Dr. Ram Manohar Lohia Institute of Medical Sciences

The wide scale use of copper oxide nanoparticles (CuONPs) due to their unique properties and important applications in magnetic, thermal, electrical, sensor devices, and cosmetics makes human beings more prone to the exposure of CuONPs and its potential adverse effects. Exposure to such nanoparticles is mainly through skin and inhalation. Therefore, the aim of the present study was to assess the apoptotic and genotoxic potential of CuONPs (50 nm) in the human skin epidermal (HaCaT) cells and its underlying mechanism of cellular toxicity. Significant decreases in cell viability were observed with CuONPs exposure in a dose- and time-dependent manner and also induced significant reduction in glutathione and induction in lipid peroxidation, catalase, and superoxide dismutase in HaCaT cells. A significant increase in caspase-3 activity was observed with CuONPs exposure in HaCaT cells indicating apoptosis. Apoptosis or necrosis was confirmed with fluorescent staining (acridine orange and propidium iodide). The CuONPs also induced DNA damage that was mediated by oxidative stress. This study investigating the effects of CuONPs in human skin cells has provided valuable insights into the mechanism of potential toxicity induced by CuONPs.

The widespread use of zinc oxide (ZnO) nanoparticles worldwide exposes humans to their adverse effects, so it is important to understand their biological effects and any associated risks. This study was designed to investigate the cytotoxicity, oxidative stress, and apoptosis caused by ZnO nanoparticles in human skin melanoma (A375) cells. MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazoliumbromide] and lactate dehydrogenase-based cell viability assays showed a significant decrease in cell viability after exposure to ZnO nanoparticles, and phase contrast images revealed that cells treated with these nanoparticles had a lower density and a rounded morphology. ZnO nanoparticles were also found to induce oxidative stress, evidenced by generation of reactive oxygen species and depletion of the antioxidant, glutathione. Induction of apoptosis was confirmed by chromosomal condensation assay and caspase-3 activation. Further, more DNA damage was observed in cells exposed to the highest concentration of ZnO nanoparticles. These results demonstrate that ZnO nanoparticles have genotoxic potential in A375 cells, which may be mediated via oxidative stress. Our short-term exposure study showing induction of a genotoxic and apoptotic response to ZnO nanoparticles needs further investigation to determine whether there may be consequences of long-term exposure to ZnO nanoparticles.

INTRODUCTION Dental caries is a chronic disease displaying drastic variations in its prevalence across multiple factors and the obscurity of data on the same hinders the attainment of dental caries prevalence reduction goals set by WHO.[1] Considering the evolving dietary patterns in last few decades, globalization has been linked to increased consumption of sugar and growing obesity in middle and low income countries.[2] Some studies in developing countries such as India report a prevalence rate of 36.7% among 13–19 year olds while others like Saudi Arabia state prevalence to be as high as 83% among 6–8 year olds.[13] Untreated dental caries can cause pain and difficulties in eating and sleeping, pain, which in turn leads to emergency dental visit, hospitalization, need for invasive treatment, and systemic health problems thereby lowering the quality of life.[4] Caries of the permanent teeth was reportedly the most common oral condition as per the Global Burden of Disease Study of 2017.[5] Globally, around 2.4 billion people suffer from caries of the permanent teeth and 486 million children suffer from caries of the primary teeth.[6] The scenario in India is no different from other developed or developing countries.[2] The available literature on the prevalence of dental caries in India shows a varied picture with prevalence of caries being very high in some areas and low in some areas.[678910] In India, there are infinite number of studies done on the prevalence of dental caries.[678910] However, only a few of them focused on dental caries across different age groups.[11121314] The dentist population ratio in India ranges from 1:1000 to 1:20,000 across different states.[15] Annually, 30,570 dentists are produced in India; however, only 10% of dentists serve the rural people.[16] With a poor dentist to population ratios in some areas, the chances of dental caries going undiagnosed are highly likely, contributing the regional disparity in dental caries prevalence rates.[11] Hence a true prevalence rate needs to be elucidated in order to address the growing concern of dental caries. Further, only a few systematic reviews on dental caries have been reported among Indian population.[17181920] However, each study has its own limitations such as the use of a limited number of articles, extraction of published reports from few electronic databases, lack of complete analysis, or unavailability of recently published articles. Few systematic reviews have focused on only children or the elder population. Dental caries can be a lifelong condition which affects children, adolescents, and adults in various forms. Manifestation of dental caries in later stages of life is likely considering the increased prevalence of gingival recession and root caries as people grow older.[21] Evidence suggests that high salivary microbial counts are found in elderly populations which may facilitate the manifestation of dental caries.[22] To the best of our knowledge, there was no data on the pooled prevalence of dental caries among Indian population from different age groups, geographical region, dentition, and diagnostic criteria. Hence, the study aimed to evaluate the prevalence of dental caries across the aforementioned characteristics in the Indian population. AIMS AND OBJECTIVE Participants from the ages of 3–75 years and hailing from different parts of India were covered in this meta-analysis of 70 studies to elucidate the overall prevalence of dental caries as well as its distribution pattern across different age groups, geographical regions, type of dentition, and the diagnostic criteria used. The findings of which are elemental in delineating the risk factors of dental caries and vulnerable sub-populations in India along with ascertaining current gaps in the scientific literature on dental caries. MATERIALS AND METHODS A systematic review and meta-analysis of the literature on dental caries was conducted to determine its prevalence among the Indian population of varying age groups. The study protocol adopted was registered in PROSPERO (CRD42019132489) and followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. SEARCH STRATEGY Research articles published between March 2009 and March 2019 were screened using databases such as PubMed, Science Direct, Google Scholar, Cochrane, and Scopus. Search strings used for electronic screening of databases included the following: prevalence, dental caries, India, DMFT, cavitated lesion, non-cavitated lesion, root caries, incisor caries, smooth surface caries, occlusal caries, proximal caries, DMF, early childhood caries, geriatric caries, premolar caries, molar caries, canine caries, coronal caries, pit and fissure caries, linear enamel caries, and age group ranging from 3 to 75 years. INCLUSION/EXCLUSION CRITERIA Full-text articles published in English during the last decade were screened for analysis. The inclusion criteria composed of observational studies (case–control, cohort, and cross-sectional) conducted on the prevalence of dental caries in India, on patient population aged 3–75 years. Investigations with nonspecific data, inadequately designed, editorials, letters, case reports, conference proceedings, and the grey literature, ongoing observational studies, reviews, and studies that did not report statistical tests for dental caries were excluded from the study analysis. DATA EXTRACTION After deduplication, the studies were screened for eligibility by two independent investigators to identify “potentially eligible” studies and the disagreements were resolved by consensus after discussion. The inter-reliability score was assessed by Cohen’s Kappa (0.00943). The information from the eligible studies were extracted which encompassed author’s name, year of publication, participants, population characteristics (age range and dentition), geographic location, type of dental caries, diagnostic criteria of dental caries, and prevalence percent of dental caries as per age group. QUALITY ASSESSMENT The quality of the studies that formed the basis of meta-analysis was assessed by adopting the Newcastle–Ottawa Scale (NOS) comprising three components (methodology, comparability based on study design, outcome). Based on this criterion, the study quality was graded on a 10-point scale. Studies with scores less than 5 were considered to have low methodological quality, scores of 5 to 7 indicated moderate quality, and those above 7 were considered as high quality. DATA ANALYSIS Statistical analyses were performed using the R software, version 3.5.2. A random effects model was employed in all meta-analysis procedures. Forest-plots were used to demonstrate the effect of each study and the summary effect size. For effect size estimates, standard errors of its logarithm were calculated from the reported or estimated CIs, assuming that the effect size was log-normally distributed. The prevalence of dental caries was extracted from individual studies and combined using the generic inverse variance method of Der Simonian and Laird random effects model. The heterogeneity of effect size among studies was quantified using I2. The influence analysis was performed by removing one study at a time to evaluate whether the pool estimates could have been altered by a single study. Subgroup analyses were conducted as per mean age, region, diagnostic criterion for estimating dental caries (DMFT), dentition, and type of dental caries. To investigate publication bias, funnel plots were constructed. The distribution of study risk estimates across the funnel plot was examined visually and Egger’s test for small study effects was performed to assess the degree of asymmetry. A P < 0.05 was considered statistically significant. RESULTS On electronic screening as described in Figure 1, 253 relevant publications were found. Among the databases explored, Google scholar yielded the most articles (n = 170), followed by PubMed (n = 62), science direct (n = 15), Scopus (n = 4), and Cochrane Library (n = 2). Initially, 115 duplicate records were excluded using EndNote which created a separate list of duplicate references that were reviewed by investigators for de-duplication. Subsequently, another 43 articles were excluded after scrutinizing the abstracts, thereby yielding 95 articles, the full texts of which were assessed for eligibility. Two independent reviewers on screening the remaining data, finally included 70 articles in this meta-analysis after excluding 25 articles due to studies lacking the prevalence rate of dental caries, no specification of DMFT index and age not matching with the inclusion criteria.[89,132324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687]Figure 1: Flowchart of the eligibility criteria as per PRISMACHARACTERISTICS OF INCLUDED STUDIES Vast spatial distribution of studies was observed, with almost all regions of India except the northeast finding representation [Figure 2]. Prevalence of crown caries was observed in 69 studies and 8 studies reported of early childhood caries. The evaluation of dental caries was conducted through clinical examinations, in accordance with DMFT and WHO criteria mainly.Figure 2: Geographical distribution pattern of the 70 studies included in the meta-analysis on prevalence of dental cariesQUALITY ASSESSMENT The quality assessment using NOS depicted 12 studies to have low methodological quality, whereas 52 studies were of moderate methodological quality and only six studies demonstrated high methodological quality. OVERALL PREVALENCE OF DENTAL CARIES META-ANALYSIS The overall prevalence of the dental caries calculated using the random effects model was 54.16% (SD 0.0229, 95% CI: 0.4966–0.5866). The test for heterogeneity produced Tau square of 0.04, Q(P < 0.0001), I2 =99.57% (95% CI: 99.4121–99.7012), H square = 232.32 (95% CI: 170.1101–334.6652). Figure 3 illustrates the forest plot for each of the studies examined and the overall prevalence of dental caries in India.Figure 3: Forest plot depicting study specific prevalence (mean and 95% CI) for dental caries in Indian populationPREVALENCE OF DENTAL CARIES BY SUBGROUP ANALYSIS META-ANALYSIS Studies were divided into various subgroups such as age, dentition, geographic location, estimation of caries using a diagnostic index and type of dental caries, to check for any possible heterogeneity. Figure 4 illustrates the subgroup analysis by age which was further divided into three categories. The overall prevalence of dental caries observed in the age range of 3–18 years was 52%. The test for heterogeneity produced Tau square of 0.0330, Q(P < 0.0001), I2 =99.5365% (95% CI: 99.3520–99.6907), H square = 215.7641 (95% CI: 154.3266–323.3308). The maximum and minimum prevalence of dental caries observed in the age range of 3–18 years were 95 and 7%, respectively.[977]Figure 4: Forest plot depicting specific age-group prevalence (mean and 95% CI) for dental caries in Indian populationSimilarly, the overall prevalence of dental caries observed in the age range of >18 years was 62%. The test for heterogeneity produced Tau square of 0.0519, Q(P < 0.0001), I2 = 99.5250% (95% CI: 98.8461–99.9014), H square = 210.5069 (95% CI: 86.6651–1014.4179). Subgroup analysis by type of dental caries depicted that the overall prevalence of crown caries was 57%, overall prevalence of dental caries was maximum in the mixed dentition (58%) followed by the primary (54%) and permanent dentition (46%). Furthermore, the overall prevalence of dental caries was observed to be higher in western India (72%) followed by northern India (57%), central India (56%), and 51% in the southern India. The lowest prevalence of dental caries, however, was observed in eastern India (36%). However, research paucity could have been the possible explanation for the low prevalence in Eastern India. The test for heterogeneity (for type of dental caries, diagnostic criteria for estimating dental caries, dentition, region) produced Tau square of 0.0329, Q(P < 0.0001), I2 = 99.38% (95% CI: 99.11–99.58), H square = 159.52 (95% CI: 112.63–242.27). META-ANALYSIS FOR DMFT BY SUBGROUP ANALYSIS Random-effect model revealed the prevalence of DMFT index as a diagnostic criterion in the estimation of dental caries in the age group of 3–18 years to be 57%. In patients aged above 18 years its usage was much higher at 77%. The prevalence of DMFT index in the overall diagnosis of crown caries was observed to be 62%. In early childhood caries, the prevalence of DMFT index was comparatively low at 29%. The prevalence of DMFT index as diagnostic criterion of dental caries in primary dentition was 59%. While in mixed dentition and permanent dentition the prevalence rates of DMFT for diagnosis of dental caries were 66 and 43%, respectively. Eastern India observed the highest overall prevalence of DMFT as diagnostic criteria for estimating dental caries at 72% followed by western part of India (60%), southern (59%), and north India (58%). The test for heterogeneity (for age, type of dental caries, dentition, region) produced Tau square of 0.0288, Q(P < 0.0001), I2 = 99.30% (95% CI: 98.9145–99.6016), H square = 143.09 (95% CI: 92.1239–250.9946). PUBLICATION BIAS AND META REGRESSION ANALYSIS The regression test on both the random-effect (without moderators) and mixed-effect (with the 6 moderators) generated P > 0.05, indicating no funnel plot asymmetry and hence, no publication bias. The absence of publication bias in the present study is depicted by the even scattering of smaller studies at the base of the funnel in Figure 5.Figure 5: Funnel plot for all studiesThe non-parametric rank-based test (trim and fill test) on random-effect model (without parameter model) also suggested symmetry (hence, no publication bias) and no missing studies. The Egger’s regression intercept was −5.417, 95% CI (−13.061, −2.227), t = −1.398 and P = 0.1663, indicating funnel plot symmetry and lack of publication bias. Results of meta-regression analysis indicated that none of the included subgroups influenced the size of the average true effect. Approximately, 9.62% of the total amount of heterogeneity can be accounted for by including the 6 moderators (region, design, caries type, dentition, age, and year of study). Remaining 90.28% of variability was due to other factors not included in this study. The test for residual heterogeneity was significant (QE = 12340.4190, df = 55, P < 0.0001), possibly indicating that other moderators (such as the sample population and gender) not considered in the model were influencing the prevalence of caries. DISCUSSION Multitude of studies have been undertaken on the prevalence of caries among children and adolescents; however, a comprehensive insight into prevalence rates of dental caries across different age groups, type of dental caries, geographical regions, dentition, and diagnostic criterion for estimating dental caries (DMFT) has remained unexplored. Hence, this systematic review and meta-analysis set out to fill these lacunae. As per our review and analysis, the overall prevalence of dental caries in Indian population aged between 3 and 75 years was 54.16%. This finding is in congruence with results of the National Oral Health Survey in India which noted a prevalence of 53.8%.[88] Although most studies have focused on dental caries in populations under 18, an age-specific prevalence of 62% in patients above 18 years and 52% among 3–18 year olds (P < 0.0001) was observed. Janakiram et al. reported a mean prevalence of 49% in 5–12 year olds, with a steady increase of 60% to 84% in 15 years olds and 65–74 year group, respectively.[21] Age-specific increase in dental caries can also be attributed to poor health seeking behaviors among adults, inadequate time for self-care, substance abuse, presence of comorbidities, and absence of organized programs that target prevention and reduction of dental caries in India.[1989909192] In reference to prevalence of dental caries across different types of dentition, highest overall prevalence was noted in the mixed dentition (58%) category, followed by the primary (54%) type. This points towards the slow increment in prevalence of caries in the transitory period between primary and mixed dentition, as dental caries takes time to manifest as clinically detectable lesions and impact of changing dietary patterns.[93] On assessing the geographical distribution of dental caries prevalence rates in India, the region wise prevalence was notably high in western India (72%). However, this is in dissonance with a meta-analysis by Janakiram et al. who found that the dental caries prevalence was markedly higher in North India among all age groups compared with the other parts of India.[21] This variation in inter-regional estimates can arise depending on the socio-economic parameters of the areas surveyed and the food practices pertaining to that region.[94] The 77% prevalence of DMFT index in the diagnosis of crown caries in adults and corresponding 29% for early childhood caries emphasizes the availability and adoption of numerous newer and age-specific indices such as ICADAS, AAPD, EAPD, DEFT, and PUFA in diagnosis of caries among children. Use of DMFT index showed significant variations across other corollary parameters such as type of dental caries, dentition, and geographical region studied. The simplicity and convenient application of DMFT have made the most widely used and preferred diagnostic index for dental caries in large epidemiological surveys or in pre-operative assessments.[95] This review has its limitations. The literature was restricted to a particular time frame, language, and could not comprehensively cover assessment of clinical symptoms, etiology, and treatment protocols associated with dental caries and thereby limiting our ability to evaluate all possible outcomes. Exclusion of studies due to incoherence in the dentition status of sampled patients further limited the number of studies analyzed. Despite these shortcomings, this systematic review and meta-analysis was able to avoid publication bias and present a cohesive understanding of dental caries prevalence among the Indian population. CONCLUSION Present findings suggest that the prevalence of dental caries is a pressing health concern affecting at least half of the Indian population. Age-specific subgroup analysis highlights the need for better preventive oral care programs and awareness campaigns among adults for pertinent management of dental caries. Taking note of the regional disparities in prevalence rates can help in better targeting of interventions and health policy formulation. In addition, the lack of anatomical site-specific investigation was observed during the literature collection and research should be focused on the prevalence of anatomical site specific caries as well. FINANCIAL SUPPORT AND SPONSORSHIP This manuscript did not receive any funding from public or private sectors. CONFLICTS OF INTEREST The authors have no conflict of interests to disclose. AUTHORS CONTRIBUTIONS First author contributed to the concepts, design, literature search, data acquisition, screening of articles, exclusion of ineligible studies, data analysis and manuscript review stages. Second author contributed to the literature search, data acquisition, screening of articles, exclusion of ineligible studies, data analysis, statistical analysis and manuscript review. Third author contributed to the concepts, design, definition of intellectual content, data analysis and manuscript review. Fourth author contributed to the concepts, manuscript preparation, manuscript editing and manuscript review. Fifth author contributed to the design, manuscript preparation, editing and review. ETHICAL POLICY AND INSTITUTIONAL REVIEW BOARD STATEMENT Not applicable. PATIENT DECLARATION OF CONSENT Not applicable. DATA AVAILABILITY STATEMENT The data set used in the current study has been sourced from PubMed, Google Scholar and Science direct, Cochrane, and Scopus indexed articles. Besides the data mentioned in the article, additional data can be made available on request. ACKNOWLEDGEMENTS Nil.

OBJECTIVE: The authors imaged the medial longitudinal fasciculus (MLF) in 58 patients with MS and chronic internuclear ophthalmoparesis (INO) to determine which MRI technique best shows the characteristic lesion associated with this ocular motor syndrome. METHODS: Using quantitative infrared oculography, the authors determined the ratios of abduction to adduction for velocity and acceleration, to confirm the presence of INO and to determine the severity of MLF dysfunction in 58 patients with MS and INO. Conventional MRI techniques, including proton density imaging (PDI), T2-weighted imaging, and fluid-attenuated inversion recovery (FLAIR) imaging, were used to ascertain which technique best shows MLF lesions within the brainstem tegmentum. T1-weighted imaging was performed to determine the frequency of brainstem tegmentum hypointensities. RESULTS: All patients studied had evidence of an MLF lesion hyperintensity on PDI, whereas T2-weighted imaging and FLAIR imaging showed these lesions in 88% and 48% of patients, respectively. With PDI, dorsomedial tegmentum lesions were seen in the pons in 93% of patients and in the midbrain of 66% of patients. Lesions were observed at both locations in 59% of patients. One patient had an MLF lesion with a corresponding T1 hypointensity. CONCLUSIONS: PDI best shows the MLF lesion in patients with MS and INO.

The aim of this study was to evaluate the histopathologic parameters that predict lymph node metastasis in patients with oral squamous cell carcinoma (OSCC) and to design a new assessment score on the basis of these parameters that could ultimately allow for changes in treatment decisions or aid clinicians in deciding whether there is a need for close follow-up or to perform early lymph node dissection. Histopathologic parameters of 336 cases of OSCC with stage cT1/T2 N0M0 disease were analyzed. The location of the tumor and the type of surgery used for the management of the tumor were recorded for all patients. The parameters, including T stage, grading of tumor, tumor budding, tumor thickness, depth of invasion, shape of tumor nest, lymphoid response at tumor-host interface and pattern of invasion, eosinophilic reaction, foreign-body giant cell reaction, lymphovascular invasion, and perineural invasion, were examined. Ninety-two patients had metastasis in lymph nodes. On univariate and multivariate analysis, independent variables for predicting lymph node metastasis in descending order were depth of invasion (P=0.003), pattern of invasion (P=0.007), perineural invasion (P=0.014), grade (P=0.028), lymphovascular invasion (P=0.038), lymphoid response (P=0.037), and tumor budding (P=0.039). We designed a scoring system on the basis of these statistical results and tested it. Cases with scores ranging from 7 to 11, 12 to 16, and ≥17 points showed LN metastasis in 6.4%, 22.8%, and 77.1% of cases, respectively. The difference between these 3 groups in relation to nodal metastasis was very significant (P<0.0001). A patient at low risk for lymph node metastasis (score, 7 to 11) had a 5-year survival of 93%, moderate-risk patients (score, 12 to 16) had a 5-year survival of 67%, and high-risk patients (score, 17 to 21) had a 5-year survival of 39%. The risk of lymph node metastasis in OSCC is influenced by many histologic parameters that are not routinely analyzed in pathologic reports. These significant independent factors were graded to design a scoring system that permits accurate evaluation of the risk of metastasis with accuracy independent of the traditional TNM system or isolated histologic parameters. The need for neck node dissection can be predicted depending upon the scores obtained.

High-risk human papillomavirus (HR-HPV) is a causative agent for an increasing subset of oropharyngeal squamous cell carcinoma. HPV 16 accounts for 90% of cases. The chance for malignant transformation due to infection with high-risk HPV is proportional to the expression of the viral oncogene products E6 and E7, which inactivate p53 and retinoblastoma (Rb) tumor suppressor functions. P16 is a surrogate marker of HPV associated HNSCC and 2+/3+ expression in more than 75% cells is diagnostic. Molecular demonstration of integrated virus by in situ hybridization is specific but has low sensitivity. HPV associated oropharyngeal carcinomas classically arise in the tonsillar crypts and commonly have basaloid morphology with a prominent lymphocytic repsonse and minimal despmoplastic reaction. In situ vs invasive carcinomas may be difficult to distinguish in histology. The HPV postitivity overrides traditional prognostic indicators such as tumour grade and histological subtype. Small cell morphology carries a poorer prognosis as does marked tumour anaplasia and multinucleation. Lymph node metastasis is extensive and frequently cystic however extranodal extension, laterality or nodal sizes do not carry prognostic implications as in conventional OSCC and OPSCC. Stage IV is reserved for distant metastasis. HPV-16-positive patients had significantly reduced overall and disease-specific mortality rates and an improved 3-year overall survival (OS) and disease-free survival (DFS) compared to patients with HPV negative tumors. Surgical treatment is the main option for primary and secondary HNSCC. Targeted therapies including drugs targeting EGFR and PIK3CA and have shown some promising results. HPV pathway expressing tumors are less aggressive and may receive adequate curative intent therapy from a reduced radiation or chemotherapy dose revision. OSCC however fails to show a distinct difference between HPV associated and tobaccco associated cancer and prognostic differences do not clearly exist.

Drug-resistant tuberculosis (DR-TB), including multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB), is considered a potential obstacle for elimination of TB globally. HIV coinfection with M/XDR-TB further complicates the scenario, and is a potential threat with challenging management. Reports have shown poor outcomes and alarmingly high mortality rates among people living with HIV (PLHIV) coinfected with M/XDR-TB. This coinfection is also responsible for all forms of M/XDR-TB epidemics or outbreaks. Better outcomes with reductions in mortality have been reported with concomitant treatment containing antiretroviral drugs for the HIV component and antitubercular drugs for the DR-TB component. Early and rapid diagnosis with genotypic tests, prompt treatment with appropriate regimens based on drug-susceptibility testing, preference for shorter regimens fortified with newer drugs, a patient-centric approach, and strong infection-control measures are all essential components in the management of M/XDR-TB in people living with HIV.

BACKGROUND AND OBJECTIVES: Although about 80% of coronavirus disease-2019 (COVID-19) cases are reported to be mild, the remaining 20% of cases often result in severe disease with the potential of crushing already overstrained health care services. There has been sustainable growth of COVID-19 cases worldwide since mid-May 2020. To keep tabs on community transmission of COVID-19 infection screening of the samples from a large population is needed which includes asymptomatic/symptomatic individuals along with the migrant population. This requires extra resources, man power, and time for detection of severe acute respiratory syndrome coronavirus 2 by real-time polymerase chain reaction (RT-PCR). In the current scenario, the pooled sample testing strategy advocated by the Indian Council of Medical Research, New Delhi is a new approach that is very promising in resource-limited settings. In this study, we have evaluated the pooled strategy in terms of accurate testing results, utilization of consumables, and identification of borderline positive cases. MATERIALS AND METHODS: Between April and June 2020, we performed COVID-19 testing by RT-PCR from areas with varying prevalence of population referred to COVID laboratory, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow. In the first step, the samples are collated into pools of 5 or 10. These pools are tested by RT-PCR. Negative pools were reported as negative whereas positive pools of 5 and 10 are then deconvoluted and each sample is tested individually. RESULTS: In the present study, we tested 4620 samples in 462 pools of 10 and 14 940 samples in 2990 pools of 5. Among 10 samples pool, 61 (13%) pools flagged positive in the first step. In the second step, among 61 pools (610 samples) deconvoluted strategy was followed in which 72 individual samples came positive. The pooled-sample testing strategy helps saves substantial resources and time during surge testing and enhanced pandemic surveillance. This approach requires around 76% to 93% fewer tests done in low to moderate prevalence settings and group sizes up to 5-10 in a population, compared to individual testing. CONCLUSIONS: Pooled-sample PCR analysis strategies can save substantial resources and time for COVID-19 mass testing in comparison with individual testing without compromising the resulting outcome of the test. In particular, the pooled-sample approach can facilitate mass screening in the early coming stages of COVID-19 outbreaks, especially in low- and middle-income settings, and control the spread by meticulous testing of all risk groups.

Sepsis is the most common cause of neonatal mortality. As per NationalNeonatal Perinatal Database (NNPD) 2002-2003, the incidence of neonatal sepsis in India was 30 per 1000 live birth. It is 3% among intramural babies and 39.7% among extramural admissions. The early manifestations of neonatal sepsis are vague and ill-defined. Novel approaches in the diagnosis of neonatal sepsis include heart rate analysis on ECG or colorimetric analysis of skin color. Although blood culture is the gold standard for the diagnosis of sepsis, culture reports would be available only after 48-72 hours. In this era of multidrug resistance, it is mandatory to avoid unnecessary use of antibiotics to treat noninfected infants. Thus, rapid diagnostic test(s) that differentiate infected from non-infected infants, particularly in the early newborn period, that include Interleukien-6 (IL-6), neutrophil CD64 index, procalcitonin and nucleated RBC count, have the potential to make a significant impact on neonatal care. The aim of this review is to specify the diagnostic criteria, treatment guidelines and a summary of the newer diagnostic tests of sepsis.KEY WORDS: Sepsis; Intramural; Extramural; Multidrug resistance

An epidural location for lymphoma is observed in 0.1-6.5% of all the lymphomas. Primary spinal epidural lymphoma (PSEL) is a subset of lymphomas, where there are no other recognizable sites of lymphomas at the time of diagnosis. The incidence of this subset of lymphomas is much less. It, however, is increasingly diagnosed, due to the increased use of more sensitive imaging modalities. For the electronic search, Pubmed was used to identify journals that enlisted and enumerated PSEL from 1961 to January 2011. The following combination of terms: "primary," "spinal," "epidural," and "lymphoma" were used. The most significant articles and their bibliographies were analyzed by the authors. The symptoms, pathogenesis, diagnostic workup, histopathology, treatment, and outcome have been analyzed in a systematic manner.

Dengue is associated with many neurological dysfunctions. Up to 4% of dengue patients may develop neuromuscular complications. Muscle involvement can manifest with myalgias, myositis, rhabdomyolysis and hypokalemic paralysis. Diffuse myalgia is the most characteristic neurological symptom of dengue fever. Dengue-associated myositis can be of varying severity ranging from self-limiting muscle involvement to severe dengue myositis. Dengue-associated hypokalemic paralysis often has a rapidly evolving course; benign nature; excellent response to potassium; and, often leads to diagnostic confusion with other dengue-associated neuromuscular disorders. Rhabdomyolysis is the most severe form of muscle involvement and may be life-threatening. Guillain-Barrι syndrome is another frequent neuromuscular dengue-associated complication. Dengue-associated Guillain-Barrι syndrome responds very well to intravenous immunoglobulins. Predominant spinal gray matter involvement has been reported in a patient presenting with areflexic paraparesis. Mononeuropathies often manifest with paralysis of the diaphragm due to phrenic nerve dysfunction. Brachial plexopathy, in the form of neuralgic amyotrophy, has been described much more frequently than lumbo-sacral plexopathy. Early recognition of these neuromuscular complications is needed for successful treatment and to prevent further disabilities.

OBJECTIVE: To assess longitudinally the severity of diffuse axonal injury in the corpus callosum in patients with moderate traumatic brain injury (TBI) through quantitative diffusion tensor imaging and to correlate these changes with neuropsychometric tests (NPT) at 6 and 24 months after injury. DESIGN: Prospective longitudinal study. PARTICIPANTS: Sixteen patients with TBI and 17 age/sex-matched healthy controls. METHODS: Patients underwent magnetic resonance imaging at 3 time points: within 2 weeks (range = 5-14 days), 6 months, and 24 months after injury. NPT could be performed only at 6 and 24 months. RESULTS: In patients with TBI, a significant increase in fractional anisotropy (FA) values in genu as well as an insignificant decrease in radial diffusivity (RD) and mean diffusivity values in genu and splenium were observed over time, respectively. FA, RD, and mean diffusivity values continued to be abnormal in patients compared with controls at the end of 2 years. Although some NPT scores improved over time in these patients, these were still significantly impaired compared with controls. CONCLUSIONS: FA and RD indices appear to be surrogate markers of microstructural alterations in patients over time and correlate significantly with some of the NPT scores. The recovery in these indices associated with recovery in neurocognitive deficits suggests that these indices may be used as an objective marker for residual injury in these patients.

BACKGROUND: Iron deficiency anemia in pregnant women may affect the iron reserves of their infants and lead to anemia later. The objective of the study was to compare hemoglobin and iron store status of infants born to anemic and non-anemic mothers and to determine any correlation. MATERIALS AND METHODS: A cohort study was conducted in the Department of Pediatrics of a Teaching hospital after obtaining ethical approval and written informed consent from all participants. Total 180 mother-infant pairs were enrolled in the study were divided into two groups; Group I: 90 term infants born to anemic mothers (Hb <11 g/dl), Group II: 90 term infants born to non-anemic mothers (Hb >11 g/dl). Hemoglobin and ferritin levels were assessed in cord blood at birth and at 14 weeks after birth in the infants of both groups. Data was analyzed using SPSS 20.0; Chi-square test and t-test were applied to test for statistical significance. RESULTS: The final sample size was 85 for Group I and 78 for Group II. For Group I, mean hemoglobin and ferritin levels in the cord blood of infants at birth were 16.33 ± 1.19 and 135.40 ± 25.94, respectively. For Group II, Mean hemoglobin and ferritin levels in the cord blood of infants at birth were 17.62 ± 1.35 and 160.45 ± 28.50, respectively; differences were statistically significant. At 14 weeks, the mean Hb and ferritin was 11.24 ± 1.03 and 55.92 ± 10.44 in Group I and 13.18 ± 0.82 and 63.56 ± 10.15 in Group II; the differences were statistically significant. A significant correlation between maternal and infant hemoglobin and ferritin levels was observed at birth and 14 weeks after birth. CONCLUSION: Maternal iron deficiency may have an effect on the iron status of their infants. Thus, timely appropriate interventions are necessary.

UNLABELLED: Helicobacter pylori and Epstein-Barr virus (EBV) infections are common worldwide. Although H. pylori infection is a major factor in gastroduodenal diseases, its role in association with EBV infection is unknown. OBJECTIVE: To study the association of H. pylori infection and EBV DNA load in patients with gastroduodenal diseases. METHODS: Biopsy samples were collected from 200 adult patients [non-ulcer dyspepsia (NUD) 100, peptic ulcer disease (PUD) 50, gastric carcinoma (GC) 50] undergoing upper gastrointestinal endoscopy. H. pylori infection was diagnosed by rapid urease test, culture, histopathology, PCR and Q-PCR. EBV DNA was detected by non-polymorphic Epstein-Barr nuclear antigen-1 (EBNA-1) gene based Q-PCR. RESULTS: In patients with GC and PUD, EBV DNA was detected more often than NUD (GC versus NUD = 90% versus 37%, p < 0.001; PUD versus NUD = 70% versus 37%, p < 0.001). The dual prevalence of H. pylori infection and EBV DNA was significantly higher in patients with GC and PUD than in those with NUD. Median copy number of EBV DNA was considerably higher in GC and PUD than NUD (p < 0.01). The copy number of EBV DNA was significantly higher in H. pylori infected patients (p = 0.015). The number of ureA gene copies was also found to be significantly higher in PUD and NUD with presence of EBV DNA. However, in GC no significant difference was seen between EBV positive and negative status. CONCLUSION: There was a trend for higher EBV DNA load in H. pylori positive individuals suggesting a probable role of H. pylori in modulating the conversion of EBV to its lytic phase.

AIMS: Programmed death-ligand 1 (PD-L1), a potential target for immune checkpoint inhibitors in various solid neoplasms, has been studied in very few cases of Gall Bladder Carcinoma (GBC). The current study aimed to evaluate PD-L1 expression at primary and metastatic sites of GBC, and its associations with standard prognostic clinicopathological parameters, as well as with overall survival. METHODS AND RESULTS: One hundred and seventy-four cases of GBC were evaluated for PD-L1 expression by the use of the SP263 clone in tissue microarrays. Clinicopathological characteristics and survival data were correlated with PD-L1 expression analysed at different cut-offs of ≥1%, ≥10% and ≥50% in tumour cells and tumour-infiltrating lymphocytes (TILs). The mean age of patients was 49.9 years, and the male/female ratio was 1:2.9. Of the cases, 73.6% presented with stage 3/4 disease. Tumour cells expressed PD-L1 in 23.0% of cases, and TILs expressed PD-L1 in 24.1% of cases. At a cut-off of 10%, 14.9% of cases expressed PD-L1, and at a cut-off of 50%, 7.5% of cases expressed PD-L1. Significant associations were seen between tumour proportion score and histological type (P = 0.004), histological grade (P = 0.004), nuclear grade (P = 0.008), nodal metastasis (P = 0.051), higher stage (P = 0.058), and TILs (P < 0.001). Tumour size, growth pattern, the presence of necrosis and lymphovascular emboli showed no significant associations with PD-L1 in tumour cells or TILs. In synchronous paired samples from primary and metastatic lymph nodes, discordantly higher PD-L1 expression was evident in lymph nodes. Overall survival was not associated with PD-L1 expression (P = 0.546). CONCLUSION: PD-L1 does not appear to be a prognostic marker or influence survival in GBC patients. However, PD-L1 expression occurs in one of four GBCs, supporting the future possibility of immune-modulation therapy to improve the dismal overall survival.

Background &amp; objectives: The growing incidence and the wide diversity of carbapenemase-producing bacterial strains is a major concern as only a few antimicrobial agents are active on carbapenem-resistant bacteria. This study was designed to study molecular epidemiology of carbapenem-resistant Gram-negative bacterial (GNB) isolates from the community and hospital settings. Methods: In this study, non-duplicate GNB were isolated from clinical specimens, and phenotypic test such as modified Hodge test, metallo β-lactamase E-strip test, etc . were performed on carbapenem-resistant bacteria. Multiplex PCR was performed to identify the presence of bla IMP , bla VIM , bla KPC , bla OXA48 , bla OXA23 , bla SPM , bla GIM , bla SIM and bla NDM . Minimum inhibitory concentration (MIC) of colistin, fosfomycin, minocycline, chloramphenicol and tigecycline was also determined. Results: Of the 3414 GNB studied, carbapenem resistance was 9.20 per cent and maximum resistance (11.2%) was present at tertiary care centre, followed by secondary care (4%) and primary centre (2.1%). Among the carbapenem-resistant bacteria, overall, the most common isolate was Pseudomonas aeruginosa (24%). On multiplex PCR 90.3 per cent carbapenem-resistant isolates were positive for carbapenemase gene. The bla NDM (63%) was the most prevalent gene followed by bla VIM (18.4%). MIC results showed that 88 per cent carbapenem-resistant Enterobacteriaceae were sensitive to fosfomycin, whereas 78 per cent of P. aeruginosa and 85 per cent Acinetobacter spp. were sensitive to colistin. Interpretation &amp; conclusions: Carbapenem resistance in GNB isolates from the community and hospital settings was found to be on the rise and should be closely monitored. In the absence of new antibiotics in pipeline and limited therapeutic options, prudent use of antibiotics and strict infection control practices should be followed in hospital to limit the emergence and spread of multidrug-resistant bacteria.

BACKGROUND: Initial formative years in every children's life are critical for their optimal development, as these frame the foundation of future well-being. With a varied prevalence of developmental delays (DDs) in the world and most of the studies representing the hospital-based data. The present study was aimed to find the prevalence and risk factors for DDs (domain wise) in children aged 2 months to 6 years in the rural area of North India. METHODS: This was a cross-sectional study in which a multistage random sampling technique was used. From 30 Anganwadi centers, 450 children aged 2 months-6 years were taken in the study. Rashtriya Bal Swasthya Karyakram screening tool developed by the Ministry of Health and Family Welfare, India, was used for developmental screening. Binary logistic regression analysis was done to identify the predictors for DDs (domain wise). RESULTS: Seventy-three (16.2%) children were found to have DDs and 60 (13.3%) children had the global DDs. About 84/421 (20.0%) children had cognitive delay, followed by 43/450 (9.6%) children who had delay in speech and language area. About 17/190 (8.9%) children had social delay while 26/407 (6.4%) children had hearing and vision impairment. Gross motor delay was seen in 24/450 (5.3%) children and 16/300 (5.3%) children had fine motor delay. Gestational age (adjusted odds ratio [AOR] - 13.30), complications during delivery (AOR - 25.79), meconium aspiration (AOR - 12.81), and child never breastfed (AOR - 8.34) were strong predictors for the delay in different domains of developmental milestones. CONCLUSION: Socio-economic, ante-natal, natal and post-natal factors should be considered for prompt identification and initiation of intervention for DDs. RECOMMENDATION: There is a need for increasing awareness and knowledge of parents regarding the achievement of developmental milestones according to the age. A multipronged approach to the holistic treatment of developmentally delayed children for early intervention is required.

BACKGROUND: Brain-derived neurotrophic factor (BDNF) has a very important role in repairing intact and injured brain, also known as neuroplasticity. Risk factors may affect neuroplasticity.OBJECTIVES: In this study, our aim was to delineate the levels of BDNF in acute stroke with different etiology and impact of risk factors on its levels.METHODS: In this prospective study, 208 patients with first-ever stroke, between 18 and 75 years, were included. All individuals were assessed for severity and type of stroke, risk factors, levels of BDNF in the acute stroke, and its association with outcome of stroke.RESULTS: The mean age of the patients in our study was 55.29 ± 11.6 years. Compared to healthy controls, a significant decline in the levels of BDNF was observed after stroke (P < 0.01). Patients with National Institutes of Health Stroke Scale (NIHSS) <6 on the 1st day of stroke had significantly higher levels of BDNF than those with NIHSS >6 (9.8 ng/ml ± 3.8; P < 0.01). A significant difference in the levels of BDNF was observed on comparing the stroke patients and healthy individuals of age <55 and >55 years (<55 years: 10.4 ng/ml ± 3.2; >55 years: 9.8 ng/ml ± 4.5 and in healthy individuals <55 years: 22.97 ± 3.8, >55 years: 15.4 ± 4.9; P < 0.01). Risk factors have negative impact on levels of BDNF (diabetics, P = 0.001; alcoholics, P = 0.003; both diabetes mellitus + hypertension, P = 0.002; smokers, P = 0.001). The difference was not significant between hypertensives and nonhypertensives (P = 0.06).CONCLUSION: BDNF level is significantly reduced in acute stroke. The presence of risk factors further affects its level.

AIM: The aim of this study was to determine the prevalence of periodontal disease in type 2 diabetes mellitus (T2DM) patients of North India. MATERIALS AND METHODS: A total of 500 patients fulfilling the selection criteria were initially given a health questionnaire to gather information regarding their demographic characteristics, attitude for oral hygiene, and disease status. Based on eligibility 427 patients were finally recruited for statistical analysis. A partial-mouth periodontal examination (PMPE) protocol which assessed one maxillary quadrant and one mandibular quadrant was used to examine three fixed sites per tooth (mesiobuccal, midbuccal, and distobuccal). Gingival Index, Oral Hygiene Index-Simplified, Debris Index-Simplified, Calculus Index-Simplified (CI-S), probing pocket depth, and clinical attachment level were examined. RESULTS: More than 90% (95.1%) of the total diabetic participants had some degree of periodontal destruction. Of the total population, 27.1% of participants had good oral hygiene, 68.8% had fair oral hygiene, and 3.9% had poor oral hygiene status. The prevalence of severe periodontitis in participants with good, fair, and poor oral hygiene status was reported as 0.8%, 17%, and 29.4%, respectively. The prevalence of severe periodontitis in participants with good, fair, and poor oral hygiene status with poor glycemic control (glycated hemoglobin ≥8%) was 2.5%, 28.1%, and 30.7%, respectively. CONCLUSION: This single-centered cross-sectional study represents that more than 95% of type 2 diabetic patients have some periodontal destruction. These results may act as baseline data to promote the collaborative integrated management of diabetes for reducing its burden on society.

: The design and materials of PPE needs further research, which might have minimal carriage of infective biological load like the use of antimicrobial repellent finishes along with adequate tensile strength and breathability through the fabric. Respirators should have the least resistance while providing maximum protection; goggles should not have fogging. Also, there is a need of formulating universal technical specifications for medically used PPE and ensuring easy availability of the testing facilities.