Journal of clinical and diagnostic research

Urinary Tuberculosis with Renal Failure: Challenges in Management

Introduction: India is the country with the highest burden of TB, an estimated incidence figure of 2.1 million cases of TB for India out of a global incidence of 9 million according to World Health Organization (WHO) statistics for 2013. Renal impairment in these patients is slow and due to continuous infection causing destruction of renal mass. Reconstruction of urinary tract which is frequently required for patients with Urinary TB poses significant challenges. This paper analyses these challenges. Aim: To analyse challenges in reconstruction of urinary tract in patients with urinary tuberculosis and renal failure. Materials and Methods: Thirty-one patients with renal tuber-culosis were seen from August 2011 to August 2013. We faced major problem in outcomes of surgery in patients with multifocal disease. Results: Out of 31 patients 18 patients were males and 13 were females. Total 11 patients had serum creatinine more than 2mg/dl (1.5 mg/dl being upper normal range of our laboratory) at the time of presentation. These patients had simultaneous kidney, ureter and bladder involvement or with bilateral disease. Four of these patients underwent uretero-calicostomy, five patients underwent augmentation cystoplasty with bilateral ureteric reimplantation and two patients underwent ileal conduit as they were having serum creatinine of more than 2.5 mg/dl. All patients who underwent ureterocalicostomy had re stricture and failure of surgery and augmentation cystoplasty had raised creatinine requiring second procedure in the form of percutaneous nephrostomy. Patients with ileal conduit remained stable with overnight bladder drainage at bed time. Conclusion: Though renal failure is not considered contrain-dication for augmentation cystoplasty, reconstruction using large segment of bowel predisposes them to metabolic complications and sepsis. Use of short segment of ileal conduit with continued drainage at night in creatinine above 2.5 mg% is reasonable option for augmentation to avoid further metabolic complications.

A Comparative Study of Pre and Post-prandial BP Recordings in Obese and Non Obese Young Adults

Anitha Sequeira, David Rosario

Introduction: Obesity is associated with varied combinations of abnormalities in the autonomic nervous system. Studies have shown that obese people who have a higher sympathetic tone have higher catecholamine levels. This can predispose to arythmogenesis and sudden death. Aim: To study pre and post-prandial BP recordings in obese and non obese young adults in the age group of 18 to 45 years. Materials and Methods: The study was conducted on 50 obese and 50 non obese patients admitted to our hospital over a period of three months. The patients are randomly selected and the BMI is calculated. Both systolic and diastolic blood pressure is measured in supine position of the right arm using digital electronic blood pressure monitor. BP recordings are taken 30 minutes before and 30 minutes after meals. Then fall in BP is recorded. Results: From this study we found that the mean systolic (pre-prandial 124.36, post-prandial 116.6) and diastolic blood pressure (pre-prandial 78.8 and post-prandial 75.4) is higher in obese than non obese patients. The study was statistically significant which was found by paired t-test (p<0.05). Conclusion: The fall in BP was significantly higher in obese (12 patients out of 50) than non obese (5 patients out of 50) patients. Probably obese patients had reduced cardiac sympathetic tone which caused post-prandial hypotension more than non obese patients.

A Case of Cervical Spine Tuberculosis in an Infant

SN Singh, Trilok C Bhatt, Savit Kumar, Vikas Chauhan, Anjali Pandey

Tuberculosis of cervical spine is an extremely rare entity in infants with only few case reports available in the literature. The diagnosis is often delayed due to less dramatic effects of paraplegia or quadriplegia in an infant as compared to older paediatric population. Along with clinical and laboratory investigations, imaging plays a crucial role in defining the extent of involvement, evaluation of complications, providing suitable differential diagnosis and monitoring response to treatment. Tuberculosis typically involves the discovertebral complex while involvement of isolated vertebral body or multiple vertebrae without involving the intervertebral discs is much less common. We present such an unusual case of cervical spine tuberculosis in an infant involving a single vertebral body without adjacent intervertebral disc involvement complicated with tuberculous meningitis (TBM) and communicating hydrocephalus. The early medical intervention in this case resulted in early diagnosis, active treatment and resultant near normal recovery.

A Cross Sectional Study on Acceptability and Safety of IUCD among Postpartum Mothers at Tertiary Care Hospital, Telangana

Sangeetha Jairaj, Sridhar Dayyala

Introduction: India is world’s 2nd largest populated country. It is first to introduce family planning services. IUCD is most effective, safe, long acting and do not interfere with coitus. Immediately or within 72 hours after delivery of placenta in a health care facility is convenient for those who are in outreach area, where family planning facilities are less available. Objectives: To study the socio demographic profile of parturients attended to obstetric ward for delivery. To assess the acceptability and safety of IUCD among study population Materials and Methods: A cross-sectional study was conducted among eligible postpartum women at Gandhi hospital secunderabad. Counseling was given about IUCD. After obtaining consent, Cu-T 380 was inserted in a 250 women, followed up to 6 weeks. The reasons for both acceptance and decline were recorded. Results: Mean age of acceptance was 23.70±2.95 years. Majority were from urban area (79.75%). Acceptance was more in those who completed their secondary school level education (23.3%). Women undergoing caesarean section were accepting PPIUCD, more frequently than those who underwent normal vaginal delivery. Majority (67.12%) accepters told that they accepted IUCD because it is a reversible method. Main reported complications were pain abdomen (17.14%), bleeding (14.28%). Expulsion rate was 6.8%. Most common reason (40%) for removal of IUCD was inclination to other methods. Conclusion: Even though expulsion rate high with, acceptance was high IUCD when it is inserted in postpartum period.

Study of Adverse Effect Profile of Parenteral Zoledronic Acid in Female Patients with Osteoporosis

Prem Kotian, Archith Boloor, Sushanth Sreenivasan

Introduction: Osteoporosis is still a under recognized entity in the population. Osteoporosis-related fractures can be prevented if people at risk can be screened, diagnosed and treated early. Bisphosphonates remain the mainstay of osteoporosis treatment as they have multimodal action. Oral bisphosphonate therapy has, significant gastrointestinal side effects leading to noncompliance. Of late parenteral Zoledronic Acid is being used as once or twice yearly infusion for the treatment of osteoporosis. Aim: Our article studies the side effect profile and tolerability of parenteral Zoledronic Acid, one of the most potent bisphosphonate used in clinical practice in patients with osteoporosis. Materials and Methods: This study was done in KMC hospitals where 49 patients diagnosed with osteoporosis were included for the study. After obtaining a written informed consent each patient received one infusion of 5 mg Zoledronic Acid as per standard treatment protocol. Patient was monitored for clinical improvement and development of any adverse effects. Conclusion: In our study all subjects reported significant pain relief after infusion of Zoledronic Acid. Zoledronic Acid had very few serious adverse effects that can be prevented through pre-infusion screening, maintaining good hydration and careful patient monitoring. In our population the patients only experienced mild symptoms of pyrexia, arthralgia myalgia and influenza like symptoms which resolved with symptomatic treatment.

Skill Learning Through Early Clinical Exposure: An Experience of Indian Medical School

Alka Rawekar, Arunita Jagzape, Tripti Srivastava, Shashank Gotarkar

Introduction: Indian Medical curriculum being discipline based, there is a line of demarcation between preclinical and clinical subjects. The challenges in medical education include the methods that would enhance the clinical education quality; one such method been Early Clinical Exposure (ECE). ECE can help to instill the skill component of medical education in the first year students helping to minimize the line of demarcation. Hence this study was undertaken to assess the skill learning of students through early clinical exposure and to collate the perception of them. Materials and Methods: In the present study, students of 1st MBBS were exposed to ECE as an adjunct teaching method with preset modules. They were evaluated by Objectively Structured Clinical Examination (OSCE). Feedback was obtained from 1st MBBS and also from the same students after passing the 1st MBBS in 4th semester. Results: Significant differences in pre and post OSCE scores were noted (p<0.0001). Seventy six percent students rated ECE as an excellent tool. Second year students also perceived ECE held in 1st year was helpful to correlate topics and increasing confidence. Conclusion: ECE had an effective influence on learning as manifested in skills gained by the students and their perceptions of ECE being helpful prospectively in their routine clinical posting.

Study of Weight Patterns in Exclusively Breast Fed Neonates- Does the Route of Delivery have an Impact?

Purnima Samayam, Pradeep Krishna Ranganathan, Ravichander Balasundaram

Introduction: Physiological weight loss is seen in all breast fed neonates. The route of delivery may have an effect on the neonatal weight loss/gain in these exclusively breast fed babies. Additional assistance and support for exclusive breast feeding is needed by mothers who undergo cesarean section. Aim: To study and compare the weight patterns in full term exclusively breast fed neonates born by normal vaginal route versus cesarean section in the first month of life. Materials and Methods: It is a prospective observational study. Healthy, full term neonates born by normal vaginal route or cesarean section in a rural tertiary hospital with uneventful perinatal periods were included. Exclusive breast feeding was given to all neonates with supervision and encouragement to the mothers. Primary outcome measure- Weight loss of the neonates at 24 hours and 72 hours of life. Results: Neonates delivered by cesarean section showed a higher weight loss (% of birth weight) at 24 hours {mean(sd)} than those delivered vaginally {3.2 (1.9) vs 2.2 (1.2); p-value=0.0016}. At 72 hours, the cesarean neonates had higher weight loss than vaginally delivered neonates {5.9 (3.1) vs 4.7 (2.5); p-value=0.0314}. At 28 days of life, the neonates born by cesarean section showed lower weight gain than those delivered by vaginal route {10.9 (2.1) vs 11.9 (2.3); p-value=0.0244}. Conclusion: The route of delivery has a significant impact on the physiological weight loss seen in exclusively breast fed neonates. Babies delivered by cesarean section showed significantly higher weight loss in the first week of life, and lower weight gain at the end of first month than babies born by vaginal route.

Tensile Bond Strength of Self Adhesive Resin Cement After Various Surface Treatment of Enamel

Sahil Sekhri, Sanjeev Mittal, Sandeep Garg

Introduction: In self adhesive resin cements adhesion is achieved to dental surface without surface pre-treatment, and requires only single step application. This makes the luting procedure less technique-sensitive and decreases postoperative sensitivity. Aim: The purpose of this study was to evaluate bond strength of self adhesive resin after surface treatment of enamel for bonding base metal alloy. Materials and Methods: On the labial surface of 64 central incisor rectangular base metal block of dimension 6 mm length, 5mm width and 1 mm height was cemented with RelyX U200 and Maxcem Elite self adhesive cements with and without surface treatment of enamel. Surface treatment of enamel was application of etchant, one step bonding agent and both. Tensile bond strength of specimen was measured with universal testing machine at a cross head speed of 1mm/min. Results: Least tensile bond strength (MPa) was in control group i.e. 1.33 (0.32) & 1.59 (0.299), Highest bond strength observed when enamel treated with both etchant and bonding agent i.e. 2.72 (0.43) & 2.97 (0.19) for Relyx U200 and Elite cement. When alone etchant and bonding agent were applied alone bond strength is 2.19 (0.18) & 2.24 (0.47) for Relyx U200, and 2.38 (0.27) 2.49 (0.16) for Max-cem elite. Mean bond strength was higher in case of Max-cem Elite as compared to RelyX U200 resin cement, although differences were non–significant (p > 0.05). Conclusion: Surface treatment of enamel increases the bond strength of self adhesive resin cement.

Multimodal versus Conventional Approach for Postoperative Pain Relief in Oral Cancer Patients

Introduction: Multimodal analgesia includes regional anaesthesia in the form of nerve block may improve recovery along with optimal rehabilitation and early resumption of day-to-day activity following major surgery. Conventional general anaesthesia consists of premedication, induction, intubation and maintenance. Aim: The aim of the study is to compare the multimodal versus conventional approach in oral cancer surgery. Materials and Methods: The patients were randomly allocated into three groups, 30 patients in each group using the computer generated random table to one of the following groups: Group A: Fentanyl 1 µg/kg, Group B: Fentanyl 1 µg/kg + bupivacaine local infiltration, Group C: Fentanyl 1 µg/kg + bupivacaine local infiltration + Dexemedetomidine infusion (Loading 0.5 µg/kg, Maintenance 0.2µg/kg/hr). Results: No significant (p>0.05) difference was found in mean arterial pressure and heart rate at different time intervals among the groups. The VAS was lower in Group C than Group B and A. The ramsay sedation scale was higher in Group C than Group B and A. The rescue analgesic for 24 hour was lower in Group C than Group B and A. The time of first time analgesia requirement was significantly (p=0.001) higher in Group C than Group B and A. The rescue analgesic was significantly (p=0.001) lower in Group C (39.29±19.67) than Group B (68.33±18.49) and A (160.83±35.16). Conclusion: Multimodal analgesia has beneficial haemodynamic effects during oral cancer surgery with reliable postoperative analgesia and sedation and less postoperative complication. Dose of drugs used in our study is not associated with any major adverse effect.

Computed Tomographic Evaluation of K3 Rotary and Stainless Steel K File Instrumentation in Primary Teeth

Introduction: The intention of root canal preparation is to reduce infected content and create a root canal shape allowing for a well condensed root filling. Therefore, it is not necessary to remove excessive dentine for successful root canal preparation and concern must be taken not to over instrument as perforations can occur in the thin dentinal walls of primary molars. Aim: This study was done to evaluate the time preparation, the risk of lateral perforation and dentine removal of the stainless steel K file and K3 rotary instrumentation in primary teeth. Materials and Methods: Seventy-five primary molars were selected and divided into three groups. Using spiral computed tomography the teeth were scanned before instrumentation. Teeth were prepared using a stainless steel K file for manual technique. All the canals were prepared up to file size 35. In K3 rotary files (.02 taper) instrumentation was done up to 35 size file. In K3 rotary files (.04 taper) the instrumentation was done up to 25 size file and simultaneously the instrumentation time was recorded. The instrumented teeth were once again scanned and the images were compared with the images of the uninstrumented canals. Statistical Analysis: Data was statistically analysed using Kruskal Wallis One-way ANOVA, Mann-Whitney U-Test and Pearson’s Chi-square Test. Results: K3 rotary files (.02 taper) removed a significantly less amount of dentine, required less instrumentation time than a stainless steel K file. Conclusion: K3 files (.02 taper) generated less dentine removal than the stainless steel K file and K3 files (.04 taper). K3 rotary files (.02 taper) were more effective for root canal instrumentation in primary teeth.

Impact of Coagulation Profile on Outcome of Head Injury

Gulzar Gupta, Chetan Wadhwa, Rajveer Garg, Ranbir S Dhaiya, Rakesh K Kaushal

Introduction: Worldwide, head injury is recognized as a major public health problem. Head injury patients often develop consumptive coagulopathy in the absence of other trauma or haemorrhages. The release of tissue factor from the damaged brain is postulated as the cause of coagulopathy. Aim: To know the impact of coagulation profile derangements and their effect on the outcome of head injury patients. Materials and Methods: Fifty patients in the age group of 20-70 years admitted with isolated head injury were taken. Samples of complete haemogram (CBC), prothrombin time (PTI), partial thromboplastin time (PTK), D-Dimers and fibrinogen were taken within 24 hour of admission. Coagulopathy was defined as platelet counts < 100,000 cells/mm2 and PTI >15 seconds or a DIC score more than 4. The outcome in each group was measured according to Glasgow outcome score. Coagulation abnormalities were analysed. Results: In case of severe head injury, p-values in patients who died with regard to DIC score, Prothrombin time and APTT were found to be significant (p< 0.05). For D-Dimers, fibrinogen and platelets counts the p-value was not significant. In case of moderate head injury, p-values in patients who died with regard to DIC score, platelet count, Prothrombin time, D-Dimer and APTT were found to be significant (0.05). For fibrinogen level it was insignificant. The mean DIC score and mean GOS in the severe head injury patients was significant (p<0.001). Conclusion: Patients with isolated head injury are at risk of development of coagulation abnormalities, which is associated with poor outcome. Based on our results we also emphasize the importance of early diagnosis of coagulation abnormalities in isolated head injury patients.

Evaluation of Serum Pregnancy Associated Plasma Protein-A & Plasma D-Dimer in Acute Coronary Syndrome

Gautam Nichenametla, Vivian Samuel Thomas

Introduction: Acute coronary syndrome (ACS), a spectrum comprising unstable angina pectoris, ST Elevated Myocardial Infarction (STEMI) & Non ST Elevated Myocardial Infarction (NSTEMI) is the major cause of presentation in Emergency Department today. Though ECG and cardiac enzymes are used for diagnosis, they mislead the diagnosis sometimes and delay in treatment initiation. This leads us to search certain new parameters which reflect the pathophysiology of ACS. Markers of plaque stability like Pregnancy Associated Plasma Protein-A and D-Dimer, a marker of ongoing thrombosis are found to be better markers in early diagnosis. Aim: To evaluate the diagnostic competence of PAPP-A and D-Dimer in acute coronary syndrome over CK-MB and to compare with the inflammatory marker High Sensitive C-Reactive Protein (hs-CRP) which is associated with atherosclerosis. Materials and Methods: Fifty patients presenting with acute onset of chest pain to Emergency Department with or without ECG changes served as cases and 50 healthy people served as controls. Serum PAPP-A is measured by Enzyme Linked Immunosorbent Assay (ELISA), D-Dimer and hs-CRP by using Latex Turbidimetry method. R esults: A statistical significant difference of PAPP-A and D-Dimer was noted between the ACS and controls (p < 0.001) whereas CK-MB shows no much difference (p 0.09). Statistically significant positive correlation is noted between parameters. Conclusion: PAPP-A marker of plaque instability and D-Dimer marker of ongoing thrombosis are raised in acute coronary syndrome and thus can be considered as one of the marker in ACS for diagnosis.

Evaluation of Cardiopulmonary Resuscitation (CPR) for Patient Outcomes and their Predictors

Introduction: Cardiac arrest continues to be a common cause of in-hospital deaths. Even small improvements in survival can translate into thousands of lives saved every year. Aim: The aim of our prospective observational study was to elicit the outcomes and predictors of in-hospital cardiopulmonary resuscitation among adult patients. Settings and Design: All in-hospital adult patients (age >14) who suffered cardiac arrest & were attended by a Code Blue Team between 1st January 2012 & 30th April 2013 were part of the study. Materials and Methods: The cardiopulmonary resuscitation (CPR) was assessed in terms of: Response time, Presenting initial rhythm, Time to first defibrillation, Duration of CPR and Outcome (Return of spontaneous circulation (ROSC), Glasgow outcome scale (GOS) at discharge). S tatistical Analysis: Age, GOS and mean response time were analysed using t-test and ANOVA. Logistic regression was applied to determine the significance of the various factors in determining mortality. Results: ROSC was achieved in 44% of a total of 127 patients included in our study. Asystole/Pulseless electrical activity (PEA) was the most common presenting rhythm (87.5%). The survival to discharge was seen in 7.1% patients of whom only 3.9% patients had good neurological outcome. Regression and survival analysis depicted achievement of ROSC during CPR, absence of co-morbidities and shorter response time of code blue team as predictors of good outcome. Conclusion: We found poor outcome of CPR after in-hospital cardiac arrest. This was mainly attributed to an initial presenting rhythm of Asystole/PEA in most cases and delayed response times.

A Prospective Study on Functional Outcome of Internal Fixation of Tibial Pilon Fractures with Locking Plate using Minimally Invasive Plate Osteosynthesis Technique

Introduction: Managing pilon fractures is still a great challenge for surgeons in terms of reduction and fixation. The soft tissue anatomy and the bony configuration, results in angular and rotational instability and other bony and soft tissue complications. Aim: To evaluate the results of minimally invasive plate osteosynthesis using locking plates in management of fractures of tibial pilon in terms of radiological fracture union, restoration of ankle function and complications. Materials and Methods: A total of 18 patients with Ruedi Allgower class I,II& III fresh pilon fractures were taken into this study. All the patients underwent ankle spanning external fixator application on the day of presentation as a first stage. Wound debridement was done in patients with open fractures. Associated distal fibula fractures were fixed in the first stage. The second stage comprised of a definitive plate fixation using the minimally invasive plate osteosynthesis technique. This employed minimal periosteal and soft tissue dissection through a medial approach to the ankle. Postoperatively, all patients were reviewed at week six and 12 when partial weight bearing and full weight bearing mobilization was started respectively. The final review was done at 24 weeks when the final assessment of function was done as per the Mazur’s scoring criteria. Analyses were done using frequency and proportions. Chi-square tests were used to assess the test of association. Results: Three patients had excellent inference, nine patients had good inference, five patients had fair and one patient had poor inference as per the Mazur’s scoring criteria. Two patients had scar dehiscence as a complication and one patient had a fixed equines deformity of the ankle who was under RuediAllgower class III. Conclusion: Minimally invasive plate osteosynthesis is an excellent method of treating pilon fractures with very good functional results and minimal complication rate.

A Hospital Based Study Regarding Awareness of Association Between Glycosylated Haemoglobin and Severity of Diabetic Retinopathy in Type 2 Diabetic Individuals

Mridula Prabhu, Anupama Kakhandaki, K.R. Pravin Chandra, M.B. Dinesh

Introduction: Diabetic retinopathy is one of the most common microvascular complications seen in diabetic patients after a long term of uncontrolled glycaemic status as assessed by glycosylated Haemoglobin A (HbA1c). Hence awareness of glycaemic control is necessary to prevent vision threatening complications. Aim: To assess the awareness regarding association between glycosylated Haemoglobin (HbA1c) and diabetic retinopathy among diabetic patients and to assess the impact of lack of this knowledge on the severity of diabetic retinopathy (DR). Materials and Methods: This hospital based cross-sectional study was conducted in the ophthalmology OPD on 200 adult diabetic patients, between November 2012 and January 2013, who were assessed for their knowledge regarding association between HbA1c and its impact on the progress of DR. The study was done with the help of a semi structured questionnaire which included demographic details, literacy levels, diabetic status and awareness of HbA1c. Statistics Used: Cochran Armitage test for trend, Fisher Exact test, chi-square for trend and Student’s t test. R esults: Among the 200 diabetic individuals attending our OPD, 180 (90%) were aware of the importance of blood sugar levels and its fluctuation in type 2 diabetes. Only 23 (11.5%) were aware of HbA1c whereas 10 (5%) misinterpreted it as levels of haemoglobin, 3 (1.5%) did not completely comprehend. About 164 (82%) patients were not aware of the significance or the terminology of HbA1c. Out of the 200 patients, 58 patients showed presence of some grade of DR. Amongst these 58 patients, 7(12.1%) were aware of HbA1c and all the11 patients with clinically significant macular oedema (CSME) were aware of the risk factors of elevated blood sugar levels but ignorant of HbA1c. Among the remaining 142 individuals who showed no signs of DR, 16 (27.5%) were aware of and comprehended the role of HbA1c. Conclusion: Our study highlights the gross ignorance of role of HbA1c in the progress of DR among diabetic individuals. It is a known fact that the risk of DR reduces by 35% for every 1% reduction in HbA1c. Hence a strict control of blood sugar level with regular monitoring of HbA1c can help diabetic individuals in prevention of progress of DR, thus preventing severe vision loss.

Can MMP-9 be a Prognosticator Marker for Oral Squamous Cell Carcinoma?

Betina Chandolia, Shiva Kumar Basu, Manish Kumar

Introduction: Invasion and metastasis of malignant tumours severely endanger the life of cancer patients. Squamous cell carcinoma is one of the commonly found malignancies in the oral cavity and its survival rate has not improved from past few decades. Since an important risk factor for oral squamous cell carcinoma is the presence of epithelial dysplasia, it is necessary to check the presence of a prognosticator marker in both of them. As matrix metalloproteinase’s (MMP’s) are involved in degradation of type IV collagen, which are one of the important components of extracellular matrix components which play a relevant role in several steps of tumour progression such as invasion and metastasis. We have studied MMP-9 expression to evaluate its prognostic potential in oral cancers as well as oral epithelial dysplasia along with tissues of normal oral epithelium. Materials and Methods: The expression was examined using immunohistochemistry procedure with MMP-9 in 100 samples including cases of epithelium from normal oral mucosa, oral dysplastic lesions and oral squamous cell carcinoma. One set of formalin fixed, paraffin embedded sections of the three categories were stained by haematoxylin and eosin. The sections were then evaluated under microscope. Data was examined for statistical significance using SPSS 13.0 by Mann-Whitney Test and Kruskal-Wallis Test. Results: With MMP-9 gain of expression was noted from Control group to oral squamous cell carcinoma. Cytoplasmic staining was seen with MMP-9. Statistically highly significant differences were seen between oral epithelial dysplasia and oral squamous cell carcinoma and statistically significant differences were found between the control group and the oral squamous cell carcinoma group. Conclusion: This study suggested that oral squamous cell carcinoma shows higher MMP-9 expression as compared to oral epithelial dysplasia followed by epithelium from normal oral mucosa. However, no correlation was found among the histological grades of oral squamous cell carcinoma.

Effectiveness of Stellate Ganglion Block Under Fuoroscopy or Ultrasound Guidance in Upper Extremity CRPS

Introduction: Stellate Ganglion Block (SGB) is an effective technique which may be used to manage upper extremities pain due to Chronic Regional Pain Syndrome (CRPS), in this study we tried to evaluate the effectiveness of this procedure under two different guidance for management of this syndrome. Aim: The purpose of this study was to evaluate the effectiveness of ultrsound guide SGB by comparing it with the furoscopy guided SGB in upper extermities CRPS patients in reducing pain & dysfuction of the affected link. Materials and Methods: Fourteen patients with sympathetic CRPS in upper extremities in a randomized method with block randomization divided in two equal groups (with ultrasound or fluoroscopic guidance). First group was blocked under fluoroscopic guidance and second group blocked under ultrasound guidance. After correct positioning of the needle, a mixture of 5 ml bupivacaine 0.25% and 1 mL of triamcinolone was injected. Results: These data represent no meaningful statistical difference between the two groups in terms of the number of pain attacks before the blocks, a borderline correlation between two groups one week and one month after the block and a significant statistical correlation between two groups three month after the block. These data represent no meaningful statistical difference between the patients of any group in terms of the pain intensity (from one week to six months after block), p-value = 0.61. These data represent a meaningful statistical difference among patients of any group and between the two groups in terms of the pain intensity (before the block until six months after block), p-values were 0.001, 0.031 respectively. Conclusion: According the above mentioned data, in comparison with fluoroscopic guidance, stellate ganglion block under ultrasound guidance is a safe and effective method with lower complication and better improvement in patient’s disability indexes.

Can Panton Valentine Leukocidin Gene And Clindamycin Susceptibility Serve As Predictors of Community Origin of MRSA From Skin and Soft Tissue Infections?

Introduction: Community associated Methicillin-resistant Staphylococcus aureus (CA-MRSA) strains have begun to replace Hospital Associated MRSA (HA-MRSA) strains in hospital settings all over the world. With the epidemiological distinctions between these strains beginning to become ill-defined, the categorisation of a strain as CA-MRSA or HA-MRSA is dependent on molecular methods to detect the presence of SCCmec (Staphylococcal Cassette Chromosome mec) elements. However other markers like the presence of Panton Valentine Leukocidin toxin (pvl) genes or Clindamycin susceptibility may also be associated with community origin of MRSA. Aim: To determine the prevalence of CA-MRSA among MRSA strains isolated from skin and soft tissue infections and to evaluate the usefulness of Panton Valentine Leukocidin and Clindamycin susceptibility as markers of community origin of MRSA. Materials and Methods: One hundred isolates of MRSA from skin and soft tissue were studied for the presence of SCCmec IV and V genes and Panton valentine leukocidin gene by Polymerase chain reaction. Inducible clindamycin resistance was screened for using the D-test. S tatistical analysis used: Fischer’s exact test. A p-value <0.05 was considered significant Results: Eighteen out of 100 MRSA strains were found to be CA-MRSA based on presence of SCCmecV. The proportion of Panton Valentine Leukocidin gene carriage among CA- MRSA as compared to HA-MRSA was found to be statistically significant (p<0.0001). Among the CA-MRSA strains, 94.4% were found to be susceptible to Clindamycin as against only 13.4% of the HA-MRSA strains (p<0.0001). The odds of an MRSA strain being CA-MRSA if it was both Clindamycin susceptible and PVL gene positive was calculated to be 68.25 (p<0.0001). Conclusion: Both Clindamycin susceptibility and pvl gene carriage were found to be independent predictors of community origin of MRSA, but taken together the association was highly significant.

Normal Motor and Sensory Nerve Conduction Velocity of Radial Nerve in Young Adult Medical Students

Sunil Chouhan

Introduction: Normal nerve conduction velocity of radial nerve is essential for differential diagnosis of various type of radial neuropathies, C7 radiculopathy and nerve lesion. Aim: To study normal motor and sensory nerve conduction velocity of radial nerve in young adult medical students. Materials and Methods: Fifty medical students of either sex from first year, aged between 17- 20 year, were recruited for this nerve conduction study of radial nerve using surface electrode. Motor Nerve Conduction Velocity (MNCV) and Sensory Nerve Conduction Velocity (SNCV) of radial nerve of both hand were taken out and analysed for statistical significance and standard deviation. Results: The mean Motor Latency (ML) in right and left hand were 8.11 msec and 8.01msec respectively, Amplitude (A) 9.08mv and 8.65mv respectively and MNCV was 66.81m/sec and 67.05m/sec respectively. The SNCV were 51.41 m/sec and 51.48m/sec in the right and left hand respectively. Conclusion: The normative value of motor and sensory NCV of radial nerve in male and female young medical students were established. The data were within the favourable range as compared with the existing data from other researchers for radial nerve. There were no difference statistically found in the radial nerve motor and sensory NCV of right and left hand of either sex.

Determination of Prevalence of Type 2 Diabetes Mellitus by Screening Tests using a Mathematical Formula in Place of Invasive Blood Tests

Neeru Gupta, Jugal Kishore, Prakash Chandra Ray, Charu Kohli, Neeta Kumar

Introduction: True prevalence rate of diabetes mellitus in a population can be obtained by using invasive tests but it is practically difficult on large scale. Aim: To find out the feasibility of mass non-invasive screening test to detect the prevalence of diabetes mellitus in rural population of India with the help of a mathematical formula. Materials and Methods: From population of 18800 residing in two adjacent rural areas of Delhi, a systematic random sample of 1005 adult subjects was screened for diabetes by using urine benedicts test, Canrisk questionnaire, Madras Diabetes Research Foundation-Indian Diabetic Risk Score (MDRF-IDRS) and determined prevalence of diabetes (pA) gauzed by each of these screening tests. Simultaneously, each subject’s glycaemic status was confirmed by standard fasting Plasma glucose (FPG) and postprandial plasma glucose (PPPG) levels. The blood test was also used to determine true prevalence which was cross-checked with the prevalence estimated (Pe) by the above stated screening tests using a mathematical formula. Results: The true prevalence of T2DM in more than 18 years of population by Fasting Plasma Sugar (FPS) was 4.5% while that by using mathematical formulae that estimated by urine test, Canrisk test and MDRF-IDRS was 4.4%, 4.4 and 4.3% respectively. When more than 35 years age-group was selected, true prevalence was 7.4% and estimated prevalence by Canrisk test was 7.1% (as against gold standard of Fasting) and 6.9% (as against PP). By fasting urine test it came out to be 7.2% and by PP urine test it was 7.4%. In population l8-35 years, the prevalence of diabetes was 1.1% by plasma glucose test. By using Canrisk, it came out to be 1.04%. Conclusion: Individual screening tests such as urine, Canrisk and MDRF-IDRS can be used to estimate prevalence rates of diabetes in rural areas by means of mathematical formula which would be close to true estimates.

Inguinal Lymph Nodes in Carcinoma Penis-Observation or Surgery?

Introduction: In Indian sub-continent the presentation of carcinoma penis is variable. Mostly presents with palpable inguinal lymph nodes but not confirm of metastases. Aim: To evaluate whether all clinically positive nodes are metastatic and decide when to address inguinal lymph node. Materials and Methods: A retrospective observational study on carcinoma penis from a regional cancer centre of south India over a period from 2001 to 2012. All the clinical, investigational, operative, pathology details and follow-up data were collected from patient records. Results: Two hundred and thirty cases of carcinoma penis have been identified and 112 cases had clinically positive nodes. In 74 cases fine needle cytology was positive for malignancy and they have been addressed with block dissection with surgery of primary lesion. At two years follow up, 70 patients were identified with inguinal lymph node metastasis and block dissection was performed and all was were positive for malignancy on histology. The rate of recurrence is related to the T stage of the primary tumour. Conclusion: It can be concluded that elective surgery is appropriate for palpable inguinal lymph nodes and prophylactic nodal dissection in high risk cases of carcinoma penis.

Enhancing Phenotypic Detection of ESBL in AmpC co-producers by using Cefepime and Tazobactam

Jaspal Kaur, Gomty Mahajan, Kailash Chand, Sheevani, Shashi Chopra

Introduction: Routine phenotypic methods employing clavulanate and third generation cephalosporins to detect ESBL are not promising for isolates that co-produce an inhibitor-resistant beta lactamase like AmpC. Aim: Enhancing phenotypic detection of ESBL in AmpC co-producers by using cefepime and tazobactam. Materials and Methods: A total of 245 isolates of Escherichia coli (123), Klebsiella spp. (87), Proteus spp.(20), Enterobacter spp. (9) and Citrobacter spp.(6) obtained over a period of 2 years from January 2013 to December 2014 from urine samples of hospitalized patients were studied. The isolates were simultaneously screened for ESBL and AmpC production. AmpC production was confirmed by modified three –dimensional test (MTDT). ESBL production was confirmed by original double disc synergy test, phenotypic disc confirmatory test (PDCT) and modified double disc synergy test (MDDST) and the results compared. Results: AmpC production was confirmed in 113 (46.1%) isolates by modified three dimensional test out of 143 screened positive for AmpC. Of the 192 isolates screened positive for ESBL, ESBL production was confirmed in 162 (66.1%). DDST detected ESBLs in only134 (54.7%) while additional 28 (11.4%) ESBL positive isolates were detected by MDDST. PDCT detected total 145(59.2%) ESBL positive isolates, with cefotaxime and cefotaxime + clavulanate detecting 139 (56.7%) and ceftazidime and ceftazidime + clavulanate detecting additional 6 isolates. All the 28 (11.4%) isolates which were additionally detected ESBL producers by MDDST showed positive three dimensional test i.e. AmpC co producers. DDST detected ESBL in none of AmpC positive isolates while PDCT detected ESBL in 11 isolates showing AmpC co-production. In MDDST cefepime was the best cephalosporin in detecting ESBL in presence of AmpC production. It showed synergism with amoxicillin-clavulanate in 11(39.3%) isolates and in 24(85.7%) isolates with piperacillin–tazobactam. Third generation cephalosporins -cefotaxime, ceftazidime and cefpodoxime were not able to detect ESBL in AmpC-co producers. Conclusion: Modification of double disc synergy tests that combine piperacillin-tazobactum with cefepime enhances the possibility of ESBL detection.

Comparison of the Root End Sealing Ability of Four Different Retrograde Filling Materials in Teeth with Root Apices Resected at Different Angles – An Invitro Study

Introduction: Insufficient apical seal is the significant reason for surgical endodontic disappointment. The root-end filling material utilized should avoid egress of potential contaminants into periapical tissue. Aim: The aim of this study was to compare the sealing ability of four root-end filling materials MTA, Portland cement, IRM, RMGIC in teeth with root apices resected at 0 and 45 angle using dye penetration method under fluorescent microscope. Materials and Methods: Hundred extracted human maxillary anterior teeth were sectioned horizontally at the cement-enamel junction. After cleaning, shaping and obturation with gutta-percha and AH Plus sealer, the tooth samples were randomly divided in two groups (the root apices resected at 0º and 45º to the long axis of the root). The root resections were carried out by removing 2 mm and 1 mm in both the groups. Following which 3 mm deep root-end cavities were prepared at the apices and the root were coated with nail varnish except the tip. The teeth in both the group were randomly divided into four subgroups each (Pro root MTA, Portland cement, IRM and Light cure nano GIC Ketac N-100). All the retrofilled samples were stored in acrydine orange for 24 hours after which they were cleaned and vertically sectioned buccolingually. The sectioned root samples were observed under fluorescent microscope. Results: The root apex sealing ability of Mineral Trioxide Aggregate (MTA) was superior to Portland cement, Intermediate Restorative Material (IRM) and LC GIC. IRM demonstrated the maximum apical leakage value among all the materials. Portland cement and LC GIC showed comparable sealing ability. Conclusion: The angulation whether 0° or 45° angle did not affect the sealing ability of all the four materials used, MTA proved to be one of the superior materials for root-end filling.

Volume Conductivity and Scatter Parameters as an Indicator of Acute Bacterial Infections by the Automated Haematology Analyser

Introduction: Complete blood picture is the first and foremost investigation ordered for evaluation of acute infectious processes which require early and prompt intervention. With the advent of automated Coulter ® Haematology analysers, the Volume, Conductivity & Scatter parameters of the leucocytes could be analysed for the early detection of the infections. Aim: To evaluate the clinical usefulness of Volume, Conductivity & Scatter parameters of neutrophils & monocytes in predicting the onset of acute bacterial infections. Materials and Methods: Peripheral blood samples from 94 patients with infections (systemic infections n=36 & localised infections n=58) and 46 control subjects were studied using the Volume, Conductivity & Scatter parameters by the Coulter Haematology analyser. Results: We observed a significant increase in the mean channel of neutrophil volume & mean channel of monocyte volume from patients with infections (both systemic & localised) as compared with control subjects (Mean Neutrophil Volume: 158.3 ± 13.7 vs 137.2 ± 4.3; p<0.001) & (Mean Monocyte Volume: 177.8± 16 vs 161.7 ± 6.04; p <0.001). However, there was no significant difference in the Mean Neutrophil Volume of patients with systemic infection &localised infections (160.5±17.5 vs 156.8±10.5, p>0.05). Conclusion: The Volume, Conductivity & Scatter parameters like Mean Neutrophil Volume & Mean Monocyte Volume are more sensitive parameters and could prove to be a quick diagnostic indicator of acute bacterial infections.

Application of WHO ‘Near-Miss’ Tool Indicates Good Quality of Maternal Care in Rural Healthcare Setting in Uttarakhand, Northern India

Introduction: Women who experienced and survived a severe health condition during pregnancy, childbirth or postpartum are considered as ‘near-miss’ or severe acute maternal morbidity (SAMM) cases. Women who survive life-threatening conditions arising from complications related to pregnancy and childbirth have many common aspects with those who die of such complications. Aim: To evaluate health-care facility preparedness and perfor-mance in reducing severe maternal out comes at all levels of health care. Materials and Methods: The present study was carried out over a period of 12 months under the Department of Community Medicine. The cross-sectional study included all the women (937) attending health-care facilities, at all levels of health care i.e. Primary, Secondary & Tertiary level in Doiwala block of Dehradun district. This study was conducted as per the WHO criteria for ‘near-miss’ by using probability sampling for random selection of health facilities. All eligible study subjects visiting health-care facilities during the study period were included, i.e. who were pregnant, in labour, or who had delivered or aborted up to 42 days ago. Results: It was found that all women delivering at the THC received oxytocin to prevent postpartum haemorrhage. Treatment of severe post-partum haemorrhage by removal of retained products was significantly associated with levels of health care. Majority (94.73%) women who had eclampsia received magnesium sulfate as primary treatment. Conclusion: Application of WHO ‘near-miss’ tool indicates good quality of maternal care in rural healthcare setting in Uttarakhand, North India. The women would have otherwise died due to obstetrics complications, had proper care not been provided to them in time.

Antecedent Drug Exposure Aetiology and Management Protocols in Steven-Johnson Syndrome and Toxic Epidermal Necrolysis, A Hospital Based Prospective Study

Samina Farhat, Muddasir Banday, Iffat Hassan

Aim: The study sought to identify the magnitude and characteristic of severe cutaneous adverse reactions (SCAR’s) like Steven–Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN). Materials and Methods: A prospective study was conducted by the Department of Pharmacology in association with Department of Dermatology in SMHS hospital. The study was carried out from June 2013-June 2015 on hospitalized cases of cutaneous adverse drug reaction reporting in hospital. The SCAR’s were reported in a structured questionnaire based on adverse drug reaction (ADR) reporting form provided by the Central Drug Standard Control Organization (CDSCO) Ministry of Health and Family welfare, Government of India. The SCAR’s were analysed for their characteristics, causality, severity and prognosis. Causality assessment was done by using a validated ADR probability scale of Naranjo as well as WHO Uppsala Monitoring Center (WHO-UMC) system for standardized case causality assessment. The management protocol were analysed for their clinical outcome through a proper follow up period. Results: A total of 52 hospitalized cases of cutaneous adverse drug reactions were reported during the study period. We identified a total of 15 cases (28%) of SCAR’s involving 9(17%) of SJS and 6 (12%) of TEN. SJS was seen in 2(22%) males and 7(78%) females. TEN was seen in all females (100%) and in no male. Drugs implicated in causing these life threatening reactions were identified as anticonvulsant agents like carbamazepine (CBZ), phenytoin (PHT) and Lamotrigine (LTG), oxicam NSAID, Sulfasalazine and levofloxacin. Despite higher reported mortality rates in SJS and TEN all patients survived with 2 patients surviving TEN suffered from long term opthalmological sequelae of the disease. Conclusion: Present study suggest that drug induced cutaneous eruptions are common ranging from common nuisance rashes to rare life threatening diseases like SJS and TEN, SJS/TEN typically occur 1-3 weeks after initiation of therapy. Aromatic AED’s, LTG, oxicam NSAID’s, sulfasalazine and levofloxacin have a tremendous potential to trigger SCARS’s. To ensure safe use of pharmaceutical agents and better treatment outcomes post marketing voluntary reporting of severe rare and unusual reactions remains inevitable.

Osteosynthesis in Distal Radius Fractures with Conventional Bridging External Fixator; Tips and Tricks for Getting Them Right

Background: Distal radius fractures are the commonest fractures occurring in the upper extremity, accounting for 15-20% of patients treated in emergency department. Although distal radial fractures were described 200 years ago, they still remain as unsolved fractures with no clear guidelines. It is often reported that anatomical reduction has a bearing on the functional outcome. Aim: To study the management of distal end radius fracture by utilizing the principle of ligamentotaxis where in the reduction obtained by closed means is maintained by external fixator till solid bony union occurs. Materials and Methods: A total of 26 cases were selected for study by scrutiny of the inclusion and exclusion criteria. Most of our cases were treated with external fixator within 8 hrs of injury. Small A.O external fixator (bridging ex-fix) with 2 pins each in radius and 2nd metacarpal percutaneously was used for all the cases. Selective k wire fixation was done in cases of instability. Fixator was removed after 6 weeks. Guided physiotherapy was ensured in all the cases. Patients were followed up for an average of 9 months. Results: Modified Gartland and Werley scoring system was used to evaluate the overall functional results. Excellent to good results were achieved in 88.45% of our cases while fair result was in 11.54 %. One case had pin loosening and two other cases had malunion. Conclusion: External fixator used for ligamentotaxis is an effective method of treating unstable extraarticular and complex intraarticular fractures of distal radius. Improved anatomical restoration with early rehabilitation has produced favourable functional outcome in our series. The complications like pin tract infection is rare due to the availability of superior antibiotics and sterile surgical technique. complications like wrist and finger stiffness has improved with physiotherapy.

Visual Outcome of Traumatic Cataract at a Tertiary Eye Care Centre in North India: A Prospective Study

Ashish Kumar Sharma, Ahmad Nadeem Aslami, Jai Prakash Srivastava, Jawed Iqbal

Introduction: One of the most common presentations of blunt and penetrating ocular trauma is traumatic cataract. It remains a significant cause of visual impairment and physical disability among adults and children. It is associated with various ocular injuries. Aim: To evaluate the associated ocular injuries and final outcome of patients with traumatic cataract along with their demographic features and modes of trauma. Materials and Methods: A prospective study done in Department of Ophthalmology in M.L.B. Medical college, Jhansi from February 2010 to July 2011. A total of 48 patients diagnosed as a case of traumatic cataract were subjected to a detailed history, systemic and local examination with relevant investigations. Medical or surgical managements were done accordingly. Patients were subsequently followed-up and visual acuity was recorded. Appropriate statistical tests were applied. Results: A 54.2% patients sustained penetrating trauma while 45.8% got blunt injury. Out of total, 79% patients were males while 50% were less than 15 years of age. Causative agents were stone, wood items, stick, metal objects etc. Among blunt trauma cases, 64% of the patients had visual acuity <6/60 while among penetrating trauma cases nobody had acuity >6/18. Anterior segment was more involved as compared to posterior segment. A 38.5% patients had corneal opacity among penetrating injury patients. The interval between trauma and surgery was less than one month among 75% of patients. After three months of surgery, 43.7% patients had visual acuity of >6/18. Conclusion: This study provides recent data of patients hospitalized after ocular trauma and diagnosed as a case of traumatic cataract. Traumatic cataract occurs mostly in younger males. Surgical intervention is necessary to improve visual outcome. Good visual outcome was obtained in nearly half of the patients. Traumatic cataract patients can have good visual outcome depending upon proper management.

Morphometric Study of Subpubic Angle in Human Fetuses

Mahboobul Haque, Nafis Ahmad Faruqi, Syed Mobashir Yunus

Introduction: The symphysis pubis is formed at the confluence of the pubic bones. Each pubic bone consists of a body and two rami; the superior ramus is joined with the ilium and the inferior ramus with the ischium. The two bones meet in the midline at the pubic symphysis. The two inferior rami at the lower border of pubic symphysis subtend the subpubic angle. In females the subpubic angle is more than 90° and in males it is less than 90°. Most of the previous studies on the subpubic angle have been in children or adults, therefore data on fetuses did merit. Aim: The aims of the present study were to measure the subpubic angle in developing human fetuses of different gestational age, whether it is sex dependent and to compare the results with that in the adults. Materials and Methods: A cross-sectional study conducted in the Department of Anatomy JN Medical College, AMU Aligarh, over a period of two years. A total of 41 fetuses immersion fixed in 10% formalin were obtained from the museum department of anatomy. For the purpose of study fetuses were divided into five groups according to gestational age. Group I comprises fetuses of 14–18weeks, group II 19–22weeks, group III 23–26weeks, group IV 27–30weeks, groupV >30weeks of gestation. Pubic symphyses were dissected, cleaned and subjected to radiological examination in the anteroposterior plane. With the help of radiographs subpubic angle was measured. Readings obtained were analysed statistically. Results: Subpubic angle ranged between 58°-64° throughout intrauterine life. Maximum angle (63°- 64°) was observed in group I and V and in the rest of the groups it was less than 60°, with highly significant (p-value<0.001) increase in the last group. Statistically significant sexual dimorphism was observed in group I and II fetuses (p-value <0.001). Subpubic angle was more in females during the first half and in the terminal part of gestation. Conclusion: Subpubic angle remained acute throughout the intrauterine life, with significant widening in fetuses more than 30 weeks of gestation. Marked sexual dimorphism was noticed only in fetuses of 14–18 weeks and 19–22 weeks of gestation fetuses, although the values were invariably less than 90º (acute) in both the sexes but in females towards the higher side as in adults. Assessment of symphysis and subpubic arch during antenatal ultrasonography of pregnant women can be done to diagnose congenital widening of the symphysis or absence of symphysis altogether.

Comparison of the Perioperative Outcomes of a Vessel Sealing Instrument-Assisted Technique with a Conventional Technique in Abdominal Myomectomy

Introduction: In gynaecologic practice, LigaSure PreciseTM is generally used in endoscopic and open surgeries, such as hysterectomy, adnexectomy, and cancer surgery. However, there is no case report or main research article where LigaSure PreciseTM has been used for myomectomy. We want to compare a technique using a vessel sealing instrument with a conventional technique in abdominal myomectomy. Materials and Methods: Fifty-five women who underwent abdominal myomectomy were divided two groups: (1) a vessel sealing instrument-assisted technique (24 patients); and (2) a conventional technique (31 patients) between January 2011 and December 2014 at the Department of Gynaecology and Obstetrics, Gulhane Military Medical Academy, Ankara, Turkey. The data for the operation times, the occurrence of perioperative complications, the hospitalization times, and changes in haemaglobin and haematocrit levels for the two techniques were collected and compared. Results: The mean operation time was 48 minutes for the vessel sealing instrument-assisted technique and 54 minutes for the conventional technique. No statistically significant differences were determined for haemoglobin and haematocrit changes, hospital stay and perioperative complications. Conclusion: We did not find any difference in the occurrence of complications, changes in haemoglobin or haematocrit levels, or hospital stay. The vessel sealing instrument-assisted technique is feasible and effective in reducing operation times.

Effectiveness of Revised Pharmacology Record Books as a Teaching-Learning Method for Second Year Medical Students

Dhanya Sasidharan Palappallil, Reneega Gangadhar

Introduction: The goal of teaching medical undergraduates Pharmacology is to form a sound foundation of therapeutics. The pharmacology record books are maintained as a part of the curriculum. The purpose of this study was to obtain feedback of the medical students about the new record adopted in the institution after major revision Materials and Methods: This was a questionnaire based study done in a Government Medical College of Kerala in February 2013. The data was analysed using SPSS. The feedback on clinical pharmacology exercises was given positive and negative scores. Results: Majority (64.5%) opined that the content in pharmacology record was good. A total of 78.1% completed the record during discussions in practical classes. Majority wrote the records for understanding pharmacology. For 79.8% General Pharmacology exercises were most relevant, 33.8% considered Clinical Pharmacology exercises to be the most thought provoking. Drug use in special groups received the maximum positive score. Conclusion: The new improved pharmacology record is an effective teaching-learning method. Inclusion of more clinically oriented exercises has increased the interest of the students in the subject.

Spectral Analysis of Hypernasality in Cleft Palate Children: A Pre-Post Surgery Comparison

Thejaswi Dodderi, Manjunath Narra, Sneha Mareen Varghese, Dessai Teja Deepak

Introduction: Change in resonance is the most commonly experienced speech problems in children diagnosed with cleft lip and palate. The degree of nasality during normal speech production is maintained by the changes in velopharyngeal port. These variations in speech signal are reported to be successfully captured using acoustical tools like spectral analysis. Aim: The present study investigated to note voice low tone to high tone ratio (VLHR) values for phonation samples of individuals with cleft palate before and after surgery. Materials and Methods: Thirty children with congenital cleft of palate within 8 to 15 years of age participated in the study. Three trials of sustained vowels (/a/,/i/ and /u/) were recorded at their comfortable pitch and loudness level in a noise free room using a hand held dynamic microphone. Praat software that utilized Hillenbrand algorithm was used to extract the VLHR values for samples recorded before and after recovery from the surgery. Results: Statistical analysis revealed significant decrease in VLHR values after surgery in comparison to before the surgery. Analysis of Variance revealed statistical significant difference at 95% confidence level. Conclusion: It is concluded that VLHR parameter could be used as an index to measure nasality and can be included in the routine tool assessment protocol.

Impact of Aprotinin - A Proteolytic Enzyme on Postsurgical Symptoms in Patients Undergoing Third Molar Surgeries

Visakan Jegadeesan, Deepa Ponnaiyan

Introduction: Dealing with postoperative pain and inflammation remains an arena for never ending research. Different agents have been the subject of many studies to prevent the occurrence of unpleasant postoperative sequel. Extraction of third molars is often associated with significant deterioration in oral health related quality of life (physical, social and psychological) in immediate postoperative period. The complaints of pain, swelling and limitation of mouth opening, which ensue as a result of acute inflammatory response, are frequent consequences of postsurgical procedures involving extraction of impacted 3rd molars. Aim: Aprotinin, a naturally occurring protease inhibitor was assessed for its effectiveness in plummeting postsurgical pain and swelling, after surgical removal of impacted 3rd molars. Materials and Methods: Thirty randomly selected adult patients age ranging from 16-35 years, who required simultaneous surgical removal of bilateral impacted mandibular third molars were recruited. Before the surgical procedure, randomly selected side of the patient was injected with 1 m of 10,000 Kallikrein Inactivator Units (KIU) of aprotinin sub-mucosally around the surgical site and the contra lateral side with 1ml of isotonic saline as a control following which adequate local anaesthesia was obtained. The surgical removal of impacted 3rd molars was conducted in a similar manner on both test and control sides on all patients. Postoperatively, the patients were evaluated for pain and swelling for one week i.e., 1st, 2nd and 7th day. Results: It was observed that there was marked clinical reduction in postoperative pain and swelling. There were no adverse affects observed after using aprotinin. Conclusion: Since, the current pharmacologic agents being used have adverse effects and associated morbidity which still pose a problem, aprotinin a naturally occurring agent could be efficiently used after surgical extraction of 3rd molars in management of postsurgical symptoms and improve patient comfort and quality of life. In future, further studies with use of aprotinin in a large number of patients and comparative studies with other drugs are required.

A Study on the Role of Heart Type Fatty Acid Binding Protein in the Diagnosis of Acute Myocardial Infarction

Shama Prakash Kabekkodu, Sudhindra Rao Mananje, Rama Prakasha Saya

Introduction: Heart type Fatty Acid Binding Protein (H-FABP) has been proposed as an early cardiac biomarker for the diagnosis of acute myocardial Infarction (AMI) using animal models and clinical samples. Aim: The study aimed to evaluate the role of H-FABP in early detection of AMI by comparing its sensitivity, specificity and predictive value with Creatinine Kinase-MB (CK-MB) and Cardiac Troponin I (cTnI). Materials and Methods: This is a cross-sectional descriptive study of 50 patients admitted with the diagnosis of AMI at a tertiary care hospital in South India. The study group was categorised in to those coming to the hospital within four hours of symptom onset and those coming in between 4 to 12 hours. H-FABP was compared with those of troponin T and myoglobin tests. Results: Among patients presenting within four hours of symptom onset, the sensitivity of H-FABP was 60% and was significantly higher than that of cardiac Troponin I (cTnI, 18.8%) and Creatinine Kinase (CK)-MB (12.5%). But specificity was only 23.53% and was less than that of cTnI (66.67%) and CK-MB (100%). In patients presenting during 4 to 12 hours of symptom onset, the sensitivity of H-FABP was 86.96% which was comparable to that of cTnI (90.9%) and CK-MB (77.3%). The specificity was 60% in the 4-12 hours group which was comparable to that of cTnI (50%) and CK-MB (50%). Conclusion: The H-FABP is a sensitive biomarker for the diagnosis of AMI in the initial hours after symptom onset when the standard biomarkers may not be elevated, but it is less specific. During 4-12 hours of symptom onset it is as sensitive and specific as standard cardiac biomarkers troponin and CK-MB. Due to these factors H-FABP can be considered as a promising cardiac biomarker which can be used along with troponins and CK-MB at present.

The Release of Elements from the Base Metal Alloys in a Protein Containing Biologic Environments and Artificial Saliva – An Invitro Study

Ashwin M Pangi, Manoj Shetty, D Krishna Prasad, Hema Kanathila

Introduction: It has been reported that protein containing solutions can accelerate the release of elements from the base metal alloys. Aim: This study aims to determine whether the solution in which an alloy is submerged and the exposure time have any effect on the amount of release of elements from the Ni-Cr and Co-Cr alloys. Material and Methods: A total of 126 specimens were made from the Ni-Cr alloy and 42 specimens were made from Co-Cr alloy in the form of 5mm diameter discs, 2mm in thickness. Dissolution experiments were carried out in Bovine Serum Albumin (BSA) and artificial saliva for a period of seven weeks and atomic absorption spectrophotometer was used for elemental analysis. Statistical Analysis: T-test was done to correlate the difference of elemental release from both BSA and artificial saliva. ANOVA test was done to compare the release at different time intervals and to compare the release of elements at different time intervals within a particular solution. TUKEY HSD test was done for comparison between the elements in a particular solution. Results: The results showed that the elemental release was seen in both the solutions with a significant increase of release in BSA. The release of elements from the Ni-Cr alloy showed the predominant release of Cr. Conclusion: The protein containing solution showed maximum release of elements from Ni-Cr and Co-Cr alloys. The elements that released from the alloys never reached their threshold for toxic effects. Hence these alloys can be safely used in fabrication of metal restorations without any ill effects.

Oral Health Status of Underground Coal Mine Workers of Ramakrishnapur, Adilabad District, Telangana, India - A Cross-Sectional Study

Introduction: Standard of living and quality of life of people has been improved by the expanding industrial activity, but at the other end it has created many occupational hazards. Coal mining is one of the major age old industries throughout the world and in India. Till date very less literature is available worldwide and in India concerning the oral health status of laborers in this field. Aim: To assess the oral health status of underground coal mine workers, oral hygiene practices, alcohol and tobacco habits. Materials and Methods: A cross-sectional descriptive study was conducted among the underground coal mine workers of a coal mine located in Adilabad district, Telangana, according to the criteria described in the World Health Organization (WHO) Oral Health Assessment form (2013). Statistical analysis: Descriptive statistics were done. Results: A total of 356 workers participated in the study. Ninety percent of the subjects were with tobacco and/or alcohol habits. Dental caries was prevalent in more than half (55.6%) of the study subjects with a mean DMFT of 2.32±2.99. About 48.3% study subjects were with untreated dental caries and 20.3% subjects were with missing teeth. DMFT ==6 was seen in 45.5% of subjects and 10.1% have DMFT scores ==7. Periodontal disease was the most prevalent condition seen in the population with 94.4% subjects having unhealthy periodontium in terms of gingival bleeding and/or periodontal pockets. About 186 (52.25%) and 145 (40.73%) of subjects were with 0-3mm and 4-5mm loss of attachment respectively. Fourteen percent of population showed dental traumatic injuries. Conclusion: The findings highlighted the high caries prevalence, higher periodontal disease, traumatic injuries which requires immediate intervention.

Adipokines and their Relation to Endothelial Dysfunction in Patients with Chronic Kidney Disease

Introduction: Chronic Kidney Disease (CKD) patients are at high risk of cardiovascular diseases (CVDs). Reduced nitric oxide (NO) bioavailability is a key element in connecting kidney disease to endothelial dysfunction (ED) and cardiovascular (CV) complications. Further, inflammation is implicated in ED in CKD. Besides these, adipose tissue factors were thought to have a role in inflammation and ED in CKD. Aim: It is proposed to evaluate the concentration changes of adipokines, inflammatory and ED markers in CKD patients compared to healthy controls. Further, to assess the associations between adipokines, inflammation and ED in CKD patients. Materials and Methods: A total of 120 CKD patients were included and classified into 3 groups based on Glomerular filtration rate (GFR). Group I (n=40) patients had a GFR between 60-119 ml/min/1.73m2 (stage I, II), group II (n=40) had 15-59 ml/min/1.73m2 (stage III, IV) and group III (n=40) had <15 ml/min/1.73m2 (stage V). Forty healthy subjects served as controls. Adiponectin, Leptin, Interleukin-10 (IL-10), Interleukin-6 (IL-6), tumour necrosis factor-a (TNF-a) were estimated by ELISA. High sensitivity C-reactive protein (hsCRP) was estimated by immunoturbidimetry and NO by Griess method. Statistical Analysis: Mann-Whitney U test was used to compare the difference in variables between controls and CKD patients. One-way ANOVA Kruskalwallis test was used for comparison of variables between groups in CKD patients. Spearman’s rank correlation was used to explore the associations between variables. Simple univariate linear regression analysis was used to predict the value of variable from another variable. Results: A significant increase in leptin, IL-6, TNF-a, IL-6/IL-10 ratio, hsCRP and decrease in adiponectin, IL-10, NO was observed in CKD patients compared to controls (p<0.05). In CKD patients, adiponectin, leptin, IL-6, IL-6/IL-10 ratio, TNF-a were significantly increased and IL-10 levels were decreased from group I to group III (p<0.05). In group III CKD patients IL-6 showed a significant negative correlation with NO (r=-0.557; p=0.005). In linear regression analysis also, IL-6 showed a significant negative association with NO (B±SE=-0.038±0.11; p=0.002) in CKD patients. Conclusion: The present study demonstrates that adipokine levels are altered from initial to final stages of CKD due to renal dysfunction which in association with an exaggerated inflammation may contribute to the ED and CV events.

Assessment of Various Biochemical Parameters and BMI in Patients with Skin Tags

Vinod Wali, Vishal V. Wali

Introdction: Acrochordon or fibroepithelial polyp, commonly known as Skin tags (STs) are one of the most common benign skin condition, consisting of skin projecting from the surrounding skin, usually occurring on the eyelids, neck and axillae. Studies have found an association of STs with conditions such as obesity, diabetes mellitus and atherogenic lipid profile. Abdominal obesity and the consequent insulin resistance are said be important contributing factors for diabetes, dyslipidaemia and cardiovascular disease. Aim: To highlight the association of lipid profile, BMI, glucose, HbA1c and leptin levels in patients with STs. Materials and Methods: This was a case control study conducted at tertiary care hospital in South India from April 2013 to May 2014. The cases were chosen those who are having minimum of 3 STs attending the dermatology clinic. A total of 171 patients were screened, out of which 126 satisfied the criteria for inclusion and were included in the final analysis. The significance of the difference between the groups was assessed by Student t-test (two tailed, independent) to find the significance on continuous scale between two groups on metric parameters, between cases and controls and p-value of <0.05 were considered as statistically significant. Results: Maximum cases were in males and in age group of 41-50 years. There was significant association between STs and triglycerides, low density lipoprotein, very low density lipoprotein cholesterol and leptin levels. Other parameters were also altered but no statistically significant difference was seen. Conclusion: STs are associated with change in markers of obesity and dyslipidaemia. Patients with STs need suitable interventions like weight reduction, smoking cessation, change in dietary habits. STs may also play a role in early diagnosis of metabolic syndrome.

Prescribing Pattern of Oral Antihyperglycaemic Drugs, Rationality and Adherence to American Diabetes Association (ADA) Treatment Guidelines among Type 2 Diabetes Mellitus (T2DM) Postmenopausal Women

Sudhaa Sharma, Vishal R. Tandon, Roshi, Annil Mahajan

Introduction: Oral antihyperglycaemic prescription trends keep on changing and thus the drug prescription trend study may prove to be powerful exploratory tool for health care providers. Aim: To investigate trends in prescriptions of oral antihyperglycaemic drugs (OHDs) among postmenopausal women suffering from T2DM in India and evaluate the rationality and adherence to ADA treatment guidelines. Materials and Methods: An observational, cross-sectional descriptive prescription audit (n=500) was carried. Postmenopausal women were interviewed in their local language using pre-tested pre validated questionnaire after verbal informed consent at a teaching tertiary care hospital of north India. Oral antihyperglycaemic drugs (OHDs) drugs were categorized as per the pharmacological classification. Adherence to available clinical practice guidelines/recommendations issued under American Diabetes Association (ADA) 2015 Guidelines as well as rationality of these prescriptions were assessed using WHO Guide to Good Prescribing. Results: Mean age of the study population was 58.14±12.86. Mean duration since menopause was 5.3 years and of T2DM was 9.5 years. A 93.4% of the prescriptions had only OHDs whereas 6.6% of the prescriptions had various insulin preprations + OHDs (p<0.0001). Biguanides followed by sulfonylureas, thiazolidinediones, DPP-inhibitors and alpha-glucosidases inhibitor were prescribed in 85.6%, 59.8%, 26.6%, 26% and 12.2% respectively as monotherapy or in combination. Among biguanides, metformin was the most frequently prescribed OHDs. In spite of black box warning on pioglitazone, it was prescribed in 26.6% as FDC. However, clear increase use of vidagliptine was noticed upto 26%. Among combinations most frequent was metformin plus glimipride followed by voglibose plus metformin, whereas, among FDC, metformin plus glimipride followed by metformin plus vidagliptine were most frequently prescribed. Conclusion: Metformin was the most common OHDs to be prescribed followed by glimepiride. Although pioglitazone still continues to be prescribed after safety alert but apparently it appears that the share of pioglitazone has been shifted to vidagliptin or combinations like metformin plus glimipride. Polypharmacy, high use of FDC, & prescription by brand names were some of the irrationalities. Relatively low adherence to ADA treatment guidelines was observed.

Comparison of Flow and Volume Incentive Spirometry on Pulmonary Function and Exercise Tolerance in Open Abdominal Surgery: A Randomized Clinical Trial

Introduction: Surgical procedures in abdominal area lead to changes in pulmonary function, respiratory mechanics and impaired physical capacity leading to postoperative pulmonary complications, which can affect up to 80% of upper abdominal surgery. Aim: To evaluate the effects of flow and volume incentive spirometry on pulmonary function and exercise tolerance in patients undergoing open abdominal surgery. Materials and Methods: A randomized clinical trial was conducted in a hospital of Mangalore city in Southern India. Thirty-seven males and thirteen females who were undergoing abdominal surgeries were included and allocated into flow and volume incentive spirometry groups by block randomization. All subjects underwent evaluations of pulmonary function with measurement of Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), Peak Expiratory Flow (PEF). Preoperative and postoperative measurements were taken up to day 5 for both groups. Exercise tolerance measured by Six- Minute Walk Test during preoperative period and measured again at the time of discharge for both groups. Pulmonary function was analysed by post-hoc analysis and carried out using Bonferroni’s ‘t’-test. Exercise tolerance was analysed by Paired ‘T’-test. Results: Pulmonary function (FVC, FEV1, and PEFR) was found to be significantly decreased in 1st, 2nd and 3rd postoperative day when compared with preoperative day. On 4th and 5th postoperative day the pulmonary function (FVC, FEV1, and PEFR) was found to be better preserved in both flow and volume incentive spirometry groups. The Six-Minute Walk Test showed a statistically significant improvement in pulmonary function on the day of discharge than in the preoperative period. In terms of distance covered, the volume- incentive spirometry group showed a greater statistically significant improvement from the preoperative period to the time of discharge than was exhibited by the flow incentive spirometry group. Conclusion: Flow and volume incentive spirometry can be safely recommended to patients undergoing open abdominal surgery as there have been no adverse events recorded. Also, these led to a demonstrable improvement in pulmonary function and exercise tolerance.

A Comparative Analysis of Dietary Habits on Sensory Motor Association and Heart Rate Variability during Menstrual Cycle

Arbind Kumar Choudhary, Tanwir Alam, Rekha Jiwane, Sadawarte Sahebrao Kishanrao

Introduction: Dietary habits can make a big difference on both physical and mental aspects of the body. Menstrual disorder frequently affects the quality of life of adolescent and young adult women. Menstrual cycle irregularities may be associated with psychological stress, and endocrine disturbances. Monitoring of sensory-motor association and cardiovascular activity across the menstrual cycle has not been evaluated with dietary habits. Aim: The present study was carried out to bridge the relation- ship between dietary habits and endogenous sex hormone mediated sensory motor association and heart rate variability (HRV) among young females during different phases of menstrual cycle. Materials and Methods: The present study was carried out on healthy volunteered 100 female medical students in the age group of 19-25 years with regular menstrual cycle. Group I (n=45) vegetarians, Group II (n=25) eggetarians and Group III (n= 30) non-vegetarians, where n denotes the number of individuals in each group. Sensory-motor association (reaction time) and cardiovascular activity (HRV) was evaluated. Results: We observed among all the dietary habits (vegetarians, eggetarians and non-vegetarians) the reaction time and HRV was comparable in follicular and menstrual phase, however it was significantly altered in luteal phase when compared to follicular and menstrual phase. Moreover, among all the dietary habits, non-vegetarians showed more significant alteration of reaction time and HRV in luteal phase when compared to vegetarians and eggetarians, as well as there was positive correlation between visual and auditory reaction time and negative correlation between LF and HF in luteal phase, among all the dietary habits. Conclusion: We concluded sensorimotor association and regulation of autonomic tone is modified in luteal phase comparable to follicular phase and menstrual phase; however non-vegetarian had showed more significant alterations as compared to eggetarians and vegetarians. These suggest that sympathetic nervous activities are predominant in the luteal phase as compared to follicular phase, and this sympathetic dominance is more among non-vegetarians, which may be due to their higher BMI. The alterations in the balance of ovarian hormones might be responsible for these changes. Long-term intake of vegetarian diets may facilitate vagal regulation of the heart without increasing the sympathetic modulations of the cardiovascular system.

A Clinical Evaluation of Gingival Overgrowth in Children on Antiepileptic Drug Therapy

Bharat Suneja, Saroj Chopra, Abi M Thomas, Jeyraj Pandian

Introduction: Gingival overgrowth, a well-known side effect of chronic phenytoin therapy has also been known to be caused by other anti epileptic drugs (AED’s). Various factors like plaque, gingival inflammation, and periodontal health have been postulated to effect gingival overgrowth. Aim: To identify the AED having an effect on gingival overgrowth and to study the factors affecting it. Materials and Methods: Three groups of 30 children each on monotherapy of phenytoin, sodium valproate, and carbamazepine were longitudinally followed for six months. Their oral and epileptic health status was assessed and were monitored for change in plaque levels, gingival inflammation, probing depth and the status of gingival overgrowth at baseline, at the end of 3 months and finally at the end of 6 months. The data was recorded and statistically analysed. Results: Phenytoin caused gingival overgrowth in a significant number of children (53.6%) within 3 months. Sodium valproate also led to gingival overgrowth, but not upto statistically significant levels. Patients on carbamazepine did not show any signs of gingival overgrowth. Gingival overgrowth is seen more on buccal side, in the anterior segment and in the lower arch. No correlation could be found between, either plaque level, or gingival inflammation with gingival overgrowth. Probing depth could be positively correlated with gingival overgrowth. Conclusion: Phenytoin is the drug, which can be chiefly implicated for causing gingival overgrowth. Sodium valproate carries the potential for gingival overgrowth, although only up to clinically insignificant levels in 6 months. Carbamazepine can be considered a safe drug in children in relation to gingival overgrowth.

Ameloblastic Fibrodentinoma: Report of a Case in an Infant

Manish Bhargava, Saloni Sood, Pallvi Rathore

Ameloblastic fibrodentinoma (AFD) is a debatable neoplasm with respect to its clinical, biological and histopathological diagnosis. The clinical and radiological presentation may mimic ameloblastic fibro odontoma, odontoma, ameloblastic fibroma and cemento-ossifying fibroma. We report an interesting case of AFD occurring in canine region of mandible in a one-year-old infant. From a review of English language literature, to the best of our knowledge this is the first case occurring in an infant. The purpose of this case report is to create awareness among the clinicians to make the best possible management of this controversial pathologic entity.

Using Movies to Strengthen Learning of the Humanistic Aspects of Medicine

Introduction: Movie screening and activities have been used during the last two semesters (spring and summer 2015) to strengthen the learning of communication skills, empathy, professionalism, and greater understanding of the process and death and dying at the Xavier University School of Medicine. Aim: The present manuscript describes the movie screening and activities. Student feedback regarding the sessions is also mentioned. Settings and Design: The activity was conducted among basic science undergraduate medical students and student feedback was obtained. A cross-sectional study design was used. Materials and Methods: Feedback was obtained towards the end of June 2015 using a questionnaire designed by the authors. Participants were asked to rate their degree of agreement with the set of statements and provide an overall rating for the sessions. No demographic information was collected. Statistical Analysis: Cronbach’s alpha was calculated as a measure of internal consistency. The normality of distribution of the scores of individual statements and of the overall rating was determined using one sample Kolmogorov-Smirnov test. The average scores were calculated. Free text comments were tabulated. Results: Forty-nine of the 63 students (77.8%) participated in the study. Cronbach’s alpha was 0.868 indicating a high level of internal consistency. The median scores indicating the degree of agreement with most statements ranged from 3 to 5. The mean participant rating of the sessions was 7.10 (maximum possible score 10). A few participants provided free text comments regarding the sessions. Conclusion: Student feedback about the session was positive. Impact of the session on humanistic issues, professionalism and death and dying should be studied in future.

Mobile Phone Usage and its Health Effects Among Adults in a Semi-Urban Area of Southern India

Introduction: Worldwide, mobile phone usage has been increased dramatically which could affect the health of the people. India has the second largest number of mobile phone users. However there are only few studies conducted in India to assess its effects on health. Aim: To determine the prevalence and pattern of mobile phone usage and to assess the relationship between certain selected health problems and mobile phone usage among adults. Settings and Design: Community-based cross-sectional study was conducted in Kottakuppam, a town panchayat in Villupuram district of Coastal Tamil Nadu, Southern India. It is a semi-urban area with a population of about 16,000. Majority of the residents are Muslim by religion and belong to different socio economic status. Materials and Methods: The study was approved by the Institutional Ethics Committee. A total of 2121 study participants were interviewed by the pre-final medical students through house-to-house survey using a pretested structured questionnaire. The questionnaire included the variables such as socio demographic profile, mobile phone usage and pattern, selected health problems, perceived benefits and threats and blood pressure. Selected health problems included headache, earache, neck pain, tinnitus, painful fingers, restlessness, morning tiredness, tingling fingers, fatigue, eye symptoms, sleep disturbance and hypertension. Statistical Analysis Used: Only 2054 were included for data analysis using SPSS 17 version. Proportions were calculated. Chi-square test was used to measure the p-value. The p-value < 0.05 was considered as statistically significant. Results: The prevalence of mobile phone usage was 70%. Calling facility (94.2%) was used more than the SMS (67.6%). Health problems like headache, earache, tinnitus, painful fingers and restlessness etc., were found to be positively associated with mobile phone usage. There was negative association between hypertension and mobile phone usage. Conclusion: The prevalence of mobile phone usage was high. There was significant association between selected health problems and mobile phone usage. In future, higher studies are required to confirm our findings.

An Evaluation of Retentive Ability and Deformation of Acetal Resin and Cobalt-Chromium Clasps

A.Meenakshi, Ranjana Gupta, Vinay Bharti, G.Sriramaprabu , Ramachandra Prabhakar

Aim: To compare the retentive ability and deformation of Acetal resin with Cobalt-Chromium clasps via Insertion Removal apparatus after subjecting them to stimulate clinical use. Materials and Methods: Materials used for this study are commercially available Cobalt-Chromium alloy namely Wironit, Bego, Germany and Acetal resin namely Biodentaplast, Bredent, Germany. The test samples were divided into two major groups based on the type of materials used in the study. Each major group is further subdivided into two sub groups based on the retentive undercut depths used to engage the clasps. So a total of 20 specimens were prepared, comprising of 5 specimens in each sub group. Then the specimens were tested for retention force and deformation. Results: The results of this study indicate that acetal resin clasps are resistant to deformation and may offer a clinical advantage over the conventional metal clasps. The retentive force of acetal resin clasps did not decrease over the cycling periods. This would be attributed to the resilient nature of acetal resin. Under the conditions of the present study cobalt chromium clasps lost retentive force within 730 cycles of placement and removal and continued to lose retentive force during the remaining test period. Conclusion: This invitro study demonstrated that retentive force of cobalt chromium clasp is superior to that of Acetal resin for removable partial dentures. As acetal resin clasps exhibits greater flexibility and long term retentive resiliency, it can be used for removable partial dentures where aesthetics or periodontal health is a primary concern.

Comparison of Epidural Bupivacaine, Levobupivacaine and Dexmedetomidine in Patients Undergoing Vascular Surgery

Introduction: Levobupivacaine is the s-isomer of racemic Bupivacaine. It is less cardio, neurotoxic and equally potent local anaesthetic compared to its racemate. It is known to cause less Depression of myocardial contractility. Dexmeditomidine when used via epidural route has synergistic effect with local anaesthetics. Majority of patients presenting for vascular surgery are elderly and have associated co-morbidities like diabetes, hypertension, and coronary artery disease. We intend to study safety and efficacy of epidural Levoupivacaine and Dexmedetomidine in this group of patients. Materials and Methods: Sixty adult patients undergoing lower limb vascular surgery under lumbar epidural anaesthesia were randomly allocated to three groups. All groups were preloaded with 10ml/kg of crystalloid solution. B group was scheduled to receive 15 ml of racemic Bupivacaine, L-group was scheduled to receive 15ml of Levobupivacaine and LD-group received 15ml of Levobupivacaine with 0.5 mics/kg Dexmeditomedine. Time to onset of sensory block to T-10, maximum sensory level achieved, Bromage scale, time to two segment regression, time to total regression, sedation level achieved and patients assessment of quality of anaesthesia were assessed. Haemodynamic parameters were monitored throughout study period. Adverse effects were noted and treated appropriately. Results: Baseline parameters were comparable among all the groups. Time to onset of sensory block to T-10 and maximum level of block achieved, was comparable among the groups. Time to two segment regression and time to total regression was significantly prolonged in LD group compared to other two groups. There was significant bradycardia noted in LD group which required treatment. Conclusion: Levobupivacaine can be safely used in elderly high risk patients undergoing vascular surgery. Addition of dexmedetomidine prolongs the duration of anaesthesia and postoperative analgesia.

Elevated Factor VIII Levels and Shortened APTT in Recurrent Abortions

Aysha Ali, Pushpapavalli Mohan, Hana Kareem, Mahsheena Kalpakapaka Muhammed

Introduction: Thrombotic disorders have been found to be associated with recurrent abortions. Several risk factors have been identified. APTT reflects the common pathway and intrinsic pathway of coagulation cascade and hence is a good marker for thrombotic work. Elevated factor VIII: C has also been identified as risk factor for recurrent miscarriage. This study aims at identifying association of elevated factor VIII levels, shortened APTT and recurrent abortions in Indian population as little has been studied about this and the literature available is also based on studies done in European population. This study also aims to find whether shortened APTT can be an independent risk as well. Materials and Methods: Women referred to the obstetrics department with a history of early recurrent early pregnancy loss (at least three pregnancy losses before 13 weeks of gestation) were included in this study. Exclusion criteria were elevated CRP levels, positive antiphospholipid antibodies, endocrine, immunological or anatomical cause of embryo demise. A total of 68 cases of recurrent abortion were included in this study, 68 normal pregnant females (<15 weeks of gestation) were also included as controls with no history of abortion. The age group of the cases as well as control was 20-45 years. Activated partial thromboplastin time and factor VIII assay (one stage APTT based) were done on the blood samples. Results: Increased factor VIII levels were seen in 25 cases (36.4%); 19 cases showed shortened APTT (27.3%); 12 cases showed both increased factor VIII levels as well as shortened APTT (18%). All risk factors were negative in 36 cases (52.9%). None of the controls showed elevated factor VIII levels or shortened APTT. The mean APTT values of the control subjects was 31.01 and cases were 27.01 (p=0.001). The mean factor VIII levels of case were 152.85% and control 144.953% (p=0.012). Conclusion: There was significant association between recurrent abortions and elevated factor VIII :c levels and shortened APTT. Shortened APTT was also identified as an independent risk factor.

Head and Neck Tuberculosis: Scenario in a Tertiary Care Hospital of North Eastern India

Soumyajit Das, Debajit Das, Uttal Taranga Bhuyan Nabajyoti Saikia

Introduction: Tuberculosis has affected mankind since time immemorial and with emergence of AIDS both extrapulmonary and pulmonary tuberculosis presents increased morbidity and mortality along with an increased financial burden upon the developing nations. Materials and Methods: The study is a hospital based observational study of one year duration carried out in the Department of ENT in a tertiary care hospital of North Eastern India. Results: Total of 63 cases were detected. Females comprised 60.3% of the study population as against 39.7% males. Most commonly affected age group were of 15 to 24 years age (57.1%). Cervical tubercular lymphadenitis was the most common lesion 90.5% (57 cases) followed by laryngeal tuberculosis 7.9% (5 cases) and tubercular otitis media with mastoiditis 1.6% (1 case). Level II lymph node was mostly affected either single or in groups (75.4%) followed by level III node (57.9%). Successful outcome of the treatment with Category I regimen was achieved in 96.8% of the cases. Conclusion: Head and neck tuberculosis is not an uncommon disease and though cervical lymphadenitis is the most common presentation, isolated involvement of the larynx, ear and other subsites are not an entirely unknown entity. The clinical presentation of tuberculosis of the head and neck region can be varied and often misleading. It is therefore important for the clinician to be aware of the condition and consider it in their differential diagnosis.

Prevalence of Lrtirti in Patients Presenting with Productive Cough and Their Antibiotic Resistance Pattern

Sunil Vijay, Gaurav Dalela

Aim: To find out the prevalence of Lower Respiratory Tract Infection (LRTI) such as bacterial, fungal, mycobacterial infections etc. in patients with productive cough of duration less than 15 days and to rule out the patients having previous history of tuberculosis or having treatment of tuberculosis. Materials and Methods: Outdoor and Indoor patients of Department of Medicine and Chest & TB, SRG hospital and Jhalawar Medical College, Jhalawar were included. After sample collection the specimens were sent to the Microbiology department, for processing of Gram staining, Acid fast staining, KOH mount and bacteriological culture and sensitivity. Results: A total of 200 samples were obtained from the outpatient and inpatient Department of Medicine and Chest & TB of which 66% were male and 34% were female. Seventy seven percent of samples were culture positive for both single pathogen and mixed infection of which 56.5% were male and 20.5% were female as males are more at risk for LRTI. Klebsiella pneumoniae was the most prevalent pathogen (71/193), followed by coagulase positive Staphylococci i.e. COPS (43/193). More resistant pattern was found in coagulase negative Staohylococci (CONS) showed 61.11% Methicillin Resistant Staohylococci (MRS) incidence compared to 41.86% in COPS, also regarding Extended Spectrum Beta Lactamase (ESBL) production Escherichia coli showed incidence of 36.36% as compared to other gram negative bacilli. Pseudomonas aeruginosa was the most resistant organism found based on the antibiotic susceptibility pattern while Proteus mirabilis was the most sensitive organism. Conclusion: Lower respiratory tract infections can spread easily among community and indiscriminate use of antibiotics contributes to their therapeutic failure. Area-wise studies on antimicrobial susceptibility profiles are essential to guide policy on the appropriate use of antibiotics to reduce the morbidity and mortality and also to control the emergence of antimicrobial resistance in local area.

Unstable Intertrochanteric Fracture Fixation – Is Proximal Femoral Locked Compression Plate Better Than Dynamic Hip Screw

Background: Intertrochanteric fractures are one of the most common fractures encountered in our practice. Most of them need operative intervention and union is achieved. As per the literature dynamic hip screw (DHS) is the gold standard for the treatment of these fractures, however problem arises with maintenance of neck shaft angle and proper reduction in unstable intertrochanteric fractures. The situation gets more complex when “cut out” of femoral head screw occurs either alone or in combination with varus collapse when they are treated with DHS. Here we are giving results of unstable intertrochanteric fractures treated with Proximal Femoral Locked Compression Plate (PFLCP) as compared with similar patients treated with Dynamic Hip Screw (DHS). Materials and Methods: The study included a total of 27 patients (17 males, 10 females) with unstable intertrochanteric fractures who were subjected to PFLCP treatment from March 2011 to November 2012 in one group. Another was a similar group of 35 patients treated with DHS from March 2008 to February 2010. Results of group 1 were compared with group 2. Detailed clinical conditions of all patients, duration of surgery, blood loss, length of incision and duration of image intensifier use were recorded. Patients were revisited at 6 weeks, 3 months, 6 months and 1 year after operation. Results were evaluated clinically by Harris hip Score and radiologically for fracture union. Progress of union and complications (limb shortening, varus collapse, cut out of femoral head screw and medialization of distal fragment) were recorded. Results: Among 27 patients treated with PFLCP, one patient expired 6 week postoperatively and one patient lost to follow up, so 25 patients were evaluated for final outcome of which 23 (92%) showed union at follow up of 12 months. One patient developed bending of proximal screws and three developed varus collapse. Among the group treated with DHS, eight patients developed varus collapse, seven developed medialization and three had femoral head screw cut out. According to Harris hip Score 88% cases had good to excellent result in PFLCP group whereas only 60% cases in the DHS group had good to excellent result. Conclusion: Treatment of unstable intertrochanteric fractures with proximal femoral locked plate (PFLCP) can give good healing, with a limited occurrence of complication.

Prevalence of Anaemia among Postnatal Mothers in Coastal Karnataka

Darshan Bhagwan, Ashwini Kumar, Chythra Raghavendra Rao, Asha Kamath

Introduction: Postpartum is the most neglected period in reproductive cycle of woman. Prevalence of anaemia in developing countries ranges from 50-95%. Aim: To estimate the prevalence of anaemia among postnatal mothers. Setting and design: A community based cross-sectional study among recently delivered mothers residing in field practice area of Department of Community Medicine, Kasturba Medical College, Manipal, India. Materials and Methods: The study sample included 401 respondents who were selected using stratified random sampling with proportionate allocation from all rural health centres. Data was collected by personal interviews followed by haemoglobin estimation by indirect cyanomethaemoglobin method. Results: The prevalence of postnatal anaemia was 26.5% (Anaemia = Hb<12gm/dl). There were no cases of severe anaemia. Postnatal anaemia was predominantly seen in mothers of age < 20 years and half of the mothers with inter-pregnancy intervals less than two years were found to be anaemic. Illiteracy was identified as a significant variable (OR=11.23, 95% CI = 1.90-65.08) for postpartum anaemia. Conclusion: The prevalence of anaemia was significantly lower in the present study; however sustained efforts have to be made to further lower the prevalence of postnatal anaemia in order to promote the health and well-being of women.

Quality Measures in Pre-Analytical Phase of Tissue Processing: Understanding Its Value in Histopathology

Introduction: Quality monitoring in histopathology unit is categorized into three phases, pre-analytical, analytical and post-analytical, to cover various steps in the entire test cycle. Review of literature on quality evaluation studies pertaining to histopathology revealed that earlier reports were mainly focused on analytical aspects with limited studies on assessment of pre-analytical phase. Pre-analytical phase encompasses several processing steps and handling of specimen/sample by multiple individuals, thus allowing enough scope for errors. Due to its critical nature and limited studies in the past to assess quality in pre-analytical phase, it deserves more attention. Aim: This study was undertaken to analyse and assess the quality parameters in pre-analytical phase in a histopathology laboratory. Materials and Methods: This was a retrospective study done on pre-analytical parameters in histopathology laboratory of a tertiary care centre on 18,626 tissue specimens received in 34 months. Registers and records were checked for efficiency and errors for pre-analytical quality variables: specimen identification, specimen in appropriate fixatives, lost specimens, daily internal quality control performance on staining, performance in inter-laboratory quality assessment program {External quality assurance program (EQAS)} and evaluation of internal non-conformities (NC) for other errors. Results: The study revealed incorrect specimen labelling in 0.04%, 0.01% and 0.01% in 2007, 2008 and 2009 respectively. About 0.04%, 0.07% and 0.18% specimens were not sent in fixatives in 2007, 2008 and 2009 respectively. There was no incidence of specimen lost. A total of 113 non-conformities were identified out of which 92.9% belonged to the pre-analytical phase. The predominant NC (any deviation from normal standard which may generate an error and result in compromising with quality standards) identified was wrong labelling of slides. Performance in EQAS for pre-analytical phase was satisfactory in 6 of 9 cycles. Conclusion: A low incidence of errors in pre-analytical phase implies that a satisfactory level of quality standards was being practiced with still scope for improvement.

Oral Radiology Safety Standards Adopted by the General Dentists Practicing in National Capital Region (NCR)

Introduction: With advancement in diagnostic techniques, the utilization of radiologic examination has risen to many folds in the last two decades. Ionizing radiations from the radiographic examination carry the potential for harm by inducing carcino-genesis in addition to the diagnostic information extracted. Radiation doses utilized in the course of dental treatment might be low for individual examinations but patients are exposed to repeated examinations very often and many people are exposed during the course of dental care. Therefore, principles of radiation protection and safety are necessary for the dentists to follow to ensure minimum and inevitable exposure. Aim: The aim of this study was to investigate the knowledge and behaviour of general dentists practicing in the National Capital Region (NCR) regarding radiation safety during oral radiographic procedures. Materials and Methods: The study was a questionnaire based cross-sectional study. A total of 500 general dentists were contacted to participate in the study. The target population entailed of general dentists practicing in the National Capital Region. Data was computed and tabulated in Microsoft excel sheet and statistical analysis was performed with the help of SPSS version 21.0. Results: The total response rate recovered was 70.6% and the respondents comprised of 59% and 41% males & females respectively. Only 64.8% of the general dentists contemplated thyroid to be the most important organ for radiation protection. Only 28.8% of the general dentists followed the position & distance rule appropriately. Conclusion: The results showed that the knowledge and behaviour of the general dentists and the practices adopted by them regarding radiation safety is not satisfactory. To ensure the following of basic and necessary guidelines for radiation safety and protection, strict rules with penalties should be implemented by the state councils and new and interesting methods of education for this spectrum of the field should be introduced.

Renal Papillary Necrosis: Role of Radiology

Harsh C. Sutariya, Vaidehi K. Pandya

Renal Papillary Necrosis (RPN) is idefined as Ischemic necrobiosis of the papilla in the medulla of the kidneys. Variety of etiological factors are recognized which cause papillary necrosis, such as analgesic nephropathy, diabetes mellitus, urinary obstruction and sickle cell haemoglobinopathy. The early diagnosis of RPN is important to improve prognosis and reduce morbidity. Radiological Imaging offers early diagnosis and can guide prompt treatment of papillary necrosis and can minimize a decline in renal function. Here we report three cases of RPN with typical imaging findings. One of them was diabetic and hypertensive female with recurrent Urinary tract Infections and other was a male with no known co-morbidity. Both of them were diagnosed to have renal papillary necrosis on CT scan and were managed operatively and conservatively, respectively. Third case was a healthy female being investigated to be renal donor for her son. Here RPN was an incidental finding and was treated conservatively. Thus CT scan could detect it pre-operatively and complications due to transplantation of a kidney with papillary necrosis were avoided. So, we want to emphasize the importance of Radiology, particularly CT scanning in detection of RPN and to guide early and prompt treatment.

Relation between Vitamin D Deficiency and Severity of Chronic Obstructive Pulmonary Disease-A Case Control Study

Shah Sanket, Jagadesh Madireddi, Weena Stanley, Pradeep Sura, Mukhyaprana Prabhu

Introduction: Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disorder characterized by irreversible and progressive limitation of expiratory airflow. COPD is now considered as a systemic disease with several extra-pulmonary manifestations which include osteoporosis, muscle weakness, arrhythmia, stroke, cancer etc. The role of vitamin D in skeletal integrity is well established. Role of it in several other diseases like autoimmune, infectious, respiratory and cardiovascular diseases has been increasingly recognised. Data on vitamin D status in COPD in Indian population was limited while those comparing vitamin D with stage, pack year and body mass index were lacking. Aim: To assess Vitamin D in subjects with COPD and matched controls and also to study the variability in serum vitamin D levels with COPD disease characteristics. Materials and Methods: A total of 162 patients aged 18-65 years from south India presenting to kasturba hospital were included in the study. Serum 25- hydroxy-vitamin D were measured in 81 COPD patients (combined COPD stage A-D) and compared with 81 age and gender matched controls. Level < 20 ng/ml defined deficiency. Risk estimate with Odds ratio and association of COPD characteristics with Vitamin D was assessed using logistic regression analysis. Results: COPD patients had an increased risk for vitamin D deficiency compared to controls after adjustment for age and gender(OR =2.687 (1.40,5.13)). Variables associated with lower 25(OH) D levels in COPD patients were higher pack year (p=0.001), current smoking status (p=0.026), Low BMI (p=0.02), and GOLD stage III- IV (p=0.001). Conclusion: COPD was associated with an increased risk of vitamin D deficiency, and there was a significant association between vitamin D levels and Combined COPD stage severity. Also, a higher pack year and a low BMI are associated with lower levels of vitamin D.

Spontaneous Subdural Haemorrhage: A Rare Association with Plasmodium Vivax Malaria

Malaria is an endemic disease in tropical countries and disease of universal importance. Central Nervous System (CNS) complications of malaria are severe and associated with significant mortality. Thrombocytopaenia in malaria causing haemorrhagic CNS complications is rare. We report a case of 35-year-old male patient presented with headache, vomiting and was diagnosed to have subdural haemorrhage (SDH). On examination patient was found to be febrile with peripheral smear showing evidence of Plasmodium vivax (P.vivax) infection with severe thrombocytopaenia. In endemic regions with malaria, SDH being rare presentation of malaria should be considered as a differential diagnosis in febrile patients with neurological manifestations. Rarity of spontaneous SDH in malaria and raising awareness amongst treating physicians about the same is the driving factor for reporting this case.

Risk of Acute Kidney Injury with Amikacin versus Gentamycin both in Combination with Metronidazole for Surgical Prophylaxis

Introduction: Surgical site infection is one of the most important complication of surgery. It increases the mortality and morbidity. In order to decrease the incidence of surgical site infections perioperative antimicrobial prophylaxis has been recommended in certain types of clean and clean contaminated surgeries. Aminoglycosides are indicated as surgical prophylaxis for prevention of surgical site infection in patients with B-lactam allergy. Aim: The present study was carried out to study and compare the renal safety profile of single high dose gentamycin and amikacin as surgical prophylactic antibiotic. Materials and Methods: Prospective and randomized study was carried out on 100 patients for over one year period in a tertiary care teaching hospital of western Uttar Pradesh, India. Patients in amikacin group received amikacin 15 mg/kg + metronidazole 500 mg intravenously single dose and those in the gentamycin group had gentamycin 5 mg/kg + metronidazole 500 mg intravenously single dose, one hour prior to incision. Result: A total of 16% patients of amikacin group and 24% patients of gentamycin group developed acute kidney injury within one week of drug administration. The rise in serum creatinine was temporary as all patients had normal serum creatinine level at one month follow up. Conclusion: Aminoglycoside intravenous single high dose is not safe as surgical prophylaxis.

The Efficacy of Topical Hyaluronic Acid 0.2% in the Management of Symptomatic Oral Lichen Planus

Rahul Raviraj Shetty, Krishna Nagappa Burde, Kruthika Satyabodh Guttal

Introduction: Oral lichen planus (OLP) is a condition frequently referred to the specialist dental clinic for diagnosis and management. It is a disease of the skin and mucous membranes with oral manifestations too. It varies in appearance from keratotic to erythematous and ulcerative form. Immunosuppressants are frequently used for patients but some of these drugs could be implicated in malignant transformation, thus there is a clear need to find an alternative therapy for OLP. Aim: To evaluate the relief of symptoms and reduction in the size of the lesions of lichen planus with 0.2% hyaluronic acid topical application and to compare the efficacy of topical hyaluronic acid (0.2%) with that of patients on placebo. Materials and Methods: A randomized controlled study was conducted on 50 symptomatic and biopsy proven patients with lichen planus. The subjective symptoms like Visual Analogue Scale (VAS) and the objective symptoms like degree of erythema and mean area of the lesion were recorded preoperatively and on day 7, day 14, day 21 and day 28. The selected patients were divided randomly into group-I comprising of 25 patients who received topical 0.2% hyaluronic acid therapy for 14 days and group-II comprising of 25 patients who received topical application of placebo for 14 days. The statistical tests used were Mann-Whitney U test, t-test, Wilcoxon matched pairs test by ranks and paired t-test. Results: Symptomatic effect of soreness evaluation- there was a significant reduction in VAS scores in the test group as compared to placebo, similarly there was also significant reduction in the degree of erythema, change in the size of the lesion and area of the lesion in the test group. There was significant improvement in relief of symptoms, in the degree of erythema and mean area of the lesion in Group-I when compared with group-II. Conclusion: Topical application of 0.2% Hyaluronic acid showed a significant clinical response when compared to topical placebo. It is easy to use; hence a frequent application scheme should be advised to improve the efficacy of hyaluronic acid.

Study of Electrophysiological Changes in Sensory Nerves Among Diabetic Smokers

Aquil Ahmad, Arsalan Moinuddin, Akif Ahsan, Ashish Goel

Introduction: Neuropathy is one of the most troublesome complication affecting individuals with diabetes. The resultant loss of function in peripheral nerves causes loss of protective sensations and impairs patient’s ability to perceive incipient or even apparent ulcerations in the feet. Aim: This study was undertaken to test the hypothesis of alteration in electrophysiological parameters of nerve before actual manifestations of neuropathy in type 2 diabetic patients and to analyse the effect of smoking on Sensory Nerve Conduction Velocity (SNCV) of diabetic subjects. Materials and Methods: One hundred and twenty diagnosed diabetics were taken as cases while 30 healthy non diabetics were taken as control. Case group was divided into diabetic non-smoker and diabetic smoker. Diabetic smoker were further subdivided into light smoker, moderate smoker and heavy smoker according to smoking index. After detailed history and physical examination SNCV of median and ulnar nerve in upper limb and sural nerve in lower limb was performed. Results: On comparison of SNCV of median and ulnar nerve of upper limb and sural nerve of lower limb between control and diabetic non-smoker only sural nerve of diabetic non smoker showed significant bilateral decrease. There was significant bilateral decrease in SNCV of median and ulnar nerve of diabetic heavy smoker when compared to control and diabetic non smoker. Similarly, SNCV of sural nerve of diabetic heavy smoker was significantly decreased when compared with control, diabetic non-smoker, diabetic light and moderate smoker. A negative and statistically significant correlation was found between SNCV and smoking index. Conclusion: Present study indicates that nerves of lower limbs are more susceptible to diabetic assault as compared to upper limb suggesting that long nerves are commonly affected. Also, apart from duration and severity of diabetes, smoking itself is an independent factor for diabetic neuropathy.

Trends of Various Techniques of Tubectomy: A Five Year Study in a Tertiary Institute

Kavita Mahadevappa, Naveen Prasanna, Ramalingappa Antartani Channabasappa

Introduction: Female sterilization is one of the best and effective methods of contraception for women who have completed their family. Tubectomy during caesarean operation and minilaparotomy are popular methods in developing countries whereas laparoscopic sterilization and hysteroscopic tubal occlusion are the preferred methods in developed countries. Aim: To know the trends, incidence and immediate complications of methods of female sterilizations performed at our institute. Materials and Methods: This is a retrospective analytical study conducted at our tertiary care centre from January 2010 to December 2014 in Karnataka Institute of Medical Sciences, Hubli, Karnataka. The case files of all the patients who underwent sterilization were taken from the medical records section and reviewed in detail. The cases were grouped as caesarean tubectomy, minilaparotomy and laparoscopic sterilization, based on the abdominal entry. For minilaparotomy and during caesarean tubectomy, modified pomeroy’s technique was used. For laparoscopic sterilization, falope rings were used. Data was analysed by Karl Pearson’s correlation co-efficient method and Chi-Square test. The p-value < 0.05 was considered significant. Results: Out of 5442 cases of female sterilization, 2872 underwent caesarean tubectomy, remaining half underwent minilaparotomy (1306) and laparoscopic sterilization (1264). Sterilizations were significantly more during puerperal period (caesarean tubectomy + post abortal + postpartum) compared to interval period. There was an increasing trend in caesarean tubectomy and laparoscopic sterilization. There were 11 procedure related complications in the laparoscopic sterilization, one in caesarean tubectomy and none in minilaparotomy. Two deaths were reported in minilaparotomy, one in laparoscopic sterilization and four in the caesarean tubectomy, which were due to septicaemia. Conclusion: An increasing trend in caesarean tubectomy and laparoscopic sterilization is seen in this study. Female sterilization should be individualized based on the timing, place and surgeons experience. Sepsis is a major cause of death and asepsis could be compromised when female sterilization is done in large numbers in camps. Hence target related approach towards female sterilization should be avoided. Laparoscopic sterilization has more procedure related complications, which can be better handled in tertiary care centres.

Celiac Axis, Common Hepatic and Hepatic Artery Variants as Evidenced on MDCT Angiography in South Indian Population

Arunthathy Thangarajah, Ramesh Parthasarathy

Introduction: With the increase in the hepatobiliary, pancreatic surgeries and liver transplantation, being aware of the anatomic variations of the celiac axis and the hepatic arteries is of paramount importance. Aim: To illustrate the normal anatomy and variants of the celiac axis and the hepatic arteries with multidetector computed tomographic (MDCT) angiography in South Indian population and determine the potential variations in the celiac axis anatomy and the hepatic arteries, thus assisting the hepatobiliary surgeon and the interventional radiologist in avoiding iatrogenic injury to the arteries. Materials and Methods: Two hundred patients undergoing abdominal CT angiography from July 2014 till July 2015 were retrospectively studied for hepatic arterial and celiac axis anatomical variation. The anatomic variations in our study were correlated with other studies. Results: The celiac axis (CA) and the hepatic artery (HA) variations were analysed as per criteria laid by Song et al., and Michel. Out of 15 possible CA variations, 5 types of celiac artery variations were seen in 14 patients. A normal CA was seen in 179(89.5%) patients of the 200 patients. In the remaining 7 patients, the CA anatomy was classified as ambiguous since there was separate origin of the right and left hepatic arteries from the CA with absent common hepatic artery (CHA). The CHA originated normally from the celiac axis in 94% of the cases. Variation of CHA origin was seen in 5 patients. Normal HA anatomy was seen in 114 (57%) patients. Variation in HA anatomy was seen in 86 (43%) patients. Origin of the right hepatic artery (RHA) from the hepatic artery proper was seen in 182 (91%) patients and replaced origin of RHA from the superior mesenteric artery (SMA) was seen in 18 (9%) of the cases. Accessory RHA was seen in 7(3.5%) patients. The left hepatic artery (LHA) originated from the hepatic artery proper in 186 (93%) patients and replaced origin of LHA from the left gastric artery (LGA) was found in 14 (7%) patients. Accessory left hepatic artery was found in 22(11%) cases. Double hepatic artery seen in 7(3.5%) patients. CHA replaced to LGA was seen in 1 patient (0.5%). CHA trifurcation was seen in 11 (5.5%) patients. CHA was replaced to SMA in 4 (2%) cases. Conclusion: Our study identified the normal anatomy and variations in celiac axis and hepatic arterial anatomy in South Indian population, which correlated well with studies in other populations.

Open-label, Prospective, Investigator Initiated Study to Assess the Clinical Role of Oral Natural or Synthetic Progesterone During Stimulated IUI Cycles for Unexplained Infertility

Jaideep Malhotra, Korukonda Krishnaprasad

Background: Unexplained infertility remains as one of the important subtype of infertility that follows expectant management with Intrauterine Insemination (IUI) in most cases. Aim: To evaluate the clinical role of progesterone supplement as luteal phase support for women with unexplained infertility following stimulation protocol with Clomiphene Citrate (CC)/Human Menopausal Gonadotropin (HMG). Materials and Methods: An investigator initiated study to survey the success rate for first cycle of IUI following stimulation protocol with CC/HMG & luteal phase support with oral natural or synthetic progesterone was conducted. 120 patient records between observation period of Jan to May ’14 were retrieved especially for subjects undergoing IUI procedure for Unexplained infertility. Patients with baseline Serum (Sr). progesterone records who received Oral Natural Micronized Progesterone Sustained Release (Oral NMP SR) (N=45) or Dydrogesterone (n=33) following CC/HMG induction protocol and human Chorionic Gonadotropin(HCG) Inj., were further analysed following Luteal Phase Support(LPS) with oral natural or synthetic progesterone. Results: Baseline demographics showed 78 patients with mean age, weight and cycle duration of 29.5 yrs, 57.3 kg & 28.6 days respectively. Progesterone was supplemented as Oral NMP SR 200/300 mg OD or Dydrogesterone 10 mg bid in 22, 23 and 33 patients respectively. In all cases ovulation was triggered with HCG inj., followed by IUI within the next 48 hours while baseline sr. progesterone levels were being assessed. Medicines and Healthcare Products Regulatory Agency (MHRA) UK recommended therapeutic compliance to suggest sr. progesterone levels of =14ng/ml were recorded as Mid-luteal levels in all of these patients. This therapeutic compliance was noted in 82.2% & 78.8% of the patients treated with oral NMP SR or Dydrogesterone respectively. Pregnancy was observed amongst 5 and 10 patients treated with oral NMP SR and Dydrogesterone respectively at the end of ‘First’ IUI cycle. Both the groups were well tolerated with drowsiness documented in three cases for Oral NMP SR. Conclusion: Clinical supplementation with ONMPSR suggests therapeutic compliance and alternative strategy to conventional formulations while offering dosing convenience with minimal side effects.

Evaluation of Specificity and Sensitivity of Oral Fluid for Diagnosis of Hepatitis B

Introduction: Hepatitis B viral infection is a global health issue. Various screening and confirmatory serological tests have evolved in the past few decades for detection of hepatitis B. However, oral fluid as an alternative to blood could provide substantial advantages. The study aimed to evaluate the diagnostic efficacy of oral fluid in detecting hepatitis B surface antigen using Enzyme Linked Immunosorbent Assay (ELISA). Materials and Methods: Salivary and blood samples were collected from 40 seropositive and 40 seronegative patients of hepatitis B viral infection and were subjected to ELISA test for hepatitis B surface antigen. Mann-Whitney U test was used to test the statistical significance and Kappa (K) statistic was used to assess the degree of agreement between serum and oral fluid samples. The p-value <0.05 was considered as significant value. Result: A sensitivity and specificity of 100% of oral fluid assay was obtained for the diagnosis of hepatitis B infection. The degree of agreement between saliva and serum for detection of hepatitis B was found to be perfect (Kappa value =1). Conclusion: Oral fluid testing can be an interesting, alternative for hepatitis B infection for diagnosis and screening for epidemiological purposes. Further research necessitates for the implementation of saliva as a diagnostic tool.

An Affordable, Indigenous Polarizer-Analyser System with Inbuilt Retardation Plate Function to Detect Birefringence using 3D Glasses: An Experience

Desai Parth Anil, Dange Prasad Sudhir, Annapurna Saksena, Nita Khurana

Introduction: Polarizing microscope plays a vital role in few but unique situations. A pair of cross polarizers is used to confirm the presence of birefringent substances. Also, a red retardation plate is needed to evaluate the sign of birefringence. However, a polarizing microscope especially with retardation plate is very expensive. Thus, an affordable yet effective substitute using the 3D Polaroid glasses used for ‘3D movies’ would enable widespread use of the polarizing system. Aim: To study the use of 3D polaroid glasses procured from cinema halls in detecting birefringence substances and to study the red retardation plate function in them. Materials and Methods: Passive 3D Polaroid glasses were procured from cinema halls. They were arranged in aspecific manner to obtain polarized light. Red retardation plate function can be obtained by changing the arrangement of the glasses. These glasses were used with various available models of different light microscope manufacturers. Various specimens observed included amyloid deposits, woven and lamellar bone, skeletal muscle striations, urate crystals, cholesterol crystals, suture material and glove powder. The comparison was based on subjective interpretation of intensity and quality of birefringence. Sign of birefringence was also determined whenever relevant. Results: The birefringence observed by our system was comparable to the commercially available polarizing system with respect to intensity and quality. Also, there were no false positive /negative results when compared with the commercial Polarizing microscope. Moreover, the system had an inbuilt red retardation plate to determine sign of birefringence. Conclusion: The system is efficient, cheap, easily accessible, portable and compatible with all models of light microscopes.

Measuring Respiratory Pressures with Mercury Manometer in Low Economic Health Care Settings- An Analytical Study

Prem Balaguru, Vishnupriya Hariharan, Rajajeyakumar Manivel, Madanmohan Trakroo

Introduction: Health care economics restricts many health centers from using hi-tech diagnostics equipment. Mercury manometers are used for calibration of pressure transducers. If standardized it would be a cost effective, simple alternative to transducers in low economic settings. Aim: To analyse the feasibility of mercury manometer usage in respiratory pressure measurement. Materials and Methods: The experimental study was conducted with 30 healthy volunteers of age group 17–19 yrs. They were recruited by using simple random sampling method. The volunteers were made familiarized to lab environment, instrument and techniques of maximum inspiratory (Pimax) and expiratory pressures (Pemax). Then parameters were recorded using mercury manometer connected to different syringes as mouth piece (2.5 ml, 10 ml, and 20 ml) and with sphygmomanometer. Statistical analysis was done by using IBM SPSS statistics version 21. Results: The Pimax was 111.07 ± 6.53 with a 2.5 ml syringe as mouth piece. With 20 ml syringe it was 61.47 ± 9.98. PEmax with 2.5 ml syringe was 70.33 ± 8.19 with a confidence limit of 2.93 and with sphygmomanometer was 99.33 ± 8.16 with a confidence limit of 2.92. There was a change in recorded pressure and the correlation analysis result showed a significant difference from both above and below 10 ml mouth piece range. Conclusion: Mercury manometers could be used for recording respiratory pressures in low economic facilities once standardized. Size of syringe to be used as mouth piece needs further more works although this study finds 10 ml syringe as suitable.

Comparative Evaluation of Antifungal Effect of Titanium, Zirconium and Aluminium Nanoparticles Coated Titanium Plates Against C. albicans

Introduction: The topographical modifications may vary from millimeter wide grooves to nano size structures. Recently growing nano technology is rapidly advancing surface engineering in implant dentistry. This advancement has resulted in difference in surface properties including the morphology, chemistry, crystal structure and mechanical properties of the implant. Aim: To evaluate the anticandidal effect of titanium, zirconium and aluminium nanoparticles against C. albicans at 24 hours, 72 hours and one week time interval. Materials and Methods: According to ISO/TR 11175:1993, the samples were prepared with the dimension of 20mm diameter and 1mm thickness in grade IV titanium. A total of 40 samples were made and the samples were divided into four groups. The samples without coating were Group-A (control), samples coated with titanium nano particles were Group-B, samples coated with zirconium nano particles were Group-C and samples coated with aluminium nano particles were Group-D. The samples were cleaned by sonicating in acetone and subsequently in water three times for 15 min. Then they were treated with TiO2, ZrO2 and Al2O3 nanoparticles. The discs were sterilized under uv radiation and placed in SDA for C.albicans. The colonies were counted in 24, 72 hours and one week intervals. Results: The values were statistically analyzed using one-way ANOVA and Tukey HSD Test. Significance p-value was < .001, which showed that significant difference in C.F.U among the groups in titanium coated samples at 24 hours, 72 hours and one week time intervals. Conclusion: TiO2 nanoparticles coated titanium plates showed significant anticandidal effect compared to ZrO2 and Al2O3 nanoparticles at 24, 72 hours and one week time interval.

A Comparison Between Phorbol 12 Myristate 13 Acetate and Phorbol 12, 13 Dibutyrate in Human Melanocyte Culture

Divya Padma, Kumar M.R. Bhat

Introduction: Melanocyte culture is an integral part of the studies of skin biology and cosmetic applications. After the introduction of selective medium for the culture of human melanocyte using Phorbol 12-myristate13-acetate (PMA) in 1982, a lot of methods of culturing were tried but till date PMA is a preferred mitogen because of its cost effectiveness compared to growth factors. We have tried to preliminarily evaluate the efficacy of another phorbol ester, Phorbol 12, 13-dibutyrate (PDBu) in melanocyte culture because of its less hydrophobic nature compared to PMA. This property minimizes the trace amount of mitogen in cell culture after washing off and hence does not interfere in other biological assays. Aim: To evaluate the differences in the melanocyte survival rate, morphology and mitotic index when grown in media supplemented with PMA and PDBu. Materials and Methods: Foreskins were collected from children undergoing circumcision. Epidermal cells were isolated from foreskin and cultured using PMA and PDBu. Melanocytes in culture were monitored for the better establishment and documented. In proliferative assay, melanocytes were treated with PMA and PDBu for 24, 48 and 72 hours and proliferation was measured using 3-(4,5-Dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay method. Results: When cultured, melanocytes acquired proliferative status and bipolar morphology quicker in PDBu medium than in PMA medium. Keratinocytes survived as contamination in PMA medium whereas PDBu medium had minimal keratinocytes. MTT assay showed that PDBu has higher proliferative induction capacity than PMA. In even lower concentration of PDBu in medium, melanocytes survived till 72 hours without significant cell loss in compared to PMA medium. Conclusion: PDBu can be a valuable replacement for PMA in human melanocyte culture. Higher proliferation induction, unfavourable to keratinocyte survival and less hydrophobicity make PDBu a promising alternative for quicker establishment of pure human melanocyte cultures especially in cosmetic in vitro experimental dermatology.

Histopathological and Immunohistochemical Evaluation of Meningiomas with Reference to Proliferative Markers p53 and Ki-67

Introduction: Meningiomas are slow growing primary central nervous system (CNS) tumours attached to the duramater, which arise from the meningothelial cells of the arachnoid. Grading of meningioma based on histological findings assisted with supplementary immunohistochemical studies, predicts the prognosis of meningioma with good precision. Aim: To evaluate proliferative markers and correlate with various histological subtypes and grade. Materials and Methods: A total of 224 meningiomas, diagnosed between January1995 and October 2011were graded according to WHO 2007 criteria. Immunostaining for p53 and Ki-67 markers were performed on 100 cases. Results: There was female predominance. There were 194 Grade I, 24 Grade II and 6 Grade III meningiomas. Brain invasion noted in 18(8%) meningiomas predominantly in grade III followed by grade II. Recurrence was seen in 7 (3.1%) cases, most common in psammomatous followed by angiomatous meningioma. Immunostaining showed p53 positivity in 72.5% of grade I, 83.3% of grade II and all the cases of grade III tumours. Ki-67 Labelling Index (LI) consistently increased from grade I to grade III tumours. Conclusion: p53 and Ki-67 LI correlated well with increasing histological grade and biological behaviour of meningioma.

In Spinal Anaesthesia for Cesarean Section the Temperature of Bupivacaine Affects the Onset of Shivering but Not the Incidence: A Randomized Control Trial

Nand Kishore, Yashwant Singh Payal, Nidhi Kumar, Nidhi Chauhan

Introduction: Postoperative shivering is a frequent event after cesarean section under spinal anaesthesia. Shivering is uncomfortable for the patient and may interfere with monitoring. The exact aetiology of shivering is unknown and therefore has no definite treatment. Aim: The temperature of injectate affects the spread of drug and so its effect. Therefore the aim of this study was to compare the effect of temperature of bupivacaine on post-spinal shivering in cesarean section. Materials and Methods: In this prospective, randomized, controlled, double-blind clinical trial 105 ASA-I/II pregnant women scheduled for caesarean section under spinal anaesthesia were selected and randomized into three groups of 35 each. In all pregnant women spinal anaesthesia was achieved with 2.2 ml of 0.5% hyperbaric bupivacaine given either at L3-L4 or L4-L5 interspace. The temperature of bupivacaine was adjusted to 4°C (group T4), 22°C (group T22) and 37°C (group T37). Shivering characteristic, onset and incidence was noted. All three groups were compared using analysis of variance (ANOVA), adverse effects was compared using chi-square test and Kruskal-Wallis H-test. The p-value < 0.05-considered as significant and p-value <0.01-considered highly significant Results: There were no differences between the groups regarding age, weight, height, amount of fluid used and blood loss. The incidence of shivering was 51.42%, 51.42% and 45.71% in group T4, group T22 and group T37 respectively, this difference in the incidence was statistically not significant (p=0.858). However, the onset of shivering was earliest (9.87±1.82 min) in group T4 as compared to 14.27±3.02 min and 12.16±2.89 min in group T22 and group T37 respectively and this difference in the onset was highly significant (p= 0.0001) Conclusion: In spinal anaesthesia for cesarean section, the temperature of bupivacaine does not influence the overall incidence of post spinal shivering; however cold bupivacaine can provoke early onset of shivering.

A Comparison Between Non-Descent Vaginal Hysterectomy and Total Abdominal Hysterectomy

Dhivya Balakrishnan, Gharphalia Dibyajyoti

Awareness and Determinants of Contraceptive use among Nursing Mothers in Bellary, Karnataka

Bhavya S Rao, Veerendrakumar Chowdapur Mathada

Introduction: The nursing mothers, who have already delivered a child in recent period, may prefer to avoid or delay future pregnancy, or may not even have given a thought about it. Among those who prefer to delay next pregnancy, many are unaware of family planning practices. This is mainly influenced by the prevailing sociodemographic factors in their families. Aim: To study the prevailing Knowledge, Attitude and Practice of contraception and the influence of sociodemographic factors on family planning practices among the healthy nursing mothers. Materials and Methods: A cross-sectional study was conducted among 2500 healthy breast feeding mothers who delivered at Medical College Hospital (MCH), Vijayanagara Institute of Medical Sciences(VIMS), Bellary during Dec 2011 to Nov 2013. They were interviewed using a pre structured questionnaire in the post natal wards on 2nd to 7th postpartum day. Later these mothers were educated and counseled regarding various suitable contraceptive methods. The data collected were analysed using percentage and chi- square test. Results: The proportion of willingness for contraception is more among women in the age group 19-29 years, among literate husband and wife, among women belonging to nuclear families and with higher socioeconomic status. Muslim women were least receptive to contraceptive advice. Regarding awareness of contraceptive methods only 46% had knowledge regarding family planning methods. A total of 43% mothers opted to limit family size. Among 16% of mothers who did not want to limit family size, 70% had no male child. In most of the families, final decision regarding family planning method was taken by husband alone or by elders. The most important reason for lack of family planning practices was lack of awareness (57.2%). Conclusion: Many of the nursing mothers are not aware of contraceptive practices. But these women are very receptive to contraceptive advice. Also, the decision of family planning depends not only on the couples but even on elders of the family. Hence, a combined family approach to educate and counsel the entire family including elders is needed. The major determinant is education of the entire family regarding family planning practices.

Assessment of Salivary Gland Function Using Salivary Scintigraphy in Pre and Post Radioactive Iodine Therapy in Diagnosed Thyroid Carcinoma Patients

Introduction: Thyroid carcinoma represents less than 1% of all cancers. The first line of treatment for thyroid cancer is partial/total thyroidectomy. High-dose Iodine131 therapy using Iodine radioisotopes is commonly used in patients with well differentiated thyroid carcinoma after total thyroidectomy. In this process, the non-thyroidal tissues, such as, salivary gland, stomach and breast tissues also take up radioactive iodine. Salivary gland scintigraphy is widely accepted as a sensitive and valid method for evaluation of salivary gland dysfunction after Radioactive Iodine131 Therapy (RIT). Aim: To assess and compare the salivary flow rates, relative uptake and ejection fractions in parotid and submandibular glands just before and one month after Iodine131 therapy. Materials and Methods: The study was conducted on 24 patients diagnosed with well differentiated thyroid carcinoma who underwent partial/total thyroidectomy and were due for radioactive iodine therapy. These patients were divided into two groups based on the lesion based dosimetry (Group A: 60-100Gy; Group B: 100-150Gy). Salivary gland assessment was done by salivary gland scintigraphy before and after RIT. Statistical Analysis: The data collected was tabulated and statistically analysed using SPSS software version16 using paired t-test and individual sample t-test. Results: A statistically significant difference in the uptake percent and ejection fraction percent in the parotid and submandibular glands before RIT and one month after RIT was observed in the study. Conclusion: We inferred from the study that there was an overall decrease in uptake percent and ejection fraction percent one month post RIT in both parotid and submandibular glands. Also, a statistically significant difference was noted in the uptake and ejection fraction percent between Group A and Group B concluding the fact that the damage is dose related.

Aesthetic Crown Lengthening Using Chu Aesthetic Gauges And Evaluation of Biologic Width Healing

Aruna Nautiyal, Sheela Gujjari, Vikas Kumar

Introduction: The principles of biologic width have governed the literature and served as a clinical guideline during the evaluation of perio- restorative interrelationships. An adequate understanding of this concept is paramount to ensure adequate form, function, aesthetics and comfort of the dentition. Biologic width violation has become a common problem as most of the practitioners tend to underestimate the amount of tooth structure that must be exposed during a crown lengthening procedure. Also, adding to the confusion, there is a lack of general agreement regarding the amount of tooth structure that must be exposed above the crest of bone for restorative purposes. Aim: The aim of this study was to perform aesthetic crown lengthening using Chu aesthetic gauges and evaluate the healing of biologic width. Materials and Methods: A total of 90 teeth in 15 patients were included into the study of which 30 teeth required crown lengthening and 60 teeth shared a proximal surface with the experimental teeth. Aesthetic crown lengthening was performed using the Chu aesthetic gauges. Presurgical and intraoperative data were recorded at baseline, three and six months at six sites per tooth. Results: The computed data suggest that although the positional changes of the periodontal tissues stabilize by three months, the biologic width if adequate crown lengthening is carried out re-establishes itself by three months to the original vertical levels and further gets stabilized by six months. Conclusion: A step by step approach to periodontal aesthetic crown lengthening using Chu aesthetic gauge can serve to be vital for successful, predictable, and aesthetic restorative outcome.

Evaluation of Salivary Nitric Oxide Levels in Smokers, Tobacco Chewers and Patients with Oral Lichenoid Reactions

S. Preethi, Joy Idiculla Jose, B. Sivapathasundharam3 B. Sabarinath

Introduction: Nitric oxide (NO), a free radical, acts as a signalling molecule affecting numerous physiological and pathological processes. Role of nitric oxide as a mediator in tobacco related habits and the resultant oral lichenoid reactions was assessed. Aim: The aim of the study is to evaluate and compare the salivary nitric oxide levels in normal patients with that of smokers, tobacco chewers and patients with oral lichenoid reactions. Materials and Methods: One hundred and twenty patients were enrolled in the study which included 30 healthy patients without any chronic inflammatory lesion and habit as controls (group I), 30 smokers without the habit of tobacco/betel nut chewing and any oral lesion (group II), 30 tobacco chewers without the habit of smoking and any oral lesion (group III) and 30 histologically confirmed cases of oral lichenoid reaction with the habit of tobacco usage (group IV). Saliva from these patients was collected and the nitrite concentration was assessed. Results: Our results concluded that there was highly significant increase in the nitric oxide levels in smokers, tobacco chewers and patients with oral lichenoid reactions compared to that of controls. Also, there was a significant increase in nitric oxide levels in patients with smoking associated oral lichenoid reactions in comparison with smokers and in patients with lichenoid reactions associated with tobacco chewing in comparison with tobacco chewers. Conclusion: Estimation of salivary nitric oxide levels is a simple, non-invasive procedure and could be analysed to suggest the role of nitric oxide in the pathogenesis of these lesions. The increased activity of the enzyme may indicate that nitric oxide has a pathophysiological role in these lesions.

Colour Doppler Evaluation of Extracranial Carotid Arteries: A Clinical and Radiological Correlation

Shivani Garg, Shivali V. Kashikar, Suresh Phatak

Introduction: Atherosclerosis (i.e. hardening and thickening of arteries) causes vascular remodeling, obstruction of lumen, abnormalities of blood flow and reduced oxygenation of target tissues. Manifestation of atherosclerosis in the form of either Myocardial Infarction or Stroke is the major cause of morbidity and mortality. This study evaluated extracranial carotid arteries of patients (>60 years) who presented with risk factors of atherosclerosis and determined the association of risk factors with carotid abnormalities. Aim: To evaluate the prevalence of atherosclerosis, haemodynamic and morphological changes that take place in extra cranial portion of carotid arteries in patients with risk factors of atherosclerosis (Diabetes Mellitus, Hypertension, Smoking, Stroke, Coronary Artery Disease, Hypercholesterolaemia) and determine the association of risk factors with carotid abnormalities. Materials and Methods: The prospective cross-sectional analytical study included the examination of Extracranial carotid arteries of 1043 patients over a period of 2 years (2013-2015) using duplex ultrasound. Assessment of CCA-IMT, ICA-IMT and percent stenosis was done using a linear probe of 8-12 MHz. Statistical Analysis: Correlation between risk factors of atherosclerosis, wall thickness of common carotid (CCA-IMT), internal carotid arteries (ICA-IMT) and stenosis was studied using statistical tools like multiple logistic regression analysis and analysis of variance (p<0.05) using SPSS 17.0. Results: Maximum percent stenosis increased with increase in age. Prevalence of severe stenosis (>70%) was low while the prevalence of mild stenosis (<50%) was quite high. In all age groups, stenosis was more prevalent and more severe in men as compared to women. Hypertension showed the strongest positive correlation with all three measures of interest CCA-IMT, ICA-IMT and maximum percent stenosis. Stroke history showed strong positive correlation with CCA-IMT and stenosis. Smoking, Diabetes Mellitus, Hypercholesterolaemia, Heart disease showed strong association with all three measures as well. Atherosclerotic plaques were mostly found at the site of carotid bifurcation. Conclusion: CCA-IMT was strongly associated with hypertension, smoking and diabetes mellitus. ICA-IMT was strongly associated with hypertension and history of heart disease. Percent stenosis was strongly associated with smoking and history of heart disease.

Prevalence of Escherichia coli O157:H7 in Children with Bloody Diarrhea Referring to Abuzar Teaching Hospital, Ahvaz, Iran

Introduction: Escherichia coli O157: H7 are recognized as important aetiological agents of diarrhea in children, particularly in developed countries. Aim: The aim of the study was to determine the rates of detection of E. coli O157: H7strains among children in Ahvaz, Iran. Materials and Methods: From June 2010 to December 2010, 137 diarrheal stool samples of children were collected. E.coli was identified by standard microbiological techniques. O157 or O157:H7 subtypes discerned by serological tests. Results: Of the 137 E. coli isolates, enteropathogens were found in 53 (38.7%) of the patients as follow: Shigella spp. (75.5%), EPEC (enteropathogenic E. coli) (16.9%), Campylobacter spp. (3.8%) and Salmonella spp. (3.8%). None of the isolated E. coli was O157:H7 serotype. Conclusion: This shows that non-O157:H7 E. coli are the major cause of paediatric infections in this region of Iran.

A Randomised Open Label Comparative Clinical Trial on the Efficacy of Latanoprost and Timolol in Primary Open Angle Glaucoma

Sharadashri Rao, P.V. Narayanan

Introduction: Timolol, a beta blocker, is the most commonly prescribed first line therapy in the treatment of primary open angle glaucoma. Latanoprost, a prostaglandin analogue, is a novel drug in glaucoma therapy. Its efficacy has to be proved for it to be included under the first line therapy in the treatment of primary open angle glaucoma. Aim: To compare the efficacy of Latanoprost with that of Timolol in the treatment of primary open angle glaucoma (POAG). Materials and Methods: In this study the enrolled patients were randomly divided into two groups by block randomization. The sample size was determined to be 60 in each group. One group received 0.005% of Latanoprost once daily in the evening and the other group 0.5% of Timolol twice daily. The efficacy was measured in terms of intraocular pressure at scheduled follow up visits. Results: At the start of the study, intraocular pressures of both groups were comparable. At the end point, reduction of intraocular pressure among Latanoprost group was significantly greater than that of Timolol group (9.72 vs 7.27, p = 0.002). Conclusion: Latanoprost was found to be superior to Timolol in reducing the intraocular pressure in treatment of patients with primary open angle glaucoma.

Age-Related Normogram for Ovarian Antral Follicle Count in Women with Polycystic Ovary Syndrome and Comparison with Age Matched Controls Using Magnetic Resonance Imaging

Introduction: Antral Follicle count (AFC) is a reliable marker for ovarian reserve. Previous studies have used transvaginal ultrasound for estimation of AFC, however we used magnetic resonance imaging (MRI) for estimation of AFC and for creating an age-related normogram in patients with polycystic ovary syndrome (PCOS) and compared it with normal patients. Aim: The aim of this study is to create an age related normogram for AFC in women with PCOS and to compare that with women without polycystic ovarian syndrome using MRI. Materials and Methods: A total of 1500 women were examined, out of which 400 fitted the criteria for PCOS. They all underwent MRI study and similar age matched women without PCOS also underwent MRI examination. Normogram for AFC were obtained using LMS software and a percentile chart was obtained. Results: Normogram for AFC in PCOS women showed decline in number of AFC as the age progresses and the decline was linear. The normogram for AFC was compared with equal number of patients without PCOS and they also showed decline in AFC as the age progresses, however the decline was exponential and faster. Conclusion: Age related normogram for AFC is widely used and considered as best clinical predictor for ovarian response in assisted reproductive technology. Knowledge of ovarian reserve is important in PCOS and non-PCOS females as PCOS patients are at risk for ovarian hyperstimulation syndrome during gonadotrophin theraphy. MRI is an equally effective and in some times better alternative to transvaginal ultrasound as it has got its own advantages.

Safe Injection Practices in Primary Health Care Settings of Naxalbari Block, Darjeeling District, West Bengal

Sudip Banik Chaudhuri, Kuntala Ray

Introduction: Unsafe injection can transmit many diseases to patients, injection providers and healthy people of community. Aim: To find out critical steps whether executed according to recommended best practice methods, availability of equipments in health facilities for safe injection practices and some important steps of waste disposal methods. Materials and Methods: This facility-based cross-sectional observational study was conducted among 30 Auxiliary nurse midwives (ANM) & 27 nursing staffs (NS) to assess certain aspects of their practice while administrating injection and disposal of the disposables. Health facilities were also observed to asses necessary equipments of safe injection and waste disposal methods. Results: Among the health workers 93.3% ANM and 100% NS took sterile syringe from sterile unopened packet, all of the study subjects washed hand before giving injection, 13.3% of ANMs and 8% of NS are fully vaccinated against Hep B, 53.3% of ANM and all NS are practices non recapping. Only 13.33% sub centres along with PHC & BPHC had at least one puncture resistant leak proof container, 86.7% sub centres, PHC are free from loose needles. Transport for off side treatment is the method of waste disposal in case of 73.3% cases sub centres, PHC & BPHC. Conclusion: There is need to educate, train and motivate service providers in proper methods of giving injection along with improve the adequacy of supply of required equipments.

A Retrospective Study of the Pattern of Sexually Transmitted Infections in Males: Viral Infections in Emerging Trend

Murugan Swamiappan, Vijayabhaskar Chandran, Prathyusha Prabhakar

Introduction: Sexually transmitted infections (STIs) continue to be a major public health problem with significant burden on the society even after so many health care programmes being organized by the governmental and non-governmental organizations and awareness created among general public about STIs. Male patients are common visitors to STI clinic than females who are generally traced as a contact in our society. Aim: The aim of this study was to give an overview of the pattern of STIs among males at a tertiary care teaching hospital over a period of 5 years. Materials and Methods: A retrospective chart review of the data collected from the clinical records of all male patients, who had attended the STI clinic of Chengalpattu Medical College Hospital, Chengalpattu, Tamil Nadu, for various complaints during the 5 year period from 2010 to 2014 was carried out. All male patients with confirmed STIs were included in the study and those patients without any evidence of STIs either clinically or serologically were excluded from the study. Results: Out of the 4454 male cases who had attended the STI clinic, 175 (3.93%) patients had STIs. Genital wart accounted for the maximum number among the STIs with 61 cases (34.86%), followed by genital herpes 56 (32%), urethral discharge 19(10.86%), non-herpetic genital ulcerative diseases 17(9.71%) and serological test for syphilis (RPR) was reactive in 22 (12.57%) patients. HIV was positive in 68 (1.53%) among the total 4454 male patients attended the clinic. Conclusion: Viral STIs occur significantly more than the bacterial STIs because of its incurable and recurrent nature. Health programmes should be still more focused on creating awareness about the minor STIs and to remove the stigma so that the patients attend the proper health care facilities in the early stage itself for treatment thereby, complications and further transmission of the STIs can be avoided.

Clinical Evaluation of Low Level Diode Laser Application For Primary Teeth Pulpotomy

Introduction: Inspite of latest advances in the materials and techniques practiced for the treatment of pulpally infected teeth with better reported success rate, still the question arises for safety and effectiveness of these medicaments. Aim: The objective of the present study was to compare the effectiveness of the Low Level Laser Therapy to Mineral Trioxide Aggregate (MTA) when used for pulpotomy in vital human primary molars. Materials and Methods: The sample consisted of 40 primary molars from 29 children aged four to seven years. The teeth were selected based on clinical, radiographic criteria and randomly allocated to two groups. All the 40 primary molars were subjected to standard pulpotomy procedure, where in 20 molars received MTA (Group I) and 20 molars received LLLT (Group II) pulpotomy. Children were recalled at 3, 6 and 12 months intervals and pulpotomised molars were examined clinically and radiographically. Data was analysed using chi-square test. Results: MTA showed 94.7% success rate at all the three intervals, where as LLLT showed a success of 95% at three months, which decreased gradually to 85% at six months and 80% at 12 months. Intergroup comparisons were not significant. Conclusion: Low level laser therapy can be considered for primary teeth pulpotomy and its success is comparable to MTA pulpotomy technique.

Reliability and Validity of Standing Back Extension Test for Detecting Motor Control Impairment in Subjects with Low Back Pain

Gauri A Gondhalekar, Senthil P Kumar, Charu Eapen, Ajit Mahale

Introduction: Low back pain is a chronic health problem with high socioeconomic impact. Specific diagnosis or treatment approach has not yet effectively established to treat chronic low back pain. Standing Back Extension Test is one of the clinical measures to detect the passive extension subgroup of Motor Control Impairment (MCI); which could have an impact on spinal stability leading to recurrent chronic low back pain. Reliability and validity of this test is not fully established. Aim: To determine the intra-rater and inter-rater reliability and concurrent validity of the Standing Back Extension Test for detecting MCI of the lumbar spine. Materials and Methods: A total of 50 subjects were included in the study, 25 patients with Non Specific Low Back Pain (NSLBP) (12 men, 13 women) and 25 healthy controls (12 men, 13 women) were recruited into the study. All subjects performed the test movement. Two raters blinded to the subjects rated the test performance as either ‘Positive’ or ‘Negative’ based on the predetermined rating protocol. The thickness of Transverse Abdominis (TrA) muscle was assessed using Rehabilitative Ultrasound Imaging (RUSI). Statistical test used: For reliability, the kappa coefficient with percent agreement was calculated and for assessing the validity Receiver Operator Characteristic (ROC) curves and Area under the Curve (AUC) were constructed. Results: The standing back extension test showed very good intra-rater (k=0.87 with an agreement of 96%) and good inter-rater (k=0.78 with an agreement of 94%) reliability and high AUC for TrA muscle. Conclusion: The standing back extension test was found to be a reliable and a valid measure to detect passive extension subgroup for MCI in subjects with low back pain.

Effect of Topical Application of the Cream Containing Magnesium 2% on Treatment of Diaper Dermatitis and Diaper Rash in Children A Clinical Trial Study

Introduction: Diaper dermatitis is referred to the inflammation in outer layers of the skin in the perineal area, lower abdomen, and inner thighs. The lesions are maculopapular and usually itchy, which could cause bacterial or candida infection, and predispose the infants to penis or vaginal and urinary infection and lead to discomfort, irritability, and restlessness. The drugs which have been so far administered for this disease (topical steroids) cause special complications for the sensitive skin in this area. Magnesium (Mg) is known for its anti-inflammatory and wound-healing properties. Aim: The aim of the present study was to study the effect of the cream containing Mg 2% on treatment of diaper dermatitis and diaper rash in children. Materials and Methods: In this clinical trial study, 64 children aged less than two years old with diaper dermatitis referring Paediatric Ward of Hajar Hospital were randomly assigned to two groups of 32. Group one was treated with the combined cream Mg 2% and Calendula and group two with Calendula cream alone. The duration of recovery was compared between the two groups. Results: The duration of recovery was significantly lower in the intervention group than the control group (p-value<0.001), but there was no significant difference in the lesions size and diapers’ number between the two groups. Conclusion: Based on the finding of this study, Mg is effective on treatment of diaper dermatitis and could be used for treating diaper dermatitis and other types of dermatitis.

Dexmedetomidine as an Adjuvant to Pre-Emptive Caudal Epidural Ropivacaine for Lumbosacral Spine Surgeries

Sandhya Kalappa, Raghavendra Biligiri Sridhara, Saraswathi Kumaraswamy

Introduction: Pre-emptive caudal epidural is a proven technique for providing analgesia for spinal surgeries. Prolonged pain relief with no motor blockade is desired for early mobilisation. Aim: Present study aimed to evaluate the effect of addition of Inj dexmedetomidine to caudal ropivacaine on the duration of analgesia, haemodynamic profile and the associated side effects. Materials and Methods: In this prospective double-blind study a total of 60 patients undergoing lumbosacral spine surgery were randomised to receive 20 cc of pre-emptive caudal epidural injection of either inj ropivacaine 0.2% ( Group R, n =30) or a mixture of Inj ropivacaine 0.2% and Inj dexmedetomidine 1 µg/kg (Group RD, n =30) under general anaesthesia after the patient was positioned prone for surgery. VAS scores, heart rate, blood pressures and time to rescue analgesia were recorded at regular intervals for the first 24 hours. Data analysis was carried out using Statistical Package for Social Science (SPSS, V 10.5 package). Results: Mean VAS scores were significantly lower in the RD group for up to 12 hours following the caudal block. No clinically significant haemodynamic changes were noted in either of the groups. No other side effects were seen in both the groups. Conclusion: These results suggest that inj dexmedetomidine is an effective additive to inj ropivacaine for pre-emptive caudal epidural analgesia in lumbosacral spine surgeries.

Clinicopathological Overview of Granulomatous Prostatitis: An Appraisal

Introduction: Granulomatous prostatitis is a rare inflammatory condition of the prostate. Granulomatous prostatitis is important because, it mimics prostatic carcinoma clinically and hence the diagnosis can be made only by histopathological examination. Aim: To study the histomorphological features and to know the prevalence of granulomatous prostatitis. Materials and Methods: Histopathological records of 1,203 prostatic specimens received in the Department of the Pathology over a period of five years (June 2009 – June 2014). Seventeen cases of histopathologically, diagnosed granulomatous prostatitis were retrieved and reterospective data was collected from the patient’s records. Results: Out of 17 cases of granulomatous prostatitis, we encountered 9 cases of non-specific granulomatous prostatitis, 5 cases of xanthogranulomatous prostatitis and 3 cases of specific tubercular prostatitis. The common age ranged from 51-75 years (mean 63 years) with mean PSA level of 15.8ng/ml. Six patients showed focal hypoechoic areas on TRUS and 11 cases revealed hard and fixed nodule on DRE. Conclusion: Non-specific granulomatous prostatitis is the most common type of granulomatous prostatitis. There is no specific pattern of clinical, biochemical and ultrasound findings that allows the diagnosis of granulomatous prostatitis or differentiates it from prostatic carcinoma. Hence, histomorphological diagnosis is the gold standard in differentiating various prostatic lesions.

ZACD: A Retrograde Panoramic Analysis among Indian Population with New System of Classification

Karandeep Singh Arora, Prabhpreet Kaur, Kirandeep Kaur

Introduction: Zygomatic Air Cell Defect (ZACD) has been considered as a normal radiographic variant with a spare knowledge. This should be judged before any surgical procedure of the temporal region as lack of which can lead to infections of cranium and may other complications. Aim: The present study was undertaken to estimate the prevalence and characteristics of ZACD and to propose a classification for the same using digital panoramic radiography. Materials and Methods: A total of 6825 digital panoramic radiographs were evaluated retrospectively of subjects aged between 4-90 years from both genders. The radiographs were evaluated by 4 (four) oral radiologists and the ZACD was recorded only when the decision was indisputable. Results: Out of 6825 digital panoramic radiographs evaluated ZACD was noticed in 133 subjects with an overall prevalence of 1.94%. A male predilection was noted in the present study with the maximum prevalence during the second, third and fourth decade of life and as the age increases its prevalence decreases. Most commonly it was found to be unilateral and the unilocular presentation being more common. Conclusion: Most of the finding of the present study is in acceptance with those conducted previously, but some of the finding contradicts those in the previous ones. It can be because of low sample size of the previous studies. Moreover this study gives a new system to classify these defects to help diagnose the nature of the defect.

Morphometric Study of Nasal Bone and Piriform Aperture in Human Dry Skull of Indian Origin

Adil Asghar, Aparna Dixit, Mamta Rani

Introduction: Nasal bone and piriform aperture shows racial and geographical differences because of variable climate. The aim of this study was to evaluate the dimensions (maximal width and length), the size and the shape of the piriform aperture (PA) and their sexual dimorphism in North Indian adult. Materials and Methods: In this observational study, dimension of piriform aperture and nasal bone were measured using digital vernier caliper after assessing landmarks around the piriform aperture on the norma frontalis in Frankfurt plane in 40 skull of Indian orgin. Results: The mean width of the piriform aperture was 24.9±1.59 mm in males and 22.77±1.57 mm in females, the mean length was 29.57±3.28mm in females and 31.16±3.58mm in males. The difference between males and females was significant, and our data correlates well with the previously data acquired from humans skulls. Most of North Indian skulls have platyrhine type of piriform aperture (triangular to oval shape with pyriform aperture index of 0.79). Mean length and width of nasal bone were 17.58±2.47mm and 12.1±0.97mm respectively without sexual. Conclusion: Shape and size analysis of the piriform aperture and nasal bone showed the existence of a significant sexual dimorphism. These results encourage us to go further with functional and imaging correlations. This study will also be helpful in forensic research and anthropology.

The Effects of In-Office Reconditioning on the Slot Dimensions and Static Frictional Resistance of Stainless Steel Brackets

Introduction: Orthodontists are commonly faced with the decision of what to do with loose brackets, and with inaccurately located brackets that need repositioning during treatment. One solution is to recycle the brackets. The potential effects of reconditioning a bracket are dependent upon many factors which may result in physical changes like alteration in slot tolerance, which may influence sliding mechanics by affecting frictional resistance. Aim: To study and compare the dimensional changes in the bracket slot width and depth in reconditioned brackets from unused brackets under scanning electronic microscope and to study and compare any consequent effects on the static frictional resistance of stainless steel brackets after reconditioning and in unused brackets. Materials and Methods: Dentarum manufactured 90 stainless steel central incisors edgewise brackets of size 0.22 X 0.030" inch and 0° tip and 0°angulation were taken. 60 samples for measuring frictional resistance and 30 samples for measuring slot dimensions. Ortho organizers manufactured stainless steel arch wires 0.019 X 0.025" straight lengths 60 in number were considered for measuring static frictional resistance. Results: The mean slot width and depth of new brackets were 0.0251" and 0.0471", which exceeded the manufacturers reported nominal size of 0.022" X 0.030", by 0.003" and 0.017". The reconditioned brackets demonstrated a further increase in mean slot width and depth to 0.028" and 0.0518" that is by 0.0035" and 0.0047" which is statistically significant (p=0.001, 0.002). The mean static frictional forces of the reconditioned brackets was nearly similar to that of new brackets that is 0.3167N for reconditioned brackets and 0.2613 N for new brackets. Conclusion: Although the reconditioning process results in physical changes to bracket structure this does not appear to result in significant effect on ex-vivo static frictional resistance.

Is There a Correlation between Languages Spoken and Intricate Movements of Tongue? A Comparative Study of Various Movements of Tongue among the Three Ethnic Races of Malaysia

Introduction: Tongue is mainly used for taste, chewing and in speech. In the present study, we focused on the secondary function of the tongue as to how it is used in phonetic pronunciation and linguistics and how these factors affect tongue movements. Objective: To compare all possible movements of tongue among Malaysians belonging to three ethnic races and to find out if there is any link between languages spoken and ability to perform various tongue movements. Materials and Methods: A total of 450 undergraduate medical students participated in the study. The students were chosen from three different races i.e. Malays, Chinese and Indians (Malaysian Indians). Data was collected from the students through a semi-structured interview following which each student was asked to demonstrate various tongue movements like protrusion, retraction, flattening, rolling, twisting, folding or any other special movements. The data obtained was first segregated and analysed according to gender, race and types and dialects of languages spoken. Results: We found that most of the Malaysians were able to perform the basic movements of tongue like protrusion, flattening movements and very few were able to perform twisting and folding of the tongue. The ability to perform normal tongue movements and special movements like folding, twisting, rolling and others was higher among Indians when compared to Malay and Chinese. Conclusion: Languages spoken by Indians involve detailed tongue rolling and folding in pronouncing certain words and may be the reason as to why Indians are more versatile with tongue movements as compared to the other two races amongst Malaysians. It may be a possibility that languages spoken by a person serves as a variable that increases their ability to perform special tongue movements besides influenced by the genetic makeup of a person.

An Evaluation of Upper and Lower Pharyngeal Airway Width, Tongue Posture and Hyoid Bone Position in Subjects with Different Growth Patterns

Introduction: It is important to evaluate the position of the hyoid bone in relation to the tongue at the beginning of orthodontic treatment so that during the treatment, its position may be directed hence overall impact on airway could be assessed. Aim: The aim of this study was to evaluate the upper and lower pharyngeal airway dimensions, posture of tongue and hyoid bone position in young adults with different growth patterns. Materials and Methods: Sample size of the study included 90 post-adolescent subjects, within the age range of 18-32 years. Based on the different growth pattern of the face, subjects were divided into Group I (n=30; average growth pattern), Group II (n=30; horizontal growth pattern) and Group III (n=30; vertical growth pattern). Lateral cephalogram were traced and analysed manually by the same investigator for evaluation of upper and lower pharyngeal airway, tongue posture and hyoid bone position. The intergroup comparison of upper and lower pharyngeal airway dimensions, posture of tongue and hyoid bone was performed with one-way ANOVA test. Results: The results showed that upper oropharyngeal widths were significantly different in different facial skeletal patterns (p=0.00). Subjects with vertical skeletal pattern have significantly narrower upper airways than those with horizontal skeletal pattern (p= 0.025). There was significantly higher difference in position of dorsum of the tongue in vertical growth pattern group (p=0.00). The hyoid bone was positioned farther from the mandibular symphysis in brachyfacial subjects, reflected by the larger H-RGN (Hyoid- retrognathion) values compared with the dolichofacial and normal subjects (p=0.044). Conclusion: The upper oropharyngeal width was found to be narrower in subjects with vertical growth pattern. The dorsum of the tongue is seen to be placed higher in subjects with vertical growth pattern. The hyoid bone was more inferiorly and posteriorly positioned in subjects with horizontal growth pattern. Variations are seen in upper and lower oropharyngeal widths, posture of the tongue and hyoid bone position in all the growth patterns.

Management of Chronic Hyperplastic Pulpitis in Mandibular Molars of Middle Aged Adults- A Multidisciplinary Approach

The molar tooth of children and young adults is a common site for chronic hyperplastic pulpitis (pulp polyp). It rarely occurs in middle aged adults. This condition is usually characterized by extensive involvement of the pulp, dictating the extraction of involved tooth. Extraction of permanent molars can lead to transient or permanent malocclusion, aesthetic, phonetic and functional problems. Here we report a case of pulp polyp in mandibular first molar of a 33-year-old woman that grew into the carious cavity. The aim of this case report is to describe the diagnosis of a chronic hyperplastic pulpitis involving the permanent molar as well as to describe its management in order to preserve them as a functional unit of the dentition.

Persistent Mullerian Duct Syndrome with Embryonal Cell Carcinoma along with Ectopic Cross Fused Kidney

Persistent Mullerian Duct Syndrome (PMDS) is a form of internal male pseudohermaphroditism, where there is normal development of male secondary sexual characters, along with the presence of bilateral fallopian tubes and uterus. Majority of these cases go undetected and some cases are accidentally diagnosed while investigating for other problems. Cross fused renal ectopia is a condition where one kidney lies in the opposite side, fused to the other kidney. We present an extremely rare case of a phenotypical male presenting with mass per abdomen and bilateral cryptorchidism, turned out to have uterus with bilateral fallopian tubes, ectopic cross fused right kidney and Embryonal cell carcinoma of left undescended testis.

Benign Lymphangioendothelioma - A Case Report

Naveen kumar Vittal, Sushruth Guruputra Kamoji, Shilpa Vinay Dastikop

Benign lymphangioendothelioma is an uncommon locally infiltrative lymphatic tumour, presenting as a slow-growing, asymptomatic, reddish-violaceous macule or plaque. Histopathologically, it is characterized by thin-walled endothelial-lined spaces that are interspersed between strands of collagen. It must be recognized and differentiated from angiosarcoma, early Kaposi’s sarcoma, in view of major differences in treatment and prognosis. A 24-year-old female presented with a raised lesion over the left leg since 2 years which was associated with minimal itching. Biopsy of the lesion showed thin walled vascular channels lined by single layer of bland endothelial cells at the dermo-epidermal junction, few vessels in the dermis.

Eccrine Porocarcinoma of the Scalp: A Rare Case Report with Review of Literature

Smita Surendra Masamatti, Aparna Narasimha, Amoolya Bhat, Vijaya Chowdappa

Eccrine porocarcinoma (EPC) is a potentially lethal neoplasm of the skin that arises from the intraepidermal portion of the eccrine sweat glands. It was previously known as eccrine adenocarcinoma or malignant eccrine poroma. It commonly occurs between 60 to 80 years of age, usually arising from hands and feet. However, few case reports on involvement of rare sites such as scalp, face and eyelids are present in literature. We herein report an unusual case of porocarcinoma arising on the right parieto occipital region of scalp in a 29-year-old young female patient. To the best of our knowledge, there have been fewer than 20 cases of porocarcinoma arising on scalp with fewer than 10 cases seen in younger age group reported previously in the literature.

Direct Sinus Lift and Immediate Implant Placement Using Piezosurgical Approach- A Case Report

Numerous studies have shown that placement of implants in the maxillary region with resultant successful osseointegration can be achieved by the use of sinus lift procedures using piezosurgical technique. In this case report a middle aged patient had come to the outpatient department of A. J. Institute of Dental Sciences with a chief complaint of missing right posterior molar. Since the radiographic ball marker showed only 4 mm bone below the sinus in #16 region, direct sinus lift procedure was done for placement of a dental implant. Piezosurgery was performed, as it reduces the risk of damaging vital soft tissues such as nerves, dura matter and blood vessels. To stabilize the implant in the maxillary sinus region and also to stimulate bone regeneration, gamma irradiated cancellous allograft was used. Periapical radiographs were taken 10 months after implant placement which showed good bone growth over the implant collar. Bone formation in the maxillary antrum was seen clearly in the panoramic radiograph. Using piezosurgical unit, sinus lift procedure with sinus grafting proved to be less traumatic and more successful.

Acute Pancreatitis in a Patient with Complicated Falciparum Malaria

Malaria is one of the most common protozoan diseases, especially in tropical countries. The clinical manifestation of malaria, especially falciparum malaria varies from mild acute febrile illness to life threatening severe systemic complications involving one or more organ systems. We would like to report a case of complicated falciparum malaria involving cerebral, renal, hepatic system along with acute pancreatitis. The patient was successfully treated with anti malarial and other supportive treatment. To the best of our knowledge there are very few reports of acute pancreatitis due to malaria. Falciparum malaria therefore should be added to the list of infectious agents causing acute pancreatitis especially in areas where malaria is endemic.

Pleural Nocardiosis in an Immunocompetent Patient: A Case Report

Smitha Bagali, Prakash Mantur

Nocardiosis is a rare infection that has attracted attention with its increased rate of occurrence in the recent years. In India there is a rare documentation of the pleural involvement in nocardiosis. We report here a case of pleural nocardiosis caused by Nocardia brasiliensis in an immunocompetent patient. This case highlights the importance of considering nocardiosis as a differential diagnosis in patients with pleural lesions.

Neurilemmoma of the Vagus Nerve in the Poststyloid Parapharyngeal Space

Yuji Shinohara, Takashi Matsumoto, Norifumi Kiga, Itaru Tojyo, Shigeyuki Fujita

We report a large vagal neurilemmoma in the poststyloid compartment of the parapharyngeal space. A 52-year-old man was referred to our hospital with a feeling of discomfort in the left upper neck. Computed tomography showed a 30mm x 30mm x 40mm mass with inhomogeneous internal enhancement in the left carotid space. Magnetic resonance imaging revealed a 30mm × 30mm × 40mm heterogeneous mass in the area of the bifurcation of the common carotid artery. We gave a provisional diagnosis of neurilemmoma or vagal paraganglioma in the parapharyngeal space preoperatively based on the results of physical examination and imaging. We selected a transcervical-transmandibular approach. Under general anaesthesia, a tumour originating from the vagus nerve was completely extirpated while protecting the internal and external carotid arteries. Although mild postvagotomy dysphagia and hoarseness were seem for 6 months postoperatively, symptoms resolved and the patient showed a satisfactory course without recurrence after 10 years. Histological examination of the excised specimen showed antoni A and antoni B pattern. Positive immunoreactivity for S-100 protein was identified, but negative results were obtained for neuron-specific enolase, chromogranin and neurofilament. The tumour was diagnosed as neurilemmoma of the vagus nerve.

Periodontal Intervention in Speedy Orthodontics-A Case Report

Snehi Kumar, Amitabh Srivastava, Ashish Sharma, Aarti Garg, Surubhi Kumar

The use of orthodontic treatment in adult patients is becoming more common and these patients have more specific objectives and concerns related to facial and dental aesthetics, specially regarding duration of treatment. Dentists are on the lookout for techniques for increased efficiency in orthodontic treatment. Alveolar Corticotomy-assisted orthodontic treatment is a recent orthodontic technique that is recently gaining wide acceptance and is recorded as effective means of accelerating orthodontic treatment. A 17-year-old female patient was undergoing orthodontic treatment for the past one year but during her space closure, a visual examination confirmed a buccal thickening that was encountered in the buccal plate between premolars and canine. Periodontal intervention involved elective alveolar decortication in the form of dots performed around the teeth that were to be moved. This was carried out to induce a state of increased tissue turnover and a transient osteopenia, which further helps in faster rate of orthodontic tooth movement. Its main advantages are reduction of treatment time and post-orthodontic stability.

Hypersensitivity Pneumonitis in a Housewife Exposed to Aspergillus flavus in Poor Living Conditions: A Case Report

Lalita Fernandes, Anita Sandhya Mendonca Estibeiro, Anthony Menezes Mesquita

Hypersensitivity Pneumonitis (HP) or Extrinsic Allergic Alveolitis (EAA) is a disease resulting from immunologically induced inflammation in response to inhalation of a wide variety of airborne allergens. The condition develops mainly in non atopic individuals sensitized to organic dust due to repeated exposures. It is a relatively rare disease constituting upto 2% of interstitial lung diseases. Knowledge of classical High Resolution Computed Tomography (HRCT) of lung findings aid in early diagnosis. We report a case of subacute hypersensitivity pneumonitis in a housewife who despite being symptomatic remained undiagnosed for two years. She showed a good response to therapy, but soon relapsed. Visit to her home revealed that she lived in a damp house full of moldy walls.

Intralesional Sclerotherapy - A Novel Approach for The Treatment of Intraoral Haemangiomas

In infancy and childhood haemangiomas are the most common neoplasms in head and neck region with an occurrence of about 60%. Approximately 40%-50% of all haemangiomas resolve incompletely, leaving permanent changes in the skin, such as telangiectases, epidermal atrophy, hypopigmentation or redundant skin with fibro-fatty residue but a few stubborn, problematic haemangiomas may result in serious disfigurement and dysfunction, and even become life-threatening. Most haemangiomas are managed by conservative methods that include corticosteroids (either systemic or local injection), sclerotherapy, interferon-alpha, laser therapy, embolization, cryotherapy, and radiation. Due to risk of haemorrhaging, surgical removal for small vascular lesions is not considered and it is more invasive than sclerotherapy. This case report presents the efficacy of intralesional sclerotherapy for the management of haemangiomas on dorsum and lateral border of tongue.

Hypokalaemic Periodic Paralysis in a Patient with Subclinical Hyperthyroidism: A Rare Case

Swati Hegde, Mohammed Aslam Shaikh, Thejaswi Gummadi

Thyrotoxic Periodic Paralysis (TPP) is an uncommon disorder. Though many cases of hypokalaemic periodic paralysis are reported in overt hyperthyroidism , hypokalaemic paralysis in subclinical hyperthyroidism is very rare. Subclinical hyperthyroidism is characterised by circulating TSH levels below reference range and normal thyroid hormone levels. We describe a case of 32-year-old Asian male who presented to the emergency department with acute onset weakness and hypokalaemia with no previous history of thyroid disorder or any signs and symptoms suggestive of hyperthyroidism. He was subsequently diagnosed with Graves’ disease with subclinical hyperthyroidism.

A Case of Metastatic Esophageal Carcinoma in a Pregnant Woman with Radiologic Findings

Zülküf Akdemir, Erbil Karaman, Harun Arslan, iskan Çalli, Hüseyin Akdeniz

The incidence of all malignant tumours during pregnancy is extremely rare and esophageal carcinoma ranges from 0.07 to 0.1% of all malignant neoplasms. The physiological changes during pregnancy frequently mask the complaints and symptoms related to the disease. The physical and physiological clinical conditions limit the diagnostic approaches. Therefore, the stage of cancer at the time of diagnosis is usually advanced. The management with cancer surgery and chemotherapy regimens must be modified in pregnant women in order to minimize fetal and maternal risks. Here, we report a very rare case of metastatic esophagus cancer in a 39-year-old woman with 28 weeks of pregnancy and aim to show the ultrasound (USG) and magnetic resonance imaging (MRI) findings with treatment and follow up management.

Severe Hypokalaemia, Hypertension, and Intestinal Perforation in Ectopic Adrenocorticotropic Hormone Syndrome

Tezcan Kaya, Cengiz Karacaer, Seyyid Bilal Açikgöz, Yusuf Aydemir, Ali Tamer

Ectopic adrenocorticotropic hormone (ACTH) syndrome is a rare cause of the Cushing’s syndrome. The occurrence of the ectopic ACTH syndrome presenting with severe hypokalaemia, metabolic alkalosis, and hypertension has been highlighted in case reports. However, presentation with lower gastrointestinal perforation is not known. We report the case of a 70-year-old male patient with severe hypokalaemia, metabolic alkalosis, hypertension, and colonic perforation as manifestations of an ACTH-secreting small cell lung carcinoma. Ectopic ACTH syndrome should be kept in mind as a cause of hypokalaemia, hypertension, and intestinal perforation in patients with lung carcinoma.

Typhoid Fever, Below the Belt

Kamakshi Mahadevan Raveendran, Stalin Viswanathan

Genital ulcers occur due to infective, inflammatory, malignant and drug-related causes. In tropical countries such as India, such ulcers are due to parasitic, tubercular, rickettsial and bacterial (sexually transmitted infections) aetiologies. Typhoid fever is endemic in the tropics. Except “rose spots”, skin manifestations in typhoid fever are unusual, and they are missed due to pigmented skin. Patients do not often complain of genital ulcers due to shame or fear. Genital examination is not routinely performed in typhoid fever. We describe scrotal ulcers as the presenting symptom of typhoid fever, which subsided with appropriate therapy.

Multiple Isolated Enteric Duplication Cysts in an Infant - A Diagnostic Dilemma

Completely isolated enteric duplication cysts are a rare variety of enteric duplication cysts having an independent blood supply with no communication with any part of the adjacent bowel segment. We report a case showing two completely isolated enteric duplication cysts originating in the greater omentum and transverse mesocolon in an infant. Multiple isolated enteric duplication cysts involving non-contiguous bowel segments have not been previously reported in the literature. In addition the transverse mesocolon duplication cyst was infected showing septations and loss of double wall sign resulting in difficulty in imaging diagnosis. Both the cysts were excised and confirmed on histopathology.

A Rare Case of Sporadic Inclusion Body Myositis (s-IBM)

Sourya Acharya, Samarth Shukla, Pritum Kitey, Shameem Khan, SN Mahajan

Sporadic inclusion body myositis (s-IBM) is an acquired inflammatory myopathy. Clinical presentation is variable. The usual presentation is progressive weakness and atrophy of the arms and leg muscles, especially of the quadriceps femoris which is invariably affected. It is classified under inflammatory myopathies, along with polymyositis and dermatomyositis. We present a case of s-IBM who presented with gradually progressive quadriparesis with characteristic quadriceps wasting and weakness in neck flexors. Electromyography revealed myopathic potential and muscle biopsy revealed features of inclusion body myositis.

Total Extraction as a Treatment for Anaemia in a Patient of Glanzmann's Thrombasthenia with Chronic Gingival Bleed: Case Report

Abhishek Ghosh, Saurabh Kumar, Rabin Chacko, Arun Paul Charlu

Glanzmann’s Thrombasthenia (GT) is a rare autosomal recessive bleeding disorder affecting the megakaryocyte lineage and is characterized by lack of platelet aggregation on stimulation. The molecular basis is linked to quantitative and qualitative abnormalities of aIIbß3 integrin. Most of the patients with severe Glanzmann’s thrombasthenia have spontaneous gum bleeding and persistent low haemoglobin levels. Often these patients are addressed with local haemostatic measures and platelet coverage. We report a case of a severe Glanzmann’s thrombasthenia with chronic gingivitis and associated spontaneous gum bleed with chronic low haemoglobin levels, managed subsequently with total dental extraction under appropriate platelet and recombinant factor VIIa coverage. Further follow up of the patient substantiated the treatment protocol with increased and stable haemoglobin levels, thus emphasizing the need for total dental extraction in patients with severe Glanzmann’s with chronic spontaneous gum bleed, as a definitive treatment option, which has not been reported so far in the literature.

Persistent Primitive Hypoglossal Artery (PPHA) – A Rare Anomaly with Literature Review

MR Srinivas, KS Vedaraju, BH Manjappa, BR Nagaraj

Persistent primitive hypoglossal artery (PPHA) is a rare embryonic carotid vertebrobasilar artery anastomosis. Hypoglossal artery arises from the internal carotid artery (ICA) between the C1 and C2 vertebral levels and traverses through the hypoglossal canal to join the vertebro-basilar system. We present a rare case of an anomalous right sided PPHA as a sole supply to posterior circulation of brain with absent/hypoplastic bilateral vertebral arteries in a two year child who had presented with acute left sided haemiplegia. Three dimensional time of flight magnetic resonance angiography identified an anomalous vessel arising from the right internal carotid artery at the level of axis vertebra and joining the vertebra-basilar arterial system after coursing through the right hypoglossal canal. This anomaly when present may predispose the person to aneurysm formation, ischaemia in the posterior circulation and atherosclerotic disease of the intracranial vessels.

Mystery of Sciatica Resolved - A Rare Case Report

Jayanth Kumar Bangalore Chikkanna, Surendra Gopal, Deepak Sampath

Schwannomas are common, benign, slow growing tumours of peripheral nerve sheath arising from the schwann cells of the neuroectoderm. They do not transverse the nerve but remain within the sheath on top of the nerve. They rarely present in the sciatic nerve. Sciatic schwannomas may mimic symptoms of herniated disc, usually with radiation of pain to buttocks and thigh region with inability to walk for long distances and sometimes may present with claudication. In the absence of low back pain and with a normal Lumbo-Sacral MRI study, causes intrinsic to sciatic nerve needs to be thought off, which often delays the diagnosis. Rarity in our case-patient presented with tingling sensation and inability to squat on hard surface for more than 10 minutes with a normal x-ray and MRI study of lumbosacral spine.

Ackerman's Tumour - A Case Report

Ackerman’s tumour or Verrucous Carcinoma (VC) is a distinct form of Squamous Cell Carcinoma (SCC). It is predominantly seen in elderly men and strongly associated with the use of tobacco. In oral cavity it occurs predominantly in buccal mucosa followed by gingiva, palate and floor of the mouth. Clinically it manifests as proliferative finger like projections resembling a cauliflower which is characteristic of its diagnosis. Histologically, papillary or verruciform surface and parakeratin plugs between the surface projections are seen with an intense infiltrate of chronic inflammatory cells in the connective tissue thus it requires enormous expertize for diagnosis. Although VC is illustrated as a benign lesion with minimum aggressive potential over a period of time it can evolve into SCC. Hence most appropriate management of Ackerman’s tumour is early diagnosis and surgical excision of the lesion. With this above background, we hereby report an enticing case of verrucous carcinoma in a left retromolar trigone extending into lower alveolar ridge in a 52-year-old male patient.

The Difficult Paediatric Airway: Two Cases of large Cystic Hygroma

Ruchi Tandon, Aditya Agarwal, Shikha Mehrotra

This is a report of a two cases of difficult intubation experienced in paediatric surgical cases. Both the infants, aged one and three-month-old respectively, had very large cystic hygroma of the neck area. Prior hematological and radiological investigations (USG and CT scan of the swelling) and preanaesthesia check up was done and cases were posted for surgical excision. Case I had difficult airway due to pressure of the tumour/cystic hygroma over the airway and posed difficulty for intubation, but was managed well. Case II had respiratory distress during preoperative period. She had been postponed for surgical excision of the cystic hygroma of neck twice due to the difficulties experienced during intubation. Needle aspiration of hygroma fluid helped to reduce the respiratory distress, and the size of the tumour as well, which further helped in the smooth intubation after a week. The postoperative period was uneventful in both the infants.

Primary Extrapulmonary Multidrug-Resistant Tuberculosis of the Sternum without HIV Infection

Sankalp Yadav, Gautam Rawal

Skeletal tuberculosis (TB) accounts for about 9% of all TB cases. Tuberculosis of the sternum is not a common presentation. The case of primary multidrug-resistant (MDR) TB of the sternum is even rare. So far no such case has been reported in the medical literature. Herein, we present the very first case of primary extrapulmonary MDR TB of the sternum in a 21-year-old immunocompetent Indian female who presented with chest pain and an increased swelling over the anterior chest with an intermittently discharging sinus. She was diagnosed with multidrug-resistant tuberculosis of the sternum without the active pulmonary disease. Conservative management with oral multidrug antitubercular therapy (ATT) completely cured the patient.

Cytodiagnosis of a Cutaneous Clear Cell Malignancy: Metastatic Renal Cell Carcinoma on Chin

Anshu Singh, Gyanendra Mohan, Sunanda Chaturvedi, Shakir Ali Khan

Clear cell type of renal cell carcinoma (RCC) is most common urological malignancy. Several diagnostic challenges arise when it presents as a cutaneous nodule, being an uncommon presentation. Fine needle aspiration cytology (FNAC) of a cutaneous nodule is crucial for distinguishing primary tumours from metastatic tumours because cutaneous metastases represent a terminal stage of illness. Due to considerable overlap of cytomorphological features determination of primary warrants need of detailed clinical history and close inspection of every cytological detail. We report here a case of cutaneous metastasis of RCC on chin in a patient 11 years after nephrectomy. Though there are reports of RCC metastases diagnosed on histology, there are fewer cytology case reports. Cytological differential diagnosis has been discussed for arriving at the final diagnosis in case of clear cell tumours. Early and accurate diagnosis is mandatory for optimal treatment. Cytodiagnosis of cutaneous metastasis of RCC is uncommon due to its low suspicion index in cutaneous nodules. More so, it presents late and an unusual sites due to its resemblance to common dermatological diseases.

Granulocytic Sarcoma in an Adult with Relapsed Acute Myeloid Leukaemia

Neethu Ann Kurien, Deepa John, Geeta Chacko, Pushpa Jacob

Granulocytic sarcoma is an extramedullary tumour consisting of malignant granulocytic precursor cells that is common among children with acute myeloid leukaemia (AML). We report a case of orbital granulocytic sarcoma in an adult with relapsed undifferentiated AML–M0. It presented as bilateral medial canthal swellings. An incisional biopsy confirmed the diagnosis of granulocytic sarcoma. The swelling resolved with re-induction chemotherapy.

Molar Pregnancy Presents as Tubal Ectopic Pregnancy: A Rare Case Report

Devi Beena, S Teerthanath, Varsha Jose, Jayaprakash Shetty

Introduction: Red Cell Exchange (RCE) is removal of a patient’s red blood cells while replacing with donor red blood cells either manually or using automated systems. RCE is beneficial in patients with Sickle Cell Disease (SCD) either during sickling crisis or prior to major surgical procedures to bring down the sickling percentage as high sickling percentage during prolonged anaesthesia may lead to vaso-occlusive crisis. It is also employed in patients infested with malaria and babesiosis where parasitic index remain high despite medical management. RCE is also tried as an adjuvant therapy in certain poisons like nitrobenzene and carbon monoxide when first line management fails. Aim: To study the effectiveness, clinical outcome, challenges and complications of RCE in various clinical scenario and to understand how this procedure can be effectively utilized in the management of patients in Indian scenario. Materials and Methods: This retro prospective study was conducted in tertiary care center in southern India which analyzed 21 RCE procedures performed on patients with different clinical conditions. Of the 21 RCE performed, 18 procedures were performed on patients with case of sickle cell disease, Two procedures were performed on patients infested with severe falciparum malaria and one procedure was performed on a patient with nitrobenzene poisoning. All procedures were performed using Spectra Optia® Apheresis System - Terumo BCT. Results: All the 18 patients who underwent the RCE for sickle cell anaemia were admitted for hemi-arthroplasty for avascular necrosis of the head of femur. The average initial HbS levels were between 73-85% and post RCE it was brought down to 22-29% and was achieved in a single sitting in all the cases. Among the two patients infested with severe falciparum malaria, RCE helped in reducing the infestation rate. In case of nitrobenzene poisoning, RCE helped in improvement of oxygen saturation and patient showed significant improvement. Conclusion: RCE is a safe and clinically effective therapeutic modality with very minimal to nil side effects. RCE is possibly underutilized therapy in developing world like India due to various reasons like inadequate awareness/ technical expertise, lack of equipments and facilities to identify the clinical conditions per se etc.

Multiple Primary Dedifferentiated Liposarcoma of the Jejunal Mesentery: A Case Report and Review of Literature

Manu Vats, Diwakar Pandey, Himani Ahlawat, Azaz Akhtar, Nain Singh

Liposarcoma arising primarily from the intestinal mesentery is a rare malignancy. Malignancy is said to be synchronous when there is occurrence of two or more tumours that have not spread from a common site or recurred and show no evidence of metastasis. Multiple synchronous primary liposarcoma of the mesentery is a very unusual clinical finding. Here, we report a rare case of synchronous multiple primary dedifferentiated liposarcoma of jejunal mesentery in a 36-year-old female patient. Radiological investigations aided in making a provisional diagnosis of an ovarian malignancy. A staging laparotomy was performed and general surgeon’s help was sought due to the presence of three separate jejunal mesenteric masses of sizes 8x6 cms, 6x6 cms and 25x20 cms respectively. Complete excision of mesenteric masses with one feet of involved jejunum was done and a jejuno-jejunal anastomosis made. The histopathology report was indicative of multiple dedifferentiated liposarcoma of jejunal mesentery. Postoperatively patient received Doxorubicin, Dacarbazine and Ifosfamide based adjuvant chemotherapy in view of poorly differentiated tumour. Patient remains tumour free for the last 12 months of follow up.

Orbital Metastasis of Cervical Carcinoma – Case Report and Review of Literature

The orbit is a frequent site of metastasis, particularly from the breast, prostate gland and the lung. Carcinoma of the cervix metastasizing to the orbit is rare. We report a 27-year-old woman with Stage II B cervical cancer who presented with progressive painless protrusion of the left eye of one month duration associated with diplopia. Histology of the orbital mass was similar to that of the cervical cancer and reported as squamous cell carcinoma. She received palliative radiation to the left orbit 30 Gy in 10 fractions along with chemotherapy (Paclitaxel and Carboplatin). This resulted in regression of the proptosis. We review published literature of cases of carcinoma of the uterine cervix with metastasis to the orbit.

Giant left Atrial Myxoma Induces Mitral Valve Obstruction and Pulmonary Hypertension

Deva Japa, Mahpaekar Mashhadi, Sanjeeth Peter

Atrial myxomas are the commonest benign primary tumours of the heart. They are generally 2 to 6 cm in size. Depending on their size and site may result in mitral valve obstruction which may lead to pulmonary hypertension. Clinical symptoms may suggest the presence of a myxoma but echocardiography is the mainstay of diagnosis and confirmation is by histopathology. A well-formed, organized thrombus is a common differential. The report of an unusually large left atrial myxoma that occurred in a 54-year-old male causing mitral valve obstruction and pulmonary hypertension is presented here.

Squamous Cell Carcinoma of the Renal Pelvis, A Rare Site for a Commonly Known Malignancy

Chronic nephrolithiasis predisposes to squamous metaplasia and subsequently SCC which is a rare malignancy of the upper urinary tract. A 60-year-old woman with a long standing history of renal calculi presented with flank pain and fever. Investigations revealed a mass in the superior pole of a non functioning left kidney while the right kidney was sub optimally functioning, hydronephrotic and there was presence of bilateral staghorn calculi. Patient underwent decompression of right kidney by double j stenting and left radical nephrectomy that revealed well differentiated squamous cell carcinoma of renal pelvis. Most SCC of the renal pelvis present with advanced disease and dismal prognosis while our patient presented with localized disease without lymphatic and distant metastasis. Thus radical nephrectomy can be curative if the disease can be diagnosed at an earlier stage. This emphasizes the need of early treatment of nephrolithiasis to prevent the development of SCC and screening of patients with long standing staghorn calculi.

Primary Epithelioid Angiosarcoma of Spleen: A Case Report and Review of Literature

Splenic angiosarcomas are usually secondary tumours, and only few primary cases have been encountered. We report a unique primary case of epithelioid angiosarcoma arising in the spleen in a male patient 55-year-old and presented to our hospital as a medical emergency with acute abdomen and haemorrhagic ascitis. CT revealed splenic focal lesion and suggested that this abdominal haemorrhage was due to ruptured splenic haemangioma, thus abdominal exploration and splenectomy were done. The histopathological examination showed an infiltrating ill-defined growth formed of high grade epithelioid cells arranged in sheet-like growth pattern, with occasional papillary appearance. The presence of rudimentary vascular channels lined by epithelioid endothelial cells with occasional intraluminal erythrocytes suggested vascular tumour origin. The neoplastic cells showed diffuse expression of CD31 together with focal expression of cytokeratin (CK) and CD34. Because of its epithelioid morphology and unmistakable positivity for CK, this case may be easily misdiagnosed as a metastatic carcinoma, which is not uncommon finding in the spleen. Epithelioid angiosarcoma is a rare type of vascular tumour in the spleen, which co-expresses vascular and epithelial markers making its distinction from metastatic carcinoma is sometimes difficult.

Pleomorphic Adenoma in Retromolar Area: A Very Rare Case Report and Review of Literature

Among all neoplasms affecting head and neck region, salivary gland neoplasms are rare. Pleomorphic adenomas are the most common benign salivary gland tumours making up to 50% of major and minor salivary gland tumours. Intraorally pleomorphic adenoma is mostly found on palate and lips and very rarely in retromolar area. Here we are reporting a rare case of pleomorphic adenoma in right lower retromolar area in a 31-year-old female, the lesion was excised in toto with safety margins under local anaesthesia and postoperative follow up after six months didn’t showed any recurrence.

A Rare Cause of Placental Abruption: Uterine Torsion

Ipek Ulu, Muhammed Siraç Günes, Gürkan Kiran, Mehmet Serdar Gülsen

Uterine torsion is defined as a rotation on its long axis and it is a dangerous, unexpected obstetric emergency. We report a case of uterine torsion at 32 weeks of gestation in a singleton pregnancy. A 37-year-old woman with multiple prior cesarean deliveries referred to emergency unit of our hospital at 32 weeks of gestation with severe abdominal pain and mild vaginal bleeding. Ultrasonography showed a single fetus in vertex position, with a normal amniotic fluid. Fetal biometer was appropriate for 32 weeks of gestation. Placental location was anterior with a subchorionic hypoechogenic small area which was suspected to be a sign of placental abruption. An emergency cesarean section was performed under general anesthesia. The 180° uterine torsion was diagnosed and it was not possible to perform detorsion of the gravid uterus by exteriorization by pfannenstiel incision. Posterior hysterotomy was performed and a male baby of 1830 grams weight was delivered. The newborn was transported to Neonatal Intensive Care Unit (NICU) of another hospital and discharged within two weeks. Patient recovered well and was discharged on second postoperation day. Uterine torsion is a very rare and life threatening situation. In unexpected cases posterior low transuerse hysterotomy is generally performed and it is suggested as a safe choice when detorsion was not accomplished. It is not easy to keep in mind the possibility of uterine torsion in cases of abdominal pain during pregnancy. Because it generally causes abruption, management of abruption is vitally important to prevent fetal mortality.

Extraskeletal Osteosarcoma- A Case Report

Osteosarcoma is the most common primary malignant bone tumour with a bimodal peak. But its extraskeletal variant is very rare. It arises exclusively in soft tissue without at any skeletal attachment. It accounts for 2% of all soft tissue sarcomas. It is usually diagnosed as an incidental finding during imaging. Here, we are presenting a case of extraskeletal osteosarcoma diagnosed incidentally during imaging in a 30 years old male for its rarity.

Crescentic Glomerulonephritis Associated with Pulmonary Tuberculosis

K.V. Kanodia, A.V. Vanikar, R.D. Patel, K. S. Suthar, H. L. Trivedi

Tuberculosis of kidney and urinary tract is caused by members of the Mycobacterium tuberculosis complex. Kidney is usually infected by haematogenous spread of bacilli from focus of infection in the lungs. Glomerular involvement in tuberculosis presenting as a rapidly progressive glomerulonephritis is a rare entity. We report a rare case of crescentic glomerulonephritis associated with pulmonary tuberculosis in a 26-year-old man. Patient was treated with corticosteroids, haemodialysis, intravenous immunoglobulin and four cycles of plasmapheresis. He did not respond to 4-drug anti-tuberculosis treatment for renal pathology and was switched over to maintenance haemodialysis. However, he responded to pulmonary TB.

Amniotic Band Syndrome - A Dreaded Condition

Durga. R1, T.K. Renukadevi

Amniotic band syndrome is a unique condition in which amnion a normal structure causes complications. A case of second gravid, obese who is a known diabetic came to OPD at 13 weeks pregnancy for regular antenatal check up. A routine ultrasonogram was advised in which multiple anomalies were noted and the diagnosis of amniotic band syndrome was made. The parents were counseled for medical termination of pregnancy and after obtaining the consent termination were performed and the parents were asked to postpone the next pregnancy for minimum 6 months. This anomaly as seen in this patient could be due to risk factors like diabetes and obesity.

Bilateral Carpal Spasm Under Spinal Anaesthesia During Abdominal Hysterectomy: A Case Report

Acute hypocalcaemia is a medical emergency that can have catastrophic implications like tetany, seizures, cardiac arrythmias or laryngospasm if left untreated. We are presenting a case of a 30-year-old female patient undergoing total abdominal hysterectomy with bilateral salpingoopherectomy under spinal anaesthesia. She developed unexpected bilateral carpal spasm intraoperatively which was promptly diagnosed and successfully managed with intravenous calcium administration. We conclude that the anaesthetist should be aware of the clinical presentation of acute hypocalcaemia, its causes and emergency management in the perioperative period to prevent any adverse outcomes.

Multiple Enchondromatosis: Olliers Disease- A Case Report

George Sunny, V. Ravi Hoisala, Soumya Cicilet, Sandeep Sadashiva

Olliers disease is a rare disease characterized by widespread enchondromas with a unilateral predominance, in early childhood. The diagnosis is based on clinical and conventional radiological evaluations. The prognosis for olliers disease is difficult to assess. Enchondromas in olliers disease present a risk of malignant transformation into chondrosarcomas. Due to its rarity literature focusing on olliers disease is limited. This case report discusses the case of a 12-year-old female who presented with difficulty in walking, leg pain and multiple painless swellings in hands and legs for a period of 2 years.

A Rare Presentation of Lupus Nephritis Flare up with Posterior Reversible Leucoencephalopathy

S. Hima Mani, S. M. Shivaprasad, L. Umesh

Systemic lupus erythematosus (SLE) is associated with various neurologic or psychiatric abnormalities and Posterior Reversible Leuco Encephalopathy Syndrome (PRES) is very rare neurological manifestation in SLE. PRES is associated with various clinical manifestations, like, seizures, visual loss, headaches, vomiting altered mental status and rarely focal neurological deficits. Other predisposing condition associated with PRES is eclampsia, accelerated hypertension, uraemia, transplantation, autoimmune diseases and/or use of immunosuppressive drugs. It is important to recognise PRES since it is a potentially reversible. We describe an unusual case of PRES caused by uraemia during lupus flare up in a patient with biopsy proven class IV lupus nephritis who presented with features of asymmetrical quadriparesis which completely reversed after haemodialysis sessions and treating lupus flare up. In our case she presented with quadriparesis which is a rare presentation and hypertensive encephalopathy was not present.

Spinal Intradural Schwannoma with Acute Intratumoural Haemorrhage: Case Report and Review

G. Lakshmi Prasad, Lakshman I. Kongwad, Manna G. Valiathan

Schwannomas account for around half of all intradural spinal tumours, with chronic progressive symptoms as the most common presenting features. Intratumoural haemorrhage as a presenting feature of spinal schwannoma is very rare and only 11 cases have been reported till date. Authors here report a previously asymptomatic 40-year-old male who presented with acute onset paraplegia 12 hours after a minor trauma. MR imaging revealed a C7-D3 intradural-extramedullary lesion with features of acute blood and showing no enhancement. Emergency laminectomy and complete removal of the mass was performed and histopathology revealed features of schwannoma with haemorrhage. Patient had modest improvement of his neurological deficits at a follow-up of 6 months. Pertinent literature is reviewed in brief.

Ventilating Patient with Refractory Hypercarbia: Use of APRV Mode

Zia Arshad, Ravi Prakash, Swati Aggarwal, Sapna Yadav

A 70-year-old patient referred to our critical care unit with the diagnosis of type II respiratory failure with shock. Patient was a known case of COPD for last 20 years. His chest radiology revealed bilateral infiltrates. Patient was managed conservatively in the form of antibiotics, vasopressor and ventilatory support with SIMV/VC mode. After ventilation with SIMV/VC mode for half an hour his blood gases revealed increasing PaCO2 levels. The same result was obtained with PC mode and ASV and his PaCO2 level reached above 170 mmHg. Then APRV mode was tried with modified settings. The results obtained were satisfactory and in next 24 hours PaCO2 decreased to <66mmHg along with an increasing P/F ratio. APRV is the not recommended as primary mode of ventilation in COPD but in resistant cases it can be helpful as it improves alveolar recruitment and pressure support is added to reduce hypercapnia.

Prenatal Diagnosis of Umbilical Artery Aneurysm with Good Fetal Outcome and Review of Literature

Neetha M Vyas, Lakshmi Manjeera, Supriya Rai, Sharath Devdas

Umbilical artery aneurysm is a rare condition. Till date, 14 cases are reported and only 4 had good fetal outcome. Umbilical artery aneurysm is associated with high risk of fetal aneuploidy and fetal demise. Though umbilical cord anomalies are rare, they are associated with significant fetal morbidity and mortality. We report a case of umbilical artery aneurysm which was detected at 33 weeks of gestation on ultrasonography as an anechoic cyst close to cord insertion with turbulent blood flow in it. The patient was hospitalized and with intensive fetal surveillance and early delivery, a live born fetus was achieved. Baby’s karyotype was normal. Pathologic examination confirmed umbilical artery aneurysm close to cord insertion.

A Case Report of Metronidazole Induced Neurotoxicity in Liver Abscess Patient and the Usefulness of MRI for its Diagnosis

Shruti Chandak, Arjit Agarwal, Arvind Shukla, Pawan Joon

Metronidazole is a very widely used drug for the treatment of multiple ailments caused by anaerobic bacteria as well as some protozoan parasites. Though its usual side effects are not very serious, yet sometimes it may cause profound adverse effects like neurotoxicity. We present here a case of liver abscess. The patient was treated for a long time with metronidazole and developed sudden onset neurotoxicity which was diagnosed by MRI. The present case also highlights the need of vigilant monitoring of patients on metronidazole for symptoms of neurotoxicity and the usefulness of MRI for diagnosis of the same.

Non Infiltrating Angiolipoma of the Palate in Geriatric Patient: A Case Report with Review of Literature

Angiolipoma is one of the rare variant of lipoma. This benign tumour consists of both fatty and vascular elements. It mostly occur in the trunk and extremities and is uncommon in head and neck region. Angiolipoma is classified as infiltrating and non- infiltrating types. Among all neoplasms of the oral cavity, lipomas account for 1 to 5% and the incidence of angiolipoma is 5 to 17% in it. There is no sex predilection for this tumour. It is classified as infiltrative and non-infiltrative type. Surgical excision is the method to be considered for both the types of angiolipoma, however the infiltrating type recurs post-surgery. We report a rare case report of 55-year-old female with non-infiltrating angiolipoma of the hard palate mimicking a mucocele treated by surgical excision with no signs of recurrence and good wound healing after three months follow up with minimal scar formation.

Parameatal Urethral Cyst in a Newborn–A Case Report and Review of the Literature

Parameatal urethral cysts are rare congenital lesions of the penis that are usually <1cm in diameter in the paediatric population and do not create any urinary difficulties. Their natural course is either to resolve or to be surgically excised without any postoperative complications. We report a case of a newborn with a parameatal urethral cyst that produced voiding difficulties and was treated by surgical excision.

Two Cases of Rectus Sternalis Muscle

Minnie Pillay, Swapna Ramakrishnan, Mahendran Mayilswamy

The sternalis muscle, an uncommon anatomical variant of the chest wall musculature, though perhaps well known to anatomists, is quite unfamiliar to clinicians and radiologists despite attempts to highlight its clinical importance in recent years. During routine dissection for undergraduate medical teaching, in the department of anatomy, we came across two cases of sternalis muscle. The first was a unique case of unilateral right sternalis with contralateral insertion on the left sternocleidomastoid, and the second case where bilateral presence of the muscle was noted with ipsilateral insertion. The former was supplied by medial pectoral nerve and the latter by lower intercostal nerves. Usually present between the pectoral and superficial fasciae, wide ranging prevalence and morphology have been attributed to this muscular variant. Opinions differ on its development and nerve supply. Its presence can be misdiagnosed as a wide range of benign and malignant anterior chest wall lesions and tumours, but it is also of great use as a pedicle flap or flap microvascular anastomosis in reconstructive surgeries of anterior chest wall, head and neck and breast. In this paper, two cases of sternalis muscle which presented very differently from each other are discussed.

Lady Windermere Syndrome: A Very Rare Entity In Indian Medical Scenario

Raghavendra Rao, Shubha Sheshadri, Navin Patil, Karthik Rao, Avinash Arivazhahan

Bronchiectasis is a common respiratory disorder, which we come across in clinical practice. Patients with bronchiectasis are prone to infections, especially of Mycobacterium tuberculosis. However, non-tubercular Mycobacterial infections may also set in, though rare. Here, we report an unusual case of Mycobacterium avium complex infection in a case of middle lobe bronchiectasis that was seen in a middle-aged immunocompetent female, a syndrome known as Lady Windermere Syndrome.

Isolated CNS Blast Crises in Chronic Myeloid Leukaemia Presenting as Hypertrophic Pachymeningitis and Bilateral Optic Neuritis: A Case Report

Ankur Jain, Naresh Gupta

Extramedullary blast crises of Chronic Myeloid Leukaemia (CML) involving CNS is rare and usually accompanies systemic relapse. Isolated CNS blast relapse is an extremely uncommon event. A 35-year-old male was diagnosed with chronic phase (CP) CML two years back at our hospital and was started on imatinib 400 mg daily. Patient achieved haematological and cytogenetic remission at three and 12 months respectively but was non-compliant with medications thereafter. He presented to our emergency with headache and bilateral visual loss. CNS examination revealed neck rigidity and fundoscopy revealed disc edema with retinal vein dilatation and haemorrhages. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis and a positive cytospin for myeloid blasts. MRI brain suggested pachymeningeal enhancement involving falx cerebri and tentorium along with bilateral optic nerve thickening. Patient maintained cytogenetic remission at current presentation. A diagnosis of isolated CNS blast crises with pachymeningitis and bilateral optic nerve involvement was made and two doses of intrathecal chemotherapy were administered. However, patient died due to a rapidly downhill course. A previously unreported finding of pachymeningitis with bilateral optic neuritis has been highlighted in this case, along with a brief review of this rare condition.

The Application of Pulsed Field Gel Electrophoresis in Clinical Studies

Elaheh Gholami Parizad, Eskandar Gholami Parizad, Azar Valizadeh

Pulsed-field gel electrophoresis is a method applied in separating large segments of deoxyribonucleotide using an alternating and cross field. In a uniform magnetic field, components larger than 50kb pass a route through the gel and since the movement of DNA (Deoxyribonucleic acid) molecules are in a Zigzag form, separation of DNAs as bands carried out better via gel. PFGE in microbiology is a standard method which is used for typing of bacteria. It is also a very useful tool in epidemiological studies and gene mapping in microbes and mammalian cell, also motivated development of large-insert cloning system such as bacterial and yeast artifical chromosomes. In this method, close and similar species in terms of genetic patterns show alike profiles regarding DNA separation, and those ones which don’t have similarity or are less similar, reveal different separation profiles. So this feature can be used to determine the common species as the prevalence agent of a disease. PFGE can be utilized for monitoring and evaluating different micro-organisms in clinical samples and existing ones in soil and water. This method can also be a reliable and standard method in vaccine preparation. In recent decades, PFGE is highly regarded as a powerful tool in control, prevention and monitoring diseases in different populations.

Various Possible Toxicants Involved in Thyroid Dysfunction: A Review

Jagminder K. Bajaj, Poonam Salwan, Shalini Salwan

About 300 million people across the world suffer from thyroid gland dysfunction. Environmental factors play an important role in causation of autoimmune thyroid diseases in susceptible individuals. Genetics contributes to 70% of the risk. In order to reduce the risk, we need to understand the association of environmental agents with thyroid dysfunction. These factors are especially relevant for those at increased risk due to positive family history. The ideal study to see the impact of a thyroid toxicant consists of directly measuring the degree of exposure to toxicant in an individual with his thyroid status. Knowledge of various factors influencing thyroid dysfunction can help in interpreting the results of such studies in a better way. This article is an attempt to highlight the various possible toxicants affecting thyroid function so that adequate measures can be undertaken to control excessive exposure in future to reduce the prevalence of thyroid disorders.

Head Injury- A Maxillofacial Surgeon’s Perspective

Injuries and violence are one of the leading causes of mortality worldwide. A substantial portion of these injuries involve the maxillofacial region. Among the concomitant injuries, injuries to the head and cervical spine are amongst those that demand due consideration on account of their life threatening behaviour. Studies have shown that facial fractures have a strong association with traumatic brain injury. Knowledge of the types and mechanisms of traumatic brain injury is crucial for their treatment. Many a times, facial fractures tend to distract our attention from more severe and often life threatening injuries. Early diagnosis of these intracranial haemorrhage leads to prompt treatment which is essential to improve the outcome of these patients. An oral and maxillofacial surgeon should be able to suspect and diagnose head injury and also provide adequate initial management.

Post-traumatic Stress Disorder (PTSD) in Children of Conflict Region of Kashmir (India): A Review

Raheel Mushtaq, Tabindah Shah, Sahil Mushtaq

Post-traumatic stress disorder (PTSD) occurs due to traumatic events. The last two decades have seen various traumatic events in Kashmiri population, which has led to psychological impact on all population, especially children. PTSD is one of the psychiatric disorders occurring after witnessing of traumatic events. A review of literature regarding PTSD in children of Kashmir (India) has been done to assess the prevalence, causes, neurobiology, risk factors and psychiatric co morbidity associated with it.

Clinical Tip for Adjusting Reverse Pull Facemask/Headgear Assembly

Sandhya Jain

Point of force application is critical in predicting the result of reverse pull headgear assembly. Different people have suggested different point of force application. A clinical tip is provided for adjusting the hook of intraoral stabilizing appliance,so that it rests on zero moment line which helps in translatory movement of maxilla. Simple and effective clinical method of adjusting the reverse pull headgear is illustrated here along with its biomechanical justification.

Clinico-Radiologic Perspective of a Case of Hemifacial Microsomia

Crouzon Syndrome: Report in a Family

Inflammatory Fibroid Polyp of the Ileum Presenting with Acute Intestinal Obstruction In An Adult Patient: A Case Report

Chumila Thinley Bhutia, Deepak Das, Phuchungla Bhutia

Supplemental Maxillary Permanent Central Incisor or Macrodontia of Lateral Incisor! A Diagnostic Challenge

Intraosseous Epidermoid Inclusion Cyst of Distal Phalanx: A Rare Entity

Fayaz Memon, Taufiq Rafiq Panjwani, Hemant Patankar

Images in Medicine - Hajdu-Cheney Syndrome: A Rare Case Report

M. Hari Kumar, M. Siva Kumar, Vishalakshi Sivakumar, Sabitha Hari Kumar

A Rare Case of Mandibular Exostoses and its Review

Sunil S Nayak, Vanishri S Nayak

Mandibular exostosis is a type of bony prominence caused due to hyperostosis in the mandibular bone. They are benign, broad-based surface masses on the outer or facial aspect of the jaw bones; slowly enlarge over the years to form the bulky masses. During the period between the 10th to 13th week of intrauterine life, changes in the structure of the Meckel’s cartilage and the protrusion of the medial lamina of the mandible onto the cartilage can result in the formation of such exostosis. We discuss here a very rare case of a 49-year-old male, in which the buccal exostoses formed underwent changes in size and shape due to certain factors, resulting in a bony bar formation in the mandibular anterior region.

Alternate Nostril Breathing at Different Rates and its Influence on Heart Rate Variability in Non Practitioners of Yoga

Rajam Krishna Subramanian, Devaki. P.R, Saikumar.P

Introduction: Heart rate variability is a measure of modulation in autonomic input to the heart and is one of the markers of autonomic functions. Though there are many studies on the long term influence of breathing on HRV (heart rate variability) there are only a few studies on the immediate effect of breathing especially alternate nostril breathing on HRV. This study focuses on the immediate effects of alternate nostril breathing and the influence of different breathing rates on HRV. Materials and Methods: The study was done on 25 subjects in the age group of 17-35 years. ECG and respiration were recorded before intervention and immediately after the subjects were asked to perform alternate nostril breathing for five minutes. Results: Low frequency (LF) which is a marker of sympathetic activity increased, high frequency (HF) which is a marker of parasympathetic activity decreased and their ratio LF/HF which is a marker of sympatho/vagal balance increased immediately after 6 and 12 minutes in comparison to baseline values whereas there was no significant difference in the means of these components when both 6 and 12 minutes were compared. Conclusion: Immediate effects of alternate nostril breathing on HRV in non practitioners of yogic breathing are very different from the long term influence of yogic breathing on HRV which show a predominant parasympathetic influence on the heart.