Journal of clinical and diagnostic research

Segmental Full Arch Reconstruction of Edentulous Patient: A Predicted Approach

Farhan Durrani, Karhick Raj

Full mouth implant reconstruction is a complex rehabilitation process. Well distribution of implants in each arch and availability of adequate bone is the prime demand for successful treatment. Biological and technical complications are often associated with the prosthesis. The irretrievability to repair and maintenance becomes a challenge for the clinician. Here, a case with a debilitated dentition which was reconstructed with an implant supported segmented prosthesis is described. Eight along with six implants were placed in maxilla and mandible respectively. Full arch segmented screw retained prosthesis is advantageous over cemented prosthesis for ease of repair and detachment. Further, it can easily correct angulations issues in maxilla for prosthesis fabrication.

The Challenging Biomechanics in a Maxillary Lateral Incisor and Canine Transposition Malocclusion

Dental transposition is an alteration that occurs in dental positioning, involving two adjacent teeth. Transpositions of canines are usually accompanied by other dental anomalies such as impaction of the incisors, missing lateral incisor, peg shaped laterals, rotations or dilacerations. Twenty percent of the transpositions involve the canine and upper lateral incisors. Dental transpositions are rare and may be complete or incomplete. The aetiology of transposition is still obscure. Several populations were studied to determine the prevalence of dental transpositions. Twenty percent of the transpositions involve the canine and upper lateral incisors. A clinical case is presented here, with canine and lateral incisor transposition and the biomechanics used in orthodontic treatment for the positioning of the canine in Class I and in the line of occlusion has been described. Correction of the transposition was performed with a fixed appliance for three-dimensional biomechanical control. The root of the left lateral incisor was moved to the palatal side to allow the movement, with the inclination movement of the crown, to distal the canine. The position of the mini-implant favoured distal movement without loss of anchorage of the teeth of this hemi-arch (left). With the canine positioned in place, third-order folds were inserted in the arch to move the lateral root to the buccal side. The canine was positioned in Class I relation in the line of occlusion with health, aesthetics, function and gingival and periodontal health remained stable after a year follow-up, demonstrating that the applied biomechanics were correct.

Hyperuricaemia, Hypoparathyroidism and Acute Hypercalcaemia: Unusual Complications in Extrapulmonary Tuberculosis

Ravi Parkash, Surekha Dabla, Neharika Saini, Kiran Bala

Hypercalcaemia may occur in patients with pulmonary tuberculosis because of abnormal extrarenal production of 1,25-dihydroxy Vitamin D3 by activated macrophages in granulomatous tissues. In Extrapulmonary Tuberculosis, derangements of calcium, Parathyroid levels are usually not seen. Rarely, serum calcium levels are raised with a normal vitamin D levels in background of an adequate sunlight exposure. Here, authors report a case of a patient with tubercular meningitis who presented with hypercalcaemia, hyperuricaemia, and hypoparathyroidism.

Irreducible Traumatic Miki Type II Dislocation of Hallucal Interphalangeal Joint: An Insight into this Rare Injury

Leon Alexander

Complex irreducible dislocation of the Interphalangeal Joint (IPJ) of the great toe is a rare injury, due to the inherent stability of the joint. Miki has classified these injuries into two types, and this article is on a case of complex type II dislocation managed by open reduction and internal fixation. These rare injuries, especially the type II variety, invariably need surgical management and overzealous attempts at closed reduction must be avoided as it risks injury to critical neurovascular and joint supporting structures, leading to poorer patient outcomes. An extensive comparative review of literature is presented here along with the optimal surgical approach, technique and post-operative rehabilitation, so as to maximise patient outcomes following these rare and challenging injuries.

Abnormal Twin Foramina on Fifth Lumbar Vertebra-Case Report

Rajani Singh, Karishma Sharma

Normally lumbar vertebrae in general and L-5 vertebra in particular are devoid of such foramen as explored in this case. Two mutually communicating foramina were detected in L-5 vertebra during demonstration classes of 1^st year MBBS students in the Department of Anatomy, AIIMS Rishikesh, Uttarakhand, India. This is a unique and rare anomaly having enormous clinical significance in very prevalent lower back pain therefore, the case is worth reporting. One foramen was located on lateral aspect near the inferior margin of right transverse process and the other between the superior articular process and right transverse process equivalent to retro-transverse foramen. First foramen was oval in shape with transverse diameter of 1 cm and vertical diameter 0.6 cm and may provide pathways to vessels irrigating surrounding structures. Second foramen was circular in shape having diameter of 0.8 cm and acts as a conduit for medial branch of dorsal ramus. The knowledge of these foramina is clinically significant to orthopaedic and neurosurgeons, anaesthesists and anatomists.

Misplaced Internal Juglar Vein Central Venous Catheter due to Thrombosis in Subclavian Vein: A Rare Occurrence

Sameer Sethi, Deepanshu Dhiman, Kaman Lileswar, Kaptan Singh

Here, authors report a case of Central Venous Catheter (CVC) malposition in a patient posted for Whipple’s procedure. A 65-year-old male diagnosed with carcinoma head of pancreas, post-chemotherapy was posted for Whipple’s procedure. Ultrasound (USG) guidance CVC line and arterial cannula placement were planned for invasive monitoring and administration of fluids and drugs post-operatively. A post-operative chest radiograph was done which showed that the CVC was malpositioned into the subclavian vein. The venography delineated a clot at the junction of the Internal Jugular Vein (IJV) and the Subclavian Vein (SCV). It was further concluded that presence of this thrombus at the junction of both the vessels prevented the movement of the guidewire towards the Superior Vena Cava (SVC) and therefore the catheter into the SVC. This case report highlights the use of USG not only to visualise the target vessel but also to scan completely till the junction SVC and right atrium for any clot or anatomic malformations in the vasculature.

Cryptococcus Infection and Lymphocytopenia: An Ill Defined Entity

Venkat Janardhan Rama Reddy, S Brunda, Amit Kulkarni, BG Chenna Keshava

Cryptococcus neoformans infections are rare. Meningitis by Cryptococcus is well known as an opportunistic infection. It is most commonly seen in immuno-suppressed patients, especially in retrovirus infections and chemotherapy patients. Herein we describe a healthy adult male patient, with no known co-morbidities, who had Cryptococcus meningitis with associated very low CD4 count. We could not ascertain a reason for the low CD 4 count and hence was labelled as Idiopathic CD4 lymphocytopenia. Patient was successfully treated with amphotericin and discharged home.

Sterile Abscess Following Hepatitis B Vaccination in a New Born- A Case Report

Jisha Myalil Lucca, Juny Sebastian, Mandyam Dhati Ravi, Gurumurthy Parthasarathi

Vaccines may cause adverse events ranging from mild reactions like fever to serious events like seizures. Both the vaccine product and the process of vaccination can cause adverse events. Non-sterile abscesses are usually a program error (an event caused by an error in the transportation, storage, handling, or administration of a vaccine) that may occur due to contamination of a multi-dose vial. Sterile abscess may occur as a delayed hypersensitivity reaction due to the presence of aluminium salt as an adjuvant in the vaccine, and are classified as vaccine product related reactions. The Hepatitis B vaccine is recommended for all infants at birth and for children up to 18 years. Here, authors report a case of sterile abscess in an eight-month-old baby, after the administration of first dose of Hepatitis B Vaccination, possibly due to an error and hence classified as Immunisation error related reaction.

Subcutaneous Phaeohyphomycosis Caused by Rhytidhysteron rufulum-A Case Report and Review of Literature

Rhytidhysteron rufulum, a melanized fungus, is usually considered as a saprophyte and human infections due to this fungus are rarely reported in literature. To the best of our knowledge, since 2008, only eight cases of human infections due to R. rufulum has been reported and all cases were exclusively from India. We, hereby, present a case of subcutaneous phaeohyphomycosis due to R. rufulum in a 55-year-old male from Puducherry (India) who presented with swelling over left leg for one year. The patient also suffered from diabetes mellitus, systemic hypertension and chronic kidney disease. The fungus isolated in culture was finally identified by molecular sequencing. With advances in molecular diagnostic techniques, many organisms which were traditionally considered as non-pathogenic are increasingly being recognised as human pathogens. Accurate identification of the organism is essential for effective treatment and hence, molecular diagnostic techniques should be applied where ever appropriate.

Cutaneous Plexiform Schwannoma of the Digit- A Case Report

Shankaran Rukmini Niveditha, Venkatesh Kusuma

A common mimicker of Plexiform Neurofibroma (PN), Plexiform Schwannoma (PS) can occur sporadically and in weak association with NF2. It is important to differentiate between the two, as recurrence and malignant potential are common with PN requiring extensive surgery and rigorous follow-up. Though light microscopic features of PN and PS overlap especially in small biopsies, IHC with S-100 would help. S-100 immunostaining is diffuse and strong in PS while weak and patchy in PN. A rare case of cutaneous PS in the right index finger of a nine-year-old boy where S-100 immunostaining helped to confirm the diagnosis is hereby reported.

A Rare Case of Ileal Inflammatory Fibroid Polyp with Small Bowel Obstruction

Inflammatory fibroid polyp is rare idiopathic benign tumour of gastrointestinal tract. The most common site is stomach (gastric antrum) followed by ileum. Ileal inflammatory fibroid polyp usually present with intussusception which has been published in various worldwide literatures. We report a case of 46-year-old lady presented with three days history of abdominal pain, vomiting and low grade fever. Clinically, she was diagnosed with acute small obstruction. Computed Tomography imaging demonstrated Ileo-ileal intussuception with polyp in the location of terminal ileum. Diagnostic laparoscopy was suggestive of Ileo-ileal intussuception due to a polyp 20 cm from ileo-caecal junction. Intussuception was spontaneously reduced and wedge resection was performed on the diseased segment.

Unilateral Grave’s Disease: A Rare Variant

Arun Pande, Ajay Aggarwal, Roopak Wadhwa

Grave’s Disease (GD), an autoimmune disorder, usually presents as diffuse goitre with involvement of both lobes of the thyroid gland. It is characterised by hyperthyroidism, ophthalmopathy and rarely dermopathy. Involvement of eyes can be unilateral or bilateral, but unilateral involvement of a lobe in a bilobar thyroid gland is very rare. Only 13 cases of unilateral GD have been reported so far. This entity may be missed quite often for thyroid hemiagenesis or hyperfunctioning thyroid nodule. Here, authors present a case of unilateral thyroid lobe involvement in a patient of GD.

A Case of Blistering Eruptions in Systemic Lupus Erythematosus

Sarojini Raman, Abhimanyu Grover, Prasant Padhan, Urmila Senapati

Cutaneous vesiculobullous lesions have a wide aetiological spectrum ranging from autoimmunity to medications and infections. Systemic Lupus Erythematosus (SLE) is one of most frequent autoimmune diseases with its cutaneous form being very uncommonly encountered. We report a case of Bullous Systemic Lupus Erythematosus (BSLE). Patient presented with fever, arthalgia and widespread blistering eruptions on face, neck and upper chest wall. Skin biopsy revealed subepidermal bulla and Direct Immunofluorescence (DIF) showed deposition of IgG, IgA, IgM, C3, C1q at the dermoepidermal junction. On treatment lesions healed rapidly. So proper clinical acumina is essential for diagnosis and management of such cases excluding the differentials.

Anaesthetic Management of a Patient with Myasthenia Gravis for Laparascopic Cholecystectomy: A Case Report

Jaya Choudhary, Aaditya Prabhudesai, Anshika Agarwal

Myasthenia gravis is an autoimmune disease, which presents as fatigue and muscle weakness due to destruction of nicotinic receptors. Perioperative management of such patients is challenging due to altered pharmacology of drugs especially muscle relaxants and opioids as well as high incidence of postoperative respiratory complications. Here, authors report a new anaesthetic technique for avoiding muscle relaxants and opioids in a myasthenia gravis patient using a combination of total intravenous anaesthesia with bilateral subcostal Transverses Abdominis Plane (TAP) block.

Ipsilateral Femoral Neck and Shaft Femur Fracture in a Child: Nonoperative Management

Manoj Aggarwal, Kunal Kishore, Chirag Arora, Sanjay Pandey, Vishal Kumar

Concomitant ipsilateral fractures of the neck and shaft of femur are a rare occurrence in childhood. Only 14 cases have been reported to date, the most common fracture pattern being Delbet Type III and a spiral fracture of midshaft femur. A four-year-old boy presented with closed fracture shaft femur and chest trauma (2-8^th rib fractures right side with underlying haemopneumothorax), fracture neck femur was incidentally detected on pelvic radiographs. Initially, he was managed according to ATLS protocols, surgical management of lower limb was deferred till vitals stabilised. Later child was managed nonoperatively in view of persistent poor chest condition with one and half hip spica cast. Successful clinic-radiological union was noted at 24 months. We should have a high index of suspicion for proximal femur fractures especially in a child with multiple organ injuries.

An Unusual Presentation of Ochronosis with Palmar Pigmentation

Ochronosis is the deposition of homogentisic acid in connective tissues resulting in bluish black discolouration. Hereby a case of ochronosis over the palmar surface of hand in 41-year-old male patient has been reported. Histopathological examination revealed yellowish brown colouration of collagen bundles in reticular dermis over palm of hand.

Tuberculous Meningitis Presenting with Sudden Deterioration and Demise after Ceftriaxone Withdrawal: A Case Report and Review of Literature

Tuberculous Meningitis (TBM) is a challenging condition to diagnose due to its non-specific clinical presentation and the limited sensitivity of existing laboratory techniques. Here we report an unusual presentation of TBM in a Nigerian teenager who presented with fever, headache, neck stiffness and progressive weight loss, and who had remarkable improvement while on ceftriaxone but had sudden deterioration and demise on withdrawal of ceftriaxone. Postmortem findings of TBM underlie the need for a high index of suspicion to enable early diagnosis, proper treatment and better prognosis.

Ayurvedic Management of a Case of Central Retinal Vein Occlusion

Manjusree Radhakrishnan Parappurathu, Aravind Kumar, Krishnendu Sukumaran

Central Retinal Vein Occlusion (CRVO) is classified based on aetiology into ischaemic and non-ischaemic varieties. Treatment modalities of CRVO include intra-vitreal anti-Vascular Endothelial Growth Factor (anti-VEGF) injections, pan-retinal LASER photocoagulation, and pars plana vitrectomy. The case of a 31-year-old female with a two-month history of blurring and fogginess of vision in her left eye (OS) and who were diagnosed previously with CRVO is presented here. Analysis of her symptoms using Ayurvedic diagnostics showed that she suffered from Timiraor blurring of vision. She underwent inpatient treatment in October 2014 and January 2015. Oral medicines such as Kashaya (decoctions), tablets, and Sattva (starch extract) were administered. External treatment included Pancakarma therapy and local therapies for the head and eye (Kriyakalpa). The Assessment was done using Distant Visual Acuity (DVA), posterior segment examination, and Optical Coherence Tomography (OCT), which showed improvement both at discharge and 2 subsequent follow-ups. This case illustrates that prompt and timely consultation and management brought about significant improvement in both her vision and well-being.

Strangulated Small Intestinal Obstruction due to Giant Meckle’s Diverticulum: A Case Report

N Thulasivasudevaiah, S Sudhir, Deepak Naik, DK Dilip, Aparna Mallya

Meckle’s Diverticulum (MD) is the most common congenital Gastro-Intestinal Tract (GIT) anomaly. Intestinal obstruction is the common presenting symptom in the adult population, due to complications like intussusception, incarceration, adhesion, stricture and torsion around a fibrous band. MD can present with similar symptoms of acute appendicitis or can present with painless lower GIT bleeding. Axial torsion of gangrenous MD can cause acute small bowel obstruction. The correct diagnosis of complicated MD before surgery is often difficult. This article is about a young boy who had signs and symptoms of acute small bowel obstruction for 15 days duration. He had MD which was adherent to umbilical region causing gangrenous small bowel obstruction. Initially, the patient was treated conservatively for suspected appendicitis in a peripheral Hospital at his native place and later he was referred for further management. He underwent surgery successfully and discharged after a week. As the acute small bowel obstruction in paediatric patients can also have associated MD with initial presentation as acute appendicitis we should have a high index of suspicion while treating such cases. Early diagnosis and surgical intervention can avoid major bowel resection and overall morbidity.

Giant Bullous Reaction in Response to Tuberculin Test in a Patient of Pelvic Inflammatory Disease

Gopal Chawla, Ram Niwas, Naveen Dutt

Tuberculin test is an example of delayed hypersensitivity type reaction. Most of the patients develop mild reaction in form of erythema and induration by 24 hours, which reaches epitome at 48 to 72 hours. Hereby the case of a middle aged female who presented with vaginal brownish discharge along with lower abdominal pain and primary infertility has been reported . Transvaginal ultrasonography showed right adnexal mass suggestive of hydrosalpinx. Intradermal tuberculin test was performed which atypically lead to formation of giant bulla of size 30×32 mm by 12 hours. We report this exaggerated response to a standard 5TU tuberculin test, which was later diagnosed as tubercular lymphadenitis with tubercular pelvic inflammatory disease that may be the reason for primary infertility.

Hepatic Tuberculous Abscess with Extension into Anterior Abdominal Wall

Sanjay M Khaladkar, Radhika K Jaipuria, Ronak Savani, Shibani Saluja

Hepatic Tuberculosis (TB) is rare form of extrapulmonary TB. Prevalence of primary tubercular abscess is 0.34% in hepatic TB. Isolated hepatic TB is rare with few reported sporadic cases. Primary hepatic tubercular abscesses rupturing into anterior abdominal wall is rare. The skeletal muscles are uncommonly affected by TB and are less preferred site for multiplication and survival of Mycobacterium tuberculosis due to abundant blood supply, lack of lymphatic and reticulo-endothelial tissue in muscles and high lactic acid content. We report a case of 36-year-old patient who presented with lump in anterior abdominal wall in right hypochondriac region since one month. On ultrasound and CT study, he was detected to have hepatic abscess in right lobe with extension to overlying anterior abdominal wall. TB-PCR showed Mycobacterium complex. Genprobe test was positive for Mycobacterium tuberculosis complex. Patient improved after Antikoch’s Treatment (AKT) with regression in hepatic and abdominal wall abscesses.

Successful Treatment of Chromobacterium violaceum in a North Indian Adult: A Case Report with Review of Literature

Charu Nayyar, Sankalp Sethi, Rajeev Vashishth

Chromobacterium violaceum, a gram negative facultatively anaerobic bacillus, although a rare human pathogen, is increasingly gaining importance, particularly because of its multidrug resistance and ability to rapidly progress to fatal sepsis with multi organ failure. Ciprofloxacin remains the most effective antibiotic, in vitro. A high index of suspicion and appropriate antibiotic treatment can help in reducing the mortality. A case of successful treatment of C. violaceum in a 62-year-old male from North India along with a review of literature has been described in this paper.

Retrieval of Separated Instruments from Root Canal Space: A Case

Mustafa Hussein Al-Attas, Saad Abdulaziz Al-Nazhan, Muhannad Salem AL -Harbi

Separation of nickel-titanium instrument during root canal treatment can cause serious complications that may lead to treatment failure. It prevents complete cleaning and filling of the entire root canal space. Retrieval of the instrument should be tried for better outcome of the therapy. This paper includes a case series of separated instruments. The instrument was successfully removed in four cases using an ultrasonic device under magnification. Case evaluation, a good armamentarium, and experience help the dentist to successfully retrieve separated instruments. Care must be taken in every case to avoid canal damage.

Tuberculosis Vaccine Development: Current Status and Future Directions

Kaushik Bharati

Does High Protein Diets Effects on the Cornu Ammonis 1 Neurons in Male Rats?

Shiva Roshankhah, Amir Abdolmaleki, Cyrus Jalili, Mohammad Reza Salahshoor

Introduction: The region of Cornu Ammonis 1 (CA1) in hippocampus has an obvious role in alteration of short-term memory to long-term. Proteins, as a crucial aspect of the cells, are involved in the structure and function of hippocampus. Aim: To study the effects of High Protein Diet (HPD) on CA1 and learning defect in rats. Materials and Methods: In this experimental study, 20 Wistar male rats were divided into two groups by random samplling: the groups of control (normal diet including 14% protein was used) and HPD (35% protein). Animals in HPD group were daily fed HPD for 10 months. Body weight was measured. Transcardiac perfusion procedure was applied for tissue fixation. Passive avoidance learning of animals was examined by shuttle-box apparatus technique. The number of dendritic spines was investigated by Golgi staining protocol. Also, Cresyl Violet staining was used to determine the number of neurons in the hippocampal area of CA1. Kolmogorov-Smirnov test was applied to confirm the normal distribution of data and t-test was used for determination of differences among the groups. SPSS version 16 was used for data analyses. Results: The Passive Avoidance Learning of the HPD rats was significantly higher compared to the control group (p-value <0.05). HPD increased the body weight, the number of neuronal dendritic spines and neurons in comparison to the control group (p-value <0.05). Conclusion: It can be concluded that the administration of HPD has useful effects on the structure and function of the hippocampal region of CA1 in male rats.

Accuracy of Cone Beam Computed Tomography Over Conventional Radiography (IOPA), Clinical Probing and Direct Surgical Measurements in the Assessment of Periodontal Defects

Introduction: Currently the main diagnostic tools for periodontal diseases are clinical probing and intraoral radiography. However, both techniques have its own limitation in assessment of periodontal bone loss. Periodontal diagnosis relies heavily on traditional two dimensional radiographic assessments. Lack of three dimensional information of the dentition was overcome by the introduction of CT scan, however the increased radiation exposure and high cost was its main disadvantage. Recently, Cone Beam Computed Tomography (CBCT) has turned this concept into potential reality because these lower-cost small machines produce high-quality data. Yet there is little research to establish periodontal bone measurement using CBCT as a valid method. Aim: To compare linear measurements of periodontal defects using CBCT to clinical, Intraoral radiographs and open bone measurements. Materials and Methods: This study was conducted in the Department of Periodontology in association with the Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Mangaluru. Sixty-three periodontal bone defects in patients suffering from periodontitis and scheduled for flap surgery were included in the study. Based on clinical and radiographic assessment, the periodontal defects were grouped into three groups. Group A- Horizontal bone loss (21 sites), Group B -Vertical bone loss (21 sites) and Group C- Furcation defects (21 sites). On the day of surgery prior to anaesthesia, after obtaining clinical probing measurements, CBCT and IOPA (Long cone paralleling technique with grid) of the quadrant to be operated was taken. After reflection of the flap, direct measurements were obtained for all the periodontal defects. The measurements taken during surgery were then compared to the measurements done with CBCT, IOPA and clinical probing subjected to statistical analysis using the Intra class correlation coefficient and Paired t-test. Results: Overall there was a very high correlation between the direct bone and CBCT measurements. For horizontal bone defects, Intra-class correlation coefficient showed excellent agreement of CBCT measurements with direct bone measurements in all the areas around the tooth where as IOPA and clinical probing showed moderate agreement. No significant difference was obtained between CBCT and direct bone measurements in the mesiobuccal, mesiolingual/mesiopalatal and distobuccal areas. For vertical bone loss, no significant difference was noted between CBCT and direct measurements from the CEJ to the crest of the bone adjacent to the defect. CBCT could detect 95% of the furcation defects whereas IOPA detected only 66% of the defects. Clinical probing appears to be the least reliable technique, with only 15% of the furcation defects being detected. Conclusion: Overall, all three modalities are useful for identifying periodontal defects. CBCT allowed more accurate assessment of horizontal, angular bony defects and furcation involvements than IOPA and clinical probing. Compared to radiographs, the three-dimensional capability of CBCT offers a significant advantage because all defects can be detected and quantified.

Effect of the Combined Use of Adhesive Systems and Oxalate-based and Fluoride-based Dentin Desensitizers on Bond Strength

Introduction: The association of adhesive systems and desensitising agents could influence the values of the bond strength. That is because these desensitising agents cause the obliteration of the tubular holes and minimise the movement of the dentin fluids, promoted by environmental stimulus that tends to cause hydrolysis at the base of the hybrid layer over time. Aim: To evaluate the microtensile bond strength of total-etch (Single Bond II, SB, 3M ESPE, USA) and self-etch (Clearfil SE Bond, SE, Kuraray, Japan) adhesive systems in dentin conditioned after the application of oxalate-based and fluoride- based desensitising agents. Materials and Methods: Discs obtained from human molars were used, which had its occlusal enamel removed to expose flat surfaces of dentin. Six groups were formed, according to the materials used: G1 (control)- hybridization with SB; G2- desensitizer based on oxalate (BisBlock, BB) and SB; G3- desensitizer based on fluoride (Aqua Prep F, AF) and SB; G4 (control)- hybridization with SE; G5- BB and SE; G6- AF and SE. On these surfaces, blocks of composite resin Filtek Z350 of 5 mm high were prepared to obtain sticks of (1×1×10 mm). The samples were stored in deionized water at 37°C for 24h and submitted to microtensile mechanical trial at 1mm/min speed till the fracture. The results were statistically analysed by one-way ANOVA followed by Tukey’s post hoc test (p<0.05). Results: The mean values of bond strength of the studied groups in MPa (SD) were as follows: G2: 46.48 (4.02), G3: 44.87 (4.68), G5: 39.02 (4.72), G4: 36.95 (3.57), G1: 36.66 (3.42), G6: 32.71 (3.41) which did not show statistically significant differences (p>0.05). Regarding the fractures analysis, the mixed type prevailed. The fracture was on the base region of the hybrid layer for the total-etch adhesive system, and at the top of the hybrid layer for the self-etch system. Conclusion: There is no significant difference in bond strength between the combined use of desensitizers with total-etch and self-etch adhesive systems on human dentine.

Quality in Surgical Pathology- A Story of Continuous Improvement Over Seven Years at Rural Teaching Hospital in Western India

Monica Gupta, Kailash Inaniya, Munira Jhabuawala

Introduction: Quality assurance in histopathology is a long sought phenomenon with a limited objectiveness and well defined quality parameters. We tried to design, implement and monitor a Quality Improvement Plan of histopathology with target based approach and required interventions. Aim: To establish and implement Quality Improvement Plan in histopathology, to identify various error rates, their reduction strategies and to assess scope for improvement in histopathology services. Materials and Methods: Various defined parameters of pre-analytical, analytical and post-analytical phases of quality were implemented and monitored with necessary corrective and preventive actions to improve the outcome over a period of seven years. Results: The study included 24,266 samples. Pre-analytical indicators showed improvement over a period of time with good performance in area of specimen fixation, specimen delivery, and completeness of requisition form and slide quality. The analytical phase showed continuous improvement in various correlations and error rates. A discordance rate of 1.09% was found in histopathology-frozen section correlation and 6.6% for histopathology-cytology correlation. Histopathology-IHC correlation rate was 87.1% and 0.2% cases showed discordance in internal peer review. Incomplete reports were found in 0.024%. In post-analytical phase, the total amended reports were 0.25%. A 96.8% of all critical alerts were intimated to clinicians. The Turn Around Time (TAT) outliers were 0.78%. External Quality Assurance Scheme (EQAS) performance was 76.3% and 97.7% for pre-analytical and analytical phase respectively. Conclusion: The effective quality improvement plan for surgical pathology can be successfully implemented at rural teaching hospital by designing a plan and executing it with continuous monitoring and necessary intervention.

Oral Health of Babies and Mothers during the Breastfeeding Period

Introduction: Puerperal woman and new-born children are vulnerable and frequently have neglected health conditions. Aim: The objective is to describe the oral health and saliva profiles of women and their babies during the breastfeeding period, including breast milk. Materials and Methods: Forty-seven mothers were interviewed and demographic data were recorded. The mother-baby pairs underwent intraoral examination. The mothers were submitted to examination of oral mucosa, oral hygiene status by O’Leary, periodontal condition and caries (DMF-T: decayed, missing and filled teeth) in order to establish buccal conditions. The babies had their oral mucosa and teeth examined. Salivary samples of babies and mothers as well the breastmilk of mothers were collected and analysed by 1H-NMR through a 600 MHz spectrometer. The data were analysed in a statistical program SPSS.21 (IBM Statistics). Results: The mothers’ mean age was 27-years-old and 53.9% of mothers were overweight. The oral condition revealed poor oral health: DMF-T=8.20, 72.4% had gingivitis and 62% had dental plaque. The babies presented 4.18% cases of oral candidiasis and 2.08% cases of Bohn nodules, with no caries. The salivary ¹H-NMR spectra from babies with more than six months of age showed increased levels of lactate, ethanol, acetate, propionate, N-butyrate and N-acetyl sugars and reduced levels of other sugars. The ¹H-NMR analysis of salivary samples from the mothers showed metabolites such as propionate, ethanol, lactate, acetate, butyrate and N-acetyl and sugar region. The ¹H-NMR breast milk demonstrated high quantity of lactose in a region of spectra characteristic from sugars. It was concluded that the mothers had low levels caries activity; however, though they had past dental caries history. This may have an impact on the oral health of their children. Conclusion: Our study focused on the oral health and saliva profiles of women and their babies during breastfeeding period. This data could design a preventive programme that would improve the oral health and quality of life.

Glycaemic Control and Mortality Outcomes in Intensive Care Unit

Haji Mohammed Ismail, CS Nagalakshmi, Shaheen Banu Shaikh, L Nivedita

Introduction: Hyperglycaemia is associated with adverse physiological outcome and high mortality rates in critically ill patients. Intensive Insulin Therapy (IIT) for glycaemic control often leads to hypoglycaemia and increases risk of death, therefore targeted glycaemic management in Intensive Care Unit (ICU) are need of the hour. Aim: To study whether achieving glycaemic control during stay in ICU can affect mortality rate in critically ill patients. Materials and Methods: The prospective observational study was conducted on 325 diabetic patients admitted in ICU at Yenepoya Medical College and Hospital, Karnataka. Upon admission to ICU, blood sugar and Glycated haemoglobin (HbA1c) levels were measured. Age, sex, duration of Diabetes Mellitus (DM), co-morbidities, Sequential organ failure assessment (SOFA) score, Acute Physiology Assessment and Chronic Health Evaluation (APACHE) II score, hypoglycaemic episodes, and drug history were recorded. Following Conventional Insulin Therapy (CIT) and Intensive Insulin Therapy treatment, the mortality outcomes were documented. Independent student t-test was used to compare mean changes between two parameters and ANOVA was used for comparison of changes between the groups in quantitative variables. Chi-square test was used for analysing qualitative variables between groups. A two-sided p<0.05 was considered as statistically significant value. Results: The patient’s population was predominantly men 210 (64.6%), 190 (57%) were older than 60 years. ICU mortality was 110 (33.8%). 56.1% of patients received IIT and 43.1% of patients received CIT. Mortality in IIT was 75 (22.8%) and mortality in CIT was 250 (77.2%). Mortality was significantly lower (p<0.05) in the IIT group than in the CIT group. Conclusion: The results of the present research supports implementation of IIT in intensively ill patients of ICU. IIT in critically ill patients was associated with an overall reduction in morbidity and mortality. The present study’s results together with data from latest studies, suggest a need for the broad implementation of IIT and a rising necessity for additional randomised clinical trials in various groups of critically ill patients.

Evaluation of Health-related Quality of Life, Voiding Pattern and Sexual Function in Patients with Status Stage 1 Urethroplasty for Pan Anterior Urethral Stricture Disease

A Bhalaguruiyyan, P Puvai Murugan

Introduction: Staged urethroplasty is used for the reconstruction of urethra in panurethral stricture disease. Aim: This study evaluated the Health-Related Quality of Life (HRQOL), voiding pattern and sexual function in patients with status stage 1 urethroplasty. Materials and Methods: This cross-sectional study included patients who had undergone staged urethroplasty from March 2008 to April 2018. Data on HRQOL, voiding pattern and sexual function were collected using Short Form Health Survey (SF-36), International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) questionnaire, respectively. Voiding pattern was further assessed by uroflowmetry, Post void residual urine assessment (PVR) and calibration of urethra with 18 Fr Foley catheter. Student t-test was used for continuous variables and Chi-square test for discrete variables. Results: A total of 37 patients were included in the study. The mean age of the patients was 53.4 years. The mean scores of physical component and mental component of SF-36 were 49 and 51, respectively. The overall IPSS score was mild in 18 (49%), moderate in 12 (32%) and severe in seven (19%) patients. Only three patients were sexually active with mean IIEF scores of 23/30 in erectile function, 8/10 in sexual desire, 7/10 in orgasmic function, 11/15 in intercourse satisfaction and 7/10 in overall satisfaction. The success of surgery assessed by voiding pattern was 75.6%. The IPSS score was significantly higher in older patient with age >55 years (p<0.001), and treatment failure group (p<0.001), however, there was no significant difference in patients who had BXO changes (p>0.05). Conclusion: These observations suggest that stage 1 component of staged urethroplasty for pan anterior urethral stricture disease has a reasonable success rate and does not adversely affect the quality of life index. However, these patients need appropriate counselling regarding sexual life.

Evaluating the Effects of Non-surgical Periodontal Treatment on Masticatory Function in Patients with Aggressive Periodontitis: A Preliminary Study

Manar Alshams, Majd Othman, Ibrahim Haddad, Ali Abou Sulaiman

Introduction: Tooth loss is considered among the most common problems in patients with aggressive periodontitis. The loss of teeth heavily affects chewing ability and the neuromuscular control of mastication. Performing basic periodontal treatments have positive effect on the perseverance of teeth and subsequently the chewing ability. Aim: To evaluate the effect of non-surgical periodontal treatment on the objective measures of masticatory function in patients with aggressive periodontitis. Materials and Methods: Twenty patients (18-35 years of age) with generalised aggressive periodontitis were studied. Patients with 20 or more teeth in the oral cavity and normal occlusion on molar teeth were selected from the Department of Periodontics, Faculty of Dentistry, Damascus University. Scaling and root planning alongside adjunctive chemical therapy (Ciprofloxacin+Metronidazole) was performed and bite-force registrations and Electromyography (EMG) records were determined on two occasions with three month intervals. Statistical analysis was done using paired samples t-test, independent samples t-test and Pearson’s correlation coefficient. Results: The overall improvement in the periodontal status following the non-surgical treatment was accompanied by a significant increase in bite-force (Newton) from 317.22±49.56 to 320.34±49.09, and a significant increase in EMG values from 347.01±51.81 to 351.74±50.65. Conclusion: Periodontal treatment demonstrated a positive effect on bite-force and EMG values after non-surgical periodontal treatment.

Safeguarding Surgeons: Utility of Ultrasonography and Computed Tomography in Reducing Diagnostic Errors in Acute Appendicitis

MM Ramashankar, Rahul Pandey, Vipin Chandra Saini, Sukumar Santosh Kumar

Introduction: Correct and urgent decision making in Acute Appendicitis (AA) is very challenging. Operative treatment based only on clinical examination has a high Negative Appendectomy Rate (NAR). Diagnostic accuracy of clinical algorithm is poor thus many surgeons resort to imaging modalities. There are medico-legal risks to surgeons either due to delayed treatment or due to diagnostic error in cases of AA leading to cases of litigation against them. Thus, complimenting a clinical diagnosis with imaging becomes a safe option in the current surgical practice. Aim: To assess the utility of abdominal Ultrasonography (USG) and Computed Tomography (CT) Scan in reducing diagnostic errors in AA. Materials and Methods: A prospective observational study was done in a tertiary care teaching hospital. The diagnostic efficacy of Alvarado Scores (AS), USG and CT scan were studied in terms of measurable outcomes such as sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), diagnostic accuracy and NAR. Results: Seventy five males and 27 females with a mean age of 27.5±10.0 years were studied. All patients underwent appendiceal USG, while 33 patients underwent CT scan. NAR was 9.33% in males and 14.8% in females with overall NAR of 10.78%. The overall sensitivity, specificity, PPV, NPV and diagnostic accuracy of AS was 78.02%, 72.73%, 95.95%, 28.57% and 77.45% respectively which was higher in males. The overall sensitivity, specificity, PPV, NPV and diagnostic accuracy of USG was 94.51%, 81.82%, 97.73%, 64.29% and 93.14% respectively and had a higher value in males. CT scan had an overall sensitivity of 96.00% and specificity of 100%. In patients with AS <7, USG and CT scan had better sensitivity, specificity, PPV, NPV and higher diagnostic accuracy. Conclusion: AS is a useful tool for diagnosing AA when AS is =7. USG is more sensitive, specific and has a higher diagnostic accuracy than AS. In patients with AS <7, USG has better sensitivity, specificity, NPV and diagnostic accuracy. CT scan has highest sensitivity, specificity and diagnostic accuracy compared to AS and USG. CT scan is more beneficial when AS is <7. On combining AS, USG and CT scan overall sensitivity, NPV and diagnostic accuracy of tests improved. USG should be used as an adjunct in all patients of suspected AA. CT scan use is highlighted in equivocal cases in which AS and USG cannot establish thereby reducing diagnostic errors in AA.

Predictive Models of Gangrenous Cholecystitis in Laparoscopic Cholecystectomy Treated Patients

Introduction: Gangrenous cholecystitis is difficult to diagnose clinically. There are no distinctive signs, symptoms or laboratory findings to distinguish it from acute cholecystitis. Furthermore, the Computed Tomography (CT) scans have a low discriminative value to distinguish between the two. To improve the diagnostic accuracy and dependability of CT scan, radiologic parameters should be analysed with clinical variables. Aim: To develop models for prediction of gangrenous cholecystitis according to preoperative patient-dependent and clinical risk factors. Materials and Methods: This retrospective, observational study included patients who underwent laparoscopic cholecystectomy for acute and gangrenous cholecystitis between February 2015 and November 2017. The study population was stratified into two groups based on surgical and histopathological diagnosis: acute cholecystitis and gangrenous cholecystitis. Predictive models for gangrenous cholecystitis were developed based on multivariate analysis of preoperative clinical and radiological variables. Results: A total of 437 patients (mean age 54.7±15.5 years, 260 males) were included in the study. Of the included patients 65.4% exhibited acute cholecystitis and 34.6% exhibited gangrenous cholecystitis. Multivariate analysis identified independent factors associated with gangrenous cholecystitis: presence of diabetes increased white blood cells >10000/mm³, gallbladder wall thickness >3 mm and pericholecystic fluid collection. Based on the aforementioned results of multivariate analysis; two predictive models were developed to predict gangrenous cholecystitis: 1) A standard predictive model for symptomatic patients (82% of sensitivity and 82.2% of specificity); 2) Quick-and-easy predictive model for asymptomatic patients (78.2% of sensitivity and 79% of specificity). Conclusion: Clinical application of standard, quick-and-easy predictive models is expected to help and improve preoperative diagnosis of gangrenous cholecystitis in symptomatic and asymptomatic patients. Moreover, application of models can assist the surgeons to prioritise patients for urgent surgical intervention.

Contemporary Outcomes Following Endovascular Therapy of Coarctation of Aorta- Experience from a Tertiary Care Centre in India

Sahil Mahajan, Arpudh Michael Anandaraj, Lijo Varghese, Oommen Kattunilam George

Introduction: Since 1980s, endovascular therapy has evolved as an important therapeutic strategy for Coarctation of the Aorta (CoA). Aim: This study sought to present a comprehensive contemporary data on the efficacy and safety of endovascular therapy in all age groups with both native and recurrent CoA in patients presenting to a tertiary care centre in Southern India. Materials and Methods: This single centre retrospective study included 91 consecutive patients who underwent Balloon Angioplasty (BA) or stenting for CoA between November 2002 and October 2017. Clinical, angiographic and procedural data was collected and outcomes including procedural success, complications, incidence of re-stenosis and hypertension at follow-up were evaluated. The effect of pre-specified variables on the procedural result was also evaluated using chi-square or two sample t-test, as appropriate. Results: Of the 91 patients, 63 were males; median age was 20 years {interquartile range (IQR):11-29}. The median follow-up duration was 17 months (IQR -7.5 to 36 months). Eighty four (92%) cases were with native coarctation. Fifty five (60%) had discrete coarctation and 36 (40%) had associated tubular hypoplasia of isthmus. Seventy two (79%) patients underwent stent implantation and 19 (21%) underwent BA. Immediate procedural success was achieved in 68 (94%) patients in the stent implantation group and 13 (68%) patients in BA group. Sixty percent of the failures were from BA group. Twelve (18%) patients had re-obstruction on follow-up. Seven (11%) patients underwent re-intervention. Conclusion: Endovascular therapy is a relatively safe and effective treatment modality in CoA when done carefully at experienced centres and in appropriately selected patients.

Serum Nitric Oxide and Plasma HbA1c Levels in Type 2 Diabetes Mellitus Patients

Shah Yasir Yousuf, Sudha Ambiger, Dnyanesh Morkar

Introduction: Diabetes Mellitus (DM) is a metabolic disorder characterised by hyperglycaemia and insufficiency of secretion or action of endogenous insulin. Glycated haemoglobin (HbA1c) is commonly used as reliable index to determine cumulative glycaemic history of preceding 2-3 months. Nitric Oxide (NO) is a potent vasodilator and an endothelium-relaxing factor. Low serum Nitric Oxide (NO) levels are known to be associated with endothelial dysfunction in Type 2 Diabetes Mellitus (T2DM). Aim: To estimate the serum nitric oxide levels in type 2 diabetic patients and correlate it with serum HbA1c levels. Materials and Methods: The cross-sectional study comprised of 100 (50 male and 50 female) T2DM patients who attended KLE’S Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India. Fasting Plasma Glucose (FPG) was measured by Hexokinase method using Roche/Hitachi COBAS 6000 Fully Automated Analyser. HbA1c was estimated using a Bio-Rad D-10 HbA1c program and serum NO was estimated by Classical Griess Reaction. Data was analysed using independent t-test within the groups and Karl Pearson Correlation Coefficient in between the groups. The p<0.05 was considered as statistically significant. Results: Statistically significant positive correlation was observed between NO and with HbA1c (r=0.7674) and NO with FBS (r=0.5688). Conclusion: Hyperglycaemia increases NO levels in T2DM patients. Measurement of nitric oxide in early course of diabetes may help in preventing the progression and development of complications like endothelial dysfunction.

Efficacy of CT Guided Perineural and Facet Joint Steroid Injection in Patients with Chronic Spinal Pain

Introduction: Image guided interventions are increasingly being used for the management of chronic low back ache. It has inherent advantages of confirming needle placement and thus increasing precision of these procedures. Aim: To assess the efficacy of pain relief provided by CT guided perineural and CT guided facet joint steroid injections respectively in patients with chronic spinal pain. Materials and Methods: A prospective study was performed to analyse the effect of image guided procedures in providing adequate pain relief. Patients were asked to grade pain on a Visual Analog Scale (VAS) for pain before the procedure as well as on subsequent reviews at 3 days, 30 days and 90 days. The pain score was used to calculate percentage of pain relief since previous follow-up and classified accordingly. Results: A total of 67 perineural injections and 20 facetal injections were administered. In present study, out of 67 perineural injections at least 31.5% reported very good pain relief as early as 3 days post-injection, while 28.3% continued to have very good pain relief at the end of 30 days but this fell to 10.4% at the end of 90 days. Out of 20 facet joint injections, none of the patients reported good pain relief during the follow-up. Conclusion: CT-guided perineural steroid injections for management of chronic low back ache are safe and effective interventions that can be incorporated into any existing interventional radiology practice.

Peritoneal Elastic Lamina Changes and D2-40 Expression in Colorectal Carcinoma: A Histopathological and Immunohistochemical Study

Introduction: Peritoneal elastic lamina invasion (PELI) has been reported as an important negative prognostic factor in pT3 Colorectal cancer (CRC). Lymphovascular invasion (LVI) is a crucial step in the dissemination of tumour cells and is correlated with lymph node metastasis and adverse prognosis. Aim: Assess PELI and LVI in colorectal carcinoma cases and determine their role in evaluating pT3 CRC and correlating them with tumour prognostic parameters and pT4a tumours. Materials and Methods: This retrospective study included 60 cases of CRC including pT3 (40 cases) and pT4a (20 cases). Samples were immunohistochemically analysed for D2-40 to highlight lymphovascular invasion. The pT3 cases stained by Verhoeff’s stain are to detect peritoneal elastic lamina invasion. The presence of PELI and LVI was correlated with clinicopathologic variables. Results: PELI was associated with lymph node metastasis (p-value=0.001), LVI (p-value=0.009), distant metastasis (p-value=0.036) and advanced TNM stage (p-value <0.001). D2-40 immunostaining identified LVI in 10 cases (16.7%) which could not be identified on H&E. D2-40 detected LVI were significantly correlated with lymph node metastasis (p-value=0.0002), H&E detected LVI (p-value=0.0007), distant metastasis (p-value=0.038) and TNM stage (p-value <0.01). The sensitivity, specificity, positive predictive value, and negative predictive value of lymphovscular invasion identified by D2-40 immunostaining to predict lymph node metastasis were 69.44%, 79.17%, 83.33% and 63.33%, respectively. pT3 cases with positive PELI and D2-40 detected LVI were significantly correlated to adverse prognostic factors. Conclusion: Positive PELI and D2-40 detected LVI are adverse prognostic factors in patients with pT3 CRC being significant predictors of lymph node deposits, distant metastasis and tumour stage. This would recommend upgrading of pT3 CRC cases with PELI into pT4a that would enable histopathological correlation with patients’ treatment.

Molecular Investigation of Extended-Spectrum β-Lactamase and Patterns of Antibiotic Resistance in Enterobacter cloacae Isolates from Teaching Hospitals in Kermanshah, Iran

Introduction: Enterobacter cloacae are responsible for a variety of hospital acquired infections including sepsis and Urinary Tract Infection (UTI). High emergence rate of Extended Spectrum β-Lactam (ESBL) resistant bacteria has led to increased rates of mortality, therapeutic failure and healthcare expenses. Identification of Cefotaximase-Munich (CTX-M), Temoneira (TEM), and Sulphydrylvariable (SHV) genes can help in determining the epidemiology, and thereby aid in development of anti-microbial therapy. Aim: To determine molecular frequency of ESBL in E.cloacae isolates obtained from Teaching Hospitals of Kermanshah, Iran. Materials and Methods: The descriptive cross-sectional study was conducted from January 2017 to November 2017, and 93 E.cloacae isolates were collected. All isolates were identified by standard microbiological and biochemical methods including Triple Sugar Iron (TSI) and Indole, Methyl red, Voges-Proskauer, Citrate (IMViC) test. After identifying the resistance pattern of such isolates via Disc diffusion test (DDST), isolates were evaluated for ESBLs using combination disc phenotypic method. Frequency of CTX-M, TEM, and SHV genes was investigated by Polymerase Chain Reaction (PCR). Chi-square and Fisher’s-tests were used for statistical analysis. The p-values <0.05 were considered statistically significant. Results: Maximum number of isolates were resistant to Amoxicillin-Clavulanic acid (97.8%), followed by Tetracycline and Ceftazidime (60.2%), and Colistin had the highest sensitivity (100%). Among them, 55 (59.1%) isolates had an ESBL phenotype and 65 (69.9%) of them were Multi-Drug Resistant (MDR). The frequency of CTX-M, TEM, and SHV genes was 26 (47.3%), 12 (21.8%) and 3 (5.5%), respectively. CTX-M was found to be resistance to Cefotaxime (p-value=0.038), Ceftazidime (p-value=0.046), and Imipenem (p-value=0.016), and TEM gene was resistant to Ceftazidime (p-value=0.024) and Chloramphenicol (p-value=0.019). Conclusion: Increasing antibiotic-resistant in E. cloacae isolates is a serious concern for public health that warrants judicious use of antibiotics, and rapid identification of ESBL positive isolates.

An Investigation into Antibacterial Activity of Fluoroquinolone-Derived Compounds on Two Gram-Negative Bacteria; Escherichia coli and Pseudomonas aeruginosa

Introduction: Quinolones are known as a class of antibiotics inhibiting two central enzymes involved in DNA replication and transcription i.e., DNA gyrase and topoisomerase IV. Among them, fluoroquinolones can be developed via substituting fluorine atoms at the sixth position of core quinolone structure, thereby enhancing antibacterial activity. As a result, growth and proliferation of bacteria may be prevented through new compounds derived from fluoroquinolones and somehow may strengthen their antibacterial effects. Aim: To assess the probable antibacterial activity of two fluoroquinolone derivatives on Pseudomonas aeruginosa and Escherichia coli as two gram-negative resistant bacteria. Materials and Methods: The present study was designed and conducted to measure inhibitory concentrations of N-4-methyl (phenyl)-2,2,2-trifluoroacetimidoyl ciprofloxacin (5a) and N-4-methyl (phenyl)-2,2,2-trifluoroacetimidoyl norfloxacin (5b) as two synthetic derivatives of fluoroquinolones. In addition, real-time PCR (RT-PCR) technique was used to assay the performance of these two derivatives on DNA gyrase gene expression levels in Escherichia coli (E. coli) and Pseudomonas aeruginosa (P. aeruginosa) as gram-negative bacteria. Broth microdilution method and disc diffusion test were also employed to determine the Minimum Inhibitory Concentration (MIC) of these synthetic compounds in comparison with conventional antibiotics of gentamycin and ciprofloxacin (a fluoroquinolone). The p<0.05 was assumed as statistically significant. Results: According to the findings; Zone Of Inhibition (ZOI) of 5a in P. aeruginosa and E. coli (18.5±0.1 and 13.2±0.1 mm respectively) compared with ZOI of ciprofloxacin (28.0±2.0 mm and 18.3.±0.1 mm) and gentamycin (21±0.1 mm and 19.0±0.1 mm). There was no significant difference between the antibacterial effect of 5a and tested antibiotics (p>0.05). So, their antibacterial effects were assumed to be less than the given antibiotics. In contrast, 5b generated a diameter of ZOI in P. aeruginosa and E. coli (28±0.1 and 38±0.1 mm) in comparison with ciprofloxacin (28.0±0.1 and 17.9±0.1 mm) and gentamycin (21±0.1 mm and 19.0±0.1 mm) showed a statistically significant difference (p<0.001). The results of the broth microdilution method also confirmed findings from the disc diffusion test. On the other hand, 5b brought about a significant reduction of DNA gyrase expression levels in both bacteria, while 5a did not show such a significant effect in this domain. Conclusion: The results of this study suggested that 5b could be used as a new and alternative antibiotic for gentamycin or ciprofloxacin against infections caused by E. coli and P. aeruginosa. However, further research focused on various dimensions, including corresponding complications, as well as clinical trials are required to draw a definite conclusion on these synthetic compounds.

Evaluation of CHROMagar^TMmSuperCARBA^TM as a Phenotypic Test for Detection of Carbapenemase Producing Organisms

Introduction: Carbapenem resistance among Enterobacteriaceae continues to escalate. Carbapenemase encoding genes borne on plasmids leads to wide-spread transmission among Enterobacteriaceae. The accurate and rapid detection of Carbapenemase producing-Carbapenem resistant Enterobacteriaceae (CP-CRE) is imperative for patient management as well as for hospital infection control measures. We therefore evaluated the CHROMagar^™mSuperCARBA^™ (CMSCs) a phenotypic screening test for detection of CP-CRE. Aim: To evaluate the performance of CMSCs as a phenotypic test for detection of carbapenemase producing organisms. Materials and Methods: A total of 150 consecutive Carbapenem resistant Enterobacteriaceae (CRE) (E. coli n=81 and Klebsiella spp. n=69), isolated from consecutive hospitalised patients with significant bacteriuria, were subjected to CRE Multiplex PCR for the detection of bla_KPC, bla_NDM, bla_VIM, bla_{OXA-48 like} and bla_IMP genes. Phenotypic detection of carbapenemase production was evaluated by the chromogenic medium CMSC, CarbaNP and Modified Hodge Test (MHT). Results: The multiplex PCR detected carbapenemase encoding gene(s) in 108 isolates. The sensitivity of CMSC, CarbaNP test and MHT in detecting isolates carrying bla_NDM and bla_OXA48-like genes was 94.4%, 67.6%, 56.3% and 96%, 40.8%, 38.8% respectively. While overall sensitivity of CMSC, CarbaNP test and MHT for detection of CP-CRE was 85.3%, 46.6% and 40% respectively; with a negative likelihood ratio of 0.18, 0.55 and 0.64 respectively. Conclusion: CMSC emerged as the most sensitive test for detection of isolates carrying bla_NDM and bla_OXA48-like genes, with an excellent negative likelihood ratio. In addition, it was found to be inexpensive and has the fastest turnaround time. It is a promising phenotypic test especially in geographic regions with wide spread resistance due to bla_NDM and bla_OXA48-like CP-CRE.

Challenges for Hospital Resilience in Emergencies and Disasters: A Qualitative Study in Iran

Elham Ghanaatpisheh, Hamidreza Khankeh, Gholamreza Masoumi

Introduction: Since hospitals provide crucial lifesaving services in societies, hospital resiliency plays an essential role in minimising the impact of disasters on the community. A resilient hospital should be able to resist, absorb, respond to, and recover from the impacts of disasters as well as continues its normal operation. Aim: This study aims to explore the main challenges for providing a resilient hospital in emergencies and disasters in context of Iran. Materials and Methods: This was a qualitative content analysis study. Interviews are in-depth and semi-structured. Each interview begins with open questions and questions become progressively narrowed based on the participants responses. Six themes were initially formed based on analysing the primary codes. Themes were also composed of 21 categories and 20 sub-categories. Interviews were conducted with 18 experts {9 hospital managers and 3 doctors (Ph.D.) in emergency and disasters, 3 supervisors and 3 matrons} and analysed using qualitative inductive content analysis approach. Finally, an expert panel was conducted by a team of experts including 10 people {3 hospital managers and 2 doctors (Ph.D.) in emergency and disasters, and 5 supervisors}. Results: The main concepts which have been explored in the study include; lack of preparedness, continuity of essential service, non-coherent function, emotional response, developing functionality and non-resilient confrontation. Each concept includes several main categories, and main categories are also divided into several subcategories based on their field and according to their significant characteristics. Conclusion: Exploring the challenges which a hospital faces in emergencies and disasters that affect the normal operation of the hospital helps the disaster managers to improve their plans to handle the disaster situations. Findings show that the challenges of all phases of disaster management (such as prevention, preparedness, response, and recovery) must be considered by the disaster managers together. Since disaster situation is very stressful for both injured peoples and disaster management team, therefore, it is recommended that the psychological challenges of a resilient hospital after a disaster occurs are clarified.

Effects of Slow Breathing on Blood Pressure and End Tidal Carbon Dioxide in Hypertension: Randomised Controlled Trial

B Srinivasan, D Rajkumar

Introduction: Inhibition of breathing elevates End-tidal Carbon dioxide (EtCO²) and contributes to sustained Hypertension (HT). Aim: To find out the immediate efficacy of Slow breathing (SB) in controlling Blood Pressure (BP) and its influence on EtCO² in patients with hypertension. Materials and Methods: Randomised control parallel group study was undertaken at outpatient department of medicine in Rajah Muthiah Medical College and Hospital, Annamalai University, Chidambaram, Tamil Nadu, India. Forty hypertensive patients were randomly assigned to receive either slow breathing training for half an hour or as controls. For study group, 30 minutes of SB was practised through recorded auditory command. The breathing instruction consists of four seconds of inspiration and 6 seconds of expiration. Main outcome measured BP {Systolic (S) and Diastolic (D)} and EtCO2. Paired sample t-test and independent sample t-test were the statistical tools used for inferential analysis. Results: The mean drop in S0BP and DBP was 12.30±2.79 mmHg and 3.90±4.44 mmHg respectively in study group following training and it was statistically significant. The mean drop in SBP and DBP in controls was 1.05±3.34 and 0.30±2.10, respectively. There was significant reduction in EtCO² following training in study group, the mean difference was 1.80±2.46. Between group analysis shows that, there was significantly greater reduction in SBP and DBP in study group following training but statistical significance was not achieved for EtCO². Conclusion: Practice of slow breathing is effective in immediate reduction of systolic and diastolic BP. EtCO² could play a role in reducing BP, but long-term study is warranted to better evaluate its role in BP reduction.

The Role of Type 2 Diabetes Mellitus on the Clinical Manifestation of Pulmonary Tuberculosis: A Study from Nepal

Roshan Kumar Mahato, Wongsa Laohasiriwong, Rajendra Koju

Introduction: Tuberculosis (TB) ranks as the seventh leading cause of death in Nepal. Similarly, the prevalence of Diabetes Mellitus (DM) has also shown an increasing trend in the country and it has been observed that diabetes is strongly associated with falling treatment outcome of tuberculosis. Hence, the association of tuberculosis with Type 2 Diabetes Mellitus (T2DM) might be higher than the assumption and it needs more attention as well as appropriate measures to improve treatment outcomes of both diseases. Aim: To determine the risk factors of T2DM comorbidity among TB patients in the Central Development Region of Nepal. Materials and Methods: A case-control study was conducted by administration of structured questionnaire interview among all forms of pulmonary tuberculosis patients. A total of 102 tuberculosis patients with T2DM who met the inclusion criteria were considered as cases and 306 non-diabetes tuberculosis cases were considered as controls. The study was conducted among the patients attending the tuberculosis treatment centres of all 19 districts of central Nepal. The risk factors of diabetes among tuberculosis patients was estimated by using unconditional multiple logistic regression, adjusted odds ratio and their 95% CI were measured. Results: This present study found that the risk factors of type 2 DM comorbidity among tuberculosis patients were; age =45 years (adj. OR=8.00, 95% CI: 4.21-15.21, p-value <0.001), formal education (adj. OR=2.12, 95% CI: 1.08-4.15, p-value is 0.027), being underweight {Body Mass Index (BMI) <18.5 Kg/m2} (adj. OR=2.61, 95% CI: 1.49-4.59, p-value <0.001) and with diastolic blood pressure =80 (adj. OR=3.05, 95% CI: 1.72-5.43, p-value <0.001). In addition, tuberculosis patients who visited more than two health facilities for diagnosis and treatments (adj. OR=2.06, 95% CI: 1.10-3.85, p-value is 0.024) and had medium level of knowledge (60-80%) on tuberculosis and diabetes (adj. OR=2.19, 95% CI: 1.09-4.39, p-value is 0.027) were more prone to having tuberculosis and diabetes. Conclusion: Tuberculosis with diabetes is strongly associated with age, education, hypertension comorbidity as well as delayed diagnosis. Therefore, regular DM screening program as well as timely health monitoring system of tuberculosis patients will enhance the tuberculosis control program in reducing TB burden from delayed cure in Nepal.

Exploring the Dimensions of Group Discussion in Problem-based Learning among a Diverse Group of International Students: A Qualitative Study

Reem Rachel Abraham, Janneke M Frambach, Mascha Verheggen, Diana HJM Dolmans

Introduction: Group discussions have the potential to contribute positively to the learning process in Problem-based learning (PBL) but can be challenging for newcomers. Aim: To explore factors which influenced group discussions in PBL, among a group of international students pursuing an undergraduate medical program at International Track in Medicine, Maastricht University, The Netherlands. Materials and Methods: Semi-structured in-depth individual interviews were conducted with students (n=11) and tutors (n=4). The interview data were subjected to thematic analysis. Following the initial coding, the codes were analysed for patterns and similar or related codes were put under a category. Thereafter, these categories were clustered into common themes and interpreted. Results: Factors such as international diversity in PBL groups, tutors’ friendly approach and subject expertise, and a curriculum with sufficient self-study time, were found as facilitating factors for discussion. Both dominant and silent behaviour of students, as well as some cultural factors were found to hinder discussions. Three recommendations in terms of providing adequate training to tutors, sensitising students regarding cultural values and providing avenues for socialisation emerged from the study. Conclusion: This study provided evidence that international diversity is a positive factor for group discussions. It also added to the existing body of PBL research that cultural and contextual factors influenced group discussions in PBL sessions. Cultural factors were found to have less positive impact on year 1 students from some countries. However, students from these countries were able to overcome their cultural barriers due to the beneficial effects of the diverse nature of PBL groups, and were found to be active participants in second year.

Role of Cerebrospinal Fluid Lactate and C-Reactive Protein in Differential Diagnosis of Meningitis in Adults

Pediakkal M Jabir, V Valappil Ashraf, Thekkedath Manojan

Introduction: Differentiating various types of meningitis is still a challenge as yield of microbiological tests are generally low in these disorders. Aim: To find out the role of Cerebrospinal Fluid (CSF) lactate and CSF C-reactive Protein (CRP) for the differentiation of bacterial, tuberculous and viral meningitis. Materials and Methods: A cross-sectional study was conducted in which 90 adult patients were included and in them CSF lactate and CRP measurements were done in 26 patients of tuberculous meningitis, 23 patients of bacterial meningitis and 43 patients of viral meningitis. Data were analysed using SPSS version 17.0. Descriptive statistics are represented using mean with standard deviation or median with interquartile range for continuous variable. Categorical data were represented using frequency with percentages. Continuous variable between the groups tested using ANOVA/Kruskal wallis test for more than two groups. Results: The mean CSF Lactate level in bacterial, tuberculous and viral meningitis was 10.67, 4.46 and 2.84 respectively. The mean CSF lactate level was significantly raised in bacterial compared to tuberculous and viral meningitis (p <0.001). In a pair wise comparison, the mean CSF lactate in bacterial meningitis group differed significantly from both viral (p-value <0.001) and TB meningitis (p-value <0.001). However, CSF lactate did not differ between viral and TB meningitis. With a cut-off value of 4.35 mmol/L, CSF lactate was useful in differentiating bacterial from tuberculous and viral meningitis with a sensitivity of 90.5% and specificity of 82.6%. The mean CSF CRP level in bacterial, tuberculous and viral meningitis was 4.44, 3.04 and 3.16, respectively. The difference was not significant (p-value 0.39). In a pairwise comparison, mean CSF CRP-value in bacterial meningitis did not differ from both viral meningitis and TB meningitis. Conclusion: Lactate levels in CSF can be used as a good rapid screening test to differentiate bacterial meningitis from non-bacterial meningitis like tuberculous and viral meningitis along with other CSF parameters.

Prevalence of Myths Regarding Oral Health, among Patients Attending a Dental Institute: A Study from Taif, Saudi Arabia

Introduction: To provide good dental health care to patients and healthy individuals, understanding the myths and misconceptions is very important. In the field of dentistry, most myths lead the patients to a wrong protocol, which intern can lead the dentist to a state where it is diffcult to provide proper and satisfying treatment. Aim: To determine the prevalence of myths and misconception regarding oral health in Saudi Arabia. Materials and Methods: A cross-sectional questionnaire survey was administered on the patients visiting a dental institute in Taif city, from March 2018 to April 2018. The questionnaire consists of 14 self-structured close-ended questions about common dental myths. The questionnaire was administered to patients at the registration counter. Completion of the questionnaire took 10-15 minutes and participation in the study was completely voluntarily. The data collected were coded and entered into SPSS inc., IBM, version 21.0. Descriptive statistics were expressed in the form of frequency and percentage. Chi-square test was applied to determine the statistical significance. Results: A total of 121 subjects participated in the study. Majority of the participants (69%) were in the 20-40 year age group, 81% of them were males and about 67% of the subjects had completed University level education. Males and subjects with a higher level of education fared better in their responses. More than half of the respondents 56% believed that “When gums bleed it is better not to brush your teeth”. A few respondents (44%) believed that “Using home stuff like coal, salt, etc., make your teeth whiter”. Around 35% of participants in the study believed that “Placing of milk bottle inside the mouth of the baby during sleep does not harm teeth”. About 34% of the subjects believed that no dental treatment should be done during pregnancy. Conclusion: Results of this study show that generally, people believe in various myths in dentistry which results in poor oral health. This might be due to lack of knowledge and awareness about dental health and its importance.

Comparison of New Injury Severity Score and Revised Trauma Score in Predicting Outcome of Trauma Patients

Namo Narayan Meena, Deeksha Mehta

Introduction: Trauma is an important area of research, as it tends to take away a heavy toll of life regularly. To compare the severity and clinical outcome for the trauma patients, a number of injury severity scores have been designed as standardised tools. Although several systems exist, there is no consensus on, which is the best for predicting mortality. Aim: To correlate various clinico-radiological parameters of the trauma patients and their trauma scores i.e., Revised Trauma Score (RTS) and New Injury Severity Score (NISS) and their outcome with respect to survival accordingly. Materials and Methods: Sixty-one patients were randomly included in this study after taking informed written consent from the patients above 18 years of age and well oriented to time, place, and person or from such guardians if the patients were less than 18 years. Patients were then subjected to a fixed trauma protocol regularly followed at the study institute and trauma scoring was done for each one of them. The statistical analysis was done using statistical software SPSS for Windows (version 16), chi-square test was used for non parametric variable, Student’s t-test was used for comparing two groups and one way ANOVA test was used for multiple groups’ comparisons. p-value <0.05 was stated as statistically significant. ROC curve was used as a tool for diagnostic test evaluation. Results: Out of 61 patients, RTS at presentation of survived patients were 7.2504±0.73178 and the patients who died were 6.09990±1.23611 with a p-value of 0.014 and sensitivity as 85%. NISS at presentation of survived patients was 17.39±6.614 and for the patients who died were 26.29±4.990 with a p-value being <0.001 and sensitivity being 100%. Conclusion: New Injury Severity Score is a more sensitive scoring system and a better outcome predictor in comparison to RTS system.

Effect of 12-week High Intensity Interval Training Program on C-Reactive Protein and Insulin Resistance in Women with Polycystic Ovary Syndrome

Bahar Faryadian, Vahid Tadibi, Naser Behpour

Introduction: Polycystic ovary syndrome (PCOS) is associated with metabolic derangements including insulin resistance which causes dyslipidemia and glucose intolerance. In addition, low-grade inflammation reflected by elevated serum High-sensitivity C-Reactive Protein (hs-CRP) levels is common in PCOS patients. Non-pharmacological interventions such as exercise training can play an important role in reducing insulin resistance and inflammatory markers. Aim: To determine the effect of 12-weeks of High Intensity Interval Training (HIIT) program on insulin resistance and hs-CRP in women with PCOS. Materials and Methods: In this Quasi-experimental study, 24 female patients with PCOS were included and divided into two groups {HIIT (12 cases) and control group (12 cases)}. HIIT consisted of three sessions for 12-weeks of intense anaerobic exercise with short periods (4 minutes) to reach 90% of maximal heart rate for 2 sessions and 1 session with moderate exercise to reach 70% of maximal heart rate. The control group resumed normal daily life without any intervention. Serum hs-CRP and fasting glucose and insulin levels were measured at baseline and after 12-weeks and HOMA-IR was calculated. Paired t-test was used to compare the measured continuous variables. Results: Mean (±SD) HOMA-IR in HIIT group decreased from 3.22 (±1.72) to 1.99 (±0.66); p=0.001. Mean (±SD) serum hs-CRP level in HIIT group decreased from 6.3 (±1.41) to 4.7 (±1.25) mg/L; p=0.033. No significant decrease was seen in control group. Conclusion: HIIT is associated with improvement of insulin resistance and decrease in hs-CRP in PCOS patients. This exercise training can be used as early intervention in PCOS patients.

Effectiveness of Hand Made Models: An Innovative Teaching Tool for Undergraduates in Obstetrics and Gynaecology

Sandhya Subhash Gadre

Introduction: In medical science, students are expected to know the fundamentals and the details of the subjects they learn. Especially by the time student start learning Obstetrics and Gynaecology, they tend to forget the concerned anatomy. Many models and simulators are available for teaching the students, which are very expensive. Teaching by Hand-Made Models (HMM) is an innovative method, where models are made from on-the-spot available objects, without spending a single penny. Aim: To know the impact of HMM prepared with on-the-spot available objects for teaching Obstetrics and Gynaecology to undergraduate medical students. Materials and Methods: An interventional study was carried out at Department of Obstetrics and Gynaecology, Chirayu Medical College and Hospital, Bhopal, Madhya Pradesh, India on 115 students. Few areas from the subject were selected for the teaching purpose. These were: 1) Anatomy of female genital tract; (2) Method of per vaginal examination; and (3) Method of Intra Uterine Contraceptive Device (IUCD) insertion. The students were divided into two groups. Both the groups were administered the same information (1,2,3) with two different teaching methods. Group A was given demonstration of (1,2,3) by HMM prepared on-the-spot, with on-the-spot available objects. Group B was given the same information (1,2,3) by readymade videos. The difference in the knowledge in each group was evaluated on the basis of Objectively Structured Clinical Examination (OSCE). Students’ perception was noted on five-point Likert’s scale. The result obtained was compared between both the groups. Statistical analysis of OSCE scores was done by chi-square test, unpaired t-test of significance. The statistical software used was SPSS version 20. Results: The mean OSCE score in group A (HMM) was 10.96 and in group B (Video) it was 8.96, (maximum score 20). The p<0.001 showed statistically significant difference. Conclusion: Teaching by HMM is an effective, simple, zero-cost method of teaching Obstetrics and Gynaecology to medical undergraduates.

Panoramic Radiographs vs. Calcaneus Ultrasonography in Diagnosis of Osteoporosis in Postmenopausal Women

Sanyukta Rajiv Golhar, Mukta Bhagwandas Motwani, Apurva Dhruv Khator

Introduction: The risk factors for the development of osteoporosis include ageing, menopause, insufficient consumption of food containing calcium, and decreased physical activity. Dual-energy X-ray Absorptiometry (DXA) and quantitative ultrasound are among the techniques developed to identify individuals with osteoporosis and serve as the gold standard. These methods are very expensive and hence there is a need to develop alternative methods to diagnose osteoporosis in post-menopausal women. Aim: To evaluate Mental Index (MI) and Mandibular Cortical Index (MCI) by means of panoramic radiographs, and thereby assess osteoporosis in post-menopausal women by comparing with USG-calcaneus and to assess the changes in the serum calcium levels in osteoporosis in post-menopausal women by comparing with USG-calcaneus. Materials and Methods: A hospital based cross-sectional study was carried out in Department of Oral Medicine and Radiology. Hundred patients were divided into 2 groups, premenopausal (control group) and post-menopausal women (study group). Digital panoramic radiographs were made and MCI and MI were determined. A 2 mL of blood sample was taken from antecubital vein by venipuncture method and serum calcium was estimated. USG-Calcaneus Estimation was done and the speed of sound in m/sec for every patient was also noted. Results: The sensitivity of cortical quality when compared to USG class was 49.15% while specificity was 90.24%. The positive predictive value was found to be 87.88% while negative predictive value was 55.22%. The mean serum calcium of patients in Pre-menopausal group was 8.91±0.75 (Mean±SD), while in Post-menopausal group the mean serum calcium was 8.98±0.71 (Mean±SD). The difference in two means was statistically insignificant with p-value of 0.6593 (p>0.05) as obtained using t-test for independent samples. Conclusion: Panoramic radiographs seem to be a promising tool in screening post-menopausal women for osteoporosis. The indices used in the study are readily reproducible and easy to learn.

Point-of-Care Testing of Blood Glucose: Clinical Performance and Laboratory Efficiency

Introduction: Rapid laboratory glucose testing assists prompt on-site treatment for abnormal glycaemic episodes. New generation Point-of-Care Testing (POCT) for whole blood glucose analysis have high sensitivity and short processing time, which is competent for on-site rapid glucose testing. Aim: To assess the accuracy and Turn Around Time (TAT) of the POCT (Rightest GM700 Pro) compared with the Central Laboratory Testing (CLT) at a National Level, Urban Hospital. Materials and Methods: A retrospective study of 1,812 patients was conducted for glucose testing at the Laboratory Department of Cathay General Hospital from November 2016 to November 2017. Consistency between GM700 Pro and Beckman Coulter AU680, used as CLT, was analysed. TAT was measured from phlebotomy to result availability in Laboratory information system (LIS). Two widely accepted standards for blood glucose meters ISO 15197:2013 (for self-monitoring) and USFDA Prescription Point-of-Care Use (for hospital use) were adopted to evaluate the accuracy. Pearson’s correlation and Passing-Bablok regression were used for the analysis. Bland-Altman analysis was used to determine the agreement between POCT and CLT glucose results. Results: Linear regression analysis of GM700 Pro showed significant agreement (y=0.97×-0.89, r2=0.99) with CLT. Results of TAT indicated that POCT generated glucose report for clinical decision-making was 7 times faster than CLT (p<0.0001) in general practice. Conclusion: Point-of-Care Testing GM700 Pro is reliable and efficient for on-site glucose analysis.

The Effects of Plasma Prothrombin Time and Activated Partial Thromboplastin Time Based on Different Instruments and Methods

Yetti Hernaningsih, Trieva Verawaty Butarbutar

Introduction: Many laboratories have more than one coagulometer with different types and methods that are used simultaneously. In patients requiring Plasma Prothrombine Time (PPT) and Activated Partial Thromboplastin Time (APTT), follow-up treatments may be performed on different instruments. Aim: To analyse whether there are differences in the value of PPT and APTT between 3 instruments with different methods. Materials and Methods: This study took 64 samples of patients with End Stage Renal Disease (ESRD) who underwent haemodialysis in Haemodialysis Centre of Dr. Soetomo General Hospital Surabaya between April 2017 and October 2017. All samples were carried out for examination of PPT and APTT on three instruments: CoaDATA 501 with one wavelength optical detection, Sysmex CS2100i with three wavelengths optical detection, and STA Compact using electromechanical methods. Results: Significantly different results were obtained in the PPT comparison between the group of CoaData with Sysmex CS2100i (p=0.001) and CoaData with STA Compact (p=0.001). While in the intergroup APTT, all gave significantly different test results (p<0.001). Because of difference value of PPT and APTT in difference instrument and method, therefore serial tests should be performed in the same instrument to obtain valid and reliable results.

Final Maxillary Incisor Inclination in Class II Div 1 Malocclusion Treated with Standard Edge Wises or Straight Wire Appliances

Vahid Mollabashi, Azadeh Kazemisaleh, Maryam Seyedtabib
Introduction: There are different orthodontic treatment systems, and currently the most common include standard edgewise and straightwire. Achieving ideal axial inclinations of all teeth at the end of active treatment is regarded as one of the criteria to possess a functional occlusion. As the frequency of use of pre-adjusted edgewise appliance become increasingly prevalent, it is important to compare them with standard edgewise appliances. Aim: Considering the fact that the buccolingual angle of the crown has significant effect on the treatment outcomes, the present paper aims at comparing the treatment outcomes and buccolingual angle of crowns in patients treated with standard edgewise and straightwire (MBT). Materials and Methods: This retrospective cohort study compared 100 cephalometric radiographs from 50 class II division 1 patients extracting the maxillary first premolar with twenty-five patients being treated with an edgewise system and 25 patients with straightwire system. The cephalometric landmarks were selected in hard and soft tissue. Linear and angular measurements were used to investigate the soft and hard tissue. U1-SN was used during the cephalometric analysis to measure the inclination of the maxillary incisors. Data analysis was performed using ANCOVA (Analysis of Covariance) at the significant level of 0.05 in SPSS ver. 23. Results: There was no significant difference between the two study groups in terms of gender and age (p>0.05). Also, the buccolingual angle of the crowns was similar between the two groups. Considering the adjustment of the pre-intervention effect, the mean of the U1-SN after the intervention did not show a statistically significant difference between the two groups (F=0.01, P=0.942). The result of ANCOVA was significant only for the OCC Plan _FH after the intervention between two groups (F=4.65, P=0.036). Conclusion: The present study concluded that the buccolingual angle of the crowns was similar between the two groups.

Study on Peripheral Eosinophilia among Paediatric Patients in a Tertiary Care Hospital

Madhumitha Senthilnathan Sasikala, Yogalakshmi Eswaran, P Jayaganesh, Sulochana
Introduction: Eosinophilia may be due to primary or secondary causes. They are divided based on absolute eosinophil count as: mild (less than 1500 cells per cubic millimeter); moderate (1500 to 5000 cells per cubic millimeter); and severe (more than 5000 cells per cubic millimeter). In the paediatric population the prevalence of Hypereosinophilia (HE) is still unknown, because there is no completed population base studies recorded. Evaluating the underlying pathology is an essential step in the management of Paediatric HE. On the basis of the underlying aetiological factors, clinical manifestations may vary from benign, self-resolving eosinophilia to life-threatening disorders with the significant end-organ damage. There is an increase in incidence rates of paediatric eosinophilic esophagitis, gastritis and colitis among the hypereosinophilic patients. Aim: To correlate eosinophilia in different age groups and various diseases among the paediatric patients attending the tertiary care hospital for various illnesses. Materials and Methods: It was a retrospective study conducted for a period of five months, among the paediatric patients who attended the tertiary care centre for various reasons. Complete blood count was done for these patients with the automated haematology analyser. The eosinophil count was assessed by peripheral smear study. Results: Among the total 1341 cases, moderate eosinophilia was observed in 29 patients (17%), severe eosinophilia in 2 patients (1%) and mild eosinophilia in 138 patients (82%). Asthma and Urinary Tract Infection (UTI) (one case each) constituted the two cases of severe eosinophilia. The most common cause of moderate eosinophilia was observed in patients with other causes like iron deficiency anemia and infected wound. The most common cause of mild eosinophilia was due to diseases involving Gastrointestinal system (31 cases). Conclusion: In the present study majority of the cases were found to have mild eosinophilia with a male preponderance.

Risk Factors for Stillbirths: A Case-control Study

Ritika Kumar, Banashree Nath, Manjula Sharma, Harsha S Gaikwad, Sonam Topden
Introduction: The occurrence of Stillbirths (SBs) is a tragic event faced by the obstetrician and causes great psychological trauma and emotional devastation to the couple and the family. It is estimated that approximately 3.2 million stillbirths occur in the world every year. The SB rate across India is about 20 per 1,000 live births accounting for highest absolute number of stillbirth in the world. Aim: To analyse the risk factors for stillbirths in a tertiary teaching centre in northern India. Materials and Methods: Sample size was calculated to be 150. In the study institution, nearly 600 stillbirths occur annually and since the required sample size was 150, every 4^th woman delivering a stillbirth was included as case and the live birth matched for gestational age consecutive to the case was taken as control. All babies of the study and control group were examined by the neonatologist. Mothers of all babies were interviewed through a stillbirth review proforma (by WHO apps SEARO) within 24 hours of delivery. Qualitative data analysis was done by chi-square test and quantitative data by using t-test. The p-value <0.05 was be considered significant. Logistic regression was applied to get odds ratio for the risk prevalence. Variables with statistically significant association on univariate analysis were included in a multivariable binary logistic regression model. Results: Stillbirth rate was 25.4 per 1000 births. A significant association of pre-existing hypertension (p=0.008) and anaemia (p=0.05) as maternal comorbid conditions were found with stillbirths. There were 66 Fresh SBs (44%) and 84 Macerated SBs (56%). When intrapartum risk factors were analysed, significant association was found with antepartum haemorrhage, cord prolapse, malpresentation, obstructed labour and rupture uterus as compared to control group. On multivariate analysis of various risk factors, maternal age >30 years, maternal BMI >25 kg/m², antenatal checkups <3 in number, maternal illiteracy, lack of periconceptional folic acid intake along with pre-existing hypertension, fetal malpresentation, and antepartum haemorrhage were observed to have an independent, significant association with the occurrence of stillbirths. Conclusion: Among sociodemographic factors, older mothers, obesity, inadequate antenatal checkups, lack of maternal education, lack of periconceptional folic acid intake were associated with high risk of SBs. Maternal morbidity especially pre-existing hypertension which led to antepartum haemorrhage along with fetal malpresentation was observed to have an independent, significant association with the occurrence of SBs. Hence apart from improved intrapartum care, essential screening during antenatal visits with allotment of cards of varied identity with appropriate precedence can be an important step in monitoring the high-risk cases which can also prove crucial in timely referral to tertiary care units.

Fibrinogen Levels in Obese and Normal Individuals

Dinesh Nath, Meera Shivashekar, VM Vinodhini
Introduction: Obesity is a risk factor for Cardiovascular Disorders (CVDs). Adipose tissues associated with obesity secrete large number of peptide hormones, cytokines and non-peptide biologically active molecules. Interleukin-6 (IL-6) is a key regulator that modulates acute phase fibrinogen synthesis and high levels of fibrinogen leads to increased platelet aggregation and thrombus formation, which ultimately lead to coronary artery disease. Aim: To evaluate the fibrinogen levels, and correlate them with IL-6 levels in obese and normal weight individuals. Materials and Methods: The present cross-sectional study was conducted in SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India. Sixty obese individuals aged 20 to 65 years, and 60 age and sex-matched normal weight individuals attending the Master Health Check-Up and Medicine OP was selected for the study. Serum IL-6 was measured by Enzyme-linked Immune Sorbent Assay (ELISA) and fibrinogen was measured by antigenic method. Statistical analysis was done using student’s t-test and Pearson correlation analysis. The p-value <0.05 was considered as statistically significant. Results: The mean fibrinogen level in obese individuals (407.74±38.31 mg/dL) was significantly higher (p-value <0.001) than the normal weight healthy controls (287.49±52.46 mg/dL). The mean IL-6 level in obese individuals (78.52±8.95 pq/mL) was also significant (p-value <0.001) higher than the normal weight healthy controls (9.41±6.15 pq/mL). Statistically significant correlation (r-value 0.521 and p-value <0.001) was observed between serum IL-6 and fibrinogen level in obese individuals. Conclusion: Fibrinogen plays a major role in platelet aggregation in the final step of coagulation cascade. It is a major determinant of plasma viscosity, erythrocyte aggregation and formation of fibrin. Increased level of fibrinogen seen in obesity is associated with increased risk of Coronary Artery Disease (CAD) and myocardial infarction.

Elizabethkingia meningoseptica: Waiting to Strike

Girisha Pindi, Pratibha Kale, Vikas Khillan, Arvind Khodhare
Introduction: The prevalence of nosocomial infection by Elizabethkingia meningoseptica (E. meningoseptica) has increased. It has been found to be associated with outbreaks of neonatal, adult and device related infections with mortality rates as high as 50%. Conventional empirical antibiotics against Gram-Negative Bacteria (GNB) are not effective against E. meningoseptica and interpretive Minimum Inhibitory Concentration (MIC) breakpoints are not available yet, making the treatment tricky. Hence, early detection is essential to prevent morbidity and mortality associated with E. meningoseptica. Aim: To know the incidence, clinical profile, associated risk factors and antibiotic susceptibility of E. meningoseptica isolates from suspected patients. Materials and Methods: This prospective study was done on patients admitted from January 2017-December 2018 to a tertiary care Hepatobilliary center in India. Clinical details, demographic details, associated risk factors and antibiotic sensitivity pattern of E. meningoseptica isolates obtained from various clinical samples during the study period were analysed. Analysis was done using SPSS software version 22. The categorical data was represented in frequency (%) and continuous data in mean. Results: A total of 32 isolates from 20 patients were included. Out of the 20 patients, 15 (75%) were males with a mean age of 43.05 years (range, 2-71 years). E. meningoseptica was most frequently isolated from respiratory samples (87.5%). Risk factors were chronic liver disease (75%), diabetes mellitus (50%), prolonged hospital admission (55%), prior ICU stay (100%), invasive procedures like insertion of Central Venous Catheter (CVC) (100%), need for life supports like prolonged ventilation (70%) and haemodialysis (55%). Minocycline was the most susceptible drug with 100% sensitivity followed by cotrimoxazole (65.6%). Conclusion: Patients with E. meningoseptica infection have significant morbidity and mortality. Hence awareness about the organism, active surveillance and investigation for the source of the organism will help in implementation of appropriate infection control measures and prevent outbreaks or recurrence.

Carotid Intima Media Thickness and High Sensitivity C-Reactive Protein Levels in Prediabetes and its Correlation with Homeostatic Model Assessment for Insulin Resistance
Introduction: Hyperglycaemia and insulin resistance are two important risk factors for the development of atherosclerosis and Atherosclerotic Cardiovascular Disease (ASCVD). Whilst the association of diabetes and atherosclerosis has well been studied and is well known, the data on prediabetes is limited. Carotid Artery Intima-media Thickness (CIMT) and high sensitivity C-reactive Protein (hsCRP) are recognised markers of subclinical atherosclerosis. Aim: To measure CIMT and hsCRP levels in prediabetics in cases and controls and correlate them with Homeostatic Model Assessment for Insulin Resistance (HOMA-IR). Materials and Methods: Fifty prediabetic patients and 50 age, sex and Body Mass Index (BMI) matched controls were enrolled in this case control study. Serum fasting and postprandial blood sugars, glycated haemoglobin (HbA1c) and fasting insulin levels were measured in cases and controls. HOMA-IR index was calculated from fasting glucose and insulin values. All cases and controls were subjected to bilateral CIMT measurements and the mean was tabulated. Serum hsCRP values were assessed and compared between both the groups by unpaired t-test. Results: The mean serum fasting insulin level among cases was 12.22 mIU/mL and that of the control group was 5.37 mIU/mL (p-value <0.0001). HOMA-IR mean values were 3.31±1.56 and 1.16±0.44 in cases and controls respectively (p-value <0.0001). Mean CIMT was found to be statistically higher in prediabetics (0.59±0.11 mm) when compared to controls (0.45±0.07 mm) (p<0.0001). Serum hsCRP levels were also statistically higher in prediabetics (5.75±4.16 mg/L) than that of controls (1.86±1.67 mg/L) (p<0.0001). There was a positive correlation between mean CIMT and HOMA-IR (p-value=0.0001) (r=0.515), hsCRP levels and HOMA-IR (p-value=0.0001) (r=0.512). Conclusion: Serum hsCRP levels and CIMT can be employed as predictors of atherosclerotic risk and ASCVD in prediabetics. This would help us to identify high risk individuals and thus targeting them for early lifestyle and pharmacological management.

Expression of Salivary Secretory Leukocyte Protease Inhibitor in Smokers, Leukoplakia and OSCC
Introduction: The unsatisfactory prognosis and morbidity by contemporary treatment modality of carcinoma and late diagnosis due to lack of simple non-invasive early marker has driven researchers to explore and identify new molecules which can be used as markers or for targeted therapy for cancer. Secretory Leucocyte Protease Inhibitor (SLPI) is one such molecule of interest, whose association with smoking and cancer is controversial and less researched. Aim: To estimate and compare the salivary levels of SLPI in healthy control, smokers with and without leukoplakia and oral squamous cell carcinoma. Materials and Methods: A prospective, case-control study was conducted in which whole unstimulated saliva samples were collected from total of 80 participants which included 20 controls, 20 smokers without leukoplakia, 20 smokers with leukoplakia and 20 cases of Oral Squamous Cell Carcinoma (OSCC). Salivary SLPI levels were measured using enzyme-linked immunosorbent assay and comparison of SLPI levels between groups was done using Mann Whitney Test. Results: The study results showed a higher concentration of SLPI in controls than leukoplakia and OSCC. The median SLPI of controls was 144 ng/mL, while concentration of SLPI in smokers without leukoplakia, with leukoplakia and squamous cell carcinoma were 101 ng/mL, 112 ng/mL and 113 ng/mL, respectively. Conclusion: Results from this study suggest that smoking, premalignancy and OSCC are associated with lower concentrations of salivary SLPI compared to controls. Hence, salivary SLPI could be a potent biomarker in cancer diagnosis and can have a great value in immune therapy of OSCC.

A Study on the Prevalence and Phenomenology of Hoarding in Patients with Obsessive Compulsive Disorder
Introduction: Hoarding behaviour is a common symptom seen in patients with Obsessive Compulsive Disorder (OCD). The phenomenology and prevalence of hoarding in OCD have been under studied in India and the phenomenon is less explored on routine clinical examination. Aim: To study the prevalence and phenomenology of hoarding as a symptom in patients with OCD and tried to elucidate some differences between OCD patients with and without hoarding symptoms. Materials and Methods: A total of 50 patients with OCD and 50 relatives of psychiatric patients were the subjects for the study. The OCD group was administered the Yale Brown Obsessive Compulsive Scale (YBOCS), the Hoarding Rating Scale and the Clutter Image Rating Scale. The 50 cases of OCD were further divided on the presence and absence of hoarding as a symptom into 2 groups and the scores on the scales used were statistically analysed using descriptive statistics like frequency and percentages, chi-square test and unpaired t-test. Results: The mean duration of illness was 8.01±5.17 years and the mean age of onset of the illness was 27.28±7.11 years for all patients with OCD. OCD patients with hoarding had a shorter total duration of illness than those without hoarding. Newspapers and scrap were hoarded the most with sentimental reasons along with importance of goods were cited as reasons for the behaviour. The two groups showed significant differences on compulsive sub scale of the YBOCS and no differences were noted in the other scales used. Conclusion: Patients having OCD with hoarding as one of the symptoms may differ from those not having hoarding. However larger studies across diverse groups are needed to corroborate these findings.

Investigation of Immunohistochemical Expression of Programmed Death-Ligand 1 (PD-L1) in Female Mammary Carcinoma and its Correlation with the Extent of Stromal Tumour Infiltrating Lymphocytes
Introduction: Breast Cancer (BC) is the most common type of cancer among women worldwide and a leading cause of cancer related deaths. Based on insight into immune system/cancer interactions, cancer immunotherapy strategies have been developed. Of these strategies, immune checkpoints regulators are among the most important. Programmed Death Ligand 1 (PD-L1) is one of the 2 ligands of Programmed Death-1 (PD-1); an important immune checkpoint regulator. Clinical trials using PD-L1 antibodies have shown efficacy in various cancers. Some of these antibodies have received Food and Drug Administration (FDA) approval for clinical use. Aim: Detection of Immunohistochemical (IHC) expression of PD-L1 by Tumour Cells (TC) and stromal Tumour Infiltrating Lymphocytes (TILs) in female BC, as well as, correlation of this expression with the pathologic parameters of the tumours. Materials and Methods: One hundred BC tissue sections were collected from mastectomy specimens. IHC expression of PD-L1 was investigated in TC and TILs. Correlation of PD-L1 expression with the tumours pathologic parameters was performed using Statistical Package of Social Science (SPSS) Software program, version 25.0. Results: TC PD-L1 expression was detected in 61% of cases and showed statistically significant correlation with higher tumour grade, higher prognostic stage, Estrogen receptor negativity, Human Epidermal Growth Factor Receptor Type 2 (HER2) enriched molecular subtype and LVI (p-value <0.05). TILs PD-L1 expression was detected in 55% of cases and showed statistically significant correlation with higher tumour grade, higher prognostic stage, Estrogen and Progesterone receptor negativity, HER2 overexpression, higher Ki-67 index, triple negative molecular subtype and higher stromal TILs (p-value <0.05). Conclusion: The present results supported PD-L1 expression in BC by both TC and TILs, with higher expression in subset of tumours that are high grade, TILs rich and lacking hormone receptors, highlighting them as candidates for anti-PD-1/PD-L1 therapy.

A Prospective Randomised Study of Clinical Outcome and Toxicity Patterns of Head and Neck Squamous Cell Carcinoma Treated with Accelerated Fractionated Radiotherapy versus Concurrent Chemoradiotherapy
Introduction: Locally advanced Head and Neck Squamous Cell Carcinoma (HNSCC) is a diverse group of patients and the treatment needs to be individualised. Although Concurrent Chemoradiotherapy (CTRT) remains the standard of care, not all patients are suitable to receive the same. Accelerated Fractionated Radiotherapy (AFRT) is one of the treatment options in these patients and may achieve equivalent therapeutic ratio. Aim: To compare outcomes of patients of HNSCC treated with concurrent CTRT versus AFRT in a prospective randomised trial. Materials and Methods: A total of 322 patients of Stage III-IV (AJCC, 6^th Edition), HNSCC of oropharynx, larynx and hypopharynx were randomised to receive either definitive CTRT or AFRT. Radiotherapy (RT) dose was 70 Gray (2 Gray, 5 fractions per week over 7 weeks) to the primary and nodes and 46-60 Gray to the elective neck nodes. RT was delivered 5 fractions per week along with concurrent cisplatin 35-40 mg/m² weekly in the CTRT arm. In the AFRT arm, RT was delivered as 6 fractions per week of 2 Gray each over 6 weeks. Acute and late toxicities were graded as per RTOG morbidity scoring. Kaplan Meier method was used for survival analysis. Results: Patients characteristics were balanced between CTRT arm and AFRT arm (161 patients each). Median overall treatment time for CTRT and AFRT arms were 43 and 49 days respectively. A 5-year actuarial locoregional control, disease-free survival and overall survival was 32% vs. 42%; 28% vs. 35% and 30% vs. 35% respectively for CTRT vs. AFRT arm. Need of Ryle’s tube feeding (p=0.001), acute mucositis (p=0.015), late subcutaneous toxicity (p=0.05) and late xerostomia (p=0.042) rates were higher for CTRT arm. Conclusion: AFRT was associated with comparable clinical outcome as compared to CTRT in patients of HNSCC, albeit with reduced acute and late toxicities.

Laboratory Request Form Revamped: Pictogram Based Symptoms Afford Adequate Patient’s Clinical Information in High Patient Load Setting

Mahadevan Ganesan, Ganesan Sucila Thangam, Ramalingam Sekar, Robert Sudha
Introduction: Laboratory Request Form (LRF) offers communication triad involving patient, physician and diagnostic service providers. LRFs with complete patient’s clinical information along with the diagnostic results may be used as predictor tool for emerging diseases. Overcrowding of wards in developing countries, especially in India, may affect physician’s effectiveness causing an appalling lack of clinical symptoms in LRFs or mostly left unattended by form attendees. Solving this problem certainly requires a novel method of data collection with the aim of improving the physician’s attention. Aim: The objective of this study was two-fold: (1) to determine the proportion of unattended and partially filled LRFs; and (2) to evaluate the effectiveness of pictograms over text oriented symptoms. Materials and Methods: A total of 645 Pictogram based LRF (PLRF) were provided as an overleaf along with the Text oriented LRFs (TLRF). The percentages of blank form, total symptoms per form, and individual symptoms per form were calculated. Physicians Attention Index (PAI) was also calculated based on the number of LRFs in which physicians filled the duration of one or more symptoms. The difference in frequencies of categorical responses between two dependent groups was calculated by way of the comparison of proportions and chi-square. A two-sided p-value <0.05 was considered as the test of significance for all parameters. Results: A significant proportion of unattended forms decreased upon implementation of PLRFs (23.4% vs. 11.8%; p-value =0.0001). Notably, symptoms such as headache, abdominal pain, rhinorrhea, knee pain showed the most improved proportions of all. During this study period, dengue accounts for >80% of the test request provided with more number of associated symptoms. Interestingly, PAI was 0.125 (21.7%) in PLRFs and this could not be possible in the default TLRF. Conclusion: Revisiting of LRF is need of the hour in order to get maximum attention from form attendees thereby improving adequacy in test requesting information. This will ultimately aid the physician or diagnostic service providers to offer differential diagnosis which in turn improves the quality of patient care.

Vital Pulpal Therapy in Primary Teeth: A General and Paediatric Dentists’ Perspective
Introduction: Management of pulpally involved primary teeth has recently gained importance inspite of the barriers faced by general dentists such as limited exposure to paediatric dentistry, skill and chair-side time. The advancements in technological and material sciences necessitate a practicing dentist to update themselves to deliver comprehensive dental care in most effective way. Aim: The study was aimed to assess and compare the perspective of pulpal treatment of primary teeth among general and paediatric dentists of Saudi Arabia. Materials and Methods: Close-ended, multiple-choice questionnaire evaluating their preferences towards pulp therapy in primary teeth was designed as part of a survey and mailed to 100 general dentists and 50 paediatric dentists across Kingdom of Saudi Arabia. Descriptive statistics followed by ?2-test was applied to test of variables in the questionnaire to determine their association. Results: Paediatric dentists (68%) performed pulpal treatment in primary teeth more frequently under rubber dam isolation than general dentists (47%) (p=0.025). Traditional indirect pulp capping was preferred to Indirect Pulp Treatment (IPT) by both groups under local anaesthesia. Caries detector dye was used to facilitate precise caries removal more frequently by Paediatric dentists than general dentists (p=0.001). Pulpotomy was preferred over IPT by both groups when there was a probability of pulp exposure following complete caries excavation. Pulpectomy was infrequently performed. Zinc oxide eugenol was the material preferred for obturation in both groups. Paediatric dentists preferred stainless steel crown whereas General dentists preferred glass ionomer restoration after pulp therapy (p=0.004). There was no significant difference between follow-up schedule followed by general and paediatric dentists even though most dentists recalled their patients immediately and after 3 months follow-up. Conclusion: The survey helps in refining the approaches of dentists towards pulp therapy in primary teeth and ascertains whether they are according to recent trends.

Ameloblastic Fibro-odontoma or Immature Odontoma: A Retrospective Analysis of 134 Cases

Vorapat Trachoo, Vichittra Vipismakul
Introduction: According to 2017 WHO classification of odontogenic tumour, Ameloblastic Fibro-Odontoma (AFO) is no longer classified as an entity, probably representing immature stages of complex odontoma. However, there were few studies that revealed the differences between the lesion previously designated as AFO and complex odontoma. Aim: To critically analyse the clinical, radiographic features and behaviour of AFO. Materials and Methods: Eligible criteria included publications from PubMed, Scopus and Google Scholar reporting cases of AFO from 1975 to June, 2019 with available clinical, radiologic, and histologic information to confirm the diagnosis. Demographic data, localisation, size, treatment approach, follow-up period and recurrence were included. Results: Analysis of 134 cases (124 previously reported and 10 new cases). The patient’s age ranged from 7 months to 31 years (mean 10.3 years). There were 72 (54.1%) males, with a male-to-female ratio of 1.2:1. The mandible was involved in 79 (59%) cases, and the mandible-to maxilla ratio was 1.43:1. Nearly 80% of the lesions located in the posterior region of the jaws, and 48.5% were in the posterior mandible. Radiographically, most of the lesions were unilocular (95%) and only 5% were multilocular. The majority was mixed radiolucent radiopaque, and 15.8% were radiolucent. Almost all lesions (91%) were associated with the crown of an unerupted tooth. The range of follow-up was 6 months to 25 years. There were five recurrences among 134 cases accounting for a recurrence rate of 5.6%. Conclusion: According to 2017 WHO classification of odontogenic tumours, AFO was not considered as an entity and was included in odontoma. However, there are some discrepancies between AFO and odontoma especially regarding the biologic behaviour. Therefore, long term follow-up for cases previously designated as AFO is warranted.

Imaging of Breast Hamartoma on Mammography, Ultrasound and MRI

Pratiksha Yadav
Hamartoma or fibroadenolipomas are rare benign tumours. These tumours present as painless, mobile masses or it can be asymptomatic and detected incidentally on screening mammogram. This article intends to review the characteristic findings of breast hamartoma on mammography, tomosynthesis, ultrasound and Magnetic Resonance Imaging (MRI) techniques. Multiparametric MRI is a sensitive non invasive modality for diagnosis of these masses. There is a need to evaluate the characteristic imaging features of hamartoma in order to make an accurate diagnosis. Most of the patients with breast hamartomas are young patients so we can avoid the radiation based imaging techniques. MRI can be used in the uncertain cases of hamartoma on mammography and ultrasound. Advanced MRI techniques e.g., Diffusion Weighted Imaging (DWI) with mean ADC calculation and MR Sepctroscopy (MRS) are useful non-invasive techniques which can be used for effective diagnosis and can avoid biopsy in these patients. Pathologically, a distinctive appearance lacks in these masses as these consists of lactiferous tissue, fat and fibrous tissue. Clinical finding of breast lump or breast asymmetry and imaging features are helpful in the diagnosis.

Role of Microbiota in Aetiopathogenesis of Colorectal Cancer

Arpita Suri, Sanjiv Kumar Bansal, Prajwal Ammalli, Busi Karunanand
Colorectal Cancer (CRC) accounts for sizeable disease burden globally. The symbiotic association between gut inhabitants and the digestive tract contributes to gut homeostasis. Studies suggest that altered microbiota composition or dysbiosis can contribute to colorectal carcinogenesis. This review outlines the complex interplay between the microbiome, diet and CRC with a special emphasis on microbial metabolites, gut barrier function, specific bacterial species which influence the micro environment by various mechanisms like oxidative stress, DNA damage, immune modulation and inflammation. This would help in establishing novel diagnostic, prognostic markers and newer therapeutics for CRC.

Dual Practice on Health Service- Should it be Promoted in Qatar?

Saad Al Kaabi, Betsy Varughese, Anil K John
Dual Practice (DP) is a widespread phenomenon of public healthcare employees working concurrently both within and outside the public-sector environment for personal profit. The impact of dual practice varies in its potential for access, quality, cost and equity of healthcare services. Unregulated growth of the private sector, low salaries and poor working conditions in the public sector have made an attractive opportunity for healthcare workers to work simultaneously at both public and private facilities. This generates additional income for healthcare workers which are minimising the budgetary burden of the public sector to retain skilled staff, especially at the scarcity of resources. However, its negative impact far exceeds the positive impact, which includes the rise of detrimental and predatory behaviour, ethical issues and migration of healthcare workers. Also, there are limitations for time and resources that compromises the service delivery, where healthcare workers who are engaged in dual practice are available only for a limited time at public facilities; many times found as absenteeism, tardiness, inefficiency and lack of motivation. In many countries, the health sector managers are forced to accept dual practice to retain their highly skilled employees, sometimes detrimental to health service provision. Though several reasons for dual practice such as a wide gap between physicians’ income expectations and their wages, long waiting lists and unsatisfactory working conditions prevail in the public sector of many countries, none of these factors is reflecting in Qatar. Most of the healthcare professionals in Qatar are expats and dual practice may further inflate substantial workforce shortfall in the public healthcare sector. Hence policymakers should pursue strict policies to prevent dual practice of healthcare workers in Qatar.

Oral Myiasis: The Diagnostic Conundrum- A Systematic Review
Introduction: Myiasis is a parasitic infection, which is infested in the skin by developing larvae (maggots). There are a variety of fly species (myiasis is Greek for fly) within the arthropod order Diptera. Their infestation in oral cavity is a rare condition. Aim: To systematically analyse the data available on the oral Myiasis, its aetiology, clinical presentation including age, gender, location of lesion, various treatment modalities and preventive measurements. Materials and Methods: A systematic review of studies which included case reports on oral myiasis was included and a literature search was conducted using online databases (Pubmed and google scholar) along with hand-searching. Case reports and case series on oral myiasis, oral myiasis reported in humans, articles from 1980 to 2017, full text availability and text available in English language were the inclusion criteria. Review articles, oral myiasis reported in animals and text available in other language were excluded. Results: A total of 98 articles from PubMed, 18 from Google Scholar, and 2 from hand search were identified. Out of 98 articles, 17 were shortlisted based on the inclusion criteria. Based on the analysis of collected data, gingiva of the anterior teeth and palate was the most commonly affected site with a male prediction and commonly seen between the age group of 20 to 40 years and was usually associated with patients presenting with CNS disorder. Conclusion: Oral myiasis is relatively a rare entity of the oral cavity and only few cases have been documented till date. Hence, further documentation of cases is required to comment elaborately on the inherent susceptibility of individuals with similar condition and associated complications of the disease.And it is the role of the dentist to be aware of the condition and manage them accordingly.

Seasonal Variation in Incidence and Severity of Dog Bites in a Union Territory of Northern India

MA Bashar, Mona Duggal
Introduction: Dog bites pose a serious but underestimated public health problem in developing countries like India as it causes millions of injuries and thousands of deaths among its sufferers due to risk of rabies transmission. Studying their seasonal pattern and variations would help in understanding their determinants and guide in formulating policies to contain this problem and eventually help in achieving elimination of rabies. Aim: To study the seasonal pattern and variations in incidence of dog bites and its association with severity in union territory of Northern India. Materials and Methods: A retrospective study was carried out at an Anti-Rabies Clinic (ARC) providing pre and post-exposure prophylaxis for rabies in Union Territory of Chandigarh, Northern India. All the cases of dog bite registered at the clinic for receiving post-exposure prophylaxis during the time period of 1st January to 31st December 2015 were examined from records and classified across the seasons according to timing of the bite to look for seasonal pattern and variation. Categories of all the dog bites registered as per WHO classification (Category II and III) of bite severity were also extracted from the records and were tabulated across the seasons. The severity of the dog bites was then correlated with the seasonality. One-Way analysis of Variance (ANOVA) was applied for comparing mean number of dog bites per month across the seasons. The chi-square test was applied to determine the statistical significance between the dog bite severity across the seasons. Results: A total of 853 cases of dog bite were registered at the clinic for post-exposure prophylaxis during the reference period. Mean number of dog bite cases per month were recorded highest in the spring season (90.0±16.9) followed by winters (82.5±13.0), the difference across the seasons being statistically significant (F value=5.26, p=0.02). Severity wise too, Category III bites were reported significantly more during spring (57.7%) and winter seasons (65.2%) as compared to summer and autumn seasons (c2 =12.87, p=0.005). Conclusion: The present study provides the evidence that dog bites in a union territory of Northern India have wider seasonal variation. A significantly higher number of cases were observed in spring and winter seasons compared to other seasons which require further investigations.

Correction :2018 Dec: 12(12): ZD08-ZD10
Eleonora Ortu , Davide Pietropaoli , Ruggero Cattaneo , Mario Giannoni , Annalisa Monaco, Overjet Reduction with the Use of ELIBA Device: A Case Report (Published in Journal of Clinical and Diagnostic Research. 2018 Dec: 12(12)). This errata is meant for the above article published in Dec 2018 issue of JCDR (https://www.jcdr.net/articles/PDF/12341/35530_CE[Ra1]_F(SL)_PF1(AB_SL)_PFA(SHU)_PB(AB_SL)_PN(SL).pdf). Lately the editorial office received a letter raising few questions and seeking clarifications from the authors of the article. The letter is attached as a supplementary file. The following are the statements issued from the authors’ end. 1. The E.Li.Ba device was invented by Luigi Balercia and Dino Capparè more than 25 years ago. Since then, many clinicians belonging to IAPNOR, as direct or indirect students of Balercia have used this instrument. 2. After the death of L. Balercia the founder of IAPNOR, both technical (D. Capparè 2001) and clinical (Salvatore Tucci 2006, and Angelo Zobi 2014) aspects of ELIBA and its use and construction appeared in IAPNOR Journal ISSN 1127 -1647 (D. Capparè 2001, S. Tucci 2006 and A. Zobi 2014) and on Doctor OS (A. Zobi 2016). 3. In 2011 IAPNOR developed its own protocol for use and production of E.Li.Ba. 4. The authors were not aware of the book published in 1998 by Luigi Balercia entitled "Balercia Lingual Elevator phisiopathology of swallowing" (italian book). Not knowing their existence they could not refer to this text.

Correction :2019 Mar: Vol-13(3): OD01-OD03
Animesh Das, Sunil Pradhan,Diffuse Tuberculous Cerebritis in Immunocompetent Hosts- An Uncommon Entity (Published in Journal of Clinical and Diagnostic Research. 2019 Mar: 13(3) The correction: In this article there was an oversight.An important contributor was excluded at the time of publication, and the same person has been added as the second author.