Medicine

Editorial RN Srivastava Apollo Medicine 2019 16(1):1-1

Posttraumatic brain edema: Pathophysiology, management, and current concept Subhas K Konar, Dhaval Shukla, Amit Agrawal Apollo Medicine 2019 16(1):2-7 Post traumatic cerebral edema is a multiplex process. Mainly two types of cerebral edema occurred after traumatic brain injury-vasogenic edema and cytotoxic edema. Cytotoxic cerebral edema is due to accumulation of water in the intercellular space. Mitochondria mainly cause cytotoxic edema due to the involvement of oxidative metabolism. Various molecules are involved in the formation of cytotoxic edema- like aquaporin, Sulfonylurea-receptor 1 – transient receptor potential member 4 (Sur1-Trpm4), Glutamate, Na+-K+-2Cl− cotransporter, Arginine vasopressin, Histamine, and Erythropoietin .Vasogenic edema develops due to disruption of blood-brain barrier or altered permeability of blood-brain barrier so correlate with the level of impact and or activation of molecular pathways related with neuroinflammation. Molecules involved in neuroinflammation are tumor necrosis factor (TNF), interleukins (IL) 6 and I beta, Substance P and Bradykinin. Management is mainly dived into two part- medical and surgical. Medical management includes management of increased intracranial pressure and later blocking of the pathways involved in the formation and progression of cerebral edema. In refractory cases, surgical decompression plays a role in controlling the intracranial pressure due to cerebral edema.

The importance of microscopic diagnosis of respiratory infections Isabella Princess, Rohit Vadala Apollo Medicine 2019 16(1):8-10 The need for mastering microscopic diagnosis arises in all laboratory specialties, especially when working in resource-poor community laboratories which lack newer diagnostic instruments. Certain clues from microscopic appearance should be carefully analyzed to clinch diagnosis and to not miss out these findings. In addition, if turnaround time is reduced, there is better patient outcome and satisfaction from the clinical colleagues.

Primary fungal laryngitis: An overlooked clinical entity Santosh Kumar Swain, Mahesh Chandra Sahu, Priyanka Debdta, Manas Ranjan Baisakh Apollo Medicine 2019 16(1):11-15 Primary fungal laryngitis is a fungal infection of the larynx without affecting the other body parts such as lungs, pharynx, and oral cavity. It is an extremely rare clinical entity, especially in immunocompetent patients. Aspergillus fumigatus and Candida albicans are common fungi associated with primary fungal laryngitis. Hoarseness of the voice is common clinical presentations. The diagnosis of the primary fungal laryngitis is often overlooked and delayed among patients as it is usually evident among immunocompromised patients. It is often confused with certain laryngeal diseases such as granulomatous diseases, leukoplakia, and malignancy. Misdiagnosis or delayed diagnosis or inadequate treatment may lead to impaired functioning of the larynx and sometimes suffered from permanent disability. It is always important to identify the lesion earliest for avoiding morbid or life-threatening consequences. The purpose of this review article is to discuss the etiopathology, clinical presentations, diagnosis, and treatment of primary fungal laryngitis.

Isolation and identification of fungus associated with skin and nail scalps of patients in a tertiary care teaching hospital Kaniska Uthansingh, Manoj Kumar Sahu, Nagen Kumar Debata, Debasmita Behera, Kirtika Panda, Mahesh Chandra Sahu Apollo Medicine 2019 16(1):16-21 Background and Objectives: Ringworm of the scalp is starting at now a disease of overall criticalness and a general prosperity teaching care hospitals. It is otherwise known as dermatophytes, which attack and create on dead animal keratin. This assessment was intended to recognize the regular dermatophyte causing parasitic infection with both minute just as social strategies. Materials and Methods: This is a Prospective study which was carried out for the period 1 year and included the patients with tinea cruris and tinea corporis, tinea unguium, tinea pedis, and tinea barbae which are seen in the patients between 6 to 70 years of age. Dermatophytes were confirmed with microscopic examination of skin and nail tests taken from the influenced lesion of the body. Both cotton blue and potassium hydroxide grouping of 10%– 30% were utilized to see under magnifying micrioscope. All information were broken down with SPPS 20 programming. Results: Out of 78 patients, the recurrence of ringworm infection among those patients attending in the department of Skin and VD, IMS and SUM Hospital was Trichophyton rubrum (73%), Trichophyton mentagrophytes (53%), Epidermophyton floccosum (26.82%), and Trichophyton verrucosum (7.31%). T. rubrum was the most widely recognized etiological fungus in tinea corporis, and this positioned first in the other type of ringworm infection. Recurrence of dermatophytes infection partner with various clinical examples; for example, nail pieces and skin swabs from the infected area. Conclusions: The greater part of the tinea corporis patients were infected with T. rubrum then comes the disease of Trichophyton violaceum, Trichophyton tonsurans, and T. mentagrophytes. The most astounding recurrence of disease was among the patients matured 20– 30 years. It is additionally essentially noticed that this infection takes a somewhat serious turn in patients of cutting edge in older age (60– 80 years).

Assessment of level of depression and anxiety in pre- and postoperative stages: A prospective cross-sectional study in SCB Medical College, Cuttack Srikanta Panda, Narendranath Samantaray, Monisha Patanaik, Debasish Sahoo, Anshuman Sarangi, Somanatha Jena Apollo Medicine 2019 16(1):22-25 Objectives: Mood disorders are considered to be prevalent in hospitalized patients. Our study aimed to investigate the prevalence of depression and anxiety symptoms in pre- and postoperative stage in surgical patients. Methods: We included 60 surgical patients in this cross-sectional study which includes 43 male and 17 female patients and average age of 38.8 years. Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale were used to screen for symptoms of depression and anxiety at 12 h after admission for electively scheduled surgeries and 12–24 h after the surgery for patients undergoing emergency surgery. Results: In presurgery stage, anxiety was found to be prevalent in 43.3% of patients while depression is 38%. In postsurgery stage, anxiety and depression were found in 18.3% and 35% of patients, respectively. Conclusions: Both anxiety and depression are highly prevalent in pre- and postoperative stage of surgery. Such symptoms should be attended with more seriousness, otherwise would lead to higher morbidity and mortality.

Surgical outcome of 60 operated patients with acute extradural hematomas based on the preoperative glasgow coma scale Ajaydeep Singh, Arvinpreet Kour, GS Bindra, Ajay K Gehlot, Rahul Midha, Kartik Nandra Apollo Medicine 2019 16(1):26-32 Aim and Objective: This study aims to evaluate the outcome of the patients operated for acute extradural hematoma (EDH). Patients and Methods: Sixty consecutive cases of acute EDH were treated at medical college hospital to assess the outcome of the patients based on their Glasgow Coma Scale (GCS), radiological assessment, and pupil size. The patients were monitored of their GCS, pupillary size, and vitals. The Glasgow outcome scale was used to evaluate patient outcome at the discharge from the hospital and after 3 months. Observation and Results: Sixty patients constituting 56 males and 4 females were the part of the study. The mean age of the patients was 23.21 years (range: 2–47 years). On an average, the patients were operated around 9.91 h after the trauma (ranging 2–24 h). Out of sixty patients, 25, 17, and 18 patients had GCS of mild, moderate, and severe groups. Prompt surgery with better care obtained us with mortality 1.6%, morbidity 21.7%, and complete recovery in 83% patients. Conclusion: We may conclude in our study that presurgical clinical findings such as sensorium of patient and pupillary status were an important indicator for surgical outcome. In most of the cases, the outcome was favorable with progressive recovery.

Aggressive surgical resection following neoadjuvant imatinib therapy for advanced duodenal tumor with hepatic metastasis Varun Madaan, Rigved Gupta, GK Adithya, Satya Prakash Jindal, Deepak Govil Apollo Medicine 2019 16(1):33-35 Duodenal gastrointestinal stromal tumors (GISTs) are rare tumors which constitute <5&#37; of all cases of GIST. The treatment of locally advanced/inoperable and metastatic GIST is primarily tyrosine kinase inhibitor therapy (TKI), i.e., imatinib mesylate. In some patients, initial TKI therapy may result in significant downstaging of the primary tumor and metastatic disease. The role of aggressive surgical resection in such patients remains controversial. We present a case of advanced duodenal GIST treated successfully by Whipple&#39;s procedure with liver wedge resection following neoadjuvant TKI therapy. This case shows that aggressive surgical resection for metastatic duodenal GIST following neoadjuvant imatinib seems to be a feasible treatment option.

Primary paravertebral low-grade fibromyxoid sarcoma Binod Kumar Singhania, Jummo Jini, Gobinda Pramanick Apollo Medicine 2019 16(1):36-38 Low-grade fibromyxoid sarcoma is a distinctive variant of fibrosarcoma. Despite its benign histological appearance, it is a tumor with malignant potential. Usually, it is occur in the proximal lower extremities and trunk. However, it is very rare in paravertebral region. The diagnosis is based on the histology and specific immunohistochemistry results. The treatment of choice is total excision followed by radiotherapy to prevent the possibility of recurrence. We excised the tumor to near total and a wide fixation has been done. Frozen section biopsy was misleading and reported a schwannoma.

Multiple spinal neurofibromas Kodeeswaran Marappan, Prabhu Marudamuthu, Sherina Paul Raj Apollo Medicine 2019 16(1):39-41 A 55-year-old male, with a 2-month history of urinary incontinence, a suspected case of pyelonephritis was initially treated by a nephrologist, but with no relief in spite of medication. On further evaluation, he was found to have a history of back pain, progressive bilateral weakness of lower extremities, and difficulty walking. He was thus referred to us for further management. Magnetic resonance imaging (MRI) of the spine was done, which revealed the presence of multiple bilateral dumbbell-shaped lesions at multiple spinal levels, associated with widening of the neural foramina of the cervical, dorsal, and lumbar regions. Surgical excision of all lesions was done in a single sitting. The patient had postoperative weakness and urinary incontinence, which slowly recovered and weakness gradually improved by physiotherapy. On follow-up, the patient was able to walk without any weakness. Surgical excision is the treatment of choice for spinal neurofibromatosis. Diagnosis of the condition may be difficult due to the lack of symptoms in majority of the cases or presentation with rare symptoms. However, it is recommended that a routine MRI of the spine be performed in patients with a history of urinary incontinence associated with weakness of limbs.

Surgery

The duration of intra-abdominal hypertension and increased serum lactate level are important prognostic markers in critically ill surgical patient's outcome: A prospective, observational study Hnuman Prasad Gupta, Pema Ram Khichar, Rekha Porwal, Amit Singh, Anil Kumar Sharma, Mukesh Beniwal, Satyaveer Singh Nigerian Journal of Surgery 2019 25(1):1-8 Aim: The present study analyzed the clinical significance of duration of intra-abdominal hypertension (IAH) associated with increased serum lactate in critically ill patients with severe sepsis. Materials and Methods: Our study was an observational, prospective study carried out in the Surgical Intensive Care Unit (ICU) at J.L.N Medical College, Ajmer, Rajasthan, India. In our study, we included a total of 100 patients and intra-abdominal pressure (IAP) was measured through intravesical route at the time of admission and after 6, 12, 24, 48, and 72 h via a urinary catheter filled with 25 ml of saline. Duration of ICU and hospital stay, need for ventilator support, initiation of enteral feeding, serum lactate level at time of admission and after 48 h, and 30-day mortality were noted as outcomes. Results: In our study, an overall incidence of IAH was 60%. Patients with cardiovascular surgery and renal and pulmonary dysfunction were 93.3%, 55%, and 60%, respectively, at the time of admission and 65%, 10%, and 10%, respectively, after 72 h of admission in the surgical ICU. Nonsurvivors had statistically significant higher IAP and serum lactate levels than survivors. Patients with longer duration of IAH had longer ICU and hospital stay, longer duration of vasopressors and ventilator support, and delayed enteral feeding. Conclusion: There is a strong relationship “risk accumulation” between duration of IAH associated with increased serum lactate and organ dysfunction. The duration of IAH was an independent predictor of 30-day mortality. Early recognition and prompt intervention for IAH and severe sepsis are essential to improve the patient outcomes.

Bone level measurements around platform switched and platform matched implants: A comparative study Vivek Rana, Varsharani Madhukar Dhakne, Shrikant Jadhawar, Ishan Kadam, Koyena Mishra, Parisha Patil Nigerian Journal of Surgery 2019 25(1):9-13 Background: The overall success of dental implants depends on the crestal bone support around the implants. During the initial years, the bone loss around the implants determines the success rate of treatment. Platform switching (PLS) preserves the crestal bone loss, and this approach must be applied clinically. Aim: The purpose of this study was to determine the changes in vertical and horizontal marginal bone levels in platform-switched and platform-matched dental implants. Materials and Methods: One fifty patients received one fifty dental implants in the present study over a 1-year period. Measurement was performed between the implant shoulder and the most apical and horizontal marginal defect by periapical radiographs to examine the changes of peri-implant alveolar bone before and 12 months after prosthodontic restoration delivery. Results: These marginal bone measurements showed a bone gain of 1.56 ± 2.4 mm in the vertical gap and 1.49 ± 2.24 mm in the horizontal gap of the platform matching, while in the PLS, a bone gain of 2.67 ± 2.0 mm in the vertical gap (P < 0.05) and 2.89 ± 1.67 mm in the horizontal gap was found. Only a statistically significant difference was found comparing bone gains in the vertical gap between the two groups (P < 0.05). Conclusion: PLS helps preserve crestal bone around the implants, and this concept should be followed when clinical situations in implant placement permit.

Comparison of vacuum-assisted closure therapy and conventional dressing on wound healing in patients with diabetic foot ulcer: A randomized controlled trial Sangma M D James, Sathasivam Sureshkumar, Thirthar P Elamurugan, Naik Debasis, Chellappa Vijayakumar, Chinnakali Palanivel Nigerian Journal of Surgery 2019 25(1):14-20 Background: Vacuum-assisted closure (VAC) therapy has been shown to be beneficial in a variety of wounds. However, evidence of its benefit in diabetic foot ulcers (DFUs), especially with respect to Indian population, is sparse. Methodology: This randomized controlled trial included DFUs of Wagner's Grades 1 and 2. Patients were further stratified with respect to DFU size <10 cm and ≥10 cm. Patients with vascular disease, osteomyelitis, and bilateral DFUs were excluded from the study. The enrolled patients were randomized to receive VAC therapy or conventional dressing. The time to wound healing, granulation tissue formation, and complications such as pain, infection, and bleeding were compared between the two groups. Results: A total of sixty patients were randomized, of which 27 in each group were analyzed. The mean time to healing in days was significantly less in VAC group (22.52 vs. 3.85; P < 0.0001). Mean time to achieve 75%–100% granulation tissue cover was significantly less in VAC group (23.33 vs. 32.15; P < 0.0001). Rate of granulation tissue formation was also found to be significantly better in VAC group (2.91 cm2/day vs. 2.16 cm2/day; P = 0.0306). There was no difference between the two groups with respect to wound infection and bleeding which are commonly attributed to VAC therapy. VAC therapy group had significantly lesser pain at week 3 (Visual Analog Scale score 3 vs. 4; P = 0.004). Conclusion: VAC therapy significantly decreases the time to complete wound healing, hastens granulation tissue formation, and reduces the ulcer area compared to conventional dressing. The study did not find any significant increase in the bleeding and infection in the VAC therapy group.

Histopathological changes in gallbladder mucosa associated with cholelithiasis: A prospective study Amandeep Singh, Guramritpal Singh, Kanwardeep Kaur, Gagandeep Goyal, Girish Saini, Deepika Sharma Nigerian Journal of Surgery 2019 25(1):21-25 Background and Aims: Cholelithiasis is known to produce diverse histopathological changes in the gallbladder mucosa. In the present study, we aimed to find the correlation between various gallstone characteristics (i.e., number, size, and morphological type) with the type of mucosal response in gallbladder mucosa (i.e., inflammation, hyperplasia, metaplasia, and carcinoma). Methods: The present study was conducted prospectively on 100 patients undergoing cholecystectomy for symptomatic cholecystitis. Gallstones were assessed for various parameters, i.e., number, size, and morphological type. Gallbladder mucosa was subjected to histopathological examination. Sections were taken from body, fundus, and neck of gallbladder. Results: Of 100 cases, maximum type was of mixed stones (54%) and was multiple in number (46%). However, gallstone type and number are nonsignificant variables to produce precancerous lesions (i.e., hyperplasia and metaplasia). Statistically significant results were obtained while comparing the mucosal response with gallstone size (P = 0.012). Conclusion: As the gallstone size increases, the response in gallbladder mucosa changes from cholecystitis, hyperplasia, and metaplasia to carcinoma. Gallstone type and number are nonsignificant variables to produce precancerous lesions.

Endoscopic management of ureteric stones: Our initial experience Taiwo Opeyemi Alabi, Emmanuel Ajibola Jeje, Moses Adebisi Ogunjimi, Rufus Wale Ojewola Nigerian Journal of Surgery 2019 25(1):26-29 Aims: The aim of this study is to present our initial experience with intracorporeal pneumatic ureterolithotripsy highlighting the pattern of patients' clinical presentation, techniques, and limitation of the procedure. Materials and Methods: This is a retrospective study of cases of ureteric stones managed over a period of 18 months in a private hospital. Data obtained include patients' sociodemography, clinical presentation, stone burden, procedural technique, complication, and need for a secondary procedure. Data were analyzed using the Statistical Package for the Social Sciences version 21. Results: The total number of patients managed was 20 with an age range of 28–75 years and a mean of 48.2 ± 12.4 years. Majority of them, i.e., 11 (55%) were middle aged. Female gender was more predominant, 11 (55%). Flank pain was the most common mode of presentation. Right-sided stone occurred in 9 (45%), left sided in 7 (35%), and bilateral in 4 (20%). Stone location was in the upper ureter in 4 (16.7%), mid-ureter in 7 (29.2%), and lower ureter in 13 (54.2%). The stone size ranged from 6 to 18 mm with a mean of 9.7 ± 2.5 mm. Four patients (20%) required initial bilateral ureteric stenting before definitive procedure to allow for recovery from sepsis and/or nephropathy. All patients had double-J stenting and were discharged 2 days after the procedure. The procedure was successful in 19 (95%) with 100% stone clearance rate and complete resolution of symptom without any complication. One patient (5%) had a very hard upper ureteric stone which retropulsed into the renal pelvis requiring open nephrolithotomy. Conclusion: Endoscopic treatment of ureteric stone with intracorporeal pneumatic lithotripsy is a safe and effective treatment modality. It is, however, limited in the management of hard upper ureteric stone, especially those that are close to the pelviureteric junction due to the risk of retropulsion of the stone into the kidney.

Determination of visual portfolio for surgeons overseas assessment of surgical needs Nigeria study: Consensus generation through an e-Delphi process Felix Makinde Alakaloko, Etienne St-Louis, Adesoji O Ademuyiwa, Dan Poenaru, Christopher Bode Nigerian Journal of Surgery 2019 25(1):30-35 Background: Surgery as a public health priority has received little attention until recently. There is a significant unmeasured and unmet burden of surgical illness in low- and middle-income countries (LMICs). Our aim was to generate a consensus among expert pediatric surgeons practicing in LMICs regarding the spectrum of pediatric surgical conditions that we should look out for in a community-based survey for Surgeons OverSeas Assessment of Surgical Needs Nigeria study. Materials and Methods: The Delphi methodology was utilized to identify sets of variables from among a panel of experts. Each variable was scored on a 5-point Likert scale. The experts were provided with an anonymous summary of the results after the first round. A consensus was achieved after two rounds, defined by an improvement in the standard deviation (SD) of scores for a particular variable over that of the previous round. We invited 76 pediatric surgeons through e-mail across Africa but predominantly from Nigeria. Results: Twenty-one pediatric surgeons gave consent to participate through return of mail. Thirteen (62%) answered the first round statements and 8 (38%) the second round. In general, the strength of agreement to all statements of the questionnaire improved between the first and second rounds. Overall consensus, as expressed by the decrease in the mean SD from 0.84 in the first round to 0.68 in the second round, also improved over time. The strength of consensus improved for 23 (74%) of the statements. The strength of consensus decreased for the remaining 8 (26%) of statements. Out of the 31 consensus-generating statements, 16 (51%) scored high agreement, 13 (42%) scored low agreement, and 2 (15%) scored perfect disagreement. Conclusion: We have successfully identified the pediatric surgical conditions to be included in any community survey of pediatric surgical need in an LMIC setting.

Fast-track protocol versus conventional protocol on patient outcome: A randomized clinical trial Sandhya P Iyer, Zeeshan Kareem Nigerian Journal of Surgery 2019 25(1):36-41 Background: The aim of this study is to compare fast-track methodology with traditional methods of surgical care in achieving better patient outcome, and ensuring a timely discharge from the hospital, and also note the factors that are responsible for a delayed discharge from the hospital. Materials and Methods: One hundred patients undergoing elective surgeries were randomly allocated into fast-track and traditional protocol of perioperative care. Patients who underwent fast-track protocol (FTP) were started on early oral feeding and were encouraged for early discharge, while the others were made to follow the traditional method of recovery. The gastrointestinal functions, postoperative complications and hospital stay time were recorded. The results were tabulated and analyzed. Results: Early feeding was well tolerated by all the patients in the “fast track” group, while the patients in the control group had increased number of “nil by mouth” days, and this result was statistically significant. Ambulation was started earlier in the case group as compared to the controls, and the mean period of starting of ambulation was statistically significant, in the cases as compared to the controls. The patients in the case group had an earlier discharge from the hospital, as compared to the control group. The most common reason for a delay in discharge from the hospital, in either group, was seen to be inadequate pain relief postoperatively. Conclusion: The FTP can significantly shorten the postoperative hospital stay after elective surgery, as compared to the traditional protocol.

Ocular fireworks injuries in Eastern Nigeria: A 3-year review Akunne Ijeoma Apakama, Cosmas C Anajekwu Nigerian Journal of Surgery 2019 25(1):42-44 Aim: The aim of this study is to determine the incidence and types of ocular injuries caused by fireworks in patients seen at Guinness Eye Centre Onitsha and their effects on vision. Methods: This was a 3-year retrospective study evaluating case files of patients with ocular fireworks injuries seen at Guinness Eye Centre Onitsha during the Christmas and New Year festivities (2010–2012). Information was extracted into a pro forma and analyzed using Excel, AutoSum, and calculators. Results: Subconjunctival hemorrhage, corneal lacerations, and hyphema were the most common injuries seen. Patients had multiple ocular pathologies, and the left eye was affected in 62.5% of cases. Bystanders accounted for 75% of those with ocular fireworks injuries. All were males. Half of the affected eyes went blind. Conclusion: Fireworks injuries constituted only 5.1%, 0%, and 10% of ocular injuries in 2010, 2011, and 2012, respectively, with devastating consequence of blindness in 50% of affected eyes.

Risk-adjusted analysis of patients undergoing emergency laparotomy using POSSUM and P-POSSUM score: A prospective study Mohan Lal Echara, Amit Singh, Gunjan Sharma Nigerian Journal of Surgery 2019 25(1):45-51 Background: Comparison of operative morbidity rates after emergency laparotomy between units may be misleading because it does not take into account the physiological variables of patients' conditions. Surgical risk scores have been created, and the most commonly used is the Physiological and Operative Severity Score for the enumeration of Mortality (POSSUM) or one of its modifications, the Portsmouth-POSSUM (P-POSSUM), usually requires intraoperative information. Objective: The objective of this study is to evaluate the POSSUM and P-POSSUM scores in predicting postoperative morbidity and mortality in patients undergoing emergency laparotomy. Methodology: This is a prospective, cross-sectional, and hospital-based study that was conducted at J.L.N. Medical College and Hospital, Ajmer, Rajasthan, India, from April 2017 to December 2017. Adult patients who presented at the causality and underwent emergency laparotomy were included in the study. Observed and predicted mortality and morbidity were calculated using POSSUM and P-POSSUM equations, and statistical significance was calculated using Chi-square test. Results: A total of 100 patients were included in this study, with a mean age of 42.83 ± 18.21 years. The observed (O) mortality was 12 (12.0%), while POSSUM predicted 40 (40%) and P-POSSUM 27 (27%). The O/E ratio for POSSUM was 0.29 and for P-POSSUM was 0.44, and this means that they both overestimate mortality. When the results were tested by Chi-square test, the P value was found to be 0.55 and 0.85 for POSSUM and P-POSSUM, respectively, which showed no significant correlation for observed and expected mortality. The observed morbidity was 69 (69%), while POSSUM expected morbidity was 79 (79%), O/E ratio is 0.87, and this again overestimates the morbidity. POSSUM is overpredicting the rate of morbidity, and test of correlation showed no significance with P = 0.75. Conclusion: POSSUM and P-POSSUM were found to overestimate mortality and morbidity in our patient's population.

Micronuclei in exfoliated cells: A biomarker of genotoxicity in tobacco users Meenakshi Upadhyay, Parul Verma, Robin Sabharwal, Santosh Kumar Subudhi, Suruchi Jatol-Tekade, Vihang Naphade, Basanta Kumar Choudhury, Pravudeva Devidutta Sahoo Nigerian Journal of Surgery 2019 25(1):52-59 Aims: The aim of this study was to analyze the tobacco-related genotoxic effects in individual with habit of smoking and chewing tobacco. Materials and Methods: The present study sample consisted of 120 individuals attending the outpatient department of D. J. College of Dental Sciences and Research, Modinagar, Uttar Pradesh (UP). The sample was divided into four groups as follows: Group I (individuals with habit of smoking tobacco), Group II (individuals with habit of chewing tobacco), Group III (individuals with habit of smoking and chewing tobacco), and Group IV control group (nontobacco-exposed individuals). Patients were asked to rinse their mouth gently with water. The exfoliated cells were obtained by scraping the buccal mucosa of individuals with a wooden spatula. The scraped cells were placed on the precleaned slides. The smears were then stained with RAPID-PAP™ and analyzed under the microscope. Data were analyzed using SPSS statistical software. Results: In the present study, an arbitrary unit was obtained using frequency/day multiplied by the duration of years (risk multiplication factor [RMF], a positive and significant correlation were observed between the RMF and the mean percentage of micronucleated cell count in smokers, chewers, and in individuals with both smoking and chewing habit, respectively. A weak positive and nonsignificant correlation were observed between age and mean percentage of micronucleated cells in smokers and smokers + chewers, respectively, while it was weak negative and nonsignificant in chewers. In control group, correlation between age and percentage of micronucleated cells was weak positive and nonsignificant at 5% level of significance. Conclusion: The micronuclei in exfoliated mucosal cells from buccal mucosa can be used as a biomarker of genotoxicity in predicting the effects of carcinogens.

Burns

Skin bank – the need of hour for burn treatment Vijay Kumar Indian Journal of Burns 2018 26(1):1-2

Burns management in India: The way ahead Arun Kumar Singh Indian Journal of Burns 2018 26(1):3-5

Restoring hope: The Burn Unit, KEM Hospital Vinita Puri, Raghav Shrotriya Indian Journal of Burns 2018 26(1):6-8

Reconstruction of postburn crippled hands: A study of functional outcome Narayanan Chandramouli Hariharan, Rajagopal Sridhar, B Sankari, VS Valarmathy, Ebanesar Asirvatham, Krishnamurthy Geetha Indian Journal of Burns 2018 26(1):9-14 Introduction: In postburn survivors, quality of life depends on the functional ability of one's hands. However, restoring useful function in crippled hands is a formidable challenge. Understandably in such cases, there are no standardized rules regarding the sequence of release, the type of skin cover, the duration of immobilization by K wires, and the intensity of hand therapy. Patients and Methods: We formulated a protocol and evaluated the outcome for cases of severe contractures with a total loss of hand function and distorted hand architecture. It is a cross-sectional study of 10 consecutive patients and 14 hands operated in our department from January 2014 to June 2017. The patients were operated in two stages. At the first stage, contractures of the wrist, dorsum, and thumb web space were released. Extension contractures of the fingers and thumb were also released. During the second stage, the contractures of the palm, volar aspect of the fingers, and web spaces were released. In both the stages, the fingers were maintained in released position for 3 weeks by K wires and the raw areas were covered with split skin graft/skin flap. Results: Patients were assessed for the improvement of hand function by the disabilities of the arm, shoulder and hand (DASH) scores of the 10 patients operated, four returned to the original employment/school. Four found meaningful employment. Conclusion: The aim in crippled hands is to restore useful function in the least number of stages rather than improving the range of movement in individual joints. Maintaining the release achieved by surgery with K wires, coupled with aggressive therapy, prevent the recurrence of the contractures.

Role of autologous fat grafting in burn wounds M Rahul, Sunil Sharma Indian Journal of Burns 2018 26(1):15-19 Introduction: The role of autologous fat grafting in burn wound healing was not studied adequately although there are few references in favor of the same. Autologous fat grafting was used in the treatment of burn wounds showing no signs of healing even after 3 weeks of injury. This study was done to study the role of autologous fat grafts in the treatment of burn wounds and to assess outcome in terms of healing or production of granulations suitable for skin grafting. Materials and Methods: The study was conducted in a tertiary burn care center. It was a prospective case–control study. The study was done on 30 cases and 30 controls. Burn wounds of duration >21 days with size <40 cm2 were selected for the study. The study group underwent wound debridement followed by autologous fat grafting, whereas controls underwent wound debridement only. The results were assessed on day 3, 6, 10, and 14. Chi-squared test was used; P < 0.05 was statistically significant. Results: Statistically significant differences were noted in the early appearance of healthy granulation tissue, epithelialization from margins, and reduction in size of the wounds, leading to early healing. All patients in the study group developed healthy granulations by day 3, whereas only 6.7% of the control group developed healthy granulations. All the cases among the study group showed epithelisation from margins on day 6, whereas only 3.3% of the controls showed epithelialization from margins. On day 14, 10% of cases in the study group were healed with statistically significant reduction in size of the wounds compared to those on the control group. Discussion: The cases undergoing autologous fat grafting showed significantly improved healing with respect to faster appearance of healthy granulations, epithelialization from margins, and thereby reduction of wound surface area and healing, proving the usefulness of autologous fat grafting in burn wounds. The autologous nature of fat grafts is remarkable considering the solution to the longing problem found inside the body itself.

Exfoliative diseases of the integument and mucous membrane that mimic deep 2nd-degree burns with or without sepsis K Mathangi Ramakrishnan, Bala Ramachandran, KG Ravikumar, K Ravikumar, R Ramkumar, V Jayaraman, T Mathivanan Indian Journal of Burns 2018 26(1):20-23 Introduction: Exfoliative skin diseases in children can mimic burns in many ways and require early diagnosis and management. Here we enumerate the different skin conditions with four case based examples and their management. Clinical Presentation: Varying degrees of skin involvement may be seen with severe involvement in DRESS syndrome and milder involvement in Stevens-Johnson syndrome. Management: The management of this exfoliative lesion is the application of collagen membrane to the wound as we treat burns. Although systemic symptoms can produce mortality (e.g., dress), collagen dressing heals the wound well with good epithelialization. Early and appropriate antibiotic therapy is mandatory. Conclusion: Careful attention to correct diagnosis, early intervention and use of collagen dressing have improved outcome in these children.

Correlation of burn injury and family history of burns among patients hospitalized at a public hospital in Nairobi, Kenya: A case–control study Joseph Kimani Wanjeri, Mary Kinoti, Tom H. A. M. Olewe Indian Journal of Burns 2018 26(1):24-28 Introduction: Burn injuries are physically and psychologically devastating types of trauma and are common among children especially in the home environment. They are more prevalent and are a public health problem in developing countries principally because of poor socioeconomic conditions. Effective prevention programs should be tailored for specific geographic locations and guided by the results of well-designed studies aimed at investigating local risk factors for burns. Studies targeting households can result in the identification of risk factors operating within family setups. Study Objective: To determine the association between occurrence of burn injury and family history of burns among patients hospitalized at a large hospital in a developing country in Africa. Methodology: This was age- and gender-matched case–control study comprising 202 patients admitted with burns (cases) and 202 nonsurgical patients (controls) admitted into the pediatric and medical wards. The study site was Kenyatta National Hospital, an 1800-bed national referral and teaching hospital in Kenya. The dependent variable was burn injury whereas the independent variables were family history of burn injury, history of hospitalization, and presence of a burn injury scar in the burnt family member. History of hospitalization following burn injury was termed as an indicator of severe burn injury having been sustained. Data Analytical Methods: The Chi-square test was used to identify the differences between the cases and control group variables, and logistic regression analysis and odds ratio were done to determine the relationship between the dependent and independent variables. Results: The male:female ratio was found to be 1:1, and burn injuries were found to be most common in the 0–4 years age bracket (n = 86, 42.6%), with the second most common age bracket being 20–40 years (n = 78, 38.6%). The injuries were mainly sustained in homes (n = 161, 80.9%) and the remainder at work (n = 15, 7.5%) and other places (n = 23, 11.6%). There was no significant difference between the two groups with regard to family history of burns (odds ratio [OR] = 0.689, 95% confidence interval [CI]: 0.443–1.073, P = 0.062) and presence of a burn scar in previously burnt family members (OR = 1.083, 95% CI: 0.308–3.805, P = 1.0). There was, however, a statistically significant higher incidence of postburn injury hospitalizations among the cases than the controls (OR = 2.354, 95% CI: 1.064–5.208, P = 0.033). Conclusion: Family history of burn injury with hospitalization of those affected is an indicator of households at a higher risk for burn injuries. More of the cases had history of hospitalization for burn injury among their family members, indicating that they had more risk factors operating within their environment, or their practices made them more prone to burn injuries. Identification of the specific risk factors involved is key in the prevention of burn injuries in homes.

Nanocrystalline silver gel versus conventional silver sulfadiazine cream as topical dressing for second-degree burn wound: A clinicopathological comparison Gouranga Dutta, Nandini Das, Abhishek Adhya, Kinkar Munian, Bijay Kumar Majumdar Indian Journal of Burns 2018 26(1):29-37 Background: The use of topical chemotherapy is fundamental to prevent infections thereby reducing local inflammation, pain and early healing in superficial, and deep dermal burns. Among the whole gamut, choice of topical agents became an important decisive factor. Silver sulfadiazine (SSD) cream has been an important part of burns management for many years. The major complications attributed to silver compounds are due to the complex or anion sulfadiazine, not the silver itself. With better understanding of the physical and chemical properties, nanocrystalline silver particles have emerged as the most studied material for burn wound dressing recently. Having in mind the difficulties experienced, the aim of the present study is to compare SSD with nanosilver (nano-Ag) gel dressing to treat second-degree burn wounds. Materials and Methods: Over a period of 24 months, a total of 90 cases were studied. 45 patients randomly included in each group, further divided into two subgroups depending on depth (superficial and deep) and involvement of total body surface area (10%–20% and >20%–30%) to minimize bias. Clinical, microbiological, and histological parameters were analyzed. Results: In NS group, significantly less pain observed throughout the study period in both superficial and deep dermal burn patient. Pseudomonas was the predominant flora. Nano-Ag gel was effective in controlling most of the microorganisms except Klebsiella and Proteus sp. Healthy granulation tissue appeared faster (P = 0.0009) in deep dermal burns in nano-Ag group and confirmed histologically. Overall wound healing was more satisfactory in nano-Ag group for both superficial and deep dermal wounds, clinically as well as by histological examination. Conclusions: Clinical and histological studies showed that nano-Ag gel has a positive impact on overall healing process of the patients and proved more beneficial for the management of partial thickness burn as compared to SSD.

Oxidative stress in major thermal burns: Its implications and significance Ranjith James Babu, Mary Babu Indian Journal of Burns 2018 26(1):38-43 Introduction: Thermal burns could prove dreadful to humankind. The morbidity and mortality is the interplay of intraneous and extraneous factors. Multidisciplinary approach plays a cardinal role in managing this catastrophe. This study is carried out to analyze the oxidative stress in thermal burns, its implications in management, and the significance it carries with it. Materials and Methods: This prospective study was carried out in 30 patients from January 2016 to December 2016. Quantitative analysis of oxidative stress and total antioxidant capacity was done on postburn day 3 and every 5 days thereafter. Results: The quantitative oxidative stress level was high, and antioxidant capacity was low in patients who had higher percentage total body surface area burn and predominant deep burn with temporal analysis. The patterns were strikingly different in patients who had mortality with patients who survived. Discussion: Thermal burn releases reactive oxygen species which causes profound changes in internal and external milieu. This alters the physiological response to treatment and impresses on the morbidity and mortality of the patient. Conclusion: Thereby, it could be construed that oxidative stress along with tailored intervention, timing of treatment, and recalcitrant attitude to treatment methodology has a significant role in determining the outcome of burn patients.

Early burn team consultation in the emergency department improves efficiency and patient throughput Paige L Myers, Alap U Patel, Derek E Bell Indian Journal of Burns 2018 26(1):44-47 Objective: The objective of the study is to assess the relationship between expedited burn surgery evaluation and total length of stay (LOS) in the emergency department (ED) in a high-volume tertiary burn care institution and extrapolate these results to the efficiency and cost-effectiveness of patient care. Methods: A retrospective review was performed of all patients evaluated by the burn surgery team and discharged from the University of Rochester Medical Center ED between November 2012 and June 2013. One hundred and three primary patients were identified and their time from arrival to discharge and the timing of burn surgery consultation were analyzed. Patients were stratified into two groups, early and late, based on how soon after arrival they were seen by the burn surgery service. Tests of statistical significance were performed, comparing total time in the ED, time to evaluation by ED provider, and time to evaluation by the burn surgery service. Results: Burn surgery was consulted and evaluated the early group significantly sooner than the late group (early mean: 63 min, late mean: 191 min; P < 0.001). Total ED stay (arrival-to-discharge time) was significantly lower for the early burn evaluation group (early mean: 181 min, late mean: 285 min; P < 0.001). Conclusions: Early burn surgery consultation is associated with a significantly reduced total ED LOS, arguing for immediate burn surgery consultation irrespective of ED provider contact so that patient throughput can be increased. Furthermore, the reduced LOS may translate into higher patient satisfaction, improved patient care, and lower opportunity cost of ED space.

Medical Physics

Dosimetric comparison of four volumetric-modulated arc therapy beam arrangements utilized for hippocampal-sparing whole-brain radiation therapy Alejandro Prado, Ana Isabel Milanés, Eduardo Cabello, Raúl Díaz, Alejandro Ferrando, Gustavo Pozo, Mario Leonor, Marta Manzano Journal of Medical Physics 2019 44(1):1-8 Purpose: In the present study, the performance of four VMAT beam arrangements used for hippocampal-sparing whole-brain radiation therapy is addressed. Material and Methods: Data corresponding to 20 patients were utilized so as to generate plans for every beam configuration. A preliminary study was conducted to assess the optimal distance between optimization structures (PTVx) and hippocampi. V25, V30, D50%, D2%, D98%, homogeneity index (HI) and Paddick conformity factor (CF) were evaluated for PTV. D100% and Dmax were considered for hippocampi. All plans were required to perform at least as recommended in RTOG 0933 trial regarding organs at risk (OAR) sparing and PTV objectives. Results: Considerable hippocampi sparing alongside with a reasonably low decrease in PTV coverage was achieved using a 7 mm distance between hippocampi and PTV optimization structure. Beam setup 3 (comprised of two full arcs with 0° couch angle and two half arcs with 90° couch angle) achieved the best PTV coverage, HI and CF, while it performed the second-best sparing in hippocampi and lenses. Moreover, beam setup 3 was the second-fastest treatment, although it resulted in the highest number of delivered MU among all beam setups. Beam setup 1 (comprised of two full arcs with no couch angles) was the fastest and it delivered a significantly less amount of monitor units compared with the other beam setups evaluated. Furthermore, a higher robustness was obtained by using no couch angles. Although beam setup 1 was the least optimal considering OAR sparing, it still performed better than required in the RTOG 0933 trial. Conclusions: Overall, beam setup 3 was considered to be the best. It is worth mentioning that, apart from our results, the election of one of these beam arrangements might be dependent on the amount of patient workload at a specific institution.

Pretreatment dose verification in volumetric modulated arc therapy using liquid ionization chamber Nitin R Kakade, Rajesh Kumar, Sunil Dutt Sharma, Vikram Mittal, D Datta Journal of Medical Physics 2019 44(1):9-15 Purpose: The purpose of the present study was to evaluate the practicability of liquid ionization chamber (LIC) for pretreatment dose verification of the advanced radiotherapy techniques such as volumetric modulated arc therapy (VMAT). Materials and Methods: The dosimetric characteristics of LIC such as repeatability, sensitivity, monitor unit linearity, dose rate dependence, angular dependence, voltage-current response, and output factors were investigated in 6 MV therapeutic X-ray beams. The LIC was cross-calibrated against 0.125-cc air-filled thimble ionization chamber. A dedicated dosimetry insert made up of Perspex to incorporate the LIC at proper location in the intensity-modulated radiation therapy thorax phantom was locally fabricated. The collection efficiency and ion recombination correction factor was determined using the two-dose rate method. Pretreatment dose verification measurement of VMAT treatment plans were carried out using the liquid ionization chamber as well as small volume (0.125 cc) air-filled thimble ionization chamber. The measured dose values by the two dosimeters and TPS calculated dose at a given point were compared. Results: The relative percentage differences between the TPS calculated and measured doses were within ± 1.57% for LIC and ± 2.21% for 0.125 cc ionization chamber, respectively. Conclusions: The measured dose values by the two dosimeters and TPS calculated dose at a given point were found comparable suggesting that the LIC could be a good choice of dosimeter for pretreatment dose verification in VMAT.

Validation of three-dimensional electronic portal imaging device-based PerFRACTION™ software for patient-specific quality assurance A Aziz Sait, Jason Figueredo, Glenn W Jones, Kai Jones, Thomas McGowan, Jeff Kapatoes, Ramani Ramaseshan Journal of Medical Physics 2019 44(1):16-20 Purpose: PerFRACTION™ is a three-dimensional (3D) in vivo electronic portal imaging device-based dosimetry software. To validate the software, three phantoms with different inserts (2D array, ionization chamber, and inhomogeneity materials) were constructed to evaluate point dose and fluence map. Materials and Methods: Phantoms underwent independent computed tomography simulation for planning and received repetitive fractions of volumetric modulated arc therapy, simulating prostate treatment. Fluence and absolute point dose measurements, PerFRACTION™ reconstructed doses, and the dose predictions of the planning system were compared. Results: There was concordance between ionization chamber and PerFRACTION™ 3D absolute point dose measurements. Close agreement was also obtained between X- and Y-axis dose profiles with PerFRACTION™ calculated doses, MapCHECK measured doses, and planning system predicted doses. Setup shifts significantly influenced 2D gamma passing rates in PerFRACTION™ software. Conclusions: PerFRACTIONTM appears reliable and valid under experimental conditions in air and with phantoms.

Extraction of retinal blood vessels on fundus images by kirsch's template and Fuzzy C-Means T Jemima Jebaseeli, C Anand Deva Durai, J Dinesh Peter Journal of Medical Physics 2019 44(1):21-26 Purpose: Accurate segmentation of retinal blood vessel is an important task in computer-aided diagnosis and surgery planning of diabetic retinopathy. Despite the high-resolution of photographs in fundus photography, the contrast between the blood vessels and the retinal background tends to be poor. Materials and Methods: In this proposed method, contrast-limited adaptive histogram equalization is used for noise cancellation and improving the local contrast of the image. By uniform distribution of gray values, it enhances the image and makes the hidden features more visible. The extraction of the retinal blood vessel depends on two levels of optimization. The first level is the extraction of blood vessels from the retinal image using Kirsch's templates. The second level is used to find the coarse vessels with the assistance of the unsupervised method of Fuzzy C-Means clustering. After segmentation, to remove the optic disc, the region-based active contour method is used. The proposed system is evaluated using DRIVE dataset with 40 images. Results: The performance of the proposed approach is comparable with state of the art techniques. The proposed technique outperforms the existing techniques by achieving an accuracy of 99.55%, sensitivity of 71.83%, and specificity of 99.86% in the experimental setup. Conclusion: The results show that this approach is a suitable alternative technique for the supervised method and it is support for similar fundus images dataset.

Evaluation of nanoDot optically stimulated luminescence dosimeter for cone-shaped small-field dosimetry of cyberknife stereotactic radiosurgery unit: A monte carlo simulation and dosimetric verification study Fadil Akyol, Neslihan Sarigul, Mete Yeginer, Yagiz Yedekci, Haluk Utku Journal of Medical Physics 2019 44(1):27-34 Aim: The aim of this study was to investigate the adequacy of nanoDot optically stimulated luminescence (OSL) dosimeter for small field dosimetry before its in vivo applications in CyberKnife SRS unit. Materials and Methods: A PTW 60018 SRS Diode, 60019 microDiamond, and Gafchromic EBT3 films were used along with a nanoDot carbon-doped aluminum oxide OSL dosimeter to collect and compare beam data. In addition, the EGSnrc/BEAMnrc code was employed to simulate 6-MV photon beams of CyberKnife SRS system. Results: All detectors showed good consistency with each other in output factor measurements for cone sizes of 15 mm or more. The differences were maintained within 3% for these cones. However, OSL output factors showed higher discrepancies compared to those of other detectors for smaller cones wherein the difference reached nearly 40% for cone size of 5 mm. Depending on the performance of OSL dosimeter in terms of output factors, percentage depth doses (PDDs) were only measured for cones equal to or larger than 15 mm. The differences in PDD measurements were within 5% for depths in the range of 5–200 mm. Conclusion: Its low reliable readings for cones smaller than 15 mm should be considered before its in vivo applications of Cyberknife system.

Effective dose display system in gastric cancer X-ray screening Kenyu Yamamoto, Naoko Fujiwara, Masahiko Kiyama, Yoshihiro Takeda, Tadao Kuwano, Toshizo Katsuda, Masami Azuma, Toshinori Ito Journal of Medical Physics 2019 44(1):35-38 Purpose: The purpose of this study is to build a system for effective dose display immediately after the gastric cancer X-ray screening. Materials and Methods: The regression equation of effective dose and dose area product (DAP) was introduced from the data of 500 persons including DAP and effective dose calculated using program for X-ray Monte Carlo. Results: The effective dose was 5.39 mSv of median, 1.18 mSv of minimum, and 38.38 mSv of maximum. The regression equation was Y=0.354+0.0003772X (Y: effective dose, mSv, X: DAP, mGy cm2). Using the regression equation, the effective dose can be estimated from DAP and displayed just after the individual screening. Conclusions: “Effective dose display system” was constructed to display effective dose immediately after gastric cancer X-ray screening. This system is on the way to be reformed by improving the regression equation on larger data.

Phantom-based feasibility studies on phase-contrast mammography at Indian synchrotron facility indus-2 Reena Sharma, SD Sharma, PS Sarkar, B Singh, AK Agrawal, D Datta Journal of Medical Physics 2019 44(1):39-48 Introduction: Use of synchrotron radiation (SR) X-ray source in medical imaging has shown great potential for improving soft-tissue image contrast such as the breast. The present study demonstrates quantitative X-ray phase-contrast imaging (XPCI) technique derived from propagation-dependent phase change observed in the breast tissue-equivalent test materials. Materials and Methods: Indian synchrotron facility (Indus-2, Raja Ramanna Centre of Advanced Technology [RRCAT]) was used to carry out phantom feasibility study on phase-contrast mammography. Different phantoms and samples, including locally fabricated breast tissue-equivalent phantoms were used to perform absorption and phase mode imaging using 12 and 16 keV SR X-ray beam. Edge-enhancement index (EEI) and edge enhancement to noise ratio (EE/N) were measured for all the images. Absorbed dose to air values were calculated for 12 and 16 keV SR X-ray beam using the measured SR X-ray photon flux at the object plane and by applying the standard radiation dosimetry formalism. Results and Conclusion: It was observed in case of all the phantoms and test samples that EEI and EE/N values are relatively higher for images taken in the phase mode. The absorbed dose to air at imaging plane was found to be 75.59 mGy and 28.9 mGy for 12 and 16 keV SR energies, respectively. However, these dose values can be optimized by reducing the image acquisition time without compromising the image quality when clinical samples are imaged. This work demonstrates the feasibility of XPCI in mammography using 12 and 16 keV SR X-ray beams.

Development of a method to determine electron density and effective atomic number of high atomic number solid materials using dual-energy computed tomography Avinav Bharati, Susama Rani Mandal, Arun Kumar Gupta, Amlesh Seth, Raju Sharma, Ashu S Bhalla, Chandan J Das, S Chatterjee, Pratik Kumar Journal of Medical Physics 2019 44(1):49-56 Aim: This study aims to develop a method using dual-energy computed tomography (DECT) to determine the effective atomic number and electron density of substances. Materials and Methods: Ten chemical substances of pure analytical grade were obtained from various manufacturers. These chemicals were pelletized using a hydraulic press. These pellets were scanned using DECT. A relation was obtained for the pellet's atomic number and electron density with their CT number or Hounsfield unit (HU) values. Calibration coefficients were determined. Five new chemical pellets were scanned, and their effective atomic number and electron densities were determined using the calibration coefficients to test the efficacy of the calibration method. Results: The results obtained for effective atomic number and electron density from the HU number of DECT images were within ±5% and ±3%, respectively, of their actual values. Conclusions: DECT can be used as an effective tool for determining the effective atomic number and electron density of high atomic number substance.

Radiation shielding for helical tomotherapy vault design Amanjot Kaur, PN Pawaskar, G Sahani Journal of Medical Physics 2019 44(1):57-64 Purpose: The purpose of the present study is to carry out radiation shielding calculations to find out adequate thicknesses of protective barriers such as walls and ceiling based on minimum space required to house helical tomotherapy unit. This study also aim to derive expression for use factor and estimation of patient workload for tomotherapy facility for optimizing radiation shielding requirements.Materials and Methods: The basic definitions and formulae given in NCRP/IAEA reports were referred and modified for tomotherapy machine to calculate optimized shielding thicknesses requirements. Workload is estimated based on observations of patient treatments on tomotherapy machine and analysis of their treatment plan data. A mathematical expression is derived for calculating use factor in terms of beam divergence angle at source corresponding to field length, angle of source rotation about isocenter, and distance of primary barrier from isocenter. Radiation shielding requirement of protective barriers such as walls and ceiling of helical tomotherapy vault is calculated based on minimum room dimensions as specified by the manufacturer, permissible dose limit (s), and values of optimizing parameters such as workload, use factor etc. for tomotherapy machine. Results: Using derived mathematical expression for use factor in this study, it was found that value of use factor varies with distance of primary barrier from isocenter and its value was found to be 0.093 for given minimum room dimensions. Radiation shielding requirements for protective barriers (walls/ceiling, etc.) were arrived and reported in this paper. Conclusions: A typical helical tomotherapy vault design is proposed based on the calculated shielding thicknesses of protective barriers. Further, it is also concluded that tomotherapy machine can be installed in a vault designed for 6 MV conventional linear accelerator with minor modification.

Determination of optimal clinical target volume to planning target volume margins for conformal radiotherapy planning using image guidance system in rectal cancer in prone position Shashank Bansal, Mouchumee Bhattacharyya, Apurba Kumar Kalita, Moirangthem Nara Singh, Rubu Sunku, Partha Pratim Medhi, Ghritashee Bora Journal of Medical Physics 2019 44(1):65-67 Context: In advanced radiotherapy techniques such as three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT), geometrical uncertainties are very crucial as they may lead to under dosing of tumor and over dosing of the nearby critical structures and hence, it is important to determine planning target volume (PTV) margins which are specific for every center. Aims: The aim of this study is to determine adequate clinical target volume (CTV) to PTV margins specific to our radiotherapy center. Settings and Design: To calculate CTV to PTV margins for rectal cancer patients in prone position using kV cone beam CBCT data sets. Materials and Methods: With the Patient immobilized in prone position using thermoplastic mask, a CT simulation was done and a comprehensive 3DCRT plan was generated. Daily kV CBCT was done to check the patient setup error. Daily setup errors were recorded and evaluated retrospectively. Results: CTV-PTV margin calculated for pelvis in the prone position was calculated using van Herk Formula and were found to be 0.5, 1.8, 0.7 cm in the lateral, longitudinal, and vertical directions, respectively. Conclusions: Image guidance is an effective method to evaluate patient setup errors. Good quality immobilization devices and stringent patient setup policies can help to reduce PTV margins further.

Community Medicine

Strategies for ensuring quality health care in India: Experiences from the field K Madan Gopal Indian Journal of Community Medicine 2019 44(1):1-3

Antimicrobial resistance: Progress in the decade since emergence of New Delhi metallo-β-lactamase in India Avika Dixit, Neeta Kumar, Sanjiv Kumar, Vidyasagar Trigun Indian Journal of Community Medicine 2019 44(1):4-8 Antimicrobial resistance (AMR) has emerged as a major threat to public health estimated to cause 10 million deaths annually by 2050. India carries one of the largest burdens of drug-resistant pathogens worldwide. NDM-1 reported in 2008, rapidly spread to other countries was named after India's capital. India is one of the largest consumers of antibiotics worldwide, and antibiotic sale is increasing rapidly. AMR develops when microbes develop mechanisms to evade the action of antimicrobials. The factors that contribute to AMR include irrational and overuse of antibiotics. In India, various actions have been taken including setting up of a National Task Force on AMR Containment (2010), “Chennai Declaration” by a consortium of the Indian Medical Societies (2012), Setting of Indian Council of Medical Research national surveillance network of laboratories, “Redline” campaign for educating public and National Action Plan on AMR 2017. There is a need integrating AMR education in medical education. India needs to start the subspecialty of infectious diseases and strengthen laboratory services. Every hospital needs to have an AMR policy including infection control, improvement in hygiene, and sanitation and antibiotic use. An element of research needs to be integrated into the AMR policy and encouragement of the pharmaceutical industry to develop “superbug antibiotics.” Unless AMR is addressed effectively the gains made in health are likely to be lost.

Revisiting the relevance of community medicine in undergraduate medical curriculum Anand Krishnan Indian Journal of Community Medicine 2019 44(1):9-11 There have been attempts recently to bring clarity as to the role/functions of the discipline of community medicine. Debates on whether community medicine is a discipline in itself and if so is it a clinical discipline has been there for decades across the world. As the departments of community medicine do not exclusively teach any clinical skill to undergraduate or postgraduates, it is difficult to argue that our discipline is a clinical discipline. Our stalwarts are also known for their work at community and government level and not as clinicians. Our current undergraduate course does not prepare the students adequately for their role in society, profession and health system. Our mandate is to prepare the would-be-doctors as a “finished product” to the country. Our training should address the current crisis that afflicts our profession. A list of learning objectives to be achieved in the three domains of profession, health system, and society and suggestions to improve the teaching of this discipline are provided in this paper.

Role of social support and spouse abuse in low birth weight: A Case–control study from Puducherry, India Yamini Marimuthu, Sonali Sarkar, Shivanand Kattimani, Yuvaraj Krishnamoorthy, Bharathnag Nagappa Indian Journal of Community Medicine 2019 44(1):12-16 Background: Low birth weight (LBW) is a major cause of neonatal morbidity and mortality. In addition to medical/clinical risk factors, various socio-demographic factors also have an impact on birth weight. Objective: The objective of the study is to determine the association of antenatal social support and spouse abuse during pregnancy with LBW in Urban areas of Puducherry. Materials and Methods: A community-based case–control study was conducted in Puducherry. Mothers of 100 LBW infants and normal birth weight infants in 2016 were studied. Functional Social Support Questionnaire and Index of Spouse Abuse scales were used. Conditional logistic regression for matched pair studies was done for multivariate analysis. Results: Mean (± standard deviation) age and education of the study participants was 25.6 (±3.5) and 8.28 (±3.6) years, respectively. The proportion of girl child was 59% and 43% among cases and controls, respectively. Mothers with higher perceived social support (odds ratio [OR] = 0.5; 95% confidence interval [CI]: 0.4–0.7) had lesser odds of LBW. The odds of LBW was 3.6 (adjusted OR [aOR] = 3.6; 95% CI: 1.3–9.9) times and 6.9 (aOR = 6.9; 95% CI: 1.5–31.9) times greater among mothers who experienced nonphysical abuse and had pregnancy-induced hypertension respectively and it was statistically significant after adjusting for child's gender, social support, and parity. Conclusions: The presence of nonphysical abuse during the antenatal period increased the risk of LBW. The awareness should be created in the community to prevent maternal exposure to abuse.

Burden of pulmonary tuberculosis among tribal population: A cross-sectional study in tribal areas of Maharashtra, India Anil J Purty, Amit Kumar Mishra, Ramesh Chand Chauhan, Rajendran Prahankumar, Prabakaran Stalin, Joy Bazroy Indian Journal of Community Medicine 2019 44(1):17-20 Background: It is very important to identify and treat infectious pulmonary tuberculosis (PTB) patients at the earliest to save the life of the patients and to prevent the transmission of infectious agent to others. As per Global Tuberculosis (TB) Report 2017, an estimated 28 lakh new TB cases occur and 4.23 lakh people die due to TB annually. Due to the poor health services and lack of awareness, particularly vulnerable tribal groups are vulnerable or at risk to many diseases including TB. Methodology: A community-based cross-sectional study was conducted to determine the burden of pulmonary TB (PTB) among adult tribal population of Maharashtra. House-to-house visit was conducted to identify the presumptive TB cases and sputum microscopy and chest X-ray were done to confirm the diagnosis. Results: In the survey, 6898 tribal adults were interviewed from 8 tribal clusters, and among them, 144 (2.1%) presumptive TB cases were identified. The most common symptom among the presumptive TB cases was cough for >2 weeks (93.1%). The prevalence of PTB in the study area estimated is 261per lakh tribal population per year. Conclusion: The current study shows that the estimated burden of PTB among tribal population is within the wide variation of prevalence reported from other studies in different tribal communities (133–3294 per lakh population) in India. The current study provides vital information on the burden of TB among the tribal population of Maharashtra which can be used as a baseline data for future epidemiological studies.

Prevalence and determinants of metabolic syndrome among the rural adult population of Puducherry Vinayagamoorthy Venugopal, Amol R Dongre, Sumathi Saravanan Indian Journal of Community Medicine 2019 44(1):21-25 Background: Burden of metabolic syndrome (MS) is rising. There were many previous studies conducted in India on MS, yet it is less studied in Puducherry which has embraced modern culture and lifestyle. Hence, we aimed to study the prevalence and predictors of MS. Materials and Methods: A cross-sectional study was undertaken on a representative sample of 489 adults of age 30 years and above over the period of 18 months. MS was defined according to the International Diabetes Federation (IDF) criteria. Data on sociodemography, lifestyle characteristics, and biochemical parameters were collected by a well-trained health professional using standard methods. Generalized linear models with Poisson distribution and log link function were used to calculate the adjusted prevalence ratio (PR). Results: The prevalence of MS was 39.7% (95% confidence interval [CI]: 35.3–44.1) among the study participants. The most commonly deranged component of MS was central obesity (63.6%). Increasing age, upper socioeconomic status, low fruit intake, physical inactivity, use of refined sunflower oil (PR: 1.40, 95% CI: 1.07–1.83) for cooking, and high perceived stress (PR: 1.77, 95% CI: 1.32–2.37) were found to be associated with MS. Conclusion: The prevalence of MS in Puducherry was high as per the IDF criteria. Usage of refined sunflower oil for cooking and perceived stress was independently associated with an increased risk of MS along with other routinely studied risk factors.

Maternal mortality in rural Varanasi: Delays, causes, and contributing factors Kalpana Kumari, Ratan Kumar Srivastava, Manushi Srivastava, Neeti Purwar Indian Journal of Community Medicine 2019 44(1):26-30 Background: Pregnancy and motherhood are natural processes and considered to be full of positive experiences. However, for various reasons many women end up dying during pregnancy, childbirth, and the postpartum period. Improving maternal health and reducing maternal mortality have been prioritized in several international declarations and national policies. Objectives: The objective of the study is to assess delays, cause, and its contributing factors related to maternal deaths in rural Varanasi. Methodology: Verbal and Social Autopsy have been done for each maternal death occurred between April 2015 and March 2016 in four randomly selected blocks of rural Varanasi. The “3 Delay Model” and “Pathway analysis” concept was used in collection and analysis of data through in-depth interview of three people (family member, neighbor, and a health worker) for each maternal death. Cause of death and delays was identified by two reviewers (obstetrician) independently. Results: In almost half of the autopsied cases two different delays were found, and in one-third case, only one delay was found. Direct obstetric cause found in more than half (54%) cases. Hemorrhage and anemia were found major direct and indirect obstetric cause, respectively. Other causes identified were sepsis (direct), jaundice, and meningitis. A number of social, behavioral, and cultural factors were identified, that had been contributed to different delays related to the maternal deaths. Conclusions: First delay was present in most of (90%) cases. Nonbiological (social, behavioral, and cultural) and health service factors were also identified in this study.

Comparison of performance of digital hemoglobinometer over automated hematology analyzer for hemoglobin estimation and its user-friendliness among the pregnant women in selected district hospitals of Madhya Pradesh Manju Toppo, Dinesh Kumar Pal, Devendra Gour, Veena Melwani, Manju Dubey, Archana Mishra Indian Journal of Community Medicine 2019 44(1):31-34 Context: There is a need for a simple screening method for the detection of anemia that can be used by public health workers in the field. Aims: The aim of this study was to compare two methods for hemoglobin estimation, i.e., automated hematology analyzer and Digital Hemoglobinometer, and to find out the sensitivity and specificity of Digital Hemoglobinometer for the estimation of hemoglobin. Subjects and Methods: A hospital-based cross-sectional study was carried out for 6 months from April to September 2017 in a District Hospital of five High Priority Districts of Madhya Pradesh. Two hundred and sixty antenatal females per district were selected for the study. Results: The mean hemoglobin by autoanalyzer is 10.19, and that by Digital Hemoglobinometer device is 9.89. Overall, sensitivity of Digital Hemoglobinometer for hemoglobin estimation was calculated to be 89.4% and specificity was calculated to be 63.6%. Positive predictive value was found to be 82.6% and negative predictive value was 75.8% compared against AutoAnalyser (gold standard). Conclusions: As the Digital Hemoglobinometer device has high sensitivity and specificity and good diagnostic accuracy, it must be used at the community level in resource-poor setting for hemoglobin estimation. In primary health-care conditions, Digital Hemoglobinometer can significantly reduce misdiagnosis of anemia compared with clinical assessment alone.

A cross-sectional study of gender-based violence against men in the rural area of Haryana, India Jagbir Singh Malik, Anuradha Nadda Indian Journal of Community Medicine 2019 44(1):35-38 Background: Research across the globe highlights rights violations and abuses experienced by women and seldom are channeled toward any atrocities being experienced by men. Objectives: To find the prevalence, characteristics, and sociodemographic correlates of gender-based violence against men. Materials and Methods: It was a community-based, cross-sectional study using multistage random sampling in which a total of 1000 married men in the age group of 21–49 years were interviewed using modified conflict tactics scale. Results: In the present study, 52.4% of men experienced gender-based violence. Out of 1000, males 51.5% experienced violence at the hands of their wives/intimate partner at least once in their lifetime and 10.5% in the last 12 months. The most common spousal violence was emotional (51.6%) followed by physical violence (6%). Only in one-tenth cases, physical assaults were severe. In almost half of the cases, husband initiated physical and emotional violence. Gender symmetry does not exist in India for physical violence. Less family income, education up to middle class, nuclear family setup, and perpetrator under the influence of alcohol were identified as risk factors. Earning spouse with education up to graduation is the risk factor for bidirectional physical violence. Conclusion: Besides women, men are also the victims of gender-based violence. This demands the future investigation and necessary intervention on gender-based violence against men in India.

Effectiveness of color coded diabetic control monitoring charts among elderly diabetics attending outreach primary care geriatric clinics in rural Karnataka: An open label randomized control trial Farah N Fathima, Neethu George, Meera George, Savan Sara Mathew, M Rajitha, Twinkle Agrawal, Arvind Kasturi Indian Journal of Community Medicine 2019 44(1):39-43 Introduction: Type 2 diabetes mellitus problem is progressively rising every day. The adherence to the treatment approaches and health-seeking make major difference in case of diabetics particularly elderly. Visual tools improve the involvement of patients in their care, especially among populations with low health literacy. Objective: To evaluate the effectiveness of color-coded diabetic control monitoring charts on glycemic control among elderly diabetics. Methodology: 144 elderly diabetic patients attending rural primary care geriatric clinics were randomized into two groups. Those randomized to the intervention group received the color-coded diabetic monitoring chart and a health education package in addition to the usual consultation services. Baseline and 1-year follow-up glycated hemoglobin (HbA1C) values were used to assess the effectiveness of the intervention. Results: The results of multivariate linear regression analysis showed that there was an average reduction of 0.265% in HbA1C value in the intervention group when compared to the nonintervention group when adjusted for baseline HbA1C and number of visits during the intervention period (β coefficient = 0.265,P < 0.05). Conclusion: Color-coded diabetes charts are effective in achieving glycemic control among elderly diabetics, and steps should be made to inculcate visually appealing management approaches in case of elderly diabetic patients.

Psychiatry

Insurance for mental illness: Government schemes must show the way Om Prakash Singh Indian Journal of Psychiatry 2019 61(2):113-114

Distance training for the delivery of psychiatric services in primary care BN Gangadhar Indian Journal of Psychiatry 2019 61(2):115-116

Consultation–liaison psychiatry in India: Where to go from here? Sandeep Grover, Ajit Avasthi Indian Journal of Psychiatry 2019 61(2):117-124 Consultation–liaison psychiatry (CLP) is a young and upcoming subspecialty of psychiatry. When one looks at the history of CLP in India, the progress in the area of CLP paralleled that seen in various developed countries. However, over the years, compared to developed countries, CLP started lagging behind in India. In India, CLP services are mostly been provided as per the consultation model and true liaison model practice is missing. There has been meager research in the area of CLP in India, and there is marked heterogeneity in training across different centers. There is lack of specialized training programs in this country. Considering the increasing emphasis on providing person-centered care, there is a need to shift the focus of training from identifying and managing only primary psychiatric disorders to interphase of psychiatry and other disciplines.

High-risk behavior in patients with alcohol dependence Anupama Korlakunta, C M Pavankumar Reddy Indian Journal of Psychiatry 2019 61(2):125-130 Context: Severity of alcohol dependence is related to the high-risk behavior of alcohol dependents. Aim: To assess the high-risk behavior in patients with alcohol dependence and study the association between them. Settings and Design: This is a descriptive study of high-risk behavior in patients with alcohol dependence, conducted over a period of 15-month duration that is from January 2011 to April 2012 on 200 alcohol-dependent patients (178 men and 22 women) in the Department of Psychiatry, Mamata Medical College and General Hospital, Khammam (TS), India. Materials and Methods: Patients and their caregivers fulfilling the selection criteria were included in the study, and informed consent was obtained. Interview was carried out after 2 weeks to rule out the possibility of the presence of withdrawal symptoms in alcohol-dependent patients. Tools used for data collection include Sociodemographic and Clinical Profile Schedule, Clinical Institute of Withdrawal Assessment for Alcohol, Mini–Mental Status Examination, Severity of Alcohol Dependence Questionnaire, and High Risk Behavior Questionnaire. Statistical Analysis: Descriptive statistics, Chi-square test, and logistic regression test were used. Results: The occurrence of high-risk behavior was substantial among patients with alcohol dependence syndrome. Event analysis method indicated that road traffic accidents associated with prior heavy drinking was the most frequently observed high-risk behavior. Conclusions: The study reiterates the relationship between alcohol and sexual behavior and also highlights that individuals dependent on alcohol are a specifically vulnerable group.

Study of family burden in substance dependence: A tertiary care hospital-based study Anita Sharma, Arvind Sharma, Sanjay Gupta, Satish Thapar Indian Journal of Psychiatry 2019 61(2):131-138 Background: A substance-dependent person affects almost all aspects of family life, for example, interpersonal and social relationships, leisure time activities, and finances. Substance dependence invariably increases conflicts, negatively affects family members, and burdens the families. Aims and Objectives: To assess family burden perceived by primary caretakers (PCTs) of individuals with substance dependence and relevant clinico-socio-demographic profile of individuals as well as PCTs. Materials and Methods: Individuals and primary caretakers (n = 150) attending psychiatry OPD and emergency were included in the study. Individuals were selected by convenient sampling. The individuals and PCTs were administered psychiatric thesis/interview pro forma and drug abuse schedule. PCTs were administered “family burden interview schedule.” Results: Majority of caretakers had moderate objective burden (65.3%) and severe subjective burden (74%). Objective burden was more in areas of “financial burden” and “disruption of routine activities.” Objective burden had correlation (P < 0.05) with monthly family income, monthly expenses on substance, number and type of substances, treatment history, sex and type of caretaker. Subjective burden was dependent on sex and type of caretaker and treatment history of the patient. Conclusion: Our study concluded that substance dependence is associated with substantial burden for family members, more for subjective and objective burden in families with low income and with patients who are dependent on more number of substances and had taken treatment in the past. Higher proportion of severe burden was reported by female caretakers. These findings suggest directions for future research in this area.

Effect of adjunctive intermittent theta-burst repetitive transcranial magnetic stimulation as a prophylactic treatment in migraine patients: A double-blind sham-controlled study Amiya Krushna Sahu, Vinod Kumar Sinha, Nishant Goyal Indian Journal of Psychiatry 2019 61(2):139-145 Background: The left dorsolateral prefrontal cortex (DLPFC) seems to exert a bilateral control of chronic pain states such as migraine. Repetitive transcranial magnetic stimulation (rTMS) is known to modulate brain excitability, neurotransmitters, and endogenous opioids involved in pathophysiology of migraine. Aim: This study was designed to assess the efficacy of adjunctive intermittent theta-burst stimulation (iTBS) to the left DLPFC, as a prophylactic treatment in migraine. Materials and Methods: The study was a double-blind, sham-controlled experiment. Patients with migraine were allotted to active (n = 20) or sham (n = 21) rTMS, respectively. Each patient received ten sessions of iTBS over the left DLPFC. Patients were rated at baseline and at 2, 4, 6, and 12 weeks after receiving the treatment. Scores were obtained from the headache diary and by applying the Migraine Disability Assessment Scale (MIDAS). Results: There was a significant decrease in frequency, duration, and severity of migraine in the active group than the sham group over the study period. The effect was more pronounced during the initial 2 weeks. The MIDAS score reduced significantly in the active group than the sham group at 12 weeks. There were no significant adverse effects observed during the entire period of study. Conclusion: Compared to sham stimulation, adjunctive active iTBS over the left DLPFC was safe and effective in reducing the frequency, duration, and severity of migraine headache and in reducing disability associated with the illness.

Impairment of cognitive functions in congestive cardiac failure patients Ottilingam Somasundaram Ravindran, S Vaishnaruby, MS Karthik, Alex Divya Merciline Indian Journal of Psychiatry 2019 61(2):146-150 Background: Congestive cardiac failure (CCF) patients show several neuropsychological impairments and reduced quality of life and impairment of functioning. Objective: The objective of this study was to recognize the deficits in cognition in CCF patients and comparing this cognitive function in the same number of healthy participants. Materials and Methods: A case–control study design was adopted. The study was conducted in the cardiology department of a tertiary care hospital. Convenience sampling was done. Twenty-one participants with CCF (New York Cardiac Association – Class III severity) and 21 healthy participants participated in the study. Each participant in the control group was screened by the General Health Questionnaire-12-item version. We evaluated both groups for the various domains of their cognitive function using a comprehensive battery of neuropsychological tests. Student's t-test was used to analyze the difference between the means for the study variables. Results: We observed that attention, executive function, working memory, psychomotor speed, and visuospatial ability were impaired in the patients with CCF compared to the controls. However, they did not differ significantly in language function. Conclusions: Cognitive functioning is significantly impaired in CCF patients.

Clinician attitude and perspective on the use of coercive measures in clinical practice from tertiary care mental health establishment – A cross-sectional study Guru S Gowda, Peter Lepping, Sujoy Ray, Eric Noorthoorn, Raveesh Bevinahalli Nanjegowda, Channaveerachari Naveen Kumar, Suresh Bada Math Indian Journal of Psychiatry 2019 61(2):151-155 Background: Use of coercive measures in mental health care is an important issue for research. There are scarce data available on perception and attitudes toward coercion among Indian psychiatrists. Aims: This study aims to study psychiatrists' attitude and perspectives on the use of coercive measure in clinical practice against the background of family and patients' opinion. Materials and Methods: The study was conducted at the Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, India. Psychiatrist in charge of the inpatients was asked about their general opinion on coercion and was administered Staff Attitude to Coercion Scale questionnaire. Findings were compared to previously published studies on patients' opinion and family opinion in the same sample. Data were analyzed using descriptive statistics. Results: Coercion proved to be a common measure applied in nearly 70% of the patients studied. The 189 psychiatrists participating in the study almost all perceived coercion as care, protection and safety, and as protection from dangerous situations. About 66% of psychiatrists perceived physical and chemical restraint (sedation) as necessary and acceptable in acute emergency care. One-third of the psychiatrists felt their patients lost autonomy, dignity, and the possibility of interpersonal contact. The same amount agreed that some patients could have been treated with less restriction and fewer coercive measures. Conclusion: Psychiatrists felt that physical and chemical restraints are necessary and acceptable in acute emergencies. Most psychiatrists considered coercion as a caring protective and safety attitude but also acknowledged its potential negative impact on patient dignity and therapeutic relationships.

Impulsivity differences between bipolar and unipolar depression Mustafa Ozten, Atila Erol Indian Journal of Psychiatry 2019 61(2):156-160 Background: Even though particularly bipolar depression and unipolar depression seem to be similar, they show differences in terms of the etiology, phenomenology, course, and treatment process. Bipolar depression is associated with mood lability, motor retardation, and hypersomnia to a larger extent. Early age of onset, a high frequency of depressive episodes, and history of bipolar disease in the family are suggestive of bipolar disorder (BD) rather than major depression. Bipolar and unipolar disorders are also associated with increased impulsivity during illness episodes. However, there is little information about impulsivity during euthymia in these mood disorders. The aim of this study was to illustrate the difference in impulsivity in euthymic bipolar and unipolar patients. Materials and Methods: Impulsivity was evaluated by the Barratt Impulsiveness Scale (BIS-11A), in 78 interepisode BD patients, 72 interepisode unipolar disorder patients, and 70 healthy controls. The diagnosis was established by severe combined immunodeficiency. One-way between-groups ANOVA was used to compare the BIS-11A mean scores for all three groups. Results: Impulsivity scores of the bipolar and unipolar disorder patients were significantly higher than controls on total and all subscales measures. There was no difference between the bipolar and unipolar disorder groups on total, attentional, and nonplanning impulsivity measures. However, BD patients scored significantly higher than the unipolar patients on motor impulsivity measures. Conclusions: Both interepisode bipolar and unipolar disorder patients had increased impulsivity compared to healthy individuals. There was no significant difference on attention and nonplanning impulsivity subscales; however, on the motor subscale, bipolar patients were more impulsive than unipolar disorder patients.

Roles of 5,10-methylenetetrahydrofolate reductase C677T and A1298C polymorphisms in early- and late-onset obsessive-compulsive disorder Metin Caliskan, Seda Orenay-Boyacioglu, Ayse Dondu Indian Journal of Psychiatry 2019 61(2):161-166 Background: The C677T and A1298C mutations of 5,10-methylenetetrahydrofolate reductase (MTHFR) have been linked with conditions such as depression, bipolar disorder, and schizophrenia, but there are not clear the relationship between MTHFR polymorphisms and obsessive-compulsive disorder (OCD). Aim: The current study was planned to investigate the link between the MTHFR polymorphisms and OCD in patients to reveal any potential correlations that may be used as a novel marker in diagnosis of people who are in high-risk group of developing OCD. Materials and Methods: Blood samples from 64 highly characterized symptomatic cases and 64 gender- and age-matched control participants were analyzed for MTHFR C677T and A1298C gene variants. The MTHFR gene polymorphisms were detected through real-time polymerase chain reaction, followed by melting curve analysis. The results were tested with analysis of variance test and the differences with P < 0.05 were reported as statistically significant. Results: A statistically significant difference in age, education level, and marital status was found in the comparison of all groups in sociodemographic findings (P = 0.004, P = 0.001, and P = 0.001, respectively). A statistically significant difference was found in the comparison of the tic story of early- and late-onset OCD patients (P = 0.002). There was no significant difference in the genotype frequencies and allele distributions of MTHFR polymorphisms between the patients and controls (P > 0.05). Conclusion: The results suggest that MTHFR polymorphisms are unlikely to play a major role in the pathogenesis of OCD. Further studies are needed in biochemical data on folate metabolism to clarify the effect of the MTHFR polymorphisms in OCD pathophysiology.