Journal of clinical and diagnostic research

Fracture Neck of Femur with Proximal Femoral Nail Antirotation Insitu: A Rare Case

Hip fractures are common in elderly population due to osteoporosis. Proximal Femur Nail Antirotation (PFNA) system has gained more importance in management of peritrochanteric fractures than conventional Proximal Femur Nail (PFN) due to ease of application and low complication rate. We report a case of a 64-year-old male patient who has sustained fracture neck of femur, seven months’ post PFNA. It’s a rare association to have fracture neck of femur with PFNA insitu and hence reported. Patient treated with removal of implant and hemi-replacement of hip.

Diffuse Tuberculous Cerebritis in Immunocompetent Hosts-An Uncommon Entity

Animesh Das, Sunil Pradhan

Central Nervous System (CNS) tuberculosis is a common disease in developing countries with varied presentation, the most common being tuberculous meningitis. Meningitis, in many cases leads to infection of the underlying cortex resulting in cerebritis, encephalitis or abscess formation. Tuberculous cerebritis has either been described as a focal entity in normal subjects or as a diffuse entity in immunocompromised hosts. We present here two cases of diffuse tuberculous cerebritis in immunocompetent patients. One had presented with left focal seizure with paraparesis while the other presented with non-localising features of raised intracranial pressure. Tubercular Polymerase Chain Reaction (PCR) was positive in Cerebrospinal Fluid (CSF) in the first patient while CSF picture was suggestive of tubercular meningitis in the second making him a possible case of tuberculosis. Both the patients improved significantly on anti-tubercular drugs.

Schwannoma of the Larynx- A Rare Case Report

Head and neck neoplasms are often referred to as areas more commonly inclusive of the upper aerodigestive tract, which includes the oral cavity, pharynx, larynx, cervical oesophagus, paranasal sinuses, thyroid, the associated bone and soft tissues, along with nodes. In the head and neck area, amongst the various mesenchymal tumours, schwannoma form a major portion, accounting for not less than 25% to 45% of tumours. Laryngeal schwannoma arising in the glottis area of the larynx is an extremely rare entity. It arises from the nerves supplying the organ and despite having a benign growth pattern; the schwannomas can pose extreme diagnostic as well as operative complexity. The strategic location of the larynx with its special functioning can both be hurdles in management of even such benign tumours like schwannoma, resulting in considerable post operative sequel. Here, we report a case of 30-year-old female with chief complaints of severe dyspnea and dysphonia. On radiological as well as histopathological examination, diagnosis of schwannoma was confirmed.

Idiopathic Charcot’s Arthropathy of Ankle Joint: A Rare Case

Rohan Somani, Pratik Panda, Mayank Dungarwal, Suvarn Gupta, Pratik Kawde

Charcot’s Arthropathy also known as Neuropathic Joint of ankle in a non-diabetic patient is a rare entity. We identified similar case who presented to us with the swelling over left ankle and foot with a discharging sinus. On further evaluation with X-ray and Magnetic Resonance Imaging (MRI), diagnosis of Charcot’s arthropathy was made. Initially patient was managed with conservative trial and later arthrodesis of left ankle joint was done. Postoperatively, patient had pain relief and was on full weight bearing with regression of symptoms.

Olfactory Bulb Hyperplasia in Genetically Confirmed Infantile Alexander Disease

Alexander Disease (AxD) is a well-known leukodystrophy with characteristic findings on brain Magnetic Resonance Imaging (MRI) including bilaterally symmetric, frontal confluent white matter signal abnormality with relative sparing of the parietal and occipital lobes, abnormal signal in the cerebellum and brainstem, as well as swelling of the deep grey nuclei. Aside from tumour-like “masses” thought to reflect collections of Glial Fibrillary Acid Protein (GFAP), there are no additional reported associations within the central nervous system in this disease. However, in our experience authors have noted that the olfactory bulbs are more prominent in patients with AxD than in age-matched controls. Here, a 12-year-old boy with genetically confirmed AxD, with classic brain parenchymal changes and large olfactory bulbs is reported. Although the clinical implications of this finding are currently unclear, identification and reporting of this potentially associated finding may have a role in the management of patients with AxD and could be valuable for treatment of unrelated medical issues.

An Interesting Case of Acute Encephalitic Syndrome with Pancytopenia and Splenomegaly

Satyendra Kumar Sonkar, Satish Kumar, Neeraj Kumar Singh

Human Parvovirus infection is a rare condition causing encephalitis as well as pancytopenia. Similarly patient of Wilson disease presenting as hepatic encephalopathy as an initial manifestation is also a rare phenomenon. A previously healthy 20-year-old female patient presented as acute encephalitis syndrome with hepatitis and pancytopenia. Bone marrow examination showed the presence of inclusion bodies and PCR (Polymerase Chain Reaction) showed the presence of DNA of human parvo virus B19. Patient was suspected as a case of Wilson’s disease due to the persistence of splenomegaly and radiological findings and was confirmed by increased 24 hours urinary copper and low level of serum ceruloplasmin. Patient was treated symptomatically and gained consciousness and pancytopenia improved over course of time.

Crossed Fused Renal Ectopia showing Pelviureteric Junction Obstruction with Single Ureter and Single Renal Artery

Rahul Dev, Gitanjali Khorwal, Mohit Tayal, Vibhu Goel, Udit Chauhan

Crossed fused renal ectopia is a rare anomaly remaining asymptomatic by far and detected invariably as either incidental finding or in view of pre-existing kidney disease. We report a case of crossed fused renal ectopia presenting as lumbar pain in a young female patient with no associated calculus or cystic kidney disease. It was an inferior type of renal ectopia on right side drained by a common artery and common ureter along with additional aberrant vascular supply. Multidetector computed tomography with multiplanar and three dimensional reconstruction helps in the proper delineation of renal fusion and ureteric anomaly if any, as well as mapping of aberrant vascular supply.

Therapy Related Acute Promyelocytic Leukaemia (APML) in a Breast Cancer Survivor: Another Tale of an Ally Turned Adversary

Sujaya Mazumder, Debdatta Basu, Biswajit Dubashi

With an increase in the use of high dose chemotherapeutic regimens, higher cure rates and longer survival periods of cancer patients, the incidence of secondary malignancies are increasing. Therapy related Myeloid Neoplasm (t-MN) is a second malignancy after chemotherapy/radiotherapy given for a prior malignancy. Of the various t-MN Acute Promyelocytic Leukaemia (APML) as a complication of chemo-radiotherapy is very rare. We report a rare case of therapy related APML in a breast cancer survivor.

Unusual Low-grade Occipito-temporal Ganglioglioma with Calcification

AK Kapoor, Divya Saxena

Ganglioglioma (GG) is a rare benign tumour which may present as focal convulsions. Complete resection of the tumour may lead to excellent recovery. The present case report describes the features of a mixed neuronal-glial tumour in a young female patient. She complained of seizures for the last several years. Magnetic Resonance Imaging (MRI) was done. T1-weighted MRI revealed a hypointense cystic lesion in right occipitotemporal region. It measured 2.8×2.2×2.2 cm. The t2-weighted image showed a hyperintense mural nodule which measured 0.4 cm approximately. The craniotomy was done and the tumour was resected. Microscopically, the tumour showed the proliferation of astrocytes and dysplastic multinuclear neuronal cells. Dysplastic cells were large with round nuclei, abnormal clustering and irregular distribution of variably sized neurons. Few multinuclear neurons were also seen. Neoplastic neuronal cells were both synaptophysin and chromogranin A positive. Proliferated astrocytes showed pilocytic features. Eosinophilic granular bodies and perivascular inflammation were also seen. The tumour was diagnosed as a case of the World Health Organisation (WHO) Grade I ganglioglioma.

Primary Ewing’s Sarcoma of Adrenal Gland-A Rare Case

Krishnendu Maity, Akash Agrawal, Chhanda Datta, Dilip Kumar Pal

Ewing’s Sarcoma (ES) or Primitive Neuro-Ectodermal Tumour (PNET) typically occurs in long or flat bones, the chest wall, extra-skeletal soft tissue, and rarely in solid organs. Incidence of urological ES is uncommon. Here, we report a case of primary ES of the right adrenal gland in a 16-year-old boy who presented with an adrenal mass, with a successful outcome.

Salmonella Sepsis and Urinary Tract Infection Complicating with Acute Kidney Injury in a HIV Positive Female Patient

Urinary Tract Infection (UTI) can rarely be caused by salmonella species. UTI salmonellosis may present as uncomplicated UTI, pyelonephritis or haemorrhagic cystitis. We present a case of a 44-year-old HIV positive female who presented with frank haematuria, fever, dysuria and confusion. These were preceded by non-bloody diarrhea that had resolved on presentation. Blood and urine culture grew salmonella species. The course of the patient was complicated by acute kidney injury that required haemodialysis. Patient improved on a two-week course of antibiotics with subsequent negative blood and urine cultures. We emphasise the importance of prevention on exposure of risk factors and close follow-up due to high risk of recurrence in special groups of patients.

Transverse Abdominis Plane Block for Cancer Related Abdominal Pain: A New Modality in Horizon

Murali S Patri, Suchit Khanduja, Steven Halter, Jose Navas

Primary or metastatic cancers involving the intra-abdominal organ systems frequently result in abdominal pain, of both abdominal visceral and somatic types. This pain can be extremely severe and distressing to patients, and very often requires the use of opioid-based medications for modification of pain to tolerable levels. Adjunctive therapies have also been described, including interventional procedures such as celiac plexus blockade. Both treatment modalities have obvious benefit, but also substantial risk. We present a case of significant and intractable abdominal cancer pain, and describe successful management of this pain with the relatively safe and simply performed ultrasound guided transverse abdominal plane (TAP) block.

IgG4-Related Disease Causing Facial and Recurrent Laryngeal Nerve Palsies: A Case Report

Immunoglobulin G4-Related Disease (IgG4-RD) is a systemic fibro-inflammatory disorder. It can affect many different organs and tissues including salivary glands, orbits, retroperitoneum and many others. Neurological involvement by IgG4-RD is rare and its early diagnosis is important to avoid permanent organ dysfunction and disability. The effects of medications have not been evaluated adequately and need to focus on. So, in this article we present a rare case of IgG4-RD with parotid mass and facial and recurrent laryngeal nerve palsies which was successfully treated with rituximab and oral prednisolone.

Diffuse Nodular Pseudoangiomatous Stromal Hyperplasia causing Bilateral Gigantomastia with Follow-up of 2 Year Post Reduction Mammoplasty

Teena Sleeba, Jojoe John, Gigy Raj Kulangara, Madhu Sudheendran, Sunita Thomas

Pseudoangiomatous Stromal Hyperplasia (PASH) is an uncommon benign mesenchymal tumour of the breast with no known potential for malignancy. PASH is often detected incidentally or in a background of other breast pathologies. Being hormonally driven, these are most commonly seen in women in the reproductive age group. The size of the PASH varies with small microscopic PASH being much more common than the tumourous or infiltrative varieties. It is uncommon to see PASH presenting as diffuse nodular masses replacing the entire glandular parenchyma symmetrically on both sides. We report a case of a 31-year-old non lactating lady, in whom PASH caused bilateral symmetrical gigantomastia. As PASH has been shown to have a high chance of recurrence, review of literature revealed that most women with PASH-associated gigantomastia undergo mastectomy rather than reduction mammoplasty. We followed up our patient for two years post-reduction mammoplasty with no increase in dimensions of existing lesions or development of new lesions both clinically and on imaging.

Primary Squamous Cell Carcinoma of the Renal Pelvis: Unexpected Diagnosis of an Uncommon Malignancy- A Case Report

Matteo Ferrari, Jessica Barizzi, Julien Renard

Squamous Cell Carcinoma (SCC) of the renal pelvis represents a rare malignancy associated with nephrolithiasis. The aim of this report is to describe an unexpected diagnosis of renal pelvis SCC. We report a case of an 82-year-old female who came to our attention for onset of hematuria and left flank pain. A computed tomography scan showed a mass of 8×7 cm involving the middle and upper third of the left kidney associated with hilar lymphadenopathy. Patient underwent radical nephrectomy with para-aortic lymphadenectomy. Histopathological examination of the kidney showed a SCC arising from the renal pelvis, involving the renal parenchyma and perirenal fat, with emboli in the renal vein and lymph node invasion. No postoperative surgical complications were recorded and at follow-up no signs of clinical recurrence were found. However, the patient’s clinical condition declined progressively until death occurred three months later. In addition to being a very rare entity, this case demonstrates that renal pelvis SCC can also develop in the absence of predisposing risk factors. Moreover, renal pelvis SCC has no specific clinical presentation and often being diagnosed at an advanced stage.

Isoniazid Induced Toxic Epidermal Necrolysis in a HIV Positive Patient during Treatment for Extra Pulmonary Tuberculosis: A Case Report

Bhanukumar Muthaiah, George Mathew Panachiyil, Tirin Babu, Allu Harshavardhini

Toxic Epidermal Necrolysis (TEN) is characterised by extensive erythema, necrosis, and bullous detachment of the epidermis and mucous membranes. Drug induced TEN is commonly seen with sulphonamides, penicillins, other antibiotics, non-steroidal anti-inflammatory drugs, anticonvulsants etc., Human Immunodeficiency Virus (HIV) infected patients are more susceptible to these drug reactions than the general population. Isoniazid (INH) remains one of the first line agent for Antitubercular Therapy (ATT) in HIV patients co-infected with tuberculosis. An alteration in the treatment of tuberculosis is recommended if the patient develops TEN on any first line antitubercular drugs. Here, we report a case of INH induced TEN in a HIV patient during treatment for extra pulmonary tuberculosis. She was non-compliant to the Antiretroviral Therapy (ART) drugs and was on ATT drugs (INH and ethambutol) for the past four months. She was admitted to the hospital with the complaints of extensive skin lesions of one-week duration which was diagnosed to be TEN clinically and also based on the biopsy report. The frequency of INH causing TEN was not defined by the clinical trial investigators, however this was suspected to be due to INH. The severe cutaneous adverse reaction subsided after the withdrawal of INH followed by the supportive therapy for skin lesions.

Rare Isolate of Stephanoascus ciferrii from the Aural Discharge of Post-mastoidectomy Patient-A Case Report

Stephanoascus ciferrii is an ascomycetous yeast-like fungus, rarely causing human infections. It is also a teleomorph of Candida ciferrii. This species has a strong tendency to become resistant especially in patients on fluconazole prophylaxis. We report a case of post-mastoidectomy with continuous aural discharge not responding to topical and systemic treatment. Further characterisation showed ascospore formation and fluconazole resistance. Therefore, in vitro susceptibility testing is mandatory for the selection of appropriate antifungal drugs. This case report will alert the clinicians to look for fluconazole resistant yeast causing highly resistant aural infections.

Novel Treatment for Hard-to-Heal Chronic Plantar Ulcers in Hansen’s Disease

Gatha M Upadya, Srinidhi Govindarajan

Hansen’s disease is an important public health problem and it is one of the important cause of disability in patients with non-healing trophic ulcer in Hansen’s disease, and also the long-term management of these trophic ulcers works out to be very costly. Reduction in the healing time would be a major step in the rehabilitation of these patients. Authors hereby present one such case of chronic plantar ulcer in Hansen’s patient which was refractory to standard treatment like oral and topical antibiotics and daily dressings for more than six years. Hence, Platelet Rich Fibrin Matrix (PRFM) was applied along with adequate rest using Plaster of Paris (POP) cast. The wound was opened and the dried PRFM was cleared from the bed of the wound after 10 days. Procedure was repeated every third week. This led to dramatic healing of the ulcer with a reduction in wound diameter with no noticeable side-effects.

Rehabilitation Challenge in Congenital Lower Limb Deficiency: A Case Report

Rehabilitation of congenital lower limb deficiencies remains a challenge. A four-year-old boy presented with bilateral lower limb deficiency since birth and inability to stand. Orthoprosthesis with modified bucket type socket accommodating the right rudimentary limb, connected by a tubular shank and a modified foot piece on right side was prescribed. The left side of socket was incomplete inferiorly for the limb to pass through. An additional left Ankle Foot Orthosis (AFO) was also prescribed. The child achieved independent standing as well as started taking steps with a rollator.

A Rare Case of Paranasal Sinus Schwannoma with Intracranial Extension

Mihir Mohan Vaidya, Asha Sharad Shenoy, Naina Atul Goel

Paranasal sinus schwannomas are uncommon and account for less than 4% of head and neck schwannomas. Intracranial extension and aggressive behaviour are very rarely observed in these tumours leading to misdiagnosis of a malignant neoplasm. Here, we report a case of a 35-year-old male with complaint of proptosis. MRI showed a tumour in the region of ethmoid sinus with expansion into anterior cranial fossa. Microscopy revealed a biphasic tumour with compact and loose areas. Tumour was composed of spindle cells with wavy nuclei, showing focal palisading and a strong immunoreactivity for S100. MIB-1 index was around 1%. A diagnosis of Schwannoma was favoured based on histology and immunohistochemistry.

Virtual Amputation as a Conservative Surgical Approach in Treating Diabetic Foot Osteomyelitis- A Case Series

Abdul Wafiy Mohd Padzil, Mohd Yazid Bajuri

Diabetic Foot Osteomyelitis (DFO) has been described as one of the factor that can interrupt the healing process of a Diabetic Foot Ulcer (DFU). It shows that it has a significant correlation with lower limb amputation. One of the methods to treat this condition is by virtual amputation in which the infected bone is debrided with the ulcer site and the wound has a better chance to heal faster. This also shortens the duration of antibiotic course. We present a case series consisting of six patients that have been treated with virtual amputation from June 2017 till August 2017. These patients were treated by removing part of the osteomyelitic bone and dead tissues. Although there is no bone to support but the surrounding soft tissue coverage helps to maintain the configuration of the affected part in which it retained good appearance, cosmetically.

Varied Clinical Spectrum of a Rare Entity Pneumonia-Pasteurella canis: Case Series and Review of the Literature

Mani Arun, Gopalkrishna Bhat, Vishak Acharya, Shalini Shenoy

Pasteurella canis is a gram-negative coccobacillus belonging to the Pasteurellaceae family. Pasteurella species are prevalent among many animals where they are present as part of normal microbial flora of oral, nasopharyngeal and upper respiratory tract mucosa. Over 28 genera have been recognised in genus Pasteurella. They cause endemic and epizootic infections in animals. Zoonotic pneumonias are rarely encountered and diagnosed in routine clinical practice and often there is a lack of insight on zoonotic pneumonia amongst pulmonologists and microbiologists. We report five cases of pneumonia caused by P. canis. The novelty of our case series is the fact that P. canis is sparsely reported in the medical literature as a cause of pneumonia. Also, in most of our patients no definite source of contact with pets could be traced and all had an underlying structural lung disease or systemic immunocompromised conditions.

Chairside Pickup of Hader Attachment Sleeves using Condensation Silicone Putty and Pattern Resin- A Novel and Precise Technique

BC Muddugangadhar, Arindam Das, Dipal P Mawani, Arindam Mukhopadhyay

This article describes an easy, economic and precise method for chairside pickup of Hader bar sleeves using condensation silicone putty and pattern resin. After torquing the titanium bar, proper block out is carried out using condensation silicone putty, followed by precisely creating space in the intaglio of the denture surface for picking up of the sleeves. Finally, pattern resin is used to pick up the attachment sleeves onto the intaglio surface of the denture.

Hyper IgE Syndrome

Poonam Marwah, Sunil Kumar, Ashish Marwah

Correspondence: Association of Serum Vitamin D Levels and Recurrent Wheezing in Children

Prawin Kumar, Jagdish Prasad Goyal

Does Training of Sensory Processing Helps in Improving Motor Execution in Children with Cerebral Palsy?

Kovela Rakesh Krishna, Ajay Thakur, HS Sunjyoth

Diarrhoea Due to Intestinal Acariasis

Evaluation of Chronic Pain and Pain Intensity: A Study among Nurses of Iran

Fatemeh Kheiry, Mahnaz Rakhshan, Maryam Shaygan

Introduction: Nurses are exposed to various injuries in the upper and lower extremities. Aim: To evaluate features of chronic pain in the upper and lower extremities and factors associated with the intensity of chronic pain among nurses. Materials and Methods: This cross-sectional study recruited nurses with chronic pain using census sampling (n=414). Data were collected using a structured self-administered questionnaire. Data analysis was performed by using descriptive and inferential statistics. Results: The findings of this study shows that off 414 subjects, 277 subjects (66.9%) reported chronic pain in the upper extremity and 137 subjects (33.1%) intheir lower extremity. The quality of pain, pain frequency, and pain-related disabilities were statistically different between nurses with upper limb pain and lower limb pain (p<0.05). The intensity of pain was not statistically different between the two groups of nurses with chronic pain in either upper or lower extremities (p>0.05). Results also showed that pain intensity was significantly associated with age, time spent in a new work position, evening shift work, and levels of pain frequency (p<0.05). Conclusion: Nurses usually complain of chronic pain in different parts of their bodies. The characteristics of pain are different in upper and lower body extremities. However, there was no significant difference in pain intensity between upper and lower limbs. Thus, implementing the preventive intervention based on the characteristics of chronic pain would help in improving the quality of nursing care.

Knowledge, Perceptions and Psychosocial Impact of Acne Vulgaris: An Indian Scenario

Amit Gupta, Priti Dhande

Introduction: Acne vulgaris is a chronic inflammatory disease of pilosebaceous unit characterised by areas of seborrhoea, comedones, papules, nodules, pimples, and possibly scarring that may remain for rest of the life. Acne is a treatable disease but needs prolonged treatment with patience and its onset in adolescence has been found to influence the patient physically, socially, economically as well as psychologically. This can seriously affect their quality of life. Aim: To determine patients’ knowledge and perception about acne vulgaris and analyse the association of patient characteristics with the impact of acne on their psychosocial life. Materials and Methods: A total of 183 subjects of acne vulgaris of either gender, visiting Dermatology OPD and willing to participate in the study were asked to fill in a pre-tested, pre-validated questionnaire consisting 20 items- 6 based on general information about their condition, 5 based on knowledge about acne and 9 questions on perception about their condition and its treatment. A total of >4 questions about knowledge correctly answered was considered as good knowledge and <4 correctly answered as poor knowledge. Data were analysed by using chi-square test. Results: Study participants had inappropriate knowledge about the causes or predisposing factors of acne as well as about the treatment options for this condition. Social advertising media was seen to be influencing their beliefs and decisions regarding the same but was unable to provide complete and correct information which was a significant finding (p<0.001). <57% of study participants believed that the disease had a moderate to severe impact on their self-image and this was found to be statistically significant (p<0.001). There was a statistically significant association (p=0.002) between the study subjects who had poor information about the causes of acne vulgaris and the impact (moderate to severe) this disease had on their psychosocial life-meaning impact on self-image, relationship with friends and family and impact on work or school performance. Results were interpreted based on direct analysis of study questionnaire without using any scoring system. Conclusion: Study subjects lacked correct knowledge about acne and its treatment where advertising media was the most influential but was incomplete source of information. Acne had a significant impact on their psychosocial life, specially self-image.

Duodenal Biopsy in the Evaluation of Chronic Diarrhoea in Immunosuppressed Patients from a Tertiary Care Center in Southern India

Archana Lakshmanan, Ubal Dhus, Sarojini A Parameswaran, Ashok Parameswaran

Introduction: Chronic diarrhoea in immunocompromised patients is due to a variety of causes including opportunistic pathogens that flourish in such a milieu. While stool examination may diagnose some pathogens, at times this may be negative and upper GI endoscopy and colonoscopy findings maybe unremarkable. Aim: To evaluate the effectiveness of a duodenal biopsy in determining the aetiology of otherwise not diagnosable chronic diarrhoea in a background of immunosuppression and to note the variety of causes in this setting. Materials and Methods: The study was done in the Department of Histopathology over a period of 26 months (February 2010 to March 2012). This study includes duodenal biopsies from 42 immunosuppressed patients. These patients presented with chronic diarrhoea undiagnosable by routine non-invasive investigations such as stool routine examination, stool culture and sensitivity, etc. Data entry was done in MS excel sheet and data analysis was done. Results: Infectious aetiology was identified in 18 cases (43%). The most frequently found pathogens were protozoans (15 cases, 35.7%), followed by viruses (two cases, 4.8%) and helminths (one case, 2.4%). Kaposi sarcoma was noted in one biopsy. Conclusion: The duodenum is a good site for biopsy in the investigation of chronic diarrhoea in a setting of immunosuppression. In this study a diagnostic yield of a duodenal biopsy alone was 45.24% for specific aetiology. The diagnostic features in these situations are often scanty or subtle, requiring careful systematic examination of multiple sections at high power and the use of special stains not otherwise performed.

Long Term Clinical Outcome and Late Toxicity of Intensity Modulated Versus Conventional Pelvic Radiation Therapy for Locally Advanced Cervix Carcinoma

Introduction: Role of intensity modulated radiotherapy in definitive management of Locally Advanced Cervical Carcinoma (LACC) is not yet well defined with limited available literature. Aim: We had earlier reported early clinical outcome and acute toxicities in patients with locally advanced carcinoma cervix treated with Whole Pelvic Conventional Radiotherapy (WP-CRT) versus Intensity Modulated Radiotherapy (WP-IMRT). This study aims to evaluate the long term clinical outcome and late toxicities. Materials and Methods: A total of 44 patients of stage IIB-IIIB {International Federation of Gynaecology and Obstetrics (FIGO 2009)} squamous cell carcinoma of the cervix was randomised between WP-CRT or WP-IMRT to receive 50.4 Gy in 28 fractions with weekly cisplatin 40 mg/m2 followed by high dose rate intracavitary brachytherapy (7 Gy in 3 fractions each one week apart). Survival was calculated from the date of initiation of treatment. Late toxicity was graded as per the Radiation Therapy Oncology Group (RTOG) system. Results: A total of 22 patients each were assigned to the two treatment arms. Out of 44 patients, 13 and 12 patients belonged to stage IIB; 9 and 10 patients had stage IIIB disease respectively in WP-CRT and WP-IMRT arms. Median follow-up time was 46.7 months (22.8-59.8 months) for the WP-IMRT and 51.23 months (21.7-59.8 months) for the WP-CRT arm. Five-year loco-regional failure free survival and distant metastasis free survival rates were 85.7% versus 90.9% (p=0.58) and 76.4% versus 69.4% (p=0.79) in WP-IMRT versus WP-CRT respectively. Five-year disease free survival and overall survival rate in the WP-IMRT arm versus the WP-CRT were 72.7% versus 66.2% (p=0.80) and 72.4% versus 74.4% (p=0.61). For combined Grade-1-3, patients in the WP-IMRT arm experienced significantly fewer chronic gastrointestinal toxicity (18.2% versus 50%, p=0.027). Grade-2 late bladder toxicity was seen more in WP-CRT arm versus WP-IMRT arm (13.6% versus 0%, p=0.116). Conclusion: WP-IMRT continues to show comparable long term survival outcome and is associated with significantly less chronic gastrointestinal toxicity compared to WP-CRT. We suggest the use of WP-IMRT for LACC till further results from ongoing multicentric trial are available.

The Relationship between Depression and Internet Addiction among Paramedical Students in Larestan, Iran

Introduction: Depression is the fourth leading cause of disease burden in both sexes and it is the first cause of disease burden among women in Iran. Depression in college students is more common than the general population and they are considered as high risk group for internet addiction. Aim: The purpose of this study was to determine the relationship between internet addiction and depression in the students in Iran. Materials and Methods: A descriptive-correlative study was carried out in two medical sciences faculties in Fars Province, Iran. The participants were selected through convenient sampling among the students, interested in participation. Total 150 questionnaires were distributed out of which 119 questionnaires were returned and used in data analyses. Questionnaires included Beck Depression Inventory (BDI-II) and Internet Addiction Scale (IAS). The relationships between variables (among Depression, Internet dependence and duration of using the internet) were examined by using t-test and Pearson’s correlation coefficient and analysed by SPSS 20 version. Results: There was a significant correlation between internet addiction and depression (p<0.001; r=0/222). A total of 21% of subjects had trivial, 18.5% mediocre and 17.6% had severe depression. A total of 9.6% of samples had mild internet addiction. There was a significant correlation between average number of hours of Internet usage and BDI-II and IAS scores of students. Independent sample t-test revealed that there were no significant differences in BDI-II and IAS scores in both sexes and also marriage status of samples. Conclusion: According to the results of this study, it can be stated that internet addiction can be considered as a predictor of depression in medical students who are now a days increasingly dealing with internet. Therefore, planning and attention of the authorities is essential for developing methods to prevent the harm of these students who play a major role in the health care of a community; such as Positive Psychology Interventions (PIs) which denotes individual/group-based treatment methods that lead to positive emotions and can augment social relationships of individual.

The Outbreak of Classic and Norwegian Type Scabies, in Mentally Handicapped Persons in a Rehabilitation Centre-Iran

Hamed Ramezani Avval Riabi

Introduction: Scabies is an ectoparasitic infection caused in humans by the scabies mite Sarcoptes scabiei variety hominis. Aim: The aim of this study was to detect early disease scabies, finding its risk factors, and prevention of epidemic diseases among the people who are susceptible to scabies, because of disability and mental retardation. Materials and Methods: This was a descriptive cross-sectional study which was managed in a rehabilitation centre, which is responsible for the care of disabled and mentally retarted in Iran for a period of two months from July 27, 2018 until September 28, 2018. This centre had five units (A, B, C, D and E) comprising of 46 employers (34 staff; 2 nurses and 10 service personnel) who were catering to 110 handicapped persons. The index case of scabies in disability centre was a 16-year-old child with Down Syndrome, who was in contact with the patients in Unit E. On July 27, 2018, it reported one outbreak of scabies in this rehabilitation dormitory to one Centre Care Health (CCH) of Iran. All of 19 patients had symptom including: skin itching; papule on testis and penis and generalised rash on the body and two patients had thick crust on skin in armpit and anal area. Four service personnels had itching and papule on the neck. The patients were examined by a team including entomologists and dermatologists and demographic information of the patients was collected by completing the questionnaire (with regard to the principles of medical ethics). Mentally retarded persons were treated with 5% permethrin cream and for staff; nurses and service personnel 10% crotamiton cream was given except for pregnant women who used 10% sulfur ointment. Results: A total of 110 individuals with mental and physical disorders (23.6% males and 76.4% females) were resident in five units out of which 19% of individuals were exposed and 81% unexposed. The sex ratio of male to female was 1:3.2. The mean age of patients was 27 years (SD=7.09, Range 14-48 years) that most affected age group was 21-30 years (45.4%), 92% of exposed group was females and 8% were males. Using of sharing towels (odds ratio: 23.25, 95% CI: 8.91-60.64), sharing bathroom supplies (odds ratio: 3.31, 95% CI: 1.03-10.64), sleeping in a common bed (odds ratio: 23.25, 95% CI: 8.91-60.64) and sharing glove (odds ratio: 0.86, 95% CI: 0.28-2.18) were the most important risk factors of the scabies. Conclusion: It is an urgent need that in social places, including hospitals, centres for the care of the elderly and mentally handicapped people, the nurses and service personnel get trained about the importance of urgent report of epidemic diseases especially scabies to Health care centres.

Role of Dietary Habits Modification in Improving Haemoglobin of Anaemic Children in a Rural Village in Egypt

Introduction: Iron deficiency anaemia is the most common cause of childhood anaemia worldwide. In Egypt, more than one in four children aged from 6-59 months suffer from some degree of anaemia. Nutritional education intervention is required in any population as it improves knowledge and practices which reinforces healthful eating. Moreover, because habits and attitudes formed in early life are transferred into the future adult’s life style, it is important that nutritional education intervention to target children and their mothers. Aim: To test the impact of a nutrition education message delivered to mothers of under-five years of age children presenting with mild anaemia, through encouraging mothers to provide a diverse range of local iron rich food to their anaemic children. Materials and Methods: This community-based intervention study was conducted on mothers of children under age of five in Meet rahina rural Primary Health Center (PHC) Giza, along a period of one year starting from January 2017. Phase I: Screening of children under-five years of age (1220) seeking PHC services for a long period of two months by Eastern Oregon University anaemia questionnaire. A score of =5 means children are at risk for anaemia. Phase II : Total 660 children with score =5 at risk for anaemia were screened by laboratory investigations (haemoglobin, urine, stool). Phase III : Among 660, 323 mild anaemic children were subjected to clinical examination and anthropometric measures. Phase IV : Mothers, whose children were anaemic were provided with group health education sessions, aiming to enhance children feeding practices and their dietary intakes. Statistical analysis for different variables was done. To evaluate the effect of intervention, haemoglobin percent change was calculated as an indicator of improving health status of anaemic children. Results: The mean haemoglobin level before intervention was 10.4±0.2 then it improved after the intervention to become 10.7±0.4. The mean of the haemoglobin percent change was 2.5±1.8. The majority of the children (268 (89.3%)) whose mothers received the intervention evinced haemoglobin improvement. Families whose monthly income was sufficient with saving ability and those who lived in houses with crowding index less than three individuals per room displayed significantly higher mean haemoglobin percent change (p-value =0.001). Also, it showed a positive, correlation with mean of haemoglobin before intervention and weight for age Z-score. Conclusion: Practically, knowledge acquired through educational intervention is translated into better children feeding practices. Comprehensive nutritional education regarding anaemia can have a great impact on the lives of future adults.

Estimation of Chemical Composition of Renal Stones: An Observational Study from a Tertiary Care Centre of North East India

Introduction: Qualitative analysis of renal stone provides valuable information on both their aetiology and origin which, can help in the treatment and prevention of recurrence of nephrolithiasis. Aim: To determine the composition of renal stones on patients reporting to tertiary care center. Materials and Methods: A total of 140 renal stones were studied over a period of 18 months. Renal stones were collected by surgical intervention in the Urology Department and analysed chemically as per standard methods for inorganic, carbonate, oxalate, phosphate, ammonia, calcium, organic, magnesium and uric acid. Results: Chemical analysis of 140 stones, removed from patients, showed that ammonia was most frequent salt (100% for males and 97.83% for females) found in the age group of 18-40 years. This was followed by magnesium (97.83%), oxalate for males (97.83%) and calcium for female (97.83%). On microbiological analysis, Proteus spp. was found to be most common organism in 18-40 years age group in both sexes and Pseudomonas aeroginosa in the young age. Conclusion: The study showed that ammonia was present in the highest amount in the renal stones in both sexes followed by magnesium, indicating that these were struvite stones.

Preoperative Biochemical, Haematological and Radiological Parameters in Breast Cancer: A Case-control Study

TS Rekha, Smriti Bhargava

Introduction: Haematological, biochemical and radiological investigations are prerequisite for surgical resection in breast cancer. Deranged parameters predict a poorer outcome following surgery and also may adversely influence the risk factors, clinical presentation, predict morbidity, mortality and provide guidelines for treatment in breast cancer. Aim: To evaluate the significance of breast cancer preoperative investigation when compared with apparently normal control. To assess the association of the significant preoperative investigations with the established breast cancer risk factors, clinical findings and histopathological prognostic factors. Materials and Methods: This was a case-control retrospective study with 156 histopathologically confirmed breast cancer cases and 102 controls and data were collected through structured questionnaire that included risk factors, clinical, histopathologic, and investigation details. Descriptive statistics, Pearson’s chi-square, Odds ratio, Student’s t-test and ANOVA were calculated. Results: There were 3 (1.9%), 81 (51.9%) and 72 (46.2%)cases of Grade I, II and III respectively. When compared to apparently normal controls haemoglobin (Hb), RBC, ESR, RBS, Urea, Creatinine, Sodium, Potassium and Chloride levels were statistically significant. On analysing these significant presurgical investigations with the established breast cancer risk factors, clinical findings and histopathological prognostic factors it was found that Hb with grade; WBC with stage; urea with lymphadenopathy and nipple discharge; creatinine with in-situ and Lymphovascular Invasion (LVI); sodium with grade, mobility of breast lump, lymph node metastasis and Progesterone Receptor (PR); potassium with in-situ had significant association. Radiological parameters were not statistically significant. Conclusion: The results obtained indicate that the presence of preoperative anaemia, leukocytosis and renal impairment has adverse influence in breast cancer and thereby aid to plan the treatment accordingly.

HbA1c Levels in Children with Persistent Asthma on Inhaled Corticoids: A Descriptive Cohort Study

Kaarthikeyani Sankaravadivelu, Padmasani Venkat Ramanan, Rajesh Balan

Introduction: Asthma is one of the most common chronic respiratory conditions in children. Inhaled corticoids have revolutionised the treatment of asthma but long-term inhaled and systemic corticoids have been shown to have an effect on glucose metabolism. Aim: To compare the glycosylated haemoglobin (HbA1C) levels in children with asthma on Inhaled Corticosteroids (ICS) for less than 6 months with that of children on ICS for 1-6 months. Materials and Methods: The study was a descriptive cohort study done in the Paediatric Asthma clinic in a tertiary care teaching hospital in Southern India. Authors enrolled 75 children aged 1-18 years with persistent asthma (GINA guidelines) on inhaled corticosteroids for six months or more (cases) and another 75 age-matched children on inhaled corticosteroids for 1-6 months (controls). The HbA1c levels in the two groups and its relationship with cumulative dose of ICS was analysed. Various clinical factors were compared using chi-square test. Mean HbA1c levels between the two groups were compared using Student’s t-test. Results: Among the children studied, 7 (9.3%) of cases and none of controls had elevated HbA1C levels above 6%. The difference was statistically significant (p-value=0.0067). The Mean HbA1C level in cases was 5.27 and 5.07 in controls. The difference was statistically significant (p-value=0.007). There was an increase in HbA1c levels with increase in total cumulative dose of steroids (Coefficient of correlation 0.23). Conclusion: HbA1c levels become significantly higher in children on inhaled corticosteroids for more than six months. Hence glycaemic status needs to be monitored in all children on long-term inhaled corticosteroids.

Effectiveness of Mulligan’s Sustained Natural Apophyseal Glide (SNAG) over First Rib in Reducing Pain and Improving Cervical Rotation in Individuals with Mechanical Neck Dysfunction

Bhattarai Prayerna, Kanthanathan Subbiah, P Antony Leo Asser, Steve Milanese

Introduction: Mechanical Neck Pain (MNP) is any type of pain caused by placing abnormal stress and strain on the structures that constitute the vertebral column. Elevated first rib dysfunction is one potential somatic lesion that could lead to neck pain. Little information is available regarding this somatic lesion and its management. Aim: To assess the impact of treating first rib dysfunction with Mulligan’s Sustained Natural Apophyseal Glide (SNAG) among subjects with mechanical neck dysfunction. Materials and Methods: A quasi-experimental-study with 40 patients with elevated first rib and neck pain were included in this study. After baseline evaluation comprising of history, pain intensity, Pressure Pain Threshold (PPT), Cervical Range of Motion (CROM) and Neck Disability Index (NDI), the subjects were divided into two groups (n=20). The Experimental group was treated with SNAG with neck isometrics and the control group was treated with interferential therapy with neck isometrics. After six sessions of treatment the PPT, CROM and NDI were measured. The results were tested using Paired t-test and Mann-Whitney U-tests with a statistical significance level set at p<0.05. Results: Subjects in experimental group had clinically significant improvement post-treatment on Pain (p<0.002), Pressure Pain Threshold (PPT) (p<0.009), Cervical rotation range (p<0.001) and Neck disability (p<0.001) when compared to the control group. Conclusion: Treating the first rib elevation dysfunction with Mulligan SNAG will improve cervical range of motion, decrease pain and related disability.

Is Interleukin-18 an Early Diagnostic Biomarker in Contrast Induced Nephropathy?

Mohammed Mujahid, Mohammed Shobha

Introduction: The rise in number of cases of hospital-acquired acute kidney injury in patients undergoing diagnostic and therapeutic procedures by the use of contrast medium is a growing concern among nephrologists. Despite being a delayed marker, the measurement of creatinine level is one of the most popular methods in medical fraternity, to identify the degree of damage caused to the kidneys. Therefore there is a need for development of method for early detection and treatment of the contraindication of contrast media. Since serum Interleukin-18 (IL-18) levels rise early in the disease course, it may be a promising novel biomarker and an early indicator of tubular damage as compared to creatinine and other novel biomarkers. Aim: The current study investigated the early rise in serum IL-18 after contrast induction. Materials and Methods: Randomly selected 30 male wistar rats were given 0.6 mL of contrast iohexol (325 mg of iodine per mL) intraperitoneally and blood samples were collected before and after the induction of contrast by bleeding retro-orbital plexuses under isoflurane (USP) inhalation anaesthesia. Blood samples were collected at 3 hours, 6 hours, 12 hours, 24 hours and 48 hours of post-contrast administration. Results were analysed by using paired Student’s t-test and p-value<0.05 was considered to be statistically significant before and after contrast induction. Results: Statistically significant increase in IL-8 levels at 3 (p<0.01), 6 (p<0.001), 12 (p<0.01) and 24 (p<0.01) hours pre- and post-contrast treatment was observed. However, no statistical difference was found at 48 hours pre- and post-contrast treatment (p>0.07). Conclusion: The present study reveals an increase in IL-18 levels from 48% to 100% at 6 hours post-contrast induct in comparison to other standard markers like creatinine levels which increases at 48-72 hours post-contrast insult, revealed by the literature. Therefore it can be concluded that IL-18 is a better early novel biomarker for tubular damage assessment, after contrast insult.

Recall of Complications and Satisfaction of Consent in Mandibular Third Molar Surgery: A Randomised Controlled Single Blind Study

Mohd Mazharul Md Yusoff, Syed Nabil, Muhd Fazlynizam Rashdi, Roszalina Ramli

Introduction: Informed consent prior to any medical procedure is important for legal, ethical and administrative reasons. Informed consent intends to improve the patients’ knowledge which will allow involvement of the patient in the decision making process. Identifying the most effective and well-received ways to conduct this process is an important aspiration for clinicians. This is especially true for common procedure such as the Mandibular Third Molar Surgery (MTMS). Aim: The aim of this study was to compare the recall of complications of MTMS and satisfaction between two informed consent interventions. Materials and Methods: This parallel randomised controlled study involved subjects between 18-42-year-old who underwent wisdom tooth surgery in the 10-month study period in the Oral and Maxillofacial Surgery Clinic, Universiti Kebangsaan Malaysia. A total of 120 subjects were enrolled and assigned to the verbal (V) or combined Written-Verbal (WV) groups. The recall of complications was assessed in three phases specifically during the first consultation phase (first phase), the preoperative phase (second phase) and the postsurgery phase a week after the surgery (third phase). The score was categorised into poor, moderate and good. The association between the score of recall and interventions was assessed using the Fisher’s-exact test. Comparison of the percentage of recall between the first, second and third phases used the Friedman test while the Wilcoxon signed-rank test was performed to compare the percentage of recall response (median) between the first and second phases, second and third phases and first and third phases. Results: There was no statistically significant difference in the recall rate between the V compared to VW group in all three phases. A statistically significant difference was observed between the first and the second phases (Z= -2.50, p=0.01) and between the first and third phases (Z=-2.55, p=0.01) in the WV group. In the V intervention, only the first and the third phases showed a statistically significant difference (Z=-2.11, p=0.04). Overall, 97.5% of subjects were satisfied with the information received. Conclusion: The current practice of obtaining informed consent with verbal intervention is equivalent to the verbal and written intervention.

Hypernatremia and Acute Kidney Injury in Exclusive Breast Fed Babies-Time to Reconsider!

Shobha Sharma, Sanjukta Poddar, Anita Yadav, Pradeep Kumar Debata, Neelam Roy

Introduction: Hypernatremia in breast fed babies is not very commonly reported. But incidence seems to be increasing. Exact pathophysiology is not clear but hypothesised to be due to relative lactation failure in early postnatal period especially in primiparous mothers, and it can be severe enough to cause life threatening complication like Acute Kidney Injury (AKI) which is even less reported. Moreover, clinical presentation can be misleading even in presence of severe AKI. Presence of other co-morbidities further adds to the problems and may lead to adverse outcome. Aim: To study clinical presentation, severity and outcome in hypernatremic term breast fed young infants who develop AKI. Materials and Methods: This was a retrospective study in which data analysis of all consecutively admitted young infants, =2 months age, who had hypernatremia as well as deranged kidney functions in last six months, was done. AKI was assessed by neonatal RIFLE criteria. Analysis was done by student’s t-test or Fischer-exact test or one-way ANOVA (multiple groups) or non-parametric test as applicable. Pearson correlation coefficient was used to analyse correlation between groups. Statistical analysis of data was done using SPSS version 21.0. Results: Sixteen babies were included. Majority i.e., 81% (13/16 in each group) were born to primiparous women and were on exclusive breast feeding; 75% babies presented with poor oral acceptance and 56% with fever. Other complaints were lethargy, poor urine output and excessive crying. An 80% of the babies had severe AKI (AKI stage III). A total of 31% (5 out of 16) died. Mean serum sodium was 165±8.4 mEq/L with range of 156-183 mEq/L. Median creatinine value was 2.4 mg/dL. Presence of sepsis, requirement of mechanical ventilation, vasopressors, high mean values of blood urea and serum creatinine (p<0.05) were significantly associated with poorer outcome. Conclusion: Hypernatremia is severe enough to cause AKI in exclusive breast fed babies which is not uncommon and is difficult to recognize clinically. Presence of other co-morbidities like sepsis portends poorer outcome. High index of suspicion in all babies specially without predisposing factors may lead to early diagnosis and timely management.

Bupivacaine (0.5%) Versus (0.5%) Bupivacaine with Ketamine (50 mg) for Subarachnoid Block in Lower Abdominal Surgeries: A Randomised Comparative Study

Bhargav Vishnu Gantasala, Amol Singam, Karuna Taksande

Introduction: Spinal anaesthesia is the preferred technique for most of the lower abdominal surgeries nowadays. Currently, Bupivacaine is the most commonly used drug in spinal anaesthesia. A number of adjuvants have been used to improve post-operative analgesia, along with the bupivacaine. Intrathecal ketamine, which is a N-Methyl D-Aspartate (NMDA) blocker prolongs the duration of post-operative analgesia due to inhibition of dorsal horn. Aim: To assess the duration of post-operative analgesia between two groups i.e., bupivacaine alone and bupivacaine with ketamine and also to assess the intraoperative and post-operative haemodynamic stability, onset and duration of sensory as well as motor block, side-effects of injection ketamine when given intrathecally as an adjuvant with injection bupivacaine. Materials and Methods: A prospective, randomised study was conducted in 60 patients with American society of Anaesthesiologist (ASA) Class I and II aged between 20-60 years posted for elective lower abdominal surgeries under subarachnoid block and were randomly selected and divided into two groups of 30 each. Bupivacaine Group B received intrathecal bupivacaine 12.5 mg (2.5 mL)+1.0 mL normal saline (total volume of 3.5 mL) whereas, ketamine Group BK received intrathecal bupivacaine 12.5 mg (2.5 mL)+1 mL (50 mg) Ketamine (total volume of 3.5 mL). Statistical analysis was done by using descriptive and inferential statistics using chi-square test and Student’s t-test. Results: The onset of sensory block was faster in group BK than compared to group B. Duration of sensory block and the time for 1st pain medication was significantly prolonged in Group BK. Haemodynamic parameters were comparatively more stable in Group BK than Group B. Conclusion: Ketamine, when added to bupivacaine intrathecally, decreased onset and prolonged the duration of sensory block. It also prolonged the post-operative analgesia with better haemodynamic stability than bupivacaine alone.

Efficacy of Yoga as an Add-on to Physiotherapy in the Management of Patients with Paraplegia: Randomised Controlled Trial

Introduction: Traumatic Spinal Cord Injury (SCI) is a leading cause of disability. Varying injury level and severity generate a spectrum of neurological dysfunction and a reduction in long-term Quality of Life (QoL) with a decrease in mobility. Aim: To evaluate the add-on effect of a Yoga program along with physiotherapy on individuals with paraplegia. Materials and Methods: A total of 124 SCI patients of both genders with age range 18-60 years, having incomplete SCI (AIS)-C and (AIS)-D, and admitted to the rehabilitation centre, India, were randomly allocated into two groups i.e.,: (i) Study group-Integrated Yoga and Physiotherapy (IYP) (n=62; age means and SD: 33.97±10.0 years); and (ii) control group-Physiotherapy (PT) (n=62; age mean and SD:32.84±9.5 years). These participants were assessed on primary outcome measures: (i) American Spinal Injury Association (ASIA) Impairment scale; (ii) c-Reactive Protein (CRP); (iii) Spinal Cord Injury Independence Measure (SCIM); and (iv) Medically Based Emotional Distress Scale (MEDS). The secondary outcome measures were: (i) Body Mass Index (BMI); and (ii) Quality of Life Index Spinal Cord Injury - Version III (SCI-QOL index), were measured before and after one-month interventions. Results: The IYP group showed a significant reduction in scores of CRP (p<0.001), SCIM (p<0.001), MEDS (p<0.001), and improvement in SCI-QoL Index (p<0.001) compared to the control group. There was no significant change observed in the ASIA impairment scale between the two groups. Conclusion: One-month Integrated Yoga and Physiotherapy program is more effective than physiotherapy intervention alone, in the management of paraplegia patients.

Estimation of Stature from Hand Dimension among Indigenous Karbi Tribal Population of Assam, Northeast India

Doloi IM Rongpi, Nitish Mondal

Introduction: Estimation of stature is an important parameter in the personal identification from human remains such as hand, foot and limbs in forensic examination in the field of Forensic Anthropology. Aim: To understand the relationship between stature and hand dimensions among indigenous Karbi tribal population of Assam, Northeast India. Materials and Methods: The present community based cross-sectional investigation was carried out among 300 (150 males and 150 females) adults of Karbi population of age group 20-50 years of Karbi Anglong, Assam, India. Anthropometric measurements of stature, Hand Length (HL) and Hand Breadth (HB) were collected using standard anthropometric procedures. Descriptive statistics, paired t-test, ANOVA, Pearson correlation and regression analysis were applied using SPSS (version, 17.0). Results: The results indicated that female individuals exhibit significantly smaller stature and hand dimensions than their male counterparts (p<0.05). Using ANOVA, there were statistically significant differences in stature, HL and HB (p<0.05) between sexes. The bilateral difference was found to be statistically significant in HL and HB (p<0.05), but the difference found was not significant in HL among females (p>0.05). The Pearson correlation analysis showed that anthropometric measures of stature are positively correlated with LHL, RHL, LHB and RHB (p<0.01). The results showed that the sex-specific regression equations in linear and multiple linear equations showed significant coefficient correlation with stature and LHL, RHL, LHB and RHB (p<0.01). The mean differences between the actual and estimated stature using derived equations of hand dimensions were observed to be statistically not significant (p>0.05). Conclusion: The present study has successfully reported the possible relationships and estimation of stature from the HL and HB. Similar studies are also recommended for ethnic/population specific equation and/or utilise and validation of equations to estimate the stature from HL and HB.

Effect of Deep Breathing on Cardiac Axis of Young Normal Subjects in Various Postures- A Pilot Study

Vishnu Priya Hariharan, Krishnan Srinivasan, MadanMohan Trakroo

Introduction: Cardiac axis is altered in many physiological and pathological states. Hence its measurement is important. Position and movements of diaphragm determine the position of heart because the pericardium is firmly attached to the central tendon of the diaphragm. Effect of change in body posture and breathing on cardiac axis has not been well documented. The changes in cardiac axis during deep breathing are greater in aged patients. Aim: To study the effect of deep breathing on cardiac axis of young normal subjects in various postures. Materials and Methods: This was a cross-sectional study done on 45 normal healthy volunteers. After 10 min of supine rest, with the help of INCO RMS Vesta 101 electrocardiograph, ECG was recorded in leads I and aVF during eupnea, after maximum inspiration and after maximum expiration. The measurement was repeated in sitting and standing postures. The cardiac axis was calculated from Einthoven triangle. Data was analysed using ANOVA and inter-group was analysed using post-hoc test. Results: Maximum inspiration produced a significant (p<0.001) increase in cardiac axis as compared to eupnea, in supine, sitting and standing postures. Maximum expiration produced a significant decrease in cardiac axis as compared to eupnea only in sitting (p=0.05) and standing postures (p=0.01). Conclusion: Cardiac axis varies with posture as well as breathing. Maximum inspiration produces significant increase in cardiac axis whereas maximum expiration produces an insignificant decrease.

A Histo-Morphological Study of Changes in Neoadjuvant Chemotherapy in Breast Malignancies

Cheryl Sarah Philipose, T Umashankar, Rohan Chandra Gatty

Introduction: The administration of systemic chemotherapy in order to shrink the size of the tumour before surgical resection is termed as Neoadjuvant Chemotherapy (NACT) and has been shown to improve the overall disease free survival. It also helps in downstaging the tumour and monitoring treatment efficacy. Aim: To study the histo-morphological features following NACT in breast malignancies. Materials and Methods: The present study was carried out in a tertiary care hospital in Southern India between November 2013 and December 2014. Twenty two cases of breast carcinomas were analysed and the histo-morphological alterations were studied. Results: Twenty two cases of breast carcinomas were studied. The age group ranged from 27 to 70 years. Five cases showed marked response following NACT while 17 cases showed poor response. The nuclear alterations were pyknosis (n=16), karyorrhexis (n=14) and karyolysis (n=14). The cytoplasmic alterations included vacuolation and foamy cell change. The stromal alterations included lymphoplasmacytic infiltrate (n=19), hyalinisation (n=17), collection of foamy macrophages (n=5), fibrosis (n=5), haemosiderin laden macrophages (n=5), giant cell formation (n=5). Conclusion: As NACT is increasingly becoming the standard of care for patients with breast malignancies, Pathologists need to be aware of the myriad of histo-morphological features that may be seen in specimens following radical surgery and be able to predict the probable chemoresponsiveness to NACT. In the present study, the histo-morphological features included nuclear, cytoplasmic and stromal alterations.

Disrupted Value System among Nursing Care Managers: A Qualitative Study

Introduction: The degradation of moral and professional values and incompatibility between value and performance affects the individual’s value, and leads healthcare staff to completely abandon the profession. Aim: To investigate the experience of nursing care managers regarding the disrupted value system. Materials and Methods: In this qualitative research paper, data were collected using semi-structured interviews with nursing care managers. Content analysis (based on Graneheim and Lundman’s approach) was utilised in data analyses. A total of 14 Iranian nurses with at least five-year experience of working in the hospital as nursing managers participated in this study. Results: The data analysis revealed one main category “disrupted value system” and two subcategories “impaired moral integrity and breaking the moral framework”. The findings of the study indicated that the experience of nursing care managers in disrupted value system is associated with the sense of ignoring own beliefs, distortion of learned values, distortion of transparency, emptiness, victimisation, scarifying for the organisation, failure to observe the ethical framework and rules, ignoring ethical principles and moral degradation. Conclusion: Nursing care managers experience a great deal of moral distress on a daily basis and despite their efforts to manage and tolerate these distresses, they suffer from many psychological complications. The results of this research can propose new meanings of disrupted value system, and thus facilitate the plans to control and reduce it based on new meaning.

The Effect of Hydroalcoholic Extract of Nigella sativa on Plasmodium berghei-Infected Mice: An Evaluation of Immune Deviation and Serum Levels of Interferon Gamma (IFN-?) and Interleukin 4 (IL-4)

Introduction: In tropical countries, malaria is known as one of the most widespread infectious diseases with an estimated 212 million cases globally. Treatment of malaria has become more difficult when the drug resistance appears against parasites. Therefore, safe and effective new drugs are highly required. Because of simplicity, lower cost, low rate of serious complications, and greater tolerability, traditional medicine is an important source for new drugs. Aim: To evaluate the anti-malaria and immune modulatory effects of Nigella sativa against Plasmodium berghei in vivo. Materials and Methods: This study was conducted in the Department of Parasitology, the Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran during January 2014 to January 2015. N. sativa powder was macerated in methanol and filtered with Bokhner hopper, and solvent was separated in a rotary evaporator. In the result of toxicity test, the 450 mg/kg was determined as maximum dose with minimum toxicity. Antimalarial efficacy and interferon gamma (IFN-?) and Interleukin 4 (IL-4) cytokines level were investigated in five groups of P. berghei-infected BALB/c mice. The percentage of parasitaemia and surveillance were also evaluated. Results: The results of our study showed no toxicity, even at high concentration of herbal extract. A significant reduction in the percentage of parasitaemia was not observed in the treatment group. N. sativa-treated infected mice showed a significant increase in the IFN-? but not IL-4 serum level, In addition, no higher surveillance was observed in the mice group treated with N. sativa compared to treated mice. Conclusion: Hydroalcoholic extract of N. sativa has the weak efficiency against P. berghei. However, there is requirement to evaluate the immune mechanism and also find the major component of this herbal extract by further studies.

Prevalence and Genotypes of Nosocomial Clostridium difficile Infections in the Eastern Province of the Kingdom of Saudi Arabia: A Multi-Centre Prospective Study

Doha Hudhaiah, Nasreldin Elhadi

Introduction: Clostridium Difficile Infection (CDI) is a critical public health problem in hospitals due to unique characteristics and many countries have reported increased incidence and outbreak of severe cases of CDI. Aim: To investigate the prevalence of C. difficile in the Eastern Province of the Kingdom of Saudi Arabia (KSA) in patients with inflammatory bowel disease relative to those with other diseases. The second objective was to understand the antimicrobial susceptibility patterns of clinical isolates of C. difficile against the antibiotics commonly used to treat CDI in hospitals and to identify the genotype and toxigenic profile of these isolates. Materials and Methods: From October 2015 to May 2016, a total of 374 non-duplicated stool samples were collected from four hospitals in the Eastern Province of KSA and screened for the presence of C. difficile. Each sample was divided into two portions. One portion was cultured on C. Difficile Selective Agar (CDSA) and C. difficile CHROM agar and incubated in anaerobic conditions at 37°C for two days. The other portion was tested for Glutamate Dehydrogenase (GDH) activity. When this test was positive, authors tested the sample for toxins A and B using the VIDAS CDAB test. Results: Authors found that 88 of the 374 samples (23.5%) were positive for C. difficile. The prevalence rate of toxigenic strains was 18.7% (70/374). The genotypes were distributed across five different ribotypes: 001 (63.6%), unknown (9.1%), historic 027 (3.4%), 017 (2.3%) and 015 (2.3%). In terms of toxigenic profile, 62 strains were (70.5%) tcdA+, tcdB+, Cdt-, 17 strains were tcdA-, tcdB-, Cdt- (19.3%), four strains were tcdA+, tcdB+, CdtA-, CdtB+ (4.5%), three strains were tcdA-, tcdB+, Cdt- (3.4%), one strain was tcdA+, tcdB-, CdtA+, CdtB+ (1.1%) and one strain was tcdA+, tcdB-, CdtA-, CdtB+ (1.1%). The in vitro antibiotic susceptibility of the 88 strains revealed that 94.3% were sensitive to all three tested antibiotics. Resistance to metronidazole and vancomycin was observed in 3.4% (n=3) of the samples and resistance to moxifloxacin in 2.3% (n=2). Conclusion: The high prevalence of toxigenic strains in the present study indicates that CDI may be an underestimated problem in the Eastern Province of the KSA. Genotype 001 is the predominant strain present in this region. Vancomycin- and metronidazole-resistant strains were identified from this clinical setting.

Enhanced Inflammatory Status in Patients with Simple Central Obesity in Absence of Metabolic Syndrome

Introduction: Abdominal obesity is associated with cardiovascular risk factors. Metabolic Syndrome (MS) describes a constellation of metabolic abnormalities, including abdominal obesity. However, there is limited data on the comparison of inflammatory biomarkers in centrally obese subjects without MS. Aim: To examine the biomarkers of inflammation in subjects with MS, central obesity without MS, and normal controls. Materials and Methods: This was a cross-sectional study involving 501 subjects categorised into MS, central obesity without MS (COBXMS), and healthy controls (NC). Soluble biomarkers of inflammation {high sensitivity C-reactive protein (hs-CRP), Interleukin-6 (IL-6), Soluble Intercellular Adhesion Molecule-1 (sICAM-1), Soluble Vascular Cell Adhesion Molecule-1 (sVCAM-1) and soluble E-selectin} were measured. Results: MS had significant elevation in all biomarkers, while COBXMS had higher concentrations of all biomarkers except sVCAM-1 compared to NC. COBXMS had elevated hs-CRP, IL-6 and sICAM-1 comparable with MS. Obesity categories of subjects (MS, COBXMS or NC) were associated with quartiles of each biomarker concentration (p<0.001). Waist circumference was significantly correlated and associated with all biomarkers, and was the independent predictor for sICAM-1 and E-selectin after correcting for confounding factors. Conclusion: Centrally obese subjects without MS have elevated concentration of inflammatory biomarkers comparable to those with MS, suggesting the pivotal role of simple central obesity even in the absence of MS in inflammation and possible enhanced atherogenesis.

Early Versus Delayed Intervention with Intracameral Liposomal Amphotericin B in Recalcitrant Keratomycosis: Experience of a Large Case Series

Introduction: Fungal keratitis has been reported to cause up to 50% of all corneal ulcers in the Indian subcontinent. Fungal keratitis is also associated with a very poor outcome with conventional treatment modalities. A few limited case reports/series have demonstrated the usefulness of Intracameral injection of liposomal Amphotericin B in severe fungal keratitis. However, several questions regarding intracameral therapy using antifungal agents are, as yet, unanswered, including when to intervene with this treatment modality. Aim: To evaluate whether an ‘early’ versus ‘delayed’ intervention using Intracameral Injection of Liposomal Amphotericin B (ICAMB) influences the efficacy, outcomes and complications in severe recalcitrant Keratomycosis. Materials and Methods: This prospective interventional study enrolled 50 eyes of proven fungal keratitis, not responding to conventional antifungal therapy administered over two weeks. They were randomly allocated to Group A (25 eyes) and Group B (25 eyes). Intervention with Intracameral injection of liposomal Amphotericin B, 10 micrograms/0.1 mL was done at either two weeks (Group A) or at four weeks (Group B). The clinical profile, visual acuity, time to epithelial defect closure, time to heal, final anatomical outcome, surgical interventions and complications were compared between the groups. Spearman correlation between healing time and other clinical characteristics was also done. The primary outcome measures were healing time, functional (final visual acuity) and anatomical outcomes (type of corneal opacity). Results: The mean healing time in Group A was 17.5±3.64 days and 32.2±8.89 days in Group B (p<0.001). The anatomical outcome in the form of a maculo-leucomatous corneal opacity was observed in 12 (48%) eyes in Group A versus 4 (16%) eyes in Group B (p=0.03), leucomatous corneal opacity in 13 (52%) eyes in Group A versus 16 (64%) eyes in Group B (p=0.56), and adherent leucoma in none of the eyes in Group A versus 5 (20%) eyes in Group B (p=0.05). None of the eyes in Group A required additional surgical intervention while 10 eyes in Group B developed corneal perforation, thus requiring surgical intervention (p=0.006). Conclusion: The present data has shown that eyes with severe non-responding keratomycosis may have a satisfactory outcome if Intracameral liposomal Amphotericin B therapy is initiated early rather than delaying this adjunctive treatment. In the authors’ experience, ICAMB significantly hastened the resolution and reduced the incidence of corneal perforation and ocular morbidity in resistant keratomycosis.

Prevalence of Core Weakness in Bank Employees

Prachiti Rajan Bhore, Khushboo Bathia, Smita Kanase, Amrutkuvar Jadhav

Introduction: Adults working in full time sedentary jobs spend 75% of their job time sitting, in terms of total time of sedentary behaviour of individuals. This population is at a greater risk of sedentary behaviour, due to elevation in the prevalence of sedentary office work and leisure time habits, resulting in 9-11 hours of total sitting time per day. Some of the occupations have adapted a sedentary behaviour, they demand long hours of being in one position. Adults adapt to faulty postures due to prolonged hours of work leading to muscular imbalances which highly contribute to the increased risk of musculoskeletal disorders. These disorders mainly occur due to weakening of the “core” musculature i.e. the central musculature of the body. This in turn may lead to excessive load on the lumbar spine, back, poor endurance of muscles, muscle imbalance and lower extremity disorders. Aim: To find out the prevalence of core weakness in bank employees with respect to their gender, age and Body Mass Index (BMI). Materials and Methods: A total of 99 healthy bank employees (67 males and 32 females), who were physically inactive for 6-8 hours daily and exercising for less than 2 hours per week, with their age between 20-50 years, were selected for the assessment of their core for finding its weakness. To find whether the bank employees had core weakness, outcome assessment was done by using a Chattanooga Pressure Stabilizer™. Results: In this study, statistically significant difference was noted within individuals with normal BMI (18.5-24.99 Kg/m²), whereas with respect to the age and gender, no statistically significant difference was noted. Conclusion: The prevalence of core weakness in bank employees was found to be 72.73%; majority of core weakness was found within the age group of 45-50 years (23.6%) which was relatively higher than other age groups. Prevalence of core weakness was found to be more in male population (65.3%) and in individuals with normal BMI (52.8%).

Sonographic Diagnosis of Brain Abnormalities in Infants: A Retrospective Study

Introduction: Central Nervous System (CNS) anomalies are the second most frequent serious congenital anomalies, after congenital heart diseases. Cranial ultrasound presents a non-invasive as well as safe and cost-effective tool for proper diagnosis, follow-up and management of these patients. Aim: The present retrospective study aimed to investigate the prevalence and type of brain anomalies using cranial ultrasound as a diagnostic tool. Materials and Methods: Data of infants who underwent cranial ultrasound at the study center, between January 2010 and December 2017, were retrospectively studied. Indications for cranial ultrasound scanning were: prematurity, respiratory distress, neurological deficiency, suspected syndromes and other congenital anomalies. Results: Selective cranial ultrasound was performed in 4256 (5.8%) infants, and 371 (8.7%) of them were found to have brain abnormalities. Major abnormalities were found in 245 (66%) patients. Conclusion: Intracranial haemorrhages and their possible consequences (ventriculomegaly, hydrocephalus, periventricular leukomalacia) were the most common anomalies detected. Hence, prematurity and other perinatal risk factors still present a major issue in Kosovo. Also, prenatal diagnosis rate was very low. Familiarity with ultrasound features of brain anatomy, in particular during prenatal period, contributes to an early diagnosis and proper management of major and rarer congenital brain anomalies.

Buccal Mucosa Squamous Cell Carcinoma: Analysis of ECOG Performance Status and its Association with Sociodemographic, Socioeconomic, Clinico-Pathologic Factors and Overall Survival

Padma Ramasamy, Amitkumar Kalaivani, Sivapatham Sundaresan

Introduction: Despite, progress in cancer therapeutics, survival remains very poor due to various factors. However, treatment decision making is an important factor for a better survival outcome. Aim: To evaluate Eastern Cooperative Oncology Group Performance Status (ECOG-PS) in buccal mucosa squamous cell carcinoma and its association with sociodemographic, socioeconomic, clinicopathologic factors and overall survival. Materials and Methods: This prospective study was conducted in the Regional Cancer Centre, Tamil Nadu between March 2013 and January 2016. Chi-square test and binary logistic regression were performed to evaluate the association between the covariates and ECOG-PS. Further, Kaplan-Meier and log-rank test were used for survival analysis. All statistical significance was set at p<0.05. Results: A total of 198 subjects which comprised 125 (63.1%) male and 73 (36.9%) female. In the study, demographic characteristics (Gender, Age, Body mass index and Risk habits) were failed to show the significance whereas socioeconomic status (p=0.001) and clinicopathological features like cell differentiation (p=0.034), TNM stage (p=0.001), lymph node status (p=0.001) and metastasis (p=0.001) exhibited significant association at p<0.05. Further, the presence of lymph node and metastasis had 2.27 fold and 1.053 fold risk of disease recurrence/death of subjects than negative lymph node and metastasis respectively. All the subjects were followed for an average of 18 months. Of 198 subjects, 24 (12.1%) reported recurrence and 7 (3.5%) were identified with disease-specific death and the rest of 167 (84.4%) were alive at last follow-up. The estimated overall survival rate was 48% and the study revealed a lower survival outcome of poor ECOG-PS than good ECOG-PS (p=0.046, p<0.05). Conclusion: The present study concludes that the subject’s physical performance score using ECOG-PS scale at diagnosis may help to identify aggressiveness of the disease and may help medical care requirements, specific therapeutic and rehabilitative interventions.

High-Sensitivity C-Reactive Protein and 24-Hours Ambulatory Blood Pressure Variability in Type 2 Diabetes Mellitus Patients

BE kalinga, y chethan

Introduction: The association between C-Reactive Protein (CRP) and cardiovascular events with hypertension being the risk factor has been studied extensively and correlated with the end-organ damage. Blood pressure variability has been linked to target organ damage and cardiovascular outcome irrespective of severity of hypertension. Aim: To understand the correlation between hs CRP, blood pressure variability during 24-hours ABPM in Type 2 Diabetes Mellitus (T2DM) compared to control subjects. Materials and Methods: The case-control study included data from T2DM patients with HTN (n=50), and healthy controls (n=50). Hs-CRP was assessed using Enzyme-Linked Immunosorbent Assay (ELISA) technique. All subjects underwent 24-hour ambulatory Blood Pressure (BP) monitoring; BP variability was calculated using standard deviation. Results: Among cases there was significant positive correlation between Hs-CRP, Systolic BP (SBP) Variability, Diastolic BP (DBP) Variability and Duration of DM i.e., with increase in Hs-CRP, there was significant increase in SBP Variability, DBP Variability and Duration of DM and vice-versa. Among controls there was significant negative correlation between Hs-CRP, SBP, SBP Variability and BMI i.e., with increase in Hs-CRP, there was significant decrease in SBP, SBP Variability and BMI and vice-versa. Conclusion: Hs-CRP is associated with 24-hour SBP variability, 24-hour diastolic BP variability and duration of T2DM. Blood pressure variability was independent predictors for Hs-CRP. The highest Hs-CRP levels were detected in T2DM patients and high BP variability.

Clinico-radiological Difference between Primary and Secondary MDR Pulmonary Tuberculosis

Deependra Kumar Rai, Alok

Introduction: Multidrug Resistant Tuberculosis (MDR-TB) is classified into primary and secondary type depending upon history of Anti-TB drug received in past. MDR-TB generally remains undetected in newly detected TB cases as the index of suspicion is low. Aim: To compare the clinical and radiological features of primary and secondary MDR-TB. Materials and Methods: This was a hospital based retrospective observational study on 74 MDR Pulmonary Tuberculosis (PTB) patients seen in the pulmonary medicine department of a tertiary hospital of Bihar, India between 1st January 2016 and 31st December 2017. Because of the lack of conventional culture or Line Probe Assay (LPA) facilities at the institute, rifampicin resistance on GeneXpert was taken as a surrogate marker for MDR-TB. Results: A total of 85 patients were diagnosed as having MDR PTB in the study period. Eleven patients were excluded from the study due to non-availability of clinical details. Out of the 74 patients, 19 (25.67%) were primary MDR cases and 55 (74.33%) were secondary. The mean age of primary MDR-TB was 24.2±13.8 years and secondary MDR-TB was 27.8±13.13 years. A 78.9% of primary MDR and 81.8% of secondary MDR patients were male. Patients were symptomatic for a mean duration of 4.5 months in primary and 11.9 months in the case of secondary MDR-TB before the diagnosis. Haemoptysis as a presenting symptom was more common in primary MDR-TB (47.3%) than in secondary MDR-TB (20%) (p<0.05). On the other hand breathlessness was more common in secondary MDR tuberculosis (52.7% vs 15.7%) (p<0.05). Moderate lesion on Chest X-ray (CXR) was most common in both primary and secondary MDR-TB (73.68% vs 45.54%) (p<0.05). Conclusion: Haemoptysis was more common in primary MDR than secondary MDR PTB patient, while breathlessness occured more frequently in secondary MDR PTB; bilateral and moderate lesion in chest radiograph was seen more with primary MDR PTB.

Mainstream Capnography Correlates Well with Central Venous Carbon Dioxide Levels in Non-intubated Children in PACU

Introduction: Monitoring exhaled Carbon Dioxide (CO₂) in non-intubated patients is challenging but has value for detecting hypoventilation, apnoea and hypercarbia. The study investigated a mainstream mask capnography system (cap-ONE®) especially designed for children. Aim: To compare the accuracy of peak exhaled CO₂ (PexCO₂) using mainstream mask capnography to partial pressure of central venous CO₂ (PcvCO₂). Materials and Methods: After Institutional Review Board approval, this prospective study was conducted enrolling children (weight range 7-40 kg) undergoing minor procedures who had indwelling central venous access for clinical indications. Infant and paediatric mainstream capnography masks were used according to patient body weight. Central venous blood was collected for analysis of PcvCO₂ during capnography recording. Values for PcvCO₂ and PexCO₂ obtained from mainstream mask capnography monitoring were compared in individual patients. Results: Forty children were enrolled and analysed. All patients had an uneventful anaesthetic course and entered the PACU without respiratory compromise. The average and Standard Deviation (SD) of PcvCO₂ were 47.5 (5.0) mmHg. Measurement error between PexCO₂ at blood sampling was 6.1 (SD; 3.2) mmHg. When PcvCO₂ >50 mmHg and PexCO₂ >45 mmHg from the mask was used as the threshold for hypercapnia the sensitivity was 77%, specificity 96%, and Area Under the Curve (AUC) 0.866 at the time of blood sampling. Conclusion: Measurement error between PexCO₂ and PcvCO₂ was similar to known exhaled-arterial PCO₂ difference (4-6 mmHg). We conclude that a mainstream mask capnography is a reliable method to assess hypoventilation and hypercapnia in non-intubated children.

Orientation of Cut Angle in Distal Tibia Derotation Osteotomy Can Create Unintended Sagittal and Coronal Plane Deformity at the Ankle

Kaeleen A Boden, Derrick M Knapik, Mark Biro, Raymond W Liu

Introduction: Distal tibial osteotomy is commonly used for surgically correcting tibial torsion. While the effect of purposeful oblique osteotomies are well described, minimal data exists regarding how variation of distal tibial osteotomy cut angle may inadvertently affect final ankle alignment. Aim: To assess changes in orientation of the cut angle in distal tibial osteotomies on ankle alignment in specimens with existing rotational deformities. Materials and Methods: Using preserved human tibia specimens; we identified ten specimens with the greatest degree of rotational deformity. Surface scanning produced a three-dimensional image of each tibia. Digitally, we created transverse and 10° angled cuts, five centimeters above the distal tibial articular surface. Specimens were three-dimensionally printed and cross-pinned at 0°, 20° and 40° of internal or external rotation. Anterior-posterior and lateral radiographs were obtained at each degree of rotation and the Anterior Distal Tibial Angle (ADTA) and Lateral Distal Tibial Angle (LDTA) were calculated. Results: No significant differences in LDTA or ADTA measurements was found based on degree of rotation in internally and externally rotated specimens using a transverse osteotomy. In angled osteotomies, LDTA and ADTA measurements were significantly different based on the degree of angulation in internally rotated (p=0.02, p=0.007; respectively), but not externally rotated (p=0.74, p=0.40; respectively) specimens. Conclusion: Distal tibia osteotomy cuts parallel to the distal joint surface can result in unanticipated coronal and sagittal plane deformity particularly with correction of internal tibial torsion. Osteotomies made perpendicular to the axis of the tibial shaft maintain native ankle alignment.

Evaluation of Visual Outcomes of Cataract Surgery in Diabetic Patients and Assessment of Post-operative Complications as Compared to Non-diabetics

Neha Singh, Shobha G Pai, Tina Anne John

Introduction: A leading cause of vision loss in the young adult population worldwide is sequelae and complications of diabetes. Cataract surgery performed on diabetic patients accounts for approximately 20% of total cataract surgeries. Cataract in patients with diabetes leads to decreased visual acuity and poses difficulty in examination of the retina adequately. Hence, it is advantageous to perform cataract surgery for diagnostic and therapeutic benefits, even if there is possible associated risk of aggravating the retinopathy. Aim: Evaluation and comparison of visual outcomes after cataract surgery in diabetic and non-diabetic patients; and assessment of post-operative complications. Materials and Methods: A prospective study was done to evaluate visual outcomes and post-operative complications after cataract surgery in 150 diabetics as compared to 150 non-diabetics; among the diabetics, 114 eyes were with mild Non Proliferative Diabetic Retinopathy (NPDR), 32 with moderate and 4 with severe NPDR. Central Foveal Thickness (CFT) measurement using Optical Coherence Tomography (OCT) was done for a homogenous group of 20 diabetics without proliferative retinopathy or Clinically Significant Macular Oedema (CSME) at baseline, and compared to 20 non-diabetics, to look for macular oedema, before and 6 weeks after cataract surgery. Qualitative data analysis was performed using student’s unpaired t-test. Quantitative data analysis was performed using Chi-square test. SPSS version 17.0 was used for analysis. Results: The parameters to be evaluated were CFT, visual outcome and macular oedema before and 6 weeks after surgery. Diabetics showed a marginally higher incidence of increased CFT on OCT after cataract surgery. Poor glycaemic control and pre-existing diabetic retinopathy were compared with a significant decrease of the visual outcomes and these patients had an increased incidence of post-operative complications. Conclusion: Adequate glycaemic control and the management of diabetic retinopathy would help to improve post-operative vision following cataract surgery.

Assessment of Common Risk Factors Between Oral Diseases and Non-communicable Diseases in a Hospital-based Population in Kerala, India- A Cross-sectional Study

Chandrashekar Janakiram, Farheen Taha, Joe Joseph, Venkitachalam Ramanarayanan

Introduction: Non-Communicable Diseases (NCDs) have assumed epidemic proportions around the world. Oral diseases also pose tremendous physical and emotional burden on the people. Both these conditions (NCDs and oral diseases), are largely caused by a cluster of risk factors like tobacco, unhealthy diet, physical inactivity and harmful use of alcohol. Aim: The objective of the study was to assess the common risk factors between Non- Communicable diseases (cardiovascular diseases, pulmonary diseases, diabetes mellitus type 2 and stroke); and oral diseases. Materials and Methods: A cross-sectional study was conducted with a sample of 280 patients in four NCDs groups like cardiovascular diseases, pulmonary diseases, diabetes mellitus type 2 and stroke. The risk factors for each of NCDs disease were assessed by their medical records, interview of the Physician and patients. In the same patients, oral disease risk factors were assessed and enumerated by clinical examination and a validated clinical questionnaire. Descriptive statistics were used with the demographic data. Cohen’s Kappa was used to assess the degree of agreement for the risk factor to be common to both the NCDs and oral diseases. Results: History of smoking was the most common risk factor between dental caries and diabetes mellitus type 2 (agreement of 15%). Cardiac valve abnormalities were a common risk factor between dental caries and stroke with a 31% degree of agreement. Diabetes as a common risk factor between dental caries and Myocardial Infarction (MI) had a degree of agreement of 44%. Asthma and oral diseases (dental caries and periodontal diseases) had obesity, history of smoking and positive family history as common risk factors. Conclusion: Smoking is the most common risk factor across the oral diseases and all the six NCDs included in the study followed by family history, obesity, hypercholesterolemia, high blood pressure, diabetes and excessive alcoholism. Thus, oral disease prevention programs can be integrated with the NCD prevention programs..

Gender Dimorphism in Tooth Dimensions- Where Exactly Does it Exist?

Vineetha Krishnan, Sreehari Sathyanadhan, Shobha Sundareswaran

Introduction: There are several studies which evaluate the interactions of mesiodistal tooth size among Angle’s malocclusion groups. Gender dimorphism in tooth size has also been established in previous studies. However, there is lack of information regarding interactions between Angle’s classification, gender and individual tooth size. Aim: Therefore, the aim of this study was to identify the Class of malocclusion more prone for gender dimorphism of individual teeth as well as the most variable and most homogenous teeth. Materials and Methods: The sample consisted of 308 study models with 104 belonging to Class I (53 males, 51 females), 104 to Class II division 1 (54 males, 50 females), and 100 to Class III malocclusion (50 males, 50 females). An electronic digital caliper was used to measure the mesiodistal width of all 14 maxillary and mandibular teeth from the right second permanent molar to the left. Statistical evaluation was done using independent t-test, analysis of variance and post-hoc Bonferroni test. Results: Class III malocclusions showed significantly larger dimensions in males for all teeth except upper central incisors and second bicuspids, whereas in Class II division 1, gender variations were limited to canines and upper second molars only. Class I showed gender dimorphism in canines, upper central incisors and lower first molars. Also, tooth dimensions were larger in Angle’s Class I and smaller in maxillary Class III in both genders. Conclusion: Gender dimorphism in tooth dimensions was found to be predominant in Class III malocclusion only. Canines were the most variable teeth showing gender variation in all three classes of malocclusion. The second premolars were the most homogenous, displaying no variations with gender in any of the classes.

Comparative Study of Unit Cost-analysis among Urban and Rural Dental Primary Health Services in Padang City, Indonesia

Febrian, Syukri Lukman, Hardisman, Suhairi, Desy Purnama Sari

Introduction: The reformation of The Indonesian Health System that became National Health Insurance (NHI) by using capitation method made a significant change in basic healthcare services. Capitation method is influenced by utilisation and unit cost calculation. Puskesmas that stand for Community-based health service is a primary healthcare full financed by Indonesian government capitation and focus on free simple healthcare. Inequalities of puskesmas distribution spread all over Indonesia, including in urban and rural area and impacted the oral health outcome and dental service delivery. Aim: To calculate and to analyse the comparison of dental service-unit cost value after the reformation of Indonesian NHI at the urban and rural puskesmas in Padang City, Indonesia. Materials and Methods: Two of 22 total puskesmas were chosen by random sampling, one puskesmas was representative for urban and rural the counterpart. The data was collected, extracted and analysed the database, then interviewed the two administrative officers at each puskesmas. The Activity Based Costing (ABC) method was used to calculate the unit cost of dental healthcare services. Results: Unit cost of dental service in urban puskesmas was IDR 86,652, and rural was IDR 108,721. Rural puskesmas has high total cost and low activity driver. On the other hand, low total cost with high activity driver was found at urban puskesmas. Conclusion: Rural puskesmas has higher unit cost value than urban puskesmas. Hence, it may help the Indonesian government to distribute equal capitation expenditure on dental service at each puskesmas in Indonesia.

Morphometric Study of Foramina Transversaria and the Incidence of Accessory Foramina in Cervical Spine of Indian Population

Monika Gupta, Sneh Agarwal

Introduction: The Foramina Transversaria (FT) are known to exhibit variations in their size, shape and they may be absent or duplicated/triplicated. The deformation of foramina may result in derangement of neurovascular structures passing through these foramina. This necessitates the need of extensive analysis of variation of the foramina. Aim: To present morphometric details of FT of cervical vertebrae as well as incidence of accessory FT in intact cervical spine of Indian population and to make a comparison with previous studies done. Materials and Methods: The study was conducted on 319 FT of 161 dry cervical vertebrae of 23 complete vertebral spines of Indian population (3 FT were absent in 2 C7 vertebrae). For morphometric measurements, transverse and anteroposterior diameters were measured on both sides of all cervical vertebrae using digital vernier calliper. Accessory transverse foramina were also noted and photographed. Mean, range and standard deviation of morphometric measurements of these foramina were analyzed. The comparison was made between their various parameters on right and left side using student’s t-test and p-value. Results: Transverse and anteroposterior diameters were higher on left side than right. Mean value of foramen transversarium of C1 was highest on both sides where as of C7, it was lowest. Forty two cervical vertebrae (26.09%) among 161, showed accessory FT. Here, 25 vertebrae (15.53%) showed unilateral and 17 vertebrae (10.56%) bilateral showed accessory foramen. Accessory foramina were most commonly seen in C6 vertebrae. Two C7 vertebrae showed absence of FT, one bilaterally and one unilaterally. Accessory foramina were always smaller than main foramina transversarium. All accessory foramina were located posterior to main foramina transversarium except in one C4 vertebrae where accessory foramen was present anterior to main foramina transversarium. Conclusion: The present morphometric study done on intact cervical vertebral column demonstrates that different cervical vertebrae (C1-C7) shows considerable variation in terms of their size, shape and number of FT. This detailed report on morphology of cervical vertebrae would be useful for neurosurgeons and will help in better surgical outcome. It would also help radiologist for better understanding.

Prevalence of Iron Deficiency Anaemia and its Associated Factors among Reproductive Age Women in a Rural Area of Karaikal, Puducherry, India

K Mujibur Rahman, K Mohamed Ali, S Vijayalakshmi, S Ramkumar, Gulrukh Hashmi

Introduction: Iron Deficiency Anaemia (IDA) is considered as one of the most common public health problem which affects low, middle and high level countries it also affects all age groups including reproductive age group women. Aim: To find the prevalence of IDA and its associated factors among reproductive age women in a rural area of Karaikal, Puducherry, India. Materials and Methods: A cross-sectional study was conducted in the rural field practice area of Department of Community Medicine, Vinayaka Mission Medical College and Hospital, Karaikal among reproductive age group women from 18 to 45 years residing at Serumavilangai Village, during November 2015 to April 2016. Results: The mean age of the participants was 30.5±5.6 years. The prevalence of anaemia among study participants was 35.9%. Their different levels of severity of anaemia were as follows: 23.6% with mild anaemia, 8.9% with moderate, and 3.4% with severe anaemia. The mean haemoglobin level among the participants was 11.9±3.6 g/dL. Significant association was also found between socio-demographic variables and anaemic status of the reproductive age group women in terms of religion, literacy status, occupation and socio-economic status with p-value <0.01. Conclusion: In the current study anaemia is a major public health problem; coordinated efforts should be paid to control anaemia. Recognised risk factors should be considered in prevention and control strategies of IDA among reproductive age group women in this region.

Efficacy and Safety of High-Flow Nasal Cannula Oxygen Therapy in Moderate and Severe Bronchiolitis

Sunil V Kapur, Jitendra S Oswal, Bhakti Sarangi

Introduction: Heated humidified High-Flow Nasal Cannula therapy (HFNC) is a non-invasive form of oxygen delivery, in which oxygen supports respiration by reducing nasopharyngeal dead space, decreasing airway oedema, enhancing ciliary activity and providing positive airway pressure. Aim: To evaluate efficacy and safety of HFNC oxygen therapy in children with moderate and severe bronchiolitis. Materials and Methods: The present prospective study was carried out in PICU of a tertiary care hospital over a period of 24 months. Twenty two children between the ages of 2 months to 2 years who were previously healthy and diagnosed with moderate and severe bronchiolitis were included. A standard protocol was used for all the children with regards to the initiation, monitoring and weaning from HFNC. Outcome parameters measured were Heart Rate (HR), Respiratory Rate (RR), oxygen saturation (SpO2), Arterial Blood Gases (ABG), hours of therapy, and failure of HFNC oxygen therapy. Parameters were compared using two tailed test. Results: Out of 22 children, 15 were male and 7 were female with M:F ratio 2:1. Eight children had moderate bronchiolitis and 14 children had severe bronchiolitis. The mean age (±SD) was 7.18±4.48 months. The mean baseline HR, RR, SpO2, PaCO2, PaO2 levels were 158.50±35.19 beats/min, 68.64±10.72/min, 88.68±2.12%, 31.23±6.12 mmHg, 122.73±44.94 mmHg respectively. At the end of one hour of HFNC oxygen therapy, mean HR was 151.59±14.61 beats/min, RR 59.32±9.61/min, SpO2 99.59±0.59%, PaCO2 30.99±6.16 mmHg and PaO2 125.71±37.12 mmHg. There was statistically significant improvement (p<0.05) in the work of breathing as indicated by fall in mean HR and RR along with increase in mean SpO2 level after one hour of HFNC oxygen therapy. This improvement was consistently seen till the end of the study. The mean hours for which HFNC oxygen therapy was required was 43.27±16.31 hours. One child failed HFNC oxygen therapy and required invasive ventilation. There were no serious adverse events. Conclusion: HFNC oxygen therapy significantly decreases the work of breathing and improves oxygen saturation in moderate and severe bronchiolitis.

Comparison of Fentanyl and Nalbuphine as an Adjuvant to 0.5% Bupivacaine for Ultrasound Guided Supraclavicular Brachial Plexus Block

Introduction: Supraclavicular brachial plexus block is a commonly used, reliable regional anaesthetic technique for surgery of the upper limb. An adjuvant such as fentanyl/Nalbuphine is used to prolong the effect of bupivacaine. Aim: To evaluate the efficacy of adding fentanyl/nalbuphine as an adjuvant to bupivacaine in Ultrasound (US) guided supraclavicular brachial plexus blockade. Materials and Methods: A total 60 ASA I and II adult patients undergoing upper limb surgeries were randomly allocated to two groups. Group A received 20 mL of 0.5% bupivacaine with 2 mL fentanyl 100 µgm with 10 mL of normal saline and Group B received 20 mL of 0.5% bupivacaine with 2 mL of nalbuphine 20 mg with 10 mL Normal Saline (NS) for supraclavicular brachial plexus blockade. The two groups were compared for the time of onset, duration of sensory and motor blocks, hemodynamic stability, post-operative analgesia and complications. Student’s t-test, chi-square test, and Mann-Whitney U-test were used for statistical analysis. Results: The onset time of sensory block (12.07±1.08 and 8.20±1.32 minutes) and motor block (16.80±1.27 and 14.03±1.22 minutes) were significantly different in between Group A and Group B. The duration of sensory block (466.87±39.84 and 719.23±19.45 minutes) and motor block (16.80±1.27 and 14.03±1.22 minutes) were significantly different in between Group A and Group B. The duration (min.) of analgesia was significantly different between Group A (660.67±31.77) and Group B (836.13±25.74). Conclusion: Nalbuphine 20 mg significantly prolongs the duration of analgesia of supraclavicular brachial plexus block as compared to fentanyl group.

Comparative Evaluation of The Efficacy of Aloe Vera Gel with Milk and Hank’s Balanced Salt Solution in Maintaining the Viability of PDL Cells in Avulsed Teeth

Baren Abraham, Parvathy Kumaran, B R Varma, Arun Mamachan Xavier, Suresh J Kumar

Introduction: Various storage media have been investigated due to their ability to maintain the viability of the Periodontal Ligament (PDL) cells, thus permitting longer extra-alveolar periods prior to replantation of avulsed teeth. Aim: To assess the efficacy of a newer storage medium, Aloe Vera Gel in comparison with milk and Hank’s Balanced Salt Solution (HBSS) in maintaining the viability of PDL cells in simulated avulsed teeth. Materials and Methods: The present in-vitro study was performed on 40 freshly extracted human premolars with intact crown and closed apices, extracted for orthodontic reasons. They were randomly assigned to one of the three storage medium groups (N=10 each) and a positive and negative control (N=5 each). The positive and negative controls corresponded to 0 minute and an eight hours dry time respectively. The teeth in the experimental group were dried at room temperature for 30 minutes followed by 45 minutes immersion in one of the three experimental media. After drying and soaking, the root surface of each tooth was treated with an enzymatic solution containing 1 mL of Collagenase Type II and Dispase Type I in phosphate buffer saline (PBS). The cells were then labelled with 0.4% Trypan blue and counted using a haemocytometer under a light microscope at 10x magnification. Kruskal Wallis H-test was used to analyse the mean difference in the number of viable cells among the five groups. Results: The teeth stored in HBSS demonstrated the highest number of viable PDL cells followed in rank order by milk, positive control, aloe vera and negative control. There was no significant difference in the number of viable PDL cells between HBSS and milk. Conclusion: From the results of the present study it can be concluded that aloe vera may be better than negative control to maintain PDL cell viability but not more than HBSS and milk.

A Study on TRUS-Guided Prostatic Biopsy and its Correlation with Serum PSA, Gleason Score and Grade-Grouping in a Tertiary Care Centre of Eastern India

Gopinath Barui, Manas Talukdar, Tripti Das

Introduction: Adenocarcinoma of the prostate may be clinically suspected based on elevated serum PSA (Prostate Specific Antigen) and/or abnormal digital rectal examination. Serum PSA has been used in prostatic carcinoma screening and for diagnostic, therapeutic and prognostic purposes. Aim: To evaluate the role of serum PSA to differentiate between benign and malignant pathology of prostate diagnosed by Transrectal Ultrasound (TRUS) guided prostatic core biopsy with special emphasis on its correlation with risk stratification based on Gleason score and Grade grouping system. Materials and Methods: Total 45 cases of Prostatic core biopsy specimens of the patients where serum PSA value was known were included in this cross-sectional observational study. Biopsy specimens were processed for routine Haematoxylin-Eosin stain and diagnosed as benign or malignant by histopathological examination along with Gleason score and Grade-Grouping was done. The comparison of PSA value between benign and malignant cases along with its significance of association with higher Grade-Grouping was statistically judged by unpaired t-test. Results: Out of total 45 cases, 23 (51.11%) cases showed presence of adenocarcinoma and rest 22 cases were of benign pathology. Mean PSA value (ng/mL) was significantly higher in malignant cases i.e., 58.47 (±22.191) compared to benign cases i.e., 3.45 (±0.987). However, in malignant cases which have been categorised as low to intermediate risk group (Gleason score <8) and high risk group (Gleason score =8), the mean PSA values (ng/mL) were 58.75 and 58.18 respectively and they were not so statistically significant (p-value=0.95) to differentiate between these two groups. Conclusion: Estimation of serum PSA has got definite significance in differentiating benign cases from malignant cases in prostatic core biopsy specimens (TRUS guided). But in cases of prostate adenocarcinoma while considering the disease stage based on Gleason Score and Grade-grouping, the serum PSA value has got no statistically significant role.

Efficacy of Tongue Brushing and Mouth Rinsing as Adjuvants to Tooth Brushing in Children

Reena Sharma, Ullal Anand Nayak, Prathibha Anand Nayak, Saakshe Wadhwa

Introduction: High prevalence of dental caries in children has led to search simple and easy adjunctive preventive strategies of caries prevention. A plethora of products claim success in reducing cariogenic bacteria there by increasing the available choice for clinician. Aim: The study comparatively evaluated the adjunctive effect of tongue brushing and mouth rinsing in addition to regular tooth brushing on salivary Mutans Streptococci (MS) Colony Forming Units (CFU). Materials and Methods: A total of 48 selected children were randomly assigned to four mouthwash groups: distilled water, chlorhexidine gluconate, HiOra and xylitol. The phase I salivary MS CFU levels were determined at baseline (after oral prophylaxis) and after one week use of mouthwashes. After one-week washout period, the children again underwent oral prophylaxis and second baseline salivary MS CFU levels were estimated. The phase II evaluation (addition of tongue brushing) was carried out for one week, after which the salivary MS CFU levels were again recorded. Paired t-test or Dependent sample t-test was used for intragroup comparison. The intergroup comparison of salivary mutans streptococci was done by Unpaired t-test of Independent sample t-test and then ANOVA followed by Post-hoc Bonferroni test. Results: Inclusion of tongue brushing significantly reduced the salivary MS CFU’s only in the control group (p=0.009) but not in experimental mouthwash groups. Conclusion: Mouth rinsing alone is effective in reducing the salivary MS CFU’s. Performing tongue brushing in addition to mouth rinsing does not significantly reduce MS levels in saliva.

Sex Estimation from Index and Ring Finger Lengths in Turkish Population

Introduction: Sex estimation using unknown fragmented remains is one of the most important supplementaries in forensic identification. If sex cannot be determined by anatomical structures in forensic cases, it is a benefit to use anthropometric methods as a supplement to estimate sex of the individuals. Aim: To evaluate the ability of estimating sex from index and ring finger lengths and their ratios in Turkish adults. Materials and Methods: A cross-sectional study was carried out on 394 adult volunteers (197 males and 197 females) aged between 18-25 years, and were selected from the Karadeniz Technical University, Turkey by stratified randomisation method. The train group comprised of 314 individuals (157 males and 157 females). The reliability of the sex estimation derived models was evaluated in the test group (40 males and 40 females) of same age range. Sex estimation models were developed by using Binary Logistic Regression Analysis. Results: The results indicate that the Index Finger Length (IFL) and Ring Finger Length (RFL) were found to be significantly longer in males than females in both right and left hands (p<0.001). The RRFL and LRFL were found to be longer than RIFL and LIFL among both sexes. The mean values of IFL/RFL ratio were not statistically significant (p>0.05) for both sexes. Bilateral asymmetry was observed in RIFL and LIFL for both sexes (p<0.05). Statistically significant side differences were not observed in RRFL and LRFL for both sexes in train group (p>0.05). Accuracy percentage for models ranged between 70.0% and 75.0% in the test group for both sexes. The most successfully classified sex variable was found to be RIFL (AUC=0.75). Conclusion: The study concluded that sex estimation from the IFL and RFL may be a useful parameter when there is no more reliable sex estimation approach for forensic investigations.

Evaluation of the Quality of the Pregnancy Care from the Perspective of Service Recipients using the SERVQUAL Model

Rahil-Golipour, Golbahar Gaderkhani, Daem Roshani, Roonak Shahoei

Introduction: Now-a-days, pregnancy care is considered as one of the main public health focus. Pregnancy care plays an important role in the health of the mother, the newborn and the family. Therefore, efforts to evaluate the quality of care are necessary for encouraging the policymakers to create an effective program for improving the quality of health services. Aim: To determine the quality of pregnancy care from the perspective of service recipients using the SERVQUAL model in comprehensive health centers of Sanandaj of, Iran in 2018. Materials and Methods: This descriptive-analytic study was conducted on 384 pregnant women who were referred to the comprehensive health centers of Sanandaj for receiving pregnancy care. Population sampling was done based on the classification method. Data collection was performed by the standard SERVQUAL questionnaire, which measures the quality gap in five dimensions of the service (sensibility, reliability, assurance, responsibility, and empathy) using 22 questions. Data were analysed by SPSS-23 software using descriptive statistics, ANOVA, and t-tests. Results: In all five dimensions of the quality of services provided (sensibility, reliability, responsibility, assurance, and empathy), there was a negative quality gap. The highest mean quality gap was in the reliability dimension (-1.84) and the lowest mean gap was seen in the empathy dimension (-1.49). Conclusion: Data analysis showed that in all five dimensions of the quality of services, the expectation level of service recipients was beyond the level of their perceptions, and the quality improvement in the various aspects seems to be necessary.

Factors Associated with Low Muscle Tone and Impact of Common Musculoskeletal Problems on Motor Development in Preterm Infants at One Year of Corrected Age

Srivarsha Teledevara, M Rajeswari, R Siva Kumar, N Udayakumar

Introduction: Structural immaturity of muscular system in Preterm Infants (PTI) results in maturation related hypotonia which is found to be influenced by risk factors present at the time of birth. Low muscle tone can lead to lower extremity malalignment, abnormal positioning and loading resulting in musculoskeletal problems that could have an impact on motor development which is not well established. Aim: This study was carried out to analyse the risk factors associated with low muscle tone in PTI and the impact of common musculoskeletal problems on motor development of PTI at 1 year of corrected age. Materials and Methods: This Cross sectional study was carried out in 36 PTI and 36 Full Term Infants (FTI) who were recruited from Child Development unit and the details of risk factors were obtained from the records. Infants were assessed for muscle tone using Amiel Tison Angles (ATA) and Hyperextension of knee (HEK) was measured using goniometer. Foot prints were obtained and assessed for the level of Pes planus by Foot Arch Index (FAI) and Calcaneovalgus by Staheli index (SI). Peabody Developmental Motor Scale 2 (PDMS 2) was used to evaluate motor development. Backward multiple regression, Chi-square test Pearson’s correlation were used for data analysis. Results: Backward multiple regression analysis showed statistically significant association of Birth weight, Gestational Age, and Apgar score with low muscle tone in PTI (p<0.05). Chi-square test was used to compare the muscle tone of PTI and FTI which showed that ATA of PTI was significantly higher than FTI but within physiological limits (p<0.05). Pearson’s correlation coefficient showed that there is statistically significant positive correlation between muscle tone and musculoskeletal problems and a negative correlation between musculoskeletal problems and Gross Motor Quotient (GMQ) of PDMS 2 in PTI at 1 year of corrected age (p<0.05). Conclusion: Maturation related hypotonia carried during the first year of life brings about musculoskeletal problems which have an impact on motor development in PTI. The result accentuates that clinicians should address the subtle tonal deviations at an early age to prevent musculoskeletal problems and intervene if required when they are affecting the motor development of PTI.

Changes in Central Corneal Thickness with Varying Post-prandial Blood Sugar Levels in Type 2 Diabetics

Introduction: Central Corneal Thickness (CCT) affects measurement of Intraocular Pressure (IOP) using Goldmann Applanation Tonometry (GAT). Variation in CCT with blood sugar levels in diabetics could affect IOP measurement and subsequent glaucoma management. CCT has been described to vary with glycaemic levels in diabetics but variation in CCT in the same individuals with variation in the blood sugar levels has not been adequately described. Aim: To study for changes in CCT in patients with Type 2 Diabetes Mellitus (Ty2DM) during hyperglycaemic blood sugar levels in comparison to euglycaemic blood sugar levels and to look for co-relation if any between changes in blood sugar levels and CCT. Materials and Methods: This was a non-interventional crosssectional observational study. Ty2DM patients with Post-Prandial Blood Sugar (PPBS) ≥200 mg/dL underwent CCT measurements using optical biometry. CCT was re-measured a month later when they returned for repeat PPBS estimations. Those patients achieving PPBS values <200 mg/dL and a minimum drop of 50 mg/dL were included for analysis. CCT at each visit was measured within 30 minutes of blood sugar measurement. Paired t-test was used to compare mean changes in CCT and PPBS levels. Pearson correlation coefficient was used to assess the relationship between CCT and PPBS levels. Results: The mean CCT of 89 Ty2DM patients with PPBS ≥200 mg/dL was 501.38±25.28 µm. When the PPBS reduced to <200 mg/dL, the CCT was 502.20±25.05 µm. The difference was not statistically significant (p=0.167). There was no correlation between change in blood sugar levels and CCT (Pearson’s r=0.148). Conclusion: The present study demonstrated no significant change in CCT with varying blood sugar levels in Ty2DM patients. Therefore, in routine clinical practice, the correction for GAT IOP based on a single CCT measurement on one occasion, does not have to be revised depending on glycaemic control in Type 2 diabetics.

Distribution of ABO and Rh Blood Groups among Patients Admitted to a Gynaecology, Obstetrics and Children Hospital in Konya, Turkey

Nadire Seval Gündem, Erkan Atas

Introduction: ABO and Rh-blood groups vary among different populations in the world. Also, this variability of blood groups has been observed in different geographical regions and populations within a country. Determination of ABO and Rh-blood group distribution in a country plays an important role in blood transfusion and many fields of medicine. Aim: To determine distribution of ABO and Rh-blood groups among patients admitted to gynaecology, obstetrics and children Hospital in Konya, Turkey. Materials and Methods: A total of 30291 patients were included to this retrospective study between September 2015-December 2017 for a period of 27 months. Patients were divided into two major groups according to age. There were 29548 (97.5%) women in the age group of 17-75 and they admitted to gynaecology and obstetrics departments. The number of children in the age group of 0-16 were 743 (2.5%) and they were admitted to paediatrics departments. ABO and Rh-blood group tests were performed by gel centrifugation method on fully automated immunohematology analyser. Data analyses were performed by using chi-Square and Monte Carlo exact test. Results: A Rh-positive had the highest rates (37% and 35.4%) among women and children, respectively and was followed by O Rh-positive (28.4%, 29.8%), B Rh-positive (16.1%, 16.9%) and AB Rh-positive (7.3%, 6.8%). AB Rh-negative had the lowest frequency as its rate was under 1%. The rate of Rh positivity was 89% and that of Rh negativity was found to be 11% in both study groups. Distribution of blood groups according to gender among children population was not found statistically significant (p>0.05). Conclusion: The present results were similar to data obtained from previous studies in Turkey, but indicated a different ABO and Rh-blood group profile compared to many studies worldwide because of genetic and ethnic factors. Authors think the present study will contribute to literature by reporting the knowledge of blood group distribution in different populations and creating a database for blood banks in our country.

Bone Mineral Density among Lean Type II Diabetes Mellitus Patients-A Cross-sectional Comparative Study

Deepak Kumar Garg, Manoj Kumar Dutta

Introduction: In case of diabetes mellitus, the pathological process behind fragility of the bone are complex. This process is found to be mediated by various factors like hyperglycaemia, oxidative stress and the accumulation of products of glycation. Aim: To study bone mineral density in lean diabetics and to compare with normal population. Materials and Methods: The present study was undertaken as a cross-sectional comparative study among 60 participants (30 cases of lean diabetics and 30 normal controls). The convenient sampling technique was done to select study participants and the study was carried out during the period from January 2015 to December 2016. Patients who were already a known case of Type 2 diabetes mellitus or newly diagnosed to have Type 2 diabetes mellitus whose BMI was <18.5 kg/m2 were considered as cases. Chi-square test was used for finding a statistically significant difference in proportions; Independent student t-test was used for finding the statistically significant difference between means; Pearson’s correlation coefficient was estimated for finding linear association between two continuous variables; a p-value <0.05 was considered to be statistically significant. Results: On comparison of cases with controls no statistically significant differences were observed between the two groups in terms of age, waist-hip ratio and BMI (p-value >0.05). Bone mineral density parameters were found to be significantly lower among lean diabetes mellitus patients. HbA1C was found to negatively correlate with that of bone mineral density. Conclusion: Osteopenia and osteoporosis, characterised by low bone mineral density values were found to be highly prevalent among lean diabetics.

Evaluation of Quality Assurance in a New Clinical Chemistry Laboratory by Six Sigma Metrics

Suresh Babu Ganji, Suneetha Revupalli

Introduction: Six sigma is a new tool in quality assurance widely applied in several industrial quality control processes including health care industry, especially in clinical laboratories. Aim: To evaluate retrospectively the quality in a new clinical biochemistry laboratory and to take corrective measures to improve the analytical performance on sigma scale. Materials and Methods: This study was undertaken in a new clinical biochemistry laboratory at a Government tertiary care level hospital for a period of six months from February to July 2018. Imprecision (CV) calculated from the Bio-Rad Internal Quality Controls (IQC) of both normal (L1) and abnormal (L2) levels for 16 most common analytes were run on Beckman Coulter AU5800 analyser and inaccuracy (peer bias) calculated from the Bio-Rad External Quality Assurance Scheme (EQAS). The Allowable Total Error (TEa) values taken from CLIA and Biological Variation (for D BIL) guidelines and authors calculated sigma metrics from the standard sigma equation, S(s)=(TEa-bias)/CV. Windows 7, MS Excel was used for statistical analyses. Results: Authors got a similar sigma value for both the level of controls. Nine parameters out of 16, (albumin, aspartate transaminase, total cholesterol, creatinine, glucose, total protein, urea, phosphorus and calcium) are of sigma metrics =3.0 and 4 parameters (alanine transaminase, alkaline phosphatase, total bilirubin and uric acid) have s =5. Amylase had a s of =5 and only two out of 16 tests (direct bilirubin and HDL-C) achieved a sigma value of 6. Conclusion: Further steps were taken to implement QC strategies to improve the sigma metrics as per Westgard and Cooper guidelines.

Serum Calcium and 25-Hydroxy Vitamin D Level in Normal and Early Onset Pre-eclamptic Pregnant Women: A Study from Indonesia

Introduction: Pre-eclampsia is one of the most common causes of fetomaternal morbidity and mortality worldwide. This disorder is categorised into Early Onset Pre-eclampsia (EOPE) and Late-Onset Pre-eclampsia (LOPE). EOPE is usually accompanied by severe complications for both the mother and fetus, while LOPE is accompanied by relatively mild fetomaternal complications. Although the pathogenesis of EOPE is not yet fully elucidated, recent studies indicate that serum calcium and 25 Hydroxy Vitamin D (25(OH)D) levels may play a role in its pathogenesis. Aim: To find out the relationship of calcium and 25(OH)D serum levels in pregnant women with normal pregnancy and with EOPE in Indonesia. Materials and Methods: This study was a case-control study, conducted in Dr. Soetomo General Hospital from July to October 2017. A total of 36 women with EOPE and 64 women with normal pregnancy were included in this study. Inclusion criteria were pregnant women in 2^nd or 3^rd-trimester with BMI >18 kg/m². Blood sample analysis was done to measure serum calcium and 25(OH)D level. Data were expressed as Mean±Standard Deviation. Data distribution was analysed using Shappiro-Wilk test. Comparison of serum calcium and 25(OH)D level between groups was analysed using Independent t-test. Correlation between serum calcium and 25(OH)D level was analysed using Pearson±s correlation test. The p-value of <0.05 was considered significant. Results: There was a significant difference in serum calcium level between case and control group (8.294±0.725 vs 8.670±0.405 mg/dL; p=0.006). In 25(OH)D level, there was no difference between both groups (16.128±7.5463 vs 17.325±6.4992 ng/mL; p=0.406). No correlation was found between calcium and 25(OH)D level (r=0.165; p=0.101). Conclusion: Calcium deficiency plays a role in the incidence of EOPE among pregnant women in Indonesia. The actual role of calcium deficiency in EOPE needs further investigation.

The Efficacy of Sandostatin (Long Acting Release) on Acromegalic Patients: A Study from Northwest Iran

Introduction: Acromegaly is a clinical syndrome resulting from excessive secretion of growth hormone with the approximate prevalence of six cases per million. Somatostatin agonists are the only drug approved which can actually control, to some extent, the secretion of growth hormone after surgery. Short-acting analogues of these compounds should be taken three times a day which is very undesirable. In contrast, long-acting analogues of somatostatin have the market availability for more than one decade, but Iranian physicians have the drug accessibility only within the last few years. Aim: To determine the effects of long-acting analogue octreotide (Sandostatin Long Acting Release (LAR) on the level of Growth Hormone (GH), Insulin-like Growth Factor 1 (IGF-1) and clinical symptoms in patients with acromegaly in the northwest of Iran. Materials and Methods: The level of GH, IGF-1 and clinical symptoms were evaluated after long-acting analogue Sandostatin LAR administration in 40 acromegalic patients with no surgical history or any remarkable improvement in clinical features and IGF-1/GH levels after surgery, referred to outpatient endocrinology sections, Tabriz University of Medical Sciences were included. The serum level of GH and IGF-1 were evaluated using electro-chemiluminescence system before and after 3, 6 and 12-months of drug administration. Repeated measure test was used for statistical analysis. p<0.05 was considered as statistically significant. Results: Use of Sandostatin LAR showed 72.5% and 27.5% absolute and partial recovery, respectively. Mean level of IGF-1 before and after 3, 6 and 12-months treatment were 654.17±199.12, 423.95±228.94, 356.22±169.53, 296.25±110.6 µg/L, respectively, (p<0.001). Additionally, Mean GH level before and after 3, 6 and 12-months treatment were 31.71±3.03, 10.31±5.23, 7.28±3.11 and 6.77±4.38 µg/L, respectively, (p<0.001). Conclusion: Sandostatin LAR treatment may be an effective and proper method for treatment of GH producing adenoma in patients who are not good candidates for surgery or having high GH/ IGF-1 levels after surgery.

Functional Recovery after Stroke: Role of Irrational Beliefs

Sonal Paliwal, Dipti R Christian

Introduction: Stroke is a disabling condition that affects the physical as well as cognitive areas of functioning. Recovery from a stroke can be interrupted by many factors including psychological. Our beliefs play an important role in determining our perceptions and behaviour and may thereby affect the recovery process. Presence of irrational beliefs can act as a detrimental factor to recovery. Aim: To understand the functional recovery process of brain stroke patients and to examine the effect of irrational beliefs on physical and cognitive functional recovery. Materials and Methods: The present study was conducted on 85 first-ever right-hemispheric patients with 53 males and 32 females. The assessment was done in two phases i.e., Phase I-within 3-10 days of stroke and Phase II- after three months of stroke. Barthel Index (BI), Mini-Mental State Examination (MMSE) and Irrational Beliefs Scale (IBS) were used to assess the patients. Paired t-test and Wilcoxon Signed Rank test were used to find out Phase I and Phase II differences in scores of irrational beliefs, BI, and MMSE variables. Kruskal-Wallis Test was used to find out differences between the functional recovery scores of low, moderate and high groups according to irrational beliefs. Post-hoc analysis with pairwise comparison was done to find out intergroup differences. Results: Significant differences were found in Phase I and Phase II scores of BI (p<0.001) and MMSE areas namely; Orientation (p<0.001), Attention and calculation (p<0.001), Language (p<0.001) and Construction/praxis (p<0.001). According to the level of irrational beliefs, significant differences were found in BI (p<0.001) and Recall (p=0.016). Low-moderate-high group differences of BI were found significant (p<0.001) and on Recall only high-low group difference was found significant (p=0.013). Conclusion: The study highlights the impact of irrational beliefs on the recovery process of stroke patients. The findings indicate the crucial part that psychologists can play in the rehabilitation process of stroke patients.

The Relationship between Location and Size of Nephrolith in the Pelvicalyceal System

Sultan Abdulwadoud Alshoabi

Introduction: Nephrolithiasis is a common health problem worldwide. Both location and size of nephrolith are essential factors in planning of clinical management. Due to lack of previous studies on the relation between the two, the present study was conducted. Aim: To assess the relationship between the size and location of renal stones inside the kidney. Materials and Methods: The study included 284 cases of nephrolithiasis. The location and the largest diameter of nephrolith were determined. Nephrolith was classified according to location as follows: lower calyx, middle calyx, upper calyx, renal pelvis, and Pelviureteric Junction (PUJ). Size of nephrolith was classified into three categories: =10 mm, 11-20 mm and =21 mm stones. Data were analysed using the SPSS program. Analysis of variance (ANOVA) and post-hoc analysis were performed. The results were reported as frequencies and percentages. Results: Among 284 cases, 270 (95.1%) were adults and 194 (68.3%) were males. Majority of the nephrolithiasis were located in the middle calyx (35.9%), followed by the lower calyx (32%), upper calyx (19.7%), renal pelvis (5.6%) and PUJ (6.7%). There was a true association between stone location and size (p<0.001). Stones located in the lower, middle and upper calyces were significantly smaller in size than those in the renal pelvis (p<0.001) and PUJ (p<0.001). Conclusion: There was a true relationship between the location and size of nephrolith in the kidney. Stones in the renal pelvis and PUJ tended to be larger than stones in the calyces.

Effectiveness of Diclofenac Plus Paracetamol for Postoperative Pain Control after Caesarean Delivery: A Randomised Controlled Trial

Siriluk Norsuwan, Patcharin Napamadh, Srisuda Songthamwat, Metha Songthamwat

Introduction: Caesarean delivery is one of the commonest operations. Postoperative pain control is important for a good pregnancy experience. Although, diclofenac and paracetamol are commonly used; data about their effectiveness by the oral route in combination for pain control in the first 24-hours is limited. Aim: To compare the effectiveness of diclofenac plus paracetamol with placebo in pain control after caesarean delivery. Materials and Methods: A double-blind, randomised, placebo-controlled trial was conducted on term singleton 100 pregnant women who underwent caesarean sections under spinal anaesthesia using 0.5% bupivacaine plus morphine. The participants randomly received oral diclofenac 50 mg plus paracetamol 500 mg or placebo at 12-hours postoperative then every eight hours. Both groups received the same regimen of intravenous opioid by Patient Controlled Anaesthesia (PCA). The primary outcome was the comparison of pain score measured by numerical rating scale at 12, 20 and 24-hours postoperative. Secondary, outcomes were the amount of opioid use and adverse effects in both groups. The mean pain scores of both groups and all continuous variables were compared using an unpaired t-test. Chi-square and Fisher-exact tests were used for comparison of all categorical variables. Results: A total of 100 participants were randomly placed, 50 in intervention group and 50 in the control group. The mean pain scores at 20 and 24-hours postoperative were 2.10±1.39 and 1.66±1.33 in the intervention group compared with 2.86±1.60 and 2.92±1.55 in the placebo group. The mean difference was 0.76 at 20 hours (95% CI 0.17 to 1.36, p-value=0.01) and was 1.26 at 24-hours (95% CI 0.69 to 1.83, p-value<0.01). The amount of opioid used was 1.46±2.81 mg in the intervention group and 3.34±4.53 mg in the placebo group (p-value<0.01). The adverse effects, such as nausea, vomiting, were decreased in the intervention group. There was no severe postoperative complication in either group. Conclusion: The addition of diclofenac 50 mg plus paracetamol 500 mg orally provided better pain control with less opioid used in 24-hours after a caesarean delivery compared with intravenous opioid PCA only.

Pedicled Thoracodorsal Artery Perforator Flap to Resurface Locoregional Soft Tissue Defects-A Prospective Study

Prabir Kumar Jash, Mainak Mallik, Santanu Suba

Introduction: Soft tissue defects of different etiopathologies over axilla, breast, upper arm and shoulder entail resurfacing with thin and pliable tissue coverage, with good colour and consistency match and minimum donor site morbidity. Previously Latissimus Dorsi Muscle or Myocutaneous flap (LDMC) were the main option for pedicled tissue transfer to those defects. With evaluation and refinement of the perforator and perforosome concept in reconstructive surgery, the Thoracodorsal Artery Perforator (TDAP) flap has taken up an important role replacing LDMC. Aim: To study the versatility of TDAP in soft tissue defects of different etiopathologies and regions and the post-operative complications. Materials and Methods: A prospective study was conducted on 12 patients (3 males/9 females) with post traumatic or post excisional soft tissue defects in anterior chest wall, breast, neck, axilla and arm with various pathologies over a period of two years. Patients were chosen as per inclusion criteria, informed consents were taken with institutional ethical clearance, pre-operative planning was done, intra-operative and post-operative results were documented and analysed. Results: Out of 12 cases, the recipient sites were breast in 42% cases and axilla in another 42%. Soft tissue defects following post tumour resection constituted 33% of the cases, 84% flaps survived, septocutaneous perforators (58%) were predominant, primary closure of the donor site was successful in 75% of the cases with scar widening of the upper back (donor area) seen as the most common complication in 50% of the cases. Conclusion: TDAP as a pedicled flap is a versatile flap for resurfacing loco-regional soft tissue defects of different etiologies. Also a durable, thin, pliable skin cover is obtained with excellent cosmesis.

Relation of Heavy Metals in Cord and Maternal Blood to Neonatal Anthropometric Indices

Introduction: Heavy metals are environmental pollutants and can cross the placental barriers and affect fetal health and growth. Aim: To estimate serum Cadmium (Cd), Mercury (Hg), Lead (Pb) and Arsenic (As) in pregnant mothers and their newborns and to assess the association between the levels and newborns anthropometric indices. Materials and Methods: This cross-sectional study was conducted on 113 mothers, aged 18 to 40 years and their healthy newborns. Inductively Couples Plasma Mass Spectrometry was used to assess levels of Cd, Hg, Pb and As, in maternal and cord blood serum samples. Correlation analysis was used to elucidate the association of these heavy metals with infant anthropometric parameters. Results: There was a significant, negative association between neonatal serum levels of As and Cd, and the neonatal birth weight (r=-0.336, -0.386; p=0.043, 0.024, respectively). Maternal serum levels of As and Cd also had a significant, negative correlation with the neonatal birth weight (r=-0.382, -0. 372; p=0.041, 0.019, respectively). Significant negative association was found between the gestational age and maternal serum As and Pb (r=-0.368, -0. 316; p=0.042, 0.035, respectively). Conclusion: The current study provides a clinical evidence that the increased maternal exposure to Cd and As has a great burden on fetal growth, as the finding of the present research indicate an inverse correlation between Cd and As exposure and birth weight of newborns. These findings highlight the importance of monitoring populations at risk, and to enhance awareness about the hazards of heavy metals and potential sources of exposure.

Surface Electromyographic Activity of Shoulder Muscles among People with Type 2 Diabetes- A Case-control Study

Surendra Kiran Wani, Rajani Mullerpatan

Introduction: Increased prevalence of shoulder dysfunction among people with diabetes is a recognised source of disability resulting in functional impairments. Metabolic perturbations in diabetes result in glycosylation and microvascular abnormalities in shoulder muscles altering muscle mechanics and activation pattern. Aim: The present study was aimed to evaluate surface electromyographic activity of shoulder muscles among people with diabetes with and without shoulder dysfunction with an objective of suggesting clinical recommendations to maximise shoulder function. Materials and Methods: The present observational, case-control study was conducted over two years from March 2015 to May 2017 at Physiotherapy Department, Sancheti Hospital, Pune, Maharashtra, India. Following Institutional Ethical Committee Approval, surface-Electromyography (EMG) was recorded in 45 patients with diabetes and shoulder dysfunction, 45 patients with diabetes without shoulder dysfunction; within the age group of 40-60 years and 45 healthy aged matched controls. Muscle activity was recorded from pectoralis major, supraspinatus, infraspinatus, upper trapezius, biceps and middle deltoid muscles during Maximal Voluntary Isometric Contraction (MVIC) and various functional tasks after normalisation. Shoulder Pain and Disability Index (SPADI) was used to assess shoulder function and compared among the groups using post-hoc tests. Results: Significant linear decline in muscle activity of pectoralis major (p<0.001), supraspinatus (p<0.001), infraspinatus (p>0.001), upper trapezius (p>0.001), biceps (p<0.001), and deltoid (p<0.001) was noted during MVIC from healthy controls to group of people with diabetes without shoulder dysfunction to the group with shoulder dysfunction (p<0.05). Pectoralis major muscle demonstrated a maximum of almost 41.3% reduction in muscle activity. However, muscle activity did not vary between groups while performing various functional tasks (p>0.05). Post-hoc comparison revealed higher score of SPADI in people with shoulder dysfunction compared to healthy controls (p<0.05). Conclusion: Shoulder muscles demonstrated linear decline in muscle activity from healthy people to patients with diabetes without shoulder dysfunction to people with shoulder dysfunction with maximum affection of pectoralis major muscle. Reduced shoulder muscle activity was reflected in approximately 59% higher SPADI score; suggesting moderate shoulder disability. Hence, it is recommended to commence appropriate prophylactic shoulder muscle strengthening exercise program from the onset of diabetes to maximise shoulder function among people with diabetes.

Short Course Hypofractionated Radiotherapy versus Conventional Radiotherapy for Poor Prognosis Glioblastoma Multiforme: A Randomised Controlled Trial

Sunil Choudhary, Neha Gupta, Punita Lal, Shaleen Kumar

Introduction: Glioblastoma Multiforme (GBM) has a variegated outcome due to several prognostic factors, radiotherapy dose being one of them. Aim: To find whether short course hypofractionated Radiotherapy (RT) in poor prognosis GBM is equivalent to standard 6 weeks of RT, in terms of survival and Quality of Life (QOL). Materials and Methods: Patients of GBM belonging to Radiotherapy Oncology Group Recursive Partitioning Analysis (RTOG RPA) class IV, V and VI were prospectively randomised into study arm (35Gy in 7 fractions over 15 days) and control arm (60Gy in 30 fractions over 6 weeks). A sample size of 40 with 20 patients in each arm was decided. The changes in Karnofsky Performance Status (KPS), Clinical Performance Status (CPS) and Neurological Performance Status (NPS) were noted as an assessment of QOL. Kaplan Meier method was used to analyse the overall survival and progression free survival. Log rank test was used to test the difference between the survival curves. Results: The two arms had similar demographic profile. The survival outcomes were identical for patients in the study arm (median survival 7.2 months) and the control arm (median survival 10.4 months) with log rank p=0.09. Freedom from progression was also identical at a median value of 5.5 months vs. 3.8 months, log rank p=0.34. The two arms had no difference in terms of QOL i.e., KPS, CPS and NPS. Conclusion: Hypofractionated short course RT is equivalent to standard 6 weeks RT for poor prognosis GBM patients both in terms of survival and QOL.

Stroke Volume Variation and Pleth Variability Index- Are They Two Faces of the Same Coin?

Sujatha P Prabhu, Anitha Nileshwar, HM Krishna

Introduction: Fluid requirement in patients undergoing major bowel surgery has been a matter of debate and no consensus has been reached. Stroke Volume Variation (SVV) and Pleth Variability Index (PVI) are dynamic indicators of preload. One is invasive and well established where as the other, is non-invasive and relatively new. Aim: This study was designed to compare SVV and PVI when used simultaneously and continuously in patients undergoing major open abdominal surgery. Materials and Methods: This prospective observational study was conducted on patients undergoing major open abdominal surgery. They were monitored continuously with FloTrac® to measure SVV and Masimo pulse oximeter to measure PVI, along with standard monitoring. Readings of both SVV and PVI were noted at baseline and every 10 minutes thereafter till the end of surgery. SVV was used for clinical decision-making and fluid infusion. The displayed PVI at each of these time points was observed for concurrence between the pair of measurements. Statistical analysis was performed using the SPSS 15.0 software. SVV and PVI measurements were compared by correlation coefficients and Bland-Altman analysis. Interclass correlation coefficients with respect to individual patient data are expressed using R software. Results: A total of 516 pairs of measurements were obtained from 15 patients. The pattern of variation of both SVV and PVI was similar in all patients. Mean PVI reading was ˜2-3% higher than SVV. When individual readings of PVI and SVV were plotted against each other, there was very weak positive correlation (r=0.3742). Bland-Altman plot showed the scatter to be wide, reiterating lack of agreement. The median (IQR) difference between SVV and PVI was -2% (-4 to -1%) but the range was very wide (-18% to 9%). Perfusion Index (PI) was > 0.5 in 95% of all individual readings (490/516). Conclusion: PVI overestimates and is unreliable as an indicator of fluid requirement as compared to SVV. PVI cannot be substituted for SVV in patients undergoing major open abdominal surgery.

Molecular Profile of Emerging Multidrug Resistant Klebsiella pneumoniae Clinical Isolates from Southern India

Introduction: Multidrug Resistance (MDR) in Klebsiella pneumoniae isolates is an increasingly recognised threat to hospital infection control. It is known to produce a wide array of cephalosporinase and carbapenemase enzymes. Aim: This study was done to determine the prevalence of MDR in K. pneumoniae with phenotypic and genotypic characterisation of Extended Spectrum Beta-Lactamase (ESBL), AmpC and carbapenemase mediated resistance mechanisms. Materials and Methods: Out of 562 K. pneumoniae isolates recovered during November 2014 to June 2015 in our tertiary care hospital in Pondicherry, 117 MDR strains were phenotypically analysed for presence of various types of beta lactamases and carbapenemases by ceftazidime-clavulanic acid combined disc test, AmpC disc test, Modified Hodge's test and meropenem-EDTA combined disc test. These isolates were further screened for ESBL (blaCTX-M, blaSHV-1, blaTEM) and Carbapenemase genes (blaNDM-1, blaIMP-1, blaVIM-2, blaSIM-1 and blaKPC) by multiplex PCR. Results: Prevalence of MDR strains of K. pneumoniae was 20.8%. Out of 117 MDR K. pneumoniae, ESBL, AmpC and MBL mediated resistance was identified by phenotypic method in 91, 27 and 16 isolates respectively. Among the ESBL and MBL genes, blaCTX-M (60.6%), blaSHV-1 (69%), blaNDM-1 (33%) and blaIMP-1 (9%) genes were detected. Co-production of multiple enzymes was observed in 32% isolates. Conclusion: Beta-lactam hydrolysing enzymes are prevalent among MDR K. pneumoniae stains in our region. Co-expression of ESBL and MBL genes are found in a large proportion of clinical isolates of K. pneumoniae.

Prevalence and Characteristics of Asymptomatic Bacteriuria among Pregnant Women in Eastern Saudi Arabia

Introduction: Asymptomatic Bacteriuria (ASB) in pregnancy is not an uncommon clinical condition. It could lead to pyelonephritis and adverse obstetric outcomes. Regional and national difference in its prevalence exist, which are shown to be influenced by socio-demographic, medical and obstetric factors. Aim: The study aimed at finding the prevalence of ASB in pregnancy and to identify its characteristics in Eastern Saudi Arabia. An insight into the current extent of this problem was sought to be established. Materials and Methods: A descriptive cross-sectional study was conducted in three hospitals of Al-Ahsa and Al-Khobar cities of Saudi Arabia. Semi-quantitative urine culture was done to identify ASB. Identification of bacterial isolates from urine culture and their antibiotic sensitivity testing was done by VlTEK 2 Compact bacterial identification system for Gram positive cocci and by standard bacteriological methods for Gram negative bacilli. Data was collected through a structured questionnaire. Results: Of the 449 urine samples, 64 (14.25%) grew bacteria in significant counts. Streptococcus agalactiae was the most frequent cause of ASB (32.81%) followed by Escherichia coli (25%). Other common bacterial isolates were: Klebsiella pneumoniae (17.19%), Enterococcus faecalis (12.5%) and Staphylococcus saprophyticus (6.25%). The relatively higher number of women in the age group of 30-34 years (16.67%, p-value: 0.05), in the third trimester of pregnancy (15.47%, p-value: 0.03) and with a history of Urinary Tract Infections (UTI) (18.18%, p-value: 0.03) were found to have ASB. No significant association of ASB was seen with hypertension, diabetes melitus or gestational diabetes. Conclusion: The prevalence of symptomless bacteriuria in pregnancy is relatively higher in Eastern Saudi Arabia. This is a matter of concern as affected women could develop adverse complications later. Relatively greater prevalence of ASB among pregnant women in our study could be attributed to greater number of subjects from public hospitals, presumably belonging to lower strata of society, multiple gravidity and personal hygiene.

Categorical Data Analysis: Fundamentals and Perspective Applications in Health Sciences

Nilima, Veerendra Nayak, Vasudeva Guddattu

This paper introduces the statistical methods for testing differences between paired categorical responses. Application of the independent sample tests while analysing paired data is observed among health science researchers. Four common tests are described in detail for identifying specific differences between pairs of groups. Situation to use each test is discussed in general and in comparison with others. Almost all statistical analysis techniques involve assumptions about the data to be analysed. The paired situation tests including paired t-test and repeated measures analysis of variance requires the distribution of the differences be approximately normal, on the other hand, the unpaired t-test requires an assumption of normality to hold separately for both groups of observations. The data analysis technique also requires an assumption regarding the data generation process. Categorical data analysis approaches provide a series of statistical methods that require limited assumptions on the data. The tests more commonly used are McNemar’s, and Cochran’s Q, while some are not so widely reported, like Stuart Maxwell McNemar’s, and Cochran Mantel Haenszel correlation method.

Feeding Behaviour and its Association with Stress: A Review

Pravallika Pagadala, MS Vinutha Shankar, Karthiyanee Kutty

Feeding behaviour is a complex behaviour in the present daily life which is regulated by many mechanisms. So many factors influence the feeding behaviour, among the most common one, is stress. So in the present review authors tried to explain about feeding behaviour, factors regulating it, stress and its probable causes.

The Role of Optic Disc, Retinal Blood Vessels and Exudates in Detection of Diabetic Retinopathy: A Literature Review

GR Hemalakshmi, D Santhi, NB Prakash

Diabetic Retinopathy (DR) is among the most common disease which leads to the cause of blindness. The abnormality in the anatomic and pathological structure has to be analysed for the prevention of retinal diseases. In this review, the Optic Disc (OD), blood vessels and exudates has been studied. We searched databases like Google scholar, IEEE, Elsevier, Springer and other relevant databases to find literature on segmentation of OD, blood vessels and exudates (Pathology) carried out by the researchers with various image processing algorithms with publicly available datasets such as DRIVE, STARE, DRION, DIARETDB0, DIARETDB1, MESSIDOR, etc. After the wide search, we got 32 articles on the retinal disease DR for review. The search revealed that, exclusively for the retinal disease DR, the detection of abnormality in OD and blood vessels alone never gives fruitful results. Therefore, for patients with the chronic diseases DR, the pathological sign exudates have to be analysed by the radiologists while diagnosing and the patients not falling in the DR group can be diagnosed only with OD and blood vessels. From the review, it was inferred that, the morphological operation based segmentation gains more importance due to its better accuracy rate.

Radiological Features of Thalassaemia-An Update

Thalassaemia is an inherited disorder of haemoglobin synthesis which causes different craniofacial defects. The clinical features results from anaemia and also iron transfusion therapy. This article presents skeletal and non-skeletal radiological features of thalassaemia using conventional and advanced imaging modalities by thorough search of literature which may be useful for clinical diagnosis. A review of radiological features by conventional, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Cone Beam Computed Tomography (CBCT) is compared and presented in this article.

Midwifery Professionalism: An Integrative Review

Zohreh Khakbazan, Abbas Ebadi, Mehrnaz Geranmayeh, Zohre Momenimovahed

Introduction: In the world today, professionalism has a special meaning and significance in various fields of medical science. Although the professional behaviour of students and midwifery professionals is very important, the concept of professionalism in this field is not explained. Aim: The aim of this study was to clarify the concept of professionalism in midwifery and to determine its characteristics. Materials and Methods: The present study was a concept analysis based on the Knafl and Whittemore’s method. Six databases (MEDLINE, Embase, PsycINFO, CINAHL Plus (EBSCO), Web of Science Core Collection (Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan) and Scopus were systematically searched using these keywords: “professional behaviour”, “professionalism”, “professional competence”, “professional conduct”, “professional practice” and “Midwifery”. Qualitative, quantitative, review, mixed method studies in english or persian language with abstracts available, containing the keywords in their title, abstract or keywords and address definition, dimension, and measurement of professionalism in medical sciences and specifically midwifery were included in this study. The articles were synthesised using a content analysis approach. Results: In the initial search, 1983 articles were obtained from six databases and 48 articles were obtained using manual search. After screening of titles and abstracts and removing duplicates, 178 articles were assessed for eligibility and finally, 41 english articles were included in the study. Based on the aggregation of the results from the literature review, three main themes of personal requirements, professional requirements, and intra-professional morality were extracted. Conclusion: The results of present study confirmed the lack of a well-defined definition of professionalism in literature. According to the literature, professionalism in midwifery is a multidimensional concept and the main components of professionalism include personal requirements, professional requirements and intra-professional morality.

Use of Oral Antiseptics and its Association with Cardiovascular Events: Review

Ali Abdulrahman Alsofyani, Bader Ashaq Alotaibi, Hesham Mohamed El-sharkawy

Most nitrates which circulate in the plasma become concentrated in salivary glands and released into saliva. Nitrate molecules are reduced to nitrites via oral facultative anaerobic bacteria. After swallowing, some nitrites are absorbed into the circulating blood and represent one of the sources of vasodilatory Nitric Oxide (NO). It has been recently found that the antiseptic mouth rinse used by healthy individuals for more than one week elevates the blood pressure to some extent and reduces nitrate reduction. In the present review, we discuss the disruption of the nitrate-nitrite-NO pathway after using the antibacterial mouthwashes. Reduction of commensal bacteria by antiseptics prevent endogenously produced nitrates from being recycled to systemic nitrite which has the potential to decrease blood pressure. Thus, it can be concluded that excessive use of oral antiseptic mouthrinses could lead to cardiovascular events particularly in patients with high risk to cardiovascular accidents.

Insidious Role of Diabetes Mellitus on Nerves and Dental Pulp

Saramma Mathew Fenn, Mohan Narayanan, Mathew Jacob

Diabetes Mellitus is a metabolic disorder with deleterious effect on the physiological functioning of body systems. The predisposition of body organs and tissues to infections, nervous and circulatory dysfunction brands this disease with a wide spectrum of clinical manifestations. The present scenario in the management of patients with diabetes has shifted from symptom-specific treatment to a holistic approach in the overall treatment of soft and hard tissue pathologies presented by the disease. A deeper comprehension of the pathogenesis of diabetic complications, both general and local, can serve as an ally in rendering a “tailored” treatment which not only alleviates the symptoms but treats the underlying cause. This article addresses the generalised effect of hyperglycaemia and its insidious but progressive effect on the dental pulp.

The Ethical Principles in Pharmacist-Patient Relationship

Kourosh Delpasand, Leila Afshar, Saeed Nazari Tavakkoli

As the pharmaceutical services are growing these days, author witness an increase in relationship between the pharmacists and patients. So, the legitimacy of their interaction plays an important role. In the present article, in addition to introducing the ethical principles governing the pharmacist-patient interaction, certain ethical challenges associated with these principles are also addressed. These principles have been categorised into six groups based on medical ethics.

The Potential Role of Social Media in Pharmacovigilance in Nepal: Glimpse from a Resource-limited Setting

Sunil Shrestha, Subish Palaian, Bibek Shrestha, KC Santosh, Saval Khanal

Introduction: An ever-increasing trend in the use of social media offers a potential forum for exchanging information in developing countries. Easy access, quick dissemination and widespread use necessitate the incorporation of social media in adverse drug reactions reporting and pharmacovigilance activities. Aim: To highlight the potential role of the use of social media in pharmacovigilance activities in a developing country like Nepal. Materials and Methods: A review of all relevant literature was conducted from scholargoogle and PubMed databases using the search terms ‘Social media’, ‘Pharmacovigilance’, ‘Nepal’, ‘drug safety’, ‘social network’ and ‘adverse drug reaction’. In addition, a general search was conducted in Google search engine using similar terminologies. The identified literature was reviewed by the authors and the most relevant ones within the scope of the topic were included. Results: Social media use is common; the number of social media users is on increasing trend even in developing countries like Nepal. There are some unique scopes of social media in pharmacovigilance, including improving awareness, reporting and signal detection. In resource-limited settings, social media can play a crucial role in disseminating drug safety and related information. Incorporating social media in pharmacovigilance has challenges, particularly the problem associated with the authenticity and validity of information available in social media platform. Conclusion: Social media may have an opportunity in the pharmacovigilance system. However, there is limited evidence about its feasibility and validity. Systematic research should be conducted to investigate the feasibility of using social media for the pharmacovigilance system.

CAD/CAM Prosthetic Options in Rehabilitation of Compromised Ridges with Implants: A Scoping Review

C Kasthuri, Vinod Krishnan, Anna Serene Babu, Arun Keepanasseril

Introduction: Ridges compromised by tumour resection, trauma and severe atrophy are clinically challenging in prosthetic rehabilitation, predominantly owing to increased crown height space that acts as a stress magnifier. The use of Computer Aided Design/Computer Aided Manufacturing (CAD/CAM) in rehabilitating compromised ridges with implants is on the rise. A search of literature revealed few studies that collated the various Computer Aided Design/Computer Aided Manufacturing options available. Aim: The aim of this scoping review was to enumerate the various CAD/CAM prostheses available in rehabilitation of compromised maxilla and mandible with implants. Materials and Methods: A systematic search was conducted in MEDLINE and Embase between 2005 and 2018 for all articles that were published in English satisfying the eligibility criteria of rehabilitation of compromised ridges with implant supported/retained prostheses fabricated using CAD/CAM technology. We also searched Google Scholar and internet for industry brochures. Data was entered into covidence systematic review software for screening and extraction. We included studies that utilised CAD/CAM technology in fabrication of either implant prosthesis or prosthetic components such as frameworks, attachments or suprastructures in patients with compromised ridge. Results: Nineteen studies were included in the review, of which 15 were case reports and 4 were prospective cohort studies. An additional search yielded 4 industrial reports which were included separately. Majority of the studies reported implant-supported fixed prosthesis with CAD CAM milled framework and supra structures as a reliable option in terms of patient satisfaction and functional outcome. Three studies reported implant supported overdentures with bar attachments to compensate for the increased crown height space. Conclusion: This evidence mapping review, hence enumerates the various options and designs of CAD/CAM fabricated implant prostheses available for rehabilitating compromised maxilla and mandible.

Diagnosis and Treatment of Conidiobolomycosis: A Review of 75 Cases from the Indian Subcontinent

Nitin Gupta, Manish Soneja

Introduction: Conidiobolomycosis is a subcutaneous rhinofacialzygomycosis caused by Conidiobolus spp. Its epidemiology in the Indian subcontinent is not well understood. Aim: The aim of this study was epidemiological characterisation of conidiobolomycosis in the Indian subcontinent. Materials and Methods: We conducted a review of literature using the terms “conidiobolomycosis”, “conidiobolus”, “entomophthoramycosis” and “entomophthoromycosis” in the Pubmed database combined with the following: India and publication language (English). Results: A total of 75 cases of conidiobolomycosis were reported from 12 states of India, between October 1966 and December 2017, who presented with centrofacial swelling (males-62, females-13). The mean age of presentation was 35 years. Majority of the patients were immunocompetent with only one patient being immunosuppressed (acute leukaemia). A total of 21 patients were diagnosed only on the basis of culture, while the rest of them were diagnosed either on histopathology alone (n=33) or a combination of histopathology and culture (n=21). Saturated solution of potassium iodide (SSKI) was the most common drug (alone or in combination) used for treatment. Except one mortality, which was unrelated to the disease, all patients (n=56) responded to therapy. Conclusion: Conidiobolomycosis is reported from most parts of the country, primarily in immunocompetent males and has an excellent response to anti-fungals.

Burkholderia Infections in Diabetic Patients Emerging as a Challenge for Physicians: A Case Series

Shubhransu Patro, Sudhansu Sekhar Panda, Debashish Mishra, Sonapuram Keerthi

The genus Burkholderia comprises more than 40 species. Medically important members of this genus are Burkholderia cepacia (B.cepacia), Burkholderia pseudomallei (B.pseudomallei) and Burkholderia mallei (B.mallei). Burkholderia cepacia complex (Bcc) can cause Cepacia syndrome which includes necrotising pneumonia, respiratory failure and bacteremia in Cystic Fibrosis (CF) patients and can be fatal. B.cepacia can be potentially pathogenic in individuals with impaired host defences and can cause pneumonia, bronchiectasis, pyopneumothorax and cavitatory lesions. The clinical manifestations of Melioidosis range from localised infection to overwhelming sepsis and death with Pneumonia being the most common presentation. The most significant risk factor for Melioidosis is diabetes. Musculoskeletal Melioidosis is not common in India even though sporadic cases have been reported mostly involving soft tissues. In the present two cases of Melioidosis in diabetics who presented with septic arthritis treated with surgical debridement followed by antibiotics and two cases of Cepacia syndrome in diabetics whose hospital course was complicated by pneumothorax and Acute Respiratory Distress Syndrome (ARDS). These reports raise the concern regarding the potential severity of Burkholderia infections and prompts early diagnosis by physicians to prevent morbidity and mortality.

Anaplastic Carcinoma Occurring in a Longstanding Multinodular Goitre Diagnosed by FNAC: A Rare Case

Devi Beena

Anaplastic Thyroid Carcinoma (ATC) remains one of the most virulent of all cancers in humans with a survival rate of only 1%. The widespread use of Fine Needle Aspiration Cytology (FNAC) has significantly changed the approach to thyroid nodules and has made it possible to identify such aggressive thyroid neoplasm from aspirated cellular material. ATC can arise from pre-existing well-differentiated thyroid carcinoma. This case is presented due to the rarity of anaplastic carcinoma occurring in Multi-Nodular Goiter (MNG) in an early age group which was diagnosed by FNAC.