Journal of clinical and diagnostic research

Sarcomatoid Lung Carcinoma-A Rare Entity

Jyoti Bajpai, Surya Kant, Abhishek Verma, Darshan Kumar Bajaj, Ved Prakash

Sarcomatoid Carcinoma (SARC) of lung is an uncommon poorly differentiated variant of lung cancer. It is biphasic neoplasm and combination of malignant epithelial and mesenchymal cells. Most of the cases are associated with advanced disease and metastasis. It is aggressive form of non small cell lung cancer. Here we report a case of sarcomatoid lung cancer in 65-year-old smoker male.

Sebaceous Gland Hyperplasia at Episiotomy Site: A Causal or an Incidental Association

Uma Kumar, Annu Nanda, Sangeeta Lamba

Sebaceous Gland Hyperplasia (SGH) is a benign skin lesion that commonly occurs on the face of elderly patients. Vulva is an extremely rare site to be reported. Only 20 cases of vulvar SGH have been reported in literature. We report a case of vulvar SGH associated with episiotomy surgery. A 22-year-old female presented in gynaecology Out Patient Department (OPD) with complaints of vulvar swelling for three months. She had spontaneous vaginal delivery one year ago during which mediolateral episiotomy was performed. A clinical diagnosis of fibroepithelial polyp was made and the lesion was excised under local anaesthesia. Haematoxylin and eosin stained sections showed numerous sebaceous glands in a lobular arrangement associated with an infundibulum. A diagnosis of SGH was rendered on histopathology. Though, a rarity, vulvar SGH should be kept in mind while dealing with vulvar polypoidal lesions.

Autoimmune Pancreatitis Type 2: Disentangling a Rare Entity of Obstructive Jaundice

Autoimmune Pancreatitis (AIP) can be a clinical challenge in diagnosis and treatment. It often presents with painless obstructive jaundice, which mimics pancreatic cancer. Surgical treatment is not recommended in the management of AIP. However, there are cases of AIP that were diagnosed after surgical resection, due to suspicion of malignancy. Improvement in radiological imaging modalities, offer an accurate diagnosis. We hereby present the case of a 52-year-old female patient with obstructive jaundice who was diagnosed with AIP Type 2, after a meticulous diagnostic workup. The response to high doses of corticosteroids prevented her from unnecessary surgery. Her symptoms were alleviated by biliary stenting.

Antiphospholipid Syndrome Associated with Lung Embolism: A Case Report

Mohammed Alaidarous

Antiphospholipid Syndrome (APS) is an autoimmune disease, where the immune system antibodies damage and attack the body’s own cells and tissues. Antibodies are proteins that protect the body against infections. Cells are damaged when these autoantibodies attack the phospholipids causing blood clots in the veins and arteries. An individual is diagnosed with APS if tested positive for autoantibodies and have a history of autoimmune diseases. Here, the case of a 33-year-old Saudi male is being reported, who was diagnosed with APS, treated with warfarin. The available knowledge about this disease and its relevance to the symptoms of the patient was also summerised.

Rare Multiple Open Dislocation of Carpometacarpal Joints

Kung-Hung Lin, Cheng-Tse Lee, Hsing-Ning Yu, Jung-Ju Cheng

Fracture dislocations of Carpometacarpal (CMC) joints are high-energy injuries, often occurring from vehicle accidents. We here by present a rare case of open dislocation of the second, third, and fourth CMC joints associated with comminuted fracture of the first and fourth phalanges. The fracture in radius and ulna was managed by open reduction and fixed with multiple Kirschner wires (K-wires) and plates. The Disabilities of the Arm, Shoulder and Hand (DASH) score was used to assess functional status at the end of physiotherapy, which improved from 74.2 to 0 over two years. Union was achieved at the end of three months, with an eventual good functional outcome and joint alignment. A high index of suspicion along with good clinical examination and careful assessment of radiographs can ensure early diagnosis and proper management of this rare injury.

A Rare Variant of Germ Cell Ovarian Tumour with Glandular Differentiation and Cutaneous Metastasis

Smriti Agrawal, Vinita Das, Anjoo Agarwal, Amita Pandey, Namrata Kumar

A 35-year-old lady presented with a large ovarian tumour with cutaneous metastasis and tumour markers suggestive of germ cell tumour. Earlier, she underwent laparotomy for suspected chronic ectopic pregnancy of which details were unavailable. Her tissue biopsy from tumour as well as cutaneous deposit showed adenocarcinoma. She was confirmed to have a rare variant of glandular differentiation of germ cell tumour. In view of inoperable masses, Bleomycin Etoposide Cisplatin (BEP) chemotherapy was initiated and tumour along with cutaneous metastasis showed features of regression after two cycles. However, patient died due to complications, following chemotherapy. Glandular differentiation of germ cell tumour must be kept in mind if histopathology shows adenocarcinoma in presence of elevated a Fetoprotein (a-FP), ß-HCG, LDH. Cutaneous metastasis in ovarian malignancy carries a poor prognosis.

Spontaneous Inguinal Faecal Fistula due to Incarcerated Richter’s Hernia-Managed Conservatively

Spontaneous enterocutaneous fistula due to strangulated inguinal Richter’s hernia is a rare presentation and occurs mostly either due to ignorance of the patients or delay in seeking timely medical intervention. It is seen mostly in patients from developing countries like India, Nigeria, etc., Reported here is the case of a 50-year-old female patient who presented with left sided fecal fistula which on investigation was found to be due to incarcerated inguinal Richter’s hernia. The patient refused for any surgical intervention and hence was managed successfully and conservatively. No similar case reports have been found in the literature thus highlighting its significance.

Enteric Fever in Two Siblings with Severe Haemorrhage and Shock

Parul Bhati, Garima Gupta, PC Goyal

Enteric fever is an infectious disease caused by Salmonella typhi, more common in developing countries. It can affect almost all organ systems of the body. There have been occasional reports in literature of patients with enteric fever presenting with severe haemorrhage and very rarely both haemorrhage and shock. Here, we report cases of two siblings, both of them suffering from enteric fever simultaneously, presenting with severe multiple site haemorrhage, shock and with severe thrombocytopenia. The elder sibling presented with encephalopathy as well. Both siblings survived after receiving appropriate platelet and blood transfusions alongside ionotropes and appropriate antibiotics.

Unearthing an Unusual Presentation of Chondrosarcoma Rib as Breast Mass: A Diagnostic Dilemma

Vijeta Tomar, Parul Dargar, Neha Vijay, Paras Nuwal

Chondrosarcomas usually arise in the pelvis or bones of the trunk, but rarely primary chest wall (rib) chondrosarcomas are also noted. We report the case of an 18-year-old female, who presented with left breast mass. On mammography and Ultrasonography (USG), possibility of giant fibroadenoma with cystic changes was given. On Fine Needle Aspiration Cytology (FNAC) and trucut biopsy of the mass, a diagnosis of pleomorphic adenoma was given. However, during resection it was found to be arising from left 4th rib, breast parenchyma was uninvolved and pushed to a side by the mass. Grossly, the mass was capsulated, lobulated and grey white measuring 17×13×10 cm. On cutting, it had a glistening bluish grey colour. On histology, a diagnosis of chondrosarcoma was given.

Severe Anaphylactic Reaction with Ferric Carboxy Maltose: A Case Report

Iron deficiency is one of the commonest nutritional deficiencies among women of child bearing age, in both the developed and developing world. Iron deficiency anaemia is potentially preventable as well as treatable with the use of various iron preparations. Of all the injectable iron formulations Ferric Carboxy Maltose (FCM) has best efficacy and safety profile, however, rare adverse events can occur which should always be borne in mind. The index case is a 30-year-old women G4P2L2A1 attended casualty with bleeding per vaginum. Suction and evacuation was done for incomplete abortion. Patient received FCM after two weeks for moderate anaemia. She developed anaphylactic shock within five minutes of starting the drug. Patient was managed symptomatically with inotropes and blood transfusion. She recovered fully and was discharged well. Reports of severe anaphylactic reactions with the use of FCM are less but not absent thus, judicious and cautious use of the preparation is warranted.

Perforated Jejunal Diverticulitis: An Uncommon Cause of Abdominal Pain

Diverticular disease of the jejunum is a rare entity. Most patients with small bowel diverticula are asymptomatic. Patients who develop symptoms generally report symptoms that reflect associated complications. The most common are non specific epigastric pain or flatulent dyspepsia, mainly postprandial. Complications including haemorrhage, intestinal obstruction, diverticulitis and perforation may be life threatening and warrants early surgical intervention. We report a case of a 68-year-old male admitted with jejunal diverticulosis complicated by sealed off perforation and phlegmon formation who has been admitted and treated for abdominal pain previously with different diagnosis in two occasions, once with a diagnosis of symptomatic cholelithiasis and second time with mild pancreatitis which could be the manifestation of jejunal diverticulitis. On admission CT abdomen confirmed the diagnosis of diverticulitis and he underwent laparoscopic assisted resection of involved segment of jejunum and jejuno-jejunal anastomosis. On one year follow-up patient was pain free and symptom free throughout the period. The purpose of presenting this case is to evaluate a presentation of diverticulitis which can delay the diagnosis and contribute to diagnostic dilemma.

Rigid Bronchoscopy and Jet Ventilation in Foreign Body Aspiration in A Two-Year-Old Female: A Case Report

Tridip Jyoti Borah, Jaideep Sonowal, LT Sailo, Saurav Nandy

Foreign body aspiration is a leading cause of mortality in children of age group 1-3 years and presents significant challenges to the anaesthesiologist in maintaining oxygenation and ventilation while there is instrumentation of the airway by the endoscopist. Here, we report a two-year-old child who came to the emergency room with sudden onset breathlessness, coughing and bluish discolouration. The foreign body lodged in the right mainstem bronchus was removed with the help of a rigid bronchoscope and oxygenation was maintained with jet ventilation. The cooperation between the anaesthesiologist and the endoscopist, proper timing of the procedure, choice of anaesthetic technique and familiarity with equipments saved the child.

Primary Large Cell (Atypical) Ewing Sarcoma/Primitive Neuroectodermal Tumour of Kidney

Kiran Agarwal, Reema Bhushan, Partap Singh Yadav

Primary Ewing Sarcoma/Primitive Neuroectodermal Tumour (ES/PNET) of the kidney is a rare entity. Here we describe a case of renal ES/PNET in 10-year-old girl who complained of abdominal pain and lump for a month. Contrast Enhanced Computed Tomography (CECT) revealed a huge heterogeneous solid cystic mass in the right kidney. We received a distorted specimen of kidney with rupture at upper pole and lateral wall. Sections from the renal mass showed an unencapsulated tumour separated into multiple nodules by thin fibrous septa with areas of extensive haemorrhage and necrosis. The tumour was composed of large round cells with moderate amount of clear to eosinophilic cytoplasm, round to irregular nucleus showing moderate to marked nuclear pleomorphism, coarse granular chromatin and prominent nucleolus. Mitotic figure were 3-4/10 high power fields. Differential diagnosis of large cell lymphoma, malignant melanoma, rhabdoid tumour, rhabdomyosarcoma and atypical ES were considered. Immunohistochemistry revealed diffuse strong positivity for CD99 with focal positivity for vimentin, Neuron Specific Enolase (NSE) and Cytokeratins (CK). Periodic Acid Schiff (PAS) stain showed intra cytoplasmic glycogen in few cells. Hence, the final diagnosis of large cell (atypical) ES/PNET was given. This case report highlights rare occurrence of primary renal large cell (atypical) ES/PNET.

Melanoacanthoma of Pinna-Treated with Skin Grafting: A Case Report

Santosh Uttarkar Pandurangarao, Sridurga Janarthanan, Aravind Darga Ramachandra

Melanoacanthoma is a very rare cutaneous lesion and it is considered to be a benign neoplasm, which is composed of large dendritic melanocytes and epidermal keratinocytes. Very few case reports of melanoacanthoma have been described in Indian literature in recent past. We hereby report a case of melanoacanthoma in a 50-year-old male, who presented to us with a growth in right ear, since 30 years. On examination of right pinna, a 4×3 cm blackish irregular mass occupying the conchal region, encroaching towards the external auditory canal. Surgical excision of the growth was done, since the patient had cosmetic problem and for biopsy (to differentiate it from melanoma and to confirm the diagnosis). As the lesion was big so, to close the primary defect, split skin grafting was used as one of the treatment.

Management of an Electrocuted Burn Injury in a District Hospital-A Case Report and Literature Review

Khoo Kah Seng, Leong Qi Wen, Bustaman Syamimi, Ho Choon Aik, Lim Chen Hong

Electrical burns are one of the important health burdens throughout the world with incidences varying between 4-18% of all burns. They comprise of several types, including lighting injury, high voltage injury (>1000V) and low voltage injury (<1000V). The severity of injury depends on the type and strength of current, current pathway and duration of contact. Injuries sustained from high voltage electrical current can result in cardiac arrest and death, while the other survivors may have extensive damage to soft tissues and bones along with muscle necrosis and rhabdomyolysis. Hereby, we present a case of 45-year-old man whom sustained a high voltage electrical injury (railway voltage) with 25% Total Body Surface Area (TBSA) of mixed partial burns over the path of current. He was managed primarily by general surgical team in a district hospital. In this article, we discuss about management of electrocuted burns in district hospital setting without burn unit. A prompt resuscitation and monitoring of potential complications secondary to electrical burns are vital to reduce morbidity and mortality.

Complete Paraplegia Due to Anterior Spinal Artery Syndrome Following Total Knee Arthroplasty under Epidural Anaesthesia: A Case Report

Nikolaos Anastasopoulos, Trifon Totlis, Nikolaos Lazaridis, Konstantinos Natsis

Anterior Spinal Artery Syndrome (ASAS) is an uncommon devastating neurological condition caused by ischemia in the spinal cord. We present a rare case of complete paraplegia due to ASAS following a total knee arthroplasty under lumbar epidural anaesthesia. The patient was a 78-year-old woman with mild hypertension. Epidural anaesthesia was performed at the L3-L4 interspace after a single uneventful attempt. Twenty hours postoperatively, the patient developed a flaccid paralysis of both legs, with complete loss of motor function, rectal tone and tendon reflexes, but no Babinski reflexes. Pinprick and temperature sensation were both absent bilaterally from T11 down. Proprioception and vibration sensation were intact in the ankle joint only. An immediate MRI of the spine and a second one, 48 hours postoperatively, demonstrated only a central disc herniation at T10-T11 with concomitant spinal canal stenosis. Based on neurological and MRI findings, the diagnosis of ASAS was made. The epidural catheter was removed immediately. Methylprednisolone 30 mg/kg iv bolus over 15 minutes, followed by a 5.4 mg/kg/h iv infusion for the next 23 hours was given. The patient was transferred to a rehabilitation center but no improvement was noticed and one year later the deficit was considered permanent and 2 years later the patient died. The present case alerts the orthopaedic surgeons and anaesthesiologists for the risk of ASAS in patients having predisposing factors for blood flow restriction to the spinal cord, such as elderly patients with degenerative spine disorders. The guidelines of ASAS management are analysed on a case-based approach.

Osseous Metaplasia of Juvenile Polyp

Vinitkumar Deshmukh, Abhijit Jagdale, Rahul Dhake, Deepak Naik

Bone formation in the gastrointestinal tract is very uncommon. We came across a case of 12-year-old boy with rectal bleeding because of rectal polyp. Snare resection of that polyp was done, and pathology report was suggestive of juvenile polyp with osseous metaplasia. There are only 6-7 similar cases which were reported worldwide. There is striking similarity in presentation and histopathological findings of these patients. This study also tries to throw some light on possible pathological mechanism of osseous metaplasia.

Lymph Node Myeloid Sarcoma as a First Presentation of CML Blast Crisis: A Rare Case Report with Review of Literature

Jahnvi Dhar, Naresh Gupta

Myeloid Sarcoma (MS) is an extra-medullary accumulation of the immature cells of granulocytic cell lineage. It has been reported commonly in the setting of acute myelogenous leukaemia, however its occurrence in Chronic Myeloid Leukaemia (CML), though reported as rare, is also common, although only isolated case reports are available. It is commonly misdiagnosed as non Hodgkin lymphoma. Occurrence of MS in a patient with CML defines the case as an extra medullary blast crisis, even without evidence of systemic disease. It is a tell-tale sign of poor prognosis. Here we describe a case of a 45-year-old female who presented with prolonged febrile illness with generalised lymphadenopathy who on extensive workup turned out to be MS as a first presentation of CML in blast crisis. We will review the intricacies of the case, discussing the diagnostic conundrum and treatment dilemma we faced and the systematic approach we followed to manage the patient.

Rectal Necrosis: A Rare Complication of Palliative Radiotherapy for Sacral Spine Metastasis

Radiation proctocolitis is a common side effect of radiation therapy. In rare cases, chronic radiation injury can be severe enough to cause rectal necrosis. In this study, a case of rectal necrosis after sacral spine radiotherapy was presented. Anterior rectal wall necrosis and rectovaginal fistula is thought to be rare, severe and challenging rectal long-term complication of the previous sacral spine irradiation. Although, rectovaginal fistula which resulted in intractable rectal bleeding seems to be a rare side-effect of radiotherapy, physicians must not forget about this complication, as it can be fatal in patients who often have been cured of cancer.

Conservative Medical Treatment of Emphysematous Gastritis

Lamine Hamzaoui, Mouna Medhioub, Amal Khsiba, Selim Sassi, Mohamed Msadak Azouz

Emphysematous gastritis is a very rare disease characterised by the presence of air within the stomach wall with an unfavourable prognosis. Diagnosis is generally made by radiologic findings with CT scan as the procedure of choice. We report a case of emphysematous gastritis in an 81-year-old diabetic man with stenosis of celiac trunk and mesenteric artery. We noted a clinico-biological, radiological and endoscopic improvement with conservative treatment despite the presence of stomach necrosis. Early diagnosis with conservative treatment is essential for the successful management of emphysematous gastritis.

Anaesthetic Management of a Patient with a Mobile Pedunculated Oropharyngeal Mass

Julie CR Misquith, Karl Nicholas SA Ribeiro

As an anaesthesiologist, who faces several challenges in the Operating Room (OR), difficult intubation seems to be the most arduous. Anticipated difficult intubation if not planned well can be both cumbersome and disastrous. We describe the successful management of a case of anticipated difficult intubation due to a rare oropharyngeal mass, which was mobile and moved with respiration, arising from the left lateral wall of oropharynx. We used the technique of awake Fibreoptic Intubation (FOI) for intubating the trachea with dexmedetomidine infusion for sedation. Clinical findings and radiological imaging was used for assessment of difficult airway. Managing a case of difficult airway is highly individualised and meticulous planning is required in anticipated cases. A difficult airway complicates up to one tenths of cases of elective general anaesthesia. Such situations can be anticipated and tackled by fibreoptic flexible bronchoscopy assisted tracheal intubation.

A Case of Severe Hyperkalemia Presenting with No Significant ECG Changes

An increase in serum potassium levels is followed by progressively severe electrophysiological derangements in cardiac impulse generation and conduction, which are reflected in the electrocardiogram (ECG). Severe hyperkalemia with minimal or nonspecific ECG changes is unusual. Here we report a 69-year-old female who presented to our emergency department with hyperkalemia and was found to have no significant ECG changes.

Misdiagnosis of Central Motor Dysfunction in a Child with Craniovertebral Junction Anomaly-A Case Report

Kriti Mishra, Judy A David

Congenital anomalies of the Craniovertebral Junction (CVJ), though clinically significant, have often been misdiagnosed especially in the paediatric age group. Timely diagnosis and interventions can improve clinical outcome and prevent complications. Better understanding of the regional anatomy and pathophysiology of anomalies along with a strong clinical suspicion, accurate examination of clinical signs and better clinical correlation can aid in early diagnosis. We illustrate the above by exploring the clinical scenario of an 11-year-old female child with multiple CVJ anomalies resulting in spastic qaudriparesis and thereby, discuss what could have prevented the delay in diagnosis.

Indwelling J Ureteral Stents Associated Asymptomatic Bacteraemia Caused by Multidrug Resistant Strain of Kocuria kristinae

Muhammed A.P. Manzoor, K.S Shabeena, M Mujeeburahiman, Altaf Khan

Kocuria kristinae is a Gram positive non pathogenic bacterium belonging to the family of micrococcacae. It may cause opportunistic infections in patients with indwelling devices and severe underlying diseases. Indwelling double J ureteral stent is commonly used in urological practice and bacterial colonisation in the ureteral stent plays an important role in the pathogenesis of stent associated infection. Here, we report a rare case of bacteraemia by Kocuria kristinae. Antimicrobial susceptibility testing was performed by Kirby Bauer disc diffusion method. The isolate were found to be multidrug resistant. Regular surveillance of drug resistance is of utmost importance to minimise the spread of infections.

Computed Tomography Imaging Findings of Hepatic Hereditary Haemorrhagic Telangiectasia

Nayna Goyal, Neha Nischal, Sakshi Arya, Neeraj Wadhwa, Sunil Kumar Puri

Hereditary Haemorrhagic Telangiectasia (HHT) also known as Osler Weber Rendu disease is a rare, under diagnosed, autosomal dominant multiorgan angio dysplasia. We present a case of 61-year-old female with complaints of abdominal distension and recurrent epistaxis. Contrast Enhanced Computed Tomography (CECT) abdomen revealed arterio portal shunt, disseminated intrahepatic telangiectasias, dilated hepatic arteries, and hepatic haemangioma. Furthermore presence of cirrhosis with focal left lobar Intra Hepatic Biliary Radical Dilatation (IHBRD) suggested advanced disease. On further investigation pulmonary involvement was also identified. HHT being clinicoradiological diagnosis, knowledge of its feature is essential for its timely correct diagnosis and to obviate inadvertent biopsy.

Periosteum Transposition Technique for Coverage of Exposed Root Surface

Awadhesh Kumar Singh, Anurag Saxena, Dhananjay Kumar Mali

Coverage of exposed root surface should be evaluated not only by the amount of exposed root coverage, but also by the reduced risk of donor site recession, minimal secondary intension healing and improved colour match. To achieve these goals, a new technique, the periosteum transposition technique was designed. A patient with an isolated Miller Class I labial gingival recession at lower left central incisor of 6.0 mm was treated by this technique. In this technique, a partial thickness flap was reflected and underlying periosteum was elevated and transposed on exposed root surface and sutured. The partial thickness flap was sutured at its original position. After one year, complete root coverage was obtained. Thus, the periosteum transposition technique is an assuring technique that has the potential for complete coverage of exposed root surface.

Multiple Impacted Supernumerary Teeth in Non-Syndromic Monozygotic Twins: A Case Report

Supernumerary teeth are defined as teeth that appear in addition to the normal dental formula regardless of their location and morphology. Many individuals present with supernumerary teeth however the presence of multiple supernumerary teeth in individuals with no other associated disease or syndrome is rare. Herein we report a case of 17-year-old monozygotic twins who had presented for orthodontic treatment. Radiographic and histopathological examination revealed the presence of impacted #43 along with multiple developing supernumerary teeth in the elder twin and of impacted #32, #33, #34, #35 along with 1 supplementary tooth and 1 odontome in the younger twin without any other associated syndromes. The presence of multiple supernumerary teeth in non-syndromic monozygotic twins suggests the role of genetics in their formation.

A Rare Cause of Haemoptysis-Carcinoma Thyroid

Deependra Rai

Thyroid cancer generally metastasises to lung parenchyma while endobronchial metastasis is rare. Tracheal invasion may lead to haemoptysis or dyspnea. Most patients who present with thyroid carcinoma have well differentiated histology, having an excellent prognosis. We report a case of thyroid swelling which presented with haemoptysis as chief complaint which on investigation came out to be papillary variant of thyroid carcinoma with lung metastasis and tracheal invasion in a 46-year-old male.

Acalvaria: Case Report and Review of Literature of a Rare Congenital Malformation

Deeksha Anand Singla, Anand Singla

Acalvaria, defined as absent skull bones, is an extremely rare congenital anomaly with only a handful of cases reported in literature. Hypocalvaria is its hypoplastic variant where the skull bones are incompletely formed. Due to such a rare incidence, it has been given the status of an orphan disease. In this report we present the case of a female neonate with acalvaria born in our institute. The neonate survived a short and stormy course of 12 days as she also had associated co-morbidities. The condition per se has been described as having high mortality rate. Very few living cases, less than ten have been reported till date.

Gorham's Syndrome Associated with Chiari I Malformation and Recurrent Meningitis without Fistula: Case Report

Gorham’s syndrome is a rare osteolytic disease in which progressive and spontaneous resorption of bone occurs. We present a case of a boy who presented with Chiari I malformation and recurrent meningitis without fistula. The patient was submitted to occipital bone biopsy and due to lymphocytic infiltration and intraosseous vascular ectasia the diagnosis of Gorham-Stout Syndrome was made. The patient underwent conservative treatment but, unfortunately he died by cardiorespiratory arrest secondary to atlanto-occipital dislocation. This case emphasizes the rarity of this pathology and the previously unreported association with recurrent meningitis without fistula.

Flexor Digitorum Profundus Irritation and Pseudotumour Formation Ten Years after a Penetrating Glass Injury

Baris Polat, Deniz Aydin, Mehmet Alp Dirik, Ali Caygur, Ayse Esin Polat

Retained foreign bodies inside the soft tissue following penetrating injuries are common. Late onset of symptoms and complications are possible in these cases. In the present report, we present a case of late flexor digitorum profundus irritation and pseudotumour formation caused by a retained glass piece 10 years after the injury. Pseudotumour is formed by reaction to the retained material as an enlarged portion of tissue that resembles a tumour. The complaints were completely improved soon after removal of the foreign material. Retained soft tissue foreign bodies should be suspected in differential diagnosis of soft tissue masses. History of a penetrating trauma should be questioned persistently. The authors recommend the removal of retained foreign bodies with sharp edges to avoid further injury to the surrounding anatomical structures.

Andrographolide, A Novel Repressor of Hepcidin Gene Expression

Introduction: Hepcidin is the most important factor in iron metabolism and plays a potential role in erythropoiesis. It is a small peptide hormone which is cysteine-rich and is mostly secreted by hepatic cells. Aim: The purpose of this study was to evaluate the effect of andrographolide on the expression of hepatic hepcidin in an iron overload model. Materials and Methods: For the current study, 48 male Wistar rats were used in six groups. These groups included control group, andrographolide with 3.5 and 7 mg/kg doses groups, iron plus andrographolide groups with 3.5 and 7 mg/kg doses, and iron group. Hepcidin gene expression was performed by real-time method. Iron serum levels were measured by photometry. We used ANOVA and Kruskal Wallis to compare the means of the factors under investigation. Results: The results revealed that the quantitative expression levels of mRNA hepcidin decreased in all groups except in iron group compared with the control group. This decrease in andrographolide 7 mg/kg, iron plus andrographolide 3.5 mg/kg, and iron plus andrographolide 7 mg/kg groups was significant compared to the control group (p<0.05). The quantitative expression level of mRNA hepcidin significantly increased in iron group as compared to the control group (p<0.05). The findings also indicated that serum concentration of iron in groups with secondary iron overload significantly increased compared with the control group (p<0.05). Conclusion: Andrographolide with 3.5 and 7 mg/kg doses decreases the expression of hepcidin and increases iron serum levels in secondary iron overload model.

Multiple Recurrent Simultaneous Salivary Calculi

Correspondence: Prevalence of Iron Deficiency and Iron Deficiency Anaemia in Adolescent Girls in a Tertiary Care Hospital

Himel Mondal, Shaikat Mondal

Correspondence: Health-related Quality of Life of Persons after Rhinoplasty: A Longitudinal Study among Iranian Population

Milad Ebrahimi

The Leverage Method: A Novel Technique for Difficult Temporomandibular Joint Reduction

Ozkan Onal, Emine Aslanlar, Merih Onal, Cagdas Elsurer, Cansu Ciftci

Efficacy and Safety of Different Prophylactic Doses of Phenylephrine for Prevention of Spinal Anaesthesia induced Hypotension in Cesarean Section-A Randomised Controlled Trial

Chanchal Kumar Dalai, Soumita Roy, Madhumita Ray, Abhishek Ghosh

Introduction: Spinal anaesthesia is a standard technique for elective caesarean section. But, hypotension is the main complication, which adversely affects both mother and foetus. Aim: To evaluate the efficacy and safety of different prophylactic doses of phenylephrine for prevention of spinal anaesthesia induced hypotension. Materials and Methods: This prospective, randomised, double blinded controlled study was conducted on 104 pregnant mothers who fulfilled the subject selection criteria. Patients were randomly allocated into four groups: Group A received 2 mL of 0.9% saline solution Intramuscularly (IM), Group B, Group C and Group D received 1 mg, 2 mg, and 3 mg of phenylephrine (made in 2 mL of 0.9% saline) IM, respectively. Hyperbaric bupivacaine 0.5%, 2.5 mL was administered intrathecally to all subjects. Haemodynamic parameters: Systolic Blood Pressure (SBP), Mean arterial Blood Pressure (MBP), Diastolic Blood Pressure (DBP), Heart Rate (HR) were recorded throughout the surgery at three minutes interval and 10 minutes interval for one hour after surgery (study period). Adverse events were also noted throughout the study period. Fisher’s exact test, Kruskall-Wallis test, Friedman’s ANOVA were done for statistical analysis. Results: Subjects of Group D had least episode of hypotension (2 times) than Group A (13 times). Subjects of Group D required least amount of rescue medication (73.91±22.85 mcg) than Group A (435±39.25 mcg) that was statistically significant (p<0.001). Incidence of nausea and vomiting were least in subjects of Group D (7.69%) than Group A (66.67%) which was statistically significant (p<0.001). Conclusion: Prophylactic 3 mg IM phenylephrine is effective to lower the incidence of spinal anaesthesia induced hypotension in elective caesarean section with minimal tolerable adverse effects.

Assessment of Osteoporotic Alterations in Brazilian Postmenopausal Women: A Retrospective Study

Isabela Goulart Gil Choi, Luciana Munhoz, Emiko Saito Arita

Introduction: Peripheral Dual X-Ray Absorptiometry (DXA) has been recognized as convenient to assess Bone Mass Density (BMD) and fracture risk. Nevertheless, DXA is not largely available mainly in developing countries and early diagnosis in high-risk groups become impaired as the screening is not usually performed. Meanwhile, panoramic radiographs are commonly used in routine dentistry practice and mandibular cortical bone may reflect changes in bony architecture from other sites of skeleton. Aim: To assess BMD by peripheral DXA and osteoporotic alterations in mandibular cortical bone by panoramic radiographs using Mandibular Cortical Index (MCI) in Brazilian women, according to age ranges. Materials and Methods: The T-scores of peripheral DXA were assessed in 252 female patients considering eight age ranges. The relationship between age and T-scores were performed by logistic regression. In addition, non-parametric correlations between MCI and peripheral DXA (pDXA) results were carried out with Spearman’s test at a level of significance of 5%. Results: The age-related bone loss showed to be less significant at distal site and markedly more evident in proximal sites. The higher T-score values at proximal radius was observed in 25-39 age range group; in 40-44 age range group for distal forearm and in 45-49 age range group at the proximal R+U site. For MCI test, interobserver and intraobserver reproducibility were confirmed for MCI categorical measurements (kappa=0.81, p=0.01). It was found different inverse correlations between MCI and the different forearm sites: stronger for proximal sites and weaker for the distal site. Conclusion: Within the limitations of this study, we concluded that age-related bone loss is more evident in proximal forearm than in the distal forearm and MCI can express better inverse correlation with proximal forearm.

Tubercular Osteomyelitis of Clavicle: A Rare Clinico-radiological Diagnostic Dilemma and Master Mimicker

Introduction: Tuberculosis (TB) is one of the most common infections in developing countries. However, TB of the clavicle is a rare entity. Clinical suspicion and early radiological diagnosis of this entity is of utmost importance for patient outcome. Aim: To evaluate and define the role of cross-sectional imaging in tubercular osteomyelitis of clavicle. Materials and Methods: A hospital based prospective study was conducted in a tertiary care centre from June 2015 to December 2016. The study group comprised of pathologically proven eight patients of tubercular clavicular osteomyelitis. CT scans were done in six patients and MRI was done in two patients. Data were presented in terms of percentage, mean and standard deviation. Results: The mean age of presentation of our study population was 37±1.8 years with a male: female ratio of 3:1. Medial 1/3rd of the clavicle was the most commonly affected site. Irregular expansile osteolytic lesions with bony destruction was noted in 5 (62.5%) patients, mild bony erosions in 3 (37.5%) patients, periosteal reaction in 4 (50%) patients, bony sclerosis in 4 (50%) patients and sequestrum formation in 2 (25%) patients. Contiguous affection of adjacent sterno-clavicular joint was seen in 3 (37.5%) patients. Conclusion: Cross-sectional imaging, especially MRI is essential not only in the diagnosis of clavicular tubercular osteomyelitis, but also is important to evaluate the extent of bone marrow involvement, surrounding soft tissue involvement and myositis. This in turn may affect patient management and prognosis, where some of them may require surgical intervention.

Z–Score and CIAF–A Descriptive Measure to Determine Prevalence of Under–Nutrition in Rural School Children, Puducherry, India

S Ramkumar, S Vijayalakshmi, P Kanagarajan, Rajkumar Patil, A Lokeshmaran

Introduction: Under-nutrition is a major public health distress affecting significant number of school children markedly influencing their health, growth and development, and also their school academic performance. Composite Index of Anthropometric Failure (CIAF) and z-score system provides a comprehensive magnitude of undernutrition. Aim: To determine the magnitude and compare the prevalence of undernutrition using z-score and CIAF in the rural school going children, Puducherry, India. Materials and Methods: Total 792 school children were enrolled from six schools during November 2013 and January 2014. All the students who were present during the survey were included. The z-score for nutritional indices were calculated using WHO Anthro-Software. Statistical analysis was done using EPI-Info 7. Chi-square test was used to find the associations. A p-value <0.05 was considered statistically significant. Results: Nearly 48.7% of the children had anthropometric failure. The most common anthropometric failure as per CIAF was underweight with wasting (18.7%). The prevalence of underweight and wasting were more among male children than female children with significant difference (p<0.05), whereas in stunting, no significant difference was found between male and female. Using underweight as the sole criteria for assessing the magnitude of undernutrition in this study would give us an underestimate of undernourished children of about 10%. Conclusion: Our study also suggests that using conventional method (Weight for Age), centres has chance of missing nearly 10% of the undernourished children. Thus, by using z-score system we have an advantage of identifying school children with wasting and stunting in addition to the children who are underweight. Also, by using CIAF classification, undernourished children were disseminated into different groups, which helps to identify children with multiple anthropometric failures and priority can be set for planning the management.

The Effects of Fetal Movements Counting on Maternal-Fetal Attachment: A Randomised Controlled Trial

Masoumeh Delaram, Lobat Jafar-Zadeh, Sahand Shams

Introduction: With the decrease in fetal activity, the risk of adverse pregnancy outcomes increases and timely reporting by mother may decrease the risk of fetal death. There are conflicting reports about the impact of fetal movement counting on maternal-fetal attachment and this study is trying to address this issue. Aim: The aim of this study was to determine the effects of fetal movements counting on maternal-fetal attachment. Materials and Methods: In a randomised controlled trial from October 2012 to December 2013, 250 nulliparous women referred to Health Centers to receive the prenatal care. The Ultrasound screening was performed in 16th-18th weeks of gestation and multiple pregnancy and fetal malformations were excluded (n=4). Thirty-eight of participants did not return the baseline questionnaire and 208 women were randomly allocated into the two groups to either fetal movement counting or to standard antenatal care. Main outcome was maternal-fetal attachment, measured by the Prenatal Attachment Inventory. The analysis was performed by SPSS and p<0.05 was considered significant. Results: No difference was found between the groups with respect to individual characteristics. At 28 weeks of gestation, the mean scores given to Prenatal Attachment Inventory items, was 90.23±9.64 in the intervention group and 90.00±10.04 in the control group and the difference was not significant (Mean difference=0.230, p=0.866). Also, no significant difference was found at 37 weeks of gestation between the two groups (93.75±7.59 vs 92.78±9.90 respectively, mean difference=0.961, p=0.433). Conclusion: The counting of fetal movements by mother from 28 to 37 weeks of gestation did not affect the maternal-fetal attachment in nulliparous women. The investigation of fetal movement counting on psychological factors of mother was suggested.

Nested PCR for Detection and Typing of Rare High Risk Human Papilloma Viruses like Genotype 73 Associated with Carcinoma Cervix

Nidhi Gupta, Pradyot Prakash, Amrita Ghosh Kar, Nisha Rani Agrawal

Introduction: There are 15 high risk genotypes of Human Papilloma Viruses (HPV) which are associated with Carcinoma Cervix (CaCx), of which genotype 16 and 18 are the commonest. Aim: To evaluate nested multiplex Polymerase Chain Reaction (PCR) protocol for simultaneous detection of HPV, and typing of high risk genotypes mainly genotypes 16 and 18 in cervical scrape/biopsy samples. Materials and Methods: This prospective cohort study was done on 63 females in the age group 21-70 years attending outpatient Department of Gynaecology, Sir Sunderlal Hospital, BHU, Uttar Pradesh, India from March 2015 to August 2016. Cervical biopsy (n=14) and cervical scrape (n=49) samples from 63 females were subjected to histopathology/cytology and nested multiplex PCR for detection and typing of HPV. Further, in HPV positive tissue samples, in which virus was not typed as genotype 16 and 18, 142 bp consensus sequence of L1 capsid gene was amplified by nested PCR employing MY/GP+ primers and subjected for sequencing to ascertain the HPV genotypes. Results: On histological examination, 13 (92.8%) out of 14 biopsies were diagnosed as cases of Squamous Cell Carcinoma (SCC). Of the 13 cases of SCC of uterine cervix, all were HPV positive and yielded either 134 bp L1 capsid amplicons (n=12) or HPV 16 specific amplicon (n=1). On subjecting cervical scrape samples for the PCR, 24.3%, 100%, 57.1%, and 66.7 % cases with Negative for Intraepithelial Lesion or Malignancy (NILM), Atypical Squamous Cells of Undetermined Significance (ASCUS), Low Grade Intraepithelial Lesion (LSIL), and High Grade Intraepithelial Lesion (HSIL) respectively were positive for HPV. Conclusion: Detection of High Risk HPVs (HR HPV) in all the tissue samples of SCC of uterine cervix indicates the usefulness of the nested multiplex PCR protocol in detection and typing of HPVs in tissue samples of CaCx. Further, this protocol may be used to detect HPVs in scrape samples along with cervical cytology as a tool for screening CaCx.

Serum HE4 Detects Ovarian Cancer Recurrence Earlier Than CA 125: Indian Study

Introduction: Recurrence is a frequent phenomenon of the natural history of epithelial Ovarian Cancer (OC). Early detection of recurrence is important. Clinical examination combined with Carbohydrate Antigen 125 (CA125) and imaging are used for the follow-up of these patients. Human Epididymis Protein 4 (HE4) is a recent marker which is found to have elevated in OC. Aim: To study the role of HE4 in detection of OC recurrence. Materials and Methods: This prospective study was conducted at Department of Surgical Oncology, King George’s Medical University, Lucknow, Uttar Pradesh, India. Patients were enrolled from January 2014 to January 2016 after informed written consent. Total 65 patients of carcinoma ovary were prospectively followed up after completion of their primary treatment. 19 patients had clinical evidence of recurrence as detected by radiological imaging and subsequently proved by pathological examination. Timing and levels of rise in tumour marker were studied and correlated with timing of clinical evidence of disease. Results: HE4 and CA125 detected recurrence in 19 (100%) and 14 (73.7%) patients respectively. Among these 5 (26.3%) recurrence were detected by HE4 alone. In 10 (52.6%) patients, simultaneous rise in both of these markers were noticed and in 4 (21.1%) patients HE4 started rising before CA125 with a lead time of 3.25 months. CA125 was found to be in normal range in all mucinous carcinoma and two out of 16 serous carcinoma. Conclusion: HE4 is a potential useful serum marker to detect OC recurrence timely and better as compared to traditional utilised CA125. Future studies based on recurrence detection by HE4 may provide evidence on its role on survival.

Does the Addition of Melatonin to Quadruple Therapy Increases the Eradication Rate of Helicobacter pylori? A Double-Blind Randomized Clinical Trial

Introduction: The failure in eradication of Helicobacter pylori (H.pylori) using standard treatments is a common concern all over the world. Limited data have shown efficacy of melatonin against H.pylori in vitro. We hypothesise that, melatonin as adjuvant to quadruple therapy may improve H.pylori eradication rate. Aim: To evaluate additive effects of melatonin combined with a quadruple therapy for the eradication of H.pylori. Materials and Methods: This was a double-blind, placebo-controlled, randomized clinical trial. The trial comprised a 14-days, quadruple eradication regimen (omeprazole 20 mg twice daily; bismuth subsalicylate 525 mg four times daily; amoxicillin 1000 mg twice daily; and metronidazole 500 mg twice daily) supplemented with melatonin 3 mg/d (MEL group) or a comparable placebo (placebo group) without melatonin. The data were analysed using the SPSS version 19 and p-values less than 0.05 was considered statistically significant. Results: Eradication rates of intention-to-treat analysis (ITT; n = 118) were 73% in the MEL group and 65% in the placebo group. Eradication rates of per protocol analysis (PP; n = 98) were 80% and 79% in the MEL and placebo groups, respectively. There was no significant difference between the two groups either by ITT or PP analysis (p = 0.74 and p = 0.91, respectively). Conclusion: According to the result of the trial, MEL 3 mg/d does not have an additive effect on the eradication of H.pylori infection.

Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6): Translation and Psychometric Validation of the Iranian Version

Introduction: Urinary incontinence is a common health, physical, and social problem in the world. There is an urgent need of effective questionnaires for its evaluation in Iranian women. Aim: The present study aimed to assess validity and reliability of the adapted and translated version of the Incontinence Impact Questionnaire (IIQ-7) and the Urogenital Distress Inventory (UDI-6) in the Persian language. Materials and Methods: This cross-sectional study was conducted from April to October 2015. A sample of 200 consecutive women who participated in this study filled the final version of the questionnaires. Eligible samples were divided into two groups (with and without UI). Standard forward-backward procedure was applied for translating the questionnaires into Persian. Reliability was assessed using test/retest reliability and internal consistency. In addition, validity was evaluated using face and content validity, comparison with known groups, and convergent validity. Results: Two hundred women participated in this study and filled both the questionnaires. Both the normal and incontinent groups had 100 subjects. Mean age of the respondents was 47.52±9.84 years. The content validity analysis produced favourable results. IIQ and UDI successfully discriminated the two groups. There was a significant negative correlation between the two questionnaires and all subscales of the Short Form Health Survey (SF-36). The Cronbach’s alpha coefficient for UDI-6 and IIQ-7 was 0.88 and 0.95, respectively. The Intraclass Correlations (ICC) scores for the Persian language versions were 0.96 for UDI-6 and 0.97 for IIQ-7. Conclusion: This study demonstrated that the newly developed Persian language version of IIQ-7 and UDI-6 are short, valid, and reliable methods for assessing the quality of life of women with UI.

Clinico Pathological Analysis of Uterine Serous Carcinoma in a Cancer Centre from Northern Kerala-A Retrospective Study

Introduction: Uterine Serous Carcinoma (USC) accounts for 10% of malignancies of uterine corpus. They are characterised by high propensity for local spread, extra uterine metastasis, recurrence and are having poor prognosis. The disease can be highly aggressive even if it is confined to uterus at time of surgery. Aim: To assess the clinico-pathologic features of uterine serous carcinoma in patients of north Kerala and to analyse its predictors of outcome. Materials and Methods: Data of cases diagnosed with uterine serous carcinoma for five years from 2012 January to 2016 December were retrieved from medical library. Overall survival and progression free survival were assessed. Results: It is observed that all patients were post menopausal women with the age of 59.5+8.535 with predominant clinical presentation of vaginal bleeding. As per the FIGO staging, 13 patients were in Stage I, 11 cases were in Stage III, 4 cases were in IV and no cases reported in Stage II. Out of 28, 9 cases (32.1%) were died and 12 patients (42.8%) had recurrence during the follow-up period. 19 cases (67.9 %) had the five year over all survival. For stage I patients the overall survival was 76.9%, Stage III had 72.7%, and Stage IV had only 25%. 3 out of the 13 cases in Stage I, 6 out of 11 cases in Stage III and 3 out of 4 cases in Stage IV showed recurrence irrespective of the adjuvant treatment. Conclusion: Uterine serous carcinoma has distinct clinico-pathologic features compared to the more common endometrioid carcinoma. It carries poor prognosis. Complete surgical staging with close follow-up is needed even in cases confined to uterus.

Tumour Budding and MMP-2 Expression in Breast Invasive Ductal Carcinoma

Introduction: Breast cancer is a major cause of cancer death among females. Tumour buds are clusters of undifferentiated malignant cells (one cell to less than or equal to five cells) at the invasive front of a tumour. They are believed to be the basis of tumour progression and metastasis. Over expression of MMP-2 {an Extracellular Matrix (ECM) proteolytic enzyme} is considered important for tumour invasion and metastasis. Aim: This study is designed to evaluate tumour budding and expression of MMP-2 in breast invasive ductal carcinoma. Materials and Methods: This cross-sectional observational study was conducted on 61 cases of female breast invasive ductal carcinoma. Cases were obtained from the Department of Pathology, Faculty of Medicine, Cairo University, Giza, Egypt and a private laboratory during the period from June 2015 until September 2016. Tumour budding detection using pan cytokeratin and expression of MMP-2 were evaluated immunohistochemically in 61 cases of female breast invasive ductal carcinoma. MMP-2 expression was evaluated in both neoplastic cells and accompanying stromal component. Results: Significant positive correlations were found between tumour budding and ill defined borders, positive lymph node metastasis and low mitotic count. There were statistically significant positive correlations between expression of MMP-2 in invasive tumour and its expression in both in situ and stromal components. Significant positive correlations were found between expression of MMP-2 in tumour stromal cells and expression of MMP-2 in the in situ component and infiltrated resection margins. When budding was combined with MMP-2 expression in tumour cells; there were significant correlations with Oestrogen Receptor (ER) expression and MMP-2 expression in the in situ component and tumour stroma, and when combined with expression of MMP-2 in tumour stroma; there were significant correlations with expression of MMP-2 in invasive tumour and infiltrated resection margin. Conclusion: Tumour budding might help in assigning subsequent treatment strategies in early breast cancer as in colorectal cancer. MMP-2 expression is seen in the in situ breast cancer and subsequent invasive components and the surrounding stroma, which points to its crucial role in tumour invasiveness and subsequent growth.

Role of Serum Lactate Dehydrogenase in Pregnancy Induced Hypertension with its Adverse Feto-Maternal Outcome- A Case-control Study

Introduction: Hypertensive Disorders of Pregnancy (HDP) affect 6-8% of all pregnancies, contributing immensely to maternal morbidity and mortality. Pre-eclampsia is a common, yet a major medical complication of pregnancy and is responsible for 10%-15% of maternal deaths. Lactate Dehydrogenase (LDH) is an intracellular enzyme, which when present in serum signifies tissue damage and haemolysis. Aim: To study the correlation of serum LDH levels with blood pressure range in patients with gestational hypertension and pre-eclampsia, and the feto-maternal outcome. Materials and Methods: Based on the eligibility criteria, 150 hypertensive pregnant women were enrolled as cases. Also, 150 normotensive women admitted after 28 weeks of gestation were taken as controls in the study. Serum LDH was measured in both the groups and its correlation with blood pressure was studied, after applying appropriate clinical tests. (Quantitative variables-unpaired t-test/Mann-Whitney test between two groups and ANOVA/Kruskal Wallis test between more than two groups; Qualitative variables: chi-square/Fisher exact test. Pearson/Spearsman correlation coefficient was used to assess correlation between various quantitative parameters) Association of other biochemical parameters with feto-maternal outcome was also studied. Results: The mean age of women in hypertensive group was 25.06±4.13 years, while that in normotensive group was 24.38±3.8 years. Most women belonged to lower and lower middle class (75.33%). The mean serum LDH levels in hypertensive group was 1011.81±539.31 IU/L, while it was 555.24±237.69 IU/L in normotensive groups (p-value=0.017). Serum LDH levels were significantly associated with the range of blood pressure (p-value<0.0005). High levels of LDH were found in pre-eclamptic women with adverse maternal outcomes (p-value=0.001). Elevated levels of LDH (1058.88±575.19 IU/L) were also associated with Low Birth Weight (LBW) babies and poor foetal outcome, including low Apgar, higher rates of NICU admission and neonatal mortality (p-value<0.0005). Conclusion: LDH level estimation and its correlation with range of blood pressure is a simple and reliable method for prediction of adverse maternal and foetal outcome in hypertensive disorders of pregnancy. It may also help in assessing the severity of the condition.

Evaluation of Micronucleus and Associated Abnormalities in Buccal Cells Post CT Scan Exposure- An Observational Study

Introduction: Dental diagnostic radiation is reported to cause significant damage in buccal cells while, the same effects due to Computed Tomography (CT) scans have not been routinely cited in literature. The buccal cells were studied in patients exposed to CT scans for evaluating the cells with micronuclei, associated nuclear abnormalities and changes in Proliferative Index (PI) of cells. The obtained head and neck CT scans i.e., CT for brain and facial bone, CT paranasal sinuses and CT cervical spine were compared in terms of the micronuclear counts. Aim: To estimate the counts of micronucleus associated nuclear abnormalities and changes in PI in patients before and after head and neck CT scans. Materials and Methods: An observational study, wherein 40 patients undergoing CT scans for head and neck region, were selected by consecutive systematic sampling. Buccal smears were made before and 10 days after CT scan. Papanicolaou (PAP) staining and micronuclear analysis were performed as per Tolbert’s criteria. The obtained cell counts were compared for differences before and after scans by paired t-tests. Results: Significant differences (p<0.05; paired t-test) were noted between pre and post exposure values for head and neck CT scans in terms of Micronucleus (MN) counts, Binulceated cells (BN), Nuclear buds (NBUDs) and Multinucleated Micronucleus (MMN) cells. The post exposure radiation induced cell PI was found to be 6.0, a 3 fold rise from normal value of 2.0. Conclusion: CT scans taken for head and neck region caused changes related to DNA damage and genotoxicity in buccal mucosal cells. Comparatively, CT cervical spine have showed more nuclear abnormalities than CT for brain and facial bone and CT paranasal sinuses. The associated micronuclear cells have contributed to rise in PI.

A Study of the Status of Students’ Social Health at Kermanshah University of Medical Sciences and the Role of Demographic Variables

Parvin Abbasi, Neda Kianipour, Arash Ziapour

Inroduction: Given the significance of social health among people from all walks of life in societies, paying attention to the status of students’ social health is of the essence. Aim: The present study aimed to investigate the status of students’ social health at Kermanshah University of Medical Sciences and the role of demographic variables in 2016. Materials and Methods: In this descriptive study, the statistical population comprised of 400 students from different majors in Kermanshah University of Medical Sciences who were selected through multi-stage cluster sampling. For data collection, an instrument comprising the demographic questions and Keyes social health questionnaire was utilised. To analyse data, the independent t-test and one-way ANOVA were employed in the SPSS Statistics software version 23.0. Results: The mean and standard deviation of students' social health measured (3.27±0.59). Moreover, the highest mean score of social health dimensions was related to social contribution (3.36±0.69), and the lowest mean score was related to social integration (3.20±0.68). The social health of male students (3.33±0.55) was higher than that of female students (2.25±0.66). In addition, there was a significant relationship between the demographic variables and the total scores of social health components (p<0.05). Conclusion: The results of the present study demonstrated that the status of students’ social health was at a favourable and good level at Kermanshah University of Medical Sciences. It is hoped that the results of the present study pave the way for improving the dimensions of students’ social health. Therefore, it is suggested that workshops and training courses be considered for strengthening the social health of students more and more by the planners of the University of Medical Sciences.

Brainstem Auditory Evoked Potential in Preterm Infants and its Relation with Gestational Age

Introduction: Preterm births are associated with different neuro developmental abnormalities. During the last trimester of pregnancy, a part of foetal brain development occurs. Some area of the brain does not show normal growth even after the birth of preterm babies. Due to advanced obstetric and neonatal care of the present time, neonatal complications and mortality has reduced substantially. However, the preterm newborns experience many perinatal developmental abnormalities including prematurity of auditory pathway. Among the paediatric population, subjective tests for auditory evaluation are non reliable. Brainstem Evoked Response Audiometry (BERA), which assesses Brainstem Auditory Evoked Potential (BAEP), is a simple, non-invasive and an objective way of evaluating functional integrity of auditory pathway. Aim: To assess the neurological maturation and integrity of the auditory pathway by BAEP in preterm infants with respect to the gestational age. Materials and Methods: The present cross-sectional study was done in the Eastern region of India. A total of 74 preterm infants and 30 fullterm infants were included from the Department of Paeadiatrics, R.G. Kar Medical College, Kolkata, India. In the Department of Physiology, BAEPs were compared among preterm and full-term infants. The preterm babies were divided into three subgroups according to gestational age, Group 1 (=28 weeks); Group 2 (29-32 weeks); Group 3 (33-36 weeks). Intergroup comparison was done by Student’s t-test, ANOVA and Post-Hoc test. Results: Preterm babies had prolonged wave I, wave V latency and I-V Interwave latency in the right ear (p<0.05) In Group 1, wave V and I-V latency were prolonged in both the sides. Right sided prolongation of wave I and wave V latency were present in Group 2. Left I-V interwave latency was prolonged in Group 1 than Group 3. A total of 24 preterm infants had absent waves. Conclusion: Preterm infants had premature peripheral and central auditory pathway. Group 1 showed central pathway immaturity compared to term infants and Group 3. Group 2 showed immature peripheral pathway. Absent waves were present in all the groups but maximum in Group 3, suggestive of dysfunction of auditory pathway but exact location of pathology was uncertain.

Vibration Perception Threshold Values and Clinical Symptoms of Diabetic Peripheral Neuropathy

Anirudhan Arya Medakkel, Pavithran Sheela

Introduction: Diabetic Peripheral Neuropathy (DPN) causes damage to the peripheral nerves. Vibration Perception Threshold (VPT) helps to test the loss of protective sensation of the nerves. Aim: To find the association between VPT values and clinical symptoms of DPN. Materials and Methods: The descriptive study assessed association between the VPT values and clinical symptoms of 220 diabetic patients selected by purposive sampling. The VPT was measured by a sensitometer. A metal probe was placed under the toes of the patient and the voltage was increased gradually from zero and the transition from no vibration to the point of vibration is marked as VPT. Average of three measurements were taken to calculate the VPT value of the given patient. The VPT values were graded as ‘normal’ (<15v), ‘mild’ (15-20v), ‘moderate’ (20-25v) and >25 as ‘severe’ neuropathy. Data were collected using S-LANSS pain score and questionnaire on clinical symptoms of DPN. Frequency and percentage were used to analyse the sample characteristics and Fishers exact to find the association between VPT values and the clinical symptoms. Pearson’s correlation was computed between the VPT value and number of neuropathic symptoms. Results: Almost all 219 (99.5%) the patients were symptomatic and a moderate positive correlation (r=+0.59) was found between VPT values and clinical symptoms of DPN. Sensory symptoms were observed in 96.5% of patients. Clinical symptoms of diabetic peripheral neuropathy such as unsteadiness, slipping of foot from chappal, tingling, callus, dry skin, cut/ulcer, hyper pigmentation, black discolouration, oedema, pin and needle sensation (plantar), muscle cramps, night symptoms, osteomyelitis were significantly associated with VPT value. There was a positive correlation between VPT values and the number of symptoms of DPN (r=0.590). Conclusion: Diabetic patients are at risk for DPN and proper foot care is mandatory to prevent foot complications and probable amputation. So, VPT score can be considered an indicator of DPN and be used to identify high-risk patients.

Obstructive Uropathy with Renal Failure

Nambakam Tanuja Subramanyam, Girish P Vakrani

Introduction: Renal failure is often seen with Urinary Tract Obstruction (UTO), which could be acute or chronic (obstructive nephropathy). With early diagnosis and treatment, it is often reversible. The data being sparse in literature, hence this study was planned. Aim: The present retrospective study was undertaken to discuss about causes, pathophysiology, site of obstruction, clinical features, diagnostic tests, management and factors affecting renal failure outcomes in cases of obstructive uropathy. Materials and Methods: All outpatient and inpatient cases of obstructive uropathy in 2016 were included and were subjected for renal function tests, radiological investigations. Stenting, diversion surgeries were performed to relieve obstruction. Student’s t-test, Levene’s test, chi-square/Fisher Exact-test were used for statistical analysis. Results: Of the 107 patients enrolled, bilateral UTO, intrinsic cause, chronic obstruction (>3 months duration), acute on Chronic Kidney Disease (CKD), Acute Kidney Injury (AKI), most common site of obstruction was ureter, seen in 58 (54%), 78 (72%), 71 (66%), 63 (58%), 44 (41%) and 47 (43%) cases respectively. Among co-morbities, history of past Urinary Tract Infection (UTI), past urological surgeries and diabetes mellitus were seen in 70 (65%), 62 (57%), and 62 (57%) cases respectively. Among the aetiology, blood clots, abdomen lymphadenopathy, ureter calculus were seen in 62 (57%), 16 (15%), and 14 (13%) cases respectively. Most common symptom was pain abdomen present in 98 (91%) cases. Among the complications, UTI was seen in 65 (60%). Dialysis therapy and most common urological intervention, ureter stenting was needed in 38 (35%) and 37 (34%) cases respectively. Renal failure recovery, post obstructive diuresis, death were noted in 34 (31%), 25 (23%) and 18 (16%) cases respectively. Conclusion: Comparing with renal failure recovered group, the non recovered group had statistically significant dominant males, were much older, had higher incidence of congenital blocks, acute on CKD, Pelvi-Ureter Junction (PUJ) obstruction, blood clots, abdomen lymphadenopathy, weight loss, abdomen mass, mineral bone disorder, emphysematous Acute Pyelonephritis (APN), lower haemoglobin, leukocytosis, dialysis need and Extracorpeal Shock Wave Lithotripsy (ESWL) therapy.

Prevalence of Asymptomatic Atherosclerotic Plaque at Carotid Bifurcation in Individuals of 20-70 years of Age

Amit Kumar Choubey, Hirdesh Sahni, Mukul Bhatia, Samaresh Sahu

Introduction: Stroke is the second most common cause of death worldwide. Among 20-30% of all ischaemic infarcts are caused by carotid artery stenosis. Computed Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Digital Subtraction Angiography (DSA) and duplex imaging are the available modalities for evaluation of extracranial atherosclerosis. Duplex imaging for Carotid Intima-Media Thickness (CIMT) and plaque evaluation in carotid vessels is a good screening tool for atherosclerosis. No prevalence study for carotid atherosclerosis is available in Indian population. Aim: To determine the prevalence of asymptomatic atherosclerotic plaques and asymptomatic critical stenosis at carotid bifurcation in individuals of 20-70 years of age. Materials and Methods: The present prospective consecutive cross-sectional study was carried on 250 volunteers (125 males and 125 females) in the 20-70 years age group with no history of TIA/cerebral ischaemic stroke with 50 subjects in each decade. The carotid arteries of volunteers were screened by duplex imaging. Descriptive and inferential statistical analysis was carried out by statistical software SPSS 15.0. Results on categorical measurements were presented in Number (%). Results: Overall prevalence of carotid plaque was 14% in 20-70 years of age. Prevalence of plaque in Common Carotid Artery (CCA), Internal Carotid Artery (ICA) and External Carotid Artery (ECA) was 4%, 10% and 0.4% respectively. Plaque prevalence was 2%, 4%, 2%, 24% and 38% in age groups of 20-30 years, 31-40 years, 41-50 years, 51-60 years and 61-70 years respectively. Prevalence of percentage stenosis was 2% for 50-69% stenosis and 0.4% for >69% stenosis. Conclusion: In the present study, the overall prevalence of Carotid plaque was 14% and prevalence of percentage stenosis was 0.4% for >69% stenosis. So screening of asymptomatic population for carotid atherosclerosis is not recommended in view of low prevalence rate of significant stenosis and the management will remain same based on standard preventive therapy.

Clinical Profile, Predictors of Death and Anthropometric Follow up in Neonates with Classical 21-Hydroxylase Deficiency

Usha Devi Rajendran, Chinnathambi Kamalarathnam

Introduction: More than 95% of cases of Congenital Adrenal Hyperplasia (CAH) are due to 21-hydroxylase deficiency. This enzyme deficiency can present as either severe classic form or the non classic form. Severe classic forms present early in life and include the salt wasting and simple virilising types. Data regarding the clinical profile and particularly follow up of the neonates admitted with this deficiency are lacking in developing countries. Aim: To study the clinical profile, predictors of outcome and anthropometric parameters at follow up of neonates admitted with classical 21-hydroxylase deficiency. Materials and Methods: This observational study (retrospective part for clinical profile and predictors of outcome, prospective cross-sectional assessment of height, weight, z scores and adequacy of treatment on follow up) included 40 neonates admitted with classical 21-hydroxylase deficiency to newborn ward of Institute of Child Health, Tertiary Neonatal Teaching Hospital in Chennai, South India from September 2006 to September 2016. Descriptive statistics were used to describe baseline variables. Results: Out of 40 neonates, 22 presented with salt wasting and 18 with simple virilising type. Five babies were lost to follow up. Eight babies with the salt wasting and one with simple virilising form of CAH passed away on follow up. Presence of shock/severe dehydration, hyponatraemia (Na<125), weight loss in the salt wasting group at admission was not statistically significant predictors of their death. Poor compliance to medication was significantly higher in the parents who lost their children on follow up. Twenty-six children were present for recording anthropometric data after all the losses to follow up. Conclusion: A high index of suspicion of CAH in babies with typical clinical features will prevent any delay in diagnosis and treatment. Not only the acute management, but adequate counseling, compliance to medication and growth monitoring are also of utmost importance in managing these children.

Analysis of Functional Outcome Following Rigid Skeletal Stabilisation of Unstable Proximal and Middle Phalangeal Fractures of the Hand

Introduction: Phalangeal fractures commonly occur in hand injuries. As hand is a complex structure of bones, joints, ligaments, muscles, tendons and neurovascular structures, the biomechanics play an important role in mobility and dexterity of the hand. Operative fixation of these fractures with miniplates and screws allows for earlier mobilisation of the hand and hence avoids the complications of other methods of fracture fixation. This allows for shorter hospital stay and faster returns to work. Aim: This prospective study was undertaken to evaluate and analyse the functional outcome following rigid skeletal stabilisation and early mobilisation of fractures of proximal and middle phalanges of the hand with plate and screw technique. Materials and Methods: There were a total of 21 patients with 26 phalangeal fractures. All the data were collected from Government Chengalpattu Medical College Hospital, Chengalpattu during the period of December 2008 to December 2010. An informed written consent and x-rays of the hand were taken, pre and postoperatively. The fractures were reduced and fixed with miniplates and screws. The results were analysed using the Belsky’s criteria using the parameters of pain with or without union, deformity and total active flexion range of metacarpophalangeal and interphalangeal joints. Results:Among the patients, 84.6% of the fractures showed an excellent or good functional outcome and 15.4% had a poor outcome following rigid skeletal stabilisation. Eighteen (86%) fractures were in male patients, of third to fourth decade, involving mainly the proximal phalanx, due to Road Traffic Accident (RTA), with six patients having complications. Conclusion: Phalangeal fracture fixation with miniplates and screws gives a good functional outcome.

Effect of Botulinum Toxin Type A on Functional Mobility in Cerebral Palsy with Lower Limb Spasticity

Abhimanyu Vasudeva, Nonica Laisram, Asem Rangita Chanu

Introduction: Children with Cerebral Palsy (CP) often start walking much later than typically developing children and they do so with a slower speed and higher energy cost. Mobility varies across different environmental settings and Functional Mobility Scale (FMS) was devised to illustrate functional mobility in these children over three distinct distances, chosen to represent mobility in the home, at school and in the wider community. Botulinum toxin A injections into the gastrocnemius muscle for equinus foot deformity, as well as multilevel lower limb injections have shown improvements in gait, however, there is paucity of literature on its effect on functional mobility. Aim: To study the efficacy of Botulinum toxin A injection in CP with lower limb spasticity in terms of reduction in spasticity and effect on functional mobility. Materials and Methods: A total of 31 children were enrolled and evaluated for various outcome measures just before injection and at 4 and 12 weeks after injection. Change in FMS on follow-up was analysed using Wilcoxon signed-rank test. Spearman’s correlation analysis was performed between the number of injected muscles in each child and change in FMS scores on follow-up. A p-value of <0.05 was considered statistically significant. Analyses were done using SPSS version 21.0 statistical software (IBM Corp., Armonk, NY). Results: At distances of 5, 50 and 500 meters, FMS showed statistically significant improvement at four weeks (p-value <0.001 at 5; 0.002 at 50; 0.006 at 500 meters) and at 12 weeks (p-value <0.001 at 5; 0.001 at 50; 0.002 at 500 meters) compared with baseline but no significant change from 4 to 12 weeks (p-value=0.102 at 5; 1.000 at 50; 0.157 at 500 meters). There was moderate positive correlation between the number of injected muscles in each child and the change in FMS from baseline to 12 weeks at 5 meters distance; however, a moderate negative correlation was observed for the same at 500 meters. Conclusion: Local injection of Botulinum toxin A is effective in reducing the lower limb (gastrocnemius, hamstring, adductor) spasticity in CP children. It also improves the FMS in CP children.

A Study of Men’s Sexuality and their Attitude during their Wives’ Pregnancy

Introduction: Pregnancy is a very sensitive period that is often accompanied by changes in the couple’s sexual relationship due to various physical and psychological changes. Aim: The purpose of this study was to evaluate men’s sexuality and their attitude toward sexual relationship during their wive’s pregnancy. Materials and Methods: The present cross-sectional study was conducted on the husbands of 272 pregnant women who attended healthcare centers of Jahrom, Iran, from March 2016 to May 2016. International Index of Erectile Function (IIEF) questionnaire was used to assess the sexual function. T-test utilised to compare overall satisfaction score with characteristics of the participants, ANOVA test used in order to compare domains of male sexual function with pregnancy trimesters. Besides, p-value <0.05 was considered as statistically significant. Results: The husband’s mean age was 32.57±6.12 years. Of the total 62, 81, and 129 subjects were in their first, second and third trimesters, respectively. Comparison of the first, second and the third trimesters revealed a significant difference in the scores of all IIEF domains. Among the study subjects, 82.7% had erectile dysfunction, 84.2% had orgasmic dysfunction, 92.64% had sexual desire dysfunction, 95.6% had intercourse dissatisfaction, and 80.1% had overall dissatisfaction. Almost 62.2% of the men displayed a negative attitude towards sexuality and only 11% men had positive attitude. Conclusion: The results of the present study showed that sexual disorders were highly prevalent among men. The most prevalent sexual dysfunction was desire disorder and intercourse dissatisfaction. Since, attitude towards sexuality affected their general sexual behaviour during pregnancy, it is crucial to provide proper consultation regarding sexual relations in prenatal care services.

Endoflas FS Decreases the Viability and Mineralisation Process in Human Alveolar Osteoblastic Cells

Introduction: Endoflas FS, a root canal filling material, is indicated for the endodontic management of deciduous teeth. Several studies have shown undesirable effects of Endoflas FS on periodontal tissues. It is important to determine the possible toxic effects of Endoflas FS on osteoblast cells, as a small amount of microfiltration may exist following obturation of the root canal resulting in a direct contact with bone cells. Aim: To evaluate the effect of different amounts of Endoflas FS on viability, mineralisation and production of TNF-a and IL-6 in a human alveolar osteoblastic cell line. Materials and Methods: The present in vitro study was done using a human alveolar osteoblastic cell line which was exposed to different amounts of Endoflas FS. The MTT assay was performed to determine the cell viability (2-24 hours). Mineralisation was evaluated by red alizarin at 7-14 days. The production of TNF-a and IL-6 was determined by Enzyme-Linked Immunosorbent Assay (ELISA) at 12 and 24 hours. Results: At high amounts Endoflas FS decreased the viability of osteoblasts and reduced the formation of mineralisation nodules and the production of IL-6 and TNF-a. Conclusion: At low amounts Endoflas FS may not generate changes in osteoblastic cells; however, at high amounts Endolfas FS may be toxic, decreasing cell viability and mineralisation.

Neostigmine as an Adjuvant to Caudal Bupivacaine in Paediatric Population

Manjit George, Sheela Prabhakaran, Maya Gomathyamma

Introduction: Postoperative pain in children is very distressing for the parents as well as the Anaesthesiologist involved. Pain assessment in children has its limitations. Caudal analgesia is the most popular central neuraxial block in paediatric age group for perioperative analgesia and attenuation of stress response particularly in infra umbilical surgeries. Use of adjuvants to local anaesthetic agents enhance the duration of analgesia. Aim: To assess the efficacy of Neostigmine as an adjuvant to Bupivacaine in Caudal blocks in paediatric inguinal herniotomies. Materials and Methods: This was a prospective, double blinded randomised clinical study. Forty ASA1 children in the age group, 2-6 years, were randomly allocated to two groups (n=20 each). The 1st group (Group B) received caudal injection of 0.25% Bupivacaine 1 mL/kg plus 1 mL NS after induction of general anaesthesia. The 2nd group (Group BN) received caudal injection of 0.25% Bupivacaine 1 mL/kg plus Neostigmine 2 mcg/kg made up in 1 mL NS after administration of general anaesthesia. Both groups received IV Ondansetron 0.1 mg/kg towards the end of the surgery. The pain scores, haemodynamic parameters, requirement of analgesics, duration of sedation and motor block, time to first micturition and incidence of nausea and vomiting were studied. The quantitative data was statistically analysed using Student’s t-test. Results: Demographics were similar and haemodynamics were stable in both groups. Better analgesia was noted in Group BN compared to Group B (15.16 hours vs 6.52 hours) with more post op analgesic requirement in group B compared to Group BN. There was no incidence of nausea and vomiting in both groups. Conclusion: Addition of Neostigmine as adjuvant to Bupivacaine in Caudal block resulted in superior analgesia in post paediatric inguinal herniotomy patients with lesser requirement of postop analgesics. Use of IV Ondansetron towards end of surgery prevented postoperative nausea and vomiting.

A Study on Drug Use and Medication Management Perspectives among Elderly and the Impact of Professional Oversight

Arunava Biswas, Nirmalya Sinha, Krishnangshu Ray, Santanu Kumar Tripathi

Introduction: The geriatric population of the world is increasing, who very often suffers from multiple comorbidities and exposed to polypharmacy by multiple treating physicians. Aim: The study attempts to understand the challenges of pharmacotherapy in the elderly and to explore if expert oversight could address such problem optimally. Materials and Methods: A prospective, randomized, observational and interventional community based study was conducted for a year on 75 elderly subjects (>60 years) of either sex in a specific semi urban community who were randomly divided into supervised (n=40) and unsupervised (n=35) groups. The supervised group received professional counselling and guidance throughout the study period where as the other group were just routinely followed up every two months and data were collected in predesigned and validated questionnaire at each intervention. Results: Knowledge regarding medicines like the dose, frequency, duration of treatment etc., was limited across the study subjects. The impact of supervision on medication adherence was evident in the supervised group (p <0.0001). Inappropriate medication was found in almost one third of study subjects with no significant impact of professional supervision. Compliance was a very big challenge across all the elderly subjects and the most common cause for not taking medicines at regular basis was forgetfulness (41.33%) followed by inconvenience of some sort in taking medicines (13.34%) which remained unaffected by supervision. Conclusion: Communication between patient and health care provider has a significant role to play though limited for medication use and its management among the elderly subjects. Continuous monitoring by professional experts can exert a positive impact on the quality of health of the elderly population.

Utility of Acridine Orange Fluorescence Microscopy in Cytodiagnosis of Oral Lesions

Vaishali Verma, Amarjit Singh, Sudarshan Kapoor, Davsheen Bedi

Introduction: Oral exfoliative cytology is a reasonably effective technique for rapid initial evaluation of suspicious lesions. Exfoliated cells obtained from saliva, lavage or scrapings are ideally stained with Papanicolaou stain. Acridine orange stain imparts nuclear and cytoplasmic fluorescence in malignant cells which have increased nuclear activity. This cytochemical property can be utilized for diagnosis of cancer. Aim: The aim was to determine utility of Acridine Orange (AO) fluorescence microscopy as a rapid and easier method for oral cytodiagnosis as compared to Papanicolaou stain. Materials and Methods: The study group included a total of 50 cases, 25 cases clinically suspicious of malignancy (Group I) and 25 non suspicious cases, e.g., inflammatory lesions etc., (Group II) in both sexes, aged > 40 years. The control group comprised 5 individuals in the age group of 20 years and above, without any clinically observable lesions. Scrapings were obtained from oral mucosa, stained with AO and Pap stains, visualised with fluorescence and light microscopy, respectively, and results were compared & analysed statistically. Results: AO staining: Amongst 25 cases in group I, 18 were confirmed as Squamous Cell Carcinomas (SCC) on histopathology. Sixteen out of 18 confirmed cases (88.89%) showed greenish yellow nuclear fluorescence with brownish red cytoplasmic fluorescence. In group II, 18 cases showed too little fluorescence to be labelled as positive with limited nuclear details which were hence counted as negative for fluorescence. Papanicolaou staining: In group I, 13 out of the 18 confirmed cases (72.22%) were positive for malignancy. In group II, only one case was false positive for malignancy and the rest were negative. The differences between the two groups were compared using Chi-square test. A p value of less than 0.05 was considered statistically significant. Conclusion: AO stain reliably demonstrated malignant cells based on differential fluorescence – a cytochemical criterion. Thus, AO proved to be more sensitive than Papanicolaou staining for diagnosing malignancies. Hence, it can be used for screening and early detection of potentially malignant lesions.

Association between Coronary Artery Ectasia and Neutrophil:Lymphocyte Ratio

Introduction: Inflammation, endothelial dysfunction and atherosclerosis are associated with the aetiopathogenesis of Coronary Artery Ectasia (CAE). The Neutrophil to Lymphocyte (N/L) ratio has emerged as a new inflammation marker for cardiovascular disease. Aim: To assess the association between the CAE and the N/L ratio. Materials and Methods: A total of 179 patients with isolated CAE, Obstructive Coronary Artery Disease (O-CAD) and normal coronaries (controls) were enrolled. Clinical characteristics and pattern of ectatic involvement were seen. N/L ratio values were compared between the three groups using Analysis of Variance (ANOVA). Results: Study findings showed that the patients with isolated CAE had significantly elevated N/L ratio values compared to O-CAD and control groups (2.63±0.36 vs. 2.20±0.27, p<0.001 and vs. 1.93±0.24, p<0.001) respectively. Right Coronary Artery (RCA) was the most commonly involved ectatic artery (64.2%). Single vessel ectasia (44.6%) and Type IV (32.1%) were the most common pattern of involvement. Conclusion: In present study, we found that patients with isolated CAE had a significantly higher WBC count and N/L ratio than patients with O-CAD and control groups. This finding suggests that severe inflammatory process could be involved in the development of CAE as compared to CAD.

Changing Antibiogram Profile of Acinetobacter baumannii in Diabetic and Non-Diabetic Foot Ulcer Infections

Diwan Mahmood Khan, MS Moosabba, I Venkatakrishna Rao

Introduction: Foot ulcer infection relies on the hosts immune status and pathophysiological condition. The differences between Diabetic Foot Ulcer Infections (DFU) and non-DFU patients may alter the biofilm-forming capabilities of microorganism and thereby playing a key role in regulation of ulcer healing. Extended Spectrum of ß-Lactamase (ESBL) and Metallo-ß-Lactamase (MBL) producing Acinetobacter baumannii isolates are reported as important causative agents of infection. Aim: To determine the antimicrobial susceptibility, ESBL, MBL production, and biofilm formation in A.baumannii among diabetic and non-diabetic foot ulcer patients. Materials and Methods: This is a hospital based study, done for a period of 10 months. Samples were collected from general surgery outpatients and inpatients suffering from foot ulcer infections and also include wagner grade II to V. Pus/tissue was collected and processed for standard methods of culture, antimicrobial susceptibility, biofilm formation assay, ESBL, MBL, Modified Hodge Test (MHT) and Minimum Inhibitory Concentration (MIC). Results: A total of 70 bacterial isolates were obtained from 400 patients with DFU and non-DFU from pus and tissue specimens. Antibiogram profiles of DFU isolates were sensitive to colistin and resistant to all the major groups of antibiotics classes. Non-DFU isolates were sensitive to amikacin, ceftriaxone, gentamicin piperacillin/tazobactam, imipenem, meropenem, colistin and resistant to ceftazidime, cefotaxime, ciprofloxacin, co-trimoxazole, piperacillin, tetracycline in A.baumannii isolates. This result showed that DFU isolates 13/35(37.14%) were ESBL, MBL 10/35 (28.57%) and showed strong biofilm formation 9/35(25.71%). Non-DFU isolates were ESBL 8/35 (22.85%), MBL 5/35 (14.28%) and showed strong biofilm formation 3/35 (8.57%). Almost all the isolates of Multi-Drug Resistance (MDR) are ESBL and MBL producer as well as biofilm formers. Conclusion: Colistin is the drug of choice for the efficient treatment of multi-drug resistant isolates of foot ulcer patients. The rapid spreading of ESBL, MBL producers, and MDR require the implementation of not just surveillance study but also proper and rational selection of antibiotics, especially for MDR for better clinical outcomes.

Effectiveness of Formative Assessment in Motivating and Improving the Outcome of Summative Assessment in Pharmacology for Medical Undergraduates

Kala Parvathy Kesavan, Dhanya Sasidharan Palappallil

Introduction: Assessment is a basic component of teaching and learning. Formative assessment (FA) with timely comprehensive feedback can prepare the students to be good learners. Aim: To understand the role of FA in changing the outcome of summative assessment in Pharmacology. Materials and Methods: This was an interventional study done in Government Medical College for a period of one year. A supplementary batch (n=27) which wrote Pharmacology university exams in September 2016 formed the sample. Monthly tests were conducted among the participants and feedback on their perceptions on FA was collected using a structured questionnaire at the end of course. Short answer questions on topics covered during the study period were conducted at a frequency of one month. The Summative Assessment (SA) marks of participants were compared with that of all students of the affiliated university as well as with that of the previous year’s supplementary batch of the Institution. The data were analysed using SPSS 16. Unpaired t-tests and correlation was done to assess the effectiveness of FA. Results: The mean scores of the intervention batch (54.04± 4.86) was better than that of the non-intervention batch (49.18± 7.81) as well as whole university score (50.68 ± 8.50) and it was statistically significant. A positive correlation was seen between the marks gained in formative and SA. Majority opined that FA guided them for subsequent performances by strengthening knowledge in the subject. Conclusion: FA can improve the outcome of SA. It may be positively correlated to the performance in SA. Well-designed FA should be used in medical education to assist students in learning.

Validity and Usefulness of Revised WHO Guidelines in Children with Dengue Fever

Introduction: Dengue fever is the most rapidly spreading mosquito borne viral infection with a 30-fold increase in the disease burden over last five decades with a variable clinical course and outcome. The World Health Organization (WHO) published treatment guidelines in 1997 and further revised in 2009 to facilitate early diagnosis and intervention in severe cases. Aim: To evaluate the validity and usefulness of Revised 2009 WHO guidelines in comparison to 1997 guidelines in children with dengue fever. Materials and Methods: All children (0-12 yrs of age) diagnosed and confirmed as dengue fever admitted at a tertiary care hospital in Puducherry from 1st August 2012 to 31st December 2015 were reviewed retrospectively from hospital case records. All children were classified as per the 1997 and 2009 Revised WHO guidelines for dengue fever. Results: Out of 434 children admitted with dengue fever the diagnosis was confirmed in 294 cases (67.7%). The mean age of presentation was 7.0(3.3) years. M:F ratio was 1.1:1. As per 1997 WHO guidelines the cases were classified as dengue fever 246(83.7%), dengue haemorrhagic fever 22(7.5%) and dengue shock syndrome 26(8.6%). As per WHO 2009 guidelines they were classified as dengue without warning signs 42(14.3%), dengue with warning signs 215(73.1%), and severe dengue 37(12.6%). Dengue fever requiring early intervention as per 1997 and 2009 WHO guidelines were seen in 96(27.2%) and 153 cases(52%) respectively. The most common manifestation of severe dengue infection was shock (40.1%), bleeding (20.4%) and multiorgan failure (2.0%). Conclusion: The revised WHO 2009 dengue fever guidelines classified more cases requiring early and timely intervention but remained to be too broad and non-specific in terms of pathophysiology, fluid management and use of blood products. Our experience recommends a need for further modifications in the guidelines especially with changing epidemic pattern of presentation.

Effect of Blood Transfusions on Oxidant/Antioxidants Balance in Beta Thalassaemia Major Patients

Introduction: Thalassaemia is the major health problem all over India which is prevalent amongst all population groups irrespective of caste, religion and creed. Number of studies from different parts of the country provides the data on distribution of various haemoglobinopathies but there are limited data from Northern Maharashtra, India. Regular blood transfusion is one of the conventional treatments for survival in patients with Beta Thalassaemia Major (BTM). This may cause oxidative stress and tissue injury due to iron overload and altered antioxidant enzymes. Aim: To assess the effect of number of blood transfusions on oxidant/antioxidant balance in patients with beta thalassaemia major of North Maharashtra region. Materials and Methods: Patients were divided into two groups on the basis of number of blood transfusions. Group A having number of transfusion =140 and Group B having number of transfusion >140. These groups were compared on the basis of haematological and biochemical parameters. Results: Iron overload in Group B than Group A was indicated by significantly (p<0.0001) high levels of iron, ferritin and Transferrin Saturation (TS) with significantly low level of Total Iron Binding Capacity (TIBC). Oxidative stress in Group B is higher indicated by significantly (p<0.0001) high level of Malondialdehyde (MDA) and Copper (Cu) with significantly low levels of Glutathione Peroxidase (GPx), Zinc (Zn) and vitamin C than Group A. We also observed non significant difference in Superoxide Dismutase (SOD) and serum Ceruloplasmin (CP) in both groups. Conclusion: The above data implies that after each blood transfusions, accumulation of free iron in the body of thalassaemic patients increases. This excess iron deposited in body tissues leads to many pathophysiological conditions like expanded plasma volume, cardiac output, reduced glucose tolerance, hepatitis, various endocrine abnormalities, cardiac and renal dysfunctions. Estimation of these biochemical parameters along with blood transfusion would help in early detection of the associated complications in these patients. This would be quite helpful to reduce the burden of this disease through preventive measures.

The Lipase Activities of Malassezia Species Isolated from Seborrhoeic Dermatitis/Dandruff Patients

Introduction: Malassezia a commensal yeast, can become pathogenic leading to different clinical forms of dermatosis. Being an obligatory lipophilic, the lipolytic enzymes produced by them help in their growth by obtaining useful lipids from the environment further contributing to the pathogenesis of dermatosis. There are no comparative reports concerning secreted lipase activities of Malassezia species associated with Seborrhoeic Dermatitis/Dandruff (SD/D). Aim: To analyse and compare lipase activities of Malassezia spp. isolated from SD/D patient’s lesional area and Healthy Controls (HC) and correlates this feature in pathogenesis of SD/D. Materials and Methods: Lipase activities of Malassezia species isolated from lesional area of SD/D patients and HC were analysed and compared. Extracellular proteins of Malassezia spp. were extracted from the Leeming and Notman agar after removing and weighing the yeast cells from the agar surface. The lipase activity was measured using an assay based on hydrolysis of p-Nitrophenylpalmitate (pNPP). ANOVA test and GraphPad were used for statistical analysis. Results: Malassezia furfur wet fungal weight was higher (1.1±0.13 g) compared to M. globosa (0.36±0.4 g) and M. restricta (0.26±0.4 g). The mean extracellular lipase activity of M. globosa (0.15 U) and M. restricta (0.18 U) was significantly higher than M. furfur (0.08 U) isolates (p<0.001). No significant difference was observed among M. globosa (SD/D-0.15 U vs. HC-0.14 U), M. restricta (SD/D-0.2 U vs. HC-0.16 U) and M. furfur (SD/D-0.08 U vs. HC-0.1 U) isolated from SD/D patient’s lesional area and HC. Conclusion: The lipase activity of M. globosa and M. restricta was higher despite slow growth rate. Lipase activity alone may not play a role in the onset of SD/D. As the pathogenic mechanism of fungi is complex, it is difficult to explain the pathogenicity of Malassezia based only on lipase activities.

Trends in Septicaemic Patients Admitted in Tertiary Care Teaching Hospital in Andhra Pradesh, India

Uma Mylandlahalli Anandkumar, Nagarajan Natarajan, Revathi Jeripiti

Introduction: Septicaemia is one of the significant causes of morbidity and mortality in Intensive Care Units (ICUs). The rate of antimicrobial resistance in ICU is very high compared to general hospital setting. Aim: To enumerate common bacterial pathogens causing sepsis and to identify their antimicrobial susceptibility pattern. Materials and Methods: This was a retrospective descriptive study done in patients with sepsis during January 2016 to December 2017. The Institutional Ethical Committee clearance was obtained. Data were collected from inpatient case files regarding clinical history, laboratory parameters with special reference to causative organisms and antibiotic sensitivity pattern. Data were entered in Microsoft Excel sheet and analysed using strata 14.0. Results: Among 216 subjects of sepsis admitted to ICU during study period, 130 (60.1%) were males, with mean age of 52.83 year (±16.6 SD). Pneumonia (31.94%) was the major cause of sepsis followed by urosepsis. Gram negative organisms were the major cause of sepsis accounting for 76.25% of organisms isolated. Escherichia coli was the most common organism isolated in urine (65.9%) and blood cultures (32%). All Gram negative bacteria had high level of resistance to Amoxicillin Clavulunic Acid (Amoxyclav) (85.9%), ampicillin sulbactum (66.7%) and third generation cephalosporins (70%). Conclusion: Gram negative organisms were the principal causes of septicaemia. Cephalosporin resistance was more than 70%. Acinetobacter species was resistant to most antibiotics. The knowledge of bacterial profile of sepsis and antibiotic susceptibility pattern not only helps in improving outcome but also prevents emergence of drug resistance strains.

Prevalence of Inborn Errors of Metabolism in Neonates

Preeti Sharma, Pradeep Kumar, Mayurika S Tyagi, Rachna Sharma, PS Dhot

Introduction: Among the most advanced public health promotion and disease prevention programs, the newborn screening is of paramount importance, seeking timely detection, diagnosis and treatment of genetic disorders which may otherwise lead to serious consequences upon the health of newborn. Aim: To evaluate the prevalence of Inborn Error of Metabolism (IEM) disorders among neonates of various ethnic or racial groups from east, west, north and south, zones of India through newborn screening. Materials and Methods: A cross-sectional, population based prospective study was conducted at PreventiNe Life Care Laboratories, Navi Mumbai, Maharashtra, India. Study was conducted for a period of three years from October 2012 to November 2015. Mass screening of newborn blood samples was done via TMS/GCMS/Enzyme assay/HPLC/ELISA technique. The blood and urine samples were used for analysis. The samples have been collected from 150 locations through various hospitals across India. Samples obtained were categorised zone wise (east, west, north, south zones of India). For analysis of blood, samples were collected by heel prick method. Results: In the present study, 2.9% prevalence (of the total 70,590 samples analysed, 2053 cases were found positive) of IEM was observed. Of these positive cases, 13% (279 of 2053 positive cases) cases belonged to eastern zone, 24% (493 of 2053 positive cases) were from northern zone, 38% (793 of 2053 positive cases) were from southern zone and 23% (488 of 2053 positive cases) were from western zone. Among these, the highest prevalent disorder was found to be G6PD deficiency, with 1.3% (923 positive of 70,590) cases reported followed by haemoglobinopathies, 0.5% (360 positive of 70,590) and congenital hyperplasia with 0.34% (239 positive of 70,590) cases of the total newborns, screened. Conclusion: The newborn screening is expanding its wings throughout the world. The outcome of present data offers a unique opportunity to explore the birth prevalence of inborn metabolic disorders in the current population. Understanding the birth prevalence of these disorders in India from its various zones will definitely improve the short term and long term medical needs faced by affected communities.

Relationship between Anthropometrics Characteristics and Dynamic Balance in Children of Anand City, Gujarat

Nirav P Vaghela, Jigar N Mehta, Dhruveshi Rana

Introduction: Paediatric physical therapists use a variety of functional balance screening tools developed for adults including the Functional Reach Test (FRT), the Time Up and Go test (TUG), and the Berg Balance Scale (BBS). Aim: To assess the relationships among age, gender, anthropometrics and dynamic balance in 5 to 12 years of children in Anand city, Gujarat, India. Materials and Methods: Cross-sectional study was conducted in which 150 school going children of 5-12 (75-females, 75-males) years were recruited from the school of the Anand city, Gujarat, India. Height, weight, arm and foot length were measured. Dynamic balance was assessed using TUG, FRT, Paediatric Balance Scale (PBS). Results: Positive relationship (r=0.58 and r=0.77) were found between increasing age and FRT and PBS scores. A negative relationship (r=-0.46) was observed between age of males and TUG test. Significant gender by age group difference was observed in FRT. Arm length and height has the strongest influence on FRT. Age, height, foot length and arm length has the strongest influence on PBS. Conclusion: Age and arm length have the strongest relationship with the dynamic balance (FRT, PBS). It helps the paediatric therapists in selecting dynamic balance test according to the age.

Diagnostic Value of Digital Radiography in Gap Detection of Implant-Abutment Connection with Zirconia Abutments in Different Vertical X-ray Projection Angles

Marzieh Alikhasi, Alireza Salehi, Maryam Memarian, Mahtab Tabesh

Introduction: Accurate seating of abutments on implants is an important factor for long term success of implant supported restorations. Among different methods of evaluating abutment seating, radiography is most commonly used, while some clinical factors such as angulation of radiography film and radiography tube can adversely affect its diagnostic value. Aim: To evaluate diagnostic value of digital periapical radiographs in terms of sensitivity, specificity and accuracy of gap detection at implant-abutment connection with different angles of X-ray projection when using a zirconia abutment. Materials and Methods: In this in vitro study radiographs were made of three different implant connections (internal tri-channel, external hex and internal hex with platform switching) to which zirconia abutments were fastened, once with and once without using a spacer between implant and abutment. Radiographs were taken at different projection angles of -20, -15, -10, -5, 0, +5, +10, +15, and +20. Then 10 prosthodontists were asked to assess all the radiographs, two times for each one with an interval of 10 days. Sensitivity, specificity and accuracy indices were calculated for each system. Results: Findings showed that sensitivity of gap detection in all study groups was amongst acceptable range (85-100%). In general external hex connection system showed better results (95-100%) while the platform switching internal hex system had the weakest results (85-100%). Conclusion: Angle of X-ray projection is better to be between -10 to +10 when evaluating complete seat of zirconia abutments on implants especially if a platform switching system is used.

Evaluation of Indications of Saline Infusion Sonohysterography in a Private Hospital in Nigeria: A Retrospective Study

Introduction: Despite the obvious advantages of Saline Infusion Sonohysterography (SIS) in the evaluation of infertile couples, its uptake is still poor in developing countries. Aim: To evaluate the indications and findings of SIS and also to compare the findings in the fallopian tubes of women who had Hysterosalpingography (HSG) before SIS. Materials and Methods: This was a retrospective study of consecutive SIS done in 27 women with infertility and 1 woman with abnormal uterine bleeding at The Light Specialist Hospital Nnewi, Anambra, Nigeria (November 2012 to May 2017). The ultrasound registers were used to identify women who had SIS. Relevant information was extracted from their folders and ultrasound records. These included sociodemographic characteristics, parity, and indication for the procedure, previous HSG findings and findings from the SIS. Data obtained were entered into SPSS version 24.0 and analysed. Results: The mean age of the women was 33.6±7 years with 13 (46.4%) out of 28 being greater or equal to 35 years. The mean duration of infertility was 3.4 years. A total of 28 women had SIS during the study period and the procedure could not be completed in one of the patients. Twenty one of the patients had done a HSG before presentation with bilateral tubal blockade demonstrated in 17 of the women while the procedure could not be completed in the four other women. Twenty-two of the women showed spillage of saline during the SIS procedure, of which 12/22 had previously been shown to have bilateral tubal blockade by HSG. Within six months after the procedure, six women had spontaneous intrauterine pregnancy one of whom was diagnosed with tubal blockade by both HSG and SIS. Conclusion: This study has demonstrated the usefulness of SIS as part of the initial investigations for tubal factors in the management of subfertility. The procedure should be made accessible and available to the women who need it especially in developing countries with high burden of tubal factor infertility.

Comparison of Patients with Ankylosing Spondylitis and Non-radiographic Axial Spondyloarthritis-A Cross-sectional Study

Uday Prabhakar, Anup Singh

Introduction: The Assessment of Spondylo Arthritis International Society (ASAS) classification criteria for Axial Spondyloarthropathy (axSpA) published in 2009 aimed to achieve a greater sensitivity in diagnosing patients of axial spondyloarthritis. Whether the radiographic form Ankylosing Spondylitis (AS) and the Non Radiographic Axial Spondyloarthritis (nr-axSpA) form, are subgroups or different phases of the same disease is a pertinent question because this could have affected the pharmacological management of the two subgroup. Whether a distinction between AS and nr-axSpA in clinical practice is useful, remains unknown. Therefore, the present study was undertaken with the following aim. Aim: To investigate the differences in clinical presentation and disease activity between nr-axSpA and AS. Materials and Methods: A cross sectional study was conducted in Division of Rheumatology, Banaras Hindu University, Varanasi, India from January 2016 to June 2017. All the patients presenting with history of chronic back pain for =3 months and age at onset =45 years after taking written informed consent were included in the study. Using the ASAS criteria, patients were then classified into two groups of 50 patients each, patients having AS (if there was sacroilitis on radiographs as defined in modified New York criteria) and nr-axSpA diagnosed using ASAS criteria. The various SpA related variables were then compared including gender, age, duration of illness, enthesitis, dactylitis, uveitis, peripheral arthritis, psoriasis, family history, Human Leucocyte Antigen (HLA) B27 positivity, baseline C-Reactive Protein (CRP), baseline Erythrocyte Sedimentation Rate (ESR), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI). Results: Patients with AS, as compared with nr-axSpA had a longer disease duration {4.5(1.875-8.250) vs. 2.0(1.000-4.000); p-value 0.023} and had a significantly higher levels of objective markers of inflammation i.e., CRP {4.7(2.325-6.525) vs. 2.20(0.588-4.125); p-value<0.001)} and ESR {(41.98±16.936 vs. 34.20±14.552; p-value 0.015)}. No statistically significant difference was found in age of onset, male: female ratio, enthesitis, dactylitis, uveitis, peripheral arthritis, psoriasis, family history and HLAB27 positivity. Neither any statistically significant difference was noted between the mean BASDAI and BASFI in the two groups. Conclusion: Other than elevated levels of markers of inflammation (CRP/ESR) and a longer disease duration in AS, most other features do not vary significantly between the two groups. Thus, the two groups might represent same disease in different phases.

Comparative Study of Etomidate and Midazolam with Fentanyl as Inducing Agents in Patients Undergoing Off-pump Coronary Artery Bypass Graft Surgery

Introduction: Off-pump Coronary Artery Bypass Graft (CABG) surgery has promising out come with minimal morbidity and mortality. Conduction of anaesthesia is still a challenge in Coronary Artery Disease (CAD) patients. Agents used for induction of general anaesthesia adversely effects haemodynamics. Etomidate is considered the agent of choice in such patients but it has its own adverse effect. Aim: To compare etomidate and midazolam-fentanyl as inducing agents in patients undergoing off-pump CABG and to monitor the haemodynamic changes during induction, laryngoscopy and intubation. Materials and Methods: Patients of both sex with CAD registered for CABG of age between 40 to 80 year and American Society of Anesthesiologist (ASA) grading I-IV, were divided in two groups (n=30). All patients received morphine 0.2 mg/kg intramuscularly 30 minutes before entering operation theatre. Group I patients received etomidate 0.5 mg/kg intravenously and Group II patients received midazolam 0.1 mg/kg+fentanyl 5 µg/kg slow intravenously for induction. The laryngoscopy and intubation was facilitated with rocuronium bromide 0.9 mg/kg and anaesthesia was maintained with O2 and N2O in 1:2 ratio with isoflurane 0.6%. The chi-square test was used. All the statistical analysis was carried out by using SPSS 16.0 version. Results: Heart rate was lower in Group I (71.00±5.00 beat/minutes) as compared to Group II (76.87±7.16 beat/minutes). In both the group maximum decline was observed after induction but before intubation and maximum increase at one minute after intubation. Systolic Blood Pressure (SBP) (135.4±8.00 and 127.93±12.95 mmHg) and Diastolic Blood Pressure (DBP) (72.20±6.31 and 62.73±7.03 mmHg) were significantly lower before induction (82.13±7.22 and 87.00±6.10) respectively. The SBP (147.20±80 and 158±8.39 mmHg) and DBP (83.67±7.28 and 90.40±5.49) were significantly rise after one minute intubation and gradually lower to baseline approximately 10 minutes after intubation in both groups. Conclusion: In both the groups variation in haemodynamic was in the same trend but range of variation was less (10%) in patients induced with etomidate, and more in patients induced with midazolam and fentanyl (20-30%).

Non Linear Heart Rate Variability Study During Pregnancy in Indian Women

Manish Sawane, Rakhee Ambade, Anjali Kawthalkar

Introduction: Adaptation of Autonomic Nervous System (ANS) in pregnancy can be suitably assessed by Heart Rate Variability (HRV). Non linear methods of HRV better quantify the chaotic dynamics of HRV. However, non linear HRV studies are not found in literature for Indian pregnant women. Aim: To investigate the adaptation of autonomic control during pregnancy based on non linear HRV analysis. Materials and Methods: Twenty five normal healthy non pregnant volunteer women and 22 pregnant women underwent various analyses of HRV following a standard sampling. Time domain and frequency domain measures as well as non linear analysis parameters of HRV were compared between same pregnant women in first and third trimester by paired Student's t-test as well as with non pregnant women as controls by unpaired Student's t-test. Results: Time domain, frequency domain and even non linear parameters of HRV showed no statistically significant differences in control group and pregnant women during first trimester. Comparison between control group and pregnant women in third trimester showed statistically significant alterations in absolute High Frequency (HF) power, Root of Mean Squared Standard Deviation (RMSSD) of RR intervals and some non linear parameters like Standard Deviation 1 (SD1) and correlation dimension D2, whereas almost all the parameters both linear and non linear showed statistically significant differences with progression of pregnancy from first to third trimester. Conclusion: Normal pregnancy is characterised by enhancement of sympathetic component and attenuation of parasympathetic component of ANS. Decrease in non linear HRV parameters suggested decreased complexity of the autonomic control system. Non linear HRV parameters were altered to a larger extent than linear HRV parameters suggesting a need to study non linear parameters while doing HRV analysis. Further longitudinal studies with large sample size are needed to generate normative data of linear and non linear HRV parameters in pregnancy.

A Six Year Trend in Treatment Outcomes among Tuberculosis Patients and its Determinants in Andaman and Nicobar Islands

Shivani Rao, G Jahnavi, SP Burma, Pandurang V Thatkar

Introduction: Directly Observed Treatment Short (DOTS) course strategy is aimed at diagnosing 70% of infectious Tuberculosis (TB) and curing 85% of it. Aim: To analyse the trend in TB treatment outcomes in the newly diagnosed patients from 2010 to 2015 in Andaman and Nicobar Islands. Materials and Methods: A retrospective cohort study was conducted among TB patients registered from 2010 to 2015 at DOTS TB State Center. Patient particulars like age, sex, TB category at the beginning, and treatment outcomes were collected from the records that were available with DOTS. Results: Incidence of TB in Andaman and Nicobar islands was about 171 per 1,00,000 population during 2010 to 2015, a total of 3917 cases were registered. The total annual new case detection rate increased from 72% to 78%, treatment success rate increased from 84.9% to 89.3%, default rate decreased from 4.1% to 1.4%. Conclusion: The present study analyses the situation of newly diagnosed TB patients in Andaman and Nicobar Islands from 2010 to 2015. Over the years there was a significant increase in the cure rate and a significant decrease in failure and defaulter rates. Over the years there was a significant transition of the treatment outcomes in these islands.

Knowledge and Practice of Small Family Norm among Married Women in an Urban Area of Tamil Nadu

S Gopalakrishnan, M Muthulakshmi

Introduction: India is the second most populous country in the world having a rapidly growing population. To strike a balance between population growth and resource usage, strategies like family planning came into force. People may have different levels of awareness and acceptance of methods of family planning. Research must identify best practices in the program implementation and the awareness levels among the population to propagate it further. Aim: To study the knowledge and practice of adopting small family norms among married women in the urban field practice area of a Medical College (Sree Balaji Medical College and Hospital, Bharath University, Chennai, Tamil Nadu, India). Materials and Methods: This cross-sectional descriptive study was carried out in the urban field practice area attached to a medical college in Kancheepuram district. Using simple random sampling method, 300 married women of reproductive age was identified. The data were collected using a pretested structured questionnaire containing five questions for assessing the knowledge and nine on practice. Data were analysed using SPSS software version 17.0. Results: It was observed that, of 300 married women, almost 78% of the women uses contraceptive. Nearly 72% of the mothers said they were aware about the idea of small family norm and about 70% of them informed that they know how small family norm is practiced. Nearly 68% of the mothers said small family norm means a family with 2 or less children. Conclusion: Awareness about small family norm should be enhanced through various strategies under the family welfare programs. More people should be encouraged to embrace family welfare measures in order to control the population.

Mutation Analysis of Beta-thalassaemia in 30 Families of India: A Report

Introduction: The ß-thalassaemia is one of the haemoglobinopathies related to genetic disorders. It occurs due to mutation in ß-gene of autosome 11. In India, it affects 1-7% of couples annually. Reports are available in few states of India about ß-thalassaemia affected families. But much data is not reported in families of various states of India. Further, the incidence of case index and mutations in parents and siblings of these families are limited. Aim: To analyse patient case index and mutation analysis of parents and siblings {Children and Chorionic villus sampling/Amniotic fluid (CVS/AF) cases} of 30 families of India and to develop preventive measures. Materials and Methods: A total of 101 referral cases of 30 families filled consent forms and then blood was drawn in a sterilised tube from each case (71) for the study. The AF/CVS (30) were also included. The red cell markers like Mean Corpuscular Volume (MCV), Red Cell Distribution Width (RDW) etc., biochemical, case types and molecular analysis were done using respective techniques for red cell indices, Haemoglobin (Hb) types and mutation analysis. Results: We report a number of 30 referral families (101 cases) having parents (60), children (11) and CVS/AF samples (30) for their ß-thalassaemia, as these traits also cause ß-gene mutations. Out of these 101 cases, 88 (87%) cases were positive for this disease. Only 74 (73%) were detected carriers. The case analysis in present cohort indicated parents (56.5%), CVS/AF (19.8%) and proband (children) (10.9%) were found affected. All children moreover, were affected and did, not have CVS/AF samples. The mutations analysis, indicated c.92+G>C (50/94; 53.19%) was maximum and parents contributed 62% followed by siblings (38%) with CVS/AF (22%) and proband (16%) in present cohort. Thus, in the present study, mutation analysis further pointed out that parents transmit these to the offsprings in the subsequent generation who would be the targets of thalassaemia disease. Conclusion: The present study, points out that mutations transfer from parents to offspring follows the laws of inheritance. Case index study showed parents constituted high percent of cases followed by CVS/AF and children/probands, comparable to mutation analysis in present cohort. Hence, carrier parents must undergo counseling and genetic testing to confirm their genetic disorder to limit the burden of the disease.

The Effect of Training Intervention on Nurse’s Performance in Execution of Drug and Food Delivery via Nasogastric Tube

Milad Borji, Asma Tarjoman, Masoumeh Otaghi

Introduction: The safety of a patient who receives nutritional support by tube feeding depends on nursing care and proper implementation of method and detection by the nurse in case of potential damage threatening the patient. Serious and fatal complications can occur if these considerations are not enacted correctly. Aim: The study was conducted to determine the effect of training intervention on nurses’ performance in execution of drug and food orders using a Nasogastric Tube (NGT). Materials and Methods: The present quasi-experimental study was carried out with experimental and control groups by observing 240 cases of executing drug and food orders. The sample consisted of 60 nurses (30 in each group). The experimental group was divided into three groups containing 10 nurses each. Training session of about one and a half-hour was held for each of the three groups. Nurse’s performance was observed by the researchers using an active participation method. Then, data were analysed using SPSS version 21.0 with descriptive (mean and standard deviation) and analytical (independent t-test) statistical tests. Results: Findings showed that there was no statistically significant difference among the nurses’ performances before intervention. Training implementation improved the performance level of nurses in the experimental group from 10.05±1.47 before intervention to 13.40±1.94 after intervention (p=0.01). Conclusion: With respect to the effectiveness of training intervention based on training in small groups, implementation of this intervention is recommended to improve the performance of nurses.

The Level of Professional Autonomy in Iranian Nurses

Masoumeh Shohani, Mahboobeh Rasouli, Ali Sahebi

Introduction: Professional autonomy plays an important role in nurses’ job satisfaction and the outcomes of patient care. A review of literature shows the presence of nurses’ dissatisfaction in regard to their professional autonomy. Aim: To assess the Iranian nurses’ perspectives of their professional autonomy. Materials and Methods: In this cross-sectional study, 150 nurses with bachelor or higher academic degrees and clinical experiences participated. The professional autonomy questionnaire by Blegen MA, composed of the domains of decision-making for ward’s affairs and decision-making for patient care, were used for data collection. The data was collected from November 2015 to April 2016 and analysed using descriptive and inferential statistics. Results: The mean (SD) of professional autonomy was 152.06 (28.181). Also, the means of professional autonomy in the domains of decision-making for ward’s affairs and decision-making for patient care were 71.91 (17.687) and 80.15 (13.088), respectively. The majority of the nurses (66.7%) stated that they had high levels of professional autonomy. There were statistically significance relationships between the nurses’ age, work experience, and educational level and nurses’ professional autonomy (p<0.05). Conclusion: The nurses had high levels of professional autonomy. Also, the nurses’ autonomy in decision-making for patient care was greater compared with decision-making in ward’s affairs. Nurses’ managers need to consider our findings for improving the condition of nurses’ autonomy in healthcare settings.

Determining the Frequency of Macroamylasemia in Patients with Hyperamylasemia using PEG Precipitation Method

Introduction: The term acute abdomen refers to severe and sudden abdominal pain requiring urgent reorganisation. One of the factors causing acute abdomen is acute pancreatitis, which needs immediate measurements. Acute pancreatitis is also associated with increased levels of serum amylase and lipase. Increased serum amylase also appears under other conditions including macroamylasemia and would result in misdiagnosis. Aim: This study aimed to investigate the frequency of macroamylasemia in hyperamylasemia patients using Polyethylene Glycol (PEG) precipitation method. Materials and Methods: In this cross-sectional study, 100 patients with high serum amylase who received healthcare services in Tabriz Imam Reza Hospital from 2014 to 2015 were included. Presence of macroamylase was evaluated in patients using PEG sedimentation method. Collected data were analysed using SPSS software version 17 and chi-square test, as well as independent sample t-test were carried out. The significance level was set at <0.05. Results: Of 100 patients, 63% were male and 37% were female and their mean age was 50.2±0.7 years. The mean level of serum amylase was 740.4±277.567 U/L and the mean level of serum amylase after PEG precipitation was 578±240.05 U/L. No significant correlation was found (p=0.478). In this study, the frequency of macroamylasemia was 4 (4%) and the frequency of real hyperamylasemia was equal to 96 (96%). The mean level of serum amylase after PEG precipitation was higher in real hyperamylasemia patients than in macroamylasemia patients and a significant association was observed in this regard (p<0.001). Conclusion: The current study showed that a high percentage of hyperamylasemia patients experience macroamylasemia. Regarding the findings and the significance of this issue, it is recommended to consider the diagnosis of macroamylasemia as one of the best approaches to prevent undertaking unnecessary diagnostic procedures and treatments.

Evaluation of Diagnostic Efficacy of Pipelle Endometrial Sampling in Abnormal Uterine Bleeding

Introduction: Abnormal Uterine Bleeding (AUB) is a major clinical problem among women in peri and postmenopausal age groups which needs complete scrutiny. Various methods are in vogue for the assessment of endometrium. Histopathological interpretation of endometrial tissue is the gold standard investigation. Studies have raised concern about diagnostic accuracy and adequacy of pipelle endometrial sample. Aim: To compare the efficacy of pipelle endometrial sampling method with conventional Dilatation (D) and Curettage (C) in diagnosis of AUB. Materials and Methods: This comparative cross-sectional study was carried out at DM Wayanad Institute of Medical Science, Kerala, India (January 2016 to June 2017). Endometrial samples collected from 210 patients with AUB initially by pipelle method followed by D and C formed the material for this study. Slides were prepared after routine histopathological processing and sectioning. Staining was done using Haematoxylin and Eosin (H&E) stains and the slides were subjected to thorough and independent microscopic examination for comparative analysis. Data analysis was performed using IBM SPSS Software version 21.0. Results: Histopathological examination of endometrial samplings by pipelle method revealed endometrial carcinoma in seven cases, atypical endometrial hyperplasia in seven cases, endometrial hyperplasia in 85 cases and disordered proliferative endometrium in 30 cases. These were correlated with histopathological findings of conventional D and C sampling method which showed pipelle sampling method had sensitivity and specificity in endometrial carcinoma (80% and 100% respectively), atypical endometrial hyperplasia (100% and 99.5% respectively), endometrial hyperplasia (100% and 93.98% respectively) and disordered proliferative endometrium (81.1% and 100% respectively). There was significant positive correlation (p<0.01) between the two techniques. Endometrial sampling by pipelle method had a high sensitivity and negative predictive value in diagnosing abnormal endometrium. Conclusion: Endometrial sampling by pipelle method is a safer and simpler alternative for diagnosis of endometrial lesions in patients with AUB. It has a fair degree of diagnostic accuracy almost comparable to that of curettage material. The diagnostic accuracy is high if interpreted by an experienced pathologist.

Characterisation of Benign Ovarian Lesions among Sudanese Women Undergoing Pelvic Ultrasound Scans: The Impact of Parity and Age

Moawia Bushra Gameraddin, Nagla Khalid Bashab

Introduction: Ovarian cysts are the most common benign lesions detected by routine ultrasound (US) examination. Characterisation and classification by ultrasound play a central role in diagnosis and management and also helps to avoid complications, such as haemorrhage, torsion, and malignancy. Aim: To classify ovarian cysts based on sonographic appearance and to explore the potential relationship of ovarian cysts with age, parity, occupation, and laterality within the ovaries. Materials and Methods: A cross-sectional study was conducted from March 2015 to December 2015 in Khartoum state, Sudan, in which 100 women who were investigated with Transvaginal Ultrasound Scanning (TVS). Coronal, longitudinal and transverse sections were obtained through the ovaries using a 7 MHz probe to measure and characterise the cysts. Prevalence of the benign ovarian cysts was calculated and association of presence of these cysts with parity, age, occupation and laterality was observed. Chi square test was used to analyse the results. Results: The classification of ovarian cysts among Sudanese women was as follows: Polycystic Ovaries (POC) comprised 50%, theca lutein cysts 20%, follicular cysts 19%, corpus luteal cysts 7% and haemorrhagic cysts 4%. POC mainly involved both ovaries and were common in nulliparous women and housewives (38% and 47.1%, respectively). It is significantly associated with parity (p-value=0.02) Theca lutein, follicular cysts and corpus luteal cysts were not significantly associated with parity, with p-values of 0.42, 0.18 and 0.66 respectively. Age, parity, laterality and cyst size were statistically significant factors affecting the classification of ovarian cysts, with p-values of =0.001, 0.02, =0.001and =0.001respectively. The prevalence of benign ovarian cysts was more frequent in nulliparous women than multiparous. The incidence decrease with advancing age. Conclusion: Sonographic evaluation is essential to classify and differentiate various types of benign ovarian cysts. Age, parity, laterality and cyst size were statistically significant factors influencing the occurrence and classification of ovarian cysts. POC and theca lutein cysts were the most frequent types of ovarian cysts in Sudanese women of reproductive age. These findings could be useful in decision making in clinical practice for gynaecologists when evaluating several ovarian cysts.

Endometriosis: A Clinicopathological Study of 29 Cases

Introduction: Endometriosis is a chronic inflammatory condition that primarily affects women of reproductive age and it is characterised by the presence of endometrial glands and stroma outside the uterus. Aim: The aim of the study was to review the cases of endometriosis with varied clinical presentation having one underlying disease and to emphasise the role of Fine Needle Aspiration Cytology (FNAC) in preoperative diagnosis of scar endometriosis. Materials and Methods: All the cases diagnosed as endometriosis either by FNAC or by histopathology in the Department of Pathology at Alluri Sitarama Raju Academy of Medical Sciences, Eluru, Andhra Pradesh, India were included in the study from the period January 2012 to November 2017. Descriptive data were collected and analysed. Results: A total of 29 cases with the diagnosis of endometriosis were found. The patient’s age ranged from 20 to 45 years of age, with mean age of 29.4±7.7 and median of 28.8 years. Out of 29 cases, 16 cases (50%) were diagnosed as scar endometriosis involving anterior abdominal wall at Lower Segment Caesarean Section (LSCS) scar site (56.25% by cytology and 43.75% by histopathology), 10 cases (37.5%) were diagnosed as ovarian endometriosis (bilateral in one case), two cases (8.3%) of urinary bladder endometriosis and one case (4.2%) of bowel endometriosis involving sigmoid colon. Conclusion: A high level of suspicion is required for early diagnosis and intervention of endometriosis, to provide better quality of life and to reduce infertility.

Dental Age Estimation Using Percentile Curves and Regression Analysis Methods - A Test of Accuracy and Reliability

Introduction: Age estimation using the developmental stages of tooth is considered the most reliable method for forensic investigations and for planning the age dependent treatment modalities in clinical applications. Aim: To evaluate the accuracy and reliability of percentile curves and regression analysis methods in dental age estimation of Indian population. Materials and Methods: The study includes orthopantomographs (OPGs) of 224 individuals (107 males and 117 females) belonging to the age group of 8-24 years. The study participants were divided into two groups as Group I (8 to 14 years) and Group II (15 to 24 years). The study groups were evaluated under two percentile curve methods (Demirjian's seven teeth method and Demirjian's eight teeth method) and two regression analysis methods (Indian specific models and South France models). The accuracy of each method was evaluated using Mean Errors (ME), Mean Absolute Errors (MAE) and Root Mean Square Error (RMSE), the reliability of each method was tested using the percentage of misclassifies (%M) under 99% of confidence intervals. Results: In Group I, for males South France regression models showed accurate (MAE=1.05) and reliable results (%M=0.15), for females Indian models showed accurate results (MAE=1.25) and South France models showed reliable results (%M=0.11). In Group II, for males (MAE=2.16; %M=0.67) and females (MAE=1.71; %M=0.58), Indian models showed accurate and reliable results. Conclusion: The regression analysis methods showed accurate and reliable results than the percentile curve methods in both the age groups.

Relationship of Renal Length with Height and Weight of an Individual using Computed Tomography

Introduction: Variety of clinical disorders such as diabetes mellitus, chronic hypertension, renal artery stenosis, chronic renal failure affects the kidney and alters renal length. It also varies according to height, weight, age and ethnicity. So there should be standardised values for renal length to evaluate the pathological condition of kidney. Aim: To determine the normal range of renal length and also to evaluate the relationship of renal length with body height and body weight of an individual. Materials and Methods: Abdominal Computed Tomography (CT) scans of 70 individuals between the age of 21-79 years without any renal disease were reviewed and their anthropometric data like height, weight, age and sex were also recorded. Renal length was calculated as the maximum longitudinal length in coronal section parallel to the renal long axis by using CT scan images of abdomen. Results: The mean renal length of the total study population group was 9.38±1.08 cm and 9.23±0.92 cm for left and right kidney respectively. Mean height for the study group was 158.53±9.64 cm and mean weight was 49.24±9.77 kg. We found significant relationship between renal length and height of an individual in combined group consisting of both males and females whereas, weight of an individual did not show any significant relationship with renal length when correlation was done in combined group. Moreover, renal length was in negative relationship with age which was statistically significant for total population group (Left kidney p=0.0001, Right kidney p=0.011). Conclusion: Measurements of renal length plays a vital role in detecting renal abnormalities. Thus, the measurement of renal length is very useful for early diagnosis in urological and nephrological practices. In the present study, renal length has a direct positive relationship with height and significant inverse relationship with age. We also have formulated regression equations to predict the probable renal length with the help of body height and body weight which can be used in routine practices without imposing the patients to the toxic ionising radiation and to the financial stress.

Apical Extrusion of Debris in Mesiobuccal Root of Maxillary Molars with Five Rotary File Systems

Introduction: Flare-ups in endodontics are multifactorial and may cause severe discomfort to the patient. Apical extrusion while preparing root canal space in any form such as debris, bacteria or irrigants has been found to be associated with many flare-up events and may even lead to treatment failure. Aim: To quantitatively evaluate apically extruded debris with five rotary instrumentation systems in mesiobuccal root of maxillary molars. Materials and Methods: A total of 120 human maxillary first molars extracted between January and March of 2017 in oral and maxillofacial surgery department at Drs. Sudha and Nageswara Rao Siddhartha Institute of Dental Sciences, Gannavaram, Andhra Pradesh, India, were included in the current study. Only the Molars with a three rooted pattern were selected and mesiobuccal root was used to evaluate apical extrusion. An experimental apparatus for evaluation of extruded debris as previously described by Myers and Montgomery was fabricated. All samples were divided into six groups (n=20 each) and instrumentation was done with five rotary file systems (K3XF, ProTaper NEXT, HyFlex CM, Revo-S, and FLEXICON) and HAND K FILES which served as control. The weight of the micro tubes in the apparatus before and after the instrumentation was calculated using an electronic weighing balance with a minimum sensitivity of 10-4 and weights were compared to quantify the apical extrusion. Statistical analysis was analysed with the ANOVA and multiple comparison (Post-hoc-Dunnett and Tukey) tests. Results: It was found that all the instrumentation systems showed a considerable amount of apical debris extrusion. HAND K FILES were associated with most debris extrusion compared to all rotary files (p<0.01). FLEXICON file system showed lowest debris extrusion among all experimental groups. However, there was no statistically significant difference between K3XF and FLEXICON file systems (p=0.312). Conclusion: The rotary systems extruded less debris compared to HAND K FILES. However, it was observed that there was no statistically significant difference between apical extrusion of K3XF and HyFlex CM, K3XF and FLEXICON X7, HYFLEX CM and Revo-S file systems. Among all the rotary groups, FLEXICON X7 and ProTaper NEXT files showed lowest and highest apical extrusion respectively. Design of rotary endodontic instruments may have a greater impact on their innate apical extrusion potentials.

Incidence and Outcomes of Early Stent Thrombosis in Patients Receiving Drug-eluting Stents: A Retrospective Study from a Tertiary Care Centre in India

Introduction: Early stent thrombosis is a relatively rare but deleterious complication of Percutaneous Coronary Intervention (PCI). Data on early stent thrombosis from an Indian setting are rare and indistinct. Aim: To determine the incidence and clinical outcomes of early stent thrombosis in patients receiving drug-eluting stents. Materials and Methods: In this retrospective study, data of all consecutive patients who underwent PCI with stenting and reported an incidence of early stent thrombosis between March 2014 and November 2016 at our Tertiary Care Centre (King George’s Medical University, Lucknow, India) were considered. Incidence of early stent thrombosis was determined based on total number of patients who underwent PCI with drug-eluting stents during the study period. Subsequently, the patient-related, lesion-related, procedure-related, and stent-related characteristics were examined for patients with early stent thrombosis. Clinical outcomes of stent thrombosis were also analysed for these patients. Additionally, a comparative analysis for various characteristics was performed between patients who died and patients who survived. Results: Early thrombosis was noted in 41 (1%) patients out of 3,869 PCI that were performed during the study period. Among this cohort, substantial presence of established risk factors of stent thrombosis was observed including for diabetes (n=12, 29.3%), smoking (n=19, 46.3%), STEMI (n=30, 73.2%), chronic total occlusion (n=8, 16.3%), thrombus-containing lesion (n=24, 49%), Type C lesions (n=36, 73.5%). Although, all patients were aimed to manage appropriately, mortality in patients with early stent thrombosis was reported in 18 (43.9%) patients and re-infarct was reported in 26.8% (n=11) patients. Conclusion: Although, the incidence of stent thrombosis in patients receiving drug-eluting stents was around 1%, it was found to be associated with a higher 30-day mortality rate. Further studies examining a larger cohort of patients, incidence of late and very late stent thrombosis, and a comparative analysis of characteristics between patients with and without stent thrombosis are warranted.

Study on the Use of Methylene Blue Spray in Identification of Recurrent Laryngeal Nerve During Thyroid Surgery

Introduction: Thyroidectomy is one of the most commonly performed surgeries in iodine deficient regions. Injury to parathyroids and Recurrent Laryngeal Nerve (RLN) are two of the complications of thyroidectomy that cause significant postoperative morbidity. Hence, intraoperative identification of these structures and prevention of iatrogenic injury are important. Aim: To study the use of methylene blue spray in identification of RLN during thyroid surgery. Materials and Methods: This was a prospective study done on patients who presented to ENT OPD in teaching hospitals attached to JJM medical college, Davangere (Bapuji Hospital and Chigateri general hospital). After indirect laryngoscopic confirmation of normal vocal cord mobility, 30 patients chosen at random underwent thyroidectomy. During the surgery, after ligation of superior pole of thyroid and before ligation of inferior pole, methylene blue dye, in a 1:10 dilution (with normal saline) was sprayed over the thyroid lobe and perilobar area, in the region where RLN is expected to be found. RLN and parathyroid glands were identified and safe dissection of the thyroid, without injuring these structures was ensured. Results: RLN was not stained and remained white in all the cases, in contrast to the blue stained surrounding tissue, and could be identified easily. The parathyroid glands washed out the stain within 3 minutes and were visible in its normal yellow colour in all cases. Conclusion: Spraying of methylene blue dye during dissection of thyroid is a safe and effective method for identification and avoiding injury to RLN and parathyroid glands during thyroid surgeries.

Comparative Study on Outcome of Non-invasive Ventilation in Patients with Acute Exacerbation of COPD Admitted in General Ward vs. High Dependency Unit

Debabani Biswas, Susmita Kundu, Arnab Bera, Atin Dey, Subrata Rath, Amitava Pal

Introduction: Non-Invasive Ventilation (NIV) is getting popularity in management of acute exacerbation of COPD with hypercapnic respiratory failure because of its effectiveness. However, there is still a dilemma regarding the site of initiation of NIV. There are several publications comparing outcome of NIV in highly sophisticated Intensive Care Units (ICU) and general ward in western literature, there is paucity of data from this part of the world. Considering unavailability of beds in highly monitored ward, the studies related to feasibility and acceptability of using NIV in general ward might be helpful in reducing suffering of distressed COPD patients. Aim: To assess the outcome and relative feasibility of NIV use in general ward and High Dependency Unit (HDU) in hypercapnic respiratory failure due to Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) in a tertiary care hospital. Materials and Methods: It was a prospective observational study. Patients admitted with AECOPD in HDU and general ward, satisfying all inclusion and exclusion criteria, over a period of six months were recruited as study population. All the patients received NIV along with other conventional treatment protocol. The outcome of NIV was noted in terms of frequency of complications, duration of hospital stay and need for mechanical ventilation. The statistical analysis was done using SPSS Minitab software version 15.1.0. Results: A total of 70 patients, age ranging from 45-89 years, were included. A 32 patients were put on NIV in general ward while 38 in HDU, depending on availability of bed. There were no significant differences in the clinical parameters at the time of initiation of NIV between the two subsets except the total leukocyte count and the frequency of occurrence of exacerbation in last one year. The outcome of NIV use as analysed found no significant difference in average duration in hours ‘on NIV’ (p=0.088) among patients who were successfully treated with NIV. Similarly the complication profile and overall failure rate comparable was (p=0.515) between the two subsets. Conclusion: The NIV is as effective in management of AECOPD with hypercapnic failure in HDUs and less monitored general medical ward in face of non-availability of ICU beds, particularly in a resource constrained setting.

Flexor Tenosynovitis in Early Untreated Rheumatoid Arthritis: What do Ultrasound and MRI Show

Sonal Saran, Pradeep Bansal, Nishtha Parashar

Introduction: Rheumatoid Arthritis (RA) is the most common inflammatory arthritis which primarily affects the synovial lining of joints. Tendon sheath is also composed of synovial lining and tendon involvement in RA is generally in the form of tenosynovitis. Modern imaging techniques like Ultrasonography (USG) and Magnetic Resonance Imaging (MRI) target mainly soft tissue pathological changes in RA, and have lead to the early diagnosis and prognostication of disease, which in turn has guided rheumatologist to start biologic therapy in the early stage of disease and thereby prevent complications. Aim: To evaluate flexor tenosynovitis in untreated early RA using USG and to compare its findings with that of MRI along with studying distribution of flexor tenosynovitis using both USG and MRI across hand. Materials and Methods: The present hospital based descriptive study was conducted in the Department of Radiodiagnosis of Subharti Medical College and hospital from January to December 2016. A total of 40 patients of RA underwent high frequency USG and MRI of 2nd to 5th Flexor Tendon Sheaths (FTS) of both hands whereas 25 healthy controls underwent only high frequency USG. Normal anatomy and inflammatory changes in the FTS were recorded on both the modalities by two radiologists specialised in doing musculoskeletal imaging. No patient had received prior steroid or Disease-Modifying Antirheumatic Drug (DMARD). Diagnostic accuracy of USG was calculated using MRI as gold standard using agreement statistics. Statistical analysis was done using SPSS version 12.0. Results: Flexor tenosynovitis was found in 102 (31.8%) of 320 and FTS in 22 (55%) of 40 patients on ultrasound compared with 210 (65.6%) of 320 with Flexor tensosynovitis on MRI. FTS were completely normal in control subjects on ultrasound. Considering MRI as the gold standard, the sensitivity, specificity, negative and positive predictive values for ultrasound were 0.52, 0.83, 0.69, and 0.70, respectively, for detecting flexor tenosynovitis. The most frequently involved FTS on both the modalities were the second and third. Conclusion: Both ultrasound and MRI can be used for detection of flexor tenosynovitis in patients with early untreated RA. MRI is more sensitive for detecting flexor tenosynovitis for obvious reasons. A negative ultrasound scan does not exclude inflammation and an MRI should be considered. In developing countries like India, where MRI is limited in availability, ultrasound can become the imaging modality of choice specially to evaluate soft tissue changes in early RA.

Choosing the Best Microalgae and Optimising its Culture Medium to Produce More Starch for Medicinal Use

Hamid Ramezani Awal Riabi, Hamed Ramezani Awal Riabi

Introduction: Some species of microalgae have the ability to produce high amount of carbohydrates, rather than lipids. The extracted starch obtained from the ultrasonic treated green microalgae has high level of antioxidant activities and in animal studies, the extracted starch from Chlorella vulgaris (C. vulgaris) exhibited anti-atherogenic, anti-cholesterolemic, anti-inflammatory and anti-tumour effects. The green microalga has been widely used as a food source containing a complete set of nutrients including carbohydrates, proteins, vitamins, and minerals. Aim: To optimise the microalgae culture medium to increase starch production for medicinal use. Materials and Methods: This study was conducted as a field, observational and experimental research. For this purpose, 5 mL of microalgae C. vulgaris, Scenedesmus dimorphus (S. dimorphus) and Scenedesmus quadricauda (S. quadricauda), in the test tube containing Bold’s Basal Medium (BBM). BBM and Z8 media were used to grow freshwater microalgae. Light absorbance, cell count and biomass of microalgae in these media were studied. The experimental design method based on Taguchi method was conducted for optimising medium for microalgae with highest starch production, with light intensity, nitrogen and phosphorus factors, in three levels (1, 0,-1). Results: Specific growth rates of C. vulgaris in the media BBM and Z8 were 0.075 and 0.055 d-1, and for S. quadricauda and S. dimorphus were 0.072 and 0.008; 0.038 d-1, respectively. Due to significant difference (p=0.034) between Z8 and BBM media, BBM was selected for growing C. vulgaris, S. quadricauda (p=0.308) and S. dimorphus (p=0.033). In addition, growth rate and starch production of desired microalgae were achieved. Starch content in S. dimorphus, C. vulgaris and S. quadricauda were 19%, 29% and 20% of biomass weight, respectively. Conclusion: It was found that starch content was increased with increasing light, reducing phosphorus and nitrogen in Chlorella and the results showed that C. vulgaris could be a good choice as a starter for producing starch for medicinal purpose.

A Study of Tear Ferning Patterns in Elderly Individuals with Dry Eye Disorder

Amit Kumar Singh, Shubha Nagpal, Rupali Tyagi

Introduction: Anomalies of the mucin layer of the tear film have generally been studied in relation to contact lens users who represent a young population. Since the prevalence of dry eye increases with age and causes considerable discomfort to elderly patients, a proper assessment of tear film quality is required to facilitate a targeted approach in managing Dry Eye Disorder (DED) in older age. Aim: To study the ferning pattern of the precorneal tear film in elderly individuals and compare the results with standard tests for dry eye. Materials and Methods: A questionnaire based screened cohort of 75 individuals with DED and 75 controls, all above 50 years of age, were studied using Schirmer’s Test, Tear Break Up Time (TBUT), Lissamine green staining and ferning tests. Ferning patterns were graded by Rolando’s classification. Data were analysed by Fisher’s-exact test. Results: Dry eye tests and tear ferning were found to be abnormal in majority of the subjects who had positive scores on screening with the dry eye questionnaire. Abnormal ferning patterns (62% Grade III and 24% Grade IV) correlated significantly with positive Schirmer’s test (p=0.001), positive TBUT test (p=0.001) and positive Lissamine green staining (p=0.001) of eyes with DED. Less than 14% individuals (22 eyes) exhibited Grade II ferning in the dry eye group. Greater disturbances of ferning patterns were seen with increased age. All patients above the age of 75 (n=22 eyes) with symptomatic DED had abnormal ferning. Amongst the controls, all 150 eyes, regardless of age, showed normal ferning patterns (56% Grade 1 and 44% Grade 2). Conclusion: A significant majority of elderly individuals with DED have an abnormal mucin layer in the tear film. Tear ferning test is a simple and inexpensive test and if combined with the other tear film tests may be helpful in a better assessment of DEDs, especially in the elderly. This is relevant especially for targeted treatment in cases of DED where the cause is not aqueous deficiency.

Estimation of Salivary Tumour Necrosis Factor-a Levels in Post-menopausal Women with Chronic Periodontitis

Introduction: Periodontitis and increased levels of Tumor Necrosis Factor-alpha (TNF-a) are considered as key factors contributing to the bone loss observed in oestrogen deficient post-menopausal women. Aim: The present study aimed at assessing the levels of salivary TNF-a in pre- and post-menopausal women with chronic periodontitis and evaluating its potential as a biochemical marker of periodontal disease in post menopausal women. Materials and Methods: A total of 80 female subjects, within the age range of 35-55 years, were divided into 4 groups of 20 subjects each, pre- and post-menopausal women with chronic periodontitis and pre- and post-menopausal periodontally healthy controls. After assessment of clinical periodontal status, unstimulated whole saliva was collected and levels of TNF-a were examined using ELISA. One-way ANOVA, post-hoc Tukey’s test, Student’s unpaired t-test and Karl Pearson’s co-efficient of correlation were used. SPSS version 17.0 and MedCalc version 10.2 were used to perform the data analyses. Results: The mean of salivary TNF-a levels in pre- and post-menopausal women with chronic periodontitis were 4.25±1.20 pg/mL and 5.13±1.35 pg/mL, respectively, whereas that in pre- and post-menopausal healthy controls were 2.05±1.11 pg/mL and 2.40±1.08 pg/mL, respectively. The levels of salivary TNF-a were significantly higher in the periodontitis groups than the controls and correlated positively with the assessed clinical parameters (p<0.001). Also the levels were significantly higher in post-menopausal women with chronic periodontitis than the pre-menopausal women with chronic periodontitis (p<0.05). Conclusion: Salivary levels of TNF-a were increased in both menopause and chronic periodontitis. This increased secretion of TNF-a could be implicated as a contributing factor in the progression of periodontal disease in post-menopausal women, suggesting that salivary TNF-a can act as a potential biomarker and a valuable adjunct for screening of periodontal disease in post-menopausal women.

Evaluation of Functional Outcomes of Intra-articular Fractures of Distal Humerus by Open Reduction and Internal Fixation

Gokul Chand Verma, Sarita Jilowa, Jitendra Singh, Dinesh Rathi

Introduction: Different points of view exist regarding choice of surgical approach and of implants in management of distal humerus intra-articular fractures. The results of open reduction and internal fixation of these fractures are variable in terms of functional outcome. Aim: To evaluation of results of surgical fixation of intraarticular distal humeral fractures with Arbeitsgemeinschaft fur Osteosynthesefragen (AO) reconstruction plates in terms of functional outcome. Materials and Methods: A total of 20 patients with intraarticular fractures of distal humerus were operated with open reduction and internal fixation using olecranon osteotomy approach. Provisional fixation was done with K-wires. Interfragmentary compression was given with 4.0 mm cancellous lag screw and definitive fixation was done using 3.5 mm AO reconstruction plates and one third tubular plates. K-wire and tension band wiring fixation were used for osteotomy. Results: Approximately 90% cases were inter-condylar type C fractures. The average elbow flexion achieved at final follow up was 110.25°. Approximately 75% patients showed excellent or good results based on clinical, radiological evidence of union and functional outcome which was assessed using Mayo Elbow Performance Index Score (MEPIS). Average MEPI score in this study was 86.0, based on points assigned to Pain, Motion, Stability and Function. Conclusion: Open reduction and internal fixation of distal humerus fractures gives good results after restoration of complex geometry of condyles and shaft in all three planes. The AO reconstruction plates and one third tubular plates were found to be very effective and useful in treatment of adult distal humerus intra articular fractures with good functional outcome.

Factors Affecting the Prognosis and Overall Survival in Patients with Uterine Papillary Serous Carcinoma

Incim Bezircioglu, Mehmet Hakan Yetimalar, Derya Kilic

Introduction: Uterine Papillary Serous Carcinoma (UPSC) is a prototype of Type II Endometrial Cancers (EC) and represents 5-10% of all EC. It is clinically aggressive and responsible for over 50% of relapses and deaths in EC patients. Aim: To investigate factors affecting the overall survival in patients with UPSC. Materials and Methods: Forty-three women treated for UPSC between January 2006 and October 2015 were analysed retrospectively. Subjects were included if histology revealed a minimum of 10% component of serous carcinoma. Patients who required neoadjuvant therapy were excluded. All women underwent surgical treatment with at least total hysterectomy and bilateral salpingo-oophorectomy. The effect of age, tumour size, myometrial invasion, presence of malignant peritoneal cytology, lymph node metastasis, presence of the tumour outside the uterus and in the upper abdomen on the survival were investigated. The Kaplan-Meier method was used for survival analysis. Univariate analysis was used to evaluate the importance of each parameter and log rank test was used for significance. Significant parameters were analysed by multivariate Cox regression. Results: Forty-three patients diagnosed and treated for UPSC were analysed. Out of them, 38 (88.4%) underwent surgical staging. Relapse and disease progression despite therapy was observed in 9 (20.9%) cases. The overall survival was estimated to be 46.5%. Conclusion: The present study demonstrated that myometrial invasion, lymphovascular space involvement, and presence of a tumour in the upper abdomen were statistically significant parameters affecting the overall survival in UPSC patients.

Cognition and Opioid Substitution Therapy Adherence in Patients with Opioid Dependence

Shabina A Sheth, Nilanjan C Chandra, Ritambhara Y Mehta

Introduction: Opioid Substitution Therapy (OST) is an effective long term treatment option for opioid dependence as well as Human Immunodeficiency Virus (HIV) prevention and intervention for opioid dependent Intravenous Drug User (IDUs). Department of Psychiatry is running DOST centre for opioid dependent patients for last four years. The dropout rates are also high. Aim: To assess the cognition, medical complications, social, financial impact of opioid addiction and to study correlation of cognition with OST adherence in patients with opioid dependence. Materials and Methods: The cross-sectional study was conducted in the DOST Centre, OPD-13, New Civil Hospital, Surat, Gujarat, India, in August 2015. All 22 patients taking OST as a part of DOTS in DOST centre (name of the OST centre) were enrolled in this study. After giving ‘Participant Information Sheet’ informed valid consent were taken from all participants. Semistructured questionnaire which investigated qualitative and quantitative information about opioid and other substance use with related complications, scales Addenbrooke’s Cognitive Examination-III (ACE-III) Hindi and Mini Mental State Examination (MMSE) for cognitive assessment were used and analysed. Results: Out of 22 patients coming to DOST centre for OST 22.72%, 31.81% and 45.45% patients were Irregular (IR), Regular (R), Very Regular (VR) respectively (as per, criteria given by NACP-IV). Mean MMSE score in IR, R and VR patients were 21.8, 23.29, 22.8 respectively and ACE-III score in IR, R and VR patients are 63.2, 79.57, and 67.9 respectively. Patients who were non adherent and irregular had statistically significant lower ACE-III score (p=0.032). Cognition (ACE-III) and adherence showed a statistically significant linear positive relationship (p<0.001) with moderate strength on Pearson’s correlation test. Conclusion: As there is no significant result outcome regarding comparison of adherence with other variables like education, marital status, socioeconomic status, social support, it can be concluded that the only robust factor which affects OST adherence is cognitive decline of the patient which is responsible for no behavioural changes, harmful use, relapse and not maintaining abstinence in opioid dependent patients.

Sialochemical Profile in Depressive Individuals under Antidepressant Therapy: An Observational Study

Introduction: Depression is a mental disorder that is pervasive and affects people all around the World. In India about one in five people are affected by depressive disorders. Autonomic Nervous System (ANS) affected by depressive disorder can affect salivary composition, since salivary secretion is controlled by the sympathetic and parasympathetic innervations. Likewise, antidepressants are the drugs which can elevate mood in depressive disorders, and also have potential to alter salivary secretion rate and their composition. Alteration in salivary composition can affects oral health and makes them vulnerable for oral infection. Aim: To study the sialochemical alteration in depressive individuals and to compare the effect of antidepressant therapy (selective serotonin reuptake inhibitors-two month course) on the same patients. Materials and Methods: A total of 80 subjects-Group I (40 controls), Group II (40-depressive individuals) and Group III (Group II depressive individuals after two months course of antidepressant therapy). Depression level was assessed with Hospital Anxiety and Depression Scale (HADS). Whole unstimulated saliva was collected and subjected to sialochemical analysis (sodium, potassium, chloride, total protein, urea, salivary amylase, calcium, pH). The parameters were statistically analysed using Unpaired t-test to compare Group I and II and Paired t-test to compare Group II and III. Results: It showed statistically significant alteration in parameters such as total protein, salivary a-amylase, chloride, and calcium. While comparing Group II and Group III it showed significant reduction in total protein and calcium levels in Group III individuals. Conclusion: The post-treatment sialochemical analysis showed that depressive individuals got stabilised and reverted back to the normal baseline value of the healthy individuals which proves that Selective Serotonin Reuptake Inhibitors (SSRI) does not produce profound sialochemical alteration.

Biochemical Markers of Liver Function in Smoking and Non-Smoking Alcohol-Dependent Males

JB Honnamurthy, AR Shivashankara, SS Avinash, P JohnMathai, M Malathi

Introduction: Various biochemical parameters in blood have been proposed as biomarkers of alcoholism. There is paucity of studies on alcohol biomarkers of saliva, particularly in alcoholdependent smokers. Aim: The aim of the study was to compare and correlate the Liver Function Tests (LFT) in saliva and blood of Alcohol-dependent Smokers (AS) and Alcohol-dependent Non-Smokers (ANS). Materials and Methods: The study included 45 AS, 38 ANS admitted to the de-addiction centre and 38 age matched healthy volunteers (C). The assay of Total Protein (TP), albumin, ?-Glutamyl transferase (GGT), Aspartate aminotransferase (AST), and Alanine aminotransferase (ALT) in saliva and serum were analysed spectrophotometrically. Analysis of the data was performed by one-way ANOVA and Somers D correlation using SPSS version 23.0 software. Results: History of smoking correlated significantly with salivary TP (p<0.049), AST (p=0.001) and blood GGT (p<0.001), AST (p<0.001), ALT (p=0.001). The salivary levels of GGT (p<0.001), AST (p<0.001) and ALT (p=0.001) were significantly higher in AS and ANS compared to healthy controls before withdrawal and was normalised in abstainers. The blood levels of GGT (p<0.001) and AST (p<0.001) were significantly higher in AS and ANS compared to healthy controls in both before withdrawal and abstainers. There was a significant but weak association in the study subjects between LFT and amount of alcohol. Salivary GGT, AST and ALT correlated positively with their respective blood levels in AS and ANS. Conclusion: Significant correlation was observed between blood and saliva with respect to activities of liver function enzymes. Salivary enzymes could serve as sensitive markers of liver function in alcohol dependence.

Acute Kidney Injury: Prevalence and Outcomes in Southern Indian Population

Zabiuddin Ahad Mohammed, Anna Asa Suresh, Prasanna Kumar, Ravindra Prabhu Attur

Introduction: Acute Kidney Injury (AKI) is characterised by a rapid reduction in the kidney function and gets effected to varying degrees based on the aetiology. An AKI increases the chances of Chronic Kidney Disease (CKD) if not treated properly or assessed timely. Aim: To identify the common aetiologies and to assess the prognosis and outcomes of AKI in a tertiary care centre in southern India. Materials and Methods: A retrospective observational study was conducted, in a tertiary care teaching hospital over a period of six months (August 2015 to February 2016), upon receiving approval from Institutional Ethics Committee (KH IEC 392/2015). Data of patients aged =18 years admitted during JanuaryDecember 2012 were collected from the medical records using the ICD10 code for AKI, unspecified (N17.9). Patients with renal transplantation and chronic dialysis were excluded. Age, gender, aetiology, management, and association between treatment and outcome were analysed using descriptive statistics, univariate and multivariate logistic regression and chi square test. Results: Among 528 patients, with AKI, male predominance of 72.7% (n=384) and median {Interquartile Range (IQR)} age of 56 (20) years was observed. Prevalence of AKI was found to be 8.36/1,000 people. Community Acquired-AKI (CA-AKI) and Hospital Acquired-AKI (HA-AKI) accounted for 35% (n=185) and 65% (n=343) respectively. CKD 23% (n=79) and sepsis 22.4% (n=77) were the major aetiologies among CA-AKI whereas sepsis 49.2% (n=91) and CKD 11.9% (n=22) were the majorities among the HA-AKI. Chi square test for association between treatment and outcomes (recovery) showed a statistically significant relationship with dextrose normal saline (?2 =10.96, p<0.05), sodium bicarbonate (?2 =7.63, p<0.05), dopamine (?2 =112.14, p<0.05), calcium gluconate (?2 =17.20, p<0.05) and haemodialysis (?2 =12.13, p<0.05). Complete recovery in 64% (n=341) whereas 16% (n=82) of patients died. Conclusion: Sepsis and CKD were seen to be the leading aetiologies. Male gender with AKI is more likely to develop CKD. AKI with Diabetes Mellitus (DM), sepsis or Urinary Tract Infection (UTI) might worsen the prognosis. Fluid replenishment shows to improve the prognosis.

Palmer Freckling as a New Clinical Marker: Clinico-epidemiological Study of 26 Cases of Neurofibromatosis Type-1

Introduction: Neurofibromatosis Type 1 (NF-1) is an autosomal dominant genodermatosis characterised by Café Au lait Macules (CALMs), multiple neurofibromas, iris Lisch nodules, axillary and inguinal freckling and bony abnormalities. Axillary and inguinal freckling has been considered under the major criteria for diagnosis, however we found unusually high occurrence of hitherto under-reported patterns of freckling in our patients. Aim: To study the patterns of freckling in patients with NF-1. Materials and Methods: A total of 26 consecutive patients presenting with features of NF-1 to the dermatology OPD of a tertiary care centre of eastern India were examined for various features of NF-1 including the presence of freckling in various parts of the body. Results: Out of 26 patients in this cross-sectional observational study, 76.92% patients had axillary freckling or inguinal freckling or both; whereas 88.46% patients had palmer freckling. Conclusion: The unconventional patterns of freckling like palmer and facial freckling may be occurring at a higher frequency than reported and in some scenarios, may be more than the established criteria like axillary freckling.

Is Low Cholesterol a Predisposing Factor for Primary Intracerebral Haemorrhage? A South Indian Perspective

Introduction: Stroke is an important cause of mortality and morbidity in low-income and middle-income countries like India. Primary Intracerebral Haemorrhage (PICH) refers to Intracerebral Haemorrhage (ICH) in the absence of a single clear underlying lesion. Cholesterol levels are inconsistently associated with risk of ICH. Aim:To assess their relationship between lipid parameters and PICH. Materials and Methods: One hundred sixty patients with PICH were retrospectively recruited and compared with apparently healthy subjects. Low cholesterol was defined by Total Cholesterol (TC) <200 mg/dL; Low Density Lipoprotein Cholesterol (LDL-C) <100 mg/dL; High Density Lipoprotein Cholesterol (HDL-C) <40 mg/dL; and Triglyceride (TG) level <150 mg/dL. Results: Out of 160 patients recruited majority of the patients were males (n=122). Mean age was 53.47±9.33 years. Most frequent risk factor of PICH was hypertension (72.5%). Most common site of bleed was in basal ganglion (n=63). The proportion of PICH patients with low TC was significantly higher than control (81.9% vs. 70%). TG levels and LDL-C were significantly low in PICH compared with controls (p-value<0.0001). Mean TC in PICH was 159 mg/dL vs. 180 mg/dL (p-value<0.0001); Mean TG level was 114 mg/dL vs. 168 mg/dL (p-value<0.0001); Mean LDL-C was 93 mg/dL vs. 119 mg/dL (p-value<0.0001). In a subgroup analysis, among older age (=50 years) mean TC, TG levels and LDL-C were significantly low in PICH group compared to controls (p-value<0.0001). In multivariate analysis presence of low value of TG, LDL-C and TC remained a significant risk factor of PICH. Odds ratio for TG was 5.55 with 95% Confidence Interval (CI) of 3.295 to 9.36; odds ratio for LDL-C was 3.81 with 95% CI of 2.392 to 6.084. Conclusion: Our present study confirms low cholesterol as risk factor for PICH especially in older individual and both sexes.

Assessment of Microbial Contamination in Indoor Air of Private Maternity Homes in Moga, Punjab

Introduction: Assessment of indoor air quality has become important as the bacteria and fungi are omnipresent. Human diseases caused by microorganisms can be classified as bacterial, fungal and viral infection and infection type is determined by the source of infection which can be air, food, water and soil via which the infection transmits in immune-suppressed patient leading to the pathogenic diseases in the hospital wards. Aim: To assess the microbial contamination in the air of general and private ward of the private maternity homes in the province of Moga region, Punjab, India. Materials and Methods: The microbial contamination of indoor air of five different maternity homes in Moga district of Punjab, India was studied. The sampling of air (duplicates) was done by employing the passive air sampling procedure (exposed-plate technique) for a one-month period. Different culture media was used for the analysis. Spearmans rank correlation was used to find the regression coefficient among bacteria and fungi load in wards. Results: The number of viable bacteria and fungi were ranging between 259-2665 CFU/m3 for bacteria and 79-826 CFU/m3 for fungi. A total of eight bacterial and six fungi were identified up to genus level. The correlation between bacteria vs. fungi was plotted using Spearmans correlation which shows the positive linear association (p<0.001) with regression coefficient. Conclusion: The current study enlightens us about the presence of the microbes in air in the maternity homes that can be potent to induce nosocomial infection. The high concentration of bacteria and fungi indicates that there is a need for the intrusion to regulate the growth and development of microbes in the hospitals and maternity homes.

Advanced Stage Lung Cancer: Persisting Challenges in the Era of Molecular Targeted Therapy-Our Experience

Introduction: Lung cancer is the pioneer among all the cancers and also the leading cause of cancer related mortality worldwide. In India unlike in western countries most patients are diagnosed at advanced stage (Stage III/Stage IV) which in turn adversely affects the patient prognosis and survival. Studying the proportion of the total lung cancer cases which will present in advanced stage and their clinical, pathological and radiological profile will give us an insight into the problem. Aim: To know the percentage incidence of patients presenting with advanced stage lung cancer (Stage IIIB/Stage IV) and to study the clinical, pathological and radiological profile of these patients along with treatment details and follow-up. Materials and Methods: This was a descriptive retrospective study spanning 4 years from January 2013 to December 2016. All patients with a histopathological diagnosis of Stage IIIB and Stage IV lung cancer, treated during this period were included. Clinical features, radiological (X-ray and CT) findings, histopathological findings including immunohistochemistry if done, treatment modality and survival were analysed based on the information collected from the medical records. Results: Out of 82 cases diagnosed as advanced stage disease, complete clinical data was available for 67 cases which formed the material for the study. Of 67 patients, 47 were male and 20 were female forming a Male: Female ratio of 2.35:1. The mean age of the patients was 61.3 years. Patients presented with cough (59.7%), chest pain (34.3%) dyspnoea (29.8%), weight loss (17.9%), fever (16.4%), haemoptysis (11.9%). Histologically majority were Adenocarcinoma (ADC) (35.8%) followed by Squamous Cell Carcinoma (SCC) (29.8%) small cell carcinoma (14.92%) and just one case of large cell carcinoma. Forty three cases (64.17%) presented with metastases. The most common site for metastasis was bone followed by brain. Three patients who tested positive for Epidermal Growth Factor Receptor (EGFR) mutation were treated with Erlotinib/Gefitinib. The remaining 64 cases were treated with regimens including combinations of premetrexed, platinum based compounds and etoposide. On follow-up 17 patients died during the course of the treatment. Conclusion: High proportion of lung cancer patients present at advanced stage. This demand for public awareness programs about the smoking hazards, early symptoms and importance of early treatment.

Risk Factors of Community Acquired Pneumonia among Adults in Tigray, Ethiopia: A Case-control Study

Haftu Berhe Gebru, Fikre Enqueselassie Gahse, Alemayehu Bayray Kahsay

Introduction: Community Acquired Pneumonia (CAP) is an acute disease which represents a common cause of hospital admission and mortality. However, little is known about the risk factors and other related issues in sub-Saharan Africa including Ethiopia. Aim: To identify the risk factors of community acquired pneumonia among adults in Tigray, Ethiopia. Materials and Methods: Unmatched case-control study design was used and 120 cases and 240 controls were participated. Cases were patients with CAP, while controls were patients without the problem. A questionnaire was used to collect the data and analysed by SPSS version 20.0. Associations between variables were determined using bivariate and multivariable logistic regression analysis. Odds Ratios (OR) with 95% confidence interval was calculated to measure the strength of associations. Result: The results revealed that working in a dusty environment {OR (95% CI); 2 (1.1, 4.1)}, history of respiratory infection {OR (95% CI); 2.3 (1.5, 5.7)}, contact with people who had respiratory infection {OR (95% CI); 2.5 (1.2, 5.3)} and previous history of pneumonia confirmed by radiograph {OR (95% CI); 39 (19.4, 78.6)} were significantly associated variables to CAP. Conclusion: The common risk factors of CAP included working in a dusty environment, having a history of pneumonia, history of respiratory infection and having contact with people who had respiratory infections as seen in this study. Hence, measures have to be taken to prevent and properly treat the problem.

Trace Element Status in Type 2 Diabetes: A Meta-Analysis

Namrata Sanjeevi, Jeanne Freeland-Graves, Natasha S Beretvas, Prageet K Sachdev

Introduction: Type 2 diabetes is a chronic metabolic disorder that has been associated with alterations in the status of trace elements, including zinc, copper, iron and manganese. However, clinical studies reporting statuses of these trace elements in type 2 diabetes patients compared to controls have shown conflicting results. Aim: This meta-analysis aimed to summarize the existing literature on the statuses of zinc, copper, iron, and manganese in type 2 diabetes mellitus patients. Materials and Methods: A literature search of Embase, PubMed, EBSCOHost, ScienceDirect, Scopus, Cochrane library and Web of Science electronic databases was conducted to find studies published from 1970 to November 2016 that compared the trace elements of interest between type 2 diabetic patients and healthy controls. The bias corrected Hedges’ g, was utilized as the effect sizes. Due to the biological interaction between trace elements, it is important to collectively evaluate the statuses of these minerals in type 2 diabetes. Thus, the robust variance estimation method was chosen to handle dependency between multiple outcomes. Results: A total of 52 studies met the inclusion criteria, amounting to 98 effect sizes. Diabetic patients (n=20183) had significantly lower zinc status when compared to controls (effect size = -1.73, p<0.01); whereas copper (effect size = 1.10, p<0.05) and ferritin levels (effect size = 1.05, p<0.01) were significantly higher. Although not significant, ceruloplasmin (effect size = 1.85, p=0.06) and iron (effect size = 1.42, p=0.06) levels were higher, and manganese (effect size = 0.27, p=0.34) was lower in patients. Conclusion: Results from this meta-analysis indicate lower zinc status accompanied by increased copper and ferritin levels in patients with type 2 diabetes when compared to controls.

Percutaneous Left Appendage Closure with the Watchman Device; The Challenges Lie Ahead: A Narrative Mini Review

Atrial Fibrillation (AF) is the most prevalent arrhythmia occurring especially in the elderly. The extremely dire complication of this condition is cardiac thromboembolism that commonly arises from the Left Atrial Appendage (LAA) and may lead to stroke. Currently, guidelines recommend Oral Anticoagulants (OACs) as the therapy of choice for AF patients who are considered susceptible to develop stroke. Although, OACs have been proven effective for this purpose, they are not always an appropriate choice as they increase the likelihood of major bleeding, which can be specifically problematic to patients who for any reason, already have a moderate to high risk for bleeding. Moreover, the need for frequent PT, PTT and INR assessments and patients’ non-compliance can add to the problems of long-term use of OACs. The search for alternative treatment choices has resulted in the evolution of Percutaneous Left Atrial Appendage Closure (LAAC). Multiple devices have been developed to be applied to this method, the most well-studied of which is the Watchman device. At the moment, percutaneous LAAC is being recommended only by European guidelines and just for patients with non-valvular AF (NVAF) who have a high potential for stroke and who are contraindicated to OAC therapy. The method still offers several challenges and requires more evidence to be approved as a definitive treatment option. In this article, we reviewed the concept behind LAAC and its indications, the available evidence on safety and effectiveness of LAAC with Watchman and focused on the challenges underlying this developing therapy.

Patellar Tendinopathy: A Review of Literature

Shibili Nuhmani, Qassim I Muaidi

Patellar Tendinopathy (PT) is an overuse disorder commonly seen in athletes who participate in jumping and running activities, and it can interfere with their athletic participation. It is characterised by progressive activity-related anterior knee pain and tenderness in the patellar tendon. This study presents an overview of the current knowledge on PT focusing on prevalence, risk factors, symptoms, and management strategies. This review can guide healthcare practitioners in decision making on the management of athletes with this condition.

Classification of Root Canal Configurations: A Review and a New Proposal of Nomenclature System for Root Canal Configuration

Rashmi Bansal, Sapna Hegde, Madhu Sudan Astekar

Pulp space is complex, root canals may divide and rejoin. In the simplest form each root with one canal and single apical foramen is not observed always, other canal configurations are present which exit the root with two, three or more foramen. Several classifications have been proposed to describe root canal configurations for communication. With the advent of three dimensional imaging technique researchers are reporting newer configurations which cannot be classified using current system. Hence, newer classifications are proposed by each researcher. It is difficult to retain all classifications. Secondly, these newer classification are not the continuation of previous ones. Also, similar terminology has been used by different researchers for different configurations. Hence, in this paper instead of grouping root canal configurations into types, nomenclature system is proposed to identify each configuration individually.

Evaluation of Congo Red Staining Kit to Determine Proteinuria in Preeclampsia

JL Rodríguez Chávez, EK Fuentes Gutiérrez, MJ Angelesvázquez, H Mendieta Zerón

Introduction: Preeclampsia is characterised by the increased excretion of misfolding protein, attracted by a Diazo dye denominated congo red. Aim: To compare congo red staining kit versus a urocolor test to determine proteinuria in patients with preeclampsia. Materials and Methods: This was a prospective, transversal study, performed between August 2010 to July 2011, including pregnant and puerperal women with the clinical diagnosis of preeclampsia. From all patients, a single sample of 24 hours urine was tested with congo red to determine the presence of proteinuria, comparing the qualitative results of the urine dipstick for proteinuria and the gold standard determination of protein in 24 hours urine collection. Differences among nominal conditions were evaluated by the Mann-Whitney U-test. Results: A total of 50 pregnant and puerperal women were included in this study. The statistical comparison between 2 vs. 3, 2 vs. 4 and 3 vs. 4, congo red positive fields reached significant difference (p=0.001) in relation to the mean proteinuria values for each one. In contrast, with the urocolor test there were no differences per number of positive crosses. Conclusion: The congo red has a high selectivity for beta-folded proteins in preeclampsia being a promising screening test of high value to the clinician.

Isolation of Haemophilus influenzae from Urine of an Elderly Male Patient with Carcinoma Bladder-An Under-recognised Pathogen?

Ramya Raghavan, Jharna Mandal, Sreerag Kodakkattil Sreenivasan

Haemophilus species are rare uropathogens. The incidence and significance of Haemophilus species isolated from the genitourinary tract are not well studied. Here we describe the serendipitous isolation of Haemophilus influenzae in an elderly male, with an underlying urothelial carcinoma of bladder, who presented with Urinary Tract Infection (UTI). This case report further strengthens the cause of inclusion of special medium like chocolate agar in the work up of UTI in selected population.

Jaffe Lichtenstein Type Polyostotic Fibrous Dysplasia with Unilateral Absent Testis

Anand Ramakrishnan, Radha Kumar, Kishore Narayan, Santhosh Kumar

Fibrous dysplasias are developmental bone disorders in which the medullary cavity is replaced by fibrous tissue. It can be monostotic involving a single bone or polyostotic involving multiple bones. Unlike the monostotic type, the polyostotic type of fibrous dysplasia is associated with non skeletal manifestations like café au lait macule and/or endocrine hyperfunction. The presence of endocrine involvement differentiates McCune Albright syndrome from Jaffe Lichtenstein syndrome. We hereby report a case of an 11-yearold male child presenting with polyostotic type of fibrous dysplasia involving bilateral femurs with café au lait macule having no endocrine disease consistent with the diagnosis of Jaffe Lichtenstein disease. He also had unilateral absent testis which is rarely reported in this syndrome.

Cervical Vagal Schwannoma: Peculiarity in Diagnosis and Treatment

Vagal Nerve Schwannoma (VS) is a rare tumour, usually seen in patients of 30-50 years of age, affecting both sexes equally. Clinically, VS presents as a slow growing, asymptomatic tumour, often with minimal symptoms in the patient. It is necessary to distinguish VS from other neck masses and to arrive at a diagnosis only after ruling out commonly occurring neck lesions. Cytology in cases of VS is often inconclusive; hence, there is a higher degree of reliance on Magnetic Resonance Imaging (MRI) to establish a preoperative diagnosis. Treatment involves complete excision of the tumour. Other less frequently employed options include intracapsular enucleation. Postoperative morbidity has been reported and includes hoarseness of voice or speech difficulties. The final diagnosis is achieved by findings on histopathological examination. Here, a case of VS occurring in a 60-year-old female is described. The presenting clinical features, diagnosis and surgical management are further discussed.

Histopathological Analysis of Dens Invaginatus in an Immature Permanent Incisor

Liming Jiang, Xuejuan Ma, Yao Liu, Ming Zhong, Xu Chen

Dens Invaginatus (DI) is a congenital development malformation. The complex anatomy of DI aids in the retention of food and bacteria, which leads to pulp necrosis and develops into periapical inflammation. The histopathology of DI is not very clear. This study reports an unusual case of a 6-year-old boy who had a malformed immature permanent mandibular central incisor with DI Type III and apical periodontitis. The malformed tooth was extracted due to the severe infection and short tooth root. Histological results showed that typical pulp tissues were in the main root canal whereas a typical granuloma existed in the invaginated part. This case report indicate that the apical periodontitis in DI Type III was mainly induced by the invaginatus canal and the pertinent treatment for the invaginatus canal was the key for DI Type III.

Stress Among Pregnant Women: A Systematic Review

Maria Pais, Murlidhar V Pai

Introduction: Stress is a complex situation which is genetically determined pattern of response of the human physiology to a challenging situation. Persistent emotional neglect and constant stress response reflects differences in individual behavior, as well as differences in physical strength or general physical condition. Aim: To systematically review the available literature on stress and its adverse effect on pregnant women. Materials and Methods: A comprehensive review from PubMed and CINAHL database was done from 1998 to 2015. Search strategy specific to each database was used. During initial search 43,071 titles were retrieved and after screening 58 articles were selected for eligibility. Finally 14 research articles were selected based on the inclusion criteria. Results: All the 14 studies showed that increased maternal stress was associated with gravidity, gestational age at delivery, monthly family income, prematurity and preterm delivery. The maternal stress present during antenatal period for a long time has adverse effect on foetal and maternal outcomes. Conclusion: Antenatal stress during pregnancy has adverse effect on maternal and foetal outcomes. Hence, maternity healthcare provider should understand the consequences of antenatal stress leading to long term effect. The health care providers can offer educational material as well as conduct programs to improve the maternal and infant health and initiate healthy therapeutic measures for all pregnant women.

Difficulty in Cytological Diagnosis of Clear Cell Sarcoma - A Clinicopathological Correlation

Sheetal Arora, Geetika Khanna, Rajni, Deepshikha Rana

The rarity of Clear Cell Sarcoma (CCS) and its overlapping morphology with other soft tissue tumours brings diagnosis under suspicion. Several series have described histopathologic features however, only few series have described cytological features. This series represents cytohistopathological correlation with emphasis on diagnostic difficulties and the role of ancillary studies. This series concerns six patients who presented at our hospital between 2002-2012. FNAC smears showed epithelioid to spindle cells, scattered or in focal clusters or pseudoacinar pattern. Most cells (n=5) had round to oval eccentrically placed nuclei. Multinucleated tumour giant cells and binucleated cells were (n=2) present. The cell clusters (n=2) demonstrated three dimensional clustering and pseudoacinar structures. Necrosis (n=1) was noted. The histopathological pattern showed variable sized nests of uniform plump to spindle cells with clear to pale cytoplasm separated by fine to coarse fibrous septae. Cells were epithelioid (n=2), with nuclear pleomorphism (n=2), prominent nucleoli (n=3), cytoplasmic vacuoles (n=1) and multinucleated giant cells (n=1). The mitotic rate varied from 3 to 11/HPF. Tumour necrosis and bone involvement were seen (n=2). A microcystic growth pattern (n=1) was seen in the locally recurrent tumour. Melanin and Masson-Fontana were negative. All cases were positive for HMB-45 antibodies. Accurate pathologic recognition could aid in the institution of prompt surgery and could delay or avoid recurrences.