Journal of clinical and diagnostic research

Hypertension in Indian Scenario

Aarti Garg

Anterior Space Maintainer Incorporating a Pontic Derived from a Strip Crown

Paul Chalakkal, Roshni Chandran, Kaveri Gandhi, Neil De Souza

Various designs of functional and aesthetic space maintainers have been used in the anterior region to replace missing upper primary anteriors. All of these had utilised pontics made of composite, acrylic or natural teeth. Strip crowns have been widely used in paedodontics for restoring damaged maxillary anterior primary teeth. This case report highlights a case in which a composite resin formed tooth, derived from a strip crown, was used as a pontic in a functional and aesthetic space maintainer with the aid of Ribbond, including the various steps in its fabrication.

Biclonal Gammopathy in Multiple Myeloma with Vertebral Compression Fracture

Amit Ranjan, Rukmini Mysore Srikantiah, K Ashok Prabhu, Urmila N Khadilkar

Biclonal gammopathy is characterised by simultaneous appearance of two different monoclonal proteins. A rare case of Biclonal gammopathy [IgA lambda(?)and IgG kappa (?)] and D10 vertebral fracture in a 46-year-old male patient with complaints of sudden onset low back ache while lifting a heavy object, which was aggravated for one month presented to the Orthopaedic department of our institute. Magnetic Resonance Imaging (MRI) of dorso-lumbar spine revealed anterior wedge collapse of D10 vertebral body with enhancement causing compressive myelopathy. Bone marrow biopsy of D10 vertebrae was performed and the features were suggestive of plasma cell myeloma. Serum protein electrophoresis indicated biclonal gammopathy and immunofixation electrophoresis showed intense IgA?and faint IgG?. The patient was started on chemotherapy following a decompression surgery of the D10 vertebra.

Drumstick-An unusual Foreign body in Common Bile Duct

Amaresh Mishra, Sakti Prasad Sahoo, Subrat Kumar Mohanty, Chinmaya Ranjan Behera

Obstructive jaundice due to biliary foreign bodies are extremely rare and most of reported cases are due to materials used in the previous surgical procedures. Organic foreign bodies in Common Bile Duct (CBD) are still very rare and here we present a very unusual organic foreign body drumstic in CBD in a 56-year-old man presenting as biliary colic and jaundice. This is the first reported case of organic foreign body drumstick in Common Bile Duct, operated by laparoscopic CBD exploration.

Giant Cells Tumour of the Distal Phalanx of the Finger- A Case Report

Selim Daas, Med Ali Sbai, Sana Ben Slama, Adel Khorbi

Giant Cell Tumour (GCT) of the hand phalangeal bones are rare but with local aggressiveness and high risk of recurrence. Their treatment is exclusively surgical. We report a case of GCT occurring in the third phalanx of the index. A 83-year-old woman, right-handed, presented with a painful tumefaction of the distal phalanx of the right index finger. Examination revealed a swelling of the distal phalanx, of hard consistency, fixed, slightly painful to the palpation. The radiography showed an expensive lytic lesion taking up the entire third phalanx. A surgical biopsy revealed an aspect of a GCT invading bone, soft tissue and dermis. It was Stage 2 of the radio histological classification of enneking. In view of the local progression of the GCT, a proximal trans-phalangeal amputation to the index was performed. Until her last follow up after 24 months, the patient didn’t show any recurrence or metastasis. The location of GCT in the metacarpal bones is rare. The diagnosis is based on the clinical, radiological and histopathological findings. After surgery, the prognosis is related to rate of recurrence.

Cerebellar Cognitive Affective Syndrome-A Case Report

MS Bhatia, Nimisha Doval, Rashmita Saha, Aparna Goyal

There are an increasing number of reports suggesting that cerebellum, apart from its significance in movement coordination, plays an important role in cognitive and emotional regulation. Cerebellar Cognitive Affective Syndrome (CCAS) also known as Schmahmann syndrome, refers to deficits in the cognitive domains of executive function, spatial cognition, language and affect resulting from damage to the cerebellum. There are only few case reports reflecting the affective features in CCAS. We present a 17-year-old girl brought to psychiatry Outpatient Department (OPD) with depressive features, who was subsequently diagnosed as a case of CCAS and started on fluoxetine 20 mg and propranolol 20 mg daily. There was improvement in the affective symptoms on follow up.

Management of Miller’s Class III Recession Defect with Gingival Unit Transfer-A Promising Technique

Priyalochana Gajendran, Harinath Parthasarathy

In all the periodontal plastic surgical procedures, blood supply is the single most significant concern and must be the underlying issue for all the decisions regarding the individual surgical procedure. A major complicating factor is the avascular root surface and many modifications are done to existing techniques to overcome this. One such modification of Free Gingival Graft (FGG) as introduced by Allen and Cohen known as “Gingival Unit Graft” (GUT) where they harvested a palatal graft along with the marginal and the interdental tissue. The present case reports the clinical effectiveness of a novel technique known as gingival unit graft that was evaluated for the management of Miller’s class III gingival recession. This technique showed complete defect coverage and superior aesthetics.

Intracardiac Air Embolism in the Newborn: Presentation of Two Cases and Review of the Literature

Shilpa Kalane, Sheela Patil, Rajan Joshi, Uday Devaskar

Intracardiac air embolism is a rare but potentially life threatening event with a very high mortality. It should be suspected in any infant with sudden cardiopulmonary decompensation. Hereby, we describe cases of two preterm neonates with sudden cardiopulmonary decompensation. Retrospectively, it was diagnosed to be due to cardiac air embolism on chest radiograph. One of the neonate responded to aggressive treatment and survived. The prognosis for this condition remains poor and it may improve with early recognition and aggressive therapy.

Gall Bladder Carcinoma with Concurrent Metastases to Bone (Sclerotic) and Urinary Bladder

Gall bladder carcinoma is an aggressive malignancy with varied presentation. Liver is most commonly involved initially with distant metastasis in virtually all possible organs. We report a case of middle aged female who presented with pain in upper abdomen and progressive jaundice. Imaging studies were suggestive of gall bladder carcinoma involving hilum with disseminated osteosclerotic lesions and metastasis to Urinary Bladder (UB). Patients of carcinoma gall bladder with disseminated metastatic disease have poor prognosis and are managed with palliative chemotherapy. To the best of our knowledge, this is one of the rare initial presentation of gall bladder carcinoma in the literature.

Reversible Cerebral Vasoconstriction Syndrome in a Young Female: A Case Report

Neeraj Wadhwa, Udit Chauhan, Sachin Agarwal, Sanjay Pandey, Sunil Kumar Puri

Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a syndrome mimicking diverse clinical and radiological conditions. Pathologically there is altered cerebral vascular tone without histological evidence of active inflammation or vasculitis. Most common clinical presentation is hyper acute thunderclap headache with or without neurological deficit. It poses a great diagnostic dilemma; however knowledge of symptoms and radiological manifestations can help in accurate diagnosis and treatment.

Cushing Syndrome: Secondary to Squamous Cell Carcinoma of the Lung

Vishnu Vardhan Garla, Christine Oakley

Cushing syndrome secondary to ectopic Adrenocorticotrophic (ACTH) hormone secretion is an uncommon entity mostly caused by small cell lung cancer or bronchial carcinoids. It can be characterised by absence of classical cushingoid features. Ectopic ACTH syndrome is characterised by severe and progressive hypercortisolemia. Thus, prompt identification and treatment can significantly decrease morbidity in affected patients. A 57-year-old male patient with a history of Stage 4 squamous cell cancer of the lung presented with worsening hyperglycemia and hypokalemia. Physical exam was notable for facial plethora and hypertension. Hormonal testing showed a very high serum cortisol, ACTH and 24 hours urinary free cortisol levels. MRI of the brain was normal. A diagnosis of ectopic ACTH syndrome was confirmed. The patient was started on Ketoconazole and his cortisol levels improved. The patient was discharged and eventually was lost to follow up.

Gitelman Syndrome in a Case of Diabetic Kidney Disease: A Diagnostic and Therapeutic Dilemma

Vaibhav Seth, Niladri Sarkar, Somnath Mandal, Subhasis Neogi, Shambaditya Das

Gitelman syndrome is an autosomal recessive disorder that usually presents with hypokalemia, hypomagnesemia, hypocalciuria and normal blood pressure. In contrast to Bartter syndrome it presents in late adulthood. Hypokalemia in a patient of chronic kidney disease is not a usual finding. Here we present a case of intractable hypokalemia due to Gitelman syndrome with hypertension in a background of chronic kidney disease, which poses both a diagnostic as well as a therapeutic dilemma.

Cytodiagnosis of Extraoral Plasmablastic Lymphoma in an HIV-positive Paediatric Patient- A Case Report and Review of the Literature

Alka V Gosavi, Bhakti D Deshmukh, Nayan A Ramteerthakar, Kalpana R Sulhyan

Plasmablastic Lymphoma (PBL) is a rare and aggressive form of Non-Hodgkin Lymphoma (NHL), initially described in the oral cavity of Human Immunodeficiency Virus (HIV) positive individuals. Recently, it has been described in HIV negative patients and at several extraoral locations. It shows heterogeneous cytological findings but has a distinct immunophenotype. Knowledge of the cytomorphologic spectrum of PBL and detection of plasma cell markers by ancillary techniques help in achieving the correct diagnosis. Here, we present a 15-year-old HIV positive boy who presented with left periorbital, left chest wall and perianal swellings. A diagnosis of PBL was offered on Fine Needle Aspiration Cytology (FNAC) in conjunction with immunocytochemistry and was confirmed on histopathology with immunohistochemistry.

Penile Carcinoma in Young Age Masquerading as Mondor’s Disease

Pritesh Jain, Debansu Sarkar, Dilip Kumar Pal

A 26-year-old unmarried male presented with voiding difficulty and penile oedema, was initially diagnosed and treated for Mondor’s disease, which is a rare, benign, usually self-limiting pathology of anonymous origin. When he failed to respond to conservative management, a biopsy from glans penis was taken which revealed it to be moderately differentiated Squamous Cell Carcinoma (SCC). Apart from being an old man’s affliction, usual presentations of penile cancer range from ulcerative lesion to exophytic growth. Thus, its presentation as thrombosis of dorsal vein of penis is astounding as depicted in this case.

Onychomycosis by Trichosporon Inkin: A Rare Clinical Entity

Charu Jain, Ravinder Kaur, Deepti Rawat, Suraiya K Ansari

Trichosporon species are basidiomycetous yeasts that are widely distributed in the nature and regularly found on normal skin. The cylinder-shaped arthroconidia forming yeast has undergone a major taxonomic reclassification with Trichosporon inkin associated with white piedra of hair shafts. Here in we report a rare case of onychomycosis in an otherwise healthy adult.

Peritonitis due to Galactomyces geotrichum: A Rare Case Report

Anushka V Devnikar, PM Beena, A Bhaskaran, MR Shivaprakash

Galactomyces geotrichum is the teleomorphic stage of several unnamed Geotrichum species. They are filamentous yeast like fungi that are ubiquitous in nature. They have been isolated from various sources such as fruits, vegetables, plants and soil and are also found to be a part of the normal flora of the human gastrointestinal tract. It is an emerging pathogen associated with superficial or disseminated infections in an immunocompromised host or in patients with debilitating diseases. This report describes an unusual case of peritonitis due to Galactomyces geotrichum secondary to hollow viscus perforation in a young woman without any underlying co-morbidities.

Glycogenic Hepatopathy in a 19-year-old Male with Uncontrolled Insulin Dependent Diabetes: Clinical Presentation and Review of Literature

Dustin L Little, Creticus Petrov Marak, Achuta Kumar Guddati, William G Simpson

Glycogenic Hepatopathy (GH) is a rare entity encountered in patients with poorly controlled insulin-dependent diabetes. GH results from excessive accumulation of glycogen in the hepatocytes and is characterised by tender hepatomegaly and transaminitis. Hyperglycaemia in these patients leads to frequent use of high doses of insulin. High plasma levels of both serum glucose and insulin causes increased production and storage of glycogen in the hepatocytes. We present the clinical course and management of a patient who presented with hyperglycaemia and was found to have glycaemic hepatopathy. The presentation of similar cases that have been reported in medical literature has been reviewed and discussed in this review. GH is an underdiagnosed entity and should be considered in the differentials of any patient presenting with hepatomegaly and transaminitis, particularly among uncontrolled diabetics.

A Case of Insulinoma with Improved Reactive Hypoglycaemia after Operation

Shunsuke Funazaki, Hodaka Yamada, Yuko Matsumoto, Kazuo Hara

It is well known that fasting hypoglycaemia is common in insulinoma, but postprandial hypoglycaemia has also been reported. In almost all cases, the serum Immunoreactive Insulin (IRI) level is not suppressed. A 54-year-old Japanese woman experienced repeated temporary loss of consciousness simultaneously with hypoglycaemia. 5-hour on admission, she had repeated hypoglycaemia without suppression of insulin. A 5-hour Oral 75 gm Glucose Tolerance Test (5-hour OGTT) showed reactive hypoglycaemia. Her serum IRI level was suppressed. Enhanced pancreatic Magnetic Resonance Imaging (MRI) revealed a 10 mm sized tumour in the pancreas; we thus diagnosed her with insulinoma. A laparoscopic distal pancreatectomy was performed. The 5-hour OGTT was performed again post operatively. Her abnormal glucose tolerance remained, but her reactive hypoglycaemia improved. We conclude that reactive hypoglycaemia may occur in cases of insulinoma, and may be eliminated through operation. This case report has two important points. Firstly, the patient’s reactive hypoglycaemia was demonstrated. Secondly, her improving reactive hypoglycaemic state was recorded in detail.

Culprit or Companion-Foetal Right Ventricular Diverticulum: Role of M-mode Echocardiography in Distinguishing it from Ventricular Aneurysm

Ashwal Adamane Jayaram, Krishnanand Nayak, Abdul Razak, R Padmakumar, Umesh Pai

Congenital ventricular diverticula and aneurysms are very rare. Prenatal diagnosis of such cases is reported only by few authors. Differentiating these two entities by echocardiography alone is very difficult. We present a case of prenatally diagnosed right ventricular diverticulum at 33 weeks of gestation. She was 37-year-old and primigravida with no past medical history. She underwent a routine prenatal scanning and was suspected to have a foetal cardiac abnormality and referred to us. It was diagnosed as foetal right ventricular diverticulum with the help of Motion-mode (M-mode) echocardiogram and was advised follow up after delivery. One of the differential diagnosis is ventricular aneurysm. Unfortunately, she had a miscarriage at 36 weeks due to unknown cause.

A Rare Presentation of an Incomplete Vertical Fracture in the Furcation Area of a Mandibular Molar and its Multidisciplinary Management

Specialists in the dental field often get habituated to having a partial or biased assessment of clinical findings or disorders by virtue of practicing a niche speciality over long periods of time. This can lead to a disadvantage to the patient in terms of prognosis unless a wider and all encompassing prespective is inculcated and maintained. Often in the field of endodontics, a patient presents with a finding which leads to a terminal conclusion of extraction. However, with an aim of preserving the tooth, if various principles of treatment modalities of other branches of dentistry are employed, the prognosis can take a 360° turn for successful preservation of the tooth in the arch in complete functional state. We present one such case of an incomplete vertical fracture in the furcation area of a mandibular molar, destined for extraction, but conserved with concomitant orthodontic banding followed by intentional surgical bicuspidisation and full coverage restoration.

Myocardial Infarction with Alkaptonuria: A Case Report

KS Lakshmi, R Gomathy, S Arundhathi, S Prathibha

Alkaptonuria is an autosomal recessive disorder due to deficiency of homogentesic acid oxidase, an important enzyme in the catabolism of aromatic amino acids. Homogentesic acid is finally converted to fumarate and acetoacetate. Reduced activity of this oxidase causes accumulation of homogentesic acid in the cells and body fluids. Here we describe an interesting case of alkaptonuria in a 50-year-old man, previously diagnosed as osteoarthritis who succumbed to myocardial infarction, which is one of the complications of alkaptonuria.

Primary Sclerosing Lipogranuloma: A Rare Cause of Scrotal Mass

Smita Singh, Anamika Kashyap, Kiran Agarwal, Manoj Andley

Sclerosing Lipogranuloma (SLG) is a rare disease that affects many organs, with male genitourinary system being the most common site. It is a benign disease which occurs due to a granulomatous reaction of fatty tissue in this area. In most cases, it occurs secondary to exogenous foreign bodies. However, endogenous lipid degeneration can occur due to infection, trauma, and allergic mechanisms. We describe a 34-year-old male patient who presented with a growing, painless scrotal mass on physical examination. Clinical suspicion of paratesticular tumour was made and on cytological examination, possibility of adenomatoid tumour was considered. Histopathological evaluation confirmed the diagnosis of paratesticular SLG.

Recurrent Primary Angiosarcoma of Breast–A Rare Entity

Namrata Rao, Siddiq M Ahmed

Angiosarcoma of the breast is a rare tumour with a reported incidence of only 0.04% of all breast malignancies. A 34-year-old lady presented with a lump in her right breast. In view of haemorrhage and few stromal fragments on Fine Needle Aspiration Cytology (FNAC), a diagnosis of phylloides was given. Simple mastectomy was done which showed a tumour with areas of haemorrhage. On microscopy anastomosing irregular vascular channels filled with RBC’s were noted. Sheets of tumour cells with high mitotic activity was observed at places. There were areas of haemorrhage and ischaemic necrosis. A diagnosis of angiosarcoma was made which was confirmed by immunohistochemistry (CD 34 and factor VIII). Eight months later she presented with a recurrent lump in her right chest wall following which lumpectomy was done. Microscopy showed similar features as in the earlier mastectomy specimen. On reviewing the fine needle aspiration slides we realised that the endothelial fragments were mistaken for stromal fragments. The importance of this case report lies in the fact that primary breast angiosarcoma is a rare tumour which can develop without radiation exposure/history of previous breast surgery. The presence of spindle cells on fine needle aspiration slides necessitates careful examination and evaluation to rule out malignancy. It is important that the cytopathologist is aware of this possibility, to enable an early diagnosis.

Combined Hereditary Spherocytosis and ß-thalassemia trait: A Rare Co-existence

Haemoglobinopathies are the commonest haemolytic disorders, prevalent in India and form a major bulk of patients in most of the haematology outpatient clinics. ß-thalassaemia is the commonest inherited haemolytic anaemia and presence of ß-Thalassaemia Trait (BTT) goes mostly undetected due to its asymptomatic clinical course. However, BTT should be diagnosed so as to conduct a genetic counselling and to prevent the number of births of affected children in turn reducing the financial burden on the affected family. Detection of combined haemolytic anaemia is on a rise due to better screening modalities in haemoglobinopathies. We hereby present two cases of combined BTT and Hereditary Spherocytosis (HS), and their clinical outcome.

A Case of Immunotactoid Glomerulopathy in a Patient with Multiple Myeloma

Irina G Rekhtina, Larisa P Mendeleeva, Patricia E Povivaitite

Cases of Immunotactoid Glomerulopathy (ITG) in patients with Multiple Myeloma (MM) are extremely rare. Consequently, data on efficacy and therapy results are limited. We report on a rare case of long-term follow-up patient with MM and ITG. After chemotherapy the patient achieved complete remission with complete recovery of renal function. A repeat renal biopsy revealed complete resorption of the deposits. After 4 years, ITG was diagnosed again in another kidney biopsy during a relapse of MM. There was excessive glomerular infiltration by lymphoid cells and obstruction of capillary lumen was identified. Bundles of microtubules, similar to the deposits in kidneys, were revealed in some lymphoid cells.

Dizziness: Smell the Smoke!

Dizziness in a child is often mistaken for giddiness, vertigo or syncope and at times it is considered equivalent to malingering or foolishness. We hereby report a case of a child whose dizziness stayed neglected and unevaluated for three years. This case is an eye opener for physicians to not take the symptom lightly. A detailed assessment and prompt evaluation can seriously unmask the underlying morbidity like Moyamoya Disease (MMD).

A Rare Association of Aqueductal Stenosis with Subependymal Heterotopia

Pooja Gupta, Kamlesh Kumar Singh, Satish Mendonca

Aqueductal stenosis is one of the known causes of hydrocephalus and the most common cause of congenital hydrocephalus. Gray matter heterotopias are malformations of cortical development where the migration of neurons along specialized glial cells from near the ventricle to the cortex is interrupted, causing "normal neurons in abnormal locations". In this case report we have a case of a two-year-old girl who presented with obstructive hydrocephalus due to a stenosis in the aqueduct associated with nodular grey matter heterotopias along the walls of occipital and temporal horns of both lateral ventricles. We hereby describe the characteristic radiological features along with a review of the relevant literature.

Removal of a Deeply Impacted Ectopic Mandibular Third Molar through a Buccal Corticotomy in Severe Trismus-A Case Report

Ranjeet Bodh, Saroj Kumari, Sujata Mohanty, Rudra Deo Kumar, Catherine Diana

Management of deeply impacted mandibular third molar in itself is a surgical challenge and when it is associated with restricted mouth opening, it becomes more devious job. Deeply impacted tooth can be approached by buccal corticotomy/osteotomy, lingual split, extraoral approach or sagittal split ramus osteotomy. In patients with restricted mouth opening, options get limited to buccal corticotomy and extraoral approach. Extraoral approach is not a preferred option pertaining to scar formation and potential risk of injury to the marginal mandibular branch of the facial nerve leaving buccal corticotomy as most viable option.

Cor Triatriatum Dexter in a Male Cadaver

Pooja Bhadoria, Neelam Vasudeva

Cor Triatriatum Dexter (CTD), is a very rare congenital anomaly in which right atrium is partitioned to form three chambered heart. It is caused by the persistence of the right valve of the sinus venosus. We herein report a case, where during routine dissection on the heart of male cadaver, a well-developed membrane was seen, separating the smooth and rough parts of right atrium. This can have varying clinical manifestations depending on the degree of partition of the right atrium. Knowledge about presence of such membrane is important for physician’s, as severe partition can lead to obstruction of the tricuspid valve, the right ventricular outflow tract, or the inferior vena cava associated with right-sided heart failure and elevated central venous pressures.

Adrenal Gland Haemangioma Mimicking a Non-functional Pheochromocytoma

Gwendolyn Fernandes, Munde Shital, Sanjeet Kumar

Haemangiomas of adrenal gland are rare, non-functioning benign tumours with less than 100 cases documented in literature. They are difficult to diagnose preoperatively and are often clinically mistaken for other benign adrenal lesions like myelolipoma, ganglioneuroma and non-functional pheochromocytoma. We report a case of a 38-year-old male with haemangioma of the adrenal gland which presented exclusively with pain in the right side of the abdomen.

A Rare Case Report of Iniencephaly with Anencephaly and its Rare Associated Congenital Malformation

Tanima Dwivedi, Ranjit Kangle

Iniencephaly is an extremely rare neural tube defect with incidence range from 0.1 to 10 in 10,000. It is diagnosed by a triad of fixed retroflexion of the head, variable degrees of cervical lordosis and dysraphism, and an occipital bone defect involving the foramen magnum. It is usually reported as an isolated anomaly and it rarely occurs along with anencephaly. We report here such a rare case of Iniencephaly in association with anencephaly and multiple rare congenital malformations such as asplenia, craniospinal rachischisis, occipital cervical spina bifida and congenital diaphragmatic hernia. It was rare type of congenital diaphragmatic hernia in which intestine coils were lying in front of vertebrae. These anomalies are rare in themselves.

Intraoral Styloidectomy in Eagle’s Syndrome-A Risky and Infrequently Performed Approach

Eagle’s syndrome is a symptomatic anomaly due to elongation of styloid process or calcification of stylohyoid ligament manifesting as a pain in cervicofacial region. The present report is of a 45-year-old female who presented with bilateral cervical pain and vague throat complains, not relieved by medical line of management. She was diagnosed with bilateral elongated styloid process on radioimaging. Intraoral styloidectomy was performed, following which she was completely relieved of her symptoms. This is a rarely performed approached for removal of elongated styloid procedure due to the grave vascular complications, but it has several advantages including minimally invasive, scarless, cost-effective technique with good patient compliance.

Reversible Sinusoidal Obstruction Syndrome with Nodular Regenerative Hyperplasia Following Oxaliplatin-Based Chemotherapy

Khalil Aloreidi, Maheedar Gedela, Dheera Keerthi Kattula, David Bean, Lokesh Jha

Sinusoidal Obstruction Syndrome (SOS) is a form of hepatic injury characterized by damage to small hepatic vessels resulting in occlusion of the terminal hepatic venules and hepatic sinusoids. Oxaliplatin has been associated with distinct side effects; one of them reported recently which is SOS. We report a patient with history of colon cancer who presented with elevated liver enzymes and liver nodules. After extensive evaluation, the patient found to have a severe form of SOS which is the Nodular Regenerative Hyperplasia (NRH) as a result of oxaliplatin based chemotherapy. We also report the reversibility of this condition after treatment cessation which is something that is not always feasible. The diagnosis of this case was challenging as the liver nodules thought to be metastases initially and that is why we believe recognizing this entity is crucial to prevent misdiagnosis and consequent unnecessary surgical intervention.

Labial Agglutination in a Pubertal Girl

Pushpawati, Vinita Singh, Snehil Sinha, Amrita Singh

Labial agglutination is a state of partial or complete adhesion of the labia minora. It occurs in prepubertal or postmenopausal women and usually associated with low estrogen levels. Labial agglutination is rare in women of reproductive age group due to abundance of estrogen. We are presenting a neglected case of labial agglutination in pubertal girl of 16 years age due to its rare presentation and different approach for treatment in this age group who was suffering since birth. After taking detailed history, thorough clinical examination and all required laboratory and imaging investigations we could reach to the correct diagnosis which was followed by skilful surgery. This approach cured her distorted vestibular anatomy without any complication. Patient was treated by surgery i.e. labial adhesinolysis under vaginoscopic guided approach using our standard hysteroscope light and camera. Labial adhesion can be treated both medically and surgically however treatment is individualised in every case ranging from medical treatment to minimally invasive surgery or invasive skilful surgery.

B12 Deficiency in a Breastfed Infant Due to Maternal B12 Deficiency: A Case Report

Saritha U Kamath, Nalini Bhaskaranand, Anjali Rao

We report a case of eight-month-old breastfed male infant presented with developmental delay and knuckle pigmentation. Peripheral smear examination showed microcytic hypochromic anaemia. Knuckle pigmentation has given a clue for vitamin B12 deficiency and got confirmed by detailed biochemical investigations. On examination mother was found to be vitamin B12 deficient who also presented with knuckle pigmentation. Subsequently the infant was administered oral vitamin B12 and responded to the therapy as indicated by weight gain, improvement in development, normalisation of serum B12 and blood haemoglobin level.

Early Intestinal Obstruction in Iron Toxicity – An Unheard of Occurrence

Deliberate self-harm by overdosing on iron tablets although rare is an emergency and requires early recognition and intervention. We present the case of a 19-year-old girl who presented with abdominal distension, colicky abdominal pain, obstipation and intractable vomiting two days after an attempt at deliberate self-harm with ingestion of 30 iron tablets. She was admitted at another hospital, underwent gastric lavage and was monitored in their intensive care unit (ICU) for two days following which she was asymptomatic at discharge. At our hospital, abdominal radiographs showed multiple air fluid levels and dilated bowel loops. CECT showed focal thickening of the distal ileum with luminal occlusion, mesenteric hyperemia and fat stranding. She made complete recovery after conservative management with bowel rest, Deferoxamine (DFO) therapy and supportive care. Segmental enteritis caused by iron ingestion has not been well described and its sequelae causing luminal occlusion leading to intestinal obstruction within a week is very rare. Due to the infrequent occurrence of this condition and lack of evidence, management of intestinal obstruction following iron toxicity is case based. However, rigorous monitoring and follow up until complete resolution of symptoms is essential.

Laser Assisted Management of Telangiectatic Granuloma in Third Trimester of Pregnancy – A Case Report

Telangiectatic granuloma is an uncommon overgrowth of the tissues that occurs as a result of various stimuli such as low grade local irritation, traumatic injury or hormonal factors. It generally develops as a solitary, granuloma like, pedunculated, easily bleeding tumour which mostly affects the gingiva followed by buccal mucosa, tongue, lips and palate. Telangiectatic granuloma is also known as granuloma pyogenicum, granuloma gravidarum, pregnancy tumour, vascular epulis, benign vascular tumour and haemangiomatous granuloma. Commonly involved treatment protocols include conventional surgical excision, electrocautery and lasers. The purpose of this article is to report the laser assisted management of an unusual case of telangiectatic granuloma in a 22-year-old female patient in her 32nd week of pregnancy.

Mucormycosis in Intestines–An Underdog among Invasive Intestinal Infections

Simrandeep Kaur Jagdev, Ruchita Tyagi, Bhavna Garg, Neena Sood

Mucormycosis is an opportunistic invasive fungal infection caused by Mucorales of class Zygomycetes. It is commonly seen in immunosuppressed cases. Gastrointestinal infection (GI) is very uncommon among adults and is diagnosed only on histopathological examination of biopsy or resection specimens. Due to non-specific clinical presentation, intestinal mucormycosis is diagnosed late. We report a series of six cases of intestinal mucormycosis in adults. Three years retrospective analysis of ileal and colonic resection specimens was performed in our tertiary care institute. All the cases had mucosal ulceration and necrosis on microscopic examination and one case also exhibited angioinvasion. Histopathology is the cornerstone of diagnosis and prompt management of invasive mucormycosis which may follow a rapid and fatal course in the absence of timely and optimum management. The clinicians need to keep the possibility of this vasculotropic fungus in mind in all cases presenting with abdominal symptoms.

A Novel Complete Denture Impression Technique with Thermoplastic Stock Trays

Sivaranjani Gali, Priyanka Aiyer, Anoop Sharma

Primary impressions in complete dentures are generally made with stainless steel stock trays. Conventional clinical procedures therefore, require additional patient appointments for primary and master impressions. We propose a unique single appointment technique of a thermoplastic stock tray for peripheral tracing and master impression for complete denture patients.

Home Based Blood Pressure Monitoring in Indian Setting: A Consensus Document

Expert group

Hypertension is one of the most significant public health problem and a common lifestyle disease today in India. Monitoring of blood pressure along with appropriate and timely management is critical in order to avoid any morbidity and mortality associated with hypertension. The use of Home Blood Pressure Monitoring (HBPM) for the measurement of blood pressure by the patient outside the clinical setting, either at home or at work place, is increasing across the world. The practice of monitoring blood pressure at home is well accepted by the patients as well and can be a useful adjuvant to the routine office based blood pressure measurements. Recently, experts in the field of hypertension management across India were invited to develop a consensus document on the role of HBPM in the Indian setting. This consensus document reflects the views and suggestions of the experts who had participated in developing this document.

Preliminary Evaluation of Human Gingiva as an Extrapineal Site of Melatonin Biosynthesis in States of Periodontal Health and Disease

Balaji Thodur Madapusi, Suresh Ranga Rao

Introduction: Melatonin is a pineal gland hormone that plays an important role in periodontal homeostasis. Extra pineal melatonin production has been found to occur in tissues like the ovaries, retina and gastrointestinal tract. It is not known if the human gingiva could synthesise melatonin and whether melatonin receptors are present in the gingival tissues. Aim: To investigate if human gingiva is an extrapineal site of melatonin biosynthesis in non smokers and current smokers with and without chronic generalised periodontitis. Materials and Methods: The present study has a case control design with a total of 60 participants divided into four groups namely, Periodontally Healthy Non smokers (PHN)-Group 1, Non smokers with Chronic generalised Periodontitis (NCP)-Group 2, Periodontally Healthy current Smokers (PHS)-Group 3, and current Smokers with Chronic generalised Periodontits (SCP)-Group 4. Gingival tissue samples were obtained from the study participants after obtaining informed consent, using an aseptic protocol. Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) was carried out to assess the presence of the genes encoding N-Acetyl Transferase (AANAT), Hydroxyindolyl-O-Methyltransferase (HIOMT), Melatonin Receptor 1 (MT1) and Melatonin Receptor 2 (MT2). Further flow cytometry experiments were carried out in freshly obtained gingival tissue samples to quantify melatonin receptors. Immunohistochemistry experiment was performed on paraffin embedded tissue sections to study the qualitative distribution of melatonin receptors. The results were documented and analysed using SPSS software version 23.0. Results: The current study showed that the human gingival tissues are an extrapineal site of melatonin biosynthesis. RT-PCR, flow cytometry and immunohistochemistry techniques revealed that MT1 receptor was present in the human gingiva. Furthermore statistical analysis revealed that the expression of AANAT, HIOMT and MT1 genes and the MT1 receptor protein levels were significantly lower in current smokers with and without chronic generalised periodontitis compared to non smokers. Conclusion: It can be concluded that the gingiva could synthesise melatonin as a defense mechanism to protect against oxidative stress and inflammation. Habits like smoking can reduce the levels of gingival melatonin and MT 1 receptor expression which could reduce the cytoprotective benefits of melatonin.

Ciprofloxacin Induced Stevens-Johnson Syndrome

Correspondence: “Postoperative Pain and Flare-Ups: Comparison of Incidence between Single and Multiple Visit Pulpectomy in Primary Molars”

Paola Cecibel Manrique, Eduardo Martín Castillo-Cabezudo

Correspondence: Is Alexidine Really More Effective than Chlorhexidine?

Tahir Yusuf Noorani

Raising Rogue Authors: Urgent Need of a Training Program on Publication Ethics

Himel Mondal, Shaikat Mondal

Effect of Cleistanthin A on Voltage Gated Proton Channels of Human Neutrophils

Introduction: Cleistanthus collinus (C. collinus), a well known plant toxin, contains active principles like Cleistanthin A, Cleistanthin B, Cleistanthin C and Diphyllin. Previous human case reports and animal studies have revealed that C. collinus poisoning leads to type I Distal renal tubular acidosis and type II respiratory failure. However, the mechanism of toxicity of this plant is still uncertain. Based on the hypothesis that blockade of proton channels could result in type II respiratory failure, patch clamp experiments were done to see if Cleistanthin A blocked the proton channels. Aim: To record and compare the changes in the magnitude of voltage-gated proton currents in human neutrophils, before and after addition of Cleistanthin A (test) and control solution. Materials and Methods: The test compound Cleistanthin A was isolated by partition chromatography and characterised using thin layer chromatography. Neutrophils were isolated by density gradient centrifugation method. Using voltage clamp protocol, proton currents were recorded before (pre-intervention currents) and after (post-intervention currents) the addition of Cleistanthin A or control solution. The pre and post-intervention current densities for different voltages were compared within the groups (control and test) by Wilcoxon signed-rank test and the percentage current remaining in both the groups were compared using Mann-Whitney U test, p<0.05 was considered significant. Results: Normal proton currents were recorded in human neutrophils. Comparison of the pre and post-intervention current densities within the control and test group revealed a significant depletion effect in the control group but not in the test group. However, comparison of the percentage current remaining after intervention across the groups did not show any significant difference between the control and test groups. Conclusion: Cleistanthin A does not seem to have any significant effect on the voltage-gated proton channels of human neutrophils.

Immunogenicity and Safety of a Novel MMR Vaccine (Live) (Freeze-dried): Results of a Phase II Clinical Trial

Introduction: This is the first study in Indian paediatric subjects to evaluate the novel Measles, Mumps and Rubella (MMR) vaccine developed by M/s Cadila Healthcare Limited, India, containing the Hoshino mumps strain. This phase II study was done as part of clinical development programme to evaluate the safety and immunogenicity of the novel vaccine in small cohort of target population before conducting the larger comparative phase III study. Aim: To evaluate the immunogenicity and safety of the single-dose and multi-dose formulations of the novel vaccine. Materials and Methods: One hundred and twenty three healthy children 15-18 months of age were administered a single dose of the novel MMR vaccine from either the single-dose or the multi-dose formulation. Immunogenicity of the vaccine was assessed by measuring IgG antibodies against the measles, mumps and rubella viruses before and six weeks after the vaccination. Safety of the vaccine was assessed by recording adverse events during the six week study period. Results: The seroconversion rate for anti-measles and anti-mumps antibodies was 100% while that for anti-rubella antibodies was 98.9% after the MMR vaccination. There was no difference in the seroconversion rates in the subjects receiving the MMR vaccine either from the single-dose or the multi-dose formulation. The Geometric Mean Titre (GMT) of anti-measles, anti-mumps and anti-rubella antibodies was 3154.0 mIU/mL, 90.6 EU/mL and 141.7 IU/mL, respectively. The vaccine was well tolerated, 28 subjects (out of 123) reported 43 adverse events during the study (adverse event rate of 21.8%). The most common adverse event reported during the study was fever in 19 subjects (15.4%) followed by rash and rhinorrhoea in five subjects (4.1%) each. Conclusion: The results of this phase II clinical trial show that both the single-dose and the multi-dose formulation of the novel MMR vaccine are immunogenic and well tolerated by healthy paediatric subjects aged 15-18 months.

Effect of Critical Thinking Education on Problem Solving Skills and Self-Esteem in Iranian Female Students

Maryam Azizi, Zeinab Sedaghat, Ashraf Direkvand-Moghadam

Introduction: Critical thinking is a process of analysing, synthesising and evaluating the information in order to achieve an answer or conclusion. Aim: To evaluate the effect of critical thinking education on problem solving skills and self-esteem. Materials and Methods: A quasi-experimental study was carried out among Iranian female high school students, from November 2016 to December 2016. Cassidy and Long’s Problem Solving Questionnaire and Rosenberg Self-esteem Scale were used for data collection. A multistage random sampling was used. First, two high schools of girls were randomly selected and all study participants were asked to complete the problem solving questionnaire. Then, 60 students who had lower scores in problem solving skills (10-14) were identified and randomly assigned to the experimental and control group. The experimental group received eight 60 minutes sessions of critical thinking education. Before and after the intervention, students completed Problem Solving questionnaires and Rosenberg self-esteem scale. Data analysis was performed by the Multivariate Analysis Of Variance (MANOVA). Results: There was a significant correlation between problem solving skills and self-esteem (r=0.389, p=0.002). There was a significant difference between groups in problem solving skills (p=0.0001) and self-esteem (p=0.0001). Conclusion: Educating about critical thinking to the students had a positive effect on problem solving skills and self-esteem. Therefore, it can be said that critical thinking education is one of the important tools to create, cultivate and increase problem solving skills and self-esteem.

Anatomical Study of Left Coronary Artery and its Variations– Cadaveric Study

Introduction: Variations of the anatomy of the Coronary arteries are quiet common and have been reported previously in the literature. Right and Left coronary arteries which supply blood to the heart originates from the ascending aorta. Any coronary artery disorder may have serious implications by reducing the blood supply to heart leading to myocardial infarction and death. Aim: To identify left coronary artery branching pattern and its variations. Materials and Methods: Fifty formalin fixed wet specimens of heart of both sexes with intact coronary arterial pattern were collected and studied. The left coronary artery and its branches were carefully dissected out and were analysed for variable pattern in each specimen. Results: Left coronary artery (LCA) was found to be hypoplastic in six (12%) specimens. In one specimen (2%), hypoplastic LCA was crossed by a vein and had communication with the vein. Trifurcation of LCA was seen in 17 (34%) specimens, Circumflex artery was short in one (2%) specimen. Kugel’s artery was observed in three (6%) specimens. Median artery was found in seven specimens (14%). The left coronary artery and circumflex artery were absent in one (2%) specimen. In case where left coronary artery was absent, left anterior descending artery and circumflex artery were taking origin directly from left anterior aortic sinus. Left anterior descending artery showed variation in the form of short course (2 cm), discontinuous and embedded within myocardial tissue in 2% of cases each. However the circumflex artery also showed short course in one (2%) case. Conclusion: The variations of the left coronary artery observed in the study are important for interpretation of coronary angiography, surgical revascularization of myocardium and embryological interpretations.

Depression, its Correlates and Effects in Ever Married Urban Women Residing in Kumaon Region of Uttarakhand

Introduction: In the global context, independent studies on depression show that women are twice as likely as men to suffer from clinical depression. It is also described as an important cause of premature mortality either from physical disorders or from suicides. Aim: To determine the burden of depression, to identify the related factors and assess its effects on functionality and suicidal ideation. Materials and Methods: The present cross-sectional study was conducted in urban area of Haldwani, Kumaon Region, Uttarakhand, India. Taking anticipated prevalence of depression as 24.9% and taking non-response rate of 15% the sample size was estimated to be 320. Ever married women of age group 18-59 years who gave informed consent were included. Population proportional to size method was used to determine the number of women to be interviewed and individual households were selected by systematic random sampling. The data was collected on relevant factors using a pre-tested, semi-structured questionnaire along with the PHQ-9 scale administration. Results: Clinically significant depression was present in 18.8% women. Burden of depression was found to be maximum in women belonging to 35-44 years. Significantly higher odds of developing depression was seen in women who stayed in joint families or families with issues of substance abuse, economic instability, and family disputes with husband. Education of children and concern about their future also acted as an important factor along with unsatisfactory self-image. Depression was found to be significantly associated with functionality and suicidal ideation. Conclusion: Burden of depression was found to be high in the ever-married women residing in urban area and is particularly related with social factors and self-image.

Person-centered Nursing to Improve Treatment Regimen Adherence in Patients with Myocardial Infarction

Introduction: Person-Centred Care (PCC) relies on effective communication and emphasises on co-operation in care between patients and healthcare professionals. WHO advocates this type of care as a key component of quality health care. Aim: To evaluate if person-centred nursing can improve treatment regimen adherence in patients with Myocardial Infarction (MI). Materials and Methods: During August-November 2016, 101 patients with MI, of age =85 years were randomly assigned to person-centred nursing group and usual care group and followed for two months. In the intervention group, a person-centred nursing process was added to care, emphasising the patient as a partner in care. Care was provided in co-operation with the patient, registered nurse and researcher. Data were collected using self-report adherence to the treatment regimen questionnaire and were analysed using SPSS software version 22 and chi-square test, independent samples t-test and paired t-test were applied wherever required. Results: Study results showed that the mean score of treatment regimen adherence did not have a significant difference before intervention, three weeks and two month after intervention in control group (p=0.692; p=0.581), but three weeks after intervention, the intervention group had a significant difference in the mean score of the treatment regimen adherence (p<0.001). Also, paired t-test results showed that two month after intervention the mean of adherence in person-centred nursing group was higher than control group (p<0.001). Conclusion: Person-centered nursing improved treatment regimen adherence in patients with MI. Further work is needed to examine whether this intervention can be sustained to improve clinical outcomes.

Spiritual Self-care in Iranian People: A Qualitative Study using a Phenomenological Approach

Leili Mosalanejad, Mehdi Dastpak, Saeed Abdollahifard, Rahim Pendar

Introduction: There is a considerable amount of evidence concerning the existing links between religion, spirituality and health. Spirituality improves individual’s attitude towards environment and causes reduction in negative feeling and tension. Aim: To evaluate the experience of individuals in relation to spiritual self-care, using phenomenological approach. Materials and Methods: The present qualitative study was conducted with a phenomenological approach. A total of 47 ordinary people (including students, retired people, housewives, and unemployed people) were selected through purposive sampling technique. The data were collected through semi-structured interviews and continued until data saturation. Lincoln and Guba criteria (including, credibility, transferability, dependability, and confirmability) was used to confirm the reliability of the data. Walcott thematic analysis method was used to analyse the data. Results: Based on the analysis, results were placed in two main categories, including religious care and non religious care based on spirituality and four subcategories including religious compliance, respect for the rights and dignity, commitment to humanist and ethical behaviour and finding meaning and purpose in life. Conclusion: The people take care of themselves by religious and non religious ways based on spirituality. Hence, attention to the religious needs is one of the key factors in their health promotion.

General Public and Community Pharmacists Perception on Counterfeit Medicines: A Preliminary Cross-sectional Study in Qatar

Introduction: One major contributing factor to the prevalence of counterfeit medicines in a country is the lack of knowledge and awareness of the society. Information on general public and healthcare professionals awareness and vulnerability towards counterfeit medicines in developing countries is limited. Aim: To assess how the general public and pharmacists perceive counterfeit and substandard medicines and to evaluate their vulnerability level toward counterfeit medicines. Materials and Methods: A cross-sectional study was conducted in Qatar where a prevalidated questionnaire was used to collect information about: a) demographic characteristics, b) attitude, c) subjective norm, d) motivation, and e) behavioural intentions of pharmacists and public regarding counterfeit medicines on a Likert-scale. A total of 190 questionnaires were distributed conveniently to the public and community pharmacists. Chi-square and independent t-tests were used at p-value of 0.05. Results: One hundred ninety questionnaires were distributed to both community pharmacists and public, however, only 167 (87.8%) were collected which resulted in response rate. Most of the results of the survey (41 items) were not significant (p-value>0.05). Only questions about awareness towards counterfeit medicines, its societal consequences, the effect of price affordability and the effect of pressure exerted by relatives and friends on purchase intent of counterfeit medicines gave significant difference between public and pharmacists (p-value = 0.05). Conclusion: Overall findings suggested that there is no significant difference between pharmacists and public in the way they perceive counterfeit and substandard medicines. Both of them have the same susceptibility level toward counterfeit medicines. Both pharmacists and public have low-level of knowledge and moderate level of vulnerability to counterfeit and low-quality medicines.

Assessment of Diastolic Dysfunction Parameters and Cardiac Chamber Size in Smokers with COPD: A Case Control Study

Vasudeva Acharya, Sudhakar Mugularao, Sneha Seshadri, Ranjan K Shetty

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a critical health care burden across the globe. Pulmonary Hypertension (PH) is a widespread feature of advanced COPD and is estimated to affect 20% of individuals with advanced COPD. Aim: To compare the variables of cardiac function, chamber size and diastolic parameters across various stages of COPD. Materials and Methods: A prospective case control study was conducted among 50 subjects and 50 controls (convenient sampling) with COPD over a period of two years in kasturba Medical college, Manipal (July 2012-July 2014). Chronic smokers who met the criteria for COPD according to GOLD criteria were included in the study. All patients underwent Pulmonary Function Test (PFT) using spirometer. Results: Twenty seven out of 50 studied patients (54%) had Pulmonary Artery Hypertension (PAH). Nineteen patients had mild PAH (38%). Dimension of cardiac chamber across various stages of COPD were found to have a significant decrease in Left Atrial (LA) area. Our study found an increase in Isovolumic Relaxation Time (IVRT), Pulmonary Artery Pressure (PAP) and TEI index (myocardial performance index) across stages of COPD however it was not statistically significant. Conclusion: Majority of the patients with COPD had PH, with increasing frequency of PAH across the GOLD stages. A decrease in cardiac chamber size was demonstrated with increasing severity of COPD.

Recent Trends of Seroprevalence of Dengue in a Tertiary Care Hospital in Southern Odisha

Introduction: Dengue is a most common arthropod borne viral infection. It is endemic in several parts of India. It can lead to life threatening severe complications such as Dengue Haemorrhagic Fever (DHF)/Dengue Shock Syndrome (DSS). Aim: This study was conducted to know the seroprevalence of Dengue virus in a tertiary care hospital, Berhampur, Southern Odisha, India. Materials and Methods: Over a period of four years from January 2013 to December 2016, a total of 7345 blood samples from clinically suspected dengue patients were received in department of Microbiology laboratory. Serum was separated and subjected to enzyme immunoassay for detection of both Non Structural (NS1) antigen and IgM antibody. Results: Out of 7345 serum samples positive infection detected in 712 (9.6%) cases. Maximum number of cases were detected in the year 2016 and less number of cases were detected in 2013. Majority numbers of cases were detected in the month of September. Combination of NS1Ag ELISA and IgM antibody ELISA were used for early detection of dengue infection. Conclusion: Regular epidemiological studies are necessary to monitor the dengue situation in an area which helps in early detection of an outbreak and to initiate effective control measures.

A Comparative SEM Evaluation of Cleaning Efficacy of Endo Finisher, Self Adjusting File and Conventional Irrigation Regimen in Simulated Internal Resorptive Defects: An in vitro Study

Introduction: Difficulties associated with the comprehensive cleaning and disinfection of the canals with Internal Resorptive Defects (IRD) still remains a challenge. Hence, it is essential to improvise the existing or develop new root canal cleaning techniques. Aim: To comparatively assess the cleaning efficacy of XP Endo finisher (XP), Self-Adjusting File (SAF) and Conventional Syringe Needle Irrigation (CSNI) from mechanically unreachable region like Internal Root Resorption (IRR) in the middle third of relatively straight root canals. Materials and Methods: The root canals of 30 freshly extracted single rooted human maxillary anterior teeth were prepared using Nickel (Ni) Titanium (Ti) rotary files up till apical size 40. The prepared teeth were longitudinally split into two halves and internal resorptive defects were simulated in each half at uniform level by a demineralisation protocol with nitric acid and Sodium Hypochlorite (NaOCl) solutions in a sequential manner. Thereafter, the prepared specimen halves were reattached and randomly allocated to three equally sized groups (n=10) according to the technique to be used for smear layer/debris removal as follows: Group 1-CSNI, Group 2-SAF, Group 3-XP Endo finisher. The finally prepared specimens were again detached and evaluated for cleaning efficacy using Scanning Electron Microscope (SEM). One-way ANOVA test for means of the group and Post–Hoc Tukey’s test for interrelationship between groups were used for statistical analysis. Results: The mean scores of SAF and XP Endo Finisher group depicted comparatively cleaner canal surfaces and did not differ statistically (p>0.001). However, both the groups showed statistically significant difference with CSNI group (p<0.001). Conclusion: Maximum cleaning efficacy was obtained with SAF and EF followed by CSNI. In the cases of IRD the debris from resorptive defects may be adequately cleaned by both SAF and XP.

Repeated-Dose Toxicity in Mouse Liver and Kidney after Skin Exposure to Silver Nanoparticles

Introduction: Silver Nano Particle (SNPs) are the most widely used in consumer products. Thus, because of increasing potential for exposure of human to SNPs, there is an increasing concern about possible side effects of this nanoparticle. Despite the number of studies that have been done, little attention was paid to the dermal toxicity of these particles on human health. Aim: To investigate the possible histopathological toxicity at different doses of SNPs in the liver and kidney of mice. Materials and Methods: In this experimental study, 50 male BALB/c mice of about six weeks were randomly divided into negative control, positive control, pseudo-control (sham) and two experimental (10 and 100 µg/ml SNPs) groups (n=10). After giving general anaesthesia and shaving the back of all the rats, near the vertebral column, the bandage surface was treated in the experimental groups, the positive control group, and in pseudo-control group respectively with a volume of 50 microliters of the SNPs solution (10 and 100 µg/ml), AgNO3 solution (100 µg/ml), and distilled water was added to the sterile bandage of mice, then the bandages were fixed in the shaved surface, but the negative control group was without treatment and bandage. After 3 and 7 days, histologic sampling of liver and kidney of mice were subsequently analysed. Results: Histopathological studies demonstrated some changes such as dilatation of the central vein, hyperemia, inflammatory cells in liver, and vacuolar degeneration, cloudy swelling in kidney. Conclusion: These findings demonstrate that SNPs (40 nm) can induce hepatotoxicity and nephrotoxicity in mice following skin absorption in a dose-dependent manner. Therefore, it is necessary to measure tissue levels of SNPs in all treatment mice. It is also recommended for further research with various doses for different periods of time following various routes of administration of SNPs.

Group-based Asynchronous E-learning Incorporating Revised Bloom’s Taxonomy: An Innovative Approach

Arunita Tushar Jagzape, Kamal Shigli, Kirti Patel

Introduction: Faculty development programs like Foundation for Adavancement of International Medical Education and Research (FAIMER) have integral mentoring learning web sessions, a type of group based asynchronous e-learning. The e-learning sessions, mostly involving cognitive domain, should not only stimulate the senses but also bring out the best from participants. The Revised Bloom’s Taxonomy (RBT) involving cognitive domain was therefore selected to conduct the mentoring learning web session. Aim: To explore the dimensions of Early Clinical Exposure (ECE) in an innovative manner incorporating RBT in an e-learning activity. Materials and Methods: It was a qualitative study with 16 participants from 2014 batch and 16 participants from 2015 batch of GSMC FAIMER. The topic was ECE for the whole month (continuous) divided into four weeks and objectives for the week were as per the verbs mentioned in RBT. Week one objectives incorporated the verbs “remember and understand”; week two “apply and analyse”, week three incorporated the verbs “analyse and evaluate”; and week four’s verb was “create”. Week four activity also had a section on feedback divided into themes like input, process and output. The topic of ECE was discussed comprehensively during the month. The data gathered was analysed according to the number of responses for the week and the excerpts of the week. Results: There were 49, 34, 41 and 46 responses in week one, week two, week three and week four respectively. The excerpts from the feedback incorporating the themes of input, process and output had an affirmative dimension, stressing the need for such innovative methods to conduct the e-learning sessions. Conclusion: The learning journey of ‘ECE’ through this innovative method of using RBT was appreciated and the participants endorsed that conduction of e-learning sessions incorporating this method helped them to engage in discussion and elucidated their concepts.

Clinicopathological Profile of Cutaneous Metastasis from Internal Malignancies: A Five Year Retrospective Study

Nupur Goyal, Kanthilatha Pai, Sathish B Pai, Padma Priya Jaiprakash

Introduction: Cutaneous metastasis is the infiltration of skin by malignant cells from an underlying internal malignancy. Aim: To analyse clinicopathological profile of patients with cutaneous metastasis from internal malignancies. Materials and Methods: This was a five year retrospective study that included patients diagnosed with cutaneous metastasis from internal malignancies during the period January 2010 to December 2014. Information pertaining to patient demographics and disease details including site and type of previously diagnosed malignancy were noted. Results: Eighteen patients with cutaneous metastasis were identified. Cutaneous metastasis was the presenting feature in six patients, in others it occurred in previously diagnosed cases of malignancy after a mean duration of 25 months. Patients presented with painless cutaneous nodules in 10 (55.56%), ulcerated nodules in six (33.33%), painful nodules and indurated plaques in one (5.56%) each. Most common site of involvement was anterior abdominal wall. Most common histological subtype of metastatic carcinoma was adenocarcinoma, followed by squamous cell carcinoma. Conclusion: Cutaneous metastases are relatively uncommon, but it is important to recognise them. They may occasionally be the first manifestation of an underlying malignancy. The prognosis is usually poor in patients with cutaneous metastases, although early recognition offers some chance of survival.

Prevalence and Pattern of Congenital Musculoskeletal Anomalies: A Single Centre Study

Om Kumari, Vivek Singh

Introduction: Musculoskeletal defects are second most common birth defects after central nervous system anomalies.Only very few studies from India concentrates on the pattern of patients specifically dealing with congenital musculoskeletal anomalies. Aim: To determine the pattern and birth prevalence of musculoskeletal congenital malformations among the subset of neonates and infants born in a single tertiary care centre of north India and referred to Orthopaedic Department from Obstetrics and Gynaecology and Paediatric Department. Materials and Methods: A retrospective analysis of all the referrals made from Obstetrics as well as Paediatric Department to Orthopaedic Department from September 2014 to August 2016 for assessment of any visible congenital limb defect in a neonate was done. Only those infants were included in the study who were born in the same hospital during the study period. A record of all the deliveries conducted during the study period was also analysed. Pattern of anomalies in upper limb, lower limb and axial skeleton was noted. Birth prevalence of all the musculoskeletal anomalies was also determined. Results: During the study period a total of 10,126 births were recorded and 71 infants were found to have some form of musculoskeletal defect with prevalence of 7.01/1000 births. Out of 71 cases, 43 (60.56%) were males and 28 (39.44%) females. Ten (14%) children had the anomalies affecting the upper limb with a prevalence of 0.99/1000 births while in 49 (69%) the lower limb was affected with a prevalence of 4.84/1000 births. Twelve (16.9%) children had anomalies affecting the axial skeleton (birth prevalence 1.18/1000). The most common anomalies were Congenital Talipes Equinovarus (CTEV) (33 cases; 46.48%), Developmental Dysplasia of Hip (DDH) (10 cases; 14.08%) and spina bifida (seven cases; 9.86%) with a birth prevalence of 3.25/1000, 0.99/1000 and 0.69/1000 respectively. Conclusion: Congenital musculoskeletal anomalies has a prevalence of 7.01 per 1000 live births. CTEV and DDH are one of the commonest anomalies which are easy to treat if recognised early. Screening of every newborn by an Orthopaedic specialist is warranted.

High Yield Expression and Modified Purification of Novel Recombinant Truncated Protein FimH.MrpH against Urinary Tract Infections by Escherichia coli and Proteus mirabilis

Introduction: Urinary Tract Infections (UTIs) rank third among the list of most common bacterial infections. FimH and MrpH are the most important antigens of Escherichia coli and Proteus mirabilis isolates, respectively. Aim: To design a novel truncated fusion protein of immunogenic virulence factors and to assess expression efficiency of fusion protein made. Materials and Methods: N-terminal domains of MrpH (first 405 nucleotides) and FimH (first 495 nucleotides) that have functional and antigenic properties were selected to make a fusion protein. In silico and bioinformatics studies were designed to determin physico-chemical parameters. The Fusion gene was amplified by overlap PCR. After sequencing, it was inserted and expressed into pET28a vector. The expressed protein was purified by Ni-NTA column according to a modified protocol. Results: According to in silico studies, fusion tMrpH.tFimH was predicted as high quality model. About 900 bp long fragment was amplified by overlap PCR. Enzyme digestion and sequencing confirmed the cloning of the fusion gene in pET28a vector. Sodium Dodecyl Sulfate Polyacrylamide Gel Electrophoresis (SDS-PAGE) showed approximately 30 kDa band and Western blot confirmed the presence of fusion protein. A modified purification method has been tested which resulted in higher yield with high level of purity. Conclusion: In order to have effective vaccine against UTI, we must study a wide variety of strategies. This study provides the new protocol for efficient purification of tMrpH.tFimH protein in which the quantity and purification of protein is high. This recombinant protein could be introduced as vaccine candidate in the future study.

Comparison of the Effects of Zonisamide and Flupirtine on Paclitaxel Induced Peripheral Neuropathy in Rats

Bhuvaneswari Krishnamurthy, Prashanth Ashok Kumar, Abilash Sathyanarayanan

Introduction: Many peripheral and central causes lead to neuropathic pain disorders. Effective treatment of neuropathic pain is not completely manageable and hence, it becomes necessary to evaluate the application of Zonisamide as a sodium channel and T-type calcium (Ca+) current inhibitors and Flupirtine by activation of potassium (K) channel through N-methyl-D-aspartate (NMDA) receptor inhibition in the treatment of neuropathic pain. Aim: To analyze the analgesic effect of Zonisamide and Flupirtine in paclitaxel induced neuropathic pain model in rats by hot plate and cold allodynia test. Materials and Methods: Total of six groups of animals, each with six rats were given with single intraperitoneal (i.p.) injection of 1 mg/kg of paclitaxel on four alternate days (day 0, 2, 4, and 6). Drugs Zonisamide (50 mg/kg daily for group 2, 100 mg/kg daily for group 3, Flupirtine (10 mg/kg, daily for group 4, 20 mg/kg daily for group 5) and Gabapentin daily for group 6 were administered in the dosages per group from days 0 to 7. Nociceptive tests were done for all animals on days 0, 7, 14, 21, 28 to assess the pain threshold. Students t-test was used to analyze the statistical significance. Results: In our study, on the 21st day of testing we observed that 100 mg/kg dosage of Zonisamide group has shown a significant increase in reaction time suggesting analgesic effect. Prominent increase in the reaction time was also observed that on day 14 of testing, both the Gabapentin and Flupirtine groups showed an earlier analgesic effects when compared with the Zonisamide group. Conclusion: Zonisamide and Flupirtine showed anti-nociceptive activity in the Paclitaxel model of peripheral neuropathy compared with the standard treatment of Gabapentin.

Antibiotic Resistance in Community Acquired Urinary Tract Infection in Children: Data from a Tertiary Center in Eastern India

Introduction: Antibiotic resistance is an increasing global problem which hampers appropriate treatment of Urinary Tract Infection (UTI) in paediatric population, rendering the developing kidneys vulnerable for scarring and long-term complications. The present study stressed upon the most severely affected patients who required hospitalisation for treatment of UTI. Authors conducted this study observing the higher degree of drug resistance in patients admitted to general paediatric ward lately, suffering from UTI. Aim: To observe different clinical presentations of paediatric patients hospitalised with UTI. Authors also intended to identify locally prevalent community acquired bacterial uropathogens of clinical importance and note the sensitivity and resistance patterns of the isolated organisms against different antibiotics. Materials and Methods: This prospective observational pilot study was conducted at the Institute of Child Health, Kolkata, a tertiary care paediatric referral hospital. A total of 950 urine samples (single sample per patient) were collected from hospitalised children (from neonatal age group, upto 12 years) with suspected UTI/sepsis, between October 2014 to April 2016. Of 132 culture positive samples, 35 were excluded as per exclusion criteria, and 97 isolates had antimicrobial sensitivity performed on them. Clinical presentation was documented. Statistical analysis was done using the Chi-Square test. Results: The most common clinical presentations were fever, pain abdomen and anorexia. The most common isolates were Escherichia coli 59/97 (60.82%), followed by Enterococcus spp. 19/97 (19.59%) and Klebsiella pneumoniae 9/97 (9.28%). The majority of E. coli (n=59) isolates showed resistance against all Cephalosporins: 49-52 (83.1-88.1%), meropenem: 39 (66.1%), cotrimoxazole: 42 (71.1%), amoxycillin-clavulanic acid: 55 (93.2%) and quinolones: 50-51 (84.8-86.4%). Most Enterococcus spp. (n=19) isolates were resistant to amikacin: 17 (89.5%). Overall, a large proportion, 79/97 (81.4%) of uropathogens isolated showed Multidrug-Resistance (MDR). Conclusion: The alarming rates of resistance of uropathogens to commonly used antibiotics calls for review of empiric treatment guidelines and emphasises the need for preventing antibiotic misuse in day-to-day practice.

Utility of E-Cadherin as a Prognostic Marker in Oral and Cervical Squamous Cell Neoplastic Lesions

Introduction: E-cadherin is a glycoprotein cell adhesion molecule, which is important for maintenance of epithelial integrity and its loss is a useful biomarker for diagnosis and prognosis of preneoplastic and neoplastic squamous cell lesions. Aim: To evaluate and compare the expression of E-cadherin in oral and cervical premalignant and malignant squamous cell lesions. Materials and Methods: A total of 66 specimens (nine normal, 32 premalignant and 25 malignant) were obtained from oral cavity and cervix including 41 female and 25 male patients, which were divided into Group-I (control), Group-II (premalignant) and Group-III (malignant). Tumour grading and staging was performed. Immunohistochemical staining was done using monoclonal mouse antibody, E-cadherin as per manufacturer’s instruction. Analysis was performed using SPSS software version 17.0. Results: E-cadherin expression showed significantly (p=0.006) higher grades of expression in Group-I as compared to Group II and group III. Expression of E-cadherin was homogenous with membranous pattern in 100% cases of group I and was found in basal and parabasal layers of epithelium. Among group III, well-differentiated squamous cell carcinoma showed strong staining (++) in 92.3% of cases as compared to moderately/poorly differentiated tumours (16.7% of cases). As tumour become poorly differentiated, cytoplasmic staining was predominant pattern in 50% of cases of moderately/poorly differentiated tumour. Overall comparison of E-cadherin expression between oral and cervix lesions showed insignificant difference (p>0.05). Conclusion: E-cadherin expression was found to inversely correlate with the loss of cell differentiation. It can be used as prognostic marker for both oral and cervical premalignant and malignant squamous cell lesions.

Blood Agar for the Isolation of M. tuberculosis in Comparison with LJ Medium and BACTEC MGIT 960

Swetha Kamble, P Shashikala Reddy, CH Navaneetha

Introduction: The evolution of laboratory diagnostic methods of Tuberculosis (TB) over the past few years are designed to achieve more rapid, less expensive, and accurate results. However, acid-fast staining and culture for Mycobacteria remains the core of any diagnostic algorithm for TB. Aim: To assess 7% Sheep Blood Agar (BA) for the primary isolation of Mycobacterium tuberculosis in comparison with the Lowenstein-Jensen (LJ) medium and BACTEC Mycobacterial Growth Inhibitor Tube (MGIT) 960. Materials and Methods: This is a prospective study and was carried over a period of seven months in State TB Demonstration and Training Centre Intermediate Reference Laboratory (STDC-IRL), Erragadda Hyderabad, India from March 2014 to September 2014. About 100 clinically suspected TB cases (95 pulmonary and 5 extra pulmonary) were selected and respective samples were subjected to Ziehl-Neelsen (ZN) staining. Twenty one samples were positive and 79 were negative for Acid-Fast Bacilli (AFB). The samples were processed and inoculated on BA slants, LJ medium and BACTEC MGIT 960 (Becton, Dickinson and Company) bottles. The cultures were confirmed by ZN staining and speciated by biochemical reactions. Further, validation of growth on BA was identified by Genotype MTBDR plus (Hains Lifescience, Nehren, Germany) to confirm the growth of M. tuberculosis. Results: Approximately 100 samples inoculated, 40 {38 M. tuberculosis and 2 Non tuberculous mycobacteria (NTM)} were isolated on MGIT 960, 37 (34 M. tuberculosis and 3 NTM) on BA and 32 (30 M. tuberculosis and 2 NTM) on LJ medium. The average isolation time of BA LJ and BACTEC MGIT 960 TB was 13.2 days, 26 days and 11.8 days. Nearly 37 blood culture positive samples tested by Genotype MTBDR plus, 34 (91.89%) were confirmed as Mycobacterium Tuberculosis Complex (MTBC). The contamination rate was 2% on BA, 6% on LJ and 12% on BACTEC MGIT 960. Conclusion: Primary isolation of M. tuberculosis was achieved 8 to 18 days after inoculation of clinical samples on BA. It requires no specific equipment and therefore, BA can be prepared, utilised and also have the advantage of shorter turnaround time.

Post-approval Surveillance on Safety and Clinical Utility of Garenoxacin Mesylate in Patients with Community Acquired Respiratory Tract Infections

Himanshu Garg, Pramod Harishchandra Katke, K Krishnaprasad

Introduction: Respiratory Tract Infections (RTIs) have become increasingly difficult to treat owing to the increase in resistant Gram positive and Gram negative bacteria. Garenoxacin mesylate, a novel synthetic des-F(6)-quinolone has been approved in India in the year 2013 for treatment of bacterial RTIs. Aim: The aim of the present study was to perform a post marketing surveillance study on garenoxacin mesylate in the treatment of bacterial RTIs as a post approval requirement to assess the safety and clinical utility in Indian population. Materials and Methods: This study was a single-arm, phase IV, non-interventional, observational study to assess the safety profile of garenoxacin mesylate across eight established medical centers in India. Community acquired RTI patients were prescribed a single daily dose of garenoxacin mesylate 2×200 mg tablets administered orally for 5 to 14 days which included four follow up visits. A total of 461 patients were considered for analysis on safety as they had received at least a single dose. This subset was referred to as Safety Analysis Set (SAS). The primary endpoint of the study was to estimate the percentage incidences of adverse events experienced during the study with an intent to treatment basis. Clinical utility was assessed qualitatively based on the symptomatic improvement assessment done during each follow up. Results: The safety results were analysed for the intent to treat a population of 461 patients with community acquired RTIs. Baseline demographics showed males 268 (58.1%) and 193 female (41.9%) patient distribution with mean age of 33.7 years and comorbid history for 221 (45.8%) cases. Out of 461 patients, 53 (11.5%) patients developed 54 Treatment Emergent Adverse Events (TEAEs). The most common adverse drug reactions noted in 39 (74.1%) patients included abdominal discomfort (3, 0.6%), dizziness (10, 2.1%), headache (10, 2.1%) and decreased appetite (5, 1.1%). None of the patients reported serious adverse events including persistent symptoms that required drug discontinuation, hospitalisation or treatment with alternative drugs or antibiotics. Conclusion: Garenoxacin mesylate demonstrates excellent tolerability and safety profile and offers a therapeutic strategy in the management of bacterial or atypical RTIs.

Vaginoplasty: An Innovative Method of Making the Mould

Introduction: Vaginal agenesis is a rare congenital malformation of female genital tract. It is often associated with other organ anomalies. The patient generally presents with primary amenorrhoea in late puberty or early adolescent age. Various surgical and non-surgical methods have been used to create a functional neovagina. McIndoe’s vaginoplasty with its various modifications has been mentioned in the literature. Putting a graft and usage of a mould in the neovagina are essential for the success of this surgery. Various graft materials as well as various types of moulds have been used by various workers. We have used a different type of mould for this surgery. Aim: To evaluate the success of vaginoplasty in vaginal agenesis and to assess the acceptability and final outcome by the use of the soft mould in the postoperative period Materials and Methods: In a prospective study, nine patients aged between 14 to 29 years underwent vaginoplasty in our institution from 2013 to 2016. A team of gynaecologists, reconstructive and plastic surgeons were involved in management of all the cases. McIndoe technique was adopted for creating the neovaginal space and a split thickness skin graft was used on a specially made mould. The subsequent moulds on removal of the first one with skin graft, we used a soft mould instead of the hard acrylic mould which is generally uncomfortable to the patients. Results: All the nine cases presented were with primary amenorrhoea. Four of them had associated anomalies of kidney besides having hypoplastic uterus. Surgical procedures remained uneventful in immediate and late postoperative period. Skin grafts were well taken in all the cases. Two cases developed vaginal stenosis due to failure to use dilator regularly. However, they improved following resumption of regular use of dilator. Satisfactory intercourse is experienced by the married couple and those who got married subsequently. Conclusion: McIndoe technique of vaginoplasty is simple, minimally invasive and without any significant complications and gives satisfactory coital function. Use of soft mould in the immediate postoperative period is a useful option.

Knowledge, Attitude and Practice of Over the Counter Drugs among Dispensers Working in the Retail Pharmacies of a South Indian City-A Cross-sectional Questionnaire Based Study

Bikash Ranjan Meher, Sakthi Balan, Elambirai Pugazhentni

Introduction: Over The Counter (OTC) drugs are drugs which can be sold in the pharmacy without the prescription of registered medical practitioners. Drug dispensers have an important role in modifying patients' behaviors and curbing the misuse of OTC. Aim: To assess the Knowledge, Attitude and Practice (KAP) of OTC drugs among dispensers working in the retail pharmacies. Materials and Methods: A cross-sectional questionnaire based study was conducted to assess the KAP of OTC drugs among dispensers working in the retail pharmacies. Questionnaire was distributed to 62 pharmacies situated in Puducherry, India. All the data were analysed by using Microsoft excel sheet and applying descriptive statistics. Results: A total of 80.64% participants responded to the questionnaire. About 34% participants were pharmacy degree holder; whereas, 66% were non pharmacy degree holder. The mean score of dispensers with pharmacy and without pharmacy degree for knowledge (5.121±0.17, 4.09±0.17) attitude (4.59±0.12, 3.05±0.25) and practice (4.71±0.19, 3.27±0.24) respectively. Conclusion: Drug dispensers have a great role in promoting the proper use of OTC drugs but they lack the adequate knowledge about various aspects of it, so they should be properly trained and regularly updated for that.

Role of Clinical Evaluation of Ischaemia Modified Albumin in Diagnosis of Acute Coronary Syndrome: Unstable Angina to Myocardial Infarction

Nastaran Mojibi, Babak Bagheri, Mehryar Zargari

Introduction: Acute Coronary Syndrome (ACS) includes a spectrum of disorders ranging from unstable angina to myocardial infarction. Since, ACS is an important cause of mortality in the world, early diagnosis of the disease is very important. Ischaemia Modified Albumin (IMA) is an ischaemia biomarker that has been approved by the US Food and Drug administration and has clinical application. Although, many studies have been done on IMA as a biomarker in ACS patients, role of IMA for differentiating patients with unstable angina, Non ST-Segment Elevation Myocardial Infarction (NSTEMI) and ST-Segment Elevation Myocardial Infarction (STEMI) requires further study. Aim: To assess the diagnostic role of IMA in ACS patients and evaluate correlation between IMA and necrotic biomarkers such as cardiac Troponin I (cTnI) and Creatine kinase-myoglobin binding (CKmb) in ACS patients. Materials and Methods: The study included 75 subjects with ACS, who were divided into three groups of 25 patients each: Unstable angina, NSTEMI and Myocardial Infarction (MI) and 25 healthy people as control. They were enrolled into the study from the Fatemeh Zahra Heart Center, Sari, Iran, between November 2015 and October 2016. IMA was measured by the Cobalt-Albumin Binding (CAB) assay, cTnI was measured by rapid immunoassay and CKmb was estimated utilising colorometric enzyme method by commercial kits. The correlation between IMA and necrotic biomarkers was determined using a Pearson correlation analysis. Receiver Operator Characteristic (ROC) curve was used to assess role of IMA in diagnosis of ACS. Results: IMA levels in unstable angina patients were significantly higher than NSTEMI and MI (p<0.001). While there was no significant difference in IMA levels between NSTEMI and MI (p=0.675). Bivariate correlation analyses were performed to assess for any relationship between IMA levels and two common cardiac biomarkers (p>0.5, r=0.25). The area under the ROC curve of IMA for ACS patients was 0.783. The sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of IMA was 74.7%, 72%, 88.9% and 48.6% respectively. Conclusion: IMA is a useful biomarker in diagnosis of ACS especially unstable angina patients and there is no significant correlation between IMA and necrotic biomarkers (cTnI and CKmb) in ACS patients.

Assessment of Serum Ceruloplasmin Levels in Gingivitis, Chronic and Aggressive Periodontitis Patients- A Clinico-Biochemical Study

Introduction: Pro-inflammatory mediators are mainly responsible for periodontal tissue breakdown in periodontitis. Ceruloplasmin is one such biomarker, the levels of which seems to be elevated in presence of inflammation. Hence, assessing biomarkers of inflammation is a valuable tool for determining periodontal disease activity. Aim: To evaluate and compare the levels of serum ceruloplasmin in chronic generalised gingivitis, chronic generalised periodontitis and generalized aggressive periodontitis patients. Materials and Methods: Patients visiting the dental Outpatient Department (OPD) during the period of January 2017 to March 2017 were screened for gingival index, probing pocket depth, bleeding on probing and categorised into the following four groups based on the clinical signs and symptoms; healthy controls, chronic generalised gingivitis, chronic generalised periodontitis and generalised aggressive periodontitis groups. Ten patients were enrolled in each group. Blood samples were collected from the antecubital vein of the subjects. The collected samples were taken for serum ceruloplasmin assessment with essential precautions. The test results were subjected to statistical analysis using Tukey’s multiple post-hoc procedure, Karl pearson’s correlation coefficient and One-way ANOVA. Results: The results showed that serum ceruloplasmin level in chronic periodontitis was increased when compared to gingivitis group. Further, rise in levels of serum ceruloplasmin was comparatively higher in aggressive periodontitis subjects than chronic periodontitis subjects. Conclusion: Inflammatory markers are being used extensively for the diagnosis of periodontal diseases. It can be inferred from the results of the present study that ceruloplasmin is one such biomarker which seems to be elevated with progress in attachment loss.

Evaluation of Gingival Microleakage in Deep Class II Closed Sandwich Composite Restoration: An In vitro Study

Jewel Darsan, Veena S Pai, Vedavathi Bore Gowda, GR krishnakumar, Roopa R Nadig

Introduction: Microleakage is a major problem beneath deep Class II composite restorations where little or no enamel remains. One technique to overcome this problem is sandwich restoration in which an intermediate liner is sandwiched between tooth and composite restoration. Aim: This study evaluated and compared gingival microleakage at tooth restoration interface in deep Class II composite closed sandwich restorations (mesio-occlusal) using different liners like Resin Modified Glass Ionomer Cement (RMGIC), Biodentine, Theracal LC. Materials and Methods: Standardised conventional mesio-occlusal cavities were prepared on 40 extracted maxillary first premolars with dimension 2 mm buccolingually and the gingival seat placed at the level of cementoenamel junction. Teeth were divided into four groups (n=10). In Group 1 (control group) cavities were restored with composite (Filtek 250) using self etch bonding agent (scotch bond). In Group 2, 3 and 4, 0.8 mm thick liner of RMGIC, Biodentine and Theracal LC were applied respectively on the axial wall of the cavity. All the cavities were then restored with composite using self-etch bonding agent similar to Group 1. The specimens were then immersed in 0.5% aqueous solution of rhodamine B dye for 24 hours, sectioned and observed for the extent of dye penetration using confocal laser scanning microscope. Statistical analysis was performed using Kruskal-Wallis test for intergroup comparison followed by Mann-Whitney test for intragroup comparison. Results: Microleakage scores indicated that use of a liner beneath deep Class II composite restorations significantly reduced microleakage. Among the liners used, Biodentine and Theracal LC showed better results than RMGIC. Conclusion: This study concluded that use of a liner beneath deep Class II composite restoration reduced microleakage and Theracal LC performed similar to Biodentine and better than RMGIC, when used as a liner in deep Class II composite closed sandwich restorations.

A Study on Expression of Vascular Endothelial Growth Factor in Colorectal Malignancies and its Correlation with Various Clinicopathological Parameters

K Ashwini, Rajagopalan Padmavathi

Introduction: Tumours require neovascularisation for growth and metastasis. Vascular Endothelial Growth Factor (VEGF) is an important regulator of tumour angiogenesis and is associated with metastasis and poor prognosis. Aim: To assess the expression of VEGF in colorectal cancer by Immunohistochemistry (IHC), to compare it with the clinicopathological parameters and to determine the prognostic significance. Materials and Methods: We received 147 cases of resected specimens of colorectal carcinomas for histopathological examination in Institute of Pathology, Madras Medical College, Chennai, Tamil Nadu, India, during the period between July 2013 to July 2015. Relevant clinical details of the patients undergoing surgery for colorectal malignancy, regarding age, gender, procedure done were collected. Four µm thick sections were taken from formalin fixed paraffin embedded tissue blocks and stained with haematoxylin and eosin. Among them, 50 random cases were selected for immunohistochemical studies. Results: The median age at presentation was 60 years. Maximum number of cases occurred in the age group of 51-60 years. There was a male preponderance with 85 cases (57.8%). Left sided tumours were more common (104 cases, 70.7%). About 53.7% cases had tumours less than 5 cm in greatest dimension. Most common gross appearance was ulceroproliferative (92 cases, 62.6%). Most common histopathological subtype was infiltrating adenocarcinoma (123 cases, 83.7%). Most common grade was moderately differentiated (95 cases, 64.6%). Fifty three cases (36.1%) belonged to stage C2, 66 cases (44.9%) had lymph node involvement, 74 cases (50.3%) had lymphatic invasion, 67 cases (45.6%) had vascular invasion and resected margins were free in 143 (97.3%) cases; 4 cases (2.7%) had tumour infiltration in their resected margins. Among the 50 cases on which IHC was done, 9 (18%), 20 (40%) and 21 (42%) cases had 1+, 2+ and 3+ levels of VEGF expression respectively. A total of 21 cases (42%) had strong cytoplasmic staining for VEGF and 15 cases (30%) and 14 cases (28%) showed moderate and weak cytoplasmic VEGF positivity respectively. Statistically significant association was found between VEGF expression in colorectal carcinoma and factors like presence of lymphatic invasion, vascular invasion, lymph node metastasis and stage of the tumour. Conclusion: VEGF expression in colorectal malignancies seems to be an independent prognostic marker of tumour behavior and may be used to identify patients with unfavourable clinical outcome.

Morphologic Characterisation of 1693 Cholecystecomy Specimens- A Study from Tertiary Care Center in Northern India

Savita Agarwal, Pinki Pandey, Megha Ralli, Ranjan Agarwal, Priyanka Saxena

Introduction: Cholecystectomies are most common surgical specimens sent in pathology laboratories. Most common histologically identified lesion of gallbladder is chronic cholecystitis which on most occasions is associated with cholelithiasis. It is most common indication for cholecystectomy and also associated with gallbladder carcinomas. Aim: The aim of the present was to study the morphological spectrum of gallstone disease and correlation of cholelithiasis with benign and malignant lesions. Materials and Methods: A retrospective study was carried out from January 2012 to June 2016. A total of 1693 specimens were assessed for size of gallbladder, serosa, wall thickness, mucosa, presence/absence of stones, their number, and type along with any mass lesions. Microscopic features assessed included inflammation, cholesterolosis, granulomas, metaplasia, calcification, dysplasia, benign and malignant neoplasms. Results: Maximum numbers of cases were between 31 to 40 years with female preponderance. Chronic cholecystitis was the most common lesion seen in 1170 (69.1%) cases. Associated calculi was present in 1625 cases, mixed and cholesterol type accounting for 1050 (64.6%) and 382 (23.51%) respectively based on morphological appearance. Amongst 439 cases showing metaplasia, antral type metaplasia was most common followed by intestinal metaplasia. Most frequent stromal change was cholesterolosis. Dysplasia was seen in 15 (0.88%) cases and malignancy in 16 cases. Conclusion: Incidental detection of gallbladder malignancy on microscopic examination is the most significant information for the surgeon as well as for the patient and this fact emphasises the importance of subjecting each gallbladder specimen for histopathological examination.

A Clinical Study of Colour Vision Status of Female Relatives of Indian Males with Defective Colour Vision

Neelam Puthran, Tejaswini Prashant Khandgave, Jitesh Satija

Introduction: Around 15% of females are carriers of congenital colour blindness. Variable colour vision status exists in these heterozygous carrier females due to various factors such as retinal mosaicism and the likelihood of the presence of an additional cone with different photosensitivity. These heterozygous carriers are considered to be tetrachromats. Aim: To determine the colour vision status of female relatives of Indian colour blind males. Materials and Methods: In this cross-sectional observational study, screening of males was done by Ishihara plates, and those with Colour Vision Defects (CVD) underwent a digital Farnsworth Munsell hue test (FM 100 test). First degree female relatives and a control group of normal females underwent the same tests. Statistical analysis was done using one-way ANOVA test, Tukey’s test and unpaired t-test. Results: Thirty one colour blind males accounted for 3.04% of the 1017 males screened. All participating female relatives, i.e., 31 obligatory carriers (23 mothers and 8 daughters) and 12 sisters, had normal test results on Ishihara plates as well as FM 100 test, barring one mother. FM error score above 70 is considered to be abnormal. The FM error scores in the obligatory carrier females ranged from 39 to 62, while that in sisters' group ranged from 36-67. This error score was lower in control group with range from 14 to 49. Although, all female relatives made errors within the normal range, they had statistically significant higher FM error scores than the controls. Conclusion: Obligate carriers have normal colour vision on Ishihara plates. Higher error scores, albeit within normal limits, were seen on FM 100 test in obligate carriers than controls. Poor performances of genetic tetrachromats on the FM 100 test can be attributed to the fact that these tests are designed specifically for trichroamatic normal individuals, and thus, may not be sensitive enough to detect the superior colour discrimination abilities of tetrachromats. Detection of tetrachromacy will require customisation of colour vision tests as well as their availability to clinicians.

Comparison of Retinal Nerve Fiber Layer Thickness in Pregnancy and Postpartum Period

Introduction: The physiologic retention of water during pregnancy causes oedema in many organs. Optical review of Retinal Nerve Fiber Layer (RNFL), located in the undersurface of the retina, and is clinically useful in many diseases. Aim: This study assessed pregnancy induced oedema in retina by using the measurement of RNFL in pregnant women before and after delivery. Materials and Methods: In a prospective cohort study, 32 pregnant women with 28 weeks or more gestational age were compared during pregnancy and postpartum period. The RNFL thickness was measured by Optical Coherence Tomography (OCT). Results: The mean RNFL thickness was significantly more during pregnancy in comparison with the postpartum period, 107±9 µm versus 103±9 µm (p=0.013). Conclusion: RNFL thickness in diabetes and chronic hypertension or other chronic diseases might be misdiagnosed in pregnancy due to pregnancy induced increased thickness.

Neurocognitive Developmental Outcomes in Early Adolescent Rats Prenatally Exposed to Choline and Docosahexaenoic Acid

Introduction: Prenatal nutritional status plays a remarkable role in neurocognitive development of an offspring. Although, essential nutrients like iron, calcium, and vitamins are being supplemented during pregnancy, very few studies have focussed on essential brain nutrients and its role on foetal mental development and neurocognitive outcomes through ageing. Studies show that prenatal supplementation of essential brain nutrient such as choline alone enhances learning and memory functions and protects adult rats against spatial memory deficits across the lifespan. Similarly, studies also show that supplementation of Docosahexaenoic Acid (DHA) during pregnancy confers positive developmental outcomes in the offspring such as increased birth weight, enhanced visual acuity, hand to eye coordination, attention, problem solving and information processing. Aim: To assess the neurocognitive developmental outcomes of early adolescent rats prenatally supplemented with either choline or DHA or both. Materials and Methods: E0 Day pregnant dams were divided into five groups 1: Normal control, 2: Saline control 3: Choline 4: DHA, 5: Choline+DHA. Pregnant dams from the normal control group were undisturbed in their home cage and were provided normal animal feed and water ad libitum. Saline, choline (4.6 mmol/kg/day) and DHA (400 mg/day of DHA) were supplemented to appropriate groups during the same period. Subsequent to weaning period, rat pups from all groups of dams were subjected to t-maze and passive avoidance tests. Results: The behavioural studies indicate that offspring prenatally treated with (Group 5) both choline and DHA showed significantly (p<0.001) enhanced memory and learning ability, when compared to the same in age matched untreated groups or those treated with choline and DHA alone separately. Conclusion: Synergistic supplementation of choline and DHA rather than anyone of them singly during foetal development periods enhances their neurocognitive outcomes during early adolescence.

Sacroiliac Joint Mobilisation versus Transcutaneous Electrical Nerve Stimulation for Pregnancy Induced Posterior Pelvic Pain- A Randomised Clinical Trial

Shlesha Maulik Vaidya

Introduction: The prevalence of back pain in pregnancy is reported to be 75% especially in the last trimester, 20% of these report posterior pelvic pain. Aim: To compare the effect of Sacroiliac Joint (SIJ) mobilisation and Transcutaneous Electrical Nerve Stimulation (TENS) on pain and functional status in individuals with pregnancy induced posterior pelvic pain. Materials and Methods: A single blinded randomised clinical trial was conducted at Department of Physiotherapy, KM Patel Institute of Physiotherapy, Shree Krishna Hospital, Karamsad, Gujarat, India. A total of 30 pregnant participants of 20 to 35 years with uncomplicated pregnancy and positive FABER’S (Patrick’s) test were selected and randomly assigned into two groups. SIJ mobilisation and TENS was given to Group A and Group B respectively thrice a week for five sessions. Both the groups received lumbo-pelvic stabilisation exercises, activity modification and ergonomic advises. Visual Analogue Scale (VAS) was used for pain assessment and Roland Morris disability score was used to find impact on functional status. Baseline assessment was noted for pain and functional disability. Data were collected immediately after first intervention and at the end of five sessions. Results: Both the outcome measures in intragroup analysis showed improvements. Mean change in VAS score after five sessions for Group A was 6.91 and for Group B was 4.91. Functional improvement as assessed by RMDQ was 91% for Group A and 89% for Group B. Intergroup analysis proved that SIJ mobilisation was more effective in reducing pain and improving functional status (p<0.05). Conclusion: SIJ mobilisation and TENS are effective in treating pregnancy induced posterior pelvic pain and reducing associated disability. SIJ mobilisation is more effective in terms of improvement.

Combination of Proximal Fibulectomy with Arthroscopic Partial Meniscectomy for Medial Compartment Osteoarthritis Accompanied by Medial Meniscal Tear

Introduction: Medial compartment osteoarthritis is usually accompanied by medial meniscal tear. The treatment of symptomatic mild medial compartment osteoarthritis and medial meniscal tears in middle-aged and elderly patients is controversial. Aim: This study aimed to assess the efficacy of proximal fibulectomy combined with Arthroscopic Partial Meniscectomy (APM) for symptomatic middle-aged and elderly patients with mild medial compartment osteoarthritis and medial meniscal tears. Materials and Methods: Consecutive hospitalised patients treated with concomitant proximal fibulectomy and APM from April 2013 to June 2014 were included in the study. Proximal fibulectomy and APM were done by the same group of surgeons. APM was performed initially to manage medial meniscal tears. This was followed by the proximal fibulectomy, during which a 20-mm long proximal fibular segment was excised. Preoperative and postoperative Visual Analog Scale (VAS) pain scores, Hospital for Special Surgery (HSS) knee scores, and Ahlbäck grading of knee osteoarthritis were collected. Postoperative complications and subjective patient satisfaction were recorded. For statistical analysis of the VAS and HSS score, Wilcoxon signed-rank test and the paired t-test were used to compare over time, respectively. Results: A total of 31 out of 38 patients were included. Seven patients were excluded due to follow up loss. The mean follow up duration was 25.3±1.5 months. The postoperative median VAS score and Interquartile Range (IQR) were 0 (0–1), which was significantly lower than the preoperative median VAS score and interquartile range 6 (5–7) (p< 0.001). The mean HSS score improved from 78.2±8.2 points preoperatively to 90.1±4.5 points postoperatively (p< 0.001). No patients had radiographic evidence of osteoarthritis progression or fibular bony union, or required conversion to other surgeries. Subjective patient satisfaction was rated very satisfied in 7 patients (22.6%), satisfied in 20 patients (64.5%), fairly satisfied in 3 patients (9.7%), and not satisfied in 1 patient (3.2%). Complication in a single patient included a temporary palsy of the superficial peroneal nerve. Conclusion: Proximal fibulectomy combined with APM produced satisfactory surgical outcomes in our patient cohort at two years after treatment. Concomitant proximal fibulectomy and APM may be considered to be a safe and minimally invasive treatment.

Comparison of the Effect of Oestrogen Plus Foeniculum vulgare Seed and Oestrogen alone on Increase in Endometrial Thickness in Infertile Women

Introduction: Foeniculum vulgare seed is used to treat infertility because of phytoestrogenic properties. Aim: The present study was conducted to compare the effects of F. vulgare plus oestrogen and oestrogen alone on Endometrial Thickness (ET) in infertile women. Materials and Methods: In this study, 92 people with infertility were enrolled by convenience sampling and randomly divided into treatment case (45 women) and control (47 women) groups. Both groups were administered with oestradiol valerate 2 mg tablet three times a day since the third day of the menstrual cycle. Treatment group was also administered with F. vulgare tea on a daily basis. Then, ultrasound was conducted once every three days to determine ET. Other data such as serum ß-hCG level and increase in oestrogen dose were recorded in a checklist. The data were analysed by independent t-test and Chi-square in SPSS version 17.0. Results: There were no significant differences in mean age, BMI, number of years of infertility, number of children, cause of infertility, positive ß-hCG, failure to achieve adequate endometrial thickness, and increase in oestradiol dose between the treatment and control groups (p>0.05). The mean number of days to achieve ET of at least 8 mm was 13.1±3.2 in the treatment group and 14.2±3.5 in the control group with no significant difference (p>0.05). Conclusion: F. vulgare seed tea was not significantly effective in increasing the ET as compared to oestradiol valerate 6 mg alone.

Thyroid Function among Children with Iron Deficiency Anaemia: Pre and Post Iron Replacement Therapy

Introduction: Metabolism of thyroid hormones and iron is quite interdependent. Data indicates that Iron Deficiency (ID) could impair thyroid metabolism. Aim: To investigate the possible occurrence of thyroid dysfunction among children with isolated Iron Deficiency Anaemia (IDA) of various severities, and test if the oral iron replacement therapy alone can reverse the associated thyroid function disturbances, if present or additional therapies are required. Materials and Methods: This prospective study was carried out on 60 children selected from the attendants to the outpatient paediatric clinics of Al-Azhar University, Assiut and Qena university hospitals, Egypt, in addition to 60 controls. Complete blood count, thyroid profile, ferritin, iron, Total Iron Binding Capacity (TIBC), Transferrin Saturation% (TFS%), unsaturated iron binding capacity and Urinary Iodine Excretion (UIE) were assessed in the studied groups at baseline, then haemoglobin level and thyroid profile repeated among the studied patients after three months of oral iron supplementation therapy. Thyroid profile and ferritin were measured using commercially available Enzyme Linked Immunosorbent Assay (ELISA) kits; while, iron, TIBC and UIE were measured using colorimetric methods. Results: Significant higher serum Thyroid Stimulating Hormone (TSH) levels with significant lower serum levels of Free Triiodothyronine (FT3) and Free Thyroxine (FT4) among patients versus controls (p<0.001 for all). Significant positive correlation between serum iron and FT3 (r=0.284, p<0.05) with significant negative correlations between TSH versus both serum iron (r=-0.635, p<0.001) and ferritin (r=-0.342, p<0.01). Significant decrease in the serum levels of TSH, with significant increase in the serum levels of FT3 and FT4 (p<0.001 for all) to euthyroid status following oral iron replacement therapy. Conclusion: Subclinical or primary hypothyroidism can occur among children suffering from moderate to severe IDA, which is reversible following oral iron replacement therapy only, without need to add thyroid replacement therapy.

Antihypertensive Prescription Pattern, Self-reported Reasons for Non adherence to Antihypertensives and Lifestyle Practices among the Elderly

Introduction: Adherence to antihypertensives is not to be assumed just because people seek help. It is a complex issue and requires individualised care. Individuals above the age of 60 years have double the risk of cardiovascular diseases for each rise in 20 mmHg Systolic Blood Pressure (SBP) or 10 mmHg Diastolic Blood Pressure (DBP). Aim: To identify the antihypertensive prescription pattern among elderly hypertensives and to explore the reasons for non adherence to antihypertensives expressed by the elderly hypertensive patients on assessment using the Morisky Medication Adherence Scale (MMAS-8). Materials and Methods: The study was conducted using the cross sectional survey design. A total of 800 elderly hypertensives attending Medicine Outpatients Department (OPDs) of a tertiary care hospital, Karnataka, were surveyed using purposive sampling technique from July 2013 to July 2015. The tools used were demographic and clinical proforma, scale on lifestyle practices and MMAS-8 (r=0.83). Results: The study findings revealed that most of the participants 205 (25.6%) were on calcium antagonists. Majority 309 (38.6%)were found to be non adherent to antihypertensives. About 59.4% were following the life style practices required for the control of BP. The majority i.e., 249 (31.1%) expressed that forgetfulness is the major factor for their non adherence. Conclusion: With the mainstay of pharmacotherapy for hypertension, lifestyle modifications play a vital role in the management of hypertension.

Analysis of Risk Factors and Outcome of Renal Failure in Benign Prostatic Hyperplasia

Introduction: Benign Prostatic Hyperplasia (BPH) is one of the most common diseases of aging men, affecting 50% by 60 years of age and increasing to 90% by ninth decade of life. A small percentage of men with obstruction secondary to BPH have azotemia, some of whom progress to irreversible renal failure, while others recover remarkably well. Aim: To assess the risk factors and outcome of renal failure in patients of BPH in comparison to those patients without renal failure. Materials and Methods: This was a retrospective study of 60 patients with a diagnosis of BPH with and without renal failure who underwent treatment in the Department of Urology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India, between January 2015 to December 2016. All patients were evaluated with clinical history and physical examination including Digital Rectal Examination (DRE) and appropriate laboratory examination. Uroflowmetry followed by ultrasound abdomen was done. All patients underwent transurethral resection of prostate, postoperatively uroflowmetry and Ultrasonography (USG) of abdomen for post void residual volume were done at the time of discharge and at one, three months follow up. Results evaluated with student t-test, fisher’s-exact test and Chi-square test. Results: Obstructive voiding symptoms mean International Prostate Symptoms (IPSS) score, comorbidity factors like diabetes and hypertension (24), Urinary retention (24), Urinary Tract Infections (UTIs) (16) and median lobe enlargement (19) were more common in patients with renal failure. Weight of the gland resected and mean operative time were similar in patients with or without renal failure. Once obstruction was relieved 23 patients had normal serum creatinine. Seven patients had renal failure at one month follow up after Transurethral Resection of the Prostate (TURP). All these patients had either diabetes mellitus (1) or hypertension (2) or both (4). Conclusion: Men with large residual urine volumes with retention and concurrent UTIs are at higher risk for renal failure. Renal failure in the presence of comorbid illnesses, such as diabetes mellitus and hypertension, may be augmented by BPH and also have an impact on the recovery of renal function after relieving the obstruction.

Factors Predicting Outcome of Trial without Catheter in Patients with Acute Urinary Retention Secondary to Prostatic Enlargement

Introduction: Acute Urinary Retention (AUR) is an important feature of progression of Benign Prostatic Hyperplasia (BPH). The management of AUR is immediate urethral catheterisation followed by Trial without Catheter (TWOC). Aim: The aim of this study was to evaluate the factors predicting outcome of TWOC in patients with AUR due to BPH. Materials and Methods: Ninety patients with spontaneous AUR secondary to BPH were selected for the study. Various factors e.g., age, duration of Lower Urinary Tract Symptoms (LUTS), drained urinary volume, Digital Rectal Examination (DRE) prostate size, Ultrasonography (USG) prostate volume, thickened bladder wall, Intravesical Prostatic Protrusion (IPP) grade were recorded. Tamsulosin was administered for three days before trial. The TWOC was considered successful if patient voided within six hours with Qmax >5 mL/second and Post Void Residual (PVR) urine <200 mL. Logistic regression analysis was performed to identify predictors and Receiver Operating Curve (ROC) was constructed. Results: It was observed that among 90 patients with AUR due to BPH, 56.7% had successful TWOC and rest failed the attempt. Cases in failure group had thicker bladder wall compared to those in successful group (97.4% v/s 80.4%, p=0.020). Grade III IPP was associated with higher percentage (72.7%) of failure of TWOC than Grade I (10%) and II (52.6%). A cut-off value of two and a half months for duration of LUTS (AUROC=0.625), 775 mL for drained urinary volume (AUROC=0.726) and 49.5 mL for prostate volume (AUROC=0.588) gave modest sensitivity for trial to fail. Conclusion: Our data concludes that drained urinary volume and IPP are significant predictors of outcome of TWOC in patients with AUR due to BPH.

Contribution of Corollary Discharge in Elderly People with Peripheral Proprioception Deficit

Jampana Suman Raju, Sivakumar Ramachandran

Introduction: Corollary discharge which is otherwise known as sense of effort is assumed to be the internal signal that arises from centrifugal motor command and that influences perception of movement. This provides proprioceptive cues during muscular activity, apart from the peripheral proprioceptive inputs. With ageing the peripheral proprioception acuity decreases. Aim: To examine the contribution of sense of effort to compensate the deficit in peripheral proprioception. Materials and Methods: Proprioception acuity was tested using an electronic goniometer by doing passive and active reposition test in the knee joint. A total of 20 elderly subjects with normal passive proprioception angle error (control group) and 10 elderly subjects with abnormal passive proprioception angle error (study group) were studied. Paired and unpaired t-tests were used to analyse the results. Results: Between the groups passive error angles were statistically different (p<0.05). Subjects who had abnormal passive proprioception error did not show abnormal active proprioception error. Conclusion: Active proprioception error angles are smaller than passive angle errors. An active proprioception error angle is not affected even when passive proprioception angle error is affected. The results suggested that, the sense of effort does compensate in the elderly for loss of peripheral proprioception.

Outcome of Critical Pregnant and Postpartum Patients of Swine flu- Experience of Seven Years

Archana Mishra, Harish Chandra Sachdeva, Sunita Malik, Archana Kumari

Introduction: Pregnancy and postpartum confers four to five fold increased risk for complications and mortality if affected by Swine flu. Swine flu in pregnancy contributes to almost 18-25% of total ICU admissions and high perinatal morbidity and mortality. Aim: The present study was an analysis of the pattern of critical illness and mortality due to Swine flu virus in pregnant and postpartum women. Materials and Methods: It was a retrospective study of all clinically suspected, probable as well as confirmed cases of Swine flu, in pregnancy and postpartum period up to two weeks; who were admitted to Swine flu Intensive Care Unit (ICU) from February 2009 to December 2015. We analyzed the presenting complaints, condition on admission, criteria for admission in ICU, abnormalities in laboratory reports, course of illness and perinatal outcome. Results: In the span of seven years 30 pregnant and 10 postpartum women were admitted in Swine flu ICU. Mortality was 40% (16 out of 40) in pregnant and postpartum women. There were 17 (42.5%) cases which were positive for H1N1 confirmed by Real time-PCR (RT-PCR) and culture. Mean interval of onset of symptoms to start of oseltamivir was four and a half days. Perinatal outcome was poor and only 18% babies were alive after one week of birth. Conclusion: We emphasize that high index of suspicion, early diagnosis, early antiviral therapy and immunization to pregnant women are the key factors which can reduce the complications, ICU admissions and mortality in this group.

Effect of Bamboo Salt on Inhibition of Adhesion of Candida albicans to Denture Acrylic Resin: An in vitro Study

Introduction: Adhesion of Candida albicans on denture surfaces is one of the main aetiology of denture stomatitis. Currently, chemical disinfectant agents have been employed to prevent its adhesion on the denture surface. However, due to its harmful effects on the physical properties of the denture material there has been a lookout for a natural product as a replacement. Aim: Investigate the effects of Bamboo Salt Solution (BSS) on inhibition of adhesion of Candida albicans (C. albicans) to denture acrylic surface. Materials and Methods: Transparent acrylic strips were pretreated with bamboo salt at concentration of 5, 10, 20 w/v %, normal saline (negative control) and 0.2% chlorhexidine gluconate (positive control) for 30 minutes followed by inoculation with C. albicans (107 cells/mL). Adherent yeast cells were then counted under microscope at 40X magnification in 20 randomly selected fields on each strip after staining with crystal violet. The statistical significance was calculated by Kruskal-Wallis and Mann-Whitney non-parametric tests at a significance level of p<0.05. Results: The mean percentage of inhibition after pretreatment with 5%, 10% and 20% of the extract were 43.9%, 65.7% and 86.7% respectively. Pretreatment with BSS significantly reduced the adhesion of C. albicans to acrylic surfaces in a dose dependent manner. Conclusion: This observation indicates that BSS has an inhibitory effect on the ability of C. albicans to adhere to denture acrylic and could be employed as a denture disinfecting agent for preventing denture stomatitis.

A 3D Geometric Morphometric Analysis of the Palatal Morphology in Marfan’s Syndrome: A Preliminary Study

Introduction: Marfan’s Syndrome (MS) is a multisystem disorder of the connective tissue. A number of oral manifestations and craniofacial characteristics show a strong correlation with MS. There are no data available in the literature with regard to morphological characteristics of the maxilla in Marfan’s syndrome assessed by 3D morphometric analysis. Aim: To use geometric morphometric analysis in order to evaluate the characteristics of palatal shape in a group of Marfan subjects compared with a control group. Materials and Methods: For this preliminary study, a group of five male subjects (mean age of 9.1±0.8 years) with a clinical diagnosis of MS were selected for the Marfan Group (MG). The Control Group (CG) was composed of five non-syndromic male subjects (mean age 9.3±0.6) years. Maxillary study casts of all subjects were scanned using an extraoral scanner. Landmarks and semi landmarks were digitized (239 landmarks) and geometric morphometric methods were used. Procrustes analysis was applied and principal component analysis was performed to reveal the main patterns of palatal shape variation. Results: A statistically significant difference between the palate’s shape of MG and CG was found. The variability described by the first principal component was morphologically the most significant because it defines the 65.7% of total shape variability and describes changes in all three dimensions. MG mainly presents alteration of the palatal vault in the vertical plane and in the transverse dimension of the posterior region. Conclusion: Marfan subjects have a specific palatal morphology characterised by high palatal vault and narrow maxillary posterior region.

Influence of Different Thickness of Mineral Trioxide Aggregate, Resin Modified Glass Ionomer Cement and Intermediate Restorative Material on Sealing Ability of Root End Fillings: An in vitro Study

Introduction: A wide variety of root end filling materials has been tried, though the biocompatibility and sealing ability have been always in question. Hence, the latest innovation towards better sealing materials like Mineral Trioxide Aggregate (MTA) and bone cement was discovered. However, in previous published research the thickness of the cements used for the study was an uncontrolled variable. Aim: To assess and compare the apical sealing ability of MTA Resin Modified Glass Ionomer Cement (RMGIC) and Intermediate Restorative Material (IRM) at three different thicknesses. Materials and Methods: In sixty three sound human maxillary anterior teeth, standard access cavities were prepared with diamond burs and were completed by using the step back technique; which were obturated with gutta-percha using a zinc oxide eugenol sealer by lateral condensation technique. Apical 3 mm of roots were resected. After root-end resection all teeth were randomly distributed into three groups consisting of 21 teeth in each group. Each group was divided into three subgroups with seven teeth in each. Retrograde cavities of 4 mm, 3 mm, and 2 mm depths were prepared in resected root ends of all groups. Cavities were filled with MTA, RMGIC and IRM. Teeth were placed in 50% weight silver nitrate solution for an hour and were transversely sectioned at each mm with hard tissue microtome and examined under stereomicroscope at 30X magnification for microleakage. Results:The study showed 2mm thickness of MTA, 3mm thickness of RMGIC and 4mm thickness of IRM is effective to prevent microleakage. IRM presented higher leakage than other materials, which was statistically significant (p<0.05) and best sealing abilities were obtained with MTA. The ascending order of microleakage was MTAConclusion:The minimal thickness with better sealing ability is ideal for sealing because of space constraint. So, the MTA is better agent compared to other two for sealing at periapical area.

Comparison of Lipid Profile in Normotensive Pregnant Women and Hypertensive Pregnant Women in the Third Trimester

Mohammad KS Shaikh, Shilpa Mittal

Introduction: Toxemia in pregnancy or Pregnancy Induced Hypertension (PIH) is an idiopathic multisystem disorder specific to human pregnancy. It is a dangerous complication of pregnancy but phasic and is still one of the leading causes of maternal and foetal morbidity and mortality. Aim: The aim of the study was to assess the serum lipid profile in normotensive pregnant women and hypertensive pregnant women in third trimester and to explore the possibility of serum lipid profile as a marker of severity of PIH. Materials and Methods: The present study was conducted on 60 hypertensive (toxemic) (B1-40 pre-eclamptic) (B2-20 eclamptic) pregnant women and 60 normotensive pregnant women (A) of age between 19-35 years and gestational age ranging between =28 weeks to term as a case-control study. Serum lipid profile for both the groups were determined using various biochemical kits. Data was subjected to statistical analysis using mean, standard error and student’s t-test etc. A p-value <0.05 was accepted as significant. Results: The mean serum Triglyceride (TG) levels in Group B {Group B1 (266±22.2) and B2 (253.17±21.56)}, Low-density Lipoprotein Cholesterol (LDL-C) levels {Group B1 (134.60±11.32) and B2 (149.30±11.78)} and Very Low-density Lipoprotein Cholesterol (VLDL-C) levels in Group B {Group B1 (49.83±11.76) and B2 (50.16±5.42)} were higher than that in Group A {203±11.9, 124.89±8.11 and 34.94±5.95 respectively} and mean serum High-density Lipoprotein Cholesterol (HDL-C) levels in Group B {Group B1 (45.10±5.92) and B2 (44.90±8.31)} were lower than Group A {58.92±5.95 i.e., Hypertensive pregnant women (Group B) as compared to normotensive pregnant women (Group A)}. Conclusion: This study concludes that serum lipid profile can be added as a marker of severity of PIH.

A Comparative Study to Identify the Effects of Transcutaneous Electrical Nerve Stimulation Combined with Sensorimotor Task Oriented Training to Improve the Hand Function in Hemiplegic Cerebral Palsy Children

Durairaj Satheeskumar, KU Dhaneshkumar, K Rajasenthil

Introduction: Impaired hand function is one of the major growing concerns for hemiplegic cerebral palsy children. Poor hand function is more often due to either individual or combination of the motor and sensory deficit. Aim: To find the effectiveness of Transcutaneous Electrical Nerve Stimulation (TENS) combination with sensorimotor task-oriented training to improve hand function in spastic hemiplegic cerebral palsy children. Materials and Methods: This single-blind, randomised, multi-center study was conducted in Mangalore and Coimbatore from March 2014 to November 2016. This study included 60 hemiplegic cerebral palsy children aged from four to 12 years who were randomly assigned into two groups: Group-A received high frequency TENS combination with sensorimotor task-oriented training and Group-B received only placebo TENS combination with sensorimotor task-oriented training for three sessions per week for eight weeks. Tactile registration, tactile localisation, two point discrimination, stereognosis, nine-hole peg test, grasp domains of quality of upper extremity skill test and ABILHAND-Kids questionnaire were measured at before and after the interventions. Results: The Group-A showed significant improvement in tactile registration, tactile localisation, nine-hole peg test and quality of upper extremity skill test score than Group-B at p <0.001 level. There was no significance difference in two point discrimination, stereognosis and ABILHAND-Kids questionnaire score. Conclusion: Transcutaneous electrical nerve stimulation with sensorimotor task-oriented training can improve hand function of hemiplegic cerebral palsy children but further studies are required to analyse the contribution of TENS as a sensory intervention.

Fatal Myocardial Infarction: A Retrospective Autopsy Study

Sunday Sokunle Soyemi, Francis Adedayo Faduyile, Fadesewa Ibiolagbajosi Osuolale

Introduction: Myocardial infarction is one of the complications of Coronary Artery Disease (CAD). Recent study has shown that the incidence of acute myocardial infarction is on the increase in developing countries such as Nigeria. Autopsy based studies have proven to be a reliable and valuable method for studying this disease. Aim: To determine the prevalence and morphological pattern of fatal myocardial infarction resulting from CAD in our centre. Materials and Methods: This was an eight year (January 2008 to December 2015) retrospective study of all autopsy cases in which death was caused by myocardial infarction. The age, sex, percentage of occlusion of each artery, weight of the heart and evidence of old infarction and any accompanying illness were all recorded. Results: A total of 79 cases of myocardial infarction were seen out of 8334 autopsies. This represents 0.9%. The age ranged from 27 to 80 years with mean age of 57±10 years. Males and females constituted 22.8% and 77.2% respectively with a male to female ratio of 1: 3.4. The highest incidence of myocardial infarction occurred in the sixth decade while the lowest occurred before the third decade. The most common vessel involved was the Left Anterior Descending (LAD) coronary artery. Only 48.1% and 64.6 % of study population had accompanying old myocardial scars and hypertensive heart disease respectively. Fewer subjects had accompanying diabetes mellitus. Conclusion: A prevalence of 0.9% was seen in this study. We also observed more myocardial infarction in women than in men.

Histopathological Changes in Skin after Electric Current Injury: An Autopsy Study

Introduction: With the proliferation of electrical equipment and devices, there is a rise in deaths due to electrocution injuries. There may be allegations of electric burns either by way of accident or torture. Many a times no specific findings may be present to support such a claim. Electric contact mark is pathognomic of electrocution. Aim: To decide whether the electric current mark was antemortem or postmortem in nature or no conclusion regarding the same can be drawn even after histopathological examination. Materials and Methods: The present study was conducted on 40 dead bodies brought to the mortuary of a Tertiary Care Institution, Government Medical College, Amritsar, Punjab, India, with history of death due to electric shock over a period of two years. Another 20 corpses, who had not died due to electric current injury, but were given the same after death, were taken as control. All the 40 cases were thoroughly examined for medicolegal purposes at the time of conducting postmortem examination and findings were recorded as per proforma attached. Skin was examined for the wound of entry and exit (if any) of electric current injury. Skin biopsies, from the electric current sites of the deceased, were taken from the edge of the wound and subjected to histopathological examination. Results: About 85% cases had visible electric current injury. Involvement of clothes was seen in 15% cases. Microscopic findings included bulla (22.5%), flattened papillae (47.5%), erosions (12.5%), charring (45%), nuclear changes (2.5%), vacuolisation (12.5%) and necrosis (62.5%). In the 20 control cases studied, charring of the skin was present in the epidermis/dermis and no other change was observed. Conclusion: Histopathological changes can be used as supportive evidence in giving cause of death in such cases.

Weight Loss and/or Hypernatraemia in Inadequately Breastfed Term Neonates having Non-haemolytic Unconjugated Hyperbilirubinaemia

Mani Singla, Sushma Malik, Charusheela Sujit Korday, Ashutosh Abhimanyu Paldiwal

Introduction: Insufficient breast milk intake can lead to increased incidence of neonatal jaundice, inadequate weight gain, hypernatraemic dehydration in neonates and occasionally may cause serious complications. Aim: To know the proportion of neonates admitted with non-haemolytic unconjugated hyperbilirubinaemia exhibit inadequate weight gain and hypernatraemia and their relationship to breastfeeding pattern. Materials and Methods: We conducted a prospective observational study at the Neonatal Intensive Care Unit (NICU)/Postnatal Care (PNC) ward of our tertiary care hospital, over a period of one year. We enrolled 60 full term neonates with birth weight >2500 gm and >48 hours old, who were admitted for non-haemolytic unconjugated hyperbilirubinaemia. These neonates were evaluated for daily weight, serum sodium levels, mother’s milk sodium levels and breastfeeding patterns. Mean, median and standard deviation were calculated for all the quantitative parameters. The correlations between various study parameters were assessed with the help of chi-square test and Pearson’s correlation coefficient. Results: Analysis revealed that maximum neonates 55 (91.6%) presented with hyperbilirubinaemia in the first week of life and 50 (83%) neonates were on exclusive breastfeeding. There were 21(33%) neonates with significant weight loss of >10% and of these seven (33.3%) had hypernatraemia, whereas in 39 babies who had no significant weight loss only two babies had hypernatraemia. This difference was found to be statistically significant (p-value=0.004). There were high mother’s milk sodium levels in neonates with weight loss and hypernatraemia (p=0.017). Incidence of combined weight loss and hypernatremia among all studied hyperbilirubinemic neonates was 12%. The weight loss pattern in babies was similar in multiparous or primiparous mothers and there was no statistical association of weight loss with parity (43% vs 30% respectively). Conclusion: We observed that a significant proportion of neonates admitted with unconjugated hyperbilirubinaemia which were inadequately breastfed had severe weight loss and hypernatraemia. High mother’s milk sodium levels in subset of babies with severe weight loss can suggest the possibility of lactation failure in their mothers.

To Compare the Efficacy of Local Anaesthetic Administration via Spray as you Go Technique and Ultrasonic Nebulisation for Awake Fiberoptic Intubation

Harpreet Kaur, Ranjana Khetarpal, Veena Chatrath, Harkomal Kaur, Piyush Khanna

Introduction: Awake fiberoptic intubation using local anaesthetics is the most dependable procedure to secure a difficult airway. It is electively done under various techniques of local anaesthesia which include administration of local anaesthetic via nebulisation, airway blocks and spray as you go with or without sedation. Aim: To compare the efficacy of nebulisation with 4% lignocaine versus spray as you go technique for awake fiberoptic intubation. Materials and Methods: Sixty patients of American Society of Anesthesiologists (ASA) grade I-III were randomly divided into two groups (group N and group S). Patients in group N were nebulised with 4ml of 4% lignocaine while group S patients received four aliquots of 1ml 4% lignocaine through the working channel of the fiberoptic bronchoscope. The patients were compared for haemodynamic parameters, intubating conditions, intubation attempts, time taken for intubation and patient satisfaction score. The results were statistically analysed using SPSS 22 software and compared. Results: On comparing the intubating conditions, the patients in group S showed better intubation score than the patients in group N (p-value=0.004). The time taken for intubation was lesser (4.56±0.85 minutes in group S and 4.0±0.45 minutes in group N) and the patient satisfaction score was also better in the spray as you go group. Conclusion: Spray as you go technique offers more effective local anaesthesia and better patient satisfaction as compared to nebulisation for awake fiberoptic intubation.

Comparison of Dexamethasone and Ketorolac as an Adjuvant to Bupivacaine in Axillary Brachial Plexus Blocks for Isolated Hand and Forearm Injuries: A Randomised Double-Blind Prospective Study

Introduction: Brachial plexus nerve blocks for upper limb surgery provide superior analgesia and reduce opioid consumption. Dexamethasone has been an effective adjuvant to local anaesthetics in brachial plexus block but there are very less studies with ketorolac. Aim: To compare the duration of analgesia and block characteristics with dexamethasone versus ketorolac as an adjuvant to bupivacaine in axillary plexus blocks. Materials and Methods: This randomised double-blinded study was conducted on 120 patients with isolated hand and forearm injuries who were divided into three equal groups. Ultrasound guided axillary brachial plexus block was performed in patients in Group C with 30 mL of 0.375% bupivacaine plus 2 mL of normal saline, Group D with 30 mL of 0.375% bupivacaine plus 8 mg dexamethasone and Group K with 30 mL of 0.375% bupivacaineplus 30 mg ketorolac. The onset, duration of sensory and motor block and total duration of analgesia were recorded for each patient. Analysis of variance and student’s t-tests were used for statistical comparisons. Results: The duration of sensory block was 389.75±40.35 minutes in Group C, 909.25±76.74 minutes in Group D and 651.50±75.77 minutes in Group K. The total duration of motor block was 281.75±38.68 minutes in Group C, 522.00±53.74 minutes in Group D and 426.00±60.07 minutes in Group K. The time to first rescue analgesic was 570.00±0.197.37 minutes in Group C, 1260.0±184.93 minutes in Group D and 964.61±190.41 minutes in Group K (p<0.001). Conclusion: Dexamethasone and ketorolac as adjuvant to bupivacaine in axillary plexus blocks significantly prolonged analgesia and duration of motor and sensory block. These effects were more enhanced with dexamethasone than ketorolac.

Femoral Neck Anteversion in Sub Himalyan Population: Digital Radiography vs Dry Bone Measurements

Introduction: Femoral neck anteversion is an important parameter of proximal femoral geometry. It has not only an anthropological value but also it gives an insight into possible underlying hip pathology. Aim: To measure femoral neck anteversion values in sub himalyan population of north west India using digital radiography and dry bone measurements. Materials and Methods: This was a prospective hospital based study. Anteversion in 89 patients (89 paired femora) was measured by digital radiography and dry bone measurements. 93 unpaired dry cadaveric bones from the collection of bones maintained by Department of Anatomy of our institute were analysed by direct measurements. The results obtained were statistically analysed. Results: The mean femoral neck anteversion by digital radiography method was 14.70±2.26 while 14.57±2.67 by dry bone measurements. Males had higher anteversion values when compared to females in both groups. All these differences were not statistically significant. Conclusion: Increased femoral anteversion values are associated with clinical conditions like intoeing gait, hip osteoarthritis, femoroacetabular impingment, Developemental dysplasia of hip and Perthes disease. The data from this study would help establish values of femoral neck anteversion for sub himalayan population of north west India, provide insight into above mentioned disease conditions and help in planning orthopaedic surgeries like osteotomies about the hip and total hip replacement.

Is Position Induced Movement Re-education Helpful on Early Functional Recovery in Acute Adhesive Capsulitis? A Randomised Controlled Trial

Arif Abdulsalam Muhammed, Sukumar Shanmugam, Dhanesh Kumar

Introduction: Adhesive Capsulitis (AC) is a common musculoskeletal disorder of shoulder caused by inflammation and adhesion formation in the capsule and periarticular structures. The increased nociception from the shoulder can suppress the movement perception and related functions of shoulder and upper limb. Active range of motion of shoulder may be more painful and limited due to pain, spasm and stiffness. Positioning of shoulder joint in end ranges may activate the mechanoreceptors of muscles, tendon, ligaments, joint capsule which may reduce the nociception and increase the movement perception. Aim: To compare the effect of Position Induced Movement Re-education (PIMR) combined with Low Level Laser Therapy (LLLT) over active free shoulder exercises with LLLT and Grade-I Maitland Mobilisation adjunct with moist heat therapy in the management of acute adhesive capsulitis of shoulder. Materials and Methods: A total of 30 subjects diagnosed with stage I AC were randomly allocated in three groups. Group A received PIMR and LLLT, Group B received Codman’s pendular exercises along with LLLT and Group C received Grade I Maitland Mobilisation and moist heat therapy for five days a week for two consecutive weeks. The pre and post-intervention scores of shoulder joint range of motion and shoulder pain disability index were obtained and analysed. Results: A statistically significant difference was seen in the shoulder pain and disability index score and shoulder range of motions among three groups with the p-value less than 0.05. The patients treated with position induced movement re-education combined with LLLT showed better improvement in shoulder disability and range of motion scores when mean differences were compared with other two groups using Mann-Whitney U test (for SPADI score) and One-way ANOVA (shoulder range of motions). Conclusion: Position induced movement therapy along with LLLT is effective in reducing pain, improving range of motion and disability in stage I AC.

Screening for Comorbidities in Obstructive Sleep Apnea

Sheikh Shoib, Javid Ahmad Malik, Shariq Rashid Masoodi, Aatif Rashid

Introduction: Obstructive Sleep Apnea (OSA) is a common sleep disorder among middle-aged adults which often results in a wide range of co-morbid conditions, predominantly of the cardiovascular/respiratory, endocrine/metabolic and neuropsychiatric manifestations. These comorbidities pose a significant burden on health care and considerably influence the disease as well. Aim: To look for any association between obstructive sleep apnea and other comorbidities and to study the prevalence of these comorbidities in patients suffering from obstructive sleep apnea. Materials and Methods: A cross-sectional study was performed at the Modern hospital, Srinagar, Jammu and Kashmir, India, on patients that were referred from various subspecialty clinics from July 2011 to August 2012. Polysomnography studies were performed in152 patients identified as having OSA (71 men and 81 women). Statistical analysis was performed by means of the computer program SPSS using a t-test for independent groups, a probability value of 0.05 was considered significant. Results: A total of 152 patients were identified as having OSA (71 men and 81 women) with a mean age (±SD) of 54.1 years (± 13.6). Various comorbidities were found in 60.5% patients diagnosed with OSA. 59.2% of men and 61.7% of women with OSA had comorbidities. The individual prevalence of each comorbidity in order of decreasing prevalence was hypertension (63.2%), endocrine disorders (40.8%), coronary artery diseases (9.2%), depression (11.2%), dysthymia (5.3%), hypercholesterolemia (5.9%), asthma (7.9%), and approximately 19.7% had no comorbidities’’. (?2: 13.2, df: 3, P: 0.004 (S). Conclusion: This study demonstrates significant overlap between sleep apnea and multiple medical comorbidities. Understanding of various co-morbid conditions associated with OSA and their clinical consequences helps in prevention, early identification and improving the quality of life of these patients. Clinicians need more information about screening for these diseases in patients with OSA to ensure proper diagnosis and treatment of those with these conditions.

Heart Disease in Pregnancy-Evaluation of Spectrum, Association of Predictors with Obstetric Outcome and Need for Comprehensive Medical Care

Reenu Kanwar, Manjula Sharma, Sheeba Marwah, Pratima Mittal, Nikita Kumari

Introduction: Cardiac disorders of varying severity complicate nearly 1% of pregnancies and are an important cause of maternal morbidity and mortality. It is important to define the risk stratification of women with heart disease for optimal pre-pregnancy counselling and obstetric management. Aim: To study the spectrum of heart disease in pregnancy, identification of various predictors of feto-maternal complications and comparison of the obstetric outcome in women with heart disease who received Comprehensive Medical Care (CMC) beginning at =28 weeks, with those who began Antenatal Care (ANC) supervision after 28 weeks. Materials and Methods: A prospective observational study was conducted in the Department of Obstetrics and Gynaecology in Safdarjung Hospital (SJH), New Delhi, India, from October 2014 to March 2016. Pregnant women with heart disease attending the OPD/or delivering in labour room were scrutinised through the eligibility criteria. Out of the 66 eligible women, beginning antenatal supervision at =28 weeks of gestation were designated as Group A (n=32) who received CMC. Remaining women (n=34), who supervised after 28 weeks in the hospital for further management were designated as Group B. Analysis was done after applying appropriate tests: t-test, Chi-square test and univariate analysis, as applicable. Results: Incidence of heart disease was 0.35% (71/21,000), out of which Rheumatic Heart Disease (RHD) was predominant. Left heart obstruction was the most common (29/66) predictor for adverse maternal cardiovascular and neonatal event, followed by baseline New York Heart Association (NYHA) Class>II (22/66). Cardiac complications were 2.4 times higher and cardiac mortality was ~3 times more in Group B as compared to Group A. Neonatal mortality occurred in 5.6% (2/36) women in Group B. Conclusion: All pregnant women with heart disease should receive comprehensive multidisciplinary prenatal care. Early ANC supervision and extra prenatal surveillance is recommended according to pregnancy associated risk status. Women with =1 predictor of cardiac and neonatal events should be referred to a tertiary care centre for CMC.

Opioid Sparing Effect of Anaesthesia on Postoperative Inflammatory Cytokine Response in Oral Cancer Surgery

Introduction: Dexmedetomidine is a potent and highly selective alpha-2 adrenoreceptor agonist with the unique sedative, analgesic, perioperative sympatholytic, anaesthetic-sparing and haemodynamic-stabilizing properties. Fentanyl is a potent, synthetic opioid pain medication with a rapid onset and short duration of action. Aim: To examine the effects of fentanyl and dexmedetomidine with paracetamol administered by intravenous route on the postoperative Interleukin (IL-6) and C-reactive protein (CRP) response in oral cancer surgery. Materials and Methods: This prospective comparative study included 60 patient of American Society of Anaesthesiologists (ASA) grade I or II, aged 18 to 70 years. 60 patients were divided into two groups: Group A- Paracetamol (10 mg/kg) with fentanyl (2 µg/kg), maintenance with fentanyl (3 µg/kg); and Group B- Paracetamol (10 mg/kg) with dexmedetomidine (0.5 µg/kg), maintenance with dexmedetomidine (0.4 µg/kg). Blood samples were collected before induction at the end of surgery and 24 hours after surgery for serum level of CRP and IL-6. Results: The demographic profiles such as age, weight, duration of surgery, ASA grade and tumour stage were similar in both groups. CRP and IL-6 level were significantly lower in groups postoperatively at 24 hours as compared to preoperatively and immediate postoperatively. The Visual Analogue Scale (VAS) score and rescue analgesic for 24 hour were lower in group B than group A. Conclusion: Dexmedetomidine is an effective drug which reduces requirement of opioid and potentially increases the analgesia. Adverse effects were not significantly different between the groups.

Superficial Soft Tissue Swellings: Accuracy of Ultrasonography in Diagnosis with Pathological Correlation

Introduction: Ultrasonography (USG) is a low cost, non invasive, readily available, safe and a patient comfortable modality. With all USG parameters being complimented with the other variables such as demography and anatomical location of the swelling, USG has a specificity to accurately diagnose the type of superficial soft tissue swelling. Aim: To determine the accuracy of ultrasonographic findings in the diagnosis of superficial soft tissue swellings with histopathological correlation. Materials and Methods: All the soft tissue swellings were imaged with high resolution USG transducer, and the following various sonographic indices were noted; location/plane, nature, size, margin, echo pattern, vascularity, calcification and compressibility. Maneuvers such as panoramic views were obtained for large lesions for better assessment. The low frequency curvilinear transducer was also required for deep seated and larger swellings of superficial origin. The ultrasonographic diagnosis was then correlated initially on the surgical diagnosis. Soft tissue swellings such as foreign bodies and haematomas were readily confirmed to evaluate the accuracy of USG in these lesions. Probable diagnosis obtained by USG was then correlated with histopathology. The data obtained was statistically analysed using SPSS (Software Package used for Statistical Analysis) software and was analysed using sensitivity, frequency and other appropriate statistical tests. Results: The sensitivity of the study was 97% with confidence interval of 91.48% to 99.38%. The positive likely hood ratio was 0.97. Positive predictive value of the study was 100% with confidence interval of 96.27% to 100%. Conclusion: We conclude that USG has high specificity and predictive value to diagnose superficial soft tissue swellings and it wouldn’t be erroneous to infer that USG is almost equivalent to the pathological diagnosis especially in non tumoural superficial soft tissue swellings.

Non Alcoholic Fatty Liver Disease: Problems in Perception and Solution

Charu Arora, Bipin Sinha, Piyush Ranjan, Anita Malhotra

Non Alcoholic Fatty Liver Disease (NAFLD) is now being recognised as a healthcare burden in India and abroad. An inevitable increase in its incidence is expected in future, presenting before the physicians a larger number of NAFLD patients to manage. The NAFLD patients are prescribed calorie restricted diets for weight loss, along with increased physical activity as the first line of treatment. However, the real challenge lies in making the patients adhere to this prescription. NAFLD, being asymptomatic, is often overlooked by the patients as well as the physicians. Many patients do not perceive it as a serious problem, unless it reaches an advanced stage. Poor awareness, lack of seriousness towards the disease and unwillingness to change behaviour are the major hurdles in the success of NAFLD treatment. Correct perception about this growing epidemic and adoption of an interdisciplinary and multifaceted approach for its effective treatment can go a long way in controlling NAFLD. Initiatives that encourage healthy lifestyle, using the component of behaviour therapy for sustained results, may be a promising solution to this liver condition.

Natural Killer Cells: An Insight into its Role in Pregnancy

Shailaza Shrestha, Preeti Sharma, Pradeep Kumar, SP Saxena, Rachna Sharma

Tight regulation of immunotolerance at fetomaternal interface facilitates the survival of allogeneic embryo. Natural Killer (NK) cells are immune cells capable of lysing the target cells via the release of cytolytic granules containing perforin, granzyme and granulysin. Besides the peripheral circulation, NK cells are also present in the uterine mucosa. In contrast to peripheral NK (pNK) cells, uterine NK (uNK) cells are not the killer cells, rather they provide a suitable microenvironment in the pregnant uterus making it compatible to the growing foetus and promoting normal placentation, vascular remodeling and trophoblast infiltration, all of which are essential for healthy pregnancy. Although, uNK cells are loaded with cytolytic factors which can lyse the trophoblasts if activated, the control mechanisms mediated by balance between activating and inhibitory receptors block the cytolytic function of these uNK cells. Intensive research has elucidated the roles of NK cells in normal and abnormal pregnancy outcomes, such as recurrent spontaneous abortion. Much of the facts are still to be unraveled to fully understand the underlying mechanisms and to introduce newer and potential treatment modalities to support healthy pregnancy.

Diabetic Dyslipidemia: Current Concepts in Pathophysiology and Management

Debasish Chaudhury, Ankita Aggarwal

Diabetes Mellitus (DM) has assumed pandemic proportions worldwide. The increase in prevalence of this non-communicable disease has been quite alarming. South East Asia is home to approximately 71.4 million of the diabetics, out of which 61.3 million diabetics are in India in 2011 as per the data of International Diabetic Federation. The leading causes of morbidity and mortality for such patients have been attributed to the rising incidences of Cardiovascular Diseases (CVD) as a complication of type 2 diabetes. A major proportion of CVDs are attributed to the occurrence of atherogenic dyslipidemia. The pathophysiologic mechanisms and treatment regimens for dyslipidemia have been evolving and several newer mechanisms are being proposed. The purpose of the review is to throw light on the new concepts regarding pathophysiology and management guidelines of diabetic dyslipidemia. A literature review was performed in pubMed and google using the key words: type 2 DM, dyslipidemia, pathophysiology, treatment. A total of 30 articles over last 10 years were scanned for review. The newer mechanisms of dyslipidemia included: activation of transcription factors, decreased Lipoprotein Lipase (LPL), decreased clearance. The role of remnant particles, adiponectin an anti-inflammatory molecule has also been proposed. The current treatment regimens are based on Low Density Lipoproteins (LDL) and high density lipoproteins (HDL) and the recommendations are different for the various associations. Statins are considered the standard lipid lowering agents in diabetics and have shown mortality benefits in these patients. However, many new drugs like Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors, saroglitazar are emerging as possible alternates for statins in the treatment of dyslipidemia, though their overall cardiovascular benefit is yet to be studied.

Internet Technology based Research for Smoking Cessation in India-Hope of a New Era

Sarika Palepu, Sumit Malhotra

Tobacco smoking has been a rampant problem in India since decades. It poses a great burden on the socioeconomic life of the individuals and affects country’s progress. Burden of smoking had been on a rise in India. Efforts to curb smoking cessation were made but desired results have not been achieved. In recent time, there is an increase in communicable and non communicable diseases due to smoking. Even second hand smoke imposes a huge burden on the health of the individuals. With failure of the existing strategies to curb the burden, novel methods in promoting smoking cessation ought to be considered. Thus, recent technological advancements can be given a focus. With the launch of digital India, internet based interventions for smoking cessation can be considered in the country. With the growing number of internet users, this method can be promising to yield beneficial results. These interventions are tailored, preserve anonymity and are easily accessible. Hence, this can be an effective medium to reach the masses. Interventions tapping internet as a medium are lacking in India. With many success stories of such interventions around the globe, consideration to conduct such trials can be done in the country. Focused conduct of trials overcoming the constraints of feasibility, acceptability and recruitment of participants is needed to achieve the desired success. With developing technology and changing demands of healthcare, effective internet based interventions are the need of the hour.

Understanding Cancer Stem Cells in Head and Neck Squamous Cell Carcinoma: A Critical Update in Development of New Approaches

Shubha Ranjan Dutta, Deepak Passi, Dhruv Kacker, Deepak Chahal, Mansi Atri

Cancer Stem Cells (CSCs) have an important role in Head and Neck Squamous Cell Carcinoma (HNSCC). HNSCC is considered as one of the major health problems throughout the world. These self-renewing cells are responsible for resistance to conventional anti-cancer therapy. CSCs have the ability of cancer recurrence; metastasis and can form a heterogeneous tumour. The idea of 'CSCs' has led the scientific community to a new era in the field of research and possibly effective treatment modalities for cancer in the future. This paper aims primarily to review the recent advancements made in the use of stem cells in the treatment of cancer. Secondly, this review presents a discussion on the consideration of CSCs being the backbone in the development of cancer and, precisely the role played by the CSCs in carcinogenesis and its outcome leading to development of possible cancer treatment in the future. Medical databases including Pubmed Central, Google Scholar, Scopus, Copernicus, Science Direct, etc., were used to find all relevant articles related to HNSCC and its relation with CSCs, various mechanisms and therapeutic approaches. Various therapeutic approaches have been employed for the management of HNSCC such as surgical method, chemotherapies and radiotherapies and combinations or formulations of different drugs, but in most cases complete cure has been a failure. This is mostly because the CSCs escape such therapies. However, recent developments have led to the use of targeted therapy such as targeting cell surface markers or signalling pathways, targeting micro environment or blocking epithelial mesenchymal transition, immunotherapy and other approaches as well, leading to the complete eradication of CSCs in HNSCC successfully. Thus, this review presents a better understanding of CSCs and its mechanism of action for development of new treatment modalities.

Periodontal Disease and Neurodegeneration: The Possible Pathway and Contribution from Periodontal Infections

Rajeev Ranjan, Gyanaseni Dhar, Swetapadma Sahu, Nibedita Nayak, Monalisa Mishra

Neurodegeneration is a process in which the neurons lose its structure, function and ultimately the death of the neurons follows. Various neurodegenerative diseases like Alzheimer’s, Parkinson’s etc., are thus gaining enormous interest in health plans. Scientists are in search of finding the various markers to detect the onset of neurodegeneration. So far, Amyloid-beta (Aß) and neurofibrillary tangle are the two markers found in most neurodegenerative diseases. Besides that, neural inflammation is also considered as one of the parameters for the onset of neurodegeneration. Inflammation may be caused either by insult of central nervous system or by peripheral infections. Numerous microbes get a chance to enter into the brain due to bacterial infection especially periodontal infection. The current review summarises the role of periodontal infection and the mechanism via which it contributes for neurodegeneration.

Coconut Oil and Virgin Coconut Oil: An Insight into its Oral and Overall Health Benefits

Varsha Salian , Pushparaja Shetty

Oral health is of prime importance to all individuals. The traditional use of oil in India for maintenance of good oral hygiene has been mentioned in the Vedic literature since ancient times. Oil pulling therapy also known as ‘Kavala Gandoosha’ is a traditional procedure involving rinsing or swishing of the oil in the mouth, which is said to have anti-inflammatory and antimicrobial effect thus reducing plaque formation in the oral cavity. Coconut oil is an edible oil that is highly desired and easily available in India and has antimicrobial effect against a wide range of microorganisms found within the body. The growing popularity of Virgin Coconut Oil (VCO) has opened up new research in its clinical application apart from its role as functional food oil. The present review aims to highlight the general benefits of coconut oil usage and the traditional concept of oil pulling with coconut oil as a supplemental oral hygiene aid and acknowledge the use of traditional medicine as part of primary healthcare.

Music Induced Emotion and Music Processing in the Brain– A Review

B Geethanjali, Kanagasabai Adalarasu, Mohan Jagannath

Music has been a constant source of fascination and constitutes the major and oldest socio-cognitive fields of the human. Music is considered to be the strongest stimulus to induce human emotion and also has the ability to enhance or weaken the listener’s emotion. Self-selected music is predominantly chosen to observe its effect on task performance. Listening to music plays a major role in preventing the mental fatigue associated with performing repetitive and monotonous tasks. This article focusses the reviews on human emotion, methods of evaluating emotion induction, music processing in the brain and its effect on Autonomic Nervous System (ANS).

The Anticariogenic Efficacy of 5000 ppm Fluoridated Toothpaste: A Systematic Review

Introduction: Dental caries continues to be one of the most prevalent human diseases, affecting children and adults alike. Fluoride has played a central role for several decades in caries prevention. Aim:To systematically review the literature on the effect of 5000 ppm fluoridated toothpaste in prevention of dental caries. Materials and Methods: A literature review was performed in PubMed Central and Cochrane Library, Embase, Google Scholar from 1960 up to February 2016 to identify appropriate studies. The primary outcome was to measure reduction in dental caries and caries related factors like dental plaque and salivary variables. Results: Out of the total 69 titles that appeared, 14 articles fulfilled the eligibility criteria and were selected for the review. The use of toothpaste with 5000 ppm fluoride significantly reduces the dental caries prevalence rate, the amount of plaque accumulated, decrease the number of mutans streptococci and lactobacilli and possibly promotes the fluorapatite crystal formation to a higher degree than after the use of traditional fluoride containing toothpaste. Conclusion: Use of 5000 ppm fluoride toothpaste significantly improves the remineralisation, salivary concentration of fluoride, fluoride retention in plaque, modifies caries risk, reduces root caries susceptibility and prevent mineral loss.

Idiopathic Unilateral Gynaecomastia in Prepubertal Age: A Rare Presentation and Review of Literature

Kamal Nain Rattan, Dayanand Hota, Jasbir Singh, Ahmad Khursheed

Unilateral idiopathic gynaecomastia of prepurtal age is a rare presentation. Complete evaluation of unilateral gynaecomastia should be done to identify etiology. We managed a case of unilateral gynaecomastia in a 10-year-old male child by surgical excision without any post-operative complications.

Non Specific Interstitial Pneumonia: A Case Report

Vinitha K Anirudhan, Arun Prasannan, Sahana Devadas

Idiopathic Non-Specific Interstitial Pneumonia (NSIP) is a rare entity in children and classified into cellular NSIP (c-NSIP) or fibrotic NSIP patterns. It comes under major idiopathic interstitial pneumonia. Both conditions are characterised by Ground Glass Opacities (GGO), irregular linear opacities and consolidations in a bilateral, symmetrical or sub pleural distribution. It’s a disease with diagnostic difficulty so a multidisciplinary diagnosis was approached for the diagnosis i.e., clinical, radiological and histopathological. The prognosis of this condition is variable; it is a reversible disease with risk of progression. Therefore, early diagnosis and disease stratification are important in this disease. Here we report the case of a three-year-old girl child who presented with atypical clinical and radiological features, but had been diagnosed to have c-NSIP.

ALK-1 Positive Anaplastic Large Cell Lymphoma Presenting as Extensive and Exclusive Osseous Involvement: Report of a Rare Association and Review of Literature

Primary Bone Lymphomas (PBLs) are uncommon. Most of these tumours are Non Hodgkin Lymphoma (NHL) with Diffuse Large B-cell Lymphoma (DLBCL) being the most common. Anaplastic Large Cell Lymphoma (ALCL) constitutes approximately 2% of all NHL and involves both nodal and extra nodal sites. ALCL presenting as exclusive and extensive bone involvement is rare. We report a case of 31-year-old man who presented with osseous involvement only. Imaging showed multiple lytic lesions involving the vertebral column, ribs and sternum. Clinical differential diagnosis included osteomyelitis and bone neoplasms. Histopathology and immunohistochemistry of the lytic lesion proved it to be Anaplastic Lymphoma Kinase (ALK-1) positive ALCL. The patient relapsed three months after completion of six cycles of combination chemotherapy with Cyclophosphamide, Hydroxydaunorubicin, Vincristine and Prednisone (CHOP).

Quadricuspid Aortic Valve: A Rare Congenital Anomaly

Quadricuspid Aortic Valve (QAV) is a rare, but well-recognised congenital anomaly, which may result in significant aortic regurgitation. We report a case of asymptomatic young male who was inadvertently diagnosed with QAV with moderately severe aortic regurgitation, through Transesophageal Echocardiography (TEE).

Regenerative Endodontic Procedure: Clinical and Radiographic Evaluation of Two Cases

Monalisa Das, Shabnam Zahir, Gautam Kundu

The regenerative endodontic procedures can re-establish the vitality of teeth to some extent and retain the physiological functions. The endodontic treatment of permanent as well as deciduous teeth supported with regenerative procedures, may be the treatment of choice in regular day-to-day practice. This procedure may help to abolish the era of dentistry practicing conventional endodontic treatment compromising the vitality of teeth. This article reports two cases of non-vital young teeth (each with different maturation of apices and periodontal health) treated with Lesion Sterilisation and Tissue Repair (LSTR) and revascularisation procedure.

People Present at Road Traffic Crash Scene: Challenges in Defining and Categorising

Aidin Aryankhesal, Davoud Khorasani-Zavareh, Mohammad Heidari

RETRACTED Article

Aasim Farooq Shah, Manu Batra, Ambrina Qureshi, Evaluation of Impact of Pregnancy on Oral Health Status and Oral Health Related Quality of Life among Women of Kashmir Valley (Published in Journal of Cilinical and Diagnostic Research. 2017 May: 11(5):). ZC01–ZC04 The article had to be retracted because of an error in the data. This was brought to the editorial notice, post-publication, by the authors. Due to this error, the complete analysis stands out to be wrong.