Anatomy Teaching: A Student’s Perspective

Background: The advent of 21st century has brought about revolutionary changes in medical education. Medicaleducators are debating the effective application of traditional and newer teaching and learning (T/L)methodologies. The present study aimed to obtain the student’s perspective on the present T/L methodology inanatomy and also the content and duration of anatomy teaching so as to help the educators design a moreeffective anatomy T/L programme.Methodology: The 4th, 5th year MBBS students and interns were administered questionnaires to rate the T/L aidsand give suggestions to improve the teaching of anatomy through close and open ended questions.Results: Amongst the teaching aids, excellent / good rating was given by 80.3% students to classroom teaching onthe black-board, followed by 68.3% to dissection. Amongst the learning aids, excellent / good rating was given by72.3% students to dissection and 67% to lectures. Further, 55% students opined that anatomy should be taughtover 12 months (excluding examinations) whereas 37.6% suggested it to be taught in 18 months. The need tointroduce anatomy teaching sessions during the later part of the medical curriculum was felt by majority (95.2%)of the students.Conclusions: The traditional T/L methods like dissection, lectures and black-board teaching are preferred by thenewer generation learners also and should be integrated with newer teaching modalities and modern technology.The anatomy syllabus being taught in the present MBBS curriculum is adequate, however the time allotted foranatomy teaching needs to be increased by 2 to 6 months. The study further suggests that there is a need toreinforce anatomy teaching in the clinical years.

Improved detection of Shigella using Escherichia coli medium enrichment: Polymerase chain reaction from stool samples.

Laboratory diagnosis of shigellosis using conventional culture technique is limited by lower sensitivity and higher turnaround time. Here, we have evaluated the role of polymerase chain reaction from stool samples after enrichment in Escherichia coli medium for detection of Shigellae. The technique not only increased the sensitivity but also decreased the turnaround time.

Clinicopathological characteristics of ameloblastomas in Western Uttar Pradesh population: An institutional study.

OBJECTIVE: The aim of this study was to compare the clinical, radiologic, and histopathological features of 28 intraosseous ameloblastomas. In addition, we compared the data obtained in this study with that of previous studies. MATERIALS AND METHODS: Data with regard to age, gender, clinical manifestation, radiographic aspect, anatomical distribution, and histopathological subtypes were analyzed in 28 subjects. RESULTS: The patients’ age ranged from 7 years to 65 years (mean, 30.4 years). Sixteen (57.14%) of the 28 subjects were males, and 12 (42.85%) were females. A total of 22 cases (78.5%) were located in the mandible, posterior region was more often affected with 17 cases (77.27%) than only 5 cases (22.72%) in the anterior segment. Swelling was the most common symptom and was experienced by 12 (42.85%) patients. Radiographically, 14 cases (50%) were multilocular with a well‑demarcated border. Of the remaining 14 cases, 10 were unilocular and 4 were unknown in appearance. The most common histopathological pattern was follicular followed by plexiform or acanthomatous. CONCLUSIONS: The clinical epidemiological profile to patients in the present study is similar to that in other populations, with follicular ameloblastoma being the most common histological subtypes seen.

Iniencephaly and Associated Anomalies In A 13 Week Fetus.

Iniencephaly is a rare neural tube defect (1 in 65,000 births in India). It involves defect of occiput and inions combined with rachischisis and retroflexion of head. We present a rare case of inencephaly diagnosed on ante-natal ultrasound in a 13 weeks fetus and associated with cystic hygroma and single umbilical artery. The fetal cervico-thoracic spine was retroflexed, occipital area was soft and brain tissue and spinal cord was visible externally in cervical region. The side of neck showed subcutaneous edema and two vessels (1 umbilical vein and 1 umbilical artery) were present in the umbilical cord. On x-ray examination spinous processes of all vertebrae showed presence of ossification centers except in the cervical region.

Trends in antimicrobial susceptibility of Salmonella Typhi from North India (2001-2012).

Purpose: Enteric fever is endemic in India with Salmonella Typhi being the major causative agent. Antibiotic therapy constitutes the mainstay of management. The present study was undertaken to find the susceptibility profile of Salmonella enterica var Typhi (S. Typhi) blood isolates in a tertiary care hospital between January 2001 and December 2012. Materials and Methods: A retrospective analysis of laboratory records was carried out. Conventional blood culture method was used until 2009; from January 2010 onwards BACTEC 9240 system has been in use. Salmonella were confirmed by serotyping using group and type specific antisera. Antibiotic susceptibility was performed using the disk diffusion method. In addition 116 isolates were subjected to minimum inhibitory concentration testing for chloramphenicol, ciprofloxacin, amoxicillin and nalidixic acid (NA) using agar dilution and for ceftriaxone and azithromycin using E‑strips (Biomerieux). Result: A total of 1016 typhoidal salmonellae were obtained. The predominant serotype obtained was S. Typhi (852, 83.8%) followed by Salmonella enterica var Paratyphi A (164, 16.2%). We observed a re‑emergence of susceptibility to first line antibiotics and a notable decline in multidrug resistant (MDR) strains. We also found all recent isolates resistant to NA and susceptible to third generation cephalosporins and 84.5% of isolates having decreasing ciprofloxacin susceptibility using revised criteria as per Clinical and Laboratory Standards Institute 2012 guidelines. Conclusion: There has been re‑emergence of susceptibility to first line antibiotics and a notable decline in MDR strains of S. Typhi. We have a very high resistance to NA and decreasing susceptibility to ciprofloxacin. Third generation cephalosporins and azithromycin seem to be effective therapeutic options. Judicious use of these antibiotics is mandatory to prevent emergence of resistant strains.

Multiplex polymerase chain reaction using insertion sequence 6110 (IS6110) and mycobacterial protein fraction from BCG of Rm 0.64 in electrophoresis target genes for diagnosis of tuberculous lymphadenitis.

Purpose: Tubercular lymphadenitis (TBLA) is a common manifestations of extrapulmonary tuberculosis (EPTB) accounting for 30-40% of cases. Prompt diagnosis and timely initiation of anti-tubercular therapy (ATT) is the key for successful clinical outcome. This study was carried out to evaluate multiplex polymerase chain reaction (MPCR) using MPB64 and IS6110, and compare with the conventional methods for rapid diagnosis of TBLA. Materials and Methods: In our study, lymph node fine-needle aspirates of patients were evaluated for TBLA. They were classified as Group I: TBLA group, divided into (a) Confirmed TBLA cases (n0 = 80): Culture/smear-positive or cytological examination showing presence of epithelioid cell granuloma with or without multinucleate giant cell and caseation necrosis with presence of AFB, and (b) suspected TBLA cases ( n = 30): Culture/smear-negative and cytological examination showing presence of epithelioid cell granuloma and response to ATT and Group II (Control) (n = 25): Patients of lymphadenopathy confirmed to be caused by other diseases such as sarcoidosis, lymphoma, etc., All samples were subjected to conventional tests and MPCR. For MPCR we used Mycobacterium tuberculosis-specific deoxyribonucleic acid sequences specific for the MPB64 and IS6110 region. Results: In the confirmed TBLA group, Ziehl-Neelsen (ZN) smear, cytology, culture, and MPCR positivity was 30%, 70%, 26.3%, and 91.3% respectively. In the suspected TBLA group, smear and culture were negative, and sensitivity of cytology and MPCR was 73.3% and 86.6%, respectively. In the control group all tests were found to be negative, thus giving a specificity of 100% to all the tests in the study. Conclusion: In conclusion, techniques like MPCR with high sensitivity and specificity can play an important role in rapid diagnosis of TBLA.

Randomized, double-blind study on role of low level nitrogen laser therapy in treatment failure tubercular lymphadenopathy, sinuses and cold abscess.

Background: Effectiveness of low level nitrogen laser therapy along with antitubercular treatment (ATT) in cases of treatment failure and drug resistant tubercular lymphadenopathy, sinuses and cold abscess. Methods: In a double-blind randomized controlled trial of LLLT ,104 patients assigned to either the low level nitrogen laser therapy along with ATT ( LLLT group) (n =54) or ATT only(Chemotherapy group)(n=50). Both groups were treated two times per week for five weeks. Those in the treatment group received pulse nitrogen laser with a pulse duration of seven nanosecond, wave length 337 nanometer and average power output of 5 mW whereas those in the control group were treated with sham laser. The primary outcome measure was bacteriological conversion and the secondary outcome measures were decrease in size of lesion and the clinical improvement. Results: Acid Fast Bacilli (AFB) smear, AFB culture and Polymerase Chain Reaction(PCR) conversion rate at five weeks (after 10 sittings of laser) were 49.15%( Fishers P exact test-p= 0.015), 60%, 44.44% (Fishers P exact test-p= 0.048 ) in LLLT group as compared to 11.86%,20%,17.77% in chemotherapy group. Average percentage reduction in the size of gland at 5 weeks was 70.67% (p value 0.01) as compared to 54.81 in chemotherapy group. Average time taken for closure of sinuses was 11.03 weeks in LLLT group as compared to 26 weeks in chemotherapy group. The follow up was conducted for two years. Conclusion: Low level nitrogen laser therapy can be used as an adjunctive therapy along with antitubercular drugs in cases not responding and drug resistant tubercular lymphadenopathy, sinuses and cold abscess.

In vivo and in vitro bradycardia induced by local anesthetics is potentiated by calcium channel blockers.

The present study examined the interactions of local anesthetics (LA) and calcium channel blockers (CCBs) on rhythmicity of heart using in vivo and in vitro experiments. ECG recordings were made from the anesthetized rats for in vivo preparations and spontaneously beating isolated rat right atrial potential for the in vitro experiments. The in vivo experiments with LA showed dose-dependent bradycardia with lignocaine (LIG, 100-500 μg/kg) and bupivacaine (BUP, 10-100 μg/kg). BUP was 4-5 times more potent than LIG. Verapamil (VML) and diltiazem (DTZ), CCBs also produced dose (10-100 μg/kg) -dependent bradycardia. However, none of them affected the PR/QT interval or QRS complex. Further, LA-induced bradycardia was potentiated by CCBs. In addition, flattening of P-wave in ECG was observed with doses (10-25 μg/kg) of LA in the presence of CCBs. Similarly, the in vitro experiments demonstrated a concentration-dependent decrease in atrial rate by BUP or VML. The BUP-induced decrease was potentiated in the presence of VML. Thus, the results suggest that CCBs potentiate the LA-induced bradycardia by involving pacemaker activity. Further, the flattening of P-wave in ECG serves as an early indicator of the cardiotoxicity produced by these drugs.

PNH revisited: Clinical profile, laboratory diagnosis and follow-up.

BACKGROUND: Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by intravascular hemolysis, marrow failure, nocturnal hemoglobinuria and thrombophila. This acquired disease caused by a deficiency of glycosylphosphatidylinositol (GPI) anchored proteins on the hematopoietic cells is uncommon in the Indian population. MATERIALS AND METHODS: Data of patients diagnosed with PNH in the past 1 year were collected. Clinical data (age, gender, various presenting symptoms), treatment information and follow-up data were collected from medical records. Results of relevant diagnostic tests were documented i.e., urine analysis, Ham's test, sucrose lysis test and sephacryl gel card test (GCT) for CD55 and CD59. RESULTS: A total of 5 patients were diagnosed with PNH in the past 1 year. Presenting symptoms were hemolytic anemia (n=4) and bone marrow failure (n=1). A GCT detected CD59 deficiency in all erythrocytes in 4 patients and CD55 deficiency in 2 patients. A weak positive PNH test for CD59 was seen in 1 patient and a weak positive PNH test for CD55 was seen in 3 patients. All patients were negative by sucrose lysis test. Ham's test was positive in two cases. Patients were treated with prednisolone and/or androgen and 1 patient with aplastic anemia was also given antithymocyte globulin. A total of 4 patients responded with a partial recovery of hematopoiesis and 1 patient showed no recovery. None of the patients received a bone marrow transplant. CONCLUSION: The study highlights the diagnostic methods and treatment protocols undertaken to evaluate the PNH clone in a developing country where advanced methods like flowcytometry immunophenotyping (FCMI) and bone marrow transplants are not routinely available.

Carotid intimomedial thickness in type 2 diabetic patients and its correlation with coronary risk factors.

AIMS: To compare the carotid intimal-medial thickness in type 2 diabetics with and without coronary artery disease (CAD), and to correlate the intimal-medial thickness (IMT) with known coronary risk factors. METHODS: One hundred and eleven patients of type 2 diabetes were recruited for the study. History and physical examination were recorded. Laboratory investigations included fasting and 2-hour post-prandial blood sugar, blood urea, serum creatinine, lipid profile, glycated haemoglobin, and microalbuminuria. Ultrasonographic scanning of the carotid arteries was performed to measure the carotid IMT. For identification of cases of silent ischaemia, treadmill test (TMT) was performed. RESULTS: The study group was divided into a non-CAD group (n=40), and a CAD group (n=71). The mean carotid IMT of the group as a whole, was 0.840 +/- 0.2 mm. The mean carotid IMT was significantly higher (p<0.0001) in type 2 diabetics with CAD (both overt and silent) than in those without CAD. In diabetics with CAD, the systolic blood pressure, diastolic blood pressure and triglycerides were found to be predictors of high mean carotid IMT. On subgroup analysis of the cases with silent ischaemia, the variables affecting carotid IMT were serum creatinine, total cholesterol, microalbuminuria/proteinuria, serum triglyceride levels, and diastolic blood pressure. CONCLUSION: A high carotid IMT is a surrogate and reliable marker of higher risk of CAD amongst type 2 diabetic patients, even in those without overt CAD. The study underlines the utility of carotid IMT as a simple, non-invasive, safe, and cheap screening test for the assessment of risk/prognosis of CAD in type 2 diabetics. We have also demonstrated the usefulness of measuring IMT, as a means to detect silent CAD among type 2 diabetics.

Is seroprevalence of anti-IGM CMV among blood donors relevant in India?

BACKGROUND: Infection with cytomegalovirus (CMV) is more common in developing nations and the people belonging to the lower socioeconomic section of the society. The immunosuppressed population for whom CMV-seronegative blood products are requested is increasing due to advances in medical care. AIM: To study the prevalence of CMV antibodies among the different sexes and age groups in healthy blood donors. MATERIALS AND METHODS: A retrospective study was done on 5600 serum samples stored frozen in a repository for CMV antibodies using the ELISA technique. RESULTS: Five thousand three hundred and fifty (95.5%) were male and 250 (4.5%) were female. Four cases (0.071%) out of 5600 samples were positive for anti-IgM CMV with 95% Confidence Interval (95% C.I) of 0.02 - 0.17. CONCLUSION: In a developing country like India, screening for IgM antibody on a routine basis may not be feasible, given the likely positive yield to be low and the cost being high. It is recommended that in a tertiary care hospital, blood units to be transfused to neonates, organ transplant recipients, those suffering from malignancies and other immunocompromised patients should be screened for anti-IgM CMV or preventive strategies like universal leucodepletion to be implemented to decrease the transmission of CMV in these groups of patients.

Multimeric analysis in diagnosis of vWD variants in Indians.

von Willebrand disease is a common inherited bleeding disorder and the problem is undefined in developing countries due to limitation of its diagnostic facilities. The aim of the study was to diagnose vWD in patients with history of muco - cutaneous bleeding and characterization into its variants by multimeric analysis. 224 patients presenting with history of muco - cutaneous bleeding were selected. In all patients, platelet count, BT, PT, APTT, PF3 availability, clot solubility and factor VIII assay were done. Diagnosis of vWD was confirmed by RIPA, vWF: Ag, and vWF: RCo and its sub-characterization was done by multimeric analysis. 64 patients were diagnosed to have vWD. Of these, 21.9% were of type 1 vWD, 43.7% type 2 vWD, 1.6% acquired vWD and 32.8% type 3 vWD. By multimeric analysis, 2 patients had supranormal HMW multimers and two patients had normal distribution of vWF multimers were diagnosed as type 2M 'Vicenza'; and type 2M vWD respectively. It is concluded, that vWD is not an uncommon condition amongst Indian population.

A study of Low Level Nitrogen Laser Therapy in the treatment of non-responding tubercular Lymphadenopathy and Sinuses.

Forty-four cases of tubercular lymphadenopathy and sinuses, who were taking anti-tubercular treatment for more than 6 months and not responding to it, were randomly selected in this study. Overall cure rate in cases of lymphadenopathy was 93.99% , sinus 77.77% and cold abscess 100%. Mean age of the patients was 30.13 (Male: female1:4.5). Most common site of lymphadenopathy was cervical , smear was positive in 19(43.18%) cases and culture in 25(56.81%) cases. Low Level Nitrogen Laser Therapy may be used as an adjuvant to anti-tubercular drugs in cases of chronic non-responding tubercular lymphadenopathy and sinuses.

Is seroprevalence of HTLV-I/II among blood donors in India relevant?

Human T-cell lymphotropic virus type I/II (HTLV-I/II) is associated with certain hematologic and neurologic disorders. Seroprevalence studies demonstrate that the distribution of HTLV-I/II is heterogeneous worldwide and not specific to one region. Because blood is one of the major routes of transmission of the virus, blood banks of several countries routinely screen all blood donations for HTLV-I/II. The aim of the present study was to assess the seroprevalence rate of HTLV-I/II antibodies among Indian blood donors and to confirm the positive rates by polymerase chain reaction (PCR). Between Jan 2004 to May 2005, consecutive blood samples of 10,000 blood donors were collected at the blood bank of Armed Forces Medical College, Pune. The samples were screened for HTLV-I/II by enzyme-linked immunosorbent assay (ELISA) method. Screening resulted in 18 (0.18%) positive samples, of which 14 (77.8%) samples were also positive by PCR. The prevalence of HTLV-I/II carriers in India seems to be negligible and is not a major public health hazard. Hence, routine screening of Indian blood donors for antibody to HTLV-I/II is not warranted due to its low prevalence in India.

Role of low Level Nitrogen Laser Therapy in chronic drug resistant Pulmonary Tuberculosis.

Aim: In this longitudinal study, the Role of Low Level Laser Therapy in Chronic Drug Resistant pulmonary tuberculosis has been studied for a period of 10 years from 1995 to 2004 and follow up was done for a period of 3 years. Material and Methods: 61 patients in Nitrogen Laser Therapy group (LLLT Group) and 61 were kept as control group. The aim of study was to describe the efficacy and safety of low level nitrogen laser therapy in management of chronic drug resistant pulmonary tuberculosis. All the patients, included in this study, had already taken anti-tubercular drugs for more than one year and were still sputum smear and culture positive. Results: Among LLLT group, 44 (72.13%) patients became sputum smear and culture negative for MTB (Mycobacterium Tuberculosis) as compared to 26 (42.62%) in control group. Of the 44 patients, 22(50%) converted within first month. Conclusion: Low Level Nitrogen Laser Therapy may be used as an adjuvant to anti-tubercular drugs in cases of chronic drug resistant pulmonary tuberculosis.

Role of gel based technique for Coomb's test.

The direct (DAT) and indirect antiglobulin tests (IAT) are one of the most important diagnostic tools used in the investigation of immune mediated disorders. Recently, transfusion laboratories have seen the introduction of column technology in the form of the gel technology (GT). Aim of this study is to compare the conventional tube tests (CTT) and the GT for Coomb's test and to evaluate their sensitivity and specificity. 1656 samples were included in this study, in which 1054 samples were subjected to IAT and 602 samples were subjected to DAT Of the 602 samples tested for DAT, 587 (97.5%) showed concordant DAT results. DAT by the GT could detect 8.6% positivity as compared to 6.1% by CTT. The sensitivity and specificity of the GT was 100% and 97.3% respectively and its negative predictive value was 100%. Among the 1054 samples for IAT, 1041 (98. 8%) showed concordant results. The IAT by the GT showed 6.6% positivity as compared to 5.4% positivity by CTT The sensitivity, specificity and the positive and negative predictive value were 100%, 97.7%, 81.4% and 100% respectively. In conclusion, the GT is a better alternative to the CTT for both DAT and IAT. The GT is highly recommended to be implemented as a routine method of testing in all zonal / regional blood transfusion centers.

Cancer related thrombophilia: clinical importance and management strategies.

Acquired thrombophilic state associated with a significant risk of thrombosis is frequently encountered in malignancy. Venous and arterial thromboembolism is a common complication and patients with cancer, also present with a hypercoagulable state, even in the absence of thrombosis. Furthermore, clotting activation may play a role in tumor progression. The pathogenesis of thrombosis in cancer is multifactorial; however, a relevant role is attributed to the tumor cell capacity to interact with and activate the host hemostatic system. Among other factors, the prothrombotic action of antitumor therapies is also important. Thrombotic events can influence the morbidity and mortality of the underlying disease. Therefore, preventing these complications in cancer patients is a clinically relevant issue. Recently, new approaches to the prevention and cure of thrombosis in cancer have been investigated, and the hypothesis that the strategies to inhibit clotting mechanism may favorably affect malignant disease is gaining increasing interest. In this article the various aspects of the complex relationship between thrombosis and cancer, from pathophysiology to therapy, are reviewed.

Comparative evaluation of whole blood D-dimer test to plasma D-dimer test for diagnosis of disseminated intravascular coagulation.

Three rapid D-dimer test methods were compared for the diagnosis of acute disseminated intravascular coagulation (DIC). These were (a) SimpliRED, an autologous red cell agglutination assay. (b) DIMERTEST latex agglutination assay, containing monoclonal antibody DD-3B6/22(6), and (c) D-DI latex agglutination assay containing mouse anti-human D-dimer monoclonal antibodies. The D-DI latex method having higher sensitivity (100%) and specificity (81%) in clinically acute DIC was postulated as the gold standard and compared with the other two methods. The results suggest that D-DI latex agglutination assay containing mouse anti-human D-Dimer monoclonal antibodies are the better assay methods amongst all the three kits analyzed. It is advisable to look for the nature of the antibody used to coat the latex particles in plasma based kits. In emergency setting RBC kits may be of some use as rapid diagnosis is advantageous.

D-dimer test: diagnostic role in clinical and sub-clinical DIC.

D-dimer test is used as a diagnosis test for acute disseminated intravascular coagulation (DIC). This study was undertaken to find out its sensitivity and specificity in the diagnosis of acute DIC and its role in diagnosis of sub-clinical DIC, as there is limited data available on the subject. Of the 29 patients of clinically acute DIC, all had positive D-dimer test, and markedly prolonged PT, APTT and TT were seen in 24 (83%) of these patients. D-dimer test was found to be highly specific but less sensitive for the diagnosis of acute DIC. Of the 29 patients predisposed to sub-clinical DIC. D-dimer was positive is 26 (90%) patients and PT, APTT and TT were mildly prolonged in 11 patients. It is suggested that D-dimer positivity for the diagnoses of sub-clinical DIC need to be considered with caution and to be supplemented by other coagulation test including serial follow up with d-dimer and coagulation tests.

Red cell indices for distinguishing macrocytosis of aplastic anaemia and megaloblastic anaemia.

Megaloblastic anaemia and aplastic anaemia are important causes of pancytopenia in India. Since both may have presence of macrocytes, peripheral smear examination alone may pose a difficulty in distinction between the two in the absence of macro-ovalocytes and hypersegmented neutrophils. The present study was conducted to evaluate the role of red cell indices in differentiation between macrocytosis of aplastic anaemia and megaloblastic anaemia. Haemogram from 25 cases each of biopsy proven megaloblastic anaemia and aplastic anaemia were reviewed. It was observed that MCV was greater than 97 fl in 15 cases of aplastic anemia (mean MCV 109.7 fl), and 25 cases of megaloblastic anaemia (mean MCV 113.2 fl). Hb, MCV & MCHC were comparable in the two groups. However, mean RDW in megaloblastic anaemia (mean 87.7 fl) was significantly higher than those in aplastic anaemia (mean 71.4 fl). The difference in RDW of patients with megaloblastic anaemia and aplastic anaemia was statistically significant. We conclude that RDW can be of help to differentiate between the two conditions.