Feto-Maternal Outcomes in Pregnancy With Factor VII Deficiency in a Tertiary Care Institution.

This paper aims to study antepartum and postpartum bleeding manifestations of patients with factor VII (FVII) deficiency, their management, and feto-maternal outcomes, to establish danger signs and management protocols. We describe a case series of nine pregnancies in four patients with FVII deficiency diagnosed at a tertiary care referral center in India between 2012 and 2023. Out of nine pregnancies, six had cesarean deliveries, two had vaginal deliveries, and one had dilatation and curettage for unwanted pregnancies. One out of nine pregnancies (11.11%) with an unknown FVII deficiency had antepartum hemorrhage (abruption) necessitating multiple transfusions, ICU stay, and neonatal loss. Three patients with no prior history of obstetric hemorrhage were diagnosed with severe deficiencies and received prophylactic recombinant FVII preoperatively, averting the potential loss of lives. In patients with no history of bleeding, no hemorrhage was reported with or without prophylaxis while 33.33% of hemorrhage was reported in patients with a history of bleeding. Factors like the history of bleeding, FVII levels, mode of delivery, and other risk factors for hemorrhage should all be considered to predict the risk of bleeding in delivery. Cesarean is a surgical procedure, and prophylactic use of recombinant FVII concentrate (rFVIIa) should be considered.

Post-introduction evaluation (PIE) of rotavirus vaccine in India.

Background: India became the first country in the WHO South-East Asia Region (SEAR) to introduce the rotavirus vaccine (RVV) in the Universal immunization programme (UIP) in 2016 with nationwide expansion by 2019. It was a landmark move to reduce the diarrheal disease burden in under-five children. To assess the implementation process of introduction of RVV, Post Introduction Evaluation (PIE) was conducted in March 2022. Methods: The evaluation was conducted across 14 states, 28 districts and 28 health facilities to obtain a nationwide geographical inclusion. Stakeholders involved in program decision-making, planning, training, vaccine delivery, logistics, and communication from all levels (National, state, district, health facility, health worker, caregiver) were interviewed using standardized data collection tool for PIE (adapted from the standard WHO PIE questionnaire) and scripted on a digital tool. Results: A total of 260 interviews were conducted. Political willingness, well-planned preparedness activities, securing vaccines timely, strong supply chain monitoring, availability of domestic RVV products, quality trainings and intense communication activities were the key factors identified for the successful RVV introduction. Key activities during the introduction included cold chain space assessment, trainings of healthcare workforce, dissemination of job aids, updation of recording & reporting formats and strengthening of AEFI surveillance. Lack of community awareness for immunization in a few areas, fear of AEFI amongst some caregivers and local issues with Alternate Vaccine Delivery (AVD) were some reported challenges in achieving high coverage for RVV. Conclusions: Overall, the nationwide roll-out of RVV was smooth and the vaccine has been well-accepted in the community. The assessment emphasizes on having a well-strategized operational and communication planning, which is very crucial for any new vaccine introduction.

Digitizing tools for post introduction evaluation of rotavirus vaccine introduction in India.

Background and aims: The Rotavirus vaccine (RVV) introduction is a landmark event in the history of Indian public health as for the first time a novel, low-cost indigenous vaccine was introduced in a short timeline between 2016 and 2019. As per WHO mandate, post-introduction evaluation (PIE) be conducted within 6 to 12 months of vaccine introduction to provide an understanding of the operational aspects of the program. For RVV PIE, an innovative approach to developing and deploying a digitized tool was employed. The present study aims to document the processes followed for digitizing the data collection and analysis tools. Methods: The development of the RVV-PIE digital tool was undertaken in two phases. In the first phase, conceptualization and iteration of the modified WHO PIE tool were undertaken. Questions were organized sequentially to ensure natural progression in responses. The finalized questionnaire was converted to a digital version and extensive dummy data was entered to improve automated qualitative data analysis. Phase 2 involved updating the draft tool and incorporating changes to provide a field-tested version for deployment. Results: The digital version of the tool was successfully developed. The GPS functionality of the tool allowed live tracking of data collection making the process more accountable. The tool was prepopulated with reference materials and data points for easy reference and retrieval by the evaluators. The digitization of the tool also allowed easy visualization of data through maps, charts, and graphs on a real-time user-friendly dashboard. Conclusions: The digitization of the PIE tool for RVV in India has been a great learning experience where the dire situation of an ongoing pandemic catapulted us towards a more efficient and comprehensive process innovation. The RVV PIE tool could serve as a customizable digital PIE tool for other health programs heralding an era of a more effective and proficient process of PIE.

Does the adjunctive use of autologous platelet concentrate during secondary alveolar bone grafting reduce the risk of wound dehiscence? A systematic review and meta-analysis.

Wound dehiscence is a common complication after secondary alveolar bone grafting (SABG), leading to unfavourable surgical outcomes. Studies have shown that autologous platelet concentrates (APC) may enhance wound healing and improve outcomes. Therefore, this review aimed to evaluate in patients with alveolar clefts, whether using APC and iliac crest bone graft can mitigate the likelihood of wound dehiscence formation compared with those who underwent iliac bone grafting only following SABG. A comprehensive literature search was conducted using various electronic databases, including PubMed, Embase, Scopus, Web of Science, EBSCOhost, Ovid MEDLINE, LILACS, Cochrane Library, and grey literature, to include studies until July 31, 2023, without any restriction to language and time of publication. Only randomized (RCT) and controlled (CCT) clinical trials were included. Two independent reviewers screened the studies based on the predefined criteria, after which a qualitative and quantitative analysis was conducted. The search yielded 821 studies, of which seven were deemed eligible for systematic review. The risk of bias assessment done using "The Cochrane collaboration tool for risk of bias assessment" for six RCTs and the "Risk of Bias in Non-randomized Studies - of Interventions" for one CCT revealed a moderate to high risk of bias. The meta-analysis of five studies showed that the overall risk of developing wound dehiscence was lower in the APC group (RR = 0.33; 95% CI: 0.16, 0.71; p = 0.005; χ2 = 0.82; I2 = 0%). Subgroup analyses based on study design further supported these findings. Although the adjuvant use of APC for alveolar cleft reconstruction reduces the risk of wound dehiscence, more studies with increased scientific rigour and fewer confounding variables are warranted.

Enablers and barriers to rotavirus vaccine coverage in Assam, India- A qualitative study.

Background: Estimates suggest that 78,000 children died due to rotavirus gastroenteritis annually between 2011 and 2013 in India. The north eastern state of Assam reported 38.4% pediatric diarrheal admissions testing positive for rotavirus. Rotavirus vaccine (RVV) was introduced in Assam in 2017 following which the National Family Health Survey-5 (NFHS-5) (2019) revealed low RVV coverage in Assam with wide variation between the districts. the current study was conceptualized and undertaken to capture the enablers and barriers to RVV coverage in Assam. Methods: Qualitative study conducted in 5 randomly selected districts in Assam. Participants (key informants) were recruited by purposive sampling at each level of the health system including healthcare officials, service providers and caregivers based on availability. Thirty-five in-depth interviews (IDIs) and five focus group discussions (FGDs) were conducted. Interviews were tape recorded and transcribed. Data was coded and analyzed using the thematic framework approach. Results: Findings from the qualitative data collection were collated and analyzed under 7 identified themes. Difficult terrain, limited service provider availability and no catch-up training for new recruits were some of the barriers to RVV coverage. In contrast, Information, Education & Communication (IEC) in vernacular language, RVV safety profile, development partner support and adequate RVV supply were identified as some of the enablers of RVV coverage. Conclusion: Few broad recommendations to overcome identified barriers include comprehensive inter-sectoral coordination, regular monitoring and frequent refresher training sessions. There is a need for a future study utilizing existing coverage data and larger sample size to triangulate the findings of this study.

Heterotopic Ossification After Reconstruction with Free Fibula Flap - an Ambiguous Mishap.

Heterotopic ossifications (HO) are rare, yet, well reported complications after free flap transfer. We present a case of HO that occurred within a month, and has not been previously described in the literature. This serves as a reminder that bony hard swellings proximal to the free flap within a month should raise the suspicion of HO.

Chyle leak after head and neck surgeries: a comprehensive review of diagnosis and management strategies.

Chyle leaks are uncommon complications after head and neck surgeries. Although uncommon, such a complication is noteworthy mention due to its perplexing diagnosis and management strategies. This scoping review aims to highlight and emphasize the diagnosis and management options proposed in the literature. A comprehensive search was performed in PubMed, Google Scholar, Cochrane Library, and Scopus databases and identified 617 articles that were reduced to 40 studies and reports after applying the eligibility criteria. Although numerous treatment options ranging from simple, conservative measures to invasive surgical procedures have been mentioned for low-output, high-output, and massive leaks, there is no concrete evidence on the best method. Thus, a combination of management options must be customized by case for optimum results.

Minimal clinically important difference in maxillofacial trauma patients: a prospective cohort study.

The present study estimated the minimal clinically important difference (MCID) for pain on a visual analogue scale - numerical rating scale (VAS-NRS) and mean bite force (MBF) in patients treated for maxillofacial trauma (MFT). This cohort study included 120 MFT patients treated according to AO principles. Preoperative and four-week postoperative pain on the VAS-NRS, and MBF were measured to calculate MCIDs as indicators of functional rehabilitation. The patient's perspective of the treatment was assessed using a four-item anchor question. The MCID was determined by two anchor-based approaches, namely, the change difference (CD) method and receiver operating characteristic (ROC) curve method. According to the CD method, the MCID for pain was 2.4 and the MBF was 147.9 N. Based on the ROC curve, the MCID for pain was 2.5 (sensitivity 91.7%, specificity 47.2%) and MBF was 159.1 N (sensitivity 71.4%, specificity 61.1%). This study demonstrated a high sensitivity (>70%) for MCID, which implies that pain reduction of 2.4-2.5 points on the VAS-NRS and a gain in MBF of 147.9-159.1N are clinically relevant for patients treated for MFT.

Valorization of wheat straw into paper by ultrafiltered enzymatic bleaching approach.

In this study, the potential of ultrafiltered xylano-pectinolytic enzymatic bleaching approach was investigated, for manufacturing wheat straw-based paper. The enzymatic step was found to be most effective, with xylanase-pectinase dose of 4-1.7 IU/g pulp and time period of 180 min. The absorption spectra of the pulp free filtrate samples obtained after treatment of the pulp with ultrafiltered enzymes showed the removal of more impurities, in comparison to the treatment with crude enzymes. Microscopic analysis also showed the removal of lignin impurities in enzymatically bleached pulp samples. This bleaching approach using enzymes resulted in 27% reduction in ClO2 dose. Ultrafiltered enzymes treated pulp samples also showed improved quality-related parameters, and Gurley porosity, burst index, breaking length, double fold, tear index, and viscosity increased by 19.05, 13.70, 8.18, 29.27, 4.41, and 13.27%, respectively. The lignin content, TDS, TSS, BOD and COD values also decreased in the effluent samples obtained after enzymatic bleaching plus 73% chemical bleaching dose. The BOD and COD values of the effluent samples improved by 23.01 and 23.66%, respectively. Thus, indicating the potential of ultrafiltered xylano-pectinolytic enzymes in reducing pollution during bleaching of wheat straw. This is the first study, mentioning the efficacy of ultrafiltered enzymes in the bleaching of wheat straw-based paper with better optical-strength-related properties and effluent characteristics.

Refractory supraventricular fetal tachycardia as a cause of non-immune hydrops: management conundrum.

Supraventricular tachyarrhythmia (SVT) is the most common form of fetal tachyarrhythmias. The presentation can vary from ill-defined, non-sustained episodes of tachyarrhythmia to frank non-immune hydrops. The standard of care is transplacental therapy by treating the mother with oral antiarrhythmic drugs, followed by direct fetal therapy in refractory cases. We report a case of primigravida in her late 20s, who presented at 28.1 weeks of gestation with fetal hydrops and SVT. She was initially managed with oral digoxin and flecainide, but due to worsening hydrops, risk of fetal demise and extreme prematurity, further management by direct fetal therapy was given in terms of intramuscular digoxin and intraperitoneal flecainide. Following which, the fetus had a favourable outcome. This case highlights the possible role of direct fetal therapy in refractory cases of SVT.

Indications and types of keratoplasties: Trends in the past 10 years (2011-2020) in Eastern India.

Purpose: To observe the trends of various types of keratoplasties in different etiologies over a period of 10 years (2011-2020) in a tertiary eye care center of eastern India. Methods: A retrospective review of patients undergoing keratoplasties from 2011 to 2020 was performed in a tertiary eye care hospital situated in eastern part of India. Apart from demographic data, primary indication for each surgery and type of procedure carried out was recorded. For comparison, data were divided into two time periods: Group I: Jan 2011 to Dec 2015 and Group II: Jan 2016 to Dec 2020. Results: Over a period of 10 years, a total of 2365 (Group I: 902, Group II: 1463) keratoplasties were performed. The average age of patients was 45.8 ± 19.9 and 46.9 ± 20.9 years in Group I and Group II, respectively. Among all the corneal grafts, 1747 (74%) surgeries were full-thickness. Although optical penetrating keratoplasty (OPK) was most the common indication for full-thickness keratoplasties, Descemet's stripping endothelial keratoplasty (DSEK) remained most performed lamellar keratoplasty. Keratitis, corneal scars, and bullous keratopathies remain to be most common indications in both groups. Number of lamellar keratoplasties increased significantly from Group I to Group II for corneal scars (P = 0.02), bullous keratopathies (P = 0.01), and endothelial dystrophies (P = 0.00). Conclusion: With change in time, the indication and technique of keratoplasty has witnessed a changing trend from full-thickness keratoplasty to lamellar keratoplasty. There is rise in trend of lamellar keratoplasties over the period.

Enablers and Barriers to the Scaling Up of Pneumococcal Conjugate Vaccine in India During the COVID-19 Pandemic: A Qualitative Study.

Background: Pneumonia is one of the leading causes of death in under-5 children in India. This led the Ministry of Health & Family Welfare (MoHFW) in India to decide for the nationwide roll-out of the Pneumococcal Conjugate Vaccine (PCV). However, the introduction of PCV became more complex in the face of unprecedented challenges set forth by the COVID-19 pandemic. The study aims to assess enablers and barriers to the introduction of PCV in India during the pandemic. Methodology: Qualitative research approach involving key-informant interviews from John Snow India (JSI), the lead technical agency that supported MoHFW in the PCV expansion was employed to delineate the enablers and barriers. Principle of saturation was employed to derive the sample size. Thematic analysis using inductive approach was based on the modified World Health Organization (WHO) framework for new vaccine introduction impact on the Immunization and Health Systems, using NVIVO 12 qualitative data analysis software. Results: A total of 11 key informants (4 national-level program managers and 7 state technical officers) were telephonically interviewed. The study found social acceptance, lower cost of the vaccine, and intensive communication activities as potential enablers. Other enablers for PCV introduction included a robust vaccine supply-chain system, ample cold-chain space availability, and strong political commitment, despite the ongoing second wave. Further, the identified barriers included poor physical access, insufficient social mobilization, and limited advocacy along with a stretched workforce. Conclusion: The study delineated several enablers and barriers to introducing PCV in the country during the pandemic. The existing barriers in the PCV roll-out prompted the need to address these gaps, making key program-based recommendations to improve future new vaccine introductions during the pandemic.

Efficacy of Enhanced Recovery after Surgery (ERAS) protocol in maxillofacial trauma: A randomized controlled trial.

INTRODUCTION: Enhanced Recovery after surgery (ERAS) guidelines have been formulated in the literature for various different specialties but none is present for maxillofacial trauma patients. Hence, we have formulated ERAS protocol for maxillofacial trauma (ERAS-MT) patients and compared with the patients receiving the standard traditional care for post trauma outcomes. METHODOLOGY: A randomized controlled trial included 74 patients divided into two groups: Group 1 (ERAS group:37 patients) and Group II (Control group:37 patients). ERAS group were intervened according to the formulated ERAS protocol based on the previous literature and the control group received the standard of care. The both groups were compared for various post trauma outcomes. RESULTS: Baseline demographic data was non-significant between both the groups. There was significant decrease in pre-operative IV fluid use and total number of IV analgesics used till 72 h as well as in the immediate post operative period in the ERAS group(p = 0.001). ERAS group started oral feeds within 6 h and they were significantly compliant for oral carbohydrates in the pre-operative phase(p = 0.001). PONV episodes, swelling and infections were insignificantly less in the ERAS group(p > 0.05), however a significant difference was seen throat pain and decreased anxiety as well as Oral Hygiene Index(p = 0.001). At two weeks, a significant difference was seen in overall patient's satisfaction and cost analysis in the ERAS group (p = 0.001). CONCLUSION: Our study suggested that ERAS protocol was associated with shorter hospital stay, early recovery with better overall satisfaction of the patients, lesser post-operative complications and significantly decreased cost analysis.

Treatment for Adult Mandibular Condylar Process Fractures: A Network Meta-Analysis of Randomized Clinical Trials.

PURPOSE: Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical trial. To date, there has not been a NMA of randomized clinical trials (RCT) that compares all types of treatments for mandibular condylar process fractures (MCPFs). The aim of this NMA was to compare and rank all the available methods used in the treatment of MCPFs. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in 3 major databases up to January 2023 to retrieve RCTs that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF with intermaxillary fixation screws, AB + functional therapy with elastic guidance (AB functional treatment), AB rigid MMF/functional treatment, single miniplate, double miniplate, lambda miniplate, rhomboid plate, and trapezoidal miniplate. Postoperative complications were the outcome variables and included occlusion, mobility, and pain, among other things. Risk ratio (RR) and standardized mean difference were calculated. Version 2 of the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluations system were used to determine the certainty of the results. RESULTS: The NMA included a total of 10,259 patients from 29 RCTs. At ≤6 months, the NMA revealed that the use of 2-miniplates significantly reduced malocclusion compared to rigid MMF (RR = 2.93; confidence interval [CI]: 1.79 to 4.81; very low quality) and functional treatment (RR = 2.36; CI: 1.07 to 5.23; low quality).Further, at ≥6 months, 2-miniplates resulted in significantly lower malocclusion compared to rigid MMF with functional treatment (RR = 3.67; CI: 1.93 to 6.99; very low quality).Trapezoidal plate and AB functional treatment were ranked as the best options in 3-dimensional (3D) plates and closed groups, respectively.3D-miniplates (very low-quality evidence) were ranked as the most effective treatment for reducing postoperative malocclusion and improving mandibular functions after MCPFs, followed closely by double miniplates (moderate quality evidence). CONCLUSIONS: This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat MCPFs (low evidence).However, 2-miniplates led to better outcomes than closed treatment (moderate evidence).Additionally, 3D-miniplates produced better outcomes for lateral excursions, protrusive movements, and occlusion than closed treatment at ≤6 months (very low evidence).

Critical factors in the successful expansion of Pneumococcal Conjugate Vaccine in India during the COVID-19 pandemic.

India had decided to roll out PCV in India in 2015, but successful implementation of any new vaccine introduction mandates an enormous effort. PCV was scaled up during the COVID-19 pandemic, which posed new, unprecedented challenges in the vaccine rollout. However, India successfully expanded PCV in the country in record time across all states and Union Territories. During the pandemic, supply-side restrictions, delayed vaccine shipments, staff shortages, and restrictions in conducting training negatively affected the roll-out of PCV across the country. However, despite the ongoing pandemic, India successfully rolled out PCV across the country in 7 months. In this review, the authors have conducted a narrative review to delineate the crucial factors that helped in the successful expansion of PCV.

Optimization of Radiation Shielding Considerations for Designing Halcyon Vault.

Purpose: To determine the radiation shielding considerations for optimization of Halcyon vault shielding requirements. Materials and Methods: The primary and leakage workloads were estimated using actual clinical treatment planning and treatment delivery data acquired from three busy operational clinical Halcyon facilities. The effective use factor was determined based on a newer approach proposed in this paper using the percentage of patients treated with different treatment techniques. The transmission factor of the primary beam block, maximum head leakage, and patient scatter fractions around the Halcyon machine were experimentally determined. The first tenth-value layer (TVL1) and equilibrium tenth-value layer (TVLe) for 6 MV - flattening-filter-free (FFF) primary X-ray beam for ordinary concrete were measured. Results: The primary and leakage workloads are estimated as 1 × 105 cGy/wk and 3.1 × 105 cGy/wk at 1 m respectively. The effective use factor is found as 0.114. The primary beam-block transmission factor is determined as 1.7 × 10-4 at 1 m distance from isocenter along the central beam axis. The maximum head leakage is noted as 6.23 × 10-4. The patient scatter fractions are reported for various planar angles around the Halcyon machine at a radial distance of 1 m in a horizontal plane passing through isocenter. The TVL1 and TVLe of 6 MV-FFF X-ray beam energy for ordinary concrete are found to be 33 and 29 cm, respectively. Conclusion: Using experimentally determined shielding considerations, the optimized vault shielding requirements for the Halcyon facility are calculated and a typical layout drawing is proposed.

Gap areas in mitigation of oral cancer: A cross-sectional study evaluating awareness and knowledge of risk factors in oral cancer in a tertiary hospital.

Purpose and Objectives: One of the main causes of the increasing oral cancer (OC) burden in India is a lack of awareness and a significant gap in knowledge about risk factors and symptomology of OC. Materials and Methods: A questionnaire-based cross-sectional study was to evaluate the knowledge and awareness about OC among 500 random patients presenting for care at a tertiary hospital in western Rajasthan which serves a wide area of western, northern, and central Rajasthan. Results: A total of 446 participants, among which 83.6% were males enrolled in the study. Much to our despair, the results showed 35.23% of the participants (P = 0.007) started their habit at age <15 years. Nearly 60.3% of the participants were well aware of the harmful temporary or permanent effects of the tobacco. Around 40.85% of the participants taking tobacco products were ignorant about their changes in the tissues (site of tobacco placement). TV and Radio (50.5%) were the main source of information of the ill effects of tobacco and form a major contribution in public awareness. More than 90% of the participants had read the warnings on the tobacco packets. No doubt participants have knowledge about the ill effects of tobacco still there was a lack in behavioral modifications for tobacco cessation, leading to nonsuccess in quitting, with actual nonunderstanding about the ill effects of tobacco and overall lack of belief in the tobacco control measures. Conclusion: Our findings have found a gap in the awareness efforts of OC for the general population and will make public health professionals, clinicians, policymakers, and government a better judge and motivate them to strengthen existing national tobacco control efforts.

Correlation of hsa miR-101-5p and hsa miR-155-3p Expression With c-Fos in Patients of Oral Submucous Fibrosis (OSMF) and Oral Squamous Cell Carcinoma (OSCC).

Aim: MicroRNAs have been widely acknowledged as a diagnostic, prognostic, and/or therapeutic biomarker for the progression of OSCC, but the correlation of hsa-miR-101-5p and hsa-miR-155-3p is yet to be established with c-Fos in OSCC and OSMF. Methodology: An observational study enrolled 40 patients divided into 2 groups: Group I-21 OSMF patients without malignant transformation, Group II-19 patients with locally advanced, large-operable, or metastatic OSCC, after applying inclusion and exclusion criteria. Both miRNAs were extracted and analyzed from the tissue sample excised from the involved site. The linear regression analysis of the expression of hsa-miR-155-3p, hsa-miR-101-5p, and levels of c-fos in OSMF and OSCC patients and its correlation for habits, age, and gender were evaluated. Results: The expression of hsa-miR-101-5p was 0.81 times downregulated in OSCC tissue compared to OSMF, whereas hsa-miR-155-3p and c-fos were both upregulated 9.30 times and 1.75 times, respectively, in OSCC tissue. In Gutkha and tobacco chewers, the hsa-miR-155-3p expression could explain 12.3% (p = 0.031) for Gutkha chewers, whereas c-fos could explain 38.6% of the cases (p = 0.020) for tobacco chewers. The expression of hsa-miR-101-5p and hsa-miR-155-3p explained 43.7% and 59.5% of OSCC cases in alcoholics, respectively. Interestingly, in non-alcoholics, hsa-miR-155-3p and hsa-miR-101-5p were significant predictors of OSCC. Conclusion: Downregulation of tumor-suppressor hsa-miR-101-5p and upregulation of proto-onco hsa-miR-155-3p is responsible for intricate regulation of the progression of OSMF to OSCC via deregulated expression of c-Fos and tobacco chewing and advancing age is significant contributors for OSCC.