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Although chronic lymphocytic leukemia (CLL) is the most common leukemia in the Western world, neurologic complications arising from direct leukemic involvement of the nervous system are reported in only 1% of patients with CLL. Ocular involvement in CLL, direct or indirect, is less known and exceptionally rare. This case involves a 63-year-old female with CLL undergoing chemotherapy for a year, who recently presented with unusual eye movements in the horizontal plane (ocular flutter), resting and intentional tremors in the right upper and lower limbs, and intermittent jaw movements. With no established protocol for CLL with central nervous system involvement, collecting case data becomes crucial for determining optimal treatment and diagnostic approaches early on.

BACKGROUND: Rh-DEL type is not detected on routine serology and requires specialized adsorption elution methods which are laborious. Identifying the DEL phenotype in blood donors is important to prevent alloimmunization in transfusion recipients. The present study aimed to determine the frequency of DEL phenotype in RhD-negative North Indian blood donors and correlate the results with Rh Cc/Ee phenotype. MATERIALS AND METHODS: In this prospective descriptive cross-sectional study, a total of 205 blood donors with historic blood group RhD-negative were enrolled. All samples were subjected to blood grouping using a fully automated immunohematology analyzer and samples that typed as RhD negative by two different anti-D antisera were tested for Weak D. Weak D-negative samples were subjected to adsorption and elution for DEL phenotype. All samples were also tested for extended Rh phenotype for C/c and E/e antigens. RESULTS: Of the total 11934 donors during the study, 6.2% (n = 743) donors were RhD negative. Of the 205 donors enrolled in the study, two donor samples were serologically weak D positive. None of the remaining 203 donors tested positive for the DEL phenotype. The extended Rh phenotype performed for these donors showed that 6.83% (n = 14) donors were positive for RhC antigen and 1.46% (n = 3) were positive for Rh E antigen. Both weak D-positive donors were also positive for the Rh C antigen. CONCLUSION: The prevalence of DEL phenotype is low in the Indian population and studies with larger sample sizes are required to determine the effectiveness of routine C/E typing as a strategy to identify DEL-positive individuals.

Currently, there are no guidelines or consensus recommendations on the antithrombotic management of peripheral artery disease (PAD) from an Indian perspective. In this article, we have summarized clinical practice recommendations on antithrombotic management of (i) asymptomatic chronic PAD (cPAD), (ii) symptomatic cPAD (intermittent claudication [IC] and chronic limb-threatening ischemia [CLTI]), and (iii) after revascularization (endovascular and surgical). An electronic search of the PubMed database was undertaken to identify relevant articles. Various combinations of keywords such as PAD, chronic peripheral arterial disease, asymptomatic chronic peripheral arterial disease, symptomatic chronic peripheral arterial disease, dual antiplatelet therapy, single antiplatelet therapy, dual pathway inhibition, antithrombotic, revascularization, endovascular, and surgical were used. Randomized controlled trials, case reports, practice guidelines, systematic literature reviews, and meta-analyses were screened and assessed. A roundtable meeting of experts (n = 13) was conducted to arrive at clinical practice recommendations. Experts made their decisions based on the evidence and guideline recommendations. In patients with asymptomatic cPAD and significant peripheral artery stenosis (PAS), long-term single antiplatelet therapy may be considered at the discretion of the clinician. There is no clear evidence in favor of long-term dual antiplatelet therapy in symptomatic cPAD. Experts agreed that low-dose rivaroxaban plus aspirin should be considered in patients with asymptomatic cPAD with >50% PAS and conditions such as diabetes and polyvascular disease. This combination was also suggested in patients with IC, CLTI, postendovascular (stent based/nonstent), and surgical revascularization to reduce cardiovascular and limb ischemic risk, including major amputation in the absence of high bleeding risk or other contraindications.

Background and Aims: Norepinephrine is recently being investigated for mitigation of spinal-induced hypotension. Our study aimed at evaluating the role of manually titrated infusion of norepinephrine in preventing hypotension in patients undergoing lower segment cesarean section (LSCS) under subarachnoid block (SAB). Subjects and Methods: This prospective, randomized, double-blind, placebo-controlled trial was conducted in 140 parturients undergoing LSCS under SAB. Patients were randomly allocated to two groups: group A received an infusion of 5 μg/mL norepinephrine started at 30 mL/h (2.5 μg/min) immediately after SAB and manually adjusted within the range 0–60 mL/h (0–5 μg/min), according to the values of systolic blood pressure (SBP) until delivery; in group B, no prophylactic vasopressor was given, and bolus 1 mL norepinephrine (5 μg) was given whenever the SBP decreased to

Chronic kidney disease (CKD) is a complex disease that is asymptomatic in its early stages. Its delayed recognition may predispose patients to adverse outcomes. Early detection and management of kidney disease through screening programs is widely recommended. In the present study, we conducted a screening program at a hospital set up on World Kidney Day for 10 years to detect patients with CKD. The current study constituted 1324 apparently healthy adults, aged >18 years. Information on age, sex, height, weight, history of diabetes mellitus (DM) and hypertension (HTN), and familial history of kidney disease was recorded. Systolic and diastolic blood pressure, random blood sugar; urinalysis, and serum creatinine (Cr) levels were measured. The study outcome was the presence of CKD. Binary logistic regression analysis was applied to find the predictors of CKD. The median age of the study subjects was 40 years. CKD was found in 35.6% of subjects. Age, DM, HTN, and abnormal Cr levels were associated with increasing risk of CKD. The main objective of the present study was to identify the extent of risk relative to the co-factors of CKD and thereby target those who are potentially modifiable, like DM, to intervene at the earliest possible stage to treat the current disease condition and prevent the future health impairment.

Introduction and Objective: The reported incidence of COVID-related acute limb ischemia (CRALI) ranged from 3.7% to 9.6% in the literature. We report on consolidated data of patients with CRALI from 21 centers across India, which spanned the first two waves of COVID-the period of May 2020 to June 2021. Materials and Methods: Study design: Multicenter study from May 2022 to June 2021. Retrospective analysis of prospectively collected data was done. Inclusion criteria: All patients who presented with signs and symptoms of acute limb ischemia or acute on chronic limb ischemia and who also tested positive for COVID through rapid antigen test or real time polymerase chain reaction. Results: Data for 268 patients from 21 centers across India was available for analysis. 71% were males and 85% were >45 years of age. Majority of patients (n = 191) presented with acute symptoms. Best medical management with antiplatelets and anticoagulants was the only treatment in 34% of patients. Open embolectomy was attempted in 42%, endovascular procedures in 8% and amputation as primary procedure in 14.5%. Higher grades of ischemia were associated with significantly poorer limb salvage, amputation and mortality in the immediate and 14 days follow up (P < 0.001). At 14 days 173 limbs were salvaged (64.5%). Eighty patients underwent amputations (29.8%); 26 of the 80 (32%) were minor amputations (trans-metatarsal and less), so the major amputation rate was 20.1%. Maximum number of deaths were in the group that had undergone medical management (23%), while the least number of deaths were seen in the patients that had undergone some form of intervention, open surgical (2%) or endovascular procedure (4%). Looking at 14-day outcomes, the numbers of deaths in the patients managed with medical methods increased to 30%, open surgical to 7% and endovascular procedures to 8%. Conclusion: CRALI presented both as a primary presentation or developed later during the disease. Early surgical and endovascular interventions in these patients can help in achieving decent limb salvage rates.

Background: Varicose veins is a common disease in nearly 37.25% of the Indian population significantly affecting the quality of life. Endovenous thermal ablation has been the first-line treatment for superficial venous reflux. A new technique, available now, is nonthermal nontumescent vein sealing system (VenaSeal™), which comprises endovenous delivery of cyanoacrylate tissue adhesive into the vein causing obliteration of lumen and has shown better results in terms of safety and efficacy. Being a new modality, only handful of institutes across India perform this procedure and there is a scarcity of Indian data on its outcomes. Aims and Objectives: To evaluate the outcomes of VenaSeal™ glue ablation in terms of vein occlusion rates and improvement in Venous Clinical Severity Score (VCSS). Materials and Methods: Single-centre prospective study of fifty patients over 1 year and 4 months with 3- and 6-month follow-up. Results: The study showed the mean age of the study group to be 43.8 years and the majority (90%) had an early varicose vein (C2/C3) disease. The average length of vein treated per limb was 89.1 cm, and the average glue used per limb was 2.95 ml. All patients showed improvement in VCSS score from preoperative average of 2.6 ± 1.4 to 0.32 ± 0.19 (P < 0.0001, n = 89) with target vein occlusion rate of 100% at 3 months and 97.75% at 6 months. Conclusion: Thus, VenaSeal™ glue ablation procedure is a promising and effective modality for the treatment of varicose veins with excellent treatment success rates, minimal complications, and maximum patient acceptability. It is a feasible Out patient department (OPD) based procedure.

Aim: The study was aimed to evaluate the role of two-dimensional (2D) perfusion angiography (PA) as a predictor in wound healing outcomes in patients of critical limb ischemia. Subject and Methods: It was a pilot study conducted over a period of 16 months after taking informed consent and institutional ethical clearance. The study included 40 patients of which 8 were lost to follow-up, hence the prospective data of 32 patients was collected and analyzed. Patients were subjected to endovascular intervention and 2D perfusion software was applied to the digital subtraction angiography images and its parameters were assessed. Transcutaneous oxygen tension (TcPO2) was measured pre- and postintervention and patients were closely followed up for the time taken for wound healing. Results: The median age was 62 years ranging from 30 to 85 years. Most common comorbidity was diabetes (21/32 patients). The mean Ankle–Brachial Index in the study was 0.55 and mean TcPO2 at admission was 26.5 mm of Hg. Most common involved angiosome was percutaneous transluminal angioplasty angiosome. Fifteen patients underwent direct, 9 indirect, and remaining 8 patients underwent revascularization in both territories. The mean percent improvement in TcPO2 was higher in indirect when compared to direct revascularization but it was not statistically significant. The time taken in wound healing was significantly higher in diabetics when compared to nondiabetics with P = 0.03. Most reliable parameter in 2D PA was area under the curve (AUC) which correlated with increase in volume of tissue perfusion. Patients with >100% improvement in AUC showed significantly better wound healing rates when compared to patients with

Introduction: Regeneration, in the field of endodontics, is the process of restoring and maintaining both architectural form and biological functions of damaged tooth. Presently, regenerative endodontics is not hypothetical and is an alternative to conventional apexification procedures. There is a deficient knowledge concerning the role of intracanal medicaments and their effect on dental stem cells. Aim: The aim of this study was to evaluate the effectiveness of commonly used intracanal medicaments on the viability of dental stem cells of the apical papilla (SCAPs). Materials and Methods: SCAPs were cultured and subjected to various concentrations including triple antibiotic paste, double antibiotic paste, Augmentin, and calcium hydroxide (Ca(OH)2). Viable percentage of stem cell counts was obtained 3 days after treatment. Results: All three antibiotics used hereby significantly decreased SCAP cell survival at particular concentrations, whereas Ca(OH)2 showed stimulating effect on SCAP survival. Conclusion: As per results obtained within limitations of this study, use of Ca(OH)2 in regenerative endodontics in comparison to different commonly used antimicrobial combinations is recommended. Hereby, for clinical use, we suggest adequate concentrations of antimicrobials with adequate antibacterial efficacy should be used.

Purpose: To describe the the appearance and behavior of subretinal hyperreflective material (SHRM) in eyes with central serous chorioretinopathy (CSCR). Methods: This retrospective study included 20 eyes of 20 patients with CSCR presenting with SHRM, defined as sub-retinal deposits that appear hyper-reflective on OCT The eyes underwent either laser (15 eyes) or observation (5 eyes). Optical coherence tomography and fundus fluorescein angiography (FFA) characteristics were analyzed at baseline and resolution of neurosensory detachment, which were then co-related with the visual acuity at resolution. Results: Improvement in vision was seen in 16 eyes. Ellipsoid zone damage (P = 0.03) and external limiting membrane (ELM) damage (P = 0.000) at resolution; diffuse retinal pigment epithelium (RPE) abnormalities on FFA (P = 0.04), and the presence of scar (P = 0.000), were associated with poor visual outcome in univariate analysis. ELM damage at resolution was statistically significant (P = 0.001) in multivariate analysis. Conclusion: CSCR with SHRM have a good visual prognosis. ELM damage at resolution corelates with a poor visual acuity at resolution.

Aim: We have conducted a study of the clinical profile of esophageal atresia (OA) at our institution over a period of 9 years with an aim toward improving our results. We have attempted to find the significant indicators of mortality to be able to focus on improving the survival of these patients in future. To achieve this end, we applied the Waterston's prognostic classification and the Spitz' prognostic criteria to our patients and studied the effects of each variable independently as a cause of mortality. We have also compared the two prognostic criteria to see, which has more significance for us at our institution. Materials and Methods: Over a period of 9 years, from 2006 to 2014, 73 neonates were treated for OA at our institute. There were 27 mortalities. We analyzed our results using the Waterston and the Spitz criteria and studied each independent variable within the two prognostic classifications for the more highly significant cause of mortality. The variables considered as significant indicators of mortality were low birth weight (LBW), pneumonia, associated congenital heart disease (CHD), other associated anomalies, and very LBW. Results: The Waterston prognostic classification was very highly significant (P < 0.0005) as an indicator of prognosis in this study. The two most significant variables affecting survival were LBW, as described by Waterston (P = 0.005) and the association of major CHD (P = 0.006). We had 63% survival and none below the birth weight of 1.8 kg. Conclusion: The study clearly points out that LBW is a highly significant indicator of prognosis followed by the association of major CHD. Waterston's risk classification continues to be a highly significant indicator of prognosis. Further studies are required to assess the combined effects of more than one variable on babies with OA.

Introduction: Coronal microleakage holds importance among various causes of failure after endodontic treatment leading to infection in the periradicular, periodontal ligament, or supporting osseous structures. Loss of coronal seal may occur due to leakage of temporary filling material or fracture of the permanent restoration. Therefore, the use of an intraorifice barrier material would be advantageous in reducing leakage and increasing possibilities for success. Materials and Methods: Fifty single-rooted mandibular premolars were decoronated, cleaned, shaped, and obturated. Gutta-percha was removed to the depth of 3 mm from the orifice. Ten specimens each were sealed with Cention N (Ivoclar Vivadent), Biodentine (Septodont), and glass-ionomer cement (GIC, GC9 high-strength posterior restoration) along with positive and negative control groups, respectively. The teeth were then submerged in dye. Specimens were longitudinally sectioned, and leakage was measured using ×10 stereomicroscope and graded for the depth of microleakage. Results: The samples were subjected to statistical analysis using one-way ANOVA and post hoc Tukey's test and showed that mean microleakage values in all the groups were significantly different from each other (P < 0.001) with the lowest microleakage in Biodentine followed by GIC and Cention N and highest in positive control group. No microleakage was seen in negative control group. Conclusion: The present study concluded that intraorifice barrier placement provides better coronal seal, prevents microleakage, and enhances the longevity of postobturation restorations. Biodentine proved to be the best followed by GIC, Cention N, and control groups.

Background: Vascular injury in extremity is a complication of both blunt and penetrating trauma. In Indian scenario, patients generally present late to the tertiary care center with mangled extremity for treatment. The aim of the study is to assess the risk factors affecting the outcome in the management of patients with lower extremity arterial trauma. Materials and Methods: A single-center, observational study was conducted at Sir Ganga Ram Hospital, New Delhi, from January 2013 to June 2017. Sixty patients of lower extremity arterial trauma who underwent revascularization were included and followed up for 6 months. All the risk factors (mode/mechanism of injury, time since injury, compartment syndrome, mangled extremity severity score [MESS], etc.,) and limb salvage were assessed at 6 months. Statistical analysis was performed using Chi-square test and Fisher's exact test. Results: Majority of the patients presented late (6–24 h) of injury and had high mean MESS (7.85). The most common mechanism of injury was blunt trauma (83.3%), and popliteal artery (72%) was the most commonly injured artery. Limb salvage was achieved in 75% of the patients. Time since injury and MESS score affected the limb salvage significantly. On multivariate analysis, MESS score was the single independent factor which affected the limb salvage (95% confidence interval, 0.231–0.769, P = 0.005). Conclusions: MESS is the most important predictors for limb salvage. Multidisciplinary team approach with timely diagnosis and immediate repair is the key to the ultimate goal of functional limb salvage.

Obesity has already been a global epidemic, and its prevalence has been projected to grow by 40% in the next decade. Its increasing prevalence has implications on the epidemiology of chronic kidney disease (CKD), which, in turn, could impact the health system and thereby the society in an adverse manner. Lack of community-based screening programs can lead to missed or late detection of CKD. The current study aims to estimate the prevalence of CKD in overweight and obese general population attending a screening camp in a tertiary care hospital in a North Indian city. In this cross-sectional study, 103 overweight and obese people from a community attending a health camp were screened for serum creatinine, urine analysis, random blood sugar, and uric acid. Demographic and anthropometric parameters were noted. Binary logistic regression analysis was used to find the predictors of CKD in these patients. The median age of the participants was 43 years with a male predominance (68%). More than half (58.4%) of the participants were obese and the remaining 41.6% were overweight. The overall prevalence of CKD was 17.5%. Individuals with obesity and diabetes were more prone to develop CKD (odds ratio = 4.868 and 7.941, respectively). CKD was prevalent in individuals with obesity. Obesity and diabetes were the significant predictors for the development of CKD. All the overweight and obese individuals should be periodically screened for kidney diseases.

AIM: The aim of this study was to study the effect of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser iridotomy on corneal endothelial cell count in patients with subacute angle closure using specular microscope. MATERIALS AND METHODS: In this prospective study, 50 cases of narrow-angle Grade 1 and Grade 2 (Shaffer gonioscopic grading) visiting the Regional Institute of Ophthalmology, Government Medical College, Amritsar underwent Nd:YAG laser peripheral iridotomy. After obtaining informed written consent, specular microscopy was performed before and after iridotomy at 1 week, 1 month, 3rd month, and at 6th-month follow-up visits. Central, nasal, and temporal endothelial cell counts were evaluated through noncontact specular microscopy. RESULTS: The mean participant age was 51.52 ± 7.9 years, and majority of the participants were females (76%). The mean IOP before the laser was 19.25 ± 1.914 mmHg and it varied from 18.50 ± 1.647 to 18.25 ± 1.699 mmHg (day 1, p = 0.06 and at 6 months, p = 0.04) following laser procedure. The mean corneal endothelial cell count at superotemporal site before laser peripheral iridotomy was 2844 ± 260, and this value decreased to 2807 ± 263, 2699 ± 267, 2656 ± 270, and 2591 ± 275 cells/mm2 at postiridotomy, 1, 3, and 6 months' follow-up visits, respectively; these differences were statistically significant (p < 0.05). The mean total energy required to produce iridotomy was 14.88 ± 6.71 mJ, ranging from 5 to 37 mJ. The linear regression analysis indicated no statistical correlation between change in endothelial cell count at the treated site and total mean energy used. No significant difference was found between preiridotomy and postiridotomy corneal thickness at any site. CONCLUSION: This study demonstrated a significant endothelial cell loss at the treated site in 6 months' follow-up and suggested that Nd:YAG laser iridotomy may pose hazard to the corneal endothelium, although corneal decompensation at the treated site or as a whole was not seen.

The process of forensic handwriting examination consists of two steps: the first step is the objective phase of the process and requires correct ocular observation to make a note of similarities and dissimilarities in the two samples of writing; the second step is subjective phase and depends on proper evaluation of what is observed based on expert’s belief, assumption and experience. The second phase, because of its subjective nature, can also be exploited by dishonest expert resulting in conflicting evidence. This scenario is obviously disruptive for justice, and generally weakens the credibility of this type of evidence.

Background: Deep vein thrombosis (DVT) often goes unrecognized and can cause severe morbidity and even mortality. Exposure to high altitude, immobilization, trauma and surgery are commonly recognised risk factors. Thrombophilia is also one of the important risk factors for recurrent thromboembolic events in younger population. Material and Methods: A prospective case series conducted at a zonal service hospital, in the chain of rearward evacuation from high altitude area in north India, among all the patients diagnosed with DVT (N=144) during the study period from Jan 2014 to Dec 2016. After history and clinical examination, the patients proven to have DVT with Colour Doppler Flow Imaging (CDFI) were included in the study. All the patients were treated with low molecular weight heparin (LMWH) initially and overlapped with oral anti-coagulants (OAC). Results: DVT accounted 0.41 % of total hospital admissions. Exposure to high altitude was recognised as the commonest predisposing factor in 25.7% cases. Immobilization, trauma, and surgery were the other common causes identified. Lower extremities, especially left lower limb was found to be most commonly affected in 57.6% cases. Involvement of multiple anatomical venous segments was commonly observed. The incidence of pulmonary embolism was 0.69%. LMWH followed by OAC proved to be an effective treatment modality with 81.2% patients showing improvement,4.9% remaining static and only 13.9% showing worsening.Conclusion: Acute DVT is responsible for the substantial burden of venous thrombo embolism (VTE) in healthy personnel posted to high altitude (HA). Exposure to high altitude, immobilization, trauma and surgery are common predisposing factors of DVT.

Chronic kidney disease (CKD) is no longer considered just a health burden, but a major health priority owing to its high treatment costs and poor outcome. The lack of community-based screening programs has led to the detection of CKD patients at advanced stages. This study aims to estimate the prevalence of CKD and patterns of known risk factors among the general population (middle-aged and elderly) attending a screening camp in a community-based setting. The study participants constituted a part of the general population of Varanasi (aged ≥45 years) who volunteered in a screening camp that was organized as part of the World Kidney Day Initiative at Opal Hospital. Information on age, sex, height, weight, smoking and drug history, history of diabetes, hypertension, and family history of kidney disease was extensively interrogated, while laboratory investigations such as urinalysis and serum creatinine levels were recorded. More than three-fifths of the participants were middle-aged adults (i.e., 45–64 years) and the remaining 34.8% were elderly population, i.e., ≥65 years. The overall prevalence of CKD in the 198 studied participants was 29.3%. Higher number of participants (40.6%) of elderly population had CKD (P = 0.011). The serum creatinine, albuminuria, and estimated glomerular filtration rate levels were strongly associated with CKD (P

Introduction: Postthrombotic syndrome (PTS) occurs in 20%–60% of patients after acute deep-vein thrombosis (DVT) treated with anticoagulation alone. Residual thrombus after DVT leads to ambulatory venous hypertension which consequently causes PTS. Thus, evacuating the clot during DVT itself might prevent PTS – the “Open Vein Hypothesis.” Pharmacomechanical catheter-directed thrombolysis (PCDT) evacuates the thrombus working on this very hypothesis. PCDT is usually performed using specialized devices which are expensive and not easily available in our country. In this study, we describe a method to perform PCDT using a commonly available and inexpensive guiding catheter in an aim to prevent PTS after DVT. Aims and Objectives: This study aimed to evaluate if in acute DVT, our method of PCDT reduces the occurrence of PTS, as compared to anticoagulation alone. Design: This is a prospective, randomized, comparative, cohort study. Study Period: The study was conducted from June 2016 to May 2017 with 1-year follow-up. Materials and Methods: Patients presenting with acute DVT of

Introduction: Polycystic ovarian syndrome (PCOS) is a common endocrinopathy typified by oligo-ovulation or anovulation, signs of androgen excess, and multiple small ovarian cysts. Materials and Methods: The study participants included fifty clinically diagnosed PCOS patients (diagnosed using according to the Rotterdam criteria) and twenty group-matched healthy female attendants of these patients. All controls had self-reported spontaneous regular menstrual cycles and no history of sub/infertility. Results: The mean fasting blood sugar levels in the study group of PCOS patients were 79.92 ± 8.55 mg%, the mean body mass index was 26.54 ± 5.14 kg/m2, and mean luteinizing hormone (LH) levels in the study group and control group were 10.46 ± 3.02 mlU/ml and 5.89 ± 2.12 mlU/ml, respectively. The mean difference between two groups was found to be statistically significant (P < 0.001). The mean LH-follicle-stimulating hormone (FSH) ratio in the study group was 1.97 ± 0.83, and in control group, it was 1.17 ± 0.37. The mean LH-FSH ratio was higher in study group than in control group and this difference was found to be statistically significant (P < 0.001). The mean thyroid-stimulating hormone in study group was 2.42 ± 0.99 μIU/ml, and in control group, it was 2.48 ± 0.72 μIU/ml. The difference between them was found to be statistically nonsignificant (P = 0.811). Thirty-six patients, i.e., 72% cases were found to be positive for polycystic ovaries on ultrasonography, while in control group, all women had normal ovaries. Conclusions: The possible pathophysiological mechanism of ovarian cyst formation in patients with PCOS is immune mediated and possibly similar to subclinical hypothyroidism.

Background and Aims: The aim is to determine the effect of addition of clonidine to ropivacaine for epidural labor analgesia with regard to onset of analgesia, duration of analgesia, neonatal outcome, and quality of analgesia. Material and Methods: A total of 60 term parturients of the American Society of Anesthesiologists Grade I and II with uncomplicated pregnancy, vertex presentation, posted for on-demand epidural labor analgesia after informed consent were divided in two groups. Group R (n = 30) patients received 10 ml solution comprising 0.2% ropivacaine. Group RC (n = 30) patients received a total of 10 ml of 0.2% ropivacaine and clonidine 1 μg/kg. Characteristics of the block, onset and duration of analgesia, and total analgesic requirements were noted. Pain and overall satisfaction scores were assessed with a 10-point visual analog scale. Mode of delivery and neonatal APGAR scores were recorded. Results: Maternal demographic characteristics were comparable between the groups. Addition of clonidine to ropivacaine shortened the onset and prolonged the duration of analgesia with decrease in ropivacaine requirement in Group RC. There was a significant difference between the two groups regarding visual analog score and quality of analgesia, which was better in Group RC. There were no significant differences between the two groups regarding motor block, hemodynamic parameters, and neonatal outcomes. Conclusion: We conclude that clonidine in low doses is a useful adjuvant to local anesthetics for epidural labor analgesia and a good alternative to opioids.

Background: Laser etching has several advantages as compared with conventional acid etching. However, results of earlier studies on conditioning surfaces with erbium, chromium:yttrium–scandium–gallium–garnet (Er, Cr:YSGG) before application of the fissure sealant have been inconclusive. Aim: The study aimed to evaluate the microtensile strength of resin-based fissure sealant bonded to primary enamel conditioned by Er, Cr:YSGG laser with varying power outputs. Materials and Methods: Fifty sound primary first molars were randomized into the following five groups based on pretreatment choice: Group 1: 3.5 W laser etching + acid etching; Group 2: 2.5 W laser etching + acid etching; Group 3: 3.5 W laser etching with no acid; Group 4: 2.5 W laser etching with no acid and Group 5: acid etching with no laser. Acid etch was performed with 35% orthophosphoric acid for 30 s. Laser etching was performed with Er, Cr:YSGG (2780 nm) laser using G6 tips and 600 μm diameter, 2.5 W or 3.5 W power outputs, pulse duration of 140 μs and a repetition rate of 20 Hz. Sealant was applied on the buccal surface followed by an incremental buildup with composite resin. Microtensile bond strength was assessed and compared among the five groups using one- and two-way ANOVA. Results: There was no statistical difference in the mean bond strength between groups except in Group 4 (9.66 MPa) (Group 1: 15.57 MPa; Group 2: 14.18 MPa; Group 3: 14.78 MPa; Group 5: 14.63 MPa). Conclusion: Pretreatment with 3.5 W Er, Cr:YSGG laser alone results in microtensile bond strengths similar to that produced by acid etching, indicating that enamel etching using 3.5 W Er, Cr:YSGG laser would result in the long-term success of pit and fissure sealants in primary teeth.

Background: In dialysis-dependent end-stage renal disease patients, arteriovenous access (AV access) is the chief mode of hemodialysis access. Basilic vein transposition (BVT) is an alternative in patient with failed multiple AV access. The aim of the study is to assess the outcomes of BVT at 1 year of follow-up. Materials and Methods: This prospective, nonrandomized, observational study was conducted in the Department of Vascular Surgery at Sir Ganga Ram Hospital, New Delhi. Forty consenting patients with end-stage renal failure on maintenance hemodialysis having no other options utilizing superficial veins of the upper limb for AV access formation were included. All the complications, secondary interventions and patency rates were calculated at 1 year of follow-up. Statistical analysis was performed using Chi-square test, and patency rates were assessed using Kaplan–Meier survival curve. Results: Most of the patients were in the age group of 51–70 year with the mean age of 51.98 year. The mean basilic vein diameter was 2.84 mm. Fistula thrombosis was the most common complication and was seen in 17.5% cases followed by limb edema in 13% of cases. Re-interventions (fistula thrombectomy, balloon angioplasty etc.) were performed in 27.5% of the patients. The primary patency rate and secondary patency rate at 1 year of follow-up were 77.5% and 85%, respectively. Conclusions: BVT is a feasible and suitable surgical option to provide a durable and autogenous AV access to end-stage renal disease patients requiring maintenance hemodialysis.

Intimal sarcoma is a highly aggressive and rare malignant tumor of the vascular system. We are reporting this unusual primary tumor of popliteal artery presenting as aneurysm in an infant. We report a case of an 8-month-old girl with the incidental observation of nontender and pulsatile swelling in the right popliteal fossa. An arterial duplex scan and computed tomography angiography revealed an intensely enhancing well-defined lesion (3.2 cm × 2.4 cm) of the popliteal artery suggestive of pseudoaneurysm/aneurysm. The patient underwent exploration of the popliteal artery with excision of aneurysmal sac. On histopathological examination and immunohistochemical staining, findings were suggestive of intimal sarcoma. Postoperative recovery was uneventful. At 1-year of follow-up, patient is clinically stable with no disability and any signs of recurrence or metastasis. Malignancy in peripheral arterial aneurysmal is extremely rare. More empirical evidence is yet required to make the diagnostic and therapeutic protocol to deal with this aggressive tumor of the vascular system.

Pseudomonas aeruginosa is an important opportunistic pathogen causing a variety of acute infections including nosocomial pneumonias, sepsis, urinary tract infections, keratitis, wound and skin infections. P. aeruginosa continues to be a leading cause of infections in immunocompromised host including patients with cystic fibrosis and is among the most virulent of the opportunistic pathogens as listed by the Centers of Disease Control (CDC). P. aeruginosa has also developed mechanisms to colonize surfaces by coordinately expressing genes in a density dependent manner regulated by the production of small diffusible molecules called auto inducers or quorum sensing (QS) molecules. Activation of the QS cascade promotes formation of biofilms which provide an encapsulated communal structure that coats mucosal surfaces and invasive devices. These biofilms make conditions more favorable for bacterial persistence as embedded bacteria are inherently more difficult to eradicate by both antibiotic regimens as well as by innate immune systems as compared with those in the planktonic state. The objective of this report is to provide an overview; (i) propagation of P. aeruginosa biofilms; (ii) components of the biofilm matrix and their transcriptional regulation; (iii) key signaling pathways regulating C-di-GMP dependent biofilm dispersal; (iv) characterization of experimental models of biofilms.

Background: Vascular trauma can threaten both limb as well as life of the patient. Combat-related vascular injuries are different from civilian vascular injuries in terms of epidemiology, mechanism, pathophysiology, and outcome. Combat or military trauma is generally penetrating trauma (high energy weapons). Difficult evacuation and transportation from the battle field complicates the vascular injury and its outcome. Materials and Methods: This is a single-center, prospective, observational study conducted at a service hospital in Jammu and Kashmir. Twenty-five patients with mean age 25.76 years (18–43 years) who underwent vascular intervention for trauma from December 2013 to November 2016 were included. Data pertaining to vascular injury regarding to site of injury, associated injuries, type of vascular repair, outcome, and complications were recorded and analyzed. Results: Five hundred and eighty trauma patients were admitted during the study period with 4.3% of the patients having vascular injury. All the patients were males and most of them were in the second or third decade of life. The mean time interval between the trauma and arrival to the hospital was 7 h. Lower extremity was the most common site of trauma (52%) of the patients followed by upper extremity. In 56% of the patients, vessels were repaired with reverse saphenous vein graft harvested from the uninjured limb. Two patients (8%) had secondary amputation and one patient (4%) died due to sepsis. Conclusion: Expeditious evacuation, quick transfer, early diagnosis and management including advanced endovascular care are essential for the limb salvage and survival of the serving soldiers.

>Background: Dural puncture epidural (DPE) is a method in which a dural hole is created prior to epidural injection. This study was planned to evaluate whether dural puncture improves onset and duration of labor analgesia when compared to conventional epidural technique.Methods and Materials: Sixty term primigravida parturients of ASA grade I and II were randomly assigned to two groups of 30 each (Group E for conventional epidural and Group DE for dural puncture epidural). In group E, epidural space was identified and 18-gauge multi-orifice catheter was threaded 5 cm into the epidural space. In group DE, dura was punctured using the combines spinal epidural (CSE) spinal needle and epidural catheter threaded as in group E followed by 10 ml of injection of Ropivacaine (0.2%) with 20 mcg of Fentanyl (2 mcg/ml) in fractions of 2.5 ml. Later, Ropivacaine 10 ml was given as a top-up on patient request. Onset, visual analouge scale (VAS), sensory and motor block, haemodynamic variables, duration of analgesia of initial dose were noted along with mode of delivery and the neonatal outcome.Results: Six parturients in group DE achieved adequate analgesia in 5 minutes while none of those in group E (P < 0.05) achieved adequate analgesia. The mean VAS score was 4.97 ± 0.85 in group E and 4.33 ± 0.922 in group DE at 5 min (P < 0.05). Duration of analgesia of initial bolus dose was 99.37 ± 23.175 min in group E and 98.77 ± 24.955 min in group DE (P > 0.05).Conclusions: Both techniques of labor analgesia are efficacious; dural puncture epidural has the potential to fasten onset and improve quality of labor analgesia when compared with conventional epidural technique.

Objective: Blood products are vital resources to health-care institutions with constantly growing demands. Gross over-ordering of blood causes exhaustion of valuable supplies and resources and add financial burden to patients undergoing surgical procedure. Aims: Study was undertaken to evaluate blood requisition, utilization, and management in cardiac surgery patients in a tertiary care hospital. Materials and Methods: Prospective study was conducted in cardiac surgery patients over 3 years from 2013 to 2015. Blood utilization indices were computed. Cross match to transfusion ratio (C:T) ratio of 2.0 and below, transfusion index (TI) value of 0.5 or more, and transfusion probability (%T) value of 30% and above were considered indicative of significant blood usage. Statistical analysis was done using Student's t-test. Results: During the study, a total of 15,392 patients' requisitions were received. Out of 25,190 units of blood cross-matched, 18,741 units were issued (C:T ratio 1.34) implying that overall 25.60% of blood was unutilized. From a total of 2752 units cross-matched for cardiac surgery cases, only 1296 units were transfused with C:T Ratio 2.12 implying that 52.91% of blood was unutilized which was much higher and statistically highly significant than in total patients. Overall TI was 1.22 and %T as 83.07% while for cardiac patients, TI was 2.32 with %T as 85.84%. Conclusions: Blood transfusion plays a major role in resuscitation and management of cardiac surgery patients. Blood transfusion services need to adopt blood conserving policies. Efforts should be made to adopt more conservative transfusion thresholds, conduct regular auditing, and periodic feedback to improve blood ordering, handling, distribution, and utilization practices of this scarce resource.

Introduction: Transfusion of serological safe blood is an essential requirement in transfusion medicine. Development of anti- red blood cell antibodies remains a major problem. Materials and Methods: A study was conducted on 24237 donors and 25155 patients between August 2013 and July 2016 to determine the prevalence of RBC autoantibodies and management of autoantibody screen positive cases. Results: 19 donors (0.078%) were identified with RBC autoantibodies. 16 of 19 donors showed warm autoantibodies (WAAs), one showed cold autoagglutinin and two showed autoantibodies; type not identified. Ten patients (0.039%) were identified with autoantibodies, of which nine showed warm autoantibodies and one showed cold autoagglutinin. Conclusion: Autoantibodies are mostly formed against the high incidence antigens and therefore react with red cells of random donors' blood, causing difficulty in interpretation of cell typing, compatibility testing, antibody detection and antibody identification. There are wide variations in testing and RBC selection practices in patients with WAAs, further studies are required to evaluate and compare different testing algorithms and transfusion strategies.

Background: The success of hemodialysis depends on a functioning vascular access. The most important factor limiting the arteriovenous fistula (AVF) growth and patency is the availability of a good caliber venous segment: Cephalic veins smaller than 2.5 mm have been reported to have increased failure rates. Unfortunately, in the Indian population, we frequently come across patients with a poor cephalic vein diameter ≤2 mm. The present study was done to evaluate if primary balloon angioplasty (PBA) of these small cephalic veins could improve the primary patency rates and maturation time of autogenous AVFs, and also to compare this technique with the standard hydrostatic dilatation technique. Materials and Methods: Sixty patients requiring arteriovenous access surgery (but having small cephalic veins (≤2 mm) were randomized into two groups of thirty patients each. All patients underwent a thorough preoperative evaluation, after which they were subjected to AVF surgery. Thirty of these patients underwent standard hydrostatic dilatation (HD) whereas the remaining thirty were offered PBA of the vein before creating the fistula. These patients were followed up for 6 months and primary patency, reintervention rates, and maturation times were recorded. Results: Immediate technical success was 100% in the PBA group, with 6-month primary patency of 93.3%, whereas HD group had 73.3% immediate success and a 6-month primary patency of 63.3%. In HD group, 36.7% patients underwent re-intervention over a follow-up of 6 months, as compared to only 6.7% in PBA group. The average maturation time for PBA group was 32.83 days, whereas in HD group, it was 52.53 days. Conclusions: PBA of very small cephalic veins (≤2 mm) is a safe and feasible procedure. The technique is associated with excellent primary patency rates and decreased maturation time, significantly decreases the need for re-intervention, and is superior to the standard hydrostatic dilatation technique. It has the potential to maximize the number of patients with autogenous AVF by including those patients who have been rejected due to small cephalic veins.

Endovascular aortic repair is becoming the standard of care for abdominal aortic aneurysm. Despite aorta being a high flow system, there is still a definite risk of endograft occlusion. Management of occluded aortic endograft is highly controversial. Successful endovascular relining in aortic endograft occlusion is a technically demanding and forthcoming secondary intervention, not been studied extensively. We are reporting a case of aortic endograft thrombosis in a morbidly obese, 64-year-old gentleman with multiple comorbidities presenting with lifestyle-limiting claudication. The patient had a history of abdominal aortic aneurysm repair with aorto-uni-iliac device and femorofemoral bypass. The patient was managed by relining of aortic endograft with graft thrombectomy and snorkeling of the left renal artery. Postoperative course was uneventful. After 1 year of follow-up, the patient is free of symptoms with patent endograft. More empirical evidence is yet required to make the standard guidelines for the management of aortic endograft occlusion.

Abdominal vascular injuries are the most common cause of early death after penetrating abdominal trauma if especially associated with a chest injury and fracture of long bones. The surgical exposure and associated intraabdominal injuries may challenge the skills and judgment of even the most experienced surgeons. Rapid transportation to a trauma center, early recognition of injuries, damage control resuscitation, and early surgical intervention are critical for patient's survival.

Aim: The purpose of this investigation is in vitro comparison of the shear bond strength (SBS) of composite resin bonded to enamel pretreated with an acid etchant against enamel etched with erbium, chromium: yttrium, scandium, gallium, garnet (Er, Cr:YSGG) laser. Materials and Methods: Sixty premolars were sectioned mesiodistally and these 120 specimens were separated into two groups of 60 each (Groups A and B). In Group A (buccal surfaces), enamel surface was etched using 37% phosphoric acid for 15 s. In Group B (lingual surfaces), enamel was laser-etched at 2W for 10 s by Er, Cr:YSGG laser operational at 2780 nm with pulse duration of 140 μs and a frequency of 20 Hz. After application of bonding agent on all test samples, a transparent plastic cylinder of 1.5 mm × 3 mm was loaded with composite and bonded by light curing for 20 s. All the samples were subjected to SBS analysis using Instron Universal testing machine. Failure modes were observed under light microscope and grouped as adhesive, cohesive, and mixed. Failure mode distributions were compared using the Chi-square test. Results: SBS values obtained for acid-etched enamel were in the range of 7.12–28.36 megapascals (MPa) and for laser-etched enamel were in the range of 6.23–23.35 MPa. Mean SBS for acid-etched enamel was 15.77 ± 4.38 MPa, which was considerably greater (P < 0.01) than laser-etched enamel 11.24 ± 3.76 MPa. The Chi-square test revealed that the groups showed no statistically significant differences in bond failure modes. Conclusions: We concluded that the mean SBS of composite with acid etching is significantly higher as compared to Er, Cr: YSGG (operated at 2W for 10 s) laser-etched enamel.

Background: Carotid endarterectomy (CEA) using eversion technique has been used by vascular surgeons across the world. A simpler technique, modified eversion endarterectomy (MEE) is emerging as a promising option. Advantages are shorter clamping time, less neurological complications, and avoidance of prosthetic patch plasty. Selective shunting can be done whenever required. In the climate of carotid artery stenting versus CEA debate, one would consider this method to reduce the morbidity of CEA. Materials and Methods: This is a retrospective analysis of patients undergoing CEA at a single institution by four vascular surgeons over a period of 2½ years (January 2012–June 2014). Data were collected from computerized medical records and various parameters analyzed. Forty patients underwent MEE during the given period. The majority were symptomatic 34 (85%). Results: One patient (2.5%) required conversion to conventional endarterectomy with patch plasty because of the long length of the plaque. One patient (2.5%) had lateralizing transient ischemic attack (TIA) in the postoperative period. Two patients had hematoma of which one was returned to operating theater for evacuation. Seven patients underwent MEE along with coronary artery bypass grafting with uneventful recovery. Selective shunting was done for four patients (10%) who had a contralateral occlusive disease or poor back bleed from an internal carotid artery (ICA) on table. Average ICA cross-clamping time was 13 min. None of the patients had cerebrovascular accident/TIA in the follow-up period. Conclusions: MEE is a simpler and easier technique to perform with comparable results when compared with other conventional techniques. MEE, in our assumption, will be the technique of choice in the future for open CEA; however, larger studies with longer follow-up are required before final validation of this technique.

Defensins are abundant and widely distributed peptides in human and animal tissues that are involved in host defence. Defensins not only have the ability to strengthen the innate immune system but can also enhance the adaptive immune system by chemotaxis of monocytes, T-lymphocytes, dendritic cells and mast cells to the infection site. Defensins also improves the capacity of macrophage phagocytosis. A greater understanding of how these peptides act in the healthy, gingivitis and periodontitis conditions would definitely open new opportunities for identification, prevention and treatment of periodontal diseases. This discussion focuses on recent studies about biological function of defensins in human diseases and animal models.

Long gap esophageal atresia (OA) is a challenging condition. While discussing the various methods of management available to us, we report the use of magnetic resonance imaging in a case of pure OA to judge the gap between two ends of the esophagus.

Ameloblastoma has intrigued clinicians as well as pathologists due to its diverse clinical behavior and histomorphologic presentations. Keratoameloblastoma is a rare histologic sub type, characterized by extensive keratin formation within ameloblastic epithelium, with only a handful number of cases described in the literature. Here, we report a case of this uncommon sub type of ameloblastoma in a young female patient presenting as an extensive lesion in mandibular ramus area. The radiological and fine needle aspiration findings suggested of a keratinizing cystic lesion and incisional biopsy showed features of ameloblastoma. Patient underwent segmental mandibulectomy and histological examination of excisional specimen revealed features of ameloblastoma with abundant keratinization leading to a diagnosis of keratoameloblastoma. The diagnostic pitfalls related with the lesion have been discussed along with a short review of the literature.

Background: Dengue virus infection has recently taken endemic proportions in India with dengu type-3 (DEN-3) as a predominant serotype. In this study, we carried out the selection pressure analysis of three critical immunogenic regions of DEN-3. Phylogenetic analysis was then carried out on the positively selected genomic region in the DEN-3 virus strains isolated in the Indian subcontinent over a time span of 25 yr (1984-2008). Bayesian Markov chain Monte Carlo (MCMC) calculation of the substitution rate was carried out for the DEN-3 genotype-III sequences. Methods: Sequences corresponding to the C-prM, E-NS1 and NS1 sequence regions of DEN-3 strains were taken for the positive selection analysis. The C-prM junction sequences were then used to construct a maximum likelihood (ML) phylogenetic tree. Substitution rates were also calculated under various models of population growth. Results: It was found that codon 86, corresponding to a conserved arginine residue in a crucial T-cell epitope of the C-protein was under significant positive selection. The K86R substitution was found to exist in almost all the Indian strains isolated after 2004. The ML tree constructed from the C-prM junction sequences indicated that strains from the 2006 dengue incidences in Delhi, namely: 04/03/del2006, 05/03/del2006, and 06/03/del2006 were the most rapidly evolving. Substitution rates of a DEN-3 genotype-III sequences from the Indian subcontinent were found to be ~3.0 times higher than those reported from other parts of the world. Conclusion: Positive selection in the codon corresponding to R86 of the highly conserved surface C-protein is important in view of its occurrence in a T-cell epitope as well as its strict conservation in all the DEN strains. Phylogenetic analysis of the C-prM junction sequences showed that three strains of 2006 are rapidly evolving. These results were also supported by calculations of the substitution rates. Their significance in the expansion of viral epidemics requires to be investigated.