Journal of clinical and diagnostic research

Button Battery Ingestion: A Conundrum of Preventable Sequelae Management

Nikitha Periasamy, Ajay Bhandarkar, Balakrishnan Ramaswamy, Kailesh Pujary

Foreign body ingestion is frequently encountered in infants and young children. In recent years, button batteries have become extremely common among household use. As a result of this, there has been an increase in the outcomes related to this button batteries ingestion. Literature reports that there has been a 6.7 fold increase in the major or fatal outcomes associated with button battery ingestion. The complications are attributed to the electric current generated at the negative pole of the battery and the discharge of alkaline electrolytes, leading to liquefaction necrosis and also due to pressure necrosis. Here, authors’ report with two cases of button battery ingestion, of which one case had a fatal outcome and about the measures taken in the second case to avoid major or fatal consequences.

Malakoplakia of the Uterus: A Rare Cause of Postmenopausal Bleeding Mimicking Malignancy

Malakoplakia is a rare chronic granulomatous disease. It was first reported in 1902 by Michaelis and Gutmann. It may involve any part of the body, most commonly affecting the urinary tract, mainly the urinary bladder. The involvement of uterus resulting in post-menopausal bleeding is extremely rare but not unusual. So, in the differential diagnosis of post-menopausal bleeding, this condition should be kept in mind which poses as a diagnostic enigma requiring a high degree of suspicion from the clinician, the radiologist and the pathologist. Due to paucity of data owing to the rarity of the condition, there are no treatment guidelines for this condition, leading to a therapeutic dilemma. We report herein an unusual case of malakoplakia of the uterus with actinomycoses co-infection in a 60-year-old lady with postmenopausal bleeding and an abdominopelvic lump mimicking malignancy.

Elephantiasis and Maintenance of Results Following Intensive Treatment

Lymphoedema is a chronic clinical condition with no cure. However, novel therapy concepts developed in recent years aim to bring the affected limb within or close to the limits of normality. Elephantiasis is the most advanced stage of this condition, but the results of therapy can be maintained with continued treatment. The aim of the present study was to demonstrate the continual reduction in Lymphoedema, Clinical Stage III, elephantiasis, after intensive treatment with the maintenance of therapy. A 42-year-old female patient reported a history of oedema in the groin region at 12 years of age, for which no cause was defined. At 17 years of age, the patient noticed swelling of the left ankle and sought a physician, who diagnosed lymphoedema. At the time, stage III lymphoedema (elephantiasis) was confirmed, body weight was 66.0 kg and the Body Mass Index (BMI) was 27.1 kg/m². Intensive treatment was performed. Body weight was reduced to 61.3 kg and the BMI was reduced to 25.2 kg/m². Bioimpedance analysis revealed reductions in fluid and volume to 5618 gm, which was a reduction of 2517 gm (47%). After three years, the patient was submitted to another intensive treatment, during which the volume was reduced to 3520 gm (40.2%). She was discharged to continue treatment at home, but with a volumetric difference of 784 gm in comparison to the unaffected limb. Patients with elephantiasis who are submitted to intensive treatment and maintain treatment at home can continue to experience a significant reduction in oedema, with decreases in both intracellular and extracellular water to within patterns of normality.

Sublingual Foregut Cyst Lined by Respiratory Epithelium- A Rare Cause of Cystic Lesion in the Floor of the Mouth

Foregut cysts of the oral cavity are rare developmental anomalies which are lined by gastric, intestinal, squamous or respiratory epithelium or a mixture of these epithelia. A 10-year-old boy presented with a large cyst in the floor of the mouth and had difficulty in speech and chewing of food. On Magnetic Resonance Imaging (MRI) examination a diagnosis of ranula was given. Surgical excision was done and a diagnosis of foregut cyst lined by respiratory epithelium was given on histopathological examination. Till now only 21 cases of lingual foregut cyst with respiratory lining have been reported. We report the 22^nd case for its rarity and because these lesions can pose a diagnostic dilemma and should be included in the differential diagnosis of cystic lesions in the oral cavity especially in paediatric population.

Partial Anodontia-An Untold Clinical Presentation of Diamond Blackfan Anaemia: Case Report

K Shanthi, Deepak Chandrasekaran, V Ravi Pavan, Sri Vandanathirumal

Diamond blackfan anaemia (DBA) is an inherited bone marrow failure syndrome characterised by severe anaemia resulting in depletion or absence of erthyroid progenitor cells and haemopoesis. The pathophysiology of DBA is still undescribed. It is usually manifested in infancy but is not restricted to paediatric patients. Sometimes it might predispose to malignancy. In this paper, we present a single case of DBA with clear oral findings. This case report describes the medical importance of this condition and its risk in dental management (tooth extraction under local anaesthesia).

Recurrent Postprandial Hypoglycaemia in Insulin Autoimmune Syndrome

Suresh Kumar Sinha, Kalyan Gaud, Rajashekar Mummadi

Insulin autoimmune hypoglycaemia syndrome (IAS) is not a common entity. It is characterised by auto-antibodies to endogenous insulin in persons without previous exposure to exogenous insulin. IAS is relatively common cause of spontaneous hypoglycaemia in Japan (third most common cause of hypoglycaemia). First case in India was reported in 2013. Since then only four cases of IAS have been reported so far. The present case is about a middle aged Indian male, who presented with spontaneous, recurrent postprandial hypoglycaemia. He had palpitations, sweating, tremor of hands, feeling of hunger 2-5 hours after meal. He got relief by taking sweets, sugar or orange juice. Estimation of anthropological parameters revealed his BMI to be 28.5 kg/m2. Laboratory findings of serum glucose were 52 mg/dL, serum Insulin >1000 units/mL, Connecting peptide 14.56 ng/mL, Serum Insulin antibody level was >300 units/mL. He was a non-diabetic with HbA1C 5.63%: Rise of serum cortisol was appropriate for hypoglycaemic stress. A diagnosis of IAS was made. He was put on steroid which was tapered in three months. The patient was advised frequent low carbohydrate meals. His symptoms subsided in six moths and after one year all his hormonal parameters returned to normal. Spontaneous hypoglycaemia with unusually high serum Insulin, high C-Peptide and presence of insulin auto antibodies are strongly suggestive of IAS.

Right Psoas Abscess as a Consequence of Ruptured Appendix with Caecal Perforation and Presenting as Right Lumbar Swelling in a Toddler: A Rare Presentation of Appendicitis

Rafey Abdul Rahman, Umesh Kumar Gupta

Psoas Abscess (PA) is a very rare form of presentation of appendicular pathology, especially in a toddler. A three-year-old male child presented to the casualty with complaint of right lumbar swelling for 14 days. There was no other significant history. On clinical examination, there was 5×5 cm right lumbar swelling with a prominent bulge, which was non tender. USG and Contrast Enhanced Commuted Tomography (CECT) abdomen revealed PA which was drained by incision made on the bulge. There was feculent output noted from the incision and drainage site the following day. Child underwent exploratory laparotomy and was found to have ruptured partially sloughed of appendix along with perforated caecum going deep to the psoas muscle which in turn was communicating via tract to the incision and drainage site. Residual appendectomy along with caecal repair was done. Diverting proximal loop ileostomy was made and an abdominal drain was placed. Postoperatively, the child recovered well and was discharged on postoperative day 5 with a functioning ileostomy and on full oral feeds. In the follow-up distal cologram was done which revealed free flow of contrast along the entire colon up to rectum. The child has now been planned for stoma closure. Prompt diagnosis and prompt intervention was responsible for significantly reducing morbidity in the present case.

Anaesthetic Management of a Patient with Giant Pulmonary Bullae for Surgical Resection of Carcinoma Upper Alveolus: A Case Report

Patients with incidental bullous lesion of lung occasionally present for non-thoracic surgeries, these patients are at increased risk of potential complications which can arise due to bullae, during perioperative period. Anaesthetic management of these patients planned for a major non-lung volume reduction surgery is challenging as it is rare and requires careful understanding of anatomical and pathophysiological variation of disease. Safe conduct of anaesthesia can be delivered without isolation of the lung or sub-segment in which bulla is involved in these patients so that perioperative respiratory crippling conditions like pneumothorax, emphysema, atelectasis of the surrounding lung parenchyma leading to postoperative respiratory failure can be avoided. Eternal vigilance, monitoring, ventilator strategies are required to avoid possible perioperative complications and a successful outcome, few essential precautionary measures to be taken include vigilant monitoring of patient perioperatively, avoidance of nitrous oxide, low airway pressures, immediate availability of chest drains, periodic auscultation of chest, arterial blood gas analysis. Here, the present authors report a successful perioperative anaesthetic management of a patient with giant bulla in left upper lobe and right upper lobe developed as post tubercular sequelae that underwent inferior partial maxillectomy with neck dissection and reconstruction for carcinoma upper alveolus without isolation of lung.

Oral Leukoplakia Management using Diode LASER: A Case Report

Shweta Chaudhri, Aditya Singh, Jay Dutt Tiwari

Management of oral leukoplakia should begin with elimination of predisposing habits. Several treatment modalities have been proposed for the treatment of Leukoplakia. Excision of precancerous oral lesions using LASER offers comparative advantages over traditional scalpel excision. These advantages include homeostasis, precision in removal, good patient acceptance, low morbidity and reduced postoperative complications. In the present case, patient reported minimal intraoperative and postoperative discomfort and the wound healing was also satisfactory.

Reconstruction of Extraoral Fistula of Dental Origin

Metin Berk Kasapoglu, Gülsah Guven, Sabri Cemil Isler, Çetin Kasapoglu

Odontogenic extraoral fistulas often lead to intense levels of patient discomfort and incidence of complications, which are relieved by treatment. However, the cosmetic outcome following treatment may not meet the expectations of the patient. A 51-year-old male presented with a chronically draining lesion on his left cheek. Clinical examination revealed necrosis in the mandibular left first molar and a panoramic radiograph demonstrated periapical abscess surrounding the root apex. A diagnosis of extraoral fistula of odontogenic origin was made, and the affected tooth was extracted. The extraoral fistula disappeared but the defect on the cheek exhibited no improvement over the 2 month follow-up period. Surgical revision of the defect was therefore necessary. A Limberg flap was designed and then transposed to the defect region, followed by primary closure of the donor region. The 6-month follow-up visit revealed satisfactory results for both the patient and the surgeon. This manuscript is the first case report focusing on residual defect elimination of an extraoral fistula with the use of a transpositional flap in the cheek region.

A Segmental Medial Malleolus Fracture: A Rare Entity

Anurag Varshney, Sumedh Manohar Sandanshiv, Selvamari Mariappan

Though medial malleolus fracture is very common ankle injury, here the present authors are presenting a very rare segmental medial malleolus fracture in a young person with indefinable mechanism of injury. The present authors aimed to provide a treatment so to achieve perfect anatomical reduction of the ankle mortise and avoid any alteration in mechanism of ankle joint. Open reduction internal fixation and stabilisation with conventional tension band wiring were performed. After six months, patient achieved full range of motion with no pain.

Rare Case of Symptomatic Ovarian Leiomyoma in Perimenopausal Woman

Vaibhav Kanti, Vandana Verma, Savita Agarwal

Leiomyoma is a very rare benign tumour to be found in ovary. Here, we report a case of 40-year-old perimenopausal women with large left ovarian mass. The Computerised Tomography (CT) showed left ovarian solid mass without ascites, right ovary was normal. Her CA125 level was 46 units/mL. Total abdominal hysterectomy with bilateral salpingo-oophrectomy was done. Histopathological findings were suggestive of ovarian leiomyoma. Since, it is very rare to be found in ovary so immunohistochemistry was done to confirm the diagnosis. Symptomatic ovarian leiomyoma is very rare but it should always be considered in the differential diagnosis of ovarian mass.

Teaching Points: Appropriate Evaluation of Ascitic Fluid in an Acutely Ill Cirrhotic Patient

Laila Khan, William G Simpson

Spontaneous Bacterial Peritonitis (SBP) is a serious and dangerous complication of cirrhosis with portal hypertension. Prompt diagnosis mandates paracentesis with appropriate handling and evaluation of ascitic fluid obtained. A 37-year-old female with cirrhosis and portal hypertension, with a history of SBP, presented with abdominal pain and encephalopathy. With medical management the encephalopathy cleared and the patient was able to return home. The presented clinical scenario provides valuable teaching insight into the need to appropriately evaluate such a patient with the mandate to diagnose spontaneous peritonitis promptly. Timely evaluation and appropriate management offers clinicians an opportunity to reduce morbidity and mortality in patients with advanced liver disease.

A Novel Laboratory Technique of Fabricating a Definitive Hollow Obturator using Brown Sugar

Sivaranjani Gali, Aiswarya Premanand, Hima Bindu Lanka

Obturators are prostheses that help to seal congenital or acquired tissue openings of hard, soft palate and adjacent structures and restore patient’s lost function, comfort and aesthetics. In the process of its fabrication, the extension of the obturator often depends on the patient’s presentation of the tissue defect. In large maxillofacial defects, the retention of the obturator is often compromised due to increased inter-ridge distance and the weight of the prosthesis. In such cases, light weight hollow obturators can enhance the retention, stability of the prosthesis and further improve patient comfort. Brown sugar is soluble in water and can be shaped with ease and removed from the prosthesis, without leaving any residue. We propose an investment technique using brown sugar as a three dimensional spacer for fabricating hollow obturator. Solubility of brown sugar over the commonly used hollow spacer materials such as salt and granulated sugar was compared and further verified for any residues in the hollow obturator. Uniform thickness of the obturator wall has been accomplished through use of heat polymerized pellets on the tissue surface of the obturator mould.

Malaria Vaccine Development: Challenges and Prospects

Kaushik Bharati, Sunanda Das

Effect of Lycopene on Antioxidant Status and Serum Corticosterone in Wistar Rats Subjected to Chronic Mild Stress

Venkata Naveen Kumar Paruchuri, P Elango, S Asmathulla, S Kavimani

Introduction: Stress is one of the major causative factors in developing depression. Depression is described as a stress-related disorder which often gets precipitated with chronic stress. Lycopene unlike other carotenoids has the highest antioxidant property and is readily soluble in lipids and crosses the blood-brain barrier, is widely found in fruits and vegetables. Epidemiological data shows that lycopene can prevent and treat various diseases like cardiovascular and neurological disorders. Chronic Mild Stress Method (CMS) is the most valid animal model in inducing depression in rodents. Imbalance in the activities of both oxidant and antioxidants are the important etiological factors in depression. This therapeutic effect can be potential too for various disorders. Aim: To investigate the possible beneficial effects of lycopene on the antioxidant enzyme activity, serum corticosterone levels and adrenal gland weights in Wistar albino rats subjected to chronic mild stress. Materials and Methods: The study group consisted of 42-male Wistar rats divided into 7 groups with each group consisting of 6 animals. Control group, CMS group, Vehicle group and Imipramine (10 mg/kg) as a standard drug and lycopene with varying doses of (5, 10, 20 mg/kg) as the test drug. Blood samples were used in estimating serum corticosterone and brain tissues were used in estimating brain antioxidant enzyme activity. Differences in the groups were analysed statistically by one way-ANOVA, followed by post-hoc test was used to find out significant differences between the control and CMS group. Results: The data analysis showed that CMS could show a significant increase in serum corticosterone levels in the CMS group (only stress) in comparison with the control group (p<0.05). Significant decrease in the levels of SOD, CAT and GSH levels and an increase in the MDA levels were observed in CMS and vehicle-treated group rats. Lycopene supplementary doses of 10 mg/kg and 20 mg/kg administration for 6-weeks significantly improved antioxidant enzyme activity. Conclusion: The study results, support that chronic mild stress induces oxidative stress in the rodents. There was a decrease in SOD activity and an increase in the serum corticosterone levels and adrenal gland weight in CMS and vehicle groups in comparison to the control groups. Lycopene supplementation reverses this state and shows antidepressant-like activity.

Acceptance of Human Immunodeficiency Virus Testing among Caregivers of Children using Provider-Initiated Testing and Counselling Strategy in Ido-ekiti, Nigeria: A Cross-sectional Study

Introduction: Missed opportunities exist for early detection of HIV infection in children visiting healthcare institutions. Provider Initiated Testing and Counselling (PITC) strategy is a means for reducing missed opportunities for children who are HIV exposed or infected. It enhances the access of such children to HIV preventive measures, care interventions and treatment. There is a gap in knowledge concerning the acceptability of the PITC strategy in detection of HIV infected or exposed Nigerian children, most especially Children from Ekiti state. Aim: To determine the acceptability of PITC Strategy for HIV testing among caregivers of children seen at the Paediatric Emergency Unit of FMC, Ido-Ekiti, Ekiti State and the factors that influenced acceptability. Materials and Methods: This was a prospective, hospital-based cross-sectional study on acceptability of HIV testing using PITC model. Consecutive caregivers of patients attending the PEU for the first time aged 6 weeks-15 years were offered HIV testing using WHO guideline on PITC. Pre-test and post-test information was provided in individual sessions. Those whose HIV status was already known were excluded. Data were analysed using Statistical Package for Social Sciences (SPSS), version 15.0. Results: An amount of 530 out of 543 counselled for HIV testing gave consent for the test. The age range of the caregivers was 19-56 years with a mean of 30.2 (±6.8) years. The predominant group of caregivers in attendance were mothers only accounting for 504 (92.8%) of the total 530 caregivers studied. Acceptability rate was inversely associated with the level of education and social class of the caregivers. An amount of 348 (99.4%) of the 350 caregivers whose wards required admission accepted testing, while 182 (94.3%) of 193 caregivers whose wards did not require admission accepted testing. This difference was statistically significant (p=0.001). Conclusion: Acceptability rate for HIV testing, using PITC Strategy was high in all the age-groups of the caregivers; acceptability rate was however inversely related to the level of education and social class.

Glycaemic Control and Inflammatory Mediators in Diabetic Patients with Coronary Artery Disease

Yogita Suresh Phapale, Zunjarrao G Badade, Shibban K Kaul, Sandeep Rai

Introduction: Glycaemic control in diabetic patients is directly related to the severity of Coronary Artery Disease (CAD) and increased morbidity and mortality rates. Inflammation plays an important role in the pathogenesis of disease and inflammatory markers such as High sensitive C-Reactive Protein (hsCRP), and inflammatory cytokines such as Interleukin-6 (IL-6), and Tumour Necrosis Factor-alpha (TNF-α) have been found to be implicated in the initiation and progression of CAD. Literature suggests that inflammation is a key feature for atherogenesis in Type 2 Diabetes Mellitus (T2DM). Aim: To compare the severity of CAD and assess the level of glycaemic control and inflammatory mediators in CAD patients with and without T2DM. Materials and Methods: The present prospective study was conducted on 80 angiographically diagnosed CAD patients (aged >30 years) with (40) and without (40) T2DM. The metabolic risk factors including levels of blood sugar fasting and post-prandial were assessed by Glucose Oxidase Peroxidase (GOD-POD) method, and glycated haemoglobin (HbA1c) level by ‘‘Nycocard’’ reader. Serum Total Cholesterol (TC) was estimated by CHOD-POD method, Triglyceride (TG) by GPO-PAP method, and High density lipoprotein-cholesterol (HDL-C) by Immuno-inhibition method. Low-density lipoprotein cholesterol (LDL-C) and Very low-density lipoprotein (VLDL-C) was calculated by Friedewald formula. Serum insulin, hsCRP, IL-6, TNF-α levels was assessed by sandwich Enzyme linked Immunosorbent Assay (ELISA), and Homeostasis Model was used for assessment of insulin Resistance (HOMA-IR). Chi-square test, Independent t-test and ANOVA were used for statistical analysis, and p-value <0.05 considered as significant. Results: The level of hsCRP, IL-6, TNF-α, and HbA1c was significantly increased due to cytokines released by monocytes/macrophages mediated β-cell damaging process. Diabetic patients with poor glycaemic control, i.e., HbA1c >8.5%, had higher incidence of triple/multivessel disease suggesting involvement of higher number of coronary vessels with higher severity of the stenosis. Among lipid profile, significantly raised TG and LDL-C levels (p<0.005) and significantly decreased HDL-C in CAD patients with T2DM and its severity (p<0.005) was observed. Significantly elevated inflammatory markers, hsCRP, IL-6 and TNF-α were found to be associated with severity of CAD. Conclusion: Combinatorial analysis of glycaemic control (HbA1c) and serum cytokines (IL-6, TNF-α, and hsCRP) with clinical risk factors (Triglyceride and LDL-C) may contribute to the assessment of the severity of CAD, and thereby help in the risk stratification of T2DM and CAD.

Comparison of Pulmonary Function in Children with Cerebral Palsy and Normally Developed Children

Sandeep Kumar Gupt, Diganta Borah, BD Athani

Introduction: Cerebral Palsy is one of the most common neurological disorders in children. It is characterised by varying degrees of disability affecting multiple domains. Respiratory complications, especially in severely disabled cerebral palsy patients are a major cause of morbidity and mortality. However, respiratory deficiencies in children with cerebral palsy is often overlooked and rarely assessed in the clinical setting. Aim: To assess the pulmonary function in children with cerebral palsy and compare the same with normally developed children. Materials and Methods: Thirty seven patients diagnosed with spastic cerebral palsy in the age range of 5-18 years and 37 age matched normally developed controls were enrolled. Assessment of pulmonary function in terms of Forced Vital Capacity (FVC), Forced Expiratory Volume in 1^st second, FEV₁/FVC, Peak Expiratory Flow (PEF), Forced expiratory flow over 25-75% of FVC (FEF25-75), Inspiratory Reserve Volume (IRV), Expiratory Reserve Volume (ERV), Tidal Volume (TV) and Vital Capacity (VC) was done for each subject. Statistical analysis was done using SPSS version 21.0 and a p-value of <0.05 was considered as statistically significant. Results: Most of the children with cerebral palsy were found to have lower FVC, FEV₁, PEF25-75, IRV, ERV, TV and VC in comparison to normally developed children indicative of predominantly restrictive pulmonary pathology. Conclusion: Routine pulmonary function testing in cerebral palsy children may reveal compromised pulmonary function. This will enable early therapeutic intervention for management of respiratory dysfunction in these children.

Shear Bond Strength of Metal Brackets to Zirconia Following Different Surface Treatments using a Universal Adhesive

Introduction: As there is increase in demand of orthodontic treatment by adult patients, bonding of orthodontic brackets to dental restoration surfaces is now a common necessity because most adult patients have composite resin, amalgam, gold, acrylic resin or ceramic restorations. Orthodontic bracket bonding to teeth restored with zirconia crowns is a challenge in orthodontics. Aim: This study aimed to assess the Shear Bond Strength (SBS) of metal brackets bonded to zirconia with universal adhesive following different surface treatments. Materials and Methods: In this in-vitro study, 30 zirconia blocks (1×1×1 cm) were divided into three groups of 10. One surface of each block was subjected to one of the following three surface treatments: no surface treatment (control group), sandblasting with 50 µM aluminium oxide particles and acid etching with 37% orthophosphoric acid. Metal orthodontic brackets (Dentaurum) were bonded to zirconia blocks using Scotchbond Universal Adhesive (3M) and Transbond XT composite. The SBS was measured at a crosshead speed of 2 mm/minute using a universal testing machine. The fractured surfaces were inspected under a stereomicroscope, and the Adhesive remnant index (ARI) score and the mode of failure were determined. Data were analysed using SPSS 16 via ANOVA and the Kruskal-Wallis test (p<0.05). Results: The SBS values were 12.85±7.16, 19.25±9.07 and 9.89±9.28 MPa in the control, sandblasting and acid etching groups, respectively. The mode of failure was mixed in all groups. No significant difference was noted among the three groups in SBS (p=0.06) or the ARI scores (p=0.19). Conclusion: This study showed that sandblasting or acid etching of zirconia blocks with orthophosphoric acid had no significant effect on SBS of zirconia to metal brackets.

End of Life Holistic Care for Cancer Patients: A Qualitative Study

Mahnaz Ghaljeh, Nasrin Rezaee, Zahra Imanigoghari, Foozieh Rafati

Introduction: Cancer is one of the most important causes of death in the world. Many cancer patients are hospitalised at the end of their life, requiring end-of-life care. Aim: To elucidate the Iranian oncology nurses’ experience of caring for dying cancer patients. Materials and Methods: This qualitative study was conducted with a conventional content analysis method. Data was collected by semi-structured interviews, which were conducted with16 purposefully selected nurses who were providing end of life care for cancer patients in the oncology wards. Qualitative thematic analysis was used to analyse the data. Results: Three themes emerged from the text including: patient-centered care, family-centered care, and personal and professional characteristics of the nurses. These three themes defined a more general class or category entitled; “holistic care”. Conclusion: The results of the study revealed that end-of-life patients require holistic care. Therapeutic relationships underlie professional holistic care and are essential for the end of life care. Proper education and professionally led supervision should be included in the curriculum of nursing education in Iran.

Psychometric Properties of Persian Version of the 8-item Morisky Medication Adherence Scale in Type 2 Diabetes Patients

Mehran Nakhaeizadeh, Ali Khalooei
Introduction: The 8-items Morisky Medication Adherence Scale (MMAS-8) is a brief questionnaire that is applied to assess medication-taking behaviours. Aim: To evaluate the validity and reliability of the Persian version of MMAS-8 among Type 2 Diabetes Mellitus (T2DM) patients in Iran. Materials and Methods: A cross-sectional study was conducted among 589 T2DM patients in Kerman city (southeast Iran) from January to March 2017. Data were collected using MMAS-8 and diabetes self-management questionnaires. To check test re-test reliability and to determine the internal consistency Intra-class Correlation Coefficient (ICC) and Cronbach’s alpha method were employed. Also, convergent validity was assessed by correlation analysis method. Results: Cronbach’s alpha and ICC of MMAS-8 were 0.75 and 0.88, respectively. The correlation coefficient between MMAS-8 and medication adherence subscale of diabetes self-management questionnaire was 0.85 (p<0.001). Exploratory Factor Analysis (EFA) showed two factors for MMAS-8. The first factor included items 1, 2, 3, 4, 6, and 8. Moreover, items 5 and 7 fell in the second factor. Confirmatory Factor Analysis (CFA) indices for modified MMAS-8 without Items 5 and 7 model (X2=9.3, DF=6, P=0.15, CFI=0.99, RMSEA=0.04, TLI=0.98, and NFI=0.98) were acceptable. Conclusion: In this study, the Persian version of MMAS-8 was investigated to find out whether it is a reliable and valid scale for assessing medication-taking behaviours in T2DM patients. The results showed that it can be applied for Iranian diabetic patients by health care providers and researchers.

Association of Androgen Receptor (AR) CAG Repeats and Cytochrome P450 3A5*3 (CYP3A5*3) Gene Polymorphisms in South Indian Men with Prostate Cancer
Introduction: Prostate Cancer (PCA) is the second most common cancer diagnosed in men worldwide. Prostate Specific Antigen (PSA) is the readily used biomarker for PCA screening, but lack of specificity limits its usefulness. Hence, role of Androgen receptor (AR) CAG repeat polymorphism and Cytochrome P450 3A5*3 gene polymorphism involved in the metabolism of testosterone, and growth and differentiation of prostate gland were evaluated to assess their association with pathogenesis of prostate lesions. Aim: To determine CAG repeats in AR gene and CYP3A5*3 gene polymorphism in South Indian men with PCA and Benign Prostate Hyperplasia (BPH). Materials and Methods: Genomic DNA was isolated from 312 (100 men with PCA, 109 BPH patients and 103 controls). Formalin fixed paraffin embedded tissue/peripheral blood samples using salting out method were used. Polymerase Chain Reaction (PCR) procedure was carried out using specific primers for AR and CYP3A5 genes. Bands were visualised by electrophoresis on 2% ethidium bromide (EtBr) stained agarose gel. Odds ratios were calculated using MedCalcR version 18.2.1 and Chi-square analysis was carried out to determine the association among groups. Results: AR gene with <22 CAG repeats and ‘GG’ genotype of CYP3A5*3 gene polymorphism were identified in 61 (61%), PCA patients, 11 (10%) BPH and 13 (13%) control individuals. A statistically significant association was observed between AR short repeats and CYP3A5*3 ‘GG’ genotype with PCA (p-value<0.05). Conclusion: The results suggest that the best age for PCA screening is 48 years or above for early detection and prevention of this malignancy. A <22 CAG repeats in AR gene and ‘GG’ genotype of CYP3A5*3 (rs#776746) gene can be together considered as specific molecular marker for identifying men at a risk of developing PCA.

Comparison of QF-PCR and FISH for Aneuploidy Detection in Prenatal Diagnosis
Introduction: Among all chromosomes (46) in the human genome, particular significance has been given to chromosomes 13, 18, 21, X and Y. This is primarily because of aneuploidy in these chromosomes that result in viable pregnancies with congenital defects. As a result, standardised methods like Rapid Aneuploidy Test (RAT) for detection is the need of the hour in addition to Non-Invasive Prenatal Testing (NIPT) and Chromosomal Microarray (CMA). Aim: To compare and analyse the diagnostic utility of Fluorescent In-Situ Hybridization (FISH) and Quantitative fluorescent Polymerase Chain Reaction (QF-PCR) in aneuploidy of detection. Materials and Methods: In the present observational study, 120 pregnant women suspected of having fetal aneuploidies were subjected to amniocentesis and Chorionic Villus Samplling (CVS). Following DNA extraction, FISH and QF-PCR were carried out using pre-designed chromosomal markers and specific FISH probes for trisomy of 13, 18 and 21. Results: Of 120, 5 prenatal samples showed Trisomy (T) 13, 18 and 21 chromosomes, amounting to a frequency of 4.2% (5/120). These results were concordant by both tests i.e FISH and QF-PCR trisomy 18 and 21 detected. Four amniotic fluid samples, two each respectively (4/108; 3.7%), and one Chorionic Villus Sampling (CVS) (1/12; 8.3%) were tested positive for trisomy of chromosome 13. Conclusion: From the present study, it can be concluded that QF-PCR is a better technique for detection of aneuploidies. However, both these techniques, together called RAT of Invasive Prenatal Screening (IPS) should be performed for errorless results before termination of pregnancy (TOP).

Accuracy of Sonographic Modules in the Estimation of Birth Weight: An Analytical Study of Antenatal Women in Enugu, Nigeria
Introduction: Antenatal sonographic estimation of foetal weight is a common practice. The use of these estimates to predict actual birth weight is crucial for appropriate management of certain pregnancy conditions, to improve fetomaternal outcome. Aim: To evaluate the accuracy of foetal weights derived from six selected sonographic modules, in estimating the actual birth weight of neonates in Enugu, Nigeria. Materials and Methods: This was a cross-sectional, analytical study of 245 consenting consecutive antenatal women with term singleton pregnancies at the UNTH, Enugu, Nigeria, from October 2013 to May 2014. For the Estimated Foetal Weights (EFW), foetal parameters obtained after obstetric ultrasound scan of each participant were keyed into the sonographic modules. Actual Birth Weight (ABW) and Scan Delivery Interval (SDI) were obtained after delivery. Accuracy of the sonographic modules in estimating the ABWs was determined using percentage (%) error, the proportion of EFW within 10% of ABW, sensitivity/specificity tests, and ROC curve analysis. Results: The Hadlock Biparietal Diameter (BPD)/Abdominal Circumference (AC)/Femur Length (FL) and Hadlock BPD/AC modules had the least systematic error (-0.5% and -0.7% respectively) compared to other modules, and higher proportions of accurate estimated foetal weight within 10% of actual birth weights (78% versus 78.4%). For new-borns in the normal weight category, Hadlock BPD/AC module best predicted the ABW (ROC curve area=0.737, p=0.006). Conclusion: The Hadlock BPD/AC formula consistently showed a high accuracy for estimation of foetal weight. It is comparable with Hadlock BPD/AC/FL module but, has an advantage of requiring fewer foetal parameters.

Dental Students’ Perception of Dentine Hypersensitivity and Awareness about its Management

Abdul Majeed, Emad Alshwaimi, Muhammad Ashraf Nazir, Khalid Almas
Introduction: Dentine hypersensitivity is a common painful oral condition that can interfere with drinking, eating, tooth brushing and even breathing. Successful management depends on the identification and elimination of aetiological factors, careful clinical examination and differential diagnosis. Aim: The purpose of the study was to report dental students’ understanding of dentine hypersensitivity and knowledge of its aetiology and management. Materials and Methods: A total of 218 questionnaires were distributed among dental students who routinely provided treatment to patients at College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. The questionnaire consisted of pre-coded and open-ended questions related to the knowledge of students about dentine hypersensitivity. Descriptive statistics were used to summarise data. Pearson’s chi-square test (Fisher-Exact test as appropriate) was performed to assess differences in male and female students’ response at significance level of p<0.05. Results: The response rate was 75.7% as 165 of 218 students returned the questionnaires. According to participants (66%; n=109), one in four of their patients suffered from dentine hypersensitivity complaint. Nearly 57% (n=92) reported that sensitivity was a severe problem in 25% of their patients with discomfort lasting up to 5 weeks. Majority agreed that patients asked questions about dentine hypersensitivity. About 66.6% (n=110) did not know regarding the steps to diagnose dentine hypersensitivity. Treatment options included at-home (18%; n=30) and in-office desensitising agents (8.5%; n=14), education on appropriate tooth brushing techniques and restorative treatment (16.4%; n=27). Almost 47.3% (n=78) believed that patients complied with professional advice on dentine hypersensitivity. About 55.8% (n=92) highlighted the need to provide patients with an educational leaflet. Conclusion: Students lacked the knowledge and confidence to manage dentine hypersensitivity in clinics. A comprehensive informational handout should be developed to guide diagnosis, prevention and treatment for both students and patients.

Oxidative Stress, DNA Damage and Serum Vitamin D Levels in Prediabetes

Ajay Chauhan, Amrinder Singh, Parul Goyal, Jasmeet Kaur, Priyamvadha Ramesh
Introduction: Prediabetes or intermediate hyperglycaemia is a high risk condition with blood glucose levels higher than the normal glycaemic values but lower than the Diabetes Mellitus (DM) diagnostic value. Individuals in prediabetic state have increased likelihood of development of Cardiovascular Diseases (CVD), endothelial dysfunction and obesity. Increased oxidative stress leads to pathogenesis of DM. Early assessment of DNA damage and vitamin D helps in timely management of the condition. Aim: To assess the association of oxidative stress and serum vitamin D levels in prediabetic individuals. Materials and Methods: This cross-sectional study was conducted in the Departments of Medicine and Biochemistry, PGIMER and Dr. Ram Manohar Lohia Hospital, New Delhi, India. A total of 60 prediabetic cases and 30 age and sex matched healthy controls were included in the study. Serum and urinary levels of 8-hydroxy-2' -deoxyguanosine (8-OhdG) (a marker of oxidative stress) and serum levels of vitamin D were compared between prediabetic subjects and healthy controls. An 8-OHdG was measured by sandwich Enzyme-linked Immunosorbent Assay (ELISA) and serum vitamin D levels were measured by enhanced chemiluminescence. Continuous variable was assessed using t-test and nominal variables were compared using chi-square test. The p-value <0.05 was considered significant. Results: Serum levels of 8-OHdG was significantly higher in prediabetic subjects than controls (826.4±583 pg/mL vs. 584.567±375.205 pg/mL, p-value=0.042). Similarly, urinary levels of 8-OHdG were significantly higher in prediabetic subjects than controls (571.975±421.7 pg/mL vs. 374.9±291.877 pg/mL, p-value=0.024). Serum levels of vitamin D were significantly lower in prediabetic subjects than controls (18.3±14.9 ng/mL vs. 26.7±15.75 ng/mL, p-value=0.016). Conclusion: Oxidative stress, as confirmed by the biomarker, 8-OHdG, was significantly increased while serum levels of vitamin D were significantly lowered in prediabetes. Therefore, the study recommends the use of vitamin D supplementation as preventive intervention for management of dysglycaemia.

Changes in Posterior Segment Optical Coherence Tomography after Intravitreal Triamcinolone Acetonide Injection

Shazia Arrin, Simi Zaka Ur Rab
Introduction: Triamcinolone acetonide is a potent synthetic corticosteroid. It is a long acting depot preparation of triamcinolone having solely glucocorticoid activity. As a part of glucocorticoid activity, it also possesses a profound anti-inflammatory property that forms the basis of its therapeutic uses in various inflammatory and oedematous diseases of posterior segment of eyes. Optical Coherence Tomography (OCT) is a very useful tool to monitor the therapeutic response of various posterior segment pathologies after Intravitreal Triamcinolone Acetonide (IVTA) injection. Aim: To study the effect of IVTA injection on central foveal thickness in various diseases of posterior segment and to see the impact of OCT changes on visual acuity. Materials and Methods: This prospective interventional study was conducted on 30 patients (30 eyes) out of which 17 were males and 13 were females, with age ranging from 15 to 75 years. Control group consisted of 30 patients (untreated healthy other eye of the patients enrolled in the study). The study group comprised of cases of posterior uveitis (n=12), retinal vascular occlusive diseases (n=10), Eales’disease (n=6), pseudophakic cystoid macular oedema (n=1) and idiopathic cystoid macular oedema (n=1). All patients in the study group received single intravitreal injection of 4 mg triamcinolone acetonide. A thorough ophthalmic examination (including LogMAR visual acuity, applanation tonometry, slit lamp biomicroscopy and fundus examination) was also done at baseline and two weekly follow-up after IVTA injection up to 12 weeks follow-up. Posterior segment OCT and Fundus Flourescein Angiography (FFA) were done at baseline and in the follow-up at 6 weeks and at 12 weeks to study the response to treatment. Macular thickness was documented in a modified Early Treatment of Diabetic Retinopathy Study (ETDRS) macular map. The retinal thickness in each of quadrants (of parafoveal and perifoveal subfields) and Central Foveal Thickness (CFT) were measured at baseline and at 6 and 12 weeks follow-up. Continuous variables were expressed as mean, Standard Deviation (SD) and range. Paired t-test was used to assess the statistical significance of differences in various variables at baseline and in the follow-up within the group. Pearson’s correlation coefficient was used to find out correlation between CFT and LogMAR visual acuity and between change in CFT and change in LogMAR visual acuity on follow-ups in study group. Results: The mean LogMAR visual acuity was 0.67±0.55 at baseline. After IVTA injection it improved to 0.37±0.33 at 6 weeks (p<0.001) and 0.30±0.29 at 12 weeks (p<0.001) compared with the baseline. The mean baseline CFT in study group was 350.73±149.14 µM. After IVTA it decreased to 228.47±67.85 µM (p<0.001) and 250.27±82.09 µM (p<0.001) at 6 weeks and 12 weeks follow-up respectively. The mean baseline Intraocular Pressure (IOP) in study group was 14.27±3.53 mmHg. After 4 mg of IVTA injection mean IOP was 16.54±4.29, 18.54±5.50, 19.00±5.98, 18.82±5.00 and 22.50±0.71 mmHg at 2, 4, 6, 8 and 12 weeks follow-up respectively. IOP elevation of =6 mmHg from baseline was seen in 17 out of 30 eyes. The majority of patients belonged to younger age group. In 15 out of 17 eyes, IOP was controlled with topical anti-glaucoma medications while 2 eyes required filtering glaucoma surgery. Conclusion: There was significant decrease in macular thickness after intravitreal triamcinolone acetonide injection in all cases of inflammatory diseases of posterior segment like posterior uveitis and Eales’disease but recurrence in macular oedema was seen in pseudophakic eyes at 12 weeks follow-up. Significant improvement of Visual Acuity (VA) was seen and change in macular thickness was associated with change in visual acuity in all cases after IVTA.

Comparative Evaluation of Formocresol, Propolis and Growth Factor as Pulpotomy Medicaments in Deciduous Teeth- An Invivo Study
Introduction: Formocresol (FC) has evolved as the preferred medicament for routine pulpotomy procedures in pedodontics. With the introduction of newer materials, the emphasis has shifted towards regeneration. In this scenario, novel materials such as Platelet derived growth factor (PDGF) and Propolis (PS) have been considered. Aim: To compare and evaluate FC, PS and PDGF as pulpotomy agents clinically, radiographically and histologically in primary teeth. Materials and Methods: Ninety human primary teeth from children aged between 5-10 years were divided into three equal groups in whom pulpotomy procedure was performed and they were recalled after three and six months interval for clinical, radiographical and histological evaluation. Observations were subjected to statistical analysis using pearson chi-square test. Results: The results obtained indicated greater clinical and radiographical success for PDGF group (96.3%, 88.89%) followed by PS group (96.3%, 88.4%) and FC group (76%, 72%). Histological examination showed thick and continuous dentin bridge formation with minimal inflammation in both PS and PDGF group. Conclusion: PDGF and PS showed greater efficacy than FC clinically, radiographically and histologically with PDGF relatively having a lead in success rate. Thus, justifying their use as a novel and promising pulpotomy medicaments with regenerative property.

Evaluation of Knowledge, Attitude and Practice Regarding Stress Management among Undergraduate Medical Students at Tertiary Care Teaching Hospital

Sundeep Mahani, Pavan Panchal
Introduction: Medical schooling demands substantial level of dedication, patience, commitment and perverseness from undergraduate students. Hence, medical undergraduates face high level of stress and which has negative effects on their learning aptitudes and perceptive thinking. Aim: This cross-sectional questionnaire-based study was conducted to evaluate the knowledge, attitude and practice regarding stress management among undergraduate medical students at GMERS Medical College and Hospital, Himmatnagar, Gujarat, India. Materials and Methods: A total of 260 undergraduate students of first year, second year and third first year of MBBS were briefed on the aims and objectives of the study and written informed consents were obtained from those who were willing to participate in the study. The questionnaire of 12 questions was to be filled within 30 minutes. Out of 12 questions, 4 questions were of knowledge, 3 of attitude and 5 of practice regarding stress management among medical undergraduates. The questionnaire were collected and evaluated for their completeness. The data were recorded in Microsoft Excel Worksheet and analysed. Results: Out of 260 total undergraduates, 26.9%, 46.1% and 26.9% of students were of first, second and third year MBBS, respectively. The college was new (recently open), hence, there was zero student batch in fourth year of MBBS, hence, there was not any student from fourth year to participate in this study. There were 49.2% male and 50.7% female students. 30.7% could give a relevant definition of stress. The most common condition related to stress is depression (57.6%), followed by anxiety (36.3%). Only 35.7% of students could answer the correct clinical features confronted by a person under stress. Most common stressors were vast syllabus and tough topics of MBBS curriculum (first-year), followed by procrastination (second-year) and less study time (third-year). 11.9% of students strongly agreed and 45.7% of students fairly agreed that they have faced difficulties in adapting to the new environment and away from home, these observations were particularly founded in first-year students. Socio-behavioural problem was the most common non-academic cause of stress faced by 41.1% of students. 64.6% students of all years (except fourth year) of MBBS had confronted stress because of study performance anxiety among colleagues. Most commonly used stress coping strategy by the students was listening to music especially in female students, followed by watching internet videos particularly in male students. Male students preferred to sleep for 6-8 hours for maintaining good mental health; however, meditation and prayer were commonly practiced method among female students. A total of 12.3% students thought that a balanced and healthy diet can make mind healthier, 68.1% of students indulged themselves in various hobbies when felt stressed out and listening to music and singing (32.7%) and playing outdoor games (23.1%) were the most common hobbies. Only 19.7% of students worked harder and faster when under stress, 13.8% of students behaved irritably and took out their stress on surrounding people and 24 (9.2%) third-year male students became addicted to smoking and alcohol. Conclusion: Among MBBS students of GMERS medical college, Himmatnagar, there are different stressors for each year and which cause undue academic stress. Pressure of study among medical undergraduates leads to their negative physical and mental health. Effective stress coping system for medical students must be established and implemented by concerning authorities at local and central level. Medical course curriculum should include academic teaching and extracurricular activities to upsurge cognitive thinking and adaptive skills of students to deal with various stressors. This issue should be addressed by concerning authorities as to create conducive medical teaching atmosphere for undergraduates.

Aesthetic Crown Lengthening with Flapless Piezoelectric Surgery in Comparison with Traditional Open Flap Approach

Suleiman Taher Dayoub, Mohammad Ali Yousef
Introduction: Aesthetic crown-lengthening surgery is still the most common treatment for gingival smile caused by altered passive eruption type 1B. The traditional techniques and instruments of this surgery have many disadvantages like gingival tissue coronal rebound, trauma, and pain, which necessitate further research into methods that produce more effective and satisfying results. Aim: This study aimed to compare the clinical results of a minimally invasive flapless approach and an open-flap approach in aesthetic crown lengthening for the treatment of gingival smile up to three months after piezoelectric bone surgery. Materials and Methods: This prospective, split-mouth, controlled clinical study was carried out in the periodontal department of Damascus University. A total of 16 patients were selected from those who fulfilled the inclusion and exclusion criteria. 32 sites of the maxillary arch were treated by either open flap or flapless aesthetic crown lengthening technique. The right quadrant was distributed at random to receive either the open flap or flapless technique by a computer-generated table. Afterwards, the contra-lateral left quadrant was allocated to the other group. Both therapies were performed during one appointment by the same operator. Paired and independent sample t-tests were used for statistical analysis. Results: Sixteen patients (11 females, 5 males), aged 24.4±3.5 years (range: 21-35 years), were recruited at the beginning of the study. The results revealed that using piezosurgery in bone resection is effective with both surgical approaches. Both approaches created a significant increase in the length of clinical crowns compared to baseline (p<0.05) without significant differences between the groups (p>0.05). Statistically lower means of pain, bleeding on probing, and surgical time were observed in the flapless group (p<0.05). Conclusion: The minimally invasive flapless approach and piezosurgery offer truly promising alternative techniques compared to traditional methods of aesthetic crown lengthening.

Utility of Microwave Processing in Plasma-Thromboplastin Method of Cell Block Prepared from Fine Needle Aspirates

Maniyan Prakash Sumitha, Shankaran Rukmini Niveditha, Thejasvi Krishnamurthy
Introduction: Cell Blocks (CBs) in cytology complement routine smears and increase diagnostic accuracy. However, routine processing of CBs on an average varies between 12-18 hours, thereby delaying the additional information it can provide. Though application of microwaves in histopathology is well known, its use in cytology has been sparse. In an attempt to decrease the turnaround time microwave processing of CBs have been attempted. Aim: To assess the utility of microwave processing of Plasma Thromboplastin Method of Cell Block (PTCBs) from Fine Needle Aspirates (FNAs). Materials and Methods: All aspirates (80) from routine FNA procedure done over a period of two months in the Department of Pathology, in a Tertiary Care Hospital were included in the study. The aspirates were clotted by Plasma Thromboplastin (PT) method (slid onto Whatman filter paper, wrapped) and fixed in 10% formalin. Dehydration, clearing and wax impregnation were carried out in a domestic microwave and blocks were ready within 10 minutes for embedding. Results: The PTCBs processed by microwave technique were available for section cutting and staining within 10 minutes. Majority of the aspirates (27.5%) were from breast followed by thyroid (25%), lymph node (13.75%), parotid (10%) and lipoma (10%). Females constituted 75% of study population with adequate material in 70% of all cases. The quality of the sections, staining, architecture and morphology were comparable to routine paraffin sections. IHC was possible on PTCBs. Conclusion: Microwave processing of PTCBs is possible which hastens the turnaround time and assist in planning therapeutic modalities.

Contributory Factors for Obstetric ICU Admission: A Prospective Cross-sectional Study

Himsweta Srivastava, Shilpa Singh, Sushil Srivastava, Neerja Goel
Introduction: The physiological changes of pregnancy can turn pathological leading to Intensive Care Unit (ICU) admission of mother. The contributory factors to these ICU admissions need to be properly identified so that quality of obstetric services could be improved. Aim: To identify contributory factors to obstetric ICU admission. Materials and Methods: A prospective observational study was conducted in a multidisciplinary ICU of a tertiary care hospital of East Delhi, India. Maternal characteristics of women requiring ICU admission as well as contributory factors to ICU admission were observed and analysed. ‘Contributory factor’ was defined as modifiable component of health system and quality of care covering organisational, personnel and social factors. Descriptive data was tabulated as absolute figures and percentages. Results: Hypertensive disorder of pregnancy was most common primary diagnosis of ICU admission. Massive intraperitoneal haemorrhage leading to Disseminated Intravascular Coagulation (DIC) and multiorgan failure was major cause of death in ICU admitted patients. Delay in referral and lack of transportation were found to be most contributory (84%) in obstetric ICU admission. Conclusion: Social factors are major hurdle in achieving safe motherhood in India. There is a strong need of sensitisation regarding primary obstetric care among illiterate and poor women to decrease obstetric ICU admissions.

Assessment of Insulin Resistance in Ultrasonographically Diagnosed Cases of Non-Alcoholic Fatty Liver Disease
Introduction: Non-Alcoholic Fatty Liver Disease (NAFLD) is the excessive accumulation of fat primarily in form of triacylglycerols in more than 5% of the hepatocytes without significant consumption of alcohol and other known causes of steatosis. Literature suggests an association of NAFLD with Insulin Resistant (IR) Metabolic Syndrome (MetS). In clinical settings, ultrasonography is commonly used for diagnosis of NAFLD as opposed to expensive biopsy procedures. Aim: To assess the diagnostic utility of the surrogate markers of IR in ultrasonographically diagnosed cases of NAFLD. Materials and Methods: The cross-sectional study was carried out at College of Medicine and Sagore Dutta Hospital (CMSDH), Tertiary Care Hospital and Teaching Institute in Kolkata, West Bengal, India. Ultrasonographically diagnosed 116 cases (aged 32-65 years) of NAFLD were selected and 100 apparently healthy age and sex-matched individuals were recruited as controls. Overnight fasting blood samples were analysed for fasting glucose, insulin, glycated haemoglobin (HbA1C), lipid profile and transaminases levels. IR was estimated with the Homeostasis Model Assessment index for Insulin Resistance (HOMA-IR). One-way analysis variance (ANOVA) was used for normally distributed data and Kruskal Wallis for a non-parametric data. Receiver Operator Curve (ROC) were generated to identify the cut-off values of HOMA-IR, Aspartate aminotransferase (AST), Alanine aminotransferase (ALT), the AST/ALT ratio and fasting triglycerides to predict the existence of fatty liver. Adjusted Odds Ratio (OR) was also calculated to measure the independent effect of the risk factors. Results: Statistically significant differences were observed in insulin (p-value=0.033), HOMA-IR (p-value=0.049), triglycerides (p-value=0.00008), HbA1C (p-value=0.030), AST/ALT ratio (p-value=0.012), AST (p-value=0.015), ALT (p-value 0.00001) levels among cases and controls. The predictive cut-off for possibility of existence of fatty liver was HOMA-IR was >2.9 (sensitivity was 63.27%, specificity of 93.94), triglycerides =137 mg/dL, (60.67% sensitivity and 60.98% specificity) and AST/ALT ratio of 0.74 (specificity of 65.15% and a sensitivity of 62.50%). For HOMA-IR >2.5, the relative risk was 5.56 and OR was 7.15. For triglycerides >150 mg/dL, the relative risk was 1.88 and OR was 2.87. Conclusion: While ultrasound remains method of choice for diagnosis of NAFLD, assessment of parameters like IR, AST/ALT ratio aids in detection of associated MetS such as Cardiovascular Disorders (CVD) and Diabetes Mellitus (DM) that warrants proper lifestyle modification and therapeutic intervention.

Obstetric Cerebral Venous Thrombosis- A Clinical Dilemma

Charu Sharma, Anita Yadav, Shiv Shankar Singh, Manju Mehrotra, Avinash Prakash
Introduction: Cerebral Venous Thrombosis (CVT) is one of the important causes of stroke which is not very common. It has a varied clinical presentation and pathogenesis. It most often involves the superior sagittal sinus but may occur anywhere in the cerebral venous circulation. Pregnancy and puerperium are in itself a high-risk factor for its occurrence. Aim: To assess the frequency of different clinical features, risk factors and prognostic outcome of patients diagnosed as CVT. Materials and Methods: A hospital based observational study was conducted in the Department of Obstetrics and Gynaecology and the Department of Medicine at Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, Andaman and Nicobar Islands, India, from January 2015 to December 2016. All cases of cerebrovascular accidents were followed and those diagnosed as CVT on the basis of Computed Tomogram (CT), Magnetic Resonance Imaging (MRI) and/or Magnetic Resonance Venogram (MRV) were included in the study, managed and followed till discharge from the hospital and at three months post-delivery. Means and percentages were used as statistical analysis. Results: Out of total of 4,767 deliveries in the study period, we found six cases of puerperal CVT. The incidence of puerperal CVT in our study population came out to be 125.8 per 100,000 deliveries. The mean age of women presenting with CVT was 23.6±3.204 years. The most common presenting symptom was headache (6/6, 100%) followed by seizure (4/6, 66.6%), hemiparesis (1/6), diplopia (1/6) and blindness (1/6). The most common area of infarct was superior sagittal sinus (6/6, 100%). The average period between the onset of symptoms and consultation was 1.8 days. Mortality at discharge was 16.6% (1/6). Conclusion: In CVT precise diagnosis is decisive as based on the diagnosis timely and suitable therapy can be started which can reverse the disease process.

A Randomised Controlled Trial of Lactobacillus in the Prevention of Ventilator Associated Pneumonia
Introduction: Ventilator Associated Pneumonia (VAP), continues to complicate a significant proportion of critically ill mechanically ventilated patients, resulting in increased morbidity, mortality and hospital costs. Probiotics offer a novel approach to the prevention of VAP. Uncertainty still exists regarding its benefit for the prevention of VAP. Aim: To study the efficacy of probiotic prophylaxis in preventing VAP in the Medical Intensive Care Unit (MICU) of a tertiary hospital in Southern India. Materials and Methods: The study was a prospective, randomised, double-blind, placebo controlled trial that included 146 critically ill, mechanically ventilated adult patients admitted to a 24 bed MICU. Patients in the probiotic group received 2×109 Colony Forming Units (CFU) of Lactobacillus rhamnosus on a twice daily basis (as oral slurry and via nasogastric tube) upto seven days, while those in the placebo arm received identical appearing inert base powder. The primary outcome was incidence of VAP as defined by the clinical criteria of Johansen. Secondary outcomes included duration of mechanical ventilation, MICU stay, hospital stay and mortality. The differences in means and proportions between the two study groups were assessed using independent-t-test and two-sample proportion tests respectively. Results: The incidence of VAP, though lower in the Lactobacillus arm, was not statistically significant- (10% vs. 11%, Lactobacillus vs. placebo). Other outcomes including ICU mortality, median time to VAP, duration of mechanical ventilation, duration of ICU and hospital stay were also not significantly different in the two groups. There were no episodes of Lactobacillus bacteraemia. Conclusion: In critically ill, adult patients admitted to the MICU administration of Lactobacillus rhamnosus did not prevent VAP. ICU mortality, in hospital mortality and median time to VAP were also not influenced by the administration of probiotics.

Correlation between Frequency of Flaps in Asterixis and Severity of the Liver Disease in Patients with Hepatic Encephalopathy
Introduction: Frequency of flaps in asterixis is not uniform and varies among the patients. However, this flap frequency has not been given much importance in the literature. Neither it alters the grade of severity of Hepatic Encephalopathy (HE), nor has it been included in any of the scoring systems determining the severity of liver disease such as the Child Turcotte Pugh (CTP) and Model for End stage Liver Disease (MELD) scores. Aim: To study the correlation between frequency of flaps in asterixis and severity of the liver disease in patients with HE. Materials and Methods: Patients with decompensated cirrhosis and HE with asterixis had their flap frequency (per 30 seconds) counted at the time of their discharge, after clinical stabilisation. CTP and MELD scores were also calculated and the correlation between number of flaps and CTP and MELD scores was studied. A total of 63 such patients were followed up for a period of 12 months. We also studied whether patients with increasing number of flaps have a poorer clinical outcome, as suggested by re-hospitalisation. Results: The correlation between number of flaps and CTP score was non-significant (rs=0.02, p=0.87). Correlation between number of flaps and MELD score was also non-significant (rs=0.16, p=0.20). A 13% of patients with <5 flaps/30s were subsequently re-hospitalised for both hepatic and non-hepatic causes as compared to 64% of patients with >15 flaps/30s. A total of 27 patients were re-hospitalised out of which 12 (44.4%) had worsening HE, 5 (18.5%) had Spontaneous Bacterial Peritonitis (SBP) and worsening HE, 6 (22.2%) had worsening ascites and 4 (14.8%) had acute kidney injury. Conclusion: There was no significant correlation between number of flaps and CTP and MELD scores. However, higher number of flaps was an independent predictor for re-hospitalisation.

Nasal Colonisation of MRSA in Oral Cancer Patients in a Tertiary Care Hospital of Northern India

Deesha Kumar, Ankur Goyal, Surabhi Gupta, Nidhi Gupta, Arti Agrawal, Sapna Goyal
Introduction: Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of healthcare-associated infection worldwide. Immunocompromised patients are more susceptible to develop infection from own colonised MRSA. Aim: To screen oral cancer patients for nasal colonisation of MRSA at two time point during study period. Materials and Methods: The study was conducted in SN Medical College, Agra for a period of six months. Anterior nares of 50 participants having oral cancer were screened for colonisation of Staphylococcus aureus. Isolates were identified as Staphylococcus aureus as per standard protocol and were further subjected to see the production of MRSA as per CLSI criteria. Results: Total 50 patients were enrolled in the study, out of these, 34 were put on chemotherapy while 16 were put on radiotherapy. Before starting any treatment modality 29 (58%) patients were colonised with Staphylococcus aureus out of which 16 (32%) were MRSA strains and 13 (26%) were MSSA. Patients who did not show MRSA colonisation in their anterior nares (34/50; 68%) were further screened for MRSA colonisation after three weeks of chemotherapy and four weeks of radiotherapy. 50% patients (7/14) of chemotherapy group demonstrated the conversion of nasal flora in MRSA after three weeks of treatment and 33.3% (3/9) of radiotherapy group showed the conversion in MRSA after four weeks of treatment. Conclusion: The present study suggests that if a patient is colonised initially with MSSA in oral cancer patient then the patient should not be left as non MRSA producer. As patient might develop MRSA colonisation after chemotherapy and radiotherapy which may further be the reason for resistant infection in immune-compromised cancer patients.

Prevalence of bla_CTX-M, bla_CTX-M-2, bla_CTX-M-8, bla_CTX-M-25 and bla_CTX-M-3 Genes in Escherichia coli Isolated from Urinary Tract Infection in Kermanshah City, Iran
Introduction: Urinary Tract Infection (UTI) is one of the most common bacterial infections and Escherichia coli is the most common organism that causes UTI. However, the incidence of community acquired UTI caused by Extended spectrum beta-lactamase (ESBL)-producing strains of E.coli, in particular CTX-M genes, is on the rise worldwide. Aim: To detect the frequency of CTX-M gene subgroups in uropathogenic E.coli. Materials and Methods: In this descriptive-analytical study, 240 isolates of E. coli were studied. All isolates were isolated from UTIs in Kermanshah University of Medical Sciences, Kermanshah, Iran, in 2014 to 2015. After screening for ESBL, the CTX-M, CTX-M-2, CTX-M-8, CTX-M-25 and CTX-M-3 genes were detected among ESBL- producing isolates using PCR. Results: Of the 240 E. coli isolates, 67 were ESBL-producing isolates. Sixty one isolates (91%) contained CTX-M gene, of which 57 (85%), 3 (4.5%), 3 (4.5%) and 1(1.49%) contained CTX-M-3, CTX-M-8, CTX- M-25 and CTX-M-2, respectively. Conclusion: Due to the high resistance of E. coli to beta-lactam drugs in this region, these drugs have limited effects for treatment of UTI in outpatient. The frequency of CTX-M-2, CTX-M-8, CTX-M-25 beta-lactamases in isolates of E. coli is relatively low but the overall prevalence of CTX-M and CTX-M-3 beta-lactamases is high which indicates the spread of drug resistance.

Effect of Technique of Disinfection by Ultrasonic Nebulization on Accuracy of Vinyl Polysiloxane Impressions
Introduction: To prevent cross-contamination, impressions should be properly disinfected after removing from the mouth. To be efficacious, a successful disinfection must maintain the physico-chemical properties of the impression materials and should not interfere negatively in the fabrication of stone casts. Aim: To evaluate the effect of different disinfection techniques on the accuracy of dental impressions made of vinyl polysiloxane. Materials and Methods: 40 test samples made of vinyl polysiloxane were obtained using a pattern cylinder. The samples were randomly divided into 5 experimental conditions: I-Control, impressions without any disinfection, II-Immersion in 2% glutaraldehyde for 10 minutes, III-Immersion in 0.2% peracetic acid for 10 minutes, IV-ultrasonic nebulization for 10 minutes in 2% glutaraldehyde and V-ultrasonic nebulization for 10 minutes in 0.2% peracetic acid. The impressions obtained were poured in type IV gypsum and both the height and diameter of the stone casts were measured. For this purpose a profile projector joined to a digital measurement system was used. The data were submitted to statistical analysis using Bioestat 5.3 software. The Shapiro-Wilk test was applied to assess normal data distribution. Data were analysed by one-way ANOVA and Tukey’s test for comparisons of the means of the different groups, p-value less than 0.05 was considered as statistically significant. Results: Groups I, II and III did not differ statistically among themselves, both in diameter and height. Group IV presented statistically different results from the others for diameter. Whereas for height, the results were shown to be similar among groups I, II, III and IV. For Group V, the results obtained were statistically different for both height and diameter from those of the other groups. Conclusion: The immersion technique did not interfere in the accuracy of the stone casts however the ultrasonic nebulization with 2% glutaraldehyde solution did not show significant differences for height and presented better values of dimensional accuracy in diameter, when compared to the control group. The ultrasonic nebulization method associated with 2% peracetic acid solution presented the worst dimensional accuracy values for height and better values for the diameter compared to the other groups.

Assessment of Enamel Surface Microhardness with Different Fluorinated Compounds under pH Cycling Conditions: An in-Vitro Study

Cecilia Carlota Barrera Ortega, Miguel Angel Araiza Tellez, Alvaro Garcia Perez
Assessment of Enamel Surface Microhardness with Different Fluorinated Compounds under pH Cycling Conditions: An In-Vitro Study

Clinico-mycological Study of Otomycosis Comparing the Cavity Slide Technique and the Conventional Agar Block Slide Culture

Tabindah Jahan, Mohsin Bin Mushtaq, Nargis Bali, Sabah Nargis, Yousuf Ul Bashir
Introduction: Otomycosis is a sub-acute or chronic superficial fungal infection of the external auditory canal that occurs primarily in hot dry weather of tropics and sub tropics. The disease occurs in all age groups and is generally unilateral in presentation. Different species of Aspergillus and Candida usually invade the ear canal following a primary bacterial infection although other fungal pathogens are also infrequently associated with otomycosis. Slide culture technique is often used to delineate the fungal etiology in otomycosis however the morphology is not very clear as compared to the cavity slide culture which preserves the morphology well. Aim: To isolate various fungal agents involved in otomycosis and to compare the cavity slide culture technique with the conventional agar block slide culture for their identification. Materials and Methods: A total of 120 cases were studied from January 2015 to June 2016. Ear discharge specimen were collected on three sterile cotton swabs. Direct examination of the specimen was carried out by Gram stain and 10% KOH mount. All specimens were inoculated on Sabouraud dextrose agar, Blood agar and Mac Conkey agar and only the ones with fungal growth were further processed. Comparison of agar block slide culture and cavity slide culture technique was done for identification of fungi. Statistical analysis was done using one-way ANOVA (analysis of variance) method and a p-value of <0.05 was taken as significant. Results: Out of 120 fungal isolates the most common fungal isolate was Aspergillus flavus (39.2%) followed by A. niger (26.7%), A. fumigatus (15%), Penicillium (10.8%), Candida glabrata (5%) and Candida albicans (4%). Prevalence in females (65.8%) was more than males and itching (67.5%) was the most common presenting symptom. The cavity slide culture technique was found to be better in terms of proper visualisation and preservation of morphology of fungi. Growth was appreciated within 72 hours, with minimal morphological distortion of conidial attachment especially for Aspergillus and Penicillium spp. Less quantity of media was used in cavity slides which were stored for a week without the chances of contamination. Conclusion: Cavity slide culture should be used routinely for the visualisation and identification and fungi as the morphology is better preserved and appreciated in it and the results are available in a short period of time.

Parents Awareness about the First Dental Visit and Behaviour Management
Introduction: It is a well-accepted fact that regular dental checkups help to uncover the problems that can be easily managed at the early stages. An early dental visit can provide a perfect opportunity to the dentist to detect caries at early stages and save the primary teeth. In addition, this can be an ideal time for dentist to educate the parents about various aspects of preventive dentistry and provide well-timed anticipatory guidance. Aim: To evaluate the awareness and attitude about the first dental visit and behaviour modification techniques for the children of Saudi parents. Materials and Methods: A self-administered questionnaire consisting of 10 items were distributed to parents reporting at the Registration Appointments and Records Division of Taif University, College of Dentistry, Taif, Kingdom of Saudi Arabia. The questionnaire was prepared in both English and Arabic and the choice of language was made by the recipient (parent). The questionnaire response rate was 97.87%. The data analysis was performed using the Chi-square test with the help of SPSS software. Results: Even though almost half of the parents believed the child’s visit to the dentist should be as early as possible (49%) they believed the ideal age to visit should be at 3 years of age. The majority of parents (59%) appeared to be aware of the importance of the first dental visit and during this visit they expected the dentist to preferably focus on reducing the child’s anxiety/fear. Regarding behaviour management, the majority of parents (7.1%) were reluctant to choose pharmacological methods, but were also willing to give the choice of the ideal method to the operating dentist. Conclusion: The data indicated that parents were aware of the importance of the child’s visit to the dentist; there was a relatively low level of knowledge about the timing of a child’s first dental visit. Parents also appeared reluctant to choose the pharmacological method as a behaviour management tool, but the brighter side was they were also willing to leave the decision to the dentist. Hence, dental professionals have a good opportunity and also the responsibility to improve the knowledge and the attitude of the parents regarding child’s dental care.

Histopathological Analysis of Psoriasis in a Study of 24 Cases

Jagadish Gayathri, Padma K Shetty, Jayaprakash K Shetty
Introduction: As for any other organ system, diagnosis of skin disease involves history and examination. An instant diagnosis can be arrived upon by virtue of visibility of the skin taking into account various visual clues such as scaling, colouring, arrangement and the site of distribution of lesions. Although this appears effortless, the pattern of recognition is complicated while factoring in the individual components and analysing them separately. Aim: To study the varying histopathological findings in cases of psoriasis. Materials and Methods: Prospective study was conducted for two years. All patients who have been clinically diagnosed/suspected and untreated cases of psoriasis attending the Department of Dermatology were taken for the study. Wedge biopsy was taken under local anaesthesia. Results: In the present study, the age group of patients ranged between 8-83 years with 17 of them being males and 07 of them being females. The ratio being 2.4:1 and the mean age was 43 years. The most common histopathological finding was elongated rete ridges, suprapapillary thinning and acanthosis within the epidermis. Munroe microabscess, hyperkeratosis and parakeratosis were the other findings noted within the epidermis. Within the dermis the most common finding was aggregates of lymphocytes which varied from mild to marked along with perivascular infiltration of lymphocytes. Conclusion: Histopathological diagnosis forms the diagnostic tool for the dermatologists to arrive at a conclusion for their differential diagnosis since many skin disorders overlap with clinical presentations of psoriasis. This helps in excluding the differential diagnosis given by the clinician and to arrive at a definite histopathological diagnosis for the betterment of the patient.

Variation in Circulating Betatrophin/ANGPTL8 Levels in Normal and Overweight/Obese Pregnant Women

Mohammad Ahmad Hamza, Yassar Yahya AL Tamer, Omar Abdul Majeed AL-Habib
Introduction: Betatrophin as hepatokine and adipokine influences glucose homeostasis and implicates in the pathophysiological process of obesity and pregnancy. Various studies suggest that metabolic changes in normal weight/lean Pregnant women (PL) are significantly different from overweight/obese pregnant women (PO). However, the exact mechanism of how pre-gravid Body mass index (preBMI) affects betatrophin levels during normal pregnancy and the relationship of betatrophin to other clinical variables in PL and in PO have not been elucidated. Aim: To elucidate the effect of preBMI on betatrophin level in the initial three trimesters of pregnancy, and to determine the possible correlation between betatrophin and lipid profile parameters/thyroid profile. Materials and Methods: The cross-sectional study was carried out from December 2016 to May 2017 at Maternity Hospital, Zakho City, Kurdistan Region (Iraq). Betatrophin levels were estimated in 59 pregnant women in initial three trimester of pregnancy. Among 32 PL (pre BMI=24.9 kg/m2) and 27 PO (pre BMI>25 kg/m2), 10 and 8 were in First trimester (FT), 10 and 10 were in Second trimester (ST), 12 and 9 were in Third trimester (TT) respectively. Ten Non-pregnant normal weight/lean (NPL) (BMI=24.9 kg/m2) and 12 Non-pregnant overweight/obese (NPO) (BMI>25 kg/m2) healthy married women of reproductive age were selected as controls. Serum total betatrophin, total triiodothyronine (T3), total-thyroxin (T4), thyroid stimulating hormone (TSH), and estradiol (E2) were estimated by Enzyme linked immunosorbent assay (ELISA) and Triglyceride (TG) was estimated by the glycerophosphate oxidase colorimetric method. One-way analysis of variance (ANOVA), Welch test, Kruskal Wallis test, Games-Howell test, Independent t-test, Mann-Whitney test, and Pearson/Spearman correlation analysis were performed to assess the parameters. The p-value <0.05 was considered statistically significant. Results: Betatrophin levels were elevated by 21.3% in the PL as compared to NPL group. The raised levels in FT gradually decreased towards the end of gestation. Conversely, in the PO, betatrophin was significantly decreased as compared to NPO group (p-value=0.03). In FT, betatrophine showed a significant decline compared to ST, TT and NPO groups (p= 0.017, 0.006 and 0.001 respectively). In PL, betatrophin was correlated with TSH in ST (r=0.721, p=0.019) and with T3 in TT (r=0.759, p=0.004). In NPL, betatrophin correlated with T3 (r=0.823, p=0.003). In PO, Betatrophin correlated with T3 (r=0.433, p=0.024), T4 (r=0.499, p=0.008), E2 (r=0.609, p=0.001), TG (r=0.570, p=0.002) and Gestational weight gained (GWG) (r=0.676, p=0.0001). TG levels were elevated in all trimesters in PO than in PL. Conclusion: Our results highlight the potential involvement of T3 and TSH in regulating betatrophin levels during pregnancy. Therefore, T3 and TSH levels beside TG level should be taken into consideration when interpreting clinical studies of betatrophin. Depending upon the preBMI; betatrophin change in different ways in PL and PO women. Conversely to PL, betatrophin levels increased during pregnancy in PO, and correlated with TG. Therefore, maintaining an ideal weight before pregnancy is recommended to avoid pregnancy-related complications such as hypertriglyceridemia and insulin resistance.

Journey from Fighters to Survivors: Quality of Life and Mental Status in Cancer Patients in a Rural Tertiary Care Hospital

Raza Shaheed, Samarth Shukla, Sourya Acharya, Uplabdh Gopal, Neema Acharya
Introduction: Cancer is a major public health burden in India. Though modern medicine has made tremendous advancements in the treatment of cancers, still morbidity and mortality remain high. It affects different domains of Quality of Life (QOL). So apart from the conventional treatment protocols, cancer care seems to be the corner stone to reduce patient morbidity and ultimately prolonging survival. Aim: To assess QOL and mental status in cancer patients undergoing treatment. Materials and Methods: Patients diagnosed with cancer and undergoing treatment and patients attending the oncology clinics for follow-up after receiving chemo or radiotherapy during January 2019 to March 2019 were studied. The scores of WHOQOL-BREF and WEMWBS questionnaires were evaluated. Pearson’s Correlation Coefficient was applied to determine different domains of WHOQOL-BREFwith WEMWBS. Reliability analysis of WHOQOL-BREF and WEMWBS by Cronbach Alpha. Regression analysis of different Domain of WHOQOL-BREF with age, gender and WEMWBS. Results: A total of 42 patients were enrolled in the study. The correlation between WHOQOL-BREF and WEMWBS was found to be significant. Physical health was significantly (p-value <0.05) associated with psychological, social relationship and environmental domain. Psychological domain was significantly (p-value <0.05) associated with physical health and environment domain. Social relationship was significantly (p-value <0.05) associated with physical health only. Environment was significantly (p-value <0.05) associated with physical health and psychological domain. Internal consistency of WHOQOL-BREF and WEMWBS were acceptable . Regression analysis of Physical health=8.090+0.205*WEMWBS. Regression analysis of Psychological domain=1.020+0.317*WEMWBS. Conclusion: Awareness amongst the patients diagnosed with cancer is very important. Special emphasis should be given to improve the QOL and overall well-being of cancer patients apart from the normal treatment protocols.

The Effect of a 16-week Home-based Aerobic Exercise Program on Serum High-sensitivity C-Reactive Protein (Hs-CRP) and Insulin Resistance in Polycystic Ovary Syndrome

Nahid Mohammadi Javid, Naser Behpour, Vahid Tadibi
Introduction: Polycystic Ovarian Syndrome (PCOS) is one of the most common hormonal disorders that affect 10 to 15% of women of reproductive age. Women with PCOS are at risk for complications such as pregnancy poor outcomes, insulin resistance, Type 2 Diabetes Mellitus (T2DM), metabolic syndrome, cardiovascular diseases and some malignant conditions where increase in serum C-reactive protein (CRP) level is known to be a marker. Aim: To investigate the effect of a 16-week home-based aerobic exercise program on high-sensitivity CRP (hs-CRP) and insulin resistance index in females with PCOS. Materials and Methods: In this quasi-experimental study, 24 female patients with PCOS were included and were divided into experimental (a home-based aerobic exercise program for 16 weeks) group (12 subjects) and control group (no intervention, 12 subjects). Serum hs-CRP and insulin resistance index (HOMA-IR) were measured and compared between the two groups. The paired t-test was used to compare the variables at baseline and after 16-weeks. Results: Mean (±SD) hs-CRP level in experimental group at baseline was 6.31 (±2.64) mg/L which decreased to 3.91 (±1.59) mg/L (p=0.004). Mean (±SD) HOMA-IR in the experimental group at baseline was 3.24 (±1.3) which decreased to 1.87 (±0.47) after 16-weeks. However, no significant change in hs-CRP or HOMA-IR was seen in control group. Conclusion: The home-based aerobic exercise program had a beneficial effect on improving insulin sensitivity (decrease in HOMA-IR) and reduction in hs-CRP in women with PCOS. This exercise could be recommended as a safe treatment for these patients.

Prevalence of Intestinal Parasitic Infections among Pulmonary Tuberculosis Patients in a Tertiary Care Hospital, Bhubaneswar, Odisha, India
Introduction: In developing countries like India, Intestinal Parasitic Infections (IPIs) and Tuberculosis (TB) co-infection have been perceived to be high. The geographic distributions of helminths and TB overlap substantially. Parasitic infections affect the outcome of TB by shifting cell mediated immune response to humoral; while mycobacterium infection favours immune escape of helminths. Aim: To determine the prevalence of IPIs among pulmonary TB patients, to find out the type of intestinal parasitic infection in them and to analyse the association of risk factors with the prevalence of co-infection. Materials and Methods: A hospital based cross-sectional study was done among the 118 newly diagnosed pulmonary TB (PTB) patients attending the Pulmonary Medicine department of a tertiary care hospital, from 15th July-15th September 2016; after obtaining informed written consent. Demographic and clinical data was collected using structured questionnaire. Stool samples for direct microscopy and formalin-ether concentration technique was done for detection of intestinal parasites. Statistical analysis was performed using Epi Info software. Descriptive statistics, chi-square test were used; p-value of <0.05 was considered as statistically significant. Results: Of the 118 PTB patients enrolled, 71.18 % were sputum smear positive. The co-infection with intestinal parasites was 27.11%; 87.5% of the infections were due to helminths, of which 65.63% were due to hookworm (Ancylostoma duodenale and Necator americanus), 15.6% were due to Strongyloides stercoralis and 6.25% due to Ascaris lumbricoides. Co-infection was seen more in males (59.32%) and 1-15 years age group. Hookworm infections were higher in sputum smear positive cases than negative ones; this difference was also found to be statistically significant. Co-infection with E. histolytica was also found to have statistically significant difference between smear positive and negative cases. Conclusion: The study results reiterate the fact of a high prevalence of co-infection in this part of eastern India. There was a higher rate of co-infection among sputum positive TB cases. As co-infection is known to have a negative impact on the treatment outcome of these patients, healthcare providers should screen and treat all TB patients for intestinal parasitic co-infections in order to ensure good prognosis.

KRAS, NRAS, and BRAF Mutation Pattern in Metastatic Colorectal Cancer: A Study from Northwest Iran
Introduction: Colorectal cancer is currently the third most common cancer in terms of incidence and mortality in Iran. Different gene mutations may confer different degrees of biological aggressiveness and reduce the effectiveness of targeted therapeutic strategies in metastatic Colorectal Cancer (mCRC) patients. Aim: To evaluate any mutation pattern in mCRC, and then evaluate clinical and epidemiological correlations with the detected mutations. Materials and Methods: This study was a cross-sectional analytical study, and all mCRC cases referred to two main central hospitals and oncologists’ clinics, in Tabriz, Iran, from January 2016 to November 2018 were enrolled. KRAS, NRAS, and BRAF mutation tests were performed routinely for all mCRC cases before considering any treatment strategies. Idylla Biocartis NV system{Test Type Package (TTP)}, determined the presence of mentioned mutations. Logistic regression models were used to statistically analysis. Results: The present authors included 173 cases with confirmed mCRC. Among 102 patients with KRAS gene mutation detection, the frequency of mutations was 38.23% (n=39) while most were in exon 2, codon 12 (61.54%), followed by patients who had mutations in codon 13 (n=5, 12.82%). NRAS mutations were only observed in one patient (1.33%) from among the 75 cases who were tested. BRAF codon 600 was tested in 39 cases, and only one case (2.56%) had the mutation. Patients with left-sided tumours had about 9.5 times higher likelihood of KRAS mutation than right-sided tumours (OR=9.64; 95% CI=1.24-75.27). Smoking increased the odds of KRAS mutation about 50%, and mCRC who had alcohol consumption had about two times more likelihood of mutation. Conclusion: The overall frequency of KRAS mutations in the present study was high, while the frequency of KRAS mutations in mCRC patients is lower in Asian populations. KRAS mutation results in this study were most similar to European populations.

The Effect of Cognitive-Behavioural Counselling on Pregnant Women’s Weight Gain during Pregnancy: A Randomised Controlled Clinical Trial

Mahnaz Farhodimoghadam, Sousan Heydarpour, Nader Salari, Nasrin Jaberghaderi
Introduction: Weight gain during pregnancy has a close relationship with fetomaternal health. An increase in BMI is associated with the risk of premature rupture of membrane, placental abruption and stillbirth. Insufficient weight gain during pregnancy is also associated with small for gestational age, low birth weight and infant mortality, preterm labour, and fetal neural defects. Aim: To determine the effect of cognitive-behavioural counselling on weight gain in pregnant women. Materials and Methods: This randomised controlled clinical trial was performed in health centres of Sanandaj, Iran. Sixty-six pregnant women with gestational age of 20-24 weeks were selected and randomly assigned to intervention (n=33) and control (n=33) groups. The control group received routine care and the intervention group received 8-weekly sessions of 60 to 90 minutes counselling with a cognitive-behavioural approach in addition to routine pregnancy care. The weight of both groups was measured before, immediately and one month after the intervention using Seca Digital Scale. The collected data were analysed using repeated measures, Mann-Whitney U test and independent t-tests. Results: There was no significant difference in mean weight of mothers between the intervention and control groups before the cognitive-behavioural intervention (p=0.824), immediately after (p=0.905) and one month after intervention (p=0.989). Conclusion: Cognitive behavioural counselling did not affect the weight gain of mothers during pregnancy.

A Study on Chronic Proton Pump Inhibitor Usage and Small Intestinal Bacterial Overgrowth (SIBO)

VR Mujeeb, AS Prasad, RK Anadure, AB Mishra, Viswapriya Pillai
Introduction: Small Intestinal Bacterial Overgrowth (SIBO) has a wide clinical spectrum, and may be associated with both maldigestion and malabsorption. Proton Pump Inhibitors (PPI) are one of the most widely prescribed medications in view of their safety profile. This has lead to their indiscriminate usage, giving rise to growing concerns of SIBO in the setting of long term PPI usage. Aim: To evaluate the correlation between chronic PPI usage (>2 months) and SIBO, as diagnosed by duodenal aspirate cultures. Materials and Methods: A total of 80 subjects were included in this prospective observational study. All patients were subjected to Upper Gastrointestinal Endoscopy (UGIE) and one mL duodenal aspirate was collected for bacterial cultures. A growth of more than 105 CFU/mL was considered positive for SIBO. The inter-group statistical comparison was done using Chi-square test, and a p-value of <0.05 was taken as significant. Results: The mean age of the entire study group was 45.4 years. Gender wise, 72.5% of the patients were males. Gastritis, as detected by endoscopy was seen in 37.5% patients, and 35% patients had infection with H.pylori. The use of NSAIDS was noted amongst 36% of the study population. The most common PPI used was Pantoprazole and majority of the patients had used it for greater than six months. Flatulence was the predominant symptom of SIBO in 41% study subjects. On UGIE, 34 out of 80 (42.5%) patients had abnormal findings and 19 out of 80 (23.8%) patients had SIBO as per positive duodenal aspirate culture reports (>105 CFU per mL). Based on various intergroup analysis, SIBO was not significantly (p>0.05), associated with any form of PPI usage, H.pylori infection, NSAID use or smoking/alcohol abuse. Conclusion: It was observed in this single center study that, SIBO was not associated with duration/ dose/ type of PPI usage. This study needs further validation with a case-control design in a diverse patient population.

Oncogenic Human Papillomavirus Genotypes and Cervical Cancer: A Focus on Multiple Infections and Patient Age

Jae-Sik Jeon, Jae Kyung Kim
Introduction: Cervical cancer is the leading cause of cancer-related deaths in the female population. Human Papillomavirus (HPV) genotypes 16 and 18 accounts for 70% of cervical cancer cases. HPV infection is associated with the development of cervical carcinoma and its precancerous lesions, and early intervention can effectively prevent cervical cancer. Therefore, it is essential to evaluate the prevalence of HPV types. Aim: To evaluate the incidence of HPV infection in a university hospital in Cheonan, Korea over 5 years and its changes over time. Materials and Methods: This was a retrospective study. HPV detection and genotyping were performed on 7,874 consecutive cervical swab specimens between 2013 and 2018. Cervical swab specimens were obtained from women aged 21-81 years using a cervical brush and specimen transport medium. HPV DNA was detected by multiplex real-time PCR. The detected HPV types were classified according to risk. HPV data were analysed using R. (version 3.3.3, Comprehensive R Archive Network; https://www.r-project.org) The chi-square test was performed to analyse categorical data. The prevalence and 95% confidence intervals were calculated for the overall HPV genotypes and each individual genotype. Statistical significance was considered at p<0.05. Results: The positive detection rate was 18.5%. The average age of all the patients was 38.6±8.55 years, and the most commonly detected virus types were Types 52 (n=223), 68 (n=185), and 39 (n=154). Among the positive specimens, 70.4% were single infections and 30.6% were multiple infections. The ratio of multiple to single infections for various age groups was 49.7% for patients in their twenties and 31.0% for those in their sixties. Conclusion: The incidence of HPV infections and the average age of infected patients were similar to the global averages. While Types 16 and 18 are frequently detected in the international community, Type 52 was particularly unique in the present study. The high incidence of HPV infection and high frequency of multiple infections observed in the present study highlight the need for intensive management in young women.

Randomised Controlled Trial to Compare the Efficacy of Epidural Analgesia versus Intravenous Analgesia during Thoracotomy for Repair of Oesophaeal Atresia

Sarita Singh, Vinita Singh, Prabudh Goel, Souvik Maitra, JD Rawat
Introduction: The repair of oesophageal atresia by thoracotomy (or thoracoscopy) is one of the most common neonatal surgical emergencies. Peri-operative pain management in these patients is challenging due to fear of respiratory depression, post-opioid administration. The morbidity of inadequately treated pain is significant and may result in physiological instability, altered mental development and inappropriate stress response. Efficacy of use of fentanyl by the epidural route has been compared with intravenous routes often; no clear-cut consensus exists in literature. However, it has been suggested that epidural fentanyl reduces the needs for intraoperative analgesics, improves the quality of post-operative analgesia and shortens the recovery time. However, the same phenomenon has not been studied in neonates with oesophageal atresia undergoing primary repair by the thoracotomy route. Aim: To compare the analgesic efficacy of fentanyl via epidural vs. intra-venous routes of administration during thoracotomy for primary repair of oesophageal atresia in neonates. Materials and Methods: This was a randomised controlled trial for a span of over two years, on neonates (n=60) undergoing thoracotomy under general anaesthesia, for primary repair of oesophageal atresia. The participants were randomised into two groups to receive thoracic epidural analgesia with fentanyl and bupivacaine (Group A, n=30) and intravenous fentanyl (Group B, n=30) respectively. The monitoring and pain assessment was done in first 24 hours, adequacy of respiration was assessed by respiratory rate and oxygen saturation. Data were represented as Mean (Range±SD). Independent sample t-test and Mann Whitney U test were used to compare the heart rate and total fentanyl consumption respectively between the two groups. Results: Patients in Group A were hemodynamically more stable (post-incision heart rate (mean±SD) was 179.4±10.9 beats per minute in Group A vis-à-vis 186±9 beats per minute in Group B, p-value=0.01) and required less analgesia (need for intraoperative fentanyl boluses: n=2 of 30 in Group A vis-à-vis 9 of 30 in Group B, p-value=0.02); total fentanyl consumption: median (IQR) 1.2 (0-2.5) mcg in Group A vis-à-vis 7.75 (6-12) mcg in Group B; p<0.0001). Extubation after surgery in operating room was more in Group A (18 of 30 vs. none in Group B, p-value <0.0001) and ventilatory requirement after six hours of surgery was more in Group B (11 of 30 vs. 2 of 30 in Group A; risk ratio (95% CI): 0.26 (0.07-0.94), p=0.005). Pain scores at the time of extubation were significantly higher in Group B (p<0.001). Conclusion: Use of epidural fentanyl and bupivacaine has been found to be safe and superior to intravenous fentanyl in this study with a potential to offer an awake and comfortable patient at the end of surgery. However, the technique of insertion of epidural catheter neonates are demanding and require expertise with caution.

In silico Prediction of Anti-plasmodial Activity of Spices: Targeting Malarial Proteases

Pragya Chaturvedi, Vishakha Raina, Pooran Singh Solanki, Vijay Laxmi Saxena
Introduction: Malaria, a tropical disease, caused by Plasmodium is curable; still, the burden of malaria infection exists in third world countries. India, particularly among the South-East Asian region, has the maximum mortality rate. The parasites have developed resistance against antimalarial drugs. Alternatively, plants are the most important and ancient source of the drug and spices, in particular, are being used to treat various ailments. Aim: To identify the effect of common Indian spices in targeting malarial proteases. Materials and Methods: A bioinformatics approach was used to target malarial proteases which exhibit an important role in the erythrocytic cycle of the pathogen by degrading Haemoglobin. Proteases, in particular, Falcipain and Plasmepsin were used to perform docking studies to identify potent molecule for inhibition of malarial progression. Data were collected in the form of structural files from PDB (for protein) and PubChem (for ligands). The Protein structures and ligands were prepared and molecular docking had been done to predict interactions. Results: All the eighteen compounds used in study have shown quite a good affinity with target proteins in the terms of energy (negative binding energy). However, comparatively, interactions of falcipain 2 with thymol and gingerol were almost three times lower than other ligand. Except these, energy ranges were in between 30-40 kilo Joule in negative. Strongest interactions were found in between Plasmepsin 4-piperamide and plasmepsin 2-gingerol. Also, it was found that gingerol was most potent bioactive molecule interacting with almost all proteins as predicted by docking studies. Conclusion: Plasmepsin 2 and Plasmepsin 4 with gingerol and piperamide with highest cdocker energy might indicate the potential of molecules in targeting these proteases. Also, Gingerol was found to be most potent in interacting with malarial proteases.

Clinical Spectrum of Rheumatologic Manifestations in HIV Patients: A Study from Southern India

Praveen Kumar Yadav, B Jayakumar
Introduction: HIV infection is a common disease in India and a variety of rheumatological manifestations are known to occur in HIV Infection. Rheumatological manifestations are significant cause of morbidity in these patients. Aim: To study the clinical spectrum and prevalence of rheumatologic manifestations in HIV patients. Materials and Methods: Patients with HIV 1 and 2 attending the Infectious disease outpatient department of Medical College Hospital, Thiruvananthapuram during the study period (March 2009 to March 2010) were assessed by clinical examination and with relevant laboratory investigations, to diagnose the rheumatological manifestation. Based on the clinical manifestations and investigations a rheumatological diagnosis was made. Patients with diabetes mellitus, hypothyroidism and other pre-diagnosed rheumatologic illness were excluded from the study. Statistical analyses were done using SPSS IBM Statistics 17.0 version and chi-square test. Results: Out of 385 patients, 161 (41.8%) of HIV patients were in the 30-39 years age group. Male and female were 225 (58.4%) and 160 (41.6%) respectively. A total of 276 (71.7%) patients were receiving antiretroviral therapy (ART). Disease duration of 1-5 year in 174 (45.19%), <1 year in 135 (35.06%) and rest had more than 5 years of disease. A total of 97 (25.2%) of HIV patients had rheumatological manifestations. HIV Arthralgia was the most common manifestation affecting 34 patients (35.1%) of the population with rheumatological manifestations. Knee joint was the most common joint which was involved. The other manifestations noted along with percentage were Myalgia/muscle ache in 18 patients (18.6%), inflammatory back pain in 14 patients (14.4%), soft Tissue Rheumatism in 12 patients (12.4%), undifferentiated spondyloarthropathy in 11 patients (11.3%), fibromyalgia in 9 patients (9.3%), HIV wasting in 7 patients (7.2%), HIV arthritis in 4 patients (4.1%) and psoas abscess (3.1%). Each of plantar fascitis, psoriatic Nail changes, pyomyositis, painful articular syndrome, erythema nodosum and episcleritis constituted about 2.1% each of the rheumatological manifestations. Degenerative joint disease constituted 17.5% of the rheumatological manifestations. One patient had evidence of tuberculosis of the spine. Conclusion: The rheumatological manifestations are common in HIV Infected patients. HIV arthralgia, myalgia and undifferentiated spondyloarthropathy are the common manifestations.

Effect of Inspiratory Muscle Training and Diaphragmatic Breathing Exercises on Dyspnea, Pulmonary Functions, Fatigue and Functional Capacity in Pregnancy during Third Trimester

Mamta Amola, Sonia Pawara, Sheetal Kalra
Introduction: Pregnancy induces various physical and psychological alterations that cause dyspnea, reduced exercise capacity, fatigue, anxiety, altered pulmonary functions, nausea and vomiting. These alterations affect the maternal quality of life. Aim: To compare the effect of Inspiratory Muscle Training and Diaphragmatic Breathing Exercises on dyspnea, pulmonary functions, fatigue and functional capacity in pregnancy during third trimester. Materials and Methods: This experimental study was conducted on 34 subjects based on inclusion and exclusion criteria, which were randomly divided into Group A & B. Experimental group A received Inspiratory Muscle Training whereas group B performed Diaphragmatic Breathing Exercises for 4 weeks. The baseline measurement was taken on day one of the study. Dyspnea was assessed by Modified borg scale (MBS), Pulmonary functions (Expiratory Reserve Volume) were assessed by Spirometry, Fatigue was assessed by Multidimensional assessment of fatigue scale (MAFS) and Functional Capacity was assessed by 6 Minute Walk Test. All measurements were repeated at the end of 4^th week. The baseline measurements at the end of 4^th week were compared using the Independent t-test. Results: Significant improvement in pulmonary function (ERV from mean value of 0.61 to 0.658) and functional capacity (6 MWT from mean value of 303.43 to 370.88) with decrease in dyspnea (MBS from mean value of 5.7 to 2.06) and fatigue score (from mean value of 31.1 to 22.29) were found in the group A that received the inspiratory muscle training as compared to group B that received diaphragmatic training. It is suggested that inspiratory muscle training improve the quality of life in pregnancy by reducing the work of breathing. Conclusion: The Inspiratory muscle training was found to be effective and beneficial in relieving dyspnea, fatigue and improving pulmonary functions. Therefore, it can be used as a part of rehabilitation protocol in pregnancy.

Liver and Splenic Volumes in the Indian Population: Is There a Single CT Measurement Correlate?

Anitha Jasper
Introduction: Several techniques using Computed Tomography (CT) have been used to determine liver and splenic volumes/sizes. Aim: To calculate liver and splenic volumes in patients with normal livers and spleens on cross-sectional imaging and determine if there is a single CT measurement index that can correlate with liver or splenic volume. Materials and Methods: This was a retrospective study in which liver and splenic volumes were measured using CT in 100 patients. Volumes were obtained by summing the area of the liver or spleen on each section and multiplying it by the image reconstruction interval using available software. The relationship between liver and splenic volumes with various unidimensional indexes and other variables were assessed using Pearson’s correlation coefficient. Linear regression equations were obtained to correlate these indices with liver and splenic volumes. Results: Mean liver and splenic volumes were 1281±219 cm3 and 194.6±78 cm3 respectively. The upper limit of normal for the anteroposterior diameter of the liver was 16.15 cm (r=0.56, p-value <0.001) and the upper limit of normal for splenic length was 10.81 cm (r=0.74, p-value <0.05). Multi-dimensional indices correlated better with liver and splenic volume than the unidimensional indices. A significant positive correlation was seen between the height, weight, Body mass index (BMI) and Body Surface Area (BSA) of the patient with liver volume; however, no significant correlation was seen between height, weight, BMI and BSA with splenic volume. Conclusion: In this study, authors have determined that the antero-posterior diameter of the liver of 16.15 cm and splenic length of 10.81 cm are simple measurements which can be used as reliable indicators of hepatosplenomegaly during routine practice.

Region Specific Reference Intervals for TSH in the First Trimester of Pregnancy: A Three Year Retrospective Study

Vijayalakshmi Chandrasekhar, Subbarayudu Boda, Viswa Kalyan Kolli
Introduction: Alterations in thyroid hormones levels affect maternal health and fetal neurocognitive development. Variation in geophysical and socio-economic factors, and placental Human Chorionic gonadotropin (hCG) influence thyroid hormone secretion, and decreases Thyroid Stimulating Hormone (TSH) levels. Therefore, American Thyroid Association (ATA) recommends establishment of trimester and region-specific ranges for better detection and management of thyroid hormone dysfunction. Aim: To determine the region-specific TSH values in the first trimester of pregnancy. Materials and Methods: In the three-year retrospective study, serum TSH levels of 1221 healthy pregnant women attending the antenatal OPD at GITAM Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India, were measured by the Electrochemiluminescence Immunoassay “ECLIA”. Reference interval of TSH was calculated using the Statistical Package for the Social Sciences (SPSS) software by applying the non-parametric statistical method. The central 95% intervals (normal range), the 90% confidence intervals and the confidence ratios were calculated. Results: For TSH levels in the first trimester, the central 95% intervals were 0.43-4.5 mU/L, 90% confidence intervals were 0.27-0.45 (Upper Limit), 3.9-4.84 (Lower Limit) and the confidence ratio was 0.24. These values were found to be slightly higher than the ATA 2017 guidelines. Conclusion: Our region-specific reference interval for TSH was found to be 0.43-4.5 mU/L. The established region-specific reference intervals will help assessment of TSH levels in the first trimester of pregnancy and thereby prevent misdiagnosis and inadequate treatment.

Head Circumference and Birth Length as Predictor of Low Birth Weight among Bengali Hindu Population of Kolkata, West Bengal, India

Sima Dey, Nitish Mondal, Parasmani Dasgupta
Introduction: Low Birth Weight (LBW) is an important decisive factor for most of the neonatal deaths, hence, Birth Weight (BW) is essential to identify immediately after birth for neonate survival and post-natal growth. The proper neonatal care and logistics are not available in every situation, especially in non-institutional or home deliveries bear’s difficulties to identify the relative risks of intra-uterine growth retardations and/or of newborns LBW. Aim: To identify the surrogate anthropometric measurements of Birth length (BL) and Head circumference (HC) as a proxy measure of newborns LBW and determine the operational cut-off points among the Bengali Hindu population of Kolkata, West Bengal, India. Materials and Methods: A total of 495 newborn BW data were collected from the hospital records from August 2016 to March 2017. Data were collected among Bengali Hindu mothers completed full gestational periods and delivered a normal singleton newborn. The data comprises of BW, BL and HC which were recorded using standard anthropometric procedures. The data were analysed in terms of descriptive statistics, correlation coefficients, linear and Binary logistic regression (BLR) and AUC-ROC analysis using SPSS (version, 16.0). Results: Out of 495 newborns included mean BW and LBW were 2.72±0.44 kg and 27.10%, respectively. The BW was correlated with BL (r=0.791) than HC (r=0.757) (p<0.001). Linear and BLR analysis showed that BL and HC exhibited significant influences on newborns BW (p<0.01). ROC-AUC analyses of BL (AUC=0.89, 95% CI 0.86-0.92) and HC (AUC=0.91, 95% CI 0.88-0.94) showed optimal surrogate indicators with LBW (p<0.01). The optimal cut-points for BL and HC to identify LBW newborns were <46.5 cm and <32.5 cm, respectively. Conclusion: BL is the best suitable anthropometric measure followed by HC to predict LBW newborns. These proxies anthropometric indicators would help to identify the relative risks LBW and neonates requiring intervention in field situations.

Utility of DxH 800 VCS Parameters and Lymph Index in Predicting Dengue
Introduction: Dengue is an acute febrile illness where high fever is accompanied by headache, arthralgia and myalgia. Volume, Conductivity and Scatter (VCS) positional parameters have been reported to be useful in indicating dengue infection. The derived indices like lymph index are being introduced to predict dengue. Aim: To evaluate diagnostic utility of lymph index and VCS positional parameters in dengue fever. Materials and Methods: Peripheral blood samples of 100 serology proven cases of dengue, 25 proven cases of malaria and 50 healthy controls were evaluated in Coulter DxH 800 automated analyser, VCS positional parameters were analysed, and lymph index was derived. Results: Lymphocytes, neutrophils and monocytes positional parameters were significantly different in dengue group when compared to the cases of malaria and healthy individuals, indicating morphological changes in leucocytes. The mean volume of lymphocytes, neutrophils and monocytes were significantly increased, whereas the mean conductivity of neutrophils and monocytes were significantly decreased in dengue. Lymph index was significantly increased (mean: 16.64±5.63) in cases of dengue as compared to control (mean: 11.56±1.68), and had a sensitivity of 73% and specificity of 88%. Conclusion: Lymph index, along with the positional parameters, the scatterplot, and the histogram, is a fairly accurate parameter in prediction of dengue in suspected cases and could be used to select cases for testing dengue.

Effectiveness of Scapular Mobilisation in the Management of Patients with Frozen Shoulder- A Randomised Control Trial

S Arul Pragassame, VK Mohandas Kurup, A Kifayathunnisa
Introduction: Frozen shoulder is a condition of uncertain etiology characterised by progressive loss of both active and passive range of motion in the Glenohumeral (GH) joint. It is clear that the GH joint and the scapula do not function independently. Obviously, dysfunction in either joint has a direct impact on the other. Reverse scapulohumeral rhythm means that the scapula moves more than the humerus and it is evident with frozen shoulder. Current manual therapies for the frozen shoulder focus primarily on GH joint mobilisation. Very few studies have addressed the scapular restriction. Aim: To evaluate the effectiveness of scapular mobilisation in patients with frozen shoulder by comparing with conventional treatment. Materials and Methods: A total of 30 subjects with frozen shoulder were selected based on the selection criteria. The participants were then randomly allocated into two groups A and B. Group A were given wax therapy, capsular stretching, scapular mobilisation and home exercises and Group B were given wax therapy, capsular stretching, home exercises. Pain, Range of motion (ROM) and functional disability was measured using a Numerical Pain Rating Scale (NPRS), universal goniometer and shoulder constant score for both the groups. The two groups received therapy for five days in a week for two weeks. Pre and post treatment evaluation were compared and statistically analysed. Results: Group A had significant improvement in NPRS (Z=4.39, p=0.001), shoulder abduction (Z=3.51, p=0.001), shoulder external rotation (Z=4.08, p=0.001) and shoulder constant score (Z=5.39, p=0.001) when compared to group B. Conclusion: Both the treatment approaches are effective in reducing pain, improving ROM and functional disability in patients with frozen shoulder. However the patients who received scapular mobilisation had significantly higher improvement than the control group.

Early Clinical Experience with Simvastatin for Treating Pain in Patients with Idiopathic Chronic Pancreatitis
Introduction: Chronic Pancreatitis (CP) is a progressive inflammatory disorder characterised by recurrent episodes of severe abdominal pain. Experimental studies demonstrated protective effects of statins in pancreatic fibrosis. Aim: To assess impact of simvastatin therapy on the severity of pain in patients with idiopathic CP or recurrent acute pancreatitis. Materials and Methods: This prospective, single centre and open-label study included patients with idiopathic CP and recurrent acute pancreatitis, depending upon inclusion and exclusion criteria. Patients were treated with either simvastatin (40 mg per day) (Group-A; n=25) or standard therapy (proton-pump inhibitor and antioxidant therapy) (Group-B; n=25). Severity of the pain was assessed using a Visual Analogue Score (VAS) at the start of treatment and at 12-month of treatment. Results: Between June 2017 and August 2017, a total of 50 patients, age ranging from 18 years to 54 years, were included in the study. The study population predominantly included male patients (n=38). The intensity of pain in patients of Group-A reduced significantly (p=0.0001) from 8 (range 6-10) at baseline to 2 (range 0-9) after 12 months of the treatment. There was significant reduction in the intensity of pain in Group-B also {7 (range 6-10) at baseline vs. 5 (range 0-7); p=0.0001}. However, the reduction of VAS score was significantly higher in Group-A as compared to Group-B at 12-month follow-up {6 (range-1-8) vs. 3 (range 0-6); p=0.032}. Conclusion: Simvastatin treatment improved severity of pain in patients with CP or recurrent acute pancreatitis at 12-month follow-up. However, large randomised trials are needed to replicate these findings.

Fast-tracking Histopathology: Is Microwave the Way Forward?

Anamika Sinha, Sukumar Santosh Kumar
Introduction: The conventional method of tissue processing involves a long turnaround time. An early diagnosis of tissue biopsies would enable quick decision making and prompt institution of therapy. The use of microwave in tissue processing can reduce the turnaround time of biopsy reports from hours to minutes. Aim: To compare the quality of tissue processed by a microwave with that of the conventional method. Materials and Methods: This was a prospective study in which 40 pairs of tissues were studied as test and control groups. Both groups were processed by the microwave and the conventional methods and stained with Haematoxylin and Eosin (H&E), special histochemical stains and immunohistochemical stains. Quality of tissues of both groups was compared using statistical analysis. Results: Use of microwave reduced the time required for tissue processing from 17 hours to 36 minutes. The strength of agreement between the results obtained by the two methods was very good (Kappa coefficient: 0.806). Tissue sections of both groups were optimal for rendering diagnoses. Tissues of both groups showed crisp and specific staining with histochemical stains and immunohistochemical stains. Conclusion: The study shows that use of microwave significantly reduces processing time for biopsies without compromising either quality or suitability for special stains including immunohistochemistry. This method has tremendous potential in reducing the turnaround time of routine biopsy reports and in intraoperative diagnosis.

Characterisation of Breast Cancer Lesions using Image Processing Based Technique

Yousif Mohmed Abdallah, Nouf Hussain Abuhadi, Dalia Bilal
Introduction: Characterisation of mammographs deliberates as influential approaches in cataloguing of breast tissues and tumour. In breast, unravelling of nearby tissues in the mammographs is one of the tough processing procedures. The existence of speckle noise in these mammographs boundaries makes the pathology analysis more difficult. Aim: To characterise breast cancer lesions using different image processing algorithms in order to improve the mammographs and increase their diagnostic value. Materials and Methods: This retrospective study aims to locate structures and lesions in breast images. The algorithms use the noise speckles deletion, augmentation and subdivision of the breast tissue and the background in mammographs. More precisely, it aims to ascribe a label to pixels within the mammographs that have the same graphic characteristics. The segmented images were associated with the binary image mask to the original mammograph. The Root-Mean-Square Error (RMSE) and Peak Signal-to-Noise Ratio (PSNR) were studied in images database. Both percentage match between ground truth and segmentation results were calculated. Results: Percentage match measure of watershed algorithm was 96.60 (p<0.05) and Corresponding Ratio (CR) was 0.019 (p<0.05). The edge detection gave good and clear visualisation of the processed images that increased the diagnostic value of them. Conclusion: The edge detection and water-marker technique are able to identify the breast lesions precisely and improves radiological analysis and diagnosis.

Is Anticipatory Postural Adjustments Focused Training Effective for Fall Prevention and Quality of Life in the Elderly?

Hamed Arghavani, Vahid Zolaktaf, Shahram Lenjannejadian
Introduction: Two important problems of ageing include decreased Balance Confidence (BC) and consequently decreased Quality of Life (QOL). There is a relationship between BC and QOL, and that the elderly who have more fear of falling, have a significantly lower QOL. Aim: To study the effects of anticipatory postural adjustments focused training that is a novel approach to balance rehabilitation, on Balance Confidence and Quality of Life of the elderly. Materials and Methods: This study was an experiment with pre-test and post-test design, that was conducted in Aramesh Rehab Gym, Isfahan, Iran. The sample size included 40 elderly males with a history of falling. They were randomly allocated into Experimental Group (EG) (70.4±3.21 years) and Control Group (CG) (69.6±3.09 years). EG participated in a training program which provided different ways to catch a ball for eight weeks, and CG did not receive any training. Before and after the intervention, all participants completed the Activities-Specific Balance Confidence (ABC) scale and the SF-36 questionnaire to evaluate BC and QOL, respectively. The Independent t-test and Mann-Whitney U test were used to analyse the data. Results: Both the ABC scale mean score and the total mean score of QOL in the EG significantly increased compared to the CG in the post-test (p<0.05). Also, in the post-test, the EG noticeably improved in every QOL survey domain compared to the CG (p<0.05), except the mental health domain. Conclusion: The findings appear to suggest that entertaining ball exercises that involve catching and throwing a ball in different conditions can improve the BC and the QOL, hence reducing the probability of falling in older people with records of a fall.

Effectiveness of Indian Diabetes Risk Score as a Screening Tool for Non-alcoholic Fatty Liver Disease: A Study from Anand, Gujarat, India

Krishna S Mori, Alpa N Patel, Amee A Amin, Ajay G Phatak
Introduction: Non-alcoholic fatty liver disease (NAFLD) is widely prevalent in the Gujarati population and also shares risk factors with other Non-communicable diseases (NCDs) such as diabetes, obesity, and metabolic syndrome. Hence, more established screening tools like Indian Diabetes Risk Score (IDRS) may be considered for screening of NAFLD. Aim: To evaluate the prevalence of NAFLD in Anand, Gujarat and to assess whether IDRS may be used as a screening tool for NAFLD in Gujarat. Materials and Methods: A cross-sectional observational study involving 217 participants with a mean age of 56.83±11.39 years was conducted at the Health Check-up department at Shree Krishna Hospital, Anand, Gujarat, India. Participants were classified as having NAFLD using the USG parameters. Their IDRS score was calculated and applied to the participants following which its ability to screen NAFLD was compared with that of screening tools such as BMI, W/H Ratio and HBA1c, and risk factors associated with NAFLD. The IDRS was classified as high (=60), medium (30-50), and low (<30) risk. Using univariate analysis in STATA (14.2), factors associated with NAFLD were identified, following which stepwise logistic regression analysis was performed. Differences between the risk groups of IDRS were tested using the chi-square test and analysis of variance. Results: The prevalence of NAFLD (37.79%) was significantly higher among those with a high (67.7%) and medium IDRS (16%) compared to the low IDRS group (7.4%) (trend chi-square; p<0.001). In stepwise logistic regression, IDRS was associated with NAFLD with an adjusted odds ratio of 1.03 (95% confidence interval 1.00-1.07 with a p-value of 0.036), even after adjusting for potential confounders. Conclusion: IDRS score can be used to screen for the prevalence of NAFLD.

Ethics and Attitude- From Seed to Sapling: Perspective from India

Padmavathi Ramaswamy, Veni Ramaswamy
Ethics and attitude are important attributes in one’s life. These values have to be taught from the childhood in schools and should be reinforced during the adolescent phase in college life. Methods to impart these values can vary in different phases of life and in different professions, but it is mandatory that these values have to be given paramount importance in the curriculum of primary education in schools and in the medical undergraduate curriculum. Parents, teachers have to be the role models for the young children to imbibe the right attitude and ethical principles. Two professions (among others) i.e., teachers and doctors require the values of empathy, compassion, kindness and humility. School teachers and medical college faculty have to be the role models for their students. If the former sows the seeds, the latter converts the seeds to saplings. Hence it is important to have structured program in the school curriculum and medical undergraduate and postgraduate curriculum for imparting the ethical principles, values and the right attitude. Realising this need for transformation, Samsidh Group of Schools based at Karnataka state has introduced a structured Character Development Programme intertwined with Academics. MCI has now introduced into its revised competency based undergraduate MBBS curriculum, an AETCOM (Attitude, Ethics and Communication) module where Ethics is taught using several case scenarios. This review article highlights the importance and need of incorporation of Ethics education in school and college curriculum.

Vaccine Development Against Salmonella Typhi: The Search is Still On

Shailendra Singh, Chandra Bhan Pratap, Gopal Nath
Salmonella serovar typhi still remains a serious problem in South Asia, South-East Asia, and sub-Saharan Africa. The emergence of multidrug resistance, lack of proper diagnosis and chronic typhoid carrier are the main causes of such a high level of morbidity and mortality. Presently, three vaccines have been licensed for typhoid infection but none of them is optimum for complete eradication for want of safety and long lasting immunity. Several subunit and attenuated candidate vaccines are under trial. Recently, in India Typbar TCV conjugate vaccine has been licensed. However, this vaccine being subunit may not induce appropriate immune response and also it cannot be given to infants. We need a multivalent attenuated vaccine which can induce both cellular as well as humoral immunity against different pathogenic serovar of Salmonella. Live attenuated vaccine could be an attractive choice taking care of all the above points. In this review, we focus on the pathogenesis of Salmonella serovar typhi, role of humoral as well as Cell-Mediated Immune (CMI) response, different licensed vaccines with their pros and cons, and also the targets which are already been put on clinical trials. We have discussed the attenuation of the candidates by modification of certain structural and functional genes especially looking for induction of CMI.

Osteoclasts: Multifaceted Molecule in Vesicular Trafficking

Anil Kumar Kanakamedala, Jaideep Mahendra, Nashra Kareem, Little Mahendra
It has been widely accepted that periodontitis is a result of the host immune inflammatory response caused by various periodontal microorganisms leading to tissue degradation and bone resorption. One important mechanism of the inflammatory mediators present in periodontal tissue is the stimulation and formation of osteoclasts that are believed to be the major cell type responsible for bone resorption. This review article comprehensively explains the various molecular activities of osteoclasts and their role in periodontitis.

Polyetheretherketone (PEEK) in Dentistry

Veena B Benakatti, Jayashree A Sajjanar, Aditya Acharya
There has been a constant research in identifying ideal restorative materials to replace lost dentofacial structures. Material such as wood, shell, ivory and rubbers to metals and plastics have been tried in the past. Advancements in dental materials have given dentistry more promising materials, yet each material remains short of being the ideal one. Oral conditions demand a material with good mechanical and biologic properties in addition to aesthetics. At present Polyetheretherketone (PEEK) is one of the viable materials among scientifically approved and safe materials in restoring the lost orofacial tissues. Due to its excellent properties peek has several applications in field of dentistry like implants, removable and fixed partial dentures, and orthodontic wires.

Reciprocal Relations between Work and Health: A Theoretical Understanding from the History of Occupational Health and Behaviour

Parthsarathi Dehury, K Anil Kumar
A healthy workplace is always required for promotion of good health and wellbeing of workers. Health depends on reinforcement of various external factors of productivity. Performance of a worker is influenced by remuneration and compensation irrespective of occupational risk and hazards. The paper tries to understand the relationship between work and health from various aspects of established theories and health behaviours in industry. The theoretical perceptive of occupational health is discussed in the context of self-defensive and self-protective behaviours of working population. Various search engines like PubMed, scopus, web of sciences, and jstore were searched to explore the phenomena of occupational health. Further, several themes and sub-themes have been identified according to the classification of theories in occupational health. The health belief and behaviour towards occupational health of working population have been derived from various theories. Further, the relationship of various factors has been studied based on the theoretical understanding of occupational health.

Implant Abutment Screw Loosening: A Review of Effective Factors

Mohammad Ali Seddigh, Azam Sadat Mostafavi
One of the prevalent complications of dental implants is screw loosening. It has been revealed that screw loosening is a matter of concern for both manufacturers and dental professionals, and this complication imposes more time and money to clinician and patient. The clinical long-term success of implant restorations depends, in part, on the actions to minimise the parameters causing screw loosening. This review article aims to throw light on explaining these effective factors and parameters that determine screw stability. Literature based-search was performed to find related articles till December 2018 using EMBASE, Google Scholar and MEDLINE. Search terms used were Implant-abutment (I/A) connection/interface, screw-joint stability, lubricants (such as chlorhexidine (CHX), blood and saliva), mechanical and biological factors (such as contamination, micro-gap formation, settling effect, metal fatigue and abutment screw coating and loosening) in implant functional failure. Results were limited to papers available in English. The references of all related literature were also searched for further citations. A large number of factors including lubricants and mechanical factors have been proposed to have the potential of increasing screw loosening. In-vitro and in-vivo studies concerning the detailed role of biomechanical agents in incidence of screw loosening may be interesting area to improve the existing knowledge in this field. This paper presents the comprehensive insight into effective factors in incidence of screw loosening.

Journal of clinical and diagnostic research

Button Battery Ingestion: A Conundrum of Preventable Sequelae Management

Malakoplakia of the Uterus: A Rare Cause of Postmenopausal Bleeding Mimicking Malignancy

Elephantiasis and Maintenance of Results Following Intensive Treatment

Sublingual Foregut Cyst Lined by Respiratory Epithelium- A Rare Cause of Cystic Lesion in the Floor of the Mouth

Partial Anodontia-An Untold Clinical Presentation of Diamond Blackfan Anaemia: Case Report

Recurrent Postprandial Hypoglycaemia in Insulin Autoimmune Syndrome

Right Psoas Abscess as a Consequence of Ruptured Appendix with Caecal Perforation and Presenting as Right Lumbar Swelling in a Toddler: A Rare Presentation of Appendicitis

Anaesthetic Management of a Patient with Giant Pulmonary Bullae for Surgical Resection of Carcinoma Upper Alveolus: A Case Report

Oral Leukoplakia Management using Diode LASER: A Case Report

Reconstruction of Extraoral Fistula of Dental Origin

A Segmental Medial Malleolus Fracture: A Rare Entity

Rare Case of Symptomatic Ovarian Leiomyoma in Perimenopausal Woman

Teaching Points: Appropriate Evaluation of Ascitic Fluid in an Acutely Ill Cirrhotic Patient

A Novel Laboratory Technique of Fabricating a Definitive Hollow Obturator using Brown Sugar

Malaria Vaccine Development: Challenges and Prospects

Effect of Lycopene on Antioxidant Status and Serum Corticosterone in Wistar Rats Subjected to Chronic Mild Stress

Acceptance of Human Immunodeficiency Virus Testing among Caregivers of Children using Provider-Initiated Testing and Counselling Strategy in Ido-ekiti, Nigeria: A Cross-sectional Study

Glycaemic Control and Inflammatory Mediators in Diabetic Patients with Coronary Artery Disease

Comparison of Pulmonary Function in Children with Cerebral Palsy and Normally Developed Children

Shear Bond Strength of Metal Brackets to Zirconia Following Different Surface Treatments using a Universal Adhesive

End of Life Holistic Care for Cancer Patients: A Qualitative Study

Psychometric Properties of Persian Version of the 8-item Morisky Medication Adherence Scale in Type 2 Diabetes Patients

Association of Androgen Receptor (AR) CAG Repeats and Cytochrome P450 3A5*3 (CYP3A5*3) Gene Polymorphisms in South Indian Men with Prostate Cancer

Comparison of QF-PCR and FISH for Aneuploidy Detection in Prenatal Diagnosis

Accuracy of Sonographic Modules in the Estimation of Birth Weight: An Analytical Study of Antenatal Women in Enugu, Nigeria

Dental Students’ Perception of Dentine Hypersensitivity and Awareness about its Management

Oxidative Stress, DNA Damage and Serum Vitamin D Levels in Prediabetes

Changes in Posterior Segment Optical Coherence Tomography after Intravitreal Triamcinolone Acetonide Injection

Comparative Evaluation of Formocresol, Propolis and Growth Factor as Pulpotomy Medicaments in Deciduous Teeth- An Invivo Study

Evaluation of Knowledge, Attitude and Practice Regarding Stress Management among Undergraduate Medical Students at Tertiary Care Teaching Hospital

Aesthetic Crown Lengthening with Flapless Piezoelectric Surgery in Comparison with Traditional Open Flap Approach

Utility of Microwave Processing in Plasma-Thromboplastin Method of Cell Block Prepared from Fine Needle Aspirates

Contributory Factors for Obstetric ICU Admission: A Prospective Cross-sectional Study

Assessment of Insulin Resistance in Ultrasonographically Diagnosed Cases of Non-Alcoholic Fatty Liver Disease

Obstetric Cerebral Venous Thrombosis- A Clinical Dilemma

A Randomised Controlled Trial of Lactobacillus in the Prevention of Ventilator Associated Pneumonia

Correlation between Frequency of Flaps in Asterixis and Severity of the Liver Disease in Patients with Hepatic Encephalopathy

Nasal Colonisation of MRSA in Oral Cancer Patients in a Tertiary Care Hospital of Northern India

Prevalence of blaCTX-M, blaCTX-M-2, blaCTX-M-8, blaCTX-M-25 and blaCTX-M-3 Genes in Escherichia coli Isolated from Urinary Tract Infection in Kermanshah City, Iran

Effect of Technique of Disinfection by Ultrasonic Nebulization on Accuracy of Vinyl Polysiloxane Impressions

Assessment of Enamel Surface Microhardness with Different Fluorinated Compounds under pH Cycling Conditions: An in-Vitro Study

Clinico-mycological Study of Otomycosis Comparing the Cavity Slide Technique and the Conventional Agar Block Slide Culture

Parents Awareness about the First Dental Visit and Behaviour Management

Histopathological Analysis of Psoriasis in a Study of 24 Cases

Variation in Circulating Betatrophin/ANGPTL8 Levels in Normal and Overweight/Obese Pregnant Women

Journey from Fighters to Survivors: Quality of Life and Mental Status in Cancer Patients in a Rural Tertiary Care Hospital

The Effect of a 16-week Home-based Aerobic Exercise Program on Serum High-sensitivity C-Reactive Protein (Hs-CRP) and Insulin Resistance in Polycystic Ovary Syndrome

Prevalence of Intestinal Parasitic Infections among Pulmonary Tuberculosis Patients in a Tertiary Care Hospital, Bhubaneswar, Odisha, India

KRAS, NRAS, and BRAF Mutation Pattern in Metastatic Colorectal Cancer: A Study from Northwest Iran

The Effect of Cognitive-Behavioural Counselling on Pregnant Women’s Weight Gain during Pregnancy: A Randomised Controlled Clinical Trial

A Study on Chronic Proton Pump Inhibitor Usage and Small Intestinal Bacterial Overgrowth (SIBO)

Oncogenic Human Papillomavirus Genotypes and Cervical Cancer: A Focus on Multiple Infections and Patient Age

Randomised Controlled Trial to Compare the Efficacy of Epidural Analgesia versus Intravenous Analgesia during Thoracotomy for Repair of Oesophaeal Atresia

In silico Prediction of Anti-plasmodial Activity of Spices: Targeting Malarial Proteases

Clinical Spectrum of Rheumatologic Manifestations in HIV Patients: A Study from Southern India

Effect of Inspiratory Muscle Training and Diaphragmatic Breathing Exercises on Dyspnea, Pulmonary Functions, Fatigue and Functional Capacity in Pregnancy during Third Trimester

Liver and Splenic Volumes in the Indian Population: Is There a Single CT Measurement Correlate?

Region Specific Reference Intervals for TSH in the First Trimester of Pregnancy: A Three Year Retrospective Study

Head Circumference and Birth Length as Predictor of Low Birth Weight among Bengali Hindu Population of Kolkata, West Bengal, India

Utility of DxH 800 VCS Parameters and Lymph Index in Predicting Dengue

Effectiveness of Scapular Mobilisation in the Management of Patients with Frozen Shoulder- A Randomised Control Trial

Early Clinical Experience with Simvastatin for Treating Pain in Patients with Idiopathic Chronic Pancreatitis

Fast-tracking Histopathology: Is Microwave the Way Forward?

Characterisation of Breast Cancer Lesions using Image Processing Based Technique

Is Anticipatory Postural Adjustments Focused Training Effective for Fall Prevention and Quality of Life in the Elderly?

Effectiveness of Indian Diabetes Risk Score as a Screening Tool for Non-alcoholic Fatty Liver Disease: A Study from Anand, Gujarat, India

Ethics and Attitude- From Seed to Sapling: Perspective from India

Vaccine Development Against Salmonella Typhi: The Search is Still On

Osteoclasts: Multifaceted Molecule in Vesicular Trafficking

Polyetheretherketone (PEEK) in Dentistry

Reciprocal Relations between Work and Health: A Theoretical Understanding from the History of Occupational Health and Behaviour

Implant Abutment Screw Loosening: A Review of Effective Factors

Association of Androgen Receptor (AR) CAG Repeats and Cytochrome P450 3A53 (CYP3A53) Gene Polymorphisms in South Indian Men with Prostate Cancer

Prevalence of bla_CTX-M, bla_CTX-M-2, bla_CTX-M-8, bla_CTX-M-25 and bla_CTX-M-3 Genes in Escherichia coli Isolated from Urinary Tract Infection in Kermanshah City, Iran