Indian Guidelines on Nebulization Therapy.

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Intraoperative Use of Ultrasonography in the Reduction of Zygomatico-Maxillary Complex Fractures.

Study Design: A single blind randomized controlled study. Objective: The aim of this study is to evaluate the use of ultrasonography intraoperatively to assess the reduction of unilateral zygomatic complex fractures with a control group using the conventional blind digit palpation. Methods: The study comprised of a sample size of 24 patients with 21 male and 3 female patients. Patients of all age groups diagnosed with unilateral displaced zygomatic complex fracture with or without mandible fracture were included in the study. The subjects were randomized into study and control groups based on a standard protocol with a total of 24 patients. Imaging was in the form of a preoperative and postoperative 3D computed tomography scan with reconstruction of the maxilla and mandible to interpret the diagnosis for all subjects. The inter-fracture distance of the fractured infraorbital rim were measured in 3 dimensions (antero-posterior, medio-lateral and supero-inferior) and compared pre and postoperatively. Preoperative, intraoperative and postoperative ultrasonographic examination was performed and recorded on all patients at the frontozygomatic region, infraorbital rim and zygomatic buttress to assess the proximity of the fractured margins pre reduction, post reduction and post fixation of the fracture segments. Result: Statistical analytic results were significant in all 3 dimensions when measured postoperatively using computed tomography. Conclusion: Ultrasonography is an effective screening and intraoperative tool in the armamentarium of oral and maxillofacial surgery to assess zygomatic complex fractures, avoiding incisions in aesthetic areas of the maxillofacial region.

Reliability of Modified Hertels Exophthalmometer as an Intraoperative Tool for Assessment of Relative Globe Position in Orbital/Zygomatic Fracture.

INTRODUCTION: Axial globe position assessment is commonly carried out with Hertels Exophthalmometer. Hertels requires an intact lateral orbital rim for its placement, which is often fractured in zygomatic fractures. Hence, to overcome this problem, we have modified the instrument for its application in zygomatic/orbital fractures. Reliability of this Modified Hertels Exopthalmometer has been already validated in normal healthy patients. Therefore, the aim of this study is to assess the efficacy of the Modified Hertels Exophthalmometer in pateints with zygomatic/orbital fracture. MATERIALS AND METHODS: This is a prospective study carried out between April 2015 and October 2017, including 20 patients with a mean age of 34 years. Enophthalmos was measured using Modified Hertels in patients with unilateral orbital/zygomatic fracture indicated for surgical intervention by a single observer. The data was collected and statistically analyzed. Paired sample t-test was done to compare the preoperative exophthalmometer reading with readings at different time points. RESULTS: A statistically significant difference was noted (P = 0.031) among the variables of Modified Hertels. We believe this instrument to be of practical use in the assessment of enophthalmos/exophthalmos in patients with lateral orbital trauma, surgery or disease and also precludes the use of rim-based exophthalmometry and other modifications of same.

Association of Human Papilloma Virus in Oral Squamous Cell Carcinoma: An Alarming Need for Human Papillomavirus 16 Screening in Cancer Patients.

BACKGROUND: The percentage of cancers of the tongue and palatine tonsils has continued to increase by 2%-4% among younger men. This increased prevalence of a subsection of oropharyngeal carcinoma can be associated with human papillomavirus (HPV). Among the head-and-neck cancers, a strong association with HPV infection is evident with oropharyngeal cancers, particularly tonsillar and basal tongue cancers. OBJECTIVES: Oral carcinoma, with an overall incidence of 16.1 adults per 100,000, is one of the leading malignancies worldwide, presenting a noticeable geographic variation in its distribution. Squamous cell carcinoma (SCC) being the most common of all oral malignancies, the objective of the study is to detect the HPV antigen p16 over-expression in patients with oral SCC using immunohistochemistry (IHC). MATERIALS AND METHODS: Oral SCC (OSCC) diagnosed formalin-fixed-paraffin embedded blocks were processed for IHC. RESULTS: Out of 50 cases, 3 were deferred due to insufficient tumor sample and 2/47 cases were p16 positive and the site was the lateral border of the tongue. CONCLUSION: The HPV antigen overexpression in patients with OSCC was investigated to detect the incidence of HPV in SCC of oral cavity. P16 was used as a marker for the detection of OSCC using IHC in HPV-induced OSCC. Positives were detected thus concluding the significance of studying HPV expression during diagnosis.

Intraoperative Management of Recurrent Leukoplakia at Red Zone.

Oral leukoplakia (OL) is a potentially malignant oral disorder (PMOD) that sometimes trans-form into oral squamous cell carcinoma (OSCC). OL is one of the most frequent PMODs seen in the oral cavity. The global prevalence of OL is approximately 2.6%, with its worst prognosis of undergoing a malignant transformation. Leukoplakia is clinically divided into red zones (tongue and floor of mouth) and nonred zones (buccal mucosa, palate, and soft palate) areas. The red zone areas have more potency of transforming into malignancy. Hence, patients with red zone areas need to be followed up more frequently and treated appropriately. This case report signifies the importance of treating one such case of leukoplakia at red zone area.

Pleomorphic Sarcoma of the Oral Cavity: A Rare Case Entity.

Pleomorphic sarcomas are extremely rare in the oral cavity, representing only 5% of all soft tissue sarcomas in the extremities of adults. They form a group of highly undifferentiated pleomorphic malignant tumors. A 36-year-old male reported to the OP with a chief complaint of a tooth ache in the right lower quadrant for the past 6 months. The patient gave a history of extraction of a mobile tooth in that region. A radiograph of the region was advised. An incisional biopsy was also done and sent for histopathological examination. The microscopy revealed the presence of spindle-shaped cells showing dysplastic features. A panel of immunohistochemical markers were performed to identify the tissue of origin of the lesion. The article details the clinical, radiographic, and microscopic features of a pleomorphic soft tissue lesion along with the array of immunohistochemical markers, leading to the final diagnosis of such enigmatic lesions.

A Prospective, Randomized Double-Blinded Study to Evaluate the Efficacy of Buffered Local Anesthetics in Infected and Inflamed Pulp and Periapical Tissues.

AIM: The aim of this study is to evaluate the efficacy of sodium bicarbonate as an additive alkalizing agent to local anesthetic solutions in inflamed and infected pulpal and periapical tissues. TYPE OF STUDY: A prospective, randomized crossover double-blinded study was carried out in a university-affiliated hospital in Chennai. MATERIALS AND METHODS: A randomized crossover double-blinded study was designed wherein ninety-six patients were enrolled for the study. 1.8 ml of 2% lignocaine with 1:200,000 adrenaline was administered. The latency time period was found to be 5-10 min and extraction was attempted. During extraction, if the patient experienced pain, 0.5 ml of 8.4% sodium bicarbonate was injected into the previously injected local anesthesia site. A time period of 3 min was allowed for the alkalinization to occur. Extraction was carried out only when the patient did not complain of pain. Pain score was assessed before and after administration of 8.4% sodium bicarbonate using visual analog scale. Pulse rate at the baseline, before and after administration of 8.4% sodium bicarbonate, was recorded and the pain scale values were correlated with pulse rate. RESULTS: It was found that there was a significant decrease in pain after injecting buffered local anesthetics (p < 0.1). Pain score before injecting sodium bicarbonate was higher when compared to post-injection of sodium bicarbonate. There was also significant reduction in pulse rate following the administration of sodium bicarbonate. CONCLUSION: Buffered 2% lignocaine with 1:200,000 epinephrine had early onset of anesthesia when compared to unbuffered form. Injecting 2% buffered lignocaine pain was significantly reduced during extraction in the teeth.

Comparision of Vital Surgical Parameters, after Administration of Midazolam and Dexmedetomidine for Conscious Sedation in Minor Oral Surgery.

AIM: The aim of this study is to compare the efficacy between midazolam and dexmedetomidine in relation to vital parameters, sedation score, pain score, cognitive judgment, and postoperative amnesia to the event in conscious sedation for minor oral surgical procedure. MATERIALS AND METHODS: A sample size of 30 patients were selected in each group: Group M (midazolam) and Group D (dexmedetomidine). RESULTS: The mean heart rate (HR) and systolic and diastolic blood pressure measurements were significantly higher in Group M after the 20th min when compared to Group D. The visual analog scale (VAS) scores of pain were not statistically significant between the two groups during the procedure, but at the time of discharge, statistically significant VAS scores were found between the two groups. Nine (30%) patients in Group D and 21 (70%) patients in Group M showed cognitive judgment impairment with the Stroop Color and Word Test at the 30th min. CONCLUSION: The dexmedetomidine group of patients had reduced blood pressure and HR. No significant differences were noted in oxygen saturation or in respiratory rate between the two drugs. Patients had better sedation, analgesia, lesser cognitive impairment, and amnesia in the dexmedetomidine group.

Evaluation of the Role Played by Cyclin D1 as a Diagnostic and Prognostic Marker in the Progression of Oral Carcinogenesis.

ABSTRACT: Cyclin D1 is linked with the development and progression of oral squamous cell carcinoma (OSCC). This case-control study was directed to characterise the immunoreactivity of the protein cyclin D1 and its correlation with the clinicopathological parameters of patients with OSCC and potentially malignant disorders (PMD). A group of patients with OSCC were followed up after treatment, and the cyclin D1 expression was reviewed for correlation of cyclin D1 expression with prognosis of the patients. METHODOLOGY: Sixty individuals were included in this study: OSCC (20), PMD (20) and Control (20). Immunohistochemistry assay was evaluated. The clinicopathological parameters were correlated with the staining intensity of cyclin D1. The results were subjected to Pearson's correlation test. RESULTS: Age, gender and site showed no statistically significant correlation with cyclin D1 expression in OSCC and PMD. The cyclin D1 score did not show a significant difference with histopathological diagnosis of OSCC. Cyclin D1 was not expressed in 60% of the Control and 30% PMD cases while the expression of cyclin D1 was seen in 100% of OSCC cases although cyclin D1 score did not show a statistically significant association in the prognosis of the disease among the OSCC patients.

Intra-alveolar extraction of impacted distoangular mandibular third molars: A novel technique.

Recent trends in maxillofacial surgery are to reduce the trauma to the adjacent soft tissue. The distoangular impaction presents a challenge to the maxillofacial surgeon and also results in more surgical morbidity. Here, we present a minimally invasive extraction technique for the distoangular mandibular third molar impaction.

Mini review: Multifaceted role played by cyclin D1 in tumor behavior.

The objective of this paper is to discuss and put forward the various diversified roles of cyclin D1 in cancer. Neoplasia is defined by abnormal regulation of the cell cycle. Cyclin D1 could be a protein derived from the PRAD1, CCND1, or bcl-1 sequence on body 11q13 that is concerned in each traditional regulation of the cell cycle and pathologic process. Within the G1 (resting) part of the cell cycle, cyclin D1 in conjunction with its cyclin-dependent enzyme (cyclin-dependent kinase) partner is accountable for transition to the S (DNA synthesis) part by phosphorylating the merchandise of the metastatic tumor sequence (protein retinoblastoma) that then releases transcription factors vital within the initiation of DNA replication. Amplification of the sequence or overexpression of the cyclin D1 releases a cell from its traditional controls and causes transformation to a malignant composition. Analysis of those changes provides vital diagnostic information in oral carcinogenesis and is of prognostic value in several cancers. Data of cyclin D1's role in malignancy at the assorted sites provide a basis on which future treatment directed against this molecule will proceed.

Intraoral neurilemmoma of mental nerve mimicking as traumatic fibroma: An unusual presentation - A case report and literature review.

Neurilemmoma, neurinoma or schwannoma is a benign tumor of neurogenic origin, arising from the myelin sheath of a neuron. Head and neck region accounts for 25%-48% of these tumors reported till date. On the contrary, intraoral sites form only 1% of the cases accounted. Although a few cases of intraoral neurilemoma of mental nerve has been reported in English literature, none has been reported to arise from the terminal fibers of the mental nerve. In this particular article, we present a case were the tumor was noted in the lower labial mucosa.

Use of C-Arm to Assess Reduction of Zygomatic Complex Fractures: A Comparative Study.

The aim of this study was to analyze the use of C-arm and its significance in accurate reduction of zygomaticomaxillary complex (ZMC) fractures. Orbital volume is used as parameter to compared pre- and postoperative volumes of injured orbit. Differences in orbital volume calculated in cases done with intraoperative imaging and in controls treated without the use of intraoperative imaging were evaluated using Student t-test. C-arm is definitively an effective tool in the armamentarium of oral and maxillofacial surgery in assessment of reduction of ZMC fracture.

Micropropagation, Micromorphological Studies, and In Vitro Flowering in Rungia pectinata L.

A tissue culture protocol was developed for an important medicinal plant Rungia pectinata L. in the present study. Nodal shoots were used as explants and surface-sterilized with 0.1% HgCl2 solution. Murashige and Skoog (MS) medium was used to establish the cultures of R. pectinata. The bud break was reported on MS medium supplemented with 1.0 mg L(-1) 6-benzylaminopurine (BAP). About 98% response was observed with this media combination and maximum 3.2 shoots per explant with 4.3 cm length were recorded. The shoots were further multiplied using MS medium augmented with 0.5 mg L(-1) each of BAP and kinetin (Kin) + 0.1 mg L(-1) indole-3 acetic acid (IAA). Maximum 13.2 shoots per explant with 5.2 cm length were observed. All the shoots were rooted (4.9 roots per shoot with 3.5 cm length) on half strength MS medium fortified with 2.0 mg L(-1) indole-3 butyric acid (IBA). In vitro flowering was induced from the shoots on half strength MS medium supplemented with same concentrations and combinations of growth regulators used for shoot multiplication under 12/12 hr light/dark photoperiod. The plantlets were hardened in the greenhouse for two months and finally transferred to the field. The foliar micromorphological studies revealed the developmental changes in stomata, vein density, and trichomes during the culture of shoots under in vitro conditions.

An Improved Micropropagation Protocol by Ex Vitro Rooting of Passiflora edulis Sims. f. flavicarpa Deg. through Nodal Segment Culture.

A procedure for rapid clonal propagation of Passiflora edulis Sims. f. flavicarpa Deg. (Passifloraceae) has been developed in this study. Nodal explants were sterilized with 0.1% HgCl2 and inoculated on Murashige and Skoog (MS) basal medium. The addition of 2.0 mgL(-1) 6-benzylaminopurine (BAP) to MS medium caused an extensive proliferation of multiple shoots (8.21 ± 1.13) primordial from the nodal meristems. Subculturing of these multiple shoots on the MS medium augmented with 1.0 mgL(-1) of each BAP and Kinetin (Kin) was successful for the multiplication of the shoots in vitro with maximum numbers of shoots (25.73 ± 0.06) within four weeks of incubation. Shoots were rooted best (7.13 ± 0.56 roots/shoots) on half strength MS medium supplemented with 2.0 mgL(-1) indole-3 butyric acid (IBA). All in vitro regenerated shoots were rooted by ex vitro method, and this has achieved 6-7 roots per shoot by pulsing of cut ends of the shoots using 200 as well as 300 mgL(-1) IBA. The plantlets were hardened in the greenhouse for 4-5 weeks. The hardened plantlets were shifted to manure containing nursery polybags after five weeks and then transferred to a sand bed for another four weeks for acclimatization before field planting with 88% survival rate.

Giant cell tumor of the mandible.

Giant cell tumor (GCT) of bone is a distinctive neoplasm characterized by abundance of multinucleated giant cells scattered throughout the stroma of mononuclear cells. Its importance lies in recognizing and differentiating the characteristic histology, which at times may mimic several other bone tumors and endocrine disorders ranging from locally aggressive giant cell granulomas to hyperparathyroidism to malignant tumors. The jaw bones account for less than 1% of the lesion. Ina literature search, we found only five cases of GCT of jaw bones based on the new criteria. We present a rare case of GCT of the mandible which occurred in a 12-year-old female.

In vitro regeneration of shoots and ex vitro rooting of an important medicinal plant Passiflora foetida L. through nodal segment cultures.

Methods were developed in the present investigation for cloning and large scale plant production of Passiflora foetida L. germplasm selected from the East-Coast region of South India. Nodal shoot segments were used as explants. The explants were dressed and surface sterilized with 0.1% (w/v) HgCl2. Multiple shoots were induced (6.13 ± 0.22 shoots per explant) by proliferation of nodal shoot meristems on Murashige and Skoog (MS) semi-solid medium + 2.0 mg l-1 6-benzylaminopurine (BAP). The shoots of P. foetida were further multiplied (16.45 ± 0.44 shoots per explant) on MS medium + 0.5 mg l-1 each of BAP and Kinetin (Kin). The in vitro generated shoots were rooted on half-strength MS medium containing 2.5 mg l-1 indole-3 butyric acid (IBA). By this method 67% shoots were rooted. About 97% shoots were rooted ex vitro (8.33 ± 0.29 roots per shoot) when the cut ends of the shoots were treated with 300 mg l-1 IBA for 5 min. The in vitro rooted plants were hardened and acclimatized in the greenhouse and successfully (100%) transplanted to the field.

Vertical Alveolar Ridge Augmentation by Distraction Osteogenesis.

INTRODUCTION: Compromised alveolar ridge in vertical and horizontal dimension is a common finding in patients visiting practitioners for dental prosthesis. Various treatment modalities are available for correction of deficient ridges among which alveolar distraction osteogenesis is one. AIM: To study the efficacy of alveolar distraction osteogenesis in augmentation of alveolar ridges deficient in vertical dimension. MATERIALS AND METHODS: Ten patients aged 16 to 46 years with deficient alveolar ridge underwent ridge augmentation in 11 alveolar segments using the distraction osteogenesis method. For each patient a custom made distraction device was fabricated. The device was indigenously manufactured with SS-316 (ISO 3506). RESULTS: The vertical bone gain reached more than 10mm without the use of bone transplantation. Certain complications like incorrect vector of distraction, paresthesia, pain and loss of transport segment were encountered during the course of the study. CONCLUSION: Alveolar vertical distraction osteogenesis is a reliable and predictable technique for both hard and soft tissue genesis. Implant placement is feasible with primary stability in neogenerated bone at the level of the distracted areas.

Finite element analysis comparison of plate designs in managing fractures involving the mental foramen.

Introduction The aim of the study was to propose an ideal plating design for fractures running through the mental foramen. Methods The study compared three plating designs-two four-hole miniplates, 2 × 2-hole three-dimensional (3D) plate, and modified 2 × 2-hole 3D plate (posterior strut removed)-using finite element analysis. Von Mises stresses generated around the plates and bone were measured, as well as the mobility that is generated between the fracture fragments by applying muscle forces to generate bite force in one test and applying a force of 500 N over the premolars and first molar region in the second test. Results Von Mises stress in bone with miniplates measured 9.24 MPa in test 1 and 131.99 MPa in test 2. The stress with unmodified 3D plates measured 34.9 MPa in test 1 and150.03 MPa in test 2. The stress with modified 3D plates measured 24.98 MPa in test 1 and 150.59 MPa in test 2. Von Mises stress on the plates and screws measured 28.23 MPa, 95.97 MPa, 72.93 MPa in test 1 and 458.63 MPa, 779.01 MPa, 742.39 MPa in test 2 on miniplates, unmodified 3D plates, and modified 3D plates, respectively. The fracture mobility generated in the model with miniplates measured 0.001 mm in test 1 and 0.01 mm in test 2 and 0.007 mm and 0.02 mm in the model with unmodified 3D plates in test 1 and in test 2, respectively. In the model with modified 3D plates, the value was 0.001 mm and 0.01 mm in tests 1 and 2, respectively. Conclusion The ideal plate design is the two-plate technique with minimal stress generation on the bone and the hardware. The modified 3D plate has adequate strength to be used in the region but needs to be studied in detail.

Morbidity and mortality at five years after initiating Category I treatment among patients with new sputum smear positive pulmonary tuberculosis.

BACKGROUND: Evaluation of disease outcome is central to the assessment of tuberculosis control programmes. Most of the follow up studies in RNTCP are short-term. Five year follow up studies have not been done previously in this region. The objective of the present study is to [corrected] evaluate the outcome of Category I treatment in smear positive tuberculosis, five years after treatment in terms of relapse, sequelae and death and to know the associated factors. MATERIAL AND METHODS: Patients who had registered for Category 1 treatment during the period 2002 - 2004 were followed up at five years with clinical evaluation, Chest X-ray, ESR and sputum AFB smear. RESULTS: Of the 224 patients who were studied, 81% patients were males. Addictions, including smoking and alcoholism, were prevalent in 136 patients (61%). Treatment success rate at six months was 94.2%. At the end of five years, 124 patients (57.9%) were symptomatic, 59% patients had radiological sequelae, relapse in 10 patients (4.5%), and mortality in 12 (5.4%) patients. Diabetes mellitus was the most common comorbid illness. Smoking and age > or = 45 years were associated with radiological sequelae. Smoking was significantly associated with mortality. Smokers had worse outcomes in all parameters. CONCLUSIONS: Relapse rate was 4.5% and overall mortality was 5.4% at the end of five years. Significant proportion of patients has radiological sequelae. Smoking was the preventable risk factor associated with sequelae, relapse and mortality.