Journal of clinical and diagnostic research

Chyluria: An Unending Illness- A Case Report

Dwijesh Kumar Panda

Chyluria is the passage of milky urine due to a lymphourinary fistula. It is secondary to lymphatic stasis caused by obstruction of the lymphatic flow. It is caused by the parasite Wuchereria bancrofti in more than 95% of cases in tropical countries. Chyluria occurs in 2% of filarial-infested patients. When an abnormal connection between intestinal lacteals and the urinary tract develops, chyluria appears. The diagnostic approach is aimed to define the site of lymphourinary fistula. It is a benign disease that can be controlled by medical treatment and dietary restrictions. A small number of patients require surgical intervention. The 45-year-old thin built woman was suffering from chyluria, flank pain in the abdomen, weakness and loss of weight for the last 10 years. The serum test for circulating adult filarial antigen was positive in moderately high titer. Antifilarial treatment was advised. The symptoms improved for three months and again relapsed.

Variations in the Axillary Artery Branching Pattern

Deepshikha Singh, Minakshi Malhotra, Sneh Agarwal

Variations in axillary artery branching pattern can lead to iatrogenic injuries during invasive procedures. Knowledge of the same is critical to prevent such events. Multiple bilateral variations were observed in the branching pattern of axillary artery. These variations were noted in a female cadaver, during routine undergraduate dissection in September 2019 in Lady Hardinge Medical College, New Delhi. On the left side, an anomalous branch running with the medial pectoral nerve was found. A common stem arising from the 2nd part of left axillary artery divided to give the lateral thoracic artery, the subscapular artery and an alar artery. Another alar branch arose from the left subscapular artery before it bifurcated into thoraco-dorsal and circumflex scapular arteries. The right axillary artery gave an aberrant branch proximal to the lateral thoracic artery. A common trunk arising from the 2nd part of right axillary branched out to give the posterior circumflex humeral artery, the subscapular artery and an alar artery. The brachial artery divided 13.5 cm proximal to the intercondylar line of humerus on the left and 14.4 cm on the right side. On both sides, the ulnar artery arose proximally and the radial and common inter-osseous arteries continued as a common trunk and divided distally. This case study reports multiple bilateral axillary artery anomalies and complements to the existing knowledge of vascular anomalies. Comprehensive knowledge of these variations is essential from anatomical, radiological and surgical point of view. During surgeries involving axillary and pectoral group of lymph nodes, such variations should be kept in mind.

Henoch Schonlein Purpura as Late Manifestation of Hepatitis A Infection

Prateek Jindal, Kapil Bhalla, Neha, Sanjiv Nanda

An uncommon presentation of Hepatitis A Virus (HAV) Infection is cutaneous vasculitis. This report is about a seven-year-old male patient that came to the pediatric emergency with complaints of bilateral swelling of lower limbs and pain in right knee for the last three days. Patient had history of jaundice one month back. On examination, he was febrile and had swelling over right knee with decreased range of movements and multiple palpable purpura over lower extremities and buttocks. Laboratory evaluation showed deranged Liver Function Test (LFT) and positive HAV IgM antibodies. Histopathological examination of skin biopsy was suggestive of leukocytoclastic vasculitis and IgA deposition. Final diagnosis of Henoch Schonlein Purpura (HSP) was established based on clinical findings and skin biopsy findings which are usually sufficient for confirmed diagnosis. Patient was admitted and managed conservatively with oral analgesics. After a few days, patient was discharged in satisfactory condition.

High Grade Serous Carcinoma Presenting as a Huge Pelvic Mass with Normal Looking Ovaries: A Diagnostic Challenge for Pathologist

Vaishali Walke, Amrapali Gaikwad, Madiha Shaikh, Balwant Kowe

High-grade serous carcinoma represents 50-60% of all ovarian cancers and is the most common type of malignant surface epithelial tumour. Serous carcinoma is often diagnosed in the sixth and seventh decade, while the mean age for high-grade tumours is 63 year. It’s not only the non-specific symptoms like vague abdominal pain, nausea, gastrointestinal disturbances, but also the unusual presentation which is responsible for delayed diagnosis. This diagnostic delay can become the reason for increased mortality, despite advances in surgical management and chemotherapy. Here, authors discuss a case of 60-year-old postmenopausal women who presented with a huge pelvi-peritoneal mass and with grossly normal ovaries. Considering clinical findings and histomorphology, the possibility of malignant mesothelioma was considered as the first differential diagnosis; however extensive sampling of ovaries and supportive immunohistochemical markers helped us to arrive at a definitive diagnosis. The present case emphasises the importance of extensive tissue sampling and ancillary techniques in arriving at a correct diagnosis.

Seronegative Lupus- A Wolf in Sheep's Skin

Eram Nahid, Saumya Gupta, Deepak Gautam, Indrajeet Singh Gambhir

Systemic Lupus Erythematosus (SLE) is a chronic inflammatory multisystem autoimmune disease. Most of the SLE cases are seropositive, but rare (5%) seronegative SLE cases can also present with complications. Hepatic involvement SLE is multifactorial like hepatotoxic drugs, steatohepatitis, viral hepatitis and Autoimmune Hepatitis (AIH). However, the differentiation between lupusrelated hepatitis and AIH remains a challenge to the clinician because of many similar features. It is very difficult to differentiate whether hepatitis is due to autoimmune involvement or purely lupus related on the basis of clinical and biochemical parameters. The patient must fulfill ACR criteria for SLE and International Autoimmune Hepatitis Group (IAIHG) criteria for AIH. Histological diagnosis is considered to be definative in differentiating SLE-related hepatitis and AIH. The cardiac manifestations of SLE are multiple with pericardial disease being the most common. While pericardial effusion is rarely haemodynamically significant, the occurrence of subsequent constrictive pericarditis is even less frequent with only occasional reports in the literature. Authors described a case of a 17-year-old female with Antinuclear Antibody (ANA) negative active SLE (seronegative) with AIH and constrictive pericarditis. The patient responded well to the conservative management initially but later developed drug induced myelosuppression and bilateral pneumonia and succumbed.

Facial, Skeletal and Radiological Features of Larsen Syndrome: A Case Report

Ravishankar Pillenahalli Maheshwarappa, Juhi Bansal

Larsen syndrome is a rare congenital osteochondrodysplasia resulting in multiple joint dislocations and typical facial features. The inheritance pattern can be autosomal dominant or recessive, with the recessive pattern being more severe. This condition requires prolonged orthopaedic treatment and achievement of complete normal function is unlikely. The author hereby present a case report of three-year-old female child with this syndrome which was diagnosed by clinical examination and radiological findings

Enterovesical Fistula: A Serious Complication of Crohn Disease

Atef Mejri, Badreddine Aloui, Khaoula Arfaoui

Due to the anatomical proximity of the last ileal loop and the bladder, Crohn’s disease can affect the urinary tract by the formation of an Enterovesical Fistula (EVF). Although rare, it represents a complication with a potential impact on the patient’s quality of life and it is often difficult to manage. In addition to the Computed Tomographic (CT) findings, several other examinations can contribute to the diagnosis of EVF, which calls for adequate management based on disconnection of the digestive tract from the bladder and maintenance of medical treatment. Despite therapeutic advances in the context of Crohn’s disease, the EVF remains a surgical indication. The present case reported is of a successfully managed EVF which was revealed by fecaluria aiming to emphasise the clinical aspects and various diagnostic tools with a special mention of the key role of medical imaging in the diagnostic process and the surgical management.

Neuroleptic Malignant Syndrome Presenting with Self Injurious Behaviour

Varsha Muddasani, Raghavendra Bakki Sannegowda

Introduction: Inflammatory state is considered as the pathogenesis of Gestational Diabetes Mellitus (GDM). Cytokines can cause insulin resistance and maybe the molecular basis of inflammation in Diabetes Mellitus (DM). Aim: To assess the level of Interleukin-10 (IL-10) in addition to a new anti-inflammatory cytokine marker Interleukin-35 (IL-35) in pregnant women with and without GDM. Materials and Methods: Participants in the study included 29 pregnant women with GDM (case group) and 29 healthy pregnant women (control group). Blood levels of IL-10, IL-35, Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) were measured in all participants. Independent t-test and Chi-square test were used for data analysis. Quantitative data between three gestational subgroups (<29, 29-32 and >32 weeks) in each GDM and control group were compared by ANOVA test. The p-value <0.05 was considered significant. Results: The mean levels of IL-10 were 1.03±0.85 and 0.83±0.57 pg/mL (p=0.284) and the mean IL-35 concentrations were 10.2±8.1 and 8.8±4.3 pg/mL (p=0.437) in GDM and control groups, respectively. The mean CRP and ESR levels were higher in the GDM group than the controls but the differences were not statistically significant. In the GDM group, IL-10 was significantly lower at the early stage of pregnancy (<29 weeks) compared to the later stage (>32 weeks) (p=0.04), but this was not true in the control group. There was no significant difference between the mean level of IL-35 at different gestational ages in both GDM and control groups. Conclusion: The present study showed the decreased level of anti-inflammatory marker IL-10 in the late stage of pregnancy in diabetic women especially during the last weeks of gestation. New inflammatory marker IL-35 was not statistically significant in GDM subjects.

A Case of Unilateral Hyperlucency on Chest X-Ray- A Diagnostic Dilemma

Unilateral hyperlucency of the lung is not an uncommon finding which arises from a variety of conditions, like technical, congenital and acquired. Here, the author presents a case of diaphragmatic hernia which presented as unilateral hyperlucency on chest radiography. A 45-year-old female, presented with complaint of shortness of breath for 2-3 years, increased since 15 days and pain in abdomen for 2-3 years. She consulted a doctor where a chest X-ray was done and was advised Intercostal tube insertion with the diagnosis of left-sided pneumothorax and was referred to us for further management. Instead of her vitals were stable on examination. On auscultation, breath sounds were of decreased intensity. A chest X-ray was then done which showed unilateral hyperlucency of the left side with the presence of air fluid level. The CECT thorax showed a large diaphragmatic hernia through which the large intestine and stomach were occupying the left hemithorax. Therefore, a thorough evaluation should be done before reaching a definitive diagnosis in such patients

Curious Case of a Foldable Intraocular Lens that did not Unfold

Nimisha Nagpal, Pawan Prasher

Phacoemulsification is a modern technique of cataract surgery that allows the removal of cataractous lens and implantation of a foldable Intraocular Lens (IOL) through a small sub 3 mm incision. For a good visual outcome, it is imperative that the IOL is well centered and its haptics unfold properly inside the capsular bag and keep it distended. However, at times the IOL haptics may not unfold properly leading to adverse visual symptoms. Herein, Authors present an unusual case of a 61-year-old elderly male with no other associated ocular or systemic illness, who presented nine months after cataract surgery in his left eye, with both haptics of the IOL unusually folded and the edge of one haptic encroaching into the pupillary area leading to visual symptoms. As multiple attempts to dial the haptics into the capsular bag were unsuccessful, likely due to strong capsular adhesions, the unfolded haptics were placed in the sulcus with attempted optic capture. The postoperative period was uneventful with BCVA of 20/20 at one year. The current case highlights the need to be vigilant about the proper positioning of the haptics at the end of routine cataract surgery and the need for early intervention in the event of any complication.

Ectopic Ureter in Single System Kidney in Association with Anorectal Malformation in Male Patient

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

Anorectal Malformations (ARM) are known to be associated with urogenital abnormalities. However, the incidence of ectopic ureter in these patients is rare. This report is about a two-year-old male child with ARM. The patient presented after a failed Posterior Sagittal Anorectoplasty (PSARP). The presenting complaint was urinary leak from rectum. Subsequently, the patient was taken up for redo-PSARP. During surgery, bilateral ectopic ureters were identified, incidentally. Surgeons operating on the patients of ARM should be vigilant about this rare association of ectopic ureter with ARM, so as to avoid its injury during perineal dissection.

Bilateral Accessory Central Cusp on Permanent Mandibular Second Molars: An Unusual Occurrence

Paras Mull Gehlot, Jumana Haseen, Veena Jayadevan, BM Annapoorna

Anomaly like central cusp is accessory cusp which is similar to Dens Evaginatus (DE) in premolars. Such accessory occlusal/ central cusps are rarely being reported in mandibular molars. The presence of these structures can be a cause of concern when they interfere with occlusion, get fractured or pulp is exposed. This report presents an unusual case of 21-year-old male patient with bilateral accessory cusp in permanent mandibular second molars, the left with Occlusal central cusp (7-cusp anatomy) and the right with a prominent expression of tuberculum sextum (5-cusp anatomy). The patient reported with sensitivity on lower left second molar. Radiograph did not reveal any pulpal extension in both the teeth. Buccal caries on left second molar was restored with composite resin and the accessory cusp was incrementally grinded. The patient reported on follow-up visit after 6 months and was asymptomatic. Early identification of supernumery occlusal central cusp and proper treatment can avoid pulpal complications.

Bortezomib Induced Paralytic Ileus: Are we Aware?

Bortezomib is one of the most commonly used drugs in the treatment of multiple myeloma. It has many well-known side effects like peripheral neuropathy, thrombocytopenia and diarrhoea. Paralytic ileus has been rarely reported in patients of multiple myeloma receiving bortezomib and one should be aware about this entity. Stool frequency should be carefully monitored and the drug should be stopped timely to prevent complications of paralytic ileus. The patient was admitted for management of multiple myeloma and supportive care. He was started on the VTD (Bortezomib/thalidomide/dexamethasone) protocol. He developed abdominal distension and absolute constipation soon after the 2nd weekly dose of bortezomib. Abdominal X-ray revealed grossly dilated large bowel loops. Although he was given lactulose, glycerine suppository enema, the problem of abdominal distension and constipation persisted. His gastrointestinal symptoms improved and he was able to pass stools after bortezomib was removed from the protocol. One should be aware of this rare side effect of bortezomib. Bortezomib dose should be modified or it should be stopped timely to prevent complications.

A Case of Macrophagic Activation Syndrome in a Child with Epilepsy Treated with an Excessive Dose of Sodium Valproate

Macrophagic Activation Syndrome (MAS) is a rare disorder and is thought to result from non-malignant activation and proliferation of macrophages and T-cells. It can be of primary or secondary origin and its prognosis is often poor. Authors report a case of a three-year-old boy admitted in the intensive care unit for MAS secondary to an overdose of sodium valproate to remind practitioners to think about it in the presence of a febrile pancytopenia.

Unilateral Nevus of Ota with Palatal and Optic Disc Pigmentation with Coincidental Preauricular Tag- A Case Report

Prasanna Nareddy, Ambati Divya

Nevus of Ota also known as oculodermal melanosis presents as hyperpigmentation of face involving ophthalmic and maxillary branches of trigeminal nerve associated with ocular hyperpigmentation. It is due to confinement of melanocytes in the dermis. Most commonly it is unilateral but sometimes it may have bilateral presentation. Typically, it presents at birth but can also be an acquired condition. Frequently seen in Japanese and rarely in Indian subcontinent. It has more predilection towards females. Less frequently, hyperpigmentation is seen in other sites like oral mucosa, tympanum and nasal mucosa. These patients are at high risk of developing glaucoma and malignancy. The author reported a case of 12-year-old male child with unilateral pigmentation of left side face involving forehead, periorbital and cheek, along with ocular pigmentation. Hyperpigmentation of conjunctiva, iris and angles is present in left eye with intraocular pressure being normal in both eyes. Fundus showing optic disc pigmentation in the left eye with cup disc asymmetry in both eyes. Child has coexistent preauricular tag on the left side.

Neonatal Autopsies with Heart Disease: A Challenge for Pathologist

Smita Singh, Srijan Srivastav, Kiran Agarwal

Congenital Heart Diseases (CHD) carry significant morbidity and mortality in paediatric patients. Transposition of Great Arteries (TGA) is a common cyanotic CHD. However, onset of Pulmonary Arterial Hypertension (PAH) is potentially severe and rare complication reported in 1-3% of newborns. Hypertrophic Cardiomyopathy (HOCM) is a primary disease of cardiac muscle usually recognised in adulthood. Neonatal HOCM without other congenital anomalies, no family history of HOCM, no history of exposure to corticosteroids or any inborn errors of metabolism is rarely recognised. Authors hereby report two cases of neonatal autopsy showing TGA with PAH (Grade 2) and another with HOCM without any primary cause received in our hospital. With this case report authors wish to stress on the importance of cardiac examination (heart and the associated vessels) in autopsy specimen which in turn requires training of pathologists in cardiac pathology along with routine fetal anomaly scanning in arriving successively at the final diagnosis and detecting the cause of death which helps in management of future pregnancies by the clinicians.

Incidental Detection of Microfilaria in Fine Needle Aspiration Cytology- A Report of Three Cases

Gayatri Rath, Ashok Kumar Panda

Lymphatic filariasis, a major global health problem, is a mosquito-borne parasitic disease, encountered mainly in the tropics and subtropics. The disease is endemic in Southeast Asia, including the Indian subcontinent. It is transmitted by mosquitoes and is caused by the filarial nematodes Wuchereria bancrofti, Brugia malayi and Brugia timori. Usually, the infected person remains asymptomatic for years together and later manifests with features and consequences of lymphatic obstruction. The adult forms of the nematodes live in human lymphatics, whereas the infective larval form, the microfilaria circulates in the peripheral blood. The nocturnal periodicity of the microfilaria makes it challenging to detect in routine peripheral blood smear examinations. Also, it is quite unusual to find the microfilaria in fine needle aspirations. However, rare cases have been reported in certain unusual sites, like lymph nodes, cutaneous swellings, bone marrow, bronchial aspirate, breast, nipple discharge, cervicovaginal smears, pleural, pericardial, ascitic fluids, ovarian cyst fluids or even thyroid. Very few cases of microfilaria in thyroid aspirates have been reported till date. Also, it is unusual to find microfilaria in lymph node and breast aspirations. Herewith, three cases of microfilariasis are reported at three uncommon sites like thyroid, lymph node and breast.

Clinical Profile of nCOVID-19 Cases in Andaman and Nicobar Islands: A Case Series

nCOVID-19 (2019 novel corona virus) is a naive infective virus that brought the whole world to standstill. The clinical features attributing to its infection have a broad spectrum, ranging from minimally symptomatic to respiratory failure and death. The aim of present case series was to assimilate data regarding the clinical characteristics of first 11 cases of COVID-19 infection in the local population of Andaman and Nicobar Islands. Various clinical features, biochemical and individual parameters were compiled that may affect the disease evolution and then, subjected to descriptive analysis. Out of 11 patients, six patients had a definitive known source of their infection and four patients had history of close contacts with first six ones. Only one patient had unknown source of the infection. Majority of the patients remained asymptomatic to pauci-symptomatic. Mean duration of symptomatic period was less than seven days (5.6 days). In this series, out of 11 patients, 2 (18%) were females and rest all were males (82%). Four of the patients had fever, four had cough and four had weakness and fatigue, two had malaise, three had anorexia, one had dyspepsia and one diarrhea. None of the patient landed in Intensive care unit (ICU). Patients were treated with empirical combination therapy including Azithromycin (500 mg OD) and Oseltamivir (75 mg BD) irrespective of their symptoms. Additionally, Hydroxychloroquine (200 mg BD) was given to symptomatic ones. Conclusively, less dreadful clinical presentation of this infection was faced in this population.

The Neuroprotective Effect of Ginkgo Biloba Extract on Valproic Acid Induced Autistic Features in Mice

Marwa A Al-Gholam, Omnia Ameen

Introduction: Autism Spectrum Disorders (ASD) are among the severe developmental disorders, but have no specific treatments available. Ginkgo biloba (GK) has been reported to affect the neurotransmitter system and have anti-oxidant and anti-inflammatory properties that could impact the pathogenesis of valproic acid-induced autistic features. Aim: To identify the neuromodulatory effects of Ginkgo biloba extract on ASD induced by valproic acid in mice. Materials and Methods: A total of 24 male Wistar albino mice, 14-day-old, were used and divided into four groups (6 mice/ group): Control, Ginkgo biloba extract-treated group {received GK at a dose 100 mg/kg via intraperitoneal injection once daily from Postnatal Day (PND) 13 to PND 40}, Valproic acidtreated group (VPA) (received Sodium Valproate at a dose 400 mg/ kg via subcutaneous injection once on PND14), and Valproic acid + Ginkgo biloba extract-treated group (received VPA on PND14 and GK from PND 13 to PND 40). Neuro-behaviour tests (Open field, Social approach (three-chamber) test and T-maze spontaneous alternation) of mice were assessed. Biochemical tests (brain tissue malondialdehyde (MDA), Glutathione (GSH), Interleukin-6 (IL-6), Transforming Growth Factor-Beta (TGF-ß1) and serum interleukin-17 (IL-17) were done. Also, histopathological, immunohistochemical and morphometric studies for the cerebellum were done. Analysis of Variances (ANOVA) was used for statistical analysis of the different groups followed by a post-hoc Tukey test. Results: VPA showed significant neuro-behavioural changes with a significant increase of (MDA, IL-6 and IL-17) and a significant decrease in (GSH and TGF-ß1). Histopathological results revealed widespread neuronal affection, specifically of the Purkinje Cells (PCs) layer with a significant decrease in the expression of Myelin Basic Protein (MBP) and Serotonin. Ginkgo biloba ameliorated significantly VPA-induced autistic changes. Conclusion: Ginkgo biloba extract can ameliorate the autistic changes in mice through its anti-inflammatory and anti-oxidant activities in addition to its ability to modulate serotonin and MBP expression. It can be concluded that GK can be used as a potential disease-modifying treatment for Autism.

Biomechanical Analysis of the Zirconia and Graphene-based CAD-CAM Dental Bridges at Different Pontic Length: A Finite Element Analysis

Mohammed Sulaiman Alruthea

Introduction: During masticatory loading, dental bridges are subjected to various forces that might generate deflections in the bridge framework. For this reason, designing long-span bridges require great care about flexions that happen during the function. This can be compensated by increasing occlusogingival height, using rigid materials and enhancing resistance to deflection by modifying the abutments’ preparations. The current study hypothesied that the stress, deflection, strain and deformation of the fixed partial dentures are guided by the three-dimensional configurations of the pontic areas, and all other parameters could be mutually changed with different influence on the overall outcome. Aim: The study aimed to evaluate the difference in the amount of stress, deflection, strain and deformation on using different materials and configurations in the pontic and connector area of the dental bridge using the 3D Finite Element Analysis (FEA). Materials and Methods: An invitro virtual biomechanical analysis using 3D FEA method was conducted. 3D models were created from the Cone Beam Computed Tomography (CBCT) of a dentulous patient and two materials were selected for this study, Zirconia and enhanced graphene-based polymer. The study models were assembled into four groups as the following: Group I: 3-unit Zirconia fixed-fixed bridge; Group II: 3-unit Graphene fixed-fixed bridge; Group III: 4-unit Zirconia fixedfixed bridge; Group IV: 4-unit Graphene fixed-fixed bridge. Using FEA software a 600 N load was applied and the resultant normal stress, deflection, maximum equivalent strain and total deformation data were monitored, collected and interpreted. Results: The findings of the current study showed higher values of normal stress, deflection, equivalent elastic strain and total deformation in Graphene-based bridges (group II and IV) than the Zirconia-based bridges (group I and III). It should also be mentioned that normal stress, deflection, equivalent elastic strain, and total deformation showed higher values in the threeunit bridge (group I and II) than their corresponding 4-unit bridge groups (group III and IV). Conclusion: This biomechanical analysis confirmed that the stress concentration and deflection of the fixed bridge are influenced by material characteristics. However, configuration of the pontic area could influence the studied mechanical parameters regardless the length of the dental bridge.

Should Dentist be a Part of COVID Care Team?

Aradhana Nagarsekar, Ridhima Gaunkar, Praveen Jodalli, Ashley Santimano

Dear Editor, The Coronavirus Disease-19 (COVID-19) pandemic sweeping across the globe can cause an altered immune reaction similar to the autoimmune damage, deleteriously affecting the cellular response of the host. At times, body’s first line of defence mechanism fails to defeat the virus as it does not respond effectively to inflammatory shield (1). The morbidity rate is reportedly higher in the geriatric population and in patients with underlying comorbidities such as asthma, diabetes, cancer and cardiac diseases (2). Interestingly, COVID -19 patients do not follow a categorical pattern of infection. Population specificity of Angiotensin Converting Enzyme 2 (ACE2), which is the receptor of Severe Acute Respiratory Syndrome-Corona Virus-2 (SARSCoV- 2) and mutation of viral surface proteins (spike-S-protein and nucleocapsid-N protein) could be responsible for atypical symptoms of the disease (3). Though lungs are the primary site of COVID-19 infection with manifestations ranging from flu-like symptoms to sudden respiratory distress, mucotropic ability of SARS-CoV-2 could potentially lead to altered salivary gland function, reduced sensation of taste and changes in oral mucosa (1). Studies have revealed expression of ACE2 receptors in tongue, buccal and gingival tissue and minor salivary gland ducts in oral cavity. Oral symptoms like amblygeustia and dry mouth in COVID-19 patients suggest dysfunction of these receptors (4). SARS-CoV-2 could also provoke oral atypical herpetic look alike lesions like ulcers or blisters that may resemble other viral infections (6). However, more robust scientific evidence is required to support this claim. It is still not clear if oral manifestations are caused primarily due to COVID-19 or secondary to immunodeficiency condition considering the possibility of opportunistic infections (6). Moreover, the effect of intricate pharmacotherapy and emotional distress during intense hospitalisation for COVID-19 cannot be underestimated while assessing patient’s oral health (1). India’s COVID-19 cases are escalating at an alarming rate. Currently, Indian Public health care system catering to the world’s second highest population is under-resourced and over-stretched. Adopting a multidisciplinary approach of including a dentist in person or via teledentistry in the COVID care team may have a positive impact on patient’s quality of life. Dentist can provide supplementary treatment by suggesting rehydration therapy, alleviating pain and discomfort in oral cavity and reinforcing oral hygiene measures. This will help to tackle nutritional deficiencies thereby aiding faster recovery from COVID-19. Thus, dentists can provide curative as well as preventive oral care for hospital/home quarantined COVID-19 patients.

Subungual Melanoma- An Enigmatic Entity

Madhusmita Jena, Rajeswari Bhat

Dear Editor, Subungual melanoma is a rare variant of melanomas that originates from the nail matrix accounting for 1.5-2.5% of all melanomas (1). These melanomas get misdiagnosed as pyogenic granuloma or onychomycosis clinically [1,2]. The role of recurrent trauma in the progression of the lesion has been described; but its role in the pathogenesis of acral melanomas is not clear as many a times the injury draws the attention of the lesion (3). The history of recurrent injury and clinical presentation is often misleading resulting in delayed diagnosis and treatment (3). A 61-year-old male, stenographer by profession presented with chief complaint of a painful reddish mass in the nail matrix of the right thumb, associated with bleeding following a history of repeated trauma of three months with loosening of nail plate from the nail bed and a slowly growing mass with a increased tendency to bleed. The patient gave a history of a linear brown to blackish discolouration of the nail plate eight years back which was stored in his mobile camera [Table/Fig-1a]. The patient had been treated with antifungals and antibiotics for a long time on a clinical suspicion of Onychomycosis after eight years of the blackish discolouration of the nail, the patient presented with a fleshy reddish irregular mass measuring about 1 × 0.9 cm along with blackish pigmentation of the nail bed and tip of right thumb (Hutchinson’s sign). The mass was friable and was bleeding easily on touch [Table/Fig-1b]. A surgical removal of the nail plate was done at our institute and a small biopsy from the mass was taken. Microscopy showed layers of lamellar keratin and granular squamous epithelium with intracytoplasmic melanin pigments [Table/Fig-2a]. The other tissue fragment was composed of malignant cells arranged in sheets showing mild pleomorphism with hyperchromatic to vesicular nuclei, occasional small prominent eosinophilic nucleoli and moderate cytoplasm. Intracytoplasmic and extracellular melanin pigment was noted [Table/Fig-2b]. Mitotic activity was not seen in the tumor tissue. The Breslow’s thickness could not be assessed as the epidermis was separated out from the tumour tissue. However, the thickness of the tumour in the tissue received was found to be 4 mm. A negative Periodic Acid Schiff (PAS) stain ruled out fungal infection. A Perls stain done on tissue which was negative excluded the haemosiderin pigment from melanin. A melanin bleach was also performed. As, both the tests favoured towards melanin pigment in the malignant cells, a diagnosis of melanoma was signed out. There were no enlarged and palpable epitrochlear or axillary lymphnodes. Systemic examination and routine investigations were all normal. Screening for metastasis was negative on radiology like ultrasound and CT scan. The patient was referred to a higher centre where he underwent disarticulation of the interphalangeal joint of the thumb and the melanoma was confirmed on histopathology with margins free of tumour. This patient had a history of recurrent trauma to his right thumb as he was using it for stenography. The association of trauma with melanoma has been reported in the literature (3). Also, the patient gave a long history from the time of the blackish linear discolouration till the appearance of a bleeding mass from the nail bed. Inspite of such a long history, there was no evidence of distant metastasis which is quite unusual unlike other malignant melanomas. Subungual melanomas are rare and account for 0.7% to 3.5% of all malignant melanomas worldwide. They are more frequent in Asians than whites (4). The diagnosis of a subungual melanoma needs a stepwise approach of clinical examination, dermoscopic findings and histopathological examination [4,5]. The findings of linear discolouration of the nail plate >5 mm, single nail involvement, periungual pigmentation, enlargement of the pigmented band from distal to proximal end should raise a suspicion of malignancy [3,5]. The poor prognostic factors include elderly age group, ulceration and mitosis. Delay in diagnosis of the lesion can result in a poor prognosis. The five year survival rate ranges from 16% to 87% [1,2,5]. Management is surgical involving amputation of fingers or toes. Subungual melanoma is extremely rare in Indian population and only a few cases are reported in the Indian literature because the cases are missed in the early stages, but it has to be kept in mind while dealing with pigmentary lesions of the nail unit (2). What is enigmatic of this entity is getting missed in its early stage and also the absence of local and distant metastasis despite a very long history of eight years as in this case. This case is presented to highlight its rare incidence amongst Indian population and the need for an awareness of this entity to make an early detection.

Prevalence of Mineral Bone Disease in Chronic Kidney Disease Patients using Biochemical Markers

Introduction: Chronic Kidney Disease (CKD), a condition characterised by a gradual loss of renal function over the time, has emerged as a major public health concern with 17% prevalence in Indian population. Decrease in renal function in CKD leads to progressive metabolic derangements of mineral and bone homeostasis which in turn makes them susceptible to bone related and cardiovascular complications. Aim: To calculate the prevalence of Mineral Bone Disease (MBD) in CKD patients by estimation of biochemical markers Calcium (Ca), Phosphorus (P), Alkaline Phosphatase (ALP) and intact Parathyroid Hormone (iPTH) and to analyse their prevalence across different stages of CKD. Materials and Methods: This was a hospital based crosssectional study conducted at Medanta-the Medicity hospital in 2300 previously diagnosed CKD cases who visited the Nephrology OPD for their follow-up visits, from October 2017 to December 2018. Serum levels of Ca, P, ALP and iPTH were estimated in VITROS 4600 and ARCHITECT I system automated analysers using commercially available kits. Stagewise and overall prevalence of deranged levels of these markers was calculated and based on this the prevalence of MBD was calculated. Statistical analysis was done using SPSS version 24.0. Descriptive analysis of quantitative parameters was expressed as means and standard deviation. The analysis for comparison among three or more categories was done using one-way ANOVA. Categorical data was analysed using Chi square test for proportions and data was expressed as absolute number and percentage in a contingency table along with the chi square and p-values. The p-value <0.05 was considered statistically significant. Results: Prevalence of MBD in overall CKD patients was 81.6%; the stage-wise prevalence being 63.4% (stage 3), 76.9% (stage 4), 87.6% (stage 5) and 91.3% (stage 5D). The overall prevalence of hypocalcaemia, hyperphosphatemia, high ALP and secondary hyperparathyroidism was 27.8%, 48.3%, 26.5% and 75.6%, respectively. Conclusion: The present study reports an alarmingly high prevalence of MBD in CKD cases; the disease burden being maximum in stage 5 and 5D. This was despite the administration of relevant medications and supplements to prevent MBD. Thus, there needs to be some change in treatment protocol to reduce the prevalence of MBD to improve the quality of life and reduce mortality rate in CKD patients.

Effect of Premedication with Ibuprofen, Paracetamol and Diclofenac Sodium on the Outcome of Maxillary Infiltration Anaesthesia in Patients with Irreversible PulpitisA Double-blind Randomised Controlled Trial

Chelikani Lakshmikanth Manoj, Avinash Patil, Sanjana Patil, Suresh Shenvi

Introduction: The most important aspect of endodontic treatment is pain control. The quest for newer ways of pain control is always a topic of interest among the researchers. Though local anaesthesia proved to be the effective method of pain control, there are many instances of failure to achieve successful anaesthesia even with proper technique of administration in cases of irreversible pulpitis. Aim: To determine the effect of Preoperative Oral Administration of Paracetamol (PARA), Ibuprofen (IBUP) or Diclofenac Sodium (DS) on the success of maxillary infiltration anaesthesia in patients with irreversible pulpitis in a double-blinded randomised controlled trial. Materials and Methods: One hundred and twenty patients having irreversible pulpitis of a maxillary first molar were selected for this prospective, randomised, double-blind, placebo- controlled study. Patients indicated their pain scores on a Heft Parker visual analog scale, after which they were randomly divided into four groups (n=30). The subjects received identical capsules containing either 500 mg PARA, 400 mg IBUP, 50 mg DS or 400 mg lactose powder (placebo, PLAC), 1 hour before administration of maxillary infiltration anaesthesia with 2% lidocaine containing 1:80,000 epinephrine. Access cavities were then prepared and anaesthesia was defined as successful if pain is absent or patient has mild pain during access preparation and pulp extirpation. The data was analysed using two-way ANOVA and Tukey’s multiple post-hoc tests. p-value at <0.05 to be considered significant. Results: The success rates in descending order were 65% (IBUP), 60.83% (DS), 58.33% (PARA), and 20% (PLAC). A significant (p-value 0.0001) difference was found between the drug groups and the PLAC group. Conclusion: Preoperative administration of PARA (500 mg), IBUP (400 mg), and DS (50 mg) significantly improved the efficiency of maxillary infiltration anaesthesia in patients with irreversible pulpitis.

Comparative Evaluation of Root Dentin Microhardness after using Different Standard Irrigating Solutions and Stevia Leaf Extract- An In vitro Study

Introduction: Success in endodontic therapy largely depends on mechanical and chemical debridement of the root canals by using instruments and effective irrigating solutions which are not only important for cleaning and disinfecting the root canals, but also, are capable of altering the chemical and structural properties of dentin. As the microhardness test is sensitive to surface changes of tooth structure, it is useful in making a correlation between irrigating solutions and root dentin microhardness. Aim: To evaluate the effect of different standard irrigating solutions at standard concentrations and Stevia leaf extract (2.5%) on the microhardness of root canal dentin. Materials and Methods: This is an in-vitro comparative study where forty intact single rooted teeth were selected and decoronated to get an apico-coronal length of 10 mm and were randomly divided into four groups as per the irrigant used; Group 1 (control): Irrigation with Normal saline, Group 2: Irrigation with 2.5% Sodium Hypochloride (NaOCl) followed by 17% EDTA, Group 3: Irrigation with 2.5% Stevia extract solution, Group 4: Irrigation with SmearClear solution. They were prepared using ProTaper Universal Rotary Files with intermittent irrigation with the respective irrigating solution. The teeth were then embedded in acrylic resin and subjected to Vicker’s Hardness test and the data obtained were analysed using one way ANOVA test. p<0.05 was taken to be statistically significant. Results: At 500 microns, Vickers Hardness Number (VHN) value was less than at 1000 micron, but was not statistically significant, (p>0.05). Between the groups, the control group showed the highest microhardness at 500 and 1000 microns, namely, 51.27±4.36 VHN and 53.60±5.12 VHN, respectively. Group 3 and 4 showed a comparable reduction in microhardness with Group 3 showing slightly better results (47.98±4.34 VHN and 48.89±5.26 VHN, respectively) as compared to Group 4 (47.36±5.50 VHN and 48.62±5.84 VHN, respectively). Group 2 showed the least value (36.60±5.71 VHN and 37.11±5.82 VHN, respectively). Conclusion: Within the limitations of this study, teeth irrigated with normal saline showed least reduction in microhardness followed by irrigation with Stevia leaf extract solution, SmearClear and Hypochlorite followed by EDTA.

Prevalence of Horseshoe Kidneys by Multidetector Computed Tomography in a Tertiary Care Hospital in South India

Arunthathy Gnaneshwar, Atshara Rajendran, VB Giri Prabhu

Introduction: Horseshoe Shaped (HSK) Kidneys are often asymptomatic and are frequently diagnosed incidentally. The prevalence varies from approximately 1 in 400 to 600 with preponderance in males (male: female ratio of 2:1). This abnormality can affect the drainage of the kidney leading to Pelviureteric Junction Obstruction (PUJO), renal calculi, urinary tract infections and some renal cancers. The superficial location also makes it more vulnerable to injury during trauma or surgical procedures. Aim: To assess the prevalence of HSK and report their morphological features as evidenced following examination with a 64-slice Computed Tomography of the Kidney and Urinary Bladder (CT KUB). Materials and Methods: A retrospective study was conducted in the Department of Radiology, Sri Muthukumaran Medical College and Hospital & Research Institute, Chennai from January 2017 to December 2018. The study included 861 patients who underwent 64 slice CT KUB during that period and review of both plain and contrast enhanced CT KUB examinations were done. For deciding the fusion site, the isthmus, the authors measured a maximum diameter of the outline of the HSK on the axial image and decided the center of the kidneys. The HSK was classified based on fusion site and type of isthmic tissue connecting two kidneys. Results: HSK was found in 4 (3 male and 1 female) out of 861 patients examined. Thus, the prevalence of HSK in the study population was 1 in 215 (0.46%). Two patients with a thick isthmus and anteriorly facing, pelvises had PUJO and urolithiasis. Variant vascular anatomy was found in all four patients. No crossed fused ectopia was found in this study. Conclusion: This study showed that HSK is the most common congenital fusion anomaly and is more common in males. It also demonstrated that patients with a thick isthmus and associated anteriorly facing renal pelvis were more prone to develop PUJO

Evaluation of Postoperative Pulmonary Complications after Emergency Abdominal Surgery- A Prospective Study

Kailash Charokar, Akash Shrikhande

Introduction: The clinical outcomes following the emergency abdominal surgery besides the surgical complications and the complications due to co-morbidities are influenced by Postoperative Pulmonary Complications (PPC). Continuous health care improvements are directed towards delivering quality care for postoperative patients is the need of the hour in prevailing patient-centric health services in the society. Aim: To evaluate the outcomes after emergency abdominal surgery in relation to pulmonary complications. Materials and Methods: A prospective observational study was conducted in the Department of Pulmonary Medicine and General Surgery at Peoples College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India for a period of one year. Thirty five patients who were operated for emergency abdominal surgery were included in the study. A predesigned and validated proforma was used for the collection of data. In the postoperative period, continuous clinical monitoring and evaluation was done periodically. The primary outcome was PPC like atelectasis, pneumonia, pleural effusion, pulmonary edema, acute respiratory failure. The European Perioperative Clinical Outcome (EPCO) definitions were used for the primary outcome. Descriptive statistics were used for data analysis. The association of pre and postoperative data with the occurrence of PPC was analysed using the Z-test for two sample proportions. The p-value <0.05 was taken as statistically significant. Results: In the study group of 35 patients, 18 patients (51.4%) developed PPC as defined by the selected criteria. Nine (25.7%) patients had pneumonia, 4 (11.4%) patients had acute respiratory failure, 2 (5.7%) patients had pleural effusion, 2 (5.7%) patients had pulmonary edema and 1 (2.9%) patient had atelectasis. The habit of smoking (p=0.003), presence of pre-existing underlying lung disease (p=0.004), and low socioeconomic status (p=0.012) were associated with increased risk for PPC in patients undergoing emergency abdominal surgery with statistically significant results. Conclusion: Pulmonary complications after emergency abdominal surgery are common and leads to the morbidity of patients and may result in fatal outcomes.

Intrathyroid Parathyroid Adenomas-Uncommon Tumours at Unusual Sites: A Cross-sectional Study

Introduction: Ectopic Intrathyroid Parathyroid Adenomas (ITPAs) are rare and known to pose preoperative and intraoperative diagnostic challenges in localisation, resulting in failure of parathyroid surgery. The common histopathological features of these tumours are not elaborately described in literature. Aim: To describe the clinico-pathological features of ITPAs, identified among all parathyroid adenomas, diagnosed at a tertiary care hospital. Materials and Methods: This was a cross-sectional study of all ITPAs diagnosed between January 2012 to December 2019, at Christian Medical College Hospital, Vellore, Tamil Nadu. The gross examination and microscopic findings of ITPAs were reviewed and tabulated. Clinical, radiological and intraoperative findings were compiled to obtain preoperative and intraoperative diagnostic rates. Results: Among 409 parathyroid adenomas, there were ten ITPAs (2.4%), with eight ectopic inferior (80%) and two ectopic superior parathyroids (20%). Four ITPAs were completely intrathyroid (0.97%). Histopathological features of ITPAs were those of usual parathyroid adenomas. Four patients (40%) had concomitant thyroid disease, including one papillary micro-carcinoma (10%). Correct preoperative diagnostic rate was 40%. Intraoperative misjudgment of location occurred in two patients (20%). Conclusion: ITPAs are rare and correct preoperative and intraoperative diagnosis may not be always possible. Histopathological evaluation of suspicious intrathyroid nodules is necessary in such instances to correctly diagnose them.

Study of Glycation of Transferrin and its Effect on Biomarkers of Iron Status in Uncontrolled Diabetes Mellitus Patients

Introduction: Diabetes Mellitus (DM) is a metabolic condition linked by the inability to produce enough insulin and/or to respond to insulin. This can lead to a number of acute and chronic health problems. In erythrocytes, transferrin is the main source of iron. Alterations in transferrin glycation affect transferrin saturation because the affinity of transferrin for Fe3+ is extremely high but it decreases progressively with increasing glycation. Aim: To investigate the influence of uncontrolled diabetes on transferrin glycation and iron metabolism. Materials and Methods: A total of 136 samples from 3 groups of HbA1c levels (<6.0% non-diabetic, 6.4-8% diabetic, >8.0%- uncontrolled DM) were studied for the correlation pattern of iron with other variables. Chi square test and student’s t-test were performed to reveal the association between serum free iron levels and other variables with DM. Results: Serum iron has shown to be depleted significantly (p=0.02) along with percentage saturation (p=0.0006) with increase in diabetic severity. No significant differences were observed in serum ferritin in controlled DM and uncontrolled samples. Total Iron Binding Capacity (TIBC) was found to be significantly increased in uncontrolled DM samples (p=0.01). Abnormal transferrin was observed uncontrolled diabetes with subsequent depletion in transferrin, which in turn results in low serum iron, lower percentage saturation and high TIBC. Conclusion: Uncontrolled diabetes affects the glycation of transferrin also thus perturbating iron metabolism. The present study emphasises the need to monitor transferrin glycation status and iron deficiency anaemia in subjects with uncontrolled diabetes.

Incidence of Diphtheria among Clinically Probable Cases in a Tertiary Care Centre- A Prospective Study

Gunturu Sowjanya, Pennagaram Sarguna

Introduction: Diphtheria is a vaccine preventable communicable acute infectious disease of upper respiratory tract caused by Corynebacterium diphtheriae (C. diphtheria) which is endemic in India. Delayed diagnosis of the disease leads to spread of infection in the community and causes increased morbidity and mortality in the affected individuals. To reduce the delay, an early attempt for microbiological diagnosis of diphtheria should be done as it is crucial and complimentary to clinical diagnosis. Aim: To know the prevalent toxin producing biotypes of Corynebacterium among the clinically probable cases of diphtheria. Materials and Methods: Throat swab samples from 300 clinical cases of diphtheria were processed by direct microscopy and culture. Microscopic examination was done by direct throat swab and samples were inoculated in Loeffler’s Serum Slope (LSS). Antimicrobial susceptibility testing was done by Kirby-Bauer disc diffusion method. Results were analysed using MS Excel. Results: Out of 300 samples, presumptive diagnosis of diphtheria by microscopic examination of direct throat swab was 3% and swab inoculated in LSS was 10%. Confirmed cases of diphtheria by culture were 48 (16%). A 100% sensitivity was seen for all antibiotics tested for all 48 isolates in antimicrobial susceptibility testing. Conclusion: A shift in the age wise incidence of the disease from pre-school to school age has been observed with more cases reported. C. diphtheriae gravis was the highly prevalent strain isolated. Culture should be considered as confirmatory method for diagnosis.

Prospective Observational Cohort Study on Dexmedetomidine and Midazolam in Mechanically Ventilated Children

Introduction: Though target sedation was achieved with Midazolam and Dexmedetomidine, Dexmedetomidine has demonstrated the lesser complications and shorter duration of stay in Intensive Care Unit (ICU). Most of the studies are reported from high income countries. The studies on Midazolam and Dexmedetomidine use in mechanically ventilated children are scanty in low-middle income regions. Aim: To compare the efficacy of Midazolam and Dexmedetomidine for sedation in mechanically ventilated children. Materials and Methods: This prospective observational cohort study was conducted in academic hospital Paediatric Intensive Care Unit (PICU) from March 2015 to June 2016. Children aged less than 13 years mechanically ventilated for more than 24- hour and received sedative with either infusion of Midazolam or Dexmedetomidine without loading dose were involved. Patients with unstable haemodynamic throughout PICU stay and expired within 24-hour and incomplete medical data were excluded. Intermittent Fentanyl/Morphine was used as when needed as per treating team decisions. Sedation assessment was performed with Ramsey sedation scale (RSS, target=3-4 out of 6), Tracheal suctioning score and PICU sedation score. The primary outcome was “percentage of time with target sedation” till extubation. The secondary outcome was the cumulative dose of sedation used, the need for rescue sedation and the rate of complications, organ dysfunction {by Sequential Organ Failure Assessment (SOFA) score and Paediatric Logistic Organ Dysfunction (PELOD) score} and the length of stay in ventilation, PICU and mortality. Results: A total of 115 patients (Midazolam-group, n=63 and Dexmedetomidine-group, n=52) were enrolled. The median age was 12 months (IQR 8-30). Mean (±SD) PRISM-III score was 11.3±7.2. About 54.8% were ventilated for respiratory pathology, followed by CNS pathology (25.2%) and sepsis (10.4%). Mean (±SD) percentage of the duration of proper sedation was not significantly different in Midazolam-group (83.4±15.6) and Dexmedetomidine-group (81.4±17) (p=0.510). The cumulative dose (microgram per kg) requirement was higher in Midazolamgroup {median (IQR) 12.2 (9.8-17.1) vs. 9.6 (5-15.3); p=0.019)}. No difference was note in need for “rescue dose of sedation” per patient {median (IQR) 1 (0-2) vs. 1 (0-2)}, rate of complications (bradycardia 9.5% vs. 1.9%; hypotension 9.5% vs. 5.8%). No difference was noted in organ dysfunction score {mean difference, 95% CI; SOFA score: -0.2 (-1.6 to 1.33); p=0.808 and PeLOD score: 1.3 (-1.5 to 4.1); p=0.364}, duration of ventilation (median, IQR 2.7 (2-3.3) vs. 2.0 (1.5-3.1) days and mortality (20.6% vs. 21.2%). PICU stay was significantly lower in Midazolam-group (median, IQR 3 days, 1-5 vs. 5 days, 4-6; p=<0.001). Conclusion: Midazolam and Dexmedetomidine were associated with similar target sedation with a comparable rate of complications in mechanically ventilated children. However, Midazolam required a higher cumulative dose to achieve target sedation.

Upper Extremity Dysfunction after Trans-Radial Interventions- Experience from a Tertiary Care Center of North India

Manazir Iqbal, Mohd Iqbal Dar, Aamir Rashid, Khursheed A Khan
Introduction: Coronary artery disease treatment by percutaneous intervention has revolutionised the management of this disease and the choice and safety of vascular access site has significantly contributed to the outcome of the overall procedure. Aim: To assess upper extremity dysfunction in patients undergoing Transradial Coronary Angiography (CAG) and Percutaneous Coronary Interventions (PCI). Materials and Methods: This study involved patients planned for transradial coronary intervention. Patients were assessed for development of upper extremity dysfunction and other local complications post procedure at 24 hours, 2 weeks, 1 month and 6 months. Data analysis was done using SPSS Version 21. Results: A total of 165 patients were enrolled in the study. There were 123 (74.5%) males. Total 156 patients (94.5%) had stable angina as underlying diagnosis, 4 (2.4%) had unstable angina, 2 (1.2%) had Non ST Elevation Myocardial Infarction (NSTEMI), 1 (0.6%) had ST Elevation Myocardial Infarction (STEMI) and 2 (1.2%) required CAG before valve replacement. A 5F sheath was used in 110 (66.67%) and 6F sheath in 55 (33.33%) cases. Tiger catheter was used in all 165 patients initially for diagnostic angiography. Dynamometer testing showed reversible downgrading of hand grip in 49% of patients post-procedure. Local site haematoma was seen in 3 (1.8%) at 24 hours, reversible vascular occlusion in 2 (1.2%) at 24 hours and Thrombolysis in Myocardial Infarction (TIMI) Minor bleed in 1 (0.6%) at 24 hours. No significant correlation was seen between sheath or catheter size with dynamometer testing or local complication. Conclusion: There was no significant upper extremity dysfunction after trans-radial intervention in the study population.

A Study of Serum Lipid Profile Changes in Children with Dengue Haemorrhagic Fever and its Correlation with Severity in a Tertiary Care Hospital
Introduction: Dengue Virus (DENV) infection now remains as the most rapidly spreading viral disease worldwide. Lower lipid level occurs in critically ill patients with DENV infection and is postulated as an independent predictor of the clinical outcome. Aim: To find the correlation between serum lipid levels and severity in children admitted with various grades of Dengue Haemorrhagic Fever (DHF) and secondarily to correlate serum lipid levels with factors like platelet count and duration of hospital stay. Materials and Methods: This was a prospective descriptive study done in the Paediatric ward from October 2019 to December 2019. Febrile Children with a platelet count of less than 1 lakh/cu.mm and positive for DENV IgM antibodies by Enzyme Linked Immuno Sorbent Assay (ELISA) formed the study group. Demographic details, number of days of fever on admission, duration of stay in hospital and severity grading of DENV infection as per the National guidelines were collected. These children were evaluated with Complete Blood Counts (CBC), fasting lipid profile, X-ray chest and ultrasound abdomen. Mean and standard deviation was used for categorical variables. Chi-square test was used to assess the strength of association between lipids and severity of DENV infections. Pearson correlation coefficient was used to assess R value between length of stay and serum lipid levels. Results: The total cholesterol, Low Density Lipoprotein (LDL), Triglyceride and Very Low Density Lipoprotein (VLDL) showed a simple linear decline as the severity grade advanced from grade I to grade IV. However statistical significance was found only for total cholesterol and LDL with p-values of 0.046 and 0.041 respectively. The distribution of High Density Lipoprtotein (HDL) across the grades of severity did not follow any pattern and was randomly distributed. On analysis of Pearson correlation between number of days of hospital stay and lipid profile, statistical significance was observed for LDL alone (p=0.023). Conclusion: The serum levels of total cholesterol and LDL were significantly reduced in severe grades of DHF. Serum levels of total cholesterol and LDL can be used as an economical surrogate marker to predict the severity of DHF at the time of admission.

Assessment of Knowledge and Awareness of Radiation Hazards and Protection among Patient’s Relative in Southeast, Nigeria
Introduction: Significant level of exposure of patient’s relatives to ionising radiation during medical imaging procedures has been observed and no attention has been paid to the knowledge of radiation hazards of patient’s relatives that follow the patient for a procedure. Aim: To assess the knowledge and awareness of radiation hazards and protection among patient’s relatives in Southeast, Nigeria. Materials and Methods: This was a questionnaire hospitalbased survey, which was conducted in two teaching hospitals, and one national hospital in Southeast Nigeria from January 2019 to June 2019. A 21 items semi-structured questionnaire were administered to 376 patient’ relatives selected purposively based on the inclusion criteria using one-on-one method. Information on demographic variables of the respondents, knowledge of ionising radiation effect, radiation protection and source of their knowledge of ionising radiation were collected. The obtained data were analysed using descriptive statistics. Results: Majority of the participants were females 221 (58.78%). Most of the participants, 263 (69.95%) did not have knowledge of ionising radiation. Only 118 (31.38%) knew that ionising radiation is hazardous to health. Greater number of the participants 289 (76.86%) were informed by the radiographers about the effects of ionising radiation while 87 (23.14%) read about it. Larger number of the participants, 325 (86.44%) had no idea about the meaning of radiation protection. Majority of the participants 287 (76.33) assisted their relatives during the examination. Most of the participants, 269 (71.54%) said they have seen the radiation warning sign before. Conclusion: This study revealed poor level of knowledge and awareness of radiation hazards and protection among patient’s relatives. It is obvious that public education will contribute immensely in the promotion of awareness of the harmful effect of ionising radiation and radiation protection measures.

Spirometry Function after Decortication for Chronic Pleural Empyema: A Retrospective Study

Subhash Minda, Lata Khatnani Koneru, Nimish Rai
Introduction: Chronic Pleural Empyema (CPE) is a major medical concern. It gives rise to “trapped lung” due to the thickened pleural peel. This results in impairment of pulmonary function. The treatment of choice for CPE is open thoracotomy decortication. Aim: To evaluate changes in Pulmonary Function Test (PFT) in an immediate postoperative period of decortication for CPE. Materials and Methods: A retrospective study was conducted in which 25 patients who had undergone decortication for CPE in the last one year (from October 2018 to September 2019) were included. Baseline clinical and demographic data were collected. Duration of ICU stay, hospital stay and complications were reviewed. In Preoperative period Forced Vital Capacity (FVC) and Forced Expiratory Volume In First Second (FEV1) was investigated. It was again repeated after 3 and 6 months of postoperative period. Preoperative and postoperative data at 3^rd and 6^th month were analysed. Percentage change in PFT was assessed. Repeated measure ANOVAs were used for statistical analysis. Results: Preoperatively the mean FVC was 2.09L (56.63%) and the mean FEV1 was 1.82L (60.26%). The mean FVC, 3 months after surgery was 2.27L (61.52%) and after 6 months was 2.53 L (68.56%). The mean FEV1, 3 months after surgery was 1.92 L (63.58%) and after 6 months was 2.17 L (71.58%). Spirometry values of FEV1 and FVC improved at 3^rd and 6^th month, postoperatively. Improvement in these Spirometric values after 6 months was quantified statistically significant. Conclusion: Decortication for CPE resulted in progressive improvement in spirometry values in a follow-up period of 3 and 6 months.

Effect of Juvenile Idiopathic Arthritis on the Temporomandibular Joint and Occlusion in Children and Young Adolescents: A Descriptive Cross-sectional Study
Introduction: Juvenile Idiopathic Arthritis (JIA) is a chronic rheumatic disease, with a prevalence of 1 in 1000 children under the age of 16 years. The clinical symptoms include inflammation of joints, swelling of synovial membrane resulting in growth disturbances and loss of bone density. Aim: To assess the effect of JIA on the development of Temporomandibular Joint (TMJ) and occlusion in children and young adolescents in the age group of 8-16 years and to evaluate the effect of TMJ arthritis on the growth of maxilla and mandible. Materials and Methods: This is a descriptive cross-sectional study with a study and control group. A total of 44 children with JIA attending the Department of Rheumatology, Nizam Institute of Medical Sciences (NIMS), within the age group of 8-16 years were screened and enrolled in study from MayJuly 2014. A gender and sex-matched healthy control group were enrolled from Paediatric Dentistry outpatient specialty. For the measurement and comparison of arch perimeters of mandible and maxilla, the JIA and control group were divided into sub-groups 1 (8-10 y), 2 (11-13 y), and 3 (14-16 y). All the parameters were recorded and subjected to statistical analysis. An Independent sample t-test was used to find a significant difference for maxillary and mandibular arch perimeters among both the groups. Chi-square test was used to know the difference for TMJ parameters, occlusion and occlusal abnormalities. The level of significance was set at p<0.05 for all tests. Results: Children in the JIA group had reported TMJ pain on movement (40.9%), clicking sounds (36.4%), and dislocation (22.7%). Angle’s class II malocclusion was seen in 36.4% compared to the control group (4.5%). The mean arch perimeter of the mandible was significantly less among JIA children in subgroups 2 (73.00±3.03 mm), and 3 (71.77±6.27 mm) when compared to healthy controls. Other occlusal abnormalities such as increased overjet (34.1%), decreased overbite (31.8%), and crowding (54.5%) were reported in significant percentages compared to healthy controls. Conclusion: The mean arch perimeter of the mandible in the JIA group is less when compared to children of the same age in the control group. There is increased predilection of developing Angle’s class II Malocclusion in the JIA group. From a paediatric dentist perspective, it’s important to understand the overall impact of JIA on stomatognathic system, and an early intervention is recommended.

Knowledge and Awareness of Turkish Population about Dental Treatment during COVID-19- A Questionnaire based Survey

Ferruh Semir Smail, Mehmet Muzaffer AteS
Introduction: SARS-CoV-2, also known as Coronavirus (COVID19), is a zoonotic virus, which can spread from animals to humans, such as SARS-CoV and the Middle East Respiratory Syndrome (MERS-CoV) virus. The first case was reported on 31 December 2019 by the WHO Country Office in China. Aim: This study aimed to assess the knowledge and apprehension of the Turkish population about dental treatments during SARS-CoV-2. Materials and Methods: A cross-sectional questionnairebased survey was conducted which consisted of 8 self-prepared questions with two parts. A total of 560 participants, participated in this study. Participants was selected randomly and chi-square analysis was used to analyse statistical significance difference in the response between different groups. Results: Most of the participants (80.9%) thought that their level of knowledge about coronavirus (COVID-19) was sufficient. More than half of the participants (57.2%) evaluated themselves in the risk group in the COVID-19 pandemic. A few of the participants (16.4%) had dental problems during pandemic and 83.6% did not have any dental problem. Apart from this, 53.3% of the participants think that it is not risky to have treatment with vibrating tools used in dentistry; 47.6% of the participants do not prefer to go to dentist even if they had an abscess. Conclusion: The majority of the participants thought that they were knowledgeable enough about the risks of dental treatments in the pandemic period. However, the results have shown us that further steps need to be taken to educate people about the risks of dental treatments and the necessary situations that they have to go to the dentist during this period.

Sonographic Evaluation of Uterine Dimensions in Postpartum Women of Reproductive Age-Study from Enugu, Southeast Nigeria
Introduction: Uterine involution, a physiological process in which the uterus reverts to prepregnant size, occurs during puerperium. The latter is a time of substantial maternal risk. Ultrasound is considered the most appropriate tool in monitoring the progression of uterine involution because it is cheap, convenient and repeatable with no radiation risk. Aim: To sonographically evaluate the involution of the uterus and uterine cavity in postpartum women in Enugu, Nigeria. Materials and Methods: This was a prospective longitudinal cohort study on 400 postpartum women at the University of Nigeria Teaching Hospital, Enugu, Nigeria. Transabdominal ultrasonography to measure uterine dimensions was done on day 1, day 3 and day 42 of puerperium using a 3.5-5 MHz curvilinear probe of a portable ALOKA ultrasound machine. Statistical analysis was done with the Statistical Package for Social Sciences (SPSS) software version 20.0. The uterine dimensions were expressed as mean±standard deviation and student 's t-test analysis was used to compare the values for day 1, day 3 and day 42 of puerperium. Regression analysis was carried out to measure the relationship between uterine measurements on days 1, 3 and 42. A p-value of <0.05 was considered statistically significant. Results: The mean longitudinal, anteroposterior and transverse diameters of the uterus at day 1 were 14.51 cm, 8.54 cm and 10.97 cm, respectively. The corresponding values for day 42 were 8.27 cm, 4.78 cm, and 6.22 cm. The uterine diameters decreased significantly as puerperium advanced (p<0.001). The mean uterine cavity diameters also decreased significantly as puerperium advanced (p<0.001). There was significant regression between longitudinal diameters of both uterus and uterine cavity on days 1 and 3 but not between days 3 and 42. Conclusion: This study has established a normal range of diameters for the uterus and uterine cavity on day 1, day 3 and day 42 of puerperium. It can serve as reference data for further studies in the study area.

A Comprehensive In-Silico Analysis of Deleterious Missense SNPs in Human Trehalase Gene: Gaining an Interactome Insights into Type 2 Diabetes Mellitus

Asura Khanam Lisa, Al Hakim
Introduction: Trehalase (TREH), a glycoside hydrolase enzyme that catalyses the conversion of trehalose to glucose in sugar metabolism. In spite of severe health threats caused by diabetes worldwide, no systematic and programmed study on human TREH Single Nucleotide Polymorphism (SNPs) and its functional role in Type 2 Diabetes Mellitus (T2DM) has been performed. Aim: This study aimed to identify pathogenic missense SNPs in the human TREH gene. Materials and Methods: A series of different bioinformatic tools including Sorting Intolerant from Tolerant (SIFT), Polyphen, I-mutant, Variant Effect Predictor, Project Hope and GeneMANNIA were used for this study. At all stages, a p-value of 0.05 was considered as statistically significant. Results: This study demonstrated 10 potential mutations out of 241 missense human TREH SNPs from the SNP Database (dbSNP) database of National Center for Biotechnology Information (NCBI), three of which confirmed to have damaging effects on protein function. Out of these three, rs535722007 had the most deleterious effect that altered secondary properties and tertiary structure of the experimental TREH protein and decreased the stability. Further analysis showed a strong connection among TREH, Insulin (INS) and other genes of carbohydrate metabolism associated with T2DM. Gene expression studies found the down-regulation of TREH in all of the experimental studies linked toT2DM. Conclusion: As the probability of the disease predisposition increases with SNPs in primary or co-expressed gene(s), therefore, characterisation of TREH SNPs from human and its gene networking analysis can aid in better understanding of genetic variations and signalling pathways as well as to elucidate the effective diagnostic and treatment strategies

Correlation between Serum Iron, Serum Ferritin and Bile Cholesterol Level in Gallstone Disease

Bindesh Ashok Kumar Dube, KS Kher
Introduction: The cholesterol stones are formed by supersaturation of the bile with cholesterol. Iron deficiency alters activity of several hepatic enzymes, leading to increased cholesterol saturation of bile in gall bladder thus promoting cholesterol crystallisation. Iron has a role in gallstone pathogenesis and ferritin is the most specific marker for iron levels in the body, but there are less studies which depict correlation between serum iron, serum ferritin and bile cholesterol. Aim: To study the correlation between serum iron, serum ferritin and bile cholesterol level in gallstone patients. Materials and Methods: The observational study was conducted in the Department of Surgery. The study population was 45 patients with gallstone disease. Serum iron, Serum ferritin and Bile cholesterol contents were analysed. Serum cholesterol levels were estimated using Folch method and estimation of bile cholesterol was done by Enzopak kit. Statistical analysis was done by using descriptive and inferential statistics using chi square test and software used in the analysis were SPSS 24.0 version and p<0.05 was considered as level of significance. Results: A positive but negligible correlation between serum iron and serum ferritin was observed (Pearson’s correlation coefficient of 0.247). Negative correlation between serum iron vs serum cholesterol and serum ferritin vs serum cholesterol was observed. Conclusion: It can be concluded that a low value of serum iron and serum ferritin is a risk factor for cholelithiasis, whereas, if the value of bile cholesterol increases then there is a high probability of cholelithiasis.

Identification of Non-tuberculous Mycobacteria by Partial Gene Sequencing and Matrix Assisted Laser Desorption Ionisation Time of Flight at a Tertiary Care Hospital in Telangana, India
Introduction: Non-tuberculous Mycobacteria (NTM) pulmonary disease is often unrecognised or misdiagnosed as Mycobacterium tuberculosis (MTB), Multi-Drug Resistant Tuberculosis (MDRTB), because of similar clinical presentation in counties with high burden of Tuberculosis (TB) including India. In India due to lack of awareness among clinicians and lack of laboratory facilities to diagnose these infections, its prevalence is largely unknown. Aim: To evaluate the efficacy of identification of NTM species by Matrix Assisted Laser Desorption Ionisation Time of Flight (MALDI-TOF) and Heat Shock Protein (hSP65) gene sequencing and to determine their Antimicrobial Susceptibility Testing (AST). Materials and Methods: All the clinical specimens from pulmonary and extra-pulmonary TB suspects at Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India, over a period of one year i.e., from June 2017 to May 2018 were included in the study. The specimens were subjected to microscopy, culture and GeneXpert. The NTMs isolated in the culture were further characterised genotypically by MALDI-TOF and hsp65 gene sequencing. The identified NTM isolates were subjected to AST. All the methods were followed as per the standard protocols. Data was analysed using SPSS 25. Results: A total of 1085 samples were processed out of which Mycobacteria was detected in 201 cases (18.5%). Among the culture positives, MTB complex was detected in 146 cases (13.5%) and NTM in 55 (5.06%). Mycobacterium abscessus was the predominant isolate. The most common co-morbidities were bronchiectasis and Chronic Obstructive Pulmonary Disease (COPD). Linezolid, clarithromycin, moxifloxacin and amikacin showed high sensitivity. Conclusion: Molecular assay helps in rapid identification which can lead to targeted therapy and can thus combat antimicrobial resistance. The MALDI-TOF and hsp65 gene sequencing also offers quick results at a low cost and is easy to perform hence it can be considered as an alternate diagnostic tool for identification.

Comparison of Five Cytochemical Stains used for Fine Needle Aspiration Cytology of Breast and Lymph Node Lesions: A Comparative Study

Kusuma Venkatesh, PJ Swetha
Introduction: Fine Needle Aspiration Cytology (FNAC) is an established diagnostic tool aiming at an early diagnosis of mass lesions which in turn aids in planning further management of the patients. The need for minimal turnaround time with good quality of cell morphology has encouraged the development of different staining techniques. Quality Index (QI) of cytochemical stains is evaluated with a scoring system based on morphological features. Aim: To find rapid staining methods which were economical without compromising on the quality of FNAC smears. QI of five stains namely Papanicolaou stain (Pap), Haematoxylin and Eosin (H&E), May Grunwald Giemsa (MGG), Modified Ultrafast Papanicolaou (MUFP) and Rapid Economic Acetic acid Pap stain (REAP) were studied and compared. Materials and Methods: This was a prospective study conducted in the Department of Pathology, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India, from August 2011 to July 2013. FNAC of 80 mass lesions including 44 of breast lesions and 36 lymph nodes were included in this study. A minimum of five smears were made in each case and stained with Pap, H&E, MGG, MUFP and REAP. The QI of stain was assessed by the scores given for background of the smear, overall staining, and preservation of cell morphology, nuclear characteristics, cytoplasmic details and air drying artifacts. Statistical analysis of the data was done using chi-square test and Statistical Package for the Social Sciences (SPSS) version 15.0. Results: Pap stain showed maximum QI score followed by H&E, REAP, MGG and MUFP in case of breast lesions. In cases of lymph node highest QI was again with Pap followed by H&E, REAP, MUFP and MGG. Good cytomorphology with lesser expenditure and turnaround time was obtained by REAP and MUFP stains. Conclusion: Pap stain is still the best for cell morphology whereas MUFP and REAP are good, economical and with lesser turnaround time and can be used in routine cytopathology.

Anti-Inflammatory Markers IL-10 and IL-35: Role in Developing Gestational Diabetes Mellitus
Introduction: Inflammatory state is considered as the pathogenesis of Gestational Diabetes Mellitus (GDM). Cytokines can cause insulin resistance and maybe the molecular basis of inflammation in Diabetes Mellitus (DM). Aim: To assess the level of Interleukin-10 (IL-10) in addition to a new anti-inflammatory cytokine, Interleukin-35 (IL-35), in pregnant women with and without GDM. Materials and Methods: Participants in the study included 29 pregnant women with GDM (case group) and 29 healthy pregnant women (control group). Blood levels of IL-10, IL-35, Erythrocyte Sedimentation Rate (ESR), and C-Reactive Protein (CRP) were measured in all participants. Independent t-test and Chi-square test were used for data analysis. Quantitative data between three gestational subgroups (<29, 29-32, and >32 weeks) in each GDM and control group were compared by ANOVA test. The p-value <0.05 was considered significant. Results: The mean levels of IL-10 were 1.03±0.85 and 0.83±0.57 pg/mL (p=0.284) and the mean IL-35 concentrations were 10.2±8.1 and 8.8±4.3 pg/mL (p=0.437) in GDM and control groups, respectively. The mean CRP and ESR levels were higher in the GDM group than the controls but the differences were not statistically significant (p=0.33). In the GDM group, IL-10 was significantly lower at the early stage of pregnancy (<29 weeks) compared to the later stage (>32 weeks) (p=0.04), but this was not true in the control group. There was no significant difference between the mean level of IL-35 at different gestational ages in both GDM and control groups. Conclusion: The present study showed the decreased level of anti-inflammatory marker IL-10 in the late stage of pregnancy in diabetic women especially during the last weeks of gestation. There was no correlation between GDM and IL-35.

Histomorphological Spectrum of Mediastinal Masses with Special Emphasis on Rare Lesions

Sakthisankari Shanmuga Sundaram, S Vidhyalakshmi
Introduction: Mediastinal lesions are not frequently observed in routine clinical practice. A wide variety of disease process can occur within the mediastinum. Tissue from needle biopsies forms the major diagnostic material. There is need for detailed studies to make pathologists aware of the wide histological spectrum and to know the unusual lesions that can be encountered during diagnosis. Aim: To describe the histomorphological spectrum of various mediastinal lesions and to highlight the rare lesions that posed a diagnostic challenge. Materials and Methods: This was a retrospective study done on all mediastinal masses over a period of two years from January 2016 to December 2018. The clinical data and imaging findings were collected from the test request forms and patients’ files for all the cases. Haematoxylin and eosin stained slides of all cases and immunohistochemistry markers and cytochemical stains wherever done were reviewed and analysed. Mean, median and percentage were used for statistical analysis. Results: Thirty-four cases of mediastinal lesions were included in the study. Of these, 28 cases (82.4%) presented as anterior mediastinal masses, three cases (8.8%) each in the middle and posterior mediastinum. Thymoma (n=15) followed by lymphoma (n=4) were the most frequent neoplasms reported. There were five lesions which were rare in the mediastinum with unusual presentation that posed diagnostic difficulties. These lesions included Primitive neuroectodermal tumour in an adult, Primary Mediastinal B Cell Lymphoma (PMBCL), Malignant Peripheral Nerve Sheath Tumour (MPNST) with nodal metastasis, Seminoma deposits in mediastinal node occurring as late relapse and dedifferentiation of thyroid carcinoma in mediastinal node metastasis without an obvious primary. Conclusion: Primary mediastinal tumours were more frequent than metastasis. Although thymomas and lymphomas are dealt extensively in literature, this article highlights the fact that pathologists must be aware of those lesions that don’t display the classical histological and/or clinical features as observed in this study

Cartridge Based Nucleic Acid Amplification Test: Utility as Diagnostic Modality in Clinically Diagnosed Childhood Tuberculosis
Introduction: Tuberculosis (TB) remains one of the deadliest communicable diseases worldwide. The introduction of early and rapid diagnostic test such as Cartridge Based Nucleic Acid Amplification Test (CBNAAT) creates opportunities for improvement in early and fast detection of TB and drugresistance. Aim: To determine the prevalence of Tubercular cases in clinically diagnosed TB patients and to determine the prevalence of Rifampicin resistance by CBNAAT. Materials and Methods: This prospective observational study involved a total of 107 children from January 2018 to June 2019, fulfilling the inclusion criteria who were clinically diagnosed and found positive in conventional tests for TB. CBNAAT was used to confirm Mycobacterium tuberculosis (MTB) for the diagnosis of childhood TB and compare with other conventional methods. Chi-square test for the proportion was applied and p-value <0.05 taken as significant. Results: Of the 107 patients studied, 44.9% were female and 55.1% were male. The age range was 3 months to 12 years. The cases were confirmed by CBNAAT in clinically suspected case of TB was found to be 17.8% (19 cases out of 107 patients). CBNAAT was able to detect MTB in 14% (15 cases out of 107 patients) of the gastric aspirate/sputum sample. Out of 107 patients, 69 children were clinically diagnosed as Neurotuberculosis and 13% (9 out of 69 cases) cases were confirmed by CBNAAT in Cerebrospinal Fluid (CSF). OF which 29 patients had CSF analysis suggestive of Tubercular Meningitis (TBM). Out of 29 patients, 10 (34.5%) cases were confirmed by CBNAAT. This test showed a significant association with positive Mantoux test (p-value 0.020) and CSF analysis (p-value 0.021) suggestive of TBM. Conclusion: CBNAAT should be used in preference to conventional methods as the initial diagnostic test for patients suspected of having TB. CBNAAT positivity shows significant association with positive Mantoux test and CSF analysis suggestive of TBM.

Role of Pleural Fluid C-Reactive Protein in the Aetiological Diagnosis of Exudative Pleural Effusion

Praveen Radhakrishnan, S Mathanraj
Introduction:Pleural effusions, the result of the accumulation of fluid in the pleural space, are a major diagnostic problem due to its anatomical nature with no direct access. There is variation in management, depending on the pleural disease. The pleural effusion can either exhibit specific or nonspecific characteristics. Aim: To determine the clinical significance and diagnostic role of pleural fluid C-Reactive Protein (CRP) level in the aetiological diagnosis of exudative pleural effusion. Materials and Methods: This was a cross-sectional study performed during the study period of September 2013 to December 2014. A total of 53 Patients identified with pleural effusion were recruited in the study and pleural fluid was subjected for the measurement of CRP level. Pleural fluid CRP was assessed with CRP-Turbilatex-Quantitative turbidimetric immunoassay method which is based on the principle agglutination reaction. The data was subjected to statistical analysis using Epi info software version 3.4.3. The Receiver Operating Characteristic (ROC) curve was plotted to illustrate the diagnostic ability. The smallest cutoff value was the minimum observed test value minus 1, and the largest cut-off value was the maximum observed test value plus 1. All the other cut-off values were the averages of two consecutive ordered observed test values. Results: Among the 53 patients in the study, 42 had exudative effusions (79.20%) and 11 had transudative effusions (20.80%). The common cause of exudative effusion was tuberculosis 26 (61.90%), followed by 9 malignancy (21.40%) and 7 parapneumonic effusion (16.70%). In our study, the pleural fluid CRP was statistically significant (p<0.001) marker to differentiate exudative effusions with CRP-value <30 suggestive of malignancy, CRP-value 30-50 mg/L suggestive of tuberculosis and CRP-value >70 mg/L suggestive of parapneumonic effusions. Conclusion: Determination of pleural fluid CRP is a useful diagnostic marker for differentiating exudative and transudative effusions. Also, Pleural fluid CRP is a statistically significant marker in differentiating tubercular effusions from nontubercular exudative effusions.

Willingness and Perception of Dental Interns towards Working in Rural Areas in Riyadh, Saudi Arabia- A Cross-sectional Study
Introduction: The shortage of dental workforces in rural areas is a major concern in Saudi Arabia, which affects the delivery of oral health care services. Although there is an improvement in the dentist to population ratio, there still a wide disparity in dentist to population ratio in rural and urban areas. Aim: To assess the perception of dental interns to work in rural areas in Riyadh, Saudi Arabia and to know their willingness to serve rural population and factors associated with their decision. Materials and Methods: A cross-sectional study was conducted among 400 dental interns from 6 dental colleges located in Riyadh, Saudi Arabia over a period of October to December 2019. Data was collected using a self-administered structured close ended questionnaire. Chi-square test and multiple logistic regression analysis were applied to measure the association of age, gender and marital status on their responses. A p-value <0.05 was considered as statistically significant. Results: Out of 400 participants, 58% were willing to work in rural areas. Close proximity to hometown, in need for a job, rural placement program, fees and loan forgiveness and having rural background were the most favouring factors for working in rural area, whereas unfavourable working condition, lack of transportation facilities, poor accommodation, less scope for professional development and lack of necessary infrastructure were the main factors for reluctance. The male participants, Saudi nationals, rural residents, and the one whose fathers are less educated, were more likely to work in rural areas. Conclusion: Based on the findings of the study a comprehensive human resource strategy be designed by health or medical educators in order to encourage dental students to take up jobs in rural areas.

Ketamine-Dexmedetomidine Combination for Monitored Anaesthesia Care in Tympanoplasty Surgery: An Observational Study

Vikas Sharma, GV Krishna Prasad, Debashish Paul
Introduction: Monitored Anaesthesia Care (MAC) has been widely used for patients undergoing middle ear surgeries. Previous studies have shown that the use of local anaesthesia has many advantages over general anaesthesia in performing ear surgeries. The use of Dexmedetomidine as a sole anaesthetic agent had many disadvantages owing to its insufficient sedative effect, increased recovery time and haemodynamic instability. Hence, using a combination of low dose ketamine with Dexmedetomidine can prove to be useful in middle ear surgeries. Aim: To evaluate the effects of Dexmedetomidine-Ketamine (DK) combination on the quality of sedation/analgesia and recovery profiles for MAC in tympanoplasty surgery. Materials and Methods: In this observational study, a total of 20 patients were included. All the demographic data- including, age, sex and American Society of Anesthesiologists (ASA) grade were recorded before the surgery. Before the surgery, all patients received 1 µg/kg dexmedetomidine over 15 minutes followed by infusion of 0.2-0.7 µg/kg/h to maintain 2 or 3 of modified observer’s assessment of analgesia and sedation score. Both the scores were checked every 10 minutes. Ketamine was infused at the rate of 10-15 mcg/kg/min, 10 minutes before the start of the procedure. The Heart Rate (HR), systolic and diastolic pressure, pain score and sedation score were monitored every 10 minutes until 120 minutes of the preoperative condition after the nerve block was used. Statistical analysis was performed using IBM SPSS Version 25.0 (IBM, New York, United States). Continuous data values were shown in the form of mean±standard deviation. To compare the mean difference between the groups, student’s t-test was used and p<0.05 was considered as statistically significant. Results: The mean age of the population was 39.45±12.66 years; among which 15 patients (75.0%) were females. Out of 20 patients, 12 (60.0%) were in the ASA-I and 8 (40.0%) were in the ASA-II grade. The result of the study showed not a single instance of complication. All the patients were haemodynamically stable and HR was also found to be constant in both pre and postoperative instances. The pain score was found to be around 2 even after 120 minutes after the surgery (2±0.93). No rescue analgesia was required in any of the patients and all the patients recovered within 3-5 minutes after the infusion was stopped. No postoperative nausea and vomiting instances were also reported. Conclusion: The present study showed that DK combination provides good haemodynamic stability, higher sedation score and lower pain score. In addition, this study also showed that for patients undergoing tympanoplasty surgery this is a safe and effective method of anaesthesia that provides good MAC.

Association of p53, VEGF and Microvascular Density in Colorectal Carcinoma

Rituparna Ghosh, Sarojini Raman, Jayasree Rath
Introduction: Colorectal Cancer (CRC) is third most common malignancy worldwide. Various genomic alterations play fundamental role in initiation and progression of CRC. Among these, p53 mutation has a crucial role in survival and metastasis and its point mutation induces Vascular Endothelial Growth Factor (VEGF) promoting vascular permeability, migration and differentiation. The degree of angiogenesis can be measured by Microvascular Density (MVD) using CD34, which is helpful in identifying high risk patients for recurrence and metastasis. Aim: The aim of the study was to analyse the expression of p53, VEGF and MVD in CRC and their association with clinicopathological parameters. Materials and Methods: The ambispective study of 2 year duration was conducted from September 2015 to July 2017 in the Department of Pathology, Kalinga Institute of Medical Sciences and PBMH, Bhubaneswar. It included CRC resection specimens and archival tissue blocks. Tissue microarray blocks were prepared manually for IHC application in total 70 cases (58 (82.9%) adenocarcinomas and 12 (17.1%) adenomas) which were histologically staged and graded as per American Joint Committee on Cancer (AJCC) and World Health Organisation (WHO) guidelines. Pearson chi-square test and fisher’s-exact method were used to find significance of p53, VEGF and CD34 expression in adenomas and adenocarcinomas with respect to clinicopathological parameters. Results: No significant statistical association was found between p53, VEGF and MVD with tumour grade and nodal status. Majority, 41 (70.69%) cases were hypervascular (MVD-High). Adenomas 9 (75%) cases, were mostly hypovascular (MVD-Low) with p-value of 0.003. There was significant statistical association between VEGF and MVD with a p-value of 0.01. VEGF and MVD were more expressed on left-sided colon cancers. There was significant statistical association (p=0.01) between p53 graded expression and diagnosis in the present study. MVD and tumour nodal status had an inversely significant relationship (p=0.03). Conclusion: p53 and VEGF expressed more on carcinomas than adenomas. Both p53 and VEGF induce angiogenesis which can be effectively measured by CD34 expression (MVD). There is a directly proportional relationship of angiogenesis and malignant transformation. So these three IHC markers together can be considered a significant prognostic factor involved in CRC.

Why Some Mothers Could Be Saved and Not Others? Evaluating Different Phases of Delay in Causing Maternal Near Misses and Maternal Deaths

Banashree Nath, Kashika Nagpal, Nandini Rajamani, Harsha S Gaikwad
Introduction: The factors playing key role in determining death and survival among the Maternal Mortality (MM) and Maternal Near Miss (MNM) cases are multidetermined and interdependent. It ranges from initial illness to perception of patients to seek healthcare services and initiation of management at primary health care settings. Aim: To evaluate the factors responsible for causing delay at different phases and thereby assess the key determinants of survival and death of mothers. Materials and Methods: This cross-sectional observational study was undertaken at the tertiary care centre and teaching hospital in northern India from October 2015 to December 2016. Study population consisted of all women who were identified as MNM and MM which occurred at Centre. Attendants accompanying the patient, mostly nearest kin who were able to give details of her health were questioned. Details regarding the sequence of events that caused her severe morbidity were taken right from recognition of morbid status to landing up in the tertiary setup. Approximate duration of delay for each case of MNM and MM was assessed. Any delays in accessing or receiving medical care were recorded, if available. Data Entry was done on MicroSoft Excel spreadsheet. Proportions were calculated for qualitative data. Mean score with confidence interval was calculated for quantitative data. Qualitative data was analysed by Chi-Square test and t-test was applied for quantitative data. Results: Out of 31,111 live births during the study period, there were 249 maternal near miss cases and 131 maternal deaths. Delay in women seeking help was observed in a total of 92.36% of cases in MNM group and 97.70% of cases in MM group (p=0.034). The study discovered significant differences when referral status (p=0.4904) as well as when number of referrals (p=0.041) were considered. There was a significant difference between the women of the two groups who reported only first phase delay (p=0.033). The major pregnancy related morbidities were haemorrhage and hypertensive disorders of pregnancy. Patients with hypertensive disorders of pregnancy with delay more than 12 hours survived the acute insult but were unable to cope with dysfunction of multiple organs and passed on after prolonged intensive care whereas in cases of Postpartum Haemorrhage (PPH), delay >6 hours were observed with extremely poor prognosis. Conclusion: Delay in taking decisions to seek healthcare is a major cause of MM. There is a little difference in outcome in terms of survival and death of mothers with delay in any of three phases despite increased intervention taken in adequate referral facilities. Precious time lost in deferral and referral contributes immensely to poor prognosis of mothers as compared to direct referral to an adequate health facility.

A Study on Perception of Students Regarding Newer Teaching Methods in Medical Education
Introduction: Learning is a complex and multifaceted phenomenon. Research findings suggest that a deep, integrated understanding of the basic sciences is important for solving clinically relevant tasks. Evidence suggests that students today may be more engaged and learn better when there are different teaching approaches incorporated into the educational environment. Crossword Puzzle (CWP) is a form of active learning which is helpful to review and summarise concepts. Mind Map (MM) is a powerful graphic technique that can be applied to improve learning and clearer thinking. E-learning is an innovative modern technology which can support and enrich medical education. Aim: To assess the perceptions of students regarding newer teaching methods like CWPs, MMs and online resources in medical education. Materials and Methods: This was a cross sectional study conducted in the Department of Pathology for 2nd year Medical, Physiotherapy and Nursing students for a period of one year from October 2018 to September 2019. A total of 206 students participated in the study, of which 90 were MBBS students, 30 were Physiotherapy students and 86 were Nursing students. Newer teaching methods like CWPs and MMs were introduced in the classes. A feedback form was given at the end of the class and their responses were collected regarding newer methods. Perceptions of students regarding newer teaching methods were represented using descriptive statistics in frequencies and percentages. Results: Female students were more compared to male students across all the branches with 63.3% female students in MBBS, 80% in Physiotherapy and 82.6% in Nursing. 84.4% of MBBS students, 86.7% of Physiotherapy students and 97.7% of nursing students were interested in filling CWPs. 94.4% of MBBS students, 93.3% of Physiotherapy students and 100% of nursing students opined that MMs help in memory retention. 93.3% of MBBS students, 96.7% of Physiotherapy students and 91.9% of nursing students wanted newer teaching methods to be part of the curriculum. Conclusion: Educators need to constantly change their teaching methods in order to hold the attention of students. CWP’s and MM’s created interest among the students in learning subject. CWPs enhanced group interaction among peers whereas MMs helped in retaining the key points and also bringing out the creative talent.

Clinical Manifestations and Associated Complications of Scrub Typhus in Odisha, India

Lalatendu Mohanty, Aditya Dhanawat, Partisha Gupta, Guncha Maheshwari
Introduction: Scrub typhus is a re-emerging illness in the South-East Asia and other parts of the world caused by Orientia tsutsugamushi, which is a mite-borne bacterium belonging to the Rickettsiaceae family. It has varied clinical manifestations and affects multiple organ systems. In Asia, about 1 million new cases are identified annually. Aim: The aim was to conduct a retrospective study to observe the clinical profile and complications of scrub typhus in SouthEastern India. Materials and Methods: Clinical data of 240 patients who were 18 years of age or above, admitted in the Department of Internal Medicine and diagnosed with scrub typhus by means of IgM Enzyme-linked Immune Sorbent Assay (ELISA) was collected. Demographic profile, clinical signs and symptoms, laboratory parameters, co-infections and complications were reviewed. Statistical analyses were performed using Chi-square test. Results: Majority of the patients were males, between the age of 18-29 years and lived in rural areas. Forty-three (17.9%) patients were admitted in the ICU and the remaining in wards. Sixty-nine (28.8%) patients had consolidation and 11 (4.6%) had Acute Respiratory Distress Syndrome (ARDS). Twenty-one (8.8%) patients had jaundice and 76 (31.7) had hepatomegaly. Twenty-one (8.8%) patients had meningo-encephalitis and 18 (7.5%) had acute kidney injury. Twelve (5%) patients had coinfection with dengue and 8 (3.3%) had malaria. Conclusion: This study shows wide and varied presentation of scrub typhus infection along with the course of the disease and response to the treatment. The diagnostic clues such as fever, eschar, rashes, lymphadenopathy should be kept in mind by a primary care physician as early recognition and treatment can prevent its dangerous complications and reduce the mortality due to the disease. Occurrence of co-infections should also be kept in mind for better management of the patient.

Safety Measures in Biochemistry Laboratory: Need of the Hour

Ashish Prakash Anjankar, Swanand Pathak, Archana Dhok
Introduction: Biochemistry laboratories like any other laboratory contain certain inherent dangers and hazards for the students. Proper guidelines regarding laboratory safety are missing in Biochemistry curriculum. So, skill training about laboratory safety in Biochemistry laboratory will be useful for the MBBS students. Aim: To train the undergraduate medical students about laboratory safety using “Safety measures in Biochemistry Laboratory” module and to assess their perception about this module. Materials and Methods: A prospective interventional study was conducted in which 100 students of first year MBBS 2017 batch were included which were divided into study and control groups. In Study Group, 50 students were trained in the topic of laboratory safety using a module on “Safety measures in Biochemistry Laboratory” which included three sessions of didactic lectures and two sessions of hands-on training. In Control Group, 50 students were not given any intervention. Outcome of training was assessed with the help of “Biochemistry Laboratory Safety Index” (BLSI) scores, which was designed by authors and was validated from 10 external subject experts of the Biochemistry Department. Pre-test and post-test marks of study and control group participants were compared using paired t-test for each group. Absolute learning gain (Post-test score-Post-test score) and relative learning gain (Post-test score-Pre-test score/Pre-test score) was calculated. Results: Absolute learning gain for control and study group was 0.11 and 5.53, respectively, while relative learning gain for control and study group was 0.16 and 89.62 respectively. Pre-test and post-test scores are statistically non-significant (p>0.05) in the control group, while Pre-test and post-test scores are statistically significant (p<0.001) in the study group. BLSI scores in control group was excellent for 9 (18%), good for 16 (32%), average for 19 (38%) and poor for 06 (12%) students; while in study group it was excellent for 41 (82%), good for 08 (16%) students, average for 01 (02%) students and poor for nil students. Conclusion: Module of “Safety measures in Biochemistry Laboratory” is significantly effective educational intervention as it improves the knowledge about Laboratory safety and its implication for medical students during Biochemistry practicals. Training about “Safety measures in Biochemistry Laboratory” can be incorporated in the existing undergraduate Curriculum of Biochemistry.

Assessment of Relationship between Galectin-3 and Biochemical Parameters in Peritoneal Dialysis Patients with Left Ventricular Hypertrophy

Sultan Alouffi, Ahmed Alsalloom, Menawer Alharbi, Wajid Khan, Waleed Tamimi
Introduction: Cardiovascular complications are considered as the main cause of mortality in patients with End-Stage Renal Disease (ESRD). Cardiovascular Disease (CVD) includes disorders of the Left Ventricular Hypertrophy (LVH) of the heart which is the most frequent cardiac alteration in ESRD. Galectin-3 (GAL-3), a ß-galactoside-binding protein has been proposed to be a new clinical biomarker that reflects cardiac fibrosis in patients with Heart Failure (HF). Aim: To evaluate the relationship between GAL-3 and biochemical parameters in Peritoneal Dialysis (PD) patients with and without LVH. Materials and Methods: This cross-sectional study enrolled 45 patients (25 women and 20 men) with ESRD who were categorised as having CVD with (n=12) or without (n=33) LVH. Demographic, biochemical and clinical characteristics of 45 patients were analysed. The relationship of plasma GAL-3 levels was analysed with the biochemical parameters for both the groups of patients. For comparison between groups, Student unpaired t-test was used for the data of normal distribution while Mann-Whitney test was used for data of non-Gaussian distribution. Pearson’s correlation test was performed to examine various correlations. Results: Significantly high number (83.3%) of female patients were observed in ESRD with LVH. The groups did not differ significantly in their demographic, and biochemical and clinical parameters. There was significant increase in Left Ventricular End-Diastolic Diameters (LVEDD), Left Ventricular (LV) mass and LV mass index in patients with LVH as compared to the patients without LVH. The levels of GAL-3 showed slight increase (91±23.98 ng/mL) levels in LVH patients as compared to the patients without LVH (83.68±32.8 ng/mL). Exponential positive correlation between serum levels of GAL-3 and creatinine in ESRD patients without LVH (r=0.563, p=0.001). GAL-3 also showed positive correlations with urea without (r=0.563, p=0.001) as well as and uric acid (r=0.416, p=0.0178) for ESRD patients without LVH. However, GAL-3 showed no association with uric acid and urea (r=0.04487, p=0.896; r=0.2383, p=0.48) in ESRD patients with LVH. Conclusion: GAL-3 positively correlated to the biochemical parameters in ESRD patients. Patients with LVH only showed positive correlation between GAL-3 and creatinine. Moreover, GAL-3 could not be used as the biomarker because it did not correlate with established diagnostic parameter like LV mass and LV mass index. Hence, in this study GAL-3 is not a potential clinical biomarker for the progression of cardiovascular complications in ESRD patients. Overall, these data reflect the need for further investigation of GAL-3 to HF in patients with ESRD.

Symptomatic Biliary Pseudolithiasis in Adult Patients Treated with Parenteral Ceftriaxone: A Prospective Study

Sibi Eranki, Aman Arora, Vasundhara Singh
Introduction: Ceftriaxone is a frequently used antibiotic in inpatients treated for a number of bacterial infections. Biliary calculi formation called pseudolithiasis is a well-known asymptomatic and reversible complication of this drug. However, a percentage of patients do present with new onset of abdominal symptoms which can be attributable to presence of pseudoliths. Aim: To evaluate incidence of pseudolithiasis in inpatients treated with parenteral Ceftriaxone, to assess resolution of pseudoliths and development of abdominal symptoms attributable to pseudolithiasis on long term follow-up over one year. Materials and Methods: A prospective observational cohort study including all patients admitted at our centre and started on Ceftriaxone. These patients were subjected to sonographic examination on day 1 and day 7 of treatment. Patients who developed pseudolithiasis were prospectively followed-up at one month, three months, six months and one year to assess for resolution or whenever they presented with symptoms. Incidence of pseudolithiasis and complications in patients who developed pseudolithiasis was calculated using standard formulae. Descriptive statistics in terms of numbers and percentages were used. Results: A total of 1490 patients were included in the study from August 2016 till July 2017 and followed for a period of one year (June 2018). The incidence of pseudolithiasis in inpatients treated with parenteral ceftriaxone was 8.7% (131 patients) as observed on Sonographic examination performed on day 7 of therapy. Ten (7.6%) patients had pseudoliths at one month and 1 (0.76%) patient out of these had persistent pseudoliths at all subsequent reviews till one year after diagnosis of the condition. Eleven (8.3%) patients who developed pseudolithiasis during therapy with Ceftriaxone had presented with upper abdominal symptoms suggestive of biliary colic before resolution of pseudolithiasis. Conclusion: Biliary pseudolithiasis is a common side effect of ceftriaxone therapy, occurring in approximately 10% of patients. Biliary colic, cholecystitis and pancreatitis may also result due to these pseudoliths complicating the course of primary illness. Further consultations and interventions like cholecystectomy can be reserved not only to symptomatic individuals but also for those with persistent pseudoliths.

Use of Echogenic Needles for Ultrasound-guided Transversus-Abdominis-Plane Block: Better Visibility Transforming into Better Postoperative Analgesia
Introduction: Ultrasound (USG)-guided Transversus-Abdominis-Plane (TAP) block is recommended due to its safety and reliability. Echogenic needles provide better needle visibility and might result in better postoperative analgesia after USG-guided TAP block. Aim: To compare visibilty and block-characteristics (including postoperative analgesia) of echogenic vs. non echogenic needle for USG-guided TAP block. Materials and Methods: This randomised double-blind study was carried out at King George’s Medical University, Lucknow over a period of one year (November 2018 to October 2019). Seventy patients undergoing abdominal surgeries were enrolled and randomly allocated to one of two groups Group-E (echogenic) and Group-NE (non echogenic). Bilateral TAP block was performed postoperatively in all the patients and 20 mL of 0.25% Bupivacaine was deposited on each side. In Group-E, echogenic needle was used and in Group-NE, non echogenic needle was used for TAP block. Research assistant documented the start and finish time of the block procedure, number of attempts and redirections based on predetermined criteria. Visibility of needle tip and shaft were graded on a 3-point scale based on recorded and de-identified video-clips. Total procedure-time, number of needle redirections and skin punctures, incidence of vascular punctures, Visual Analogue Scale (VAS) scores and rescue analgesia requirement were also noted. Statistical analysis was done using SPSS Version 21.0. Results: Needle visibility on USG was significantly better in Group-E than Group-NE (χ²=57.24, p<0.001). Mean time to reach the TAP plane (t=-16.89, p<0.001) and total procedure time (t=-15.76, p<0.001) were also significantly lesser in Group-E. Mean number of needle redirections (t=-11.21, p<0.001), mean number of skin punctures (t=-2.12, p=0.038) and postoperative VAS scores throughout the study were found to be significantly lesser in group-E as compared to group-NE. Postoperative analgesia required in 24 hour was lesser in group-E and time of first rescue analgesia required was earlier in group-NE (p<0.001). Patients in both the groups were haemodynamically stable throughout the study. Conclusion: Use of echogenic needle for USG-guided TAP block provides much better needle-visibility resulting in better block-performance. It also provided better analgesia in our study as evident by lesser VAS-scores and lesser requirement of rescue analgesia postoperatively. So, use of echogenic needle should be advocated in all the patients undergoing USG-guided TAP blocks provided there are no financial constraints.

Antibiotic Prescribing for Endodontic Infections and Prophylaxis for Medically Compromised Patients: A Survey on Dental Students in Turkey

Sema Sönmez Kaplan, Tuna Kaplan, Güzide Pelin Sezgin
Introduction: High and wrong antibiotic usage causes Antimicrobial Resistance (AMR) which is a worldwide problem. Dental students, as future dentists are likely to provoke this public health issue by inappropriate prescribing choices. There is a need of further education of antibiotic prescription in endodontic infections, as well as prophylaxis. Aim: The aim of this study was to establish the knowledge of dental students on the suitable use of systemic antibiotics for endodontic infections and prophylaxis for medically compromised patients. Materials and Methods: A survey was done on dental students at the end of third, fourth and fifth years, who answered a questionnaire about antibiotic use for endodontic infections and prophylaxis for various immunocompromised patients. Pharmacology and endodontics lectures should be taken by respondents; was the inclusion criterion. Data were analysed using descriptive statistics and Chi-square test. Statistical significance was fixed at p<0.05. Results: Amoxicillin + clavulanic acid (500/125 mg) was the first-choice antibiotic of students. The percentage of fifth grade students who would prescribe amoxicillin + clavulanic acid (500 mg/125 mg) was lower than third and fourth grade students (p=0.006). In case of allergy to penicillin, clindamycin 300 mg was selected as a first-choice antibiotic by 78.3% of students. About 50.2% of the respondents indicated a treatment duration of 3-7 days, while 28.5% chose more than seven days usage. Fourth grade dental students who would prescribe antibiotics for more than seven days (40.7%) were found to be statistically more significant than third (27.8%) and fifth (16%) grade students (p=0.004). In case of acute apical abscess with systemic manifestations, 94.5%, which is the highest percentage of all, of students would prescribe antibiotic. Third grade dental students were the most antibiotic prescribing group for chronic apical periodontitis and periradicular (pocket) cyst (p=<0.001). Patients with history or risk of bacterial endocarditis, were prescribed prophylactive antibiotics at a rate of 92.3% by students. Conclusion: Even though the results showed acceptable levels of competence, dental education should place greater focus on prescription of antibiotics to prevent Antimicrobial Resistance (AMR).

High-sensitivity C-reactive Protein as a Marker of Future Cardiovascular Events in Chronic Kidney Disease Stage-5 Patients

Nisha Abraham, C Beena, Sangeetha Merrin Varghese
Introduction: Chronic Kidney Disease (CKD) has been recognised as a worldwide health threat and understanding its complex patho-physiological mechanisms could go a long way in taking care of patients with CKD. One of the most important causes for mortality in End Stage Renal Disease (ESRD) patients is Cardiovascular Disease (CVD). ESRD is a low grade chronic inflammatory state, suspected to promote atherosclerosis. Aim: To determine, if there is any association between elevated High-sensitivity C-Reactive Protein (hs-CRP) and development of future cardiovascular events in stage-5 CKD patients. Materials and Methods: Forty-five CKD stage-5 patients were included in the study, after ruling out patients with established CVD. According to categorisation proposed by the American Heart Association for the cut-off value of hs-CRP-value (3 mg/L), patients were divided into two groups. Those who had hs-CRP more than 3 mg/L were considered to have ‘elevated hs-CRP’ and those who had a value 3 mg/L and below were considered to have ‘normal hs-CRP’ levels. These patients were followedup monthly, for a period of one year to record any occurrence of cardiovascular events (coronary events/cerebrovascular accidents/peripheral occlusive vascular disease). Statistical Package for the Social Sciences (SPSS) 16.0 was used for analysis. Chi-square test and Mann-Whitney U-test were used for statistical comparison between the groups and a p-value of 0.05 or less was considered to be statistically significant. Receiver Operating Characteristic (ROC) curve was also plotted to determine the cut-off value for hs-CRP based on the occurrence of any cardiovascular event. Results: Baseline hs-CRP level was more than 3 mg/L in 42% of patients. Among those who had elevated hs-CRP, 78.9% of patients developed cardiovascular events during the follow-up period. This signifies a strong association between elevated hsCRP and CVD in ESRD patients. The hs-CRP cut-off point of 3 mg/L was obtained from ROC curve. Conclusion: There was a significant association between elevated hs-CRP and development of cardiovascular events in ESRD patients. Hence, hs-CRP can be used as a marker of future cardiovascular events in CKD stage-5 patients.

Comparison of Intrathecal Fentanyl and Butorphanol as an Adjuvant to Intrathecal Bupivacaine 0.5% in Infraumbilical Surgeries- A Randomised Double Blind Study

Sandip Roy Basunia, Prosenjit Mukherjee, Md Bakir Hossain Munshi
Introduction: Neuraxial opioids are widely used as adjuvants to local anaesthetic as they improve quality and duration of block. Neuraxial opioids like Butorphanol and Fentanyl allow prolonged analgesia in the postoperative period and faster recovery from spinal anaesthesia. Aim: To compare the safety and efficacy of Butorphanol and Fentanyl combined with bupivacaine for spinal anaesthesia in infraumbilical surgeries. Materials and Methods: The present study was a randomised controlled trial in which 110, ASA I and II patients of either sex who underwent elective infraumbilical surgeries under spinal anaesthesia were selected. Patients were allocated randomly into two groups A (n=55) and B (n=55). Group A (F) received intrathecal 0.5% hyperbaric bupivacaine 12.5 mg (3 mL) with fentanyl 25 microgram (0.5 mL) to make it total 3.5 mL. Group B (B) received intrathecal 0.5% hyperbaric bupivacaine 12.5 mg (3 mL) with butorphanol 250 microgram (0.25 mL) and Normal Saline (NS) 0.25 mL to make it total 3.5 mL. Heart Rate (HR), Systolic and Diastolic Blood Pressure (SBP, DBP), two segment regression time of sensory block, motor block were assessed at preset intervals. Chi-square test or Fischer’s-exact test were used and a p-value ≤0.05 was considered as statistically significant. Results: Mean of two segment sensory regression time of Group A was 41.94±1.73 minutes and Group B was 50.56±4.43 minutes (p<0.0001). Time to onset of motor block in Group A was 5.28±.32 minutes and Group B was 5.27±.32 minutes (p=0.96). Mean duration of motor block in Group A was 81.23±4.87 minutes and Group B was 109.83±2.61 minutes (p<0.0001). Time to rescue analgesic was 289.27±7.37 minutes in Group A and 378.41±10.25 minutes in Group B (p<0.0001). HR, SBP and DBP were comparable among the groups. Conclusion: Intrathecal bupivacaine-butorphanol mixture was clinically better as it provided longer duration of analgesia with lesser incidences of pruritus and nausea/vomiting compared to intrathecal fentanyl-bupivacaine mixture.

Phenotypic Pattern of Vibrio cholerae Isolates from a Tertiary Care Hospital in Vadodara, Gujarat, India

Sonia Sandeep Barve, Srujana Prabhala, Tanuja Bakul Javadekar, Sandeep Om Nanda
Introduction: Cholera is an acute diarrhoeal disease caused by Vibrio cholerae (V.cholerae). Based on antigenic differences of O antigen, O1 serogroup can be divided into three serotypes. In addition, by performing various biochemical reactions, O1 Serogroup can be differentiated into two biotypes. Outbreaks of Cholera occur seasonally. It is associated with monsoon season, warm temperature, heavy rainfall and increased plankton population. Aim: The aim was to determine the trends in resistance pattern and phenotypic Pattern of Vibrio cholerae. Materials and Methods: A retrospective study was conducted during the period from June 2019-December 2019. Culture of Stool specimens were done on different agar media. Biotyping was done by conventional methods. Serotyping and phage typing was also done along with the Antibiotic susceptibility testing. Descriptive analysis was used and presented in terms of percentage. Results: V.cholerae was isolated in 72 patients and they belonged to serogroup O1 and biotype El Tor. The most common serotype was Ogawa. The predominant phage type were T2 by old scheme and T27 by new scheme of phage typing. The maximum number of V. cholerae isolates was seen in the month of November, 2019 followed by October, 2019. Conclusion: The phenotypic pattern and fluctuating seasonal trend of V. cholerae and antimicrobial resistance encourage the continued epidemiological and microbiological surveillance of the disease.

Effectiveness of Preventive Oral Health Measures among Special Care School Children (boys) in Al-Kharj, Saudi Arabia
Introduction: Special needs children experience poorer oral health when compared to their compatriots. Moreover, Special Care School Children (SCSC) experience significant barriers to access proper oral health care. It has been found that they have high unmet oral health needs. Aim: The aim of this study was to assess the effectiveness of preventive oral health measures in a group of SCSC; boys, in Al-Kharj Governorate of Saudi Arabia. Materials and Methods: A longitudinal study was designed among SCSC in Al-Kharj Governorate of Saudi Arabia starting from October 2016 for a period of eight months. Only schools for boys were included in the study. Out of 936 students enrolled in the special needs education programme in 18 boys schools; 163 SCSC (boys) from eight primary schools were eventually included in the study. After the base line survey; the subjects were evaluated with predefined criteria at three monthly intervals until six months. The effectiveness of various preventive measures was evaluated for reduction in the risk of oral diseases. SCSC were divided into groups as per their specific health care need. Preventive oral health measures such as supervised tooth brushing with a fluoridated tooth paste was introduced with the help of teachers and parents of SCSC. Plaque levels were assessed by means of Plaque index. Various indices were used to measure dental caries including Decayed, Missing, and Filled Teeth (DMFT/dmft) as well as Decayed, Missing, and Filled Surfaces (DMFS/dmfs) index. The risk for dental caries was assessed by means of a cariogram model at the start and at the end of campaign. The data was computed using SPSS v20 programme. Means of the overall plaque score and the caries indices scores were calculated and compared among various special need groups among the SCSC. The significance level was set at p<0.05. Results: The overall mean plaque score of the group was 1.55. Plaque scores and mean decayed (D) component were significantly higher in intellectual disabilities as compared to physical disabilities. The mean DMFT and DMFS score was 3.2 and 6.42, respectively with mean decayed (D) component score of 2.67. There was no significant difference among caries prevalence and decayed (D) component among various groups of disabilities. Plaque index score reduced to 1.35 after three months and finally to 1.1 after six months. This was statistically significant (p<0.05). The actual chance to avoid new cavities in the cariogram increased from 5% to 73% at the end, for the SCSC boys. Conclusion: There was a significant decrease in the risk for oral diseases after incorporation of preventive oral health measures for SCSC.

Graphic Simulation of SARS-CoV-2 Droplets: Why Respirators should be used in Dental Healthcare Settings?
Introduction: Knowledge about the morphological characteristics of facial masks/respirators and their relationship with the possibility of interaction with respiratory droplets in the COVID19 pandemic is fundamental in dental healthcare settings. Aim: This study evaluated interfibrillar gaps of cloth mask, surgical mask and Filtering Face Piece 2 (FFP 2) respirator through Scanning Electron Microscopy (SEM) in order to perform a graphic simulation of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) respiratory droplets in the gaps among mask fibres. Materials and Methods: A fragment (1 cm2 ) of the cloth mask were used to perform a SEM analysis. The distance among fibres was determined by Energy Dispersive Spectrometry (EDS). Graphic simulation of droplets with different sizes (0.5 µm; 5.7 µm; 12 µm) was performed by an image editing program (Adobe Illustrator). Results: The image analysis showed that average distance among the fibres was 67.91 µm (cloth mask), 11.72 µm (surgical mask), 11.97 µm (respirator FFP2). Superimposition of masks layers resulted in no gaps between FFP2 fibres. Surgical mask exhibited openings between fibres in 1.43% of the studied total area. The cloth mask showed large gaps, in which it would be possible to transpose more than 680 million droplets (5.75 µm). Conclusion: FFP2 respirator showed no spaces among fibres after superimposition of structural layers, which would promote the blockage of the graphic simulation of SARS-CoV-2 droplets.

Dynamic Gesture Controlled User Interface Expert HCI System using Adaptative Background Masking: An Aid to Prevent Cross Infections
Human-Computer Interaction (HCI) interfaces need unambiguous instructions in the form of mouse clicks or keyboard taps from the user and thus gets complex. To simplify this monotonous task, a real-time hand gesture recognition method using computer vision, image, and video processing techniques has been proposed. Controlling infections has turned out to be the major concern of the healthcare environment. Several input devices such as keyboards, mouse, touch screens can be considered as a breeding ground for various micro pathogens and bacteria. Direct use of hands as an input device is an innovative method for providing natural HCI ensuring minimal physical contact with the devices i.e., less transmission of bacteria and thus can prevent cross infections. Convolutional Neural Network (CNN) has been used for object detection and classification. CNN architecture for 3d object recognition has been proposed which consists of two models: 1) A detector, a CNN architecture for detection of gestures; and 2) A classifier, a CNN for classification of the detected gestures. By using dynamic hand gesture recognition to interact with the system, the interactions can be increased with the help of multidimensional use of hand gestures as compared to other input methods. The dynamic hand gesture recognition method focuses to replace the mouse for interaction with the virtual objects. This work centralises the efforts of implementing a method that employs computer vision algorithms and gesture recognition techniques for developing a low-cost interface device for interacting with objects in the virtual environment such as screens using hand gestures.

Dietary Patterns and Association with Overweight and Obesity among Adolescents of Rewa City, Madhya Pradesh

Neera Marathe, Anshuman Sharma, Chakresh Jain, Achla Jain, Prayank Jain
Introduction: Prevalence of overweight/obesity has been increasing around the world. Obesity among adolescents is associated with both immediate and long-term health complications. Unhealthy dietary habits are the major modifiable risk factors which promote weight gain. Dietary patterns analysis may provide insight about effect of diet on overweight/obesity. Aim:To assess the association of overweight and obesity with dietary patterns among adolescents of Rewa city, MP (Madhya Pradesh). Materials and Methods: A cross-sectional community-based study was conducted among 744 adolescents of 10-19 year age group of Rewa city, MP from January 2018 to December 2018 with multistage random sampling procedure. Information was collected for socio-demographic variables and pattern of dietary habits and standardised anthropometric measurement were taken following STEPS manual. Data was collected through house-to-house visits. Data was interpreted using descriptive statistics with SPSS version 20.00 software. Chi-square test was used to find out the association of dietary with overweight and obesity. The p-value of less than 0.05 was considered as statistically significant. Results: In the present study prevalence of over-weight and obesity showed positive association with increased frequency of consumption of carbonated soft drinks (p=0.006), energy dense food intake (p=0.009), non-vegetarian food (p=0.04), less consumption of fruits and vegetables (p=0.005 and 0.02, respectively). In summation, the dietary behaviour showed a significant association with overweight or obesity. The study participants who had a poor dietary pattern showed a greater prevalence of overweight and obesity. Conclusion: The present findings suggest that increased intake of carbonated soft drinks, junk food (like pizza, samosa), sweets/ candies/chewing gums/chocolates, potato chips/popcorns/ packed food are highly significant in increasing the prevalence of overweight and obesity. So healthy dietary pattern and limited intake of unhealthy dietary pattern should be followed and before this widely neglected problem acquires gigantic proportions, more research and timely intervention are much needed.

Association between Blood Pressure and Obesity Indices in Medical Students
Introduction: Obesity is strongly associated with other metabolic disorders including Hypertension (HTN), diabetes and Cardiovascular Diseases (CVD). High Blood Pressure (BP) is ranked as the third most important risk factor for attributable burden of disease in south Asia. Aim: The aim of present was to study the association between BP and obesity indices in medical student’s population. Materials and Methods: A cross sectional study was conducted on a group of 100 healthy young medical students. BP, pulse and Hb O₂% was measured by using sphygmomanometer, pulse oximeter. Obesity indices were measured by using weighing machine, stadiometer, measuring tape and impedance based Body Composition Analyser (BCA). Results: There was poor correlation of Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) with Total Body Fat (TF) and the association was not significant. SBP and DBP were mildly correlated with BMI. Whole body Visceral Fat (VF) correlation of SBP was moderate and significant. DBP was correlated with whole body VF and correlation was significant. But the whole body, trunk, leg Skin Fat (SF) and Muscle Fat (MF) were not having significant correlation with SBP and DBP. Finger to heart distance was positively correlated with SBP (p<0.05). Also, O₂ %, chest and hip size were positively correlated with SBP (p<0.05). Only whole body VF and Waist Hip Ratio (WHR) were significantly (p<0.05) affected SBP. None of the other parameters affected DBP. Conclusion: The present study results found that Body Mass Index (BMI), VF and WHR had significant correlation with systolic and SBP and DBP. VF and WHR were significant predictors of SBP.

Evaluation of Bacteriological Profile and their Antimicrobial Susceptibility Pattern in Blood Stream Infections in a Multispeciality Hospital

Mariyah Yousuf, Tarana Sarwat, Dalip K Kakru
Introduction: Bloodstream Infections (BSIs) are one of the major cause of morbidity and mortality worldwide. To decrease the mortality from septicaemia early diagnosis and appropriate treatment of BSIs is most important. Early diagnosis of a BSI will markedly improve patient management. Aim: To identify various pathogenic organisms causing BSIs and determine their susceptibility to various antibiotics. Materials and Methods: A total of 1367 blood samples were received in the bacteriology laboratory for culture out of which 274 samples showed culture positivity. Among the positive cases 32 cases of Multidrug Resistance (MDR) were found. MDR cases show resistance to ≥3 classes of antibiotics. Enterobacteriaceae family showed highest MDR cases. Blood cultures were repeated for confirmation of results. Simple descriptive analysis of data was done and results presented in frequencies and percentages. Results: Out of 274 positive samples obtained, Coagulase Negative Staphylococci (CoNS) constituted maximum proportion of isolates (66%) followed by Pseudomonas species (12%), Escherachia coli (6.2%), Klebsiella species (3.2%), Citrobacter spp. (2.9%), Staphylococcus aureus (2.9%) and Enterococcus (2.9%). Conclusion: The present study highlighted the bacteriological aetiology of BSIs along with their antibiogram that may provide necessary information for the formulation of antibiotic policy in effective management of such cases.

Juvenile Granulosa Cell Tumour of Ovary in Young Females- A Clinico-pathological Evaluation of 11 Patients

Deepa Hatwal, Chitra Joshi, Ranjan Agrawal
Introduction: Ovarian sex cord-stromal tumours, including Granulosa Cell Tumours (GCTs), are a group of neoplasm that occurs rarely, especially in children. Only 0.1% of all ovarian tumours and 4-5% of GCTs occur in children. They commonly present as precocious puberty especially in prepubertal girls. Aim:To analyse the clinico-pathological features along with the laboratory findings of ovarian mass. Materials and Methods: A prospective study in tertiary care teaching institutions was carried out during a three year study period starting from April 2017 to March 2020. The study was carried out in tertiary care teaching institutions i.e., VCSGG Medical Sciences and Research Institute, Srinagar Garhwal, PauriGarhwal, Doon Medical College, Dehradun and Rohilkhand Medical College, Bareilly. A total of 11 cases of Juvenile Granulosa Cell Tumour (JGCT) among girls in the age group of 5-13 years who presented with precocious puberty were included in the present study. The results were analysed especially the clinico-laboratory parameters including histopathology and Immunohistochemistry (IHC) findings. All the patients underwent resection of the ovarian mass and were subjected to histopathological examination. Microscopy and IHC was compatible with the diagnosis of juvenile GCT in all the 11 cases. Results: Majority of the patients with GCTs of the ovary presented in the early stage. Of the 11 cases included, only one patient was aged 13 years; seven were in the age group of 5-8 years and three in the 9-12 years of age group. The laboratory profile in all showed an elevated Estradiol level, low Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) levels. Among the thyroid profile only the Triiodothyronine (T3) levels were raised while Thyroid Stimulating Hormone (TSH) and Thyroxine (T4) levels were within normal limits. All cases were histopathologically proved and confirmed using IHC markers. Surgery is the primary treatment modality for GCTs. Conclusion: Histopathology along with specific IHC is important in the diagnosis of JGCT. A careful search provides good insight of the tumour and its final outcome. Diagnosing JGCT especially in the early stage is important as they carry a favourable prognosis when treated in the initial phase.

Evaluation of Risk Factors Influencing Instability after Total Hip Replacement

Nikhil Deo, Gajanan Pisulkar, Suvarn Gupta, Kiran Saoji
Introduction: Total hip arthroplasty has been successful in relieving pain arising from hip joint diseases and maintains functional stability of hip joint. Instability can be rephrased as subluxation or dislocation of femoral head from the acetabulum. The study has been undertaken to find out causes related to instability after Total Hip Replacement (THR). Aim: To evaluate preoperative, intraoperative and postoperative risk factors influencing instability after THR. Materials and Methods: This retrospective study was carried out from June 2013 to June 2019. Preoperative, postoperative and six months follow-up data was recorded in the questionnaire. A total of eight patients were included in the group having postoperative dislocation and 122 patients were in normal THR group. Clinical outcome was measured using Harris Hip score. Data analysis was done by using Statistical Package for the Social Sciences (SPSS) software version 17.0 and parametric tests like paired t-test, Analysis of Variance (ANOVA) were used. Results: Majority of the patients in the study were in the age group of 31-40 years and 41-50 years (27.69% each) with total mean age of 41.14±12.40 years. About 77.69% were male and 22.31% were female. Mean Harris hip score of the total population was 74.73±5.35. Dislocation post THR was observed in 8 (6.15%) and all these patients were males. Six (75%) patients in hip dislocation group were chronic alcoholics while 41 (33.61%) in non-dislocation group were alcoholics and incidence of dislocation and alcoholism was statistically significant. Capsulectomy was done in 50% patients of hip dislocation group and 16.39% of non-dislocation group thus capsulectomy appears as a significant risk factor for postoperative hip dislocation. Conclusion: The incidence of hip instability after THR was 6.15%. Alcohol addiction was identified as a statistically significant independent preoperative risk factor. It was observed that capsulectomy was a significant risk factor for hip dislocation.

Study of Menstrual Abnormalities and its Association with Demographic Factors among Female Medical Students

Vaibhav Kanti, Vandana Verma, Naresh Pal Singh
Introduction: The regularity of menstrual cycle depends on many factors like genetic makeup, hormonal balance, weight and height, chronic medical illness and psychological problems. Life of medical students is very stressful, their food habits and sedentary lifestyle make them more prone for many menstrual abnormalities. Aim: This study was conducted to find out the menstrual abnormalities and its association with different biological variables like BMI, food habits and physical activity. Materials and Methods: This was a cross-sectional study conducted at U.P.U.M.S. Saifai, Etawah between July-August 2019 on 150 Female medical students. All the willing female medical students were asked to fill preformed self-structured questionnaire (weight, height, menstrual pattern and abnormalities, food habits, addiction, physical activity, relevant medical and surgical history) and association was sought between menstrual abnormalities and different demographic factors by using Pearson chi-square test. Results: The mean age of students were 21.9 years. Mean age at menarche was 13.4 years. A total of 2.7% students ate junk food daily; 18% (27) girls had irregular cycles out of which only five girls had taken treatment for this. Amount of blood loss during menstruation was found to be increased in 5.8% girls that consumed junk food (p=0.13). There was no significant correlation found between pattern of menstrual cycle and BMI, physical activity, addiction. Dysmenorrhea and PMS was less in the girls that were on restricted diet for weight reduction (46.1% and 61.5%, respectively) but this difference was not statistically significant. There was significant association between dysmenorrhea and regular consumption of junk food. Dysmenorrhea and PMS was also less in the girls that exercised regularly (45.2% and 69% respectively) (p=0.4). PMS was significantly associated with addiction to tea or coffee (p=0.04). Conclusion: In this study dysmenorrhea and PMS was the most common menstrual abnormalities. Medication was being taken mostly for dysmenorrhea. Most of the parameters did not show a significant association so a larger study or multicentric study is required.

Bronchogenic Carcinoma: Endoscopy versus Histopathology
Introduction: Lung cancer is the malignancy with the highest mortality (1.76 million deaths per year, 18.4% of the total) worldwide, being the only one whose incidence of death has progressively increased despite improved and more aggressive therapy in recent years. Early diagnosis plays an important role in increasing survival in lung cancer patients. Fiber Optic Bronchoscopy (FOB) is currently considered the first method for evaluating the tracheobronchial tree in patients with suspected lung cancer. Even though histopathological examination of bronchial biopsy specimen remains the confirmatory or the gold standard test, morphological appearance along with side and site of the lesion is also important in the diagnosis. Aim: To compare the bronchoscopic presentations of bronchogenic carcinoma in relation to side, site and morphology with histopathology. Materials and Methods: This descriptive cross-sectional study was conducted prospectively in the Institute of Respiratory Diseases, SMS Medical College, Jaipur, Rajasthan, India. It included 122 patients suspected clinico-radiologically and bronchoscopically with lung cancer and admitted to the hospital during the period from March 2018 to May 2019. FOB findings were noted carefully with regard to side, site and type of the lesion. One hundred and two patients were pathologically diagnosed with primary lung cancer. The bronchoscopic findings were correlated with histopathology. Statistical analysis were done using the chi-square test using the software IBM Statistical Package for the Social Sciences (SPSS) Statistics, Version 25.0. Results: A total of 102 patients (90 males and 12 females) with primary lung cancer were included in the study; most of them were in the sixth decade of life. The main anatomical site of bronchogenic carcinoma were; main bronchi (n=36, 35.29%), followed by lobar bronchi (n=28, 27.45%). Most common morphologic presentation was endobronchial growth (n=86, 84.31%) and for all the endobronchial growths, Squamous Cell Carcinoma (SQCC) was the most common histopathological diagnosis i.e., 32 cases out of 86 (37.21%). For Adenocarcinoma (AC), non-specific morphological finding was the most common (7 out of 13, 53.85%) rather than endobronchial growth (6 out of 13, 46.15%). External compression was the most common among the non-specific findings of AC (n=3 out of 13, 23.08%). Conclusion: Bronchoscopic appearance was associated to histological type. Both SQCC and Small Cell Carcinoma (SCC) were more in the central airways and endoscopically had the presentation of intraluminal growth commonly. ACs were more in the peripheral airways and endoscopically had non-specific findings more than endoscopic growth.

C-Reactive Protein Kinetics in Prognosis of Ventilator Associated Pneumonia
Introduction: Prognosis of Ventilator Associated Pneumonia (VAP) is commonly predicted by on-site assessment of clinical, haematological and biochemical parameters. Sequential measurement of C-Reactive Protein (CRP) which is one of the low-cost biomarkers could be useful in the early identification of poor outcome of VAP. Aim: To assess the prognostic value of progressive CRP levels in patients with VAP and compare with non-VAP group of ventilated patients. Materials and Methods: This was a prospective observational cohort study at medico-surgical ICU between November 2017 and October 2018. The patients on mechanical ventilator for more than 48 hours were divided into VAP (n=27) and non-VAP group (n=38). VAP was considered based on modified Clinical Pulmonary Infection Score (CPIS) more than 6 along with microbiological evidence from Tracheal aspirate or Bronchoalveolar lavage fluid with consolidation in Chest X-ray. Study subjects were monitored for the development of VAP. CRP measurements were done daily for the first 7 days then on 14^th day. The evolution of mean CRP concentration throughout the course of VAP and non-VAP were analysed and compared between survivors and non-survivors. Results: Mean CRP level of VAP patients on the day of diagnosis was almost similar to non-VAP cohort. The mean CRP of non-survivor groups of both VAP and non-VAP patients had shown a gradual increase after day 4. However, the mean CRP after day 4, in the survivor group of both VAP and non-VAP showed either decreasing or unchanged trends. Conclusion: It was evident that the dynamics of the CRP levels in patients with VAP can be used to assess the effects of the therapy for a better outcome.

Maternal Serum Uric Acid Levels and Adverse Pregnancy Outcomes in Women with Hypertensive Disorders of Pregnancy
Introduction: Hypertensive Disorders of Pregnancy (HDP) are the major cause of maternal morbidity and mortality worldwide. The maximum burden of maternal mortality and morbidity is due to HDP and its related complications which is further followed by obstetric haemorrhage, pre-existing medical diseases, infections and abortions. Aim: To study the association between the serum uric acid level in hypertensive pregnant women and their association with maternal and foetal morbidity and mortality. Materials and Methods: It was a prospective observational study conducted at BLDE (Deemed to be) University, Shri BM Patil Medical College Hospital and Research Centre, Vijayapura, Karnataka, India from January to June 2019. A total of 165 pregnant women with HDP were included (44 (27%) had Gestational Hypertension (GH); 86 (52%), Pre-eclampsia (PE) and 35 (21%) eclampsia) in each group in the study and they were subjected for obstetric history, examination and laboratory evaluation. The laboratory evaluation included complete blood count, liver function test, renal function test, serum uric acid level and urine albumin, sugars and microscopy. The maternal and foetal outcomes were measured, which included mode of delivery, Neonatal Intensive Care Unit (NICU) admission, neonatal outcomes in terms of preterm or term delivery, intrauterine death, fresh still born, neonatal deaths. Results: A total of 165 cases with HDP were enrolled in the study. Mean serum uric acid level in GH, PE and eclampsia group was 5.13±1.32, 5.34±1.4, 6.05±1.67, respectively. A total of 118 participants presented at term and 47 were preterm (11 in GH, 20 in PE and 16 in eclampsia group). About 103 (62.42%) had vaginal delivery and 62 (31.51%) underwent caesarean section (14 in GH, 28 in PE and 20 in eclampsia group). All the perinatal deaths occurred were in women with PE (n=5) and eclampsia (n=2) and was not statistically analysed. Conclusion: Present study shows that increased levels of maternal serum uric acid levels were associated with PE and eclampsia compared to GH patients and were associated with adverse foetal outcomes and increase in the instrumental and operative interventions.

Topical Insulin and Normal Saline in Chronic Diabetic Foot Ulcers- A Prospective Analytical Study
Introduction: Diabetic foot ulcers are important diabetes-related microvascular complications aggravated due to multiple pre-existing factors such as peripheral arterial disease, immune system factors, bone abnormalities, diabetic neuropathy, infections and repetitive external or minor trauma. Diabetic foot ulcers could lead to lower limb amputation if not managed appropriately. Aim: To evaluate the use of topical insulin in chronic diabetic foot ulcers at a tertiary care centre. Materials and Methods: This prospective analytical study of 12 months duration was conducted in Department of Surgery, in diabetic patients between the age group of 25 to 70 years, presenting for the first time with diabetic foot ulcer. A total of 60 patients were divided into two groups alternately as group A patients underwent dressing with topical insulin and group B patients underwent dressing with regular normal saline. Sterile transparent gauze was placed on the wound to mark the wound borders and the wound area measured. With the help of ruler the two largest perpendicular diameters were measured and these were multiplied to obtain the wound area in cm². Ulcers were cleaned with normal saline and a sterile gauze soaked with Human mixtard insulin and normal saline. Four units of 0.1 mL-Human mixtard insulin with 1 mL normal saline used for each 10 cm² of wound in group A. Data was analysed by using SPSS software. Chi-square test was used and p-value of <0.05 was considered as significant. Results: Mean age distribution was 51.2±9.6 years and 50.6±10.9 years in group A and B, respectively. Mean HbA1c at admission was 6.3±0.9 and 6.1±0.8 in group A and B, respectively. On day 0,7,15 wound measurements were done. A statistically significant difference was noted in reduction of average surface area of wound at day 7, 15 between group A and B. Insulin dressing group showed better changes than saline dressing group. Percentage reduction of surface area of wound at day 15 was 67.8±11.45 in insulin dressing group and 49.51±18.21 in saline dressing group, statistically significant difference was noted. Average time required for granulation tissue to appear was 6.08±2.15 days and 9.48±4.21 days in group A and B, respectively, statistically significant difference was noted (p<0.001). Conclusion: The application of topical insulin is secure and successful in patients with diabetic foot ulcers. Topically applied insulin can increase speed of wound healing and there are no chances of systemic side effects.

Prevalence of Injury Pattern among Karate Players in Delhi-National Capital Region- A Cross-sectional Survey

Sajjan Pal, Joginder Yadav, Sheetal Kalra, Bijender Sindhu
Introduction: With increasing participation in karate over the past 20 years, many injuries are reported in karate sports. Although many articles and studies regarding injuries in Karate have been published till now, there is lack of studies in the Indian context, to specifically evaluate and document the injury patterns in karate players. Aim: To identify the prevalence, onset of injury, mechanism, and pattern of injury in aspiring national and international level karate players. Materials and Methods: This cross-sectional study was conducted on the karate players of Delhi NCR (National Capital Region) during December 2018 to February 2019. The survey was conducted on 204 karate players (132 male and 72 female karate players). Data was obtained by one on one methods of the interview using a self administered and close ended questionnaire in various karate academies. Karate players included were in the age group between 15-25 years and aspiring for national and international level with a minimum of 2 years of experience of playing. Recreational and novice players were excluded from the study. Data was analysed by using Statistical Package for Social Sciences version 20 (SPSS). Results: Out of 204 karate players, 84 (41.2%) karate players were found to be injured at the time of the study and 90 (44.12%) players had injuries in the past 24 months. According to the location of the injury, head and face constituted the most injured body part (28.58%) followed by lower limb and upper limb. The onset of injury was found to be sudden in 57.15% of injuries and gradual in 35.71% of injuries and 65.48% injuries occurred due to direct contact mechanism due to punches and kicks. Conclusion: The current study revealed that karate was associated with a high injury rate. In karate the head and face were found to be injured the most followed by the lower limb and upper limb. More epidemiological studies are needed to understand mechanism or location of injuries during training and compare them to those injuries which are sustained in competition only.

Tracing the Origin and Transmission of Severe Acute Respiratory Syndrome-CoV-2: Does Genome Research Hold the Key?

Thangam Menon
The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was first identified in December 2019 in Wuhan, China. Since then, the virus has been rapidly spreading across countries, resulting in the present Corona Virus Disease (COVID-2019) pandemic. Thousands of genomes of different strains of the virus have been sequenced and made available in the public domain which has helped to detect viral mutations and track movement of the virus across the globe. The whole genome sequence of SARS-CoV-2 isolated from a human strain has 96.2% similarity to a bat coronavirus. The strains of SARS-CoV-2 found in different countries are genetically diverse and infections have been shown to be caused by multiple introductions in the same country. Though there are several theories regarding the origin of this virus, genetic studies indicate that it may have appeared by natural selection in humans following zoonotic transfer. This review highlights the recent knowledge of the origin of the coronavirus, its diversity in different geographical regions and mutations, which have aided it to infect the human host.

Dental Practice in the Era of nCOVID-19 Pandemic

Vandana Chhabra, Poonam Sood, Ajay Chhabra, Gourav Ahuja, Krittika Chhabra
The recent outbreak of nCOVID-19 pandemic has shaken the world. Dentists are at a great risk of contracting and transmitting this fatal disease. However, as health care personnel, this is our duty to treat patients especially in emergency situations when treatment is inevitable. Equipping ourselves with adequate knowledge and safety measures will not only protect us, but our patients as well. The routes of transmission of nCOVID-19 include direct and indirect contact with the infected person. Dental operatory offers plethora of opportunities for transmission because of the nature of the work done so it is important that clinical management should begin even before the patient enters the dental clinic. Dentist should be aware of the disinfection protocols and proper use of barrier techniques and Personal Protective Equipment (PPE) and about the disposal of the waste generated.

Intelligent Use of Mask in the View of Extraordinary Shortage Situation of COVID-19 Pandemic

D Sarumathi, Anitha Gunalan, Haritha Madigubba, Apurba Sankar Sastry
In the current situation of Coronavirus Disease (COVID-19) pandemic, frontline workers are trying hard with maximum possible efforts to lessen the transmission of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) with the help of available resources. Due to existing shortages of the Personal Protective Equipments (PPE) more frequently facemasks and respirators, the rational use of these PPEs and their prioritisation becomes absolutely necessary. Other measures such as the use of respirators beyond their shelf-life, extended usage, limited reuse of respirators and decontamination, reprocessing and re-use of respirators have to be considered. This review article focused on the current situation of shortage of masks, rational use of various types of respiratory protective devices, mask use in laboratories and different methods of decontamination and reprocessing of the respirators. Intense literature search of ongoing COVID-19 pandemic and Influenza pandemic 2009 were done and various guidelines inclusive of Centre for Disease Control and prevention (CDC), World Health Organisation (WHO), Public health agency of Canada were adapted for this review.

Utility of Digital Technology in Tackling the COVID-19 Pandemic: A Current Review

Prashanth Kulkarni, Shruthi Kodad, Manjappa Mahadevappa, Sushanth Kulkarni
The Coronavirus Disease (COVID-19) pandemic has rampaged across the globe, creating a major public health emergency and economic crisis. In this pandemic, digital technology tools, such as Artificial Intelligence (AI), big-data analytics, block chain technology, robotics, and drone technology are playing a vital role, and are increasingly being utilised by many countries for devising major public health strategies. This article discusses the utility of digital technology in combating coronavirus infection and also highlights the current limitations and future prospects of these tools.

Role of Health Financing in Provision of Health Care and Universal Health Coverage in India
Financing is an important aspect of any program for successful transformation. Financial commitment of government is considered to be the highest form of commitment for successful work. Without budgetary provision, no program can achieve the desired target. The role of health financing of central government, international donor agencies, provincial government, and local bodies have been identified. The paper focused on monitoring and evaluation mechanisms for health financing in the context of recent developments. Health financing models have been discussed to gain an understanding about relation of financing and overall healthcare development. The search engines like PubMed, Scopus, Web of Sciences, and jstor (journal storage) were consulted to unearth the mechanism of health finances for development of good health. The paper put forth various themes and sub-themes according to financial implications on health structure of India. All healthcare programs need a continuous stream of resources like medicine, workforce, physical infrastructure, monitoring, and evaluation to achieve good health. Whereas, different stakeholders also need financial support to evolve with great vigour and vivacity. There is a pressing need to infuse financial resources into public health system for achievement of universal health care rather than incremental growth in traditional financial processes spreading over several decades. The specific roles and responsibilities of central, provincial, local governments and international donors have to be delineated to expedite resource mobilisation. However, while implementing programs, there should be coordination among all the stakeholders.

Effect of COVID-19 on Individuals with Hearing Impairment in India

Abishek Umashankar, Prashanth Prabhu
COVID-19 has proven to be pandemic and affecting the day to day life of normal individuals. However, individuals with disability, especially with hearing impairment face even more difficulty. They are unable to get their routine evaluation and therapy, the maintenance of their hearing restoration devices has also found to be cumbersome. The strategy that they can use during this lockdown period has been discussed.

Engaging School Going Children During COVID-19 Lockdown

Pooja Rameshrao Kasturkar, Jaya Pranoykumar Gawai
Corona Virus Disease 2019 (COVID-19) pandemic is current crisis in more than 200 countries in the world. The virus originated in bats and was transmitted to humans in December 2019 via still unknown intermediate animals in Wuhan, Hubei Province, China. In India, Corona virus confirmed cases are 101,139, recovered cases are 39,174, deaths 3,163 and active cases are 58,802 on the date of 19 May 2020. “In India, Prime Minister Narendra Modi declared phase wise complete lockdown for corona virus pandemics to save India and every Indian.” In this lockdown period, children are getting bored, separation from playgroups and friends and their daily routine of playing is creating a lot of anxiety for children, they are losing their attachments. Children’s social life and learning have been affected. Due to the corona virus (COVID-19) pandemic, closure of schools has affected the education of more than 1.5 billion children and young people worldwide. It should be well-known that school closures are liable to broaden the learning gap between the lower-income and higher-income families among children. So we need to engage the children in purposive and creative activity and give them some leaning task related to their studies. This short communication concludes with the key learning for the parents of children on how to engage school going children during covid-19 lockdown.

Journal of clinical and diagnostic research

Chyluria: An Unending Illness- A Case Report

Variations in the Axillary Artery Branching Pattern

Henoch Schonlein Purpura as Late Manifestation of Hepatitis A Infection

High Grade Serous Carcinoma Presenting as a Huge Pelvic Mass with Normal Looking Ovaries: A Diagnostic Challenge for Pathologist

Seronegative Lupus- A Wolf in Sheep's Skin

Facial, Skeletal and Radiological Features of Larsen Syndrome: A Case Report

Enterovesical Fistula: A Serious Complication of Crohn Disease

Neuroleptic Malignant Syndrome Presenting with Self Injurious Behaviour

A Case of Unilateral Hyperlucency on Chest X-Ray- A Diagnostic Dilemma

Curious Case of a Foldable Intraocular Lens that did not Unfold

Ectopic Ureter in Single System Kidney in Association with Anorectal Malformation in Male Patient

Bilateral Accessory Central Cusp on Permanent Mandibular Second Molars: An Unusual Occurrence

Bortezomib Induced Paralytic Ileus: Are we Aware?

A Case of Macrophagic Activation Syndrome in a Child with Epilepsy Treated with an Excessive Dose of Sodium Valproate

Unilateral Nevus of Ota with Palatal and Optic Disc Pigmentation with Coincidental Preauricular Tag- A Case Report

Neonatal Autopsies with Heart Disease: A Challenge for Pathologist

Incidental Detection of Microfilaria in Fine Needle Aspiration Cytology- A Report of Three Cases

Clinical Profile of nCOVID-19 Cases in Andaman and Nicobar Islands: A Case Series

The Neuroprotective Effect of Ginkgo Biloba Extract on Valproic Acid Induced Autistic Features in Mice

Biomechanical Analysis of the Zirconia and Graphene-based CAD-CAM Dental Bridges at Different Pontic Length: A Finite Element Analysis

Should Dentist be a Part of COVID Care Team?

Subungual Melanoma- An Enigmatic Entity

Prevalence of Mineral Bone Disease in Chronic Kidney Disease Patients using Biochemical Markers

Effect of Premedication with Ibuprofen, Paracetamol and Diclofenac Sodium on the Outcome of Maxillary Infiltration Anaesthesia in Patients with Irreversible PulpitisA Double-blind Randomised Controlled Trial

Comparative Evaluation of Root Dentin Microhardness after using Different Standard Irrigating Solutions and Stevia Leaf Extract- An In vitro Study

Prevalence of Horseshoe Kidneys by Multidetector Computed Tomography in a Tertiary Care Hospital in South India

Evaluation of Postoperative Pulmonary Complications after Emergency Abdominal Surgery- A Prospective Study

Intrathyroid Parathyroid Adenomas-Uncommon Tumours at Unusual Sites: A Cross-sectional Study

Study of Glycation of Transferrin and its Effect on Biomarkers of Iron Status in Uncontrolled Diabetes Mellitus Patients

Incidence of Diphtheria among Clinically Probable Cases in a Tertiary Care Centre- A Prospective Study

Prospective Observational Cohort Study on Dexmedetomidine and Midazolam in Mechanically Ventilated Children

Upper Extremity Dysfunction after Trans-Radial Interventions- Experience from a Tertiary Care Center of North India

A Study of Serum Lipid Profile Changes in Children with Dengue Haemorrhagic Fever and its Correlation with Severity in a Tertiary Care Hospital

Assessment of Knowledge and Awareness of Radiation Hazards and Protection among Patient’s Relative in Southeast, Nigeria

Spirometry Function after Decortication for Chronic Pleural Empyema: A Retrospective Study

Effect of Juvenile Idiopathic Arthritis on the Temporomandibular Joint and Occlusion in Children and Young Adolescents: A Descriptive Cross-sectional Study

Knowledge and Awareness of Turkish Population about Dental Treatment during COVID-19- A Questionnaire based Survey

Sonographic Evaluation of Uterine Dimensions in Postpartum Women of Reproductive Age-Study from Enugu, Southeast Nigeria

A Comprehensive In-Silico Analysis of Deleterious Missense SNPs in Human Trehalase Gene: Gaining an Interactome Insights into Type 2 Diabetes Mellitus

Correlation between Serum Iron, Serum Ferritin and Bile Cholesterol Level in Gallstone Disease

Identification of Non-tuberculous Mycobacteria by Partial Gene Sequencing and Matrix Assisted Laser Desorption Ionisation Time of Flight at a Tertiary Care Hospital in Telangana, India

Comparison of Five Cytochemical Stains used for Fine Needle Aspiration Cytology of Breast and Lymph Node Lesions: A Comparative Study

Anti-Inflammatory Markers IL-10 and IL-35: Role in Developing Gestational Diabetes Mellitus

Histomorphological Spectrum of Mediastinal Masses with Special Emphasis on Rare Lesions

Cartridge Based Nucleic Acid Amplification Test: Utility as Diagnostic Modality in Clinically Diagnosed Childhood Tuberculosis

Role of Pleural Fluid C-Reactive Protein in the Aetiological Diagnosis of Exudative Pleural Effusion

Willingness and Perception of Dental Interns towards Working in Rural Areas in Riyadh, Saudi Arabia- A Cross-sectional Study

Ketamine-Dexmedetomidine Combination for Monitored Anaesthesia Care in Tympanoplasty Surgery: An Observational Study

Association of p53, VEGF and Microvascular Density in Colorectal Carcinoma

Why Some Mothers Could Be Saved and Not Others? Evaluating Different Phases of Delay in Causing Maternal Near Misses and Maternal Deaths

A Study on Perception of Students Regarding Newer Teaching Methods in Medical Education

Clinical Manifestations and Associated Complications of Scrub Typhus in Odisha, India

Safety Measures in Biochemistry Laboratory: Need of the Hour

Assessment of Relationship between Galectin-3 and Biochemical Parameters in Peritoneal Dialysis Patients with Left Ventricular Hypertrophy

Symptomatic Biliary Pseudolithiasis in Adult Patients Treated with Parenteral Ceftriaxone: A Prospective Study

Use of Echogenic Needles for Ultrasound-guided Transversus-Abdominis-Plane Block: Better Visibility Transforming into Better Postoperative Analgesia

Antibiotic Prescribing for Endodontic Infections and Prophylaxis for Medically Compromised Patients: A Survey on Dental Students in Turkey

High-sensitivity C-reactive Protein as a Marker of Future Cardiovascular Events in Chronic Kidney Disease Stage-5 Patients

Comparison of Intrathecal Fentanyl and Butorphanol as an Adjuvant to Intrathecal Bupivacaine 0.5% in Infraumbilical Surgeries- A Randomised Double Blind Study

Phenotypic Pattern of Vibrio cholerae Isolates from a Tertiary Care Hospital in Vadodara, Gujarat, India

Effectiveness of Preventive Oral Health Measures among Special Care School Children (boys) in Al-Kharj, Saudi Arabia

Graphic Simulation of SARS-CoV-2 Droplets: Why Respirators should be used in Dental Healthcare Settings?

Dynamic Gesture Controlled User Interface Expert HCI System using Adaptative Background Masking: An Aid to Prevent Cross Infections

Dietary Patterns and Association with Overweight and Obesity among Adolescents of Rewa City, Madhya Pradesh

Association between Blood Pressure and Obesity Indices in Medical Students

Evaluation of Bacteriological Profile and their Antimicrobial Susceptibility Pattern in Blood Stream Infections in a Multispeciality Hospital

Juvenile Granulosa Cell Tumour of Ovary in Young Females- A Clinico-pathological Evaluation of 11 Patients

Evaluation of Risk Factors Influencing Instability after Total Hip Replacement

Study of Menstrual Abnormalities and its Association with Demographic Factors among Female Medical Students

Bronchogenic Carcinoma: Endoscopy versus Histopathology

C-Reactive Protein Kinetics in Prognosis of Ventilator Associated Pneumonia

Maternal Serum Uric Acid Levels and Adverse Pregnancy Outcomes in Women with Hypertensive Disorders of Pregnancy

Topical Insulin and Normal Saline in Chronic Diabetic Foot Ulcers- A Prospective Analytical Study

Prevalence of Injury Pattern among Karate Players in Delhi-National Capital Region- A Cross-sectional Survey

Tracing the Origin and Transmission of Severe Acute Respiratory Syndrome-CoV-2: Does Genome Research Hold the Key?

Dental Practice in the Era of nCOVID-19 Pandemic

Intelligent Use of Mask in the View of Extraordinary Shortage Situation of COVID-19 Pandemic

Utility of Digital Technology in Tackling the COVID-19 Pandemic: A Current Review

Role of Health Financing in Provision of Health Care and Universal Health Coverage in India