Evaluation of lung transplant perfusion using iodine maps from novel spectral detector computed tomography

p. 436
Nils Große Hokamp, Amit Gupta
DOI:10.4103/ijri.IJRI_35_18  
We report the case of a 51-year-old patient who underwent bilateral lung transplantation and presented with an unstable condition and sepsis 6 days after transplantation. The performed contrast enhanced spectral detector computed tomography (CT) using a dual-layer detector showed absence of perfusion in the left lung on iodine maps, although branches of the pulmonary artery were patent. This prompted retrospective evaluation of CT images and total venous occlusion of the left pulmonary veins was found. Here, iodine maps helped in raising conspicuity of loss of lung perfusion.
http://www.ijri.org/currentissue.asp?sabs=y

Pulmonary atresia and ventricular septal defect,Coronary artery as the primary source of pulmonary blood flow

Collateral or fistula? Coronary artery as the primary source of pulmonary blood flow in a patient with pulmonary atresia and ventricular septal defect p. 433
Anurag Yadav, Salil Bhargava, T B S Buxi, Krishna Sirvi
DOI:10.4103/ijri.IJRI_489_17  
In patients with pulmonary atresia and ventricular septal defect (PA/VSD), a coronary artery being the primary source of pulmonary blood flow is a rare entity. We describe two cases of PA/VSD with coronary-to-pulmonary artery fistula with emphasis on the role of Computed Tomographic Angiography (CTA) in depicting all the sources of pulmonary blood supply, to predict surgical management and need for unifocalization of Major Aortopulmonary Collateral Arteries (MAPCA's).
http://www.ijri.org/currentissue.asp?sabs=y

An accurate tool to detect cardiac amyloidosis

Myocardial nulling pattern in cardiac amyloidosis on time of inversion scout magnetic resonance imaging sequence – A new observation of temporal variability p. 427
Harshavardhan Mahalingam, Binita Riya Chacko, Aparna Irodi, Elizabeth Joseph, Leena R Vimala, Viji Samuel Thomson
DOI:10.4103/ijri.IJRI_84_18  
Context: The pattern of myocardial nulling in the inversion scout sequence [time of inversion scout (TIS)] of cardiac magnetic resonance imaging (MRI) is an accurate tool to detect cardiac amyloidosis. The pattern of nulling of myocardium and blood at varying times post gadolinium injection and its relationship with left ventricular mass (LVM) in amyloidosis have not been described previously. Aims: The aim is to study the nulling pattern of myocardium and blood at varying times in TIS and assess its relationship with LVM and late gadolinium enhancement (LGE) in amyloidosis. Materials and Methods: This was a retrospective study of 109 patients with clinical suspicion of cardiac amyloidosis who underwent MRI. Of these, 30 had MRI features of amyloidosis. The nulling pattern was assessed at 5 (TIS5min) and 10 (TIS10min) minutes (min) post contrast injection. Nulling pattern was also assessed at 3min (TIS3min) in four patients and 7min (TIS7min) in five patients. Myocardial mass index was calculated. Mann-Whitney U test was done to assess statistical difference in the myocardial mass index between patients with and without reversed nulling pattern (RNP) at TIS5min. Results: RNP was observed in 58% at TIS5minand 89.6% at TIS10min. Myocardial mass index was significantly higher in patients with RNP at TIS5min[mean = 94.87 g/m2; standard deviation (SD) =17.63) when compared with patients with normal pattern (mean = 77.61 g/m2; SD = 17.21) (U = 18; P = 0.0351). Conclusion: In cardiac amyloidosis, TIS sequence shows temporal variability in nulling pattern. Earlier onset of reverse nulling pattern shows a trend toward more LVM and possibly more severe amyloid load.
http://www.ijri.org/currentissue.asp?sabs=y

Gujarati hypertensives

: A cross-sectional study p. 153
Jayesh Dalpatbhai Solanki, Hemant B Mehta, Sunil J Panjwani, Hirava B Munshi, Chinmay J Shah
DOI:10.4103/jpp.JPP_59_18  
Objective: To study the effect of different classes and combinations of antihypertensive agents on arterial stiffness and central hemodynamic parameters. Materials and Methods: A cross-sectional study was conducted in 446 treated apparently healthy hypertensives. Oscillometric PWA was performed by Mobil-o-Graph (IEM, Germany) to derive cardiovascular parameters that were further analyzed in groups stratified by antihypertensive used. Study parameters were brachial hemodynamics (blood pressure (BP), heart rate, and rate pressure product); arterial stiffness (augmentation pressure, augmentation index, pulse wave velocity, total arterial stiffness, and pulse pressure amplification); and central hemodynamics (central BP, cardiac output, and stroke work). Statistical significance was kept at P < 0.05. Results: All groups were selected by matching of age, gender, and body mass index. They were comparable with major confounding factors. There was no difference between study parameters in hypertensives taking exclusive angiotensin-converting enzyme inhibitor (ACEI), calcium channel blocker (CCB), or angiotensin II receptor blocker. Multitherapy showed better hemodynamics and monotherapy showed better stiffness parameters. Addition of CCB to ACEI did not make a difference except with diastolic BP. For most comparisons, most of the results lacked statistical significance. Conclusion: Discrete PWA parameters showed no class difference in hypertensives, treated by conventional monotherapy or combination, ACEI appears to be the best drug. This also indicates that early diagnosis and blood pressure control are more important than antihypertensive used.
http://www.jpharmacol.com/currentissue.asp?sabs=y

contrast media-induced nonrenal adverse drug reactions

contrast media-induced nonrenal adverse drug reactions over the last three decades: A systematic review p. 131
Maurizio Sessa, Claudia Rossi, Annamaria Mascolo, Antonella Scafuro, Rosanna Ruggiero, Gabriella di Mauro, Salvatore Cappabianca, Roberto Grassi, Liberata Sportiello, Concetta Rafaniello
DOI:10.4103/jpp.JPP_92_18  
The aim of this study was to investigate the scientific contribution of Italian clinical research for contrast media-induced nonrenal adverse drug reactions over the last three decades. Ovid Embase, Ovid MEDLINE, Web of Science, and Cochrane Methodology Register were used as data sources to identify Italian descriptive studies, observational studies, meta-analyses, and clinical trials assessing contrast media-induced nonrenal adverse drug reactions as a safety outcome. The population of interest was men and women exposed to a contrast medium. Between 1990 and 2017, 24 original articles investigating contrast-induced nonrenal adverse drug reactions were identified. The cohort study was the most representative study design (10/24; 41.7%). The 24 studies were conducted mainly as monocenter studies (14/24; 58.3%) and without receiving funding (17/24; 70.8%). Seventeen out of 24 studies provided a level of evidence ranging from III-2 (11/24; 45.8%) to IV (6/24; 25.0%) on a Merlin scale. In total, 14 of 24 (58.3%) studies were published in a scientific journal ranked in the first quartile of their subject area. The 24 original articles mainly focused on adverse drug reactions already observed during clinical trials (i.e., idiosyncratic systemic reactions). In conclusion, during the last three decades and a burst was not observed in the Italian clinical research investigating contrast-induced nonrenal adverse drug reactions. High-quality clinical research is needed especially for procedures to prevent the onset of the aforementioned events, to identify risk factors, to minimize the risk of their occurrence, and to optimize their related prognosis.
http://www.jpharmacol.com/currentissue.asp?sabs=y

Phosphodiesterase 7B1 as therapeutic target for treatment of cognitive dysfunctions in multiple sclerosis

 p. 126

Arthi Balsundaram, Darling Chellathai
DOI:10.4103/jpp.JPP_77_18  
Multiple sclerosis (MS) is an autoimmune, chronic degenerative neuroinflammatory disorder affecting younger age groups of the United States of America and Europe. MS prevalence studies in India have shown that India is no longer a low-risk zone. Many studies have shown the seriousness of cognitive impairments (CIs) and its types caused in MS. In this review, the pathological basis for CI in various stages of MS was reviewed and revealed to provide a basis for the treatment. Role of phosphodiesterase 7B1 (PDE7B1) inhibitors in treating CI related to MS were also stated in this review. The literature for this review was collected from PubMed and Embase.
http://www.jpharmacol.com/currentissue.asp?sabs=y

Intermediate type of Gerbode defect: rare type of the left to right shunt

https://ift.tt/2EClDmW

Clostridium difficile colitis in the setting of subacute thyroiditis: the chicken or the egg

Subacutethyroiditis is a self-limited inflammatory condition commonly of viral aetiology, that manifests through phases of thyroid hormone changes over a 6–8 month period. A 24-year-old active duty military man, undergoing treatment for recurrent Clostridiumdifficile infection, presented for clinical evaluation and was found to have a thyroid stimulating hormone level of 0.003 mg/dL. Further labs revealed a normal T4, elevated T3 at 5.0 pg/mL and elevated C reactive protein at 3.69 mg/L. The patient was followed with monthly labs and the abnormal thyroid stimulating hormone and triiodothyronine levels resolved after the completion of his C. difficile treatment. While subacute thyroiditis has historically been due to viral causes, rarely do we see this condition associated with an intestinal bacterial source.

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Persistent primitive olfactory artery: a hairpin easy to miss!

https://ift.tt/2EF1T27

Splenectomy for breast carcinoma diffusely metastatic to the spleen presenting as severe transfusion-dependent anaemia and thrombocytopaenia

We report a 48-year-old woman with metastatic infiltrating lobular carcinoma of the breast. Though her metastatic disease remained stable, she was repeatedly admitted for symptomatic anaemia and treated by red blood cell and platelet transfusions with increasing frequency as time elapsed. Abdominal examination and ultrasound revealed splenomegaly (27 cm span). A bone marrow biopsy showed fibrosis and foci of metastatic carcinoma. Splenectomy ameliorated her transfusion-dependent anaemia and thrombocytopaenia. Histopathology revealed multiple foci of metastatic carcinoma and scattered foci of extramedullary haematopoiesis. Differential diagnosis of anaemia and thrombocytopaenia in patients with cancer include bone morrow involvement by cancer cells, iron-deficiency anaemia, microangiopathies and chemotherapy suppression of haematopoiesis. Splenic involvement with cancer is common in patients with multivisceral disease. Many may regard transfusion-dependent severe anaemia and thrombocytopaenia as an end-stage disease in these patients. Nevertheless, palliative splenectomy should be considered in patients with possible hypersplenism who will otherwise survive for a relatively prolonged period of time.

https://ift.tt/2EtOBV6

Role of the body mass index in the genesis of ascites in ovarian cancer: a forensic case and review of the literature

The ovarian tumour is the seventh female cancer for incidence. In the advanced stages of cancer, tumour cells nourish on the peritoneal serous causing carcinomatosis and peritoneal function abnormalities with liquid build-up inside it. Ascites from peritoneal carcinomatosis is common in patients with ovarian cancer. An obese woman suffering from ovarian cancer was found dead in her home from secondary cardio-respiratory arrest due to Multiple Organ Failure (MOF). An autopsy was performed. The abdominal incision showed an ascitic fluid outflow about 20 litres in volume and a flood about one metre and half. An association between obesity and intraperitoneal fluid volume secondary to peritoneal carcinomatosis has been demonstrated. This finding could improve the prognosis of patients through actions aimed to reduce body weight.

https://ift.tt/2EDciej

Prenatal diagnosis of cervical ribs by three-dimensional ultrasound in a foetus with a herniated Dandy-Walker cyst

We present a case report of a foetus with a herniated Dandy-Walker cyst and bilateral rudimentary cervical ribs. The cervical ribs were visualised prenatally by three-dimensional ultrasound and confirmed by post-termination radiography. The prevalence of cervical ribs is higher in deceased fetuses and neonates with or without structural abnormalities compared with healthy individuals and might be regarded as a marker of disadvantageous fetal development. We demonstrate that evaluation of the fetal vertebral pattern by three-dimensional ultrasonography, including the cervical region, is feasible and could provide valuable information regarding fetal and neonatal prognosis.

https://ift.tt/2EtOqco

Complication of dislodged gastrostomy Foley catheter: antegrade migration into small bowel

A 65-year-old man with dysphagia underwent placement of a percutaneous endoscopic gastrostomy tube. He was cared for at a nursing facility where the tube became dislodged and was replaced with similar size Foley catheter. Patient was brought to the hospital with dislodged feeding Foley but none was found at the bedside. Diagnostic workup revealed antegrade migration of the catheter into the small bowel. Push enteroscopy was unsuccessful in retrieving the catheter because it was too far distal. Patient was observed for a total of 7 days. Due to lack of progress with conservative measures, a colonoscopy was performed to extract the catheter, thus avoiding the need for more invasive surgical measures. If a Foley catheter is used as a gastrostomy tube, it should be replaced with a dedicated feeding tube as quickly as possible and should always be affixed to the skin to prevent antegrade migration and associated complications.

https://ift.tt/2EDp8JU

Comparative analysis of duration of postoperative analgesia between levobupivacaine and levobupivacaine with clonidine after ultrasound-guided transversus abdominis plane block in patients undergoing lower segment cesarean section

Ranjita Acharya, Ranjita Baksi, Pratik Mohapatra

Anesthesia: Essays and Researches 2018 12(4):943-948

Background: Transversus abdominis plane (TAP) block in cesarean section is carried out by local anesthetics such as bupivacaine or ropivacaine with a limited duration of analgesia. The addition of adjuvants such as clonidine and dexmedetomidine has increased the duration of postoperative analgesia. Aims, Settings and Design: The aim of this study was to compare the duration of postoperative analgesia between clonidine and levobupivacaine (0.25%) versus levobupivacaine (0.25%) alone in the bilateral TAP block after lower segment cesarean section (LSCS). Materials and Methods: In this prospective randomized double-blind interventional study, 100 parturients undergoing elective LSCS were included in the study. Patients were randomly divided to receive either 20-ml levobupivacaine 0.25% (Group A; n = 50) or 20-mL levobupivacaine (0.25%) +1-μg/kg clonidine bilaterally (Group B; n = 50) in TAP block in a double-blind fashion. The total duration of analgesia, patient satisfaction score, postoperative visual analog scale score, total requirement of analgesics in the first 24 h, and the side effects of clonidine were observed. Statistical Analysis: Statistical tests were conducted using SPSS. P < 0.05 was considered as statistically significant. Results: A total of 92 patients were analyzed. Duration of analgesia was significantly longer in Group B (17.94 ± 0.76 h) compared to Group A (7.16 ± 0.41 h) (P < 0.001). Mean consumption of tramadol was 197.77 ± 14.90 mg and 8.889 ± 28.77 mg in Groups A and B (P < 0.001), respectively. All patients in Group B were extremely satisfied while those in Group A were satisfied (P < 0.01). None of the patients experienced hypotension or bradycardia. Conclusion: The addition of clonidine 1 μg/kg to 20-ml levobupivacaine 0.25% in TAP block bilaterally for cesarean section significantly increases the duration of postoperative analgesia, decreases postoperative rescue analgesic requirement, and increases maternal comfort compared to 20 ml of levobupivacaine 0.25% alone.

https://ift.tt/2EEzGbD

Comparative evaluation of different doses of intravenous dexmedetomidine on hemodynamic response during laryngoscopy and endotracheal intubation in geriatric patients undergoing spine surgeries: A prospective, double-blind study

Ravi Kumar Keshri, Mukesh Kumar Prasad, Amit Kumar Choudhary, Gurdeep Singh Jheetay, Yashowardhan Singh, Kali Kapoor

Anesthesia: Essays and Researches 2018 12(4):897-902

Background: Dexmedetomidine, a selective alpha 2 (α2)-adrenergic receptor agonist, has been used to blunt the hemodynamic response associated with laryngoscopy and tracheal intubation, which is a common concern for the anesthesiologist, especially in high-risk patients and geriatric age group. Aim and Objectives: The current study is to evaluate and compare the effects of different doses of dexmedetomidine in controlling hemodynamic response during tracheal intubation in geriatric patients. Materials and Methods: After getting approval from the Ethical Committee, 90 patients of the American Society of Anesthesiologist Physical Status Classes I and II, aged ≥60 years, were randomly assigned into three groups: Group I (normal saline, n = 30), Group II – dexmedetomidine (0.50 μg/kg, n = 30), and Group III – dexmedetomidine (1.00 μg/kg, n = 30). Dexmedetomidine was infused for 10 min before induction. Data were recorded as before infusion (T0), at the end of infusion (T1), before tracheal intubation (T2), at the moment of tracheal intubation (T3) 5 min after tracheal intubation (T4), and 10 min after tracheal intubation (T5). Modified observer's assessment of alertness/sedation scale score was observed at the time of T0 and T1. All statistical analyses were done using SPSS version 22. Results: Mean systolic blood pressure was statistically significantly (P < 0.05) more among Group I compared to Group II and III at T2, T3, and T4. Mean heart rate (HR) value was significantly (P < 0.05) more among Group I compared to Group III from T1 to T5, whereas there was no significant change in HR between Group I and Group II and at T4 and T5 h was comparable in Group II and Group III. Conclusion: This study concluded that more acceptable hemodynamic changes were seen with 0.50 μg/kg dexmedetomidine when compared with 1.0 μg/kg dexmedetomidine during intubation. A lower dose besides being cost-effective is also free of side effects associated with the higher dose of 1 μg/kg dexmedetomidine.

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Comparison between multisite infiltration analgesia versus adductor canal block for pain management in total knee arthroplasty: A prospective study

AV Gurava Reddy, Mohammed Shafeekh, Sukesh Rao Sankineani, Khubchand Jhakotia, Muralidhar Sagi, Deepesh Daultani, Vishesh Khanna, Krishna Kiran Eachempati

Anesthesia: Essays and Researches 2018 12(4):774-777

Background: Severe acute postoperative pain after total knee arthroplasty (TKA) may cause significant morbidity to patients. Recent techniques such as peripheral nerve blocks have shown promising hope in providing appropriate pain control without systemic side effects. Adductor canal block (ACB) and multisite infiltration analgesia (MIA) are two techniques that are proven to be effective individually. Aim: This study aims to compare the efficacy of ACB versus MIA in postoperative analgesia and functional recovery after unilateral knee arthroplasty. Settings and Design: A prospective study was conducted between July 2016 and December 2016 involving 200 patients undergoing unilateral TKA. Materials and Methods: Patients were either administered MIA (Group I, n = 100 patients) or ACB (Group II, n = 100 patients). All the patients were assessed for severity of pain by visual analog scale (VAS) at 8, 24, and 48 h postoperatively and knee range of motion (ROM) at 48 h after surgery. Statistical Analysis: The Statistical Package for the Social Sciences (SPSS 19.0, SPSS Inc., Chicago, IL, USA) was used for descriptive and inferential analysis. Results: Patients who received MIA showed significantly better VAS scores 8, 24, and 48 h after surgery. Furthermore, this subset of patients showed a marginally better ROM postoperatively. However, there was no difference number of patients requiring rescue analgesia for breakthrough pain or technique-related problems between both groups. Conclusion: This study demonstrates that MIA is a safe technique that provides effective analgesia at 8, 24, and 48 h postoperatively. This leads to faster rehabilitation compared to ACB in patients undergoing TKA.

https://ift.tt/2EBOvLX

Endocavitary versus linear array high-frequency probe in ultrasound-guided supraclavicular subclavian vein central access

Maged Labib Boules

Anesthesia: Essays and Researches 2018 12(4):873-878

Background: Vascular access is a top priority in the critically ill patients. Cannulation – venous and/or arterial – is the first step in any emergency situation. Ultrasound (US)-guided vascular cannulation was found to have a higher success rate and a decreased incidence of mechanical complications as compared with the landmark one. Aim: This study aims to compare subclavian vein (SCV) access through supraclavicular (SC) approach by endocavitary (EC) probe technique versus linear array high-frequency probe technique. Settings and Design: A prospective, randomized controlled study conducted on 60 patients. Patients and Methods: Study was carried out on 60 adult patients presenting for the surgical intensive care unit in Fayoum University Hospital. Patients were classified into two groups: Group (A) (n = 30): Catheter was inserted using the EC probe and Group (B) (n = 30): Catheter was inserted using the linear array high-frequency probe. Statistical Analysis Used: Student's t-test was applied for calculation of normally distributed variables and Mann–Whitney U-test for nonnormally distributed variables. Categorical data between the groups were compared using Chi-squared test. P < 0.05 indicated a statistically significant difference. Results: The frequency of successful cannulation of the SCV at first attempt was significantly higher in Group A compared to Group B (P = 0.044). The number of attempts and the time needed for venous access were significantly lower in Group A compared to Group B (P = 0.038, <0.001 respectively). No significant difference was found regarding the incidence of posterior wall puncture, arterial puncture, or hematoma, (P = 0.671, 0.055, 1 respectively). Conclusion: The use of EC probe technique for Subclavian venous access through the SC approach significantly increased the success rate compared to the linear array high-frequency probe.

https://ift.tt/2EuLKv5

Intravenous low dose fentanyl versus lignocaine in attenuating the hemodynamic responses during endotracheal intubation: A randomized double-blind study

Ranjithkumar R Thippeswamy, Supreeth R Shetty

Anesthesia: Essays and Researches 2018 12(4):778-785

Background: The laryngotracheal stimulation is known to cause reflex sympathoadrenal response with a marked increase in heart rate and blood pressure. Arrhythmias can be precipitated. The harmful nature of this response has been noted in patients at risk. Therefore, it is important to find an effective means of attenuating sympathetic response to laryngoscopy and intubation. The present study is undertaken to determine the efficacy of intravenous low dose fentanyl (2 μg/kg) and lignocaine (1.5 mg/kg) in attenuating hemodynamic response to laryngoscopy and tracheal intubation. Aim: The aim of this study is to compare the efficacy of intravenous low dose fentanyl (2 μg/kg) versus lignocaine (1.5 mg/kg) in attenuating the hemodynamic responses during endotracheal intubation. Settings and Design: This was double-blinded randomized controlled study. Materials and Methods: After obtaining institutional ethical clearance and informed consent, a total of 90 patients, with the American Society of Anaesthesiologists Physical Status I and II scheduled for elective surgeries, were selected randomly and divided into three groups of 30 each. The general anesthesia technique was standardized for all three groups as follows: Group 1 (control-received normal saline), Group 2 (Lignocaine 1.5 mg/kg), and Group 3 (Fentanyl 2 μg/kg). Heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure were recorded preinduction, postinduction and 1,3,5,7, and 10 min after endotracheal intubation. Statistical Analysis: Descriptive data presented as mean ± standard deviation and in percentage. Multiple group comparisons were made using one-way ANOVA followed by unpaired "t" test for pairwise comparison. "P" <0.05 was considered for statistical significance. Results: The fentanyl group showed significantly lesser rise (26%) in heart rate compared to lignocaine (33%) (P = 0.018) and control group (42.5%) (P = 0.000). The lignocaine group showed lesser rise in systolic blood pressure (14.5%) compared to control group (20%) (P = 0.000) at intubation. The fentanyl group showed a significant decrease in systolic blood pressure after administration, which came back to normal at 7 min following intubation and again decreased 10 min after intubation. Conclusion: Lignocaine and fentanyl both attenuated the rise in heart rate, though fentanyl was better. Lignocaine attenuated the rise in blood pressure with intubation whereas fentanyl prevented it totally. Of the two drugs low dose fentanyl 2 μg/kg i. v. bolus provides a consistent, reliable, and effective attenuation as compared to lignocaine 1.5 mg/kg i. v. bolus.

https://ift.tt/2ECXaO6

A comparative study of transversus abdominis plane block versus quadratus lumborum block for postoperative analgesia following lower abdominal surgeries: A prospective double-blinded study

G Dilip Kumar, N Gnanasekar, Pranjali Kurhekar, T Krishna Prasad

Anesthesia: Essays and Researches 2018 12(4):919-923

Context: Traditional truncal blocks are devoid of visceral analgesia. Quadratus lumborum (QL) block has shown greater efficacy in providing the same. Aims: This study was done to compare the efficacy of transversus abdominal plane (TAP) block versus QL block in providing postoperative analgesia for lower abdominal surgeries. Settings and Design: This was a prospective, randomized, double-blinded study. Subjects and Methods: Seventy adult patients were randomly allocated into two groups, where Group A received TAP block with 20 ml of 0.25% ropivacaine on each side (n = 35) and Group B received QL block with 20 ml of 0.25% ropivacaine on each side (n = 35). The time of block, duration of surgery, Numerical Pain Intensity Scale (NPIS) score at the 1st, 2nd, 4th, 8th, 12th, 16th, and 24th postoperative hours, and the total analgesic drug requirements were noted and compared between the two groups. Statistical Analysis Used: Data were analyzed with SPSS version 23 (IBM corporation, Armonk, NY, USA) with independent t-test and Chi-square test as appropriate. P < 0.05 was considered statistically significant. Results: The time for first analgesic requirement was 243.00 ± 97.36 min and 447.00 ± 62.52 min and the total analgesic consumption (morphine in mg) was 5.65 ± 1.55 and 3.25 ± 0.78 in Group A and Group B, respectively, both of which were statistically significant (P < 0.01). There was a significant difference in postoperative pain scores (NPIS scale 0–10) at rest, between the two groups, up to 16 h. Conclusions: Patients who received QL block had a significant improvement in postoperative pain relief with reduced consumption of opioids.

https://ift.tt/2Es3IhT

Comparison of two different volumes of ropivacaine used in nerve stimulator guided inter-scalene block for arthroscopic shoulder surgery – A randomized controlled trial

Ghanshyam Kumar Sahu, Dharam Singh Meena, Suman Saini, Ajisha Aravindan, Priyankar Kumar Datta

Anesthesia: Essays and Researches 2018 12(4):786-791

Background: This study was conducted to compare the analgesic efficacy of 10 ml versus 20 mL of 0.5% ropivacaine in nerve stimulator guided interscalene brachial plexus block, in patients undergoing arthroscopic shoulder surgery. Methods: A total of 70 American Society of Anesthesiologists physical status classes 1 and 2 patients, aged 18–65 years, undergoing unilateral arthroscopic shoulder surgery, were randomized into two groups. Group A received single shot inter-scalene block with 20 mL of 0.5% ropivacaine whereas Group B received the same with 10 mL. The primary outcome was difference in the total postoperative fentanyl consumption over 24 h. Secondary outcomes were difference in block onset, intra-operative hemodynamic parameters, intra-operative fentanyl consumption, duration of effective analgesia, visual analogue scale (VAS) scores at various time intervals, duration of motor block, and incidence of hemidiaphragmatic (HD) palsy. Results: Total 24 h fentanyl consumption was significantly higher in Group B (558 ± 112 mcg) compared to Group A (296 ± 88 μg). Block onset was slower in Group B than Group A. There was no difference in intra-operative fentanyl consumption. Postoperative VAS scores were significantly higher in Group B compared to Group A, at 6 h and thereafter. Duration of motor block was significantly shorter in Group B (6.25 ± 1.25 h) compared to Group A. HD palsy was seen in all the cases in both the groups. Conclusion: Single shot nerve stimulator guided interscalene block with 10 ml of 0.5% ropivacaine was inferior to 20 mL of 0.5% ropivacaine with respect to postoperative analgesic efficacy.

https://ift.tt/2EEcXfM

Erratum: Assessment of relationship between vitamin D deficiency and pain severity in patients with low back pain: A retrospective, observational study

Anesthesia: Essays and Researches 2018 12(4):970-970



https://ift.tt/2EvfdF5

Evaluation and comparison of clonidine and dexmedetomidine for attenuation of hemodynamic response to laryngoscopy and intubation: A randomized controlled study

Sana Yasmin Hussain, Abhijit Karmarkar, Dhruv Jain

Anesthesia: Essays and Researches 2018 12(4):792-796

Background: Laryngoscopy and tracheal intubation are noxious stimuli which evoke a transient but marked sympathetic response. Alpha-2 adrenoceptor agonists attenuate the sympathoadrenal responses by inhibiting noradrenaline release. Aim: This study aims to evaluate and compare the effect of intravenous dexmedetomidine and clonidine on cardiovascular response resulting from laryngoscopy and endotracheal intubation. Settings and Design: This was a prospective randomized controlled study carried out in the operating room. Materials and Methods: Ninety American Society of Anesthesiologists Physical Status I and II patients were randomly allocated into three groups, that is, Group C (clonidine 2 μg/kg), Group D (dexmedetomidine 1 μg/kg), and Group S (normal saline) infused over 10 min. Blood pressures – systolic (SBP) and diastolic (DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded after drug administration and intubation at subsequent intervals. Statistical Analysis Used: Quantitative data were analyzed using ANOVA test (with post hoc Bonferroni correction for intragroup comparison). Qualitative data were analyzed using Chi-square test. P < 0.05 was considered statistically significant. Results: HR, SBP, DBP, and MAP were lower in Group C and D compared to Group S at all times measured. HR was significantly lower in Group D compared to Group C after drug infusion. At 1 min after intubation, SBP and MAP were lower in Group D compared to Group C. At 3, 5, and 10 min after intubation, SBP, DBP, and MAP were lower in Group D compared to Group C. Conclusion: There was significant reduction in hemodynamic response by dexmedetomidine and clonidine as compared to controls. Furthermore, attenuation of the pressor response to intubation was better following premedication with dexmedetomidine than with clonidine.

https://ift.tt/2EzRC7j

Comparison of nebulized ketamine with nebulized magnesium sulfate on the incidence of postoperative sore throat

Sivakumar Segaran, Arish T Bacthavasalame, Ranjan R Venkatesh, Mamie Zachariah, Sagiev Koshy George, Ravichandran Kandasamy

Anesthesia: Essays and Researches 2018 12(4):885-890

Background: Postoperative sore throat (POST) is a known complication following general anesthesia requiring endotracheal intubation. Its incidence ranges from 21% to 65% and remains the eighth most undesirable postoperative event. Various measures have been tried to decrease the incidence of sore throat with various success rates. Aim: This study aimed at reducing the incidence of POST with ketamine and magnesium sulfate nebulization. Settings and Design: This study is a prospective randomized, double-blinded study. Materials and Methods: After Institutional Ethics Committee approval and written informed consent, 80 patients who fulfilled the inclusion and exclusion criteria were randomly divided into two groups to receive magnesium sulfate 250 mg in 5 ml saline in Group A and ketamine 50 mg in 5 ml saline nebulization in Group B before the start of general anesthesia. All patients received standard anesthesia protocol. After extubation, all patients were enquired about the incidence and severity of sore throat at 0, 2, 4, 6, and 24 h. Statistical Analysis Used: Paired t-test and Wilcoxon signed-rank test were used to compare hemodynamic variables and Chi-square test to compare the incidence and severity of sore throat. Results: There were no differences in the demographic profile, duration of laryngoscopy, time taken to intubate, and duration of surgery between the two groups. The incidence and severity of sore throat were significantly decreased in ketamine group at 4 and 6 h when compared to magnesium sulfate group. Conclusion: Nebulization with ketamine 50 mg significantly decreases the incidence of POST when compared to magnesium sulfate 250 mg.

https://ift.tt/2EwaPpp

A prospective study on operation theater utilization time and most common causes of delays and cancellations of scheduled surgeries in a 1000-bedded tertiary care rural hospital with a view to optimize the utilization of operation theater

Shraddha Vidyadhar Naik, Vithal Krishna Dhulkhed, Rewa Hemant Shinde

Anesthesia: Essays and Researches 2018 12(4):797-802

Background: The operation theater (OT) complex is a costly component of a hospital budget expenditure. This area of hospital activity requires maximum utilization to ensure optimum cost benefit. To achieve a high level of utilization in the OT, it is necessary to efficiently coordinate number of activities and personnel. Methods: This study was conducted in a 1000-bedded tertiary care teaching hospital in rural maharashtra over aperiod of two months. The OT complex consists of eight major OTs. Normal working hours for routine scheduled cases on all working days except Sundays and public holidays. Results: Total study period consisted of 96 working days. There were a total of eight OT tables of various specialties, and parameters were observed during the routine hours excluding Sundays and holidays. The total procedure time was maximum for ENT followed by orthopedics and least for obstetrics. Room turnover time was maximum for obstetrics followed by general and oncosurgery. Case delays were maximum in general surgery and least for ophthalmology. The most common reason for delay in starting the operation table was patient getting shifted late from the ward and administrative causes. The most prominent reasons for cancellation were lack of operating room time followed by medical reasons of the patient. Conclusion: We concluded that most of the causes of delays and cancellations of surgeries were avoidable with proper preoperative planning and optimization of patients and resources and good communication between surgeon anesthesiologists and the nursing staff.

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Practice pattern of fresh gas flow and volatile agent choices among anesthesiologists working in different Indian hospitals: An online survey

Mayank Kumar, Mamta Sinha, Habib Md Reazaul Karim, Chinmaya Kumar Panda, Subrata Kumar Singha

Anesthesia: Essays and Researches 2018 12(4):907-913

Background: Fresh gas flow (FGF) during volatile inhalational agent-based anesthesia is a concern for many reasons. Advancement in anesthesia workstation (WS) and monitoring of anesthesia gas concentrations has led to the feasibility of lower flow safely. However, the practice pattern is not yet well known. The information can help us in better protocol formation. Aim: The survey was aimed to know the prevailing practice pattern of FGF and volatile agent choices and compare them among anesthesiologists of different working setups and experiences. Materials and Methods: With approval, the present cross-sectional survey was conducted using SurveyMonkey® software from January 2018 to May 2018. Anesthesiologists working in different organizations across India were approached through E-mail and WhatsApp. Anonymous responses were collected, expressed in number and percentage scale, as well as compared using INSTAT software and appropriate tests; P < 0.05 was considered statistically significant. Results: A total of 251 (15.2%) responses were received and 249 were analyzed. Overall, 87% of respondents were using anesthesia WS and 71% were using nitrous oxide as balance gas. The FGF of <600 mL/min was highest with desflurane. Minimum alveolar concentration (MAC) monitoring was very poor in nonteaching (NT) hospitals as compared to teaching hospitals; P < 0.0001. The Boyle's machine was more common in use in NT hospitals as compared to medical colleges and corporate hospitals; P < 0.0001. Conclusion: Low-flow anesthesia (LFA) use is still suboptimal, and there are ample opportunities to increase and optimize the FGF used. The use of Boyle's machine is associated with higher flow use. MAC monitoring and LFA use are poor in NTs.

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The effect of intravenous dexamethasone on intraoperative and early postoperative pain in lumbar spine surgery: A randomized double-blind placebo-controlled study

Mamta Sharma, Shikha Gupta, Shobha Purohit, Amit Kumar Goyal

Anesthesia: Essays and Researches 2018 12(4):803-808

Background: The surgical procedures of spine are generally associated with intense pain in the postoperative period. Opioids are commonly used for perioperative analgesia but are associated with many side effects. Co-analgesic drugs are used to decrease these side effects. One such supplemental drug is dexamethasone. Its strong anti-inflammatory effect contributes to perioperative analgesia. Aim: This study was done to evaluate the effect of intravenous (i.v.) dexamethasone on intraoperative and early postoperative pain in lumbar spine surgery. Settings and Design: This was a hospital-based randomized, double-blind, placebo-controlled study, done between June 2016 and December 2016 after permission of institutional ethical committee. Materials and Methods: This Study was conducted on 60 patients undergoing lumbar spine surgery, and randomization was done in two groups. Group A (study) received dexamethasone 2 ml (8 mg) i.v. and Group B (control) received 2 ml normal saline. Anesthesia technique and rescue analgesia regimen were standardized. Intraoperative pain was assessed by hemodynamic variability and postoperative pain by verbal rating score. All the quantitative data were analyzed using Student's t-test and all the qualitative data using Chi-square test. Results: Heart rate in the control group was significantly higher than the study group during intraoperative period. Mean pain scores in the early postoperative period were significantly higher in control group than the study group (P < 0.001). Mean time of first rescue analgesic in the postoperative period was 149.17 min and 34.33 min in the study group and control group, respectively (P < 0.001). Conclusion: Hence, we conclude that administration of 8 mg of preoperative i.v dexamethasone was effective in reducing intraoperative and early postoperative pain in the lumbar spine surgery.

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Tunneling does not prevent dislodgment of epidural catheters: A randomized trial

Hussein Y Abukhudair, Esam N Farhoud, Khalid M Abufarah, Abdullah T Obaid, Ola A Yousef, Aqel M Aloqoul

Anesthesia: Essays and Researches 2018 12(4):930-936

Background: Epidural analgesia is preferred in postoperative pain control, but dislodgment is a major factor for failure. Tunneling is well known to control displacement of catheters. In this study, we evaluated if we can depend on tunneling in preventing dislodgment of epidural catheters. Aims: The aim is to study if tunneling is effective and safe in reducing the rate of epidural catheters' dislodgment. Setting and Design: The study was carried out at a single tertiary cancer center. The trial was parallel, simple randomized, controlled, and single blind. Allocation of treatments was generated using random number tables. Subjects and Methods: Two hundred patients undergoing major surgeries were randomized. Epidural catheters were affixed to the skin through subcutaneous tunneling to a length of 5 cm or using standard adhesive tape without tunneling. Patients were on follow-up for 6 days postsurgery according to policy. Statistical Analysis Used: Categorical variables were analyzed by Chi-square and Fisher's exact test. Student t-test was used for continuous variables. Results and Conclusion: A total of 200 patients were randomized, 92 patients received tunneled catheters and 108 received nontunneled catheters. Patients were between 20 and 85 years; 63% were male. The mean days of epidural analgesia were similar in both groups (2.7 compared to 2.5 days). About 7.6% of epidurals were dislodged in the tunneled group compared to 10.2% in the nontunneled group (P = 0.699). No differences were identified in the incidence of pain or adverse events between the groups. Tunneling did not improve the rates of dislodgment in epidural catheters. There were no safety concerns associated with tunneling epidural catheters.

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Addition of dexmedetomidine to ropivacaine in subcostal transversus abdominis plane block potentiates postoperative analgesia among laparoscopic cholecystectomy patients: A prospective randomized controlled trial

B Sarvesh, BT Shivaramu, Kanchan Sharma, Amit Agarwal

Anesthesia: Essays and Researches 2018 12(4):809-813

Context: Laparoscopic cholecystectomy is associated with moderate intensity postoperative pain especially in the early postoperative period. Transversus abdominis plane (TAP) block has been shown to reduce pain scores and analgesic requirements after abdominal surgery. Aims: We hypothesized that a subcostal TAP block with ropivacaine and dexmedetomidine will prolong the duration of postoperative analgesia following laparoscopic cholecystectomy. Settings and Design: This prospective, randomized study was done in 60 patients undergoing laparoscopic cholecystectomy surgery done at a tertiary care institution. Subjects and Methods: Sixty patients undergoing laparoscopic cholecystectomy were randomized into two groups to receive either bilateral ultrasonography-guided subcostal TAP blocks with 18 mL 0.375% ropivacaine and 2 ml of normal saline (n = 30, Group R) or 18 ml. 375% ropivacaine with 0.5 μg/kg dexmedetomidine 2 mL (n = 30, Group RD). Numerical rating scale was measured postoperatively to primarily assess the pain severity and analgesic requirement for the first 24 h, hemodynamic parameters, and adverse effects were recorded. Statistical Analysis Used: Categorical data were analyzed using Chi-square test/Fisher's exact test and quantitative data were analyzed using Student's t-test and the Mann–Whitney U-test. Results: The study group (Group RD) had significantly prolonged postoperative analgesia (485.6 min) as compared to Group R (289.83 min). Moreover, consumption of morphine over 24-h period is significantly less in Group RD (14.5 mg) as compared to Group R (28.5 mg). Conclusions: Addition of dexmedetomidine to ropivacaine in TAP block prolongs postoperative analgesia and reduces opioid consumption without any major adverse effects.

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Pantoea dispersa it the next emerging “monster” in our intensive care units? A case report and review of literature

Mridul Panditrao, Minnu Panditrao

Anesthesia: Essays and Researches 2018 12(4):963-966

Hospital-acquired infections and their consequences are the main cause of morbidity/mortality in critically ill and immunocompromised patients. It becomes interesting when an unusual and uncommon microorganism is found to be the causative agent, rather than the known commensals and opportunists. We present such a case, when a multiparous female, in post lower uterine segment cesarean section period presented with fulminant septic shock, hepatic failure, coagulopathy, and ventilator-associated pneumonitis. The organism grown in the tracheal secretions turned out to be an uncommon, unusual Gram-negative Coccobacillus by the name of Pantoea dispersa, resistant to almost all the conventional antimicrobial agents. In spite of all the efforts, the patient could not be saved. However, the case has opened up a virtual "Pandora's box" of questions. Are these microorganisms, known plant pathogens, really harmful to humans? Are they commensals or virulent opportunists? Are we once again on the way to a new "Acinetobacter," like near-epidemic? This is an attempt to try and find some insight about this presently uncommon and not well known genus of Pantoea! We have tried to trace and review the related available literature in the clinical medicine.

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Topographic sonoanatomy of infraclavicular brachial plexus: Variability and correlation with anthropometry

Abhyuday Kumar, Ajeet Kumar, Chandni Sinha, Chhavi Sawhney, Rajnish Kumar, Debesh Bhoi

Anesthesia: Essays and Researches 2018 12(4):814-818

Objective: The aim of the study was to assess the effectiveness of ultrasound in analyzing topographic relationship of nerve cords with axillary artery at lateral infraclavicular level, their variations, and the distance from the skin and to correlate findings with anthropometric parameters. Materials and Methods: Two hundred patients aged 18–75 years were enrolled for the study after informed written consent. A 7–12 MHz linear ultrasonic transducer was used for scanning of the brachial plexus at lateral infraclavicular fossa. The results of the cord positions were expressed on a 12-section pie chart, and the number of arteries and veins was reported. Measurements included the vertical distance from the upper part of the artery to the skin, diagonal distance to the apical corner of the ultrasound image, and distances from center of cords to the center of artery. Age, sex, weight, height, body mass index, and biceps girth were recorded. Data were expressed as mean with standard deviation or frequency and percentage for categorical variables, and statistical analysis was done using correlation analysis and two-sample t-test. Results: The most frequent positions of the cords were observed in 2–4 sections (92%) for the medial cord, 6–7 sections (92%) for the posterior cord, 10–11 sections (89%) for the lateral cord, and 4–5 sections (95%) for the axillary vein. More than one axillary vein was seen in 12.5% and two axillary arteries were seen in 1.5% of cases. Cord visibility and distance between artery and apical corner of the ultrasound image correlated with anthropometric parameters. Conclusions: A topographical study of brachial plexus at lateral infraclavicular fossa showed anatomical variations and abnormal vascular formations. This sonoanatomic knowledge can be helpful in improving safety and success of nerve blocks.

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Effect and safety of labor epidural analgesia with intermittent boluses of 0.1% bupivacaine with fentanyl on fetal and maternal outcomes and wellbeing

Rajesh Kesavan, Sunil Rajan, Lakshmi Kumar

Anesthesia: Essays and Researches 2018 12(4):769-773

Background: Labor analgesia has been shown to have few undesirable effects on the course and outcome of the labor as well as on the fetal well-being. Aims: This study aims to assess neonatal outcome following lumbar epidural analgesia with intermittent boluses of 0.1% bupivacaine with fentanyl. The secondary objectives included assessment of maternal analgesia, complications, and outcome of labor. Setting and Design: Prospective observational study conducted at a tertiary care teaching institute. Subjects and Methods: Sixty-three patients for labor epidural analgesia were recruited. Epidural catheter was inserted in L4–L5 or L3–L4 interspace. After confirmation of the position of catheter, 3 mL of 0.5% bupivacaine with 20 μg of fentanyl made to 15 mL was administered. After 30 min, efficacy of analgesia was assessed by visual analog scale (VAS). The same bolus dose was repeated after 90 min if the patient complained of pain. A maximum of five top-up doses were allowed. Statistical Test Used: Mean and standard deviation, number and percentage Results: After 30 min of first bolus dose, 93.3% had VAS score of <4. More than 90% patients had adequate analgesia till 4th epidural bolus. During contraction stress test, only two fetuses had late deceleration. About 80% and 98.3% newborns had Apgar of >7 at 1 and 5 min, respectively. Umbilical cord blood pH was ≥7.1 in 98.3% neonates with base excess of >−12. 58.3% delivered normally, 23.3% had instrumental vaginal delivery, and 18.3% required cesarean section. Conclusion: Lumbar epidural analgesia with 0.1% bupivacaine with fentanyl provides optimal neonatal outcome, labor analgesia, and labor outcome.

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Clinical audit on the practice of documentation at preanesthetic evaluation in a specialized university hospital

Yophtahe B Woldegerima, Semira D Kemal

Anesthesia: Essays and Researches 2018 12(4):819-824

Background: Performing preanesthetic evaluation, documenting, and keeping readily accessible record are responsibilities of anesthetists. Documentation can improve overall patient outcome. It also has an irreplaceable role in medico-legal aspects. Documentation is one of the challenges of providing quality care. Aim: The aim of this study was to evaluate the quality of documentation practice during preanesthetic visits. Materials and Methods: This clinical audit was conducted in the University of Gondar Hospital. Predefined 22 practice quality indicators were prepared according to modified global quality index. Statistical Analysis: Descriptive statistics was performed using SPSS version 20. Results: A total of 122 preanesthetic evaluation tools (PAETs) were reviewed. None of PAETs found fully completed according to the indicators. Trends differ between elective and emergency conditions. Indicators with high completion rate (>90%) were signed a consent, medical history, history of medication, allergy, anesthesia and surgery, cardiopulmonary examination, airway examination, preoperative diagnosis, and planned procedure. Anesthetic plan, vital signs, a name, per-oral status, premedication, and age were found with below average (<50%) completion rate. Conclusions: Documentation practice during the preanesthetic visit was below the standard. Unclear instructions should be replaced with standardized contents. Providing regular trainings on clinical documentation for students and staffs, and introducing modern electronic-based documentation system and preanesthetic clinics may improve the practice.

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Comparison between colloid preload and coload in bone cement implantation syndrome under spinal anesthesia: A randomized controlled trial

Ayca T Dumanlı Özcan, Elvin Kesimci, Cemile Altın Balcı, Orhan Kanbak, Hülya Kaşıkara, Abdulkadir But

Anesthesia: Essays and Researches 2018 12(4):879-884

Background: Bone cement implantation syndrome (BCIS) is characterized by hypoxia hypotension cardiac arrest. There is not any research that investigated the hemodynamic effects of colloid use during and before cement implantation regarding BCIS development. Aims: We aimed to compare the effects of colloid preloading before or coloading simultaneously at cement implantation on BCIS development and hemodynamic parameters in patients who underwent total knee arthroplasty. Settings and Design: This is a prospective, randomized, clinical trial with the participation of 109 patients over 60 years of age and patients physical status American Society of Anesthesiologists Classes I and II to undergo knee surgery. The patients were administered spinal anesthesia, divided into three groups. Subjects and Methods: The patients in Group I were infused 8 mL/kg hydroxyethyl starch (130/0.4) 20 min before the cement implantation, those in Group II were infused the same simultaneously during cement implantation. Group III was infused 8 mL/kg/h sodium chloride during the anesthesia management. Hemodynamic parameters of the patients were recorded at before and after cement implantation and once the tourniquet was removed. Statistical Analysis Used: The descriptive statistics were presented as the mean ± standard deviation for normally distributed variables, as the median for nonnormally distributed variables, and as the number of cases and (%) for nominal variables. Pearson's Chi-square test and Fisher's exact test were used in the analysis of categorical variables. Results: Compared to the control group, Groups I and II were hemodynamically more stable. The development of moderate hypoxia during cement implantation was significantly different between the study groups (P < 0.05). Conclusions: We suggest that avoiding intravascular volume depletion by using the colloids, particularly in elderly patients, is important for preventing from the BCIS.

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Undiagnosed hypertrophic obstructive cardiomyopathy during transcatheter aortic valve replacement: a case report

Transcatheter aortic valve replacement is indicated for severe symptomatic aortic stenosis in patients who have a very high or prohibitive surgical risk as assessed pre-procedurally by the Society of Thoracic ...

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Evaluation of tooth wear and associated risk factors: A matched case–Control study p. 1607 C Atalay, G Ozgunaltay DOI:10.4103/njcp.njcp_203_18 Aim: The aim of this case–control study was to compare the associated risk factors between adults with tooth wear (TW) and age- and sex-matched controls without TW. Methods: Fifty participants with TW and 50 age- and sex-matched controls participated in this study. A questionnaire was prepared to assess oral healthcare and consumption of erosive food and drinks. All participants completed the diet analysis forms. Saliva characteristics were evaluated with GC Saliva-Check BUFFER test. Examiners measured the TW of case patients, using the TW index. Data were statistically analyzed using Chi-square and Mann–Whitney U-tests (P < 0.05). Results: Individuals in the case group brush their teeth more often (P < 0.05). The difference in erosive food consumption between the case and control groups was significant (P < 0.05). There was no erosive

Evaluation of tooth wear and associated risk factors: A matched case–Control study p. 1607
C Atalay, G Ozgunaltay
DOI:10.4103/njcp.njcp_203_18  
Aim: The aim of this case–control study was to compare the associated risk factors between adults with tooth wear (TW) and age- and sex-matched controls without TW. Methods: Fifty participants with TW and 50 age- and sex-matched controls participated in this study. A questionnaire was prepared to assess oral healthcare and consumption of erosive food and drinks. All participants completed the diet analysis forms. Saliva characteristics were evaluated with GC Saliva-Check BUFFER test. Examiners measured the TW of case patients, using the TW index. Data were statistically analyzed using Chi-square and Mann–Whitney U-tests (P < 0.05). Results: Individuals in the case group brush their teeth more often (P < 0.05). The difference in erosive food consumption between the case and control groups was significant (P < 0.05). There was no erosive effect of acidic food when consumed as a main meal or a snack (P > 0.05). Although there was no difference between stimulated saliva flow rate and buffering capacity between groups, the difference between the resting saliva flow rates and pH values was significant (P < 0.05). Although some wear was seen on buccal/labial surfaces of teeth, cervical and occlusal/incisal surfaces were scored higher. No TW was observed on palatal/lingual surfaces. The cervical surfaces of mandibular premolars and incisal surfaces of anterior teeth were most affected. Conclusion: Of the factors investigated, TW in the case group was correlated with consumption of acidic foods, lower salivary flow rate, and pH.
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Anal melanoma: Outcomes of current surgical approaches p. 1622 S Kaya, M Kement, YE Altuntas, O Altin, A Seker, S Mazmanoglu, L Kaptanoglu, N Bildik, HF Kucuk DOI:10.4103/njcp.njcp_254_18 Aim: In this study, we aimed to evaluate the clinical characteristics and outcomes of the patients with anal melanoma (AM), who underwent surgical treatment. Materials and Methods: This study was conducted in Kartal Training and Research Hospital between January 2010 and December 2017. All patients, who underwent surgical resection with a diagnosis of AM, were enrolled. Results: A total of 10 patients were examined, 8 of them were females, and their average age was 69.2 years (range, 47–85 years). Abdominoperineal resection (APR) was performed in five (50%) patients, and local excision (LE) was performed in other five (50%) patients. Three patients (30%) had stage I disease, two (20%) had stage II disease, and five (50%) had stage III disease. All five patients in APR group had stage III disease

Anal melanoma: Outcomes of current surgical approaches p. 1622
S Kaya, M Kement, YE Altuntas, O Altin, A Seker, S Mazmanoglu, L Kaptanoglu, N Bildik, HF Kucuk
DOI:10.4103/njcp.njcp_254_18  
Aim: In this study, we aimed to evaluate the clinical characteristics and outcomes of the patients with anal melanoma (AM), who underwent surgical treatment. Materials and Methods: This study was conducted in Kartal Training and Research Hospital between January 2010 and December 2017. All patients, who underwent surgical resection with a diagnosis of AM, were enrolled. Results: A total of 10 patients were examined, 8 of them were females, and their average age was 69.2 years (range, 47–85 years). Abdominoperineal resection (APR) was performed in five (50%) patients, and local excision (LE) was performed in other five (50%) patients. Three patients (30%) had stage I disease, two (20%) had stage II disease, and five (50%) had stage III disease. All five patients in APR group had stage III disease. In the comparison of the survival period after surgery, the mean survival period of the APR group was 6.2 months (range, 1–16 months) while that of the LE group was 19.6 months (range, 7–43 months). Conclusion: LE with adjuvant radiation seems to offer good locoregional control without reducing the survival and may be an option of treatment for patients with small, superficial AM. However, APR should be offered for patients with locally advanced disease or as a salvage following recurrence.
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Rhabdomyoblastic differentiation in rosai dorfman disease of the orbit in a 12-year-old male p. 1670 E Ezeanosike, OB Ezeanosike, SI Akpan, CN Ezisi DOI:10.4103/njcp.njcp_262_17 Extranodal Rosai–Dorfman disease involving the orbit has been reported severally with extensive discourse on management strategies. However, rhabdomyoblastic differentiation coexisting with the disease is yet unreported. We present the clinical and histopathological features of a 12-year-old boy presenting with both. A 12-year-old boy was referred to our Ophthalmic Plastic Surgical Service with a 5-year history of bilateral, progressively enlarging eyelid, orbital masses causing proptosis, and severe cosmetic blemish. He had suffered vision loss to the right eye following trauma 2 years prior to the onset of the disease. Computed tomography of the orbits revealed preseptal and intraorbital components of well-defined multi-lobulated masses in both orbits. No significant nodal involvement was noted. He unde

Rhabdomyoblastic differentiation in rosai dorfman disease of the orbit in a 12-year-old male p. 1670
E Ezeanosike, OB Ezeanosike, SI Akpan, CN Ezisi
DOI:10.4103/njcp.njcp_262_17  
Extranodal Rosai–Dorfman disease involving the orbit has been reported severally with extensive discourse on management strategies. However, rhabdomyoblastic differentiation coexisting with the disease is yet unreported. We present the clinical and histopathological features of a 12-year-old boy presenting with both. A 12-year-old boy was referred to our Ophthalmic Plastic Surgical Service with a 5-year history of bilateral, progressively enlarging eyelid, orbital masses causing proptosis, and severe cosmetic blemish. He had suffered vision loss to the right eye following trauma 2 years prior to the onset of the disease. Computed tomography of the orbits revealed preseptal and intraorbital components of well-defined multi-lobulated masses in both orbits. No significant nodal involvement was noted. He underwent excision biopsy of the tumor in both eyes performed 1 month apart. A histopathologic diagnosis of the Rosai–Dorfman disease with focal areas of rhabdomyoblastic differentiation was made. He was treated postoperatively with a course of oral steroids with close observation for the rhabdomyoblastic differentiation. Rosai–Dorfman disease is an uncommon disease and has been reported to coexist with other pathologies. We highlight focal myoblastic differentiation within the excised tissues which may not necessarily warrant a diagnosis of rhabdomyosarcoma. Long-term follow-up of this patient is required to establish the safety of observation.
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Recurrent oral squamous papilloma in a pediatric patient: Case report and review of the literature p. 1674 OO Orenuga, Oluwo A, RT Oluwakuyide, AB Olawuyi DOI:10.4103/njcp.njcp_407_17 Squamous papillomas are common lesions of the oral mucosa. They are benign proliferating lesions often painless, slow growing and with a cauliflower appearance. However, its clinical appearance which sometimes mimics exophytic carcinoma, verrucous carcinoma or condyloma acuminatum raises concern when it occurs in the oral cavity. Squamous papilloma occurs predominantly in 30- to 50-year old's. However, they may be seen in children <10 years and accounted for 8% of all oral tumors in children. There is no sex predilection. It has a predilection for the tongue and soft palate, but may occur on any other surface of the oral cavity. Oral squamous papillomas have been associated with infection by the human papilloma virus (HPV). The present report is a case of a recurrent squamous papilloma of the hard pal

Recurrent oral squamous papilloma in a pediatric patient: Case report and review of the literature p. 1674
OO Orenuga, Oluwo A, RT Oluwakuyide, AB Olawuyi
DOI:10.4103/njcp.njcp_407_17  
Squamous papillomas are common lesions of the oral mucosa. They are benign proliferating lesions often painless, slow growing and with a cauliflower appearance. However, its clinical appearance which sometimes mimics exophytic carcinoma, verrucous carcinoma or condyloma acuminatum raises concern when it occurs in the oral cavity. Squamous papilloma occurs predominantly in 30- to 50-year old's. However, they may be seen in children <10 years and accounted for 8% of all oral tumors in children. There is no sex predilection. It has a predilection for the tongue and soft palate, but may occur on any other surface of the oral cavity. Oral squamous papillomas have been associated with infection by the human papilloma virus (HPV). The present report is a case of a recurrent squamous papilloma of the hard palate in a 5-year-old patient with a review of the literature.
http://www.njcponline.com/currentissue.asp?sabs=y

severe skeletal open bite using temporary anchorage devices p. 1678 WX Lv, S Chen, TM Xu, B Han DOI:10.4103/njcp.njcp_223_18 This case report presents the treatment and long-term follow-up of a patient with severe skeletal hyperdivergent open bite, Class II malocclusion, and a severely retruded chin. After failure of early treatment using high-pull headgear with a bite block during the early permanent dentition stage due to an unfavorable growth pattern, orthognathic surgery was proposed but rejected by the patient. Then, temporary anchorage devices were used to correct the occlusion and establish an acceptable overbite and overjet. The overall observation time was 8.5 years; the treatment time using fixed appliances was 3 years and 4 months. The achieved tooth position and occlusal relationship remained stable 2.5 years later without recurrence of the open bite.

severe skeletal open bite using temporary anchorage devices p. 1678
WX Lv, S Chen, TM Xu, B Han
DOI:10.4103/njcp.njcp_223_18  
This case report presents the treatment and long-term follow-up of a patient with severe skeletal hyperdivergent open bite, Class II malocclusion, and a severely retruded chin. After failure of early treatment using high-pull headgear with a bite block during the early permanent dentition stage due to an unfavorable growth pattern, orthognathic surgery was proposed but rejected by the patient. Then, temporary anchorage devices were used to correct the occlusion and establish an acceptable overbite and overjet. The overall observation time was 8.5 years; the treatment time using fixed appliances was 3 years and 4 months. The achieved tooth position and occlusal relationship remained stable 2.5 years later without recurrence of the open bite.
http://www.njcponline.com/currentissue.asp?sabs=y

Feulgen stain as a special stain for mitotic figures and apoptotic bodies in oral squamous cell carcinoma p. 164 Sankari Radhakrishnan, Ramesh Venkatapathy, PD Balamurali, Karthik Shree V Prashad, B Premalatha, Saikat Chakraborty DOI:10.4103/srmjrds.srmjrds_49_18 Background: Oral cancer is one of the most prevalent cancers worldwide. The oral squamous cell carcinoma (OSCC) is graded for the proper treatment planning, and it has been a subjective phenomenon. This grading depends on several features, of which the presence of mitotic figures and apoptotic bodies is one of the important criteria. The routine hematoxylin and eosin (H and E) staining may help in identifying the mitotic figures and apoptotic bodies, but it is difficult to identify accurately. Thus, an attempt was made to evaluate the efficacy of crystal violet and Feulgen stain in identifying the mitotic figures and apoptotic bodies and to observe any variation in different grades of carcinoma. Aims: This study was aimed

Feulgen stain as a special stain for mitotic figures and apoptotic bodies in oral squamous cell carcinoma p. 164
Sankari Radhakrishnan, Ramesh Venkatapathy, PD Balamurali, Karthik Shree V Prashad, B Premalatha, Saikat Chakraborty
DOI:10.4103/srmjrds.srmjrds_49_18  
Background: Oral cancer is one of the most prevalent cancers worldwide. The oral squamous cell carcinoma (OSCC) is graded for the proper treatment planning, and it has been a subjective phenomenon. This grading depends on several features, of which the presence of mitotic figures and apoptotic bodies is one of the important criteria. The routine hematoxylin and eosin (H and E) staining may help in identifying the mitotic figures and apoptotic bodies, but it is difficult to identify accurately. Thus, an attempt was made to evaluate the efficacy of crystal violet and Feulgen stain in identifying the mitotic figures and apoptotic bodies and to observe any variation in different grades of carcinoma. Aims: This study was aimed at using crystal violet and Feulgen stain in identifying mitotic figures and apoptotic bodies in different grades of OSCC. Materials and Methods: Fifteen diagnosed cases of OSCC were retrieved and stained with routine H and E, crystal violet stain, and Feulgen stain. All the sections were scanned for mitotic figures and apoptotic bodies. Apoptotic index (AI) and mitotic index (MI) were calculated. AI and MI were expressed as the average of a total number of apoptotic and mitotic cells counted in ten high-power fields. Results: A significant increase in MI and AI was found in Feulgen stain than crystal violet and H and E stain. Conclusion: Feulgen stain can be considered as the best, cost-effective, relatively cheap stain to visualize mitotic figures and apoptotic bodies.
http://www.srmjrds.in/currentissue.asp?sabs=y

Regenerative periodontics in restoring oral functions: A power to regenerate what's lost p. 168 Hunny Sharma, Swati Verma DOI:10.4103/srmjrds.srmjrds_24_18 Although human oral cavity benefits from remarkable mechanical and functional properties, still it faces continuous insult and damage resulting from exposure to microbial attacks. In the past where conventional dentistry was only focused on evaluating, restoration, and replacement of the diseased oral structures. The recent era of advancement in the field of materials science, molecular biology, tissue engineering, and stem cell research's had let to the path of development of new era of periodontal engineering known as regenerative periodontics. The ultimate goal of regenerative periodontics is the regeneration of the lost periodontium due to advanced periodontal disease. Currently, scientists are working on a wide range of biomaterials and scaffolds, genes, stem cells, and growth factors in the hope of achieving more predictab

Regenerative periodontics in restoring oral functions: A power to regenerate what's lost p. 168
Hunny Sharma, Swati Verma
DOI:10.4103/srmjrds.srmjrds_24_18  
Although human oral cavity benefits from remarkable mechanical and functional properties, still it faces continuous insult and damage resulting from exposure to microbial attacks. In the past where conventional dentistry was only focused on evaluating, restoration, and replacement of the diseased oral structures. The recent era of advancement in the field of materials science, molecular biology, tissue engineering, and stem cell research's had let to the path of development of new era of periodontal engineering known as regenerative periodontics. The ultimate goal of regenerative periodontics is the regeneration of the lost periodontium due to advanced periodontal disease. Currently, scientists are working on a wide range of biomaterials and scaffolds, genes, stem cells, and growth factors in the hope of achieving more predictable outcomes in regenerative periodontics. Future research areas in regenerative periodontics include three-dimensional printing, tissue engineering, and gene therapy strategies which give more positive and predictable outcomes of regenerative periodontics. This review provides an overview of current on-going technique and researches in the field of regenerative periodontics and also will show a glimpse of what the future holds.
http://www.srmjrds.in/currentissue.asp?sabs=y

Importance of cone-beam computed tomography in dentistry: An update p. 186 Shruthi Hegde, Vidya Ajila, Jasmine Shanti Kamath, Subhas Babu, Devika S Pillai, S Mithula Nair DOI:10.4103/srmjrds.srmjrds_26_18 In this era of advanced technology, cone-beam computed tomography (CBCT) has gained popularity in the field of oral radiology due to its advantages over conventional radiography. The use of CBCT is profoundly increasing for diagnosis and treatment planning in different specialties of dentistry. The incorporation of cone-beam technology into clinical practice is taking place because of the progress in image acquisition and three-dimensional (3D) imaging. The equipment design is easier to use, image distortion is minimal, and the images are compatible with other planning and simulation software. The 3D imaging has made the complex craniofacial structures more accessible for examination. Early and accurate diagnosis of deep-seated lesions is possible. CBCT provides a high-spatial res

Importance of cone-beam computed tomography in dentistry: An update p. 186
Shruthi Hegde, Vidya Ajila, Jasmine Shanti Kamath, Subhas Babu, Devika S Pillai, S Mithula Nair
DOI:10.4103/srmjrds.srmjrds_26_18  
In this era of advanced technology, cone-beam computed tomography (CBCT) has gained popularity in the field of oral radiology due to its advantages over conventional radiography. The use of CBCT is profoundly increasing for diagnosis and treatment planning in different specialties of dentistry. The incorporation of cone-beam technology into clinical practice is taking place because of the progress in image acquisition and three-dimensional (3D) imaging. The equipment design is easier to use, image distortion is minimal, and the images are compatible with other planning and simulation software. The 3D imaging has made the complex craniofacial structures more accessible for examination. Early and accurate diagnosis of deep-seated lesions is possible. CBCT provides a high-spatial resolution of bone and teeth which allows accurate understanding of the relationship of the adjacent structures. CBCT has helped in detecting a variety of cysts, tumors, infections, developmental anomalies, and traumatic injuries involving the maxillofacial structures. It has been used extensively for evaluating dental and osseous disease in the jaws. This paper reviews current advances in CBCT and their uses in dentistry.
http://www.srmjrds.in/currentissue.asp?sabs=y

Chemical burns of gingiva and its management p. 174 MM Dayakar, Prakash G Pai, Radhika Priyadarshini M Sooranagi, Vintu Vijayan, Abdul Waheed DOI:10.4103/srmjrds.srmjrds_16_18 Chemical burns on the gingiva can be caused by the use of certain pharmaceutical and nonpharmaceutical products by patients or by injudicious use of caustics by the dental clinician. These lesions in the oral cavity, however, are rarely reported. Hence, information about the product and needful instructions is necessary to be given to the patients for prevention of the same. These burns can be caused by the way of self-infliction, allergic tendency toward certain products, or it may be iatrogenic. A detailed history is the key to diagnosing and managing these cases. Chemical burns are usually treated by eliminating the etiology and managed by palliative therapy.

Chemical burns of gingiva and its management p. 174
MM Dayakar, Prakash G Pai, Radhika Priyadarshini M Sooranagi, Vintu Vijayan, Abdul Waheed
DOI:10.4103/srmjrds.srmjrds_16_18  
Chemical burns on the gingiva can be caused by the use of certain pharmaceutical and nonpharmaceutical products by patients or by injudicious use of caustics by the dental clinician. These lesions in the oral cavity, however, are rarely reported. Hence, information about the product and needful instructions is necessary to be given to the patients for prevention of the same. These burns can be caused by the way of self-infliction, allergic tendency toward certain products, or it may be iatrogenic. A detailed history is the key to diagnosing and managing these cases. Chemical burns are usually treated by eliminating the etiology and managed by palliative therapy.
http://www.srmjrds.in/currentissue.asp?sabs=y

Mucormycosis – Can the diagnosis be challenging at times?? p. 191 Vandana Raghunath, K Hanna Rose Priyanka, C Geetha Kiran, R Manasa Deepthi DOI:10.4103/srmjrds.srmjrds_53_18 Mucormycosis is an aggressive and often rapidly progressing fatal form of fungal infection mainly affecting the immunocompromised patients and characterized by destruction and necrosis. The paranasal sinuses get affected commonly in the rhinocerebral type with or without oral cavity involvement. At times, even in the setting of immunosuppression, it presents as a subtle clinical infection posing both as a diagnostic and therapeutic challenge to the clinicians. Further, in such immunocompromised cases, early diagnosis and prompt treatment become utmost demanding to prevent the ensuing morbidity and mortality. We present one such indolent case which presented as a sinus infection in a 50-year-old diabetic woman. Further, the granulomatous presentation on hematoxylin and eosin-stained sections led to an erroneo

Mucormycosis – Can the diagnosis be challenging at times?? p. 191
Vandana Raghunath, K Hanna Rose Priyanka, C Geetha Kiran, R Manasa Deepthi
DOI:10.4103/srmjrds.srmjrds_53_18  
Mucormycosis is an aggressive and often rapidly progressing fatal form of fungal infection mainly affecting the immunocompromised patients and characterized by destruction and necrosis. The paranasal sinuses get affected commonly in the rhinocerebral type with or without oral cavity involvement. At times, even in the setting of immunosuppression, it presents as a subtle clinical infection posing both as a diagnostic and therapeutic challenge to the clinicians. Further, in such immunocompromised cases, early diagnosis and prompt treatment become utmost demanding to prevent the ensuing morbidity and mortality. We present one such indolent case which presented as a sinus infection in a 50-year-old diabetic woman. Further, the granulomatous presentation on hematoxylin and eosin-stained sections led to an erroneous initial diagnosis, which later upon Grocott's methenamine silver staining was diagnosed as mucormycosis-rhinocerebral type. Thus, both clinical and histopathological presentations were defying.
http://www.srmjrds.in/currentissue.asp?sabs=y

Salmon calcitonin - a boon in the management of central giant cell granuloma p. 197 D Nivethitha Gangai, G V. Murali Gopika Manoharan DOI:10.4103/srmjrds.srmjrds_50_18 Central giant cell granuloma is an uncommon, benign, proliferative lesion of unknown etiology, most commonly affecting anterior mandible of younger age group. Early diagnosis may be of benefit to the patient as conservative treatment modalities may be used as compared to radical surgical treatment. Calcitonin as a therapy for central giant cell granuloma of the jaws is a promising alternative to surgical curettage, particularly for larger lesions. We report a case of central giant cell granuloma of mandible in a 14-year-old female patient, who is being treated solely with intranasal spray of salmon calcitonin for 14 months showing greater results.

Salmon calcitonin - a boon in the management of central giant cell granuloma p. 197
D Nivethitha Gangai, G V. Murali Gopika Manoharan
DOI:10.4103/srmjrds.srmjrds_50_18  
Central giant cell granuloma is an uncommon, benign, proliferative lesion of unknown etiology, most commonly affecting anterior mandible of younger age group. Early diagnosis may be of benefit to the patient as conservative treatment modalities may be used as compared to radical surgical treatment. Calcitonin as a therapy for central giant cell granuloma of the jaws is a promising alternative to surgical curettage, particularly for larger lesions. We report a case of central giant cell granuloma of mandible in a 14-year-old female patient, who is being treated solely with intranasal spray of salmon calcitonin for 14 months showing greater results.
http://www.srmjrds.in/currentissue.asp?sabs=y

Schwannoma of the base of the tongue mimicking fibroma p. 202 Sukhvinder Singh Rana, Neera Ohri DOI:10.4103/srmjrds.srmjrds_35_18 Schwannoma is a slow-growing benign tumor of the nerve sheath. It originates from the Schwann cell of the peripheral, autonomic, and cranial nerve. It is usually a single, circumscribed, firm, painless lesion of variable size. 25%–40% of all schwannomas are considered to affect the head and neck region, with the parapharyngeal space being the most common location. Only 1% of cases are intraoral. The treatment of choice is surgical excision of the tumor. Schwannomas do not show recurrence if completely excised. We report a case of schwannoma of the base of the tongue mimicking fibroma.

Schwannoma of the base of the tongue mimicking fibroma p. 202
Sukhvinder Singh Rana, Neera Ohri
DOI:10.4103/srmjrds.srmjrds_35_18  
Schwannoma is a slow-growing benign tumor of the nerve sheath. It originates from the Schwann cell of the peripheral, autonomic, and cranial nerve. It is usually a single, circumscribed, firm, painless lesion of variable size. 25%–40% of all schwannomas are considered to affect the head and neck region, with the parapharyngeal space being the most common location. Only 1% of cases are intraoral. The treatment of choice is surgical excision of the tumor. Schwannomas do not show recurrence if completely excised. We report a case of schwannoma of the base of the tongue mimicking fibroma.
http://www.srmjrds.in/currentissue.asp?sabs=y

Clear-cell squamous cell carcinoma: An uncommon variant of very common malignancy in the head and neck p. 136 Lopa Mudra Kakoti, Debanwita Mahanta, Jagannath Dev Sharma, Zachariah Chowdhury DOI:10.4103/ijohs.ijohs_23_18 Clear-cell squamous cell carcinoma (SCC) is an extremely rare and incompletely understood entity. Clear-cell change occurs due to cytoplasmic accumulation of glycogen, water, intermediate filaments, immature zymogen granules, or a paucity of cellular organelles. Clear-cell change can be seen in any of the neoplasms, but as pure form variant, it is difficult to find in head-and-neck SCC. The World Health Organization has recognized clear-cell SCC as separate entity at other few sites such as penis but not in the head-and-neck SCC, and these are known to aggressive variant. We, hereby, present a case of clear-cell variant of squamous carcinoma in lower gingivobuccal mucosa in a 59-year-old male patient. Histopathology showed sheets of clear cell separated by fibrous s

Clear-cell squamous cell carcinoma: An uncommon variant of very common malignancy in the head and neck p. 136
Lopa Mudra Kakoti, Debanwita Mahanta, Jagannath Dev Sharma, Zachariah Chowdhury
DOI:10.4103/ijohs.ijohs_23_18  
Clear-cell squamous cell carcinoma (SCC) is an extremely rare and incompletely understood entity. Clear-cell change occurs due to cytoplasmic accumulation of glycogen, water, intermediate filaments, immature zymogen granules, or a paucity of cellular organelles. Clear-cell change can be seen in any of the neoplasms, but as pure form variant, it is difficult to find in head-and-neck SCC. The World Health Organization has recognized clear-cell SCC as separate entity at other few sites such as penis but not in the head-and-neck SCC, and these are known to aggressive variant. We, hereby, present a case of clear-cell variant of squamous carcinoma in lower gingivobuccal mucosa in a 59-year-old male patient. Histopathology showed sheets of clear cell separated by fibrous septa and foci showing squamous cells with malignant features. Periodic acid–Schiff and immunohistochemistry (IHC) were done to rule out differentials of clear-cell variants of different sites such as salivary gland, odontogenic origin, and cutaneous adnexal origin. To establish the prevalence, biological nature, significance, and clinical course of clear-cell SCC in the head-and-neck region, more number of case reports are expected to be published in future. We concluded by emphasizing on the need of further analysis of all clear-cell tumors in the head and neck with histochemistry and IHC investigations to arrive at the proper diagnosis.
http://www.ijohsjournal.org/currentissue.asp?sabs=y

The course of double mandibular canal - confront to dentist p. 133 Jayasheela Mallappa, Neeharika Sree, B H Dhanya Kumar, Dhoom Singh Mehta DOI:10.4103/ijohs.ijohs_40_18 The mandibular canal is usually a single canal that begins with mandibular foramen on the medial surface of the ascending mandibular ramus. It transmits the inferior alveolar artery, vein, and the inferior alveolar nerve. The identification of the mandibular canal and its anatomic variations is of great importance in many branches of dentistry, especially in implant dentistry. Sometimes, there may be variations in the normal anatomic structures; one of the rarest among them is double mandibular canal. The clinician should be aware of such variations to avoid complications during the treatment. In the present case report, we have discussed about a case with double mandibular canal and the complications that can arise during the treatment.

The course of double mandibular canal - confront to dentist p. 133
Jayasheela Mallappa, Neeharika Sree, B H Dhanya Kumar, Dhoom Singh Mehta
DOI:10.4103/ijohs.ijohs_40_18  
The mandibular canal is usually a single canal that begins with mandibular foramen on the medial surface of the ascending mandibular ramus. It transmits the inferior alveolar artery, vein, and the inferior alveolar nerve. The identification of the mandibular canal and its anatomic variations is of great importance in many branches of dentistry, especially in implant dentistry. Sometimes, there may be variations in the normal anatomic structures; one of the rarest among them is double mandibular canal. The clinician should be aware of such variations to avoid complications during the treatment. In the present case report, we have discussed about a case with double mandibular canal and the complications that can arise during the treatment.
http://www.ijohsjournal.org/currentissue.asp?sabs=y

Actinomycotic infection of the tonsils: A case report and review of the literature p. 129 Stavanger Singh Bakshi, Ramiya Ramachandran Kaipuzha, Suriyanarayanan Gopalakrishnan, A Govindarajan DOI:10.4103/ijohs.ijohs_43_17 Actinomycotic infections of the head and neck, although fairly uncommon, represent an important entity because of its varied presentation, difficult diagnosis, and long course of treatment. A 20-year-old female presented with throat pain and difficulty in swallowing for 1 year. Examination revealed a Grade IV enlargement of the left tonsil. The patient underwent tonsillectomy, and the postoperative histopathology revealed actinomycosis. Actinomyces is anaerobic filamentous bacteria which are known to colonize as commensals in tonsillar crypts which on histology show an outer zone of granulation tissue and a central zone of necrosis containing many sulfur granules that represent microcolonies of Actinomyces. Actinomycosis of the head-and-neck region is a significant

G.Actinomycotic infection of the tonsils: A case report and review of the literature p. 129
Stavanger Singh Bakshi, Ramiya Ramachandran Kaipuzha, Suriyanarayanan Gopalakrishnan, A Govindarajan
DOI:10.4103/ijohs.ijohs_43_17  
Actinomycotic infections of the head and neck, although fairly uncommon, represent an important entity because of its varied presentation, difficult diagnosis, and long course of treatment. A 20-year-old female presented with throat pain and difficulty in swallowing for 1 year. Examination revealed a Grade IV enlargement of the left tonsil. The patient underwent tonsillectomy, and the postoperative histopathology revealed actinomycosis. Actinomyces is anaerobic filamentous bacteria which are known to colonize as commensals in tonsillar crypts which on histology show an outer zone of granulation tissue and a central zone of necrosis containing many sulfur granules that represent microcolonies of Actinomyces. Actinomycosis of the head-and-neck region is a significant entity because it can mimic other common lesions, especially in the oropharynx. In cases of recurrent tonsillitis and tonsillar hypertrophy, tonsillectomy is the treatment of choice, and histopathological examination of resected tissue is strongly advocated. This report supports the view that Actinomyces may have a causal association with recurrent acute tonsillitis and tonsillar hypertrophy.
http://www.ijohsjournal.org/currentissue.asp?sabs=y

Hemorrhagic bulla on the lip: A diagnostic dilemma p. 124 Aravinda Konidena, Hena Shaw, Mansimran Kaur Uppal DOI:10.4103/ijohs.ijohs_17_18 Angina bullosa hemorrhagica (ABH) is a rare benign disorder characterized by the sudden onset of painless blood-filled blister in the oral cavity that rupture in 24–48 h. We recently encountered an interesting case of ABHon the lower lip of 68-year-old female patient referred back from the prosthodontic department following the procedure of impression making. This case will be presented along with a review of previous case summaries reporting four or more cases.

Hemorrhagic bulla on the lip: A diagnostic dilemma p. 124
Aravinda Konidena, Hena Shaw, Mansimran Kaur Uppal
DOI:10.4103/ijohs.ijohs_17_18  
Angina bullosa hemorrhagica (ABH) is a rare benign disorder characterized by the sudden onset of painless blood-filled blister in the oral cavity that rupture in 24–48 h. We recently encountered an interesting case of ABHon the lower lip of 68-year-old female patient referred back from the prosthodontic department following the procedure of impression making. This case will be presented along with a review of previous case summaries reporting four or more cases.
http://www.ijohsjournal.org/currentissue.asp?sabs=y

unusual presentation of mucoepidermoid carcinoma with review of literature p. 120 Gadadasu Swathi, Tatapudi Ramesh, Moturi Kishore, Govind Raj N Kumar DOI:10.4103/ijohs.ijohs_24_18 Head-and-neck cancers constitute about 30% of cancers in India, of which salivary gland tumor such as mucoepidermoid carcinoma (MEC) was the most common malignant salivary gland tumor. The parotid gland was the most common site of origin in both benign and malignant tumors, followed by submandibular and sublingual glands. Salivary gland tumors comprise a morphologically diverse group of rare tumors. Their multifaceted clinical presentation, varied morphologic configuration, and relatively unpredictable prognosis attract significant medical interest. Here is a rare case report of an asymptomatic swelling in the cheek region which was thought to be pleomorphic adenoma at the outset which on further investigations proved as MEC of early detection.

unusual presentation of mucoepidermoid carcinoma with review of literature p. 120
Gadadasu Swathi, Tatapudi Ramesh, Moturi Kishore, Govind Raj N Kumar
DOI:10.4103/ijohs.ijohs_24_18  
Head-and-neck cancers constitute about 30% of cancers in India, of which salivary gland tumor such as mucoepidermoid carcinoma (MEC) was the most common malignant salivary gland tumor. The parotid gland was the most common site of origin in both benign and malignant tumors, followed by submandibular and sublingual glands. Salivary gland tumors comprise a morphologically diverse group of rare tumors. Their multifaceted clinical presentation, varied morphologic configuration, and relatively unpredictable prognosis attract significant medical interest. Here is a rare case report of an asymptomatic swelling in the cheek region which was thought to be pleomorphic adenoma at the outset which on further investigations proved as MEC of early detection.
http://www.ijohsjournal.org/currentissue.asp?sabs=y

Colonic phenotype of adenocarcinoma base of the tongue: An entity rarely reported and treated with definitive chemoradiation p. 116 Neelam Sharma, Abhishek Purkayastha, Chhavi Arora, Kavita Sahai DOI:10.4103/ijohs.ijohs_55_17 The predominant histological type of oropharyngeal cancer is squamous cell carcinoma and approximately 9 times more frequent when compared with other types. Adenocarcinoma common histopathology for digestive system is very rarely reported in this region. In literature, there are limited data about the clinical presentation, histopathology, and treatment modalities for the primary adenocarcinoma of the base of the tongue (BOT). To the best of our knowledge, five cases of adenocarcinoma of the BOT with colonic differentiation have been reported in the world literature till date, and this is the first case report from India. The challenge in these type of cases is to differentiate between the primary adenocarcinoma of BOT which is extremely rare, metastatic lesio

Colonic phenotype of adenocarcinoma base of the tongue: An entity rarely reported and treated with definitive chemoradiation p. 116
Neelam Sharma, Abhishek Purkayastha, Chhavi Arora, Kavita Sahai
DOI:10.4103/ijohs.ijohs_55_17  
The predominant histological type of oropharyngeal cancer is squamous cell carcinoma and approximately 9 times more frequent when compared with other types. Adenocarcinoma common histopathology for digestive system is very rarely reported in this region. In literature, there are limited data about the clinical presentation, histopathology, and treatment modalities for the primary adenocarcinoma of the base of the tongue (BOT). To the best of our knowledge, five cases of adenocarcinoma of the BOT with colonic differentiation have been reported in the world literature till date, and this is the first case report from India. The challenge in these type of cases is to differentiate between the primary adenocarcinoma of BOT which is extremely rare, metastatic lesion to this site from any other site, or its origin from minor salivary glands which is a more common possibility because all these situations have different treatment implications.
http://www.ijohsjournal.org/currentissue.asp?sabs=y

Multivariant lichen planus of lips and gingiva: Report of a case and a review p. 109 SM Rekha, Apeksha Basawant Annigeri, Sushama R Galgali, P Jagadish DOI:10.4103/ijohs.ijohs_18_18 Oral lichen planus (OLP) is a relatively common inflammatory mucocutaneous disorder that frequently involves the oral mucosa. There are many etiological factors, and some among them are stress, diabetes mellitus, and hypothyroidism. An important complication of OLP is the development of oral squamous cell carcinoma, which led the World Health Organization to classify OLP as a potentially malignant disorder. This article reports a multivariant (reticular, erosive, and papular) case of lichen planus that has affected a 40-year-old medically compromised female who was managed successfully and still under follow-up.

Management of flabby ridge case: An arduous task in undergraduate practice p. 104 Jnanashree Chiplunkar, Masrie Tumbil, MD Chethan, DB Nandeeshwar, Disha Patel DOI:10.4103/ijohs.ijohs_41_18 A fibrous or flabby ridge is a superficial area of mobile soft tissue affecting the maxillary or mandibular alveolar ridges. It can develop when hyperplastic soft tissue replaces the alveolar bone and is a common finding particularly in the upper anterior region of long-term denture wearers. Masticatory forces can displace this mobile denture-bearing tissue, leading to altered denture positioning and loss of peripheral seal. Unless managed appropriately, such “flabby ridges” adversely affect the support, retention, and stability of complete dentures. Many impression techniques have been proposed to help overcome this difficulty. This paper presents case report for prosthodontic rehabilitation of a patient with flabby ridge with McCord and Ahmad impression technique.

Assessment of mandibular retrognathism and maxillary prognathism as contributory factors for skeletal Class II malocclusion: A cephalometric study p. 99 Suraj Prasad Sinha, Krishna U S Nayak, Crystal Runa Soans, PS Murali, Akhil Shetty, MS Ravi DOI:10.4103/ijohs.ijohs_3_18 Aim: The aim of this study is to evaluate the skeletal factor (maxillary excess and/or mandibular deficiency) contributing for the skeletal Class II malocclusion. Materials and Methods: Lateral cephalograms of 100 individuals (50 males and 50 females) in the age group of 18–30 years, having skeletal Class II malocclusion with ANB of more than 4, were evaluated. The parameters to be used for prediction of maxillary prognathism include linear measurement of Nasion perpendicular to point A, and for the mandibular retrognathism, it is linear measurement of Nasion perpendicular to Pogonion, as suggested by Burstone analysis. Results: The 34% of the studied sample size had the Class II skeletal pattern (ANB >4), but

New Guidelines Differ in Advice on PSA Screening

The benefits of prostate specific antigen (PSA) screening for prostate cancer in men has been under controversy for a number of years. Some of the issues are that although prostate cancer is the second leading cause of cancer death in men, most prostate cancers are slow-growing and never cause problems. And while PSA screening can detect cancer early, when it is curable, it is most commonly positive with benign prostatic hyperplasia (BPH), not prostate cancer. (For more details about the issues, see the articles on PSA and Prostate Cancer.)

An international panel of experts recently published in The BMJ (formerly the British Medical Journal) their "Rapid Recommendations" that outlined initiatives advising against routine PSA screening for prostate cancer. Moreover, they suggest that healthcare practitioners should not feel compelled to routinely ask patients about their desire for screening, though they should help patients who raise the issue to make an informed decision.

The recommendations state that for most men, the benefit of screening is small and uncertain, and that there are clear harms and possible side-effects involved in follow-up treatment for positive PSA results. The panel acknowledges that these recommendations may not apply to all men, especially those who have a family history of prostate cancer, are of African descent, or of lower socioeconomic status. For these men, the panel recommends shared decision-making between the patient and the healthcare practitioner.

However, The BMJ panel's guidance contrasts with advice from other organizations that also issue PSA screening recommendations. The U.S. Preventive Services Task Force (USPSTF) earlier this year updated and finalized guidelines that moved from recommending against routine PSA screening to advising that men ages 55 to 69 discuss the issue with their healthcare practitioners to make an informed decision about whether screening is right for them. The Task Force did recommend that men age 70 or older would not need screening.

The change came about after the Task Force reviewed published data on 1,904,950 men on the use of PSA testing to screen for cancer. The USPSTF team's research revealed that the potential harms and benefits of PSA screening for this population are about the same, leading them to conclude that the decision to screen "should be an individual one." Men considering screening should weigh the potential benefits and harms, including:

Potential benefits of PSA screening

• Early detection of cancer when it is most treatable would potentially lower the risk of cancer death for some men.
• Detecting any prostate cancer for men who value knowing their cancer status over possible PSA screening harms

Potential harms of PSA screening

• A false-positive test result (when a man has an elevated PSA level but does not have prostate cancer) could lead to stress and more unnecessary tests, including a prostate biopsy. Possible prostate biopsy side-effects and complications include blood in semen, blood in urine, pain, fever, and sepsis.
• The overdiagnosis and treatment of men with prostate cancer who would never have symptoms or die from their cancer; treatment, which typically includes surgery, chemotherapy and/or radiation therapy, can lead to urinary incontinence, bowel dysfunction and erectile dysfunction. Some men may avoid harms of overtreatment by choosing not to treat immediately but opting for "watchful waiting," which may include occasional PSA tests, or "active surveillance" that involves PSA tests done about every six months with digital rectal examsand prostate biopsies (annually) to monitor the cancer.

The BMJ panel came to their conclusion based on a detailed review and analysis of over 700,000 men in five PSA screening clinical trials who had no previous diagnosis of prostate cancer. Analyses of the clinical trial data revealed that for this population of men, PSA screening reduces prostate cancer deaths, but the effect is small. Most of the men with elevated PSA levels opted to have a prostate biopsy, but no cancer was found. As for the small number of men whose elevated PSA levels were consistent with prostate cancer, many would never experience symptoms or die from their cancer. Therefore, the panel issued a "weak recommendation" against healthcare providers actively offering PSA screening to their patients.

The BMJ panel's recommendation is categorized as weak because of the "small and uncertain benefits of screening on prostate cancer mortality and the large variability in men's values and preferences." More simply put, a weak recommendation means that shared decision-making is important. For men who ask about PSA screening, The BMJ panel urges healthcare providers to share information with their patients so that they can make educated decisions for themselves.

The American Academy of Family Physicians agrees with The BMJ Rapid Recommendations, while other groups, including the American Cancer Society, the American Urological Association, the American College of Physicians, and the U.S. National Comprehensive Cancer Network, have issued PSA screening recommendations that are similar to those of the USPSTF.

https://labtestsonline.org/news/new-guidelines-differ-advice-psa-screening