Journal of clinical and diagnostic research

Anomalous Single Coronary Artery Presenting with Acute Myocardial Infarction

The anomalous origin of the entire coronary system from the right coronary sinus is a very rare anomaly. Here a patient with this rare anomaly, who developed acute coronary syndrome, requiring revascularization, is presented and treated successfully. His coronary angiographic findings are also discussed. We would like to highlight the rarity of the origin of all 3 coronary arteries from a single coronary trunk. The case also highlights the importance of using Amplantzer AR1 guiding catheter for such anatomical variations arising in the right coronary cusp.

A Case of Verruciform Xanthoma Arising in the Tongue

Yukihiro Hiraishi, Itaru Tojyo, Norifumi Kiga, Koji Tanimoto, Shigeyuki Fujita

Verruciform Xanthoma (VX) is a rare lesion of the oral cavity. Histologically, it is characterized by papillary or verrucous proliferation of squamous epithelium and numerous foam cells. VX arising in the tongue is comparatively rare, as most cases of VX in oral cavity occur in gingiva. A 65-year-old woman was referred to our clinic with a mass on the left side of the tongue. The lesion was yellowish, and its surface was granulated. The patient had neither tenderness nor any symptoms. The lesion was clinically diagnosed to be a benign tumor, and hence, biopsy was performed, according to which it was diagnosed as hyperparakeratosis. Based on this diagnosis, the tumor was excised under general anesthesia. Histopathologically, the tumor consisted of stratified squamous epithelium with parakeratosis and elongated rete ridges. Aggregation of foam cells was observed between and under the rete ridges. From these features, a diagnosis of VX was made. The patient has had no local recurrence as of three years post-operatively.

Jejunal Epiphany: Diverticulae, Enteroliths and Strictures

Priyank Pathak, Babar Rehmani, Navin Kumar

Multiple jejunal diverticulae represent a rare entity and are usually asymptomatic. This case report is about one such jejunal diverticulae along with multiple enteroliths and jejunal strictures. All these three different findings in a short segment of jejunum is a very rare finding with all three variants seen in a segment of jejunum. We herein present a case of a 45-year-old male, who presented with vague abdominal pain for one and half years associated with nausea and vomiting and altered bowel habits. Laparotomy revealed multiple large jejunal diverticulae compressing the bowel with multiple enteroliths and two strictures in a short segment of jejunum leading to intestinal obstruction. Patient underwent resection of the involved jejunal segment and then repair by anastomosis. Post-operative period was uneventful.

Pyostomatitis Vegetans: A Clue for Diagnosis of Silent Crohn's Disease

Saede Atarbashi-Moghadam, Ali Lotfi, Fazele Atarbashi-Moghadam

Pyostomatitis vegetans is a very rare oral manifestation with unknown pathogenesis. Skin and other mucous membrane involvement may be seen. This lesion has strong association with Inflammatory Bowel Disease (IBD) and may be the first sign of it. The management of Pyostomatitis vegetans is usually based on the management of underlying bowel disease. We present a case of Pyostomatitis vegetans involving gingiva and oral mucosa with no skin lesion which led to the diagnosis of Crohn’s disease to emphasize important role of dentists in diagnosis of rare oral lesions and management of patients' systemic disease.

Simultaneous Transabdominal Hysterectomy and Cystolithotomy in an Augmented Urinary Bladder: Challenges and Outcome

Vijay Sharma, Rakesh Kapoor, Priyank Yadav, Pankaj Gaur, Deepa Kapoor

Augmentation cystoplasty is a procedure to increase the anatomical as well as functional capacity of the urinary bladder using a segment of bowel or ureter. Upto half of these patients develop complications but most of them are minor and managed easily. Urolithiasis, especially bladder calculi are seen in upto half of the cases and are removed endoscopically or by open approach. Hysterectomy is an uncommon procedure in patients with augmentation cystoplasty and is complicated by the altered anatomy of the pelvis. We describe a rare case of simultaneous abdominal hysterectomy and cystolithotomy in a patient with augmentation cystoplasty and discuss the relevant surgical anatomy.

Delayed Uterine Necrosis: Rare Cause of Nonhealing Wound

Aruna Nigam, Neha Gupta, Arifa A Elahi, Zeeba S Jairajpuri, Swaraj Batra

Uterine necrosis is a very rare condition and most of the reported cases occurred after pelvic arterial embolization for post-partum haemorrhage, embolization of fibroid uterus or application of B–Lynch sutures. A case of delayed myometrial necrosis is reported in post-cesarean patient where no embolization or uterine compression sutures have been applied. Patient presented with foul smelling discharge from the gaped abdominal wound following caesarean section. Abdomen was closed after exploration and lavage. Patient did not have complete healing and area of unhealed wound remained through which subinvoluted uterus was peeping out. Patient was taken for resuturing again but the uterus was found to be completely necrotic and hysterectomy was performed. Patient responded to treatment.

Cerebral Venous Thrombosis in Pregnancy-A Poignant Allegory of an Unusual Case

Cerebral Venous Thrombosis (CVT), also known as cortical venous, cerebral sinus, cerebral venous sinus, or dural sinus thrombosis, is an infrequent grave condition affecting pregnant females, resulting from clot formation in one of the many outflow tracts of the brain. Although pregnancy-associated stroke or CVT is uncommon, the risk of stroke is greatly increased above the low baseline rate in young patients during late pregnancy and, even more so, during the puerperium. Haemorrhagic infarction can occur in the acute stage of CVT. The article reports a case of CVT in puerperium in woman without any risk factors for thrombosis, highlighting the difficulties encountered in differentiating this rare cause from common diagnoses such as eclampsia. Also, clinical considerations and relevant literature review on prognostic factors affecting outcome have been addressed. CVT is an uncommon serious neurologic disorder in young gravidas requiring prudent assessment of the potential differential diagnoses and prompt management.

Acquired Clitoromegaly: A Gynaecological Problem or an Obstetric Complication?

Mamta Gupta, Vandana Saini, Anju Poddar, Supriya Kumari, Ashesh Maitra

Acquired non-hormonal clitoromegaly is a rare condition and is due to benign or malignant tumours and sometimes idiopathic. Few cases of clitoral abscesses have been reported after female circumcision. We hereby report a case of clitoral abscess causing acquired clitoromegaly following an obstetrical surgery.

Precautionary Measures for Successful Open Heart Surgery in G6PD Deficient Patient- A Case Report

Rupesh Kumar

Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency is among the most common enzymatic disorders of red blood cells. Cardiac surgeries on this group of individuals are associated with an additional risk in terms of impaired oxygenation, prolonged ventilation and increased risk of haemolysis. These patients have a very low threshold for haemolysis due to oxidative stress. Many commonly used drugs also predispose the individual for haemolysis when they are subjected to surgery. Here we present a known case of G6PD deficient patient with symptoms of breathlessness for the last nine years who was taken for surgery with pre-planned precautionary measures to avoid unnecessary haemolysis. The echocardiography report revealed severe mixed mitral lesion and moderate tricuspid regurgitation. On general examination she had mild pallor and icterus. We planned for a thorough investigation to prepare her for mitral valve replacement and tricuspid annuloplasty. These groups of patients are at high risk of haemolysis during perioperative period and need prolonged mechanical ventilation and hospital stay due to impaired oxygen carrying capacity and oxidative stress due to deficient free radical scavenging system. The patient underwent mechanical mitral valve replacement and tricuspid annuloplasty under cardiopulmonary bypass with precautionary measures to prevent the risk of haemolysis and associated complications. She had an uneventful recovery.

Eosinophilic Granulomatosis with Polyangiitis (EGPA) and Hepatitis B Infection – A Rare Association

Nidhi Kaeley, Kamakshi Narula

Eosinophilic Granulomatosis with Polyangiitis (EGPA) or Churg-Strauss syndrome is a rare systemic illness which is characterized by necrotizing inflammation of small and medium sized vessels. The prominent features include asthma, eosinophilia, transient pulmonary infiltration and systemic vasculitis. Various triggering factors have been reported as putative aetiological agents of Churg-Strauss syndrome. They include infections, allergic desensitization, vaccinations like hepatitis B and influenza vaccination, cocaine abuse, drugs like leukotriene receptor antagonists and exposure to pigeons. We report a rare case of Churg–Strauss syndrome co-infected with Hepatitis B Virus (HBV). Very few such cases have been reported in the past.

Balanced Autosomal Translocations in Two Women Reporting Recurrent Miscarriage

Brindha Arumugam, Chandra R Samuel, Santhiya Sathiyavedu thyagarajan

Spontaneous abortion or loss of fetus prior to 20 weeks of gestation is observed in 15-20% of clinically recognized pregnancies. Recurrent Miscarriage (RM) is defined as three or more consecutive pregnancy losses and it affects 1-2% of women. Parental chromosomal rearrangements account for 2-5% of RM. This report describes two couples with a clinical history of RM who were subjected to conventional cytogenetic analysis to ascertain the chromosomal aetiology. Analysis of GTG-banded metaphases obtained from cultured lymphocytes at approximately 500-band resolution revealed balanced translocation in the female spouses as 46,XX,t(8;11)(p11.2;q23.3) in BR27W and 46,XX,t(5;7)(p15.1;q32) pat in BR49W. Both the male partners exhibited 46,XY karyotype. Fluorescent In Situ Hybridization (FISH) analysis was subsequently carried out to confirm the balanced translocation using suitable whole chromosome paint probes. These balanced chromosomal abnormalities in the parents could be responsible for the repeated fetal losses. Hence, karyotype analysis should be a mandatory etiological investigation for couples with RM towards genetic counselling. Disruption of critical genes through these rearrangements could also underlie the pregnancy outcome.

Adult Neuroblastoma-Case Report and Literature Review

Vishwapriya Mahadev Godkhindi, Maheboob M Basade, Kamran Khan, Kiran Thorat

Neuroblastoma is the most common solid malignant neoplasm in the paediatric age group; accounting for 7% of all childhood malignancies, but neuroblastoma in adult, is a rare occurrence, finding mention in aeons of medical literature with an overall incidence of 1 in 10 million adults/year. We report the case of a 24-year-old male patient presenting with the complaints of progressive abdominal distention of 2 months duration. Multiple Detector Computed Tomography (MD-CT) of abdomen revealed a huge enhancing mass in the retroperitoneum abutting the left kidney, and a subsequent CT-guided biopsy and immunohistochemistry confirmed the diagnosis of ganglioneuroblastoma. The patient was administered 3-cycles of neo-adjuvant chemotherapy with ifosphamide, carboplatin and etoposide (ICE-chemotherapy) and subsequently 3 more cycles of chemotherapy post surgery, followed by radiation. The rarity of this neoplasm in adults accounts for the lack of standardized staging and treatment protocols and the dismal prognosis even with aggressive multimodal treatment. We report this case because of its extreme rarity, and its tendency for capricious behavior.

Pseudo-Exstrophy of Bladder with Unilateral Renal Agenesis: A Rare Combination of two Anomalies

Abdolhamid Amouei, Mohammad Baghi Yazdi, Fatemeh Ehsani, Mojtaba Babaei Zarch

Pseudo-exstrophy of bladder is an uncommon condition characterized by the major musculoskeletal defects without urinary system defects. A two-day-old female neonate was presented with pseudo-exstrophy of the bladder and unilateral renal agenesis- A rare combination of two anomalies. She was born at 37 weeks gestational age with caesarean section delivery. The X-ray of hip revealed pubic diastasis. Ultrasonography clearly showed absence of the left kidney with a normal right kidney. The patient was treated successfully with proper surgical management. We, hereby, report a rare variant case of pseudo-exstrophy of bladder with lower set umbilicus and infra-umbilical midline of lower anterior abdominal wall defect in a neonate who was born in Shahid Sadoughi Hospital, Yazd, Iran.

An Unusual Occurrence of Methicillin Resistant Staphylococcal Endocarditis with Vancomycin Creep Phenomenon – A Therapeutic Challenge

Infective endocarditis by Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia is a common association and carries a high mortality. However, rising Minimum Inhibitory Concentrations (MICs) for vancomycin amongst MRSA strains is an emerging threat which carries poor prognosis and higher mortality. Here we report a case of 41-year-old young non-addict gentleman presenting with fever of 3 days duration following recovery from an acute kidney injury necessitating haemodialysis. Systemic examination revealed signs of mitral regurgitation and left sided cerebellar signs. Laboratory investigations revealed anaemia, MRSA bacteraemia and transthoracic echocardiogram showed a mitral valve vegetation. He was diagnosed with MRSA mitral valve endocarditis with acute left cerebellar infarct. He was initially treated with intravenous vancomycin based on MIC at the dose of one gram every twelfth hourly. As the MRSA strain was shown to demonstrate a vancomycin creep phenomemon along with worsening clinical condition of the patient, treatment was changed to intravenous daptomycin at dose of 9mg/kg as per blood culture and sensitivity pattern which was administered for 6 weeks. Following initiation of daptomycin patient became afebrile and vegetations reduced in size and finally disappeared.

Delirium in Parkinson's Disease: A Cocktail Diagnosis

Robin George Manappallil

Mental disturbances have been described in patients with Parkinsons Disease (PD). Of these, the common conditions are delirium and psychosis. Delirium has been attributed to change of environment, especially hospital stay and infections; while psychosis is due to drugs like dopamine agonists. This is a case of a 75-year-old male, on levodopa therapy for PD, who presented with delirium and ended up with a cocktail diagnosis: Cryptococcal meningitis, Hashimotos Encephalopathy (HE), Urinary tract infection with acute renal failure, Uremic encephalopathy and Levodopa induced psychosis. This case report, therefore, highlights the need to look for other causes of delirium in a patient with PD who is on levodopa therapy.

Isolated Hypoplasia of Left Pulmonary Artery with Agenesis of Left Lobe of Thyroid: A Case Report

Mohammed Abdul Khadir, Ganesh Narayana, Ganavi Ramagopal, Pradeep G Nayar

Isolated Unilateral hypoplasia or agenesis of a branch of pulmonary artery is very rare. It is usually seen associated with congenital heart diseases such as tetralogy of Fallot, atrial septal defect, coarctation of the aorta, right aortic arch, truncus arteriosus, patent ductus arteriosus and pulmonary atresia. It occurs as a result of lack of embryological development of either the left or right sixth aortic arch and has been found to present itself with various clinical manifestations as during childhood it presents as contralateral pulmonary hypertension and in adults as haemoptysis. Early diagnosis and early surgical indication avoids the evolution of pulmonary hypertension to unfavourble state of more severe and progressive degrees and also prevents the development of pulmonary systemic collateral circulation, which is mainly responsible for subsequent haemoptysis in the adulthood. We hereby, report the case of an infant who presented with features of lower respiratory tract infection and later diagnosed as isolated congenital hypoplasia of left pulmonary artery and hence planned for proper follow-up for early surgery thereby preventing complications in the future.

Solid-Cystic Hypoglossal Nerve Schwannoma with Fluid-Fluid Level: A Rare Case Report

Schwannomas (neurinoma, neurilemmoma) are benign slow-growing encapsulated tumours originating from well-differentiated myelin-producing Schwann cells or nerve fiber sheet cells at the glial-Schwann cell junction. Hypoglossal nerve schwannoma mostly develops in the intracranial and extra-cranial segment or in both intracranial and extra-cranial segment forming a dumbbell shape tumour. The peripheral hypoglossal schwannomas are very rare. We present a case of right hypoglossal nerve schwannoma in a 46-year-old female who presented with headache and neck pain since 2 weeks with deviation of tongue to right side since 1 week. Patient was investigated with Computed Tomography (CT) scan of head and Magnetic Resonance Imaging (MRI) of brain, which showed a dumb-bell shaped solid-cystic mass lesion with fluid-fluid level in right cerebello-pontine angle cistern.

Role of Altered Venous Blood Lactate and Hba1c in Women with Gestational Diabetes Mellitus

Introduction: Being a mirror image of metabolic syndrome, Gestational Diabetes Mellitus (GDM) is associated with significant maternal and fetal morbidity. Increased blood lactate concentration and alterations of substrate utilization are partly involved in development of insulin resistance in GDM. Fetuses born to such mothers have shown low umbilical vein oxygen saturation and low oxygen content and increased lactate concentrations. These changes may certainly reflect enhanced fetal metabolism as a result of hyperglycaemia and hyperinsulinemia and therefore, these fetuses deserve intense surveillance at term and during delivery. Ideally, HbA1C should be maintained below 5% during their first trimesters and below 6% during third trimester. We planned to investigate GDM women for their HbA1c levels too. Aim: To know if there is any alteration in blood lactate and/or HbA1c levels and to know if there is any correlation between these two parameters in GDM pregnancies, in comparison with the previous studies which measured lactate in cord blood and placental vessels of GDM women. Materials and Methods: It was a hospital based prospective study on 40 women with gestational diabetes and 40 age-matched normal pregnant women. We analysed the biochemical and metabolic mileau in these women by estimating venous blood lactate and HbA1c levels. We paid special attention to follow them up regarding maternal complications if any and perinatal outcomes. The independent samples t-test and Pearson’s correlation test were applied. Results: GDM mothers showed significantly higher lactate and HbA1c levels than normal pregnant women, both with p<0.001. Blood pressure and fetal birth weight were also significantly higher in GDM group than Normal Pregnant (NP) group, both with p-values of <0.001. Further, this increased lactate levels showed significant positive correlation with HbA1c, blood pressure and fetal birth weight. Conclusion: Maternal blood lactate and HbA1c levels have a significant role to play in determining the metabolic mileau of both mother and fetus and thus, their obstetric and general health outcomes.

Secondary Aneurysmal Bone Cyst of the Scapula Treated by Ct Guided Percutaneous Polidocanol Injection - A Case Report

Rahul Mohan, Gopakumar Thanuvan Sreekumaran

Aneurysmal Bone Cyst (ABC) is a rare benign tumour, usually affecting early age group and at the metaphysis of long bones. Scapular ABC’s are even more rare, especially successfully treated cases. Standard treatment methods like curettage have high recurrence rates hence, adjuvant therapy may be required to avoid recurrence. Polidocanol sclerotherapy is becoming popular because of its safety and efficacy and is being tried successfully for both active as well as aggressive primary ABC of size 3-5cm. We used the same principle in a large secondary ABC of the scapula, which to the best of our knowledge has not been yet reported. The index case is that of a 16-year-old girl who presented with severe pain and swelling of right scapula for 6 months duration with painful limitation of shoulder movements. After extensive evaluation, we diagnosed ABC of the scapula secondary to fibrous dysplasia which was successfully managed by CT guided percutaneous polidocanol sclerotherapy. One year after the injection, patient is asymptomatic with excellent radiological outcome. Polidocanol is an effective alternative to conventional methods since, it precludes functional disabilities like joint stiffness and shortening which are common with other methods.

A Rare Association of Pentalogy of Fallot with Situs Inversus Totalis Complicated by Brain Abscess in An Adolescent– Case Report

Muhammed Basheer, Sunil Kumar Agarwalla

Tetralogy of Fallot (TOF) is the most frequently diagnosed congenital cyanotic heart disease. It is often associated with additional findings, such as atrial septal defect (i.e., pentalogy of Fallot) or right sided aortic arch. Association of this pentalogy of Fallot with situs inversus totalis is rarely reported in paediatric literature and it can cause technical challenges to intracardiac repair. We report the case of pentalogy of Fallot with dextrocardia and situs inversus presenting as parieto-occipital abscess in a 12-year-old child. Complicated cardiac malformation like this when associated with brain abscess pose several challenges to the anaesthetist due to the altered haemodynamics and warrant a meticulous anaesthetic as well as surgical plan.

Early Post-Operative Coronary Thrombosis Following Repair of a Proximal Coronary Artery Fistula

Yashasvi Chugh, Bryan Lau, Cynthia C Taub

Patients with aneurysmal coronary artery fistulas are often a treatment challenge. We hereby, report a case of aneurysmal left main coronary artery to coronary sinus fistula repair, complicated by an early post-operative thrombosis of the left main coronary artery, necessitating an orthotropic heart transplant. Routine use of peri-procedural and long-term anti-coagulation is usually not a standard recommendation in these cases; however, early institution of the same may prevent flow stasis, thrombus formation and unfavourable outcomes pre- or post-operatively.

Spec Rekindled-A Simple Torque Correction Mechanics for Transposed Teeth in Conjunction with Pre-adjusted Edgewise Appliance System

Harpreet Singh, Raj kumar Maurya, Surbhi Thakkar

Complete transposition of teeth is a rather rare phenomenon. After correction of transposed and malaligned lateral incisor and canine, attainment of appropriate individual antagonistic tooth torque is indispensable, which many orthodontists consider to be a herculean task. Here, a novel method is proposed which demonstrates the use of Spec reverse torquing auxillary as an effective adjunctive aid in conjunction with pre-adjusted edgewise brackets.

The Dismal State of Pathology Laboratories in Dental Colleges – A Stitch in Time Can Save Nine!

Priyanka Kardam, Shweta Rehani, Sneha Sethi

Being a pathologist, we all are aware of the protocols which need to be followed in the histopathology laboratories. However, quite often due to our carelessness or busy schedules we tend to skip one or two steps in the protocol. These steps may appear to be insignificant at that time but later on they may take a toll on the diagnosis by creating an artefact. Here, we have presented a case of a similar artefact which tried to mask our diagnostic ability.

Nasal Conidiobolomycosis- The Unknown Threat

Nikhil Arora, Eishaan.K.Bhargava, Varun Rai

A Comparative Study of Neurological Complications in Chronic Kidney Disease with Special Reference to its Stages and Haemodialysis Status

Introduction: Globally, Chronic Kidney Disease (CKD) is a critical and rapidly growing health problem and also a major cause of mortality and morbidity. Neurological complications occur in all levels of the nervous system. Central nervous system complications include cerebrovascular accidents, posterior reversible encephalopathy syndrome, osmotic demyelization syndrome, cerebral infection and sinus vein thrombosis. Peripheral nervous system complications include polyneuropathy, mononeuropathy and carpal tunnel syndrome. Haemodialysis (HD) related neurological complications include dialysis disequilibrium syndrome, dementia and cerebrovascular accidents. Aim: To assess the neurological complications of CKD and to compare the various neurological complications in patients on HD with those not on HD. Materials and Methods: Hundred patients with CKD were included in the study. They were categorized into two groups according to the stage of CKD and those with stage 3 or more were considered as cases and stage 2 or less as controls. The cases and controls were followed up during subsequent visits for neurological complications. Results: This study comprised of 50 cases and 50 controls. Among 50 cases, males were 62% and females were 38% with male: female ratio was 1.6:1 and in controls, male: female ratio was 1.08:1. The maximum patients were in the age group of 51-60 years. The incidence of neurological complications was significantly higher in cases compared to controls and among people who underwent dialysis compared to those who were not. Headache was the most common complication both among cases and controls and as well as in people who were on HD. Stroke, seizures and altered sensorium were significantly associated with later stage of CKD. Cases underwent HD had significant association with headache, altered sensorium and stroke than those without HD but peripheral neuropathy and seizure did not show such association. Conclusion: The chances of development of neurological complications were significantly higher in late stages of CKD compared to early stages of CKD. Those neurological complications were more among people who underwent dialysis when compared to those not on maintenance HD.

The Effects of Spiritual Self-Care Training on Caregiving Strain in Mothers of Mentally Retarded Children

Mitra Dindar, Mozhgan Rahnama, Mehdi Afshari, Mahdieh Poodineh Moghadam

Introduction: Care for a mentally retarded child induces a lot of problems for the mother and leads her to care giving strain and ignorning her self-care. Spiritual health will co-ordinate all aspects of human life and is necessary for coping with diseases in mother of mentally retarded children. Aim: To evaluate the effects of spiritual self-care training on care giving strain in mothers of mentally retarded children. Materials and Methods: The present study, is a before and after type quasi-experimental research based on which 60 mothers of mentally retarded children who were hospitalized in Elahi Rehabilitation Center in Quchan City, were selected using convenience sampling and were randomly assigned to intervention and control groups. Data was collected by demographic characteristic questionnaire and care giving strain questionnaire that were filled by groups before, immediately and two weeks after spiritual self-care training. Data was analysed using SPSS version 20. Results: According to the results, there was no significant difference between the mean score of care giving strain in intervention and control groups before and immediately after the intervention. However, among the members of the intervention group the score of mother care giving strain decreased an average of 87.21% within two weeks after the intervention, which was statistically significant over time (p=0.001). The score of mothers in the control group increased an average of 5% over time which was not statistically significant (p=0.4). The observed differences between these groups were also statistically significant even after controlling the effects of such intervening factors as marital status, children age and the years of caring for children (p=0.001). Conclusion: Spiritual self-care training can decrease care giving strain in mothers of mentally retarded children. Therefore, strengthening their spiritual beliefs and backgrounds, mothers can greatly reduce the strain caused by care giving problems of mentally retarded children.

Preliminary SEM Observations on the Surface of Elastomeric Impression Materials after Immersion or Ozone Disinfection

Introduction: Surface integrity of dental elastomeric impression materials that are subjected to disinfection is of major importance for the quality of the final prosthetic restorations. Aim: The aim of this qualitative Scanning Electronic Microscopy (SEM) study was to reveal the effects of immersion or ozone disinfection on the surface of four dental elastomeric impression materials. Materials and Methods: Four dental elastomeric impression material brands were used (two vinyl polysiloxane silicones, one polyether, and one vinyl polyether silicone). Total of 32 specimens were fabricated, eight from each impression material. Specimens were immersion (0.525% sodium hypochlorite solution or 0.3% benzalkonium chloride solution) or ozone disinfected or served as controls and examined with SEM. Results: Surface degradation was observed on several speci-mens disinfected with 0.525% sodium hypochlorite solution. Similar wavy-wrinkling surface structures were observed in almost all specimens, when treated either with 0.3% benzalkonium chloride solution or ozone. Conclusion: The SEM images obtained from this study revealed that both immersion disinfectants and ozone show similar impression material surface alterations. Ozone seems to be non-inferior as compared to immersion disinfectants, but superior as to environmental protection.

Clinical Utility of Fractional exhaled Nitric Oxide (FeNO) as a Biomarker to Predict Severity of Disease and Response to Inhaled Corticosteroid (ICS) in Asthma Patients

Introduction: Bronchial asthma is a common chronic inflammatory airway disease diagnosed and is based on symptomatic history and Pulmonary Function Tests (PFT). Fractional exhaled Nitric Oxide (FeNO) is exclusively a non-invasive biomarker of on-going eosinophilic airway inflammation which remains unpredictable only with PFTs. FeNO measurement is recommended in predicting asthma severity and Inhaled Corticosteroid (ICS) response but further research is required to understand its clinical utility and agreement with current recommendations in a specific population. Aim: To estimate FeNO levels in Tamilian patients with mild-to-moderate persistent asthma and to correlate with disease severity and ICS response. Materials and Methods: The study was a prospective cohort with a single group of 102 persistent asthma patients under standard ICS regimen for 8 weeks (follow-up period). PFT and FeNO were measured using portable spirometry and chemiluminescence based exhaled breath analyser, at baseline and during follow-up visits. Based on PFT and FeNO parameters, the study population was sub-grouped with respect to asthma severity (as mild, moderate and moderately severe), FeNO cut-off (> or < 50ppb) and ICS response classification (good vs poor ICS responders). Results: Significant decrease in mean FeNO levels were found in mild, moderate and moderately severe asthmatic groups following ICS treatment (90.15±27.36, 75.74±31.98 and 77.18±32.79 ppb) compared to similar baseline FeNO levels (103.03±34.08, 91.38±37.60 and 97.90±43.84 ppb) in all the above groups. Similarly, significant decrease in mean FeNO levels was found - FeNO>50ppb, good and poor ICS responders groups, in post- ICS treatment (89.63±24.04, 77.90±31.12 and 86.49±32.57 ppb) compared to baseline levels (110.183±1.23, 97.12±42.04 and 99.68±34.71 ppb). Conclusion: The observed baseline FeNO values in all groups as stated above did not show significant difference to differentiate asthma severity or ICS responders groups. The present study results do not support the predictive association of baseline FeNO levels with asthma severity and future ICS response, but the decrements in FeNO levels on ICS treatment, supports its clinical utility in monitoring of ongoing airway inflammation and understanding treatment response rate.

Assessment of Correlation between Sweat Chloride Levels and Clinical Features of Cystic Fibrosis Patients

Introduction: Cystic Fibrosis (CF) is an autosomal recessive disorder and the incidence of this disease is undermined in Northern India. The distinguishable salty character of the sweat belonging to individuals suffering from CF makes sweat chloride estimation essential for diagnosis of CF disease. Aim: The aim of this prospective study was to elucidate the relationship of sweat chloride levels with clinical features and pattern of CF. Materials and Methods: A total of 182 patients, with clinical features of CF were included in this study for quantitative measurement of sweat chloride. Sweat stimulation and collection involved pilocarpine iontophoresis based on the Gibson and Cooks methodology. The quantitative estimation of chloride was done by Schales and Schales method with some modifications. Cystic Fibrosis Trans Membrane Conductance Regulator (CFTR) mutation status was recorded in case of patients with borderline sweat chloride levels to correlate the results and for follow-up. Results: Out of 182 patients having clinical features consistent with CF, borderline and elevated sweat chloride levels were present in 9 (5%) and 41 (22.5%) subjects respectively. Elevated sweat chloride levels were significantly associated with wheeze, Failure To Thrive (FTT), history of CF in Siblings, product of Consanguineous Marriage (CM), digital clubbing and steatorrhoea on univariate analysis. On multivariate analysis only wheeze, FTT and steatorrhoea were found to be significantly associated with elevated sweat chloride levels (p<0.05). Among the nine borderline cases six cases were positive for at least two CFTR mutations and rest of the three cases were not having any mutation in CFTR gene. Conclusion: The diagnosis is often delayed and the disease is advanced in most patients at the time of diagnosis. Sweat testing is a gold standard for diagnosis of CF patients as genetic mutation profile being heterozygous and unlikely to become diagnostic test.

Assessment of Serum Vaspin Levels among Type 2 Diabetes Mellitus Patients with or without Acute Coronary Syndrome

Introduction: Type 2 Diabetes Mellitus (DM) is on the verge of becoming a pandemic in India. Type 2 DM patient have two to four times increased risk of carotid artery disease. Adipokines have been regarded recently as direct link between diabetes and atherosclerosis. Visceral Adipose Tissue Derived Serine Protease Inhibitor (VASPIN); one of the most recently discovered adipokine, inhibits the proteases responsible for insulin resistance, carotid plaque development and rupture. In literature, few studies have addressed the role of vaspinvaspin in pathogenesis of Acute Coronary Syndrome (ACS) in patients with type 2 DM. Aim: To find association between serum vaspinvaspin with lipid profile, creatine kinase-total, creatine kinase-MB, troponin-I, age, height, weight, blood pressure, smoking, family history of ACS and to prove the hypothesis of low serum vaspinvaspin level as predictor of ACS in patients with type 2 DM. Materials and Methods: Forty-one type 2 DM patients (controls) and 41 type 2 DM patients with ACS (cases) were enrolled in the study. Anthropometric measurements were performed and fasting serum biochemical parameters and vaspinvaspin were measured. The results of cases and controls were compared by student t-test or Mann–Whitney test. All the parameters were correlated with serum vaspinvaspin by Pearson’s or Spearman’s correlation. Results: Fasting serum vaspinvaspin concentration was significantly (p< 0.0001) lower in the cases (0.43 ± 0.22 pg/ml) than in the controls (0.83 ± 0.29 pg/ml). Correlation analysis undertaken on all type 2 DM showed that serum vaspinvaspin concentration was negatively correlated with age, waist circumference, hip circumference, systolic and diastolic blood pressure, duration of diabetes, serum Creative Kinase-Total, CK-MB and urea (p< 0.05). Utilizing Receiver Operating Characteristic (ROC) curve, the serum vaspinvaspin level of less than 0.594pg/ml showed greatest risk of ACS among type 2 DM patients (p< 0.0001). Conclusion: Type 2 DM patients with low serum vaspin concentration were at risk of ACS independent of other cardiovascular risk factors.

Analgesics Self-Medication and its Association with Sleep Quality among Medical Undergraduates

Amit Kumar, Vandana, Ahmad Nadeem Aslami

Introduction: Self-medication especially with analgesics is a common practice among undergraduate medical students. Variation in analgesic self-medication prevalence and pattern is often seen due to geographical and target population differences. The mutual influence of pain and sleep quality might persuade students self medication behaviour. Aim: To assess analgesic self-medication and its association with sleep quality among the medical undergraduates. Materials and Methods: A cross-sectional questionnaire based study was conducted from December 2015 to February 2016 among 320 medical undergraduates. The information about socio-demographic profile, symptoms, types of analgesics, source of information and reason for analgesic self-medication was collected. The sleep quality of students was assessed by Pittsburgh Sleep Quality Index (PSQI). The qualitative variables were expressed as percentages. Odds Ratio (OR) with 95% Confidence Interval (CI) was also calculated. Chi-square test was used. Results: Analgesic self-medication prevalence was 49.7%, more prevalence seen among males, seniors, urban residents and students of working parents. Headache (48.4%) was the most common cause and paracetamol (79.7%) was most frequent drug used, based on knowledge obtained through textbook and internet (47.1%). Mildness of symptoms (49.1%) was the most important motivation behind self-medication. Analgesic use was more (57.4%) among “poor sleepers” compared to “normal sleepers” (45.2%). Conclusion: Despite having easy accessibility to expert consultations, high prevalence of analgesic self-medication among medical students and its association with poor sleep quality is a distressing issue. This indicates an urgent need of awareness programmes about harmful effects of self-medication and healthy sleep practices.

Effect of Different Phases of Menstrual Cycle on Cardio-respiratory Efficiency in Normal, Overweight and Obese Female Undergraduate Students

Nazrin Samsudeen, Archana Rajagopalan

Introduction: The influence of obesity on cardio-respiratory efficiency in the various phases of menstrual cycle is not well understood until now. As majority of Indian women have a favourable attitude towards participation in sports it is significant to understand the variation in exercise performance during different phases of menstrual cycle to have an optimum performance. Aim: To evaluate the endurance capacity and cardio-respiratory responses in normal, obese and overweight female undergraduate students during different phases of menstrual cycle. Materials and Methods: Twenty normal weight, 20 obese and 20 over weight, unmarried, undergraduate female volunteers between the age group of 18-22 years, were recruited by convenient sampling. Cardio-respiratory efficiency was assessed by cardiac efficiency test, respiratory endurance test and respiratory blast test. Results: Overall, exercise efficiency varied significantly during the different phases of the menstrual cycle with the highest during luteal phase and lowest during menstrual phase. Similar trend was observed in all the three weight sub-categories, but it was statistically significant in the normal and overweight category only. There was no significant difference in blast test during menstrual phase, follicular phase and luteal phase of menstrual cycle among three groups of individuals. Overall the obese and overweight females had a decreased value for blast test compared to the normal individuals. Significant difference was observed in endurance test among follicular and luteal phase of normal females but there is no change in overweight and obese. Significant difference was observed in Peak Expiratory Flow Rate (PEFR) among luteal phase in normal and overweight individuals but there is no change in obese females. Overall obese individuals have a significant low PEFR compared to normal and overweight individuals. Conclusion: Significant increase in cardiac and respiratory efficiency was observed in the luteal phase of the menstrual cycle in normal weight where as in overweight and obese females, there is an overall decrease in fitness capacity with increase in the Body Mass Index (BMI). Therefore, practice of regular exercise and intake of healthy diet which help in reducing the weight and in turn the BMI will help in enhancing the physical fitness of the individuals.

Neurological Disorders Complicating Pregnancy - Focus on Obstetric Outcome

Sandya Renukesh, Lavanya Rai

Introduction: Neurological disorders in pregnancy can be pregnancy related or can be caused by exacerbation of a pre-existing neurological condition or sometimes may even be detected for the first time during pregnancy in which it might be an incidental finding. The diagnosis and management of the neurological disorders in pregnancy is always a challenging task due to varied symptomatology and risks to the fetus. The evaluation and management should be performed in a stepwise fashion and requires multidisciplinary approach. Aim: The present study was conducted with the aim to study the influence of neurological disorders on outcome of pregnancy. Material and Methods: This was a prospective observational study conduted over a period of 1 year (2013-2014) including 54 pregnant women with neurological manifestations. The spectrum of neurological manifestations was divided into-pregnancy specific, incidental and pre-existing neurological disorders for analysis. Five unusual cases with varied manifestations were studied in detail. Any pregnant woman presenting with neurological manifestation, irrespective of gestational age were included in the present study. The neurological manifestation and the obstetric outcome were analysed in the present study. Results: There were 54 women with varied neurological manifestations, majority (74%) of them being primigravida. Seizure was the most common (63%) manifestation. The incidence of pregnancy specific disorder (eclampsia), pre-existing disease (epilepsy) and incidental causes were 40.8%, 37% and 22.2% respectively. Of the 22 women with eclampsia, 15(68%) had seizure during antepartum period and 7(32%) in the postpartum period. Three patients out of 22 who had eclampsia had intrauterine fetal demise on arrival itself, whereas the perinatal outcome was good in the other 19 patients who had live born babies. The most common incidental cause in the present study was tubercular meningitis (44%). There was however a maternal and perinatal mortality in woman with structural malformation who had massive intra-ventricular haemorrhage, secondary to ruptured cerebral cavernoma. Here we have described in detail 5 patients with varied clinical manifestation causing diagnostic dilemma. They are spinal arterio-venous malformation, disseminated toxoplasmosis, massive intra-ventricular haemorrhage (ruptured cerebral cavernoma), tubercular meningitis with cortical venous thrombosis, suspected Bartter syndrome presenting as coma. Conclusion: Neurological manifestation during pregnancy may not always be a primary neurological disorder, instead may be manifestation secondary to any systemic illness. Hence, a wide index of suspicion and neuroimaging aids in arriving at the diagnosis certainly improves the pregnancy outcome.

The Effect of Nutritional Status on Outcome of Hospitalization in Paediatric Liver Disease Patients

Yasmeen Mansi, Shereen Abdel Ghaffar, Shaymaa Sayed, Hanaa El-Karaksy

Introduction: Liver is an important organ for metabolism. It has a major role in integrating the various biochemical pathways of metabolism. Thus, children with chronic liver disease are at high risk for developing undernutrition, with important prognostic implications. Aim: To evaluate the nutritional status of hospitalized paediatric liver disease patients and its effect on outcome. Materials and Methods: We prospectively analysed the nutritional status of 59 consecutive patients during their first 24 hours of admission, at the Hepatology Unit, using the following indices: weight/age, height/age, weight/height, Body Mass Index (BMI), arm circumference and triceps skinfold, subcapular skinfold, and mid upper arm circumference. Results: According to the measurements: 35.6% were underweight, 49% were stunted, 10% were wasted by weight for length/height percentile and 5% were wasted by body mass index, 49% had percentage of ideal body weight below normal, 27% had head circumference below 3rd percentile, 59.4% had triceps skinfold thickness below 5th percentile, 66% had subscapular skinfold thickness below 5th percentile; 56% had arm circumference below 5th percentile. There was no correlation between these growth parameters and mortality. However, we found a positive correlation between decreased triceps skinfold thickness and prolonged hospital stay. Malnourished patients, according to triceps skinfold thickness, were significantly younger and they were the ones who suffered from cholestatic disorders of infancy. Conclusion: Only triceps skinfold thickness was found to be a useful predictor for a prolonged hospital stay. Serial measurements may be more effective.

Dexamethasone as an Adjuvant to Bupivacaine in Supraclavicular Brachial Plexus Block in Paediatrics for Post-operative Analgesia

Karl Sa Ribeiro, Anjali Ollapally, Julie Misquith

Introduction: Sensory blockade of the brachial plexus with local anaesthetics for perioperative analgesia leads to stable haemodynamics intraoperatively, smoother emergence from general anaesthesia and decreased need for supplemental analgesics or suppositories in the Post-operative period. However, increasing the duration of local anaesthetic action is often desirable because it prolongs surgical anaesthesia and analgesia. Various studies in adults prove that steroids increase the duration of action of local anaesthetics when used as adjuncts. Aim: The study aimed at determining the efficacy of dexame-thasone as an adjuvant to bupivacaine for Post-operative analgesia following sensory blockade of the brachial plexus in paediatrics. Materials and Methods: The study was divided into two groups of 15 each, group BD receiving dexamethasone (0.1mg/kg) as an adjunct to bupivacaine 0.125% and group B receiving bupivacaine alone. The duration of analgesia was taken as time from completion of the block to the patient receiving rescue analgesia, the haemodynamics were measured until 180 minutes after surgery, the incidence of Post-operative Nausea and Vomiting (PONV) was measured. Results: The duration of analgesia in the group BD was 27.1+13.4 hours and was significantly higher as compared to the group B, in which it was 13.9+11.3 hours (p<0.05). The pulse rate measured Post-operatively between both groups at 20 minutes (p-value 0.634), 60 minutes (p-value 0.888), 120 minutes (p-value 0.904) and 180 minutes (p-value 0.528) showed no statistical significance. Likewise the mean blood pressure measured between the two groups at 20 minutes, 60 minutes, 120 minutes and 180 minutes Post-operatively showed no significance. There was no significant difference in incidence of PONV in both groups with p-value of 0.624. Conclusion: Dexamethasone as an adjuvant to local anaesthetic in brachial plexus blocks significantly, prolongs duration of analgesia in children undergoing upper limb surgeries.

Transurethral Cystolithotripsy of Large Bladder Stones by Holmium Laser as a Day Care Procedure

Introduction: Bladder stones constitute around 5% of bladder stones in the developed countries. Holmium laser lithotripsy has revolutionised the treatment of urinary lithiasis. Aim: The aim of this study was to report the outcome of transurethral cystolithotripsy with Holmium Laser under Local Anaesthesia (LA) as a day care procedure in patients with bladder stones. Materials and Methods: Patients with bladder stone greater than 1.5cm attending urology Outpatient Department underwent transurethral cystolithotripsy with Holmium Laser under LA as day care procedure. The results were analysed on aspects of peri-operative pain, completion of procedure, stone clearance, hospital stay, complications and patient compliance. Results: A total of 85 patients with bladder stone =1.5cm underwent transurethral cystolithotripsy LA. The mean age of the patient was 52±7 years. There were 80 males. The mean size of stone was 3±1.2cm. Mean operation time was 40 ±10 minutes. Complete stone clearance was achieved in all the patients. None of the patients required hospital stay following the procedure. Conclusion: Transurethral holmium laser lithotripsy is an effective and safe procedure for large bladder stones. This procedure can be easily performed as a day care procedure.

Aquaporin 3 and E-Cadherin Expression in Perilesional Vitiligo Skin

Introduction: Vitiligo is a common dermatologic disorder with debated aetiology. Most studies focused on role of melanocytes and few investigated the role of keratinocytes in pathogenesis of the disease. Aim: To investigate the keratinocyte adhesion in perilesional vitiligo skin through the immunolocalization of Aquaporin-3 (AQP3) and E-cadherin. Setting and Design: Sixty five subjects were selected. These included 40 cases with vitiligo and 25 age and gender-matched healthy subjects as a control group. Materials and Methods: Skin biopsies were taken from perilesional skin of cases and from site-matched areas of control subjects. The expression of AQP3 and E-cadherin was evaluated by immunohistochemical techniques. Statistical Analysis: Results were statistically analysed using IBM personal computer and the statistical package SPSS version 11. Fisher-exact and Chi-square tests were used to study the association between two qualitative variables. Mann-Whitney test was used for comparison between quantitative variables not normally distributed. Spearmans correlation coefficient was used to assess correlation between two quantitative variables. The p=0.05 was considered significant. Results: Regarding AQP3 expression, strong intensity, diffuse distribution, higher percent of expression and higher H-score (p<0.001 for all) were significantly associated with control skin compared with perilesional skin in follicular and inter-follicular epidermis. Regarding E-cadherin expression, moderate intensity, higher percent of expression and higher H- score (p<0.001 for all) were significantly associated with control skin compared with perilesional skin in follicular and inter-follicular epidermis. No significant association was found between E-cadherin and AQP3 H-scores or percent of expression and clinical data of selected cases. No significant correlation was detected between E-cadherin and AQP3 H-scores or percent of expression and age of cases, disease duration or Vitiligo Disease Activity (VIDA) score. Conclusion: The following sequence of events can be suggested for vitiligo pathogenesis, based on findings in perilesional skin: AQP3 is downregulated by a primary unknown factor and this will lead to down regulation of its downstream molecules, mainly phosphatidylinositol 3-kinase, E-cadherin and catenins, which is followed by defective keratinocyte adhesion and decreased release of keratinocyte-derived growth factors. Subsequently a secondary event, physical trauma, oxidative stress or autoantibodies, may lead to exfoliation of keratinocytes and pigmented cells.

Study on Distribution of Scorpions to Provide Prevention and Interventions in Combating Scorpionism in Poldokhtar County, Lorestan Province, Iran

Mansour Nazari, Hassan Rastgar

Introduction: Scorpions are arthropods of medical importance classified in the class Arachnida, inhabiting hot and dry environments. All scorpions have a venomous sting and several thousand people die each year from scorpion stings, but this mortality is due to the venom of about 25 species located in northern Africa, the Middle East, India, Mexico and parts of South America. Poldokhtar County belongs to one of the southern cities of Lorestan Province, providing suitable habitats for many different species of scorpions due to its specific climatic conditions. Aim: To examine the fauna of scorpion and its distribution in the Poldokhtar County and to provide appropriate preventive and medical interventions in combating scorpionism. Materials and Methods: This present study was a descriptive and analytical cross-sectional study. This study was conducted from April 2014 to November 2014 in regions of Poldokhtar County, Lorestan Province, and west of Iran. Cluster sampling methodology was employed in the sampling and scorpion collection procedure. Sampling was undertaken for an eight-month period, in villages and districts, namely, Myankuhe sharqi, Jayedar, Jelogir and Malavi within the county. The Chi-square Keywords: Buthidae, Faunistic, Hemiscorpiidaetest and the Fisher-exact test for homogeneity of proportions were used to compare quantitative variables. Results: Totally, 393 specimens were captured entailing 193 (49.1%) males and 200 (50.9%) females. There were at least seven species of scorpions belonging to three families; BU= Buthidae, HE = Hemiscorpiidae, SCN = Scorpionidae in Poldokhtar. Out of 393 collected scorpions, seven species, Androctonus crassicauda, Hottentotta (Buthotus) saulcyi, Compsobuthus matthiesseni, Compsobuthus rugosulus, Orthochirus scrobiculosus, Scorpio maurus and Hemiscorpius lepturus were identified. The overall sex ratio of females to males was 1:1.03. Conclusion: It is crucial to improve the knowledge of residents in this region regarding preventive methods towards scorpion stinging. All the known dangerous Iranian scorpions having medical importance, including Hemiscorpius lepturus and Androctonus crassicauda were found in the study area. Additionally, other complementary research detailing the fauna of scorpions and their morphological, ecological and molecular variety in this region is highly recommended to estimate the correlation between particular scorpions’ species and ensuring clinical signs and symptoms.

Sputum Collection and Disposal Perceptions and Practices Among Pulmonary Tuberculosis Patients from Northern India

Abhishek Singh, Vipin Goyal, Shewtank Goel

Introduction: Even a single case of pulmonary Tuberculosis (TB) can infect many others. Hence, to ensure better control of the disease, it is imperative that all patients dispose their sputum safely. Outcomes of this study would highlight the gaps need to be bridged in order to curtail transmission of TB. Aim: To analyse and ascertain perceptions about the disease and determine the sputum collection and disposal practices followed by sputum-positive TB patients. Materials and Methods: In this cross-sectional study, 422 sputum-positive TB patients aged more than 15 years registered in the Tuberculosis Unit Ambala city from January 2012 – September 2012 formed the study population. After enrolment, at the end of one month, they were assessed for sputum collection and disposal practices by a trained person at their place of residences. Questionnaire was framed to collect relevant data. Results: Safe sputum disposal was practised by 46.4% of the study subjects. More females than males disposed of sputum safely (70.4% vs. 29.6%), as did more subjects of low than middle socio-economic status (74.1% vs. 25.9%). 70.9% (n=66) of the subjects with a family history of TB practiced safe sputum disposal methods as compared to 39.5% (n=130) subjects without a family history of TB practiced the same. Similarly more literate than illiterate subjects (n=150, 57.5% vs. n=46, 28.6%) practiced safe sputum disposal methods. (p< 0.001). Regarding knowledge of causation of TB only 63% of the study subjects were in the view that this disease is caused by germs. Conclusion: The study demonstrated that a large number of pulmonary TB patients practiced unsafe sputum disposal. Unsafe sputum disposal was higher among males, illiterate patients and those belonging to the lower socio-economic group. Therefore, it is need of the hour to launch Information, Education and Communication (IEC) activities so as to improve the sputum disposal practices among tuberculosis patients.

A Cross-Sectional Study of Quality of Life among Subjects with Epilepsy Attending a Tertiary Care Hospital

M Anu, K Suresh, P.L Basavanna

Introduction: Epilepsy is a chronic disorder associated with profound physical and psychological consequences leading to impaired quality of life (QoL). Evaluation of the QoL among epileptics would throw light on various factors that impair or affect the QoL in such a population. Aim: To study the QoL among epileptic patients attending outpatient departments of a tertiary care hospital and to identify various factors that affect the QoL in such a population. Materials and Methods: A cross-sectional observational questionnaire based study, including patients with epilepsy, who were on antiepileptic drugs, on follow-up for minimum one year, aged more than 18years, both sexes and who were seizure free in the previous 24hours. The World Health Organisation Quality of Life (WHOQOL-BREF) questionnaire was administered to those included in the study. The data was analysed using Statistical Package for Social Sciences (SPSS) version 20 and statistical tests like t-test for independent variables and Analysis of Variance (ANOVA) were used to compare the QoL scores. Results: Of the 98 subjects 61.2% were males, majority were educated upto high school level and most of them were employed in unskilled labour. The mean total QOL score was 53.9 (15.8). There was a significant lower mean total QOL score among people with low educational status and poor seizure control. Conclusion: Epilepsy is a syndrome associated with chronic drug use and regular long term follow-ups to hospitals. These treatment and disease associated problems affects the QOL of the subjects significantly in various squares of life. We found that a lower education and having seizure in the recent past affected the QOL scores.

N-Acetylcysteine Combined with Home Based Physical Activity: Effect on Health Related Quality of Life in Stable COPD Patients- A Randomised Controlled Trial

Vijay Tukaram Salve, Jitesh S. Atram

Introduction: Quality of life is adversely affected in Chronic Obstructive Pulmonary Disease (COPD), due to irreversible, progressive nature of the disease and limitations of current treatment options available. One of the important aim of treatment of COPD is to improve Quality of Life (QoL). Cigarette smoke contains numerous free radicals and other oxidants. Oxidative stress has been implicated in pathogenesis, progression of disease and exacerbation in COPD. Pulmonary tuberculosis, outdoor and indoor air pollution and many others are aetiologies of COPD in non-smokers. N-Acetylcysteine (NAC) is a precursor of endogenous anti-oxidant, Glutathione (GSH) and both agents act as free radical scavengers. Exercise limitation results in poor physical performance and eventually poor QoL in COPD. Aim: To observe the combined effect of 600mg of NAC once daily and physical activity (home based) in addition to standard treatment for ten weeks, compared with placebo as control group with standard treatment. Materials and Methods: This randomised controlled trial was conducted at a tertiary care centre in Mumbai for two years from December 2011 to December 2013. Hundred patients diagnosed as stable COPD (as per Global Initiative against Obstructive Lung Disease (GOLD) 2010 guidelines) were enrolled in the study. There were 50 patients in study group and control group each. The QoL was assessed using Saint George Respiratory Questionnaire-C (SGRQ-C) initially and at the end of ten weeks. The study group was treated with NAC 600mg once a day combined with daily physical activity in addition to standard treatment. Control group patients were treated with placebo and standard treatment. Results: At the end of 10 weeks, it was observed that, mean change in SGRQ-C was significant in “study group” as compared to “control group”. Mean change in score among study group was 4.72 and the same in control was 1.32, p-value=0.007. There was significant improvement in SGRQ-C score at the end of 10 weeks and QoL in the study group (p-value-0.0001 i.e.,<0.05) while improvement in SGRQ-C score and QoL score in control group was not significant (p-value=0.118 i.e., >0.05). Overall, there was statistically significant improvement in SGRQ-C score and QoL (p-value=0.03 i.e., <0.05) in the study group. Conclusion: From the current study, it can be concluded that N-acetylcysteine 600mg once a day and 20 minute daily walk in addition to regular treatment improves QoL in stable COPD patients.

Letter to Editor: Coronal Microleakage of the Resilon and Gutta-Percha Obturation Materials with Epiphany SE Sealer: An In-Vitro Study

Saravanakarthikeyan Balasubramanian, JS Sivakumar

Effect of Sleep Hygiene Education on Sleep Quality in Hemodialysis Patients

Farzaneh Soleimani, Hossein Motaarefi, Ali Hasanpour-Dehkordi

Introduction: Sleep is referred a regular, recurring and easily revocable state of organism which is characterized by relative immobility and significant increase in response threshold to environmental stimuli. Sleep disorders are common among haemodialysis patients. Aim: The aim of this study was to investigate the effect of sleep hygiene education on sleep quality in haemodialysis patients. Materials and Methods: This study is a randomized controlled clinical trial. The participants of this study were 60 haemodialysis patients admitted to the Dialysis Center of Shahid Ayatollah Madani Hospital of Khoy, affiliated with the Urmia University of Medical Sciences. Sampling was done randomly and the partcipants were randomly divided into intervention group (30 patients) and control group (30 patients). Sleep quality of participants was measured before and after the intervention by Pittsburgh Sleep Quality Index (PSQI). Training process for sleep hygiene behaviours was presented to the participants face-to-face. The data were analysed using SPSS 16. Results: A significant difference in the mean (standard deviation) score for PSQI (p<0.001) was observed before and after intervention in the intervention group, while in the control group, the difference was not significant (p=0.704), In addition, a significant difference was observed in the mean (standard deviation) score for PSQI between the two, intervention and control groups after the educational intervention (p=0.034). Conclusion: Sleep hygiene education, alongside other appro-aches, is a low-cost, accessible and practical method which can be implemented within a short period of time.

A Validation of an Examination Protocol for Cerebral Visual Impairment Among Children in a Clinical Population in India

Introduction: Cerebral Visual Impairment (CVI) is a leading cause of vision impairment in developed and developing countries due to and increased survival of preterm and low birth weight infants. There are few data concerning the validity of protocols available to diagnose CVI. Aim: This study aimed to document the face, content and construct validity of an assessment protocol namely, a 15-domain, Structured Clinical Question Inventory (SCQI), which is based on structured history taking and clinical examination, for the diagnosis of CVI in a clinical population of India. Materials and Methods: This study was a retro-spective chart analysis of all children below the age of 18years, referred to the CVI clinic of a tertiary care teaching hospital in Southern India from March 2011-Feb 2012. Clinical case-notes including the SCQI findings of all children referred to the clinic were reviewed. The data were extracted after Institutional Review Board approval. Statistical Analysis: Pearson correlation coefficient, Cronbach’s alpha and exploratory factor analysis were used to document the content and construct validity of the examination protocol. Results: A total of 342 children (35.7% male, 64.3% female), with a mean age of 3.8 years (range 0-17 years, the median was 3 years) were included in the study and their data were examined. The internal consistency of the SCQI was 0.93 suggesting it as an excellent tool to characterise and profile CVI and a 2-factor model (Dorsal Stream Dysfunction and Ventral Stream Dysfunction) based on a biologically plausible model explained 63% of the variance. Conclusion: The results of using the SCQI affirm published data and endorse a theoretical construct similar across cultures. The potential diagnostic accuracy, reliability and utility of this measure for CVI needs to be studied further. The clinical use of a short version of the SCQI may be helpful to contribute to the identification of CVI, especially for middle and low-income countries.

Open Reduction and Volar Plate Fixation of Dorsally Displaced Distal Radius Fractures: A Prospective Study of Functional and Radiological Outcomes

Arjun Ballal, Anand Kumar Sadasivan, Anoop Hegde, Ashwin Shetty

Introduction: The fractures of the distal radius have always posed a unique challenge to the orthopaedic fraternity. The complex ligamentous and bony anatomy offers a wide variety of fractures to be dealt with around this zone. Over the years these injuries have become common especially in the elderly age group as well as the implants and surgical techniques have improved. Aim: To assess the radiological and functional outcome after fixation of intra-articular dorsally displaced distal radius fractures with open reduction and volar Locking Compression Plate fixation (LCP). To study the complications occurring with this technique. Materials and Methods: A prospective study was conducted in the Department of Orthopaedics at ARS Hospital, Tirupur, Tamil Nadu, from June 2015 to June 2016. A total of 20 skeletally mature patients with Lidstrom class 2D and 2E fresh closed distal radius fractures were enrolled in the study. All the patients underwent open reduction with locking compression plating with titanium LCPs using the volar approach. The patients were reviewed regularly at three, six, 12 and 24 weeks. Final assessment of radiographic fracture union was done and scored as per the ‘Radiographic Scoring System to Evaluate Union of Distal Radius Fractures {Radius Union Scoring System (RUSS)}’ and the functional assessment of the wrist was done using the Mayo wrist score. The final results were tabulated and calculated statistically using ‘frequency and proportions’ and ‘Chi-square tests’ were used to assess the test of association. Results: Of the 20 patients reviewed, one patient had excellent Mayo wrist score, five had good scores, 12 had satisfactory and two patients had poor results. Seven patients had a RUSS score less than five points and four patients had RUSS score of five points, four patients had six points, two patients had seven points and three patients had eight points. One patient was noted to have dorsal collapse of the fracture during the final review. But, no evident of cosmetic deformity or any diminution in functional outcome of wrist was noted. Conclusion: Open reduction and internal fixation with volar plating of dorsally displaced intra-articular distal radius fractures is an excellent technique with acceptable radiological fracture union and satisfactory functional outcome of the wrist.

Pattern of Inpatient Dermatology Consultations in a Tertiary Care Centre from Northern India

Introduction: The importance of dermatology inpatient consultation is of significant importance yet is not well documented. Aim:To retrospectively analyse the spectrum of dermatology inpatient consultations from the various departments and to document the most commonly occurring dermatological disorders from each speciality. Materials and Methods: This study was done in an 800 bedded premier teaching hospital in Ludhiana, Punjab, North Western India. It was an audit of inpatient referrals to the dermatology department from January 2014 to August 2014. We analysed the spectrum of dermatological disorders in relation to the various specialities, demographic profile and age groups. Statistical Analysis: The data was entered in Microsoft Excel and analysed using SPSS Version 21. Descriptive statistics, frequency and proportions were used. Results: Of the 559 in-patients, 60% were males. The majority of the patients belonged to age group 51-60 years (25.9%). The departments most commonly requesting for dermatology consultations were Medicine (27.7%), Neurology (9.7%), Cardiology (8.8%), Urology (7%), Haematology (6.4%), Nephrology (6.1%), Intensive Care Unit (ICU) (5.4%), General Surgery (5.2%), Orthopaedics (5%), Gynaecology and Neurosurgery (2.9%) and Paediatrics (2.7%). The commonest dermatological diagnoses for which consultations were sought were eczematous dermatitis (12.9%), superficial dermatophytosis (12.3%), drug reactions (8.9%) and viral skin infections (8.5%). Conclusion: Dermatology consultations offer a significant role in diagnosis and management of the in-patients from various clinical speciality departments. There is a significant need of inter-departmental dermatology consultations which help to decrease morbidity and improve the quality of the patient’s hospital stay. Knowledge about the pattern of dermatoses in the inpatients can help the primary clinician to recognize when to seek dermatology consultation on a priority basis.

Media Matter: The Effect of Medium of Presentation on Student's Recognition of Histopathology

Ajay Telang, Nynke de Jong, Janvan Dalen

Introduction: Pathology teaching has undergone transformation with the introduction of virtual microscopy as a teaching and learning tool. Aim: To assess if dental students can identify histopathology irrespective of the media of presentation and if the media affect students oral pathology case based learning scores. The perception of students towards “hybrid” approach in teaching and learning histopathology in oral pathology was also assessed. Materials and Methods: A controlled experiment was conduc-ted on year 4 and year 5 dental student groups using a perfor-mance test and a questionnaire survey. Results: A response rate of 81% was noted for the performance test as well as the questionnaire survey. Results show a significant effect of media on performance of students with virtual microscopy bringing out the best performance across all student groups in case based learning scenarios. The order of preference for media was found to be virtual microscopy followed by photomicrographs and light microscopy. However, 94% of students still prefer the present hybrid system for teaching and learning of oral pathology. Conclusion: The study shows that identification of histo-pathology by students is dependent on media and the type of media has a significant effect on the performance. Virtual microscopy is strongly perceived as a useful tool for learning which thus brings out the best performance, however; the hybrid approach still remains the most preferred approach for histopathology learning.

Study of Aortic Valve Sclerosis as A Marker of Atherosclerosis in Acute Coronary Syndromes

Introduction: Aortic valve sclerosis has been shown to be associated with increased incidence, chances of developing myocardial infarction and even death. The epidemiological risk factors causing calcification of aortic valves have also been found to cause atherosclerosis. Aim: To analyse the epidemiological risk factors causing aortic valve sclerosis which have been studied in details and analysed to see whether they cause any significant increase in the incidence of cardiovascular events. Materials and Methods: This prospective case-control study was conducted between 1st Jan 2015 to 31st Dec 2015 in NEIGRIHMS hospital and data for age, gender, socioeconomic status, hypertension, diabetes, tobacco use, Body Mass Iindex (BMI), cholesterol levels, Electrocardiography (ECG) changes and Ejection Fraction (EF) were collected and analysed by using SPSS software version 22. Results: Hypertension, diabetes, weight, BMI, hyperglycaemia and hyperlipidemia were not found to be significantly associated with aortic valve sclerosis in patients presenting with acute coronary syndromes. The presence of aortic valve sclerosis was also not associated with increased risk of cardiovascular mortality and morbidity. Conclusion: The risk factors for atherosclerosis were found to be associated with the presence of aortic valve sclerosis more in the control group and hence finding of a sclerosed aortic valve in the apparent normal population might identify those persons at increased risk of developing coronary artery disease and appropriate preventive measures should be taken before the disease sets in.

Nurses’ Perceptions of the Concept of Power in Nursing: A Qualitative Research

Rana Rezai Sepasi, Abbas Abbaszadeh, Fariba Borhani, Hossein Rafiei

Introduction: Power is a complex and extensive concept in nursing, which has a decisive impact on the accomplishment of duties, satisfaction and achievement of professional goals. Explaining the concept of power in nursing from the perspective of nurses and accessing its various dimensions may result in a better understanding of this issue. Aim: This study was aimed to explore the concept of power in nursing, using the views and experiences of Iranian nurses. Materials and Methods: This study was a qualitative research which used a content analysis approach. Participants were selected from among nurses active in clinical, management, and educational practices using the purposive sampling method. Data were collected using a semi-structured individual interview. The results were obtained by analysing the data using an inductive approach and the constant comparison method. Results: The participants of this study regarded the power of nursing as a positive concept and the issue of power in nursing consisted of three classes, the genesis with the subclasses of “being purposeful”, “being under the shadow of the profession nature”, “being dependent on the source”, strengthening with the subclasses of “being emotional and introverted”, “being formed in the context of professional communication”, “fluidity and flowing”, and the evolution with the subclasses “based on human values”, and “being a tool for professional excellence”. Conclusion: The concept of power in nursing can be considered a purposeful issue based on the nurses’ viewpoint which flourishes in the context of human, moral and caring nature of the nursing profession. According to its dependence on the nature of profession and on the basis of professional communication, Power of nursing grows with a fluidlike flowing structure, linked with human values, reaches maturity and results in outcomes such as improving the quality of care and professional excellence.

Swiss Ball Versus Mat Exercises For Core Activation of Transverse Abdominis in Recreational Athletes

Introduction: Core stability is an essential component for improving athletic performance and injury prevention. Exercises on a Swiss ball and on the mat are two different ways of improving core stability. Comparison of these methods can help physiotherapists incorporate the better method for athletic training and rehabilitation. Aim: To compare swiss ball and mat exercises for core stability of transverse abdominis in recreational athletes. Materials and Methods: This pilot randomized control trial was performed on a total of 25 recreational athletes. Subjects were alternatively allocated into three different groups: group A performed swiss ball exercises; group B performed mat exercises; and group C was the control group. Statistical analysis: Paired t-test for pre and post values within the group and one-way ANOVA for between the groups comparison was used. Results: There was significant improvement in the core stability in Group A (Pre values: 3.6 ± 2.06; Post values: 8.3 ± 3.02; p-value: <0.05) and Group B (Pre values: 2.1 ± 2.4; Post values: 4.3 ± 2.5; p-value<0.05), however, improvement was more in group A compared to group B. Conclusion:There was significant improvement seen in the recreational athletes performing exercises on Swiss ball as compared to athletes performing exercises on mat. Therefore, Swiss ball exercises can be included in the prehabilitation and rehabilitation stages of athletic training to prevent injury and enhanced recovery post injury, thereby, improving performance of the athletes.

Effect of Surgical Curve Correction on Exercise Tolerance and Physical Capacities in Patients of Severe Spinal Deformity

Prateek C Patil, Ashok K Rathod, Mandar Borde, Vishwajeet Singh, Hemant U Singh

Introduction: Traditionally, surgical intervention for patients with a spinal deformity has been considered for cosmetic benefits, but surgical intervention can alter the lung physiology or volumes and in turn leads to increase in physical capacity and exercise tolerance. Therefore, we conducted this to determine whether a surgical correction would restore the lung physiology, physical capacity and exercise tolerance in patients with kyphoscoliosis. Aim: To evaluate the usage of six-minute walk test scores and modified Borg scores as tools/measures for exercise tolerance in patients with spinal deformity and to study the effects of surgical correction of spinal deformity on exercise tolerance with above parameters as the measures. Materials and Methods: Thirty patients with spinal deformity, who had undergone surgery for deformity correction, were evaluated. All patients were investigated pre-operatively with x-rays of the spine (anteroposterior and lateral views). Clinical tests like breath holding time (after full inspiration) in number of seconds, modified Borg scores, six-minute walk test scores (heart rate, respiratory rate, maximum distance walked); were recorded as measures of exercise tolerance. The patients were followed up on the first, third, sixth and twelfth month post-operatively and tested clinically for breath holding time, modified Borg scores, six-minute walk test scores (heart rate, respiratory rate, maximum distance walked) and x-rays of the spine (anteroposterior and lateral views). Results: In our study, breath holding time (p-value = 0.001) and modified Borg scores (p-value = 0.012) showed a significant improvement at 12 months post-operatively. We noted similar findings with heart rate, respiratory rate and maximum distance walked after a six-minute walk test. Improvements were noted in all the parameters, especially in the group of patients with greater than 60 degrees of cobb angle. However, the differences between the two groups (pre-operative cobb angle less than 60 degrees and pre-operative cobb angle more than 60 degrees) were not significant. The results were analysed and tested for significance using Student's t-test (paired and unpaired as appropriate) and Wilcoxon signed rank test. Conclusion: Surgical correction in cases of spinal deformity improves the cosmetic appearance and balance in the patients. Favourable results of surgical intervention were found in exercise tolerance with improvements in modified Borg scores, six-minute walk test results and breath holding time. The above parameters appear to be good tools for the assessment of physical capacity and exercise tolerance in patients with spinal deformity.

Nephrotic Syndrome Increases the Need for Levothyroxine Replacement in Patients with Hypothyroidism

Hareeshababu Karethimmaiah, Vijaya Sarathi

Introduction: Nephrotic syndrome is a known cause of hypothyroidism; however, its effect on replacement doses of L-thyroxine in patients with primary hypothyroidism is not systematically studied. Aim: The aim of the present study was to evaluate the effect of newly diagnosed nephrotic syndrome on the dose of L-thyroxine replacement in previously diagnosed patients with primary hypothyroidism who were on full, stable dose of L-thyroxine replacement for at least one year. Materials and Methods: Patients with previously diagnosed primary hypothyroidism on stable and full (=1.6µg/day) replacement dose of L-thyroxine for at least one year who developed newly diagnosed nephrotic syndrome were included in the study. Patients were evaluated with thyroid function tests at diagnosis and every 2-3months. Replacement doses of L-thyroxine were titrated by a single endocrinologist based on serum Thyroid Stimulating Hormone (TSH) level. Results: The study included nine patients with mean age of 42.77±9.61years. There was significant increase in TSH at diagnosis of nephrotic syndrome (8.16±2.82µIU/ml) when compared to the immediate past visit (2.08±0.7µIU/ml) and needed 17.6% increase in the replacement dose of L-thyroxine. At last follow-up four patients had remission of nephrotic syndrome and in them thyroid function tests improved with reduction in replacement dose of L-thyroxine by 15% whereas patients who did not achieve remission had required further increase in L-thyroxine dose by 19.1%. Conclusion: Development of nephrotic syndrome significantly increases the need for L-thyroxine replacement dose in previously diagnosed primary hypothyroidism patients on full stable dose of L-thyroxine replacement.

Outcomes of Capsular Dissection Technique with Use of Bipolar Electrocautery in Total Thyroidectomy: A Rural Tertiary Center Experience

Amal T. Das, S.B.Prakash, V. Priyadarshini

Introduction: Total thyroidectomy is one of the most routinely performed head and neck surgical procedures with extremely low mortality. This procedure has been associated with two major complications such as recurrent laryngeal nerve injury and hypocalcaemia due to parathyroid insufficiency. The use of bipolar electrocautery has not been widely accepted in view of thermal damage to adjacent structures. Aim: To study the outcomes and complications of capsular dissection technique along with use of bipolar electrocautery in total thyroidectomy. Materials and Methods: The study was conducted from May 2013 to May 2016. The study was performed at Department of ENT Otorhinolayngology, DM WIMS Hospital, Wayanad, Kerala, India. This retrospective descriptive study analysed the outcome of 130 patients who underwent total thyroidectomy by capsular dissection technique along with use of bipolar electrocautery for cauterization of vascular pedicles, at our institution over a 3 year period. Results: The incidence of permanent unilateral vocal cord palsy was 1.5% and permanent hypocalcaemia was 2.3%. There was no case of haemorrhage or haematoma in this study. Conclusion: Total thyroidectomy by capsular dissection technique along with the use of bipolar electrocautery has very low incidence of recurrent laryngeal nerve and parathyroid injury, as per our data. Hence, we recommend this technique along with routine use of bipolar electrocautery for total thyroidectomy.

High dose Intravenous Anti-D Immune Globulin is More Effective and Safe in Indian Paediatric Patients of Immune Thrombocytopenic Purpura

Trupti Rekha Swain, Rabindra kumar Jena, Kali Prasanna Swain

Introduction: Immune Thrombocytopenia (ITP) is characterised by an autoimmune antibody-mediated destruction of platelets and impaired platelet production. Few controlled trials exist to guide management of patients with ITP in Indian scenario for which patients require an individualized approach. Anti-D (Rho (D) immune globulin) at a higher dose can prove to be a cost effective and safe alternative for Indian patients with ITP. Aim: To compare the safety and efficacy of higher dose (75µg/kg) intravenous Anti-D immune globulin against the standard dose of 50µg/kg for the management of ITP in Indian patients. Materials and Methods: One hundred and sixty four children with newly diagnosed ITP between 4-14 years were randomly selected for inclusion and were treated with 50µg/kg (standard dose) or 75µg /kg (higher dose) of Anti-D to compare the efficacy and safety of higher dose intravenous anti-D immune globulin. Efficacy of Anti-D was measured in terms of rate of response and median time to response for increase in platelet counts. Any adverse event was noted. A decrease in haemoglobin concentration suggested accompanying haemolysis. Results: Seventy one out of 84 patients treated with Anti-D at 75µg/kg produced complete response (85%) with median time of response being 2.5 days. On the contrary, 45 patients (70%) patients treated with 50µg/kg had complete response. However, there was no significant increase in haemolysis with higher dose. A significant correlation was found between dose and peak increase in platelet count measured at 7th day following administration. However, there was no relationship between the decrease in haemoglobin and the dose given, or between the increase in platelet count and fall in haemoglobin. Conclusion: A 75µg/kg dose of Anti-D is more effective with acceptable side effect in comparison to 50µg dose for treatment of newly diagnosed Indian patients of ITP.

Management of Pneumonia and Blood Stream Infections with New Antibiotic Adjuvant Entity (Ceftriaxone + Sulbactam + Disodium Edetate)- A Novel Way to Spare Carbapenems

Mohammad Shameem, Mohammad Amin Mir

Introduction: Nosocomial infections have been considered as a major health problem causing incremental morbidity, mortality and costs of therapy. Aim: This retrospective study was initiated with aim to analyse the comparative efficacy of a novel Antibiotic Adjuvant Entity (AAE), a combination of ceftriaxone + sulbactam + disodium edetate and meropenem in combination with colistin, for the management of Multi Drug Resistant (MDR) nosocomial Gram-negative bacterial infections. Materials and Methods: Case history sheets of patients with documented MDR nosocomial Gram-negative infections who received either AAE or meropenem in combination with colistin for management of infections over a period of 3 years (November 2012 – October 2015) were included in the study. Data related to clinical management, demographics, vital signs and laboratory parameters along with prior antibiotic therapy, dose and clinical outcomes were evaluated thoroughly to analyse the clinical benefits of this new AAE+ colistin therapy for management of MDR nosocomial infections. Results: Out of 115 patients short listed for the study, 52 patients had received AAE + colistin therapy and 63 patients have received meropenem + colistin. AAE + colistin therapy resulted in significantly higher efficacy (86.53%) as compared to meropenem + colistin (63.49%). A rising trend in clinical cure rates was observed in AAE based combination therapy in contrast to the decreasing trend in meropenem based combination therapy. A progressive decline in clinical cure rates was observed in meropenem treated group over a period of 3 years due to rising carbapenemases and multiple resistance by pathogens, where as AAE maintained the same efficacy. Conclusion: The AAE + colistin therapy has shown better bacteriological and clinical efficacy as compared to meropenem + colistin in the management of various nosocomial MDR Gram-negative infections. A significant number of meropenem failure patients responded to the AAE therapy highlighting the new hope to spare carbapenems.

PBL Trigger Design by Medical Students: An Effective Active Learning Strategy Outside the Classroom

Maya Roche, Indira Kakkunje Adiga, Akshatha G. Nayak

Introduction: Problem Based Learning (PBL) is known world over as an effective active learning strategy with many benefits for the student. Usually, in medical schools, PBL triggers are designed by a well-trained group of faculty from basic and clinical sciences. The challenge was whether this task could be given to students in the first year of their curriculum and be executed by them effectively. Aim: To enhance active learning, comprehension and critical thinking with a view to promote horizontal and vertical integration between subjects. Materials and Methods: Student volunteers of the first year MBBS course (n=10), who had been exposed to the curriculum for approximately 38 weeks and were familiar with the PBL process were recruited for the study. In addition to a handout on the topic ‘gout’, they were given the freedom to access any resource in the university library to construct the PBL triggers. The PBL triggers were vetted by two faculties. In addition to a focus group discussion with students, students’ and faculty’s responses were collected on a Likert scale. Results: Students opined that the exercise helped improve their comprehension (100%), critical thinking abilities (90%) and clinical orientation to the topic (100%). They felt that designing a PBL trigger was a relevant active learning strategy (100%) and would help them answer questions on this topic better in the future (90%). The clinicians who examined the PBL triggers, felt that they were of good quality and that the process was a good tool for vertical integration between basic and clinical sciences. Discussion: The results prove that students when given a challenge will rise to the occasion. Unfamiliarity with the nuances of a disease did not prevent them from going the extra mile to achieve their target. By taking part in this exercise, students benefitted in many ways and got a holistic understanding of the topic. Conclusion: PBL trigger design can be introduced as an active learning strategy for students in medical schools where PBL is part of the curriculum. It promotes integration across subjects and is very effective in augmenting student motivation.

Genotypic Characterization of Virulence Factors in Escherichia coli Isolated from Patients with Acute Cystitis, Pyelonephritis and Asymptomatic Bacteriuria

Introduction: Urinary Tract Infections (UTIs) caused by Uropathogenic Escherichia coli (UPEC) are among the most common infections worldwide. It is well-documented that the pathogenesis of UPEC is mediated by the production of a wide variety of Virulence Factors (VFs). Thus, detection of these VFs and evaluation of their association with different clinical types of UTIs could help to understand the role of these factors in pathogenesis of UPEC isolates. Aim: To investigate the genotypic characteristics of UPEC isolates and to examine the relationship between VFs and different clinical symptoms of UTI. Materials and Methods: In this cross-sectional study conducted at Pasteur Institute of Iran, a total of 156 UPEC isolated from outpatients and inpatients (symptomatic and asymptomatic UTI patients) visiting general and private hospitals in Tehran, Iran between March 2014 and February 2015 were included. Among them, 49 patients experienced at least one episode of recurrent UTI. A Polymerase Chain Reaction (PCR) assay was developed to detect the presence of different VFs in the isolates. Moreover, Pulsed-Field Gel Electrophoresis (PFGE) was used to characterize clonal relationships among UPEC isolates. Results: The prevalence of virulence genes ranged from 0% for cdtB to 100% for fimH. The papEF, hlyA and aer genes were found to be significantly more frequent in UPEC isolated from patients with pyelonephritis, while the afa gene, the only indicator of recurrent UTIs, was more prevalent in UPEC isolated from patients with cystitis. In the present study, 34 PFGE clonal groups were found in the UPEC genome. Conclusion: Our findings showed that from outpatients and patients with pyelonephritis, isolates were more virulent than those isolated from inpatients and cystitis patients, respectively. PFGE displayed a large diversity in the UPEC isolates that could be considered as an evolutionary strategy in the survival of the bacteria.

Polymerase Chain Reaction: An Important Tool for Early Diagnosis of Leptospirosis Cases

Summaiya Mullan, Tanvi Harivadanbhai Panwala

Introduction: Various diagnostic methods like Microscopic Agglutination Test (MAT), IgM ELISA, Isolation of Leptospira from the clinical specimen, Rapid leptocheck tests etc., are available for diagnosis of leptospirosis. Polymerase Chain Reaction (PCR) is used for diagnosis of various diseases of infectious origin including leptospirosis but there is paucity of data about comparison of PCR with other available method of diagnosis of leptospirosis. Aim: The aim of the study was to detect the leptospiral DNA by PCR method and to compare the results of PCR with other available diagnostic methods used for diagnosis of suspected leptospirosis cases in acute phase of illness. Materials and Methods: A total of 207 blood samples were obtained from suspected patients of leptospirosis admitted in New Civil Hospital, a tertiary care hospital in South Gujarat, during the period of July 2008 to November 2008. These blood samples were subjected to Rapid leptocheck, IgM ELISA, MAT test to detect (IgG or IgM) antibody level, Leptospira culture and PCR. Results: In early phase of the disease, Rapid leptocheck test gave 44% detection, but along with PCR seropositivity reached upto 71%. Detection rate by IgM ELISA was 59% which increased to 80% with PCR. By MAT seropositivity was 57% but combined seropositivity of MAT with PCR was 78%. Sensitivity and specificity of PCR as compared to MAT (Gold standard) was 52% and 79% respectively. Leptospira was not growing in culture. Conclusion: In present study, PCR picked up to 50% of cases which were negative by other serological tests so these finding suggest that PCR should be used routinely in acute phase of disease.

Dengue: An Analysis of Epidemiological Pattern Over a Six Year Period

Nidhi Singla, Preeti Chaudhary, MOnika Thakur, Jagdish Chander

Introduction: Dengue is an arboviral infection transmitted among humans by Aedes aegypti, the urban vector and Aedes albopictus as a maintenance vector in sub-urban and rural areas. The diagnosis is routinely established by detection of NS1 antigen and/or by IgM antibodies testing. Dengue infects 50-100 million cases per year worldwide with atleast half million serious cases needing hospitalization. Therefore, it is necessary to keep the surveillance ongoing to timely look out for changes occurring in disease pattern over a geographical area. Aim: To study the epidemiological patterns of dengue virus infection in our region over a period of six years. Materials and Methods: The present retrospective study was undertaken in the Department of Microbiology, Government Medical College Hospital, Chandigarh during time period January 2010 to December 2015 on 10,774 serum samples from patients clinically suspected to be suffering from dengue infection. Samples were selected as per World Health Organization (WHO) criteria. All the samples were processed for the presence of dengue IgM antibodies by µ anti-body-capture Enzyme Linked Immunosorbent Assay (ELISA), MAC ELISA and/or NS1Ag by ELISA as per the instructions of the manufacturer. The data was analysed from the data sheets available. Results: During the time period, a total of 10,774 samples were processed and 2,449 (22.7%) samples came out to be positive for dengue virus infection. Marked seasonal variation was noted with 0-2 cases presenting during month of January to July but positivity peaked in post monsoon season in October (>70%) and tapered till December every year. The adult age group (16-45 yrs) showed maximum positivity (83.5%) with males affected more than females. Conclusion: The present study clearly shows that our region is endemic for the dengue virus infection and there is need to continuously monitor the transmission of the disease in the community, to plan effective measures, to control the spread of dengue virus infection timely.

Comparison of Carotid Intima Media Thickness in Children of Patients with and without Premature Coronary Artery Disease

Introduction: Increased Carotid Intima Medial Thickness (CIMT) is associated with cardiovascular risk factors and vascular events like Coronary Artery Disease (CAD) and stroke. Aim: This study was designed to identify whether CIMT is increased in the children of parents with premature coronary artery disease and compare it with age and sex matched controls who are children of normal individuals. We also tried to compare and correlate the changes in CIMT if any, among the study group with relation to family history of diabetes and hypertension. Materials and Methods: It was an observational prospective case control study. Twenty five cases (children of parents with premature coronary artery disease) were recruited as per the inclusion and exclusion criteria. Age and sex matched controls were recruited from the paediatric outpatient department. The CIMT was measured using ultrasound Doppler as per the protocol by the Mannheim intima media thickness consensus statement. Results: Ten children out of 25 controls had CIMT of 0.05cm and 5 out of 25 cases had CIMT of 0.07cm. The association between cases and controls was not statistically significant. Even though the CIMT increases after 10 years, there is no statistically significant association between cases and controls in the different age groups. Out of the total 48% of the children among the case group had family history of hypertension whereas 28% in the control group. A 33% of children in the case group with family history of hypertension had CIMT of 0.07cm; 46% of children in case group without family history of hypertension had CIMT of 0.05cm. This difference was statistically significant (p=0.005). There was no significant association between family history of diabetes mellitus and CIMT in both groups. Conclusion: There was significant association between CIMT in children with family history of premature CAD and family history of hypertension when compared with no family history of hypertension with premature CAD. There was no significant association between CIMT of children with and without family history of premature CAD.

Finger Length Ratio (2D:4D) in Central India and an A ttempt to Verify Fraternal Birth Order Effect. A Population Based Cross-Sectional Study

Arjun Maitra, Chaitali Maitra, Dilip Kumar Jha, Rakesh Biswas

Introduction: A normal physiology of a human being is not mere a series of functions occurring with specific intensities and timing. There are lot of factors that may change the normal physiological activity within normal limits. Finger length ratio is one of the markers of intrauterine androgen exposure and it is debated and contradicted by many authors. Digit ratio varies among the ethnicities. Many Indian studies show that there is considerable difference in finger length ratio in different population. Data regarding Central India was not found on extensive search. Aim: To find out the finger length ratio and explore the birth order effect on finger length ratio among the first two successive born in the said population. Materials and Methods: We conducted a survey on 1500 volunteer persons (800 male and 700 female) over two years of time. We measured the length of the index finger (2D) and ring finger (4D) of both the hands and asked about their birth order history to find out the digit ratio for Central India population and any existing correlation of the same with birth order. T Test and Analysis of Variance (ANOVA) were used for the measure of significance and difference among the groups. The p< 0.05 was considered to be significant. Results: Our study reports that, study population mean for right hand 2D:4D ratio was 0.976 (SD ± 0.031) and for left hand it was found to be 0.969 (SD ±0.035). For males, mean finger length ratio for right hand was 0.967 (SD ±0.033) and 0.963 (SD ±0.037) for left hand. In females the mean Finger length ratio was 0.982 (SD ±0.027) for right hand and 0.974 (SD ±0.034) for the left hand respectively. Finger length ratio was found to be significantly less (p=0.03) in males for right hand. No significant (p=0.24) difference was observed for left hand. When assessed fraternal birth order effect among the eldest, second born with elder brother and second born with elder sister groups, no significant (p>0.05) variation for finger length ratio of right and left hands observed in both male and female population. Conclusion: Our study reports that the finger length ratio (2D:4D) for Central India population did not show significant association between finger length ratio and fraternal birth order among the first two successive born.

Haemoglobinopathies and ß-Thalassaemia among the Tribals Working in the Tea Gardens of Assam, India

Anju Barhai Teli, Rumi Deori, Sidhartha Protim Saikia

Introduction: Prevalence of haemoglobinopathies and ß-thalassaemia are very high in India but information about its status among the tribals working in the tea gardens of Assam is very less. Aim: The present study was carried out to determine the prevalence of haemoglobinopathies and ß-thalassaemia among the tribals working in the tea gardens of Assam. Materials and Methods: A total 1204 samples from the tribals working in tea gardens of Assam were analysed for both Complete Blood Count (CBC) and High Pressure Liquid Chromatography (HPLC) for detection of haemoglobinopathies and ß-thalassaemia. Results: This study showed that the prevalence of sickle cell anaemia and ß-thalassaemia were very high among this population. Our results indicated a higher prevalence of ß-thalassaemia (3.07%) among the Munda ethnic group and higher prevalence of sickle cell anaemia (4.73%) among the Lohar ethnic group. This was the first study to report the presence of HbE among the tribals working in the tea gardens of Assam. Conclusion: Based on the present findings, sickle cell anaemia and ß-thalassaemia were major health problem for the tribals working in the tea gardens of Assam. Proper diagnostic facilities for haemoglobinopathy and thalassaemia should be established in these areas, including establishment of haemoglobinopathy and thalassaemia database collection, haematological analysis laboratories, genetic counselling clinics, prenatal diagnosis centres and neonatal screening centres.

Infant and Young Child Feeding Practices in Infants Receiving Skin to Skin Care at Birth: Follow-up of Randomized Cohort

Introduction: Skin to Skin Care (SSC) in neonatal period influences immediate breastfeeding outcomes in early childhood, especially the duration of exclusive breastfeeding. Aim: We investigated influence of 17 hours of SSC given from day one of life on Infant and Young Child Feeding (IYCF) practices through one year of life. Materials and Methods: Follow-up of a Superiority Randomized Control Trial (RCT) (CTRI/2013/06/003790) conducted in a teaching hospital located in central Gujarat. Mothers of 100 neonates (48 girls, 52 boys) from previous study cohort of RCT on SSC were followed. A survey on IYCF practices during the first year of life was administered after the end of infancy. In RCT, 50 neonates had received SSC beginning of 30 min- 1 hour after birth for average 17 hours on day 1 of life. In the control group, 50 newborn were placed next to the mother and conventional care was provided. There was a significant difference between hypothermia incidences in these groups in the first two days of life. Results: There was no difference in the groups as far as the duration of exclusive breastfeeding, number of times breastfed per day, or stoppage of night feeds. No baby in either group received bottled feeds but about 53 received some form of extra lacteal feeds in the first 6 months without significant group difference. Fewer SSC mothers reported difficulties with breastfeeding or extra lacteal supplementation. All mothers who faced problems contacted physicians for advice and 20 were advised top milk and 6 given other foods. At one year of life 66% mothers were giving less than the recommended five food servings. There was no difference in practices related to hand washing, food preparation and storage, feeding habits of child and illness episodes in the children. Conclusion: IYCF practices in this small group were not as per guidelines. Few positive trends were seen with fewer SSC mothers facing problems related to breastfeeding. The study was underpowered to detect differences in IYCF practices in relation to SSC.

Motor Nerve Conduction Velocity In Postmenopausal Women with Peripheral Neuropathy

Akanksha Singh, Naiyer Asif, Paras Nath Singh, Mohd Mobarak Hossain

Introduction: The post-menopausal phase is characterized by a decline in the serum oestrogen and progesterone levels. This phase is also associated with higher incidence of peripheral neuropathy. Aim: To explore the relationship between the peripheral motor nerve status and serum oestrogen and progesterone levels through assessment of Motor Nerve Conduction Velocity (MNCV) in post-menopausal women with peripheral neuropathy. Materials and Methods: This cross-sectional study was conducted at Jawaharlal Nehru Medical College during 2011-2013. The study included 30 post-menopausal women with peripheral neuropathy (age: 51.4 ± 7.9) and 30 post-menopausal women without peripheral neuropathy (control) (age: 52.5 ± 4.9). They were compared for MNCV in median, ulnar and common peroneal nerves and serum levels of oestrogen and progesterone estimated through enzyme immunoassays. To study the relationship between hormone levels and MNCV, a stepwise linear regression analysis was done. Results: The post-menopausal women with peripheral neuropathy had significantly lower MNCV and serum oestrogen and progesterone levels as compared to control subjects. Stepwise linear regression analysis showed oestrogen with main effect on MNCV. Conclusion: The findings of the present study suggest that while the post-menopausal age group is at a greater risk of peripheral neuropathy, it is the decline in the serum estrogen levels which is critical in the development of peripheral neuropathy.

Prescribing Pattern of Antifungal Medications at a Tertiary Care Hospital in Oman

Khalid A. Al Balushi, Mohammed A. Alzaabi, Fatma AlGhafri

Introduction: Inappropriate use of antifungal agents is implicated in the global burden of antifungal resistance, adverse outcomes like persistent infections, unnecessary exposure and increased cost. Data collection from time to time is to be done in order to have a check on the resistance/sensitivity pattern of the commonly prescribed antifungal drugs. Aim: To describe the pattern of antifungal drug prescription and administration to patients attending a university hospital in Oman. Materials and Methods: This was a descriptive, retrospective cross-sectional study conducted at Sultan Qaboos University Hospital (SQUH), a university hospital in Oman that covered the electronic patients data for a period of one year (January 2013 to December 2013). The study included inpatients and outpatients of all ages and both genders attending SQUH and receiving antifungal medications at the study period. Frequencies and percentages were reported for categorical variables, while the mean and standard deviation were used to summarize the data for continuous variables. Results: A total of 1353 antifungal drug prescriptions were prescribed for 244 patients. More than half of all antifungal drug prescriptions were prescribed by haematology, infectious disease and family medicine departments. The majority of patients to whom these drugs were prescribed were diagnosed to have infectious diseases followed by prophylactic use in leukaemias and immunocompromised conditions. Fluconazole was the most commonly prescribed antifungal drug (n=715, 52.8%) followed by nystatin and voriconazole (n=233; 17.2% and n=152; 11.2%, respectively). Conclusion: This study will help in understanding antifungal prescription practices and help in directing future studies and also in developing local policies for appropriate use of antifungal drugs.

Long Term Outcomes of Kangaroo Mother Care in Very Low Birth Weight Infants

Sunil Gavhane, Deepak Eklare, Haseeb Mohammad

Introduction: Kangaroo Mother Care (KMC) has been gaining acceptance as an effective alternative to incubator based Conventional Medical Care (CMC) in preterm or Low Birth Weight (LBW) infants especially in resource scarce developing countries. Aim: To report and analyse the long-term effects of KMC for relatively stable Very Low Birth Weight (VLBW) infants on nutritional indicators and feeding conditions at 6–12 months of corrected age. Materials and Methods: This randomized controlled trial was done at a Level III Neonatal Intensive Care Unit (NICU) of a teaching institution in southern India. One hundred and forty neonates with birth weight <1500gm were enrolled. Inborn singleton, VLBW (birth weight <1500gm) infants, tolerating spoon feeds of 150mL/kg/day and haemodynamically stable (not on oxygen or respiratory support, no apnea for 72 hours, not on any intravenous fluids) were eligible. Infants with major malformation were excluded. Babies were randomized to KMC group or CMC group. At 6 to 12 months corrected age, the assessment included the measurement of growth parameters in terms of malnutrition, wasting, stunting and having small head. Feeding information was collected in relation to duration of exclusive or partial breastfeeding (months of chronological age and of corrected age), the age (chronological age and corrected age) at which weaning diet was started and the type of weaning diet. Comparisons between study groups for primary outcomes and secondary outcomes were performed with Odds Ratio (OR) calculator using Medcalc online statistical software. Results: A total of 91 infants were followed at 6–12 months of corrected age. There was no difference between two groups in the incidence of malnutrition, wasting, stunting and having small head (47.7% vs 31.9%, p-0.13), (34.1% vs. 31.9%, p-0.83), (22.7% vs 12.8%, p-0.22) and (18.2% vs.31.9%, p-0.14). Although KMC group babies had better head growth and lesser weight and length compared to the CMC group, it was not statistically significant. The breast feeding and weaning rates at 6 months post birth were similar in both the groups. Conclusion: KMC group does not differ significantly with CMC group in terms of long-term growth and feeding pattern at 6 to 12 months of corrected age.

A Comparative Analysis of Caries Inhibitory Effect of Remineralizing Agents on Human Enamel Treated With Er:YAG Laser: An In-vitro Atomic Emission Spectrometry Analysis

Introduction: The tug of war to maintain tooth integrity is dependent on a ratio between demineralization and remineralization. Hence, demineralization should be retarded and remineralization should be enhanced to maintain a natural equilibrium in the oral cavity. Aim: To compare in-vitro acid resistance of human enamel when using Casein Phosphopeptides Amorphous Calcium Phosphate (CPP-ACP) [GC Tooth mousse] cream, Casein Phosphopeptide Amorphous Calcium Fluoride Phosphate (CPP-ACFP) [GC Tooth mousse plus] cream, Er:YAG laser alone, combination of CPP-ACP with Er:YAG laser, CPP-ACFP with Er:YAG laser. Materials and Methods: An in-vitro study was done on 100 specimens which were prepared from 50 human premolars to investigate the caries inhibitory effect of remineralizing agents and laser on enamel using an atomic emission spectrometry analysis. The enamel specimens were randomly allocated into 6 groups: Untreated (control); CPP-ACP (GC Tooth mousse); CPP-ACFP (GC Tooth mousse plus); Er:YAG laser treatment alone; CPP-ACP with Er:YAG laser; CPP-ACFP with Er: YAG laser. Then specimens were immersed individually in 5ml of acetate buffer solution (0.1mol/L, pH 4.5) and incubated at 37°C for 24 hours, to determine the acid resistance by analyzing the calcium release using atomic emission spectrometry. An ANOVA model was constructed (p-value 0.05), followed by post-hoc Tukey’s test for multiple pair wise comparisons of mean values. Results: There was a significant difference among the various groups with respect to amount of calcium released (p<0.001). The lowest mean score of calcium release was observed for CPP-ACFP with Er:YAG laser followed by CPP-ACFP but the differences between these groups were statistically not significant (p>0.05). Similarly the differences between CPP-ACP with Er:YAG laser and CPP-ACP also were not significant (p>0.05). The highest mean score of calcium release was for Er:YAG laser and no significant statistical difference was noticed in comparison with control group (p>0.05). Conclusion: Combination of CPP-ACFP with Er:YAG laser is more effective in decreasing enamel demineralization when compared with other groups.

Morphological Variations of the Thyroid Gland among the People of Upper Assam Region of Northeast India: A Cadaveric Study

Anjan Jyoti Rajkonwar, Giriraj Kusre

Introduction: The morphological variations of the thyroid gland have been reported from different parts of the world. The variations are due to remnant or non-specific development of the parts of the thyroid gland. Surgical operation of the thyroid gland has been the treatment of choice in various thyroid pathologies. Prior knowledge of the morphological variation is important to ensure better results from these surgical operations. Aim: To study the prevalence of morphological variations seen in the thyroid glands in the upper Assam region of Northeast India. Materials and Methods: This was a hospital based cadaveric study. Total number of Thyroid glands dissected were 80. The thyroid gland was examined properly for the presence of pyramidal lobe, levator glandulae thyroideae and complete absence of isthmus. Statistical analysis was done by SPSS 21.0. Results: It was found that 17 (21.25%) cadavers did not show an isthmus. The pyramidal lobe was present in 31(38.75%) cases and frequently arising from the left side (74.2%) of the isthmus. Levator glandulae thyroideae was found in 15 (18.75%) of the thyroid specimens. In all cases, it was extended from the apex of the pyramidal lobe to the hyoid bone. Conclusion: Morphological variation of the thyroid gland is very common hence requires detection prior to any surgery on the thyroid gland.

Role of Routine Subhepatic Abdominal Drain Placement following Uncomplicated Laparoscopic Cholecystectomy: A Prospective Randomised Study

Ankur Sharma, Sushil Mittal

Introduction: Routine abdominal drainage after laparoscopy cholecystectomy is an issue of considerable debate. Reason for draining is to detect early bile/blood leak and allow CO2 insufflate during laparoscopy to escape via drain site thereby decreased shoulder tip pain and post-operative nausea and vomiting. But some studies show no difference in post-operative nausea /vomiting/pain between drain and no drain group. Aim: To assess the role of drains following uncomplicated laparoscopic cholecystectomy. Materials and Methods: This prospective randomized study was conducted in the Department of General Surgery, Government Medical College and Rajindra Hospital, Patiala. Hundred patients of symptomatic gallstones satisfying the selection and exclusion criteria, undergoing uncomplicated laparoscopic cholecystectomy were included in this study, 50 cases with drains in right subhepatic space (Group I) and 50 cases without drains (Group II). Both groups were compared in terms of post-operative shoulder pain, analgesic requirement, nausea and vomiting, hospital stay and analgesic requirement in patient with drains and without drains. SPSS version 16.0 (Chi-Square Test and Fisher-Exact Test) were used for statistical analysis. Results: In this study, average operative time in both the groups was same (p-value 0.977). There was more incidence of nausea /vomiting in no drain group than in drain group. Shoulder tip pain was lower in drain group in first 12 hours post-operative. However, after 12 hours, drain group had higher shoulder tip pain than no drain group. Analgesic requirement was higher in no drain group upto 12 hours after which it was higher in drain group (statistically not significant). In terms of hospital stay patients in drain group had a longer stay in hospital as compared to no drain group (2.96 vs 2.26; p <0.001 statistically significant). Conclusion: Use of drains in uncomplicated laparoscopic cholecystectomy is not advantageous; its role in reducing post-operative nausea/vomiting is insignificant. It increases post-operative shoulder tip pain and hospital stay. Therefore, routine use of drains cannot be justified as it increases morbidity without significant advantage

BCL6 mRNA Expression Level in Invasive Duct Carcinoma not otherwise Specified

Eman Badr, Eman Masoud, Asmaa Gaber Abdou, Marwa Serag Eldien

Introduction: B-Cell Lymphoma 6 (BCL6) has an oncogenic role in tumourigenesis of various malignancies. It represses genes involved in terminal differentiation and plays complementary role with Signal Transducer and Activator of Transcription 3 (STAT3) in triple-negative breast cancer cellular function. Aim: To evaluate the expression of BCL6 in cancer breast and determine its correlation with the clinico-pathological features including the molecular subtype of breast carcinoma. Materials and Methods: This prospective case control study was carried out on 150 patients, divided into 100 cases of invasive duct carcinoma not otherwise specified and 50 benign breast lesions including fibroadenoma and fibrocystic disease. Fresh tissues were excised, which were then subjected to RNA extraction. The BCL6 mRNA level was assessed using real-time reverse transcription Polymerase Chain Reaction (PCR). Results: There was a significant higher levels of BCL6 mRNA in malignant cases compared to benign ones (p<0.001). The level of BCL6 mRNA was higher in cases showing advanced tumor stage (p<0.04), triple negative subtype and associated in situ component (p<0.001) compared to cases with an early stage, luminal or Her 2-neu positive subtypes and those lacking in situ component. Conclusion: BCL6 is up-regulated in breast cancer and is associated with poor prognostic features such as advanced stage and triple negative molecular subtype. BCL6 inhibitors might be considered as targeted therapy for breast cancer.

Topical Corticosteroid Misuse: The Scenario in Patients Attending a Tertiary Care Hospital in New Delhi

Introduction: Irrational use of Topical Corticosteroid (TC) is quite common in India due to unrestricted availability and use of TC not only by general public but also by physicians and chemists due to quick relief of symptoms in different dermatological conditions. Aim: The present study was conducted to evaluate and analyse the prevalence of misuse of TC and the causes behind misuse of TC among patients in a dermatology outpatient department in New Delhi. Materials and Methods: This was a cross-sectional observational questionnaire based study conducted over a period of 5 months (1st June 2015 to 30th November 2015). Patients were questioned and assessed for misuse of TCs in terms of indication, dose, frequency, duration and source of recommendation of TC. Results: During the study period, 256 (11.77%) patients presented with inappropriate use of TC out of 2174 patients attending OPD of dermatology unit of a government hospital. A total of 250 patients presented with adverse effects of TC resulting from the misuse of these drugs. There were 60%female patients and 20-29 years (38%) was the most common age group affected. We found fungal infection (38%) was the most common reason of abuse followed by facial acne (29%) and lightening of skin colour (8.4%). Friends and family (33.2%) were found to be the most influencing factors for misuse of TC. Betamethasone (72.8%) was the most commonly used TC preparation and tinea incognito (26.4%) followed by facial acne (25.6%) were the most common side effect experienced. Conclusion: Outcome of the misuse of TC could be dreadful and the cause for same lies at all levels- patients, family, physicians and the regulatory authorities.

Comparison of Levosimendan, Milrinone and Dobutamine in treating Low Cardiac Output Syndrome Following Valve Replacement Surgeries with Cardiopulmonary Bypass

Introduction: Low Cardiac Output Syndrome (LCOS) following Cardiopulmonary Bypass (CPB) is common and associated with increased mortality. Maintenance of adequate cardiac output is one of the primary objectives in management of such patients. Aim: To compare Levosimendan, Milrinone and Dobutamine for the treatment of LCOS after CPB in patients who underwent valve replacement surgeries. Materials and Methods: Sixty eligible patients meeting LCOS were allocated into three treatment groups: Group A-Levosimendan (loading dose 10µg/kg over 10 minutes, followed by 0.1µg/kg/min); Group B-Milrinone (loading dose 50 mcg/kg over 10 minutes followed by 0.5mcg/kg/min) and Group C-Dobutamine @ 5µg/kg/min to achieve target cardiac index (CI) of > 2.5 L/min/m2. In case of failure, other drugs were added as required. Hemodynamic parameters were monitored using EV1000TM clinical platform till 30 minutes post CPB. INSTAT software was used for statistics and p<0.05 was considered significant. Results: The mean±standard deviation of time taken by Dobutamine, Levosimendan and Milrinone to bring the CI to target were 11.1 ± 8.79, 11.3± 6.34 and 16.62 ± 9.33 minutes respectively (p=0.064). Levosimendan was equally effective in increasing and maintaining adequate CI as compared to Dobutamine (p>0.05). Levosimendan and Milrinone increased MAP (Mean Arterial Pressure) equally while Dobutamine was more effective as compared to both Levosimendan and Milrinone 20th minute onwards (p<0.01). Milrinone was less effective in increasing the stroke volume as compared to Dobutamine and Levosimendan while Dobutamine and Levosimendan were equally effective. There was no difference in the HR (Heart Rate) achieved with all these three drugs. Conclusion: Levosimendan is equally effective to Dobutamine and better than Milrinone for the treatment of LCOS following CPB in patients undergoing valve replacement surgeries.

Anti-Mullerian Hormone: A Marker of Ovarian Reserve and its Association with Polycystic Ovarian Syndrome

Introduction: Anti-Mullerian Hormone (AMH) is a useful endocrine marker for assessing the ovarian reserve. AMH serum level reflects the number of follicles that have made the transition from the primordial pool into the growing follicle pool, and it is not controlled by gonadotropins. Aim: The present study was conducted to correlate serum AMH levels with Polycystic Ovarian Syndrome (PCOS) and type of treatment protocol. Materials and Methods: Serum AMH levels were performed in the early follicular phase (on 2nd day of menstrual cycle) both in infertile females including PCOS and control women. The results were analyzed in relation to age, Body Mass Index (BMI), ovarian volume, serum Follicle Stimulating Hormone (FSH) levels, Antral Follicle Count (AFC), type of treatment protocols and also in association with PCOS patients. The serum levels of AMH were measured in all the participants on 2nd day of menstrual cycle using ultra sensitive Enzyme Linked Immunosorbent Assay (ELISA). Results: The plasma AMH levels were significantly higher in women with polycystic ovarian syndrome. The significant association was seen between FSH and AFC with AMH. However, no significant association was observed between AMH levels with age, BMI, ovarian volume and type of treatment protocols. Conclusion: The serum AMH measurement was significantly higher in PCOS patients. No association with type of treatment protocol was obtained.

High Serum Estradiol and Heavy Metals Responsible for Human Spermiation Defect-A Pilot Study

Introduction: Spermiation is a process of releasing sperm into the lumen of seminiferous tubules. Failure in releasing sperm into the lumen is designated as spermiation defect. Spermiation defect cases present as oligo-azoospermia or azoospermia despite normal gonadotropins and testicular histology/cytology. Human spermiation defect never got attention to investigate infertility practice. Most of the information on spermiation defect, so far is from animal experiments. We assume some cases of non-obstructive azoospermia with normal gonadotropins and testicular histology/cytology could be due to spermiation defect. Aim: The aim of the study was to find out the underlying aetiology in cases of human spermiation defect. Materials and Methods: A total of 13 cases of spermiation defect and 20 fertile men as control constituted study material. Cases were studied for chromosomal abnormalities by conventional karyotyping, sex chromosome mosaicism by interphase XY FISH, Yq microdeletion by STS PCR, sertoli cell quality (function) and quantity (numbers) by serum Anti-Mullerian Hormone (AMH) and inhibin B besides other hormones like Follicular Stimulating Hormone (FSH), prolactin, testosterone and estradiol. Vitamin A concentration in serum was also measured. Presence of heavy metal was investigated by elemental electron microscopy in seminal cells (eight cases) & by spectrometry in serum as well as seminal plasma. Results: Chromosomal and Yq microdeletion study failed to detect any abnormalities. AMH, inhibin B and vitamin A were also normal. Estradiol level was high in 6 out of 13 cases (46%) while platinum in seminal cells was high in 4 cases (50%). High (four times or more) serum level of lead and nickel was observed in 11 (85%) and 6 (46%) cases, respectively. Conclusion: High serum concentration of heavy metals like lead & nickel or high platinum accumulation in seminal cells or high serum estradiol alone or in combinations may be underlying aetiologic factors in human spermiation defect.

Correlation between Age, Gender, Waist-Hip Ratio and Intra Ocular Pressure in Adult North Indian Population

Shikha Baisakhiya, Surjit Singh, Prafulla Manjhi

Introduction: Intraocular pressure (IOP) is affected by various systemic and local factors. The significance of studying the factors affecting IOP is because of its association with potentially blinding condition known as glaucoma. Aim: Present study was conducted with the aim to find out the correlation between gender, age, Waist-Hip Ratio (WHR) and IOP. Materials and Methods: The study included 300 healthy individuals between 40-79years of age. The subjects were divided into 2 categories according to gender i.e., male and female. The subjects were divided into 4 categories according to age i.e., 40-49years, 50-59years, 60-69years and 70-79years. The subjects were divided into two groups according to Waist-hip ratio (WHR) as per WHO guidelines: WHR <0.9 and WHR >0.9 in males and WHR <0.85 and WHR >0.85 in females. IOP was recorded in each group using Goldmann Applanation tonometer and statistical comparisons were made to find correlation between gender, age, Waist-hip ratio and IOP. Results: There was no statistically significant difference between IOP of males and females (p=0.235). The age and IOP were positively correlated with each other i.e., IOP increases with increasing age (r=0.511, p<0.001). Higher WHR is associated with significantly higher IOP in both the genders (males r =0.644, p<0.001; females r=0.794, p<0.001). Conclusion: There is no significant difference in IOP amongst males and females. Increasing age and higher WHR are risk factors for raised IOP.

Clinical Profile of Cardiac Arrhythmias in Children Attending the Out Patient Department of a Tertiary Paediatric Care Centre in Chennai

Sarala Premkumar, Premkumar Sundararajan, Thangavelu Sangaralingam

Introduction: The presentation of symptoms of paediatric arrhythmias vary depending on the age and underlying heart disease. Physical examination of children with important arrhythmias may be entirely normal. Aim: Aim is to study the characteristics of cardiac arrhythmias in paediatric patients in a tertiary paediatric care centre in Chennai, India. Materials and Methods: The participants (n=60) were from birth to 12 years of age. Patients with sinus arrhythmias, sinus tachycardia and sinus bradycardia were excluded. Proportions of various parameters of interest like clinical features, age and sex distribution and underlying heart disease of children presenting with cardiac arrhythmias were arrived. Statistical analysis was performed using SPSS version 16.0. Results: Ventricular ectopics were the most common type of arrhythmias observed in the present study followed by Sinus Node Dysfunction (SND). The most common type of SND was sino atrial arrest. Supra ventricular tachycardia was the most frequently sustained tachyarrhythmia in the present study. An increased association of WPW (Wolf Parkinson White Syndrome) with specific congenital cardiac defects was noted. Conclusion: Cardiac arrhythmias in children can present at anytime from fetal life to adolescence and their recognition requires high index of suspicion. While majority of children with arrhythmias have structurally normal heart, they are frequently encountered in children with underlying heart disease. Treatment of paediatric arrhythmias should be guided by the severity of the patient, the structure and function of the heart.

Association of Serum Uric Acid Level with the Severity of Brain Injury and Patient’s Outcome in Severe Traumatic Brain Injury

Masoud Hatefi, Masoud Moghadas Dastjerdi, Bahareh Ghiasi, Asghar Rahmani

Introduction: The prognostic value of serum Uric Acid (UA) levels in Traumatic Brain Injury (TBI) is unclear. Aim: To investigate the relationship between serum UA levels and prognosis of patients with TBI when in hospital and at six months after discharge. Materials and Methods: All patients attended our emergency department during July 2014 and December 2015 and were consecutively entered into the study and among 890 evaluated candidates based on inclusion criteria we finally investigated the serum UA levels of 725 TBI patients. Computed Tomography (CT) images of the brain were obtained within the first 24 hours of hospitalization. Outcome was assessed using the Glasgow Outcome Scale (GOS) score at discharge and at six months after discharge. Results: Data of 725 patients (42.89% men; mean age: 54.69 ± 12.37 years) were analyzed. Mean ± Standard Deviation (SD) of Glasgow Coma Scale (GCS) scores was 4.65 ± 1.76. Serum levels of UA, when in hospital and at six months after discharge, among those who died were lower than those who survived (in hospital: 0.126 ± 0.026 vs. 0.243 ± 0.942 mmol/l, p = 0.000; 6 months post-discharge: 0.130 ± 0.044 vs. 0.286 ± 0.069 mmol/l, p<0.001). The mean UA plasma was significantly different between deceased and alive patients according to GOS scores (p<0.001 and p=0.030, respectively). The UA levels showed a significant relationship with GCS scores and severity of brain injury assessed using the Marshall Classification Score (p=0.005). Conclusion: Our results showed a strong relationship between UA levels and patients outcomes either in hospital or at six months after discharge. Serum UA level could be considered as a valuable marker for evaluating the severity of brain injury and outcomes of TBI.

Long Term Outcome in Patients with Esophageal Stenting for Cancer Esophagus - Our Experience at a Rural Hospital of Punjab, India

Introduction: Cancer of the esophagus is among the leading cause of cancer deaths in Punjab, India. Patients generally present with dysphagia as their first symptom and more often they have advanced disease at the time of presentation to a tertiary care centre. Palliative procedures have important roles in this setting. Stenting is the best option to palliate the symptoms of dysphagia, from which patient is suffering the most. Aim: To know the success rate, early and long term complications and mortality in esophageal stenting, when it was done in malignant esophageal stricture patients. Materials and Methods: One hundred patients, who had undergone esophageal stenting from January 2012 to January 2015, were included in the study. We retrospectively analysed the data for patient characteristics, causes of non-operability, early and long term complications, re-interventions, efficacy and mortality. Results: Out of 100 patients, indications for stenting were locally advanced disease not amenable to surgery (52%), metastatic disease (35%), CVA (1%), cardiac and respiratory problem (8%), un-willing for surgery in 5% of patients. Majority of patients (94%) had squamous cell carcinoma, while only 6% had adenocarcinoma. 84% of patients presented with dysphagia with or without chest pain and recurrent cough while 16% had recurrent vomiting. 58% had dysphagia to liquids and solids and 17% had complete dysphagia. After stenting 93% had significant improvement in dysphagia score from median of 3 to 1. Post procedure stay was 3.61±1.0 days. One patient had procedure related major complication in the form of post procedural bleed (after 16 days of stenting) leading to death of that patient. Minor complications were present in 52 patients treated conservatively not affecting the efficacy of procedure. These include pain after stenting (38%), stent obstruction (23%) and stent migration (6%). All the minor complications were treated conservatively except in six patients in whom re-stenting was done. Conclusion: Esophageal stenting is relatively safe procedure with short stay of the patient in the hospital. Although, it helps in alleviating patients’ morbidity very effectively and reliably, there are many technical glitches, which needs to be kept into account and patient should be properly counseled before the procedure to prevent and manage post procedure complications and medico legal aspects.

Comparison of the Load-Deflection Characteristics of Aesthetic and Conventional Super Elastic Ni-Ti Orthodontic Arch Wires in Conventional and Metal-Insert Ceramic Brackets

Hosseinagha Aghili, Soghrayassaei, Neda Joshan, Nemat Hoseini

Introduction: Coated arch wires and ceramic brackets have been introduced to improve aesthetics during orthodontic treatment. Aim: The aim of this study was to determine the effects of coating on the physical properties of aesthetic orthodontic wires. Material and Methods: Five round wires (0.016 inch) were obtained from each of three brands: conventional uncoated super elastic Nickel Titanium (Ni-Ti) (Rematitian Lite; Dentaurum, Ispringen, Germany), HUBIT (Teflon Coated, Korea), G&H (Epoxy Coated, Greenwood, Indiana, USA) which belonged to maxillary arch. Two types of standard ceramic brackets (conventional and metal-insert type, Ortho Technology, Tampa, Florida, USA) with the slot size of 0.022×0.028 inches were used. A simulation device was fabricated to resemble a model of human dental arch and each of the specimen was tested in three-point bending test. The test was conducted in the buccolingual plane with crosshead speed of 1mm/minute pressure from metal pole. Each sample was loaded until a deflection of 3.0 mm was produced. The mean values of maximum loading force, unloading force and clinical plateau length were recorded. One-way ANOVA and Tukey tests were used at p<0.05. Results: Uncoated Ni-Ti arch wire showed higher mean values of maximum loading and unloading force than that of coated aesthetic wires similar to ceramic brackets while G&H wire and metal-insert ceramic brackets presented the lowest values. The longest clinical plateau length was observed in G&H wires and metal-insert ceramic bracket. Conclusion: The coating processes for HUBIT (Teflon Coated, Korea), G&H (Epoxy Coated, Greenwood, Indiana, USA) wires might influence bending behaviour which can cause decrease in loading and unloading force.

Erectile Dysfunction and Low Sex Drive in Men with Type 2 DM: The Potential Role of Diabetic Pharmacotherapy

Hayder M. Al-Kuraishy, Ali I. Al-Gareeb

Introduction: Diabetic men with erectile dysfunction have not been widely studied. They have low testosterone levels, causing low sex drive and erectile dysfunction. Aim: To assess the erectile dysfunction and sex drive in relation to testosterone serum levels in type 2 Diabetes Mellitus (DM) patients. Materials and Methods: A total of 64 patients with type 2DM were enrolled in this cross-sectional study, according to the treatment types they were divided into three groups, group (A): 34 patients treated with metformin, group (B): 30 patients treated with sulfonylurea and group (C): 27 healthy normal non-diabetic men are taken as control. Total testosterone (TT), Free Testosterone (FT), Free Androgenic Index (FAI), Sex Hormone Binding Globulin (SHBG), lipid profile and anthropometric parameters in metformin and sulfonylurea treated patients were compared to normal healthy men along with Sexual Health Inventory for Men (SHIM). Results: Total testosterone serum levels were high in sulfonylurea treated patients as compared to metformin treated patients' p < 0.0001. Similarly, SHBG levels were significantly higher in sulfonylurea treated patients compared to metformin treated patients p < 0.0001. FT was also significantly higher in sulfonylurea treated patients compared to metformin treated patients p =0.014 and significantly low compared to the control p =0.0002. FAI was also significantly higher in sulfonylurea treated patients compared to metformin treated patients p < 0.0001. On other hand Bioavailable testosterone (BT) was low in metformin treated patients (2.75±1.12 nmol/L) compared to the control p< 0.0001. SHIM was low in metformin treated patients 10.61±3.22 which significantly differed from control and sulfonylurea treated patients p< 0.0001, intergroup differences was significant p=0.001. Conclusion: Metformin leads to significant reduction in testosterone levels, sex drive and induction of low testosterone-induced erectile dysfunction, whereas; sulfonylurea leads to significant elevation in testosterone levels, sex drive and erectile function.

Recovery of Platelet Count among Apheresis Platelet Donors

Introduction: Increase in awareness regarding use of single donor platelets and the availability of technology has resulted in increased platelet pheresis procedures. The interval between two succesive plateletpheresis donations is much less compared to whole blood donations. Plateletpheresis procedures are associated with short term and long term adverse events. The effect of plateletpheresis on haematopoietic system remains significant. Aim: To study the recovery of platelet count to baseline in plateletpheresis donors. Materials and Methods: Fifty, first time apheresis donors were followed for platelet count recovery. Platelet count was measured before donation and at 30 minutes, 48 hours, 7th day and 14th day post-donation. Donor platelet count recovery to baseline was observed during the two week period. Results were analysed statistically, p<0.05 was considered statistically significant. Results: Platelet count recovered to baseline by 7th day post-donation in 50% of donors in groups I (Pre-donation platelet count 1.5 lacs/µl to 2.2 lacs/µl) and II (Donors with platelet count >2.2 lacs/µl to 2.75 lacs/µl), 30% of donors in group III (Donors with platelet count >2.75 lacs/µl to 3.5 lacs/µl) of the donors. Donor’s platelet count recovered to baseline in 85% of donors by day 14 in across the three groups. Recruitment of platelets from spleen was observed in donors with pre-donation platelet count on the lower limit of normal. Conclusion: By day 7, donor’s platelet count recovered to baseline in majority of the donors. Allowing enough recovery periods for donor platelet count, the minimum interval between two apheresis donations can be 7 days till more prospective studies conclude on the frequency and minimum interval between plateletpheresis donations.

Cisplatin Induced Renal Insufficiency Measured by Glomerular Filtration Rate with 99mTc-DTPA and by using Serum Creatinine based Formulae: A Prospective Study

Rohini Khurana, Satyawati Deswal, Chandra Prakash, Dhananjay Kumar Singh

Introduction: Cisplatin also known as Cis-Diammine-Dichloroplatinum (CDDP) is a chemotherapeutic alkylating nephrotoxic agent. Thus, it is necessary to know if renal function is normal before starting chemotherapy. Glomerular Filtration Rate (GFR) can be assessed directly by using a radiopharmaceutical (dGFR). Estimated GFR (eGFR) method use, Serum Creatinine (SCR) levels in mathematical formulae such as Cockroft-Gault (CG) and abbreviated. Modified Diet in Renal Disease (aMDRD). The serum creatinine level is a function of GFR but is relatively insensitive for detecting early renal insufficiency. Aim: We aimed to correlate the incidence of Renal Insufficiency (RI) before and one month after completion of chemotherapy treatment by various methods. Materials and Methods: In this prospective study, we examined 64 patients with locally advanced head neck and uterine cervix cancers, before and one month after chemotherapy treatment with CDDP. Single agent CDDP was used with dose range between 35mg/m2 as concurrent weekly chemotherapy. Results: Baseline RI was seen in 9.3% of patients by SCR levels, in 21.8% by the dGFR method, in 43.75% by the GFR-CG method and in 25% by the GFR-aMDRD formula. We considered GFR of <60 ml/min and SCR >1.5mg% as RI. After completion of treatment, the median RI was seen in 12.5% by SCR levels, 34.38% by dGFR method, 53.13% by GFR-CG method and 40.63% by GFR-aMDRD formula. None of the methods of GFR estimation showed statistically significant increase in RI one month after CDDP infusion. Only a weak correlation was seen between dGFR and eGFR based on SCR value (p=0.006). Conclusion: Baseline RI was detected in 12% more cases when measured by dGFR as compared with SCR level. However, mathematical formulae overestimated baseline RI as compared to dGFR. One month after completion of treatment with CDDP chemotherapy, RI increased in 10%-15% cases as detected by all the four evaluated methods. There is weak correlation between SCR and dGFR thus implicating the importance of dGFR in assessing RI. Thus, despite normal SCR levels, GFR by radioisotope method should also be done as pre-treatment workup for cisplatin based chemotherapy.

Current Practice of Hypertension in India: Focus on Blood Pressure Goals

Introduction: Recommended Blood Pressure (BP) goals in elderly and those with co-morbid conditions like Diabetes Mellitus (DM) and Chronic Kidney Disease (CKD) vary in different Hypertension (HTN) management guidelines. Aim: To understand currently followed BP goals and practices among the physicians involved in management of HTN in India. Materials and Methods: A cross-sectional, observational survey was conducted at 66th annual conference of Cardiological Society of India (CSICON-2014, Hyderabad). A structured questionnaire related to the BP goals and HTN practices was provided and responses from voluntarily participating physicians were collected. Data was analysed with descriptive statistics. Results: Two-hundred sixty physicians completed this survey. In their routine clinical practice, physicians most frequently referred to Joint National Committee (JNC) guidelines (63.85%) followed by Indian guidelines on HTN (14.23%). In patients aged 60 years and above, BP goal <140/90mmHg and <150/90mmHg was aimed by 43.46% and 33.85% of the physicians respectively. In HTN with Type 2 DM (T2DM), most physicians (61.92%) had a BP goal of <130/80mmHg. A target BP <130/80mmHg was aimed by 48.08% physicians in CKD without proteinuria and 68.85% physicians in CKD with proteinuria. In newly diagnosed hypertensives, treatment modification was practiced after 15, 20 and 30 days by 37.31%, 16.15% and 35.77% of the physicians respectively. Beta-blockers were considered as third-line agents in HTN without co-morbidities by 45% physicians. Ambulatory BP Monitoring (ABPM) is practiced only in few patients (<5%) by most (71.93%) physicians. Conclusion: In practice, Indian physicians follow lower BP goals when compared to the recommendations from the most referred JNC guidelines. Increasing physicians’ awareness to the changes in recommendations is the need.

Spectrum of Factors Triggering Endothelial Dysfunction in PIH

Visala Sree jammalamadaga, Philips Abraham

Introduction: Pre-eclampsia (PE) is a major cause of maternal and fetal/neonatal mortality and morbidity. The aetiology and pathogenesis of PE is yet to be completely understood. Evidence shows that, Endothelial Dysfunction (ED) plays a pivotal role in the genesis of this multi-system disorder that develops in PE and eclampsia. Aim: To determine the circulating levels of factors Malondialdehyde (MDA), Ferric Reducing Ability of Plasm-a (FRAP), Tumour Necrosis Factor. (TNF-a), sFlt-1, VEGF, PlGF, Nitric Oxide (NO) that influence the ED. Materials and Methods: Study groups consisted of Normotensive pregnant women (N) preclamptic women (PE) and eclamptic women (E) with 100 subjects in each group in the 3rd trimester of pregnancy. They were investigated for MDA, FRAP, TNF-a, sFlt-1, VEGF, PlGF, NO. Statistical analysis was done using Analysis of Variance (ANOVA). Results: When compared to controls MDA, TNF-a, sFlt-1 levels were found to be significantly high and FRAP, VEGF, PIGF and NO levels were significantly low in PE, E group. E showed a significantly high level of MDA, TNF-a, sFlt-1 and low levels of FRAP, VEGF, PIGF, NO when compared to PE group. Conclusion: Our study substantiated the fact, that, oxidative stress, imbalance between anti-angiogenic factors and pro- angiogenic factors exists in Pregnancy Induced Hypertension (PIH) condition. This imbalance is directly related to the ED, the hallmark of PE. So oxidative stress, VEGF, PlGF and sFlt-1 can be used as markers to analyze the onset and progression of the disease.

Comparison of LDL-Cholesterol Estimate using Various Formulae with Directly Measured LDL-Cholesterol in Indian Population

Nishtha Wadhwa, Radhika Krishnaswamy

Introduction: Low-Density Lipoprotein Cholesterol (LDLc) is widely recognized as an established cardiovascular risk marker. Different formulae have been proposed for calculation of LDLc but have not been validated in Indian population and over a wide range of Triglycerides (TG). Friedewald formula is most commonly used which has various shortcomings. Aim: To calculate LDLc using various formulae and compare it with directly measured LDLc at various ranges of TG concentration in Indian population. Materials and Methods: One year lipid profile data of 21,503 samples was taken. Calculation of LDLc was done by the following formulae: Friedewald; Cordova and Cordova; Vujovic; Ahmadi; Anandaraja; Puavillai and Hattori. Comparison of calculated LDLc with directly measured LDLc was done at following TG ranges: <150mg/dL; 151-199mg/dL; 200-399mg/dL and >400mg/dL using Pearson’s correlation coefficient and two-paired t-test. Results: For TG range <150mg/dL, Puavillai formula correlated best with direct measurement (r = 0.978). For TG range 151-199mg/dL, Vujovic formula correlated best with direct measurement (r = 0.977and mean difference of -1.2 mg/dL). For TG range 200-399mg/dL, Vujovic formula correlated best with direct measurement (r = 0.968). For TG range >400 mg/dL, Vujovic formula correlated best with direct measurement (r = 0.791). Conclusion: Vujovic formula appears to be more accurate than any other formula when applied to Indian population.

Seroprevalence of Common Viral Diseases: A Hospital Based Study from Amritsar, India

Introduction: There is a paucity of published data on epidemiology of the viral infections in Punjab, India. The Viral Research and Diagnostic Laboratory (VRDL) located at Government Medical College (GMC), Amritsar conducts the initial diagnosis of common viruses circulating in the region. Aim: To report the seroprevalence of various viral diseases in Amritsar and neighboring districts of Punjab along with the demographic and geographical data of the patients. Materials and Methods: Whole blood sera samples from a total of 5781 patients suspected of various viral diseases (chikungunya, dengue, hepatitis A, hepatitis B, hepatitis C, hepatitis E, herpes simplex-1 or herpes simplex-2) were received at VRDL, GMC, Amritsar from January 2015 to April 2016 and a cross sectional study was conducted. The diagnosis was based on serological assays. Results: Out of total 5781 suspected cases, 1790 were diagnosed with antibodies for atleast one of the tested viral diseases. Dengue virus was the highest occurring viral disease (56.77%). Male patients infected with viruses outnumbered female cases, except for hepatitis E and herpes simplex-1. The 21-40 years age group appeared to be the most susceptible age group for nearly all studied viral infections. Among the total nine reported outbreak investigations, largest encompassed 1335 dengue cases from Amritsar district. Conclusion: VRDL established in GMC, Amritsar has become instrumental in detection of emerging and re-emerging viral diseases including outbreak investigation of communicable diseases. Timely action with the help of adequate information and capacity to diagnose the viruses might help in saving numerous lives.

Emergence of Hospital Acquired Carbapenem Resistant Non Fermenters in Teaching Institute

Introduction: Non-Fermenting Gram Negative Bacilli (NFGNB) are emerging now-a-days because of their tendency to colonize various surfaces and inherent resistance to commonly used disinfectants. They are responsible for multi-drug resistant hospital acquired infections. Detection of carbapenem resistance mechanisms is essential for treatment and infection control purpose as can spread to other organisms causing hospital outbreaks. Aim: To characterize non-fermenters from various clinical samples and to detect different carbapenem resistance mechanisms in meropenem resistant isolates. Materials and Methods: The prospective study was conducted at Sri Aurobindo Medical College and Post Graduate Institute, Indore over a period of one and half year from December 2014 to May 2016. A total of 1310 samples were collected from Ventilator Associated Pneumonia (VAP), Surgical Site Infection (SSI), Urinary Tract Infection (UTI), septicaemia, Lower Respiratory Tract Infection (LRTI) and middle ear infected patients. Non-fermenters were identified by standard microbiological tests. Meropenem resistance was determined by Kirby-Bauer disk diffusion method and resistant isolates were further tested by Modified Hodge test, Combined disc test and AmpC disc test. Results: Isolation rate of non-fermenters was 13.82% (181/1310). Colistin, amikacin and imipenem were the antibiotics with maximum sensitivity. Overall meropenem resistance was found to be 44.2% (80/181). Metallo-ß-lactamase and AmpC-ß-lactamase were produced by 56.82% (25/44) and 72.22% (26/36) of meropenem resistant Pseudomonas and Acinetobacter species respectively. Conclusion: Detection of carbapenem resistance mechanisms and implementation of antibiotic policy are needed to prevent the emergence of non-fermenter infections.

A Randomized Controlled Study of 0.5% Bupivacaine, 0.5% Ropivacaine and 0.75% Ropivacaine for Supraclavicular Brachial Plexus Block

Ranjan R. Venkatesh, Prabhat Kumar, Ramachandran R. Trissur, Sagiev Koshy George

Introduction: For any surgery in the upper extremity that does not involve the shoulder, a supraclavicular block is preferred, as it is a safe procedure associated with rapid onset and reliable anaesthesia. Although ropivacaine has been extensively studied for epidural anaesthesia, very few reports exist on its use in supraclavicular brachial plexus block. Aim: This study was conducted to investigate and compare the effectiveness of supraclavicular brachial plexus anaesthesia with two different concentrations of ropivacaine (0.5% and 0.75%) and to compare them with the standard 0.5% bupivacaine. Materials and Methods: Ninety patients of age 18 to 60 years belonging to American Society of Anaesthesiologists (ASA) status 1 or 2, admitted to Pondicherry Institute of Medical Sciences were chosen for the study and were divided into three groups. Group A received 30 ml of 0.5% bupivacaine, group B received 30 ml of 0.5% ropivacaine and group C received 30 ml of 0.75% ropivacaine into the supraclavicular region, by a nerve-stimulator technique. Onset time of each of the drug was recorded both for the sensory and motor block. Duration of sensory and motor block was recorded along with peri-operative haemodynamic monitoring. Results: The onset of complete sensory and motor block observed with both ropivacaine groups and bupivacaine was similar (16.85 ± 6.67 min in group A, 17.79 ± 5.03 min in group B and 18.48 ± 6.14 in group C, p < 0.05); onset of motor block (21.45 ± 4.45 min in group A, 22.23 ± 4.05 min in group B and 22.33 ± 5.17 in group C, p < 0.05). The duration of sensory block with 0.5% bupivacaine was 11.58 hours, with 0.5% ropivacaine was 9.02 hours with 0.75% ropivacaine was 8.87 hours (p<0.001). The duration of motor block with 0.5% bupivacaine was 12.94 hours, with 0.5% ropivacaine was 8.29 hours with 0.75% ropivacaine was 7.89 hours (p<0.001). Multiple comparison test with Bonferroni correction showed there was statistically significant difference in mean duration of sensory block between Group A (0.5% bupivacaine) and Group B (0.5% ropivacaine) and also between Group A (0.5% bupivacaine) and Group C (0.75% ropivacaine). However, there were no statistically significant difference in mean duration of sensory block between Group B (0.5% ropivacaine) and Group C (0.75% ropivacaine). The preoperative, intra operative and postoperative heart rate, systolic & diastolic blood pressure and oxygen saturation were comparable among the three study groups (p>0.05). No side effects were recorded in the study. Conclusion: The onset of sensory and motor block was similar in all the three groups. However, when compared to bupivacaine group, recovery of motor functions was faster in both the ropivacaine groups. Patients in all the 3 groups did not experience any adverse effects.

Comparison of Self-Etch Primers with Conventional Acid Etching System on Orthodontic Brackets

Introduction: The self-etching primer system consists of etchant and primer dispersed in a single unit. The etching and priming are merged as a single step leading to fewer stages in bonding procedure and reduction in the number of steps that also reduces the chance of introduction of error, resulting in saving time for the clinician. It also results in smaller extent of enamel decalcification. Aim: To compare the Shear Bond Strength (SBS) of orthodontic bracket bonded with Self-Etch Primers (SEP) and conventional acid etching system and to study the surface appearance of teeth after debonding; etching with conventional acid etch and self-etch priming, using stereomicroscope. Materials and Methods: Five Groups (n=20) were created randomly from a total of 100 extracted premolars. In a control Group A, etching of enamel was done with 37% phosphoric acid and bonding of stainless steel brackets with Transbond XT (3M Unitek, Monrovia, California). Enamel conditioning in left over four Groups was done with self-etching primers and adhesives as follows: Group B-Transbond Plus (3M Unitek), Group C Xeno V+ (Dentsply), Group D-G-Bond (GC), Group E-One-Coat (Coltene). The Adhesive Remnant Index (ARI) score was also evaluated. Additionally, the surface roughness using profilometer were observed. Results: Mean SBS of Group A was 18.26±7.5MPa, Group B was 10.93±4.02MPa, Group C was 6.88±2.91MPa while of Group D was 7.78±4.13MPa and Group E was 10.39±5.22MPa respectively. In conventional group ARI scores shows that over half of the adhesive was remaining on the surface of tooth (score 1 to 3). In self-etching primer groups ARI scores show that there was no or minor amount of adhesive remaining on the surface of tooth (score 4 and 5). SEP produces a lesser surface roughness on the enamel than conventional etching. However, statistical analysis shows significant correlation (p<0.001) of bond strength with surface roughness of enamel. Conclusion: All groups might show clinically useful SBS values and Transbond XT can be successfully used for bracket bonding after enamel conditioning with any of the SEPs tested. The SEPs used in Groups C (Xeno V+) and D (G-Bond) have significantly lowered SBS. Although, the values might still be clinically acceptable.

Approach to Carbapenemase Detection in Klebsiella pneumoniae in Routine Diagnostic Laboratories

Introduction: Resistance to Carbapenems in Klebsiella may be due to Carbapenem hydrolysing enzymes. Accurate detection of carbapenemase must be done for patient treatment and epidemiological purposes. Aim: To detect carbapenemase production by performing Modified Hodge Test (MHT), Combined Disk Test (CDT) for Metallo-b-Lactamases (MBL) and PCR for blaKPC gene, to evaluate the performance of MHT using MacConkey Agar (MCA) and to access the value of MHT for carbapenemase detection. Material and Methods: Using a prospective laboratory study design, 153 Extended Spectrum Beta-Lactamases (ESBL) producing Klebsiella pneumoniae from clinical samples of patients admitted in the Kasturba Medical College were collected from January 2014 to December 2015. Isolates resistant to carbapenems by disk diffusion were subjected to MHT on MCA and Mueller Hinton agar (MHA). All isolates were tested for (MBL) production by Imipenem and Imipenem-EDTA CDT and subjected to PCR for the presence of blaKPC gene. Results: Out of 153 isolates, 54 were resistant to one of the carbapenems. Among these, 13 were positive for MHT on MHA, while 23 were positive by MHT on MCA. Number of MBL producers was 23 (42.5%), while blaKPC was detected in 2 out of the 54 isolates. Conclusion: Though detection of drug resistance gene remains the method of choice, it can be performed only in centers with adequate resources. Hence, for most laboratories in resource poor countries, the MHT performed on MCA with concomitant CDT for MBL detection seem to be a better option for detection of Carbapenem resistance.

Stress Distribution under Commercial Denture Liners- A Finite Element and Clinical Analysis

Introduction: Previous studies have shown that 20-30% of denture users have been dissatisfied with their dentures. Aim: To evaluate the stress pattern under elastic and viscoelastic denture liners using 3-Dimensional Finite Element Analysis (FEA) and its clinical correlation using a questionnaire. Materials and Methods: The study had both in-vitro and in-vivo phases. In in-vitro phase fabrication of a virtual parametric model of edentulous maxilla and dentures with overlying mucosa was made. A virtual load of 166N was analyzed at three points (Point A=anterior ridge, Point B=right posterior ridge and Point C=left posterior ridge). For the in-vivo phase, 20 edentulous patients were provided conventional complete dentures (Group-I). The dentures were lined with silicone (elastic) liners (Group-II) and acrylic resins (viscoelastic) liners (Group-III) at regular (2 months) intervals. After each reline, the patients were evaluated using food eating ability and denture assessment questionnaires. The results were statistically analyzed. The statistical analysis was done using SPSS (Statistical Package for Social Sciences) version 15.0 statistical analysis software. Other than standard statistical test Analysis of Variance (ANOVA) and Post-Hoc tests (Tukey-HSD) were used. Results: At loading, the in-vitro result for Groups–II and III revealed pressures of 0.074231N and 0.0678364N at Point A, 0.098764N and 0.093642N at Point B, and 0.099876N and 0.093746N at Point C respectively. The in-vivo study revealed that the mean quality of life score for different groups ranged from 23.65±4.00 (Group I) to 33.10±6.15 (Group III). The mean quality of life score for Group II was 29.50±5.08. Conclusion: The viscoelastic liner provided the most uniform stress distribution and performed better than an elastic liner with hard, firm and soft foods.

Effect of Resin Bonded Luting Agents Influencing Marginal Discrepancy in All Ceramic Complete Veneer Crowns

Introduction: Marginal discrepancy severely affects the long term success of All ceramic complete veneer crowns. The precise role of resin luting agents influencing this phenomenon needs to be explored further. Aim: To estimate and compare the marginal discrepancy in CAD/CAM processed All ceramic complete veneer crowns prior and following luting with resin bonded luting agents. Materials and Methods: Extracted human maxillary first premolars were randomly allocated into four groups of 27 samples each Viz., Group I-Resin Modified Glass Ionomer Cement (GIC) (RelyX), Group II-Bis-GMA based dual cure resin cement (Variolink II), Group III-PMMA based resin cement (Superbond ), Group IV- Urethane Dimethacrylate resin cement (Calibra). Following tooth preparation, CAD/CAM All ceramic complete veneer crowns were fabricated and sectioned and marginal discrepancy was evaluated using a scanning electron microscope (TESCAN, Magnification power-1,00,000x) prior and after luting with the experimental resin cements. Results: The vertical and horizontal discrepancy before and after cementation with Group I [270.08±103.10µm, 165.3±53.00µm and 270.86±102.70µm, 166.62±54.96µm respectively]; Group II [254.21±79.20µm, 117.75±24.29µm and 234.81±79µm, 116.89±18.22µm respectively]; Group III [272.47±86.25µm, 142.08±50.83µm and 251.82±62.69µm, 136.07±44.95µm respectively]; Group IV were [260.28±64.81µm, 116.98±17.71µm and 233.08±69.44µm, 116.58±21.13µm respectively]. ANOVA inferred a statistically significant difference between the four test specimen with regards to vertical and horizontal marginal discrepancy after cementation (F=9.092, p<0.001), (F=10.97, p<0.001). Tukey HSD Post-hoc test observed significant differences in vertical and horizontal marginal discrepancies between the resin modified glass ionomer and resin cements (p<0.05). Conclusion: Resin cements exhibited a greater reduction in the marginal discrepancy than the resin modified glass ionomer following luting in All ceramic complete veneer crowns. Hence resin cements are more preferable to GIC for luting All ceramic complete veneer crowns.

Evaluation of the Efficacy of Bupivacaine (0.5%) alone or with Clonidine (1µg/kg) Versus Control in a Single Level Paravertebral Block in Patients Undergoing PCNL Procedure

Trupti S. Kamble, Charulata Mahesh Deshpande

Introduction: Percutaneous Nephrolithotomy (PCNL) is a widely used procedure to remove complex upper tract renal calculi by means of a nephroscope. Although less invasive, PCNL is associated with significant pain owing to soft tissue injury. Most of these patients have mild to moderately compromised renal function. An anaesthesia plan that reduces intraoperative requirement of anaesthetics, analgesics, muscle relaxants and postoperative requirement of systemic analgesics is essential. Paravertebral Block (PVB) in combination with general anaesthesia may be an ideal technique for achieving all the goals. Aim: To evaluate the efficacy of Bupivacaine (0.5%) alone or with Clonidine (1ug/kg) versus control in a single level paravertebral block for intra-operative and postoperative analgesia in patients undergoing PCNL procedure. Materials and Methods: In this prospective, randomized, observer blind study we evaluated the intraoperative as well as postoperative analgesic effects of paravertebrally administered Bupivacaine (0.5%) alone or Bupivacaine ± Clonidine (1µg/kg) versus Control (Conventional analgesia with IV Paracetamol). We also evaluated requirement of propofol, haemodynamic parameters, need for rescue analgesics & incidence of adverse effects. Collected data was analysed with SPSS statistical software. One way ANOVA test was applied. All pair wise multiple comparison procedures were analysed by Tukey’s Method if equal sample size and by Dunnett’s Method if unequal sample size in all groups. Results: It was observed that paravertebral block is an effective method for providing intra and postoperative analgesia for PCNL surgery. It reduced the requirement of intraoperative propofol, maintained stable intra and postoperative haemodynamics without any adverse effects or complications. Addition of Clonidine as an adjuvant to Bupivacaine enhanced the quality of paravertebral block with better haemodynamic stability, greater reduction in the intraoperative propofol requirement and provided significantly longer postoperative analgesia without any incident of bradycardia, hypotension, sedation or respiratory compromise. Conclusion: In conclusion, 0.5% Bupivacaine ± 1µg/kg Clonidine in a single level paravertebral block is useful, effective and safe for providing intra as well as postoperative analgesia during PCNL surgeries.

Evaluation of Antibiotic Residues in Pasteurized and Raw Milk Distributed in the South of Khorasan-e Razavi Province, Iran

Introduction: The presence of antibiotic residues in milk and other products livestock is a health problem which can endanger public health. Antibiotics are used widely in animal husbandry to treat diseases related to bacterial infections. Antimicrobial drugs have been in use for decades in industry. They are commonly used in livestock facilities to treat mastitis. Aim: This study aimed to investigate antibiotic residues in pasteurized milk distributed in schools, in milk collection centers, and in milk production factories in Gonabad city. Materials and Methods: This cross-sectional study was conducted on 251 samples of commercial pasteurized milk packet distributed in schools (code A), raw milk collection centers in Gonabad city (code B), and pasteurized milk production factories (code C) in Gonabad city. The Copan test kit of Denmark Christian Hansen Company was used to monitor antibiotic residues in milk. The data were analysed employing Chi-square test and one-way analysis of variance (ANOVA) to determine significant differences using SPSS software version 20. The significant level was considered at p<0.05. Results: In total, 251 milk samples were collected out of which 143 (57%) were code A, 84 (33.5%) code B and 24 (9.6%) code C. Total number of 189 samples (75.2%) were negative and 62 (24.8%) were positive. From the three types of milk samples, 41 samples (28.7%) of the code A, 18 samples (21.4%) of the code B and 3 samples (12.5%) of the code C were positive. In general, from the milk samples most contaminated with antibiotics, 17 samples were positive in January and regarding code A, 13 samples were positive in the same month. There was not a significant difference among the three types of milk (p>0.05). The highest number of milk samples (n=7) contaminated with antibiotics were related to code B (38.5%). Most positive cases were related to code A in winter. Also, there was no significant difference among the three types of contaminated milk regarding the year and month (p=0.164 and p=0.917, respectively). Conclusion: Pasteurized milk supplied in the studied city has high level of contamination due to high use of antibiotics. A standard limit needs to be set for the right level of residue of antibiotics in milk to avoid the harmful effects.

To Study the Efficacy of Difluprednate Ophthalmic Emulsion and Prednisolone Acetate Ophthalmic Suspension on Post-operative Inflammation in Cataract Surgery

Punita Garg, Nupur Tuteja, Shazia Qayum

Introduction: Senile cataract is the most common cause of visual impairment. Removal of cataract and implantation of intraocular lens implantation (IOL) is the main surgical approach for cataract. The major block in quick visual rehabilitation of the patient is post-operative inflammation. To limit post-operative inflammation corticosteroids drugs are used in routine prophylactically. Topical prednisolone acetate 1% and betamethasone 0.1% remain gold standard to control post-operative inflammation but newer drugs like difluprednate, loteprednol are also effective in controlling inflammation. Aim: To study the efficacy of difluprednate ophthalmic emulsion and prednisolone acetate ophthalmic suspension on Post-operative inflammation in cataract surgery (clear corneal phacoemulsification with foldable IOL). Materials and Methods: This study was carried out on 100 patients having visually significant cataract requiring surgery, clear corneal phacoemulsification with foldable intraocular lens implantation was done in all patients. Patients were randomly divided into two groups. In group A topical 1% prednisolone acetate ophthalmic suspension was administered six times a day Post-operatively. In group B 0.05% difluprednate ophthalmic emulsion was administered six times a day post-operatively. Efficacy of drug was evaluated in terms of decrease in ocular pain, anterior chamber reaction in the form of aqueous cells and flare and final visual acuity at 4 weeks. Results: In this study, 92% of patients in group A and 90% of patients in group B had BCVA 6/6. None of the patients in group A had ocular pain. In group B, 96% patients had no ocular pain. Remaining 4% had mild discomfort but required no medication. 98% of patients in group A and 100% of patients in group B presented with clearance of aqueous cells at the end of study. Only 2% of patients in group A had showed cell score (±). Conclusion: Though prednisolone acetate has been the gold standard anti inflammatory agent, 0.05% Difluprednate ophthalmic emulsion is equally effective in treatment of post-operative inflammation. Difluprednate have added an advantage of uniform drug dosage and absence of harmful preservative.

A Comprehensive Study of Internal Distraction Plating, an Alternative Method for Distal Radius Fractures-ARTICLE RETRACTED

Mohit J Jain, Kinjal J Mavani, A Comprehensive Study of Internal Distraction Plating, an Alternative Method for Distal Radius Fractures (Published in Journal of Clinical and Diagnostic Research. 2016 Dec, 10(12): RC14-RC17 ) The article had to be retracted to avoid any future misinterpretation of clinical knowledge because of the fallacies in the data. This unintentional error was brought to the editorial notice, post-publication by the authors.

Study of Variation in Intraocular Pressure Spike (IOP) Following Nd- YAG Laser Capsulotomy

Niharika K Shetty, Sriya Sridhar

Introduction: Posterior Capsular Opacifications (PCO) is a frequent complication of cataract surgery following posterior chamber intraocular lens implantation. Nd –Yag laser capsulotomy is the treatment of choice for PCO and is known to be associated with complications like Raised Intraocular Pressure (IOP), Intraocular lens pitting, intraocular lens cracks, cystoid macular oedema, retinal detachment, corneal burns. Raised IOP is the most common complication and prescribing anti-glaucoma drugs post capsulotomy is a common practise. Our study helps us to anticipate the post procedural IOP rise in specific patients and treat only selected group of patients with anti- glaucoma medications. Aim: To study and correlate the effect of energy used and number of shots with post procedural IOP spike following Nd-YAG laser capsulotomy cases. Materials and Methods: All patients with PCO presenting to Ophthalmology Out Patient Department at Sri Siddhartha Medical College between November 2014 to November 2015 were included. All the patients with glaucoma, uveitis and high myopia were excluded from the study. Data relevant to history, ocular examination and IOP were recorded. Results: Significant correlation of IOP spike with the number of Nd- YAG Laser shots delivered was found by One-way ANOVA Post-Hoc Tukeys Test. The p-value was significant for shots more than 40, provided the energy was restricted to 20 mJ and below. Correlation of energy with IOP spike was not significant as found by One-way ANOVA, Post-Hoc Tukey test. Predictability of 2 hours post-procedure IOP regarding persistent IOP rise was significant. Conclusion: It was observed that all pseudophakic patients may not require anti-glaucoma medication pre, or post Nd YAG laser capsulotomy. Only patients who required more than 40 shots during the procedure would need a close observation and if persistent rise is documented, ocular hypotensives may be advised.

Contributing Factors for Morbidity and Mortality in Patients with Organophosphate Poisoning on Mechanical Ventilation: A Retrospective Study in a Teaching Hospital

Gurulingappa Patil, Navya Murthy, M. Nikhil

Introduction: One of the most common causes of poisoning in agricultural based developing countries like India is due to Organophosphorus (OP) compound. Its widespread use and easy availability has increased the likelihood of poisoning with these compounds. Aim: To study the morbidity and mortality in patients with acute OP poisoning requiring mechanical ventilation. Materials and Methods: This was a retrospective study constituting patients of all age groups admitted to the Intensive Care Unit (ICU) with diagnosis of OP poisoning between January 2015 to December 2015. Of 66 OP poisoning cases those patients who went against medical advice, 20 were excluded from the study and thus 46 patients were included. Diagnosis was performed from the history taken either from the patient or from the patient’s relatives and presenting symptoms. Demographic data, month of the year, age of patient, mode of poisoning, cholinesterase levels, duration of mechanical ventilation and mortality were recorded. Data are presented as mean ± SD. Results: A 97.83% (45/46) of cases were suicidal. Out of 46, 9 were intubated and mechanically ventilated. Duration of mechanical ventilation varied from less than 48 hours to more than 7 days. Mortality rate was 50%, 0% and 100% in those who required mechanical ventilation for more than 7 days, 2 to 7 days and <2days respectively. None of the predictors like age, severity of poisoning, cholinesterase levels and duration of ventilation were independent predictors of death and all of them contributed to the mortality. Overall mortality rate in those who required mechanical ventilation was 22.22% Conclusion: Morbidity and mortality due to OP poisoning is directly proportional to the age, severity of poisoning and duration of mechanical ventilation and inversely proportional to serum cholinesterase level.

Study of Parental Perceptions on Health & Social Needs of Children with Neuro-Developmental Disability and It’s Impact on the Family

Introduction: The term Neuro Developmental Disorder (NDD) is used for conditions caused by a dysfunction in any part of the brain or nervous system, resulting in physical and/or psychological symptoms as a child develops. Family of children with NDD face many problems. It is very important to find them and create awareness so that gaps in essential services and supports can be decreased. Aim: To explore parental perceptions on health & social needs of children with NDD, to understand the impact of disability on the families having children with disability, and to find out the parental perceptions on availability of services for children with NDD and its utilization by families. Materials and Methods: The parents of 30 children with NDD were interviewed using a questionnaire and data elicited in these interviews were analysed. The questionnaire had preliminary information about parents and child with NDDs, socio-demographic profile of the family and the parental perceptions on health and social needs of their child having NDDs. Results: There were total 30 patients 17 were males and 13 were females. Most of the patients suffered from Cerebral Palsy (13 cases) and were diagnosed by General Practitioner (22 cases) while Developmental Neurologist/paediatrician had diagnosed remaining cases of NDD (8 cases). Most common disability for which parents were worried was inability to walk (17 cases). Common difficulties countered in daily care by parents were feeding and bathing (10 cases). Only 2 children were given assistance with tuition & psychologist (cases of ADHD). Most of the parents knew about special schools but didn’t know which place such facilities were available and none of the children were attending special schools. Twenty two parents said they have no plans for the future studies but wish that at least child learns to read & write. With help of spiritual power (doing prayers and pooja) 25 parents got courage to face the difficulties and discrimination. Two parents required antidepressants. Six Mothers had to quit their jobs so as to concentrate and give more time to their children. Experience with services provided was satisfactory in 17 cases, while 13 parents reported problem of arranging money, adjusting time for long travelling and regular follow-up. Conclusion: The findings can be utilized in developing supportive activities for families with disabled children. It addresses the need for new prospective of stigma reduction in our society. The study has found that the care givers of child with NDDs suffer from significant physical and mental stress, and their health should be taken into consideration. The study has found need of “care givers` support group”. The professionals can help parents in establishing positive thinking towards care giving. There is need of provision of comprehensive and latest rehabilitation/ support resources & information.

Comparing the Effects of Agnugol and Metformin on Oligomenorrhea in Patients with Polycystic Ovary Syndrome: A Randomized Clinical Trial

Introduction: Polycystic Ovarian Syndrome (PCOS) is the most common endocrinopathy and cause of oligomenorrhea in women. Aim: The present study was conducted with the aim to compare the effect of Agnugol and Metformin drugs on oligomenorrhea in patients with PCOS. Materials and Methods: This study was a clinical trial on 120 women with PCOS and had oligomenorrhea, referring to a gynaecology clinic Fatemieh, Hamadan city, Iran, 2015. Women were randomly divided into 2 groups using permutation blocks (getting the medications Agnugol and Metformin) and were treated with drugs Agnugol and Metformin for 3 months. Data collection included demographic questionnaire and check list was designed and completed before and at the end of interventions, by both groups. To analyse the data, descriptive statistics, chi-square tests, t-test, ANOVA with repeated measures was used. Results: The mean and SD of age was 39.45±4.60 for women taking Agnugol and 38.466±0.84 for those taking Metformin. Based on the results between the subjects, the two groups were not significantly different in terms of menstruation length, cycle intervals, or the number of pads, meaning that the two drugs had similar effects on menstrual cycle regulation, menstruation length and the number of pads. More side effects were reported in the group using Metformin. Conclusion: Agnugol and Metformin drugs in the treatment of oligomenorrhea patients with PCOS have the same effect. Since Metformin is a chemical drug with side effects, Agnugol can be presented as its herbal alternative to treat oligomenorrhea.

Operational Assessment of ICDS Scheme at Grass Root Level in a Rural Area of Eastern India: Time to Introspect

Introduction: Integrated Child Development Service (ICDS), a flagship program of Government of India (GoI) for early childhood development hasn’t delivered the desired results since its inception four decades ago. This could be due to infrastructural problems, lack of awareness and proper utilization by the local people, inadequate program monitoring and corruption in food supplies, etc. This study is an audit of 36 Anganwadi centres at Khordha district, Odisha, to evaluate the implementation of the ICDS. Aim: To assess operational aspects of ICDS program in a rural area of Odisha, in Eastern India. Materials and Methods: A total of 36 out of 50 Anganwadi Centres (AWCs) were included in the study. We interviewed the Anganwadi Workers (AWW) and carried out observations on the AWCs using a checklist. We gathered information under three domains manpower resource, material resource and functional aspects of the AWC. Results: Most of the AWCs were adequately staffed. Most of the AWWs were well educated. However, more than 85% of the AWCs did not have designated building for daily functioning which resulted in issues related to implementation of program. Water, toilet and electricity facilities were almost non-existent. Indoor air pollution posed a serious threat to the health of the children. Lack of play materials; lack of health assessment tools for promoting, monitoring physical and mental development; and multiple de-motivating factors within the work environment, eventually translated into lack of faith among the beneficiaries in the rural community. Conclusion: Inadequate infrastructure and logistic supply were the most prominent issues found, which resulted in poor implementation of ICDS program. Strengthening of grass root level facilities based on need assessment, effective monitoring and supervision will definitely help in revamping the ICDS program in rural areas.

The Effect of Emotion Regulation Training on Occupational Stress of Critical Care Nurses

Darya Saedpanah, Shiva Salehi, Ladan Fattah Moghaddam

Introduction: Occupational stress is a common, serious and costly health problem in work environment. Nursing is a very stressful job high level of stress in this job affects nurses’ physical and mental health. Aim: To investigate the effect of emotion regulation training of occupational stress on critical care nurses in two teaching hospitals in Sanandaj, Iran. Materials and Methods: This interventional study was conducted on 60 nurses working in the Intensive Care Unit (ICU) and Critical Care Unit (CCU) in two teaching hospitals in Sanandaj, Iran. Data were collected using Expanded Nursing Stress Scale (ENSS) questionnaire. The questionnaire in both intervention and control groups before and after the training sessions of emotion regulation training were completed. Data were analysed using SPSS Version 20. Statistical indices such as frequency, percentage, mean and standard deviation and also t-test, Chi-square test and paired t-test were used. Results: Mean occupation stress score in the intervention group before emotion regulation training was 136.6 ± 24.6 and after training was 113.02 ± 16.2 (p = 0.001). Occupational stress dimensions including; conflict with physicians, problems with peers, workload, uncertainty concerning treatment and problems related to patients and their families in the intervention group compared with the control group was statistically significant (p <0.05). Conclusion: Emotion regulation training is effective in reducing occupation stress of critical care nurses.

Diphtheroids-Important Nosocomial Pathogens

Reshmi Chandra, Dinju Raj Puthukkichal, Ethel Suman, Shashidhar Kotian Mangalore

Introduction: Diphtheroids are defined as aerobic, non-sporulating, pleomorphic Gram-positive bacilli which are more uniformly stained than Corynebacterium diphtheriae, lack the metachromatic granules and are arranged in a palisade manner. They are usually commensals of the skin and mucous membranes. They differ from C.diphtheriae in biochemical rea-ctions as well as in toxin production. Since, they are usually found as commensals on the skin, they are often considered as mere contaminants when isolated from clinical samples. However, there are increasing reports of these organisms being associated with various infections. Hence, we felt the need to study the common species associated with infections and know the properties of these organisms which are otherwise considered as mere laboratory contaminants. Aim: To identify the various species of diphtheroids isolated as pure growth from clinical specimens whose Gram’s smear revealed numerous inflammatory cells with Gram positive bacilli and had clinical evidence. Materials and Methods: A total of 100 isolates of Gram-positive bacilli from 16,242 clinical samples received in the Microbiology Department of Kasturba Medical College were considered for this study from Dec 2013-Dec 2014. Gram-positive bacilli which were seen in the smear along with pus cells, isolated as pure growth and reported as “Corynebacterium spp having clinical significance” were taken for this study while those which were reported as ‘Probable skin contaminants’ were excluded from this study. Species identification of Gram-positive bacilli was done by biochemical reactions. Antibiotic susceptibility test was done by Kirby-Bauer disk diffusion method. Biofilm production was done by the microtitre plate method of O’Toole and Kolter and statistical analysis was done by using proportion test and Chi-square test. Results: Various species of diphtheroids were isolated from different clinical specimens. C. pseudotuberculosis, C. renale, C. ulcerans, C. striatum, C. minutissimum, Corynebacterium haemolyticum isolated from catheter tips, sputum, tracheostomy secretions and wound infections were highly resistant to many antibiotics while isolates from blood namely C. pseudotuberculosis, C. minutissimum, C. ulcerans and C. renale were nearly sensitive to most of them. It was also interesting to note that there was an increased rate of biofilm production in these isolates. Conclusion: Corynebacterium pseudotuberculosis, Coryne- bacterium ulcerans, Corynebacterium renale, Corynebacterium bovis, Corynebacterium striatum, Corynebacterium minutissimum, Corynebacterium pseudodiphtheriticum and Corynebacterium haemolyticum may survive in the form of biofilms in hospitals and cause multidrug resistant infections. Hence, we need to judiciously identify these organisms, find their antimicrobial susceptibility, treat them and thus prevent infections in hospitals.

Micrometastasis Detection using Special Stains in Nodal Tissues of Oral Squamous Cell Carcinoma – A Histochemical Study

Wasim Raja Mumtaz, Veda Hegde, Nikhil Yadav

Introduction: Micrometastasis to the lymph node is an important prognostic factor in survival and recurrence and even in making critical decisions regarding postoperative radiation treatment. Methods like Immunohistochemistry (IHC), serial sectioning and Polymerase Chain Reaction (PCR) are very sensitive; however, they are expensive and time consuming. Hence, there is a need for the detection of micrometastasis by method which is easily feasible and inexpensive. Aim: This study was undertaken to identify if special stains (Modified Papanicolaou stain and Ayoub Shklar stain) are valuable in detecting micrometastasis which are routinely missed in Haematoxylin and Eosin stain and also to compare their efficacy over Haematoxylin and Eosin stain in detection of metastatic tumour cells in non-metastatic lymph nodes. Materials and Methods: This study constituted a total of 300 histopathologically proven non metastatic lymph node sections. Other than Haematoxylin and Eosin stain, Modified Papanicalaou and Ayoub Shklar stain were used for identification of micrometastatic deposit. Results: Papanicolaou stain was the only stain useful in detecting micrometastasis which accounted to 7% of non metastatic lymph node sections used in our study. Conclusion: Papanicolaou stain has definitely proved valuable in detecting micrometastasis over routine Haematoxylin and Eosin and Ayoub Shklar stain with an added advantage of being economical, easily available and technique insensitive.

Experience from Classroom Teaching to Clinical Practice Regarding Shortened Dental Arch (SDA) Concept Among Dentists – A Questionnaire Study

Introduction: Periodontal disease and dental caries are the common oral conditions which cause loss of teeth, mostly molars. This further leads to Shortening of Dental Arch and Shortened Dental Arch (SDA) concept provides the overall requirements of functional dentition at reduced cost without compromising the health. Aim: The aim of the present study was to assess the Knowledge, Attitude and Practices (KAP) towards SDA concept among dentists of Ghaziabad city (Uttar Pradesh, India). Materials and Methods: A cross-sectional study was conducted among 514 dentists working as academicians or clinicians or both. KAP questionnaire consisting of questions related to SDA concept was distributed to them. Data were analyzed using Statistical Package for Social Sciences (SPSS) 18.0 (SPSS Inc., Chicago, IL, USA) and descriptive and analytical tests, including mean, standard deviation, and Chi square test were used. Results: Of the 514 dentists, only 493 dentists responded to the questionnaire, generating the response rate of 95.5%. Only 113 (22.9%) had knowledge about this concept. Clinicians were found to have more knowledge regarding the SDA concept (p<0.05). Also years of experience and level of knowledge among dentists regarding SDA was found to be statistically significant (p<0.05). Conclusion: The study showed lack of knowledge regarding SDA concept among dentists and also only few dentists practice the SDA concept on their patients. If used judiciously the SDA concept can serve as a cost effective and functionally oriented approach in clinical management of patients.

Carrea´s Index and Tooth Dimensions– An Avant-Garde in Stature Estimation: An Observational Study

Introduction: Identifying victims in case of mass disasters when only human remains are present is quite a challenging task. Although other peripheral extremities of human body are used in estimating stature, in situations where only skull is available, teeth play an important role in personal identification. The present study used Carrea’s index in stature estimation using tooth dimensions. Aim: This study is intended to correlate the anterior mandibular tooth dimensions with that of real stature using Carrea’s index and also to know the applicability and validity of this index to the current study population. Materials and Methods: A total of 82 subjects (both males and females) which makes 164 hemiarches (normal, crowded and diastema) were included. Actual height of each subject was measured using anthropometer and tooth measurements from each cast were recorded and analyzed using Carrea’s index. Results: The results showed a strong correlation between estimated stature and real stature. Moreover, this correlation is more valid on male sample and right side of the inferior hemiarches (Normal-81.8% and 87.2%; Crowded-76.4% and 80%; Diastema-52.9% and 60% respectively). Conclusion: Although a correlation between actual stature and estimated stature was established, Carrea’s index as a predictor tool may not give accurate estimations. Nevertheless, it could only act as an auxiliary tool in person identification.

Comparative Evaluation of Fluoride Releasing Ability of Various Restorative Materials after the Application of Surface Coating Agents – An In–vitro Study

Introduction: Fluoride plays a key role in prevention of dental caries and is also an essential element for oral health promotion both in children and adults. Aim: The aim of the present study was to evaluate the effect of surface coating (petroleum jelly, G-Coat Plus) on the fluoride releasing property of conventional Glass Ionomer Cement (GIC) and Zirconomer. Materials and Methods: A total of 30 disk shaped brass mold specimens (6±0.1mm in diameter and 2±0.1mm thickness) for each test group were fabricated with conventional GIC (Group A) and Zirconomer (Group B). These test groups were further divided into three subgroups of 10 each. The unprotected specimens act as control (Group A1 and B1), G-Coat Plus specimens as (Group A2 and B2) and for the remaining specimens petroleum jelly was applied (Group A3 and B3). Fluoride ion concentration was measured with a combination of fluoride ion specific electrode and ion analyzer for every 24 hours for 15 days. The data was statistically analyzed using Kruskal Wallis and Mann-Whitney U test. Results: The Group B released significantly more fluoride than Group A. Among all the subgroups the greatest amount of fluoride was released from Group B1, in the first 24 hours followed by A1 and B2. The least was observed on 15th day with Group B3 and A3. Conclusion: Both the tested materials (GIC and Zirconomer) used in the study exhibited fluoride release whether protected or unprotected with surface coating. Though there was a difference between the groups, the pattern of fluoride release was similar and continuous throughout the study period i.e., first the initial burst followed by sustained release. The results revealed Zirconomer released more fluoride and is comparable to conventional GIC.

Ability of Oral and Maxillofacial Surgery Residents in Diagnosing Jaw Cysts: A Retrospective 20 Years Study

Hassan Mohajerani, Mohammad Esmaeelinejad, Reza Mofidian

Introduction: Diagnosis of odontogenic cysts despite of their benign nature is a critical and challenging problem especially among undergraduate and postgraduate students. Aim: This study aimed to evaluate the capability of oral and maxillofacial surgery residents in diagnosing ododntogenic cysts. Materials and Methods: This cross-sectional study was executed on 312 patient records over the past 20 years since October 1995 till December 2014 in Taleghani Hospital, Tehran, Iran. All recorded data was based on 2005 World Health Organization (WHO) classifications. The differential diagnosis was made by 65 residents based on clinical and paraclinical evaluations established in the charts. Differential diagnoses made by the residents were compared to the histopathological examination as the gold standard for identifying the nature of the cysts. Weighted kappa test was used to show the degree of agreement. Results: Data extracted from 312 records were analyzed. The mean age of examined patients was 27.6 years. The accuracy of diagnosis among the residents was moderate (kw=0.5). The diagnosis made by the residents was significantly related to the radiographic view of the cysts (p<0.05). The residents were able to identify odontogenic keratocysts and dentigerous cysts in most cases. Conclusion: There are several factors associated with the occurrence of pathologic odontogenic cysts which could help either the clinician or the pathologist in diagnosing the odontogenic cysts of the jaws. The surgeons should consider these related factors before the final diagnosis and choosing the appropriate treatment plan.

Critical Analysis of Cardiovascular and Central Nervous System Fixed Dose Combinations Available in Indian Market

Krunal Prajapati Samidh Shah, Mira Desai

Introduction: Fixed Dose Combinations (FDCs) are being increasingly used to improve compliance and achieve greater benefits of the two or more active ingredients given together than the corresponding individual drug components given separately. Aim: To analyse the rationality of Cardiovascular (CV) and Central Nervous System (CNS) FDCs available in Indian market. Materials and Methods: CVS and CNS FDCs, enlisted in Indian Drug Review, 2014, were analysed by a pretested validated eight point criteria tool. Each FDC was assessed for number of active pharmacological ingredients, approval by regulatory authority, listing in WHO Essential Medicine List. While efficacy, safety, pharmacokinetic, pharmacodynamic interactions and advantages of each FDC were analysed by literature search. The total score of the tool was 12 and score =7 was considered rational. FDCs were divided in four groups as per rationality and DCGI approval. ANOVA was used for statistical analysis and p<0.05 was considering statistically significant. Results: Out of 152 FDCs, 107 were CV and 45 belonged to CNS group and 40 had documented evidence of efficacy and safety. Majority of FDCs showed advantage of being convenient by reducing pill count and only 32 showed reducing adverse drug reactions. Out of 107 CV FDCs, 46 were rational and 61 were irrational with a mean rationality score of 6.72 ± 2.82 (CI– 95 %, 3.90 - 9.54). While out of 45 CNS FDCs, 8 were rational and 37 were irrational with a mean rationality score of 6.22 ± 2.08 (CI – 95 %, 4.14 - 8.30). A significant difference in mean rationality score of group A (DCGI approved + rational) was observed as compared to group B (DCGI approved + irrational) and group C (DCGI unapproved + rational) as compared to group D (DCGI unapproved + irrational) (p<0.05). Conclusion: The absence of watertight pre-requisite, critical analysis of the scientific validity of the formulations and ‘convenience’ category has resulted into proliferation of irrational FDCs. This calls for strict regulatory approval process to avoid miserable FDC scenario in the country.

Role of Prophylactic Tranexamic Acid in Reducing Blood Loss during Elective Caesarean Section: A Randomized Controlled Study

SJ Dhivya Lakshmi, Reena Abraham

Introduction: Obstetric haemorrhage accounts for 20-25% of maternal mortality and morbidity. Anti-fibrinolytics are being widely used in field of surgery. It is also used to reduce heavy menstrual blood loss. Aim: To analyse the effectiveness of Tranexamic Acid (TXA) in reducing blood loss during elective caesarean section. Materials and Methods: This interventional, randomized, parallel group study was done in the Department of Obstetrics and Gynaecolgy, PSG IMSR, Coimbatore, from June 2014 to May 2015. It was conducted on 120 women undergoing caesarean section. They were allocated to either Study or Control group by computer generated random number tables. TXA was given prior to surgery in study group in addition to the routine care {10 units of oxytocin added to the intravenous drip soon after baby delivery} whereas, the control group had routine care alone. Blood loss was measured in both groups by gravimetric method. Haemoglobin before and after surgery was estimated and the percentage of difference was compared. Statistical analysis: Primary outcome variables were volume of blood loss and percentage fall in haemoglobin before and after surgery. Secondary outcomes were duration of surgery, proportion of subjects with >500ml of blood loss, need for additional uterotonics and side effects. Unpaired t-test and Chi-square test were used to compare the outcome variables. Results: There was significant reduction in blood loss calculated from placental delivery till end of surgery: 347.17ml in study group versus 517.72ml in control group (p<0.001). Another parameter studied was the percentage of fall in haemoglobin before and after surgery and the number of subjects who had more than 10% fall in haemoglobin. 9.3% of subjects in study group and 39% of subjects in control group had more than 10% fall in haemoglobin (p<0.01). There were no immediate post-operative complications to the mother and neonate. Conclusion: TXA significantly reduced the amount of blood loss during Lower Segment Caesarean Section (LSCS). Use of TXA was not associated with adverse effects. Thus, TXA can be used safely and effectively in subjects undergoing LSCS.

Open Reduction and Internal Fixation of Displaced Calcaneum, Intra-Articular Fractures by Locking Calcaneal Plate

Introduction: Calcaneal fractures constitute the most common fractures in hindfoot. Lots of controversies exist in the management of calcaneal fractures but now-a-days, it is preferable to perform open reduction and internal fixation and early mobilizatation. Aim: To evaluate the functional outcome after open reduction and internal fixation of displaced intra-articular fractures of the calcaneum by locking calcaneal plate. Materials and Methods: The study was conducted in the Department of Orthopaedic Surgery from September 2013 to April 2016. Thirty intra-articular fractures of the calcaneum were treated by locking calcaneal plate. Patients were followed up for a period of 24 months. Bohler’s angle was measured in preoperative, immediate Post-operative period and after 2 years, follow-up was compared. Results were evaluated according to American Orthopaedic Foot and Ankle Society (AOFAS) Score. Results: After 24 months of follow-up, all 24 patients were available for evaluation. Radiological union was achieved in a mean time of 12.5 weeks. Mean duration of hospital stay was 21 days. Bohler’s angle was significantly higher after 2 years of follow-up when compared with preoperative x-ray. According to the AOFAS, Ankle–Hind foot Scale outcome score results were excellent in 43.3% of the patients, good in 33.3%, fair in 10%, and poor in 13.3% of patients. The mean AOFAS score was 79.9 (Range 49-96). Conclusion: Open reduction and internal fixation of intra-articular fractures of the calcaneum with locking calcaneal plate gives good results. Maintenance of calcaneal height and Bohler’s angle helps to decrease the incidence of subtalar arthritis.

Serum Iron and Haemoglobin Estimation in Oral Submucous Fibrosis and Iron Deficiency Anaemia: A Diagnostic Approach

Divya Bhardwaj, Ajit D Dinkar, Sujata K Satoskar, Sapna Raut Desai

Introduction: Oral Submucous Fibrosis (OSMF) is a premalignant condition with potential malignant behaviour characterized by juxta-epithelial fibrosis of the oral cavity. In the process of collagen synthesis, iron gets utilized, by the hydroxylation of proline and lysine, leading to decreased serum iron levels. The trace element like iron is receiving much attention in the detection of oral cancer and precancerous condition like OSMF as it was found to be significantly altered in these conditions. Aim: The aim of this study was to compare the haemoglobin and serum iron values of OSMF subjects with that of iron deficiency anaemia subjects. Materials and Methods: Total of 120 subjects were included, 40 subjects with the OSMF, 40 with the iron deficiency anemia without tobacco chewing habit, 40 healthy control subjects without OSMF and iron deficiency anaemia. A total of 5ml of venous blood was withdrawn from all the subjects and serum iron and haemoglobin levels were estimated for all the subjects. Estimation of iron was done using Ferrozine method and haemoglobin by Sahli’s method. The statistical method applied were Kruskal Wallis, Mann Whitney and Pearson correlation coefficient test. Results: There was a statistically significant difference in serum iron and haemoglobin level in all three groups (p<0.05). The serum iron level was lowest in OSMF group and haemoglobin was lowest in iron deficiency anaemia group. A progressive decrease in serum iron and haemoglobin levels from Stage I of OSMF to the Stage IV of OSMF was also observed. The iron deficiency anaemia group was not found to be suffering from OSMF in the absence of areca-nut or tobacco chewing habits, but OSMF patients with chewing habits were found to be suffering from iron deficiency anaemia. Conclusion: There is a progressive decrease in serum iron and haemoglobin levels from Stage I of OSMF to the Stage IV of OSMF so it can be used as an auxillary test in assessment of prognosis of the disease.

A Comparative Evaluation of Serum Magnesium in Diabetes Mellitus Type 2 Patients with and without Periodontitis - A Clinico-biochemical Study

Akshatha Shetty, Rahul Bhandary, Biju Thomas, Amitha Ramesh

Introduction: Magnesium is an essential cation playing a crucial role in many physiological functions and its imbalance is associated with greater number of pathological situations. Oxidative stress is usually increased due to decreased essential nutrients. Hence, any imbalance of essential nutrients like serum magnesium can significantly play a role in the pathobiology of periodontitis in the presence of diabetes, as diabetes and chronic periodontitis are two chronic diseases that have been biologically linked. Aim: To evaluate the association of serum magnesium in type 2 diabetes mellitus and chronic periodontitis patients, also to evaluate and associate the influence of serum magnesium on periodontal health. Materials and Methods: A single blinded, randomized study was conducted that comprised of 120 subjects divided into four groups. Individuals with periodontitis and type 2 diabetes mellitus formed the test group. Subjects with chronic periodontitis diagnosed clinically according to 1999 American Academy of Periodontology classification, without any medical history and drug history were included as the study subjects. Gingival Index and Plaque Index were scored for all the groups at baseline and after 21 days of scaling and root planing. Scaling and root planing was done only in the test group. Blood was drawn from the patients at baseline and 21 days after scaling and root planning and estimation of serum magnesium level was done using semi-autoanalyzer. Data obtained was statistically analyzed using the paired t-test, one-way ANOVA, post-hoc test. Results: The result of the present study showed that mean serum magnesium among healthy was 1.40±0.565mmol/l as compared to 1.01±0.287mmol/l among subjects with periodontitis, 0.920±0.23mmol/l among diabetics with periodontitis and 0.93±0.29mmol/l among diabetics without periodontitis. Serum magnesium was significantly decreased in chronic periodontitis and diabetic patients with and without chronic periodontitis as compared to controls. Conclusion: Imbalance of serum magnesium level was seen in patients with chronic periodontitis and type 2 diabetes mellitus. Hence, it can be a biomarker which can predict the occurrence of type 2 diabetes mellitus and chronic periodontitis.

Comparative Evaluation of Immediate Post-Operative Sequelae after Surgical Removal of Impacted Mandibular Third Molar with or without Tube Drain - Split-Mouth Study

Barun Kumar, Kalyani Bhate, RS Dolas, SN Santhosh Kumar, Pushkar Waknis

Introduction: Third molar surgery is one of the most common surgical procedures performed in general dentistry. Post-operative variables such as pain, swelling and trismus are major concerns after impacted mandibular third molar surgery. Use of passive tube drain is supposed to help reduce these immediate post-operative sequelae. The current study was designed to compare the effect of tube drain on immediate post-operative sequelae following impacted mandibular third molar surgery. Aim: To compare the post-operative sequelae after surgical removal of impacted mandibular third molar surgery with or without tube drain. Materials and Methods: Thirty patients with bilateral impacted mandibular third molars were divided into two groups: Test (with tube drain) and control (without tube drain) group. In the test group, a tube drain was inserted through the releasing incision, and kept in place for three days. The control group was left without a tube drain. The post-operative variables like, pain, swelling, and trismus were calculated after 24 hours, 72 hours, 7 days, and 15 days in both the groups and analyzed statistically using chi-square and t-test analysis. Results: The test group showed lesser swelling as compared to control group, with the swelling variable showing statistically significant difference at post-operative day 3 and 7 (p= 0.05) in both groups. There were no statistically significant differences in pain and trismus variables in both the groups. Conclusion: The use of tube drain helps to control swelling following impacted mandibular third molar surgery. However, it does not have much effect on pain or trismus.

Comparison of Sealer Penetration by Using Different Irrigation Techniques – An In–vitro Study

Introduction: The main goal of root canal treatment is to eliminate the microorganisms particularly in the apical third area and to prevent re-infection. In order to achieve these goals the instrumentation must be combined with adequate irrigation. Aim: To compare sealer penetration by using different irrigation techniques i.e., apical negative pressure irrigation, Passive Ultrasonic Irrigation (PUI) and combination of apical negative pressure irrigation and PUI. Materials and Methods: A total of 48 single rooted maxillary central incisors were taken. Access cavity was prepared and biomechanical preparation was done. The samples were randomly assigned into three experimental groups based on the final irrigation technique used. Group I: Apical negative pressure (Endovac); Group II: PUI; Group III: Combination of apical negative pressure and PUI. All the samples were obturated using AH plus sealer and the sections were observed under confocal laser scanning microscope to evaluate the percentage and maximum depth of sealer penetration at 1mm, 3mm and 5mm levels. Statistical analysis was done by using two way ANOVA and Tukey’s post-hoc test to compare the percentage and maximum depth of sealer penetration. Results: Combination group resulted in better sealer penetration at 1mm and 3mm from the working length than the Endovac and PUI group. However, the Endovac group showed significantly better sealer penetration at 1mm from the working length when compared with PUI. There was no significant difference in sealer penetration at 5mm level between PUI and combination group. Conclusion: Combination group was the only group to achieve better sealer penetration at 1mm and 3mm levels from the working length.

Correlation of p53 Overexpression with the Clinicopathological Prognostic Factors in Colorectal Adenocarcinoma

Akshatha C, Vijaya Mysorekar, Arundhathi S, Arul P, Adithi Raj, Smitha Shetty

Introduction: Mutation in p53 gene and accumulation of p53 protein is a common genetic event in colorectal carcinomas. p53 mutation can be detected by various techniques such as DNA sequencing, polymerase chain reaction and immunohistochemistry (IHC). However, IHC is simple and is consistent with other techniques. Aim: To establish a correlation between overexpression of p53 with the clinical features, tumour histopathology and stage of Colorectal Carcinoma (CRC). Materials and Methods: This prospective and retrospective study of clinical, histopathological and IHC features of CRC was conducted on colectomy and abdomino-perineal resection specimens received from January 2008 to June 2013. For each case, the clinical features, tumour morphology and p53 status (by IHC) were evaluated. Results: The most common histologic type of CRC was Non-Specific Type (NST) and grade II tumours were seen predominantly (60%). Overall, 67.5% of CRCs showed p53 positivity on IHC. Intense p53 positivity was observed in 37.5% of CRCs of NST type and 33.3% of mucinous adenocarcinomas showed moderate positivity. Grade III tumours showed variable p53 positivity and those with lymph node metastasis showed moderate (55.6%) or intense positivity (53.8%). But there was no statistically significant correlation of p53 status and various clinicopathological prognostic factors. Conclusion: As p53 protein overexpression is seen in a relatively high percentage of CRCs, it seems that p53 mutation plays an important role in development of CRC. However, no direct correlation could be established between p53 results and the patients’ age, sex, tumour site, size, histological type, grade, lymph node status, or TNM stage. A prolonged follow up is necessary to conclude whether p53 status has any influence on the long, term prognosis and patient survival.

The Effect of Fetal Gender on the Delivery Outcome in Primigravidae Women with Induced Labours for all Indications

Angeliki Antonakou, Dimitrios Papoutsis

Introduction: There is increasing evidence of a gender-related phenomenon where the presence of a male fetus may have an adverse effect on the outcome of pregnancy. Aim:,, The aim of this study was to investigate the effect of fetal gender on the delivery outcome in primigravidae women with induced labours. Materials and Methods: This was an observational cohort study of primigravidae women who had Induction Of Labour (IOL) for all indications during a two-year period. Women with breech vaginal deliveries, stillbirths, multiple pregnancies and elective Caesarean Section (CS) were excluded. Results: Of the 936 eligible patients identified, 493(52.6%) gave birth to male neonates and 443(47.4%) to female neonates. Age, ethnicity, Body Mass Index (BMI) and smoking were similar between women that delivered male and female neonates. More than half of all women were induced for post-date pregnancies. In women who gave birth to male neonates, the CS delivery rate was higher than in those with female neonates (23.7% vs 17.8%; p=0.029). Though emergency admission rates to the neonatal Intensive Care Unit (ICU) and arterial/venous pH from umbilical cord sampling immediately after birth were similar between male and female neonates, nevertheless male neonates had lower Apgar scores of <7 at 1 minute after birth (p=0.02). Conclusions: This study has shown that, male gender fetuses have a higher CS delivery rate in primigravidae women undergoing IOL and may be more vulnerable to fetal compromise when in labour.

Cognitive Ability as a Determinant of Socioeconomic and Oral Health Status among Adolescent College Students of Bengaluru, India

Rekha Rao Karnam, Naganandini Samapth Kumar, Shruthi Eshwar, Shravani Deolia

Introduction: Levels of oral health and economic status are unequally distributed throughout the population. Inequality has multiple causes and that the effect of Socio Economic Status (SES) and demographic factors, on oral health is mediated through several factors. Association between cognitive ability and oral health had been demonstrated in older age groups but adolescents and younger adults have received relatively little attention in this field. Aim: To establish the role of cognitive ability as a determinant of SES and oral health status among adolescent college students of Benagluru, Karnataka, India. Materials and Methods: A cross-sectional study was conducted among 1000 adolescents aged 17-19 years. Six government and six private first grade colleges were selected by multi-stage random sampling. Cognitive ability was assessed using digit symbol substitution test and digit span test. Dental caries and periodontal status were recorded by extent of bleeding, presence of calculus, periodontal pockets, loss of attachments using Community Periodontal Index, decayed, missing and filled teeth surfaces using Decayed, Missing, Filled Teeth and Surfaces Index. SES status was assessed using Kuppuswamy scale. Chi-square test was used to check the association of cognitive ability with oral health indicators and SES status. Regression analysis was performed to assess the effect of cognitive ability on oral health indicators after adjusting for SES and effect of SES status on oral health indicators after adjusting for indicators of cognitive ability. Results: Significant association and negative correlation between cognitive ability and indicators for oral health was seen in the regression models. Cognitive ability attributed for nearly 30% changes in the indicators for oral health after adjusting for SES and SES attributed for nearly 25% variance in indicators for oral health after adjusting for cognitive ability. Conclusion: There is a potential role of cognitive ability in SES and oral health.

Fine Needle Aspiration Cytology of Papulonodular Lesions of Skin: A Study of 50 Cases

Sapna Patel, Asha Mahadevappa, Gubbanna Vimalambike Manjunath

Introduction: Skin is one of the frequent site of disease in human body. Fine Needle Aspiration Cytology (FNAC) is a safe diagnostic method in these cases. FNAC has some limitation, particularly related to representativity of samples, exact typing of skin adnexal tumours and classifying the nature of metastatic cutaneous nodules. Thus, FNAC alone may not give a confirmative diagnosis regarding few skin lesions. Hence, histopathological study has been the standard technique for the diagnosis of skin lesions. Aim: To study the FNAC findings in various papulonodular lesions and to correlate them with histopathological findings wherever possible. Materials and Methods: In the present study, 50 cases of clinically diagnosed papulonodular lesions were evaluated by FNAC and correlated with histopathology wherever possible. Results: There was 100% correlation in cases of epidermal cyst, leprosy, tuberculosis, actinomycosis, acute and chronic inflammatory lesions and 67% accuracy was seen in adnexal tumours. Aspiration cytology along with radiological studies proved very useful in classifying the nature of metastatic cutaneous nodules and suggesting the possible site of unknown primary. Sensitivity of FNAC for epidermal cyst and inflammatory lesions was 100%. In case of adnexal tumours, sensitivity and specificity was 67% and 50% respectively. Conclusion: FNAC is a rapid, efficient, cost effective, relatively painless procedure and produces a speedy result with high diagnostic accuracy. It has high rates of sensitivity and specificity in diagnosing papulonodular lesions of skin and hence, is a valuable tool in the diagnosis and management of patients with papulonodular skin lesions.

The Impact of Intimate Male Partner Violence on Women’s Sexual Function: A Study in Iran

Safieh Jamali, Shohreh Javadpour

Introduction: Sexuality is an integral part of a womans life. A variety of factors can affect a womans sexuality, among them physical disorders, social-religious beliefs, age, psychological factors, depression, mental tension, disbelief, an unfulfilling relationship with ones spouse and emotional and physical violence. Aim: The present study aimed to explore the rate of domestic violence against women and its impact on womens sexuality. Materials and Methods:This cross-sectional study was conducted on 813 women referring to the gynaecology clinics of Jahrom, Iran, from April to October 2015. Data were collected using a demographics questionnaire, a violence questionnaire and Female Sexual Function Index (FSFI). The collected data were analysed using Student’s t-test and logistic regression. Results: The prevalence of violence was found to be 43.2%. Also, there was a significant relationship between violence and age (OR=1.33 95% CI=2.22-7.95, p<0.001). The rate of violence was found to increase by 3.1 times with an increase in the length of marriage (OR=3.1595% CI=1.42-4.12, p<0.001). Moreover, domestic violence significantly correlated with womens education level (OR=11.75 95% CI=2.15-64.12, p=0.002) and their husband’s education level (OR=0.194, 95%CI=0.329-0.919, p=0.02). The results showed that the sexual function mean score of non-abused women and abused women were 17.74±8.82 and 14.59±10.63, respectively. However, a significant difference was found between the two groups regarding the domains of sexual function (p<0.05). Conclusion: This study showed that the frequency of domestic violence is rather high and that can increase the risk of sexual dysfunction. Thus, routine screening for violence and sexual dysfunction is recommended for early detection of violence and sexual dysfunction.

Olopatadine Hydrochloride and Fluticasone Propionate in Topical Treatment of Allergic Rhinitis: A Single Blind Randomised Study

Introduction: The use of corticosteroids or antihistaminics in treatment of allergic rhinitis is known and practiced since long. The efficacy of topical use of fluticasone propionate and Olopatadine Hydrochloride (HCL) for symptomatic relief of allergic rhinitis has been studied either individually or with other drugs. But very few studies show comparison between these two drugs. Aim: To compare the efficacy of topical use of fluticasone propionate and olopatadine hydrochloride for symptomatic relief of allergic rhinitis. Design: In this single blind, randomized control study, the efficacy of topical use of olopatadine HCL was compared with fluticasone propionate for relieving symptoms of allergic rhinitis. Materials and Methods: The symptomatic cases were randomized in two groups for treatment using either olopatadine HCL or fluticasone propionate respectively. In each group, the Total Symptom Scores (TSS) and individual symptom scores were recorded before and after treatment with the help of symptom evaluation scale. Statistical Analysis: Chi-square test, unpaired t-test, Mann Witney U-test, and Wilcoxon signed Rank test were used during analysis. The results of the comparison were noted and analysed. Results: During four week study period both TSS and individual symptom score were reduced (p<0.05) in either groups. The TSS decreased by an average of 85.07% for those treated with olopatadine and by 95.55% for those treated with fluticasone. Conclusion: Overall fluticasone propionate was superior to olopatadine in relieving symptoms of allergic rhinitis (p<0.005).

Comparative Evaluation of Mastoid Cavity Obliteration by Vascularised Temporalis Myofascial Flap and Deep Temporal Fascial-Periosteal Flap in Canal Wall Down Mastoidectomy

Navjot Kaur, Dinesh Kumar Sharma, Jagdeepak Singh

Introduction: A consensus is emerging amongst otologists that obliteration of the mastoid cavity that results after modified radical mastoidectomy is a sound option to prevent cavity related problems such as otorrhoea, infection, granulation tissue and hearing loss. A variety of techniques have been proposed to perform the obliteration. Aim: The present study aimed to compare the conventional method of mastoid cavity obliteration by vascularised temporalis myofascial flap with deep temporal fascial-periosteal flap in canal wall down mastoidectomy. Materials and Methods: The prospective study (conducted between July 2012 and August 2013) randomly assigned patients with evidence of attico-antral disease to two groups (20 in each group). After canal wall down mastoidectomy, a superior based vascularised temporalis myofascial flap was used to obliterate the resultant mastoid cavity in group 1 patients and an inferior based deep temporal fascial-periosteal flap was used in group 2 patients for the cavity obliteration. They were then followed up till day 90. Results: Cavity obliteration was better in group 2 (90%) as compared to group 1 (80%). Similarly, the final status of epithelisation of cavity at 90th day was clinically superior in patients of group 2 (85%) as compared to group 1 (75%). However, these difference were not statistically significant. Conclusion: The clinical superiority of the results with temporal fascial-periosteal flap can be attributed to less frequent complications (partial obliteration and epithelisation of resultant mastoid cavities, residual perforation and persistent ear discharge) as compared to myofascial flap.

Knowledge, Attitude and Practice among Dental Practitioners Pertaining to Preventive Measures in Paediatric Patients

Introduction: Prevention at primary level is of great value in Paediatric Dentistry. Since use of preventive measures can prevent future complications, dental professionals share an important responsibility toward early screening, prompt referral and treatment and this knowledge must transfer into the practice of dentistry. Aim: To evaluate Knowledge, Attitude and Practice (KAP) among dental practitioners in Bhopal city (central part of India) pertaining to sealants, topical fluorides usage and orthodontic consideration in paediatric patients. Materials and Methods: A descriptive cross-sectional survey was conducted using a 20-item self-administered, closed ended, structured questionnaire. A total of 200 available private dental practitioners of Bhopal city made up the sampling frame of study. Results: Out of 200 practicing dentists, 147 participated with response rate of 73.5% in which 69.4% were males and 30.6% were females. A total of 83% dentists were less than 35 years of age, while 17% were equal to or more than 35 years of age. Qualification distribution revealed 67.3% dental graduate and 32.6% dental specialist. A highly significant difference in knowledge in relation to age was observed. The mean±SD were found for Knowledge as 8.46±1.82, Attitude as 2.65±0.780, and Practice as 1.66±1.57. Statistically significant correlations were found between attitude and practice (r=0.58, p<0.001). Conclusion: Dentists in Bhopal city have vast knowledge towards preventive dentistry. The attitude is highly commendable but underutilized in practice, which needs to be improved.

A Study of Medication Compliance in Geriatric Patients with Chronic Illnesses at a Tertiary Care Hospital

R. Shruthi, R. Jyothi, H.P. Pundarikaksha, G.N. Nagesh, T.J. Tushar

Introduction: Geriatric population is more prone for various chronic and recurrent illnesses like diabetes mellitus, hypertension, IHD, arthritic, neurodegenerative, gastrointestinal, ocular, genitourinary, respiratory disorders etc., which may require chronic medication with multiple drugs. Poor compliance in this age group accounts for medication wastage with increased cost of healthcare and substantial worsening of the disease with disability or death. Most of the human and economic costs associated with non adherence can be avoided by improving medication adherence. Aim: To assess the level of medication compliance in elderly patients with chronic illnesses and to analyse the factors influencing medication compliance. Materials and Methods: The study subjects were assessed by using twenty item structured questionnaires as per modified Morisky Medication Adherence Scale (MMAS). Results: A total of 251 subjects of geriatric age group with chronic illnesses were assessed for the level of compliance for long term medications. The average number of medications 2.96 ±1.42 per subject and most of the subjects were receiving FDCs. The compliance level was assessed by way of interview using a twenty item structured pretested questionnaire as per modified MMAS. The level of compliance was good in 45.41%, moderate in 35.45% and poor in 19.12% of the study subjects. Conclusion: The level of compliance positively correlated with the educational status of the study subjects and their awareness about the diseases and prescribed medications. The overall level of compliance was higher in subjects living with spouse or families, subjects without any functional impairment, subjects who were regular for the follow-up visits and also in subjects who did not experience any adverse events.

Assessment of Abdominal Muscle's Maximal Force of Contraction Using Surface Emg in Inguinal Hernia Patients

G. S. Sreenath, Senthil Kumar Subramanian, Vivek Kumar Sharma

Introduction: Reduction in abdominal muscle’s strength has been implicated in the development of inguinal hernia. Patients with inguinal hernia on one side are shown to be at higher risk of developing inguinal hernia on the other side. Aim: To assess the abdominal muscle strength in inguinal hernia subjects using surface Electromyography (EMG) and compare it with healthy controls. Materials and Methods: This is a cross-sectional study involving only male subjects. Abdominal (Inguinal) hernia subjects without any known complications were recruited from surgery department and the accompanying healthy individuals were taken as control (Control, n=44, inguinal hernia subjects, n=43). The subjects were asked to perform maximal contraction for three seconds targeting external and internal oblique muscles of right and left sides separately. Motor unit potentials were recorded using surface EMG for individual muscles on both sides during maximal contraction. The maximum amplitude of the motor unit potentials obtained was considered as the strength of the respective muscle. Results: In control group, there was no significant difference in strength of external and internal oblique muscles between the two sides. Strength of external and internal oblique muscles of both herniated and unaffected side was reduced in inguinal hernia subjects as compared to healthy controls. Further, the muscle strength of herniated side was less as compared to unaffected side in the inguinal hernia subjects. Conclusion: Abdominal muscle strength is reduced in hernia subjects and even the apparently normal side strength is less as compared to controls. This should be considered while performing corrective surgeries in inguinal hernia subjects.

Early Discharge of Preterm Infants- An Indian Perspective

Ankit Soni, Sandeep Kadam, Anand Pandit, Sanjay Patole

Introduction: Early home discharge of preterm infants is a priority in developing countries due to bed shortage and poor socio-economic status. There is wide variation in home discharge policies for preterm infants. Limited data exists on optimal timing for discharging such infants. In view of the socio-economic and medico-legal importance of the issue, we aimed to study the outcomes of our ex-preterm infants discharged home ‘early’, to guide our clinical practice. Aim: To study the rates of re-admissions/mortality within 4 weeks after discharge in preterm (born <34 weeks) infants. Materials and Methods: This was an analysis of retrospectively collected data on all ex-preterm infants (gestation <34 weeks at birth) discharged home from our Neonatal Intensive Care Unit (NICU) during the study period. Infants enrolled were stratified based on their gestation age: Group I (n=54): 26-29 weeks, Group II (n=181): 30-34 weeks. Data on demographic characteristics, hospital course and outcomes were analysed for infants meeting inclusion criteria. Re-admission and/or mortality within 4 weeks after discharge were studied. Results: The mean±(SD) duration of stay was 42±19 vs. 19±14 days in group I vs. II infants. Five (2.7%) infants were re-admitted within the first four weeks after discharge in group II; none in group I. Conclusion: Early home discharge for preterm infants born <34 weeks was feasible and safe in our set-up. Large prospective studies are required to confirm these benefits.

Fuchs Heterochromic Iridocylitis: Clinical Characteristics and Outcome of Cataract Extraction with Intra Ocular Lens Implantation in a Kashmiri Population- A Hospital Based Study

Wasim Rashid, Imtiyaz Lone, Adil Majid Mir, Aamir Rashid, Mehreen Latif

Introduction: Fuchs Heterochromic Iridocylitis (FHI) is a rare form of uveitis which is frequently complicated by cataract and glaucoma, but it does not show typical features of uveitis like pain, redness and posterior synechia. Aim: To study the clinical characteristics and outcome of cataract extraction with Intra Ocular Lens (IOL) implantation in patients with FHI. Materials and Methods: The present prospective study was carried out in the Postgraduate Department of Ophthalmology, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Bemina from March 2012 to January 2015. The study included 33 eyes of 32 patients of FHI who underwent thorough clinical examination and cataract surgery with IOL implantation and were evaluated based on their visual outcome and intra and post-operative complications. Post-operative follow-up was done on 1st day, one week, one month, two month, six month and at twelve months. Results: Mean age of our study group was 33.9 years (Range 18 to 65 years). No male or female preponderance was seen. There was bilateral involvement of eyes in only one case. Cataract and stellate keratic precipitates were present in all cases whereas, heterochromia was present in only six eyes (18.75%). Best Corrected Visual Acuity (BCVA) showed a significant improvement following cataract surgery (p<0.001). Post-operatively, 26 eyes (78.78%) showed an improvement of four lines or more (BCVA of > 6/12). Most common causes of decreased vision post-operatively were vitreous opacities in nine eyes (27.27%) followed by glaucoma in eight eyes (24.24%) and posterior capsular opacification in six eyes (18.18%). Conclusion: Cataract extraction with IOL lens implantation in FHI is a safe procedure associated with good visual prognosis and few complications. However, glaucoma is one of the main concerns and should be closely monitored both pre and post-operatively.

Perinatal Outcome of Second Twin with Respect to Mode of Delivery: An Observational Study

Rujul Rashmin Jhaveri, Trupti K Nadkarni

Introduction: With the advent of assisted reproductive techniques, multi-fetal pregnancies are on the rise. While caesarean section is the defined mode of delivery for triplets and higher order pregnancies, the picture for twin delivery is not so clear. While a trial for vaginal delivery is attempted, the second twin is considered vulnerable to complications. Whether this translates into worsened perinatal outcomes is not well defined. Aim: To study the perinatal outcome and to identify the various factors influencing the perinatal outcome of second twin with respect to mode of delivery. Materials and Methods: Data was collected from hospital birth records regarding the mode of delivery of viable twins (period of gestation >28 weeks) and outcome of second twin with respect to APGAR scores, NICU stay, neonatal morbidity and mortality, over a period of 12 months. Results: Of the 93 pairs of twins delivered, in 21(22.6%) pregnancies both twins were delivered vaginally, in 70(75.2%) pregnancies both were delivered by caesarean section and in 2 (1.8%) pregnancies 1st twin was delivered by vaginal route and 2nd by caesarean. In the vaginal delivery group, 85.7% times both twins were in vertex position. In the caesarean group, vertex/non-vertex (38.57%) was the most common presentation followed by non-vertex /non-vertex (25.71%) and vertex/vertex (24.28%). Comparing the perinatal outcome of second twin in both groups, the odds for APGAR score =7 was 3.385 times (OR-3.384, 95% CI 1.2099- 9.4684, p=0.02) in the vaginal group compared to the caesarean group. There was no association (OR-1.054, 95% CI 0.3344- 3.3268, p=0.9) between neonatal morbidity of second twin compared to mode of delivery. All 3 perinatal deaths were in the vaginal group (all between 28-32 weeks of gestation). Conclusion: There is an increased preference for caesarean delivery in twin pregnancies except in cases where both the twins are in vertex position and not associated with any other maternal or fetal complication. However, the caesarean mode of delivery does not influence neonatal morbidity in second twin, except when the 1 minute APGAR score is =7.

Evaluation of Association of Hyperuricaemia with Metabolic Syndrome and Insulin Resistance

Naveen Reddy Avula, Damodar Shenoy

Introduction: The prevalence of Metabolic Syndrome (MetS) ranges from <10% to as much as 84% depending on region and composition of the population studied. The MetS is a growing public health problem in the world. Aim: To evaluate association of hyperuricaemia with components of MetS and insulin resistance. Materials and Methods: Sixty patients with MetS were conveniently recruited. MetS was defined as per Adult Treatment Panel III (ATP III) guidelines. For the purpose of analysis study participants were grouped into, group-I (controls - normal serum uric acid levels) and group-II (cases - hyperuricaemia). Hyperuricaemia was defined with cut-off >6.8mg/dl in both men and women. Associated work up for MetS and insulin resistance like fasting blood sugar, fasting lipid profile, fasting insulin, serum uric acid was done. Blood pressure and anthropometric measurements including weight, height and waist circumferences were measured and BMI was calculated. HOMA IR method was used to measure the degree of insulin resistance. Logistic regression analysis was used to evaluate association of hyperuricaemia with MetS and insulin resistance. Receiver Operating Curve (ROC) was plotted to find out optimum cut-off value for insulin resistance. Results: A significant increase in systolic blood pressure (p < 0.001) and triglyceride levels (p=0.027) were observed in hyperuricaemia subjects when compared to controls. After adjusting for potential confounders, Insulin resistance (HOMA IR >3.4) was independently associated with hyperuricaemia (OR=5.79, 95% CI=1.6- 20.69, p=0.007). Conclusion: Insulin resistance beyond a threshold is independently associated with hyperuricaemia in subjects with MetS.

Study of Immunohistochemical Markers (CK-19, CD-56, Ki-67, p53) in Differentiating Benign and Malignant Solitary Thyroid Nodules with special Reference to Papillary Thyroid Carcinomas

Introduction: Solitary Thyroid Nodule (STN) has provoked increased concern owing to higher incidence of malignancy. The inter and intra observer variation in the histomorphological diagnosis of Papillary Thyroid Carcinomas (PTC) may sometimes pose a diagnostic difficulty. Aim: This study was undertaken to analyse immunohistochemical (IHC) markers (CK-19, CD-56, p53, Ki-67) to differentiate between benign and malignant surgically resected STN along with their utility in the identification of PTC. Materials and Methods: The present cross sectional study was conducted over a period of 4 years. A technique of manual tissue array was employed for cases subjected to IHC. The primary antibodies used were CK-19, CD-56, p53 and Ki-67. Analysis of the expression of IHC markers (p53, Ki-67) to distinguish between benign and malignant STN was done. Evaluation and correlation of expression of IHC markers (CK-19, CD-56) to determine its utility in reaching definitive diagnosis and assessing prognosis of PTC was tried. Results were subjected to statistical analysis. The results were considered to be significant when the p-value <0.05. Results: Out of the 160 cases of surgically resected STN specimens, 68 cases were non-neoplastic, 24 cases were benign and 68 cases were of malignant tumours (7 cases of follicular carcinoma (FCa), 61 cases of PTC). CK-19 was found to be a sensitive (83.61%) and a highly specific positive marker (100%) for the diagnosis of PTC. The difference in CD-56 expression between PTC and non-PTC group was found to be highly statistically significant. CD-56 was found to be a sensitive (85.86%) and specific (82.25%) negative marker in differentiating PTC from follicular lesions/neoplasms. The difference in p53 expression between the malignant and non-malignant STN cases was found to be highly statistically significant with a sensitivity and specificity 85.29% and 70.65% respectively. The statistical difference in mean Ki-67 Labeling Index (LI) was found to be significant between PTC versus FA, PTC versus non-neoplastic lesions, FA versus FCa and FVPTC versus FA. Conclusion: The panel of four IHC markers (CK-19, CD-56, p53, Ki-67) may be used for differentiating doubtful benign STN cases from malignant ones and also for definitive diagnosis of PTC along with histopathological examination.

Fostering Educational Research among Medical Teachers: Evaluation of a Faculty Development Program in India

Tripti K Srivastava, Lalitbhushan S Waghmare, Alka Rawekar, Ved Prakash Mishra

Introduction: Medical education can be enormously benefitted from research. Since clinicians/medical teachers are directly involved in teaching learning processes, they should participate in Educational Research (ER) practices to generate evidence and insights about teaching learning. Faculty Development Program (FDP) has a positive influence amongst health professionals and therefore can prove to be of consequence in instilling a strong educational research culture. Aim: Present study was undertaken to evaluate the efficacy of a Faculty Development Fellowship Program in Medical Education to foster educational research culture amongst medical teachers. Materials and Methods: Study utilized the Kirkpatrick model of program evaluation for evaluating the fellowship program. It aimed to evaluate the third level of the model i.e., “Change in Behaviour” of participants (n=40) after completion of the course. The tool used was a pre-validated survey questionnaire consisting of five items. Results: Study population was sparsely aware about educational research and had never attempted the same (100%) before joining the fellowship program. A 32.5% faculty with average professional experience of seven years undertook new educational projects after the fellowship and knowledge gained during fellowship program helped them in guiding educational research (coded into four categories) at their workplaces. Conclusion: There is a need, to direct effort towards focused training for educational research through FDPs for medical teachers. This will encourage academicians and clinicians to become active in ER and guide policies in Teaching Learning Practices in Medical Education.

School Based Multicomponent Intervention for Obese Children in Udupi District, South India – A Randomized Controlled Trial

Baby S Nayak, Vinod H Bhat

Introduction: Childhood obesity and overweight is a global epidemics and has been increasing in the developing countries. Childhood obesity is linked with increased mortality and morbidity independent of adult obesity. Declining physical activity, access to junk food and parenting style are the major determinants of overweight in children. Thus, there is a need for increasing the physical activity of children, educating the parents as well as the children on lifestyle modification. This can be achieved through implementation of multicomponent intervention. Aim: To evaluate the effectiveness of multicomponent intervention on improving the lifestyle practices, reducing the body fat and improving the self esteem of obese children from selected schools of Udupi District, South India. Materials and Methods: A sample of 120 obese children were enrolled for multicomponent intervention. The components of multicomponent intervention were: education provided to the obese children on lifestyle modification, education of the parents and increasing the physical education activity of these children in the form of aerobics under the supervision of physical education teacher. There was an attrition of 25% in the intervention group. Thus the final sample in the intervention group was 90. Total sample of 131 overweight/ obese children enrolled as controls. There was an attrition of 20.61% in the control group. Thus, the final sample in the control group was 104. Intervention group received the multicomponent intervention for six month. Results: Mixed Method Repeated measures Ananlysis of Variance (ANOVA) was applied for analysis of data. Results indicated that the intervention was effective in reducing the Body Mass Index (BMI), triceps, biceps, subscapular skin fold thickness of obese children. The intervention was also effective in improving the lifestyle practices and self-esteem of obese children. Conclusion: Overweight/obese children need to control diet and perform vigorous exercise at least for 20 minutes a day to reduce the excess fat and maintain their body fat level.

Alteration of Heart Rate Variability in Patients of Depression

Deepti Jangpangi, Sunita Mondal, Rajiv Bandhu, Dinesh Kataria, Asha Gandhi

Introduction: Altered cardiac autonomic functions in form of reduced Heart Rate Variability (HRV) have been found to be associated with increased cardiovascular morbidity and mortality in depressive patients. Aim: To investigate the relationship between HRV measures, which is a non-invasive marker of autonomic nervous system and depression. Materials and Methods: The study included a convenient sample size of drug naive depressive patients (n=30) diagnosed on basis of ICD-10 and compared with age and gender matched healthy volunteers (n=30). Five minute ECG recording was done for HRV analysis and frequency domain measures like LF (Low Frequency), HF (High Frequency), LF/HF ratio as well as time domain measures like SDNN (Standard Deviation of all NN interval) and RMSSD (Root Mean Square of Successive differences of NN intervals) were obtained. Results: In the frequency domain parameters, values of LF (nu) and LF/HF Ratio were found to be significantly higher (p<0.001) whereas, that of HF (nu) was significantly lower (p<0.001) in depression group as compared to control group. However, in the time domain parameters, no significant difference was observed in SDNN and RMSSD values in between the two groups. Conclusion: HRV recordings showed significant changes in frequency domain parameters in the patients suffering from depression. Thus, it could be said from our study that autonomic imbalance reflecting enhanced sympathetic activation relative to parasympathetic component is associated with depression.

Efficacy of Specific Plant Products on Dental Caries Causing Microorganisms

M Rajini Kanth, A Ravi Prakash, G Sreenath, Vikramsimha Reddy, S Huldah

Introduction: Dental caries and periodontal diseases are the most common oral diseases seen globally, both in developed and developing countries. Oral microorganisms that is gram positive and gram negative bacteria are known to be involved in causation of these diseases. Nowadays commercially available dentrifices and mouth rinses are known to contain ingredients that can alter the oral microbial flora and have undesirable side effects such as vomiting, diarrhoea, disarrangement of oral, intestinal flora and tooth staining. Naturally available plant products are known to be less harmful with fewer side effects and also economical for the patient. Aim: The aim of this study was to determine the antimicrobial properties of 10 naturally available plant products against oral microorganisms causing caries and to check the efficacy of these products in-vitro and to use these in mouth washes and dentrifices. Materials and Methods: Sample of caries material was scrapped out from the extracted teeth and transferred to liquid broth, streaked over the agar media to allow for the growth of microorganisms. Plant products like clove oil, neem, ginger-garlic paste, tea tree oil, ginger, garlic, cinnamon oil, green tea, eucalyptus oil and turmeric were used. Antimicrobial efficacy of these products, was estimated by measuring zones of inhibition in the nutrient agar media. Results: Clove oil was the most effective of all products against microorganisms causing caries with zone of inhibition - 30mm followed by ginger-garlic paste - 25mm, Neem - 15mm, tea tree oil - 15mm. Conclusion: Based on the above results, it can be inferred that these natural products have the maximum efficacy against microorganisms and can be recommended in dentifrices, mouth rinses, topical gels, etc.

2D:4D Ratio and its Implications in Medicine

Saravanakumar Jeevanandam, Prathibha K Muthu

Digit ratios, especially 2D:4D ratio, a potential proxy marker for prenatal androgen exposure shows sexual dimorphism. Existing literature and recent research show accumulating evidence on 2D:4D ratio showing correlations with various phenotypic traits in humans. Ratio of 2D:4D is found to correlate negatively to testosterone and positively to oestrogen in the foetus. Interestingly, it is constant since birth and not influenced by the adult hormone levels. Usually, males have lower ratios when compared to females. Prenatal androgen exposure and therefore, digit ratios have been reported to be associated with numerical competencies, spatial skills, handedness, cognitive abilities, academic performance, sperm counts, personalities and prevalence of obesity, migraine, eating disorders, depression, myopia, autism etc. The authors have attempted to write a brief account on the digit ratios and the dimorphism observed in various physiological, psychological and behavioural traits. Also, the authors have discussed the relevant molecular basics and the methods of measurement of digit ratios.

A Rare Case of Multiple Myeloma with Biclonal Gammopathy

Abhik Banerjee, Kshama Pimpapalgaonkar, Alap Lukiyas Christy

Multiple myeloma is a debilitating malignancy arising from plasma cells. These malignant plasma cells called myeloma cells proliferate and infiltrate the bone marrow. The disease is characterized by the presence of a monoclonal protein in plasma and/or the urine. In this report, we present a case of biclonal multiple myeloma which showed two M bands on serum protein electrophoresis. The patient had elevated serum IgA and IgG levels. To reveal the nature of M bands or clonality, serum Immunofixation study was performed which revealed IgA with Lambda and IgG with Kappa light chains. Such pattern is very rare if we consider the various immunofixation patterns observed in different gammopathies.

Case Report of Youngest Successful Bilateral Cartilage Tympanoplasty in India

Gaurav Ashish, Ankita Gupta

Paediatric Chronic Suppurative Otitis Media (CSOM) remains a challenge for the treating otologists. Usually, concurrent foci of infection lie in the oropharynx or nasopharynx and treating these eventually leads to resolution of ear discharge. However, refractory cases can be threatening in view of complications secondary to CSOM. A two year and 10-month-old child presented with recurrent profuse mucopurulent ear discharge which had been refractory to multiple medical treatment. Recently she had recurrent otitis external episodes with excoriations of canal skin. Child underwent bilateral tympanoplasty with cartilage palisading technique. At eight months follow-up, the neotympanum is intact and the child had no further episodes of ear discharge. This case to our knowledge is the youngest child to undergo a bilateral successful cartilage tympanoplasty in Indian subcontinent. This case report is written with the aim to highlight the fact that cartilage tympanoplasty can be considered in treating refractory cases of paediatric CSOM.

Acute Presentation of Juvenile Dermatomyositis with Subclinical Cardiac Involvement: A Rare Case

Rhythm, Shrayash Khare, Shailendra Kumar singh

Cardiac involvements are common in patients with Dermatomyositis, most of which are not severe enough to present definite or readily observable symptoms. However, Cardiovascular (CVS) manifestations constitute a major cause of death in these patients. The most frequently reported clinically evident of CVS manifestations in-patient of dermatomyositis are Congestive Heart Failure (CHF), conduction aberrations, that may predispose to complete heart block and coronary artery disease. The principal pathophysiological mechanisms that may produce these cardiac manifestations involve coronary artery disease as well as small vessels vasculitis of the myocardium. Our case of a seven-year-old boy represent a unique manifestation of prolong PR interval with no overt clinical manifestation and who responded well to immunosuppressive treatment. His clinical, laboratory and investigative features of Juvenile Dermatomyositis (JDM) is presented here. It is hoped that this case will heighten the index of suspicion of cardiac condition in patients with JDM among medical practitioners.

Identifying Aarskog Syndrome

Anis Ahmed, Abdullah Mufeed, Ashir Kolikkal Ra machamparambathu, Umer Hasoon

Aarskog syndrome also known as Aarskog-Scott Syndrome, Facio-digito-genital Syndrome or Faciogenital Dysplasia is a rare, X-linked disorder predominantly affecting males, characterized by facial, skeletal and genital anomalies. This is a case report of a 15-year-old male patient who visited our college complaining of poor facial aesthetics. History revealed consanguinity and his sibling to be suffering from the same. A diagnosis of Aarskog syndrome was made based upon the detailed patient history, thorough clinical evaluation and identification of characteristic findings in radiographs. Professional counselling explained him the nature of his condition and treatment options to correct dental anomalies and congenital malformations were advised.

Removal of Infected Maxillary Third Molar from the Infra-temporal Fossa by Caldwell Luc Procedure - Rare Case Report with Literature Review

Anand Kumar, Ram Kumar Srivastava, Anurag Saxena, Ruchika Khanna, Iqbal Ali

Dentigerous or follicular cysts of odontogenic origin are innocuous benign cysts that are often linked with the crowns of permanent teeth. A dentigerous cyst circumventing permanent teeth fails to erupt and is often displaced into ectopic positions in the upper and lower jaw in the maxillofacial region. In the maxilla or upper jaw region, the impacted teeth are often displaced and/or shift into the maxillary sinus and apart from the nasal septum, mandibular condyle, coronoid process and the palate, to harbour such ectopic eruptions of teeth. We report a rare case of an impacted left third molar of maxilla, associated with dentigerous cyst. The impacted tooth was embedded in the anterosuperior part of the infratemporal space. The cyst along with the tooth was removed using a modified Caldwell Luc incision.

Non-surgical Management of Skeletal Class III Malocclusion with Bilateral Posterior Crossbite: A Case Report

Lalima Kumari, Kamal Nayan

A 16-year-old female patient with skeletal Class III malocclusion and bilateral posterior cross bite complaining of difficulty in chewing was treated orthodontically without surgery (camouflage treatment). The treatment comprised of fixed orthodontic treatment with MBT prescription (0.022?×0.028? slot) using quad helix appliance for bilateral expansion of maxillary arch and Class III elastics for occlusal correction. Post-treatment records showed normal overbite and overjet with acceptable occlusion. So with this treatment strategy of expanding the maxillary arch using a quad helix appliance and use of Class III elastics, we achieved a good result with optimal occlusion.

Chikungunya and Myositis: A Case Report in Brazil

Chikungunya Virus (CHIKV) is a well-described alpha virus that causes infection in humans. The main symptoms are fever, rash and arthralgia and recently neurological disorders have been reported, in particular encephalitis. It is uncertain whether neurological symptoms are due to persistence of the virus or an ineffective immune response. One rarely described neurologic syndrome is myositis. In this paper, we report the case of a 19-year-old woman with mental confusion and aggressiveness two days after complaints of fever and arthralgia. On clinical evaluation, the patient had power 5/5 in the upper limbs and 3/5 in the lower limbs. Electromyography revealed the presence of myogenic potentials with reduced amplitudes and early recruitment predominantly in the proximal muscle. Two weeks later, she complained of muscle weakness of the lower limbs that started 15 days after acute Chikungunya infection. The patient improved within two months with only supportive care.

Effect of Thoracic Correction Exercises in Upper Body Dysfunction of 94–Year–old Male Participant – A Case Report

P. Senthil, S. Sudhakar, R. Radhakrishnan

The case report has been presented to show the effects of thoracic correction exercises on flexed posture in older men with upper body dysfunction using posture analysis software and pectoralis minor muscle length test. The present case is that of a 94-year-old male. He was guided for a specific thoracic correction exercises for 12 weeks. The program included breathing correction, thorax mobility, scapular stability and passive stretching of Pectoralis major and minor, performed thrice a week, 30 min each session, for 12 weeks. Outcome measures included the upper body dysfunction changes by posture analysis software and pectoralis minor muscle length test. The Pre and Post–test of the patient demonstrated significantly greater improvements in hyperkyphosis (forward head posture) and pectoralis minor muscle length. This case study provides a promising exercise intervention that may improve flexed posture in older men with age-related upper body dysfunction.

Meningitis with Digital Gangrene in Meningococcal Infection: An Atypical Presentation

Meningococcal infection is an important public health concern. Neisseria meningitidis usually colonizes the nasopharynx of healthy adolescents and adults and remains as asymptomatic colonizer, while in rare cases it may present as invasive disease as either meningitis or septicemia or both. Most of the cases have typical presentation of rashes. We hereby present a case of a 40-year-old male who presented with meningococcal meningitis and peripheral digital gangrene but without development of typical rashes. He improved by early institution of appropriate intravenous antibiotics with supportive care.

Pulsatile Clavicular Swelling as the Sole Presentation of Asymptomatic Renal Cell Carcinoma with an Isolated Metastasis to the Clavicle: A Case Report

Ashwani Kumar, Nitish Arora, Paras Kumar Pandove, Garima Anand, Bharti Arora

Renal Cell Carcinoma (RCC) is notorious for its unpredictable dissemination patterns involving both lymphatic and haematogenous route without a clear-cut preponderance for any. Unlike other intra-abdominal malignancies like colorectal carcinoma, renal cell carcinoma is often known to metastasize to distant sites even after a confident and unsuspecting curative resection or often as the primary presentation constantly adding and agitating our presentation patterns for this sneaky tumour. Presented below is a case of such an unsuspecting female patient. She was referred from the orthopaedic OPD to surgery OPD with a right clavicular swelling which was histopathologically examined and diagnosed as a metastatic renal cell carcinoma following which she was diagnosed with right renal cell carcinoma.

Carbamazepine-induced Life-threatening Stevens-Johnson Syndrome and Agranulocytosis: The Maiden Case

Stevens-Johnson syndrome is one of the few dermatological emergencies in clinical practice. The syndrome is often secondary to the usage of drugs, of which allopurinol, penicillins, sulfa drugs, ibuprofen, sodium valproate, phenytoin, lamotrigine and carbamazepine are commonly implicated. Agranulocytosis is the existence of a clinically significant reduction in neutrophil count.This condition is a serious threat to the patient, as he/she is at a greater risk of contracting bacterial or fungal infections, which may prove to be fatal. The co-existence of Stevens-Johnson syndrome and agranulocytosis in the same patient further increases the risk of morbidity and mortality. To the best of our knowledge, there are no reports available in the existing literature, of cases that were reported with both these life-threatening conditions in a single patient, at the same point of time. This is a case narrative of a patient who presented with both Stevens-Johnson syndrome and agranulocytosis, following the administration of carbamazepine The patient’s differential leucocyte count revealed a neutrophil proportion of 2.33%. A causality assessment done using Naranjo’s algorithm showed that carbamazepine “definitely” caused Agranulocytosis and “probably” caused Stevens-Johnson syndrome.

Central Telangiectatic Osteosarcoma of the Mandible in a Paediatric Patient: A Rarity

Divya Tomar, Manu Dhillon, Muhamad Nishad Thayath, Iram Zaidi, Shikha Singh

Osteosarcoma (OS) involving the head and neck region is rare and is a diagnostic challenge due to its aggressive nature and varied presentations. Although OS constitute 40% to 60% of all bone tumours, only 10% of these occur in the head and neck region, most commonly in the maxilla and mandible. OS of the jaw bone has a different pattern and behaviour when compared to OS at other anatomic location. It occurs in a more elderly population, less aggressive and usually spreads locally rather than distant metastases. Telangiectatic Osteosarcoma (TOS) of jaws in a paediatric patient is still a very rare variant and till date only two cases have been reported in literature. Radiographic evaluation plays an important role as the clinical symptoms are not specific to the condition. Conventional radiography should always be supplemented by advanced imaging modalities for the diagnosis, which gives a three dimensional assessment and also prevents superimposition of surrounding structures. Early diagnosis and radical surgery are the keys to high survival rates. Herein, we present a third ever reported case of TOS occurring in mandible of a nine-year-old male patient.

Interstitial Lung Disease with Chilaiditi Syndrome

Chilaiditi sign is the peculiar radiographic presentation of interposition of colon between diaphragm and liver. When associated with symptomatology, it is called as chilaiditi’s syndrome. Though rare, respiratory symptoms may be present. In such cases, it becomes difficult to determine if the symptomatology is due to the syndrome only, or there is some underlying lung involvement, until this is specifically considered in the differential diagnosis. We present a male patient, where thorough investigations revealed Interstitial Lung Disease (ILD), along with Chilaiditi sign on chest radiograph. Respiratory symptomatology responded partially to the management of underlying ILD. It is left for discussion, whether the Chilaiditi syndrome was also contributing to the overall clinical presentation or the respiratory complaints were solely due to ILD and Chilaiditi sign was an incidental finding.

Tuberculosis of Glans Penis- A Rare Presentation

C. Gangalakshmi, Sankaramahalingam

Tuberculosis (TB) of penis is a very rare entity, even in developing countries. It may present as primary or secondary to Pulmonary TB (PTB). Penile TB mimics carcinoma penis, granulomatous penile ulcer, genital herpes simplex, granuloma inguinale and HIV infection. We, hereby, present the case of a 57-year-old male patient who presented to us with ulcerative growth over glans penis and was clinically diagnosed as carcinoma penis, however biopsy of the lesion showed evidence of tuberculosis which was supported by chest X-ray.

Delusional Disorder in a Patient with Corpus Callosum Agenesis

M.S. Bhatia, Rashmita Saha, Nimisha Doval

Agenesis of corpus callosum is rare and associated neuropsychiatric abnormalities reported are epilepsy, Asperger's syndrome, learning problems, depression, schizophrenia, conduct disorder and conversion symptoms. Schizophrenia is the most common psychiatric disorder reported among corpus callosum agenesis. We report a rare case of delusional disorder with corpus callosum agenesis and seizure disorder. The patient presented with delusions of persecution towards younger brother and mother, disturbed sleep and reduced appetite. She had a history of seizure disorder of ten years duration, which was controlled with carbamazepine and levetiracetam. Neurological examination was normal. On MRI, corpus callosum agenesis was detected. She was put on an atypical antipsychotic quetiapine to which her psychiatric symptoms responded completely.

Abducens Nerve Palsy in Pregnancy: A Case Report

Sayedeh Reyhaneh Yousefi, Shokrollah Zandi

Headache, blurring of vision and confusion are neurologic symptoms of preeclampsia. Whereas abducens nerve palsy during pregnancy is an extremely rare condition, we report here a 40-year-old patient with diplopia, blurring of vision and abducens nerve palsy in the 39th week of pregnancy with history of hypertension (HTN). No specific pathology was found. Symptoms of abducens nerve palsy were resolved spontaneously by controlling blood pressure after delivery.

Uterine Tumour Resembling Ovarian Sex Cord Tumour- A Rare Entity

Mustafa Gazi Uçar, Tolgay Tuyan Ilhan, Ayhan Gül, Ceyhan Ugurluoglu, Çetin Çelik

Uterine Tumour Resembling Ovarian Sex-Cord Tumours (UTROSCTs) are an extremely rare type of uterine body tumours arising from the endometrial stroma. Epidemiology, aetiology, pathogenesis, management and natural history of UTROSCTs are still a question of debate, as there is little available data in the literature. Although rare, the possibility of UTROSCTs should be kept in mind, when a patient presents with abnormal bleeding and an enlarged uterus. utrosct s appear dirty white/cream-coloured, gelatinous, well-circumscribed mass with smooth surface on macroscopic examination. We present a rare case of endometrial stromal tumour with sex-cord-like differentiation which was successfully treated by hysterectomy with bilateral salpingo-oophorectomy. The clinical manifestations, pathologic characteristics, diagnosis and management of these tumours are reviewed here.

Shear-Wave Elastography Features of Primary Non-Hodgkin’s Lymphoma of the Breast: A Case Report and Literature Review

Youdong Kim, Kyung Hee Ko, Hae Kyoung Jung, Hyun Ju Lee

Lymphoma is a rare malignancy of the breast, comprising approximately 0.04 to 0.5% of breast malignancies. Because the clinical findings of breast lymphoma are nonspecific and similar to those of breast carcinoma, it is important to distinguish breast lymphoma from other breast disease on the basis of radiologic findings. Elastography is an interesting imaging tool that reflects the tissue stiffness, increasingly being used in the evaluation of breast tumours. However, only a limited number of studies have focused on the elastographic findings of breast lymphoma. In this report, we review the radiologic characteristics of primary breast lymphoma including elastographic feature. A 57-year-old woman presented with a painless palpable mass of the left breast. Ultrasonography revealed an irregular-shaped complex cystic and solid mass with increased vascularity in upper outer breast. On shear wave elastography, the mass was relatively stiff with maximum elasticity value (Emax) of 100.5 kilopascal (kPa). The mass was confirmed as diffuse large B-cell lymphoma by US-guided core needle biopsy.

Enterobacter Meningitis and Challenges in Treatment

Shaylika Chauhan, Jawad Noor, Balaji Yegneswaran, Hanish Kodali

Neurosurgical interventions are rarely associated with meningitis with a very low incidence rate ranging from 1.1% to 2.5%. Gram negative bacillary meningitis first described in the 1940’s, previously uncommon has been increasing in the recent past associated with advanced age, immunosuppression and neurosurgery. Enterobacter meningitis though relatively uncommon is recently increasing in incidence and treatment is frequently complicated due to resistance to antibiotics making this a challenging, difficult to treat infection that may be associated with adverse clinical outcomes. Here, we describe a case of a 27-year-old patient diagnosed with brain sarcoma at the age of four years, who presented with Enterobacter meningitis following a neurosurgical intervention for resection of a recurrent brain tumor (meningioma on pathology) and had a prolonged hospital stay with a difficult to treat infection.

Colocolic Intussusception in a Child with Pathologic Lead Point Along with Intestinal Malrotation-A Rare Case Report and Brief Review

Prasanta Kumar Tripathy, Pradeep Kumar Jena

Intestinal obstruction in children is frequently caused by intussusception and intestinal malrotation and when these two conditions co-exist, it is called Waugh’s syndrome. Intussusception cases in children are mostly ileocolic, whereas, the colocolic variety is a rare entity and very few cases have been reported in literature. In all the reported cases of Waugh’s syndrome, the intussusceptions were ileocolic type except one case, where colocolic type was mentioned with lymphangoima as Pathological Lead Point (PLP). We report a seven-year-old child of colocolic intussusception with juvenile polyp being the PLP along with intestional malrotation. It is an extremely rare association which has not been reported previously.

Extracalvarial Meningioma in the Parapharyngeal Space: Presentation, Diagnosis and Management

Sirshak Dutta, Neeraj Aggarwal, Mainak Dutta, Saurav Kumar Ghosh, Ramanuj Sinha

Extracalvarial meningioma in the cervical region presenting as a parapharyngeal mass lesion is seldom encountered in clinical practice and poses great challenge in its diagnosis and surgical management. In this report, we present a case of extracranial meningioma in a middle-aged person who presented with a large, gradually progressing cervical swelling with multiple cranial nerve pareses. The difficulties in diagnosis and surgical management of this unusual neoplasm in the setting of partial encasement and thrombosis of the internal jugular vein have been discussed, along with the computed tomography and magnetic resonance imaging providing details of its extent and character. The report emphasizes the need to consider extracalvarial meningioma as a less common but important differential diagnosis of parapharyngeal space neoplasms.

Enteric Duplication Cyst Leading to Volvulus: An Unusual Cause of Acute Intestinal Obstruction – A Case Report

Enteric Duplication Cysts (EDC) is a rare congenital malformation, usually found in mesenteric side of Gastrointestinal (GI) tract. Generally patients present with non-specific symptoms depending on size and location of the cyst in GI tract. EDC presenting as small bowel volvulus is a rare clinical entity. Herein, we are reporting a 16-year-old adolescent girl who presented to Emergency Department (ED) with the features of acute bowel obstruction with septicemia. Patient underwent exploratory laparotomy which revealed dilated, twisted, gangrenous bowel due to a cystic lesion adjacent to the mesenteric side. Resection of the cystic lesion along with the affected gangrenous segment of bowel with an end to end anastomosis performed.

Mature Teratoma at Left Lumbar Region in an Infant: A Case Report

Rajendra Kumar Ghritlaharey

Common location of teratomas in children are sacrococcygeal, gonadal, mediastinal and retroperitoneal, but teratomas may also occur at very unusual locations. A six-month-old boy presented with a large swelling at his left lumbar region. He presented with gradually increasing lump at his back, involving more on left lumbar region and midline since birth. Clinical examination revealed a solitary, non-tender, soft to firm, irregular mass, occupying more on his left lumbar and midline region and also crossing the midline. Radiological investigations revealed a well defined mass of 9.6 x 7.5cm, with bony elements and spina bifida at L1 and L2 levels. His Computed Tomography (CT) scan finding was consistent with mature teratoma. Complete surgical excision of the tumour was done without any difficulties. Histology of the excised tumour was conclusive of mature teratoma. His post-operative period was excellent, but he lost to follow-up after discharge.

Spontaneous Rupture of the Main Pancreatic Duct Synchronous With a Multi-Focal Microscopic Pancreatic Adenocarcinoma: A Case Report

Shirly Shohat, Katerina Shulman, Boris Kessel, Oren Gal, Abdel Rauf Zeina

Pancreatic cancer is one of the most lethal types of malignant tumours, commonly diagnosed at an advanced stage. The only curative treatment for this fatal disease is surgery and early diagnosis is the key to a better outcome and prognosis. In this case report we present a 57-year-old woman presenting to the emergency room with abdominal pain and weight loss. Computer Tomography (CT) imaging showed a rupture of the main pancreatic duct and a peri-pancreatic fluid collection with no evidence of a pancreatic mass. An Endoscopic Ultrasound (EUS) guided Fine Needle Aspiration (FNA) did not show any malignant cells and Carcinoembryonic Antigen (CEA) and Carbohydrate Antigen (CA) 19-9 markers were in the normal range. The patient then underwent pancreatectomy that revealed multiple microscopic foci of pancreatic adenocarcinoma with evidence of massive perineural and vascular invasion.

A Rare Case Report of Hepatic Subcapsular Pseudocyst of Pancreas

Noor Topno, Sandeep Ghosh, Arup Baruah

A pancreatic pseudocyst arises as a result of acute or chronic pancreatitis, pancreatic trauma, or obstruction of the pancreatic duct by a neoplasm. Most of the pseudocysts are located within the head and the body of the pancreas but 20% are extra-pancreatic. We report a case of a 33-year-old gentleman presenting with acute on chronic alcoholic pancreatitis with hepatic sub-capsular pseudocyst involving left lobe of liver, with intra-cystic bleed was successfully treated with Ultrasonography (USG) guided drainage. Computed tomography (CT) and high level of amylase in the collection plays an important role in diagnosing this condition. Large hepatic sub-capsular pseudocyst presenting with severe pain due to intra-cystic bleed can be treated with percutaneous drainage to pre-empt rupture.

Fatal Toxic Megacolon in a Child of Hirschsprung Disease

Shiwani R Garg, Pragati A Sathe, Annapurna C Taware, Ketaki M Surve

Hirschsprung disease (HD) in late childhood is uncommon and often undiagnosed or misdiagnosed. However, in a patient with Hirschsprung disease, of greater significance is the occurrence of life threatening enterocolitis. In its more severe form, this is associated with gross dilatation of the colon and profound toxaemia, the combination being termed toxic megacolon. Because of its relative rarity, we report a case of 10-year-old child who had a history of chronic constipation for nine years. He later developed complications and presented to the emergency department with toxic megacolon, a rare occurrence due to neglected constipation. Though patient’s condition was unstable, laparotomy with right transverse colostomy was performed after appropriate intravenous rehydration. The dilated bowel loops were decompressed and intraoperatively multiple site biopsies were done. Histopathological examination of transition zone biopsy revealed absence of ganglion cells suggestive of Hirschsprung disease. But few hours later patient’s condition worsened and he succumbed.

Rare Site of Parasitic Dermoid Cyst at Uterovesical Fold of Peritoneum with Absent One-Sided Adnexa

Sunita Dubey, Alka Sehgal, Puneeti Ballega, RPS Punia

Teratomas are the most common type of germ cell tumour. It can be congenital or acquired and are usually found in gonads (testes and ovaries). Parasitic dermoid cysts are rare and their actual incidence is unknown. We are reporting a case of 25-year-old gravida two, para one and one living child, who underwent emergency cesarean section in view of symptomatic placenta previa. A parasitic dermoid cyst was found incidently in front of uterus which was attached to uterovasical fold of bladder. This cyst did not show any connection to uterus or adnexa.Uterus, uterine cavity, right side tube and ovary were normal. Her left sided fallopian tube and ovary was completely absent. She did not have any symptoms related to the dermoid cyst. Histopathology confirmed parasitic mature dermoid cyst.

Radiological and Histopathological Outcome of Giant Cell Tumor of Femur with Denosumab Treatment: A Case Report

Preethi Dileep Menon1, R. Krishnakumar, Annie Jojo

Giant Cell Tumour of Bone (GCTB) is a benign but locally aggressive osteolytic skeletal neoplasm of young adults consisting of giant cells expressing RANK (Receptor Activator of Nuclear Factor-?B) and mesenchymal spindle-like stromal cells expressing RANKL (RANK ligand). The interaction of these cells leads to bone resorption. Recently, the RANKL inhibitor, denosumab, has demonstrated activity against giant-cell tumours. The current article reports a case of a Giant cell tumour of left distal femur with pathological fracture. A 34-year-old male patient presented with history of on and off dull aching pain in the left knee for 4 months followed by a history of trivial fall. He sustained a closed injury in the left knee, following which he was unable to bear weight and developed pain and swelling in left knee. Conventional radiographs and Computerized tomography (CT) was done which showed the presence of a left distal femoral osteolytic lesion and a histological analysis of a biopsy specimen confirmed the diagnosis of GCTB. The patient was treated with neoadjuvant denosumab therapy which resulted in successful downstaging of the tumour followed by extended curettage of the lesion with high speed burr and argon laser cautery. The post-curettage microscopic examination revealed the absence of osteoclast-type giant cells.

Female Genital Tract Involvement in Acute Lymphoblastic Leukemia: A Rare Case Report

Vikram Narang, Amit Dhiman, Bhavna Garg, Neena Sood

Female Genital Tract (FGT) involvement with hematologic neoplasms is uncommon and the hematologic malignancies which involve the female genital organs are usually non-Hodgkin’s lymphoma. Involvement of the uterus and cervix with Acute Lymphoblastic Leukaemia (ALL) is extremely rare, and ovarian involvement is even rarer. We report the case of a young lady who presented with tubo-ovarian mass, excessive post-operative bleeding (post-total abdominal hystrerctomy and bilateral salpingo-oophorectomy) and was diagnosed to have ALL with blood and tissue involvement by histopathology and flow cytometry.

Osseous Hydatidosis of Femur in a Patient with Fracture Non-union: An Uncommon Entity

Kiruthiga Kala Gnanasekaran, Anne Jennifer Prabhu, Shyjumon George

Hydatid disease caused by the larval form of the parasitic tapeworm, Echinococcus granulosus, commonly affects the liver and lungs. Bone involvement by Hydatid is extremely uncommon and is reported in 1-3% of cases. It is often a dormant disease, presenting at a late stage with non-specific clinical and radiological findings. Usually they occur as an isolated entity without liver/lung involvement and a clinical suspicion of this disease is not possible. We report a rare case of Hydatid cyst of femur in a 25-year-old female, with unresolving non-union of fracture for five years. The occurrence of this disease in atypical locations and lack of a specific radiological sign makes the diagnosis challenging and it is important for the orthopaedicians and pathologists to be aware of this entity for a precise diagnosis.

Supra Hepatic Inferior Vena Cava Thrombosis–Surgical Challenges

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a chronic affliction characterized by numerous liver and kidney cysts. There is a gradual but progressive renal and liver impairment which may require combined liver-kidney transplantation. Compression of the retrohepatic Inferior Vena Cava (IVC) by an enlarged polycystic liver may impede clear visualization on pre-operative imaging and miss an underlying thrombosis or obliteration. This may result in an intra-operative surprise. Management can be challenging requiring modification of conventional surgical approach. We present our experience of a 67-year-old patient who underwent combined liver-kidney deceased donor transplantation for decompensated chronic liver disease with chronic kidney disease due to ADPKD. She was diagnosed with ADPKD for 16 year, with progressive deterioration in kidney function over the last 6 year and liver decompensation following knee replacement surgery requiring regular renal replacement therapy. We report this case to highlight the peri-operative challenges and their management along with a review of published literature on this uncommon occurrence.

Mature Cystic Teratoma with Co-existent Mucinous Cystadenocarcinoma in the same Ovary-A Diagnostic Dilemma

Sanjeet Roy, Sramana Mukhopadhayay, Mayank Gupta, Anuradha Chandramohan

Mature cystic teratoma co-existing with a mucinous cystadenocarcinoma is an infrequently encountered entity with only a handful of cases reported till date. The possibilities in such a case are either a malignant transformation of a benign teratoma into adenocarcinoma or a collision tumor between a mature cystic teratoma and a mucinous tumour of either a primary ovarian surface epithelial-stromal origin or a secondary from a primary gastrointestinal tract tumour. The importance of distinguishing between the two entities has significant bearing on subsequent therapeutic management. We report a rare case of a mature cystic teratoma co-existing with a mucinous cystadenocarcinoma in the same ovary in a 44-year-old lady. Contrast Enhanced Computed Tomography (CECT) imaging of the left ovarian mass was suggestive of a teratoma but an intra-operative frozen section examination was reported as an adenocarcinoma with a cystic teratoma. Gross examination of the surgical specimen revealed a dermoid cyst with another multi-septated cystic lesion containing mucoid material. Histopathological examination showed a mature cystic teratoma and an associated well differentiated mucinous cystadenocarcinoma. The latter displayed a CK7-ve/CK20+ve immunoprofile. In absence of clinical, biochemical or radiological findings of a primary lower gastrointestinal tract tumour, the immunoprofile suggested the possibility of adenocarcinomatous transformation in a benign teratoma.

Atypical Pityriasis Rosea with Unilateral Presentation

Hoda Badakhsh, Fahameh Fadaei, Mahin Badakhsh, Abbas Balouchi

Pityriasis Rosea (PR) is a common skin disease and characterized by generalized scaly eruptions typically on the trunk and proximal extremities. Atypical presentations of PR are common and can be a diagnostic challenge for clinicians. Here we present a case of a 26-year-old female who presented with a sudden onset of several asymptomatic, erythematous and scaly plaques on her trunk. Plaques sized 0.5-1cm in diameter that were distributed unilaterally (right side) on her chest, back and axilla. Atypical cases of PR are fairly common and less readily recognized. Careful history, clinical evaluation and follow-up are important to avoid misdiagnosis of PR and physicians should be aware of PR variants so that appropriate management and reassurance can be offered. For atypical eruptions without a definite diagnosis, it is safer to consider lesional skin biopsy.

Functional Outcome of Conservatively Treated Bilateral Neck of Femur Fracture in an Elderly: A Case Report

Prateek Sunil Joshi

Bilateral Neck of Femur (NOF) fractures is relatively rare. Surgery, either osteosynthesis or hemireplacement arthroplasty, is the mainstay of treatment. Significant complications are known to occur in such cases. In this case report, we present the functional outcome of a conservatively treated bilateral NOF fracture at one year, in a 93-year-old man. Our patient, a 93-year-old gentleman, sustained right side NOF fracture in May 2014 and left side NOF fracture in May 2015, both after trivial fall. He did not give consent for surgery considering high operative risk. Now, at one year follow-up he has no true or apparent limb length discrepancy. He is ambulant with walker, self reliant for toilet care and other personal needs. Harris hip score is 75.80 and 69.65 after 1 year from right and left NOF fracture respectively. In view of high mortality after surgery for NOF fracture in high risk patients or unavailability of resources, conservative treatment for bilateral NOF fracture can achieve satisfactory functional outcome in selected patients.

Boron Neutron Capture Therapy - A Literature Review

Boron Neutron Capture Therapy (BNCT) is a radiation science which is emerging as a hopeful tool in treating cancer, by selectively concentrating boron compounds in tumour cells and then subjecting the tumour cells to epithermal neutron beam radiation. BNCT bestows upon the nuclear reaction that occurs when Boron-10, a stable isotope, is irradiated with low-energy thermal neutrons to yield a particles (Helium-4) and recoiling lithium-7 nuclei. A large number of 10 Boron (10B) atoms have to be localized on or within neoplastic cells for BNCT to be effective, and an adequate number of thermal neutrons have to be absorbed by the 10B atoms to maintain a lethal 10B (n, a) lithium-7 reaction. The most exclusive property of BNCT is that it can deposit an immense dose gradient between the tumour cells and normal cells. BNCT integrates the fundamental focusing perception of chemotherapy and the gross anatomical localization proposition of traditional radiotherapy.

Fracture Supracondylar Humerus: A Review

Vineet Kumar, Ajai Singh

Fracture supracondylar humerus is one of the most common fractures encountered in pediatric age group at all levels (both rural and urban). Thus it needs a special review in its management protocol as per the changing trend. Modified Gartland classification is the most accepted classification and has its importance in decision making regarding management and prognosis. Neurovascular complications are mostly associated with Type III A, III B and Type IV variety and they most of the time need surgical intervention for stabilization, exploration of brachial artery, sometimes median nerve exploration and reduction of fracture. Cubitus varus is the most common associated deformity associated with this fracture (especially in Type III A). The aim of the review was to develop an insight for the understanding of variations in presentation and management of supracondylar fracture of the humerus (both simplicity and complexity) and the flowing trend in addition to the recent advances to deal with this particular pediatric orthopaedic entity which often presents as an emergency.

An Ulcerated Giant Malignant Phyllodes Tumour Presenting in Septic Shock

Angiographic Characteristics of a Cardiac Tumor: ‘Yo Yo Ball in the Heart’

Multilocular Mesothelial Cyst of the Spleen Mimicking Hydatid Cyst on Imaging

Asmita Parihar, Usha Rani Singh, Vineeta Rathi, Vivek Agrawal

65-year-old Lady with Right Sided Chest Pain-Interesting Radiology

An Uncommon Cause of Posterior Leg Pain– Ultrasound Image of Plantaris Tendinopathy

Chen-Yu Hung, Ke-Vin Chang

Ciprofloxacin Induced Antibiomania

Ramdas Sarjerao Ransing, Dipayan Sarkar

Chronic Osteomyelitis of Skull due to Pseudomonas aeruginosa: A Delayed Uncommon Complication Following Craniotomy

Cysticercosis and Japanese Encephalitis

Beuy Joob, Viroj Wiwanitkit

Ventilator-Associated Pneumonia in Paediatric Intensive Care Unit

Anirban Mandal, Amitabh Singh, Puneet Kaur Sahi, Bhavika Rishi

Correction: 2016 Oct:10(10): PC15-PC17

E MacCraith, Niall F Davis, Cliodhna Browne, David J Galvin, David M Quinlan, Gerald M Lennon, David W Mulvin, Identification and Cost of Disposable Endourological Devices for Nephrolithiasis: A Cross-Sectional Study Among Urological Trainees. (Published in Journal of Cilinical and Diagnostic Research. 2016 Oct: 10(10)): PC15-PC17 In this article, Author name was misspelled (Eoin D Mac Craith), it is now corrected (E MacCraith).

Correction: 2016 Aug:10(8): NC01-NC04

Salil Kumar Mandal, James Christian Fleming, Shilpa Gillella Reddy, Brian T. Fowler, Total Upper Eyelid Reconstruction with Modified Cutler-Beard Procedure Using Autogenous Auricular Cartilage. (Published in Journal of Cilinical and Diagnostic Research. 2016 Aug: 10(8)): NC01-NC04 In this article, acknowledgements has been added.

Correction: 2016 Nov:10(11): ZE10-ZE13

Azzam Al-Jundi, Salah Sakka, Protocol Writing in Clinical Research. (Published in Journal of Cilinical and Diagnostic Research. 2016 November: 10(11)): ZE10-ZE13 In this article, there was a typo error in surname of first author. This has been corrected by edition of an hyphen.

Correction: 2016 Sep:10(9): ZC56-ZC60

Shailaja Rao Perala, Prameela Bhupathiraju,Efficacy of Four Fluoride Mouth Rinses on Streptococcus mutans in High Caries Risk Children – A Randomized Controlled Trial. (Published in Journal of Cilinical and Diagnostic Research. 2016 September: 10(9)): ZC56-ZC60. In this article, the Table/Fig-1 which was the flowchart of the methodology, the triclosan containing and non-tricolsan containing mouthrinses were incorrectly labeled, which has now been corrected. Also in the material and methods 5th paragraph first and second line, corresponding corrections have been made.

Institutional Experience in the Management of Hilar Liver Obstruction- A Series of 13 Cases

Adithya Malolan Pathanki, Adithya V Naragund, Basant Mahadevappa

Neoplastic hilar obstruction to the liver outflow presents a unique challenge to the surgeon, wherein, the balance between a curative and possibly larger resection has to be achieved against a more conservative local resection. These are often technically demanding and have thus, far produced equivocal outcomes on both ends. The present case series is on 13 patients who presented with hilar obstruction. They all underwent resections with possible curative intent. The focus of our review is on the technical nuances and the strategies we used, intra- and peri-operatively to make resections possible in these patients, who at first look were deemed inoperable. Among the 13, 10 had hilar cholangiocarcinoma (CCA) while the others had a more benign diagnosis e.g., Hydatid disease. We did not encounter any peri-operative mortality in our series. Two of our patients had to be re-explored for intra-abdominal complications. Among the 13, we encountered two deaths. The rest of the patients are still on follow-up as of April 2016. Hilar CCA continue to be rare and challenging tumours for the Hepato Pancreato Biliary (HPB) surgeon to manage. Outlooks are currently changing as we try to resect bigger and more complicated hilar liver tumours with better results.