Journal of clinical and diagnostic research

Gigantic Pulmonary Arteriovenous Malformation Presenting as Recurrent Lung Infection

Brajesh Kumar Kunwar, Farah Ingle, Atul Ingle, Chandrasekhar Tulagseri

The abnormal connection between pulmonary arterial and venous circulation is known as Pulmonary Arteriovenous Malformation (PAVM). It was first described by Churton in 1897. The presentation varies from incidental findings to shortness of breath, haemoptysis, chest pain, syncope and cyanosis. Patients with hereditary haemorrhagic telangiectasia are prone to develop PAVM. PAVMs are quite rare, the frequency ranges from 2-3 per 1,00,000 population. Treatment options include surgical intervention and embolisation, the former is now used seldom. The surgical intervention is more invasive than the percutaneous intervention procedure also known as embolotherapy or embolisation. In the present case, authors encountered a rare case of a 30-year-old male presented with giant PAVM with 13 mm diameter (60.65×35.32 mm in dimensions), where patient presented with fever since two months and vomiting. Considering his symptoms, he was initially suspected as Coronavirus-2019 (COVID-19) positive. However, his Reverse Transcription-Polymerase Chain Reaction (RT-PCR) test was reported negative. It was decided to treat him with vascular plug embolisation. A 16 mm Ampletzer vascular plug II was deployed in such a way that it does not occlude the lower branches of Left Pulmonary Artery (LPA). After deploying the vascular plug, the patient was stable and tolerated the procedure well. He was discharged after two days of observation considering his haemodynamic stability.

Necrotising Cutaneous Lesions in Anti Neutrophil Cytoplasmic Antibodies- Associated Vasculitis Mimicking Necrotising Fasciitis

Necrotising vasculitis is a very rare occurrence and commonly caused by an underlying autoimmune pathology. Anti Neutrophil Cytoplasmic Antibodies (ANCA) associated vasculitis is an established cause for cutaneous manifestations of necrotising vasculitis, and is associated with multisystemic involvement, in which presentations of one system may feature predominantly and lead to misdiagnosis. A 33-year-old male presented with acute history of shortness of breath and necrotising blisters over both his ankles and arms. He was initially provisionally diagnosed with necrotising fasciitis, which was eventually ruled out as the serological biomarkers (including low level of C3 and presence of cytoplasmic type of ANCA on indirect immunofluorescence) drew suspicion of an autoimmune pathology. A multidisciplinary approach led to the commencement of steroid, which improved the patient’s condition rapidly. The histological examination of sample from the skin biopsy later confirmed the diagnosis of ANCA-Associated Vasculitis (AAV). The patient eventually recovered with excellent outcomes. Despite its rarity, any abnormal skin lesion may be a subtle presentation of necrotising cutaneous vasculitis. A high index of suspicion through a multidisciplinary approach, coupled with meticulous investigative process including serological biomarkers and skin biopsy, helps to avoid misdiagnosis which may be detrimental to the patient.

Empty Sella Syndrome with Typical Facies: A Case Report

Megha Mukundan, Prativa Sethi, Prasan Kumar Panda

Empty Sella syndrome with typical facies is a rare presentation of panhypopituitarism. Here, authors presented a case of 45-year-old male with a history of altered behaviour such as low mood, passivity, talkativeness with low-hoarse voice and spells of cries for three months. He also had headache, vomiting, abdominal pain, ataxic gait, and loss of libido. He had meningitis 10 years back since then he had multiple similar episodes. He had sparse thinned out hair, male pattern temporal balding, madarosis, brownish pigmentation of face and chest and dry coarse skin. Patient had hypotension but without hypoperfusion. Hormone levels including thyroid hormones, Follicle Stimulating Hormone (FSH), Luteinizing hormone (LH), total testosterone cortisol, and plasma Adrenocorticotropic Hormone (ACTH) were less than normal. Magnetic Resonance Imaging (MRI) brain suggested streak pituitary gland (empty sella). He was supplemented with required hormones. On follow-up, he improved significantly. Trio composite hypothyroidism, hypocortisolism, and hypogonadism have characteristic facies. This unique presentation of patient with blank look facies gives a hint of empty sella, thus leading the clinician to diagnose the disease through timely evaluation and work-up.

Spontaneous Splenic Rupture: A Rare Complication of Acute Pancreatitis

Raghav Yelamanchi, Nikhil Gupta, Himanshu Agrawal, Dipankar Naskar

The spleen and its vasculature due to the close proximity with the pancreas are prone to complications during any inflammatory process affecting the pancreas. Spontaneous subcapsular splenic haematoma with rupture is one of the rarest complications of pancreatitis. In this case report one such rare complication of splenic rupture as a sequel of acute pancreatitis was reported. A 45-year-old male with a history of gallstone induced severe acute pancreatitis had presented to the emergency with abdominal pain and swelling after one month of initial attack. On evaluation, there was an ill-defined tender lump was palpable in the left hypochondrium with a drop in haemoglobin level from 10.2 gm/dL to 6 gm/dL when compared to the previous admission one month back. Imaging was suggestive of grade four splenic injury with rupture. The patient underwent splenectomy along with cholecystectomy. Spontaneous splenic rupture is one of the rarest complications of acute pancreatitis and one must consider other vascular complications as differential diagnosis.

An Autopsy of Acute Adrenal Insufficiency Resulting from Infarction of Both Adrenal Glands, in a Pregnant Woman with Metastatic Carcinoma of the Breast

Gwendolyn Fernandes, Sharada Datar

Acute Adrenal Insufficiency (AAI) is a life-threatening medical emergency, associated with high mortality, and requires early diagnosis and prompt management. This is an unusual case report of a 34-year-old female who was diagnosed with breast cancer, in the second trimester of pregnancy. She presented at 33 weeks gestation, in the emergency services, with convulsions, weakness, altered sensorium and high-grade infiltrating duct carcinoma of breast with liver metastasis. She had also received a single cycle of chemotherapy with adriamycin and cyclophosphamide, at 33 weeks of pregnancy. Her condition deteriorated within 12-16 hours, and she developed abdominal pain, generalised weakness and convulsions. The patient was induced into labour, which was complicated, and delivered a still born male child. She also developed acute kidney injury and severe electrolyte imbalance, and died within four days of admission. A complete postmortem examination was performed where the cause of death was AAI following infarction of both adrenal glands in a background of metastatic carcinoma of the breast. It is strongly suspected that chemotherapy with adriamycin and cyclophosphamide is the primary cause of AAI in the present case. However, the etiology could also be multifactorial as factors like, sepsis, intrauterine foetal death and Disseminated Intravascular Coagulation (DIC) were also present.

Sarcoidosis and Primary Biliary Cholangitis- An Overlap

Primary Biliary Cholangitis (PBC) is a chronic progressive autoimmune cholestatic liver disease. Sarcoidosis is a multisystem chronic granulomatous disease. Both diseases are known to affect the liver causing granulomas. Sarcoidosis commonly involves the skin while PBC is associated with autoimmune skin disorders. Diagnosis of PBC requires biochemical, serological and histological confirmation. Steroids are used in the treatment of sarcoidosis. The role of steroids in the treatment of PBC is not completely established. In this case report, authors present the case of a 31-years-old female diagnosed as sarcoidosis based on granulomatous lesions in skin biopsy with concurrent PBC diagnosed on basis of serology and liver biopsy.

Shepherd’s Crook Deformity with Pathological Femur Neck Fracture in a Patient with Fibrous Dysplasia Managed with Proximal Femoral Nailing and Valgus Osteotomy

Fibrous dysplasia is a rare condition in which bone is replaced by fibroosseous tissue. It is a benign condition, divided into monostotic and polyostotic fibrous dysplasia, which accounts for about 5-7% of all benign bone tumours. Here, authors reported a case of a 38-year-old male that presented with left hip pain since 15 days and had a history of trauma. X-ray pelvis and Magnetic Resonance Imaging (MRI) showed shepherd’s crook deformity in the left proximal femur with pathological femur neck fracture. It was managed with valgus osteotomy for deformity correction and fracture fixation using long proximal femur nail and cannulated cancellous screws. At one and half year follow-up, the patient showed good hip and knee range of motion with no complications.

Old Wine in a New Bottle: Acromegaly Presenting as Diabetic Ketoacidosis

Sowrabha Bhat, Subhodip Pramanik, Pradip Mukhopadhyay, Subhankar Chowdhury

Acromegaly is a rare disease characterised by chronic excess of Growth Hormone (GH) levels. Insulin signalling is impaired, gluconeogenesis is excess and peripheral insulin resistance is increased in acromegaly causing hyperglycaemia and diabetes. Diabetic Ketoacidosis (DKA) is a rare but known complication of diabetes in acromegaly. Most cases of acromegaly come into light due to the classical soft tissue changes in the face and extremities. A high index of suspicion is required to diagnose this condition in early stage. Here, a case of 22-years-old male presented with DKA and on investigation was found to have acromegaly due to a GH secreting pituitary macroadenoma. This management and subsequent follow-up of the case along with review of literature is also done. Such a presentation of acromegaly was rare but rewarding.

Female Adnexal Tumour of Wolffian Origin: A Rare Case Report

Female Adnexal Tumour of Wolffian Origin (FATWO) is a rare tumour occurring in adnexal region, arising from the remnants of the mesonephric duct, in places like the broad ligament, fallopian tube, ovarian hilum, peritoneum. Here the authors have reported a case of FATWO in a 47-year-old woman occurring in the wall of fallopian tube and confirmed with immunohistochemistry. Most of these tumours behave in a benign fashion but certain histological features like hypercellularity, cellular pleomorphism and nuclear atypia cause significant confusion in histopathological diagnosis. Multiple differential diagnoses were considered. After careful histopathological examination and thorough investigation with multiple immunohistochemical stains, the diagnosis was ultimately established.

Ileocolic Intussusception in an Infant with Ileal Duplication Cyst as a Lead Point- A Case Report

Gastrointestinal duplication cysts are uncommon congenital malformations, with small intestine being the most common site, followed by colon and stomach. It can have variable presentations such as intestinal obstruction, bleeding, palpable mass, or rarely volvulus. Here, the authors report a case of intussusception in a two-year-old child, presented with complaints of bilious vomiting and abdominal distension for three days with X-ray features suggestive of bowel obstruction. Ultrasonography revealed intussusception with ileal duplication cyst as the lead point, which was confirmed on exploratory laparotomy. In a paediatric patient, enteric duplication cyst should be included in the differential diagnosis of a cystic lesion as the lead point in intussusception.

One Lung Ventilation Using an Orotracheal Tube and an Endobronchial Blocker in a Patient with Difficult Airway

PA Sahana, Pooja Rao, Gururaj Tantry, Thrivikrama Padur Tantry

One-Lung Ventilation (OLV) is achieved in thoracic surgeries to facilitate collapse of one lung for better surgical visualisation. Double-lumen tubes and bronchial blockers are two commonly used devices for OLV. Patients with ‘difficult airway’ pose significant challenges for insertion of Double Lumen Endotracheal Tube (DLT). Dual malignancy such as carcinoma of lung and head and neck is extremely rare to present with. Patients presenting with restricted mouth opening due to previous surgeries and requiring lung isolation techniques may pose significant challenges to anaesthesiologist. The difficult airway scenario may arise in such patients owing to their previous surgery to the tongue, larynx, neck, mandible or previous radiation. The present case was of 47-year-old of lung isolation achieved in a patient with restricted mouth opening with an orotracheal tube, bougie, endobronchial blocker and a flexible Fibre Optic Bronchoscope (FOB). Left upper lobectomy was successfully performed after passing endobronchial blocker through a conventional orotracheal tube under the guidance of FOB.

Non Puerperal Uterine Inversion Secondary to Submucosal Fibroid: A Case Report

Nilaj Bagde, Sefali Shinde, Vinita Singh, Rahul Satarkar, Habung Yarang

Non Puerperal Uterine Inversion (NPUI) is a very uncommon condition. The incidence of puerparal uterine inversion make an estimate of 1/30,000 deliveries and NPUI approximately 17% of all uterine inversion. The most common cause which leads to uterine inversion is a submucous myoma attached to the fundus but diagnosis can be difficult to make. The management of uterine inversion is always challenging for a surgeon. In the present case a 38-year-old woman, presented with significant anaemia because of menorrhagia. She used to feel mass occasionally into the vaginal canal which never comes out of the introitus, the mass was elucidated as a fibroid polyp. On investigation, her haemoglobin was 6.6 gm%, with continous bleeding per vaginum, patient was transfused with three units packed red blood cells and planned for surgery. A diagnosis of incomplete uterine inversion secondary to a submucous fibroid was made at exploratory laparotomy. Total abdominal hysterectomy, right salpingectomy with left salpingo-oophorectomy was performed. The patient was discharged under satisfactory condition.

Trigeminal Nerve Choristoma- A Rare Case Report

Shibu Garg, CS Prabhu, Lokesh Kumar

Choristomas are normal tissue in an abnormal location and are classified based on their predominant epithelial lining. They may contain fibrous tissue, skeletal muscle fibres, and nerve fibres. Neuromuscular choristoma (benign triton tumour) is a rare tumour that involves a large nerve trunk. Involvement of the cranial nerves by this lesion is exceptional; trigeminal nerve involvement is even rarer. This is a very rare case of intracranial trigeminal nerve neuromuscular choristoma which had an associated fatty component that also got ruptured, in a 30-year-old female who presented with a headache. The clinical presentation, radiological findings, pathological diagnosis for this case are discussed along with a review of the associated literature.

Sacral Agenesis- Its Urological Impact and Management

Vishal Jalan, Soumya Mondal, Krishnendu Maiti, Dilip Kumar Pal

Sacral agenesis is a rare developmental disorder, in which there is absence of part or all of two or more sacral vertebral bodies. It is mostly associated with dysfunction of bowel, bladder and neuromuscular system of lower limbs. Voiding impairment (neurogenic bladder), Vescico-Ureteric Reflux (VUR) together with urinary tract infection contribute to renal injury. Here authors are reporting an 11-year-old female, who was diagnosed to have sacral agenesis with anorectal malformation at the age of six months, leading to anal transpositioning done at that age, she presented to the Urology Department with acute kidney injury. On evaluation, she was found to have overactive bladder with increased bladder capacity and bilateral grade 5 VUR. After recovery from acute kidney injury with conservative management and catherization, she was discharged with the advice of clean intermittent catheterization and anticholinergic drug. On follow-up, she was doing well. Early diagnosis and long term follow-up is required in the patients having sacral agenesis with multidisciplinary team including urologist, as these patients may develop lower urinary tract symptoms, VUR and kidney injury at any time in their growth period.

A Rare Case Report of Venous Malformation of the Submandibular Gland- Masson’s Haemangioma

Masson’s haemangioma was first described by Masson in 1923 as “haemangioendothelioma vegetant intravasculaire”. It is common in skin and subcutis which appears as red blue nodule. It also occurs in fingers, trunk, head and neck, heart, larynx and hypopharynx. Masson’s haemangioma is a rare venous malformation. Treatment is complete surgical excision. It is rarely known to recur. It is a locally occuring lesion with no reports of metastasis. Venous malformation can be distinguished by their characteristic imaging findings at doppler ultrasound vs Magnetic Resonance Imaging (MRI) and direct phlebography. A 30-year-old male presented with swelling in the left submandibular region for one month. On examination a cystic swelling was present in left submandibular region. Ultrasound Sonography test (USG) neck with doppler revealed multilocular cystic swelling with low level internal echoes in left submandibular region suggestive of low flow venolymphatic malformation. The mass was surgically excised and sent for histopathological examination and reported as masson’s haemangioma. Masson’s haemangioma is a rare venous malformation. Appropriate history, clinical examination and investigation leads to the correct diagnosis and treatment. Incomplete removal of the mass leads to recurrence. The patient was still on follow-up and no recurrence was noted.

Haemothorax, an Unusual Presentation in Dengue: A Case Report

Chirag Agrawal, Harshpreet Singh Tuteja

Dengue Fever (DF) is a self-limiting mosquito transmitted disease characterised by fever, headache, muscle pain, joint pain, rash, nausea and vomiting. Dengue Haemorrhagic Fever (DHF) is a severe and more serious form of DF, characterised by fever, bleeding manifestations, plasma leakage and thrombocytopenia. This is a report of a 32-year-old male, presented with history of fever and myalgia with two episodes of vomiting and presence of petechial rash. Patient was diagnosed with DHF. The patient presented with absent breath sounds on respiratory examination and his chest radiograph (posteroanterior view) showed right-sided pleural effusion. Pleurocentesis revealed haemorrhagic fluid in the absence of trauma. Unprovoked haemothorax as an initial presentation of DHF is a rare occurrence.

Laparoscopic Common Bile Duct Exploration as a Rescue Procedure for Failed Endoscopic Retrograde Cholangio-Pancreatography: A Case Report

Umar Riaz, Abhijit S Joshi

Across the world, choledocholithiasis is presently treated by a two staged approach of Endoscopic Retrograde Cholangio-Pancreatography (ERCP) followed by Laparoscopic Cholecystectomy (LC); in a vast majority of the situations. Modern day literature abounds with comparative outcomes studies between ERCP and Laparoscopic Common Bile Duct Exploration (LCBDE), as therapeutic modalities for Common Bile Duct (CBD) stones. There are strong arguments both in favour and against both these treatment options, in literature. As per literature, the advantage of LCBDE is that it is a single stage procedure, but requires advanced laparoscopic expertise and a choledochoscope in the setup. The advantage of ERCP is that it is a highly standardised procedure. In expert hands and well equipped setups, it rarely ever fails to deliver. However, ERCP is also a highly operator dependant procedure. Also, in the best of hands, sometimes, local factors such as abnormal anatomy, stone morphology can lead to failures or suboptimal results. As per literature, ERCP to extract CBD stones can fail for various reasons such as failed cannulation, previous Billroth II gastrectomy, large CBD stones, large number of CBD stones etc. The failure in retrieving CBD stones by ERCP is an absolute indication for performing CBDE. Here, authors present a case report of a 73-year-old male with failed ERCP (inspite of two attempts) due to a large, solitary but tightly impacted terminal CBD stone. It hopes to convey the message that in similar situations, LCBDE, tactically using some endoscopy accessories, is a sound backup therapeautic option, inspite of non availability of a choledochoscope in the setup. The novelty of this case was that instead of the standard use of choledochoscope to directly visually confirm the completeness of stone clearance during the LCBDE, intraoperative fluoroscopy has been used effectively for the same; by obtaining good quality proximal and distal occlusion cholangiograms at the end of the procedure.

Mineralising Angiopathy of Lenticulostriate Vessels in Childhood: Series of Four Cases

Kapil Jetha, Rashmin Cecil, Sarthak Soni, Somashekhar M Nimbalkar

Mineralising lenticulostriate vessels’ angiopathy is becoming an important recognisable cause of ischaemic stroke in healthy children post trauma or fall. The usual presentation is a focal neuro-deficit of acute onset following trivial trauma in infancy with or without seizures/dystonia. The authors conducted a retrospective chart review of children diagnosed with stroke in a tertiary care paediatric hospital. Based on clinical and radiological features, children diagnosed with mineralising angiopathy with basal ganglia stroke in the last two years were identified, data was retrieved from the hospital’s electronic database and included in the study. Also, the patients were contacted telephonically in case of missing data. Out of the four cases, three were less than 18-month-old, and one was 52-month-old. All were normal before illness and had a history of trivial trauma {except one who had Road Traffic Accident (RTA)} followed by hemiparesis. Investigations for other aetiologies of stroke were non contributory. With antiplatelet therapy and iron supplements, most did well with an excellent functional outcome at follow-up. None of the children had recurrence during follow-up. In a typical case, an extensive work-up is not required.

Anatomical Variations of the Extrinsic Musculature of Thumb

Martin G Rosario, Clare Hanrahan, Carley Bowman

Anatomical variations are commonly encountered during human cadaver dissections. Some of these variations are never discovered unless there is an underlying injury that requires attention. For conceivable clinical and rehabilitation treatments, anatomical modifications may have implications on function therefore it is imperative to report them. This case series depicts the anatomical inconsistency in the muscles and tendons of the extrinsic musculature of the thumb in three human specimens. During a cadaver dissection in physical therapy anatomy course, various anatomical variations were found in three human cadaveric specimens. Cadaver 1 (91- year-old Caucasian female) exhibited a new muscle with a split tendon near the distal posterolateral radius. The author uncovered the supplementary muscle between the Extensor Pollicis Longus (EPL) and Extensor Pollicis Brevis muscles. Cadaver 2 (56-year-old Caucasian male) had two other extrinsic tendons inserted at the thumb. The Extensor Digitorum provided an extra tendon to the pollicis; a similar insertion as the EPL was recognised. In Cadaver 3 (77-year-old Caucasian male) an extra muscle belly was observed within the tendon of the abductor pollicis longus. The other muscle variation was near the distolateral attachment at the base of the first metacarpal joint, between the abductor pollicis brevis and extensor carpi radialis muscles. Understanding the diverse anatomical arrangements could prove beneficial for surgeons and those involved in rehabilitating upper extremities. A detailed understanding of the forearm structural anatomy and anomalies is essential to comprehend the function and movements when lesions affect the normal biomechanics within teaching and clinical environments.

Co-existence of Malaria and Dengue: An Incidental Observation

Introduction: Malaria and dengue are two most important arthropod borne diseases responsible for high morbidity and mortality across the globe. Both these communicable diseases have been a major threat to the public health not only in India but also in other tropical and sub-tropical regions of the world. Aim: To study the prevalence of Dengue and Malaria along with the cases of co-infection among the patients visiting a tertiary care hospital located in central India. Materials and Methods: The present prospective study was conducted for a period of two years from January 2019 to December 2020, in the serology section of the Department of Microbiology of a teaching tertiary care hospital. Three to five millilitres (mL) of venous blood samples from 1519 patients were tested for both dengue (NS1 antigen, IgM and IgG antibodies) by Enzyme-linked Immunosorbent Assay (ELISA) method and malaria peripheral smear and antigen by immunochromatographic method. All demographic parameters were simultaneously analysed. Statistical analysis was performed with the help of Chi-square test. Results: Out of 1519 blood samples tested, 267 (17.5%) samples were positive for dengue and 6 (0.39%) samples were positive for malaria. No case of co-infection was detected. Maximum dengue cases were detected during post monsoon period while malaria cases were detected in monsoon and post monsoon period. Among the various dengue positive cases, 185 (69.2%) patients were diagnosed with recent primary infection while 20 (7.49%) patients had primary infection. Conclusion: The present study concluded that seroprevalence of dengue was high in our geographical region with malaria being negligible. Present study incidentally recorded the fact that the two diseases may coexist in an individual but both the vectors rarely share the same geographical site.

Metaplastic Carcinoma of Breast: A Rare Pathological Entity- A Study of 10 Cases from Tertiary Care Centre in Northern India

Introduction: Metaplastic Carcinoma of Breast (MCB) is a rare heterogeneous neoplasm characterised by a mixture of adenocarcinoma with dominant areas of spindle cells, squamous and other mesenchymal differentiation. The reported incidence is 0.2% of all breast cancers. Aim: To study the clinicopathological presentation, pathologic features and differential diagnosis of MB. Materials and Methods: This retrospective cross-sectional descriptive study included 10 cases of MCB who underwent mastectomy and biopsies at BPS GMC Khanpur Kalan, Sonipat, Haryana, India from March 2013 to February 2020. Data were analysed by Microsoft Office Excel Datasheet 2019. Results: Out of 10 cases, five cases were MCB Not Otherwise Specified (NOS) type, four cases were MCB with mesenchymal differentiation and one case showed rhabdomyosarcomatous differentiation. The right breast was involved in nine cases. The mean size of tumour was 8 cm with range of 3 to 16 cm. Five patients were treated by modified radical mastectomy and axillary dissection, four patients had lumpectomy and one patient underwent mastectomy. Half of the patients were below 40 years with the mean age being 36.8 years and range of 21-60 years. On Immunohistochemistry (IHC), 90% (9/10) cases were triple negative. Conclusion: The MCB, although rare has to be diagnosed and excised at the earliest as the prognosis is predicted to be worse similar to other triple negative breast carcinomas. Ductal Carcinoma in Situ (DCIS) at the tumour periphery and co-expression of vimentin and cytokeratin would help to clinch the diagnosis in difficult situations.

Reduced Daptomycin Susceptibility in Clinical MRSA Isolates Showing Vancomycin MIC Creep Phenomenon

Ketaki Vyankatesh Kulkarni, Niranjan Pathak, Sandhya Sadanand Kulkarni

Introduction: Infections caused by Methicillin Resistant Staphylococcus aureus (MRSA) are associated with increased morbidity, longer antimicrobial therapy, etc. First option for treating invasive MRSA infections is glycopeptide vancomycin. Daptomycin, a lipopeptide rapidly bactericidal invitro against MRSA, is an acceptable alternative. Aim: To identify MRSA isolates from clinical specimens and assess their vancomycin and daptomycin susceptibility pattern. Materials and Methods: The cross-sectional study was conducted over a period of six months (January to June 2019) on 90 clinical samples in a rural teaching hospital in Pune, Maharashtra, India, including all samples except sputum received in the Microbiology laboratory. MRSA isolates were tested for vancomycin and daptomycin susceptibility by Epsilometer (E) test Minimum Inhibitory Concentration (MIC) method. Data analysis was done using Statistical Package for the Social Sciences (SPSS) version 16.0 software. Results: Among 90 MRSA isolates, most were from pus 51 (56.7%) followed by urine 23 (25.5%), blood 9 (10%), followed by miscellaneous samples 7 (7.7%). All MRSA isolates in this study were susceptible to daptomycin with MIC in the range of 0.25-1 μg/mL with maximum isolates (39) with MIC of 0.38 μg/mL. Vancomycin MIC creep phenomenon was observed in 68 isolates. All these isolates also showed reduced susceptibility to daptomycin. Conclusion: MRSA in hospital set up mandates strict infection control practices in place. Daptomycin can be a good therapeutic alternative to treat infections caused by MRSA keeping in mind its therapeutic limitations and prior vancomycin usage in the same patient. Empirical therapy should always be based on antibiogram pattern. Adherence to hospital antibiotic policy and constant surveillance of antimicrobial resistance is the need of the hour.

Nosocomial Outbreak of Port-site Infection due to Atypical Mycobacteria following Laparoscopy: Suggested Infection Control Strategies

Mukesh Sharma, Divya Gautam, Leimapokpam Sumitra Devi, Moumita Sardar

Introduction: Atypical mycobacteria can survive in conditions that make them hard to eradicate, despite using the standard decontamination procedures and protocols. Thus, errors in sterilisation techniques for laparoscopic instruments can be responsible for outbreaks caused by such bacteria and make it a problem mainly affecting developing countries including India. Aim: To investigate the outbreak of postlaparoscopic wound infection caused by atypical mycobacteria. Materials and Methods: An institution based cross-sectional study was conducted over a two month, period from January to February 2020. A total of 14 patients presented with postlaparoscopic surgical site wound infections were evaluated with Ziehl-Neelsen (ZN) staining and pus culture on Lowenstein Jensen (LJ) medium and subsequently treated with appropriate antibiotics. For further investigation of the outbreak, environmental samples were collected and isolation rates (percentage) of atypical mycobacteria from these samples were analysed. Results: All the patients included in the study were diagnosed with postlaparoscopic surgical site wound infections caused by atypical mycobacteria. Infection control investigation of the Operation Theatres (OTs) revealed multiple sources of atypical mycobacterial contamination viz., laparoscopic surgical instruments, used disinfectant (gluteraldehyde disinfectant solution) and tap aerators. Conclusion: Negative routine bacterial culture report of samples collected from port-sites should be further investigated for other aetiology e.g., atypical mycobacteria which do not grow on routine bacterial culture. Since, high indices of suspicion followed by timely and efficient management of patients with postlaparoscopic surgical site infection are of critical importance.

Assessment of Quality of Life in Recurrent and Metastatic Head and Neck Cancer after Oral Metronomic Chemotherapy: A Prospective Interventional Study

Introduction: Most of the Recurrent or Metastatic (R/M) Head and Neck Squamous Cell Carcinomas (HNSCC) patients are treated only by palliative treatment. Metronomic Chemotherapy (MC) low doses is an emerging therapeutic option in these patients. It exerts tumour angiogenesis, stimulate anticancer immune response, induces tumour dormancy and offers a significant improvement in Quality of Life (QoL) with minimal toxicity. Aim: To assess the changes in QoL in patients with Metastatic, Recurrent (M/R) HNSCC receiving MC. Materials and Methods: This was a prospective interventional hospital-based study from February 2015 to September 2018, conducted at Cancer Research Institute, Himalayan Institute of Medical Sciences, SRHU University, Dehradun, Uttarakhand, India. A total of 175 patients more than 18 years, with Eastern Cooperative Oncology Group (ECOG) performance status score <2, with M/R HNSCC, not amenable to any radical treatment, were equally distributed by lottery method in three arms, in those receiving Capecitabine (Arm A, n: 59), Celecoxib and Methotrexate (Arm B, n: 62); and placebo with best supportive care (Arm C, n: 54). In addition to demographic and baseline clinical characteristics, patients were assessed for physical examination and questioned to score their QoL by European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) at presentation and followed every month for two months. Results: A total of 175 patients enrolled for the study, the mean age of study population was 56.73±6.84 years with male preponderance 77.71%. A 60% suffered from carcinoma oral cavity (n=105), followed by carcinoma oropharynx (24%) (n=42), carcinoma larynx and carcinoma hypopharynx consisted rest 16% (n=28). Altogether the QoL was quite divergent amongst the three arms. Symptom score for fatigue, dyspnoea, loss of appetite, nausea and vomiting showed rise representing worsening in Arm A and Arm C; whilst these symptoms also showed fall in symptom score in Arm B (fatigue: p-value=0.007; dyspnoea; p-value=0.042; Appetite loss: p-value=0.008 Nausea: p-value=0.02; Vomiting: p-value=0.03). There was a statistically significant improvement in overall EORTC QLQ-C30 score from baseline in the Methotrexate and Celecoxib arm (Arm B) compared with Capecitabine and with placebo. Conclusion: Metronomic Chemotherapy (MC) with Methotrexate and Celecoxib seems promising and well tolerated in patients with metastatic or advanced HNSCC as compared to Capecitabine or keeping on symptomatic treatment solely.

Reference Value of Nasal Peak Inspiratory Flow Rate in Indian Children: A Cross-sectional Study

Mousumi Das, Tapas Kumar Sabui, Neha Ahuja

Introduction: Peak Nasal Inspiratory Flow (PNIF) measurement is a basic, convenient, easy to use and low cost method of determining the nasal airway patency. However, normative data for paediatric population is scarce and not available for Indian children aged 6 to 12 years. Aim: To establish reference value of PNIF in Indian children aged 6 to 12 years of age. Materials and Methods: A descriptive cross-sectional study was conducted between July 2012 and June 2013 in the Himalayan range of east Sikkim district and Sub-Himalayan Terai region of Darjeeling district of West Bengal. Total 1001 children aged 6 to 12 years were selected from 16 schools by simple random sampling. Of these 1001 children, 784 children were enrolled in the study after taking into account inclusion and exclusion criteria. Repeated PNIF measurements were taken from these 784 children. Mean PNIF value was calculated. The effect of age and height on PNIF was studied. The mean and standard deviation of Peak Inhalation Flow Rate (PIFR) are calculated and compared across groups using a one-way ANOVA test. Regression analysis was done to establish an equation of predicting PNIF level based on height for normal children. The analysis was carried out using Statistical Package for Social Sciences (SPSS) version 16 statistical software. An alpha level of 5% was chosen, which means that any p-value less than 0.05 was considered significant. Results: Mean value of PNIF age group; 6-7 years-53.36 L/min, >7-8 years-56.79 L/min, >8-9 years-63.91 L/min, >9-10 years-69.45 L/min, >10-11years- 80.71 L/min, >11-12 years-85.69 L/min. PNIF increases with age and height. A simple formula has also been established to calculate mean PNIF at a given height. PNIF or PIFR (L/min)=-52.716+0.945×height in cm. Conclusion: PNIF measurements are possible in children aged six years and older. Age and height also affect PNIF.

Estimation of Glomerular Filtration Rate and Predicting Diagnostic Accuracy of Cystatin C and Creatinine in Detection of Renal Function among Longstanding Type-2 Diabetics

Introduction: Estimation of Glomerular Filtration Rate (GFR) is dependent on Serum Creatinine (SCr). Though, a sudden decrease in GFR would not result in rapid rise in concentrations of SCr, as they are imprecise but it leads to the over diagnosis of Chronic Kidney Disease (CKD). Aim: To calculate GFR using Cystatin-C (Cys-C) based formulas to contrast its accuracy with SCr based formulas and to predict the diagnostic accuracy of Cys-C in patients with diabetes. Materials and Methods: A total 48 type-2 diabetic patients were diagnosed with CKD and their GFR was assessed using the Cys-C and SCr. GFR was measured and estimated using three equations (Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CDK-EPI), that are based on SCr and three equations (LeBricon, Grubb and Hoek) based on Cys-C among the 48 CKD patients. The filtration rate was measured using labelled diethylenetriaminepentaacetic acid (^99mTc-DTPA) renal scan method as the standard for comparison. The Receiver Operating Characteristics (ROC) analysis was used to evaluate the diagnostic accuracy of the filtration rate. Results: A significant association was observed (p=0.0001) among both the estimates which were equivocal when compared with measured iGFR, SCr and Cys-C based GFR estimate. A greater difference of Area Under the Curve (AUC) was observed between SCr (0.765±0.07) and Cys-C (0.569±0.09) (p=0.04) in the ROC analysis at a creatinine clearance <60 mL/min/m². Conclusion: The SCr and Cys-C based formulae has equivocal performance in estimating GFR. SCr could be a better marker to estimate GFR among patients with Cr clearance <60 mL/min/m².

A Study on the Assessment of Galectin-3 Expression in Colorectal Neoplasm and its Relationship with Tumour Stage, in Tertiary Care Hospital, Kolkata, India

Nandini Bhaduri Bhattacharyya, Anadi Roy Chowdhury, Susmita Mukhopadhyay, Sneha

Introduction: Galectin-3 is a β-galactoside-binding lectin found in a considerable number of normal tissues and malignant neoplasms. It was found to be expressed in few thyroid tumours particularly follicular and papillary tumours. Lectins were found to be released in circulation and increased concentration was noted in colorectal cancers especially in metastatic colonic adenocarcinoma. Different types of galectins are expressed in normal colonic and rectal epithelium. Some types do increases in inflammation and cancers of these areas. It was seen that galectin-3 increases in colorectal tumourigenesis and it bears an important role in cancer progression and metastasis. Galectin-3 seems to have an important role in colorectal cancer. Some studies proved that galectin inhibitors could reduce tumour progression and metastasis and it may be a therapeutic target in metastatic colorectal adenocarcinoma. Aim: To evaluate colon cancer specimens received for biopsy, for galectin-3 expression and its relation with tumour stage, lymphovascular space invasion and tumour differentiation. Materials and Methods: The study was a cross-sectional observational study conducted in the Department of Pathology of RG Kar Medical College and Hospital from November 2018 to November 2019. It was an immunohistochemistry based assay performed to test the expression levels of galectin-3 in cancer tissues of 62 colorectal neoplasms with the help of galectin-3 primary antibody (mouse monoclonal antibody- clone 9C4). Statistical analysis was done using Statistical Package of Social Sciences (SPSS) version 19.0. Results: Out of 62 cases, 60 cases were colorectal adenocarcinoma and 2 cases were adenoma with age group between 40-75 years. Total 46 cases had cancer in caecum and ascending colon and rest were in recto-sigmoid colon. A 36/60 cases (60%) of cancer tissues were positive for galectin-3 expression. Strong association of lymphovascular space invasion (p=0.046) and depth of tumour (p=0.0078) with galectin positivity in colon carcinoma was noted. Conclusion: Evaluation of galectin-3 expression is helpful in the assessment of tumour staging and prognosis in colorectal cancer patients. It may have a therapeutic implication in the management of colon cancer in future.

Correlation between Occurrence of Psychosomatic Disorders and Age during COVID-19 Lockdown

Introduction: The Coronavirus Disease-2019 (COVID-19) has caused a serious threat to people’s mental health causing psychosomatic disorders such as panic disorder, anxiety, and depression. Aim: To find out the correlation between the occurrence of psychosomatic disorders and age during the COVID-19 lockdown phase. Materials and Methods: This cross-sectional, observational study was conducted in Department of Physiotherapy at RK University, Rajkot, Gujarat, India. Males and females of age ≥21 years, with an ability to understand and fill Google form were recruited for the study. The subjects were divided into four groups according to age 21-34 years, 35-54 years, 55-64 years, and 65 years and older. There were 250 participants in each group. The subjects were asked to fill the COVID-19 Peritraumatic Distress Index (CPDI). Data were analysed by using software Statistical Package for the Social Science (SPSS) version 20. The normality of data was checked by the Shapiro Wilk test. Data followed parametric type so; Pearson correlation test was applied to find out the correlation between age and CPDI score. Results: The mean age of the population was 49.24±18.14 years. The mean CPDI scale scores were 27.572, 31.948, 31.364, and 35.328, respectively from groups 1 to 4. There was a significant positive correlation (p-value=0.031) in group 4, while no significance was found in group 1 (p-value=0.074), group 2 (p-value=0.067), and group 3 (p-value=0.062) Conclusion: There was a significant positive correlation between age and psychosomatic disorder occurrence in the geriatric age group (65 years and older) in the Rajkot city.

Efficacy of Three Dimensional Fast Imaging Employing Steady State Acquisition Combined with Conventional MRI in Evaluation of Patients with Cerebellopontine Angle Lesions

Introduction: The Three Dimensional Fast Imaging Employing Steady state Acquisition (3D FIESTA) has higher spatial resolution between the Cerebrospinal Fluid (CSF) and cranial nerves with accurate identification of Cerebellopontine Angle (CPA) and internal auditory canal tumours and takes shorter acquisition imaging time than conventional Magnetic Resonance Imaging (MRI) scan. Aim: To evaluate the efficacy of 3D FIESTA imaging as a screening tool for CPA lesions, hence to depict the fine anatomy of the cisternal and canalicular segments of the facial nerve and vestibulocochlear nerves in order to elucidate the aetiopathogenesis of unexplained inner ear symptoms. Materials and Methods: The present study was a hospital based cross-sectional study which was done in Department of Radiodiagnosis, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu, India. The study was conducted on 30 patients, who were referred for MRI Brain to the department and diagnosed with cerebellopontine angle lesion from August 2018 to October 2019. A 1.5 Tesla, MRI scanner was used to scan all patients with a 8 channel Neurovascular (NV) radiofrequency coil. Along with routine conventional MRI sequences, 3D FIESTA sequence was also performed. All the data was collected and analysed by Statistical Package for Social Sciences (SPSS) software version 23.0. Data for descriptive statistics i.e. frequency and percentage analysis, mean±Standard Deviation (SD), sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated. Results: On Histopathological Examination (HPE), 63.3% were schwannoma, 16.7% meningioma, 10% epidermoid cyst and 3.3% intracanalicular lipoma. In 6.7% of patients, imaging features were in favour of CPA arachnoid cyst. The size of the intracanalicular part of tumour was underestimated in T2 weighted images (T2WI). 3D FIESTA gave a better estimated tumour area, even though slightly less but almost equivalent to that in post-contrast imaging. In this study, post-contrast imaging was considered as the gold standard. It was proven that conventional sequences like T2WI showed a sensitivity of 85.71% and specificity of 100% whereas 3D FIESTA sequence showed 100% sensitivity and specificity in assessing the CPA tumour extent and cranial nerve involvement. Conclusion: 3D FIESTA imaging is a sensitive technique for the diagnosis of retrocochlear and CPA lesions without contrast administration. 3D FIESTA imaging can be considered as a useful screening tool for patients presenting with inner ear symptoms.

Transvaginal Ultrasonography and Hysteroscopy in Evaluation of Abnormal Uterine Bleeding- A Cross-sectional Study

G Sindhujha Sekar, A Esther Ruby, P Lalitha

Introduction: In perimenopausal age group particularly, 70% of all gynaecological consultations are for Abnormal Uterine Bleeding (AUB). About 30% of women seek medical assistance for AUB during their reproductive age group and about one third of hysterectomies are carried out for AUB alone. Aim: To determine the sensitivity, specificity, positive predictive value and negative predictive value of Transvaginal Ultrasonography (TVS) versus hysteroscopy in detecting uterine abnormalities Materials and Methods: A cross-sectional study in patients with AUB, admitted to the Department of Obstetrics and Gynaecology at RGGWCH, Puducherry between February 2016 and February 2017 who met the inclusion criteria were included. Sample size was 85 cases. After taking detailed history and physical examination the patient was investigated to rule out organic causes of AUB and then TVS and hysteroscopy were done. Any intrauterine pathology was looked for and endometrial sampling was taken from the abnormal sites for Histopathological Examination (HPE). Both TVS and hysteroscopy results were compared with histopathology which is the gold standard. Results: The sensitivity of TVS in diagnosis of uterine fibroid in comparison to hysteroscopy was 94.74% and the specificity was 71.21%. The sensitivity of hysteroscopy in diagnosis of endometrial hyperplasia in comparison to HPE was 75% and the specificity was 87.01%. The sensitivity of TVS in diagnosis of endometrial hyperplasia in comparison to HPE was 37.5% and the specificity was 90.91%. The sensitivity of hysteroscopy in diagnosis of polyp in comparison to HPE was 100% and the specificity was 97.3%. The sensitivity and specificity of TVS in diagnosis of polyp in comparison to HPE were 9.09% and 93.24%, respectively. Conclusion: TVS had a high sensitivity to detect fibroids but its value in detecting hyperplasia and polyps was in question in this study. But hysteroscopy had a maximum sensitivity to detect polyps and high sensitivity to detect endometrial hyperplasia compared to histopathology which is a gold standard investigation.

Stress, Depression, Coping Strategy and Respiratory Health Status of Traffic Police at Anand District, Gujarat, India

Deepak Krishnamurthy, Anil Kumar Sharma

Introduction: There is lot of stress and stress associated mental illness among the traffic police fraternity. Many environmental factors are responsible for this development. Measurement of the stress levels and implementation of coping strategies are very important to maintain the health of the traffic police. Aim: To assess the level of stress, depression, coping strategy and respiratory health status of traffic police at Anand district, Gujarat, India. Materials and Methods: This cross-sectional descriptive study including 100 participants was conducted by the Department of Mental Health Nursing, Manikaka Topawala Institute of Nursing, Charotar University of Science and Technology, Anand District, Gujarat, India from December 2019 to February 2020. Validated tool Job Stress Scale, standardised tool beck depression inventory, coping strategy scale were used to assess the level of stress, depression and coping strategy respectively. Spirometer was used to assess respiratory function. Analysis was done using Statistical Package for the Social Sciences (SPSS) statistical software version 20.0 and Spirometry Longitudinal Data Analysis (SPIROLA) software version 3.0.3. Results: The study reveals that majority (69%) of the traffic police were facing extreme stress, 11% of traffic police were suffering from mild mood disorder, 73% were having adequate coping skills, 88% were non smokers and 97% traffic police were not using any substances, 65% demonstrated expiratory Forced Vital Capacity (FVC) of 2.6%-3.5%, 66% demonstrated 2.6%-3.5% Forced Expiratory Volume in 1 second (FEV1), 76% experienced 96-100 FEV1/FVC ratio1, 53% experienced 6%-8% peak expiratory flow. Pulmonary function test found to be normal however, it is declined in smokers comparative to non smokers. Conclusion: The study concludes that stress and depression were observed in traffic police which they were managing with adaptive coping strategy. However, pulmonary function is found normal in comparing to predictive value, necessary precautions need to be taken by Traffic Police Department by offering protective device like mask to decrease the respiratory health issues.

Safety and Efficacy of Fixed Drug Combination Tenofovir, Lamivudine and Efavirenz to Prevent Transmission of HIV

Introduction: Mother-to-child transmission of HIV can occur during pregnancy, labour, or breastfeeding. The first-line regimen for prophylaxis in HIV infected pregnant women is combination of Tenofovir, Lamivudine and Efavirenz (TLE). Aim: To evaluate the safety and efficacy of the TLE regimen in the Prevention of Mother-To-Child Transmission (PMTCT) of HIV. Materials and Methods: The present hospital-based, retrospective cohort study was conducted at ART centre, Prevention of Parent to Child Transmission (PPTCT) centre, and Department of Medicine, SP Medical College, Bikaner from July 2016 to June 2019. HIV positive gravidas, on triple-drug regimen TLE (Tenofovir 300 mg, Lamivudine 300 mg, Efavirenz 600 mg) before conception and, those detected HIV reactive antenatally during study period were included in this study and started on TLE regimen. After delivery, these newborns were given syrup Nevirapine as per the PPTCT guidelines. Infants were tested with Rapid test and PCR for HIV, at six weeks, six months, 12 months, and 18 months of life. Results: Out of 87 pregnant women, enrolled and delivered at the study institute, 85 were live births and two were stillbirths. Out of 85 live-born babies, four have died during infancy and two were lost to follow-up despite repeated counselling. Five babies were referred to nearby Anti-Retroviral Therapy (ART) centers. So, the study followed 74 babies out of which one girl child was found to be positive for HIV-1 at 18 months of age (transmission rate of HIV was 1.35 and efficacy of TLE 98.65%). No major adverse effects of TLE were noted and all women continued TLE. Conclusion: The use of a triple-drug regimen (TLE) declined the risk of transmission of HIV from mother-to-child at negligible level, without drug resistance and with safety and tolerability as compared to single drug.

Phenotypic Characterisation, Virulence Determination and Antimicrobial Resistance Pattern of Enterococcus Species Isolated from Clinical Specimen in a Tertiary Care Hospital in Kolkata

Introduction: Enterococci are usually normal human commensal of gastrointestinal tract predominantly. They are considered as an important nosocomial pathogen now a day due to its intrinsic as well as increasing acquired antibiotic resistance resulting in a great threat to modern Medicine. Aim: To determine prevalence of Enterococc isolated from clinical specimens with special reference to its virulence and antibiogram conventionally. Materials and Methods: A cross-sectional observational study was conducted over a period of two years (January 2019 to December 2020) with 326 Enterococci, isolated from various clinical specimens received by Department of Microbiology. Enterococc isolated from stool samples were excluded. They were identified and speciated conventionally as per standard laboratory protocol. Gelatinase, haemolysin and biofilm formation was determined for each isolate. Their antibiogram was also determined by disc diffusion methods over blood agar followed by Minimum Inhibitory Concentration (MIC) testing (as per Clinical and Laboratory Standards Institute (CLSI) guideline). All statistical analysis was done by Chi-square test using Software Statistical Package for the Social Sciences (SPSS) version 22.0. Results: Among the total 4516 samples collected, growth of Enterococc was noted in 7.22% cases. Out of them, Enterococcus faecalis (E. faecalis) (84.05%) out numbered Enterococcus faecium (E. faecium). Urine was the most predominant (55.22%) sample. A 73.93% isolates produced biofilm whereas 18.40% produced haemolysin and 19.94% produced gelatinase. Most of the isolates were susceptible to vancomycin (94.79%) and linezolid (98.77%). High level gentamicin resistance was seen in 54.6% cases. Ciprofloxacin was the most resistant antibiotic. Vancomycin Resistance Enterococcus (VRE) was detected in 5.21% cases only, out of which Van A type was detected phenotypically in most cases. Conclusion: The high rate of resistance to high level gentamicin could fail treatment of gentamicin in combination with penicillin group of antibiotics. In clinical samples, the emergence of VRE strains makes treatment options more challenging.

A Cross-sectional Study to Assess Psychiatric Co-morbidity among Patients of Migraine and Other Headaches

Pir Dutt Bansal, Deepika Garg, Priyanka Bansal, Bhavneesh Saini

Introduction: Migraine is the most common cause of vascular headache with a one-year prevalence as high as 6-14.3%. Having various pathophysiological theories, it occurs in much co-morbidity with several medical as well as psychiatric disorders like mood disorders, phobia, anxiety spectrum, etc. Migraine, especially when co-morbid with psychiatric illness stands markedly burdensome economically, diagnostically, therapeutically and prognostically. Hence, needs even further research. Aim: To study patients with migraine versus other types of headache and to study psychiatric co-morbidity among patients with migraine. Materials and Methods: This cross-sectional study was conducted on total 100 patients presenting with headache, meeting the criteria were taken up for the study and divided into two groups. Patients meeting International Headache Society (IHS) criteria for migraine were enrolled under group A and patients suffering from headache other than migraine under group B. Having subjected to detailed history and evaluation, patients were subjected to Symptom checklist-80, Hamilton’s Anxiety Rating Scale (HARS) and Montgomery Asberg Depression Rating Scale (MADRS), International Classification of Diseases (ICD)-10 criteria. The data so collected was subjected to statistical analysis and association of psychiatric morbidity with migraine patients was assessed. Results: Patients with migraine (group A) and among those too, patients having psychiatric morbidity had significantly (p<0.01) longer duration of illness (≥8 years), more frequent attacks ≥5 attacks per month and had longer duration of each attack >24 hours compared to the other groups. Patients having migraine had significantly (p<0.01) higher psychiatric morbidity, more SCL-80 symptoms (mean score 83.05); more depressive symptoms (mean MADRS score was 31.9±9.2) and more anxiety with the mean Hamilton Anxiety score was 23.3 than in patients without psychiatric morbidity. Conclusion: A thorough evaluation of psychiatric disorders in migraine is important so as to propose a non segregated model of care to direct the burden and deterioration associated with psychiatric co-morbidity in migraine.

Seroprevalence of Hepatitis B Virus Infection among the Tribal Population of Attapady, Kerala, India

Irene Jose Manjiyil, Kavitha Paul Konikkara

Introduction: Hepatitis B Virus (HBV) infection remains a significant global health concern that may cause acute or chronic hepatitis. Chronically infected patients are at risk for cirrhosis and hepatocellular carcinoma. The disease causes a problem in the tribal communities. There are lack of studies on the prevalence of HBV among the tribal population. Aim: To assess the seroprevalence of HBV infection among the tribal population of Attapady, Kerala. Materials and Methods: This was a community based cross- sectional study conducted on serum samples collected from 269 subjects among the tribal population of Attapady. Serum samples were tested for quantitative antibody to HBsAg (anti-HBs), Hepatitis B surface antigen (HBsAg) and Hepatitis B envelope antigen (HBeAg) Enzyme Linked Immunosorbent Assay (ELISA). Total hepatitis B core antibody (anti-HBc) and IgM antibody to hepatitis B core antigen (anti HBc IgM), frequencies were obtained using proportion and 95% Confidence Interval (CI). Results: The seroprevalence of HBsAg was 10.4%. HBeAg was detected in 7.1% of HBsAg positive patients. A 21.2% had protective anti-HBs titre. Anti-HBe was detected in five patients. Anti-HBc total and anti-HBc IgM were positive for 26.7% and 2.6%, respectively. Anti-HBc IgM alone and isolated anti-HBc were detected in 1.5% and 5.9%, respectively. Anti-HBs and anti-HBc total both became positive in 8.6% cases. Conclusion: The HBV infection poses a huge burden on tribal health. All HBsAg positive patients should be tested further to determine the stage of the disease. There is need to explore high HBV prevalence areas with studies on associated risk factors to bring out the ongoing transmission process and focus on preventive measures. HBV vaccination, antenatal screening, and health awareness should be given priority to tackle the burden.

Clinico-epidemiological and Outcome of Scrub Typhus in Paediatric Patients: An Observational Study from Odisha, India

Anisha Panda, SV Kishore, Madhusmita Pradhan, Jyotiranjan Champatiray

Introduction: Scrub typhus is re-emerging as a common prolonged febrile illness in children with serious complication involving major organ systems. It is easily treatable yet treatment is challenging with respect to early identification of predictors of serious disease that greatly affects the outcome in this vulnerable population. Aim: To study the clinical profile, analyse the complication and outcome of these patients. Materials and Methods: This was a hospital-based, prospective observational study. It was conducted in the Department of Paediatrics, SCB Medical College and Hospital, Cuttack from October 2017 to September 2019. All children with clinical features of scrub typhus were subjected to Immunoglobulin M (IgM) scrub typhus test. All observational data were analysed by IBM Statistical Package for the Social Science (SPSS) software, version 25.0 and Chi-square test was used with p<0.05 as statistically significant. Results: Out of total 196 subjects, majority 87 (44.4%) were found to be in the age group of 1-5 years of age and majority were males (55.1%). Fever was universally present (100%). Eschar, the pathognomonic lesion of scrub typhus was found only in 47.4% of the patients. Acute hepatitis was the most frequent complication encountered (33.2%). Majority (87.2%) of the patients improved and were successfully discharged. A total of 61 (31%) patients, out of the 196 included in the study, required admission to ICU. Mortality was more marked in patients suffering from shock, acute hepatitis, Acute kidney Injury, meningoencephalitis and myocarditis and Multiple Organ Dysfunction Syndrome (MODS) (p<0.05). Conclusion: Paediatric scrub typhus is quite common in the state of Odisha. Young age of presentation, presence of multi system involvement and delayed initiation of anti-rickettsial drugs due to delay in referral was also observed to be one of the poor prognostic factors.

Peer Assisted Learning: A New Teaching Approach in Undergraduate Medical Students

R Divya, S Abeetha, S Nedunchezhiyan, S Sadhana

Aim: To introduce peer assisted learning as new teaching and learning method in first year medical students and to compare the impact of this method on learners with traditional method of learning by Objective Structured Practical Examination (OSPE). Materials and Methods: In this observational study, first year MBBS students were randomly divided into two groups- the regular module and PAL module. In regular module, the students were taught by the faculty. In PAL module, the students were taught by a previously trained final MBBS students. In PAL module, senior medical students were trained on the clinical-practical topic to be taught. After training, the senior medical students taught their juniors. In the regular module, the junior students were taught the same clinical practical topic by the faculty. At the end of the session, the students were assessed by OSPE. Paired t-test was used for assessing effectiveness of educational methods. The p-value <0.05 was considered statistically significant. Results: Students’ post-test marks in PAL group were higher than the regular module group (12±2.9 vs 9.8±3.5, p<0.01). Majority (70%) of the students agreed that PAL is a better method of learning and develops teaching attitude. Most of the students strongly agreed that PAL provides friendly environment for learning (80%). About 70% of students gave positive response about need of similar sessions in the future. Conclusion: PAL is an interesting and exciting teaching-learning methodology in undergraduate medical training.

Splenic Haematoma as a Rare Cause of Pleural Effusion: A Case Report

Kashish Dutta, Anuj Kumar, Surabhi Jaggi, Mandeep Kaur Sodhi, Deepak Aggarwal

Pleural effusion has various aetiologies, mostly located either in the lung parenchyma or in the pleura. Subphrenic causes, leading to exudative pleural effusion are uncommon. Authors hereby, presented a case of a 50-year-old female with recurrent left sided pleural effusion. The effusion was haemorrhagic, exudative with low Adenosine Deaminase (ADA), and no malignant cells on cytology. Contrast Enhanced Computed Tomography (CECT) thorax and upper abdomen showed an incidental splenic haematoma. With conservative treatment, splenic haematoma and adjoining pleural effusion resolved completely. Thus, this case highlights splenic haematoma as a rare but important cause of pleural effusion.

Association of Diabetic Kidney Disease Markers and Urinary Beta-CrossLaps in Type 2 Diabetes

Lalithambigai Arumugasamy, Hetal G Patel

Introduction: Diabetic Kidney Disease (DKD) is a chronic complication in Type 2 diabetes. The Chronic Kidney Disease (CKD273) peptide classifier has been found to predict development of DKD even before microalbuminuria develops. Seventy four percent of peptides in the CKD273 classifier are Collagen degradation fragments. The Beta-CrossLaps (β-CTx) Enzyme Llinked Immunosorbent Assay (ELISA) assay detects the specific collagen degradation product, C terminal telopeptide of Type 1 collagen. In light of the Capillary Electrophoresis/Mass Spectrometry (CE-MS) findings, linking collagen degradation fragments excretion to early detection of DKD, the significance of urinary β-CTx levels as a DKD biomarker needs to be evaluated. Aim: To study the urinary excretion of β-CTx in type 2 diabetes patients and to evaluate its relation to microalbuminuria status and estimated Glomerular Filtration Rate (eGFR) of the patients. Materials and Methods: This descriptive cross-sectional study was undertaken at a tertiary care hospital, with enrollment of 82 type 2 diabetes patients from the diabetes Out Patient Department (OPD). Participants were divided into groups based on their Urinary Albumin Creatinine Ratio (UACR) and eGFR levels. The study participants were tested for Urinary β-CTx level, UACR and eGFR. Mean or median was calculated for the parameters with normal and non-normal distribution, respectively. All statistical testing was performed on online calculators available at the site; https://www.socscistatistics.com/. Results: The median urinary β-CTx level observed was 100.6 ng/mmol of creatinine. Among the 82 participants, 15 participants had urinary β-CTx level 15 pg/mL, the sensitivity of the kit. Among the remaining 67 participants, the minimum Urinary Beta-CrossLaps: Creatinine ratio observed was 2.6 ng/mmol and the maximum value observed was 2071 ng/mmol (i.e., 2.1 μg/mmol). The median urinary β-CTx level was highest (100.6 ng/mmol creatinine) in the patient group with eGFR in the normal range. The urinary β-CTx level was found to decline with decline in eGFR, with median urinary β-CTx 65.5 ng/mmol creatinine in the patient group with mildly decreased eGFR and 7.2 ng/mmol creatinine in the patient group with moderately decreased eGFR. Conclusion: The Urinary β-CTx concentration in type 2 Diabetes patients is dispersed over a wide range. The Urinary β-CTx concentration correlates with the eGFR of the patient and is not influenced by age, gender or duration of diabetes. This parameter is a potential early DKD biomarker.

A Retrospective Study of Roots and Root Canal Morphology in Mandibular Premolars using Cone Beam Computed Tomography in Delhi-NCR

Sneh Mishra, Sonali Taneja, Vidhi Kiran Bhalla, Akshay Rathore

Introduction: The anatomical heterogeneity of mandibular premolars has always been considered an enigma and it makes them potentially prone to high rates of endodontic failure. Only few studies have discussed the potential role of Cone Beam Computed Tomography (CBCT) in the assessment of root morphology, canal configuration and their complex variations. Aim: To investigate the number of roots and root canals along with the canal configuration in mandibular premolars in the Delhi-National Capital Region (NCR) population using CBCT imaging. Materials and Methods: The retrospective observational study was conducted where 432 CBCT images of 108 patients were acquired from different CBCT centres in Delhi-NCR region to determine the anatomy and morphology of mandibular premolars. The number of roots, root canals and their configuration and its association with symmetry and gender was evaluated. Pearson Chi-square test and Fisher’s-exact test were used for statistical analysis. Results: The mandibular first and second premolars reported with single root in 94.9% and 98.1% cases, respectively. Majority of 1^st premolars displayed 2 canals (59.7%) whereas 2^nd premolars exhibited single canal (58.3%) more frequently. Type I configuration was most prevalent in both 1^st premolar (39.8%) and 2^nd premolars (60.2%). Type V configuration was significantly reported on the left in both mandibular 1^st and 2^nd premolars (13.9% and 4.6%), respectively. There was no significant gender predilection observed for the morphology of roots, root canal and canal configuration. Conclusion: In Delhi-NCR, there was a high prevalence of multiple canals and variable configurations in 1^st premolars whereas single root canal and Type I canal configuration were more frequent in 2^nd premolars with a significant bilateral distribution. However, in both mandibular premolars there was a slight inclination reported for multiple canals and variable configurations towards left with no gender predilection.

Cost Excursion Study of Various Insulin Preparations Available in India

Mayur B Phulpagare, Smita A Tiwari, Rajesh S Hiray

Introduction: Poor drug compliance affects clinical outcome and increases healthcare costs in various disease setting. Several type II diabetes mellitus patients, not controlled on oral hypoglycaemics eventually require insulin therapy. Antidiabetic treatment is to be taken lifelong and in such a setting insulin price variation imposes a huge economic burden on poor diabetic patients. Moderating drug cost is associated with improved adherence to the medication regimen. Aim: To study the variation in cost amongst various brands of insulin analogues. Materials and Methods: This was an observational, cross-sectional study. Data regarding the 116 formulations and cost of 18 types of insulin preparations was collected from sources like Current Index of Medical Specialties (CIMS), National Pharmaceutical Pricing Authority (NPPA), Government of India official website (https://nppaimis.nic.in/nppaprice/pharmasahidaamweb.aspx) and compared with its lowest counterpart. The cost ratio and percentage cost variation was analysed and expressed as percentages. Results: This study showed a noticeable variation in the prices of insulin analogues. The highest percentage of cost variation was found for Insulin (Highly Purified) Zinc-40 IU (135.17%), followed by Insulin (Analogue) Glargine-100 IU (109.31%). The lowest percentage were for: Insulin (Human-Isophane Recombinant)-40 IU (1.40%), and Insulin (Analogue) Aspart- 100 IU (6.26%). Conclusion: A noticeable variation in cost prices was observed especially in commonly used intermediate acting insulin that help basal glycaemic control. Similarly, the lowest variation was observed with recombinant counterparts as an effect of pre-existing high prices of each. Need for vital medication like insulin at affordable costs has incited national and global efforts to make it cheaper and accessible to maximum beneficiaries.

Single vs Multiple Antibiotic Drug Regimen in Preventing Infectious Morbidity in Caesarean Section: A Randomised Clinical Trial

Introduction: Surgical site infections are a serious cause of maternal morbidity and mortality. Various preventive measures are being used to reduce the incidence of surgical site infections. One of them is the use of prophylactic antibiotics. In this study, authors have evaluated three antibiotic regimen with respect to preventing infectious morbidity in caesarean section. Aim: To study the efficacy and cost-effectiveness of a single dose (ceftriaxone) versus multiple doses of antibiotic therapy (ceftriaxone and ornidazole) administered preoperatively in women undergoing caesarean delivery. Materials and Methods: A prospective interventional study was conducted on 300 pregnant women undergoing emergency or elective caesarean delivery. Study was conducted at BLDE (DU) Shri BM Patil Medical College and Research Centre, Vijayapur, Karnataka, India. Patients were randomly assigned to three groups by block random sampling with 100 women in each group. Group A received Inj. ceftriaxone 1 gm single dose 60 minutes prior to commencement of surgery. Group B received Inj. ceftriaxone 1 gm along with Inj. ornidazole 500 mg intravenous infusion 60 minutes prior to commencement of surgery and Group C received Inj. ceftriaxone 1 gm and Inj. ornidazole 500 mg intravenous infusion 60 minutes prior to commencement of surgery and a repeat dose 12^th hourly for 24 hours followed by Tab. cefixime 200 mg and Tab. ornidazole 500 mg twice daily for four days postoperatively. The effectiveness of therapy was measured in terms of adverse effects of antibiotics such as nausea and vomiting and postoperative complications like pyrexia, foul smelling lochia, surgical site infections, uterine tenderness, peritonitis and endometritis. Results: There was no statistical difference in outcome measures in side-effects of antibiotics (p-value=0.13), fever (p-value=0.68), lochia discharge (p-value=0.88), wound infection (p-value=0.39) and peritonitis (p-value=0.30) among the three groups. The single dose medication in group A had a cost of Rs.60 INR (0.82 cents USD), which was significantly less compared to the multiple dose regimens in group B that cost Rs.203 INR ($2.76 USD). The mean hospital stay in non infectious and infectious patients were 5 and 10 days in present study (p<0.0001). Conclusion: Caesarean delivery poses 5-20 times greater risk of postoperative infection when compared to vaginal birth. There has been a shifting trend of increasing caesarean deliveries and postoperative infections can contribute to overwhelming health and economic burden. Present study shows outcome measures which were statistically insignificant among the three study groups with different prophylactic regimen for caesarean delivery, so it’s safe to state that both single dose and multiple dose regimen provided equal protective coverage in reducing maternal infectious morbidity. Also, single dose regimen proved to be cost-effective. So, to conclude single dose prophylactic antibiotic given preoperatively in caesarean section is both cost-effective and as is efficient.

Prevalence of Fatigue and its Association with Pain Intensity, Psychological Status and Sleep Quality in Patients with Neck Pain

Mosab Aldabbas, Tarushi Tanwar, Iram Iram, Zubia Veqar

Introduction: Neck Pain (NP) is a major public health problem. Social and economic participation of many individuals gets negatively impacted due to NP. Fatigue and pain are common complaints in patients with this condition. Both can interfere with the daily life of patients by affecting the quality of sleep which can lead to psychological issues. But, the prevalence of fatigue and its association with pain, sleep quality and psychological factors have not been examined properly in patients complaining of NP. Aim: To examine the prevalence of fatigue and its association with pain intensity, depression, anxiety, and sleep disturbance in patients with NP. Materials and Methods: A cross-sectional study on 296 NP patients with a mean age of 30±7.2 years (181 males and 115 females) was conducted between March 2019 till November 2019. It was conducted at the Physiotherapy Department of the University and Amarjyoti College of Physiotherapy. The Multidimensional Fatigue Inventory (MFI), Hospital Anxiety and Depression, Pittsburgh Sleep Quality Index (PSQI) and Numeric Pain Rating Scale were used to evaluate fatigue, depression and anxiety, sleep quality and pain intensity, respectively. Spearman’s rank correlation coefficient and Mann-Whitney U test were used for analysis. Results: The point prevalence rate of severe fatigue in participants was 39.86%. Fatigue was significantly related with pain intensity, psychological factors, and sleep quality (p<0.05). We also observed a significant association between sleep quality and psychological factors in this sample (p<0.05). Conclusion: Fatigue was a prominent factor in patients with NP and it was associated with pain intensity, depression, anxiety, and sleep disturbance. Prevalence of fatigue was higher in chronic stage of NP than in the acute sage. Identifying these factors may help in prevention and management of NP and its co-morbidities.

Development and Validation of the Smartphone Addiction Scale for Children- Parent Version (SASC-P)

Gopi Rajendhiran, Vikhram Ramasubramanian, P Bijulakshmi, S Mathumathi, M Kannan

Introduction: The use of smartphone among children and adolescents has been increasing steadily over the past decade and is becoming a cause of concern for parents and healthcare professionals alike. Excessive use of smartphone could make a child vulnerable to develop addictive behaviour leading to decrease in academic performance and impairments in social and personal environment. Early identification is key to addressing this issue and although there are scales to measure smartphone addiction in adults, there are no scales to measure smartphone use in children objectively. Aim: To construct a smartphone addiction scale for children that can be administered to parents. Materials and Methods: A set of statements were created to assess smartphone addiction in children. Initially, 43 statements were selected after identifying its content validity and face validity and the scale was administered to parents of children in the age group of 3-17 years after obtaining informed consent from the parents. The construct validity was examined by the exploratory factor analysis. The screen plot of ordered eigen values of a correlation matrix was used to decide the appropriate number of factors extracted. A factor loading of >0.30 was used to determine the items for each factor. Intra-class correlations were calculated for the test-retest reliability, and Cronbach's alpha was calculated for the internal consistency. The final questionnaire contained 24 statements across six subdomains of smartphone addiction and it was administered to a small sample group of 65 parents of children aged 3-17 years and the data was used to test for reliability and validity of the scale. Results: Alpha correlation for the Smartphone Addiction Scale for Children-Parent (SASC-P) ranged from 0.670 to 0.823. The intrinsic validity for the domains was calculated using Cronbach’s alpha and it ranged from 0.819 to 0.907 for the domains and was 0.972 for the whole questionnaire. Thus the scale was found to be reliable and valid for use in children and adolescents. Conclusion: The SASC-P has good reliability and validity and can be used to measure smartphone use in children and adolescent.

Clinicoepidemiological Profile and Outcome of COVID-19 Positive Healthcare Workers in a Tertiary Care Centre in South India

Introduction: Coronavirus Disease 2019 (COVID-19) is rapidly spreading in India and all over the world. Being at the frontline in the battle against COVID-19, Healthcare Workers (HCWs) are among the greatest groups at risk of COVID-19 infection. Therefore, it is very important to study the risk and sources of infection and clinical outcome of HCWs. Aim: To study the clinicoepidemiological profile and outcome of COVID-19 positive HCWs in Government Medical College Thrissur, Kerala, India. Materials and Methods: This was a hospital based crosssectional study conducted during the time period from February to December 2020. A semi-structured telephonic interview schedule and hospital based records were used to collect the demographic, epidemiological and clinical information of 235 COVID-19 positive HCWs. Proportions along with 95% Confidence Interval was used to express the results. Results: Among 235 COVID-19 positive HCWs, 51% were either nurses or auxiliary nursing staff. Non COVID-19 areas had 31.9% infections, while 17.1% of infections occured in COVID-19 areas. Around 57% acquired infection from healthcare settings. Common symptoms were fever (67.2%), myalgia (40.4%) and headache (39.6%). Around 21.3% subjects remained asymptomatic. Hand hygiene compliance was 96.6%. Among positive HCWs, 57% used N95 mask, 52.8% used gloves, 49.8% used apron and 48.9% used face shield in the hospital. Only 0.85% required Intensive Care Unit (ICU) admission. No mortality was reported in the present study. Conclusion: There is a considerable risk for COVID-19 infection among HCWs in hospital settings especially from non COVID-19 areas. Present study findings show the risk of exposure and need of infection control measures even outside the healthcare settings. Early identification and isolation of cases is very important. This study will be useful for policy makers in planning control strategies and preventing COVID-19 infections among HCWs.

Study of Histomorphological Spectrum of Granulomatous Lesions of Skin

Introduction: The granulomatous reaction is defined as a distinctive inflammatory pattern characterised by the granuloma. The term Granuloma was first coined by Virchow in 1864. The granuloma is characterised by collection of activated histiocytes, epithelioid cells and multinucleate giant cells that may or may not be rimed by lymphocytes and/or show central necrosis. The pattern of skin disease varies from one country to another and across different parts within same country. The granulomatous lesions of skin are a common and intriguing problem in developing countries. Aim: To study the histomorphological spectrum of granulomatous lesions of skin. Materials and Methods: This cross-sectional study was conducted in Department of Pathology, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India, over a period of two years (from September 2018 to September 2020). All skin biopsies coming to the Department of Pathology were fixed in 10% neutral buffered formalin for duration of 12 to 24 hours. Paraffin wax blocks were made and 3-4 micrometer section were taken and stained with Haematoxylin and Eosin (H&E), showing granulomas on histology were included in the study. On H&E, stained slide, granulomas were studied for type, morphology and site. Special stains were used for further evaluations and analysis. Results: Out of total 124 cases studied, the maximum patients 34 (27.41%) were of 11-20 years age group. The epithelioid granuloma was the most common type in 76 (61.29%) cases followed by histiocytic granuloma in 24 (19.35%). The infectious granulomatous dermatoses were the most common histological type in which tuberculosis was most common followed by leprosy. Most commonly the lesions were found to involve the whole dermis in 74 (59.68%) cases, followed by upper and mid dermis in 35 (28.22%) cases. Out of 40 cases of leprosy, 17 (42.50%) cases were found Wade-Fite Stain positive. Out of total 57 cases of tuberculosis, 31 (54.38%) cases were found Acid-Fast Bacillus (AFB) positive. Conclusion: Authors concluded that major cause of granulomatous dermatoses in developing countries is still infectious, tuberculosis and leprosy being the leading causes. Histopathology is gold standard for diagnosis and categorisation of granulomatous dermatoses. Special stains are useful in cases of any dilemma.

Evaluation of Iron Status in Children with Autism Spectral Disorder: A Case-control Study

Pritam Prakash, Rekha Kumari, Niska Sinha, Santosh Kumar, Poonam Sinha

Introduction: Iron is an important factor in neural development. Iron Deficiency (ID) and Iron Deficiency Anaemia (IDA) anaemia is highly prevalent in patients of autism. There are paucity of studies to show association between iron profile and autism. Aim: To investigate factors affecting iron status such as haemoglobin (%), serum iron, ferritin, and Total Iron Binding Capacity (TIBC) level in children with Autism Spectral Disorder (ASD) and healthy control. Materials and Methods: It was a case-control study done from April 2018 to April 2019. Total 100 participants were recruited of which 50 autistic patients were taken as cases, and 50 healthy subjects were taken as control. Childhood Autism Rating Scale (CARS) was used to evaluate the severity of autistic symptoms. Cut-off value of serum ferritin was <10 ng/mL for preschoolers (<6 years) and <12 ng/mL for school-aged (>6 years) children to evaluate ID. Anaemia was defined as haemoglobin <11.0 g/dL for preschoolers and <12.0 g/dL for school-aged categorical variables and were compared by using Chi-square test. Normally distributed parametric variables were compared between groups by using independent samples t-test. Serum ferritin, iron, TIBC values were compared between severe, mild-moderate and control groups with Analysis of Variance (ANOVA). The p-value <0.05 was accepted to be statistically significant. Results: Mean serum levels of ferritin, iron, TIBC were significantly reduced in ASD patients (p<0.001). The level of haemoglobin was also lower in ASD patients but it was not significant (p-value=0.51). Risk of ID and IDA was higher than normal subjects (RR for ID 1.74). Level of serum ferritin, iron and haemoglobin was lowest in severe autism as compared to mild-moderate autism and control groups. Conclusion: These findings suggest iron and ferritin levels should be measured in autistic patients as a baseline investigation and it may be used as a screening test for ASD.

Evaluation of Intraocular Pressure Changes with Topical Dexamethasone 0.1%, Prednisolone 1% and Difluprednate 0.05% Postcataract Surgery- A Randomised Clinical Trial

Sachit Mahajan, Sanjay Kai, Sadaf Choudhary, Kiran Bala, Bhavna Sahni

Introduction: Topical corticosteroids are most commonly used for the control of postoperative inflammation after cataract surgery. Topical steroids may cause increase in Intraocular Pressure (IOP) which, if left untreated may lead to progressive optic nerve damage and glaucomatous field defects. Aim: To compare the ocular hypertensive response of three commonly used corticosteroids in an effort to generate evidence for managing postcataract surgery inflammation more effectively. Materials and Methods: This randomised clinical trial was carried out for a period of one year from November 2018 to October 2019, among 150 patients undergoing cataract surgery. Patients were divided into three groups. Group A-50 patients received topical dexamethasone 0.1%, Group B-50 patients received topical prednisolone 1% and Group C-50 patients received topical difluprednate 0.05% four times a day for six weeks after cataract surgery. Postoperative IOP was recorded preoperatively, on first postoperative day and at the end of first week, third week and sixth week with non contact tonometer and statistical significance was assessed with the help of repeated measures mixed model Analysis of Variance (ANOVA). Results: The mean age of the patients was 64.4±9.39 years, 48% were males and 52% patients were females. Mean IOP in the three drug groups was not statistically significant at 1^st week, 3^rd week and at 6^th week after cataract surgery. Two patients belonging to difluprednate group at the end of 1^st week and one patient at the end of 3^rd week after cataract surgery developed significant rise in IOP (>31 mmHg). Conclusion: It can be concluded that all three steroids were equally safe and did not cause any statistically significant rise in IOP over six-week postoperative period. However, higher values were noted in difluprednate group at the end of first and third week after cataract surgery.

Prevalence and Clinical Pattern of Localised Hypomelanosis in Children: An Observational Study

Introduction: Pigmentary changes in children can be a concern to parents, enabling them to seek medical opinion. Hypopigmentary lesions in the paediatric age group can be a trivial finding or may be a part of a multisystem disease. Identifying and prompt management of these lesions addresses the systemic involvement if any, and parents’ concern as well. Aim: To observe the prevalence and clinical pattern of localised hypomelanotic disorders in the paediatric age group (0-18 years). Materials and Methods: This was a hospital-based observational study conducted for a period of two years (August 2017-August 2019), which included 204 paediatric patients with localised hypomelanotic lesion in children who attended the Dermatology Outpatient Department (OPD). Demographic data such as age, sex, history of onset and progression of skin lesions, general examination, specific cutaneous examination including the site, size, number, symmetry, distribution, etc., were recorded. Data were analysed using descriptive statistical methods. Results: Out of 204 cases, the most common hypopigmentary disorder was Pityriasis versicolor (38.7%), followed by Seborrhoeic dermatitis (18.1%), Pityriasis alba (8.8%) and Polymorphic light eruption (7.8%). Among them female children were 111 (54%) and male children were 93 (46%). The most commonly involved age group was 12-18 years (35%), followed by 6-12 years (32%). Face was the most commonly involved site accounting for, followed by back. The localised hypopigmented lesions are predominantly involved in the sun exposed area (78%). History of atopy and family history of atopy were seen in 5% and 8%, respectively. Conclusion: Pityriasis versicolor was the most common condition seen in this study. The sun exposed areas were frequently involved with face being the commonest. There was no underlying systemic disease involvement observed in this study. However certain conditions like hypomelanosis of Ito and Hansen’s need long term follow-up and prompt treatment to prevent complications respectively.

Time Transition of Routines in Fast Food Consumption-Importance to Public Health

Akansha Khare, Chandra Pal Sharma, Neelu Jain Gupta

Introduction: Fast Food (FF) consumption reduces the nutritional quality of daily diet. FF is even more detrimental to human health, if preferred during night-time meals, because metabolism is slower at end of the day. Quality of food and time of eating are nutritional determinants of the health. Aim: To study the association of anthropometric and societal factors such as age, Body Mass Index (BMI), health awareness with frequency of FF and preference for meal timings. Materials and Methods: Through a cross-sectional Google-form food preference survey of 2887 people, it was sought to uncover a possible association between the perception and frequency of FF and preference for mealtimes. Unadjusted associations of people’s eating preferences with age, BMI and health awareness with FF intake was analysed using Spearman’s correlation coefficients, Cronbach’s α, Eigen values, odd ratios, relative risk factors andχ²-tests. Results: The high odd ratio revealed greater FF popularity in adolescents and children as compared to adults. Principal component analysis revealed four important factors (Eigen value >0.9; factor weight >12%) viz., age, busy life, body weight and weekend drive. Taking FF as a food quality index, there was food quality jetlag between week days and weekends. Psychometric analysis revealed a positive association between preferred mealtime and FF intake. Conclusion: Mealtimes regulate the human circadian system; therefore, health consequences of FF consumption ensconce other determinants of public health like night eating and lifestyle. The deteriorating effects of FF are associated with circadian disruption. More research is needed to highlight associativity of different lifestyle factors detrimental to circadian health.

Study of Socio-demographic and Clinical Profile of Individuals with Deliberate Self-harm Attempt during COVID-19 Lockdown

NV Roopesh Gopal, SV Sathish Kumar

Introduction: Self-harm attempt is an important aspect in consultation liaison psychiatry. During lockdown due to the Coronavirus Disease-2019 (COVID-19) pandemic, many people underwent various stressors. Many individuals were referred to Psychiatry Out Patient Department (OPD) with a history of self-harm attempt. They were also aware of the travel restrictions and difficulty in reaching hospitals. So, it was necessary to understand the reasons for the self-harm attempt, especially during the lockdown. Aim: To study the socio-demographic and clinical profile of individuals with self-harm attempt during the lockdown. Materials and Methods: The cross-sectional study was done during the COVID-19 lockdown period (last week of March 2020 till end of May 2020) in the Kodagu Institute of Medical Sciences Teaching Hospital, Madikeri, Karnataka, India. A total of 52 subjects of self-harm attempt who were referred to the Department of Psychiatry for counseling and needed psychological help, on regular OPD days were recruited for the study after obtaining informed consent. Socio-demographic and clinical details like nature of self-harm attempt, method of attempt, number of attempts, reason for attempt, time of attempt, consumed alcohol prior to the attempt, how did they reach hospital, clinical depression, difficulty in reaching hospital due to lockdown, regret/remorse about the attempt were documented using the semi-structured proforma. The data was expressed as percentages and Chi-square test was applied. A p-value less than 0.001 were considered as significant. Results: Out of 52 subjects, 65.4% belonged to 21-40 years of age, 51.9% were females, 65.4% were married, 30.8% belonged to lower socio-economic status, 61.6% residing in a rural area, education below class 10 (73.07%), the predominant occupation was labourers and home maker. Poisoning was the common method and 25% had depression and needed medications. The interpersonal conflict was the common reason and had difficulties due to lockdown (5.7%). However, the findings were statistically not significant among males and females. Conclusion: Self-harm attempt was common in young married females in a rural area by poisoning, who reported depression, interpersonal conflict and economic difficulties during the lockdown.

Knowledge, Attitude and Practice Survey on Special Care Dentistry: A Cross-sectional Study

A Srividya, A Kannan, Krithika Chandrasekar Lakshmi

Introduction: Special Care Dentistry (SCD) is a dentistry branch that advocates equal dental Patient with Special Care Needs (PSCN). In several countries, it is a separate specialty. In India, it is still in its infancy. Few studies have explored the dentists' perception regarding SCD. Aim: To determine the knowledge and attitude about SCD, also the practice measures followed by the dentists in Chennai colleges. Materials and Methods: This cross-sectional observational study was conducted in three dental colleges in Chennai from September 2019 to October 2019. A total of 230 dentists were enrolled using random sampling. A set of 20 close ended multiple choice questions were formulated and administered to dentists {Undergraduates (UGs) and Postgraduates (PGs)}. Descriptive statistics and Chi-square test was performed using MATLAB software (Mathworks, 2015), with p<0.05. Results: A 78.8% of respondents got good scores of ≥7 in knowledge based questions, 25.6% of the participants showed overall positive attitude. Educational qualification did not affect respondents’ knowledge and attitude about SCD (p>0.05). Only 21.95% of UGs and 22.31% of the PGs have good self-confidence in treating patients with special needs. More than 80% have not administered Domiciliary Care (DC). A total of 65% of participants denied getting any training in their UGs/PGs curriculum. Conclusion: Dentists in the present study are aware about SCD. Clinical measures adopted by dentists and their confidence in treating these patients are suboptimal. Training in SCD should become integral part of future dental education.

Accuracy of Two-dimensional Ultrasound and Magnetic Resonance Imaging in Diagnosis of Foetal Congenital Anomalies in a Tertiary Care Hospital- A Cross-sectional Study

Jaybrata Ray, Jaharlal Baidya, Tanusri Debbarma, Jobin Joy

Introduction: Ultrasound screening for foetus congenital malformations is the mainstay in diagnosis and is commonly performed at 19-22 weeks gestation. Magnetic Resonance Imaging (MRI) is known as a problem solving tool which is used for answering a specific question. Both ultrasound and foetus MRI are highly sensitive and specific in diagnosis of congenital anomalies of the foetus with high agreement between both modalities. Aim: To determine the accuracy of Ultrasound Sonography (USG) and High Field 3 tesla MRI in diagnosis of different types of foetal Central Nervous System (CNS) and non CNS congenital abnormalities. Materials and Methods: A cross-sectional study was conducted in the Department of Radiodiagnosis at Agartala Government Medical College and GB Pant Hospital from June 2017 to May 2019. A total of 65 cases with ultrasound diagnosis of foetus abnormalities were examined by 3 Tesla MRI. MRI were performed within 15 days after USG detected anomalies. Statistical analysis was done using Chi-square test. Results: In cases with foetus anomalies high field MRI provided detailed findings leading to a more refined diagnosis. CNS anomalies were more as compared to other anomalies. Some of the antenatal findings were confirmed in some cases following termination of pregnancy and some were by postnatal examination. Among them chest anomalies was least common i.e., 1.5%. sensitivity of MRI was 88.13%, specificity was 66.66%, Positive Pressure Ventilation (PPV) was 96.29%, Negative Predictive Value (NPV) was 36.36% and USG sensitivity was 82.43%, specificity and 77.77%, PPV was 95.83%and NPV was 41.17%. Conclusion: High field MRI should be used as a second line of investigation in patients with foetus abnormalities diagnosed by ultrasound for confirmation of diagnosis and selecting the treatment protocol. In cases of fatal abnormalities, a confirmed diagnosis made before 20 weeks of pregnancy may help by terminating the pregnancy.

Surgical Outcome Following Early Decompressive Hemicraniectomy in Patients of Severe Traumatic Brain Injury: A Retrospective Study

Introduction: Traumatic Brain Injury (TBI) has become an epidemic and remains the leading cause of death and disability in people of 2^nd to 4^th decade. Road Traffic Accidents (RTA) are responsible for the majority of cases. Primary brain injury sustained on impact and secondary brain injury that develops in following hours and days contribute together to overall injury and decides ultimate outcome. The goal of management in any TBI patient aims to prevent secondary brain injury. Understanding the importance of Intracranial Pressure (ICP) is key to minimise secondary injury. Decompressive hemicraniectomy is a novel technique of reducing ICP in patients of severe brain injury. It’s judicious and timely performance not only saves life but also prevents the dreaded consequences of raised ICP. Aim: To evaluate the role of early decompressive hemicraniectomy in improving the survival rate among patients of severe TBI and analysing the important factors (glasgow coma scale, airway status, timing of surgery) affecting the surgical outcome. Materials and Methods: It was a retrospective study conducted at the Department of Neurosurgery, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India between September 2016 to March 2020. Case records of 60 patients of TBI who had undergone unilateral Decompressive Craniectomy (DECRA) were analysed. The decision for decompressive hemicraniectomy was purely based upon Glasgow Coma Scale GCS) and Computed Topography (CT) findings. The presence of an evacuable mass lesion, diffuse oedema and obliteration of basal cistern in CT was considered to be the most important criteria for the early decompressive procedure. Patients were assessed until their discharge from ward. Statistical analysis was performed by statistical package for science version 12. Results: A total of 60 patients with severe TBI, who underwent DECRA were analysed. Road Traffic Accident (RTA) was the predominant mechanism of injury. All had presence of a surgically evacuable mass lesion along with compression/obliteration of the basal cistern. The majority of mass lesions (n=42) were frontotemporal contusions (70%). Forty patients of total achieved good surgical outcome (66.67%) and rest 20 patients (33.33%) had poor outcomes. Overall incidence of complications was around 40%. The most important factors associated with good outcomes were GCS of 7 and and above, patent airway, and early surgery. Conclusion: Decompressive hemicraniectomy is a novel technique of reducing ICP which acts by directly breaking the rigid box phenomenon of Monro-Kellie doctrine. However patient selection, prompt decision, earliest intervention, adoption of standard technique of DECRA and post operative critical care management are important aspects behind the successful outcome.

Prediction of Clinical Requirement of Tocilizumab Injection in COVID-19 Patients with High Chest CT Severity Score- A Retrospective Analysis

Introduction: The ongoing Coronavirus Disease 2019 (COVID-19) pandemic has spread rapidly across the globe. Tocilizumab is a recombinant monoclonal antibody to Interleukin-6 (IL-6) receptor. An increasing number of studies across the world is reporting the use of tocilizumab in treating COVID-19 patients or at risk of developing cytokine storm. Apart from clinical and laboratory parameters, High Resolution Computed Tomographic (HRCT) chest scan is a promising tool to identify patients very early in the course of COVID-19 disease. Aim: To find whether high chest CT Severity Score (CTSS) on HRCT thorax scan predict the clinical requirement of tocilizumab injection in COVID-19 patients. Materials and Methods: In this retrospective study, during the period from May 2020 to July, 2020, 250 patients with confirmed Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) diagnosed with COVID-19 in first or repeat sample and who also underwent HRCT scan of the chest, were assigned chest CTSS. From the data obtained, patients were categorised into two groups based on mild and severe CTSS. Patients with higher CTSS have a higher future possibility of developing the cytokine storm and hence the requirement of tocilizumab can be reliably predicted. All statistical analysis was performed in IBM Statistical Package for the Social Sciences (SPSS) version 20. Results: Out of a total of 250 patients, 72 patients were given tocilizumab injection. The average CTSS was 29.8±6.38 in the tocilizumab injection group. Only 8% of patients with mild CTSS received tocilizumab injection while 60% of patients with severe CTSS received tocilizumab injection (p<0.001). Out of 72 patients who received tocilizumab injection, 16.7% had mild CTSS while 83.3% had severe CTSS (p<0.001). Average values of inflammatory markers like C-Reactive Protein (CRP), D-Dimer, Ferritin, Lactic De-Hydrogenase (LDH), and IL-6; were significantly higher in severe CTSS and tocilizumab group (p<0.001). Conclusion: CTSS may be used as a new decisive tool in triaging in-hospital COVID-19 patients. Categorising patients in mild and severe CTSS early in the disease course, even before the marked worsening of laboratory parameters and development of cytokine storm may help initiate early treatment and thereby save many lives.

Influence of Storage Temperature on Orthodontic Elastics

Introduction: Orthodontic elastics are a very significant tool in orthodontics, as it is the most commonly used force delivering unit. Temperature plays a key role in the amount of force that elastics are able to produce. Hence, there is a need to evaluate the influence of storage temperature on the properties of orthodontic elastics before its clinical use. Aim: To evaluate the influence of different storage temperature of latex orthodontic elastics. Materials and Methods: This cross-sectional study was conducted at Sathyabama Dental College and Hospital, Chennai, in November 2019. Sample of 40 latex orthodontic elastics (TP Orthodontics, medium force, standard size of 3/16??) were divided into four groups with 10 elastics each, based on their storage temperature and stored in closed plastic packages. Group 1 was kept as a Control group and Group 2, Group 3 and Group 4 were stored in three Incubators under the specified storage temperatures such as 26-28°C, 4-8°C, 37°C respectively. The elastics were stretched and their forces measured in six progressive increases of 100% of their inner diameter, starting at a level of 100% stretching, with the Universal Testing Machine, Instron. The samples were also tested for Maximum Stress (MPa), Maximum Force (N), Maximum Elongation (%) and Break Distance (mm). Data were analysed using Statistical Package for the Social Science (SPSS) software version 16.0, one-way Analysis of Variance (ANOVA) and post-hoc test. Results: On evaluating the stress at 100%, 200%, 300%, 400%, 500%, 600% of strain, there was no statistically significant difference between the groups. Maximum Stress MPa was found to be 24.12±3.32, 25.12±3.42, 23.3±3.41, 23.97±3.50 for group1, group 2, group 3 and group 4 respectively. Maximum Elongation (%) was found to be 1369.0±25.108, 1364.0±23.190, 1359.0±35.103, 1363.0±34.657 for group 1, group 2, group 3 and group 4, respectively. Break Distance (mm) was found to be 68.48±1.267, 68.28±1.267, 67.87±1.77 and 68.19±1.727 for group1, group 2, group 3 and group 4, respectively. And none of the parameters tested showed statistical significance between the four groups. Conclusion: Latex elastics may be stored under any of the conditions tested in the present study over a period of one month, since different storage temperatures over a period of one month did not interfere in their mechanical properties.

Diagnostic Accuracy of Fine Needle Aspiration Cytology in Breast Masses among Children and Adolescents Aged Below 21 Years - A Cross-sectional Study

T Rajini, K Amita

Introduction: Breast diseases in paediatric and adolescence are unusual. Fine Needle Aspiration Cytology (FNAC) has an important role in triaging breast masses, more so in younger population, wherein preoperative accurate diagnosis has significant impact on selecting and planning treatment. Role of FNAC in breast lesions amongst children and adolescents has not been explored much. Aim: To study the role of FNAC in diagnosis of breast lesions in children and adolescents. Materials and Methods: A cross-sectional study was conducted between June 2017 to May 2019 at Adichunchanagiri Institute of Medical Sciences, Mandya, Karnataka, India. All the patients presenting with breast lesion aged below 21 years, referred to FNAC clinic during this period were included in the study. The diagnoses were categorised as inflammatory, benign, atypia, suspicious and malignant. Cytohistopathology concordance was attempted wherever possible. Analysis was done using Statistical Package for the Social Sciences (SPSS) software version 17.0. Results: Out of total 45 cases, 37 (82.22%) were females and 8 (17.78%) were males. Breast lesions in paediatric and adolescents accounted for 15.20% (45/296) of total breast FNAC performed during the study period. The morphologic spectrum seen most commonly was fibroadenoma (FA) 62.22% (28/45), benign breast disease 8.88% (4/45), mastitis 4.44% (2/45). Morphologic variations observed in FA were epithelial hyperplasia 32.14% (9/28), cystic change 28.57% (8/28), hypercellular stoma 21.42% (6/28), multinucleate giant cells 32.14% (9/28), apocrine change 14.28% (4/28), adenosis 10.71% (3/28), columnar cell change 10.71% (3/28), squamous metaplasia 3.57% (1/28) and atypia 3.57%(1/28). Histopathologic association was obtained in 31 cases (68.88%). Overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of FNAC was found to be 50%, 100%, 100%, 96.6%, 96.77%, respectively. Conclusion: Majority of the breast lesions in paediatric and adolescents are benign in nature with FA being the most common. The FNAC had high specificity and diagnostic accuracy, thereby establishing its role in selecting appropriate treatment for this age group of patients.

Correlation of Serum Amylase, Lipase and Creatine Kinase with Severity of Organophosphate Poisoning- A Cohort Study

Noas Tobias Minz, Sarat Chansra Singh, Priyabrata Jena, Pranay Kumar Patro

Introduction: Organophosphate Compounds (OP) are widely used pesticides in agriculture. It is easily available and OP poisoning is most common cause of poisoning and hospital admissions. Severe poisoning is associated with high mortality. Severity of poisoning can be assessed by Peradeniya Organophosphorus Poisoning (POP) scale, Acute Physiology and chronic Health Evaluation (APACHE) II, Glasgow Coma Scale (GCS) or serum Cholinesterase Level (ChE). Serum amylase, lipase, and creatine kinase are important biomarkers raised in OP poisoning. Aim: To correlate serum amylase, lipase, and creatine kinase with severity of OP poisoning. Materials and Methods: This was a hospital based observational cohort study conducted on 130 patients of organophosphate poisoning admitted in General Medicine wards of SCB Medical College, Cuttack, Odisha from June 2019 to December 2020. Serum Acetylcholine Esterase (AChE), amylase, lipase and creatinine kinase were estimated at admission, day 2, and at discharge. Other routine investigations were done. Acetylcholine Esterase (AChE) was used to confirm the diagnosis. The severity of poisoning was assessed using POP scale and graded as mild, moderate and severe. The severity of poisoning and the level of enzymes were correlated. The parameters were tabulated and mean values and Standard Deviation (SD) were analysed using Statistical Package For The Social Sciences (SPSS) software version 22.0. Results: Out of 130 patients 91 were males and 39 were females, mostly from rural areas, both farming and non-farming community. Age ranged from 14 years to 79 years, with majority in 19 to 39 years. AChE decreased in all cases depending on severity confirming OP poisoning. Severity as assessed by POP score were mild (52 patients), moderate (46 patients) and severe (32 patients). At admission, the Amylase (U/L), Lipase (U/L), and Creatine kinase (U/L) level (mean±SD) in mild poisoning were 83.7±41.9 U, 70.9±18.6, 72.5±34.9, in moderate poisoning 153.6±109.7, 91.9±47.4, 92.6±81.5, and in severe poisoning 243.9±113.8, 195.3±147.7, 298.8±207.4, respectively. Measurements on second day also remained elevated. Among the severe cases 24 patients developed Intermediate Syndrome (IMS), and 26 patients died. There was positive correlation between increase of enzyme levels and the severity of OP poisoning as per POP score. Conclusion: Serum amylase, lipase, and creatine kinase level correlated well with the severity of organophosphorus poisoning and scan be used additionally as an indicator to assess the severity. Serum amylase is a better indicator of severity than lipase and Creatine Kinase (CPK).

Art of Paper Setting: The Blueprinting of MBBS Physiology Competency Based Curriculum

Introduction: Written examinations are integral component of students’ assessments at formative and summative level. There is no blueprint of question paper available for the new curriculum in Bachelor of Medicine and Bachelor of Surgery (MBBS) Physiology curriculum which may lead to variations in question paper setting. This lack of consistency in question papers affects the preparedness and performance of students. Aim: To prepare the blueprint of MBBS Physiology Competency Based Medical Education (CBME) curriculum and to do content validity by comparing with Preliminary Examination (PE) and University Examination (UE). Materials and Methods: This was a descriptive study conducted over a period of six months from July 2020 till December 2020. The study was conducted in Armed Forces Medical College, Pune. There are 15 topics and 140 outcomes for Physiology MBBS course as per new CBME curriculum is divided into paper I and II according to Maharashtra University of Health Sciences (MUHS) syllabus. The main topics in each paper were further subdivided into subtopics for preparing learning objectives. Marks were allotted to each system taking into consideration optimum marks 97 for subjective with included options and 20 marks Multiple Choice Questions (MCQs). The papers of UE and PE conducted with new format were analysed for content validity. Results: The blueprint of paper I (subjective) shows marks allotted for General Physiology 12, Haematology 13, Respiratory System (RS) 15, Cardiovascular (CVS) 17, Exercise 05, Renal system 15, Gastrointestinal System (GIT) 12, Lifestyle Aging and Meditation 03 and Attitude, Ethics and Communication. (AETCOM) 05 marks. The blueprint of paper II (subjective) shows marks for the Nerve-Muscle 16, Central Nervous System (CNS) 25, Special senses 14, endocrine system are 18, reproductive system 15, and temperature 09. MCQs were also allotted proportionate marks for each topic. Content analysis of papers showed exercise Physiology and body temperature regulation were not assessed in UE. Conclusion: There was disproportionate representation of topics in formative and summative examinations in absence of blueprint. The blueprint should be an integral part of assessments.

Association between Clinico-epidemiological Features in Chronic Urticaria with Autologous Serum Skin Test: A Cross-sectional Observational Study

Usha Rani Tirupathi , Bhagya Rekha Manchiryala , Sruthi Kareddy

Introduction: Urticaria is a frequent and heterogeneous skin disease characterised by the development of wheals (hives), angioedema, or both. Chronic urticaria is characterised by the occurrence of wheals lasting less than 24 hours, with or without angioedema occurring daily or almost daily lasting more than six weeks. The two subtypes of chronic urticaria are Chronic Spontaneous Urticaria (CSU) and Chronic Inducible Urticaria (CIU). Autologous Serum Skin Test (ASST) is the simplest and the best in-vivo clinical test for the detection of basophil histamine-releasing activity. ASST has a sensitivity of approximately 70% and a specificity of 80%. Aim: To study the association between clinico-epidemiological features of CSU with positive and negative ASST. Materials and Methods: The cross-sectional study was conducted on 80 clinically diagnosed cases of CSU attending the Department of Dermatology Venereology Leprology Outpatient Department at Mahatma Gandhi Memorial Hospital (Kakatiya Medical College), Warangal, Telangana, India; during the period of January 2016 to September 2017. The detailed history was taken; complete physical and cutaneous examination and laboratory investigations like Complete Blood Picture (CBP), Absolute Eosinophil Count (AEC), Erythrocytic Sedimentation Rate (ESR), Thyroid Function Test (TFT) were carried out. ASST was done and read after 30 minutes. Chi-square test was applied and the results analysed using Statistical Package for the Social Sciences (SPSS) version 10.0. Results: Out of total 80 patients included in the study, ASST was positive in 36 (45%) and negative in 44 (55%). ASST positive patients showed longer duration of the disease with increased frequency of attacks and longer duration of wheals. However, both ASST positive and negative groups did not show statistically significant difference in the age of occurrence, gender, angioedema, dermographism. Conclusion: Autoimmune urticaria has no distinctive clinical features. ASST positive, autoimmune urticaria patients have more severe disease with greater impact on quality of life. Thus, they may need more aggressive treatment.

Percutaneous Transvenous Mitral Commissurotomy in Middle Aged Indian Population- A Cross-sectional Study

Introduction: Mitral Stenosis (MS) is a chronic complication seen among patients with Rheumatic Heart Disease (RHD). Percutaneous Transvenous Mitral Commissurotomy (PTMC) is a non surgical intervention indicated exclusively for MS with favourable valve morphology. Aim: To determine the outcomes of PTMC in middle aged Indian population in relation to clinical and haemodynamic parameters. Materials and Methods: This retrospective cross-sectional study conducted at a tertiary care hospital in Chennai, Tamil Nadu, between 1994 and 2019. Study was based on analysis of data from 82 patients diagnosed with MS, that underwent successful PTMC. Patients in the age group of 40 to 60 years with symptomatic MS {Mitral Valve Area (MVA) <1.5 cm² on echocardiogram} were included in this study. Successful PTMC was defined in terms of MVA >1.5 cm². Participants were divided into two groups based on Wilkins score of 8 as a cut-off. The continuous variables of the study subjects were described and interpreted by averages and compared between the groups by independent t-test. The pre, post and follow-up characteristics were analysed by averages and interpreted by paired t-test and confirmed by repeated measures of ANOVA. Results: Group A with Wilkin’s score ≤8 showed better results in terms of functional status improvement [New York Heart Association (NYHA) classification], MVA, mean gradient across mitral valve and Pulmonary Arterial Pressure (PAP) with p-values <0.05 after a mean follow-up period of one year. Conclusion: Long-term outcomes of PTMC is better in patients with lower Wilkin’s score than those with higher scores in terms of functional status improvement, maintenance of MVA and mitral valve mean gradient pressure. These factors favour the optimal utilisation of PTMC as an alternative to surgery especially among middle aged population.

Ovarian Neoplasms: Clinicopathological Spectrum in Tribal Rajasthan, India

Geeta Mukhiya, Nalini Sharma, Kruti Arvindkumar Savalia

Introduction: Ovarian neoplasms have increased in incidence in leading sites of cancer in five old population based cancer registries on comparing first ten and last ten years data. All three germ layers are afflicted in process of ovarian neoplasm-ceolomic epithelium, germ cell and sex chord/stromal cells. Due to this, ovarian masses are spread widely over all age groups. However, a correct pathological diagnosis goes a long way in management of the disease and consequent benefit to patient. Aim: To assess the histopathological pattern, age, laterality and distribution of ovarian tumours in a tertiary care centre of tribal part of Rajasthan. Materials and Methods: Retrospective hospital based study wherein 157 ovarian specimens received in Department of Pathology of Geetanjali Medical College and Hospital, Udaipur, Rajasthan over a period of three years were studied after obtaining permission from ethical committee. Details such as age, signs and symptoms, laterality were retrieved from patient file. Only benign, borderline or malignant ovarian neoplasm specimens removed surgically were included. Physiological cysts were excluded. Descriptive statistics were used and results were expressed as percentages. Results: Out of 157 ovarian neoplasms, 42 (26.75%) were from hysterectomy specimen, 44 (28.03%) from planned cystectomy for mass, 71 (45.22%) from cytoreductive surgery or tissue obtained from Exploratory Laparotomy. A 63.06%, 33.76% and 3.18% of neoplasms were benign, malignant and borderline, respectively. Extremes of age lied between 14 to 84 years. Mean age for benign, malignant and borderline tumours respectively was 38.60 years (SD=15.21), 47.79 years (SD=14.53) and 38.4 years (SD=14.04), respectively. Unilateral tumours were clearly in abundance with 85.35%. Right-sided tumours were more (49.04%). Surface Epithelial Tumours (SET’s), Germ Cell Tumour (GCT’s) and Sex Chord Stromal Tumours (SCSCT’s) were 59.24%, 34.39% and 6.37%, respectively. Out of 10 cases, 60% were malignant (Granulosa cell tumour). No metastatic tumour was seen during the study period. Conclusion: To effectively reverse the trend in a developing country like India each and every gynaecologist should be aware and well versed with histo-morphological pattern of ovarian neoplasms specific to a region.

Novel Corona Virus and its Risk to Periodontists- How Do We Protect Ourselves?

Rajvir Malik, Apeksha Gajghate, Salman Ansari, Sneha Puri, Namrata Khetal

The Coronavirus Disease (COVID), commonly known as “COVID-19 Pandemic” has affected around 218 countries and territories across the globe. Coronavirus is a deadly virus which gains entry into the human body through various modes and causes symptoms such as dry cough, fatigue, coughing sputum, shortness of breath. The doctors are among the various frontline workers, who are at the greatest risk of contracting the COVID-19 infection. One of the major modes of transmission of coronavirus is the oral cavity. Hence, oral health care workers are at higher risk. Periodontitis is one of the most prevalent chronic inflammatory diseases of the oral cavity and is associated with much common co-morbidity making it a community health concern. Periodontal procedures are aerosol generating procedures and COVID-19 is a highly contagious disease, so it can be easily contracted during aerosol generating procedures. Periodontitis and COVID-19 have both been associated with much common co-morbidity so there is a possible association between them. The role of periodontists in preventing transmission of COVID-19 is critically important. Periodontists face direct exposure to oral fluids such as saliva and blood. So, precautionary measures are imperative for the periodontists so as to protect ourselves. Knowledge about the virus would be helpful in taking the necessary precautions. The aim of this review article was to understand the risk associated with the coronavirus and protection for periodontists in an unprecedented situation.

A Retrospective Evaluation of Combination Therapy of Methylprednisolone and Remdesivir for Severe COVID-19 Patients

Shruti Jain, Madhu Bala, Harish C Sachdeva, Vandana Talwar, Usha Ganapathy

Introduction: Severe and threatening complications of Corona Virus Disease-2019 (COVID-19) are caused by direct viral injury as well as excessive and aberrant host immune response induced by the virus. In this context, use of Methylprednisolone (MP) to prevent cytokine storm and Remdesivir to prevent viral replication seems prudent. Aim: To assess the clinical outcome of combination therapy of Remdesivir and MP pulse therapy in patients with severe COVID-19 in Intensive Care Unit (ICU). Materials and Methods: The retrospective study was conducted in the COVID-19 ICU, dealing exclusively with 21 severe illness severe illness cases at Safdurjung Hospital, New Delhi, India from June to July 2020. They were given MP pulse therapy (500 mg/day for three days, followed by 1 mg/kg orally once daily, tapered by 10 or 20 mg/day and finishing with 10 mg) along with intravenous Remdesivir. Pre and post-therapy examination of the patients included clinical features, inflammatory markers (Interleukin-6, ferritin and D-dimer), gas parameters like ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO₂/FiO₂) and changes in chest radiograph. Values of PaO₂/FiO₂, inflammatory markers on day 1 and day 3 were expressed as mean±SD and their difference compared using student t-test. Statistical significance was defined as p<0.05. Results: This treatment regimen was associated with significant improvement in PaO₂/FiO₂(p<0.001), significant decrease in inflammatory markers (p<0.001) and reversal of radiological changes. Ten patients were discharged within two weeks of treatment while six patients were shifted to high dependency unit for further oxygen requirement. They were all successfully discharged from hospital without oxygen requirement within next two weeks. Five patients developed opportunistic infections and succumbed to death. Side-effects of therapy included hyperglycaemia in nine patients, which was managed by insulin infusion. Conclusion: Combination therapy of MP pulse and Remdesivir in patients with severe COVID-19 resulted in significant clinical improvement. Given the high efficacy, it could be one of the promising approaches to the management of patients with severe COVID-19.

The Effect of Intravenous Deep Sedation on Behaviour of Non Cooperative Children in the Dental Office- An Interventional Study

Mhd Raslan Alzein, Mohamed Altinawi, Faten Rostom, Imad Katbeh, Alexander Khasan

Introduction: Recently, there has been an increasing need for sedation techniques to reduce anxiety in children undergoing painful diagnostic and therapeutic procedures. Therefore, multiple tactics (oral sedation, Intravenous (IV) sedation) were devised to help practitioners manage such cases. Aim: To determine the efficiency and effects of propofol on the behaviour of anxious children during dental treatment. Materials and Methods: This interventional study was conducted at Damascus University, Damascus, Syria, from August 2018 to September 2020. Total 23 children aged 3 to 6 years who were physically healthy (American Society of Anesthesiologists I (ASA I) and uncooperative (negative or definitely negative according to Frankel’s behaviour scale) were included to determine the effects of intravenous propofol on their behaviour during treatment. Behaviour during treatment was evaluated using the Ohio State University Behavioural Rating Scale (OSUBRS). Also, the sedation level was evaluated using the University of Michigan Sedation Scale (UMSS). Mann-Whitney test was used to compare the levels of behaviour and degrees of sedation between males and females. The significance level was set at p-value <0.05. Results: Behaviour according to OSUBRS and degree of sedation according to UMSS during treatment were favourable, and treatment was completed for all participants. The Mann-Whitney test showed no statistically significant difference between males and females regarding the level of behaviour (p-value=0.605) or the degree of sedation (p-value=0.376). A strong positive relationship between treatment time and awakening time was found using the Pearson’s correlation coefficient (0.813, p-value<0.01). Conclusion: In the presence of an anaesthesiologist, intravenous propofol deep sedation was considered effective in managing anxious and uncooperative children during dental treatment.

Role of Multidetector Computed Tomography in Patients of Acute Mesenteric Ischaemia and its Comparison with Clinicosurgical Outcome: A Cross-sectional Study

Introduction: Acute mesenteric ischaemia is an abdominal emergency occurring in nearly 1% of patients presenting with acute abdomen. Early diagnosis is very important for the improved survival of the patient. Acute mesenteric ischaemia frequently presents with non specific features such as vomiting, loose stools and abdominal distension. The classical triad of fever, haematochezia and abdominal pain is seen in only 30% of the patients so, it is difficult to diagnose clinically. Multidetector Computed Tomography (MDCT) is gold standard and first line test to diagnose intestinal ischaemia. Aim: To assess the efficacy of MDCT in the diagnosis of acute mesenteric ischaemia and to compare its outcome with surgical and/or clinical findings. Materials and Methods: In this cross-sectional descriptive study conducted from 1st November 2018 to 31^st May 2020, MDCT was performed on 40 patients (23 male; 17 female, age range: 28-93 years). Axial and reconstructed images of each patient were evaluated for evidence of bowel wall thickening, bowel wall attenuation, abnormal wall enhancement, bowel dilatation, mesenteric stranding, ascites, solid organ infarcts, pneumatosis intestinalis or portomesenteric gas, and mesenteric arterial or venous thrombosis. Multidetector CT findings were compared with the surgical findings and clinical outcome. Results were expressed in terms of frequency and percentages. Results: Out of 40 patients, most common cause of acute mesenteric ischaemia was arterial thrombosis, seen in 20 patients (50%) while 13 patients (32.5%) had portomesenteric venous thrombosis and 7 (17.5%) patients were diagnosed with non occlusive mesenteric ischaemia. CT finding of bowel wall thickening and bowel dilatation however non specific were seen in majority of patients (62.5% and 70%, respectively). Mesenteric fat stranding and ascites were seen in 95% and 77.5% cases respectively. Specific signs of acute mesenteric ischaemia includes hypoenhancing and non enhancing bowel walls seen in 27 patients (67.5%). Pneumatosis intestinalis and portomesenteric pneumatosis in 20% patients. A total of 27 patients underwent surgery and 13 patients were managed conservatively. On comparing the CT findings with intraoperative/histopathological findings, accuracy of MDCT in the diagnosis of acute mesenteric ischaemia in this study was 96.39%. Conclusion: MDCT should be the first line imaging modality to diagnose acute mesenteric ischaemia and to exclude other causes of acute abdomen. It is an excellent and fast modality to diagnose bowel ischaemia, as it can visualise both the bowel and mesenteric changes as well as accurately depict the mesenteric vasculature.

Negative Pressure Wound Therapy: A Pilot Study

Devesh Kumar, Sachin Upadhyay, Hashmukh Shantilal Varma, Darwin Kumar Thakur

Introduction: Impaired wound healing has a significant socio-economic impact. The introduction of Vacuum Assisted Closure (VAC) has been one of the major breakthroughs in the management of nonhealing wounds owing to its property of granulation tissue formation via effects related to local sub atmospheric pressure and fluid drainage. Aim: To study the efficacy of Negative Pressure Wound Therapy (NPWT) in wound healing. Materials and Methods: A pilot study was performed on 50 patients out of which 41 were males 82% and 9 were females (18%) with chronic non healing wounds of different aetiologies between the age of 15-70 years. Eligible patients were treated with NPWT at two days interval for an average of two dressings. Patients were evaluated after two dressings for appearance of granulation tissue, reduction in wound size and decrease of bacterial load in the wound. Paired t-test and Chi-square tests were used. The p<0.05 was considered significant. Results: The use of NPWT in different types of open wounds, pressure sores, postoperative wounds resulted in reduction of wound size (p-value=0.001), infection rate (p-value=0.001) within a week after two dressings to finally be closed with split skin grafting or secondary suturing. Conclusion: NPWT dressing is a safe, reliable intervention for patients with chronic wounds associated with impaired wound healing, particularly with wounds larger in surface area which requires closure by split skin grafting or musculocutaneous flaps.

Clinicohormonal Parameters as a Primary Step to Differentiate Normosmic Idiopathic Hypogonadotropic Hypogonadism and Kallmann Syndrome in a Tertiary Care Hospital in Eastern India

Ram Chandra Bhadra, Dona Saha, Arjun Baidya

Introduction: Idiopathic hypogonadotropic hypogonadism is a rare gonadal dysgenesis in which puberty does not take place naturally. It occurs due to insufficient pulsatile secretion of Gonadotrophin-Releasing Hormone (GnRH) and the resulting Follicle-Stimulating Hormone (FSH) and Luteinising Hormone (LH) deficiency leads to absence of or delayed sexual maturation. Kallmann syndrome is an uncommon genetic disorder characterised by hypogonadotropic hypogonadism associated with anosmia or hyposmia. When anosmia is absent, the same is referred as normosmic Idiopathic Hypogonadotropic hypogonadism (nIHH). Aim: To find out the significant differences between Kallmann syndrome and nIHH based on clinical features and biochemical assessment as a primary measure to initiate the treatment early. Materials and Methods: This hospital based cross-sectional observational cohort study was conducted in Department of Endocrinology, Nilratan Sircar Medical College and Hospital, Kolkata, India. The study was done on 55 cases of IHH presenting to the department with delayed secondary sexual characteristics. Results: Out of these 55 cases, 45 (81.8%) were of nIHH and only 10 (18.2%) cases were of Kallmann Syndrome. It was found that both the conditions show male predominance. Smell abnormalities were present only in Kallmann group. The level of serum testosterone was significantly higher (p<0.05) in nIHH subjects (mean-35.59 ng/dL) than patients with Kallmann Syndrome (mean-14.90 ng/dL). Patients with Kallmann syndrome showed significantly reduced pubic and axillary hair development and absence of gonadal development. Conclusion: Absence of puberty with anosmia/hyposmia with low serum FSH and LH, drastically reduced serum testosterone, are factors that point towards the diagnosis of Kallmann syndrome even in absence of genetic study, which is helpful for initiation of hormone replacement therapy for treatment.

Clinical and Radiological Outcomes of Recovered COVID-19 Patients- An Observational Study during the Early Phase of Pandemic

Introduction: The pandemic caused by the Coronavirus Disease 2019 (COVID-19) has caused huge economic and health crisis. It is reported to have pulmonary sequelae which can overburden the healthcare systems. Survivors needing medical attention in the form of pulmonary rehabilitation should be prioritised. Aim: To study the impact of COVID-19 infection in terms of the pulmonary and extrapulmonary sequelae. Materials and Methods: This cross-sectional observational study was carried out at a tertiary hospital in India. Recovered COVID-19 patients who were admitted from April to July 2020 were enrolled. Participants with radiological evidence of pneumonia during hospitalisation were assessed two months post-discharge. They were evaluated for persistent symptomatology, chest radiography, Six-Minute Walk Test (6MWT). The relationship between the outcome parameters with the baseline epidemiology, laboratory and radiology were evaluated by using student t-test, Mann-Whitney U test and multivariate logistic regression analysis. Results: Thirty participants were recruited. Their mean age was 47.93 years. Males were more than females. Persistent symptoms were reported by 17 (56.66%) and 4 (13.33%) developed pulmonary fibrosis on Chest X-Ray (CXR). Prolonged hospitalisation (mean >20 days) strongly correlated to the fibrosis (p=0.022). A fall in the finger oxygen saturation after the 6MWT was significant (p≤0.001). Higher serum levels of lactate dehydrogenase and D-dimer were associated with a more severe disease (p=0.02 and p≤0.001, respectively). Conclusion: Convalescent phase of COVID-19 is characterised by persistent symptomatology in half of the recovered patients. Simple and inexpensive CXRs and the 6MWT can be used as the primary investigation to identify post COVID-19 patients requiring pulmonary rehabilitation in resource limited settings.

Expression of Carbonic Anhydrase-IX and Vascular Endothelial Growth Factor in Renal Cell Carcinoma and their Prognostic Significance

Moumita Maiti, Ranu Sarkar, Aritra Bhattacharya, Prasenjit Sen Ray

Introduction: Renal Cell Carcinoma (RCC) is the most common adult renal malignancy. Histopathologically, clear cell RCC accounts for 65-70% of all RCCs. Carbonic Anhydrase-IX (CA-IX) is a transmembrane protein and takes a role in cancer development and progression. A 75-100% clear cell RCCs show CA-IX expression. But this varies with grade and stage of tumour. Vascular Endothelial Growth Factor (VEGF) is responsible for tumour angiogenesis and expressed variedly in RCCs. Both VEGF and CA-IX expression is mediated by Hypoxia Inducible Factor-1α (HIF-1α). Aim: The present study aimed to evaluate the expression of CA-IX and VEGF in respect to different grades and stages of RCC and assessing their prognostic significance. Materials and Methods: This was a cross-sectional, observational study done on 45 histopathogically diagnosed cases of RCC. It was performed in the Department of Pathology, Nil Ratan Sircar Medical College, Kolkata, West Banglore, India over a period of two years (February 2018 to January 2020). Expression of VEGF and CA-IX were studied by immunohistochemistry. Results were analysed in Statistical Package for Social Sciences (SPSS) software (version 16.0) using Pearson Chi-square test. A p-value of <0.05 was regarded as significant. Results: Out of 45 cases of RCC, 34 tumours (32 clear cell carcinoma and two multilocular cystic renal neoplasm of low malignant potential) were evaluated for CA-IX immuno expression. About 25 cases showed CA-IX positivity which inversely associated with grade and stage of RCC (p-value <0.05). The CA-IX had a diagnostic value in detecting clear cell RCC with sensitivity 73.53%, specificity 100% and accuracy 80%. With 28 (62.2%) cases of RCC showed VEGF positivity among which nine were VEGF 1+ and 19 cases VEGF 2+. The VEGF expression showed a positive association with the grade and Tumour-Node-Metastasis (TNM) stage of tumour (p-value <0.05). Finally, authors found a statistically significant inverse association between CA-IX and VEGF expression in RCCs with clear cell morphology including clear cell RCC and multilocular cystic renal neoplasm of low malignant potential (p-value=0.001). Conclusion: High grade RCCs show low expression of CA-IX and strong positivity with VEGF. Both these markers have a prognostic significance. From the therapeutic point of view, VEGF positive tumours, especially inoperable and metastatic cases, may be benefited by anti-VEGF therapy whereas CA-IX positive tumours respond well by treatment with Interleukin-2.

Response of First Year Medical Students of West Bengal about Compulsive Online Teaching during COVID-19 Pandemic: An Observational Study

Suranjana Sur Mukherjee, Kakali Das Sarkar, Debalina Sengupta, Sunanda Sinhababu

Introduction: Coronavirus Disease-19 (COVID-19) pandemic forced everyone to stay indoors for a long period. The institutional education system got a backseat. But Bachelor of Medicine and Bachelor of Surgery (MBBS) syllabus had to be covered within a stipulated time frame. As with every academic curriculum, online teaching had to be implemented in MBBS courses too without any scope for developing adequate logistics beforehand. Teachers, as well as students, tried their best to cope up with this ‘new normal’. Every day student had to be online for few hours to attend their classes as per the modified roster during the pandemic. Aim: To gather the data regarding perspective, satisfaction and problems of online classes from the 1^st year MBBS students and also to recommend the modifications for future curriculum and upgrade the quality based on the students’ feedback and suggestions. Materials and Methods: This cross-sectional observational study was done in a single day across three Government Medical Colleges of West Bengal after eight months of continued online classes since lockdown. An online survey was conducted among the first-year students through google forms, which was mailed to every student’s email ID at a stipulated time of the day with prior notification. Out of 700 google forms sent, 527 responses were received. Responses were automatically analysed by google and were represented graphically. Results: Out of 527 responses received, 145 were from females (27.5%) and 382 were from males (72.5%). Students were ready to adapt to this new development and 54.6% were more or less satisfied with the teaching methodologies, though interruption with the internet hampered their classes very often. Some could not afford the online class due to logistic or financial constraints. A 67.9% of students learnt to acquire in-depth knowledge by themselves though a good number of students (56.7%) disliked online classes and lost interest in the topic. Conclusion: Online teaching cannot replace classroom teaching but can complement it as compulsive prolonged online teaching made the learning self-directed. A thoughtful blending of online and offline classes can be implemented to make an Indian Medical Graduate (IMG) a lifelong learner.

Levonadifloxacin: A Novel Approved Drug Exhibiting Potent In vitro Activity against Gram Positive Bacterial Isolates from Patients Admitted in Intensive Care Units

Tasneem Siddiqui, Rafat Shamim, Sangram Singh Patel, Chinmoy Sahu

Introduction: Levonadifloxacin is a novel antibiotic belonging to the benzoquinolizine subclass of fluoroquinolone with potent activity against Methicillin Resistant Staphylococcus aureus (MRSA) and Quinolone Resistant Staphylococcus aureus (QRSA). Both intravenous levonadifloxacin and its oral formulation have recently been approved in India for the treatment of acute bacterial skin related infections. Aim: To assess the activity of levonadifloxacin against gram positive clinical isolates collected from Intensive Care Units (ICUs) using the disk-diffusion method. Materials and Methods: The present descriptive study where non duplicate isolates of Staphylococcus aureus (S. aureus) and other gram positive isolates from various clinical samples from all Intensive Care Units (ICUs) were collected from June to December 2020 and subjected to levonadifloxacin susceptibility testing (disk diffusion method) as per the Clinical and Laboratory Standards Institute (CLSI) guidelines, 2020. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) software, version 25.0. Results: A total of 142 gram positive clinical isolates collected from all ICUs of the hospital were analysed. These isolates included coagulase negative S. aureus 109 (76.8%), S. aureus 21 (14.8%) and Enterococcus faecalis 12 (8.4%). All the gram positive isolates of the study were susceptible to levonadifloxacin as per the prespecified interpretive criteria identified based on population pharmacokinetic model and Monte Carlo simulation enabled probability of pharmacodynamic target attainment analysis. Conclusion: Results of this in vitro study shows good activity of levonadifloxacin against gram positive isolates including difficult to-treat methicillin resistant staphylococcal isolates collected from ICU patients.

A Cross-sectional Study of Atherogenic Index of Plasma and Angiographic Profile by Gensini Score in Patients of Acute Coronary Syndrome

Introduction: Coronavirus Disease 2019 (COVID-19) is rapidly spreading in India and all over the world. Being at the frontline in the battle against COVID-19, Healthcare Workers (HCWs) are among the greatest groups at risk of COVID-19 infection. Therefore, it is very important to study the risk and sources of infection and clinical outcome of HCWs. Aim: To study the clinicoepidemiological profile and outcome of COVID-19 positive HCWs in Government Medical College Thrissur, Kerala, India. Materials and Methods: This was a hospital based cross-sectional study conducted during the time period from February to December 2020. A semi-structured telephonic interview schedule and hospital based records were used to collect the demographic, epidemiological and clinical information of 235 COVID-19 positive HCWs. Proportions along with 95% Confidence Interval was used to express the results. Results: Among 235 COVID-19 positive HCWs, 51% were either nurses or auxiliary nursing staff. Non COVID-19 areas had 31.9% infections, while 17.1% of infections occured in COVID-19 areas. Around 57% acquired infection from healthcare settings. Common symptoms were fever (67.2%), myalgia (40.4%) and headache (39.6%). Around 21.3% subjects remained asymptomatic. Hand hygiene compliance was 96.6%. Among positive HCWs, 57% used N95 mask, 52.8% used gloves, 49.8% used apron and 48.9% used face shield in the hospital. Only 0.85% required Intensive Care Unit (ICU) admission. No mortality was reported in the present study. Conclusion: There is a considerable risk for COVID-19 infection among HCWs in hospital settings especially from non COVID-19 areas. Present study findings show the risk of exposure and need of infection control measures even outside the healthcare settings. Early identification and isolation of cases is very important. This study will be useful for policy makers in planning control strategies and preventing COVID-19 infections among HCWs.

Comparison of Light Emitting Diode Phototherapy vs Conventional Phototherapy for Neonatal Hyperbilirubinemia: A Quasi-experimental Study

Introduction: Neonatal hyperbilirubinemia is one of the most common problem encountered during the neonatal period. Phototherapy is a widely accepted, cheap, non-invasive relatively safe and effective method of treatment for neonatal hyperbilirubinemia. Aim: To compare the efficacy of Light Emitting Diode (LED) phototherapy vs Conventional Phototherapy for treatment of neonatal hyperbilirubinemia in healthy term neonates. Materials and Methods: A quasi experimental study was conducted in Neonatal Intensive Care Unit and Post-natal wards in a tertiary care hospital affiliated to Medical College and Hospital, Ahmedabad, Gujarat from July 2018 to April 2019 with a sample size of 135 in each group. They were assessed clinically by Kramers method just before initiation of phototherapy, then using Transcutaneous Bilirubinometer (TCB) Total Serum Bilirubin (TSB) level was measured. Bilirubin assessment by these methods were done for every neonate before initiation of phototherapy and then again repeated after 24 and 48 hours of phototherapy. Data was collected and analysed in Microsoft (MS) excel Statistical Package for the Social Sciences (SPSS) 0.26. Chi-square test was used for comparison. Results: In the present study, 158 (58.51%) babies were male and 112 (41.48%) babies were female. Initially, LED was found to be better than Compact Fluorescent (CFL) conventional phototherapy on comparing the average fall in the serum bilirubin level from baseline during the first 24 hours however no such difference in the efficacy between the two light sources was seen after a period of 48 hours. Total 9 (6.66%) patients developed rebound hyperbilirubinemia after completion of conventional phototherapy whereas 14 (10.37%) developed rebound hyperbilirubinemia after completion of 48 hours of LED phototherapy. Conclusion: LED and conventional phototherapy were equally efficacious in managing non haemolytic hyperbilirubinemia in healthy term neonates.

Association of High Serum Ferritin Level in Early Pregnancy with Development of Gestational Diabetes Mellitus- A Prospective Observational Study

Abhijit Das, Shreyasi Karmakar, Sabyasachi Bid, Sudip Kumar Saha

Changing Trends of Antimicrobial Resistance in Neonatal Sepsis: Experience from a Tertiary Care Hospital from West Bengal, India

Manjula Dutta, Piyali Mitra, Shankha Subhra Nag, Abhijit Dutta

Introduction: Sepsis is the second leading cause of neonatal mortality in India. Emergence of highly resistant microorganisms as an aetiology of neonatal sepsis is a matter of serious concern. Aim: To study the prevailing aetiological agents in neonatal sepsis and their antimicrobial susceptibility pattern. Materials and Methods: A prospective observational study was performed in a tertiary care teaching hospital in neonatal care units in North Bengal Medical College and Hospital, West Bengal, India, over a period of two years from March 2017 to February 2019. All the neonates having clinical features suggestive of sepsis were subjected to blood culture using BacT/ALERT^® PF Plus. Microbial identification and antibiotic susceptibility testing was done by VITEK-2 automated systems. Chi-square test was done using Epi info software version 7.1 and p-value <0.05 was considered significant. Results: Out of 403 neonates investigated for suspected sepsis, 156 (38.7%) were found to be culture positive. Klebsiella pneumoniae was the most common organism isolated (n=90, 57.7%) followed by Staphylococcus aureus (n=24, 15.4%) and Acinetobacter baumannii (n=10, 6.4%). Klebsiella pneumoniae showed a very high degree of resistance to ampicillin, amoxycillin-clavulenic acid (100% each), cefotaxime (93.4%), ceftazidime (92.3%), gentamycin (94.5%) and tobramycin (94.5%). High resistance of Staphylococcus aureus was seen against ampicillin (100%), cloxacillin (62.5%), amoxicillin-clavulenic acid (70.9%), and cefotaxime (79.2%). Few isolates of Klebsiella pneumonia (6.6%), Acinetobacter baumannii (60%) and Enterobacter cloacae (50%) were sensitive only to colistin and tigecycline. Conclusion: Most of the isolates showed very high degree of resistance against first line of antibiotics recommended by World Health Organisation (WHO) (ampicillin and gentamycin or amikacin) for empirical treatment of neonatal sepsis. Emergence of highly resistant organisms sensitive only to colistin and tigecycline should be considered as an eye opener. Strict adherence to sepsis prevention along with regular surveillance of organisms and their sensitivity patterns is the need of the hour to improve survival by contributing to antibiotic stewardship.

Assessment of Malignant Biliary Obstruction by Percutaneous Transhepatic Cholangiography: A Prospective Cohort Study

Tushant Kumar, Pramod Kumar Dixit, Pramod Kumar Singh

Introduction: Malignant Biliary Obstruction (MBO) is caused by hepatic metastasis, gall bladder carcinoma, other distant metastasis, icteric hepatocellular carcinoma and lymphoma. Different signs and symptoms of obstruction includes pruritus, jaundice, altered food taste, renal dysfunction, anorexia, malnutrition which ultimately leads to impaired immune dysfunction and impaired quality of life. Aim: To determine the extent of biliary ductal involvement in patients with MBO through Magnetic Resonance Cholangiopancreatography (MRCP) and Percutaneous Transhepatic Cholangiography (PTC) technique and to compare the number of biliary drainage required. Materials and Methods: A prospective cohort study was undertaken at Department of Radiodiagnosis, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India. It included total 40 patients (24 females and 16 males) with strong clinicopathological and laboratory investigation suspicious of MBO. Patients with suspected MBO were examined with MR cholangiography. All patients then underwent PTC and Biliary Drainage (PTBD) and/or stent placement after MR cholangiography. The statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. Results: As out of 40 patients, 16 (40%) were males and 24 (60%) were females and the mean age was 53.87±9.49 years with maximum age noted to be 75 years and minimum age of patient in study was 35 years. The most common block observed on MRCP was type IIIA (35%) and after MRCP the distribution of level of hilar block on PTC was obtained with the most common block found was of type II (32.5%). Maximum number of biliary drains during PTBD was three. In MRCP three biliary drain were used in 47.5% patients while in PTC it was used only in 40% patients. Conclusion: Based on diagnostic performance, PTC was found to be superior for the assessment of MBO. PTC played an important role in scheduling the therapeutic strategy for malignant biliary stricture.

Effectiveness of Letrozole and Human Chorionic Gonadotropin Injection in Ovulation Induction: A Cohort Study

Peter Chukwudi Udealor, Eric Ezenwa Asimadu, Emeka Iloghalu

Introduction: Ovulation stimulation followed by timed intercourse or Intrauterine Insemination (IUI) is widely used for treatment of anovulatory infertility. Aim: To compare the effectiveness of Letrozole (LE) alone versus LE and human chorionic gonadotropin injection in ovulation induction and pregnancy rates in women undergoing ovulation induction/follicular tracking in Enugu, Nigeria. Materials and Methods: The longitudinal cohort study was carried out in University of Nigeria Teaching Hospital and Livingston Specialist Gynaecological Hospital in Enugu, Nigeria. Study population were women coming for ovulation stimulation/follicular tracking. Ovulation was confirmed by ultrasound evidence of ovulation with a progesterone level of greater or equal to 25 nmol/L on day 21, positive pregnancy test/ultrasound detection of a gestational sac. Patients were consecutively assigned to group A or B. Group A received LE only for the induction while group B received 10000 IU of human chorionic gonadotropin injection in addition to LE. A total of 5 mg of LE was given daily from day 3 to day 7. The primary outcome measured was the number of ruptured/crenated follicles on either arm while the secondary outcomes were the number of Luteinised Unruptured Follicles (LUF) and pregnancy rates. The Statistical analysis was performed using the Statistical Package for the Social Sciences version 21.0 software (SPSS Inc., Chicago, IL, United States). Results: A total of 50 women were in each arm of the study. There was no significant difference in age and parity between the two arms. There was no significance difference between the period of infertility and the number of the previous cycles of ovulation stimulation. (p=0.444 and 0.526, respectively). Ovulation was significantly associated with HCG injection (p=0.001). However, there was no statistical significance between both arms regarding the number of LUF (p=0.216). HCG injection was significantly associated with pregnancy. Subjects who took HCG injection were over two times more likely to become pregnant than those without HCG injection (OR=2.488, 95% CI for OR=1.057-5.857, p=0.037). Conclusion: This study showed that both the ovulation rate and pregnancy rate are significantly improved when human chorionic gonadotrophin injection is given after ovarian stimulation.

Expression of Aberrant Markers and its Association with Remission Postinduction Therapy in Acute Lymphoblastic Leukaemia and Acute Myeloid Leukaemia

Introduction: Haematological malignancies contribute to a significant number (8.2%) among cancer patientsin India. Bursa-Acute Lymphoblastic Leukaemia (B-ALL), Thymus-Acute Lymphoblastic Leukaemia (T-ALL) and Acute Myeloid Leukaemia (AML) are the three main types of leukaemias distinguished based on flow cytometry. Expression of Cluster of Differentiation (CD) markers of a lineage distinct to the blast population is termed as aberrant expression (expression of B/T cell markers in AML or myeloid markers in ALL). Role of aberrant marker expression in leukaemias remain an enigma till date. Aberrant expression of antigens may be associated with adverse outcomes. Aim: To study the expression of aberrant markers and their association with the remission status postinduction therapy in ALL and AML. Materials and Methods: A retrospective cross-sectional study done accessing the medical records of Acute Leukaemia patients admitted from 1^st January 2019 to 31^st December 2019 at Kidwai Memorial Institute of Oncology, Bengaluru. A total of 144 cases were included of which 86 cases were of AML and 58 cases were ALL. ALL was further divided into B-ALL and T-ALL with 40 and 18 cases respectively, 18 cases of T-ALL and 86 cases of AML were included. Demographic and clinicohaematological parameters were recorded. All quantitative variables were described as Mean {Standard deviation(SD)} and all qualitative variables were depicted as number (proportion). Statistical significance assessed by Chi-square and Fischer-Exact test using Statistical Package for the Social Sciences (SPSS) version 22.0. Results: Majority of patients belonged to 16-25 years age group with a male preponderance of 58.3%. Aberrant marker expression was associated with the remission status with a p-value of 0.23 and 0.185 in ALL and AML patients respectively and was statistically not significant. While the Chi-square test when applied to the total cases (both ALL and AML combined) the p-value was 0.03 and statistically significant. Conclusion: Aberrant marker expression might predict poor response to induction therapy in acute leukaemias. However, larger studies are needed to confirm these results.

Clinical and Histopathogical Characteristics of Salivary Gland Tumours: A Cross-sectional Study

Introduction: Regional record is a useful strategy for the analysis of the clinicohistopathological presentation of Salivary Gland Tumours (SGTs) in a specific population by which appropriate management can be established. Aim: To investigate the clinicohistopathological presentation of SGTs in a tertiary care cancer centre, Odisha, India. Materials and Methods: This single centre hospital based cross-sectional study was carried in Acharya Harihar Post-Graduate Institute of Cancer, Cuttack, Odisha, India. Five years (from January 2015 to December 2019) clinical and histopathological data of SGTs were retrieved from hospital record section. The data collection and analysis was done from January 2019 to December 2020. The SGTs cases were classified under the histological criteria suggested by the World Health Organisation (WHO) in 2017. Count data were expressed as percentages and differences between the groups were compared using the Chi-square test. The results were analysed using Statistical Package for the Social Sciences (SPSS) computer software version 17.0. Results: A total of 319 neoplastic SGTs were included out of which malignant tumours were comprised of 144 (45.14%). Mucoepidermoid Carcinoma (MEC) was the most common malignant type while Pleomorphic Adenomas (PA) was reported as the most common benign type. The mean±SD age of the patients with benign and malignant tumour was 41.94±13.94 years and 46.09±13.33 years, respectively. The percentage of malignant neoplasms in the minor salivary gland was higher (37/60, 61.66%) than benign tumours. while in major salivary glands, it was found (107/259, 41.31%). In major salivary gland, greater involvement of the parotid gland was observed. The mean tumour size of the major SGT was 3.34±1.09 cm wereas the mean tumour size of the minor salivary gland was 2.35±1.26 cm. Conclusion: The PA and MEC were the most common benign and malignant types respectively. The knowledge regarding histopathological presentation of SGTs in present study would help to pathologist and surgeons for more accurate diagnosis and further management. As, the preoperative diagnosis of SGTs is very challenging,further study in this regard is needed.

Evaluation of Salivary Procalcitonin and Macrophage Activating Factor in Generalised Chronic Periodontitis Patients with and without Type 2 Diabetes Mellitus

Introduction: Periodontitis is a polymicrobial and multifactorial oral disease and is the sixth complication of diabetes mellitus. Early diagnosis is important, and the use of non invasive biomarkers are highly useful for this purpose. The level of Macrophage Activating Factor (MAF) and Procalcitonin (ProCT) corresponds to the intensity of the inflammatory response and the severity of infection; thereby indicating that an increase in concentration or persistence of high values is considered as a prognostic indicator for severity of infection with an adverse outcome. Aim: To assess the periodontal parameters and quantify the levels of MAF and ProCT in saliva samples of generalised chronic periodontitis subjects with and without type 2 diabetes mellitus and to correlate these levels with the periodontal parameters. Materials and Methods: The study was a single centre cross-sectional study carried out at the Department of Periodontology, Meenakshi Ammal Dental College and Hospital, Chennai, Tamil Nadu, India, from November 2018 to November 2019. A total of 80 subjects with generalised severe chronic periodontitis were selected and divided into two groups. Group I comprised of 40 subjects who were diagnosed with generalised chronic periodontitis without type 2 diabetes mellitus, whereas group II comprised of 40 subjects with generalised chronic periodontitis who had already been diagnosed with type 2 diabetes mellitus. Periodontal parameters such as Plaque Index (PI), Bleeding on Probing (BOP), Probing Pocket Depth (PPD) and Clinical Attachment Level (CAL) were recorded. The collected samples were subjected to molecular analysis for evaluating ProCT and MAF using Enzyme-Linked Immunosorbent assay (ELISA). Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 25.1 (Chicago, USA Inc). Student’s Independent t-test was used to compare the mean values for the variables in the control and test group. The Pearson’s correlation test was used to evaluate correlation between all the variables. The p-value <0.05 was set as the level of significance. Results: On comparing the periodontal parameters between group I and group II, there was no significant difference between the groups p-value >0.05. The mean salivary ProCT level in group I and group II was 268.76±152.78 ng/mL and 785.75±244.37 ng/mL, respectively. The mean salivary MAF level in group I and group II was 7.15±2.02 ng/mL and 26.56±9.12 ng/mL, respectively. On comparing MAF and ProCT value between group I and group II, there was a statistically significant increase in group II (p-value <0.001) and a weak correlation value with the periodontal parameters was seen. Conclusion: There was a significant difference in levels of MAF and ProCT in saliva samples of generalised chronic periodontitis subjects with and without type 2 diabetes mellitus, however the periodontal variables in each group did not correlate with MAF and ProCT.

Do the Readings of Digital and Aneroid Sphygmomanometer Concur? A Clinic-based Study in an Urban Area of South Kolkata

Introduction: Hypertension is a major risk factor for cardiovascular and cerebrovascular diseases. Thus, regular and accurate measurement of Blood Pressure (BP) is essential for its early diagnosis and follow-up. There is a surge in popularity of digital sphygmomanometer due to its convenience of use and functionality. In contrast, the traditional universally accepted sphygmomanometer is aneroid type, hence there arose a need for comparison of digital and universally accepted aneroid sphygmomanometer in terms of agreement and correlation. Aim: To evaluate the agreement and correlation between blood pressure measurement by digital and aneroid sphygmomanometer. Materials and Methods: The clinic based cross-sectional study was conducted in the Out Patient Department (OPD) of Urban Heath Centre, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India. Adults visiting the OPD on two chosen days of the week, between June 2019 to July 2019 were selected using systematic random sampling. A total of 400 participants were included. Agreement and correlation between BP measurements by digital and aneroid sphygmomanometer was analysed by Cohen’s Kappa, Bland Altman Plot along with sensitivity, specificity and predictive values using Microsoft Excel and Statistical Package for the Social Sciences (SPSS) version 16.0. The p-value <0.05 was considered significant for the statistical test in the analysis. Results: Cohen’s Kappa value (0.59) revealed these two tools had moderate agreement in diagnosing hypertension. Sensitivity and specificity of digital sphygmomanometer taking aneroid sphygmomanometer as gold standard is 86% and 83.1% respectively. The BP readings of these two-tools showed moderate correlation as Intraclass Correlation Coefficient (ICC) for Systolic BP (SBP) and Diastolic BP (DBP) were 0.804 and 0.624, respectively. Bland Altman plot showed gross disagreement of SBP findings and disagreement between DBP findings was also noted. Conclusion: Digital device was found to be less accurate in detecting hypertension. Therefore, more similar research work is solicited to verify the accuracy of the very easy to use, the digital BP monitor.

Role of Fine Needle Aspiration Cytology in Evaluation of Bony Lesions

Arpita Singhvi, SR Negi, Hemant Jain, Meeta Dewal, Rajnee Joshi, AR Kalla

Introduction: Fine Needle Aspiration Cytology (FNAC) is increasingly being recognised for its diagnostic utility in evaluation of bone tumours. Though open surgical biopsy is the procedure of choice for diagnosis of bony tumours. Aim: To evaluate the efficacy and reliability of FNAC in diagnosis of bony tumours. Materials and Methods: This cross-sectional study included 40 patients with bony lesions from July 2018 to December 2019 in tertiary level centre of Rajasthan. The FNAC was performed after clinical and radiological assessment. The smears were stained using standard techniques. Also, open biopsy was performed in the patients who presented with bony lesions of patients and slides prepared for histopathological examination using standard techniques. The data was entered in Excel sheets and the results were evaluated using Statistical Package for Social Sciences (SPSS) software version 20.0. Results: Adequate material was obtained in FNAC in 29 (72.5%) cases. Out of 29 cases, FNAC results were accurate in 96.5% cases. False Negative report was obtained in one case with no false positives. Sensitivity of FNAC in diagnosing bony lesions comes to be 90% and Specificity was 100%. The Positive Predictive Value (PPV) was 100% and the Negative Predictive Value (NPV) 95.4%. Conclusion: The FNAC is invaluable tool in primary diagnosis of bony lesions. The technique of obtaining sufficient material though needs to be mastered and will definitely improve with more experience and radiologic correlation.

Test-retest Reliability and Minimum Detectable Change of 2-Minute Walk Test among Individuals with Knee Osteoarthritis

Shefally ChaudHary , Ammar Suhail

Introduction: The 2-Minute Walk Test (2MWT) is a simple, practical, and less time consuming test. Patients do not get fatigued while performing this test as a part of routine physical examination. 2MWT shows an excellent correlation with other walk tests and can be used as an alternative test in patients with multiple co-morbidities. The reliability of a test is a must for its recommendation to be used in clinics as well as research. Measurement properties have been reported in different populations for 2MWT. However, no data exist for 2MWT in patients with Knee Osteoarthritis (KOA). Aim: To establish the test-retest reliability and Minimal Detectable Change (MDC) scores for the 2MWT in patients with bilateral KOA. Materials and Methods: A prospective test-retest research study designed to assess the reliability of 2MWT. Eighty-two patients with KOA (27 males and 55 females) were included in the study. Health status was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The Numeric Pain Rating Scale (NPRS) and WOMAC were assessed on two consecutive days. Participants performed 2MWT on two different occasions with 48 hours difference in between. Both sessions were conducted for 45 minutes each on a 30 meter walking pathway. Data was analysed using Statistical Package for the Social Sciences (SPSS) version 20.0 for Windows (SPSS Inc., Chicago, IL, USA). Results: 2MWT showed an excellent test-retest reliability. Intraclass Correlation Coefficient (ICC) for 2MWT were 0.98. Test-retest reliability assessed by two trials of 2MWT showed 1^st trial mean±SD of 154.33±19.59 m and 2^nd trial mean±SD of 156.69±19.68 m. Mean difference±SD between both trials was 2.36±2.74, which was statistically significant (p<0.001). The Standard Error of Measurement (SEM) and Minimal Detectable Change at 95% confidence level (MDC95) for 2MWT were 2.76 and 5.52 meters, respectively. Conclusion: The study recommends that 2MWT can be used as a test for assessing walking capacity among patients with KOA. A change of more than 5.52 meters can be considered as change-free of error. It can be used as an alternative to 6MWT in patients with KOA who cannot tolerate a higher duration/intensity walk test.

Assessment of Clopidogrel Resistance in Post Myocardial Infarction Patients after 24 to 48 Hours of Initiation of Treatment: A Cross-sectional Study

Introduction: Clopidogrel is an antiplatelet agent used to prevent platelet aggregation and further blockage of coronary arteries in Acute Coronary Syndrome (ACS) patients. Inadequate response to clopidogrel has been demonstrated in some patients that might lead to re-infarction even when receiving standard doses of clopidogrel. Aim: To demonstrate the presence of resistance to standard oral doses of clopidogrel in a tertiary care hospital located in eastern India. Materials and Methods: It was a descriptive cross-sectional study conducted from January 2015 to June 2016, in Medical College Kolkata, (previously known as Calcutta Medical College), India. Total 32 patients, previously not on any antiplatelet therapy, presenting with biomarker positive ACS were evaluated. The patients were given clopidogrel (300 mg) along with aspirin (325 mg) on presentation followed by clopidogrel (75 mg) and aspirin (75 mg) once daily. Blood samples were collected after 24-48 hours of administering the above mentioned doses orally. A 3.2% citrate was used as anti-coagulant. Platelet Rich Plasma (PRP) and Platelet Poor Plasma (PPP) were prepared from this blood samples by centrifugation. Platelet aggregation was studied by adding 10 μM Adenosine Diphosphate (ADP) in that PRP and it was compared with PPP in Light Transmittance Aggregometer (LTA). Platelet aggregation ≥50% in presence of 10 μM ADP was termed as Clopidogrel Resistance (CR). Differences between groups were assessed with Chi-square test and Fisher-exact test for categorical variables. The p-value of <0.05 was considered to be statistically significant. Results: Mean age of the study participants was 60.7 years, and 23 (71.8%) out of 32 patients were male while 9 (28.2%) were female. Total 7 (21.8%) of the patients were found to be resistant to standard doses of clopidogrel. A 3 (60%) out of 5 patients with positive family history of Cardiovascular Diseases (CVD) showed CR (p-value=0.025). Incidences of CR was higher among women 3 (33.3%) and in patients receiving thrombolysis 4 (28.5%). Though these percentages were high but not statistically significant. Conclusion: In this study, 21.8% ACS patients showed resistance to the antiplatelet effects of clopidogrel in the conventional dose. A long term prospective Randomised Controlled Trials (RCT) with larger sample size is required to give an insight into this problem.

Prevalence of Dental Anomalies in Skeletal Malocclusions with Different Growth Patterns in North Indian Population- A Cross-sectional Study

Floret Jose, Maninder S Sidhu, Ashish Dabas, Seema Grover, Namrata Dogra

Introduction: Anomalies of the developing dentition occur due to absence or interruption of normal tooth development along with genetic and/or environment influences. Craniofacial development and dental malocclusion is an interplay between a number of factors such as tooth size, arch size and shape, the number and arrangement of teeth, size and relationship of the jaws and related soft tissues including lips, cheeks, and tongue. Aim: To evaluate the prevalence and distribution of dental anomalies among different skeletal malocclusions and growth patterns in North Indian population. Materials and Methods: This retrospective cross-sectional study was conducted on pretreatment diagnostic records of 260 patients belonging to the age group of 15-25 years, who had reported to the Out Patient Department (OPD) of Department of Orthodontics, Faculty of Dental Sciences, SGT University, Gurugram, Haryana, India, during the period of April 2012 to December 2020. The analysis was carried out between November 2020 and January 2021. The study sample was grouped into different growth patterns and skeletal malocclusions based on Sella-Nasion-Gonion-Gnathion (SN Go-Gn) and ANB (A point, nasion, B point), Sagittal intermaxillary angle values respectively, which were obtained from the pretreatment lateral cephalometric tracings. The prevalence of dental anomalies was evaluated in each group by examining the pretreatment diagnostic records. Chi-Square/Fisher-Freeman-Halton test were used for statistical analysis. Results: The prevalence of dental anomalies in the study sample was 65 (25%). The most common anomaly found was over retained deciduous teeth, followed by ectopic eruption with prevalence rate of 30 (11.5%) and 24 (9.2%), respectively. A total of 142 (54.6%) patients had hypodivergent growth pattern, 23 (8.8%) had normodivergent growth pattern and 95 (36.5%) had hyperdivergent growth pattern. 36 (13.8%) patients had skeletal class I malocclusion, 205 (78.8%) had skeletal class II malocclusion and 19 (7.3%) patients had skeletal class III malocclusion. Hypodivergent group showed the highest prevalence of dental anomalies with 38 (26.8%), followed by hyperdivergent group with 23 (24.2%) and normodivergent group were 4 (17.4%). Skeletal class I malocclusion group had the highest number of dental anomalies as 13 (36.1%), followed by skeletal class II malocclusion with 50 (24.4%) and skeletal class III malocclusion group with 2 (10.5%). Conclusion: Hypodivergent growth pattern and skeletal class II malocclusion were the most prevalent growth pattern and skeletal malocclusion in North Indian population. Dental anomalies were most prevalent in patients with hypodivergent growth pattern and skeletal class I malocclusion. The results of the present study indicate that dental anomalies are associated with certain malocclusions and growth patterns which may contribute to more accurate treatment predictions.

Diagnostic and Prognostic Significance of CA 19-9 as Tumour Marker in Pancreatic, Hepatobiliary and Other Gastrointestinal Cancers

Mitsu Vinay Vaishnav, Sameep Shyamlal Garg, Mayur Jitubhai Kokani

Introduction: The CA 19-9 antigen isolated by Koprowski and colleagues in 1979 is a lacto-N-fucopentaose II-like substance and one of the tumour-associated antigens present in serum in the mucin fraction. Close attention has been paid to the role CA 19-9 in the diagnosis of digestive tract tumours. In this study, serum analysis of CA 19-9 levels in 91 patients with gastrointestinal, hepatobiliary and pancreatic carcinoma was done. These data was used to evaluate the clinicians with adequate information on use of CA 19-9 as tumour marker- both diagnostic and prognostic. Aim: To study the role of tumour marker, CA 19-9 as a diagnostic and prognostic tool, and also to monitor the response of gastrointestinal, hepatobiliary and pancreatic cancer to treatment. Materials and Methods: This cross-sectional study was done on 91 cases of gastrointestinal, hepatobiliary and pancreatic carcinomas conducted in tertiary care hospital associated with medical college in Jamnagar, Gujarat, India were studied from September 2012 to March 2015 for two years and five months. The sample size was of 91 patients. Statistical method used was sensitivity, specificity, positive predictive value and negative predictive value. The material used was serum of the patient both pre as well as postoperatively and CalBiotech CA 19-9 Elisa Kit was used to determine the Value. The collected data were entered into Microsoft Excel spread sheet. The statistical methods used for variables were Mean and median along with Sensitivity and Specificity. Software used was “Epi Info”, version 7.0. Results: Total 91 cases of gastrointestinal, hepatobiliary and pancreatic carcinomas were studied. Enzyme Linked Immunosorbent Assay (ELISA) was used preoperatively and post operatively to determine the CA 19-9 values in patients of gastrointestinal, hepatobiliary and pancreatic carcinomas. It was found that CA 19-9 is an important tumour marker with sensitivity of 76.31% and specificity of 73.33% for diagnosis of the gastrointestinal, hepatobiliary and pancreatic carcinoma. When aided with Fine Needle Aspiration Cytology (FNAC) and histopathological findings it helps in giving a sure shot diagnosis. It also provides useful prognostic information for the same. Conclusion: This study helps to understand the role of CA 19-9 as diagnostic and prognostic marker for pancreatic, hepatobiliary and gastrointestinal carcinomas.

Functional Outcome of Weight Bearing Heel following its Reconstruction by Distally Based Sural Flaps

Neeraj Kant Agrawal

Introduction: Tissue defects of the heel require resurfacing by flaps that could bear a great proportion of body weight and assist in pain free locomotion with minimum morbidity. The distally based sural flaps, also known as reverse sural flaps, have found widespread applications including reconstruction of the weight bearing heel. The durability of the reverse sural flap and its ease of resurfacing peculiar contour of the heel have encouraged its use. The evaluation of the functional aspect of this flap with regards to the pain, ulceration and ambulation is vital to establish and authenticate its use in heel reconstruction. American Orthopaedic Foot and Ankle Society (AOFAS) clinical ratings scale is one of the assessment schemes for its evaluation. Aim: To evaluate the usefulness and versatility of reverse sural flap in reconstruction of heel as well as assessment of functional outcome of foot using AOFAS scoring system. Materials and Methods: In this prospective study, carried out in the Department of Plastic Surgery at a tertiary care centre in Eastern Uttar Pradesh, India, 15 patients with soft tissue defects of the weight bearing heel were found who fulfilled the inclusion criteria. Reconstruction was carried out using reverse sural flap and its surgical planning as operative details were discussed. AOFAS scale was used to measure functional outcome of the reconstructed heel. Results: Average age was 38.33±13.48 years and they presented earlier than 72 days. The dimensions of the reverse sural flap were 147.46±20.87 cm² to resurface heel defects of 57.75±17.08 cm². The largest defect was 13 cm long and 7 cm wide. Three flaps demonstrated distal necrosis as the length: width ratio was more than the well described safe limit of 3:1. They were 19-22 cm long while the width was narrowed to 5-7 cm at the base resulting in unfavourable dimensions and consequent necrosis. Other complications were persistent discharge and ulceration. AOFAS rating had a maximum score of 60, the average score being 50.2±7.39 (31-58). Conclusion: The AOFAS clinical rating is a reliable and valid quantitative tool which is used for evaluating functional outcome in patients with reconstruction of weight bearing heel. Reconstruction of such challenging defects by the distally based sural flap proves its versatility and relialibity. At the same time, the surgical technique of flap harvest is safe, of shorter duration and provides alternative to microsurgical reconstruction.

Clinical and Radiographical Evaluation of Bovine Derived Xenograft without or with Calcium Sulphate Hemihydrate in the Treatment of Intrabony Defects in Chronic Periodontitis: A RCT

Nikita Dilip Patil, Mala Dixit Baburaj

Introduction: Intrabony periodontal defects respond well to regenerative periodontal therapy. Numerous grafts and non graft materials are available for regeneration. Careful use of nonallogenic bone graft could enhance radiographic defect fill. Aim: To compare the clinical and radiographical evaluation of bovine derived xenograft (Osseograft?SUP?TM#SUP#) alone versus a combination of bovine derived xenograft and calcium sulphate hemihydrate (Osseomold?SUP?TM#SUP#) in the treatment of intrabony defects in chronic periodontitis. Materials and Methods: A prospective, single blinded randomised clinical trial was conducted in the department of Periodontics, Nair Hospital Dental College, Mumbai, India (December 2017-August 2019). A total of 42 patients presenting with 43 intrabony defects were randomly assigned to Control Group (CG) (n=21) or Test Group (TG) (n=22). Clinical parameters {Probing Pocket Depth (PPD) and Clinical Attachment Level (CAL)} were assessed at baseline (M0), one month (M1), three months (M3) and six months (M6) and radiographic parameters {Bone Fill (BF)} were measured using Intraoral Periapical Radiograph (IOPA) at baseline (M0) and six months (M6). Two patients (three defects) were lost to follow-up. Descriptive and inferential statistical analyses were performed, results on continuous measurements were presented on Mean±SD. Statistical software IBM SPSS statistics 20.0. Level of significance was fixed at p=0.05. Student’s t-test was used to find the significant difference between and within the groups. Repeated measures Analysis of variance (ANOVA) was used to find the significance of study parameters within the group (at different time intervals). Results: PPD was lowest at six months for TG (3.95±0.61) and CG (3.30±0.66) and it gradually improved from baseline to six-months (p<0.001 for both TG and CG). CAL gain was highest at six-months for TG (4.4±0.50) and CG (3.65±0.75) (p<0.001). Significant reduction in Radiographic Defect Depth (RDD) was noted in both the groups (CG: 6.65±1.08 at M0 and 4.92±1.00 at M6 (p<0.001); TG: 7.06±0.96 at M0 and 5.14±0.77 at M6) (p<0.001). Intergroup analysis was statistically significant for clinical parameters with greater improvement seen in CG control group {PPD and CAL at M3 and M6 (p<0.001)} and statistically insignificant for radiographic parameters (p>0.5). BF was higher at M6 in TG (1.87) as compared to CG (1.72), which was statistically insignificant. Conclusion: Both treatments were clinically effective showing a significant improvement in clinical and radiographic parameters and there was significant difference between the two groups- clinically in terms of reduction in PPD and CAL gain at three months and six months with greater improvement seen in CG as compared to TG, with no difference radiographically. Further studies are needed to show the stability over time of the present results.

Magnetic Resonance Spectroscopy in Evaluation of Focal Brain Lesions- A Cross-sectional Prospective Study

Introduction: The characterisation of intracranial mass lesions only with the help of conventional magnetic resonance imaging alone may be inconclusive. Magnetic Resonance Spectroscopy (MRS) is a non invasive technique which is superior to Magnetic Resonance Imaging (MRI) in the characterisation of brain lesions. Magnetic resonance spectroscopy is comparatively fast, non-invasive method that gives biochemical analysis of the normal brain parenchyma and of the pathological processes. Magnetic resonance spectroscopy has the advantage of providing characterisation of tissues based on their molecular composition. It gives information about neuronal vitality, cell proliferation, degradation and energy metabolism. Aim: To describe the spectrum of magnetic resonance spectroscopy in focal brain lesions and to detect the metabolic and biochemical changes in various focal brain lesions. Also, to distinguish neoplastic from non-neoplastic lesions. Materials and Methods: This prospective study was carried out at Department of Radiodiagnosis, Sri Manakula Vinaynagar Medical College and Hospital, Puducherry, India for a period of 18 months from November 2017 to April 2019. A total of 40 MRI brain with clinically suspected brain lesions were included in the study. Magnetic resonance spectroscopy studies were performed in all patients with focal brain lesions. On the basis of spectral and distribution patterns of the pathologic spectra seen in MR spectroscopy, a qualitative analysis was done. The metabolic area ratios Choline/Creatinine (Cho/Cr)/Cr, NAA/Cho and NAA/Cr were evaluated (NAA- N-acetyl, Cho- choline, Cr- creatine). Data was collected using prescribed proforma and analysed using Statistical Package for the Social Sciences (SPSS) 22 version software. Results: Out of the 40 patients evaluated 11 cases were high grade gliomas, seven cases were Neurocysticercosis, five low grade glioma, five meningioma, four metastasis, four tubercular abscesses, two tuberculoma and two lymphoma. Increased Cho/Cr ratio was noted in neoplastic lesions when compared to non neoplastic lesions. Conclusion: The MRS in addition to appropriate conventional MRI sequences provides useful supplementary information and has a potential to validate treatment strategies. Neoplastic lesions show elevated choline and Cho Cr ratio with reduction in N-acetyl aspartate (NAA), whereas non neoplastic lesions show decreased Cho/Cr ratio. Hence, MRS could be a problem solving tool in differentiating neoplastic from non neoplastic lesions.

Role of Valgus Osteotomy and Fixation with Double Angle Blade Plate in the Management of Neglected and Ununited Femoral Neck Fracture

Introduction: Femoral neck fracture non union in young patients is a challenging complication as joint replacement is not readily recommended and hip salvageable procedures are relatively unsatisfactory. Valgus intertrochanteric osteotomy described by Pauwels F is one of the treatment options for management of non union of femoral neck in young patients, which was later reciprocated by other surgeons. Aim: To assess the efficacy of valgus osteotomy and fixation with double angle blade plate in the management of neglected and ununited femoral neck fracture. Materials and Methods: This was a prospective cohort study, which included 30 patients of femoral neck fracture non union in whom intertrochanteric valgus osteotomy was performed and fixed with 120° double angled blade plate. The preoperative and postoperative neck-shaft angle was compared using the paired t-test. A p-value of <0.05 indicated statistically significant result. Results: There were 22 males (73.3%) and 8 females (26.7%). Mean age of patients was 35 years. Delay in presentation ranged from 8 weeks to 58 weeks (mean 24 weeks). By Pauwel’s classification, there were 13 Type II fractures and 17 Type III fractures. Mean follow-up was 18 months (12 to 36 months). The mean preoperative neck-shaft angle of 95° (range 80-110°) increased to 132° (range 120-140°) after surgery. In all patients, there was improvement in leg length discrepancy after osteotomy. Femoral neck fractures united in 25 patients (83.3%). Conclusion: Valgus osteotomy and fixation with 120° double angle blade plate is a reliable method for treating non union femoral neck fracture in young adults. It provides rigid internal fixation and good results.

Analytical Study of Conjunctival Bacterial Flora in Diabetic and Non Diabetic Patients

Tamojit Chatterjee, Shrutakirti Ghosh, Rinki Saha, Sandip Samaddar

Introduction: Conjunctiva is a transparent mucous membrane that lines inside of the eyelids and covers the sclera. It is composed of non keratinised, stratified columnar epithelium with goblet cells. Normal microbial flora constitutes organisms which are present in eyelids and conjunctiva without causing any disease. At birth eyes are sterile but they are later infected by various organisms. Gram positive organisms are mostly prevalent in ocular flora. Diabetes mellitus is a multifactorial disease that can affect all ocular structures. Aim: To compare the microbial flora between diabetic and non diabetic patients and to study there sensitivity to antibiotics. Materials and Methods: This was an analytical study conducted on a total of 100 patients attending Department of Opthalmology of Medical College and Hospital, Kolkata, India between June 2019 to July 2019. They were not using any topical ocular preparation. Conjunctival swab was taken from upper fornix of the patients and cultured and the results obtained were analysed using Chi-Square test. Results: Conjunctival flora of a total of 100 patients, 30 diabetic and 70 non diabetic, were screened. Among the 30 diabetic patients, there were 15 (50%) male and 15 (50%) female. The most common isolated bacteria in diabetic and non diabetic groups were staphylococcus aureus (diabetic 70%, non diabetic 85.7%). There was a statistically significant difference in microbial flora pattern between the diabetic and non diabetic group. There was higher proportion of staphylococcus epidermidis among diabetic patients compared to non diabetic patients (p-value <0.01) and there was a higher proportion of staphylococcus aureus among non diabetics (p-value <0.01). Conclusion: Present study found statistically significant difference in the microbial flora between diabetics and non diabetics. This will help the clinician to plan for the antibiotic prophylaxis before surgery for patients attending the Out Patient Department (OPD).

Expression of Beta-Catenin in Colorectal Carcinoma and its Association with Various Clinicopathological Parameters

Introduction: Colorectal Carcinoma (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer related mortality globally. It is a source of concern for researchers worldwide and hence, a lot of emphasis is being given towards early detection and targeted drug therapy to improve the survival rate. Aim: To study the expression of beta-catenin in colonic polyps, adenomas and CRC and to associate beta-catenin expression with various clinicopathological features. Materials and Methods: This was a prospective cross-sectional study conducted in the Department of Pathology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India from September 2018 to August 2020. Colonoscopic biopsies, mucinous carcinoma and poorly preserved tissue were excluded. Histopathological study and Immunohistochemistry evaluation of beta-catenin was done. Statistical analysis was done by using appropriate tests. A p-value of less than 0.05 was taken as statistically significant. Results: Out of 80 cases, 40 cases were benign lesions Non neoplastic polyp and adenoma) and 40 cases were adenocarcinoma. It was observed that benign lesions had maximum cases with preserved membranous expression (36/40) and very few cases (4/40) showed cytoplasmic expression of beta-catenin. But in carcinoma, high cytoplasmic expression was seen in 20/40 (50%) whereas 8/40 (20%) cases had nuclear positivity. Membranous beta-catenin expression was significantly higher in benign lesions than in the malignant lesions (IS:8.75±3.09 versus 4.30±2.70) respectively; (p<0.0001). But cytoplasmic beta-catenin expression was low in benign lesion as compared to malignant lesion (IS: 2.07±3.46 versus 5.35±3.14), respectively; (p<0.0001). However, nuclear beta-catenin expression was extremely low in benign lesions than in malignant lesions (0.08±0.47 versus 1.90±3.49), respectively; (p=0.0016), this difference was statistically significant. Conclusion: The present study demonstrates the change in beta-catenin expression with gradual transition from predominantly membranous pattern to cytoplasmic or nuclear as we progress from normal colorectal tissues to polyps, benign premalignant lesions and malignant neoplasms. This property of beta-catenin helps in determining malignant potential of various premalignant neoplasms of large intestine which in turn helps in initiating early prophylactic treatment.

Urinary Tract Infection- Knowledge and Habitual Practices among Adolescent Girls Residing in College Hostel of Mangaluru, India: A Cross-sectional Study

Sonia Karen Liz Sequera , Leena Kunnath Chacko , Priya Sweety Pereira

Introduction: Urinary Tract Infection (UTI) is a common infection among female adolescents, causing significant distress in the hospital or community settings. Most of the issues related to UTI could be prevented by adequate knowledge and safe habitual practices. Within the context of reproductive health services, nurses or nursing students being healthcare providers are typically expected to have knowledge on the causes of UTI, methods of preventing and managing such conditions and teaching the same to young girls and women. Education provided to women, particularly adolescents, by nurses and by trainers who have relevant experience and knowledge may ensure proper hygiene practices. Aim: To determine the level of knowledge, expressed habitual practice among 82 adolescent girls of a selected nursing college hostel. Materials and Methods: This was a descriptive cross-sectional study conducted between June 2019 and December 2019. Tools included structured questionnaire on knowledge of UTI and a rating scale on expressed habitual practice on UTI prevention. All the 82 students of 1^st BSc Nursing from the study institute were recruited. Adolescent girls who have undergone training on prevention of UTI in nursing curriculum and who had congenital defects of urinary system were excluded from the study. Results: The mean age of the subjects was 18.69±0.46 years. Total 13.4% experienced UTI in their life time. In terms of overall knowledge score, out of 82 subjects, around 40.2% had average (scoring between 8-10 out of 14) and few (28%) had good knowledge (≥11) on UTI prevention. In terms of overall expressed habitual practice, majority (53.7%) had average practice (score between 26-33 out of 46) whereas, 4.9% had unsafe practice (score ≤25). The Karl Pearson correlation coefficient was 0.1 and showed weak positive correlation between knowledge and expressed habitual practice. Association was found between experience of UTI p-value<0.001 and expressed habitual practice. Conclusion: Pooled results showed overall knowledge and expressed habitual practice was average and safe. Healthcare professionals, especially primary care givers such as nurses and nursing students, have the responsibility to broadcast proper information about UTI so that women/adolescents can identify the causes, risk factors, symptoms of UTI in early stages thereby preventing the mortality and morbidity related to UTI.

Epidemiological Profile and Clinical Outcome of COVID-19 Patients in a Tertiary Care Hospital, Pune, India

Prachi D Sondankar, Shubhangi U Agawane, Abhay B Mane, Parvinder S Chawla

Introduction: The COVID-19 caused by Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), has spread throughout the world from its place of origin in Wuhan city of China. From origin in December 2019 till May 2021, this disease affected 222 countries in the world with 152,534,452 confirmed cases. As on May 2021, India is the second worst affected country in the world. Aim: To know the epidemiological profile and clinical outcome of COVID-19 positive patients to help in understanding the disease dynamics. Materials and Methods: It was a cross-sectional, record based study at a tertiary care hospital. All the COVID-19 laboratory confirmed positive patients admitted from 15^th June, 2020 to 15^th September, 2020 were included in the study. Sample size was 1146. All the required data regarding patients were collected and analysed subsequently with the help of percentages, Z-test for proportion, Chi-square test and Odds ratio. Results: The mean age of the patients was 47.06±17.4 years ranging from 1 to 92 years. Males were significantly higher in numbers than females. 30.19% patients had some or other co-morbidities. 89.8% patients were discharged and 9.2% patients died. More number of deaths occurred in higher age group and highest death rate was seen in the patients who had multiple co-morbidities. Conclusion: The study concludes that most of the COVID-19 patients were middle aged and males were significantly more affected than females. Most of the patients were asymptomatic at the time of admission. It can be concluded that maximum patients had favourable clinical outcome as around 90% patients being discharged and case fatality rate was 9.2%. High rate of mortality was significantly associated with higher age and presence of co-morbidities.

Serosurveillance of SARS-CoV-2 among the Healthcare Workers of a Tertiary Care Teaching Institution during the Post Lockdown Phase in Central Kerala, India

Introduction: The hallmark of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is high infectivity, pre symptomatic transmission and asymptomatic prevalence which could result in high cumulative numbers of infections, hospitalisations, and deaths. Kerala was the first state to confirm community transmission in July 2020. Healthcare Workers (HCWs) being in the forefront in the war against Coronavirus Disease-2019 (COVID-19) are more prone to acquire the infection and could possibly be asymptomatic sources for cluster formation. Knowing the development of immunity as shown by the presence of anti COV-2 antibodies in the population contributes to the epidemiological understanding of the disease. Aim: To determine the pattern of seropositivity of SARS-CoV-2 among the HCWs at Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India, six months after revoking the lockdown. Materials and Methods: This cross-sectional study was carried out among 423 HCWs of the medical college from September 5^th to December 15^th, 2020. Multistage sampling was done with the hospital block as the first stage and departments as the second stage. Blood sample was collected and Anti SARS COV-2 IgG antibody testing which targets the Spike Protein 1 (SP1) was done using the vitros chemiluminescence platform (Orthoclinical diagnostics, USA). For the summary of demographic characteristics, continuous variables were summarised as mean values and Standard Deviation (SD) while categorical variables were summarised as proportions. The ?² test was used for comparing the epidemiological features between positive and negative cases. Chi-square test for trend analysis was done for exploring the relationship of the degree of severity with test positivity. All analyses were conducted using Statistical Package for the Social Sciences (SPSS) version 25.0. Results: Jubilee Mission Medical College had 2785 working staff at the time of study. A total of 423 staff consented and their samples were tested. Thirty seven staff members tested positive for COVID-19 antibody, yielding an overall prevalence of 8.75% (95% CI, 6.23-11.86). A 86.5% (32/37) of them were having a history of COVID-19 Antigen/Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) Positivity. A statistically significant linear trend (p-value=0.00001) was observed, between seropositivity and the degree of severity of COVID-19. Among the various factors which increase the risk of seroconversion, history of undergoing quarantine (p-value <0.001), contact with a confirmed case (p-value=0.002), contact with a caregiver for COVID-19 (p-value=0.001) and history of upper respiratory symptoms (p-value=0.001), were found to be significantly associated with positive serology. Conclusion: The pattern of seropositivity across the different category of HCWs observed in the present study showed a higher prevalence among nurses. Being an educational institution, it was obligatory to train all the elements of care delivery to the future generation of HCWs. Acquiring experience from a small but relevant sample was expected to facilitate larger community study envisaged in peripheral areas Jubilee Mission Hospital served.

Expression of Biomarkers Estrogen Receptor, Progesterone Receptor, HER2 in Primary Breast Tumour and Synchronous Metastatic Axillary Lymph Node

Introduction: Estrogen Receptor (ER), Progesterone Receptor (PR), Human Epidermal growth factor Receptor 2 (HER2) status are routinely used to guide treatment decision for breast cancer. Treatment protocol in breast cancer is currently based on biomarker characteristic of primary tumour. But this biomarker status may change as the tumour progresses from primary to synchronous metastatic lymph node. Hence, it is important to know the biomarker status of these synchronous metastatic lymph nodes as it may serve as an important tool to guide management, evaluate prognosis and to anticipate the possibility of recurrent risk of primary invasive breast cancer. Aim: To study the expression of ER, PR, HER2 status in primary breast carcinoma and synchronous metastatic lymph node and to evaluate concordance and discordance between them. Materials and Methods: This study was observational, retrospective and prospective study conducted over a period of one and half years from February 2015 to October 2016 at ESI-PGIMSR, Maniktala, Kolkata, India, where 50 cases of breast carcinoma with positive axillary lymph node metastasis were studied. Haematoxylin and Eosin (H&E) sections were reviewed and representative paraffin blocks were selected. Immunostains were performed and scoring was done following standard protocols. Standard statistical methods were applied for analysis of data using chi-square test and kappa statistics and data was analysed using Statistical Package for the Social Sciences (SPSS) version 6.1.3 software. Results: Out of 50 cases the mean age of the patients was 50.56±10.5 years. Amongst ER and PR status, 24 out of 50 (48%) and 18 out of 50 (36%) were ER and PR positive respectively. HER2 positive cases were 48% i.e., 24 out of 50 cases. The overall discordance rates of ER, PR and HER2 was found to be 10%, 8%, 18%, respectively. The discordance rates of ER positive and ER negative cases were 4.2% and 15.4%, respectively. The discordance rates of PR positive and PR negative cases were 5.6% and 9.4% respectively, whereas 29.2% of HER2 positive cases were discordant in lymph node metastases. Conclusion: There was discordance between ER, PR, HER2 status of primary tumour and metastatic lymph node. Hence, assessment of these biomarker status in axillary lymph node metastases may be considered along with primary tumour in breast carcinoma work-up.

Clinical Characteristics and Outcomes of Coronary Artery Disease among South Indian Women- A Retrospective Study

Introduction: The prevalence of Coronary Artery Disease (CAD) is increasing among Indian women and is the leading cause of death. Clinical presentation of CAD in women can widely vary from atypical chest pain, silent ischemia to massive myocardial infarction and death. Women have poor prognosis than men after myocardial infarction and are less likely to undergo revascularisation compared to men. Aim: To study the risk factors, clinical characteristics, severity of CAD and to evaluate the outcomes in women undergoing coronary angiogram. Materials and Methods: This retrospective study included 912 women who had undergone coronary angiogram in our hospital from January 2018 to December 2018. The patients were divided into three groups- Group A consisted of 230 (25%) women with age <50 years. Group B consisted of 591 (65%) women with age between 50 to 69 years. Group C consisted of 91 (10%) women with age >70 years. Continuous variables were analysed by paired t-test and categorical variables were analysed by chi-square test. Results: Most women were post menopausal (73.6%). Common risk factors were diabetes mellitus (63%) hypertension (56%), and hypothyroidism (16.8%). Out of the total study population, 51% (n=466) presented with a diagnosis of chronic stable angina, 34.7% (n=317) presented with acute coronary syndrome, and 7% (n=66) had atypical chest pain. Out of 500 patients with significant CAD, requiring revascularisation only 316 (63.2%) had undergone interventions out of which 193 (61%) had undergone percutaneous coronary intervention and 123 (39%) had undergone Coronary Artery Bypass Grafting (CABG) as the modality of revascularisation. Conclusion: Clinical presentation of CAD in women varies widely from atypical chest pain to acute infarction. Diabetes and hypertension are the most common risk factors for CAD in our study. Chronic stable angina was the most common spectrum of presentation. Single vessel disease is the most common finding on coronary angiogram.

Haematological Changes in Donors Post Apheresis

Nikhil, Subhashish Das, Snigdha

Introduction: The productivity, quality of platelet apheresis collection has improved because of the considerable advancement in the automated cell separators. Automated cell separators have lot of sizeable scientific advances, but the alertness has been centered to Platelet Concentrates (PCs) quality than on safety of donor. Aim: To find the changes in haematological parameters and the consequences of apheresis and plateletpheresis on donor’s health. Materials and Methods: It was observational cross-sectional study done in laboratory at RL Jalappa Blood Bank, Tamaka, Kolar, Karnataka, India. The study was done from March 2019 to August 2020. A total of 300 healthy donors (plateletpheresis donors) were involved in the study. The plateletpheresis (Haemonetics MCS), predonation and postdonation haematological parameters such as haemoglobin concentration, Haematocrit (Hct), platelet, white and red blood cell count were calculated in all donors. The samples for Complete Blood Count (CBC) were secured from the donors, at the beginning and end of the procedure. Postdonation haematological parameters such as platelet count, haemoglobin, haematocrit, White Blood Cells (WBC), Red Blood Cells (RBC) counts of the donor was inscribed and comparison was done with the pre donation haematological parameters. Quality control of all Single Donor Platelet (SDP) products was done. All donors were evaluated for adverse donor reactions. The mean pre and post plateletpheresis values comparison was done utilising paired t-test. Statistical analysis was accomplished utilising Statistical Package for the Social Sciences (SPSS) software version 16.0. Results: Platelet count, haemoglobin, WBC count, RBC count and haematocrit were jotted down from 262 donors and a significant decrease was noticed in these parameters postdonation. Donor parameter platelet count (lac/μL) value was decreased from 273.57-224.28 whereas WBC count (cu/mm) predonation value decreased from 9.91-8.86 Postdonation, haemoglobin (g/dL) value decreased from 14.46-12.91, haematocrit (%) decreased slightly from 45.19-44.19, RBC count (million/mm³) decreased from 5.21-5.01. This concluded that the values decreased postdonation. Conclusion: The study conducted was safe from donor’s point of view. SDP is very effective in treatment of thrombocytopenia and is safe from recipient’s point of view.

Dietary Habits and their Impact on the Physical Status of School Going Adolescents in Delhi: A Cross-sectional Study

Introduction: The dietary habits and food preferences in the adolescent age group can influence their physical growth. The importance of healthy eating habits cannot be ignored. Faulty eating habits among adolescents contribute towards undernutrition, overnutrition and micronutrient deficiency. Aim: To evaluate the dietary habits and nutritional status of school-going, urban adolescents. Materials and Methods: A questionnaire based cross-sectional observational study was conducted among 1600 adolescents from 10 government schools in Delhi between April 2018 and March 2019. The socio-demographic profile, anthropometric measurements and dietary habits using simplified dietary gap assessment tool was recorded. The nutritional status of the participants was categorised as per World Health Organisation- Body Mass Index (WHO-BMI) Z-score for adolescents. The data collected was analysed using the statistical analysis software Graph Pad version 5. Chi-square test was applied to assess the association between dietary habits and BMI status. Results: A total of 855 males (mean age 13±2 years) and 745 females (mean age 13.4±2 years) with age range between 10 and 19 years participated in the study. A total of 955 (59%) adolescents consumed milk or milk products, 655 (41%) consumed fruits, and 838 (52%) consumed green leafy vegetables in their daily dietary habits along with their staple diets. 1089 (68%) of adolescents were undernourished, out of which 328 (30%) skipped their regular meals. The Chi-square analysis revealed that consuming junk food (p=0.005) and buying eatables from street shops (p=0.0025) were significantly associated in adoloscents from the age group of 15-19 years. It was observed that male participants consumed milk and milk products more often than female participants (p<0.0001). Faulty dietary habits of skipping meals or eating junk food or buying eatables from street shop was associated with more number of participants under the obese/overweight category (p<0.0001). Conclusion: The poor choice of dietary habits significantly affects the physical development among school-going adolescents. Study participants who belonged to the late adolescent age group had more tendencies to develop faulty dietary habits. The study will help to plan for nutritional supplementation and create awareness to develop healthy food choices among adolescents.

Comparison of Sealing Efficiency of Mineral Trioxide Aggregate and Biodentine used in Perforation Repair in Acidic and Neutral Environments- An In-vitro Study

Güney Mustafa Yüzer, Sadullah Kaya

Introduction: Furcation perforation is one of the complications that occur during endodontic treatment due to anatomical differences or iatrogenic causes. Repairing the perforation with a biocompatible material eliminates the connection with the gingival sulcus and positively affects the prognosis. The sealing ability of the repair materials is very important and is affected by the conditions of the environment in which they are applied. Aim: To compare the sealing efficiency of Mineral Trioxide Aggregate (MTA) (Angelus, Londrina, PR, Brazil) and Biodentine (Septodont, Saint Maur des Fosses, France) materials used in the repair of furcation perforations in acidic and neutral environments. Materials and Methods: This in-vitro experimental study was carried out in the Department of Endodontics at Dicle University Faculty of Dentistry, Diyarbakir, Türkiye and Dicle University Science and Technology Application and Research Center from 10^th June 2020 to 22^nd July 2020. A total of 96 mandibular molars were used in the study. The specimens were randomly divided into two equal groups (n=48). When the perforations were repaired with MTA and Biodentine materials, each group was divided into four subgroups (n=12). These subgroups were kept in Phosphate Buffered Saline (PBS) and Acetic Acid (AA) solutions for different periods of time from 4 or 34 days, and all groups were immersed in methylene blue solution. The dye penetration level of the divided sections was examined under a stereomicroscope (Leica, Wetzlar, Germany). Microleakage data of all groups were statistically analysed using Kolmogorov Smirnov, Shapiro Wilk’s and Mann-Whitney U Test. Statistical significance was set at 0.05, it was stated that there was a significant difference when p-value <0.05. Results: The short-term (4 days) microleakage level of biodentine material in the AA environment was significantly lower than that of MTA material (p-value=0.005). There was no statistically significant difference between the materials in terms of long-term (34 days) microleakage levels in the AA environment (p-value >0.05). The long-term microleakage level in PBS environment of biodentine material was significantly lower than that of the AA environment (p-value=0.008). Conclusion: Lower microleakage levels were observed in the neutral environment than the acid environment with both MTA and biodentine during both holding periods.

Distribution of Apolipoprotein A1 Polymorphism (G-75A and C+83T) in Patients with Diabetic Foot Ulcers- A Parallel Group Hospital Based Observational Study

Introduction: Diabetic Foot Ulcer (DFU), a serious complications of diabetes mellitus is a result of persistent low grade infection. The Apolipoprotein A1 (ApoA1) has an anti-inflammatory role and therefore can influence the chronic inflammation associated with the DFU. Polymorphisms of ApoA1gene have been implicated as determinants of plasma High-Density Lipoprotein cholesterol (HDL-C) and Apo A1 levels. However, the influence of ApoA1 polymorphism on susceptibility to DFU has not been studied. Aim: To study the distribution of ApoA1 polymorphism (G-75A and C+83T) and association between the polymorphism and the risk of DFU in patients with Type 2 Diabetes Mellitus (T2DM) so that timely detection and prevention of DFU can be done. Materials and Methods: This was a hospital based observational study on 80 patients of DFU, 80 diabetes mellitus without ulcers and 75 normal controls. ApoA1 polymorphism (G-75A and C+83T) was detected by Real Time Polymerase Chain Reaction (RT-PCR) technique and plasma ApoA1 by immunoturbidimetric assay using blood collected in EDTA. Data was analysed using IBM^® Statistical Package for Social Sciences (SPSS) 21.0 software. A p<0.05 was considered as statistically significant. Results: The GA and CC were the most predominant genotype in all the groups. HDL and ApoA1 were significantly lower in GG (p=0.009, p=0.03) and CT (p=0.03, p=0.002) compared to GA and CC. The APOA1-75A allele and +83C allele were associated with raised levels of HDL and ApoA1 in T2DM and DFU (p<0.05). Conclusion: The two polymorphism G-75A and C+83T were found to be equally distributed across the study populations. These polymorphisms were associated with serum levels of ApoA1 and HDL in the DFU patients.

Outcome of Biological Plating of Extra-articular Proximal Tibia Fractures

Faisal S Mohammed, Akshay Babarao Ingale

Introduction: The most prominent transformation in the treatment of fractures has been modified from intensive open reduction and internal fixation with absolute stability to the biological fixation with relative stability and secondary healing with callus formation, with priority on preservation of the vascularity of bone and soft tissue to improve fracture healing. Aim: To evaluate the outcome of biological fixation of extra-articular proximal tibia fractures in adults using the locking compression plate. Materials and Methods: The present prospective longitudinal study was conducted at Government Medical College and Hospital, Nagpur, which included 30 patients who had extra-articular proximal tibia fractures belonging to AO type 41A2 and 41A3 treated by proximal tibia lateral locking plate 4.5/5.0 mm. The patients were followed-up at two weeks, six weeks, three months, six months and one year. The fracture union, coronal, sagittal alignment was assessed radiologically at the end of follow-up. Functionally the outcome was evaluated using lower extremity functional score. Descriptive statistics were used for statistical analysis. Results: Biological plating with locking compression plate has shown promising results both in terms of function and radiology. There was non-significant difference in lower extremity functional score between patients with malunion and normal alignment. Mean union time was 19.93 weeks with a standard deviation of 2.21 weeks. There was non-significant difference between the range of motion and fracture type (p-value 0.38) as well as that between Lower Extremity Functional Score (LEFS) and fracture type (p-value 0.0501). On functional evaluation of patients treated with biological plating, there was statistical significance in Knee Range of Motion (ROM) for the patients between malunion and normal alignment (p value 0.01). Conclusion: The biological fixation using minimally invasive techniques is an effective method of stabilisation for extra-articular proximal tibia fracture, yielding good mechanical alignment and protecting soft tissues and blood supply, leading to higher union rates with good functional outcome.

Evaluation of Fracture Resistance of Mandibular Premolar Canals Filled with Four Different Obturation Techniques- An In vitro Study

Introduction: To prevent the ingress of microorganisms and their byproducts into root canal space is the primary goal of obturation. Endodontically treated teeth are weak and more susceptible to fracture than vital teeth. Therefore, to increase the strength of the root canal and increase root fracture resistance by adhesion and mechanically interlocking root canal filling material with radicular dentin is also one of the goal of obturation. Aim: To evaluate and compare the fracture resistance of mandibular premolar canals filled with four different obturation techniques. Materials and Methods: The in vitro study was conducted in Department of Conservative Dentistry and Endodontics, Krishna Institute of Medical Sciences (Deemed To Be University), Karad, Maharshtra, India, from August 2020 to December 2020. A total of 100 extracted human mandibular premolars with single canals were collected for the study and sectioned horizontally to obtain a standardised length of 14 mm. With the help of 15 K-file (Dentsply) working length was determined and root canals were prepared to an International Organisation for Standardisation (ISO) size 45 file at the apex and flared using a #4 Gates-Glidden drill (Mani, Japan). The teeth were then randomly divided into four experimental groups, Group I-Lateral condensation, Group II-ROEKO GuttaFlow^® bioseal, Group III-Guttacore, Group IV-Thermoplasticised gutta percha (System B) and two control groups, they were Group V-(Negative control), instrumentation was done, but no obturation, Group VI-(Positive control), teeth were neither instrumented nor obturated. All the experimental teeth were filled as per the obturation technique. A universal testing machine was used for evaluating fracture resistance. The results were analysed using the One-way ANOVA test. The significance between the groups was tested with Scheffe’s post hoc test. Results: There were statistically significant difference among six group for mean fracture load (N) with p-value <0.001. furthermore, pair wise comparison of fracture load (N) showed that the mean difference is significant at p-value <0.05. The mean difference between Group IV and V was not significant (p-value=0.935) Conclusion: Under the limitation of this study, it was concluded that the resistance of the root to vertical fracture amongst the experimental group was maximum in Group III (Guttacore) and minimum in Group IV (Thermoplasticised gutta-percha, System B).

Impact of Co-morbidities on Outcome of COVID-19 Patients: An Observational Study among Patients Admitted to Intensive Care Unit

Introduction: Coronavirus Disease-2019 (COVID-19) has been a major cause of apprehension, morbidity, and mortality in 2020. It had been postulated that associated co-morbid conditions in COVID-19 patients increase the severity of COVID-19 which leads to six times more chances of hospitalisation than patients without co-morbid condition. Mortality is also 12 times higher in such patients. Aim: To find out the association between co-morbidities and mortalities due to COVID-19 pneumonia. Materials and Methods: A prospective, observational study was conducted in a tertiary teaching institute of North India which was designated Level 3 (L-3) facility for treatment of COVID-19 patients. All 109 COVID-19 patients confirmed by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR), admitted in Intensive Care Unit (ICU) from 1^st July 2020 to 30^th November 2020 formed the sample of the study. Data was taken regarding past history, clinical histories and examinations and ICU care and treatments. Based on their final outcome at the end of ICU care, patients were divided into two groups-group 1 (Non-survivor or Expired) and group 2 (Survived) and intergroup differences were studied. Results: COVID-19 infection was about three times more common in males. Severe category of COVID-19 patients had higher mortality (59.2% of severe category expired during hospital course, 1.7% patients expired in moderate category group). Most common co-morbidities were hypertension (n=51, 46.8%) and diabetes (n=48, 44%). Multivariate analysis showed that co-morbidities in the form of chronic liver disease (OR -0.127 (0.024-0.681, p-value 0.016)) and post tubercular sequel (OR 0.036 (0.003-0.442, p-value 0.009)) were less likely to occur in COVID-19 patients who survived, thus making these co-morbidities significant contributor to the adverse outcomes in COVID-19 patients. More number of co-morbidities in a patient were associated with higher chance of mortality and this trend was significant statistically (p-value <0.001). Conclusion: Patients with multiple co-morbidities, chronic liver disease and post tubercular sequel were associated with higher mortality in COVID-19 patients.

Incidence of Postoperative Intensive Care Admissions in Elective Surgical Patients with High-risk Anaesthesia Consent Preoperatively

Ramyavel Thangavelu, Sagiev Koshy George

Introduction: Surgical patients who require high-risk anaesthesia consent are often at risk of developing perioperative complications and morbidity often warranting postoperative Intensive Care Unit (ICU) admissions. Aim: To study the incidence of postoperative ICU admissions among surgical patients who require high-risk anaesthesia consent preoperatively. Materials and Methods: A retrospective study using chart analysis of 64 patients who required high-risk consent for elective surgery over a period of 18 months from January 2018 to July 2019 was done. The details on demographics, the American Society of Anaesthesiologists (ASA) class, the reason for obtaining high-risk consent, type of anaesthesia administered, intraoperative events, duration of surgery and reason for shifting to Intensive Care Unit (ICU) was collected and recorded. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) software, version 20.0. Multiple logistic regressions were performed to determine the predictors of postoperative ICU admissions. Results: Out of 64 high-risk patients, 35.9% of patients were shifted to ICU postoperatively, with the most common reason for ICU admission being metabolic/haemodynamic instability intraoperatively (47.8%). Among the various preoperative factors (presence of cardiovascular, respiratory diseases with poor reserve or functional impairment, chronic kidney disease, morbid obesity) for obtaining high-risk consent, anticipated long duration surgery with blood loss was associated with a 3.9 {95% CIs of 1.25 and 12.22} times higher odds of being shifted to ICU postoperatively. Conclusion: About one-third of elective surgical patients who required high-risk anaesthesia consent preoperatively required ICU admission postoperatively. In addition, anticipated long duration surgery with blood loss was found to be an independent predictor of ICU requirement postoperatively.

Coronary Perforation-A Nightmare in Cath Lab

Percutaneous Coronary Intervention (PCI) is now the standard of care in patients with coronary artery disease. With advances in modern technology, the success of PCI has relatively increased, and so is its complication, specifically in complex coronary intervention. Coronary perforation is one of the most dreadful and life-threatening complications of PCI. The most vital step in the management of coronary perforation is its identification and quick action. Multiple methods for management are now recommended in the literature, but the mainstay of treatment is still prevention. This review discusses the incidence, risk factors, prevention, identification, and management of Coronary Artery Perforation (CAP).

Applications of Bioelectrical Impedance Analysis in Diagnosis of Diseases: A Systematic Review

Mahmood Aldobali, Shabana Urooj, Harvinder Singh Chhabra, Kirti Pal

Introduction: Bioelectrical Impedance Analysis (BIA) is a safe, non-invasive, painless, portable, and inexpensive technology that has the prospect to provide information related to the dynamic performance of the human body. Body Composition (BC) assessment is widely accepted as a clinical method to diagnose and evaluate disease status. Aim: To predict and validate the applicability of BIA in diagnosis of diseases such as Chronic Kidney Disease (CKD), Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Pregnancy and Spinal Cord Injury (SCI). Materials and Methods: A systematic clinical review was conducted following the PRISMA guidelines {PubMed, The Cochrane Archive, Web of Research, Medline, and SPORTDiscus with complete text (EBSCO)}. A literature review was carried out randomly, from 2000 to 2018, published in English; the keyword combinations were evaluated using Boolean operators “OR” and “AND” for BIA, CKD, COPD, HF, Pregnancy, SCI. Results: A total of 1156 search terms, 1139 citations were excluded, and 17 potentially qualifying articles were shortlisted. Hence, as per the inclusion criteria, three articles on COPD, three articles on CKD, three articles on pregnancy, four articles on HF, and four SCI articles were shortlisted. Conclusion: The calculated BIA parameters showed that the patient’s actual health could be analysed quickly to monitor the disease progression and provide significant advances in developing therapies for the diseases. However, this paper recommends further study on BIA to improve a clinical assessment of BC.

Anti-SARS-CoV-2 Antibody Seroprevalence Surveys in India: An Insight into Current COVID-19 Pandemic Situation

Antibody test is used in seroprevalence surveys for Coronavirus Disease-2019 (COVID-19). Apart from estimating the proportion of population infected, they can help in drawing plenty of inferences about the extent, progress and course of the pandemic. They can potentially be helpful in planning and prioritising vaccine distribution by providing a broad overview into proportion of population immune to COVID-19 in a geographic area and also help in understanding the pockets of high or low seroprevalence. This review was conducted with an aim of compiling an updated and comprehensive information about the seroprevalence of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) antibody in various pockets of India in the year 2020, and thus to understand the current pandemic situation in the country. A total of 35 studies were identified through all resources and detailed review was carried out based on these studies. Additionally, indicators were devised to understand and compare the results. Results were further classified into states/Union Territories (UTs), districts, Sub-district regions. The study findings show that the anti SARS-CoV-2 antibodies seroprevalence estimates vary across different regions (states/UTs, districts, sub district regions) of India and can increase or in some instances decrease over the course of time. The study concludes by asserting the need for repeated seroprevalence surveys as well as follow-up studies for current pandemic surveillance.

The Three “R”s-Rights, Roles and Responsibilities of Healthcare Workers during COVID-19 Outbreak in India

Monalisa Biswas, Vijetha Shenoy Belle

This article addresses the rights, roles and responsibilities of Healthcare Workers (HCW) who are frontline warriors in any pandemic outbreak. Coronavirus- 2019 (COVID-19) pandemic has emerged as international public health emergency in March 2020, and exposed the weak/failed healthcare system preparedness to respond to the pandemic threat and controlling the community spread. In India, huge population, poor economic growth and unacceptable doctor to patient ratio made swift response to emergence of pandemic, safeguarding HCWs, ability to provide care without mental and physical burn out challenging. This review emphasises the need for safety of HCW and patients, infection control, security to the family, psychosocial and mental well-being, proper allocation of medical supplies, medical ethics and communication.

Architecture of the Musculus Uvulae- A Review

L Daisy, S Surraj, C Mrudula, P Rao Sushma

The architecture of the musculus uvulae is a subject of, especially with regard to its crucial role in maintaining the morphology of the cleft palate, and its involvement in surgical procedures of palate repair. Its functional role in the closure of the velum and elevation of the same leading to voice changes are also an element of debate. The fate and orientation of its muscle fibres and its reinforcement with other related muscles of the palate raise concerns with regard to its functional role. Its positioning in the soft palate would give us an insight on the exact role played by this muscle in velopharyngeal closure. Its nerve supply also remains shrouded by various theories without conclusive evidence. Hence, this review aims to highlight its morphological role for the same.

Techniques to Guide the Mandible to Centric Relation- A Systematic Review

Introduction: Centric Relation (CR) is the only physiological position which is repeatable, recordable and reproducible for prosthodontic rehabilitation. A missed CR can give rise to faulty occlusal relationships leading to a life time of trauma to the temporomandibular joints. Literature has various methods outlined to locate and record the CR but it’s confusing as to which method is best suited to take the condyles into CR position. Hence, this systematic review was conducted to find an answer to this very question. Aim: To find a reliable clinical technique to guide the mandible to a recordable, repeatable and reproducible CR position. Materials and Methods: The present systematic review was conducted from July 2019 to October 2019 at School of Dental Sciences, KIMSDU, Maharashtra. A 20-year comprehensive literature review was undertaken aiming to arrive at a reliable and repeatable method to guide the mandible to CR following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) and Patient Intervention Comparison Outcome (PICO) guidelines to the highest possible extent. The research material was sifted through MEDLINE (PubMed)-{(“CR technique”) (MeSH terms) AND/OR (Retruded mandibular position”) (MeSH terms)}, Cochrane library “CR techniques” and Google Scholar “CR techniques OR Retruded mandibular position” search engines. Cochrane collaboration tool was used to assess the risk of bias for the Randomised Controlled Trial, Methodological I index for non RCTs (MINOR). Quality and strength of the existing evidence was appraised by both the authors through Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results: Online database search was conducted from January 1998 to September 2019 resulting in a total of 950 articles being shortlisted. Post-screenings, using the exclusion criteria, nine articles of the total articles were reviewed. These were reviewed individually by both the authors and discussed for various techniques to guide the mandible to CR. The ultimate outcome of the review was that the clinicians are required to fall back on time tested models, scientifically sound and technically correct and uncomplicated to execute methods which have proven to yield the most excellent outcomes at zero or minimal cost. One such method is undoubtedly Dawson’s Bimanual Technique. Bimanual technique in supine position coupled with a simple anterior deprogrammer has consistently resulted in a physiological CR position that is recordable, repeatable and reproducible. Conclusion: The primary outcome of this systematic review is that Dawson’s bimanual manipulation technique is superior to other techniques; primarily when carried out in supine position.