Accuracy of Femoral Tunnel Placement between Anteromedial and Anterolateral Visualisation Portals in Anterior Cruciate Ligament Reconstruction - Outcomes of a CT based Cross-Sectional Study

@#Introduction: Anatomical femoral tunnel placement is critical for anterior cruciate ligament reconstruction (ACLR). Tunnel placement may vary with different surgical techniques. The aim of this study was to compare the accuracy of femoral tunnel placement between the Anteromedial (AM) and Anterolateral (AL) visualisation portals on post-operative CT scans among a cohort of ACLR patients. Materials and methods: This cross-sectional study was conducted from January 2018 to March 2020 after obtaining ethics clearance. Patients who went for arthroscopic ACLR in our institute were divided into an AM (group 1) and an AL (group 2) based on the visualisation portal for creating the femoral tunnel and a 3D CT scan was done. The femoral tunnel position was calculated in deep to shallow and high to low direction using the Bernard Hertel grid. Femoral tunnel angle was measured in the 2D coronal image. Statistical analysis was done with the data collected. Results: Fifty patients with an average age of 26.36 (18-55) years ±7.216 SD were enrolled in the study. In this study, the AM technique was significantly more accurate (p<0.01) than the AL technique in terms of femoral tunnel angle. Furthermore, the deep to the shallow position was significantly (p= 0.018) closer to normative values, as determined by the chi-square test. The chances of error in tunnel angle in femoral condyle are 2.6 times greater in the AL technique (minimal clinical difference). Conclusion: To conclude, in ACLR the anteromedial visualisation portal can facilitate accurate femoral tunnel placement compared to the anterolateral visualisation portal.

Evaluation of arjunolic acid against Brucella melitenis and in vitro cytotoxic study of lung adenocarcinomic cell line (A549)

Brucellosis, a neglected tropical disease of zoonotic nature, is caused by the genus Brucella, specifically by Brucella abortus and B. melitensis in cattle and humans, respectively. Arjunolic acid (AA) is a triterpenoid, isolated from Terminalia arjuna (Roxb.) Wight & Arn., a medicinally important plant used to treat various diseases in the Indian system of medicine. Here, we tried to evaluate AA for its antibacterial activity on Brucella and the in vitro cytotoxicity assay on human lung adenocarcinomic alveolar basal epithelial cell line (A549). Also, we assessed the synergistic effect of arjunolic acid and Tarenna asiatica (L.) Kuntze ex K.Schum. on B. melitensis. AA displayed a considerable antibacterial activity [zone of inhibition (9 mm) with a minimum inhibitory concentration of 30 ?g/mL] against B. melitensis. The rate of cell death for the cancer cells were at 100 ?g/mL concentration of AA was 82% which indicates that AA shows significant membrane disruption to cancer cells. The estimated IC50 of AA against the A549 cell line was 139.90 ?g/mL. The highest synergistic activity was exhibited forming a zone of inhibition measuring 10mm when arjunolic acid and AqE of T. asiatica was added in the concentration of 1:1, respectively.

Prenatal diagnosis: A connotation on genetic counseling being indispensable

Prenatal testing and diagnosis are gaining a strong foothold in a progressively developing country like India, and an estimated boom in the market of noninvasive prenatal testing is predicted by the year 2024. Having said this, every technique needs an adequate amount of supplementation to increase its worth and that is where genetic counseling proves to be indispensable. Postdiagnosis, the women classified as high-risk individuals likely to give birth to infants inflicted with congenital and structural anomalies are appropriately counseled regarding the clinical aspects of the disease, life expectancy associated with the same, and the consequences associated with the decision to go ahead and conceive the child. Genetic counseling is majorly done for Down syndrome as the other aneuploidies have a highly reduced life expectancy. Although there are a variety of techniques available for testing various chromosomal anomalies, information regarding the appropriate time of the test and emphasis on pre- and posttest counseling is usually not supplied to primary physicians. A considerable amount of confusion dominates the decision of which test should be employed for testing of which anomaly as an array of rather efficient techniques has been identified. Furthermore, there is no nation-wide consensus of the timing and nature of these screening protocols. Moreover, ambiguous guidelines along with an impending lacuna in terms of awareness have led to India being at the backseat of the era that has ushered in tons of technological advancement in this field.

A comparative study of saline infusion sonohysterography and hysterosalpingography for evaluation of female infertility

Background: Infertility is a complex disorder with significant psychological and emotional impact. It affects 10-15% of couples in the reproductive age group. Hence, evaluation of female genital tract is an important part of workup of an infertile woman. The most commonly used methods are hysterosalpingography which exposes the patient to ionizing radiation and laparoscopy which is invasive. This calls for the need of a low risk method that would be suited for ambulatory application. Saline infusion sonohysterography is a cost-effective, safe, non-invasive and a rapid procedure to visualize the female pelvic organ in evaluation of infertility. The objective of this study was to compare diagnostic accuracy of saline infusion sonography (SIS) over conventional hysterosalingography (HSG) for evaluation of female infertility.Methods: Total 50 patients who presented to the gynecology OPD between 2018 to September 2019 for evaluation of infertility were included for the study. The results of the two procedures were compared.Results: For evaluation of uterine cavity, SIS had a sensitivity of 95%, specificity of 100%, PPV of 100%, NPV 75% and a sensitivity of 100%, specificity of 100%, PPV of 91%, NPV of 100% for tubal patency as compared to HSG.Conclusions: For evaluation of uterine cavity, SIS had a sensitivity of 95%, specificity of 100%, PPV of 100%, NPV 75% and a sensitivity of 100%, specificity of 100%, PPV of 91%, NPV of 100% for tubal patency as compared to HSG.

Anticipating Urinary Retention Following Total Hip and Total Knee Replacements

@#Introduction: Urinary retention is a widely recognised postoperative complication. Although anecdotally lower limb arthroplasty is linked with high rates of urinary retention, there are no current accepted standards for determining which patients are at higher risk and should therefore be offered intra operative catheterisation. Materials and Methods: One hundred patients, 55 females and 45 males, who underwent uncomplicated total hip or total knee replacements at Furness General Hospital were recruited between January and April 2017. Results: Post-operative urinary retention was seen frequently, with 38 patients (38%) requiring post-operative catheterisation. Twenty-one males (46%) developed postoperative retention compared to 17 (30%) of females, representing a statistically significant increase in risk seen in male patients. (p 0.009). Post-operative urinary retention requiring catheterisation was associated with increasing age, with those over 75 years having a significantly higher risk than those less than 75 years irrespective of gender (p 0.04). There was no significant difference in urinary retention rates between patients who had general (n=21) or spinal anaesthetic (n=79) with 33% of GA patients and 39% of spinal anaesthetic patients requiring catheterisation (p 0.17). Conclusion: There are increased rates of urinary retention seen in lower limb arthroplasty patients than those described in the general surgical population, with male patients and all those over 75 years of age having a significantly higher risk. Clinically, it may therefore be sensible to consider offering routine intra operative catheterisation to this cohort of patients.

Granulomatous slack skin syndrome: Report of a unique case

Granulomatous slack skin syndrome is a rare variant of cutaneous T-cell lymphoma (mycosis fungoides). It is characterized clinically by redundant skin folds, which show a predilection towards flexural areas such as the axilla and the groin. Histologically, it shows a granulomatous T-cell infiltrate and loss of elastic tissue. It has an indolent but progressive course; and is usually refractory to treatment. We report a unique case of slack skin syndrome, sparing the classical sites with rapid and unusual involvement of non-intertriginous areas.

Effect of HPMC and ethyl cellulose polymeric granules and its combinations in press coated tablets of lornoxicam: fabrication and in vitro characterization.

The main objective of the present exploration was to formulate and evaluate chronomodulated press-coated tablets to deliver the NSAID lornoxicam, when a pain in the joints, functional disability persist in the early morning time is typically observed in most Rheumatoid arthritis (RA) patients. Pre formulation studies and drug excipient compatibility studies were carried out for lornoxicam and excipients. Core tablets containing lornoxicam was prepared by direct compression method and the tablets were subjected to various pre-compression and post-compression parameters (C1-C4 formula) based on the above result best core tablet batch was selected and used for press coating processes. HPMC and EC granules were used as controlled release polymers in the outer layer. These tablets were subjected to pre and post compression parameters, finally the tablets were evaluated for lag time and in vitro dissolution. Results of preformulation studies were acceptable limits. No interaction was observed between lornoxicam and excipients by FTIR. The results of pre and post compression studies were within limits. Formulation code CC3 was identified as best formulation that extends a release profile with 6 h lag time followed by complete lornoxicam release after 8 h. From the graphical representation it can be well perceive that this is perfectly fit in to Korsemeyer which had a Regression coefficient (R2) of 0.9431. The results of the in-vitro release data of this layer were fitted to the Korsemeyer-Peppas equation to examine the release pattern of the drug from the polymeric system. The drug release was identified as super case II transport as the “n” value found to be more than 0.89.

Effect of HPMC and ethyl cellulose polymeric granules and its combinations in press coated tablets of lornoxicam: fabrication and in vitro characterization.

The main objective of the present exploration was to formulate and evaluate chronomodulated press-coated tablets to deliver the NSAID lornoxicam, when a pain in the joints, functional disability persist in the early morning time is typically observed in most Rheumatoid arthritis (RA) patients. Pre formulation studies and drug excipient compatibility studies were carried out for lornox-icam and excipients. Core tablets containing lornoxicam was prepared by direct compression method and the tablets were subjected to various pre-compression and post-compression parameters (C1-C4 formula) based on the above result best core tablet batch was selected and used for press coating processes. HPMC and EC granules were used as controlled release polymers in the outer layer. These tablets were subjected to pre and post compression parameters, finally the tablets were evaluated for lag time and in vitro dissolution. Results of preformulation studies were acceptable limits. No interaction was observed between lornoxicam and excipients by FTIR. The results of pre and post compression studies were within limits. Formulation code CC3 was identified as best formulation that extends a release profile with 6 h lag time followed by complete lornoxicam release after 8 h. From the graphical representation it can be well perceive that this is perfectly fit in to Korsemeyer which had a Regression coefficient (R2) of 0.9431. The results of the in-vitro release data of this layer were fitted to the Korsemeyer-Peppas equation to examine the release pattern of the drug from the polymeric system. The drug release was identified as super case II transport as the “n” value found to be more than 0.89.

Nasopharyngeal carriage, antibiogram & serotype distribution of Streptococcus pneumoniae among healthy under five children.

Background & objectives: Information related to nasopharyngeal carriage of Streptococcus pneumoniae among healthy children is scanty in India. This prospective study was undertaken to determine the presence of asymptomatic nasopharyngeal colonization, assess serogroups/types (SGT) and drug resistance of S. pneumoniae in children below five years of age. Methods: A total of 109 male and 81 female children in the age group of three months to five years belonging to different socio-economic classes were enrolled. They were recruited across all age groups from those attending paediatric OPD of a tertiary care and research centre for immunization program. Fifty three isolates identified as pneumococci were tested for their antimicrobial susceptibility pattern by Kirby-Bauer’s disc diffusion and E-Test methods. Serotyping was performed by detection of the quelling reaction with specific antiserum. Result: The pneumococcal carriage rate in the study population was 27.9 per cent. The isolation rate was associated with age being higher (49.2%) in smaller children (3-12 months) and among male (62.2%). The most prevalent SGTs were 19 followed by 10, 14 and 7; 21 per cent of isolates belonging to serotype 10 (n=7) were 11 (n=4) were not covered in any of the conjugate vaccines currently available in Indian market. Resistance to co-trimoxazole, tetracycline, penicillin and erythromycin was observed in 91 per cent (n=48), 36 per cent (n=19), 17 per cent (n=9) and 9 per cent (n=5) isolates, respectively. All the penicillin resistant isolates were found to be intermediately resistant by E-Test. Multidrug resistance was observed in 19 per cent (n=10) isolates. Interpretation & conclusions: High level of antibiotic resistance was present in S. pneumoniae isolated from healthy children below age five. A pneumococcal conjugate vaccine with the prevailing SGTs would help to reduce the pool of antibiotic resistant pneumococci. Continued surveillance of serotypes and tracking susceptibility pattern of S. pneumoniae will help to introduce appropriate vaccination protocols.

Maintaining Reduced Noise Levels in a Resource-Constrained Neonatal Intensive Care Unit by Operant Conditioning.

Objective: To evaluate the efficacy of operant conditioning in sustaining reduced noise levels in the neonatal intensive care unit (NICU) Design: Quasi-experimental study on quality of care. Setting: Level III NICU of a teaching hospital in south India. Participants: 26 staff employed in the NICU. (7 Doctors, 13 Nursing staff and 6 Nursing assistants). Intervention: Operant conditioning of staff activity for 6 months. This method involves positive and negative reinforcement to condition the staff to modify noise generating activities. Main outcome measures: Comparing noise levels in decibel: A weighted [dB (A)] before conditioning with levels at 18 and 24 months after conditioning. Decibel: A weighted accounts for noise that is audible to human ears. Results: Operant conditioning for 6 months sustains the reduced noise levels to within 62 dB (A) in ventilator room (95% CI: 60.4 – 62.2) and isolation room (95% CI: 55.8 – 61.5). In the pre-term room, noise can be maintained within 52 dB (A) (95 % CI: 50.8 – 52.6). This effect is statistically significant in all the rooms at 18 months (P = 0.001). At 24 months post conditioning there is a significant rebound of noise levels by 8.6, 6.7 and 9.9 dB (A) in the ventilator, isolation and pre-term room, respectively (P=0.001). Conclusion: Operant conditioning for 6 months was effective in sustaining reduced noise levels. At 18 months post conditioning, the noise levels were maintained within 62 dB (A), 60 dB (A) and 52 dB (A) in the ventilator, isolation and pre-term room, respectively. Conditioning needs to be repeated at 12 months in the ventilator room and at 18 months in the other rooms.

Low cost calibrated mechanical noisemaker for hearing screening of neonates in resource constrained settings.

Background & objectives: There is a need to develop an affordable and reliable tool for hearing screening of neonates in resource constrained, medically underserved areas of developing nations. This study valuates a strategy of health worker based screening of neonates using a low cost mechanical calibrated noisemaker followed up with parental monitoring of age appropriate auditory milestones for detecting severe-profound hearing impairment in infants by 6 months of age. Methods: A trained health worker under the supervision of a qualified audiologist screened 425 neonates of whom 20 had confirmed severe-profound hearing impairment. Mechanical calibrated noisemakers of 50, 60, 70 and 80 dB (A) were used to elicit the behavioural responses. The parents of screened neonates were instructed to monitor the normal language and auditory milestones till 6 months of age. This strategy was validated against the reference standard consisting of a battery of tests - namely, auditory brain stem response (ABR), otoacoustic emissions (OAE) and behavioural assessment at 2 years of age. Bayesian prevalence weighted measures of screening were calculated. Results: The sensitivity and specificity was high with least false positive referrals for 70 and 80 dB (A) noisemakers. All the noisemakers had 100 per cent negative predictive value. 70 and 80 dB (A) noisemakers had high positive likelihood ratios of 19 and 34, respectively. The probability differences for pre- and post- test positive was 43 and 58 for 70 and 80 dB (A) noisemakers, respectively. Interpretation & conclusions: In a controlled setting, health workers with primary education can be trained to use a mechanical calibrated noisemaker made of locally available material to reliably screen for severe-profound hearing loss in neonates. The monitoring of auditory responses could be done by informed parents. Multi-centre field trials of this strategy need to be carried out to examine the feasibility of community health care workers using it in resource constrained settings of developing nations to implement an effective national neonatal hearing screening programme.

Association between chronic generalized periodontitis and hyperlipidemia – a case control study.

Introduction: Hyperlipidemia is a major risk factor for cardiovascular disease. Periodontal disease is caused by predominantly anaerobic gram negative bacteria. Microbial substances initiate and perpetuate the inflammation resulting in the production of high levels of proinflammatory cytokines and hyperactivity of white blood cells and of blood platelets, thus promoting the development of hyperlipidemia. Objective: To evaluate the plasma lipids (Total cholesterol, Low Density Lipoproteins and Triglycerides) as well as Fasting blood glucose levels in non diabetic, non-obese periodontal disease patients and controls. Materials and methods: 18 subjects with chronic periodontal disease (aged 38 to 50 years) were matched for age, sex and BMI (Body Mass Index) with 18 healthy subjects. Total cholesterol, low density lipoprotein, triglycerides and fasting blood glucose levels were measured using routine enzymatic biochemical methods. Results: Total cholesterol, LDL cholesterol and triglycerides was significantly higher in chronic periodontitis patients by 12 %( p<0.02), 14 %( p<0.03) and 22 %( p<0.03) respectively as compared to controls. Fasting blood glucose levels was higher by 7% (p<0.04) in chronic periodontitis patients than controls. Conclusion: Hyperlipidemia and prediabetic state may be associated with chronic periodontitis.

Efficacy of a low cost protocol in reducing noise levels in the neonatal intensive care unit.

Objective. To examine the effectiveness and cost of implementing a noise reduction protocol in a level III neonatal intensive care unit (NICU). Methods. A prospective longitudinal study was done in a level III NICU, wherein a noise reduction protocol that included behavioral and environmental modification was implemented. The noise levels were measured sequentially every hour for 15 days before and after this intervention. The statistical significance of the reduction in noise levels after implementation of the protocol was tested by paired sample student's t-test. Cost was calculated using the generalized cost effectiveness model of the World Health Organisation. The present study has 80 % power with 95 % confidence to measure 2 dB differences between groups for the maximum recommended of 50 dB. Results. The protocol in the present study reduced noise levels in all the rooms of the NICU to within 60 dB with high statistical significance (p< 0.001). The extent of noise reduction in the rooms of the NICU was as follows : ventilator room by 9.58 dB (95 % confidence interval: 6.73 – 12.42, p < 0.001) , stable room by 6.54 dB (95 % confidence interval: 2.92 – 4.16 , p < 0.001), isolation room by 2.26 dB (95 % confidence interval: 1.21 – 3.30, p < 0.001) , pre-term room by 2.37 dB(95 % confidence interval: 1.22 – 3.51, p < 0.001)and extreme preterm room by 2.09 dB (95 % confidence interval: 1.14 – 3.02, p < 0.001). The intervention was most cost-effective in the ventilator room, requiring Rs. 81.09 to reduce 1 dB and least effective in the extreme pre-term room requiring Rs. 371.61 to reduce 1 dB. Conclusion. The high efficacy and affordability of noise reduction protocols justify the need for implementation of these measures as a standard of care in neonatal intensive care units.

Spectral analysis of noise in the neonatal intensive care unit.

OBJECTIVE: To perform spectral analysis of noise generated by equipments and activities in a level III neonatal intensive care unit (NICU) and measure the real time sequential hourly noise levels over a 15 day period. METHODS: Noise generated in the NICU by individual equipments and activities were recorded with a digital spectral sound analyzer to perform spectral analysis over 0.5 - 8 KHz. Sequential hourly noise level measurements in all the rooms of the NICU were done for 15 days using a digital sound pressure level meter . Independent sample t test and one way ANOVA were used to examine the statistical significance of the results. The study has a 90 % power to detect at least 4 dB differences from the recommended maximum of 50 dB with 95 % confidence. RESULTS: The mean noise levels in the ventilator room and stable room were 19.99 dB (A) sound pressure level (SPL) and 11.81 dB (A) SPL higher than the maximum recommended of 50 dB (A) respectively ( p < 0.001). The equipments generated 19.11 dB SPL higher than the recommended norms in 1 - 8 KHz spectrum. The activities generated 21.49 dB SPL higher than the recommended norms in 1 - 8 KHz spectrum ( p< 0.001).The ventilator and nebulisers produced excess noise of 8.5 dB SPL at the 0.5 KHz spectrum. CONCLUSION: Noise level in the NICU is unacceptably high .Spectral analysis of equipment and activity noise have shown noise predominantly in the 1 - 8 KHz spectrum. These levels warrant immediate implementation of noise reduction protocols as a standard of care in the NICU.

Universal hearing screening.

OBJECTIVE: To determine the weighted incidence of hearing impairment in a standardized population of at risk and not at risk neonates seeking care at a tertiary level hospital in India. METHODS: A prospective study of a nonrandomized cohort of 1769 neonates (1490: Not at risk; 279: At risk) from a total of 8192 neonates (6509: Not at risk; 1683: At risk) who sought care at St John's medical College hospital from 1st September 2002 to 31st March 2006 were screened for hearing impairment using transient evoked otoacoustic emissions. Weighting was performed using the expected value of 10 % at risk and 90 % not at risk infants in a typical tertiary care level center in India derived from the National Neonatology and Perinatology database 2002-2003. Z test and 95 % confidence interval was used to determine the external validity of the results. P less than 0.05 was considered as statistically significant. The power of the study is 90 %. RESULTS: The incidence of hearing impairment in infants screened was 10 per 1769 infants screened (1490: Not at risk; 279: At risk) which is 5.65 per 1000 screened. 279 at risk infants were screened and 3 were detected to have hearing impairment which is an incidence of approximately 10.75 per 1000 screened. Of the 1490 not at risk infants screened 7 had hearing impairment that is 4.70 per 1000 screened. If this was extrapolated to a standardized population consisting of 10 % at risk and 90 % not at risk then the incidence would be 5.60 per 1000 screened with a 95 % confidence interval of 4.13-7.06. This narrow 95 % confidence interval with a p equal to 0.001 indicates that this value may be close to the caseload in a typical tertiary care center. CONCLUSION: In this study the incidence of hearing impairment is 3 per 279 in at risk infants screened and 7 per 1490 in not at risk infants screened. The weighted incidence in a standardized population of neonates seeking care at tertiary level center in India is 5.60 per 1000 as per this study. This high incidence calls for all pediatricians to consider incorporating a basic hearing screen for all the neonates using cost effective and appropriate technology. Initial screening may be performed using behavioral observation techniques and confirmation by otoacoustic emissions.

What do patterns of noise in a teaching hospital and nursing home suggest?

INTRODUCTION : Noise pollution is known to cause deleterious effects on human health and may especially affect frail elderly patients with poor mental and physiologic reserve. AIMS OF THE STUDY : (i) to learn levels and time- and place-patterns of noise in an urban community teaching hospital (TH) and affiliated urban nursing home (NH); (ii) to compare levels and patterns of noise in both institutions. RESULTS : Recordings were obtained in three areas of the TH: emergency room (ER), intensive care units (ICU), and medical-surgical floors (HF) - nurses' stations and patients' rooms. On nursing home floors (NHF), noise levels were recorded at nurses' stations and in patients' rooms. In all areas of the hospital and NH, noise levels were in range of 55-70 dB and exceeded the 40-50 dB limit recommended by the EPA. In ER and ICU, noise level was higher on weekdays than weekends. In ICU and on HF, noise level was higher during mid-day hours during mornings and evenings. The highest noise level was recorded in ER followed by ICU and HF. On HF, nurses' stations were noisier than patients' rooms. Noise level was higher in the TH than in the NH. On NHF, noise level was similar on weekdays and weekends. Noise was stronger at nurses' stations than in patients' rooms and stronger in the mornings and evenings than during mid-day hours. Patterns of noise followed the human factor activities observed in both facilities. CONCLUSIONS : The level of noise in both facilities was above the recommended limit and presents an environmental stressor for a frail elderly patient. With transfer from NH to TH exposure to this stressor is increased. Time- and place-patterns of noise in both institutions suggest that human factor is a major source of noise pollution. This pollution is, therefore, potentially modifiable.

Down syndrome child with 48,XXY,+21 karyotype.

Cytogenetic analysis in 60 clinically suspected cases of Down syndrome and their parents was carried out using conventional Giemsa-trypsin-banding technique. Fifty-five individuals (91%) exhibited a free trisomy 21. Robertsonian translocations were seen in three cases and two cases exhibited a normal karyotype. A four-month-old child, the second-born of non-consanguineous parents, possessed an extra X chromosome in addition to trisomy 21. The proband's parents and his brother showed a normal karyotype. The phenotypic characteristics of this child have been discussed in the light of the published reports on double aneuploidies of XXY and trisomy 21.