Journal of clinical and diagnostic research

Effectiveness of the Training Course of ASHA on Infant Feeding Practices at a Rural Teaching Hospital: A Cross Sectional Study

Introduction: Accredited Social Health Activists (ASHA) is the key functionaries for the effective implementation of maternal and child health care services at the grass root level in India. Method: The effectiveness of this training programme was assessed by conducting a pre-test and post-test assessments. The correct responses to the test items in the questionnaire were given one mark, with a maximum of 20 marks. Results: The training on the knowledge, attitude and practices of breast feeding was found to be effective. The difference in the pre and the post test score of the participants was found to be statistically significant (p<0.05). Conclusion: The ASHA workers and their supervisors gained the knowledge and skills on breastfeeding and complementary feeding after the training.

Prevalence of Methicillin, Vancomycin and Multidrug Resistance among Staphylococcus aureus

Dhanalakshmi T.A., Umapathy B.L., Mohan D.R.

Background and Objectives: The treatment of Staphylococcus aureus infections is becoming increasingly more complicated due to the emergence of various types of antibiotic resistance. The present study was undertaken to know the prevalence of methicillin resistant Staphylococcus aureus (MRSA), vancomycin intermediate and vancomycin resistant Staphylococcus aureus (VISA and VRSA respectively) and multidrug resistant MRSA and to evaluate the phenotypic detection methods. Materials and Methods: A total of 250 non-duplicate isolates of Staphylococcus aureus which were isolated from various clinical samples were tested for methicillin resistance by using the oxacillin disc diffusion test (1μg), the cefoxitin disc diffusion test (30 μg) and the oxacillin agar screen method (Muller Hinton agar (MHA) with 4% NaCl+6 μg/ml oxacillin). Vancomycin screen agar (MHA containing 5 μg/ml vancomycin) was used for screening the VISA/VRSA isolates. The MIC of vancomycin was determined by using the agar dilution method and the E-test. The antibiogram of the isolates to other antibiotics was studied by the Kirby-Bauer disc diffusion method. Results: 80 (32%) isolates were found to be methicillin resistant by the cefoxitin disc diffusion method, 78 (31.2%) were found to be methicillin resistant by the oxacillin agar screen test and 77 (30.8%) were found to be methicillin resistant by the oxacillin disc diffusion method. No VISA and VRSA isolate was detected by using the vancomycin screen agar test, agar dilution and the E-test. The vancomycin screen agar showed 100% specificity and 100% negative predictive value. Sixty seven (83.8%) of the 80 MRSA isolates and 26.8 % of the total 250 Staphylococcus aureus isolates tested were found to be multidrug resistant MRSA. Conclusions: Where the facilities are limited, the cefoxitin disc diffusion test and the vancomycin screen agar test can be used for screening the MRSA and the VRSA isolates respectively. With the revised CLSI guidelines, the screening method for VISA with an MIC of 4μg/ml needs to be evaluated with further more studies.

Chemical Sphicterotomy versus Surgical Sphicterotomy in the Management of Chronic Fissure in ANO: A Prospective, Randomized Trial

Rithin Suvarna, Panchami, Guruprasad Rai D.

Introduction: Fissure in ano is a common cause of severe anal pain. The hypertonia and spasm of the internal anal sphincter is believed to be the chief pathology in chronic fissures. The reduction of this hypertonia is most commonly achieved by surgical sphincterotomy, that results in fissure healing in more than 90% of the cases. However, the surgery carries a significant risk of incontinence. In this study, we explored chemical sphincterotomy by using topical 2% diltiazem as an effective and a safe alternative method to the surgical treatment for chronic fissure in ano. Materials and Methods: In this prospective trial, 200 patients with chronic anal fissures were randomly divided into group 1 and group 2, with 100 patients in each group. The group 1 cases received 2% topical diltiazem at the perianal skin twice daily for 6 weeks, while the group 2 subjects underwent lateral internal sphincterotomy. They were assessed biweekly during the treatment. The follow up was carried out for one year. Results: Complete fissure healing was found in 69.23% patients of group 1 (topical diltiazem) and in 95.87% patients of group 2 (surgical sphincterotomy). In the first group, the pain relief was fairly good, while in group 2, the response was quick and excellent. Mild headache was the main side effect in group1, while it was anal incontinence in group 2. 10.43% of the cases from the group 1 had recurrence, whereas none in the second group had it. Conclusion: We conclude that chemical sphincterotomy with the use of 2% topical diltiazem may be considered as first line treatment for chronic anal fissure. Surgical sphincterotomy should be reserved for patients who have failed to respond to chemical sphincterotomy.

Urinary Placental Growth Factor in Pregnancies Complicated by Preeclampsia

Introduction: Preeclampsia is associated with alterations in the maternal serum levels of the vascular endothelial growth factor (VEGF), the placental growth factor (PlGF) and the soluble fms-like tyrosine kinase-1 (sFlt-1). The serial measurement of these angiogenic factors in the serum may be used to pre-empt the diagnosis of preeclampsia, but obtaining such measurements during the routine antenatal care needs a cost-effective analysis. A promising tool is a non-invasive, alternative screening method for measuring the urinary placental growth factor (PlGF). Objective: To estimate the levels of urinary PlGF in preeclamptic and normotensive, non proteinuric pregnant women in the Indian population and also to analyze the association of this factor with the onset of the disease. Methods: A case control-study was planned in 80 patients, among which 40 were preeclamptic patients and 40 were normotensive, non proteinuric pregnant women who served as the controls. Urine samples were obtained both from the preeclamptic women and the control women and they were analyzed for the levels of urinary PlGF by using ELISA. Results: The levels of urinary PlGF were significantly reduced in the preeclamptic patients as compared to those in the normotensive, non-proteinuric pregnant women (30.08 ± 9.42 pg/ml Vs 77.70 ± 24.70 pg/ml, p< 0.0001). Further, the levels were also significantly reduced in early-onset preeclampsia compared to those in late-onset preeclampsia (25.44±6.35 pg/ml Vs 40.92 ±5.71 pg/ml, p<0.0001). Conclusion: A significant reduction in the levels of urinary PlGF was found in the preeclamptic patients and this reduced level of urinary PlGF may be used to pre-empt the onset of preeclampsia and to institute the appropriate therapeutic measures.

Lumbosacral Vertebral Defects Associated with Congenital Anomalies of Urinary Tract

Preeti P. Thute, Ratnamala R. Fulzele, Bhaurao C.Bakane

Introduction: It is reported in the literature that various anomalies of the lumbosacral spine are amongst the most common anomalies associated with that of urinary tract. Material and Methods: The present study was carried out in the department of Anatomy, JNMC, Sawangi (Meghe), Wardha, India. The study included 50 subjects divided in two equal groups as control and study group. The subjects had undergone X-ray KUB and Intravenous pyelography. Statistical analysis was done by using Chi Square Test and Test of Significance for single proportion i.e. Z- value. Results: The study revealed Pelvi-Ureteric Junction (PUJ) obstruction being the commonest congenital anomaly of urinary tract. Amongst the deformities of the lumbosacral spine sacralization and bifid spine were the commonest. However no laterality correlation was observed. Conclusion: The study highlights the association between genitourinary and lumboscaral vertebral anomalies and emphasize upon the need of thorough search of these associated anomalies in the cases presenting with genitourinary anomalies.

A Study on Effects of Meditation on Sympathetic Nervous System Functional Status in Meditators

Desh Deepak, Anant Narayan Sinha, Vimal Singh Gusain, Ashish Goel

Objective: Meditation has long been known to affect human physiology through autonomic nervous system. This study was designed to assess sympathetic autonomic functional status of meditators of various age groups. Material and Methods: Three clinical tests, Isometric handgrip test,Cold pressor test and Valsalva Meneuver were studied in 25 meditators of age ranging from 25 to 75 years. The results were compared with those observed in 25 non-meditators of matching age and socio economic status. Observation and Results: The basal cardiac parameters viz heart rate and blood pressure were uniformly lower in meditators than non meditators in all age groups, more so in senior meditators. On performing isometric handgrip test, non-meditators developed significant increase in blood pressure and heart rate during gripping than that seen in meditators. In cold pressor test, as compared to non-meditators, mediators showed blunted increase in blood pressure along with returning of blood pressure to basal level earlier, which indicated presence of controlled sympathetic drive in meditators. In Valsalva maneuver the overshoot of BP was lower in meditators than in non meditators. Conclusion: It can be concluded that the regular practice of meditation initially blunted the sympathetic drive and later on developed control over sympathetic function of meditators.

The ABO Blood Group Distribution and Pulmonary Tuberculosis

Aim: Over the years, large number of studies have examined the possible relationship between the blood group type and infection. The present study was aimed at observing the pattern of the ABO blood group distribution among the pulmonary tuberculosis patients from the Andhra region of the Andhra Pradesh state, India. Methods: The ABO blood grouping and Rhesus typing were performed by using the standard slide agglutination reaction in 100 patients with a clinical and a radiological evidence of pulmonary tuberculosis and in 1400 healthy controls. Results: A significant association was observed between the incidence of tuberculosis and the blood groups B and AB (P values are 0.048 and 0.03 respectively). The association between the incidence of tuberculosis and the blood groups A and O (P values are 0.249 and 0.069 respectively) was found insignificant. However, a significant association between the incidence of tuberculosis and a positive Rhesus antigen was observed in the blood group A (P value is 0.009). But there was no significant association between the incidence of tuberculosis and a positive Rhesus antigen with the blood groups B, AB and O. Conclusion: The present study showed that there was an association between tuberculosis and the blood groups B and AB in this region of the Andhra Pradesh state.

Haemoglobin Estimation by Non-cyanide Methods

Introduction: Haemoglobin is an oxygen carrying protein in the red blood cells. It is estimated by the haemoglobincyanide method (HiCN). This method is known to be hazardous to the environment and occasionally harmful to the laboratory personnel also. Aims and Objectives: To compare and study the haemoglobin concentrations which were estimated by cyanide and non-cyanide methods. To suggest the advantages of the cyanide free methods over the cyanide methods. To assess whether these methods were better as compared to the haemoglobincyanide method, for medical teaching, blood bank camps and for laboratory investigations. Materials and Methods: 2000 samples in which haemoglobin estimation was done by the haemoglobincyanide method, the Sodium Lauryl Sulphate method and a modified alkaline haematin method which used cetrimide were compared and statistically analyzed by using Pearson’s correlation coefficient. Results: The haemoglobin concentrations which were estimated by the Sodium Lauryl Sulphate method and the modified alkaline haematin method were similar to those which were obtained by the conventional cyanmethaemoglobin method, with r=0.986 and r=0.996 respectively. Conclusion: The modified alkaline haematin method was as accurate as the cyanmethaemoglobin method. It was economical. The toxic effects of cyanide can be prevented by using this method commercially.

Fluoroquinolone Resistant Escherichia Coli and Klebsiella Spp. in Community-Acquired Urinary Tract Infections in Rural Kanpur, India

Devjyoti Majumdar, Hariom Sharan, Desh Nidhi Singh

Introduction: In the community, most of the patients are treated by the local physicians with empirically chosen antimicrobials, without any laboratory confirmation. The aim of the present study was to determine the aetiology and the antimicrobial susceptibility of the uropathogens in culture-positive, community-acquired urinary tract infections in the rural areas around Mandhana, Kanpur, over a period of 14 months. Materials and Methods: The patients who presented with the symptoms of Urinary Tract Infection (UTI) were included in this study. The samples were inoculated in the camp on MacConkey’s agar (MAC) and Sheep Blood Agar (SBA). The incubation, identification and the Antimicrobial Susceptibility Tests (AST) for the organisms which were done in the hospital laboratory. Results: The most common bacteria which were isolated in all the age and gender groups were Escherichia coli (54%) and Klebsiella spp (11.3%). Among the oral antimicrobials which were usually prescribed by the local physicians in Kanpur, lomefloxacin, amoxicillin/sulbactum and nitrofurantoin were the ones to which the Enterobacteriaceae family was the most susceptible to. The resistance rate of Klebsiella to most of the antimicrobials was high (>20%). The resistance to the antimicrobials did not vary significantly with age, sex or any demographic factors. Conclusion: The empirical treatment of the Community Acquired Urinary Tract Infections (CAUTIs) in the rural areas of Kanpur with co-trimoxazole, chloramphenicol, ciprofloxacin or norfloxacin is inadequate. Amoxicillin/sulbactum, nitrofurantoin or lomefloxacin should be the drugs of choice.

Colposcopic Evaluation of the Unhealthy Cervix

Ramesh G., Sudha R., Jayashree A.K., Padmini J.

Background: The Papanicolaou’s (Pap) smear is the primary screening tool for Cervical Intra-epithelial Neoplasia (CIN) and for invasive cancer of the uterine cervix. Recently, the assumed accuracy of the Pap smear which was found to be 80% to 95% for detecting CIN and early invasive cancer, was questioned. The simultaneous use of cytological studies and screening colposcopy has been shown to increase the rate of the cervical cancer detection. Hence, there is an obvious need to subject the women with clinically unhealthy cervix to colposcopy and directed biopsy. This study is done to evaluate the role of colposcopy in detecting unhealthy cervix. Aims: To study the role of colposcopy in the evaluation of unhealthy cervix, to localize the lesions and to obtain biopsies from the selected areas. Study Design: A prospective, clinical study. Materials and Methods: 80 patients who were aged between 25-65 years and had clinically unhealthy cervix, were subjected to a colposcopic evaluation and the findings were noted. All the patients underwent both the acetic acid and the Schiller’s test before they were subjected to colposcopic directed biopsies. The biopsies were taken from the acetowhite areas and the iodine negative areas. Results: Out of the 80 patients, 21 (26.25%) had normal colposcopic findings. The colposcopic evaluation and the guided biopy were successful in detecting abnormalities in 20 out of 24 cases. The incidence of CIN 1 and CIN 2,3 was found to be 11.25% and 10% respectively.The sensitivity of colposcopy in the present study is 83.33%. Conclusions: The value of colposcopy has been recognized, mainly in the evaluation of patients with abnormal cervical smears because of their less sensitive and false negative cytologies and because of the poor compliance of the patients for follow up. It has been felt that apart from cervical smears, colposcopy should be offered as diagnostic method in all the patients with unhealthy cervix.

Evaluation of Dryness of Eyes after Manual Small Incision Cataract Surgery with Corneoscleral Tunnel Incision

Kavitha Chikkanayakanahalli Venugopal, Pavana Acharya Krishnaraj, Chandan N.

Context: Damage to any component of the lacrimal function unit can destabilize the tear film and it can lead to ocular surface disease that expresses itself as dry eye. Many factors can cause dry eyes in patients after cataract surgeries, which increases their agony. In a developing country like ours, the most common, efficient and economical cataract surgery is the manual small incision cataract surgery which is done with a corneoscleral tunnel incision. The study population was from a region where agriculture was a predominant occupation. The environmental exposure to wind, sunlight and a high temperature causes dry eyes, which can be aggravated after cataract surgeries. Aims: To evaluate the presence or absence of dry eyes, if present and to assess the severity of the dry eyes after manual small incision cataract surgery with a corneoscleral tunnel incision. Settings and Design: A descriptive, cross-sectional study. Material and Methods: 68 out of 71 patients who came for follow up after manual small incision cataract surgeries with corneoscleral tunnel incisions were examined and analyzed. The symptoms, marginal tear strip height, Schirmer’s test-1and the tear film break-up time were recorded. The observations were analyzed and the dryness of the eyes, when it was present, was graded according to the DEWS 2007 report. Statistical Analysis: Percentage. Results: 66.2% patients had dry eyes. Among them, 53.32% had mild grade, 26.6% had moderate grade and 20% had a severe grade of dryness. 33.8% patients did not have dry eyes. 67.7% of the male patients and 64.9% of the female patients had dry eyes. This gender difference was statistically not significant (p value–0.3922). 68.4% of the patients with a superior incision and 63.3% of the patients with a temporal incision had dry eyes. This difference in the incision site was also statistically not significant ( p value–0.9741). 60% of the patients in the early post-operative period and 75% of the patients in the late post-operative period had dry eyes. This difference was also statistically not significant (p value–0.1019). Conclusion: After manual small incision cataract surgeries with corneoscleral tunnel incisions, there was dryness of eyes in a majority of the patients and a majority of them had the mild grade of dry eyes.

Knowledge Risk Perceptions and Attitudes of Nurses Towards HIV in a Tertiary Care Hospital in Mangalore, India

Introduction: Infectious diseases like HIV are on the rise in developing countries like India, which puts a heavy burden on the health care needs. Nurses have a key role and they spend considerable time taking care of the HIV positive patients who are admitted to hospitals. Hence, a study was conducted in our hospital to have an insight into the knowledge of nurses about HIV, their apprehensions while taking care of such patients and their attitudes and willingness to take care of them. Methods: This was a cross sectional study which was done among 200 nurses of KMC Hospital, Mangalore. They were given a validated questionnaire which comprised of 67 items which included the knowledge on the spread of HIV, universal precautions, risk perceptions and their attitudes towards the HIV positive patients. Their responses were analyzed by using the SPSS software. Results: Of the 200 nurses who were selected, 152 completed the questionnaire. Regarding the knowledge of the HIV transmission, the correct response for the widely advertised modes of transmission were higher-sexual contact (97.4%) and vertical transmission (88.8%). However, 11.2% did not know about the mother to child transmission and 28.9% did not know about the transmission through breast feeding. 90.1% felt that HIV could be transmitted by the sharing of plates and 83.6% felt that it could be transmitted through mosquito bites. 93.4% knew about the universal precautions and 78.3% routinely practised it. 80.3% were aware of the post exposure prophylaxis.79.2% described that caring for the HIV positives was rewarding, 86.5% were willing to assist in the operations on HIV patients and 84.9% were willing conduct deliveries. 13.4% felt they had a right to refuse care for the HIV patients and 97% felt that the surgical patients needed to be routinely tested for HIV. Conclusions: This study demonstrated that there were deficiencies in the knowledge about HIV and that false beliefs existed among the nurses about the spread of HIV. There is a need to improve the awareness about HIV and HIV patient care through training programmes to clear the misconceptions among the nurses so that the HIV positive patients are not discriminated against and are treated without discrimination.

Effect of pH on the Adherence, Surface Hydrophobicity and the Biofilm Formation of Gardnerella Vaginalis

Udayalaxmi, Gopalkrishna Bhat, Subbannayya Kotigadde, Shashidhar Kotian

Background: Bacterial vaginosis is a common cause of the abnormal vaginal discharge in women of the reproductive age group. Although bacterial vaginosis is prevalent, not much progress has been made in identifying the factors which are responsible for and those which are associated with bacterial vaginosis and its pathophysiology. Here, we would like to evaluate the effect of the change in the pH of the vagina on the virulence factors of Gardnerella vaginalis, the main organism which has been indicated in this vaginal condition. Objective: The objective of the present study was to observe the effect of pH on the adherence, surface hydrophobicity and the biofilm formation of 10 strains of Gardnerella vaginalis which were isolated from cases of bacterial vaginosis. Result: We found that the adherence to the vaginal epithelial cells and the surface hydrophobicity was maximum at a lower pH (pH- 3,4,5) and minimum at a higher pH (pH- 6,7), but the pH did not have a significant effect on the biofilm formation. Conclusion: An increase in the pH of the vagina which is observed during bacterial vaginosis, probably occurs much later during the disease. During the early part of the disease, the bacteria adhere to the vaginal epithelium, multiply in large numbers and form a thick biofilm which is not affected by the rise in pH, which occurs probably due to the metabolic activities of this large bacterial population. This also explains the fact that all women with bacterial vaginosis do not have an elevated vaginal pH.

The Anthelmintic Activity of Eupatorium triplinerve and Alpinia galanga in Pheritima posthuma and Ascardia galli: A Comparative Study

Aim: The ethanolic extracts from the leaves of Eupatorium triplinerve and the rhizome of Alpinia galanga were compared for their anthelmintic activities, based on traditional claims. Methods: Pheritima posthuma and Ascardia galli were used as the suitable in vitro models; the time which was taken for paralysis (P) and death (D) were used as the parameters to assess their anthelmintic activities, with Albendazole 50mg/ml as the standard. Results: Eupatorium triplinerve exhibited a dose dependent anthelmintic activity in both the models at the concentrations of 50mg/ml and 100mg/ml, thus indicating a broad spectrum of action, whereas Alpinia galanga, as compared to Eupatorium triplinerve, failed to show any activity against Pheritima posthuma, but exhibited a potent activity in a dose dependent manner which was comparable to that of the standard, albendazole 23.00 + 2.60(P), 63.33 + 2.33(D) at a 100mg/ml concentration against Ascardia galli at minutes 32.83 + 4.07(P) and 69.33 + 3.93.

A Study on the Sale of Antimicrobial Agents without Prescriptions in Pharmacies in an Urban Area in South India

Introduction: Antimicrobial drug resistance is a fast emerging problem worldwide. It is a consequence of the use, particularly of the misuse of drugs. In most of the developing countries, antibiotics can be purchased without prescriptions, even when the practice is not legal. Presently, in India, Schedule H, under the Drug and Cosmetics Act and Rules, provides a list of over 536 drugs which include Antimicrobial Agents [AMAs], which are required to be sold on the prescription of a registered medical practitioner. Objectives: To evaluate the Over the Counter (OTC) sales of antimicrobial agents in allopathic pharmacies [community] within the city corporation limits. To describe the degree of difficulty which is faced in obtaining antibiotics without a prescription. To find out as to what advice, if any, was given by the pharmacists with regards to the administration of the medicines which had been sold. Methods: Three diseases were simulated by two medical students who presented as patients in randomly selected pharmacies at an Urban location. They then requested the pharmacists for medications for their illnesses. AMAs were requested for, if they were not issued at the first instance. Results and Discussion: Nearly 50% of the pharmacists declined to issue AMAs. Amoxicillin was the most common of the AMAs which were dispensed by the pharmacists. The duration and the frequency of the treatment which was advised by the pharmacists were mostly wrong. Conclusion: This study showed that the practice of dispensing AMAs without prescriptions was widely prevalent among the dispensaries which were located even in urban areas. Not only were the AMAs dispensed, but also they were dispensed without taking any history of hypersensitivity. What makes the practice worse is that the duration and the frequency of administration of these drugs are wrongly advised more often than not.

Phenotypic Methods for the Detection of Various Betalactamases in Carbapenem Resistant Isolates of Acinetobacter baumanii at a Tertiary Care Hospital in South India

Dheepa Muthusamy, Appalaraju Boppe

Purpose of the Study: The purpose of this study was to evaluate the production of various beta lactamases among multi-drug resistant Acinetobacter baumanii isolates from clinical specimens. Methods Used: A total of 100 Acinetobacter baumannii meropenem resistant isolates were used for the detection of carbapenemases (Modified Hodge test), AmpC beta lactamase (the AmpC disc test) and metallo beta lactamase (the Disc potentiation test). Results and Conclusion: Among 100 meropenem resistant isolates, 20% were carbapenemase producers, 73% were AmpC producers, and 10% were metallo beta lactamase producers. MBL production, AmpC beta lactamase production and carbapenemase production is becoming common in the multi drug resistant isolates of A. baumannii. Our study suggests that the disc potentiation test, the Amp C disc test, and the Modified Hodge test are simple tests that can be done routinely in the lab for all the multi drug resistant isolates of A. baumannii.

Prevalence of Markers of Hepatitis C virus among the Blood Donors

Harjot Kaur, Mridu Manjari, Richa Ghay Thaman, Gagandeep Singh

Introduction: Hepatitis C infections continue to be a threat to safe transfusion practices. We analyzed the prevalence and trends of the Hepatitis C infection among voluntary and replacement donors in a 6.5 years retrospective study from January 2005 till June 2011 at the blood bank at Sri Guru Ram Das Institute of Medical Sciences And Research, Vallah, Amritsar, India. The donors were evaluated for the sero prevalence of the Hepatitis- C virus (HCV). Methods: A total of 35793 healthy blood donations which were collected from January 2005 to July 2011 were screened for anti -HCV antibodies by using third and fourth generation (for confirmation) ELISA kits (HCV Microlisa; J. Mitra/ Eliscan HCV; RFCL Qualisa HCV; Qualpro) with a reported sensitivity and a specificity of 100% each (for the fourth generation kits). Results: Out of these, 7089(19.8%) were voluntary donors and 28704 (80.1%) were replacement donors. 493 blood donors tested positive for HCV. The average prevalence in percentage was found to be 1.38%. The prevalence rate showed a decline from 2.03% in 2005 to 0.87% by June 2011. The statistical analysis which was done by using the Chi-square test (51.193), demonstrated that the decreasing trend in the prevalence of HCV was statistically significant. Conclusion: The screening of blood products is the only way to prevent the transfusion associated complications and this should be rigorously implemented. There is a need to stress more stringent donor selection criteria to ensure a safer blood supply. The health authorities need to include hepatitis C on their radar as a disease which can result in significant morbidity and mortality in the years to come.

The Changing Clinical Spectrum of Dengue Fever in the 2009 Epidemic in North India: A Tertiary Teaching Hospital Based Study

Seema Awasthi, Vinod Kumar Singh, Santosh Kumar, Ashutosh Kumar, Shyamoli Dutta

Introduction: Dengue fever epidemics have been causing major concerns in India since the last two decades. Many parts of India, including the north regions, are now endemic for the Dengue infection. This retrospective study was conducted in a tertiary teaching hospital in north India to determine the changing trends of the clinical features in the Dengue patients of this region in the recent years. Materials and Methods: A retrospective study of four months was conducted on 309 cases who presented with fever, who were suspected as Dengue fever cases and they were admitted in the study. A detailed history and the clinical examination findings were recorded and all the cases were subjected to laboratory investigations which included a complete haemogram, a liver function test, a kidney function test and serological tests. All the patients were treated symptomatically. Result: Among the 309 suspected Dengue patients, the male: female ratio was 2:1. The Dengue serology was studied for all the cases and only 34 cases were found to be positive (male: female =1.6:1). On clinical examination, a maculo-papular erythematous rash was found to be present in 69% cases and petechiae were present in 38% of the cases. 8% of the cases showed a tendency for spontaneous bleeding. Among these 8% cases with a bleeding tendency, 9 interesting cases showed normal platelet counts and prothrombin times. Renal failure, an altered sensorium, pleural effusions and shock developed in 4, 1, 1 and 1 cases respectively. A platelet count of <1,00,000/cmm was found in 84% cases and 26% cases had a platelet count of less than 20,000/cmm, out of which 20% cases had platelet transfusion. The haemoglobin reduction was not significant in most of the cases and 57 % of the cases showed elevated liver enzymes. 21 cases (6.79%) showed hepatomegaly and splenomegaly was present in 28 cases (9.06%). Conclusion: This study showed slight differences in the clinical profile and the course of illness as compared to the findings of previous studies from the same region, thus indicating a need for the early identification of the Dengue cases to prevent further complications and mortality in the future.

Care Seeking Behavior of the TB Patients who were Registered in an Urban Government Tuberculosis Control in Chennai, Tamilnadu, India

Ramya Ananthakrishnan, Anita Rani Jeyaraju, G Palani, BWC Sathiyasekaran

Background: Tuberculosis (TB) is a major public health challenge for various reasons, with the patient delay in the diagnosis of TB being one of the important hurdles in the TB control. Aims: The present study was undertaken among TB patients to (a) determine the number of days that the patients delayed in seeking care (b) find out the different types of health facilities that they visited prior to their diagnosis (c) examine the association of certain socio-demographic variables with the patient delay and (d) to capture the patient’s reaction to the diagnosis of tuberculosis. Settings and Design: This was a cross sectional study which was conducted among patients who were registered under the Revised National TB control program (RNTCP) in all the Tuberculosis Units (TUs) of Chennai Corporation, an urban metropolitan city in south India. Methods and Material: A pre-tested, semi-quantitative questionnaire was administered to the TB patients who came for Direct Observed Treatment to all the TUs. Results: of the 300 patients, 30.6% patients were diagnosed at their first point of contact with the health facility and 75.6% of the patients had been diagnosed on their second visit. The mean patient delay in this study was 18.3 days, which was less as compared to that in other studies. Patients with extra-pulmonary TB had more mean patient delay (55.7) as compared to the patients with pulmonary TB. Conclusion: This study which has shown a reduced patient delay could probably reflect the efforts of the RNTCP in partnering with different stakeholders in creating both awareness about the disease and appropriate referral to health facility. This study has also highlighted the need for an active and ongoing IEC (information, education and communication) campaign, with special focus on an early diagnosis. Building partnerships with the private health sector for reducing the delays in the diagnosis of TB would also be very important.

The Haematological Pattern of the Patients with Chronic Kidney Disease in a Tertiary Care Setup in South India

Arun S., M. Venkatraya Prabhu, K. Nithyananda Chowta, Mridula Laxman Bengre

Background: With the incidence and the prevalence of chronic kidney disease (CKD) increasing worldwide and its economic repercussions, a detailed haematological workup of such patients is necessary to detect the type of anaemia, as there is a general tendency to consider anaemia to be of the normocytic normochromic type. However in India, a co-existing iron deficiency is also common. Anaemia is an independent risk factor for the mortality in patients with chronic kidney disease. Platelet dysfunction is inherently associated with the uraemic environment, and bleeding tendencies may be manifested despite the presence of normal platelet counts, due to defects in the platelet functioning. This can be detected by the prolonged bleeding times. The immunosuppressed state which is seen in chronic kidney disease is due to defects in both the cell mediated and the humoral immune systems and also due to the associated complement dysfunction. Objective: This study was chosen as an attempt towards detecting the various aspects which are associated with anaemia and its relationship with the stage of chronic kidney disease, in addition to other haematological changes which occur in the same. Materials and Methods: This observational study included 100 patients of chronic kidney disease, who were included, irrespective of their age, sex, aetiology and their clinical profiles. A thorough clinical examination and evaluation were conducted, which included serum iron studies. By using Chisquare analysis, the parameters which were used for a statistical correlation were the levels of anaemia with respect to the stages of the kidney disease, the type and the severity of anaemia, thrombocytopaenia with the bleeding time, leucocytosis and elevated ESR values. Results: Although most of the anaemia was of the normocytic type, nearly a third of the patients had microcytic hypochromic and a mixed type of anaemia. Those with a microcytic hypochromic picture correlated with a severe degree of anaemia. The elevated Erythrocyte Sedimentation Rate (ESR) levels were more distributed in the lower levels of the Glomerular Filtration Rate (GFR). There was no association between the platelet levels and the bleeding time. The leucocytosis was not necessarily associated with infections. Conclusions: It is pertinent to detect and treat subclinical iron deficiency in patients with CKD and to not over-investigate the minor haematological variations.

A Study on the Efficacy of an Open Peritoneal Biopsy for Abdominal Tuberculosis in a Tertiary Medical Centre: Analysis of 69 Cases

Background: The diagnosis of abdominal tuberculosis is often empirical, based on indirect evidences. A polymorphous clinical presentation, non-specific biological markers, a minimally contributive bacteriology and non-specific radiographic signs raise diagnostic difficulties in abdominal tuberculosis. A peritoneal biopsy may be useful in confirming the diagnosis of abdominal tuberculosis. Aims: In this study, we evaluated the efficacy of an open peritoneal biopsy for the confirmation of abdominal tuberculosis. Methods and Materials: We selected 69 cases of suspected abdominal tuberculosis. Among them, 28 cases were diagnosed by Ultrasound (USG) guided Fine Needle Aspiration Cytology (FNAC) from the abdominal lymph nodes or lumps and 38 cases were diagnosed by the examination of the lymphocytic exudative ascitic fluid with a high adenosine deaminase content. 3 cases could not be diagnosed by either means. All the 69 cases were subjected to open peritoneal biopsies. Results: Abdominal pain and tenderness were the presenting clinical features in all the cases. The histopathological examination of the open peritoneal biopsy material confirmed the diagnosis by revealing caseating granulomas in 33 (47.83%) cases. These included 2 cases among 3 which could not be diagnosed by FNAC of the abdominal lymph node or by ascitic fluid examination. Mycobacterial cultures which were done from the biopsy materials were positive in 18(26.08%) cases and all of them had caseating granulomas. The peritoneal biopsies were confirmatory in 19 out of the 38(50%) cases with ascites and in 14 out of the 31(45.16%) cases without ascites. One case could not be diagnosed by either of these three means. She was put on empirical anti tuberculour drugs to which she responded. Conclusion: The classical biological and radiological investigations are not specific and their contributions remain little in the diagnosis of abdominal tuberculosis. Open peritoneal biopsies are safe and helpful in confirming abdominal tuberculosis, particularly in the ascitic cases and the mycobacterial cultures did not improve the diagnostic yield over the histopathological examination of the biopsy materials.

The Effect of Interferon Beta-1b and Methylprednisolone Treatment on the Serum Trace Elements in Iraqi Patients with Multiple Sclerosis

Mohammed A. Al-Zubaidi

Objective: To study the trace element levels and the effect of methylprednisolone and interferon beta-1b on these levels in the serum of patients with multiple sclerosis. Methods: This study was conducted on 32 patients who received methylprednisolone, 32 patients who received interferon beta-1b and on 32 patients who received no treatment at the Multiple Sclerosis Center, Baghdad Teaching hospital, Baghdad, Iraq, from December 2010 to September 2011. In addition to these, 32 age and gender matched healthy controls too were studied for the same parameters. The serum levels of zinc (Zn), copper (Cu) and selenium (Se) were analyzed by using flame and flameless atomic absorption spectrophotometer. Results: There was a significant decrease in the mean serum levels of both zinc and selenium in both the groups of patients which received the treatment as compared to the patients who received no treatment and the control groups. The serum level of copper was found to increase significantly in the patient groups as compared to that in the controls, and there was also a significant increase in the serum level of copper in the patients who received Methylprednisolone as compared to that in the patients who received no treatment.. There was no significant increase in its level in the patients who received interferon beta-1b as compared to that in the patients who received no treatment. Conclusion: Methylprednisolone and interferon beta-1b treatments affect the serum levels of zinc, copper and selenium in patients with multiple sclerosis.

The Significance of the Plasma L-Selectin Levels in Cases of Acute Myeloid Leukaemia: A Case Control Study

A.R. Subhashree, B. Shanthi, C. Revathy

Background: Acute Myeloid Leukaemia (AML) is a heterogeneous group of haematological malignancies which are characterized by malignant proliferation and the accumulation of immature myeloid progenitor cells in the bone marrow. A clinical history of myelodysplasia, the assessment of the morphology of the blast cells, cytogenetics and immunophenotyping are the important criteria which have been used in the recent WHO classification to prognosticate as well as to guide the therapy of AML. L-selectin is a cellular soluble adhesion molecule and it mediates the initial tethering of the normal leucocytes to the endothelial surface . An increase in the plasma L-selectin levels in cases of acute leukemia has been observed in many studies, but till date, this biochemical parameter has not been used as a marker in monitoring leukaemic patients. This study was conducted to compare the L-selectin levels in fresh and treated cases of AML and also with healthy controls. The assessment of the plasma L-selectin levels is expected to add more information about the disease activity and it could also serve as an adjunct to the existing immunological and genetic markers. Aims, Settings and Design: This case control study aimed at estimating the plasma L-selectin levels in cases of acute myeloid leukaemia in comparison with those in normal healthy adults. Further, we assessed the plasma L-selectin levels during the active and the remission phases of AML. Materials and Methods: 20 freshly diagnosed and 20 treated cases of AML were included in the study group from the Haemato Oncology Department of our institution. Forty healthy people who were the staff members of the hospital were included as the controls. The quantitation of L-selectin was done by a highly sensitive immunometric ELISA assay (Manufacturers; Bendermed systems, Vienna, Austria), by using monoclonal antibodies against L-selectin. The statistical significance was calculated by using the Bonferroni T-test and Pearson’s correlation analysis. Results: There was a statistically significant (p=<.001) increase in the plasma L-selectin levels in the freshly diagnosed AML patients as compared to the control group. The plasma L-selectin levels in the patients who were in remission matched with that of the controls. Conclusions: Plasma L-selectin may be used as a marker of the disease activity in AML patients. It may also be used to assess the remission status of these patients. Abbreviations: AML=Acute Myeloid Leukaemia

Chasing a Postgraduate Degree in Ophthalmology: The Medical Intern’s Perspective

Sheetal Amarnath Savur

Background: There is a dearth of studies on career intensions of interns in India in general and Ophthalmology in particular. The exposure in ophthalmology as an undergraduate trainee as well as an intern is lesser in comparison with other major subjects like medicine and surgery. As a result their understanding of the specialty as a career option could be inadequate and biased. The results of this study could be used to assess the need of incorporating career guidance in ophthalmology during internship. Aim: To study the medical interns’ perspective of Ophthalmology as a career and to analyze the factors that might influence their decision. Methods and Material: All interns undergoing compulsory rotatory internship in a medical college in Dakshina Kannada were included in the prospective, questionnaire based study, conducted from September to December 2010. Summary statistics are generated using MS Excel, and most are presented as frequencies and percentages. Chi square /and Fisher’s exact test of significance was used wherever applicable and the significance is reported at 5% level. Observation: Most respondents (33.9%) had ophthalmology as their third choice for pursuing post graduation. There was no significant gender preference (p=0.623) for the branch. 41.5% (37) said that they would not take up ophthalmology because they felt they lacked skill / fine motor co-ordination in activities. 57.3% (51) would opt for this specialty because there was scope for more family time.56.1% (50) would not want to take it up because there was a lot of dependence on equipment for diagnosis. Conclusions: Ophthalmology is amongst the top five preferred branches for specialization. It is most preferred for its perceived controllable lifestyle. Perceived lack of inherent skill was an important deterring factor. Incorporation of career counseling and hand-eye coordination tests during internship will help dispel myths about the speciality and aid decision making .

Vitamin D in Ulcerative Colitis: A Cause or an Effect?

Background and Aims: Vitamin D deficiency is common among patients with inflammatory bowel disease, even when the disease is in remission. This study was designed to evaluate the serum levels of 25-hydroxy vitamin D [25(OH)-D3] in patients who suffered from ulcerative colitis and the control group in Golestan province in the northeast of Iran. Methods: In this case-control study, 60 patients with a definite histopathological diagnosis of ulcerative colitis were included. The control group was selected from healthy blood donors. The serum levels of 25(OH)-D3 were measured by the ELISA method (ids- UK). Data were entered into the SPSS-16 software and were analyzed by t-test and Chi-square test. Results: The mean serum level of vitamin D in the patients was significantly lower as compared to that in the control group (P-value <0.01). The differences in the levels of 25-OH-D3 were statistically significant between the two sexes, in both groups. A normal vitamin D level was seen in all cases with proctitis, in 20% of cases in the rectosigmoiditis group and in no cases in the pan-colitis group. The difference was statistically significant (p-value <0.01). Conclusions: It can be concluded that the serum levels of vitamin D in the patients with ulcerative colitis are low and that inflammatory bowel disease can be a target for the specific vitamin D therapy.

The Prevalence of Sleep Disorder and Associated Factors in Haemodialysis Patients: An Iranian Study

Babak Normohamadi, Molouk Jaafarpour, Ali Khani

This article Has Been Retracted on 1st Sept 2013 due to conflict of authorship

The Skin Preparation Knowledge, Attitudes and Practices among the Healthcare Professionals in Compliance with the World Health Organization (WHO) Guidelines

Muhammad Qamar, Syed Wasif Gillani, Syed Azhar Syed Sulaiman

Objective: To evaluate the knowledge, attitudes and the practices of healthcare professionals towards the skin preparation before giving injections. Methods: Cross sectional study. A pre-tested, pre-designed, well-structured questionnaire which was written in English was administered to the volunteer doctors, pharmacists and the nurses at Penang General Hospital during 20th March 2011 to 20th April 2011. A total of 136 anonymously completed questionnaires were returned to the investigator. The data was analyzed by using SPSS-16 and the results were expressed as counts and percentages. Results: Most of the respondents derived their knowledge from healthcare personnel (70.5%, n = 136) and medical books (44.1%, n = 136). Most of the healthcare professionals knew that an alcohol swab would not minimize the pain either during (70%-85%) or after (55%-80%) an injection and that it would not minimize the risk of bleeding (50%-82%) after an injection. Almost all the respondents (93.7%) were of the view that not using a swab was not time saving and economical. However, more than 95% thought that skin preparations would minimize the risk of an infection; therefore, they would not administer an injection without using an alcohol swab. Conclusion: The knowledge on the use of an alcohol swab before giving intra-dermal, subcutaneous and intra-muscular injections was poor. The healthcare professionals believed that skin preparations would minimize the risk of an infection and that an injection could not be given after cleaning the site with soap and water.

Topical Diltiazem is Superior to Topical Lignocaine in the Treatment of Chronic Anal Fissure: Results of A Prospective Comparative Study

Hanumanthappa M.B, Rithin Suvarna, Guruprasad Rai D

Introduction: Fissure in ano is a troubling and painful condition that affects a great majority of the population the world over. Chronic anal fissures are associated with persistent hypertonia and spasm of the internal anal sphincter and they have conventionally been treated surgically. However, concerns have been raised about the risk of faecal incontinence after surgical sphicterotomy. In this study, we have explored topical 2% diltiazem as an effective and a safe alternative method to surgical treatment. Materials and methods: In this prospective comparative study, 200 patients with chronic anal fissure from a single centre were included. They were randomly divided into the test group and the control group, with 100 patients in each group. The test group was instructed to apply 2% topical diltiazem ointment and control group was instructed to apply topical 2% Lignocaine twice daily for 6 consecutive weeks. They were asked to apply the medicine just inside the anal canal and 1cm around the anus circumferentially. The assessment was done at the 2nd, 4th and the 6th weekends for fissure healing, pain relief, bleeding control, control of discharge/perianal itching and for the side effects of the medicines. Results: Complete healing of the fissure was observed in 72% of the patients in the test group against 23% in the control group by the end of 6 weeks (P< 0.0001). The pain relief was also good as the pain score in the test group dropped from 80 (mean) to 5 (mean) over the 6 weeks time. 80% of the test group cases experienced absent bleeding by the end of the 6th week as compared to 42% in the control group (P<0.001). 90% of the subjects in the test group reported a significant reduction in the discharge and the perianal pruritis as compared to 50 % in the control group (P<0.0001). 3 patients had a mild headache, while 10 patients experienced slight perianal pruritis. In the 1 year follow up, 4.28% subjects in the test group reported recurrence of the symptoms against 34.78% in the control group. Conclusion: We conclude that 2% topical diltiazem is quite effective in the treatment of chronic fissure in ano. Statistical analysis used: Chi square and P-value (SPSS software version 17).

Comparison of Self-Directed Learning Readiness Among Students Experiencing Hybrid and Traditional Curriculum

Vasudha Devi, Dharshinie Devan, Paw Chen Soon, Wee Pang Han

Background: Self-Directed Learning (SDL) skills are required for medical graduates for them to engage in continuous learning during their medical practice. The curriculum which is followed in an institution influences the development of readiness for SDL in a student. Hence, improving the medical student’s SDL skills has been accepted as an important goal of the higher education. Aim: To compare the Self-Directed Learning Readiness (SDLR) among medical students who experienced the traditional curriculum with clinical exposure from the 2nd year of the course and among medical students who experienced a partially problem based curriculum. Setting and Design: The Manipal University, India, has 2 medical programmes which run in the Manipal Campus, India. One of these medical programmes follows the traditional curriculum with an early exposure to the clinical from the 2nd year of the course, whereas the other one follows a partially problem based curriculum (hybrid) with clinical exposure from the 3rd year of the course. In this cross sectional study, the SDLR of the students who experienced the above curriculums was compared at the beginning of the 3rd year of the course. Materials and Methods: To obtain the SDLR of the students of the traditional (n=120) and the hybrid (n=120) curriculums, the SDLR scale which was designed by Fischer et al., was suitably modified. The student’s response was collected in a five point Likert scale in September 2010. Statistical analysis: The categorical variables were described as median and interquartile range. A total SDLR score of >129 was considered as an indication for the readiness. Appropriate non-parametric tests were used to compare the groups. A p value of <0.017 was considered as statistically significant. Results: There was a statistically significant difference (p = 0.004) in the total median SDLR score between the students of the hybrid 132 (117, 137) and the traditional 137 (128, 144) curriculums. Students from both the groups scored the lowest in self-management, whereas the traditional group scored more in the desire-for-learning (p=0.001) and the self-control (p=0.004) factors as compared to the hybrid group. Conclusions: In the development of SDLR in students, the traditional curriculum with an early clinical exposure seemed to influence them more than the hybrid curriculum which used paper based cases for PBL in the initial years. However, additional support is required for students of the both curriculums in self-management.

Determination of Sex from the Tibia in the Punjab Zone

Seema, Anupama Mahajan

Aims and Objectives: Sex determination is an important aspect of forensic science and it is 100% possible when all the skeletal bones are available. Material and Methods: In the present study, 96 tibia of known sex (62 males and 34 females) were considered. Results and Conclusion: The weight, length, midshaft circumference and the widths at the upper and the lower end of the tibia were noted. The demarking points for the identification of sex from the various measurements of the tibia were calculated. None of these measurements can identify the sex of the tibia with 100% certainty. However, weight is the best discriminant factor for the identification of the male tibia and the width at the upper end is the best discriminant factor for the identifying the female tibia.

Endovascular Management of Intracranial Giant Aneurysms: Experience on 25 Patients

Lakshmi Sudha Prasanna Karanam, Santhosh Joseph

Background & Aim: Various endovascular modalities are available for the management of intracranial aneurysms. We present our experience with these modalities in the management of the giant aneurysms. Methods: A retrospective analysis of the patients presenting with intracranial giant aneurysms, suspected clinically and confirmed on neuroimaging, in our institute between February 2003 and July 2008. Patients were treated by parent vessel occlusion, stent assisted coiling, balloon assisted coiling, stent grafts or onyx based upon clinical findings, cross compression and balloon occlusion test. Clinical and angiographic follow up done at intervals of 1, 3, 6, 12, 24 and 48 months. Results: The records of 25 patients (7 males and 18 females; aged 9 to 76 years) from the study period were available for analysis. In 21 of the 25 patients, the giant aneurysms were localized in the anterior circulation (majority in caroticopthalmic segment) while in 4, they were found in the posterior circulation. Total occlusion was seen in 19 of the 25 cases. A worsening of the mass effect was seen in 3 cases, and ICH was seen in 2. Transient neurological deficits were observed in 6 patients, while permanent deficits affected 3 patients. Death occurred in one patient in our study. During the follow-up period, an improvement in mass effect was seen in 23 patients. Recanalisation was observed in 2 patients who underwent a conservative treatment. Four patients continued to have persistent symptoms and one patient expired during the follow up. Conclusion: Various endovascular modalities appear to be an effective and safe alternative treatment for the management of intracranial giant aneurysms.

Spontaneous Pneumothorax in Squamous Cell Lung Cancer

Kaushik Saha, Debabrata Saha, Arnab Maji, Debraj Jash, Arpita Banerjee

Spontaneous Pneumothorax (SP) is usually attributed to the rupture of the sub-pleural blebs or bullae. Spontaneous pneumothorax is rarely seen in association with lung cancer. Pneumothorax can be the first sign of lung cancer. The most common possibility for SP complicating lung cancer is the tumour necrosis mechanism or, in separate cases, the rupture of the emphysematous bullae. Lung cancer should always be considered as a possible cause of SP in elderly patients or in heavy smokers. We are reporting here a case of central bronchial carcinoma with spontaneous pneumothorax, as it is a very rare complication of primary bronchogenic carcinoma.

Penetrating Injury to the Neck Which was Caused by a Heavy Knife: A Case Report

Jayanta Bain, Manoj Bhargava, Pushpendra Shukla, Atul Kumar Singh

A neck injury that extends deep into the platysma is called a penetrating injury of the neck. It is a diagnostic and a therapeutic challenge to the treating surgeon, because a number of important structures are densely packed in a small area, and the injury to any of these structures may immediately cause a life threatening situation. We are describing an interesting case, where a 40- year old woman presented with a penetrating neck injury which was caused by a heavy knife, which ran transversely from the left to the right side of the neck at zone-I. On presentation, she was found to have stable vitals and no active bleeding from the wounds; but, right ulnar nerve monoplagiea was found on examination. Bilateral exploration of the neck was done. The knife passed between the trachea and the oesophagus from the left side to reach up to the right supraclavicular fossa and it rested over the brachial plexus. The weapon was retrieved under direct vision. Surprisingly, there were no injuries to any vital structures of the neck. The patient made an uneventful recovery.

A Rare Case of a Tracheal Bronchus

Thilagavathy G., Srinivasan R., Aruna S., Bonny J., Siddhuraj C.

We are reporting here a case of a right tracheal bronchus who presented with recurrent right upper lobe pneumonia. On the initial visit, the patient presented with a right upper lobe opacity which was anterior to the right main bronchus. Fiber optic bronchoscopy revealed a right tracheal bronchus, 2.5 cm above the carina. 8 months later, the patient presented with a peripheral type of right upper lobe opacity. Though the lesions simulated tuberculosis/malignancy, cytology and bacteriology were not confirmatory and the patient was treated symptomatically. After being on regular follow up after 4 months, the patient had complete resolution of both the opacities, with residual atelectasis in the upper lobe.

Caput Tertium Gastrocnemius: A Case Report

Rajan Kumar Singla, Rimpi Gupta

Introduction: Caput tertium gastrocnemius is a rare but clinically important entity, as it may lead to the conditions of intermittent claudication, arterial stasis and aneurysm, venous stasis and impaired nerve function. In the recent years, it has gained more significance due to the advent of sports and the high stakes which are involved in this area. More cases of young athletes with popliteal artery entrapment are being seen. An early diagnosis is of great importance in order to avoid vascular complications and to aid in the early rehabilitation of the athletes. Materials and Methods: The material comprised of the left lower limb of a male cadaver of approximately 50 years of age, which was dissected during the routine undergraduate dissection by the usual method of dissection. Results: A third head of the gastrocnemius was found to arise from the popliteal surface of the femur and the lower half of the medial supracondylar ridge. It passed superficial to the popliteal vessels and joined the medial head of the gastrocnemius. The two heads (the third and the medial) seemed to form a constricting circle around the popliteal vessels, putting the same even in more danger of entrapment. Ontogeny: Such muscular variations may be due to our genetic composition, errors of the developmental timings or the persistence of some embryological conditions.

Bilateral Ovarian Fibroma With Minor Sex Cord Elements: An Unusual Neoplasm

Nalini Gupta

Ovarian fibromas constitutes 4% of all the ovarian neoplasms and ovarian fibromas with minor sex cord elements are still rare. We are reporting here a case of a 36-year old female who presented with complaints of abdominal pain and an abdominal mass of one month’s duration. USG examination revealed large bilateral ovarian masses for which a panhysterectomy with a partial omentectomy was done. The histopathological examination of both the masses showed a predominantly fibromatous tumour with sex cord elements which are arranged as tubules, and are seen to occupy < 10% of the tumour area on each side. Hence, a final diagnosis of bilateral ovarian fibroma with minor sex cord elements was made.

Hydatid Cyst of Left Atrioventricular Groove: An Unusual Presentation

Meenakshi Sundaram

Cardiac involvement in echinococcal infections is very rare. We are presenting here a case of hydatid cyst of the left atrioventricular groove in a middle aged female who presented with breathlessness and chest pain. Echocardiography showed a cyst in the posterior atrioventricular groove. The cyst was excised on a cardiopulmonary bypass. The patient made an uneventful recovery.

Isolated Right Upper Eyelid Tuberculosis: A Case Report with Review of the Literature

Ranjan Agrawal, Sandeep Agarwal

We are reporting herewith a case of 54-year old lady who presented with a painless, peanut sized swelling in the right upper eyelid which was there since the past 2 months. No other local or systemic features were associated with it. An incisional biopsy was performed under local anaesthesia. The histopathological examination revealed an epithelioid granuloma with Langhans giant cells. The PCR test of the tissue confirmed the diagnosis of tuberculosis (TB). The patient was given anti-tubercular therapy and she is responding well, with the eyelid swelling being resolved.

Congenital-Left Atrial Appendage Aneurysm in an 8-Year-Old Girl

Congenital aneurysm of the Left Atrial Appendage (LAA) is extremely rare because after the first case no was described by Diamond in 1960, only 50 cases have been reported in the literature. Congenital aneurysm of the LAA is rarely diagnosed during childhood. Generally it manifests during the second or third decades of life. We are reporting here a case of congenital left atrial appendage aneurysm in an 8 year old girl who presented with breathlessness on exertion which was present since 6 months. Pre-operatively, the diagnosis of aneurysm was made by chest radiography, echocardiography and magnetic resonance imaging. The surgical findings demonstrated a kidney shaped saccular aneurysm. The microscopic findings showed myocardial layers in variable numbers. Following an aneurysmectomy, the patient is now asymptomatic and in the sinus rhythm.

Oncocytic Lipoadenoma of the Parotid Gland: Report of a Rare Case

Clement Wilfred Devadoss , Paari Murugan, Debdatta Basu, Jagdish S.

Background: Oncocytic lipoadenoma is a very uncommon, benign, salivary gland tumor. There are only rare case reports of this distinct entity. Case: A 50-year-old-female patient presented with a slow growing swelling, in the left parotid region which was clinically interpreted as a soft tissue tumor, with a differential of neurofibroma/lipoma. Based on fine needle aspiration cytology (FNAC), a diagnosis of oncocytoma with a remote possibility of an “acinic cell carcinoma with oncocytic features” was suggested. Histopathologic examination showed it to be an encapsulated tumor with an intimate admixture of mature fat cells and oncocytes. The latter was present in glandular or microacinar pattern. The cells were positive for pancytokeratin and epithelial membrane antigen and negative for smooth muscle actin. Conclusions: Histopathologists should be aware of an entity called oncocytic lipoadenoma of the salivary gland in order to differentiate it from other oncytic and lipomatous lesions of salivary gland and diagnose it precisely.

Ophthalmomyiasis External: A Case Report

Seema Bose, Santosh Saini, Rekha Barapatre, Stephen Mathew

Ophthalmomyiasis externa results from the infestation of the conjunctiva by the larval form of dipterous flies. Only a few cases of Ophthalmomyiasis externa which were caused by the larva of Oestrus ovis had been previously reported from India. Here, we are discussing a case of Ophthalmomyiasis externa which was caused by the larvae of Oestrus ovis in a 10-year old child. A prompt diagnosis and management of the condition saved the patient from a potential serious outcome. The importance of hand hygiene and the maintenance of sanitation have also been illustrated.

A Case of Onychomycosis which was Caused by Exophiala Jeanselmei

Anuradha Sharma , Smriti Chauhan, Puneet Gupta, Ramesh Chand Guleriaimprovement

Exophiala jeanselmei is a dematiaceous fungus which is associated with cutaneous, subcutaneous and invasive diseases. Only 2 cases of nail involvement with this fungus have been reported in the literature till now. We are reporting here another case of onychomycosis which was caused by Exophiala jeanselmei.

Congential Midline Cervical Cleft: A Case Report And An Embryological Review

Congenital midline cervical cleft (CMCC ) is a rare anterior neck anomaly with controversial theories / hypothesis regarding its embryogenesis. If it is not treated at an early age, it can result in complications like webbing of the neck, dental malocclusion and restricted neck movements. We are describing here, one such case, who presented at an age of 19 years. The lesion was excised and closure was done by multiple Z- plasty, with satisfactory results. We have discussed the embryological theories / hypothesis with the review of literature.

Treacher Collins Syndrome: Case Report of a Patient with a Difficult Airway

Vibha Kukreja, Sudha Khurana, Gurbaksh Kohli, Rakesh Sadhu

Treacher Collin’s syndrome (TCS) or mandibulofacial dysostosis is a rare inherited condition which is characterized by bilateral and symmetric abnormalities of the structures within the first and second bronchial arches. The patients with TCS present a serious problem to the anaesthetists in maintaining their airway, as upper airway obstruction and a difficult tracheal intubation due to a severe facial deformity make such a task difficult.Because of retrognathia, the airway management of these patients is often challenging. A 30-year male who was diagnosed with Treacher Collins Syndrome (TCS) was posted for surgery for bilateral temporomandibular joint ankylosis. He presented with dysmorphic facial features, and a difficulty in breathing, sleeping and in lying down since birth. In this case, the most challenging task was induction of anaesthesia and securing the airway.

Low Grade Fibromyxoid Sarcoma Presented with Local Recurrence and an Extensive Foot Deformity

Low Grade Fibromyxoid Sarcoma (LGFMS) is a rare neoplasm commonly affects young adults and which typically arises in the deep soft tissues of the proximal extremities. This tumour has the potential for local recurrence or distant metastasis. We are presenting here, the case of a 70-year old male who developed a large ulceroproliferative nodular mass in the dorsum of the left foot, which led to an extensive foot deformity with local recurrence. Careful consideration of light microscopy in view of its bland histopathological findings and immunohistochemical features is important to distinguish LGFMS from a number of other benign and malignant soft tissue neoplasms, for the proper management of the patient.

Endometrial Actinomycosis in Post Menopausal Female in the Absence of an Intrauterine Contraceptive Device: A Rare Cause of Bleeding per vaginum

Swati Sharma, Manna Valiathan, Lakshmi Rao, M. V. Pai

Isolated actinomycotic infections of the endometrium in the absence of Intra Uterine Device (IUD) usage is rare and only 2 cases of ovarian actinomycosis in the absence of IUD and 1 case of endometrial actinomycosis in a virgin have been reported in the literature. This case was interesting, as our patient who was post menopausal and immuno competent, presented with bleeding per vagina and was diagnosed to have endometrial actinomycosis.

Avulsion of the Common Bile Duct from the Duodenum: A Case Report

S.N. Shirbur, B.V. Goudar, Vrushab Patil, Md. Muzamil Pasha, Chethan V.N.

Rupture of the extrahepatic bile duct due to blunt trauma abdomen is an infrequently encountered condition which will tax ingenuity of the surgeon. Our aim here is to highlight one such unique injury to common bile duct and outline appropriate method of management. The complexity of injury is increased by the degree of involvement of duodenal wall, pancreatic duct and pancreas. Injuries that include ampullary area are rare, therefore require special consideration. Case report demonstrates specific injury to common bile duct and duodenal wall without injury to pancreatic duct.

Cerebral Toxoplasmosis Mimicking Intracranial Tuberculoma

Emerging and Re-emerging Infectious Diseases, Future Challenges and Strategy

The emerging infectious diseases and their basic causes present a threat to the stability of the nations worldwide. The factors for the emergence/re-emergence of infectious diseases are complex and interrelated. The spread of antimicrobial resistance is another emerging global public health issue. New pathogens and antimicrobial-resistant forms of the older pathogens continue to emerge, some with the potential for a rapid and a global spread, with high morbidity and mortality and these are of public health importance.

Managment of Paracetamol Poisoning: The Old and the New

Natasha Jayaprakash Nambiar

Paracetamol is involved in a large proportion of accidental exposures and deliberate self-poisoning cases, although subsequent hepatic failure and death are the uncommon outcomes. The optimal management of most of the patients with a paracetamol overdose still remains unclear. The following article attempts to compile a management advice with the current clinical toxicology practice, revised guidelines and recent advances

Telescopic Denture – A Treatment Modality for Minimizing the Conventional Removable Complete Denture Problems: A Case Report

Kunwarjeet Singh, Nidhi Gupta

Objective: The goal of this article was to describe the importance of saving the natural remaining teeth and the fabrication of telescopic dentures as an alternative to the conventional removable dentures, to minimize the complete denture problems. Background: Telescopic dentures consist of an inner or primary telescopic coping which is permanently cemented to an abutment and an outer or secondary telescopic coping which is attached to the prosthesis. These copings protect the abutment from dental caries and thermal irritations and also provide retention and stabilization of the secondary coping. The secondary coping engages the primary copings to form a telescopic unit and it provides retention and stability to the prosthesis. Materials and Methods: An impression was made with a polyvinyl siloxane elastomer after the preparation of the abutments and the primary copings were fabricated on the cast which was obtained from the impression. After evaluating the fit of the primary copings on the abutments, they were cemented with glass ionomer cement. An impression of the cemented primary copings was made for the fabrication of secondary copings with retention beads, which were attached to the prosthesis. Conclusion: Telescopic overdentures have better retention and stability as compared to complete dentures, they improve the chewing efficiency and the comfort of the patient and they also decrease the alveolar bone resorption..

Pleomorphic Adenoma of the Palate: A Case Report

Amit Kumar Gothwawal, Anagha Kamath, Rajdeep S. PaPavaska r, Sujata K. Satoskar

Pleomorphic adenoma, also called benign mixed tumour, is the most common tumour of the salivary glands. About 90% of these tumours occur in the parotid gland and 10% of them occur in the minor salivary glands. The most common sites for pleomorphic adenoma of the minor salivary glands are the palate, followed by the lips and the cheeks. Other rare sites include the floor of the mouth, tongue, tonsil, pharynx, the retromolar area and the nasal cavity. Here, we are reporting a case of pleomorphic adenoma of the minor salivary glands of the palate in a 36-year old Indian male. The mass was removed by wide local excision with adequate margins under GA. There were no recurrences after a follow-up period of 8 months.

A Multidisciplinary Approach for a Mid-Palatal Swelling: A Case Report

Neelam Mittal, Isha Narang, Atul Singh

A dentigerous cyst is a developmental odontogenic cyst which originates through alterations in the reduced enamel epithelium due to unknown aetiologies. They are more commonly associated with permanent teeth. The association of this cyst with the supernumerary teeth is rare and it constitutes only 5%–6%. The possible transformation of these cysts into tumours directs the exact diagnosis and the timely management. We are reporting here, a case of a mid-palatal swelling which was caused by a dentigerous cyst, which was associated with an impacted canine.

Improving the Palliative and the Supportive Care in Cancer Patients

Sunit Kr. Jurel, Ramashanker, Raghuwar D. Singh, Durga Shanker Gupta

The quality of life (QL) in oral cancer patients has become one of the most important parameters worth considering, in the diagnosis and the post-treatment follow-up. The purpose of this article was to review the papers which were published on the studies which were done on the QL in oral cancer patients, the clinical results which were obtained, and the systematic revisions which were available in the indexed literature for the last 10 years. The term QL has appeared as a keyword in an increasing number of articles throughout the past 10 years; however, only few studies had focused on oral cancer. Most of them had assessed all the head and neck cancers, which conformed to a heterogeneous group with several different features, depending on the location of the cancer (oral cavity, oropharynx, larynx, hypopharynx, nasopharynx and the salivary glands). Most of the studies evaluate the QL in short periods of time, normally within the first year after the diagnosis. The data which are related to the QL are mostly related to the patient (age, sex, co-morbidity, etc), the tumour (location and size), and the treatment (surgical treatment, radiotherapy association, reconstruction, cervical dissection, and/or feeding tube). Nowadays, the assessment of the QL is considered as an essential component of an oral cancer patient, as well as of the survival, morbidity and the years which are free of disease. Although many aspects which are related to the QL in oral cancer patients have been published throughout the past 10 years, more systematic research is needed to be able to apply it on a daily basis.

Estimation of the Infarct Size on Occlusion of the Middle Cerebral Artery in Primates

K.S. Satheesha, M.S. Somesh, Shakunthala R Pai, Girish V Patil

Introduction: The model of single artery occlusion in subhuman primates was studied, to verify whether there is any correlation between micro-circulatory perfusion impairment and area of in¬farction after occlusion of middle cerebral artery and to find out whether there is any definite “reperfusion window’ which could be used effectively to prevent or reduce the area of infarction. Materials and Methods: For the present study 24 healthy adult monkeys of either sex were procured and the Middle cerebral artery (MCA) was occluded and reperfused for given set of time periods and the infarction size of the brain was determined. Results: The percentage of the infarction size after occluding the blood vessel increased considerably, as the time interval prolonged. After the reperfusion of the arteries for shorter inter¬vals like 30 min, 4 hours and 12 hours, there was a significant decrease in the infarct size, whereas there was no effect on the infarct size after 12 hours. Conclusion: In the regions of focal cerebral ischaemia, the ad¬verse effect of focal ischemia may be minimized if, in the acute phase, functional microcirculation is increased by some thera¬peutic intervention aimed at augmenting blood flow through the ischemic region.

Unusual Malpositioning of the Central Venous Catheter

Rajashekar R. Mudaraddi

The Checklist Manifesto: A Book Review

Chaitanya Varma, P.S. Raju