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   Table of Contents - Current issue
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January-June 2017
Volume 8 | Issue 1
Page Nos. 1-135

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EDITORIAL  

Vestibular stimulation for stress management: Attributing the vestibular system networks in potentially regulating physiology beyond body movements and balance p. 1
Arun H. S. Kumar
DOI:10.4103/0976-9668.198355  
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REVIEW ARTICLES Top

Adult-to-adult living donor liver transplantation: Operative techniques to optimize the recipient's outcome p. 4
Peng Soon Koh, See Ching Chan
DOI:10.4103/0976-9668.198356  
Adult-to-adult living donor liver transplantation (LDLT) is widely accepted today with good outcomes and safety reported worldwide for both donor and recipient. Nonetheless, it remained a highly demanding technical and complex surgery if undertaken. The last two decades have seen an increased in adult-to-adult LDLT following our first report of right lobe LDLT in overcoming graft size limitation in adults. In this article, we discussed the operative techniques and challenges of adult right lobe LDLT incorporating the middle hepatic vein, which is practiced in our center for the recipient operation. The various issues and challenges faced by the transplant surgeon in ensuring good recipient outcome are explored and discussed here as well. Hence, it is important to understand that a successful recipient operation is dependent of multifactorial events starting at the preoperative stage of planning, understanding the intraoperative technical challenges and the physiology of flow modulation that goes hand-in-hand with the operation. Therefore, one needs to arm oneself with all the possible knowledge in overcoming these technical challenges and the ability to be flexible and adaptable during LDLT by tailoring the needs of each patient individually.
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Understanding the links between vestibular and limbic systems regulating emotions p. 11
Archana Rajagopalan, KV Jinu, Kumar Sai Sailesh, Soumya Mishra, Udaya Kumar Reddy, Joseph Kurien Mukkadan
DOI:10.4103/0976-9668.198350  
Vestibular system, which consists of structures in the inner ear and brainstem, plays a vital role is body balance and patient well-being. In recent years, modulating this system by vestibular stimulation techniques are reported to be effective in stress relief and possibly patient's emotional well-being. Emotions refer to an aroused state involving intense feeling, autonomic activation, and related change in behavior, which accompany many of our conscious experiences. The limbic system is primarily involved in the regulation of emotions. Considering the extensive networks between vestibular and limbic system, it is likely that vestibular stimulation techniques may be useful in influencing emotions. Hence, we review here, the possible mechanisms through which vestibular system can influence emotions and highlight the necessary knowledge gaps, which warrants further research to develop vestibular stimulation techniques as a means to treat health conditions associated with emotional disturbances.
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Xylitol in preventing dental caries: A systematic review and meta-analyses p. 16
Chandrashekar Janakiram, CV Deepan Kumar, Joe Joseph
DOI:10.4103/0976-9668.198344  
Xylitol is a sugar alcohol having the properties that reduce levels of mutans streptococci (MS) in the plaque and saliva. To assess the role of xylitol in preventing dental caries. Systematic review and meta-analysis developed by Cochrane cooperation were adapted. Electronic search was carried out in PubMed through the period up to 2014. Included clinical studies were done on (1) humans (2) participants include both individuals and as pairs (mother-child) (3) participants using orthodontic appliances (4) xylitol dispensed in any form (5) compare the effect of xylitol on dental caries and on other phenotype that determines the preventive effect on dental caries, such as decayed, missing, and filled (DMF/dmf) and salivary or plaque MS level. Twenty articles of the 477 articles initially identified. Among 20 studies indexed, 16 articles were accessed, systematically reviewed, and the meta-analysis was carried out. The evaluation of quality of the studies was done using risk of bias assessment tool. The quality of the studies was high risk and unclear risk for six and five trials. The meta-analysis shows a reduction in DMF/dmf with the standard mean (SM) of −1.09 (95% confidence interval [95% CI], −1.34, −0.83) comparing xylitol to all controls. The effect of DMF/dmf reduction by xylitol to fluoride varnish was with the SM of −1.87 (95% CI, −2.89, −0.84). The subgroup analysis, there was a reduction in MS count with SM of 0.30 (95% CI, 0.05, 0.56) when compared with all other caries preventive strategies; however, it was insignificant. Xylitol was found to be an effective strategy as self-applied caries preventive agent.
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ORIGINAL ARTICLES Top

Portsmouth physiological and operative severity score for the Enumeration of Mortality and morbidity scoring system in general surgical practice and identifying risk factors for poor outcome p. 22
Ashish Tyagi, Nitin Nagpal, DS Sidhu, Amandeep Singh, Anjali Tyagi
DOI:10.4103/0976-9668.198342  
Background: Estimation of the outcome is paramount in disease stratification and subsequent management in severely ill surgical patients. Risk scoring helps us quantify the prospects of adverse outcome in a patient. Portsmouth-Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM) the world over has proved itself as a worthy scoring system and the present study was done to evaluate the feasibility of P-POSSUM as a risk scoring system as a tool in efficacious prediction of mortality and morbidity in our demographic profile. Materials and Methods: Validity of P-POSSUM was assessed prospectively in fifty major general surgeries performed at our hospital from May 2011 to October 2012. Data were collected to obtain P-POSSUM score, and statistical analysis was performed. Results: Majority (72%) of patients was male and mean age was 40.24 ± 18.6 years. Seventy-eight percentage procedures were emergency laparotomies commonly performed for perforation peritonitis. Mean physiological score was 17.56 ± 7.6, and operative score was 17.76 ± 4.5 (total score = 35.3 ± 10.4). The ratio of observed to expected mortality rate was 0.86 and morbidity rate was 0.78. Discussion: P-POSSUM accurately predicted both mortality and morbidity in patients who underwent major surgical procedures in our setup. Thus, it helped us in identifying patients who required preferential attention and aggressive management. Widespread application of this tool can result in better distribution of care among high-risk surgical patients.
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Generic versus branded medicines: An observational study among patients with chronic diseases attending a public hospital outpatient department Highly accessed article p. 26
Manisha Das, Supriyo Choudhury, Somnath Maity, Avijit Hazra, Tirthankar Pradhan, Aishee Pal, Ranendra Kumar Roy
DOI:10.4103/0976-9668.198351  
Background: The concept of generic prescription is widely accepted in various parts of the world. Nevertheless, it has failed to gain popularity in India due to factors such as nonavailability and distrust on the product quality. However, since 2012, the Government of West Bengal, India, has initiated exclusive generic drug outlets called “fair price medicine shop” (FPMS) inside the government hospital premises in a “public-private-partnership” model. This study was undertaken to evaluate the experience and attitude of patients who were consuming generic drugs purchased from these FPMS Materials and Methods: It was a questionnaire-based cross-sectional study where we have interviewed 100 patients each consuming generic and branded drugs, respectively. The perceived effectiveness, reported safety, medication adherence, cost of therapy, and availability of drugs was compared between two mentioned groups. Medication adherence was estimated through Drug Attitude Inventory-10. Results: 93% of generic and 87% branded drug users believed that their drugs were effective (P = 0.238) in controlling their ailments. No significant difference (9% generic, 10% branded drug users, P = 1.000) was observed in reported adverse effects between generic and branded drug users. 82% and 77% of patients were adherent generic and branded drugs, respectively (P = 0.289). As expected, a significantly lower cost of generic drugs was observed compared to its branded counterpart. Conclusion: The policy of FPMS implemented by the Government of West Bengal, India appeared to be promising in terms of perceived effectiveness, safety, and adherence of generic drugs from FPMS compared to drugs purchased from open market retailers. Therefore, this study might act as an impetus for the policy-makers to initiate similar models across the country.
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Utility of cytokine, adhesion molecule and acute phase proteins in early diagnosis of neonatal sepsis p. 32
MA Fattah, Al Fadhil A Omer, S Asaif, R Manlulu, T Karar, A Ahmed, A Aljada, Ayman M Saleh, Shoeb Qureshi, A Nasr
DOI:10.4103/0976-9668.198362  
Background and Aim: Neonatal infection, including bacterial sepsis, is a major health care issue with an annual global mortality in excess of one million lives. Therefore, this study aimed to evaluate the potential diagnostic value of C-reactive protein (CRP), E-selectin, procalcitonin (PCT), interleukins-6 (IL-6), and tumor necrosis factor-α (TNF-α) both independently and in combination for the diagnosis of neonatal sepsis in its earliest stages. Materials and Methods: A total of 320 subjects were included in this study. A prospective cross-sectional study was conducted among neonates admitted to Neonatal Intensive Care Unit at King Abdulaziz Medical City, Riyadh, KSA during January 2013 to August 2015, the study based on three study groups categorized according to clinical symptoms and blood culture result. Study groups include healthy control neonates (n = 80), clinical sepsis (CS) group (n = 80) with clinical signs of sepsis but their blood culture was negative, and sepsis group with clinical signs of sepsis and their blood culture was positive. Results: The study observed significant difference in plasma levels of CRP, IL-6, TNF-α, E-selectin, and PCT in patients group when compared with control group (P < 0.001). Furthermore, the levels are significantly different between patient groups including CS and neonatal sepsis group. Moreover, result observed significant difference in CRP and IL-6 in early onset sepsis (EOS) when compared with late onset sepsis (LOS) neonates (P < 0.001 and 0.01), respectively, while there were no significant difference in TNF-α, E-selectin, and PCT between EOS and LOS (P = 0.44, 0.27 and 0.24), respectively. Regarding biomarkers accuracy, the result showed that CRP has the best diagnostic accuracy with cutoff value of 3.6 ng/ml (sensitivity 78% and specificity of 70%). The best combination is shown with CRP and IL-6 in which sensitivity increased to 89% and specificity to 79%. Conclusion: It was concluded that infected new-born babies have a higher E-selectin, PCT, IL-6, TNF-α, and CRP compared with the neonates with CS and control. IL-6, TNF-α, and CRP should be measured in combination for mare diagnostic accuracy in neonatal sepsis. Likewise, PCT should be investigated as a part of sepsis screening for all suspected neonates.
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A study on posttraumatic experience of road traffic accident afflicted maxillofacial trauma patient at tertiary hospital p. 40
Santosh Kumar Yadav, Suraksha Shrestha
DOI:10.4103/0976-9668.198358  
Objectives: Patients are usually left in a vulnerable state after an accident. Because of this, they long for a good encounter when they are brought to the hospital. Physical impairment and psychological morbidities are some of the complications that can occur to them. Traditionally, surgeons tend to pay little attention to a patient's emotional and psychological perspective. The aim of this study was to understand the experience of oral and maxillofacial trauma patients due to road traffic accident right from immediate after the accident till the end of definitive treatment. Materials and Methods: Phenomenological approach of qualitative study was used to explore these patients' experience. Twenty subjects involved in road traffic accidents without any cognitive impairment aged 18 and above were recruited. Purposive sampling was used to include maximal variation sample regarding age, gender, types of injury, and types of treatment received. Semi-structured and open-ended interview approach was used to obtain in-depth information. Results: Seven themes were identified to describe the patients' response to and experience after meeting with a road traffic accident; they are unreal experiences, emotional responses, need to inform and need for information, need for assistance, their perception toward the maxillofacial injury, their experience on treatment and staff-patient interaction. Conclusion: This qualitative study has provided an in-depth understanding of patients experience during maxillofacial trauma and treatment, which otherwise cannot be obtained by the use of surveys and test questions.
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Incidence, bacteriology, and clinical outcome of ventilator-associated pneumonia at tertiary care hospital p. 46
Harsha V Patil, Virendra C Patil
DOI:10.4103/0976-9668.198360  
Background: Ventilator-associated pneumonia (VAP) is the most frequent Intensive Care Unit acquired infection. Aims: The aim is to determine the incidence, bacteriology and factors affecting VAP and to determine the multi-drug resistant (MDR) pathogens. Settings and Design: This was a prospective observational study conducted over a period of 1 year from April 1, 2011, to March 31, 2012. Materials and Methods: The patients fulfilling criteria of VAP were included in this study. Statistical Analysis: This was performed using SPSS trial version 11.0 software (SPSS Inc., Chicago, Illinois, USA) and the values of P< 0.05 were considered statistically significant. Results: Totally 74 (27.71%) patients were developed VAP. Of total 74 patients with VAP 53 (71.62%) were females and 21 (28.37%) were females (P < 0.0001). Total 13 (17.56%) patients had early-onset VAP and 61 (82.43%) had late-onset VAP (P < 0.0001). The overall incidence of VAP rate per 1000 ventilator days was 39.59. Total 126 bacterial isolates found in 74 patients with VAP. Predominant isolates were Gram-negative 52 (70.27%). Total 41 (55.40%) patients had polymicrobial VAP, and 33 (44.59%) had single isolate. Total 55 (43.65%) isolates were MDR organisms. Total 22 patients with VAP succumbed during treatment with overall case fatality rate of 29.72%. Of total 55 MDR isolates in VAP, 13 (26.63%) were Klebsiella spp., 11(20%) Pseudomonas aeruginosa, 14 (25.45%) Acinetobacter, 8 (14.54%) Escherichia coli, and 9 (16.36%) coagulase positive Staphylococcus aureus. Total 12 (21.41%) patients succumbed among MDR isolates. Conclusions: There was a high incidence of MDR pathogens in late-onset VAP. The Gram-negative organisms Klebsiella, Pseudomonas E. coli and Acinetobacter were the most commonly isolated organisms with high mortality rates.
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Determination of the frequency of the most immunogenic Rhesus antigens among Saudi donors in King Abdulaziz Medical City - Riyadh p. 56
Mohieldin Elsayid, Faris Saeed Al Qahtani, Abdulaziz Mohammed Al Qarni, Faisal Almajed, Faisal Al Saqri, Shoeb Qureshi
DOI:10.4103/0976-9668.198361  
Background: The Rhesus (Rh) blood group system is one of the most polymorphic and immunogenic systems known in humans, because of its immunogenicity along with ABO grouping, RhD antigen testing was made mandatory before issuing a compatible blood. At present, there are five major antigens, i.e., D, C, E, c, and e in Rh blood group system. Aims: The aim of this study is to provide essential data about the distribution of the major Rh antigens and the most common phenotype among the Saudi population. Materials and Methods: This is a retrospective study to evaluate the Rh grouping and Rh sub-groups performed among some donors who donated blood or blood products at the department of donation center at King Abdulaziz Medical City Riyadh, Saudi Arabia from January 1, 2014 to December 31, 2014. Sample size included 600 donors. Donors are males and females and their ages are above 18 years. Results: The incidence of RhD was 84.8% and only 15.2% of samples were negative for D antigen. The Incidence of other Rh antigens C, E, c, and e were 62.3%, 23.5%, 74.3%, and 95.0%, respectively. The most common phenotype among RhD positive donors was DCcee (28.7%) and among RhD negative donors was dccee (13.7%). However, three donors (0.5%) were negative for antithetical antigens C and c. Conclusion: This study shows that there is a wide racial and geographical variation in the distribution of Rh antigens and phenotypes among study participants. The Rh blood group system has a vital role in population genetic study and in resolving medical legal issues and more importantly in transfusion medicine practice.
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High rates of diabetes reversal in newly diagnosed Asian Indian young adults with type 2 diabetes mellitus with intensive lifestyle therapy p. 60
Vijaya Sarathi, Anish Kolly, HB Chaithanya, CS Dwarakanath
DOI:10.4103/0976-9668.198343  
Aims: There are variable reports on the reversibility of type 2 diabetes mellitus (type 2 DM) with higher rates among younger patients with short duration of diabetes. Hence, we studied the reversibility of diabetes among young adults with newly diagnosed type 2 DM. Methods: This prospective study included 32 patients with newly diagnosed type 2 DM. All type 2 DM patients were initially treated with intensive lifestyle therapy (ILT) (low-calorie diet [1500 kcal/day] and brisk walking for 1 h/day]). Four patients who with HbA1C <9.0% were treated with ILT alone. Except for three patients with concomitant infections who were treated with insulin, remaining 25 patients with HbA1C ≥9.0% were treated with metformin (1000–2000 g) in addition to ILT. When fasting plasma glucose was <126 mg/dl or HbA1C was <6.5% antidiabetic drug dose was reduced or stopped. The patients were followed for a minimum period of 2 years. Results: Reversal/remission rates at 3 months, 1 year, and 2 years were 24 (75%), 24 (75%), and 22 (68.75%), respectively. Seventeen (53.1%) patients achieved complete reversal and seven (21.9%) patients achieved partial reversal at 3 months. Rates of complete and partial remission at 1 year were 50% and 25% and at 2 years were 46.9% and 21.9%, respectively. Conclusion: Young adults with newly diagnosed type 2 DM have high rates of diabetes reversal and should receive ILT to achieve reversal of diabetes.
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Assessment of changes in insulin requirement in patients of type 2 diabetes mellitus on maintenance hemodialysis p. 64
MJ Sudha, Halma S Salam, S Viveka, AL Udupa
DOI:10.4103/0976-9668.198348  
Background: Hemodialysis improves insulin sensitivity. Currently, there is no recommendation for the adjustment of insulin dose on dialysis day and nondialysis day in diabetic patients. This study was undertaken to determine the variations in insulin requirement based on blood glucose levels on dialysis days and nondialysis days in type 2 diabetic patients with chronic kidney disease on maintenance hemodialysis. Methodology: Twenty-eight diabetic patients on hemodialysis were recruited into the study after obtaining written informed consent and approval from Azeezia Ethics Committee. Capillary blood glucose levels, just before dialysis and 2 h after dialysis, were checked and compared with fasting and postprandial glucose levels on–off dialysis days. Results: Mean age of the patients was 59.5 (±2.3) years. The average duration of dialysis was 20.2 months. There was significant (35.8%) decrease in blood glucose levels 2 h after dialysis in comparison to predialysis levels (from mean level of 258–165 mg/dl). The decrease in the blood glucose levels from predialysis level to 2 h postdialysis level was statistically significant (P < 0.001). Both sets of data showed “strong” positive correlation with r = 0.657 and 0.849. The blood glucose levels on the day of dialysis were significantly lower than the off-day values. Conclusions: Diabetic patients with end-stage renal disease on hemodialysis have lower capillary blood glucose levels postdialysis. This has to be addressed clinically to prevent hypoglycemic episodes by reducing exogenous insulin administration on the day of dialysis.
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Spirometry findings among drug users in the Indonesian National Narcotics and illicit drug Bureau Rehabilitation Center p. 69
Erlang Samoedro, Faisal Yunus, Budhi Antariksa, Fariz Nurwidya
DOI:10.4103/0976-9668.198353  
Background: The increasing prevalence of drug user in Indonesia is affecting the health sectors. The lungs health were affected by the use of the illicit drug. However, lung function among drug users is still unclear. Methods: This descriptive-analytic study involves 144 drug users who met the inclusion criteria. Chest X-ray was performed to identify the subject with pulmonary tuberculosis to exclude from the study. Subjects were then undergone spirometry test and interviewed using questionnaires. Results: One hundred and forty-four subjects were included in this study. One hundred and twenty-one (84.03%) were male and 128 subjects showed normal lung function. Proportion of abnormal spirometry was 10.4% (n = 15). The restriction was found in ten subjects, and obstruction was found in four subjects. There was significant correlation between the ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC) and age (P = 0.000; r = −0.454, moderate correlation), time of using cannabis (P = 0.01; r = −0.345, weak correlation), time of using methamphetamine inhalation (P = 0.004; r = −0.25, weak correlation), duration of using heroin injection (P = 0.025; r = −0.337, weak correlation), time of using cigarette (P = 0.000; r = −0.365, weak correlation), and the amount of cigarette consumption/day (P = 0.04; r = −0.238, weak correlation). Conclusion: This study found that there was a weak correlation between declined FEV1/FVC with a time of smoking, the amount of cigarette consume per day, time of cannabis inhalation, time of methamphetamine inhalation, and time of heroin injection.
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Eclectic/mixed model method for upper extremity functional recovery in stroke rehabilitation: A pilot study p. 75
K Vijaya Kumar, Abraham M Joshua, Rakshith Kedambadi, P Prasanna Mithra
DOI:10.4103/0976-9668.198357  
Background: Eclectic treatment method is a flexible approach that uses techniques drawn from various schools of thought involving several treatment methods and allows the therapist to adapt to each client's individual needs. Wider application for eclectic approach is however limited in stroke rehabilitation. Aim: The objective is to find out whether eclectic approach improves upper extremity (UE) functional recovery in acute stroke rehabilitation. Methodology: Twenty-five postacute unilateral supratentorial stroke subjects recruited from tertiary care hospitals recovered with Stage 2–5 in Brunnstorm stage of UE motor recovery (BRS-UE) underwent 45 min of eclectic approach for UE every day involving seven different treatment methods (5 min for each method) for 6 days consecutively. The outcome was UE subscale of the Fugl-Meyer Motor test (UE-FM), UE subscale of the Stroke Rehabilitation Assessment of Movement (UE-STREAM), Wolf Motor Function test (WMFT-FAS), and Stroke Impact Scale-16 (SIS-16) was collected at the end of the sixth session. Results: All the participants showed significant improvement in all the outcome measures. The Stage 2 and 3 subjects showed UE-STREAM (P = 0.007) WMFT-FAS (P < 0.001), SIS (P = 0.023) respectively and for Stage 4 and 5 the subjects have shown UE FM (P < 0.001), WMFT-FAS (P < 0.001), SIS (P = 0.004) with large magnitude of treatment effect for all stages of BRS-UE. Conclusion: Our study findings are in favor of integrating eclectic approach than single intervention/approach in clinical practice to improve the UE functional recovery for motor rehabilitation when the stroke occurs.
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Vestibular stimulation for management of premenstrual syndrome p. 82
Minu Johny, Sai Sailesh Kumar, Archana Rajagopalan, Joseph Kurien Mukkadan
DOI:10.4103/0976-9668.198365  
Objectives: The present study was undertaken to observe the effectiveness of vestibular stimulation in the management of premenstrual syndrome (PMS). Materials and Methods: The present study was an experimental study; twenty female participants of age group 18–30 years were recruited in the present study. Conventional swing was used to administer vestibular stimulation. Variables were recorded before and after vestibular stimulation and compared. Results: Depression and stress scores are significantly decreased after 2 months of intervention. Anxiety scores decreased followed by vestibular stimulation. However, it is no statistically significant. Serum cortisol levels significantly decreased after 2 months of intervention. WHOQOL-BREF-transformed scores were not significantly changed followed by the intervention. However, psychological domain score (T2) and social relationships domain score (T3) were increased followed by intervention. Systolic blood pressure was significantly decreased after 2 months of intervention. No significant change was observed in diastolic pressure and pulse rate. Pain score was significantly decreased after 2 months of intervention. Mini mental status examination scores and spatial and verbal memory score were significantly improved followed by intervention. Conclusion: The present study provides preliminary evidence for implementing vestibular stimulation for management of PMS as a nonpharmacological therapy. Hence, we recommend further well-controlled, detailed studies in this area with higher sample size.
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Dynamic hip screw versus proximal femur locking compression plate in intertrochanteric femur fractures (AO 31A1 and 31A2): A prospective randomized study p. 87
Prabhat Agrawal, Sahil Gaba, Saubhik Das, Ranjit Singh, Arvind Kumar, Gajanand Yadav
DOI:10.4103/0976-9668.198352  
Introduction: Intertrochanteric fractures are common in elderly population and pose a significant financial burden to the society. Anatomically contoured proximal femur locking compression plate (PFLCP) is the latest addition in the surgeons' armamentarium to deal with these fractures. It creates an angular stable construct, which will theoretically lessen the risk of failure by screw cut-out and varus collapse, the common mode of DHS failure. We compared DHS with PFLCP in AO type 31A1 and 31A2 intertrochanteric fractures. Materials and Methods: A randomized prospective study was carried out between June 2011 and June 2013. 26 cases each of DHS and PFLCP were included. Results: Functional and radiological outcome was similar in both groups. Conclusion: Both DHS and PFLCP are good choices for stable intertrochanteric fractures, and both lead to excellent functional outcomes, but non-union might be more common with PFLCP.
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Evaluation of bone mineral density among type 2 diabetes mellitus patients in South Karnataka p. 94
Athulya G Asokan, Jayakumar Jaganathan, Rajeev Philip, Rino Roopak Soman, Shibu Thomas Sebastian, Fawaz Pullishery
DOI:10.4103/0976-9668.198363  
Background: Diabetes is one of the world's biggest health problems and the disease affects almost all organ systems. The relationship between type 2 diabetes mellitus (T2DM) and bone mineral density (BMD) has been controversial. Early identification of reduction in bone mass in a diabetic patient may be helpful in preventing the bone loss and future fracture risks. Objective: The aim is to study the effect of T2DM on BMD among patients in South Karnataka. Materials and Methods: A cross-sectional study was conducted on 150 patients between 40 and 70 years of age which included 75 diabetic and 75 nondiabetic subjects. BMD was measured using qualitative ultrasound and the data were compared among age-matched subjects of both the groups. Statistical analysis was performed using unpaired Student's t-test and test of equality of proportions. Results: No significant difference was observed in bone density of both the groups. On further analyzing the data, incidence of osteoporosis was higher among diabetic subjects, whereas incidence of osteopenia was higher among nondiabetic subjects. Conclusion: Although significant difference in bone mineral density was not observed in both the groups, the incidence of osteoporosis was higher among type 2 diabetics. Hence, all type 2 diabetics should be evaluated for the risk of osteoporosis and should be offered appropriate preventive measures.
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Evaluation of oxidative stress in chronic periodontitis patients following systemic antioxidant supplementation: A clinical and biochemical study p. 99
Manasa Ambati, Koduganti Rekha Rani, Panthula Veerendranath Reddy, Jammula Suryaprasanna, Rajashree Dasari, Himabindu Gireddy
DOI:10.4103/0976-9668.198366  
Context: Oxidative stress is associated with the pathogenesis of many systemic diseases including chronic periodontitis. Periodontal pathogen activated neutrophils liberate the reactive oxygen species (ROS), which causes the destruction of periodontal tissues. Antioxidants modulate the ROS production and inhibit the tissue destruction. Aim: We aimed to evaluate the oxidative stress marker malondialdehyde (MDA) in chronic periodontitis patients following scaling and root planing (SRP) after systemic lycopene supplementation. Materials and Methods: This was an interventional single arm study. Twenty systemically healthy patients with chronic periodontitis were recruited. Clinical parameters modified gingival index, probing depth, clinical attachment loss were recorded, and serum MDA levels were assessed by thiobarbituric acid reactive substances assay. Patients were supplemented with 8 mg lycopene daily for 2 months following SRP treatment. All the parameters were assessed at pretreatment and 2 months and 6 months posttreatment. Results: From pretreatment to posttreatment at 2 months, the mean values of all parameters were reduced. While from 2 to 6 months when lycopene was not administered, an increase in the mean values of all the parameters was observed; however, these values were still below baseline values. Conclusion: There was a reduction in oxidative stress and improvement in clinical parameters following systemic antioxidant therapy along with SRP, which was maintained up to 4 months after discontinuation of lycopene treatment.
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Acute ST-segment elevation myocardial infarction: The prognostic importance of lead augmented vector right and leads V7–V9 p. 104
Veeresh Patil Hebbal, Huliyurdurga Srinivasasetty Natraj Setty, Cholenahalli Manjunath Sathvik, Vikram Patil, Sarthak Sahoo, Cholenahalli Nanjappa Manjunath
DOI:10.4103/0976-9668.198364  
Background: Acute myocardial infarction (MI) is associated with high mortality and among survivors have high morbidity. Electrocardiogram (ECG), a cost-effective and easily available, has traditionally been used not only just for diagnosis of MI but also for culprit vessel recognition and for prognostication. However, the role of lead augmented vector right (aVR) and leads V7–V9in acute MI are often neglected in clinical practice. We studied the role of lead aVR and leads V7–V9in ST-elevation MI (STEMI) patients. Methods: A total of 209 patients presenting with STEMI were enrolled in the study. History of comorbid conditions and habits was enquired. Routine blood tests were performed. Full spectrum ECG (including V7–9) and 2D-ECHO was performed on all patients. All the patients underwent revascularization by primary percutaneous coronary intervention. The role of lead aVR, lead V7, and leads V8–9 was analyzed in anterior wall MI (AWMI) and inferior wall MI. All the patients were followed up for 1 month for outcome assessment. Results: Of the 209 patients, 85.1% were males and 35.8% were diabetic, 60.2% were smokers, AWMI accounted for 55.5%. Lead aVR ST deviation was noted in 75.1% of patients (elevation in 17.7% and depression in 47.1%). V7 ST elevation occurred in 27.6% and V8–9 elevation occurred in 7.5% of the study population. Total death was 11.9% in the study (including the in-hospital mortality), all these patients had lead aVR ST segment deviation (P < 0.001). Conclusion: Lead aVR ST deviation and Lead V7 ST deviation helps to prognosticate the STEMI patients as high risk and those with aVR ST depression had higher mortality compared to aVR ST elevation because of larger myocardial involvement.
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Evaluation of ischemia-modified albumin, oxidative stress, and antioxidant status in acute ischemic stroke patients p. 110
Itishri Jena, Sarthak Ranjan Nayak, Sudeshna Behera, Bratati Singh, Subhashree Ray, Diptimayee Jena, Santosh Singh, Subrat Kumar Sahoo
DOI:10.4103/0976-9668.198346  
Background: Oxidative stress is characterized by increased production of reactive oxygen species resulting in the generation of lipid peroxides such as malondialdehyde (MDA). The studies have shown that ischemia-modified albumin (IMA), which has widely been studied as a marker of ischemia, also increases as result of oxidative stress. Hence, the current study was done to evaluate the serum MDA, IMA along with serum uric acid, and albumin, which are important metabolic antioxidants. Materials and Methods: Fifty patients with acute ischemic stroke were taken as cases and compared with 50 age- and sex-matched controls. Serum MDA, IMA, uric acid, and albumin were estimated both in cases and controls. Serum MDA was estimated by the method of Satoh and IMA by Bar-Or et al. The results were analyzed statistically. Results: Serum MDA and IMA values were significantly increased in cases (P < 0.0001), whereas serum uric acid and albumin values were significantly decreased (P < 0.05) in comparison to controls. There was also highly significant positive correlation between serum IMA and MDA (r = 0.843,P < 0.0001), whereas there were significant negative correlations between serum IMA and uric acid (r = −0.237,P < 0.05), and albumin (r = −0.326,P < 0.05). Conclusion: Hence, we conclude the oxidative stress plays a major role in the etiopathogenesis of acute ischemic stroke, and the deranged oxidant-antioxidant balance further contributes to its severity.
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Prevalence of tuberculosis among children in North Sudan: Are we only seeing the tip of the iceberg? p. 114
Wadie M Elmadhooun, Elmuntasir Taha Salah, Sufian K Noor, Sarra O Bushara, Ekhlas O Ahmed, Hamdan Mustafa, Amel A Sulaiman, Mohamed H Ahmed
DOI:10.4103/0976-9668.198359  
Introduction: Tuberculosis (TB) is a significant cause of morbidity and mortality among children. The vague symptoms, the uncertain diagnostic tests and lack of adequate awareness among families all contributed in masking the actual prevalence of the disease. The objective of this study was to describe the epidemiology of childhood TB in River Nile State (RNS), North Sudan. Methods: All registered cases of TB aged 15 years and below, at the 13 management units in RNS during 3 years, 2011–2013 were included. The records included epidemiological, clinical, and microbiological data. Results: Out of the 1221 total TB notified cases, children were 187 (15.3%); almost equally distributed across the 3 years of the study period. Males were 56.7%. Most of the cases (89.9%) were newly diagnosed; among them, pulmonary TB (PTB) constituted 61.5%. Sputum specimen was tested in 59.4% (111/187) of cases, and only 15.3% (17/111) of specimens were sputum smear positive for new cases. The cure rate was (76.5%), and the treatment success rate was (88.2%). The death rate was 6.1% among PTB cases and 5.6% among extra-pulmonary cases. All the 20 (10.7%) children tested for HIV were negative. Conclusion: TB is under-reported in RNS and treatment outcomes are sub-optimal. Strategies to identify the active case-detection among children are recommended.
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Novel hydroxamates potentiated in vitro activity of fluconazole against Candida albicans p. 119
Maneesh Paul-Satyaseela, Periasamy Hariharan, Thirunavukkarasu Bharani, Jonathan S Franklyne, Thangapazham Selvakumar, Kuppusamy Bharathimohan, Chenniappan Vinoth Kumar, Virendra Kachhadia, Shridhar Narayanan, Sridharan Rajagopal, Gopalan Balasubramanian
DOI:10.4103/0976-9668.198349  
A set of 12 novel hydroxamate compounds (NHCs), structurally designed as inhibitors of histone deacetylase (HDAC) enzyme, were synthesized at our facility. These were adamantane derivatives with N-hydroxyacetamide as pharmacophore, and each of these compounds was tested for potentiating activity on fluconazole. The concentration of fluconazole which completely inhibited (concentration of complete inhibition [CCI]) the growth of Candida albicans ATCC 90028 and C. albicans ATCC 64550 was determined by micro-dilution method in the absence and presence of NHCs. The CCI of fluconazole without the NHC combination was 64 μg/ml and 1024 μg/ml against C. albicans ATCC 90028 and C. albicans ATCC 64550, respectively. The majority of the NHCs potentiated the fluconazole activity markedly as CCI of fluconazole against C. albicans ATCC 90028 reduced to 0.25 μg/ml. Similarly, CCI of fluconazole against C. albicans ATCC 64550 reduced to 4–8 μg/ml in combination with majority of NHCs while the best activity was displayed by the compound 1 with a reduction of CCI to 0.5 μg/ml. The study results revealed the potential usage of hydroxamate derivatives, structurally designed as HDAC inhibitors to enhance the activity of fluconazole against C. albicans.
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Profile of cervical cancer patients attending Tertiary Care Hospitals of Mangalore, Karnataka: A 4 year retrospective study p. 125
Aadhya Sharma, Vaman Kulkarni, Unnikrishnan Bhaskaran, Meher Singha, Saad Mujtahedi, Anshul Chatrath, Mallika Sridhar, Rekha Thapar, P Prasanna Mithra, Nithin Kumar, Ramesh Holla, BB Darshan, Avinash Kumar
DOI:10.4103/0976-9668.198354  
Objectives: To describe the sociodemographic characteristics and clinical profile of women presenting with cervical carcinoma and to identify factors associated with the timing of presentation and prognosis. Materials and Methods: A record-based descriptive study was carried out from 1st February to 31st March 2014 at Tertiary Care Hospitals of Mangalore. The study population included women who were diagnosed with cervical carcinoma from January 1, 2010 to December 31, 2013. A pretested data extraction sheet aimed at collecting information from the inpatient records was used as the study instrument. The collected data were entered and analyzed using SPSS version 16.0. Results: A total of 227 patients were included in the study. Mean (Standard Deviation) age of diagnosis of cervical cancer was found to be 55 ± 11 years. Majority of the women were Hindus (88.5%) and 51.0% of the women had occupational activities out of which manual labor was the most common. Forty-eight percent of the patients presented in the late stages. Squamous cell carcinoma was found to be the most common histological type. It was also observed that a slightly higher proportion of women with an age >49 years presented in late stages of the disease (n = 70, 48.6%) compared to women <49 years of age (n = 28, 46.7%); however, the difference was not statistically significant (P = 0.800). Conclusions: Our study found out a higher proportion of late presentation by the patients. It emphasizes the need for the development and implementation of an efficient screening cum prevention program for cervical cancer and to continue active research in the domains of identifying all possible risk factors and steps to mitigate them.
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CASE REPORTS Top

Amiodarone-induced loculated pleural effusion without pulmonary parenchymal involvement: A case report and literature review p. 130
Amer Hawatmeh, Mohammad Thawabi, Ashraf Jmeian, Hamid Shaaban, Fayez Shamoon
DOI:10.4103/0976-9668.198345  
Amiodarone is an extremely effective antiarrhythmic drug that is known to cause many adverse effects such as pulmonary, thyroid, and liver toxicities. Of these, pulmonary toxicity is most serious. Pulmonary toxicity can present as interstitial pneumonitis, organizing pneumonia, pulmonary nodules and masses, and very rarely pleural effusions. We present a case of a 73-year-old male who presented with progressive exertional dyspnea, nonproductive cough, generalized fatigue, and weakness. He was found to have multiorgan toxicity secondary to long-term treatment with high doses of amiodarone. This case illustrates that amiodarone may cause toxicity involving multiple organs simultaneously in patients receiving long-term therapy and represents the first reported case of amiodarone-induced loculated pleural effusion without associated lung parenchymal involvement.
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Aortoiliac reconstruction in the setting of in-stent restenosis p. 133
HS Natraj Setty, TR Raghu, BC Srinivas, CM Nagesh, Babu Reddy, Jayashree Kharge, BK Geetha, BN Krishnamurthy, Shivanand Patil, CN Manjunath
DOI:10.4103/0976-9668.198347  
Complex iliac artery obstructions, particularly bilateral stenosis or total iliac artery occlusions, are usually treated with aortofemoral or aortobifemoral graft surgery. However, surgical treatment is associated with 3% mortality rate and significant morbidity such as intestinal ischemia, spinal cord injury, and ureteral damage. Percutaneous interventions of aortic bifurcation offer a promising alternative to surgery with potentially lower morbidity and mortality risk. We report a case of peripheral artery disease who had underwent right transfemoral iliac angioplasty with femoropopliteal bypass presented again with bilateral lower limb ischemia, who was successfully treated with stent implantation with the kissing balloon technique.
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