Clinical Immunology

Compendium of synovial signatures identifies pathologic characteristics for predicting treatment response in rheumatoid arthritis patients Publication date: May 2019 Source: Clinical Immunology, Volume 202 Author(s): Ki-Jo Kim, Minseung Kim, Iannis E Adamopoulos, Ilias Tagkopoulos Abstract Rheumatoid arthritis (RA) is therapeutically challenging due to patient heterogeneity and variability. Herein we describe a novel integration of RA synovial genome-scale transcriptomic profiling of different patient cohorts that can be used to provide predictive insights on drug responses. A normalized compendium consisting of 256 RA synovial samples that cover an intersection of 11,769 genes from 11 datasets was build and compared with similar datasets derived from OA patients and healthy controls. Differentially expression genes (DEGs) that were identified in three independent methods were fed into functional network analysis, with subsequent grouping of the samples based on a non-negative matrix factorization method. RA-relevant pathway activation scores and four machine learning classification techniques supported the generation of a predictive model of patient treatment response. We identified 876 up-regulated DEGs including 24 known genetic risk factors and 8 drug targets. DEG-based subgrouping revealed 3 distinct RA patient clusters with distinct activity signatures for RA-relevant pathways. In the case of infliximab, we constructed a classifier of drug response that was highly accurate with an AUC/AUPR of 0.92/0.86. The most informative pathways in achieving this performance were the NFκB-, FcεRI- TCR-, and TNF signaling pathways. Similarly, the expression of the HMMR, PRPF4B, EVI2A, RAB27A, MALT1, SNX6, and IFIH1 genes contributed in predicting the patient outcome. Construction and analysis of normalized synovial transcriptomic compendia can provide useful insights for understanding RA-related pathway involvement and drug responses for individual patients.

Stratum corneum interleukin-33 expressions correlate with the degree of lichenification and pruritus in atopic dermatitis lesions Publication date: April 2019 Source: Clinical Immunology, Volume 201 Author(s): Naomi Nakamura, Risa Tamagawa-Mineoka, Risa Yasuike, Koji Masuda, Hiroshi Matsunaka, Yumi Murakami, Emiko Yokosawa, Norito Katoh

Cell mediated immune responses elicited in volunteers following immunization with candidate live oral Salmonella entericaserovar Paratyphi A attenuated vaccine strain CVD 1902 Publication date: April 2019 Source: Clinical Immunology, Volume 201 Author(s): Rezwanul Wahid, Karen L. Kotloff, Myron M. Levine, Marcelo B. Sztein Abstract The incidence of Salmonella enterica serovar Paratyphi A (PA) infection is on the rise and no licensed vaccines are available. We evaluated cell mediated immune (CMI) responses elicited in volunteers following immunization with a single dose (109 or 1010 cfu) of a novel attenuated live oral PA-vaccine strain (CVD 1902). Results showed increases in PA-lipopolysaccharide-specific IgG- and/or IgA B-memory cells and production of IFN-γ, TNF-α, IL-10, IL-23 and RANTES following stimulation with PA-antigens by peripheral blood mononuclear cells obtained 28 days post immunization. Flow cytometry assays revealed that vaccine elicited PA-specific CD8+ and/or CD4+ T effector/memory cells were predominantly multifunctional concomitantly expressing CD107a and/or producing IFN-γ, TNF-α and/or IL-2. Similar proportions of these MF cells expressed, or not, the gut homing marker integrin α4β7. The results suggest that immunization with CVD 1902 elicits CMI responses against PA supporting its further evaluation as a potential vaccine candidate against paratyphoid A fever.

Aberrant natural killer (NK) cell activation and dysfunction among ART-treated HIV-infected adults in an African cohort Publication date: April 2019 Source: Clinical Immunology, Volume 201 Author(s): Rose Nabatanzi, Lois Bayigga, Stephen Cose, Sarah Rowland-Jones, Glenda Canderan, Moses Joloba, Damalie Nakanjako Abstract Background We examined NK cell phenotypes and functions after seven years of ART and undetectable viral loads (<50 copies/ml) with restored CD4 T-cell counts (≥500 cells/μl) and age-matched healthy-HIV-uninfected individuals from the same community. Methods Using flow-cytometry, NK cell phenotypes were described using lineage markers (CD56+/-CD16+/−). NK cell activation was determined by expression of activation receptors (NKG2D, NKp44 and NKp46) and activation marker CD69. NK cell function was determined by CD107a, granzyme-b, and IFN-gamma production. Results CD56 dim and CD56 bright NK cells were lower among ART-treated-HIV-infected than among age-matched-HIV-negative individuals; p = 0.0016 and p = 0.05 respectively. Production of CD107a (P = 0.004) and Granzyme-B (P = 0.005) was lower among ART-treated-HIV-infected relative to the healthy-HIV-uninfected individuals. NKG2D and NKp46 were lower, while CD69 expression was higher among ART-treated-HIV-infected than healthy-HIV-uninfected individuals. Conclusion NK cell activation and dysfunction persisted despite seven years of suppressive ART with "normalization" of peripheral CD4 counts.

Initial safety analysis of a randomized phase II trial of nelipepimut-S + GM-CSF and trastuzumab compared to trastuzumab alone to prevent recurrence in breast cancer patients with HER2 low-expressing tumors Publication date: April 2019 Source: Clinical Immunology, Volume 201 Author(s): G. Travis Clifton, Kaitlin M. Peace, Jarrod P. Holmes, Timothy J. Vreeland, Diane F. Hale, Garth S. Herbert, Jennifer K. Litton, Rashmi K. Murthy, Jason Lukas, George E. Peoples, A. Mittendorf Elizabeth Abstract The development of HER2-targeted therapy has decreased recurrence rates and improved survival, transforming the natural history of HER2-positive breast cancer. However only a minority of breast cancer patients benefit as these agents are not used in patients with tumors expressing low levels of HER2. Preclinical data suggests a synergistic action of HER2-targeted vaccination with trastuzumab. We report the initial safety interim analysis of a phase II trial that enrolled patients with HER2 low-expressing (IHC 1+/2+) breast cancer who were clinically disease-free after standard therapy. Patients were randomized to receive the HER2-peptide vaccine nelipepimut-S + GM-CSF with trastuzumab (vaccine arm) or trastuzumab + GM-CSF (control arm) and were followed for recurrence. A planned analysis that occurred after enrollment of 150 patients showed no significant differences in toxicity between the two arms, including cardiac toxicity. The clinical efficacy of this combination will be reported 6 months after the final patient was enrolled.

Hydroxyfasudil alleviates demyelination through the inhibition of MOG antibody and microglia activation in cuprizone mouse model Publication date: April 2019 Source: Clinical Immunology, Volume 201 Author(s): Jing Wang, Ruo-Xuan Sui, Qiang Miao, Qing Wang, Li-Juan Song, Jie-Zhong Yu, Yan-Hua Li, Bao-Guo Xiao, Cun-Gen Ma Abstract Multiple sclerosis (MS) is an immune-mediated demyelinating disease of the central nervous system characterized by oligodendrocyte loss and progressive neurodegeneration. The cuprizone (CPZ)-induced demyelination is widely used to investigate the demyelination/remyelination. Here, we explored the therapeutic effects of Hydroxyfasudil (HF), an active metabolite of Fasudil, in CPZ model. HF improved behavioral abnormality and reduced myelin damage in the corpus callosum. Splenic atrophy and myelin oligodendrocyte glycoprotein (MOG) antibody were observed in CPZ model, which were partially restored and obviously inhibited by HF, therefore reducing pathogenic binding of MOG antibody to oligodendrocytes. HF inhibited the percentages of CD4+IL-17+ T cells from splenocytes and infiltration of CD4+ T cells and CD68+ macrophages in the brain. HF also declined microglia-mediated neuroinflammation, and promoted the production of astrocyte-derived brain derived neurotrophic factor (BDNF) and regeneration of NG2+ oligodendrocyte precursor cells. These results provide potent evidence for the therapeutic effects of HF in CPZ-induced demyelination. Graphical abstract

Identification and mutational analysis of continuous, immunodominant epitopes of the major oyster allergen Crag 1 Publication date: April 2019 Source: Clinical Immunology, Volume 201 Author(s): Lei Fang, Guoming Li, Jiangtao Zhang, Ruizeng Gu, Muyi Cai, Jun Lu Abstract Shellfish, including oysters, often cause allergic reactions in children and adults. Oysters are inevitably consumed because of its delicacy and nutritional benefit, leading to frequent occurrence of severe clinical symptoms observed in patients with oyster hypersensitivity. We aimed to identify the immunodominant epitopes of oyster tropomyosin and crucial amino acids for IgE binding, which will help us to further understand the immunochemical characteristics of Cra g 1. The potential epitopes were predicted by immunoinformatics tools and the resultant immunodominant epitopes were identified by inhibition ELISA with pooled sera and individual serum from oyster allergic patients. Surprisingly, homologous substitution of multiple amino acids led to obviously decrease affinity of IgE antibodies, but this manner did not abrogate binding completely. Five major linear epitopes were evenly distributed on the surface of homology-based Cra g 1 model and hydrophilic residues appeared to be the most important for IgE binding. These results not only offer a better understanding of the molecular mechanism of interaction between Cra g 1 and oyster-specific IgE but also have significance in clinical diagnosis and immunotherapy.

BCG-induced formation of neutrophil extracellular traps play an important role in bladder cancer treatment Publication date: April 2019 Source: Clinical Immunology, Volume 201 Author(s): Kangkang Liu, Erlin Sun, Mingde Lei, Limin Li, Jingda Gao, Xuewu Nian, Lining Wang Abstract Bacillus Calmette-Guerin (BCG) is one of the most effective treatments for bladder cancer. Little attention has been paid to the possible role of neutrophils in BCG immunotherapy. In this study, we examined neutrophil extracellular traps (NETs) formation induced by BCG stimulation, and found that BCG-induced NETs exerted cytotoxicity, induced apoptosis and cell-cycle arrest, and inhibited migration in bladder tumor cells. BCG-activated tumor cells but not non-activated ones elicited NETs formation, in which IL-8 and TNF-α from activated tumor cells both took effect. Moreover, NETs activated peripheral blood mononuclear cells (PBMCs) exhibited a higher expression of CD4 and Th1 cytokines. Additionally, the role of NETs in vivo contributed to the recruitment of T cells and monocytes-macrophages and tissue damage, thus preventing tumor growth. NETs proteins mainly caused these effects on tumor and cellular immunity. In conclusion, we demonstrated a novel immunoregulatory role for NETs in the early stages of BCG immunotherapy.

Increased proportions of γδ T lymphocytes in atypical SCID associate with disease manifestations Publication date: April 2019 Source: Clinical Immunology, Volume 201 Author(s): Inga Tometten, Kerstin Felgentreff, Manfred Hönig, Fabian Hauck, Michael H. Albert, Tim Niehues, Ruy Perez, Sujal Ghosh, Capucine Picard, Jan Stary, Renata Formankova, Austen Worth, Pere Soler-Palacín, Marina García-Prat, Luis M. Allende, Luis Ignacio Gonzalez-Granado, Polina Stepensky, Silvia Di Cesare, Alessia Scarselli, Caterina Cancrini Abstract Severe combined immunodeficiencies (SCID) comprise a group of genetic diseases characterized by abrogated development of T lymphocytes. In some case reports of atypical SCID patients elevated proportions of γδ T lymphocytes have been reported. However, it is unknown whether these γδ T cells modulate or reflect the patient's clinical phenotype. We investigated the frequency of elevated γδ T cell proportions and associations with clinical disease manifestations in a cohort of 76 atypical SCID patients. Increased proportions of γδ T lymphocytes were present in approximately 60% of these patients. Furthermore, we identified positive correlations between elevated proportions of γδ T cells and the occurrence of CMV infections and autoimmune cytopenias. We discuss that CMV infections might trigger an expansion of γδ T lymphocytes, which could drive the development of autoimmune cytopenias. We advocate that atypical SCID patients should be screened for elevated proportions of γδ T lymphocytes, CMV infection and autoimmune cytopenias.

Repository corticotropin injection reverses critical elements of the TLR9/B cell receptor activation response in human B cells in vitro Publication date: April 2019 Source: Clinical Immunology, Volume 201 Author(s): Nancy J. Olsen, Ann L. Benko, Carl A. McAloose, Patrice M. Becker, Dale Wright, Teresa Sunyer, Yuka Imamura Kawasawa, William J. Kovacs Abstract We sought evidence for direct effects of repository corticotropin (RCI; an FDA-approved treatment for selected cases of SLE) on isolated human B lymphocytes activated by engagement of TLR9 and B cell receptors. ODN 2395/αIgM treatment was found to result in induction of 162 distinct mRNAs and suppression of 80 mRNAs at 24 h. RCI treatment resulted in suppression of 14 of the ODN 2395/αIgM -induced mRNAs (mean suppression to 23.6 ± 3.1% of stimulated value). The RCI-suppressed mRNAs included two critical regulators of class switch recombination, AICDA and BATF. RCI treatment also resulted in induction of 5 of the ODN 2395/αIgM -suppressed mRNAs (mean induction by RCI = 7.65 ± 2.34-fold). The RCI-induced mRNAs included SLAMF3, a cell surface receptor capable of inhibiting autoantibody responses. These studies reveal that RCI treatment of human B cells reverses key elements of the early mRNA response to TLR9 and B cell receptor engagement.

Pediatrics

Postcardiac surgery neurodevelopmental evaluation in children with congenital heart disease Moustafa M Abdel Raheem, Naji Y Safieldeen Alexandria Journal of Pediatrics 2018 31(3):91-96 Background Congenital heart disease (CHD) is one of the most common congenital anomalies. It may carry risk of neurodevelopment (ND) delay. Open heart surgery has been widely introduced to those patients. The outcome of this surgery on patient’s development is unclear. Objective The aim was to evaluate ND outcomes in children with CHD who underwent open heart surgery. Patients and methods Fifty children with CHD were enrolled in this study: 23 were surgically repaired (group 1) and 27 had no surgical intervention (group 2). Twenty normal children of matched age and sex were enrolled in the study as controls (group 3). Bayley-III test was used to compare the ND parameters in all groups. Results ND aspects showed lower significant differences in groups 1 and 2 when matched with the control group (P<0.05). However, there were no significant differences in ND parameters between groups 1 and 2 in gross motor and receptive communication parameters (P>0.05). Conclusion CHD carries the risk of ND delay, and exposure to open heart surgery increases this risk.

Quantitative electroencephalographic changes in children with autism spectrum disorders Hanan G Azouz, Mona Khalil, Samia H Abdeldayem Alexandria Journal of Pediatrics 2018 31(3):97-105 Background Autism spectrum disorders (ASD) are a group of neurodevelopmental disorders characterized by impairment of social interaction, communication, and behavior. It has been recently suggested that ASD are characterized by abnormal brain networks and connectivity, which was studied using neuroimaging modalities. Objective The aim of this study is to assess the quantitative electroencephalographic (QEEG) findings in children with ASD compared with age-matched children and to assess if QEEG analysis is a sensitive and simple method to aid in the diagnosis of ASD in children. Patients and methods QEEG recordings of 50 children with ASD between the ages of 2 and 6 years were compared with those of 50 age-matched controls under eyes-closed condition. Brain functioning and its connectivity were examined using measurements of spectral analysis of both absolute and relative power and interhemispheric coherence. Results There were statistically significant differences in electroencephalogram spectral power and coherence between the study and control groups. It revealed an increased absolute delta power in the frontal, anterior temporal, midtemporal, central, and parietal regions and an increase of absolute alpha power mainly in the prefrontal and frontal regions. There was a greater beta power in midtemporal and posterior temporal regions. In addition, interhemispheric coherence showed a pattern of frontal overconnectivity and temporal underconnectivity with the other brain areas in children with ASD in comparison with the control group. Moreover, statistical differences in electroencephalogram spectral power and coherence between the different grades of children with ASD were noticed. Conclusion These results suggested that children with ASD have QEEG dysfunctions that underlie their symptomatology. Hence, QEEG provides a useful method that aids in the diagnosis of children with ASD.

Bedside ultrasonographic evaluation of the degree of dehydration in infants and children with acute gastroenteritis Marwa S Barakat, Hanan A El-Halaby, Hoda F Al-Domiatty Alexandria Journal of Pediatrics 2018 31(3):106-111 Background Dehydration is one of the most common problems facing pediatricians; efforts were made to detect its degree accurately. Aims Evaluate the accuracy of inferior vena cava collapsibility index (IVCCI) and IVC/aortic (IVC/Ao) ratio for the detection of dehydration degree in infants and children with acute gastroenteritis. Settings and design A cross-sectional descriptive study performed in Mansoura University Children’s Hospital from April 2014 till December 2016. Patients and methods The degree of dehydration was assessed clinically via clinical dehydration scale and by portable ultrasonography. Measurements of IVC diameters and IVC/Ao ratio were performed. IRB approved the study. Statistical analysis used Mann–Whitney test were used to compare nonparametric data. Sensitivity and specificity were tested by receiver operating characteristic curves. Results Eighty-one children, aged from 1 month to 3 years, were enrolled in this study; 41 presented with some dehydration and 40 with moderate/severe dehydration, classified according to the clinical dehydration scale. There was a statistically significant positive correlation between dehydration degree and IVCCI and IVC/Ao ratio (r=0.67 and 0.54, respectively, P=0.001 each). When plotting the receiver operating characteristic curve for IVCCI, area under the curve was 0.81, using a cutoff value of 73%, the sensitivity and specificity, for the detection of dehydration degree, were 90 and 71%, respectively, while for IVC/Ao ratio, the area under the curve was 0.78, with a cutoff value of 0.8, the sensitivity and specificity were 90 and 64%, respectively. Conclusions Measurements of IVCCI and IVC/Ao ratio aid in the detection of the degree of dehydration in infants and children with high sensitivity and moderate specificity.

Prognostic factors for the outcome of Kasai portoenterostomy for infants with biliary atresia in Egypt Sammeh M Shehata, Saber M Waheeb, Maher O Osman, Aml A.A Mahfouz, Ahmed E Elrouby Alexandria Journal of Pediatrics 2018 31(3):112-119 Background Biliary atresia (BA) is the most common surgically correctable liver disorder in the pediatric age group. If untreated, progressive liver cirrhosis leads to death by the age of 2 years. Aim The aim was to study the outcome of Kasai portoenterostomy for infants with BA in Egypt and identify some prognostic factors of this outcome. Patients and methods A prospective clinical and laboratory study including 20 patients with BA who underwent Kasai operation was conducted. A detailed history taking, clinical examination, liver function tests, ultrasound of the abdomen, preoperative liver biopsy, and intraoperative cholangiography were done for all patients. Patients were followed up for a period of 6 months postoperatively. The schedule and indications for liver transplantation were also evaluated. Results Overall, 55% of operated infants showed gradual reduction of serum bilirubin, which reached a level less than 2 mg/dl, as well as reduction of liver enzymes. On the contrary, the remaining 45% of infants failed to show satisfactory reduction of serum bilirubin, which continued to be greater than 2 mg/dl as well as liver enzymes. Both groups showed statistically significant differences regarding age at operation, presence of preoperative ascites, liver size, and patients’ Child–Pugh score. Moreover, preoperative total serum bilirubin and its direct fraction, liver enzymes, and cholestatic enzymes were significantly higher among infants with a bad outcome. There were no mortalities within the 6-month follow-up period. Conclusion Kasai portoenterostomy showed better results with short-term follow-up if done at an early age. Certain preoperative clinical, laboratory, radiological, and pathological factors might predict the outcome of Kasai operation.

Study of functional constipation among children attending the Gastroenterology Clinic at Alexandria University Children's Hospital Ahmed F Khalil, Mohamed Alkot Alexandria Journal of Pediatrics 2018 31(3):120-127 Background Functional constipation is a common health problem in the pediatric age group. Delayed management leads to a significant childhood morbidity. Aim The purpose of this study is to evaluate the prevalence, precipitating factors, and clinical characteristics and management of children with functional constipation in our community. Patients and methods This work was performed as a prospective study that included all children aged 1–15 years with functional constipation who presented to the Pediatric Gastroenterology Clinic at Alexandria University Children’s Hospital between August 2015 and January 2016. Demographic data, precipitating factors, clinical characteristics, and prereferral management were recorded. All patients were treated and followed up for at least 4 months. Results During the study period, 86 patients were enrolled. They constituted the most important cause for referral to the Gastroenterology Clinic during the study period. Most of the patients were living in low to middle socioeconomic status and were belonging to mothers of low to intermediate level of education. Low-fiber diet, diminished fluid intake, and urge postponing when present at public places were the commonest risk factors for developing constipation. Family history of constipation was positive in 32.6% of patients. The mean duration of complaints before presentation to our clinic was 19.22±22 months. Chronic abdominal pain was the most common presenting symptom (77.9%). Only 28% of the parents were aware that their children are constipated. The passage of hard painful stools was the most common character of stool in the studied group (98.8 and 95.3%) followed by infrequent evacuations (<4/week) in 85% of patients. Of the patients, 24.4% had fecal soiling. Urinary symptoms were present in 39.5%. Abdominal distention and palpable fecal mass were found in 83.7 and 67.5%, respectively. Only one-third of the patients were correctly diagnosed as having chronic constipation. None of the studied children were previously treated properly according to the accepted guidelines for functional constipation. Our cases were referred very late when they develop debilitating abdominal pain due to massive stool impaction or present with stool incontinence. Oral disimpaction was successful even in severely constipated children. All clinical symptoms and stooling characteristics were significantly improved after treatment. Conclusion Functional constipation is a very common, yet underestimated, underdiagnosed, and maltreated health problem our community.

Platelet indices as a diagnostic tool in pediatric immune thrombocytopenic purpura Maha Y Kamal, Wessam El Gendy, Ahmed Salama Alexandria Journal of Pediatrics 2018 31(3):128-131 Background Bone marrow examination is the gold-standard test in discriminating between hyperdestructive thrombocytopenia and hypoproductive thrombocytopenia. However, this procedure is invasive. Mean platelet volume (MPV) and platelet distribution width (PDW) are simple, inexpensive, and noninvasive methods that may be used in discriminating between these two types of thrombocytopenia. Aim This study investigated the significance of the platelet indices, MPV and PDW, in the diagnosis of immune thrombocytopenic purpura (ITP). Patients and methods The study population were divided into three groups: 15 patients with hyperdestructive thrombocytopenia and 15 with hypoproductive thrombocytopenia were compared with control group (15 healthy controls). The sensitivity and specificity of these platelet indices to diagnose immune thrombocytopenic purpura were also measured. Results The MPV showed a sensitivity of 93.3% and a specificity of 66.7% at a cutoff value of 7.7 fl, and the PDW showed a sensitivity of 86.7% and specificity of 73.3% at a cutoff value of 40.6%. Conclusion The study concluded that although MPV and PDW can be used as an initial hint for predicting the type of thrombocytopenia, they have limited sensitivity and specificity.

Ionized calcium, 25-hydroxyvitamin D, and parathyroid hormone in children with steroid-sensitive nephrotic syndrome Mahmoud M.E El Kersh, Ola A Sharaki, Omneya M Omar, Yasmine A.S Galal Alexandria Journal of Pediatrics 2018 31(3):132-140 Background The chief complications of nephrotic syndrome (NS) are infections and thromboembolic events. Others include hypovolemic crisis, acute renal failure, and hormonal and mineral alterations. Objective The aim was to study the level of serum ionized calcium during the active stage and after remission in steroid-sensitive nephrotic syndrome (SSNS) patients and 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone (PTH) during the active stage of the disease. Patients and methods The study was conducted on two groups. Twenty children with the first episode of SSNS were investigated and compared with 20 healthy children as a control group. Serum ionized calcium, serum 25(OH)D, PTH, phosphorus, and alkaline phosphatase were measured during the active stage of the disease and serum ionized calcium was repeated after remission. Results Children with active SSNS had low ionized calcium, low-serum 25 (OH)D levels, with high PTH and high phosphorus and low alkaline phosphatase levels compared with the control. All patients had 25(OH)D deficiency, of which, 80% were severely deficient. Both serum ionized calcium and 25(OH)D had a significant negative correlation with PTH (r=−0.655, P=0.002 and r=−0.575, P=0.008, respectively). Serum ionized calcium was negatively correlated to spot protein/creatinine ratio in urine (r=− 0.565, P=0.009). Levels of serum ionized calcium during the active stage of the disease were markedly lower than that after remission. However, both were significantly lower than the control group. Conclusion Children with SSNS are at risk of vitamin D deficiency and hypocalcemia, therefore, further research will be needed to prove the need for vitamin D supplementation to prevent the occurrence of possible complications.

Diagnostic and prognostic values of soluble CD14 (presepsin) in sepsis in pediatric intensive-care patients Mai M Ghazy, Hanan A El-Halaby, Amr M El-Sabbagh, Ali A Shaltout Alexandria Journal of Pediatrics 2018 31(3):141-147 Background Early recognition and management of sepsis is a challenge facing intensivists. Many biomarkers were investigated but none is optimal. Aim Appraise the value of presepsin as a biomarker for the diagnosis, differentiation of severity, and prognosis of sepsis. Settings and design A prospective diagnostic test accuracy study performed in Mansoura University Children’s Hospital from April 2016 to April 2017. Patients and methods Plasma presepsin was estimated in 30 patients with sepsis on the first and third days from sepsis diagnosis (group A). Pediatric sequential organ failure assessment score, white blood cells count, and C-reactive protein were assessed on the same timing. Group B patients, 30 healthy patients, were assessed for presepsin level. IRB approved the study. Statistical analysis Independent sample t-test was performed to compare parametric data. Receiver operating characteristic curves were used to detect threshold values. Results A significantly higher presepsin level in the sepsis group (983 ng/l) compared with the healthy group (300 ng/l, P=0.001) was detected. A statistically significant higher serum presepsin level on day 3 was noticed in patients with severe sepsis opposed to sepsis and in nonsurvivors versus survivors (P=0.041 and 0.012, respectively). Receiver operating characteristic curve for plasma presepsin level on day 3 for the prediction of 30-days mortality was designed. Sensitivity and specificity were 86 and 73%, respectively, for a threshold point of 1300 ng/l [area under the curve (AUC)=0.820, P=0.001]. Conclusion Presepsin is a diagnostic marker for sepsis, a good discriminator of sepsis severity, and a sensitive predictor of 30-day mortality, but it should not be alone but in combination with other biomarkers.

Echocardiography & Cardiovascular Imaging

Assessment of left ventricular mechanical dyssynchrony in left bundle branch block patients with and without heart failure by tissue doppler imaging Sambhaji Raut, Chandrakant Chavan, Deepak Phalgune Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2019 3(1):1-6 Introduction: Large number of patients with heart failure (HF) have left bundle branch block (LBBB). Most precise method for identification of intraventricular dyssynchrony is tissue Doppler imaging (TDI). Purpose of this research was to compare left ventricular (LV) mechanical dyssynchrony in LBBB patients with and without HF and to compare various methods of LV systolic dyssynchrony assessment by TDI. Materials and Methods: One hundred and sixteen patients with a diagnosis of LBBB were included in the study. All patients underwent conventional two-dimensional echocardiography for global LV function assessment. LV systolic dyssynchrony was measured by opposing wall delay, maximum delay, and Yu index. LBBB patients were grouped into four classes according to their LV function and the presence or absence of HF, normal LV function without HF (Group A), normal LV function with HF (Group B), LV dysfunction with HF (Group C), and LV dysfunction without HF (Group D). Results: LV systolic dyssynchrony was significantly higher (P <0.001) in Group C and D as compared to Group A and B. LV systolic dyssynchrony was significant higher in Group C and D as compared to Group A and B by using opposing wall delay (P <0.001), Yu index (P <0.001), and maximum delay (P <0.001) imaging criteria. Mean Yu index (P <0.001) and mean maximum delay (P <0.001) were significantly higher in Group C and D as compared to Group A and B. Conclusions: LV systolic dyssynchrony was more common in LBBB patients with LV dysfunction than those with normal LV function, irrespective of the presence or absence of HF.

Non-ischemic regional wall motion abnormality ST Yavagal, Vivek Bantwal Baliga Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2019 3(1):7-11 Regional wall motion abnormalities (RWMA) are usually described with Ischemic Heart Disease. But many other conditions also show RWMA. What are those conditions, how to recognize RWMA in them and what is it's importance is discussed.

Trans-esophageal echocardiography during off-pump coronary artery bypass grafting TA Patil, Santosh Kumar Ambli, Vaishali S Badge Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2019 3(1):12-16 Off-pump coronary artery bypass grafting (OPCABG) is fast becoming widely adopted technique for surgical revascularization of the heart. However, OPCABG presents with unique technical and hemodynamic challenges which require additions to conventional monitoring techniques. Transesophageal echocardiography (TEE) provides reliable and real-time information to monitor these challenges during OPCABG. TEE is an invaluable diagnostic tool for real-time imaging during OPCABG. It is beneficial not only in the intraoperative period but also in the postoperative care units for better patient outcomes.

Constrictive pericarditis in association with ischaemic heart disease Rajesh Krishnachandra Shah Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2019 3(1):17-22 Constrictive pericarditis (CP), a not so common condition, has symptoms and signs of heart failure and abnormal echocardiographic findings, such as jerky septal motion. These findings can be mistaken for ischemic heart disease (IHD) if the echocardiographer is inexperienced. Although the etiology of CP can be varied such as idiopathic, postviral, tuberculous, postsurgical, and radiation-induced the final common pathway is the development of fibrous thickening or calcification of the visceral pericardium resulting in pericardial noncompliance, and ultimately requiring surgical intervention. As CP is potentially reversible and surgically curable condition, with improvement in symptoms and quality of life, the diagnosis should not be missed. Here, we present a case in which the diagnosis of CP was made, and subsequently found to have IHD also.

Right-sided constrictive pericarditis: A rare variant of an uncommon disease Mehul Popatlal Oswal, Chandrashekhar Kashinath Ponde Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2019 3(1):23-26 Constrictive pericarditis (CP) is characterized by thick pericardial fibrosis and calcification that causes progressively impaired diastolic filling of the heart with associated symptoms of heart failure. Rarely, it can also present as localized CP and depending on the CP location, clinical presentation can be variable, including compression and obstruction of right ventricular inflow tract, coronary obstruction, or pulmonary stenosis. We report a rare case of isolated constriction of the right side of the heart due to loculated tuberculous pericardial effusion.

Isolated parachute mitral valve detected by two-dimensional echocardiography and cardiac magnetic resonance imaging in asymptomatic healthy adult Sushama Krishnat Jotkar, Gayatri G Harshe Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2019 3(1):27-29 A 55 year old female patient presented for preoperative evaluation for vaginal hysterectomy. Preoperative transthoracic echocardiography revealed mitral valve (MV) abnormality, with only one papillary muscle having parachute appearance. Her cardiac magnetic resonance imaging with contrast confirmed the MV abnormality. Since she was hemodynamically stable, she underwent hysterectomy uneventfully.

The lesser known lobe Arun Umesh Mahtani, Vivek Baliga, Satish Govind, Punith Reddy Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2019 3(1):30-32 The azygos lobe was first discovered by an anatomist Dr. Heinrich August Wrisberg in the year 1877. It is a rare normal variant of the lung usually present over the right lobe. The azygos lobe has been reported in various case reports where it has been mistaken to be a neoplasm, a bulla, or a paratracheal mass. It has implications in the field of surgery as well when this anatomic variant was discovered during sympathectomy and the approach had to be slightly altered. We present a rare case of an incidental finding of an azygos lobe impinging over the superior vena cava and causing axial alteration of the heart.

Rare coronary circulation anomaly causing chest pain: superdominant right coronary artery with absent left circumflex artery Sanjay Nathani, Pooja Mehta, Kapisoor Singh, Sandeep Golcha Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2019 3(1):33-35 Coronary circulation anomalies are the uncommon cause of chest pain when hemodynamically significant. Multidetector computed tomography (CT) of coronary arteries is rapidly replacing conventional angiography, nowadays, as the first line of investigation for the imaging of coronary artery disease due to its noninvasive nature. CT coronary angiography in addition to diagnosing anomalies of coronary arteries is especially good in the delineation of ostial origin and proximal course. Superdominant right coronary artery (RCA) with absent left circumflex artery (LCx) is such a rare congenital coronary artery anomaly which can mimic atherosclerotic disease clinically with very few case reports in the literature which can be diagnosed and evaluated with accuracy by CT angiography.

"Inverted" Asymmetrical hypertrophy of left ventricle: Unusual variant of an uncommon disease Shaheen Ahmad, Mukta Agarwal, Rahul Ranjan, Rashid Anwar Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2019 3(1):36-37 Hypertrophic cardiomyopathy (HCM) is a rare genetic disease. Usual presentation is asymmetrical hypertrophy of interventricular septum as compared to the posterior wall of the left ventricle. We present a rare variant of HCM in which the posterior wall of the left ventricle is more hypertrophied than ventricular septum (inverted asymmetry). Very few cases are reported in literature.

Left atrial myxomas: M-mode echocardiography characteristics – A forgotten modality Rohit Tandon, Neelesh Pandey Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2019 3(1):38-39

Dental Sciences

Prevalence of oral Candida in saliva of uncontrolled and controlled type 2 diabetes mellitus patients – Beyond reasonable doubt? Saramma Mathew Fenn, Mohan Narayanan, Mathew Jacob SRM Journal of Research in Dental Sciences 2019 10(1):1-6 Aim: The aim of this study was to compare the prevalence of Candida in the saliva of uncontrolled and controlled group of type II diabetic and in nondiabetic individuals. Settings and Design: This was a cross-sectional study. Subjects and Methods: Total study group consists of 75 type 2 diabetic patients, in which 25 patients in Group I were taken as controlled diabetics, 25 patients in Group II were considered as uncontrolled diabetics, and 25 patients were considered as nondiabetics, control group in Group III, respectively. Statistical Analysis Used: Student's t-test, Chi-square test, and one-way ANOVA test were used in this study. Results: In this study, a total of 75 patients were included, of which a total of 30 saliva samples had shown the presence of candidial growth. Out of 25 saliva samples collected from Group I (controlled diabetic patients), 11 samples showed the presence of candidial growth and out of 25 samples collected from Group II (uncontrolled diabetic patients), 19 samples showed the presence of candidial growth. Samples obtained from Group III (nondiabetic patients) were negative for any candidial growth. A significant difference was observed in candidial growth from saliva samples obtained between the various study groups. The uncontrolled diabetic patients group showed a higher candidial colony-forming unit when compared with that of controlled diabetic patients group. Conclusion: The prevalence of Candida in the oral cavity of patients with diabetes is of primary concern for dentists in the early detection of opportunistic infections, such as oral candidiasis, by understanding the predisposing local and systemic factors. The habitat provided by the predisposing disease may, beyond reasonable doubt, reset the microbiological environment to favor the proliferation and colonization of opportunistic microorganisms such as the oral commensal, Candida.

Prevalence of dental caries and gingivitis among corporation school-going children in Chennai city – A population-based cross-sectional study Gamal Abdul Nasser, Rupkumar, Mohamad Junaid SRM Journal of Research in Dental Sciences 2019 10(1):7-11 Aims: The aim was to evaluate the prevalence of dental caries and gingivitis among corporation school-going children and their treatment needs in Chennai city. Subjects and Methods: The present descriptive, cross-sectional study was conducted among 3–19-year-old corporation school-going children of Chennai city. It was conducted for a period of 2 months from August 20, 2018, to October 20, 2018. A sample size of 20,007 children (9707 males and 10,300 females) was examined. Oral health status with emphasis on dental caries, gingivitis, and treatment needs was recorded. Statistical Analysis Used: The obtained data was analysed using SPSS 21.0 (IBM, USA). Results: The prevalence of dental caries in the participants examined was 34.72% (6946). About 1663 (23.94%) participants had dental caries involving single tooth, 293 (4.22%) had dental caries involving two teeth, and 4 (0.06%) had dental caries involving >2 teeth. Clinical pulpal involvement with pain on percussion was found in 4067 (58.55%) participants. Nine hundred and nineteen (13.23%) participants exhibited grossly decayed tooth advised for extraction. The prevalence of gingivitis in the participants examined was 8259 (41.28%). About 2672 (32.35%) participants had mild gingival inflammation, 5563 (67.36%) had moderate gingival inflammation, and 24 (0.29%) had severe gingival inflammation based on Loe and Silness gingival index scoring. On the basis of treatment needs, 59.5% of the participants were in need of treatment. Almost 34.3% of the screened participants were in need of primary care, whereas 25.1% of the screened participants were in need of advanced care. Conclusions: The present study reveals the current oral health status of corporation school-going children in Chennai corporation. The results obtained demand a special attention toward these children of less effluent families for the promotion of oral health by regular conduct of treatment camps by corporation and other agencies.

Salivary gland tumors: An institutional experience Jimsha Vannathan Kumaran, Mariappan Jonathan Daniel, Mithunjith Krishnan, Sruthi Selvam SRM Journal of Research in Dental Sciences 2019 10(1):12-16 Introduction: Salivary gland neoplasm represents the most complex and diverse group of neoplasm of the head and neck. Their diagnosis and management are complicated by relative infrequency. Around 64%–80% are located in the parotid gland, 7%–11% in the submandibular glands, and the remainder being distributed between the sublingual (1%) and the minor salivary glands (9%–23%) throughout the oral cavity. Aim: The aims of this study were: (1) To assess the frequency of salivary gland tumor based on tumor type and anatomic location. (2) To correlate gender and age in different tumor type. (3) To correlate the location of benign and malignant tumors. Subjects and Methods: A retrospective study was made in the Department of Oral Medicine and Radiology from the period of January 2006 to December 2017. Data were collected from the archives maintained in the Department of Oral Medicine, and details of the patient include age, sex, and site of the tumor were obtained and confirmed with histopathological study and sent for statistical analysis. Results: Chi-square test was applied to find the distribution of malignant and benign tumors. The prevalence of salivary gland tumors in our study was 0.3%, and the benign: malignant ratio was 1:2.2, with the mean age of occurrence was 45.01 ± 16.3 years with slight overall female predominance and a male-to-female ratio of 0.7–0.9, respectively. Conclusion: The present study was a single-institutional experience where the analysis of 32 SGTs was carried out. Malignant tumors were more compared to benign. Among benign tumors, pleomorphic adenoma was the most common type. Among the malignant salivary gland tumors, mucoepidermoid carcinoma was the most common, followed by adenoid cystic carcinoma then ex-pleomorphic adenocarcinoma followed by low-grade polymorphous adenocarcinoma.

Learning preferences among clinical dental students of coastal South India: A multi-centric study Supriya Nambiar, Mahesh Jain, B Unnikrishnan, Vivek Narayan, Suresh Babu, Shaji Varghese SRM Journal of Research in Dental Sciences 2019 10(1):17-20 Introduction: Dental skills based on sound theoretical knowledge are the basis for a dental student to become a good dentist. The 3rd and 4th years of Bachelor of Dental Surgery requires integration and application of clinical knowledge, skill, and attitude. However, to understand this integration, there is a paucity of literature on the dental students' learning preferences, especially in the Indian scenario. Hence, the objective of the present study is to provide information about it. Materials and Methods: VARK questionnaire (VARK is an acronym that stands for visual [V], aural [A], read [R], and kinesthetic [K] sensory modality of learning) was used to evaluate the learning preferences of clinical dental students. This multicentric study included 350 students from four dental colleges in India. Statistical Analysis: Strong preference was calculated on Microsoft Excel using the VARK guidelines. Likert scale (1–5) was used to know their perceptions of their VARK score. Results: Majority of the students were multimodal with many students showing two preferences. Kinesthetic modality was the strongest single preference and visual was the weakest single preference. Conclusion: Majority of the students are multimodal in their learning preferences with kinesthetic modality showing strong single preference. Teachers can help students to develop learning preferences based on their preferences of learning. Teaching methodology should involve all sensory modalities so that all kinds of students can actively participate in learning process.

Prevalence of detected soft tissue calcifications on digital panoramic radiographs Derya Icoz, Faruk Akgunlu SRM Journal of Research in Dental Sciences 2019 10(1):21-25 Objectives: Some calcifications of the head and neck region may be seen on dental panoramic images due to the superimpositions and proximity of structures. The aim of the present study was to evaluate the prevalence of soft tissue calcifications observed on digital panoramic images and the relationship of the calcifications with age and gender. Materials and Methods: Four thousand two hundred and sixty-three digital dental panoramic radiographs of the individuals aged between 6 and 89 who had visited the faculty of dentistry for different oral and dental complaints were evaluated retrospectively and detected calcifications were recorded with the age and gender information. Data were analyzed by means of descriptive statistics, Pearson Chi-squared, and independent samples t-test. Results: Two hundred and seventy calcifications (6.4%) were detected in the whole study population. Observed calcification types were tonsillolith (2.5%), carotid artery calcification (2.3%), sialolith (1%), and calcified lymph node (0.6%). The prevalence of calcifications for all types increased with age (P < 0.001). Conclusions: The prevalence of calcifications seen on the dental panoramic images is relatively rare, but the detection during routine dental examinations is important in terms of the need for more detailed evaluation of the patients.

Survival trends in oral cavity cancer patients treated with surgery and adjuvant radiotherapy in a tertiary center of Northern India: Where do we stand compared to the developed world? Nishant Lohia, Sharad Bhatnagar, Sankalp Singh, Manoj Prashar, Anand Subramananiam, Sundaram Viswanath, PK Sahu, Ajay Rai SRM Journal of Research in Dental Sciences 2019 10(1):26-31 Introduction: Oral cavity cancer is the third most common cancer in India. It presents a major burden on health services in India due to the widespread and rampant use of tobacco. Moreover, as per the Indian Council of Medical Research 2016 data, it ranks the fifth in overall mortality rate among different cancers prevalent in India. Aims and Objectives: The aim was to study and present our data on patient- and tumor-related factors as well as overall survival (OS) among patients of oral cavity cancer treated with surgery and radiotherapy at our center. The objective was to find the difference in OS in various subgroups of patients at 2 and 5 years from treatment. Materials and Methods: This was a retrospective study carried out in a tertiary care center of North India. The data collected were of patients treated between November 12 and November 16. A total of 112 cases of oral cavity cancers were studied. The patient-related variables that were analyzed included age, gender, history of tobacco or alcohol use, and presence of preexisting comorbidities. The tumor-related factors that were studied were tumor subsite, stage, and histological grade. OS of patients with varying parameters was compared at 2 and 5 years. Results: OS at 5 years for Stage I was 100% and decreased to 85% for Stage II. For Stages III and IV, the 5-year survival was a mere 43% and 42%, respectively. Conclusion: Treatment results at our center were comparable to world literature.

Assessment of smoking cessation advice: Attitude, practice, and barriers among clinical dental students Mohammed Ahsan Razi, Surangama Debnath, Shekhar Prashant, Sourav Chandra, Kausar Parwez Khan, Adya Singhal SRM Journal of Research in Dental Sciences 2019 10(1):32-39 Aims: The goal of this study was to assess the smoking cessation advice (SCA): Attitude, practice, and barriers among dental students of Hazaribag College of Dental Sciences and Hospital, Hazaribag, Jharkhand, India. Subjects and Methods: The study population comprises of a total of 217 clinical dental students studying in Hazaribag College of Dental Sciences and Hospital. Data were obtained using a self-administrated questionnaire comprising of 25 multiple choice questions, based on Likert scale. Attitude-6, Practice–14, Barriers-5. The qualitative analysis on the distribution of opinion was assessed using Chi-square test, P < 0.05 was considered statistically significant. Results: The results of the present study showed that the attitude and practice of house surgeons were better than that of third and final year students for questions based on attitude toward smoking cessation questions such as – How effective do you think smoking cessation counseling provided by dentists? (P < 0.05), based on Practice in tobacco smoking cessation: Do you refer patients to appropriate service to help them stop smoking? (P < 0.05) were statistically significant. Conclusions: Despite having knowledge of smoking associated health risks and positive attitudes toward giving SCA to patients, dental students in the clinical scenario witnessed barriers to provide SCA. To ensure that when students graduate from dental school, they should not only have good knowledge but the confidence to provide effective SCA and be able to refer to specialists trained in smoking cessation programs. In conclusion, tobacco cessation advice, counseling of patients and referral to appropriate sources for treatment needs to be included as a part of the BDS curriculum to acquire skills in this aspect of dentistry.

Trace elements as a diagnostic biomarker for premalignant lesions and malignant conditions Surekha Rathod, Prachi Rathi, Vivek Harkare SRM Journal of Research in Dental Sciences 2019 10(1):40-46 The aim of this paper was to study and compare the levels of copper (Cu), iron (Fe), and zinc (Zn) in patients with premalignant lesions or malignant conditions. A schematic search was conducted according to population, intervention, comparison, outcome in order to obtain appropriate articles for critical appraisal. The review incorporated a total of 16 articles, including in vivo human studies published in English language. Studies with premalignant and malignant conditions and trace elements including Cu as an essential element and Fe and Zn as other elements were considered. No limit was placed on a number of patients and studies involving blood investigations were included in this review. The exclusion criteria were in vitro nonhuman non-English studies. Case series, case reports, retrospective studies, and studies involving only saliva/tissue investigations were also excluded and studies not having any of the above-mentioned trace elements were also excluded from the study. Results of the studies suggested that serum Cu and Zn as well as the Cu to Zn ratio can be used as biomarkers for oral precancer and cancer. Thus, a comprehensive understanding of these trace elements can be used as a reliable biomarker for development and progression of oral cancer.

Childhood bruxism Trisha Das Sarma, Abhishek Mandal, Shabnam Zahir, Gautam Kumar Kundu SRM Journal of Research in Dental Sciences 2019 10(1):47-52 Bruxism is diurnal or nocturnal parafunctional habits which includes repetitive jaw-muscle activities, clenching or grinding of the teeth and/or bringing forward the mandible. Psychological components, genetic components, peripheral and patho-physiological components are the main Etiology of bruxism. Treatment options include occlusal rehabilitation, behavioural and pharmacological therapy. We perform a scientific paper search by using ebscohost, pubmed, and Google search engines. The searched item 'Bruxism' showed total 1125 papers, among which 250 were review papers. Most of them were published between 1990 to 2017 and some of them before 1990. Through this review an overview about childhood bruxism and its various treatment options and outcomes will be provided.

Congenital midline labial sinus of the upper lip Anka Sharma, Subhash P Kumbhare, Ashita Kalaskar SRM Journal of Research in Dental Sciences 2019 10(1):53-56 Congenital midline labial sinus is a rare condition affecting both the upper and lower lips. This anomaly has been reported in either gender but with a slightly increased predilection in females. It is known to occur either in isolation or in association with other congenital malformations such as cleft lip, cleft palate, van der Woude syndrome, median lip pit, brachidactilia, tongue tie, hypertelorism, notch of median vermillion border, nasal fistula, and abnormal hair pattern. In this article, we report a case of congenital midline sinus (without any associated congenital malformation) affecting the upper lip in a 12-year-old Indian male. Furthermore, a review of literature has been attempted on this condition.

Medicine and Medical Sciences

Healthy parenting in the age of the genome: Nature or nurture? Saoud Sultan Saudi Journal of Medicine and Medical Sciences 2019 7(1):1-2

Epigenetic transmission of maternal behavior: Impact on the neurobiological system of healthy mothers Alya Elmadih, Mahdi Abumadini Saudi Journal of Medicine and Medical Sciences 2019 7(1):3-8 Quality of maternal caregiving not only impacts children's development but can also result in heritable changes in gene expression (i.e., in an epigenetic manner). Consequently, when women become mothers, they adopt parenting behavior similar to that they received at family of origin. This transgenerational transmission of maternal behavior may also be associated with changes in the neurobiological system of future mothers. This review aims to highlight the effect quality of perceived parenting has on maternal behavior and the neurobiological system of mothers, specifically the oxytocin system, brain morphology and brain function. This would likely help in finding biomarkers that profile the impact of perceived parenting on mothers, and thus allow identification of mothers who experience poor-quality parenting for intervention.

Characteristics of nonaccidental fractures in abused children in Riyadh, Saudi Arabia Ayman Hussain Jawadi, Mohammed Benmeakel, Moath Alkathiri, Maha A Almuneef, Winnie Philip, Manal Almuntaser Saudi Journal of Medicine and Medical Sciences 2019 7(1):9-15 Background: Child abuse is a major problem globally. Nonaccidental fractures are the second most common injury among physically abused children; however, there is a lack of studies describing the characteristics of nonaccidental fractures in Saudi Arabia. Objectives: The objective of this study was to determine the characteristics of nonaccidental fractures among abused children in Riyadh, Saudi Arabia, using radiography. Materials and Methods: This retrospective study analyzed the data and radiographs of all nonaccidental fracture cases in children (aged ≤14 years) registered in the National Family Safety Program Registry at King Abdulaziz Medical City, Riyadh, between 2009 and 2015. Results: A total of 1512 cases of child abuse were found in the National Family Safety Program Registry database from Riyadh city. From these, 103 fractures were identified; however, radiographs were available for only 70 fractures from 56 children. Of these, 33 (59%) were boys, and 25 (45%) were aged 1–5 years. In terms of the type of abuse, neglect was more common than physical abuse (52% vs. 45%). History of injury was identified in 75% (42) of the cases, of which fall accounted for about 55% (23). Nearly 79% of children presented with a single bone fracture, while 21% had multiple bone fractures. The most common sites of fractures were skull (40%), upper limbs (31%) and lower limbs (29%). The most common fracture pattern was transverse fractures (48%), and it was mainly diagnosed in skull fractures (51%). Conclusions: This study found that in Riyadh, Saudi Arabia, neglect is the most common cause of nonaccidental fractures, abusive head trauma is the most commonly associated injury and transverse fracture is the primary pattern of fracture in abused children. Notably, as most children experienced a single-bone fracture, the authors recommend clinicians to lower their threshold of considering abuse even in cases with an isolated fracture.

Mutation frequencies in endometrial cancer patients of different ethnicities and tumor grades: An analytical study Mohammad A Althubiti Saudi Journal of Medicine and Medical Sciences 2019 7(1):16-21 Background: Endometrial carcinoma is a predominant health problem for women worldwide. However, there is a lack of data on genetic mutation frequencies in endometrial cancer patients of different ethnicities and tumor grades. Objective: The objective of this study is to provide data regarding mutation frequencies in endometrial cancer patients of different ethnic groups and tumor grades by analyzing large-scale cancer genomic datasets of a database. Materials and Methods: The following databases of cBioPortal were explored for possible mutation frequency variations in endometrial cancer patients: the Uterine Corpus Endometrial Carcinoma (TCGA, PanCancer Atlas) database for ethnicity-based studies; the Uterine Corpus Endometrial Carcinoma (TCGA, Nature 2013) database for tumor grade-based study; and GDC Data Portal database for calculating survival rates using the Kaplan–Meier method. Results: PTEN mutation frequency was almost identical in all ethnic groups studied (White, Black/African American, Asian, Native Hawaiian or other Pacific Islander, and American Indian or Asian Native). PIK3CA and ARID1A mutation frequencies were higher in White and Asian patients compared with other ethnicities; TP53 and FAT1 mutation frequencies were higher in Black/African Americans; and CTNNB1 and RYR2 mutation frequencies were higher Native Hawaiians or Asian Natives. TTN mutation frequency was lower in Asian patients. With regards to mutation frequencies at different tumor stages, in all genes, >50% of the mutations occurred during the first stage, except in TP53 and POLQ. In terms of prognosis in endometrial cancer considering the 10 most frequently mutated genes, PIK3CA and ARID1A mutations were correlated with good prognosis, whereas TP53 and PIK3R1 mutations were correlated with poor prognosis; mutations in all other genes did not show significant differences. Conclusion: This study revealed a new mutation frequency profile for different ethnicities and tumor grades in endometrial cancer patients. However, because this is a retrospective study, future prospective studies should be conducted including large sample sizes and more controlled measurements.

Renal histology in diabetic patients Yassir Zajjari, Taoufiq Aatif, Kawtar Hassani, Sanaa Benbria, Driss El Kabbaj Saudi Journal of Medicine and Medical Sciences 2019 7(1):22-27 Background: The diagnosis of diabetic nephropathy is based on the course of clinical manifestations and renal biopsy. Renal biopsy is usually performed in patients with atypical presentations. Objectives: This study was performed to analyze various renal histopathological lesions in diabetic patients and to establish a clinicopathological correlation. Materials and Methods: In this retrospective study, the authors analyzed renal histology of 40 patients with type 2 diabetes mellitus who presented with atypical features of diabetic renal involvement and underwent renal biopsy at the Military Hospital Mohammed V, Rabat, Morocco, between January 2008 and December 2016. Results: About 60% of the patients had isolated diabetic nephropathy, 35% had isolated nondiabetic renal diseases and 5% had both. Patients with nondiabetic renal diseases had significantly higher hematuria (P = 0.02), shorter duration of diabetes (P = 0.009), higher mean estimated glomerular filtration rate (P = 0.04) and lower prevalence of diabetic retinopathy (P < 0.001). The most common histological lesion in patients with nondiabetic renal diseases was IgA nephropathy (25%). In patients with diabetic nephropathy, the most common histological class was Class III (42.3%). Furthermore, higher histological classes were associated with lower estimated glomerular filtration rate (P < 0.001) as well as higher prevalence of diabetic retinopathy (P = 0.009) and nephrotic proteinuria (P = 0.04). Conclusions: This study found that in Rabat, Morocco, the most common histopathological lesion in patients with diabetes was diabetic nephropathy. Hematuria, shorter duration of diabetes, higher mean estimated glomerular filtration rate and lower prevalence of diabetic retinopathy were reported among those with nondiabetic renal diseases. These findings are in accord with that of studies from other countries. However, large sample size and long-term follow-up clinical studies are needed to demonstrate the renal pathological implications and renal outcomes in type 2 diabetes mellitus patients with renal involvement.

Knowledge and attitude regarding toxoplasmosis among Jazan University female students Mohamed S Mahfouz, Mona Elmahdy, Ahmed Bahri, Yara Mohammed Mobarki, Atheer Ali Altalhi, Norah Abdullah Barkat, Halimah Abdullah Al-Essa, Asmaa Hussein Ageely, Nesrin Ahmed Faqeeh, Nuha Abker Areeshi, Salma Mohammed Al-Hassan Saudi Journal of Medicine and Medical Sciences 2019 7(1):28-32 Background: In Saudi Arabia, the prevalence of toxoplasmosis is high. However, to date, few studies have evaluated the degree of knowledge on toxoplasmosis among females in Saudi Arabia. Objectives: The objective of this study was to assess the knowledge, attitude and preventive behavior regarding toxoplasmosis among female students at Jazan University, Jazan, southwest Saudi Arabia. Materials and Methods: This cross-sectional study was conducted on a random sample of 440 female students at Jazan University using a semi-structured, self-administered questionnaire. Data with numerical/qualitative variables were expressed as frequency and percentage. Chi-square test was used to analyze categorical variables. P < 0.05 was used to indicate statistical significance. Results: This study found that more than three-quarters (79.1%) of the students had insufficient knowledge about toxoplasmosis. Students from healthcare faculties had higher knowledge scores (28.5%) than students from arts and humanities (20.6%) and science (18.9%) faculties; however, the differences were not statistically significant (P = 0.77). The majority of the studied sample (92.3%) was found to eat fast food on a regular basis. About 42%, 54% and 4% of the respondents reported that they never, occasionally and always ate improperly washed vegetables, respectively. Conclusions: This study found that a substantial proportion of Jazan University's female students have insufficient knowledge on toxoplasmosis. Health educational programs are necessary to increase the awareness and knowledge about toxoplasmosis and its clinical manifestations.

Low back pain among workers in a paint factory Abdulrazag H Al-Salameen, Hassan A Abugad, Sultan T Al-Otaibi Saudi Journal of Medicine and Medical Sciences 2019 7(1):33-39 Background: Back pain is common among factory workers and is responsible for about 25% of workers' compensation cases. However, data on back pain among workers from paint industry in Saudi Arabia are limited. Objectives: The objective of this study is to estimate the prevalence of low back pain and to evaluate the associated risk factors among workers of a paint factory. Materials and Methods: This cross-sectional study used a self-administered questionnaire to elicit data regarding demography, job characteristics and prevalence of low back pain in the past 12 months among workers of a paint factory (n = 102) in the Eastern Province of Saudi Arabia. In addition, a scale of low back pain risk was generated for each department by occupational health professionals using interviews and observations. Results: The annual prevalence of low back pain was 44.1%, and it was more common among Saudi workers (67.9%) compared with non-Saudi workers (35.1%). Multivariate analysis indicated significant associations between low back pain and nationality (relative risk [RR] = 1.93; 95% confidence interval [CI] = 1.29–2.88), smoking (RR = 1.85; 95% CI = 1.20–2.83) and aerobic exercise (RR = 2.37; 95% CI = 1.19–4.71). Spearman rank correlation showed correlation between the symptom pain scale and smoking (rs = 0.259; P = 0.008), and exercise was associated with lower pain scale scores (rs= −0.241, P = 0.015). Conclusion: This study found that low back pain is common among paint factory workers in the Eastern Province of Saudi Arabia. Nationality and smoking are risk factors for low back pain and are associated with each other. Many workers did not exercise, and lack of exercise was associated with an increased risk of low back pain. Reducing smoking and increasing exercise in addition to workplace ergonomic intervention may reduce this frequently occurring problem.

Visceral leishmaniasis and glomerulonephritis: A case report Marwan Jabr Alwazzeh, Zaki Hajji Alhashimalsayed Saudi Journal of Medicine and Medical Sciences 2019 7(1):40-43 Visceral leishmaniasis is an endemic in the southwestern region of Saudi Arabia, with a low incidence rate. Clinical presentations of visceral leishmaniasis include recurrent fever, substantial weight loss, hepatosplenomegaly and anemia. However, the clinical features may not be easily evident owing to the involvement of multiple organs. This, in turn, can cause difficulties in establishing the correct diagnosis, and subsequently, in managing the patient. Here, the authors report a case of a 42-year-old male from Jizan, southwestern Saudi Arabia, who presented with impaired renal function. After kidney biopsy, the patient was diagnosed with glomerulonephritis of unknown etiology and treated with mycophenolate and prednisone. After 3 months, the patient developed high fever with hepatomegaly and pancytopenia. Based on the investigations, a possible diagnosis of visceral leishmaniasis was considered. Accordingly, he was treated with liposomal amphotericin B, following which his condition improved significantly. This case report discusses the relationship between glomerulonephritis and visceral leishmaniasis and focuses on the potential consequences of glomerulonephritis management without investigating the etiology of the underlying diseases, especially in patients from tropical and subtropical areas.

Atypical presentation of pigmented villonodular synovitis: A case report Mohammed A AlDakhil, Abdulaziz M AlDakhil, Moyassar M Karami, Mohammed B Satti Saudi Journal of Medicine and Medical Sciences 2019 7(1):44-46 Pigmented villonodular synovitis is a rare, disabling disease that usually presents in young adults. Here, the authors present a unique case of pigmented villonodular synovitis in a 60-year-old female diagnosed 20 years after the initial presentation. The patient presented with a complaint of knee pain consistent with osteoarthritis. Radiological investigations, including magnetic resonance imaging, only showed degenerative changes and were inconclusive to diagnose pigmented villonodular synovitis. Intraoperative macroscopic features of the synovium suggested pigmented villonodular synovitis, which was confirmed by histopathological examination. Histopathological examination, despite being the gold standard, was performed late in this case. The authors recommend histopathological confirmation of pigmented villonodular synovitis in all suspected cases, even with inconclusive radiological manifestations.

Intralesional triamcinolone for treating mandibular langerhans cell histiocytosis: A case report and literature review Ahmed Almuzayyen, Wahbi Elhassan, Mousa Alabbadi Saudi Journal of Medicine and Medical Sciences 2019 7(1):47-50 Langerhans cell histiocytosis is a rare condition ranging in manifestation from a focal boney lesion to multisystem involvement. Several treatment modalities have been proposed including curettage, low-dose radiotherapy, chemotherapy and intralesional injection of corticosteroids. These treatment options can be used as a single or combined approach. Prognosis depends on the extent of systemic involvement, and solitary lesions respond favorable to treatment. Here, the authors report a case of a 10-year-old male patient with Langerhans cell histiocytosis affecting his right posterior mandible that was successfully treated with intralesional injection of triamcinolone in multiple sessions. Complete recovery was confirmed clinically and radiographically in 18 months from the time of diagnosis.

Public Health Dentistry

President's Message V Gopikrishna Journal of Indian Association of Public Health Dentistry 2019 17(1):1-1

Hon. Gen. Secretary's Message Sabyasachi Saha Journal of Indian Association of Public Health Dentistry 2019 17(1):2-2

From the Editor's Desk KR Sowmya Journal of Indian Association of Public Health Dentistry 2019 17(1):3-3

Comparison of hematological parameters for signs of anemia among participants with and without chronic periodontitis: A cross-sectional study Sarita Parihar, NK Sharma, Atul Bhatnagar, Dhiraj Kishore, Ajit V Parihar, Faizia Rahman Journal of Indian Association of Public Health Dentistry 2019 17(1):4-7 Background: Chronic infection has a known effect on the cytokine levels of the body which adversely affects erythropoiesis. Aim: The aim of this study is to compare hematological parameters among participants with and without chronic periodontitis which also is a known infectious inflammatory disease of the gums. Materials and Methods: Forty patients with severe chronic periodontitis (Group A) and forty periodontally healthy participants (Group B) in the age group of 30–55 years presenting to the Outpatient Department of the Faculty of Dental Sciences, Banaras Hindu University, were recruited in the study and were assessed for various hematological and periodontal parameters. SPSS 17.0 version was used. Student's t-test (unpaired) was used. P < 0.05 was considered statistically significant. Results: Group A showed lower hemoglobin (Hb, 13.47 ± 1.05, P = 0.019), erythrocyte count (4.63 ± 0.40, P = 0.002), and mean corpuscular Hb concentration (32.58 ± 0.90, P = 0.003) values compared to Group B (13.95 ± 0.70, 4.90 ± 0.33, and 33.18 ± 0.81, respectively). Conclusion: Within the limitations of the study, it can be safely deduced that a positive relationship exists between the hematological parameters and severity of chronic periodontal disease, suggesting that long-standing chronic periodontitis may lead to the development of signs of anemia.

Shutting our eyes to an open secret: Knowledge, attitude, and behavior of dentists regarding domestic violence in India Zoha Abdullah, Joseph John Journal of Indian Association of Public Health Dentistry 2019 17(1):8-13 Background: The majority of victims of domestic violence sustain maxillofacial injuries. Dental professionals can play a vital role in preventing violence against women, helping identify abuse early, providing victims with the necessary treatment, and referring women to appropriate care. Aim: The aim of this study was to assess the level of knowledge, attitude, and behavior regarding domestic violence among dental health practitioners in India. Materials and Methods: The authors surveyed a random sample of 106 dental health practitioners using a pretested, structured, and validated questionnaire to evaluate their knowledge, attitude, and behavior regarding domestic violence. Survey items were developed based on the domestic violence and health-care literatures. Collected data were subjected to statistical analysis using Chi-square test, and P < 0.05 was considered statistically significant. Results: Sixty-four percent of the responding dentists believed that it is not their responsibility to screen patients for abuse; 7.5% never screened for abuse, even when signs of abuse were present; and 34.9% did not have enough time in their practice to raise the issue of domestic violence. The majority of respondents believed that domestic abuse should be a private matter and asking about abuse is an invasion of privacy. Female respondents' attitude toward domestic violence was more positive when compared to the males. Conclusion: The level of knowledge regarding domestic violence among the respondents was insufficient. The findings of this study strongly recommend that this issue be included in the undergraduate dental education curriculum to improve the health care and assistance provided to the victims of abuse.

Tobacco use: Exploring the beliefs of street food vendors in Delhi, India Shivam Kapoor, Vikrant Mohanty, Aswini Y Balappanavar Journal of Indian Association of Public Health Dentistry 2019 17(1):14-18 Background: Tobacco-use shows a clear and continual increase with decreasing wealth quintiles. Street vendors are an integral part of the Indian economy, offering potpourri of readily available, inexpensive goods or services in public spaces since time immemorial. Aim: The current study explores tobacco-related knowledge, attitude, and behavior among street food vendors in New Delhi. Materials and Methods: An interview-based questionnaire survey was conducted among food vendors, using prevalidated tool. Apart from demography, 15-item assessed knowledge, attitude, and awareness on tobacco use and control for 2 months. Tobacco usage history was assessed on a 9-item checklist for the users. A total of 147 vendors around a tertiary care public hospital in Central Delhi, who agreed to participate in the study constituted the study sample. The data were analyzed using SPSS version 21. Gender differences for the same were ranked and tested for a significant difference using the Mann–Whitney test. P < 0.05 was considered as statistically significant. Results: The majority of the subset of this sample (n = 127) were found to be tobacco users in either forms (smoke, smokeless, or both). Eighty-seven (68.5%) of the vendors reported the initiation of tobacco use between 18–25 years and 61 (48.03%) participants admitted the morning smoke/dip as most difficult to give up. All of them were aware about the harmful systemic effects of tobacco. Around 66% of the study participants were aware of the existing tobacco legislations in relation to minors and public places. Conclusions: In the current study, most of the food vendors, although aware, were found to be tobacco users. This group constitutes as important socially relevant spot that need rigorous monitoring. Further studies need to collect nationwide data and take effective steps in defining these sites as tobacco-free.

Assessment of dental students' attitudes and perceptions toward professionalism N Amritha, MK Vanishree, K Mahesh Chandra, Priya Babu Journal of Indian Association of Public Health Dentistry 2019 17(1):19-24 Background: Professionalism is a broad competency needed by dentists to act effectively and efficiently. It is seen as a central part of both undergraduate (UG) and postgraduate (PG) curricula. Aims: This study aimed to assess the attitude and perceptions of dental students toward professionalism and the influence of gender on the same. Materials and Methods: A cross-sectional descriptive study was carried out in four different dental colleges of Bengaluru city. A stratified random sampling technique was employed to select a sample of 480 dental students. The Professional Assessment Scale was used to assess professionalism. It is a 22-item questionnaire which is divided into three domains, namely, empathy and humanism, professional development and relationship, and professional responsibility domains. The students responded on a 5-point Likert scale, ranging from strongly disagree to strongly agree. The data collected were analyzed using SPSS software version 14.0. Chi-square test, independent Student's t-test, ANOVA, and Pearson's correlation were performed. P < 0.05 was considered statistically significant. Results: The mean overall Professional Assessment Scale scores were 93.12 ± 10.35, 97.41 ± 8.59, and 94.42 ± 10.06 for UGs, interns, and PGs, respectively, and these associations were statistically significant (P < 0.001). No significant gender differences were observed in the overall mean scores. Conclusions: The study concluded that all the participants possessed at least some elements of professionalism; recognizing these concerns and integrating them into professional educational programs can result in a better and more supportive health-care service for the public.

Professional environmental stress among dental and engineering students in Bhilai, Chhattisgarh, Central India: A comparative cross-sectional study Ramakrishna Chevvuri, N Naveen, GY Yunus, Ram Tiwari, Hunny Sharma, Swati Verma Journal of Indian Association of Public Health Dentistry 2019 17(1):25-30 Background: Students undertaking professional courses such as medical, dental, and engineering are subjected to higher stress resulting in psychological problems such as depression and anxiety. This may be attributed to various factors such as academic, social events, health-related, and personal issues. Aim: This study aims to assess and compare professional environmental stress between dental and engineering students in Bhilai, Chhattisgarh. Methodology: A Modified Dental Environmental Stress Survey Questionnaire comprising 24 questions was pretested and administered among 316 students (115 dental and 201 engineering) to compare the professional environmental stress across stressor domains such as academic performance, faculty relations, personal issues, and professional identity. Descriptive statistics and independent sample t-test were applied using IBM Corporation SPSS version 23 program (New York, USA). P ≤ 0.05 was considered as statistically significant. Results: Final year dental students reported higher stress than third year students with mean scores 34.91 ± 4.55 and 32.34 ± 5.36, respectively (P < 0.01). Final year engineering students experienced higher stress than third year students with mean scores 31.84 ± 4.29 and 29.86 ± 4.14, respectively (P < 0.01). Dental students reported higher stress than engineering students with mean scores 33.66 ± 5.10 and 30.78 ± 4.31, respectively (P < 0.01). Conclusion: This study gives the glimpse of factors creating stressful environment among the two science fields, the elimination of which will result in higher productivity and student-friendly environment for higher studies. The results were indicating that the intervention is necessary for psychological well-being of the students. Henceforth effective means of reducing stress should be explored together with determining emphatic methods of coping with the tensions.

Association of personality traits with anxiety and depression among clinical and nonclinical dental students Aditi Sharma, Simarpreet Singh, Anmol Mathur, Manu Batra, Vikram Pal Aggarwal, Puneet Kaur, Deeksha Gijwani Journal of Indian Association of Public Health Dentistry 2019 17(1):31-35 Background: There are studies about anxiety and depression among medical students well narrated in literature. However, limited studies have been reported among dental students. Aim: This study aimed to evaluate the association between anxiety and depression with personality traits, type of education exposure, and their effect on coping strategies among dental students. Materials and Methods: A cross-sectional, questionnaire-based study was carried out among undergraduate dental students. Questions were related to the consumption of alcohol, smoking, chewing gums, and chocolates. Validated questionnaires such as the Hospital and Anxiety Scale and Eysenck Personality Questionnaire-A Scale were used for evaluating anxiety and depression and personality traits, respectively. The statistical analysis was done using Statistical Package for the Social Sciences (version 20.0). Chi-square test, Student's t-test, and Pearson's correlation coefficient were used for analysis, and the level of significance was set at P < 0.05. Results: The results showed that males in nonclinical years (3.81 ± 1.18) and females in clinical years (4 ± 0.85) were more extrovert than their counterparts, whereas males and females in clinical years were more psychotic than males (3.26 ± 0.45) and females (3.03 ± 0.84) in nonclinical years. It was found that females in clinical years were more anxious and depressed than their counterparts. When extraversion was correlated with anxiety and depression, a negative correlation (-0.05,-0.63) was seen which was statistically significant for depression (P = 0.01), whereas a positive correlation was seen when psychoticism was correlated with anxiety (0.16, P = 0.61) and depression (0.5, P = 0.02). Among the total participants, a majority consumed chocolates as a coping strategy. Conclusion: It was observed that many dental students who were in their clinical years had more anxiety and depression as compared to their nonclinical peers which could be due to their personality traits. Interventions should be targeted to deal with these problems.

Effect of stress, depression, and anxiety over periodontal health indicators among health professional students Gautami S Penmetsa, Pasagadugula Seethalakshmi Journal of Indian Association of Public Health Dentistry 2019 17(1):36-40 Background: Stress has become a part of one's life, which results in the development of depression and anxiety. This is commonly thought to have a net-negative effect on the efficacy of the immune response, subsequently resulting in periodontal breakdown. Aim: The aim of this study was to assess the effect of depression, anxiety, and stress [DAS] over periodontal health indicators among the health-care professional students. Materials and Methods: The study was conducted in 375 undergraduate health professional students, of which 125 were medical students, 125 were dental students, and 125 were pharmacy students, who were taken from three colleges in Andhra Pradesh. Questionnaires (self-reported oral hygiene questionnaire and DAS Scale questionnaire) were given to the participants, and clinical examination was conducted in all the participants to assess the plaque index (PI), gingival index (GI), probing depth, and clinical attachment level. Statistical analysis was performed using the ANOVA test and post hoc test to compare the psychological parameters with periodontal parameters among three groups of health professional students. P < 0.05 was considered statistically significant. Results: Medical students depicted higher mean stress levels (8.00 ± 2.75) (P < 0.001) and mean DAS score (20.23 ± 6.21) (P < 0.001) than dental and pharmacy students; the mean PI (1.05 ± 0.38) (P < 0.001) and the mean GI (0.72 ± 0.38) (P < 0.001) scores are also increased with stress levels among medical students. Conclusion: Psychological factors have an adverse effect over the plaque levels and gingival status among the students.