Journal of clinical and diagnostic research

Multifocal Presentation of a Laryngeal Disorder

TK Prakash, S Abhilash, G Rajeshwari, H Sundararaju

Multifocal presentation of a laryngeal disorder is very rare. We report a case of a 48-year-old man, who presented to our hospital with hoarse voice for two years. Stroboscopic evaluation followed by surgery was done and the specimens were sent for histopathological examination from three different anatomical sites of larynx which were diagnosed as one-benign lesion, second-benign lesion but ability of malignant transformation and the third-a malignancy.

Subconjunctival Fat Prolapse: What Radiologists Need to Know?

Gorky Medhi, Barun Kumar Sharma, Ezzat Khalda

Subconjunctival fat prolapse is a rare benign entity or disease presenting as fat containing epibulbar mass in lateral canthus region. Weakness of Tenon’s capsule secondary to age, trauma or any surgery leads to herniation of intraconal fat. Radiologists should be aware of the condition and its imaging features. We report a case of 70-year-old obese man presenting with bilateral soft yellowish lateral canthal mass. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) showed typical imaging features of epibulbar fatty lesion in continuation with the intraconal fat.

Cytological Diagnosis of an Uncommon High Grade Malignant Thyroid Tumour: A Case Report

Ruchi Nagpal, Manju Kaushal, Sawan Kumar

Anaplastic Thyroid Carcinoma (ATC) is a relatively uncommon highly malignant tumour originating from the follicular cells of thyroid gland having poor prognosis. It accounts for 2% to 5% of all thyroid carcinomas and patients typically present with a rapidly growing anterior neck mass with aggressive symptoms. A 53-year-old male presented with diffuse neck swelling measuring 8x6 cm and right cervical lymph node measuring 2x2 cm since one month which was associated with dyspepsia and dyspnoea. Ultrasound and Contrast Enhanced Computed Tomography (CECT) neck revealed enlarged right lobe of thyroid and multiple enlarged cervical lymph nodes with soft tissue density nodules in bilateral lungs. Fine Needle Aspiration (FNA) from the swelling revealed giant cell, spindle cell and squamoid pattern. Focal areas showed follicular epithelial cells arranged in repeated microfollicular pattern suggesting an underlying follicular neoplasm. FNAC smears from the lymph node also revealed similar findings. Based on the cytomorphological and radiological findings, final diagnosis of ATC probably arising from underlying follicular carcinoma with cervical lymph node and lung metastasis was given. FNAC leads to prompt and definitive diagnosis, so that therapy can be initiated as soon as possible for better outcome. Multimodality therapy (surgery, external beam radiation, and chemotherapy) is the mainstay of treatment.

Transient Thyrotoxicosis in Molar Pregnancy

Samarth Virmani, Sujatha B Srinivas, Rama Bhat, Raghavendra Rao, Ranjini Kudva

Molar pregnancy is one of the components of a broader spectrum of diseases known as Gestational Trophoblastic Disease (GTD), presenting with amenorrhoea and irregular bleeding which may be rarely associated with passage of vesicles per vagina. However, it can rarely be associated with hyperthyroidism, which may be associated with clinical features of hyperthyroidism. The following is a report of a 20-year-old woman who presented with amenorrhea followed by irregular bleeding per vagina, thyromegaly and abnormal levels of thyroid hormones. Transvaginal ultrasound revealed features consistent with molar pregnancy. A suction evacuation was done following which serum levels of ß-hCG reduced and the levels of thyroid hormones also reduced. On follow up, six weeks later, ß-hCG and thyroid hormones were within normal limits. The case and relevant literature are presented here.

Bilateral Single System Orthotopic Ureterocele with Bilateral Multiple Calculi Presented with Retention of Urine - an Urological Emergency

Rupesh Gupta, Sweta Gupta, Dawood Khan, Supriya Basu

The ureterocele is an uncommon congenital anomaly of the lower ureter. Ureterocele with a single pelvicalyceal system, bilateral, and orthotopic variety is less common. Calculi within bilateral ureterocele are a rare occurrence. To the best of our knowledge, only a few similar cases have been reported in the literature. Among the all reported presentations of this type of ureterocele, presentation with Acute Urinary Retention (AUR) has not been described in the literature. We present a case of nine-year-old child having bilateral, single system orthotopic ureterocele with calculi in bilateral ureterocele and presented with AUR due to obstructive bulbar urethral calculus. The bilateral endoscopic incision was given and all four calculi were removed endoscopically through percutaneous route. Voiding cystourethrography after two years follow-up was non-refluxing. The purpose of reporting this case is the rarity of the disease and to emphasize that delay in diagnosis and treatment of these cases may lead to complications such as recurrent urinary tract infection and renal failure.

Chondroid Syringoma: Fine-needle Aspiration Cytology of a Rare Entity at an Unusual Site

Sangeeta Lamba, Annu Nanda, Uma Kumar

Chondroid syringoma, also known as benign mixed tumour of the skin, is a rare benign adnexal tumour. It is a biphasic tumour, composed of both epithelial and mesenchymal components and constitutes <0.01% of all primary skin tumours. It is mostly located in the head and neck region, followed by the hand, foot, axillary region, abdomen, penis, vulva and scrotum. The arm is a rare site of involvement. Making a correct diagnosis of chondroid syringoma is important to guide the clinician in optimal management. We present a case of chondroid syringoma on the left arm in a 37-year-old male. Fine-needle aspiration was performed and diagnosed as chondroid syringoma, which was confirmed on histopathology. This case highlights the importance of considering chondroid syringoma in the evaluation of subcutaneous swellings of the arm and the role of Fine-Needle Aspiration Cytology (FNAC) in diagnosing this uncommon tumour.

Benign Fibrous Histiocytoma: An Uncommon Presentation

Sagarika Sarkar, Moumita Maiti, Palas Bhattacharyya, Ranu Sarkar

Intracranial fibrous histiocytomas are rare; Benign Fibrous Histiocytoma (BFH) being uncommon than its malignant counterpart. BFH comprises fibroblasts and histiocytes without any nuclear pleomorphism or atypia. We present a case of a 42-year-old male who had swelling over the occipital region for the past five years, which progressively increased in size. He developed headache, dizziness, and gait disturbance over the last six months. Computed tomographic scan revealed a posterior fossa space-occupying lesion. Fine-needle aspiration cytology from the swelling revealed spindled fibroblasts along with histiocytes and multinucleated giant cells. Later, histopathology showed presence of spindle-shaped cells in storiform pattern admixed with histiocytes and giant cells. The giant cells and histiocytes were immunopositive for CD68 and spindled cells were positive for vimentin, but immunonegative for CD34, epithelial membrane antigen, CD1a and S100. The final diagnosis was intracranial BFH. We present this case because of its extreme rarity and unusual location.

Clear Cell Adenocarcinoma of Female Urethra

Sharada Raju Rane, Ashwini Nivrutti Ghodke, Sharvari Vishwasrao

Primary malignancies of female urethra are infrequent, constituting a fraction of less than 1% of genitourinary malignancies. Primary clear-cell adenocarcinoma of the urethra, is even rarer, that histomorphologically resembles clear-cell carcinoma of the female genital tract, occurs predominantly in women and is associated with a relatively poor prognosis. The histogenesis of this rare urethral neoplasm has not been completely determined. Various hypotheses concerning the origin have been postulated, including (1) diverticular origin (2) mullerian origin (3), glandular differentiation of urothelium or urothelial carcinoma. Here, we report a case of 67-year-old female with obstructive urinary symptoms and pain in abdomen, diagnosed with adenocarcinoma of urethra. Immunohistochemistry (IHC) workup of the tumour was done to find the origin of the tumour.

Thoracoscopic Diaphragmatic Plication for Eventration in Pregnant Woman: A Case Report

J.S. Rajkumar, Deepa Ganesh, Anirudh Rajkumar, Akbar Syed, Venkatesan Guru

Diaphragmatic eventration is an uncommon malady, underdiagnosed and often treated only in emergent situations. Eventration of the diaphragm is best treated by plication of diaphragm with or without meshplasty. Various studies have shown that thoracoscopic plication is as efficient as laparotomy or laparoscopic plication. We present here the report of thoracoscopic diaphragmatic plication for eventration performed in the third trimester of pregnancy in a 28-year-old woman who presented with acute respiratory distress. To our knowledge, we believe this to be the first published case in medical literature.

Neisseria Meningitidis Causing Multiple Cerebral Abscesses in Early Neonatal Period: Case Report and Review of Literature

Laxman Basani, Roja Aepala

Neisseria meningitidis is a rare cause of meningitis and septicemia in neonates. There are few published case reports of neonatal meningococcal meningitis complicated by subdural empyema, cerebral abscess and hydrocephalus. Few cases of neonatal meningococcal meningitis have been reported in the literature with none of them having the complication of multiple cerebral abscesses in early neonatal period (greater then seven days of life). We report a case of meningococcal meningitis with multiple cerebral abscesses which presented on fifth day of life and developed hydrocephalus at five weeks of life requiring a Ventriculo Peritoneal (VP) shunt. To the best of our knowledge, this is the first documented case of neonatal meningococcal meningitis with multiple cerebral abscesses.

Riley-Day Syndrome in a Hispanic Infant of Non-Jewish Ashkenazi Descent

Riley-Day syndrome is an autosomal recessive sensory and autonomic neuropathy. Patients present a lack of fungiform papilla, alacrima, and usually feeding difficulties. It is present almost exclusively in Ashkenazi Jewish individuals and has a poor prognosis. We describe an unusual case of Riley-Day syndrome with pseudostrabismus in a non-Ashkenazi Jewish patient. A one-year-old female infant was referred for evaluation of strabismus, absence of fungiform papillae, feeding difficulty, gastroesophageal reflux, and episodes of self-mutilation. Deep tendon reflexes were depressed, the blinking rate and corneal reflex were diminished as well, and corneas were opaque due to corneal erosions. Reduced lacrimal production was confirmed by the Schirmer test. Eye drops were recommended every 2-3 hours for corneal erosion and the patient was referred to the genetics department for further diagnostic confirmation.

Pleural and Mediastinal Lipomatosis with Subpleural Fat as a Mimicker of Pleural Effusion- A Rare Case Report

Navkiran Kaur, Jasvir Singh, Samrin Haq, Sugandha Garg, Simmi Bhatnagar

Subpleural and mediastinal lipomatosis are benign intrathoracic conditions discovered incidentally on plain chest radiographs. However, diagnosis is usually made by Computed Tomography (CT). A case of both mediastinal and pleural lipomatosis associated with use of steroids in a 58-year-old male patient presented with complaints of breathlessness and dry cough is discussed in this case report. Intially, pleural effusion and bilateral upper lobe patchy opacities were suspected as a cause of breathlessness on the basis of chest x-ray findings. For which, CT scan of chest was advised.

Benign Beale Gland Hyperplasia Mimicking Malignant Biliary Obstruction

Extrahepatic bile duct obstruction can be caused by various pathologies, most of them being malignant. Painless, progressive jaundice is the usual mode of presentation. We report a case of distal Common Bile Duct (CBD) obstruction due to a Benign Intramural Beale gland hyperplasia mimicking a periampullary carcinoma. Peribiliary glands (Beale Glands) are a group of seromucinous glands, normally seen within the fibromuscular wall and periductal connective tissue in the extrahepatic and large intrahepatic ducts and also in the neck of the Gall bladder. These glands drain into the bile duct lumen through small channels referred to as sacculi of Beale. Intramural Beale ducts are lobular aggregates of mucous glands that lie within the wall of the bile duct. Beale Gland hyperplasia is uncommon, and is rarely large enough to be visible macroscopically or with imaging as an incidental finding. There are no case reports of this rare entity. It is distinguished from well differentiated bile duct adenocarcinoma by the preservation of the lobular architecture, lack of cytological atypia and lack of perineural invasion. This case is reported for its rarity.

Primary Squamous Cell Carcinoma of Submandibular Salivary Gland: A Case Report

Manmohan Agarwal, Lakshmi Agarwal, Rajeev Saxena

Primary Squamous Cell Carcinoma (PSCC) of submandibular salivary gland is a rare occurrence. Careful clinical and histopathological examination is must to diagnose it. The treatment protocol of this rare disease is not clearly defined. Though surgery is primary treatment, role of adjuvant treatment is not clear. A 40-year-old male presented to us with asymptomatic upper neck swelling. Triple endoscopy, cross-sectional investigation and FNAC suggested primary squamous cell carcinoma of right submandibular salivary gland. He was treated with bilateral modified neck dissection and wide excision of sub mandibular gland with surrounding muscles. Post surgery, he had undergone interval chemotherapy followed by radiotherapy. The patient is still on regular follow up at an interval of three months without any evidence of disease recurrence. Though difficult to diagnose and treat this kind of rare variant of salivary neoplasms, awareness of the disease and aggressive treatment depending on histopathology report, can help patient to achieve health.

A Rare Case of Primary Calcific Pleural Tuberculosis – A Case Report

G Sahana, Vishak Acharya, Santosh Rai, Nishanth Baliga

Tuberculosis is a highly prevalent disease in India. It has a myriad of presentations. Usually pleural tuberculosis occur secondary to pulmonary tuberculosis which can manifest as pleural effusion leading to pleural calcification. Primary pleural calcification due to tuberculosis is an extremely rare manifestation of active tuberculosis. We present a case of a 21-year-old female presenting with fever, cough, weight loss and loss of appetite who was diagnosed to have pleural calcification due to primary tuberculosis. We highlight the need to keep primary pleural tuberculosis in mind with above symptoms suggestive of active tuberculosis even when there is no underlying lung pathology.

“Quirky Bulb” On the Lower Jaw: An Organizing Haematoma

Organizing Haematoma is a rare, non/neoplastic benign lesion with locally destructive behaviour that may mimic a malignancy. Usually symptoms do not occur, while the lesion remains localized. An Organized Haematoma is an encapsulated blood clot undergoing neovascularization and fibrosis. It has also been referred to as a hemophilic pseudotumour and/or a haematoma like tumour, which is rarely found in the head and neck region. Other reported cases have been related to trauma or an underlying haemangioma. However, most of the cases have no identifiable underlying pathology, trauma or systemic disease. We are reporting an unusual presentation of Organizing Haematoma over the edentulous mandible.

Calcium on Mitral Valve: Decipher Aetiopathogenesis

We hereby describe an unusual case of a 17-year-old female with severe mitral regurgitation secondary to heavily calcified immobile valve leaflets. Along with the mitral valve, corneas were also calcified, due to congenital systemic metabolic disorder, distal renal tubular acidosis. Histopathology proved that there was no intrinsic pathology of the mitral valve. Congenital distal renal tubular acidosis with normokalemia presenting with severe mitral and corneal calcification is not known. This case notes important clinical features and is thought to add to the existing knowledge regarding the disease. Patient succumbed to her illness during mitral valve surgery and genetic analysis was not done prior. This is the limitation of our reporting. In this modern era, specific clinical features are also important and of equal value to try and understand molecular and genetic basics of the diseases.

Superior Vena Cava as Gateway to Heart: Metastatic Breast Carcinoma Causing Ball in a Loop Metastasis to Right Atrium

Breast carcinoma is the most common invasive cancer in women worldwide. It metastasizes commonly to bone, lungs, regional lymph nodes and brain. Cardiac metastasis of lung and breast cancers is a known but rare complication of advanced disease with tumour metastasising to pericardium via the locoregional lymphatic system. Here we present a case of 59-year-old female presenting with right upper limb oedema, facial puffiness and features of Superior Vena Cava (SVC) syndrome 15 years after mastectomy and adjuvant chemotherapy, radiotherapy for carcinoma of the right breast. Further evaluation revealed extensive thrombus invading the right internal jugular vein, subclavian vein, SVC with intraluminal extension into right atrium causing ball in a loop obstruction at tricuspid valve. Whole body Positron emission tomography scan confirmed the diagnosis of extensive metastatic disease and patient was managed on palliative therapy. Haematogenous spread and intraluminal growth of metastatic deposits from breast carcinoma 15 years ago is rare and clinical presentation as SVC obstruction has not been reported in our review of literature.

Reconstruction of Maxilla with Titanium Mesh and Fascia Lata - A Case Report

Devkumar Rengaraja, Mohan Jagade, Karthik Rao, Radhika Sonate, Arpita Singhal

Maxillary defect reconstruction has been a grave challenge which unfortunately has stopped many ENT surgeons from attempting maxillectomy due to the fear of reconstruction. With our technique of reconstructing the maxillary defect with titanium mesh and fascia lata, the need for microvascular assistance is obviated. Here we describe a revision case of ameloblastoma of maxilla in a 33-year-old female for which total maxillectomy with reconstruction was done without the aid of microvascular tissue transfer. The aim of this article is to encourage and alleviate the fear among the ENT surgeons, in attempting maxillectomy and its reconstruction for delivering an equally good aesthetic and functional outcome especially at the centres where the facility of plastic assistance is not readily available.

Morel-Lavallee Lesion: Case Report with Review of Literature

Morel-Lavallee lesions are closed degloving soft tissue injuries which occur because of trauma and in which the skin and subcutaneous tissue are separated from superficial fascia. This shear trauma results in creation of a potential space filled with serosanguinous fluid, blood and necrotic fat. We discuss a case of 52-year-old female with history of trauma one week back, who presented with a boggy swelling over the postero-lateral aspect of proximal forearm and distal arm. Local examination showed fluctuating fluid collection. MRI showed variable intensity fluid collection in a potential space between the subcutaneous tissue and deep fascia in arm and forearm. Percutaneous decompression and evacuation of the collection with systemic antibiotic therapy resulted in rapid improvement.

A Rare Instance of Levofloxacin Induced Myoclonus

Sushil Kiran Kunder, A. Avinash, Veena Nayak, Amod Tilak

Levofloxacin is a widely used fluoroquinolone, mainly as a respiratory antimicrobial agent. It is employed as a second line therapeutic modality in pulmonary tuberculosis as well. The drug has been in use for ages, and is known to be both efficacious and safe. However, it is not free of adverse effects. The most dangerous ones are those involving the Central Nervous System (CNS). Although rare, levofloxacin can cause involuntary movements like chorea and myoclonus. Here by, we present a case of an elderly male patient who developed reversible myoclonus/chorea after a course of levofloxacin (which was initiated as part of his anti-tubercular therapy) following the development of peripheral neuropathy secondary to isoniazid.

Important Diagnostic Clues for Diagnosing Splenic Marginal Zone Lymphoma in Absence of Splenic Histology

Anisha Mohanpuria, Vijay Kumar, Pooja Suteri, Sadhna Marwah, Abhay Shankar Nigam

Splenic Marginal Zone Lymphoma (SMZL) is a rare B-cell neoplasm comprising less than 2% of non-Hodgkin lymphomas. We hereby report a case of SMZL in a 66-year-old female who presented with fever and massive splenomegaly. Peripheral blood smear examination showed atypical lymphoid cells showing variable cytoplasmic processes. Flowcytometric immunophenotyping of peripheral blood showed tumour cells which were found to be positive for CD19, CD79b and showing kappa light chain restriction along with lack of expression for CD5, CD10, CD23, CD103 and lambda. These findings were suggestive of B cell chronic lymphoproliferative disorder. Various differential diagnoses considered in this case were analysed by using different diagnostic clues to arrive at the diagnosis. Bone marrow examination and Immunohistochemical (IHC) analysis showed tumour cells in nodular, interstitial and intrasinusoidal pattern of infiltration which were positive for CD20 and CD79b with kappa light chain restriction and lack of expression of CD5, CD10, CD23 and CD103 which further corroborated the flowcytometric immunophenotyping. The diagnosis of SMZL is arrived at by a combination of diagnostic clues like clinical features, peripheral smear findings, flowcytometric immunophenotyping, morphological and IHC findings in bone marrow biopsy. This case highlights the significance of flowcytometric immunophenotyping and bone marrow biopsy with immunohistochemistry to arrive at a diagnosis of SMZL even in absence of splenic histopathology.

Permanent Maxillary Central Incisor with Dilacerated Crown and Root and C-Shaped Root Canal

Vikas Allwani, Mansing Pawar, Ajinkya Pawar, Sayed Abrar, Sangeeta Ambhore

Dilaceration is a rare disturbance in traumatised permanent teeth, which constitutes about 3% of the injuries to developing teeth. It usually occurs as a result of trauma to the deciduous predecessors and results in non axial displacement of the already formed hard tissue portion of the developing crown. Endodontic treatment of such teeth presents a challenge to clinicians, and careful management is required to successfully address the root canal anatomy and other possible variations. The C-shaped canal configuration is most frequently seen in mandibular second molars, but this variation may also occur in mandibular first molars, mandibular third molars, maxillary molars, mandibular first premolars, and even in maxillary lateral incisors, with rare reports of such variations occurring in the maxillary central incisors. Diagnosis, endodontic access cavity preparation, root canal preparation and filling might be complicated by the presence of dilacerations and C-shaped canals. This paper is an attempt to provide details of an unusual case of crown and root dilacerations and a C-shaped canal in the maxillary central incisor, successfully managed by using Self-Adjusting File (SAF) system.

A Rare Case of Ileocecal Tuberculosis with Pulmonary Embolism and Deep Vein Thrombosis

Tan Jih Huei, Tan Chor Lip Henry, Choon Aik Ho, Yuzaidi Mohamad

Venous thromboembolism in tuberculosis is not a well recognised entity. It is a less frequently reported complication of severe pulmonary tuberculosis. It is exceedingly rare when it complicates extrapulmonary tuberculosis. Here, we present a case of 22-year-old young female with abdominal tuberculosis complicated with reverse ileocecal intussusception, deep vein thrombosis and pulmonary embolism. An emergency vena cava filter was inserted prior to a limited right hemicolectomy. In this article, we discuss the rare association of venous thromboembolism with ileocecal tuberculosis.

Fistulating Richter’s Hernia of Groin with Necrotizing Soft Tissue Infection: A Lethal Combination

Strangulation of groin hernia can result in significant morbidity and mortality. Spontaneous external fistulation following strangulation is rare and typically occurs with Richter’s hernia. Spreading Necrotizing Soft Tissue Infection (NSTI) secondary to Enterocutaneous Fistula (ECF) is an ominous sign, further worsening its prognosis. Early diagnosis and prompt surgical treatment is crucial to improve outcome. Herewith the authors are presenting a case of neglected inguinal hernia. It was complicated with ECF formation and rapidly spreading NSTI of flank. He underwent resection and anastomosis of the gangrenous bowel, anatomical repair of the hernia along with soft tissue debridement of flank region. This patient however succumbed to sepsis with multi organ dysfunction. Significant delay in seeking medical care led to dismal outcome.

Unusual Skin Carcinomas Induced by BRAF Inhibitor for Metastatic Melanoma: A Case Report

The most frequently reported skin tumours during treatment with targeted therapies for BRAF (B type Rapidly Accelerated Fibrosarcoma kinase) mutated metastatic melanoma are squamous cell carcinomas (SCCs). Basal cell carcinomas (BCCs) have been described in such setting, but no cases of multiple and recurring tumours have been reported so far. A patient with a history of chronic sun exposure and more than 10 BCCs removed since 1998 started treatment with vemurafenib for BRAF mutated metastatic melanoma. Therapy was complicated by sporadic episodes of atrial fibrillation and by the development of recurrent, multiple and diffuse BCCs. So, vemurafenib was discontinued and dabrafenib and trametinib were started. Since then, only four BCCs occurred in the patient. Histopathological re-examination showed that most BCCs occurred under vemurafenib presented with squamous features. Such characteristic was significantly less evident before therapy start and in lesions removed under treatment with dabrafenib and trametinib. BRAF inhibition (BRAFi) without MEK inhibition induces mitogen activated kinases overactivation, with consequent skin toxicity and acquired drug resistance. The BCCs removed from our patient showed squamous features, more evident during vemurafenib monotherapy. Both the switch from vemurafenib to dabrafenib and the addition of MEK inhibitor (MEKi) might have reduced the incidence of BCCs and their squamous differentiation.

Palatogram: A Guide to Customised, Functional Palatal Contour

The prime requisite of a sound and holistic prosthodontic rehabilitation from both the patient’s and clinician’s perspective is to be able to satiate the yardsticks of function, retention, aesthetics and comfort to the fullest. It is thereby astoundingly hard to digest that speech being an indispensably significant function of the complete denture prosthesis, is often seen upon as heedless and inconsiderate by the patient. Adaptability in speech pronunciation of complete denture prosthesis is a subjective phenomenon; cannot be predicted to entirety. To diagnose and verify speech difficulties in a complete denture patient who finds it relatively difficult to affirm to new palatal contours of prostheses, we require some simple clinical aids. Palatogram is a fairly simple, yet highly efficacious technique of assessment and verification of palatal contours, so as to improve and correct the existent speech deficiencies of affected sounds. In the present case report, readily available food colour in spray form was employed to produce and investigate inadequacies of various sounds. This case report highlights palatogram as an easy clinical technique that helps to correct, often delinquent speech difficulties, pertaining to the palatal contours of complete denture prosthesis.

Denovo High Grade Salivary Duct Carcinoma: A Case Report and Review of Literature

Heena Zainab, Ameena Sultana, Pramod Jahagirdar

Salivary Duct Carcinoma (SDC) is a distinctive and clinically aggressive adenocarcinoma of salivary origin. It arises from the ductal epithelium, predominantly occurring in the major salivary glands, especially the parotid gland. Here, we report a case of an extensive salivary gland pathology involving the right side of face, possibly arising from the parotid gland in a 25-year-old male patient. On routine histopathology, the tumour mass revealed a papillary pattern of neoplastic ductal epithelial cells showing comedo-like-central necrosis. Immunohistochemical staining showed tumour cells in the infiltrative component to be diffusely immunopositive for cytokeratin-7 and Her-2, confirming the diagnosis of SDC. This paper presents a case report on salivary duct carcinoma and highlights a review on histological variants of salivary duct carcinoma.

Synovial Sarcoma of Palmar Aspect of Hand and Survival: A Rare Case Report

Synovial sarcomas of the hand are extremely rare entities than most soft tissue sarcomas. The location at finger is further rarer than carpus of the hand. Synovial sarcoma of the hand/finger initially confused with many diagnoses such as myositis, haematoma, synovitis, tendonitis, bursitis, and other inflammatory lesions and therefore needs careful handling of the case with proper evaluation. We report a case of synovial sarcoma of the palmar surface of the right hand at interface of thumb and index finger in a 22-year-old female. The case was initially misdiagnosed as an abscess/haematoma of the finger 10 years back and treated with wide local excision. Synovial sarcoma was diagnosed on microscopic examination of excised specimen. Patient developed recurrent lesion twice locally. During first recurrence, the patient was treated with wide excision followed by radiotherapy and chemotherapy. Second recurrence was with bony destruction at the same site and below elbow amputation was performed.

Endoscopic Endonasal Approach of Blow Out Fracture Reduction- A Novel Technique

Vinod Felix, Narendrakumar Veerasigamani

Blunt trauma to orbit can lead to orbital blow out fracture. Computerized tomography of paranasal sinuses plays the main role in diagnosing it. Repairing the defect and restoring the orbital contents is a challenging task for the surgeon. Endoscopic endonasal approach in reduction of blow out fracture provides good cosmetic outcomes and grossly minimize surgical complications. We report a case of 18-year-old male presented with diplopia, restriction of eye movements and enophthalmos due to Road traffic accident. CT paranasal sinuses showed right side floor, medial orbital wall fracture with medial rectus muscle entrapment. We planned endoscopic endonasal approach to reduce the fracture and multilayered repair done using bone resected from choncha bullosa, fat and fascia lata. Patient relieved of symptoms post operatively without any complications.

Candida Albicans Infection Masquerading as a Soft Tissue Tumour Diagnosed by Fine Needle Aspiration Cytology

A 60-year-old male, diabetic presented with a soft tissue mass over the right forearm of 15 days duration. The swelling was 5 x 3 cm and a clinical diagnosis of neurofibroma was made. Fine Needle Aspiration Cytology (FNAC) was done using standard technique. Smears showed predominantly suppurative inflammation, foreign body giant cells, granulomas and fungal hyphae. KOH mount, culture and germ tube test was positive. Final diagnosis of fungal granuloma was made. Fungal infections should be included in the differential diagnosis of a soft tissue mass lesion. All soft tissue suppurative inflammatory lesions should be diligently screened to look for pathogens if any. Diagnostics in medicine have taken a major leap with advent of molecular technologies. Despite this, simple old traditional methods like FNAC supplemented by other basic laboratory techniques like KOH mount and culture still form the cream of a diagnostic laboratory and can come as a savior for the pathologist, the clinicians and the patients.

Crigler Najjar Syndrome Type 2 (CNS Type 2): An Unwonted Cause of Jaundice in Adults

Prabhat Kumar, Gargi Sasmal, Shreya Gupta, Renu Saxena, Sudha Kohli

Crigler Najjar Syndrome (CNS) Type 2 is an uncommon genetic disorder characterised by non-haemolytic unconjugated hyperbilirubinemia. It is caused by mutations in the UGT1A1 gene which codes for the enzyme uridine diphosphate glucoronosyl transferase- 1, required for the conjugation and further excretion of bilirubin from the body. Affected individuals are usually asymptomatic apart from the jaundice and investigations reveal isolated indirect hyperbilirubinemia. It can be conveniently diagnosed by evaluating the response to phenobarbitone in terms of fall in bilirubin levels. Genetic testing of the UGT1A1 gene for mutations is the diagnostic clincher. However, case reports documenting the genetic mutational analysis are sparse. We report one such rare case.

Primary Tuberculotic Osteomyelitis of Rib in a Child

Nitin Kumar Kashyap, Atul Jindal, Nitin kumar Borkar, Minal Wasnik

Although extremely rare, osteomyelitis has been reported in smaller bones like ribs. A 13-year-old male child presented with a one week history of chest wall swelling. Fine Needle Aspiration Cytology (FNAC) of the lesion and initial bacterial culture could not find the aetiology of the lesion. He underwent surgical resection of entire sixth rib for osteomyelitis and was subsequently diagnosed to have tubercular osteomyelitis. Diagnosis and treatment of rib tuberculosis is both difficult and controversial. Rib tuberculosis is often not successfully treated by medical management alone and consequently needs surgery.

Primary Amyloidosis - In a Case with Normal Plasma Cell Counts

Pooja Trehan, Mangala Gouri, Clement Wilfred, K. Rashmi, Vijaya Mysorekar

Amyloidosis is a group of disease that is characterized by the deposition of extracellular abnormal proteinaceous material (amyloid), in various organs. Amyloidosis involving the liver is common, and the radiological findings are often nonspecific. We present the case of a 40-year-old female who presented with abdominal pain. Ultrasound abdomen was reported as massive hepatomegaly with diffuse liver parenchymal disease. Bone marrow aspiration showed normomegaloblastic erythroid hyperplasia and plasma cells were within normal limits (5%). Also, amorphous, eosinophilic fragmented to smudgy material within the interstitium of cell trails was seen. Bone marrow biopsy and liver biopsy also showed similar kind of homogenous eosinophilic material. Both liver biopsy and bone marrow biopsy were subjected to special stains which confirmed the presence of amyloid. The patient did not have clinical or laboratory findings suggestive of any other organ involvement. Thus, we conclude that clinical and imaging presentations of amyloidosis are often nonspecific, hence biopsy is always required to confirm the diagnosis. Amyloid deposits on bone marrow aspiration are a rare occurrence and are often missed. It is an unusual sighting with very few studies mentioning its occurrence.

Autoimmune Hepatitis – Primary Biliary Cirrhosis Overlap Syndrome

Indira Bairy, Anupam Berwal, Shubha Seshadri

Autoimmune Hepatitis (AIH) and Primary Biliary Cirrhosis (PBC) are important immune mediated liver diseases. They are usually differentiated based on clinical, biochemical, serological, and histological parameters. The presence of autoantibodies, clinical, and serological findings can sometimes occur in different combinations leading to overlap syndromes, which is rare. Early recognition of such overlap syndromes is clinically significant from treatment point of view. Here, we report a case of AIH-PBC overlap syndrome with a brief review of literature on overlap syndromes.

Dengue Haemorrhagic Encephalitis: Rare Case Report with Review of Literature

Aditya Singh Kutiyal, Chetanya Malik, Gitika Hyanki

Dengue is an endemic arboviral infection prevalent especially in tropical countries including Southern and Southeast Asia. Central Nervous System (CNS) involvement in dengue infection is uncommon. Haemorrhagic encephalitis is a rare presentation in dengue. This is a case of a 58-year-old male who presented with fever, petechial rash and altered sensorium. Dengue serology IgM was reactive and MRI brain was suggestive of haemorrhagic encephalitis. Patient was managed in Intensive Care Unit (ICU) but eventually succumbed to his illness. We report this fatal outcome of a common viral infection with unusual neurological presentation to propose an association between dengue and neurotropism and the need to look at dengue infection beyond its classical features.

A Case Report of Largest Documented Multilocular Cystic Nephroma Removed by Thoracoabdominal Approach

Large renal tumours are not uncommon in developing countries. Enhancing renal tumours are considered to be malignant unless proved otherwise and radical surgical resection remains the mainstay of treatment of such tumours. A giant renal tumour, especially on right side, poses a big challenge for the operating team and requires a thoracoabdominal approach for successful excision. We report successful removal of the largest documented Multilocular Cystic Nephroma (MLCN, 5.5 kg) from a 28-year-old female who presented with right abdomen lump since two years. The surgery was done through a 9th intercostal thoracoabdominal incision as the mass (31 x 19 x 19.6 cm) extended from right sub-diaphragmatic space up to the dome of the bladder. We discuss here the technique of removing such a huge renal mass and the challenges an operating surgeon may encounter.

Renal Synovial Sarcoma in a Young Pregnant Lady: A Case Report and Clinico-Pathological Profile

Gregory Pathrose, Nirmal Thampi John, Pradeep Hariharan

Synovial sarcoma is a soft tissue neoplasm with clearly defined histologic, immunohistochemical and molecular features. These tumours usually arise in the extremities of young adults. Their occurrence in the kidney is extremely rare. A 25-year-old pregnant lady in her first trimester was incidentally found to have a left renal mass on perinatal ultrasonography. MRI showed a well encapsulated, heterointense mass replacing the left kidney. Following medical termination of her pregnancy, a radical nephrectomy was performed. Histopathology revealed a primary synovial cell sarcoma of the kidney. Postoperatively, she received ifosfamide based adjuvant chemotherapy. This report highlights the challenges involved in the diagnosis of this extremely rare neoplasm. A high index of clinical suspicion, complimented by the use of immunohistochemistry and cytogenetics during histopathological analysis aide in the diagnosis. Aggressive management with a combination of complete surgical extirpation and chemotherapy gives the best results.

Cellular Fibroma of Ovary Coexisting with Proliferative Endometrium Post Menopause: A Rare Presentation

Vandana Mohapatra, Susama Patra, Mamita Nayak, Radhamohan Gharei, Nibedita Sahoo

Ovarian fibromas are benign sex cord stromal tumours occurring in peri-menopausal and post-menopausal women. These tumours are composed of spindle fibroblastic cells producing collagen. They are almost always endocrine-inert and are rarely associated with hormone production. We report herein a case of a 60-year-old Indian woman presenting as postmenopausal bleeding. Imaging studies and endometrial biopsy revealed a right ovarian solid tumour coexisting with thickened proliferative endometrium, other causes of hyperoestrogenism being excluded in the woman. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. Histopathology showed cellular fibroma of right ovary and proliferative endometrium with foci of hyperplasia without atypia.

MRI in Chemotherapy induced Leukoencephalopathy: Report of Two Cases and Radiologist’s Perspective

Geetika Sindhwani, Manali Arora, Vishal Dhirenbhai Thakker, Abhinav Jain

Leukoencephalopathy is a progressive white matter disease primarily caused due to myelin damage by a variety of factors. Chemotherapy for oncological treatment is an uncommon but important cause of potentially reversible leukoencephalopathy. In current radiological setting, conventional and diffusion weighted MRI play a significant role in early and accurate detection of this entity. We are hereby presenting MRI evaluation of two cases of methotrexate and 5-fluorouracil induced toxic leukoencephalopathy.

Myeloid Sarcoma Presenting as Nasal and Orbital Mass: An Initial Manifestation of an Acute Myeloid Leukaemia

Amita Jain Gupta, Shramana Mandal, Richa Gupta, Nita Khurana, Achal Gulati

Myeloid sarcoma is an extramedullary manifestation of Acute Myeloid Leukaemia and sometimes is the only indicator of the disease. The incidence varies between 3-9.1% of acute leukaemia cases. The blast infiltration is seen most commonly in skin, lymph node, gastrointestinal tract, bone, soft tissue though can involve any body site usually as a solitary lesion and is rarely seen in nasal cavity. We present two cases of myeloid sarcoma presenting as a nasal mass in a six year old girl and other as orbital mass in 32-year-old as an initial manifestation of acute myeloid leukaemia. Histopathological examination along with immunohistochemistry clinched the diagnosis of myeloid sarcoma. Examination of bone marrow aspirate revealed blasts which fulfilled the criteria for acute leukaemia. These cases are usually misdiagnosed because often lymphoma and granulocytic sarcoma is not considered in initial list of differential diagnoses. These rare cases are being presented here as early recognition and diagnosis will ensure rapid treatment of the condition and improve the survival.

Squamous Cell Carcinoma Penis in a Case of Urethral Stricture Due to Lichen Sclerosus Balanitis Xerotica Obliterans: A Case Report and Review of Literature

Yogesh Taneja, Priyatama Ram, Santosh Kumar Dhaked, Tridib Kumar Sen

Penile carcinoma is considered a delayed sequel of lichen sclerosus. It is important to recognize this not so uncommon complication in time as survival of patients with Squamous Cell Carcinoma (SCC) depends on early diagnosis and treatment. We describe a case of a 49-year-old male presenting with urethral stricture due to lichen sclerosus. He was treated for stricture disease and later on developed SCC penis after ten years of presentation.

Malignant Pilomatricoma: A Report of Two Cases and Review of Literature

Anita Flynn, Anuradha Durga Agastyaraju, N Sunitha, Aradhana Harrison

Malignant pilomatricoma is an extremely rare tumour arising from the hair follicle. About 80 known cases are reported in literature till date. Presented herewith are two cases of malignant pilomatricoma, occurring in young female patients, each with a different clinical presentation and outcome. It is important to be aware of this entity as malignant pilomatricoma, though, initially locally aggressive, can recur if incompletely excised and also can metastasize to lungs, bones and lymph nodes.

POEMS Syndrome with Biclonal Gammopathy: A Rare Association

Dibyendu De, Sandeepan Halder, Suvro Sankha Datta

Polyneuropathy, Organomegaly, Endocrinopathy, M protein and Skin changes (POEMS) syndrome is rare plasma cell dyscrasia with multisystem involvement. The name comes from the five characteristic features: Polyneuropathy, organomegaly, endocrinopathy, M protein and skin changes. The presence of biclonal M band is a rare manifestation. Here, we are describing the cases of a 60-year-old lady, presented with bilateral pedal oedema and pericardial effusion and peripheral neuropathy. She also had hepatosplenomegaly, hyperpigmented rash and hypothyroidism and hyperparathyroidism. The serum protein electrophoresis and the immunofixation electrophoresis revealed two distinct monoclonal bands, immunoglobulin IgG kappa and IgA lambda. There was a mild increase in plasma cells and sclerotic bone lesion in pelvis. The POEMS syndrome is generally associated with lambda light chain restriction. The presence of biclonal gammopathy involving kappa and lambda is a rare manifestation. The pathogenic or prognostic role of different paraprotein is not known. Further studies are required to delineate such effect.

Tubercular Thyroiditis as a Part of Disseminated Tuberculosis in a Young Male: A Rare Clinical Presentation

Vandana Baloda, Arun Choudhary, Pradeep Chugh, Rashmi Aggarwal

Thyroid tuberculosis is uncommon even in countries like India where prevalence of tuberculosis is high. Bactericidal actions of colloid, excess iodine stores and high vascularity of the gland have been implicated for the very rare occurrence of thyroid tuberculosis. We present a case of a 16-year-old male with thyroid involvement as a part of disseminated tuberculosis. The clinical presentation of thyroid tuberculosis is varied and may be missed if not kept in the differential diagnosis of goitre. This case also highlights the role of fine needle aspiration cytology in management of goitre. It is an important diagnostic test as it avoids unnecessary surgical intervention.

Dunbar Syndrome-A Rare Cause of Foregut Ischemia

Tagore Sunkara, Megan E Caughey, Kevin Cai Zhen, Brian Chiong, Vinaya Gaduputi

Median Arcuate Ligament Syndrome (MALS) is a condition that can result from an anatomical aberration. If the median arcuate ligament is located too inferiorly in relation to the celiac axis, it can impede circulation and lead to vascular compromise. Here, we present the case of a 63-year-old woman, who came to the hospital complaining of continuous epigastric pain and who was ultimately found to have MALS. Her epigastric pain could be the result of the ischemia caused by MALS that made it difficult for the duodenal ulcer to heal properly. This case report documents an unusual presentation of an already rare condition.

Sarcomatoid Carcinoma of Renal Pelvis with Abundant Heterologous Osteosarcomatous Element: A Case Report

Mona Lisa, Guddi Rani Singh, Richa Madhawi, Bipin Kumar, Zeenat Sarmadi Imam

A 47-year-old male presented with haematuria and flank pain for two weeks. Ultrasonography and renal scan revealed a poorly functioning left kidney with multiple calculi. Simple nephrectomy was performed and the specimen revealed a mass in his renal pelvis which showed both carcinomatous and sarcomatous components on microscopy. The sarcomatous component consisted of diffuse pleomorphic osteoblasts with intervening lacy osteoid, giving an osteosarcoma-like appearance. These areas of tumor were strongly positive for vimentin and osteopontin. The carcinomatous component was transitional cell carcinoma. Patchy areas of squamous cell carcinoma which were positive for pancytokeratin on immunostaining were also seen. Few weeks later, the patient presented with metastatic lesions in the sacrum. After nephrectomy, the patient underwent palliative radiotherapy of the spine followed by sunitinib therapy. A month later, there was recurrence at the site of surgery. The patient succumbed to his illness within five months of diagnosis. This report describes an extremely rare case of carcinoma, renal pelvis with predominantly osteosarcomatous areas.

A Case of Hyperargininaemia Presenting at Unusually Low Age

Vanita Lal, Daisy Khera, Garima Guptata, Kuldeep Singh, Praveen sharma

Arginase or ARG1 gene deficiency is a Type V Urea Cycle Disorder (UCD) (catalysing the fifth reaction of urea cycle), associated with hyperammonaemia. Here, we discuss a rare case of a 13-month-old female, having Severe Acute Malnutrition (SAM) and failure to thrive, with serial high plasma ammonia, normal plasma lactate with high arginine and glutamine levels on Amino Acid Assay (AAA) which was performed on 1220 Agilent HPLC. She was admitted for about a month and eventually succumbed to her ailment after a month of discharge.

Atypical Presentation of Isolated Cerebral Aspergillosis in a Renal Allograft Recipient

Minaxi H Patel, Aruna V Vanikar, Himanshu V Patel, Rashmi D Patel

The immunosuppressive state in organ transplantation leads to infectious complications responsible for high mortality rate. Fungal infections account for 5% of all infections in Renal Transplantation (RT) recipients. Aspergillus species are filamentous fungi frequently causing fungal infections in RT recipients. Lungs and paranasal sinuses are the usual portal of entry from where it disseminates to other organs. Here, we are reporting a case of 14-year-old boy with RT from mother’s kidney, who had atypical presentation of isolated cerebral aspergillosis at 19 months post-transplant without identified portal of entry. Early diagnosis and prompt treatment saved the patient and the graft.

Foetal Magnetic Resonance Images of Two Cases of Aicardi Syndrome

Sebastián Gacio, Sebastián Lescano

Cerebral malformations are of fundamental importance in the clinical diagnosis of Aicardi Syndrome (AS). Some of these anomalies like callosal agenesis, cysts formation, posterior fossa anomalies and gross interhemispheric asymmetry are easily observed in the prenatal period with the use of foetal Magnetic Resonance Images (MRI). We present two cases of female newborns with cerebral MRI performed in the prenatal period and further diagnosed with AS. With the increase use of foetal MRI, AS will be easier suspected in the prenatal period in a female fetus with typical brain anomalies.

Caudal Regression Syndrome with Pressure Ulcers of the Foot: A Case Report

Kosaku Yamamichi, Tsuyoshi Manabe, Tatsuya Uekihara

Caudal Regression Syndrome (CRS) is a rare disorder which consists of abnormalities in the lumbosacral spine, rectum, urinary system, and lower limbs. These abnormalities also include orthopaedic deformities, such as hip dislocation, knee-flexion contracture with popliteal webbing, and talipes equinovarus. Because of the rarity of this condition, few medical personnel are aware of it. Here, we present a case of CRS in a 15-year-old girl with pressure ulcers on the lateral malleolus and plantar surface of the foot, which had come into contact with the wheelchair footrest. Although the foot [Table/Fig-1]: Appearance of the pressure ulcer on the ankle. [Table/Fig-2]: Appearance of the pressure ulcers on the planter surface of the foot. [Table/Fig-3]: A 15-year-old girl had deformed lower limbs and congenital talipes equinovarus. [Table/Fig-4a,b]: Radiograph of the patient at eight-years-old shows the agenesis of the spine L1 through L5 with complete disconnection and confirms the earlier diagnose of CRS when the patient was infant. [Table/Fig-5]: The lateral malleolar defect after the debridement, showing the outline of a lateral supramalleolar flap. [Table/Fig-6]: Appearance at 18 months after surgery. Stable coverage and good contour were obtained.ulcers healed after off-loading, the ulcer on the lateral malleolus did not heal with conservative treatment and was covered by a lateral supramalleolar flap after debridement. Stable coverage and good contours were present at 18 months postoperatively. CRS patients may have a risk factor for developing pressure ulcers of the foot due to the characteristic lower limb deformities and a loss of sensation. Preventive foot care measures such as off-loading devices combined with modern dressings should be applied as routine when the medical personnel is to attend such patients.

Plasma Exchange as a Therapeutic Modality in a Rare Case of Cryptogenic New Onset Refractory Status Epilepticus (NORSE)

Manisha Shrivastava, Smita Chouhan, Seema Navaid

Refractory Status Epilepticus (RSE) not responding to any therapy and not associated with any aetiology has been termed as New Onset Refractory Status Epilepticus (NORSE). Guidelines for optimal management of cryptogenic NORSE are not clearly defined so far in the literature. Other than common medication, use of high-dose steroids, IV immune globulins, and plasma exchanges in NORSE of unknown aetiology have been scarcely described. Immunomodulatory therapy like plasmapheresis is based on the fact that a pathological substance exists in the plasma that contributes to the disease process and its symptoms, which gets removed. We report a case of young female patient diagnosed as NORSE who responded to treatment with plasma exchange after becoming refractory to antiepileptic therapy and treatment with anaesthetic agents for recurrent seizers.

Juvenile Hyaline Fibromatosis- A Rare Autosomal Recessive Disease

Systemic hyalinosis is inherited as an autosomal recessive disease. It may also be referred to as Fibromatosis hyalinica multiplex juvenilis and Murray-Puretic-Drescher syndrome. A four and a half-year-old female child presented with multiple soft tissue swellings involving the nose, orbital ridges, ears, bony prominences of the ulna and tibia and the parietal and occipital prominence and had gum hypertrophy. The diagnosis of this rare condition was based upon clinicopathological correlation, wherein the histopathological examination of cutaneous lesions reveals accumulation of hyaline material with fibroblast in the dermis. A multidisciplinary approach helped in correct diagnosis, management and in providing counseling for the parents. The child’s parents were counseled about the surgical excision of the lesion; however, the parents opted for non-surgical conservative management.

Longitudinal Stent Deformation at Aneurysm Site: Flexibility at the Expense of Longitudinal Integrity

Bhupesh R Shah

Longitudinal stent deformation is a recently described complication of percutaneous coronary intervention. Novel stents with thin struts and reduced number of fixed links between cells improve flexibility and deliverability but in certain cases it may reduce longitudinal strength and thereby increase the risk of longitudinal deformation. Although longitudinal deformation of coronary stents is an infrequent finding, it requires clinical attention as it may lead to catastrophic clinical outcomes. We report a case of longitudinal deformation of coronary stent observed at our institution while treating ostial lesion and aneurysm of left anterior descending artery. Longitudinal deformation was identified during the procedure and treated with the deployment of another stent. Three-month follow-up of the patient was found satisfactory without any incidence of stent thrombosis.

Life Threatening Severe Hypernatraemic Dehydration in Neonates: A Report of Two Cases

Hypernatraemic dehydration in neonates may lead to potentially lethal consequences like cerebral oedema, intracranial haemorrhage, hydrocephalus and gangrene. In the light of increase in the infants presenting with hypernatraemic dehydration, there is a definitive need to heighten the awareness and have a high degree of suspicion in diagnosis for this potentially lethal condition. We report two neonates of severe hypernatraemia with dehydration highlighting its diagnosis and management. Treatment of hypernatraemic dehydration involves correction of electrolyte imbalance by careful restoration of fluids and ensuring appropriate intake of calories. Promoting, protecting and supporting breastfeeding by careful breastfeeding assessment and including an early post partum follow up in the hospital protocol to detect any unusual weight loss in the newborn period plays a significant role in preventing this condition.

Concurrent Acute Glomerulonephritis and Retropharyngeal Abscess in 10 Year Boy: A Case Report

Postinfectious Glomerulonephritis (PIGN) usually follows 1-2 weeks after respiratory tract infection and 4-6 weeks after skin infection. Acute Glomerulonephritis (AGN) is uncommon with simultaneous severe throat infections. We describe a 10-year-old boy who was presented with high grade fever, dysphagia and tender swelling over left side of neck. Examination also revealed enlarged multiple cervical lymph nodes on the same side of neck. Magnetic Resonance Imaging (MRI) of soft tissue of neck revealed evidence of retropharyngeal abscess. The next day, he subsequently developed haematuria and oliguria with borderline raised blood pressure. His corresponding blood urea and serum antistreptolysin O (ASO) levels were raised with low C3 levels. He had a remarkable improvement on injectable broad spectrum antibiotics with complete resolution of fever and neck symptoms. At eight weeks follow up, complete resolution of microscopic haematuria with normal C3 levels was observed. The present case highlights a 10-year-old young boy with retropharyngeal abscess presenting with clinical and laboratory evidence of Poststreptococcal Glomerulonephritis (PSGN).

Itolizumab in the Management of Psoriasis with Metabolic Syndrome

Shrichand G. Parasramani

Psoriasis is a chronic, relapsing, inflammatory disease that has been associated with Metabolic Syndrome (MS), a cluster of cardiovascular risk factors mainly hypertension, obesity, diabetes mellitus, and hyperlipidemia. A 49-year-old male patient presented with extensive plaque psoriasis from past 13 years. Past medications included methotrexate, PUVA therapy, topical immunosuppressants and corticosteroids. His baseline Psoriasis Area and Severity Index (PASI) score was 39.8. The patient was screened and diagnosed with MS as per Alberti’s Criteria (his waist circumference was 100 cm, blood pressure was 160/100 mmHg and High Density Lipoprotein (HDL) was 30 mg/dl). Considering severity of the disease, in this case we used anti-CD6 humanized monoclonal antibody Itolizumab (1.6 mg/kg body weight) to treat psoriasis and concurrent MS. The patient achieved PASI 50 response in six months after treatment of 10 infusions of Itolizumab (First seven doses were given every fortnightly and the last three doses every month). Further, Itolizumab treatment was continued once every three months and PASI 75 response was achieved at the end of 15 months. His PASI score increased to 30.7 after 18 months. Contemplating link between psoriasis and MS due to possibility of overlapping inflammatory pathways, we instructed patient to reduce his weight and prescribed oral tablet metformin 500 mg twice a day. After losing 6 kg weight, his PASI score came down to 22.2 at the end of 21st month. This suggests that MS was a driving factor in worsening of his psoriasis. Psoriatic patients should be checked simultaneously for co-morbid disease conditions. The report indicates direct association of psoriasis and MS.

Solid Variant of Aneurysmal Bone Cyst Masquerading as Malignancy

Ashok Singh, Abdul Majeed, Supriya Mallick, Shah Alam Khan, Asit Ranjan Mridha

Solid Variant of Aneurysmal Bone Cyst (SVABC) is an uncommon neoplasm seen in young patients. The lesion presents clinically as well as on radiology like a malignant bone tumour. The aggressive features in most of the cases lead to a wrong diagnosis. Radiologically, it is expansile osteolytic with cortical breach being seen in many of the cases. We report two cases of SVABC which were misdiagnosed as malignant bone tumours. Both cases were seen in long bones. Radiologically both lesions were expansile, osteolytic, solid cystic, with destruction of cortex and were diagnosed as osteosarcomas. Both the cases were referred to us for further management and were subsequently diagnosed as SVABC. Being extremely rare these tumours have a high chance of getting misdiagnosed and knowledge of this entity along with close correlation with clinical, radiological and histopathological findings plays a critical role in accurately diagnosing this condition. An accurate diagnosis is of utmost importance as this changes the treatment drastically avoiding mutilating surgeries and unnecessary chemo radiotherapy.

A Rare Case of Genital Malformation with Omphalocele, Exstrophy of Bladder, Imperforate Anus and Spinal Defect Complex-Autopsy Findings

K. Mamatha, B. R. Yelikar, Varsha R. Deshpande, B. S. Disha

Omphalocele, Exstrophy of cloaca, Imperforate anus, and Spinal defects (OEIS) is a severe manifestation of exstrophy-epispadias sequence with a combination of defects including OEIS. It results from improper closure of anterior abdominal wall and defective development of cloaca and urogenital septum due to defect in blastogenesis during the 4th week of gestation. Identification of this complex is important through foetal autopsy as this condition can recur in siblings. Prenatal diagnosis also helps to prevent foetal death with appropriate management in the less severe cases. In severe cases, termination of pregnancy is considered. A primigravida with 28 weeks of gestation had delivered a live baby with multiple congenital anomalies; baby died after 10 minutes. These anomalies were grouped under OEIS complex.

Spontaneous Intra–Parenchymal Rupture of Craniopharyngioma – A Rare Phenomenon

Craniopharyngioma is a relatively benign intracranial tumour that involves sellar and supra-sellar regions. Spontaneous rupture of craniopharyngioma into the sub-arachnoid space or into the ventricles is a rare phenomenon and few cases are reported in literature. We hereby report a case of sellar-suprasellar craniopharyngioma with focal intra-parenchymal rupture into brain causing aggravation of headache in a 12-year-old female child. This complication is a relatively rare phenomenon, which requires attention for early intervention. This was managed by trans-nasal endoscopic trans-sphenoidal surgery. Usually rupture of craniopharyngioma causes chemical meningitis or it can be asymptomatic. Sometimes rupture can cause complete resolution of cyst and symptoms. In the present case, there was only focal rupture and it was into brain parenchyma causing brain oedema with aggravation of headache. Magnetic Resonance Imaging (MRI) in intra-parenchymal rupture of craniopharyngioma has been emphasized in this case report.

Intracranial Aneurysms Involving Circle of Willis in a Child with Human Immunodeficiency Virus Associated Vasculitis- A Rare Case Report

Intracranial Arterial Aneurysms (IAAs) are relatively rare in paediatric population and they account for at least 10%–15% of haemorrhagic strokes which occur during the first two decades of life. Here we present a unique and unusual case of Human Immunodeficiency Virus (HIV) infected child who presented with intracranial aneurysms with formation of collaterals and vasculopathy, demonstrating low viral count despite receiving adequate antiretroviral treatment. Intracranial vascular involvement, their complications and its incidence in these patients may become increasingly common as the management of human immunodeficiency virus infection continues to improve and afflicted patients survive for longer periods because of advancement in the antiretroviral treatment. Diagnosing aneurysm of cerebral circulation needs high degree of suspicion and correlation between clinical and radiological findings.

Pigmented Trichoblastoma of Nose: An Unusual Occurrence

D.C Sathyaki, Mohammed Riyas, Mereen Susan Roy, R Jyothi Swarup, Nibha Raghu

Nevus sebaceus of Jadassohn is a congenital tumour affecting the scalp and face. It is usually presented as a pigmented patch or plaque. It is a complex cutaneous hamartoma which involves pilosebaceous follicle, epidermis and adnexal structures. Tumours that arise from nevus sebaceous are basal cell carcinoma, syringocystadenoma papilliferum, trichoblastoma and hidradenoma. The progression and frequency of the tumour increase with the age. Here we present a case of pigmented trichoblastoma over the external nose. It was a case of an elderly woman presenting with a painless swelling over the external nose which was soft, non-tender and with well defined margins.

External Drainage of Giant Infantile Choledochal Cyst before Definitive Repair: Is it Worth?

Vijai Datta Upadhyaya, Basant Kumar, Sandeep Kumar Raut, Eti Sthapak

Infantile Choledochal Cysts (IFCC) usually present with jaundice, acholic stool and abdominal lump or abdominal distension. If the surgical intervention is delayed, they rapidly progress to liver fibrosis which is considered to be irreversible if progressed to cirrhosis. We present the data of four cases (aged one month to seven months) of IFCC presented with cholangitis managed in one surgical unit in last two years. In one case, cholangitis was treated with prolonged antibiotic course before definitive repair whereas in rest, external drainage of cyst was done in addition to intravenous antibiotic to treat cholangitis. All the infants had features of cholangitis at time of presentation. Total leucocyte count ranged from 18x1000/UL to 30.6x1000/UL. Total bilirubin level at presentation ranged from 8.2 mg/dl to 18 mg/dl and Prothrombin time (INR) ranged from 1.33 to 1.9. Hepatic fibrosis was observed in all cases but cirrhosis was observed in only one case. There was no mortality but one patient had postoperative complication with prolonged hospital stay. External drainage helps in early recovery from cholangitis and better optimization of liver function. It also delays further progression to liver fibrosis by relieving the biliary outflow obstruction while waiting for definitive repair.

Effect of Methylphenidate on Orthodontic Tooth Movement and Histological Features of Bone Tissue in Rats: An Experimental Study

Hossein Aghili, Soghra Yassaei, Shokouh Taghipour Zahir, Rahele Arjmandi

Introduction: Methylphenidate is a psychostimulant drug, which is commonly used by children and teenagers. This age group receives most orthodontic treatment. Effect of this drug on tooth movement is unknown. Aim: The aim of this study was to evaluate the effect of methylphenidate on orthodontic tooth movement and histological features of bone tissue in rats. Materials and Methods: Forty-two Wistar rats (male) were selected and divided to three groups, randomly (n=14). The control group (Group 1) received no drug, the experimental Group 2 received a constant dose of methylphenidate daily for 14 days while the experimental Group 3 received increasing doses of methylphenidate daily. To exert force, a NiTi coil spring was placed between the maxillary right first molar and the maxillary right central incisor. At the end of the study period, the amount of tooth movement was measured and then the rats were sacrificed for histological analysis of bone tissue. Differences between the experimental groups were analysed using Kruskal-wallis and Mann–Whitney U tests. Results: No significant differences were found in the amount of orthodontic tooth movement or osteoclasts and lacunae, between the experimental groups (p>0.05). Mann–Whitney U analysis showed significant differences in the depth of resorption lacuna between Group 2 and 3 (p=0.037). Conclusion: Methylphenidate has no significant effect on orthodontic tooth movement or histological features of bone tissue in rats.

Anti-inflammatory and Analgesic Activities of Topical Formulations of Pterocarpus Santalinus Powder in Rat Model of Chronic Inflammation

Priti Pravin Dhande, Amit O Gupta, Sourav Jain, Jayshree Shriram Dawane

Introduction: The incidence of arthritis is quite high and there is a need for the search of natural products to halt the progression of disease or provide symptomatic relief without significant adverse effects. Aim: This study aimed at evaluating the anti-inflammatory and analgesic activities of topical Pterocarpus santalinus in an animal model of chronic inflammation. Materials and Methods: Albino rats of either sex were divided into five groups of six rats each (Group I – Control, Group II –Gel base, Group III –P. santalinus paste, Group IV –P. santalinus gel, Group V– Diclofenac gel). Chronic inflammation was induced on day 0 by injecting 0.1 ml Complete Freunds Adjuvant (CFA) in sub-plantar tissue of left hind paw of the rats. Topical treatment was started from day 12 till day 28. Body weight and paw volume (Plethysmometer) were assessed on day 0, 12 and 28. Pain assessment was done using Randall and Selitto paw withdrawal method. Data was analysed using GraphPad Prism version 5. Unpaired students t-test and ANOVA followed by Tukey’s test was used for comparison among groups. Results: Only topical P.santalinus gel significantly reduced the body weight (p=0.02) due to reduction in inflammatory oedema of the left limb. P. santalinus gel also showed significant reduction (p=0.03) in paw volume of rats compared to the other groups. There was significant reduction in pain threshold (gm/sec) due to chronic inflammation, with all the study drugs (p<0.05) but with P. santalinus gel, this reduction was less (p<0.001). Conclusion: Gel showed significant anti-inflammatory and mild analgesic activity on topical application in rat model of chronic inflammation.

Evaluation of the Potency of Kinetin on Radiation Induced Behavioural Changes in Swiss Albino Mice

Introduction: According to the various independent studies conducted, it is well evident fact that radiation induces oxidative stress in the living system. It is also proved that this oxidative stress will lead to the various behavioural changes such as anxiety and memory impairment. Kinetin is one of the important plant cytokine with anti-aging properties. However, very few studies were conducted to check its potential in ameliorating the behavioural changes induced by the ionizing radiation. Aim: This study was aimed to check the potential of kinetin in ameliorating the radiation induced behavioural changes in albino mice. Materials and Methods: In this study, survival analysis was performed using three different dose of kinetin intervention along with, one radiation control group and one normal control group (n=50). Based on the cumulative survival rate, single effective dose of kinetin was selected and used to evaluate the behavioural changes induced by radiation. The open field apparatus was used to evaluate the anxiety level (n=18, six in each group). Eight armed radial maze was used to evaluate the memory and learning ability in mice model. Results: Survival study results suggest 100 mg/kg body weight of kinetin showed highest cumulative survival rate. Therefore, this dose was selected as an effective drug dose for further study. Analysis also showed 6 Gy whole body electron beam radiation had significantly increased anxiety level, increased duration to complete the task as well as mistakes done during the task. Further, kinetin intervention had significantly ameliorated the same. Conclusion: A 100 mg/kg body weight of kinetin intervention helps in reducing the anxiety and improves the learning ability in mice exposed to electron beam radiation.

Induction with Varied Histological Patterns in Adenomatoid Odontogenic Tumour

Nawal Khan, Radhika M Bavle, K Paremala, Soumya Makarla, Reshma Venugopal

A Rare Case of Marcus Gunn Jaw Winking Phenomenon in a Community Health Setting

Monalisha Sahu

A Rare Presentation of Grossly Deformed Lungs in a Kyphoscoliotic Female Cadaver

Bikash Chandra Satapathy, Chinmayi Mohapatra, Rajashree Biswal

Early T-Cell Precursor Acute Lymphoblastic Leukemia/Lymphoma: Immunohistochemical Evaluation of Four Lymph Node Biopsies

Divya Shelly, Sumeet Gujral

Hyalinizing Clear Cell Carcinoma of Maxilla

Ersun Gushi, Umut Seki, Kaan Orhan

Coincidental Finding of Twin Dentigerous Cyst in an Achondroplasia Patient

Statistical Comments on "Assessment of Musculoskeletal Strength and Levels of Fatigue During Different Phases of Menstrual Cycle in Young Adults"

Mehrdad Farrokhi, Ali Amani-Beni

Basic Principles of Obstetric Anesthesiology: A Crossword Puzzle

Jennifer Wright, Allan F. Simpao, Omar Viswanath

Virulence Factors Detection in Aspergillus Isolates from Clinical and Environmental Samples

Raksha, Gurjeet Singh, A.D. Urhekar

Introduction: Pathogenesis of aspergillosis is dependent on various factors of the host (immune status) and virulence factors of the pathogen which could play a significant role in the pathogenesis of invasive aspergillosis. Aim: To study the virulence factors of Aspergillus species isolated from patient samples and environmental samples. Materials and Methods: This prospective and experimental study was carried out at Department of Microbiology, MGM Medical College and Hospital, Mumbai, Maharashtra, India, from July 2014 to June 2015. For detection of virulence factors of Aspergillus species, total 750 samples were included in this study (350 from patients and 400 samples from environment). Patient samples and hospital environment samples were subjected to standard methods for screening of Biofilm, Lipase, a–amylase, proteinase, haemolysin, phospholipase and pectinase. Statistical analysis was done using Chi-square test and SPSS (Version 17.0). Results: American Type Culture Collection (ATCC) control of Aspergillus oryzae, Aspergillus niger and Aspergillus brasiliensis showed production of all virulence factors. In patient samples maximum virulence factor was produced i.e., a-amylase activity (89.74%) followed by proteinase activity (87.17%), biofilm production was (82.05%) haemolysin activity (79.48%), lipase activity (66.66%), pectinase activity and phospholipase activity (61.53%). In environment samples maximum virulence factor was produced i.e., proteinase activity (41.02%) followed by biofilm production was (38.46%), a-amylase activity (35.89%), haemolysin activity (33.33%), lipase activity (28.20%), phospholipase (25.64%) and pectinase activity (23.07%). The differences in patient and environment virulence factors were statistically significant (p-value <0.05). Conclusion: Overall the presence of virulence factors was found more in Aspergillus species isolated from patient samples then environmental samples. This could be due to invasiveness nature of Aspergilli. Aspergillus niger was common isolates from both patient and environmental samples. Our study highlights the possible transmission of Aspergilli from environment to patient. Detection of virulence factors of Aspergillus species help to differentiate between pathogenic and non-pathogenic Aspergilli. Presence of virulence factors confirmed pathogenicity of the isolates. It also helps the physicians to treat the patient when appropriate treatment is needed.

Invasive Ductal Carcinoma Breast: How Neoadjuvant Chemotherapy Affects the Status of Estrogen Receptor, Progesterone Receptor and HER2/Neu- A Tertiary Care Centre Study

Swasti Shubham, Pratibha Maan, Monika Singh, Minakshi Bhardwaj

Introduction: Determination of Estrogen Receptor (ER), Progesterone Receptor (PR) and HER2/neu in primary Invasive Ductal Carcinoma (IDC) breast is the standard of care parameter for determining treatment options. Whether or not Neoadjuvant Chemotherapy (NAC) affects the receptor status is still an unanswered question. Aim: To compare immunohistochemical (IHC) profiles of ER, PR and HER2/neu in primary IDC breast before and after NAC to assess the subsequent effects on receptor status. Materials and Methods: Thirty two patients diagnosed with primary IDC breast who had a previous breast core biopsy with complete IHC profile followed by NAC and Modified Radical Mastectomy (MRM) were included. For each case demographic and histologic data was collected, including age, grade, amount of necrosis post NAC and IHC panel for ER, PR and HER2/neu in core biopsies. The same IHC panel was applied on Post NAC MRM specimen. Pre- and post NAC IHC expression was compared. Results: Patients ranged from 30 years to 75 years in range. ER, PR and HER2/neu status of core biopsies and MRM specimen were compared and overall agreement was noted. Comparison for each receptor was done using McNemar’s test and significance was calculated. There was no statistically significant difference in ER and Her2/neu expression between pre- and post-NAC specimens. However, a statistically significant loss of PR expression was noted between the two groups. Conclusion: Accurate determination of ER, PR and Her2/neu status in primary IDC breast is important to guide further treatment. Change in receptor status post NAC may warrant corresponding change in hormonal therapy.

Prevalence of Acanthosis nigricans and Related Factors in Iranian Obese Children

Introduction: Recognition of Acanthosis nigricans (AN) provides important opportunities for screening of obesity syndrome, dyslipidemia, hypertension, and insulin resistance with diabetes mellitus 2. Considering the high prevalence of obesity among Iranian children, we designed this study to estimate the prevalence of AN and related laboratory factors in Iranian obese children. Materials and Methods: Seventy-one obese children were enrolled in this study. Diagnosis of AN was done by clinical examination. Body mass index (BMI), fasting blood sugar, total cholesterol, triglycerides (TG), alanine aminotransferase, aspartate aminotransferase (AST), alkaline phosphatase, high- and low-density lipoprotein cholesterol, insulin, thyroid-stimulating hormone, free thyroxin (fT4), calcium, phosphorus, and 25-hydroxyvitamin D were measured with routine techniques. Collected data were compared between cases with AN and without AN. Independent t-test was used for comparison of variables. Results: Twenty-five of children were female (35.2%). Forty-eight children (67.6%) had AN. In 20 cases (28.2%), homeostasis model assessment-insulin resistance (HOMA-IR) was <2.5, and in 51 (71.8%), HOMA-IR was more than 2.5. Mean BMI, insulin, HOMA-IR, TG, and AST levels were significantly higher in cases with AN. Conclusion: Obese children with AN are at risk of developing diabetes. Hence early identification of this feature and precise evaluation of children is recommended.

Psychometric Utility in Determining Dental Organizational Attribute: A Cross Sectional Study in Ghaziabad, India

Introduction: Psychometrics is the field of research involved with the objective measurement of finesse and intelligence, skills, temperament, personality traits, and educational success and technique of psychological measurement. Oral healthcare along with patient satisfaction and quality of care are main factors responsible for organizational attribute. Patient safety is relatively emerging domain which will result in improving patient’s conditions without causing harm to them. Aim: To assess the psychometric behaviours as well as organization attribute with the help of modified version of Survey of Organizational Attributes for Primary Care (SOAPC) instrument among the dental care practitioners in Ghaziabad city, Uttar Pradesh, India. Materials and Methods: A cross-sectional study was conducted among 268 dental practitioner of Ghaziabad city to determine psychometric behaviours and organizational attributes using SOADC instrument. Data was analysed using SPSS software version 18.0 and was subjected to descriptive and Mann-Whitney U test. Results: Of the 268 dental practitioner, only 249 completed questionnaires. In communication, 70.3% agreed that they have constructive work relationship with staff with an overall mean score of 3.54±0.15, whereas in the subscale decision making, stress/chaos and history of change, the mean score of 2.77±0.98, 2.56±0.80 and 3.25±0.21 respectively were obtained. A statistical significant difference was noted between all the dimensions except stress/chaos and history of change (p=0.05). Conclusion: SOADC can be used to assess psychometric behaviours and organizational attributes of dental care practice. Preference should be given to dentist’s communication and reducing stress to enhance the service quality and improving safety of patient.

Immuno-Histochemical and Quantitative Study of Melanocytes and Melanin Granules in Oral Epithelial Dysplasia

Swapna Honwad, SV Ravi, Mandana Donoghue, Manjiri Joshi

Introduction: Oral Epithelial dysplasia (OED) is a potentially malignant disorder that is characterized by the presence of architectural and cytological changes. One of the prime factors responsible for the development of these lesions is the usage of tobacco. A variety of factors provide protective mechanism in order to prevent the effects of chemotoxic agents including tobacco products of which, melanin pigmentation is one of the vital elements. Aim: Role of melanocytes in progression of OED has remained unclear, so the present study was done to evaluate density of melanocyte and melanin granules in different grades of epithelial dysplasia and to correlate both findings with different grades of epithelial dysplasia. Materials and Methods: The study included 60 OED cases, of which three histopathogical sections were prepared from each block. The sections were stained with Hematoxylin and Eosin, Masson Fontana and Human Melanoma Black (HMB-45), an immunohistochemical stain. Quantification of melanin granules was evaluated under 40X magnification using arbitrary scale with micrometer square as, 0= Absence of melanin granules, 1= Rare and scattered melanin granules, 2= Dense but not aggregated melanin granules, 3= Dense and aggregated melanin granules. Density of melanocytes was evaluated under 10X magnification. Five consecutive fields were evaluated for melanocytes and melanin granules starting from the field of highest density. Results: There was an insignificant increase in number of melanocytes and melanin granules in mild and moderate dysplasia compared to normal but significant reduction was observed in severe dysplasia. Conclusion: The decrease in number of melanocytes and melanin granules was proportional to severity of epithelial dysplasia. This could be due to chronic irritation by chemical products leading to death of melanocytes.

Estimation of Serum Butyryl Cholinesterase in Patients with Oral Squamous Cell Carcinoma: A Cross-Sectional Study

Keerthi K. Nair, Gujjar Vittobarao Pramod, Kanad Chaudhuri, Lingappa Ashok

Introduction: Oral cancer is a major global threat to public health. It is one of the most common causes of mortality and morbidity in the modern era. Oral Squamous Cell Carcinoma (OSCC) accounts for over 90% of the malignancies involving the oral cavity. The enzyme- Butyryl Cholinesterase (BChE) is proposed to have a role in cell proliferation, cell adhesion, cell differentiation, apoptosis and tumorigenesis. Few studies have been conducted for understanding the significance of serum BChE as a biomarker in oral cancer patients; however literature available is insufficient to arrive at a conclusion. There is a need of a simple, rapid, convenient, inexpensive and reliable biomarker of oral cancer. So, the present study is an attempt to estimate the level of BChE in oral cancer, prior to definitive therapy. Aim: To estimate and compare the serum BChE levels in patients with OSCC with age and gender matched healthy controls. Materials and Methods: The study comprised of 80 subjects, of which 40 biopsy proven OSCC patients of either sex were selected as cases and 40 healthy, age and gender matched subjects as controls. Estimation of serum BChE levels was done by colorimetric method using RANDOX RX Imola Auto-Analyzer. The statistical analysis between the OSCC group and the control group were done using unpaired t-test. Comparison between serum BChE levels and TNM stages of OSCC were done using Kruskal-Wallis Test. Comparison between serum BChE levels and histopathological grades of OSCC were done using Mann-Whitney U Test. Results: There was statistically highly significant decrease in the mean serum BChE levels in the OSCC group compared to the control group (p<0.001). It was revealed that the serum BChE levels were further decreased in moderately differentiated squamous cell carcinoma than well differentiated squamous cell carcinoma and the difference was statistically significant (p <0.05). Conclusion: The decrease in the serum BChE level demonstrates that it as a simple, rapid, convenient, inexpensive and reliable biomarker for oral cancer. Our findings support the concept of role of BChE in apoptosis, cell proliferation, differentiation and its related link in the pathophysiology of oral cancer.

The Association between Cariogenic Factors and the Occurrence of Early Childhood Caries in Children from Salem District of India

Arokiaraj Stephen, Ramesh Krishnan, Paul Chalakkal

Introduction: Various aetiological factors for Early Childhood Caries (ECC) have been suggested in literature, but the role of each factor has been disputed in various studies. Aim: To evaluate the association between ECC and its related factors in children between three to six years of age, from rural, semi-urban and urban schools in the district of Salem (India). Materials and Methods: The study consisted of children between three to six years of age, selected randomly from schools in semi-urban, urban and rural schools at Salem. Questionnaire (comprising of the factors associated with ECC) and parental consent forms were sent to each of the parents of the school children. Filled questionnaires and parental consent forms were obtained from a total of 2771 children, out of which 1771 were boys and 1000 were girls. Clinical examination for ECC was carried out according to the WHO criteria, by a single examiner and an assistant to eliminate inter-examiner variability. Statistical analysis was carried out using the student’s independent t-test and ANOVA (one way analysis of variance). Results: Out of a total of 2771 children examined, only 443 (315 boys and 128 girls) children were found to have ECC (16 %). Significant correlations were found between the occurrence of ECC and various factors like age of parents, number of siblings, on-demand breast feeding and bottle feeding habits and sweetened pacifier use. However, factors such as age and gender of the child, type of birth and duration of pregnancy, had no significant correlation with the occurrence of ECC. Conclusion: The need for educating parents on the ill effects of improper breast feeding and bottle feeding habits is important.

Distribution of Class D Carbapenemase and Extended-Spectrum b-Lactamase Genes among Acinetobacter Baumannii Isolated from Burn Wound and Ventilator Associated Pneumonia Infections

Introduction: Resistance to Acinetobacter baumannii is dramatically on the rise in Iran. Therefore, it is important to study resistance pattern among Acinetobacter isolates which is a common cause of nosocomial infections. Aim: To investigate antibiotic resistance patterns and the role of resistant genes and biofilm formation in the induction of resistance among Acinetobacter baumannii isolated from burn wound and ventilator associated pneumonia infections. Materials and Methods: Total 103 isolates such as 33 burn samples from Rasool Akram Hospital and 70 isolates from ventilated patients in Shahid Motahhari Hospital were identified with A. baumannii using biochemical method, and then identified to species level with PCR of gyrB and blaOXA-51 gene. Antibiotic sensitivity pattern for b-lactam and carbapenem antibiotics was assessed using Agar disc diffusion test and E-test. The presence of different carbapenemase and metalo-b-lactamase (blaOXA-51-like, gyrB, blaOXA-23-like, blaOXA-24-like, blaOXA-58, blaVEB, blaPER, blaGIM, blaSIM, blaIMP, blaVIM), extended-spectrum ß-lactamases (blaTEM, blaSHV) and two insertion sequences genes (ISaba1, IS1113) was assessed. Biofilm formation of all isolates was then assessed. Chi-square analysis or Fisher’s-exact tests were used for statistical analysis. A p-value <0.05 was considered statistically significant. Results: Colistin was the most effective antimicrobial agents, although 10.7% (11/103) of the isolates were resistant. The high rate of resistance to meropenem (93.2%) and imipenem (90.3%) was determined. Also, with exception of ampicillin-sulbactam, surprisingly the resistant rate was 28.2%, the resistance to b-lactam antibiotic was dramatically increased. Co-existence of two and three blaOXA genes was also determined. The blaOXA-58 was detected in only one isolate. The blaTEM and blaOXA-23 was the most prevalent Extended-Spectrum ß-Lactamases (ESBL) gene. All isolates were biofilm producers. Conclusion: Antibiotic resistance is increasing among A. baumannii isolates which is due to excessive use of antibiotics and also acquired resistant genes and biofilm production. Resistance to nearly all antimicrobial agents especially colistin as end choice for treatment of multiple drug resistance A. baumannii is a big concern.

Effects of Different Contraceptive Methods on Cervico-Vaginal Cytology

Khushboo Garg, Anjali Khare, Rani Bansal, Sangeeta Sharma, Neha Chaudhary

Introduction: The vaginal flora of healthy adult women of reproductive age group constitutes predominantly Lactobacilli which inhibits the growth of other microorganisms (by maintaining acidic pH). The vaginal microflora is altered in favour of anaerobes in women using Intra Uterine Contraceptive Device (IUCD). Also, it can cause morphologic changes in both squamous and endocervical columnar cells. Similarly, the prevalence of vaginal lactobacilli is reduced among women using diaphragm-spermicide or spermicide alone. Aim: To study the effects of different contraceptive methods on cervical cytology and vaginal flora. Materials and Methods: Two years prospective study included 120 women of reproductive age group using barrier, tubal ligation, IUCDs, Oral Contraceptive Pills (OCPs) and injectable methods of contraception and a control group including 60 women not using any contraceptive. Cervical and vaginal smears were obtained. Cervical smears were reported using the Bethesda system and Gram stained vaginal smears were scored using Nugent scoring. SPSS (Statistical Package for the Social Sciences) software for Windows Version 19.0 and test of significance applied was Chi-square test. Results: The most common contraception used was barrier (68.3%) followed by tubal ligation (14.2%), IUCD (9.2%), OCPs (6.6%) and injectable (1.7%). The presenting complaints were pain lower abdomen (46.7%) followed by menstrual complaints (22.5%). Epithelium showed reactive changes (45%) followed by metaplasia (25%), koilocytotic change (5%), cytolytic effect (5%) and satellitosis (4.2%). Women showed normal flora in 51.7%, altered in 30% and bacterial vaginosis in 18.3%. Conclusion: Cervico-vaginal changes were more frequent in contraceptive users as compared to the control group.

Comparison of Intubating Conditions using Fentanyl plus Propofol Versus Fentanyl plus Midazolam during Fiberoptic Laryngoscopy

Introduction: Awake nasal or oral flexible fiberoptic intubation is the airway management technique of choice in known or anticipated difficult airway, unstable cervical fracture, limited mouth opening (as in temporomandibular joint disease), mandibular-maxillary fixation and severe facial burns. Both optimal intubating condition and patient comfort are important for fiberoptic intubation. Optimal intubating conditions provided by an ideal sedation regimen would ensure haemodynamic stability, patient comfort, attenuation of airway reflexes and amnesia. Aim: To compare the intubating conditions using fentanyl plus propofol versus fentanyl plus midazolam during fiberoptic laryngoscopy. Materials and Methods: A prospective, comparative and randomized study was conducted on 60 patients of either gender aged between 18 and 60 years belonging to the American Society of Anaesthesiologists (ASA) grade-I or II scheduled for elective surgery. Patients were randomly allocated into two groups of 30 each. In group I, patients received i.v. fentanyl 1 µg/kg+ propofol 1 mg/kg to achieve an adequate level of sedation that is Ramsay Sedation Scale (RSS) score of 3. In group II, patients received i.v. fentanyl 1 µg/kg + midazolam 0.03 mg/kg to achieve RSS= score of 3. Haemodynamic parameters (heart rate, systolic and diastolic blood pressure, mean arterial pressure), SpO2, EtCO2, total comfort scale values and patient’s tolerance were assessed during preoxygenation, fiberscope insertion, and endotracheal intubation. Results: Fentanyl plus midazolam group showed better patient comfort and maintenance of oxygen saturation than fentanyl plus propofol group during fiberoptic intubation. Conclusion: Both fentanyl plus midazolam and fentanyl plus propofol regimes are suitable for fiberoptic intubation. Fentanyl plus midazolam appeared to offer better tolerance, preservation of an airway and spontaneous ventilation, while maintaining haemodynamic stability.

Microperimetry – A New Tool for Assessing Retinal Sensitivity in Macular Diseases

Introduction: Macular disease is the leading cause of low vision in the Western world. Drusen and pigmentary irregularities are common among the rural Northern Indian population. The disease process leads to loss of central vision, metamorphopsia, macropsia or micropsia and colour vision defect. Aim: To study the retinal sensitivity changes in macular diseases using microperimetry. Materials and Methods: It was an observational study, conducted in the Department of Ophthalmology at a rural tertiary care hospital. This study was started from December 2014 until June 2016, in all patients with macular disease above the age of 20 years attending the outpatient department. Microperimetry was done for 84 eyes of 52 patients with macular disease. Mean retinal Sensitivity (MS) and fixation stability was evaluated. The statistical analysis of mean retinal sensitivity, central 2° and 4° fixation was done by calculating the mean and standard deviation using 95% confidence interval. Results: The range of age was between 20-81 years. Majority were 32 males (62%) and 20 females (38%). Out of the 84 eyes studied, majority of the macular disease were Age-Related Macular Degeneration (AMD) (50%). Rest 50% were other macular diseases. The mean retinal sensitivity (dB) shown by microperimetry was 10.83 in AMD, 9.12 in Cystoid Macular Oedema (CME), 10.34 in Epiretinal Membrane (ERM), 10.74 in Pigment Epithelial Detachment (PED), 8.96 in Central Serous Chorioretinopathy (CSCR), 6.43 in macular dystrophy, 7.15 in Lamellar Hole (LMH), 9.8 in Pseudomacular Hole (PMH), 3 in geographic atrophy, 11.1 in macular telangiectasia, 5.6 in Berlin oedema, 12.3 in macular scar and 15.2 in haemorrhage in macula. The study showed 64% of the eyes had stable 2° central fixation, 35% had relatively unstable fixation and 1% had unstable fixation. No significant correlation between retinal sensitivity and retinal thickness in AMD was found. Conclusion: This study shows that microperimetry can be a useful tool for objective evaluation of macular function and progression of the disease.

Short Term Efficacy and Safety of Insulin Glargine in Type 2 Diabetes Inadequately Controlled with Single or Two Oral Agents: A Prospective, Open Label Study

Ajay Aggarwal, Roopak WaWadhwa

Introduction: Basal insulin is among the second line treatment options for Type 2 Diabetes Mellitus (T2DM). Efficacy and safety of basal insulin in patients of T2DM, uncontrolled with Oral Antidiabetic Agents (OAAs) remains understudied in the Indian setting. Aim: To assess the efficacy and safety of insulin glargine in patients with T2DM who have uncontrolled glycaemic levels despite single or two OAAs therapy. Materials and Methods: In this prospective, open label study, T2DM patients above 40 years of age, having inadequate glycaemic control [Glycosylated Haemoglobin (HbA1c) above 8% and/or fasting glucose level of 140 mg/dl and above] with single or two OAAs over three consecutive months were included. Dosing of insulin glargine was adjusted as per Fasting Blood Glucose (FBG) and Post Prandial Blood Glucose (PPBG) levels. Patients were followed for 12 weeks and data was analysed by comparing 12th week findings to baseline values. Results: In 40 cases included in final analysis, mean age was 56.35 ± 6.77 years, 52.5% were females and mean body mass index was 26.96 ± 4.59 kg/m2 . Compared to baseline, significant reduction in HbA1c, FBG and PPBG blood glucose (all p<0.05) was seen. HbA1c goal of < 7% was achieved in 37.5% cases. Systolic (p>0.05) and diastolic (p<0.05) blood pressures reduced at 12 weeks as compared to baseline. Increase in weight was modest with mean increase of 1.06 kg (p>0.05). Overall, 14 symptomatic hypoglycaemia events were observed with none being severe. Conclusion: Short term administration of insulin glargine is effective in reducing glycaemia and is safe with lower rates of severe hypoglycaemia. It can be considered in patients with uncontrolled T2DM on mono- or two- OAAs treatment.

Comparison of Efficacy and Safety of Unilateral Spinal Anaesthesia with Sequential Combined Spinal Epidural Anaesthesia for Lower Limb Orthopaedic Surgery

Jyoti Sandeep Magar, Kishori Dhaku Bawdane, Rahul Patil

Introduction: Orthopaedic anaesthesia plan requires customi-zation as per patient’s need for safe outcome. Sequential Combined Spinal Epidural Anaesthesia (Sequential CSEA) and Unilateral Single Shot Spinal anaesthesia (Unilateral SA), both have advantages over conventional spinal anaesthesia that they provide longer lasting block with less hypotension. Aim: To compare safety and efficacy of unilateral spinal anaesthesia with sequential combined spinal epidural anaesthesia for lower limb orthopaedic surgery . Materials and Methods: This prospective randomized study was conducted on sixty ASA I-III patients aged 18- 65 years undergoing lower limb orthopaedic surgeries of approximately two hours duration. Sequential CSE group received spinal with 5 mg of 0.5 hyperbaric bupivacaine followed by incremental epidural top up of 2 cc of 0.5% isobaric bupivacaine to achieve and maintain T10 level. In unilateral SA group, unilateral spinal anaesthesia was given with 10 mg of 0.5% hyperbaric bupivacaine. Haemodynamic parameter, anaesthesia readiness time and block characteristics were recorded and results were analysed using unpaired Student's t-test. Results: There was no failure of block, surgical anaesthesia with T10 sensory level and bromage score three motor block was achieved by all patients in both groups. Anaesthesia readiness time was less in unilateral SA (p<0.001) Incidences of hypotension (p-0.0059) and mean ephedrine dose were significantly less in sequential CSEA. Five patients of unilateral SA required supplementation with general anaesthesia. Conclusion: Thus, our study concludes that unilateral SA is a cost-effective and rapidly performed anaesthetic technique. Unilateral SA with 10 mg bupivacaine and sequential CSEA with 5 mg spinal and incremental epidural top up, both provide good quality sensory and motor block for lower limb orthopaedic surgery but sequential CSEA provides significantly more stable haemodynamics with feasibility to prolong block. Thus sequential CSEA should be preferred over unilateral SA in high risk patients especially for major lower limb orthopaedic surgeries.

Fungal Rhinosinusitis: Microbiological and Histopathological Perspective

Introduction: On the basis of histopathology Fungal Rhinosinusitis (FRS) is categorized into non-invasive (allergic fungal rhinosinusitis, fungal ball) and invasive (acute invasive, chronic invasive and granulomatous invasive fungal sinusitis). This differentiation helps to decide the treatment. Role of latest molecular methods such as PCR and conventional methods such as KOH microscopy and culture also needs to be evaluated. Therefore, in this study we planned to categorise fungal rhinosinusitis on the basis of histopathology and compare it with other methods such as PCR, culture and KOH microscopy. Aim: To analyse fungal rhinosinusitis cases by both histopathologically and microbiologically. Materials and Methods: A total of 76 clinically suspected fungal rhinosinusitis cases were included in the study. The tissue of suspected cases were processed and examined by KOH microscopy, histopathologically, culture and PCR. Histopathological examination was done by PAS, GMS and H&E stain. Results: FRS was diagnosed in 37 (48.68%) cases out of 76 clinically suspected cases of FRS. In which 17 (22.3%) cases were positive by direct microscopy, 21 (27.6%) by culture, 27 (35.5%) by PCR and 14 (18.42%) by histopathology. Approximately 14 cases of FRS were classified according to histopathology; 10 (71.3%) as non-invasive FRS. Out of these 10, 9 (64.2%) were classified as AFRS and 1 (7.14%) as fungal ball. Only 4 cases (28.5%) were diagnosed with invasive FRS. Out of these 4 cases, 2 (14.2%) were of chronic invasive fungal rhinosinusitis, 1 (7.14%) was of granulomatous invasive fungal rhinosinusitis and 1 (7.14%) was of acute fulminant invasive fungal rhinosinusitis. Allergic Fungal Rhinosinusitis (AFRS) is the most common type of FRS. Aspergillus flavus was found to be the most common fungi causing FRS. Conclusion: Diagnosis should not be based on the single method. It should be done by both histopathological and microbiological methods, especially for those cases which are difficult to diagnose.

Periodontal Initial Radiological Findings of Genetically Predisposed Finnish Adolescents

Introduction: Periodontitis is a multifactorial infectious disease of the supporting tissues of teeth in which bacterial, genetic and lifestyle factors such as smoking have an important role. Aim: The aim was to examine if Bleeding On Probing (BOP = 20%) and = 4 mm deep pockets correlated with any suspicion of initial radiological findings of periodontitis and bone loss. We also investigated whether any pro-inflammatory-related candidate Single Nucleotide Polymorphisms (SNPs) were associated with any suspicion of radiological findings. Materials and Methods: Altogether 47 generally healthy adolescent patients of one birth cohort had given their approval for their saliva samples to be used for DNA analysis. One participant was excluded after discrepant gender check. An oral radiologist analysed right and left bitewing radiographs of 47 patients. Clinical parameters such as BOP = 20%, = 4 mm pockets, Visible Plaque Index of all teeth (VPI%), as well as smoking habits were recorded. DNA was extracted and 71 SNPs from candidate genes for initial periodontitis were genotyped. The association between = 4 mm pockets and BOP = 20% with radiological findings and selected SNPs was modelled using logistic regression. Results: Variants in Toll-Like Receptors 4 (TLR4) gene (rs498670) (OR=5.8, {CI95% 1.6–20.7}, p=0.02, FDR q-value=0.13) and TNFSF11 gene (rs2277438, OR=0.3 {CI95% 0.1–0.9}, p=0.002, FDR q-value=0.56) were associated with any suspicious radiological findings; however the significance vanished after False Discovery Rate analysis (FDR). The association between BOP = 20% and any radiographic signs of periodontitis was found to be statistically significant, OR=1.6, CI 95% 1.0-2.4, p=0.04. Conclusion: Only TLR4 (rs498670) and TNFSF11 (rs2277438) genes were found to have a positive correlation with radiological findings suggestive of initial periodontitis after adjustment for smoking and visible plaque.

New Vision for Improving the Oral Health Education of Visually Impaired Children- A Non Randomized Control Trial

Arpan Debnath, B.K. Srivastava, Punith Shetty, Shruthi Eshwar

Introduction: Visually impaired people have poorer oral hygiene when compared to others. Therefore, there is a necessity for individual training by making awareness in oral care and plaque control so as to improve their oral hygiene. Aim: The aim of the present study was to assess the effectiveness of oral health innovative educative method among visually impaired children of Bengaluru city of India. Materials and Methods: A non-randomized control trial was conducted among 40 visually impaired individuals attending special school for blind. The study was conducted for a duration of six months. Baseline data regarding oral health knowledge, attitude and practices was obtained through a questionnaire in Braille and oral plaque assessment was done using Silness and Loe plaque index (1964). Music based brushing technique, cast models and an oral health education talk and booklet in Braille was delivered stressing on importance of oral health. The results of Knowledge, Attitude and Practices (KAP) before and after health education were analysed using Chi-square test with SPSS version 22.0. Results: The overall KAP was lower in the preintervention period among the visually impaired children with mean score of 6.98 while after the modified oral health education session, it was increased to a mean score of 14.68 which was statistically significant at p<0.001. There was a significant change in the oral plaque scores with 80% of the children having fair scores in the preintervention period to 30% in the postintervention period. Conclusion: This oral health education module showed good results which can be implemented to effectively increase the awareness about dental health.

Evaluation of the Relationship between Serum 25-Hydroxy Vitamin D and Hypertension in Hamadan, Iran-A Case Control Study

Behshad Naghshtabrizi, Shiva Borzouei, Pedram Bigvand, Mohamadali Seifrabiei

Introduction: Hypertension or high blood pressure is one of the main reasons of fatality in the world. The role of vitamin D in developing hypertension has not been proved yet. Some studies have shown positive correlation between low serum vitamin D level and hypertension. Due to this fact, recognising hypertension risk factors such as potential impact of low serum vitamin D level seems to be required. Aim: This study was conducted to evaluate potential impact of serum vitamin D level on hypertension. Materials and Methods: This case-control study had 188 subjects including 55 cases suffering from hypertension and 133 controls with normal blood pressure in Hamadan, Iran. After taking the medical history and physical examination, 5 cc of their blood was taken to measure their serum 25-Hydroxyvitamin D [25(OH)D] level through ELISA test. Data analysis was done by version 16.0 of SPSS software and used independent sample t-test and Chi-square test for related comparisons. Results: Mean and standard deviation of serum 25(OH)D level in patients suffering from hypertension was 13.10±9.7 ng/ml and in control group was 20.87±10.34 ng/ml. This variance was statistically significant (p<0.001). Mean serum 25(OH)D level in both case and control groups was measured after gender and age stratification. Mean serum 25(OH)D level in cases and controls was 13.12±11.4 ng/ml and 21.38±11.47 ng/ml in males (p=0.016) and 13.10±9.91 ng/ml and 19.19±10.55 ng/ml (p=0.004) in females, respectively. Mean serum 25(OH)D level in under 50-year-old was 10.82±8.73 ng/ml and 20.07±11.17 ng/ml in cases and controls respectively (p<0.001). In over 50-year-old, there was no significant relationship between mean serum 25(OH)D and blood pressure levels (p>0.05). Conclusion: According to this study, reverse relationship between serum 25(OH)D and blood pressure levels was seen.

Effects of Intraperitoneal Local Anaesthetics Bupivacaine and Ropivacaine versus Placebo on Postoperative Pain after Laparoscopic Cholecystectomy: A Randomised Double Blind Study

Neha T Das, Charulata Deshpande

Introduction: Laparoscopic Cholecystectomy (LC) is the most frequently performed elective daycare surgery and provision of postoperative pain relief is of importance. After laparoscopic cholecystectomy shoulder and abdominal pain causes considerable distress. Visceral pain during coughing, respiration and mobilization increases morbidity, hospital stay and costs. Aim: To compare the analgesic efficacy of intraperitoneally instilled equipotent concentrations of bupivacaine and ropivacaine versus placebo in relieving postoperative pain after laparoscopic cholecystectomy when used as a part of multimodal analgesia. Materials and Methods: In this randomised, prospective, double blind, placebo controlled study, 90 ASA Class I or II patients were randomly divided into three groups of 30 each. Group S received intraperitoneal infiltration with 35 ml of 0.9% normal saline, Group B with 35 ml of 0.25% bupivacaine and Group R with 35 ml of 0.375% ropivacaine. All groups received standard general endotracheal anaesthesia and analgesia with IV paracetamol 15 mg/kg and diclofenac 1.5 mg/kg. Numerical Rating Scale (NRS) score of analgesia at rest and on cough/movement, duration of analgesia, haemodynamic parameters, need for a rescue analgesic (IV tramadol 1 mg/kg) was recorded and adverse effects of procedure and drugs if any were monitored. Data was analysed with SPSS statistical software version 21.0. One way ANOVA or the Kruskal–Wallis test was used to compare continuous data across all three groups as appropriate. Subsequent analysis of continuous data between two groups was achieved by Tukey’s post hoc test. Significance was accepted as p<0.05. Results: The mean NRS was <5 till only four hours in Group S, till eight hours in Group B and till 16 hours in Group R. The duration of analgesia was 13.47+1.38 hours in Group R, 7.93+1.44 hours in Group B and 4.47+0.86 hours in Group S. Conclusion: Intraperitoneal infiltration of LA significantly reduces pain intensity scores in the early postoperative period after LC surgery and helps in improving the postoperative recovery profile and outcome. This makes LC surgery more amenable to day care surgical setup. Ropivacaine (0.375%) is more efficacious, longer acting with a higher intensity of postoperative analgesia than bupivacaine (0.25%).

Evaluation of Oral Health Status among 5-15-Year-old School Children in Shimoga City, Karnataka, India: A Cross-sectional Study

Introduction: Oral health is an integral part of general health. Dental problems can be avoided if identified at an early stage. There is no data on oral health status of school going children in Karnataka state’s Shimoga city. Aim: To evaluate oral health status of school going children among 5-15-year-old in Shimoga city. Materials and Methods: A cross-sectional study was conducted among 1458 government and private school children aged 5-6, 9-10 and 14-15 years. Dental caries (DMFT and deft Index), oral hygiene status (OHI-S Index) and dental fluorosis (Dean’s Fluorosis Index) according to WHO diagnostic criteria (1997) were assessed. Data was evaluated using ANOVA and t-test by SPSS (IBM statistical software version 21.0.) at a level of 5% significance. Results: The deft among 5-6-year-old children was 3.36±3.511, deft and DMFT among 9-10-year-old was 2.55±2.497 and 0.45±0.996 respectively and DMFT among 14-15-year-old was 1.34±1.832. The caries prevalence among 5-6-year-old was 68.8%, 9-10-year-old was 77.2% and 14-15-year-old was 48.9% and overall prevalence of dental caries was 65.3% which was statistically significant. Among 9-10-year-old oral hygiene was good in 85.4%, fair in 13.5% and poor in 1% of school children and among 14-15-year-old oral hygiene was good in 77.4%, fair in 22.2% and poor in 0.4%. Overall 81.7% of children had good oral hygiene. The prevalence of dental fluorosis was 14.5%. Conclusion: The children from government school were found to be less caries free than the private school children, but the difference was not significant. Oral hygiene status is found to be good among both the private and government school children. So the dental awareness is required among children of government school.

Frequent Occurrence of Faulty Practices, Misconceptions and Lack of Knowledge among Hypothyroid Patients

A Goel, C Shivaprasad, A kolly, A.A Pulikkal, R Boppana, C.S Dwarakanath

Introduction: Hypothyroidism is a common endocrine disorder with a reported prevalence of 4%-10%. Previous studies have reported significant gaps in the basic knowledge about the condition in hypothyroid patients. It has also been observed that faulty practices prevail among these patients. There is paucity of data on the assessment of knowledge and practices among treated hypothyroid patients. Aim: The present study was aims to assess the knowledge, awareness and practices in treated hypothyroid patients. Materials and Methods: The current cross-sectional study was conducted on 244 consecutive hypothyroid patients, attending the Endocrinology Outpatient Department (OPD). The patients were asked to fill a structured questionnaire pertaining to knowledge and practices about various aspects of hypothyroidism. Results: Only two-thirds of the participants correctly identified thyroid as a gland and 41% were aware that hypothyroidism is caused due to decreased function of the thyroid gland. The most common symptom attributed to hypothyroidism was weight gain (139 responses). Nearly 45% of the patients believed alternative forms of medicine can be used for treatment of hypothyroidism. It was believed by 42% of the patients that hypothyroidism runs in the family and about 10% believed it could be transferred to their spouses. Only 33% of the patients gave one hour gap between levothyroxine and food intake. Conclusion: The study demonstrates the lack of knowledge about basic aspects of hypothyroidism among the patients. In addition, there is a high prevalence of misconceptions and faulty practices. The study highlights the need for comprehensive patient education to improve therapeutic outcomes and compliance among hypothyroid patients.

Comparison of Continuous Femoral Nerve Block versus Local Infiltration Analgesia as a Postoperative Analgesia in Unilateral Total Knee Arthroplasty

Introduction: Local infiltration of knee joint in arthroplasty, provide postoperative analgesia and preserves motor power of quadriceps, which helps in early mobilisation, as compared to femoral nerve block which paralyses vastus medialis. Aim: To compare the quality of postoperative analgesia provided by femoral nerve block and local infiltration in unilateral Total Knee Arthroplasty (TKA). Materials and Methods: A prospective study was conducted on 60 patients (25-65 years) of ASA I and II, which were randomly(using random number table) divided into two groups – Group 1-femoral nerve block (FNB) and Group 2-Local Infiltration Analgesia (LIA). Patients with chronic pain and on opioids were excluded. Numeric rating scale (primary objective), sedation score, nausea vomiting score and motor power were analysed. The results were analysed by parametric and nonparametric tests using SPSS software version 22. p<0.05 was considered significant. Results: Pain relief was better in FNB Group (p-value <0.001) with less fentanyl demand (p-value <0.001), low sedation score (0.013, 0.179, 0.018, 0.129, 0.287, 0.432) but associated with low muscle power grading (<0.001). Conclusion:FNB has better pain relief than LIA Group but range of motion was reduced in FNB Group grossly, effect on mobilisation remained comparable in both group.

Blood Lead Levels in Children of Southwest Iran, Aged 2-6 Years and Associated Factors

Introduction: Lead is one of the toxic metals that can cause several complications in children. Aim: This study was conducted to determine Blood Lead Levels (BLLs) in healthy children and its association with individual and environmental factors. Materials and Methods: This descriptive-analytical study was conducted on 262 healthy children aged 2-6 years in Shahrekord, Southwest Iran in 2013. After taking serum samples from the children, the checklists of effective environmental factors on lead toxicity were completed after interviewing the parents. BLLs were determined by ICP-MS. Data were analysed by descriptive and analytical statistics (chi-square and ANOVA) in SPSS 16. Results: BLLs ranged 0.4-52.8 (mean: 6.9±7.9) ng/ml. BLL was significantly associated with father’s education level, house colour damage, canned food use and soil eating (p<0.05), but not with age, gender, economic status, proximity to factory and kohl use (p>0.05). Conclusion: BLL can cause serious health risks for children in Shahrekord and is associated with certain risk factors. It is necessary to screen for these risk factors.

Comparison of Pioglitazone and Metformin Efficacy against Glucocorticoid Induced Atherosclerosis and Hepatic Steatosis in Insulin Resistant Rats

Introduction: Insulin Resistance is a major cause of Atherosclerosis (AS) and Non Alcoholic Fatty Liver Disease (NAFLD). These lipid alterations in blood vessels and liver may progress to cardiovascular abnormalities and cirrhosis respectively. Drugs like pioglitazone (PIO) and metformin (MET) are effective insulin sensitizers used in T2DM. But their efficacy and tolerability needs to be compared in IR associated abnormalities. Aim: To compare the efficacy of PIO and MET in glucocorticoid induced AS, Hepatic Steatosis (HS) and IR in albino rats. Materials and Methods: Male Wistar albino rats were randomized into four groups (n=6). Group 1 (Normal control) rats consumed 2% gum acacia orally for 12 days. Group 2 {dexamethasone (DEX) control} rats were administered 2% gum acacia orally for 12 days and DEX (8 mg/kg) intraperitoneally (i.p.) from 7th to 12th day during the study period. Group 3 and 4 (PIO and MET control) rats received oral administration of PIO (45 mg/kg) and MET (1000 mg/kg) for 12 days respectively. Both groups were treated with DEX (8 mg/kg/i.p.) from 7th to 12th day during the study period. On last day, fasting blood was collected and rats were sacrificed by cervical dislocation; aorta and liver tissues were isolated for the histopathological examination. Body weight, liver weight and liver volume were measured. Blood samples were processed for biochemical parameters. The data were analysed by One-way Analysis of variance (ANOVA) followed by Scheffe’s multiple comparison post-hoc test. The statistical significance was assumed at p<0.05. Results: Our results established the possible role of DEX in the development of AS and HS. Histopathological examination of Group 2 rats treated with DEX showed a marked lipid accumulation in the aorta and liver. Administration of MET and PIO resulted in partial to complete restoration of DEX induced fatty changes in aorta and liver. Both drugs significantly (p<0.05) prevented the elevation of insulin, lipid, glucose levels, liver weight and liver volume in DEX treated rats. They had significantly (p<0.05) improved body weight and insulin sensitivity. However, PIO was highly significant (p<0.05) compared to MET in reducing DEX induced IR complications. Conclusion: These findings suggest that PIO was more effective insulin sensitizer compared to MET in reducing AS, HS and IR induced by glucocorticoids.

Clinical Assessment of Various Obturating Techniques for Primary Teeth: A Comparative Study

Mahima Gandhi, Sandeep Tandon, Akshat Vijay, Garima Kalia, Khushboo Rathore

Introduction: Lifelong preservation of tooth in a healthy state is the ultimate goal of dentistry. Premature loss of primary teeth is common due to caries, dental trauma or other causes. As the primary teeth are the best space maintainers, teeth with infected pulps should be retained until exfoliation, whenever possible. Aim: The purpose of this in vivo study was to evaluate and compare the efficacy of different obturating methods used in primary teeth. Materials and Methods: Forty one patients aged four to nine years with a total of 60 teeth were selected. Out of the 60 teeth, 32 were primary mandibular first molars and 28 were primary mandibular second molars, the sample was randomly divided into three groups. Disposable syringe, lentulo spiral and past inject were used for obturation. Postoperative evaluation was done for; quality of canal obturation, presence of voids using postoperative radiographs following obturation of teeth. The data were analysed to assess the success rate of the three methods used for obturation using Chi-square test. Results: Among the three groups of the study, past inject exhibited the maximum number of optimally filled canals. Maximum number of underfilled canals was found with lentulospiral, and the maximum number of overfilled canals was seen with disposable syringe. Least number of voids was observed in canals filled with the past inject technique and disposable syringe. Conclusion: The results suggest that the most successful technique for obturation of primary teeth was past inject.

Role of Anthropometric Measurements in Development of CVD and Stroke among T2DM in East Godavari District, Andhra Pradesh, India

Mortha Kiran Deedi, Alavala Matta Reddy, Nelakuditi Lakshmana Kumar

Introduction: Cardiovascular morbidity and mortality have been associated with different variables of anthropometric measurements. Aim: To find out the association of anthropometric measurements in the development of Cardiovascular Disease (CVD) and stroke among Type 2 diabetes Mellitus (T2DM). Materials and Methods: Three hundred subjects were included in the study out of which 100 subjects were known type 2 diabetics with CVD or Stroke (group 1), 100 subjects were type 2 diabetic patients (group 2) and 100 subjects were normal and healthy (group 3). Blood Pressure (BP), Body Mass Index (BMI) Neck Circumference (NC), Waist Circumference (WC), Hip Circumference (HC), Glycated haemoglobin (HbA1c), high sensitive- C-reactive protein (hsCRP), Malondialdehyde (MDA), Homocysteine (Hcy), microalbuminuria and estimated glomerular filtration rate (eGFR ) were compared between all three groups by using one-way ANOVA test, comparison between males and females by t-test and association was done by using chi-square test. Results: There were a significant difference in the means of anthropometric and biochemical parameters of the three groups (p<0.05). Diastolic BP, NC, WC, HC and homocysteine, are higher in T2DM obese patients than T2DM over weight and normal weight patients are statistically significant (p<0.05). The mean of levels systolic BP, Diastolic BP, hsCRP are higher in T2DM over weight patients than T2DM obese and normal weight patients are statistically significant (p<0.05). Association of physical activity, snoring and interrupted sleep with BMI was statistical significant (p<0.05). Conclusion: Obesity and overweight in T2DM patients play important role in elevation of blood pressure and inflammation markers like hsCRP, homocysteine. Snoring and interrupted sleep also involved development of CVD and Stroke among T2 diabetes.

Comparative Evaluation of Bioactive Glass Putty and Platelet Rich Fibrin in the Treatment of Human Periodontal Intrabony Defects: A Randomized Control Trial

Introduction: Platelet-Rich Fibrin (PRF) and bioactive glass putty have been shown to be effective in promoting reduction in probing depth, gain in clinical attachment, and defect fill in intrabony periodontal defects. The individual role played by bioactive glass putty in combination with PRF is yet to be elucidated. Aim: To compare the clinical effectiveness of the combination of PRF and bioactive glass putty and bioactive glass putty alone as regenerative techniques for intrabony defects in humans. Materials and Methods: Ten pairs of intrabony defects were surgically treated with PRF and bioactive glass putty (Test group) on one side or bioactive glass putty alone (Control group) on other side. The primary outcomes of the study included changes in probing depth; attachment level and bone fill of osseous defect. The clinical parameters were recorded at baseline, 3, 6, and 9 months. Radiographic assessment was done using standardized intraoral periapical radiographs. Differences between baseline and postoperative measurements between the control and test groups were calculated using independent t-test. Comparisons were made within each group between baseline, 3 months, 6 months and 9 months using the ANOVA test followed by Bonferroni test. Results: The mean probing depth reduction was greater in the test group (bioactive glass putty and PRF) i.e., (3.2±2.3 mm) than in the control group (bioactive glass putty alone) i.e., (3.15±1.06 mm). The mean CAL gain was also greater in the test group (4.1±1.73 mm) as compared to the control group (3.15±1.06 mm), (p-value<0.95). Furthermore significantly greater mean bone fill was found in the test group (7.1±1.37 mm) as compared to the control group (5.7 ± 1.64 mm), (p-value<0.043). Conclusion: The results of this study showed both the groups bioactive glass putty alone (Control Group) and the combination of PRF and bioactive glass putty (Test Group) are effective in the treatment of intrabony defects. The bioactive glass putty appears to be a suitable vehicle to administer biologic substances like PRF and growth factors to induce the new bone regeneration.

Alexidine: A Safer and an Effective Root Canal Irrigant than Chlorhexidine

L.R Surender, A. Shikha, A Swathi, C Manaswini, Aisha Habeeb, S Shashi Prabha

Introduction: Chlorhexidine (CHX) is generally used as the final irrigating solution in root canal therapy. Recent studies have reported that, toxic precipitates containing parachloroaniline (PCA) are formed when CHX reacts with sodium hypochlorite (NaOCl). Whereas, Alexidine (ALX), a bisbiguanide disinfectant similar to CHX, has proven to form no precipitates with NaOCl. Aim: To compare antimicrobial activity of different concentrations of ALX with CHX individually and when combined with NaOCl against E. faecalis strains. Materials and Methods: Different concentrations of ALX and CHX (0.5%, 1%, and 2%) were tested individually and when mixed with 2.5% NaOCl (1:1 ratio) using disc diffusion method against E. faecalis. After 24 hours incubation at 37°C, zones of inhibition were measured for each solution. The results obtained were statistically analysed using one way ANOVA and Scheffe's post-hoc tests. The p-value <0.001 was considered as highly significant. Results: Regardless of the concentrations, ALX obtained the best results in comparison to CHX. There was no statistically significant difference between ALX + NaOCl and CHX + NaOCl mixtures. Conclusion: The present study showed that, the antimicrobial property of ALX against E. faecalis was found to be superior to CHX at same concentrations.

Oral Candidal Carriage in Subjects with Pure Vegetarian and Mixed Dietary Habits

Introduction: Candida albicans being a part of the normal oral microbial flora is one of the most commonly isolated species from the oral cavity. Recent studies have shown a steady rise in the number of non C. albicans species, which are relatively resistant to common antifungal agents and are being recognized as potential pathogens. It is vital to ascertain the predisposing factors leading to such a shift in the oral candidal flora. Aim: To estimate the prevalence of candidal species among vegetarians and non-vegetarians. Materials and Methods: Clinical data including age, gender, and diet preference of 238 participants were noted. Participants with a history of systemic disorders, oral prosthesis, salivary gland disorders and habits such as smoking, alcoholism, and tobacco usage were excluded from the study. The participants were asked to gargle a 10 ml solution of phosphate buffered saline for one minute before depositing the same in a sterile container. The samples were cultured using Hicrome agar media. Data analysis was carried out using Statistical Package for Social Sciences (SPSS software) version 10.5 and differences between individual groups were tested by Chi-square test. Results: Among 238 samples, 127 (53.3%) samples were positive for Candida. The candidal prevalence in vegetarians (68.5%) was higher than non-vegetarians (40.7%). C. albicans was the most common species to be isolated in both vegetarians (35.1%) and non-vegetarians (39.2%). Candida glabrata and Candida tropicalis showed a higher prevalence in vegetarians (30.5% and 10.1%, respectively) in comparison to non-vegetarians (8.4% and 2.3%, respectively). Candida krusei was isolated only from vegetarians (4.6%). Conclusion: Results indicate that diet plays a major role in oral candidal prevalence and species specificity which in turn may predispose the vegetarians toward these pathogenic organisms.

Effect of Cycling on Glycaemia, Blood Pressure, and Weight in Young Individuals with Type 2 Diabetes

Ashok Jhingan, Ram Mohan Jhingan

Introduction: Aerobic exercise is associated with significant improvement in glycaemia and weight loss in Type 2 diabetes (T2D). Cycling, a form of aerobic exercise can benefit young (18 to <40 years) individuals with T2D. Aim: To assess effect of cycling on glycosylated haemoglobin (HbA1c), blood pressure (BP) and weight over six months in young individuals with T2D. Materials and Methods: In this retrospective, observational study, young (18 to <40 years) T2D patients who were being treated without insulin and not on more than two Oral Antidiabetic Drugs (OADs) were identified from a group of cyclists in a metro city from Northern India. These individuals were involved in a regular exercise program (cycling 25 km/day for at least five days a week). Participants with consecutive six months of cycling were selected and those involved in other forms of exercise were excluded. From their medical records, participants’ weight, BP, and HbA1c levels were noted at baseline (i.e., before the start) and post-six months of cycling program and evaluated with appropriate statistics. Results: From 26 cases identified with T2D, 20 participants were included in analysis. Mean age of participants was 35.6±2.6 years, five were <35 years and all of them were males. Cycling resulted in significant reduction in HbA1c% (mean change from baseline at six-month: -1.18, 95% Confidence Interval (CI) 1.12, 1.24; p<0.001). Besides, systolic (-5.2, 95% CI -3.7, -6.6; p<0.001) and diastolic (-3.1, 95% CI -1.7, -4.5; p<0.001) BP and weight (kg) (-5.0, 95% CI -4.41, -5.58; p<0.001) showed significant reduction from baseline to six-months. Among two age groups (Age < 35 and = 35 years), except for reduction of diastolic BP in age < 35 years, significant reduction in all other parameters was evident in both age groups. Conclusion: Regular aerobic exercise in cycling form results in significant reduction in HbA1c, BP and weight. It should be promoted as an ideal method for exercise in young T2D cases to derive maximum benefits and to improve adherence to lifestyle intervention.

Risk of Psychiatric Morbidity in Patients with Tobacco Habits: A Cross-Sectional Study

Amita Aditya, Apoorva Kaluskar, Shretika Pandya, Vineet Vinay, Akshay Sharma

Introduction: Tobacco cessation is a challenging arena for healthcare professionals. Many patients seem to be unable to quit tobacco despite of knowing its ill-effects and several efforts. It has been speculated that patients’ psychosocial status may be associated with his/her dependence on tobacco and there could be some amount of psychiatric morbidity associated with chronic and compulsive use of tobacco. However, very few studies have been conducted to explore this aspect of tobacco dependence. Aim: To assess psychiatric morbidity in tobacco users as compared to non-users of tobacco. Materials and Methods: This cross-sectional study included 200 patients reporting to a Dental College who consented to participate in the study. The study consisted of two groups; first consisting 100 tobacco users and another age and gender matched group of 100 non-users of tobacco. Dependence to tobacco products amongst the study group was assessed using International classification of Diseases-10 (ICD-10) criteria. General Health Questionnaire – 28 (GHQ-28) was used to assess the psychological morbidity amongst both the groups. Statistical analysis was done using SPSS 21.0 version. Chi square test and Pearson’s correlation coefficient were used to assess the difference in proportion and correlation between variables respectively. Results: A 79% of tobacco users showed dependence on tobacco according to ICD-10 criteria. GHQ-28 scores analysis revealed that 61% of tobacco users with a score of 24 or above in contrast to only 17% of non-tobacco users. Tobacco users were observed to be 7.63 folds at a higher risk of developing psychiatric morbidity than non-users of tobacco (p-value< 0.001). Conclusion: There appears to be a significant risk of psychiatric morbidity prevalent amongst tobacco users. Hence, psychosocial counselling must be considered as a part of tobacco cessation strategy.

Relationship between Parental Bonding and Tobacco Specific Practices as Predictors of Tobacco Usage in Adults

Introduction: Parents influence their child’s conduct and adolescence hostility either directly or indirectly. Similarly children can acquire a particular behaviour by observing and intentionally imitating their parents in order to simply copy them without understanding the positive or negative outcome. Aim: To assess and compare the association between parental tobacco usage and parental bonding with participants tobacco usage habits. Materials and Methods: A descriptive cross-sectional study was conducted among 130 adults. Information pertaining to demographics, parental bonding (using parental bonding index) and behavioural habits (e.g., smoking, alcohol) of both participants and their parents was collected with the use of a questionnaire-based interview. Tobacco usage was measured as categorical variable as ever chewer and never chewer. Chi-square test, independent sample t-test, multinomial logistic regression and rotated factor loadings was used to analyse the data. Results: Majority of the participants were males with a mean age of 30.4±8.5 years. Tobacco use was prevalent among less educated males. Parental smokeless tobacco use, paternal alcohol and maternal paan chewing was significantly associated with participants adverse habits. Multinomial logistic regression showed a significant association between parental and participant’s tobacco usage. Perceived parental bonding were also significantly associated with participant‘s tobacco usage habit. Conclusion: Parental bonding measures and tobacco usage was significantly associated with the participant’s tobacco use. Hence, interventional and educational efforts to weaken intergenerational influences should target parents. In addition to parents, the smoking behaviour of adults should also be targeted for prevention efforts.

Diabetes and Diabetic Retinopathy: Knowledge, Attitude, Practice (Kap ) among Diabetic Patients in A Tertiary Eye Care Centre

Introduction: Diabetic retinopathy is becoming an increasingly important cause of visual impairment in India. Many diabetic patients who come to our centre have undetected, advanced diabetic retinopathy. If diabetic retinopathy had been detected earlier in these patients, irreversible visual impairment could have been prevented. Aim: To document Knowledge, Attitude and Practice (KAP) patterns of diabetic patients regarding diabetes and diabetic retinopathy, to determine association between them, and to identify barriers to compliance with follow up and treatment regimes. Materials and Methods: This was a hospital-based, cross-sectional study, conducted at the Department of Ophthalmology at Christian Medical College, Vellore, Tamil Nadu, India, over a six-month period from June 2013 to November 2013. Two hundred and eighty eight diabetic patients, who fulfilled the eligibility criteria, were included in the study. KAP of patients was assessed using a 45-point, verbally administered questionnaire. Patients were placed in different categories, such as, ‘good/poor’ knowledge, ‘positive/negative’ attitude and ‘good/poor’ practice. Data were analysed using Chi-square test and binary logistic regression, as appropriate. The proportion of patients with ‘good/poor’ knowledge, ‘positive/negative’ attitude and ‘good/poor’ practice, and the association between KAP were studied. Barriers to compliance with follow up/treatment regimes were identified. Results: Out of the 288 patients in the study, 42% had good knowledge about diabetes, but only 4.5% had good knowledge about retinopathy. Good knowledge about diabetes was significantly associated with positive attitude towards diabetes and good practice patterns regarding retinopathy; awareness of retinopathy was also significantly associated with good practice. A total of 61.1% of patients did not have periodic eye examination; most common barrier identified was lack of awareness about the necessity for this (38.5%). Conclusion: Good knowledge about the disease was significantly associated with positive attitude and good practice patterns. Knowledge about diabetic retinopathy was poor among the patients in our study. Lack of awareness concerning the need for screening for retinopathy was a major barrier to regular screening. There is an urgent need to educate diabetic patients about this potentially blinding complication of diabetes.

Atorvastatin Induced Adverse Drug Reactions among South Indian Tamils

Introduction: Atorvastatin is the most widely used statin world-over. Although atorvastatin is beneficial in reducing cardiovascular morbidity and mortality, they are associated with Adverse Drug Reactions (ADRs) which are under-recognized as well as under-reported. There is no data on safety of atorvastatin in ethnic populations like South Indian Tamils and hence the need for this study. Aim: To report the Adverse Events (AEs) associated with atorvastatin use, their causality and severity in dyslipidemic south Indian Tamils. Materials and Methods: This cross-sectional study was carried out on 304 dyslipidemic Tamils. Those on any lipid lowering therapy within one month before study enrolment, those with contraindications to statin therapy, hypothyroid patients, those with LDL cholesterol >250 mg/dL or serum triglycerides >400 mg/dL and patients who were on drugs which modulate Cytochrome P 450 3A4/5 (CYP3A4/5) activity were excluded from the study. Causality assessment for atorvastatin induced AEs were done using Naranjo adverse drug reaction probability scale criteria and severity assessment was done using Hartwig scale. AEs which were causally related to atorvastatin use were reported as ADRs. Results: One hundred and eighty three AEs were noted among 145 (47.7%) patients, during the course of first 45 days of atorvastatin therapy. AEs were probably due to atorvastatin in 11% of the patients and possibly due to atorvastatin in 89%. Most common ADRs were myalgia (41%), followed by nervous system ADRs (35.5%) and gastrointestinal ADRs (14%). Conclusion: Myalgia was the most common cause for atorvastatin discontinuation which might place these individuals at an increased risk of cardiovascular morbidity and mortality. Measures to identify and address atorvastatin induced myalgia should be given priority.

Evaluation of Anti-Cyclic Citrullinated Peptide Autoantibodies and C-Reactive Protein in Common Autoimmune Skin Diseases with and without Arthritis

Bandana Kumari, Pawan Kumar, Radha Krishna Prasad Chaudhary

Introduction: Anti-Cyclic Citrullinated Peptides (CCPs) are a well known diagnostic and prognostic noble marker for rheumatoid arthritis. C-Reactive Protein (CRP) is an acute phase protein whose level rises in response to inflammation. Aim: This study was undertaken to show the role of the two markers (anti-CCPs and CRP) in autoimmune skin disorder and their association with associated arthritis in these disorder. Materials and Methods: Serum anti-CCP antibodies and CRP was measured in 50 patients of autoimmune skin disease of which 28 were of psoriasis, 12 of Systemic Lupus Erythematosus (SLE) and 10 of Pemphigus Vulgaris (PV). These patients were categorised in two groups, with associated arthritis and without arthritis. The serum level of anti-CCP and CRP was correlated with the presence or absence of arthritis in these patients. Control group consists of 20 healthy subjects in which these two parameters were measured. Results: Out of total of 50 patients, anti-CCP was raised in 36.37% of patients with associated arthritis and 12.82% of patients without arthritis whereas CRP was raised in 63.63% of patients with arthritis and 35.89% of patients without arthritis. Mean serum anti-CCP in patient with arthritis was 15.78±13.94 U/ml and without arthritis was 7.56±7.68 U/ml with p=0.01 which was statistically significant. Mean serum CRP in arthritis was 21.11±15.51 mg/l and CRP without arthritis was 13.14±12.27 mg/l with p=0.07 which was statistically not significant. Conclusion: Although both anti-CCP and CRP are valuable markers for autoimmune skin disorder, anti-CCP seems to show significant association with arthritis.

Entropy as an Indicator to Measure Depth of Anaesthesia for Laryngeal Mask Airway (LMA) Insertion during Sevoflurane and Propofol Anaesthesia

Saranjit Singh, Sapna Bansal, Garima Kumar, Isha Gupta, J.R. Thakur

Introduction: Assessment of the depth of anaesthesia is fundamental to the anaesthetic practice. Entropy measurement is an objective monitoring and is of two types- Response Entropy (RE) and State Entropy (SE) indicating analgesic and hypnotic levels during general anaesthesia. Aim: The aim of our study was to assess the depth of anaesthesia for LMA placement using entropy as a tool. The assessment of entropy as an indicator of depth of anaesthesia in the form of haemodynamic variations and success rate of LMA placement. Materials and Methods: A prospective study was carried out after ethical committee approval in 100 patients, aged 20-50 years, with ASA grade I and II of either gender undergoing elective surgery lasting less than two hours under general anaesthesia. Anaesthesia was induced with sevoflurane 2.5% and IV propofol at 6 ml/min until entropy value fell from baseline values to 30-40 and then LMA insertion was performed. SE and RE values were noted every 30 seconds for five minutes. Mean blood pressure and heart rate were recorded every minute after induction for 5 minutes. Results: There was a significant change in RE and SE values within 30 seconds from start of induction. Desired values of RE (40.10±2.52) and SE (39.2±2.47) were achieved at 120 seconds to 150 seconds. Mean dose of propofol used during surgery was 86.5±3.5 mg and mean insertion time was 110±12 seconds Patients in study group had a stable haemodynamics throughout the procedure, (p-value -0.8). Conclusion: Entropy is a reliable indicator to assess depth of anaesthesia for LMA placement during sevoflurane and propofol anaesthesia.

Effect of Metaboreflex on Cardiovascular System in Subjects of Metabolic Syndrome

Pramita Dubey, Sunita Tiwari, Manish Bajpai, Kalpana Singh, Praveen Jha

Introduction: Metaboreflex is a reflex in which muscle receptors send signals regarding metabolic (metabolites accumulation like lactic acid, potassium, adenosine) conditions of the muscles to nucleus tractus solitarius via afferent III and IV fibres to cause haemodynamic adjustments in order to regulate blood flow on the basis of the status of contracting muscle. Dysregulation in its mechanism in metabolic syndrome is demonstrated. Aim: to study the effect of metaboreflex by both isometric and rhythmic handgrip exercise on CVS parameters {Blood Pressure (BP), Cardiac Output (CO) and Systemic Vascular Resistance (SVR)} in subjects of metabolic syndrome. Materials and Methods: In this study, 27 subjects aged 25 to 45 years were enrolled after ethical clearance and proper consent. They were divided into: a) subjects without metabolic syndrome; and b) subjects with metabolic syndrome. Impedance cardiovasography was done to assess cardiac parameters (systolic and diastolic blood pressure, cardiac output, systemic vascular resistance). Pre-exercise parameters were assessed followed by isometric exercise and post-isometric exercise parameter measurement. Again after rest, rhythmic exercise was followed. Finally post exercise parameters were assessed. Student paired t-test for comparison between pre and post exercise parameters were done. Results: Changes in diastolic BP following exercise were statistically significant in subjects without metabolic syndrome (p-value 0.01 and 0.001 following isometric and rhythmic exercise respectively). In subjects with metabolic syndrome also these changes were significant, but to a lesser extent (p-value 0.1 and 0.01 respectively for isometric and rhythmic exercise). Changes in systolic BP following exercise were statistically significant in subjects without metabolic syndrome (p-value 0.001 and 0.001 following isometric and rhythmic exercise respectively). In subjects with metabolic syndrome also these changes were significant (p-value 0.01 and 0.001 respectively for isometric and rhythmic exercise). Conclusion: Diminished pressor response is found after exercise in subjects with metabolic syndrome.

Pattern of Self Prescribed Analgesic Use in a Rural Area of Delhi: Exploring the Potential Role of Internet

Anjali Kochhar, Tanya Guptata

Introduction: Analgesics are the most common self prescribed drugs. Although considered to be relatively safe, side effects are often seen when these drugs are used for prolonged period, in high doses or used where contraindicated. Majority of the consumers are not aware of the side effects. These days ample amount of information is available on web, it is important to explore its role in educating the population regarding the safe use of self prescribed analgesics. Aim: To explore pattern of analgesic use, to identify population at risk of developing side effects related to analgesic use, awareness of side effects and potential role of internet to bring awareness about safe use of self prescribed analgesic drugs in a rural area of Delhi. Materials and Methods: A cross-sectional survey based study was done on 500 adults in the age group of 18-65 years of Madanpur Khadar area of South Delhi, India. Data collection was done by conducting visits to pharmacy shops from the people who were buying drugs without prescription and taking face to face interviews using a semi-structured questionnaire. Statistical analysis was performed using descriptive tests with Microsoft office excel 2007. Results: Results of our study showed that among all the self prescribed analgesics paracetamol (57%) was used most frequently followed by aspirin and other NSAIDs. It was found that 9.6% of the consumers were having associated co-morbid illness, 11.4% were simultaneously taking other drugs and 15.2% were alcoholics. Majority (65.4%) of the buyers were not aware about any kind of side effects of the analgesics. Internet friendly consumers were found to be 44%. Ability to use internet and education level were found to be directly related (r=0.802). Conclusion: The pattern of analgesic consumption in the rural population of Delhi shows that a large number of consumers may be at risk of developing side effects of self prescribed analgesics. The awareness about the side effects is limited. A significant number of consumers are internet friendly. Hence, we recommend use of website/mobile apps as potential source of information in educating the population regarding the use of self prescribed analgesics.

Serum Free T3 to Free T4 Ratio as a Useful Indicator for Differentiating Destruction Induced Thyrotoxicosis from Graves' Disease

Suman Baral, Pradeep Krishna Shrestha, Vivek Pant

Introduction: Thyrotoxicosis is a common disease encountered in Endocrine Outpatient Department (OPD). Two common causes of thyrotoxicosis are Destruction Induced Thyrotoxicosis (DIT) and Graves’ Disease (GD). Differentiating DIT and GD based on clinical findings, is often not possible due to nonspecific symptoms. Thyroid scan is considered most reliable method for differentiating DIT and GD. Aim: To differentiate DIT and GD using the ratio of free triiodothyronine (fT3) and free thyroxine (fT4) thus avoiding thyroid technetium scan which is expensive and not accessible in developing countries like Nepal. Materials and Methods: Patients attending Endocrine OPD with diagnosis of thyrotoxicosis at their first visit in which Thyroid technetium scan could be done were taken as sample. The study was conducted from mid-June 2016 to February 2017 and total 55 samples were taken. Only selected cases were taken where diagnostic dilemma was present. Report of Thyroid Function Test (TFT) of patient at their first visit and findings of thyroid scan were recorded. Ratio of freeT3 and freeT4 was obtained in each case. ROC curve was plotted and the cut off value for differentiation of DIT and GD was obtained. All data were analysed using SPSS software version 20.0. Results: Mean ratio of fT3 to fT4 in GD and DIT was 0.395 and 0.287 respectively which was significant. On ROC analysis, cut off ratio for differentiating GD and DIT was 0.30 with sensitivity of 87% and specificity of 62.5%. Conclusion: It is recommended that thyroid scan can be avoided if ratio of fT3 and fT4 is less than 0.3 and a diagnosis of DIT can be made.

A Comparison of the Clinico-Radiological Outcomes with Proximal Femoral Nail (PFN) and Proximal Femoral Nail Antirotation (PFNA) in Fixation of Unstable Intertrochanteric Fractures

Anirudh Sharma, Anupam Mahajan, Bobby John

Introduction: Management of unstable intertrochanteric fractures poses challenges in terms of obtaining stable fixation and good postoperative outcomes. There is a paucity of clinical data comparing the commonly used Proximal Femoral Nail (PFN) and Proximal Femoral Nail Antirotation (PFNA) implants, especially in relation to osteoporosis. Aim: To assess comparative performance of PFN and PFNA in the setting of osteoporosis. Materials and Methods: Patients presenting with unstable intertrochanteric fractures (AO 31.A2 and 31.A3) were included and treated with either PFN or PFNA. Preoperative radiographs of normal side were used to grade osteoporosis by Singh’s index. Grade 3 or less was considered significant. Postoperative radiographs were assessed for tip-apex distance, Cleveland index and quality of reduction. Patients were followed up for a minimum of nine months and any complications noted. Comparison of functional outcomes was done using the Harris Hip Score and Parker-Palmer mobility score at final follow up. Statistical analysis was done using the unpaired t-test/Mann-Whitney U test and Chi-square test/Fisher’s-exact test. A p-value of < 0.05 was considered significant. Results: The study included 48 patients with unstable intertrochanteric fractures, of which 23 were treated with PFN and 25 with PFNA. Average age of PFN group was 60.78 years and of PFNA group was 74.12 years. In PFN group 8 patients (38.09%) and in PFNA group 13 patients (54.1%) had Singh’s osteoporotic index of = 3. The average Harris Hip Score was 75.37 and 78.85 in PFN and PFNA groups (p=0.54) respectively. From PFN and PFNA groups, 35% and 32% patients respectively were able to return to pre-injury mobility status as assessed by the Parker-Palmer mobility score (p=0.83). Out of eight implant related complications; seven were in patients treated with PFN (p=0.02). Among patients with Singh’s grade = 3, 3 (37.5%) in PFN group suffered from implant failure whereas all 13 patients in PFNA group had successful outcome (p=0.04). Conclusion: Although functional outcomes achieved with both implants are similar (p=0.83), number of implant related complications were fewer with PFNA (p=0.02), even in osteoporotic group (p=0.04). We recommend use of the PFNA in unstable fractures, especially in the elderly osteoporotic population.

Pelvic Mass Lesions in Females: Tissue Characterization Capability of MRI

Introduction: Magnetic Resonance Imaging (MRI) of adult female pelvis is a well-established tool in the evaluation of utero-ovarian lesions and is often used to supplement ultrasonography. The need for diagnostic surgical intervention has largely been eclipsed with the advent of MRI, which has become the imaging modality of choice for characterization of pelvic masses. Aim: To assess the role of MRI in female pelvic mass lesions and to exploit the tissue characterization capability of MRI. Materials and Methods: A prospective observational study was done on all patients referred to Department of Radiodiagnosis, Krishna Hospital, Karad, for MRI pelvis with clinically suspected uterine and adnexal masses or with indeterminate diagnosis on ultrasonography. Study was conducted between September 2014 to August 2016 with a sample size of 100 patients. All patients were scanned using 1.5 Tesla Seimens Avanto (Tim+Dot) scanner with Body matrix coil Tim. Histopathology was taken as gold standard. Results on continuous measurements were presented on Mean±SD (Min-Max) and results on categorical measurements were presented in Number (%). Results: Among 100 cases, on MRI, the maximum number of patients was having uterine lesions (48) followed by ovarian lesions (40), inconclusive adnexal/ovarian lesions (6), adnexal lesions (4). Two patients had normal findings. This correlated well with histopathology results, which showed the maximum number of patients were having uterine lesions (48) followed by ovarian lesions (41), adnexal lesions (5). Normal findings were observed in two patients. Conclusion: Due to excellent depiction of pelvic anatomy, non-invasiveness and absence of ionizing radiation, MRI is an excellent tool for assessment of utero-ovarian disorders, for detecting and characterization of various diseases, and staging patients with carcinomas where accurate diagnosis will make an impact on their surgical and medical management planning.

Outcomes of Mechanically Ventilated Critically Ill Geriatric Patients in Intensive Care Unit

Introduction: Increase in life expectancy across the globe has led to rise in geriatric population. Geriatric population is now living longer and healthier. This rise in geriatric population has also led to increase in the geriatric ailments leading to increased number of geriatric patients requiring intensive care including mechanical ventilation. Data on outcomes of geriatric patients requiring mechanical ventilation from India is scarce. Aim: To study the profile and outcome of geriatric patients more than equal to 60 years requiring mechanical ventilation in Intensive Care Unit (ICU). Materials and Methods: The data of all the geriatric patients, more than 60 years of age, admitted to ICU between January 2008 to August 2014 requiring mechanical ventilation for various reasons were extracted from the hospital records. Various reasons for ventilation, duration of ventilation/hospital stay, mortality and associated comorbidities were recorded and analysed. Results: Total 140 geriatric patients were mechanically ventilated in the study period, out of which 43.5% (61/140) were above 70 years of age and 67.8% (95/140) were above 65 years of age. Chronic Pulmonary Obstructive Disease (COPD) was the most common cause for mechanical ventilation constituting 20% of patients followed by severe sepsis (17.8%), cerebro-vascular accident (12.8%), post-surgical patients (12.8%) and Coronary Artery Disease (CAD) in 10%. In our study, 44.28% of the geriatric patients requiring mechanical ventilation in the ICU were successfully weaned off the ventilator. Early tracheostomy helped in weaning off from ventilator as 83.33% (5/6) of patients requiring tracheostomy could be weaned off the ventilator suggesting that tracheostomy may help in improving the outcome. Reintubation carried a very poor prognosis and increased mortality, as 80% (4/5) of the patients who were reintubated in our study could not survive. Conclusion: Our study revealed that in appropriate intensive care setting and with standard protocol based therapy for primary ailments, outcomes with mechanical ventilation in geriatric population can be comparable to outcomes in younger population.

Estimation of Salivary Parameters among Autoimmune Thyroiditis Patients

Introduction: Saliva is a complex secretion that protects and lubricates the oral cavity. Various systemic diseases and their treatment alter the salivary gland function; one such disease is Autoimmune Thyroid Disease (AITD). AITD has been postulated to exert its hormonal influence on the salivary glands, leading to reduced salivary output. There’s a paucity of literature, verifying the stated conjunction in human subjects. Aim: The aim was to investigate the salivary profile in AITD patients and its comparison with controls. Materials and Methods: Descriptive cross-sectional comparative study was conducted using convenience sampling method for screening the presence of thyroid disorders. Two groups comprising of 30 patients in each group diagnosed with autoimmune hypothyroiditis (n=30) and hyperthyroiditis (n=30) respectively and thirty healthy volunteers who were age and sex matched were included as controls. Saliva was collected and evaluated for Unstimulated Salivary Flow Rate (USSFR), pH and buffer capacity. ANOVA and Tukey post-hoc test was performed to find the statistical significance and for pairwise comparison. Results: Statistically significant difference was observed between autoimmune hypothyroiditis, autoimmune hyperthyroiditis and control group with respect to USSFR (p<0.007), pH (p<0.001) and buffer capacity (p<0.001). On pairwise comparisons statistically significant difference was observed between autoimmune hypothyroiditis and autoimmune hyperthyroiditis with respect to controls. Conclusion: We conclude that significant involvement of salivary glands may occur in cases of AITD. Our study showed significant reduction of sialometric values in AITD patients when compared to controls. A strong clinical suspicion of thyroid diseases should be considered when there is chronic hyposalivation; hence thyroid profile must also be done, if the known causes have been excluded.

Antibacterial Activity of Freshly Prepared Ozonated Water and Chlorhexidine on Mutans Streptococcus When Used as an Oral Rinse – A Randomised Clinical Study

Lavanya Anumula, Kv Suneel Kumar, CHNV Murali Krishna, Ksree Lakshmi

Introduction: Dental caries is one of the most common causes of morbidity of the tooth. Attempts have been made to reduce the pathogen population size i.e., Mutans Streptococci (MS) to demote the incidence of caries and increase the resistance of the tooth to cariogenic attack. Aim: To evaluate the antibacterial efficacy of freshly prepared ozonated water, in proposing it as an alternative mouth rinse on MS in comparison to Chlorhexidine (CHX). Materials and Methods: Subjects with high caries incidence and MS counts more than 105 Colony Forming Unit (CFU) were selected and divided by block randomization into two groups of 23 subjects each. The subjects were advised to use the respective mouth rinses under the operator surveillance, consecutively for 14 days. Stimulated salivary samples were collected from the subjects on the first day, 7th and 14th day to analyse the changes in MS counts during the course of use of oral rinses. The obtained data was tabulated and statistically analysed. Results: Freshly prepared ozonated water showed a statistically significant reduction in MS counts after an interval of 7 days and 14 days when compared to CHX. Conclusion: Ozonated water when consecutively used as a mouth rinse resulted in a significant reduction of MS counts. Hence, it can be used as an alternative to chlorhexidine.

The Effect of Diabetes Mellitus Type I on Periodontal and Dental Status

Rokhsareh Sadeghi, Ferial Taleghani, Samira Mohammadi, Zahra Zohri

Introduction: Diabetes mellitus type I is a chronic metabolic disease with an autoimmune origin. The initial manifestations mainly appear during childhood and its prevalence is on the rise in many countries. Some of the complications of diabetes mellitus are problems related to oro-dental structures and periodontal diseases. Aim: The present study was undertaken to evaluate the relationship between diabetes mellitus type I and dental and periodontal status in Tehran, Iran. Materials and Methods: This cross-sectional study was carried out on 50 patients with diabetes mellitus type I who were under treatment in the Diabetic Patients’ Center in Tehran and 50 healthy individuals who did not have diabetes, all recruited from schools. The subjects were divided into two age groups of 6-12 and 13-18 years. In test group, HbA1c (glycosylated haemoglobin) level of the patients was collected from the medical records of Association of Diabetic Patients. To make sure that the control subjects did not suffer from diabetes mellitus, their blood glucose was measured with the Glucocard 01 blood glucose monitoring kit (GT-1920, Japan). The periodontal and dental status were assessed using dmft/DMFT (Decayed, Missing, Filled Permanent Teeth), GI (Gingival Index), PPD (Periodontal Pocket Depth), PI (Plaque Index) and CI (Calculus Index). The data obtained from each group were compared statistically using the Mann-Whitney test and Kruskal Wallis Test. Results: There was increase in PPD, GI and DMFT values with aging, with no significant differences between the diabetic and non-diabetic groups. PI and DMFT not only increased with aging but also were higher in both age groups in patients with diabetes compared to healthy subjects (p<0.05). GI was higher only in the 13-18 year age group in diabetic patients (p<0.01). There was no relation between the HbA1c (glycosylated haemoglobin) level, and periodontal indices (p<0.09). Conclusion: It appears that patients with diabetes mellitus type I are more susceptible to periodontal diseases and tooth loss and such problems might be aggravated with aging.

Diagnostic Accuracy and Surgical Utility of MRI in Complicated Diabetic Foot

Mayank Mahendra, Rahul Singh

Introduction: Diabetic foot complications pose a significant public health hazard and had negative effect on life quality. These complications are associated with increased risk of amputations and premature death. So focus is increasing on early treatment of complicated diabetic foot. Aim: To assess the diagnostic accuracy and surgical utility of MRI in complicated diabetic foot. Materials and Methods: Thirty four complicated diabetic patients were evaluated prospectively. Initially x-ray was done and a provisional management plan was formulated. Later T1W, T2W and FSat sequences of the affected foot and ankle was carried out. The soft tissue, tendons and osseous apparatus were evaluated and subsequently compared with histopathological examination. Before and after MRI, change in management plan was marked. Previously operated cases with persistent ulcer of affected foot were excluded from the study. Results: Twenty two males and 12 females with mean age of 52±8.8 years were analysed. The sensitivity of MRI for tenosynovitis and osteomyelitis was 88% and 100% respectively. The specificity for the same was 100% and 90%. Of all 34 cases, MRI reshapes surgical planning in 23.5% cases (8 patients). The difference between MRI and histopathological findings was evaluated statistically using Fisher-Z test and the proportion of difference between these two groups was not significant as values for tenosynovitis was Z=0.50 (p-value >0.05) and for osteomyelitis Z= 0.54 (p-value>0.05). Conclusion: The result indicates that MRI is a sensitive and accurate imaging modality for evaluation of diabetic foot and for planning proper treatment and the MRI correlates significantly with the surgical finding.

Correlation of Reciprocal Changes and QRS Amplitude in ECG to Left Ventricular Dysfunction, Wall Motion Score and Clinical Outcome in First Time ST Elevation Myocardial Infarction

Introduction: Electrocardiogram (ECG) is the simplest tool for diagnosing ST Elevation Myocardial Infarction (STEMI). We can use a12 lead ECG for prognostication purposes also. Aim: The aim of the study was to find out the role of ECG as a prognostic marker in terms of clinical outcome and wall motion abnormality. Materials and Methods: It was a prospective study done in PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India, from January 2014 to September 2014. Patients aged above 18 years admitted with first episode of ST EMI as per the inclusion and exclusion criteria were recruited for the study. Presence of reciprocal changes and QRS amplitude was measured from ECG. Presence of Left Ventricular Dysfunction (LVD) and wall motion score were calculated from ECG along with clinical outcome during first follow up visit. Statistical analysis was done using SPSS software. Probability was calculated using chi-square test, independent t-test and ANOVA analysis. Results: A total of 120 patients were recruited for the study of which six were excluded based on the exclusion criteria. Among 114 patients analysed, 55 had reciprocal changes; 38 of them developed LVD which was statistically significant (p=0.002). Of the 78 patients with Anterior Wall Myocardial Infarction (AWMI), 35 had reciprocal changes; 15 (42.9%) of them had NYHA Class 1 symptoms, 14 (40%) had Class II and 4 (11%) had class III symptoms at follow up. The association was statistically significant (p=0.001). Similar statistically significant association was found in patients with Inferior Wall Myocardial Infarction (IWMI) who had reciprocal changes and NYHA symptoms at follow up (p=0.004). The mean wall motion score in patients with AWMI and reciprocal changes was 24.83 ± 4.1; whereas, without reciprocal changes was 23.98 ± 3.6; the association was not statistically significant. The mean QRS amplitude of all patients with LVD was 33.25 ±16.34. The association between QRS amplitude and LVD was not statistically significant. The overall mean wall motion score was 24.86 ± 3.91. The association between QRS amplitude and wall motion score was statistically significant (r value = 0.210). The association between QRS amplitude and wall motion score was statistically significant when we analysed AWMI (r= -0.147, p=0.199) and IWMI (r= -0.359, p=0.031) separately. Conclusion: ECG can be used as a tool for prognostication in acute STEMI. The presence of reciprocal changes in the ECG can signify poorer outcome on follow up. Lower QRS amplitude can be used as a predictor of larger infarct.

Immunohistochemical Expression of Caspase 3 in Psoriasis

Introduction: Psoriasis is a persistent chronic immune-mediated, relapsing, inflammatory and hyper proliferative skin disorder with genetic predisposition. Psoriasis can be considered as a T-cell mediated disease, with a complex role for a variety of cytokine interaction between keratinocytes and T-lymphocytes. Caspase-3 is an enzyme that plays a key role in apoptosis; it is a member of the family of cysteinyle aspartate specific proteases. Aim: To evaluate the expression of caspase-3 in Egyptian psoriasis patients and its role in apoptosis of keratinocytes. Also, to correlate this expression with the clinicopathological parameters in order to identify the possible hypothesized role of caspase-3 in the pathogenesis of psoriasis. Materials and Methods: This was a case-control study conducted on patients suffering from chronic plaque psoriasis. A total of 20 psoriasis patients and 10 controls were selected from outpatient clinic of Dermatology, Menoufia University Hospital, between the period of October 2014 and January 2016. From each patient and control, a punch biopsy was taken. Evaluation of H&E stained sections and caspase-3 expression was done using standard immunohi-stochemical techniques. Non-parametric chi-square test, Mann-Whitney U test, Kruskal Wallis test and Spearman’s coefficient test were the statistical tests used. Results: High caspase-3 H score was significantly in favour of psoriatic group in comparison with the control group. On the contrary, in the dermis, caspase-3 was significantly higher in skin adnexa while completely absent in the psoriatic group. Strong caspase-3 expression was significantly in favour of high PASI score, early onset lesions and lesions in the extremities. Significant positive correlation was found between caspase-3 percent and PASI score (r= +0.53, p-value=0.03). Conclusion: Caspase-3 over expression in the psoriatic lesion proposes a potential role in the pathogenesis of psoriasis. Positive correlation between the caspase-3 expression and the early onset psoriatic lesion located in the extremities implies a possible poor prognostic impact of caspase-3 over expression.

Active Surveillance of Health Care Associated Infections in Neurosurgical Patients

Reshu Agarwal, Sarita Mohapatra, Girija Prasad Rath, Arti Kapil

Introduction: Health Care Associated Infections (HCAI) are frequent complications in neurosurgery. There is limited data available on the incidence and burden of HCAI in neurosurgical patients of Southeast Asian region. Aim: To identify various HCAIs, associated aetiological agents and their antimicrobial susceptibility pattern among the patients admitted in the neurosurgery unit. Materials and Methods:An observational prospective study was carried out for three months duration on all neurosurgical patients admitted to a tertiary-care center. The site-specific nosocomial infection rates and device utilization ratios were calculated. Data on demographic profiles, invasive procedures, HCAI, isolated microorganisms and antimicrobial susceptibilities were recorded. Statistical analysis of all the variables was done. The association between categorical variables was assessed by Chi-square/Fisher-exact test. Continuous variables such as infected and non-infected were compared by Wilcoxon rank-sum test. A p-value of less than 0.05 was considered significant. Results: A total of 330 patients with 4054 patient-days were analysed for HCAI. Twenty-two HCAIs were identified in 21 patients. The overall rate of HCAI was 6.67% and 5.42 per 1000 patient-days. Urinary Tract Infection (UTI) was most common (71.4%) followed by Laboratory Confirmed Blood-Stream Infection (LCBI) (28.5%) and pneumonia (4.7%). No central line-associated blood stream infection was identified. Klebsiella pneumoniae and Escherichia coli were the most common organisms causing UTI and LCBI. All the isolates (100%) were found to be multidrug resistant. Conclusion: This study generates a baseline data for records of device-associated infection in neurocritical care patients, which will further help monitoring its trend of infection and antimicrobial resistance pattern. Moreover, it will help in the formulation of the antibiotic policy and the preventive measures which may reduce morbidity and mortality.

Role of Herbal Agents - Tea Tree Oil and Aloe vera as Cavity Disinfectant Adjuncts in Minimally Invasive Dentistry- An In vivo Comparative Study

Gaurav Patri, Aliva Sahu

Introduction: The prevention and control of caries necessitates the elimination of cariogenic bacteria and cavity disinfectants have proved to play a major role in achieving the goal. The use of phytotherapy is trending and many natural products have shown anti-microbial properties which can be used as cavity disinfectant in the field of dentistry. Aim: The aim of this study was to compare the efficacy of herbal antibacterial agents (Tea Tree Oil (TTO) and Aloe vera) with commercially available 2% chlorhexidine (CHX) as cavity disinfectant for use in minimally invasive dentistry. Materials and Methods: The study included three test groups, Group I (2% chlorhexidine), Group II (tea tree oil), Group III (Aloe vera gel) with a control group (distilled water). Ten patients with atleast one tooth with an occlusal or occluso-proximal lesion suitable for Atraumatic Restorative Treatment (ART) were selected for each group, dentinal samples were collected using sterile spoon excavators at three stages from each tooth viz., pre-excavation, post-excavation and post-disinfection of the cavities. These dentinal samples were subjected to microbiological analysis for Total Viable Count (TVC). The data collected were statistically analysed using ANOVA and Bonferroni post-hoc test. Results: The results of present study showed that there was a statistically significant reduction in TVC when compared between pre and post excavation in all the groups (p<0.05) and post- excavation and post-disinfection in all the test groups (p<0.05) (except control group). Post-disinfection, 2% chlorhexidine showed highest reduction in TVC followed by 1% tea tree oil and aloe vera gel. Conclusion: Natural antibacterial agents like tea tree oil and aloe vera could be effectively used as cavity disinfectants which will help in minimizing secondary caries and rendering a long term restorative success.

Implication of Posture Analysing Software to Evaluate the Postural Changes after Corrective Exercise Strategy on Subjects with Upper Body Dysfunction-A Randomized Controlled Trial

Introduction:The postural adaptation is very common now a days in school going children, office desk oriented job, computer users and frequent mobile users, and in all major industrial workers. Several studies have documented a high incidence of postural abnormalities in a given population; however, methods of postural measurement were poorly defined. The implication of postural pro software to analyse the postural imbalance of upper body dysfunction is very rare and literature studies says that the kinematic changes in particular segment will produce pain/discomfort and thereby lesser productivity of subjects. Aim: To evaluate the postural changes in subjects with upper body dysfunction after a corrective exercise strategy using postural analysis software and pectoralis minor muscle length testing. Materials and Methods: After explaining the procedure and benefits, informed consent was taken from the participating subjects (age 25-55 years). Subjects with upper body dysfunction were randomly allocated into two groups (each group 30 subjects). The Group–A received the corrective exercise strategy and Group-B received the conventional exercise for eight weeks of study duration (15 reps each exercise, total duration of 40 min; four days/week. Pre and Post posture analysis were analysed using posture pro software along with flexibility of pectoralis minor was assessed using ruler scale method. Results: After interpretation of data, both the group showed the postural alteration and pectoralis minor muscle length changes, p-value (p<0.01) of both group showed highly significant changes. But comparing the both groups, the subjects who received the corrective exercise strategy shown more percentage of improvement in posture alteration (56.25%), pectoralis minor muscle length changes (68.69%) than the conventional exercise received subjects in posture alteration (24.86%) and pectoralis minor muscle length changes (21.9%). Conclusion: Altered postural changes and pectoralis minor muscle flexibility before and after the corrective exercise strategy evaluated by postural analysis software method shown to be a significant tool in clinical practice, which is easier and reproducible method.

Immunohistochemical Study of MUC1 and MUC5AC Expression in Gall Bladder Lesions

Introduction: Immunohistochemical (IHC) markers of mucin family are associated with various Gallbladder Lesions (GBLs). Aim: To study the distribution of GBL with respect to age and sex as well as to analyse the IHC profile of MUC1 and MUC5AC in GBLs and attempt correlation with clinical and histopathological findings. Materials and Methods: The present study was conducted over a period of six years. A technique of manual tissue array was employed for cases subjected to IHC using MUC1 and MUC5AC. Results were statistically analysed using software program “The Primer of Biostatistics 5.0”. Results: A total of 629 GBL were encountered. Out of 605 of non-neoplastic lesions, 32 (5.29%) expressed MUC1 while 515 (85.12%) cases expressed MUC5AC. Out of 24 cases of neoplastic GBL, 20 cases (83.33%) showed positivity for MUC1 and 9 cases (37.5%) were positive for MUC5AC. The rate of MUC1 expression was significantly higher in Gall Bladder Cancer (GBC) {18GB carcinoma (ca) +3 Carcinoma In Situ (CIS)} (85.71%) than chronic cholecystitis (4.71%). The positive rate of MUC5AC expression was significantly lower in GBC (28.57%) than chronic cholecystitis (87.19%). The percentage of cases showing MUC1 expression increased as the severity of disease progressed from hyperplasia to CIS. The percentage of cases showing MUC5AC expression decreased as the severity of disease progressed from hyperplasia to CIS. Conclusion: In this study, 96.18% cases were non neoplastic GBL of which chronic cholecystitis (87.77%) was predominant. 3.81% of the GBL constituted for neoplastic lesions of which 75% were GBC. MUC1 showed higher rates of expression in neoplastic GBL. MUC5AC showed higher rates of expression in non neoplastic GBL. Expression of MUC1 and MUC5AC might be closely related to pathogenesis of neoplastic and non neoplastic GBL.

Morphologic Spectrum of Duodenal Biopsies in Malabsorption: A Study from Southern India

Introduction: Duodenal endoscopic biopsy is a common investigation for various non-neoplastic conditions. Malabsorption is a common indication for duodenal biopsy in our setting. Aim: Our study was undertaken to study the morphologic spectrum of non-neoplastic conditions of duodenum emphasizing on Intraepithelial Lymphocytes (IELs) and to have a clinico-pathologic correlation. Materials and Methods: This was a prospective descriptive study. Duodenal biopsies from 101 patients with symptoms of malabsorption were studied according to inclusion and exclusion criteria. Informed written consent was taken. Clinical, laboratory, endoscopic, and serological parameters were collected wherever available. Histomorphological parameters were studied on Haematoxylin and Eosin (H&E) stained sections. Intraepithelial lymphocyte counts were done on CD3, CD4 and CD8 Immunohistochemical (IHC) stained sections and correlated. Results: We studied 101 duodenal biopsies. Our spectrum included 16 patients of celiac disease (CD) (15.8%), 15 autoimmune duodenitis (14%), 13 nutritional deficiency associated duodenitis (12.8%), 5 infectious duodenitis (5%) and 41 patients of non-specific duodenitis (40.6%). Villous crypt architecture, IEL counts; villous tip IEL counts were statistically significant between CD and other disease groups. Conclusion: A constellation of clinical, serological, endoscopic and histopathologic features is essential in diagnosing celiac disease and autoimmune duodenitis. Biopsy is also a useful tool in diagnosing infectious duodenitis that are missed in other investigations.

Risk of GERD with Diabetes Mellitus, Hypertension and Bronchial Asthma – A Hospital based Retrospective Cohort Study

Sitara Nandyal, Sweta Suria, Bharti Chogtu, Dipanjan Bhattacharjee

Introduction: The rise in Gastro-Esophageal Reflux Disease (GERD) prevalence appears to have coincided with a simultaneous increase in the prevalence of diabetes mellitus, hypertension and bronchial asthma amongst the Indian population. Despite being evaluated extensively for their role as a risk factor for GERD, till date this relationship has remained a debatable one. Moreover, literature available on such studies conducted within Indian population remains scarce. Aim: The aim of the present study was to examine the risk of developing GERD in patients suffering from diabetes mellitus, hypertension and asthma in a Southern Indian population. The present retrospective, triple cohort and hospital based study was conducted by accessing the patient records from the medical records department of a tertiary care hospital in Southern India. Materials and Methods: The patient’s records were accessed from the year 2011 onwards. Relative Risk (RR) was calculated to determine the risk of development of GERD with every disease. Chi-square test was used to determine the statistical significance of the relationship between each disease and the development of GERD. A p-value of <0.05 was considered statistically significant. Results: In view of the time constraints as well as the limitations of the inclusion and exclusion criteria, data pertaining to only 40, 71 and 53 patients in Cohort 1 (diabetics), 2 (hypertensives) and 3 (bronchial asthmatics) respectively could be analyzed in the present study. The relative risk of GERD development was greater than 1 for patients belonging to Cohort 2 and 3, suggesting that the risk of GERD development is higher amongst hypertensives and asthmatics. Surprisingly, the diabetics (Cohort 1) were not associated with a high risk of GERD development. However, the relationship between any of the disease and GERD development was not statistically significant. Conclusion: The present study found an increased risk of GERD development amongst patients suffering from hypertension and bronchial asthma, but not with diabetes mellitus.

Comparison of Effect of Lavandula officinalis and Venlafaxine in Treating Depression: A Double Blind Clinical Trial

Masoud Nikfarjam, Reza Rakhshan, Hourivash Ghaderi

Introduction: Major depressive disorder is a chronic disease which may be associated with other mental illnesses. Lavandula officinalis and venlafaxine, herbal and chemical drugs respectively, are used to treat depression. Despite pharmacotherapy, major depressive disorder has a complicated pattern of resistance and recurrence. Aim: The aim of this study was to determine the effect of L. officinalis and venlafaxine in treating depression. Materials and Methods: For this study, 120 patients referred to the psychiatry clinic of the Shahrekord University of Medical Sciences, Shahrekord, Iran, were randomly selected. The participants were randomly assigned to three groups: venlafaxine (Control Group), venlafaxine + L. officinalis (L. officinalis Group), and venlafaxine + placebo (Placebo Group). All the patients underwent treatment for six weeks. Depression test was administered to the three groups at different time intervals before the treatment, four weeks after the treatment and at completion of the treatment. The data were analysed by SPSS version17.0. Results: Depression scores of all the groups decreased over time (p=0.001). The depression scores were significantly different between the control and L. officinalis groups (p=0.004), and the control and placebo groups (p=0.002), but were not significantly different between the L. officinalis and placebo groups (p=0.95). Conclusion: Adding L. officinalis or a placebo is equally effective in decreasing mean depression score and venlafaxine obviously decreased this score.

Quantification of Liver Fat with mDIXON Magnetic Resonance Imaging, Comparison with the Computed Tomography and the Biopsy

Introduction: Accurate, non-invasive method of fat estimation is a valuable test for evaluation of diseases with abnormal hepatic fat. Aim: To determine the accuracy of mDixon MR technique in assessment of liver fat over CT and to correlate the CT and MRI findings with biopsy. Materials and Methods: A prospective observational study was conducted at Imaging Services of Narayana Multispeciality Hospital between March 2011- December 2012. Thirty patients who attended the clinic for non-hepatic complaints were included in the study. Patients with known liver disease, cirrhosis, alcoholic liver disease, bleeding diathesis and claustrophobic patients were excluded from the study. Subjects underwent sonography, CT liver and MR examination of liver for fat estimation using mDixon protocol. Biopsy of the liver was performed either by image guidance or by direct biopsy. Liver Attenuation Index (LAI), fat estimation by MR methods were reviewed independently by two observers and compared with biopsy results. The statistical analysis was performed by SPSS. Pearson correlation was used to find the correlation between the left and right lobe of liver segments by CT and histological correlation. Results: There was good correlation between the MR estimation of liver fat and histological grading. Majority (90%) of patients had fat content of less than 10%. Maximal fat content of 28% was observed in one patient. LAI values poorly correlated with the MRI and histological observations. Conclusion: MR estimation of the liver using mDixon technique yielded specific information about liver fat, correlated well with the histological grading. Technique is more accurate than CT, does not involve ionising radiation, hence recommended as method of choice.

Antibiotic Screening of Urine Culture for Internal Quality Audit at Amrita Hospital, Kochi

Aswathy Suresh, Anusha Gopinathan, Kavitha R Dinesh, Anil Kumar

Introduction: Urine antimicrobial activity is a seldom analysed laboratory test which greatly impacts the quantification of urine specimens. Presence of antimicrobial activity in the urine reduces the bacterial load in these specimens. Hence, the chances of erroneously reporting insignificant bacteriuria can be reduced on analysis of the antimicrobial activity in urine. Aim: The aim of the study was to measure the antimicrobial activity of urine samples obtained from patients in a tertiary care hospital. Materials and Methods: A total of 100 urine specimens were collected from the study group. Tests like wet mount, Gram staining and culture were performed. Antimicrobial susceptibility testing was done on the bacteria isolated from each specimen. The urine specimens were reported as significant bacteriuria (>105 Colony Forming Unit (CFU)/ml) and insignificant bacteriuria (<105 CFU/ml – clean catch midstream urine; <102 CFU/ml – catheterized urine sample) according to the CFU/ml. Staphylococcus aureus ATCC® 25923™ and Escherichia coli ATCC® 25922™ were used to identify the presence of antimicrobial activity in the urine sample by Urine Anti-Bacterial substance Assay (UABA). McNemar test was used for statistical analysis using Statistical Package for the Social Sciences (SPSS) version 21.0. Results: On analysis of the antimicrobial activity of urine sample with the prior antibiotic history of the patients, 17 were true positives and 43 were true negatives. Twenty six of samples with UABA positivity were culture negative and 28 samples with UABA positivity were culture positive. Sensitivity and specificity of the test was 85% and 53.8% respectively. Accuracy of the test was 60%. The p-value of UABA was <0.001. Enterobacteriaceae was the most common bacterial family isolated from the urine specimens. A total of 85% patients responded to treatment. Conclusion: Presence of antimicrobial activity in urine has a great impact on the interpretation of urine culture reports. Identification of urine antimicrobial activity helps in evaluating the quantification of bacterial growth reported in urine culture. It facilitates speedy recovery of patients by early administration of antibiotics.

Impact of Antibiotic Stewardship Program on Prescribing Pattern of Antimicrobials in Patients of Medical Intensive Care Unit

Nishal Shah, Anuradha Joshi, Barna Ganguly

Introduction: Rising concerns about antimicrobial resistance and inadequate development of effective new anti-infective drugs have stimulated universal efforts to strengthen infection-control interventions. Antimicrobial stewardship is a rational, systematic approach to promote the optimal selection, dosing, and duration of therapy for antimicrobial agents throughout the course of their use in order to improve the outcomes. Aim: Since in Shree Krishna Hospital (SKH), Antibiotic Stewardship Program (ASP) was first implemented in 2013, this study was planned to assess any change in antimicrobial use before and after implementation of ASP and to study the rate and pattern of antimicrobial use in medical ICU. Materials and Methods: A cross-sectional study was conducted in 12 bedded medical intensive care unit, over a period of two years from October 2014 to October 2016 at SKH. Permission was taken from Institutional Human Research Ethics Committee. Total 150 case files i.e., 75 from year 2012 and 75 from year 2015 were retrieved from medical record section of the hospital. Appropriateness of prescriptions was decided on the basis of appropriateness of choice, dose, frequency and duration of antimicrobial agents. Data were analysed by using descriptive statistics. Results: There were 68.67% males and the mean (±SD) age was 57.11 (±16.83) years. Majority of the patients were suffering from respiratory conditions. The most common group of drugs prescribed in MICU was ß-lactam antibiotics + ß-lactamase inhibitors during 2012 as well as 2015. Total 139 patients i.e., 69 (92%) patients in 2012 and 70 (93.33%) patients in 2015 were given antimicrobial for therapeutic purpose. During the year 2015, 67 (89.33%) antimicrobial prescriptions were adhering to antibiotic policy of SKH. Appropriateness of prescriptions had significantly improved in 2015 in MICU (p-value=0.031). Conclusion: In-depth analysis of the study revealed a positive impact of ASP and antibiotic policy. Implementation of ASP in year 2013, brought an effective increase in the appropriate use of antimicrobials.

A Qualitative Study on Knowledge and Attitude towards Risk Factors, Early Identification and Intervention of Infant Hearing Loss among Puerperal Mothers- A Short Survey

Ravi Dudda, Hanumanth Prasad Muniyappa, Sahana Puttaraju, M.S Lakshmi

Introduction: Maternal active participation and their support are critical for the success of early hearing loss detection program. Erroneous maternal decisions may have large life long consequences on the infant’s life. The mothers’ knowledge and their attitudes towards infant hearing loss is the basis for their decisions. Aim: The present study was done to determine the mothers’ knowledge and their attitude towards risk factors of infant hearing loss, its early identification and intervention and also awareness of effect of consanguinity on hearing loss. Materials and Methods: In this cross-sectional questionnaire survey study, a total of 100 mothers were interviewed using the questionnaire which consisted of three sections namely risk factors, early identification and early intervention of hearing loss. Chi-square test was used to establish relationship between consanguineous and non-consanguineous mother’s responses to its effect on hearing loss. A p-value < 0.05 was considered as significant. Results: Mothers’ awareness was significantly high for visible causes (ear pain/discharge, head injury and slap to ear) of hearing loss. Positive attitude was seen for importance of screening programs and follow up testing. Moderate level of awareness was found on hazards of consanguinity and benefits of early identification. However, mothers were least aware of neonatal jaundice, NICU admission (>5 days), signs of late-onset and neural hearing loss, management of hearing loss, hearing aid fitting and therapy necessity, which might interfere in early detection and intervention of hearing loss. Conclusion: It is crucial to educate mothers on few risk factors and management of hearing loss to reduce its consequences.

Maternal Outcomes Associated with Caesarean versus Vaginal Delivery

Farnaz Zandvakili, Masomeh Rezaie, Roonak Shahoei, Daem Roshani

Introduction: To choose the best mode of delivery (vaginal versus caesarean section) still remains a contentious issue. Caesarean section is a major abdominal surgery with its related medical, anesthetic and surgical complications. Maternal mortality and morbidity is higher in caesarean section compared with vaginal delivery. The most common causes of maternal mortality during caesarean section are due to anesthesia, bleeding and infection. Aim: The aim of this study was to determine the mode of delivery and maternal outcomes in Sanandaj's hospital, Iran, during one year. Materials and Methods:The study population included all women who were admitted for delivery in Sanandaj's hospital. Data collection instrument was a researcher made questionnaire. Data were entered into SPSS version 20.0 and analyzed using Chi-square test. Desired outcomes were entered into multiple logistic regression models. For estimating the parameters and increasing the level of significance we used bootstrap to generate 1000 samples. Results: During the study, a total of 5984 deliveries were conducted in Sanandaj hospital, of which 3423 (57.20%) were vaginal (vaginal, vaginal + episiotomy, instrumental delivery) and 2561 (42.80%) were caesarean section. The results showed a statistically significant association between delivery mode and demographic variables such as age, occupation and level of education; whereas, no significant association was found between place of residence and parity. Conclusion: The finding of this study showed that caesarean section delivery rate in Sanandaj was 42.18% in 2012-2013 which is higher than caesarean section rate recommended by WHO. Also, there was a relationship between mode of delivery and maternal outcomes.

Role of Multi-Detector CT (MDCT) in Evaluation of Bowel Diseases

Introduction: Multi-Detector Computed Tomography (MDCT) has revealed excellent results in various systems of the body. Its role in abdominal imaging for solid viscera has been proved beyond doubt. It is an emerging non invasive tool for evaluation of bowel diseases. Aim: To see the efficacy of MDCT in evaluation of various bowel diseases. Materials and Methods: The study was carried out in the Department of Radiodiagnosis and Imaging, Batra Hospital and Medical Research Centre, Delhi, India. A total of 60 patients were enrolled in this study from March 2008 to June 2010 over a period of 24 months. All patients suspected to have inflammatory, obstructive, ischaemic and neoplastic diseases of small or large bowel disease were included in the study. The patients with past history of chronic renal failure, allergic reaction to contrast were excluded from the study. Comparison was made between CT findings with the operative findings, endoscopy, angiography or histopathology correlation whichever was relevant with case. All this data was compiled and statistically analysed. Results: Out of 60 patients 12 patients were diagnosed having appendicitis using axial, Multiplaner Reconstruction (MPR) and curved MPR images. The findings of appendicitis were confirmed on surgery and subsequent histopathology correlation. Inflammatory bowel diseases comprised of 28 cases out of which seven persons were diagnosed with intestinal Koch's disease. Four patients had idiopathic inflammatory bowel diseases. Rest of the 17 patients were reported to have findings of non-specific colitis and they responded well with antibiotic treatment. Conclusion: The sensitivity and specificity of MDCT in case of bowel obstruction clearly demonstrates not only the site of obstruction, but also reveal the cause of obstruction which includes intraluminal, intramural and extrinsic factors. CT scan categorizes the lesion to inflammatory or neoplastic to a greater accuracy. MDCT can also demonstrate the complications associated with obstruction like strangulation and perforation. CT is now considered a good tool in the evaluation of patients with suspected bowel obstruction, particularly in indeterminate clinical and conventional radiographic findings.

Correlation of Vitamin D3 Levels and SCORAD Index in Atopic Dermatits: A Case Control Study

Introduction: Atopic Dermatitis (AD) is a common chronic inflammatory condition characterized clinically by pruritus and eczematous lesions. An inverse relationship has been suggested between serum 25-hydroxyvitamin D concentration and severity of atopic dermatitis. Aim: We carried out this controlled cross- sectional study to evaluate the association between the serum vitamin D3 levels and SCORAD index. Materials and Methods: For this study, 40 patients with clinical diagnosis of AD based on UK diagnostic criteria were enrolled and 40 patients with minor ailments like superficial bacterial, fungal or viral infections and not suffering from atopic dermatitis were taken as controls. Salient presentations were recorded in a pre-set proforma. Serum 25-hydroxyvitamin D levels were determined through Sandwich-ELISA technique. SCORAD (Scoring AD) index was used to evaluate the severity of the disease. Results: Mean value of serum 25-hydroxyvitamin D levels in cases was 30.38 nmol/l whereas in controls, it was 53.46 nmol/l. The decrease in serum levels in cases was statistically highly significant (p-value <0.001). Mean±S.D of serum vitamin D levels in mild disease was 33.29±5.89 nmol/l, in moderate disease was 31.52±6.04 nmol/l and in severe form of disease was 21.24±3.17nmol/l. The correlation between SCORAD and serum 25-hydroxyvitamin D levels was also statistically significant. Conclusion: The data suggests an inverse relationship between serum levels of vitamin D3 and the SCORAD Index.

A Comparative Study of Analgesic Effect of Intrathecal Nalbuphine and Fentanyl as Adjuvant in Lower Limb Orthopaedic Surgery

Shagufta Naaz, Usha Shukla, Swati Srivastava, Erum Ozair, Adil Asghar

Introduction: Intrathecal opioids when added to local anaesthetics decrease their dosage and provide haemodynamic stability. Nalbuphine is an agonist-antagonist and acts on kappa receptors providing analgesia. Aim: The study aims to compare the analgesic efficacy of fentanyl with that of two doses of nalbuphine when used with injection bupivacaine heavy in spinal anaesthesia. Materials and Methods: A randomised, double blinded, prospective study on 90 patients of ASA I and II undergoing lower limb orthopaedic surgery under subarachnoid block was done. Patients were randomly allocated into three groups (n=30). Each group received 12.5 mg of 0.5% of injection bupivacaine heavy along with either 25 µg of 0.5 ml fentanyl (Group F) or 0.8 mg of 0.5 ml nalbuphine (Group NL) or 1.6 mg of 0.5 ml nalbuphine (Group NH). Characteristics of sensory and motor blocks, haemodynamic changes, duration and quality of analgesia, adverse effects, sedation, VRS score and analgesic requirement were studied at different time interval intraoperatively and till 24 hours of block. Results: The duration of analgesia (in minute) was 441±119.69 in NH Group, 450±103.38 in NL Group and 300.0±88.53 in Group F (p=0.05). There was no significant difference regarding block characteristics and haemodynamic parameters. Total 24 hours analgesic requirement was titrated by analgesic score which was 2.25±0.7 (NH Group), 1.875±0.83 (NL Group) and 3.375±1.77 (F Group) p=0.0186 by ANOVA. The adverse effects of NL Group were least. Conclusion: There was no significant advantage of intrathecal fentanyl or 1.6 mg nalbuphine over low dose 0.8 mg nalbuphine.

Development of Parafollicular Cells and their Relationship with Developing Thyroid Follicles in Human Foetuses

Sushant Swaroop Das, Sabita Mishra, J M Kaul

Introduction: The parafollicular cells or clear (C) cells in man are part of neuroendocrine system under Amine Precursor Uptake and Decarboxylation (APUD) cells. Their role in adults has been reputable but in foetus is still unclear. Aim: The present study was a baseline study endeavouring to describe the chronological development of the parafollicular cells with particular focus on its correlation with developing human thyroid follicles. Materials and Methods: The study was conducted on 10 aborted foetuses (14–28 weeks), procured from the Department of Obstetrics and Gynaecology, Lok Nayak Hospital, New Delhi, India. Serial sections of foetal thyroid gland were generated, stained with haematoxylin and eosin, and immunohistochemistry using the anticalcitonin antibody and examined qualitatively. Results: In our study, the parafollicular cells were seen as earlier as by 14th week. They became morphologically and functionally mature by 16th week of gestation. The parafollicular cells were getting organized from scattering to parafollicular location then to a more localized area, i.e., intrafollicular along with the follicular development. As the follicles were enlarging, the intrafollicularly located parafollicular cells which was initially present in groups was getting displaced singly between the follicular cells in the same follicle. Conclusion: The sequential development pattern of the parafollicular cells in relation to developing thyroid follicles was established. This immunohistochemical study also concluded that the parafollicular cells might have higher character to play in the early gestational age such as regulation of ossification in the human foetus.

Distribution of SCCmec Elements and Presence of Panton-Valentine Leukocidin in Methicillin-Resistant Staphylococcus epidermidis Isolated from Clinical Samples in a University Hospital of Isfahan City, Iran

Introduction: Coagulase Negative Staphylococcus (CoNS) is considered as a major pathogen of nosocomial infections among immunosuppressed patients. Aim: The aim of this study was to identify the types of Staphylococcal Cassette Chromosome mec (SCCmec) and Panton-Valentine Leukocidin (PVL) gene among clinical Methicillin-Resistant S. epidermidis (MRSE) isolates collected from Isfahan. Materials and Methods: This cross-sectional study was performed from March 2014 to January 2015 at a tertiary care hospital of Isfahan, Iran. Antimicrobial susceptibility tests of S. epidermidis isolates were performed by the disc diffusion method. All the strains were screened for methicillin resistance based on resistance to cefoxitin (30 µg) disc and presence of mecA gene. Determination of SCCmec typing and PVL toxin gene were performed by PCR method. For categorical variables different groups were compared using the Chi-square test or Fisher exact test. A p-value of <0.05 was considered significant for all statistical tests. Results: The frequency of MRSE was 53.8% according to the presence of mecA gene. The overall resistance rate was high with ciprofloxacin (81.4%). PCR analysis showed that 17% (12/70) of MRSE isolate carried the PVL gene and 43% (30/70) were SCCmec type I; 11.4% (8/70) were type II; and 34.2% (24/70) were type IV, whereas, 11.4% (8/70) of the MRSE isolates could not be typed. Conclusion: SCCmec type I was the major type of SCCmec, which indicates an emergence of this SCCmec type in the studied medical centers. Increased prevalence of SCCmec types in community is cause of an increase in antibiotic resistance among microorganisms.

Efficacy of Health Education using Facebook to Promote Healthy Lifestyle among Medical Students in Puducherry, India: A Non-Randomized Controlled Trial

Smrithi Krishnamohan, P. Stalin, Zile Singh, Maghida Sridhar

Introduction: Increasing burden of overweight and obesity among young adults is mainly due to unhealthy lifestyle especially with respect to diet and physical activity. At the same time, younger generations are spending more time with social network sites. Therefore, this study was intended to explore the role of social networking sites in promoting healthy lifestyle. Aim: To measure the efficacy of health education using social networking sites in promoting healthy lifestyle among medical students in Puducherry, India. Materials and Methods: A non-randomized controlled trial was conducted in a private medical college located in Puducherry. The study participants were overweight/obese individuals with (intervention arm) and without Facebook account (control arm). Following a baseline survey, both the groups received health education from dietician and physical trainer using Audiovisual (AV) aids. Intervention group received health education through Facebook in the forms of messages, pictures and videos for six weeks. Then, follow up survey was done to assess the change in dietary pattern, physical activity and body weight. Data of those who attended baseline, intervention and follow up surveys (23- control and 22- intervention) were analysed. Means and proportions were calculated. Paired t-test and Chi-square test were used to calculate the p-value. The p-value<0.05 was considered as statistically significant. Results: Mean number of days of junk food intake per week was reduced in both control and intervention groups from 2.91 days/week and 3.27 days/week at baseline to 2.65 days/week to two days/week at follow up respectively. A significant decrease in the Body Mass Index (BMI) (p<0.05) was found among the control group (baseline: 25.57, follow up: 25.15). No significant changes were found with respect to physical activity and intake of fruits and vegetables. Conclusion: Except for the decrease in junk food intake, use of Facebook as an effective tool to promote healthy lifestyle could not be proved with confidence.

The Impact of Three-month Training Programme on Foot Care and Self-efficacy of Patients with Diabetic Foot Ulcers

Introduction: Patient’s self-efficacy in disease management and foot care is considered as an important indicator in controlling the complications of diabetes. Aim: This study was aimed to determine the effect of three-month training programme on foot care and self-efficacy of patients with diabetic foot ulcers. Materials and Methods: A quasi-experimental study was conducted on 60 patients with diabetic foot ulcers in Jiroft Imam Khomeini hospital from January 2016 to May 2016. These patients were randomly divided into intervention and control groups (30 patients in each group). The research instrument was a questionnaire on demographic data, self-efficacy questions for patients with diabetes and a researcher made questionnaire of diabetic foot care. Training programmes for foot ulcers care and prevention of new ulcers formation and other aspects of the disease were implemented during three months in the test group. Data were analysed using descriptive and analytic statistical tests (Mann–Whitney U, paired t-test and Pearson correlation coefficient) by SPSS version 18.0 software. Results: The results showed statistically significant difference (p<0.001) in the score of self-efficacy between intervention group (182.25) and control group (93.56), and the foot care score was 47.43 in the intervention group and 30.18 in control group after the intervention. The average scores of self-efficacy and foot ulcers care significantly increased in the intervention group after training programme (p<0.001). Conclusion: The results showed that the implementation of training programme has been able to increase the self-efficacy of patients and the rate of their foot ulcers care and the prevention of new ulcers and effectively reduce the complications in diabetic patients.

Effect of Environmental Intervention on the Consumption of Rice without Toxic Metals Based on the Health Belief Model and Ecological-Social Model

Leili Shafiei, Parvaneh Taymoori, Afshin Maleki, Bijan Nouri

Introduction: The effect of instructional models on the changing behaviour of consuming contaminated rice with toxic metals has not been investigated in Iran yet. Aim: To compare effect of Health Belief Model (HBM) and Ecological (ECO) social model on decreasing the consumption of rice contaminated with toxic metals. Materials and Methods: The study aimed at implementing a six-month interventionist program among three groups (HBM, ECO and Control). The study population comprised of 240 women, aged 18 to 50. Questionnaires were distributed which consisted of demographic information, knowledge, constructs of the models, performance of rice consumption, and the manner of rice cooking. In HBM group participants were individually provided with instructions based on HBM. However, in ECO group participants received the instruction through social networks consisted of mothers, sisters, family members, and colleagues. Results: The results of Wilcoxon test indicated improvements in people’s diet including a significant increase in the number of women consuming rice without toxic metals, a significant reduction in the number of women consuming rice contaminated with toxic metals in both intervention groups. On the other hand, such an improvement was not observed in the control group. The results of repeated measures’ analysis of variance suggested further improvement in healthy diet in ECO group rather than HBM group after the completion of the environmental intervention. Conclusion: Both methods of instructional intervention caused changes in the diet of people regarding the consumption of rice free from toxic metals and changes in the manner of cooking from Kateh (steaming rice) to Pilaw (draining rice). Development of social support had probably a more effective role on the improvement of people’s diet.

Comparative Evaluation of the Efficacy of Bioactive Ceramic Composite Granules Alone and in Combination with Platelet Rich Fibrin in the Treatment of Mandibular Class II Furcation Defects: A Clinical and Radiographic Study

Hima S Lohi, Dilip G Nayak, Ashita S Uppoor

Introduction: Predictable closure of furcation defects with bone grafts, Guided Tissue Regeneration (GTR) and a combination of the two has remained an elusive goal so far. Hence, evaluation of biomimetic agents as candidate technologies for periodontal regeneration merit due consideration. In this study, Choukroun’s Platelet Rich Fibrin (PRF), a second generation platelet concentrate, is combined with bone graft to examine if the addition enhances the therapeutic potential of bone graft in the management of Class II furcation defects. Aim: To evaluate and compare the clinical effectiveness of Bioactive Ceramic Composite Granules (BCCG) alone and in combination with PRF in the treatment of mandibular Class II furcation defects. Materials and Methods: Twenty mandibular Class II furcation defects in 16 systemically healthy patients were randomly allocated to test and control groups. Test sites were treated with PRF and bone graft, while control sites were treated with BCCG alone. Soft tissue parameters (probing pocket depth and clinical attachment loss), hard tissue parameters (vertical and horizontal depth of furcation defects) and radiographic parameter (radiographic alveolar bone density) were measured at baseline and six months post surgery. Statistical analysis was performed using Wilcoxon signed rank test for intragroup comparison of parameters and Mann-Whitney U test for intergroup comparison. Results: Statistically significant improvement was observed in the test group compared to the control group with respect to all the measured parameters. However, complete furcation closure was not observed at any of the treated sites. Conclusion: Adjunctive use of PRF with bone graft may be a more effective treatment modality in the management of mandibular Class II furcation defects when compared to bone graft alone.

An Intervention Airing the Effect of Iranian Propolis on Epithelial Dysplasia of the Tongue: A Preliminary Study

Introduction: Since oral cancer is one of the causes of mortality, the use of materials or methods that can reduce cancer or prevent its progression has particular importance. Aim: Aim of the study was to evaluate the antitumor effects of Iranian propolis on dysplastic changes of oral mucosa in rats. Materials and Methods: This study was performed on 28 Wistar male rats (aged 7-11 weeks, 160±20 g). They were divided into four groups of seven rats. The Group 1 received: 0.5% 7,12-Dimethylbenz[a]anthracene (DMBA), the Group 2: 0.5% DMBA and 100 mg/kg propolis, the Group 3: 0.5% DMBA and 200 mg/kg propolis, and the Group 4: 0.5% DMBA and 400 mg/kg propolis. DMBA in all groups was administered topically (brush) and propolis was injected intraperitoneally. DMBA was brushed twice on the lingual dorsum three times a week for 20 weeks. Propolis injection just every other day and in the days after DMBA was administered for 20 weeks. Rats were sacrificed, and histological examinations were performed on tongue specimen. Results: Propolis can reduce the degree of dysplasia in doses 100 mg/kg, 200 mg/kg, and 400 mg/kg compared to control (Group 1) (p=0.017, p=0.02, and p=0.002, respectively). Conclusion: The results of this study showed propolis can dose-dependently prevent DMBA-induced dysplasia of the oral mucosa in animal model.

Effect of Sugar-Free and Regular Toothpaste on Salivary Glucose and pH among Type 2 Diabetes- A Randomized Crossover Trial

Introduction: Diabetes is one of the most prevalent diseases of mankind having general as well as oral health manifestations. Also, there is an increase of salivary glucose level in diabetic, inducing saccharolytic bacteria in saliva which can have adverse effects on oral tissue. Aim: To assess and compare the effect of sugar-free toothpaste on salivary glucose and pH among Type 2 diabetic and non-diabetic individuals. Materials and Methods: A randomized controlled-crossover study was carried out on 30 Type 2 diabetic (Group A) and 45 non-diabetic (Group B) subjects. In first half of study, subjects in Group A and Group B were intervened with sugar-free and regular toothpaste respectively. Salivary glucose and pH was assessed before and after brushing at interval of one week for a period of four weeks. In second half, toothpastes were switched over between the groups, after sufficient washout period. Salivary glucose and pH were assessed again in the same manner for both the groups. The data was subjected to paired t-test and unpaired t-test for intragroup and intergroup comparison respectively. Results: Salivary glucose level was significantly reduced and salivary pH was increased significantly (p<0.001) in both groups with sugar free toothpaste when compared to regular toothpaste. Conclusion: Sugar free toothpaste showed beneficial effect on salivary glucose level and salivary pH level on diabetes and non-diabetes population.

Why do Patients undergoing Chronic Obstructive Pulmonary Disease Treatment Turn Defaulters ? A Follow –up Study in a Tertiary Care Hospital in Jamnagar, India

Amrita Sarkar, Abhay Javia, Pradeep Pithadia, Dipesh Parmar

Introduction: Chronic Obstructive Pulmonary Disease (COPD), a progressive respiratory illness requiring long-term treatment, is a significant cause of morbidity, mortality and economic burden on the family as well as the country. In the tertiary health care facility where the study was carried out, it was observed that many COPD patients did not come for regular follow-up. In these patients, treatment interruption may lead to increased morbidity and mortality. Aim: This study aimed to find out the reasons for defaulting follow-up and treatment in COPD patients. Materials and Methods: All patients of COPD, attending TB Chest outpatient department during the study period (September 2012 to February 2013), were classified into Group A, B, C, and D according to latest Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Data was collected on patient’s socio-demographic profile, severity of disease and reasons for defaulting follow-up and treatment using pre-tested semi-structured questionnaires, patient history and clinical examination. Data obtained were entered in Microsoft Office Excel 2007 and analysed using Chi-square test. Results: The mean age of the 200 patients recruited was 59.3 years. A total of 87% patients were male. Patients belonging to Group A, B, C and D were 11%, 25.5%, 41.5% and 22% respectively. Overall, 32% patients were defaulters. Three main reasons for default were non-affordability for treatment expenses (39.07%), resolution of symptoms (26.56%), and too ill to come (18.75%). The associations between default rate and demographic variables like age and gender were found statistically significant. Conclusion: Default rate among COPD patients is significantly associated with GOLD Group A and D, patient’s income and patient literacy level. Main reasons for default were non-affordability of treatment expenses and too ill to come or resolution of symptoms.

Elevation of Oxidative Stress and Decline in Endogenous Antioxidant Defense in Elderly Individuals with Hypertension

Introduction: Hypertension is becoming an important medical and public health problem all over the world and is the most common disorder of ageing. There is a growing evidence of involvement of vascular oxidative stress in the development of hypertension from animal studies. However, studies on humans with hypertension, particularly in elderly are least and data remained controversial. Moreover, studies in elderly people with hypertension are scarce. Aim: To investigate the possible role of oxidative stress and antioxidant defense in the pathogenesis of hypertension in elderly. Materials and Methods: A cross-sectional study was conducted on elderly males (n=60) with newly diagnosed hypertension and with normal blood pressure. Oxidative stress and antioxidant status were evaluated by assessing the following parameters: plasma Malondialdehyde (MDA), and antioxidants: Superoxide Dismutase (SOD) activity, reduced Glutathione (GSH), and vitamin C levels; and total Nitric Oxide concentration in plasma (NOx). Difference between groups was determined by using unpaired t-test/Mann-Whitney U test. Bivariate correlation and multiple regression analysis were used to determine the relationship between variables. Results: A significant rise in plasma MDA (p-value=0.013) and lower levels of endogenous antioxidants: SOD (p-value=0.001) and GSH (p-value=0.001) were observed in elderly individuals with hypertension when compared to healthy controls. Though not significant, there was a mean decrease in plasma NOx in hypertensive subjects than normotensive ones. While vitamin C showed no significant difference between two groups. Decrease in GSH (ß=-0.398; p-value=0.001) and SOD (ß=-0.423; p-value=0.001) were the significant determinants of hypertension in elderly individuals. Conclusion: Above findings indicate that elevation in oxidative stress and decrease in endogenous antioxidant level may be involved in the pathogenesis of hypertension. However, it remains unclear whether oxidative stress causes or augments hypertension.

Corneal Collagen Cross-linking for Treatment of Bacterial and Herpetic Keratitis

Mohammad Reza Khalili, Hamid Reza Jahadi, Mashaallah Karimi, Masoud Yasemi

Introduction: Optimal management of infective keratitis is a formidable challenge and subject of ongoing studies. Recently, Collagen Cross-Linking (CXL) of the cornea has been considered to be a new effective therapeutic approach for resistant infectious keratitis. Aim: Aim of the study was to evaluate the effectiveness of CXL with Ultraviolet-A (UV-A) and riboflavin for treatment of the refractory bacterial and Herpes Simplex Virus (HSV) keratitis. Materials and Methods: In this prospective interventional study, eight patients with diagnosis of infectious keratitis who were referred to Khalili Hospital eye emergency room, between 2014 and 2015 were included in the study. There were six patients with bacterial keratitis and two patients with HSV keratitis; they were resistant to conventional treatment and underwent CXL. Response to the treatment was considered as good if rapid epithelialization and rapid decrease in stromal infiltration occurred. Results: Microbial culture in the bacterial keratitis group showed coagulase negative Staphylococcus in two patients, Staphylococcus aureus in one patient, mixed infection in one patient, and Pseudomonas aeruginosa in two patients. Good response and rapid epithelialization and resolution of stromal infiltration were seen in the four out of six eyes. Two patients showed no response and underwent penetrating keratoplasty for eradication of infection. Furthermore, one patient showed a good response to CXL in the HSV keratitis group and another patient had a relative response but recurrence occurred. Conclusion: Although, CXL seems promising in the treatment of patients with refractory bacterial keratitis, but in some cases, it is ineffective. CXL may be an alternative treatment for refractory cases of HSV keratitis but recurrence is possible.

Cartilage Myringoplasty: An Ideal Grafting Technique for Complex Perforations

Munish Kambatatti Shekharappa, Shruthi Malavalli Siddappa

Introduction: Tympanoplasty is one of routinely performed surgeries in ENT practice. Using cartilage-perichondrium composite graft in selective cases gives better outcome. Aim: To study the outcome and feasibility of cartilage-perichondrium composite graft in repair of complex tympanic membrane perforations. Materials and Methods: This cross-sectional, intervention study was conducted at SSIMS and RC, Tertiary Care Teaching Hospital, Davangere, Karnataka, Southern India. Study sample consisted of 30 patients with chronic otitis media- tubo tympanic type in inactive stage. Patients were randomly selected and evaluated between January 2015 to June 2016. A detailed history, clinical examination, diagnostic nasal endoscopy, otoendoscopy were done for all patients preoperatively and postoperatively at three weeks, three months and six months. Audiological evaluation was done at six months postsurgery. Cartilage-perichondrium composite graft from tragal and conchal cartilage was used for the repair of tympanic membrane in all the cases. The data were presented in proportions, percentages. Results: Of 30 cases who underwent surgery, 24 patients (80%) had large central and subtotal perforations. Only one patient had a total perforation. The remnant tympanic membrane showed atrophic changes in 16 cases (53%) and sclerotic plaque was seen in 14 cases (46%). In our study, tragal cartilage was used in 17 and conchal cartilage in 13 cases. All the patients underwent type-1 tympanoplasty. Successful graft uptake was seen in 28 cases (93%) by six months. Two patients (7%) had a residual perforation at three months and in four cases (13%), the neotympanum showed anterior blunting by the end of six months. With respect to hearing, maximum air bone gap closure achieved in our study was 21db in one patient and minimum was 3db. Average air bone gap closure achieved was 10.1db. Conclusion: Cartilage-perichondrium composite graft can be considered a good choice in repair of tympanic membrane perforations with specific selective indications.

Prevalence of Diabetic Retinopathy and its Associated Factors in a Rural Area of Villupuram District of Tamil Nadu, India

Introduction: There is limited information on prevalence of Diabetic Retinopathy (DR) among diabetic subjects and its associated factors in a rural setting in developing countries including India. The information will be useful for initiating early screening strategies for this group in the community. Aim: To assess the prevalence and certain associated factors of DR among diabetic subjects in a rural area of Tamil Nadu, India. Materials and Methods: This cross-sectional study was conducted among 105 Type 2 diabetic subjects in Pakkam and Mandagapattu sub-center area of Kondur Primary Health Center in Villupuram district of Tamil Nadu, India. Data on associated factors which include sociodemographic factors, duration of disease, family history, and frequency of blood test, treatment regularity, hypertension, visual acuity and cataract were collected. Detailed eye examination including visual acuity, direct ophthalmoscope and Non Mydriatic Fundus Camera was done. Data was analysed by univariate analysis and described in proportion or percentages. Results: The mean age of the study population was 56.69 years. About 47 (44.8%) of the subjects were more than 60 years of age followed by 44 subjects (41.9%) in age group 45-59 years. Fundus examination in at least one eye was seen in 83 people (79.0%). Prevalence of DR in any eye and both the eye was 32.53% (27/83) and 31.58% (24/76) respectively. Severity of DR was moderate (51.9%) followed by mild (44.4%) and severe (3.7%). DR prevalence was more among >60 years age group (p=0.032) and lesser education level (p=0.057). There was no association of DR with duration of disease, family history of diabetes, treatment regularity, presence of hypertension, visual acuity and cataract (p>0.05) Conclusion: The prevalence of DR was inferred to be high and further larger follow up studies will explore the role of associated factors and its quantification in the causation of DR.

Pulmonary Artery Obstruction Index and Right Ventricular Dysfunction Signs in Initial and Follow up Pulmonary Computed Tomography Angiography in Acute Pulmonary Embolism

Mehmet Burak Cildag, Mustafa Gok, Can Zafer Karaman

Intoduction: Acute Pulmonary Embolism (APE) increases the pressure of the pulmonary arterial system with resulting Right Ventricle Dysfunction (RVD). Aim: The aim of this study was to evaluate the relationship between Pulmonary Artery Obstruction Index (PAOI) and signs of right heart dysfunction with computed tomography angiography in APE patients. Materials and Methods: We evaluated 72 consecutive patients (mean age 64.1±16.9 years; 59.7% female) with APE who had initial echocardiography with computed tomography angiography. Among these 72 patients, only 25 (34.7%) patients had follow up computed tomography angiography images and we evaluate right heart dysfunction with PAOI and Right Ventricle (RV) diameter. Results: In 72 patients with APE, PAOI and RVD signs were significantly high. Twenty five of these 72 patients (34.7%) had follow up computed tomography angiography images and among those 25 patients, there was correlation between reduction of PAOI and RV diameter in follow up period. Conclusion: PAOI and RVD signs in initial computed tomography angiography and in follow up computed tomography angiography can be used in the management of Pulmonary Embolism (PE) patients.

Detection of Cytomegalovirus in Bronchoalveolar Lavage Fluid from HIV-Positive Individuals with Community Acquired Pneumonia

Arati Mane, Pankaj Gujar, Shraddha Gaikwad, Tilak Dhamgaye, Arun Risbud

Introduction: Cytomegalovirus (CMV) pneumonia is one of the frequent viral pneumonia reported in persons with HIV infection. Knowledge of pulmonary CMV infection is important for deciding appropriate diagnostic strategies. However, there is scanty literature addressing the role of CMV aetiology among HIV positive individuals presenting with Community Acquired Pneumonia (CAP) using Bronchoalveolar Lavage (BAL) samples from India. Aim: To detect CMV in BAL fluid from HIV-positive individuals presenting with CAP. Materials and Methods: This cross-sectional study was conducted using 107 archival BAL samples collected from consecutive HIV-positive patients presenting with CAP as per the Indian Chest Society and National College of Chest Physicians guidelines at the Department of Chest and Tuberculosis, Sassoon General Hospitals, Pune, India. The samples were tested for CMV by Polymerase Chain Reaction (PCR) targeting the IRL11 region at the National AIDS Research Institute, Pune. Results: Of the 107 BAL samples tested, 8 (7.4 %) were positive for CMV, while CMV was the sole pathogen in 5 (4.7%) cases. Co-infection with other pathogens was seen in 3 patients and Mycobacterium tuberculosis, Pneumocystis jiroveci and Streptococcus pneumoniae were the co-pathogens. Five patients had fatal clinical outcome of which three had CMV as the sole pathogen. Conclusion: Ours is the first study to detect Cytomegalovirus (CMV) in bronchoalveolar lavage samples from HIV-positive individuals presenting with community acquired pneumonia from India and indicates the need for further multicentre studies to understand pulmonary CMV infection, which will eventually help in designing appropriate diagnostic strategies and therapeutic interventions.

Changes in Haematological Parameters in Newborns Born to Preeclamptic Mothers - A Case Control Study in a Rural Hospital

Introduction: Pregnancy is a physiological phenomenon. However, some women develop problems during pregnancy period, which puts both the mothers and the foetus health at risk. Hypertensive disorders of pregnancy are the type of the maternal diseases that can cause the most detrimental effects to the mother and foetus. Aims: To determine the haematological parameters in neonates born to preeclamptic mothers. Materials and Methods: It was a prospective case control study carried out on neonates born to preeclamptic mothers in our institute from March 2016 to November 2016. All the haematological parameters of the neonates were recorded and analyzed using SPSS 22.0 version software. Mean, Standard deviation, minimum and maximum values were calculated for continuous variables. The difference between the two groups was compared using independent student ‘t’ test. The p-value <0.05 was considered as statistically significant. Results: About 120 mothers were included in the study out of which 60 were of study group and 60 of control group. Mean hemoglobin, PCV, red cell count, Mean Corpuscular Volume (MCV), reticulocyte count and nRBC were significantly increased p<0.001, whereas total leucocyte count, mean neutrophil count, absolute neutrophil count, lymphocyte count, platelet count were significantly decreased p<0.001 in babies born to preeclamptic mothers. No difference was found between the two groups in the Mean Corpuscular Haemoglobin (MCH) and Mean Corpuscular Haemoglobin Concentration (MCHC) value p(>0.05). Conclusion: The babies born to preeclamptic mothers are more prone for development of prematurity, low birth weight, Intrauterine Growth Retardation (IUGR), sepsis, neutropenia, leucopenia, thrombocytopenia, increased RBC count, nRBC and reticulocyte count. Early haematological screening helps to decrease morbidity, improve growth, development and survival of the baby.

Treatment of Proximal Humerus Fractures using PHILOS Plate

Introduction: Treatment of proximal humerus fractures always holds a dilemma for the treating surgeon. Aim: To assess the functional outcome of proximal humerus fractures treated with Proximal Humerus Internal Locking System (PHILOS) plating. Material and Methods: Fifty three consecutive patients were treated with PHILOS plating between August 2013 and August 2014. The inclusion criteria were skeletally matured patients with closed fracture proximal humerus with displacement >1 cm and varus angulation of >450. Severely comminuted fractures, open fractures and valgus impacted fractures were excluded from the study. The outcome was assessed using Neer's scoring system. Results: The average age was 54.3±5.8 years. As per the Neers classification system, there were 6 (11.32%) 1-part, 19 (35.85%) 2-part, 17 (32.085) and 11 (20.75%) 3 and 4-part fracture respectively. Average surgical duration was 94±10.2 minutes. Radiological union was seen at 12±4.6 weeks. There were 2 (3.77%) cases of varus collapse. Three (5.66%) cases had screw back out, which was later revised and had a favourable outcome. As per the Neer's scoring system, 7 (13.21%) cases had excellent results, 37 (69.81%) had satisfactory, 6 (11.32%) had unsatisfactory while 3 (05.66%) cases had poor outcomes. Conclusion: PHILOS plating has a good functional outcome. However, proper patient selection, thorough knowledge of the anatomy and biomechanical principles are the pre-requisites for a successful surgery.

Interventional Angiography: Radiation Protection for the Examiner by using Lead-free Gloves

Introduction: Introduction: The radiation exposure to unprotected parts of the body requires special attention for the interventional radiologist. During angiographic procedures, hands are exposed to the direct X-ray beam and scattered radiation. Aim: The aim of the study was to evaluate the radiation exposure of examiners hand with the use of lead-free X-ray protective gloves in clinical practice in terms of shielding and sense of touch. The aim of the study was to evaluate the radiation exposure of examiners hand with the use of lead-free X-ray protective gloves in clinical practice in terms of shielding and sense of touch. Materials and Methods: Phantom measurements were conducted in the direct X-ray beam and the area of scattered radiation with and without shielding. Examiner measurements were determined in interventional angiographies in clinical routine of the lower limb in antegrade puncture technique through the femoral artery. In 24 out of 50 interventions, an elastic natural rubber latex glove with lead-free metal shielding against radiation was used. All measurements were performed with a direct dosimeter. After the intervention, an opinion of the examiner was requested for evaluation of the sense of touch. Results: Phantom measurements; when using the protective glove in the direct X-ray beam, a significant increase of the Dose Area Product (DAP) (1084.2-1603.8 mGy*cm²; 67.6%; p<0.001) as well of the examiner’s hand dose (143-221.8 µSv; 64.5%; p<0.001) was observed. A significant reduction of the examiner’s hand dose was verifiable for scattered radiation (1.76-0.75 µSv; 42.6%; p<0.001). Examiner measurements; if protective gloves were used, a significant increase of the DAP (6183.2-10462.9 mGy*cm²; 59.1%; p<0.05) and decrease of the average dose rate (0.76-0.43 mSv/h; 56.6%) for the entire procedure was determined. The tactile sensitivity was assessed as not restricted (18/24). Conclusion: The new generation of protective gloves is characterized by a shielding effect against X-ray scattered radiation, without restricting the sense of touch. A significant reduction in radiation doses to the examiner can be accomplished with these gloves in the area of scattered radiation only. If the gloves were used in the direct X-ray beam, especially while the artery puncture was performed, a significant increase of the dose values was observed.

Soft Tissue Foreign Body: Utility of High Resolution Ultrasonography

Rudresh Hiremath, Harish Reddy, Jebin Ibrahim, Ch Haritha, Rushit Sandeep Shah

Introduction: Minor percentage of wooden foreign bodies is radio-opaque. High Resolution Ultrasonography (HRUSG) though existing is sparsely used as a primary imaging modality for diagnosis and localization of retained foreign body. Aim: To evaluate the diagnostic accuracy of High Resolution Ultrasonography (HRUSG) in diagnoses and localization of retained foreign body. Materials and Methods: A prospective study with registered 46 patients with history of foreign body injury which were initially imaged with conventional radiography was enrolled. Later patients were subjected for high resolution USG of the diseased part with a linear transducer. Surface marking was done for all subjects to assist the surgical exploration. Ultrasound findings were correlated with surgical exploration and histopathological findings. Results: Out of 46 patients, forty one showed foreign body with foreign body inflammatory reaction in the form of abscess and/or granulation tissue on high resolution ultrasonography. No foreign body was detected in five patients but they showed focal hypoechogenicity which represented abscess and/or haematoma. On surgical exploration, 2 out of 41 patients did not reveal foreign body where as rest were found to have foreign body with foreign body inflammatory reaction. Sensitivity and negative predictive value of the current study is 100%. Conclusion: High resolution USG is not only an efficient modality in diagnosing and localizing the foreign body in soft tissue, but can also be utilized for guiding the foreign body removal.

The Effect of Psychological Preparation on the Level of Anxiety before Upper Gastrointestinal Endoscopy

Introduction: Anxiety is one of the problems in patients undergoing invasive procedures. One way to control anxiety is through psychological preparation. Aim: This study was aimed to evaluate the effect of psychological preparation on anxiety level in patients undergoing upper gastrointestinal endoscopy. Materials and Methods: The present study consisted of 98 patients which were referred to Ahvaz Golestan Hospital for upper gastrointestinal endoscopy. They were randomly (table of random numbers) divided into a control group and an experimental group. All of the participants filled out Spielberg State-Trait Anxiety Inventory (STAI). The experimental group was psychologically prepared for endoscopy (given information about endoscopy and behavioural intervention), and then both groups were asked to complete STAI again an hour before endoscopy. The collected data were analysed through MannWhitney, Kruskal-Wallis, and Chi-square tests using SPSS 17.0. Results: Before the intervention was carried out, there was no significant difference between the two groups in terms of the rate of state and trait anxiety (p>0.05). After the intervention, the rate of state and trait anxiety decreased significantly (p<0.05) in experimental group. Conclusion: In patients subjected to endoscopy, psychological preparation was effective in reducing their anxiety and thus this can be considered as an efficient method in decreasing anxiety

Efficacy of Foley’s Catheter and the Effect of Histopathology, Age and Endometrial Thickness Relative to the Measured Outcomes in Menorrhagia

zaheera Saadia, Robina Farrukh, Madiha Ghulam Rasool

Introduction: Menorrhagia adversely affects the quality of life. Hysterectomy is the definitive treatment for menorrhagia however, a number of conservative alternatives are available. Aim: Hysterectomy is the definitive treatment for menorrhagia however, a number of conservative alternatives are available. A thermal balloon is an effective but costly option. We used a Foley's catheter as an alternative to commercially available thermal balloons. If effective, it will provide a cheap alternative to the thermal balloon. Materials and Methods: A Foley's catheter was placed in the uterine cavity for 10 minutes using 0.9% saline. The measured outcomes were amenorrhea, eumenorrhea, oligomenorrhea or failure of the therapy. Endometrial thickness, age and endometrial biopsy results were also measured to determine if these variables had any effects on the outcome. Results: Out of the total 42 participants, nearly half had amenorrhea (42.9%, n=18). Furthermore, 28.6% had oligomenorrhea (n=12) and 26.2% experienced eumenorrhea (n=11). Only one participant failed to respond (2.4%, n=1). There were no differences in outcomes between the different forms of histopathology. This means that thermal balloon therapy is effective in causing amenorrhea. No significant relationships existed between participants' measured outcomes and a model containing predictor variables (age and endometrial thickness), R=0.313, R2=0.098, p=0.141. Conclusion: A Foley's catheter is effective with reasonable measured outcomes in cases of menorrhagia.

Evaluating the Efficacy of Levonorgestrel Intrauterine System and Danazol for Relief of Postoperative Pain in Endometriosis

Introduction: Endometriosis is an oestrogen-dependent disorder, manifests during reproductive years and is associated with pain and infertility. There is considerable debate about the effectiveness of various interventions for pain relief. Aim: To evaluate the efficacy of Levonorgestrel Intrauterine System (LNG-IUS) and Danazol in postoperative pain relief for patients with endometriosis. Materials and Methods: Hundred patients with diagnosis of endometriosis, who were treated laparoscopically, entered the study to receive either danazol (600 mg once daily) or LNG-IUS (inserted during immediate post operative period) postsurgery, for pain relief. Patients were analysed for pain relief according to VAS score and recurrence of disease using ultrasonography at third and sixth months of follow up. Results: There were 50% patients in stage IV of endometriosis. Majority of them presented with complaint of infertility (49%) and pelvic pain (43%). It was observed that LNG-IUS was significantly more effective in relieving pain compared to danazol (65.2% vs 38.0%, p<0.05). Recurrence rate was significantly lower in LNG-IUS users compared to other group. Conclusion: LNG-IUS was found to be more effective in relieving pain compared to danazol.

Correlation of Serum Prolactin Level to Child Pugh Scoring System in Cirrhosis of Liver

Chaitanya H. Balakrishnan, H Rajeev

Introduction: With the growing incidence of liver cirrhosis among Asians, the use of a biomarker such as prolactin, indicates the severity of the disease, its complications and serves as a tool for early intervention. Aim: To compare the efficacy of serum prolactin to the Child Pugh scoring system in cirrhosis of the liver and establish that serum prolactin is an early marker for complications of cirrhosis of the liver. Materials and Methods: This was a comparative study on 60 patients admitted to the Department of General Medicine, KIMSH from June 2014 to November 2015. Patients above the age of 18 years, diagnosed to have cirrhosis of the liver were included in the study. Patients having conditions/medications known to elevate prolactin levels such as cranial surgery/irradiation, pituitary disease, chronic renal failure, drugs such as neuroleptics, metoclopramide, aldosterone antagonists, etc., were excluded. All the patients were subjected to the routine work up for chronic liver disease including serum prolactin levels at admission. Results: In the present study, the most common cause of cirrhosis was found to be alcohol (73%). The complications of cirrhosis were portal hypertension in 50 (83.3%), oesophageal varices in 39 (65%) with upper GI bleed in 22 (36.7%) patients, hepatic encephalopathy in 15 (25%) patients. Serum prolactin levels were elevated in 73% of the patients with highest levels of serum prolactin (>35 ng/ml) seen in patients of Class ‘C’ Child Pugh. Elevated serum prolactin was found in 66.7% of the patients with oesophageal varices, 90.9% patients with upper GI bleed and in all patients with hepatic encephalopathy (100%). Conclusion: Serum prolactin levels correlated with the Child Pugh score in predicting the severity of the disease. Patients with a higher serum prolactin at admission had a greater incidence of complications of cirrhosis. Hence, serum prolactin is an inexpensive, non invasive blood marker which may be used to estimate the severity and the complications of cirrhosis.

Effect of Radiofrequency Radiation Emitted from 2G and 3G Cell Phone on Developing Liver of Chick Embryo – A Comparative Study

Mary Hydrina D’Silva, Rijied Thompson Swer, J. Anbalagan, Bhargavan Rajesh

Introduction: The increasing scientific evidence of various health hazards on exposure of Radiofrequency Radiation (RFR) emitted from both the cell phones and base stations have caused significant media attention and public discussion in recent years. The mechanism of interaction of RF fields with developing tissues of children and fetuses may be different from that of adults due to their smaller physical size and variation in tissue electromagnetic properties. The present study may provide an insight into the basic mechanisms by which RF fields interact with developing tissues in an embryo. Aim: To evaluate the possible tissue and DNA damage in developing liver of chick embryo following chronic exposure to Ultra-High Frequency/Radiofrequency Radiation (UHF/RFR) emitted from 2G and 3G cell phone. Materials and Methods: Fertilized chick embryos were incubated in four groups. Group A-experimental group exposed to 2G radiation (60 eggs), Group B- experimental group exposed to 3G radiation (60 eggs), Group C- sham exposed control group (60 eggs) and Group D– control group (48 eggs). On completion of scheduled duration, the embryos were collected and processed for routine histological studies to check structural changes in liver. The nuclear diameter and karyorrhexis changes of hepatocytes were analysed using oculometer and square reticule respectively. The liver procured from one batch of eggs from all the four groups was subjected to alkaline comet assay technique to assess DNA damage. The results were compared using one-way ANOVA test. Results: In our study, the exposure of developing chick embryos to 2G and 3G cell phone radiations caused structural changes in liver in the form of dilated sinusoidal spaces with haemorrhage, increased vacuolations in cytoplasm, increased nuclear diameter and karyorrhexis and significantly increased DNA damage. Conclusion: The chronic exposure of chick embryo liver to RFR emitted from 2G and 3G cell phone resulted in various structural changes and DNA damage. The changes were more pronounced in 3G experimental group. Based on these findings it is necessary to create awareness among public about the possible ill effects of RFR exposure from cell phone.

Thyroid Hormone Levels in Chronic Alcoholic Liver Disease Patients Before and After Treatment

Jaswanth Kumar Papineni, Venkata Bharat kumar Pinnelli, Raghavendra Davanum

Introduction: Alcoholic liver disease affects almost all aspects of the thyroid gland including the thyroid hormone levels and the thyroid gland size. The altered thyroid hormone levels in alcoholic liver disease may affect alcohol abstinence in withdrawal period by changing hormone milieu in brain, increasing withdrawal dysphoria and increasing craving. Aim: The aim of the present study was to assess and compare the levels of thyroid hormones- free T3, free T4, Thyroid Stimulating Hormone (TSH) and Gamma Glutamyl Transferase (GGT) in chronic alcoholic liver disease patients before and after treatment. Materials and Methods: This study was conducted on 70 alcoholic liver disease patients. Two serum samples were taken from the patient once at the time of admission and the other at the time of discharge after atleast ten days of treatment. Serum free T3, free T4, TSH and GGT were assessed on auto analyzer Beckman Coulter. Statistical analysis is done by paired t-test and Pearson's Correlation test. Results: In present study, serum GGT levels decreased significantly (before treatment-207.46±66.90 U/L; after treatment-78.47±19.71 U/L) and free T3 levels increased significantly with treatment (before treatment-2.54±0.48 pg/mL; after treatment-2.88±0.37 pg/mL). Free T4 levels are also increased with treatment (before treatment-0.78±0.19 ng/dL; after treatment-0.88±0.13 ng/dL) and TSH levels are not altered significantly with treatment (before treatment-3.34±1.62 µIU/mL; after treatment-3.32±1.51 µIU/mL). Additionally, free T3 showed a significant correlation with GGT before (p-value<0.001) and after treatment (p-value-0.003) and free T4 and TSH showed a significant correlation with GGT after treatment (free T4: p-value<0.001) (TSH: p-value <0.001) and a suggestive significance exists before treatment (free T4: p-value= 0.098) (TSH: p-value=0.062). Conclusion: Thyroid hormones levels, particularly free T3 and free T4, need to be evaluated in chronic alcoholic liver disease patients. Free T3 could be used as a marker of alcoholism and is very useful in assessing the treatment efficacy in chronic alcoholic liver disease. Also, assessing free thyroid hormones is necessary during the withdrawal and abstinent periods as decreased hormone levels may increase withdrawal effects and craving for alcohol.

Low Rate of babA2 Genotype among Iranian Helicobacter pylori Clinical Isolates

Introduction: The Blood Group Antigen-Binding Adhesion (babA), Outer Inflammatory Protein (oipA) and Sialic Acid-Binding Adhesin (sabA) as outer membrane proteins involved in Helicobacter pylori adherence to gastric mucosa have been suggested to have a role in the pathogenesis. Aim: To investigate the frequency of H. pylori isolates babA2, oipA and sabA genes in Iranian dyspeptic patients. Materials and Methods: DNAs were extracted from H. pylori –positive cultures taken from 100 different dyspeptic patients. Genotyping was performed by Polymerase Chain Reaction (PCR), using the specific primers for babA2, oipA and sabA genes. Chi square test was used to investigate association between variables, p<0.05 was considered statistically significant. Results: All (100%) isolates possessed oipA and sabA genotypes, whereas babA2 was detected in 22% of isolates. There was no significant relationship between presence of genes with clinical outcome. The combined genotype oipA +/sabA +/ babA2- was correlated with gastritis. The rate of babA2 genotype in our isolates was lower than other Iranian reports. Conclusion: Frequency of babA2 genotype among H. pylori isolates from Southwest of Iran is considerably less than other regions of Iran. Due to heterogeneity of H. pylori strains in different geographic regions, further work will be needed to understand the role of these virulence genes in H. pylori pathogenesis and their possible association with disease outcome.

Effectivity of Titanium Oxide Based Nano Particles on E. coli from Clinical Samples

Hima Bindu Mantravadi

Introduction: Nanoparticles composed of Titanium Oxide (TiO2) are non toxic, durable, stable and have a high refractive index with a lot of scope in biomedical applications. Due to their antibacterial effects, they can be applied to inanimate objects like glass, metal and even biomedical implants. Aim: This study was conducted to assess the antibacterial effect of Titanium Oxide (TiO2) alone or with Silver (Ag) as an additive on Escherichia coli. Materials and Methods: Escherichia coli isolates (n=25) sensitive to most of the drugs including first generation cephalosporins, ampicillin and amoxycillin from various samples like pus, urine, sputum and blood were placed onto the glass slides containing TiO2 annealed at 200°C, 400°C, TiO2 with 0.1% Ag as additive, TiO2 with 0.3% Ag, and TiO2 with 0.6% Ag as additive. Samples from this were inoculated at every hour onto sterile petri plates and observed for growth after overnight incubation at 37°C. Results: The organisms which were inoculated onto TiO2 annealed at 200°C showed a slower reduction rate from >1 × 108 cfu/ml to <1 × 10 cfu/ml only after six hours of incubation in visible light. Complete absence of colony forming units was observed after eight hours of incubation. The samples treated with TiO2 at 400°C showed no growth after six hours of incubation itself. Samples treated with TiO2 with increasing gradations of silver as additives showed proportional reduction in the incubation time for the complete absence of colony forming units. Conclusion: Our study shows that pure titanium oxide has a high antibacterial effect on pathogenic samples of Escherichia coli from clinical isolates, which is further increased with the addition of increasing concentrations of silver.

An Immunohistochemical Study of Anaplastic Lymphoma Kinase and Epidermal Growth Factor Receptor Mutation in Non-Small Cell Lung Carcinoma

Introduction: Lung cancer is one of the leading causes of cancer related death. Targeted treatment for specific markers may help in reducing the cancer related morbidity and mortality. Aim: To study expression of Anaplastic Lymphoma Kinase (ALK)and Epidermal Growth Factor Receptor (EGFR) mutations in patients of Non-Small Cell Lung Cancer NSCLC, that are the targets for specific ALK inhibitors and EGFR tyrosine kinase inhibitors. Materials and Methods: Total 69 cases of histologically diagnosed NSCLC were examined retrospectively for immunohistochemical expression of EGFR and ALK, along with positive control of normal placental tissue and anaplastic large cell lymphoma respectively. Results: Of the NSCLC, Squamous Cell Carcinoma (SCC) accounted for 71.0% and adenocarcinoma was 26.1%. ALK expression was seen in single case of 60-year-old female, non-smoker with adenocarcinoma histology. EGFR expression was seen in both SCC (59.18%) and adenocarcinoma in (77.78%) accounting for 63.77% of all cases. Both ALK and EGFR mutation were mutually exclusive. Conclusion: EGFR expression was seen in 63.77% of cases, highlighting the importance of its use in routine analysis, for targeted therapy and better treatment results. Although, ALK expression was seen in 1.45% of all cases, it is an important biomarker in targeted cancer therapy. Also, the mutually exclusive expression of these two markers need further studies to develop a diagnostic algorithm for NSCLC patients.

Hazards and Health Risks Encountered by Manual Sand Dredgers from Udupi, India: A Cross-Sectional Study

Sidhiprada Mohapatra, Alfiya Shaikh, Priyanka Nayak, Rajesh Navada

Introduction: Globalization and urbanization have resulted in an increased demand on sand dredging. Legal and environmental restrictions on automated dredging have led to a rise in manual technique. The working techniques and environment involved in manual sand dredging may expose the workers to multiple work related disorders. Aim: To determine the health risks and occupational hazards involved in manual sand dredging. Materials and Methods: An assessment schedule was developed and content was validated by five experts for the study. A cross-sectional study was then conducted using this assessment schedule. Thirty manual sand dredgers were recruited from three randomly selected docks on Swarna riverbed in Udupi district, Karnataka, India. A detailed work and worksite assessments were conducted using systematic observation and close-ended questions. Work-related health risk evaluation included onsite-evaluation and self-reported health complains. Results: The prevalence of musculoskeletal pain and discomfort was 93.34% with lower back (70%), shoulder (56.7%) and neck (46.7%) involvements being most common regions. Prevalence of sensory deficits at multiple site and ear pain was 66.6% and 76.6% respectively. All the workers recruited, complained of dermatological and ophthalmic involvements. Also, lack of health and safety measures like personal protective devices and security schemes were identified. Conclusion: This study shows a high prevalence of multiple work-related disorders and hazards involved in manual sand dredging, a highly demanding job in coastal Karnataka. Lack of health and safety measures were also identified.

Prevalence of Conventional Risk Factors and Evaluation of Baseline Indices Among Young and Elderly Patients with Coronary Artery Disease

Introduction: Coronary Artery Disease (CAD) is a leading cause of morbidity and mortality worldwide, manifesting in a variety of clinical spectrums such as an asymptomatic disease or acute coronary syndrome. It has become highly prevalent in Southeast Asia, including Pakistan. There has been little work done on the prevalence of traditional risk factors in different age groups and genders and there is a dire need to gauge the importance of baseline indices in CAD patients. Aim: To determine the prevalence of conventional risk factors and evaluate the variations in lipid profiles, electrolyte levels and haematological indices among patients with CAD in different age groups and gender. Materials and Methods: This cross-sectional study was carried out in a Tertiary Care Hospital in Karachi, Sindh, Pakistan from January to June 2016, among patients with CAD. We recorded the presence of conventional risk factors and baseline indices within the first 24 hours of admission. Continuous variables were compared using Independent t-test or Mann-Whitney test and categorical variables were compared using chi-square or Fisher’s exact test. Results: The most frequent risk factor was dyslipidemia (91.2%), followed by hypertension (70.4%), diabetes (51.2%), family history of CAD (40.0%) and smoking (29.2%). Total of 98.4% of patients had at least one risk factor. Diabetes and hypertension were found to be common in females; whereas, smoking was predominantly present in males. Diabetes and dyslipidemia were mostly encountered in elderly patients. The most frequent lipid alteration was low levels of High Density Lipoprotein (HDL). Cholesterol and HDL levels were found to be higher in females than males. Elderly patients had lower levels of HDL and higher levels of Cholesterol. The levels of haematological indices were found to be higher in males and younger patients. The median levels of serum sodium and potassium were found to be higher in elderly patients. Conclusion: Our study findings corroborate with the findings from previous studies regarding the significance of risk factors in causing cardiovascular pathology. Medical interventions and dietary control to improve body’s lipid status would be indispensable in the prevention of CAD. Deranged electrolyte levels necessitate correction of body electrolyte parameters as an adjunct in prevention strategies.

Effect of Transdermal Nitroglycerine on Doppler Velocity Waveforms of the Uterine, Umbilical and Fetal Middle Cerebral Arteries in Patients with Chronic Placental Insufficiency: A Prospective RCT

Suruchi Gupta, Meenakshi Chauhan, Jyotsna Sen, Smiti Nanda

Introduction: Increase in Nitric Oxide (NO) may be important in vascular adaptation needed to accommodate increased uteroplacental blood flow as pregnancy advances. Hence, in certain conditions like Pregnancy Induced Hypertension (PIH) and Fetal Growth Restriction (FGR), NO donors may play an effective role in increasing uteroplacental perfusion. Transdermal route appears to be a safe and effective route. Aim: To evaluate the effect of nitroglycerine patch on Doppler velocity waveforms of the uterine, umbilical and fetal middle cerebral arteries in patients with chronic placental insufficiency. Materials and Methods: A prospective randomized controlled clinical trial was conducted on eighty consecutive pregnant women with FGR with or without PIH and having evidence of altered waveform velocimetry in uterine, umbilical and fetal middle cerebral artery. They were divided into two groups- study and control group. Transdermal nitroglycerine patch (10 mg per 24 hours) was applied in study group for three consecutive days. Changes in various Doppler indices were noted after three days of patch application and compared between the two groups. Analysis was carried out using SPSS (Statistical Package for Social Studies) for Windows version 20.0 and online GraphPad software (Prism 5 for Windows) version 5.01. Results: A significant fall in the systolic and diastolic ratio (S/D), Pulsatility Index (PI) and Resistivity Index (RI) of the uterine (3.07±0.52, 1.04±0.14 and 0.54±0.10 respectively, p<0.001) and umbilical artery (3.73±3.30, 1.18±0.21and 0.64±0.07 respectively, p<0.001) was noted after three days of patch application. No such significant change was observed in the middle cerebral artery indices. Conclusion: The therapeutic approach of NO donor administration via transdermal route in pregnant patients with chronic placental insufficiency, apparently improved both maternal and fetoplacental haemodynamics, thus may help in improving perinatal outcome.

Comparison of the Different Definition Criteria for the Diagnosis of Amniotic Fluid Embolism

Introduction: There are several sets of criteria for the diagnosis of Amniotic Fluid Embolism (AFE), but little is known about their degree of agreement. Aim: To evaluate the concordance of the Japan criteria for AFE in comparison with two definitions: the US AFE registration entry criteria (the US criteria) and UK Obstetric Surveillance System criteria for defining cases of amniotic fluid embolism (the UK criteria). Materials and Methods: A retrospective observational study was conducted in which the AFE cases registered in the Obstetrical Gynecological Society of Kinki District in Japan for the period of April 2005 to December 2012 have been analysed by the expert steering obstetric committee, organized by the members of the Obstetric Research group. Cohen's kappa coefficient was used to calculate the agreement among three clinical diagnoses. For inter-group comparison, the Pearson Chi-square test was used (for categorical) and Mann-Whitney test was used (for continuous variables). Results: Among the 26 cases registered for this period, a total of 18 women were selected as having AFE according to the Japan criteria. Five women died (case fatality rate 27.8%). Agreement between the Japan criteria and the US and UK criteria was k = 0.453 and k = 0.538, respectively, reflecting moderate agreement. However, only 38.9% were given a diagnosis of AFE according to all three criteria. The factor that most often caused disagreement in diagnosis between the Japan criteria and the US criteria was “onset within 30 minutes postpartum”. The UK criteria excluded “women with postpartum haemorrhage as the first presenting feature in whom there was no evidence of cardiorespiratory compromise”. The case fatality rates in US and UK are higher than in Japan (50.0% and 38.5% vs 27.8%), but this did not result in a significant difference (p=0.497). Conclusion: The groups of subjects identified as having AFE by the Japan criteria had a medium agreement with the US (k=0.453) or UK criteria (k=0.538). These three definition criteria identified different subgroups of patients. Such disagreement has serious implications for research and treatment.

Connective Tissue Growth Factor Transgenic Mouse Develops Cardiac Hypertrophy, Lean Body Mass and Alopecia

Edem Nuglozeh

Introduction: Connective Tissue Growth Factor (CTGF/CCN2) is one of the six members of cysteine-rich, heparin-binding proteins, secreted as modular protein and recognised to play a major function in cell processes such as adhesion, migration, proliferation and differentiation as well as chondrogenesis, skeletogenesis, angiogenesis and wound healing. The capacity of CTGF to interact with different growth factors lends an important role during early and late development, especially in the anterior region of the embryo. CTGF Knockout (KO) mice have several craniofacial defects and bone miss shaped due to an impairment of the vascular system development during chondrogenesis. Aim: The aim of the study was to establish an association between multiple modular functions of CTGF and the phenotype and cardiovascular functions in transgenic mouse. Materials and Methods: Bicistronic cassette was constructed using pIRES expressing vector (Clontech, Palo Alto, CA). The construct harbours mouse cDNA in tandem with LacZ cDNA as a reporter gene under the control of Cytomegalovirus (CMV) promoter. The plasmid was linearised with NotI restriction enzyme, and 50 ng of linearised plasmid was injected into mouse pronucleus for the chimaera production. Immunohistochemical methods were used to assess the colocalisation renin and CTGF as well as morphology and rheology of the cardiovascular system. Results: The chimeric mice were backcrossed against the wild-type C57BL/6 to generate hemizygous (F1) mouse. Most of the offsprings died as a result of respiratory distress and those that survived have low CTGF gene copy number, approximately 40 molecules per mouse genome. The copy number assessment on the dead pups showed 5×103 molecules per mouse genome explaining the threshold of the gene in terms of toxicity. Interestingly, the result of this cross showed 85% of the progenies to be positive deviating from Mendelian first law. All F2 progenies died excluding the possibility of establishing the CTGF transgenic mouse line, situation that compelled us to work at the level of hemizygosity. The histological characterisation of left ventricle shows cardiac hypertrophy together with decrease in body mass and alopecia, this compared to the wild type. The immunohistochemical staining of aorta root showed hyperplasia with increased expression and colocalisation of renin and CTGF demonstrating that CTGF may be involved in vascular tone control. Conclusion: Genetic engineering is a noble avenue to investigate the function of new or existing genes. Our data have shown that CTGF transgenic mouse has cardiac and aorta root hypertrophy and abnormal renin accumulation in aorta root as compared to the wild-type animals. The transgenic animals developed alopecia and lean body mass adding two new functions on pre-existing CTGF multiple functions.

Diagnostic Performance of Serum Human Epididymis Protein 4 in Endometrial Carcinoma: A Pilot Study

Rupali Dewan, Abhinav Dewan, Swati Hare, Mausumi Bhardwaj, Krati Mehrotra

Introduction: Endometrial Cancer (EC) is a common female malignant disorder. To date, there are no specific tumor markers for EC that may be routinely used in clinical practice for diagnosis. Aim: To evaluate the diagnostic performance of the serum Human Epididymis protein 4 (HE4) as biomarker for EC and to determine its association with clinicopathological variables. Materials and Methods: The study population included 60 postmenopausal women with a diagnosis of EC and 60 healthy postmenopausal female subjects (control group). Concentrations of serum HE4 and CA-125 in EC patients and control group were determined using Enzyme-Linked Immunosorbent Assays (ELISA). The value of serum HE4 and CA-125 for the diagnosis and prediction of stage, histology, myometrial invasion and lymph nodal metastasis was analysed. Results: The mean serum HE4 and CA-125 levels were significantly higher in patients with EC than those with control group (p<0.05). Comparison for HE4 and CA-125 between different stages showed a statistically significant difference. Stage I EC patients with <50% myometrial invasion had a significantly lower mean serum HE4 value than patients with >50% myometrial invasion (p=0.007). Corresponding values of CA-125 showed a similar trend (p=0.023). There were significantly higher levels of HE4 and CA-125 in cases with lymph node involvement. The levels of serum HE4 and CA-125 were higher in the non-endometroid histology, but the difference was not statistically significant. The Receiver Operating Characteristics (ROC) curve analysis for EC and control group showed that HE4 had greater Area Under Curve (AUC) when compared with CA-125. Using ROC curve, a serum HE4 concentration of 69.8 pmol/l (AUC 0.974) and/or serum CA-125 level of 34.50 U/mL (AUC 0.714) was used to predict malignancy. Sensitivity of combined biomarkers showed no additional improvement in comparison to HE4 or CA-125 alone. Conclusion: Our results show that HE4 is a sensitive diagnostic serum marker for detection of EC patients, exhibiting a better diagnostic performance compared to CA-125. Good performance of HE4 in diagnosis of early stages EC indicates its usefulness as a prognostic marker and also to monitor therapy and detect early recurrence.

Association between Socioeconomic Status and Diabetes Mellitus: The National Socioeconomics Survey, 2010 and 2012

Introduction: The prevalence of Diabetes Mellitus (DM) is increasing, globally. However, studies on the association between Socioeconomic Status (SES) factors and DM have mostly been conducted in specific areas with rather small sample sizes or not with nationally representative samples. Their results have also been inconclusive regarding whether SES has any influence on DM or not. Aim: To determine the association between SES and DM in Thailand. Materials and Methods: This study utilized the data from the National socioeconomics survey, a cross-sectional study conducted by the National Statistical Office (NSO) in 2010 and 2012. A total of 17,045 and 16,903 participants respectively who met the inclusion criteria were included in this study. The information was collected by face-to-face interview with structured questionnaires. Multilevel mixed-effects logistic regression analysis was performed to determine the potential socioeconomic factors associated with DM. Results: The prevalence of DM was 3.70% (95% CI: 3.36 to 4.05) and 8.11% (95%CI: 6.25 to 9.74) in 2010 and 2012 respectively and the prevalence of DM in 2012 was 1.36 times (95% CI: 1.25 to 1.48) when compared with 2010. The multilevel mixed-effects logistic regression observed that odds of having DM were significantly higher among those who aged 55-64 years old in 2010 and 65 years old or greater in 2012 (ORadj = 18.13; 95%CI: 9.11 to 36.08, ORadj 31.69; 95%CI: 20.78 to 48.33, respectively), females (ORadj = 2.09; 95%CI: 1.66 to 2.62, ORadj = 1.77; 95%CI: 1.54 to 2.05, respectively), and had lower education attainment (ORadj = 5.87; 95%CI: 4.70 to 7.33, ORadj= 1.22; 95%CI: 1.04 to 1.45, respectively) were also found to be associated with DM . Conclusion: The study indicated that SES has been associated with DM. Those with female gender, old age and low educational attainment were vulnerable to DM.

Detection of Dental Pathologies in Routine Paranasal CT Scans: A Retrospective Study

Erdogan Bulbul, Bahar Yanik, Gulen Demirpolat

Introduction: Multidetector Computed Tomography (MDCT) is a widespread method for evaluating paranasal sinuses and nasal cavity in daily practice. The maxillary teeth are in field of view in a paranasal sinus CT scan and it is possible to detect dental pathologies with CT. Aim: To determine the incidence of maxillary teeth pathologies in routine paranasal sinus CT scans. Materials and Methods: A retrospective study was conducted. Consecutive 395 paranasal sinus CT scans were evaluated. All CT images were obtained with a 64 detector-CT. Patients with previous facial trauma, operation, invasive tumors and repeated exams were excluded. Detected findings were classified as “tooth loss, dental restorations or procedures and dental pathologies (carious lesions, dental developmental anomalies, periapical lesions and periodontal diseases). The proportion of findings was reported as simple percentiles. Results: Three hundred and eighty-four CT scans were included in the study. Dental restorations or procedures were determined in 129 (33.5%) patients. A total of 34 (8.8%) patients had normal teeth count and morphology. A total of 264 (64.3%) patients had at least one tooth loss. A total of 195 (51%) patients had at least one or more dental pathology. Number of dental carious lesions, dental developmental anomalies, periapical lesions and periodontal disease were 104 (27.0%), 78 (14.3%), 46 (11.9%), 44 (11.4%), respectively. Conclusion: Dental pathologies were encountered in more than half of the patients. Detecting dental pathologies may prevent tooth loss and improve oral health. The radiologist should keep in mind dental pathologies while evaluating paranasal sinus CT in daily practice.

Spectrum of MRI Appearance of Mayer-Rokitansky-Kuster-Hauser (MRKH) Syndrome in Primary Amenorrhea Patients

Introduction: Mayer-Rokitansky-Kuster-Hauser (MRKH) synd-rome is a malformation in female genital tract due to interrupted embryonic development of para-mesonephric ducts leading to uterine and proximal vagina aplasia or hypoplasia. Aim: To analyse the MRI findings in females suspected of MRKH syndrome in a primary amenorrhea workup. Materials and Methods: A cross sectional study comprising of 11 patients of MRKH syndrome presented in a tertiary care centre from March 2016 to February 2017 evaluated in 1.5 Tesla MRI scanner. Results: Normal positioned small vestigial uterus demonstrated in two patients (18.2%) and complete uterine and proximal vaginal agenesis were noted in nine patients (81.8%). The mean volume of rudimentary right uterine bud was 2.26 mL ±3.3 (SD) and left uterine bud was 1.27 mL±1.1 (SD). The mean volume of right ovary was 4.74 mL±2.58 (SD) and left ovary was 4.65 mL±2.2 (SD). The mean developed vaginal length was 26.2 mm±6.34 (SD). Conclusion: The rudimentary uterine buds associated with MRKH syndrome always maintained caudal relationship with ovary. Ovaries or rudimentary uterine buds can be ectopic and should be recognized with MRI before undergoing fertility treatment. Following MRI diagnosis, surgery allows patients to have sexual function with possible attainment of reproduction after assisted reproduction technique or surrogacy.

An Analysis into Metacognition and Family History of Diabetes Mellitus among First Year Medical Students

AK Sunitha Priya, Rose Babu, Pallavi Panchu, Biju Bahuleyan

Introduction: Medical course requires immense effort by the students to deal with vast curriculum and hence, the need to adopt metacognitive skill to cope up. Diabetes mellitus has an impact on cognition. Metacognition, being a component of cognition, is likely to be affected by diabetes. Children of diabetic parents have demonstrated insulin resistance which may contribute to metacognitive dysfunction. Hence, it is important to focus into the link between family history of diabetes and metacognition. Aim: To evaluate the impact of family history (parents and grandparents) of diabetes mellitus on metacognition in medical students. Materials and Methods: The present study was a questionnaire based cross-sectional study. Hundred first year medical students were recruited and they filled the Metacognitive Awareness (MA) questionnaire along with the details of the family history of diabetes. The metacognitive awareness questionnaire evaluated MA, its components (metacognitive knowledge and regulation) and their subcomponents. Positive history of diabetes in parents and grandparents were taken into account. The participants were then divided into two groups: with family history of diabetes (n=73) and without family history of diabetes (n=27). The metacognitive awareness and its subcomponents between the two groups were analysed using Student t-test between the groups (with and without family history). Pearson correlation was done to analyse the association between metacognition and family history of diabetes. Results: Metacognitive knowledge (global score) was significantly lower in group with family history of diabetes (10.25±3.01 vs 12.04±3.2, p-value<0.05) as was metacognitive regulation global score (7.08±1.83 vs 7.99±1.36, p-value<0.05). Declarative knowledge and information management showed significant difference. Metacognitive knowledge showed a significant negative correlation with family history of diabetes (correlation coefficient = -0.263, p-value<0.01). Conclusion: Students with family history of diabetes had reduced metacognitive awareness. The awareness that metacognitive dysfunction can occur in early age in individuals with family history of diabetes would help us to identify them and device strategies to delay or prevent metacognitive dysfunction.

Circulating Protein Carbonyls, Antioxidant Enzymes and Related Trace Minerals among Preterms with Respiratory Distress Syndrome

Ahmed El-Abd Ahmed, Eman Ahmed Abd-Elmawgood, Mohammed H. Hassan

Introduction: Information about oxidative stress in preterms with Respiratory Distress Syndrome (RDS) is defective, so various researches in this area are required, which may open new roads in understanding the pathogenesis of the disease, hence provide additional helpful therapeutic approaches. Aim: To assess and compare the plasma level of protein carbonyls as a marker for oxidant status and the antioxidant enzymes; Superoxide Dismutase (SOD) and Glutathione Peroxidase (GPx) and the related trace minerals in the form of Copper (Cu), Zinc (Zn) and Selenium (Se) as markers for antioxidant status, in preterms with and without RDS. Materials and Methods: A hospital-based case-control study was conducted on fifty-seven preterm neonates (37 preterms with RDS and 20 preterms without RDS) admitted to neonatal intensive care unit of Qena University Hospitals after approval of the University Hospital Ethical Committee. Plasma protein carbonyls assay was done using commercially available ELISA assay kit. Plasma Cu, Zn, Se, erythrocyte SOD and GPx activities assays were done using commercially available colorimetric assay kits. Results: Significant higher plasma levels of protein carbonyls and oxidant/antioxidants ratio (protein carbonyls/{SOD+GPx}) with significant lower plasma levels of Zn, Cu, Se, erythrocyte SOD and GPx activities were found in the preterms with RDS when compared with the preterms without RDS (p<0.001 for all measured markers for both groups). In terms of birth weights and gestational ages, they were negatively correlated with both plasma protein carbonyls and oxidant/antioxidants ratio and positively correlated with plasma copper, zinc, selenium, erythrocyte SOD and GPx activities in a statistically significant manner. Non-significant correlations were found between the measured oxidative stress markers and the severity of RDS. Conclusion: Oxidative stress may have a contributory role in the development of RDS among preterms. Lower birth weight and prematurity may increase the susceptibity to oxidative stress among such patients.

Anaerobic Bacteria in Clinical Specimens – Frequent, But a Neglected Lot: A Five Year Experience at a Tertiary Care Hospital

Introduction: Anaerobic bacteria which constitute a significant proportion of the normal microbiota also cause variety of infections involving various anatomic sites. Considering the tedious culture techniques with longer turnaround time, anaerobic cultures are usually neglected by clinicians and microbiologists. Aim: To study the frequency of isolation of different anaerobic bacteria from various clinical specimens. Materials and Methods: A retrospective study to analyse the frequency of isolation of different anaerobic bacteria, was conducted over a period of five years from 2011 to 2015 including various clinical specimens submitted to anaerobic division of Microbiology laboratory. Anaerobic bacteria were isolated and identified following standard bacteriological techniques. Results: Pathogenic anaerobes (n=336) were isolated from 278 (12.48%) of overall 2227 specimens processed with an average yield of 1.2 isolates. Anaerobes were isolated as polymicrobial flora with or without aerobic bacterial pathogens in 159 (57.2%) patients. Anaerobic Gram-negative bacilli (140, 41.7%) were the predominant isolates. B. fragilis group (67, 19.9%) were the most commonly isolated anaerobic pathogens. Anaerobes were predominantly isolated from deep seated abscess (23.9%). Conclusion: Pathogenic anaerobes were isolated from various infection sites. Unless culture and susceptibility tests are performed as a routine, true magnitude of antimicrobial resistance among anaerobic pathogens will not be known. Knowledge of the distribution of these organisms may assist in the selection of appropriate empirical therapy for anaerobic infections.

Antidiabetic Activity of Aqueous Extract of Solanum nigrum Linn Berries in Alloxan Induced Diabetic Wistar Albino Rats

MS Umamageswari, TM Karthikeyan, Yasmeen A Maniyar

Introduction: Solanum nigrum Linn. is a common medicinal plant possessing a wide variety of pharmacological activity. Current treatment of diabetes mellitus has plenty of adverse effects necessitating the search of alternate drugs. Aim: Evaluation of antidiabetic effect of Aqueous Extract of Solanum Nigrum Linn Berries (AESNB) in alloxan induced diabetic Wistar rats. Materials and Methods: There were five groups (normal control, diabetic control, AESNB 200 mg/kg/day, ASENB 400 mg/kg/day and standard i.e., glimepride 0.1 mg/kg/day) with six animals in each group. Alloxan was used to induce diabetes in rats. The standard drug glimepride in the dose of 0.1 mg/kg/day and the test drug AESNB were given orally in the doses of 200 mg/kg/day and 400 mg/kg/day. The fasting blood glucose level was measured by glucometer on day 0, 1,7,14 and 21 after 12 hour. On 21st day after the blood glucose measurement all the animals were sacrificed and pancreas were analysed histopathologically. The results were analysed statistically by using one-way ANOVA. Results:Aqueous extract of Solanum nigrum Linn berries in the dose of 200 mg/kg/day produced significant blood glucose reduction (p<0.01) from day 7 and 400 mg/kg/day produced highly significant reduction in blood glucose from day 7 (p<0.001). The standard drug glimepride reduced the blood glucose as equal to normal on day 21 (p<0.001). Histopathological examination showed the regeneration of pancreatic beta cells in AESNB group. Conclusion: Aqueous extract of Solanum nigrum Linn berries possess antidiabetic activity.

Changes in Gas Composition during Low Flow Anaesthesia without Nitrous Oxide

Ranjana Venkatachalapathy, Anusha Cherian, Sakthirajan Panneerselvam

Introduction: Low flow anaesthesia utilising Oxygen (O2) and Nitrous Oxide (N2O) mixture carries a risk of hypoxia, but avoiding N2O results in increased analgesic and volatile anaesthetic agent requirement. Aim: This study attempted to find the lowest Fraction of inspired Oxygen (FiO2) levels achieved with a mixture of 300 mL/min each of O2 and medical air over two hours, and to compare the overall analgesic requirement and cost while using similar flows of N2O and O2, respectively. Materials and Methods: A prospective observational study was conducted between March 2015 and June 2016 at the Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. Patients of American Society of Anaesthesiologists (ASA) Grade 1 and 2 undergoing surgery under general anaesthesia with an endotracheal tube were included in the study, in two groups of 40 each. In the initial ten minutes following induction of anaesthesia, both groups received high Fresh Gas Flows (FGF) of 3 L/min each (Group O: medical air and oxygen; Group N: N2O and oxygen), following which the FGF rates were reduced to 300 ml/min each. Any value of FiO2 lesser than 0.3 during the duration of anaesthesia was considered to render the technique unsafe for clinical use. SPSS software version 20.0 was used to generate data and figures. Results: The lowest FiO2 recorded was 0.33 in Group O and 0.3 in Group N which occurred at the end of two hours. Mean analgesic requirement was significantly higher in Group O compared to Group N (151.85 µg, 124.85 µg; p-value=0.004) with a 62% increase in the cost incurred. Conclusion: The use of medical air and oxygen in flows of 300 ml/min each following initial high flows of 3 L/min appears to be a safe technique. However, this combination was associated with an increase in the cost of anaesthesia and in the need for additional intra-operative analgesia.

Prediction of the Dimensions of the Spiritual Well-Being of Students at Kermanshah University of Medical Sciences, Iran: The Roles of Demographic Variables

Arash Ziapour, Alireza Khatony, Faranak Jafaafari, Neda Kianipour

Introduction: Spiritual well-being is one of the aspects of well-being which organize the physical, psychological, and social aspects. Given the outstanding and unique roles of students in society, providing spiritual well-being as well as identifying and eliminating the negative factors affecting their mental well-being are of the essence. Aim: The present study aimed to predict the dimensions of the spiritual well-being of students at Kermanshah University of Medical Sciences and to investigate the roles of demographic variables in this respect. Materials and Methods: In this descriptive and correlational study, the statistical population was comprised of 346 doctoral students in the for-profit Schools of Medicine, Dentistry and Pharmaceuticals in Kermanshah University of Medical Sciences in 2016. For data collection, an instrument comprising the demographic questions and the 20-item spiritual well-being scale by Paloutzian and Ellison (1982) was utilized. To analyze data, the descriptive (frequency distribution, mean, and standard deviation) and inferential statistics (independent t-test, one-way ANOVA, and chi-squared test) were employed in the SPSS Statistics Software Version 21.0. Results: The results of the present study demonstrated that the spiritual well-being of students was average (71.86±4.84), and of all demographic variables under study, only the variable of gender significantly correlated with the mean score of spiritual well-being. Also, the results revealed that the students’ score of religious well-being measured higher than that of their existential well-being. However, a significant correlation was found between spiritual well-being and its dimensions. Also, the religious and existential well-being were found to be significantly related (p<0.05). Conclusion: The results of the present study showed the significance of addressing the issue of spirituality among the students of the for-profit Schools at Kermanshah University of Medical Sciences. Therefore, it is recommended that appropriate plans be laid by the culture and education policy makers to promote the spiritual well-being of university students.

Diagnosis and Treatment of Duodenal Lipoma: A Systematic Review and a Case Report

Mao Wei Pei, Ming Rong Hu, Wen Bin Chen, Chao Qin

Introduction: Duodenal lipoma is very rare with limited case reports present in literature. Owing to recent advances in endoscopy and modern imaging techniques, more cases are being diagnosed and treated. However, no systematic study of duodenal lipomas has been reported. Aim: To study the diagnosis and treatment of duodenal lipoma in a female patient and review the relative literatures to enhance the knowledge of it. Materials and Methods: A literature search for ‘duodenal lipoma’ was performed on PubMed. Papers published from 1948 to 2016 in the English language were identified. Each article was then read in detail and analysed for clinical data, imaging features, diagnosis and therapy. Also, we hereby present a case of upper gastrointestinal obstruction secondary to multiple duodenal lipomas in a 67-year-old woman. The patient underwent a limited bowel resection with an uneventful recovery. Results: Literature review demonstrated 59 cases of duodenal lipoma, which indicate that duodenal lipomas are rare to occur but commonly found in the second part. The peak of incidence seems to be around the fifth and seventh decade of life. Duodenal lipomas may present as gastrointestinal bleeding, abdominal pain, obstruction or upper abdominal fullness. CT, MRI, Endoscopic Ultrasound (EUS), endoscopy are highly accurate diagnostic tools. The disease could be managed by endoscopy or surgery. Conclusion: Our review of literature indicated duodenal lipoma is extremely rare. The symptoms are nonspecific and CT is the first choice for diagnosis. The treatment depends on the patient’s condition as well as the size and position of the tumour.

Indian Perspectives on Graft Materials Used for Repair of Tympanic Membrane

Manu Malhotra, Saurabh Varshney, Rashmi Malhotra, Poonam Joshi

Introduction: Repair of Tympanic Membrane (TM) is one of the most common surgeries performed by the otologists. Literature reveals that Indian surgeons have contributed substantially in the research on techniques and graft materials used for the repair of tympanic membrane, though no review has been written so far highlighting their contributions. Aim: To summarize and analyse the contributions of Indian authors who have used different graft materials for repair of TM and their studies listed in Medline search. Materials and Methods: A literature review was conducted using a Medline search using keywords of ‘myringoplasty’ and ‘tympanoplasty’ with ‘India’ on 30th June 2016. A total of 243 articles were found listed onwards from year 1998. Out of these 50 articles in which type 1 tympanoplasty or myringoplasty was performed using different graft materials were selected. The content of each abstract was studied in order to identify studies related to topic. Results: Authors have experimented with a variety of tissues as graft materials. Temporalis Fascia (TF) has been most widely used in 58.6% studies as graft material. The next popular graft is tragal perichondrium. The graft take up rates varied from 68.5% to 100%, while method of reporting of hearing gain in most studies was inconsistent amongst studies, though most studies have reported achievement of serviceable hearing of < 25 dB in most patients. Conclusion: TF was the most prefered material due to anatomic proximity, light material and strength. It was followed in popularity by tragal perichondrium and tragal cartilage. All graft materials have given satisfactory hearing results.

First Detection and Characterization of Streptococcus dentapri from Caries Active Subject

Hamzah Abdulrahman Salman, R. Senthil Kumar, N. Chaitanya Babu, Khalid Imran

Introduction: Mutans streptococci (MS) are a group of oral bacteria generally regarded as the principal agents in the pathogenesis of dental caries. Aim: The study was aimed to characterize S. dentapri based on phylogenetic analysis and phenotypic methods from Caries Active Subject. Materials and Methods: While sequencing MS species which were isolated from 65 caries active subjects, one strain of S. dentapri was detected. Dental plaque samples were processed and cultured on mitis salivarius bacitracin agar. S. dentapri was characterized using phylogenetic analysis, colony morphology characterization and biotyping. Results: Among the study population, one strain designated as H14 was identified as S. dentapri by 16S rDNA sequencing. Morphologically, S. dentapri could not differentiate from other species of MS. S. dentapri H14 demonstrated biotype II biochemical characteristics of MS. The phylogenetic analysis showed S. dentapri is closely related to S. macacae. Conclusion: The study concludes that S. dentapri can inhabit the human oral cavity and therefore further investigations are warranted to determine its role in caries.

Large Eccrine Acrospiroma of the Hand

Eccrine acrospiroma are benign skin tumours of sweat duct origin. They usually present as small solid or cystic lesions which are confused clinically with other solid or cystic lesions. These are generally benign lesions with few reports of malignant transformation. Here, we report a case of a middle aged female presenting with a swelling of the dorsum of left first web space which was histopathologically diagnosed as an eccrine acrospiroma, which was managed with surgical excision and covered with a regional flap. This case is presented due to the large size of the lesion in the hand.