Journal of clinical and diagnostic research

Axillary Lymph Nodal Metastasis from Carcinoma of Unknown Primary (Cupaupax)- An Orphan Disease

Renuka Bangalore Nagaraj, MD Khursid Alam Ansari

Metastasis to axillary lymph node occurs in adenocarcinoma or poorly differentiated carcinoma, and is a rare clinical entity that needs to be understood for management and its clinical outcome. The present case is of 72-year-old female patient who had a metastatic nodule in the axilla. No breast mass was palpable. Histology identified as metastatic adenocarcinoma, however mammography and Ultrasound Sonography test (USG) failed to detect the primary tumour. Immunohistochemistry showed that the excised lymph node was positive for Estrogen Receptor (ER) and negative for Progesterone Receptor (PR), suggesting the breast as the site for the primary tumour. Since the patient refused surgery, she was under follow-up for eight months. Now, she presented with recurrence of similar axillary swelling for two months.

Melanosis of the Uterine Cervix: A Rare Case Report

Nikhil Sanjay Deshpande, Aditi Mittal, Anil B Munemane, Ravindra Raosaheb Karle

Cervical melanosis is a rare entity in the spectrum of melanocytic lesions of uterine cervix. Melanosis is defined as presence of melanocytes in the basal layer of squamous epithelium causing hyperpigmentation. Authors here by report a case of 57-year-old female who underwent vaginal hysterectomy for third degree utero-vaginal prolapse, showed an incidental gross pathological finding of brownish macular lesion. Histopathological examination showed hyperpigmentation of basal layer without increase in melanocytes. On immunohistochemical examination, basal melanocytes were highlighted by S-100 and HMB 45 immunostains. Thus final diagnosis of cervical melanosis was made. Clinical differentials of cervical pigmented melanocytic lesions include cervical melanomas, blue nevi, congenital or traumatic lesions and melanosis, hence vigilant clinical, gross pathological examination and biopsy is warranted.

Post-COVID-19 Physiotherapy Rehabilitation: A Case Report

Reema Joshi, Manisha Rathi, Jidnyasa Thakur

Coronavirus Disease 2019 (COVID-19) is a severe disease mostly affecting the respiratory system. Even after the acute symptoms of COVID-19 subside, there are many post acute symptoms that are still present in the COVID-19 survivors. Post-COVID-19 fatigue is seen to affect people of all age groups. This case report emphasises on the Physiotherapy view point. There are very few studies showing the benefits of Physiotherapy exercises in Post-COVID-19 manifestations. A 21-year-old female presented to physiotherapy department. An 8-week Physiotherapy protocol was given and outcomes were assessed before and after the treatment protocol. The presented symptoms were found to be relieved, thus, showing the effectiveness of Physiotherapy in Post-COVID-19 phase.

Diffuse Strong Membrane Expression of MIC2 (CD99) in Anaplastic Large Cell Lymphoma: A Diagnostic Challenge

The MIC2 [Cluster of Differentiation 99 (CD99)] has been widely used in making the diagnosis of Ewing’s sarcoma and diffuse strong membrane expression is the characteristic finding. The CD99 is a sensitive marker of Ewing’s sarcoma, but not specific. Studies have shown expression of CD99 in a wide variety of neoplasms which include epithelial, mesenchymal and haematopoietic neoplasms. In these tumours, the positivity of CD99 is described as variable with focal/patchy, irregular, membrane/cytoplasmic staining. Among the haematopoetic neoplasms, diffuse strong positivity of CD99 is seen in blasts which include T-lymphoblasts, B-lymphoblasts and myeloblasts. Recent studies have demonstrated positive staining of CD99 in mature lymphomas where the pattern of expression is heterogenous and highly variable. Herein, authors report the case of a 42-year-old male patient with expansile destructive lesion in right scapula with large soft tissue component. With clinical diagnosis of sarcoma, biopsy was taken which showed large atypical cells arranged diffusely, focally around vessels and in vague rosettoid pattern. In the initial immunopanel, neoplastic cells showed diffuse strong membrane expression of CD99 and were negative for cytokeratin, synaptophysin, chromogranin, desmin and S100. On further examination, the neoplastic cells showed focal weak to moderate positivity for CD45, diffuse strong positivity for CD30 and strong positivity for Anaplastic Lymphoma Kinase (ALK). Diagnosis of ALK positive Anaplastic Large Cell Lymphoma (ALCL) was given. The awareness of diffuse strong membrane pattern of staining of CD99 in ALCL will help to avoid misdiagnosis especially in cases with atypical clinical presentations.

Tuberculous Perforation of Meckel’s Diverticulum

JB Dharmesh , Abhishek Mahna , Parth M Khanpara , Marmik Sheth , Vanshika Munjal

Meckel’s Diverticulum (MD) is an example of a true diverticulum, consisting of all the three layers of small intestine. It is a remnant of omphalomesenteric (vitellointestinal) duct found on the antimesenteric side of the ileum. Perforation of MD is an uncommon complication of an effectively uncommon abnormality, which regularly mimics an appendicular perforation clinically. Although intestinal tuberculosis is a major issue in many parts of the world, a handful of cases of tubercular perforation of MD have been reported in the literature till date. This case of tubercular perforation of MD was reported due to the rarity of the condition and presence of fairly less literature on the topic. A 30-year-old male patient presented with abdominal pain, fever, vomiting. On examination, tachycardia, guarding, rigidity and rebound tenderness were observed. Exploratory laparotomy revealed perforation of MD with inflammation of ileum and caecum with dense adhesions. Proximal loop ileostomy was made. Histopathology showed features of tuberculosis. Postoperative recovery was uneventful and patient was started on antitubercular treatment and 4 kgs weight gain on follow-up after one month.

Management of Histologically Proven Oral Submucous Fibrosis with Intralesional Steroids and Hyaluronidase- A Report of Two Cases

R Preethi, S Aravind Warrier, CV Divyambika

Oral Submucous Fibrosis (OSMF) is a chronic debilitating disease characterised by progressive fibrosis. The disease is predominantly seen in South East Asia and mainly attributed to areca nut chewing habit. The classical presentation includes generalised blanching with palpable fibrotic bands in the oral mucosa. Patients experience severe burning sensation, trismus and difficulty in gustatory functions, thus resulting in compromised nutritional status. The OSMF has been grouped under Oral Potentially Malignant Disorders (OPMD) and has high rates of malignant transformation. Although randomised controlled trials on different treatment modalities have been conducted, currently there is no effective medical management. This paper highlights two cases of OSMF presenting with severe burning sensation and trismus, who underwent incisional biopsy for histopathological confirmation and to rule out dysplasia. Both the patients were treated with dexamethasone and hyaluronidase, biweekly for four weeks. Post-treatment there was significant improvement in the clinical symptoms, thus providing the patients with better quality of life.

Unusual Presentations of a Benign Cartilaginous Tumour- An Interesting and Extremely Rare Case Report

Chondroblastoma is one of the benign cartilaginous bone tumours. Location wise, it is mostly located in immature epiphysis of long bones. Along with epiphysis, many times it also involves metaphysis. Pure metaphyseal tumours are uncommon. Pure diaphyseal tumours are rarest with only very few cases reported in the literature. The most common age group for this tumour is 10-17 years. It is uncommon in patients less than 10 years and those more than 25 years of age. Diaphyseal chondroblastoma in less than 10 years of age group is extremely rare. Hereby, authors report a case of 14-month-old male child who presented to the paediatric orthopaedic outdoor with complaints of the swollen left leg and associated pain by the parents for the last 1 month. There was no history of trauma/weight loss/fever. No difficulty in walking was present. Local examinations of the left leg showed a well-defined globular swelling of size 3×3 cm in the middle part medial aspect. The underlying tibia was continuous with that of swelling having restricted painful movement. X-ray showed an osteolytic, expansile, cortical, eccentric lesion in the middle third (diaphysis) of the left tibia. Correlating the clinical and radiological findings, clinical diagnosis of osteofibrous dysplasia was considered. The intralesional curettage and bone grafting were done and tissue was sent for histopathology. Histopathology showed the characteristic findings of chondroblastoma. The final diagnosis of diaphyseal chondroblastoma of the left tibia was made. The postoperative events were unremarkable and the patient followed-up to eight months with a happy outcome without any residual disease or recurrence.

Long-term Implication of Metronidazole Induced Reversible Cerebellar Toxicity and Peripheral Neuropathy- A Case Report

Metronidazole Induced Encephalopathy (MIE) is rare and serious central nervous system toxicity. A 40-year-old male, on long-term self treatment with metronidazole (cumulative dose: 102 gm) presented with dysarthria, nystagmus, unsteadiness, and numbness in both legs. A Magnetic Resonance Imaging (MRI) scan of the brain revealed a symmetric hyperintensity in both the dentate nuclei of cerebellum on both T2 weighted and Fluid Attenuated Inversion Recovery (FLAIR) imaging. Discontinuation of metronidazole resulted in resolution of the imaging findings and clinical improvement occurred within one month. Metronidazole-induced neurotoxicity should be considered in patient who present with cerebellar symptoms and characteristic lesion on MRI in close temporal relation with metronidazole intake and drug should be discontinued to prevent permanent neurological deficit.

Snake Bite Presenting as Haemolytic Uremic Syndrome: A Rare Case Report

Parth Godhiwala, Sourya Acharya, Amol Andhale, Samarth Shukla, Sunil Kumar

Snake bite is predominantly an occupational hazard and causes severe health issues. Snake poisoning in India is a significant and prevalent cause of Acute Kidney Injury (AKI). In India, the occurrence of AKI after snake bite is 13-32%. All over the world every year, 1,50,000 people die as a result of it. Multiple mechanisms such as haemodynamic disturbances, direct tubular toxicity, coagulopathy, haemoglobinuria, and myoglobinuria can cause AKI after bites by snakes belonging to the Elapidae, Viperidae, and Colubridae families. Renal pathologic findings include acute tubular necrosis, cortical necrosis, interstitial nephritis, glomerulonephritis, and vasculitis. Thrombotic Microangiopathy (TMA) as a cause of snakebite-induced AKI is rarely reported in literature. Fewer details are known about the clinical course, optimal management, and overall prognosis of this entity. Haemolytic Uremic Syndrome (HUS) is a clinical disease that includes TMA, thrombocytopenia, and AKI as a triad. The HUS is a heterogeneity of illnesses with diverse aetiology which results in presentation, therapy and outcomes variance. Hereby, authors report a case of a 55-year-old female who was bitten by Russell’s viper and developed HUS. Patient eventually progressed to end stage renal disease and was advised lifelong haemodialysis. TMA should be taken into account as a probable cause of AKI following a snake bite. Plasma exchanges have yet to be determined in snake bite TMA.

Embryonal Rhabdomyosarcoma in Middle Ear: A Rare Case Report

Rhabdomyosarcoma (RMS) in middle ear and mastoid are uncommon. Presentation of RMS in these sites include purulent or blood stained discharge, polypoidal mass and granulation tissue. Clinical diagnosis may be delayed due to similar presentation as Chronic Suppurative Otitis Media (CSOM). Authors herein report a case of six-year-old male patient, who presented with a blood stained discharge from right ear for 15 days. On otoscopic examination, a polypoidal mass in external auditory canal was identified. A history of ruptured right tympanic membrane with occasional discharge for two years had been given. Clinical diagnosis of CSOM with aural polyp had been made. Radiographically, it was a soft tissue lesion with poorly defined margins. There were no bony erosions with minimal collection in right middle ear cavity. On routine histopathological examination diagnosis of round cell tumour had been made. On Immunohistochemistry (IHC), tumour was immunoreactive for desmin and vimentin, while negative for Cytokeratin (CK), Leukocyte Common Antigen (LCA), chromogranin and synaptophysin. Tumour was diagnosed as RMS (Embryonal type). This case report shows importance of early diagnosis of RMS in middle ear, which is often delayed and misdiagnosed as CSOM. Delayed diagnosis may lead to, facial nerve involvement, local meningeal involvement and distant metastasis. Histopathological examination and IHC e.g., desmin positivity are the mainstay of diagnosis.

Hand Full of Sausages-Forme Frustae of Severe Psoriatic Arthritis: A Case Report

Dactylitis or sausage shaped digits is one of the hallmark features of psoriatic arthritis which occurs in association with psoriasis. This is a report of 50-year-old female, known case of psoriasis vulgaris, presented with complaints of red, painful and swollen digits of both hands since two weeks. She also complained of pain and restricted movements of all small joints of hands since two days. On examination, all the digits were erythematous, tender and swollen. Investigations revealed elevated Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP), negative rheumatoid factor and x-ray hands showed joint space narrowing and soft tissue swelling. Based on Classification Criteria for Psoriatic Arthritis (CASPAR) with score of 3/6, psoriatic arthritis was diagnosed. Further evaluation of other joints revealed features of sacroiliitis in x-ray pelvis. Psoriatic dactylitis involving all digits and as an initial symptom of psoriatic arthritis is rarely reported in literature. Dactylitis involving all the digits may be a forerunner of severe psoriatic arthritis.

Foot Drop: A Rare Post COVID-19 Complication

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus which has caused Coronavirus Disease 2019 (COVID-19) pandemic, may also affect neural axis at different levels including Central Nervous System (CNS) and Peripheral Nervous System (PNS). There is increasing evidence of neurological complications caused by SARS-CoV-2. Though isolated facial nerve involvement has been reported in literature, isolated peroneal nerve palsy secondary to SARS-CoV-2 infection is a rare occurrence. This article reported two such rare cases (53-year-old male/45-year-old male) of foot drop where isolated peroneal nerve involvement was present on nerve conduction study. It was possibly caused by an immune mediated mechanism in patients who had recovered from COVID-19 infection.

Placental Pathology in a COVID-19 Positive Patient with Abruptio Placentae- A Case Report

Nishtha Jaiswal, Reena Yadav, Prerna Tayal, Lalita Jyotsna Prakhya

The effects of Severe Acute Respiratory Distress Syndrome-Associated Coronavirus-2 (SARS-CoV-2) on the placental tissue are still being explored. Whether these placental changes result in adverse foeto-maternal outcome is an aspect that needs to be understood. This is a report of 32-year-old pregnant woman who presented with Antepartum Haemorrhage (APH) and decreased foetal movements. She was also diagnosed to be positive for the SARS-CoV-2. The patient had abruptio placentae unrelated to pre-eclampsia. On histopathological examination, the umbilical cord showed funisitis with increased perivillous fibrin deposition on section from foetal and maternal surface of the placenta. Though the foetus was stillborn, with timely management the maternal outcome was not compromised.

Folliculosebaceous Cystic Hamartoma: A Rare Entity

Manjari Kishore, Avinash Kumar, Sarita Devdhar, Monisha Choudhury

Folliculosebaceous Cystic Hamartoma (FSCH) is an uncommon cutaneous hamartomatous lesion. It is basically a tumour like malformations exhibiting abnormal overgrowth of biphasic elements i.e., epithelial and mesenchymal components that are normally found in the skin. Few other hamartomas of pilosebaceous origin are trichofolliculoma, trichodiscoma, fibrofolliculoma and pilar sheath acanthoma. Though distinct, this entity shares similar histological features to Sebaceous Trichofolliculoma (STF). Hence, a proper histological examination is must in differentiating it from STF and other clinical and histological entities. Authors hereby, describes a case of FSCH in a 37-year-old male who presented with a slow growing cystic mass on his left earlobe, an uncommon location for such lesion. The mass was excised, and a detailed histological evaluation showed a characteristic multinodular growth pattern with lobules of pilosebaceous glands forming nodules around cystically dilated follicular infundibular structures. No hair shafts were seen in the cystic cavity ruling out differential diagnosis of sebaceous hyperplasia which could have been a close mimic. The intervening stroma revealed dense collagen, sheets and lobules of adipocytes, many vascular channels filled with fibrinous deposits. Perivascular adipocytes were also noted along with few nerve tissues (perineurium). A detailed clinicopathological work-up helped in arriving at a final diagnosis of FSCH with neural component. The patient was doing well till last six months of follow-up. No recurrence of similar lesion was noted in the patient.

Nodular Subcutaneous Phaeohyphomycosis due to Medicopsis romeroi in an Immunocompetent Patient

Smita Deshkar, Niranjan Patil, Ashish Lad, Shraddha Amberkar, Swati Sharan

Fungal infections like subcutaneous phaeohyphomycosis are uncommon but are increasing lately, especially in tropical regions like India. Identification of correct aetiologic agent is essential as different species can have different organ tropism. Here, a rare case of nodular subcutaneous phaeohyphomycosis in an immunocompetent 62-year-old male patient who developed nodule over right dorsum of foot is reported. After various diagnostic tests a rare dematiaceous fungus Medicopsis romeroi was identified as a causative agent in the nodular material by Internal Transcribed Spacer (ITS) sequencing. Surgical excision and antifungal therapy of itraconazole proved beneficial with no recurrence during a six months of follow-up. Medicopsis romeroi has been debated for its role in human infections however, it should be considered as one of the aetiologic agents of subcutaneous phaeohyphomycosis.

Bilateral Sacroiliac Joint Fusion: A Case Report

NB Pushpa, MV Ravishankar, K Pushpalatha

Sacroiliac (SI) joint is the articulation which forms the part of the bony pelvis. It plays an important role in locomotor activity, and childbirth during labour. It helps in the transmission and distribution of axial body weight from the spine to the pelvis. This synovial joint exhibit limited gliding movements within the joint cavity. About 15-30% of low backache aetiologies are attributed to SI joint dysfunction. People who are overweight, have co-morbid conditions, and pregnant women are at higher risk of developing vertebral joint deformities called spondylarthropathies. They are group of inflammatory disorders which are involving the vertebral spines and peripheral joints, where the symptom of stiffness is prominently seen. The anatomical variations in the SI joint morphology like accessory SI joint, iliosacral complex and sacral defect, dismorphic joint, are of compelling interest concerning SI joint pathologies from the orthopaedic viewpoint. This case report presents a bilateral fusion of SI joint, found in a skeleton in the museum of medical college.

Ruptured Cervicoisthmic Pregnancy with 20 Weeks Intrauterine Foetal Death Lying in Left Broad Ligament- A Case Report

Ruby Bhatia, Khyati Sharma, Trisha Arora, Surbhi Gupta, Disha Jindal

Abnormal Low Lying Implantation of Ectopic Pregnancy (LLIEP) may occur in cervix, cervico isthmic region or caesarean scar. Cervicoisthmic pregnancy remains the rarest form of LLIEP, a life threatening cause of maternal morbidity and mortality with an incidence of 1 in every 2400 to 4500 pregnancies. In isthmic implantation, the gestational sac is located more cranially and between the cervix distally and the decidualised functional endometrium cranially. Transvaginal Ultrasound (TVS), Colour Doppler and Magnetic Resonance Imaging (MRI) remain gold standard modalities for early diagnosis. Ultrasonography depicts bulging lower uterine segment with a normal cervical length and consistency. Here, the author reports a rare case of ruptured isthmic pregnancy with 20 weeks intrauterine foetus death lying in left broad ligament in a 33-year-old unbooked G₃P₂L₂ with gestation of 31 weeks presenting in emergency. Ultrasonography depicted intrauterine foetus death with foetus lying in lower segment of uterus. Lower section caesarean section for failed induction confirmed hour glass uterus with empty upper uterine segment and bulging, distended, couvelaire lower uterine segment and left lateral rupture at cervicoisthmic junction. Dead 20 weeks foetus lying in leaves of left broad ligament. Peripartum hysterectomy was done as a life saving procedure. Cervicoisthmic pregnancy is rarest form of LLIEP and diagnosis may result in rupture with need of peripartum hysterectomy.

Calcium Pyrophosphate Deposition Disease in the Craniovertebral Junction: An Unusual Cause of Neck Pain

Crowned Dens Syndrome (CDS) is a rare manifestation of Calcium Pyrophosphate Deposition (CPPD) disease characterised by calcification around the odontoid process in the atlantoaxial joint. It manifests as intense neck pain with signs of systemic inflammation, including elevated acute phase reactants. Thus, it can simulate other causes of neck pain and diagnosis can be challenging. Moreover, CPPD disease can be asymptomatic and observed as radiological finding. Here in, two cases of spinal CPPD disease with distinct presentations are reported. The first of 83-year-old woman describes CDS that was misdiagnosed as Polymyalgia Rheumatica (PMR) whereas in the second case of 70-year-old female calcification around the odontoid process was incidentally found in a patient with acute cervical spine fracture. These two reported cases highlight the spectrum of manifestations of spinal CPPD disease and support the notion that careful discrimination of the cause of neck pain is essential for improving outcomes.

A Case of Partial Trisomy of 10q and Partial Monosomy of 6p Resulting from Maternal t(6;10) (p23;q24

Anjali Satyen Sabnis, Anurita S Pais, Gauri Pradhan

Chromosomal analysis is practiced routinely since long time in congenital malformations to find out structural and or numerical chromosomal aberrations. Translocation is one of the structural chromosomal aberrations where exchange of genetic material between the chromosomes is seen because of two breakpoints. On the basis of involvement of type of chromosome, two different types of translocation are defined. A case of two-year-old girl child with the history of developmental delay, generalised hypotonia and recurrent infections was reported whose cytogenetic analysis showed additional genetic material on ‘p’ arm of one chromosome 6. To find out the additional genetic material, parental chromosomal study was done which revealed balanced translocation between ‘q’ arm of chromosome 10 and ‘p’ arm of chromosome 6 and normal chromosomal pattern in father. Balanced translocation in mother gave rise to formation of derivative chromosome 6 which was transmitted to daughter causing partial trisomy of 10q and partial monosomy of 6p. This gain and loss of genetic material could be the cause of phenotypic features. In the current case, karyotyping was an investigation of choice and offering genetic counselling regarding prenatal diagnosis in future pregnancy was a thoughtful step.

Gastroduodenal Artery Pseudoaneurysm as a Complication of Pancreatitis Presenting with Lower Gastrointestinal Bleed

Gursimran Nayyar, Ashish Behera

Chronic pancreatitis is associated with an uncommon but important complication, the formation of the pseudoaneurysm with an incidence of 10%. The splenic artery is the most common artery affected by pseudoaneurysm. A 55-year-old male patient with pseudoaneurysm of the gastroduodenal artery, an unusual complication of chronic pancreatitis. He presented with haematemesisf and was managed with transfusion of blood and blood products and coil embolisation with the help of digital subtraction angiography. Pseudoaneurysms are one of the rare but important complications of chronic pancreatitis which requires treatment even if they are asymptomatic and incidentally diagnosed on imaging. A history suggestive of upper gastrointestinal bleeding in a case of pancreatitis requires adequate evaluation for source of the bleeding.

Carcinoma Rectum with Prostate and Urinary Bladder Metastasis- A Rare Case Report

Tumours of the colon and rectum are one of the most common malignancies worldwide. In India, its incidence is less compared to the developed countries however,recently it has increased from past few decades due to sedentary lifestyle and more consumption of animal fats with less dietary fibre intake. The liver and lungs are most common sites of metastasis from colorectal carcinoma; however, it occasionally metastasised to atypical sites by making diagnosis difficult. Due to the high frequency of colorectal carcinoma, even infrequent metastatic sites are important to diagnose as early as possible. Hereby, authors present a case of 53-year-old male, with history of carcinoma rectum and treated with Abdominoperineal Resection (APR) with permanent colostomy three years back. Three years after the diagnosis of carcinoma rectum, the patient was diagnosed with metastasis of colorectal adenocarcinoma to prostate and urinary bladder which was proven histopathologically. Despite the fact that this condition is uncommon in clinical practice, the possibility of metastatic involvement of prostate and urinary bladder should always be considered when the diagnosis of other primary carcinoma is made.

Hairy Projections on Non Hairy Cells- A Case Report

Rhituparna Das, Sriranjan Mukherjee, Moumita Sengupta

Adult T-Cell Leukaemia/Lymphoma (ATLL) is a mature T-cell neoplasm. It is caused by human retrovirus Human T-cell Lymphotropic Virus Type 1(HTLV-1). The neoplastic cells after monoclonal integration begin to express T-cell associated antigens namely CD2, CD3 and CD5. These leukaemic cells are highly pleomorphic in light microscopic appearance and also they have a highly variable clinical presentation ranging from acute to lymphomatous to chronic to smouldering. There is a chance of missed or miss diagnosis due to their morphological and clinical heterogeneity and specialised test like immunophenotyping or flow cytometry is essential for exact categorisation. Authors hereby, report a case of 45-year-old female patient suffering from ATLL whose peripheral smear showed leukaemic cells with unusual hairy projections resembling hairy cell leukaemia posing diagnostic dilemma.

Rare Case of Multilocular Cystic Renal Neoplasm of Low Malignant Potential with Chronic Pyelonephritis

Multilocular Cystic Renal Neoplasm of Low Malignant Potential (MCRNLMP) represents a rare variant of clear cell (conventional) renal carcinoma. They constitute between 3-6% of clear cell Renal Cell Carcinoma (RCC). The RCC constitutes less than 1% of all renal tumours. The MCRNLMP has an excellent prognosis with no reports of recurrence or metastasis. Authors reported a case of 67-year-old male patient on account of its rarity, co-existing pyelonephritis and incidental detection of MCRNLMP. Differentiation between MCRNLMP, RCC variants and other cystic lesions with clear cells is important as prognosis, treatment differ markedly. Radiological Bosnaik classification of complex cysts in category IIF and III is challenging and requires microscopic examination for correct diagnosis. Histopathology shows cysts separated and fibrous septae having groups of clear cells with low grade nuclei. Immunohistochemistry with Carbonic Anhydrase-IX (CA-IX), Epithelial Membrane Antigen (EMA), Cytokeratin (CK7) and CD10 is confirmatory. Diagnosis requires detailed imaging studies, meticulous grossing of nephrectomy specimens, extensive sampling of cystic tissue to find clear cells and immunohistochemistry (IHC).

Co-infection of SARS-CoV-2 with Dengue Fever-A Case Report

The current pandemic circulation of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) along with Dengue Virus (DENV) in disease endemic countries may produce unfavourable circumstances with co-infection, delays in emergency mitigation measures and management of the disease as both the viral diseases have many similar close characteristics and presentations. This is a case report of a 50-year-old diabetic and hypertensive female admitted with complaints of fever with chills for one week duration. On initial evaluation due to the ongoing pandemic as per the protocol, the patient was found negative with rapid antigen testing for SARS-CoV-2, Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) test along with negative High-Resolution Computed Tomography (HRCT) of the chest. Basic initial investigations suggested decreased platelet count and elevated acute phase proteins. Two days after admission, the patient was found to be Dengue IgM and IgG positive and the patient’s symptoms were managed accordingly. Later, the patient suddenly showed decrease in oxygen saturations and warranted a ventilator immediately. The CT pulmonary angiogram was done to rule out suspected pulmonary thromboembolism, which was showing infective lesions with Coronavirus disease 2019 Reporting and Data System grade 4 (CO-RADS 4). Repeat RT-PCR for SARS-CoV-2 was positive. The Patient was immediately shifted to high isolation Intensive Care Unit (ICU) and treated according to the Standard Operating Protocol (SOP) of SARS-CoV-2 infection. The overlapping clinical presentations of SARS-CoV-2 infection and DENV in resource-constrained settings and the complexities of interpreting results make identification of SARS-CoV-2 in the dengue endemic areas difficult. Therefore, a high degree of alertness should be maintained for SARS-CoV-2 infection in DENV endemic areas.

Hepatoid Adenocarcinoma of Lung Presenting as Unknown Primary with Cervical Lymphadenopathy: A Rare Case Report

Hepatoid adenocarcinoma is a rare Alpha Fetoprotein (AFP) producing extrahepatic malignant tumour commonly seen in the stomach but can also arise from the ovary, endometrium lung. It is a rare type of adenocarcinoma with hepatocyte like histological differentiation and occurs outside the liver. In the lung, it is often presented as a bulky tumour, highly malignant, and associated with a poor prognosis. Early diagnosis and appropriate treatment options can result in long term survival. Here, authors reported a case of 58-year-old male patient, with no history of smoking presented as an Unknown Primary (UKP) with cervical and mediastinal lymphadenopathy which was later diagnosed histopathologically and confirmed by Immunohistochemistry (IHC) as Hepatoid Adenocarcinoma Lung (HAL) without any lesion in the lung on Computed Tomography (CT) chest. The serum AFP levels were normal. It expressed IHC markers Cytokeratin (CK7), CDX-2, Hep Par1 positivity, Thyroid Transcription Factor 1 (TTF-1) cytoplasmic positivity, and abnormally raised serum Carcinoembryonic Antigen (CEA). The patient was treated with definitive lower neck and mediastinal irradiation followed by adjuvant chemotherapy with five cycles of three weekly pemetrexed and carboplatin. Post treatment the serum CEA levels are decreasing and attained clinically complete response. The patient was in a close follow-up. To date, the review of literature about HAL didn’t showed any case presented as UKP with neck nodes without any lesion in the lung. The purpose of this case report was to present a new case of HAL with nodal metastasis, its unique histological findings, and its approach to diagnosis and treatment.

Large Lactobezoars Causing Postoperative Small Bowel Obstruction in a Neonate- A Case Report and Review of Literature

Usha Devi, Giridhar, Vembar, Logavengatesh

Lactobezoars causing small bowel obstruction in the postoperative period has been rarely reported. Here, a term baby with severe intrauterine growth restriction was admitted in neonatal unit for low birth weight care. Baby was started on mother’s milk and gradually upgraded to full feeds. He developed Necrotising Enterocolitis (NEC) requiring surgery. Subsequently, amino acid based formula was warranted because of Short Bowel Syndrome (SBS). After reaching full feeds, baby demonstrated signs of small bowel obstruction requiring relook laparotomy. Large lactobezoars were found throughout the small bowel which were kneaded out. Postoperative period was also complicated by Enterocutaneous Fistula (ECF) which was conservatively managed. Child was discharged on full feeds after he showed consistent weight gain.

Scalp Reconstruction with Novel Unopposing Double Hatchet Flaps- A Case Series

Though there are regional and distant approaches for acquired scalp defect reconstruction, use of local flaps always have the advantage of retaining the topography of scalp. As in treatment of any other defect the choice of a local flap in scalp wound coverage is dictated by the location, size, and depth of the defect and by the availability of adjacent tissue for reconstruction. The versatile and adaptable triangular hatchet flap with a partial skin and subcutaneous bridged pedicle has great versatility. When used singularly or in pair to cover small and medium sized defects, utilising both rotation and advancement components for its movement, has the benefit of maintaining cosmetic appearance. Double hatchet flaps are used commonly in an opposing manner so as to convert a circular wound to a ‘S’ shaped suture line. In the current case series, with a description of four representative cases, authors have presented a modification of this double hatchet flap in unopposing configuration instead of an opposing pattern to cover scalp defects when the type and extent of injury affecting the scalp prevents in heaving flaps at 180 degree to each other. Authors opine that this technique adds into the ever expanding armamentarium of reconstructive surgeon and can be made use of in the aforementioned conditions wherein the standard pattern cannot be employed to cover moderate sized scalp defects.

Neonatal Outcome of Choanal Atresia Surgical Corrections- Experience from a Tertiary Care Centre from Eastern India

Choanal atresia is a congenital condition that occurs due to developmental failure of nasal cavity to communicate with the nasopharynx. There can be both unilateral and bilateral occlusion, bony, soft tissue and both. It can present at birth or early in the neonatal period or even later in life. This case series included three patients, who were admitted in the Neonatal Intensive Care Unit (NICU) and they underwent surgical correction in the hospital. All these cases had different presentations and clinical course. First case was admitted for respiratory failure and sepsis and, later was diagnosed as bilateral choanal atresia. Second case was admitted at 17 days of life with diagnosis of Hypoxic Ischaemic Encephalopathy (HIE) and multiple extubation failure and later was diagnosed as unilateral choanal atresia. Third case had respiratory distress soon after birth and was referred with a diagnosis of suspected choanal atresia. It was confirmed as bilateral choanal atresia and the child improved after surgical correction. All three cases were out born and referred in the hospital at different postnatal ages with varied symptoms. The lessons learnt in management of first case helped in subsequent cases resulting in better outcome.

Diarrhoea in COVID-19 with Emphasis on Non Respiratory Presentation: A Case Series

Rahul Tyagi, Manu Madan, Saurabh Mittal, Anant Mohan, Pawan Tiwari

Coronavirus Disease 2019 (COVID-19) infection can have myriad presentations ranging from non specific constitutional symptoms to respiratory failure and extrapulmonary manifestations. As COVID-19 is viewed predominantly as an illness of the respiratory tract, extrapulmonary manifestations are often overlooked. The case series is of seven COVID-19 diagnosed patients who presented with diarrhoea, without respiratory symptoms. Clinicodemographic characteristics, hospital course and outcome of these patients are described here. Median age of the patients was 42 years. There were four males and three females. One patient had diabetes mellitus and hypertension, one had hypothyroidism and one had Hodgkin’s lymphoma along with tuberculosis. Five patients had fever while all had diarrhoea as the predominant presenting complaint. Median duration of symptoms was four days before admission. Laboratory abnormalities included anaemia (n=5; 57.1%), lymphopenia (n=3; 42.9%) and elevated inflammatory markers i.e., ferritin and C-reactive protein (n=2; 28.6%). Most patients did not require any specific treatment other than supportive care. All patients were successfully discharged after a median hospital stay of 10 days. Isolated diarrhoea without respiratory symptoms can be presenting complaint of COVID-19 and should be considered by clinicians in current pandemic scenario.

Tubeless Supine Percutaneous Nephrolithotomy in Calyceal Diverticular Stone

Sandeep Gupta, Ankit Verma, Dilip Kumar Pal

Percutaneous Nephrolithotomy (PCNL) has routinely been performed in prone position as a treatment for calyceal diverticular stone. PCNL is performed supine as an alternate modality for calyceal diverticular stones. The objective of the procedure is to reduce operative time and anaesthetic morbidity during supine tubeless PCNL in calyceal diverticular stone. The series is about three patients with calyceal diverticular stones. These patients underwent supine tubeless PCNL in Galdakao modified supine Valdivia position. There was no intraoperative, postoperative or on follow-up complications in any of the the patients. In all the patients stones were cleared completely in single sitting. Supine PCNL in calyceal diverticular stone could be an alternative with similar outcomes to the standard prone PCNL. It provides an additional benefit of performing the procedure in a single position, which is known to reduce total operating time and also reduces anaesthesia complications.

Hyponatremic Unconsciousness as a Presenting Symptom of COVID-19: A Case Series

Ajay Chauhan, Asmita Gupta, Kari Suguna, Shashikant Shukla, Parul Goyal

The novel Coronavirus Disease-2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection can present with a multitude of clinical symptoms. The virus, disease symptomatology, pathogenesis and complications are being studied and new concepts are evolving rapidly. The current worldwide situation caused by the disease makes it exceedingly important to recognise varied presentations of the disease. Three cases are being discussed hereby, wherein the patients presented with altered sensorium secondary to hyponatremia as the initial and only presentation of SARS-CoV-2 infection, in the absence of fever or any respiratory involvement. Acute symptomatic hyponatremia is an under-recognised presentation with only a few cases reported till date and needs further awareness and understanding.

Protocol Based Blood Management in Major Obstetric Haemorrhage- A Case Series

Major obstetric haemorrhage remains the leading cause of maternal mortality globally. Irrespective of the etiology of haemorrhage, rapid and efficient intervention using proactive standardised protocols should gain precedence in the management of major obstetric haemorrhage. As the available resources vary between institutions, protocol specific to each institution is important for timely intervention. This case series reports a few successfully managed cases of obstetric haemorrhage by the implementation of institution based Massive Transfusion Protocol (MTP). Two antenatally diagnosed patients with placenta percreta had elective hysterectomy with bladder repair. The massive haemorrhages in both these cases were managed efficiently with the use of MTP without any sequelae. Another case of atonic Postpartum Haemorrhage (PPH) which did not respond to first line management also was treated successfully with the prompt activation of protocol. A case of uterine rupture with haemorrhagic shock was managed with massive transfusion according to protocol and vasopressors and she survived with no major side effects. A case of traumatic PPH which presented with severe anaemia (Hb 4.6 gm/dL) could also be successfully resuscitated by the timely activation of MTP.

Custom Made Finger Prosthesis to Rehabilitate Partially Amputated Finger

Neha Hajira, Atulya Sharma, Krutika Dang, HS Shashidhara, Pulkit Khandelwal

Potentially Misleading Radiograph: Neglected Developmental Dysplasia of the Hip

A 66-year-old man was admitted in the Emergency Centre who was hit by a car. At initial presentation immediately after the accident, the patient was alert and complained of chest pain, dyspnoea, lumbar pain, and left elbow pain, but no pain of the hip joints. His vital signs were haemodynamically stable, with a respiratory rate of 24 breaths/min and percutaneous oxygen saturation of 100%. There was no notable asymmetry with regards to the patient’s hip and gluteal region. Neurological tests showed a glasgow coma scale score of 15 with no neurologic localising signs. Ultrasonographic examination did not detect intra-abdominal bleeding. Laboratory data were white blood cells was 11,330/μL; haemoglobin was 9.9 g/dL; platelets was 282,000/μL; serum creatinine was 0.66 mg/dL; aspartate transaminase was 124 IU/L; alanine aminotransferase was 31 IU/L; and prothrombin time was 10.9 sec. Chest radiography and Computed Tomography (CT) revealed multiple rib fractures causing flail chest and lung contusion. The patient was treated with chest tube insertion and endotracheal intubation/mechanical ventilation under positive airway pressure. Anteroposterior pelvic radiography demonstrated bilateral flat and irregular femur heads, dysplastic acetabula, and high dislocations of the bilateral femoral heads (Table/Fig 1)a. The CT scan of the pelvic bone demonstrated articulation of both femoral heads with false acetabula in the ilium, indicated by white arrows (Table/Fig 1)b. When collecting an in-depth orthopaedic history, the patient reported that his parents were advised to use a harness when the patient was one-year-old; however, the patient had not received any treatment for Developmental Dysplasia of Hip (DDH) for as long as he remembered. Since, his childhood, he moved all four extremities without restriction. Our emergency clinicians made the final diagnosis of neglected DDH. The patient was discharged to the rehabilitation hospital on day 18 without gait disturbance and was followed-up as an outpatient thereafter. Gait analysis of patient demonstrated normal cadence, normal stride/step length and normal walking speed. Developmental Dysplasia of Hip (DDH) is a common congenital musculoskeletal deformity with an incidence of 2-4% and has serious morphologic repercussions, with distorted soft tissue contractures and bony anatomy around the hip. Hip luxation is its severe form, which occurs in 0.4-0.7% of all cases (1). The condition may be present at birth or from early in life, increasing the chances of joint dislocation (2). The condition’s aetiology is unknown; however, racial background and heredity are some factors that can account for congenital hip dislocation. The DDH can be associated with other conditions, including acetabular dysplasia, an abnormality of the cap-shaped hip socket, and connective tissue disorders. A shortened limb with internal rotation, adduction, and flexion of the hip joint is how posterior hip dislocation typically presents in trauma patients. The condition can be unilateral or bilateral. Only one joint is deformed with unilateral dysplasia, and resulting effects may show on the contralateral side (3). In most unilateral cases, the dysplasia is in the left hip. If the condition affects both hip joints as with our patient, some diagnostic signs like leg length inequality and asymmetric folds don’t apply. Clinical presentation of bilateral cases like our patient may be less severe due to pro¬portional length of the lower limbs despite overt instability. Radiographic X-ray and CT imaging have shown a significantly hypoplastic bony anat¬omy characterised by shal¬low acetabula, insufficient coverage of the femoral head, deficient anterior acetabular wall, and excessive anteversion. Anteroposterior pelvic radiography is the primary imaging method used to diagnose DDH (3). The patient had a pelvic inclination due to high lumbar lordosis in the presence or absence of scoliosis, which is significant for acetabular component anteversion. The treatment strategy for DDH depends on each patient’s age and condition severity. Residual DDH in adulthood has been often associated with a history of pain and early development of osteoarthritis (3), which was unlikely in this patient. In terms of management, closed reduction is the gold standard treatment in patients under six-month-old. This treatment strategy is controversial, because worse outcomes are noted with hip open reductions in those over eight-year-old (2). In cases of untreated DDH in adults, total hip arthroplasty may be proposed; however, this is often challenging. If the hip remains dislocated for a long time as in our patient, the fatty tissue in the depth of the acetabula ligamentum teres thickens and elongates and the capsule becomes stretched and very loose. Gradually, the acetabular cavity flattens and the medial wall thickens. A subluxated hip consistently leads to symptomatic hip disease. Traumatic hip dislocation, accounting for 2-5% of all joint dislocations, is considered an orthopaedic emergency that can potentially cause significant complications and long-term morbidity in patients (4),(5). Traumatic hip dislocation is still a therapeutic challenge for trauma surgeons and should be reduced as soon as possible to decrease complications. Asymptomatic hip dislocation may be difficult to diagnose, particularly in an elderly patient with dementia or an unconscious patient. Although the patient did not report a past medical history of hip joint dislocation, DDH should be presumed, and careful radiologic testing is imperative to avoid misdiagnosis. Emergency physicians should familiarise themselves with the unique characteristics of DDH in medical imaging to avoid unnecessary work up.

Multinucleated Cells in PAP Smear- An Institutional Experience

Aarthi Kannan, Vijayashree Raghavan, Jane Betsy Isaac, Ayeesha Sithika

Xerostomia in Coronavirus Disease-19 Pandemic: Causes and Prevention

Kaveh Nasiri, Aleksandra Dimitrova

Efficacy of Oral Bilastine in Comparison with Levocetirizine in Allergic Rhinitis-A Randomised Clinical Study

M Vanitha, K Sowmini, K Santha Sheela Kumari, Resu Neha Reddy

Introduction: Allergic rhinitis is a heterogeneous disorder characterised by major symptoms like sneezing, itching, nasal congestion and rhinorrhea. Because of bothersome side effects of first-generation antihistaminic drugs, second generation antihistaminic drugs have been used since few years. Recent studies have showed that novel drug Bilastine has been approved as an effective treatment in Allergic rhinitis. Aim: To evaluate Total Nasal Symptom Scores (TNSS), Serum Immunoglobulin E (IgE), Serum Absolute Eosinophil Count (AEC) in patients with allergic rhinitis, pre and post-treatment with Bilastine and Levocetirizine. Materials and Methods: A randomised, open-labelled, study was conducted between January 2020 to March 2020. Hundred patients with allergic rhinitis were enrolled into the study. They were randomised into two groups of which group A received tablet Bilastine 20 mg once daily for two weeks and group B received tablet Levocetirizine 5 mg once daily for two weeks. The results of TNSS, IgE, AEC and pre and post-treatment values were compared in both the treatment groups. Unpaired t-test was used as the test of significance between the two treatment groups. Results: The prevalence of allergic rhinitis in the study was 49% in males and 51% in females. The mean difference in pre and post-treatment in TNSS (group A=1.627, group B=1.143), serum IgE (A=33.118, B=49.653), serum AEC (A=28.00, B=27.245) showed no statistically significant difference between two groups (p-value >0.05). Conclusion: Bilastine and levocetirizine are equally efficacious. Though there is clinical significance in treatment of allergic rhinitis between the groups, there is no statistical significance which would prove Bilastine is clinically superior to Levocetirizine for the allergic rhinitis treatment.

Expression of B-type RAF V600E in Thyroid Carcinoma and its Association with Histological Type

Sonia Kumari, Turuvekere Narayanrao Suresh, SM Azeem Mohiyuddin

Introduction: Thyroid cancer is one of the most common cancers amongst all endocrine cancers. Incidence of thyroid malignancy is about 3-4% of all malignancy in India and 80% of thyroid malignancy belongs to Papillary Thyroid Carcinoma (PTC). Factors affecting the prognosis of PTC include patient’s gender, age, histological findings, tumour size, lymph node metastasis, extrathyroidal extension, and remote metastasis. Presence of B-type RAF V600E (BRAF V600E) mutation in thyroid carcinoma patients tends to present with more aggressive clinicopathological behaviours of PTC, prompting more aggressive radioiodine treatment. Aim: To find out the frequency of occurrence and expression of BRAF V600E mutation by Immunohistochemistry (IHC) in thyroid cancer and its association with histological type and Tumour Nodes Metastases (TNM) Staging. Materials and Methods: The present observational retrospective study included patients treated for thyroid carcinoma between January 2014 to February 2019 at RL Jalappa hospital and Research centre, Kolar, Karnataka, India. The IHC was done with rabbit monoclonal anti-BRAF V600E antibody IgG Clone RM8 (VE1). Clinical records, Fine Needle Aspiration Cytology (FNAC) diagnosis were analysed for 45 thyroid carcinoma cases. Immunopositivity was scored positive when unambiguous clear cytoplasmic staining for the antibody was observed in tumour cells. Categorical data was presented in the form of frequencies and proportions and continuous data was presented as mean and standard deviation. The t-test were applied to find out the difference in means among the groups. The p-value <0.05 was considered statistically significant. Results: Out of total 45 cases, 18 were classical PTC, 18 were Follicular Variant of Papillary Thyroid Cancer (FV-PTC), 4 were micropapillary carcinomas, 3 were Follicular carcinomas, 1 was Oncocytic variant of PTC and 1 undifferentiated thyroid carcinoma. Out of total 45 cases, 33 cases (73%) were found to be BRAF V600E positive and 12 (26%) were negative for BRAF V600E. Out of the total 33 BRAF V600E positive cases, 19 cases showed strong staining, 14 cases showed moderately positive staining. Conclusion: The PTC is the most frequent type of thyroid carcinoma amongst all the sub-types. BRAF V600E expression is commonly seen in higher tumour size (T3, T4) and classical PTC. Tumours with extrathyroidal extension and capsular invasion showed strong positivity.

Blood Gas Analysis among COVID-19 Patients: A Single Centre Retrospective Observational Study

Introduction: The dominant respiratory feature of Coronavirus Disease 2019 (COVID-19) is arterial hypoxaemia, greatly exceeding abnormalities in pulmonary mechanics. Arterial Blood Gas (ABG) analysis helps to find out respiratory, metabolic acidosis and alkalosis. Aim: To evaluate the blood gas levels among critically ill COVID-19 positive patients admitted in Intensive Care Unit (ICU). Materials and Methods: A retrospective, observational study was conducted in East Midnapore district of West Bengal, India from July 2020 to February 2021. Data of ABG analysis {pH, PaO₂ (partial pressure of oxygen in arterial blood), PaCO₂(partial pressure of carbon dioxide in arterial blood) and bicarbonate (HCO₃)} in 314 adult COVID-19 positive cases, were obtained from ICU records. All critically ill COVID-19 patients those who were admitted in ICU with more than 15 years of age were included in this study. Data were analysed and Pearson correlation test was applied for statistical significance. Results: Among the study subjects, 234 (74.5%) were males. Most affected age group was 51-60 years among males and above 60 years among females. Most common ABG finding was high pH indicating alkalosis, found among 183 (58.3%) patients. Acidosis was rare and seen in only 19 (6.0%) patients. A total of 174 (55.4%) patients developed respiratory alkalosis with low PaCO₂. Hypoxaemia was found in 144 (45.9%) patients. High HCO₃, indicating metabolic alkalosis, was seen in 144 (45.9%) patients. Statistically significant correlation was found between PaCO₂ and pH (pearson correlation coefficient (r)=-0.153, p=0.007) and PaCO₂ and HCO₃ standard (r=0.185, p=0.001). Conclusion: ABG should be done in all COVID-19 patients during admission. A regular interval monitoring of ABG can help in early identification of respiratory damage, silent hypoxia and cytokine storm and with early detection many lives can be saved with early initiation of management.

CSF Neurofilament-H Levels as a Potential Prognostic Marker in Patients of Guillain-Barré Syndrome- A Cohort Study

Introduction: The prognosis of Guillain-Barré Syndrome (GBS)at an early stage with explicit biomarkers is critical to distinguish patients with possibility of poor recovery. Cerebrospinal Fluid (CSF) serves as an impending source for biomarkers that portrays the exact biochemical changes. Aim: To find out if there is any prognostic value of high CSF phosphorylated Neurofilament Heavy subunit (pNf-H) levels, measured during first two weeks of onset of GBS, as assessed by the level of disability at six months after the onset of GBS. Materials and Methods: The cohort study was conducted in the Department of Neurology and Department of Immunology and Molecular Medicine, at the Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India, over a period of two years from August 2015 to August 2017. Sixty two patients who satisfied the required diagnostic standards for GBS (study group) and 35 patients with tension-type headache (control group) were selected for the study. After clinical and electrophysiological assessment, CSF samples were collected. A commercially available sandwich enzyme immunoassay kit, manufactured by BioVendor-Laboratorní medicína (Czech Republic), was used for measuring human pNf-H quantitatively. Results: Mean CSF pNf-H level in patients with good outcome was 325.3 pg/mL whereas, in patients with poor outcome it was 3655.2 pg/mL. CSF pNf-H levels were found to be suggestively higher in GBS patients with poor outcome as compared to those with good outcome. Only eight patients in good outcome group had pathologically high CSF Nf-H levels whereas 10 patients in poor outcome group had CSF Nf-H levels ≤730 pg/mL. The odds ratio was 17.1 (95% Confidence Interval (CI) 3.83-76.29). Thus, high CSF Nf-H levels on admission predicted poor outcome in GBS (p-value <0.001). Moderate degree of positive correlation was found between CSF Nf-H levels and outcome (F score) at six months (R=0.684; p-value <0.001). Conclusion: It can be determined that higher values of CSF pNf-H in GBS (acute stage), could serve as a predictive marker indicative of poor prognosis.

Predictors of Mortality in Patients of COVID-19 Pneumonia in Intensive Care Unit: An Observational Study in a Tertiary Care Hospital, Lucknow, India

Introduction: Coronavirus Disease-2019 (COVID-19) is caused by the Severe Acute Respiratory Coronavirus-2 (SARS-CoV-2) which is an enveloped positive-sense single-stranded RNA virus. Initial steps of the infection involve binding of the spike protein (S) of the virus to Angiotensin Converting Enzyme-2 (ACE-2) receptor on the mucosal surfaces of various organs like lungs, kidney, heart, intestine. Pathogenesis of complications are still poorly understood. Aim: This study was designed to find out the baseline biochemical parameters at the time of admission which may predict outcome in COVID-19 patients. Materials and Methods: This observational study was conducted in a dedicated COVID-19 hospital, Dr. Ram Manohar Lohia Institute of Medical Sciences (Dr. RMLIMS), Lucknow, Uttar Pradesh, India, from 1^st July, 2020 to 30^th November, 2020. A total of 109 moderate to severe COVID-19 pneumonia patients who required Intensive Care Unit (ICU) admission, were enrolled. Based on their outcome, patients were divided into two groups: “Survived” and “Expired”. Biochemical characteristics of patients were compared among the two groups using univariate and multivariate analysis. Results: On Univariate analysis Coagulation profile, Prothrombin Time (PT), International Normalised Ratio (INR), Activated Partial Thromboplastin Time (APTT) and D-Dimer values were raised significantly in the expired group. Among other acute phase reactants Lactate Dehydrogenase (LDH), C-Reactive Protein (CRP), Interleukin-6 (IL-6), and Creatinine Phosphokinase-MB (CPKMB) were raised in expired group and this difference was significant statistically too. On Multivariate analysis among all acute phase reactant only IL-6 was increased significantly. All other variables were found to be non significantly associated with mortality, statistically (p-value <0.05). Conclusion: Baseline biochemical parameters have prognostic values in COVID-19 patients. Raised IL-6 levels can be viewed as an independent predictor of mortality among COVID-19 patients at the time of admission in ICU.

Orthodontic Diagnostic Tools and Material Usage in Saudi Arabia

Laila Fawzi Baidas, Lubna Faleh Alfaleh

Introduction: The evaluation of changes in orthodontic practice over the years, is essential for defining treatment efficacy. Accordingly, shedding light on the profile of orthodontic practice in Saudi Arabia is crucial. Aim: To investigate current trends in orthodontic practice in Saudi Arabia and the factors affecting choices regarding materials and techniques among orthodontists. Materials and Methods: This cross-sectional study was conducted from July 2019 to December 2019 at the College of Dentistry, King Saud University, Riyadh, Saudi Arabia. An electronic survey of 29 objective questions was sent to 1,500 orthodontic members of the Saudi Orthodontic Society. The survey collected demographic data, diagnostic records and information on the fixed orthodontic appliances used by the respondents. Frequency and percentages were calculated for all variables. Chi-square test was used to determine the effects of factors, including years of experience and place of work, on the choice of diagnosis protocol and fixed appliance material, with the significance set at p-value ≤0.05. Results: Two hundred and nine respondents completed the survey. The respondents reported a highly significant use of computers for digitising cephalometric analysis, with the traditional method of obtaining study models reported as highly significant (p<0.001). Orthodontists routinely used the MBT preadjusted bracket system (52.6%) and performed direct bonding of the bracket (91.4%). Bonding of the first molars was preferred by 36.4% of the clinicians. Glass ionomer cement was the most frequently used band cement (55.5%), and the most popular archwire material was nickel–titanium shape memory. Clinicians with less than five years of experience used significantly more postcephalometric radiographs (p=0.006) and postorthodontic treatment models (p=0.028). Senior orthodontists (10-15 years of experience) had a higher use of indirect bonding techniques (p=0.05). Conclusion: This study provides information on the relevant aspects of orthodontists in Saudi Arabia in terms of their individuality, training and techniques used. The findings can be used as a reference for future national surveys to evaluate changes in orthodontic practice in Saudi Arabia.

Efficacy of Ascitic Fluid Dipstick Leukocyte Esterase Activity in Early Diagnosis of Spontaneous Bacterial Peritonitis

Sanjay Gupta, Heerak Singh

Introduction: Spontaneously occurring ascitic fluid infections {Spontaneous Bacterial Peritonitis (SBP)} are the most common and recurring complications in patients with decompensated cirrhosis with ascitis. Unlike other infections, ascitic fluid infections usually present with non specific symptoms and may be asymptomatic in a large number of patients. They not only accelerate hepatic decompensation, but may also lead to, or exacerbate other complications like hepatic encephalopathy, hematemesis, renal failure and death. The existing protocol of diagnosis of SBP includes ascitic fluid total and differential leukocyte counts, and ascitic fluid cultures, by inoculating the ascitic fluid in blood culture vials, which are not only cumbersome, but also costly, time consuming and cannot be followed in all patients presenting for outpatient treatment for therapeutic peracentesis. Aim: To evaluate the efficacy of testing ascitic fluid pH, protein and Leucocyte Esterase (LERS) activity, by using Siemens Multistix 10SG Reagent Strips (SMRS) for early screening of patients for SBP. Materials and Methods: The observational study was conducted at SGRR Institute of Medical and Health Sciences Dehradun, Uttarakhand, India, from January 2018 to March 2019. The study included 329 patients with cirrhosis and ascites presenting in either the Outpatient Department (OPD) or Emergency Room for therapeutic paracentesis or with cirrhotic complications were evaluated for SBP using SMRS for ascitic fluid pH, Leukocyte Esterase (LERS) activity and ascitic fluid protein, for early detection of SBP. The standard diagnostic criteria i.e., ascitic fluid Polymorphonuclear Counts (PNM) more than 250 cells/mm³, by Chamber Counting Method or positive ascitic fluid culture after 48 hours incubation were used as gold standard for diagnosis of SBP. Chi-square test was applied to find out significant association between independent and dependent variables. A p-value of <0.05 was considered significant. Results: Among total 329 patients with cirrhotic ascitic, 81 were diagnosed to have SBP. At a cut-off of 2+, SMRS correctly detected SBP in 77/81 patients, was negative in 4/81 patients and falsely positive in 7/248 NSBP patients, thereby having a sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of 95%, 97.33%, 98.96% and 96.69%. At a cut-off of 3+, SMRS was able to detect SBP in 53/81 patients, and was falsely positive in 1/248 patients, thereby, although decreasing the sensitivity to 64%, but improving the specificity and PPV to 99.6% and 98.11%, respectively. Conclusion: During diagnostic paracentesis, ascitic fluid LERS activity using SMRS are highly sensitive markers for early detection of SBP, especially in the presence of fever, vomiting and shock.

Brixia Chest X-ray Scoring System in Critically Ill Patients with COVID-19 Pneumonia for Determining Outcomes

Introduction: In early stage of disease of Coronavirus Disease 2019 (COVID-19) infection chest Computed Tomography (CT) imaging is considered as the most effective method for detecting lung abnormalities. A Brixia Chest X-ray (CXR) scoring system which uses an 18-point severity scale to grade lung abnormalities due to COVID-19 was developed to improve the risk stratification for infected patients. Aim: To ascertain the validity of Brixia scoring system and to measure the outcome in COVID-19 patients. Materials and Methods: A retrospective study was conducted from 1^st April 2020 to 31^st July 2020, at a tertiary care hospital in India. Baseline CXR of COVID-19 patients were scored based on Brixia scoring system. The lungs were divided into six equal zones. Subsequently, scores (from 0-3) were assigned to each zone, based on lung abnormalities. A group comparison was implemented using Chi-Square test for categorical variables. Whereas an independent t-test was applied for continuous variables that followed normal distribution. Results: The study included 130 patients. The mean age was 57.09±13.73 years, 70.8% patients included were males. Out of 130 patients, 79 patients died. Among patients who died the mean CXR score was calculated to be 12.13±2.50. The mean CXR score was calculated to be 11.18±2.30 in patients who recovered and got discharged. During the process of comparison of CXR scores with the outcomes, the t-value came out to be 2.20 and the resulting p-value was 0.03 (statistically significant). Conclusion: Brixia score more than 12 was associated with increased mortality due to COVID-19, with p-value of 0.03.

Association of Human Leukocyte Antigen-Cw6 in Psoriasis Patients with Disease Severity and Morphological Patterns: A Cross-control Study in a Tertiary Care Referral Centre in Eastern India

Akhilesh Behra, Gobinda Chatterjee, Aditi Chandra, Raghunath Chatterjee

Introduction: Psoriasis is a multifactorial disorder in which genetic and environmental factors play an essential role in disease pathogenesis. The Human Leukocyte Antigen-Cw6 (HLA-Cw6) allele has shown the strongest genetic association with this condition across several populations studied. Aim: To estimate the risk of HLA-Cw6 association with psoriasis compared to the control group and its association with the severity of psoriasis expressed as Psoriasis Area and Severity Index (PASI) score and morphological patterns. Materials and Methods: A cross-control study was conducted from March 2014 to February 2015 in a tertiary care centre in the eastern part of India. All patients who were diagnosed clinically as psoriasis and gave written informed consent were included in the study. Healthy controls were taken to compare the HLA-Cw6 after duly signing the informed consent for detailed history, clinical examination, PASI score, and digital photographs of lesions were taken. A blood sample was taken from patients and the control for HLA-Cw6 typing by sequence-specific Polymerase Chain Reaction (PCR) method. Data was analysed by appropriate statistical test (Chi-square test) using R statistical software. Results: A total of 100 patients with psoriasis and 100 controls were recruited, of which 61 were positive for HLA-Cw6 among the psoriasis group and nine in the control group. Positivity of the HLA-Cw6 allele was significantly higher in psoriasis cases (n=61) compared to normal individuals (n=9) (p-value: 1.79×10^-15, OR: 15.8148, 95% CI: 7.15-34.99). It was also observed that HLA-Cw6 positive individuals had a more severe form of the disease, determined by a PASI score >6 (p-value: 0.0494, OR: 2.22, 95% CI: 0.96-5.15), and significant involvement of scalp psoriasis (p-value: 0.0054, OR: 13.125, 95% CI: 1.55-111.42). However, no significant association of HLA-Cw6 was seen with positive family history, nail involvement, and joint pain (arthralgia). Conclusion: The HLA-Cw6 positivity was associated with a more severe form of disease and scalp psoriasis.

Assessing the Relationship between Digit Ratio as a Marker for Prenatal Androgen Exposure and Different Blood Pressure Components among North Indian Males: A Pilot Study

Arjun Maitra, Vinita Ailani, Nitin Srivastava, Sajjan Lal Verma

Introduction: Digit ratio (2D:4D) has been associated with cardiovascular diseases using association with surrogate markers. Studies showing an association of digit ratio with cardiovascular parameters within normal limits are scarce. Aim: To explore the relation between different blood pressure components and digit ratio in normal young males within physiological range. Materials and Methods: In this cross-sectional pilot study, 25 apparently healthy male volunteers were included. Digit ratio (2D:4D) was measured. Body Mass Index (BMI) was estimated. Peripheral blood pressure, central aortic blood pressure and all four limb blood pressures were measured using periscope arterial health and cardiovascular analysis system. Blood pressure was measured using oscillometric method from all peripheral sites and estimated central aortic pressure by a validated transfer function. Pearson’s correlation studies were performed to assess any preliminary association. Two groups were formed of low and high digit ratio and Student’s t-test was performed to assess any significant difference between the groups. Results: Digit ratio of both hands correlated best with peripheral Diastolic Blood Pressure (DBP) (Right 2D:4D r=0.43, p<0.05/Left 2D:4D r=0.40, p<0.05). No significant association observed for peripheral systolic pressure (p>0.05) and digit ratio of both hands. Significant association observed for all four limb blood pressure components and digit ratio. Pulse pressure components did not show any association with digit ratio. Significant difference of blood pressure components was observed when low and high digit ratio groups were compared. It was observed that blood pressure components were on higher side within the normal limits among the subjects with high digit ratio. Conclusion: Preliminary observations from this pilot study suggests that in normal young adult males digit ratio associate positively with different blood pressure components in normotensive males and has the potential to be used as a potent marker for early changes in cardiovascular diseases.

Difficulties Faced by the Healthcare Workers Wearing Personal Protective Equipments in COVID-19 Pandemic during Summers of Mumbai City

Introduction: The coronavirus pandemic poses a massive challenge for the healthcare system and overburdens the Healthcare Workers (HCWs) in a developing country like India. The coronavirus may survive on various surfaces and/or aerosols for hours to days, making it a necessity to use Personal Protective Equipment (PPE) while treating infected patients. Wearing the PPE is often uncomfortable while working, more so in the summer season, when the temperatures in a tropical country like India are soaring. Aim: To identify, quantify and highlight the difficulties faced by the HCWs while wearing PPEs. Materials and Methods: This descriptive cross-sectional study was conducted in June 2020, by a team of researchers working in a government owned designated Coronavirus Disease-2019 (COVID-19) hospital in metropolitan city, West India. The questionnaire was prepared for a multicentre survey for 230 HCWs who had used PPE kits during their COVID-19 duties. The online questionnaire responses were recorded in an Microsoft Excel sheet and the results were analysed using Statistical Package for the Social Sciences (SPSS) software version 19.0. Results: Total 230 responses were received out of which 74% were doctors, 21.7% nurses and 4.3% paramedical staff. The mean duration of work was 6.24 hours and per duty one, PPE was used by almost all of the respondents. The most common difficulty faced by the responders while on duty was excessive sweating (96%/n-221), itching of the nose (56%/n-129) and face (50.9%/n-117). While after the duty 61.7% of respondents reported being dehydrated and 68.2% complained of de novo headache. In a subset with a history of migraine, almost all reported worsening of migraine with increased frequency and severity of attacks. Many (40%) reported occasionally lowering the masks or face shield due to unbearable heat, risking self-contamination. Conclusion: The PPEs in current use and in the hot and humid conditions of summer months in tropical countries poses a unique challenge for the HCWs. Customisation of PPEs and working conditions is essential in the mitigation of the problems faced by the HCWs.

Efficacy of Spectral Doppler Indices in Predicting Malignancy in BI-RADS 3 Breast Lesions: A Prospective Cohort Study

Introduction: Breast Imaging, Reporting and Data System (BI-RADS) is an effective tool for management of patients with breast pathologies. While the BI-RADS 1 (negative) and BI-RADS 2 (benign) categories patients are advised for routine mammography screening. BI-RADS 4 (suspicious abnormality) and BI-RADS 5 (highly suggestive of malignancy) categories patients are recommended for tissue diagnosis, BI-RADS 3 category patients are managed with follow-up examinations. But upto 2% of BI-RADS 3 lesions are proved to be malignant on follow-up examinations and tissue diagnosis. Aim: To evaluate the efficacy of spectral Doppler indices in predicting malignancy in BI-RADS 3 category breast lesions. Materials and Methods: A prospective cohort study was conducted in the Department of Radiology, Katuri Medical College, Guntur, Andra Pradesh, India from July 2019 to February 2021. Study was conducted on 292 BI-RADS 3 lesions from 257 patients to evaluate the efficacy of spectral Doppler indices in differentiating malignant BI-RADS 3 lesions from benign ones. All the breast masses were evaluated with spectral doppler and the resistive and pulsatility indices were compared with histopathology findings of the suspicious lesions detected in follow-up examinations. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) 2017 version 25, and the quantitative data was expressed in mean and standard deviation. Results: The patients recruited in the study were in age range of 27-80 years, and the mean age of the patients was 46±15 years (mean±SD). Follow-up examinations and tissue diagnosis of suspicious lesions revealed 8 out of 292 BI-RADS breast masses to be malignant. On spectral Doppler analysis, high resistivity and pulsatility indices are predictive of malignancy. A resistive index of more than 0.6 as a sign of malignancy proved to have a sensitivity of 87.5% and specificity of 85.5% and more than 0.8 as a sign of malignancy has a sensitivity of 25% and specificity of 95%. A pulsatility index of more than 0.9 as a sign of malignancy has a sensitivity of 87.5% and specificity of 87% and more than 1.6 as a sign of malignancy has a sensitivity of 37.5% and specificity of 96%. Conclusion: Spectral doppler is reliable in the prediction of malignancy of BI-RADS 3 breast masses.

The Multifaceted Impact of COVID-19 Pandemic on Dentists in Tamil Nadu, India: A Qualitative Study

Nesa Aurlene, R Sindhu, A Haripriya

Introduction: India has become the Coronavirus Disease 2019 (COVID-19) epicentre with the highest number of COVID-19 cases being reported each day. This has caused a major impact on healthcare workers including dentists across the country. Most dental clinics in Tamil Nadu were closed during the initial two months of draconian lockdown enforced by the Government of India (GOI). As partial lockdown measures were introduced over the subsequent months, dental clinics have started functioning and receiving patients for emergency dental treatment. Aim: This study was done among dentists practicing in Tamil Nadu amidst the COVID-19 pandemic to understand how the pandemic has impacted their professional and personal lives. Materials and Methods: A qualitative study using online focus group discussion was conducted among 32 dentists practicing in Tamil Nadu, India using a structured interview guide in the month of July 2020. After data collection, the focus group discussions were transcribed manually and an inductive thematic analysis was performed using Braun and Clarke’s six phases for thematic analysis. Results: Three major themes were identified after the thematic analysis namely limitations of off-campus distance learning, challenges faced in dental practice during the COVID-19 pandemic and social life impacts of COVID-19 among dentists. Conclusion: Dentists in this study felt that the COVID-19 pandemic was negatively impacting their dental practices owing to lack of clarity in COVID-19 protocols, lack of patient awareness, high cost of Personal Protective Equipment (PPE), increasing overhead expenses, ergonomic difficulties in treating patients while wearing PPE, patients’ unwillingness to pay higher charges for treatment under COVID-19 protocols and fear of contracting COVID-19. Majority of participants in this study did not report any negative impacts of social isolation as many of them had stayed with their families during the lockdown.

A Cross-sectional Study to Determine the Factors Affecting the Quality of Life in Patients with Grand Mal Epilepsy

Jagriti Yadav, Priti Singh, Surekha Dabla, Rajiv Gupta

Introduction: Epilepsy is a chronic neurological condition that affects various domains of life apart from causing physical dysfunction. It is associated with various cognitive and psycho-social complications that can adversely affect the Quality of Life (QoL). Aim: To study the socio-demographic and clinical factors affecting QoL in Patients With Epilepsy (PWE). Materials and Methods: This cross-sectional study was conducted at a tertiary care centre in northern India on patients with Grand Mal Epilepsy. Total 60 PWE were assessed for psychiatric co-morbidity using Mini International Neuropsychiatric Interview version 6.0 and were divided into two groups, Group I and Group II, based on absence and presence of psychiatric co-morbidity, respectively. Self-administered QoL in Epilepsy-31 Scale was then used in both the groups to assess QoL in the study subjects and statistical analysis was done. Normally, distributed quantitative data was analysed using independent t-test for two groups and Analysis of Variance (ANOVA) test for three or more groups. Results: The mean age of the study population was 27.68±9.51 years. A 55% of the study population were males and 45% of total study population were females. The mean total duration of epilepsy was 7.42±6.98 years. There was significant main effect due to socio-economic status for domains of emotional well-being (F=7.513, p=0.010), energy/fatigue (F=5.625, p=0.021), cognitive functions (F=7.708, p=0.007) and overall score (F=6.876, p=0.011) on QOLIE-31 scale. There was a significant main effect due to total duration of seizure disorder for domains of energy/fatigue (F=2.724, p=0.03) and cognitive functions (F=2.852, p=0.03). The mean scores of PWE with psychiatric co-morbidity were lower than PWE without psychiatric co-morbidity in all the domains of QoL in epilepsy scale and the differences in two groups were statistically significant (p=0.01). Conclusion: The present study showed that QoL in PWE is associated with various socio-demographic and clinical factors beyond seizure control.

To Assess Relationship of Lipoprotein (a) with Severity of Coronary Artery Disease in Patients with Acute Myocardial Infarction: A Hospital based Cross-sectional Study

Gaurav Bhandari, Girish Rajadhyaksha, Meghav Shah

Introduction: Elevated plasma concentrations of lipoprotein {Lp(a)} have been consistently shown to be a risk factor for the development of a spectrum of thrombotic and atherosclerotic disorders including Coronary Artery Disease (CAD). Aim: To assess relationship of Lp(a) with severity of CAD in patients of Acute Myocardial Infarction (AMI). Materials and Methods: A hospital based, cross-sectional study was conducted at Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India, between November 2016 to April 2018 (18 months). A total of 200 diagnosed cases of AMI who were willing to undergo coronary angiography were enrolled for this study. Prior to coronary angiography, a fasting blood sample was assessed for lipids and Lp(a) levels. The Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) score was calculated according to the coronary angiography results. Patients were divided into two groups based on Lp(a) levels: <25 mg/dL and >25 mg/dL and categorised based on CAD severity and SYNTAX scores as low (<22), intermediate (23-32) and high (>32). Lp(a) levels were categorised as low (<25 mg/dL) and high (>25 mg/dL). A p-value of <0.05 was considered as statistically significant. The statistical evaluation of data was done using the Statistical Package for Social Sciences (SPSS; Chicago, IL, USA) program, version 20.0. Results: Majority of the patients belonged to the age group 41-60 years. Males comprised 161 (80.5%) patients of the study population. Hypertension was the most prevalent risk factor, observed in 101 (50.5%) patients. Left ventricular ejection fraction <40% was observed in 85 (42.5%) patients. Majority had low SYNTAX score {92 (46%)}. There was a significant difference in patients with Lp(a) <25 mg/dL compared to patients with Lp(a) >25 mg/dL with low (45.7% vs. 54.3%, p-value=0.0001), intermediate (9.9% vs. 90.1%, p-value=0.0001) and high SYNTAX scores (10.8% vs. 89.2%, p-value=0.0001), respectively. Conclusion: The Lp(a) was significantly associated with severity of CAD and it also displays prognostic significance.

Clinical Profile, Need for Dialysis and Mortality of Community Acquired versus Hospital Acquired Acute Kidney Injury

B Dushyanth, Archana Dambal, Siddaganga, CP Vrushabhveer, CS Hithashree

Introduction: Occurrence of Acute Kidney Injury (AKI) is high in hospitalised and critically ill patients. Most of the cases reported by the developed countries are Hospital Acquired Acute Kidney Injury (HA-AKI). AKI is a major medical complication in the developing world also and is due to predominantly community acquired causes, where the epidemiology differs from that in developed countries. Many studies have reported that Community Acquired Acute Kidney Injury (CA-AKI) and HA-AKI differ in mortality, need for renal replacement and residual renal injury. Aim: To know the difference in need for renal replacement therapy and in-hospital mortality between patients diagnosed with CA-AKI and HA-AKI using Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Materials and Methods: A prospective cohort study was conducted from January 2018-December 2018 after obtaining Institutional Ethical Clearance by comparing 50 cases of CA-AKI and 50 cases of HA-AKI admitted by the General Medicine Department as per the inclusion and exclusion criteria. Serum Creatinine (S.Cr) at admission, after 48 hours and at the time of discharge were measured. Serial urine output measurements were done. Need for dialysis was noted in both the groups. Both groups were compared based on need for dialysis, difference in mortality and residual renal injury at the time of discharge. Chi-square and student t-tests were applied respectively and p-value ≤0.05 was considered as significant. Statistical Package for Social Sciences (SPSS) version 17.0 was used for data entry and analysis. Results: The CA-AKI and HA-AKI groups were comparable in age and gender but differed in some co-morbidities. CA-AKI group had underlying hepatobiliary disorders and Non steroidal Anti-Inflammatory Drug (NSAID) abuse more often than HA-AKI group. There was a significant reduction in S.Cr over the duration of hospital stay in CA-AKI (mean S.Cr at admission was 4.85 mg/dL, at 48 hours 2.05 mg/dL and at discharge 1.20 mg/dL). S.Cr increased after 48 hours of admission from baseline and declined later in HA-AKI but did not reach baseline in many patients in comparison to CA-AKI group (mean S.Cr at admission was 1.10 mg/dL, at 48 hours 2.38 mg/dL, at discharge 1.57 mg/dL). The highest stage of AKI was stage 3 in CA-AKI group (22 vs 11 of HA-AKI). HA-AKI group had more number of patients in stage 2 AKI (26 vs 18 of CA-AKI). There was no significant difference in mortality and requirement of haemodialysis between CA-AKI and HA-AKI groups. Conclusion: There was no difference between the two groups in terms of mortality and need for renal replacement therapy but there was significant residual renal injury in HA-AKI group.

Clinico-epidemiological Profile and Outcomes of COVID-19 Patients Admitted in Jawaharlal Nehru Medical College and Hospital: A Retrospective Study

Introduction: Coronavirus Disease-2019 (COVID-19) has taken the world by storm since its detection in China. The pandemic swept across the globe and affected India. The presence or absence of co-morbidities may determine the clinical outcome. Clinical manifestations include cough, fever and dyspnoea mainly. Aim: To elucidate epidemiological findings, clinical features, co-morbidities of COVID-19 disease and clinical outcomes in first 500 COVID-19 patients admitted at a tertiary care teaching hospital in Northern India. Materials and Methods: The retrospective observational study was conducted at Jawaharlal Nehru Medical College and Hospital (JNMCH), Aligarh Muslim University, Aligarh, Uttar Pradesh, India, from 21^st April to 27^th October 2020 on first 500 Reverse Transcription-Polymerase Chain Reaction (RT-PCR)/Rapid Antigen or TruNatBeta positive patients. During January to March 2021 period data was collected and analysed. Data was analysed for epidemiological parameters, symptoms and clinical hospital outcomes of patients. Data was analysed using Statistical Package for the Social Sciences (SPSS) version 21.0 IBM and p-value <0.05 was taken as significant. Results: Out of total patients, 284 (56.80%) and 216 (43.20%) were males and females respectively and 11.12% of females were pregnant. Difference in mean ages of males and females was significant (p-value <0.001). The results show that 434 patients (86.80%) recovered fully and were discharged (more males were discharged), whereas 47 (9.40%) patients died. Out of total 500 patients 75.60% patients stayed in the hospital for more than 72 hours and 24.40% stayed for less than 72 hours. The mean age of patients who stayed for less than 72 hours was 48.85±17.93 as compared (44.23±17.45) to those who stayed for more than 72 hours and the difference was significant (p-value=0.012). Most common symptom was fever (58%) followed by cough (32%) and dyspnoea (31%). The association between the duration of stay and clinical outcome was significant (p-value <0.001). Conclusion: Gender, advancing age, duration of stay and associated co-morbidities appear to play role in infection and outcome of COVID-19.

Correlation of Serum Zinc Levels with Postpartum Depression- A Case control Study in North Karnataka

Introduction: Pregnancy is an important event in reproductive mother. At the same time it is associated with stress, which exaggerates the depression. Many factors leads to depression, among them nutrient deficiency like zinc, selenium, iron, calcium, folic acid and vitamin B12 plays a major role. Aim: To estimate and compare serum zinc levels in females with postpartum depression subjects and healthy controls. To find the relationship between serum zinc levels and extent of postpartum depression. Materials and Methods: The present study was a hospital- based case-control study, conducted over a period of three months. It included 40 postpartum depression cases and 40 healthy controls. All the participants were subjected to serum zinc levels estimation. Edinburgh Postnatal Depression Scale (EPDS) score was applied. The individuals who scored greater than 10 were taken as cases and those scoring less than 10 were taken as controls. Data was tabulated and results expressed as mean±SD, student’s t-test and Pearson correlation test was applied for correlation. Results: The present study found decreased serum zinc levels in postpartum depression cases compared to controls. It was found serum zinc levels in cases were 21.63±15.73 μg/dL and 54.16±19.72 μg/dL in controls. There was a negative correlation between the severity of postnatal depression and the serum zinc levels. Not only this, but certain risk factors were also identified, such as age of the mother, months of postpartum, mode of delivery, and the education of the mother. Conclusion: Decreased serum zinc levels do indeed correlate to a change in maternal mental health, and then the knowledge would not only help in diagnosis by tests, but also further patient care.

The Relationship of Vitamin D Level with Renal Prognosis in Focal Segmental Glomerulosclerosis Patients- A Retrospective Study

Introduction: The level of 25-hydroxyvitamin D₃ is an independent predictor of disease progression and death in Chronic Kidney Disease (CKD) patients. However, there are insufficient data to evaluate the possible effects of plasma 25(OH)D₃ levels on the prognosis of Focal Segmental Glomerulosclerosis (FSGS). Aim: To analyse the relationship between renal prognosis and serum 25(OH)D₃ status in FSGS. Materials and Methods: The study was conducted on 56 patients, who were followed-up for at least one year and diagnosed with primary FSGS. Participants were grouped according to their baseline 25(OH)D₃ levels (≤15 or >15 ng/mL) and treatment response at the end of one year (remission group or no remission group) was evaluated. Results: Mean age of the 56 participants was 44±13.92 years and 27 (48.2%) were male. Remission achievement in the first year was significantly higher and interstitial fibrosis was significantly lower for the group with a 25(OH)D₃ above >15 ng/ mL (p<0.001, p=0.002, respectively). Basal serum 25(OH)D₃ level was significantly lower and interstitial fibrosis and tubular atrophy percentages were higher for the ‘no remission’ group (p<0.001, p<0.001, p=0.005, respectively). Results of the binary logistic regression analysis revealed that low 25(OH)D₃ level and higher interstitial fibrosis were independent predictive factors that increased the risk of no remission in the first year (p=0.036, p=0.004, respectively). Conclusion: In primary FSGS patients, low baseline 25(OH)D₃ level at the time of biopsy and high interstitial fibrosis are independent predictors that reduce remission rates in the first year.

Uncommon High Resolution Computed Tomography Features of Pulmonary Tuberculosis: A Case Series

Swarna, Anuradha Sharma, Reeta Kanaujia, Shalabh Jain, Rohit Sharma

Classical imaging manifestations of pulmonary Tuberculosis (TB) include consolidation, cavitation, necrotic mediastinal lymphadenopathy and pleural effusions. On the other hand, atypical imaging findings of pulmonary TB are sometimes encountered which create a diagnostic dilemma; three such patients are reported here. The predominant finding in the first patient (24-year-old female) was diffuse cystic lung disease with associated bilateral secondary spontaneous pneumothoraces. The subacute onset of symptoms, associated nodules and ground glass opacities were a pointer towards an infective aetiology of the diffuse cysts in this case. The second patient (41-year-old female) presented with peribronchovascular and perifissural nodules with the galaxy or cluster sign leading to an erroneous diagnosis of sarcoidosis. However, the patient’s serum Angiotensin Converting Enzyme (ACE) levels were within normal limits; whereas her bronchial washings culture was positive for Mycobacterium TB. Therefore, this was actually a case of pulmonary TB with lymphatic involvement mimicking sarcoidosis. In the third patient (20-year-old female), there were pulmonary parenchymal lesions with the reversed halo sign classically described in cryptogenic organising pneumonia. Micronodularity in the wall and central part of the reversed halo lesion clinched the diagnosis of TB in this case. Laboratory investigations revealed acid fast bacilli or caseating granulomas consistent with TB in all these patients. Therefore, awareness regarding the atypical Computed tomography (CT) findings and a high index of suspicion is necessary to avoid delays in diagnosis and enable early institution of appropriate Antitubercular Therapy (ATT) in such cases.

Knowledge, Attitude and Practices of Clinicians, Nurses and Pharmacists Regarding Antimicrobial Stewardship: A Five Center Survey from India

Akshata Mane, Shweta Kamat, Harish Thanusubramanian

Introduction: Increasing awareness and practice of Antimicrobial Stewardship (AMS) has gained immense importance in Indian hospitals for preventing the irrational use of antibiotics. India is one of the world’s largest consumers for antibiotics. Assessment of the local Knowledge, Attitude and Practices (KAP) of Antimicrobial Resistance (AMR) and AMS among Healthcare Providers (HCPs) will help in designing effective public health policies and engaging the community in campaigns against increasing microbial resistance. Aim: To understand the status of AMS programs and practices in five private sector multispecialty hospitals situated in the East, West, North and South zones of the country and to assess the KAP of HCPs regarding AMR and AMS. Materials and Methods: The cross-sectional survey was conducted to assess the implementation of AMS in five hospitals among clinicians, nurses and pharmacists across India using a predeveloped AMS checklist between June 2019 and October 2019. The analysis was done between July and August 2020. Responses were collected using a five-point Likert scale, with choices ranging from ‘strongly agree’ to ‘strongly disagree’.Descriptive analysis was done for the KAP survey to determine the percentages of participants under each response category. Results: Total 32 clinicians, 55 nurses and eight pharmacists responded to the KAP survey (100% response rate). The clinicians were aware that AMR is caused by irrational prescribing of antimicrobials (n=31, 96.87%) and improper diagnosis of infective conditions (n=27, 84.37%). However, knowledge of clinicians on infection control practices (n=6, 18.75% disagreed) in controlling AMR and practice of referring local epidemiology before prescribing antimicrobials (n=7, 21.87% did not follow routinely) could be improved. The knowledge and practice of nurses and pharmacists on antibiotic use were spread over a wide range. According to the nurses, AMR was mainly caused by using antimicrobials for non bacterial infections (n=30, 54.54%) and deviations from their standard duration (~63.64%-72.73%). As per pharmacists, the lack of restrictions on antimicrobial usage and widespread use or overuse of antibiotics were major contributors to AMR (n=3, 37.5% strongly agreed). Both nurses and pharmacists could benefit from reinforced training on antibiotic usage. Conclusion: Implementation of AMS was not adequate in private Indian hospitals. Although clinicians have good knowledge on antibiotic use, it was not equally reflected in their practice. The KAP data of nurses and pharmacists suggest that training and education on appropriate antibiotic usage should be emphasised. More efforts are required to improve AMS practices in hospitals.

Efficacy and Safety of Linagliptin and Insulin in Patients of Type 2 Diabetes Mellitus with Grade 3-5 Chronic Kidney Disease in a Tertiary Care Hospital

Saajid Hameed, Pankaj Kumar, Ved Prakash, Manish Kumar, Harihar Dikshit

Introduction: Insulin therapy is preferred as safest for glycaemic control in patients with elevated serum urea/creatinine level. Management of diabetes in grade 3-5 Chronic Kidney Disease (CKD) with oral hypoglycaemic is very challenging because most of them cause renal impairment and thus dose adjustment is needed in renal disease. Linagliptin, a DPP-4 (dipeptidyl peptidase-4) inhibitor has only 5% renal excretion; hence its dose adjustment is not needed in patients with CKD. Aim: To compare the efficacy and safety of linagliptin with insulin in patients of Type 2 Diabetes Mellitus (T2DM) with CKD. Materials and Methods: The present study was a longitudinal study, in which a total of 101 patients of grade 3-5 CKD with T2DM were divided into two groups, insulin group (n=54) and linagliptin group (n=47), based on their drug therapy. All the cases were tested for HbA1c (Glycated Haemoglobin), Random Blood Sugar (RBS), Creatinine clearance, Urine Protein-Creatinine Ratio (UPCR) and different adverse drug events at their first visit (baseline) and then during follow-up at 1^st, 3^rd, 6^th and 12^th month. Statistical analysis was done through GraphPad Instat by unpaired t-test for group comparison and Analysis of Variance (ANOVA) for intragroup comparison. Results: At the end of study, mean difference of RBS, Creatinine clearance and UPCR in both the groups were not significant. But mean HbA1c level was less in linagliptin group (6.62±0.10) as compared to insulin group (6.82±0.23) on long term therapy and the difference was statistically significant. Hypoglycaemia (33 vs 24), urinary tract infection (6 vs 5) and respiratory tract infection (5 vs 4) were more frequent in insulin group versus linagliptin group. Conclusion: Linagliptin for glycaemic control provides clinically meaningful improvements in long term glycaemic control without unacceptable side effects in CKD like vulnerable group of patients.

Phenotypic and Genotypic Study of Klebsiella species with Reference to Extended Spectrum Beta-Lactamase

Rakesh Prasad Sah, Rakesh Kumar Mukhia, AD Urhekar, Kshitija Rane

Introduction: Klebsiella species is an important nosocomial pathogen with the emergence of Multi Drug Resistance (MDR). MDR in Klebsiella species is increasing worldwide with the production Extended Spectrum Beta-Lactamase (ESBL). The emergence of ESBL is a critical concern in Klebsiella species due to resistance to ceftazidime and other cephalosporins which compromise the efficacy of life saving antibiotics against these infections. Aim: To know the factors responsible for antimicrobial drug resistance in Klebsiella species with respect to ESBL and their responsible genes. Materials and Methods: A prospective and experimental study was carried out over a period of three years (August 2013 to July 2016). Total 200 isolates of Klebsiella species were screened for cefotaxime and ceftazidime. The resistant strains (cefotaxime/ceftazidime) were subjected to ESBL agar, Phenotypic Confirmatory Disc Diffusion Test (PCDDT) and Modified Three Dimensional Test (M3DT). Genetic analysis by Polymerase Chain Reaction (PCR) was done for the detection of beta-lactamase (bla) genes i.e., bla_TEM, bla_SHV & bla_CTX-M in 58 isolates of Klebsiella species. The data was presented using frequency and percentage. The proportion was compared using Z-test for the proportions. Results: Out of 200 isolates, 135 (67.5%) were found resistant to cefotaxime and 125 (62.5%) were resistant to ceftazidime. Among which 110 (55%), 75 (37.5%) and 95 (47.5%) Klebsiella species were found positive for production of ESBL by ESBL agar, PCDDT and M3DT respectively. PCR analysis in 48 isolates were positive by PCDDT/M3DT or both were also positive for beta-lactamase genes i.e., 43 (89.58%) bla_TEM; 44 (91.67%) bla_SHV and 48 (100%) bla_CTX-M. Ten negative isolates either by PCDDT/M3DT or both were also negative by PCR. Co-existence of (bla_TEM+bla_SHV +bla_CTX-M), (bla_TEM+bla_SHV), (bla_TEM+bla_CTX-M) and (bla_SHV+bla_CTX-M) were found 81.25%, 0%, 8.33% and 10.42%, respectively. Conclusion: The M3DT is the best phenotypic method for the confirmation of ESBL producer in Klebsiella species which is not included by CLSI while inclusion with PCDDT enhances the detection of ESBL producers. Co-existence of all three genes (bla_TEM, bla_SHV and bla_CTX-M) in a single strain is a serious concern for us. So it is important to include M3DT and PCDDT in routine basis for the detection and management of ESBL producers which will help clinician to prescribe proper antibiotics.

Ability of Optical Coherence Tomography in Early Detection of Primary Open Angle Glaucoma

Pinky Jewariya, Manish Sharma, Sandeep Parwal, Kamlesh Khilnani

Introduction: As glaucoma is one of the leading causes of blindness, its early diagnosis is crucial. Standard Visual Field (VF) examinations are used in the diagnosis and follow-up of glaucoma, but the major drawback is that the abnormalities do not appear until 20-40% of ganglion cells are lost. Defects in the Retinal Nerve Fiber Layer (RNFL), measured by Optical Coherence Tomography (OCT), is an excellent objective and quantitative method in the diagnosis and management of glaucoma at earlier stages. Aim: To assess the ability of OCT in diagnosing early glaucomatous changes using RNFL, Optic Nerve Head (ONH) and macular thickness parameters. Materials and Methods: A hospital-based case control study was done for 18 months at Department of Ophthalmology, Sawai Man Singh (SMS) Hospital and Medical College, Jaipur, Rajasthan, India. Fifty patients meeting the inclusion criteria were evaluated in the study as case group. To compare the results with those of a normal population 50 age and sex matched subjects were included. Each subject underwent detailed ocular examination and RNFL, ONH and macular thickness parameters were measured using Spectral Domain (SD) OCT. The unpaired t-test was used to compare continuous variables and Chi-square test was used to compare categorical variables. The Area Under the Curve (AUC) with its 95% Confidence Interval (CI) was calculated. The p-value <0.05 was considered significant. Results: A total of 50 glaucoma or glaucoma suspect cases and 50 controls partcipated in the present study, i.e., 100 eyes in each group were studied. Mean RNFL thickness, superior thickness, inferior thickness and temporal thickness were significantly (p<0.05) lower among cases than controls. Cup area, cup/disc (C/D) area ratio, horizontal and vertical cup to disc ratio (CDR) were significantly (p=0.0001) higher among cases than controls. Vertically Integrated Rim Area (VIRA) was significantly (p<0.05) lower among cases (0.19±0.13) than controls (0.28±0.05). There was no significant (p>0.05) difference in disc area between cases and controls. All the macular thickness parameters were significantly (p<0.05) lower among cases than controls except fovea. Overall, ONH and macular thickness parameters had high sensitivity and specificity than RNFL parameters in glaucoma patients. Conclusion: The present study found that a combination of RNFL, ONH and macular thickness parameters improved the diagnostic accuracy of OCT in early detection of Primary Open Angle Glaucoma (POAG).

Can the 12-Lead Electrocardiogram Predict Myocardial Viability?

Introduction: In patients with coronary artery disease and left ventricular dysfunction, the assessment of myocardial viability, prior to revascularisation has been shown to be of significant benefit. Most methods to assess myocardial viability such as Positron Emission Tomography (PET) and Cardiac MRI (CMR) are not readily available in resource constrained settings. The present study sought to determine if an easily available and inexpensive tool, such as the 12-lead surface Electrocardiogram (ECG) can be used as a screening tool to assess for myocardial viability. It is hypothesised that the R wave height as a marker of electrical activity would correlate with viability. Aim: To determine if the surface ECG can be used to predict myocardial viability. Materials and Methods: This retrospective study was conducted at the Christian Medical College and Hospital, Vellore, Tamil Nadu, India. Among all patients who had undergone CMR viability assessment as part of their routine care between February 2008 and October 2017, and analysis and preliminary write up was done between November 2017 and Decemeber 2018, 119 patients with previous anterior wall myocardial infarctions were identified. The 12-Lead ECGs of these patients were assessed for the height of R wave in lead V3 and sum of R wave heights in all precordial leads. Myocardial viability was assessed based on the extent of Late Gadolinium Enhancement (LGE) on CMR. Measures of diagnostic accuracy including sensitivity, specificity, predictive values and likelihood ratios were calculated. Results: It was found that a R wave height of less than 3 mm in lead V3 was 90.3% sensitive for the detection of non viable myocardium. Similarly, when the sum of the R wave heights in all precordial leads was less than 28.5 mm, it was 93.2% sensitive for the detection of non viable myocardium. Conclusion: In patients with previous anterior wall myocardial infarctions when the R wave height was less than 3 mm in lead V3, it was 90.3 % sensitive to identify those with non viable Left Anterior Descending artery (LAD) territory. The 12-Lead ECG is therefore a sensitive, inexpensive and easily available screening test to assess for LAD territory non viability.

Positive Emotion Induction for Pain Associated with Rheumatoid Arthritis- A Quasi-experimental Study

Nidhal A Amanullah, Dushad Ram, Subramanian Ramaswami, Muath Alammar

Introduction: Rheumatoid Arthritis (RA) is a chronic disease and a substantial proportion of patients continue to suffer from chronic pain and disability despite standard pharmacotherapy. A substantial proportion of patients with RA also develop anxiety and depressive symptoms. Positive Emotion Induction (PEI) has been shown to reduce pain symptoms. Aim: To know the effect of positive emotion induction as an adjunctive intervention on RA associated pain and disability. Materials and Methods: The longitudinal hospital based study was conducted at the Outpatient Department of Rheumatology and Psychiatry, Jagadguru Sri Shivarathreeshwara Hospital, Mysuru, Karnataka, India, from January 2018 to June 2019, included 85 consecutive participants with RA were recruited and assessed at baseline with Health Assessment Questionnaire scale {HAQ-DI and Visual Analog Scale (VAS)}, Hamilton Anxiety Scale (HAM-A), and Hamilton Depression Scale (HAM-D). Six session of PEI was done using recreating pleasant memory and the same was practiced at home daily by the patient. All participants were reassessed with the same parameter after three months. Paired sample t-test was done to know the change in the score pre and post test on the score of HAQ-DI and VAS, HAM-A, HAM-D. The value of statistical significance was p-value ≤0.05. Results: The majority of the participants belonged to 40-50 years of age, were married, females, studied to middle school, of low socio-economic status, had a nuclear family. The majority had duration of RA been two to four years, with severe illness and were on regular medication. Statistically significant difference was observed in pre and post test on the score of HAQ-VAS (t=8.23, p<0.05), HAM-A (t=11.40, p<0.05) and HAM-D (t=10.95, p<0.05). Conclusion: Brief psychological intervention (PEI) may be a useful adjunct intervention in patients with RA. Further study is needed to explore the clinical use of the PEI for intervention in RA.

Microalbuminuria and Serum Cystatin C Correlation as Early Markers of Kidney Dysfunction in Patients with Type 1 Diabetes Mellitus

K Anuja, R Kalaivani, MP Saravanan

Introduction: Diabetes mellitus is the most common single cause of End Stage Renal Disease (ESRD). About 20-30% of patients with Type 1 Diabetes Mellitus (Type 1 DM) develop diabetic nephropathy as a serious complication which is the major cause of morbidity and mortality. Early identification of renal impairment is crucial to prevent the progression of nephropathy to a significant degree, because several interventions have greatest impact if initiated very early in the course of the disease. Aim: To study the correlation of microalbuminuria and serum cystatin C for the early prediction of renal impairment in patients with Type 1 DM. Materials and Methods: This was a cross-sectional study conducted from January 2016 to June 2016 on type 1 DM patients attending Diabetology Outpatient Department (OPD). According to the duration of diabetes, pateints were divided into two groups, Group I with <5 years and Group II with >5 years duration. The patients in each group were categorised as cases and controls, based on the Albumin Creatinine Ratio (ACR), serum urea, creatinine, cystatin C, glycated haemoglobin (HbA1c), and urine ACR levels were estimated. Student’s unpaired t-test was used to compare the means between two independent groups. Pearson correlation coefficient was used to estimate the degree of correlation between two quantitative variables. Results: Seventy-two patients with type 1 DM were included in the study. Cystatin C levels in cases (0.89±0.35) when compared to controls (0.67±0.26) in more than five years duration of type 1 DM was found to be statistically significant (p<0.01). Positive correlation between cystatin C and ACR (r=0.4, p<0.05) was found to be statistically significant in more than five years duration. It indicates that serum cystatin C levels increases as the values of ACR increases. There was no significant difference in cystatin C levels in patients with less than five years duration of type 1 DM. Conclusion: Serum cystatin C may be considered as an early predictor of renal impairment in type 1 DM patients with more than five years duration. However, in this study cystatin C carries no significance in less than five years duration of type 1 DM patients.

Effect of Short Term Resistance and Endurance Exercise Training on Resting Heart Rate and Inflammatory Marker in Young Adults: A Cross-sectional Study

Introduction: In a normal healthy adult, sympathetic and parasympathetic system should be in synergy. Measuring resting heart rate is a one of the methods to assess health condition. It can be affected by different factors such as exercise, mental health, any disease, etc. Normal subjects with reduced heart rate are associated with better cardiovascular health. Physical inactivity is associated with high level of inflammatory markers. Increased inflammatory markers are related to inflammation and chronic diseases. The C-Reactive Protein (CRP) is a biomarker of inflammatory diseases. High CRP level is a potent risk factor for obesity, diabetes, atherosclerosis, etc. Aim: To study the effect of short term resistance and endurance exercise training on resting heart rate in healthy young adults, CRP, Body Mass Index (BMI) and also to compare the changes between two exercise groups. Materials and Methods: A cross-sectional study was conducted from May 2019 to May 2020 in the Department of Physiology at King George’s Medical University, Lucknow, Uttar Pradesh, India. The study included 60 healthy young adults with normal BMI (18.5-24.9 kg/m²) and age between 18-25 years. Subjects were equally divided into Group I- Resistance exercise and Group II endurance groups. Subjects did moderate intensity exercise (based on maximum heart rate) for five days in a week for eight weeks. Endurance group did jogging. Resistance group did push-up, pull-up and squats. Target heart rate during moderate intensity of activities was 64-76% of maximum heart rate. Heart rate measurement was done before the start of exercise and after five to seven minutes of exercise when it reached 64-76% of maximum heart rate. It was measured by pulse oximeter. Follow-up was done after eight weeks of exercise training in both the groups. Evaluation was done by comparing resting heart rate and CRP level before the start of training and after the completion of training programme. Statistical analysis was done using student t-test and paired t-test. Results: Mean age of subjects of group I was found to be higher (19.98±1.26 years) as compared to group II (19.97±0.98 years). Mean pre intervention BMI of both the groups was found to be similar (21.97±1.78 kg/m²). No statistically significant change in resting heart rate was found in both resistance group (p=0.096) and endurance group (p=0.326) after exercise training. Statistically significant increase in CRP was found in resistance group (p<0.001) and endurance group (p<0.001). The increment in CRP was more in endurance group (55.04%) than resistance group (35.34%). Conclusion: Short duration of exercises increase inflammation but no significant effect on resting heart rate was seen.

Effect of Colours on Perception and Cognition of Students Belonging to Two Different Age Groups: A Cross-sectional Study

Shubham Gupta Lalbabuprasad, Anita Rahul Gune

Introduction: Colour is believed to stimulate senses. It improves the attention span and helps in developing cognitive abilities and hence, can be beneficial in the educational set-up. There is a void in literature about usefulness of colours in the education settings in India. Aim: This study was conducted to assess students’ preference, perception, emotional responses, memory, and cognition related to colours. Materials and Methods: A cross-sectional study conducted over a period of two months (January-February 2018) comprised of 300 students divided into two equal groups: Group A with 13 to 18 years of age, Group B with 19 to 25 years of age. On four consecutive days, both the groups were exposed to the same power point slide with some words highlighted with a single colour (red: material related to discovery of earth’s polarity, blue: material related to arbovirus, yellow: material related to pathophysiology of diabetes mellitus, or green: material related to Mangalyan). At the end of the fourth session, a validated questionnaire was used to evaluate the students’ perceptions and responses to various colours. The data were analysed using R software v 3.6.1. The Kruskal-Wallis test was used to find significant differences within the group, p<0.05. Results: In group A, the highest mean preference was observed for the colour red (mean=8.02±2.83; p=2.20e^-16), blue was found to be a soothing colour (n=65) and yellow helped in better recollection of facts (n=44). In contrast, in group B, the highest mean preference was observed for the colour blue (mean=8.35±3.59; p=5.90e^-15). Yellow was considered a more soothing colour (n=43), and black helped in better recollection (n=41). Conclusion: Colour perception varies in different age groups. It also affects emotions, memory, and influences mood disposition.

Serological Characterisation of Auto-antibodies in Patients with Direct Antiglobulin Test Positive Autoimmune Haemolytic Anaemia at a Tertiary Care Teaching Hospital in Tirupati, India

Introduction: Haemolysis in Autoimmune Haemolytic Anaemia (AIHA) is a result of Immunoglobulin G (IgG) or Immunoglobulin M (IgM) auto-antibodies with or without complement components binding to the Red Blood Cell (RBC) surface and initiating its destruction. Serologic evidence is provided by autocontrol or Direct Antiglobulin Test (DAT). Diagnostic work-up is essential as the management depends on the antibody type. Characteristics of the bound antibody and the target antigen determine the degree of haemolysis. Serological characterisation in AIHA helps to differentiate into its various types which help the clinician to decide on the treatment to be given. Aim: To serologically characterise the auto-antibodies in patients with DAT positive AIHA at a tertiary care teaching hospital. Materials and Methods: This cross-sectional study was carried out in the Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India, from March 2019 to February 2020. A 40 consecutive patient samples were included in the study. Characterisation of antibody was done using polyspecific Anti-Human Globulin (AHG) reagent followed by mono-specific AHG reagent by gel method. If antibody was of IgG type, then the subclass was determined by a mono specific anti-IgG1 and anti-IgG3 gel card. Association between antibody types, subtype, and strength of DAT with severity of haemolysis were compared using Chi-square/Fisher’s-exact test. A p-value of less than 0.05 was considered statistically significant. Results: The total study population was 40 patients. The mean age of the study population was 45 years (range 13-78). Out of 40 patients, males were 30 (75%) and females were 10 (25%). The primary and secondary causes for AIHA include 4 (10%) and 36 (90%) respectively. Among 40 patients, 22 (55%) patients had IgG antibody alone, 17 (42.5%) patients had IgG antibody with combination of other antibodies and 1 (2.5%) had only complement (C3d). IgG1 was identified in 7 (18%) of patients, combination of IgG1 and IgG3 in 3 (7.7%). There was a significant association with IgG+combination (p-value=0.03), IgG1+IgG3 (p-value=0.029) and strength of reaction (p-value=0.003) with respect to severity of haemolysis. Conclusion: Presence of multiple antibodies, presence of IgG1 and IgG3 and with complement combination and presence of higher grading of reaction in gel column were associated with severity of haemolysis. We recommend that serological characterisation of auto-antibody in AIHA would help the clinician in assessing the severity of haemolysis so that management can be done appropriately.

Coronectomy versus Extraction of Third Molar with Inferior Alveolar Nerve Proximity: A Cross-sectional Study

Introduction: A tooth that failed to erupt in its expected time of eruption is called impacted tooth. Mandibular impacted teeth are common than any other tooth. Management of impacted teeth depends upon depth, angulations and type of impaction. Certain factors may increase the complications of tooth extraction. One of them is Inferior Alveolar Nerve (IAN) approximation with third molar roots. Coronectomy is surgical procedure through which crown of tooth can be removed at cementoenamel junction level and leaving the root part is a new procedure to avoid nerve injury. Aim: To compare outcome of extraction of lower third molar and coronectomy in management of impacted third molar with close proximity to inferior alveolar nerve. Materials and Methods: This cross-sectional study was conducted at Oral and Maxillofacial Surgery Department at Liaquat University of Medical and Health Science Jamshoro/Hyderabad, Pakistan. Ethical approval was sought from the ethical review committee of university. The written informed consent was taken from the patients. Total 36 patients were included in this study, divided into two groups using random number table. Patients with mandibular impacted third molar, with inferior alveolar nerve approximation diagnosed clinically and radiographically were included in this study. Group A was treated with surgical extraction and group B with Coronectomy. The data was analysed by Statistical Package for the Social Sciences (SPSS) statistical software version 20.0. The Chi-square test and Independent t-test was applied to check the statistical difference in outcomes of both treatment procedures. Results: Total 36 patients were included in two groups and the mean age of patients were 25±2 years with male to female ratio as 1.1:1. Preoperatively, all patients were having normal mouth opening and no neurosensory deficit. Postoperatively neurosensory deficit seen in both groups at follow-up visits but, at six weeks follow-up, all patients were recovered from IAN deficit in coronectomy group with statistically significant p-value <0.001. Conclusion: With this small sample size, it cannot be concluded which technique is better than other. With this single centre study, it was observed that coronectomy appears to be simple, easier and better procedure and more effective technique for minimising the risk to inferior alveolar nerve injury, limited mouth opening and dry socket that corresponds to impacted molar extraction.

Evaluation of Secondary Chronic Suppurative Osteomyelitis of Jaw in 15 Cases: A Retrospective Analysis

Varsha Manekar, Vandana Gadve, Vijaya Dhote, Sulabha Radke

Introduction: Chronic osteomyelitis may become a refractory condition and is more difficult to treat. Therefore, for correct diagnosis and evaluation of chronic osteomylitis, primary health care practitioners must have knowledge of signs and symptoms associated with osteomyelitis for effective management. Aim: To evaluate secondary chronic suppurative osteomyelitis of jaw in 15 cases. Materials and Methods: This was a retrospective study of all patients treated for maxillo-mandibular secondary chronic osteomyelitis over a period of six years (January 2013 to December 2018) in Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Nagpur, Maharashtra, India. This study was carried out in between November 2019 to November 2020. A total of fifteen cases were identified which were diagnosed as Secondary Chronic Suppurative Osteomyelitis (SCO) and treated for same. The cases were evaluated for demographic data, risk factors, aetiology, clinical presentation, radiological findings and the management. Data was collected through retrospective search of records and was arranged in descriptive tabular format without statistical analysis. Results: Out of 15 cases 9 (60%) were female. The patients ranged in age from 21 to 56 years with a mean age of 36.6±9.0 years. The mean age at first symptoms was 35.5 years (20-55), with a standard deviation of 9.12 years. The distribution of osteomyelitis in the jaws was dominated by the cases that occurred in the mandible i.e., 73.33% (11 cases) and the maxilla 26.66% (four cases) with most common involved site was body and angle region of mandible (eight cases) followed by premolar region two cases and anterior region one case. In this study, five cases (33.33%) had carious lesion and seven cases (46.67%) had infected extraction socket. Other causes of infection were osteoradionecrosis in one case and superimposed infection like mucormycosis in two cases. The most common causes of chronic osteomyelitis of the jaws were directly related to odontogenic infections like infected unhealed socket. Decortication and curettage was done in four cases. Decortication and sequestrectomy were performed in five cases and debridement of necrosed bone in three cases. Sinus opening, debridement of necrosed wall and packing were done in three cases of SCO involving maxilla. Duration of antibiotic therapy in all patients averaged five weeks. Conclusion: The accurate diagnosis with the help of recent imaging techniques, adequate antibiotic therapy as well as surgical treatment was keys for the success of SCO management.

Effectiveness of Sabouraud’s Dextrose Agar and Dermatophyte Test Medium in Detection of Candidiasis and Dermatophytosis in Superficial Skin Lesion

V Geethalakshmi, KA Jasmine, Anu P John, Priya Prathap

Introduction: As time evolves fungal infections have increased its prevalence. Among the fungal infections, superficial fungal infections are the most common type. They can be either chronic or recurrent, therefore simple incidence figures are not the most useful means of understanding the burden of disease. Aim: Isolation and identification of pathogenic fungi from clinically suspected cases of dermatophytosis and candidiasis of skin, also to compare two media used in isolation of the fungus. Materials and Methods: A cross-sectional study was conducted over a period of one year, clinically suspected cases of dermatophyte infection and candidiasis who attended the Outpatient Department of Dermatology and Venereology Government Medical College, Thrissur, Kerala, India, were included randomly in the study. Sample size was taken as 150. Samples were collected from clinically suspected cases of dermatophytic infections and candidiasis of skin and was transported to the Microbiology Department in sterile bottles. Direct examination under KOH (Potassium hydroxide) solution was done. Culture of these samples on Sabouraud’s Dextrose Agar (SDA) with chloramphenicol/gentamycin and Dermatophyte Test Medium (DTM) was analysed. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software. Results: Trichophyton mentagrophytes was the commonest isolate 57%, followed by Trichophyton rubrum 27%. Out of six clinically suspected cases of candidiasis, no organism was isolated in the cultures. Almost all dermatophytes isolated were grown in DTM within one week of incubation except Trichophyton rubrum which appeared in the second week, while in SDA only 31% of isolates were grown. Direct smear positivity was found in 95% of the cases, while culture positivity was 45%. All isolates were grown in DTM while 31% were grown in SDA. Conclusion: Trichophyton mentagrophytes was the commonest species isolated. The next common isolate was Trichophyton rubrum. DTM was more useful as a screening medium as opposed SDA as identification medium and the isolation is more rapid.

A Study of Anatomical Pattern of Inferior Phrenic Artery using Multidetector CT

Anil Kumar Singh, Archna Gupta, Zafar Neyaz, Prabhakar Mishra

Introduction: Inferior Phrenic Artery (IPA), though a small artery, is important from several points of view. Apart from being arterial supply to normal structures, it is also involved in many pathological conditions such as tumours, haemoptysis, gastroesophageal bleeding and traumatic conditions where interventional radiology or surgery play an important role in management. A preprocedure idea about variations in its anatomical pattern may help better treatment planning and minimise morbidity. Aim: To study variations in anatomical pattern of IPA in terms of vessel of origin, vertebral level of origin and diameter of IPA using Multidetector Computed Tomography (MDCT). Materials and Methods: The present study was a cross-sectional study conducted in Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. A retrospective analysis of CT angiography or Triple phase CT abdomen studies of 200 adult patients (M:F 119:81) performed during December 2020 to April 2021 was done to look for anatomical pattern variations in IPA. Vessel of origin and level of origin were recorded. Diameters of IPAs were also recorded and statistical analysis was done. Results: Common Inferior Phrenic Artery (CIPA) was seen in 23% cases, with independent Right and Left Inferior Phrenic artery (RIPA and LIPA) in remaining 77%. Vessels of origin for CIPA were aorta (n=27; 58.7%), celiac trunk (n=16; 34.8%) and right Main Renal Artery (right MRA) (n=3; 6.5%); for RIPA, celiac trunk (n=69; 44.8%), aorta (n=57; 37.01%), right MRA (n=23;14.94%), Left Gastric Artery (LGA) (n=5; 3.25%), and for LIPA, celiac trunk (n=97; 63%), aorta (n=53; 34.4%), left MRA (n=2; 1.3%) and LGA (n=2; 1.3%), respectively. Level of origin from aorta for RIPA was L1>T12>T12/L1 disc>others; LIPA, T12>T12/L1>L1>others; celiac trunk, T12>L1>T12/L1 disc>others. Mean diameters of apparently normal RIPA and LIPA were 1.75 mm and 1.76 mm, respectively. Conclusion: The most common vessels of origin for CIPA, RIPA and LIPA were abdominal aorta (58.7%), celiac trunk (44.8%) and celiac trunk (63%), respectively. The predominant vertebral levels of origin for CIPA, RIPA and LIPA arising from aorta were T12, L1, and T12 respectively, and for celiac trunk T12. The mean diameter of IPA was found to be greatest in cirrhotic group followed by chronic pancreatitis and apparently normal IPA group, but not statistically significant. These can be efficiently and readily demonstrated by CT angiography or arterial phase of multiphasic CT study.

Upper and Lower Gastrointestinal Endoscopic Lesions in Patients with Unexplained Iron Deficiency Anaemia- A Cross-sectional Study

Introduction: Anaemia, due to iron deficiency, is very common in India. In many cases, the underlying cause of iron deficiency remains unknown even after detailed laboratory investigations. It is often due to malabsorption of iron from the gut and occult blood loss from the Gastrointestinal (GI) tract. Bidirectional GI endoscopy can help in finding these causes. Aim: To study the upper and lower GI endoscopic lesions in patients with unexplained Iron Deficiency Anaemia (IDA). Materials and Methods: This was a cross-sectional observational study, conducted on 75 patients with unexplained IDA in Dr. DY Patil Medical College and Hospital, Pune, Maharashtra, India, between June 2019 to June 2020. Patients above the age of 18 years and with Haemoglobin (Hb) of less than 13 g/dL (males) and less than 12 g/dL (females) underwent upper GI endoscopy and colonoscopy with biopsies, after ethics committee approval and informed consent. Complete haemogram with blood indices, iron studies and faecal Occult Blood Test (OBT) were conducted for all the patients. The patients were divided into Group A, those with upper/lower GI endoscopy lesions thought to be responsible for IDA and Group B, those without GI endoscopic lesions. Statistical analysis was performed using IBM, Statistical Package for the Social Sciences (SPSS), version 21.0 and statistical tests (Chi-square test, Student’s t-test and multivariate logistic regression analysis, with 95% Confidence Interval (CI) and p-value <0.05 was taken as significant) were used when required. Results: There were 44 females and 31 males in the study, with the age range of 20-81 years. The mean age of patients in Group A (n=44) was 58.57±11.68 years and Group B (n=31) was 49.68±14.45 years. On multivariate analysis, advance age, history of weight loss and faecal occult blood were statistically significantly associated with the presence of GI endoscopic lesions responsible for IDA (p-value<0.05). Maximum lesions responsible for IDA were found in stomach (48%), erosive and inflammatory lesions causing IDA were more common in upper GI tract. Peptic ulcers were found in 12% cases. The GI malignancies were found in 14.66% subjects. Colorectal cancers (8%) were more common than upper GI cancers (6.66%). Conclusion: In patients with IDA, erosive oesophagitis and haemorrhagic gastritis were commonly found followed by peptic ulcers and malignant GI lesions on bidirectional endoscopy. GI endoscopy is a very important tool to diagnose the cause of IDA. All patients with advanced age, history of weight loss and a positive faecal OBT should undergo bidirectional GI endoscopy routinely.

The Ergonomic Challenges Students Face during Operative Dentistry Treatment

Introduction: Students must possess good theoretical knowledge in order to perform correct clinical treatments with good prognosis and in safe conditions but merging theoretical knowledge and clinical practice in dental education is a challenge for both the training staff and the students. Up until now, no studies have been published in our country regarding the challenges faced by dental students in their clinical works performance for restorative dentistry and endodontic treatments. Aim: The aim of this study was to assess the factors that may influence the performance of restorative and endodontic treatment procedures performed by 5^th year dental students and their own perception on clinical work. Materials and Methods: This was a cross-sectional study carried out in February 2020. A self-made questionnaire with 13 questions was distributed via e-mail link to 5^th year dental students at the University of Medicine and Pharmacy Iuliu Hat‚ieganu Cluj Napoca, Romania, Department of Conservative Dentistry, all 5^th year dental student who had previously undergone two years of clinical training. One hundred eleven students were selected after applying the inclusion criteria that were, having two years of clinical training experience and having passed their theoretical ergonomics, restorative dentistry and endodontics examinations. Descriptive Statistics were used for data analysis. Results: The majority of the students 83% (n=92) encountered difficulties applying the rules of ergonomics related to posture. The most common causes that prevented students from applying the rules of ergonomics during the clinical work were challenges related to working in indirect vision (n=90), lack of help by an assistant during treatment (n=52), working time allocated being too short (n=50), lack of sufficient space around the unit (n=43). Regarding the theoretical level required for restorative cases diagnosis, treatment plan and treatment itself, 64% (n=71) of students claimed to have had the necessary theoretical knowledge in most cases they met and only 25% (n=28) could confidently treat all cases. Establishing the diagnosis and treatment plan for endodontic cases was difficult stage for 3.6% (n=4) of students, of average difficulty in the case of 81.1% (n=90) of students, while 15.3% (n=17) did not consider them difficult at all. Conclusion: The results indicated that students had high levels of confidence in their theoretical knowledge when establishing the diagnosis and the treatment plan, but they encountered multiple challenges both with working ergonomically and with mastering the practical skills needed in different stages of the treatment.

Primary Ovarian Non-Hodgkin LymphomaA Diagnostic Challenge with Clinicopathological Study of Eight Cases

Introduction: The involvement of the Female Genital Tract (FGT) by lymphoma is extremely rare, with ovaries being most commonly affected. Less than 1% of lymphomas present with ovarian involvement and less than 1.5% of ovarian neoplasms are of lymphoid origin. Secondary involvement of ovary by systemic lymphoma is more common than Primary Ovarian Lymphomas (POL) which is usually Primary Ovarian Non-Hodgkin lymphoma (PONHL) of B-cell lineage. Aim: To understand the clinicopathological and immuno-morphological features of Primary Ovarian Non-Hodgkin lymphoma. Materials and Methods: This was a descriptive retrospective study conducted at Department of Pathology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka. India, for a duration of 14 years between July 2006 to June 2020. Eight cases of PONHL were identified from departmental archives and clinicopathological and Immunohistochemistry (IHC) findings of these tumours were analysed. Results: The PONHL constituted 0.4% of all Non-Hodgkin lymphoma (NHL) reported during the study period. The patients age ranged from 13-60 years with a mean age of 34 years. Among eight cases of PONHL, two cases were of Diffuse Large B-Cell Lymphoma (DLBCL), followed by one case each of High-Grade B-Cell Lymphoma, Not Otherwise Specified (HGBL, NOS), Follicular Lymphoma (FL), Burkitt Lymphoma (BL), Plasmablastic Lymphoma (PBL), Precursor B-Lymphoblastic Lymphoma (B-LBL), and precursor T-Lymphoblastic Lymphoma (T-LBL). Seven cases were staged IE(Ann Arbor staging system) while one case was designated as stage IIE. Conclusion: This was probably the first study on PONHL from India. The diagnosis of PONHL is challenging unless there is a high index of suspicion as these patients present with non specific pelvic symptoms and can be misdiagnosed as other epithelial, stromal or germ cell ovarian neoplasm which differs in treatment and prognosis. Histological examination with IHC and molecular testing are essential to establish a diagnosis.

Clinical, Angiographic Profile and Short-term Prognosis in Patients with ST Elevation Myocardial Infarction- A Cross-sectional Study

Introduction: Acute Myocardial Infarction (MI) is one of the most common causes of death and disability throughout the world. The most common of all Acute Coronary Syndrome (ACS) in Indian patients is acute ST Elevation Myocardial Infarction (STEMI). Although acute MI more commonly occurs in patients older than 45 years of age, young men and women can also have MI. Aim: To study the risk factors, clinical presentation, angiographic profile and short-term prognosis in patients with STEMI with age ≤45 years. Materials and Methods: A cross-sectional study was carried out in the Department of Cardiology, SCB Medical College and Hospital, Cuttack, Odisha, India. A total of 198 patients of age ≤45 years with acute STEMI, of both genders diagnosed based on symptoms, Electrocardiogram (ECG), Echocardiogram (Echo) and biomarkers were enrolled from June 2019 to November 2020. Categorical variables were tabulated in frequency with percentage distribution and continuous variables were summarised in mean±SD (Standard Deviation). Results: This study included 198 patients, aged ≤45 years, with STEMI. STEMI was more common in males. The mean age was 38.28 and 42.15 years for males and females, respectively. Smoking (63.5%) was the most common risk factor, followed by dyslipidemia (28.5%). Most of the patients (86.5%) presented with typical chest pain. Killip’s Class I was most common (92.5%) at the time of admission. Anterior Wall Myocardial Infarction (AWMI) was the presentation in the majority (61%). Most patients (47%) had Single Vessel Disease (SVD). One third of the patients had re-canalysed vessels. Type A lesion was commonly seen (61%) and 60% patients underwent coronary angioplasty. Conclusion: In young STEMI patients males were commoner and smoking and dyslipidemia were found to be the common risk factors, smoking being twice more common than dyslipidemia. Typical chest pain of Killip Class I and AWMI were seen in majority. Half of the patients had SVD and one third was found to be re-canalysed. Type A was the commonest lesion and two thirds of the study population could undergo coronary angioplasty.

Correlation of Oxygen Saturation Index and Oxygenation Index in Hypoxaemic Respiratory Failure among Neonates

B Sunil, E Nithya

Introduction: Hypoxaemic Respiratory Failure (HRF) is severe arterial hypoxaemia that is refractory to supplemental oxygen. Oxygen Saturation Index (OSI) can be an alternate method of diagnosing and assessing the severity of HRF as it uses Oxygen Saturation (SpO₂) in place of Partial Pressure of Oxygen (PaO₂) and may be utilised with reasonable sensitivity and specificity. Aim: To evaluate the correlation between OSI and Oxygenation Index (OI) in HRF in neonates. Materials and Methods: The prospective observational study was conducted in Kempegowda Institute of Medical Sciences and Hospital, Bengaluru, Karnataka, India, from December 2016 to July 2018. Fifty neonates who were admitted to Neonatal Intensive Care Unit (NICU) and conventionally ventilated in view of HRF were included. Arterial blood gases in the first 24 hours of life and corresponding oxygen saturations and ventilator settings were recorded. OI and OSI was calculated using the standard formula and their correlation was analysed. Results: The neonates were all on first day of life at admission to NICU and were invasively ventilated due to HRF. The mean birth weight was 1.89±0.84 kg. Of the 50 neonates, 22 (44%) were preterm babies ( < 34 weeks), 17 (34%) belonged to late preterm group (34 weeks to 36 weeks +6 days), 9 (18%) were term babies ( > 37 weeks), two neonates were extremely preterm (less than 28 weeks). In this study, OSI and OI significantly associated and correlated (p-value < 0.01) with a correlation coefficient r=0.727. Area under the Receiver Operating Characteristic (ROC) curve for OSI was 0.912 which indicates that OSI is an excellent test to assess the severity of HRF. Conclusion: That OSI can be used to diagnose and assess the severity of lung disease in neonates having HRF.

Determining New Anthropometric Markers for Screening Hypertension in the Caribbean Region

Introduction: The prevalence of hypertension in the Caribbean is high [26% in Saint (St.) Kitts]. It contributes to 51% of deaths secondary to ischemic heart disease and hence being a leading cause of death in the Caribbean region. Aim: To determine the association between Indices using height, waist, hip, thigh, arm, and wrist circumference (cm) with development of hypertension and to compare existing markers in test subjects and assessing their feasibility as predictive indicators for the development of hypertension. Materials and Methods: In the present cross-sectional study, a total of 635 subjects were involved in the study which included health centres and health camps in St. Kitts (West Indies). Study was conducted from December 2019 to November 2020. Height to Waist Ratio (HtWR), Arav Body Index (ABI), Waist to Thigh Ratio (WTR) and Wrist to Arm Ratio (WAR) was compared to common existing markers such as Waist to Height Ratio (WHtR), Waist to Hip Ratio (WHR) and Body Mass Index (BMI). Statistical analysis was done using using IBM Statistical Package for the Social Sciences (SPSS) version 23.0. Results: A total of 635 participants were included with most of the participants (n=540) between age group of 40 to 70 years, 35.4% (n=225) of participants were males and 64.6% (n=410) were females. In the present study, 47.92% (n=304) were non hypertensive and 52.1% (n=331) were hypertensive. In males, Area Under Receiver Operating Curve (AUROC) of HtWR (0.690) and Inverse ABI (0.632) was superior as compared to other anthropometric markers for predicting the development of hypertension and Waist to Thigh Ratio (WTR) (0.687) was superior in females. Among females recommended cut-off values for WTR is 1.6 and among males for HtWR and Inverse ABI were 2.3 and 2.84, respectively. Conclusion: Height to waist ratio and inverse ABI were more reliable markers in males for predicting the development of hypertension whereas, WTR being more reliable in females in population of St. Kitts. This will help at risk individuals to take preventive measures like lifestyle modification.

Trend of Dengue Virus Infection with Seasonal Variation at HIMS, Varanasi, Uttar Pradesh, India

Hari Om Trivedi, Asim Kumar Singh, Mukesh Kumar Singh

Introduction: Dengue is the most common mosquito borne arboviral infection in India, and it has become endemic in India with consistent episodes. Dengue is an acute febrile illness caused by Dengue Virus (DENV-1, DENV-2, DENV-3, DENV-4), an arthropod of family Flaviviridae, transmitted through the bite of female Aedes aegypti mosquitoes. Although, dengue is more prevalent in humans but also it may sometimes be seen in monkeys. The only animals to be affected when bitten by a mosquito, infected with dengue fever are monkeys other animals do not carry or spread dengue. Patient presents with hyperthermia, headache, severe joint and muscle pain, fatigue and skin rashes. Neurological manifestation in sever dengue results from multiorgan dysfunction due to cerebral edema, haemorrhage due to vascular leak, cerebral hypoperfusion, and electrolyte disturbances. Aim: To study serological markers with association of platelet count and trend of DENV infection with seasonal variation. Materials and Methods: The present retrospective study was conducted for a period of two years in Heritage Institute of Medical Sciences (HIMS), Varanasi, Uttar Pradesh, India, from January 2017 to December 2018. Blood samples were collected for 2140 suspected dengue patients. Out of the serologically positive cases, serological confirmation and platelet count was done for dengue infection. Data was presented as percentages. Results: Total 2140 suspected cases were admitted and out of them 199 (9.3%) were found to be seropositive for dengue infection. Non structural protein 1 (NS1) positive cases out of which total seropositive cases were reported to be 127 (63.81%) and 147 (73.86%) cases were positive for NS1 antigen either alone or along with antibody. Out of the total 199 positive cases thrombocytopenia was observed in 126 (63.31%) cases. Positive cases which were under 15 years of age were reported to be 92 (46.23%). Conclusion: The study concludes that NS1 antigen and IgM-IgG antibody consideration in the diagnosis of dengue infection builds the opportunity of early diagnosis so as to keep away the complications significantly.

Effect of Stress due to COVID-19 Pandemic on Time Management Skills among University Professionals

Introduction: Time management skills are necessary for professionals to accomplish their goals and succeed in their career. The recent changes in the educational environment that were caused by the Coronavirus Disease 2019 (COVID-19) could be stressful and might affect the structure of faculty work. Aim: To evaluate the stress level among university personnel during the COVID-19 outbreak and its relation to their time management skills. Materials and Methods: A cross-sectional web-based survey was conducted on a sample of 56 university professionals. Each participant filled a google form questionnaire consisting of Perceived Stress Scale (PSS) and Time Management Scale (TMS). The results were analysed using the Statistical Package for the Social Sciences (SPSS) version 20.0. Results: A total of 56 responses were received from full-time faculty and staff with 60% response rate. The overall PSS (mean±SD) was 15.29±7.13, indicating a low level of stress among the professionals. The mean TMS of 37.98±7.63 indicates an average time management skills. Significant negative correlation was found between PSS and TMS (r=-0.371, p=0.005). A positive correlation was found between TMS and years of experience (r=0.278, p=0.038). Both PSS and TMS had insignificant association with age, gender and years of experience. Conclusion: The stress level during the COVID-19 outbreak is relatively low among the University professionals. The TMS has a negative correlation with the PSS; however, it improves with the increase in years of job experience.

Current Practice of Branched Chain Amino Acids Administration in Patients with Liver Cirrhosis: A Physician Survey

Vaishali Bhargava, Kushal Sarda, Srirupa Das

Introduction: Protein Energy Malnutrition (PEM) is prevalent in about 65-90% of patients with liver disorders. PEM is usually associated with poor quality of life, high risk of complications, morbidity and mortality, and longer duration of hospital stays. PEM is also associated with decreased skeletal muscle mass and reduced levels of serum albumin and Branched Chain Amino Acids (BCAAs). Therefore, BCAAs are recommended as nutritional therapy in various liver disorders. Aim: To understand the current practice of BCAA use in patients with liver cirrhosis in India. Materials and Methods: A cross-sectional, questionnaire-based survey was conducted pan India involving 100 gastroenterologists over a period of four months from September 2019 to December 2019. Each physician participated in the survey after verbal consent. Ample time was given for completion of the questionnaires. Results: Out of 83 participating physicians, nearly 3/4^th considered liver cirrhosis as the most common Gastrointestinal (GI) disorder where nutrition is important in patient management. Malnutrition was commonly observed in patients with cirrhosis by nearly over 80% physicians and was most common in patients with decompensated cirrhosis. Weight loss and loss of appetite can be early signs of sarcopenia as these were common profiles observed in patients with malnutrition. Total 51.8% physicians considered BCAA administration in all Child-Pugh class patients. The practice of BCAA treatment with regards to its dose and duration highly varied for patients with cirrhosis, Hepatic Encephalopathy (HE), and Liver Transplantation (LT). Proteins from vegetarian source (50.6%) and BCAA supplementation (96.4%) were considered as major treatments for HE patients. Majority of the physicians reported that BCAA administration improved quality of life (52.4%), reduced HE episodes (49.4%), improved muscle mass (50%), and reduced hospitalisation rates (49.4%) in 20-40% of their patients. In all, 92.8% of physicians suggested that early administration of oral BCAA can prolong the waiting period for LT. Conclusion: Branched Chain Amino Acids (BCAA) is an integral part of nutritional management in patients with liver cirrhosis in India. Further studies are required to guide the decision on dose and duration of BCAA treatment in the management of cirrhosis.

Epidural Ropivacaine and Dexmedetomidine with that of Epidural Ropivacaine and Fentanyl for Postoperative Analgesia in Lumbar Spine Surgeries- A Randomised Double-Blinded Study

G Prashanth, Sulochana Dash, Sudeep Mohapatra, Nupur Moda

Introduction: Epidural with opioids as adjuvants are the most common agents of choice for postoperative analgesia in spine surgeries which promote early ambulation, increased patient satisfaction and improved outcome. Recently, epidural administration of alpha-2 (α₂) agonists in combination with local anaesthetics in low doses offers new dimensions in the management of postoperative pain. Aim: To compare the analgesic efficacy, sedation score and haemodynamic stability of Epidural Ropivacaine and Fentanyl (RF) with that of Ropivacaine and Dexmedetomidine (RD) in the postoperative period in lumbar spine surgeries. Materials and Methods: This was a randomised, double-blinded study conducted on 60 patients at IMS and SUM Hospital, Bhubaneswar, Khordha, India. Haemodynamic parameters, Visual Analogue Score (VAS), sedation score, time to 1^st dose of rescue analgesics requirement and complications were observed. The study consisted of group RF that received ropivacaine and fentanyl and group RD that received ropivacaine and dexmedetomidine, with 30 patients in each group. Continuous variables were analysed with the unpaired t-test and categorical variables were analysed with Chi-square test and Fisher-exact test. Statistical significance was taken as p<0.05 Results: The mean age of participants in group RD was 39.73±7.192 years and in group RF was 40.67±7.434 years (p-value 0.872). Heart rate was in lower range in RD group throughout the study and was statistically significant with a p-value <0.05. VAS score was lower, sedation score was higher and time to 1^stdose of rescue analgesia were longer in RD group compared to group RF (p<0.005). Complications like hypotension (33.3%), bradycardia (20%) were more common in group RD while nausea, vomiting (16.67%) and pruritis (10%) were noted in group RF. Conclusion: Dexmedetomidine seems to be a better neuraxial adjuvant with good postoperative analgesic efficacy, better patient comfort and haemodynamic stability compared with that of fentanyl.

Anneroth’s Histopathological Grading System in Non Metastatic and Metastatic Oral Squamous Cell Carcinoma- A Pilot Study

Introduction: Prognostic evaluation of Oral Squamous Cell Carcinoma (OSCC) is mainly based on [Tumour (T), Nodes (N), and Metastases (M)] staging. To predict the biological and clinical behaviour of a tumour, histological grading systems plays an important role. Modified Anneroth’s grading system includes three parameters each for histologic features and tumour-host relationship. Aim: To compare and analyse the histological features of tumour center and periphery of non metastatic and metastatic OSCC according to Anneroth’s histopathological classification and its association with regional lymph node metastasis. Materials and Methods: A retrospective pilot study was conducted on 20 histopathologically proven cases of OSCC collected from the Department of Oral Pathology and Oral Microbiology, Vinayaka Mission’s Sankarachariyar Dental College, Salem, Tamil Nadu, India. The OSCC cases those reported from March 2018 to June 2020 were included in the study. Among 20 cases, 10 non metastatic and 10 metastatic cases, were retrieved from archival blocks. Scores for the morphology and tumour-host relationship of non metastatic and metastatic tumours was assessed and graded by Anneroth’s grading system; then compared with the Broder's histopathological grading system. The histopathological scoring of lymph node was based on TNM staging. Chi-square test and Spearman’s correlation coefficient analysis was done. Results: Anneroth’s grading system showed a significant difference in pattern of invasion in tumour periphery of metastatic OSCC (p-value=0.01). Compared to Broder’s, Anneroth’s classification showed a highly significant corelation with lymph node metastasis (p-value=0.001). Conclusion: Hence, Anneroth’s histopathological grading system can be used to predict the biological changes in metastatic and non metastatic OSCC and its increased possibility of regional lymph node metastasis.

A Morphometric Analysis of Intra-articular Disc of Temporomandibular Joints in Cadavers

Introduction: Temporomandibular Joint (TMJ) has been a controversial topic in Oral and Maxillofacial Surgery speciality especially regarding temporomandibular joint disorders and internal derangement of articular disc. The aetiology behind it has been related to the anatomic variations of the disc and its impact on the functioning of the articular disc. To understand such anatomic variation, the study has been conducted that will help future maxillofacial surgeon’s in designing accurate prosthetic articular disc that will improve the overall mechanics of the functioning of the prosthetic disc. Aim: To analyse the morphometric variations of the intra-articular disc in terms of circumference of the disc, perforations and their thickness within the disc in cadavers. Materials and Methods: The present observational study was carried out on cadavers in the Department of Anatomy. SBKS Medical College and Research Centre, Sumandeep Vidyapeeth University, Gujarat, India. The study was done from January 2017 to October 2018. Temporomandibular joints were dissected bilaterally from 10 human cadavers, i.e., 20 articular discs. The disc was removed and was measured with the help of thread, vernier callipers and standardised metallic scale and the circumference and thickness in the disc were evaluated. Descriptive statistical test was used and Chi-square test was applied. Results: Mean thickness of disc, both in males as well as females ranged from 1.4-2.0 mm in the Posterio-Medial (PM) and Posterio-Lateral (PL) region, while in Anterio-Medial (AM) and Anterio-Lateral (AL) region it ranged from 1.6-1.8 mm. Maximum length of disc ranged from 12-13 mm in anterio-posterio dimension while in Medio-Lateral (ML) it was 22-23 mm. Conclusion: The study gives an indepth knowledge about the various morphometric variations of articular disc and also shows its impact on the functioning of the disc. The study also directs maxillofacial surgeons to design prosthetic articular disc with greater accuracy and anatomical knowledge so that the procedures like surgical replacement of the disc can be carried out with greater potency and efficacy for the betterment of the patient.

Study of Trauma Profile and its Outcomes at a Tertiary Care Centre: Cohort Study of 1000 Cases

Introduction: Trauma has been the leading cause of mortality and morbidity. However, there are changes in pattern of trauma and their outcomes with time. Aim: To study the mode and nature of injury and mortality associated with trauma of head, chest and abdomen. Materials and Methods: A prospective cohort study was conducted on 1000 individuals that presented to emergency surgery ward from 2014 to 2019. Patients presented to emergency surgery of Government Medical College, Amritsar, Punjab, India were observed for various characteristics i.e., age group, mode of injury, site of injury, outcomes and management. Results: The mean age of patients was 33.91±16.29 years with significant male predominance (n=794, 79.4%) (p-value 0.00001). Road Traffic Injuries (RTIs) were the most common mode of trauma affecting 490 patients (49%). Head injury was the most common of all injuries (n=834). Overall mortality was 3.6% (n=36). Mortality was higher in males (p-value 0.00933) and mortality rate of 25% was seen in age group of 61-70 years. Conclusion: RTIs followed by assaults are the most common cause of trauma and it significantly affects young male population. However, mortality rate increases with increase in age group with higher rates in older age groups.

Impact of Enforcing Lockdown in Spread of COVID-19 Infection in Central India: An Observational Study

Introduction: The lockdown was implemented nationally for six weeks, followed by another two weeks of graded lockdown in districts in India as a means to prevent spread of infection. During this period, there was restriction of movement of residents except for those engaged in providing essential services. Aim: To find out socio-demographic profile of patients along with the impact of lockdown and spread of Coronavirus-19 (COVID-19) infection post-lockdown. Materials and Methods: A prospective observational study conducted in Bairagarh, a suburban area of Bhopal. The study was conducted for three months i.e. from 9^th April 2020 to 9^th July 2020. A contact tracing questionnaire was used for data collection. The data was collected by actual visiting the patient’s address. The data collected was compiled and analysed using Microsoft Excel 2020. The patients were instructed to inform the data collector of any post-viral symptoms after 15 days of diagnosis to find out any post-viral complaints. Percentages and proportions were derived using Epi info-7.0. Results: During the study period of three months, in total 90 patients were interviewed. Almost 85.5% cases were found post-lockdown. Most common age group to be involved was 31-45 years. Males were more commonly infected. Only 14.44% patients who worked during lockdown were infected. Almost 26.6% patients were involved in cloth merchandise business which was closed during lockdown and had a sudden upsurge in business during unlock. In total 47.7% patients were asymptomatic when tested. Relative Risk (RR) of acquiring infection post-lockdown was 1.13. Doubling rate of infection among study population during lockdown was found to be 14.05 days compared to 5.35 days post-lockdown. Almost 80% patients did not have any post-viral symptoms. The most common symptom seen was nose block. Conclusion: The lockdown was found to be effective strategy in controlling spread of COVID-19 infection as post-lockdown there was sudden increase in number positive cases.

Comparison of Central Corneal Thickness and Endothelial Cell Density in Patients with Various Types of Glaucoma and Patients without Glaucoma: A Case-control Study

Khushboo Chawla, Shailesh Gadaginamath, Ashish Kumar Shah

Introduction: Corneal affection in glaucoma patients is very high due to various risk factors that may lead to unforeseen and unplanned deleterious effects on the cornea leading to vision loss. Accurate intraocular pressure determination requires corneal thickness measurement and uncontrolled intraocular pressures, use of long term medication, intra ocular surgeries including cataract and glaucoma shunt surgeries may cause significant endothelial loss. Therefore, adequate planning and management and follow-up in these patients is required weighing all the long term consequences and emphasis the need for implementing adequate precautions. Aim: To evaluate and compare the Central Corneal Thickness (CCT) and corneal Endothelial Cell Density (ECD) in patients with glaucoma and without glaucoma by specular microscopy. Materials and Methods: A case-control study conducted in a Shekar Eye Hospital, Bengaluru, Karnataka, India, was conducted from August 2016 till April 2018 on a total 182 eyes from 182 patients were evaluated comprising of 91 cases and 91 controls. All participants underwent a detailed ophthalmological examination including slit lamp biomicroscopy, Intraocular Pressure (IOP) measurement, and CCT and ECD measurement by Tomey EM 3000 noncontact specular microscopy. The Statistical analysis was completes using Statistical Package For the Social Sciences (SPSS) 18.0 and R environment version 3.2.2 software’s. Results: The CCT of the glaucoma patients and the controls showed no significant difference (p-value=0.172). The CCT was comparatively thicker in Ocular Hypertension (OHTN) patients and thinner in Normal Tension Glaucoma (NTG) however statistical significance was not established. The mean ECD of controls was 2509.05±298.48 (cells/mm³) and that of cases was 2465.68±392.91 (cells/mm³) (p-value=0.404). The difference in the ECD amongst the glaucoma subgroups was not statistically significant (p-value=0.588). However, a lower ECD were seen in Pseudoexfoliation Glaucoma (PXG) and Primary Angle Closure Glaucoma (PACG) subgroups. Conclusion: No significant difference was found in CCT and endothelial cell in cornea of patients with and without glaucoma. Normal Tension Glaucoma (NTG) patients have comparatively thinner corneas and OHTN patients had thicker corneas. There was no significant correlation established between ECD of Normal corneal vs. Glaucoma and its subgroups.

Incidence, Clinical Signs and Co-morbidities of Feeding Intolerance among Preterm Infants Aged 28-34 Weeks of Gestation in a Tertiary Care Hospital of Western Nepal- A Prospective Observational Study

Introduction: Feeding intolerance is common among the preterm neonates and is associated with different co-morbidities like respiratory depression, respiratory distress syndrome, apnea, hyperbilirubinaemia, and hypoxic ischaemic encephalopathy. Aim: To find the incidence of feeding intolerance in preterm neonates from 28-34 weeks of gestation along with the clinical signs and co-morbidities associated with feeding intolerance. Materials and Methods: A prospective observational hospital based study was conducted in Neonatal Intensive Care Unit (NICU) and postnatal ward of Universal College of Medical Sciences, a tertiary care hospital situated in western Nepal for 12 months (June 2018 to May 2019). All admitted preterm neonates between 28-34 weeks of gestation were included in the study and were followed-up for any neonatal morbidities along with feeding intolerance. Feeding intolerance was defined when the newborn had vomiting and/or abdominal distension and/or increased gastric residual volume with normal disruption of feeding process. Babies with feeding intolerance were subjected to final analysis for clinical signs and co-morbidities. Results: Out of 490 admitted preterm babies (28-34 weeks), 54 (11.02%) had feeding intolerance with 33 (61.1%) babies in the very low birth weight group. The mean birth weights of the total enrolled babies (n=490) and feed intolerant (n=54) babies were 1550 gm and 1418 gm, respectively. Different co-morbidities associated with feeding intolerance were respiratory distress (25.9%), respiratory distress syndrome (22.2%), jaundice (16.7%), apnea (5.6%) and necrotising enterocolitis (3.7%). Among the total 37 preterm deaths, four babies were in the feeding intolerance group. Majority of all feed intolerant babies had vomiting 49 (90.7%) followed by gastric residue (57.4%), abdominal distension (55.6%), and reduced or absent bowel sounds (7.4%), respectively. The incidence of feeding intolerance was increased in babies fed with formula feed (p=0.46) and when feeding was started <24 hours (p=0.22) but the results were statistically insignificant. Conclusion: The incidence of feeding intolerance was 11.02% in the preterm neonates (28-34 weeks) with high proportion in very low birth weight babies. Vomiting, gastric residue and abdominal distension were three important signs of feeding intolerance in newborns.

Outcome of Pregnancy in COVID-19 Positive Pregnant Women: A Retrospective Observational Study

Shreetoma Datta, Sonali Jitendra Ingole, Jitendra R Ingole

Introduction: Pregnant women have also been affected globally due to the Coronavirus Disease 2019 (COVID-19) pandemic. As foeto-maternal unit is involved, hence it is important to know possible manifestations and outcome of COVID-19 affected pregnant women. The findings of the study can be a guide for betterment of COVID-19 affected antenatal patients care. Aim: To find the outcome of pregnancies affected by the COVID-19 infection of the Antenatal care (ANC) patients who presented to the tertiary care hospital in terms of laboratory parameters, treatment of the infection, mode of delivery, adverse outcome if and presence of documented infection in newborn. Materials and Methods: This was a retrospective observational study done from May 2020 to December 2020 conducted on the admitted pregnant women to the tertiary care hospital who tested positive for the COVID-19 virus were included in the study. Data collection (symptoms, reports and treatment) from these pregnant COVID-19 positive patients was done. Patients who were discharged before delivery were contacted telephonically and were asked the relevant information. Results: During the study period, total 1150 COVID-19 positive patients were admitted to the hospital. Amongst these, there were 441 female patients including pregnant and non pregnant women. Amongst the 441 COVID-19 infected female patients, 20 were pregnant. Majority of the patients were in the age group of 21-30 years. An 85% of women were in their third trimester at the time of admission. Pre-eclampsia and Hypothyroidism were the major co-morbidities observed. Six maternal Intensive Care Unit (ICU) admissions were noted. Breathlessness was the main symptom seen followed by sore throat, fever and cough. Previous Lower Segment Caesarean Section (LSCS) and foetal distress were cited as the main reasons for undergoing LSCS. No vertical transmission of virus was seen in the study. There were two neonatal ICU admission. Low Molecular Weight Heparin (LMWH) was administered to 33% patients. Fifty percent of the patients were prescribed steroids. Conclusion: Advanced gestational age, pre-eclampsia, hypothyroidism, elevated levels of d-dimer, Neutrophil/Lymphocyte (NL) ratio and C-reactive protein were seen as the main findings. Mother to child transmission was not observed in this study.

Comparison of Growth in Children of 6 to 59 Months of Age According to Birth Order: Insights from the National Family Health Survey-4

Introduction: Undernutrition continues to be a major public health problem throughout the world. Higher birth order of the child contributes to higher chance of being undernutrition. But, the relationship between birth order and undernutrition has not been fully studied and understood, especially in India where the fertility rate was high. Aim: To understand the prevalence and determinants of undernutrition using National Family Health Survey-4 (NFHS-4) India. Materials and Methods: A national cross-sectional survey was conducted during January 2015 to December 2016. This study used information from a total weighted sample of 128859 children from India NFHS-4. Univariate and multivariate binary logistic regression were used to investigate the association of undernutrition with birth order, other child, maternal and socio-economic factors. Three models were constructed for the study, model 1 as univariate, model 2 adjusting with birth order and socio-economic predictors and model 3 adjusting with all the predictors included in the study. Results: Of the 128859 children, median Inter Quartile Range (IQR) age was 26 (16-41) months with female/male ratio was 1:1.2. The prevalence of stunting, underweight and wasting was 37.93% (95% Confidence Interval (CI) 37.67-38.20), 34.02% (95% CI 33.76-34.28) and 20.70% (95% CI 20.48-20.92), respectively. Model-1, 2 and 3 showed that the child's higher birth order was found to have higher odds of being stunted and underweight compared with first born children. Children with lower wealth quintiles, male, vaginal delivery had higher odds of being stunted, wasted and underweight in the model-3 adjusted analysis. Conclusion: This study indicates that higher birth order was a significant predictor of a child being stunted and underweight, as it is significant in all three models. However, further longitudinal studies are required to establish a cause-effect relationship between birth order and undernutrition and future interventions to prevent undernutrition should consider birth order as an important factor.

A Comparative Analysis of Force Deflection Property of Nickel-Titanium Wires of Four Manufacturers using Five Point Bending Test: An In-vitro Study

Georgy John, Vaishali Vadgaonkar, Parag Gangurde

Introduction: Over the last century, material science has made rapid progress. In orthodontics, not only the materials improved, but also the philosophies have changed. Orthodontic wires, which generate biomechanical forces through brackets for tooth movement, are central to the practice of this profession. Aim: To measure the force deflection properties of Nickel-Titanium (NiTi) wires of four manufacturers, used during orthodontic treatment. Materials and Methods: In this in-vitro study, 480 NiTi wires from four different manufacturers [American Orthodontics (AO), 3M-Unitek (3M), Rabbit Force Orthodontics (RO) and Modern Orthodontics (MO)], of various cross-sections was obtained. Samples of each wire were obtained by cutting the straightest distal portion of an arch wire, thus an approximate length of 5.5 cms was recovered. These wires were subjected to a five point bending test. Five lower anterior stainless steel brackets of tooth number 31, 32, 41, 42 (MBT 0.022” Libral traders Centrino brackets) were fixed with the face of the bracket facing upwards on the acrylic block. Each NiTi wire was placed in the slots of orthodontic brackets and secured with stainless steel ligature wires. These wires were subjected to artificial saliva (Wet Mouth) for 30 days at 37°C. This temperature was regulated by using an incubator. The main assessment criterion was the force deflection property of the wire material. Force deflection was measured using a graph paper where initially the wire was placed and plotted on the graph paper. After the deflection of the wire, it was again placed on the same graph paper such that wire ends coincided and the force deflection at the highest point was measured in millimetres using a digital Vernier Caliper (Mitutoyu). The Design of Experiments (DOE) model was used for analysis and a three-way Analysis of Variance (ANOVA) with wire shape as covariate was used for analysing the variability. Results: A 0.014” NiTi wire showed more mean deflection when compared to 0.016” NiTi wire. When a comparison between 0.016”×0.022” and 0.017”×0.025” NiTi wires was done, mean deflection was almost the same. When round and rectangular wires were compared it showed more mean deflection in round wires. When AO was compared with other three manufacturers. A significant difference (p-value <0.0001) was seen in the mean deflection values of MO and RO. When 3M was compared with the other three manufacturers a significant difference (p-value <0.0001) was seen in the mean deflection values of MO and RO. Three-way ANOVA test with wire shape as co-variate showed a significant amount of difference (p<0.0001) for AO, 3M wires with their counterparts. Conclusion: Round NiTi wires showed more force deflection as compared to rectangular NiTi wires. AO and 3M wires were superior as compared to RO and MO wires. Superelastic wires showed more deflection as compared to conventional and heat-activated NiTi. This can be attributed to the property of the wire. Stiffer the wire, less deflection was seen. Cost of the wire also played a role. Cheaper wires were not able to match the quality and standards of their counterparts.

Polysomnographic Study to Evaluate Obstructive Sleep Apnoea Syndrome in Obese and Non Obese Adolescents

HP Arun Kumar, K Pushpa

Introduction: Obesity in adolescents is an emerging problem in developing countries like India, especially among higher socioeconomic status group. Obesity is the most important reversible risk factor for Obstructive Sleep Apnoea Syndrome (OSAS) in adolescents. Adolescent obesity with OSAS if not treated, can result in serious morbidity in cognitive, cardiovascular, somatic growth, development and metabolic disorders in future. Aim: To compare the sleep pattern between the obese and non obese adolescents and to evaluate OSAS. Materials and Methods: This was an observational study carried out at Life Style Laboratory, Department of Physiology, Bangalore Medical College and Research Institute, Karnataka, India. The study involved 30 obese and 30 non obese male adolescents, who were subjected to overnight Polysomnography (PSG) in the sleep laboratory. According to Kale’s criteria, epochs were manually scored which were compiled and statistically analysed for parameters like Sleep Latency (SL), Actual Sleep Time (AST), wake after sleep onset, percentage of Non Rapid Eye Movement (NREM), Rapid Eye Movement (REM) sleep stages, Sleep Efficiency (SE). The number of apnoeas and hypopnoeas were also noted to calculate Apnoea Hypopnoea Index (AHI). These parameters were compared for statistical significance using student t-test. Adolescents with AHI ≥1 were diagnosed with OSAS. Results: Mean age of obese adolescents was 17.7±0.97 years and their mean BMI was 28±0.73 kg/m². OSAS was found in 22 out of 30 obese (73%) and 14 out of 30 (46%) non obese adolescents. It was found that apnoeas (3±4.80 vs 1±0.89), hypopnoeas (27.36±26.5 vs 5.46±2.97) and AHI (4.17±3.90 vs 0.89±0.43) were significantly more among obese adolescents when compared with non obese adolescents respectively. PSG parameters like SL, Wake After Sleep Onset (WASO) were prolonged and AST, SE were reduced significantly in obese adolescents. Conclusion: Adolescents with obesity had greater occurrence of OSAS, along with altered sleep architecture in them.

Oral Health Awareness and Practices among Pregnant Women Receiving Antenatal Care in a Low Resource Setting: A Cross-sectional Study of Antenatal Attendees in Enugu, Southeastern Nigeria

Introduction: Poor oral health status in pregnant women is known to be associated with poor outcomes in pregnancies. Despite this, the oral health status of pregnant women has been grossly overlooked during antenatal period. Aim: To determine the awareness and practices of oral health among pregnant women in Enugu, Southeastern Nigeria. Materials and Methods: This was a cross-sectional questionnaire based study of 413 women who attended the antenatal clinic of University of Nigeria Teaching Hospital (UNTH), Ituku/Ozalla from January 2018 to May 2018. An interviewer administered semi-structured questionnaire which was pretested before the commencement of the study was used. The information obtained was analysed using Statistical Package for the Social Sciences (SPSS) version 22.0. A p-value of <0.05 was considered statistically significant. Results: A total of 350 (84.75%) of the respondents used toothbrush and toothpaste for oral cleaning, 229 (55.45%) brushed at least twice a day while 258 (62.5%) changed their brushes every three months. Only 161 (39%) of the respondents knew that pregnancy can affect oral health while 101 (24.5%) of the respondents knew that poor oral health in pregnancy could have adverse effects on the unborn child; of whom only 30 (29.70%) got the information from their Obstetricians. Conclusion: There were knowledge gaps in the oral health of pregnant women in Enugu southeastern Nigeria. It is therefore important to provide oral health education for pregnant women during antenatal period in order to improve the health of the mother and her baby.

Clinico-epidemiological and Outcome Analysis of Anogenital Injuries in Children: Retrospective Study from a Tertiary Care Centre, Central India

Introduction: Paediatric perineal trauma or Anogenital Injury (AGI) in the paediatric age group remains lesser reported in under-developed areas or rural areas of India. Most of these injuries remain under reported to tertiary care centres because of a social stigma or poor access to a health facility. Aim: To present the clinico-epidemiological parameters of AGI in children and to assess the outcome of staged and definitive management in these children, comparing the results with other similar studies. Materials and Methods: This was a retrospective study on data of 11 cases (age range 1-14 years, seven cases were boys and 4 cases were girls) of paediatric anogenital injuries, admitted at the tertiary care centre from 1^st July 2018 to 30^th June 2020 were analysed. Data of all the patients, demographic details, relevant clinical history such as time of presentation, mode of injury and type of management, outcomes and complications was collected and studied. All the collected data was analysed by calculating mean±SD, frequency (n) and percentages (%). Results: Road traffic accident was the most common cause of AGI (n=5, 45.5%), followed by sexual assault (n=3, 27.3%). Wound infection in late presenters (n=5, 45.5%) was the most common complication affecting the outcome. Children with a primary diversion of the faecal stream or diversion colostomy (n=5, 45.5%) as an associated procedure had a better outcome. Primary repair without diversion (n=3, 27.3%) was noticed to have a high incidence of wound infection and anovaginal scaring. Conclusion: A high incidence of poor wound healing related to late presentation and malnutrition noted among these AGI cases belonging to rural or semi-urban settings. Management of these injuries, therefore, needs to be individualised on case-to-case basis. The diversion stoma formation seems to be considered in all high grade anogenital injuries and selected lower grade injuries with evidence of secondary infection or poor healing of the primary repair.

Cerebroplacental Ratio as a Predictor of Fetal Growth Restriction and Perinatal Outcome in Women with Hypertensive Disorder in Pregnancy: A Prospective Cohort Study

Upma Saxena, Alka

Introduction: Hypertensive Disorders in Pregnancy (HDP), is a common complication of pregnancy leading to majority of adverse perinatal outcome. The timely diagnosis of fetal compromise, before irreversible damage, is possible by doing Cerebroplacental Ratio (CPR), on doppler ultrasonography. CPR is calculated as ratio of Pulsatility Index (PI) of Middle cerebral Artery and Umblical Artery (UA). It reflects both the circulatory insufficiency in UA along with adaptive changes in Middle cerebral Artery (MCA). Aim: To evaluate role of Cerebroplacental Ratio as predictor of Fetal Growth Restriction and perinatal outcome in singleton pregnancy with HDP at 28-41 weeks of gestation. Materials and Methods: A prospective observational cohort study was carried out in the Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. The study included 150 women with singleton pregnancy, HDP and 28-41 weeks of gestation. Doppler ultrasound was performed and CPR calculated as ratio of MCA PI and UA PI, using ultrasound study performed within two weeks of delivery. All women were followed-up till delivery and perinatal outcome i.e., birth weight, preterm birth, cesarean for fetal distress, Meconium Stained Liquor (MSL) , APGAR at 5 minutes, still birth, Neonatal Intensive Care Unit (NICU) admission and early neonatal death, were recorded. The data entry was done in the Microsoft excel spreadsheet and the final analysis was done with the use of Statistical Package for Social Sciences (SPSS) software version 21.0. Results: Out of 150 women, 20% (30) had abnormal CPR. Abnormal CPR had significant association with Low Birth Weight (LBW) (p-value=0.0001), preterm delivery (p-value=0.0001), fetal distress (p-value=0.0001), caesarean for fetal distress (p-value=0.0001), 5-minute APGAR score <7 (p-value=0.0001), NICU admission (p-value=0.0001), Meconium Stained Liquor (MSL) (p-value=0.0001) and neonatal death (p-value=0.025). CPR had 100% sensitivity and 100% Negative Predictive Value (NPV) for predicting adverse perinatal outcome with diagnostic accuracy of 47.33%. Conclusion: The CPR is an independent predictor of Fetal Growth Restriction (FGR) in women with HDP. It can also independently predict perinatal outcome in women with HDP with or without FGR. Abnormal CPR had 100% sensitivity for identifying women with high risk of adverse perinatal outcomes, whereas normal CPR, with NPV of 100%, almost excludes it.

Role of High Dose Calcium Supplementation in Pre-eclampsia: A Pilot Study

Introduction: Pre-eclampsia is a serious condition complicating pregnancy. It is a multisystem disorder responsible for significant maternal and perinatal morbidity and mortality. Thus, prevention of pre-eclampsia may improve both maternal and foetal outcomes. It has been found that reduced serum calcium level may cause high blood pressure by stimulating parathyroid hormone, rennin release and also by producing vasoconstriction in smooth muscle. Aim: To evaluate the role of high dose (2000 mg/day) calcium compared to normal dose (1000 mg/day) calcium in preventing the incidence and severity of pre-eclampsia. Materials and Methods: This was a pilot study and this prospective interventional study conducted from January 2017 to June 2018 in Kolkata, India with 200 primigravidas. About 100 women were given 1000 mg calcium and 100 women were given 2000 mg (high dose) calcium in a day. Incidence of gestational hypertension, pre-eclampsia, severe pre-eclampsia, neonatal outcome etc were assessed in both the groups. Normally distributed data were compared with Student’s unpaired t-test. p-value was considered statistically significant when ≤0.05. Results: There was a significant reduction in the incidence of pre-eclampsia (p-value=0.03) among the cases receiving high dose calcium, without any statistically significant reduction in severity of it. There was no reduction in incidence of gestational hypertension with high dose calcium. In neonatal outcome, there was better APGAR score in the high dose group compared to control group (16% in cases and 7% in control group, p-value=0.04). Conclusion: This pilot study paves the way for larger studies to study the role of high dose of calcium which may have a significant role in reduction of pre-eclampsia.

Correlation of Diffusion-Weighted Magnetic Resonance Imaging Determined Infarct Volume with Clinically Assessed National Institutes of Health Stroke Scale in Patients of Acute Stroke: A Cross-sectional Study

Bhavya Kataria, Shibani Mehra

Introduction: Infarct volume is an essential factor in predicting patient prognosis. National Institutes of Health Stroke Scale (NIHS) allows consistent reporting of neurological deficits in stroke patients. Limited studies have been done in the Indian population correlating the volume of infarct and the NIHS Scale. Aim: To correlate the Diffusion-Weighted Magnetic Resonance Imaging (DW-MRI) assessed infarct volume with the clinically assessed NIHS to prognosticate clinical outcomes in patients of acute stroke. Materials and Methods: This was a cross-sectional study comprising 36 patients of acute stroke with a study duration from November 2017 to April 2019. Diffusion-Weighted MRI was obtained on Siemens Magnetom 3 Tesla, and diffusion restriction on b=1000 image was measured with a Region of Interest (ROI) tool using manual contouring in each slice. Assessment of the neurological deficit was done by NIHS scale at the time of admission and 7 days post admission for each patient. Correlation of the infarct volume with NIHS Scale was done with p<0.05 considered statistically significant. Receiver Operating Characteristic Curve (ROC) was used to predict cut-off of the volume of infarct and NIHS Scale to predict adverse patient outcome. Results: Present study consisted of 36 patients of acute stroke with a mean age of 52.05±18.53 years. The minimum age of the patient was one year, and the maximum age was 78 years. There was a statistically significant correlation between the volume of infarct and NIHS Scale at time of admission admission (p=0.001; r=0.807) and the NIHS Scale at one week (p=0.002; r=0.602).The Area Under the Curve (AUC) for a cut-off of 115 cc of the volume of infarct in predicting adverse patient outcomes was 0.931, whereas that for the NIHS scale of 20 was 0.998. Conclusion: Volume of infarct of 115 cc and NIHS Scale of 20 are excellent as prognostic tools in predicting patient outcome and have comparable efficacy.

Predictive Value of Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio in Immediate Outcomes of ST-elevation Myocardial Infarction: A Cross-sectional Study

Sneha Barkur Sadashiva, KS Chenthil

Introduction: There have been various inflammatory markers implicated in the pathogenesis of Acute Coronary Syndromes (ACS). However, the role of the Neutrophil Lymphocyte Ratio (NLR) and Platelet Lymphocyte Ratio (PLR) as prognostic markers in ST-elevation Myocardial Infarction (STEMI) remains poorly researched. Aim: To determine the prognostic value of NLR and PLR to predict the immediate outcomes in patients with acute STEMI, and if any association exists between NLR/PLR and Thrombolysis in Myocardial Infarction (TIMI) risk score. Materials and Methods: This was a cross-sectional study conducted at a tertiary care centre, Puducherry, India, where 190 patients who presented to casualty with STEMI were enrolled. The patient co-morbidities, personal and family history were obtained. The routine laboratory parameters including platelets, lymphocytes, neutrophils and their corresponding ratios were calculated. Patients were grouped into low and high NLR/PLR groups and were assessed for occurrence of in-hospital mortality or Major Adverse Cardiovascular Events (MACE). Analysis was made to see if there is an association between NLR/PLR and MACE. Chi-square test and one-way ANOVA test was used for statistical significance. Results: Among 190 subjects, 157 male and 33 female with mean age of 55.72±11.24 years were included. A total of 8.94% patients 8.94% had MACE. NLR was positively associated with MACE (p-value=0.0006), whereas PLR was not associated with MACE. Patients with high NLR had 1.45 times higher odds of having MACE. NLR was significantly associated with TIMI risk score. Both NLR (F ratio=6.341) and PLR (F ratio=4.600) showed significant association with Killip classification, however NLR showed higher association (p-value <0.001). Conclusion: NLR can be used as a powerful prognostic marker for predicting immediate MACE and death in STEMI patients. In addition, NLR showed positive correlation with Killip classification and TIMI risk score.

Correlation of Nutrition with Parental Literacy Status among School Going Adolescent Children in Telangana: A Cross-sectional Study

Introduction: National Family Health Survey-4 reports that 44.8% of boys and 41.9% of girls aged 15-19 are underweight. Globally, there is a lacuna of data on early adolescent children (10-14 years). Aim: To estimate the prevalence of malnutrition among school going adolescent children in Medchal, Telangana and also to assess the correlation between nutritional status of adolescent children and their parents’ literacy level and socio-economic class. Materials and Methods: A cross-sectional study was carried out in 1000 adolescent children aged between 10-16 years. Pilot study was conducted on 110 students to test the questionnaire comprising basic data and socio-demographic characteristics before starting the study. Weight and height were measured. Body Mass Index (BMI) was calculated and based on BMI, children were classified into undernutrition, normal, overweight and obese. Parental literacy was ascertained. Parents were divided into five categories of socio-economic class according to BG Prasad Classification. Primary endpoint measured was prevalence of malnutrition among adolescent children and secondary endpoint measured was correlation of mother’s and father’s literacy status with nutritional status which was ascertained using spearman’s rank correlation test. Data was analysed using Statistical Package for the Social Sciences (SPSS) version 21.0. Results: Prevalence of undernutrition and overnutrition (overweight and obesity) was 48.5% and 4.6% respectively. There was statistically significant (p=0.046) difference between boys and girls with respect to prevalence of undernutrition and overnutrition. Majority of undernourished boys (49.1%) and girls (46.8%) were 13-14 years old. Spearman’s rank coefficient (rho-ρ) showed strong positive correlation between nutrition and socio-economic class (ρ:0.706) with moderate and weak correlation seen for mothers’ education (ρ:0.425) and fathers’ educational status (ρ:0.333), respectively. Conclusion: Undernutrition remains to be a common problem among early adolescents. Socio-economic class and literacy level of parents play significant role in nutrition of adolescents. At school level, adolescent children and their teachers need to be empowered to understand better about the necessity and impact of maintaining a normal nutritional status on their future health.

Aerodontalgia among Airline Pilots of India: A Cross-sectional Survey

Sabreen Gujral, Shruti Chopra, Shveta Sood, Naresh Sharma, Akshara Singh

Introduction: Barometric pressure-induced dental pain is a clinical entity elicited by atmospheric changes in pressure. Barodontalgia (also known as aerodontalgia) among pilots is of marked interest as it can be a potential flight safety hazard and compromise the personnel’s operational capability and performance. Due to its overlapping signs and symptoms, it may also remain unnoticed and represent itself during a pressure change which may be during ascend or descend of flight. Aim: To assess presence of barodontalgia and awareness of the phenomenon among commercial pilots based in India. Materials and Methods: This cross-sectional study was conducted from June to August 2020 using self-reported questionnaire submitted via Google forms (Alphabet, Mountain view, CA, USA) among 410 pilots based in India. It consisted of questions inquiring about the occurrence, localisation, intensity and recurrence of in-flight dental pain. Inferential statistics were performed using Chi-square test, One way analysis of variance (ANOVA) and Independent t-test. The level of statistical significance was set at 0.05. Results: A total of 370 pilots responded to the questionnaire with a response rate of 90.24%. The incidence was reported among 10.54% (n=39) pilots although 42.7% (n=158) lacked awareness regarding the same. Only a single case of recurrence of pain was reported while none reported any risk to flight safety or accident, secondary to barodontalgia. Conclusion: The incidence level of barodontalgia among commercial pilots in India is low. However, the lack of awareness is still an unsettling risk and was not found to be of significant difference when compared on the basis of gender and work experience.

Electromyography Scanning in the Diagnosis of Tension Headache

Lata Sachan, Parth Sarthi, Namita Pal

Introduction: Several attempts have been made to validate the purported aetiological mechanism after the prescribed proposal by the Ad Hoc Committee (1962), on the Classification of Headache which was recognised as muscle contraction or tension as a distinct headache diagnosis. The Electromyography (EMG) of the temporalis muscle in tension headache patients is measured to identify whether the correlation of EMG amplitude and intensity of pain reported by patients can be attributed to the diagnosis of Tension Type Headache (TTH). Aim: To correlate between Surface Electromyography (sEMG) activity and pain scale in TTH patients. Materials and Methods: The present study cross-sectional study was conducted in the Out Patient Department (OPD) of Psychiatry MLB Medical College, Jhansi, Uttar Pradesh, India during the period of 2009 to 2012 in which surface EMG responses of the temporalis muscle were recorded on 100 TTH patients before they go for any sort of treatment. Subjects aged 20 to 45 years were included, out of which 58 were females and 42 males. In this study, Pearson’s correlation coefficient was calculated to investigate the correlation between muscular activity and subjective pain scores. Results: The correlation value was (r=0.857) between EMG amplitude and pain scale in all 100 TTH patients. Male to female ratio was 1:1.38. Among the age groups 20-25 (years) and 26-30 (years) had the maximum number of patients 32% and 25% respectively. Conclusion: All age groups showed a positive correlation between EMG amplitude and headache intensity. It was found that females in every age group was more frequently affected as compared to males and the young population had more chances of being diagnosed as TTH patients because it emerged as the largest number 32% among all age groups.

Designing a National Haemodialysis Registry Model for Iran

Farkhondeh Asadi, Roya Rezaei, Azamossadat Hosseini, Hamid Moghaddasi

Introduction: The global prevalence of End-Stage Renal Disease (ESRD) requiring therapeutic dialysis is on the rise. Haemodialysis is the main therapeutic dialysis method. Evaluating its effectiveness and planning to promote the quality of care and epidemiological research necessitate the development of registries as the main management tool. Aim: To design a national haemodialysis registry model for Iran. Materials and Methods: This was an applied descriptive study. Based on a review of articles and information sources, and a comparative study of national hemodialysis registries in developed countries, a national haemodialysis registry model was designed for Iran. After confirming the reliability and validity of the questionnaire, the designed model was given to nephrologists in a two-stage Delphi technique, and their comments were applied to the final model. Results: The presented national haemodialysis registry model main components consist of: goals, structure, data sources, minimum dataset, standards, and processes, all of which received 100% expert consensus. Conclusion: This registry is a powerful database for the progress of treatment, understanding changes in the treatment and outcomes, examining the factors affecting prognosis and quality of life.

Impact of Jacobson’s Progressive Muscle Relaxation on Stress Levels of Exam Going MBBS Students of a Medical College in South Gujarat, India

Devashish Palkar, Sanjibani Panigrahi, Pooja Shatadal, Ritambhara Mehta

Introduction: Academic examinations are a very stressful event for an Bachelor of Medicine and Bachelor of Surgery (MBBS) student. While many students learn to deal with it through the use of helpful or unhelpful coping skills, many still end up with considerable psychological morbidity in the form of anxiety and depression along with deterioration in overall health. Jacobson’s Progressive Muscle Relaxation (JPMR) causes deep muscle relaxation. Aim: To find out the prevalence of stress and exam anxiety in students of 1^st year MBBS and to study the impact of JPMR. Materials and Methods: It was a quasi-experimental, pretest and post-test interventional study conducted amongst the first year MBBS students studying at the Government Medical College Surat, Gujarat, India, during March to May 2019. Two months before their internal exams, 114 1^st year MBBS students were recruited for the study. They were given a pretest proforma which comprised of socio-demographic profile, Perceived Stress Scale (PSS), Test Anxiety Scale (TAS) and General Health Questionnaire (GHQ) 28. They were asked to attend JPMR sessions over the following month in batches of 30 each and asked to practise JPMR for one month leading up to their exams. Total 43 students attended these sessions while 71 did not. After one month, all 114 students were again given a post-test proforma comprising of the same scales. Paired t-test was applied to compare the pretest and post-test scores to see the impact of JPMR. Results: The mean age of participants was 19 years.The students who completed their schooling in Gujarati medium and those who reported to be staying at hostel experienced significantly more TAS scores at baseline evaluation as compared to their counterparts from English medium schools and those staying at home respectively. There was a statistically significant reduction in mean scores of PSS and TAS before and after practice of JPMR in the 43 students who attended and practiced JPMR (p-value=0.005 and p-value=0.002, respectively; p-value <0.05 was considered to be significant). Conclusion: One month practice of JPMR was found to be effective in reduction of stress and exam anxiety.

Comparison of Nitrous Oxide-Oxygen as Inhalation Agent, Midazolam, Ketamine alone and in Combination as Oral Sedative Agents for In-office Paediatric PatientsA Randomised Control Trial

Monika Nagpal, Mohan Lal Khatri, Anil Gupta, Ankit Srivastava, Shalini Garg

Introduction: In-office pharmacological sedation techniques are best applied to manage an extremely fearful preschooler, especially during primary dentition or a child’s early mixed dentition period. These should be used when non pharmacological behavioural management techniques fail either due to lack of communication or in children with special care needs. Aim: To compare the efficacy of oral administrations of midazolam, ketamine, combination of midazolam-ketamine (M+K) and nitrous oxide-oxygen (N₂O) inhalational sedation in achieving favorable behavioural outcome compared by using the Houpt scale in the treatment of anxious and uncooperative paediatric patients. Materials and Methods: A randomised clinical trial was conducted in the Department of Paediatric and Preventive Dentistry, SGT University, Haryana, India between September 2018 to December 2019. The study included 100 anxious children (Venham’s picture scale) aged three to five years, who required procedures under local anaesthesia administration were divided into four groups using envelop method. Each group was given either oral midazolam (M) (0.3 mg/kg) or oral ketamine (K) (3 mg/kg) or oral combination of midazolam+ketamine (M+K) (0.3 mg/kg and 2 mg/kg) or inhalational nitrous oxide-oxygen (N₂O). The behaviour response of the child was recorded using the Houpt scale. The oxygen saturation level and heart rate of each patient were also recorded before, after, and during the procedure. Adverse drug reactions post-treatment was also recorded. Analysis of Variance (ANOVA), Chi-square test and Mann-Whitney U test was used for statistical analysis. Results: The study comprised of 100 anxious children (mean age was 4.1±0.5 years) requiring administration of local anaesthesia with intent to complete in-office treatment. Statistically, a significant difference was found among behaviour outcomes of four groups (p-value=0.047). Acceptable behaviour was seen best in K+M group (88%), followed by oral ketamine (K) (68%), N₂O (59%), and oral midazolam (M) (52%). Adverse reactions were most commonly seen in the oral ketamine group. Conclusion: Oral M+K combination group is significantly better than oral ketamine (K), oral midazolam (M) or N₂O inhalation sedation to achieve the required behaviour for dental treatment in three to five years old patients.

Influence of Renal Impairment on Serum Parathyroid Hormone and Vitamin D Status and their Association with Serum Creatinine in Patients Undergoing Haemodialysis: A Case-control Study

Nida Suhail, Baraah Tomah Abualsel, Shiza Batool

Introduction: A transition in the lifestyle of Saudi population over the past few decades has increased the burden of various metabolic disorders including, diabetes mellitus type 2, Chronic Kidney Disease (CKD), cardiovascular diseases, and vitamin D deficiency. Deficiency of vitamin D has been linked to the progression of kidney disease and many cardiovascular complications. Aim: The study focuses on the vitamin D status and associated changes in serum Parathyroid Hormone (PTH) in End Stage Renal Disease (ESRD) patients undergoing haemodialysis in the Northern Border Region (Arar city) of Saudi Arabia. The present study also investigated the relationship between serum creatinine, PTH and vitamin D levels in these patients. Materials and Methods: This case-control study was carried out for a period of five months (September 2019 to January 2020). It included 60 patients, suffering from ESRD on haemodialysis (cases) attending the Nephrology Centre of Prince Mohammed bin Saud Al Kabeer renal dialysis unit in Arar Central Hospital, Arar, Saudi Arabia. A control population (n=60) with normal kidney function, who visited the hospital for other reasons, was also identified. Their blood samples were collected for estimation of renal function parameters {Blood Urea Nitrogen (BUN) and creatinine}, serum calcium, phosphate, vitamin D and PTH. Statistical analysis was performed using the Statistical Package for the Social Sciences version 22.0. Results: The study included 60 patients (50% males and 50% females) undergoing haemodialysis and 60 healthy controls (50% males and 50% females) with a mean age of 46.83±14.19 (range 18-73 years) and 39.25±5.11 (range 30-54 years) years, respectively. The mean BMI of the patients was 27.3±3.4 kg/m² and that of controls was 23.7±2.2 kg/m². A significant elevation (p-value <0.001) of serum PTH showing hyperparathyroidism accompanied by significant (p-value <0.001) hypovitaminosis D and hypocalcaemia was observed in the patients as compared to controls. The results also demonstrated significantly elevated (p-value <0.001) levels of BUN and serum creatinine in ESRD patients. Results of correlation analysis exhibited a significant (p-value <0.05) positive correlation between serum creatinine and PTH whereas, there was a significant (p-value <0.05) negative correlation between serum creatinine and vitamin D; and serum PTH and vitamin D among the patients. Conclusion: This study highlights the importance of monitoring changes in PTH levels in patients with impaired renal function for the early detection and treatment of CKD. The study also showed a significant (p<0.05) positive association between serum creatinine and PTH followed by a significant (p<0.05) negative correlation between serum creatinine and vitamin D; and serum PTH and vitamin D.

Management of Extra-articular Proximal-third Tibia Fractures by Expert Tibia Nail and its Functional Outcome: A Longitudinal Cohort Study

Introduction: Tibia, being anatomically placed subcutaneously throughout its length, is very prone to fractures. Incidence of extra-articular proximal tibia fractures accounts for 5-11% of all tibia shaft fractures. Among the various treatment modalities available, locked intramedullary nailing is a safe and adequate modality with fewer complications. Expert tibia nail is anatomically designed with multi-directional locking, which attains better angular stability and thereby allowing fixation of very proximal fractures. Aim: To analyse and assess the functional and radiological outcome of expert tibia nailing used for treating extra-articular proximal-third tibia fractures. Materials and Methods: A longitudinal cohort study was conducted for a duration of three years and five months, which included 31 patients. Standard descriptive statistical method was used to describe parameters. All these patients had extra-articular proximal-third tibia fractures and were managed with expert tibia nail. All patients underwent clinical and radiological evaluation based on the Klemm and Borner scoring system at a regular interval of six weeks, three months, six months, and at one year. Results: The most common mode of injury was road traffic accidents (80.64%). Patients were in the age group of 26-63 years with an average mean of 41.80±9.7 years. The male to female ratio was 4.16:1, suggestive of male predominance. According to the Klemm and Borner scoring system, 71.42% of patients belonged to the excellent group, 17.85% were in good, 7.14% in fair and 3.57% in poor. Radiological union was achieved in an average period of 20.9±2.09 weeks. Conclusion: In this study, scores obtained on the basis of Klemm and Borner scoring system, depicts that intramedullary expert tibia nailing is a good treatment modality for the management of extra-articular proximal-third tibia fractures, which provides good angular stability and adequate fixation resulting in early rehabilitation and union with excellent functional outcome and mere complications. It is also a safer treatment modality in case of compromised surrounding soft tissue.

Factors Facilitating Hand Hygiene Practices in Eateries of Coimbatore: A Cross-sectional Study

Introduction: Improper hand hygiene practices and eating at unsanitary eateries are a major cause for many of the life-threatening diseases. Although studies done in the past have focused on the hand hygiene of the restaurant staff, the customers’ hand hygiene, which is equally, if not more important, has not been studied in detail. Aim: To assess the factors facilitating hand hygiene for the customers as well as the general hygiene in the eateries of Coimbatore, Tamil Nadu, India. Materials and Methods: A cross-sectional study was done in the eateries of Coimbatore in June 2017, after obtaining clearance from Institutional human ethics committee. A list of eateries was collected from a food delivery application and 30 of them were chosen by systematic random sample. The restaurants were further categorised into low, medium and high-price ranged eateries based on the price of a standard food item (coffee). As a mystery client, the restaurants were inspected and observations were noted in a hidden checklist, which was constructed for the purpose of this study. The checklist consisted of three major categories, the washing area (9 marks), the customer (7 marks) and the general hygiene of the restaurant (7 marks). There were 23 items in the checklist and each item, if present, was awarded a score of 1. No negative scoring was done. Hence, the maximum score an eatery could get was 23 and minimum was zero. ANOVA test was applied to compare the scores of different types of eateries. Results: The mean and standard deviation hygiene scores of the low, medium and high-cost eateries were 7.7±4.05, 11±6.02 and 14±5.43, respectively. There was a significant difference in the (hygiene and sanitation) scores between low, medium and high-cost eateries (p-value=0.04). It was found that in lower priced restaurants, most of the restaurants failed to provide adequate facilities for hand hygiene. Medium and high price range eateries were similar in the fact that they scored better with regard to general hygiene and wash area facilities. Although none of the restaurants scored a full mark higher price ranged eateries had better wash area facilities. Customer hand hygiene practices were found to be subpar in all the three categories, even though facilities were present in some medium and high-end eateries. Conclusion: It was noticed that in some of the lower end restaurants, facilities for hand hygiene were not adequate. It was also found that if adequate facilities for hand hygiene were present in a restaurant, there was a higher chance of a customer to utilise that. This was found to be true especially in higher priced restaurants. Hence, the importance of hand hygiene and awareness among customers should be emphasised.

Role of Squash Cytology in Intraoperative Diagnosis of Meningioma

Gowri Prakasam, K Karkuzhali, Veeraraghavan Gurusamy

Introduction: Primary Central Nervous System (CNS) tumours constitute less than 2% of overall cancers in adults and are the second most frequently encountered tumours in children. Meningiomas form 24-30% of primary intracranial tumours. Most intrinsic brain tumours are soft and gelatinous in consistency, smear preparation can readily made which gives excellent cytological details when compared to frozen section as the latter produces ice crystal artifacts. Aim: To assess the diagnostic utility of squash cytological evaluation of meningiomas and its comparison with final histopathological diagnosis. Materials and Methods: The cross-sectional study was done at Thanjavur Medical College, Thanjavur, Tamil Nadu, India for period of three years from January 2015 to December 2017. Total of 54 clinically diagnosed and radiologically suspected case of meningiomas were selected. Smears were prepared from the biopsy samples sent in normal saline and stained by Haematoxylin and Eosin (H&E) method. The cytological features were noted and matched with biopsy findings. Descriptive statistics were used to analyse the results. Results: Total of 54 squash smears with male to female ratio was 1:1.5. Maximum number of cases were seen between 41-50 years followed by 51-60 years. Complete concordance was obtained in 51 cases (94.44%) and partial concordance was noted in a case due to underestimation of malignancy grade in squash cytology. Out of 54 cases, two cases were found to be discordant with final histopathological diagnosis. Conclusion: Intraoperative squash cytology is easy, rapid, reliable and cost-effective technique for neurosurgical consultation with fairly high accuracy in diagnosing meningiomas.

An Observational Study of Corneal Endothelial Alterations in Eyes with Unilateral Pseudoexfoliation

Archana Thool, Rashmi Ramani, Pravin Tidake

Introduction: Pseudoexfoliation (PXF) is an age-related generalised disorder of extracellular matrix primarily affecting eyes. It is characterised by deposition of pseudoexfoliative material in the anterior segment of eye. Also it is a bilateral condition but can have asymmetric presentation and can be clinically seen only in one eye. Alteration in endothelial cell morphology along with other alteration in anterior segment of the eye can compromise the surgical outcome. Aim: To evaluate the corneal endothelial cell density and morphology in patients with unilateral PXF. Materials and Methods: The present study was hospital-based cross-sectional observational study which included 55 patients with unilateral PXF, who came to the Department of Opthalmology, Acharya Vinoba Bhave Rural Hospital (AVBRH), Wardha, Maharashtra, India between June 2020 to November 2020. Specular microscopy was performed on all eyes to evaluate cell density and morphology, coefficient of variation in cell size and percentage of hexagonal cells in corneal endothelium and compared with fellow normal eye. Statistical analysis was done by using descriptive and inferential statistics using students unpaired t-test, p-value <0.05 was considered as level of significance. Results: The present study included 55 patients, of which 26 were males and 29 were females. Mean age of the patients was 63.85±7.05 years. Majority of patients were in the range of 61 to 70 years (56.36%). The mean corneal endothelial cell density in the PXF eye was 2299.54±84.95 cells/mm², which was significantly lower as compared to fellow normal eye with p-value <0.001. Mean coefficient of variation of cell size in PXF eye was 35.49±4.62, p-value=0.064 and hexagonality was 51.12±4.91, p-value=0.13. Both the parameters were statistically non significant on comparison of two eyes. Central corneal thickness was thicker in pseudoexfoliative eye of 551.29±33.11 microns (μm), than fellow eye but was statistically non significant. Conclusion: Eyes with PXF had alteration in endothelial cell morphology with decrease in cell density as compared to eyes without PXF clinically.

Effect of Serum Uric Acid Level on Acute Ischaemic Stroke Patients in South Indian Population: A Prospective Cohort Study

Introduction: Stroke is one of the most common causes of morbidity and mortality in the world. Various studies have shown the correlation between the uric acid levels and acute ischaemic stroke. There are several studies which project the cerebro-protective effect of uric acid in acute ischaemic stroke patients by its antioxidant effect. However, still it is a wide area of controversy. Aim: To assess the short term (14 days) clinical outcomes in acute ischaemic stroke patients with reference to their serum uric acid levels on day of admission day. Materials and Methods: This prospective cohort study, which included a total of 74 acute ischaemic stroke patients who presented to Emergency Department in a Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Pondicherry (a tertiary care hospital in South India) within 48 hours from the month of April 2018 and June 2019. The severity of stroke was quantified in all patients using National Institute of Health Stroke Scale (NIHSS) during admission and serum uric acid levels and other routine investigations were measured in all cases. All patients were managed as per American Heart Association (AHA) guidelines and at the end of 14 days their outcome was reassessed by modified Rankin Scale (mRS). The correlation between severity of stroke and the clinical outcome on 14 days with reference to admission day serum uric acid was analysed. Results: A total of 74 patients were analysed, 51 were male and 23 were females and mean serum uric acid was 6.07±0.78 (mg/dL), and mean NIHSS score at admission was 18.32±3.8. Severity assessment by NIHSS scoring system showed majority percentage of population in elevated serum uric acid group were in moderate and severe categories (73.7%, 62.9%, respectively) in adjunct with normal uric acid group. Outcome assessment by mRS showed major percentage population in elevated uric acid group with score 2,3 (score 2-89.3%, score 3-80%) in relation to normal uric acid group. Conclusion: The present study supported the hypothesis that acute ischaemic stroke patients with elevated serum uric acid levels at the time of admission had reduced severity and favourable short term clinical outcome due to its neuroprotective effect secondary to antioxidant property.

Effectiveness of Add-on Emotional Freedom Technique on Reduction of Depression: A Quasi-experimental Study

Deepak Krishnamurthy, Anil Kumar Sharma

Introduction: Depression is a common psychological disorder prevalent in all age groups irrespective of gender, religion, ethnicity and geographical area. Emotional Freedom Technique (EFT) is a brief treatment and consists of cognitive therapy, acupoint stimulation on selected meridians of the body. The EFT is a self-help therapeutic tool to reduce the distress level. However, existing literature may not be sufficient to demonstrate effectiveness of adding adjuvant therapy, EFT will enhance the outcome among depressive patients along with conventional treatment. Aim: To determine effectiveness of add-on EFT on treating depression among patients with depression and to find out the effect of predictive variables on depression level. Materials and Methods: It was a quasi-experimental study with pre-test and post-test design, involving a control group, conducted among patients admitted in open ward for observation and treatment in Hospital for Mental Health, Vadodara, Gujarat, India, with in this study, 100 samples were selected by convenience sampling technique and data collection was done from March 2019 to July 2019. The Beck Depression Inventory was administered on first day to all the patients. In one group EFT was administered for 40 minutes for three consecutive days along with routine treatment. The other group {Treatment as usual (TAU) group} received only conventional treatment. Depression level was evaluated on third day after intervention by an independent assessor among both the groups. Data were analysed using frequency distribution, Wilcoxon test and Mann-Whitney test. Results: A total of 100 subjects were included in study. Mean age (years) of EFT group was 44±12 and 42±13 among TAU group. In EFT group 24 (48%) were males and 26 (52%) were females; while it was 26 (52%) males and 24 (48%) females in TAU group. Mean depression score was 30.82±2 before intervention and after intervention it was found 27.20±4 among TAU group. Mean depression score was 30.96±3 before intervention and after intervention it came down to 24±4 in EFT group. On univariate logistic regression analysis, significant association was found with age less than 29 years {Odds Ratios (OR) 2.68; 95% Confidence Interval (CI) =0.398- 18.1}, primary education (OR 6.759; 95% CI=1.106- 41.296), secondary education (OR 2.95: 95% CI=0.56-15.66). Conclusion: Study concludes that adding EFT as an adjuvant therapy along with conventional treatment antidepressant and psychotherapy will enhance the outcome of depression level among patients with depression.

Intravenous Propofol and Inhalational Sevoflurane for Ease of Classic Laryngeal Mask Airway Insertion in Patients Undergoing Elective Surgery: A Randomised Clinical Trial

Nilanjan Chakraborty, Prosenjit Mukherjee, Rita Pal

Introduction: The Laryngeal Mask Airway (LMA) has gained extensive popularity for airway management during surgery. Propofol, the most commonly used induction agent for LMA insertion, causes significant haemodynamic changes. Sevoflurane has the potential to be as good an induction agent as propofol. Aim: To compare ease of insertion of classic LMA in patients undergoing elective surgery using intravenous propofol and inhalational sevoflurane. Materials and Methods: The study was a randomised clinical trial conducted in the Operation Theatres of Midnapur Medical College and Hospital, Medinipur, West Bengal, India, from August 2019 to July 2020. Eighty patients of American Society of Anaesthesiologists (ASA) physical status grade I and II, of both sexes, and aged between 18 years to 65 years were equally divided into two groups: group P (Propofol group) and group S (Sevoflurane group). Group P was given injection Propofol 2.5 mg/kg body weight and group S was given vital capacity breath induction with 8% sevoflurane and oxygen at 8 litres/min. Loss of Consciousness (LOC) was confirmed and induction time was noted for each group. After confirmation of ease of mouth opening, by an independent observer, LMA insertion was attempted. Ease of LMA insertion was assessed by a predefined 18 points table along with time to LMA insertion and number of attempts. Haemodynamic changes and adverse effects were also recorded. Chi-square test or Student’s t-test were used and a p-value ≤0.05 was considered as statistically significant. Results: With respect to age, sex and weight there were no significant differences between the two groups. Induction time was significantly less in group P (51.85±6.66 seconds) compared to group S (68.38±13.93 seconds) (p-value=0.0001), but LMA insertion time, number of attempts and overall ease of LMA insertion conditions according to the 18 points score were comparable between the two groups. Mean arterial pressure at certain points after induction was significantly less in group P (at 3 minute p-value=0.009 and at 5 minute p-value=0.007). Apnea was significantly more in group P (p-value=0.023). Conclusion: Sevoflurane was comparable to propofol for LMA insertion in respect of ease of insertion and insertion time. Although induction time was significantly less for propofol, sevoflurane offered better haemodynamic stability and lesser incidence of apnea.

Effect of Maternal Body Mass Index on Intrapartum and Neonatal Outcome in Nulliparous Women in North Karnataka: A Prospective Cohort Study

Introduction: Nutrient intake and weight gain are the two main modifiable factors during pregnancy that influence maternal and infant outcome. Body Mass Index (BMI) derived from weight and height is a marker of metabolic and endocrinal status and is used to classify people from underweight to obese. Pregnancy complications related to maternal BMI is a growing problem. Both lean and obese mothers carry an increased risk of adverse perinatal outcome. Aim: To assess the effect of maternal BMI on labour and mode of delivery, neonatal outcome and to detect the obstetric complications in relation to different BMI’s. Materials and Methods: A prospective study was conducted in Mahadevappa Rampure Medical College, Kalaburagi, Karnataka, India, from August 2014 to July 2016 in which total of 200 primigravidas with singleton pregnancy; in labour after 28 weeks of gestation were included. BMI was calculated using the formula by Quetelet. The women were categorised into underweight, normal, overweight and obese according to World Health Organisation (WHO). Results: Out of 200 cases, 111 (55.5%) were of normal BMI, 61 (30.5%) overweight, 16 (8.0%) obese and 12 (6.0%) underweight. Pre-eclampsia, oligohydramnios, Intrauterine Growth Restriction (IUGR), anaemia, foetal birth weight <2.5 kg, increased incidence of Neonatal Intensive Care Unit (NICU) admissions and early neonatal complications were commonly seen in underweight which was statistically significant (p<0.01). Gestational hypertension (n=5), increased incidence of caesarean sections (n=13), foetal birth weight >3.5 kg (n=5), failed spinal anaesthesia (n=2), postpartum haemorrhage (n=4), post Lower Segment Caesarean Section (LSCS) wound gape (n=2) and prolonged hospital stay (n=3) were the complications seen in obese individuals. Conclusion: Maternal BMI showed a strong association between pregnancy complications and outcomes. Therefore, all the pregnant women need to be advised to maintain normal BMI in order to achieve a healthy outcome as both underweight and obese women carry risk for adverse pregnancy outcome.

Prevalence of Vitamin D Deficiency and its Associated Risk Factors on Osteoarthritis: A Cross-sectional Survey

Introduction: Vitamin D Deficiency (VDD) and several other metabolic factors are known to be involved in the aggravation of Osteoarthritis (OA). A better understanding of the role of these metabolic factors and diseases is required to alleviate the OA progression. Aim: To analyse the prevalence of VDD in OA patients and its correlation with co-morbidities such as diabetes, hypertension (HT), Cardiovascular Disease (CVD) and acidity and also to assess the effect of Body Mass Index (BMI) and increasing age on the developmental process of OA. Materials and Methods: A cross-sectional survey was undertaken during September 2018 to March 2019 in King Khaled, King Salman and Hail General Hospitals located in Ha’il province of Kingdom of Saudi Arabia (KSA). The study included 501 participants of OA patients that visited these hospitals. Data pertaining to the variables in this study such as diabetes, HT, cardiovascular problems, vitamin D and calcium deficiency, acidity and anthropometric details was obtained using a structured questionnaire. Data analysis was done using descriptive statistics and Pearson’s correlation with the statistical program SPSS version 21. Results: VDD, calcium deficiency and acidity were the most prevalent factors observed in the patients. Vitamin D and calcium deficiency was observed to be higher in females than males. VDD significantly correlated to diabetes, HT, acidity and age, both in females and males. Cardiovascular disease and BMI correlated with VDD only in males but not in females. BMI showed positive correlation with HT in males (p<0.01) but not females, and also correlated with age (p<0.01) irrespective of gender. Conclusion: The study concluded that VDD is more prevalent in females than males in Ha’il region. It is correlated to variables such as diabetes, HT, acidity, BMI and increasing age, which are identified as risk factors contributing to the progression of OA.

Assessment of Intensive Inpatient Rehabilitation Program in Acquired Brain Injury Patients using UK FIM+FAM Scale: A Retrospective Study

Harleen Uppal, Shipra Chaudhary, Siddharth Rai

Introduction: Acquired Brain Injury (ABI) can lead to a combination of physical, cognitive, and behavioural impairments and requires comprehensive and structured inpatient rehabilitation program. A multidisciplinary rehabilitation program can deal comprehensively with all these issues together rather than focussing on a single aspect like motor function. Number of people suffering from Traumatic Brain Injury (TBI) in India has been documented to be between 1.5 million to two million per year whereas out of this approximately one million die due to TBI. The rationale of the present study was to document the outcome of multidisciplinary inpatient rehabilitation program objectively using a standard functional outcome measure. Aim: To determine the change in functional outcomes of ABI patients being rehabilitated with a multidisciplinary inpatient neurorehabilitation program using UK version of Functional Independence Measure and Functional Assessment Measure (UK FIM+FAM). Materials and Methods: The retrospective observational study was conducted in Medanta Hospital, Gurugram, Haryana, India, from September 2017 to June 2018. Retrospective analysis of previously maintained data was done from June 2018 to November 2018. Data was collected from the Department of Neurorehabilitation. Demographic data was collected including age, sex, type of injury, time from injury to admission and duration of stay in the neurorehabilitation unit. Functional outcome measure used in the study was the UK FIM+FAM. Data was collected in paper forms and collated in Microsoft Excel and transferred to IBM^® Statistical Package for the Social Sciences (SPSS)^® version 22.0 (IBM Corp., Armonk, NY) for analysis. The UK FIM+FAM data was analysed as aggregate total scores and motor and cognitive subscales. Non parametric tests were used as UK FIM+FAM is an ordinal scale. The test used to measure the change in score was Wilcoxon Test. The p-value <0.05 was considered statistically significant. Results: Total number of patients who were analysed in the study were 45. Motor subset of scores showed significant improvement from admission (50) to discharge (72) (p-value=0.001). Similarly, the cognitive subset of scores also showed a significant improvement from admission (58) to discharge (68, p value=0.002). Apart from motor and cognitive subscales of UK FIM+FAM, change in score in sub divisions of self-care and transfers showed the maximum change with p-value=0.001. Other sub divisions of locomotion, sphincter, communication, psychological and cognition also showed a significant difference of p-value <0.05. Conclusion: A physiatrist led intensive interdisciplinary inpatient rehabilitation program for patients with ABI may significantly reduce residual disability and improve functional independence. Such a program is not only effective in high income countries but also in Low Middle Income Countries (LMIC).

Drug Utilisation Pattern and Adverse Drug Reactions in Stage II Breast Cancer Patients in a Tertiary Care Centre of Odisha- An Observational Study

Introduction: Breast cancer is the most common cancer occurring in women with an estimated prevalence of 28.94% in Cuttack, Odisha, India. Adverse Drug Reactions (ADRs) associated with the use of anticancer drugs is a worldwide problem which needs further attention. Aim: To know about treatment regimens, premedications used for toxicity amelioration or any associated ADRs occurring during treatment of stage II breast cancer patients. Materials and Methods: This was a prospective observational study carried out in the Department of Pharmacology in collabo- ration with Acharya Harihar Regional Cancer Center (AHRCC), SCB Medical College and Hospital, Odisha, India. A total of 181 female breast cancer patients of stage II were finally analysed about their treatment protocol pattern including premedication, chemotherapy regimen, associated ADRs and their treatment. Different outcomes measured were Absolute Neutrophil Count (ANC), febrile neutropenia, anaemia, thrombocytopenia. ADRs were analysed by using World Health Organisation-Uppsala Monitoring Centre (WHO-UMC) Scale and Hartwig-Siegel Scale. All analysis was performed using Statistical Package For the Social Sciences (SPSS) version 18.0. Results: Most common chemotherapy combination regimen used was cyclophosphamide+doxorubicin+paclitaxel+trastuzumab in 30.9% of patients, out of which 28.7% showed ADRs. Ondansetron and aprepitant were commonly used as premedication in 96% of patients. Most commonly reported ADR was Chemotherapy Induced Nausea and Vomiting (CINV) in 43.6% patients and Chemotherapy Induced Neutropenia (CIN) (34.8%). Fifty percent ADRs were mild and 3.3% ADRs were severe in nature. A 64% ADRs were possible and 23% ADRs were probable according to WHO-UMC causality assessment scale. Grade 4 Neutropenia was present in 1.3% patients. Mild haematological problems were treated by blood transfusion while severe cases by additional growth factor support like Granulocyte Colony Stimulating Factor (G-CSF). In this study, mean age of presentation was found to be 44.6 years. Conclusion: Despite use of drugs for toxicity amelioration, some grade four life threatening ADRs were observed. Mostly ADRs were missed and under-reported. Regular monitoring, increased care and patient compliance was needed to detect new ADRs and to reduce the morbidity as well as burden on the patients.

Comparison of Dexmedetomidine vs Midazolam for Sedation during Awake Fiberoptic Intubation in Oral Cancer Surgeries- A Randomised Clinical Study

Reema Meena, Adhokshaj Joshi, KM Sherbina, Purbali Singha Roy

Introduction: Fiberoptic nasotracheal intubation is a prime method for managing difficult airway in patients. Besides local blocks, some sedation is required during the procedure to make it more tolerable to the patients. Dexmedetomidine (DEX) and Midazolam (MDZ) can be used for this purpose. Aim: To compare dexmedetomidine versus midazolam for sedation and intubating condition during Awake Fiberoptic Intubation (AFOI) in patients undergoing oral cancer surgeries. Materials and Methods: This was a prospective randomised double blind study on total of 60 patients randomly allocated into group 1(MDZ) and group 2(DEX). Group 1 received intravenous (i.v.) Midazolam 0.05 mg/kg bolus in 10 mL normal saline over 10 minutes followed by 0.1 mg/kg/hr infusion titrated upto 0.2 mg/kg/hr to achieve a Ramsay Sedation Score (RSS) ≥2. Group 2 (DEX) received i.v. Dexmedetomidine 1 µg/kg bolus in 10 mL normal saline over 10 minutes followed by infusion at the rate of 0.2 µg/kg/hr titrated upto 0.7 µg/kg/hr to achieve a RSS ≥2. Comfort Scale values, haemodynamic parameters, patient’s tolerance score and patient’s satisfaction score (24 hours after the surgery) were assessed. Significance was calculated using Student t-test. The number of patients with adverse effects was compared using Chi-square test. Results: In the total sample of 60 patients (30 subjects in MDZ group and 30 subjects in DEX group). The demographic data, blood pressure and Oxygen(O₂) saturation were comparable. Significant change in Heart Rate (HR) was observed in group MDZ while HR was stable in DEX group (p<0.001). Group DEX patients were more comfortable and had greater endurance with tolerance score <2.5 compared to MDZ group >2.5 (p<0.001) and had an acceptable level of RSS. After 24 hours, DEX group patients judged their sedation more positively than MDZ group with a score of 6.16 vs. 3.6 (p<0.001). Conclusion: Both Midazolam and Dexmedetomidine are effective for AFOI. But Dexmedetomidine provided better patient comfort and satisfaction along with stable haemodynamics.

Seasonal Variation and Time Trend Analysis of Dog Bite Cases Attending the Anti Rabies Clinic in Delhi using ARIMA Model Forecasting

Neha Taneja, Vinoth Gnana Chellaiyan, Sujata Gupta, Rajesh Gupta, AY Nirupama

Introduction: Rabies is a fatal viral disease which is transmitted to humans through animal bites, most commonly via dogs. Fortunately, this disease is preventable through timely pre and postexposure vaccination. Aim: To study the seasonal predisposition and trend analysis of dog bite cases attending the anti rabies clinic. Materials and Methods: This retrospective cross-sectional study was conducted in the anti rabies clinic of a government hospital in Delhi. Enumeration and inclusion of all dog bite cases were made. An Autoregressive Integrated Moving Average (ARIMA) model was used to analyse the available data of dog bites, from 2011 to 2018. In this study, the least Bayesian Information Criterion (BIC) value was 12.2 and the corresponding model is ARIMA (1, 0, 0) with the goodness of fit 2 (R²=44%). The model verification was done by noise residual check. The model was applied for time series analysis and forecasting of rabies cases in subsequent years. Results: Total number of dog bite cases were 1,46,344 in last eight years (2011-2018). The maximum number of cases being 27961 in the year 2014 followed by 22385 in the year 2013. A seasonal predisposition of dog bite cases was seen for the month of February to April. The trend analysis forecasting for 2019, 2020, 2021, 2022 and 2023 predicted 11317, 11676, 10157, 8639 and 7120 cases, respectively. Conclusion: Although the dog bite cases will be on a decline in the future, adequate measures need to be strengthened further to sensitise the community about rabies prevention and timely reporting to anti rabies clinic for prophylaxis.

Comparison of Intrathecal Dexmedetomidine and Fentanyl as Adjuvants to Hyperbaric Bupivacaine: A Randomised Controlled Trial

Anuradha Deotale, Sandeep S Kadam

Introduction: Subarachnoid block using bupivacaine along with fentanyl is routinely used in regional anaesthesia technique in lower limb and lower abdominal surgeries. However, fentanyl is often associated with various side effects. The use of dexmedetomidine as an alternative to fentanyl in regional blocks is emerging due to minimal adverse effects and prolonged duration of action. Aim: To compare intrathecal dexmedetomidine and fentanyl as adjuvants to hyperbaric bupivacaine. Materials and Methods: The prospective, randomised study was performed on 100 patients, divided into two groups. Group I patients were administered with bupivacaine 12.5 mg (2.5 mL)+ fentanyl 25 μg (0.5 mL) whereas group II patients received bupivacaine 12.5 mg (2.5 mL) + dexmedetomidine 5 μg (0.5 mL). Post anaesthesia Heart Rate (HR) and Blood Pressure (BP) were recorded. The onset of sensory and motor block, level of sensory block, time for two segment regression, motor and sensor recovery, duration, quality of analgesia and Visual Analog Scale (VAS) score were recorded. Data were analysed using R Studio V 1.2.5001 software. Wilcoxon signed rank test and independent sample t-test were used to find the difference between mean. The p<0.05 was considered statistically significant. Results: Time for onset of sensory block (p=0.0027), motor block (p<0.001) and peak sensory block (p<0.001) was significantly high in group I patients. Most of the patients of group I had a T8 level of sensory block (38%) while in group II around 36% of patients had T6 level of sensory block. Time for full motor recovery (p=0.0015) and sensor recovery (p<0.001) was high in group II patients. Conclusion: Dexmedetomidine is associated with long term motor and sensory block, excellent analgesia and there was less demand for rescue analgesics as compared to fentanyl.

Paediatric Blood Lead Levels and its Correlation with Anaemia: A Study from Central India

Introduction: Lead is a toxic element used commonly in many products like lead-acid batteries, paints, toys etc. Young children are particularly vulnerable to lead poisoning because of higher absorption capacity in comparison of adults. Safe level of lead exposure has to be established yet. Literature suggests a threshold lead level of 20-40 μg/dL for a decrease in haemoglobin in children. Aim: To assess the correlation between Blood Lead Levels (BLL) and anaemia in children. Materials and Methods: This cross-sectional study was conducted in a Paediatric Tertiary Care Hospital of Gwalior, Madhya Pradesh, India, during the period of May 2019 to September 2020. A 81 children between one to five years of age were included in study. Information was collected regarding general profile of the children and other parameters like socio-economic status (Modified Kuppuswamy scale), history of pica, application of surma, type of toys used, scholastic performance and somatic symptoms. Routine blood investigations were done including Haemoglobin (Hb) and BLL through venous blood sampling. BLL were done at Defense Research and Development Establishment (DRDE) Gwalior. Data entry was done in Microsoft Office Excel 2010 and analysed using Statistical Package for the Social Sciences (SPSS) software version 21.0. Chi-square test with Yates correlation was applied and p-value <0.05 was considered statistically significant. Results: Among 81 study subjects, 53 were males and 28 were females. Total 48 (59.2%) children had Hb <11 gm/dL, 42 (51.8%) children had BLL <5 μg/dL and 32 (39.5%) had BLL between 5-10 μg/dL. There were 9% children (n=7) with BLL more than 10 μg/dL and none beyond 15 μg/dL. In the children it was found to have BLL ≥5 μg/dL, 20 children had Hb levels between 7-11 gm/dL whereas 19 had Hb levels above 11 gm/dL. No statistically significant association was found between the BLL and childhood anaemia. Conclusion: This study did not show any relationship between BLL and Hb in children of age one to five years. Scarcity of diagnostic tools for detecting BLL and lack of public awareness regarding the probable sources of lead and its complications may result in missing the diagnosis.

A Study on Requirement of Cold Chain Maintenance for Reliable Testing of SARS-CoV-2 Samples

Introduction: Coronavirus Disease 2019 (COVID-19) has been haunting the world since December 2019 and has grown to pandemic proportions from March 2020. Even after a full year of research and study, the most effective way to control the spread of this infection is early diagnosis and isolation of the cases. Real-time Reverse Transcription Polymerase Chain Reaction (RT-PCR) is considered the standard test all over the world for the diagnosis of Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) infection. All the sample collection guidelines have recommended stringent maintenance of the cold chain for the sample transport. However, it is not possible for the resource constrained developing countries with inadequate infrastructure to comply with these guidelines all the time. Aim: To determine necessity of stringent transport criteria and the effect of temperature on the clinical sensitivity of a RT-PCR assay for diagnosis of SARS-CoV-2 infection. Materials and Methods: In this prospective experimental study conducted in November 2020, 49 positive samples were kept at ambient room temperature and were tested everyday with RT-PCR for the detection of SARS-CoV-2 Ribonucleic Acid (RNA). The samples were also kept under refrigeration at 4°C and were also tested by RT-PCR and the results were compared with their respective counterparts kept at room temperature till nine days. Python Jupiter notebook SciPy and Anaconda software was used for statistical analysis. Results: It was observed that the positivity of the RT-PCR results were not deteriorated till five days and there was no significant deterioration even after nine days of samples being stored at room temperature suggesting that even if the viral RNA itself is not stable outside strict temperature control but small fragment or target genetic sequences are enough for detection of virus by RT-PCR. Conclusion: It is possible to keep samples at this ambient temperature for five days without any loss of positivity in RT-PCR.

Emerging Role of Prenatal Magnetic Resonance Imaging in the Diagnosis of Placental Adhesion Disorders and its Relation with Intraoperative Findings- A Cross-sectional Study

Saryu Gupta, Preetkanwal Sibia, Sarabhjit Kaur, Puneet Gambhir

Introduction: Placental Adhesion Disorders (PADs) aka Placenta Accreta Spectrum (PAS) of disorders are a common cause of postpartum haemorrhage, which in turn is an avoidable cause of significant maternal morbidity and mortality. The exponential increase in the prevalence of PADs worldwide primarily ascribed to increasing percentage of caesarean section deliveries therefore contributes significantly to potentially life-threatening obstetrical emergencies. Accurate prenatal diagnosis of PAD is hence fundamental for patient management and prognostication. Imaging plays an indispensable role in the antenatal diagnosis of PAD thereby translating to improved maternal outcomes. Aim: To determine the diagnostic accuracy of prenatal Magnetic Resonance Imaging (MRI) in predicting abnormal invasive placentation and to associate MRI findings with intraoperative findings. Materials and Methods: The present cross-sectional study was conducted between March 2019 to March 2020. Pregnant females with clinically and/or sonographically suspected PAD and having major risk factors of PAD {Lower Segment Caesarean Section (LSCS) in previous and placenta previa in present gestation} were subjected to dedicated placenta protocol MRI examination. The placental morphology, localisation and adhesion suggestive features were evaluated in detail. Descriptive statistical analysis was done for final assessment. Results: A total of 27 study participants, with mean age of 28±2.15 years, showed MRI findings compatible with PAD. Placenta previa complete (66.67%); was the dominant subtype observed in the study. In terms of degree of invasion, placenta accreta in 44.44% (n=12) was predominantly observed on preliminary MRI based assessment. The most reliable MRI features predictive of placental invasion in the present study (seen in 100% cases of PAD) included T2 dark intraplacental bands, heterogenous intraplacental signal intensity, disorganised intraplacental vascularity, myometrial thinning, loss of the uteroplacental interface and maternal neovascularity. In one case, MRI erroneously over-diagnosed increta as percreta. The overall diagnostic performance of these MRI parameters was with sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of 100%, 95%; 87.5% and 100% in those with placenta percreta compared to 94.12%, 100.00%, 100% and 95% for the placenta accreta or increta cases, respectively. Conclusion: MRI has high diagnostic accuracy in detection of PADs among the high-risk patients. Dedicated placenta protocol prenatal MRI should hence be incorporated in diagnostic work-up of all high-risk patients of PAD for reaping benefits of timely management, planning and saving lives.

Guiding Antimicrobial Therapy using Gram Stain in Patients with Ventilator Associated Pneumonia- An Effective Preliminary Diagnostic Tool

Nivedita Thass, Shweta Singh, Sonal Saxena, Ravinder Kaur

Introduction: Empirical antimicrobial therapy is the mainstay of antimicrobial stewardship. The gram stain can be used to guide initial empiric antimicrobial therapy in cases where culture report is not available. This rapid test can therefore be helpful in preventing the initiation of inappropriate therapy and its adverse outcomes. Aim: To determine the effectiveness of gram stain of tracheal aspirate samples in order to predict the causative microorganism and starting appropriate initial antimicrobial therapy. Materials and Methods: This cross-sectional study was done for 208 tracheal aspirate samples that were sent to Department of Microbiology, Lady Hardinge Medical College, New Delhi, India, with a request for bacterial culture and Antibiotic Susceptibility Testing (AST) from January 2019 to June 2019. Each sample was inoculated on 5% Sheep blood agar, Chocolate agar and MacConkey agar followed by gram stain preparation and smears. The culture plates were checked after 24 hours for any bacterial growth and further identification was done by gram stain, motility and biochemical tests. The AST was performed as per Clinical and Laboratory Standards Institute (CLSI) 2019 guidelines. All data entry was done on MS excel software and appropriate statistical tests were applied. Results: Out of total 208 samples significant gram stain findings were seen in 90 cases (43.2%). Out of 208 samples 132 (63.5%) cases grew significant pathogens on culture. Out of these 90 cases, 68 (75.5%) of gram stain finding matched with culture results. The correlation between gram stain and culture was found to be 75.5%. Conclusion: Gram stain is not only a quick and cost-effective method but also easily available in most laboratories and is highly reproducible. Gram stain, a rapid diagnostic tool, can thus be very useful in antimicrobial stewardship especially for the critically ill patients.

Prevalence and Involvement of Different Valves in Rheumatic Heart Disease- An Observational Echocardiographic Study in a Tertiary Care Centre, Bengaluru, India

S Lalitha, Vijay Sai, Prajith Pasam, V Bhargavi

Introduction: Rheumatic Heart Disease (RHD) is a non suppurative sequelae of group A beta haemolytic streptococci, resulting from inadequately treated streptococcal sore throat or scarlet fever and leading to valvular heart disease. Rheumatic heart disease is a major cause of morbidity and mortality in younger population in developing countries. The present study was done at a tertiary care medical college hospital with the objective of establishing prevalence and involvement of different valve patterns by Echocardiography (ECHO). Aim: To analyse the valvular pattern of RHD over a period of four years in a tertiary care centre and highlight the importance of ECHO in the definitive diagnosis of RHD, and to know the continuing burden of RHD. Materials and Methods: This was a hospital based retrospective observational study conducted at Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. A total of 518 cases of RHD were selected as a study population among the ECHO performed between January 2016 and January 2020 after an exclusion criterion of degenerative mitral and aortic valve disease, congenital aortic and mitral valve disease, myxomatous mitral valve disease, trivial and functional regurgitation. Analysis of valvular pattern was performed. Data analysis was done by tables, charts, percentages and ratio. Results: A total of 518 patients were diagnosed to have RHD by 2-Dimensional ECHO. Among them 276 (53%) were females and 242 (47%) were males. The average age was 41.9 years. The most common valve involved independently and in combined lesions was the mitral valve. Of the study population, 446 patients had Mitral Stenosis (MS) and 393 had Mitral Regurgitation (MR). Aortic Stenosis (AS) was found among 111 patients and 304 patients had Aortic Regurgitation (AR). Tricuspid Stenosis (TS) (organic) was found in seven cases. Multiple valves were involved in 204 cases. Among them 104 of the cases had MS, MR and AR, 69 cases had MS, MR, AS and AR, 21 cases had MS, AS and AR, seven cases had MR, AS and AR and three cases had MS, AS, AR and TS. Though aortic valve was involved in multi valvular lesions, significant AR (moderate and severe) was seen in 109 patients and significant AS (moderate and severe) was seen in 67 patients. Conclusion: RHD continues to be a major burden to population in developing countries. In the present study, various patterns of valvular involvement were noted. Drastic measures are to be taken primary and secondary prevention of RHD.

A Prospective Cohort Study of Catheter Drainage versus Percutaneous Needle Aspiration in Treatment of Liver Abscess

RK Vineeth Kumar, Ashish Pratap Singh, Ashish Singh, Priyank Sharma

Introduction: India has second highest incidence of liver abscess worldwide. Image guided drainage methods are increasingly used to treat liver abscesses with fairly high success rates and with low cost and patient preference. But to choose a preferred one among these two methods of Percutaneous Catheter Drainage (PCD) and Percutaneous Needle Aspiration (PNA) still is a dilemma. Aim: To compare the effectiveness and outcome of PCD and PNA in treatment of liver abscess. Materials and Methods: A prospective cohort study was conducted on 150 liver abscess patients in Shyam Shah Medical College in Vindhya region Rewa, Madhya Pradesh, India, from June 2019 to May 2020. They were divided into two groups PNA (n=75) and PCD (n=75) by simple randomisation. Patient outcome was on the basis of duration to attain clinical relief (assessed subjectively), duration of hospital stay and days required for reduction in cavity size below 50%, death, and success rates were assessed in terms of number of attempts for adequate pus drainage. Chi-square test, non-paired Student’s t-test and ANOVA tests were used. Results: In this study mean age was 40.57 years with 92.67% males. Most common lobe to involved was right lobe (87.3%). E.coli was the most common organism. All patients in PCD group were successfully treated in a single attempt. PNA group had a success rate of 84%. Mean number of days of clinical improvement were less for PCD (mean was 5.27 days) than PNA group (mean was 7.49 days) p-value=0.002. Mean days required for reduction in cavity size to less than 50% was lower in PCD (mean was 7.20 days) than PNA group (mean was 8.75 days) p-value=0.01. Total duration of hospital stay was higher in PNA (mean was 11.59 days) than in PCD group (mean was 9.28 days) p-value=0.03. All multiloculated cavities in PNA group were failures. Conclusion: PCD method was found to be more efficacious than needle aspiration method in this study.

Ultrasound Assessment of Carpal Tunnel Syndrome in Comparison with Nerve Conduction Study: A Case-control Study

Introduction: Carpal Tunnel Syndrome (CTS) is the entrapment neuropathy which is diagnosed based on the clinical history, examinations and the electrophysiological findings. The Cross-sectional Area (CSA) measurement of the median nerve has emerged as an alternative to Nerve Conduction Studies (NCS) for diagnosis of CTS. This study was done to correlate NCS and Ultrasonography (USG) in clinically diagnosed CTS patients. Aim: To evaluate the diagnostic value of Cross-sectional Area (CSA) of median nerve at carpal tunnel inlet in patients with clinically and NCS confirmed Carpal Tunnel Syndrome (CTS) and to assess severity of the syndrome by NCS and its correlation with USG results. Materials and Methods: This was a hospital based, case-control study done on a total of 109 patients of CTS and analysed during the period from June 2017 to June 2019. Total 203 hands of the patients with abnormal NCS formed case group while 101 hands from healthy volunteers constituted the control group. All the patients underwent neurological evaluation by Boston Carpal Tunnel Questionnaire (BCTQ) and were divided into mild, moderate and severe according to the score. An electromyography machine was used to perform electrophysiological studies of both the limbs in all subjects. CTS was diagnosed electro-diagnostically based on the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) guidelines and were classified as mild (Grades 1 and 2), moderate (Grades 3 and 4), and severe (Grades 5 and 6) grades using Bland’s electrophysiological grading scale. USG was performed for all the subjects and all the data of various investigations was analysed using Statistical Package for Social Sciences (SPSS) version 22.0 software. Chi-square test and Mann Whitney U-test were used as test of significance for qualitative data. Results: The mean age of subjects was 44.38±9.561 years. Strongly significant association was observed in BCTQ symptom, functional and total scores with NCS severity grading (p-value <0.001). Moderately significant association was found between BCTQ symptom and total scores with USG severity grading (p-value<0.02). Tunnel grade and NCS grade were found significantly correlated (p-value <0.001). The mean CSA cut-off value of 8.5 mm² at the inlet of carpal tunnel had a good sensitivity 86.21%, specificity 83.17%, Positive Predictive Value (PPV) 91.1% and Negative Predictive Value (NPV) 75%. Conclusion: The diagnostic accuracy of USG assessment and NCS was found to be correlated comparably and complement each other in all grades of CTS. USG, can be considered a preferable screening tool by the patients of CTS due to its painless nature and easy accessibility. It requires minimal time and many a times detects those structural abnormalities which have great therapeutic implications. In mild CTS cases, USG should always be combined with NCS for proper diagnosis as USG might give negative result.

A Cross-sectional Study to Assess Neutrophil Lymphocyte Ratio as a Predictor of Microvascular Complications in Type 2 Diabetes Mellitus Patients

Sutanay Bhattacharyya, Neelima Jain, Himanshu Verma, Kavish Sharma

Introduction: Neutrophil Lymphocyte Ratio (NLR) is a novel marker of chronic inflammation that exhibits a balance of two interdependent components of the immune system and can be used to predict microvascular complications in diabetes. Aim: To study the NLR in type 2 diabetes patients and its association with microvascular complications in these patients. Materials and Methods: This was a cross-sectional study conducted over 18 months at Safdarjung Hospital, New Delhi. Eighty patients of type 2 Diabetes Mellitus (DM) were selected for the study. Detailed history was taken including duration of DM, symptoms suggestive of any complications or co-morbidity and treatment history. Physical examination (height and weight) and systemic examination was performed to check for presence of any diabetic complications. NLR was obtained from the complete blood counts by dividing the absolute number of neutrophils to the absolute number of lymphocytes. Data recorded were analysed using Statistical Package for Social Sciences (SPSS) software version 21.0 Logistic regression analysis and Receiver Operating Curve (ROC) curve were used. Results: Total 38.7% (31) of the patients had high NLR, with mean±Standard Deviation (SD) of NLR being 3.29±1.49. There was a statistically significant association between poorly controlled diabetes HbA1C >7%, high-sensitivity C-Reactive Protein (hs-CRP) levels and NLR. NLR was found to be the best predictor of diabetic neuropathy and diabetic nephropathy. NLR was also significantly higher in DM patient having more than one microvascular complication. Conclusion: NLR can be used as a simple parameter to predict presence of diabetic microvascular complications. Thus, an early diagnosis and subsequently targeting inflammatory pathways could possibly be a component of the strategies to prevent and control diabetes related complications.

A Prospective Interventional Study of Xanthelasma Palpebrarum Treated with Ultrapulse Carbon Dioxide Laser

Manjeet Naresh Ramteke, Usha Naraindas Khemani

Introduction: Xanthelasma palpebrarum (XP) is the most common of all the xanthomas which presents as asymptomatic, often bilateral, soft, yellow, papules and plaques around the eyelids. Although, the lesions are benign, it is aesthetically upsetting. The surgical laser is the most effective treatment modality to this problem. Aim: To evaluate the efficacy and safety of ultrapulse Carbon dioxide (CO₂) laser in XP in Indian patients. Materials and Methods: It is a prospective, interventional study carried out for two years in which 29 patients with 61 XP lesions were part of the study. Ultrapulse CO₂ (Fraxis Duo laser; 10,600 nm) laser treatment was done in every patient for a single sitting. Statistical significance was calculated using Chi-square test using Statistical Packages for Social Sciences (SPSS) version 19.0. The p-value of 0.001 was considered statistically significant. Results: A total number of 29 patients with 61 xanthelasma lesions were included in the study, of which 11 were males and 18 were females with an age range of 27-54 years. In the present study XP lesions were completely resolved in majority (54 lesions in 25 patients) of treated patients. No intraoperative complications were observed. Two patients showed hypopigmentation. There was neither scarring nor recurrence seen after six months follow-up. Conclusion: Ultrapulse CO₂ laser is a safe and effective option of treatment for xanthelasma. It is considered as less painful procedure with fewer side effects and recurrences in the present study.

Perinatal Outcome Following Gentiourinary Tract Infection in Preterm Labour: A Hospital Based Cross-sectional Study

Mangala Gowri, Shahina Begum

Introduction: Preterm labour (PTB) is one of the major concerns in obstetrics with respect to both or neonates and the mother. Aim: To study the genitourinary tract infections among the cases of preterm labour in a tertiary care hospital; and to estimate the Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) scores and birth weights of preterm babies. Materials and Methods: This was a descriptive cross-sectional study conducted in the Department of Obstetrics and Gynaecology of AJ Institute of Medical Sciences and Research Centre, Mangalore, India. All the preterm labours that occurred in the study setting in the calendar year of 2020 were considered as potential study participants. After screening for eligibility criteria, study participants were finalised. Intra-natal and immediate postnatal details (gestational age at delivery, mode of delivery, birth-weight of the baby, APGAR score, Neonatal Intensive Care Unit (NICU) admission) were noted. Investigations like C-Reactive Protein (CRP), urine routine and microscopy, urine culture and sensitivity, high vaginal swab analysis were also noted. Data entry and analysis was done in Microsoft Excel version 2013. Results: There were 130 study participants, out of which 102 were eligible for the study. Most of the preterm deliveries occurred in primigravida between 32 and 37 weeks. Symptoms and signs of genitourinary tract infection was found in many (29% to 99%) mothers delivered preterm. Common organisms found in culture from urine sample and high vaginal swab were Escherichia coli (E.coli) (23.5%) and Candida (43.9%), respectively. Among 102 preterm new-borns, 58.8%% were delivered vaginally and 42.2% of the new-borns required NICU care. Proportion of infection among those undergoing preterm labours was higher. Hence, preterm labour and the complications can be avoided by good hygienic practices and medications. Conclusion: Proportion of infection among those undergoing preterm labours was higher. Hence, preterm labour and the complications can be avoided by good hygienic practices and medications.

Determination of Corneal Endothelial Cell Count and Morphology in Patients with Pseudoexfoliation: A Cross-control Study

Purva Shailesh Nagle, Varsha Nitin Kulkarni

Introduction: Pseudoexfoliation Syndrome (PEX) is characterised by the formation or deposition of abnormal fibrillar material on intraocular structures. Various ocular complications, such as chronic open-angle glaucoma, zonular dehiscence causing lens subluxation/dislocation, poor mydriasis are associated with PEX. In PEX eyes, corneal endothelial changes have been demonstrated along with thinner Central Corneal Thickness (CCT). Aim: To evaluate the CCT, corneal Endothelial Cell Density (ECD) and morphology in patients with pseudoexfoliation and to compare the results with age matched controls. Materials and Methods: A case-control study was done on a total of 147 eyes of 81 patients with pseudoexfoliation with equal number of eyes in age matched controls were evaluated for corneal ECD, coefficient of variation in cell size, percentage of hexagonal cells and CCT using a non-contact specular microsope. The quantitative data was represented as their mean±Standard Deviation (SD). The paired t-test was used for analysing quantitative data. Results: The average ECD in the PEX group was 2301.30±117.37 cells/mm². It was significantly lower than the average ECD in controls 2632.91±24.04 cells/mm² (p-value <0.001). The average CCT in the PEX group was 508±19.09 microns and in the age matched controls was 524.22±6.36 microns. The average CCT was low in the PEX group and difference was statistically significant (p≤0.001). The coefficient of variation and percentage of hexagonality were altered but did not show any statistical significance in both the groups. Conclusion: ECD and CCT is significantly decreased in eyes with PEX. Pleomorphism and polymegathism was not found significant in this study.

A Systematic Review of Studies Comparing Actigraphy Indices in Patients with Depression and Schizophrenia

Ramdas Ransing, Pradeep Patil, Anurag Khapri, Aditya Mahindru

Introduction: Abnormalities in sleep-wake activities are frequently observed among patients with depression and schizophrenia. These abnormalities are variable and may have discriminative, clinical, diagnostic, and therapeutic significance if measured objectively with actigraphy. Aim: To systematically review the published literature on actigraphy in depression and schizophrenia, particularly to identify areas of research that need to be addressed before their clinical application in practice. Materials and Methods: The electronic databases (PubMed and Google Scholar) were searched for studies using the the key terms ‘actigraphy’ OR ‘actigraphic recording’ OR ‘wrist actigraphy’ OR ‘actometer’ OR ‘actimeter’ OR ‘actical’ OR ‘actiwatch’ OR ‘sleep-watch’ AND ‘schizoaffective’ OR ‘schizophr*’ OR ‘psychosis’ AND ‘depression’ OR ‘depressive’ in title and abstract. The literature search was limited to articles published in English and until 31^st December, 2020. Data were abstracted by two reviewers and presented as a narrative summary of the findings. A qualitative synthesis of the study designs, populations, and outcomes was conducted. The quantitative synthesis of the results was not possible to conduct due to the heterogeneity and scarcity of the included studies. Results: Out of 33 searched articles, a total of four studies (three observational and one case report) were included for the review. The included studies were heterogeneous, small in sample size, divergent in methods, inclusive of clinical population, having more than two groups (depression, schizophrenia, mania, or bipolar disorders), and with a low degree of evidence. Overall, the patients with schizophrenia have more structured and less complex activity pattern than those with depression. Furthermore, the patients with schizophrenia showed more irregular patterns in the morning period and increased fluctuations inactivity in the evening period than depression patients. Conclusion: Currently, available information is insufficient to draw firm conclusions on use of actigraphy indices (e.g., duration of active periods, a pattern of activity, and sleep) for diagnosis and discrimination among the patients with schizophrenia and depression. Large, prospective, and comparative studies are required to identify role of actigraphy among these patients.

Prenatal Markers of Foetal Complications

Hanan L Al-Omary, Zainab M Alawad

Prenatal markers are commonly used in practice to screen for some foetal abnormalities. They can be biochemical or ultrasonic markers in addition to the newly used cell free Deoxyribonucleic Acid (DNA) estimation. This review aimed to illustrate the applications of the prenatal screening, and the reliability of these tests in detecting the presence of abnormal chromosomes such as trisomy-21, trisomy-18, and trisomy-13 in addition to neural tube defects. Prenatal markers can also be used in the anticipation of some obstetrical complications depending on levels of these markers in the mother’s circulation. In the developed countries, prenatal screening tests are regularly used during antenatal care period. Neural tube defects, numerical and structural chromosomal abnormalities, in addition to some obstetrical problems are commonly screened for, by using prenatal tests. Maternal education about the importance of performing these tests should be done in order to improve the detection rate of foetal abnormalities and some pregnancy complications.

Microimplant Assisted Rapid Palatal Expansion: A Comprehensive Review

Maxillary transverse deficiency routinely requires expansion of the palate. In prepubertal patients, Rapid Maxillary Expansion (RME) is a reliable treatment modality. However, in skeletally mature patients due to progressively interdigitated mid palatal suture, decreased elasticity of bone and increased stiffness of the osseous articulations of the maxilla with the adjoining bones, palatal expansion becomes challenging. Patients are frequently suggested to opt for more invasive procedures, like the Surgically Assisted Rapid Palatal Expansion (SARPE). The quest for minimally invasive expansion appliances with pure orthopaedic movement led researchers to incorporate mini-implants with conventional RME. Microimplant Assisted Rapid Palatal Expansion (MARPE) maximises skeletal expansion and minimises dentoalveolar undesirable effects and obviates the need for orthognathic surgery. This comprehensive review aims to discuss MARPE as an effective, non surgical, minimally invasive treatment modality for skeletally mature patients with maxillary transverse insufficiency. Furthermore, various designs of MARPE with different placement sites, lengths, and numbers of miniscrews along with the latest technological advancements to improve diagnosis and treatment planning using CBCT and intraoral scan, as well as the use of Computer-Aided Design/Computer-Aided Manufacturing (CAD-CAM) technology to custom fabricate three dimensional (3D) miniscrew insertion surgical guide, 3D laser-printed metallic mini-implant to enhance implant placement accuracy and comfort were discussed along with the clinical significance and limitations of the MARPE. Maxillary Skeletal Expander (MSE) is a unique lineage of MARPE when combined with facemask results in distraction osteogenesis like movement of midface and forms a promising basis for non surgical orthopaedic treatment modality for skeletal class III mature patients. Bone-anchored maxillary expansion appliances provide better vertical control, especially beneficial for hyperdivergent skeletal pattern patients. MARPE significantly increases transverse widths of the nasal floor, nasopharyngeal volume and significantly lowers mean nasal airway resistance thereby facilitating nasal breathing. MARPE results in greater orthopaedic expansion and safety, with fewer undesirable effects and high success rates.

Oral and Periodontal Manifestations of COVID-19 and its Plausible Association with Periodontal Disease

Narayane Ramkumar, Hanumanth Sankar

The coronavirus disease 2019 (COVID-19), has caused a significant and urgent threat to the global health. It has markedly affected the delivery of healthcare services all over the world. Early diagnosis of the disease is imperative to contain the spread of the viral infection. The virus can also lead to potential systemic complications such as lungs involvement, skin, and oral manifestations. The presence of oral lesions is emerging evidence that may indicates the presence of COVID-19 infection. Since, the virus has affinity for Angiotensin Converting Enzyme (ACE2) receptors present in the respiratory tract, oral mucosa, tongue and salivary glands; therefore, the oral cavity serves as a major habitat for invasion of the virus. This review aimed to discuss the oral and periodontal manifestations of COVID-19. Articles between December 2019 and April 2021 were searched for this narrative review in Pub Med, Scopus, Science Direct related to COVID-19 and its oral manifestations, using the following terms: “Corona virus,” “COVID-19,” and “SARS-CoV-2” in combination with “Stomatognathic diseases,” “Oral manifestation,” and “Mouth diseases” and “Periodontal diseases”. The oral manifestations commonly associated with COVID-19 are salivary gland disorders, xerostomia, alteration of taste and smell and lesions in oral mucosa. The appearance of these oral manifestations during the asymptomatic phase of disease helps in early identification of the disease. The recent COVID-19 infection has been strongly associated with the appearance and establishment of cytokine storm. It is found that many components of the cytokine storm are common with the cytokine expression found in periodontitis. This narrative review aims at exploring the association between COVID-19 and periodontal disease through their cytokine profiles.

Cervicogenic and Vestibular Vertigo-Bridging the Gap

Aditya Ranjan, Shraddha Jain, Shyam Jungade

The diagnosis and management of vertigo is still a challenge. Vertigo is managed by heterogenous group of specialists, including Otolaryngologists, Neurologists and Physiotherapists. The cause of vertigo could be vestibular, central or cervicogenic. The current review was undertaken as an attempt to highlight the various gaps in knowledge about vertigo of varied aetiologies. Cervicogenic vertigo is caused due to neck pathologies and is considered by some authors to be one of the most common vertigo syndromes. However, there is little mention of it in otolaryngology textbooks. Barriers across the specialties and lack of communication between the specialists are an impediment in vertigo management. This review has attempted to highlight the likely multifactorial aetiologies and fallacies in the pathophysiology of Meniere’s disease. The clinical overlaps in cervicogenic and vestibular vertigo have been discussed, some of them being, the occurrence of aural symptoms and neck pain in both the entities. This review article brings out the need to revisit the pathophysiology of vestibular vertigo syndromes and include cervicogenic dizziness in the list of vertigo syndromes in Otolaryngology textbooks. The authors found a dire need of an interdisciplinary approach to elucidate the cause of vertigo of varied presentation with the goal of better patient management.

Need Based Role of E-Learning in Current Medical Education Environment: Skepticism to Acceptability

Prerna Agarwal, Aarti Sood Mahajan

E-learning has taken centre stage during this period of social distancing and lockdowns, in the current pandemic, by enabling education to continue. There are perceptibly no limitations to the utility of e-learning tools in the cognitive domain of learning. It complements traditional learning in other domains, namely, psychomotor, affective and communication skill, fairly well. Not only does it ease learning in terms of availability and accessibility, but with the options of asynchronous learning and personalisation of content, it also empowers learners with more autonomy. Despite the limitation of lack of ‘hands-on’ training and experience with e-learning, it has been accepted quite well, although initially both teachers and learners had been skeptical about its applicability and quality. In the ongoing pandemic period, e-learning may assume a bigger role as blended learning in medical education. While this transition may be smooth for the better resourced nations who already have the required infrastructure and resources ready, the resource limited nations may first have to develop the same before being able to implement it. Ensuring the availability of cheap and high-speed internet, computers in various forms (desktops, laptops, tablets and smartphones) within reach of every learner, will enable them to go online.

Hype and Hope of Emerging Therapies to Safeguard against COVID-19 Pandemic

The Coronavirus Disease-2019 (COVID-19) is a highly contagious disease presenting with multiple non specific symptoms and caused by Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2). Despite its dissemination and worsening trends researchers are still searching for the best treatment option. Timely diagnosis is the key to get more appropriate treatment regimen. Several clinical trials are ongoing to determine the efficacy and safety of existing and new therapies against Coronavirus Disease -2019 (COVID-19). These include corticosteroids, antivirals, monoclonal antibodies, interferon Alpha 2b and other immune modulators. In addition to treatment, efficacious and safe vaccines are required to slow viral transmission and to prevent further morbidity and mortality. The vaccination is useful tool to get control over the virus. Although, mass immunisation campaigns are ongoing in many countries, global coverage is crucial for getting the pandemic under control. This descriptive review collated the information on current diagnostics tools for determination of COVID-19 infection and available preventive and therapeutic strategies based on the ongoing clinical trials data and published literature.

Prevention of SARS-CoV-2 Infection with Antioxidants and Anti-inflammatory Action of Indian Spices: Light at the End of the Tunnel

Sandeep Negi, Sonal Bhatt, Lakshmi Bala

Today, we are living in the era of Coronavirus Disease-2019 (COVID-19), a pandemic that has affected almost the whole globe. It has rightly been called as the ‘twenty-first-century plague’ which has garnered considerable attention from researchers, pharma companies, policymakers, and media. Though vaccines are being deployed and people are eagerly receiving vaccination; the duration of conferred immunity, the possibility of re-infection of recovered/vaccinated individuals, the consequence of the new mutation in SARS-CoV-2 and its impact and challenge for the efficacy and degree of protection that a potential vaccine could provide is under question. In the absence of any definite answer, people are turning towards natural remedies and spices. India is known globally as the land of spices. Spices like ginger, garlic, black pepper, cardamom, turmeric, clove, cinnamon, etc., are known for their rich aroma, texture, and immunity boosting ingredients. These are rich sources of antioxidants such as flavonoids and alkaloids. The antioxidants present in them, neutralise the free radicals generated inside the body during viral infections and also prevent cellular damage. These exhibit anti-inflammatory activity and have the potential to combat “cytokine storm” in severe COVID-19 infection. Their potential has been realised by the public and has led to a tremendous increase in global demand and consumption. The present review enlists the active ingredients present in important spices and addresses their antioxidants, anti-inflammatory, and anti-viral action. Traditional Indian spices that are not only a cardinal part of the diet but are affordable, easily available can be viewed as the light at the end of the tunnel to combat the current COVID-19 conditions as a preventive measure.

Salivary Metabolic Profiling of Systemic Disorders and Oral Neoplastic and Preneoplastic Conditions- A Narrative Review

Salivary metabolic profiling has emerged as an important mode of analysing the metabolic markers that aids in early disease detection in various systemic diseases. The metabolomics study states that, the transitional and the end products of interactions that take place between genes, proteins, and the environment are found to be involved in various disease processes. Salivary metabolomics stands as a highly specific and sensitive method in diagnosis of various conditions making it a better alternative to the conventional serum and tissue-based methods well. These metabolomics studies incorporate various analytical technologies for identifying each component that could be used as a biomarker. Hence, we reviewed the current state of salivary metabolomics, diagnostic efficiency and its associated technologies and its future role in identification and monitoring the disease prognosis. The study selection was done by locating those research papers that provided information on salivary diagnostics using metabolic markers for early diagnosis in systemic disorders, neoplastic and preneoplastic conditions with help of search engines like Pubmed, Google Scholar, Web of Science and Cochrane library. The results of each study were critically evaluated to accentuate the principal role played by these biomarkers in the field of salivary diagnostics.

The Relevance of Freud in the Modern World

Utpreksha Gaude

Sigmund Freud has affected generations not only in the field of psychology but also in social scenarios, home life and popular culture. His views and theories have shaped our current concepts ranging from development to therapy. His beliefs, in his time, not only inspired his contemporaries with theirs’ but they also sparked controversies with other intellectuals. Despite being subject to criticism, his ideas have been and are still relevant. The terms introduced by him like the ‘Freudian slip’ and ‘denial’, have been incorporated into the present dictionaries and everyday life. Massively influential, his ideas, theories and his school of thought, psychoanalysis, continue to have a strong impact on psychology as well as psychotherapy even today.

Jejunojejunal Intussusception in an Adult- Secondary to Lipoma

Annie Nitisha, Shobana, Mary Lilly

Gastric lipomas are very rare Tumours of Gastrointestinal Tract (GIT) accounting for about 2-3% of all benign gastric tumours. They are asymptomatic and discovered incidentally, most lipomas being submucosal. Authors hereby discuss a case of 50-year-old female patient who presented with abdominal pain and vomiting since four days. Transabdominal Ultrasound (TAUS) revealed long segment jejunojejunal intussusception and a hypoechoic lesion in the distal end of intussusception which was successfully treated by removing the lipoma along with the intussuscepted loop. Histopathological features revealed normal jejunal mucosa with a segment of intussusception and edematous submucosa which was thought to be submucosal lipoma or subserosal lipoma. As these lesions present at later dates, proper follow-up and early intervention is needed.

Book Review on “Essentials of Biostatistics and Research Methodology”

Shilpa S Kottoor

Essentials of Biostatistics and Research Methodology, 3^rd edition, stands out from the usual books on statistics with its presentation style. Each chapter starts with the vital basics, yet manages to cover all the key topics. Authors have simplified every concept by employing appropriate examples. Explanations are in the form of crisp bullet points, which makes for an effortless read. Noteworthy terms are highlighted, schematic diagrams and tables are aplenty and chapters end with self review exercises; all of which will aid in examination preparations. Moreover, there are boxes highlighting important points and footnotes with supplementary facts which provide much food for thought. The layout of the book is visually appealing along the lines of its cover page. It is 400 pages long, nevertheless, has a compact structure and is easy to carry. The contents are systematically organised into two broad sections of Biostatistics and Research Methodology; the latter being the quintessential add-on to the previous editions. Personally, I felt that this segregation of topics makes the book more reader-friendly and coherent. The first segment pertains to the fundamentals of statistics, while the next segment is devoted to the principles and practicalities of research. Both the authors are stalwarts in the teaching field which clearly reflects in their explanatory writing. Their vast editorial and research experience ensures that the book is cognizant of recent updates in the field of publication as can be seen in the chapters: “Ethics in Biomedical Research” and “Publication Technicalities”. Evidently, this is a go-to book for students and research scholars in the fields of healthcare and allied sciences. It will come in handy for all graduate and post graduate level biostatistics examinations as well as for various entrance exam preparations. Finally and above all, this book will be a mandatory guide for scientific writing and publication of research papers. Future editions could include a link for free access to the soft copy which would help students avail the content from their electronic devices. Also, a chapter on critical appraisal of research papers can be incorporated which would facilitate evidence based practice.