Journal of clinical and diagnostic research

Congenital Midline Tongue Base Mass in An Infant: Lingual Hamartoma

Noraziana Fadzilah, Mawaddah Azman, Goh Bee See

Lingual hamartoma is a rare finding of congenital midline posterior tongue mass. The lesion may be seen as a single anomaly or maybe associated with syndrome especially the Oral Facial Digital Syndrome (OFDS). Here, we report an otherwise normal and healthy two-month-old boy with a congenital midline base of tongue mass presented with snoring and episodic vomiting since the age of 1 month. Tumour excision from the area of foramen of caecum recovered a pinkish pedunculated tumour. Histopathology examination confirmed the diagnosis of leiomyomatous lingual hamartoma. Differential diagnosis, especially for midline tongue mass and other paediatric tongue lesions are discussed. We also discuss the epidemiology, histopathologic features, treatment and prognosis of lingual hamartoma based on the literature review.

Exostosis Bursata – Multimodality Imaging Approach

Asik Ali Mohamed Ali, Praveen Sharma, Rujuta Rege, Cr Seena, Saveetha Rajesh

Osteochondromas or exostosis are common benign bone tumours, commonly arising from the metaphyseal region of long bones (femur, humerus, tibia). Osteochondroma of the scapula are rare and cause mechanical irritation leading to bursal formation. We hereby report a case of 30-year-old man who presented with painful chest wall swelling and its multimodality approach to establish the diagnosis.

Benign Pulmonary Metastasizing Leiomyoma of the Uterus

Nurettin AKA, Reyyan Iscan, Gültekin KÖSE, Isik Kaban

Benign Metastasizing Leiomyoma (BML) is a rare disease which represents with multiple leiomyomatous lesions in many tissues and organs especially in lungs. These patients have been operated for leiomyoma of the uterus. Here we report a case of a 41-year-old woman who was evaluated in a thoracic surgery hospital for dyspnea and bilateral nodules in chest roentgenogram. She had no history of neoplasm, only myomectomy history of uterine leiomyoma 10 years ago. Biopsy and histopathological examination were consistent with pulmonary leiomyoma. The patient was reffered to our clinic and we performed a total abdominal hysterectomy for her multiple uterine leiomyomas. The final diagnosis was ‘benign pulmonary metastasizing leiomyoma’. After this diagnosis, surgical castration was performed but two years later, repeat imaging showed progression in pulmonary lesions and progesterone therapy was administered to the patient. Patient has continued on this hormonal therapy to date and during the 5-years follow-up, the persisting lesions in both lungs regressed.

Superficial Acral Fibromyxoma: A Rare Entity - A Case Report

Superficial acral fibromyxoma (SAF) is a rare lesion initially described by Fetsch as a tumour with histological and immunohistochemical features located at acral sites. It is a benign slow-growing soft tissue lesion occurring in males. Patients generally look for late medical help as it is generally painless. The lesion consists of spindled and stellate-shaped cells in the myxocollagenous stroma with immunohistochemical positivity for CD34, CD99 and vimentin. Treatment is surgical excision with regular follow-up. Here we present a case of a superficial acral fibromyxoma of the left index finger which radiologically showed features of vascular anomaly on MRI. The lesion was surgically excised and histopathology revealed features suggestive of superficial fibromyxoma with positive immunohistochemistry for CD34 and negative for S-100.

Ureteral Reflux into an Ectopic Upper Moeity of a Duplex Kidney from the Bladder Neck with Distal Ureteral Pseudodiverticulum Formation

Denver Steven Pinto, Tom George, Deepali Saxena, Thara Joseph, V Ravi Hoisala

Urinary incontinence is a condition causing significant psychological trauma and affects the quality of life of the affected individual. Though common causes of urinary incontinence of non-traumatic aetiology in young adults include detrusor instability and congenital conditions like meningomyelocoele, an ectopic ureter is an important surgically correctable cause of urinary incontinence. The cause of incontinence in an ectopic ureter is insertion of the ureter distal to the internal urethral sphincter. The authors describe a case report of an ectopic ureter arising from a duplex moiety with poor renal function using multiple modalities. This highlights the utility of multiple modalities in arriving at an accurate diagnosis, with adequate clinically useful information. In this case, the formation of a pseudo-diverticulum resulted in diagnostic confusion.

Masquerading Bundle Branch Block: A Poor Prognostic Sign Revisited

Suheil Dhanse, Hashir Kareem, Tom Devasia, Mugula Sudhakar Rao

Masquerading bundle branch block is a rare but important finding on the Electrocardiogram (ECG). It is an indication of severe and diffuse conduction system disease and usually indicates poor prognosis. The precordial leads show a Right Bundle Branch Block (RBBB) pattern while the limb leads resemble a Left Bundle Branch Block (LBBB). This finding on an ECG is almost invariably associated with severe underlying heart disease. It is extremely important to be aware of this finding as it is a marker of poor cardiac outcomes. We report the case of a 68-year-old gentleman, who presented with progressive dyspnoea on exertion over three months. ECG showed a broad QRS complex with a RBBB pattern on the precordial leads and a LBBB pattern on the limb leads (suggestive of masquerading bundle branch block). A coronary angiogram revealed severe Triple Vessel Disease (TVD). The patient was scheduled for an early Coronary Artery By-Pass Grafting Surgery. However, his clinical condition deteriorated and he died while awaiting the surgery.

Acute Right Heart Failure in a Patient with Right Heart Thrombus and Pulmonary Thromboembolism

Mohammad Mostafa Ansari-Ramandi, Samaneh Ansari-Ramandi, Nasim Naderi

Right Heart Thrombus (RiHT) management is really controversial, and appropriate guidelines are not present for the management. In patients referring with RiHT and Pulmonary Embolism (PE), there are three ways of managing these patients. Out of the three, one is thrombectomy, which is with high risk taking in mind the comorbidities these patients have. The other is using thrombolytic which, in many cases is contraindicated or with high risk. The other less effective way is full anticoagulation. It is really controversial to choose between these ways of management and no clear approach is present. The case presented is a 44-year-old morbid obese male with history of dyspnea on exertion (functional Class II) and foot oedema or the last three months, who was transferred to the emergency department with respiratory distress and hypoxia. Echocardiography was done for the patient which showed moderate Right Ventricular (RV) dysfunction with severe RV enlargement and a severe Tricuspid Regurgitation (TR) with TR gradient of 70mmHg. He also had a semi-mobile large pedunculated mass in favour of a clot in his RV cavity. With the impression of PE heparin was administered to the patient and he was admitted in the coronary care unit. Pulmonary Computed Tomography (CT) angiography showed sub-segmental Pulmonary Thromboendarterectomy (PTE) in the left lung. He had negative cardiac markers and stable vital signs and so full anticoagulation was chosen for his treatment. His clinical course was uneventful and after 10 days of treatment the RV size and function improved significantly. On follow-up after a month he was doing well. Although recent Guidelines of European Society of Cardiology in management of acute PE stated that RiHT, particularly mobile, are associated with a significantly increased early mortality risk in patients with acute PE. Immediate therapy is mandatory, but optimal treatment is controversial in the absence of controlled trials. Thrombolysis and embolectomy are probably both effective while anticoagulation alone seems to be less effective.

Unexplained Persistent Hyperglycaemia in a Type I Diabetes Patient - Is Injection Site Lipohypertrophy the Cause?

Ranjana Ajit Sahasrabudhe, Tejas Yashwant Limaye, Vidya Sanjay Gokhale

Type I diabetes patients depend on insulin injections. Proper injection technique is essential for good glycaemic control. Incorrect technique can also lead to local injection site adverse effects, commonest being lipohypertrophy. Hypoglycaemia, by far the most dreaded adverse effect of insulin, receives utmost focus in management of patients on insulin. Lipohypertrophy, on the other hand, is a relatively neglected adverse effect. It is necessary for health care providers to realize that it can also have serious clinical implications. We present a case of persistent unexplained hyperglycaemia in a Type I Diabetes Mellitus (TIDM) patient with severe injection site lipohypertropy. After switching to normal unused sites, her blood sugar levels improved, along with reduction in insulin requirement. The case highlights the importance of continuous patient education and alert monitoring by health care providers.

Small Cell Carcinoma of Anal Canal - A Rare Case Report

Surag, Chandrashekar Neeralagi, Arun Prasath, Puneeth Kumar, Bharath Reddy

Anal canal malignancy is one of the dreadful conditions. Most of the anal canal malignancies are squamous cell carcinomas for which the treatment is well established and the prognosis is usually favourable. Small cell carcinoma of anal canal is a very rare condition and poorly understood, which can present as haemorrhoids in its early stages and has an aggressive course. We present a case of small cell carcinoma of anal canal who underwent Abdomino Perineal Resection (APR) and chemotherapy. He developed liver metastasis during the course of chemotherapy and succumbed to the condition 4 months later.

Angiomatous Hamartoma - A Rare Presentation

Eccrine Angiomatous Hamartoma (EAH) is a benign rare skin neoplasm characterised histologically by abnormal proliferation of sweat glands and surrounding capillaries and other dermal elements like fatty lobules and hair. It usually presents at birth or in early childhood in the form of solitary nodules mostly affecting the extremities. Here, we report a case of angiomatous hamartoma over the face which presented as a cystic swelling in preauricular region in a 55-year-old man. The late onset and a rare site for presentation of EAH prompted us to report the case. There is not even a single case of EAH arising in the “preauricular” region, reported.

Amyloidosis: The Newer Discovered ALECT2 Associated with der7q add(7)

Amrita Chakrabarti, Priyanka Samal, Joydeep Chakrabartty

Amyloidosis is characterized by pathological deposition of abnormal protein aggregates in various tissues, AL protein being the commonest. ALECT 2 is the newest protein described, having a predisposition to affect the kidneys, sometimes the liver and rarely other organs. We present a case of renal amyloid ALECT 2 due to leucocyte cell derived chemotaxin 2, a novel amyloidogenic protein. The patient presented with mild proteinuria, scattered plasma cells on bone marrow examination and altered kappa/lambda ratio with associated cytogenetic abnormality of der7q add(7). It is essential to correctly type this protein and differentiate it from AL during diagnosis for appropriate and effective clinical management.

Steroid Cell Tumour of Ovary – A Rare Case Report

Ranjeev Bhagat, Vijay Kumar Bodal, Nishit Gupta, Pooja Garg

Introduction: Provisional restoration is an analytical component of fixed prosthodontics serving as a ground plan for the design of fixed dental prosthesis. Flexural strength is critical in case of long standing fixed dental prosthesis, to appreciate success of full mouth rehabilitation cases and temporomandibular joint dysfunction therapies. Aim: The present study was to evaluate the flexural strength of different provisional restorative resins used for prosthetic rehabilitation. Materials and Methods: Forty identical samples (n=10 for each material) measuring 25mm×2mm×2mm according to ADA/ANSI specification no. 27 were fabricated using autopolymerizing Poly Methyl Methacrylate (PMMA) (Group A); heat activated PMMA (Group B); autopolymerizing Bis-GMA composite resin (Group C) and light activated Urethane Dimethacrylate Resin (UDMA) (Group D). For 14 days all these samples were stored in artificial saliva. Ten samples from each material were subjected to thermal cycling for 2500 cycles (5°C to 55°C). Later, a standard three point bending test was conducted on all the specimens with a universal testing machine at a crosshead speed of 0.75mm/min. Statistical analysis used included Kruskal-Wallis and Mann-Whitney U test. Results: The mean flexural strength of specimens confirmed higher flexural strength for Group C (102.98 Mpa) followed by Group B (91.86 Mpa), Group A (79.13 Mpa) and Group D (60.01 Mpa). There were significant differences between any two materials tested (p <0.05). Comparison between mean flexural strength values between four groups revealed significant difference between the interim materials (p <0.05). Conclusion: The greatest flexural strength was observed for Bis-GMA composite resins followed by heat cure methacrylate resins, autopolymerizing methacrylate resins and was least for light cure resins. While fabricating provisional restorations, these greater values should be considered for better outcome of the treatment.

Successful Pregnancy Outcome in an Operated Case of Lipomeningomyocele: A Rare Case

Vineet Vashistha Mishra, Sakshi Nanda, Rohina Aggarwal, Tanvir

Lipomeningomyocele is one of the types of occult spinal dysraphism associated with tethered cord syndrome, which is characterised by neurodeficit symptomatology due to stretch- induced functional disorder of the spinal cord with its caudal part attached by an in elastic tissue. There is stretching of conus medullaris and nerve roots due to disproportionate growth between vertebral column and spinal cord, resulting in various neurological deficits. Its incidence is approximately 1 in 4000 births in the USA, with a slightly higher female preponderance, although its true incidence is not known. There are very few studies on pregnancy outcome in these patients and the management dilemma in this group has prompted us to report this case.

Lymph Node Fibrosis in a Case of Primary Lymphoedema- A Report of Two Cases

Lymphoedema can be classified into primary and secondary. Primary lymphoedema arise in patients where the cause is not known. Secondary lymphoedema are those in which the lymph system has been damaged by some well recognised pathological process, such as extensive malignancy, filariasis, radiation etc. The changes may occur either in the lymph node, or in lymph vessels or both. The clinical evolution and the prognosis of the oedema in the limb involved will depend on the extension and evolution of these lesions. The degree of fibrosis and its distribution in lymph node play an important role on the prognosis, clinical course and treatment of the patient. Hence pathologist should be aware of the microscopic distribution and patterns of lymph node fibrosis in primary lymphoedema. We hereby report two cases- a 50-year-old male diabetic patient and a 35-year-old male patient presenting with varicose veins, lymphoedema showing lymph node fibrosis.

Portal Vein Thrombosis and Arterioportal Fistula in Post Liver Transplant Recipient: A Case Report

Shruti P. Gandhi, Kajal Patel, Vaibhav Sutariya, Pranjal Modi

An intrahepatic Arterioportal Fistula Refers (APF) to abnormal shunt or fistulous connection between the portal venous system and a hepatic arterial system within the liver. Here, we present a case of portal vein thrombosis with APF in post-transplant liver, developed 2 years and 6 months after transplantation. The condition was diagnosed by Triphasic CT angiography. In this case report we have discussed various causes and pathophysiology of APF with its imaging findings.

Tuberculosis of Distal Radius Presenting as Cystic Lesion in a Nine-Month-Old Infant: A Rare Case Report

Tuberculous osteomyelitis affecting long bones is a rare form of tuberculosis. Among infants born in endemic region, often it is difficult to diagnose owing to its subtle clinical features. Here, a case of tuberculous osteomyelitis affecting the distal radial metaphysis is reported, presenting as a cystic lesion in a nine-month-old male infant. Open biopsy with curettage was performed followed by filling of the cavity with synthetic bone substitute (beta tricalcium phosphate granules). The diagnosis was confirmed by histopathological examination and demonstration of acid fast bacilli. Further treatment with anti-tubercular drugs led to clinical and radiological improvement. This case report highlights the importance of keeping tuberculosis as a differential diagnosis while dealing with cases with similar presentation in an endemic region.

Adult Idiopathic Renal Vein Thrombosis Mimicking Acute Pyelonephritis

Arpan Choudhary, Prasenjit Majee, Rupesh Gupta, Supriyo Basu, Ranjit Kumar Das

Renal Vein Thrombosis (RVT) is a rarely encountered condition. It occurs due to a hypercoagulable state in the body, caused by nephrotic syndrome and membranous nephropathy in the adults. Mode of presentation is variable. In chronic form, it may remain silent for a long time and presenting later with symptoms of pedal oedema, varicocele, proteinuria. In acute state, it manifests as flank pain, nausea or haematuria. We present a case of 25-year-old male, with left sided flank pain, haematuria and nausea for 4 days. Ultrasound showed enlarged kidney with altered echogenecity. No calculus was found on x-ray. Empirical antibiotics were started considering possibility of Acute Pyelonephritis (APN). With no improvement seen after 3 days along with no growth on urine culture, CT-urography was done. It revealed enlarged non-excreting left kidney with thrombus seen over left renal vein extending into Inferior Vena Cava (IVC). Immediate anticoagulant therapy was started. Patients recovered gradually and after 6 months, follow-up CT showed disappearance of thrombosis. Anticoagulants were withdrawn gradually. So we highlight the possibility of RVT as a differential diagnosis to APN or renal colic and its evaluation and management.

Umbilical Pilonidal Sinus: A Report of Two Cases and Recent Update of Literature

Umbilical Pilonidal Sinus (UPS) is a rare differential diagnosis of umbilical disease as encountered by general surgeons. They usually present with history of pain and umbilical discharge. Young active adolescent males with dense hairy abdomen with a deep naval are at risk of developing this disease. There are no consensus guidelines for the management of this disease probably because of its rarity. Treatment depends on the type of presentation. Most of the cases are managed by conservative treatment with hair extraction and personal hygiene. Surgery is indicated in case of failure of conservative management. Although umbilectomy is a commonly done procedure, complete sinus excision with reconstruction which can be done to have better cosmesis. Incomplete hair extraction from the sinus tract has been found to be the commonest cause of failure of conservative management. In this paper we have presented two cases of UPS, managed conservatively, with no recurrence after one year of follow-up. We have also presented a recent update on current literature about this uncommon disease.

Large Dumbbell Shaped Vesicovaginal Calculus Managed with Holmium Laser Cystolithotripsy Followed by Staged Repair of Vesicovaginal Fistula

Complicated Vesicovaginal Fistulae (VVF) is prevalent in developing countries following obstetric injury. We report a rare case of a large dumbbell shaped vesicovaginal calculus measuring 7x 4.6cm in a patient with recurrent, complicated VVF managed successfully in two stages 6 weeks apart. Holmium laser (30 Watt) cystolithotripsy was used to break the vesical portion of the stone at the waist of the dumbbell, followed by delivery of vaginal part of the stone. Trans-abdominal VVF repair (O’Connor method) with omental interposition flap with right side ureteric reimplant was done after six weeks. Our case was unique because of occurrence of a larger sized fistula after a gynaecological surgery. She had developed larger stone (weight more than190gm- vaginal component) into the fistula tract. Also she had undergone multiple failed VVF repair attempts before. Use of holmium laser energy to break the stone was unique which minimized the morbidity of the first procedure leading to early recovery followed by staged repair of fistula after six weeks.

Mucocele like Tumour of the Breast Associated with Ductal Carcinoma in situ and Focal Ductal Carcinoma: What is the Best Approach to these Patients?

Serdar Altinay, Safak Ersöz, Yavuz Üye, Feyyaz Özdemir

Mucocele Like Tumours (MLT) of the breast are quite rare neoplasms displaying a broad spectrum. These lesions were considered benign initially. But now, they are believed to be related to atypical ductal hyperplasia, ductal carcinoma, or mucinous carcinoma. Preoperative diagnosis in fine needle aspiration and core biopsy is difficult. We are reporting a case of mucocele like tumour with ductal carcinoma in situ and ductal carcinoma in a 71-year-old Turkish woman. The patient had a palpable mass in her left breast. Mammograpy showed ill defined and lobulated mass with widespread tiny microcalcifications. A few cells with sporadic nuclear atypia, were detected on FNAB (Fine Needle Aspiration Biopsy). Mastectomy was done on the left side because of the suspicion of malignancy as evident by mammograpy and FNAB. We examined adequate tissue samples from resection material. Histopathologic findings were consistent with MLT and microscopic focus of ductal carcinoma was also noted in mastectomy specimen. She is currently disease-free in the 118th month. We believe that our case will be the first patient from Turkey and will be added to the database as one of the longest term follow-up MLT cases reported. If a mucocele-like tumour is suspected in fine needle biopsy, surgical excision should be recommended and the specimen should be carefully evaluated to exclude the presence of ductal carcinoma in situ or carcinoma.

Urothelial and Squamous Cell Carcinoma of Renal Pelvis – A Rare Case Report

Surekha B. Hippargi, Savitri Mallikarjun Nerune, Mayank Kumar

Primary malignant tumors of the renal pelvis are relatively rare. Urothelial carcinoma of renal pelvis accounts for 7% of all renal neoplasms, with Squamous Cell Carcinoma (SCC) forming a very small percentage of these cases. Urothelial and SCC of renal pelvis is still a rarer entity. This malignancy of the renal pelvis lacks the characteristic presentation of common renal cell carcinoma and usually presents at an advanced disease stage. We report a case of urothelial and SCC of renal pelvis in a 61-year-old male who presented with non-specific clinical complaints like dysuria and right flank pain.

Primary Renal Lymphoma - A Case Report and Review of Literature

Shraddha Shetty, Avinash Chandra Singh, Vinod Babu

Primary Renal Lymphoma (PRL) is rare and its existence has been called into question due to the absence of lymphatic tissue within renal parenchyma. Non-specific abdominal pain with mass in the lumbar region and otherwise unexplained renal failure is the most common presentation. Almost all patients eventually develop extrarenal lymphomatous disease and few patients survive beyond one year. Surgical treatment is rarely feasible as primary modality of treatment since the tumour often encases major vessels and surrounding organs necessitating major resection. Instead, an attempt can be made to downstage the tumour with chemotherapy before attempting surgery. Here we present a case of primary renal Non-Hodgkins Lymphoma (NHL) which was treated with chemotherapy but the patient succumbed to disease before the third cycle.

Rifampicin-Induced Concomitant Renal Injury and Hepatitis

Adverse drug reactions are not unusual during Anti-Tubercular Therapy (ATT). One of the common complications of anti-tubercular treatment is drug induced hepatitis and renal insufficiency has also been reported. Renal failure and/or hepatitis encountered during treatment of tuberculosis can have varied aetiologies: drug induced, concomitant viral infection, pre-existing co-morbidities or a combination of these. Since, hepatitis and/or renal insufficiency can be life threatening a prompt diagnosis is warranted, where drugs should be kept as one of the important cause. Identifying the drug helps in treating hepatitis and/or renal insufficiency along with helping the physician to change the combination of ATT regimen. Rifampicin is one of the most important first line drugs in the treatment of tuberculosis. Hepatitis, epigastric distress, anaemia, thrombocytopenia, and interstitial nephritis are reported adverse drug reactions to rifampicin. As per literature rifampicin induced renal toxicity is usually seen on rifampicin re-exposure, or rifampicin administration on alternate days, both being present in this case. Here we are reporting a case of ATT induced renal failure with concomitant hepatitis where rifampicin was suspected to be the cause.

Primary Pure Keratinising Squamous Cell Carcinoma: A Rare Malignancy with Aggressive Behaviour

Mansi Chandna, Leela Pant, Malini Garg, Garima Singh, Sompal Singh

Primary well differentiated keratinising Squamous Cell Carcinoma (SCC) is a rare gall bladder malignancy accounting for 3.3% of all gall bladder carcinomas. Here we present a case of a 70-year-old female with complaints of dyspepsia and right upper quadrant pain for 3 months. Ultrasonography showed gall stones along with thickened and irregular gall bladder wall. Grossly an exophytic growth was noted involving large part of the body of gall bladder. Histological features were of well differentiated SCC with extensive keratinisation involving full thickness of the wall. No glandular component was seen. Metastasis from other primary was ruled out after thorough work-up. SCC of gall bladder has an infiltrative growth pattern and behaves aggressively. Early diagnosis plays the most important role in increasing the survival.

Body Donation- Consent from Non-Related Persons: Case Series, Review, and Recommendations

S.S.S.N Rajasekhar, K. Aravindhan, V. Gladwin, Parkash Chand

Learning anatomy by dissection of cadavers is the best way to learn anatomy. Voluntary body donation is one of the sources of procuring cadavers. In the case of donations after hospital or non-institutional deaths, the family members of the deceased approach the hospital authorities regarding body donation of the deceased. There are situations, where there is no available accompanying near relatives of the deceased, which pose a challenge for personnel involved in the process of body donation. In two of the reported cases, the body donation was done by the live-in partner and a friend of the deceased. In another reported case, the son of the deceased was nominated by the donor at the time of registration. As the son of the deceased was not available at the time of death of the donor, donation was executed by another near relative. Anatomy Acts of individual States in the Union of India and Acts of other countries are examined about the consent for body donation by persons other than near relatives. None of the Anatomy Acts of various States in India provide an alternative in the absence of near relatives for claiming the body or for donating the body, except for Acts of Delhi and Kerala. There is a need to bring in a Unified Anatomy Act, common for all the States and Union territories in India and include: friend, live-in partner and a nominated person in the provisions of the Act to enable them to give consent for body donation.

Bilateral Vocal Cord Palsy with Arnold Chiari Malformation: A Rare Case Series

Nikhil Arora, Ruchika Juneja, Ravi Meher, Eishaan K. Bhargava

Stridor in paediatric age group is not an uncommon presentation to the ENT emergency. The range of differential diagnosis is vast. The presentation may vary from noisy breathing to severe respiratory distress and apnea. Early and meticulous diagnosis is crucial for the management as the condition may be life threatening. We report a rare case series of 3 infants with Arnold Chiari Malformation who presented to the hospital with stridor and were diagnosed with bilateral vocal cord palsy. These 3 infants had similar underlying neurological condition with hydrocephalus and raised intracranial pressure. Chiari malformation is the one of the most common congenital central nervous system anomaly associated with bilateral vocal cord paralysis. However, the presentation is rare. This article, thus, emphasizes the significance of early diagnosis and immediate management of this condition.

Antiulcer Activity of Ethanolic Extract of Salvadora indica (W.) Leaves on Albino Rats

Background: Ulcer can be developed inside the inner lining of the stomach (gastric ulcer) or the small intestine (duodenal ulcer). Both the ulcers are also cumulatively referred as peptic ulcers. It affects nearly 10% of world population. Aim: To investigate the antiulcer activity of ethanolic extract of Salvadora indica W. leaves (ESIL) on albino rats. Materials and Methods: The present study was carried by pylorus ligation, ethanol and cysteamine induced ulcer models in albino rats. The antiulcer activity of ESIL (150, 300 and 600 mg/kg p.o. for 7 days) was compared with standard drugs (Ranitidine). In pyloric ligation induced ulcer model, the studied parameters were gastric volume, pH, total acidity, free acidity, and ulcer index whereas in ethanol and cysteamine induced ulcer model, the ulcer index was determined for severity of ulcers. The parameters studied were ulcer index, gastric juice volume, pH, free acidity and total acidity. Results: In pyloric ligation model; the volume of gastric content, total/free acidity and pepsin activity was significantly decreased at p<0.05 and p<0.01 and pH of the gastric juice was significantly increased at p<0.05 and p<0.01 in ESIL treated groups as compared to control group. All the doses of ESIL showed dose dependent antiulcer effect as well as significant (p<0.05 and p<0.01) reduction in the ulcer index as compared to control group in all the experimental models. Conclusion: The results of the study indicate that the ESIL have better potential against ulcer which supports the traditional claims in folklore medicine.

Mandibular Canine with Two Roots and Two Root Canals – A Rare Case

Congenital Sideroblastic Anaemia- Classic Presentation

Abhishek Dubey, Amit Kumar Dey, Kunal Nandy, Abhinav Garg, Meet Kadakia

A Multimodal Approach is Necessary to Manage Mucormycosis in Patients with Diabetes

Devi Dayal

Change in Oxidative Stress of Normotensive Elderly Subjects Following Lifestyle Modifications

Anubhav Bhatnagar, Yogesh Tripathi, Anoop Kumar

Introduction: Oxidative stress is associated with aging, which ultimately causes deterioration of muscles. Antioxidant defense system deteriorates while enhancing accumulations of Reactive Oxygen Species (ROS) due to lipid peroxidation and altered enzyme activities in old age. Regular practice of yoga can maintain the antioxidants level of the body, even in stressful conditions. Aim: The present study was designed to assess the effects of lifestyle technique on oxidative stress and lipid profile in normotensive elderly subjects. Materials and Methods: Seventy four healthy elderly subjects (43 males and 31 females) 60 to 80 years of age were selected from the Santosh Medical College, Ghaziabad Uttar Pradesh, India, for three months lifestyle modification program which included morning walk, Nadi shodan pranayama, dietary restrictions and increased intake of water. Blood pressure and oxidative stress markers Glutathione (GSH), Super Oxide Dismutase (SOD) and Malondialdehyde (MDA) were recorded twice, one at baseline and another after three months of lifestyle modifications. Results: Post lifestyle modifications technique values revealed a significant increase in GSH (88.03±9.58 ng/ml vs 93.12±9.17 ng/ml, p < 0.0001) and SOD (78.22±11.97 ng/ml vs 85.22±11.08 ng/ml, p < 0.0001), and a decline in MDA (5.28±0.52 m mol/ml vs 4.48± 0.69 m mol/ml, p < 0.0001) levels. Further, there was significant reduction in the systolic blood pressure (p <0.0001) and diastolic blood pressure (p<0.0002); besides all fasting lipids decreased significantly except High Density Lipids (HDL). Conclusion: The findings of the present study show that lifestyle modification is helpful in reducing cardiovascular disease risk but also assuring for good health by decreasing oxidative stress level along with lipid profile. Further, all these modifications are easy to follow. However, more studies are required to make a generalized lifestyle modification program in normotensive elderly subjects.

Clinical Evaluation of Insulin like Growth Factor-I and Vascular Endothelial Growth Factor with Alloplastic Bone Graft Material in the Management of Human Two Wall Intra-Osseous Defects

Renu Devi, Jaya Dixit

Introduction: In recent years, emphasis on the use of growth factors for periodontal healing is gaining great momentum. Several growth factors showed promising results in periodontal regeneration. Aim: This study was designed to compare the clinical outcomes of 0.8µg recombinant human Vascular Endothelial Growth Factor (rh-VEGF) and 10µg recombinant human Insulin Like Growth Factor-I (rh-IGF-I) with ß-Tricalcium Phosphate (ß-TCP) and Polylactide-Polyglycolide Acid (PLGA) membrane in two wall intra-osseous defects. Materials and Methods: A total of 29 intra-osseous defects in 27 subjects were randomly divided into 3 test and 1 control group. Test group I (n=8) received rh-VEGF+ rh-IGF-I, Test group II (n=7) rh-VEGF, Test group III (n=7) rh-IGF-I and control group (n=7) with no growth factor, ß-TCP and PLGA membrane was used in all the groups. Baseline soft tissue parameters including Probing Pocket Depth (PPD), Clinical Attachment Level (CAL), and Gingival Recession (GR) at selected sites were recorded at baseline and at 6 months. Intrasurgically, intra-osseous component was calculated as a) Cemento-Enamel Junction to Bone Crest (CEJ to BC), b) Bone Crest to Base of the Defect (BC to BD) at baseline and at re-entry. The mean changes at baseline and after 6 months within each group were compared using Wilcoxon Signed Rank Test. The mean changes for each parameter between groups were compared using Mann-Whitney U test. Results: After 6 months, maximum mean PPD reduction occurred in test group I followed by test group II, III and control group. Similar trend was observed in CAL gain. Non-significant GR was present in test group I and control group whereas in test group II and III GR was absent. The use of rh-VEGF+ rhIGF-I exhibited 95.8% osseous fill as compared to 54.8% in test group II, 52.7% in test group III and 41.1 % in the control group. Conclusion: Within the limitations of this study, it can be concluded that, rh-IGF-I+rh-VEGF treated sites resulted in greater improvement in PPD reduction, CAL gain as well as in osseous fill after 6 months when compared with rh-VEGF, rh-IGF-I and control sites.

Efficacy of Aqueous and Methanolic Extracts of Rheum Spiciformis against Pathogenic Bacterial and Fungal Strains

Introduction: Rheum spiciformis is a newly identified edible medicinal plant of genus Rheum. The plant is used to treat various diseases on traditional levels in Kashmir Valley, India. Aim: To evaluate the phytochemical screening, antibacterial and antifungal potential of aqueous and methanolic extracts of Rheum spiciformis, a traditionally used edible medicinal plant. Materials and Methods: Methanolic and aqueous extracts of Rheum spiciformis were tested for their antimicrobial activities against six bacterial strains namely Bacillus subtilis, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus vulgaris and Escherichia coli and four fungal strains Penicillium chrysogenum, Aspergillus fumigatus, Candida albicans and Saccharomyces cerevisiae. The susceptibility of microbial strains to the two extracts was determined using agar well diffusion method. Phytochemical screening was carried out by using various standard procedures. Results: Methanolic extract showed potent antimicrobial activity as compared to aqueous extract at the concentrations of 10, 30, 50, 80 and 100mg/ml. The most susceptible bacterial strains were Staphylococcus aureus with zone of inhibition (25±0.10mm), Klebsiella pneumonia (23±0.25mm), Proteus vulgaris (22±0.10mm) at the concentration of 100mg/ml. Aqueous extracts at the higher concentration were found effective against Proteus vulgaris and Bacillus subtilis with zone of inhibition (17±0.24mm) and (17±0.10mm), respectively. Among fungal strains the most susceptible were Aspergillus fumigatus (21±0.10mm), Saccharomyces cerevisiae (20±0.20mm) and Penicillium Chrysogenum (17±0.15mm) at the concentration of 100mg/ml methanol extract. The zone of inhibition for aqueous extract against fungal strains ranged between 14±0.13mm to 16±0.19mm at the highest concentration of plant extract. Phytochemical analysis revealed the presence of various secondary metabolites like flavonoids, saponins, volatile oils, phenols, steroids, terpenoids and alkaloids. Conclusion: Our results indicate that this plant has enough potential to serve as an excellent candidate for obtaining antimicrobial compounds to combat bacterial and fungal infections.

Pure Titanium Membrane (Ultra – Ti®) in the Treatment of Periodontal Osseous Defects: A Split–Mouth Comparative Study

Introduction: Although many different types of Guided Tissue Regeneration (GTR) membranes (resorbable/non-resorbable, including titanium mesh) have been used in the field of Periodontics till now, but this is the first and only clinical study testing the effectiveness of an ultra thin pure Titanium Membrane (Ultra Ti) as a GTR membrane in infra-bony periodontal defects. Aim: To compare the efficacy of GTR in intra-bony defects with newly introduced non-resorbable barrier membrane, made of titanium called “Ultra-Ti ® GTR Membrane” versus open flap debridement. Materials and Methods: A prospective, randomized, controlled, clinical split mouth study was designed wherein each patient received both the control and test treatment. Two similar defects were selected in each of the 12 patients and were randomly assigned to one of the two treatments. Both the surgeries consisted of identical procedures except for the omission of the barrier membrane in the control sites. Full mouth Plaque Index (PI), Gingival Index (GI), Pocket Probing Depth (PPD) and Relative Attachment Level (RAL) were recorded before surgery and after 6 months and 9 months along with hard tissue measurements at the time of surgery and then at re-entry after 9 months. Radiographs were also taken before surgery and 9 months post operatively. Student's paired t-test and unpaired t-test (SPSS software version 9) were used to analyze the results. Results: Nine months after treatment, the test defects gained 4.375 ± 1.189mm of RAL, while the control defects yielded a significantly lower RAL gain of 3.417 ± 0.996mm. Pocket reduction was also significantly higher in the test group (4.917 ± 0.996mm) when compared with the controls (3.83 ± 0.718mm). There was a significant bone fill (54.69% of defect fill) obtained in the test site, unlike the control site (8.91%). Conclusion: The present study demonstrated that GTR with “Ultra-Ti® GTR Membrane” resulted in a significant added benefit in comparison with open flap debridement.

A Study of Assessing Errors and Completeness of Research Application Forms Submitted to Instituitional Ethics Committee (IEC) of a Tertiary Care Hospital

Pruthak C. Shah, Ashwin K Panchasara, Manish J. Barvaliya, C.B Tripathi

Introduction: Application form of research work is an essential requirement which is required to be submitted along with the research proposal to the Ethics Committee (EC). Aim: To check the completeness and to find the errors in application forms submitted to the EC of a tertiary care hospital. Materials and Methods: The application forms of research projects submitted to the Institutional Review Board (IRB), Government Medical College, Bhavnagar, Gujarat, India from January 2014 to June 2015 were analysed for completeness and errors, with respect to the following - type of study, information about study investigators, sample size, study participants, title of the studies, signatures of all investigators, regulatory approval, recruitment procedure, compensation to study participants, informed consent process, information about sponsor, declaration of conflict of interest, plans for storage and maintenance of data, patient information sheet, informed consent forms and study related documents. Results: Total 100 application forms were analysed. Among them, 98 were academic and 2 were industrial studies. Majority of academic studies were of basic science type. In 63.26% studies, type of study was not mentioned in title. Age group of subjects was not mentioned in 8.16% application forms. In 34.6% informed consent, benefits of the study were not mentioned. Signature of investigators/co-investigators/Head of the Department was missing in 3.06% cases. Conclusion: Our study recommends that the efficiency and speed of review will increase if investigator will increase vigilance regarding filling of application forms. Regular meetings will be helpful to solve the problems related to content of application forms. The uniformity in functioning of EC can be achieved if common application form for all ECs is there.

Comparison between Thoracic Epidural Block and Thoracic Paravertebral Block for Post Thoracotomy Pain Relief-ARTICLE RETRACTED

Soniya Biswas, Reetu Verma, Vinod Kumar Bhatia, Ajay Kumar Chaudhary, Girish Chandra, Ravi Prakash, Comparison between Thoracic Epidural Block and Thoracic Paravertebral Block for Post Thoracotomy Pain Relief (Published in Journal of Clinical and Diagnostic Research. 2016 Sep, 10(9): UC08-UC12) The article had to be retracted as the data has errors which could mislead the readers. This error was brought to the editorial notice, post-publication by one of the reader.

Student Project in Anatomy (SPA) – Making the First Year Medical Students Responsible and Creative

Satheesha B Nayak, Snigdha Mishra, Bincy M George, Naveen Kumar

Introduction: Creativity is a combination of ones’ capacity to think outside the box, the gained knowledge and the passion for creating something. It very easily and effectively provides the creator a chance to be responsible for his/her creation and acts as a confidence booster for him/her. Creativity is inherent, but needs to be polished and nurtured. If nurtured well through proper motivation, the creator excels leaps and bounds. It develops an empathetic behaviour in the creator, when he allows his creations to be used by others. Aim: The study was done to generate learning resources through academically good students and make them available for the entire class. Materials and Methods: Academically, top 16 students were involved in a project of their choice. The projects included preparation of question answers, powerpoint presentations, cross-word puzzles, videos, models, atlases and wall hangers etc., ten weeks were given to finish the project. The project was guided and monitored by teachers. The end product of the project was given to the entire class for use. The perception of users of the end products of the projects was recorded through mini interviews. Results: All the students who took part in the project liked working on the project. They felt motivated, rewarded and had mastery on the topic which they used in the project. The students who did not do the project but used the end product of the project also liked the project work. They felt that the end products of the projects were simple, informative and creative. Conclusion: By participating in Student Project in Anatomy (SPA), the students get to show their total potential through these creative ways. It provides a fresh and welcome change from the common routine followed otherwise in medical schools. The outcome of the projects can help the entire class. This type of projects can be easily tailored into existing curriculum and in disciplines other than anatomy too.

Efficacy and Safety of Clonidine as an Adjuvant to Bupivacaine for Caudal Analgesia in Paediatric Infra-Umbilical Surgeries

Samita Priolkar, Shirley Ann D’Souza
Introduction: Caudal analgesia, has gained popularity in paediatric intraoperative and postoperative pain management, more so with the use of adjuvants to prolong its duration, each of them having various results. Clonidine, an alpha2-adrenergic agonist is being used for its analgesic effects in various doses with 0.25% Bupivacaine. Aim: The study was conducted to compare the analgesic efficacy, haemodynamic safety and side effects of 1 µg/kg Clonidine added to 1 ml/kg of 0.125% Bupivacaine solution for caudal analgesia. Materials and Methods: A prospective, randomised, double-blind, controlled study was carried out in 60 children of ASA Physical Status I, aged 1-10 years, scheduled for infraumbilical operations in a tertiary care centre. They were randomly assigned for caudal analgesia, to either group B: 1ml/kg of 0.125% Bupivacaine solution or group BC: 1ml/kg of 0.125% Bupivacaine and preservative free Clonidine 1µ/kg. All were premedicated with midazolam 0.75 mg/kg orally 30 minutes prior to induction of anaesthesia. Heart rate (HR), Mean Arterial blood Pressure (MAP) and oxygen saturation (SpO2) were monitored. General anaesthesia was induced with thiopentone (1.25%) 5mg/kg and inhalation of oxygen, nitrous oxide and sevoflurane. Postoperative pain, sedation and motor block was assessed by the various scores and patients were monitored for adverse effects. Results: The mean duration of postoperative analgesia was 3 times longer in group BC. Group B received significantly more doses of rescue analgesic than group BC (p-value of 0.004). There was no significant bradycardia, hypotension, sedation or urinary retention in either of the groups. There was no residual motor blockade at 6 hours. Incidence of vomiting was similar in both the groups. Conclusion: Caudal Clonidine in the dose of 1 µg/kg in children is a satisfactory and efficacious adjuvant to caudal Bupivacaine for producing prolonged postoperative analgesia with minimum side effects.

Comparison of Stress Distribution in a Maxillary Central Incisor Restored with Two Prefabricated Post Systems with and without Ferrule Using Finite Element Method

Aarti Rajambigai, Arun Kumar, Sabarinathan, Ramesh Raja
Introduction: When restoring an endodontically treated tooth with deficient coronal tooth structure, posts can be used to strengthen the tooth. Recently prefabricated posts are widely used as they exclude the need for complex laboratory procedures making the procedure time saving. But the post-placement can produce stresses that cause root fracture. Different techniques can be used to study the stress distribution due to different posts, but most of them are two-dimensional and difficult to reproduce. Aim: The aim of the study was to compare the stress distribution in a maxillary central incisor with Titanium and Glass fiber posts with and without ferrule using the three dimensional finite element analysis. Materials and Methods: In this study 3D finite element analysis was used. Four models P1(Endodontically treated maxillary central incisor with a ferrule of coronal dentin and restored with parallel sided prefabricated titanium post and composite resin core), P2 (Endodontically treated maxillary central incisor restored with parallel sided prefabricated Titanium post and composite resin core without a ferrule of coronal dentin), P3 (Endodontically treated maxillary central incisor with a ferrule of coronal dentin and restored with parallel sided prefabricated glass fiber reinforced composite post and composite core), P4 (Endodontically treated maxillary central incisor restored with parallel sided prefabricated glass fiber reinforced composite post and composite core without a ferrule of coronal dentin), were modeled using PRO E software. Then stress analysis was done using ANSYS WORKBENCH 10.0software. A load of 100 N was applied to the models at 2mm from the incisal edge on the palatal surface with an angle of 45o to the long axis of the tooth. Results: The results suggested that maximum stresses were seen around posts in order of Titanium post without ferrule followed by Titanium post with ferrule next Glass fiber post without ferrule followed by Glass fiber post with ferrule. Conclusion: Stress distribution in a maxillary central incisor restored with titanium post is greater than when restored with glass fiber post. Stress distribution around posts is greater when a ferrule is not present.

Efficacy of Four Fluoride Mouth Rinses on Streptococcus mutans in High Caries Risk Children – A Randomized Controlled Trial

Shailaja Rao Perala, Prameela Bhupathiraju
Introduction: Dental caries has been traditionally described as a multifactorial disease that involves the interaction of various factors like host, agent, substrate and time. Landmark studies have established the fact that Mutans Streptococci are the primary etiologic agents of dental caries. The prevention of dental caries by fluoride supplements in various vehicles, such as water and toothpaste, constitutes one of the most successful prevention measures. Aim: The aim of the present study was to compare the clinical efficacy of four fluoride mouth rinses on Streptococcus mutans in high caries risk children and also to check the efficacy of the ingredient Triclosan which is present in two of the four mouth rinses. Materials and Methods: The study is double blinded, consisting of 1000 children in age group 6-14yrs who were screened from residential schools. Of the total, 200 children were categorized as high caries risk group based on caries risk assessment tool form given by American Association of Pediatric Dentistry (AAPD) guidelines 2011. Prior to the study, salivary samples were collected and sent for microbial analysis to estimate Streptococcus mutans counts. Out of 200 salivary samples, 132 showed 106CFU of Streptococcus mutans and these children were included in the study. The 132 children from each group received the assigned mouth wash for 14 consecutive days. On 15th day the salivary samples were collected and sent for microbial analysis and the obtained results were subjected to statistical analysis. Results: All the mouth washes showed a significant reduction in Colony Forming Units (CFU) counts of Streptococcus mutans. Among the four groups Group D (S flo) showed greater percentage reduction of Streptococcus mutans followed by Group A (Act), B (Kidodent) and C (Zerocary). There was no stastically significance reduction of Streptococcus mutans among the Triclosan containing and non containing groups. Conclusion: The mean pre rinse CFU was significantly higher than post rinse CFU for all the study groups, suggesting that all the four mouth rinses were effective in decreasing the levels of Streptococcus mutans in the saliva. Both the Triclosan containing and non Triclosan groups showed the same amount of CFU count reduction.

Anatomical and Radiological Aspects of the Supratrochlear Foramen in Brazilians
Introduction: The supratrochlear foramen is an anatomic variation of great clinical and anthropologic interest. Although many studies addressed this subject in different ethnic groups, there are no studies regarding Brazilians. Aim: To verify the incidence and morphometric measures of the supratrochlear foramen in Brazilian humeri. Materials and Methods: A total of 330 dry humeri were analysed and divided in three groups: bones presenting the supratrochlear foramen (Group 1), bones displaying a translucent foramen (Group 2) and humeri without the foramen (Group 3). The aperture was measured with a digital vernier caliper. Radiographic pictures with different incidences were taken. Results: Our analysis showed that 22.5% of humeri belonged in Group 1, 41.2% in Group 2, and 36.3% in Group 3. The mean vertical diameter and the mean horizontal diameter of the supratrochlear foramen on the left side were 2.779±2.050 mm and 2.332±1.23 mm, respectively. The mean vertical diameter and the mean horizontal diameter of the foramen on the right side were 2.778±2.197 mm, and 2.365±1.396 mm, respectively. The student’s t-test showed that there was no significant difference regarding the size of the foramen between both sides. The best X-ray machine setup was 50 kilo voltage and 0.08 milliamperage per second, associated with a slight increase in the distance of the x-ray tube. Conclusion: The aperture seems to be the key point during the pre-operative planning of intramedullary fixation, since it has direct relation to the size of the intramedullary canal, thus, being an entity of clinical, anatomical, anthropological, radiological, and surgical interest.

Supracostal Punctures for PCNL: Factors that Predict Safety, Success and Stone Free Rate in Stag Horn and Non-Stag Horn Stones: A Single Centre Experience and Review of Literature

Hariharasudhan Sekar, Sriram Krishnamoorthy, Natarajan Kumaresan, Venkat Ramanan
Introduction: Supra-costal Percutaneous Nephrolithotomy (PCNL) procedure has now become an established standard of care in patients with renal stone disease, in terms of morbidity, stone clearance, duration of stay and shorter convalescence period. Gone are the days when supracostal punctures were considered to be associated with a high morbidity. With increased expertise gained in performing multiple punctures and further refinements in focusing techniques, more and more of these procedures are being performed with an intention to achieve a maximum stone clearance with least morbidity. Aim: To prospectively analyze the various factors that predict the safety, efficacy and stone clearance rate in patients who have undergo supracostal punctures for PCNL procedures. Materials and Methods: Three hundred seventy six patients underwent PCNL for renal stones. Ninety two (n=92) of them needed supra-costal puncture. All patients were subdivided into groups 1 and 2 based on the size, location of the stone and the stone burden. In all, 132 tracts were established. Results: About 83% of patients achieved a complete stone free rate after initial PCNL. Stones more than 3 centimeters were found to be associated with significant residual stones. Radio opacity under image intensifier also had a significant impact on the ultimate stone free status. About 23% of those (n=5/22) who needed longer duration of surgery had a clinically significant residual stones, needing ancillary procedures. Fifteen patients (16%) had complications related to the procedure, of which 13 were in group 1 (87%). High percentage of complications in patients with larger stone burden was found to be statistically significant. In about 76% (n=70), the procedure required only less than 90 minutes. Also, in those 22 patients in whom the duration of procedure exceeded 90 minutes, 12 of them had complications, with a p-value of <0.0001. Conclusion: Supra-costal punctures are safe and effective options in a selected group of patients. The overall results are almost on par with that of the infra costal punctures, with an acceptable morbidity.

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

Rohan Bhatia, Gaurav Chopra
Introduction: Lumbar radiculopathy is a major health problem often treated by surgery or guided lumbar epidural steroids for pain relief. We have used Platelet Rich Plasma (PRP) a novel therapeutic tool of autologous nature that has emerged strongly in recent years to treat patients of prolapsed intervertebral disc. Aim: To evaluate the efficacy of PRP via interlaminar epidural route in treatment of pain in patients with prolapsed inter vertebral disc. Materials and Methods: Ten patients were injected with five ml of autologous platelet rich plasma under fluoroscopic guidance via interlaminar lumbar epidural injection into area of affected nerve root. They were followed using VAS (Visual Analogue Scale), SLRT (Straight Leg Raising Test) and MODQ (Modified Oswestry Disability Questionnaire) for clinical improvement. Results: Patients who had received epidural injections of autologous PRP showed improvements in their scores of evaluation tools. Improvement was sustained during the 3 month study period and was not associated with any complications. Conclusion: Autologous PRP can be considered as a good alternative to epidural steroids and surgery in management of patients with chronic prolapsed intervertebral disc.

The Feto-Maternal Outcome of Preeclampsia with Severe Features and Eclampsia in Abakaliki, South-East Nigeria
Introduction: Preeclampsia with severe features and eclampsia has remained a serious challenge in tropical obstetric practice. It is a major cause of maternal and perinatal morbidity and mortality in Nigeria. Aim: This study was aimed at determining the prevalence, the risk factors and feto-maternal outcome of preeclampsia with severe features and eclampsia in Abakaliki. Materials and Methods: This was a 5-year retrospective case-control study of preeclampsia with severe features and eclampsia at the Federal Teaching Hospital, Abakaliki. Case notes of preeclampsia with severe features and eclampsia between January 2008 and December, 2012 were retrieved. Similarly, the case file of next parturient that did not have any medical disease was included in the study. The cases and controls were selected at the ratio of 1:1. The data assessed were information on maternal age, parity, booking status, diagnosis, mode of delivery, complications, maternal and perinatal outcomes. Results: A total of 13,750 deliveries were recorded within the study period. The prevalence of preeclampsia with severe features and eclampsia were 136(0.99%) and 104(0.76%) respectively. Preeclampsia with severe features and eclampsia was more common among adolescents, rural dwellers, poorly educated, unemployed, unbooked and nulliparous women. It was more associated with preterm delivery, caesarean section, low birth weight babies, maternal and perinatal mortality. Conclusion: Preeclampsia with severe features and eclampsia is common among the adolescents, unbooked, rural, and low socio-economic group of women in this study. It has also contributed to high maternal and perinatal morbidity and mortality. There is need for policy makers to formulate policies toward female education, women empowerment and provision of social amenities in rural areas. These policies may reverse the current ugly trend in this environment.

Cytogenetic Analysis for Suspected Chromosomal Abnormalities; A Five Years Experience
Introduction: Chromosomal abnormalities are the results of alterations in the number or structure of chromosomes causing significant human morbidity and mortality. They are responsible for a large proportion of miscarriages, developmental delay, disorders of sexual development, congenital malformations and mental retardation. Aim: The aim of this study was to describe the prevalence of different chromosomal abnormalities in North Indian patients referred for cytogenetic analysis. Materials and Methods: Total of 859 patients ranging from newborn to 37 years of age were referred to the division of genetics, Department of Paediatrics between 2010 and 2015, with a variety of clinical disorders; Down syndrome (DS), Turner’s syndrome (TS) and Klinefelter syndrome; amenorrhea; ambiguous sex and multiple congenital malformations. Chromosomal analysis was performed on lymphocyte culture according to standard methods. Results: Of the 859 cases studied, 371 (43.1%) had chromosomal abnormalities. The most common autosomal abnormalities were DS 302 (81.4%) and sex chromosomal abnormalities were TS 51 (13.7%). Numerical abnormalities were accounted for 353 (41.0%) and structural abnormalities 18 (2.0%), respectively. Various other chromosomal anomalies were also reported. Conclusion: We have reviewed the incidence and distribution of chromosomal abnormalities and found higher rate of chromosomal abnormalities 43.1% in the referred cases. Our data suggest that chromosomal analysis is important tool in the evaluation of genetic disorders and helps clinicians to provide accurate diagnosis and proper genetic counselling.

Effect of Continued Support of Midwifery Students in Labour on the Childbirth and Labour Consequences: A Randomized Controlled Clinical Trial

Nahid Bolbo l-Haghighi, Seyedeh Zahra Masoumi, Farideh Kazemi
Introduction: Childbirth experience is a process throughout women’s life and the most important consequence of labour. Support is the key factor to have a positive experience of childbirth. In order to improve and reduce the stress and anxiety levels in women during labour and cope with the childbirth pain, the emotional, physical and educational support of doulas can be used. Aim: This study was aimed to evaluate the effect of continued support of midwifery students in labour on the childbirth and labour consequences. Materials and Methods: The present study was conducted using a randomized controlled clinical trial design on 100 pregnant women referred to the maternity ward at Fatemieh Hospital, Shahroud, Iran. The participants were assigned to the supportive or non-supportive group based on allocation sequence using a randomized block design and table of computer-generated random numbers prior to beginning the study. Supportive care was provided by the trained midwifery students. Childbirth and labour consequences were analysed by chi-square test, Fisher-exact test, independent t-test, Mann-Whitney U-test using SPSS-21 software. Results: The results showed a significantly lower duration of the first stage of labour in the supportive group, as compared to that in the non-supportive group (p <0.001). Moreover, Apgar scores in the supportive group, compared to those in the non-supportive group, significantly increased at minutes 1 and 5 (p <0.001 and p = 0.04, respectively). Conclusion: The findings of this study showed that the supportive care provided by the midwifery students shortens duration of the first stage of labour and improves the Apgar scores in the first and fifth minutes.

Efficacy of Sciatic Nerve Block for Pain Management in Below Knee Orthopaedic Surgery

Subhadra Arun Sinha, Sandeep Champalal Mutha, Deepak Sadashiv Phalgune
Introduction: Perioperative pain management is an integral part of anaesthesia and patients are most satisfied if there is minimal or no pain after surgery. Sciatic nerve block provides postoperative pain relief after below knee surgery and knee surgery. Many studies with different approaches for sciatic nerve block have been conducted to demonstrate the efficacy of sciatic nerve block with different local anaesthetic drugs over the past decade. Aim: To study the efficacy of single-shot sciatic nerve block for postoperative pain management in below knee orthopaedic surgery. Materials and Methods: Sixty patients of American Society of Anaesthesiologists (ASA) grade I and II aged 18 to 60 years of either sex (male or female) scheduled for unilateral below knee open orthopaedic surgery under spinal anaesthesia and ready to participate in this study were included. Sciatic nerve block with Bupivacaine was given by classic (posterior) approach of Labat using peripheral nerve stimulator and /or ultra sound. Intraoperatively heart rate, noninvasive mean BP, respiratory rate, ECG, SpO2 was monitored. Pain was assessed using “Visual Analogue Scale” (VAS) postoperatively. Diclofenac sodium was given as rescue analgesia when VAS was > 3. Time of supplemental analgesia was noted. Results: Mean VAS was maximum at 18 hours, 16 (26.7%) patients did not require any rescue analgesia, whereas 93.4% patients did not require rescue analgesia upto 18 hours after surgery. Mean VAS score of the patients who did not require rescue analgesia was 2.06 at 24 hours postoperatively which is far below the level where rescue analgesia was required. The mean time by which rescue analgesia was given was 19.3 hours with standard deviation of ± 3 hours. Inj. diclofenac sodium 75 mg was given intravenously as rescue analgesia when VAS score exceeded 3. No adverse systemic toxicity of Bupivacaine was observed within 24 hours after the operation. Conclusion: Single shot sciatic nerve block provided effective pain relief to majority of the patients upto 18 hours in below knee orthopaedic surgery and also decreased analgesic drugs requirement postoperatively. Sciatic nerve block was safe with no adverse effects.

Clinicopathological Study of Triple Negative Breast Cancers
Introduction: Triple Negative Breast Cancers (TNBC) are a subset of breast cancers which are composed of different molecular subtypes. The most common is the basal like subtype, which has an adverse prognosis and limited treatment options. Aim: This study was undertaken to assess the clinico-pathologic and immunohistochemical subtypes of triple negative breast cancers and assess how each of these subtypes correlate with clinical behaviour and survival outcomes. Materials and Methods: Fifty-three (22.2%) of 238 cases of primary invasive breast carcinomas diagnosed from January 2010 to June 2011 were found to be negative for immunohistochemical markers- ER, PR and HER2. These fifty three cases were included in the study and were classified into four histological subtypes proposed by Ishikawa et al. Basal markers- CK5/6, EGFR and CK14 were done on these cases and they were further classified immunohistochemically into basal and non basal subtypes. The morphological features, disease free survival and overall survival were evaluated for both basal and non basal subtypes. Results: Majority (96%) of TNBC cases were classified according to WHO as invasive ductal carcinoma (NOS). Type C Ishikawa histological subtype was found to be the commonest subtype in both basal and non-basal TNBC. Of 53 TNBC cases, basal immunohistochemical markers were performed on 47 cases only because of paucity of tissue. Of these 47 cases, thirty-five (74.4%) were found to be of basal like subtype and all these cases were picked up by a combination of CK5/6 and EGFR. Conclusion: High grade morphological features, hormonal markers with additional use of basal markers can help identify the basal like subtype of TNBC, thereby predicting breast cancer survival. The combination of CK5/6 and EGFR identified all cases of basal subtype. EGFR in addition also has potential therapeutic implications. The morphological features and survival outcomes were not significantly different between basal and non-basal phenotypes.

Invitro Activities of Polymyxins and Rifampicin against Carbapenem Resistant Acinetobacter baumannii at a Tertiary Care Hospital from South India

Dheepa Muthusamy, S.Sudhishnaa, Appalaraju Boppe
Introduction: Acinetobacter baumannii (A.baumannii) is rapidly emerging as a potent organism causing a multitude of nosocomial infections. The organism also carries various resistance mechanisms to antibiotics, making treatment more difficult. Very few choices are left, as A.baumannii strains have begun to develop resistance against cephalosporins, aminoglycosides and even carbapenems. Aim: To examine the sensitivity pattern of three older antibiotics namely colistin, polymyxin B and rifampicin against carbapenem resistant A.baumannii by disk diffusion method and the sensitivity of colistin alone by Minimum Inhibitory Concentration (MIC) determination by VITEK automated system. Materials and Methods: Hundred clinical isolates of carbapenem resistant A. baumannii were tested for sensitivity to colistin, polymyxin B and rifampicin by Kirby-Bauer disk diffusion method. They were also tested for sensitivity to colistin by VITEK 2C (biomérieux) automated microbial identification system. The zone diameters and Minimum Inhibitory Concentration values for the above two methods, respectively were observed and analysed. All the Antibiotic Susceptibility Tests were done according to the CLSI guidelines. Results: By Kirby-Bauer disk diffusion method, 78% of the carbapenem resistant strains were found to be sensitive, 12% intermediate sensitive and 10% resistant to colistin. All the isolates were sensitive to polymyxin B and 80% were resistant to rifampicin. By the VITEK automated system, 99% of the isolates were sensitive to colistin (more in number than by disk diffusion method). Conclusion: Polymyxins (colistin - polymyxin E and polymyxin B) are the next choice for multidrug resistant serious nosocomial infections like those of A. baumannii, till newer antibiotics are discovered to treat such infections. Rifampicin resistance was found to be very high and hence, is not advised for monotherapy.

Blonanserin – A Novel Antianxiety and Antidepressant Drug? An Experimental Study

Ramchandra Prabhakar Limaye, Aditi Nitin Patil
Introduction: Many psychiatric disorders show signs and symptoms of anxiety and depression. A drug with both, effects and lesser adverse effects is always desired. Blonanserin is a novel drug with postulated effect on anxiety and depression. Aim: The study was aimed to evaluate the effect of Blonanserin on anxiety and depression in animal models. Materials and Methods: By using elevated plus maze test and forced swimming test, the antianxiety and antidepressant effects were evaluated. Animal ethics protocols were followed strictly. Total 50 rats (10 rats per group) were used for each test. As a control drug diazepam and imipramine were used in elevated plus maze and forced swimming test respectively. Blonanserin was tested for 3 doses 0.075, 0.2 and 0.8mg. These doses were selected from previous references as well as by extrapolating human doses. Results: This study showed an antianxiety effect of Blonanserin comparable to diazepam, which was statistically significant. Optimal effect was observed with 0.075mg, followed by 0.2 and 0.8mg. It also showed an antidepressant effect which was statistically significant. Optimal effect was observed at 0.2mg dose. Conclusion: The results showed that at a dose range of 0.075 and 0.2mg Blonanserin has potential to exert an adjuvant antianxiety and antidepressant activity in animal models. In order to extrapolate this in patient, longer clinical studies with comparable doses should be planned. The present study underlines potential of Blonanserin as a novel drug for such studies.

Salivary IgA versus HIV and Dental Caries
Introduction: The inter-relationship of Human Immunodeficiency Virus (HIV) infection and dental caries as well as Salivary Immunoglobulin-A (S-IgA) level appear to remain under explored while a manual and electronic search of the literature was made. Hence, the present study was undertaken to assess the relationship of S-IgA and dental caries status in HIV positive children. Aim: The aim of this study was to find out the relationship of S-IgA antibody with dental caries by measuring the concentration of IgA in saliva of HIV positive and negative children and determine the dental caries status in HIV positive and HIV negative children, which may help in treatment planning and prevention of the same. Materials and Methods: A total of 28 HIV positive children aged between 6-14 years and 28 age matched HIV negative children were included in this study and both samples were randomly selected from the same Non-Governmental Organization (NGO). The HIV status of both these samples was confirmed from their medical records provided by the NGO. Only 2cc of unstimulated saliva was collected from both groups in special tubes coded numerically using the method described by Collins and Dawes and the samples were analyzed to measure the concentration of IgA using commercially available ELISA kit (DRG Diagnostics, Germany). Examination of dental caries was carried out according to WHO criteria (1997) using a flat mouth mirror and CPI probe. Results: In HIV +ve group mean S-IgA level was calculated as 81.61 ± 6.20 µg/ml, mean DMFT was 3.86 ± 3.37, mean deft was 4.75 ± 2.86. In HIV -ve group mean S-IgA level was calculated as 145.57 ± 17.83µg/ml, mean DMFT was 2.54 ± 0.69, mean deft was 2.43 ± 2.01. Strong-ve correlation between S-IgA and DMFT (r = -0.781, t = 6.38, p < 0.001) and negative but Not Significant (N.S.) correlation (r = -0.19, t = 0.99, p > 0.05) between S-IgA and deft was found in HIV +ve group. Strong –ve correlation between S-IgA and DMFT (r = -0.655, t = 4.42, p < 0.001), S-IgA and deft (r = -0.942, t =14.32, p=<0.001) was found in HIV-ve group. Conclusion: This study suggests that the individuals who are suffering from IgA deficiency in general, are more susceptible to dental caries than normal individuals.

The Effects of Transcutaneous Electrical Acupoint Stimulation (TEAS) on Fatigue in Haemodialysis Patients
Introduction: Fatigue is one of the most common symptoms in End-stage renal disease (ESRD) patients receiving haemodialysis treatment. In recent years, researchers investigated the role of alternative medicine methods such as acupuncture in treatment of the chronic disease; however, there is a paucity of information regarding the fatigue of haemodialysis patients. Aim: To evaluate the effects of Trans Cutaneous Electrical Acupoint Stimulation (TEAS) on fatigue among ESRD patients receiving haemodialysis treatment. Materials and Methods: This randomized clinical trial was conducted over a five month, in Kermanshah-Iran haemodialysis centers in 2009. Fifty six 56 patients who had undergone to haemodialysis and meeting the inclusion criteria, were divided into two groups by simple random sampling; TEAS (28 cases) and TEAS-Sham group (28 cases). The data was gathered through the Brief Fatigue Inventory (BFI), entered into SPSS-16 software and analysed by descriptive and inferential statistics. Results: Out of 56, 38 patients (67.9%) were male and 45 were (80.4%) married. The mean and standard deviation of age were 52.29±15.26 years. The inferential tests showed no differences in the clinical and the demographic characteristics of patients among two groups (p > 0.05). The mean rank of fatigue score in TEAS and TEAS-Sham groups was 30.68 and 26.32 respectively (p=0.317) at the first of study. The results of the Mann-Whitney U-test indicated that there were significant differences between the TEAS and Sham groups after intervention (p = 0.002). Conclusion: Findings of the present study revealed that application of the TEAS on these acupoints had produced a better recovery rate of fatigue in TEAS group than Sham group after a course of ten session intervention. So, it is suggested that this plan will be provided to the haemodialysis patients.

Early Clinical Implications of Microalbuminuria in Patients with Acute Ischaemic Stroke

Anupa Thampy, Christopher C. Pais
Introduction: Cardiovascular and cerebrovascular diseases are leading causes of morbidity and mortality worldwide. Stroke accounts for the second leading cause of death, about 11.13% of total deaths worldwide. Microalbuminuria is known to be associated with increased risk of mortality in ischaemic stroke patients. But there have been no studies to assess whether microalbuminuria affects the early clinical outcome of patients with acute ischaemic stroke. Aim: This study aims to investigate whether microalbuminuria affects the early clinical outcome of patients with acute ischaemic stroke. Materials and Methods: This is a prospective study of patients with ischaemic stroke (who presented within 24 hours of symptom onset) who were consecutively admitted in three tertiary care centres during the time period from November 2013 to June 2015. Early clinical outcomes in patients were assessed by investigating the presence of Early Neurological Deterioration (END) using the National Institute of Health Stroke Scale. Urine albumin creatinine ratio was divided into two categories – Normal (less than 30mg/g of creatinine) or Urine Microalbuminuria (30-300 mg/g of creatinine). Results: Total 42 out of 70 patients (60%) were found to have microalbuminuria. In multivariate logistic regression analysis, microalbuminuria was found to be independently associated with END in patients with acute ischaemic stroke (p=0.044). Conclusion: In the early periods following acute ischaemic stroke, patients with microalbuminuria have worse clinical outcome.

Comparative Assessment of Antimicrobial Efficacy of Different Antibiotic Coated Gutta-Percha Cones on Enterococcus faecalis An Invitro Study
Introduction: The major goal of endodontic treatment is to eliminate bacteria from the root canals and prevent re-infection. Enterococcus faecalis (E. faecalis) has been attributed to be the most common organism for the endodontic treatment failures. The choice of endodontic material that have high antimicrobial efficacy can help in decreasing/avoiding growth of micro-organisms and facilitate the success rate of treatment. Aim: The present study was designed with an aim to evaluate the antimicrobial efficacy of antibiotic coated gutta-percha cones on E. faecalis. Materials and Methods: The present study was an invitro experimental study, conducted at Department of Public Health Densitry and Department of Microbiology. Gutta-percha cones were coated with different medicaments like Zinc Oxide-Eugenol cement (ZOE i.e. Group A), ZOE plus Amoxicillin-Clavulanic acid combination (Group B), ZOE plus Amoxicillin (Group C), ZOE plus Ofloxacin-Ornidazole combination (Group D). Agar plates were inoculated with E. faecalis and antibiotic coated gutta-percha cones along with conventional gutta-percha cones (coated only with ZOE) were placed in those agar plates. After 24hours incubation; diameter of zone of inhibition around gutta-percha stick was considered to assess the antimicrobial activity. Results were statistically analysed with analysis of variance (ANOVA) followed by Tukey post-hoc test for group-wise comparisons. Results: Mean diameter of zone of inhibition (in mm) obtained for Group A, Group B, Group C and Group D were 5±0.03, 26.6±0.05, 21.5±0.04 and 15.8±0.03 respectively. The difference in values of different antibiotics was statistically significant. The p-value < 0.001 was considered statistically significant. Conclusion: Group B was most effective against E.faecalis compared to other combinations used which increase the success rate of endodontic treatment as compared to conventional gutta-percha cones.

Comparative Evaluation of Efficacy of Three Different Herbal Toothpastes on Salivary Alkaline Phosphatase and Salivary Acid Phosphatase - A Randomized Controlled Trial

Mahesh Khairnar, Arun Dodamani, G. N. Karibasappa, Manjiri Deshmukh, Rahul Naik
Introduction: Very few researches in the past have tried to evaluate the effect of herbal toothpaste on saliva and salivary constituents like alkaline phosphatase and acid phosphatase which play an important role in maintaining oral health. Aim: To evaluate and compare the effect of three different herbal toothpastes on Salivary Alkaline Phosphatase (ALP) and salivary Acid Phosphatase (ACP). Material and Methods: The present study was a preliminary study conducted among 45 dental students (15 subjects in each group) in the age group of 19-21 years. Subjects in each group were randomly intervened with three different herbal toothpastes respectively (Group A – Patanjali Dant Kanti, Group B - Himalaya Complete Care and Group C – Vicco Vajradanti). Unstimulated saliva sample were collected before and after brushing and salivary ACP and salivary ALP levels were assessed at an interval of one week each for a period of four weeks starting from day one. Compiled data was analyzed using chi square test, paired t-test and ANOVA based on the nature of the obtained data. Results: All the three toothpastes showed significant (p<0.001) reduction in ACP and ALP levels at each interval. For patanjali toothpaste, the mean reduction was in the range of 2.55 – 2.62 IU/L for ACP and 2.94 – 2.99 IU/L for ALP. For Himalaya toothpaste, the mean reduction was in the range of 1.39 – 1.47 IU/L for ACP and 1.55 – 1.61 IU/L for ALP. For Vicco toothpaste, the mean reduction was in the range of 2.46 – 2.50 IU/L for ACP and 2.64 – 2.77 IU/L for ALP. Patanjali and Vicco toothpaste were significantly effective in reducing the levels of salivary ACP and ALP more than Himalaya toothpaste (p<0.05). Conclusion: Herbal toothpastes, especially Dant Kanti and Vicco Vajradanti, showed significant reduction in levels of ACP and ALP resulting in overall improvement towards the oral health.

Prevalence of ESBL in Escherichia coli Isolates Among ICU Patients in a Tertiary Care Hospital
Introduction: Resistance to common antibiotics is a matter of grave concern in treating infections in hospital settings especially in Intensive Care Units (ICUs). One of the most commonly used and effective group of antibiotics, cephalosporins, exhibit resistance due to production of Extended Spectrum Beta- Lactamases (ESBLs). The prevalence of ESBL producing Escherichia coli (E.coli) has increased throughout the world and is a major cause of treatment failure in ICUs. As per our knowledge studies were not available on the prevalence of ESBL producing E.coli in ICUs of this region. Aim: To determine the prevalence of ESBLs among Escherichia coli isolates in ICUs of a tertiary care hospital. Materials and Methods: A cross sectional study was conducted over a period of 4 years (Sept 2011 to Sept 2015) in the Department of Microbiology, Kalinga Institute of Medical Sciences (KIMS), Bhubaneswar. Consecutive non-duplicate isolates of E.coli recovered from 6800 clinical samples of patients admitted to different Intensive Care Units (ICUs) were subjected to ESBL screening test and then to CLSI recommended Phenotypic Confirmatory Disc Diffusion Tests (PCDDT) for ESBL production determination. Results: Out of 6800 samples, 1038 were E.coli isolates and 452(44%) were resistant to third generation cephalosporins. ESBL producing Escherichia coli among them were 276 (61.1%). Paediatric ICU showed the highest prevalence of ESBL E.coli at 80.9%. The highest prevalence of ESBL E.coli was in urine samples (82.6%) followed by pus (9.8%). The most effective antibiotic for ESBL producers was imipenem (96.7% sensitive), followed by amikacin (88.4%) and piperacillin- tazobactum (87%). Conclusion: This study has highlighted the high prevalence of ESBL producing E.coli in the ICUs of our hospital. An in depth analysis of their antibiogram will be helpful in formulating the antibiotic policy and prevent spread of ESBL strains. It is recommended that ESBL testing should be done routinely to curtail antibiotic resistance and to effectively implement infection control measures.

Diversity of Vaginal Lactic Acid Bacterial Microbiota in 15 Algerian Pregnant Women with and without Bacterial Vaginosis by using Culture Independent Method
Introduction: Bacterial Vaginosis (BV) is the most common lower genital tract disorder among women of reproductive age (pregnant and non-pregnant) and a better knowledge of Lactobacillus species richness in healthy and infected vaginal microbiota is needed to efficiently design better probiotic products to promote the maintenance of normal flora which will help prevent bacterial vaginosis. Aim: To evaluate and compare the diversity of lactic acid bacterial species in pregnant women with and without BV. Materials and Methods: A pilot study was carried out during November-2014 to March-2015 in University Badji Mokhtar, Annaba, Algeria. Vaginal swabs were collected from 15 pregnant women aged between 19 and 35 years (mean 27.6 years; n=15) living in the East of Algeria visiting Gynecology service, hospital Abdallah Nouaouria- El bouni, Annaba. Vaginal samples were gram-stained, and scored by the Nugent method. The cohort included cases of women with healthy “normal” vaginal flora, infected flora with bacterial vaginosis and women with “intermediate” flora. The vaginal LAB community from pregnant women was identified by culture independent method based on Denaturing Gradient Gel Electrophoresis (DGGE), with the 16S rRNA gene sequencing. Results: A majority of LAB affiliated to the genus Lactobacillus was found in “normal” and “intermediate” flora (87.5% and 43.75% respectively), while a majority of LAB affiliated to the genus Enterococcus was identified in women with bacterial vaginosis and intermediate flora (60% and 46.75% respectively). Our results showed that the presence of Lactobacillus iners and Lactobacillus delbruekii promotes stability of the vaginal microbiota. Conclusion: This result confirms the findings of previous studies suggesting that the occurrence of predominant Lactobacillus negatively correlates with bacterial vaginosis incidence and their current use as probiotics. Lactobacillus iners and Lactobacillus delbruekii can be defined as critical for defense of the vagina. In addition, Enterococcus feacalis can be considered as an indicator of imbalance of the vaginal ecosystem.

Arterial Stiffness and Trace Elements in Apparently Healthy Population- A Cross-sectional Study
Introduction: Stiffening of arteries is a natural ageing process. Any diseases/disorders or risk factors that escalate oxidative stress, microvascular inflammation and endothelial damage may promote to premature vascular stiffening. Any imbalance in these trace element levels may independently contribute to the changes in the components in the arterial wall and thus, arterial stiffness via one or more mechanisms. Aim: To evaluate the severity of arterial stiffness in apparently healthy population and also to evaluate role of various risk factors and trace elements in the severity of arterial stiffness Materials and Methods: Male and female subjects living in urban and rural areas of Nellore district, Andhra Pradesh, India, between 20-60 years, apparently normal as judged by the clinician basing on clinical and laboratory findings, were studied. Carotid-Femoral Pulse Wave Velocity (cf-PWV) a marker of arterial stiffness was assessed using non-invasive blood pressure curve monitoring (periscope). Furthermore, we also estimated serum levels of Copper (Cu), Zinc (Zn), Selenium (Se), chromium (Cr), Aluminium (Al), silicon (Si), Manganese (Mn), Molybdenum (Mo), Vanadium (V) and lead (Pb) using atomic absorption spectrophotometer. ANOVA and Chi-Square test were used to study the clinical correlations between severity of arterial stiffness, risk factors and trace elements. Results: A total of 737 apparently healthy subjects participated in this cross-sectional study. Of the total 542 (73.5%) were from rural and the remaining 195 (26.5%) were living in urban areas, 328 (44.5%) were males, and 409 (55.5%) were females. A 63.5% (468/737) had normal arterial stiffness followed by 14.5% (107/737) with mild stiffness, 7% (57/737) had moderate stiffness and 14.2% (105/737) had severe arterial stiffness. Smoking, alcohol, blood pressures, fasting blood sugar, and total cholesterol, Cu, Al and V correlated (p<0.05) with different grades of arterial stiffness. Conclusion: A 36.5% had high arterial stiffness despite being apparently healthy. Smoking, alcohol, blood pressures, fasting blood sugars, and total cholesterol, Cu, Al and V could have contributed for such an abnormality. Caution has to be executed while understanding the study results since the pathophysiological process is complex.

Psychosocial Illness in Children with Type 1 Diabetes Mellitus: Prevalence, Pattern and Risk Factors
Introduction: Type 1 Diabetes Mellitus (T1DM) and psychosocial illness influence each other in multiple ways. The extent of psychosocial disorders in children with T1DM remains largely unstudied in India. Aim: To assess the prevalence, severity, pattern and variables affecting psychosocial illness in children with type 1 diabetes mellitus. Material and Methods: This observational study included 84 children (6-14 years of age) having T1DM at least for 1 year and 100 non diabetic children for comparison. “DSM-5 parent/guardian-Rated Level 1 & 2 Cross-Cutting Symptom Measure –Child age 6-17” was used to assess psychosocial illness, specific domains and severity. Socio-demographic variables were studied and HbA1c levels were measured. Results: Significantly higher prevalence of psychosocial illness was observed in children with T1DM as compared with non diabetic group (55.95% vs 20%; p<0.0001). The prevalence for mild, moderate and severe psychosocial illness was 8.33%, 27.38% and 20.24% respectively in diabetic children. Most common psychosocial abnormality was irritation (38.1%), followed by depression (36.9%) and anxiety (32.1%). The prevalence of psychosocial illness was significantly higher in T1DM patients with poorer metabolic control (HbA1c>7.5, p=0.014). Significant association of psychosocial illness was also noticed with poor dietary compliance (p=0.021) and higher mean HbA1c level (p<0.001). Conclusion: This study established T1DM as a risk factor for development of psychosocial illness. Irritation, depression and anxiety were most common abnormalities. Significant association of psychosocial illness with poor dietary compliance and poor metabolic control was observed. Psychosocial assessment of every diabetic child is suggested for optimal management.

Oral Clonidine vs Oral Pregabalin Premedication to Attenuate Pressor Response to Direct Laryngoscopy in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Double Blind Study

Shirin Parveen, Devendra Singh Negi, Rajesh Kumar, Mohd Chand Bagwan
Introduction: Direct laryngoscopy and tracheal intubation has adverse effects like tachycardia, hypertension, myocardial ischemia and cerebral haemorrhage. There are several studies on various pharmacological agents to attenuate this response. Aim: This study was designed to compare efficacy and safety of oral clonidine and oral pregabalin premedication to attenuate stress response in patients undergoing laparoscopic cholecystectomy. Materials and Methods: Total 80 patients of ASA grade I and II, aged between 20-60 years of both sexes scheduled for elective laparoscopic cholecystectomy were included in the study. All the patients were randomized into two groups. Group A received oral clonidine 0.3mg and group B received oral pregabalin 150mg, 60 minutes before surgery. Anaesthesia technique was standardized. Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), mean arterial pressure (MAP) and heart rate were recorded preoperatively, after premedication, immediately after intubation, then at 1 min, 3 min, 5 min, 10 min and 15 min after intubation. Level of sedation, postoperative pain scores and any adverse effects were also noted and compared. Results: Oral clonidine 0.3mg as well as oral pregabalin 150mg were effective in blunting haemodynamic stress response to laryngoscopy and tracheal intubation. Clonidine was found to be better than pregabalin in lowering of systolic blood pressure, diastolic blood pressure, mean arterial pressure and heart rate changes associated with laryngoscopy. We also found that bradycardia was common with both the drugs, more so in clonidine group. Post-operative analgesia was better in pregabalin group as compared to clonidine group. Both the drugs cause sedation, but it was more with the use of pregabalin. Conclusion: Both the drugs can be used as an effective premedicant to attenuate the sympathetic response to laryngoscopy and tracheal intubation without much side effects and the added advantage of intraoperative and postoperative analgesia.

Utility of Transcutaneous Capnography for Optimization of Non-Invasive Ventilation Pressures
Introduction: Nocturnal Non-invasive Positive Pressure Ventilation (NPPV) is the treatment of choice in patients with chronic hypercapnic respiratory failure due to hypoventilation. Continuous oxygen saturation measured with a pulse oximeter provides a surrogate measure of arterial oxygen saturation but does not completely reflect ventilation. Currently, Partial Pressure of Arterial (PaCO2) measured by arterial blood analysis is used for estimating the adequacy of ventilatory support and serves as the gold standard Aim: To examine the safety, feasibility and utility of cutaneous capnography to re-titrate the non-invasive positive pressure ventilation settings in patients with chronic hypercapnic respiratory failure due to hypoventilation. Materials and Methods: Twelve patients with chronic hypercapnic respiratory failure prospectively underwent complete polysomnography and cutaneous capnography measurement on the ear lobe. Non-invasive ventilation pressures were adjusted with the aim of normalizing cutaneous carbon dioxide or at least reducing it by 10 to 15 mmHg. Sensor drift for cutaneous carbon dioxide of 0.7 mmHg per hour was integrated in the analysis. Results: Mean baseline cutaneous carbon dioxide was 45.4 + 6.5 mmHg and drift corrected awake value was 45.1 + 8.3 mmHg. The correlation of baseline cutaneous carbon dioxide and the corrected awake cutaneous carbon dioxide with arterial blood gas values were 0.91 and 0.85 respectively. Inspiratory positive airway pressures were changed in nine patients (75%) and expiratory positive airway pressures in eight patients (66%). Epworth sleepiness score before and after the study showed no change in five patients, improvement in six patients and deterioration in one patient. Conclusion: Cutaneous capnography is feasible and permits the optimization of non-invasive ventilation pressure settings in patients with chronic hypercapnic respiratory failure due to hypoventilation. Continuous cutaneous capnography might serve as an important additional tool to complement diurnal arterial carbon dioxide tension values.

Glycaemia Status, Lipid Profile and Renal Parameters in Progressive Diabetic Neuropathy

Debahuti Mohapatra, Komaladevi Sampath Damodar
Introduction: Diabetic Peripheral Neuropathy (DPN) is a common complication of diabetes. Existence of systemic co-morbidities in DPN patients has not been studied much, especially in Indian population. Aim: To evaluate glycaemic status, lipid profile, renal parameters and blood count to assess occurrence of co-morbidities as severity of DPN progresses. Materials and Methods: A case control study involving 104 DPN patients and 43 controls of age 31-70years were selected. Patients were categorized into stage 0, 1, 2 and 3 of severity as per Dyck system of classification. Fasting Blood Sugar (FBS), Post Prandial Blood Sugar (PPBS), Glycosylated haemoglobin (HbA1c), Lipid profile, Vitamin B12, Thyroid Stimulating Hormone, Urea, Creatinine and Complete blood counts were assessed along with baseline characteristics. Results: Glycosylated haemoglobin was in uncontrolled range for DPN patients (9.03±2.09) FBS and PPBS were significantly more with progress of severity of DPN (p<0.001). HDL decreased (p<0.001) as severity progressed and Triglyceride increased in DPN cases. Mean urea values increased (p=0.008) while haemoglobin levels and RBC count decreased (p<0.001) as severity of DPN progressed. Conclusion: Abnormal lipid profile, increased urea and decreased RBC levels point to co-existence of cardiovascular and renal comorbidities as severity of DPN progressed.

Beneficiary Satisfaction Regarding Old Age Pension Scheme and Its Utilization Pattern in Urban Puducherry: A Mixed Methods Study
Introduction: National Old Age Pension Scheme (NOAPS) was aimed at providing a safety net for India’s aging population in terms of social, economical and moral support by helping eligible elderly citizens with direct cash benefit. Aim: To assess the beneficiary satisfaction and utilization pattern of the monetary benefit received under the old age pension scheme and to explore the perception of the stakeholders regarding delivery of the pension. Materials and Methods: This is a mixed method research consisting of both quantitative surveys and qualitative in-depth interviews. The survey was conducted among 205 randomly selected beneficiaries of old age pension scheme belonging to urban Puducherry. Around 12 qualitative interviews were conducted with beneficiaries, family members and Anganwadi workers. Results: The mean age of the study participants was 71 years. Almost 80% of participants avail pension from banks. Majority of participants (98%) were satisfied with the overall scheme, though half of them expressed their dissatisfaction with the amount of pension received. Among the study subjects, 65% were satisfied regarding the mechanism of delivery of old age pension. Anganwadi was the preferred mode of payment in 80% subjects. Around 85% of them spent the entire pension amount for their own use (health needs, travel, daily activities and social needs) while the remaining gave some economic support to their family. Half of them (55%) felt that they possess financial autonomy in planning their expenditure. Majority felt that receiving pension had given them economic empowerment, self-esteem and renewed confidence in life. Conclusion: Financial assistance to the elderly empowers them and improves their social status, independence, self-esteem and overall quality of life. With increasing proportion of elderly in Indian population, it is important to study the effectiveness of such schemes so that corrective measures can be taken to facilitate its access to the disadvantaged section of the society.

Developing a Novel, Sustainable and Beneficial System for the Systematic Management of Hospital Wastes

Sanket Mohan Doiphode, Indira N. Hinduja, Harish S. Ahuja
Introduction: India is the 2nd most populated country in the world. Population of India is increasing at a tremendous rate. Proportionately, the numbers of people seeking health care are increasing. In that ratio the quantities of hospital wastes, in wider terms, healthcare wastes that are getting generated is also increasing. Current methods for the safe disposal of healthcare wastes are not able to cope up with the rate of generation of healthcare wastes and moreover are not eco-friendly at all. Due to this, the current rules and regulations regarding the safe disposal of healthcare wastes are getting violated, ultimately leading to improper management of healthcare wastes, posing a serious threat to the environment and to the community. Aim: To develop a novel, sustainable and beneficial system for the systematic management of healthcare wastes utilizing the strategies of waste reduction, waste segregation and recycling of Non Hazardous Hospital Wastes (NHHWs). Materials and Methods: Firstly a detailed study of the Healthcare Waste Management System (HCWMS) operational at the Jaslok Hospital and Research Centre was done. A pilot study was then performed. After that, data regarding the generation and management of healthcare wastes in the other healthcare settings was collected and analyzed. Considering all this, a novel, sustainable and beneficial template system for the systematic management of healthcare wastes was proposed. Lastly the possible positive impacts from the implementation of HCWMSs designed using proposed template HCWMS in significant numbers of healthcare establishments was gauged. Results: The healthcare waste management system operational at the Jaslok Hospital and Research Centre was found to be very efficient and provided vital inputs about developing the novel HCWMS. The pilot study was successfully completed generating significant revenue from the hospital’s own NHHWs while managing them in an eco-friendly way. The total healthcare waste generation in Maharashtra was approximately estimated at about 2,89,200kg/day of which about 43,380kg/day was Bio-Medical Wastes (BMWs) while about 2,45,820kg/day were the NHHWs. This stresses the need of implementing HCWMSs in Healthcare Establishments (HCEs) based on the proposed novel template of HCWMS. Conclusion: The novel template system is proposed in a detailed manner under various heads in the form of a handbook which is scalable upwards or downwards as per the requirement of a HCE. The enormous economic and environmental positive impacts from the implementation of the HCWMSs based on the proposed HCWMS in significant numbers of HCEs were presented numerically, putting light on the necessity and tremendous potential of this field of research.

A Comparative Study of Lipid Profile and Cardiovascular Risk Biomarkers Among Chronic Haemodialysis Patients and Healthy Individuals
Introduction: Lipid abnormalities and increase in inflammatory markers are common among patients with End Stage Renal Disease (ESRD) and it tends to persist/worsen even after initiating Intermittent Haemodialysis (IHD). The cardiovascular mortality and morbidity remains significantly high in this population. Aim: The present study was carried out to assess the pattern of lipid abnormality in our population and to find its association with inflammatory markers. Materials and Methods: It was a cross-sectional, observational study on ESRD patients undergoing Haemodialysis (HD) in comparison with age and sex matched healthy individuals in a tertiary care hospital. About 40 adult male and female patients aged >18 years, undergoing chronic HD for more than 6 months were enrolled in Group A. Patients who were alcoholics, tobacco consumers and those on steroids and hypolipidemic drugs were excluded. Group B consisted of healthy, age and sex matched controls. Serum lipid profile, lipoprotein A, apolipoprotein A1, apolipoprotein B and apo B/A1 ratio, serum uric acid, homocysteine, hs-crp and testosterone levels were estimated among patients undergoing intermittent HD and healthy individuals. Chi-square/Fisher’s-exact test was used for comparing ratios. A p-value of <0.05 was considered statistically significant. Results: The mean Total Cholesterol (TC), Low Density Lipoprotein (LDL) and Non-HDL High Density Lipoprotein cholesterol was significantly lower in HD patients as compared to control group with all the three parameters attaining statistical significance (p<0.005). The mean lipoprotein A level was significantly higher (p=0.037), while Apo A1 was found to be significantly lower (p=0.001) in patients receiving HD. Inflammatory markers like uric acid was high (p<0.005) and serum testotsterone level in male HD patient was significantly low (p<0.005). Conclusion: The mean values of traditional serum lipid profile remained lower in HD patients than the control group. The abnormalities in lipoprotein A and apolipoproteins were more pronounced in patients undergoing HD. The mean level of testosterone also was found to be lower in male patients receiving HD. Hence, estimation of lipoprotein A, apolipoproteins and inflammatory markers may serve as a potential tool in cardiovascular risk stratification.

Estimation of Antimicrobial Properties of Aqueous and Alcoholic Extracts of Salvadora Persica (Miswak) on Oral Microbial Pathogens - An Invitro Study

Salman Siddeeqh, Amrita Parida, Maji Jose, Vidya Pai
Introduction: Twigs of Salvadora persica (Miswak) plant are being used as a means of oral hygiene since ages for brushing teeth. Though clinical research and trials have shown promising results on effectiveness of Miswak, but some reports are conflicting. Aim: To evaluate the antimicrobial activity of crude aqueous and alcoholic extracts of Salvadora persica (Miswak) against the common microbial pathogens causing dental caries and periodontitis. Materials and Methods: A prospective study of one year duration was conducted in Yenopoya dental and medical college, Mangalore. The twigs of Salvadora persica were collected and alcoholic and aqueous extracts were prepared using standard techniques. The antimicrobial properties of the extracts against common oral pathogens like Streptococcus mutans, Streptococcus mitis, Candida albicans, Lactobacillus acidophilus, Prevotella intermedia, & Peptostreptococcus were performed by agar well diffusion method and two fold broth dilution method. Results: No significant results was obtained when water extracts of Salvadora persica was tested except for minimum inhibitory effect against Streptococcus mutans, Prevotella intermedia & Peptostreptococcus and Candida albicans. Relatively significant inhibitory effect was noted with respect to alcoholic extract of Salvadora persica. Conclusion: Although comparatively less than chlorhexidine which is a known antimicrobial agent, the alcoholic extracts of Salvadora persica showed antimicrobial effect against the common microbial pathogens causing dental caries and periodontitis indicating a potential beneficial effect of this plant. However, further research with more standardized extraction procedure and advanced techniques is required to find out the exact chemicals responsible for the antimicrobial properties of the plant extract.

Glycated Hemoglobin (HbA1c) Correlation with Severity of Coronary Artery Disease in Non-diabetic Patients - A Hospital based Study from North-Eastern India

Bornali Dutta, Mahesh Neginhal, Farhin Iqbal
Introduction: Glycated Hemoglobin (HbA1c) levels are predictive of cardiovascular disease and mortality in patients with diabetes mellitus, however, association of HbA1c with Coronary Artery Disease (CAD) in non-diabetics is inconsistent. Aim: To evaluate the correlation between HbA1c level and severity of CAD in non-diabetic patients using syntatax score in a cohort of proven CAD on angiography at Gauhati Medical College, Guwahati, Assam, India, which is a major tertiary care hospital of North-Eastern India. Materials and Methods: We prospectively collected data of non-diabetic patients with proven CAD on angiography from June 2014 to June 2015. Patients were divided into four groups (interquartiles) according to HbA1c levels, less than 4.8%, 4.8% to 5.1%, 5.1% to 5.6%, and 5.6% to 6.5%. Severity of CAD was assessed using syntatax score and the number of coronary vessels diseased. We compared different quartiles of HbA1c with regard to syntatax score and number of diseased vessels. Results: A total of 346 patients were included in the study. Mean age was 58.1±10.4 years. Of the total 91.9% (318) were males, 44.8% (155) were hypertensives, 29.2% (101) were smokers and 34.7% (120) were dyslipidemic. We found that CAD severity by syntatax score as well as number of vessels involved was significantly different among quartiles (p-values <0.001 and <0.001 respectively). Increase in HbA1c level was strongly correlated with disease severity and higher syntatax score. A significant increase was noted in the mean number of diseased vessels (p-value <0.001) as HbA1c level increases. Age, gender, hypertension and dyslipidemia did not show significant difference among quartiles however smoking was found to be an independent predictor of severity of CAD by syntatax score (p <0.05). Conclusion: From this clinical study, we can conclude that a significant correlation exists between HbA1c and severity of CAD by syntatax score as well as number of vessels involved in non- diabetes.

Association of Vitamin D Deficiency with Coronary Artery Disease
Introduction: Coronary Artery Disease (CAD) is a major global health problem. Recent studies demonstrated that lower vitamin D level (<30ng/ml) is associated with higher blood pressure and directly or indirectly with CAD, due to vascular endothelial damage. However the results are inconsistent. Aim: To find the association of vitamin D deficiency with CAD Materials and Methods: In this cross-sectional observational study, serum vitamin D level was measured in 315 patients who underwent coronary angiography. Result: The mean (±SD) vitamin D was 13.40ng/ml (±10.40). However, the patients with normal coronary artery had much lower mean vitamin D (11.30ng/ml±9.50) as compared to the patients with CAD (14.10ng/ml±10.70). The mean (±SD) vitamin D levels were 19.00ng/ml (±16.50), 14.10ng/ml (±11.10) and 13.20ng/ml (±8.80) in patients with CAD with 50%-70%, >70%-90% and >90% stenosis respectively (p= 0.46) and 15.20ng/ml (±13.00), 15.50ng/ml (±11.30) and 11.80ng/ml (±7.00) in patients with CAD with single, double and triple vessels disease respectively (p= 0.14). The frequency of vitamin D deficiency were 66.70%, 83.20 % and 83.10% in patients with CAD with 50% -70%, >70%-90% and >90% stenosis respectively and 81.40%, 80.00% and 83.50% in patients with single, double and triple vessel disease respectively, as compared to 89.30% in patients with normal coronary artery (p= 0.41 and 0.075). So, all the study groups of CAD had low serum vitamin D level and high frequency of vitamin D deficiency, which was statistically insignificant. Conclusion: Prevalence of vitamin D deficiency is very high in CAD, but it does not correlate with the angiographic severity of CAD.

Study of Myringoplasty in Wet and Dry Ears in Mucosal Type of Chronic Otitis Media

UP Santosh, KB Prashanth, MS Sudhakar Rao
Introduction: Chronic otitis media is the most common cause of hearing impairment in the developing countries. Hearing loss can have serious effects on day to day life. Ear discharge in chronic otitis media may continue for months to years with increasing hearing impairment and also life threatening infective complications, which is more common in active and also in inactive disease form as well. Myringoplasty is an operative procedure to close the perforation in tympanic membrane. Aim: To compare the success rate of graft uptake in dry and wet ears and to compare the postoperative hearing improvement in dry and wet ear following myringoplasty. Materials and Methods: The comparative study was carried out on total 30 patients with chronic otitis media with central perforation. Of these 15 patients belong to dry ear group and 15 patients with wet ear group. These selected patients on simple random basis were subjected to clinical, audiological, radiological and laboratory investigations and one day before operation, patients were admitted to the hospital and written informed consent was taken in all cases. All patients underwent underlay technique myringoplasty. Postoperatively all patients were evaluated for graft uptake and hearing improvement by pure tone audiometry at 3rd month follow-up. Results: In our study, the successful graft uptake was seen in 80% in dry ear and 73.3% in wet ear, statistically p-value (?2=1.24) is (p>0.05) which is insignificant. Postoperatively hearing gain was (0-5 dB) in 3 patients (20%) with dry ear and 2 patients (13.5%) with wet ear; (6-10 dB), in 4 patients (26.6%) with dry ear and 6 patients (40%) with wet ear; more than 10 dB in 5 patients (33.3%) with dry ear and 3 patients (20%) with wet ear, statistically p-value is ?2=1.24 (p >0.05) which is not significant. Conclusion: In this study the success rate of graft uptake and hearing improvement is found almost equal in dry and wet ear by using underlay technique of myringoplasty, also found statistically insignificant.

Effect of Poly Unsaturated Fatty Acids Administration on Children with Attention Deficit Hyperactivity Disorder: A Randomized Controlled Trial

Puneet Anand, Ankur Sachdeva
Introduction: Attention Deficit Hyperactivity Disorder (ADHD) is a common disorder of childhood. Studies have indicated nutritional deficiencies, particularly Poly Unsaturated Fatty Acids (PUFA) deficiency in these children and have suggested supplementation with PUFA for clinical improvement. Aim: The present study aimed at evaluating the effect of PUFA administration in Indian children with ADHD. Settings and Design: The study was conducted in the paediatrics and psychiatry departments of a tertiary care hospital. We conducted a prospective double blind randomized control trial on children aged 4-11 years, diagnosed with ADHD according to DSM-IV TR criterias and Kiddie-Schedule for Affective Disorders and Schizophrenia - Present and lifetime version. Materials and Methods: The study subjects were randomized into study and control groups. The control group was administered Atomoxetine, while the study group received Atomoxetine along with Eicosapentanoic acid (EPA) and Docosahexanoic acid (DHA). Both groups were followed up every 2 weeks over the next 4 months using Conner’s Parent Rating Scale - Revised (CPRS-R). Statistical Analysis: The data was carefully analysed by SPSS (17th version) software with the help of a statistician. Confidence interval of 95% was used. The complete data was analysed using appropriate parametric and non parametric tests. Correlation was done between various socio-demographic and illness related parameters. For all analyses, probability of 5% or less was assumed to represent statistical significance. Results: Fifty children diagnosed with ADHD were randomized to study group (n=25) and control group (n=25). The study group had greater reduction in ADHD scores as compared to the control group, although not statistically significant (p = 0.08). Improvement was more significant in male study subjects with combined type of ADHD. Conclusion: It may be concluded that PUFA supplementation improves the symptoms of ADHD. However, the effect is not clinically significant if supplementation is not given for prolonged duration and in adequate doses.

In vitro Comparison of Generic and Branded Preparations of Amoxicillin with Potassium Clavulanate

Priyanka Pathak, Jayshree Dawane
Introduction: The Medical Council (MCI) of India has guidelines for physicians to prescribe drugs with generic names. But physicians and patients might have prejudices against generic drug substitution or concerns regarding quality and generics effectiveness. If the drugs are ineffective, they can result in adverse clinical outcomes such as treatment failure. According to WHO, ß-lactams are the most common substandard drugs to be produced amongst antibiotics. Aim: To evaluate and compare invitro efficacy of generic and branded preparations of Amoxicillin with Potassium Clavulanate. Materials and Methods: One generic (C) and 5 branded formulations (A,B,D,E,F) of amoxicillin with potassium clavulanate were taken for microbiological assay. Coding was done. Sterile disks were instilled with 10µl of preparations and disk diffusion was screened by Kirby Bauer Method using Mueller Hinton Agar. Bacterial Strains used were Staphylococcus aureus (S. aureus) and Escherichia Coli. Zone of inhibition was measured. Statistical Analysis was done using repeated measures one-way ANOVA followed by Tukey’s test. Results: Disk Diffusion test showed that branded Drug F has statistically significant less zone of inhibition (p < 0.001) for S. Aureus and (p < 0.05) for E.coli in comparison with generic drug C. Zone of inhibition of branded Drug A, B & E was comparable with the generic drug C. Conclusion: The results of this study indicate that the generic drug tested was equally effective compared to the tested branded drugs except branded Drug D and F. This suggests that efficacy of generic drug is equivalent to branded drugs and maybe used interchangeably with branded drugs.

The Role of MR Mammography in Differentiating Benign from Malignant in Suspicious Breast Masses

Padhmini Balasubramanian, Vijaya Karthikeyan Murugesan, Vinoth Boopathy
Introduction: Magnetic Resonance (MR) Mammography is being increasingly used now-a-days for the evaluation of breast lesions. Aim: To find out the effectiveness and the exact role of MR mammography in differentiating benign lesions from malignant lesions in patients with palpable, suspicious breast masses found on routine conventional imaging techniques. Materials and Methods: It was a prospective study wherein patients with suspicious breast lesions were subjected to MR mammography. The morphological feature (smooth vs irregular margin) and the enhancement patterns (Type Ia/Ib vs Type II vs Type III) of the lesions were assessed and finally the effectiveness of MR mammography in differentiating benign and malignant lesions was judged by taking the histopathological diagnosis as the gold standard. Results: A total of 33 patients with 35 breast lesions were finally analysed. The sensitivity, specificity, Positive Predictive Value (PPV) and the Negative Predictive Value (NPV) in differentiating benign from malignant breast lesion for the type of margin on MR mammography was 95.45%, 84.6%, 91.3% and 91.7%, while for the type of enhancement curve it was 76.2%, 90.9%, 94.1% and 66.7% respectively. The sensitivity and negative predictive value for the type of margins was statistically better when compared to the type of enhancement curve in differentiating benign from malignant lesions but the specificity and PPV though better for the type of enhancement curve was not found to be statistically significant. Conclusion: MR mammography was found to be an effective tool in differentiating benign from malignant suspicious breast lesions. The type of margin and the enhancement patterns both individually and in combination provide the clinicians with ample information so as to decide on further management.

Evaluation of Time in Therapeutic Range (TTR) in Patients with Non-Valvular Atrial Fibrillation Receiving Treatment with Warfarin in Tehran, Iran: A Cross-Sectional Study

Bahram-Fariborz Farsad, Mohammad Abbasinazari, Atousa Dabagh, Hooman Bakshandeh
Introduction: Anticoagulant control is assessed by Time in Therapeutic Range (TTR). For a given patient, TTR is defined as the duration of time in which the patient’s International Normalized Ratio (INR) values were within a desired range. Aim: To assess TTR in patients receiving treatment with warfarin for non-valvular atrial fibrillation at a referral center for cardiovascular diseases in Tehran, Iran. Materials and Method: Over 6 months, we enrolled eligible patients presenting to Shaheed Rajaie Hospital in Tehran for regular INR testing. Demographic data, medical history, and current medications were determined for all participants. TTR was assessed by the Rosendaal method. Results: A total of 470 patients (mean age 58.0±14.2 years, 60.2% women) underwent 1450 INR measurements. The mean TTR was calculated as 54.9±11.9%. Of the sample patients, 37.3% were in the good control category (TTR > 70%), 24.6% were in the intermediate category (50% < TTR < 70%), and 38.1% were in the poor control category (TTR < 50%). The number of current medications above four was a significant predictor of poor control (OR = 2.06; 95% CI, 1.87, 2.23). The mean TTR of the studied patients (54.9%) was below the good control range. Conclusion: The quality of anticoagulant therapy with warfarin in Iranian patients was poorer than that reported in European countries. Based on these results, research considering the causes of poor TTR among Iranian patients is recommended.

Outcome Analysis in Cases of Spinal Conus Cauda Ependymoma

Srikant Balasubramaniam, Devendra K Tyagi, Ketan I Desai, Mohnish P Dighe
Introduction: One half of all central nervous system ependymomas, arise within the spinal canal and about 40% of these arise from filum terminale. The myxopapillary variant of spinal ependymoma almost exclusively occurs in the lumbosacral region and they are histologically designated as Grade I. Long term control is best achieved by gross total removal at the initial operation. There is as yet no consensus on the management of incompletely excised tumour. Opinions regarding radiotherapy are controversial and the indications are empirical. Aim: In the present study, we investigated the clinical characteristics and long-term outcomes in patients with conus cauda ependymoma that were managed at our center with baseline comparison of our findings with those reported in literature. Materials and Methods: A retrospective analysis of 44 cases of conus cauda ependymoma tumours treated at the Department of Neurosurgery at a tertiary care centre from January 2001 to December 2015 was done. Detailed scrutiny and analysis of the patient’s data with respect to the demographic features, clinical findings, investigative procedures, extent of surgical resection, intra and postoperative complications, efficacy of adjuvant therapy, postoperative results and long term follow-up were done. Results: The analysis was done in 44 patients with conus cauda ependymoma over a period of 15 years. The mean age of presentation was 31 years. Incidence of male predominance was noted. Average duration of presenting features was 10 months. Back pain and motor weakness in the lower limbs were the commonest clinical findings. Total excision of the tumour was possible in 89% cases. Myxopapillary ependymoma was the commonest variant. Radiotherapy was only given in patients with near total to subtotal excision of tumour. Back pain and motor weakness improved in majority of patients after surgery. There is limited role of radiotherapy in cases with total tumour excision. Conclusion: Conus cauda ependymomas are relatively benign tumours. The long term prognosis is excellent with respect to recurrence and functional outcome in cases with complete tumour excision. Early diagnosis and surgery will prevent occurrence of permanent neurological deficits. Radiotherapy can be given in cases of subtotal excision but there is limited role of radiotherapy in cases with total tumour excision.

Variation in Cuspal Morphology in Maxillary First Permanent Molar with Report of 3 Cusp Molar- A Prevalence Study

Sandhya Jain
Introduction: Human teeth has always been known for morphological variations in both the crown and root structures. The corono-morphological variations can be in the form of extra cusp or missing cusp. Permanent maxillary first molars are the biggest teeth in maxillary arch and have a high anchorage value and are known for their four cusp and five cusp patterns, if present with cusp of Carebelli. Aim: The aim of this study was to determine the prevalence of cuspal variations and quantification of cusps of permanent maxillary first molar in Malwa population. Materials and Methods: A total of 1249 individuals were studied at Government College of Dentistry, Indore, Madhya Pradesh, India, to evaluate the number of cusps in permanent maxillary first molars. Results: Of the studied 1249 individuals, permanent maxillary first molars had five cusps in 407 (32.6%) cases while 838 (67.08%) cases had four cusp and four (0.32%) cases had three cusps. The four cases having three cusp permanent maxillary first molars were present unilaterally and only in females. Conclusion: This article emphasizes the presence of permanent maxillary first molar with only three cusps in the Malwa population of India. It also reviews the literature in respect to this rare anomaly and calls for continuous and close monitoring to report such cases in the future.

Predictive Value of Total Serum Bilirubin within 6 Hour of Birth for the Development of Hyperbilirubinemia After 72 hours of Birth
Introduction: Neonatal jaundice is benign and no intervention might be required, but jaundice can be associated with an underlying disease condition, which therefore warrants accurate and unbiased estimation of bilirubin. Timed Total Serum Bilirubin (TSB) measurements (at discharge between 18 hours and 72 hours) can be used to predict the chances of developing severe hyperbilirubinemia. Materials and Methods: The present hospital-based prospective study was undertaken to determine the predictive value of serum bilirubin before 6 hours of life for subsequent hyperbilirubinemia in healthy term neonates. One hundred and fifty healthy term newborns delivered during January 2013–December 2013 at Hanagal Shri Kumareshwara Hospital and Research Centre, S. Nijalingappa Medical College, Bagalkot Karnataka, India, were included in the study. Serum bilirubin levels were estimated twice, first, within 6 hours of life and second, after 72 hours of life. Bilirubin values were plotted on previously published nomograms. Sensitivity, specificity of the test was established. Results: A measure of TSB levels (within 6 hours of life) across the study population, showed that maximum number of infants (70/150) had TSB level between 4.1 and 5.5 mg/dL and 16 infants had TSB level >5.6 mg/dL. The TSB levels (after 72 hours of life) showed that maximum newborns (83/150) had TSB levels between 12.8 and 15.3 mg/dL and 9 infants had TSB levels between 7.7 and 10.2mg/dL. Eighteen infants developed hyperbilirubinemia. Newborns with TSB value of >4.95mg/dL within 6hours of life had developed significant hyperbilirubinemia after 72 hours of life with sensitivity of 100% and specificity of 89% (p=0.0001), which was highly statistically significant. Conclusion: A TSB level of >5 mg/dL within 6 hours of birth would serve as a predictor for risk of subsequent hyperbilirubinemia in the near future.

The Role of Vibrio cholerae Haemagglutinin Protease (HAP) in Extra-Intestinal Infection

Amit Ghosh, Hemanta Koley, Amit Pal
Introduction: Based on the diversity of surface O antigen Vibrio cholerae can be classified into 206 serogroups. Vibrio cholerae is the causative agent of cholera and extra intestinal infections like, septicemia, wound infection and haemorrhagic reactions. Pathogenic factors of V. cholerae extra-intestinal infection are yet to be explored. Aim: To identify the pathogenic factor associated with V. cholerae extra-intestinal infection. Materials and Methods: This study was carried out between April, 2007 to October 2007 in National Institute of Cholera and Enteric Diseases (NICED). Haemagglutinin Protease (HAP), a major secreted proteolytic enzyme, was purified from the culture supernatant of Vibrio cholerae O1 strain C6709 after removal of outer membrane vesicles using a single step ion-exchange chromatography. Function of HAP was characterized by animal model, like, subcutaneous mouse assay, basement membrane component’s degradation assays and tissue culture assays. Results: When suckling mouse was subcutaneously injected with culture supernatant of C6709 strain or purified HAP in both cases, distinct in vivo haemorrhagic response along with histopathological changes like necrosis of the capillaries and muscle layer, acute myofibre degeneration as well as moderate number of erythrocyte scattered through the skin, capillary necrosis, acute myofiber degeneration and necrosis of muscle layer were found. When Tryptic Soy Broth (TSB) media was used, the haemorrhagic effects in suckling mouse were not detectable. The major protein components, laminin and collagen, of basement membrane comprising of vascular endothelial cells, were degraded by HAP. Purified HAP showed cell rounding effects on Int 407 cells. Conclusion: Result indicates that HAP may be a causative agent of Vibrio cholerae mediated extra-intestinal infection. This study confirms that Vibrio cholera as a sole pathogen can cause the extra-intestinal infection. This information is important for public health notification. Besides this, result indicates appropriate testing for Vibrio cholerae and intervention are important for the patient management.

Hemostasis and Post-operative Care of Oral Surgical Wounds by Hemcon Dental Dressing in Patients on Oral Anticoagulant Therapy: A Split Mouth Randomized Controlled Clinical Trial
Introduction: Hemostasis is a fundamental management issue post-operatively in minor oral surgical procedures. To ensure safety and therapeutic efficacy in patients, under oral anti coagulant therapy, is complicated by necessity for frequent determination of prothrombin time or international normalised ratio. Aim: The aim of the study was to determine whether early hemostasis achieved by using Hemcon Dental Dressing (HDD) will affect post-operative care and surgical healing outcome in minor oral surgical procedures. Materials and Methods: A total of 30 patients, aged 18 years to 90 years, except those allergic to seafood, who consented to participate, were enrolled into this study. Patients were required to have two or more surgical sites so that they would have both surgical and control sites. All patients taking Oral Anticoagulation Therapy (OAT) were included for treatment in the study without altering the anticoagulant regimens. Institutional Review Board approval was obtained for the same. The collected data was subjected to statistical analysis using unpaired t-test. Results: All HDD surgically treated sites achieved hemostasis in 1.49 minutes and control wounds in 4.06 minutes (p < 0.001). Post-operative pain at HDD treated sites (1.87,1.27 on 1st and 3rd day respectively) was significantly lower than the control sites (4.0,1.87 on 1st and 3rd day respectively) p-value (0.001, 0.001 respectively). HDD treated oral surgery wounds achieved statistically significant improved healing both at 1st and 3rd post-operative days (p <0.0001). Conclusion: The HDD has been proven to be a clinically effective hemostatic dressing material that significantly shortens bleeding time following minor oral surgical procedures under local anaesthesia, including those patients taking OAT. Patients receiving the HDD had improved surgical wound healing as compared to controls.

Subtalar Joint Instability and Calcaneal Spurs Associated with the Configuration of the Articular Facets of Adult Human Calcaneum in Indian Population

Shilpi Agarwal, Shilpi Garg, Neelam Vasudeva
Introduction: Morphological variations of articular facets of calcaneum may predispose people to joint instability, ligamentous laxity and development of arthritic changes in the subtalar joint. Knowledge of such variations is essential for treatment and diagnostic procedures in orthopaedic surgeries. Aim: The aim of this study was to determine patterns of articular facets of calcanei and to establish its correlation with calcaneal spurs. Materials and Methods: The study was conducted on 580 adult calcanei of Indian origin at Maulana Azad Medical College and pattern of articular facets were observed and classified according to five patterns described in literature. A digital vernier calliper was used to measure separation between anterior and middle facet. Degree of intersecting angle between anterior and medial facets was calculated using UTHSCSA Image Tool software. The calcaneal spurs were observed by visual inspection. Results: Out of 580 calcanei, 66.55% had fused anterior and middle facets (Pattern I), 27.59% had all three facets separate (Pattern II), 5.52% had absence of anterior facet (Pattern III), 0.17% had all three facets fused (Pattern IV) and 0.17% had fused middle and posterior facets (Pattern V). A significant side variation was present in Pattern III with predominance on left side. Mean angle of intersection was 147.700 in Pattern I and 133.340 in Pattern II calcaneum. Calcaneal spurs were found in 61.38% out of which it was associated with Pattern I in 43.62%, Pattern II in 14.66% and Pattern III in 2.76%. Conclusion: Individuals with Pattern I and III calcaneum were found to be at a greater risk of subtalar joint instability than individuals with Pattern II. Angle of intersection was obtuse in Pattern I which resulted in ligament laxity and unstable joint. Pattern I was more common in Indian population and this fact necessitates modifications of the western surgical techniques to suit the Indian scenario. An association between the presence of spur and facet configuration was found to be significant.

Fungal Infection in Thermal Burns: A Prospective Study in a Tertiary Care Centre

Sanjeev Sharma, Deepak Bajaj, Pritika Sharma
Introduction: Burn Wound Infection (BWI) is primarily caused by aerobic bacteria followed by fungi, anaerobes and viruses. There has been a worldwide decrease in incidence of bacterial infections in burns due to better patient care and availability of effective antibiotics. Consequently, the fungal burn wound infection has shown an increasing trend. Aim: The aim of study was to assess the frequency of fungal infections in thermal burn wounds with respect to age of wounds, total body surface involved, depth of burns and to assess common fungal pathogens. Materials and Methods: The study was conducted on 50 patients admitted with thermal burn wounds having 20-60% burns in the surgical unit. Pus swab and scrapings were taken under local anaesthesia from each burn patient. Scrapings were put in a sterile container and sent to Mycology section of Microbiology department and were examined by direct microscopy and culture studies on Sabouraud’s Dextrose Agar medium in the Mycology section of Microbiology department. Results: In our study, the incidence of fungal infection in burn wound patients came out to be 26%. The incidence of fungal infection increased with increase in Total Body Surface Area, (TBSA) increase in depth and age of burn. In our study, the maximum positive fungal cultures were seen in the third week of post-burn period. No positive culture was seen in the first week and 30.76% positive fugal cultures were seen in second post-burn week. Candida albicans was found to be the most common organism followed by Non-albicans Candida and Aspergillus. Conclusion: It was concluded from the study that incidence of fungal infections in thermal burns increased with increase in post-burn period and with increasing depth and TBSA of burns. Candida albicans was found to be the most common fungus.

Diagnostic Accuracy of B-mode USG and Doppler Scan for Ovarian Lesions

Mamta Goyal, Vinish Kumar Agarwal
Introduction: Ultrasonography (USG) is considered as the primary imaging modality for confirmation of ovarian mass and to differentiate them in to benign or malignant. Aim: The present study was conducted with the aim to evaluate accuracy of B- mode USG and Doppler scan (Colour Doppler + Spectral Doppler) for ovarian lesions. Materials and Methods: The patients included in the study were from those referred with either palpable adnexal mass or incidentally detected adnexal masses. Total 250 women were evaluated by USG, Doppler scan. Only fifty patients who had true ovarian mass intraoperatively and on histopathology were included in study, rest masses were excluded. Study parameters were morphological indexing on B- Mode USG, flow study, vessel arrangement, and vessel morphology and vessel location in Colour Doppler and resistive index and pulsatility index in spectral Doppler. Results: Total 50 women were included in present study. Out of these 46% were pre-menopausal while 54% were menopaused women, 66.7% of post-menopausal women had malignant ovarian masses compared to 8.7% of premenopausal. Sensitivity, specificity, positive predictive value and negative predictive value of B-Mode USG for ovarian masses were 94.44%, 48.15%, 54.84% and 92.86% respectively, with p-value = 0.007, while sensitivity, specificity, positive predictive value and negative predictive value of Doppler scan were 85%, 90%, 85% and 90% respectively, with p-value = 0.0001. Conclusion: USG and its different techniques are accepted as the primary imaging modality for early stage diagnosis of an ovarian malignancy. Statistical analysis suggests that Doppler Scan (Colour + Spectral) was more accurate (88%) than B-Mode USG (67%), but author is in view that both of these modalities should be used in conjunction to screen the ovarian lesions.

Prehypertension and Its Determinants in Apparently Healthy Young Adults

Sunandha Senthil, Subbalakshmi Narasajjana Krishnadasa
Introduction: High incidence of prehypertension is reported in medical undergraduates. Prehypertension may progress to hypertension and eventually cardiovascular disease, a leading cause of morbidity and mortality. Therefore, identifying the risk factors of hypertension in prehypertensive state may aid in effective control of blood pressure. Aim: To find whether clustering of known risk factors of hypertension or certain individual risk factors alone affect blood pressure in young adults. Materials and Methods: This was a cross-sectional study done in 84 apparently healthy medical students of either sex aged between 18-23 years. It included students with at least one known risk factor of hypertension. Blood pressure levels of 120 to 139/80 to 89 mm Hg were defined as prehypertension. The risk factors considered were male gender, family history of cardiovascular disease, sedentary life, general and central obesity, sleep quality, perceived stress and dietary pattern. Clustering of risk factors was assessed based on collective scoring system in which each risk factor was scored appropriately. Statistical analysis was done by unpaired t, Chi-square and Pearson correlation coefficient tests. The p<0.05 was considered significant. Results: There was a positive correlation between total risk factor score and systolic blood pressure (r = 0.266, p = 0.015). Among the risk factors, frequency of males with systolic and diastolic prehypertension was higher compared to females (p <0.0001,= 0.022 respectively). Body mass index was higher in systolic and diastolic prehypertensives compared to normotensives (p <0.001, 0.002, respectively). Waist circumference was higher in systolic and diastolic prehypertensives compared to normotensives (p< 0.0001). Conclusion: In apparently healthy young adults, male gender and obesity are the major risk factors of elevated blood pressure.

Antimicrobial Efficacy of Various Essential Oils at Varying Concentrations against Periopathogen Porphyromonas gingivalis

Veenu Madaan Hans, Harpreet Singh Grover, Himanshu Deswal, Preeti Agarwal
Introduction: Porphyromonas gingivalis (P.gingivalis) is a notorious perio-pathogen with the ability to evade host defense mechanism and invade into the periodontal tissues. Many antimicrobial agents have been tested that curb its growth, although these agents tend to produce side effects such as antibiotic resistance and opportunistic infections. Therefore search for naturally occurring anti-microbials with lesser side effects is the need of the hour. Aim: The aim of this study was to substantiate the antimicrobial activity of various essential oils; eucalyptus oil, chamomile oil, tea tree oil and turmeric oil against P. gingivalis. Materials and Methods: Pure cultures of P. gingivalis were grown on selective blood agar. Antimicrobial efficacy of various concentrations of essential oils (0%, 25%, 50% and 100%) was assessed via disc diffusion test. Zone of inhibition were measured around disc after 48 hours in millimeters. Results: Zones of inhibition were directly proportional to the concentration of essential oils tested. At 100% concentration all the tested oils possess antimicrobial activity against P.gingivalis with eucalyptus oil being most effective followed by tea tree oil, chamomile oil and turmeric oil. Conclusion: All essential oils tested were effective against P.gingivalis. After testing for their clinical safety they could be developed into local agents to prevent and treat periodontitis.

Influence of Smile Arc and Buccal Corridors on Facial Attractiveness: A Cross-sectional Study
Introduction: Two aspects of the smile: the Smile Arc (SA) and Buccal Corridors (BC) have been the interest of the orthodontist in recent years. Aim: The present study was undertaken to evaluate the influence of the smile arc and buccal corridors on facial attractiveness as evaluated by orthodontists, general dentists and laymen. Materials and Methods: Two subjects (one male & one female) were selected from the regional population fulfilling the criteria of an ideal smile arc and ideal buccal corridors. Frontal smile view photographs of these subjects were taken and modified by using adobe photoshop 7.0 to create combination of three smile arc variance and three buccal corridors variations respectively which were shown to 25 orthodontists, 25 general dentists & 25 laymen, to rate the facial attractiveness of each image on a rating scale. Results: All the three groups (laypersons, dentists and orthodontists) showed significant difference in ratings, indicating that they had different perceptions on the facial attractiveness. Conclusion: Orthodontists were more precise in discerning the smile arc and buccal corridors compared to dentists and laypersons.

Evaluation of Xerostomia in Different Psychological Disorders: An Observational Study
Introduction: Psychiatric diseases like anxiety, depression, schizophrenia and bipolar disorders are increasing at an alarming rate. These diseases can affect the quantity and quality of saliva leading to multiple oral diseases. Although many researchers have evaluated xerostomia in general population, its prevalence is not been assessed in patients suffering from different psychological disorders. Aim: To investigate the prevalence of xerostomia and to assess the correlation between xerostomia and dryness of lip and mucosa in different psychological disorders. Materials and Methods: A cross-sectional observational study was conducted over a period of six months in Department of Psychiatry and Department of Oral Medicine. Patients with anxiety, depression, schizophrenia and bipolar disorder, as diagnosed by an experienced psychiatrist, were given a questionnaire to evaluate the xerostomia. Patients with symptoms of xerostomia were subjected to oral examination by a skilled oral diagnostician to check for dryness of lips and mucosa. One hundred patients from each group of psychiatric diseases were included in the study using a consecutive sampling technique. An equal number of healthy individuals reporting to oral medicine department for routine oral screening were included as control group after initial psychiatric evaluation. Results: In this study statistically significant increase in the xerostomia in psychiatric patients was recorded when compared to the control group (p<0.01). Xerostomia was significantly higher in anxiety patients (51%) followed by depression (47%), bipolar disorder (41%), schizophrenia (39%) and control group (27%). The majority of the psychiatric patients had ‘moderate’ to ‘severe’ xerostomia whereas the control group had ‘mild’ xerostomia. Xerostomia was significantly higher in younger age group (18–49 years) than in older age group and females patients had higher xerostomia than male patients. Psychiatric patients had significantly more dryness of lip and mucosa than healthy controls. A moderate to strong spearman correlation (r=0.72) was observed between xerostomia and psychological alterations. Conclusion: A positive association was established between psychological alterations and xerostomia and dryness of lip and mucosa. Emotional alterations may act as a precipitating factor that could influence the salivary secretion resulting in multiple oral diseases. Psychiatrists can screen for xerostomia and collaborate with dentists for comprehensive management of xerostomia in psychiatric patients.

Antegrade Unreamed Locked Intramedullary Nailing in Open Fractures of Shaft of Humerus

Amit Thakur, Jasbir Singh, Mukand Lal, Desh Raj Chandel
Introduction: Open fractures of shaft of humerus have been treated conservatively as well as operatively. Plate osteosynthesis has been considered as the gold standard treatment. Intramedullary nailing also has same success rate in closed fractures. The results of 30 open fractures of shaft humerus fixed with locked unreamed antegrade intramedullary nailing were evaluated. Aim: The purpose of the study was to evaluate the role of locked intramedullary nailing in open fractures of shaft humerus in terms of bone union, secondary procedure required, complication, shoulder dysfunction and infection. Materials and Methods: Of consecutive 365 humeral shaft fractures, 63 fractures were open. Thirty-two patients were operated with plate osteosynthesis, while 31 patients who were treated with locked unreamed intramedullary nails fulfilling the inclusion criteria entered the study. Results: Twenty eight of thirty patients united in mean duration of 10.5 weeks. There were two non-unions both of them united with bone grafting and plate osteosynthesis. Seven patients had superficial infection which healed with antibiotic course, while two patients had deep infection, which healed with repeat debridement. Eleven patients had preoperative radial nerve palsy, nine of which healed completely in average of six months. Twenty eight patients had excellent functional outcome at final follow-up while two patients had good outcome. Conclusion: Antegrade nailing is associated with good union rates and low infection rates and is a good option in open fractures and in polytrauma patients.

Knowledge, Attitudes and Practices (Kap ) Relating to Dietary Supplements Among Health Sciences and Non-Health Sciences Students in One of The Universities of United Arab Emirates (UAE)

Farah Kais Alhomoud, Mohammed Basil, Andrey Bondarev
Introduction: The use of Dietary Supplements (DS) has increased substantially in the United Arab Emirates (UAE) in recent years, despite the fact that the efficacy and safety of these supplements are not proven yet. In addition, the practices of supplement users in the UAE remain undocumented. Aim: To determine the usage of DS in health sciences and non-health sciences students; and to determine their knowledge, attitudes and practices (KAP) regarding these supplements. Materials and Methods: A descriptive, cross-sectional, questionnaire-based study was conducted among university students. Based on the Raosoft online calculator, it was anticipated that the sample of 383 students would enable us to achieve the study objectives. Students were recruited from Ajman University of Science and Technology and identified by the academic staff through students’ records. All students who were registered at Ajman University of Science and Technology – including medical (i.e. dental, pharmacy and health sciences) and non-medical colleges (i.e. engineering, business administration, law, information technology, mass communications and humanities) – were invited to participate, after obtaining the approval of the Institutional Ethics Committee (IEC), (during the period of January-February 2015). This study used quantitative method approach. Therefore, data were analysed quantitatively using SPSS version 22.0. Results: More than one-third of participants (39%) were found to consume DS. The most common reasons for consuming supplements were to maintain good health (58,21%) and ensure adequate nutrition (43,15%). Almost two-thirds of participants (65%) perceived that the best way to obtain nutrients is through food and DS together (49%), or DS alone (16%). Therefore, there was a relatively high amount of DS intake among participants in this study. With regard to medical and non-medical students’ use of DS, there were no significant differences in the use (p=0.139). However, other findings suggest that there are significant differences in the knowledge of health sciences and non-health sciences students pertaining to the health benefits and safety of these supplements (p<0.001), what they are (p=0.040) and the source of help that should be sought when using them (p<0.001). Conclusion: There is a relatively high prevalence of DS consumption among students, which they reported as using to maintain good health and ensure adequate nutrition. However, findings suggest that there are significant differences in the knowledge of health sciences and non-health sciences students pertaining to the health benefits and safety of these supplements. Therefore, awareness of DS usage and information should be integrated into everyday practice.

A Study to Assess the Validity of Estimation of Serum Ostase Level in Hyperthyroid and Hypothyroid Cases
Introduction: One of the more specific assessments of the metabolic status of bone in normal and in disease conditions is the measurement of bone specific alkaline phosphatase or ostase. The measurement of serum ostase has several advantages over the measurements of other bone parameter. Because of its relatively long half-life, in-vivo (1 to 3days), it is relatively unaffected by diurnal variation. Aim: To find the correlation of serum ostase level in hyper and hypothyroid cases and also to study the validity of routine estimation of serum ostase in hyper and hypothyroid cases so as to monitor the base level bone health on presentation. Materials and Methods: Serum ostase level was studied in 74 patients with disorder of thyroid function. Serum ostase level, Thyroid Stimulating Hormone (TSH), FT3, FT4 levels were estimated by chemiluminescent technique. The instrument used was Beckman- coulter Access 2. A total of 39 patients were hypothyroid, 31 were hyperthyroid and 4 patients had subclinical hyperthyroidism. Results: The serum ostase level was found to be elevated above 40 µg/L in 26 of the cases and above 16 µg/L but below 40µg/L in 5 cases of hyperthyroidism along with decrease in Bone Mineral Density (BMD). Serum ostase level was found to be directly proportional to the serum FT3 level (Normal range of serum ostase is 8-16 µg/L). Conclusion: From this study, an inference can be drawn that a routine estimation of serum ostase level in hyperthyroid cases will help in proper monitoring of decrease bone turnover as indicated by increase serum ostase level. Besides, the estimation of serum ostase level in hyperthyroid cases it is found to be valid in this study, which can turn to be an important guiding parameter to the treating physician to formulate necessary protocols and guidelines for prophylaxis, treatment and to monitor the response to therapy in cases of reduced bone turnover related to hyperthyroid state.

Prevalence and Predictors of Alcohol Consumption during Pregnancy in South-Eastern Nigeria
Introduction: Alcohol consumption during pregnancy is a major public health problem because of the enormous deleterious effects on a developing fetus. Sub-Saharan Africa (SSA) is among the highest per capita rates of alcohol consumption in the world, thus suggesting a high burden of Fetal Alcohol Syndrome Disorder (FASD) in the sub-region. Despite this, there is limited data on alcohol exposed pregnancies for most SSA countries including Nigeria. Aim: To determine the prevalence and predictors of alcohol consumption during pregnancy in Enugu, South-Eastern Nigeria. Materials and Methods: It was a cross-sectional study of 380 consecutive consenting parturients accessing antenatal care at the University of Nigeria Teaching Hospital, Enugu, Nigeria. The information sought for, included the women’s socio-demographic characteristics, alcohol use in pregnancy, awareness of the harmful effects of alcohol on the babies including FASD, sources of initial information on awareness, type and quantity of alcohol ingested, reasons for taking alcohol and willingness to stop alcohol ingestion in pregnancy after counseling on the risk of alcohol use in pregnancy. Statistical analysis was both descriptive and inferential at 95% confidence level. A p-value of less than 0.05 was considered statistically significant. Results: The prevalence of alcohol consumption in pregnancy was 22.6%. The most common brand of alcoholic beverage consumed was stout beer (62.8%, 54/86). A total of 135 (35.5%) respondents were aware that alcohol is harmful to the fetus. Maternal age 30 years or less, nulliparity, less than tertiary education, pre-pregnancy alcohol consumption and lack of awareness of the harmful effect of alcohol on the fetus, were associated with alcohol consumption during pregnancy (p< 0.05). Conclusion: The prevalence of alcohol consumption during pregnancy among women in Enugu, South-Eastern Nigeria is high and lack of awareness of harmful effect of alcohol on fetus was a major predictor. There is need for a concerted public health campaign to improve the awareness of harmful effects of alcohol on the fetus.

P3 Fraction: Effect on HbA1c Values by HPLC

Mrinal Gupta, Mohit Thalquotra, Pragna Rao
Introduction: The availability of the haemoglobin A1c test has been a major advance in diabetic care and its measurement has become an integral part for the management of diabetes. When glycated haemoglobin (HbA1c) is estimated by High Performance Liquid Chromatography (HPLC), one of the fractions that are eluted is known as “P3” fraction which is labelled as “degenerated haemoglobin”. The P3 fraction is not taken into account while estimating HbA1c or HbA values. Aim: To study the effect of P3 on the final reported value of HbA1c by HPLC and the significance of this fraction in the final chromatogram. The possibility that HbA1c fraction is under reported due to increase in P3 fraction was also examined. Materials and Methods: HbA1c, various fractions of HbA1 and P3 were estimated by HPLC method in 430 subjects. Patient data was divided into 3 groups on the basis of HbA1c% (group I - <6%, group II - 6 – 12%, group III - >12%). Result: P3% as well as P3 area increases as the HbA1c increases (p-value - <0.001). Statistical significant increase was seen as HbA1c% increases, P3% also increases and correlation (r = 0.6) became stronger with increasing HbA1c levels. HbA1a%, HbA1b% fraction increases with increase in HbA1c% and HbA1a area, HbA1b area also shows the same increase with increasing HbA1c%. Conclusion: From this study we conclude that sub fractions of glycated haemoglobin and P3 fraction influence the final reported value of HbA1c by HPLC. P3 fraction might indicate the possible presence of variant haemoglobin in the sample.

The Effect of Ridge Expansion on Implant Stability in Narrow Partially Edentulous Ridges - A Preliminary Clinical Study
Introduction: Currently, dental treatments with better aesthetic results and less treatment time is more acceptable by the patients. Inadequate amount of bone for implant placement at functionally and aesthetically most appropriate position is a common problem. Aim: To assess the effect of ridge expansion on implant stability in narrow partially edentulous ridges and to evaluate clinically and radiographically the success of dental implants, placed immediately following ridge expansion procedure. Material and Methods: Ten participants (nine males, one female, average age - 28 years) with partial edentulism associated with narrow atrophic alveolar ridges with adequate height and willing to participate in the study were included. The ridge expansion was performed using osteotomes and simultaneous implant placement was done. A total of 10 implants were placed. Stability, achieved ridge width and radiographic crestal bone loss were assessed three months post-operatively. Results: Three months follow-up revealed stable implants both clinically and radiographically. All 10 implants were surrounded by adequate amount of bone required for successful functional rehabilitation. Conclusion: The study reveals that the technique of ridge expansion using osteotomes is successful in horizontal expansion, in cases of atrophic alveolar ridges thus, eliminating the need for more complex treatment as well as reduces the rehabilitation time along with improving the quality of bone support.

Role of Urinary and Serum Carbohydrate Antigen 19-9 as a Biomarker in Diagnosis of Adult Giant Hydronephrosis
Introduction: The most common cause of adult Giant Hydronephrosis (GH) is congenital Uretero-Pelvic Junction (UPJ) obstruction. Conventional imaging modalities, like Intravenous Urography (IVU) and Computed Tomography Urography (CTU) and radionuclide renal scan can be fallacious. Serum carbohydrate antigen 19-9 (CA19-9) is a useful tumour marker for gastrointestinal and pancreatic cancer. Only a few studies and case reports have shown raised serum levels due to benign hydronephrosis and GH. Aim: To investigate the prognostic role of urine and serum CA19-9 in the diagnosis and follow-up of adult GH due to UPJ obstruction. Materials and Methods: The present hospital based observational study was conducted on 24 adult patients (Group 1) with unilateral GH due to UPJ obstruction. Twenty four healthy adults were included as control (Group 2). Serum and voided urine samples were collected to evaluate Carbohydrate Antigen (CA) 19-9 in each group. During surgery, urine from the affected pelvis was collected to determine CA19-9 level. Patients were followed up after surgery at 3 and 9 months with serum and voided urine samples for CA19-9 level. Results: Preoperative Serum and voided urine CA19-9 were significantly greater in Group1 than in controls, which significantly correlated inversely with preoperative percentage renal function and glomerular filtration rate. Postoperative improvement in renal function significantly correlated inversely with serum and voided urine CA19-9 at 3 and 9 months. Conclusion: Voided urine CA19-9 can be a non-invasive clinical marker in adult GH due to UPJ obstruction. The clinical implications of these data for diagnosis and follow-up of these patients are significant. Our findings suggest, significant decrease in urinary Ca19-9 level during follow-up is predictive of excellent surgical outcome and resolution of renal damage.

Ischemia Modified Albumin as a Marker of Oxidative Stress in Normal Pregnancy

Jyotirmayee Bahinipati, Prakash Chandra Mohapatra
Introduction:Normal pregnancy is always associated with immense stress in order to accommodate the increasing demands of the developing fetus. Various metabolic changes along with vascular remodeling occur in maternal system. Due to this, pregnancy is always associated with oxidative stress and generation of Reactive Oxygen Species (ROS). Ischemia Modified Albumin (IMA) generated by ROS is found to be sensitive and early biochemical marker of ischemic heart disease and now used as an important marker to distinguish between ischemic and non-ischemic pathologies. Pregnancy being a hypoxic ischemic condition may lead to increase in serum IMA. Aim: The present study was aimed at evaluating maternal serum Ischemia Modified Albumin (IMA) in normal pregnancy and correlate it with serum Malondialdehyde (MDA), a known lipid peroxidation marker. Similarly IMA/Albumin was evaluated for correction of decrease in serum albumin in pregnancy and correlated with serum MDA. Materials and Methods: Serum IMA, IMA/Albumin and MDA was analysed in 40 healthy normal pregnant women and 41 non-pregnant healthy controls. Serum IMA was estimated by albumin cobalt binding test. Student t-test and Pearson’s correlation coefficient was used for statistical analysis. Results: Serum IMA and IMA/Albumin was significantly higher (p < 0.001) in normal pregnant women (72.54±9.89 U/L, 20.16±3.94) compared to non-pregnant healthy control (48.47±8.30 U/L, 10.51±1.76). Serum MDA was also significantly higher in normal pregnant women. A statistical significant positive correlation was found between serum IMA, IMA/Albumin with MDA in normal pregnant women. Conclusion: Maternal serum IMA is also increased in normal pregnancy and its correlation with MDA shows maternal serum IMA, can be considered as the marker of oxidative stress and can be used to monitor the progress of pregnancy, which may be remarkably increased in various complications related to pregnancy.

Effect of Guava in Blood Glucose and Lipid Profile in Healthy Human Subjects: A Randomized Controlled Study

Suchitra Kumari, R Rakavi, Manaswini Mangaraj
Introduction: The fruit of Psidium guajava (P.guajava) is known to contain free sugars yet the fruit juice showed hypoglycaemic effect. Hypoglycaemic activity of guava leaves has been well documented but not for guava fruit. Aim: So we aimed to evaluate the effect of ripe guava (with peel and without peel) fruit supplementation on blood glucose and lipid profile in healthy human subjects. Materials and Methods: Randomized Controlled study undertaken in: 1) Baseline; 2) 6 weeks supplementation phase. Forty five healthy MBBS students were included and randomly enrolled into Group A, Group B and Group C. In Baseline phase: Fasting Plasma Glucose (FPG) and serum lipid profile was done in all 3 groups. Group A were supplemented with 400g of ripe guava with peel and group B without peel, for 6 weeks. Rest 15 treated as control i.e., Group C. Result: Supplementation of ripe guava fruit with peel reduced BMI as well as blood pressure (p<0.05) in group A, whereas the FPG, Total cholesterol, Triglycerides were found significantly increased (p<0.05). Group B registered a significant fall (p<0.05) in BMI as well as blood pressure. Fall in FPG level after guava pulp supplementation was not significant. Serum Total cholesterol, Triglycerides and Low Density Lipoprotein Cholesterol (LDLc) levels decreased significantly (p<0.05) indicating that guava pulp without peel may have a favourable effect on lipid levels and blood sugar as well. Conclusion: Guava fruit without peel is more effective in lowering blood sugar as well as serum total cholesterol, triglycerides and LDLc. It increases HDLc levels also.

Antimicrobial Efficacy of Contemporary Obturating Materials used in Primary Teeth- An In-vitro Study
Introduction: Preservation of primary tooth with non-vital pulp has been a major problem for pediatric dentist. In such cases, the preferred treatment modality is pulpectomy. The objective of pulpectomy is complete removal of necrotic and irreversibly infected pulp of an affected tooth but, in spite of chemomechanical preparation and copious irrigation of canal, there are chances of failure of pulp therapy due to the entrapped micro organisms in the canal space owing to the tortuous and complex nature of the root canal system and change in their morphology with root resorption. Thus, for optimal success of endodontic treatment, obturating material with antimicrobial properties is advocated in deciduous teeth. Aim: The aim of the study was to assess the antimicrobial efficacy of different obturating materials used in pediatric dentistry. Materials and Methods: In the present study, antimicrobial efficacy of endoflas, Zinc Oxide Eugenol (ZOE), calcium hydroxide with chlorhexidine, calcium hydroxide with iodoform and distilled water, metapex and saline as control were assessed and compared with each other. The antimicrobial efficacy of obturating materials was evaluated against E. faecalis (ATCC 29212) by agar diffusion method. The statistical analysis was done using SPSS Version 15.0. The Analysis of Variance (ANOVA) and Post-Hoc Tests (Tukey-HSD) were performed to reveal the statistical significance. Results: Intergroup comparison at 24 hours (Tukey’s test) revealed significant difference amongst all the groups. Endoflas had significantly higher zone of inhibition as compared to all the other groups except group treated with ZOE (p-value <0.001). Conclusion: The antimicrobial activity of obturating materials according to results obtained from the present study can be summarized as follows: Endoflas > ZOE >Calcium hydroxide + Chlorhexidine > Calcium hydroxide + Iodoform +Distilled water ~ Metapex > Saline.

Variations in the Origin and Course of Right Hepatic Artery and its Surgical Significance
Introduction: Variations in the Right Hepatic Artery (RHA) are exceedingly common and these variations are of great importance to surgeons and interventional radiologists. A thorough knowledge of the right hepatic arterial anatomy is mandatory while performing hepatic surgery and hepatic arteriography. Aim: To find out the variations in the origin and course of the RHA and its surgical significance. Materials and Methods: This study was conducted in 60 embalmed adult cadavers of both sexes of age group between 50 to 80 years. Abdomen was opened by a linear midline incision extending from the xiphoid process to the pubic symphysis. The origin of RHA from the proper hepatic artery was traced. The presence of aberrant right hepatic arteries -replaced and accessory were noted. The source of origin of accessory or replaced RHA arising from the superior mesenteric artery (SMA), right renal artery and inferior mesenteric artery was traced. The course of normal and aberrant RHA from its origin to the entrance into the right lobe of the liver was followed and structures related to it were noted. Results: The RHA mostly originated from the main trunk of the proper hepatic artery in 52 specimens (86.6%). Presence of aberrant RHA was found in 8 specimens (13.3%). Among 8 specimens of aberrant RHA, replaced RHA arising from SMA was found in 5 specimens (8.3%) and accessory RHA arising from SMA was observed in 3 specimens (5%). In 86.6% of specimens, the RHA coursed dorsal to the duct system to enter the Calots triangle. In 8.3% of specimens, the RHA coursed ventral to duct system to reach the Calots triangle. The caterpillar like loop of the RHA was found in two specimens (3%). The replaced and accessory RHA (13.3%) arising from the SMA had a course dorsal to duct system to reach the Calots triangle. Conclusion: Right hepatic artery is subject to anatomical variation in its origin and course. Our study identified the variations in the origin and course of right hepatic artery. Adequate knowledge of these variations would be of incredible help to the hepatobiliary surgeon and interventional radiologist.

Assessment of Function of Eustachian Tube in Oral Submucous Fibrosis – A Tympanometric Study

Alagiri Chandran, Nalini Aswath
Introduction: Oral Submucous fibrosis (OSMF) is a chronic insidious disease of oral mucosa that occurs due to areca-nut chewing, consumption of chillies, autoimmunity and genetic predisposition. The disease starts with burning sensation and inability to tolerate spicy foods with gradual reduction in mouth opening due to fibrosis of the oral mucosa. The extension of fibrosis into the naso pharynx leads to reduction in hearing efficiency. It is a potentially malignant lesion and can transform into oral cancer. Aim: To assess the functional impairment of eustachian tube by audiogram and tympanometry in both ears in stage IV and stage III OSMF cases. Materials and Methods: This was a case-control study in which 30 cases of OSMF, which included 15 stage IV (30 ears), 15 stage III (30 ears) were compared with 15 normal controls. Results: 1) Stage IV cases showed 76.3% positive audiogram with 63.3% of cases having Sclerosis of tympanic membrane i.e. As curve in Tympanogram; 2) 43.3% of Stage III cases showed positive audiogram with 46.7% of cases having Sclerosis of tympanic membrane i.e. As curve in tympanogram; 3) 100% negative audiogram with 100% normal A curve was seen in all controls. Conclusion: From this study, it is evident that functions of Eustachian tube were affected as fibrosis of oral mucosa progressed.

Living with Amputation: Anxiety and Depression Correlates

Sukriti Bhutani, Jaikrit Bhutani, Anurag Chhabra, Rajesh Uppal
Introduction: Trauma accounts for 16% of the total burden of disease in the world, making it a leading cause of morbidity and mortality especially in the developing nations. India represents about 10% (225million) of the total world workforce in agriculture. With the evolution of new machinery and better techniques of agriculture, there has been a substantial increase in the associated injuries. Depression, anxiety and post-traumatic stress are among the predictors of poor quality of life (QOL). Aim: This study was aimed to assess and correlate of traumatic amputation on the patient’s mental health in the Northern Indian rural setting. Materials and Methods: This cross-sectional study included subjects who had undergone traumatic amputations. A pre-tested, semi-structured questionnaire was administered to each study participant after an informed verbal consent. The questionnaire had two parts. The first part gathered socio-personal and the disability related information from the patient and the second part included a Hospital Anxiety and Depression Scale (HADS). Results: The mean anxiety and depression scores were 9.10±5.7 and 3.44±3.42, respectively. The length of original inpatient stay, people at hand for help, number of hospitalizations, number of follow ups per year, type of family (nuclear versus joint), pain perception, optimism, rehabilitation satisfaction and lower limb amputations correlated significantly with anxiety levels in the patients. The depression levels correlated significantly only with perception of pain. Conclusion: The amputees have a large number of psychosocial concerns which need to be addressed to provide a holistic care and a better QOL. It is essential to sensitize the community, the health care providers and the patient’s family to the additional psychosocial needs of the amputee.

Screening for Intestinal Colonization with Vancomycin Resistant Enterococci and Associated Risk Factors among Patients Admitted to an Adult Intensive Care Unit of a Large Teaching Hospital

Rajesh Amberpet, Sujatha Sistla, Subhash Chandra Parija, Molly Mary Thabah
Introduction: Gut colonization with Vancomycin Resistant Enterococci (VRE) increases the risk of acquiring infection during hospital stay. Patients admitted in the ICU’s are the major reservoirs for VRE colonization due to higher antibiotic pressure. Aim: To determine the rate of VRE colonization among patients admitted in the Medical Intensive Care Unit (MICU) and to assess the various risk factors which are associated with VRE colonization. Materials and Methods: This was a prospective study carried out over a period of 18 months from September 2013 to February 2015 in the Jawaharlal Institute of Post graduate Medical Education and Research (JIPMER), Pondicherry, South India. After 48 hours of ICU admission rectal swabs were collected from a total of 302 patients, admitted in MICU. The samples were inoculated on to Bile Esculin Sodium Azide agar with 6mg/L of vancomycin. Vancomycin resistance was confirmed by determination of Minimum Inhibitory Concentration (MIC) by agar dilution method. Isolates were identified up to species level by standard biochemical tests. Vancomycin resistance genes such as van A, van B and van C, were detected by Polymerase Chain Reaction (PCR). Risk factors were assessed by multivariate logistic regression analysis. Results: The rates of VRE colonization in patients admitted to MICU was 29%. Majority of the isolates were Enterococcus faecium (77.2 %) followed by Enterococcus faecalis (23.8%). All the VRE isolates were positive for van A gene. Increased duration of hospital stay, younger age, consumption of ceftriaxone and vancomycin were found to be significantly associated with VRE colonization in MICU. Among VRE colonized patients, six (4.5%) acquired VRE infection. Conclusion: The rates of VRE colonization in our ICU were similar to other hospitals worldwide. Educating health care workers on the importance of adherence to hand hygiene is essential to bring down VRE colonization rates.

Risk Stratification in Paragangliomas with PASS (Pheochromocytoma of the Adrenal Gland Scaled Score) and Immunohistochemical Markers
Introduction: Paragangliomas (PGLs) are rare tumours that arise in sympathetic and parasympathetic paraganglia and are derived from neural crest cells. Presence of metastasis is the only absolute criterion for malignancy. There is no single histo-morphological feature indicating malignant potential and multiple parameters have been proposed to prognosticate the individual case. This includes studies conducted using Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) and Immunohistochemical (IHC) markers. Aim: We have studied ten cases of paraganglioma and attempted to correlate the prognosis with multiple clinicopathological variables. Materials and Methods: This study was done in a tertiary care general hospital over a period of five years. Available clinical records and histopathology slides of all patients were reviewed. Using Pheochromocytoma of the Adrenal Gland Scaled Score (PASS), we divided the cases into two groups-tumours showing high risk behaviour (PASS≥4) and tumours showing benign behaviour (PASS<4). IHC analysis was done using synaptophysin, chromogranin, S100 and Ki67. We correlated S100 immunoreactivity and Ki67 proliferative index with PASS score. Both PASS score and IHC markers were also correlated with clinical outcome. Results: There were six Pheochromocytomas (PHC) and four Paragangliomas (PGL). Two paragangliomas were retroperitoneal and one each was located in ear (HNPGL) and broad ligament. PASS score was ≥ 4 in five cases and <4 in five cases. Out of five cases in which PASS was ≥ 4, three cases showed clinical evidence of malignancy and two cases were benign. All the cases in which PASS was <4 were clinically benign. S100 immunoreactivity was grade 1 in two cases, grade 2 in six cases and grade 3 in two cases. The cases in which S100 immunoreactivity was grade 1 were malignant. One case in which S100 was grade 2 was clinically malignant. Ki67 labeling index was raised (>3%) in two cases, which were malignant correlated with malignant PASS score. Conclusion: We conclude that the following clinicopathological parameters should be taken into account for risk assessment of malignant behaviour of paragangliomas- location, size, PASS score, S100 immunoreactivity and Ki67 labeling index.

Autonomic Reactivity Differs in Young Adults Classified using Revised Indian and WHO Guidelines for Obesity

Arohi Jain, Nikhilesh Singh, Richa Gupta
Introduction: Many studies have reported alteration in autonomic activity in obesity. However, there is paucity of literature comparing autonomic reactivity using different guidelines of obesity. As Indian guidelines were revised recently and WHO states that countries should use all categories of BMI for reporting purposes, it is prudent to compare physiological state in different categories of BMI. Aim: The aim of the present study was to compare the autonomic alteration in young adults using revised Indian and WHO guidelines for obesity. Materials and Methods: A battery of autonomic tests (Valsalva Manoeuvre (VM), Deep Breathing Test (DBT), Lying to Standing Test (LST) and Hand Grip isometric exercise Test (HGT) was conducted on 34 overweight and obese and 30 normal weight volunteers categorised using revised Indian guidelines of body mass index. Same participants were regrouped and analysed using WHO guidelines of BMI and waist hip ratio (WHR). Results: For analysis, participants were grouped into 3 categories of normal, overweight and obese using revised Indian guidelines for obesity. Same participants were regrouped according to WHO guidelines. E:I ratio during DBT, 30:15 ratio during LST, Valsalva ratio during VM and increase in DBP during HGT were compared in different subgroups. There was no difference in sympathetic and parasympathetic activities in participants classified according to revised Indian guidelines. In participants classified using WHO criteria, sympathetic reactivity in overweight subjects was significantly less as compared to normal subjects (p<0.05). Conclusion: Autonomic alterations might be more related to body fat percent rather than BMI. Indian guidelines are based on the observation that Asian population has more adipose tissue in WHO range of BMI. As the guidelines of BMI are applicable to all age groups and do not consider physical activity profile, they might still not be a good predictor of body fat.

Seroprevalence of Human Immunodeficiency Virus Among Antenatal Women in One of the Institute of Northern India

Preetkanwal Sibia, Manjit Kaur Mohi, Amith Kumar
Introduction: As per NACO publication there are an estimated 2.08 Million HIV/AIDS cases in India as of February 2014. The estimated adult HIV prevalence in India is 0.27%, with a gender spit of 0.32% males and 0.22% females. Estimating the seroprevalence of HIV in a low risk population such as pregnant women provides essential information for an effective implementation of AIDS control programmes. In spite of an estimated adult HIV prevalence rate of 0.18% in Punjab, there are no previous studies among antenatal women to assess seroprevalence. Aim: To assess the prevalence of HIV infection, among otherwise healthy pregnant females. Materials and Methods: This retrospective study reviewed treatment records of 3686 antenatal women who underwent HIV testing. Demographic, obstetric and laboratory data was recorded into a preset proforma. Available data was analysed using SPSS version 13. Results: Total of 38 subjects tested positive for HIV infection. Seroprevalence rate was 1.03%. A 25 -30 years age group had most number of infected individuals with 22 (57.89%) subjects. Seropositivity was common among rural domicile. Only 9 (23.68%) was aware of their seropositive status. A total of 20 (52.63%) subjects were illiterate, 14 (36.84%) had received primary school education. Conclusion: Seroprevalence rate of 1.03% reported in this study has been the highest among the contemporary articles published in last decade. Efficient surveillance along with proper implementation of Prevention of Parent to Child Transmission (PPTCT) is the need of the day. A prompt action at the hands of the authority will enable us to safeguard our present and future alike.

Association between Chewing Side Preference and Dental Caries among Deciduous, Mixed and Permanent Dentition
Introduction: Chewing Side Preference (CSP) is said to occur when mastication is recognized exclusively/consistently or predominantly on the same side of the jaw. It can be assessed by using the direct method - visual observation and indirect methods by electric programs, such as cinematography, kinetography and computerized electromyography. Aim: The present study was aimed at evaluating the prevalence of CSP in deciduous, mixed and permanent dentitions and relating its association with dental caries. Materials and Methods: In a cross-sectional observational study, 240 school going children aged 3 to 18years were randomly allocated to three experimental groups according to the deciduous dentition, mixed dentition and permanent dentition period. The existence of a CSP was determined using a direct method by asking the children to chew on a piece of gum (trident sugarless). The Mann Whitney U-test was used to compare the CSP and also among the boys and girls. The Spearman’s Correlation Coefficient was used to correlate CSP and dental caries among the three study groups and also among the groups. Results: CSP was observed in 69%, 83% and 76% of children with primary, mixed and permanent dentition respectively (p>0.05). There was no statistically significant association between the presence of CSP and dental caries among the three study groups. Conclusion: There was a weak or no correlation between gender and distribution of CSP and between presence of CSP and dental caries.

Does 24bp Duplication of Human CHIT1 Gene (Chitotriosidase1) Predispose to Filarial Chyluria? A Case-Control Study
Introduction: Chyluria which is endemic in many parts of the world is mainly caused by Wuchereria bancrofti. CHIT1 (chitotriosidase) is produced by macrophages and plays an important role in the defense against chitin containing pathogen such as filarial parasite. Variation in the coding region with 24 bp duplication allele results in reduced CHIT1 activity that enhance the survival of parasite which may play a role in the occurrence of disease. Aim: To examine the role of 24bp duplication of CHIT1 gene in patients of filarial chyluria (FC). Materials and Methods: A case-control study was carried out where 155 confirmed FC patients and equal number of age-, sex- and residence-matched controls without any symptoms or signs of lymphatic filariasis, confirmed by negative immunochromatographic card test (ICT) and IgG/IgM combo rapid antibody test, from a hospital-based population were enrolled. Filarial aetiology was confirmed on the basis of DEC-provocative test (Giemsa staining), ICT and IgG/IgM- antifiarial antibody test. The patients positive by either of these tests were enrolled as FC cases. 24bp duplication in CHIT1 gene in FC was detected by the product size 99bp of amplified gene using polymerase chain reaction. Results: The mean ages of patients and controls were 38.25±12.09 and 35.45±12.53 years, respectively while male: female ratio was 2.4:1. The mean duration of illness in chyluria patients was 62.81±60.83 months and mean number of episodes was 2.54±1.11. Homozygous wild type, heterozygous and homozygous mutant frequencies were 10.3%, 81.3% and 8.4% in FC patients and 18.7%, 75.5%, and 5.8% in controls, respectively. The 24bp duplication in CHIT1 gene showed a significant association in Heterozygous (HT) genotype with Odd Ratio (OR) of 1.95, 95% Confidence Interval (CI) (1.01-3.77); p=0.04. However, the homozygous mutant genotype (TT) was found to be non-significant with OR of 2.61, 95% CI (0.91-7.45); p=0.07. The combination of both HT+TT was also found to be significant with OR of 2.00, 95% CI (1.03-3.85); p=0.03. Conclusion: In this study from Northern India, CHIT1 gene polymorphism showed an influence as a possible risk factor for susceptibility to FC. Further studies need to be done on a larger number of FC patients in different regions of the country.

Act Fast as Time Is Less: High Faecal Carriage of Carbapenem-Resistant Enterobacteriaceae in Critical Care Patients

Sanjith Saseedharan, Manisa Sahu, Edwin Joseph Pathrose, Sarita Shivdas
Introduction: Carbapenem-resistant Enterobacteriaceae (CRE) are drug-resistant Gram-negative bacteria that are present in the community as well as in hospitals. Their infection and colonisation puts critically ill patients at high risk due to the drug-resistant nature of the strains and possible spreading of these organisms, even in a hospital environment. Aim: To examine the presence and types of Enterobacteriaceae species in patients admitted directly from the community. Materials and Methods: The present study was a one-month pilot conducted in the ICU of a tertiary care hospital in Mumbai, India in 2015. Faecal samples of patients admitted from the community directly to the ICU were analysed using tests like MHT (Modified Hodge) and EDTA for the presence of IMP (action on Imipenem) and KPC (Klebsiella Test Pneumoniae Carbapenemase) producing strains of Enterobacteriaceae. Polymerase Chain Reaction (PCR) was performed to look for VIM, IMP, NDM1, OXA, and KPC genes. Antibiotic Sensitivity Test was carried out as per CLSI guidelines. Results: The results showed an alarming level of faecal carriage rates in adult ICU patients. Klebsiella pneumonia was the most common carbapenem-resistant isolate, closely followed by Escherichia coli. PCR results revealed nine strains were positive for bla(KPC) gene, from which 7 were Klebsiella pneumoniae and one each of Escherichia coli and Klebsiella oxytoca was observed. Antibiotic Sensitivity Test results showed that the isolates had maximum sensitivity to Colistin (100%) and Tigecycline (95%). Conclusion: These levels indicate that in the absence of CRE screenings, proper isolation of carrier patients is not possible, leading to possible spreading of these resistant bacteria strains in ICUs. A longer period of study is required to obtain more substantial data to validate the results of this pilot.

The Effect of Oxygen Inhalation Plus Oxytocin Compared with Oxytocin Only on Postpartum Haemorrhage: A Randomized Clinical Trial

Zainab Suhrabi, Hamid Taghinejad, Ashraf Direkvand-Moghadam, Malihe Akbari
Introduction: Post Partum Haemorrhage (PPH) is the leading cause of maternal mortality across the world, mainly in the developing countries. Aim: The present study was conducted with the aim to investigate effect of oxygen inhalation plus oxytocin compared with oxytocin only on PPH. Materials and Methods: This study was a clinical trial which was performed in Shahid Mustafa Khomieni Teaching Hospital of Ilam (western Iran) from April 2012 to Nov 2013. One hundred and twenty pregnant women who were referred to delivery ward for normal vaginal delivery were selected with convenience sampling method and they were randomly assigned into two groups. For both groups management of the third stage of labour was done using 1000CC Ringer and 20 units of Oxytocin. In the intervention group, in addition to the routine administration, 8 liters of oxygen via face mask was used continuously until 2 hours after delivery. Blood loss was determined by regular weighing of the buttocks that were previously weighted. The difference was calculated before and after weighing (1 gram increasing of weight was considered to be equivalent to 1CC blood loss). Data were analysed by SPSS 16 version using Student- t and Chi-square tests. Results: The two groups were homogenous in regard to all the base line variables. The study results indicated that the mean of blood loss were (256.16±97) ml at two hours after delivery in the control group and (149.5±46.49) ml in the intervention group. There was a significant difference between PPH of the two groups (p<0.006). Conclusion: Research findings showed that the use of inspired oxygen during the third stage of labour and oxytocin infusion during 2hours later resulted in a significant decreasing in the amount of bleeding after normal vaginal delivery.

Nursing Instructor and Students' Perspectives on Clinical Education Apprenticeship Problems

Ali Hasanpour-Dehkordi, Masoumeh Shohani
Introduction: Different problems might lead to reduction in the efficiency of nursing students apprenticeship education and solving those problems. Aim: This study was conducted to determine nursing internship problems from the perspective of trainers and students. Materials and Methods: In this descriptive cross-sectional study, 20 trainers and 43 senior students of nursing were selected using census method. A researcher-made questionnaire was used to collect data. Total internal consistency (a) of the questionnaire was 0.88 and had proper convergent validity. SPSS was used to analyse data with applying descriptive and inferential statistics. Results: More than 50% considered their course relatively weak or weak in helping intern nurses to acquire comprehensive view of the nursing profession that takes a social perspective into account, skills required for the processes of nursing and instructing patients. Problems such as insufficient access to welfare and educational facilities, lack of co-operation among clinical team and scattering of internship sessions during a course were mentioned by nurses and their trainers. They believed that changes must take place in the way internship courses are carried out. Conclusion: Although the internship courses seem to achieve their aim of improving students skills and independence in providing different nursing services to students and their trainers generally have a positive attitude towards such courses, there are still problems in effective exercise of the training.

The Effect of Anti-Thyroid Peroxidase Antibodies on Pregnancy Outcomes in Euthyroid Women

Monika Meena, Seema Chopra, Vanita Jain, Neelam Aggarwal
Introduction: Thyroid autoimmunity can have an adverse impact on the outcome of the pregnancy. Although the adverse effects of antithyroid antibodies have been well studied in hypothyroid women, their effects in euthyroid women are not well evaluated. Aim: The study was conducted to assess the overall prevalence of anti-Thyroid Peroxidase (anti-TPO) antibodies in pregnant women and the effect of anti-TPO positivity on the outcome of pregnancy in euthyroid women. Materials and Methods: One thousand Indian women, in their first trimester were screened for anti-TPO antibodies to know the prevalence. Of this, euthyroid women who were positive for the presence of anti-TPO antibody were selected and their obstetric history was recorded. These women were followed up and the incidences of maternal and foetal complications were recorded. The complications were compared with the past obstetric history and outcomes in parity and gestation matched controls (anti-TPO negative). Results: The prevalence of anti-TPO positivity was 11% (n=110). Out of the positives, those with elevated Thyroid Stimulating Hormone (TSH) were 6.5%. The prevalence of euthyroid women who were anti-TPO positive was 4% (n=40). Anti-TPO positive, euthyroid females had a higher prevalence of infertility, anaemia and preterm delivery as compared to the controls (p<0.0001). No differences were observed between the two groups in terms of history of abruption recurrent abortions, intrauterine growth restriction, postpartum haemorrhage, symptomatic hypothyroidism, hypertensive disorders of pregnancy and foetal complications. Conclusion: Anti-TPO positivity is common in pregnant women. Anti-TPO positive euthyroid females had a higher prevalence of infertility, anaemia as well as preterm delivery. Our results indicate that anti-TPO screening in pregnancy, may aid in early identification of the women at risk.

A Randomized Controlled Study to Compare Conventional and Evidence Based Treatment Protocols in Fresh Compound Fractures

Kanika Mahajan, Vikas Verma, Girish Kumar Singh, Santosh Kumar, Sachin Avasthi
Introduction: A recent concept review in Journal of Bone and Joint Surgery (JBJS) outlines evidence to control peri-operative infections in compound fractures. However, evidence for impact of adopting a protocol combining measures that have some evidence is lacking in literature. The present method of treatment at King George’s Medical University (KGMU) is representative of the conventional practice of managing compound fractures in India and is an appropriate control for trial against the Experimental Evidence Based Protocol (EBP). Aim: To study the additional impact of adopting Evidence Based Protocol on parameters defining infection rate and bone union. Materials and Methods: This randomized controlled study was conducted at the orthopaedics department of KGMU. Two hundred and twenty six patients of compound fractures of both bone leg, age > 12y were randomized to two groups. One group received standard treatment and the experimental group received treatment as per JBJS review. Statistical Analysis: Random allocation was tested by comparing baseline characteristics of the two groups. The two groups were compared for all the outcome variables in terms of time to a negative wound culture, time to wound healing, time to union at fracture site and time to achieve complete range of motion at knee joint. Results: Random allocation was successful. EBP group reported significantly lesser time to a negative culture report from wound (mean in conventional=4.619, experimental=1.9146, p=0.0006), lesser time to bony union (mean in conventional=23.8427 weeks, experimental=22.8125 weeks, p=0.0027), lesser time to wound healing (mean in conventional=14.4425 weeks experimental=10.4513 weeks, p=0.0032), and a lesser duration of hospital stay (mean in conventional=6.5982 days, experimental=4.5000 days, p=0.0343). Conclusion: EBP based on the guidelines suggested by Fletcher et al., significantly shorten the time taken for achieving a negative culture and hasten wound and fracture healing. Therefore EBP is recommended for use in settings like the KGMU trauma center.

Quantification of DNA Extracted from Formalin Fixed Paraffin-Embeded Tissue Comparison of Three Techniques: Effect on PCR Efficiency
Introduction: Mutation detection from Formalin Fixed Paraffin-Embedding (FFPE) tissue in molecular lab became a necessary tool for defining potential targeted drug. Accurate quantification of DNA extracted from FFPE tissue is necessary for downstream applications like Polymerase Chain Reaction (PCR), sequencing etc. Aim: To check and define which method for FFPE DNA quantification is suitable for downstream processes. Materials and Methods: In this experimental experience study Biorad Smartspec Plus spectrophotomery, Qubit Fluorometer, and Qiagen Rotorgene qPCR was used to compare 20 FFPE DNA quantification in Rajiv Gandhi Cancer Institute and Research Centre, in 2015 and quantified amount of DNA used for PCR reaction. Results: The average concentration of DNA extracted from FFPE tissue measured using the spectrophotometer was much higher than the concentration measured using the Qubit Fluorometer and qPCR. Conclusion: Results varied depending upon the technique used. A fluorometric analysis may be more suitable for quantification of DNA samples extracted from FFPE tissue compared with spectrophotometric analysis. But qPCR is the best technique because it details DNA quantity along with quality of amplifiable DNA from FFPE tissue.

An Examination of Income Effect on Consumers’ Ethical Evaluation of Counterfeit Drugs Buying Behaviour: A Cross-Sectional Study in Qatar and Sudan
Introduction: There are limited studies on consumer behaviour toward counterfeit products and the determining factors that motivate willingness to purchase counterfeit items. Aim: This study aimed to fill this literature gap through studying differences in individual ethical evaluations of counterfeit drug purchase and whether that ethical evaluation affected by difference in income. It is hypothesized that individuals with lower/higher income make a more/less permissive evaluation of ethical responsibility regarding counterfeit drug purchase. Materials and Methods: To empirically test the research assumption, a comparison was made between people who live in the low-income country Sudan and people who live in the high-income country Qatar. The study employed a face-to-face structured interview survey methodology to collect data from 1,170 subjects and the Sudanese and Qatari samples were compared using independent t-test at alpha level of 0.05 employing SPSS version 22.0. Results: Sudanese and Qatari individuals were significantly different on all items. Sudanese individuals scored below 3 for all Awareness of Societal Consequences (ASC) items indicating that they make more permissive evaluation of ethical responsibility regarding counterfeit drug purchase. Both groups shared a basic positive moral agreement regarding subjective norm indicating that influence of income is not evident. Conclusion: Findings indicate that low-income individuals make more permissive evaluation of ethical responsibility regarding counterfeit drugs purchase when highlighting awareness of societal consequences used as a deterrent tool, while both low and high-income individuals share a basic positive moral agreement when subjective norm dimension is exploited to discourage unethical buying behaviour.

Comparative Evaluation of Volatile Anaesthetic Agents for Attenuation of Venous Cannulation Pain: A Prospective, Randomized Controlled Study
Introduction: Topical application of volatile anaesthetic agents has been found to attenuate the response to a mechanical stimulus; however, this effect of volatile anaesthetic on perception of pain during venous cannulation is not known. Aim: To compare the efficacy of topically administered volatile anaesthetic agents for attenuating venous cannulation pain. Materials and Methods: This prospective, randomized, placebo controlled and double blind study was conducted on 120 patients, aged 20-60years. They were of American Society of Anaesthesiologists (ASA) I or II physical status, of either sex, planned for elective surgeries. These patients were randomized into 4 groups, of 30 each. Equipotent doses of halothane (1ml), isoflurane (1.5ml), sevoflurane (2.7ml) and sterile water (2.5ml; Control) were topically administered on the volar surface of forearm wrapped with cotton and aluminium foil; venous cannulation was performed with 18G intravenous cannula after 30 min. These patients were assessed for the incidence and severity of pain upon venous cannulation {visual analog scale (VAS), 0-100mm; 0 = no pain and 100 = worst imaginable pain}. Data were analysed by one-way ANOVA, Chi-square test and Kruskal-Wallis test. The p<0.05 was considered as significant. Results: A significant reduction in the incidence of venous cannulation pain was observed in the halothane (79%) group as compared to control (100%; p<0.05), isoflurane (100%; p<0.05) and sevoflurane (100%; p<0.05) groups. The severity of venous cannulation pain as assessed by median (interquartile range, Q1-Q3). VAS scores was reduced in the halothane {10 (10-20); p<0.001}, isoflurane {20 (10-30); p<0.001} and sevoflurane {20 (20-30); p<0.001} groups as compared to the control group {40 (30-40)}; VAS score in the halothane group was significantly less as compared to isoflurane (p<0.05) and sevoflurane (p<0.05) groups. Conclusion: Topical application of halothane is most effective in reducing incidence and severity of venous cannulation pain; however, topical application of isoflurane and sevoflurane decreases only the severity of venous cannulation pain.

Comparative Evaluation of the Marginal Sealing Ability of two Commercially Available Pit and Fissure Sealants
Introduction: The occlusal surfaces of the teeth usually have pits and fissures which provide a good environment for demineralization with minimal salivary access and make them caries prone. The success of pit and fissure sealing materials is highly dependent on the marginal sealing ability of the fissures. Aim: The present study was carried out to evaluate and compare the marginal sealing ability of two commercially available pit and fissure sealants. Materials and Methods: A total of 50 human premolar teeth were used in this invitro study. Group 1 included 25 teeth for application of Clinpro sealant and Group 2 included twenty 25 for application of Helioseal F sealant. Samples were stored in artificial saliva for 72 hours before thermocycling. The samples were immersed in 2% methylene blue solution for 24 hours. The sectioned samples were examined under an Optical Stereomicroscope and compared in terms of the extent of microleakage based on the amount of dye penetration between the sealant and tooth substance interface. The dye penetration scores in both the groups was statistically analysed using Chi square test and Mann Whitney Test. A p-value of less than 0.05 was considered to be statistically significant. Results: It was seen that in Group 1, 12 samples (48%) had no dye penetration (Grade 0) while in Group 2, 6 samples (24%) demonstrated Grade 0 penetration. Group 2 had the most extensive dye penetration (Grade 3) in 8 of 25 samples (32%) (p=0.014). Conclusion: On comparison of the microleakage scores of the groups, a statistically significant difference was found between the two groups; indicating a much better performance of Clinpro as compared to Helioseal F.

Efficacy and Safety of Complete RAAS Blockade with ALISKIREN in Patients with Refractory Proteinuria Who Are Already on Combined ACE Inhibitor, ARB, and Aldosterone Antagonist

Prabitha Panattil, M Sreelatha
Introduction: Proteinuria is always associated with intrinsic kidney disese and is a strong predictor of later development of End Stage Renal Disease (ESRD). As Renin Angiotensin Aldosterone System (RAAS) has a role in mediating proteinuria, inhibitors of this system are renoprotective and patients with refractory proteinuria are put on a combination of these agents. The routinely employed triple blockade of RAAS with Angiotensin Converting Enzyme (ACE) inhibitor, ARB and Aldosterone antagonist has many limitations. Addition of Aliskiren to this combination suppresses the RAAS at the earliest stage and can offset many of these limitations. Aim: This study was conducted to assess the safety and efficacy of complete RAAS blockade by the addition of Aliskiren in those patients with refractory proteinuria who were already on triple blockade with ACE inhibitor, ARB and Aldosterone antagonist. Settings: This study was conducted in Nephrology Department, Calicut Medical College. Materials and Methods: A total of 36 patients with refractory proteinuria who were already on ACE inhibitor, ARB and Aldosterone antagonist were divided in to two groups A and B. Group A received Aliskiren in addition to the above combination whereas group B continued the same treatment for 12 weeks. Efficacy of the treatment was assessed by recording 24hr urine protein and safety by S.Creatinine, S.Potassium every 2 weeks of the treatment period. Statistical Analysis: Statistical analysis of the lab values was done using SPSS software. Unpaired t-test, Paired t-test and Chi-square test were done for data analysis. Results: Statistical analysis revealed that addition of Aliskiren to the combination therapy with ACE inhibitor+ ARB+ Aldosterone antagonist offers no advantage. But mean reduction in proteinuria was more with Group A than Group B. There is no statistically significant change in S.Creatinine and S.Potassium at the end of treatment. Conclusion: As proteinuria is a strong risk factor for progression to ESRD, even a mild decrease in proteinuria by treatment is renoprotective. Hence treatment with group A may be considered clinically superior to group B with no alteration in safety and tolerability. But further multicentre studies with larger sample size and dose escalation are required for confirmation.

Dynamic Hip Screw with Trochanteric Stablization Plate Fixation of Unstable Inter-Trochanteric Fractures: A Prospective Study of Functional and Radiological Outcomes

Ashwin Shetty, Arjun Ballal, Anand Kumar Sadasivan, Anoop Hegde
Introduction: Management of unstable intertrochanteric fractures have posed a unique challenge to orthopaedicians over years. Several surgical techniques and implants have been developed for the same. Fractures of the lateral wall have been considered as the major cause of femoral medialization after fixation by Dynamic Hip Screw (DHS). Studies have shown that supplementation of trochanteric stabilization plate reduces the incidence of femoral medialization. Aim: To assess the radiological union and hip function after fixation of unstable intertrochanteric fractures with DHS and Trochanteric Stabilization Plate (TSP). Materials and Methods: A prospective study was conducted with a total of 32 patients between age groups of 30-70 years with Evan Jensen unstable and very unstable type of intertrochanteric fractures, between August 2013 to March 2015 in the Department of Orthopaedics ARS Hospital, Tirupur, Tamil Nadu, India. They underwent open reduction and DHS and TSP fixation. They were started on full weight bearing mobilization on post op day three. They were reviewed at post-op weeks 3,6,12 and 24. Hip mobilization and rehabilitation exercises were instituted during course of reviews. Radiographs were taken to assess fracture union and hip function was evaluated during follow-ups. At the end of 24 weeks, degree of radiographic union was scored as per Radiological Union Score for Hip (RUSH). Hip function was scored with Harris hip score. Analyses were done using frequency and proportions. Chi-square tests were used to assess the test of association. Results: Fifteen patients had RUSH scores between 10-20 and 17 patients had scores between 20-30 points. RUSH score had mean of 21.03+/- 2.132 points. 9 of 32 patients had excellent results as per Harris hip score, 10 had good, nine had fair and four had poor. On comparison of Harris hip score with RUSH score: Interval between 10-20 points, of 15 patients; two had excellent results, five had good, five had fair and three had poor. Of 17 patients between 20-30 points, seven had excellent, five had good, four had fair and one had poor results. Conclusion: DHS and TSP fixation of unstable intertrochanteric fractures is an effective technique with good radiological and functional outcome.

Toxicity Profile of Imrt mrt Vs 3D-Crtrt in Head and Neck Cancer: A Retrospective Study

Gopa ghosh, Ramanjis Tallari, Anupam Malviya
Introduction: Role of radiotherapy in comprehensive management of head and neck cancer for achieving tumour control and organ preservation is now well established and radiotherapy is routinely used in adjuvant setting after surgery, concurrently with chemotherapy or targeted agents and for palliation. Development of linear accelerator with Multileaf Collimator (MLC) have revolutionized radiation delivery techniques, allowing conformal and Intensity Modulated Radiotherapy (IMRT) to deliver highly conformal sculpted radiation dose to a very complex structure with improved sparing of adjoining critical structures like salivary glands, spinal cord, eyes, brainstem and larynx amounting to better therapeutic gain. Aim: This retrospective study was to compare toxicity profile of IMRT with Three Dimensional Conformal Radiotherapy (3D CRT) in head and neck cancer. Materials and Methods: Total of 80 patients from January 2013 to July 2015 with proven head and neck cancer who underwent radiotherapy on linac 2300 C/D machine were included in the study, IMRT group and 3D-CRT group comprised of 40 patients each. We have searched patients radiotherapy details in record section of our institute and observations were noted down. Patients received 70Gy/35 fractions, Monday to Friday as radical treatment and 60 Gy/30 fractions as adjuvant treatment were included. Results: The 3D-CRT group demonstrated significantly more acute toxic effects compared with the IMRT group in our analysis. Acute Grade 3 or greater toxic effects to the skin occurred in 5 of 40 (12.5%), patients in the 3D-CRT group compared with 3 of 40 (7.5%) patients in the IMRT group. Acute Grade 3 or greater toxic effects to the mucous membranes occurred in 23 of 40 (57.5%) patients in the 3D-CRT group and only 16 of 40 (40%) patients in the IMRT group. Statistically significant dysphagia developed in 34 of 40 (85%), patients in 3D-CRT group compared with 23 of 40 (57.5%) patients in IMRT group, while statistically significant xerostomia developed in 29 of 40 patients in 3D-CRT group (72.5%), compared with18 of 40 (45%) patients in IMRT group. Conclusion: In our analysis, IMRT was associated with a significantly lower incidence of Grade 3 or greater xerostomia, acute toxic effects to skin and mucous membranes than 3D-CRT. In addition, compared to 3D-CRT, IMRT had lower rates of Grade 3 or greater mucositis and skin toxicity as well as less feeding tube use during radiotherapy. Our analysis showed potentially less toxicity in patients treated with IMRT in comparision to 3D-CRT.

What Should Constitute a Health Related Quality of Life Scale for Parkinson’s Disease?
Introduction: Health Related Quality of Life (HRQoL) in Parkinson’s Disease (PD) lacks universally agreed definition and its components. A conceptual framework helps in understanding the essential domains and their inter-relationship while developing patient reported outcome measure. Aim: To construct a conceptual framework for developing HRQoL scale in PD. Materials and Methods: A panel of 7 experts extracted 6 major domains for measuring HRQoL in PD from literature review including 8 disease specific scales for PD, 2 books on quality of life, 5 websites, relevant articles; and content analysis of semi-structured interviews of stakeholders (28 persons with PD, 6 caregivers and 9 clinicians). Extracted domains were subjected to consensus of stakeholders (7 persons with PD, 7 caregivers and 7 clinicians) on 7 point Likert scale. The panel constructed a conceptual framework and a definition of HRQoL in PD in context of available guidelines for developing patient reported outcome measures. Results: The extracted domains were physical, non motor symptom, psychological, family/social, finance and treatment domains. Median of all six domains on 7 point Likert scale was 7 and inter-quartile distance was <1 in consensus agreement. The conceptual framework consisted of indicator domains and causal domains. Indicator domains (physical, psychological, and social and family) estimate the influence of causal domains (motor symptoms, non motor symptoms, finance and treatment) on quality of life. The definition emphasizes upon the person’s perception of their symptoms and its impact on their lives. Conclusion: This study defined and developed a conceptual framework for HRQoL scale for PD.

Study to Evaluate Current Trends in Appropriate Usage of Tread Mill Exercise Testing

Suresh V Sagarad, Neha Sukhani, Basavaraj Machanur, Shashidhar Patil
Introduction: Non-invasive tests are used to diagnose and prognosticate Coronary Artery Disease (CAD) patients and also in pre-operative evaluation and rehabilitation. Millions of these tests are performed worldwide in these situations. However, previous studies have shown inappropriate use of these tests. Aim: The study was to evaluate the appropriate use of treadmill exercise test. Materials and Methods: The present retrospective study was done in Rajiv Gandhi Super Speciality Hospital, Raichur and Institute of Medical sciences and RKB Super Speciality Clinic, Raichur, Karnataka, India. Tread Mill Tests (TMT) which were done between November 2013 and February 2016 were included in the study. A total of 600 tests were evaluated for appropriateness. Demographic, clinical and risk factors, indications were studied. Results: Overall 298 (49.66%) tests were found to be inappro-priate. Younger age, female sex, pre-operative evaluation, evaluation in master health check up and insurance were predictors of inappropriate use (p<0.05) in this study. Conclusion: The treadmill exercise testing appears to be particularly vulnerable to overuse in clinical setting due to its wide availability, affordability and awareness. The inappropriate use of the method, however, may result in additional unnecessary cost to health care system.

Mycological Profile of Sputum of HIV Positive Patients with Lower Respiratory Tract Infection and its Correlation with CD4+ T Lymphocyte Count

Jyotsna Chandwani, Nitya Vyas, Saroj Hooja, Babita Sharma, Rakesh Maheshwari
Introduction: Fungal respiratory infections are important cause of mortality and morbidity among HIV positive individuals. They account for up to 70% of illness in Acquired Immunodeficiency Disease Syndrome cases (AIDS). The range of illness varies from asymptomatic mucosal candidiasis to overwhelming disseminated infections. In these patients dissemination of fungus leads to very serious outcomes hence, it is important to have the knowledge of prevailing profile of fungus causing infections, so that it can be treated at the onset. Low CD4+ T lymphocyte count is an excellent indicator of decreased immunity and can also be helpful to predict opportunistic fungal respiratory infections and other complications. Aim: To define the fungal aetiology of lower respiratory tract infections in HIV positive patients and to correlate the occurrence of different fungi with CD4+ T lymphocyte count. Materials and Methods: This was a cross sectional study conducted between May 2014 to April 2015, on 180 treatment naive HIV seropositive patients with lower respiratory tract infections attending the Integrated Counselling and Testing Centre, SMS Medical College, Jaipur, Rajasthan. Early morning expectorated and induced sputum samples were collected and processed for isolation and identification of fungal species. CD4+ T lymphocyte count estimation was done by BD FACS Calibur. Results: Fungal species were isolated from 155 (86.1%) patients. The most common isolate was Candida albicans (31.7%), followed by Aspergillus niger (17.7%) and Aspergillus flavus (10%). The fungal species were most commonly isolated from patients with CD4+ T lymphocyte cell less than 200 cells/µl. Conclusion: Fungal infections were seen in 86.1% of HIV positive patients with lower respiratory tract infections hence, high level of clinical suspicion for fungal aetiology of respiratory infections in HIV positive patients should be kept in mind.

Comparison of Conventional Mercury Thermometer and Continuous TherCom® Temperature Recording in Hospitalized Patients
Introduction: Detection of accurate body temperature fluctu-ations in hospitalized patients is crucial for appropriate clinical decision-making. The accuracy and reliability of body temperature assessment may significantly affect the proper treatment. Aim: To compare the conventional and continuous body temperature recordings in hospitalized patients. Materials and Methods: This cross-sectional study was carried out at a tertiary care centre and study included 55 patients aged between 18-65 years with a history of fever admitted to a tertiary care hospital. A noninvasive continuous temperature recording was done using TherCom® device through tympanic temperature probe at tympanic site at one-minute intervals for 24 hours. The conventional temperatures were recorded in the axilla using mercury thermometer at specific time intervals at 12:00 noon, 8:00 PM and 5:00 AM. Peak temperature differences between continuous and conventional methods were compared by applying Independent sample t-test. Intra class Correlation Coefficient (ICC) test was performed to assess the reliability between two temperature-monitoring methods. A p<0.05 was considered as significant. Results: The average peak temperature by non-invasive continuous recording method was 39.07°C ±0.76°C while it was 37.55°C ±0.62°C by the conventional method. A significant temperature difference of 1.52°C [p<0.001;95% CI(1.26-1.78)] was observed between continuous and conventional temperature methods. Intra class Correlation Coefficient (ICC) between continuous and conventional temperature readings at 12:00 noon was a= 0.540, which had moderate reliability. The corresponding coefficients at 8:00 PM and 5:00 AM were a=0.425 and 0.435, respectively, which had poor reliability. Conclusion: The conventional recording of temperature is routinely practiced and does not reflect the true temperature fluctuations. However, the continuous non-invasive temperature recording is simple, inexpensive and a better tool for recording the actual temperature changes.

Surgical Site Infection by Methicillin Resistant Staphylococcus aureus– on Decline?
Introduction: Surgical Site Infection (SSI) is the most common healthcare associated infection that could be averted by antibiotics prophylaxis against the probable offending organisms. As Staphylococcus aureus has been playing a substantial role in the aetiology of SSIs, Methicillin Resistant Staphylococcus aureus (MRSA) happens to be a problem while dealing with the postoperative wound infection. Aim: To determine the prevalence of SSI caused by MRSA and the antibiotic sensitivity pattern of MRSA. Materials and Methods: A cross-sectional study was conducted at Nil Ratan Sircar Medical College, Kolkata, West Bengal from July 2009 to December 2012. A total of 19,359 surgical procedures were done of which 3003 culture positive SSIs have been documented. The clinical samples were collected from patients of both sexes and all ages suspected to be suffering from SSI from different specialities. Samples were processed according to CLSI, 2007 guidelines. The isolated strains of Staphylococcus aureus were screened for MRSA by detection of resistance to Cefoxitin disc (zone of inhibition was =21 mm) and slidex staph latex agglutination tests were done on cefoxitin resistant strains to spot phenotypic expression of mec A gene. Then PCR was performed for detection of mecA gene. Antibiotic sensitivity test was done following Kirby Bauer technique. Results: In this 3½ year study, 1049 Staphylococcus aureus (34.93%) were reported from 3003 cases of SSI followed by Escherichia coli (20.34%), Klebsiella spp. (18.08%), Pseudomonas spp. (7.99%), Acinetobacter spp. (7.49%) respectively. Among the Staphylococcus aureus, 267 strains were derived as MRSA (25.45%). MRSA were isolated from 167 (62.54%) male patients and 100 (37.45%) female patients having surgical site infections. Inpatients and outpatients distribution of MRSA were 235 (88.01%) and 32 (11.98%) respectively. Majority of the MRSA cases were reported from Surgery (12.49%) and Orthopaedics (11.85%) departments in the age group above 75 years (15.63%). The MRSA strains have been found to be 100% sensitive to linezolid and tigecycline followed by fucidin (92.51%), mupirocin (88.39%), levofloxacin (75.66%) and doxycycline (72.28%). No vancomycin resistant strains were detected, but 3 strains (1.12%) were found to be intermediately susceptible to it (VISA). Incidence of MRSA in SSI has been decreased by 15.17 % in 2012 in comparison to 2009. PCR revealed mecA gene was present in 96.25% of cefoxitin resistant Staphylococcus aureus strains. Conclusion: Staphylococcus aureus being the predominant organism causing SSIs, MRSA needs the attention for its resistance to commonly used antibiotics in the hospital like penicillin, cephalosporin group of drugs. Regular monitoring of the MRSA, involved in the SSI of a particular setup is the basic requirement to trim down the incidence of the postoperative wound infections by proper antibiotic prophylaxis.

Evaluation of Flexural Strength of Thermocycled Interim Resin Materials Used in Prosthetic Rehabilitation- An In-vitro Study
Introduction: Provisional restoration is an analytical component of fixed prosthodontics serving as a ground plan for the design of fixed dental prosthesis. Flexural strength is critical in case of long standing fixed dental prosthesis, to appreciate success of full mouth rehabilitation cases and temporomandibular joint dysfunction therapies. Aim: The aim of the present study was to evaluate the flexural strength of different provisional restorative resins used for prosthetic rehabilitation. Materials and Methods: Forty identical samples (n=10 for each material) measuring 25mm×2mm×2mm according to ADA/ANSI specification no. 27 were fabricated using autopolymerizing Poly Methyl Methacrylate (PMMA) (Group A); heat activated PMMA (Group B); autopolymerizing Bis-GMA composite resin (Group C) and light activated Urethane Dimethacrylate Resin (UDMA) (Group D). For 14 days all these samples were stored in artificial saliva. Ten samples from each material were subjected to thermal cycling for 2500 cycles (5°C to 55°C). Later, a standard three point bending test was conducted on all the specimens with a universal testing machine at a crosshead speed of 0.75mm/min. Statistical analysis used included Kruskal-Wallis and Mann-Whitney U test. Results: The mean flexural strength of specimens confirmed higher flexural strength for Group C (102.98 Mpa) followed by Group B (91.86 Mpa), Group A (79.13 Mpa) and Group D (60.01 Mpa). There were significant differences between any two materials tested (p <0.05). Comparison between mean flexural strength values between four groups revealed significant difference between the interim materials (p <0.05). Conclusion: The greatest flexural strength was observed for Bis-GMA composite resins followed by heat cure methacrylate resins, autopolymerizing methacrylate resins and was least for light cure resins. While fabricating provisional restorations, these greater values should be considered for better outcome of the treatment.

Patient and Healthcare System Delays in the Start of Pulmonary Tuberculosis Treatment Among Tribal Patients Registered Under DOTS, Odisha

Sudipta Basa, S. Venkatesh
Introduction: Tuberculosis (TB) is a highly infectious disease which continues to be an important public health problem worldwide. Aim: This study puts an effort to determine patient and health system delay in diagnosis and treatment and association to specific types of delay among tribals in Mayurbhanj district, Odisha. Materials and Methods: A total of 261 TB patients reporting to 4 TB Units of Mayurbhanj were interviewed using pre-tested structured questionnaire. Extra-pulmonary TB patients and death cases were excluded. Data entry and analysis was carried out in Epi-info 3.32 version. Chi-square test was used to test the association between dependant variable (patient and health system delays) with different independent variables (age, sex, reasons for delay etc.). Results: Median patient, health system and total delay were 24, 3 and 24 days respectively. Risk factors that were significantly associated with patient delay were education (95% CI= 1.01-1.11, p=0.015), cost of treatment/transport (95% CI=0.87-1.01, p=0.020), distance (95% CI=1.00-1.29, p=0.002) and lack of awareness about TB (95% CI=1.01-1.34, p=0.001). Health system delay risk factors were distance (95% CI=0.32-0.96, p=0.043), delay due to administrative verification (95% CI=1.18-57.97, p= 0.005) and delay due to traditional healers/ private practitioners (95% CI=1.61-15.45, p=0.0008). Conclusion: This study revealed longer patient delay compared to health system delay. Therefore, public awareness in tribal dialect about chest symptoms and availability of free diagnostics services should be increased along with involvement of traditional healers.

A Randomized Trial Comparing Efficacy of Bubble and Ventilator Derived Nasal CPAP in Very Low Birth Weight Neonates with Respiratory Distress

Sheetal Agarwal, Arti Maria, Mahesh K. Roy, Ankit Verma
Introduction: Continuous Positive Airway Pressure (CPAP) has an established role in the care of Very Low Birth Weight (VLBW) babies with respiratory distress. Bubble CPAP (BCPAP) is a cheap alternative for countries where resources are limited. However, data comparing efficacy of BCPAP with conventional ventilator derived (VCPAP) is limited. Aim: To compare CPAP failure rates between BCPAP and VCPAP among VLBW, with moderate respiratory distress. Secondary objectives were to compare the rates of Intraventricular Haemorrhage (IVH), pulmonary air leaks and deaths between the two groups and determine the predictors of CPAP failure. Materials and Methods: VLBW babies with moderate respiratory distress (Silverman Anderson score 4-7), born or admitted in Neonatal Intensive Care Unit (NICU) within 28 days of life were randomized to receive either BCPAP (n=34) or VCPAP (n=34). CPAP failure rate in both the groups was compared. Results: The baseline characteristics were similar in both the groups. Five out of 34 (14.70%) babies in BCPAP group and 11 out of 34 (32.35%) in VCPAP failed CPAP (p=0.08). IVH (BCPAP group 24% and VCPAP group 9%, p= 0.10) and mortality (BCPAP group 6% and VCPAP group 9%, p=0.642) were comparable in both the groups. Factors such as gestational age <30 weeks, weight <1000 grams, Respiratory Distress Syndrome (RDS), shock, pulmonary haemorrhage, Disseminated Intravascular Coagulation (DIC) and multi-organ dysfunction were significantly associated with CPAP failure in our study. Conclusion: The CPAP failure rates in VLBW babies with moderate respiratory distress were found to be similar whether bubble CPAP or ventilator CPAP was used. There was no difference in complication rates of IVH or mortality with either method of CPAP.

Immunohistochemical Expression of Cyclin B1 in Epithelial Hyperplasia, Dysplasia and Oral Squamous Cell Carcinomas - A Comparative Study
Introduction: Cyclin B1 is important in the cell cycle progression from G2 to M phase. Cyclin B1 binds to CDC2, which then becomes dephosphorylated and gets relocated to the nucleus, ensuring the transition toward mitosis. Aim: Over expression of Cyclin B1, has been reported more recently in breast, colon, prostate, oral and esophageal carcinomas. Thus, the aim of the present study was to examine the expression of Cyclin B1 in hyperplasia, dysplasia and Oral Squamous Cell Carcinomas (OSCC). Materials and Methods: A total of 64 histopathologically diagnosed cases of epithelial hyperplasias, dysplastic oral epithelium and OSCC were included in the study. Immunohistochemical procedure was carried out using the monoclonal mouse Cyclin B1 antibody (Clone V-152). The Cyclin B1 positive tumor cells counted were expressed as percentage of positive tumor cells. Nuclear and cytoplasmic labeling index (n&cLI) were calculated. The results were tabulated and statistically analyzed by Kruskal Wallis test- One Way ANOVA and Mann Whitney U- test. Results: Combined n&cLI was considered only 28.57% of epithelial hyperplasias, 40.7% of oral epithelial dysplasias and 72% of OSCC showed over expression of Cyclin B1 with p value being 0.029. Cyclin B1 expression was not significantly different between the grades of dysplasia, between the grades of OSCC and between the marginal groups. Conclusion: The present study demonstrates more than 50% of the study group showing less than 20% of nuclear staining. The importance of such variations within a type of lesion requires further investigation, since Cyclin B1 has proved useful in many studies from esophageal and laryngeal squamous cell carcinoma as a prognostic indicator, an indicator of recurrence and as an indicator for tumor sensitivity to radiotherapy. Further studies are to be extended towards evaluating the role of Cyclin B1 as a prognostic indicator.

Barriers to Early Initiation and Continuation of Breastfeeding in a Tertiary care Institute of Haryana: A Qualitative Study in Nursing Care Providers

Jai Pal Majra, Vijay Kumar Silan
Introduction: Ever increasing institutional deliveries in India has shifted the responsibility of timely initiation and continuation of breastfeeding from peripheral health workers and families to the nursing care providers of health facilities where the births take place. While institutional deliveries have increased to 72.6%, only 44.6% of the newborns enjoy early breastfeeding in India. Aim: To study the barriers to early initiation of breastfeeding in institutional delivery. Materials and Methods: A total 34 nursing care providers were selected randomly and five Focus Group Discussions (FGDs) were carried out. This Qualitative Study was conducted through FGDs among the nursing care providers of a tertiary care institute in the Indian State of Haryana, India. Statistical Analysis: The analyses continued throughout the group discussions as the newly emerged themes were tested in the subsequent discussion. FGDs transcripts were analysed to enhance the robustness of the emerged domain. Results: Major barriers to initiation of breast feeding identified included: lack of awareness regarding proper technique of breastfeeding and benefits of colostrum; breast abnormality like inverted/retracted nipples; obstetric/neonatal complications requiring specialised care; and cultural practices like giving pre-lacteals and gender discrimination. It was further reported that the manpower has not been rationalised with ever increasing number of institutional deliveries. The respondents though willing to promote early initiation and continuation of breastfeeding felt excessive workload as one of the major barriers due to multi-tasking nature of their job. Conclusion: The new challenges to the early initiation and continuation of breastfeeding are emerging due to change in the place of delivery which needs to be addressed at the policy level.

Predictability and Reliability of Different Anterio-Posterior Skeletal Discrepancy Indicators in Different Age Groups - A Cephalometric Study
Introduction: The lateral cephalometric skeletal discrepancy indicators play a major role in diagnosing and preparing a case for orthognathic surgeries and the dentofacial corrections. Aim: The study was aimed to check the reliability and the predictability of different anterio-posterior skeletal discrepancy indicators in different age groups and to derive the most reliable indicator for the orthodontic diagnosis. Materials and Methods: A cross-sectional study was conducted on a sample of 100 subjects including 29 adolescent (15 males and 14 females) and 71 adult (41 males and 30 females) subjects with the mean age of 19.05 ± 5.78 years. All the subjects had Angle’s Class I molar relationship. The lateral cephalograms of the sample were taken under the standard setting and hand tracing of the cephalometric radiographs using a sharp 4H pencil were made on acetate tracing paper. The anterio-posterior cephalometric indicators like ß-angle, Wits appraisal (mm), Sella- Nasion plane to Point A and Point B distance (SN-AB mm) and Maxillo-Mandibular plane angle bisector to Point A and Point B distance (MM-AB mm) were measured. Intra-examiner reliability of tracings was evaluated using Intra Class Correlation (ICC) test. Mann Whitney U-test was applied for comparison of parameters between different malocclusion groups. Concurrent validity of various parameters was calculated using Cohen's kappa. A p-value <0.05 was considered statistically significant. Results: The comparison of intra-examiner reliability of tracings in Angle’s Class I adolescent group showed, MM-AB to have an almost perfect agreement followed by Wits. Intra-examiner reliability of tracings in Angle’s Class I adult group showed moderate agreement for Wits and MM-AB showed almost perfect agreement and all the parameters showed statistically significant ICC. Comparison of parameters between adolescent and adult, Angle’s Class I malocclusion group showed significant difference between adolescent and adult group for the Wits and SN-AB parameter. Conclusion: The final outcome of the present study revealed that, the MM–AB is highly reliable in the reproducibility and also highly valid parameter for checking antero-posterior discrepancies and ANB angle was least reliable for diagnosing the antero-posterior skeletal discrepancies.

Clinical and Radiologic Evaluation of Regenerative Potential of NHA Paste and DBM in the Treatment of Periodontal Intra-bony Defects -A Randomized Control Trial
Introduction: Previous studies have shown that Hydroxyapatite (HA) has shown good results in the treatment of intra-osseous periodontal defects. A newer variety of HA has been designed over a period of research which has nano-sized particles and is availed in a paste consistency called Nanocrystalline Hydroxyapatite paste (NHA paste). This variation in size and surface area of NHA paste can provide better results when used in intra-bony defects. Aim: The purpose of this study was to compare the clinical and radiographic outcomes obtained with usage of NHA paste to those obtained with Demineralized Bone Matrix (DBM) in the treatment of periodontal intra-bony defects. Material and Methods: A clinical trial was carried out for a period of 12 months. A total of 26 intra-bony defects in 10 patients were divided into experimental and control sites. The experimental sites were debrided and grafted with NHA paste. The control sites were debrided and grafted with DBM-Xenograft. Probing Depth, Clinical Attachment Level (DCAL) and Gingival Margin (GM) position were recorded at baseline 3, 6, 9 and 12 months. Standardized radiographs were also documented at these recalls. The results were averaged (mean± standard deviation) for each parameter and Student t-test was used to determine intra-group statistical difference and One way analyses of variance (ANOVA) to test the difference between groups using Excel and SPSS (SPSS Inc, Chicago) software packages. Results: On completion of 12 months, the mean percentage of PD reduction achieved in the experimental and control sites was 67.45% and 69.03% respectively (p<0.05). The mean percentage of gain achieved in CAL was 63.58% and 61.42% in the experimental and control sites respectively (p<0.05). Gingival recession was seen to be non-significant in the experimental and control sites. The mean percentage of bone fill in the control group obtained was 48.16% where as the percentage of bone fill obtained in the experimental group was 48.64% (p<0.05). Conclusion: Overall, both therapies led to significant improvements of the investigated parameters. The NHA paste was as effective in terms of improving clinical and radiographic parameters as DBM-Xenograft, which is an already established bone graft. There is a need for further long term controlled studies evaluating the adjunctive benefits of usage of NHA paste in the treatment of periodontal intra-bony defects.

Prevalence of Bone Mineral Density Abnormalities and Factors Affecting Bone Density in Patients with Chronic Obstructive Pulmonary Disease in a Tertiary Care Hospital in Southern India
Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a disease of wasting with airflow limitation, associated with a variety of systemic manifestations such as reduced Bone Mineral Density (BMD). There is a paucity of Indian studies on the effects of COPD on BMD. Aim: This study was conducted to estimate the prevalence of osteopenia and osteoporosis in COPD patients and the correlation between bone density and severity of COPD classified according to GOLD Global initiative for chronic Obstructive Lung Disease guidelines (GOLD). Materials and Methods: A prospective study of 60 patients diagnosed to have COPD, was conducted in the outpatient department of Respiratory Medicine, at a tertiary care hospital in Southern India, between September 2012 and September 2013. BMD was measured using ultrasound bone densitometer (ACHILLES GE HEALTH CARE). Patients with a T-score between -1 and -2.5 were considered to be osteopenic while patients with a T score less than -2.5 were considered to be osteoporotic (WHO criteria). Results: Overall, 40 (67%) patients had an abnormal bone mineral density. A total of 21 (35%) patients were osteoporotic while 19 (33%) were osteopenic. BMD levels correlated with severity of obstruction (p<0.001), smoking status (p=0.02), age (p=0.05) and number of pack years (p=0.001). Conclusion: Patients with COPD are at an increased risk for lower BMD and osteoporotic fractures and the risk appears to increase with disease severity. Further studies are required to assess whether routine BMD measurements in COPD patients is beneficial to diagnose osteoporosis and reduce morbidity.

Clinico-Radiological Correlation of Subcoracoid Impingement with Reduced Coracohumeral Interval and its Relation to Subscapularis Tears in Indian Patients
Introduction: Clinically, subcoracoid impingement is characterized by pain at the anterior aspect of the shoulder that is induced by adduction, internal rotation and forward flexion. This position leads to narrowing of the Coraco-Humeral Interval (CHI)-that is, the space between the coracoid process and the lesser tuberosity of the humerus. Structures in the rotator interval are at greatest risk for impingement which includes the subscorapularis tendon, tendon of the long head of the biceps, and the middle gleno-humeral ligament. This may result in Rotator interval pathologies such as subscapularis tear and long head of biceps tendon subluxation or fraying. Aim: To study the prevalence of radiological evidence of reduced Coraco-Humeral Interval (CHI) in patients with clinically evident subcoracoid impingement and to examine the presence of Subscapularis tears in these patients. Materials and Methods: Twenty four patients (6 males, 18 females, average age 52.83 years) were included in this prospective study who were diagnosed to have rotator cuff tears clinically. Nine of these patients were clinically found to have concomitant Subcracoid impingement. All patients were subjected to MRI of shoulder. Measurement of the CHI was done in images with humerus in maximal internal rotation. Presence of subscapularis tear was examined intraoperatively. Statistical evaluation of the data was performed using Student's t-test and Fisher’s exact test and the results were applied to two cohorts of patients. One cohort consisted of patients who had a CHI value of less than 5.5mm and the other cohort had a CHI value greater than 5.5mm. Average CHI values in patients with and without a subscapularis tear were determined. Results: Nine patients who had clinical subcoracoid impingement were found to have an average CHI of 5.33mm. All nine of them had an associated tear of subscapularis with long head of Biceps tendon subluxation and/or fraying. Remaining 15 patients had an average CHI of 10.48 and they did not have either signs of Subcracoid impingement or subscapularis tear but had a tear elsewhere (Supraspinatus or Infraspinatus). Difference between these two groups was found highly significant (p-value<0.001). All patients with a CHI value of equal to, or less than 5.5mm had a subscapularis tear, whereas only 11% of patients with a CHI value more than 5.5mm had a tear (p-value<0.001, highly significant). Conclusion: Reduction in the CHI has a significant association with rotator interval pathologies such as subscapularis tears and subluxation or fraying of long head of biceps tendon. Treatment of such patients should include modalities such as coracoplasty or anterior shoulder stabilisation. We recommend that clinical evidence of subcoracoid impingement should lead to further Investigation in the form of MRI and estimation of CHI. A CHI of less than 5.5 mm may indicate subscapulais tear in Indian patients.

Molecular Classification of Oral Squamous Cell Carcinoma
Oral Squamous Cell Carcinoma (OSCC) is the commonest tumour in the oro-facial region with increasing incidence in the recent years. The disease is challenging as it still depicts a high morbidity and mortality rate. Clinico-pathological data, tumour site, pathologic site tumor, lymphnode, metastasis (TNM) staging, histological grade, invasion, perineural invasion and metastasis have been evaluated to a great depth in relation to OSCC. Co-morbidity factors like use of tobacco, alcohol consumption and various other factors including genetic predisposition have been looked at for finding a suitable treatment protocol. The crux of the matter in understanding the complexity of oral cancer lies in the biological heterogeneity of the tumour. Similar heterogeneity is seen in clinical presentation, histopathology and molecular changes at the cellular level. In spite of the disease being diagnosed, a prediction of the same related to behaviour has remained elusive. Hence, it is time to look beyond at the genetic and epigenetic events leading to molecular and cytogenetic changes that elucidate the pathogenesis and help in design and implementation of targeted drug therapy. A molecular classification of OSCC needs to be put in place much before a clinician can design the treatment protocol of the same and predict the prognosis.

Global Tourist Guide to Oral Care - A Systematic Review
Introduction: Dental tourism means travelling abroad for economical dental treatment as the cost of treatment is high in one’s own country. This trend has been emerged due to high priced health care and long waiting lists in many Western countries. In spite of large debates on dental care, tourism has taken place; still there is lack of scientific studies related to the dental tourism. Aim: The present review aims to analyze the opportunities, feasibilities, treatment cost variability and popularity of dental tourism. Materials and Methods: The search strategy used a combi-nation of controlled vocabulary and free text terms. The main database was PubMed, PubMed Central, Cochrane Review, Embase and Google Scholar from 2000 – 2015. Out of the total 69 titles appeared seven articles fulfilled the criteria and were selected for the review. One article which was hand searched and one article through email were also included. Results: This review focused the strengths of India’s dental tourism service as there is a lot of cost difference with good quality work when we compared India to the other countries. Like cost for smile designing in US is 8,000$ and in India is 1,000$ and for dental implants in the US is 2,000$, in Hungary is 1070$ and in India 600$ approximately. Conclusion: Government and industrial infrastructure favours the growth of dental tourism in India. The opportunities like less price with good quality care in India helps to make further progress in dental tourism.

Recanalization of Chronic Total Occlusion Lesions: A Critical Appraisal of Current Devices and Techniques

BHARGAV DAVE
Chronic Total Occlusion (CTO) has been considered as one of the “final frontier” in interventional cardiology. Until recently, the patients with CTO are often managed surgically or medically due to lack of published evidence of clinical benefits and lower success rate of percutaneous recanalization of CTO. However, the introduction of enhanced guidewires, microcatheters combined with novel specialized devices and techniques reduce the number of unapproachable CTO. In this review article, current techniques and devices of percutaneous recanalization of CTO have been systematically summarized, which may help budding interventional cardiologists to theoretically understand these complex procedures and to deliver safe and effective percutaneous management of CTO to the patients.

Maternal Health Situation in Bihar and Madhya Pradesh: A Comparative Analysis of State Fact Sheets of National Family Health Survey (NFHS)-3 and 4

Ranjit Kumar Dehury, Janmejaya Samal
Introduction: Maternal health constitutes the health of women during pregnancy, childbirth and the postpartum period. Bihar and Madhya Pradesh (MP) constitute the Empowered Action Group (EAG) states under National Rural Health Mission (NRHM) and are consistently having poor maternal health indicators. Aim: The main objective of this study was to assess the maternal health situation of Bihar and MP based on National Family Health Survey (NFHS-3) and 4 fact sheets. Materials and Methods: The study adopted a narrative description in which the NFHS fact sheets (NFHS-3 & 4) of both these states were obtained from appropriate sources and compared for various maternal health indicators. Results and Discussion: Albeit progress has been observed from NFHS-3 to NFHS-4 however, the progress is very dismal compared with the progress of other similar Indian states. Relatively MP has shown better progress compared to Bihar. Poor performance is being observed in all the three levels of maternal health; pregnancy {Ante-Natal Care (ANC), Tetanus toxoid (TT) and Iron and Folic Acid (IFA)}, child birth (Institutional delivery by Skilled Birth Attendant (SBA), Caesarean Section (CS) and post partum care (hospital stay and Janani Suraksha Yojna (JSY). The poor performance of both these states in all these indicators requires multipronged approach strong political will, health system strengthening, community mobilization and awareness. Conclusion: Given the status of maternal health in India and more especially in states BIMARU (Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh) and EAG states (Empowered action group), improvement in the performance of maternal health related activities is highly necessary.

The Association between Dystemperament and Prevention of Diseases: A Systematic Review

Rafieian Kopaei, Alireza Khajegir, Sara Kiani
Introduction: Temperament or mizaj is referred to four different humors differentiating individuals and as a result, proposing different preventive measures for their diseases. Aim: In this study, a systematic and purposeful review with emphasis on the research question was done to retrieve, evaluate and consolidate the required information. Materials and Methods: Computerized search of published original articles with fulltext was performed using PubMed and Web of Science, Medline data Science direct, ProQuest, SID and Cochrane Library bases as well as local references from March 1990 to March 2016. The key terms used were “temperament”, “Dystemperament”, “prevention”, “health promotion”, “sue mizaj”, “treatments” and “preventive measures”,”preventive medicine”. Original and translated books were also used. Out of 25 articles, 9 were selected. Results: The findings of this study indicated that there are six essential factors (asbab-e-sitlah Zarooriya), in preventing diseases which includes air, water, food, rest and improvement of body, soul and mind, sleeping and awakening, retention and discharge of fluids, solids, gases and energy from the body and based on the aforementioned causes, some Tadbeer were introduced as Tadabir-i-Nafas (air), Tadbeer-bil-food, Tadbeer-bil-drinks, Tadbeer bil-exercise and physical relaxation, Tadbeer-bil-sleep and wakefulness, Tadbeer bil-retention and discharge. Conclusion: There are two differences between these two kinds of medicine; firstly, although some preventive factors are overlapped in traditional and mainstream medicines (including nutrition (both food and drink), physical activity and sleep), some of the traditional preventive factors become undelined (retention, air) and some new preventive factors get highlighted in mainstream medicine (e.g., not smoking, not having stress, …); secondly, rules of preventive medicine in Unani system were mentioned in detail and were different for different people with different types of temperament, while the mainstream medicine states its rules, generally for different types of people.

Vascular Disease in Young Indians (20-40 years): Role of Ischemic Heart Disease
Coronary Artery Disease (CAD) occurs at a younger age in Indians with over 50% of Cardiovascular Disease (CVD) mortality occurring in individuals aged less than 50 years. Although several risk factors have been suggested; smoking, dyslipidemia and hypertension are major risk factors in the young. In this review, we have pooled the current evidence on Ischemic Heart Disease (IHD) in young (20-40 years) and provided an opinion for the effective management of IHD in young Indians

Short Implants: New Horizon in Implant Dentistry

Neha Jain, Manisha Gulati, Meenu Garg, Chetan Pathak
The choice of implant length is an essential factor in deciding the survival rates of these implants and the overall success of the prosthesis. Placing an implant in the posterior part of the maxilla and mandible has always been very critical due to poor bone quality and quantity. Long implants can be placed in association with complex surgical procedures such as sinus lift and bone augmentation. These techniques are associated with higher cost, increased treatment time and greater morbidity. Hence, there is need for a less invasive treatment option in areas of poor bone quantity and quality. Data related to survival rates of short implants, their design and prosthetic considerations has been compiled and structured in this manuscript with emphasis on the indications, advantages of short implants and critical biomechanical factors to be taken into consideration when choosing to place them. Studies have shown that comparable success rates can be achieved with short implants as those with long implants by decreasing the lateral forces to the prosthesis, eliminating cantilevers, increasing implant surface area and improving implant to abutment connection. Short implants can be considered as an effective treatment alternative in resorbed ridges. Short implants can be considered as a viable treatment option in atrophic ridge cases in order to avoid complex surgical procedures required to place long implants. With improvement in the implant surface geometry and surface texture, there is an increase in the bone implant contact area which provides a good primary stability during osseo-integration.

Knowledge and Awareness Regarding Swine-Influenza A (H1N1) Virus Infection among Dental Professionals in India - A Systematic Review
Introduction: Swine flu or Influenza A (H1N1) flu is the most recent of the pandemic disease that has affected the world’s population. We, as health care providers should feel responsible for reducing the transmission of influenza. Aim: To conduct a systematic review of observational studies and to assess dental professionals’ knowledge and awareness regarding swine flu. Materials and Methods: Relevant cross-sectional observational studies were included in the systematic review to assess the level of knowledge and awareness regarding swine flu among dental professionals. Three studies out of 28 were finally included in the present review after conducting both electronic and manual search of scientific databases like Pubmed, Medline, and EMBASE. No limitation in terms of publication date and language was considered. Potential biases were reported and appropriate data were extracted by the concerned investigators. Descriptive statistics, student t-test were used for analysis. Results: Majority of the subjects (92.6%) had heard about swine flu, and 64.3% of them knew about the H1N1 virus in one of the study reports. More than 80% of subjects were aware regarding the availability of swine flu vaccine in one study reports as compared to another study in which only 31.5% had awareness. Majority of the subjects were of the opinion that frequent hand washing and use of sanitizer are one of the effective methods to prevent swine flu in all the three studies. Conclusion: The results of the present review showed that some knowledge gaps existed among dental professionals regarding swine flu. Therefore, there is an urgent need for training and continuous education programs regarding infectious diseases.

Epithelial – Mesenchymal Interactions in Tooth Development and the Significant Role of Growth Factors and Genes with Emphasis on Mesenchyme – A Review
The recent advancements in medical research field mainly highlights the genetic and molecular aspects of various disease processes and related treatment options, in a specialized “custom-made” approach. The medical and dental field has made tremendous progress in providing even with the smallest insight into pathological entities, thus, making patient management more fruitful. But, short comings have occurred in dental treatments involving odontogenic lesions mainly due to poor understanding of the developmental cycle involved during early stages of developmental process. Multiple numbers of interactions take place during embryo formation and further proliferation of tissue. One such important step is the interaction between epithelium and mesenchyme which tantamount to functional requirements of an individual tooth. The role of extra cellular molecules and genes has to be studied in depth to assess the impact and significance attached to it as the synergistic function of various elements underlines the complex process of development.

Outstanding Prevalence of Methicillin Resistant Staphylococcus aureus in Neonatal Omphalitis

Mallika Sengupta, Sayantan Banerjee, Pritam Banerjee, Partha Guchhait
Introduction: Omphalitis is the infection of the umbilical cord stump, which can lead to septicaemia and significant neonatal morbidity and mortality. Very little data is available on the aetiology of neonatal omphalitis in India. Aim: To identify the causative agents of omphalitis in neonates and determine the antimicrobial susceptibility patterns of the isolates. Materials and Methods: A prospective study was conducted at ESI-PGIMSR and ESIC Medical College, Joka, a tertiary care teaching hospital in Eastern India for a period of four months (from 1st January 2016 to 30th April 2016). Neonates were screened for omphalitis on the basis of presence of pus and redness for inclusion. Clinical examination, Gram stain and culture of umbilical discharge, identification of organisms by biochemical tests and VITEK 2 Compact (bioMereiux Inc., France) was done. Antimicrobial susceptibility by Kirby Bauer disc diffusion method and E-strip agar diffusion method (for vancomycin and teicoplanin) were performed and interpreted according to the Clinical and Laboratory Standards Institute (CLSI) guidelines version 2015. Results: A total of 623 neonates were screened, among whom 21 (3.37%) were positive for our screening criteria for omphalitis. Cultures from the exudates of those cases yielded growth of Staphylococcus aureus in 19 (90.47%) samples, all of which were found to be methicillin resistant Staphylococcus aureus (MRSA). Resistance to erythromycin was seen among 36.82% isolates and inducible clindamycin resistance was seen among 31.57% isolates of Staphylococcus aureus. Conclusion: MRSA can be the most common cause of omphalitis. However, this finding needs to be evaluated in larger prospective studies.

Primary Salivary Gland Malignancy of Trachea: A Clinical Masquerader

Monika Singh, Megha Sharma, Minakshi Bhardwaj, Prajwala Gupta, Arvind Ahuja
Primary tracheal malignancies are rare and present with non specific symptoms hence delaying the diagnosis. A 41-year-old male presented with repeated paroxysmal episodes of breathlessness for which he was being treated with bronchodilators and steroids. Computed Tomography (CT) chest was done revealing a small polypoidal mass lesion arising from lower trachea/carina. On fibre optic bronchoscopy an infiltrative growth was seen at the lower end of trachea following which biopsy was obtained. On histopathologic examination a diagnosis of primary adenoid cystic carcinoma was made. It was concluded that in a case of refractory obstructive pulmonary disease, primary tracheal tumours should be considered as an important differential diagnosis. CT chest, bronchoscopy and biopsy play a vital role in making an accurate diagnosis of such a clinical masquerader.

Cytomorphologic Attributes of Epithelial Myoepithelial Carcinoma of Nasal Cavity - A Rare Tumor with Unusual Clinical Presentation

Krishnappa Amita, Shivshankar Vijayshankar, MG Abhishek, Amita Kumari
Epithelial-Myoepithelial Carcinoma (EMC) is a rare low grade epithelial malignancy of major Salivary Glands (SG). Though the histomorphology of this tumor is distinct, unusual location and clinical presentation may pose diagnostic difficulties especially when this lesion is first encountered at cytology. We report a case of 60-year-old female presenting with nasal obstruction of three months duration. At FNAC the diagnosis of EMC was suggested and it was confirmed on histopathology. We present this case highlighting the cytomorphologic attributes of this rare tumor occurring at an extremely uncommon location – Nasal cavity.

Pure Large Cell Neuroendocrine Carcinoma of the Ovary with Metastasis to Cervix: A Rare Case Report and Review of Literature

Lakshmi Agarwal, Bhawna Gupta, Ayushi Jain
Ovarian Large Cell Neuroendocrine Carcinoma (LCNEC) is a recently described rare entity, which even more rarely occurs in a ‘pure’ form without any associated surface epithelial-stromal or germ cell component. Cervix metastasis of ovarian LCNEC has not been reported previously. We report here a case of ovarian LCNEC in a 35-year-old female who presented with abdominal pain and amenorrhea. Grossly the left ovary showed a solid cystic tumour measuring 6 cm in diameter. Histological examination showed a pure LCNEC without any associated component, confirmed by immunohistochemistry. Metastatic tumour deposits with numerous lymphovascular emboli were identified in the cervix. A comprehensive review of literature along with the various differential diagnosis is discussed.

Isolated Mesenteric Vascular Injury Following Blunt Abdominal Trauma Leading to Massive Segmental Gangrene of Small Gut: A Case Report

Sibabrata Kar, Vandana Mohapatra, Pratap Kumar Rath
Isolated mesenteric vascular injury following blunt abdominal trauma as a result of road traffic accidents is rare. Delay in reaching hospital, delay in diagnosis, or late operative intervention could lead to increased morbidity, prolonged hospital stay and even mortality. We herein report a case of such injury with subsequent massive segmental small bowel infarction. The patient was referred to our institute ten hours after the alleged accident. Resection of the infarcted bowel segment with end-to-end anastomosis was done. We highlight the various techniques for timely diagnosis and management of isolated mesenteric injuries. A high index of suspicion, early detection and prompt surgical intervention is required when there are minimal symptoms and signs, which might avert adverse outcome.

Clinicopathological Characteristics of Thymic Tuberculosis- A Rare Entity

Keerthi Ramachandran Pillai, Meenu Prakash, Muktha Ramesh Pai
Tuberculosis is a severely debilitating disease and it rarely presents with involvement of the thymus. Only fifteen cases have been reported worldwide. We report a case of thymic tuberculosis in a 12-year-old female presenting with cervical lymphadenopathy. Computed tomographic imaging revealed a mediastinal mass which was then excised via thoracotomy. The gross appearance of the cut surface of both lobes was variegated with white, granular caseating material. Microscopy revealed multiple, caseating, epithelioid granulomas with dispersed Langhans giant cells surrounded by thymic parenchyma with Hassals corpuscles. The patient was treated with anti-tubercular drugs and her condition improved. On follow up, the patient is healthy and has gained weight.

Incisional Hernia as a Cause of Blader Outlet Obstruction: A Case Report

Suhani, Shadan Ali, Gunjan Desai, Kartikeya Sharma, Shaji Thomas
Incisional hernia usually contains intra peritoneal organs as its content. Extra peritoneal structures like bladder as a content of incisional hernia are relatively uncommon. We managed a young male with an incisional hernia containing a large bladder diverticulum as its content. The bladder diverticulum was going up to the base of scrotum along the posterolateral surface of penile corpora. The patient was diagnosed pre operatively with radiological investigations and underwent exploration with release of diverticulum from corpora and pubic arch followed by diverticulectomy and herniorraphy. To the best of our knowledge and available literature search, there isn’t any similar reported case.

Cutaneous Metastasis from Cholangiocarcinoma Presenting as Thigh Mass

Kachnar Varma, Anshu Singh, Vatsala Misra
Skin is an uncommon site for metastasis with only 0.7-9% of all patients with cancer being affected when compared to other organs. Generally, the time lag between the diagnosis of primary malignancy and the recognition of the skin metastases is long, but sometimes these metastases may be the first indication of otherwise clinically silent visceral malignancies as seen in our case. In cholangiocarcinomas, the occurrence of cutaneous metastases is extremely rare. Their most common sites of metastasis are visceral organs i.e., lungs, bones, adrenal glands and brain. The present case is unique and describes a patient with metastatic cutaneous thigh nodule as the first sign of cholangiocarcinoma. The early recognition of skin metastasis of previously undiagnosed cancers is critical for timely intervention as it indicates poor prognosis with overall survival after cutaneous metastasis of only few months. Very few reports of cutaneous metastases from cholangiocarcinomas have been published. Also, most of these were derived from direct tumour seeding by percutaneous procedures whereas our case showed distant metastasis to thigh. Extensive literature search showed ours to be the first case of cholangiocarcinoma presenting as thigh nodule where Fine Needle Aspiration Cytology (FNAC), histopathology and immunohistochemistry helped in clinching an early diagnosis and judicious management of a patient with unsuspecting thigh nodule.

Massive Pulmonary Embolism in a Patient Using Warfarin at Therapeutic Dose

Sunnetcioglu Aysel, Esen Ramazan, Arisoy Ahmet
Warfarin sodium is commonly used for the prevention and treatment of thromboembolism. The efficacy of warfarin therapy depends on maintaining the International Normalised Ratio (INR) within the target range for the indication. A 56-year-old male presented to the emergency department with dyspnea and chest pain, together with pain and swelling in both legs. The patient had been taking warfarin at the therapeutic dose since having undergone an aortic valve replacement four years ago. His vital signs were an arterial pressure of 60/30 heart rate of 138 beats per minute, respiratory rate of 30 per minute and oxygen saturation of 60%. Computed tomography of the chest revealed thrombosis of the right pulmonary artery and its segmental branches. On investigating the aetiology of the venous thromboembolism, the level of Antithrombin III (AT III) activity was found to be at 37% (normal range, 80–120%).

Intra Luminal Metastasis to Duodenum: A Histological Surprise

Kaushik Subramanian, Tirou Aroul, Sasikumar Kuppusamy, Vijay Gunashekaran
Carcinoma cervix is one of the most common malignancies seen in women worldwide and more so in the Indian subcontinent. Carcinoma cervix is known for its orderly lymphatic spread. Skip metastasis or intraluminal metastasis is not a frequent occurrence. A 50-year-old diabetic and hypertensive female patient who was diagnosed to have carcinoma cervix (stage II A 2) Grade II to III and post radiotherapy (3 years back) presented to the surgical outpatient with dyspeptic symptoms and vague abdominal pain. On examination she was found to have a 1x1cm hard, fixed, left supraclavicular node and a palpable liver. Ultrasound abdomen revealed multiple retro peritoneal lymphadenopathy and Contrast Enhanced Computerised Tomography (CECT) abdomen revealed secondary deposits in the pancreatico-duodenal groove infiltrating the duodenal C-loop and pancreatic head, with multiple retroperitoneal nodes with necrosis. Fine needle Aspiration Cytology (FNAC) from left supraclavicular node revealed metastatic squamous cell carcinoma. Oesophagogastroduodenoscopy showed 2 sessile lesions in the anterior wall of duodenum with mucosa stretched and central umbilication with almost complete luminal obstruction. Biopsy from the duodenal lesion also turned out positive for metastatic squamous cell carcinoma. Gynaecological examination was negative for any local recurrence. Patient was managed symptomatically for dyspepsia and is currently undergoing chemotherapy. She is at present on regular follow-up and is asymptomatic for the bowel metastasis. Given the frequency of cancer cervix and the rarity of intra luminal metastasis, this case report serves to reiterate the fact that the abdomen is truly a pandora’s box.

Cystic Dystrophy of the Duodenum Due to Heterotopic Pancreas – A Case Report and Review of Literature

Gunjan Shailesh Desai, Aniruddha Phadke, Dattaprasanna Kulkarni
Cystic Dystrophy and Heterotopic Pancreas (CDHP) is a rare cause of chronic pancreatitis, duodenal obstruction and obstructive jaundice. The diagnosis is often delayed and requires multimodal imaging with Computed Tomography (CT), Magnetic Resonance Cholangio-Pancreatography (MRCP) and Endoscopic Ultrasound (EUS). The treatment is not standardized but Pancreatoduodenectomy (PD) provides long-term relief in some cases. The present case is about a 47-year-old male with history of alcohol abuse for 10 years who presented with a history of recurrent acute pancreatitis. CT scan revealed bulky head of pancreas with a hypodense area between pancreatic head and second part of duodenum, prominent pancreatic duct, Dilated Common Bile Duct (CBD) (15mm) and stenosis of second part of duodenum. EUS confirmed CT findings. A Fine Needle Aspiration Cytology (FNAC) showed only inflammatory infiltrate. A diagnosis of groove pancreatitis was made. The patient was subjected to a pylorus preserving PD. Histopathological examination showed cystic dystrophy of duodenum due to heterotopic pancreas. The patient is doing well at 5 years of follow-up.

Imaging Findings in Dysgerminoma in a Case of 46 XY, Complete Gonadal Dysgenesis (Swyer syndrome)

Pratiksha Yadav, Sanjay Khaladkar, Aditi Gujrati
A 46 XY pure gonadal dysgenesis also known as Swyer syndrome. These patients are phenotypic females with normal female external genitalia and absent testicular tissue. The patients with swyer syndrome have streak gonads and increased risk of dysgerminoma and gonadoblastoma. We present a case of dysgerminoma in dysgenetic gonads of swyer syndrome. A 23-year-old female had come with complaints of primary amenorrhea, pelvic mass and abdominal pain. Clinical findings, pathology investigation and imaging findings revealed swyer syndrome. On MRI it showed a large lobulated mass in the pelvis. Mass was excised and dysgerminoma was given on the histopathology.

Unique Application of Cryocone to Diagnose Umbilical Pilonidal Cyst

Kimberly Mallin, Sudhakar Pemminati
Patients with umbilical disorders who present with complaints of a mass, pain, tenderness or discharge will typically have a differential diagnosis including umbilical hernias, pyogenic granuloma, endometriosis, Sister Mary Joseph nodule and urachal or epidermoid cysts. We would add the inclusion of pilonidal sinus disease and present the case of a patient with an umbilical pilonidal cyst. The use of a cryocone with lubricating jelly, in this case, proved to be an easy and convenient method that aided in visualization and diagnosis of this fairly uncommon condition.

An Unusual Presentation of Scrub Typhus
Presentation of scrub typhus associated with brachial neuritis is extremely rare with only a few cases reported so far. Here, we report a case of a 45-year-old female who presented with fever and right shoulder pain. Laboratory parameters showed leucocytosis with ELISA and PCR for scrub typhus positive. Electromyography (EMG) and Nerve Conduction Velocity (NCV) study was suggestive of brachial neuritis. She was given doxycycline therapy for 10 days following which her shoulder pain resolved.

Prosthodontic Rehabilitation of Accidental Maxillofacial Gunshot Injury Using Dental Implants: A Five Year Follow-Up Clinical Report

Vinod Balla, Angleena Y Daniel, Nirmal Kurian
Gunshot injuries to the face can have serious aesthetic, functional, and psychological consequences. The incapacitating nature of maxillofacial defects makes reconstruction of the maxilla and mandible challenging, owing to multiple surgeries and extensive rehabilitation phase. Outcome of prosthodontic treatment is one of the important parameters by which a patient measures the success of rehabilitation. A 5-year follow-up of comprehensive surgical and prosthodontic reconstruction of a gunshot injury using dental implants is described. This case report illustrates the contribution of immediate dental implants with proper oral hygiene follow-up as an effective treatment modality in restoring a patient to near normal function and aesthetics.

Chondroid Metaplasia in a Fibroepithelial Polyp of Gingiva
Gingival masses are commonly encountered in clinical practice and can be a result of many conditions one of them could be metaplasia. Metaplasia is defined as the replacement of the lining of an organ with the type of lining normally found at another site. We are reporting a case of a 17-year-old Mexican male who presented with a pedunculated nodule associated to maxillary anterior gingiva.The histopatological examination revealed a chondroid material covered by stratified squamous epithelium and was diagnosed as chondroid metaplasia.

A Unique Flask Design for Processing Cranial Prosthesis Using Heat Cured Acrylic - A Case Report

Godwin Clovis Da Costa, Meena Ajay Aras, Paul Chalakkal
In a 30 year old male patient, the absence of a cranial bone fragment had left the brain covered only by dura mater, subcutaneous tissue and scalp, resulting in aesthetic and functional impairment. A prosthetic replica of the bone fragment made of PMMA (Polymethylmethacrylate) was fabricated using a unique flask design that consisted of a medium sized stainless steel instrument tray with lid, four large headed screws and a C clamp, since the prosthesis was too big to be invested in a conventional flask.

Simultaneous Bennett’s Fracture/Dislocation and Dorsal Fracture/Dislocation of Inter Phalangeal Joint of Thumb- A Case Report
Simultaneous closed double dislocations of the hand are not a common presentation. We hereby report a 40-year-old male patient with an unusual presentation of Bennett’s fracture/dislocation associated with dorsal fracture dislocation of the interphalangeal joint of thumb along with its management by Open Reduction and Internal Fixation (ORIF) with K-wires and physiotherapy. The patient had near normal functions after three months.

Left Pulmonary Agenesis with Right Lung Bronchiectasis in an Adult

Prabhat Kumar, Ghazal Tansir, Gargi Sasmal, Juhi Dixit, Ratnakar Sahoo
Pulmonary agenesis is a rare congenital anomaly characterized by the absence of pulmonary parenchyma and vasculature. Bilateral pulmonary agenesis is incompatible with extrauterine life. Unilateral agenesis is often associated with other congenital cardiovascular, genitourinary and gastrointestinal malformations. Right lung agenesis is more frequently associated with congenital anomalies and has poor prognosis as compared to left lung agenesis. Diagnosis is often made in childhood but can be delayed, if the clinician is not aware about this entity. Chest radiograph in unilateral lung agenesis shows opaque hemithorax and these patients are often confused with other common causes of opaque hemithorax like collapse, pleural effusion and diaphragmatic hernia. We report a case of left lung agenesis with right lung bronchiectasis in a middle-aged adult who was treated for as tuberculous pleural effusion and was referred to our institute for persistent symptoms despite treatment.

Cavernous Sinus Thrombosis due to Streptococcus mitis and Staphylococcus lugdunensis

Sandhya Nagarakanti, Eliahu Bishburg, Melinda Brown
Cavernous Sinus Thrombosis (CST) is a rare, life-threatening condition that may result from the direct spread of infection from the nose, ears, teeth or sinuses. It is most commonly caused by Staphylococcus aureus and Streptococcus sp. We present a case of CST caused by Strepotococcus mitis and Staphylococcus lugdunensis. Early surgical intervention with aggressive medical management is needed as the syndrome carries a high mortality. To our knowledge this is the first case of CST associated with these two organisms.

Meyer’s Muscle Pedicle Bone Graft a Novel Procedure in Treatment of Neglected Fracture Neck of Femur in Pediatric Age Group-A Case Report

Manjunath S Daragad, KM Ponnanna, Sunil Mannual
Meyers muscle pedicle graft has been used in delayed presentation and non-union of neck femur fracture in adults with good results. Delayed presentation or non-union neck femur in children is not uncommon in children. Subtrochanteric valgus osteotomy with or without fixation has been suggested with varying results. We present meyers muscle graft being used in paediatric age group with excellent result at 3 years follow-up. There are limited report literature of meyers muscle pedicle graft being used in children.

A Case of Macrophage Activation Syndrome with Acute Respiratory Distress Syndrome

Robin George Manappallil
Macrophage Activation Syndrome (MAS) is a rare form of Haemophagocytic Lymphohistiocytosis (HLH) associated with rheumatologic conditions. It is characterised by haemophagocytosis and cytokine overproduction, resulting from the activation and uncontrolled proliferation of T lymphocytes and macrophages. The patient being reported is an elderly female with Rheumatoid Arthritis (RA), who presented with fever and was found to have MAS. She later developed Acute Respiratory Distress Syndrome (ARDS) and died. Such a scenario has rarely been reported.

Clinical Profile with Angiographic Correlation in Naïve Acute Coronary Syndrome

Vikas Agrawal, Balaji V Lohiya, Bhupendra K Sihag, Rajpal Prajapati
Introduction: Despite cardiovascular diseases having grown to epidemic proportions, there are few studies from India pertaining to Acute Coronary Syndrome (ACS), more so from the region of Purvanchal which is less developed with more poverty. Our study is first of its kind in this region of patients presenting for the first time with ACS. Aim: The present study was undertaken to study the clinical and angiographic characteristics of ACS patients of Purvanchal. Materials and Methods: This was a prospective cohort study of 100 patients admitted with ACS. Patients were excluded if they had prior cardiac pathology like valvular heart disease, cardiomyopathy, pericardial disease, cor pulmonale, ischaemic heart disease or cardiac revascularisation. Patients who did not undergo angiography were excluded. Patients were divided into ST Elevation Myocardial Infarction (STEMI) and non STEMI (NSTEMI). Presentation delays as well as clinical characteristics analysed in each group were age, gender, presence or absence of diabetes mellitus, hypertension, dyslipidaemia, smoking, Body Mass Index (BMI), family history, duration of chest pain, and treatment received. Results: Mean age of patients was 58.9 years with 27% below 50 years. Of the total 75% were males. Patients with STEMI were 65%. Median time to reach hospital was 24 hours with only 27% patients reaching hospital within 6 hours. Among patients with STEMI only 43% received fibrinolytic therapy. 23% patients had diabetes, 21% were hypertensive, 16% were smokers, family history of cardiovascular disease present in 11% and 21% had body mass index more than 30. Mean LDL was 115mg/dl and HDL 39mg/dl with 54% of patients having at least one risk factor. Factors favouring triple vessel involvement were female sex, higher age, smoking, presence of diabetes and NSTEMI. Conclusion: Indians develop ACS at earlier age. Precious time is lost before seeking treatment. There is a need for aggressive risk factor modification which along with health awareness will be the key to prevent premature cases of ACS and limit morbidity and mortality due to delayed treatment.

Carcinoma of Maxillary Sinus Masquerading as Odontogenic Infection
Malignant tumours of maxillary sinus are rare. They are usually diagnosed in the late stages when they perforate the sinus walls. The presence of large air space in the maxillary sinus facilitates asymptomatic growth of the sinus malignancy. The clinical presentation of these tumours depends on the sinus wall involved by the disease. The medial wall is usually the first to become eroded, leading to nasal obstruction, epistaxis or discharge. Rarely, symptoms of maxillary sinus carcinoma can resemble dental infection and the affected patients may visit dental clinic seeking treatment. This report presents a case of carcinoma of maxillary sinus mimicking odontogenic infection. Computed tomographic findings explained the reason for the present lesion to masquerade as an inflammatory condition. The importance of advanced imaging modalities for prompt identification of such lesions is discussed.

Hymenolepis diminuta Infection in a School Going Child: First Case Report from Uttarakhand
Hymenolepis diminuta (H.diminuta) is prevalent worldwide, and a few hundred human cases have been reported till date. It is primarily a rodent parasite and humans (usually children) can act as accidental hosts. Infections are usually asymptomatic but abdominal pain, irritability, pruritis, mild diarrhoea and eosinophilia are among the existing symptoms in a few of the reported cases. Here, we report a case of an 11-year-old female child from Bijnor, who presented to us with complaints of abdominal pain, fatigue and irregular episodes of fever. Routine stool examination showed characteristic eggs of H.diminuta. Patient was given a single oral dose of praziquantel (25 mg/kg) and she improved. This case is presented to emphasize that till date there are very few reports on H.diminuta and there is limited data regarding its treatment protocols (dose and duration). Furthermore, albendazole which is commonly used drug for deworming helminthic infections is less effective in these infections.

Role of Endoscopic Ultrasound for the Diagnosis of Isolated Gastric Cavernous Haemangioma

Jinlong Hu, Hua Sao, Siyu Sun
Isolated gastric cavernous haemangioma is extremely rare in the stomach. Historically, endoscopy, computed tomography and MRI had been used to diagnose gastric cavernous haemangioma. Biopsy, is not an option due to its vascular nature and submucosal location. We report an isolated gastric cavernous haemangioma that was diagnosed by end-oscopic ultrasound in a 25-year-old male and treated by laparotomy. The final diagnosis of cavernous haemagioma was confirmed by post-operative pathology. There was no recurrence during 3-month follow-up period.

Accessory Upper Subscapular Nerve – The Neurotisation Tool
During the routine dissection classes for undergraduate students, uncommon variation in relation to the upper subscapular nerve of posterior cord of brachial plexus was observed. Normally upper subscapular nerve takes origin from the posterior cord, but in this case report, it arises in triplet fashion, just above the circumflex scapular artery. All these accessory nerves were supplying upper part of the subscapularis muscle. As per our knowledge, this is a rare variation of brachial plexus. Many variations are encountered in the formation of brachial plexus. The normal and the abnormal origin of nerves are important considering neurotisation surgeries as well as during the infraclavicular nerve block for various axillary and upper limb surgeries.

Bilateral Adrenal PNET: A Rare Presentation

Santosh Kumar, Vijayant Govinda, Shravan Kumar Singh, Jyotsana Singh
Primitive neuroectodermal tumours or PNET's are rare, malignant tumours with aggressive course and extremely poor prognosis. They have no sex preference. They arise mostly in the second decade of life. They are believed to be of neural crest origin and carry the name primitive because majority of the neuronal cells in these tumours appear undifferentiated. Solid organ origin is very rare and tumours arising from the adrenals are very infrequent. We report a case of metastatic bilateral adrenal PNET in a 45-year-old man. We believe this to be the first such case reported in the urological literature.

Gossypiboma: An Unusual Presentation as Perforation and Intraluminal Migration
Gossypiboma is a mass formed around cotton material acting as foreign body in visceral cavity. In our study, we present a case of gossypiboma following open cholecystectomy. A surgical sponge left in the peritoneal cavity following cholecystectomy, caused inflammatory reaction, perforation and intraluminal migration. It is a relatively rare presentation. This patient underwent emergency laparotomy with Billroth II anastomosis and sponge removal.

Bilateral Chorioretinitis as Syphilis Presentation: Multimodal Characterization and Therapy Response

Mónica Miranda Loureiro, Paula Alexandra Sepúlveda
Ocular involvement of syphilis may occur in any stage of infection. We report a case of bilateral syphilitic chorioretinitis, in an immunocompetent patient, as the presenting feature of a tertiary syphilis we performed a multimodal characterization through Fundus Autofluorescence (FAF), Fluorescein Angiography (FA) and Spectral-Domain Optical Coherence Tomography (SD-OCT).

Bilateral Renal Lymphangiectasia

Vaidehi K Pandya, Maulin K Shah, Shruti P Gandhi, Himanshu V Patel
Renal Lymphangiectasia (RLM) is very rare benign lymphatic malformation. It can be misdiagnosed for other cystic renal masses, most commonly polycystic kidneys. Though incidentally found in most cases, it may be the cause for hypertension and renal failure in undiagnosed patients. Here, we report a case of an adult asymptomatic male with bilateral RLM which was detected as an incidental finding on ultrasound. Confirmation by CT-scan and laboratory diagnosis of aspirated fluid was done, and patient was managed conservatively.

Ventilator Associated Pneumonia in an Infant Caused by Stenotrophomonas maltophila – A Case Report
Stenotrophomonas maltophila (S.maltophila) is an aerobic Gram-negative bacillus that is a frequent colonizer of fluids used in the hospital setting. The organism is known to cause life threatening infections in immuno-compromised patients especially in those who are neutropenic, on chemotherapy or on broad spectrum antibiotics. We report a case of ventilator associated pneumonia caused by Stenotrophomonas maltophila in a two-month old infant who later developed multi organ dysfunction syndrome. In seriously ill paediatric patients, S.maltophila should also be considered as a possible pathogen for Ventilator-Associated Pneumonia (VAP), hence empiric antibiotic choice should include antimicrobials that are active against S. maltophila. An early identification and treatment of VAP with Multi-Drug Resistant (MDR) strains with appropriate antibiotics has a significant impact on morbidity and mortality.

Intrathecal Dexmedetomidine for Anaesthetic Management of a Patient with Chronic Inflammatory Demyelinating Polyneuropathy

S Bala Bhaskar, D Srinivasalu
Chronic demyelinating disorders have multifactorial origin but common important physiologic and anaesthetic considerations. Choice of anaesthesia technique and the drugs used, undertanding the pros and cons of using central neuraxial blocks will help in successful management of such patients. We describe the anaesthetic management of a 34-year-old male with chronic inflammatory demyelinating polyneuropathy posted for cystolithotripsy.

Osteochondroma Complicated by a Popliteal Vein Aneurysm- A Rare Case Report

Sonali Sethi, Meenakshi Prakash, Anil Dhal, Sunil Kumar Puri
Osteochondroma is the most common benign skeletal tumour. It frequently causes pain and local symptoms, however, vascular complications are rare. The popliteal artery is more commonly affected and there are isolated case reports of popliteal artery pseudoaneurysm in literature. However, venous complications are extremely rare. We hereby report a case of 21-year-old male patient with distal femoral osteochondroma complicated by a popliteal venous aneurysm and deep vein thrombosis. This association has not been described in the past. The patient was put on anticoagulants as he refused surgery and was asymptomatic at six months follow-up. Awareness of this complication is important for timely diagnosis and surgical management as it is a source of life threatening pulmonary thromboembolism.

Incidental Ventricular Septal Defect (VSD) in the Donor of a Live Donor Liver Transplant: Tackle and Proceed

Dinesh Zirpe, Cs Muthukumaran, Anil Vaidya, Anand Ramamurthy
Live Donor Liver Transplantation (LDLT) is an act of selflessness on the part of the donor who is subjected to a major hepatectomy. Ensuring safety and long-term well being of the donor is of utmost priority. We describe a 21-year-old otherwise healthy donor with perimembranous Ventricular Septal Defect (VSD) who successfully underwent donor hepatectomy after closure of the VSD. There is no literature available to guide regarding course of action in such a condition neither any study to substantiate the risk involved. Optimum anticoagulation, endocarditis prophylaxis and optimum interval between the two procedures are areas to be defined as our experience with similar cases increases. Our case emphasizes the importance of multidisciplinary approach and management of such patient at high volume centers.

Cutaneous Melioidosis

Basavaprabhu Achappa, Deepak Madi, K. Vidyalakshmi
Melioidosis is an emerging infection in India. It usually presents as pneumonia. Melioidosis presenting as cutaneous lesions is uncommon. We present a case of cutaneous melioidosis from Southern India. Cutaneous melioidosis can present as an ulcer, pustule or as crusted erythematous lesions. A 22-year-old gentleman known case of diabetes mellitus was admitted in our hospital with an ulcer over the left thigh. Discharge from the ulcer grew Burkholderia pseudomallei. He was successfully treated with ceftazidime. Melioidosis must be considered in the differential diagnosis of nodular or ulcerative cutaneous lesion in a diabetic patient.

The Soft Palate Friendly Speech Bulb for Velopharyngeal Insufficiency

Sukhdeep Singh Kahlon, Monaliza Kahlon, Shilpa Gupta, Parvinder Singh Dhingra
Velopharyngeal insufficiency is an anatomic defect of the soft palate making palatopharyngeal sphincter incomplete. It is an important concern to address in patients with bilateral cleft lip and palate. Speech aid prosthesis or speech bulbs are best choice in cases where surgically repaired soft palate is too short to contact pharyngeal walls during function but these prosthesis have been associated with inadequate marginal closure, ulcerations and patient discomfort. Here is a case report of untreated bilateral cleft lip and palate associated with palatal insufficiency treated by means of palate friendly innovative speech bulb. This modified speech bulb is a combination of hard acrylic and soft lining material. The hard self-curing acrylic resin covers only the hard palate area and a permanent soft silicone lining material covering the soft palate area. A claw-shaped wire component was extended backwards from acrylic and was embedded in soft silicone to aid in retention and approximation of two materials. The advantage of adding the soft lining material in posterior area helped in covering the adequate superior extension and margins for maximal pharyngeal activity. This also improved the hypernasality, speech, comfort and overall patient acceptance.

Calcifying Epithelial Odontogenic Tumour of the Mandible: An Unusually Aggressive Presentation of an Indolent Tumour
Calcifying Epithelial Odontogenic Tumour (CEOT) or Pindborg tumour is a rare odontogenic tumour of epithelial origin. They constitute less than 1% of odontogenic tumours. Intra-ossseous variant of CEOT are more common compared to extra-osseous variant. Although benign, these can exhibit deceptively aggressive presentation. Here we report a rare case of CEOT in a 36-year-old female patient who presented with aggressive intra-osseous lesion with cortical breach and exuberant soft tissue proliferation. The lesion was treated with resection and reconstructed with titanium reconstruction plate.

In vivo and In vitro Anti-Inflammatory Activity of Indazole and Its Derivatives

Chakrapani Cheekavolu, M. Muniappan
Introduction: The inflammatory response is closely intertwined with the process of repair. However in some diseases the inflammatory response may be exaggerated and sustained without apparent benefit and even with severe adverse complications. For decades, we have been primarily relying upon Nonsteroidal (NSAID) and Steroidal Anti-Inflammatory agents for management of various inflammatory conditions. However, adverse effects of these drugs are severe which often leads to patient’s non-compliance with inadequate relief. Therefore, there has been a constant pursuit to develop newer anti - inflammatory treatment with fewer side effects. Aim: The study was designed to investigate the possible anti- inflammatory activity of indazole, its derivatives and to further investigate the possible cellular mechanisms underlying the anti-inflammatory effect. Materials and Methods: Carrageenan induced hind paw oedema in rats was employed to study the acute anti-inflammatory activity of indazole and its derivatives. Further, the role of cyclooxygenase – 2, pro-inflammatory cytokines like Tumour Necrosis Factor – a, Interleukin – 1ß and free radical scavenging activity (LPO, DPPH and NO) in the action of indazole and its derivatives was investigated using in vitro assays. Results: SPSS version 16.0 software was used for analyse the anti-inflamatory data. The IC50 values of indazole and its derivatives obtained in in vitro experiments were calculated by linear regression analysis. Indazole and its derivatives significantly, dose dependently and time dependently inhibited carrageenan induced hind paw oedema. In addition, the test compounds inhibited cyclooxygenase–2, pro-inflammatory cytokines and free radicals in a concentration dependent manner. Conclusion: The results of the present study revealed the potential anti-inflammatory action of investigated indazoles. The inhibition of cyclooxygenase -2, cytokines and free radicals may contribute to the anti-inflammatory effect of the test compounds.

The Effects of Dietary Supplements of Calcium, Vitamin D and Estrogen Hormone on Serum Levels of OPG and RANKL Cytokines and their Relationship with Increased Bone Density in Rats
Introduction: Osteoprotegerin (OPG)-Receptor activator of nuclear factor kappa-B ligand (RANKL) pathway is one of the contributing factors in the regulation of osteogenesis and bone resorption routes. Aim: The purpose of this study was to evaluate the effects of various dietary supplements on this pathway. Materials and Methods: The samples for this study (24 newborn rats) were divided in three groups according to the experiment applied for each group. Rats were given special diet according to their group plan for six weeks. Blood samples were collected to measure their serum levels of OPG and RANKL and all organs of rats were used to measure their bone density too. The results were analysed using appropriate statistical analysing tests. Results: Levels of whole-body bone mineral density in calcium plus vitamin D plus Estrogen (Ca + D + E) group and calcium plus vitamin D (Ca + D) group were significantly increased compared to control group. Mineral density was highest in calcium plus vitamin D plus Estrogen group and was about 0.1357 g/cm². RANKL had a significant decrease in calcium plus vitamin D plus Estrogen group compared to control and calcium plus vitamin D groups. There was a significant increase in the mean calcium and OPG in both experimental groups rather than control. Also, significant increase in estrogen was observed in Ca + D group than the control group. Conclusion: The results showed that intake of calcium and vitamin D and estrogen at determined dose led to an increase in OPG and RANKL cytokines reduction which ultimately led to an increase in bone mineral density. But Ca, D and E synergies were more effective in increasing bone mineral density compared to only the use of Ca and D.

Comparison between the Effect of Cow Ghee and Butter on Memory and Lipid Profile of Wistar Rats

Yogita Surendra Karandikar, Akshata Sanjay Bansude, Eesha Ajit Angadi
Introduction: The traditional texts designate Cow Ghee as Medhya Rasayana, beneficial for mental alertness and memory. There has been concern about increased risk of cardiovascular disease due to its high percentage of saturated fatty acids in ghee. Amongst all edible fats, nutrition composition of cow ghee and butter is comparatively similar. Hence we had planned a study to assess effect of cow ghee on memory and lipid profile. Aim: So the aim of this study is to assess the effect of cow ghee on memory and lipid profile Materials and Methods: Nootropic activity of test drugs was assessed by Elevated Plus Maze (EPM) and Morris Water Maze (MWM) model. Rats were divided into four groups namely control, Piracetam, cow ghee and butter. All drugs were given orally for 21 days. Transfer latency was measured in EPM model and probe test was done in MWM model. Results: Cow ghee and butter group showed no significant effect on memory in EPM and MWM model. There was reduction in weight of animals in Cow Ghee group and increase in weight with Butter. In both the models there was a significant increase in Triglyceride (TG) and Very Low Density Lipoproteins (VLDL) levels of rats in butter groups and increase in TG and VLDL of rats with cow ghee in EPM model. Conclusion: The result of experiment suggests that no beneficial effect cow ghee and butter on cognition was seen. However, ghee is relatively safer when compared to Butter in considering lipid profile.

Modified Occlusal Settling Appliance in Twin Block Therapy

Harpreet Singh, Rajkumar Maurya, Pranav Kapoor, Poonam Sharma
Early treatment with the Twin-block appliance is effective in reducing overjet and severity of malocclusion in Class II division 1 malocclusions with functional mandibular retrusion. Appearance of bilateral severe posterior open bite in some cases subsequent to completion of active phase of Twin block therapy poses a challenge to an orthodontist. Closure of posterior open bites of large magnitude is difficult to achieve with conventional upper anterior inclined plane used during support phase of Twin-block therapy. A simple yet effective modification of upper anterior inclined plane is proposed, which is an effective and invaluable adjunctive aid in correction of posterior open bite.

Treatment of an Adult with Skeletal Class III and A Hemimandibular Elongation A Multidisciplinary Approach

Eshan Awasthi, Nitin Bhola, Ranjeet Kamble, Sunita Shrivastav, Abhilasha Goyal

Fistular Opening below the Intertragric Notch: A Rare Variant of Pre-Auricular Sinus

Topical Mitomycin-C Chemotherapy in Ocular Surface Squamous Neoplasia

Charudutt Kalamkar, Nishant Radke, Amrita Mukherjee, Snehal Radke

Biodentine-A New Novel Bio-Inductive Material For Treatment of Traumatically Injured Tooth (Single Visit Apexification)

Erupted Large Anterior Maxillary Complex Odontoma: A Rare Dental Hamartoma

Shubha Ranjan Dutta, Deepak Passi, Sarang Sharma, Purnima Singh, Musharib Ahmed

Crossbite: An Orthodontic Exigency

Fine Needle Aspiration of a Subcutaneous Nodule Showing Eggs of Adult Filarial worm

Sandeep Ojha, Leena Naik, Kanchan Kothari, Mona Agnihotri

Effect of Fermented Food on General Anaesthesia in North Eastern Part of India

M S Faridi, Jasim Khan, Rajendra Sinam Singh

Correspondence: Growth and Nutrition of HIV Seropositive Children from West Bengal Under Direct Care of Medical Caregivers

Anirban Mandal, Amitabh Singh, Puneet Kaur Sahi, Bhavika Rishi

Avascular Necrosis of Femoral Head in a Child with Beta Thalassaemia Major

Adharsh Narain Thulasidhar, Sandeep Kumar, Shrikiran Aroor, Suneel Mundkur

An Unusual Case of Facial Hyperpigmentation Solved on Histopathology

Kiran Agarwal, Vandana Puri, Ruchika Kumar Goel, Deepti Verma

Multiple Antibiotic Resistance Patterns of the Enterobacteriaceae in the Untreated Municipal Sewage

Harsh Kumar