Oral and dental care before radiotherapy: Guidelines and development of a time?bound protocol

Involvement of multidisciplinary team is the mainstay in the holistic treatment outcome in head and neck cancer patients. Achieving a state of oral health is regarded as an essential treatment goal before radiation therapy but, it may get overlooked due to many competing priorities, lack of multidisciplinary facilities and/or incoordination, and limited overall awareness with regards to means of achieving oral health and in a time?bound manner and its relevance in improving quality of life in cancer survivors. Radiation inflicts an immense amount of damage upon the entire maxillofacial complex and consequently oral treatment after radiotherapy may remain untreated and/or undertreated. It is, therefore, vital to eliminate oral foci of infections well within a time frame before radiation so that tumor prognosis is not compromised.This article describes the current guidelines combined with a time?bound protocol developed in our center to not only prepare a patient for conventional radiotherapy but also to provide a logical perspective towards the feasibility of the oral rehabilitation post?cancer cure. The protocol aims to maximize the quality of life in head and neck cancer survivors by; patient education, minimizing preventable oral complications, and retaining strategic teeth for function, aesthetics, speech, and prosthetic support. The time?bound pre?radiation oral care protocol is rational, achievable, and is aligned towards the sustained oral health care goals in head and neck cancer patients and can be utilized as a useful resource in multidisciplinary head and neck cancer care facilities

Circulatory Cytokine Levels as a Predictor of Disease Severity in COVID-19: A Study from Western India

Objectives: Neuroborreliosis is generally known to be a disease confined to the Western part of the globe. It is not commonly encountered in this part of the world. Interestingly, we recently came across a series of cases of Lyme’s disease with a plethora of neurological presentations. Most of the cases were a diagnostic dilemma, with poor response to immunotherapy and on subsequent evaluation all were found to have positive Borrelia antibodies. Materials and methods: Eight cases were selected from the tertiary care hospital in North western India. Patients were suspected to have Neuroborreliosis whose neurological presentations were atypical for other classical neurological disorders, who had a progressive or relapsing clinical course and had responded poorly to the initial treatment given for the previous neurological diagnosis. Skin lesions were present in some cases. The patients underwent a detailed clinical assessment which comprised of an elaborate history including history of travel, any insect bite or skin rashes along with a complete systemic and neurological examination. All the required blood investigations, Magnetic Resonance Imaging (MRI) Brain, Computer Tomography Angiography (CT), Nerve conduction study (NCS) and Electromyographic (EMG) studies and Cerebrospinal fluid (CSF) studies were done as indicated in each case. Borrelia antibody titre was done in all the patients using immunoblot technique. Results: Among the 8 patients, 6 were male and 2 were females. The age group was between 25-70 years. The clinical presentation was acute, subacute or chronic. One patient gave a clear history of tick bite. Two patients had skin lesions and one had the pathognomic "eschar". All the suspected 8 patients had either IgG or IgM or both IgG and IgM Borrelia antibodies positive. Almost all the patients had previously received either steroids or intravenous immunoglobulins, but had not adequately responded to immunotherapy. These patients were given a trial of injectable Ceftriaxone and oral Doxycycline. Most of them either showed partial or complete clinical improvement. Conclusion: Lyme’s disease, a common disease of the west does exist in the Indian subcontinent as well. Because of increasing global travel and migration and change in vector habitat the disease seems to have percolated in the non endemic areas too. Proper history of travel or exposure to tick bite is important. We want to emphasize, Neuroborreliosis, a great mimicker may have diverse and varied neurological presentations and has a potential for reversibility with appropriate treatment even after a significant delay in diagnosis.

Extra-pulmonary Manifestations of COVID-19 in Western India

Background: SARS-CoV-2 is well known disorder to affect respiratory system, although it can also influence several extrapulmonary organs through variety of pathological mechanism. In this study, we aimed to discuss the prevalence of atypical and/or extrapulmonary manifestations in COVID-19, therefor action for early isolation and diagnosis can be initiated to prevent spread of infection. Methods: This retrospective observational study included 4200 admitted COVID-19 patients. The patient’s data concerning medical history, clinical symptoms at presentation and during course of hospitalization, laboratory and radiological diagnosis and underlying chronic medical illness were extracted from their medical records. Data of extrapulmonary and/or atypical presentations of COVID-19 were compiled and tabulated to know prevalence of these manifestations. Results: In this study, 1260 patients (30%) had symptomatic presentation. Major extrapulmonary clinical manifestation includes fatigue in 72.22% patients, impaired sense of taste (ageusia) in 58.73%, loss of appetite in 52.78%, impaired sense of smell (anosmia) in 46.83%, palpitation in 33.33%, headache in 33.17%, nausea/vomiting in 31.43%, diarrhoea in 25.40% patients. Among symptomatic COVID-19 patients, 95.56% patients had sinus tachycardia, 38.49% had lymphocytopenia, 36.83% had hepatitis, 35.48% had leukopenia, 27.83% had gastroenteritis, 22.22% had sepsis, 20.87% had proteinuria, 17.30% had coronary artery disease and 16.34% had acute kidney injury in decreasing order. Prevalence of coagulation defect associated disorder were found to be deep venous thrombosis in 15.56% patients, acute coronary syndrome in 7.78%, brain infarct in 6.35%, pulmonary artery thrombosis in 3.25% and SMA thrombosis in 0.32% of symptomatic patients. Conclusion: Patients of SARS-CoV-2 had widespread organ-specific manifestations with involvement of almost all organ system of body. Clinicians must have knowledge of these extrapulmonary symptoms or atypical presentation of COVID-19 as it assists in early diagnosis, isolation of suspected patients and limit the transmission of infection in the hospital settings.

Orbital magnetic resonance imaging profile and clinicoradiological correlation in COVID-19-associated rhino-orbital-cerebral mucormycosis: A single-center study of 270 patients from North India

Purpose: To study the clinical profile and magnetic resonance imaging (MRI) features in patients of COVID?19?associated rhino?orbital?cerebral mucormycosis (CA?ROCM) with orbital involvement and perform a clinicoradiological correlation. Methods: A cross?sectional study was performed at a tertiary care center in north India from May 2021 to June 2021. Consecutive patients with clinical, nasal endoscopic, and/or microbiological evidence of CA?ROCM underwent MRI of paranasal sinuses, orbit, and brain as per the study protocol. Orbital MRI findings were studied in detail and were correlated with clinical signs. Results: Two hundred and seventy patients were studied. The mean age was 48.4 (± 16.82) years. A male predilection was noted (male:female = 1.77). Orbital involvement was seen in 146 (54%) patients on clinical evaluation and in 184 (68%) patients on MRI. Unilateral orbital involvement was more common (134; 92%). The most common presenting symptom was periorbital and/or facial pain (141; 52.2%) and the most common clinical sign was periorbital edema (116; 43%). The most common MRI finding was suggestive of orbital cellulitis (160; 59%). Orbital compartment syndrome was found in 17 (6.3%) patients. The inter?rater agreement between clinical and radiological assessments to detect the involvement of infraorbital nerve and frontal nerve was found to be 85.56%, (? 0.621) and 93.70% (? 0.776), respectively. The diagnostic accuracy, sensitivity, and specificity of MRI to detect medial orbital wall defect were found to be 87.9%, 65%, and 97%, respectively. Conclusion: Orbital imaging features of a cohort of ROCM patients have been presented with clinicoradiological correlation.

Lopinavir/ritonavir: is early administration better in Covid-19?

Background: To share the data of coronavirus 2019 (Covid-19) patients started on lopinavir-ritonavir (lopi/r) in relation to time period from the onset of symptoms.Method: Observational descriptive study of 23 Covid-19 patients admitted in a tertiary care center in India from March 2020 to May 2020. Patients categorized into 2 groups based on the timing of initiation of lopi/r from the onset of symptoms. Group 1 were given the drug early (≤7 days) and group 2 late (>7 days). The clinical events (oxygen requirement days and ICU stay) and outcomes of hospital stay between the two groups were evaluated.Results: Patients were started on lopi/r for a period of 14 days on admission, out of which 12 patients were in group 1 and 11 patients in group 2. Underlying co-morbidities were present in 15 patients (65.21%). The mean duration from onset of symptoms to lopi/r initiation was 4 days and 11.1 days in Group 1 and 2 respectively. Requirement for oxygen support (2.16 versus 6.54 days), mean duration of hospitalization (8.58 versus 11.54 days) and mean duration of obtaining first Covid-19 negative report from the onset of symptoms (10.5 versus 19.57 days) were all significantly lesser in group 1 (p<0.05). All patients belonging to Group 1 and eight patients of group 2 recovered completely and were discharged whereas 3 patients of group 2 expired. Diarrhea was the most commonly observed adverse effect of lopi/r in our patients.Conclusion: With no approved weapon to tackle the Covid-19 pandemic, we should keep lopi/r in our armamentarium of drugs and use it at the earliest. More clinical trials are needed in future to ascertain if lopi/r can reduce hospital stay, prompt faster recovery and result in better clinical outcome.

Use and inappropriate use of proton pump inhibitors in hospitalized patients

Background: The discovery of Helicobacter pylori infection in etiology of peptic ulcer disease and proton pump inhibitors (PPI) in management of upper gastrointestinal diseases had been the milestones in medical science. PPI are currently being both overused and misused. In countries like India, where over 500 branded formulations of PPI are available, probability of misuse and abuse increases exponentially. The aim of the study was to find out inappropriate use of PPI, among hospitalized patients.Methods: In order to find answer to the research question a cross sectional study was conducted in indoor patient of a tertiary care private hospital at Jaipur, Rajasthan. Patients of either sex, aged 18 years or above belonging to rural and urban communities were participating in study. The sample size was 500.Results: It was noted that Inappropriate PPI use was observed in most of the hospital admitted patients (78%). Most common diagnosis among inappropriate PPI use was dengue fever (due to increased number of dengue cases during study period), followed by cerebrovascular accidents and urinary tract infection. Most common indication for appropriate PPI use was stress ulcer prophylaxis, again in dengue case (due to cardinal manifestation of thrombocytopenia).Conclusions: Almost all patients were once prescribed PPI after admission and discharged on PPI (99.2%). Thus, we recommend evidence-based prescription of PPI, to reduce side effects and excess cost.

A Study to Evaluate the Effect of Saroglitazar in Type 2 Diabetes

Introduction: Type 2 diabetes mellitus is a commoncondition characterized by high blood sugar level. This riskgets inflated by lipid abnormalities additionally. Diabeticshave high risk of developing dyslipidemia (AtherogenicDiabetic Dyslipidemia-ADD) which is characterized by hightriglycerides and/or low HDL-C and/or small dense LDL-C.Study aimed to assess difference in mean Fasting plasmaglucose (FPG), Post prandial plasma glucose (PPPG), Lipidparameters [ triglycerides (TG), total cholesterol (TC), verylow density lipoprotein (VLDL), low density lipoprotein(LDL), high density lipoprotein (HDL) and non-HDL] beforeand after adding saroglitazar in patients of type 2 diabetes.Material and Methods: A total of 36 cases with DiabetesMellitus Type 2 aged between 18 and 65 years with their BMI>25kg/m2, HbA1c between 7 and 9% and total cholesterollevels >150mg/dl were enrolled. Their baseline glycemicand lipid parameters were measured and they were givenSaroglitazar 4mg every day for 3 months and their parameterswere checked again at the end of 3 months.Results: It was found that the mean Fasting plasma glucose(FPG), Post prandial plasma glucose (PPPG), Lipid parametersdecreased after 3 months of Saroglitazar therapy and thisdecrease was found to be statistically significant (P<0.001).Conclusion: Thus, addition of Saroglitazar to the drugregimen of the patients with Diabetic Dyslipidemia can bringabout significant improvement in the glycemic and lipidparameters with the added advantage of insignificant adverseeffects, thus proving beyond doubt the efficacy and safety ofthis drug in the treatment of Diabetic Dyslipidemia.

Survival and complications of unconventional fixed dental prosthesis for maintaining diastema and splint pathologically migrated teeth: A case series up to 8 years follow-up.

Spacing in dentition negatively interferes with harmony of the smile. A lot of literature has been devoted to prosthetic closure of such space(s) in the dentition; however, the only option for maintaining space(s) in tooth-supported fixed dental prosthesis (FDP) is with the aid of loop connectors. Eleven patients (seven males and four females) with mean age of 45.18 years (range 22-70 years), previously treated with porcelain fused to metal full coverage restorations joined with loop connectors, were evaluated clinically to assess the clinical status and longevity of treatment provided. All the patients were asked to fill a simple close-ended questionnaire to provide their perspective on the limitations and outcome of the treatment and rate their satisfaction level on the scale of 1-10. The cumulative survival of the FDPs with the aid of loop connectors was 90.9%. There was no reported esthetic failure and, at the time of responding to the questionnaire, none of the patients had active complaint with respect to the prosthesis and all but one of the patients were satisfied with the treatment provided. Clinical survivability and the patient feedback suggests that customized designing of loop connectors for each patient is an excellent treatment modality to successfully maintain excessive (single/generalized) spacing between teeth and effectively splint pathologically migrated and mobile teeth. The reported problems with this treatment option are all transient in nature.

Immediate natural tooth pontic: A viable yet temporary prosthetic solution: A patient reported outcome.

Introduction: In patients with hopeless prognosis of the anterior teeth there is still a strong desire to save them for the sake of esthetics. If not grossly carious, broken down or discolored the extracted tooth after suitable modifications can be placed back in its original site by splinting it to the adjacent stable teeth. Materials and Methods: Fifteen patients (10 males, 5 females) in the age range of 40-65 years with pathologically migrated, unsalvageable teeth were treated by splinting the extracted teeth immediately with the stable adjacent teeth. After 12 weeks, all the patients were explained various treatment options available for replacement of the lost teeth. The patients were asked to fill out a simple closed ended questionnaire citing the various difficulties encountered during this transitional period, selection of further treatment modalities and the reasons for their choice. The feedback obtained was then analyzed statistically. Results: Hundred percent of patients were happy with the esthetics; however, 60% of them were dissatisfied with the function that it provided. The primary problem being apprehension of splint fracture and difficulty while incising and the data was found to be statistically significant (P=0.01**). All patients demanded a permanent treatment option following this with a fixed prosthesis. None of the patients were interested in the implant supported prosthesis due to cost, treatment time involved, and need for surgery. Conclusion: The concept of immediate pontic placement is surely a viable treatment option and promises an excellent transient esthetic solution for a lost tooth as well as enables good preparation of the extraction site for future prosthetic replacement.

An interdisciplinary approach to reconstruct a fractured tooth under an intact all ceramic crown: Case report with four years follow up.

Trauma causing the fracture of a restored tooth with the extracoronal full coverage prosthesis remaining intact is a common occurrence in dental practice. Reconstruction of the damaged tooth foundation and recementation of the crown can pose quite a challenge for the restorative dentist. This case report describes an innovative interdisciplinary chairside technique for the recementation of an all-ceramic crown on a fractured maxillary central incisor. The course of care described is effective, affordable, and saves time in comparison with other treatment options for such clinical situations.

Dentinogenesis imperfecta: a review and case report of a family over four generations.

Dentinogenesis imperfecta (DGI) is one of the most common hereditary disorders of dentin formation. It follows an autosomal dominant pattern of transmission, affecting both the formation and mineralization of dentin. Either or both primary and permanent dentition is affected by it. This paper briefly reviews the manifestations of DGI Type II (DGI1) and presents a case report of a family affected with DGI1 over four generations.