A Case of Imported Leptospirosis: Rhabdomyolysis and Severe Hyperbilirubinemia in a Traveler Returning From Puerto Rico.

Leptospirosis is a zoonosis transmitted through human contact with the urine or fecal material of infected animals. Here, we report the case of a young male who presented with hyperbilirubinemia and rhabdomyolysis after returning from Puerto Rico which was confirmed to be severe leptospirosis. An 18-year-old Caucasian male was admitted due to a four-day history of jaundice, fever, headache, abdominal pain, vomiting, dark urine, and pain in his calves. Two weeks before, in Puerto Rico, he swam in caves and at the shoreline in an area recently impacted by a hurricane. Laboratory studies demonstrated leukocytosis, thrombocytopenia, hypokalemia, acute kidney injury with elevated creatine kinase, and hyperbilirubinemia. Due to clinical suspicion of leptospirosis, a serological test was ordered which was positive for Leptospira IgM. In this case, the history of swimming in caves and on the shoreline a few weeks after a hurricane that caused flooding in the region made leptospirosis the most likely diagnosis. The patient's condition improved after initiation of intravenous penicillin G, 8 million units/day, with a resolution of symptoms after completing a seven-day course of antibiotics. Bilirubin started to trend down on day seven, and the patient was discharged on day eight of hospitalization with minimal jaundice. It is important to obtain a detailed medical history when treating patients who have returned from tropical areas, as leptospirosis can mimic other diseases and can be easily mistaken or underrecognized in non-endemic regions, such as the continental United States.

Simulated drought stress unravels differential response and different mechanisms of drought tolerance in newly developed tropical field corn inbreds.

Corn is one of the most important cereal crops in the world with highest yield potential. Nevertheless, its potential productivity is constrained by the occurrences of drought stress worldwide. Besides, in the era of climate change, frequent occurrences of severe droughts are predicted. The present investigation was carried out at Main Agricultural Research Station, University of Agricultural Sciences, Dharwad in split plot design to study response of twenty-eight new corn inbreds under drought free (well-watered) conditions and drought simulated by withholding irrigation from 40 to 75 DAS to create water stress. Significant differences among the corn inbreds, moisture treatments and interaction between inbreds were observed for morpho-physiological, yield and yield components indicating differential response of corn inbreds. The inbreds CAL 1426-2 (higher RWC, SLW& wax and lower ASI), PDM 4641(higher SLW, proline, & wax, and lower ASI) and GPM 114 (higher proline & wax, and lower ASI) were drought tolerant. These inbreds are having higher production potential (>5.0 t/ha) under moisture stress condition with less per cent reduction (<24.4%) over non-moisture stress condition and hence are putative candidates for developing drought tolerant hybrids suitable for rainfed ecosystem besides using them in population improvement program to combine different drought tolerant mechanisms to evolve highly potent drought tolerant inbreds. The results of the study suggested that proline content, wax content, anthesis silking interval, relative water content can be better surrogate traits to identify drought tolerant inbreds in corn.

Persistent Bacillus cereus Bacteremia in an Immunocompetent Patient With a History of Polysubstance Abuse.

Extraintestinal infections are rare with Bacillus cereus and include endocarditis, pneumonia, and meningoencephalitis. It has been primarily reported in immunosuppressed individuals with hematological malignancies and rarely in people who inject drugs (PWIDs). Herein, we report the case of a healthy adult woman with no underlying conditions except for injection drug use who presented with signs of meningitis. A 40-year-old female intravenous (IV) drug addict presented to the hospital with a chief complaint of severe headache. She had a fever of 38 °C, and her neurological examination was unremarkable. Laboratory results were significant for a white blood cell (WBC) count of 20.0 × 109/L (reference range: 4.5 to 11.0 × 109/L) and urine toxicology that was positive for amphetamines and cocaine. A lumbar puncture showed a total of 1,736 nucleated cells/µL, 88% neutrophils, a glucose level of 73 mg/dL, and a significantly elevated protein level of 155 mg/dL. B. cereus grew in blood cultures and cerebrospinal fluid (CSF) cultures. Once the growth of B. cereus was identified in the CSF, intravenous vancomycin was started. After leaving against medical advice (AMA), the patient presented again to the hospital, and a lumbar puncture was repeated. Cerebrospinal fluid showed total nucleated cells of 13 cells/µL, but the patient remained bacteremic. An echocardiogram, computerized tomography (CT) of the abdomen and pelvis, and tagged white blood cell scan could not identify a source for the bacteremia. Despite receiving two weeks of IV vancomycin, her blood cultures remained consistently positive for B. cereus without identifying a clear source of infection. Although B. cereus rarely affects the central nervous system, there have been a few cases where immunosuppression has been linked to the infection. We report an unusual case of a patient who continued to be bacteremic despite a thorough search for a source of B. cereus infection and IV vancomycin treatment. As a result, we raise the possibility of addictive behavior due to the patient's pattern of leaving the hospital against medical advice and returning with recurrent bacteremia. A thorough history and careful search for a source of infection are required when B. cereus grows persistently in blood cultures.

Emergence delirium after intracranial neurosurgery- a prospective cohort study.

OBJECTIVES: The primary objective of this study was to estimate the incidence of emergence delirium (ED) including hypo- and hyperactive ED, after intracranial neurosurgery. Secondary objective was to identify perioperative risk factors of ED in these patients. METHODS: This prospective observational study was conducted at an academic neurosciences hospital. All consecutive adult patients (age ≥ 18 years) with a preoperative Glasgow Coma Scale score of 15 undergoing elective intracranial surgery under general anesthesia during the six-month period from October 2020 to March 2021 were included in this study. Perioperative patient data were collected till one hour after surgery. ED was defined as per Riker's sedation agitation score (SAS) as hyperactive ED when SAS was >4 and hypo active ED when SAS was <4 on a 1 to 7 scale. RESULTS: Data of 320 patients were analyzed in this study. The overall incidence of ED was 22 % (71/320), with incidence of hyperactive ED of 4.3 % (n = 14) and hypoactive ED of 18 % (n = 57). The risk factors for ED were preoperative delirium (odds ratio [OR], 95 % confidence interval [CI] and p value of 4.41, 1.3-15.19, and 0.002), education level (OR = 2.21, [0.98-4.94], p = 0.05), minimum alveolar concentration of inhalational anesthetic (OR = 1.47, [1.17-1.88], p = 0.002), postoperative nausea and vomiting (OR = 4.56, [2.04-10.32], p = 0.001), and body weight (OR = 1.69, [1.1-2.68], p = 0.02). Hyperactive ED was predicted by preoperative delirium (OR = 5.28, [1.12-21.21], p = 0.024) and low education level (OR = 4.35, [1.2-17.04], p = 0.027). CONCLUSIONS: Atleast one in five patients undergoing brain surgery under anesthesia develop ED. Addressing modifiable risk factors might reduce ED.

Finite element method for estimation of applanation force and to study the influence of intraocular pressure of eye on tonometry.

PURPOSE: Discover the associations of force of applanation on the eye with the plunging depth of the cornea and quantify them. The results will be utilized as the feedback parameter in the new prototype development of eye care instruments as additional force may damage the internal structure of the eye or may result in erroneous output. METHOD: A finite element-based eye model is designed utilizing the actual dimensions of the human eye. A standardized tonometer is designed and the simulation is carried out at predetermined deformation of the cornea to find the force of applanation on the cornea during tonometry. Adding on, the influence of IOP during tonometry is analyzed for a range of plunging depths of the cornea. RESULTS: The graphical results inferred the linear relation between the force of applanation with the deformation of the cornea and the results are quantified. The resulting deformation and stress plot of FEM based simulation approach is analyzed and observations regarding deformations and stress are made. CONCLUSION: The human eye is successfully developed and also computed force on the cornea during tonometry is validated. The inference drawn from the deformation plot and stress plot is that the junction of cornea-sclera along with cornea-tonometer periphery undergo maximum deformation and experiences the highest stress compared to other areas of the eye while during tonometry.

A Case of Concomitant Plasmodium falciparum Malaria and Bacillus cereus Bacteremia in a Returning Traveler From Tanzania.

Malaria has been associated with bacterial co-infections, but the importance of bacterial co-infections in uncomplicated malaria is poorly described. We report a unique case of a 27-year-old female with concomitant Plasmodium falciparum and Bacillus cereus bacteremia who acquired those infections while traveling in Tanzania but became ill only after returning to the United States. Blood parasites screen revealed Plasmodium falciparum and blood cultures obtained at presentation showed Bacillus cereus. Even after completing treatment for malaria, she continued to have abdominal pain and watery diarrhea, which improved only after IV vancomycin. Bacillus cereus bacteremia cases are reported in travelers and immigrants returning from countries where malaria transmission occurs, mainly from sub-Saharan Africa but co-infection with Plasmodium falciparum and Bacillus cereus has not been described in the literature yet. In this case, malaria symptoms resolved after targeted treatment was initiated but persistent diarrhea improved only after appropriate therapy against Bacillus cereus. Persistent watery diarrhea and dehydration in patients with malaria should raise concerns about Bacillus cereus co-infection.

A study of unprotected left main intervention in the ACS population 2013-2018.

OBJECTIVES: Our objectives were to evaluate the outcomes of left main percutaneous coronary interventions in Acute Coronary Syndrome population. METHODS: This is a retrospective& observational study. Primary endpoint is a composite of death, stent thrombosis/MI, target lesion revascularization. Secondary endpoints include individual components of the primary events analyzed separately. RESULTS: Seventy five patients, two year follow - up data was analyzed. The primary event analysis showed that the Elective Double Stent (EDS) group had a higher primary events (36% vs. 14%, p value - 0.008, Hazard ratio - 0.76 (0.51-1.15, 95% CI), in secondary event analysis stent thrombosis (ST)/Myocardial infarction (MI) rates were higher in EDS group (8% Vs 36%, p Value - 0.008, Hazard ratio- 0.63(0.35-1.14, 95%CI), there is no difference in target lesion revascularization (TLR)and death rates in both the groups. CONCLUSIONS: The provisional strategy is better than EDS in treatment of left main bifurcation lesions in the ACS population.

Tocilizumab for treatment of patients with severe COVID-19: A retrospective cohort study.

BACKGROUND: Tocilizumab was approved for chimeric antigen receptor T-cell therapy induced cytokine release syndrome and it may provide clinical benefit for selected COVID-19 patients. METHODS: In this retrospective cohort study, we analyzed hypoxic COVID-19 patients who were consecutively admitted between March 13, 2020 and April 19, 2020. Patients with lung infiltrates and elevated inflammatory markers received a single dose of tocilizumab if no contraindication was present. Systemic steroid, hydroxychloroquine, and azithromycin were concomitantly used for majority of the patients. FINDINGS: Of the 51 patients included for analysis, 28 (55%) received tocilizumab and 23 (45%) did not receive tocilizumab. Tocilizumab cohort required more invasive ventilation (68% vs. 22%) at baseline and during entire hospitalization (75% vs. 48%). The median time to clinical improvement in tocilizumab vs. no tocilizumab cohorts was 8 days (Interquartile range [IQR]: 6·25 - 9·75 days) vs. 13 days (IQR: 9·75 - 15·25 days) among patients who required mechanical ventilation at any time (Hazard ratio for clinical improvement: 1·83, 95% confidence interval [CI]: 0·57 - 5·84) and 6·5 days vs. 7 days among all patients (Hazard ratio for clinical improvement: 1·14, 95% CI: 0·55 - 2·38), respectively. The median duration of vasopressor support and invasive mechanical ventilation were 2 days (IQR: 1·75 - 4·25 days) vs. 5 days (IQR: 4 - 8 days), p = 0.039, and 7 days (IQR: 4 - 14 days) vs. 10 days (IQR: 5 - 15 days) in tocilizumab vs. no tocilizumab cohorts, p = 0.11, respectively. Similar rates of hospital-acquired infections occurred in both cohorts (18% in tocilizumab and 22% in no tocilizumab cohort). INTERPRETATION: In patients with severe COVID-19, tocilizumab was associated with significantly shorter duration of vasopressor support. Although not statistically significant, tocilizumab also resulted in shorter median time to clinical improvement and shorter duration of invasive ventilation. These findings require validation from ongoing clinical trials of Tocilizumab in COVID-19 patients.

Early Use of Tocilizumab May Prevent Clinical Deterioration in Select COVID-19 Patients: A Case Series.

Coronavirus disease 2019 (COVID-19) is a respiratory viral illness caused by the novel severe acute respiratory syndrome coronavirus 2. It is known to cause severe illness in certain patients, who develop acute respiratory distress syndrome (ARDS) often requiring intubation and mechanical ventilation adding to significant morbidity and mortality. Tocilizumab is an interleukin-6 inhibitor that has shown promise in improving outcomes in patients with COVID-19. It is usually administered to patients with severe COVID-19 who develop ARDS. We present three cases of COVID-19 where the patients were admitted to the hospital for observation and were found to be worsening clinically. They were believed to be developing ARDS, and intubation and mechanical ventilation were anticipated. Tocilizumab was administered in the early phase of the disease before intubation. Patients improved clinically and ultimately did not require intubation. Our findings suggest that early use of tocilizumab might be beneficial in preventing clinical deterioration and intubation in select COVID-19 patients.

Improving Physician-patient and Physician-nurse Communication and Overall Satisfaction Rates: A Quality Improvement Project.

Introduction Communication between healthcare providers and patients is a key component associated with the quality of healthcare and patient satisfaction. Often, simple communication skills may be insufficient to sustain a successful provider-patient relationship. The aim of this project was to assess and improve patient and nurse satisfaction with physicians via improvement in physician-patient and physician-nurse communication to a level greater than 90%. Methods Initial surveys were given to the patients and nurses on admission to the regular nursing floor to assess current satisfaction rates. Afterward, visual handouts were given that provided details about the current medical team members and the role of each team member. which were updated daily along with the medical plan. Surveys were then handed out to the patients and their nurses at the time of discharge. All surveys were conducted anonymously. Results A total of 26 surveys (n = 13 patients, n = 13 nurses) were collected and analyzed for a preliminary assessment. Surveys concluded that 68.8% of patients were satisfied with the patient-provider communication; similarly, 74.4% of the nurses were satisfied with the nurse-provider communication. In the next six weeks, visual handouts were implemented. During this period, surveys involving a total of 40 patients and 40 nurses were collected. The results after the intervention revealed that 93.3% of patients were satisfied with the patient-provider communication, and 94.7% of nurses were satisfied with the nurse-provider communication. Post-intervention, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) displayed an improvement in physician communication, reaching the expected goal of 84.4%. Conclusion Ineffective communication often goes undetected in many healthcare settings, causing serious effects on the health and safety of patients, and may ultimately jeopardize overall satisfaction. Literature has shown a positive correlation between patient satisfaction and improved clinical outcomes. Using visual aids and updating medical care plans on a daily basis are simple yet effective tools to improve communication. Written materials should be created in a patient-friendly manner to enhance communication, clarity, and understanding.

Reducing All-cause 30-day Hospital Readmissions for Patients Presenting with Acute Heart Failure Exacerbations: A Quality Improvement Initiative.

Background Congestive heart failure (CHF) is the most common cause of hospitalization in the US for people older than 65 years of age. It has the highest 30-day re-hospitalization rate among medical and surgical conditions, accounting for up to 26.9% of the total readmission rates. We conducted a quality improvement project at our hospital with the objective to reduce the 30-day all-cause readmissions of patients with CHF by improving the transition of care and setting up scheduled follow-up appointments within two weeks of patient discharge. Method Retrospective data were collected to understand the pattern of admission for CHF during November 2017. Data on 30-day readmission post-discharge was also collected to understand readmission rates. Similarly, all patients who were admitted with acute CHF exacerbation to our hospital during the month of November 2018 were included in our intervention cohort. The 30-day readmission rates of these patients post-intervention were calculated and compared to the initial cohort. Results As part of our study, we ensured that 58% of the enrolled patients had a follow-up appointment scheduled within two weeks of discharge compared to only 30% in 2017. Also, 56% of the enrolled patients kept their follow-up appointments compared to 37% in 2017. The 30-day readmission rate of CHF patients was reduced in half after the implementation of our project, with a 14% readmission rate for our study patients compared to 28% in 2017. Conclusion Patient education and measures to augment post-discharge follow-up appointments can lead to substantial reductions in the readmission rates of heart failure (HF) patients.

Improved Genetic Map Identified Major QTLs for Drought Tolerance- and Iron Deficiency Tolerance-Related Traits in Groundnut.

A deep understanding of the genetic control of drought tolerance and iron deficiency tolerance is essential to hasten the process of developing improved varieties with higher tolerance through genomics-assisted breeding. In this context, an improved genetic map with 1205 loci was developed spanning 2598.3 cM with an average 2.2 cM distance between loci in the recombinant inbred line (TAG 24 × ICGV 86031) population using high-density 58K single nucleotide polymorphism (SNP) "Axiom_Arachis" array. Quantitative trait locus (QTL) analysis was performed using extensive phenotyping data generated for 20 drought tolerance- and two iron deficiency tolerance-related traits from eight seasons (2004-2015) at two locations in India, one in Niger, and one in Senegal. The genome-wide QTL discovery analysis identified 19 major main-effect QTLs with 10.0-33.9% phenotypic variation explained (PVE) for drought tolerance- and iron deficiency tolerance- related traits. Major main-effect QTLs were detected for haulm weight (20.1% PVE), SCMR (soil plant analytical development (SPAD) chlorophyll meter reading, 22.4% PVE), and visual chlorosis rate (33.9% PVE). Several important candidate genes encoding glycosyl hydrolases; malate dehydrogenases; microtubule-associated proteins; and transcription factors such as MADS-box, basic helix-loop-helix (bHLH), NAM, ATAF, and CUC (NAC), and myeloblastosis (MYB) were identified underlying these QTL regions. The putative function of these genes indicated their possible involvement in plant growth, development of seed and pod, and photosynthesis under drought or iron deficiency conditions in groundnut. These genomic regions and candidate genes, after validation, may be useful to develop molecular markers for deploying genomics-assisted breeding for enhancing groundnut yield under drought stress and iron-deficient soil conditions.

Interventions to Decrease Overuse of Cardiac Monitoring (Telemetry) When Transitioning from the Intensive Care Unit to the Regular Nursing Floor.

Background Cardiac monitoring (telemetry) is a common over-utilized hospital resource in the United States. Previous studies have shown that telemetry does not improve outcomes for low-risk patients. Inappropriate utilization occurs because of lack of awareness of guideline-based indications or non-adherence to known indications. Objective A quality improvement study was conducted to reduce telemetry overutilization during the transition of care from the intensive care unit (ICU) by 15% through increasing awareness of indications for telemetry. Methods The study cohort included patients originally admitted to the ICU for sepsis who had improved and were stable for transfer to a non-ICU setting. Subjects were identified and included during pre-intervention (six weeks) and intervention (six weeks) periods. Resident physicians and nurse practitioners were targeted using multiple modalities of education: didactic lectures during week one, poster demonstrations during week three, and video presentations during week five. Results A total of 246 study subjects during the pre-intervention and 94 study subjects in the intervention period were studied; 187 of the 246 subjects in the pre-intervention arm (76%) and 58 of the 94 subjects in the intervention arm (61.7%) were transferred with telemetry. Telemetry utilization dropped by 23.1% at the end of the intervention period. Conclusion Educating the caregivers about the indications for telemetry led to a decrease in over-utilization of telemetry on the transition of care from the ICU to the regular nursing floor. Repetitive and multi-modality educational interventions were effective tools and associated with increased adherence to established guidelines for telemetry usage.

Candida pneumonia with severe clinical course, recovery with antifungal therapy and unusual pathologic findings: A case report.

BACKGROUND: Candida is frequently isolated from the respiratory tract and usually reflects airway colonization. True Candida pneumonia is rare. Our aim is to document a case of Candida pneumonia confirmed by cultures, molecular techniques, and surgical lung biopsy, and to highlight a previously unreported pathologic manifestation of this infection. CASE SUMMARY: A 59-year-old man with a history of chronic obstructive pulmonary disease (COPD) presented with dry cough, low-grade fever, and progressive dyspnea. He was eventually diagnosed with sarcoidosis based on bilateral lung infiltrates and granulomas in a transbronchial biopsy. His condition worsened after immunosuppression, prompting surgical lung biopsy, which revealed suppurative granulomas containing Candida albicans, confirmed by cultures and polymerase chain reaction. Despite multiple episodes of respiratory failure and a prolonged course in intensive care, he recovered fully after antifungal therapy and is currently alive with COPD-related dyspnea 3 years after his initial presentation. CONCLUSION: Candida can rarely cause clinically significant pneumonia in adults, and should be considered in the differential diagnosis of suppurative granulomas in the lung.

A Delayed Complication of Temporal Craniotomy Leading to a Potentially Difficult Airway.

Pseudoankylosis of the temporomandibular joint may occur as a complication of frontotemporal craniotomy. We report a patient who presented for surgery with a restricted mouth opening resulting from an infectious complication after frontotemporal craniotomy. Early identification of the potentially difficult airway helped manage this patient. We explain the mechanism of this late complication that may result in a difficult airway. If this is not identified preoperatively when a patient presents for emergency surgery or when the patient is in altered sensorium, it may lead to an unanticipated difficult airway.

Evaluation of radiological methods of assessing cup anteversion in total hip replacement.

STUDY DESIGN: Prospective clinical study. BACK GROUND: In total hip replacement, the placement of the cup is critical as inaccurate placement can cause impingement, accelerated wear and dislocations. The position of the cup is assessed by abduction and anteversion. There are many radiological methods available for this purpose, while the reliability and validity of the methods have not been adequately done. Calculation by CT method is a gold standard. The aim of study was to evaluate the reliability and validity of all the methods. METHODS: In 30 hips of 25 consecutive patients, 13 females and 12 males who underwent primary total hip replacement in our institution, the component version in all the five radiological methods was calculated and compared with CT evaluation of angles. The intra- and interobserver reliabilities were assessed. RESULTS: Average CT measurement was 23.28 for anteversion. Lewinnek, Liaw, Hassan, Widmer and Ritun methods had average deviation of 4.330, 4.390, 4.880, 6.840 and 6.220, respectively. All the radiographic and CT methods had excellent intra- and interobserver reliabilities (C.I. 0.894-0.960 and 0.861-0.953). All the methods except Widmer had a significant validity against CT. CONCLUSION: Plain X-rays (AP) are reliable for measuring cup anteversion. Lewinnek, Liaw, Riten and Hassans methods for calculation of cup anteversion are closer to CT in accuracy (p value >0.05). Widmer method varies significantly (p value <0.05) from CT.

Paraganglioma Presenting as Postpartum Fever of Unknown Origin.

A young healthy postpartum mother presented with intermittent high fevers and tachycardia. Appropriate testing was done to rule out infectious causes including pan cultures but no identifiable infectious source was found. A CT of the abdomen showed a retroperitoneal mass with two small pulmonary nodules and a bony metastatic lesion. She was found to have stage 4 extra-adrenal paraganglioma with metastases to the lungs and spine. She underwent resection of the mass and is currently undergoing palliative radiation to the spine for pain control. Subsequent genetic testing identified a likely pathogenic variant in SDHB, confirming a diagnosis of Hereditary Paraganglioma-Pheochromocytoma syndrome.

Evaluation of alignment in total knee arthroplasty: a prospective study.

BACKGROUND: Successful results of knee arthroplasty demand precise surgical technique, sound implant design, kinematics, appropriate materials and patient compliance with rehabilitation. The precision with which the implants are placed directly affects patient outcome as implant position and alignment influence the stability, durability and patellar tracking. Evaluating the alignment in total knee arthroplasty and functional outcome with respect to the alignment is the need of the hour. AIM AND OBJECTIVE OF THE STUDY: (1) To evaluate the accuracy of the overall limb alignment and component alignment in jig-assisted TKR. (2) To evaluate the functional outcome with respect to the alignment parameters. METHODOLOGY: This is a prospective study of 120 knees in 80 patients that underwent total knee replacement at Victoria and Bowring and Lady Curzon hospitals. Patients were selected according to the inclusion and exclusion criteria and evaluated using knee society score at regular follow-up. Preoperative and postoperative standing 'long-leg radiographs' and postoperative CT scans were taken from all the patients. In our study, we had 54 female patients and 26 male patients. Indications were OA in 72 and RA in 48 knees. The average follow-up period was 36 months. RESULTS: Preoperatively, all the patients had moderate to severe pain. Mechanical and tibiofemoral axes were outside the acceptable range. Postoperatively, with respect to mechanical axis, the inliers had significantly better knee score (p = 0.026) compared to the outliers. But the functional score did not show any significant difference between these two groups (p = 0.2093). Inliers in tibiofemoral axis alignment parameter had extremely significant better knee score (p = 0.0001) and also functional score (p = 0.0082) compared to outliers group. Sagittal and rotational femoral component angles in all 120 cases were coming within the 'inliers group'. Similarly, the sagittal, the coronal and the rotational component angles of tibia were also coming under inliers group in all 120 replaced knees. CONCLUSION: Aligning the mechanical axis, tibiofemoral angle within (0° ± 3°) and placement of prostheses within (0° ± 3°) to the normal alignment in all the three planes significantly produce excellent result with respect to functional outcome.