Objectives: The aim of this study was to assess the drug use pattern using World Health Organization (WHO) prescribing, patient care and health facility indicators at Secondary Care Referral Hospital of South India. Methods: A cross-sectional study was conducted at Secondary Care Referral Hospital of South India. WHO core drug use indicators questionnaire was used for the assessment of drug use pattern which comprise of five prescribing care indicators, five patient care indicators and two health facility indicators. 603 patient encounters were reviewed prospectively for a 6 months period from November 2013 to April 2014. Data were collected from outpatients of the pharmacy and results were represented in descriptive statistics. Results and Discussion: The average number of drugs prescribed per prescription was 2.7. The percentage of prescriptions in which antibiotics and injections were comprised about 9.6% (n = 159) and 1.6% (n = 27), respectively. The percentage of drugs prescribed by generic and from essential drug list (EDL) was 42.9% (n = 709), and 95.6% (n = 1578), respectively. The average consulting and dispensing time was 3.7 min and 2.3 min, percentage of drugs actually dispensed and adequately labeled was 96.6% and 99.3%. Percentage of patients had knowledge of correct dosage was 89.3%. The copy of EDL was available and the percentage of key drugs available was 88%. Conclusion: On the basis of above findings, the study was concluded that the prescribing indicators were met WHO standard criteria. The patient care and health facility indicators are rational and the importance of these indicators was encouraged by the doctors and the pharmacists. It shows that available drugs are satisfying unlimited healthcare needs of the public. Further, such studies at different regions of India and their review may produce beneficial results for the betterment of the society.

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Opportunistic fungal infections are common in human immunodeficiency virus (HIV) infected patients and commonly occur at some point during their illness. Though estimates show that these infections can occur in HIV patients with the same frequency as in the control group, their presentations are more severe and variable in HIV/acquired immunodeficiency syndrome. We present an HIV infected case with multiple fungal infections. This patient had onychomycosis due to Aspergillus niger, tinea cruris caused by Trichophyton rubrum, oral thrush and balanoposthitis due to Candida albicans.

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Background and Aims: Irritable bowel syndrome (IBS) is a highly prevalent functional gastrointestinal disorder long considered a diagnosis of exclusion. It is associated with decreased quality of life and significant economic burden to both the individual patient and society. To the best of our knowledge, this was the first study from this part of India assessing the relative impact on quality of life with respect to subtype of IBS. Subjects and Methods: The study was conducted between December 2011 and December 2013 among 1000 IBS patients attending general medical outpatient department of a tertiary care hospital in Kolkata (West Bengal, India). The Rome III criterion was used for diagnosis of IBS. IBS was further classified as diarrhea predominant (IBS-D), constipation-predominant (IBS-C) and mixed variety (IBS-M). This was a prospective, observational, cross-sectional study to assess the demographic and socioeconomic parameters, and impact of IBS on the quality of life of the patients by using short form-36 (SF-36) questionnaire. Results: The study found that IBS-D (67.6%) was the most common type, followed by IBS-M (30.4%) and IBS-C (2%). The majority of patients were males (59.2%). Overall none of the demographic and socioeconomic parameters analyzed in the study was found to have any significant bearing on the subtype of IBS affecting them. Eight scales of the SF-36 questionnaire were individually analyzed and correlated with the different subtypes of IBS. IBS-D group had the worst scores while IBS-M had the best score of quality of life. The difference between IBS-D and IBS-M was found to be statistically significant (P < 0.001) on every aspect. Conclusions: The study highlights that IBS is a bio-psychosocial disorder with poor quality of life. Most of the patients of IBS reporting to physicians have IBS-D. The socioeconomic and demographic factors do not appear to be significant determinants in this condition. IBS-D causes worst impact on quality of living among all subtypes.

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Context: The human immunodeficiency virus (HIV) seropositive patients have decreased immunity predisposing them to various opportunistic infections (OI). The CD4 counts in the patient can be taken as a marker to evaluate the immune status. Aim: The aim of the study is to screen the HIV seropositive patients for OI in relation to their CD4 counts in a tertiary care hospital. Settings and Design: The present study was prospective in design conducted in the Department of Microbiology in a tertiary care hospital. Materials and Methods: A total of 80 HIV-seropositive patients, admitted from a period of 1΍ years were screened for OI. CD4 counts were done in all patients and measured by flow cytometry. Sputum and bronchoalveolar lavage samples were tested for tuberculosis and pneumocystis carinii pneumonia (PCP); oral candidiasis was detected by potassium hydroxide preparation; stool samples were subjected to direct and ether concentration method and stained for opportunistic stool infections; serum samples were tested for toxoplasmosis and cytomegalovirus (CMV) infection by enzyme-linked immunosorbent assay. Cerebrospinal fluid samples were tested for cryptococcosis. Results: A total of 38 (47.5%) patients were positive for OI. There were 13.6% patients presenting with infections having a CD4 count of below 200 cells/μL of whom, oral candidiasis (40.8%), cryptosporidiosis (23.68%), tuberculosis (5.92%), and CMV immunoglobulin M (IgM), PCP, isosporiasis and cryptococcosis were (2.96%). Conclusions: Majority of OI are present in patients with HIV with a low CD4 count, which emphasizes the need for monitoring such patients.

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Aims: A case-control study was conducted to examine the prevalence of periodontal disease and oral hygiene practices in ischemic stroke patients. Settings and Design: Case-control study. Materials and Methods: This study was conducted from March 2010 to March 2011. Control subjects were either the relatives of stroke patients or selected randomly from the patients reporting to the hospital for treatment. The detailed case history and stroke characteristics were collected. Oral examination was done using the WHO Oral health assessment questionnaire and oral hygiene practices were obtained from the patients. Stroke outcome was assessed using modified Rankin scale (mRS) (good [mRS ≤ 2]; poor [mRS > 2]). Results: One hundred and eight first-ever ischemic stroke patients and 108 age- and gender-matched healthy controls were included. Thirty-six (33.3%) patients showed periodontal damage, only 15 (13.9%) of controls had periodontal involvement (P = 0.001). Periodontal disease was commonly seen in stroke patients than the control subjects (odds ratio 3 [95% confidence interval: 1.6-6.1]; P = 0.0007). Stroke patients (17.4%) were more likely to use a finger or twig to clean their teeth than controls (1.9%) (P < 0.0001). Stroke patients had more number of missing teeth (4.02 ± 5.85) as compared to controls (1.81 ± 3.89) (P = 0.002). Conclusions: Periodontal disease was common in stroke patients as compared to controls. Oral hygiene-related behavior of stroke patients may have a role to play in the complex interplay of factors linking periodontal disease and edentulism to stroke.

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Background: The experience of death and dead bodies usually generates psychological reactions among nursing students. This study attempted to interpret the lived experiences of nursing students with regards to death and dead bodies. Materials and Methods: Using a hermeneutic phenomenological approach, texts from the reflective diaries of nursing students were interpreted in relation to their experiences with death and dead bodies during their clinical postings. The interpretation involved three stages: Naive reading, structural analysis, and comprehensive understanding. Reflective diaries of 12 students met the inclusion criteria and thus were used for the interpretation. Results: Three themes emerged from the structural analysis; (i) personal reflection on harsh reality, (ii) unavailability of required support and abandonment, (iii) identification of individual strength and weakness based on experience. Conclusion: Nursing students expressed some emotional reactions that require the attention of their instructors. Nurse educators should always be available to support the students during clinical exposures. End-of-life components of the nursing curriculum should be improved.

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Cholesterol is a lipid molecule which is biosynthesized by all animal cells. Also, it is an essential structural component of cell membranes which is normally required for maintaining both fluidity and membrane structural integrity. Dyslipidemia is known as abnormal blood lipids considered as one of the major risk factors for heart disease. In an attempt to increase the effectiveness of healthy diet in reducing serum cholesterol, the American Heart Association along with the National Cholesterol Education Program Adult Treatment Panel III recently recommend the use of functional foods or foods high in components that reduce cholesterol as options in the dietary strategy. These foods include, green vegetables, fruits, avocado, fish oil, almond and nuts. Furthermore, those foods items are all permitted by the USA Food and drug administration to carry a health claim that they reduce the risk of cardiovascular disease. Individually, these foods have been shown to lower serum cholesterol by 4-7%. Dietary modification can be considered as a powerful nonpharmacological approach for improving blood lipids. Physical activity can improve lipid profiles either directly by reducing body weight or indirectly without reduced body weight; when weight loss occurs in conjunction with activities, low-density lipoprotein and total cholesterol are usually lowered.

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Ectopic eruption is a developmental disturbance in which the tooth fails to follow its normal eruption pathway. The purpose of this clinical report was to introduce a simple and effective way of performing ectopic eruption treatment with a stainless steel crown (SSC). In this report, the ectopic eruption case was successfully treated with SSC in 2 months. This case report demonstrates that a SSC could provide many benefits over other traditional treatment modalities and thus could be used for correcting ectopic eruption at an early age.

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Brucellosis is primarily a disease of domestic and wild animals that can be transmitted to humans (zoonosis). Infection with Brucella spp. continues to pose human health risk globally. Brucellosis in endemic and nonendemic regions remains a diagnostic puzzle due to misleading nonspecific manifestations and increasing unusual presentations. It may affect any organ of the body with clinical manifestations that include fever, joint pains, loss of weight, sweating, cough, sciatica, splenic enlargement, liver enlargement, orchitis, etc. Fewer than 10% of human cases of brucellosis may be clinically recognized and treated or reported. Routine serological surveillance is not practiced even in Brucella endemic countries. Whereas, this should be a part of laboratory testing coupled with a high index of clinical suspicion to improve the level of case detection. Rapid and reliable, sensitive and specific, easy to perform and semi-automated detection systems for Brucella spp. are urgently needed to allow early diagnosis and adequate antibiotic therapy in time to decrease morbidity and mortality.

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Pulmonary actinomycosis being a rare disease is an important and challenging diagnosis to make. The disease is commonly confused with conditions such as chronic suppurative lung diseases and malignancy thus requiring a high index of suspicion. Considerable psychological and physical morbidity, including unwarranted surgery can be prevented with an early and accurate diagnosis. We hereby present a case of 60-year-old male who presented to a tertiary care hospital with the chief complaint of hemoptysis and chest pain. On evaluating for the cause of hemoptysis, the clinical and radiologic findings were suggestive of lung cancer. The diagnosis of actinomycosis was determined by computed tomography guided transthoracic lung biopsy. Respiratory physicians should be aware of this important differential when investigating patients for persistent pulmonary shadowing.

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Arterial variations of the lower limb have been reported in the past. However, we report in here a very unusual variation. During routine dissections, an anomalous origin of the dorsalis pedis artery (DPA) was noted on the right foot of an adult male cadaver. In here, the arteries of the crural region arose from the popliteal artery, as usual. However, the anterior tibial artery (ATA) was very slender. The peroneal artery (PA) was larger than usual and reached the anterior compartment of the leg by piercing the interosseous membrane at its lower part. In the foot, the ATA joined with the PA to form the DPA. Knowledge of such type of variations in the anatomy of DPA is important for angiographers, vascular surgeons and reconstructive surgeons who operate upon these regions.

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Background: The mandible is seen as an important tool for radiological identification because of several growth parameters that can be exploited using cephalometric analysis, ease of imaging, and no overlying bony structures. These parameters can be handy in age and gender assessment in extreme situations like mass murders, remains of dead exhumed and murderous mutilations, missing or severely burnt individuals, etc. Material and Methodology: The study was conducted on randomized 90 lateral cephalograms obtained from the Department of Orthodontics. Tracings of the radiographs were done manually and cephalometric points were marked. Three linear measurements of mandibular growth were; mandibular body length, mandibular length and mandibular height. Gonial angle was measured as the angle formed by the ramus line (RL) and mandibular line (ML). The values obtained were statistically analyzed by Student's t-test using Statistical Package for Social Sciences (SPSS), Version 7.0. Results: An increase in gonial angle was observed with increasing age in the present study but no statistically significant result could be obtained. However, a larger gonial angle was certainly observed in females. In the present study, the maximum mandibular growth rate was observed among females in the age group of 8-12 years. This finding is in accordance with the fact that growth spurt in females is noted at the age of 10-12. A statistically significant increase in the mandibular length (Gn to Go) was observed in females in the age group of 8-12 years (P > 0.05). Conclusion: The linear and angular parameters used in the study, when combined together, might prove to be of importance in studying the growth pattern of mandible in different age groups and gender. Further studies are recommended on a larger sample size of different ethnic inhabitants to derive an unvarying formula of age and gender assessment.

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Background: Central nervous system (CNS) infections associated with Human immunodeficiency virus (HIV) has decreased markedly in the developed countries. However, the scenario is different in Indian patients and is not unusual to have CNS infections as their initial presentation. Considering this, we undertook this study to look at the incidence of CNS manifestations in HIV infected patients. Materials and Methods: This was a cross sectional study conducted in the Departments of Medicine and Neurology in Christian Medical College Ludhiana, a tertiary teaching institution in North West India. All the HIV infected patients with Central nervous system manifestations who presented to our institution from 1st April 2009 to 31st of March 2014 were included in the study. The demographic and clinical profile along with the outcome of these patients was studied. Results: There were 280 patients diagnosed during this 5 year period, 43(15%) of who had CNS manifestations. The male: female ratio was 5:1. Majority of them were in the age group of 31 to 50 years of age (68.89%).In 72% of patients CNS manifestations were the initial manifestation of HIV infection.The CNS manifestations noted were cryptococcal meningitis in 20, toxoplasmosis in 3, CNS tuberculosis in 11, PMLE in 6, ischemic stroke in 4 and Diffuse B cell Lymphoma (DLBCL) with aseptic meningitis in 1. Conclusions: Even though in the era of HAART the incidence of CNS manifestations has decreased, CNS manifestations continue to be the presenting symptom for HIV infection in over 16% of the cases.

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Background: Juvenile hypothyroidism is a very common problem in developing parts of world, and produces various skeletal manifestations. One of them is short stature and it is the most common reason for referral to endocrinologist. Aim and Objectives: To study the prevalence of short stature in juvenile hypothyroidism, to study the various radiological manifestations of juvenile hypothyroidism and to study the impact of treatment on growth velocity and various skeletal manifestations. Materials and Methods: Out of total nine hundred hypothyroid patients, eighty seven patients found to be of juvenile hypothyroidism were enrolled in the study those were 6-18 years of age with newly diagnosed or on follow in the endocrine clinic over a period of 1 ½ years were evaluated clinically and by laboratory tests. Serial assays of TSH, T4, and skeletal X-rays and anthropometry were done at regular interval and clinical and radiological outcome of patients were analyzed. Statistical Analysis: Data were analyzed by SPSS version 17, the P < 0.05 was considered significant. Result: The mean age of diagnosis of juvenile hypothyroidism was 11.2 years, and the females had twice the incidence than that of males, the mean TSH value was 118 ± 24.3 μIU/ml. Prevalence of short stature was found to be 45% while delayed bone age was found to be 72% in juvenile hypothyroid populations. Height SDS increased from -2.9 ± 0.9 at the start of thyroxine therapy to -1.8 ± 0.8 after 12 months (P < 0.001). Bone age SDS increased from 8.9 ± 2.5 at the start of thyroxine therapy to 10.8 ± 2.7 after 12 months. Height of velocity increased from 4.9 ± 0.8 cm/year in the year before treatment to 8.7 ± 1.3 during treatment (P < 0.001). Conclusion: The presentations of juvenile hypothyroidism may be varied; prompt recognition of the findings can lead to early and effective treatment, and improving the skeletal defects.

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Context: The level of cardiorespiratory fitness (CRF) among the early adolescent would provide a measure of future burden of cardiovascular disease in Ludhiana, North West India. Aims: The aim was to estimate the level of CRF with the help of multi-stage-fitness (Bleep) test in high school students. Settings and Design: Cross sectional study in urban Ludhiana. Subjects and Methods: Totally, 200 school children were selected by simple random sampling from four schools. After the consent, a pretested questionnaire was administered, and the Bleep test performed. Statistical Analysis Used: Frequencies and proportions were calculated, Chi-square and t-test were the tests of significance. Results: The prevalence of obesity was 2.5%, overweight, severe thinness, and thin was15.5%, 1.5%, and 5%, respectively. There were more extreme weights among boys compared to girls (Chi-square = 7.59 and P = 0.022). The mean hours of weekly vigorous sports activity was 2.14 ± 0.63. The mean maximum aerobic capacity was 26.80 ± 4.37. CRF scores of very poor in 72.0% with only 7.05% scoring as Fair. More boys (93.8%) had very poor CRF scores compared to girls (43.7%). Score of Fair CRF in 16.0% girls and 0.9% boy. Conclusions: The high school children in urban Ludhiana, Northwest India exhibit high levels of physical inactivity, worsening obesity, and low levels of CRF, boys are more affected compared to girls. The bleep test is a low-cost and feasible quantitative tool to measure cardio respiratory fitness in limited resource setting.

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Osteomas are most common benign, slow growing bone-forming tumors of the skull. These bony outgrowths develop from membranous bones, composed of compact or trabecular bone limited exclusively to craniofacial bones, especially of paranasal sinuses. Congenital in growing osteomas presenting in neonates is extremely rare. Authors did not come across any case of congenital osteoma reported in the literature.

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This is a case report of occurrence of paroxysmal atrial fibrillation (AF) in a previously healthy 50-year-old man after suffering from a nonfatal electrical injury. The patient developed palpitation and sustained nonfatal electrical burn in his right hand after coming in contact with 440 voltage alternating current. His electrocardiogram done at the emergency revealed AF. However he was hemodynamically stable and hence put under conservative therapy. He reverted back to sinus rhythm within 24 h of admission and continued to remain so. Although ventricular arrhythmia is common after electrical injury, AF has been rarely reported in literature.

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A significant number of secondary hypertension could be due to endocrine etiology. The pheochromocytoma/paraganglioma (PGL) syndrome is one among them. We herein report a case of PGL in a young woman, who presented to us with hypertension and its reversal after surgical treatment. In this review, we also discussed in detail about this rare entity.

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Regional odontodysplasia is a rare developmental dental anomaly affecting both primary and permanent dentition in any of the jaws with uncertain etiology. Clinically, affected tooth are impacted and if erupted are hypoplastic or hypocalcified. Radiographically, the affected teeth show a typical "ghost-like" appearance. In this article, two such case reports are presented by the authors associated with supernumerary teeth in the same region.

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An 87-year-old female, a known case of diabetes mellitus was admitted with acute febrile illness with altered sensorium and uncontrolled hyperglycemia. She was evaluated and diagnosed to have urosepsis, septic shock and lactic acidosis. In view of the difficulty in securing a peripheral intravenous line, a central venous catheterization was performed. Though nonpulsatile venous blood was aspirated from the needle initially, blood stained serous fluid was aspirated after insertion of the catheter. The fluid was analyzed and found to have high triglyceride concentration suggesting that it was lymph. A chest X-ray was taken which too confirmed malposition of the catheter. This case represents a rare complication of right thoracic duct cannulation during central venous catheterization of the right internal jugular vein (IJV), when anecdotal reports advice preferring right IJV to left in view of possible thoracic duct cannulation.

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Candidiasis of the gastrointestinal tract most commonly involves the esophagus and rarely involves the stomach and small bowel. The association of gastric carcinoma with candidiasis is even rare and only a very few case reports are available. We present here a 40-year-old female who presented with complaints of gastric outlet obstruction who on endoscopy showed a malignant ulcer involving the lesser curvature. The histopathological examination of biopsy from the ulcer showed adenocarcinoma intestinal type along with yeast and pseudohyphae forms of candida species.

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Os odontoideum is a rare congenital anomaly predisposing to atlantoaxial instability. It may rarely present with a history of trivial trauma followed by slow progressive features of compressive myelopathy. Dens fractures, though not uncommon, may also remain undiagnosed and present later on with nonunion. Hence, it is very important for these patients to undergo proper clinical evaluation and appropriate imaging.

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Pediatric melioidosis is an under-diagnosed entity and rarely reported from India. This condition, if not treated early and appropriately, can have a fatal outcome. A 17-month-old female child presented with fever and ulcer on the right leg; she eventually succumbed to the infection. Culture from blood and wound swab from ulcer site grew Burkholderia pseudomallei.

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The risk of renal arteriovenous malformations (AVMs) must be kept in mind as a cause as sudden hematuria in patients with previous renal injury. Treatment of renal AVMs has evolved from nephrectomy to angioembolization, as it allows good control bleeding while preserving maximum renal function and appears to be the first treatment of choice. Hence, angioembolization facilities must be available in centers dealing with renal trauma.

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Few decades ago, the mission hospital surgeons felt that if they did not operate the patients had no other place to go, and hence attempted a wide variety of surgeries. Now, with the vast improvement in facilities available in urban areas and the improvement in travel capabilities should the mission hospital surgeons be prepared to do a wide variety of procedures? To answer the above question, we followed up the patients who were referred for surgical procedures elsewhere during the last 12 years. Only 24 out of the 128 patients could afford treatment elsewhere. Twenty of them came back to our hospital and had surgery at a much higher risk because they could not afford the treatment elsewhere. The others chose not to have treatment. Hence, is important then for the few surgeons working in rural areas to a "Jack of all trades" and learn a wide variety of surgical skills if they are to treat the poor patients in rural areas.

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Background: On August 31, 2014, eighty cases of the gastroenteritis were reported in Ghallour sub-center area. We investigated the outbreak to identify the source, propose control, and preventive measures. Materials and Methods: We defined a case as occurrence of three or more watery stools with or without vomiting, w.e.f January 27, till February 2, 2014 in residents of Ghallour sub-center area of Jawalamukhi block. We hypothesized it as a water borne outbreak. We determined age and sex specific attack rate. We collected information about personal history on age, sex, residence, and date of onset of symptom from case patient and established line list. We collected nine stool samples/rectal swabs from the cases; three pre and four post chlorination water samples and sent them for microbiological testing. We mapped water supply pipelines of the area and reviewed the water chlorination record. Results: We identified 390 cases in 16 villages under the sub center. The overall attack rate was 8% with a range of 1.3% to 36%. The cases patients were reported from all age groups and both the genders with the youngest student; 1-year old to the oldest one as 88 years. Two-third of the cases reported vomiting with some complaining of pain abdomen. Villages like Jathman, Khattni, Rajol Patta, Kohara has 100% case patients of loose motions while villages like Dhroli, (100%), Sasan (63%) and Ghallour (50%), etc., have combined symptoms of loose motions and vomiting. No fatality was reported. Escherichia coli was detected in the samples from water samples. Records of chlorination were not properly maintained. Conclusion / Recommendation: The outbreak was associated due to contamination of water at the source in Jolly Khad. Regular treatment of the water needs to be done right at the source before being lifted.

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Background: Helicobacter pylori (H. pylori) infection is one of the most common causes of gastrointestinal morbidity and mortality worldwide. Early diagnosis of infection is imperative for the cure of distressing symptoms and prevention of complications. Objective: The objective of the study is to evaluate imprint cytology of gastric biopsy specimens as a rapid and cost-effective diagnostic tool and its comparison with conventional diagnostic tests. Materials and Methods: Antral biopsies were collected from 130 patients and evaluated for H. pylori infection by imprint cytology and histopathological examination by different stains and rapid urease test (RUT). Histopathological features of gastric biopsy specimens were also assessed. Results: A total of 118 patients showed H. pylori infection by two or more methods. Giemsa histology showed highest sensitivity, specificity, positive predictive value, negative predictive value and Youden's Index (YI). Among imprint cytology stain methods, toluidine blue showed highest sensitivity and highest YI was obtained for PAP stain. Conclusion: Helicobacter pylori infection is associated with gastric mucosa changes like chronic active gastritis, atrophy, intestinal metaplasia, ulceration and carcinoma. Imprint cytology has high sensitivity and comparable predictive values to conventional diagnostic tools-histopathological examination and RUT in the detection of H. pylori infection.

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