Journal of clinical and diagnostic research

Periradicular Cystic Enucleation and PRF Grafting Following Apicoectomy in Trichotillomania Patient- A Case Report

Vimanyu Kataria, Surender Sodhi, Shikha Dogra, Vignesh Guptha Raju

Diagnosis and treatment planning of untreated traumatised anterior teeth specially in children with psychiatric disorders or special health care needs is a challenge to paediatric dentist, that too in non-pharmacological means is a difficult task. Most of the time when these patients report with such complaint, it is already too late. This could be due to unintentional reasons like lack of parent awareness or patient’s response at the time of insult. All these factors bypass the time of conservative and minimal invasive treatment approaches. Ultimately, delayed treatment of trauma to anterior region exposes pulp and infection progress to periradicular region with cystic changes. Here, in this case report, the non-pharmacological management of periradicular cyst enucleation, followed by apicoectomy and Platelet Rich Fibrin (PRF) grafting was done in a 15-year-old female patient with obsessive compulsive disorder i.e., Trichotillomania (TTM) under local anaesthesia. Symptoms and intraoral swelling was resolved postoperatively in follow-up visits.

Severe Pulmonary Air Leak Complicating Neonatal Resuscitation

Supriya, Perumalla Bhavani Deepthi, S Giridhar

Air leaks are an important respiratory morbidity in neonates and can result from positive pressure breaths administered at birth. The presentations can vary from being asymptomatic to severe respiratory distress and hypoxaemia. This report is about a term boy who presented with respiratory distress immediately after birth, following resuscitation. He also had a diffuse swelling in the nape of the neck and interscapular region with crepitus on palpation. Serial chest radiographs initially revealed a pneumomediastinum and a subcutaneous emphysema, followed later by a right-sided pneumothorax. After chest drain insertion and supportive care, the air leaks resolved, with no residual complications. Severe air leaks with multi-site air tracking can rarely complicate positive pressure administration at birth, requiring timely intervention to optimise outcomes.

Abrikossoff’s Tumour of Oesophagus- An Innocent Bystander or a Silent Killer?

Oesophageal Granular Cell Tumour (GCT) is a rare tumour arising from schwann cells of the submucosal nerve plexus. They are slow-growing generally, benign though malignant potential has been reported. They are usually found incidentally during endoscopic evaluation of dyspepsia or dysphagia. They rarely produce symptoms on their own unless the size is larger, ulceration occur on their surface or when it compresses the adjacent structure. Though they are submucosal, they are usually diagnosed by standard biopsy techniques or after an endoscopic resection. Oesophageal GCTs without muscularis propria attachment are amenable for Endoscopic Submucosal Dissection (ESD) which is a minimally invasive procedure when compared to surgical resection. They may require follow-up after resection. Here, we report a case of 39-year-old male who presented with epigastric pain, heart burn and underwent endoscopy for the same, which revealed a sub-centimetric yellowish white flat lesion above oesophago-gastric junction. Biopsy was done and histopathology and immuno-histochemistry revealed sheets of tumour cells with clear granular cytoplasm which stained positive for S100 and Calretinin, with a Ki-67 index of 2%, confirming the diagnosis of a benign GCT. Endoscopic Ultrasound (EUS) revealed no local invasion and the patient was advised three months follow-up and annual surveillance endoscopy

Concurrent Occurrence of Bilateral Hypodontia and Microdontia in a Nonsyndromic Paediatric Patient: A Case Report

Hypodontia is a developmental dental anomaly defined as the absence of one or more primary or permanent teeth excluding third molars. It can be associated with syndrome or nonsyndromic condition accompanied with other developmental dental anomalies like microdontia. Bilateral occurrence of hypodontia alongside microdontia is a rare condition. This case report presents a rare occurrence of bilateral hypodontia and microdontia in a nonsyndromic patient. Owing to its nonsyndromic background, other parameters like developmental delay, height, weight and body mass index are used as the predicting factors for the occurrence of hypodontia. Developmental milestones are one of the important factors in deriving the treatment plan. Treatment options in this case were directed at delaying the treatment until the eruption of the permanent successor teeth followed by the use of mini-implants for hypodontia, porcelain jacket crown for microdontia and the orthodontic treatment for final space closure.

A Rare Case of Coexistence of Homozygous β-Thalassaemia and Glucose 6 Phosphate Dehydrogenase Deficiency

Jitendar Mohan Khunger, Monika Gupta, Ankur Jain, Monica Khunger Malhotra

β-thalassaemia is one of the most prevalent autosomal disorders worldwide. Mutations/deletions in globin gene underlie deficiencies in Haemoglobin (Hb) production, which can interfere with oxygen delivery by Hb, resulting in thalassaemias causing anaemias with a wide range of disease severity. Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency is a genetic abnormality resulting in inadequate amount of G6PD in the Red Blood Cells (RBCs). In patients with G6PD deficiency, the reduced or absent activity of the enzyme in RBCs causes premature haemolysis and symptomatic anaemia. The marked oxidative stress caused by homozygous ß-thalassaemia is apparently incompatible with G6PD deficiency. Here, a rare case of six-month-old male child is described who presented with severe pallor hepato-splenomegaly and these two conditions co-existed in this patient.

Paediatric Embryonal Tumours in Multilayered Rosettes Presenting as a Low Grade Glioma- An Unusual Case Report

Sibhi Ganapathy, Nikunj Godhani

Paediatric Embryonal Tumours in Multilayered Rosettes (ETMR) are rare aggressive tumours with poor survival statistics, defined in 2016 by World Health Organisation (WHO) classification of brain tumours. The tumours have a characteristic radiological appearance on Magnetic Resonance Imaging (MRI) of the brain, which is easily decipherable. This combined with a clinical picture of raised intracranial pressure symptoms, seizures and rapidly progressive new onset neurological deficits make the diagnosis fairly obvious. The final confirmation of the diagnosis is done by immunohistochemical analysis of the C19Myc gene alteration. Rarely, certain radiological presentations are uncharacteristic and resemble other more benign pathologies with overlapping clinical presentations. This can be misleading, as ETMRs require aggressive surgery followed by adjuvant chemotherapy and radiation to ensure best possible survival. We present such a case report of what appeared to be a low-grade glioma in the frontal lobe. This tumour presented with one episode of generalised tonic clonic seizures not unusual as a presenting complaint in low-grade gliomas per se. Surgical debulking under ultrasonic guidance was done and the specimen was sent to histopathological analysis. The histopathological analysis showed a surprise ETMR diagnosis which was sent for confirmation to two other centers. This case report highlights the need to keep ETMRs as a rare differential diagnosis for even low-grade gliomas of the brain, thereby allowing accurate prognostication only after histopathological and immunohistochemical assessment. We present a brief literature review on unusual presentations of ETMRs reported in literature to further illustrate the chimeric nature of this rare disease.

Fetal Autopsy Showing Two Ventral Body Wall Defects: An Unusual Presentation

Anupriya Kaur, Arun Prasad, Jessy Jayaraman Pushpaja, Kanchan Kapoora

Thoracoschisis and gastroschisis are types of ventral body wall defects. Usually thoracoabdominoschisis presents as a continuous defect. Here the authors present the case of autopsy of 18 weeks old fetus with two well-separated ventral body wall defects. Thoracoschisis was a right lateral thoracic wall defect while gastroschisis, a midline infraumblical abdominal wall defect. Through the right lateral thoracic wall parts of two organs appeared to be protruding. On dissection, 8^th and 9^th ribs with the liver and the lower lobe of the right lung were herniating outside the body. The right lung was haemorrhagic. Various embryological theories on ventral body wall defects have been discussed in view of the present case.

Type II Proximal Focal Femoral Deficiency in a Three-Year-Old Female: A Case Report

Muhammad Baba Sule, Ibrahim Haruna Gele, Yakubu Bababa Shirama, Muhammad Abacha

Proximal Focal Femoral Deficiency (PFFD) is a term used to describe a condition where the femur is short and associated with an apparent loss of continuity between the shaft and neck. PFFD is reported as an uncommon but complex clinical condition. This was commonly grouped with other disorders like coxa vara and short bowel tumours. This has a female to male ratio of 2:1 and an incidence of 1 case per 50,000 population to 1 case per 200,000 population. This is a case report of a three-year-old female that was referred for plain radiograph of the lower limbs on account of limb-length discrepancy and abnormal gait. The plain pelvic and lower limb radiograph showed a markedly shortened femur with non-demonstration of the femoral head and neck. There was a vertically oriented acetabula fossa with altered acetabula and iliac angles. The patient is currently managed conservatively mainly by reassurance and use of crutches.

Marburg Denture System: Aiming to Preserve the Proprioception-A Case Report

All efforts to save the natural teeth should be made during restoration to achieve optimum functionality and aesthetics. Tooth loss is associated with appetite loss and loss of nutritional values. Thus, rehabilitating complete or partial edentulous conditions contributes to improvement in the functioning of the masticatory system. In the latter case of partially dentate condition, the natural teeth present preserve the residual ridges. Extraction of teeth causes alveolar ridge resorption. Poor foundation or ridge form donot provide support for the denture bases which is the factor of utmost consideration for stabilisation of the denture bases. In these instances, use of the telescopic dentures may be indicated. A telescopic denture retains and preserves the natural teeth beneath it. Every dentist aims at preserving the natural and restoring the lost. Preservation of the remaining teeth in turn preserves the natural proprioception mechanism, was thus followed and applied in this case report in which a 25-year-old female patient with diabetic history and on medication since past four years, presented with multiple missing teeth in December 2019. After thorough evaluation, the patient was treated by Marburg double crown system or synonymously termed as telescopic denture opposing the tooth supported overdenture. Follow-up and recall schedule was then explained and operator noted a satisfactory response from the patient. Consecutive follow-ups were maintained.

Rare Dysplastic Gangliocytoma of Cerebellum: A Case Report

Nidhish Kumar, Sharvani Singh, Bipin Kumar

Lhermitte and Duclos first described Dysplastic Gangliocytoma in 1920. Lhermitte Duclos Disease (LDD) is an extremely rare disorder of uncertain prognosis and pathogenesis. LDD is recognised as a part of Cowden Disease, which being an autosomal-dominant phacomatosis and cancer syndrome. Till date only about 225 cases of LDD have currently been reported in medical literature. It is most commonly seen in young adults with a peak incidence in third or fourth decade with signs and symptoms of cerebellar dysfunction or increased intracranial pressure leading to obstructive hydrocephalus. A 36-year-old female came to Neuromedicine Outpatient Department (OPD) in a Tertiary Care Superspecialty Hospital with chief complaints of headache and vomiting, difficulty in swallowing liquid food since two months with no significant family history. The patient’s general condition was not good with significant weakness on presentation. The patient was conscious, oriented with pulse rate of 78/bpm, blood pressure of 118/80 mm of Hg with bilateral clear chest with normal S1 S2 sound. The Glasgow Coma Scale (GCS) was found to be Eye response-4, Verbal response-5, Motor response-6. Magnetic Resonance Imaging (MRI) of patient showed large heterogeneous non-enhancing lesion involving left cerebellar hemisphere, vermis and cerebellar peduncle with widened cerebellar folia with a "Tigroid appearance". A diagnosis of Cerebellar Gangliocytoma was made and was treated successfully with surgery and diagnostically proven with biopsy and immunohistochemistry. The background history of Cowden syndrome was not present in index case.

Bilateral Ovarian Mature Cystic Teratoma- A Rare Case Presentation

Kafil Akhtar, Mohd Talha, Saquib Alam, Zehra Mohsin

The incidence of bilateral mature cystic teratoma of the ovary is only 10%. Ovarian mature cystic teratomas are common, benign, pelvic tumours and can be easily detected by ultrasonography. Recurrent ovarian teratomas are very rare, and cases of bilateral teratomas are even rarer. So, it is advisable to routinely check the ovary contralaterally during the surgical procedure along with careful pelvic sonographic examination of both the ovaries. Inadvertent extensive surgery should be avoided in this benign condition that might further compromise the fertility of young patients. We report a rare case of bilateral mature cystic teratoma of the ovary in a 28-year-old female, who presented to the gynaecologic outpatient department with complaints of intermittent dull aching, diffuse lower abdominal pain and dysmenorrhea for three months. Transvaginal ultrasonography revealed bilateral complex ovarian masses that raised suspicion of dermoid cysts with hypoechoic endometrial collections. Her Cancer Antigen 125 (CA-125) was normal. A bilateral ovarian cystectomy was performed and histopathology confirmed the diagnosis. This case highlights a rare occurrence of bilateral ovarian mature cystic teratoma, where cystectomy was performed to preserve the fertility in a young female.

Solitary Cysticercosis of Temporalis Muscle: A Rare and Challenging Diagnosis

Sweta Singh, Uday Shanker Singh

Taeniasis is an endemic parasitic infection of developing countries, including India. It is caused by pork (Taenia solium), beef (Taenia saginata), and Asian (Taenia asiatica) tapeworms and the route of transmission is faeco-oral. It usually occurs due to ingestion of uncooked green leafy vegetables, undercooked meat or unsafe drinking water contaminated with faeces. The mode of presentation can be severe in the form of Neurocysticercosis (brain) or solitary muscular cysticercosis. Neurocysticercosis can prove to be fatal and life-threatening in the form of seizures and focal neurological signs. Diagnosis of cysticercosis is usually based on direct stool examination for eggs on three consecutive days or proglottids of the tapeworm, serological tests such as Enzyme Linked Immunosorbent Assay (ELISA) and radiological imaging for confirmation. Here, a rare and very interesting case of cysticercosis was reported in temporalis muscle in a young female. The patient presented with only a solitary swelling in preauricular region. Both radiological and microbiological investigations played a very vital role in the diagnosis and the patient was finally diagnosed as a case of muscular cysticercosis. She was started on conservative treatment with Albendazole and steroids for two weeks. Repeat radiological scans showed improvement in her swelling and complete resolution in about a month. Cysticercosis of temporalis muscle is in itself a very rare event and there are only a few reported cases in literature. The present case was also unique in terms of localisation of the cyst as it was inside the superficial fibers and fascia of the muscle and not intramuscularly.

Role of Plasma Exchange in Steroid Resistant Neuromyelitis Optica with Loss of Vision

Neuromyelitis Optica (NMO) is a demyelinating inflammatory disorder of the spinal cord and optic nerve. As per American Society For Apheresis (ASFA) guidelines, Therapeutic Plasma Exchange (TPE) is considered as a second-line treatment in patients with weak or no response to steroid therapy. A patient of NMO presented to the tertiary care institute with a sudden loss of vision in the right eye. The patient was resistant to steroid treatment and improved significantly with TPE. Hence, TPE may be an effective treatment modality in steroid-resistant NMO with vision loss.

A Case of Small Cell Carcinoma of Lung Presenting as Opaque Hemithorax

Keerthan Ganapathi, Saood Ali, Ulhas Jadhav, Babaji Ghewade

The most common cause of an Opaque Hemithorax is Pleural Effusion. It is a rare occurrence to find patients with extensive mass leading to an opaque hemithorax. Thorough search of literature did not yield any case with such a large lung mass leading to opaque hemithorax, without the presence of pleural effusion. Lung cancer is the most common cancer diagnosed worldwide and has predominantly been attributed to tobacco smoke exposure. Of the several types, small cell lung cancer differs from others by its early spread and extensive dissemination leading to metastatic classification at the time of diagnosis. Here, is a case of a 50-yearold female patient who presented to the outpatient department with dry cough, weight loss and appetite loss since five months. Her chest radiograph revealed a right-sided homogeneous opacity involving the entire right hemithorax and left-sided pleural-based homogenous mass. Contrast Enhanced Computed Tomography (CECT) thorax revealed an enlarged hemithorax with evidence of large, ill-defined heterogeneously enhancing multilobulated soft-tissue density mass lesion occupying the entire right hemithorax. Biopsy was suggestive of Small Cell Carcinoma of Lung (SCLC), chemotherapy was given and patient is under regular follow-up.

Prosthetic Rehabilitation of a Patient with Severe Early Childhood Caries: A Case Report

Early Childhood Caries (ECC) continues to be one of the most common chronic diseases in children throughout the world, exerting a negative impact on quality of life. This condition can cause pain, infection, and tooth loss as well as problems with speaking, chewing, and nutrition. The aetiology of ECC is complex and involves socioeconomic, biological, and behavioural factors. Rehabilitation in very young patients is challenging due to difficulties inherent to the age of the child, which limits cooperation, the extent of tooth decay, and the motivation of family members, especially in patients with the early loss of primary teeth. Therefore, paediatric dentists need to plan and implement individualised approaches on a case-by-case basis. This paper reports a case of a three-year-old boy diagnosed with ECC involving extensive carious lesions, root remnants, and multiple abscesses. The treatment plan involved prosthetic rehabilitation with complete dentures. Regular check ups were important to the functional adaptations and proper hygiene counselling. The child adapted extremely well to the dentures. Improvements in appearance, speech, and chewing function enhanced the child’s self-confidence and assisted in establishing proper dietary patterns.

Congenital Lacrimal Fistula in a Seven-Year-Old Female: A Rare Cause of Epiphora

Praveena Kher, Jigna Motwani

Congenital lacrimal fistulas are rare epithelium-lined tracts that tend to have a direct communication between skin and the lacrimal drainage system. These are benign developmental abnormalities, that may require no treatment. This is a rare diagnosis since patients are usually asymptomatic and presents only when epiphora is associated. When symptomatic, congenital lacrimal fistula presents as epiphora, or mucoid discharge, rarely patients could develop nasolacrimal duct obstruction, which may present as recurrent dacryocystitis. Thorough clinical examination is the best way to diagnose the condition, where a fistula ostium may be found inferonasal to medial canthus of the eye. Further, lacrimal probing and irrigation is helpful. Surgical management of the fistula is advised only if the disease is symptomatic which ranges from simple excision to dacryocystorhinostomy. This is a report of one such patient with congenital lacrimal fistula which was treated surgically by fistulectomy.

Surgical Treatment of Eagle Syndrome by Intraoral Approach: A Case Report

Eagle Syndrome is the sensation of presence of a foreign body along with pain in the oropharynx and face that is exacerbated by swallowing, chewing and yawning due to the elongation of the styloid process. Its aetiology is usually tonsillectomy or throat injury. The associated pathological feature is the compression of neurovascular structures surrounding the styloid process due to its lengthening. In this report, a case of 37-year-old female presenting with Eagle syndrome treated surgically by intraoral approach is presented. Computed tomography showed hyperdense bilateral areas in the regions of styloid processes suggestive of elongated styloid processes. The patient underwent general anaesthesia due to the possibility of airway obstruction during the procedure and the proximity of important neurovascular structures. In the region of the tonsillar pillars, electrocautery and tissue dissection was performed and the styloid processes were accessed. The electrocautery incisions were placed in the region of the tonsillar pillars, surrounding tissues were dissected to expose the styloid processes in oral cavity. With Kelly forceps, the styloid processes were fractured and removed. The surgical treatment with intraoral approach provided definitive treatment of the Eagle syndrome quickly, without causing obvious scarring and favouring the patient’s recovery.

Management of Peripartum Cardiomyopathy with Secondary Large Left Ventricular Apical Clot using Novel Oral Anticoagulants: A Case Report

Mrigakshi Aggarwal, Manav Aggarwal, Prem Aggarwal

Peripartum Cardiomyopathy (PPCM) is a major life-threatening complication of pregnancy, as only half of them or slightly more patients show improvement of Left Ventricular (LV) dysfunction. A 28-year-old woman with a history of gestational hypertension and diabetes during pregnancy, underwent full-term normal vaginal delivery. She started developing dyspnea, Class II which progressed to Class IV postpartum. Kidney and liver functions were found to be grossly deranged along with thrombocytopenia. Provisional diagnosis of Haemolysis, Elevated Liver Enzymes and Low Platelets (HELLP) was made. Electrocardiography (ECG) revealed the left anterior fascicular block. Eventually, bedside echocardiogram revealed severe LV dysfunction and the presence of a large soft LV apical clot with an Ejection Fraction (EF) of 30%. Adequate anticoagulation was achieved using Novel Oral Anticoagulants (NOAC). After six days and a 3-month follow-up, an echocardiogram demonstrated a significant improvement of LV function (EF-45%) and a complete resolution of LV apical clot, respectively.

Uterine Torsion Masquerading as Abruptio Placentae: Diagnosed on Laparotomy

Niranjan Mayadeo, Anusha Devalla

Uterine torsion is a rare, life-threatening and unexpected obstetric emergency. It is almost always diagnosed at caesarean section. Its ill-defined clinical presentation may pose a diagnostic dilemma. Here the authors present a case of 32-year-old, Primigravida, 36 weeks pregnancy with acute abdomen and intrauterine foetal demise. Clinical features resembled Abruptio Placentae. The diagnosis of uterine torsion (180°) was established on laparotomy where the left ovarian ligament was seen on the right side anteriorly. A posterior hysterotomy was done to extract the baby which was followed by detorsion of the uterus. The postoperative period was uneventful.

Lumbosacral Spondylodiscitis- An Atypical Localisation of Salmonella Typhi Infection: A Case Report

Sruthi Vinayan, Vimal Karnaker, V Sreelatha, Sanjana Nair

Salmonella belongs to the family Enterobacteriaceae. The various members of the genus cause diseases that are important public health problems. Apart from causing typhoid, Salmonella can cause an array of diseases ranging from osteomyelitis to meningitis, though rare. Herein, authors report one such uncommon scenario, in an otherwise healthy 40-year-old female who presented with lower back pain. Magnetic Resonance Imaging (MRI) was suggestive of lumbosacral spondylodiscitis and she underwent a spine stabilisation surgery. The pathogen was confirmed to be Salmonella Typhi by microbiological workup. She responded well to treatment with ceftriaxone. This case report implies the significance of culture studies in the early management of the patient. It is imperative for the diagnosis, as the symptoms of the aforementioned disease are usually non-specific and imaging studies are indiscernible from spine tuberculosis.

Frantz's Tumour an Unusual Pancreatic Neoplasm: A Case Report

Mejri Atef, Khaoula Arfaoui, Jasser Yaakoubi, Bacha Dhouha, Najet Mahjoub

Solid-Pseudopapillary Tumour of the pancreas (SPT) or Frantz’s tumour is a rare epithelial neoplasm and represents 2% of exocrine pancreatic tumours. Its origin remains enigmatic and they are of little known aetiopathogenesis. These tumours occur in young women and must be suspected in any case of left hypochondrium’s mass. It has a good prognosis through radical surgical excision. The five-year survival rate is around 97%. Here the authors present a case of 26 years old female patient, who presented to the emergency department with three weeks history of abdominal pain and vomiting. Physical examination did not reveal any abnormalities and her blood tests were normal. Cross-sectional imaging modalities which showed a caudal pancreatic mass with cystic and necrotico-haemorrhagic components evocative of a pseudo-papillary solid tumour of the pancreas. The patient had a distal pancreatectomy and splenectomy with good outcome.

Study of Iron Profile and Effect of Oral Iron Supplementation in Patients of Attention Deficit Hyperactivity Disorder: A Case Series

Attention Deficit Hyperactivity Disorder (ADHD) is a neuropsychiatric condition affecting the preschoolers, children, adolescents and adults globally. Dopamine synthesis is dependent on availability of iron in the body and dopamine deficit theory is the widely accepted ADHD causation theory. So, serum iron levels are important to watch out for in patients suffering from ADHD. This article describes six cases to emphasise the importance of diagnosing and treating underlying Iron Deficiency (ID) state with oral iron supplementation for effective management of patients suffering from ADHD. All the six cases which were given oral iron supplementation along with methylphenidate had shown improvement in inattentive domain and in hyperactivity-impulsivity domain at both home as well as school settings. They were given doses of methylphenidate and oral iron supplement as per the recommended body weight. Their parents and teachers were asked to mark the responses on Swanson, Nolan, and Pelham Rating Scale (SNAP-IV) 26 item parent and teacher rating scale respectively. Scores on SNAP-IV were recorded at the first visit and after three months of treatment. Scores were then evaluated on both occasions for evidence of improvement in ADHD symptoms.

Identification of Non-fermenters by Matrix Assisted Laser Desorption/Ionisation- Time of Flight Mass Spectrometry: Case Series of Achromobacter Infections

Pratik Thosani, Mahima Lall, Shelinder Pal Singh Shergill, Mukesh Dhillon

Achromobacter is a non-fermenting Gram Negative Bacillus (GNB) belonging to the family Alcaligenaceae. It is emerging as a pathogen, causing myriad of infections in different patient groups. Often wrongly identified by conventional microbiological techniques, Achromobacter when recovered from clinical specimens have often been discarded as contaminants. Accurate species identification of the currently known 21 species of Achromobacter, is difficult, labour-intensive and time consuming. Automation has made it possible to reliably and correctly identify Achromobacter species and other non-fermenters. Matrix Assisted Laser Desorption Ionisation-Time Of Flight-Mass Spectrometry (MALDI-TOF-MS) is a boon as it rapidly and accurately identifies Achromobacter species in clinical specimens. Three cases of Achromobacter infection, highlighting the pathogenic potential of the bacteria and the role of automation in its identification are presented with due consent from relatives or patient themselves. This case series highlights that Achromobacter when recovered from clinical specimens should not be discarded as contaminants especially if isolated repeatedly. Case one was a patient who had developed pyelonephritis and sepsis, associated with bacteraemia and ended fatally, Achromobacter was recovered on two occasions from the blood culture. Case two was a patient who was diagnosed of acute pancreatitis with an infected peripancreatic collection who recovered with prolonged therapy, Achromobacter was repeatedly isolated from the pus draining from the peripancreatic collection. Case three was a patient with an infected malignant ulcer with purulent discharge from the swelling. In all three cases Achromobacter was isolated and identified by MALDI-TOF-MS.

Single Centre Based Clinico-pathological Experience of Adrenal Tumours Including Some Rare Entities

Moumita Maiti, Ranu Sarkar, Krishnendu Maiti

Adrenal tumours are relatively uncommon neoplasms, broadly divided into adrenal cortical and medullary tumours. They show bimodal age distribution. This is a retrospective case series of 36 cases of adrenal tumours over three years (September 2016- August 2019) in NRS Medical College Kolkata, West Bengal, India. Apart from Haematoxylin and Eosin (H&E) staining relevant Immunohistochemistry (IHC) (synaptophysin, Ki-67, Human Melanoma Black 45 (HMB 45) were done for proper histopathological diagnosis. Amongst 36 cases, 12 cases (34%) were myelolipoma, five cases (14%) were neuroblastoma, six cases (17%) of adrenocortical adenoma, two cases (06%) adrenocortical carcinoma, five cases (14%) pheochromocytoma, two cases (06%) mature teratoma, one case (03%) of epitheiloid PECOMA (Perivascular epithelioid cell tumour), one case haemorrhagic pseudocyst (03%) and two cases (06%) were metastasis from renal cell carcinoma. Eleven patients had specific hormonal symptoms. Bimodal age distribution with 10 cases in younger than 14 years, eight cases in more than 50 years and rest 18 cases were in range of 14-50 years. Overall male: female ratio is 5:4 but myelolipoma was common in female. We have encountered few rare entitiesEpithelioid PECOMA (angiomyolipoma), Pheochromocytoma with Von Hippel-Lindau (VHL), Receptor for Neurotrophic Factor (RET) Mutation and uncommon presentation with Cushing’s Syndrome, one Adrenal Oncocytoma and two Mature Teratoma.

Morel-Lavallée Lesions of Lower Extremity: A Case Series in a Tertiary Centre

Himanshu Pandey, Manish Kumar, Rakhi Chhikara, Rohit Kaushik, Lalit Kumar

Morel Lavallée lesions (ML lesions) are a rare degloving type of injury occurring after blunt trauma, usually in the peritrochanteric region and resulting into a progressive subcutaneous swelling. The current case series includes three patients with a history of trauma and development of rapidly increasing fluctuant soft tissue swelling during a time period of 18 months. Though these lesions are typically described in peritrochanteric region, two cases were encountered in the knee region. ML lesions were diagnosed precisely using Ultrasound (USG) and Magnetic Resonance Imaging (MRI) modalities and were managed accordingly. Classification of these lesions is paramount to enhance patient outcome and reduce complications.

Anecdote from Editors Desk Anecdote 8- Whom to Ask if Not the Corresponding Author!

Sunanda Das, Aarti Garg, Hemant Jain

The role of a researcher does not end once the experiment is over and rewarding results are accomplished. Primarily, the need to publish outcomes of a study came into being when the scientific community found it pertinent to share knowledge among peers. This dissemination of knowledge would then form the basis of further researches. However, this elementary need gave birth to other complicated issues like misconduct, data falsification, fabrication, plagiarism etc. Thus, arose the requirement for scientists to acknowledge and take the onus of their work. Associations like COPE and ICMJE have laid well-accepted instructions, specifying criteria for authorship contribution. This helps categorise the roles and responsibilities of each author towards the manuscript as well as the research work. It is expected that every contributing author is privy to the course of a research, its outcome and has substantially contributed to and consented to the manuscript that documents the research. However, seldom it happens that senior researchers lend their names just because they were part of the research team, having no or very less knowledge of the content of the documental version of the work. These manuscripts when reach a journal and the glaring flaws are brought to light, the senior-most author is usually (and rightfully so) made the convict. This anecdote stems out of two experiences in which two Head of Departments (HoD) admitted of being part of individual ethical misconducts. The predicament for the editorial was that it was left with no option to put up the case of misconduct for an institutional enquiry. The first incident relates to a case report where the therapeutic outcome was falsified (morphed follow-up image). The editorial came to know about the wrongdoing and wrote to the HoD, also the corresponding author. He affirmed that such a patient had reported to the department but he had no knowledge about the treatment and outcome of the patient. When the handling physician (Post Graduate student) drafted an article based on the patient, as a ‘norm’ he added the HoD as the first author along with another Associate teacher of the department. As a resort, we deleted the morphed image and added a note that the patient could not be followed-up. The second anecdote involves an even higher institutional authority. In this case, the Director of a medical institute (also the HoD) was found to have submitted an already published article (he shared authorship in both the papers). He wasted no time to reach us back when the Chief Editor wrote a stern mail showing disbelief on the conduct of a person holding a chair of authority in one of the most reputed medical education centers of the country. To our dismay, he denied having any information about the paper being published elsewhere. We did not prude further about the requirement of copyright without signing which a journal cannot publish a manuscript. If he did not sign this copyright how could the paper get published and if he did sign how can his memory fall short so fast? The manuscript was finally rejected and the authors barred from further submissions to the journal. Next comes the question of setting up an investigation, which every journal wants to avoid. There are very high and strong limitations beyond which the editorial cannot step forward to block such misconducts for good. Though there are accounts where higher institutions got involved and either imposed temporary embargo or levied high compensation on the researchers that were implicated of misconduct these occasions make up a very small part of the literary content and happen only in handful of the cases. Research is mostly a collaborative effort. There can be a single primary investigator but it requires a team to put the whole study together and later get it published. Hence, scientific studies have multiple authors. The role and responsibility of each author would nonetheless vary. Often a multidisciplinary team collaborates for a study. Some journals have a strict policy wherein they require the authors to fill in a name for ‘guarantor of data’. This saves the face of the publishing house when the ground becomes murky. There remains a scope to blame the person who stood as guarantor, in situations when ethical misconducts come into light. In this regard, the American Psychological Association suggests that first authors should be the guarantor (1). Hussinger found that it is 38% more likely that the first authors are the ones responsible for any misconduct. Next in line come the corresponding authors who have a 14% share (2). This further clarifies, the known but covert fact that, not all authors are equally responsible for any research fraud. There is an opposing idea held by Committee on Publication Ethics (COPE) and All European Academies (ALLEA). These bodies recommend investigating all involved researchers in cases of malpractice (3). Some researchers also share the same thought. Jeffery Kovac of the University of Tennessee says ‘In cases of alleged scientific misconduct it is important to investigate the entire team to find out who is responsible’ (4). The irony is that, no matter how many bouncers we employ, there always remains a backdoor through which a fraudulent manuscript enters the editorial and often makes its way up and gets published. It is not sensible at all times to retract a published article justifying a fraud or ‘probable’ fraud. A journal is pushed to its extreme and it has to make some move to at least know what and to which extent the misconduct exists. There is no way to brush the matter off the editorial desk and get the article unpublished, neither would that be a ‘good conduct’ on the part of a journal. Here comes the role of a corresponding author. Though there are guidelines to control authorship abuse, there is not much clarity on the share of responsibility that the corresponding author should bear. Out-of-the-mould incidences occur where none of the laid principles and guidelines help and the editorial finds itself setting up its own court of law. How to resolve a case when the most senior author (also the corresponding author) says that he did not read the final draft of an article and does not want to take the blame? At times one or more among the authors just sign the copyright form and do not consider reading the manuscript before submitting it for publication. Shady data reflect adversely on the whole team of authors and not only the corresponding author. Even a grammatically faulty manuscript brings in bad reputation to the authors. The least that a busy researcher, lending his name to an article, can do is proofread the manuscript. The fact still remains unresolved as to who should be held responsible and whom the journal should approach when the departmental heads or the senior-most author takes no accountability or plays the role of a ‘on paper’ author? We strongly recommend that the veteran authors take up the initiative to ensure research integrity and read the final version of a manuscript before pushing it for publication.

Knowledge, Attitude and Practice of Health Science Students/Researcher on Status of Usage of Animals, 3R’s Strategy and their Alternatives for Pharmacological Studies: An Exploratory Study

Rishabh Sharma, Ravi Thakur, Malika Arora, Rakesh Kumar, Parveen Bansal

Introduction: The number of students in health science education is increasing day by day due to mushrooming of the private institutes. Hence, there is an increase in number of animals that have been used for animal experimentation irrespective of any known significance. Aim: To assess the Knowledge, Attitude and Practice of health science students/researchers on status of usage of animals, 3R’s strategy (Reduction, Refinement, Replacement) and their alternatives for pharmacological studies. Materials and Methods: This was a cross-sectional paper-based survey that was conducted between June 2019 to September 2019 using a semi-structured questionnaire to assess the knowledge, attitude and practice of the students. The study was conducted at the Guru Gobind Singh Medical College and Hospital, Faridkot and ISF College of Pharmacy, Moga, Punjab, India. The questionnaire consisted of three domains: Socio-demographic and professional characteristics, Knowledge (10 questions), attitude and practice of participants (9 questions). Out of 440 questionnaires distributed to the participants, 310 filled the survey (response rate was 70.5%) and were included in the study. The study participants comprised of MBBS interns, Junior residents/MD students, B pharmacy students, M pharmacy students and the PhD scholars. Results: Majority of the students belonged to the age group of 19-23 years. It was observed that 79.6% (n=247) students didn’t know about the 3Rs (i.e., Reduction, Refinement, Replacement) Strategy. A 39.6% (n=123) respondents knew about the various alternatives to animal experimentation. Majority of the students 90.9% (n=282) believed that animal experiments are useful for medical research and human benefit. Conclusion: There was an almost complete lack of knowledge among participants regarding alternative animal models and 3R’s strategy. Therefore, there is a need to incorporate education intervention about alternative animal use in their curriculum.

Oral Stings Caused by Sperm Bags of Squid

Toshinori Iwai, Satomi Sugiyama, Hiroaki Kitajima, Makoto Hirota, Kenji Mitsudo

With the increasing global popularity of Japanese delicacies made of raw seafood, such as sashimi and sushi, sufficient attention should be paid to the conditions caused by raw-food consumption. It is recognised that in ingesting raw squid, bacterial or planktonic toxin, and anisakid larva often cause food-poisoning and anisakiasis, respectively. Oral stings caused by sperm bag of squid are rare. A 21-year-old female had severe pain in her oral cavity immediately after eating a raw squid (Todarodes pacificus), and consulted the department of oral and maxillofacial surgery. Oral examination showed several small whitish, club-shaped foreign bodies stuck in the surface of the floor of mouth and left buccal mucosa. Because the removal with forceps was difficult due to the tight attachment to the mucosa, foreign bodies were removed completely using forceps with slight incisions under local anaesthesia. The stings were diagnosed as a sperm bag of squid.

Soil Transmitted Helminthiasis: An Interesting Scenario

Amrit Koirala, Godfred Antony Menezes

DESCRIPTION Ascaris infection caused by Ascaris lumbricoides (A. lumbricoides) is a neglected, soil transmitted, common human nematodal disease. For centuries, it has been affecting the people worldwide. A. lumbricoides infects nearly one billion people worldwide with 60,000 deaths annually. The disease affects mainly tropical and sub-tropical regions of the world, mostly East Asia, China, Latin America and Sub-Saharan Africa (1). Additionally, the parasite’s endurance and ubiquity pose struggles in control measures. Hence, further research on measures of control of ascariasis infections is required (2). There are data available on the prevalence of Ascaris infection from North-eastern region of India, like Assam (3). The adult female grows up to 30 cm, whereas adult male grows up to 20 cm in length. The female adult worms can produce environmentally resistant large numbers of eggs. The transmission of infection is due to ingestion of eggs contaminating food (fruits and salad) and water (1). The migrating larvae in the lungs can cause cough, fever, skin rashes and haemorrhage. When a subject has a large burden of adult worms it leads to mechanical obstruction of the intestine, abdominal pain and vomiting. Large worm burden with their migration may also result in bowel perforation; peritonitis and passing from mouth and anus (diarrhea/bloody stools) (1). A. lumbricoides, intestinal nematode out numbers all other parasitic pathogens of infection some even presenting obstructive necrosis of the bowel from where large bunches of the adult worms were recovered. This picture taken at the bus stop of Tezpur town in Indian state of Assam raises several questions (Table/Fig 1). At the time of taking of picture, the worm was still sluggishly motile while vomitus was just drying. Tezpur town is surrounded by rural population most of whom are tea tribes of Assam, also the nearest large town for the western Arunachal Pradesh, keeping this in mind it will be difficult to say where the infected person was exactly living. However, it makes it clear that the worm burden here is alarming and the infection rate is very high. This picture raises question on the several aspects of the infection such as burden, response to drug and the awareness (4). Assam was one of the 12 states to be included to launch the National Deworming Programme in February 2015 (6). Stool microscopy is still the best and easiest diagnostic test, screening for fertilised eggs which are rounded with a thick shell and an external mammillated layer that is brown (bile stained). The best diagnostic test is still the stool exam for ova and parasites, searching for large oval brown trilayered eggs with a mamillated coat. Eosinophilia can be demonstrated during the active larval migration phase to the lungs. Abdominal X-rays, ultrasound, Endoscopic Retrograde Cholangiopancreatography (ERCP) and CT scan can be used for diagnosis (1). Dearth of continuous studies from many regions of India draws consistent attention for the surveillance and prevalence determination of soil transmitted helminthiasis. LEARNING POINTS ‣ There is requirement for upgraded food, personal hygiene, accessibility to potable water and farming practices. ‣ It is crucial to eliminate cultural sensitivities and advance compliance with medications. ‣ The World Health Organisation (WHO) along with healthcare workers strives to lower the burden of Ascariasis.

Profile of Congenital Cardiovascular Anomalies among Stillborns at a Tertiary Care Hospital

SP Vinutha, D Narayanappa, GV Manjunath, MS Sujatha, MC Sapna Patel, Deepa Bhat

Introduction: Congenital cardiovascular anomalies refer to anatomic malformation of the heart and great vessels occurring during the intrauterine developmental process. Aim: To determine the pattern of distribution of cardiovascular anomalies through autopsy and to find an association between maternal factors and congenital anomalies, and also an association between autopsy and ultrasound findings. Materials and Methods: This was a descriptive cross-sectional study, which consisted of 50 stillborn foetuses. The foetuses were obtained from the Department of Obstetrics and Gynaecology at a JSS Medical College and Hospital, Mysuru, Karnataka, India. The foetus was fixed in 10% formalin and the autopsies were carried out as per standard foetal autopsy protocol. The cardiovascular anomalies were studied in detail. Data collected were entered in MS Excel 2010 and analysed using Statistical Package for the Social Sciences (SPSS) version 22 to obtain relevant statistics. Descriptive measures like percentages were calculated and the distribution of birth weight, gestational age, maternal age, gravida of the mother, and socioeconomic status of parents among the stillborn foetuses were studied. Fisher’sexact test was done to find out the association between maternal diabetes and cardiovascular anomalies. The results were interpreted as statistically significant at p<0.05. Results: Out of the total 50 stillborn foetuses studied, cardiovascular anomalies were present in five cases. The ventricular septal defect was the most common anomaly. Other anomalies were an atrial septal defect, tetralogy of fallot, and pulmonary stenosis. The occurrence of cardiovascular anomalies was four times more common in male foetuses than in the female. Each stillborn foetus was classified, based on birth weight, gestational age, maternal age, gravidity of the mother, and socioeconomic status of parents. Maximum foetuses 29 (58%) were having a birth weight between 500-1000 grams. Maximum foetuses 20 (40%) were from the gestational age group of 22-26 weeks. The maximum number of foetuses 24 (48%) were born to mothers in the age group of 26-30 years and 22 (44%) mothers were primigravida. The maximum number of stillborns 25 (50%) belonged to the lower middle class of socioeconomic status according to Kuppuswamy’s socioeconomic scale. History of consanguinity was present in 10 (20%) mothers. Fisher’s-exact test showed a significant association between maternal diabetes and cardiovascular anomalies (p<0.016). The autopsy confirmed the antenatal ultrasound findings in 40 (80%) of the cases. There were significant additional findings observed in 7 (14%) cases and ultrasound diagnosis was completely changed in 3 (6%) cases, after the final autopsy procedure. Conclusion: This study focuses on the importance of concomitant foetal autopsy in providing accurate genetic counseling. It is mandatory to have an autopsy study for all the stillborn foetuses to predict and counsel for safe future pregnancy outcomes. The preventive measures for maternal diabetes should be taken care of to avoid cardiovascular anomalies in the antenatal period and future pregnancies.

Comparative Evaluation of Antimicrobial Efficacy, Depth of Penetration into Dentinal Tubules and Effect on Microhardness of Root Dentin by Sodium Hypochlorite, Neem Extract and Gau Ark as Root Canal Irrigants: An In-vitro Study

Introduction: Disinfection of root canals can be done using intracanal irrigants. Sodium hypochlorite or NaOCL is amongst the most commonly used endodontic irrigants. Due to disadvantages of NaOCl, there is a need to identify a more biocompatible irrigant. Aim: To evaluate the antibacterial efficacy, depth of penetration into dentinal tubules and effect on microhardness of root dentin when NaOCl, Neem extract, Gau ark and Normal saline used as an irrigant against Enterococcus faecalis. Materials and Methods: Prepared Neem leaf extract, 3% NaOCl, Gau ark, Normal saline, Brain Heart Infusion (BHI) broth and BHI Agar were used in the present in-vitro study conducted from August-October 2019. Antimicrobial efficacy was measured by agar well diffusion method on 10 petriplates. After access opening and biomechanical preparation, each tooth sample was irrigated with 5 mL of irrigant. Samples were decoronated and roots were split along the longitudinal axis to check penetration depth of irrigants under stereomicroscope for 40 teeth samples. After preparation of 40 teeth sample, 2 mm dentin discs prepared were embedded in acrylic resin. Microhardness was checked under Vickers Microhardness (VHN) tester after samples were irrigated. Statistical Analysis of Variance and Tukey post-hoc test were used. Results: Zones of inhibition were highest with NaOCl (7.66 mm). Irrigants penetration depth into dentinal tubules was significant with NaOCl with average value 0.35 mm. Microhardness of root dentin of saline was 145.90 VHN, followed by Neem 136.59 VHN which was then followed by Gau ark 123.05 VHN hence, Neem has lesser effect on microhardness value as compared to NaOCl and Gau ark. There was statistically significant difference among four groups regarding antimicrobial efficacy, depth of penetration into dentinal tubules and microhardness of root dentin. Conclusion: Neem extract showed significant antimicrobial property as compared to Gau ark and normal saline, good penetration depth and less effect on microhardness of root dentin. Herbal irrigant like Neem extract can be used as a root canal irrigant

Aetiological Subclassification of Chronic Rhinosinusitis: A Retrospective Study

Turki M Bin Mahfoz, Talal Alandejani

Introduction: Chronic Rhinosinusitis (CRS) is a major health problem with very high prevalence worldwide. The information available about the pathophysiology of the disease is not enough to allow development of curative therapies. Classification of CRS is based on the presence of asthma and allergy that can be useful to understand the disease aetiology and allow better patient’s care through individualised treatment plans. Aim: To classify CRS cases into subgroups depending mainly on the presence of asthma and allergy in addition to comparing the characteristics of these subgroups. Materials and Methods: A retrospective descriptive study was carried out, and the data of CRS’ patients were collected from medical records of consecutive patients attending the ENT clinic in, King Abdulaziz Medical City, Saudi Arabia. Based on collected data, CRS cases were classified into six subclasses, and patients’ characteristics such as gender and Immunoglobulin E (IgE) values in these subclasses were compared. Data entry and statistical analysis was carried out in Statistical Package for the Social Sciences (SPSS). Mean, Standard Deviation (±SD) for numerical parametric variables and Inter-Quartile Range (IQR) for numerical non-parametric variables was calculated. Appropriate statistical tests like Analysis of Variance (ANOVA) for parametric data and Kruskal Wallis test for non-parametric were applied. Results: The most prevalent subclass was Non-Asthmatic Sinusitis without Allergy (NASsA) 30 (48.4%) followed by, Asthmatic Sinusitis Without Allergy (ASsA) 13 (21.0%), Asthmatic Sinusitis With Allergy (AScA) 6 (9.7%), Non-Asthmatic Sinusitis With Allergy (NAScA) 5 (8.1%) and Allergic Fungal Sinusitis (AFS) 5 (8.1%). The highest levels of total IgE were found in patients with NAScA. It was found that nasal polyps’ presence was significantly linked to higher Computed Tomography (CT) Lund-Macky scores and MASNOT (Modified Arabic Sino-Nasal Outcome Test) scores. Conclusion: Classification of CRS based on the presence of asthma and allergy can be an informative tool for providing better care to CRS patients.

Subtypes of Breast Cancer in Northern India- An Immunohistomolecular Subtypes of Invasive Breast Cancer

Amit Kumar Sinha, Amrita Ghosh

Introduction: Breast cancer is a heterogeneous disease that may differ in therapeutic response and prognosis despite similarities in histopathologic types, grade and stage. Molecular studies have identified distinct subtypes of breast carcinoma each having unique recognisable phenotypes and clinical outcomes. Aim: To study the histomorphological features and Immunohistochemical (IHC) profile of breast cancer, to study the distribution of molecular subclass, and to study the morphological features of different molecular subclasses and to determine the association between the pathological features associated with adverse prognosis with the molecular subclass. Materials and Methods: Present study was a prospective crosssectional observational study based on mastectomy specimens of 122 cases of consecutive cases of invasive breast cancer submitted from June 2012 to February 2014 in Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India. On IHC staining with Estrogen Receptors (ER), Progesterone Receptors (PR), Human Epidermal growth factor Receptor 2 (HER2), Cytokeratin (CK5/6) and Epidermal Growth Factor Receptor (EGFR) these cases were classified into Luminal A, Luminal B, HER2 overexpression, basal like and normal breast like molecular subclass. All statistical analysis were performed using Statistical Package for the Social Sciences (SPSS) version 16 (SPSS, Inc., Chicago, IL, USA). Results: The proportion of each subytpes detected in present study were: Luminal A-28.69% (35), Luminal B-17.21% (21), HER2 over expressing-25.41% (31), Basal Like Breast Carcinoma (BLBC)-26.23% (32) and the rest unclassified category (normal breast like)-2.46% (3). The following variables were significantly associated with molecular breast cancer subtypes. The tumours of BLBC and HER2 overexpressing were larger, poorly differentiated, higher mitotic index, more number of positive lymph nodes and with more geographic and central necrosis than Luminal A group. These features were statistically significant (p<0.05). Conclusion: Identification of molecular subtype of breast cancer is extremely important for predicting prognosis and therapeutic response of the breast cancers and thus has role in management of patients of breast cancers. BLBC is a molecular subtype of breast cancer known for its aggressive behaviour and poor prognosis is identified by expression of basal CKs.

Evaluation of Efficacy and Safety of Age-Based Intrathecal Dosing of 0.5% Hyperbaric Bupivacaine in the Paediatric Age Group

Introduction: Spinal anaesthesia in the paediatric population is a safe and reliable method of anaesthesia for infraumbilical surgical procedures. As there is greater variation in intrathecal dosing using a conventional weight-based schedule, a prospective cohort study was designed to administer an agebased intrathecal dosing schedule using 0.5% hyperbaric bupivacaine for infraumbilical surgeries in paediatric patients. Aim: To find the efficacy of age-based intrathecal dosing in terms of level of sensory blockade, success rate and adequacy of blockade for infraumbilical surgery in the paediatric age group. Materials and Methods: One hundred and thirty paediatric patients, aged between 2-12 years, posted for elective infraumbilical surgeries were given spinal anaesthesia at a dose of Age/5 (Partha formula) using 0.5% hyperbaric bupivacaine. Sedation during the procedure was provided using a combination of effective doses of pentazocine, midazolam, and atropine. The number of attempts, the success rate, the level of sensory blockade, the duration of anaesthesia and cardio-respiratory complications if any were noted. Results: The mean age of the children was 8±2.55 years. The mean dose of 0.5% hyperbaric bupivacaine used in this study was 8±2.55 milligrams. The desired sensory level of T10 was achieved in the first attempt in all the cases (100%) within 10 minutes of the subarachnoid block. The mean duration of anaesthesia was 73.42±18.6 minutes. In all the patients, the surgical procedures were completed within this anaesthetic time and none of the cases had any conversion to general anaesthesia. No complications were found in any of the patients. Conclusion: Administration of intrathecal dosing of 0.5% hyperbaric bupivacaine using Partha formula (Age/5) is a safe and successful method to provide subarachnoid blockade for infraumbilical surgeries in the Indian paediatric population.

An Audit of Indications for Hysterectomy in a District Hospital, Madikeri
Introduction: Hysterectomy is the removal of the uterus and is the most common gynaecological operation done in females worldwide. In the early 20^th century, hysterectomies were done for many conditions like leiomyoma, Dysfunctional Uterine Bleeding (DUB), chronic pelvic pain, endometriosis, adenomyosis, prolapse, and malignancies. Considering that the procedure has a 20-35% life risk, it calls for a thorough justification before consideration. A hysterectomy has mental, physical, social, economic and psychosexual impact, apart from intraoperative and postoperative complications. Thus, an audit on hysterectomies was done to help students, medical fraternity, and the women of Kodagu in having a better understanding of hysterectomies. Aim: To conduct an audit on hysterectomies performed for gynaecological indications to correlate pre-operative diagnosis with the histopathological diagnosis. Materials and Methods: This was a cross-sectional study which included all elective hysterectomies performed for gynaecological indications conducted at the District Hospital of Kodagu Institute of Medical Sciences, Madikeri from January 2018-June 2019. All cases of hysterectomies were considered except Caesarean peripartal hysterectomies. The histopathological findings of the endometrium, myometrium, cervix, ovaries and fallopian tubes were recorded. Findings were tabulated as frequency and percentage. Then, using the data, preoperative indications were compared with postoperative histopathological findings to know if hysterectomy was justified. Results: A total of 238 hysterectomies were performed during 18 months in the District Hospital. Abdominal and vaginal approaches were used. Panhysterectomy via abdominal approach was the most common type of hysterectomy. The most common age group where hysterectomy occurred was 41-60 years. The most common indication for hysterectomy was found to be Fibroid uterus. Analysis of the myometrial findings revealed that the most common finding was leiomyoma. Majority of ovaries and fallopian tubes did not show significant pathology. Conclusion: Panhysterectomy was the most common type of hysterectomy. Fibroid were the most common histopathological findings and medium and small sized fibroids can be given a trial of nonsurgical management. Injudicious use of hysterectomy procedure has multiple loop holes involving medical fraternity, socioeconomic conditions of women and attitude of society towards female reproductive health.

Thyroid Function and Anti-TPO Antibody Status among Tribal Perimenopausal Women Near Bengaluru, Karnataka, India

KS Manjula, R Reena, Swapna Jaswanth, SMR Usha
Introduction: Higher prevalence of thyroid diseases are noted with increasing age. Symptoms of thyroid disorders often develop so insidiously, that they go unnoticed and there is also the risk of being misinterpreted for menopausal symptoms. Present study was executed in view of paucity of data regarding thyroid disorders among tribal perimenopausal age group and there was a need for timely intervention of this chronic noncommunicable disorder among these women. Aim: To determine the thyroid function and anti-Thyroid Peroxidase Antibody (anti-TPO Ab) status among the tribal perimenopausal women. Materials and Methods: A descriptive, cross-sectional study was conducted for a period of six months from July 2017 to December 2017 among perimenopausal women in the age group of 40-55 years residing at Hakki Pikki Tribal Colony near Bengaluru, Karnataka, India. Thyroid Stimulating Hormone (TSH), Total T₃ (Total Tri iodothyronine), Total T₄ (Total Tetraidiodothyronine) and anti-TPO antibody levels were estimated by Chemiluminescence Immuno Assay (CLIA). Data was analysed using Open Epi software to find out Mean±SD, p-value (Student's t-test with significance set at p<0.05) and r-value (Pearson's correlation coefficient). Results: Subclinical Hypothyroidism (SCH) was observed in 3 (7.32%) women and anti-TPO Ab positivity (anti-TPO antibody level >30 IU/mL) was found in 14 (34.14%) women amongst 41 perimenopausal subjects. Raised anti-TPO Ab was observed in all the 3 (100%) SCH women and 11 (26.82%) euthyroid women. Significant difference (p<0.001) between anti-TPO Ab values among SCH and euthyroid women with significant positive correlation (r-value 0.7023 and p<0.05) between TSH and anti-TPO Ab values in anti-TPO Ab positive women was noted. Conclusion: Anti-TPO Ab positivity was seen in 34% of perimenopausal women, out of them majority 79% was in euthyroid state and 21% had SCH. Hence in addition to routine thyroid profile, we suggest estimation of anti-TPO Ab levels in this age group.

Prevalence of Soft Tissue Tumours in Duhok-Iraq: A Practical Immunohistochemical Approach

Intisar Salim Pity, Omar Salim Muhi
Introduction: The field of Soft Tissue Tumours (STT) is enormously vast, and yet histologically and relatively vague. Although benign tumours are more common than malignant tumours, the relative rarity of sarcomas, little knowledge, and insufficient local studies, made the authors eager to search more through this field and explore the hidden and unobvious features of these tumours in our locality. Aim: The study aimed to apply traditional and updated antibodies to characterise STT in Duhok-Iraq, morphologically and immunohistochemically. Materials and Methods: In this cross-sectional study, 886 STT were received in the Department of Histopathology in Central General Laboratories and Vin Private Laboratories, Duhok-Iraq, over a period of 11 consecutive years (January, 2009 to December, 2019). Cases were studied clinically and then, morphologically categorised. Immunohistochemical workup was performed when needed, to sub-classify undifferentiated tumours. Results: Benign tumours (n=768) ovarian sarcomas (n=118) by a ratio of 6.5:1, both showed a wide age range (1 month to 82 years), with peak in the fourth decade and with no sex predilection. Also, limbs were more commonly affected by both benign and malignant tumours. Lipomas topped the benign STT 328 (42.7%) followed by vascular tumours 178 (23.2%). Regarding sarcomas, 29 (24.5%) remained unclassifiable and were typed as Sarcoma Not Otherwise Specified (NOS). For the specifically diagnosed malignancies, leiomyosarcoma 24 (20.3%) topped the list, followed by rhabdomyosarcoma and Ewing’s/Primitive Neuroectodermal Tumour (PNET) 12 (10.1%) each, Dermatofibrosarcoma Protuberans (DFSP) and liposarcoma 11 (9.4%) each and synovial sarcoma 6 (5.1%). Conclusion: Benign STT were more common than sarcomas. Diagnosis and classification of STT should be based on acumen histologic grounds which is sufficient for most benign tumours and to some extent for sarcomas. Undifferentiated sarcomas cannot be categorised without immunohistochemistry. However, loss of some differentiation antigens in undifferentiated cancers often necessitate the use of panels of antibodies, and considerable cases even need further evaluation, like molecular studies.

Prevalence of Metabolic Syndrome and Urinary Albumin to Creatinine Ratio as a Predictor of Cardiovascular Disease in Metabolic Syndrome Patients
Introduction: Metabolic Syndrome (MetS) is a condition that increases the risk of cardiac disease, diabetes, hypertension and may be associated with microalbuminuria. Aim: To investigate the prevalence of metabolic syndrome and to determine albumin to creatinine ratio as a predictor of cardiovascular disease in metabolic syndrome. Materials and Methods: This was a hospital based crosssectional study conducted from February 2019 to January 2020 in the Department of Biochemistry and Outpatient Department of Muzaffarnagar Medical College, Muzaffarnagar, Uttar Pradesh. Out of enrolled 795 subjects, 452 were male and 343 were female. The prevalence of metabolic syndrome was calculated on the basis of metabolic syndrome criteria. Anthropometric parameters like age, weight, height, blood pressure and the biochemical parameters including fasting blood sugar, triglyceride, Lipid Accumulation Product (LAP), urinary albumin, serum creatinine and urinary Albumin to Creatinine Ratio were measured in study population. SPSS version 16 was used for statistical analysis and student independent sample t-test was used for comparing differences amongst the variables. A p-value less than 0.05 was considered as statistically significant. Results: Out of 795 subjects, 152 patients (19.12%) were hypertensive, 85 patients (10.69%) were diabetic and 29 patients (3.65%) were hypertensive with diabetic. The prevalence of metabolic syndrome was around 18.11% (144 subjects), out of which 52.78% were female and 47.22% were male. Out of 144 Metabolic Syndrome subjects, 23 subjects were diabetic, 32 were hypertensive, 14 were diabetic with hypertensive and 75were others. The mean levels of urinary albumin creatinine ratio were increased significantly in metabolic syndrome subjects and the increase in urine Albumin to Creatinine Ratio (uACR) was more in metabolic syndrome subjects having Diabetes and Hypertension both. Conclusion: The present study concluded that the microalbuminuria is associated with metabolic syndrome. The microalbuminuria was found to be more significant in metabolic syndrome subjects who were diabetic with hypertensive as compared to diabetic or hypertensive alone.

Effects of Kinesiotaping on the Improvement of Sensorimotor Function along with Disability in Chronic Mechanical Neck Pain

Mohammad Zeeshan, Siddhartha Sen, Pooja Bhardwaj Dhawan
Introduction: Mechanical neck pain is a significant societal burden and may include symptoms in the neck and upper extremity. It has been reported that the lifetime and point prevalence of neck pain are almost as high as those of low back pain. It appears to run a chronic episodic course, which is characterised by episodes of persistent, recurrent, or fluctuating pain and disability. It has been found that an altered muscle activity in the Trapezius and the Serratus anterior muscles can be associated with the presence of pain in the neck during functional activities. Aim: To find out the effects of Kinesiotaping on the improvement of sensorimotor function and neck disability in patients with chronic neck pain. Materials and Methods: This was a pre-test, post-test control group design with 30 subjects randomly selected and divided into two groups, an experimental group (Group A) and a control group (Group B) with 15 subjects in each. Experimental group received Kinesio Tape (KT) for 1 week whereas control group received Sham tape. Measurements were taken on the first day and 1 week after the intervention for Cervical Joint Position Sense (CJPE), range of motion and neck disability using an inclinometer instrument, universal goniometer, Neck Disability Index (NDI) questionnaire, respectively. The data was analysed using SPSS 17 software package. Independent t-test was done to find effect between the groups and paired t-test was done to find out the effect within the group. Results: The study clearly demonstrated a significant improvement in CJPE, Cervical Range of Motion (CROM) and NDI within group A (p<0.05) whereas improvement showed significance in CROM and NDI for group B. While comparing both the groups, significant improvement in proprioception and NDI was shown but not in CROM. Conclusion: The study concludes that patients with chronic mechanical neck pain can be benefitted by the use of Kinesiotaping with improvement of sensorimotor function.

Synergistic Anxiolytic Effect of Curcumin and Zinc on Acute and Chronic Models of Anxiety in Mice
Introduction: Anxiety disorders being ranked at sixth position in the global burden of diseases is affecting over 250 million people. Curcumin, an active phytochemical flavonoid, has shown to induce the monoamine neurotransmitter serotonin, a prominent neurotransmitter in modulating the brain state in anxiety. Also, evidences reveal that zinc plays a key role in human neurodevelopment and supplementation of zinc enhanced the efficacy of antidepressant drugs through synergistic action. Aim: To evaluate the synergistic antianxiety effect of curcumin and zinc on acute and chronic models of anxiety in male swiss albino mice. Materials and Methods: A total of 36 male Swiss Albino mice, weighing 20-30 g, were randomly grouped to six groups, such that each group consisted of six mice. Group 1 served as control. Group 2 received standard drug diazepam 3 mg/kg Intra Peritoneal (IP). Group 3 and 4 received curcumin at doses of 5 and 10 mg/kg, respectively. Group 5 and 6 received curcumin at doses 5 and 10 mg/kg per oral (p.o) along with zinc chloride 10 mg/kg IP, respectively. The anxiolytic effect was studied in two validated models of anxiety such as Elevated Plus Maze (EPM) test and light/dark box test. Each animal was tested initially in the EPM followed by light/dark box test after administration of drug/vehicle one hour prior to the experiment in acute study. Following a washout period of one week, the animals were utilised for the study of chronic anxiolytic effect wherein the drugs were administered once daily for 14 days. Results: Curcumin at doses of 5 mg/kg and 10 mg/kg with zinc chloride 10 mg/kg showed a significant increase in the number of entries and time spent in open arm in EPM both on acute and chronic administration (p<0.001). In the light/dark box test, curcumin at doses of 5 mg/kg and 10 mg/kg when given along with zinc chloride 10 mg/kg significantly increased the number of entries and time spent in the light compartment both in acute and chronic models (p<0.001). Conclusion: The anxiolytic effect of synergistic action of curcumin and zinc was efficacious in both acute and chronic models of anxiety in mice.

IMP3 Expression in Ovarian Serous Tumours: Correlation with Epithelial-Mesenchymal Transition-Related Markers (E-Cadherin and Vimentin) and Clinicopathological Factors
Introduction: Ovarian epithelial cancer is an aggressive malignancy of which Ovarian Serous Carcinoma (OSC) represents a common type. The insulin-like growth factor mRNA-binding protein 3 (IMP3) is one of mRNA-binding protein family that is overexpressed in a variety of human cancers, including ovarian carcinomas. Being associated with adverse prognostic outcome in these cancers, which makes this protein a reliable biomarker to distinguish some cancers from their benign mimetic lesions. Aim: To analyse IMP3 expression in serous ovarian tumours and correlates the expression in malignant tumours with EpithelioMesenchymal Transition (EMT) related markers (Epithelial(E)- cadherin and vimentin) and clinicopathological factors to assess the clinical application of IMP3 in the diagnosis, prognosis and possible application in targeted therapy of such tumours. Materials and Methods: This was a cross-sectional research that was done at the Departments of Pathology, Obstetric and Surgery, Zagazig and Banha Universities Hospitals, Egypt. Fifty-nine formalin-fixed paraffin-embedded specimens (including 43 cases OSC, 6 cases border line serous tumour and 10 cases benign serous cystadenoma) were collected from January 2014 to December 2018. Each case was stained immunohistochemically with IMP3, E-cadherin and Vimentin. Markers expressions were statistically analysed using SPSS software (version 19.0; SPSS, Chicago, IL). The p-values =0.05 was regarded statistically significant. Results: IMP3 was detected in 76.7% (33/43) of the studied OSC. IMP3 was in a significant association with advanced FIGO (International Federation of Gynaecology and Obstetrics) stage and with lymph node metastases (p=0.02 and 0.019, respectively). E-cadherin was predominantly lost in 53.5% (23/43) of the studied OSCs and was significantly associated with advanced FIGO stage (p=0.004). Vimentin was detected in 79.1% (34/43) of the studied OSCs and was in association with high grades and advanced stage (p=0.018 and 0.007, respectively). An inverse significant correlation was detected between IMP3 and E-cadherin expressions (Spearman correlation (r)=-0.480, p-value=0.001), while positive significant correlation was detected between IMP3 and Vimentin expressions (Spearman correlation (r)=0.393, p-value=0.009). Conclusion: IMP3 is an oncogene unregulated in OSC. It is a prognostic marker associated with tumour aggressiveness. Moreover, IMP3 could promote tumour invasion and metastasis via EMT in OSCs.

Evaluation of Relation between Bizygomatic Width and Mesiodistal Dimension of Maxillary Central Incisor in Saudi Population: An In-vivo Study
Introduction: Selection of the maxillary anterior teeth is one of the most crucial steps in fabricating a removable prosthesis. To overcome this challenge, the relationship between facial measurements and natural teeth could be used as a guide in selecting the Maxillary Central Incisor (MCI) teeth. To improve aesthetics, various efforts have been made to associate the Mesiodistal Dimension (MD) of the MCI with various facial parameters. Aim: To determine the relationship between Bizygomatic Width (BZW) and the MD of the MCI in the Saudi population. Materials and Methods: The cross-sectional study selected two hundred dentulous subjects (100 males and 100 females) using a simple random sampling technique from December 2019 to March 2020. BZW was measured between the two most prominent points on the zygomatic bone, and the MD of the MCI was measured between the interproximal contact points. Both measurements were made with the help of a digital vernier caliper. Descriptive statistics and student’s t-test were used to compare all the measurements between males and females with a level of significance at 5% (0.05) and the power of the study of 95%. Pearson’s correlation coefficient (r) was used to find the interconnection between MD of MCI and BZW by linear correlation analysis. Results: The average values for BZW for males and females were found to be 123.56±3.74 mm and 117.33±3.21 mm, respectively. The average MD values of MCI for males and females were found to be 8.6±0.46 mm and 8.4±0.53 mm, respectively. A statistically significant difference was observed in the mean values of the BZW (p-value<0.001) and MD of MCI (p-value 0.002) when a comparison was done among males and females. The average ratio of MD of MCI to BZW was found to be 0.07±0.004 for males, whereas it was 0.072±0.004 for females and was statistically significant (p-value 0.001). The ratio of MD of MCI to BZW was found to be 1:14 for males and females. Pearson’s correlation coefficient (r) was positive and ranged from 0.067 to 0.007. Conclusion: Males had greater values for BZW and MD of MCI than females. There was an inconsistency when Berry’s biometric ratio was applied and when compared with the actual MD of MCI measurement in the present study. The findings of this study showed that there was a weak positive correlation between the MD of MCI and the BZW.

Comparative Study of Stress among Depressed and Non-depressed Medical Students

Amit Singh, Achyut Kumar Pandey, Abhinav Pandey, Pankaj Sureka
Introduction: Stress and depression are common among medical students. There are number of studies on this topic, but only few have assessed stress in clinically non-depressed medical students. Aim: To study the prevalence, severity and profile of stress and depression in undergraduate medical students and to compare the same between depressed and non-depressed students. Materials and Methods: A cross-sectional study was done, on 150 undergraduate medical students of a medical college in Northern India from February, 2018 to January, 2019. Students Stress Dimension Questionnaire (SSDQ) was used to assess the stress severity and to categorise various domains affected. Hamilton Depression Rating Scale (HAM-D) was used to measure the depressive symptoms. Chi-square, independent-t test and one-way ANOVA were used to make the group comparisons. Results: Mean age of the participants was 20.767 (SD=1.888). A total of 68.67% of the participants were males. Stress and depressive symptoms were present in 66.67% and 52% of the participants, respectively. Of the participants having no depressive symptoms, 50% had stress. On group comparisons, depressed group had significantly lower mean age, higher rates of past history of psychiatric illness, higher prevalence and severity of stress, than non-depressed group. Prevalence of stress and depressive symptoms decreased with increasing seniority. Conclusion: Medical students have high prevalence of stress and depression. In majority of medical students having depression, stress is present. There are still a significant proportion of students having no depression, but having high levels of stress. So, policy makers should take note of this while planning interventions to address the mental health of medical students.

Beta-lactamase Profile and Biofilm Production of Pseudomonas aeruginosa Isolated from a Tertiary Care Hospital in Kolkata, India
Introduction: Nosocomial infections caused by Multidrug Resistant (MDR) Pseudomonas aeruginosa (P. aeruginosa) have become a major clinical and public health concern. Moreover, the biofilm production protects the bacteria from antibiotics and thereby makes the drugs ineffective. Aim: To find out the β-lactamases profile of antimicrobial resistance and biofilm production of P. aeruginosa isolated from different clinical specimens of patients attending a tertiary care hospital of Kolkata, West Bengal, India. Materials and Methods: A total of 394 consecutive, nonduplicate isolates of P. aeruginosa were identified from 3559 Gram negative bacilli over a period of two years from July 2016 to June 2018. Identification of the isolates and antibiotic sensitivity testing was performed by using automated method and interpreted. Extended Spectrum β-Lactamases (ESBLs), Amp-C β-lactamase (AmpC) and Metallo-β-Lactamases (MBLs) were phenotypically detected by disk synergy test and MBLencoding genes were detected by multiplex Polymerase Chain Reaction (PCR). Biofilm production was done by tissue culture plate assay. Laboratory data and test results were statistically analysed in counts and percentages using MS Excel 2010 version. Results: Out of 394 strains of P. aeruginosa 288 (73.10%) were isolated from male patients whereas 106 (26.90%) were isolated from female patients. Maximum number of cases (67.26%) were from adult populations. The resistance pattern showed 72.33% resistance to ticarcillin-clavulanic acid followed by ciprofloxacin (53.80%), levofloxacin (50.25%), gentamicin (51.52%), ceftazidime (CAZ) (45.93%), cefoperazone-sulbactam (40.1%), aztreonam (34.77%), imipenem (33.5%), piperacillin/ tazobactum (30.96%) and Meropenem (MRP) (29.18%). Out of 394 Pseudomonas spp. isolates, 204 (51.77%) were MDR. Overall, ESBLs, AmpC and carbapenemase (MBL) production was detected in 145 (36.80%), 51 (12.94%) and 49 (12.43%) isolates by phenotypic methods. By genotypic method 53.34% were carbapenemase producing and bla_NDM-1 (68.75%) was the most prevalent carbapenemase gene detected followed by bla_VIM (18.75%) and co-production of bla_NDM-1+ bla_VIM was 12.5%. Biofilm production was observed in 158 (40.10%) isolates. Conclusion: Early detection of these β-lactamases production is crucial not only for epidemiological study and effective infection control practices to limit the spread of infection but also for planning appropriate therapy according to the resistance mechanisms of the MDR strains.

A Study on Variation of Blood Pressure and Associated Factors among Adolescent School Students in North 24 Parganas, West Bengal, India
Introduction: Adolescent Hypertension (HTN) is one of the most alarming public health problems and is a potential risk factor for non-communicable diseases as asymptomatic, mostly remain undiagnosed. Simple anthropometric indicators acting as preliminary screening tool to predict HTN among adolescents is the need of hour. Aim: To find out the magnitude of pre HTN and HTN among adolescent school students of North 24 Parganas and to find out the variation of blood pressure with different anthropometric parameters. Materials and Methods: A cross-sectional study was carried out from June to September, 2019 among 369 adolescent school students of class VIII to XII in two Government higher secondary schools, selected conveniently, in North 24 Parganas. Data was collected by face to face interview, blood pressure recording and anthropometric measurements in the selected schools was done. Data was analysed using SPSS version 16.0. Results: Among 369 participants, 189 (51.2%) were boys and 180 (48.8%) were girls. Mean Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) among boys were 110.2 (±14.9), 68.0 (±9.3) and among girls 113.1 (±14.3), 71.2 (±9), respectively. Overall HTN was found to be 7.0% (6.3% in boys and 7.8% in girls) and pre HTN was 13.8% (12.2% in boys and 15.6% in girls). There were significant (p<0.05) positive correlation of SBP and DBP with BMI (r=0.692; r=0.673), Body fat percentage (r=0.686; r=0.676,), Waist Circumference (WC) (r=0.708; r=0.640), Neck Circumference (NC) (r=0.593; r=0.509,). HTN was significantly associated with physical activity and salt intake (p<0.05). Conclusion: As a rising trend of HTN was found among adolescents, early lifestyle modification and strengthening of school health setup using simple anthropometric measures are recommended for early detection of adolescent HTN and to prevent detrimental consequences.

Efficiency of Corticision in Accelerating Leveling and Alignment of Crowded Lower Anterior Teeth in Young Adult Patients: A Randomised Controlled Clinical Trial
Introduction: The evaluation of flapless corticision in conjunction with the conventional treatment in the non-extraction decrowding of lower anterior teeth has not been performed yet in any randomised clinical trial, particularly in terms of treatment time and periodontal indices. Aim: The aim of the study was to compare the duration of leveling and alignment of mild and moderate crowding cases in the lower dental arch between the corticision-assisted fixed orthodontic treatment and the traditional method; and to compare the periodontal indexes between the two groups. Materials and Methods: A parallel-group Randomised Controlled Clinical Trial (RCT) was conducted on 60 patients (mean age 2 1.40±1.63 years). Patients were randomly assigned to either the corticision group or the control group (30 each). Immediately after fixed appliance bonding, three radiographic-guided incisions were performed on the labial surfaces of the alveolar bone between lower anterior teeth by reinforced scalpels and mallets in order to accelerate alignment for patients in the corticision group. Patients in the control group were treated with conventional orthodontics. The outcome measures were the overall time needed for leveling and alignment, periodontal parameters such as Plaque Index (PI), Probing Depth (PD), Gingival Index (GI), and the width of the attached gingiva. Results: The overall treatment time was significantly shorter in the corticision group than the control group. The average leveling and alignment period for the corticision group was 116.46±15.97 days, while it was 159.69±13.76 days in the control group. Comparing the groups, a significant reduction of about 27% was found in the leveling and alignment duration of the corticision group. There were no significant differences in the periodontal parameters (PI, PD, GI, the width of attached gingiva) at the end of leveling and alignment phase in both the groups. Conclusion: Corticision seems to be an effective method to accelerate leveling and alignment in cases of mild and moderate crowding. It did not cause negative effect on the periodontal tissues.

Change in Trauma Patterns in Hilly Areas of Northern India during Nationwide Lockdown: A Cross-sectional Study
Introduction: The countries all over the world are experiencing COVID-19 pandemic. This has led to a change in the operational guidelines in all trauma centres. Lockdown, limiting vehicle traffic, has affected trauma patterns everywhere. Aim: To study the effect of lockdown on orthopaedic trauma in hilly areas of Northern India. Materials and Methods: A cross-sectional retrospectively study collected the data of patients admitted in the emergency trauma ward like age, gender, mechanism of injury, fracture type, number of emergency admissions, and number of surgeries pertaining to the complete lockdown period (25^th March to 3^rd May 2020 i.e., 40 days) at our hospital situated in the hilly areas of North India. This was compared with the trauma cases dealt during the same time period last year (2019). Results: More than 50% decrease in the outpatient load did not parallel to decrease in admissions in emergency department (164 in 2019 vs 169 in 2020). However, operated trauma cases did decline from 62 in 2019 to 51 in 2020. Some injuries like fracture proximal tibia, cut injuries of hand with sharp object increased while incidence of fragility fractures has remained the same. Conclusion: The trauma pattern in and around the hilly places in our area of Northern India portrays a unique picture where one does not see a foreseeable decline in trauma despite the lockdown. With the lockdown in effect, some patterns have emerged which may prove to be useful adjuncts in our efforts to improve public health and the trauma burden.

The Effect of Simultaneous Application of Transcutaneous Electrical Nerve Stimulation (TENS) on Specific Lumbar and Acupuncture Points on Labour Pain Relief: A Randomised Clinical Trial
Introduction: Labour pain is among the most challenging experiences a woman could face during life. Non Pharmacological modalities like Transcutaneous Electrical Nerve Stimulation (TENS) are rather new methods, introduced for relieving this pain. Aim: To investigate the effect of concurrent use of TENS application on the labour pain relief. Materials and Methods: This is a double-blind randomised clinical trial study where, a total of 104 eligible pregnant women qualified for normal vaginal delivery. They were randomly divided into four groups treated with Lumbar-TENS or Acupuncture points-TENS as A: both inactive (placebo group), B: Active Acupuncture points TENS, C: Active Lumbar TENS and D: both active. TENS was applied on four points of toraco-lumbo sacral, while Acupuncture points-TENS was applied on Hegu and Sanyinjiao points. The pain scores were evaluated by Visual Analogue Scale (VAS) criteria, four times during the study for each individual. A questionnaire was used to evaluate the final impression of the subjects about the TENS method. The groups were compared using chi-square or Kruskal Wallis test. The trend of pain score over the study time points were assessed using Generalised Estimating Equation (GEE). Results: The mean age of the women were 27.86±5.92 years. There were no significant differences between the groups based on the pain scores over the study periods (p-value=0.588). There was a statistically significant difference between groups for satisfaction about the procedure and the placebo group had the lowest rate of tendency to reuse TENS at the future Labour (74%) compared to the other three groups (93-100%) (p-value=0.046). Conclusion: Lumbar or Acupuncture points-TENS had no significant relieving effects on Labour pain among the participants.

Effects of Momordica Charantia Seed Extract on Dexamethasone-Induced Biochemical and Histological Abnormalities in Albino Rats

Dasaraju Rajesh, Muppala Thejaswini, MV Advaitha
Introduction: Many preclinical studies and randomised trials in humans have documented the antidiabetic properties of bitter melon, Momordica charantia (M. charantia). Aim: To examine the effects of Momordica Charantia Seed Extract (MCSE) in comparison to Pioglitazone on Dexamethasone-induced biochemical and histological abnormalities in Albino rats. Materials and Methods: An interventional study was conducted from October, 2015 to December, 2015, with 24 adult healthy Albino rats of Wistar strain, which were divided into four groups of six rats each. Group I (diabetic controls) received dexamethasone alone in a dose of 8 mg/kg intraperitoneally for six days to induce metabolic changes. Group II rats received MCSE 2.5g/kg six days before dexamethasone and six days during dexamethasone administration. Group III rats received pioglitazone 75 mg/kg orally six days before dexamethasone and six days during dexamethasone administration. Rats in Group IV did not receive any medication and was considered as normal control. Blood glucose levels and lipid profiles were measured. Liver weight, liver volume, and histopathological analysis were done. Data were analysed using an Independent t-test followed by ANOVA with Scheffe’s Post-Hoc Test. Statistical significance was set at p<0.05. Results: A significant decrease in the Fasting Blood Sugar and Postprandial Blood Sugar levels was observed in the MCSE and pioglitazone-treated groups as compared to the dexamethasone control group (p<0.01). A significant decrease in the total cholesterol and triglycerides and an increase in High Density Lipoprotein (HDL) levels was observed in MCSE and pioglitazone-treated groups as compared to the dexamethasone control group (p<0.01). In the case of dexamethasone-induced diabetic model, both MCSE and pioglitazone significantly reduced hepatomegaly, dyslipidemia, and hyperglycaemia (p<0.01). Conclusion: MCSE has comparable efficacy to pioglitazone in the prevention of dexamethasone-induced hepatomegaly, dyslipidemia, and hyperglycaemia.

Symptomatic Omphalomesentric Duct Anomalies in Children: Analysis from a Paediatric Surgery Department Catering Primarily to the Rural Population
Introduction: Omphalomesenteric Duct (OMD) anomalies are rare congenital disorders of primitive yolk sac. The spectrum of OMD anomalies has varied clinical presentations. Aim: To study the spectrum and management of symptomatic OMD anomalies in children at a rural tertiary care centre. Materials and Methods: This was a retrospective study done at Uttar Pradesh University of Medical Sciences, Saifai, Etawah, a tertiary care centre located in rural part of Northern India. Medical records of all children less than 15 years of age who were diagnosed with symptomatic OMD anomalies and managed surgically between January 2016 to December 2019 (four years) were carefully analysed and data were recorded. The recorded parameters were age, sex, symptomatology, clinical presentation, intraoperative findings, surgical procedure performed, complications that developed during the early postoperative period, length of hospital stay and Histopathology Examination (HPE) of the specimens excised. The collected data were statistically analysed. A p-value <0.05 was considered statistically significant. Results: Records revealed that 40 children underwent surgeries for symptomatic OMD anomalies which constituted 6.21% of all surgeries (644) performed by the Department of Paediatric Surgery during January 2016 to December 2019 (four years). There were 29 males (72.5%) and 11 females (27.5%) (M:F=2.6:1). Out of 40 patients, 17 (42.5%) were infants and 23 (57.5%) were of post-infancy age. Mean age of cohort was 41.77 months. The three predominant clinical presentation in children were intestinal obstruction, acute abdomen and umbilical abnormalities. The commonest clinical presentation of the symptomatic OMD anomalies was umbilical abnormalities (50%). Clinical presentation of umbilical abnormality was significantly higher in infancy (p=0.0039*). The incidence of Meckel’s diverticulum was 50%. Wedge resection was the commonest surgical procedure performed (67.5%). On HPE, ectopic gastric mucosa was identified in 12 out of 40 patients (30%). Conclusion: Symptomatic OMD remnants have varied clinical presentation. Patients presenting with umbilical abnormalities are common in infancy. Presence of ectopic tissue is commoner in patients with symptomatic OMD remnants. Surgery is the treatment of choice.

Prevalence of Non-autoimmune Hypothyroidism in Steroid Resistant Nephrotic Syndrome in Paediatric Age Group
Introduction: It was observed that approximately 10% of children with Nephrotic Syndrome (NS) are found as Steroid Resistant NS (SRNS). The data on the prevalence of non-autoimmune hypothyroidism among the SRNS in India is limited. Aim: To assess the prevalence of non-autoimmune hypothyroidism in the case of SRNS. Materials and Methods: A case control cross-sectional study was conducted in which 52 cases of SRNS and 52 healthy controls were enrolled. Thyroid profile like serum Thyroid Stimulating Hormone (TSH), Free Triiodothyronine (T3), Free Thyroxine (T4) done in the all cases and controls but anti-Thyroid Peroxidase (TPO), and anti-thyroglobulin antibody test was done in the case and control group with deranged thyroid function test. Low Free T4 (normal: 0.7-2 ng/mL) and elevated serum TSH above the upper limit of the reference range (>4.5 mIU/L) was defined as overt hypothyroidism, whereas elevation in serum TSH with a normal serum FT4 concentration was defined as sub clinical hypothyroidism. MedCalc statistical software Version 19.2.6 was used to do statistical analysis. Results: Prevalence of Non-autoimmune hypothyroidism was 38.46% (20 out of 52), 16 (30.76%) had subclinical and 4 (7.69%) had overt hypothyroidism in case of SRNS in comparison to 1.96% (1 out of 52) in control group. Out of 16 subclinical hypothyroid patients, two cases with grade 1, 12 cases with grade 2, and two cases with grade 3 found. Patients with SRNS had a mean (SD) TSH value was 4.5±4.7 mlU/L which was significantly higher than control (1.8±1.1 mlU/L). Serum levels of FT4 were within normal range. Anti-TPO and anti-thyroglobulin titre were in normal range in children with hypothyroidism. Conclusion: The prevalence of non-autoimmune hypothyroidism was high in cases of idiopathic SRNS. So, on the basis of this study estimation of thyroid profile in children with SRNS seems to be the rational approach which will lead to early diagnosis and timely management of hypothyroidism in SRNS.

Non-therapeutic Management of Adhesive Small Bowel Obstruction: A Descriptive Map of Practice Patterns among General Surgeons in Saudi Arabia

Nasser Alzerwi
Introduction: Adhesive Small Bowel Obstruction (ASBO) is a common postoperative complication, and its management is challenging and controversial. Published guidelines for management are inconsistent and therefore, management practices vary based on institutions and individual surgeons. Aim: To evaluate variation of practice patterns among general surgeons and residents in investigation and non-therapeutic management of ASBO. Materials and Methods: This descriptive multi-centric crosssectional study was done on 250 general surgery trainees and practitioners who were selected to be part of the study between January-February 2020 by simple random sampling. The participants were evaluated by questionnaire method which included standard of care, current practices and variability in non-therapeutic management of ASBO. Results: In total, 198 (79.2%) participants with mean (SD) age and duration of practice 36.5 (7.70) and 9.40 (7.26) years, responded, the majority (60%) of the respondents agreed on the use of routine abdominal Contrast-Enhanced Computed Tomography (CECT) for suspected ASBO. Resuscitation as per haemodynamics was preferred over positive fluid balance by 64.6%; nasogastric drainage was considered mandatory by 76.3% and the passage of flatus was considered the most important determinant of clinical resolution of the obstructive episode by 55.1% of respondents. Around a third of the respondents (36.4%) were of the opinion that resumption of oral intake should begin with sips of water and another 47.5% thought that 48 hours is the maximum waiting period for Nonoperative Management (NOM). Conclusion: This study demonstrates that there is high variability between general surgeons in most aspects of ASBO non-therapeutic management. The findings underscore the need for developing national standard consensus-based guidelines to allow timely and effective management of this complex and potentially life-threatening condition.

Antimicrobial Resistance Profiles and Molecular Characterisation of Vancomycin Resistance Genes in Enterococcus spp in Algeria
Introduction: The vanA gene continues to spread throughout the world. Algeria does not seem to be spared, but the data, which remain sporadic, are also old. This has justified the overriding interest in exploring the current state of antibiotic resistance in Enterococci, while focusing on the presence of certain genes. Aim: To study the isolation frequency and the level of antibiotic resistance of Enterococcus faecalis (E. faecalis) and Enterococcus faecium (E. faecium) isolated during two years at the Tlemcen Hospital (northwest Algeria), while investigating the possible presence of Vancomycin Resistant Enterococci (VRE). Materials and Methods: The present study was a prospective study in which Enterococcus spp was isolated from five different departments which were identified and confirmed by molecular identification with ‘tuf’ gene. Antibiotic sensitivity was done by the agar diffusion and Minimum Inhibitory Concentration (MIC) method. The vancomycin resistance genes (van A, van B) were researched by Polymerase Chain Reaction (PCR) and then sequenced by the Genoscreen laboratory in Lille (France). SPSS software version 20 (IBM Statistical Package for the Social Sciences (SPSS) statistics 20) was used to analyse the data obtained from the study. Results: The PCR of the “tuf” gene revealed two predominant species E. faecalis and E. faecium. All isolates have a multidrug resistance, two E. faecium were distinguished by their resistance to vancomycin with MICs >256 μg/mL. At the origin of this resistance, the vanA gene was characterised and sequenced; the obtained sequence has been introduced into the Genbank National Center for Biotechnology Information (NCBI) database. Conclusion: This work revealed alarming levels of antibiotic resistance in Enterococci, the vanA gene was found in two E. faecium; sequencing of this gene has revealed a total homology with another isolated in Cuba, which demonstrates a worldwide spread of this resistance gene.

Perception of Undergraduate Medical Students Regarding Mentorship in Medical Education

Darshan J Dave, Jitendra Patel
Introduction: Although there is a definite need of mentorship in medical education, there is lack of well organised mentorship program in medical institutions in our country. It is essential to identify the perception of medical undergraduates regarding mentorship. Aim: To assess the student’s perception regarding mentoring at different stages of their studies. Materials and Methods: A Questionnaire based observational study was carried out on second year MBBS regular batch students. Enrollment of the students for study was purely on voluntary basis after taking informed consent. All the study participants were given 30 minutes for filling of questionnaire which was predesigned, structured and validated. The collected data were entered in Microsoft excel and analysed accordingly. Results: A total of 203 students participated in the study. Out of these, 173 (85.2%) students felt that mentorship is guiding the students. About 81 students (39.9%) strongly agreed that mentorship is a relationship rather than set of activities. About 198 students (98%) felt that there is a definite need of mentorship in medical education. About 151 students (74.4%) felt that contact session with mentor should be done as and when required but definitely more before exam. About 181 students (89.6%) felt comfortable if mentor had expectations from them. Conclusion: Almost all students perceived that there is definite need of mentorship in medical education with subject expertise; availability and nature of mentor were given priority in choosing mentor. Perception regarding frequency and place of meeting for mentorship varied widely among students. Through this study we came to know about the perception of medical undergraduates which will be helpful to identify their expectations from the mentor.

Anastomotic Leaks after Gastrointestinal Operations- A Prospective Cohort Study

Amit Kumar, Sambedna, Sribatsa Kumar Mahapatra
Introduction: Anastomotic leak is the release of intestinal contents into the abdomen at the site of surgical stitch line, where two ends of the bowel have been joined for restoration of the gastrointestinal continuity. There are considerable variations in incidence of anastomotic leaks following gastrointestinal operations which have motivated the present study. Aim: The objective of the present study was to prospectively follow all the patients who underwent gastrointestinal surgeries and look for clinical signs of anastomotic leak in postoperative period. Materials and Methods: Study population comprised of 613 patients who underwent gastrointestinal operation at a tertiary care hospital during the period from September 2011 to September 2013. After taking institutional ethical committee clearance enrolment in the study was done with written and informed consent. The site of leak, postoperative day of leak was diagnosed and noted based on clinical examination and radiological investigations. It was a prospectively designed descriptive study so no specific tests were applied. Statistical analysis and percentages were calculated using SPSS 16.0 software. Results: Most of the leaks occurred between eighth to ninth postoperative day and most of the obstruction occurred on sixth and seventh postoperative day. Incidence of anastomotic leaks in the study group was 3.26%. Incidence of anastomotic leaks in small bowel anastomosis is 6.25% compared to large bowel leaks reported to be 9.8%. Peritonitis was present in majority of patients presenting with leak. Incidence of obstruction in recto sigmoid anastomosis was 9.92%. Conclusion: The study suggests that as we move distally in Gastrointestinal Tract (GI) the incidence of anastomotic leak increases and it becomes maximum for colorectal surgeries. Anastomotic complication depends on various factors like age, sex, mode of presentation, procedure done, Hb%, dehydration, nutrition, blood sugar, albumin, peritonitis etc.

Investigating the Recovery Properties of Auditory Nerve Fibres at Different Cochlear Regions using Electrically Evoked Compound Action Potential

Abishek Umashankar, Deepika Jayachandran
Introduction: Investigating the recovery function and refractory properties of auditory nerve is essential for us to understand the physiology at neural level, not many tools are available to carry out research in humans. Electrically Evoked Compound Action Potential (ECAP) helps us to record the action potential and also provides us with an option of varying the Interpulse Interval (IPI), hence there is a need to carry out research in Cochlear Implant (CI) users with the help of ECAP. Aim: To investigate the refractory property of the neurons and the response characteristics at different cochlear regions. Materials and Methods: Fifty CI users from age 3-10 years with a minimum hearing experience of three months underwent ECAP measures at various IPI. The data were further statistically analysed using SPSS software version 20.0, descriptive and inferential statistics were carried out using ANOVA. Results: It was found that a high ECAP threshold (648 cu) could be found at the basal region of cochlea when compared to medial (658 cu) and apical region (785 cu) at 300 μs and similar higher thresholds at different IPI, thus attributing to the fact that with increase in population of nerve fibres, a better threshold could be achieved. Another finding revealed that with very low IPI, the ECAP thresholds were elevated, with neural recruitment being a contributing factor. Conclusion: There was a difference in neural population amongst individuals, even with better auditory performance. ECAP is one of the objective tool to measure neural function and outcomes in CI individuals.

A Comparative Study of Cytomorphological Patterns of Lymph Node Aspirates in Paediatric and Adult Populations

M Dedeepya, AS Ramaswamy, BN Kumarguru, M Udaya Kumar
Introduction: Lymphadenopathy is one of the most common clinical presentations of patients. Lymph node is a commonly aspirated organ for diagnostic purposes. Fine Needle Aspiration Cytology (FNAC) of lymph node has become an integral part of initial diagnosis and management. Aim: To compare the cytomorphological patterns of the lymph node lesions in the paediatric population with that of the adult population and to correlate with the available histopathological diagnosis. Materials and Methods: It was a retrospective observational study of lymph node lesions conducted at a rural tertiary care referral institute, PES Institute of Medical Sciences and Research (PESIMSR), Kuppam, Andhra Pradesh, India, from January 2017 to June 2018 for a period of 18 months. Cytology smears were retrieved, reviewed and analysed. Cytological diagnosis was compared with available histopathological diagnosis and concordance was calculated. Chi-square test was the statistical tool used to analyse the data in the study. Results: Two hundred and seventy four cases were analysed. Adult population constituted 225 cases (82.12%). Paediatric population constituted 49 cases (17.88%). Reactive lymphadenitis was the commonest pattern in both the groups. Chronic lymphoproliferative lesions {4 cases (1.7%)} constituted the least common lesion in adults and mycobacterial lymphadenitis {1 case (2.04%)} constituted the least common lesion in paediatric population. Conclusion: Distribution of cytological patterns of lymph node lesions in paediatric and adult populations are different and are found to be statistically significant. Cytological evaluation of lymph node lesions has a high diagnostic efficacy for the diagnosis of neoplastic lesions.

Adverse Effects Associated with Urethral Catheter Placement- Patient’s Perspective
Introduction: Although Indwelling Urinary Catheter (IUC) have an important role in the care of hospitalised patients, nevertheless it is associated with numerous issues that must be addressed on a daily basis. Due to its invasive nature, it is a cause of discomfort and/or pain and also a potential threat to patients safety. The various adverse effects of IUC are associated with higher risk of infection, longer hospital stay and negative impact on daily activities of the patients. Patients perspective is the best source of information for IUC related adverse effects. Aim: To estimate the incidence of all adverse effects (complications) associated with the IUC use and to reproduce patients perception about how their well-being and safety is affected by it. Materials and Methods: In this observational study, hospitalised patients with an IUC were identified and followed-up for 30 days after its insertion. Information regarding both infectious and non-infectious IUC related adverse effects (complications) was collected through patients interviews. Follow-up assessments were performed 15 days and 30 days after the catheter insertion. During this assessment patient’s perspectives about the IUC and its adverse effects were collected. All variables were categorical and percentage and proportions were calculated manually. Results: Total 390 patients were evaluated and analysed. Study comprised of 73.85% males and 26.15% females. The mean age was of 56.7±6.5 years. The IUCs was inserted before surgical procedures in 305 patients (78.2%) with 284 patients (72.82%) having them removed within five days of insertion. A total of 259 patients (66.4%) reported at least one complication because of the IUC. The non-infectious complications were 54.1% and infectious were 12.3%. Both infectious and noninfectious complications were described more commonly by patients who still had their IUC. Most common complications were feeling of urgency/bladder spasms (25.9%) in catheter removal group and pain/ discomfort (52.7%) in catheter in situ group. Conclusion: As per the patients perspective the non-infectious complications are also bothersome in addition to the infectious one and management programme should include both the component essentially.

Aetiological Pattern of Vulvovaginal Infections in Asymptomatic and Symptomatic HIV Seropositive Women on Antiretroviral Therapy
Introduction: Human Immunodeficiency Virus (HIV) causes severe public health problems. Despite the use of Highly Active Antiretroviral Therapy (HAART), opportunistic infections remain a serious problem in HIV infection. HIV seropositive women are at a higher risk of acquiring Vulvovaginal Infections (VVI), compared to their HIV seronegative counterparts. Also, the large untreated asymptomatic populations remain a source for transmitting agent. Aim: To identify the occurrence of vaginitis in symptomatic and asymptomatic HIV seropositive women. Materials and Methods: HIV seropositive female patients (60 symptomatic and 60 asymptomatic for vulvovaginitis) in the reproductive age group of 18-60 years were screened for their vaginal flora in a tertiary care hospital in East Delhi, India. Wet mount, Gram stain, and culture were performed to screen the samples for vaginitis. Asymptomatic samples were processed to check for asymptomatic VVI. Nugent and Amsel’s score were calculated for Bacterial Vaginitis (BV), and Donders classification was used for Aerobic Vaginitis (AV). Sabouraud’s Dextrose Agar (SDA) was used for fungal cultures, and Fluconazole and Voriconazole sensitivity was tested. The descriptive analysis of compiled data with Chi-square tests where applicable to compare differences between proportions was done. Results: As per the Nugent's score, 90% of symptomatic and 86.66% asymptomatic HIV reactive females had BV. Nugent scoring was found to be a better diagnostic criterion for BV. AV was observed in 33.33% asymptomatic patients. Candida albicans (C.albicans) was the most common agent isolated from 68.75% of Vulvovaginal Candidiasis (VVC) cases. Dual infection of BV and Candidiasis was reported to be 18.33% in symptomatic and 15% in asymptomatic HIV seropositive females. Conclusion: In the present study, despite Antiretroviral Therapy (ART), attendees manifested significantly with BV infection in both groups. VVC due to C. albicans was also predominant in both groups. Co-infection with BV and VVC was the highlight of this study as dual infections of BV and AV remain under-diagnosed as per Sexually Transmitted Infection (STI) syndromic management protocols. The clinicians need to identify AV as a separate entity as treatment modalities are essentially different.

Symptomatic and Incidental Meckel’s Diverticulum in Children: Our Experience and Lesson

Rakesh Kumar, Vivek Srivastava, Vaibhav Pandey
Introduction: The management of incidentally detected Meckel’s Diverticulum (MD) at laparotomy or laparoscopy has been debatable. In asymptomatic cases, the surgical management is associated with complication of around 1% but the complication rates are variable in other conditions like peritonitis. Aim: To assess the management and outcome of incidentally diagnosed MD. Materials and Methods: A retrospective study was conducted from January 2012 to December 2019 using the case records of the patient. The study included all the patients who were diagnosed with cases of MD in the Department. The patients were divided into two groups: Symptomatic Group and Incidental Group. The case records of all the patients were reviewed and data were collected for the demographic details, mode of presentation, the basis of diagnosis, treatment, outcome and follow-up. Results: Total 132 patients were included in the study, 74 (56.06%) subjects were in symptomatic group and 58 (43.9%) were in incidental group. The mean age of symptomatic patients was 3.1±1.1 years and the incidental group was 6.5±2.4 years. It was significantly less in the symptomatic group (p≤0.001). All the patients in the symptomatic group were managed by laparotomy with diverticulectomy in 8 (10.8%), Wedge resection in 10 (13.5%) cases, segmental bowel resection in 44 (59.4%) and ileostomy in 12 (16.2%) cases. In the incidental group 9 (15.5%) patients underwent laparoscopic diverticulectomy and in rest 49 (66.2%) cases, only the primary procedure was performed. Six (10.3%) patients of incidental group without any intervention presented with complication in follow-up. Conclusion: The laparoscopic diverticulectomy of MD should be performed in incidentally diagnosed cases of younger age group.

Assessment of Effect of Low Dose Succinylcholine on Facilitating Insertion of Laryngeal Mask Airway- A Single-blind Randomised Study

Shivani Rao, Anjali Modak
Introduction: Laryngeal Mask Airway (LMA) insertion is often associated with complications such as gagging, laryngospasm and mobility of the head and neck while insertion. To overcome this and achieve a smooth insertion, many drugs are tried one of them is being succinylcholine. Aim: To assess the effects of low dose succinylcholine (0.1 mg/kg) on facilitation of LMA insertion to achieve adequate conditions with fewer or no side effects. Materials and Methods: Sixty patients of American Society of Anesthesiologists (ASA) I and II grade were posted for elective surgeries under general anaesthesia with LMA. Patients were randomly allocated into two groups of 30 each. Control group (Group C) received a bolus dose of 2 mL of 0.9% sodium chloride IV post induction. Study Group (Group S) received a bolus of succinylcholine 0.1 mg/kg diluted in 2 mL of 0.9% sodium chloride IV post induction. Following activities like jaw relaxation, coughing/gagging, head and limb movements, presence or absence of laryngospasm and duration of apnea were noted and were compared using chi-square test, while performing LMA insertion under general anaesthesia. Results: It was found that the number of incidences of gagging (mild) and coughing (mild) in Group S was 3.33% and 0%, respectively, while it was 23.33% and 26.66% in Group C. It was found that group S had excellent insertion conditions in 94% of patients as compared to 36% of group C (p<0.001). In 93.33% of patients, LMA was inserted in 1st attempt in group S, whereas 40% of patients in group C required more than one insertion attempt and also 93.3% of patients in group S did not require excess propofol, whereas supplement doses of propofol in control group was required in 60% of patients. Conclusion: Low dose succinylcholine provides better LMA insertion conditions with reduced number of attempts, incidences of gagging and coughing.

Identification of Dengue Serotypes using a Single Serum Specimen Algorithm in a Tertiary Care Hospital, Alappuzha, Kerala, India

Parvathy Vijayamohana Das, Balakrishnan Anukumar, Sobha Balakrishnan
Introduction: The geographic location of Alappuzha, a district in the South Indian state of Kerala, the distinct weather conditions and frequent natural calamities present a unique ecology that contributes to the prevalence of vector-borne diseases like dengue. Early dengue virus infection can be detected by using a combination of tests on a single serum specimen. Aim: To identify the dengue virus serotypes among hospitalised patients in a South Indian teaching hospital in Alappuzha, Kerala, India. Materials and Methods: Patient samples that tested positive for dengue non-structural protein-1 (NS1) antigen by ELISA were further evaluated for dengue virus RNA by real-time, multiplex reverse transcriptase Polymerase Chain Reaction (PCR) and the serotype was determined. Anonymised patient data was collected using a questionnaire as a data collection tool. The data was analysed for statistical significance. Results: Among 422 non-duplicate patient serum samples received in the Department of Microbiology, in the year 2019, 30 were positive for dengue NS1 antigen by ELISA. Dengue viral RNA was detected in 50% of the samples (15/30). DENV-3 serotype was the most prevalent (nine) followed by DENV-1 (five) and DENV-2 (one). Common presentations of the patients were fever, headache, and myalgia. No statistically significant association was found between a PCR positive result and the presence of warning signs and thrombocytopenia. Conclusion: DENV-3 was the most common serotype in the study population. Early dengue virus infection is associated with varied symptoms

Effectiveness of Intravenous Dexmedetomidine vs. Fentanyl for Attenuation of Haemodynamic Response to Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomised Double Blind Study

Reema Meena, Chandrakant Parashar, Priyanka Jain, Manoj Soni
Introduction: Laparoscopy is a widely performed minimal invasive surgical procedure, wherein various haemodynamic changes are faced by anaesthesiologists during Pneumoperitoneum (PNP). Aim: To compare the effectiveness of dexmedetomidine vs fentanyl for attenuating the haemodynamics response to PNP in Laparoscopic Cholecystectomy (LC). Materials and Methods: A total of 84 patients of 18-50 years age, American Society of Anaesthesiologists (ASA) Class I/II of either sex for elective LC were included. The patients were divided into two groups (A, B) of 42 patients each. Group A received dexmedetomidine and Group B received fentanyl. Both the drugs were given as loading dose of one µg/kg over ten min followed by maintenance 0.2µg/kg/h throughout the surgery. Haemodynamic parameters were recorded at different time intervals throughout the surgery. In recovery room patients were observed for postoperative analgesia by using Visual Analogue Scale (VAS), sedation level using RAMSAY Sedation score at every 30 minutes till the time of giving first rescue analgesia and side effects, if any. Results: Intraoperatively, throughout the period of PNP, Group A showed statistically better attenuation of haemodynamic responses in comparison to Group B (p<0.05). After creating PNP, rise in Mean Arterial Pressure (MAP) was observed in both group A and group B, 99.38±6.32 and 103.43±9.81, respectively but this rise was more in group B which was statistically significant (p<0.05) throughout the surgery except 40 minutes after PNP creation. Time to first rescue analgesia or mean duration of postoperative analgesia (VAS>3) was significantly longer in dexmedetomidine group (102.14±32.50 minutes) than fentanyl group (42.86±15.03 minutes). There was better control of pain but more sedation in Group A than in Group B. Conclusion: This study concludes that intravenously administered dexmedetomidine shows better attenuation of haemodynamic responses to CO² insufflation as compared to fentanyl. Dexmedetomidine also provides better sedation and has more analgesic sparing effect.

Functional Diarrhoea in a Nigerian Community: Prevalence, Risk Factors and Associated Quality of Life
Introduction: Diarrhoea, in general, is well investigated but the epidemiology of Functional Diarrhoea (FDr) as a disease entity has not been adequately evaluated globally, and more especially, in the sub-Saharan African population. Aim: To determine the prevalence and risk factors of FDr, and the associated quality of life in a Nigerian community. Materials and Methods: The study was a community-based cross-sectional survey involving 515 consenting adults aged 18-70 years. Data collection was done from February to March 2019. Ten participants were excluded because of inappropriately filled questionnaires, thus leaving a total of 505 subjects. The research instrument contained sociodemographic information, the Rome IV Functional Bowel Disorder questionnaire, the Short Form 12, version 2 Health Survey (SF-12v2) questionnaire, the Beck Depression and Anxiety Inventories, the Pittsburgh Sleep Quality Index (PSQI), and the Early Trauma Inventory-Self Report. Respondents who were positive for FDr were the cases while those who had no FDr were the controls in the data analysis. Independent Student t-test was used to compare means. The odds ratios of prospective risk factors of FDr were calculated with logistic regression. Odds Ratios (OR) >1 and p-value ≤0.05 were considered significant. Results: The mean age of the participants was 32.7±12.9 years. Six participants {1.2% (95% CI, 0.4%-2.4%)} had FDr with a 1:2 Male/Female ratio. Functional diarrhoea had a statistically significant association with depression (18.0±12.8 vs 8.2±9.5, p-value=0.021) only among the possible risk factors considered. The mean SF-12v2 scale scores, except Vitality, were lower in subjects with FDr than the controls, though only Social Functioning was statistically significant (p-value=0.003). Conclusion: The prevalence of FDr is low in the present study population. The disease is associated with depression and it impacts the Health-Related Quality of Life (HRQoL) negatively.

A Study of Indications and Outcome of Non-Invasive Ventilation in Respiratory Care Unit of a Tertiary Care Hospital in Eastern India
Introduction: Patients with Acute Respiratory Failure (ARF) can be ventilated noninvasively through Bi-Level Positive Pressure Ventilation (Bi-PAP). The proper timing, indications and outcome of Non-invasive Ventilation (NIV) have been evaluated worldwide by many investigators. Optimum selection of patients leads to better outcome reducing need for invasive ventilation; while the reverse can cause inappropriate delay in intubation leading to clinical deterioration, increased morbidity and mortality. Aim: To evaluate the indications and outcome, with relevant factors in all patients requiring NIV in Respiratory Care Unit (RCU) of a teaching hospital. Materials and Methods: This was a hospital-based observational study conducted from April 2016 to March 2017. After ethical approval, all patients who were put on NIV in RCU of the institution during the period of one year were enlisted. Evaluation by history, detailed clinical examination and necessary investigations including blood count, biochemistry, Arterial Blood Gas (ABG) analysis, oxymetry, microbiological investigations, imaging of thorax etc., was done. Examination and investigations were periodically repeated as necessary. Pre-fixed NIV protocol and end point definitions were followed. Descriptive statistics done using Mean and Standard Deviation (SD). Mann-Whitney U test was done for comparing quantitative data. Chi-square test or Fisher's-exact test was used to compare categorical data. Results: Most common age group for Respiratory Failure (RF) was 41 to 60 years, (mean 56.5±11.6), with a male predominance (M:F=1.4:1). The most common underlying disease leading to RF and requiring NIV support was Acute Exacerbation of Chronic Obstructive Pulmonary Disorder (COPD) (n=31) in Type 2 and pneumonia (n=11) in Type 1 RF. Hypertension (25%) and diabetes mellitus (20%) were common co-morbidities. Favourable outcome was seen in 68.33% patients an average hospital stay of 15 days. The baseline APACHE-II (Acute Physiology and Chronic Health Evaluation) score (p≤0.0001) and Partial Pressure of Oxygen(PaO² )/ Fraction of Inspired Oxygen (FiO² ) at 1st hour of NIV (p=0.0054) have significant predictive value the outcome. Reasons for shifting to IMV were: non-improvement of ABG (37.93%), worsening of dyspnoea (24.14%) and haemodynamic instability (20.7%). Average time gap from initiation of NIV to mechanical ventilation in failure cases was 8.03 hours in Type 2 RF and 5.78 hours in Type 1 RF. Fatality rate in Type 2 RF (23.68%) was much less than in Type 1 RF (45.45%). Conclusion: This study strengthens the fact that efficient utilisation of NIV therapy in properly selected patients of acute RF can lead to reduced need for IMV, thus reducing the cost and complications. Disease severity at admission (APACHE-II score), non-improvement of ABG parameters in 1st and 4th hour of NIV initiation, PaO² /FiO² ratio, development of haemodynamic instability and deteriorating level of consciousness, all play pivotal roles in the outcome assessment.

A Multicentric Study on the Clinical Profile, Serology, Neuroimaging and Treatment of Neurocysticercosis
Introduction: Neurocysticercosis (NCC) is the most common parasitic disease affecting the human brain, and the leading infectious cause of seizures/epilepsy in India. It is often a diagnostic challenge due to varying clinical and imaging presentations. Aim: To describe the clinical profile, serological testing, imaging features and treatment outcomes of NCC, in an Indian population. Materials and Methods: This prospective observational study with a case control design was carried out over a period from June 2015 to June 2019, at two Tertiary Care Hospitals in Mumbai and Bangalore. Seventy four (74) cases who had evidence of parenchymal/extra-parenchymal NCC lesions based on Contrast MRI Brain (1.5 Tesla), were included in the study. Fifty matched controls with Idiopathic epilepsy were also recruited in the study, so as to establish the sensitivity and specificity of the commonly used ELISA test (IgG antibody) for NCC. All patients with viable parenchymal NCC lesions were given standard cysticidal therapy (Albendazole), along with anti-epileptic drugs, as per clinician discretion. Disability at six months follow-up was assessed using the modified Rankin Scale (mRS). Pearson’s Chi-square test was used to compare dependent variables. The p-values <0.05 were accepted as statistically significant. Results: Of the 74 cases with NCC enrolled in the study, 81% (60) were males and the mean age of the population was 36.4 years. Total 91% cases (68) presented with seizures. Neuro-imaging revealed majority of lesions were vesicular (28%). Total 42% (31/74) had Solitary Cystisercal Granuloma (SCG), only 26% (19/74) cases and 8% (4/50) controls were positive for the IgG anti-cysticercal antibody by ELISA. This gave the antibody test a sensitivity of 26%, and a specificity of 92%. This translated into a Positive Predictive Value (PPV) of 83%, Negative Predictive Value (NPV) of 45%, and a positive likelihood ratio of 3.21. In patients who had single or multiple viable parenchymal NCC lesions (57/74), cysticidal therapy with Albendazole (under steroid cover) was safe and effective in 88% (50/57) cases. Conclusion: NCC commonly presents with seizures, and is best diagnosed with contrast MR imaging of the brain. The commercially available ELISA based antibody test do not add significantly in the management of this tropical infection. Cysticidal therapy is safe and effective in a majority of the patients, however treatment of extra-parenchymal NCC remains a challenge.

Evaluation of Usefulness of Mannheim Peritonitis Index and APACHE II Score in Predicting Mortality and Morbidity in Patients with Peritonitis- A Prospective Diagnostic Test Study

D Paul Trinity Stephen, Vijay Abraham, Reka Karuppusami
Introduction: Peritonitis, defined as inflammation of the peritoneal cavity can be of various causes, and is one of the most common surgical emergencies. This continues to be a challenge to diagnose and treat. Early intervention is essential to select patients who will need intensive care which brings out better outcome for the patients. This also helps us use the resources optimally. Over years, many scoring systems have been developed and studied to predict outcomes in patients with peritonitis. Aim: To evaluate the ability of Mannheim Peritonitis Index (MPI) and APACHE II (Acute Physiology And Chronic Health Evaluation II) scores in predicting mortality and morbidity in patients with peritonitis. Materials and Methods: A prospective, observational study was conducted at Christian Medical College and Hospital, Vellore, Tamil Nadu, India, for a period of two years from September 2014 to August 2016. A total of 78 patients were recruited for this study. These patients were scored with MPI and APACHE II scores. The primary outcome studied was in hospital death or discharge. The secondary outcome studied was morbidity in terms of local and systemic complications. The risk factors associated with mortality in patients with peritonitis were also studied. The best cut-off value for MPI and APACHE II from the data was calculated using Yuden index. The sensitivity, specificity and likelihood ratios were calculated and presented with 95% Confidence Interval (CI). The sub-group analysis was done for risk factors and complications. Results: There were more males than females. Age ≥48 years (p=0.002) and serum creatinine ≥1.3 g/dL (p=0.012) were found to be significant risk factors for mortality. The sensitivity and specificity of MPI ≥27 in predicting mortality was found to be 90% and 57% respectively. The sensitivity and specificity of APACHE II score ≥10 in predicting mortality was found to be 40% and 78%, respectively. MPI scores ≥27 were strongly associated with morbidity like prolonged ICU stay (p=0.004), mechanical ventilation requirement (p=0.001) and need for dialysis (p=0.035). Conclusion: Present study showed MPI to be a better predictor of mortality than APACHE II, though APACHE II showed better specificity. MPI score also was helpful in predicting morbidity such as prolonged ICU stay, mechanical ventilation requirement postoperatively and need for dialysis postoperatively. MPI was easier to use as it contained lesser variables. MPI could be of use in rural areas with no facility for laboratory investigations and blood gas analysis.

Aetiology and Management of Vascular Injuries in Extremity Trauma: An Observational Study

Lata Khatnani Koneru, Subhash Minda, Nimish Rai
Introduction: Management of peripheral vascular injury is a challenging task. To save life and to salvage the limb, early diagnosis and prompt intervention is required. Aim: To analyse the cause of injury, surgical approach, outcome and complications in patients with peripheral vascular trauma. Materials and Methods: This observational study assessed 60 consecutive patients who were operated for peripheral vascular injuries in the last one and half year (October 2018 to March 2020). Diagnostic tools were clinical examination in combination with vascular Doppler. Vascular repair with interposition autologous vein graft or primary repair was performed. Extensive injury with non-viable limb requiring primary amputation was excluded from the study. The primary outcome in form of limb salvage was selected. Fisher-exact test was used to analyse limb salvage rate between two groups having median revascularisation time less than six hours and more than six hours. Results: In the present study there were 55 male patients (91.6%) out of 60 patients. The mean age was 24.8±7.0 years. The mechanism of injury in 28 (46.6%) cases was blunt trauma and in 32 (53.3%) cases it was penetrating trauma. The associated orthopaedic injury was present in 20 (33.3%) patients. The most commonly injured artery was brachial 26 (43.3%) followed by popliteal 13 (21.6%) and femoral artery nine (15%). Primary repair was performed in 18 (30%) cases and interposition vein graft in 42 (70%) cases. Majority of patients, 53 cases (88.3%) had functional viable limb. Complications found were wound infection in six cases (10%), revision surgery in five cases (8.3%) and secondary amputation in seven cases (11.6%). Median time interval between injury and revascularisation surgery was 9.04 hours. Those who presenting late (>6 hours) had a higher amputation rate but it was not statistically significant. Conclusion: Management of vascular injuries require prompt localisation and early surgical intervention. A successful outcome is seen in patients who were early diagnosed. However, limb salvation is possible, even in patients with delayed presentation.

Role of Dynamic Contrast Enhanced MRI in the Evaluation and Characterisation of Breast Lesions with Pathological Correlation
Introduction: Magnetic Resonance Imaging (MRI) has an excellent soft tissue resolution and can detect and accurately characterise lesions which are not seen on other imaging modalities like mammography or ultrasonography. Dynamic Contrast Enhanced (DCE) MRI is better for characterisation of fibroglandular tissue and breast lesions as it further improves specificity of MRI. Kinetic Curves (KC) derived from DCE MRI according to the wash in and wash out patterns of intravenous contrast are analysed and correlated with morphology of a lesion. Aim: To evaluate the efficacy of DCE MRI in detection and characterisation of breast lesions according to KC analysis and to correlate MRI findings with pathological findings. Materials and Methods: A prospective observational study was conducted at Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India. DCE MRI was performed after informed consent in 50 females (Age ranging from 17 years to 80 years). MRI was conducted on Siemens “MAGNETOM Avanto” 1.5 Tesla machine using standard dedicated breast matrix coils. The standard MRI protocol included the T1 and T2 weighted fat-sat sequences along with DCE MRI after intravenous administration of Meglumine-Gadoterate (0.1 mmol/kg body weight) followed by a 20-mL saline flush. Post processing manipulation included standard subtraction, reverse subtraction, Maximum-Intensity Projection (MIP) images and KC analysis. Findings of DCE MRI were graded according to Breast Imaging-Reporting and Data System (BI-RADS) category after morphological and KC analysis and were correlated with pathological findings. Results: MRI is a highly sensitive modality to detect breast lesions especially bilateral and multifocal/multicentric lesions with sensitivity of 98.18%. However, specificity was relatively low (55.56%). The Positive and Negative Predictive Values (PPV, NPV) of MRI in characterisation of breast lesions in present study were 93.10% and 83.33%, respectively. Conclusion:Although MRI is extremely sensitive for detecting breast lesions it has a relatively low specificity. Both morphological characteristics and KC analysis should be used in combination for interpretation as it improves the specificity of MRI.

Status of Serum Calcium, Phosphorus, Magnesium and Copper in Hypothyroid Patients- A Case Control Study

Diana Athokpham, Shrabani Mohanty, Venkata BharatKumar Pinnelli
Introduction: Thyroid disorders are the most common endocrine abnormality in the world secondary to diabetes mellitus. Thyroid hormones are essential for growth, neuronal development, reproduction and regulation of energy metabolism. It influences the metabolism of all substrates including minerals. Many studies have shown that mineral metabolism is frequently disturbed in thyroid disorders. Aim: To estimate the levels of serum calcium, phosphorus, magnesium and copper in hypothyroid cases and to correlate each of the parameter with serum Triiodothyronine (T3), Thyroxine (T4), Free T3 (FT3), Free T4 (FT4) and Thyroid-Stimulating Hormone (TSH), respectively. Materials and Methods: The study was conducted on sixty newly confirmed hypothyroid cases based on the thyroid profile and sixty euthyroid cases were recruited as controls. Blood samples were collected from all the patients for the estimation of serum T3, T4, FT3, FT4, TSH, calcium, phosphorus and magnesium by autoanalyser method. Modified spectrophotometric micro-method was used to measure Serum copper using Bathocuprine Disulphonate Disodium Salt (BCDS) and Guanidine hydrochloride salt. The Statistical software namely SPSS 18.0, and R environment ver.3.2.2 were used for the analysis of the data. Results: Study results shows that mean serum calcium, magnesium and copper levels were significantly (p<0.001) decreased while serum phosphorus levels were increased significantly (p<0.001) in hypothyroid cases as compared to euthyroid cases. A significant positive correlation was found between serum Ca vs T3, serum Ca vs T4, negative correlation with serum Ca vs TSH, serum Ca has no significant correlation with serum FT3 and FT4. Significant positive correlation was found between serum phosphorus and TSH while significant negative correlation of phosphorus in comparison with T3 and T4. No significant correlation was found between serum phosphorus with FT3 and FT4. Suggestive significant positive correlation was found between serum Mg with T3, T4 and significant negative correlation with serum TSH, Mg has no significant correlation with FT3 and FT4, there was no significant correlation of serum copper with serum T3, T4, TSH and FT4 but significant positive correlation with serum Cu with FT3 were observed. Conclusion: The present study has shown that metabolism of minerals are altered in thyroid dysfunction cases. This study concluded that impaired metabolism of minerals like calcium, phosphorus, magnesium and copper can lead to various metabolic disorders. Preventive measures like supplementation of minerals or hormone replacement therapy can be initiated early to control these secondary disorders.

Association of GCK Gene Promoter Polymorphism and their Role in its mRNA Expression among Type 2 Diabetes Mellitus Patients

Waseem Fatima, Farah Khan, Ashraf Ali, Amit Kumar Verma
Introduction: Glucokinase (GCK) gene alteration or inactivation leads to Maturity-Onset Diabetes of the Young (MODY) and Neonatal Diabetes. Alterations in GCK gene has been shown to be associated with increased risk of type 2 diabetes, hyperglycaemia and impaired beta cell function. Aim: To evaluate the GCK (-30G/A, rs1799884) alterations in Type 2 Diabetes Mellitus (T2DM) patients. Materials and Methods: After patients’ selection, blood samples were taken and all biochemical parameters were analysed by auto-analyser using serum. Whole blood samples were used to extract DNA and RNA for genotyping of -30G/A polymorphism using Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP) as well as GCK mRNA expression using quantitative real time PCR. Results: Several parameters such as fasting sugar, serum uric acid, Low Density Lipoprotein (LDL), High Density Lipoprotein (HDL), Triglyceride (TG), Cholesterol, high-sensitivity C-Reactive Protein (hs-CRP) were analysed among T2DM cases and healthy controls and differences among them were found to be significantly associated (p<0.0001). It was observed that patients who were smoking among T2DM cases, were found to be associated with increased fasting sugar (p=0.001), postprandial sugar (p<0.0001), HbA1c (p=0.003), blood urea (p=0.01), cholesterol (p=0.02) compared to those who were not smokers. T2DM patients who were alcoholic, showed increased LDL (p=0.006) and cholesterol (p=0.01) compared to non-alcoholic T2DM patients. T2DM cases which were reported hypertensive, showed increased hs-CRP (p=0.02) and cholesterol (p=0.02), compared to non-hypertensive T2DM cases and differences among them were found to be significantly associated. Significant differences were observed in distribution of GCK -30G/A genotypes among T2DM cases and healthy controls (p<0.0001). Odds ratio was calculated and it was observed that the heterozygous GA genotype had 4.66 odds ratio while odds ratio for mutant AA genotype was 35.98 in reference to wild type. Patients with homozygous GG showed 0.25 mean fold decreased GCK mRNA expression while heterozygous GA and mutant AA genotype showed more than 0.17 and 0.16 fold decreased. GCK mRNA was observed and differences among them was found to be significant (p<0.0001). Conclusion: Study revealed that GCK heterozygous GA and mutant AA genotypes were associated with T2DM risk and decreased expression may be responsible for disease progression and worsening of the disease

Prescribing Pattern of Proton Pump Inhibitors (PPI) and Histamine Blockers in a Tertiary Care Hospital

Anjali Manoj Goyal, Alpa Pragnesh Gor
Introduction: Gastric problems are the most common diseases seen in many countries for which majority of the population prefer Proton Pump Inhibitors (PPI) and Histamine (H2) Blockers. They are prescribed most commonly for Gastroesophageal Reflux Disease (GERD), Dyspepsia, Peptic Ulcer Disease, alongwith medications like Non-Steroidal Antiinflammatory Drugs (NSAIDs) and other drugs. Concerns have been raised about the increasing costs associated with prescription of these drugs as they are often prescribed for minor symptoms and without clear indications. Prescribing pattern should be evaluated periodically to promote rational use of medicines. Aim: To assess the prescribing pattern of PPIs and H2 Blockers in Surgery and Medicine Department of a Tertiary Care Hospital. Materials and Methods: An observational study was conducted in a Tertiary Care Hospital, Karamsad over a period of one year from November, 2018 to October, 2019, among patients visiting to Out Patient Department (OPD) and In Patient Department (IPD) of Medicine and Surgery Department that were prescribed PPI and H2 Blockers. Total 1100 prescriptions and 1265 PPI, H2 Blockers were analysed. The data were analysed for sociodemographic variables along with details of PPI and H2 Blockers. co-prescribing drugs, Fixed Dose Combinations (FDCs) and drug interactions of each prescription was analysed. Results: In the study, PPI and H2 Blockers were prescribed more in males (54.36%). The predominant age group was 18-40 years (42%). Among studied drugs, most commonly prescribed single drug was Pantoprazole and FDC was Ranitidine + Domperidone. The drugs were most commonly prescribed through oral route (90.9%). They were most commonly prescribed along with an NSAID for gastroprotection (28.9%). Pharmacokinetic drug interactions were observed more in the study. Conclusion: This study showed that physicians prescribe PPI and H2 Blockers as a co-medication for gastroprotection. There is a need to increase documentation for prescribing PPI and H2 Blockers.

Effect of Cigarette Smoking on Selected Antioxidant Enzymes and Oxidative Stress Biomarkers

Basant Joshi, Sangeeta Singh, Preeti Sharma, Tapan Mohapatra, Pradeep Kumar
Introduction: Cigarette Smoking (CS) is the single greatest preventable cause of disease and death and is rich in Reactive Oxygen and Nitrogen Species (ROS and RNS). These can cause the production of other free radicals, which, in turn, initiate lipid peroxidation and cause several diseases. Free radical scavenger enzymes namely Superoxide Dismutase (SOD), Catalase (CAT) and Glutathione Peroxidase (GPx) represent the enzymatic part that have the ability to inhibit oxidative stress by scavenging the highly destructive free radicals. Aim: To study the effect of CS on selected antioxidant enzymes and oxidative stress biomarkers. Materials and Methods: A case control study was conducted from September 2016 to September 2019 in which total of 284 healthy (without any systemic diseases) cigarette smokers (cases) in the age group of 18-60 years compared with age and sex matched 284 nonsmokers (controls) were included in the study. Estimation of serum 8-hydroxydeoxyguanosine (8-OHdG) by Enzyme Linked Immunosorbant Assay (ELISA), Malondialdehyde (MDA) by Thiobarbuturic Acid Reactive Substances (TBARS), SOD by water soluble tetrazolium salt 1, GPx and CAT by colorimetric method. The analysis was carried out using the SPSS 19.0.2 program for windows. Unpaired t-test and one-way ANOVA were used to analyse all the data for statistical significance. Results: The mean Serum MDA and 8-OHdG levels were significantly raised 7.47±1.84, 63.41±22.44 as compared to nonsmokers (3.90±1.03, 40.04±20.14) and serum SOD, Gpx and CAT levels were decreased 62.55±19.97, 44.45±16.60 and 12.92±10.16 in cigarette smokers as compared to nonsmokers 274.04±68.37, 208.56±75.63 and 127.82±18.68, respectively. These differences were also found to be statistically significant in cigarette smokers according to duration and number of cigarette smoked at the level of <0.05. Conclusion: Cigarette Smoking, especially long-term smoking may leads to significant changes in the enzymatic antioxidant defense systems of smokers. Discontinuation of smoking and general awareness needs to be created to minimise the risk of smoking related diseases.

Knowledge, Attitude and Practices regarding Diabetes Mellitus among Type 2 Diabetes Mellitus Patients in a Tertiary Care Hospital in Nortwest Rajasthan
Introduction: As per the International Diabetes Federation (IDF) statistics, around 463 million people are presently living with diabetes worldwide, and this is anticipated to be 578.4 million by 2030. Awareness regarding diabetes is a major determinant for early detection and prevention of diabetes. Information regarding Knowledge, Attitude, and Practice (KAP) among diabetics from Northwest Rajasthan, India is not readily available. Aim: This study was designed to assess KAP regarding diabetes among patients with Type 2 Diabetes Mellitus (T2DM). Materials and Methods: This hospital based, cross-sectional study was conducted over a period of one and half years from July, 2018 to December, 2019 in a Tertiary Care Center in Northwest Rajasthan, India among 960 patients with T2DM. KAP was assessed by a structured questionnaire derived from a validated set of questionnaires and was categorised as poor, average, and good. Bivariate and multivariate analyses were done to assess the association between diabetes-related KAP and sociodemographic variables. Results: The mean age of the subjects was 55.45±11.64 years. The proportion of good, average, and poor knowledge scores among subjects were 10.83%, 65.84% and 23.33%, respectively. The corresponding values for attitude scores were 9.16%, 74.17% and 16.67%, respectively. Subjects from young age group, urban habitats, higher educational background, upper socioeconomic class, longer duration of diabetes, with a family history of diabetes, those who attended diabetes education program and with higher Body Mass Index (BMI) demonstrated significantly greater KAP score (r=0.73, p=0.001). Better knowledge was associated with a better attitude and practice (r=0.81, p=0.001) and better attitude was associated with better practice (r=0.77, p=0.001). Conclusion: The overall level of KAP regarding diabetes was average. To prevent diabetes and its complications, there is an urgent need to carry out extensive awareness programs with a prioritised focus on poorer, rural and less educated groups.

Awareness towards COVID-19 among Medical Students: A Cross-sectional Questionnaire Based Study
Introduction: The coronavirus disease (COVID-19) pandemic has surfaced as a public health emergency and the world has witnessed the evolution of unprecedented measures for slowing down the disease progression and reducing the morbidity/mortality associated with the disease. In such scenario healthcare workers assume the most vital and the most vulnerable responsibilities. Aim: To investigate the awareness of undergraduate students of pre-final and final year, interns and postgraduate students in Shyam Shah Medical College, Rewa, MP towards COVID-19 and the sources on which the respondents depend for acquiring information through a web based questionnaire. Materials and Methods: This was a cross-sectional study, conducted from 25th April to 1st May 2020 based on a close-ended, time bound, online questionnaire containing 16 questions based on aetiology, mode of transmission, risk factors, signs, symptoms, treatment and prevention of COVID-19. It was administered to a total of 320 students of which final respondents were 183 (112 undergraduate students and 71 post graduate students and interns) as a Google form through a cross platform messaging application namely WhatsApp. Data about the information sources and the perceived reliability of the respondents on them was also obtained. The filled information was evaluated and the collected data was presented as frequencies and percentages. Awareness was graded as good when the respondents were able to answer more than 75% (>12) questions correctly, average when they answered >50% and ≤75% (9-12) answers correctly and poor when they could answer ≤50% (≤8) questions correctly. Continuous variables were presented as mean±SD. Student’s Independent t-test was performed to compare the mean awareness level of both groups. A p-value of less than 0.05 was considered statistically significant. Results: Out of a total of 320 students to whom the questionnaire was sent, 183 participated in the survey (response rate=57.1%). The study revealed a good awareness level of the respondents towards COVID-19 (mean score >12) in both the groups (undergraduate/postgraduate). The percentage of correct answers for entire study population for awareness related questions was 82.24%. The difference in awareness level between undergraduate students in comparison to interns and postgraduate students was found to be statistically significant (p<0.001). The respondents obtained maximum information from the official government websites (mean=3.6) and had maximum confidence on the same for the credibility of data (mean=3.9). Conclusion: The awareness level of the students was found to be good. To cope up with this new emerging infectious disease, the health care workers must remain updated with all recent developments. Comprehensive educational programs focused on field epidemiology, infection control practice and public health are the need of the hour.

Prevalence of Oral Microbial Flora during Orthodontic Space Closure: A Pilot Study

Abirami Selvaraj, Sumathi Felicita, Smiline Girija
Introduction: Orthodontic treatment with fixed appliances especially during the retraction stage makes it challenging to maintain the oral hygiene. Attachments used, such as elastic chains, loops and springs, result in changes in the oral environment due to the accumulation of plaque and increase in the levels of bacterial count mainly Streptococcus mutans and Lactobacilli species. Aim: To determine the prevalence of oral microbial flora during orthodontic space closure. Materials and Methods:This was a cross-sectional pilot study conducted during the month of December 2019 which consisted of eight patients who were randomly selected among the age group of 18-25 years. Mean and SD of age in Males (4) and Females (4) were 22±2.16 years and 22.25±1.70 years, respectively and had reported to the Department of Orthodontics of a private dental college, Saveetha Dental College. In each patient, after 6-8 months of orthodontic treatment, plaque samples were collected only once around the orthodontic brackets at the cervical aspect of the maxillary lateral incisor, maxillary premolar, mandibular canine, mandibular premolar in 1st, 2nd, 3rd, and 4^th quadrant respectively, by the method of cotton swabbing for the evaluation of micro flora. Independent paired t-test and One-way ANOVA with Post-hoc Tukey HSD test were done to estimate the prevalence of microorganisms at different sites. Results: Independent paired t-test showed highly significant differences in the levels of Streptococcus mutans when compared to Lactobacillus (p<0.001) with mean values of 4.8±2.5 and 23.1±9.2 for Streptococcus and Lactobacillus, respectively. One-way ANOVA with Post-hoc Turkey HSD analysis showed significant difference at the region of maxillary lateral incisor compared to other sites whereas Lactobacilli showed no significant differences between the various sites tested (p-value<0.001). Kappa statistics was performed which revealed an inter examiner reliability of 0.91. Conclusion: During orthodontic space closure, bacterial count of Streptococcus mutans showed a statistically significant difference between different sites (maxillary lateral incisor, mandibular canines, maxillary and mandibular premolars) with highest being the maxillary incisor region followed by that of mandibular canines. However, the incidence of Lactobacillus acidophilus did not show any difference between the various sites evaluated.

A Randomised, Double Blinded Study on Comparison of Intrathecal Morphine and Clonidine as Adjuvant for Post-caesarean Analgesia
Introduction: Caesarean section is a common obstetric operation which requires adequate and safe postoperative analgesia sometimes using morphine or clonidine to provide comfort to the mother and ease in handling the new born. Aim: To compare the adjuvant effect of morphine and clonidine when co-administered intrathecally with 0.5% bupivacaine heavy during caesarean section. Materials and Methods: A randomised double-blinded study was conducted on 90 parturient were randomly divided into three groups, during March to November 2011, receiving intrathecal 100 mcg morphine, 75 mcg clonidine and 0.5 mL normal saline along with 2.5 mL of 0.5% bupivacaine respectively. The quality and duration of postoperative analgesia and any side effects were assessed at fixed time interval. APGAR (Appearance, Pulse, Grimace, Activity and Respiration) score of foetus was also done to assess their wellbeing. Statistical analysis was done using Analysis of Variance (for continuous variables like Blood Pressure, heart rate, etc.,) and chi-square test (for discrete variables like VAS score, side effects, etc.,). Results: Postoperative VAS score at different time were much lower in the morphine group as compared to clonidine group (p-value<0.001) at 2,8,24-hour interval postoperative period. The time required for 1st rescue analgesia was longer in morphine (14 ±7.33 hours) as compared to clonidine (7 ±1.02 hours) (p<0.001). The total dose of rescue analgesic required in 24 hours was less (p<0.001) in morphine (75 ±48.25 mg) group. Hypotension bradycardia and sedation (p-value 0.028) were more in clonidine group as compared to morphine group. Conclusion: Low dose morphine is better as an adjuvant than clonidine during spinal anaesthesia for relieving pain following caesarean section.

C-Reactive Protein as a Predictor for Early Intervention in Patients with Ureteric Calculus- A Prospective Study
Introduction: Inflammation of ureteric wall may impede the passage of calculus which reduces the chances of spontaneous expulsion. C-Reactive Protein (CRP) being an acute phase reactant elevates in almost all inflammatory conditions. Aim: To determine whether CRP levels can predict the need for early intervention in symptomatic ureteric calculus. Materials and Methods: The sample was estimated to be 140 patients over the age of 18 years during the study duration of six months. Ureteric calculus measuring 5-10 mm were subjected to Medical Expulsion Therapy (MET) (Silodosin 8 mg at night). CRP levels were estimated on day 1 and day 7 from the presentation. CRP less than 6 mg/L was considered normal, represented as ‘negative’ in the present study; more than or equal to 6 mg/L was taken as ‘positive’. Patients who demonstrated rising/ elevated CRP were considered for early endoscopic/surgical intervention. Data was analysed by Statistical Package for the Social Sciences (SPSS) v19.00. Results: Out of the 140 patients, 56 patients had positive CRP on day 7, of which only nine patients had expelled the stone at the end of two weeks (16.07%). Out of 84 negative CRP group patients, 56 showed evidence of spontaneous calculus expulsion within one week and 18 patients at the end of two weeks and 10 patients did not demonstrate spontaneous expulsion at the end of two weeks and required intervention. The present study showed a statistically significant correlation between the positive CRP levels and the rates of spontaneous expulsion of ureteric calculus (p=0.0001). Conclusion: CRP can be used as a predictor for an early intervention of symptomatic ureteric calculus.

Role of Magnetic Resonance Spectroscopy in the Evaluation of Ring Enhancing Lesions of the Brain

D Rajasree, T Lokesh Kumar, K Vijayalakshmi
Introduction: The ring enhancing lesions of the brain are a challenging group of lesions with the variable possibilities of diagnosis under conventional Magnetic Resonance Imaging (MRI). Employing advanced techniques such as Magnetic Resonance Spectroscopy (MRS) could increase the success rates of the diagnosis. Aim: To assess the role of MRS in evaluating varying ring enhancing lesions of the brain. Materials and Methods: This prospective observational study involved 50 patients aged between 3-82 years who were detected with ring enhancing lesions of the brain on contrast MR studies. The patients underwent MRS evaluation. Categorical data was represented as frequency (%). The metabolite peaks of choline, lipid, lactate, N-Acetyl Aspartate (NAA), succinate and amino acids were recorded. The choline/creatine ratio was calculated and associated with the type of lesion the patients exhibited. Results: Among the 50 patients screened, the most prevalent pathologies were tuberculoma (36%) and neurocysticercosis (22%). While the patients diagnosed with tuberculoma presented with higher peak level of lipids and choline/creatine ratio of >1-2. Increased lactate, succinate, choline peak concomitant with no or insignificant lipid peak, were noted in the cases of neurocysticercosis. Primary brain tumour showed high choline peaks and elevated choline/creatine ratio (>2). Metastasis showed increased choline peak. Cerebral abscess showed increased amino acids and lactate peak. Conclusion: The diagnosis of varying ring enhancing lesions of the brain was accurately investigated by MRS. This accuracy enables delineating a treatment plan void of any dilemma.

Study of Autoantibodies and DQ Antigens in Patient with Celiac Disease
Introduction: Celiac Disease (CD) is a chronic autoimmune mediated disorder triggered by the ingestion of gluten. It is seen in genetically predisposed person and results in small intestine injury. Its aetiopathogenesis is not clear. Simple histopathology is not able to diagnose the disease many times. Aim: Aim of present study was to assess the prevalence of HLADQ alleles and autoantibodies in diagnosis of the disease and association of DQ antigens with T1DM and autoimmune hypothyroidism in CD patients. Materials and Methods: Total 100 cases of CD and 31 healthy controls were studied, within a period of 2015-2016. Autoantibodies like ANA, anti-Ttg, anti TPO and anti-scl 70 were done by ELISA kits. HLADQ typing was done in 44 cases of CD, 20 cases of CD with T1DM, 22 cases of CD with autoimmune thyroid disease and 31 healthy controls. HLADQ typing was done by SSO hybridisation method by Mr. SPOT machine. Results: About 70% patients were children between 6 months to 20 years of age and female formed the maximum number of cases (60%). Anti-Ttg ab was positive in all cases (100%), anti-Scl 70 Ab was positive in 25%, anti-TPO ab was found in 22% and ANA was positive in only 10% cases. Most frequent DQβ1 haplotype in CD were DQβ1*02:01 (45.5%, p=0.000) and DQβ1*02:02 (20.5%, p=0.007) while DQ*06:01 was significantly more common in controls suggesting its protective role. Among DQα1 typing DQα1*05:01 (45.5%, p=0.000) and DQα1*05:05 (40.9%, p=0.000) which were significantly more in CD than controls. Contrary to this DQα1*01:01, DQα1*01:03 and DQα1*01:04 were significantly reduced in CD patients. CD patients associated with TIDM and autoimmune thyroid disease had significantly more DQβ1 02:01, DQβ1*02:02, DQα1*05:01 and DQα1*05:05. Conclusion: Thus this study concludes that CD is an autoimmune disease. DQ typing should be kept in diagnostic criteria of CD. Association of autoimmune thyroid diseases and TIDM in CD is due to common sharing of these DQ antigens suggesting its role in predisposing autoimmune diseases.

Prevalence of Para-Aortic Lymphadenopathy in Locally Advanced Cervical Cancer using Computed Tomography: A Retrospective Study

Garba Haruna Yunusa, Usman Malami Aliyu
Introduction: Determination of status of Para-Aortic Lymph Node (PALN) in patients with cervical cancer is one of the most important factors guiding the treatment. It is essential in determining individualised therapy and prognosis. Aim: To assess the prevalence of para-aortic lymphadenopathy among patients with advanced cervical carcinoma referred for radiotherapy. Materials and Methods: A retrospective study of patients referred to Radiotherapy and Oncology Department of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria was carried out. Patient demographics, history of co-morbid conditions, histology, stage at diagnosis, and Computed Tomographic (CT) scan findings of enlarged PALN greater or equal to 10 mm in short axis diameter were retrieved. Data was analysed using IBM SPSS statistics version 23. Results: A total of 220 patients, age range 27-84 years with mean age 49.95±11.96 years were studied. The histological diagnosis were squamous cell carcinoma in 182 (87.2%), adenocarcinoma in 22 (10%), clear cell carcinoma in 9 (4.1%) while 7 (3.2%) patients had other histological variants. Co-morbities found were chronic cervicitis and HIV in 27 (12.3%) and 19 (8.6%) of the patients, respectively. CT prevalence of PALN was 23 (10.5%). The prevalence of PALN according to International Federation of Gynaecology and Obstetrics (FIGO) stage were 4.3%, 17.4%, 34.8%, 30.4% and 13.0% in stages IIB, IIIA, IIIB, IVA and IVB, respectively. Clinical stage determined based on physical examination and imaging findings, was shown to be related to PALN by univariate analysis (χ² =29.162, p=0.0001). Conclusion: This study found a 10.5% prevalence of paraaortic lymphadenopathy and a significant relationship between clinical stage and PALN. This should be taken into consideration during treatment planning for patients with advanced cervical carcinoma.

Association of Anti-TPO Antibodies with Insulin Resistance in Patients of Hypothyroidism with Metabolic Syndrome: A Cross-sectional Study

Amit Jain, Sagar Dholariya, Mirza Masroor, P Lali, L Chandra, Dinesh Dhanwal
Introduction: Hypothyroidism and Metabolic Syndrome (MetS) are associated with insulin resistance. Exact reason for development of insulin resistance in hypothyroidism is still unclear. Aim: To determine the association between Anti-Thyroid Peroxidase Antibodies (Anti-TPO Abs) and Thyroid Stimulating Hormone (TSH) with components of MetS, Fasting Insulin (FSI) and Homeostatic Model Assessment Index for Insulin Resistance (HOMA-IR). Materials and Methods: Total 118 subjects of hypothyroidism were included in this cross-sectional study. The diagnosis of MetS was made based on National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. Independent association of components of MetS, FSI and HOMA-IR with TSH and anti-TPO Abs was analysed by multivariate linear regression analysis. Results: MetS was more prevalent in subclinical hyperthyroidism (53.0%) compared to overt hypothyroidism (49.3%). Serum anti-TPO Abs level was significantly high in MetS group compared to non-MetS group in both overt (200.0±170.2 and 122.8±98.9, p=0.02*) and subclinical (184.9±142.9 and 114.5±90.9, p=0.04*) hyperthyroidism. Waist Circumference (WC), Fasting Plasma Glucose (FPG), FSI and HOMA-IR were independently associated with anti-TPO Abs in both overt and subclinical hypothyroidism. Anti-TPO was also increased significantly in linear trend along with increased in the number of MetS components in both overt and subclinical hypothyroidism. Conclusion: MetS is highly prevalent in hypothyroidism and anti-TPO Abs rather than TSH and is more associated with insulin resistance in patients of hypothyroidism with MetS.

Comparison between Intra-abdominal and Extra-abdominal Repair of the Uterus with Relation to Intraoperative Haemodynamic Changes in Patients Undergoing LSCS under Spinal Anaesthesia: A Cohort Study

Arati Rai, Meyong Pincho Bhutia, Anup Pradhan
Introduction: Exteriorisation of the uterus during caesarean section offers the benefit of faster repair of uterine incision, reduced blood loss and shorter Duration of Surgery (DOS). However, this technique has been associated with haemodynamic disturbances in the intraoperative period particularly while repositioning the uterus into the abdominal cavity after repairing it. This could prove detrimental for the patient, if not corrected promptly. Aim: To assess whether exteriorisation of the uterus for the repair of uterine incision has an effect on the haemodynamic changes and comparing the same with the intra-abdominal repair technique of uterine incision. Materials and Methods: ASA I and II pregnant females undergoing elective/emergency caesarean section under spinal anaesthesia for various obstetric indications were enrolled in this cohort study. The duration of study was 6 months after getting approval from IEC (September 2019 to February 2020). As per the discretion of the operating surgeon, the uterus of the patients undergoing caesarean section was repaired either intra-abdominally (Group I) or after exteriorisation of the uterus (Group E) and the patients were grouped accordingly. Haemodynamic monitoring was done every 5 minutes after giving spinal anaesthesia until the completion of the caesarean section using a standard automated multi-parameter monitor. Data was recorded and the two groups were compared with regard to the haemodynamic changes during intraoperative period, DOS, the incidence of any adverse events namely nausea and vomiting and Time To First Rescue Analgesia (TTFRA) in the postoperative period. Unpaired t-test was used to compare and analyse the data between the two groups, where ever applicable. A p-value of less than 0.05 was considered statistically significant. Chi-square test was used for qualitative data analysis. Results: Analysis of data between the two groups showed a significant fall in Systolic and Diastolic Blood Pressure (SBP and DBP) in Group E compared to Group I at 10 minutes [p=0.046 (SBP) and p=0.039 (DBP)], 30 minutes [p=0.047 (SBP) and p=0.002 (DBP)] and 35 minutes [p=0.046 (SBP) and p=0.006 (DBP)] time interval after giving spinal anaesthesia which was attributed to uterine exteriorisation to repair the uterine incision in Group E. The incidence of nausea, hypotension and pelvic discomfort was also significantly higher in Group E compared to Group I. Owing to less uterine handling, patients in Group I secured analgesia for a significantly longer time (TTFRA=244 min) in the postoperative period compared to patients in Group E (TTFRA=217 min) (p≤0.001). Conclusion: Extra-abdominal repair of the uterine incision carries the risk of haemodynamic disturbances associated with nausea and vomiting.

Dengue and Chikungunya Mono and Co-infections among Patients with Acute Febrile Illness

Swati Gupta, Sachee Agrawal, Jayanthi Shastri
Introduction: Dengue and Chikungunya fever are arboviral diseases which are spread by a common vector. Being clinically indistinguishable, it is necessary to distinguish both either by molecular or serology testing. Aim: To estimate the seroprevalence of Dengue and Chikungunya mono-infection as well as dual infection in patients with acute febrile illness. Materials and Methods: Two hundred patients with acute febrile illness were enrolled from April 2015 to October 2016. Detailed clinical history was documented. Samples were collected and subjected to Polymerase Chain Reaction (PCR) and Enzyme Linked Immuno Sorbent Assay (ELISA) testing. For qualitative data, frequency percentage table was used and association was done using Chi-square test. Results: Out of 200 patients, 8.5% had Chikungunya monoinfection and 41.5% patients had Dengue mono-infection. Dengue and Chikungunya co-infection was found in 4.5% patients. Most affected age group was 18-60 years wherein male preponderance was seen. In Chikungunya fever, 82.4% had morning stiffness and 35.3% had joint swelling; elbow and knee were the most commonly affected joints. In Chikungunya fever, 76.5% patients had restricted joint movements and 52.9% had Visual Analog Score (VAS) of 6-10. In Dengue fever, myalgia (67.5%) and rash (20.5%) were common symptoms. A total of 61.4% patients of Dengue fever had low platelet count. All Chikungunya cases and 88.1% Dengue cases detected by PCR had fever duration of less than five days. 85% of Chikungunya and 69% of Dengue cases detected by IgM ELISA had fever duration of more than five days. Conclusion: Diagnostic algorithms of acute febrile illness cases should include testing by both molecular and serology for both the viruses, which is the absolute need of the hour.

Aromatase Gene Polymorphism (rs2470152) in Polycystic Ovary Syndrome Patients of Eastern Uttar Pradesh

Kusum Kusum, Sandeep Patel, Radha Chaube, Ashish Ashish, Sangeeta Rai
Introduction: Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder occurring in fertile age women. Its prevalence is increasing and varies day by day in the present population depending on the diagnostic criteria. The diagnostic features of PCOS are known at least but the causative factors which directly or indirectly play a part in it are yet not known. Few studies have demonstrated that aromatase gene with many factors (hormonal, environmental etc.,) may play a role together for the causes of PCOS. Aim: The purpose of this study was to characterise the salient features, frequency of PCOS in Eastern Uttar Pradesh population and aromatase gene polymorphism (rs2470152) analysis with Glyceraldehyde 3-Phosphate Dehydrogenase (GAPDH) as reference gene. Materials and Methods: It was a pilot study where participants were recruited from SS Hospital, BHU between January 2018- 2019. Participants completed a questionnaire with proforma and had to undergo physical examination before inclusion in the study. Single Nucleotide Polymorphisms (SNP) analysis was done for aromatase gene by PCR-RFLP. Allele and genotype distribution among groups were evaluated using the chi-square test or Fisher’s-Exact test. Two-tailed p-values less than 0.05 were considered statistically significant. Results: The data indicated that the prevalence of PCOS was high in reproductive age group and hormone profiles differ in different participants, with features of PCOS. With this it was found that aromatase gene was expressed in both control and PCOS patients, but the aromatase gene polymorphism was not significantly related to PCOS. Conclusion: PCOS was increasingly high in reproductive women of eastern Uttar Pradesh population. Its diagnostic criteria have many parameters that differ from individual to individual. The aromatase gene polymorphism is not found significantly associated with PCOS in the Eastern Uttar Pradesh population.

Evaluation of Knowledge, Psychological, Social and Economic Aspects of Covid-19 Pandemic among Dental Professionals- A Cross-sectional Study

Maya Ramesh, Ramesh Krishnan, Sabarinathan Jaganathan
Introduction: Medical as well as dental professionals are always at an increased risk of contracting infections in pandemics. The novel Coronavirus (nCoV), the causative agent of the COVID-19 pandemic is more contagious than other known members of Coronaviridae family. Aim: This research aims to evaluate the knowledge, psychological, social, and economic aspects of COVID-19 pandemic among dental professionals using a closed-ended questionnaire study. Materials and Methods: A cross sectional study with close ended questionnaire was planned. The questionnaire form was prepared in the Google platform after receiving ethical clearance, with 39 questions under the headings of General Information, Knowledge, Psychological aspects, and Social and Economic aspects. The questionnaire link was circulated among dental professionals known to the research team through Email, WhatsApp, and Messenger. A total of 504 dental professionals participated in this study in five days. Knowledge score was calculated, and psychological stress was calculated using Likert scale. Economic aspect was measured using yes/no answers. Data were entered in an excel sheet and the data obtained were statistically analysed using the SPSS software, version 11.5. Chi-square test was done to evaluate whether there is an association between knowledge score and demographic factors and p-value was obtained. Results: There was almost equal gender distribution of respondents in the study. p-value obtained from chi-square test results correlating knowledge score with various demographic factors was not significant. A 59.9% of study participants were poorly informed on methods used to diagnose COVID-19 infection. A 44.4% of the respondents were psychologically stressed about infecting their family members and 72.22% were economically affected because of their profession. A 98.61% of the participants reported that they will wash their hands frequently, avoid crowded places and cancel travel plans in the near future. Conclusion: The present study evaluated the knowledge, psychological, social and economic aspects of COVID-19 pandemic among dental professionals. We identified that there is an urgent need to intensify the knowledge on COVID-19 and also to give psychological, social and economic support to dental professionals.

Effect of Haemodialysis on QTc in Newly Diagnosed Chronic Kidney Disease Patients
Introduction: Cardiovascular disease and mortality is twice as common in patients with Chronic Kidney Disease (CKD) compared to the general population. The QT interval which depicts ventricular repolarisation, is a crude non-invasive marker of susceptibility to ventricular arrhythmias. Effects of haemodialysis on corrected QT (QTc) interval in newly diagnosed CKD patients is undocumented till date. Aim: To assess the effect of haemodialysis on QTc in patients with newly diagnosed CKD. Materials and Methods: This was a prospective cohort study of 50 newly diagnosed CKD patients admitted for their first session of haemodialysis in the Departments of General Medicine and Nephrology, at Bapuji Hospital between October and November 2019. ECGs were recorded before the first and after the third session of haemodialysis. Serum electrolytes (sodium, potassium, chloride, phosphorous and calcium), blood sugar and haemoglobin levels before haemodialysis were recorded. QT interval was calculated and corrected using Bazett’s and Framingham’s methods. Descriptive statistics, simple and multiple linear regression were used for analysis using Microsoft® Excel. Results: The mean predialysis QTc was 0.434 seconds and postdialysis QTc was 0.477 seconds. QTc prolongation was observed in 44 (88%) patients (mean=0.042 seconds). The QTc prolongation correlated positively with postdialysis QTc (p=0.00001, Framingham; p=0.0009, Bazett) (R_Bazett=0.61 and R_Framingham=0.74). Conclusion: Substantial QTc prolongation after three sessions of haemodialysis screens a population that has a greater risk of adverse cardiovascular events. This warrants vigilant cardiac monitoring in patients on haemodialysis.

Effects of Low Dose Dexmedetomidine Infusion on Intraoperative Haemodynamic Stress Response in Patients Undergoing Oral Oncological Surgeries: A Randomised Control Study

Gifty Susan Philip, GS Shashidhar, Namrata Ranganath
Introduction: Maintaining stable haemodynamics throughout oral and maxillofacial surgeries helps to decrease intraoperative bleeding and thus improves the surgical field avoiding unnecessary damage to vital structures and tissues. Dexmedetomidine improves haemodynamic stability when used as an adjuvant during general anaesthesia. Limited studies have been done using low dose of dexmedetomidine for the attenuation of haemodynamic stability perioperatively in oral oncological surgeries. Aim: To study the effect of two doses of dexmedetomidine, 0.4 mcg/kg/hr, 0.2 mcg/kg/hr and normal saline (0.9%) on haemodynamic stress response in patients undergoing elective oral oncological surgeries. Materials and Methods: The present study was a randomised control study. After institutional Ethical Committee clearance, one twenty patients of American Society of Anaesthesiologists (ASA) physical grades I and II aged between 18-65 years, undergoing elective oral oncological surgeries under general anaesthesia were enrolled. Patients were randomly assigned to 3 groups with 40 patients in each group. Group A received dexmedetomidine 0.4 mcg/kg/hr, Group B received dexmedetomidine 0.2 mcg/kg/ hr and Group C received normal saline. The infusion was initiated 15 minutes prior to pre-oxygenation and continued intraoperatively till the beginning of skin closure. Parameters noted were Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP) and Mean Arterial Pressures (MAP). Any adverse effects during the observation period were also noted. Statistical tests done were analysis of variance (ANOVA), Post-Hoc Tukey's test, Chi-square, Nonparametric setting for Qualitative data analysis. Results: Intravenous (lV) dexmedetomidine 0.4 mcg/kg/ hr effectively attenuated haemodynamic stress response to intubation and surgical stimuli throughout the observation period compared to 0.2 mcg/kg/hr and saline, being statistically significant (p<0.05). No significant side effects were noted. Conclusion: Inj. dexmedetomidine 0.4 mcg/kg/hr IV is the minimum effective dose required to attenuate the haemodynamic stress response to both intubation and surgical stimulus intraoperatively in patients undergoing oral oncological surgeries.

Does PCR Cycle Threshold for SARS-CoV-2 have Association with ABO Blood Group Types?
Introduction: Corona Virus Disease-19 (COVID-19) caused by the Severe Acute Respiratory Syndrome-Corona Virus-2 (SARSCoV-2) has led to a global pandemic. Currently, the standard method for the diagnosis of COVID-19 is the detection of SARSCoV-2 by Reverse Transcriptase Quantitative Polymerase Chain Reaction (RT-qPCR). Lower Cycle threshold (Ct) value of PCR is found to be associated with increased probability of progression to severe disease and infectivity. Blood group A individuals have been found to be more susceptible to infection by SARS-CoV-2 while that of O blood group have lower risk of infection. There has been growing scientific interest to obtain data which may characterise the susceptibility to COVID-19 infection and determine the risk factors which may be associated with progression and severity of the disease. Aim: To study the association of RT-qPCR Ct values for SARSCoV-2 with ABO blood group types. Materials and Methods: A prospective observational study was conducted at tertiary care centre in western Maharashtra, India where in a total of 116 symptomatic admitted patients between mid-July to mid-August 2020 and was found to be positive for SARS-CoV-2 by RT-qPCR were enrolled in the study. Ct values for pan-Sarbecovirus E-gene and SARSCoV-2 specific RdRP gene were recorded for each patient. In addition, all the patients were typed for ABO blood grouping. Distribution of different ABO blood group types in SARS-CoV-2 positive patients were analysed and was compared with blood groups in 882 non-COVID-19 blood donors comprising control group. Ct values for E and RdRP gene were also analysed in respect to different age group, gender and blood group types. Blood group records of voluntary healthy blood donors reporting at our centre between September to November 2019 were obtained. Results: Of the 116 patients, 33 (28.45%) comprised of type A, 34 (29.31%) of type B, 41 (35.34%) were of type O and remaining 8 (6.90%) had AB blood group type. Compared to the control group, no significant difference was noted in the distribution of ABO blood types in SARS-CoV-2 positive patients. Also, no statistical significance was found in the Ct values with respect to age, gender and different ABO blood group types. Conclusion: RT-qPCR Ct values for SARS-CoV-2 infection have no association with ABO blood group types.

Public Knowledge and Awareness Regarding the Use of Dental Implants for Replacing Missing Teeth: A Questionnaire-based Survey in Riyadh, Saudi Arabia
Introduction: In recent years, dental implants have become a viable option for replacement of missing teeth in completely or partially edentulous patients. However, due to inadequate knowledge or information many patients do not prefer implant therapy. Aim: The main study objective was to evaluate the knowledge and awareness regarding dental implants as an option of treatment among dental patients according to their level of education in Riyadh, Saudi Arabia. Materials and Methods: The knowledge and awareness of patients regarding the use of dental implants for substituting missing teeth were assessed with the help of a cross-sectional study from January 2018 to June 2018 utilising standardised self-explanatory questionnaire that were circulated at two places in Riyadh: dental patients visiting the college of dentistry, King Saud University and outpatients visiting King Khalid University Hospital. Patients were provided with the questionnaires during their routine visits to the dental clinics. A total of 1471 subjects participated in this study. Chi-square test was performed to find association between education level of study subjects and their knowledge on various aspects of dental implants, and a p-value <0.05 was considered as statistically significant. The statistical analysis was performed using IBM’s Statistical Package for Social Sciences (SPSS) software, version 20. Results: This study results revealed that 67% of the patients were aware regarding the dental implants and 467 (31.7%) hadn’t heard of dental implants. Among the participants who were aware of dental implants, 555 (37.7%) had college level education and this association was statistically significant (χ²=64.18; p<0.001**). The main information source regarding dental implants was dentists and friends. There was a significant association between source of information and education (χ²=122.53; p<0.001**). Among the subjects, 386 (26.2%) subjects were aware that oral surgeons are the most qualified to place dental implants followed by periodontist-314 (21.3%) and Prosthodontist-174 (11.8%). High expenses (53%) and fear of surgery (21%) was the main reasons for not availing implants among the study subjects. Our data depicted that deficits in knowledge are distributed widely across education. Conclusion: We found a significant education level influenced knowledge deficit in almost all the aspects of dental implants. There is a need for awareness programmes from dental care experts and specialists to raise the knowledge and awareness level of the public regarding the use of dental implant as a replacement option for missing tooth.

Effect of Hydroxyethyl Starch on Blood Sugar Levels in Surgeries under Subarachnoid Block: A Cross-sectional Study
Introduction: Ringer’s Lactate (RL), a crystalloid is the most common co-loading fluid used to limit haemodynamic complications following the Subarachnoid Block (SAB). Colloids like Hydroxyethyl Starches (HES) are occasionally used as the co-loading fluid despite controversies due to its better haemodynamic effect and are not written-off to date. So knowledge of the effect of co-loading fluid is of paramount importance if it contributes to hyperglycaemia, a detrimental factor for the outcome. Aim: To compare the Blood Sugar Levels (BSL) in different preparations of HES and to that of RL when administered as co-loading fluid following SAB. Materials and Methods: Eighty-nine patients were randomly allocated into three groups, namely HES 200, HES 130, and RL, and were co-loaded with either 20 mL/kg body weight of HES 200/0.5, 20 mL/kg body weight of HES 130/0.4 or 20 mL/kg body weight of RL respectively. BSL for each subject was recorded at 0, 15, 30, 45, 60, 120, 180, 240 min (post-hoc analysis was done with Tukey’s test). Results: In all the three groups, there was a statistically significant rise in BSL from baseline. The BSL in the RL group reached its peak at 45 minutes and gradually dropped down to baseline. BSL increased more gradually with HES 130/0.4 reaching a peak value at 60 minutes, and at around 240 minutes for HES 200/0.5. Conclusion: HES causes an increase in BSL, though within physiological limits.

Incidence and Clinical Profile of Antituberculosis Treatment-Induced Hepatitis in a Tertiary Care Hospital in Southern India

TP Jai Juganya, PL Alagammai, TP Jei Karthykayani
Introduction: Tuberculosis (TB) is a major health problem. After the widespread use of Antituberculosis Treatment (ATT) effective control has been achieved. As with any drug ATT has its own side effects among which hepatitis is of main concern as it can cause significant morbidity and mortality. Aim: To assess the incidence of hepatitis in patients receiving ATT as per Revised National Tuberculosis Control Programme (RNTCP) and to know the possible risk factors for the development of drug-induced hepatotoxicity. Materials and Methods: This study was done on 318 presumed and confirmed cases of TB patients with baseline bilirubin, liver enzymes (transaminases) and albumin values. Out of these 48 lost follow-up and remaining 270 were followed-up and repeat bilirubin, liver enzymes and albumin were done at two weeks or even earlier in patients with symptoms after starting ATT. ATT was reintroduced in a stepwise manner as per American Thoracic Society guidelines. Results were analysed using MS Excel. Results: Out of the 270 cases, 30 (11.1%) developed ATTinduced hepatitis, among which 26 (86.67%) were followedup and 4 (13.33%) lost to follow-up. Among 26, 3 (11.53%) developed hepatitis after reintroduction of ATT, two patients with Rifampicin and one with Isoniazid (INH) hence they were treated with alternative regimen and cured. According to this study, CNS tuberculosis had higher incidence of ATT-induced hepatitis. Old age and alcoholism were the independent risk factors. ATTinduced hepatitis commonly developed within two weeks of start of treatment. Average time for resolution of symptoms and restart of ATT was one month. There was no mortality in the study. Conclusion: The incidence was comparable to other studies. Alcoholism, old age and CNS tuberculosis needs caution when starting ATT. Patients usually require follow-up of two weeks after starting ATT. Caution is required while reintroducing ATT and it is advisable to introduce in a stepwise manner.

The Gray Never Married: An Integrative Review

Arya Hamedanchi, Hamid Reza Khankeh, Yadollah Abolfathi Momtaz, Nasibeh Zanjari
Introduction: The increasing marriage age in societies can have many consequences, one of which is the emerging phenomenon of singlehood in older age. Meanwhile, most of the available studies on the never married older adults; have only focused on a limited area of their life and many of the results are not consistent. Aim: To classify the results of various studies on the characteristics of never married older adults and to identify the gaps in the literature with a holistic approach. Materials and Methods: An integrative review method was utilised for gathering and analysing data from February 2019 to August 2019. A total of 1007 articles were extracted by searching PubMed, Scopus, Web of Science, ProQuest and other available records. Based on inclusion and exclusion criteria, ultimately 40 related articles (published between 1975 and 2019), were selected and analysed. The extracted findings were coded and classified into the sub and main categories. Results: In the analysis step, 33 of the extracted articles had a quantitative approach and only seven of them had used qualitative or mixed methods. The relevant results in the articles were coded and clustered in 11 subcategories and three main categories of “as well as others”, “singleness as a premium” and “downsides”. These clusters illustrate the advantages and disadvantages of being single in later life as reported in the reviewed studies. Conclusion: The study discusses consistent as well as contradictory results. Most studies on the never married older adult are quantitative and have been conducted in developed countries. The controversial and unknown perspectives should be explored in further researches, using different approaches.

Effectiveness of Mulligans Mobilisation with Movement on Shoulder Dysfunction: A Systematic Review

V Meena, Jibu George Varghese
Introduction: Shoulder dysfunction is common musculoskeletal disorder. This is due to repeated wear and tear of structures around the shoulder joint causing the malpositioning of shoulder. The Mulligan Mobilisation with Movement (MWM) has shown good results in treating the shoulder dysfunction. Aim: To systemically review the available literature of MWM is effective in improving pain, Range Of Motion (ROM) and functioning in patients with shoulder dysfunction. Materials and Methods: Five electronic databases like MEDLINE, PUBMED, Cochrane (CENTRAL), PEDro, and Google Scholar were searched up from March 2019 to September 2019 for randomised control trails of MWM in shoulder dysfunction subjects. The key words used were mobilisation with movement, mulligan’s mobilisation with movement, shoulder dysfunction. Eligibility criteria were Randomised Control Trials (RCT) with 6 out of 12 Cochrane review group of risk of bias assessment published in English language. Results: Nine out of ten studies showed significant changes in mulligan’s MWM group than the general treatment, active ROM exercises, sham’s technique, stretching’s strengthening and stabilisation exercises, end range and mid-range mobilisations, electrotherapeutic modalities and only one showed no significant difference between the two groups but improvements in the pain, ROM, strength and functioning of the subjects with shoulder dysfunction. Conclusion: On overall study of mulligan’s MWM treatment in shoulder dysfunction it has very good improvements on outcome measures such as ROM, pain, strength and functional ability. Further more studies are required for knowing the individual effects of mulligan’s MWM and its short term, long term effects.

Ileosigmoid Knotting Causing Double Lumen Acute Intestinal Obstruction and Gangrene: Review and A Case Report
Ileosigmoid Knotting is a rare cause of intestinal obstruction. It is also called as compound volvulus or double volvulus. It is caused by the wrapping of the ileum around the sigmoid colon and its mesentery or vice-versa. It is a rapidly progressive condition, leads to acute intestinal obstruction and gangrene in ileum as well as in the sigmoid colon. Early diagnosis and intervention is the key to a better outcome. Due to the rarity and unfamiliarity of this entity, diagnosis is usually made intraoperatively. Surgical removal of the gangrenous segment with either stoma formation or anastomosis is the only hope. An additional systemic search of the literature was done in PubMed, MEDLINE, ISIS, Embase, and CAS searches with the following free text keywords: ileosigmoid knotting, intestinal knotting, compound volvulus and double volvulus in English literature. Around 64 studies were identified, out of which 38 studies were selected for this article after the removal of duplicates and unrelated articles. These case series and reports were reviewed for aetiopathogenesis, presentation, diagnostic modalities, surgical interventions, and outcome. Along with this review article, there was a case report of ileosigmoid knotting in a 38-year-old male patient that presented in the surgical Emergency Department; with complaints of generalised pain and distention of abdomen for two days. Also, he had complained of not passing flatus and motion for two days. On examination, patient had generalised tenderness and bowel sounds were absent. X-ray abdomen showed dilated small and large bowel with multiple air-fluid levels. After resuscitation, an emergency exploratory laparotomy was done, and the diagnosis of ileosigmoid knotting with gangrene of both ileum and sigmoid colon was made intraoperatively. After resection of both gangrenous segment, colocolic anastomosis and double barrel ileostomy was performed. The postoperative course was uneventful, and patient was discharged on 7th postoperative day.

Effect of Transcutaneous Electrical Nerve Stimulation (TENS) on Lung Function among Covid-19 Patients- A Review Study

Nikhil Aggarwal, Nidhi Ved
Corona Virus Disease (COVID-19) is a highly contagious disease mainly affecting the respiratory system, the virus is transmitted from person-to-person through large droplets from coughing, sneezing or rhinorrhea, it remains viable for at least 24 hours on a hard surface and up to eight hours on a soft surface. If it enters into the human respiratory system, it attacks the lungs and induces serous fluid, fibrin exudates, and leads to hyaline membrane formation in the alveoli which highly affects the respiratory system. The aim of this review is to collect the present evidence on effect of Acupuncture-Transcutaneous Electrical Nerve Stimulation (Acu-TENS) on pulmonary function which can help the clinicians to do further clinical trials and recommend the usage of Modality TENS which can significantly improve lung function among COVID-19 patients. Till now, it is found that few breathing techniques improve lung function among hospitalised COVID-19 patients but yet no study has been found which shows the effect of modality like TENS on lung function among COVID-19 patients. TENS is a non-invasive and inexpensive peripheral stimulation technique that markedly improves lung function after a single session of 30-45 minutes. Hence, usage of TENS can be recommended for COVID-19 patient treatment.

Review of SARS-CoV-2 and Conjunctivitis: Ophthalmologists Be Safe

Mona P Sune, Pradeep Sune, Vishal Kalode
The COVID-19 or the Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) has become pandemic with its origin in Wuhan, city of China. Within few weeks, it became a global health threat involving more than 200 countries. Though the main route of transmission is by respiratory droplets; trans-conjunctival aerosol infection is a known mode of disease transmission. Patients with COVID-19 conjunctivitis have the transmissible virus in the tears. Close contact during ophthalmic procedures poses the risk of patient to ophthalmologist disease transmission. Conjunctivitis may be the first symptom of COVID-19. In context to this and the close proximity of an ophthalmologist and Health Care Workers (HCW) with the patient, and the nature of work, standard infection protection measures guidelines have been given by prominent healthcare societies.

Coronavirus Disease (COVID-19) Outbreak and Adaptive Immune System of the Body: A Review

Amar Deep, Suchit Swaroop, Ajay Kumar, Sumit Rungta
In December 2019, a severe disease with an unknown aetiology has appeared in a Wuhan City, Hubei province, China. Immediately, it was identified as novel Coronavirus Disease (COVID-19) that has spread globally and also called Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), and was characterised in China. As we know the presence of viruses with new genetic diversity in nature, it is unclear from where this virus has evolved and transmitted to humans at the first place. As the outbreak of COVID-19 progresses, epidemiological data is essential to guide situational awareness, and intervention strategies and also immune response in COVID-19. That’s why treatments dealing with the immune-pathology of SARS-CoV-2 infection is a major issue for focus now-a-days, while a rapid and well-coordinated immune response represent the first line of defence against the viral infection. Presently, limited data and information is available on the host innate and adaptive immune status of SARS-CoV-2 infected patients. Here, authors described that how the immune system plays the first line of defence against viral infection, and attempt to compile, accumulate and disseminate the immune response information on COVID-19 from the World Health Organisation (WHO), MEDLINE, Embase, Cochrane Library, Centers for Disease Control and Prevention COVID-19 Research Database and trials registries for the recognition in progress and finished studies, cohort, and from Randomised Controlled Trials (RCTs).

Can Intricate Modus Operandi of Interferons in Viral Diseases Bring Real Hope in COVID-19 Pandemic Situation?

Samarpita Mukherjee, Ushasi Banerjee, Shubhrajit Saha
Interferons (IFN), a family of naturally occurring proteins, are secreted mainly from White Blood Cells (WBC), Natural killer cells, fibroblasts and epithelial cells. They are the primary modulator of response of the immune system to viruses, bacteria, cancer and other foreign substances that invade the body. Three types of IFNs have been identified till date and commercially available now by recombinant DNA technology. Type 1 IFN especially IFN-ß has already successfully passed the clinical trial against Middle East Respiratory Syndrome related Corona Virus (MERS-CoV) and also being tried in “Solidarity clinical trial for COVID-19 treatments” announced by World Health Organisation (WHO) in March, 2020. Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) emerged from China in December, 2019. It has rapidly spread out all over the world and become pandemic now. It has infected more than eight million and killing around four lac people worldwide up to June 17, 2020. Elderly persons and people with comorbidities like diabetes, chronic lung diseases, cardiovascular diseases and immune compromised states are the primary victim of this deadly virus. In this regard, we are trying to evaluate the potential benefits of type 1 IFN as a promising and safer treatment modality as well as specific prognostic marker when there are no specific and established vaccines, drugs or prognostic biomarkers available yet against SARS-CoV-2. We can hypothesise that thorough evaluation of these molecules against COVID-19 may open-up a new opportunity to successfully combat this evil.

Oral Health-Related Quality of Life Outcomes for Individuals with Disabilities: A Review

AlBandary Hassan AlJameel
Individuals with disabilities experience poor oral health status and poor access to health care services due to many barriers. This can negatively affect their well-being and Quality of Life (QoL). The important benchmark to determine the impact of oral health conditions were clinical examinations using established indices. Relying only on clinical assessments and objective measures lead to the ignorance of patients’ perspectives and subjective aspects of oral health assessments that consequently gave an incomplete picture of patients’ experiences. There are various Oral Health-Related Quality of Life (OHRQoL)tools which can determine or measure patient-reported outcomes to assess the impacts of oral diseases and/or conditions among the general population. This article aims at reviewing the commonly-reported OHRQoL measures among adults and children of the general population. OHRQoL studies conducted among individuals with disabilities, and findings of existing studies are also covered in this paper.

Intellectual Use of Personal Protective Equipment in the View of COVID-19 Global Demand Crises

Anitha Gunalan, D Sarumathi, Haritha Madigubba, Apurba Sankar Sastry
A pandemic of an intense respiratory condition brought about by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) which started first in Wuhan, China, presently known as Coronavirus Disease 2019 (COVID-19), started in December 2019 has pulled in an exceptional measure of consideration around the world. A far-reaching knowledge on the prevention strategies is rudimentary for Health Care Providers (HCPs) when trying to ensure themselves, patients, associates and the overall population from this transmission of disease. Personal Protective Equipment (PPE) - which includes masks, coverall, aprons, and other additional outfits are one of the important prevention strategy and control for all healthcare staff including attendants. Understanding the usage of PPE will help HCPs to properly utilise PPE thereby, lessening redundant expense. A convenient comprehension on ideal utilisation of PPE and executing compelling preventive measures are critical for a good control of the disease and can assist clinicians with mitigating further transmission by taking appropriate measures.

Biological Connection to the Feeling of Happiness

Josmitha Maria Dsouza, Anirban Chakraborty, Jacintha Veigas
Happiness is a psychological state, resulting from the secretion of certain chemicals by specialist cells in the brain. It is a very tricky multifaceted theory that is challenging to comprehend. Humans desire to be happy and strive for the same throughout their lives. There is nothing else that can give more pleasure than being happy. Without knowing how happiness is achieved, humans tend to slog for worldly things that are perceived to bring joy. But the fact is that the human brain is a master programmer that controls when and how one feels happy. The determinants that offer happiness are numerous like biological, cognitive, behavioural, sociocultural, etc. Amongst these the biological factors are the endogenic constituents that top the table in defining human happiness. Today, happiness is a typical problem that is being examined by several researchers. It is thus, obligatory to comprehend the biological outlook of joy and understand the quality of life. Therefore, this paper intends to reflect on the biological factors that hold happiness. The data acquired from the database search is categorised under the subheadings hormones/ neurotransmitters, genetics, and the anthropometric typology. The neurotransmitters identified to offer happiness are dopamine, oxytocin, serotonin, endocannabinoids, endorphins, epinephrine, norepinephrine, cortisol, and melatonin. These are secreted in humans and have a designated purpose in ascertaining happiness. Although there is no extensive proof available on the genetics of happiness, studies suggest that 35-50% of the joy is hereditary. Genes like Serotonin Transporter Polymorphism (5-HTTLPR) and Monoamine Oxidase (MAOA) and their role in happiness are explored through various research studies. Also, the physical features of an individual have a link to human happiness. Therefore, the existing knowledge points out that the biological factors’ role is vital in determining happiness which is undebatable.

Painful Bladder Syndrome’s Diagnostic and Therapeutic Controversies: A Review

Sulaiman Almutairi
Painful Bladder Syndrome (PBS) is a controversial disease with no consensus on its nomenclature, diagnostic criteria, or aetiology. Interstitial Cystitis (IC), PBS, chronic pelvic pain syndrome, and Hypersensitive Bladder Syndrome (HBS) are closely related clinical diseases. Hence, underdiagnosis or misdiagnosis of PBS and consequent failure of disease management may occur. This review aims to explore the established and emerging controversies regarding the epidemiology, aetiology, pathogenesis, pathophysiology, clinical presentation, diagnostic criteria, workup and management strategies of PBS. A literature search was carried out in the following electronic databases, PubMed, Scopus, Embase, Google Scholar, Directory of Open Access Journals and Cochrane electronic databases from starting of May to first week of June 2020. Keywords including Bladder Pain Syndrome (BPS), aetiology, histopathology, management and diagnosis were used to search these various databases. Accurate data on the prevalence of PBS is scarce, primarily as there is no standardised definition. Furthermore, there are there no fixed criteria for diagnosis, leading to variability in the reported prevalence of PBS in the literature. Management approaches in patients with PBS must be individualised and tailored to each case in terms of aetiology, diagnosis, and treatment.

Preventive Methods for Karate Injuries- A Review

Sajjan Pal
Sports injury is a major concern for athletes. Karate is a form of martial art that is practiced widely across the world. Injuries are inherent in karate as it is a combative sport. Therefore, there is a need of implementation of preventive strategies which play a great role in reducing the injuries. This review aimed to identify common injuries and preventive strategies for injury prevention in karate athletes. An electronic search in Google Scholar, MEDLINE, PubMed, Web of Science and Scopus was conducted by using following keywords: karate athletes, common injuries, prevention and protective equipment. Studies on injury prevention in karate athletes and studies published in English language were included in this review. Reviews and studies with free access to only abstract have been excluded. Protective equipment like mouthguards, groin guards, knuckle protection, gloves and proper padding help in prevention of injury. Strict implementation of rules and specific conditioning programs were found to be effective in injury prevention and should be encouraged for injury prevention in karate athletes. Athletes, parents and coaches should be educated regarding evolving injury prevention methods. Also, it was found that there were very few number of RCTs done in regards to preventive training programs in martial arts and karate.

Novel Coronavirus-In the light of Epidemiological Findings

Yachna Setu, Anika Sulania, Shelesh Kumar Goel
Coronavirus Disease (COVID-19) caused by SARS-CoV-2/Novel Coronavirus (nCov), a newly identified strain in 2019, with different strains (SARS-CoV-1 or SARS-CoV) coronavirus earlier had caused respiratory illnesses like Middle East Respiratory Syndrome (MERS) in 2012 and Severe Acute Respiratory Syndrome (SARS) in 2004. For COVID-19, initially virus was identified in Wuhan city of China when 27 Pneumonia cases of unknown origin were found. The number of confirmed cases was increased up to 9000 in Wuhan city and 98 people were also diagnosed positive in 18 different countries, including United States. On 30 January 2020, World Health Organisation (WHO) has declared the Coronavirus outbreak as a Public Health Emergency of International Concern (PHEIC). The case fatality rate is high (2%), as globally 376,320 deaths from 6,194,533 confirmed cases were reported and still it is increasing. This review describes about the current updates with regard to COVID-19 burden, history, transmission agent, host factors, environment, reservoir and source, routes of transmission, pathogenesis and clinical features, laboratory diagnosis and prevention and its management.

Push-Out Bond Strength of MTA as Root Canal Sealer: A Systematic Review

Manoj Chandak, Chanchal Rathi, Madhulika Chandak
Introduction: Endodontic treatment includes different phases like controlling the growth of microorganism, thorough cleaning and shaping and fluid-tight seal. Sealer plays an important role in Root Canal Treatment (RCT). Sealer fills the space between filling material and dentin. Sealer also acts as a lubricant. Sealer has ability to fill the spaces and prevent microleakege from the root canal. Mineral Trioxide Aggregate (MTA) is a calcium silicate based sealer which has high radiopacity, low solubility and good antibacterial activity. Aim: To evaluate push-out bond strength of MTA as a root canal sealer. Materials and Methods: Studies which were published in English, studies with different years of publication were included. Studies which includes bond strength of MTA as Endodontic Sealer to dentinal wall were also included. Studies used in this review were in-vitro studies and clinical trials. Studies showing tissue toxicity, biocompatibility of MTA were excluded. Also, case reports and in-vivo studies were excluded. All abstracts as well as full texts were studied. PubMed/Medline, Web of Science and Scopus were used for this study. Keywords used were “root canal sealer”, “push-out bond strength”, “MTA”. Total 18 articles were collected. But only five articles fulfilled the inclusion and exclusion criteria. So only five articles were included in this study and discussed in detail. Results: According to the results, of articles which were chosen for this study stated that MTA can be used as an endodontic sealer though it shows lesser push-out bond strength when compared with different newer sealers. Conclusion: In this systematic review, only one in-vitro study showed that Proroot MTA used as root canal sealer exhibits high push-out bond strength than other sealers like MTA Fillapex sealer and AH plus sealer. While MTA Fillapex show lesser push-out bond strength in comparison with other sealers like Proroot MTA sealer, AH plus, Endo CPM sealer. So this systematic review partially fulfills the hypothe

Medical Education in India: Current Scenario of Teaching-Learning Methods
Introduction: India struggles the concerns of poor quality of medical education, incompetent medical workforces, and insignificant research contribution to the world. Aim: Teaching-learning methods form an integral part of any curriculum hence we aim to review the application of technology in teaching-learning methods at medical institutions across the world. Materials and Methods: An online search for articles and abstracts published from 2000 to 2020 on PubMed Central, Medline, Scopus, Google scholar using the MeSH terms like medical, education, innovative teaching, three dimensional, curriculum, etc., was conducted. A total of 49 articles were shortlisted by applying inclusion and exclusion criteria. A total of 38 articles were finally selected after thorough reading and were analysed and summarised. Results: Four themes emerged from this review: understanding learner characteristics; innovative newer techniques with the incorporation of advanced technology; cast models and plastination; and future trends for medical education. The more specific findings can be further divided into: online digital learning module; flip classroom; 3D printed models; 3D virtual reality based technology; simulation techniques; real patient learning practical’s; medical student collaborative clinics; student driven undergraduate research committee; patient-family interactive programs; death and dying discussions and community-based service project. Conclusion: Amendment in the curriculum and selection of teaching-learning methods should be considered after understanding the student characteristics. Modern technology should be used rationally in teaching-learning methods thereby restricting its negative impact on the students.

Journal of clinical and diagnostic research

Periradicular Cystic Enucleation and PRF Grafting Following Apicoectomy in Trichotillomania Patient- A Case Report

Severe Pulmonary Air Leak Complicating Neonatal Resuscitation

Abrikossoff’s Tumour of Oesophagus- An Innocent Bystander or a Silent Killer?

Concurrent Occurrence of Bilateral Hypodontia and Microdontia in a Nonsyndromic Paediatric Patient: A Case Report

A Rare Case of Coexistence of Homozygous β-Thalassaemia and Glucose 6 Phosphate Dehydrogenase Deficiency

Paediatric Embryonal Tumours in Multilayered Rosettes Presenting as a Low Grade Glioma- An Unusual Case Report

Fetal Autopsy Showing Two Ventral Body Wall Defects: An Unusual Presentation

Type II Proximal Focal Femoral Deficiency in a Three-Year-Old Female: A Case Report

Marburg Denture System: Aiming to Preserve the Proprioception-A Case Report

Rare Dysplastic Gangliocytoma of Cerebellum: A Case Report

Bilateral Ovarian Mature Cystic Teratoma- A Rare Case Presentation

Solitary Cysticercosis of Temporalis Muscle: A Rare and Challenging Diagnosis

Role of Plasma Exchange in Steroid Resistant Neuromyelitis Optica with Loss of Vision

A Case of Small Cell Carcinoma of Lung Presenting as Opaque Hemithorax

Prosthetic Rehabilitation of a Patient with Severe Early Childhood Caries: A Case Report

Congenital Lacrimal Fistula in a Seven-Year-Old Female: A Rare Cause of Epiphora

Surgical Treatment of Eagle Syndrome by Intraoral Approach: A Case Report

Management of Peripartum Cardiomyopathy with Secondary Large Left Ventricular Apical Clot using Novel Oral Anticoagulants: A Case Report

Uterine Torsion Masquerading as Abruptio Placentae: Diagnosed on Laparotomy

Lumbosacral Spondylodiscitis- An Atypical Localisation of Salmonella Typhi Infection: A Case Report

Frantz's Tumour an Unusual Pancreatic Neoplasm: A Case Report

Study of Iron Profile and Effect of Oral Iron Supplementation in Patients of Attention Deficit Hyperactivity Disorder: A Case Series

Identification of Non-fermenters by Matrix Assisted Laser Desorption/Ionisation- Time of Flight Mass Spectrometry: Case Series of Achromobacter Infections

Single Centre Based Clinico-pathological Experience of Adrenal Tumours Including Some Rare Entities

Morel-Lavallée Lesions of Lower Extremity: A Case Series in a Tertiary Centre

Anecdote from Editors Desk Anecdote 8- Whom to Ask if Not the Corresponding Author!

Knowledge, Attitude and Practice of Health Science Students/Researcher on Status of Usage of Animals, 3R’s Strategy and their Alternatives for Pharmacological Studies: An Exploratory Study

Oral Stings Caused by Sperm Bags of Squid

Soil Transmitted Helminthiasis: An Interesting Scenario

Profile of Congenital Cardiovascular Anomalies among Stillborns at a Tertiary Care Hospital

Comparative Evaluation of Antimicrobial Efficacy, Depth of Penetration into Dentinal Tubules and Effect on Microhardness of Root Dentin by Sodium Hypochlorite, Neem Extract and Gau Ark as Root Canal Irrigants: An In-vitro Study

Aetiological Subclassification of Chronic Rhinosinusitis: A Retrospective Study

Subtypes of Breast Cancer in Northern India- An Immunohistomolecular Subtypes of Invasive Breast Cancer

Evaluation of Efficacy and Safety of Age-Based Intrathecal Dosing of 0.5% Hyperbaric Bupivacaine in the Paediatric Age Group

An Audit of Indications for Hysterectomy in a District Hospital, Madikeri

Thyroid Function and Anti-TPO Antibody Status among Tribal Perimenopausal Women Near Bengaluru, Karnataka, India

Prevalence of Soft Tissue Tumours in Duhok-Iraq: A Practical Immunohistochemical Approach

Prevalence of Metabolic Syndrome and Urinary Albumin to Creatinine Ratio as a Predictor of Cardiovascular Disease in Metabolic Syndrome Patients

Effects of Kinesiotaping on the Improvement of Sensorimotor Function along with Disability in Chronic Mechanical Neck Pain

Synergistic Anxiolytic Effect of Curcumin and Zinc on Acute and Chronic Models of Anxiety in Mice

IMP3 Expression in Ovarian Serous Tumours: Correlation with Epithelial-Mesenchymal Transition-Related Markers (E-Cadherin and Vimentin) and Clinicopathological Factors

Evaluation of Relation between Bizygomatic Width and Mesiodistal Dimension of Maxillary Central Incisor in Saudi Population: An In-vivo Study

Comparative Study of Stress among Depressed and Non-depressed Medical Students

Beta-lactamase Profile and Biofilm Production of Pseudomonas aeruginosa Isolated from a Tertiary Care Hospital in Kolkata, India

A Study on Variation of Blood Pressure and Associated Factors among Adolescent School Students in North 24 Parganas, West Bengal, India

Efficiency of Corticision in Accelerating Leveling and Alignment of Crowded Lower Anterior Teeth in Young Adult Patients: A Randomised Controlled Clinical Trial

Change in Trauma Patterns in Hilly Areas of Northern India during Nationwide Lockdown: A Cross-sectional Study

The Effect of Simultaneous Application of Transcutaneous Electrical Nerve Stimulation (TENS) on Specific Lumbar and Acupuncture Points on Labour Pain Relief: A Randomised Clinical Trial

Effects of Momordica Charantia Seed Extract on Dexamethasone-Induced Biochemical and Histological Abnormalities in Albino Rats

Symptomatic Omphalomesentric Duct Anomalies in Children: Analysis from a Paediatric Surgery Department Catering Primarily to the Rural Population

Prevalence of Non-autoimmune Hypothyroidism in Steroid Resistant Nephrotic Syndrome in Paediatric Age Group

Non-therapeutic Management of Adhesive Small Bowel Obstruction: A Descriptive Map of Practice Patterns among General Surgeons in Saudi Arabia

Antimicrobial Resistance Profiles and Molecular Characterisation of Vancomycin Resistance Genes in Enterococcus spp in Algeria

Perception of Undergraduate Medical Students Regarding Mentorship in Medical Education

Anastomotic Leaks after Gastrointestinal Operations- A Prospective Cohort Study

Investigating the Recovery Properties of Auditory Nerve Fibres at Different Cochlear Regions using Electrically Evoked Compound Action Potential

A Comparative Study of Cytomorphological Patterns of Lymph Node Aspirates in Paediatric and Adult Populations

Adverse Effects Associated with Urethral Catheter Placement- Patient’s Perspective

Aetiological Pattern of Vulvovaginal Infections in Asymptomatic and Symptomatic HIV Seropositive Women on Antiretroviral Therapy

Symptomatic and Incidental Meckel’s Diverticulum in Children: Our Experience and Lesson

Assessment of Effect of Low Dose Succinylcholine on Facilitating Insertion of Laryngeal Mask Airway- A Single-blind Randomised Study

Identification of Dengue Serotypes using a Single Serum Specimen Algorithm in a Tertiary Care Hospital, Alappuzha, Kerala, India

Effectiveness of Intravenous Dexmedetomidine vs. Fentanyl for Attenuation of Haemodynamic Response to Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomised Double Blind Study

Functional Diarrhoea in a Nigerian Community: Prevalence, Risk Factors and Associated Quality of Life

A Study of Indications and Outcome of Non-Invasive Ventilation in Respiratory Care Unit of a Tertiary Care Hospital in Eastern India

A Multicentric Study on the Clinical Profile, Serology, Neuroimaging and Treatment of Neurocysticercosis

Evaluation of Usefulness of Mannheim Peritonitis Index and APACHE II Score in Predicting Mortality and Morbidity in Patients with Peritonitis- A Prospective Diagnostic Test Study

Aetiology and Management of Vascular Injuries in Extremity Trauma: An Observational Study

Role of Dynamic Contrast Enhanced MRI in the Evaluation and Characterisation of Breast Lesions with Pathological Correlation

Status of Serum Calcium, Phosphorus, Magnesium and Copper in Hypothyroid Patients- A Case Control Study

Association of GCK Gene Promoter Polymorphism and their Role in its mRNA Expression among Type 2 Diabetes Mellitus Patients

Prescribing Pattern of Proton Pump Inhibitors (PPI) and Histamine Blockers in a Tertiary Care Hospital

Effect of Cigarette Smoking on Selected Antioxidant Enzymes and Oxidative Stress Biomarkers

Knowledge, Attitude and Practices regarding Diabetes Mellitus among Type 2 Diabetes Mellitus Patients in a Tertiary Care Hospital in Nortwest Rajasthan

Awareness towards COVID-19 among Medical Students: A Cross-sectional Questionnaire Based Study

Prevalence of Oral Microbial Flora during Orthodontic Space Closure: A Pilot Study

A Randomised, Double Blinded Study on Comparison of Intrathecal Morphine and Clonidine as Adjuvant for Post-caesarean Analgesia

C-Reactive Protein as a Predictor for Early Intervention in Patients with Ureteric Calculus- A Prospective Study

Role of Magnetic Resonance Spectroscopy in the Evaluation of Ring Enhancing Lesions of the Brain