine (KT-XY) on thermoregulatory functions in rodents. Aim: To explore the impact of seasonal variant temperatures and laboratory room ambient temperatures on mortality of rats following BCCAO surgery. Materials and Methods: The study has two parts: 1 The first part is an analysis of a three year retrospective data to explore the association between the geographical season (hot summer and cold winter) induced laboratory room ambient temperature variations and the mortality rate in KT-XY anaesthetized BCCAO rats. 2. The second part investigated the effect of conditioned laboratory room ambient temperature (CAT) (23-250C) in KT-XY anaesthetized BCCAO group of rats. Rats were divided into 4 groups(n =8/group) as-Normal control, BCCAO and Sham BCCAO where they were all exposed to unconditioned ambient temperature (UCAT) during their surgery and postoperative care. And finally fourth group rats exposed to CAT during the BCCAO surgery and postoperative care. Results: Pearson’s chi-square test indicates a significantly high association (p<0.006) between post-BCCAO mortality and hot season of the year. CAT during the hot season reduced the mortality rate (24% less) in post- BCCAO rats compared to the rats of UCAT. Conclusion: Despite seasonal variations in temperature, conditioning the laboratory room ambient temperatures to 230C-250C, induces hypothermia in KT-XY anaesthetized ischemic brain injured rodents and improves their survival rate.

Testing of Hypothesis in Equivalence and Non Inferiority Trials-A Concept

Atul Juneja, Abha R. Aggarwal, Tulsi Adhikari, Arvind Pandey
Establishing the appropriate hypothesis is one of the important steps for carrying out the statistical tests/analysis. Its understanding is important for interpreting the results of statistical analysis. The current communication attempts to provide the concept of testing of hypothesis in non inferiority and equivalence trials, where the null hypothesis is just reverse of what is set up for conventional superiority trials. It is similarly looked for rejection for establishing the fact the researcher is intending to prove. It is important to mention that equivalence or non inferiority cannot be proved by accepting the null hypothesis of no difference. Hence, establishing the appropriate statistical hypothesis is extremely important to arrive at meaningful conclusion for the set objectives in research.

Novel Matricing Technique for Management of Fractured Cusp Conundrum – A Clinician´s Corner

Ganesh Ranganath Jadhav, Priya Ramesh Mittal
Longitudinal tooth fracture can be classified as craze lines, fractured cusp, cracked tooth, split tooth and vertical root fracture based on extent and severity of the fracture line. The most common type of longitudinal tooth fracture is fractured cusp that poses the treatment dilemma. Retention of the fractured cusp segment temporarily with matrix band followed by permanent bonded restoration and finally removal of tooth fragment during crown preparation is a novel technique. This paper throws light on a matricing and holding technique for the management of supra-crestally fractured palatal cusp of maxillary first premolar in a 29-year-old Asian male.

Lipoleiomyoma of Cervix

josephine Adaikkalam

Christmas Tree Cataract - A Cataract that Glitters

Tanie Natung, Lanalyn Thangkhiew, Avonuo Keditsu, Wakaru Shullai

Red Eye and Red Face Following Defibrilation

Pinar Dog?an, Sinan I?nci, Bihter S¸ Entürk, Fatih Mehmet Uçar, Ümit Güray

Follicular Variant of Papillary Carcinoma Arising in Struma Ovarii

M. Ananta Satya Narayana, K. Praveen Kumar, B.A. Rama Krishna

Correspondence: Ebola Virus Disease in ASEAN Countries

Beuy Joob, Viroj Wiwanitkit

Hip Pain and Gait Disturbance Associated with Idiopathic Hypoparathyroidism

Rana Kaynar, Murat Uludag, Nilay Yalcin, Mehmet Hamza Turkcanoglu, Mahir Cengiz

Mobile Phone Dependence among Adolescents; Can We Utilize Mobile Phone as a Therapeutic Approach?

Amin vahedi, Amin Zarghami

Tiger Food for Short Bowel: Two Cases

Aswini Kumar Pujahari

Effect of Gender on the Total Abdominal Fat, Intra-Abdominal Adipose Tissue and Abdominal Sub-Cutaneous Adipose Tissue among Indian Hypertensive Patients

Jaya Prakash Sahoo, Savita Kumari, Sanjay Jain
Introduction: Abdominal obesity is a better marker of adverse metabolic profile than generalized obesity in hypertensive subjects. Further, gender has effect on adiposity and its distribution. Aim: Effect of gender on obesity and the distribution of fat in different sub-compartments of abdomen among Indian hypertensive subjects. Materials and Methods: This observational study included 278 adult subjects (Males-149 & Females-129) with essential hypertension from a tertiary care centre in north India over one year. A detailed history taking and physical examination including anthropometry were performed in all patients. Total Abdominal Fat (TAF) and abdominal adipose tissue sub-compartments like Intra-Abdominal Adipose Tissue (IAAT) and Sub-Cutaneous Adipose Tissue (SCAT) were measured using the predictive equations developed for Asian Indians. Results: Female hypertensive subjects had higher Body Mass Index (BMI) with more overweight (BMI = 23kg/m2), and obesity (BMI= 25 kg/m2). Additionally, they had higher prevalence of central obesity based on both Waist Circumference (WC) criteria (WC= 90 cm in males and WC= 80 cm in females) and TAF criteria {=245.6 cm2 (males) and =203.46 cm2 (females)} than male patients. But there was no difference in the prevalence of central obesity based on Waist Hip Ratio (WHR) criteria (WHR =0.90 in males and WHR = 0.85 in females) between two genders. High TAF & IAAT were present in more females although there was no difference in the distribution of high SCAT between two genders. Conclusion: Female hypertensive subjects were more obese with higher abnormal TAF & IAAT compared to male patients. However, there was no difference in the distribution of high SCAT among them.

Usage of Plastic Bags and Health Hazards: A Study to Assess Awareness Level and Perception about Legislation Among a Small Population of Mangalore City

Introduction: Plastic bag users are at risk of number of health hazards. There is paucity of data with regard to awareness of health hazards among general population in India. Aim: This study was done to find out the status of awareness of the health hazards associated with the usage of plastic bags among people and their perception towards the legislation prohibiting the usage of plastic bags. Materials and Methods: This cross-sectional study conducted in Mangalore city in August 2013. Data was collected by interviewing any adult member (aged above 18 years) in each of the selected households using an interview schedule. Results: Mean age of the 250 participants was 32.8±10.8 years. Majority 160(64%) were females educated up to undergraduate level or above 187(74.8%). Among the participants 216(86.4%) were aware of the health hazards associated with the use of plastic bags. Awareness was significantly more amongst females (p=0.027), well-educated participants (p=0.004) and among professionals and semi-professionals (p<0.001). There were 50(20%) participants reusing plastic bags for shopping after initial usage. The cloth bags were used for shopping in place of plastic bags by 13(5.2%) participants. Among the participants 213(85.2%) were aware of the legislation banning the use of plastic bags and out of which 166(77.9%) were in its favour. Semi-professionals and students favoured the ban on plastic bags whereas unskilled and semiskilled workers were against the ban (p=0.01). Conclusion: Most of the participants in the settings had the awareness of hazards of plastic bag usage. However, there is a need for spreading the awareness of using alternative strategies and effective implementation of legislation in order to minimize the usage of plastics in the community.

A Innovative Technique - Modified Feeding Bottle for a Cleft Palate Infant

Cleft lip and cleft palate are one of the most common craniofacial anomalies. Infants suffer a lot of difficulty in sucking during the initial few days after birth. There is even psychological stress to the parents due to improper feeding and the infants lose weight and are prone to nutritional insufficiency. Due to recent advancement in the medical field, there is a total repair of cleft lip and cleft palate and these procedures are performed in the later stages of infants. It is the multidisciplinary approach which includes pedodontist, oral surgeon, prosthodontist and speech therapist. In this article, the technique is highlighted to fulfill the feeding problem of infants in the early stages of birth with a modified feeding bottle.