Journal of clinical and diagnostic research

Scrub Typhus Meningismus: A Diagnostic Dilemma

Somnath Maitra, Ujjal Kumar Chakravarty, Koushik Ray

Scrub typhus is an acute, febrile infectious illness caused by Orientia tsutsugamushi, an obligate intracellular gram negative bacterium. Serious complications occur in the second week of illness. Absence of eschar indicates a high risk of mortality. An interesting case of meningitis is presented here in a 42-year-old male patient presented with the history of fever and breathlessness for the last seven days and headache, vomiting and disorientation for the last one day. On examination, patient had fever with disorientation and neck rigidity in the initial part of neck flexion in anteroposterior direction only. USG Whole Abdomen revealed hepatosplenomegaly with bilateral mild pleural effusion. Scrub typhus meningismus was diagnosed in the absence of eschar. IgM Scrub typhus antibody was positive by Immunochromatographic method. The importance of the case lies in the fact that since India is endemic for both Tuberculosis (TB) and Scrub typhus; specific tests like IgM antibody and CSF ADA (Adenosine Deaminase) may go a long way in avoiding unnecessary treatment in patients.

Renal Vein Thrombosis in Idiopathic Thrombocytopenic Purpura

Renal Vein Thrombosis (RVT) is thrombotic occlusion of one or both main renal veins, resulting in acute or chronic kidney disease. The clinical presentation of RVT depends on the degree of venous occlusion. Of the various causes of RVT, Idiopathic Thrombocytic Purpura (ITP) is a rare occurrence. Use of thrombopoietin receptor agonists, corticosteroids, or splenectomy for the management of ITP may result in thromboembolism. Here, the present authors report a 23-year-old female with ITP who was on medication for the same (prednisolone 20 mg daily), presented with complaints of severe flank pain; ultrasonogram and CT scan revealed RVT. She was started with anticoagulant therapy but had no improvement, hence, she was planned for nephrectomy. The vein was ligated and divided with removal of the left kidney. Thus, while managing patients with ITP, it is important to consider the risk of thromboembolism.

An Intriguing Case of Infrarenal Aortic Hypoplasia

Dilip Vincent, Rohini Avantsa, Kabekkodu Venkata Tejaswi

Infrarenal aortic hypoplasia is a very rare anomaly of the vascular tree characterised by diffuse stenosis of the infrarenal abdominal aorta. The pathogenesis of this condition seems to be unclear despite the advancements of vascular surgery. In general, the most common presenting symptom is claudication occurring in 3rd to 4th decade of life. Here, a rare and interesting case of infrarenal aortic hypoplasia is reported in a 32 year-old female patient who presented with a history of low backache and bilateral intermittent lower extremity claudication. Using Doppler ultrasonography and computed tomographic angiography, we could demonstrate the abrupt termination of the infrarenal aorta with collateral reformation.

Splenic Abscess with Aortic Thrombosis and Right Renal Artery Thrombosis

Yeshwant Lamture, Aditya Mehta

Splenic abscess is an uncommon condition encountered with an incidence of around 0.1-0.7%. The most common cause of infection of the spleen is usually from the hematogenous route resulting from endocarditis or seeding from sites of infection. Splenic abscess is unusual and mostly involves the splenic vessels. The diagnosis is often missed due to lack of or non-specific clinical symptoms. Authors present a rare case scenario of a 50-year-old female patient who presented with pain in abdomen. On examination, there was tenderness in left hypochondrium region along with splenomegaly. Ultrasonography (USG) abdomen-pelvis revealed splenic abscess. Since patient had raised WBC count and Random Blood Sugar (RBS), she was started on antibiotics and hyperglycaemic management was started. USG guided Percutaneous Drainage (PCD) of the abscess was done. Contrast Enhanced Computed Tomography (CECT) abdomen-pelvis showed splenic abscess with drainage catheter in-situ and thrombosis in abdominal aorta involving the right renal artery causing renal infarcts. Patient’s bilateral lower limb Colour Doppler test revealed decreased arterial flow in right lower limb. Prothrombin time was deranged, thus anti-platelets were started and which was later shifted onto oral anti-coagulant therapy. Successive USGs revealed resolution of the abscess, so PCD was removed. Right kidney showed vascularity and no thrombosis was noted in aorta. Due to singular nature of the splenic abscess and early detection of thrombus on CT scan, the present case responded well to PCD and conservative management, which lead to complete resolution of abscess and prevented the likely complications of thrombosis.

Hallucination with Tapering Dose of Buprenorphine

Poonam Bharti, Tanujveer Singh Chandok, Chahat Sahoonja, Sana Usmani

Opioid dependence is one of the most common types of drug dependence in India which requires pharmacological intervention. Buprenorphine is one of the commonly prescribed drugs in Opioid Substitution Therapy (OST). Few reported cases of buprenorphine induced hallucination but none published cases of hallucination with tapering dose of buprenorphine. This is a unique case of hypnagogic hallucination induced during the initial tapering dose of buprenorphine in a patient of opioid dependence. A 20-year-old boy came for de-addiction therapy with history of opioid use from 4 years, used to have withdrawal symptoms in form of lacrimation, body aches and yawning. All relevant blood investigations were done which were within normal limits; drug urine screening was positive for opioid. MRI head showed normal study. Patient was started with OST (buprenorphine) and showed improvement but on tapering the initial dose, patient started having hallucinations which continued for 2-3 days until started with olanzapine.

Caution in Interpreting Diethylenetriamine Pentaacetic Acid Renal Scan in Renal Failure

Gautamram Choudhary, Himanshu Pandey, Suresh Goyal, Prateek Gupta

Since the invention and use of dynamic radionuclide renal imaging techniques, the diagnosis of urinary tract obstruction has become easier. Amongst this, diuretic renogram using Technetium 99 m Diethylenetriaminepenta-Acetic acid (99 mTc-DTPA) is the most widely used for detecting upper urinary tract obstruction. This is even widely used amongst paediatric population for its higher diagnostic success. But, even these techniques might misdiagnose or may reveal incomplete data of the renal derangement causing increased morbidity and mortality. We present a case of a 34-year-old male with impaired renal function for which DTPA scan was done twice, which revealed partial obstructive nephropathy with hydronephrosis of left kidney. But a retrograde pyelogram was performed which showed complete obstruction at the upper part of the ureteric segments. This required a robot assisted pelvi-ureteric anastomosis to release the hydronephrosis. Here the DTPA scan findings were misleading on both occasions. This does emphasise the need for an array of investigations to evaluate or exclude any clinical suspicion.

Placenta Previa Partial Accreta Managed Successfully with Lower Segment Caesarean and Methotrexate Injection

Gowri Dorairajan, Aghalya Muraliswaran

Placenta accreta is defined as an abnormal trophoblast invasion or pathologic adherence of part or all the placenta into the myometrium of the uterine wall. Patients with complete placental adhesive disorders are more likely to require classical caesarean and insitu hysterectomy or delayed hysterectomy during the postpartum period. The management of partially adhered placenta is controversial. We report a patient who was diagnosed to have partial adherence of the central previa placenta with intrauterine fetal demise. She was successfully managed by lower segment cesarean section after bilateral uterine artery ligation followed by excision of the non-adhered placenta and postoperative methotrexate. The operative and postoperative management is detailed. Lower Segment Caesarean Section (LSCS) and postoperative methotrexate should be considered a feasible and safe option for a woman with partial adhered placenta previa in the set up of a tertiary institute with intensive care unit and blood bank.

Gastric Volvulus with Torsion of Wandering Spleen: A Rare Case of Acute Abdomen

Vijaya L Patil, Prasad Sasnur, Shruti G Sheelin, Nagaraj Biradar

Gastric volvulus with splenic torsion presenting as acute abdomen is a rare entity. Gastric volvulus is characterised by rotation of more than 180° either along long axis (organo-axial) or short axis (mesentrico-axial), resulting in partial or complete obstruction of the gastric lumen. If untreated, it results in strangulation, ischemia, necrosis, and finally gastric perforation with increased mortality. Wandering spleen is also a rare entity characterised by underdevelopment or absence of one or all of the ligaments that hold the spleen in its normal position, which may rarely lead to splenic torsion. It requires urgent diagnosis and treatment to overcome life threatening complications. Here we report a case of a 17-year-old females patient with acute gastric volvulus, presenting with perforative peritonitis with torsion of wandering spleen as seen in Contrast enhanced computed tomography of abdomen which showed pneumoperitoneum, raised left dome of diaphragm with organo-axial gastric volvulus, with non-visualisation of spleen in its normal position with ascites. Upper GI Endoscopy confirmed that visualised part of mucosa to be gangrenous, scope was partially negotiable till fundus. Patient was posted for emergency laparotomy. On laparotomy-spleen was seen anterior to fundus and gangrenous with visible torsion of splenic pedicle.

A Forearm Gossypiboma which Mimicked a Deep Seated Abscess: A Case Report from a Tertiary Care Institute in Eastern Part of India

Sanyal Kumar, Sanjay Kumar Pandey

Gossypiboma is a foreign body that contain non absorbable cotton matrix, retained in tissue after a surgical procedure. 24-year-old male who came to our outpatients department with soft cystic painful swelling over ulnar side of Left forearm having sero-sanguinous discharge for last 6 months. Open reduction and internal fixation was done for fracture distal end radius, 2 years back followed by plate in situ which was removed 6 month back. Radiograph showed soft tissue swelling with healed fracture and multiple screw foot print present over distal end of radius. MRI showed thick calcified abscess, which appear isointense on T1WI and heterogeneous hyper intense on T2WI in intramuscular and intermuscular plane in posterior compartment of right forearm. Incision and drainage was done through open exploration with extraction of retained gauge piece and removal of dead and necrosed tissue. Postoperative period was uneventful and patient was well during 3 month follow-up.

Spontaneous Spleen Rupture: Rare But Not Exceptional

Atef Mejri, Mohamed Firas Ayadi, Khaoula Arfaoui

Spontaneous splenic rupture is a rare life threatening condition that occurs in 0.1% to 0.5% of all the spleen rupture cases. In case of a young patient with no history who consults for acute abdominal pain, the diagnosis of spontaneous spleen rupture is often forgotten or ignored in favour of other more frequent diagnoses. However, it has the highest mortality rate so it should always be kept in mind in front of signs of internal haemorrhage especially if it is associated with haemodynamic instability. Emergency Splenectomy is often performed with good reported outcomes. We present a case of a spontaneous idiopathic splenic rupture, diagnosed early and managed successfully.

Variable Antenatal Sonographic Findings of Thanatophoric Dysplasia- A Case Series

Richa Verma, Navneet Sharma

Thanatophoric dysplasia is a lethal osteochondral dysplasia which occurs sporadically in 1/64,000-100,000 total live births and it is very common of the congenital lethal skeletal dysplasias. It is diagnosed on antenatal ultrasound based of findings of cloverleaf skull, macrocephaly, hydrocephalus, narrow thorax, shortened limbs, thickened subcutaneous tissue of extremities, platyspondyly and polyhydramnios. Two subtypes have been recognised on the basis of presence of bowing of shortened femur and cloverleaf skull. Type I is more frequent than Type II. Autosomal dominant mutations in the fibroblast growth factor Receptor 3 gene result in both subtypes. This condition has characteristic sonographic features that suggest the diagnosis prenatally. It is lethal condition with most neonates being dead within the first few hours or days of life. At present no specific treatment regimen is available. This condition can be diagnosed by ultrasonography in mid gestation scan. So the radiologist should carefully scan the fetus for any features of this entity and proper patient counselling should be done regarding prognosis of fetus and future implications. The present authors report three cases depicting antenatal findings of Thanatophoric dysplasia which include both subtypes. One of the cases includes twin pregnancy with one fetus being normal and another showing sonographic feature of thanatophoric dysplasia.

Testing the Effectiveness of Various in Office Hydrogen Peroxide Based Bleaching Agents: A Case Series Using Split Mouth Design

A large variety of in-office bleaching agents are available in the market, causing confusion among the clinicians about selecting the most effective bleaching agent. The aim of the present study is to assess whether the composition, concentration and therapeutic protocols recommended by the manufacturers have any influence on the effectiveness of bleaching agents through an evaluation of 8 in-office bleaching agents in a case series using split mouth design. In total, 4 patients of the same age (22 years) and teeth colour (A2) were selected as study participants and eight bleaching agents were randomised among them between March and July 2019. Overall, 3 bleaching sessions were performed and the colour obtained was recorded using a digital spectrophotometer (Vita Easy Shade). The colour variation (ΔE) and lightness variation (ΔL) were calculated based on the CIELab system parameters, which is an objective assessment and assigns numerical values for colour variations. Colour measurements were made before and after tooth bleaching sessions. ΔE and ΔL were calculated from the difference between the last assessment and the baseline. Colour measurements were performed on the central portions of the upper central incisors (11 and 21). No colour differences were observed between the hemi-arches of the same patient treated with different bleaching agents. The different bleaching gels did not influence the bleaching result. Thus we conclude that the bleaching effect seemed to be related to the active component (hydrogen peroxide) and was not influenced by the other components of the bleaching gels.

Use of Bubble Gum to Check Border Extensions of the Custom Tray Before Border Molding

Over-extension or under-extension of denture borders leads to loss of retention and to some extent stability of the removable prosthesis which is attributed to mistakes made during the border molding step. To check border extensions of the custom tray before border molding using bubble gum. Bubble gum is softened in warm water and adapted to the borders of the custom tray. The custom tray is inserted into the mouth and the usual functional movements that are done during border molding are done to check any over-extension. This technique is simple, convenient, and bubble gum is easily available

Medical Peer Reviewing: Key Points to Keep in Mind

Kaushik Bharati, Aarti Garg, Sunanda Das

Anecdote from Editors Desk Anecdote 3- Duplication and Theft

Hemant jain, Sunanda Das, Aarti Garg

Locked-in State with Ondine's Curse in a Case of Vertibro Basilar Territory Stroke

Sreekarthik Pratapa, Sourya Acharya, Swapnil Lahole, Amol Andhale

Correspondence- ‘Role of Diffusion Weighted Imaging in Differentiating Benign from Pathological Vertebral Collapse using ADC Values’; Is It Possible to Discriminate Multiple Myeloma with Magnetic Resonance Imaging?

Takahiko Nagamine

Correspondence-Efficacy of Platelet Rich Plasma Via Lumbar Epidural Route in Chronic Prolapsed Intervertebral Disc Patients-A Pilot Study

Nikunj Gupta, Vivek Jha, Gaurav Sharma, Sidharth Sood

Utilisation Pattern, Safety Profile and Cost Analysis of Antimicrobials Prescribed in an Intensive Care Unit of a Teaching Hospital

SJ Sushmita Ann, Reneega Gangadhar, R Priyanga

Introduction: Drug utilisation studies are the corner stone of pharmaco-epidemiology. They give us an overview of the pattern, quality and outcome of drug use, which can help in rationale use of medications. Antimicrobial Agents (AMA) are the frequently utilised drugs in an Intensive Care Unit (ICU) setting because of frequent infection, eventually leading to poor adherence with evidence based guidelines and broad-spectrum antibiotic overuse. There is need to conduct many studies to educate the prescribers, the rational drug therapy for safety and benefit to the patient. Aim: To estimate utilisation and prescribing trends of AMAs in medical (MICU) and to evaluate their safety in respect to the adverse drug reaction and their cost analysis in medical ICU. Materials and Methods: A prospective observational study was conducted on 123 patients during February 2016 to February 2017. The demographic data, disease data, the utilisation of different classes of AMAs as well as individual drugs, their safety and costs were recorded. Their prescribing pattern was assessed using WHO prescribing indicators. Causality of adverse drug reactions assessed using WHO-UMC causality assessment scale. Descriptive statistics was used for data analysis. Results: Prescription with single drug accounted for 34.15% and combination of AMAs was 65.85%. Out of 123 patients admitted in MICU, most common cause was respiratory tract infections (24.39%). Ceftriaxone was the most common single AMA (n=56, 29.95%) prescribed. Ceftriaxone+metronidazole were commonly used combination (n=19, 15.44%). Polypharmacy (7-8) was seen as compared to WHO indicators (2-3). Overuse of injections noticed. Percentage of drugs (30.67%) prescribed by generic name was low. Percentage of drugs from Essential Drug List (EDL) (90.41) was comparable to WHO (80-100). Cost of Betalactams for single day was Rs 14963/-. The causality of Adverse Drug Reaction (ADR) was probable. Conclusion: An increased usage of AMAs were noticed which has led to the high cost of the treatment procedures. Frequent use of newer group of antibiotics was noticed. Data of antimicrobial utilisation pattern are required for planning an antibiotic policy.

Impact of Sense of Coherence on Oral Health Behaviour and Perceived Stress among a Rural Population in South India- An Exploratory Study

Swapna Sarit, Gururaghavendran Rajesh, Monica Eriksson, Mithun Pai

Introduction: Sense of Coherence (SOC) measures a person’s ability to use currently existing life scenarios to overcome the associated problems and cope with life stressors to lead a healthy lifestyle, free from any disease to stay well. It is the central construct of the salutogenic theory put forth by Aaron Antonovsky. Few studies have examined its impact on Oral Health Behaviour (OHB) in adults, especially in the rural Indian context. Aim: To determine the impact of SOC on OHB and perceived stress among adults in rural South India. Materials and Methods: Present study was carried out among 230 adults aged 18 years and above visiting a Primary Health Centre in Ullal, Karnataka. SOC was assessed by employing the SOC-13 scale and perceived stress was assessed by using Perceived Stress Scale (PSS-10). OHB was assessed by a structured, pre-tested, self-administered questionnaire. Information about socio-demographics was also collected. Correlation analysis employed Pearson’s correlation coefficient and multivariate regression analysis was performed with OHB as dependant variable. Results: Education was significantly associated with OHB (r=0.16, p=0.01) and socio-economic status had a significant association with SOC (r=-0.13, p=0.04). OHB was significantly associated with SOC (r=0.31, p<0.001). Stress was also associated with SOC (r=-0.21, p=0.001) and OHB (r=-0.19, p=0.003). Multi-variate regression analysis revealed SOC (OR=1.02, p=0.04, CI 1.01-1.04) and PSS (OR=0.83, p<0.001, CI 0.76-0.91) as significant predictors for OHB. Conclusion: More favourable OHB like twice daily tooth brushing, maintaining adequate oral hygiene and no associated tobacco habits were observed among those with a stronger SOC and less perceived stress. Salutogenic model might have critical implications for OHB in rural India.

Prevalence of Refractive Errors and Colour Blindness in School Going Children of Wardha Tehsil: A Prospective Study

Sana Beg, Sohan Lohiya

Introduction: Subnormal vision in childhood affects performance in school or day to day activity and has a poor effect on the future life of a child. Refractive errors are one of the most common reasons and is the most easily correctable cause of vision loss as the spectacles are inexpensive, non-invasive, and useful. Aim: To determine the Prevalence of Refractive error and Colour Blindness in school going children of Wardha District. Materials and Methods: A Prospective cross-sectional study was conducted in 6 co-educational randomly selected schools of Wardha. History taking, torchlight examination was performed followed by recording of visual aquity by Snellen’s chart and colour vision by Ishihara 38 plate edition. Children with visual acquity less than 6/9 were dilated using 2% homatropine eye drops, complete mydriasis was achieved following which retinoscopy was done. The Statistical analysis was performed by using “descriptive and inferential statistics” using “chi-square test” and software used in the analysis were “SPSS 24.0 version” and “GraphPad Prism 7.0 version” and the p-value of <0.05 was considered as significant. Results: Children in the study group were in the range of twelve to fifteen years. About 55.49 percent of the children were males in the study group, 88.67% belonged to upper high socioeconomic status. Only 18.61% of children had a refractive error. Prevalence of myopia was 59.01% followed by astigmatism (26.71%), and hypermetropia (14.29%). The number of cases of refractive errors increased with advancing age. There was no significant association between gender and refractive error. About 60.87% of the children with refractive errors complained of blurring of vision and 28.57% complained of headache. A total of 85.75% of the children with refractive errors in present study were not wearing spectacles. It was observed that 1.62% had colour blindness. Among protans, 1.045% were male, and 0.35% were females. Among deutans 0.23% were male children. Conclusion: Inspite of refractive error being reversible cause of blindness, we see that uncorrected refractive error is still rampant, even in areas with families of good socio-economic status. This is alarming and it highlights the need to strengthen the existing screening programs.

Entrance Skin Dose Measurement for Diagnostic Spinal Radiographic Examinations in King Khalid Hospital, Saudi Arabia: A Prospective Study

Yousif Mohamed Abdallah, Nouf Hussain Abuhadi

Introduction: Radiographic examinations has necessary role in the identification of spine injuries and pathologies. There are many hazards associated with the radiation exposure which included the acute (radiation injury) and chronic exposure effects (cancer). Aim: To measure the entrance skin dose of spine vertebra (cervical, thoracic, lumbar and sacral) in AP and Lateral Views. Materials and Methods: A prospective study was conducted with a sample of 250 adults and 100 paediatrics patients. The imaging apparatus, which was used in this study was Siemens with pipe Filtration 2.0-3.0 mm of AL/70 KVp. The parameters of patients collected were patients’ characteristics and exposure factors. The dose was measured using Entrance Skin Dose (ESD) and International Atomic Energy Agency (IAEA) formula and compared nationally and internationally. Results: The measured exposure parameters were 78.1±5.7 and 19.9±7.8 for the machine kVp and mAs, respectively. The measured ESD dose for cervical, thoracic, Lumbosacral (AP and LAT.) and sacral (AP) for adult population were 0.11±0.06 mGy and 0.15±0.07 mGy, (0.86±0.06 and 0.91±0.09 mGy, 0.88±0.07 and 0.92±0.09 mGy and 0.25±0.04 mGy, respectively. Similarly, measured ESD dose for cervical, thoracic, Lumbosacral (AP and LAT.) and sacral (AP) for paediatrics population were 0.09±0.01 mGy and 0.12±0.07 mGy, 0.32±0.03 mGy and 0.42±0.06 mGy, 0.38±0.06 and 0.74±0.08 mGy and 0.09±0.01, respectively. Conclusion: The results of the study were within the range of permissible dose of the spine vertebrae dose (4.0-30.0 mGy). More studies are recommended to study radiation dose of the spine vertebrae with large patients’ data and more than one modalities to compare.

Pre-Eclampsia: Epidemiology and Renal Biomarkers at Brazzaville University Hospital

Introduction: Renal function exhibits physiological changes during the gestational period such as increased renal blood flow and glomerular filtration. These effect certain renal biomarkers whose normal and abnormal nature is necessary to be apprehended. Aim: To analyse the epidemiological characteristics and renal biomarkers during Pre-Eclampsia (PE) at the Brazzaville University Hospital. Materials and Methods: A case-control study was conducted at the Brazzaville University Hospital from 1 June to 30 November 2018, comparing PE and non-hypertensive gestates according to the ratio of one case for two controls. Assays for renal biomarkers were performed spectrophotometrically and potentiometrically. The variables studied were epidemiological, clinical, and renal biomarkers including creatinine, creatinine clearance, uraemia, serum uric acid, 24-hour creatinine, 24-hour proteinuria, sodium, chloride, and potassium. The tests of t-student and Mann Whitney were used respectively for the comparison of means and medians. The p-value of the probability was considered significant for a value less than 5%. A multivariate analysis was performed to eliminate confusion bias. Results: PE were not different from controls with respect to median age {31.5 years (23-39.5) vs. 28 years (23.5-32), p>0.05}; parity {1.5 (1.5-2.5) vs. 1.5 (1.5-2), p>0.05} and the term of pregnancy (32.2±2.8SA vs. 32.1±2.7SA, p>0.05). Diuresis was lower in the cases (852.5 mL vs. 1365 mL, p<0.05). In bivariate analysis, renal markers associated with pre-eclampsia were serum creatinine (81.5 µmol/L vs. 56.5 µmol/L, p<0.05), creatinine clearance (91.8 mL/min vs. 140, 1 mL/min, p<0.05), serum uric acid (408 µmol/L vs. 250.5 µmol/L, p<0.05), and hypocreatinuria (p<0.05). The concentrations of azotaemia and electrolytes were not different from those of the controls. After logistic regression, the renal biomarkers retained were hypocreatinuria (p<0.05) and hyperuricaemia (p<0.05). Renal biomarkers were not influenced by age, parity, and the term of pregnancy (p<0.05). Conclusion: Although having identical epidemiological characteristics, creatinuria and serum uraemia are significantly disturbed in pre-eclamptic patients. A subsequent multi-center study integrating multi-organ recall would clarify their prognostic value as well as the biological profile of PE in Brazzaville.

Evaluation of Reliability of Tissue Specimens over Wound Swabs in Diagnosis of Orthopaedic Implant Related Infections

Syeda Saba Hashmiya, Kanne Padmaja, Sukanya Sudhaharan, Vijay Dharma Teja

Introduction: Postoperative infections in orthopaedic implants is a major concerning factor. It can lead to the failure of implants and in severe cases can even lead to amputation and mortality. Total joint replacements and fracture fixations do help by reducing the agony of many patients but postoperative infections are a detrimental complication. It is an economic disaster for hospitals that treat large number of these patients therefore identification of risk factors, common pathogens involved, early initiation and prompt use of empirical therapy is necessary to prevent implant failures and also collection of deep tissue samples improves the diagnostic reliability and microbiological yield of implant related infections. Hence, appropriate collection of specimens is a key factor for early diagnosis and differentiating colonisers from true pathogens. Aim: To evaluate the rate of implant related infections, sensitivity of Gram’s stain and its accuracy in tissue samples over wound swabs and also to determine the trends in the antibiogram. Materials and Methods: A retrospective analysis was performed from the samples (tissues and wound swabs) received to the Department of Microbiology from October 1st 2017-October 30th 2018 (a period of one year) in patients with orthopaedic implants. Identification and susceptibility patterns of the bacterial pathogens were identified by the automated Vitek 2 compact system (biomeriux). The data was analysed in terms of frequency and percentage. Results: A total of 141 cases were analysed out of which 45.3% (64/141) were tissue samples and 54.6% (77/141) were wound swabs. Culture positivity observed in tissues was 43.7% (28/64), in wound swabs 50.6% (39/77) and mixed infections were observed in 7.14% (2/28) of tissues and 5.12% (2/39) of wound swabs. Colonisers were observed in 14.2% (11/77) of wound swabs. Specificity of Gram’s stain in comparison with tissue cultures was found to be 83.3% and sensitivity was 50%. Methicillin Sensitive Staphylococcus aureus (MSSA) 17.8% (05/28) and Escherichia coli 21.4% (6/28) were the major pathogens isolated from tissue cultures. Methicillin Resistant Staphylococcus aureus (MRSA) was isolated from 33.3% (13/39) of wound swabs followed by Escherichia coli (28.2%) (11/39). In the present study 25% (7/28) of tissue isolates showed Multidrug Resistance (MDR) and 3.5% (1/28) were Extended Spectrum Beta Lactamase (ESBL) producers. Among wound swabs 23% (9/39) isolates were MDR and 10.2% (4/39) were ESBL producers. Conclusion: In the present study it was observed that tissue samples were found to be better specimens in comparison with wound swabs for the diagnosis of implant infections. Hence, appropriate collection of sample helps in accurate isolation of pathogens in implant infections.

Prevalence and Treatment Need of Molar Incisor Hypomineralisation in 8-12 Year Old School Going Children of Cuttack, Odisha

Prayas Ray, Utkal K Mohanty, Debashish Sethi, Manoranjan Mahakur, Gaurav Sharma

Introduction: Molar Incisor Hypomineralisation (MIH) is a condition where one or more first permanent molars with or without permanent incisors are hypomineralised due to disturbances during the maturation phase. Aim: To determine the prevalence, severity and treatment need of MIH among 8-12-year-old school-going children in Cuttack, Odisha. Materials and Methods: A cross-sectional epidemiological survey was conducted, including 1525 students, using diagnostic criteria established by the European Academy of Paediatric Dentistry (EAPD) 2003. Two calibrated examiners examined the children using artificial light. A descriptive analysis of the prevalence and distribution of the clinical recordings was performed using the Statistical Package for Social Sciences, version 17.0 (SPSS Inc., Chicago, IL, USA). Results: A total of 87 children (5.7%) were found to have MIH. Boys showed higher prevalence (57.4%) compared to girls (42.4%). Mandibular molars and maxillary incisors were found to be affected more frequently compared to other teeth. Conclusion: MIH is more prevalent in boys than girls and mandibular molars are affected more frequently than maxillary molars. Hypomineralised molars are more susceptible towards developing dental caries than molars which are not affected by the condition. Molars affected by this condition need wide spectrum of treatment ranging from preventive care, pit and fissure sealant application, restoration, pulp therapy and extraction. Early intervention of these teeth can reduce the complications and expenses incurred towards dental treatment.

Value of Enhancer of Zeste Homolog 2 (EZH2) for Determining Prognosis in Colon Cancer

Introduction: It has been reported that Enhancer of Zeste Homolog 2 (EZH2) enhancer is expressed in Colorectal Cancer (CRC), but there are only limited findings of its overexpression with prognosis in CRC. Aim: To investigate the association between EZH2 expression and clinicopathologic variables and outcome in CRC. Materials and Methods: This retrospective study retrieved the archived histological samples for immunohistochemistry evaluation of EZH2 and PCR analysis of KRAS from patients with CRC who were followed-up between April 2009 to June 2019. Kaplan-Meier methods were used for Overall Survival (OS) and Disease-Free Survival (DFS). Cox proportional hazard model and time dependent Cox model were used to evaluating association of clinicopathologic factors with OS and DFS. Results: Hundred patients with CRC were included with mean age and range 57.39±13.52 years and 21-83 years respectively. There were no significant association between OS (log-rank p-value=0.50) and DFS (log-rank p-value=0.74) with EZH2 expression. Third quartile of OS was 30.7 days and for DFS was 107.83 days. According to the result of multivariate cox regression after adjusting for confounding variables, there was no significant association between EZH2 and OS (HR =1.53, 95% CI=0.63-3.72, p=0.35). Also, a borderline association was observed between EZH2 and DFS (HR=11.08, 95% CI=1.02-119.72, p=0.05). There were no significant associations between the DFS, OS and other clinicopathologic parameters except for the stage, respectively (HR=3.51, 95% CI=1.71-7.20, p=0.001) (HR=3.55, 95% CI=1.71-7.35, p=0.001). Conclusion: The expression of EZH2 in patients with CRC was not associated with clinical features, and does not appear to be associated with OS or DFS. EZH2 is an attractive target in cancer and much more research is clearly warranted.

Efficacy of Carica Papaya Leaf Extract in Reducing Treatment-Delay Secondary to Chemotherapy induced Thrombocytopenia

Priyanka Sreelatha, Wesley Mannirathil Jose

Introduction: Chemotherapy Induced Thrombocytopenia (CIT) is a common problem in clinical oncology. It leads to delay in administration of chemotherapy resulting in inferior outcomes. Timely administration of chemotherapy is necessary to ensure maximal benefits to the patient. Aim: This study was carried out to assess the efficacy of Carica Papaya Leaf Extract (CPLE) in reducing the delay in administration of chemotherapy. Materials and Methods: This was a retrospective single centre study conducted at Amrita Institute of Medical Sciences, Kochi, Kerala from July to December 2018. Fifty events of chemotherapy induced thrombocytopenia in forty five patients with proven malignancy were assessed for therapeutic response to standard doses of CPLE. Wilcoxon signed rank test and Karl Pearson’s correlation coefficient was applied to test the statistical significance in mean values from baseline to follow-up period and to obtain correlation between continuous variables respectively. Results: There was a significant improvement in the platelet count in 54% (n=27) patients within 5 days and another 16% (n=8) by 7 days of CPLE administration. The 18% (n=9) patients took longer than one week to recover their platelet counts. The 12% (n=6) patients had deteriorating platelet counts even after CPLE intervention, one among them mandating platelets transfusion. The results suggest that use of CPLE may help mitigate the treatment delay in majority of patients with chemotherapy induced thrombocytopenia and should be considered as an option to prevent anti-neoplastic treatment delay.

Role of p16 Immunohistochemistry in Cervical Intraepithelial Neoplasia

Nicholas Joseph Dcunha, Medha Khandekar, Shaila Puranik

Introduction: p16 or p16/INK4a is a Cyclin Dependant Kinase Inhibitor 2 (CDKN2) and is upregulated in HPV-related lesions. Therefore, p16 can be considered an indirect marker for altered HR-HPV and growth cycle transformation. Aim: To study p16 Immunohistochemistry (IHC) in spectrum of Cervical Intraepithelial Neoplasia (CIN) and access the possible utility of p16 IHC in differentiating Low grade Squamous Intraepithelial Lesions (CIN1/L-SIL) from High Grade Lesions (CIN2,3/H-SIL). Materials and Methods: Retrospective Hospital Based study of 50 consecutive biopsies with CIN changes was conducted from January 2016 to March 2017. Routine Hematoxylin and Eosin (H&E) and IHC with p16 was performed. p16 IHC was scored according to a scoring system by a previous study. HPV status wherever present was correlated. Statistical analysis was done using SPSS 18.0 software and Fisher’s-exact test was used for comparison between p16 IHC and CIN. Association of p16 IHC and HPV DNA was calculated using the Phi co-efficient test. Results: The age range of CIN cases was 24-50 years and mean age was 35.9 years. The percentage of p16 positive cells, the intensity of IHC reaction, cellular reaction pattern and p16 IHC positivity, all increased with increasing grades of dysplasia. The use of p16 was statistically significant to differentiate between CIN1/L-SIL and CIN2, 3/H-SIL but not between CIN2 and CIN3. In p16 IHC intracellular pattern, weak cytoplasmic positivity of p16 was seen in L-SIL while strong cytoplasmic positivity was seen in H-SIL cases. High risk HPV positivity increased with increase in grade of dysplasia. Conclusion: p16 can be used as an adjunct to histopathology and will definitely improve reporting of grades of CIN.

Study of Oxidative Stress and One Carbon Metabolism in Prostate Neoplasm in a Tertiary Care Hospital

Sovan Sannigrahi, Dilip Kumar Pal, Mousumi Mukhopadhyay

Introduction: Prostate neoplasm is a major health problem globally since last two decades. Among the contributory factors in aetiopathogenesis, oxidative stress and one carbon metabolism are also important. Aim: To compare the serum level of vitamin B12, homocysteine and Malondialdehyde (MDA) between prostate cancer, Benign Prostatic Hyperplasia (BPH) and control subjects to find out the status of oxidative stress and one carbon metabolism in prostate tumours. Materials and Methods: Forty patients each with BPH and Prostate cancer along with 40 age matched healthy controls were selected in an observational cross-sectional study, attending the outpatient and inpatient Department of Urology, IPGME&R, Kolkata, West Bengal, India, as per predetermined inclusion and exclusion criteria. Oxidative stress for these patients was estimated by measuring lipid peroxidation product MDA by Thiobarbituric Acid Reactive Substances (TBARS) assay with spectrophotometer. Vitamin B12 and homocysteine were also analysed as a marker of one carbon metabolism by chemiluminescent method. Biochemical parameters such as fasting and post prandial blood sugar, urea, creatinine and liver function tests were measured by autoanalyser to rule out diabetes and any underlying hepatic and renal pathology. All the data were then analysed using statistical software SPSS version 24. The groups were compared using student’s unpaired t-test and Pearson’s correlation coefficient was applied to observe the correlation between variables. Results: A statistically significant rise of oxidative stress was found in BPH and prostate cancer cases compared to age matched control. Regarding one carbon metabolism, this study fails to demonstrate any statistically significant difference of Vitamin B12 level between BPH and control as well as between prostate cancer and control group. However, high serum homocysteine is associated with both BPH and prostate cancer compared to controls. Conclusion: In the present study, statistically significant increase in oxidative stress and serum homocysteine level and no difference of serum vitamin B12 was found in BPH and prostate cancer cases compared to control group. Longitudinal studies are however required to establish any relationship and to investigate the potential role of homocysteine as a novel tumour marker.

To Assess the Quality of Life in Patients with Benign Prostate Hyperplasia (BPH) Based on Urinary Symptoms

Divmehar Kaur, Harpreet Kaur Massaon, Harjinder Singh, Maninder Kaur

Since the invention and use of dynamic radionuclide renal imaging techniques, the diagnosis of urinary tract obstruction has become easier. Amongst this, diuretic renogram using Technetium 99 m Diethylenetriaminepenta-Acetic acid (99 mTc-DTPA) is the most widely used for detecting upper urinary tract obstruction. This is even widely used amongst paediatric population for its higher diagnostic success. But, even these techniques might misdiagnose or may reveal incomplete data of the renal derangement causing increased morbidity and mortality. We present a case of a 34-year-old male patient with impaired renal function for which DTPA scan was done twice, which revealed partial obstructive nephropathy with hydronephrosis of left kidney. But a retrograde pyelogram was performed which showed complete obstruction at the upper part of the ureteric segments. This required a robot assisted pelvi-ureteric anastomosis to release the hydronephrosis. Here the DTPA scan findings were misleading on both occasions. This does emphasise the need for an array of investigations to evaluate or exclude any clinical suspicion.

Comparison of Efficacy of Slit Skin Smear and Fite Faraco Stain on Histopathology Specimens in Cases of Leprosy

Introduction: Hansen’s disease is an infectious granulomatous disorder with Mycobacterium leprae being the causative agent. Mycobacterium Leprae is an acid-fast bacillus which grows slowly inside host cells mainly neural Schwann cell as well as cutaneous macrophages. Aim: To study the efficacy of Slit Skin Smear (SSS) and Fite Faraco stain on histopathology for diagnosis in leprosy. Materials and Methods: The present cross-sectional study carried out on patients clinically diagnosed as Leprosy attending dermatology OPD in AVBRH, Sawangi, Wardha, Maharashtra, India from sepetember 2017 to August 2019. A total of 88 patients who gave informed consent to participate in study and their clinical features were recorded including number, size and location of lesions and loss of sensation. Any contiguous cutaneous nerve or peripheral nerve trunk enlargement was noted and were classified according to the Ridley-Jopling Classification. SSS and Fite Faraco stain on histopathology specimens was done. The quantitative variables were compared using Kruskal Wallis Test and qualitative variables were correlated using Chi-square test/Fisher’s-Exact test. Results: Out of 88 (n=88) clinically diagnosed leprosy cases enrolled in this study, 2, 17, 15, 6, 20, 25 and 3 cases were diagnosed as indeterminate, Tuberculoid Leprosy (TT), Borderline Tuberculoid Leprosy (BT), Mid Borderline leprosy (BB), Borderline Lepromatous Leprosy (BL), Lepromatous Leprosy (LL) and pure neural leprosy, respectively. Mycobacterium leprae detection by SSS was possible in 21.59% cases while detection by Fite Faraco staining on tissues sections was possible in 11.36% cases. There were 10 (11.36%) cases in which Mycobacterium leprae was detected by SSS but not by Fite Faraco, while in 7 (7.95%) cases. Mycobacterium leprae was detected by Fite Faraco staining but not by slit skin smear microscopy. The difference in detection by the two methods was found statistically significant with p-value 0.002. On comparison-slit skin smear had sensitivity of 26.47% whereas Fite Faraco had 23.53%. The specificity Fite faraco staining was 100% while that of SSS was found to be 95%. Conclusion: On comparison of efficacy of SSS and Fite faraco staining on tissue sections, SSS had the highest detection rate and sensitivity in diagnosing leprosy whereas Fite Faraco was found to be more specific.

Safety and Efficacy of Almagate and Simethicone Combination in Symptomatic Management of GERD: Post-marketing Observational TRIALMA Study

Introduction: Gastroesophageal Reflux Disease (GERD) is one of the most common conditions worldwide with a significant impact on quality of life. Almagate and simethicone act as antacid and antiflatulent agents, respectively and aid in relief of GERD symptoms. Aim: To evaluate the safety and efficacy of almagate and simethicone combination in symptomatic management of GERD. Materials and Methods: A prospective, post-marketing observational, multicenter study was conducted between January 2019 and May 2019. Patients aged between 18 and 65 years, with uncomplicated symptomatic GERD, frequent episodes of heartburn, regurgitation or dyspepsia symptoms, and those who required add-on antacid therapy were included. Patients received a suspension of almagate plus simethicone during their initial visit (5-10 mL thrice-a-day for 15 days). The intensity of heartburn, regurgitation, and dyspepsia was recorded using visual analog scale of 0 (no symptoms) to 10 (severe symptoms) at baseline and after 15 days. Overall, patient satisfaction score (0-5) was assessed and adverse events were recorded. Descriptive statistics and Mann-whitney U test was used for statistical analysis. Results: Out of the 1812 patients enrolled in the study, 1767 patients continued and completed the 15-day treatment. The mean age of patients was 43.59 years {male: 793 (44.9%); female: 974 (55.1%)}. The mean symptoms score for heartburn, regurgitation, and dyspepsia was significantly reduced after treatment compared with baseline (p<0.01). Post-treatment, around half of the patients (46%) had an overall satisfaction score of 4 followed by a satisfaction score of 5 (43%) and 3 (11%). The mean overall satisfaction score was 4.31 and 38 patients (2.15%) reported adverse events. All the adverse events were mild and were resolved within a week. Conclusion: The combination of almagate and simethicone was efficacious in relieving severe symptoms of heartburn, regurgitation, and dyspepsia and was well tolerated in patients with symptomatic GERD.

Utility of Lemon Solution Rehydration Technique for Processing Haemorrhagic Cytology Samples: A Comparative Study using Different Techniques

BN Kumarguru, G Karthik, M Udaya Kumar, R Prashanth, P Janakiraman

Introduction: Haemorrhagic fluids samples are commonly received for cytological evaluation. The presence of erythrocytes obscures the morphology of cells and thus poses great diagnostic difficulty. Haemorrhagic body fluids are processed by using a variety of techniques. The idea of each technique is to select and concentrate an adequate number of tumor cells having intact cell morphologies, without losing the diagnostically important cells during processing. Aim: To evaluate the effect of known haemolysing solutions [Carnoy’s Fixative (CF) and normal saline {Normal Saline Rehydration Technique (NSRT)}] and 10% lemon solution {Lemon Solution Rehydration Technique (LSRT)} on haemorrhagic cytology samples; and to compare various cytomorphological features in haemorrhagic cytology samples processed by different haemolysing solutions. Materials and Methods: It was an analytical study done at a rural tertiary care referral institute, PES Institute of Medical Sciences and Research (PESIMSR), Kuppam, Andhra Pradesh, India. Fifty-seven haemorrhagic samples were analysed. For each case, totally eight smears were prepared. Out of eight smears, two smears served as control (not treated with any haemolysing agent. Remaining six smears (two smears each) were treated with haemolysing agents (CF, normal saline and 10% lemon solution). Smears stained with Haematoxylin and Eosin (H&E) and May-Grunwald Geimsa (MGG) stains were evaluated for haemolysis in the smear background, retention of cells and cytomorphological details in comparison with control smears. Each smear were scored (1-4) according to a modified scoring system. Chi-square test was the statistical tool used to analyse the data in the study. Results: MGG stained smears showed best haemolysing effect with NSRT (78.95%), maximum retention with LSRT (85.96%) and best cytomorphological details with CF (12.28%). H&E stained smears showed best haemolytic effect with LSRT (56.14%), maximum retention with LSRT (87.72%) and best cytomorphological details with CF (8.77%). Conclusion: LSRT is a novel rehydration technique developed to improve the quality of processing haemorrhagic cytology samples. LSRT showed best overall performance and it may be utilised to overcome the disadvantages of CF and NSRT.

A Novel Basic Oral Rinse Assay for Monitoring of Disease Activity in Chronic Periodontitis Patients: A Case Control Study

Veenu Madaan Hans, Arshiya Goswamy, Mayank Hans

Introduction: The migration of neutrophils into gingival crevice is the first line of defence against the subgingival plaque. Although neutrophils are mandatory for maintaining health of the periodontium, their excess also seems to be detrimental. Excess of neutrophils within the periodontal tissues leads to tissue destruction. Aim: To develop a simple, economical non-invasive oral rinse assay to assess oral inflammatory load and to find a correlation between Oral Inflammatory Load (OIL) and periodontal disease activity and severity. Materials and Methods: In this case control study fifty subjects were enrolled in two different groups: Chronic Periodontitis (CP) and Periodontally Healthy (PH). Pocket Probing Depth (PD), Clinical Attachment Loss (CAL) and Bleeding On Probing (BOP) were assessed on six sites per tooth. Saliva expectorate was collected, processed and stained with Methylene blue. Oral Neutrophil Count (ONC) was made under 40x magnification of a light microscope. Demographic and clinical characteristics of the two groups were compared using unpaired t-test while the statistical difference between the two rinses in the same subject was assessed via paired t-test. Spearman’s correlation coefficient was applied to assess the association between log transformed neutrophils and clinical parameters. Results: All the clinical parameters were significantly increased in CP Group compared to the PH group (p<0.001). On comparing, ONC count was significantly higher in the CP group compared to PH group (p<0.001). Spearman’s co-relation showed a highly significant, positive correlation between ONC and all clinical parameters (p<0.001). Conclusion: ONC increases significantly in the periodontitis patients and OIL could be employed as an indicator of periodontal disease activity and severity.

Role of Platelet Indices as a Predictive Tool in Hypoproliferative and Hyperdestructive Type of Thrombocytopenia

Chaitra, Tejeswini Vaddatti, Renuka Venkata Inuganti, Manasa Burela

Introduction: Platelet count below 150×109/L defines thrombocytopenia, which can be due to hypoproliferation or peripheral hyperdestruction, distinction of which is made by bone marrow examination. Advances in automated blood cell analysers have made it possible to measure various platelet indices like Mean Platelet Volume (MPV), Platelet Distribution Width (PDW), and Plateletcrit (PCT) which may be helpful in evaluating thrombocytopenia cases. Aim: To investigate the role of platelet indices in discriminating hypoproliferative and hyperdestructive type of thrombocytopenia. Materials and Methods: This was a cross-sectional study of 300 thrombocytopenia cases investigated with bone marrow examination over a period of four years from September 2015 to August 2019. Cases were divided into hypoproliferative and hyperdestructive types, Platelet indices (MPV, PCT, PDW) and platelet count were evaluated for any significant correlation between both types of thrombocytopenia and normal controls using student’s t-test. Results: Out of 300 cases of thrombocytopenia, 200 cases were hypoproliferative type and 100 cases were hyperdestructive type with their mean age of 40.03 years and 38.58 years; and male to female ratio of 1.59:1 and 1:2.57, respectively. Statistically significant correlation (p=0.05) was noted when means of platelet count, MPV, PDW and PCT of hypoproliferative and hyperdestructive group was compared with control group individually. When platelet parameters of hypoproliferative groups were compared with hyperdestructive group, only platelet count and MPV showed significant (p=0.05) correlation. Among the three platelet indices, only MPV showed significant correlation (p=0.02) among the study groups for which Receiver Operating Characteristic (ROC) curve analysis was performed with AUC (area under the ROC curve) of 0.591, sensitivity 57% and specificity 55% at MPV cut-off of 8.8 fl. Conclusion: MPV can be useful as a screening test for differentiating hypoproliferative type of thrombocytopenia from hyperdestructive type and may help in avoiding or delaying irrelevant invasive procedure such as bone marrow aspiration or preventing useless transfusion of platelets among hyperdestructive thrombocytopenia patients.

Genotoxicity of 22% Carbamide Peroxide Bleaching Agent on Oral Cells using the Micronucleus Technique

Introduction: Several bleaching products and methods were introduced over the last years. However, the consequences of 22% carbamide peroxide on the genetic material of oral mucosal cells is uncertain. Aim: This study investigated the genotoxic effect of 22% carbamide peroxide on oral mucosal cells using the Micronucleus (MN) technique. Materials and Methods: Sixteen volunteers participated in the study. At-home bleaching was performed for 2 hours per day for 21 days. Cells were collected by scraping the oral mucosa at four different evaluation times: Baseline (before treatment), 14 days, 21 days, and 52 days after the beginning of bleaching procedure. One thousand cells from each volunteer were examined and the frequencies of MN, binucleated cells, and metanuclear alterations were recorded. After preparing the slides, the microscopic fields were analysed from right to left, until a total of 1,000 cells were analysed. Data were analysed statistically using Kruskal Wallis test at 5% significance level. Results: There was a significant increase in the number of metanuclear alterations and binucleated cells between the baseline and day 21 (p<0.0001). The frequency of MN between the evaluation times was not significantly different (p=0.08). One month after bleaching, the alterations were similar to the baseline values. Conclusion: Although at-home bleaching using 22% carbamide peroxide can cause temporary effects on mucosal cells, the alterations disappear one month after finishing the bleaching treatment.

Alteration in Biochemical and Antioxidant Parameters in Patients with Alcoholic Liver Injury

Haresingh Makwane, Pawan Kumar Kare, Meena Verma

Introduction: Alcoholic Liver Disease (ALD) is a result of excessive consumption of alcohol for long duration. Although several biomarkers associated with liver status are known to be influenced by excessive consumption of alcohol, however, the effect of alcohol quantity on biochemical changes and oxidative stress in ALD patients has not explained very well in previous studies. Aim: To find out the alteration in biochemical parameters related to liver functions, antioxidants levels and oxidative stress in ALD patients (both moderate and heavy drinkers). Materials and Methods: In the present study, 260 subjects were recruited from the Department of Medicine, Gastroenterology, Sri Aurobindo Institute of Medical Sciences (SAIMS) and Hospital, Indore, India and divided in three groups: Group I-(n=75) diagnosed cases of ALD with moderate drinkers Group II-(n=92) diagnosed cases of ALD with heavy drinkers; and Group III included (n=93) normal healthy controls. The levels of serum enzymes such as Aspartate Transaminase (AST), Alanine Transaminase (ALT), Alkaline Phosphatase (ALP), and ?-Glutamyl Transferase (GGT), total protein, total bilirubin and lipid parameters such as total cholesterol, triglyceride, High Density Cholesterol (HDL) and Low Density Cholesterol (LDL) were measured by fully automated chemistry analyser. The levels of antioxidants such as Superoxide Dismutase (SOD), Catalase (CAT) and oxidative stress marker such as Malondialdehyde (MDA) was estimated by spectrophotometric method. p<0.05 was considered as a significant level. Results: The present study demonstrate that the serum levels of AST, ALT, ALP, GGT, total bilirubin total cholesterol, triglyceride, LDL, VLDL and plasma MDA were significantly increased (p<0.001) and serum total protein, blood levels of SOD and CAT activity were significantly decreased (p<0.001) in Group I (ALD with moderate drinkers) as well as Group II (ALD with heavy drinkers) when compared with Group III (healthy controls), respectively. On comparison of Group I (ALD with moderate drinkers) with Group II (ALD with heavy drinkers), a significant difference was found only for LDL cholesterol, serum total bilirubin and plasma MDA. Conclusion: Alcohol-induced liver injury is linked to significant alteration in various biochemical parameters and oxidative stress as observed by reduced levels of antioxidants in moderate as well as in heavy drinkers.

Assessment of Serum Cytokine Concentrations in Infective Endocarditis Patients

Rayvathy Balasubramanian, Thangam Menon

Introduction: Infective Endocarditis (IE) remains a devastating disease despite advances in diagnosis and treatment. The main stay of diagnosis is blood culture, however many cases are culture negative. Measuring levels of inflammatory markers in serum of these patients will aid in the diagnosis. Aim: To estimate the levels of various cytokines in the serum samples of IE patients and to compare them with two control groups- healthy individuals and patients with non-IE infections. Materials and Methods: Serum concentration of Interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12, Tumour Necrosis Factor (TNF)-α and Interferon (IFN)-γ of 52 IE patients, 10 patients with non-IE infections and 10 healthy individuals were determined, between February 2017 and June 2018, using quantitative Enzyme Linked Immuno Sorbent Assay (ELISA). Comparison of cytokine values among the groups was done using Kruskal Wallis test, post-hoc test and ROC curve. Results: IE patients presented with high serum concentration of IFN-γ, TNF-α, IL-1β, IL-6 and IL-8 when compared to control groups. ROC curve analysis comparing IE patients with non-IE patients suggested that IL-6 (AUC-0.8) and IL-8 (AUC-0.876) may serve as reliable markers for the diagnosis of IE. Conclusion: Measurement of various serum cytokines showed that the levels of all of them except IL-10 and IL-12 were significantly higher in patients with IE and non-IE infections as compared to healthy controls. IL-6 and IL-8 levels may serve as additional biomarkers in the diagnosis of IE.

Choosing the Right Strategy for Haemodialysis Central Venous Catheter Placement: A Retrospective Study

Vishal Singh, Pulkit Singh

Introduction: Vascular access is the ‘Achilles heel’ for patients requiring haemodialysis. The gold standard for vascular access is an Arteriovenous Fistula (AVF). In clinical practice, situations mandating the use of Central Venous Catheters (CVCs) are often encountered. The successful outcome for CVC placement depends on variables like operator experience and use of aids like ultrasonography and fluoroscopy. Aim: To determine the difficulty level, outcome, and safety profile of the various prevalent modalities of CVC placement. Materials and Methods: A total of 243, Internal Jugular Vein (IJV), CVC were placed during the study period. Depending on the availability and the clinical circumstances, various techniques including landmark guidance (n=99), ultrasound guidance (n=108) and ultrasound plus fluoroscopic guidance (n=36) were used. The data were retrospectively analysed with regards to the difficulty level and the safety profile. The surrogate marker for assessment of difficulty level included the number of passes required for successful cannulation and technique failure. The safety profile was assessed using procedure-related complication. The binomial outcome was assessed using Fisher’s-exact test. Results: The rate of successful first-pass IJV cannulation in the landmark guided arm was 75% which improved to 92% by the second pass. The use of ultrasound guidance significantly improved the rate of first pass successful cannulation to 97.2%. Technique failure requiring the use of an alternative venous sites was noted in 6.1% of patients in the landmark guided arm. The common procedure related complication included local haematoma formation and carotid artery puncture. Compared to the landmark technique, the incidence of carotid artery puncture was significantly lower in the ultrasound guided arm. Conclusion: In a resource poor environment, the use of landmark guided cannulation by a trained operator continues to be a safe procedure. The use of fluoroscopy and ultrasound, if available, is the gold standard. It improves the outcome while reducing procedure related complications.

Prevalence of Substance Abuse in Patients with Schizophrenia

Introduction: Substance abuse is a common comorbidity in patients of Schizophrenia. Link between the use of substances and development of psychosis is demonstrated by high prevalence of substance abuse in schizophrenia. Substance use disorders and their effects on schizophrenia have made identification and treatment of these patients a high priority. Aim: To study the prevalence of substance abuse, preferred types of substances of abuse and its association with socio demographic characteristics and clinical features of schizophrenia. Materials and Methods: It was an observational cross-sectional study conducted at Jawaharlal Nehru Medical College, Wardha, Maharashtra, India. Sample size was 100 patients. The participants were assessed for socio demographic details and questionnaires on Positive And Negative Symptom Scale (PANSS) and Alcohol Use Disorder Identification Test (AUDIT). Patients with substance abuse were compared with patients without substance abuse on demographic and disease related characteristics. SPSS version 22.0 was used for statistical analysis. Categorical data was analysed by Chi-square test and quantitative data was analysed by t-test. Results: 48% patients of schizophrenia had substance abuse. Smokeless tobacco was found to be the most commonly abused (42%) by patients of Schizophrenia. Substance use was more common in males than females. Smokeless tobacco was the only substance abuse in females (18%). Schizophrenia patients with substance abuse had more PANSS positive score than those without substance use. Conclusion: Substance abuse is a significant comorbidity in patients of schizophrenia in India.

Underfilled K2EDTA Vacutainer on Automated Haematological Blood Cell Indices- To Reject or Reconsider?

Introduction: The most common reason for rejection of blood samples in laboratory is because they are under-filled. Clinical and Laboratory Standards Institute (CLSI) guidelines state that blood vacutainers that contain either 10% higher or lower blood than the recommended volume must be rejected. Repeated phlebotomy has to be performed for such samples which can delay the turnaround time. Aim: To study the effects of underfilled K2EDTA vacutainers on automated haematology indices and compare them with the standard. Materials and Methods: This observational and comparative study was conducted at the department of pathology, Chettinad Hospital and Research Institute, Tamil Nadu for a duration of 6 months from January 2019 to June 2019. A 100 paired samples of underfilled K2EDTA vacutainers were compared with the standard for Complete Blood Count (CBC) analysis using BECKMAN COULTER LH 780 analyser. Statistical analyses was done using Statistical Package for Social Science (SPSS) software v.18 and paired student’s t-test. The p-value <0.05 was considered statistically significant. Results: All the parameters in the CBC showed comparable results between under-filled K2EDTA vacutainers of 1 mL blood volume and standard 3 mL blood volume vacutainers. There was no significant variation in statistics even when the blood volume is as low as 1 mL which is 67% less than that of the recommended volume. Conclusion: Blood samples which are under-filled upto 67% less than recommended volume, i.e. upto 1 ml can be accepted for CBC analysis using BECKMAN COULTER LH 780 analyser. Therefore, the CBC data obtained from the under-filled vacutainers can be used for clinical diagnosis in situations where repeat blood collection is challenging or impossible.

Lead Induced Oxidative DNA Damage among the Occupationally Exposed Workers: A Case-Control Study

Jyoti Batra, Ajit Thakur, Deepak Juyal, Shrawan Kumar Meena

Introduction: The element Lead (Pb), which is considered as one of the most widely distributed enviornmental contaminants plays an important role in various industrial enterprises in India; hence bio-monitoring of occupationally exposed subjects becomes imperative. Adverse effects associated with Pb exposure, if identified at initial stages, can not only reduce the prolonged exposure but the carcinogenic risk as well. Aim: To evaluate the blood Pb levels and the associated DNA damage among the workers in Jaipur, Rajasthan, India who were occupationally exposed to Pb. Materials and Methods: This cross-sectional, case-control study was conducted for a period of three years from January 2016 to December 2018. A total of 220 subjects were included in the study (110 in each, Pb-exposed group and control group). Confounding factors like age, alcohol consumption, smoking and duration of working years were also investigated. The selection of cases was based on a predesigned questionnaire. The blood Pb levels were quantified by using an Inductively Coupled Plasma Mass Spectrometry (ICP-MS) technique based on triple quadropole technology (iCAP^TM TQ ICP-MS) and the DNA damage in the blood lymphocytes was analysed using alkaline comet assay. The data were analysed through student’s t-test. Results: The mean blood Pb levels (38.03 μg/dL) and the mean % of tail DNA (14.80 μm) of the exposed group were found to be significantly higher when compared to the control group (4.89 μg/dL and 6.12 μm, respectively). The blood Pb values and the level of DNA damage were significantly different for smokers in comparison to non-smokers in the exposed group. The blood Pb levels of the exposed subjects positively correlated with the years of exposure. Higher DNA damage was also found in subjects with prolonged exposure to Pb. Conclusion: Present study results showed that exposure to Pb induces genotoxic effects in peripheral lymphocytes, as measured by comet assay, a rapid and sensitive method suitable for bio-monitoring studies. The increased blood levels and the associated DNA damage observed in the exposed subjects mandates the routine periodical screening of such workers for evaluation of the genotoxic effects of Pb. Effective and efficient preventive measures need to be taken, not only to improve the working conditions but also to ensure better safety measures to minimise the occupational exposure of the workers towards Pb.

Comparison of Ocular Microbiome in Non-contact Lens and Contact Lens Users

L Raksha, GB Shantala, Nagaraju Gangashettappa, Deepa Sinha

Introduction: The resident/normal flora of conjunctiva is linked to infections of the eye in most cases in the wake of ocular surgery, trauma, implants in the eye or contact lens-related infections. Contact lenses due to their direct contact with the ocular surface exert shear stress, cause local trauma and thinning of the cornea. These factors may alter the ocular microbiome and hence may predispose the eye for corneal infiltrations and hence, infections. Aim: To analyse the normal conjunctival flora and compare the same with the microbiome of contact lens users. Materials and Methods: Two samples each from both the eye was collected from 40 non-contact lens users (n=80) and 40 daily contact lens users (n=80) from June 2018 to September 2018. The samples were inoculated onto blood agar, Mac Conkey agar and Sabouraud’s Dextrose Agar (SDA). Organisms were identified according to standard microbiological techniques. Antimicrobial susceptibility testing was done for Staphylococcus aureus and Gram-Negative Bacilli (GNB) isolates. The data obtained was in the form of percentages and were analysed using IBM SPSS statistics software version 25.0. Results: GNB including non-fermenter GNB, Pseudomonas, E.coli, Enterobacter cloacae, Citrobacter koseri, Proteus vulgaris, Klebsiella pneumoniae and Moraxella were isolated only from the conjunctiva of contact lens users and none from non-contact lens users (p-value <0.001). There were 12 GNB isolated from conjunctiva of contact lens users. Of them, 10 were ampicillin resistant, seven were amoxicillin-clavulanate resistant and three were cefotaxime resistant (p-value=0.012) but they were all sensitive to ceftriaxone, imipenem, levofloxacin, amikacin and ciprofloxacin. Conclusion: The use of contact lens significantly alters the normal conjunctival flora and are a potential source of infection. The present study helped in formulating antibiotic policy (prophylactic use and empiric treatment) for our healthcare establishment in both contact lens users and non-contact lens users.

Correlation of Auditory Event Related Potential (P300) and Mini Mental State Examination to Measure Cognitive Function in Healthy Young Adults: A Pilot Study

Jitender Sorout, Sudhanshu Kacker, Neha Saboo, Harsha Soni

Introduction: Cognition is composed of intellectual function, memory, speech and language, complex perception, orientation, attention, judgment, planning and decision-making. Behaviour is the exhibition of these cognitive functions. Cognitive function can be assessed by different methods. The most commonly used are P300 and Mini Mental State Examination (MMSE). As both measures evaluate cognitive functions but objective method P300 evaluate endogenously and give the best picture of cognitive functions. Aim: To check the correlation between the results of MMSE with event related potential (P300). Materials and Methods: A prospective cross-sectional study was done on 100 healthy young adult subjects of both genders, aged between 18-25 years after taking written informed consent from January 2019 to June 2019. Cognitive functions were assessed by using MMSE questionnaire through face to face interview and event related potential (P300) latency and amplitude were assessed by using octopus NCV/EMG/EP- 4 Ch. Machine (model- CMEMG 01). Pearson correlation was performed to identify correlation. Results: The mean MMSE score was 24.28±2.89. The mean P300 (latency and amplitude) was 269.61±43.11 ms and 3.1±4.13 µV. Pearson correlation were used to calculate the correlation between P300 (latency and amplitude) with MMSE. The inverse correlation (-0.086) was in between P300 latency and MMSE. There was no correlation between P300 amplitude and MMSE. Conclusion: There was no correlation established between P300 amplitude and MMSE and inverse correlation was seen between P300 latency and MMSE. Hence, P300 cannot replace the MMSE in clinical settings.

The Role of Circulating Tumour DNA as a Marker of Adequate Resection in Oral Cancer and its Correlation with Clinico-pathologic Parameters: A Prospective Study

Akhlak Husain, Ashish Singhal, Akash Agarwal, Rahat Hadi, Nuzhat Husain

Introduction: Oral Cavity Squamous Cell Carcinoma (OSCC) is prevalent worldwide. The genetic heterogeneity of this disease and the limitation of biopsy in selective mapping, made use of conventional biopsy sub-optimal for advanced molecular profiling. There is a lacuna for non-invasive tests which are easy to perform, helpful in diagnosis, follow-up and in analysing the completeness of treatment. Sensitive and specific detection of circulating tumour DNA (ctDNA) has potential to direct early treatment and permits monitoring of systemic dissemination. Aim: To evaluate ctDNA as response assessment tool and as a clinico-pathological parameter. Materials and Methods: This prospective study of 25 patients, carried out at Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh India, from May 2017 to November 2018. The study evaluated ctDNA as a marker of completeness of resection after upfront surgery for OSCC. ctDNA levels were assessed in peripheral blood, before and after surgery to determine whether its quantification can be useful in evaluation of response to surgery and if circulating DNA levels correlate with clinic-pathological prognostic variables. Data analysis was done using Cox proportional model with univariate and multivariate analysis. Results: The ctDNA levels were higher among the patient with age =40, females, short duration of disease (=3 months), infiltrative variety of tumours and lower tumour volume. The levels increase with increase in mitotic index, lymphocytic infiltrate, tumour budding and decrease with the amount of necrosis, and dysplasia but none reached statistical significance. The level of pre-operative ctDNA does not vary widely with margin status, with treatment and do not correlate with the percentage of positive nodes among the total number of nodes dissected. The cases with local recurrence or death had higher pre-operative ctDNA values (Mean pre-operative ctDNA were 294.725 and 185.6, respectively, with a p-value 0.3673). Conclusion: The ctDNA levels are persistently elevated in OSCC and may be a measure of aggressiveness. The surgical treatment of resectable oral cavity cancers may lead to the decrease of ctDNA levels. ctDNA maybe used as a complementary method along with biopsy/histopathological findings.

Total Serum Calcium and Ionic Calcium Levels in Birth Asphyxia: A Prospective Study

Bharat Bhushan Singh, Charu Chandwani, Kusum Mahajan, Gurnoor Singh

Introduction: Birth asphyxia is one of the common neonatal problems resulting in significant mortality and morbidity. It is associated with several biochemical abnormalities which may coexist and alter the course of disease process. One of biochemical abnormality is hypocalcaemia and is associated with poor outcome. Aim: To compare total serum calcium and ionic calcium levels at birth and at 48-hours among asphyxiated and non-asphyxiated neonates. Materials and Methods: This was a case-control study consisting of 50 term asphyxiated (cases) and 50 term healthy (controls) neonates admitted under NICU MMIMSR Mullana, Ambala (Haryana) from Feburary 2018 to August 2019. Total serum calcium and ionic calcium levels were estimated and compared at birth and at 48-hours of life among cases and controls. Results: Total serum calcium and ionic calcium levels at birth were significantly lower in cases (8.04±0.89 mg/dL, 3.62±0.46 mg/dL) as compared to controls (9.32±0.72 mg/dL, 4.79±0.49 mg/dL). Total serum calcium and ionic calcium levels at 48 hours were also significantly lower in cases (9.03±0.84 mg/dL, 4.51±0.41 mg/dL) as compared to controls (9.56±0.49 mg/dL, 4.80±0.69 mg/dL). Conclusion: Total serum calcium and ionic calcium levels are decreased in birth asphyxia both at birth and at 48-hours.

Comparative Study of Ondansetron and Palonosetron for Prevention of Nausea and Vomiting Following Upper Abdominal Surgeries under General Anaesthesia: A Randomised Control Trial

Deepak Premnarayan Gupta, Vijay Chandak

Introduction: Postoperative Nausea and Vomiting (PONV) is a common entity following surgical procedure. It may result into serious complication like aspiration of gastric contents, prolonged recovery period. Palonosetron is a selective serotonin antagonist that is 5HT3 receptor antagonist with little to no affinity for other receptors and has a longer duration of action. Ondansetron is also a 5HT3 receptor antagonist with shorter duration of action and some side effects. Aim: To compare the effectiveness of ondansetron and palonosetron for the prevention of PONV following upper abdominal surgeries. Materials and Methods: This prospective single-blind study included 120 patients randomly assigned to the palonosetron group (n=60) or the ondansetron group (n=60). Using the chi-square test and calculating p-value, the two groups were compared. Results: The incidence of nausea, vomiting and use of rescue antiemetic was significantly less in palonosetron group as compared to ondansetron group. Conclusion: From the study, it can be concluded that palonosetron at a dose of 0.075 mg is safe, with lesser side effects and proved more effective than ondansetron 4 mg in prevention of PONV.

Comparative Evaluation of Intravenous Dexmedetomidine and Clonidine on the Extent and Duration of Bupivacaine Spinal Anaesthesia: A Randomised Control Trial

Akoijam Nikhil Singh, Amol Singam

Introduction: Several methods have been tried in recent years to alleviate post-operative pain, with partial or greater success. Alpha 2 adrenergic agonists have analgesic property when used as an adjuvant to regional anaesthesia. Clonidine is a partial a2-adrenoceptor agonist used intrathecally with a proven record of efficiency and safety. Dexmedetomidine is a selective a2-adrenoceptor agonist. Some studies have shown that intravenous dexmedetomidine is better than intravenous clonidine to provide better intraoperative analgesia during bupivacaine spinal anaesthesia. Aim: To compare and evaluate the efficacy of intravenous dexmedetomidine with clonidine on the onset and duration of sensory and motor block following intrathecal bupivacaine. Materials and Methods: In this randomised, double-blind clinical study, a total of 100 patients aged 20-60 years, American Society of Anaesthesiologists physical Status I or II scheduled for elective surgery under spinal anaesthesia were taken. These patients were randomly allocated to two equal groups of 50 with the help of a computer generated table of random numbers to receive the drugs after ethical approval. Group A received dexmedetomidine 0.5 µg/kg iv and Group B received clonidine 1 µg/kg iv. Time for the onset of sensory and motor blockade and duration of analgesia was noted. Haemodynamic changes, duration of post-operative analgesia and side-effects were also recorded. Data were analysed using chi-square test and the value of p<0.05 was considered statistically significant. Results: Onset of sensory block was significantly shorter in Group A (2.60±1.12 minutes) as compared to Group B (3.45±1.50 minutes). Thus, dexmedetomidine has faster onset of sensory blockade than clonidine. Onset of motor blockade was significantly shorter in Group A (3.52±0.45 minutes) as compared to Group B (4.20±1.46 minutes). Thus, dexmedetomidine has faster onset of motor blockade than clonidine. Time for first analgesic request was 250.46±52.10 minutes in Group A and 180±50.28 minutes in Group B, thus post-operative analgesia was longer in Group A. The mean intraoperative RSS was higher in Group A, thus indicating that dexmedetomidine provides better sedation than clonidine. Conclusion: Premedication with intravenous dexmedetomidine is better than intravenous clonidine to provide early onset of sensory analgesia, prolonged post-operative analgesia and adequate sedation.

Study between Ultrasound Guided Technique and Conventional Landmark Technique for Internal Jugular Vein Cannulation: A Randomised Controlled Trial

Atiyah Misbah M Ehtesham, Charushila Patkar, Deepak Phalgune

Introduction: Internal Jugular Vein (IJV) cannulation is carried out for administration of fluids over a prolonged period, massive blood transfusion, antibiotics, inotrope infusions, total parenteral nutrition, haemodynamic monitoring, haemodialysis and in patients in whom there is difficult peripheral venous access. Aim: To compare success rate, number of attempts, time required for successful cannulation, and complications between Ultrasonography (USG) guided IJV cannulation and conventional landmark technique. Materials and Methods: Ninety patients scheduled for IJV cannulation were randomly divided into two groups. Forty-five patients in Group A and 45 patients in Group B were cannulated with USG guidance, and landmark technique respectively. Primary outcome measures were number of attempts, time required for successful catheterisation, and success rate whereas secondary outcome measures were complications. Comparison of quantitative and qualitative variables between groups was done using unpaired student’s t-test and chi-square test or Fisher’s-exact test respectively. Results: In Group A, all were successfully cannulated whereas, in Group B, 43 (95.6%) were successfully cannulated (p=0.494). The percentage of patients who required ≥2 attempts was significantly higher in Group B (97.8%) compared to Group A (60.5%). Mean time required for successful cannulation was significantly higher in Group B (4.7 m) compared to Group A (4.2 m). The complications were significantly less in Group A compared to Group B. Conclusion: USG guided cannulation of IJV decreases access time, reduces attempts, and complication rates. USG guided technique may be preferred for cannulation of IJV.

A Study of Incidence of Hypoglycaemia and Hypocalcaemia in Infants Born to Diabetic Mothers and a Correlation with Maternal Third Trimester Glycaemic Control

R Kavitha, R Vanitha

Introduction: Incidence of anatomical as well as metabolic complications in infants born to diabetic mothers are increasing. Most of them are due to poor maternal glycaemic control during third trimester. Among the metabolic complications, hypoglycaemia and hypocalcaemia are the most common. This study highlights the importance of third trimester glycaemic control in antenatal diabetic mothers to prevent metabolic complications in babies born to such mothers. Aim: To correlate the relationship between maternal third trimester glycaemic control and metabolic complications in infants born to them. Materials and Methods: This study was done in diabetic mothers who were admitted in the hospital for delivery and the newborn babies born to them. Maternal HbA1C level was checked during third trimester and blood samples were collected from newborn for estimation of blood sugar and serum ionised calcium levels. One-way Chi-square test was used. Results: Among the 52 mothers included in this study, 30 (57.7%) had HbA1C level >6.1 (poor glycaemic control). Among the 30 babies born to these mothers, 18 babies (85.7%) had hypoglycaemia and 4 babies had hypocalcaemia. The statistical interpretations showed that there was no definite relation between incidence of hypocalcaemia in neonates born to diabetic mothers and their glycaemic control. Conclusion: Hypoglycaemia is common among infants born to diabetic mothers with poor third trimester glycaemic control. Meticulous glycaemic control during pregnancy is essential to avoid complications.

Cytomegalovirus Infection Monitoring in Bone Marrow Transplant Recipients from Whole Blood versus Plasma using Real-Time PCR

Introduction: Cytomegalovirus (CMV) infection in immune compromised bone marrow transplant recipients is known. Its infection is about 90% in Indian population, but its symptoms in various age groups in different blood components are scanty and variable. Aim: To evaluate the Whole Blood (WB) and Plasma (PL) samples in population of adult and paediatric leukaemia bone marrow recipients using real-time PCR for CMV infection monitoring. Materials and Methods: In present observational study, total of 1021 allogeneic bone marrow transplant recipients from our referral centre, including 90 adults and 171 children (paediatric) with follow-up cases were analysed for viral loads in all cases. A suitable RT PCR assigned to amplify the conserved region of the UL132 gene to study with respect to two biological components (WL & PL) was investigated in all the patients. Results: The results for CMV infection analysed on both PL and WB showed a good correlation. The kinetics of CMV DNA viral load within the same patient in both WB and PL showed no significant difference. In 2112 follow-up low level of CMV DNA persisted in WB (4.78%), while it was absent in PL. Conclusion: The use of CMV PCR for WB and PL is appropriate to guide implementation and discontinuation of therapy to CMV might lower the risk of CMV disease when given accurate treatment. It might also assist reduce the side effects and duration of treatment. Detection of residual viremia in WB and PL might also offer comparable results in our study cohort.

Evaluation of Pain, Discomfort, and Acceptance during the Orthodontic Treatment of Class III Malocclusion Using Bone-Anchored Intermaxillary Traction Versus the Removable Mandibular Retractor: A Randomised Controlled Trial

Introduction: Bone-Anchored Intermaxillary Traction (BAIMT) is a relatively new method for class III treatment in growing patients, therefore evidence about their acceptability as well as the levels of pain, discomfort and functional impairments among orthodontic patients is still lacking. Aim: To evaluate levels of pain, discomfort and acceptance between the BAIMT system and a commonly used treatment modality in the correction of Class III malocclusion. Materials and Methods: Two-arm parallel-group randomised controlled trial was conducted at the Department of Orthodontics, Al-Baath University Dental School between Febuary and October 2015. Fifty-six patients who met the inclusion criteria were distributed randomly and equally into two groups: the bone-anchored intermaxillary traction group (the BAIMT group with a mean age of 11.3 years) and the removable mandibular retractor group (the RMR group with a mean age of 11.5 years). A special questionnaire (originally designed by Sergl) was used and included six questions regarding patients’ feelings of appliance-related tension/pressure, pain, impaired speech, swallowing difficulty, oral constraint and lack of confidence in public. This questionnaire was administered at T1 (1 day), T2 (1 week), T3 (6 weeks), T4 (3 months) and T5 (6 months) following appliance initial wear. Results: Fifty-one patients were included in the analysis (BAIMT group: 26; RMR group: 25). Patients treated with the BAIMT system had higher levels of pressure, tension (p<0.001) and pain (p<0.001) compared to those in the control group. No statistically significant differences were found between the two groups in relation to impaired swallowing, whereas the RMR caused more constraint in mandibular movements (p<0.05) and more speech impairment (p<0.001) in addition to increased levels of lack of confidence (p<0.001). Conclusion: The BAIMT system caused more pain than the RMR but the levels of pain gradually decreased especially after one week following application. RMR caused more mandibular restriction and more speech impairment because of the presence of the reverse bow, and it caused relatively high levels of social avoidance and lack of confidence for the patient.

Immunohistochemical Expression of Ki67 and p53 in Primary Breast Carcinoma and Combined Ki67-p53 Status Phenotypes in Hormone Receptor Positive Breast Carcinoma

Rishiraj Baruah, Bukanakere Sangappa Sumana

Introduction: The conventional Immunohistochemical (IHC) biomarkers used to assess breast cancer patients include Hormone Receptor (HR) status and HER2 status. IHC analysis of Ki67 is useful to stratify the HR-positive tumours into good and bad prognosis categories; p53-status can identify patients likely to respond to chemotherapy. Aim: To evaluate the IHC status of Ki67 and p53 in invasive primary breast carcinoma and to assess their relationship with HR status, HER2 status and clinico-pathologic factors. Materials and Methods: This observational study conducted between August 2014 to April 2016 included fifty patients with invasive primary breast carcinoma comprising 48 ductal carcinoma, No Special Type (NST) and two mucinous carcinoma cases. Patients treated with neoadjuvant therapy were excluded from the study. The IHC analyses for ER, PR, HER2, Ki67 and p53 status were done on paraffin-embedded tissue sections. The Ki67 and p53 statuses were correlated with the clinicopathological parameters and ER, PR, HER2 status. Based on their IHC profiles, the tumours were classified into clinically definedtreatment oriented subtypes. The association between the clinicopathological parameters and positivity of IHC biomarkers were analysed using Chi-square test and Fisher’s-exact test. The p-value was calculated to ascertain a statistical significance. Results: The 50 cases analysed comprised 54% postmenopausal and 46% premeno-pausal patients. Luminal cancers constituted 46% followed by 30% HER2- like and 24% basal-like tumours. Molecular subtypes showed significant correlation with age, menopausal status, and histologic grade. Ki-67 showed significant correlation with grade, HER2 status and molecular subtypes. p53 showed significant correlation with menopausal status and nodal status. The combined Ki67- p53 status showed a significant correlation with menopausal status, grade, nodal status and HER2 status of the HR-positive tumours. Conclusion: The inclusion of Ki67 in the routine breast IHC panel, facilitates the subtyping of breast cancers into therapy oriented surrogate molecular subtypes. Further, when compared to Ki67 alone, the Ki67-p53 combination will provide even better cost-effective, predictive and prognostic information for the routine clinical management of breast cancers, especially for the HR-positive tumours.

Diagnostic Value of Cell Block Method in Ascites Fluid of Ovarian Cancer

Introduction: The traditional studies documented that peritoneal washing cytology in ovarian tumour could detect a subclinical intraperitoneal extension effectively though, they didn’t mention the detailed methodological technique for it. In conventional Cytological Smears (CS), identification of malignant cells has occasionally posed a diagnostic problem, whereas there are some studies corroborating that undetermined malignancies on CS showed conclusive diagnosis with the aid of Cellblock (CB) preparation. Aim: To assess and compare the accuracy of CB method in the cytological diagnosis of ascites in ovarian cancer with CS. Materials and Methods: All ovarian cancer specimens for cytopathology consisting of both CS and CB over a 4-year period were reviewed and analysed. The available specimens from 64 cases were compared on sensitivity and yield for malignancy by histologic type. Results: The overall sensitivity of CS (91%) was almost the same as CB (95%). However, the yield for malignancy could be improved by 6.3% (4/64) when CB were utilised together. The same trend is noted on high grade serous (100% vs 100%; N=27) and clear cell carcinoma (100% vs 92%; N=17) though no improvement on definitive cytologic conclusion for malignancy was observed. Whereas, in endometrioid carcinoma (N=11), the sensitivity of CS (20%) was remarkably inferior to CB (80%) and the yield for malignancy on CS alone (8.2%; 1/11) was significantly improved to 45.5% (5/11) (p=0.048) when CB was combined with CS. More importantly, all four cases exhibiting negative CS with positive CB showed endometrioid carcinoma with endometriosis comorbidity. Conclusion: These findings strongly suggest that, compared to CS alone, CB technique along with CS provided significant improvement on the yield for malignancy specifically in endometrioid carcinoma.

Expression of Brain Derived Growth Factor in Hippocampus of Mid Gestational Human Fetuses

Shilpi Garg, Sabita Mishra, Swati Tiwari

Introduction: Brain Derived Growth Factor (BDNF) is a sub member of neurotrophin family and is a critical regulator of formation and plasticity of neuronal networks in hippocampal formation. It acts in an activity dependent manner and its expression is highly sensitive to developmental and environmental factors. Aim: To observe the expression of BDNF in the developing hippocampus of mid gestational aborted human fetuses. Materials and Methods: In the present study 15 aborted fetuses from 14 to 30 weeks of gestation, were procured from the department of Obstetrics and Gynaecology, LN hospital after obtaining ethical clearance. For each gestational age the tissue was stained with cresylviolet and H&E to see the general morphology of hippocampus and immunostaining of the sections was done for the expression of BDNF. Results: Subparts of hippocampus including Ammons horn, subiculum and dentate gyrus were identified in all age groups. Immunostaining was detected in both cell bodies and fibers. Expression of BDNF was more marked in the pyramidal cells of hippocampus and granule cell layer of the dentate gyrus of higher gestational age groups as compared to lower ones. Conclusion: There is gradual increase in the BDNF expression as fetal age advances. Increased expression of BDNF in higher gestational age groups showed that neurotrophins like BDNF influence the neuronal differentiation and is important to neuronal survival.

Effectiveness of Planned Teaching Programme in Terms of Knowledge of Teachers on Attention Deficit Hyperactivity Disorder in Children

Neelam Narula, Santosh Mehta, Sunita Patney

Introduction: Attention Deficit Hyperactivity Disorder (ADHD) is a neurological and psychiatric condition which mainly affects school going children, adolescent and even adults. There is a constant prototype of inattention, hyperactivity or both. Such children suffer from numerous types of behavioural problems. Aim: To identify children (6-9 years) with symptoms of ADHD and to evaluate the effectiveness of Planned Teaching Programme (PTP) in terms of knowledge of teachers on ADHD. Materials and Methods: A quasi experimental pre-test and post design study was conducted in the Frank Anthony Public School, Lajpat Nagar, New Delhi, India. The study duration was from December 2015 to March 2016. Total of 40 teachers and 100 children were included. A structured knowledge questionnaire and standard Diagnostic Statistical Manual (DSM)- V criteria was used for collection of data. Mean, median and standard deviation value of pre-test and post-test knowledge scores of teachers were calculated and chi-square values were obtained to find association between post-test knowledge score of teachers on ADHD and selected demographic factors. The p-value <0.05 was taken as level of significance. Results: The prevalence of ADHD in study population was 4%. Most of the teachers (65%) were in the age group of 35 years and above with the mean age being 36.53±5.90 years. Majority (55%) of children included under study fall under the age group 8-9 years followed by 45% in the age group 6-7 years. The mean post-test knowledge scores of teachers were higher than mean pre-test knowledge score and the obtained mean difference of 9.31 was found to be statistically significant. A significant association was observed between post-test knowledge scores and professional education and years of teaching experience (p<0.05). Conclusion: Planned teaching programme was effective in enhancing the knowledge of the teachers regarding ADHD and early identification of children presenting with symptoms of ADHD should be made as it is effective in a scenario like that of India to reduce the burden on society and health care system.

Knowledge, Attitude and Practice of Research among Second Year Undergraduate Medical Students in a Medical College of Telangana, India

Sirisha Goli, Baswaraj Munge, Prasanna Vedula

Introduction: Research experience is important for practice of evidence based medicine among the physicians. It is important to assess the opinion of medical students on research, as it helps us to take necessary measures to motivate them towards research. Aim: To assess the knowledge, attitude and practice of research among second year undergraduate medical students in Kamineni Institute of Medical Sciences, Hyderabad, Telangana, India. Materials and Methods: This cross-sectional study was conducted on 120 undergraduate medical students in Kamineni Institute of Medical Sciences, Narketpally from December 2018-January 2019. The basic awareness about research was assessed using a validated questionnaire. The basics of research methodology were then taught to these students and improvement in knowledge was assessed after lecture. The attitude of students towards research was also assessed by a questionnaire. The practice of research among the students was then evaluated on a 5 point likert scale. Results: There was a significant improvement (p<0.05) in the knowledge domain among both boys and girls after the lecture. A total of 76 students had opinion that interest in particular field was driving force for doing research (63.02%). Lack of guidance (31.2%) and funding (46.2%) were the perceived barriers for conducting research in the undergraduate days. A total of 49.5% students felt that teaching research methodology should be an integral part of MBBS curriculum. Conclusion: Learning research methodology from undergraduate days helps the students inculcate research in practice and choose research as their long term career goal.

Study of Contaminants Growing on Lowenstein Jensen Media during Mycobacterium tuberculosis Culture from a Respiratory Speciality Hospital in Northern India

Amit Aggarwal, Ritu Singhal, Manpreet Bhalla, Vithal Prasad Myneedu

Introduction: Lowenstein Jensen (LJ) culture contamination is one of the most frequent problems encountered during Mycobacterium tuberculosis (M. tuberculosis) culture. Contaminated cultures are repeated at an additional cost and thus hinder diagnosis. This problem is of more significant concern in Extrapulmonary (EP) samples which have very fewer bacilli loads. Unfortunately, our current contaminant knowledge from past studies is minimal, which is entirely based on pulmonary samples, and not on EP samples. Development of newer culture methods will remain incomplete unless we have a good knowledge about contaminant profiles from both types of samples. Aim: To isolate and identify bacterial and fungal contaminants growing on LJ media during M. tuberculosis complex culture in both pulmonary and EP samples. Materials and Methods: LJ media pairs (5074) were inoculated, of which 2030 were inoculated with pulmonary samples and 3044 with EP samples. Mycobacterial, non-Mycobacterial and fungal growth were differentiated based on characteristics like colony morphology (on Chocolate agar, blood agar, Mackonkey Agar and Sabouraud’s Dextrose Agar), staining (Gram stain and Ziehl Neelsen) and biochemical reactions (Indole, Urea, Citrate and Triple Sugar Iron). Statistical analysis was done using SPSS version 20 (IBM®, New York, NY, USA) and Chi-square test was performed. Results: Overall Contamination Rate (CR) was 2.2%. Individually, CR was 2.9% (60/2030) in pulmonary samples and 1.7% (52/3044) in EP samples (p<0.05). Of the total 303 organisms isolated in the study, 87.8% (266/303) were of bacterial origin and remaining 12.2% (37/303) were fungal. Bacteria isolated belonged to 12 different genera amongst which aerobic spore bearers (Bacillus spp) were the most common. All the 37 fungal isolates were moulds, of which 22 were Aspergillus spp (A. flavus, A. fumigatus and A. niger). Bacterial contaminants were more in pulmonary samples, whereas fungal in EP samples (p<0.05). All the contaminants were breakthrough as none grew as mixture along with acid-fast organisms. Conclusion: Breakthrough nature of contaminants indicates that they probably act by completely inhibiting the growth of any acid-fast bacilli present in the sample. This observation becomes quite relevant in EP samples wherein M. tuberculosis bacilli load is already very less. This M. tuberculosis growth masking can thus decrease the overall sensitivity of LJ culture.

Effects of Maxillary Protraction with Skeletal Anchorage and Petit-Type Facemask in High-Angle Class III Patients: A Retrospective Study

Burak Kale, Muhammed Hilmi Buyukcavus

Introduction: Skeletal anchorage-supported applications are performed to increase the skeletal effect of maxillary protraction used in the treatment of Class III malocclusions related to maxillary retrognathia. Aim: To assess the craniofacial and soft tissue effects of the maxillary protraction with skeletal anchorage and Petit-type facemask in high-angle growth Class III young adolescent patients due to maxillary retrognathia. Materials and Methods: The archives for this retrospective study were scanned according to inclusion criteria as follows: skeletal Class III malocclusion due to maxillary retrognathia, high-angle growth pattern, treated using face mask with miniplate anchorage. This study consisted of 15 patients (7 females and 8 males; mean age,11.96±1.03 years) treated using Petittype face mask with mini-plate anchorage inserted in maxillae. Face-mask was used with an approximately 500 g force applied bilaterally from the hooks of the mini-plates. Patients used Petit-type face mask for a total of 6 months for the first three months throughout the day, the next 3 months for 12 hours a day. Cephalometric measurements were made to evaluate the effects of the maxillary protraction. The paired t-test was applied to evaluate differences between pre- and post-treatment variables. Results: In the present study, the skeletal Class III relationships were improved; maxillary measurements significantly increased (SNA° 3.48±0.42°; A–VRL 3.94±0.81 mm), SNB° decreased (-0.50±0.30°), ANB° increased (3.85±0.46°) (p<0.001) and SNGoGn° slightly increased (0.25±0.21°) (p>0.05). The maxillary and mandibular incisors showed retroclination (-3.12±0.42° p<0.01;-0.46±0.24°; respectively). The changes in skeletal and dental parameters caused a significant increase in overjet (3.56±1.01 mm; p<0.001). Conclusion: Using skeletal anchorage with Petit-type facemask has been successfully treated in patients with high-angle Class III young adolescent patients that provided an average increase in maxillary skeletal and soft tissue structures of 3.9 mm and undesired effects of conventional face mask treatment on vertical dimensional measurements were reduced.

Comparative Evaluation of Antibacterial Efficacy and Microhardness after Adding Different Combinations of Triple Antibiotic Powder in Conventional Restorative Glass Ionomer Cement

Introduction: Atraumatic Restorative Treatment (ART) use only hand instruments for caries removal therefore bacteria may remain and survive underneath these restorations. This problem can be solved if the restorative material also possesses antibacterial activity. Aim: To evaluate antibacterial efficacy and microhardness of different combinations of Triple Antibiotic Powder (TAP) mixed in Glass Ionomer Cement (GIC). Materials and Methods:This in-vitro study from December 2019 to February 2019 evaluated the antibacterial effect and microhardness of conventional GIC containing antibiotics in different combinations. Group I (only GIC), Group II (Ciprofloxacin+Metronidazole+Minoc ycline), Group III (Ciprofloxacin+Metronidazole+Cefaclor), Group IV (Ciprofloxacin+Metronidazole) were added to powdered GIC (FUJI IX) to obtain 1.5% w/w ratio. The antibacterial activity of set GIC discs was evaluated against Streptococcus mutans using agar-diffusion methods and microhardness was evaluated using vicker’s microhardness test. ANOVA with post-hoc Tukey multiplerange test was used to determine significant differences. Results: The results showed that antibacterial efficacy of Group III (GIC+TAP having Cefaclor) was increased and statistically significant (p<0.001) while the results of microhardness test of the same group were also higher. Conclusion: Current study shows, greater antibacterial and microhardness results with TAP containing cefaclor mixed in GIC.

Matrix Metalloproteinase-2: A Possible Marker for Non-Small Cell Lung Carcinoma

Asha Sharma, Rati Mathur, Hemant Malhotra

Introduction: Lung carcinoma is the foremost cause of death among cancer related deaths globally. Matrix Metalloproteinase’s (MMPs) are Ca⁺² and Zn⁺² dependent endopeptidases which are involved in degradation of Extracellular Matrix (ECM) and have been widely associated with the development of various diseases, including cancer. Matrix metalloproteinase-2 (MMP-2, gelatinase A) the main mediator of ECM degradation, is important in cell proliferation, apoptosis and angiogenesis. MMP-2 exhibits a high level of expression in many human tumours; plays a role in cancer initiation and development. Aim: To evaluate the level of serum MMP-2 in Non-Small Cell Lung Carcinoma (NSCLC) patients and to establish the clinical significance of this biomarker in NSCLC patients. Materials and Methods: One hundred and twenty newly diagnosed patients of NSCLC of both sexes and 60 age and sex matched healthy control were taken in this study. Serum MMP-2 level was evaluated in NSCLC patients and healthy controls by ELISA method. The independent t-test was used to compare the level of MMP-2 in healthy controls and NSCLC patients and also in different group of NSCLC patients. Results: Serum MMP-2 level was found significantly higher in NSCLC patients when compared with healthy controls (p<0.001). Significantly, high MMP-2 level was also found in stage III and IV NSCLC patients compared to those in stage I and II NSCLC patients (p<0.001). Conclusion: Present study suggests that serum MMP-2 level can be used as a marker for NSCLC along with other investigations. As MMP-2 is more feasible and economical than already established methods for diagnosis of NSCLC, and many broad spectrum oral MMP inhibitors have been developed which has very potent anti-metastatic effects in lung cancer, hence estimation of MMP-2 could be very beneficial as a marker and for better treatment of NSCLC patients.

Comparison of Static Conformal Beam and Intensity Modulated Radiation Therapy for Intracranial Stereotactic Radiosurgery

Pramod Kumar Gupta, SA Yoganathan, KJ Maria Das, Shaleen Kumar

Introduction: Stereotactic Radiosurgery (SRS) by high end Linear Accelerator is very common. There are different treatment planning and delivery options for doing Linear accelerator based SRS namely by Conformal beam or dynamic conformal arc or Intensity Modulated Radiotherapy (IMRT). Aim: To perform a dosimetric comparison between the static conformal beam and fixed field IMRT for intracranial SRS planning. Materials and Methods: A retrospective study was conducted in which four patients treated for single lesion brain metastasis by frame-based SRS (18 Gy) on a 6 MV linear accelerator equipped with microMLC (3 mm) were included. All these patients were planned using BrianLAB iPlan system (PBC algorithm with heterogeneity correction) using 9-14 non-coplanar static conformal fields. For each case, fixed-field IMRT plans were also generated using the same field arrangement. Target coverage V95% (target volume receiving 95% dose) and D95 (dose to 95% target volume), normal tissue sparing 80% dose volume (V80%), 50% dose volume (V50%) and 25% dose volume (V25%) and treatment efficiency (total Monitor Units (MU)) were compared between conformal fields and IMRT. Results: The median target volume for all the lesions was 10.67cc, range 2.90-28.85 cc. Target coverage of conformal beam and IMRT was almost similar (p=0.78). V95% and D95 of conformal beam plan were 96.9±1.7 % and 17.4±0.3 Gy; whereas the readings for IMRT were 98.9±1.6 and 17.7±0.3 Gy, respectively (p=0.18). V80%, V50% and V25% of conformal beam plan were 21.9±18.5cc, 41.1±33.4cc, and 121.5±89.3cc, respectively; on contrary the same for IMRT were 23.9±18.5cc, 45.8±33.8cc, and 122.5±94.5cc. (p= 0.11) When comparing the treatment efficiency, the conformal beam plan resulted in a significantly smaller total MU. The total MU of conformal beam plan was 3080.5±306.8 MU (median: 3172.5 MU); whereas the same for IMRT was 4905.3±360.1 MU (median: 5034 MU) (p=0.04). Conclusion: Conformal beam SRS planning is no different from fixed field IMRT plan in terms of target coverage and normal tissue sparing; however conformal beam plan resulted in a significantly smaller total MU which may have a clinical impact.

Comparison of Quality of Life of Caregivers of Children with and without Disabilities

Ritu Majumdar, Shweta Jain

Introduction: Taking care of a child with disability not only affects the health of the caregiver but also has a detrimental effect on their quality of life. Presently heath providers are focussing on the child with disability, their caregivers are ignored to a large extent. Aim: To compare the quality of life of the caregivers of children with or without disabilities. Materials and Methods: A cross sectional study was conducted in the outpatient department of Physical Medicine and Rehabilitation, Lady Hardinge Medical College and associated Kalawati Saran Children’s Hospital, New Delhi from November 2011 to October 2012 with prior approval from the Institutional Ethics Committee. After obtaining informed consent, a total of 400 participants (200 each in case and control group) who satisfied the inclusion criteria were included in the study. A pre-structured proforma containing the demographic details of the family and WHOQoL-BREF questionnaire to assess quality of life of caregivers was filled. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. Results: In the present study it was observed that quality of life of caregivers of children with disabilities had statistically significant lower scores in all domains using WHOQoL-BREF scale as compared to control group. Conclusion: Protocols should be framed in departments managing children with disabilities to address the health issues of the caregivers. Help in the form of regular counselling, peer group interaction within the hospital and respective local communities, support including respite care services are few things that can be incorporated in order to improve their quality of life.

Estimation of Serum Electrolytes and Renal Profile in Hypothyroidism: A Cross-Sectional Study

B Jyothirmayi, J Thirunavukkarasu, VM Vinodhini

Introduction: Kidneys has important role in the metabolism and removal of thyroid hormones. The water and electrolyte balance in the body was influenced by thyroid hormone. Thyroid dysfunction is usually related with disturbances of calcium and phosphorous homeostasis. It causes significant changes in tubular and glomerular functions of water and electrolyte homeostasis. Both hypothalamus-pituitary-thyroid axis and thyroid hormone peripheral metabolism were affected in Chronic Kidney Disease (CKD). Aim: To assess the renal parameters and electrolytes in well-defined hypothyroid patients and in age matched apparently healthy controls. Materials and Methods: The present cross-sectional study was carried in department of endocrinology and internal medicine at SRM Hospital, Tamil Nadu, India from July 2015 to July 2016. A total of 65 aged 35-50 years known hypothyroid patients both males and females were included in this study which forms the study group and 65 age matched controls were also recruited. Serum Urea, Creatinine, Uric acid and electrolytes were estimated by Ion Selective Electrodes (ISE) in the Beckman Coulter (California, USA) AU480 auto analyser. Free Tri iodotyronine (FT3), Free Tyroxine (FT4) and Thyroid Stimulating Hormone (TSH) was done by Fluorometric Enzyme Immunocapture Assay (FEIA) method in TOSOH AIA 360 (Japan) hormone analyser were measured. Estimated Glomerular Filtration (eGFR) was calculated by using MDRD (Modification of diet in renal disease) formula. Statistical analysis was done by using Student t-test and Pearson correlation analysis. Results: Hypothyroid patients showed significant elevation of serum creatinine, urea and potassium levels (1.39±0.33, 36.7±5.4, 4.78±0.40,p<0.005) when compared to controls. eGFR was decreased significantly in study group (66.8±1.29) when compared to control (96.2±4.69) and (p<0.005). Conclusion: Hypothyroidism is associated with decreased renal function. Hypothyroid patients should be monitored regularly for renal parameters to prevent chronic kidney diseases.

Contrast Sensitivity and Visual Acuity Before and After Nd:YAG Capsulotomy in Patients with Posterior Capsular Opacification: A Prospective Study

Ritica Mukherji, Pradeep Sune

Introduction: Posterior Capsular Opacification (PCO) not only affects Visual Acuity (VA) but also Contrast Sensitivity (CS). Although main motive of performing Neodymium: Yttrium-Aluminium-Garnet laser (Nd: YAG laser) remains improvement in VA, an added benefit of improved contrast sensitivity makes the patient more satisfied in terms of quality of vision. Aim: To evaluate the changes in VA and CS before and after Nd:YAG capsulotomy. Materials and Methods: This was a hospital based prospective study conducted over a period of six months. Thirty five patients with PCO after uncomplicated cataract surgery were evaluated for VA and CS using Snellen’s chart and Pelli-Robson chart respectively. Nd:YAG capsulotomy was done in one eye and patients were followed up on 4^th week and the same parameters were measured. Results: There was an improvement in VA in the range of 6/12-6/9 and the patients with Grade 3-4 of PCO were found to have CS in the ranges of 0.60-1.05 and 0-0.45 with the singular exception of one patient with CS in range of 1.20-1.65. Conclusion: Nd:YAG capsulotomy in patients with PCO following uncomplicated cataract surgery results in an improved visual outcome not only in terms of VA but also in terms of CS. There was a significant difference in pre-laser CS based on the grade of PCO.

Fertility Potential of Microsurgical Subinguinal Varicocelectomy in Non-obstructive Azoospermia, Virtual Azoospermia and Severe Oligospermia Patients in a Tertiary Care Setup

Introduction: The role of varicocelectomy in Non-Obstructive Azoospermia (NOA) and Severe Oligospermia (SO) remains controversial with some studies reporting improvement in these patients. Aim: To analyse the improvement in semen parameters and pregnancy outcomes after microsurgical varicocelectomy in NOA, SO and Virtual Azoospermia (VA) groups. Materials and Methods: A single centre six year prospective study, evaluating 25 adults with primary infertility having NOA, VA (<1 million/mL) or SO (1-5 million/mL) with clinical varicocele and normal female partner evaluation was conducted at a tertiary care centre. Microsurgical varicocelectomy along with needle aspiration biopsy of bilateral testes was done in all patients. Follow-up semen analysis was done at six months’ postoperatively. The improvement in sperm count and sperm motility postoperatively was compared using Wilcoxon signed rank test and paired t-test respectively. Results: The mean age of patients were 31 years. There was significant overall improvement in both sperm count and progressive motility. Mean sperm count improved from 1.052 to 8.456 (million/mL) (mean improvement of 8.65 million/mL in VA group, and of 6.25 million/mL in SO group) while mean progressive motility improved from 15.76% to 24.4%. A total of 21 (84%) patients responded on follow-up. The non-responders’ group had two patients each from VA and SO groups. Pregnancy was achieved in five patients (20%), with spontaneous pregnancy in two and Intrauterine Insemination (IUI) in three patients. All patients with early maturation arrest were non-responders. Conclusion: Microsurgical subinguinal varicocelectomy can lead to significant increase in semen parameters in severe oligospermic men, which aids spontaneous or assisted pregnancy (IUI) in these couples. Hypospermatogenesis and late maturation arrest are favourable predictors of response after surgery.

The Ethical Framework for Policy-making of Universal Health Coverage: A Systematic Review

Ali Farzaneh, Hamid Ravaghi, Abolghasem Fanaei

Introduction: Countries have set a central policy to achieve universal health coverage by 2030. Resource constraint and the variety of ways to fulfill the purposes of the universal health coverage, however, have led policymakers to face ethical challenges. An elaboration of ethical frameworks can facilitate the right move in this direction. Aim: This study examines the ethical frameworks used by countries and postulated by studies for policy-making on universal health coverage. Materials and Methods: This systematic review built on the PRISMA guidelines to search the Scopus and PubMed databases for papers published from January 2010 to March 2018. Studies will be considered for inclusion that have focused on the dimensions of policy-making ethics on universal health coverage and referring to the role of ethics in policy-making on health universal coverage. State and organisational reports, book’s chapters, proceedings and editorials were not included. The data were analysed using the thematic analysis method and categorised into two groups according to the data extraction forms. The first was related to articles that were the result of a research study and recommendations from international organisations; the second concerned with articles that reflected the experiences of different countries. The extracted data of both groups were classified into three themes, including the role of ethics in universal health, ethical principles, and ethical criteria. Results: Out of the 685 articles found in the initial search, 24 met the inclusion criteria. Findings indicate that ethics acts as the driving force, guidance for decision-making, provider of public acceptance, and a guarantee for justice administration. The ethical framework contains principles of fairness, justice, equality, maximisation of benefits, solidarity, sustainability, good governance, human rights, financial risk protection measures, efficiency, and cost-effectiveness. Most studies have emphasised the principles of human rights, solidarity, justice and fairness, cost-effectiveness, and financial risk conservation in the policy-making of health universal coverage. Varying cultural and social conditions, the political orientation of countries, and local values underlie the difference in the contents of the moral framework. Conclusion: In their attempts to realise universal health coverage, countries must undertake a selection of principles and criteria for their ethical framework through a research process. Given the emergence of the scientific field of ethics for health policy-making, researchers can review the ethical principles and criteria identified in this study in other areas of health policy-making and determine the generalisability of these principles.

Analysis of Quantity and Quality of Medical Research in India: A Narrative Review

Geetu Singh

The research output and quality from Low and Middle-Income Countries (LMICs) such as India grades lower than high-income countries. 12th five-year, planning document, also cited that “health research in India has yet to make a major impact” on public health. The recent report of the Parliamentary Standing Committee on Health, has described the state of medical colleges as “rotten”. This review presents an overview of quantity and quality of medical research in India; identifies poor performance of medical research in overall rankings, international collaborations, indexation and impact factor. Good quality research is imperative to produce indigenous and original data to address public health problems within the country.

Implications of Artificial Intelligence (AI) on Dynamics of Medical Education and Care: A Perspective

Tripti K Srivastava, Lalitbhushan Waghmare

Artificial Intelligence (AI) applies to the development of systems endowed with the intellectual processes characteristic of humans. The AI era is likely to profoundly impact present system of Health care. Large data storing, processing and its interpretation through Electronic Medical records (EMRs) indicate great potential benefit to health services. Devices are likely to outperform humans, more so cognitively; and coming to terms with this fact require physicians to brace themselves to practice in a technologically enhanced environment. In near future, AI is likely to take a central place in health care with everything revolving round its mechanics. The era of AI envisages new roles of a physician and health professionals should realise the importance of being efficient in interacting with these machines in an efficient manner. Patient psychology and empathy shall take a central place in patient care and budding doctors should be braced with such relevant competencies. Accordingly, AI needs to find a suitable place within the curriculum of medical education that deals with technology, interactive learning environments and managing AI systems. It is also imperative that medical teachers realise the potential of AI on health care and are suitably equipped to train these emerging concepts to future doctors.

Hypoplastic Bone Marrow Failure in a Patient with Hereditary Persistence of Foetal Haemoglobin (HPFH) Trait

AK Kapoor, S Maurya, Geeta

Hereditary Persistence of Foetal Haemoglobin (HPFH) trait is a rare genetic disorder and is caused by a large deletion involving δ and β globin genes. It is characterised by persistence of Foetal Haemoglobin (HbF) even in an adult. HbF level may vary from 2 to 30% in carriers of HPFH. Clinically, HPFH trait is asymptomatic without relevant haematological alterations. Mostly, HPFH trait is detected incidently while screening for other haemoglobinopathies. Herewith, we report a case of HPFH trait in our population. A 10-year-old boy born of non-consanguineous marriage complained of dyspnoea on exertion and dizziness. On examination he had generalised pallor. Earlier, he gave history of exposure to pesticides while spraying on crops. Later, he developed neutropenia (neutrophils 2000/mm3). He was immediately treated with piperacillin and gentamicin. Later, he was found to be severely anaemic (haemoglobin 3.0 gm/dL). His serum ferritin was within normal range. He also had severe thrombocytopenia (Platelets 10×109/L). Subsequently, Haemoglobin High Pressure Liquid Chromatography (Hb HPLC) was done. His chromatogram showed raised HbF concentration (5.8%) and borderline/or reduced HbA2 concentration (3.1%). He was finally diagnosed as a case of HPFH trait. He was given folic acid and 250 mL of the whole blood transfusion during his stay in hospital. Pesticide and/or insecticide might have caused severe hypoplastic anaemia. Moreover, piperacillin and gentamicin might have also contributed to thrombocytopenia. Detection of HPFH trait appeared to be important for its prevention in our region.

Uretero-pelvic Junction Obstruction and Posterior Urethral Valve Diagnosed with Contra Lateral Multicystic Dysplastic Kidney: Association Unveiled

Amit Kumar Sinha, Amit Kumar, Rashi, Bindey Kumar, Prem Kumar

Paediatric obstructive uropathy is defined as any congenital obstruction in the urinary tract severing renal function to any extent. More frequent causes in male counterpart include posterior urethral valve and uretero-pelvic junction obstruction. Multicystic dysplasia of kidney, on the other hand, is an enlarged kidney almost completely replaced by multiple non-communicating cysts. The association of these three entities in the same child could prove fatal and very rare. The article is on the clinical trajectory of a four-year-old male child reporting with these three conditions and the stepwise protocol followed in the management.