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Background: Essential step in the management of septic shock is prompt recognition at an early stage and prediction of fluid responsiveness. Existing methods of assessing septic shock in children have limited accuracy. This study was conducted to determine the serial inferior vena cava (IVC) dimension and its correlation with clinical cardiopulmonary-cerebral assessment in children with septic shock. Subjects and Methods: A prospective observational study was conducted from 1 month to 12 years of children with septic shock resuscitated in the emergency department. Serial ultrasound measurements of IVC/aorta ratio were obtained before and after each fluid bolus of 10 ml/kg over 20 min. Chi-square tests were used to find out whether the statistical differences between assessing fluid status with clinical parameters and assessing fluid status with IVC/aorta ratio after fluid boluses were really significant or not. Results: Hundred patients were enrolled and included in the final analysis. Using Chi-square test, there were significant (P < 0.05) strong associations between heart rate, pulse volume, capillary refill time, blood pressure, and IVC/aorta ratio during multiple assessments following fluid boluses. Conclusions: IVC/aorta ratio was statistically significantly associated with volume status and clinical assessment. A single assessment of IVC/aorta ratio did not appear useful. Serial determinations of IVC/aorta ratio emerged statistically significant in the assessment of fluid status in children with septic shock during resuscitation in the emergency department.

Background: Glycemic control in diabetes can be achieved by adopting self-care practices. It also leads to reduction of complications and improvement in the quality of life. Identification of barriers to adopting these practices can help devise strategies to overcome them. This study was conducted to understand the self-care practices among diabetics and the barriers affecting those practices among diabetics in the urban slum area. Materials and Methods: This qualitative study using Focus Group Discussions (FGDs) was conducted in a chronic disease Outpatient clinic in Mumbai, in November 2020. Four FGDs with 32 participants were conducted. Thematic analysis of the transcripts was done. Results: Three major themes were identified – living with diabetes, practices to maintain glycemic control, and potential barriers. Barriers for self-care practices were - confusing advice provided by family and doctors, feeling rejected (stigmatized), lack of motivation for exercise, complications of diabetes, lack of family cooperation, lack of knowledge on foot care, physical constraints, nonavailability of medications, lack of social and financial support, suboptimal knowledge regarding diabetes, and misconceptions. Conclusions: Motivating diabetic patients for regular physical activity by starting from simple indoor exercises to outdoor exercises are necessary. Counseling the family members on the complications of diabetes due to inappropriate dietary practices should be advocated. Improvement in doctor-patient communication and providing information on the foot care practices is the need of the hour.

Aim: A tissue-equivalent bolus of sufficient thickness is used to overcome build up effect to the chest wall region of postmastectomy radiotherapy (PMRT) patients with tangential technique till Radiation Therapy Oncology Group (RTOG) Grade 2 (dry desquamation) skin reaction is observed. The aim of this study is to optimize surface dose delivered to chest wall in three-dimensional radiotherapy using EBT3 film. Materials and Methods: Measurements were conducted with calibrated EBT3 films with thorax phantom under “open beam, Superflab gel (0.5 cm) and brass bolus conditions to check correlation against TPS planned doses. Eighty-two patients who received 50 Gy in 25# were randomly assigned to Group A (Superflab 0.5 cm gel bolus for first 15 fractions followed by no bolus in remaining 10 fractions), Group B or Group C (Superflab 0.5 cm gel or single layer brass bolus, respectively, till reaching RTOG Grade 2 skin toxicity). Results: Phantom measured and TPS calculated surface doses were within − 5.5%, 4.7%, and 8.6% under open beam, 0.5 cm gel, and single layer of brass bolus applications, respectively. The overall surface doses (OSD) were 80.1% ±2.9% (n = 28), 92.6% ±4.6% (n = 28), and 87.4% ±4.7% (n = 26) in Group A, B, and C, respectively. At the end of treatment, 7 out of 28; 13 out of 28; and 9 out of 26 patients developed Grade 2 skin toxicity having the OSD value of 83.0% ±1.6% (n = 7); 93.7% ±3.2% (n = 13); and 89.9% ±5.6% (n = 9) in Groups A, B, and C, respectively. At the 20th–23rd fraction, 2 out of 7; 6 out of 13; and 4 out of 9 patients in Groups A, B, and C developed a Grade 2 skin toxicity, while the remaining patients in each group developed at the end of treatment. Conclusions: Our objective to estimate the occurrence of optimal dose limit for bolus applications in PMRT could be achieved using clinical EBT3 film dosimetry. This study ensured correct dose to scar area to protect cosmetic effects. This may also serve as quality assurance on optimal dose delivery for expected local control in these patients.

Bezoars are usually defined as collections of nondigestible matter that most commonly accumulates in the stomach and can sometimes extend to the small bowel. Trichobezoars are a rare entity which is most commonly observed in young psychiatric females with trichotillomania and trichophagia. Here, we report a case of giant gastric trichobezoar and a novel technique of laparoscopic removal in a 16 year old female with trichophagia. The giant gastric trichobezoar weighing about half a kilogram was removed en masse laparoscopically by a novel technique. She had an uneventful postoperative recovery and was discharged after psychiatric counseling.

Aim: In some situations of radiotherapy treatments requiring application of tissue-equivalent bolus material (e.g., gel bolus), due to material's rigid/semi-rigid nature, undesirable air gaps may occur beneath it because of irregularity of body surface. The purpose of this study was to evaluate the dosimetric parameters such as surface dose (Ds), depth of dose maximum (dmax), and depth dose along central axis derived from the percentage depth dose (PDD) curve of a 6 MV clinical photon beam in the presence of air gaps between the gel bolus and the treatment surface. Materials and Methods: A bolus holder was designed to hold the gel bolus sheet to create an air gap between the bolus and the radiation field analyzer's (RFA-300) water surface. PDD curves were taken for field sizes of 5 cm × 5 cm, 10 cm × 10 cm, 15 cm × 15 cm, 20 cm × 20 cm, and 25 cm × 25 cm, with different thicknesses of gel bolus (0.5, 1.0, and 1.5 cm) and air gap (from 0.0 to 3.0 cm), using a compact ionization chamber (CC13) with RFA-300 keeping 100 cm source-to-surface (water) distance. The dosimetric parameters, for example, "Ds," "dmax," and difference of PDD (maximum air gap vs. nil air gap), were analyzed from the obtained PDD curves. Results: Compared to ideal conditions of full contact of bolus with water surface, it has been found that there is a reduction in "Ds" ranging from 14.8% to 3.2%, 14.9% to 1.1%, and 12.6% to 0.7% with the increase of field size for 0.5, 1.0, and 1.5 cm thickness of gel boluses, respectively, for maximum air gap. The "dmax" shows a trend of moving away from the treatment surface, and the maximum shift was observed for smaller field size with thicker bolus and greater air gap. The effect of air gap on PDD is minimal (≤1%) beyond 0.4 cm depth for all bolus thicknesses and field sizes except for 5 cm × 5 cm with 1.5 cm bolus thickness. Conclusions: The measured data can be used to predict the probable effect on therapeutic outcome due to the presence of inevitable air gaps between the bolus and the treatment surface.

Purpose: The aim of this study is to estimate delivered radiation doses inside planning tumor volume (PTV) using the in vivo (mid-plane dose) measurement and transit measurement methods in gynecological malignancy patients undergoing three-dimensional conformal radiotherapy (3DCRT) using calibrated ionization chambers. Materials and Methods: Six patients with histopathologically proven carcinoma of the cervix or endometrium were planned with four-field 3DCRT to the pelvic site. Isocenter was at the geometric mid-plane of PTV with a dose prescription of 50 Gy in 25 fractions. Clinical mid-plane dose (Diso,Transit) estimates were done in one method (transit) using the FC-65 positioned at electronic portal imaging device level. In another method, a repeat computerized tomography scan was performed (at the 11th fraction) using CC-13 having a protective cap in the vaginal cavity for in vivo measurements (Din vivo). Simultaneous measurements were performed with the two chambers from the 11th fraction onward at least 3–4 times during the remaining course of treatment. Results: The agreement of mean doses from these two described methods and treatment planning system reference doses was in the range of −4.4 ± 1.1% (minimum) to −0.3 ± 2.0% (maximum) and −4.0 ± 1.7% (minimum) to 1.9 ± 2.4% for Dinvivoand Diso,Transit, respectively, which are an acceptable range of daily radiation dose delivery. Conclusion: The fundamental importance of this study lies in simultaneous validation of delivered dose in real time with two methods. A study in this small number of patients has given the confidence to apply transit measurements for quality assurance on a routine basis as an accepted clinical dosimetry for the selected patients.

Introduction: Cardiac autonomic neuropathy (CAN) is a key complication of type 2 diabetes mellitus (Ty2DM). Vascular endothelial-derived growth factor (VEGF-A) plays a key role in diabetic macrovascular and microvascular complications. It is shown to be elevated in diabetic neuropathy and has the potential to serve as a biomarker in Ty2DM. We evaluated VEGF-A levels and cardiac autonomic function in newly diagnosed Ty2DM patients. Materials and Methods: Forty-four newly diagnosed patients (with symptoms within 1 year from the date of recruitment) were included in the study. Cardiac autonomic function was assessed using heart rate variability (HRV) and Ewing's battery tests. Ewing's scores were computed and tabulated. VEGF-A levels were estimated using enzyme-linked immunosorbent assay (ELISA). Results: The patients demonstrated normal responses to the reactivity tests. Ewing's scores were 0 (0-0) and 0 (0-0) for sympathetic and parasympathetic parameters, respectively. The autonomic tone was impaired as assessed by HRV parameters. VEGF-A levels were elevated (308.3 ± 167.2 pg/mL) when compared with the previous literature. Discussion: Impaired tone with normal reactivity was suggestive of early stage of autonomic neuropathy. Elevated VEGF-A levels may be attributed to a protective action of the factor seen in early stages of neuropathy in Ty2DM. Serial VEGF-A estimation in large cohorts of newly diagnosed diabetics may validate it as a biomarker in CAN seen in Ty2DM.

Background: Stress is a psychophysiological phenomenon. Due to recent lifestyle modifications prevalence of stress is increasing among adults and adolescents. Adolescence is a period of storm and stress and any excess stress would have negative impact on their sleep and would ultimately affect their academic performance and health. Hence the current study proposes to evaluate the effect of stress on sleep hygiene among school going adolescents in Chennai. Materials and Methods: A cross-sectional study and participants were healthy male (84) and female (48) school going adolescents between the age group of 15-19 years (n = 132). Stress was assessed using Perceived Stress Scale (PSS) and sleep hygiene was assessed using Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD). Results: In all, 84.8% of the adolescents reported that they are academically overloaded. Both the genders were found to be moderately stressed (Males: 63.6%; females: 66.7%). Prevalence of sleep disturbances was found to be 23.5% and increase in stress was found to be associated with decrease in sleep quality. Discussion: The study shows that prevalence of stress is high among adolescents and it is negatively influencing their sleep hygiene. Hence, early identification and management of stress is required for school going late adolescents for better academic performance and wellbeing.

Rehabilitating hospitalized bedridden elderly patients is a challenging task for multidisciplinary team. The reasons for their hospital stay, their level of physical activity before hospitalization, and their disease prognosis interfere with the physiotherapist's intervention in mobilizing the patient out of bed. In this case study, Mr. S, a 66-year-old patient, hospitalized for hyponatremia and bounded to bed for 2 weeks due to his comorbid illness (hypertension and type II diabetes) and delirium was mobilized with cognitive activity, and the physiotherapy interventions have been discussed. This case study demonstrates the impact of cognitive therapy combined with physiotherapy interventions in mobilizing the elderly patient with delirium. In this case study, the patient was treated with cognitive therapy and physiotherapy for 7 days. Baseline and postintervention assessment of timed up and go test (TUG) and 6-min walk test (6MWT) was screened by a senior physiotherapist who is not aware of the interventions provided. Cognitive therapy and physiotherapy interventions are provided by a therapist who is not aware of the baseline and postintervention results. After 7 days, Mr. S was physically active and performed TUG in 12 s and achieved 245.4 m in 6MWT. Cognitive activity is essential among elderly patients expressing the state of delirium. Without sound cognition, it is not easy to rehabilitate elderly patients. In this case study, cognitive activity combined with physiotherapy is found to be effective.

Background: Different pattern materials do not produce copings with satisfactory, marginal accuracy when used on stone dies at varying time intervals. Purpose: The purpose of this study was to evaluate and compare the vertical marginal accuracy of patterns formed from three materials, namely, thermoplastic resin, light cured wax and inlay casting wax at three-time intervals of 1, 12, and 24 h. Methodology: A master die (zirconia abutment mimicking a prepared permanent maxillary central incisor) and metal sleeve (direct metal laser sintering crown #11) were fabricated. A total of 30 stone dies were obtained from the master die. Ten patterns were made each from the three materials and stored off the die at room temperature. The vertical marginal gaps were measured using digital microscope at 1, 12, and 24 h after reseating with gentle finger pressure. Results: The results revealed a significant statistical difference in the marginal adaptation of three materials at all the three-time intervals. Light cured wax was found to be most accurate at all time intervals, followed by thermoplastic resin and inlay casting wax. Furthermore, there was a significant difference between all pairs of materials. The change in vertical marginal gap from 1 to 24 h between thermoplastic resin and light cured wax was not statistically significant. Conclusion: The marginal adaptation of all the three materials used, was well within the acceptable range of 25–70 μm. The resin pattern materials studied revealed significantly less dimensional change than inlay casting wax on storage at 1, 12, and 24 h time intervals. They may be employed in situations where high precision and delayed investing is expected.

Lasers have come up as the newest therapeutic modality in dermatological conditions including melasma. In this article, as a group of experts from Pigmentary Disorders Society in collaboration with South Asian Pigmentary Disorders Forum (SPF), we have tried to discuss the lasers which have been used in melasma and formulate simple consensus guidelines. Following thorough literature search, we have summarised the rationale of using the lasers and the supporting evidences have also been provided. It is clear that laser cannot be the first line treatment for melasma. However, it can be used as an adjuvant therapy in resistant cases, provided the selection of patient and counselling has been done properly.

Melasma is a notorious dermatosis, often resistant to treatment. Chemical peeling constitutes an acceptable option of management of melasma (of any type and duration). In this article, as a group of experts from Pigmentary Disorders Society (PDS) in collaboration with South Asian Pigmentary Forum (SPF), we have tried to elaborate the various chemical peeling agents for the treatment of melasma. Besides, we have reviewed the indications, mechanism of action, rationality and the detailed procedure of peeling. The evidence in favor of various peeling agents have been summarized as well.

Melasma is one of the most common hyperpigmentary disorders found mainly in women and dark-skinned patients. Sunlight, hormones, pregnancy, and genetics remain the most implicated in the causation of melasma. Although rather recalcitrant to treatment, topical agents such as hydroquinone, modified Kligman's Regime, azelaic acid, kojic acid, Vitamin C, and arbutin still remain the mainstay of therapy with sun protection being a cornerstone of therapy. There are several new botanical and non botanical agents and upcoming oral therapies for the future. There is a lack of therapeutic guidelines, more so in the Indian setup. The article discusses available evidence and brings forward a suggested treatment algorithm by experts from Pigmentary Disorders Society (PDS) in a collaborative discussion called South Asian Pigmentary Forum (SPF).

Background: Parkinson's disease is a movement disorder that seriously affects body balance and gait; therefore, increases the risk of fall and related complications. Freezing of gait and postural instability are disabling symptoms, which compromises motor independence among Parkinson's disease patients. Aims and Objectives: The purpose of this study analyses the effects of square-stepping exercise (SSE) among Parkinson's disease patients in terms of improving balance and reducing fall risk. Materials and Methods: This is a pilot randomized controlled study, in which thirty male and female Parkinson's disease patients between 60 and 70 years of age were selected by simple random sampling method and randomly divided into SSE group (N-15) and conventional physiotherapy (CPT) group (N-15). Interventions were provided for 4 weeks. Baseline and posttest outcomes were measured using the Berg balance scale (BBS) and timed up and go test (TUG). Results: Statistical measures of mean, standard deviation, and t-test were performed using SPSS 21. SSE exhibited statistical significant improvement in BBS (P < 0.05) and TUG (P < 0.0001) compared to CPT group. Conclusion: SSE is more effective in improving balance and gait in Parkinson's disease. Although further studies with larger samples are required, the result of this study implies that SSE could be used as a mean of rehabilitation in Parkinson's disease.

Background: Achilles tendinitis is a common overuse injury among both elite and recreational athletes involved in activities such as repetitive jumping and running. Aim: The aim of this single-blinded randomized study was to compare the efficacy of muscle energy technique (MET) and eccentric loading exercise (ELE) interventions on improving functional ability and pain reduction among athletes with Achilles tendinitis. Methods: A single-blinded, pilot, randomized study was conducted in the Department of Physical Therapy, Global Hospitals and Health City, India, with 6-week follow-up. A total of 30 patients with Achilles tendinitis were randomly allocated to receive either MET (n = 15) or ELE (n = 15) treatment. Treatment effects were evaluated by pre- and post-treatment assessment of visual analog scale (VAS) and Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Measures were performed by single-blinded evaluators at baseline and at 2, 4, and after 6 weeks of treatment. Results: Both groups showed a significant difference in VAS after 6 weeks' ELE group showed a significant improvement during treatment at 2 and 4 weeks in comparison with MET group. The VISA-A scale score significantly improved in both groups. Yet, comparison of VISA scores between groups showed marginally significant difference (P = 0.012). Conclusion: This pilot randomized controlled trial (RCT) showed the efficacy of ELE in reducing pain and improving functional ability among patients with Achilles tendinitis. The findings of this study provide the rationale for undertaking a large-scale RCT. A large sized trial is needed to establish evidence for clinical practice of ELE in Achilles tendinitis cases.

With conventional diagnostic X-ray machines with over couch X-ray tubes, it is not possible to obtain anteroposterior (AP) and lateral (Lat) radiographs without changing the posture of the patients. In an old 300 mA X-ray machine with a fluoroscopy screen (12.4 kg) (1995 model), by substituting the screen with suitable counterweight and making provision to take the hoist pillar up to the edge of the wall, we could get isocentric setup for a hospital stretcher kept near the chest stand. This setup provided acceptable AP–Lat radiographs for brachytherapy localization using “Perspex jig” (Nucletron, Netherlands) and field check radiographs in head and neck, esophagus patients for treatment planning.

Background: Topical antifungals especially azole group of drugs are effective agents in the treatment of dermatophytoses producing 100% clinical and mycological cure. Each of them vary having specific characteristics to tackle several clinical challenges like high relapse rate, recurrences and quality of life. Aims and Objectives: To compare the efficacy and safety of Eberconazole and Sertaconazole in tinea infection. Materials and Methods: This was a randomized, observer-blinded, parallel-group study conducted at a dermatology out-patient department (OPD) of tertiary care teaching hospital in Puducherry. 85 patients with tinea corporis and tinea cruris infections who visited the dermatology OPD were enrolled in this study. The treatment phase involved two groups receiving either Sertaconazole 2% cream or Eberconazole 1% applied topically twice daily for 4 weeks. At the end of treatment phase, there was a 'follow-up phase' at the end of 4 weeks, where the patients were assessed clinically and mycologically. The data were analyzed using descriptive statistics using MS Excel version 2019 and SPSS version 15 for Windows. Results: The primary efficacy variables namely change in pruritus, erythema, induration, scaling and mycological cure significantly improved in both the groups, as compared to baseline (P < 0.001), in the treatment phase and follow-up phase. Intergroup comparison with respect to pruritus and scaling showed significant difference (P < 0.001), suggestive of better reduction of pruritus and scaling scores at 4 weeks with Sertaconazole when compared to Eberconazole. Conclusions: Sertaconazole was better than Eberconazole in relieving signs and symptoms of dermatophytoses, especially pruritus, thereby improving patients' quality of life.

Background: Stroke is one of the leading causes of death and disability worldwide. Poststroke, most survivors experience trunk control impairment and instability. Previous works on exercise on an unstable surface to improve trunk stability in nonstroke population had proven effective. Thus, physioball exercises (PBEs) in poststroke subjects may be useful in the recovery of trunk stability and thereby reduce disability. We hypothesize that PBE is feasible and effective in enhancing trunk stability. Aims: To test the feasibility and successful implementation of conducting a randomized controlled study to assess the clinical effectiveness of PBE and proprioceptive neuromuscular facilitation (PNF) technique to enhance trunk control in poststroke subjects. Methods: This study was conducted in a stroke unit of Global Hospitals and Health City, Chennai, India. Thirty patients with the first onset of stroke within 40 days of stroke duration, lesion to one side, and ability to sit independently with or without arm support for 15 days were recruited. All thirty poststroke subjects were randomized either into PBE group or PNF group, and outcome assessors involved in the trail were blinded to allocation. PBE group performed task-oriented activities on an unstable surface and PNF group were treated with PNF-specific trunk stability exercise program for 4 weeks (30 min/day, 5 times/week). Trunk impairment scale (TIS) was used as a main outcome measure. Results: Data were analyzed using Wilcoxon signed rank sum test and Mann–Whitney U-test for intra- and inter-group comparison. The baseline characteristics between both groups were statistically nonsignificant. Within groups, there were significant improvements between baseline and at 4 weeks in the measure of TIS. In addition, PBE group showed a significant increase in trunk control (mean 2.33, 95% confidence interval 1.14-3.52, P = 0.002) than the PNF subject. Conclusion: This pilot randomized controlled trial (RCT) showed the potential efficacy of PBE in developing more trunk stability than PNF in poststroke subjects. The current study had proved the feasibility of undertaking a large-scale RCT. Since this is a pilot study to establish any sort of conclusive evidence on the efficacy of PBEs in the poststroke population, a larger sample-sized trial is needed.

Background: A controversy exists regarding the association between subclinical hypothyroidism (SH) and dyslipidemia. Moreover, studies on lipid ratios and atherogenic index of plasma (AIP) in SH are rare, particularly in the Indian scenario. Aim: This study aimed to investigate abnormalities in conventional lipid profile, lipid ratios, and AIP in SH and attempted to correlate thyroid stimulating hormone (TSH) and AIP in SH. Materials and Methods: In this retrospective analysis of patient records of SH subjects and euthyroid subjects, age, free triiodothyronine, free thyroxine, TSH, total cholesterol, triglycerides, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol, lipid ratios, and AIP were compared between the two groups. The correlation of TSH and AIP in SH was studied. Spearman′s correlation, Mann-Whitney U-test and logistic regression analysis were performed. Results: Triglyceride, triglyceride/HDL-C, and AIP were significantly higher in SH as compared to euthyroid group, but there was no correlation between TSH and AIP in SH. AIP emerged as the significant single factor associated with SH in multiple logistic regressions. Conclusion: The positive association of dyslipidemia and SH indicates a need for regular screening of these patients to enable early diagnosis and treatment of dyslipidemia. Even in patients who have a normal conventional lipid profile, lipid ratios, and AIP have to be calculated for better assessment of atherogenic risk.

Pancreatic duct disruption may follow acute pancreatitis, chronic pancreatitis, pancreatic surgery, and trauma. Diagnosis in these patients is usually made by endoscopic retrograde cholangiopancreaticogram or secretin-stimulated magnetic resonance cholangiopancreaticogram. We report five cases where pancreatic duct disruption was diagnosed by contrast-enhanced computed tomography (CECT). Five patients with acute pancreatitis were studied; three were secondary to alcohol and two were posttraumatic. Three patients developed pancreatic ascites, one developed pancreatico-pleural effusion, and the other had pancreatic pseudocyst. CECT of the abdomen revealed pancreatic ductal injury in all the patients. In one patient with pancreatic ascites, multiple peripancreatic collections and dilated and disrupted pancreatic duct communicating with the peritoneal cavity were noted. The patient of traumatic pancreatitis had a fracture of the head of the pancreas, with peripancreatic collection communicating with the main pancreatic duct (MPD). In the other traumatic pancreatitis, there was a pseudocyst near the head of pancreas communicating with the MPD. CECT can provide a comprehensive assessment in acute pancreatitis including duct integrity, type and location of pancreatic ductal injury and can be an effective noninvasive alternative imaging modality in diagnosing pancreatic duct disruption.

Transmission of radiation fluence through patient′s body has a correlation to the planned target dose. A method to estimate the delivered dose to target volumes was standardized using a beam level 0.6 cc ionization chamber (IC) positioned at electronic portal imaging device (EPID) plane from the measured transit signal (S t ) in patients with cancer of uterine cervix treated with three-dimensional conformal radiotherapy (3DCRT). The IC with buildup cap was mounted on linear accelerator EPID frame with fixed source to chamber distance of 146.3 cm, using a locally fabricated mount. S t s were obtained for different water phantom thicknesses and radiation field sizes which were then used to generate a calibration table against calculated midplane doses at isocenter (D iso,TPS ), derived from the treatment planning system. A code was developed using MATLAB software which was used to estimate the in vivo dose at isocenter (D iso,Transit ) from the measured S t s. A locally fabricated pelvic phantom validated the estimations of D iso,Transit before implementing this method on actual patients. On-line dose estimations were made (3 times during treatment for each patient) in 24 patients. The D iso,Transit agreement with D iso,TPS in phantom was within 1.7% and the mean percentage deviation with standard deviation is −1.37% ±2.03% (n = 72) observed in patients. Estimated in vivo dose at isocenter with this method provides a good agreement with planned ones which can be implemented as part of quality assurance in pelvic sites treated with simple techniques, for example, 3DCRT where there is a need for documentation of planned dose delivery.

The purpose of this study was to update, discuss the accumulated knowledge regarding clinical evaluation and physical therapy rehabilitation for scapular dyskinesis. The aim of this study was to educate health professionals and athlete regarding scapular dyskinesis to make them aware of its consequences in affecting shoulder kinematics. Normal movement of scapula should not be compromised. Its deficiency results in restriction in shoulder joint functions. Mr. X, 26-year-old volleyball player with shoulder pain, was clinically assessed with scapular dyskinesis and rehabilitated through conservative physical therapy at three levels for 8 weeks. A single case study design was used to assess and rehabilitate the volleyball player with scapular dyskinesis. Scapular dyskinesis alters normal position and kinematics of scapula. Hence, it needs early diagnosis with appropriate clinical examination to rehabilitate. Physiotherapy plays a major role in it.

Organ motions during inter-fraction and intra-fraction radiotherapy introduce errors in dose delivery, irradiating excess of normal tissue, and missing target volume. Lung and heart involuntary motions cause above inaccuracies and gated dose delivery try to overcome above effects. Present work attempts a novel method to verify dynamic dose delivery using a four-dimensional (4D) phantom. Three patients with mobile target are coached to maintain regular and reproducible breathing pattern. Appropriate intensity projection image set generated from 4D-computed tomography (4D-CT) is used for target delineation. Intensity modulated radiotherapy plans were generated on selected phase using CT simulator (Siemens AG, Germany) in conjunction with "Real-time position management" (Varian, USA) to acquire 4D-CT images. Verification plans were generated for both ion chamber and Gafchromic (EBT) film image sets. Gated verification plans were delivered on the phantom moving with patient respiratory pattern. We developed a MATLAB-based software to generate maximum intensity projection, minimum intensity projections, and average intensity projections, also a program to convert patient breathing pattern to phantom compatible format. Dynamic thorax quality assurance (QA) phantom (Computerized Imaging Reference Systems type) is used to perform the patient specific QA, which holds an ion chamber and film to measure delivered radiation intensity. Exposed EBT films are analyzed and compared with treatment planning system calculated dose. The ion chamber measured dose shows good agreement with planned dose within ± 0.5% (0.203 ± 0.57%). Gamma value evaluated from EBT film shows passing rates 92–99% (96.63 ± 3.84%) for 3% dose and 3 mm distance criteria. Respiratory gated treatment delivery accuracy is found to be within clinically acceptable level.

Background and Objective: Tremor, the most common form of abnormal involuntary movement, affects the performance of activities of daily living. Evidence on effective form of physiotherapy techniques which can help manage intentional tremor and improve hand function among cerebellar dysfunction patients in inconclusive. Hence, this study aims to establish the effectiveness of stretching and proprioceptive loading among cerebellar patients with intentional tremors. The objective of this study is to compare the efficacy of stretching and proprioceptive loading among patients with cerebellar intention tremor. Materials and Methods: A total of thirty patients with intention tremor due to cerebellar lesion were recruited for this study. They were randomized into two groups, Group I received stretching exercise and Group II received proprioceptive loading exercise. Pre- and post-test outcome measures were taken at the end of duration of 3 weeks intervention. Outcome measures were Fahn's tremor rating scale and nine hole peg test. Results: Statistical analyses were done by McNemar test, Wilcoxon's signed rank test, and Mann–Whitney test. Post-test scores of both groups were compared and found that Group II treated with proprioceptive loading exercise had higher significant result than the group treated with strengthening exercise program. Conclusion: Proprioceptive loading exercise has demonstrated signifi cant effect on reducing cerebellar tremor and improving muscle coordination in reaching activities.

Tuberculosis is one of the most common opportunistic infections noted after renal transplantation. It can present in unusual ways making it a diagnostic challenge. Gastrointestinal tuberculosis after renal transplantation is rarely reported. We present 2 rare cases of gastrointestinal tuberculosis that was diagnosed promptly and treated.

Blended learning (BL) refers to a systematic teaching method, which combines the aspects of face-to-face and online interactions using appropriate Information and Communication Technologies. This mixed-method systematic review (SR) protocol is developed with the objective to determine the effectiveness and appropriateness of BL in the health-care professional education. Mixed-method SR protocol: For the purpose of this SR, PICO is defined as P-entry level graduate students of health sciences program; I-BL; C-traditional face-to-face training; and O-achievement of learning outcomes, learner's and teacher's perception (primary). The search will be done through possible database using predetermined search strategy. Eligible studies will be appraised independently by authors. Joanna Briggs Institute's mixed-method protocol will be used to assess and synthesis the data. This protocol is registered with the International Register of Systematic Reviews (PROSPERO) with the registration number CRD42018082699.

Background: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, potentially fatal, hyperinflammatory syndrome that may rarely complicate the clinical course of disseminated Mycobacterium tuberculosis (MTB). The clinical course of tuberculosis-associated HLH (TB-HLH) has been reported to be unpredictable. Materials and Methods: Here we describe the clinicopathological features, laboratory parameters, management, and outcome data of a patient who satisfied the 2004 diagnostic criteria for HLH secondary to disseminated MTB; we also do a systematic review of the international literature on TB-HLH. The literature review (January 1975–March 2014) found that HLH complicated the clinical course of 63 tuberculosis patients (41 males, 22 females, mean age = 45 ± 23.5 years) with a high mortality rate of 49% (31/63 died). The mean serum ferritin level (n = 44/63) was 5963 ng/mL (range 500–38,539 ng/mL); and a higher proportion (54.2%) of patients had pancytopenia at presentation. On univariate analysis (n = 53/63), age >30 years [hazard ratio (HR): 2.79, 95% confidence interval (CI):1.03–7.56, P = 0.03], presence of comorbidities (HR 4.59, CI: 1.08–19.52, P = 0.04), marked hemophagocytosis in bone marrow (HR: 2.65, CI: 1.16–6.05, P = 0.02), and nonusage/delayed usage of antitubercular therapy (ATT) (HR: 3.44, CI: 1.51–7.87, P = 0.003) were associated with decreased survival, though none of these parameters attained statistical significance (P > 0.05) in multivariate analysis. Usage of corticosteroids and/or immunomodulator drugs (HR 1.00, CI: 0.66–3.22, P = 0.35) did not alter the outcome in these patients. Conclusion: HLH should be considered as a differential diagnosis in patients with tuberculosis who present with cytopenias, organomegaly, and coagulopathy. Strong clinical suspicion and early usage of ATT might be useful in reducing the morbidity and mortality. The utility of immunosuppressive/immunomodulator therapy lacks general concensus among treating physicians, and warrants further studies.

Aim: To evaluate the therapeutic effectiveness of muscle energy technique (MET) and mobilization with the movement of elbow in subjects with lateral epicondylalgia (LE). Settings and Design: This study was conducted in Global Hospitals and Health City, Chennai 100. Subjects were allocated into group A and B through simple randomization method and double-blinded randomized controlled trial was performed. Materials and Methods: An interventional comparative study was conducted on 30 patients having LE. They were randomly assigned to one of the two groups. Group A (n = 15) was treated using movement with mobilization, group B (n = 15) was treated with MET. Both groups received conventional treatment of therapeutic ultrasound, after corresponding interventions. Visual analog scale (VAS) and elbow functional assessment (EFA) scales were the outcome measures, respectively. Measurements were performed before the beginning of treatment, after 10 days and 3 weeks afterward. Statistical Analysis Used: ANOVA and post-hoc analysis Bonferroni method were used to analyze measurements taken at baseline and follow-up at 10 th day and 3 rd week. Results: Subjects who received mobilization with movement showed a significant improvement in both VAS and EFA than the other group which received MET. Conclusion: We conclude that mobilization with the movement of elbow appears to be more effective manual technique in treating LE in comparison with MET.

External beam radiotherapy (EBRT) for carcinoma of uterine cervix is a basic line of treatment with three dimensional conformal radiotherapy (3DCRT) in large number of patients. There is need for an established method for verification dosimetry. We tried to document absorbed doses in a group of carcinoma cervix patients by inserting a 0.6 cc Farmer type ion chamber in the vaginal cavity. A special long perspex sleeve cap is designed to cover the chamber for using in the patient′s body. Response of ionization chamber is checked earlier in water phantom with and without cap. Treatment planning was carried out with X-ray computed tomography (CT) scan and with the chamber along with cap in inserted position, and with the images Xio treatment planning system. Three measurements on 3 days at 5-6 fraction intervals were recorded in 12 patients. Electrometer measured charges are converted to absorbed dose at the chamber center, in vivo. Our results show good agreement with planned dose within 3% against prescribed dose. This study, is a refinement over our previous studies with transmission dosimetry and chemicals in ampules. This preliminary work shows promise that this can be followed as a routine dose check with special relevance to new protocols in the treatment of carcinoma cervix with EBRT.

INTRODUCTION: Smoking is one of the leading factors of mortality in Malaysia. Most youngsters start at adolescence, fascinated by the concept of smoking. Interventions that harness the broad availability of mobile phones, as well as adolescents' interest in their appearance, may be an innovative way to advance school-based prevention. This study aims to determine the perceptions of facial-aging apps among secondary school students. METHODOLOGY: For this research, descriptive cross-sectional study using simple random sampling method was used. Population sampling was targeted toward three government schools. The total number of respondents is 383, with all of them aged between 13 and- 16 years of age. Legal considerations were taken to maintain the confidentiality of respondents. The specific objectives are: 1. To determine the level of change of intention on smoking, 2. To know the perceived reactions of the peer groups on the appearances of students as nonsmokers, 3. To determine whether the students learned new benefits of nonsmokingand, 4. To measure the impact of a facial-aging app among students. RESULTS: The number of respondents who smoke was 40 (10.4%), while the number of respondents who do not smoke was 343 (89.6%). About 89% of the respondents agree that their three-dimensional selfie image motivates them not to smoke. In addition, 87.8% of respondents admit that the perceived reactions of their classmates make them think that they look better as nonsmokers. After learning the effects of smoking, about 86.4% of the respondents acknowledged that they would educate their peer groups. Furthermore, 85.9% of the respondents found this “Smokerface” app enjoyable. CONCLUSION: The facial-aging intervention was effective in motivating Malaysian pupils to stay away from tobacco use. Thus, the analysis on the study of facial app usage in smoking prevention among youngsters concludes that most of the adolescents concur that the “Smokerface” app helps in the prevention of smoking among youths.

Cutaneous B cell lymphomas can arise primarily from the skin or may occur due to secondary spread from nodal lymphomas. Primary lymphomas are confined to the skin without systemic spread and they differ from secondary lymphomas in their clinical behavior, treatment and prognosis. Cutaneous lymphomas being relatively rare, lack of precise definition and understanding of their clinical behavior diseases leads to pitfalls in the diagnosis. We report two cases of cutaneous B cell lymphomas who presented with fever of unknown origin initially and later found to have skin lesions. Hence, skin can be a potential diagnostic clue in the evaluation of patients with fever of unknown origin. The distinctions between the primary and the secondary lymphomas become important in choosing the treatment and assessing the prognosis.

Inversely planned intensity-modulated radiotherapy (IMRT) and stereotactic small field radiotherapy should be verified before treatment execution. A second verification is carried out for planned treatments in IMRT and 3D conformal radiotherapy (3D-CRT) using a monitor verification commercial dose calculation management software (DCMS). For the same reference point the ion-chamber measured doses are compared for IMRT plans. DCMS (Diamond) computes dose based on modified Clarkson integration, accounting for multi-leaf collimators (MLC) transmission and measured collimator scatter factors. DCMS was validated with treatment planning system (TPS) (Eclipse 6.5 Version, Varian, USA) separately. Treatment plans computed from TPS are exported to DCMS using DICOM interface. Doses are re-calculated at selected points for fields delivered to IMRT phantom (IBA Scanditronix Wellhofer) in high-energy linac (Clinac 2300 CD, Varian). Doses measured at central axis, for the same points using CC13 (0.13 cc) ion chamber with Dose 1 Electrometer (Scanditronix Wellhofer) are compared with calculated data on DCMS and TPS. The data of 53 IMRT patients with fields ranging from 5 to 9 are reported. The computed dose for selected monitor units (MU) by Diamond showed good agreement with planned doses by TPS. DCMS dose prediction matched well in 3D-CRT forward plans (0.8 ± 1.3%, n = 37) and in IMRT inverse plans (−0.1 ± 2.2%, n = 37). Ion chamber measurements agreed well with Eclipse planned doses (−2.1 ± 2.0%, n = 53) and re-calculated DCMS doses (−1.5 ± 2.6%, n = 37) in phantom. DCMS dose validation is in reasonable agreement with TPS. DCMS calculations corroborate well with ionometric measured doses in most of the treatment plans.

Radioactive wastes from hospitals form one of the various types of urban wastes, which are managed in developed countries in a safe and organized way. In countries where growth of nuclear medicine services are envisaged, implementations of existing regulatory policies and guidelines in hospitals in terms of handling of radioactive materials used in the treatment of patients need a good model. To address this issue, a brief description of the methods is presented. A designed prototype waste storage trolley is found to be of great help in decaying the I-131 solid wastes from wards before releasing to waste treatment plant of the city. Two delay tanks with collection time of about 2 months and delay time of 2 months alternately result in 6 releases of urine toilet effluents to the sewage treatment plant (STP) of the hospital annually. Samples of effluents collected at releasing time documented radioactive releases of I-131 much below recommended levels of bi-monthly release. External counting of samples showed good statistical correlation with calculated values. An overview of safe procedures for radioactive waste disposal is presented.

Objective: To examine self-reported knowledge, attitude, and preventive practices on cancer among Saudis. Materials and Methods: Data was collected from Saudis aged 15 years or more, who attended one of the randomly selected 20 Primary Health Centers (PHC) or the four major private hospitals located in the Riyadh region, either as patients or their escorts. The association between the variables was evaluated by the Chi square test. Results: The study population consisted of 618 males and 719 females. Among the female respondents 23.1% reported that they practiced breast self-examination (BSE); 14.2 and 8.1%, respectively, had clinical breast examination (CBE) and mammography. However, 10.0 and 16.1% of the females, aged 40 years and older, reported having had mammograms and CBE, respectively. The BSE performers were more educated, knew someone with cancer, and had heard of the cancer warning signal. Both educational level and ′heard of cancer warning signal′ were significantly related to CBE. Cancer information was received from television / radio by 65.1% and from the physician by 29.4%. Even though 69.4% believed that cancer could be detected early, a vast majority (95.8%) felt early detection of cancer was extremely desirable and 55.1% said their participation was definite in any screening program. A majority of the respondents (92.6%) insisted on the need for physician recommendation to participate and 78.1% expected that any such program should be conducted in the existing hospitals / clinics. Conclusion: Culturally sensitive health education messages should be tailored to fulfill the knowledge gap among all population strata. Saudis will benefit from partnerships between public health educators and media to speed up the dissemination of cancer information.

The objective of the present study is to establish radiation standards for absorbed doses, for clinical high energy linear accelerator beams. In the nonavailability of a cobalt-60 beam for arriving at Nd, water values for thimble chambers, we investigated the efficacy of perspex mounted extrapolation chamber (EC) used earlier for low energy x-rays and beta dosimetry. Extrapolation chamber with facility for achieving variable electrode separations 10.5mm to 0.5mm using micrometer screw was used for calibrations. Photon beams 6 MV and 15 MV and electron beams 6 MeV and 15 MeV from Varian Clinac linacs were calibrated. Absorbed Dose estimates to Perspex were converted into dose to solid water for comparison with FC 65 ionisation chamber measurements in water. Measurements made during the period December 2006 to June 2008 are considered for evaluation. Uncorrected ionization readings of EC for all the radiation beams over the entire period were within 2% showing the consistency of measurements. Absorbed doses estimated by EC were in good agreement with in-water calibrations within 2% for photons and electron beams. The present results suggest that extrapolation chambers can be considered as an independent measuring system for absorbed dose in addition to Farmer type ion chambers. In the absence of standard beam quality (Co-60 radiations as reference Quality for Nd,water) the possibility of keeping EC as Primary Standards for absorbed dose calibrations in high energy radiation beams from linacs should be explored. As there are neither Standard Laboratories nor SSDL available in our country, we look forward to keep EC as Local Standard for hospital chamber calibrations. We are also participating in the IAEA mailed TLD intercomparison programme for quality audit of existing status of radiation dosimetry in high energy linac beams. The performance of EC has to be confirmed with cobalt-60 beams by a separate study, as linacs are susceptible for minor variations in dose output on different days.

This paper describes the initial experience of quality assurance (QA) tests performed on the millennium multi-leaf collimator (mMLC) for clinical implementation of intensity-modulated radiotherapy (IMRT) using sliding window technique. The various QA tests verified the mechanical and dosimetric stability of the mMLC of linear accelerator when operated in dynamic mode (dMLC). The mechanical QA tests also verified the positional accuracy and kinetic properties of the dMLC. The stability of dMLC was analyzed qualitatively and quantitatively using radiographic film and Omnipro IMRT software. The output stability, variation in output for different sweeping gap widths, and dosimetric leaf separation were measured. Dose delivery with IMRT was verified against the dose computed by the treatment planning system (TPS). Monitor units (MUs) calculated by the planning system for the IMRT were cross-checked with independent commercial dose management software. Visual inspection and qualitative analysis showed that the leaf positioning accuracy was well within the acceptable limits. Dosimetric QA tests confirmed the dosimetric stability of the mMLC in dynamic mode. The verification of MUs using commercial software confirmed the reliability of the IMRT planning system for dose computation. The dosimetric measurements validated the fractional dose delivery.

The objective of this study was to conduct an audit on QA aspects of treatment delivery by the verification of the treatment fields′ position on different days to document the efficiency of immobilization methods and reproducibility of treatment. A retrospective study was carried out on 60 patients, each 20 treated for head and neck, breast, and pelvic sites; and a total of 506 images obtained by electronic portal imaging device (EPID) were analyzed. The portal images acquired using the EPID systems attached to the Varian linear accelerators were superimposed on the reference images. The anatomy matching software (Varian portal Vision. 6.0) was used, and the displacements in two dimensions and rotation were noted for each treated field to study the patient setup errors. The percentages of mean deviations more than 3 mm in ′lateral (X) and longitudinal (Y)′ directions were 17.5%, 11.25%, and 7.5% for breast, pelvis, and head and neck cases respectively. In all cases, the percentage of mean deviation with more than 5 mm error was 0.83%. The maximum average mean deviation in all the cases was 1.87. The average mean SD along X and Y directions in all the cases was less than 2.65. The results revealed that the ranges of setup errors are site specific and immobilization methods improve reproducibility. The observed variations were well within the limits. The study confirmed the accuracy and quality of treatments delivered to the patients.

There is need for simple methods for checking consistency of beam outputs and energy in linear accelerators used for radiotherapy. A method was designed by the department using perspex phantom with which the dosimetric data of two medical linear accelerators (Clinac 600 CD, Clinac 2300 CD) were evaluated over a period of 30 months. The efficacy of methods followed was checked. Routine beam consistency checks were designed for photon beams with 15 cm/ 5 cm depth ionizations in perspex phantom and variable depth combinations for electron beams. Calculated ionization ratios were compared with measured values to show their significance. The dose/MU for all radiation beams was maintained within 2% accuracy over the period of 30 months. Clinac 600 CD machine showed decreasing trend of cGy/MU, while Clinac 2300 CD showed increasing trend of cGy/MU over a period, which needed tuning of monitor chamber two times each. Tuning of output to achieve standard value was carried out once, for all electron energies when the output dose/MU exceeded 3%. During one week (June 2005), there were slight changes in electron energy detected using the ratio method, which did not recur anytime afterwards. The methods designed are adequate to find the consistency in the beam output and energies in the radiotherapy linacs.

The present paper illustrates our attempt to design and test the reproducibility of low-cost patient positioning devices prepared in-house in our radiotherapy department. Rigid thermocole boards with angulations, scales and support were designed as breast, pelvis and head positioning devices. Reproducibility and accuracy were tested by serial electronic portal imaging detector imaging. The positioning devices (with or without superimposed moulds) showed variations within 2-3 mm on serial treatment days which were within acceptable limits. It is therefore concluded that low-cost patient positioning devices for head, breast and pelvis (the common sites of treatments in radiotherapy) can be fabricated from available materials in-house. These have been shown to be resulting in accurate immobilization, can be customized for particular techniques and are considerably cheaper than commercially available solutions.

Background: Medicine is not grasped as a whole subject by the students. Also, the teaching creates disinterest among the students to learn the subject. Teaching basic sciences in different blocks gives no chance for the student to correlate and integrate the knowledge what they had gained. Aim: To assess the effectiveness of the integrated teaching method over the conventional method of teaching among the first year MBBS students. Materials and Methods: A prospective study was done on 100 first year MBBS students of VMKV Medical College, Salem, during April 2012. The students were divided into two groups on a random basis, with 50 in each group. The first group students underwent the conventional type of teaching and for the other group, integrated teaching was practiced. Finally, an evaluation test was conducted for both the groups and the mean marks obtained by the students were analyzed by using unpaired "t" test. Results: The total marks (out of 30) in conventional teaching method was found to be 15.40 ± 4.62, and in integrated teaching method it was 21.8 ± 4.48. So, the marks obtained by students after integrated method were found to be higher than the marks obtained after conventional teaching and this difference was found to be statistically significant (P < 0.0001). Conclusion: The integrated teaching was found to be an effective method of teaching than the traditional conventional method in terms of students′ performance in assessment examinations.

Hand and foot syndrome (HFS) is a well-known complication of chemotherapeutic drugs given in a dose-dense manner. Our patient was a 52-year-old female with metastatic breast carcinoma on salvage chemotherapy regimen with docetaxel at a dose of 60 mg/m 2 . The patient had grade 3 HFS characterized by symmetrical, tender, and erythematous skin lesions over the palms and soles associated with dysesthesia necessitating interruption of treatment. She developed this syndrome at a much lower dose than previously described due to her altered hepatic function. An insight regarding this unique distressing side-effect and assessment of various contributing factors would help us identify and treat the patient at the earliest.