Article 603

National Board of Examinations - Journal of Medical Sciences
Volume 2, Issue 5, May; ISSN 2583-7524
National Board of Examination (NBE)

Journal of Medical Sciences
NBEJMS Transformative potential of AI and ML in medical sciences
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© 2024 National Board of Examination
EDITORS-IN-CHIEF
DR. MINU BAJPAI
Vice President and Honorary Executive Director,
NBEMS, New Delhi
DR. ABHIJAT SHETH

Director of Medical Services, Apollo Hospital, Ahmedabad, Gujarat
President, NBEMS, New Delhi
HONORARY EDITORIAL BOARD

Dr. Abhijat Sheth Dr. Rakesh Sharma
President, NBEMS Member, NBEMS
Director of Medical Services OSD to President, NBEMS
Apollo Hospital, Plot No-1A, GIDC Bhat, Estate
Ahmedabad, Gujarat-382424 Dr. Hem Chandra
Member, NBEMS
Prof. Minu Bajpai Vice-Chancellor, HNB Uttarakhand Medical
Vice President, & Honorary Executive Director, Education University
National Board of Examinations in Medical Dehradun, Uttarakhand
Sciences,
New Delhi Dr. Sudha Seshayyan
Member, NBEMS
Prof. Nikhil Tandon Vice-Chancellor, HNB The Tamil Nadu Dr. MGR
Vice President, NBEMS Medical University,
Professor and Head, Dept. of Endocrinology & Chennai, Tamil Nadu
Metabolism,
AIIMS, New Delhi Lt. Gen. (Dr.) Bipin Puri
Member, NBEMS
Dr. Shiva Kant Misra Vice-Chancellor, King George's Medical
Vice President, NBEMS University,
Director & CEO, Shivani Hospital and IVF, 120, Lucknow, Uttar Pradesh
Post Office,503, Shivaji Nagar,
Kanpur, Uttar Pradesh Dr. S N Basu
Member, NBEMS
Dr. C Mallikarjuna Senior Director & Head (OBGY), Max Super
Vice President, NBEMS Specialty Hospital, Shalimar Bagh,
Managing Director & Chief Consultant Urologist, New Delhi
Asian Institute of Nephrology and Urology,
Hyderabad, Telangana Prof. Randeep Guleria
Member, NBEMS
Dr. Rajoo Singh Chhina Formerly- Director, AIIMS, New Delhi
Member, NBEMS
Prof of Gastroenterology Director, Prof. M. Srinivas
Gastroenterology and Hepatobiliary Sciences Professor of Paediatric Surgery &
Fortis Hospital Director, AIIMS, New Delhi
Ludhiana, Punjab- 141001
NBEMS Office
Mr. Pranaw Kumar Mr. Jayaprakash P
Section officer, NBEMS & I.T. Editorial Manager
Assistance to NBE-Journal of Medical NBE-Journal of Medical Sciences,
Sciences, New Delhi New Delhi
NATIONAL BOARD OF EXAMINATIONS –
JOURNAL OF MEDICAL SCIENCES
Volume 2 • Issue 5 • May 2024
EDITORIAL
Artificial Intelligence and Machine Learning: Revolutionizing Medical Education,
Training, and Practice
Minu Bajpai and Abhijat Sheth 416
ORIGINAL ARTICLES
Intercountry Interactions to Reduce the Endemic Burden of Oral Cancer: An
Exploratory Observership Model in India
O.P. Kharbanda, Gampo Dorji, Harsh Priya, Anupama Ivaturi, Priyanka Ravi, Diptajit Das,
Upendra Singh Bhadauria, Charu Khurana and Monica Dev 419
Pattern of pulmonary function tests in subjects recovered from COVID 19 infection

Chaithanya K S, Anahita R Shenoy Basti and Srilakshmi M Prabhu 431
Assessment of teaching learning methods under CBME among second year medical
students
C. Dinesh M Naidu, Vanlalhruaii, Lalromawii and Christina Zosangpuii 440
Effect of Total Hemoglobin on Glycated Hemoglobin (HbA1c) in Type 2 Diabetes

Mellitus
Vidya LE, Anitha Misquith, Harish Rangareddy, Lia Maria, Jelena Stankovic and Ashakiran
Srinivasaiah 448
Impact of Tobacco Consumption During COVID-19 Lockdown: Insights from

Employees at a Government Medical College in Gujarat
Swati Misra, Jimmy Kagathara, Eshwar Kumar Gupta and Dipesh Parmar 458
Comparative Evaluation of Imaging Techniques for Paraspinal Muscle Fat

Quantification
Umaiban KV, Jeevithan Shanmugam, Seetharaman Cannane, Niva B and Santhosh
Poyyamoli 471
Assessment of PSR as a Novel Parameter in Perfusion Imaging for CNS Tumor

Characterization: An Observational Study
Niva B, Jeevithan Shanmugam, Shriram Varadharajan, Seetharaman Cannane and Umaiban
KV 482
REVIEW ARTICLE
Review of National Suicide Prevention Strategy and Other Suicide Prevention
Initiatives in India
Akshithanand KJ, Anshita Mishra, Sahadev Santra and Bratati Banerjee 493
(Contents Continued)
LETTER TO THE EDITOR

Paraquat Toxicity on Substantia Nigra: Pioneering Insights from an Autopsy Based
Pilot Study
Mohit Kumar Moses T, Rema Nair Sarkar, Jacinth Karunya Midde, Devaraj Boddepalli,
Rakesh Miriyala and Kattamreddy Ananth Rupesh 500
PERSPECTIVE
Toilet Scrolling: A Predisposing Factor for Haemorrhoids?
Kaushik Bhattacharya, Neela Bhattacharya, Aditya Shikar Bhattacharya, Vipul D Yagnik and
Pankaj Garg 507
CASE REPORTS
Rhomboid Flap Reconstruction for the Treatment of Pilonidal Sinus: A Case Series
Jashanpreet Singh, Dhiraj Kumar, Sharad Syangden, Mahesh Kumar, Joe Nepram, Kiratpal
Singh Brar, Ghaiyoor Ahmad, Diwakar Kumar, Shahnawaz Alam, Hibah Niyaz, Akash
Kumar and Kaushik Bhattacharya 511
Gangrene and Partial Auto-Amputation of the Penis in a Case of Priapism

Anil Kumar Nallabothula, Naveen Vulia Thillainathan, Vignesh N C, Karthik Kosuri, K
Dheeraj Kumar and Sumegha Malika 518
Laparoscopic Spleen-Preserving Decapsulation of the Splenic Cyst: A Case Report

Vijay N, Muvva Sri Harsha M and Prasanna Kumar Reddy 522
A Late presentation of Gossypiboma presenting as a cutaneous fistula with purulent

discharge in an operated case of Lower segment caesarean section
Ojas Vijayanand Potdar, Akash Shah, Darshan Rathi, Prakhar Chaudhary and Ashish
Chaubey 528
National Board of Examinations - Journal of Medical Sciences, Volume 2, Issue 5
National Board of Examinations - Journal of Medical Sciences

Volume 2, Issue 5, Pages 416–418, May 2024
DOI 10.61770/NBEJMS.2024.v02.i05.001
EDITORIAL
Artificial Intelligence and Machine Learning: Revolutionizing Medical Education,

Training, and Practice
Minu Bajpai1,* and Abhijat Sheth2
1Vice President and Honorary Executive Director, National Board of Examinations in

Medical Sciences, Medical Enclave, Ansari Nagar, Mahatma Gandhi Marg, Ring Road, New
Delhi, Delhi – 110029
2Senior Consultant, Cardiothoracic Surgeon & C.E.O., Apollo Hospital, Ahmedabad &
President, National Board of Examinations in Medical Sciences, Medical Enclave, Ansari

Nagar, Mahatma Gandhi Marg, Ring Road, New Delhi, Delhi – 110029
Accepted: 28-April-2024 / Published Online 01-May-2024
Artificial Intelligence (AI) and human clinicians. Powerful diagnostic and

Machine Learning (ML) have predictive algorithms are built using a range
transformative potential in the field of of additional data, including electronic
medical sciences, offering numerous health records (EHR), -omics, monitoring
benefits that can revolutionize healthcare signals, insurance claims, and patient-
delivery, patient outcomes, and research. generated data.
The integration of machine learning in
clinical settings holds great promise for Personalized Medicine
improving healthcare outcomes, enhancing AI and ML algorithms can analyze
diagnostic accuracy, and advancing large volumes of patient data, including
medical research and innovation. genetic information, medical history, and
Machine learning algorithms, lifestyle factors, to tailor treatment plans to
particularly convolutional neural networks individual patients. This approach, known
(CNNs), have shown remarkable as personalized medicine, enables
performance in various clinical healthcare providers to deliver more
applications, especially in fields like targeted and effective treatments,
radiology, pathology, and dermatology. minimizing adverse effects and optimizing
Applications of machine learning on patient outcomes.
clinical data are now conquering levels of
performance that match or exceed those of
*Corresponding Author: Minu Bajpai
Email: bajpai2b@gmail.com
416
Some Key Applications and Achievements (Figure 1)
Figure 1. Transformative potential of AI and ML in medical sciences
Disease Diagnosis and Prognosis biological processes, accelerating the

ML models trained on medical identification of potential drug candidates
imaging data, such as MRI scans, X-rays, and reducing the time and cost associated
and histopathology slides, can assist with traditional drug development
healthcare professionals in the accurate and pipelines. Moreover, AI-driven approaches
timely diagnosis of various diseases, enable the design of personalized therapies
including cancer, cardiovascular disorders, based on an individual’s genetic profile,
and neurological conditions. Additionally, improving treatment efficacy and
AI algorithms can analyze patient data to minimizing adverse reactions.
predict disease progression and identify
individuals at high risk of developing Healthcare Operations and Resource
certain conditions, facilitating early Management
intervention and preventive measures. AI-powered solutions can optimize
healthcare operations and resource
Drug Discovery and Development management, enhancing efficiency and
AI and ML techniques are reducing healthcare costs. For example,
increasingly being utilized in predictive analytics models can forecast
pharmaceutical research and drug patient admission rates, enabling hospitals
discovery processes. These technologies to allocate resources effectively and
can analyze molecular structures, predict streamline patient flow. Additionally, AI-
drug-target interactions, and simulate driven chatbots and virtual assistants can
417
automate administrative tasks, facilitate sensors has enabled continuous monitoring

patient scheduling, and providing of vital signs and health metrics outside
personalized health recommendations, traditional healthcare settings. AI
freeing up healthcare professionals to focus algorithms can analyze streaming data from
on patient care. these devices to detect anomalies, predict
health-related events, and provide early
Medical Research and Discovery warning signs of deteriorating health
AI and ML technologies play a conditions. This facilitates remote patient
crucial role in advancing medical research monitoring and telehealth services,
and driving scientific discovery. These enabling healthcare providers to deliver
tools can analyze large-scale biomedical proactive and personalized care to patients,
datasets, uncover patterns, correlations, and particularly those with chronic diseases or
identify novel biomarkers and therapeutic limited access to healthcare facilities.
targets. Furthermore, AI algorithms can AI and ML hold tremendous
assist researchers in designing and promise for transforming the landscape of
conducting clinical trials, optimizing trial medical sciences, offering innovative
protocols, and identifying patient cohorts solutions to enhance patient care, drive
for specific interventions, ultimately medical research, and improve healthcare
accelerating the translation of research delivery worldwide. As these technologies
findings into clinical practice. continue to evolve, their integration into
clinical practice has the potential to
Health Monitoring and Remote Patient revolutionize healthcare systems and
Care contribute to the advancement of global
The proliferation of wearable public health.
devices and IoT (Internet of Things)
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National Board of Examination - Journal of Medical Sciences, Volume 2, Issue 5
National Board of Examination - Journal of Medical Sciences

DOI 10.61770/NBEJMS.2024.v02.i05.002
ORIGINAL ARTICLE
Intercountry Interactions to Reduce the Endemic Burden of Oral Cancer: An Exploratory

Observership Model in India
O.P. Kharbanda,1,2 Gampo Dorji,3 Harsh Priya,4,* Anupama Ivaturi,5 Priyanka Ravi,5 Diptajit
Das,6 Upendra Singh Bhadauria,7 Charu Khurana6 and Monica Dev6
1
Ex Chief, Department of Orthodontics, Centre for Dental Education and Research, All India Institute of
Medical Sciences, New Delhi, 110029, India
2
Pro Vice Chancellor (Health), Ramaiah University of Applied Science, Bengaluru, Karnataka 560054
3
Responsible Officer (NCD), WHO SEAR office, New Delhi, 110029, India
4
Additional Professor, Department of Public Health Dentistry, Centre for Dental Education and Research,
All India Institute of Medical Sciences, New Delhi, 110029, India
5
Department of Public Health Dentistry, Centre for Dental Education and Research, All India Institute of
6
National Oral Health Programme, Centre for Dental Education and Research, All India Institute of
7
Senior Resident, Department of Public Health Dentistry, Centre for Dental Education and Research, All
India Institute of Medical Sciences, New Delhi, 110029, India
Accepted: 22-February-2024 / Published Online: 01-May-2024
Abstract
Background: Lip and oral cavity cancers are the second most common cancers in India and Sri
Lanka. Hence, there is a need to enhance partnership among countries and institutions to develop
the capacity to ameliorate the huge burden of oral cancer in the SEAR region. Methods: An
observership model was field tested with the inter-country collaboration from India and Sri Lanka
in December 2018 on seven Sri Lankan dentists from National Cancer Control
Program participated in the observership model conducted in India. Results: This model covered
all the components of oral cancer prevention including awareness on oral cancer and oral
potentially malignant disorder management training. Conclusions: This model emphasized the
significance of inter-country handholding and strengthening of the existing cancer prevention
activities.
Key words: Oral cancer, Cancer Prevention, Cancer Screening, Observership model, South-East
Asia, Capacity Building, Health Promotion, Medical Education
*Corresponding author: Harsh Priya

Email: drharshpriya@gmail.com
419
Graphical Abstract
Introduction better quality diagnostic and treatment

The Global Cancer Observatory facilities and increased skilled workforce and
(2018) [1] reports that the cancers of the lip their capacity building in the regions with
and oral cavity are the second most common high oral cancer burden [4].
cancers in India (10.4%) and Srilanka (9.1%), The skillset of the primary health care
high prevalence is seen among males in both team, pertaining to oral cancer early
India (16.1%) and Sri Lanka (14.8%). The detection, in most of the South-East Asian
prognosis represented as five year survival Region (SEAR) Countries is fragmentary and
rate for early stage oral cancer is 60.2% and there is a need to build capacities through
advanced stage is only 3.3% [2]. concerted efforts. A leap forward was the
Most of the times the oral cancers are development of the Training Module on early
preceded by array of disorders that can be detection and prevention of oral cancer which
easily detected in the mouth because of an is integrated into PEN (Package of Essential
easy access of the site hence oral examination Non-Communicable Diseases).
is possible; early identification and detection International health organizations are
of these oral potentially malignant disorders committed to prevention of oral cancer
is also possible during routine general health through primary care and encourage national
check-up or screening by physicians, dental and international government associated
professionals, healthcare workers and even health authorities, research institutions and
by self-examination of one’s oral cavity [3]. agencies, non-governmental organizations
There is a dire need for improved and and self-help groups and civil society groups
enhanced primary prevention measures, and residential welfare associations to
420
strengthen their efforts for the effective and

Material and Methods
efficient control and prevention of oral
The structure of the proposed observership
cancer [5]. The inter country collaboration in
model was exploratory and takes into
this regard can serve as an ideal method for
cognizance the burden of oral cancer, the
prevention of oral cancer and can serve as an
risks endemic to this region, the similarities
integral measure in promoting oral cancer
of the governance structures and the growing
awareness across different countries where
trend of a health policy change in this region.
the countries can learn and adopt best
The cycle of events in the algorithm was need
practices on oral cancer screening and
based. The crux of the model was the
prevention. An exploratory observership
advocacy by the public health fraternity to the
model was thus conceptualized to train public
relevant governing bodies in the member
health professionals in oral cancer screening
states (Figure 1).
and prevention.
Figure 1. Observership Model
421
Approvals of the Ministries of Health, oral cancer and its subsequent burden on the
Home Affairs and External Affairs are economy. Prevention on a large scale would
important to ensure the entire capacity be the optimal way to ultimately lower the
building plan for smooth run through physical, social, emotional, and financial
validated channels. The needs and burden as well as improve the overall quality
expectations of the trainees may then be of life of oral cancer survivors by reducing
gathered before formulation of an agenda. the risk of recurrence and provision of
The observership may involve palliative care.
participation of multiple institutions of a The common risk factor approach
country along with field level activities. needs to be adopted by the oro-dental health
Handholding of nations with low capacities programmes globally and integrate with
may be subsequently planned on the lines of broader health promotion rather than
the current model. standalone oral health promotion [8]. It is
A blending of the didactics and field clearly visible that the use of tobacco is a
visits may be planned for achieving common risk factor between the majority of
objectives which may spread across the non-communicable diseases (NCDs) and oral
following domains (Figure 1) disease burden. This forms a logical
explanation regarding the integrative
 Risk reduction approach especially for tobacco control
 Preventive Strategy initiatives.
 Empowerment and Engagement The aim of the WHO Oral Health
 Training Programme is to ascertain that oral health
 Surveillance and Research fraternity and oral health systems are directly,
 Referral Pathways and Management appropriately, continuously and consistently
Protocols. involved in influencing and benefitting
patients and the masses to increase their
Risk Reduction awareness of the risks of tobacco use, and to
Tobacco use along with excessive decrease and be abstinent of use of all forms
alcohol intake have been estimated to of tobacco. Management of tobacco
account for about 90% of the cancers in the dependence is a key feature of the tobacco
oral cavity; the risk escalates when tobacco is control strategy indicated in the Article 14 of
used in combination with alcohol or areca nut the WHO Framework Convention on
[6]. The International Agency for Research Tobacco Control and MPOWER, where it is
on Cancer has provided evidence that emphasized about “Offer help to quit tobacco
smokeless tobacco causes oral cancer [7]. use” [9]. Cessation support which can be
In the recent times federal and private either behavioural motivation to quit with or
agencies have been actively working in the without cessation medications can increase
concerted actions towards promoting oral the likelihood that a tobacco user will quit
cancer prevention, risk reduction, research successfully.
and strategies in view of rising cost to treat
422
Longitudinal studies with decade of recommendations on minimum requirements

follow-up have shown that educational and for essential medicines and inexpensive
awareness creation interventions reduce technologies, and standards and indicators to
tobacco use and dwindle incidence of oral measure improvements. It also consists of
potentially malignant disorders [10]. The agreement tools for behavioural interventions
main obstacles to provide tobacco cessation to talk about the main modifiable risk factors:
methods are lack of awareness, knowledge, cessation of tobacco habit, dietary
skills and professional leadership. Hence, modification, avoiding harmful use of
there is a need to integrate initiatives that are alcohol and augmenting physical activity,
targeting tobacco cessation with programmes which can be delivered by medical or non
including oral health and train the medical health-care workers.
professionals on the same. An inter country Population based screening
collaboration can aid in promoting targeted programmes also serve the purpose of
interventions which can significantly help in increasing awareness in the community about
increasing awareness and skills ultimately cancers, risk factors and the need for periodic
leading to risk reduction. screening. It also enables an understanding of
Limiting the intake of alcohol, better health and avoidance of risk factors in
chronic irritation due to sharp tooth or the general community. Effective and
denture and malnutrition are other modifiable accessible cancer screening program ensure
risk factors, which can be prevented through early detection and increase in cancer
capacity building (reference). Educating the survival rates. One of the best practices is the
public about the risk factors for cancer, mobile screening and awareness building
prevention through risk-factor modification operation which was being carried out
also play important roles in minimizing the throughout Sri Lanka, where the common
impact of oral cancers. cancers of the country including oral cancer
were screened. Training of health
Preventive Strategy professionals is a cost-effective, evidence-
The survival rates of oral cancer are based strategy for controlling tobacco use
good, provided if they are detected and dependence. This will also help oral health
treated at the early stages. WHO [11] has care providers to perform their role as health
developed a cost-effective Package of communicators in the dental clinic setting
Essential Non-communicable (PEN) disease [12].
and health conscious lifestyle interventions Ministry of Health and Family
for the SEAR. It contains a battery of Welfare, Government of India [13], provided
validated, evidence-based easy to follow the guidelines for common cancer screening
clinical blueprints and guidelines for clinical which included a spectrum of health care
diagnosis and treatment of cardio vascular professionals from doctors to primary health
diseases, management of chronic respiratory care workers including Accredited Social
diseases, suspected oral, breast and cervical Health Activist (ASHA) and Auxiliary Nurse
cancers (the three most common cancers), Midwife (ANM) to be trained in oral cancer
423
screening. The training included an algorithm These materials aim to increase

for oral cancer screening for the health care awareness, alter attitudes and bring about a
workers and the referral system. Training the change in specific behaviors like tobacco
health care professionals on a similar model consumption, delay in reporting, use of home
will help in channeling the cancer screening remedies for early signs of oral cancer,
at the national level. It is important to train stigmatizing oral cancer and early onset of
the dentist, doctors and other health care engaging in risk behaviors like chewing
professionals in oral cancer screening. Oral tobacco, smoking, alcohol consumption,
visual examination of the mouth is an well- among others. Sharing updated information
established method of screening to detect the and novel ideas in a way that is culturally
oral potentially malignant disorders or very sensitive and locally acceptable to the
early stages of oral cancer with systematic community, using appropriate social media
visual inspection of the buccal and labial platforms and channels would go a long way
mucosa; gingivae; bucco-alveolar sulci; in prevention since it works at the societal
ventral, dorsal and lateral borders of the level.
tongue; palate; and floor of mouth, by trained A campaign mode that involves
and calibrated caregivers under adequate sun relevant civil society groups, for instance,
or torch light with disposable instruments religious leaders invoking a ban on areca nut
like wooden spatulas. usage in Sri Lanka, was more relatable to the
locals and yielded a better response to health
Empowerment and Engagement communication that followed, addressing the
Efforts to promote a mutual exchange socio-cultural barriers. This offered a
of information, ideas and resources between pragmatic approach for advocacy in the
the masses and the advocators of oral health political corridors too. Empowerment at both
are pertinent for prevention of oral cancer, individual and community levels through
ensuring appropriate dissemination of thoroughly tested engagement activities that
information, as well as adequate utilization of involved all the responsible societal groups
resources. A key component of created a supportive environment and
empowerment and engagement model for strengthened community action. The
oral cancer prevention included development proposed observership model thus
of Information, Education and accommodated a specific domain on
Communication (IEC) and Behavior Change empowerment and engagement paving way
Communication (BCC) materials Module for for enhanced outcomes of efforts to prevent
Multi-Purpose Workers (MPW) [14] - oral cancer in this region.
Female/Male on Prevention, Screening and
Control of Common Non Communicable
Diseases.
424
Training Surveillance and Research

Building capacities of health and non- Surveillance and research are integral
health professionals through training on early for effective and efficient cancer control
detection and referral of oral cancer is a programmes and monitoring and evaluating
significant step towards prevention in the their stepwise and overall performance. A
SEAR. The diverse workforce in the eleven comprehensive surveillance and research
countries have similar responsibilities at the system provides data on the magnitude of the
primary health care level thus making it oral cancer burden, trends in risk factors, and
possible to train this workforce on similar the effect of prevention, early detection,
lines. This may involve didactics and treatment and palliative care. These have
demonstrations on Oral Visual Examination been innovatively utilized in artificial
(OVE) and Mouth Self Examination in intelligence solutions and precision
premiere teaching institutions at the modelling frameworks. Cancer registries are
individual and institutional level. Training part of the surveillance system and there is a
may involve certain on-site field visits to need for a registry on Oral Potentially
provide a hands-on experience on working in Malignant Disorders. Research contributes to
low resource settings. Capacity building may determining causes of cancer, evaluation of
also go the digital way. Multiple telemedicine strategies for prevention, treatment and
and online avenues exist which may be control.
exploited to reach out to a wide audience. The
Extension for Community Health Outcomes Referral and Management
(ECHO) is one such platform in vogue for Cancer screening programmes
educating medical professionals, dentists, require assured linkages at every level, with
nurses and primary workers dealing in health mechanisms in place for clinical handover
care on common cancer screening, early and follow up, including high quality
identification and detection, tobacco documentation processes that are accessible
cessation and management of common at any level of care at which the patient
cancers [15]. Observership is also one such presents. There is a need to have a country
method that may be tested for sustainability. wide uniform linkage referral system for
The professionals may be trained on a effective and timely management of
Training of Trainers model to build diagnosed oral cancer or oral potentially
capacitates which may encompass the malignant cases up to the tertiary level. The
resources needed, budgeting, logistics and oral cancer management should also be
contingencies. An exemplary training included as part of this model to ensure the
programme may serve as a lead for health care professionals are familiar with the
adaptation in the regional countries based on different treatment modalities/ protocol
the language, population and current service followed in other regions. Surgery,
delivery mechanism perspectives. radiotherapy and chemotherapy methods
should be sensitized to the health care
professionals.
425
The primordial and primary

Results prevention including tobacco and alcohol
National Cancer Control Program cessation counseling methods were discussed
(NCCP), Sri Lanka expressed interest in oral at the National Drug Dependence Treatment
cancer prevention activities in India and Centre. The National Institute of Cancer
requested for an observership program. An Prevention and Research was visited for the
observership model was developed by the training on the national level oral cancer
Centre for Dental Education and Research prevention research and tobacco control
(CDER), AIIMS, India. Seven dentists from activities adopted in the India. As a part of the
the NCCP, Sri Lanka participated in the secondary prevention the oral potentially
observership program, prior to the start of the malignant disorder management training was
program ethical and legal considerations given at CDER, AIIMS. The tertiary care
were taken by gathering approval from the prevention activities were briefed at the Dr.
Ministries of Health, Home Affairs and B.R.A Institute-Rotary Cancer Hospital –
External Affairs before the programme. AIIMS where the oral cancer surgery and
Following this, the profile of the trainees was rehabilitative techniques were discussed. The
verified by the governing councils of the program ended on a note to continue similar
medical/dental education. The needs and exchange programs in the future. A similar
expectations of the trainees (questionnaire program based on the same module may be
google form) were gathered before planned for other countries in the SEAR
formulating the agenda. region. A visit to the WHO office
The exchange programme/ training strengthened the intercountry relation
involved participation of multiple institutions towards health care and an urgent need to
of the country, especially those at the involve other SEAR countries into similar
premiere level of programme execution along initiatives.
with field level activities. The flow of events
is depicted in Figure 2.
426
Efforts to reduce the endemic burden of oral cancer in the SEA

Region: An exploratory Observership model from India
Advocacy for capacity building exercises by the Ministries of Health and the governing
bodies of SEAR Countries including country offices of WHO
Initiation of the collaboration through email exchange / formal

conferences/ meetings where ideas are discussed
Formulation of an agenda and agreement on the time

and frequency of capacity building workshops
Clearance from the TRAINEE country’s Clearance from the Host country’s
Need Based Review
Ministries of Health, External Affairs Ministries of Health, External Affairs

and Home affairs and home affairs
Verification of the trainees’ profiles by the governing body of medical

and dental education in the host country
Exchange of needs and expectations

Before formulating the capacity building exercise
Organization of the themes for capacity building in consultation with

experts and the WHO Country Office
Pre-training assessment and

interactions with the host institution
Blending of need based didactics and

hands on sessions/ demonstrations
Orientation to the local service Risk reduction Referral

delivery mechanisms, care Prevention & Early Detection Empowerment and
pathways and the differences Capacity Building engagement
from global/ regional practices Research & Surveillance Management
Post training assessment and decision on next workshop
Report to the WHO Regional office and the ministry of health, advocate further workshops
Hand holding the countries which do not have a set protocol on early detection
Centre for Dental Education and Research,
AIIMS New Delhi
Figure 2. Efforts to reduce the endemic burden of oral cancer in the SEA region – A flow of events
427
Discussion a cut off score of 12 or more are referred for

The observership of Sri Lankan oral examination to a dental professional.
delegates in India explored the possibility of Ministry of Health, Timor-Leste [17]
inter country interactions in achieving cancer has included oral cancer screening at least
prevention. The method was holistic and once in lifetime under the National Strategy
involved visit of the delegation to tertiary for prevention and control of NCD, Injury,
level institutions. The delegates got an Disabilities and care for elderly and NCD
overview of institutional and national action plan 2014-2018. Currently, the oral
perspectives of oral cancer management from cancer screening program is fragmented in
screening to surgery, budgeting cancer other SEAR regions. Hence there is a need to
control programs to training primary health appropriately channelize the screening
care workers. The team also visited the WHO system.
regional office for a regional overview. The
programme is itself a strength of the model Conclusion
and provides immense opportunities to This model provides a road map for
interact, learn and adopt relevant practices, the observership program for oral cancer
suited to the needs of their country. A healthy screening and prevention in the high oral
exchange of ideas leads to a pragmatic cancer burden countries. This model may
approach where countries come together and also include retraining assessments and
commit to reduce the endemic burden of oral exchange programme at young learner level.
cancer. A similar model can be adopted for reduction
A National Cancer Screening of other common cancers such as breast and
Program under which the common cancers - cervical cancer in the SEAR region. Future
oral, breast and cervical cancer are screened research should focus on evaluation of this
for, was operationalized by the Ministry of model at various regions.
Health and Family Welfare, Government of
India in 2017 [13]. A well designed Acknowledgements
framework which highlights the Dentist, We humbly appreciate the efforts of
Dr. S.D. Gunatilaka, Dr. A.H.T.S.
medical officers and primary health care
Karunatilleke, Dr. J.L.P. Jayasekara, Dr.
workers’ duties in oral cancer screening and N.W.K.V. Nanayakkara, Dr. S.
tobacco cessation are outlined. Alahapperuma, Dr. B.R.M.J. Prasanna and
National Cancer Control Programme, Dr. S.V.I.P. Suriyapperuma dental surgeons
Sri Lanka [16] has adopted a risk factor from Sri Lanka for their active participation
model (RFM) for oral cancer screening, in the observership program. We also would
under their National Cancer Control extend our thanks to the NICPR team headed
by Dr. Ravi Mehrotra, Director, ICMR-
Program. According to the RFM scores are
NICPR who was instrumental in the
calculated according to the individuals age, delegate’s visit to their centre. We have
socioeconomic status, habit history such as sincere gratitude for NDDTC team of AIIMS
tobacco smoking, betel quid chewing and New Delhi for entrusting on us and
alcohol consumption. Those individuals with organising an educational visit and hands-on
for the delegation especially in relation to
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430

DOI 10.61770/NBEJMS.2024.v02.i05.003
ORIGINAL ARTICLE
Pattern of pulmonary function tests in subjects recovered from COVID 19 infection
Chaithanya K S,1 Anahita R Shenoy Basti2,* and Srilakshmi M Prabhu3
1FatherMuller Medical College, Mangalore - 575002, India

2Department of Physiology, Father Muller Medical College, Mangalore -575002, India
3Department of Medicine, Father Muller Medical College, Mangalore - 575002, India
Accepted: 22-February-2024 / Published Online: 01-May-2024
Abstract
Introduction and Aim: The pulmonary sequelae of COVID-19 have not been extensively studied in
the Indian population. This study was taken up with the aim to assess the pulmonary function tests
(PFT) in subjects recovered from COVID-19. Material and Methods: In this observational cross-
sectional study PFT was assessed in 50 adults in the age group of 18-60years. Rapid Antigen
Testing was performed to rule out active COVID-19 infection. Subjects with acute or chronic
respiratory illnesses that could affect lung functions were excluded. Results: We performed
PFT on 50 subjects, with a mean age and BMI of 36.09 years and 25.17 kg/m2. Fatigue and/or
breathlessness were the most common complaints present post-recovery. A normal PFT was
found in 22 participants and 28 showed a restrictive pattern. Based on the severity of the disease
they had experienced the study population was classified into three groups mild, moderate or
severe COVID. The three groups were found to be comparable in their demographic
parameters, the PFT parameters were significantly different between the groups with
significantly lower values seen in subjects who recovered from severe COVID. Conclusions:
Restrictive pattern on PFT was the common abnormality found in patients recovered from
COVID-19. This finding emphasises the need for long-term follow-up and establishment of a
plan of assessment and management in patients recovered from COVID-19.
Keywords: SARS CoV 2, coronavirus, lung function test, lung disease
*Corresponding Author: Anahita R Shenoy Basti

Email: anahita203@gmail.com
431
Graphical Abstract
Introduction alveolar epithelium destruction,

Severe acute respiratory syndrome hyalinisation of the membranes, capillary
coronavirus 2 (SARS CoV-2) is the damage and bleeding, alveolar septal
coronavirus that has led to the coronavirus fibrous proliferation and pulmonary
disease 2019 (COVID-19) pandemic. consolidation leading to pulmonary fibrosis
6,931,000 confirmed cases comprising and hypertension [4,5].
400,857 deaths globally were reported by Although the pathophysiology of
8th June 2020 [1]. With the onset of the the disease has been determined to some
second wave, an accumulative global surge extent, the long-term consequences and its
of up to 141 million confirmed cases and effect on pulmonary function tests have not
3.01 million global deaths as of April 2021 been studied in detail.
have been reported [2]. Evaluation of pulmonary function
The most common symptoms in recovered patients is important in
include fever, fatigue, cough and assessing and understanding the prognostic
expectoration accompanied by frequent attributes of the virus [6].
muscle soreness, anorexia, chest tightness, A wide spectrum of tools can be
dyspnoea, nausea, vomiting, diarrhoea and used to objectively assess functional
headache. The patients developing respiratory parameters and the most
COVID-19 pneumonia had bilateral lung commonly used tools are the pulmonary
lesions and respiratory failure or acute function tests such as spirometry, diffusion
respiratory distress syndrome (ARDS) capacity and lung volumes, and evaluation
[1,3]. of airway resistance or respiratory muscles.
Evidentiary studies have shown Epidemiological study report implicates
lungs to be the most common organ that is that the above tools help in analysis of
affected. Pulmonary injury following abnormalities which can lead to pulmonary
COVID-19 pneumonia occurs as a result of fibrosis [4,7,8].
pathophysiological events like diffused
432
Reports have shown that short-term performed to exclude active COVID

radiological and abnormal pulmonary infection. Negative RAT was followed by
functions are most likely to be evaluated in performance of Pulmonary function test by
recovered patients’ post-acute phase of a trained technician.
infection. Little light has been thrown on Subjects with acute or chronic
long-term changes in the PFT which aids in respiratory illnesses that could affect lung
understanding the recovery post-infection functions were excluded.
[1]. PFT was conducted and interpreted
Thus, it is of utmost importance to using easy one connect software. The
determine pulmonary functions in the parameters assessed were Forced vital
follow-up of patients recovered from capacity (FVC), forced expiratory volume
COVID-19. This study was taken up with 1 second (FEV1), FEV1/FVC ratio, Forced
the objective of analysing pulmonary expiratory flow (FEF) 25-75%, Peak
function tests (PFT) in subjects who have expiratory flow (PEF).
recovered from COVID-19 infection. Descriptive statistics were reported
as mean ± standard deviation [SD].
Methodology Differences between the groups were
This observational descriptive study analysed for statistical significance by chi-
recruited 50 adults in the age group of 18- square or Fisher’s exact test for categorical
60 years who survived mild, moderate or variables and by t-test or Wilcoxon rank
severe infection with COVID-19 virus. sum test for continuous variables as
Subjects who were previously applicable.
diagnosed with COVID-19 by positive
PCR on nasopharyngeal swab and/or Results
presence of bilateral lung infiltrates on In this study, we performed PFT on
chest X-ray were included in the study. 50 participants majority of whom had
Baseline information regarding symptoms complaints fatigue and/or breathlessness.
at initial presentation and severity of the Their mean age and BMI were found to be
disease was retrieved from medical records. 36.09 years and 25.17 kg/m2. Their
Subjects underwent clinical examination demographic data is represented in Table 1.
and any persisting symptoms were noted. A normal PFT was found in 22 participants
Rapid Antigen testing (RAT) was and 28 showed a restrictive pattern.
Table 1. Shows the demographic characteristics of the study population

n=50 Count (%)
Sex F 39(78.0%)
M 11(22.0%)
Presence of comorbidities No 32(64%)
Yes 18(36%)
Severity of COVID Mild 32(64.0%)
Moderate 15(30.0%)
Severe 3(6.0%)
PFT Restrictive pattern 28(56.0%)
Normal pattern 22(44.0%)
433
A comparison of demographic been depicted in Figure 1. The two groups

parameters between subjects with were found to be comparable.
restrictive pattern PFT and normal PFT has
Figure 1. Comparison of demographic parameters between subjects with restrictive pattern PFT and
normal PFT
Table 2 Compares the demographic weight between the three groups, indicating
data and PFT values between subjects the groups were comparable in these
recovered from mild, moderate and severe aspects. However, there were highly
COVID-19. Based on the ANOVA p significant differences (p <0.01) in FVC,
values, no statistically significant FEV1, FEV6, FEV1/FVC and FIVC values
differences were found in age, height and between the groups.
Table 2. Compares the demographic data and PFT values between patients recovered from mild,
moderate and severe COVID-19
n=50 Mean± Std. Deviation ANOVA p
Age Mild 32 35.19±11.31
Moderate 15 35.67±12.10 0.497
Severe 3 43.67±16.50
Ht Mild 32 158.56±5.67
Moderate 15 162.13±9.56 0.194
Severe 3 163.67±8.39
Wt Mild 32 65.44±13.42
0.441
Moderate 15 62.80±12.99
434
Severe 3 73.33±8.33
BMI Mild 32 26.03±5.26
Moderate 15 23.73±3.90 0.249
Severe 3 27.30±0.89
FVC (% of Mild 32 77.88±9.99

predicted)
Moderate 15 63.73±14.59 <0.001*
Severe 3 55.33±4.73
FEV1 (% of Mild 32 81.44±9.68

predicted)
Moderate 15 65.60±16.23 <0.001*
Severe 3 47.67±16.04
FEV1/FVC (% Mild 32 105.63±7.69

of predicted)
Moderate 15 102.93±8.25 0.008*
Severe 3 86.33±29.14
FEV6 (% of Mild 32 78.94±10.22

predicted)
Moderate 15 64.73±14.61 <0.001*
Severe 3 56.67±4.16
FEF25-75 (% Mild 32 97.34±22.56

of predicted)
Moderate 15 74.47±33.19 0.007*
Severe 3 56.67±48.69
PEF (% of Mild 32 91.13±12.52

predicted)
Moderate 15 76.40±16.69 0.004*
Severe 3 69.33±37.82
FIVC (% of Mild 32 75.69±12.03

predicted)
Moderate 15 63.53±14.74 0.003*
Severe 3 56.33±5.51
*statistically significant
Table 3 Depicts Post hoc between the mild and moderate, mild and
Bonferroni test performed for PFT between severe group, however, no significant
patients recovered from mild, moderate and difference was found between moderate
severe COVID. On comparing the PFT and severe group except in FEV1/FVC. P
values between the groups a significant value < 0.05 was considered significant for
difference was found in the PFT values all the parameters.
435
Table 3. Post hoc Bonferroni test performed for PFT between patients recovered from mild, moderate
and severe COVID-19
Post hoc analysis-Bonferroni test p value

FVC (% of predicted) Mild Moderate 0.001*
Severe 0.006*
Moderate Severe 0.751
FEV1 (% of predicted) Mild Moderate <0.001*
Severe <0.001*
FEV1/FVC Mild Moderate 1.000
(% of predicted) Severe 0.006*
Moderate Severe 0.030*
FEV6 Mild Moderate 0.001*
(% of predicted) Severe 0.007*
FEF25-75 (% of Mild Moderate 0.033*
predicted) Severe 0.056
PEF (% of predicted) Mild Moderate 0.013*
Severe 0.079
FIVC (% of predicted) Mild Moderate 0.011*
Severe 0.045*
*statistically significant
Discussion total lung capacity was significantly

We performed PFT on 50 subjects, decreased in severe as compared to non-
with a mean age and BMI of 36.09 years severe cases. However, in their study, only
and 25.17 kg/m2. Generalised weakness 12.3% of their subjects showed restrictive
and/or breathlessness were the most pattern and 10.5% showed obstructive
common complaints present post-recovery. pattern, as compared to 56% showing
Among the 50 participants, 28 (56%) restrictive pattern in our study and none of
showed a restrictive pattern while the rest our subjects showed obstructive pattern in
showed a normal PFT. PFT [9].
In a study done during the early In another study that performed
convalescence phase found that abnormal PFT on 100 post-COVID pneumonia
pulmonary function tests especially subjects, found that restrictive pattern was
impairment of diffusion capacity and the present in 55% of the patients (N = 55),
decline in FEV1/FVC ratio were detected in mixed pattern in 9% of patients (N = 9),
43 (75.4%) patients. They also found that
436
obstructive in 5% of patients (N = 5) with A case series where 5 patients who

31% (N = 31) having normal pattern [10]. were asymptomatic or had very mild
A possible explanation for the symptoms of COVID-19 infection upon
absence of obstructive pattern in our study diagnosis and were not hospitalized for the
could be due to the exclusion of smokers same, were found to have interstitial lung
and asthmatics who were included in the disease four to eight weeks after a COVID-
previous study [9]. Although a high 19 diagnosis [12].
percentage of our study population showed In our study, 64% of the participants
a restrictive pattern, majority (67%) had had recovered from mild COVID yet the
mild restriction. A higher percentage of percentage of participants showing
restrictive pattern can also be attributed to restrictive pattern was high. As mentioned
the fact that the subjects included in our in the study by James A Stockley et al, other
study were symptomatic with complaints of factors of extrapulmonary restriction could
fatigue and breathlessness at the time of have been attributed to the restrictive
PFT recording. Our institution being a pattern on PFT and should be considered
tertiary health care centre could also have while evaluating post-COVID sequelae.
contributed to a higher percentage of We further classified the study
abnormal PFT. A high percentage (36%) of population into three groups based on the
our study population also had comorbidities severity of their disease into mild, moderate
which could also be attributed to the or severe COVID. Mild COVID was
presence of higher restrictive pattern on defined as patients with signs of upper
PFT. respiratory tract infection without evidence
In another study lung function was of breathlessness or hypoxia. Moderate
assessed in COVID-19 survivors more than COVID was defined as pneumonia with no
3 months after discharge. They compared signs of severe disease, presence of clinical
patients who had been admitted to the features of dyspnea and or hypoxia, fever,
intensive care unit and those who received cough, including SpO2. Severe COVID
ward treatments and found pulmonary was defined as Severe Pneumonia plus one
restriction characterized by reduced vital of the following; respiratory rate >30
capacity and/or alveolar volume in breaths/min, severe respiratory distress,
65.4% of all participants. They found that SpO2. The three groups were found to be
36.1% of patients had reduced transfer comparable in the demographic data
factor (TLCO) but the majority (78.1%) had however the PFT parameters were
a preserved/increased transfer coefficient significantly different between the groups
(KCO), indicating an extrapulmonary cause. with lower values seen in subjects who
They attributed this to obesity, fatigue of recovered from severe COVID.
the respiratory muscles, localized In a study with findings
microvascular changes, or hemosiderosis contradictory to ours no difference was
from lung damage. They also concluded found between mechanically ventilated
that this restrictive pattern was independent patients for severe COVID pneumonitis
of whether or not the patients had received and non-ventilated patients 3 months post-
mechanical ventilation or had ward-based recovery [10]. In another cross-sectional
respiratory support [11]. follow-up study of 220 COVID-19 patients
437
performed 10 weeks post-COVID, found The study was initiated after ethical
restrictive pattern to be prevalent in 38% of approval and written informed consent
the study population. They found the TLC from the subjects.
to be below normal in patients recovered
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439

DOI 10.61770/NBEJMS.2024.v02.i05.004
ORIGINAL ARTICLE
Assessment of teaching learning methods under CBME among second year medical students
C. Dinesh M Naidu,1 Vanlalhruaii,2 Lalromawii3 and Christina Zosangpuii3,*

1Professor and Head, Department of Pharmacology, Zoram Medical College, Falkawn Aizawl,
Mizoram, India
2Associate Professor, Department of Pharmacology, Zoram Medical College, Falkawn Aizawl,
Mizoram, India
3Assistant Professor, Department of Pharmacology, Zoram Medical College, Falkawn Aizawl,
Mizoram, India
Accepted: 8-March-2024 / Published Online: 01-May-2024
Abstract
Background: Medical institutions are progressively transforming their medical curriculum from a
traditional approach to Competency-Based Medical Education (CBME), which is a student-centered
curricular activity. Self-assessment of the teaching methods by the students is an important tool to
ensure the best possible academic environment for the students. The main aim of the study was to
assess the teaching learning methods under CBME among 2nd-year medical students based on
student’s feedback, in the Dept of Pharmacology. Materials and methods: A cross-sectional study
was conducted using a questionnaire distributed to the 2nd year MBBS students who met the
inclusion criteria. Data was analysed and expressed as percentages. Results: A total of 95 students
met the inclusion criteria and all responded to the questionnaire. Majority responded positively
towards the current teaching-learning methods. Small group discussion (SGD) seemed to be the
preferred teaching learning method garnering a total of 67% vote. Most of the students mentioned
their preference of learning in small groups but found the adult learning principles like Self
Directed learning (SDL) to be less useful. Conclusion: Majority responded positively towards the
current methods. It was evident from the study that facilitators need to focus on inclusivity in SGD.
Incorporation of teaching learning methods suggested by the students would be an ideal tool to
ensure the best academic environment for the students. Implementation of more problem based &
critical thinking centric methods may encourage students to utilize the adult learning principles like
SDL etc.
Keywords: Small group discussion, Competency based Medical Education, Self directed Learning
*Corresponding author: Christina Zosangpuii

Email: zosangi10@gmail.com
440
Graphical Abstract
Title: Assessment of teaching learning methods under CBME among second

year medical students
Authors: C. Dinesh M Naidu, Vanlalhruaii, Lalromawii, Christina Zosangpuii
Background: Medical institutions are progressively

Materials and methods: A
transforming their medical curriculum from a traditional
cross-sectional study was
approach to Competency-Based Medical Education
conducted using a
(CBME), which is a student-centered curricular activity.
questionnaire distributed to
Self-assessment of the teaching methods by the students is
the 2nd year MBBS students
an important tool to ensure the best possible academic
who met the inclusion
environment for the students. The main aim of the study was
criteria. Data was analysed
to assess the teaching learning methods under CBME among
and expressed as
2nd-year medical students based on student’s feedback, in
percentages.
the Dept of Pharmacology.
Table : Students perception of new teaching modalities under CBME
Neither
Sl. Question Strongly Agree agree nor Disagree Strongly
no Agree disagree disagree
1. CAL helps me understand ANS better 42% 43% 13% 2% 0%
2. Injection practices on a mannequin gives
me confidence to perform on a real 13% 49% 23% 14% 1%
patient
3. I find AETCOM modules helpful for 31% 7% 3%
21% 38%
MBBS curriculum
4. ADR reporting exercises gives me the
confidence to report real cases in the 29% 58% 10% 2% 1%
Wards/OPDs
Conclusion: Majority responded positively towards the current methods. Improvements suggested are
now incorporated into our teaching learning methods. Focus should be on inclusivity in SGD and
implementation of more problem based & critical thinking centric methods.
441
Introduction undergraduate teaching [3]. Since CBME has

Medical institutions are progressively now been successfully implemented for two
transforming their medical curriculum from a batches in the department of Pharmacology
traditional approach to Competency-Based i.e. 2019 and 2020 batches, conducting an
Medical Education (CBME), which is a assessment to analyse how much the students
student-centered curricular activity. In India, have benefited with the new curriculum
the realm of medical education is currently in would help the department fill up gaps where
the midst of a significant transition, moving it is required. Feedback is an important tool
away from conventional frameworks towards that can help assess the ground reality of
competency-based medical education newly introduced teaching methods. It will
(CBME). This method places a strong ensure that the department is driven in the
emphasis on students acquiring tangible skills right direction to achieve the learning
in a manner centered around the learner, outcome of the course [4]. Hence it is
fostering the growth of capable Indian imperative for the department to have a self-
Medical Graduates with a focus on assessment of the teaching methods by the
metacognition. At the heart of CBME is the students, in order to ensure the best possible
provision of skill-based training, with the outcome for the students. Conducting an
overarching goal of preparing physicians who assessment to analyse the teaching learning
can effectively function as the primary methods in the department of Pharmacology
healthcare provider for their community, all would help the department to identify the
the while ensuring their global applicability shortcomings and help improve the overall
[1]. Competency based medical education has teaching method. Moreover, teaching method
been implemented by National Medical evaluation by the students in colleges is not a
Commission since August 2019 in medical common practice, but is one that may help
colleges all over India. The goal of NMC is to enormously in gap identification and
streamline medical education across India so introduction of new innovative methods in
that, quality is maintained irrespective of teaching for future batches [5].
where a student may study. Apart from the
conventional didactic lecture, certain teaching Materials and Methods
learning methods like self-directed learning A cross-sectional study was conducted
and small group discussion has been in the Department of Pharmacology, Zoram
emphasized in this new curriculum [2]. The Medical College after taking approval from
practical classes also have received a the Institute’s Research Committee (IRC No.
complete make over. For Pharmacology G.28045/1/2021-ZMC/IRC/48) as well as
subject, an entire new teaching aid like from the Institutional Ethics Committee (IEC
mannequin for practicing drug administration No. F.20016/1/18-ZMC/IEC/104).
has been introduced. Students are now Questionnaire was framed in the department
exposed to all the common types of injection of Pharmacology by faculties, with a focus on
techniques required for a normal hospital the new teaching methods introduced under
setting. Even the conventional method of competency based medical education
learning drug effects using experimental (CBME), where majority of the questions
animals has been replaced with Computer were framed on a Likert’s scale with few
Assisted Learning (CAL), making the being open ended. The questionnaire was then
relevance of animal house obsolete for validated for its relevance and feasibility by
442
the Institutes research board, as well as Ethics the route of drug administration exercises on a
committee. The questionnaire along with mannequin, 62% agreed that practicing
consent form was distributed at the end of the injections like IV, IM, SC on a mannequin
university practical exam. The students were gives them the confidence to perform the skill
not required to fill in their personal on a real patient. As the department of
information and confidentiality was strictly Pharmacology is an ADR (Adverse drug
maintained in an attempt to eliminate bias. monitoring) centre, ADR reporting exercises
Inclusion criteria: 2020 batch students are given to the Phase 2 students, which also
who were eligible to appear for university requires them to fill up the report in a PvPI
exam in 2023 (Pharmacovigilance programme of India)
Exclusion criteria: (i) 2020 batch prescribed reporting format. This was
students who were not eligible to appear for included in the questionnaire and 89% agreed
university exam in 2023 (ii) Repeater students that the exercise would help them report real
from senior batch who were eligible to appear ADRs in the wards & OPDs. However,
for university exam in 2023. AETCOM module seems to be the least
Data collected was entered and favourite among the newly introduced
analysed using Microsoft Excel and expressed teaching aspect of CBME, where 41% of the
in frequencies and percentages. students were either unsure or disagree with
its relevance for their curriculum, (Table 2).
Results While 37% of the students agreed that
There were a total of 95 respondents the current lecture classes were good enough,
who met the inclusion criteria. Among the 40% suggested the use of more videos,
current mode of teaching/learning method, animations & mnemonics. 53% of the
majority (48%) preferred SGD (small group students also suggested that grading system
discussion) as compared to didactic lecture after every small group discussion could be
and SDL (Self-directed learning) (Table 1). beneficial, in order to assess the individual
Likert scale was used to evaluate students contributions of each group member.
feedback on the newly implemented practical Regarding Self-Directed Learning (SDL),
training module such as computer assisted only 9% were satisfied with the current
learning (CAL) and Injection practices on a method and 83% wanted an improvement
mannequin. Majority (85%) of the students either in the form of a more elaborate test,
agreed that CAL exercises helped them in while some wanted more exam oriented topics
understanding the Autonomic nervous system to be included. (Figures 1-3).
better while 13% were undecided. Regarding
Table 1. Preference of teaching learning methods by Phase II MBBS students
Sl no Teaching/Learning method Percentage
1. Didactic lecture 35%
2. Small group discussion 48%
3. Self-Directed Learning 19%
443
Table 2. Students perception of new teaching modalities under CBME
Neither
Sl. no Question Strongly Agree agree nor Disagree Strongly
Agree disagree disagree
5. CAL helps me understand ANS better 42% 43% 13% 2% 0%
6. Injection practices on a mannequin
gives me confidence to perform on a 13% 49% 23% 14% 1%
real patient
7. I find AETCOM modules helpful for 31% 7% 3%
21% 38%
MBBS curriculum
8. ADR reporting exercises gives me the
confidence to report real cases in the 29% 58% 10% 2% 1%
Wards/OPDs
45
40
40 37
35
30
25
20
15
9
10
6 6
5
1
0
Present method is More video, flow Hightlight Provide MCQ from Board and chalk To reduce noise
good enough chart, mnemonics, important and the topic after teaching pollution
animation in the common exam every class
slide lecture questions
Figure 1. Students suggestion on how to improve Pharmacology theory classes
444
60
53
50
40
30
21
20
11 10
10
3 2
0
Grading after every Quiz after every Smaller groups for Changing of group Exam oriented Assignment – pre
SGD class SGD class – either the SGD member regularly discussion led by and post SGD
individual or group teacher
competition
Figure 2. Students suggestion on how to improve SGD
50
45 43
40
40
35
30
25
20
15
9 8
10
5
0
Test /viva after each SDL Commonly asked question in Present method is good Provide better/easier study
session exam to be included in the enough material /links
SDL topic
Figure 3. Students perception on Pharmacology SDL
445
Discussion to self-directed learning, especially with the

This cross-sectional study was assessment method used by the facilitator.
conducted to assess the student’s perspective The major limitation of the study is
on the teaching learning methods in the that it was conducted among 2nd year MBBS
Department of Pharmacology, after the students of a single medical college. Hence
implementation of CBME. Assessment was the findings regarding students’ impression of
done by distribution of questionnaires to CBME may have limitations in
Phase II MBBS students who met the representation.
inclusion criteria.
Small group discussion garnering a Conclusion
vote of 67% was observed to be the most This cross-sectional study was
appreciated method with some suggestions for conducted to assess the student’s perspective
improvement from the students themselves. on the teaching learning methods in the
Other studies like Thind et al. [6] and Department of Pharmacology, after the
Ramanathan et al. [7] also observed that any implementation of CBME. As this new
form of teaching in a small group was ranked curriculum has only been implemented
high by the students. Chelani & Mahajan [8] recently, many medical colleges across India
also pointed out that students appreciated are yet to adhere strictly to all the guidelines.
sessions with direct interaction with teachers, Hence, assessment studies on student's
where active participation from students was perceptions will be an important tool to
highly encouraged. Hence, from this study as facilitate the transition from the old to the new
well as similar ones mentioned, it is evident curriculum. It was also an important means
that students learn better in small groups as it for gap identification in the academic
provides a better environment to clear their activities of the department. The innovative
doubts and spark interest for an extended ideas suggested by the students are also
period of time. planned for later incorporation in the
Self-Directed Learning was observed departmental academic activities.
to be the least appreciated teaching-learning
method as only 19% chose it as their preferred Conflict of interest
method. Similar findings were observed by The authors declare they do not have
Ramanathan et al. [7] where many students conflict of interest
claimed SDL to be time consuming and felt it
to be unnecessary for their curriculum. Funding support
Regarding AETCOM, though roughly 60% of There is no funding support for this
the students responded positively, about 40% work
were still not sure about the purpose of
AETCOM in their curriculum especially References
during 2nd year, which is during phase II 1. Ramanathan R, Shanmugam J, Sridhar
MBBS. However, proper faculty training and MG, Palanisamy K, Narayanan S.
student sensitization workshops especially Exploring faculty perspectives on
during their 1st year may alleviate some of the competency-based medical education: A
negative perceptions towards the adult report from India. J Edu Health Promot
learning principles incorporated in the new 2021;10:402.
curriculum. Special emphasis has to be given
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2. Bhutani N, Arora D, Bhutani N. 6. Thind A, Jain A, Kumar A, Kaur P,

Competency-Based Medical Education Bansal R, Singh R. Effectiveness of
in India: A Brief Review. Int J Rec competency-based teaching and
Innov Med Clin Res. 2020;2(2):64-70. comparison to traditional teaching of
3. National Medical Commission. Phase I MBBS students. Natl J Physiol
Competency based undergraduate Pharm Pharmacol 2022;12(06):765-770.
curriculum for the Indian Medical 7. Ramanathan R, Shanmugam J,
Graduate volume-1 [Internet]. 2018 Gopalakrishna SM, Palanisami K,
[cited 2024 Feb 5]. Available from: Narayanan S. Exploring the learners'
https://www.nmc.org.in/information- perspectives on competency-based
desk/for-colleges/ug-curriculum/ medical education. J Edu Health Promot
4. Wanjari S. Feedback in Medical 2021;10:109.
Education. JHSE 2018;5(2):53-7. 8. Chellani G and Mahajan AS. Medical
5. M. Senthil Velou, E. Ahila. Types of students’ evaluation of competency-
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447

DOI 10.61770/NBEJMS.2024.v02.i05.005
ORIGINAL ARTICLE
Effect of Total Hemoglobin on Glycated Hemoglobin (HbA1c) in Type 2 Diabetes Mellitus
Vidya LE,1 Anitha Misquith,2 Harish Rangareddy,3,* Lia Maria,1 Jelena Stankovic4 and
Ashakiran Srinivasaiah5
1
Allied Health Sciences, Sapthagiri Institute of Allied Health Sciences, Karnataka, India
2
Assistant Professor, Department of Biochemistry, Sapthagiri Institute of Medical Sciences &
Research Center, Bangalore, Karnataka, India
3
Assistant Professor, Department of Biochemistry, Haveri Institute of Medical Sciences, Haveri,
Karnataka, India
4
Pathologist at University Clinical Center Nis (Univerzitetski klinički centar Niš), Serbia
5
Professor & HoD, Department of Biochemistry, Haveri Institute of Medical Sciences, Haveri,
Karnataka, India
Accepted: 03-April-2024 / Published Online: 01-May-2024
Abstract
Background: Glycated hemoglobin (HbA1c) is a pivotal marker in the diagnosis, prognosis, and
therapeutic monitoring of diabetes mellitus. Given the involvement of hemoglobin in non-enzymatic
glycation reactions, it is hypothesized that total hemoglobin concentration might impact HbA1c levels
alongside blood glucose concentrations. Objectives: This study aimed to estimate and compare
plasma fasting glucose level and total hemoglobin level in type 2 diabetes mellitus (T2DM) patients
with and without anemia. The study also aimed to estimate HbA1C and compare with calculated
HbA1C using formula in T2DM patients with and without anemia and to correlate between total
hemoglobin levels with directly measured HbA1c in T2DM patients with and without anemia.
Methodology: This cross-sectional study, employing purposive sampling, investigated 30 anemic and
30 non-anemic Type 2 Diabetes Mellitus (T2DM) patients at the Central Diagnostic Laboratory. Total
Hemoglobin, HbA1C, and Fasting Plasma Glucose were measured for the patients and the data was
analyzed. Results: Independent 't' tests revealed significant differences (p < 0.0001) in estimated
HbA1c, fasting blood sugar, calculated HbA1c, and Hb levels between the two groups. Subgroup
analyses exhibited significant differences in estimated HbA1c for both groups individually (p = 0.003
for T2DM without anemia and p<0.0001 for T2DM with anemia). Pearson's correlation analysis
indicated no significant correlation between HbA1c and hemoglobin in either subgroup. Similarly
linear regression analysis treating HbA1c as the dependent variable yielded a non-significant p-value,
suggesting that hemoglobin levels do not significantly influence HbA1c. Conclusion: In conclusion,
regardless of anemia status, our findings suggest that hemoglobin is not a significant predictor of
HbA1c levels in T2DM patients, offering valuable insights into factors influencing HbA1c variability
in diabetic populations.
Keywords: glycated hemoglobin, type 2 Diabetes Mellitus, anemia in diabetes
*Corresponding Author: Harish Rangareddy

Email: harishreddy1349@gmail.com
448
Graphical Abstract
Background non-enzymatic glycation reactions, it is

Glycated hemoglobins are hypothesized that total hemoglobin
hemoglobins that have a sugar moiety concentration might impact HbA1c levels
attached to them, forming the HbA1 alongside blood glucose concentrations
fraction within the adult hemoglobin HbA [2]. This study aimed to estimate and
[1]. The HbA1c fraction, in particular, compare plasma fasting glucose level and
serves as a predominant component of total hemoglobin level in type 2 diabetes
HbA1 and provides an estimate of an mellitus (T2DM) patients with and without
individual's blood sugar levels over the anemia. The study also aimed to estimate
previous three months [2]. Studies have HbA1C and compare with calculated
indicated that maintaining an HbA1c level HbA1C using formula in T2DM patients
below seven percent can decrease with and without anemia and to correlate
microvascular complications in diabetic between total hemoglobin levels with
patients [3,4]. Glycated hemoglobin directly measured HbA1c in T2DM
(HbA1c) is a pivotal marker in the patients with and without anemia.
diagnosis, prognosis, and therapeutic
monitoring of diabetes mellitus. However, Methodology
it's crucial to note that HbA1c is Study design
influenced by factors beyond just blood This cross-sectional investigation
sugar levels. Other variables also play a was conducted within the department of
role in affecting HbA1c measurements [5]. Biochemistry, employing purposive
HbA1c is dependent on the interaction sampling to select previously diagnosed
between the concentration of blood cases of Type 2 Diabetes Mellitus (T2DM)
glucose and the lifespan of the erythrocyte. patients attending follow-up visits. The
Given the involvement of hemoglobin in Institutional Ethics Committee approved
449
the study protocol and access to the fluoride-containing vacutainers, followed

database was strictly limited to analytical by processing for Hemoglobin, HbA1C,
purposes, with personal information and Fasting Plasma Glucose. Hemoglobin
remaining inaccessible. Laboratory reports levels were assessed using the Automated
of T2DM patients from the Central Hemato Analyzer SYSMEX XNL 550,
Diagnostic Laboratory were gathered, while HbA1C was measured via National
ensuring data anonymization procedures Glycohemoglobin Standardization
were rigorously followed. Program (NGSP) certified turbidometric
Sample size was calculated inhibition immune assay [7]. Fasting
considering the mean differences of plasma glucose (FBS) levels were
HbA1c measured by the National determined using the Glucose Oxidase-
Glycohemoglobin Standardization Peroxidase method on VITROS 5600 [8].
Program (NGSP) certified Calculated HbA1c values were derived
immunoturbidimetric method in a study by using the formula: HbA1c = 2.6 + 0.03 ×
Silva et al. [6] Fasting Blood Sugar (mg/dL) [9].
n = (Zα/2+Zβ) 2 *2*σ2 / d2 Statistical analysis

Data was tabulated and entered in
where Zα/2 is the critical value of the Microsoft excel. Kolmogorov-Smirnov
Normal distribution at α/2 (for a test revealed that the data was normally
confidence level of 95%, α is 0.05 and the distributed. Independent ‘t’ test was
critical value is 1.96), Zβ is the critical applied for HbA1c values in Type 2
value of the Normal distribution at β (for a Diabetes Mellitus Patients with anemia
power of 80%, β is 0.2 and the critical and checked for significant difference in
value is 0.84), σ2 is the population comparison to the data obtained from Type
variance, and d is the mean difference. 2 Diabetes Mellitus Patients without
Sample size was estimated to be 26. anemia. Pearson’s correlation analysis was
The study population comprised of performed to assess the relationship
already diagnosed 30 T2DM patients both between HbA1c and total hemoglobin.
with anemia and 30 T2DM patients Linear regression analysis was done with
without anemia, who were recruited from HbA1c as a dependent variable and total
individuals visiting the Central Diagnostic hemoglobin as a predictor. Statistical
Laboratory, after obtaining written analysis was performed using SPSS v16,
consent. Exclusion criteria encompassed and significance was set at p < 0.05.
hemolysis, hemoglobinopathies, renal
disorders, severe anemia (defined as Results
hemoglobin levels <7g/dL), inadequate The T2DM with anemia patients
sample volume, mislabeling, illegible included 53.3% females and 46.7% males
slips, and erroneous sample collection as shown in Figure 1. Independent 't' tests
techniques. were employed to compare HbA1c, fasting
Biochemical analyses were blood sugar (FBS), calculated HbA1c, and
conducted under aseptic conditions, hemoglobin concentrations between the
involving the collection of approximately two groups. The results revealed
3 mL of blood into EDTA and sodium statistically significant differences in
450
estimated HbA1c, FBS, calculated HbA1c, an F-statistic of 1.023 (Y = 0.3044*X +

and Hb levels (p < 0.0001) between T2DM 5.008) with a non-significant p-value of
patients with and without anemia as 0.3205 as shown in Figure 3.This suggests
depicted in Table 1. Further subgroup that hemoglobin levels do not significantly
analyses demonstrated significant influence HbA1c. Calculated HbA1c relies
differences in estimated HbA1c for both on FBS levels and Bland Altman plot
groups individually (p = 0.003 for T2DM analysis was done in T2DM patients with
without anemia and p<0.0001 for T2DM anemia to check there was proportional
with anemia). Pearson's correlation bias between the means of estimated
analysis indicated no significant HbA1c and calculated HbA1c considering
correlation between HbA1c and the possibility of decreased Hb in anemia
hemoglobin in either subgroup as depicted to affect the estimated HbA1c values.
in Table 2. Linear regression analysis, with However, the β coefficient was -0.172 and
Hb as the predictor in T2DM with anemia p=0.364 indicating that there was no
yielded an F-statistic of 1.915 (Y = - proportional bias as shown in Figure 4.
0.5055*X + 13.97) with a non-significant This further implies that though anemia
p-value of 0.1773 as shown in Figure 2. may be having an impact on the HbA1c it
Linear regression analysis, with Hb as the may not be substantial.
predictor in T2DM without anemia yielded
Figure 1. Gender distribution of T2DM with anemia
Table 1. Comparison of estimated HbA1C, FBS, Calculated HbA1C and Hb among type 2
diabetes mellitus with and without anemia
T2DM without T2DM with anemia,

Parameters anemia, n=30 n=30 p value
(Mean±SD) (Mean±SD)
Estimated HbA1C (%) 9.3±1.2 9.1±2.3 <0.0001
FBS (mg/dL) 182.43±74.08 144.53±91.09 <0.0001
Calculated HbA1C <0.0001
8.1±2.2 6.9±2.7
(%)
Hb (g/dL) 14.3±1.2 9.7±1.2 <0.0001
p<0.05 statistically significant
451
Table 2. Pearson’s correlation analysis of estimated HbA1c with Hb
r p value
T2DM without anemia
0.188 0.321
n=30
T2DM with anemia
-0.253 0.177
n=30
p<0.05 statistically significant
Figure 2. Linear Regression of Hb as a predictor of HbA1c in T2DM with anemia
Figure 3. Linear Regression of Hb as a predictor of HbA1c in T2DM without anemia
452
Figure 4. Bland Altman plot analysis of estimated HbA1c and calculated HbA1c in T2DM
with anemia
Discussion individuals with anemia tend to have

This study looked into how anemia comparatively shorter lifespan compared
affects glycated hemoglobin (HbA1c) to individuals without anemia [12].
levels in individuals with Type 2 Diabetes According to a research conducted by SC
Mellitus (T2DM) and examined various Thambiah et al., patients with anaemia
factors that could influence HbA1c showed elevated levels of serum urea,
measurement. The study involved 30 creatinine, and reduced FBS, estimated
patients with T2DM who had anemia and glomerular filtration rate (eGFR) when
30 who did not, with gender distribution of compared to patients without anaemia
53.3% females and 46.7% males in T2DM [13]. Patients with diabetes and
with anemia. The average age was nephropathy who were anaemic had a
52.5±6.3 years in T2DM with anemia. significantly lower level of haemoglobin
This is similar to the prevalence study by than those without this complication
Panda AK et al but in contrast in their (p=0.022). At a threshold eGFR value of
study anemia was more common in males 38.3 mL/min/1.73 m2 with a maximum
[10]. Anemia is recognized as a common Youden index of 0.462, the accuracy to
condition that can have detrimental effects differentiate mild from moderate anemia
on their overall health. In a study by was 66.7% for sensitivity and 79.5% for
Hizomi Arani et al., it was found that a specificity. This research demonstrates that
high number of patients with T2DM in anemia is detected in T2DM patients when
northern Iran (around 22%) had anemia, they first visit the specialist outpatient
which is linked to obesity, high levels of clinic and is closely linked to CKD [13].
triglycerides, duration of T2DM, and However, in a prospective study by
chronic kidney disease [11]. Additionally, Mounika et al., found that diabetics even
in a study by Sharif et al., observed that without kidney problems experienced a
453
high occurrence of anemia. Additionally, deficiency anemia (IDA) tend to have

their research also indicated that lower HbA1c levels compared to non-IDA
inadequate blood sugar management and diabetic patients [17].
advanced age are linked to the In a prospective interventional
development of anemia in diabetic case-control study conducted by Kalairajan
individuals with unaffected kidney et al., a significant correlation was found
function [14]. between Hb and HbA1c levels, with a
In a study by Çetinkaya Altuntaş et coefficient of correlation of 0.26 and a p-
al., it was observed in iron deficiency value of less than 0.01 [18]. Urrechaga et
anemia individuals otherwise healthy al., study highlighted a positive association
without any other illness had low HbA1c between HbA1c levels and iron deficiency
levels and following iron administration as [19]. In a study by Madhu SV et al,
therapy the HbA1c levels increased; the significant increase in HbA1c among
possibility of hemoglobin affecting the patients with iron deficiency anemia (IDA)
HbA1c levels was highlighted [15]. In our with a p-value of less than 0.001 was
study we selected T2DM with anemia observed, and they also noted a substantial
patients and T2DM without anemia as the enhancement in HbA1c levels following
comparator group showed significant oral iron supplementation [20]. Esfahani et
variations in estimated HbA1c, FBS, al., observed a noteworthy enhancement in
calculated HbA1c, and hemoglobin levels HbA1c levels following iron therapy
between T2DM patients with and without treatment in patients with Type II diabetes
anemia, suggesting that anemia could and iron-deficiency anemia (IDA) [21].
affect these parameters. Further analysis of This indicates that using only HbA1c to
subgroups confirmed notable disparities in monitor T2DM anemia individuals could
estimated HbA1c and calculated HbA1c provide inaccurate information. Hence,
levels within each group, indicating the healthcare providers and physicians need
diversity in HbA1c levels among various to take this into consideration prior to
patient profiles. making treatment decisions.
In a study by Son et al., anemic In a study by Alsayegh et al.,
individuals (n=112), their age and gender revealed a significantly elevated
matched controls (n=217) suspected of prevalence of anemia among diabetic
diabetes were included. They underwent patients (p < 0.001). Additionally, they
glucose tolerance and HbA1c tests. Mean found a frequent correlation between
HbA1c levels were compared for anemia and diabetic peripheral neuropathy
sensitivity and specificity in diabetes as well as diabetic foot conditions.
diagnosis. Clinical traits were similar. In Interestingly, no significant association
normal glucose, HbA1c didn't differ was observed between HbA1c and Hb
significantly (P=0.580). Yet, anemic levels (p = 0.887) [22]. Similarly in our
subjects with higher glucose showed study Pearson's correlation analysis
slightly higher HbA1c levels. Anemia revealed no significant relationship
lowered HbA1c specificity in diabetes between HbA1c and hemoglobin in either
diagnosis (p<0.05) [16]. Our study results subgroup, indicating that hemoglobin
align with the findings of Solomon et al, levels may not have a substantial impact
indicating that diabetic patients with iron on HbA1c values in T2DM patients.
454
Linear regression was also carried out to A larger sample size may facilitate
evaluate the association between Hb levels the exploration of potential confounding
and HbA1c. The results showed that the F- variables or modifiers that might have
statistics and p-values were not significant been overlooked in a smaller cohort. This
(F-statistic = 1.915, p = 0.1773 for T2DM step could contribute to a more
with anemia; F-statistic = 1.023, p = comprehensive understanding of the
0.3205 for T2DM without anemia), complex dynamics between hemoglobin
suggesting that hemoglobin levels do not and glycemic control in diabetes. In
have a significant effect on HbA1c. conclusion, while the current study
Moreover, the Bland-Altman plot provides valuable initial insights,
analysis indicated no significant advocating for further exploration with a
proportional bias between the mean values larger sample size is a prudent suggestion
of estimated HbA1c and calculated to strengthen the scientific validity and
HbA1c, indicating that while anemia could widen the applicability of the findings.
affect HbA1c levels to some extent, it may
not have a considerable impact. These Acknowledgments
results add to our knowledge of the We would like to express our
variables influencing HbA1c measurement gratitude to Sapthagiri Institute of Medical
in T2DM individuals and underscore the Sciences and Research Center, Bangalore
necessity for more studies to clarify the for providing the necessary resources and
intricate connection between HbA1c and support for this research project which was
hemoglobin levels when anemia is present. conducted as part of the Rajiv Gandhi
University of Health Sciences
Conclusions Undergraduate Research. The authors
The comparative analysis between would also like to thank the Rajiv Gandhi
T2DM patients with and without anemia University of Health Sciences, Bangalore,
reveals substantial differences in estimated India for opportunity provided.
HbA1c, fasting blood sugar (FBS), The authors would also like to
calculated HbA1c, and hemoglobin thank Ms. Ashwini, Statistician,
concentrations. These results emphasize Department of Community Medicine,
the importance of considering anemia SIMSRC for the support extended during
status when interpreting HbA1c levels in data analysis.
diabetic individuals. Moreover, the
subgroup analyses for T2DM patients with Conflicts of Interest
and without anemia individually highlight The authors declare no conflicts of
distinct patterns, further refining our interest.
understanding of the factors influencing
HbA1c variability within these Funding
subpopulations. The lack of significant Rajiv Gandhi University of Health
correlation between HbA1c and Sciences, Bengaluru, Karnataka funded
hemoglobin in both subgroups challenges this study under the short term research
previous assumptions, suggesting a more grants for undergraduate research.
nuanced relationship between these
variables.
455
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DOI 10.61770/NBEJMS.2024.v02.i05.006
ORIGINAL ARTICLE
Impact of Tobacco Consumption During COVID-19 Lockdown: Insights from

Employees at a Government Medical College in Gujarat
Swati Misra,1,* Jimmy Kagathara,2 Eshwar Kumar Gupta1 and Dipesh Parmar3
1Senior Resident, Department of Community Medicine, M P Shah Government Medical
College, Jamnagar, Gujarat

2Junior Resident, Department of Community Medicine, M P Shah Government Medical

3Professor & Head of Department of Community Medicine, M P Shah Government Medical
Abstract
Background: Tobacco consumption is consistently harmful to one's well-being, and for
individuals with respiratory conditions, it can elevate the likelihood of contracting infections,
raise the potential for complications, and enhance the probability of transmission. In this study
awareness about the association and the impact of the lockdown on tobacco use among current
tobacco users of Government Medical College, Gujarat was assessed. Objectives: To evaluate
the level of insight regarding the connection between COVID-19 and tobacco use and to assess
the influence of COVID-19 related lockdown measures on the rate of tobacco consumption
among current tobacco users at Government Medical College, Gujarat. Methods: A study was
conducted among Class 3 & Class 4 employees of Government Medical College using
convenient sampling technique. Study population who was ready to participate in the study and
had been actively engaged in the 10-month counselling program from January 2020 to
November 2020. Data was gathered through a pre-tested closed-ended questionnaire. Statistical
analysis was carried out using the SPSS software (version 22). Ethical approval was obtained
from the Institute Ethical Committee, and written informed consent was acquired from all the
participants. Results: A significant majority, comprising 68% of tobacco users, lacked
awareness of the link between tobacco use and COVID-19. Among the 173 current tobacco
users, 49 of them successfully abstained from tobacco use during the lockdown period. The
primary reasons cited for this change were the unavailability and higher prices of tobacco
products. Conclusions: The level of awareness regarding the connection between tobacco and
COVID-19 played a crucial role in motivating tobacco users to discontinue their tobacco
consumption.
Keywords: COVID-19, Lockdown, Counselling, Tobacco Cessation, Employees
*Corresponding author: Swati Misra

Email: swati.d100@gmail.com
458
Graphical Abstract
Introduction Understanding that COVID-19 primarily

The outbreak of Coronavirus spreads through respiratory droplets
Disease 2019 (COVID-19), caused by the released when an infected person coughs,
SARS-CoV-2 virus, was initially identified sneezes, or talks is crucial. These droplets
at the close of 2019 in Wuhan, China [1] can be inhaled by individuals in close
COVID-19 is an infectious illness caused proximity, potentially leading to infection.
by the highly contagious SARS-CoV-2 Given that COVID-19 primarily targets the
virus. It can lead to severe pneumonia, respiratory system, any factor that
acute respiratory distress syndrome, and, in compromises lung health and the immune
many cases, fatal outcomes, particularly response can potentially increase the risk of
among vulnerable populations. These at- severe illness. Tobacco use is recognized
risk groups include older adults and for its harmful impact on the respiratory
individuals with chronic medical conditions system, with smoking being a significant
like cardiovascular disease, diabetes, contributor to respiratory conditions like
respiratory issues, hypertension, and chronic obstructive pulmonary disease
malignancies [2]. The importance of (COPD) and lung cancer. Smoking causes
maintaining optimal respiratory health has damage to the lungs, diminishing their
been underscored by the COVID-19 ability to function optimally. It also impairs
pandemic. One noteworthy aspect that has the cilia, tiny hair-like structures in the
received significant focus in the context of airways that help remove mucus and
COVID-19 is the link between tobacco use, particles, making it harder for the body to
which includes both smoking cigarettes and clear infections. In the context of COVID-
using other tobacco products, and the 19, this is concerning because individuals
heightened risk of contracting the virus and with compromised lung health may be less
experiencing severe consequences. equipped to combat the virus. This had
459
affected severely the whole world resulting tobacco use, particularly in populations
into implementation of ‘lockdown’ vulnerable to COVID-19 complications. By
interventions at different degrees and at understanding the socio-demographic
different times [3]. The Prime Minister of factors influencing tobacco consumption
India initiated a nationwide lockdown as a patterns, the study can provide valuable
measure to combat the COVID-19 insights for public health initiatives aimed
pandemic on 24th march, 2020 [4]. While at reducing both tobacco use and the burden
the COVID-19 pandemic and lockdown of COVID-19. According to Almu'atasim,
measures were linked to increased levels of Khamees et al. [8], the study found that the
anxiety, fear, sadness, adjustment lockdown had a notable effect on
problems, post-traumatic stress disorder, individuals' lifestyles, particularly their
and suicidal tendencies, these smoking behaviors. The majority of
psychological issues may raise the risk of smokers in our sample reported a shift in
engagement in and exacerbation of their smoking habits, with a predominant
substance misuse as an unhealthy coping increase observed. Conversely, those who
mechanism in various populations [5]. reported a decrease in smoking levels
Columbia University [6] also conducted the generally exhibited a healthier lifestyle in
study to know initial COVID-19 lockdown terms of nutrition and other facets.
period witnessed a potential surge in Quitting tobacco is a critical step in
tobacco use. However, quitting tobacco reducing the risk of severe COVID-19
consumption has the potential to alleviate outcomes. It not only helps improve lung
the burden of non-communicable diseases function and the immune system but also
[7] and also respiratory diseases. reduces the overall risk of respiratory
According to few studies [8-10], infections. For individuals who are
COVID-19 prevalence and its association concerned about their susceptibility to
with tobacco use have been extensively COVID-19 and its potential consequences,
studied. According to those studies, the quitting tobacco should be a priority.
global prevalence of COVID-19 continues Keeping in mind the above facts regarding
to fluctuate, with periodic surges in cases lockdown and tobacco consumption, the
driven by variants, vaccination rates, and aim of present study to assess the effect of
public health measures. However, ongoing covid-19 related lockdown over quit rate of
research consistently highlights the tobacco consumption. Whereas, objectives
association between tobacco use and of the current study to assess the
adverse COVID-19 outcomes. Studies have understanding about the association with
shown that smokers are at a higher risk of covid-19 and tobacco consumption and to
severe illness, hospitalization, and death analyze the effect of covid-19 related
from COVID-19 compared to non- lockdown on tobacco consumption rate of
smokers. Additionally, tobacco use may current tobacco users of Government
exacerbate respiratory symptoms and Medical College, Gujarat.
impair the body's immune response,
making individuals more vulnerable to Methodology
respiratory infections like COVID-19. The current study was the
These findings underscore the urgent need longitudinal follow-up study type which
for targeted interventions to address was carried out in medical college of
460
Gujarat on Class 3 and Class 4 (total 307) like bidi, cigarette, pan masala or any
employees working there. Using the other chewable form in last 12
universal sampling technique and after months.
taking their interview it was found that out 2) Former tobacco user – An employee
of all the employees, 178 were consuming who used to have tobacco in any form
tobacco in one or the other form. 5 in any time during his life but stopped
employees were not willing to participate in from the past 12 months.
the study. Hence, 173 was the final sample 3) Non-user – An employee who had
size, considered for the study. Study never used tobacco in any form
duration was January 2020 to November during his life.
2020 with 5 follow-ups. Each time
questions related with their current status of Results
tobacco consumption, their perception for Among 307 employees of the
covid and tobacco, their reason for institute who were interviewed, 56.35%
decreasing/ quitting were asked. participants were current tobacco user,
Participants in the study provided verbal 7.81% were former tobacco user while
informed consent, and they were assured of 35.83% were not using tobacco. Out of
the confidentiality of their data. The study those current tobacco user Class 3
commenced after receiving Institutional employees were 24.43% while 75.57%
Ethical Clearance from the Ethics belonged to the Class 4. According to Table
Committee, with the Ethical Clearance 1, the socio-demographic distribution of
Certificate Reference Number current tobacco users in the study sample
IEC/CERTI/66/02/2020. The current article reveals several key insights. Firstly, in
is a component of a comprehensive study terms of age, the majority of participants
conducted on tobacco users in the fall within the age brackets of 28-37 and 38-
designated area. The study employed a pre- 47, comprising 31.79% and 28.32% of the
tested, semi-structured questionnaire for sample, respectively. This suggests that
data collection. Initial data was gathered tobacco use is more prevalent among
through individual interviews, and individuals in their late twenties to mid-
subsequently, five focused group forties. Interestingly, participants aged 18-
discussions were conducted, involving a 27 and those aged 48-57 also constitute
total of 15 groups with seven members in significant proportions, though slightly
each group. During the Focused Group lower. However, individuals over 58
Discussions (FGD), we evaluated represent a minimal portion of the sample,
information pertaining to the reduction or indicating a decline in tobacco use among
cessation of tobacco consumption, along older age groups. Secondly, regarding
with the associated reasons. Additionally, gender, males significantly outnumber
we assessed the quitting rate among current females, with 75.14% of participants being
tobacco users and its correlation with male. This gender disproportionality aligns
awareness of COVID-19 and tobacco. with broader trends indicating higher
tobacco consumption rates among men.
Definition/Criteria used in the study [11] Thirdly, marital status analysis reveals that
1) Current tobacco user – An employee the vast majority of participants are married
who was using tobacco in any form (87.28%), potentially implying that marital
461
status might be associated with tobacco use consumption (chewing) is notably more
behavior. Lastly, in terms of family type, prevalent (90.75%) compared to smoking,
nuclear families constitute the majority, indicating a preference for this form of
followed by joint and third-generation tobacco among the study participants.
families, suggesting that family structure Additionally, the majority of participants
may play a role in influencing tobacco use report daily tobacco use (92.48%), with a
habits. Overall, this data underscores the significant proportion using tobacco 3-5
importance of considering socio- times per day (48.55%). This suggests a
demographic factors when studying pattern of regular and frequent tobacco
tobacco use patterns and designing targeted consumption among the sample.
interventions for prevention and cessation. Furthermore, a relatively small percentage
According to Table 2, the of participants report using other substances
association between socio-demographic (12.13%), implying that tobacco is the
details and tobacco consumption patterns primary substance of choice for the
among study participants reveals several majority of individuals in this study.
significant findings. Firstly, the prevalence Overall, these findings highlight the
of family history of tobacco consumption interconnectedness of socio-demographic
and friends/ colleagues’ history of tobacco factors and tobacco consumption behaviors,
consumption is high, with 80.92% and emphasizing the need for targeted
85.55% respectively. This suggests a strong interventions that address social influences
influence of social networks and familial and patterns of tobacco use among specific
factors on tobacco use behavior among demographic groups.
individuals. Secondly, smokeless tobacco
Table 1. Socio-demographic Distribution of study participants (Current Tobacco Users)

Variable No. of Participants (%)
A] Age
18-27 29 (16.76%)
28-37 55 (31.79%)
38-47 49 (28.32%)
48-57 36 (20.81%)
>58 4 (2.31%)
B] Gender
Male 130 (75.14%)
Female 43 (24.85%)
C] Marital Status
Married 151 (87.28%)
Unmarried 22 (12.72%)
D] Family Type
Nuclear 112 (64.73%)
Joint 41 (23.69%)
rd
3 Generation 20 (11.56%)
462
Table 2. Association between socio-demographic details and tobacco consumption pattern in

study participants
A] Family History of Tobacco Consumption
Yes 140 (80.92%)
No 33 (19.08%)
B] Friends/ Colleagues History of Tobacco Consumption
Yes 148 (85.55%)
No 25 (14.45%)
C] Tobacco Form
Smokeless (chewing) 157 (90.75%)
Smoke 16 (9.25%)
D] Tobacco Use
Daily 160 (92.48%)
Occasional 13 (7.52%)
E] Frequency of Tobacco Use (per day)
0-2 25 (14.45%)
3-5 84 (48.55%)
6-8 57 (32.94%)
>9 7 (4.04%)
F] Use of other substances
Yes 21 (12.13%)
No 152 (87.87%)
After Covid-19 lockdown on follow harmful tobacco use and COVID-19

up after 10 months it was found that 49 outcomes, while 55 (31.79%) were aware
participants had quit tobacco consumption of the association [χ2=11.53, p-
completely. For the sake of convenience value=0.00069]. Among participants with
abstinence of tobacco intake for at least 1 awareness of the association between
month was considered as quit. As per tobacco consumption and COVID-19
Figure 1, people who quit tobacco, majority outcomes, 43.64% quit tobacco during the
of them gave reason for quitting and study period. The quit rate among those
decreasing use was increased price or aware of the COVID-19 and tobacco
financial crisis and unavailability of connection was twice that of those who
tobacco. Least common reason given by were unaware, indicating a significant
users was that of opportunity to quit. difference and a higher likelihood of
(Figure 2). As per Figure 3, nearly two- quitting tobacco when individuals were
thirds of the participants were unaware of informed about the association [χ2=12.057,
the link between tobacco consumption and p-value=0.00051]. The prevalence of
COVID-19. Out of the total 173 current tobacco users exhibited a
participants, only 118 (68.2%) were decreasing trend before and after the
uninformed about the connection between lockdown, as illustrated in Figure 4.
463
Figure 1. Outcome of COVID-19 Lockdown among Current Tobacco Users (%)

*Increased use due to increased stress
Less (38) Quit (49)
15.78
Homestay**
14.28
29
Lockdown rules*
22.45
5.2
Opportunity to quit
10.2
29
Unavailability of tobacco
28.57
23.68
Increased Price/ Financial Crisis
24.48
Figure 2. Reasons for Decreasing / Quitting Tobacco Use (%)

**Decreased due to family
*Can’t go outside
464
78.82
56.36
43.64
21.18
Awareness about the association No awareness
Quit Didn't Quit
Figure 3. Association between Awareness and Quit Rate (%)
56.35
41.36
Before Covid-19 Lockdown After Covid-19 Lockdown
Figure 4. Prevalence (%) of Current Tobacco Users Before and After Lockdown showing a
decreasing trend
Discussion chewing pan masala, gutkha and mawa

Using a series of monthly follow up, masala also tobacco consumption was
we observed changes in tobacco intake, highly common in males (75.14%) as
reduction, attempts to quit from January compared to females (24.85%); while as per
2020 till November 2020 when covid-19 Himanshu A. Gupte et al. [12] 46% were
lockdown was implemented by smokers, 45% smokeless tobacco users.
government. In the current study, 56.35% The majority of participants, comprising
were current tobacco user, almost 90.75% 96%, were males, with an average age of 40
participants were using smokeless form like years. In alignment with S. Veeraiah et al.
465
[13], the mean age was 42.5 years (SD=14; abstained was twice as high (51%)
range: 15–76), and the majority were males compared to those who were unaware
(n = 243, 97%). Out of the total participants, (25%). According to Romain Guignard et
101 (40%) were current tobacco users, with al. [14], among current smokers, 26.7%
61% being smokers, 35% using smokeless reported an increase in tobacco
tobacco, and 4% employing both forms. consumption since the beginning of the
Notably, almost two-thirds of the lockdown (i.e., during the 2 weeks before
participants in the current study were the survey), 18.6% reported a decrease,
unaware of the association between tobacco while it remained stable for 54.7%.
consumption and COVID-19. The quitting According to S. Veeraiah et al. [13], 64% of
rate among individuals aware of the tobacco users reported a reduction in
association between COVID-19 and tobacco use during the lockdown, while
tobacco was twice that of those who were usage remained unchanged for 20%, and it
unaware. This significant difference increased for 16%. A significant portion,
suggests a higher likelihood of quitting nearly two-thirds (63%), expressed an
tobacco when a person is informed about intention to quit during the lockdown. Out
the connection between tobacco of those with intentions to quit, 6% sought
consumption and COVID outcomes [p- help or consultation, and 38% made an
value<0.05]. The reasons for quitting or actual quit attempt during the lockdown.
reducing tobacco use in our study included Interestingly, only 15% had the urge to
the heightened prices or financial increase tobacco use during this period. In
constraints and the unavailability of our study, reduced tobacco use during the
tobacco. This aligns with findings by lockdown was associated with both the
Himanshu A. Gupte et al. [12], where 67% intention to quit (P = 0.02) and actual quit
were unaware of the tobacco and COVID- attempts (P = 0.01). Notably, over 50% of
19 association. The most common impacts participants cited increased tobacco prices
reported were non-availability of tobacco or financial constraints and unavailability
products (45%) and increased prices (27%). of tobacco as reasons, with the least
Some users saw this as an opportunity to common reason being the 'opportunity to
quit (24%), while a small proportion (4%) quit.' In contrast, Himanshu A. Gupte et al.
reported an increase in tobacco use due to [12] found that the main reason for stopping
heightened stress in the current context. tobacco use was related to lockdown or
In the current study during follow concerns about the coronavirus, accounting
up of 10 months, 49 participants had quit for 51%. Additionally, as per S. Veeraiah et
tobacco consumption completely but 3 al. [13], more than half (56%) reported easy
participants started tobacco consumption availability of tobacco products. During the
for the first time; while as per Himanshu A. lockdown, almost two-thirds (66%) of
Gupte et al. [12] out of the contacted tobacco users bought tobacco products
tobacco users, a total of 219 individuals daily from shops, 27% had existing stocks,
(38%) claimed to have refrained from and the remaining 6% obtained tobacco
tobacco use since the onset of the from peers. The majority of tobacco users
lockdown. Notably, among those aware of reported easy access to tobacco products,
the association between COVID-19 and with a significant proportion being able to
tobacco use, the proportion of users who purchase them daily from shops during the
466
lockdown. The data indicates blatant inadvertently expose smokers to the virus,
breaches of lockdown regulations, particularly in public settings or shared
particularly in the context of a strict ban on smoking areas. Addressing this concern
tobacco product sales in the city. necessitates comprehensive education and
Encouragingly, nearly two-thirds of awareness initiatives regarding COVID-19
tobacco users reported a reduction in and tobacco. Remarkably, individuals who
tobacco use, with an equal number were aware of the link between COVID-19
expressing an intention to quit during the and tobacco were more inclined to quit
lockdown. A recent study by Elling et al. compared to those without awareness.
[15,16] highlighted that smokers were more Consequently, increasing awareness about
motivated to quit due to the heightened risk the harmful effects of tobacco and fostering
of contracting COVID-19 as a smoker and an environment with restricted access to
increased social support for tobacco tobacco products can play a role in partially
cessation. reducing tobacco consumption. To sum up,
the relationship between COVID-19 and
Conclusion tobacco usage is complex and worrisome.
The COVID-19 pandemic and the Tobacco use can undermine lung health,
ensuing lockdown have acted as substantial suppress the immune system, and instigate
catalysts for various mental health inflammation, collectively heightening the
challenges, such as anxiety and depression. risk of severe outcomes in the context of
Additionally, there has been a notable COVID-19. Ceasing tobacco use not only
increase in unhealthy behaviors, including contributes to long-term health but also
heightened tobacco consumption, as plays a crucial role in alleviating immediate
individuals seek coping mechanisms for risks linked to the pandemic. It's vital for
negative emotions. However, within our tobacco users to seek support and resources
study, a subgroup of participants saw the for quitting, alongside adhering to public
lockdown as a chance to decrease or quit health guidelines to minimize the risk of
tobacco use, and notably, some of them COVID-19 transmission. Combining these
successfully initiated quit attempts. In our efforts can yield improved individual and
research, approximately 28.32% of public health outcomes in the fight against
participants managed to quit tobacco COVID-19.
entirely, while 21.96% reduced their
tobacco intake. To further increase the rate Recommendation
of successful quitting, it is imperative to Based on the research findings
implement effective measures aimed at concerning COVID-19 and tobacco use,
motivating and supporting tobacco users in several recommendations can be put forth
their cessation efforts. Another critical to mitigate the potential risks linked to
aspect of tobacco use that demands tobacco consumption during the pandemic.
attention within the context of COVID-19 It's important to recognize that tobacco is
is the behavioral component. Smoking detrimental in any circumstance. Therefore,
often involves repeated hand-to-mouth based on multiple follow-up assessments,
contact, which could elevate the risk of in-depth interviews, and focus group
virus transmission from contaminated discussions, a strong emphasis should be
surfaces to the mouth. This behavior might placed on deaddiction as the preferred
467
approach to address this issue. Primary care Author Contributions

physicians and mental health specialists The manuscript has been read and
should take special care to consider this approved by us and we believe that the
possibility. Healthcare professionals should manuscript represents honest work.
conduct thorough assessments of their
patients, ensuring a comprehensive Conflict of Interest
examination that includes evaluating for The authors declares that they do
signs of substance abuse. Additionally, not have conflict of interest.
sustaining ongoing research efforts to delve
into the complex interplay between tobacco Funding
use and COVID-19 outcomes is crucial. No funding was received for
This involves studying the impact of conducting this study.
various tobacco products and shifts in
smoking behavior during the pandemic. Ethical Approval
Such research forms the foundation for Ethical Clearance Certificate
evidence-based policies and interventions Reference Number
aimed at diminishing the health risks linked IEC/CERTI/66/02/2020)
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470

DOI 10.61770/NBEJMS.2024.v02.i05.007
ORIGINAL ARTICLE
Comparative Evaluation of Imaging Techniques for Paraspinal Muscle Fat

Quantification
Umaiban KV,1 Jeevithan Shanmugam,2 Seetharaman Cannane,3,* Niva B4 and Santhosh

Poyyamoli5
1Consultant Radiologist, Cloudex Scans, Kannur, Kerala
2Professor, Department of Preventive Medicine, KMCH Institute of Health Sciences and
Research, Coimbatore
3Associate Professor, Department of Radiodiagnosis, KMCH Institute of Health Sciences and
Research, Coimbatore
4Consultant Radiologist, Sri Jayadeva Medicover Diagnostic Centre, Mysuru, Karnataka
5Consultant, Department of Interventional Radiology, Kovai Medical Centre and Hospital,
Coimbatore
Abstract
Introduction: Low back pain (LBP) is a prevalent health issue associated with morphological
changes in paravertebral muscles. Magnetic resonance imaging (MRI) is effective in
identifying muscle steatosis, with MR spectroscopy (MRS) considered the gold standard.
However, MRS is limited by technical challenges, prompting interest in Dixon sequences for
fat quantification. Materials and Methods: We conducted a study comparing Multi Echo
VIBE Dixon with single-voxel MR spectroscopy in quantifying fat fractions in lumbar
multifidus muscles of chronic LBP patients. Ninety-eight measurements from 49 patients were
analysed. Qualitative and quantitative image analyses were performed, and statistical analysis
was conducted using SPSS 27. Results: Significant positive correlation (correlation
coefficient: 0.992, p < 0.001) was found between Dixon and MRS fat fraction measurements.
Intra-class correlation coefficient was 0.991 (p < 0.001), indicating strong agreement. No
proportion bias was observed. Factors such as age, sex, and spinal degeneration correlated
positively with multifidus fat atrophy. Conclusion: T2*-corrected Dixon imaging aligns well
with spectroscopic measurements, offering an accurate alternative for estimating paraspinal
muscle fat content in chronic LBP patients. Further studies are needed to establish threshold
values for Dixon imaging. Chronic LBP is associated with multifidus muscle atrophy and fat
infiltration, highlighting the need for effective management strategies.
Keywords: Low back pain, multifidus muscle, MRI, Dixon imaging, MR spectroscopy.
*Corresponding author: Seetharaman C

Email: drcseetharaman@gmail.com
471
Graphical Abstract
Introduction tomography, and magnetic resonance

Low back pain (LBP) poses a imaging (MRI), MRI stands out as the most
significant health concern and is a primary objective and sensitive method for
cause of disability among working-age detecting and quantifying muscle steatosis.
individuals. Over the past decade, the MR imaging offers superior accuracy in
prevalence of low back pain in adults has identifying and quantifying fat infiltration
doubled, with a particular rise noted in the within the muscles of the lumbar spine,
aging population [1]. Scholars have long particularly in patients experiencing low
acknowledged the link between chronic back pain. MR spectroscopy, a technique
low back pain and morphological within MRI, accurately displays increased
alterations in the paravertebral muscles. fat signal fractions in lumbar paraspinal
Substantial research efforts have been muscles and is considered the "gold
dedicated to investigating fatty infiltrations standard" for fat quantification in MR
and reductions in paravertebral muscle imaging. This spectroscopic method has
volume as potential clinical indicators for found widespread use in measuring fat
post-operative outcomes, spinal stability, deposition not only in the liver, heart,
and certain chronic conditions like age- pancreas, and skeletal muscle but also in
related sarcopenia [2]. Histologically, the bone marrow [3-5]. Although MR
decline in muscle endurance often spectroscopy is lauded for its ability to
correlates with changes in muscle structure, detect even minute amounts of fat, it is not
such as atrophy of muscles and infiltration commonly utilized in routine clinical
of fat, which can be identified through settings due to several drawbacks. Firstly,
cross-sectional imaging techniques [3]. the technique is time-consuming, which
Among various imaging modalities limits its feasibility for widespread use.
such as ultrasonography, computed Secondly, it requires specialized technical
472
expertise, making it challenging to perform the Institute's ethical and scientific

reliably in routine practice. Additionally, committee and obtaining written informed
MR spectroscopy is susceptible to sampling consent from all research participants. The
errors stemming from the arbitrary study included adult patients aged >18
placement of the region of interest and the years experiencing chronic low back pain
relatively low spatial resolution compared (defined as “disabling pain in the lower
to other imaging modalities. These factors spine persisting for more than 3 months”)
collectively contribute to its limited who underwent MRI examination of the
adoption in everyday clinical practice.5 lumbosacral spine at the hospital between
Quantitative Dixon sequences have August 2019 and July 2021. Patients with
emerged as a promising and dependable general MRI contraindications, a history of
tool for both fat suppression and fat prior spine surgery, or patient motion
quantification [6]. When compared to MR during acquisition were excluded, along
spectroscopy (MRS), the Dixon method with cases of inflammation that could
offers several notable advantages, interfere with total water fraction
including rapid and volumetric data measurements. Those who were eligible for
acquisition, the visualization of anatomical the study were contacted by the principal
structures, and the ability to determine fat investigator and were explained about the
content within a defined region of interest background for the study, need for the
(ROI) [7]. Multi-echo variants that has been study, its objectives and other ethical
developed recently enhances the separation considerations. The Patient Information
of fat and water signals consistently, sheet was given to them, and adequate time
correcting for confounders that may was given to understand the contents.
introduce systematic errors in fat-signal Those who were willing to participate were
fractions. requested to sign the written informed
The primary objective of our study consent form.
is to compare Multi Echo VIBE Dixon with MRI sequences were supplemented
single-voxel MR spectroscopy in by multi-echo Dixon and MR spectroscopy
quantifying fat signal fractions within the to quantify fatty degeneration of bilateral
lumbar paraspinal muscles. Specifically, lumbar multifidus muscles at the L4-L5
we aim to estimate the degree of fat intervertebral level.
infiltration in the multifidus muscle among
patients experiencing chronic low back A) MRI Technique
pain. Additionally, we seek to explore All MRI procedures were
whether factors such as age, sex, duration conducted using a 3.0 Tesla MRI system
of pain, degenerative disc disease, nerve (Siemens) with dedicated spine coils.
compression, and endplate changes exert Standard clinical MR imaging protocols for
any influence on the fat content of low back pain assessment were performed,
paraspinal muscles. including whole spine T2 sagittal, lumbar
spine T1 sagittal, IR sagittal, IR and T1
Materials and Methods coronal SI joint, and T2 axial sequences.
This study was conducted at the Additionally, a T2-weighted multi-echo
Radiology department of a tertiary care VIBE Dixon sequence with 6 echoes was
hospital in South India, with approval from added to the protocol, providing water-
473
only, fat-only, fat fraction, and R2* - Repetition Time: 9.00 ms

mapping image series with corrections for - Field of View (FOV): 450 mm
multiple resonance lines in the fat - Matrix: 111 x 160
spectrum. Single-voxel point-resolved MR - Bandwidth: 1080 Hz/Pixel
spectroscopy was also acquired as a - Acquisition Time: 13 sec
standard reference. - Slice Thickness: 3.5 mm
B) Qualitative Image Analysis Data were inputted into an Excel

Standard MR imaging sequences were spreadsheet and analyzed utilizing SPSS
assessed for spinal degenerative features version 27. Categorical variables were
such as disc desiccation, facet arthropathy, depicted as proportions or percentages,
endplate signal changes, nerve root while numerical variables were presented
compression, and spondylolisthesis, with as mean ± standard deviation (SD) or
findings recorded for each patient. median with interquartile range (IQR). To
compare the Multi Echo VIBE Dixon with
C) Quantitative Image Analysis single-voxel MR spectroscopy in
MR Spectroscopy (MRS) measuring fat signal fraction within the
Single voxel point-resolved MR lumbar multifidus muscles of patients
spectra were obtained by placing experiencing chronic low back pain,
spectroscopy voxels in bilateral multifidus Spearman's rank correlation was utilized.
muscles on axial T2-weighted MR images The difference in mean fat fraction
at the L4-L5 intervertebral level. Fat concerning study variables was evaluated
fraction (FF) was automatically calculated using either the Mann-Whitney U test or
based on signals from fat and water at each Kruskal-Wallis test. Additionally, intra-
echo time, with spectroscopy voxel class correlation was computed to assess
positioning documented for reference in the relationship between both methods. A
Dixon fat fraction mapping images. Bland-Altman plot was generated to
elucidate the agreement between the two
Dixon techniques. Statistical significance was
Regions of interest (ROIs) were defined as a p-value below 0.05.
drawn on automatically generated axial fat
fraction mapping images from the T2*- Results
corrected six-echo VIBE Dixon sequence, A total of 98 measurements of
corresponding to the location of spectroscopic fat fraction were obtained
spectroscopic voxels. Two independent from 49 patients, evenly split between
observers recorded FF values for Dixon and males and females. All patients underwent
MRS, blinded to each other's measurements bilateral examinations, and those with
except for the voxel position. The diameter incomplete assessments were excluded.
of the circular ROI was determined based Spectroscopic values served as the
on the voxel size of MR spectroscopy. reference standard.
Imaging parameters for Dixon were as Age of the study participants ranged
follows: from 22 to 77 years, while the mean age
was 50.56±14.01 years. The duration of
- Echo Time: 1.05 ms back pain Ranged from 3 months to 6 years,
474
with a mean duration of 25.95±26.35 spondylolysis at L4/L5 (12.2%), modic end

months. Most patients (67.3%) couldn't plate changes (37.8%), and ligamentous
localize their pain, while 17.3% reported flavum atrophy (26.5%). Additionally,
left-sided pain and 15.3% reported right- 42.9% had mild disc desiccation, 25.5%
sided pain. Conditions observed included had moderate desiccation, and 18.4% had
nerve compression (68.4%), facet severe desiccation (Table 1).
arthropathy (48%), spondylolisthesis or
Table 1. Socio demographics and clinical parameters of study population

Parameter Sub classification FREQUENCY PERCENTAGE
AGE Below 30 years 9 9.1
31 - 40 years 18 18.4
41 - 50 years 20 20.5
51 - 60 years 26 26.6
Above 60 years 25 25.4
SEX Male 48 49.0
Female 50 51.0
SIDE OF PAIN Indifferent 66 67.3
Left 17 17.3
Right 15 15.4
NERVE COMPRESSION Present 67 68.4
Absent 31 31.6
FACET ARTHROPATHY Present 47 48
Absent 51 52
SPONDYLOLISTHESIS/ Present 12 12.2

SPONDYLOLYSIS AT
L4/L5 Absent 86 87.8
ASSOCIATED MODIC Present 37 37.8

END PLATE CHANGES
Absent 61 62.2
DISC DESSICATION No 13 13.3
Mild 42 42.9
Moderate 25 25.5
Severe 18 18.4
475
LIGAMENTUM FLAVUM Present 26 26.5

ATROPHY
Absent 72 73.5
Table 2. ICC values for Fat measurement between DIXON and MRS
ICC 95% Confidence Interval Significance
Lower limit Upper limit F Value P Value
0.991 0.984 0.994 235.97 <0.001
Regarding fat content 1) Analysis of agreement limits showed no

measurements, the mean percentage fat proportion bias between fat fraction values
content of the multifidus muscle was from MRS and DIXON (Fig. 2).
14.87±12.89 using the MRS method and Statistical analysis revealed a
15.46±12.84 using the DIXON method. positive correlation between multifidus fat
(Table 2) There was a strong positive atrophy, spinal degenerative factors,
correlation (correlation coefficient: 0.992, p increasing age, and female sex. The
< 0.001) between fat fractions derived from association between disc desiccation grades
DIXON and MRS methods. The intra-class and paraspinal muscle fat percentage also
correlation coefficient between MRS and indicated higher fat fraction values with
DIXON was 0.991 indicating strong increasing severity of desiccation.
agreement between the two methods (Fig.
Figure 1. Correlation between DIXON and MRS score
476
Figure 2. Bland Altman Plot
Discussion low spatial resolution [5]. Conversely,

MRI is widely acknowledged as a Dixon sequences enable precise analysis of
reliable and effective method for muscle fat and its distribution in large
investigating muscles due to its excellent volumes with superior spatial resolution
soft-tissue contrast. Continuous and minimal sampling errors in clinical
advancements in technology, along with the settings [7].
introduction of new sequences and tools, In this study, we aimed to validate
have led to improving accuracy in assessing whether chemical shift imaging with Dixon
pathological changes in tissues [8]. Many sequences could accurately calculate the fat
studies have emphasized the importance of percentage of paraspinal skeletal muscles,
quantitatively evaluating muscle fat content comparable to MRS.
for precise detection and grading of Our study yielded consistent
diseases, even when muscles are minimally findings, demonstrating a significant
affected [9]. Advanced MR imaging positive correlation between fat fraction
techniques, such as MR spectroscopy, have measurements obtained from T2-corrected
been utilized to evaluate and quantify fatty multi-echo Dixon and MR spectroscopy.
atrophy in muscles such as the Several researchers have investigated the
supraspinatus and paraspinal muscles. quantification of skeletal muscle fat using
There has been considerable research MR imaging in various anatomical regions,
focused on quantifying local fat levels in such as thigh muscles, rotator cuff, and
skeletal muscle, liver, and bone marrow paraspinal muscles, employing the Dixon
lesions using various techniques. Among technique with or without T2 correction.
these, single-voxel MRS imaging is Yoo et al., in their study,
commonly considered the gold standard for highlighted that fat fraction derived from
accurate local fat analysis in vivo [4]. T2-corrected six-echo VIBE Dixon
However, MRS poses technical challenges sequences displayed superior agreement
and is prone to sampling errors due to its with MR spectroscopic fat fraction data, in
477
contrast to non-T2 corrected two-echo and fat infiltration in the lumbar multifidus
T2-corrected three-echo VIBE Dixon data. muscle and low back pain in adults [15].
This finding is consistent with previous Likewise, Mengiardi et al. discovered
research in liver fat fraction analysis, which significantly elevated fat content in the
has demonstrated that T2 correction multifidus muscles of individuals
enhances the precision of fat fraction experiencing low back pain compared to
calculation in multi-echo VIBE Dixon asymptomatic volunteers, with no notable
sequences [10]. difference observed in the fat content of the
Contrary to the findings by Yoo et longissimus muscle. In our investigation,
al., Fisher et al. observed that T2 correction we observed that the percentage of
did not result in a stronger correlation multifidus fat content in patients with
compared to non-T2 corrected multi-echo chronic low back pain was around 15%,
sequences when compared with which is notably lower than the 23.6%
spectroscopic fat fraction data. They reported by Mengiardi et al. [5] This
proposed that this inconsistency might be discrepancy may be attributed to
due to the decrease in signal-to-noise ratio differences in patient selection criteria and
(SNR) that occurs following T2 correction the average duration of symptoms in our
[9]. Another study by Gaeta et al. reported patients was shorter compared to those in
that T2 correction did not offer greater prior studies, although the age of patients
benefits than the non-T2 corrected method was comparable.
in skeletal muscle fat quantification [11]. Our study revealed a significant
Although the necessity of T2 correlation between age and gender with
correction for estimating skeletal muscle fat multifidus fat fraction, suggesting that
remains uncertain, we opted to incorporate differences in body composition may
T2 correction into the six-echo VIBE Dixon contribute to variations in multifidus
sequence. This decision was based on the muscle fat content between males and
consideration of potential factors that could females. This raises questions regarding
induce T2 decay in skeletal muscle. whether grading scales and cutoff points for
Multiple investigations have underscored fat percentage should be unique for each
the association between chronic low back gender. Additionally, we observed a higher
pain and the reduced strength and prevalence of fat infiltration in paraspinal
endurance of paraspinal muscles [12,13]. muscles among the elderly, irrespective of
However, whether these changes are the duration of back pain [16].
causative factors or consequences of back However, further longitudinal
pain remains a subject of debate. studies are needed to elucidate the extent to
Researchers have specifically noted that which age and duration of low back pain
among paraspinal muscles, fatty contribute to the development of fat atrophy
degeneration in chronic low back pain is in the lumbar multifidus muscle. Numerous
particularly prominent in the multifidus authors have reported declines in cross-
muscle, which plays a crucial role in lumbar sectional area (CSA) and density of back
segmental stability [14]. muscles with age, underscoring the
Kjaer et al. presented compelling importance of considering age as a
evidence from a sizable population sample, confounding factor in studies evaluating the
demonstrating a robust association between association between paraspinal muscle fat
478
content, spinal degeneration, and low back multifidus fat atrophy require special
pain. Additionally, personal factors such as treatment [20,21].
activity level, smoking, type II diabetes Our study has limitations, including
mellitus, and cardiovascular diseases may its single institutional nature with a limited
influence fatty infiltration of paraspinal number of subjects. Additionally, we used
muscles, necessitating further investigation MR spectroscopy as the standard of
into these influences. reference rather than conventional
Although body mass index (BMI) histopathology confirmation via muscle
was not recorded in our study subjects, biopsy, which is invasive and may not
previous research has failed to establish a always be feasible due to ethical concerns.
significant association between BMI and Moreover, clinical data such as pain
muscle fat concentration. Similarly, the intensity, functional ability, BMI, and level
thickness of subcutaneous fat has not been of physical activity were not evaluated in
found to correlate significantly with the our study, and there was no control group.
quantity of fat accumulated in muscles [17].
We observed a positive correlation Conclusion
between spinal degeneration features such Our study demonstrates that T2-
as disc desiccation, facet arthropathy, corrected multi-echo VIBE Dixon
modic endplate changes, nerve measurements align well with T2-corrected
compression, ligamentum flavum spectroscopic measurements of fat fraction
hypertrophy, and spondylolisthesis with estimates in the lumbar multifidus muscles
multifidus fat content. Disc desiccation and of patients with chronic low back pain.
modic endplate changes were found to be Therefore, T2*-corrected Dixon imaging
independently associated with increased fat can be favoured over MR spectroscopy in
percentage of the multifidus muscle. routine clinical practice as it offers an
While lumbar disc herniation with accurate alternative for estimating
compression of nerve roots can lead to paraspinal skeletal muscle fat content.
muscle dysfunction [18], we did not However, further large-scale studies are
observe a statistically significant warranted to establish threshold values for
correlation between the side of pain and chemical shift Dixon imaging that indicate
muscle fat atrophy in our study. However, fatty degeneration within the muscle.
severe fatty infiltration of the lumbar Chronic low back pain is associated
multifidus muscle was observed in a patient with atrophy and fat infiltration of the
with unilateral disc protrusion and severe multifidus muscle. Our findings also reveal
nerve compression on the same side, a significant association between various
indicating a potential link between nerve spinal degenerative factors and multifidus
compression and muscle fat atrophy [19]. fat infiltration. It is crucial to conduct
Numerous studies have reported further research to determine the
associations between spinal degeneration, effectiveness of specific approaches for
spinal muscular fat, and low back pain. managing low back pain and preventing
However, it remains unclear whether fat progressive fat infiltration of the lumbar
infiltration of the lumbar multifidus muscle paraspinal muscles and spinal
serves as a prognostic indicator or if degeneration.
patients with both low back pain and
479
Statements and Declarations accurate fat spectral modeling. J Magn

Conflicts of interest Reson Imaging. 2009 Jun;29(6):1332–9.
The authors declares that they do not have 5. Mengiardi B, Schmid MR, Boos N,
conflict of interest. Pfirrmann CWA, Brunner F, Elfering A,
et al. Fat content of lumbar paraspinal
muscles in patients with chronic low
Funding
back pain and in asymptomatic
No funding was received for conducting volunteers: quantification with MR
this study. spectroscopy. Radiology. 2006
Sep;240(3):786–92.
Ethics approval 6. Dixon WT. Simple proton spectroscopic
Ethical approval obtained from all patients. imaging. Radiology. 1984
Oct;153(1):189–94.
Human and animal rights 7. Yanik B, Keyik B, Conkbayir I. Fatty
This article does not contain any studies degeneration of multifidus muscle in
with human participants or animals patients with chronic low back pain and
in asymptomatic volunteers:
performed by any of the authors.
quantification with chemical shift
magnetic resonance imaging. Skeletal
Informed consent Radiol. 2013 Jun;42(6):771–8.
For this type of study formal consent is not 8. Zhang Y, Zhou Z, Wang C, Cheng X,
required. Wang L, Duanmu Y, et al. Reliability of
measuring the fat content of the lumbar
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DOI 10.61770/NBEJMS.2024.v02.i05.008
ORIGINAL ARTICLE
Assessment of PSR as a Novel Parameter in Perfusion Imaging for CNS Tumor

Characterization: An Observational Study
Niva B,1 Jeevithan Shanmugam,2 Shriram Varadharajan,3 Seetharaman Cannane4,* and Umaiban
KV5
1
Consultant radiologist, Sri Jayadeva Medicover Diagnostic Centre, Mysuru, Karnataka
2
Professor in Community Medicine, KMCH Institute of Health Sciences and Research, Coimbatore – 14,
Tamil Nadu
3
Senior Consultant Neuroradiology, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu
4
Associate Professor, Department of Radiology, KMCH Institute of Health Sciences and Research,
Coimbatore –14, Tamil Nadu.
5
Consultant Radiologist, Cloudex Scans, Kannur, Kerala
Abstract
Introduction: Magnetic resonance imaging (MRI) has emerged as the primary modality for diagnosing
and evaluating central nervous system (CNS) tumors, transitioning from structural to functional assessment.
Advanced MRI techniques, including MR spectroscopy and perfusion imaging, offer insights into
functional, metabolic, and hemodynamic changes in addition to structural abnormalities. The study aims to
assess the role of PSR (Post-Contrast Signal Recovery) alongside rCBV (Relative Cerebral Blood Volume)
and rPSR (Relative Percentage of Signal Recovery) in differentiating grade IV glioma, solitary brain
metastasis, and primary CNS lymphoma. Materials and Methods: An observational study was conducted
on 38 patients with lymphoma, metastases, and grade IV glioma, utilizing DSC (Dynamic Susceptibility-
Weighted Contrast-Enhanced) perfusion imaging and histopathology reports. Sociodemographic, clinical,
and MRI parameters were collected. PSR measurements were obtained from perfusion maps using
dedicated software. Statistical analysis was performed using SPSS version 27.0. Results: Among the study
population, the mean age was 54.16±12.47, with male predominance (63.2%). Conventional imaging
characteristics revealed significant differences, including T2 hypo intensity in lymphoma and FLAIR
hyperintensity in all gliomas. Perfusion parameters showed higher rCBV in metastases and grade IV glioma
compared to lymphoma, whereas PSR and rPSR were higher in lymphoma. PSR and rPSR effectively
differentiated among the tumor types (p<0.001). Conclusion: Our study underscores the critical role of
advanced MRI techniques, particularly DSC perfusion imaging, in differentiating between grade IV
gliomas, solitary brain metastases, and primary CNS lymphomas. PSR emerges as a valuable parameter
alongside rCBV and rPSR, demonstrating potential for accurate tumor characterization.
Keywords: Magnetic resonance imaging, CNS tumors, PSR, rCBV, rPSR

*Corresponding author: Seetharaman C
Email: drcseetharaman@gmail.com
482
Graphical Abstract
Introduction classification. These may in the future be

Magnetic resonance imaging (MRI) incorporated into radiogenomic signatures. In
after its widespread availability has evolved 2016, the World Health Organization revised
as the imaging modality of choice in the its basic classification of primary brain
diagnosis and evaluation of CNS tumors. The tumors to incorporate genetic information
role of neuroimaging in brain tumors has and molecular status superseding histological
advanced from purely structural to functional grade.
imaging. Apart from assessing structural There is considerable intersect in the
abnormality and tumor-related conventional MRI appearances of common
complications, MRI is also used to identify intracranial malignant lesions, such as
functional, metabolic, hemodynamic, gliomas, metastases, and lymphoma. Early
cellular, and cytoarchitectural changes. Prompt diagnosis is important as
Advanced MRI techniques are now management differs in these three groups.
commonly used in the evaluation of brain Although the histopathological examination
tumors. These include MR spectroscopy for is the gold standard for the diagnosis of brain
metabolite assessment and perfusion imaging tumors, it carries an inherent risk of sampling
for microvascular characterization. Often bias. Molecular status and advanced imaging
these advanced imaging techniques are useful can therefore supplement routine work up
in predicting the grade of the neoplasm and such as conventional imaging for more
its biological behavior, especially given the accurate diagnosis and prognostication.
recent modifications in the WHO Therefore, newer techniques in MRI should
483
be utilized to differentiate between these related parameter whose role is still under
various brain tumors. evaluation. Hence in this study, we wanted to
Dynamic susceptibility-weighted evaluate the role of PSR as compared to
contrast-enhanced (DSC) MRI is a perfusion rCBV and rPSR in differentiating grade IV
imaging that is used to assess the capillaries glioma, solitary brain metastasis, and primary
and microvascular characteristics of these CNS lymphoma.
tumors. Relative cerebral blood volume
(rCBV) is a commonly used perfusion Materials and Methods
parameter that is a marker of vascularity and We conducted an observational study
neo-angiogenesis in brain tumors. It is in the Department of Radiology, Kovai
considered as one of the most important Medical Centre and Hospital, Coimbatore. In
hemodynamic variables used in the our study, 38 patients with lymphoma,
characterization of tumors. In lymphomas, metastases, and grade IV glioma with
rCBV is lower than in gliomas and optimum DSC perfusion imaging and
metastases owing to the lack of neo- histopathology report during the period of
angiogenesis. However, rCBV values often August 2019 to July 2021 were included after
overlap in gliomas and metastases. discussing with the participants about the
Percentage of signal recovery (PSR), which need for the study, objectives and other
is a lesser utilized DSC derived parametric, ethical issues concerned. Patient information
plays an important role in such cases. was given to the participant. Ample time was
PSR, or Post-Contrast Signal given to the study participant for
Recovery, denotes the proportion of signal understanding the study. Once they agreed to
intensity regained following the initial participate, written informed consent was
administration of contrast relative to the obtained. A structure clinical proforma was
baseline signal intensity (before contrast designed for the study. Sociodemographic
administration). Initially, there is a decline in variables, clinical history/ findings and MRI
signal intensity after the contrast agent is parameters were elicited. None of the
administered, which gradually reverts lymphoma patients had signs of
towards the baseline due to the first pass immunosuppression and no patient had signs
circulatory effect. The extent of this recovery of systemic involvement. Only patients with
determines the PSR value and is influenced solitary metastasis were included in this
by various factors such as contrast agent study.
leakage, extravascular space size, and blood Exclusion criteria included general
flow rate [1-6]. contraindications for MRI, incomplete
There are reports of low values of studies due to various reasons like an
PSR in metastatic lesions, intermediate in uncooperative patient, poor image quality,
glioblastoma (GBM), and high and extensive artifacts. Those who had
(overshooting) in primary central nervous contraindication for MRI contrast were also
system lymphomas (PCNSL). The relative excluded.
percentage of signal recovery (rPSR) is a
484
Imaging was performed with either a contrast baseline. At the end of the 5th
1.5 T [Ingenia; Philips Medical Systems] or image volume, 0.1-0.2mmol/kg
3T [MAGNETOM Skyra; Siemens gadolinium contrast was injected using a
Healthcare]. Our tumor protocol included T1 power injector at a rate of 2.5-3 ml/s
in three orthogonal planes, coronal T2, axial through an 18 or 20 G intravenous
T2 FLAIR, SWI, DWI axial, ADC, MR catheter. This was immediately followed
spectroscopy, and post-contrast T1 images in by a bolus injection of saline (a total of 20
all 3 planes. Using a gradient recalled ml at the same flow rate).
T2*weighted echo-planar imaging sequence
(ep2d_perf), DSC imaging was performed. PSR measurement
All perfusion data were transferred to
Parameters used in 1.5 T were as follows: a stand-alone workstation for post-processing
● TR/TE of 2341/40 ms, using dedicated advanced software packages
● FOV of 220 mm, [Neuro Perfusion Evaluation, Syngo
● Voxel size of 2.4 x 2.4 x 5 mm, multimodality workplace (MMWP) VE61B,
● Slice thickness of 5 mm. Siemens Healthcare Gmbh, Germany or T2*
● A total of 30 image volumes each with 40 MR Neuro Perfusion, IntelliSpace Portal
image sets were acquired (a total of 1200 (ISP) Version 9.0, Philips Medical Systems
images), in which the first 5 image Netherlands B.V.]. From the processed
volumes were acquired before starting the perfusion images color-coded CBV maps
contrast agent injection to establish a pre- were obtained. For PSR measurement, an
contrast baseline. At the end of the 5th ROI (Region of Interest) of 25-40 mm2 was
image volume, 0.1-0.2mmol/kg drawn on the perfusion maps carefully
gadolinium contrast was injected using a excluding areas of necrosis or hemorrhage.
power injector at a rate of 2.5-3 ml/s The signal intensity curves were thus
through an 18 or 20 G intravenous obtained and the PSR value was calculated as
catheter. This was immediately followed follows:
by a bolus injection of saline (a total of 20
ml at the same flow rate). PSR = 100% x (S1 - Smin)/ (S0 - Smin)(1,2),
Parameters used in 3 T were as follows: Where,

● TR/TE of 2340/30 ms, S0: baseline pre-contrast T2*W signal
● FOV of 220 mm, intensity.
● Voxel size = 1.7 x 1.7 x 4 mm, S1: recovered post-contrast T2*W signal
● Slice thickness= 4 mm. intensity.
● A total of 30 image volumes each with 60 Smin: minimum T2*W signal intensity
image sets were acquired (a total of 1800 Another ROI was simultaneously
images), in which the first 5 image placed in the contralateral normal-appearing
volumes were acquired before starting the brain and rPSR was calculated as follows:
contrast agent injection to establish a pre-
485
rPSR= PSR (lesion)/PSR (contralateral arameters studied, SWI blooming and

normal brain)(3). cystic necrosis were also found to be
statistically significant. Blooming on SWI
Statistical analysis was found in 45.8% of patients in the grade
The data were entered into MS Excel IV glioma group and 85.7% in the metastases
and analyzed using Statistical Package for group. Cystic necrosis was present in 45.8%
Social Sciences (IBM SPSS) version 27.0. of patients in the grade IV glioma group and
Sociodemographic variables were analyzed 85.7% in the metastases group (Table 1).
as proportions or percentages for categorical Figures 1, 2 and 3 show the representative
variables, either mean ± SD or Median (IQR) conventional images of a case of CNS
were analyzed for numerical variables. The lymphoma, solitary brain metastasis, and
difference in mean between the different grade IV glioma.
types of tumors was analyzed using the Among perfusion parametrics, the
Kruskal Wallis test. A Chi-square test was mean rCBV value was higher in metastases
used to analyze the relationship between (3.23±0.51) and grade IV glioma
various study variables and different types of (3.08±0.67), whereas low in lymphoma
tumors. The p-value <0.05 was considered (1.14±0.25) with a p-value of <0.001. The
statistically significant. mean PSR value was lower in metastases
(56.03±7.87) and grade IV glioma
Results (80.69±6.48), whereas higher in lymphoma
A total of 38 patients including 24 (146.13±40.97) with a p-value of <0.001.
high-grade IV gliomas, 7 primary CNS The mean rPSR value was lower in
lymphomas (PCNSLs), and 7 brain metastases (0.69±0.03) and grade IV glioma
metastases were included in the study. In our (0.92±0.05), whereas higher in lymphoma
study, the mean age of the participants was (1.84±0.68) with a p-value of <0.001, which
54.16±12.47. Out of 38 patients, 24 (63.2%) is statistically significant. In our study, we
were male and 14 (36.8%) were female. The found that PSR and rPSR values can
most common location of the tumors differentiate lymphoma, metastases, and
included in our study was frontal parenchyma grade IV glioma lesions (Table 2).
(47.4%). Baseline signal characteristics on Chi-square test was done for various
conventional imaging were analyzed. categorical variables measured to find out if
Lymphoma was the only tumor to show frank any association is present with the HPE
T2 hypointensity more commonly while all diagnosis. There was no significant
gliomas showed FLAIR hyperintensity difference between the HPE diagnosis and
(Table 1). Thus, these signal characteristics sex, Laterality, Location of tumor, supra/
on the T2 weighted image and FLAIR were infratentorial region, Predominant signal on
found to be statistically significant. Among T1, Diffusion restriction of solid component
the various other p and Lipid Lactate Peak.
486
Table 1. Distribution of study population according to Socio demographic and clinical variables
HPE
Grade IV χ2 p
Variables Lymphoma Metastases
glioma Value Value
n=7 % n=24 % n=7 %
Age
≤60 3 42.9 18 75 6 85.7
3.620 0.164
>60 4 57.1 6 25 1 14.3
Sex
Male 6 85.7 14 58.3 4 57.1
1.880 0.391
Female 1 14.3 10 41.7 3 42.9
Predominant signal on T1 weighted image
Hypointense 4 57.1 15 62.5 2 28.6
2.536 0.281
Isointense 3 42.9 9 37.5 5 71.4
Predominant signal on T2 weighted image
Hypointense 1 14.3 0 0 0 0
Isointense 1 14.3 0 0 2 28.6 11.283 0.024
Hyperintense 5 71.4 24 100 5 71.4
Signal on Flair
Hyperintense 5 71.4 24 100 5 71.4
7.664 0.022
Isointense 2 28.6 0 0 2 28.6
Perilesional edema
Mild 1 14.3 13 54.2 0 0
Moderate 5 71.4 10 41.7 4 57.1 12.722 0.013
Marked 1 14.3 1 4.2 3 42.9
SWI blooming 0 0 11 45.8 6 85.7 10.433 0.005
Cystic necrosis 0 0 11 45.8 6 85.7 10.433 0.005
Diffusion restriction of solid
7 100 22 91.7 6 85.7 1.000 0.607
component
Lipid lactate peak 4 57.1 6 30 4 80 4.717 0.095
Enhancement of solid
5 71.4 21 87.5 7 100 2.252 0.283
component
487
Table 2. Comparison of Mean rCBV, PSR, rPSR with HPE diagnosis
HPE Maximum rCBV PSR rPSR
Mea SD Median Mean SD Median Mean SD Median

n (IQR) (IQR) (IQR)
Lymphoma 1.14 0.25 1.03 146.13 40.97 150 2.05

(0.96-1.46) (106.1-186.7) 1.84 0.68 (1.04-
2.42)
Grade IV 3.08 0.67 3.06 80.69 6.48 81.65 0.92

glioma (2.52-3.70) (75.53-86.83) 0.92 0.05 (0.91-
0.96)
Metastases 3.23 0.51 3.04 56.03 7.87 53.4 0.70

(2.88-3.72) (51.6-62.8) 0.69 0.03 (0.67-
0.71)
Kruskal 17.077 26.742 20.401

Wallis Value
p Value <0.001 <0.001 <0.001
Figure 1: Axial T2 space (A), post-contrast T1 W (B), rCBV map (C) and PSR (D) images in a case of
lymphoma show a well-defined solid intra-axial mass lesion involving the right parasagittal frontal
parenchyma which appears relatively hypointense on T2, shows heterogeneous enhancement, relative
hypoperfusion with few eccentric areas of raised rCBV and high PSR with overshooting.
488
Figure 2. Axial T2 space (A), post-contrast T1 W (B), rCBV map (C) and PSR (D) images in a case of
solitary brain metastasis show an irregular solid intra-axial lesion in the right occipital lobe. It appears
heterointense on T2 with central cystic area, enhancement of solid component on post-contrast images,
increased perfusion in enhancing component and low PSR
Figure 3. Axial T2 space (A), post-contrast T1 W (B), rCBV map (C) and PSR (D) images in a case of
glioblastoma show an ill-defined infiltrative intra-axial left parasagittal lesion involving superior frontal
and cingulate parenchyma which appears heterointense on T2, shows heterogenous post-contrast
enhancement with internal necrosis and anterior non-enhancing areas, increased perfusion in enhancing
component and intermediate PSR.
489
All those who were diagnosed with many occasions. Among the various
Glioma had hyperintensity on T2 and FLAIR perfusion methods, T2* is the most used
compared to 71.4% in lymphoma and technique, and relative cerebral blood
metastasis. SWI blooming and cystic volume is the most common parameter
necrosis was not present in Lymphoma, it studied. Although percentage signal recovery
was present in 45.8% of Glioma and 85.7% has been additionally studied as a parameter
in Metastasis. in various previous studies, it has not been
routinely incorporated into the imaging
Discussion guidelines and practice protocols. In our
In this study, we looked at the role of study, we have included advanced perfusion
T2* MRI perfusion imaging, focusing on the parameters of the common brain tumors
lesser utilized parametric namely the namely grade IV glioma, PCNSL, and
percentage signal recovery (PSR) in the solitary brain metastases. We aimed to
differentiation of the various malignant brain evaluate their role in the accurate diagnosis
tumors, and compared its diagnostic accuracy of these brain lesions. We have also tried to
with the more commonly used perfusion compare the diagnostic accuracy of the
parameter, relative cerebral blood volume. perfusion parameters like rCBV, PSR, and
This study included high-grade gliomas rPSR using histopathology as the gold
(Grade IV gliomas/GBMs), CNS standard.
lymphomas, and solitary metastases. In our study, almost all the grade IV
Accurate diagnosis of these tumors is crucial glioma and lymphoma cases were
for preoperative treatment planning and supratentorial in location. This correlates
prognostication. There is a substantial well with other studies in the past which have
difference in management strategies for these also shown that nearly all GBMs were
brain tumors. Although histopathology is the localized to the supratentorial parenchyma
gold standard, surgical methods are invasive [7].
and even within certain tumors have With respect to signal characteristics,
sampling bias. Pre-operative diagnosis can T2 and FLAIR signals were found to be
help the surgeon decide on the optimal discriminatory. It also varies according to the
treatment strategy. Although conventional immune status. Prior literature has shown that
MRI helps narrow down the differential the T2 hypointensity usually seen in
diagnosis of a brain tumor, its diagnostic lymphomas may be attributed to the high
accuracy in their differentiation is low and nuclear-cytoplasmic ratio [8]. All grade IV
can be increased using advanced imaging gliomas in this study showed hyperintense
methods such as perfusion and spectroscopy. signal on FLAIR as compared to 70% of the
Considerable overlap exists in the signal other two groups, which was statistically
characteristics on conventional sequences significant. This is similar to a prior study
among these tumors. Advanced imaging adds done by Elghany et al. [9], where the majority
as an adjunct in further narrowing the of GBM (98.1%) were hyperintense.
differential and excluding certain tumors on
490
It is important to differentiate PCNSL emphasize the significance of incorporating

from other tumors as the first line of advanced imaging modalities into routine
treatment for lymphoma is chemotherapy and clinical practice, aiding in early and precise
not surgical resection [10]. We have found diagnosis, thereby facilitating tailored
that PCNSL has low rCBV as well as higher therapeutic interventions for improved
PSR and rPSR values. Possibly here, the T1 patient outcomes.
effect is dominant over the T2* effect leading
to the overshoot above baseline. Other factors Statements and Declarations
like cellularity, blood volume, and vascular Conflicts of interest
permeability may also have a role in this [11- The authors declares that they do not
13]. Even though the signal intensity curve of have conflict of interest.
PCNSL showed characteristic overshoot, the
diagnostic performance of rCBV was found Funding
to be better than PSR. Nonetheless, both the No funding was received for
parameters were significant with varying conducting this study.
thresholds.
Ethics approval
Due to the significant overlap of the
Ethical approval obtained from all
perfusion values in gliomas and metastases,
patients.
rCBV was not sensitive enough to
differentiate between grade IV glioma and
Human and animal rights
metastases with similar higher values. This article does not contain any
However, the mean PSR was statistically studies with human participants or animals
significant among these groups. We reckon performed by any of the authors.
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492

DOI 10.61770/NBEJMS.2024.v02.i05.009
REVIEW ARTICLE
Review of National Suicide Prevention Strategy and Other Suicide Prevention

Initiatives in India
Akshithanand KJ,1 Anshita Mishra,1,* Sahadev Santra2 and Bratati Banerjee3

1Junior Resident, Department of Community Medicine, Maulana Azad Medical College, New
Delhi, India
2Senior Resident, Department of Community Medicine, Maulana Azad Medical College, New
Delhi, India
3Director Professor, Department of Community Medicine, Maulana Azad Medical College,
New Delhi, India
Abstract
India's launch of the National Suicide Prevention Strategy in 2022 underscores the gravity of
suicides as a pressing public health issue. Globally, suicides rank as the fourth leading cause
of death among individuals aged 15 to 29, with low and middle-income countries bearing the
brunt. Within India, suicides increased by 7.2% from 2020 to 2021, with Maharashtra and
Tamil Nadu reporting the highest numbers. Despite decades of initiatives, including the
National Mental Health Program (NMHP) since 1982, challenges persist in policy
implementation, skilled manpower, and political hurdles, impeding desired outcomes. While
commendable, the recent National Suicide Prevention Strategy faces limitations in execution.
A critical review of government efforts reveals gaps in resource allocation and execution,
hindering the impact of mental health programs. Addressing these challenges demands
enhanced policy implementation, mental health infrastructure, and resource allocation.
Additionally, public awareness and destigmatization are crucial components. In conclusion,
India's efforts in suicide prevention reflect progress, yet significant gaps remain. Sustained
commitment and innovative strategies are needed to mitigate the escalating burden of suicides.
This review underscores the urgency for comprehensive measures to combat rising suicide
rates effectively.
Keywords: Suicide, National Suicide Prevention Strategy, India
*Corresponding author: Anshita Mishra

Email: amishra371@gmail.com
493
Graphical Abstract
Background times more likely to die by suicide than

Mental health, as defined by the women, though the Southeast Asia region
World Health Organization (WHO), is exhibits a higher female age-standardized
integral to overall well-being and is suicide rate than the global average,
affected by disorders present worldwide, warranting attention to factors influencing
affecting approximately 1 in 10 individuals, young women's high suicide rates [4].
with depression and anxiety being the most Over half of all suicides occur
common [1]. Severe cases of mental health before age 50, emphasizing its significance
disorders can escalate to suicide, a critical as a leading cause of death among young
public health concern across all age groups. people [5]. Pesticide self-poisoning is a
The Sustainable Development Goals prevalent method, particularly in rural
(SDGs), particularly Goal 3, aim to ensure agricultural regions of low- and middle-
healthy living and promote well-being, with income countries, with hanging and
Target 3.4 specifically addressing mental firearms also commonly employed. Low
health promotion. The Suicide mortality and Middle-Income Countries account for
rate serves as an indicator for measuring 77% of total suicide deaths, with most
progress toward reducing suicide [2]. adolescent suicides occurring in these
Suicide surpasses malaria, regions. India, ranking 38th globally,
HIV/AIDS, breast cancer, war, and reported a suicide rate of 12.7 per lakh
homicide in causing mortality globally. population in 2019, marking a gradual
While the global age-standardized suicide decline over two decades [6,7,8].
rate decreased by 36% from 2000 to 2019, In 2021, India experienced a 7.2%
over 700,000 deaths were attributed to increase in reported suicides compared to
suicide in 2019, making it the fourth 2020, with Maharashtra and Tamil Nadu
leading cause of death among individuals recording the highest numbers [9]. Mental
aged 15-29 worldwide [3]. Men are 2.3 health disorders like depression and alcohol
494
use disorders often precede suicide, but The NMHP was adopted with the
impulsive acts during crises, financial objectives of increasing accessibility and
difficulties, relationship strains, and availability of mental health care for all,
chronic illness also contribute [10]. encouraging the application of mental
Previous suicide attempts pose a significant health knowledge in general health care,
risk, yet suicide is preventable, with and promoting community participation in
interventions possible at population, sub- mental health services. However, the
population, and individual levels. program faced many challenges from its
The article aims to critically review inception due to various ambiguities like
India's efforts to address rising mental the absence of proper budgetary allocation,
health concerns, including the recently lack of clarity funding for the program, and
launched National Suicide Prevention the lack of support from psychiatrists.
Strategy, recognizing the multifaceted Later, in 1996, as the government tried to
approach required to combat suicide trends set the district as the basic unit for
effectively. implementing and monitoring the program
to cover for the shortcomings of NMHP, the
Indian Mental Health Programs District Mental Health Program (DMHP)
In 1974, the WHO expert was launched. This was done based on the
committee recognized that there is a heavy Bellary model shown by the National
burden and huge treatment gaps concerning Institute of Mental Health and Neuro-
mental health disorders and that mental Sciences (NIMHANS). NMHP was re-
health has become a severe public health strategized in 2003 with increased
problem without any fundamental budgetary allocations for the program, and
guidelines or infrastructure to meet the later, in 2009, along with the development
population's mental health needs, and of the Center of Excellence in Mental
asserted mental health care of the Health, manpower development became
developing countries as its priority [11]. important. Over the years, there has been an
Following this, in 1979, the WHO Mental increasing need to focus on community
Health Advisory Group advised all member mental health using Information Education
nations to prepare their own National and Communication (IEC) activities.
Mental Health Programme (NMHP) to Further along, the NMHP was gradually
meet the mental health needs of the inculcated into the National Health Mission
population, making use of the existing (NHM) to meet the needs of both rural and
healthcare facilities and in 1982, per the urban areas [14].
WHO directives, India became one of the Various other acts, policies, and
first nations to launch its own NMHP [12]. programs have come into place over time to
In 1982, it was through dedicated and support the mental health framework of the
relentless efforts that the senior country like the National Mental Health
psychiatrists of India drafted the NMHP Policy (NMHP), The Mental Health Care
after multiple reviews and workshops Act (MHCA) 2017, the National Tele
before it was tabled in the Central Council Mental Health Program, the National
of Health and Family Welfare, where the Suicide Prevention Strategy.
NMHP was adopted [13]. In 2014, the National Mental Health
Policy (MHP) was launched with the vision
495
to promote mental health, prevent mental of mental health-related institutions and

illness, enable recovery from mental illness, their regulations [16].
promote de-stigmatization, and ensure The launch of the National Tele
socio-economic inclusion of persons Mental Health Programme in 2022, known
affected by mental illness by providing as Tele Mental Health Assistance and
accessible, affordable, quality health and Networking Across States (Tele MANAS),
social care. The National Mental Health underscores the government's commitment
Policy, with its 3 goals and 10 objectives, to providing universal, accessible, and
aims to bridge the treatment gap, thereby quality mental health care through tele-
reducing mortality and morbidity along mental health counseling services across all
with an enhanced understanding of the states and union territories. [17].
issue and strengthening the leadership at all Despite these various programs and acts in
levels in the mental health sector [15]. action, the government has consistently
The Mental Health Care Act 2017 failed to meet the manpower needs that
was passed on 7 April 2017 and came into form its backbone. From the data depicted
existence on 29 May 2018, it superseded in Table 1, India faces a significant shortfall
the previous Mental Health Act 1987. The of mental health professionals, including
major highlight of the act was that it psychiatrists and clinical psychologists,
decriminalized suicide attempts. Also, it compared to the growing demand for
focused on promoting and fulfilling the mental healthcare services. Addressing this
rights of people during the delivery of shortage is crucial to improving our
mental healthcare and services for matters country's mental health support and
connected therewith or incidental thereto services [18,19,20].
and created provisions for the registration
Table 1. Current scenario of mental health professionals in India [18,19,20]

Manpower Requirement (per Availability (per lakh
Availability (2012)
lakh population) population)
Psychiatrist 36,000 (>3) 3,800 Approx 9000 (0.75)
Clinical 17,250 (1.5) 898 0.05
psychologist
Psychiatric social 23,000 (2.0) 850 0.07
worker
Psychiatric nurse 3000 (1.0 per 10 1,500 N/A
psychiatric beds)
Total 79,250 7,048 -
National Suicide Prevention Strategy priority. The NSPS intends to reach this
In line with WHO’s Strategy on objective by implementing efficient
suicide prevention, the National Suicide surveillance systems by 2025, ensuring the
Prevention Strategy (NSPS) was launched availability of suicide prevention services
in November 2022, with the aim to reduce and incorporating a mental well-being
suicide mortality by 10% in the country by curriculum into all educational institutions
2030 in comparison to the prevalence in the by 2030 [21].The NSPS has mapped out the
year 2020. It is the first of its kind in India, ‘REDS’ pathway for suicide prevention as
making suicide prevention a public health shown in Figure 1.
496
Figure 1. REDS pathway for suicide prevention envisaged by World Health Organization [21]
The Action plan formulated to defining the timelines to achieve our

realize these crucial objectives has five key objectives [21]. NSPS has taken a multi-
themes: recognizing strategies, delineating sectoral approach to suicide prevention
actions to be taken, specifying the involving international, national, and
indicators that will help us plot our regional agencies and NGOs, as shown in
progress, identifying key stakeholders, and Figure 2.
Figure 2. A multi sectoral approach under National Suicide Prevention Strategy [21]
Swoc Analysis along with certain challenges that are to be

Even with extreme efforts put in by kept in mind. Figure 3 highlights some of
various agencies, there is always a scope for the points of Strength, Weakness,
improvement. Hence, NSPS has been Opportunities, and Challenges (SWOC)
identified with its shortcomings, its analysis that can be further utilized to
strengths, and the opportunities it has to improve the policy-making process and
prevent the coming mental health pandemic more importantly its implementation.
497
Figure 3: SWOC analysis of Mental health initiatives in India
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12. Gupta S, Sagar R. National Mental 2023.
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%20Strategy.pdf
499

DOI 10.61770/NBEJMS.2024.v02.i05.010
LETTER TO THE EDITOR
Paraquat Toxicity on Substantia Nigra: Pioneering Insights from an Autopsy Based

Pilot Study
Mohit Kumar Moses T,1 Rema Nair Sarkar,2 Jacinth Karunya Midde,3 Devaraj Boddepalli,4
Rakesh Miriyala4 and Kattamreddy Ananth Rupesh1,*
1Assistant Professor of Forensic Medicine and Toxicology, Andhra Medical College,
Visakhapatnam.
2Associate Professor of Pathology, Andhra Medical College, Visakhapatnam.
3Senior Resident, Department of Forensic Medicine, and Toxicology, GIMSR, Visakhapatnam.
4Junior Resident, Department of Forensic Medicine and Toxicology, Andhra Medical College,
Visakhapatnam.
Paraquat (N,N′-dimethyl-4,4′- this substance is responsible for a poor

bipyridinium dichloride) is one of the prognosis, even with minimal consumption.
widely used herbicides in Indian Paraquat neurotoxicity studies in
agriculture. This compound is at the centre Wistar rats indicated changes, including the
of polemics, involving debates on its effects loss of dopaminergic neurons and astrocyte
on sustainable agriculture, potential health proliferation, with the degree of changes
risks, and unintended applications. escalating proportionally with increased
Paraquat (PQ) also gained ill repute dosage [3]. However, human autopsy-based
globally due to the controversy surrounding studies on this subject are limited. A
its association with Parkinson’s disease [1]. thorough review of literature (light
Furthermore, our country witnessed a rise microscopy and electron microscopy) in
in paraquat-related deaths attributed to its cases of paraquat and diquat poisoning
misuse for suicide, prompting a consistent indicated a few neuropathological changes,
call for proper regulation and a potential encompassing findings such as brain
ban [2]. Paraquat exerts its toxicity through oedema, haemorrhagic
corrosion and the generation of Reactive leukoencephalopathy, anoxic neuronal
Oxygen Species (ROS) causing cytotoxic depletion, myelin destruction, astrocytic
effects that contribute to multiorgan failure. fibrous gliosis, and hypoxic purpuric
There is no specific antidote for paraquat staining in the basal ganglia etc. [4].
(PQ) poisoning, and the lethal toxicity of
*Corresponding author: Kattamreddy Ananth Rupesh
Email: ananth.kattam@gmail.com
500
In the context of limited availability neuromelanin pigment content. The

of human studies on histopathological neuropathological features were
changes in the substantia nigra related to accentuated in long-term survivors,
paraquat poisoning, a pilot project was characterized by astrocytosis, rarefaction
initiated. A thorough case selection process and inflammatory markers (Figures 1-7).
was conducted, excluding deceased Contrastingly, the substantia nigra of the
individuals with pre-existing control brains demonstrated a superior
neurodegenerative disorders or any staining affinity, indicating a dense
neuropathology. This pilot study was congregation of neurons without
conducted collaboratively between the discernible rarefaction and normal
Department of Forensic Medicine and the neuromelanin pigment levels (Figures 7-
Department of Pathology at Andhra 11). These observations highlight a notable
Medical College, Visakhapatnam, spanning disparity between the substantia nigra of
a 6-month period from August 2023 to cases and controls, implicating the
January 2024. We utilized formalin neurotoxicity of paraquat.
(immersion)-fixed brain samples obtained The current pilot study is a
during forensic autopsies conducted at our pioneering attempt in the domain of
institute. These specimens were immersed paraquat neurotoxicity. Nevertheless, our
and fixed in 10 percent formalin for a results are concordant with an MRI-based
duration of 3-6 weeks. It is crucial to note imaging study in acute paraquat poisoned
that all samples were derived from cadavers patients which revealed CNS toxicity and
promptly preserved in cold storage at 4 lesions in multiple areas of brain, including
degrees Celsius as early as possible the basal ganglia [5]. Indeed, studies that
following death, ensuring the preservation integrate clinical examination of patients
of the brains under standardized conditions with MRI imaging will yield fruitful results
to the extent possible. in understanding the acute toxicity of PQ on
The substantia nigra of fixed brains humans. By the same token, conducting
in paraquat poisoning cases (n=9, 5 Males, serial follow-ups with PQ poisoning
4 Females) was subjected to survivors will help us comprehend the
histopathology, stained with Hematoxylin subacute and chronic toxicity of this
and Eosin, and compared with a control substance on the basal ganglia, shedding
group (n=6, 5 Males, 1 Female) comprising light on its potential association with
autopsy cases with causes of death Parkinson’s disease.
unrelated to paraquat poisoning. The details In conclusion, the present study
of the cases and controls are presented in indicates that paraquat crosses blood brain
Table 1. The diagnosis of poisoning was barrier and exerts its toxicity on brain in
confirmed through postmortem chemical general and substantia nigra in particular.
analysis of viscera in all the cases. However, the limitations of the present
The examination of the substantia study include its reliance on a limited
nigra in post-mortem brain specimens in the sample size, and the absence of exact age-
cases revealed distinctive matched controls. Similarly, special stains
neuropathological changes compared to were not employed for the examination of
controls. Specifically, the substantia nigra brain tissue. Future studies are needed to
in paraquat-exposed brains exhibited a further validate the results of our study
considerable reduction in neuronal density, preferably with a larger sample size and
accompanied by oedema and a decrease in more standardized sampling and processing
501
conditions to minimize the impact of investigating toxicopathology is poised to

postmortem artifacts. The significance of become a pivotal subspecialty within the
traditional autopsy and virtopsy in field of toxicology in the near future.
Table 1. Details of Cases and Controls in the Pilot Study

S.No Case/Control Time Time Since Consumption of Cause of death
(Age (in years) & Since Paraquat (in hours)
Sex) Death(in
hours)
1 Case 1(22, F) 15 72
2 Case 2(31,F) 16 48
3 Case 3(58,M) 15 29
4 Case 4(20,F) 19 52 PARAQUAT
5 Case 5(21,M) 10 168 POISONING
6 Case 6(20,M) 23 42
7 Case 7(21,F) 18 264
8 Case 8(29,M) 12 54
9 Case 9(22,M) 16 25
10 Control 1(32,M) 26 Cut Throat Injury
11 Control 2(59,M) 24 Blunt Injury to the
NOT APPLICABLE Chest
12 Control 3(29,M) 25 Olanzapine
Poisoning
13 Control 4(53,M) 98 Coronary Artery
Disease
14 Control 5(38,M) 24 Hanging
15 Control 6(6,F) 15 Thermal Burns
M: Male, F: Female
502
Figures 1-3. Photomicrograph H & E, High Power.

Cases 1-3, Substantia Nigra Showing a Decrease in Neuromelanin Pigmentation, Paraquat
Poisoning.
Figure 4. Photomicrograph H & E, Scanner View

Case 5, Substantia Nigra Showing A Decrease In Neuronal Density, Paraquat Poisoning.
503
Figure 5. Photomicrograph H & E, Low Power.

Case 5, Substantia Nigra Showing A Decrease In Neuronal Density, Paraquat Poisoning.
Figure 6. Photomicrograph H & E, High Power

Case 7, Substantia Nigra Showing Astrocytosis, Paraquat Poisoning.
Figure 7. Photomicrograph H & E, Low Power

Case 7, Substantia Nigra Showing Astrocytosis, Paraquat Poisoning.
504
Figures 8-9. Photomicrograph H & E, High Power

Control 3, Showing Neuromelanin In Substantia Nigra (Normal Histology)
Figure 10. Photomicrograph H & E, Low Power

Control 5, Showing Normal Histology of Substantia Nigra
505
Figure 11. Photomicrograph H & E, Scanner View.

Control 2, Substantia Nigra Showing Normal Histology
Acknowledgements doctors-want-this-pesticide-banned
We sincerely thank Prof. Dr. C. V. (accessed March 2, 2024).
Lakshmi and Prof. Dr. K. Mamatha from 3. Liou H-H, Chen R-C, Tsai Y-F, Chen
Andhra Medical College for their W-P, Chang Y-C, Tsai M-C. Effects of
invaluable support. paraquat on the substantia nigra of the
wistar rats: Neurochemical,
Ethical Issues histological, and behavioral studies.
All ethical issue to be addressed by Toxicol Appl Pharmacol
the authors 1996;137:34–41.
https://doi.org/10.1006/taap.1996.00
Conflicts of interest 54.
The authors declares that they do 4. Kattamreddy AR, Thathapudı̇ MKM,
not have conflict of interest. Ghosh V, Mı̇ dde JK, Kalyankar P.
“Paraquat Brain”: Have we
Funding Researched Enough? Eurasian
No funding was received for Journal of Toxicology 2023
conducting this study. (3).https://doi.org/10.51262/ejtox.13
44451.
References 5. Wu B, Song B, Tian S, Huo S, Cui C,
1. Dorsey ER, Ray A. Paraquat, Guo Y, et al. Central nervous system
Parkinson’s disease, and agnotology. damage due to acute paraquat
Mov Disord 2023;38:949–52. poisoning: A neuroimaging study
https://doi.org/10.1002/mds.29371 with 3.0T MRI. Neurotoxicology
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pesticide banned. Scroll.in 2023. https://doi.org/10.1016/j.neuro.2012.
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506

DOI 10.61770/NBEJMS.2024.v02.i05.011
PERSPECTIVE
Toilet Scrolling: A Predisposing Factor for Haemorrhoids?
Kaushik Bhattacharya,1,* Neela Bhattacharya,2 Aditya Shikar Bhattacharya,3 Vipul D

Yagnik4 and Pankaj Garg5
1Associate Professor, Department of Surgery, Mata Gujri Memorial Medical College and
LSK Hospital, Kishanganj - 855107, Bihar, India
2Consultant Plastic and Reconstructive Surgeon, Anandaloke Multispeciality Hospital,
Siliguri -734001, West Bengal, India

3Government Stanley Medical College, Chennai, Tamil Nadu - 600001, India
4Associate Professor, Department of Surgery, Banas Medical College and Research Institute,
Palanpur – 385001, Gujarat, India

5Department of Colorectal Surgery, Garg Fistula Research Institute (GFRI), Haryana, India
Abstract
Scrolling smartphones while sitting on the toilet is believed to be one of the reasons
predisposing to haemorrhoidal disease. Not much is written about the problem of the use of
smartphones and the development of haemorrhoidal disease in the literature, but the rising
incidence of haemorrhoids globally does require guidelines to be set for toilet hygiene,
especially in the young generation to prevent this issue from becoming an epidemic in future.
It may be time to designate the washroom as a smartphone-free zone.
Keywords: Toilet scrolling, Haemorrhoidal disease, Smartphone Free Zone, Smartphone

addiction
*Corresponding author: Kaushik Bhattacharya

Email: kbhattacharya10@yahoo.com
507
While the incidence of conducted by the London School of

haemorrhoids is on the rise in countries like Hygiene & Tropical Medicine and Queen
Australia, Israel, and Korea, India is also Mary, University of London concluded that
contributing significantly to the case list 1 in 6 smartphones was contaminated with
with 50% of the population predicted to faecal matter [5]. But another surgical
have had symptoms of haemorrhoids at problem that is lurking behind is the
some point in their life at 50 years of age, formation of haemorrhoids because of
and approximately 5% of the population prolonged sitting in the washroom due to
suffer from haemorrhoids at any given toilet scrolling.
point of time [1]. Apart from a sedentary A recent study did find a linear
lifestyle leading to chronic constipation, the association between the time spent on the
role of sitting for a prolonged period in the toilet and the degree of haemorrhoids [6],
washroom with a smartphone performing but not much literature has predicted the
‘toilet scrolling’ needs to be investigated dark side of toilet scrolling associated with
and highlighted in the etiopathogenesis of the grades of haemorrhoids. Toilet reading
haemorrhoids. habits were evaluated in the general
Toilet scrolling is a global issue population from Israel and it was found to
with studies revealing that 79.8% of involve 52.7% of the population and these
respondents from Spain take their people had an increased incidence of
smartphone to the loo followed by Poland, haemorrhoids, though it was not
the USA, Lithuania, and Canada [2]. This statistically significant [7]. Though chronic
survey also revealed that while Canadians constipation and straining at defecation are
like to play games with their smartphones important etiological factors, the use of cell
while sitting in the washroom, Americans phones during defecation diverts one's
prefer to chat or call people while in the attention from the so-called "Nature's call"
toilet. The French divide the bathroom and thus affects the normal anal synergia of
phone time between social media scrolling, the defecatory reflex. It may be graded as a
gaming, and reading the news. A recent part of attention disorder. A psychological
study found that 90% of residents of Hong angle of "cell phone addiction" may also be
Kong take their smartphones to the toilet contributory.
and 61.1% toilet -scrolling of social media It is well established that
[3]. Social media platforms like Facebook, haemorrhoids develop when the supporting
Twitter, and Instagram were the primary tissues of the anal cushions disintegrate or
focus of scrolling for 61.6% of respondents deteriorate resulting in an abnormal
during their toilet time. downward displacement of the anal
The two important health concerns cushions resulting in dilatation of the veins.
of toilet scrolling are the development of Though the amount of toilet time and
haemorrhoids due to prolonged sitting in pressure required to initiate this pathology
the washroom and the touchscreen is still not established, the incidence of
becoming a potential source of haemorrhoidal disease was found to be
contamination for bacterial infection. higher in the patients using a bidet
Smartphones are regarded as “mosquitoes (Western) toilet compared to those using a
of the digital age" as they carry ten times squat (Indian) toilet, which could be
more germs than toilet seats [4]. A study attributed to the longer toilet sitting periods
508
in the bidet toilet and scrolling on the Summary – The Association of Colon
mobiles [8]. 10 minutes has been the & Rectal Surgeons of India (ACRSI)
maximum recommended time to be spent in Practice Guidelines for the
the toilet according to various non-peer- Management of Haemorrhoids-2016.
reviewed data available as there are no Indian J Surg. 2017 Feb;79(1):58-61.
hard-core evidence-based retrospective or doi: 10.1007/s12262-016-1578-7.
prospective studies in this matter [9]. 2. NordVPN. Staying busy when nature
Smartphone addiction has been associated calls: Smartphone use in the toilet.
with teenage anxiety, depression, stress, Available from
and loneliness which might indirectly lead https://nordvpn.com/blog/staying-
to spending more time sitting in the toilet busy-when-nature-calls-smartphone-
for scrolling in solitude. use-on-the-toilet/
With the prevalence of 3. PR Newswire. NordVPN study: 90%
haemorrhoidal disease estimated to be of Hong Kong residents use
around 20.8 to 38.2% by colonoscopy smartphones while on the toilet.
findings [10], it is extremely important to Available from
declare the washroom as a ‘Smartphone https://www.prnewswire.com/apac/n
Free Zone’ and all types of mobile scrolling ews-releases/nordvpn-study-90-of-
to be discouraged right from the school hong-kong-residents-use-
days. Toilet training and toilet hygiene smartphones-while-on-the-toilet-
should make it mandatory for all to avoid 301817431.html
mobiles inside the washroom. To prevent 4. TIPS. Touchscreens: The Mosquito
the future generation from developing of the Digital Age. Available from
various grades of haemorrhoids, a timer or https://infectioncontrol.tips/2016/08/
alarm has to be set for spending a maximum 08/touchscreens-the-mosquito-of-
of 10 minutes inside the washroom. Until the-digital-age-433/
and unless strict guidelines and health 5. CNN Health. Study: 1 in 6 UK cell
regulations on the use of smartphones in the phones is contaminated with faecal
washroom are made with lifestyle matter. Available from
modifications, we may be encountering an https://edition.cnn.com/2011/10/14/h
epidemic of bleeding per rectum in the ealth/mobile-phones-
future. contamination/index.html
6. Giuliani A, Romano L, Lazzarin G,
Conflicts of interest Maffione F, Valiyeva S, Schietroma
The authors declares that they do M, Carlei F. Relationship between
not have conflict of interest. haemorrhoidal grade and toilet habits.
Ann Ital Chir. 2020;91:192-195.
Funding 7. Goldstein O, Shaham Y, Naftali T,
No funding was received for Konikoff F, Lavy A, Shaoul R. Toilet
conducting this study. reading habits in Israeli adults.
Neurogastroenterol Motil. 2009
References Mar;21(3):291-5. doi:
1. Agarwal N, Singh K, Sheikh P, Mittal 10.1111/j.1365-2982.2008.01204.x.
K, Mathai V, Kumar A. Executive
509
8. Yildiz T, Aydin DB, Ilce Z, Yucak A, 10. Hong YS, Jung KU, Rampal S, Zhao
Karaaslan E. External hemorrhoidal D, Guallar E, Ryu S, Chang Y, Kim
disease in child and teenage: Clinical HO, Kim H, Chun HK, Sohn CI, Shin
presentations and risk factors. Pak J H, Cho J. Risk factors for
Med Sci. 2019;35(3):696-700. doi: hemorrhoidal disease among healthy
10.12669/pjms.35.3.442. young and middle-aged Korean
9. News 18. This is why you should not adults. Sci Rep. 2022 Jan
spend more than 10 minutes in the 7;12(1):129. doi: 10.1038/s41598-
toilet. Available from 021-03838-z.
https://www.news18.com/news/buzz
/this-is-why-you-should-not-spend-
more-than-10-minutes-on-the-toilet-
4435799.html
510

DOI 10.61770/NBEJMS.2024.v02.i05.012
CASE SERIES
Rhomboid Flap Reconstruction for the Treatment of Pilonidal Sinus: A Case Series
Jashanpreet Singh,1 Dhiraj Kumar,2 Sharad Syangden,3 Mahesh Kumar,3 Joe Nepram,1
Kiratpal Singh Brar,1 Ghaiyoor Ahmad,1 Diwakar Kumar,1 Shahnawaz Alam,1 Hibah Niyaz,1
Akash Kumar1 and Kaushik Bhattacharya4,*
1Post Graduate, Department of Surgery, Mata Gujri Memorial Medical College and LSK
Hospital, Kishanganj - 855107, Bihar, India
2Professor, Department of Surgery, Mata Gujri Memorial Medical College and LSK Hospital,
Kishanganj - 855107, Bihar, India

3Assistant Professor, Department of Surgery, Mata Gujri Memorial Medical College and

4Associate Professor, Department of Surgery, Mata Gujri Memorial Medical College and
Abstract
Pilonidal sinus disease (PSD) is a chronic inflammatory disease affecting the soft tissue of the
sacrococcygeal region and remains a challenging disease for surgeons to treat. With
controversies in management to prevent recurrence leading to economic burden to the patient,
these cases require special care by expert surgeons. From Jan 2023 to Nov 2023, 10 patients
with pilonidal sinus were treated with complete excision of the tract and reconstruction using
a rhomboid flap. The factors evaluated included the duration of surgery, postoperative pain,
length of hospital stay, and postoperative complications. The patients were followed up on an
outpatient basis, monthly for the first three months. The majority of the patients were young
males with a mean age of 28 years. The surgery time was 40 to 75 minutes, and the mean
operation time was 55 minutes. The stitches were removed after 2 weeks. Among
complications, two patients developed mild discharge with infection. In one patient, necrosis
at the tip of the flap was noted. We recommend the Rhomboid flap as a method of choice for
surgical management of Pilonidal sinus in a postgraduate medical college as it is easy to teach,
learn, and perform and gives complete recovery of the patient with negligible recurrence rate.
Keywords: Pilonidal sinus, Bascom procedure, Limberg procedure
*Corresponding author: Kaushik Bhattacharya

Email: kbhattacharya10@yahoo.com
511
Introduction eliciting the most successful aesthetic

The incidence of pilonidal outcome.
infections and chronic pilonidal sinuses are
usually found in the midline of the Materials and Methods
sacrococcygeal region of young hirsute This study was conducted from Jan 2023 to
men with the incidence of disease Dec 2023 in the Department of Surgery of
approximately being 26 per 100,000 Mata Gujri Memorial Medical College and
population. The hall mark in the LSK Hospital, Kishanganj, Bihar. 10
pathogenesis of the disease is the presence patients were taken for the study who
of hair in the gluteal cleft [1]. The disease underwent surgery for pilonidal sinus
rarely occurs in those with less body hair. disease by wide sinus excision followed by
Other risk factors include obesity, local rhomboid flap reconstruction procedure.
trauma, sedentary lifestyle, deep natal cleft, The inclusion criteria were each patient
and family history. Diagnosis is generally a who had undergone operation because of
clinical one; patients usually present with pilonidal sinus and exclusion criteria was
chronic inflammation or a sinus with patients with acute pilonidal sinus diseases
persistent drainage. They may also present and highly complicated sinuses, past
acutely with an abscess or multiple history of pilonidal sinus surgery and
complex subcutaneous tracks. Several history of systemic diseases (DM,
surgical procedures have been described to malignancy, etc.)
treat pilonidal sinus, each claiming to be the Three patients had a history of
best. But without prospective trials, such perianal abscess drainage in the past.
claims are just not scientific evidence. Patients were placed in a jack-knife
Usually, the surgeon decides the treatment position with strapping of the buttocks for
plan according to his preference, his maximum pull for giving a wide exposure.
perceived recurrence rates, and the patients' Preoperative incision and planning were
ability to be off work and afford treatment. done, and flap lines marked with a sterile
Marsupialisation, Wide excision with marker pen (Figure 1). The marked
laying open of all tracks, the excision of all rhomboid encompassed the pilonidal sinus.
tracks with primary or secondary closure, The skin incisions (with each side equal in
and excision with cover by a flap to offset a length) were made up to the pre-sacral
midline closure through a Limberg fascia centrally and to the gluteal fascia
procedure, Z-plasty or a Karydakis laterally (Figure 2), the pilonidal sinus tract
procedure are the common treatment was excised in toto until the sacrum or
options [2]. An ideal surgical treatment coccygeal bone was exposed. All the hair
option for pilonidal disease is still elusive, follicles seen during the excision were
the most essential factor being tension-free removed. A hydrogen peroxide wash was
healing with a negligible recurrence rate. given before flap cover. The flap was raised
The rationale behind selecting a Rhomboid without undermining the skin up to the
flap in pilonidal sinus is because it presacral fascia (Figure 3). The flap was
maintains continuity of texture, colour, and then mobilised into the defect with minimal
vascularity with the surrounding tissue, tension and primary skin closure was done
over a suction drain (Figure 4). The skin
512
was approximated with 2-0 Nylon, and the Postoperative sitz bath twice a day was
excised specimen was sent for advised, and all postoperative patients were
histopathology (Figure 5). followed up in the outpatient department
Intravenous Metronidazole was monthly for 6 months. All the records of the
given for 2 days, and the drain removed patient were maintained throughout
after 72 hours. Skin sutures were removed hospitalization including the postoperative
after the 10th postoperative day. course till the date of discharge.
Figure 1. Marking of the rhomboid flap with pilonidal sinus tract
Figure 2. Deepening until presacral fascia
513
Figure 3. Preparation of the flap
Figure 4. Closure of the flap
Figure 5. Excised tract with hairs
514
Results management. Most of the patients

Our case series consisted of 8 males underwent stitch removal on the 10th day
(80%) and 2 females (20%), with a mean and were advised rest and to avoid sitting
age of 28 years (range 16–50 years) with an for a long duration for the first 2 weeks. All
average operative time of an hour. Three the patients were advised to have a soft
patients developed mild infection with pus cotton pad under the undergarment to
discharge which was treated with prevent soiling of the dress during office
Metronidazole for a week. All patients work or outside activities. The
recovered completely except one patient postoperative course was uneventful and all
who developed flap necrosis in the tip the patients were completely cured at the
which healed with conservative time of discharge (Table 1).
Table 1. Postoperative complications

Complications Number
infection 1
necrosis 1
gaping 0
recurrence 0
Discussion management of the pilonidal sinus but also

Though the incidence of pilonidal preventing recurrence and complications.
sinus is 26 per 100,000 population, there is The recurrence rates range from
a significant increase of this disease 0.3% for Limberg/Dufourmentel flaps to
incidence after the Covid-19 pandemic 6.3% for incision and drainage at 1-year
probably due to long hours in sitting posture follow-up [4]. A recent study found
for online activities, especially among the postoperative wound healing in a case of
young generation [2]. According to the pilonidal sinus being influenced by the
latest report, the prevalence of pilonidal presence of Seborrheic dermatitis, obesity,
sinus is estimated at 6.6% in India with the and psychiatric illness [5].
peak age of incidence at 16 years to 25 Given the surgery is being
years. Males are generally more commonly conducted in a postgraduate teaching
affected than females and common risk hospital, it was preferred to perform a
factors are poor hygiene, stiff body hair, rhomboid flap as compared to other
obesity, a less bathing habits, and a choices.
sedentary lifestyle, especially in those who The rhomboid flap is a type of
sit for more than six hours a day [3]. transposition local flap commonly used in
Management requires not only operative the treatment of hidradenitis suppurativa. It
is an easy and reproducible surgery, has less
515
postoperative pain, infection rates, and Statements and Declarations

early return to work with a negligible Conflicts of interest
recurrence rate. The disadvantage of The authors declares that they do
rhomboid flap is in patients with a lower not have conflict of interest.
body mass index and with less available
skin. Funding
Historically, rhomboid flap design No funding was received for
was first described in 1928 by Professor conducting this study.
Alexander Alexandrovich Limberg of
Leningrad and the first description in Author Contribution
English language was a chapter in Modern All authors are equally contributed.
Trends in Plastic Surgery, edited by Thomas
Gibson in the year 1963. It is only after this
description, the flap became popular References
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One of the earliest evidence Bosque BA. Surgical reconstruction
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behind after excision of sacrococcygeal Wound Care. 2021 Jul
pilonidal disease on 641 patients found 1;30(Sup7):S28-S34. doi:
rhomboid flaps significantly cause lower 10.12968/jowc.2021.30.Sup7.S28.
wound infection and dehiscence. The study 2. https://timesofindia.indiatimes.com/c
concluded that the rhomboid flap was ity/pune/pilonidal-cyst-cases-surge-
superior to primary closure [7]. in-students-during-
Finally, the first original research on pandemic/articleshow/87265493.cms
pilonidal sinus disease was started by Dr 3. Bi, S., Sun, K., Chen, S. et
AW Anderson in the year 1847, who al. Surgical procedures in the
removed tufts of hair from the pilonidal sinus disease: a systematic
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4. Doll D, Orlik A, Maier K, Kauf P,
Conclusion Schmid M, Diekmann M, Vogt AP,
Given the easy technique with a Stauffer VK, Luedi MM. Impact of
negligible learning curve, we recommend geography and surgical approach on
rhomboid flaps for the surgical recurrence in global pilonidal sinus
management of pilonidal sinus in post- disease. Sci Rep. 2019 Oct
graduate medical institutions where there 22;9(1):15111. doi: 10.1038/s41598-
are no plastic surgeons or colorectal 019-51159-z.
surgeons available. Rhomboid flaps give 5. Kaba M. New factors affecting
excellent postoperative recovery with wound healing and recurrence after
hardly any recurrence. pilonidal sinus surgery in
516
adolescents; seborrheic dermatitis 7. Chasmar LR. The versatile rhomboid

and psychiatric co-occurring (Limberg) flap. Can J Plast Surg.
conditions. Int Wound J. 2024 2007 Summer;15(2):67-71. doi:
Jan;21(1):e14404. doi: 10.1177/229255030701500207.
10.1111/iwj.14404. Epub 2023 Sep 8. Doll D, Stauffer V, Diekann M, Van
18 Wyk P, Luedi MM. Turkey is leading
6. Kang AS, Kang KS. Rhomboid flap: in the 21st century pilonidal sinus
Indications, applications, techniques disease research. Turk J Surg. 2020
and results. A comprehensive review. Sep 28;36(3):284-290. doi:
Ann Med Surg (Lond). 2021 Jul 10.47717/turkjsurg.2020.4750.
7;68:102544. doi:
10.1016/j.amsu.2021.102544.
517

DOI 10.61770/NBEJMS.2024.v02.i05.013
CASE REPORT
Gangrene and Partial Auto-Amputation of the Penis in a Case of Priapism

Anil Kumar Nallabothula,1 Naveen Vulia Thillainathan,2,* Vignesh N C,2 Karthik Kosuri,2
K Dheeraj Kumar2 and Sumegha Malika2
1Professor and HOD, Department of Urology, Sri Venkateswara Institute of Medical
Sciences (SVIMS), Tirupati, Andhra Pradesh, India
2Senior Resident, Department of Urology, Sri Venkateswara Institute of Medical Sciences
(SVIMS), Tirupati, Andhra Pradesh, India
Accepted: 03-April-2024 / Published Online: 01-May-2024
Abstract
Background: Penile Gangrene is rare, usually associated with extensive pelvic trauma,
mechanical constriction, infection due to urinary extravasation and uncontrollable systemic
infection. The objective of this case report is to stress upon the need for early detumescence
by means of aspiration of accumulated blood, injection of phenylephrine, proper shunting of
blood and adequate compression dressing with necessary antibiotic cover. Case
Presentation: We present a case of 33-year-old married man who was hospitalized under
general surgery department for left AK amputation because of lower limb gangrene. On 3rd
postop day, patient was noted to have a turgid penis and unable to urinate. Urology
consultation was sought after 3 days for suspected priapism. We immediately shifted the
patient to OT and the detumescence of penis was achieved by means of aspiration and
injection of phenylephrine followed by Winter’s shunting. The penis was noted to be flaccid
with normal hue and patient was discharged. After 1 month, he returned to the hospital with
extensive gangrene of the entire distal half of the penis with features of auto amputation of
distal portion of penis. Conclusions: This report is aimed to prevent ischaemic complications
of priapism like penile gangrene. Various factors like time of intervention, urethral catheter,
tight pressure bandage dressing around the penis and local infection alone or in combination,
have been implicated in causing penile gangrene in cases of priapism. Penile detumescence
should be achieved on an emergency basis to prevent its ischaemic complications.
Keywords: Penile gangrene, detumescence of penis, Winter’s shunt
*Corresponding author: Naveen Vulia Thillainathan

Email: naveenvt1504@gmail.com
518
List of Abbreviations
AK: Above Knee
DVT: Deep Vein Thrombosis
Background revealed no abnormalities except an erect,
Penile Gangrene is not very tender and oedematous penis with bluish
common, usually associated with extensive discolouration. Routine laboratory
pelvic trauma, mechanical constriction, analyses were normal. Iliac vessel Doppler
infection due to urinary extravasation and was done in which internal iliac vein
uncontrollable systemic infection [1]. In couldn’t be commented upon, but rest of
our case, penile gangrene occurred despite the vessels were normal. We immediately
treatment for priapism shifted the patient to OT and the
(idiopathic/Ischaemic). The objective of detumescence of penis was achieved by
this case report is to emphasize the need means of aspiration and injection of
for early detumescence by means of phenylephrine followed by Winter’s
aspiration of accumulated blood, injection shunting. Gentle compression dressing
of phenylephrine, proper shunting of blood was done and adequate antibiotic cover
and adequate compression dressing with was given. The patient was shifted back to
necessary antibiotic cover. general surgery department, after brief
observation, with only minimal erection.
Case Details Two days postoperatively, the
A 33-year-old married man was compression dressing was removed, penis
hospitalized under general surgery was noted to be flaccid with normal hue
department for left AK amputation and patient was discharged. After 1 month,
because of gangrene. Doppler showed left he returned to the hospital with extensive
lower limb DVT and absent arterial flow gangrene of the entire distal half of the
in posterior tibial and dorsalis pedis penis with features of auto amputation of
arteries. Post operatively patient developed distal portion of penis. Debridement was
right lower limb edema with persistent left done under local anaesthesia and we could
thigh edema, and after Doppler insert 14FR Foleys catheter through the
confirmation, he was started on heparin proximal part of penile stump. The
infusion in view of B/L lower limb DVT. postoperative recovery was uneventful and
On 3rd postop day, patient was noted to he was discharged next day. As the patient
have a turgid penis and unable to urinate. is improving with spontaneous
He was catheterised. Urology consultation epithelisation by nature, he is being
was sought after 3 days for suspected followed up at regular intervals.
priapism. Complete physical examination
519
Figure 2. Penile gangrene (ventral view)

Figure 1. Penile gangrene with partial
amputation (dorsal view)
Figure 3. Gangrenous part debrided.

Figure 4. Post debridement
Discussion compressive dressing nor local infection as

Priapism is an infrequently a causative factor for the gangrene.
encountered disease with most cases being However, the occurrence of peripheral
idiopathic in origin. Priapism is described limb gangrene led to further investigations
as involuntary, painful, and prolonged and Doppler study showed arterial and
erection of penis persisting for more than venous thrombosis at multiple levels of
four hours not related to sexual stimulation bilateral lower limbs. The treatment
and unrelieved by ejaculation. Ischemic involves resuscitation of the patient and
priapism accounts for >95% of cases of decompression of the cavernosal bodies to
priapism [2]. Our patient had neither tight achieve penile detumescence. Various
520
factors like time of intervention, urethral References

catheter, tight pressure bandage dressing 1. Kraus EM, Tessler AN. Gangrene of
around the penis and local infection alone the penis following bilateral corpus-
or in combination, have been implicated in saphenous shunts for idiopathic
causing penile gangrene in cases of priapism. J Urol. 1973
priapism [3]. Jun;109(6):1021-2. doi:
10.1016/s0022-5347(17)60612-8.
2. Panwar VK, Mavuduru RS, Devana
Conclusions
SK, Vaiphei K, Bora GS. Priapism
This report is aimed to prevent
with penile gangrene: An unusual
ischaemic complications of priapism like
presentation of multiple myeloma.
penile gangrene. Penile detumescence Indian J Urol. 2017 Jul-
should be achieved on an emergency basis Sep;33(3):251-252. doi:
to prevent its ischaemic complications [4]. 10.4103/iju.IJU_41_17.
3. Khoriaty N, Schick E. Penile
Conflicts of interest gangrene: an unusual complication
The authors declares that they do of priapism. How to avoid it?
not have conflict of interest. Urology. 1980 Sep;16(3):280-3. doi:
10.1016/0090-4295(80)90043-6.
Funding 4. Mehdi S, Sharma D, Pandey S,
No funding was received for Sankhwar S. Isolated glanular
conducting this study. gangrene; a rare sequel of priapism.
BMJ Case Rep. 2019 Apr
3;12(4):e229432. doi: 10.1136/bcr-
2019-229432.
521

DOI 10.61770/NBEJMS.2024.v02.i05.014
CASE REPORT
Laparoscopic Spleen-Preserving Decapsulation of the Splenic Cyst: A Case Report

Vijay N,1,* Muvva Sri Harsha M1 and Prasanna Kumar Reddy2
1
Academic Registrar, Minimal Access Surgery, Apollo Hospital, Greams Road, Chennai, Tamil
Nadu
2
Senior Consultant, Surgical Gastroenterology and Minimal Access Surgery Apollo Hospital,
Greams Road, Chennai, Tamil Nadu
Abstract
Worldwide the Incidence of Primary nonparasitic splenic cysts are rare. They were incidentally
diagnosed while evaluating other diseases by imaging. We here by present our experience of a
case of 23-year-old woman, with a primary nonparasitic splenic cyst. The patient underwent
laparoscopic spleen-preserving decapsulation of the splenic cyst. The patient recovered well and
had no postoperative complications.
Keywords: primary splenic cyst, laparoscopic decapsulation, spleen-preserving surgery
*Corresponding author: Vijay N

Email: vijay150691@gmail.com
522
Introduction Case Report

Splenic cysts are rare and are A 23-year-old young woman with
discovered incidentally during workup for hypothyroidism presented with complaints of
other diseases. According to Martin's generalized weakness and back pain for one
classification [1], a primary or true splenic year. The pain was intermittent, dull, and
cyst lined by the epithelial lining, whereas a worsened with physical activity. History
secondary or pseudocyst lacks the epithelial revealed early satiety and weight loss. The
lining. Primary cysts may be parasitic (75%) patient gave no history of fever, altered bowel
or nonparasitic (25%). Secondary cysts are habits, or trauma.
mainly due to trauma. On examination, the patient was pale.
Most patients are asymptomatic Abdominal fullness was visible in the left
unless the cyst enlarges to the point of hypochondric region. A palpable intra-
compressing surrounding structures. Splenic abdominal mass with four-finger widths
cysts are diagnosed by imaging, primarily below the left costal margin, which is well
abdominal ultrasonography and computed defined and was not painful. On further
tomography (CT), with CT playing an investigation with contrast-enhanced
important role in diagnosis. Splenectomy was computed tomography (CECT) of the
once considered the treatment of choice but abdomen (Figure 1), the spleen was enlarged
was associated with post-splenectomy and measured 17.4 cm with a large, well-
complications, with OPSI (overwhelming defined cyst measuring 14x15x12 cm
post-splenectomy infection) being the most (anterior-posterior x cephalo-caudal x medio-
feared. In recent years, spleen-preserving lateral), displacing on the adjacent fundus
surgery has emerged as a viable treatment and proximal body of the stomach to the
modality that avoids post-splenectomy right. Inferiorly, the lesion was closely
complications. With the advent of abutting and exerted a mass effect on the
laparoscopy and increasing experience in superior border of the distal body and tail of
laparoscopic surgery, laparoscopic spleen- the pancreas, preserving the intervening fat
preserving surgery is increasing worldwide. plane. Carcinoembryonic antigen (CEA) and
cancer antigen (CA) 19.9 levels were within
the normal range, and serologic testing for
hydatid was negative.
523
Figure 1. CT SCAN -axial and coronal plane showing splenic cyst

Because of the size of the cyst, a entering the abdomen, a large solitary splenic
detailed discussion was held with the patient cyst, about 15x12 cm in size, arising from the
about the risks and possible complications superior pole of the spleen and pushing the
after splenectomy. We proceeded with the stomach to the right side (Figure 3). 1200 ml
spleen-preserving surgery. of hemorrhagic fluid was aspirated. Using a
Under general anesthesia, the patient harmonic shear (Ethicon) most of the cyst
was positioned in the modified recumbent wall is excised by decapsulation (Figure 4);
right lateral position. After standard preserving the remaining part of the spleen,
preoperative maneuverers, inserting a Veress and hemostasis is achieved. Placing the
needle at the level of the umbilicus and omentum into the residual cyst cavity (Figure
created a pneumoperitoneum. A 10-mm 4) performed omentopexy. A size 16 Fr
camera port was inserted at the level of the Romovac suction drain was placed in the cyst
umbilicus. A 5-mm working port for the left cavity. On postoperative day 1 the abdominal
hand was inserted into the epigastrium, a 12- drain were removed, and on the same day
mm port for the right hand at the patient was discharged. The patient
midclavicular line, and a 5-mm port for recovered well postoperatively and was
retraction were placed in the left anterior asymptomatic at later follow-up visits.
axillary line, as shown in (Figure 2). On
Figure 2. Port positions
524
Figure 3. Splenic cyst pushing the stomach to the right
Figure 4. Laparoscopic splenic cyst deroofing and Omentopexy
Histopathologic examination impression was a hemorrhagic cyst wall with

revealed a densely fibrotic cyst wall with focal calcification and nonspecific chronic
fibro collagenous stromal tissue and inflammation.
dystrophic calcification (Figure 5). The final
Figure 5. Histopathology showing fibro collagenous stromal tissue
525
Discussion the size, morphological features of the

The true incidence of splenic cysts is splenic cyst and its relationship to the
unknown. Splenic cysts are more common in adjacent organs [5].
the younger age groups of the second and Because of the rare incidence of
third decades. The first case of splenic cyst primary splenic cysts, there is no
was reported by Andral in 1929 [2]. After standardized protocol for the management
studying the patterns and findings of more cysts and its controversial. Aim of the
than 400 cases, Fowler was the first to Surgical treatment is to remove the cyst and
classify splenic cysts. prevent a recurrence. Surgical options
In 1958, Martin et al. [1] on the basis include both open and laparoscopic
of the histopathological findings classified techniques. These includes open or
splenic cysts: (a) True/type 1 cysts are laparoscopic total splenectomy, partial
primary cysts characterized by the presence splenectomy (preserving more than 25% of
of inner epithelial lining of the stratified the spleen), deroofing, and marsupialization
squamous epithelium. They account for 20% [6].
of all cysts, which are sub-classified into Asymptomatic cysts, which is less
congenital and neoplastic cysts. Congenital than 5 cm is managed by regular follow-up.
cyst is thought due to the entrapment of Surgical treatment is mainly for the Cysts
peritoneal mesothelial cells into the splenic more than 5 cm and are symptomatic. Spleen
parenchyma during embryogenesis [3]. preserving surgery is mainly preferred for the
Neoplastic cysts of the spleen consist of upper pole and lateral cysts. For the cysts
hemangiomas and lymphangiomas. The other which are located in the lower pole or at the
is parasitic and is most commonly caused by hilum, Splenectomy is recommended [7].
the tapeworm Echinococcosis granulosus Indications for splenectomy include multiple
infestation. (b) False splenic cysts/type 2 are cysts, very large cysts, cysts in the hilum of
secondary cysts; they lack epithelium lining the spleen, intrasplenic cysts completely
and are called pseudocysts. False splenic covered by splenic parenchyma, and
cysts are more common than the true cysts, intraoperative uncontrollable hemorrhage
account for 80% of all splenic cysts. These [8]. Other non-surgical options include
false cysts are secondary to trauma, image-guided drainage / aspiration of the
disorganized hematoma, splenic infarction, cysts. But the recurrence rate following the
and splenic abscess. drainage / aspiration has been reported to be
Although most patients are as high as 100%. For this reason, surgery is
asymptomatic, symptoms result from the considered the treatment of choice [9].
compressive effect of the enlarging cyst on In this era of laparoscopic surgery,
surrounding structures. In our case, the laparoscopic deroofing of splenic cysts was
patient suffers from early satiety due to the performed with shorter stay in hospital, less
compressive effect on the stomach. In the complications, and better outcomes [6]. It
primary splenic cysts levels of CEA and CA also prevents the potential post operative
19-9 may be elevated [4]. In our case, CEA complications of the splenectomy by
and CA 19-9 are in the normal range. The preserving the splenic parenchyma. To
splenic cysts are mainly diagnosed by reduce the recurrence risk, most of the cyst
imaging modality, which include wall should be excised while preserving the
ultrasonography, computed tomography, and parenchyma, as done in our case. An
magnetic resonance imaging (MRI). CT and omentopexy helps to prevent the risk of cyst
MRI can provide detailed information about recurrence [10].
526
Conclusion Wandering Spleen: An Unusual

In conclusion, treatment options for Enigma. Case Rep Surg. 2019;2019:1-
primary splenic cysts focus mainly on the 4
laparoscopic approaches with spleen 4. Madia C, Lumachi F, Leroux M,
presevation. Because of the important Fiamingo P, Gringeri E, Brolese A, et
immunologic functions of the spleen in al. Giant splenic epithelial cyst with
inducing peripheral tolerance through its elevated serum markers CEA and CA
various immune components, phagocytosis 19-9 levels: an incidental association?
of the capsulated microorganism and the risk Anticancer Res. 2003;23(1B):773-6
of overwhelming infection after 5. Robertson F, Leander P, Ekberg O.
splenectomy, the trend has shifted toward the Radiology of the spleen. Eur Radiol.
conservative spleen preserving surgery with 2001;11(1):80-95
minimal invasive approaches. 6. Szczepanik AB, Meissner AJ. Partial
splenectomy in the management of
Statements and Declarations nonparasitic splenic cysts. World J
Surg. 2009 Apr;33(4):852-6
Conflicts of interest 7. Yoh T, Wada S, Kobayashi A,
The authors declares that they do not Nakamura Y, Kato T, Nakayama H, et
have conflict of interest. al. Laparoscopic splenectomy for a
large multilocular splenic cyst with
Funding elevated CA19-9: Report of a case. Int
No funding was received for J Surg Case Rep. 2013;4(3):319-21
conducting this study. 8. Karfis EA, Roustanis E, Tsimoyiannis
EC. Surgical management of
References nonparasitic splenic cysts. J Soc
1. Martin JW. Congenital splenic cysts. Laparoendosc Surg. 2009;13(2):207-
Am J Surg. 1958 Aug 1;96(2):302-8 12
2. Termos S, Othman F, Aljewaied A, 9. Wu HM, Kortbeek JB. Management of
Alkhalil AM, Alhunaidi M, Parayil splenic pseudocysts following trauma:
SM, et al. Symptomatic giant primary a retrospective case series. Am J Surg.
nonparasitic splenic cyst treated with 2006 May;191(5):631-4
laparoscopic decapsulation: A case 10. Geraghty M, Khan IZ, Conlon KC.
report and review of the literature Large primary splenic cyst: A
review. Am J Case Rep. 2020;21:1-7 laparoscopic technique. J Minim
3. Algino SE, Sorrentino S, Luyimbazi Access Surg. 2009;5(1):14-6
DT, Grider DJ. Epidermoid Cysts in a
527

DOI 10.61770/NBEJMS.2024.v02.i05.015
CASE REPORT
A Late presentation of Gossypiboma presenting as a cutaneous fistula with purulent

discharge in an operated case of Lower segment caesarean section
Ojas Vijayanand Potdar,1,* Akash Shah,2 Darshan Rathi,3 Prakhar Chaudhary3 and Ashish
Chaubey3
1AssistantProfessor in Urology, Grant Medical College and J.J. Group of Hospitals,
Mumbai-400091
2Consultant Uro-Oncologist and Robotic Surgeon, HCG Cancer Hospital, Borivali
3Senior Resident-2 in Urology, Grant Medical College and J.J. Group of Hospitals, Mumbai-
400091
Abstract
Gossypiboma, a retained surgical sponge, is a rare complication following any surgical
procedure and is primarily a result of human error. Such patients often have vague clinical
presentations and the diagnosis often comes as a surprise and has serious medicolegal
implications. We present a case of a 28-year-old female with a long-standing duration of 9
months with purulent discharge from the operated scar site of Lower segment caesarean section
done 2 years back and then diagnosed to have a gossypiboma in the ureterovesical space
causing structuring of the ipsilateral ureter which was successfully managed by Exploratory
laparotomy with removal of the retained gossypiboma and right sided ureteric reimplantation.
Keywords: Gossypiboma, cutaneous fistula, lower segment caesarean section.
*Corresponding author: Ojas Vijayanand Potdar

Email: ojaspotdar@yahoo.com
528
Introduction gossypiboma in the ureterovesical space

The literal definition of causing structuring of the ipsilateral ureter
gossypiboma means finding Surgical which was successfully managed by
sponges and gauze retained in the body Exploratory laparotomy with removal of
after a surgical procedure. This term is the retained gossypiboma and right sided
derived from the Latin word, Gossypium ureteric reimplantation.
(cotton) and the Kiswahili word, boma (a
place of concealment) [1]. It is often a rare Case report
clinical entity. Patients often experience A 28-year-old female presented to
symptoms for years before a definitive the outpatient department of a tertiary care
diagnosis is made. In most such cases, the centre with complaints of purulent
diagnosis is unexpected and comes as a discharge from abdominal wound since last
surprise [2]. Although it is an iatrogenic and 9 months. Patient reports history of 3 lower
preventable entity; it can be a source of segment caesarean section in the past. The
significant morbidity for the patient. last lower segment caesarean section was
Another important aspect of such an done 2 years back. There was no history of
inadvertent occurrence is the medicolegal wound related complications in the
implications behind it. Several such cases immediate postoperative period. After
have been reported in the literature up until around 15 months post-surgery, patient
now. However, physicians seldom consider developed a small pustule in the centre of
it in their differential diagnoses. We present the scar of the operated site which burst
a case of a 28-year-old female with a long- leading to purulent discharge which
standing duration of 9 months with purulent continued over a period of 9 months for
discharge from the operated scar site of which she visited the treating gynaecologist
Lower segment caesarean section done 2 (Figure 1).
years back and then diagnosed to have a
Site of discharge
from the healed
abdominal scar
Figure 1. Clinical picture showing the healed abdominal scar with the site from where the
purulent discharge was seen.
529
Patient was evaluated using hydrouretero-nephrosis. The imaging

ultrasound followed by Contrast enhanced findings were suggestive of a retained
Computerised Tomography of Abdomen gauze piece with pus collection in the
and pelvis which revealed heterogenous vesico-uterine space with resultant
mass with collection in the vesicouterine involvement of the right sided ureter
space with Right ureter seen involved by causing right sided upstream hydro-
the mass and causing upstream right sided ureteronephrosis.with a fistula formation
(Figure 2).
Collection in the vesicouterine

space seen as extravasation of
contrast from the right ureter.
Fistulous
communication
Gossypiboma
Figure 2. Contrast Enhanced Computerised scan images of the patient.

;
RGP image showing the

site of involvement of
right ureter in the
gossypiboma
Figure 3. Retrograde pyelography image showing the site of involvement of the right ureter
segment in the gossypiboma.
530
Patient underwent exploratory be involved in this retained gossypiboma

laparotomy through a lower midline along with pus containing cavity and was
vertical incision. Intraoperative, in the seen to be dilated proximally. The pus was
lower midline part the bowel was adherent drained and the retained gauze piece was
to the lower abdominal wall and the bladder removed followed by right sided ureteric
and the uterus. On careful dissection and reimplantation by Lisch-Gregoir technique
separation of the bowel, the vesicouterine followed by omental transposition in the
space was created and it was found to uterovesical space with placement of pelvic
contain pus and retained gauze piece drain. (Figures 4 to 6)
(gossypiboma). The right ureter was seen to
Vesicouterine space with pus

collection with the
gossypiboma
Figure 4. Intraoperative picture showing Vesicouterine space with pus collection with the
gossypiboma.
531
Right sided ureteric

reimplantation by
Lisch Gregoir
technique
Figure 5. Intraoperative image showing Right sided ureteric reimplantation by Lisch Gregoir
technique.
Figure 6. Clinical picture of the bits of the removed gossypiboma.
532
Patient tolerated the procedure well Government Medical College, Mumbai for
and was discharged after 7 days of his constant support to promote academic
admission. Patient underwent right sided and research activities. I would also like to
DJ stent removal after 6 weeks and has been thank all the co-authors for providing their
on regular follow up for a period of 6 inputs in this case report.
months with 3 monthly ultrasound which
has shown normal findings. Conflict of Interest
The authors declares that they do
Discussion not have conflict of interest.
Gossypiboma is a condition in
which every reported case in literature is a Funding
unique presentation and hence, provides a No funding was received to assist
lot of valuable information and insights with the preparation of this manuscript.
about what erev the circumstances in which
it occurred, how the patient presented with Ethical approval
different symptoms, how it was diagnosed Patient consent was obtained for
and finally, how it was effectively publication of the case report.
managed. Therefore, a high clinical
suspicion is necessary and essential to Data availability
diagnose it. Since gossypiboma is a It is a case report and data was
preventable iatrogenic complication that obtained from the hospital records.
can have detrimental effects on both
patients and operating surgeon, careful References
measures should be made to prevent and 1. Yildirim S, Tarim A, Nursal TZ,
minimize the morbidity-related Yildrim T, Caliskan K, Torer N,
complications [3]. Karagulle E, Noyan T, Moray G,
Haberal M; Retained surgical sponge
Conclusion (gossypiboma) after intraabdominal
Gossypiboma is a rare iatrogenic
or retroperitoneal surgery: 14 cases
disorder with substantial morbidity and
significant medicolegal implications. Such treated at a single center.
incidents are wholly avoidable and Langenbecks Arch Surg. 2006;
prevention is far better than cure. 391:390–395.
Emergency nature of surgery and poor 2. Wilson CP. Foreign bodies left in the
communication among members of the abdomen after laparotomy. Gynecol
healthcare team are strongly associated Tr. 1884; 9:109–112.
with the possibility of a retained surgical
3. Alsuhaimi MA, Alghamdi HS,
sponge. Most patients with this disorder
present with vague clinical features. Alshaiji SA, Fayi MA, Aldhafeeri
Therefore, a high clinical suspicion is SM. Retained surgical item
required on part of the treating physician is (Gossypiboma): a case report and
required in diagnosing and managing this literature review. Ann Med Surg
condition. (Lond). 2023 Jun 17;85(7):3717-
3721. doi:
Acknowledgements
10.1097/MS9.0000000000000992.
I would like to thank Dr.
Mohammed Ayub Karamnabi Siddiqui,
Head of Department Urology at Grant
533

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National Board of Examinations - Journal of Medical Sciences

Volume 2, Issue 5, May; ISSN 2583-7524

National Board of Examination (NBE)

NBEJMS Transformative potential of AI and ML in medical sciences

DR. ABHIJAT SHETH

HONORARY EDITORIAL BOARD

Pattern of pulmonary function tests in subjects recovered from COVID 19 infection

Effect of Total Hemoglobin on Glycated Hemoglobin (HbA1c) in Type 2 Diabetes

Impact of Tobacco Consumption During COVID-19 Lockdown: Insights from

Comparative Evaluation of Imaging Techniques for Paraspinal Muscle Fat

Assessment of PSR as a Novel Parameter in Perfusion Imaging for CNS Tumor

LETTER TO THE EDITOR

Gangrene and Partial Auto-Amputation of the Penis in a Case of Priapism

Laparoscopic Spleen-Preserving Decapsulation of the Splenic Cyst: A Case Report

A Late presentation of Gossypiboma presenting as a cutaneous fistula with purulent

National Board of Examinations - Journal of Medical Sciences

Artificial Intelligence and Machine Learning: Revolutionizing Medical Education,

Minu Bajpai1,* and Abhijat Sheth2

1Vice President and Honorary Executive Director, National Board of Examinations in

President, National Board of Examinations in Medical Sciences, Medical Enclave, Ansari

Accepted: 28-April-2024 / Published Online 01-May-2024

Artificial Intelligence (AI) and human clinicians. Powerful diagnostic and

Some Key Applications and Achievements (Figure 1)

Figure 1. Transformative potential of AI and ML in medical sciences

Disease Diagnosis and Prognosis biological processes, accelerating the

automate administrative tasks, facilitate sensors has enabled continuous monitoring

National Board of Examination - Journal of Medical Sciences

Intercountry Interactions to Reduce the Endemic Burden of Oral Cancer: An Exploratory

Accepted: 22-February-2024 / Published Online: 01-May-2024

*Corresponding author: Harsh Priya

Introduction better quality diagnostic and treatment

strengthen their efforts for the effective and

Figure 1. Observership Model

Longitudinal studies with decade of recommendations on minimum requirements

screening. The training included an algorithm These materials aim to increase

Training Surveillance and Research

The primordial and primary

Efforts to reduce the endemic burden of oral cancer in the SEA

Initiation of the collaboration through email exchange / formal

Formulation of an agenda and agreement on the time

Ministries of Health, External Affairs Ministries of Health, External Affairs

Verification of the trainees’ profiles by the governing body of medical

Exchange of needs and expectations

Organization of the themes for capacity building in consultation with

Pre-training assessment and

Blending of need based didactics and

Orientation to the local service Risk reduction Referral

Post training assessment and decision on next workshop

Discussion a cut off score of 12 or more are referred for

d%20Control%20of%20Common%20NC Dental and Medical Practitioners.

National Board of Examination - Journal of Medical Sciences

Pattern of pulmonary function tests in subjects recovered from COVID 19 infection

Chaithanya K S,1 Anahita R Shenoy Basti2,* and Srilakshmi M Prabhu3

1FatherMuller Medical College, Mangalore - 575002, India

Accepted: 22-February-2024 / Published Online: 01-May-2024

Keywords: SARS CoV 2, coronavirus, lung function test, lung disease

*Corresponding Author: Anahita R Shenoy Basti

Introduction alveolar epithelium destruction,

Reports have shown that short-term performed to exclude active COVID

Table 1. Shows the demographic characteristics of the study population

n = (Zα/2+Zβ) 2 2σ2 / d2 Statistical analysis