Study of Non-Thyroidal Illness Syndrome and Its Recovery in Critically Ill Patients at a Tertiary Care Centre in South India.

Background and Objectives: Transient thyroid hormone alterations are common during critical illness and are termed non-thyroidal illness syndrome (NTIS). We studied the prevalence of NTIS in the ICU setting and its impact on predicting mortality and other outcomes and compared it to the Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Materials and Methods: The study included 119 consecutive patients admitted with a critical illness. APACHE II score was calculated. Total T3, total T4, TSH, free T3, and free T4 were measured at admission and after six weeks of discharge. NTIS and euthyroid groups were studied for ICU, hospital stays, mortality, readmission, and recovery. Predictors of mortality were compared between survivors and non-survivors. Results: The mean age was 60.15 ± 14.50 years with M:F = 84 (71%):35 (29%). NTIS was observed in 84 (71%), low T3 being the most common abnormality in 53 (63%). The occurrence of NTIS was significantly higher among non-survivors (28/30, 93%) versus survivors (56/89, 63%) (P = 0.002). Non-survivors showed significantly lower T3, TSH, and FT3/FT4 ratios and higher readmissions. NTIS group showed significantly greater ICU stay (P = 0.02) and had higher readmission rates (P = 0.032). Baseline T3 had the greatest power to predict mortality. APACHE II score also correlated significantly with mortality (19.60 ± 10.58 vs 11.99 ± 6.80, P < 0.001). The area under the curve (0.677) for the T3 level was lower than the APACHE II score (0.760). After six weeks, 61% had recovered from NTIS. Conclusions: NTIS was common amongst critically ill patients (71.5%), which reversed in 61% at six weeks. Low T3 was the most common abnormality and independently predicted mortality. Free T3/free T4 also significantly predicted mortality. The correlation between thyroid dysfunction and the severity of primary illness makes it an additional attractive low-cost marker of mortality.

Immunotherapy with Autoimmune Complication in Renal Cancer.

INTRODUCTION: Newer modalities like immunotherapy with checkpoint inhibitors are widely being used in oncology. Complete remission with immunotherapy comes along with immune related adverse effects which warrant prompt diagnosis and treatment. Below is a case metastatic RCC treated with pembrolizumab, humanized monoclonal antibody to programmed cell death receptor with autoimmune complications during therapy and subsequent complete remission after re-challenge. MATERIALS: 72 year old gentleman with background history of diabetes mellitus, hypertension presented with complaints of hematuria and neck pain. Upon evaluation, found to have RCC with metastasis to lungs and left occipital condyle. Patient underwent excision nd prosthesis for unstable atlanto-occipital joint, left nephrectomy for malignant focus in left kidney. He was then started on immunotherapy, inj. pembrolizumab +tab. axitinib. RESULT: After three cycles of immunotherapy, patient presented with easy fatigability, weakness and drowsiness. Baseline TSH and liver functions were normal. Investigations revealed high TSH and transaminitis. Autoimmune hepatitis was treated with steroids and oral levothyroxine was started for autoimmune thyroiditis. Patient improved with treatment and immunotherapy was re-challenged. After 12 cycles of pembrolizumab, review PET-CT scan showed no lung lesions and complete metabolic response. CONCLUSION: Immunotherapy has very good results in advance malignancies. It has unique side effects of auto immune phenomenon. Therapy can be re-challenged if its complications of autoimmune adverse events are diagnosed and treated promptly. References Nagra NK, Siddique A, Singhvi G, et al. S2684 pembrolizumab induced hepatitis: a severe complication effectively treated with steroids. Am J Gastroenterol 2020;115:S1405-S1406. Choueiri TK, Tomczak P, Park SH, et al. Adjuvant pembrolizumab after nephrectomy in renal-cell carcinoma. N Engl J Med 2021;385:683-694.

Sialography: a pictorial review.

Non-tumour inflammatory and obstructive salivary gland pathologies such as sialadenitis, sialolithiasis, sialadenosis, ductal strictures, etc. require precise radiological evaluation and mapping of salivary gland ductal system for better treatment outcome. Conventional sialography is considered as a useful and reliable technique in evaluation of salivary glands especially intrinsic and acquired abnormalities involving the ductal system and is useful for detection of non-radiopaque sialoliths which are invisible on routine plain radiographs. Primarily sialography is used as a diagnostic tool, additionally it plays an important therapeutic role as salivary gland lavage in cases of recurrent salivary gland infections and in obstructive salivary gland disorders by helping in clearance of mucous plugs or small sialoliths within the ducts. Recently, diagnostic performance of computed tomography (CT) sialography is being explored and has been reported to have high sensitivity in detection of small sialoliths and allows differentiation of sialoliths from other calcifications in glandular ductal system. Multiplanar three dimensional (3D) reconstructed CT images have been reported to play a key role in determination of anatomical location or extent of salivary gland disease without superimposition or distortion of structures. This review aims to discuss the disease specific applications of sialography and CT Sialography in particular for visualization of salivary gland disorders.

Oral Submucous Fibrosis: Correlation of Clinical Grading to Various Habit Factors.

OBJECTIVES: The aim of this study was to correlate the clinical grading of oral submucous fibrosis (OSMF) with various habit factors and to observe the habit factors associated with the severity of OSMF. MATERIALS AND METHODS: This study was carried out in the Department of Oral Medicine and Radiology, Kalinga Institute of Dental Sciences, Bhubaneswar, Odisha, India. Two hundred patients clinically diagnosed with OSMF were included in the study. The observations were tabulated and subjected to statistical analysis using chi-square test and Spearman's rank correlation test. RESULTS: A total of 200 subjects participated in the study of which 182 were males and 18 were females. Forty-eight males and nine females had Grade I OSMF. One hundred nineteen males and eight females had Grade II OSMF. Fifteen males and only one female had Grade III OSMF. On the basis of functional staging, the total participants in stage I, stage II, and stage III were 185, 14, and 1, respectively. The participants having Grade I, Grade II, and Grade III OSMF with functional staging I were 57, 122, and 6, respectively. The participants having Grade II and Grade III OSMF with functional staging II were 5 and 9, respectively. CONCLUSION: It is alarming that nearly half of the total subjects were in the younger age group and were having OSMF. Also, as the age increased, the subjects were found to be more attracted to consuming areca nut derivatives in the form of betel quid with or without tobacco. It is recommended that community-oriented outreach programs on oral health awareness be developed, emphasizing children who represent the upcoming future, to avoid/quit areca nut and its derivatives.

Assessment of the Anterior Loop of the Mandibular Canal Using Cone-Beam Computed Tomography in Eastern India: A Record-Based Study.

OBJECTIVE: The aim of this study was to assess the presence and course of the anterior loop (AL) in an Odisha sample population using cone-beam computed tomography (CBCT) and to accurately identify and analyze the length, height, and diameter of AL in male and females. MATERIALS AND METHODS: CBCT images from 1000 patients obtained for various clinical indications were randomly selected and evaluated to determine the presence, length, height, and diameter of the AL. The various parameters were then compared based on gender, age, and the side of the mandible. The data were analyzed using the Chi-square test, independent t-test, multiple post hoc procedure, and one-way ANOVA test. RESULTS: An AL was identified in 9.7% of the cases, and its mean length ranged from 1.8 to 4.8 mm. The loop had a greater mean length and was significantly more prevalent in males. The diameter ranged from 1 to 4 mm and height ranged from 7.8 to 15.1 mm. The AL was most commonly found in the middle-aged patients (39-48 years) which attributed to around 27.83%. CONCLUSION: In this study, a lower prevalence of the AL of the mandibular canal was found. Being an anatomical variation, an exact evaluation of the AL must be established using the imaging techniques prior to any surgical procedure.

Chronic Recurrent Non-specific Parotitis: A Case Report and Review.

BACKGROUND: Chronic recurrent non-specific parotitis is characterized by recurrent episodes of swelling and pain of unknown etiology in the parotid gland. Sialography is a hallmark in the diagnosis of salivary gland disorders; newer imaging modalities like CT-Sialography, sialoendoscopy and MRI can be used. Various treatment modalities have been tried, from conservative approach to surgical excision depending on the recurrence rate and severity of the condition. Although symptomatic treatment with antibiotics and analgesic, injection of intraductal medicament, aggressive treatment like duct ligation or excision of gland are some of the treatment modalities, there is no established algorithm as to which treatment method should be opted in such clinical situation. CASE DETAIL: A 20 years old male patient reported with pain and salty taste in the mouth that had began before a week. Examination revealed an elevated right parotid papilla; ropy, cloudy appearing saliva was oozing out on milking the gland. Unstimulated and stimulated whole salivary flow rate was assessed using drooling method. Sialography was used as a diagnostic and a therapeutic aid. In our case, sialography as a treatment showed a good response with no recurrence after two years of follow-up. We highlighted the role of sialography as a therapeutic aid. CONCLUSION: Recurrent attacks significantly affect the quality of life and also lead to progressive gland destruction. Preventing or reducing the frequency of recurrence remains the goal of therapeutic procedure. Hence, conventional sialography is useful in the diagnosis and also effective as a therapeutic aid in recurrent parotitis.

Bilateral necrotising sialometaplasia.

Necrotising sialometaplasia is a benign, necrotising, self-healing inflammatory condition categorised as idiopathic disease of salivary glands. This condition holds diagnostic importance because of its clinical and histopathological presentation, which is ambiguous, and can be misdiagnosed as carcinoma particularly squamous cell carcinoma or mucoepidermoid carcinoma. This report describes a case of bilateral necrotising sialometaplasia occurring in a 38-year-old male patient.

Awareness of hepatitis B infection among healthcare students in a private medical college in Odisha.

BACKGROUND: The emergence of the blood-borne pathogens and the increasing number of infected patients and the increasing interest in dental health care compel the dental professionals to have thorough knowledge about communicable diseases and the MBBS and nursing students are always at risk because of their profession. As hepatitis B infection is a major health hazard throughout the world, healthcare students should have through knowledge about this disease. Setia et al. had conducted a similar kind of study in Punjab in which the sample size was smaller and it included only the interns, whereas the present study was conducted to assess the level of knowledge, attitude, and behavior about hepatitis B infection among healthcare students of all academic years because they are indulged in clinical work since third year of their curriculum. MATERIALS AND METHODS: A cross-sectional survey was conducted of all the students starting from 1(st) year to final year and the interns of MBBS, BDS, and nursing at KIIT University. The questions were obtained from a study performed in Turkey in 2010 and were modified by an infection control expert. Questions in multiple choice format were in English and it was a self-administered questionnaire consisting of three parts (knowledge, attitude, behavior). Then, ethical clearance for the study was obtained from the institutional ethical committee, KIMS. Subsequently, the students were well informed and explained about the study. Students who voluntarily wanted to participate were included in the study. Questionnaire containing 20 questions to assess the level of knowledge, attitude, and behavior about hepatitis B was distributed among the students. Data were compiled and statistical analysis was done. RESULTS: The response rate was 83% (N = 332). In our study, majority (96.99%) were aware of transmission of HBV infection by blood, body fluid, and secretion. The level of knowledge was higher in MBBS students than BDS and nursing students (MBBS > BDS > nursing). Attitude toward the disease was higher in MBBS students than BDS and nursing students (MBBS > BDS > nursing), whereas behavior was higher in BDS students than MBBS and nursing students (BDS > MBBS > nursing). CONCLUSION: In our study, overall knowledge and attitude toward hepatitis B infection were higher in MBBS students than in dental and nursing students, whereas behavior of dental students toward the disease was quite satisfactory than MBBS and nursing students.

Controlling pain during orthodontic fixed appliance therapy with non-steroidal anti-inflammatory drugs (NSAID): a randomized, double-blinded, placebo-controlled study.

BACKGROUND: Despite all the technological advances in orthodontics, orthodontic treatment still seems to involve some degree of discomfort and/or pain. Pain control during orthodontic therapy is of great concern to both orthodontists and patients. However, there has been limited research into controlling such pain. AIMS: The purpose of this work was to assess patient-perceived pain following fixed orthodontic treatment and to evaluate the comparative analgesic efficacy of non-steroidal anti-inflammatory drugs for controlling pain. METHODS: A total of 45 patients about to undergo fixed appliance orthodontic treatment were enrolled in this double-blind prospective study. Patients were evenly and randomly distributed in a blinded manner to one of three groups as follows: paracetamol/acetaminophen 500 mg thrice daily; placebo in the form of empty capsules; and etoricoxib 60 mg once daily. Drug administration began 1 h before initiating the bonding procedure and archwire placement, and given until the day 3. The pain perceived was recorded by the patients on a linear and graded Visual Analogue Scale at time intervals of 2 h after insertion of the appliance; 6 h thereafter and again at nighttime of the same day of the appointment; 24 h later and on the 2nd day at nighttime; 48 h after the appointment and on day 3 at nighttime. RESULTS: Our results revealed that moderately intense pain is associated with routine orthodontic treatment, and that the amount of pain individuals perceive varies widely. We observed statistically significant differences in the pain control among the three groups, and that etoricoxib 60 mg proved most efficient. CONCLUSION: Etoricoxib 60 mg is highly efficacious for controlling pain during fixed orthodontic appliance therapy.