Prevalence of Health Problems, Professional and Financial Satisfaction among Doctors Working Across Vadodara City: A Cross-sectional Study

Background: The present study was conducted to know the distribution of various health problems among doctors and to assess professional and financial satisfaction levels among doctors. Methods: A Google Form questionnaire-based cross-sectional study was conducted among 122 doctors in Vadodara selected purposively after taking consent. Google form was circulated by email and WhatsApp groups. The form consisted of questions related to demographic details, health problems, financial and job satisfaction. All the responses were recorded and analyzed in MS Excel 2019. Results: Among the 122 doctors, 89 (72.95%) were male and 33 (27.04%) were female and 101 (82.78%) doctors were taking treatment for some ailment. Around 86.9% of doctors regularly opt for a health check-up. Among the health problems reported by doctors, the most common were musculoskeletal ailments (72.13%) followed by hypertension (28.9%), diabetes (17.2), cardiac (12.3%), endocrinal (10.65%), eye (9.01), mental (6.55) problems. Approximately 37.70% of doctors answered that health problems temporarily affect their work; 5.73% of doctors felt the need to modify their work pattern. About 91.80% of doctors were satisfied by their profession, while 108 (88.52%) doctors were financially satisfied with their work. Conclusion: More than half of the professionals complained of musculoskeletal problems. The majority of health care professionals were professionally and financially satisfied.

In-Silico Analysis of Chromatin Modifiers and Profiling of Histone Deacetylases (HDAC’s) in Human Oral Cancer / 전남의대학술지

Histone modifications have been demonstrated to play a significant role in oral squamous cell carcinoma (OSCC) epigenetic regulation. An in-silico analysis of The Cancer Genome Atlas (TCGA) of various histone acetyl transferases (HATs) and histone deacetylases (HDACs) suggested that HATs do not differ between normal and tumor samples whereas HDAC2 and HDAC1 change maximally and marginally respectively between normal and tumor patients with no change being noted in HDAC6 expression. Hence, this investigation was carried out to validate the expression states of HDAC 1, 2 and 6 mRNAs in buccal mucosa and tongue SCC samples in an Indian cohort. Buccal mucosa and tongue squamous cell carcinoma tissues with intact histopathology were processed for RNA isolation followed by cDNA synthesis which was then subjected to q-PCR for HDACs. The average RNA yield of the tongue tissue sample was ∼2 μg/mg of tissue and the A260/280 ratios were between 2.03 and 2.06. The average RNA yield of buccal mucosa tissue sample was ∼1 μg/mg of tissue and the A260/280 ratio were between 2.00 and 2.08. We have demonstrated that HDAC2 was overexpressed in tongue and buccal mucosa samples. Over-expression of HDAC2 imply potential use of HDACi along with standard chemotherapeutic drug in oral cancer treatment.

In-Silico Analysis of Chromatin Modifiers and Profiling of Histone Deacetylases (HDAC’s) in Human Oral Cancer / 전남의대학술지

Histone modifications have been demonstrated to play a significant role in oral squamous cell carcinoma (OSCC) epigenetic regulation. An in-silico analysis of The Cancer Genome Atlas (TCGA) of various histone acetyl transferases (HATs) and histone deacetylases (HDACs) suggested that HATs do not differ between normal and tumor samples whereas HDAC2 and HDAC1 change maximally and marginally respectively between normal and tumor patients with no change being noted in HDAC6 expression. Hence, this investigation was carried out to validate the expression states of HDAC 1, 2 and 6 mRNAs in buccal mucosa and tongue SCC samples in an Indian cohort. Buccal mucosa and tongue squamous cell carcinoma tissues with intact histopathology were processed for RNA isolation followed by cDNA synthesis which was then subjected to q-PCR for HDACs. The average RNA yield of the tongue tissue sample was ∼2 μg/mg of tissue and the A260/280 ratios were between 2.03 and 2.06. The average RNA yield of buccal mucosa tissue sample was ∼1 μg/mg of tissue and the A260/280 ratio were between 2.00 and 2.08. We have demonstrated that HDAC2 was overexpressed in tongue and buccal mucosa samples. Over-expression of HDAC2 imply potential use of HDACi along with standard chemotherapeutic drug in oral cancer treatment.

Immunization status of children admitted to a tertiary hospital in India

Background: In spite of the ongoing Universal immunization program (UIP), National family health survey data shows declining trend in the number of children fully immunized in Maharashtra. Hence this study was undertaken to determine immunization status in 12-23 months age children admitted to pediatric wards of a tertiary care hospital and factors affecting it.Methods: A prospective, cross sectional study was carried out in which children between 12-23 months age admitted to paediatric wards of a tertiary care hospital were included. Immunization history for Universal immunization program vaccines and socio-demographic information was collected and analysed to find the immunization status and its correlation with various demographic factors.Results: Of total 418 children, 70.3% were completely immunized, 27.8% incompletely immunized and 1.9% unimmunized. Majority were immunized in government centers. 83.3% subjects were of 1st/2nd birth order, 90.4% were delivered institutionally and 76.1% were delivered vaginally. Around half of the children’s fathers and mothers were illiterate. Only father was employed in 75.4% while both parents were employed in 23.4%. Birth order, place of delivery, mode of delivery, father and mother’s education and employment status were statistically associated with immunization while gender, presence of immunization card, migrant status and place of immunization were not associated. Reasons for incomplete immunization included lack of knowledge about immunization and ‘child not well’ at time of immunization.Conclusions: Even in a population with health seeking behaviour almost one third of the children were incompletely immunized. Special efforts are required for finding groups of children with high chances of being incompletely immunized.

Primary pelvic hydatid cyst: a rare case report

 Primary pelvic hydatid cyst disease is a zoonotic parasitic disease most frequently caused by Echinococcus granulosus or Echinococcus multilocularis. Primary pelvic hydatid cyst is a rare entity. A 39-year-old, para 3 living 3 presented to casualty with acute pain abdomen and a suprapubic mass. Patient gave history of acute lower abdominal pain since 4 days associated with vomiting. On examination, a palpable mass around 18 weeks size, firm to hard in consistency with ill-defined margins and restricted mobility and suprapubic tenderness. Lower limit could not be reached, extending from right iliac fossa to midline. Per vaginum findings suggestive of mass deviated to right side with fullness in right fornix. No cervical motion tenderness. The pre-operative tumor marker levels were as follows: CA125=12.44 U/mL (normal=0-35), CEA=0.09 ng/mL (normal=0-2.5). CA19.9=16.79 U/mL (normal=1.2-30). Erythrocyte sedimentation rate (ESR) was found to be 82 mm in the first hour. Transabdominal ultrasound suggestive of adnexal mass? ovarian with moderate ascites. Urinary bladder seen separately. Contrast enhanced computed topography (CECT) suggestive of complicated right para-ovarian /ovarian cystic mass like cystadenoma. Exploratory laparotomy was done and specimen (uterus, cervix, omental biopsy and peritoneal washings) was sent for Histopathological report. Histopathological examination of the haematoxylin and eosin-stained section revealed ruptured brood capsule releasing daughter cyst. Post-operative period was uneventful. Patient received full course of anti-helminthic treatment.

Audit of transfusion practices in pediatrics in a tertiary care hospital

Background: Audit of transfusion practices in pediatric patients was performed to study indications, clinical profile and whether transfusions were in accordance to guidelines.Methods: Retrospective analysis of all episodes of transfusions from a tertiary care centre was done. The study period was from January 2018 to December 2018.Patients in the age group of 4 months to 12 years were enrolled in the study. The data was reviewed according to the British Committee for Standards in Haematology guidelines for transfusion.Results: During the study period of 12 months,168 units of hemocomponents were transfused to children, 66.07% (111/168) of the total products transfused were packed red cell units, followed by 36 units (21.42%) of fresh frozen plasma and 21 units (12.5%) platelets. Overall usage of blood components was found to be appropriate in 58.33% (98/111). Red blood cells were the most appropriately transfused (64.86 %) (72 units out of 111) blood product as compared to 42.85% of platelets (9/21) and 47.22% of FFP (17/36).Conclusions: Most frequently transfused blood components are red blood cells in pediatrics. Inappropriate transfusion of blood components is hinders the utility of this valuable resource, Thus it becomes necessary to conduct regular audit of blood component transfusion for optimum utilization.

Ectopic ovarian pregnancy following in vitro fertilization: case report

Ovarian pregnancy is a rare form of extrauterine ectopic pregnancy. Risk factors such as reproductive treatments and infertility have been identified in recent studies. In this article, we present a case of ovarian ectopic pregnancy occurring following in vitro fertilization treatment and a fresh embryo transfer. The diagnosis of ovarian pregnancy was made during transvaginal sonography performed due to suspected ectopic pregnancy. Ovarian ectopic pregnancy is a rare clinical phenomenon. Late diagnosis and lack of appropriate intervention may have catastrophic results. Several mechanisms and risk factors are proposed, and their acknowledgment may improve early diagnosis and prevention of complications.

Condom catheter: a simple and efficacious alternative of hysterectomy in postpartum haemorrhage

Background: The aim of this study was to evaluate the effectiveness of the condom catheter in treating postpartum hemorrhage refractory to medical treatment.Methods: This prospective study included 21 women with postpartum hemorrhage treated with a condom catheter as a conservative therapeutic option.Results: The condom catheter was successful in controlling hemorrhage in 90.4% of the women. It was effective in all women with vaginal delivery (11 of 12) and highly effective in women with uterine atony who did not respond to medical uterotonic treatment (6 of 7 women).Conclusions: Its ease of use and high effectiveness make the condom catheter a useful approach for the conservative management of acute postpartum hemorrhage. This device reduces bleeding, shortens the hospital stay and avoids the need for surgical management.

Comparison of maternal and perinatal outcome in pregnancy with altered thyroid profile and euthyroid patients: a prospective, observational and case control study in a tertiary care centre

Background: Thyroid disease is one of the commonest endocrine disorder affecting women of reproductive age, and when untreated during pregnancy is associated with an increased risk of complications. The objective of this review was to increase awareness and to provide a review on adverse effect of thyroid dysfunction on maternal and perinatal outcome.Methods: This prospective, observational hospital-based case-control study carried on women coming for antenatal check-up in a Tertiary Care Hospital in INDORE from May 2018-December 2018. 50 known booked antenatal (case) patient with established thyroid disorder, more than 32 week of gestation, and 50-matched euthyroid patients (control) were taken.Results: Women suffering from overt and subclinical hypothyroidism and hyperthyroidism are nulliparous in 72% cases as compared to 32% in euthyroid patient. Increased maternal age was associated with higher incidence of thyroid dysfunction. Normal vaginal delivery by spontaneous labour seen in 56% of euthyroid, while it is reduced with thyroid dysfunction. 38% of altered thyroid profile patient undergo induction of labour and 24% cases undergo caesarean section as compared to control (17%). Adverse fetal outcome like intrauterine growth retardation, preterm birth and ICU admission seen increased with thyroid dysfunction  as compared to euthyroid patients.Conclusions: Thyroid dysfunction in pregnancy, although has a low incidence, but is associated with adverse maternal and fetal implications. Thus, thyroid screening should be done in antenatal period to improve fetomaternal outcome.

Hyperhidrosis–Hypertension–Hypotension in Scorpion Envenoming Syndrome: Insulin–Glucose Infusion Reverses All the Clinical Manifestations Caused by Massive Release of Counter-Regulatory Hormones due to Killer Scorpion (Buthidae family) Stings

Death due to poisonous scorpion (Buthidae family) stings is common in many of the developing countries all over the world. Severe uncontrollable pain at the site of sting (without local oedema) results in autonomic storm, release massive quantities of catecholamines, angiotensin II, ACTH, glucocorticoids, glucagon, ADH, aldosterone, either suppressed insulin secretion/or hyperinsulinemia – insulin resistance causing hyperglycemia and a sudden increase in Free Fatty Acid levels (FFA). The increase in catecholamine and angiotensin II hormonal levels cause hyperhidrosis, initial transient hypertension, hyper salivation, hypotension, mydriasis, miosis, DIC, acute pancreatitis, and many other clinical manifestations. Suddenly increased FFA levels are toxic, produce inactivation of Na+–K+ATPase activities, arrhythmias, conduction defects, myocardial infarction, cardiogenic pulmonary oedema, Acute Respiratory Distress Syndrome (ARDS), multisystem organ failure and death. Hyperhidrosis is harmful and wasteful loss of fluid and electrolytes resulting in peripheral circulatory failure, hypotension and death. Based on our animal experimental studies and treating the scorpion sting victims with insulin glucose infusion, we consider that insulin has a primary metabolic role in preventing and reversing hyperhidrosis, hypertension, hypotension, cardiovascular changes, cardiogenic and non-cardiogenic pulmonary (ARDS) oedema. Treatment: Continuous infusion of regular crystalline insulin at the rate of 0.3 U/g glucose and glucose at the rate of 0.1 g/kg body weight/hour, for 48–72 hour, supplementation of potassium (if required), and maintenance of acid–base fluid and electrolyte balance.

Dissecting aortic aneurysm complicating pregnancy

Dissection of the aorta which is very rare in pregnancy usually occurs in the third trimester when blood volume and cardiac output rise to a maximum. We present here, a case of a 38-year-old pregnant woman with acute aortic dissection Type B. Management was conservative and after stabilization of vitals, obstetric hysterotomy was performed

Pacing Indications and Modes in Bradyarrhythmia Patients: Gender Related Differences.

Gender differences are increasingly recognized in cardiology. It is also well known that women have higher complications and a higher mortality related to coronary procedures. In arrhythmias, gender-specific variations in the electrophysiological structure of the heart or hormonal effects may explain some of the gender differences. The aim of this study was to evaluate gender differences according to their risk factors, indications and modes of pacing. A total of 267 patients who had pacemaker implantation for bradyarrhythmia indications were enrolled in our study. A pre-designed questionnaire was filled to record their baseline characteristics, clinical indications and mode of pacing. Out of 267 patients 190 were male and 77 were female. Data was analyzed with SPSS 16.0 software (SPSS, Chicago, IL, USA) The pacemaker implantation requirement was 31% significantly lower among males compared with females who were hypertensive (RR=0.69, 95%CI=0.58-0.82, p=0.0001) and 1.57 times (RR=1.57, 95%CI=1.32-1.87, p=0.0001) significantly higher among male patients than females who were the tobacco user in any form. The single chamber requirement was 1.41 times significantly (RR=1.41, 95%CI=1.16-1.71, p=0.0001) higher in males than females. The risk analysis showed that complete heart blockage (p= 0.02) and sick sinus syndrome (p= 0.01) were significantly higher in males as compared with females. In conclusion male patients had more CHB, sick sinus syndrome and syncope as primary pacemaker indication, compared with female patients. Smoking was the most prominent risk factor in male and hypertension in female and most importantly there were significant gender differences in indications leading to pacing.

Bioactivity, physical and chemical properties of MTA mixed with propylene glycol

AbstractObjective To investigate the physical (setting time, hardness, flowability, microstructure) and chemical (pH change, calcium release, crystallinity) properties and the biological outcomes (cell survival and differentiation) of mineral trioxide aggregate (MTA) mixed using different proportions of propylene glycol (PG) and water.Material and Methods White MTA was mixed with different water/PG ratios (100/0, 80/20 and 50/50). Composition (XRD), microstructure (SEM), setting time (ASTM C266-13), flowability (ANSI/ADA 57-2000), Knoop hardness (100 g/10 s) and chemical characteristics (pH change and Ca2+ release for 7 days) were evaluated. Cell proliferation, osteo/odontoblastic gene expression and mineralization induced by MTA mixed with PG were evaluated. MTA discs (5 mm in diameter, 2 mm thick) were prepared and soaked in culture medium for 7 days. Next, the discs were removed and the medium used to culture dental pulp stem cells (DPSC) for 28 days. Cells survival was evaluated using MTS assay (24, 72 and 120 h) and differentiation with RT-PCR (ALP, OCN, Runx2, DSPP and MEPE) and alizarin red staining (7 and 14 days). Data were analysed using one-way ANOVA and Tukey’s post-hoc analysis (a=0.05).Results The addition of PG significantly increased setting time, flowability and Ca2+ release, but it compromised the hardness of the material. SEM showed that 50/50 group resulted porous material after setting due to the incomplete setting reaction, as shown by XRD analysis. The addition of PG (80/20 and 50/50) was not capable to improve cell proliferation or to enhance gene expression, and mineralized deposition of DPSC after 7 and 14 days as compared to the 100/0.Conclusion Except for flowability, the addition of PG did not promote further improvements on the chemical and physical properties evaluated, and it was not capable of enhancing the bioactivity of the MTA.

Suppressed Insulin Secretion, Elevated Mediators of Inflammation, Hyper-Insulinemia-Insulin Resistance: Insulin Administration Reverses Cardiovascular, Metabolic Changes, Pulmonary Edema and All Other Clinical Manifestations in Scorpion Envenoming Syndrome

Death due to poisonous scorpion stings is common in many tropical and sub-tropical countries. Scorpion envenoming syndrome causes stimulation of neuro-endocrine axis resulting in autonomic storm, intense stimulation of sympathetic nervous system, massive release of catecholamines, angiotensin II, suppressed insulin secretion, glucagon, glucocorticoids, increased free fatty acid levels, hyperglycemia, hyper-insulinemia, insulin resistance, acute myocarditis, initial hypertension, hypotension, arrhythmias, conduction defects, ischemia, infarction, acute pancreatitis, CNS damage, motor aphasia, hemiplegia, mydriasis, hyperhidrosis, acute respiratory distress syndrome, disseminated intravascular coagulation, multi system organ failure, shock and death. The scorpion envenoming syndrome also causes stimulation of immuno-pathological axis, systemic and local inflammation, increase in production of proinflammatory cytokines IL-1α, IL-1β, IL-4, IL-6, IL-10, IL-12, TNF-α, IFN-γ and NO and contribute to immunological imbalance, hyperglycemia, hyper-insulinemia, insulin resistance, multi-system organ failure, shock and death. Elevated levels of TNF-α cause impaired glucose tolerance and induce insulin resistance for endogenously secreted insulin. Insulin administration reversed metabolic, respiratory changes, cardiogenic and non-cardiogenic pulmonary edema, electrocardiographic, cardiovascular changes and many other manifestations in our experimental animals and in our scorpion sting victims with scorpion envenoming syndrome. Treatment: Continuous infusion of regular crystalline insulin at the rate of 0.3 U/g glucose and glucose at the rate of 0.1g/kg body weight/h, for 48–72 h, with supplementation of potassium as needed, maintenance of fluid, electrolytes, acidbase balance.

Utility of First Trimester Anomaly Scan in Screening of Congenital Abnormalities in Low and High Risk Pregnancies.

The primary objective of the present study is to assess the feasibility and value of first trimester anomaly scan in both high risk and low risk pregnant patients. All high risk and low risk patients with live fetus and 11- to 14-week gestation were enrolled in study after informed and written consent. All patients were screened for congenital anomalies by 11-14 week ultrasound scan (first trimester anomaly scan) as part of routine prenatal care. Second trimester scan was conducted at 18 to 22 weeks gestation. The results of the first trimester anatomic survey were correlated with second trimester target scan to evaluate value of first trimester scan for early detection of anomalies. Overall prevalence of congenital anomalies in study population was 2.6%. Out of these 64.4% were detected by first trimester anomaly scan, while another 35.6% were detected by mid gestation scan. Detailed first trimester anomaly scan and first trimester fetal echocardiography should be performed to detect the fetal anomalies early.

Evaluation of MC4R [rs17782313, rs17700633], AGRP [rs3412352] and POMC [rs1042571] polymorphisms with obesity in Northern India

Genetic variants of the melanocortin-4 receptor gene [MC4R], agouti related protein [AGRP] and proopiomelanocortin [POMC] are reported to be associated with obesity. Therefore, the aim of this study is to examine MC4R rs17782313, MC4R rs17700633, AGRP rs3412352 and POMCrs1042571 for any association with obesity in North Indian subjects. The variants were investigated for association in 300 individuals with BMI >/= 30 kg/m2 and 300 healthy non-obese individuals BMI <30 kg/m[2]. The genotyping were analyzed by Taqman probes. The statistical analysis was performed by the SPSS software, ver.19 and p /= 30 kg/m2] in North Indian subjects. This study provides the report about the significant association of MC4R [rs17782313] and POMC [rs1042571] with morbid obesity [BMI >/= 30 kg/m2], but MC4R [rs17700633] and AGRP [rs34123523] did not show any association with obesity in the studied North Indian population.

Initial drug resistance pattern among Pulmonary Tuberculosis patients.

Background: Drug resistant tuberculosis (DRTB) is an emerging problem that adversely affects treatment outcomes and public health in the developing world. Objective: To determine the initial drug resistance pattern among pulmonary tuberculosis patients registered under the Revised National Tuberculosis Control Programme. Study Design: A cross-sectional study design. Setting: Two urban Directly Observed Treatment Supervised (DOTS) centres in Lucknow District of Uttar Pradesh. Methods: The present study consisted of newly diagnosed sputum smear-positive for acid-fast bacilli (AFB) cases at the time of registration under the tuberculosis control programme. All sputum smear positive cases were subjected to culture and drug-susceptibility testing by 1% proportion method on Lowenstein-Jensen (LJ) medium. Results: A total of 185 newly diagnosed sputum smear positive for AFB in pulmonary tuberculosis patients were subjected to culture and drug sensitivity test. Among 185 isolates, 170 (91.4%) isolates were culture positive. Of these 170 isolates, 169 (99.4%) were M. tuberculosis and one (0.5%) was Mycobacterium other than tuberculosis (MOTT). Out of 99.4% M. tuberculosis positive isolates, 21.3% were resistant to at least one drug. Resistance pattern of 21.3% strains of M. tuberculosis showing resistance to single, double, triple, and quadruple drugs were 5.9%, 10.7%, 2.4% and 2.4% respectively. Multi-drug resistance (MDR) was observed in 4.7% isolates. Conclusion: The present study highlights the high rate of drug resistance pattern among the new sputum smear positive pulmonary tuberculosis patients and also high MDR tuberculosis. Routine surveillance of drug resistance profile of patients provides useful information for adopting new strategies of effective treatment within National Tuberculosis Control Programmes in order to combat the threat of MDR-TB in the general population.

Hepsin immunohistochemical expression in prostate cancer in relation to Gleason's grade and serum prostate specific antigen.

Background: Hepsin (HPN), a type II trans-membrane serine protease, has been reported to be one of the most up regulated genes in prostate cancer. The aim of the present study was to find out immuno-histochemistry based phenotypic expression of HPN in formalin fixed paraffin embedded sections of prostate cancer compared with that in benign prostatic hyperplasia, in a prospective clinical setting, to know the differential status of HPN expression in benign and malignant prostatic disease. Materials and Methods: Tissue biopsies of histologically proven cases of prostatic cancers (48), benign prostatic hyperplasia (42), benign prostatic hyperplasia with prostatic intraepithelial neoplasia (7) and 4 cases of benign prostatic hyperplasia with prostatitis, were subjected to immunohistochemical staining with HPN antibody by strepavidin biotin method. Results: Hepsin expression was 100% in prostate carcinoma, 11.9% (5/42) in benign prostatic hyperplasia, 57.14% (4/7) in benign prostatic hyperplasia with prostatic intraepithelial neoplasia (PIN), and none in benign prostatic hyperplasia with prostatitis. Hepsin staining showe higher expression in high grade tumor in comparison to low grade tumor. Conclusions: Positive immunohistochemical expression of hepsin in cent percent cases of prostate cancer cases is intriguing, underscoring the significance of hepsin gene expression in prostate cancer.

Lipid peroxidation and antioxidants in different stages of cervical cancer: Prognostic significance.

Background: Free radical Injury is associated with cancer, but how the extent of oxidative stress correlates with the FIGO (International Federation of Gynecology and Obstetrics) stage in Carcinoma Cervix (Ca Cx), and its significance as a prognostic marker, is not clear and needs an in-depth study. Aim: To correlate the blood levels of Lipid Peroxidation (LPO), Reduced Glutathione (GSH), Superoxide Dismutase (SOD), and Vitamin A and E levels with the clinical stage in Ca Cx. Settings and Design: This is a Prospective Case Control Study. Materials and Methods: LPO, SOD, reduced GSH were estimated by Bio Chemical Assays and Vitamins by High Performance Liquid Chromatography (HPLC). Statistical Analysis: The cases and controls were compared using One Way ANOVA and different stages over different time periods were individually compared by Repeated Measure Analysis of Variance. Results: The results indicated a statistically significant increase of LPO vis-a-vis the FIGO stage of Ca Cx and control, while the antioxidant status as depicted by GSH and SOD decreased. Vitamin A and E levels were significantly lower in cancer cases as compared to the control. Conclusion: Increased LPO and reduced antioxidant levels may be taken as associated predictive markers, thus suggesting that Ca Cx cases should get nutritive supplements to contain the blood LPO level and maintain a positive balance of antioxidants for a better outcome in terms of delayed recurrence and better Quality of Life (QOL).