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   Table of Contents - Current issue
January-March 2019
Volume 6 | Issue 1
Page Nos. 1-78

Online since Thursday, February 14, 2019

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Dental stem cells – Sources and identification methods Highly accessed article p. 1
Anjali Narwal, Shruti Gupta, Anita Hooda
The banking of mesenchymal cells from the umbilical cord and harvesting them for future use is the current trend in medical science. Such sources are reservoirs of stem cells. Over the past decade, the field of dentistry has embossed its presence by taking major lead in the field of regenerative medicine and more precisely in the field of stem cells. These stem cells have the capacity for regeneration and repair by converting into any other cell type. However, these cells require signals for differentiation in a timely manner. Tooth and its associated structures have been discovered as the latest reservoirs of stem cells. In this review, a light has been thrown on such sources and their identification has been emphasized.
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Bacteriological profile of diabetic foot ulcers p. 7
Sarita Otta, Nagen Kumar Debata, Bichitrananda Swain
Background: Foot infections are the major complications of diabetes mellitus and lead to the development of gangrene and ultimately amputation of the limb. Proper diagnosis of the causative agents and their antibiotic susceptibility play a significant role in preventing adverse prognosis of diabetic foot. Aim: The study aims to establish the bacteriological profile of diabetic foot ulcers as well as to note resistance pattern of the implicated organisms. Materials and Methods: One hundred and forty-eight patients having diabetic foot ulcers of Wagner's Grade 1 or above were included in this study. Debrided tissue, pus, or swabs from the base of the ulcers were subjected to aerobic and anaerobic culture. The organisms were identified, and further antibiotic sensitivity of the aerobic bacteria was conducted by Kirby–Bauer's disc diffusion method. Results: Two hundred and forty aerobic and 21 anaerobic bacteria were isolated from these ulcers; Staphylococcus aureus and Bacteroides spp. are the most common aerobic and anaerobic bacteria isolated, respectively. Of the S. aureus, 77.8% were methicillin resistant, while 42.1% of the Gram-negative Enterobacteriaceae were extended-spectrum beta-lactamase (ESBL) positive. Klebsiella spp. was the highest ESBL producer whereas Acinetobacter spp. was the highest metallo-beta-lactamase producer. Linezolid, teicoplanin, and vancomycin were the most sensitive drugs for Staphylococcus spp. Gram-negative isolates were mostly sensitive to cefoperazone-sulbactam and imipenem. Pseudomonas spp. was mostly sensitive to imipenem and piperacillin-tazobactam, whereas Acinetobacter spp. was sensitive to netilmicin and levofloxacin. Conclusion: As diabetic ulcers are often infected by multidrug-resistant bacteria, a knowledge of the common bacterial pathogens implicated as well as their sensitivity pattern helps the clinician to choose the proper antibiotic for a timely treatment.
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Delay in initiation of treatment of tuberculosis: A cross-sectional study from rural Wardha p. 12
Gauri A Patki, Abhishek V Raut, Shrinidhi Datar
Background: India with 2.2 million incident cases annually contributed to around 25% of global incidence. Along with conventional indicators, magnitude of treatment delay would prove as a performance indicator for tuberculosis (TB) control in high TB burden countries like India. Objectives: The objectives of the study were to find out the magnitude of treatment delay among the TB patients, to describe the factors responsible for delay in treatment, if any, and to assess the knowledge of patients in a rural area about TB and directly observed treatment short course (DOTS). Study Design: Descriptive cross-sectional study was conducted among patients registered in the DOTS center at Mahatma Gandhi Institute of Medical Sciences Sewagram. Materials and Methods: Information of all 40 new sputum smear-positive TB patients registered at DOTS center between February and April 2015 was collected. Of these, thirty patients could be contacted successfully and were included in the study after obtaining consent. Data were entered in Microsoft Excel and analyzed using Epi Info software. Mean and median delay in terms of days were estimated. Mann–Whitney U-test was used to determine factors associated with treatment delay. Descriptive analysis using frequency and percentage was carried out to assess the knowledge regarding TB and DOTS. Results: Median delay was 35.5 days with diagnostic delay comprising 84% of it. Male patients and patients belonging to Below Poverty Line (BPL) families had significantly (P < 0.05) lesser median delay. Conclusions: Definite delay was seen in treatment initiation for TB with diagnostic delay contributing the most to the total delay.
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Out-of-Pocket expenditure for diagnosis of lung cancer: A significant pretreatment financial burden – Study from a tertiary care cancer center in North India p. 18
Vijay Kumar Barwal, Anita Thakur, Salig Ram Mazta, Gopal Ashish Sharma
Background: The incidence of catastrophic expenditure due to health-care costs is growing and is estimated to be one of the major contributors to poverty. The need to pay out-of-pocket can also mean that households do not seek care when they need it. The total economic burden of cancer therapy amounts to the mean of 36,812 Indian National Rupee (INR). Out of this, 40% comprises expenditure incurred before coming to the hospital. Objectives: This study assessed the total out-of-pocket expenditure (OOPE) of lung cancer patients before they seek services for treatment at a tertiary care center. Materials and Methods: This was an institution-based cross-sectional survey in newly diagnosed and registered lung cancer patients > 18 years old. Self-designed, pretested, semi-structured questionnaire for sociodemographic details and direct costs incurred under various subsets was used. Data were analyzed using Epi Info version Results: Out of 91 patients registered, 73 (80.2%) were male. The median OOPE was 19000 INR (range: 8000–40,000). We found that the total mean expenditure (19,516.48 ± 6488.22) was almost ten times their per capita income (2012.444 ± 1283.09). The total mean direct medical costs incurred were 8974.73 ± 5252 INR and direct nonmedical costs incurred were 10,574.73 ± 4414 INR. This study further showed that the direct nonmedical costs incurred were significantly higher (P = 0.02) than the direct medical costs. Similarly, the costs incurred on diagnostics were significantly higher (P < 0.001) as compared to the cost incurred on medicines. Conclusion: Lung cancer patients face the burden of OOPE at every stage, starting from the initial visit to a local health facility till the final diagnosis and treatment at a tertiary health-care facility. More measures are warranted to curtail preregistration and pretreatment expenses such as preventing people from traveling long distances just for imaging and diagnostic facilities and hence curtailing nonmedical cataclysmic expenditure.
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Overweight and obesity among adults in rural Bengal: A community-based cross-sectional study p. 23
Nabarun Karmakar, Udit Pradhan, Indranil Saha, Soumalya Ray, R Parthasarathi, Rabindranath Sinha
Background: Globally, more people are obese than underweight – this occurs in every region except parts of Sub-Saharan Africa and Asia. Overweight and obesity are linked to more deaths worldwide than underweight. Objective: The objective of this study is to find the prevalence of overweight and obesity and its association with sociodemographic and behavioral factors, if any among adult population in rural communities of Singur block of West Bengal. Materials and Methods: This community-based study was conducted among 510 people aged 20 years and above from October 2014 to June 2015 in rural communities of Singur block, West Bengal, a rural field practice area of All India Institute of Hygiene and Public Health, Kolkata. The study participants were interviewed using predesigned and pretested questionnaire regarding sociodemographic characteristics supplemented with clinical and anthropometrical examination. Results: Among 510 participants, 22.4% were overweight and 30.4% fall in the obese category. Nearly half 46.5% of the participants (21.2% males vs. 68.2% females) had abdominal obesity. The prevalence of obesity was more among in the age group of 30–40 years (26.4%) and 20–30 and 40–50 years (each group, 25.3%, P < 0.001). Female participants were predominantly obese (58% vs. 42%) than males (P < 0.05). Higher prevalence of obesity was seen among participants belonging to Hindu religion (87%), general caste (48%), currently married (84.8%), and joint families (52%) which were statistically significant (P < 0.05). Nonworking group of participants was more obese (58.4% vs. 41.6%) than working group (P > 0.05). Less overweight/obesity was seen among those having family history (29%) of noncommunicable disease (P < 0.001), habit of consumption of alcohol (5.2%), and tobacco (20.4%) (P > 0.05). Conclusion: The study revealed rising trend of overweight and obesity among adults in rural area of West Bengal. Prevention of overweight and obesity has to be recognized as a public health priority, creating awareness among rural population.
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A digital analysis comparing the surface staining characteristics of two commercially available porcelains on exposure to commonly consumed beverages p. 30
Nitasha Gandhi, Surbhi Mehdiratta, Nirmal Kurian, Neethu Roy, Vijay Alageshan, George Abraham
Aim: This in vitro study aimed to evaluate the color stability of two commercially available porcelain systems (Vita VMK®, VITA Zahnfabrik GmbH and Ceramco-3, Dentsply, India) against discoloration caused by commonly consumed beverages using digital analysis. Materials and Methods: Sixty porcelain samples in disc form were fabricated and divided into two groups (Ceramco-3® and Vita VMK®) consisting of thirty samples each. They were photographed digitally utilizing CIELAB system to obtain the baseline L*, a*, b* values. Samples were then immersed in test solutions for 180 days and the posttreatment images of the test materials were acquired at the 30th, 90th, and 180th day. All L*, a*, and b* values were analyzed by a graphic software, and the total color change (ΔE*) of each specimen was calculated. Statistical Analysis Used: Statistical analysis of the mean ΔE values among the groups was achieved by one-way analysis of variance paired Student t-test, post hoc Tukey's honest significant difference test, and the level of significance was set as 0.05. Results: Statistical analysis did not reveal a significant difference between the groups with the Group II (Vita VMK®) showing slightly more discoloration as compared to Ceramco-3® when immersed in all the test samples. It was also observed that both the feldspathic porcelains exhibited a greater color change when immersed in coffee when compared to tea. Conclusion: Both Ceramco-3® and Vita VMK® after immersion in test solutions showed minimum color change (i.e., maximum color stable) in water units and maximum color change in coffee with Vita VMK® exhibiting more change than Ceramco-3®.
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Drug utilization pattern in adult medical intensive care unit of a tertiary care hospital p. 35
Anitta Thomas, Utkarsha Adake, Apurva Ashokkumar Sharma, Asawari Raut
Aims: This study aims to evaluate the drug utilization pattern in terms of Defined Daily Dose (DDD) in adult Medical Intensive Care Unit. Methods: In this prospective study conducted over a period of 8 months, data pertaining to all adult (age ≥18 years) patients' demography, diagnosis, treatment, and laboratory investigation were collected. The drugs were categorized by anatomical therapeutic classification, and their DDD was calculated. Results: A total of 452 patients were evaluated, of which 62.6% were males. The most common reason for hospitalization was cardiovascular disorder (21.4%), followed by respiratory disorder (21%) and central nervous disorder (20%). An average of 9.9 drugs was prescribed per patient. Nearly 52% of drugs were administered parenteral, 43% were oral and 5% were either nebulization or topical. Among the drugs prescribed, the most common drugs were pantoprazole, ondansetron, aspirin, furosemide, and atorvastatin and most common antimicrobials were ceftriaxone followed by piperacillin + tazobactam and metronidazole. Conclusions: Drug utilization produces an important impact on quantitative data for Intensive Care Unit patients and should be conducted regularly so as to understand the drug consumption as well as for protocol implementation to improve the quality of health care.
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Predictive accuracy of cervical cytology and colposcopy in diagnosing premalignant and malignant cervical lesions: A hospital-based study from the sub-Himalayan region of Indian subcontinent p. 39
Amrita Singhal, Rashmi Kaul Raina, Suresh Verma, Ashok Verma
Background: Cancer of the cervix is one of the most common cancers among women in India. The study aimed to detect the predictive accuracy of cytology and colposcopy in cervical cancer screening among Himachali married women who had a high risk for cervical cancer. Materials and Methods: This was a hospital-based cross-sectional study. Two hundred nonpregnant married women with a high risk for cervical cancer and attending the gynecology clinic of a tertiary care center of Himachal Pradesh were included in the study over a period of 1 year. A detail clinical history was taken, and examination was performed in all the cases. Papanicolaou (Pap) smears for cytological examination were taken in all the cases. Colposcopy was performed in all the cases, and cervical punch biopsy was taken in all the women with suspicious lesions on colposcopy. Bethesda classification system (2001) and the WHO classification of tumors of the uterine cervix (2003) were used for reporting cytology and histopathology, respectively. Results: The mean age of the women in the study is 38.6 ± 6.2 years. Pap was reported as negative for intraepithelial lesion or malignancy in 88.5%, inflammatory in 32.5%, low-grade squamous intraepithelial lesion (LSIL) in 5.5%, high-grade SIL (HSIL) in 2.5%, and atypical squamous cells of undetermined significance in 1%. In the current study, the diagnostic accuracy of Pap smear and colposcopy for LSIL was 79.4% and 73.5%, respectively. The diagnostic accuracy of Pap smear and colposcopy for HSIL was 100% and 91.3%, respectively. Conclusion: This study has established the utility of Pap smear cytology and colposcopy as a screening tool for the detection of normal as well as abnormal lesions while analyzing cervical pathology in patients with high risk of cervical cancer.
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Light-emitting diode-fluorescent microscopy: Determining its sensitivity and specificity in diagnosis of pulmonary tuberculosis in a high-burden tuberculosis region and resource-limited country like India p. 44
Shariq Ahmed, Indu Shukla, Nazish Fatima, Sumit K Varshney, Mohammad Shameem, Uzma Tayyaba
Background: Tuberculosis (TB) remains a major global health problem. India accounts for the one-fourth of the global TB burden. For resource-limited countries like India having high burden of TB, smear microscopy is the most commonly used method for microbiological diagnosis. Although culture being highly sensitive and specific method, it is time-consuming. Under Revised National TB Control Program (RNTCP), Ziehl–Neelsen (ZN) stain-based microscopy and light-emitting diode-based fluorescent microscopy (LED-FM) are being recommended. Aim: The present study was done to determine the sensitivity and specificity of ZN stain-based microscopy and FM (LED-FM) keeping solid culture as gold standard. Materials and Methods: A total of 1503 sputum samples were collected from suspected cases of pulmonary TB (new or previously treated). They were processed and subjected to ZN (conventional light microscopy), Auramine-O (AO) staining (LED-FM) and solid culture on Lowenstein–Jensen medium for detection of acid-fast bacilli. Positive smears were graded according to RNTCP guidelines. Results: Sensitivity, specificity, positive predictive value, and negative predictive value of ZN staining technique were 84.93%, 95.74%, 96.50%, and 82.16%, respectively, and that of FM was 95.25%, 91.33%, 93.81%, and 93.31%, respectively. Conclusion: LED-FM being more sensitive, especially in detecting the paucibacillary cases and less time-consuming, has advantage over ZN method. Nation-wide implementation will lead to improved diagnosis, thus better control of TB.
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Burden, pattern, and causes of road traffic accidents in South India: Estimate of years of life lost p. 52
Paramjot Panda, Vamsi Krishna Boyanagari, Ravishankar Ayyanar
Context: Road traffic accident (RTA) is one of the major preventable public health problems and is on the rise. Aims: The aims of this study were to estimate the burden of RTA in Andhra Pradesh calculating years of life lost (YLL) and age-standardized YLL rates and to evaluate sex- and age-related differences in premature mortality. Subjects and Materials: The data were obtained from State Crime Record Bureau of Andhra Pradesh and Census of India 2011 for age-specific population to calculate YLL and mortality rates were calculated based on the age of the person involved in the accident. Results: A total of 24,258 RTA cases were reported from January 2015 to December 2015. Most of the cases 16,995 reported RTA are from rural areas. The time slot with the highest rate of road accidents in the morning was 09:00 am–12:00 am and in the evening was 06:00 pm–09:00 pm. The age group 25–34 years were the most vulnerable toward road accidental death of which male and female died in RTA were 929 (26.57%) and 101 (28.06%), respectively. Most of the RTA occurred at T-Junctions causing 5548 accidents with a share of 31.52% the total RTA on Junctions, the total YLL was 89,557, and highest YLL was 25,486 in 25–34 years of age group. Conclusions: We conclude that there is high fatal mortality and YLL in young age group in Andhra Pradesh. These are preventable events, and efforts to reduce the associated economic and social burden must be made.
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A double-blind, placebo controlled study to assess the clinical and microbiological effects of a probiotic lozenge as an adjunctive therapy in the management of chronic periodontitis p. 57
Grace Tara Paul, D Gandhimadhi, S P. K Kennedy Babu
Background: The study was conducted to determine the effect of a probiotic lozenge as an adjunct to scaling and root planing in patients having chronic generalized periodontitis in a double blinded, placebo-controlled design. Materials and Methods: A total of 30 chronic generalized periodontitis patients, in the age group of 25–60 years were recruited for the study. Clinical parameters of plaque index (PI), bleeding index (BI), gingival index (GI), probing pocket depth (PPD), clinical attachment level (CAL) and microbiological levels of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Prevotella intermedia were assessed at baseline, 3, 6, and 12 weeks. All patients underwent scaling and root planing (SRP) at baseline and were recalled after 3 weeks. At 3 weeks, the patients were prescribed either probiotic or placebo lozenges for a 3-week period. Statistical analysis was conducted for clinical and microbiological parameters. Results: The PI, PPD, and CAL significantly reduced in both the groups from baseline to 12 weeks. GI and BI reduced significantly at 3 and 6 weeks in the probiotic group and at 3, 6, and 12 weeks in the placebo group. There was a significant decrease in the assayed periopathogens in both the probiotic and placebo groups at all-time intervals. Conclusions: The present study did not show a significant difference of using probiotic over SRP. As the duration of the study was limited to a period of 3 months, the need to conduct large multicenter studies is warranted to substantially validate the use of probiotics in the management of chronic periodontitis.
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Management of Type 1 diabetes mellitus with autologous mesenchymal stem cells p. 64
Pradeep V Mahajan, Aabha Morey, Swetha Subramanian, Anurag Bandre, Harshal Ware
Type 1 diabetes mellitus (DM) is one of the most common chronic metabolic disorders among children. The condition is associated with dysregulation of the immune system resulting in loss of self-tolerance and destruction of pancreatic β-cells by autoreactive T-lymphocytes. Regulation of β-cell homeostasis is vital to maintain optimum blood glucose control as well as prevent the development of complications. Exogenous insulin and oral hypoglycemic agents do not achieve this, as they do not address the core pathology of type 1 DM. This report describes a case of a 17-year-old female patient with fluctuating blood glucose levels and high glycosylated hemoglobin, unresponsive to conventional therapy. After undergoing two sessions of cell-based therapy, within a year, optimum control of blood glucose was achieved along with negative anti-insulin antibodies. The patient was able to discontinue insulin and has not experienced any adverse effects till date. Improvement in general health was noticed, and the patient is now free from any symptoms associated with her former diabetic status. Mesenchymal stem cells (MSCs) possess immunomodulatory and pro-angiogenic properties, which may aid in arresting β-cell destruction. In addition, MSCs may preserve residual β-cell mass and facilitate endogenous β-cell regeneration. These cells are capable of differentiating into glucose-responsive insulin-producing cells, making them ideal candidates in treatment of and prevention of complications in T1DM.
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Rare cause of recurrent iron deficiency anemia p. 67
Rajesh Sharma, Vishal Bodh, Brij Sharma, Vineeta Sharma, Sanjay Mahajan
Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder, characterized by multifocal venous malformations predominantly affecting skin, soft tissues, and gastrointestinal (GI) tract. Its presentation is usually sporadic although cases of autosomal dominant inheritance have been reported. Usually seen in children, BRBNS presentation in adults is rare. Most common symptoms of GI tract involvement are iron deficiency anemia and bleeding. We present a case of 16-year-old boy, who presented with recurrent anemia requiring multiple blood transfusions.
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Complete annular pancreas with biliary ascariasis p. 70
Mohd Ilyas, Muiez Bashir, Naseer A Choh, Feroze A Shaheen
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Clubbing: The oldest clinical sign in medicine p. 72
Rakesh Agarwal, Rashmi Baid, Dhurjati Prasad Sinha
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Childhood diabetes mellitus in a rural tertiary hospital in North-West Nigeria p. 76
Mahmood Dhahir Al-Mendalawi
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Namastey!! Greet the Indian way: Reduce the chance of infections in the hospitals and community p. 77
Sudip Bhattacharya, Amarjeet Singh
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