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Background: Rheumatoid arthritis (RA) is a chronic autoimmune disorder characterized by pain stiffness and swelling in the joints with long standing effects on quality of life and is complicated by the presence of medical and psychiatric comorbidity. The current study was aimed at comparing the psychopathology, quality of life and life satisfaction between patients with RA and healthy controls. Methodology: There were two groups in the study – a study group with RA patients (n=97) and control group with their first-degree relatives (n=93). A semi-structured proforma collected data related to socio-demographic variables and RA. The groups were assessed using the Mini International Neuropsychiatric Interview, WHO Quality of Life scale brief version and Satisfaction with Life Scale. The scores were statistically analyzed and presented. Results: The mean age of the sample was 44.94 ± 13.02 years (range 18-82 years) and that of the control group was 23.02 ± 8.41 years (range 18-55 years). The mean duration of illness of the group was 7.2 ± 16.9 years (range 1-40 years). Major depression was the commonest disorder seen in 73.1% (n=73) patients with RA. Generalized anxiety disorder, panic disorder and suicidal feelings were also detected. The RA group had significantly lower QOL scores in the psychological and environmental domains of QOL Life satisfaction scores were also significantly lower in the RA group (p=0.0001) when compared to controls. Conclusion: Patients with RA have significant psychopathology that warrants attention and this affects their quality of life and life satisfaction. Further longitudinal studies in this area to gain clinical and epidemiological Indian data are warranted. Keywords: Rheumatoid arthritis, Depression, Psychopathology, Quality of life, Life satisfaction.

Objectives: Little is known about the outcome of major depressive disorder in India, especially in primary care contexts not usually associated with research. This large, prospective, naturalistic observational study examined the feasibility of studying first-episode major depressive disorder outcomes in such contexts, and examined outcomes after antidepressant drug treatment. Methods: A convenience sample of 205 psychiatrists across India each recruited five adults with first-episode major depressive disorder. No patient had clinically significant suicidal ideation, psychotic symptoms, or significant medical or psychiatric comorbidity. Patients were naturalistically treated with antidepressant medication and rated using the Montgomery-Asberg Depression Rating Scale and other instruments, including patient-reported outcome measures. Assessments were obtained at baseline and at a 6-week follow-up. Results: Of 900 patients recruited, 92 did not meet selection criteria, and there were 10 dropouts, leaving 798 evaluable patients. The most common antidepressants received were desvenlafaxine, vilazodone, and escitalopram. The primary outcome, response (50% attenuation of Montgomery-Asberg Depression Rating Scale score), was identified in 66.1% of the sample. The patient-reported outcome measures-defined response rate was 53.1%. Remission (endpoint Montgomery-Asberg Depression Rating Scale score of 10 or less) was observed in 36.7% of the sample. Response (but not remission) was very slightly but significantly better in women than in men on some but not all measures. Conclusions: It is feasible to conduct simple but meaningful observational studies in primary care contexts that are not usually associated with research. About two-thirds of real-world adults in primary care in India diagnosed with uncomplicated first-episode major depressive disorder respond to 6 weeks of antidepressant medications; about one-third of the adults remit.

Objectives:The use of cone-beam computed tomography (CBCT) is well-established in clinical practice. This study seeks to categorize and quantify the incidental finding (IF) rate on CBCT in patients with cleft lip and palate (CLP) prior to orthodontic or surgical treatment.Methods:This is systematic retrospective review of head and neck CBCTs in patients with nonsyndromic CLP taken between 2012 and 2019 at a single tertiary referral center. All assessments were performed independently by 4 observers (a head and neck radiologist and 3 orthodontists, including 2 fellowship-trained cleft-craniofacial orthodontists ). The images were divided into 9 anatomical areas and screened using serial axial slices and 3D reconstructions. The absolute number of IFs was reported for each area and statistical analysis was performed.Results:Incidental findings were found in 106 (95.5%) of the 111 patients. The most common sites were the maxilla (87.4%, principally dental anomalies), paranasal sinuses (46.8%, principally inflammatory opacification), and inner ear cavities (18.9%, principally inflammatory opacification). Eleven patients had skull malformations. Thirty-three patients had IFs in 1 anatomical area, 49 patients in 2 anatomical areas, 19 patients in 3 areas, and 5 patients presented with IFs in 4 of the 9 anatomical areas.Discussion:In patients with CLP, IFs on CBCT exam were present in the majority of cases. Most patients with IFs had them in multiple anatomical areas of the head and neck. The maxillary dental–alveolar complex was the most common area. Inflammatory changes in the inner ear cavities and paranasal sinuses were also common; however, cervical spine and skull abnormalities were also identified. Clinicians caring for patients with CLP should be aware of IFs, which may warrant further investigation and treatment.

Introduction: There is a growing need for BRCA1/BRCA2 mutation frequencies among hereditary breast and ovarian carcinoma (HBOC) cases, specifically determined on the grounds of personal and family history profiles in the Indian population. The current study was intended to identify BRCA1/2 mutation frequency and spectrum in Indian women fulfilling the National Comprehensive Cancer Network criteria. Methods: One hundred and sixty unrelated women were screened for germline variations in BRCA1 and BRCA2 genes by sequencing. The variants were classified as pathogenic or benign on the basis of American College of Medical Genetics (ACMG) guidelines. Results: Of 160 women screened for BRCA mutations, 51 (31.9%) carried a pathogenic variant in BRCA1 (n = 36) or BRCA2 (n = 15) gene. An increased frequency of mutation was seen in women with a personal history of breast or ovarian cancer (34.5%) in comparison to unaffected family members (25%). A spectrum of 34 different pathogenic variants (20 in BRCA1 and 14 in BRCA2) was identified in 51 cases. This included a novel variant c.3683_3684dup in BRCA1 which was categorized as a pathogenic variant. The variant c.68_69delAG in BRCA1 was identified in 12/51 positive cases and appears to be the hotspot mutation in the Indian population. In addition, 11 different missense variants were identified in 10 of the study participants and were categorized as variants of unknown clinical significance (VUS) based on the ACMG guidelines. Of these, three of the variants (c.389A>C in BRCA1 and c.3179G>A and c.10124G>T in BRCA2) were unreported in the published literature. Conclusion: The prevalence of pathogenic variants in the Indian HBOC cohort is high and is similar to other Indian studies. The spectrum of BRCA variants is also diverse, and it is very important to correctly classify them as pathogenic, VUS, or benign. We reinforce the importance of complete BRCA gene screening in the index case, followed by genetic counseling and targeted mutation analysis in other at-risk family members.

Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a form of encephalitis occurring primarily in women and associated with antibodies against NR1 or NR2 subunits of the NMDA receptor. As psychiatric symptoms may predominate at the onset or over the course of the disease, the diagnosis is frequently delayed. Yet, the patients’ prognosis depends on the speed with which the disease is detected, identified, and managed. Because the presence of pronounced psychiatric symptoms drives the patients to psychiatric institutions, physicians need to be aware of autoimmune encephalitis and propose the detection of autoantibodies as early as possible to provide optimal medical care to such patients. Here, we report the case of a 24-year-old female who presented to the hospital with symptoms suggestive of postpartum psychosis but further investigations revealed her to be positive for anti-NMDA receptor autoantibodies.

Background: The COVID-19 pandemic has been followed by the shutting down of bars and liquor shops. This condition has led to the acute unavailability of alcohol, and subsequently increasing the number of cases of alcohol withdrawal. Objectives: This paper reports the clinical profile of cases of alcohol withdrawal presented to the psychiatry department following the non-availability of alcohol due to the COVID-19 lockdown. Methods: The patients were referred to the psychiatry department from the emergency medicine department and some of them directly to the psychiatry department. Thirty-two patients with alcohol use disorder and alcohol withdrawal were included in the study. The study data were collected using a semi-structured proforma and then were tabulated. The obtained data were assessed by the Chi-square test and unpaired t-test where appropriate. Results: The Mean±SD age of the study patients were 38.84±11.64 years. The Mean±SD years of consumption of alcohol was 13.50±7.8 years in the sample (range 1-30 years) and Mean±SD days of last consumption of alcohol was 3.88±1.8 days (range 2-10 days). There were no significant differences between stockers and non-stockers in various parameters. Conclusion: Alcohol and substance withdrawal have increased in the wake of the lockdown and COVID-19 pandemic and there is a need for non-COVID-19 setups to be created to cater to the needs of these patients.

OBJECTIVE Recurrent disease occurs in a significant proportion of early-stage oral squamous cell carcinoma (OSCC) despite removal of the entire tumor with clear surgical margins. Our study sought to identify clinicopathologic factors that increase the risk of locoregional recurrence in T1N0 OSCC. STUDY DESIGN We conducted an observational retrospective analysis of 65 cases of T1N0 OSCC over a period of 13 years. For each case, we examined the clinical presentation, histopathologic appearance, and treatment characteristics of interest to evaluate the association between these variables and locoregional recurrence. RESULTS The 5-year and 10-year locoregional recurrence rates were 29.2% and 33.8%, respectively. Individuals with prior oral dysplasia had significantly higher odds for locoregional recurrence (P < .01) and reduced 5-year disease-free survival rates (P < .01). OSCC of the tongue and floor of the mouth had lower recurrence odds than carcinomas of the gingiva, buccal mucosa, and palate (P < .05). Histologic grade (P = .80), depth of invasion (P = .82), and elective neck dissection (P = .80) did not appear to influence locoregional recurrence for T1N0 tumors. CONCLUSIONS Given the morbidity and mortality associated with OSCC, understanding of the clinicopathologic factors associated with recurrent disease may lead to improved treatment and follow-up protocols for a subset of early-stage patients.

OBJECTIVES: Presentation of pancreatic adenocarcinoma (PC) as acute pancreatitis (AP), association of chronic pancreatitis (CP) with PC, and role of inflammation in PC carcinogenesis are well recognized. We hypothesized that inflammatory changes associated with remote history of AP (≥2 yrs prior to PC diagnosis) would result in earlier age of PC diagnosis. METHODS: We evaluated PC patients prospectively enrolled in the Pancreatic Adenocarcinoma Gene Environment Risk (PAGER) study at the University of Pittsburgh for history of pancreatitis and reviewed relevant medical records and imaging studies. Univariate and multivariable linear regression analyses evaluated the relationship between PC and remote history of AP. RESULTS: Among 790 patients with histologically confirmed PC, 114 (14.4%) had a history of pancreatitis (AP within 2 years of PC diagnosis in 69 [8.7%], remote history of AP in 28 [3.5%], CP in 4 [0.5%], and unknown duration of pancreatitis in 13 [1.6%]). After controlling for age, sex, body mass index, smoking, alcohol history and diabetic status at diagnosis, patients with a remote history of AP were diagnosed on average 4.7 years earlier with PC when compared to PC patients without history of AP (P < 0.035). CONCLUSION: Remote history of AP may accelerate carcinogenesis in PC.

Background. Adolescent obesity is a national epidemic that recently has been shown to increase risk for pancreatic adenocarcinoma (PC) and is associated with an earlier age of PC onset. We hypothesized that PC patients who are overweight or obese at age 18 would have an earlier age of PC onset. Methods. Retrospective review of 531 patients in our PC registry was completed. Self-reported weight at age 18 and maximum lifetime weight were used to calculate body mass index (BMI) at age 18 (BMI-18) and maximum lifetime BMI. Results. Complete BMI and baseline covariate data was available in 319 PC patients. Mean age (in years) of PC diagnosis for patients whose BMI-18 was overweight (64.0) or obese (59.9) was significantly different when compared to patients with a normal BMI-18 (66.7). No significant difference was observed in the mean age of PC diagnosis in those patients who maintained a normal BMI-18 when compared to those patients who subsequently became overweight or obese (67.0 versus 66.6; p=0.65). Conclusions. An elevated BMI at age 18 is associated with an earlier age of PC onset and should be factored into determining the optimal age of beginning screening for patients at high risk for PC.

Huntington’s disease (HD) is an autosomal-dominant neurodegenerative disorder with an average age at onset of 40 years. It is a polyglutamine (polyQ) disorder that is caused by an increase in the number of CAG repeats in the huntingtin (HTT) gene. Genetic tests that accurately determine the number of CAG repeats are performed for confirmation of diagnosis, predictive testing of persons at genetic risk for inheriting HD, and prenatal testing. The aim of our study was to evaluate efficacy of triplet-primed polymerase chain reaction (TP-PCR) for routine diagnosis of HD in suspected cases from India. We evaluated a combination of CAG flanking PCR and triplet-primed PCR for estimation of CAG repeats in 503 cases with clinical suspicion of HD. There were 250 cases (49.7%) that showed the presence of expanded alleles, with 241 (47.9%) being fully penetrant alleles and nine (1.8%) in the reduced penetrance category. There were seven juvenile cases with an age of onset of

CONTEXT: Hemoglobinopathies constitute the world's most common genetically inherited red blood cell disorder. Screening and accurate identification of hemoglobin (Hb) variants have become increasingly important in antenatal diagnosis and prevention of Hb disorders. AIM: The aim of this study was to screen and identify Hb fractions prevalent in the Central Reference Laboratory of India. MATERIALS AND METHODS: A total of 65,779 cases were screened for hemoglobinopathies on the bio-rad variant high-performance liquid chromatography (HPLC) system by beta-thalassemia short program. The retention times, proportion of the hemoglobin (%) and the peak characteristics for all hemoglobin fractions were recorded. Molecular analysis of the beta-globin gene was carried out by DNA sequencing on eight cases. RESULTS: Total number of abnormal Hb fractions on cation exchange-HPLC (CE-HPLC) was seen in 12,131 (18.44%) cases. Beta-thalassemia trait was the predominant genetic Hb disorder accounting for 7377 cases (11.21%) of the total cases. This was followed by sickle cell trait (2.01%), sickle cell disease (1.59%), beta-thalassemia syndrome (0.80%), HbE trait (0.79%), and borderline HbA2 (0.51%). Molecular characterization of eight rare cases of hemoglobin variants by beta-globin gene sequencing identified three cases of Hb Beth Israel, two cases of Hb Hofu trait, and one case each of Hb J Cambridge, Hb Mizunami, and Hb Sherwood Forest. CONCLUSION: Superior resolution, rapid assay time, and accurate quantification make CE-HPLC suitable for the routine investigation of hemoglobinopathies.

BACKGROUND Use of rectangular collimators has been shown to reduce exposure rates compared with round collimators.1-3 However, transitioning from round to rectangular collimators can result in higher numbers of retakes because of a smaller margin for error.4 OBJECTIVE(S) The aim of the study was to examine the extent and distribution of retakes in digital intraoral imaging when transitioning from round to rectangular collimators and the effect on radiation exposure to patients. STUDY DESIGN Retake data for intraoral radiographs in a dental school radiology clinic were collected for 2018 to 2019. Round collimators were used throughout 2018, with a shift to rectangular collimators with same class rotating through radiology starting in 2019. Overall exposure values were obtained by comparing exposure factors registered for images in the picture archiving and communication system (PACS) system to published exposure values for periapical images.1 RESULTS `There was a significant increase in retakes across all semesters while using rectangular collimation. However, retakes decreased from summer to fall semesters. A significant reduction in radiation exposure to patients due to use of rectangular collimation despite the higher retake numbers was also noted. DISCUSSION/CONCLUSIONS Even with didactic courses and training, an increase in numbers of retakes with the transition to rectangular collimation was noted. However, as students gained more practice and confidence in capturing radiographs, retakes decreased. Because a significant reduction in radiation exposure to patients while using rectangular collimation was noted, increased effort to train and implement rectangular collimation should be made. With proper clinical and didactic training and emphasis on the importance of rectangular collimators, a transition from round to rectangular collimation can be made with a minimal initial increase in numbers of retakes and subsequent normalization, resulting in significant reduction of undue radiation dosage to the population.

Background Social Anxiety Disorder (SAD) is a globally prevalent, chronic, debilitating psychiatric disorder affecting youth. With comorbidities including major depression, substance abuse, lower educational and work attainment, and increased suicide risk, it has a significant public health burden. The objective of this study was to estimate the prevalence of SAD in urban Indian undergraduate students and to study their Facebook (FB) usage patterns. Methods In this exploratory cross-sectional study, 316 undergraduate students were screened for social anxiety using validated instruments, Social Interaction Anxiety Scale (SIAS) and Social Phobia Scale (SPS), and divided into two groups based on scores obtained. The groups were then compared with regards to behaviors and attitudes toward Facebook, obtained from a self-report questionnaire. Results SAD was estimated to be a significant, prevalent (7.8%) disorder in otherwise productive youth, and showed female preponderance. Higher specific social phobia scores were associated with the inability to reduce Facebook use, urges toward increasing use, spending more time thinking about Facebook, negative reactions to restricting use, and using it to forget one's problems. Conclusions SAD was estimated to have a prevalence of 7.8% in our study, and was associated with stronger FB usage attitudes and patterns. We recommend that the relationship between social anxiety and Internet use be explored further, to study the possibility of Internet-based screening and intervention strategies having wider reach and appeal in socially anxious individuals.

Stress is a contributing factor to job stress, lack of satisfaction at work and poor quality of life. Job stress and job satisfaction are interlinked in most organizational settings. The present study aimed to assess the quality of life, level of job stress and level of job satisfaction amongst hospital staff in a public tertiary general hospital. The sample consisted of 110 workers from the hospital across various departments and classes of work. The sample was administered the WHO Quality of Life questionnaire brief version, the Workplace Stress Scale and the Generic Job Satisfaction Scale. The sample was divided as per the department in which they worked and the type of work involved. The scores on various scales were statistically analyzed. It was observed that quality of life was highest amongst those working in psychiatry and the ICU settings. Job stress (p

Byline: Devavrat. Harshe, Harshal. Thadasare, Sagar. Karia, Avinash. De Sousa, Rashmin. Cholera, Sanjiv. Kale, Omkar. Mate, Nilesh. Shah Aims: This study aimed to evaluate the patterns of platelet counts during the course of alcohol withdrawal and its relationship if any with liver enzymes. Methodology: Forty consecutive patients, with alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders-fourth edition, Text Revision criteria, willing for a 10-day inpatient detoxification program and presenting within 12 h of the last consumption of alcohol were recruited in the study. Details about the diagnosis and alcohol consumption patterns were assessed with a detailed psychiatric interview. After admission, routine investigations (complete blood counts [CBCs] and liver function tests) were sent and records were kept. CBC was sent for platelet counts on the 2[sup]nd, 4[sup]th, 6[sup]th, 8[sup]th, and the 10[sup]th day of alcohol withdrawal. Results: Nearly 40% of the patients developed delirium tremens (DT group) and rest had an uncomplicated alcohol withdrawal (ND group). Platelet counts at baseline and all the 4 days of collection were significantly lower in DT group than the ND group. Platelet counts increased gradually from baseline till 10[sup]th day of alcohol withdrawal, mean increase in platelet counts being 88.61 [+ or -] 11.60% (median: 61.11%, range [23.41–391.23%]). Platelet counts in 63% of the patients showed a drop on the 4[sup]th day of withdrawal before rising till the 10[sup]th day of alcohol withdrawal. Platelet counts were not affected by liver enzymes or other alcohol consumption patterns. Conclusions: Transient thrombocytopenia and reverse thrombocytosis during alcohol withdrawal are associated with an initial drop in platelet counts. The synchrony between the drop and the onset of DT needs to be evaluated. Introduction Alcohol withdrawal syndrome (AWS) is a clinical entity which ensues after a sudden cessation of or reduction in quantity of absolute alcohol consumed daily in those who are dependent on alcohol. AWS has a self-limiting course in most cases, 5%–20% of patients however develop a complicated AWS [sup][1] with alcohol withdrawal seizures or delirium tremens (DT). Evidence suggests that low platelet count has a good predictive power in predicting the development of DT [sup][2],[3],[4],[5],[6] in cases of AWS. Kim et al ., 2015,[sup][3] Berggren et al ., 2009,[sup][4] Eyer et al ., 2011,[sup][5] and Monte et al ., 2009,[sup][6] demonstrated that platelet count in patients with DT was in thrombocytopenia range ( Interestingly, with the exception of Berggren et al ., 2009,[sup][4] who showed a significantly higher aspartate transaminase (AST) levels in patients with DT compared to those without DT, neither any study nor the meta-analysis showed any significant difference between DT and non-DT groups for AST and alanine transaminase (ALT)! Thus, we planned this study to evaluate the stability of platelet count during the course of alcohol withdrawal and its relationship if any with serum liver enzymes. Methodology Sample The study was cleared by the Institutional Ethics Committee. Eighty consecutive patients diagnosed with alcohol dependence and presented within 12 h of their last drink were screened. Patients with (1) dependence on any other substance except nicotine, (2) a history of traumatic brain injury, peripheral vascular disease, past myocardial infarction and cerebrovascular accidents, comorbid psychosis and mood disorder, and alcohol withdrawal seizure during the past alcohol withdrawal, and (3) patients taking anti-platelet/anti-coagulation medications were excluded from the study. …

Objective: The treatment of bipolar disorder is challenging because of its clinical complexity and availability of multiple treatment options, none of which are ideal mood stabilizers. This survey studies prescription practices of psychiatrists in India and their adherence to guidelines. Method: In total, 500 psychiatrists randomly selected from the Indian Psychiatric Society membership directory were administered a face-to-face 22-item questionnaire pertaining to the management of bipolar disorder. Results: For acute mania, most practitioners preferred a combination of a mood stabilizer and an atypical antipsychotic to monotherapy. For acute depression, there was a preference for a combination of an antidepressant and a mood stabilizer over other alternatives. Electroconvulsive therapy was preferred in the treatment of severe episodes and to hasten the process of recovery. Approximately, 50% of psychiatrists prescribe maintenance treatment after the first bipolar episode, but maintenance therapy was rarely offered lifelong. While the majority (85%) of psychiatrists acknowledged referring to various clinical guidelines, their ultimate choice of treatment was also significantly determined by personal experience and reference to textbooks. Limitations: The study did not study actual prescriptions. Hence, the responses to queries in the survey are indirect measures from which we have tried to understand the actual practices, and of course, these are susceptible to self-report and social-desirability biases. This was a cross-sectional study; therefore, temporal changes in responses could not be considered. Conclusion: Overall, Indian psychiatrists seemed to broadly adhere to recommendations of clinical practice guidelines, but with some notable exceptions. The preference for antidepressants in treating depression is contrary to general restraint recommended by most guidelines. Therefore, the efficacy of antidepressants in treating bipolar depression in the context of Indian psychiatrists’ practice needs to be studied systematically. Not initiating maintenance treatment early in the course of illness may have serious implications on the long-term outcome of bipolar disorder.

Background: Cerebroprotein hydrolysate (cerebrolysin) is a nootropic and neurotrophic drug used widely in the management of various forms of dementia, stroke and head injury. A number of case series and anecdotal case reports on its efficacy exist. This study is a retrospective chart review of 34 patients with dementia treated at a tertiary general hospital psychiatry department that were given oral cerebroprotein as add on to their existing treatment for dementia. Methodology: 34 patients were administered twice daily oral cerebroprotein 90 mg tablets for 90 consecutive days. The cognitive assessment was done before the first injection and after the last dose using the Adenbrook's Cognitive Examination-Revised (ACER) and the Mini Mental Status Examination (MMSE). Results: Changes on cognitive assessment were minimal and no major improvements were seen though isolated areas of improvement were reported by many patients. The scores on the ACER and MMSE remained in the dementia range though improvement in scores were noted. None of the patients experienced any major side effects with the drug. Conclusions: Oral cerebroprotein is a useful agent in the management of dementia and must be tried as an add-on to regular dementia treatment. Larger studies in prospective cohorts with further stringent assessments warrant exploration.

SummaryBackground Simulation-based medical education has been shown to produce substantial educational benefits; however, the integration and effectiveness of high-fidelity simulation within the internal medicine (IM) clerkship remains largely unexplored. Investigators sought to determine the effectiveness of simulation in improving student confidence in acute coronary syndrome (ACS) and the Advanced Cardiac Life Support (ACLS) curriculum. Secondary goals included examining student perceptions of the role of simulation in medical education. Methods Investigators implemented a formative high-fidelity simulation curriculum in the IM clerkship at a large teaching institution. Third-year medical students enrolled in the IM clerkship between January and June 2014 attended a simulation course during their ambulatory block. Following a 2-hour session, participants completed a 17-item questionnaire. Descriptive statistical analyses and a thematic qualitative analysis were performed. Integration of high-fidelity simulation within the internal medicine clerkship remains largely unexplored Results The response rate was 100 per cent (n = 43). Students reported improvements in their ability to identify and manage ACS and ACLS before and after the simulation course: 93 per cent felt that simulation boosted their self-confidence in performing these tasks on a real patient; 86 per cent reported receiving useful feedback during the training sessions; 98 per cent agreed that their experience was enjoyable; and 95 per cent would recommend this course to other students. Conclusions Internal medicine (IM) clerkship students participating in our pilot course demonstrated increased confidence in identifying and managing pathologies associated with ACS and arrhythmias. Students viewed simulation as an engaging and useful activity, desiring additional training sessions.

Background: Gender identity disorder (GID) is a distressing disorder characterized by a persistent unhappiness with one's own sex and a desire to be of the opposite sex as well as seeking sex reassignment surgery for the same. The aim of the study was to assess the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) profiles in patients with GID and examine differences in the profiles based on original gender of the patients. Methodology: Twenty-seven patients with GID that fulfilled the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision criteria for the same were participants of the study. They were administered the MMPI-2 and the scores across various scales were statistically analyzed. Before analysis, the sample was divided into groups according to gender, i.e., male-to-female and female-to-male patients who were requesting sex reassignment surgery. Results: No significant elevation of scores on any of the scales was noted in keeping with the fact that patients with GID usually demonstrate minimal psychopathology. All patients showed elevation on at least one subscale other than the masculinity-femininity subscale. No differences across gender were noted indicating that gender was probably not a determinant of psychopathology in GID. Conclusions: MMPI-2 profiles in patients with GID failed to reveal major psychopathology though the MMPI still remains a useful tool in the assessment of this population.

Association of Vitamin D Level With Clinical Status in Inflammatory Bowel Disease: A 5-Year Longitudinal Study

Introduction: A growing empirical literature has examined insomnia symptoms as a possible risk factor for a range of suicidal behavior. Not much literature is available in normal adolescent population. Aims: The aim is to find insomnia prevalence, studying various dream factors, and suicidality prevalence among students of various courses. To check if there is a relation between insomnia and suicidal behavior and dreams, particularly nightmares and suicide. Materials and Methods: A total of 400 students of various courses were assessed using Insomnia Severity Index and The Mannheim Dream Questionnaire and Suicide Behaviour Questionnaire. Results: Insomnia was present in 11%, 23%, 19%, and 19% and suicide behavior in 16%, 17%, 12%, and 22%, respectively, in medical, commerce, engineering, and arts students. Statistically significant correlation was found between suicide and insomnia severity and various dream factors. Conclusions: Insomnia and dreams had relation with suicidality in normal adolescent population.

Background: Atomoxetine has been widely used for treating attention deficit hyperactivity disorder (ADHD) in children, adolescents and adults. Several studies have confirmed its efficacy as assessed by parent and teacher ratings with respect to school performance and social and family functioning. Loss of appetite and weight has been its well documented side effect. In this study, we tried to assess the frequency and severity of the side effect of loss of appetite and weight loss in children diagnosed with ADHD and treated with atomoxetine. Methods: This study was conducted at a tertiary care hospital. Children diagnosed as having ADHD were started on the minimum effective dose of Atomoxetine (0.5–1mg/kg body weight). The weight and calorie consumed by the patient per day were recorded before starting the medication. The doses were titrated over the next one month at the end of which parents were asked about any apparent change in appetite of patients. Weight and the caloric intake were noted and comparisons made with the previous record. Results: 49 patients completed the study. 21 (42.9%) patients had a decrease in weight. However, ‘clinically significant weight loss’ (>5% body weight) was seen in 3 (6.1%) patients only. 17 patients (34.7%) reported a decrease in their daily calorie intake. 15 (30.6%) parents reported appetite loss, out of which 9 (18.4%) parents reported a ‘major decrease’ in the appetite of their children, warranting a change of dose/dosing schedule. Conclusions: Though a significant number of patients and their parents reported loss of appetite and weight, more frequently in females, clinically significant weight loss was seen only in a minority (6.1%) of patients. Nevertheless, a regular weight monitoring is a must in daily clinical practice when maintaining a patient on atomoxetine.

Child sexual abuse (CSA) is a hidden and under-reported problem in psychiatry. CSA has been studied in various epidemiological data based studies and has been found to be a significant risk factor for the development of psychiatric illness in later life. Depression, suicide and suicidal attempts as well as self-injurious behaviour have all been reported to be significantly greater in patients than have been exposed to CSA versus those who have not been exposed to the same. There are studies that demonstrate higher rates of substance abuse, body image disturbances, eating disorders and cluster B personality traits in patients that have been exposed to CSA. The paper looks at the available data on lifetime occurrence of psychiatric disorders in patients that have been exposed to CSA. The various mechanisms by which CSA exposure can lead to psychiatric disorders in adulthood are discussed and the need for identification, assessment and clinically evaluating the presence of CSA in patients in routine clinical practice is highlighted.

Background: Suicide is a grave mental health problem in India, and suicide rates in India have risen over the past decades. Suicide reporting by the media is a common cause for spurts of suicides that may occur from time to time. The aim of the present study was to assess the change in trends in media reporting of suicide after a celebrity suicide. Methodology: Suicide by the renowned actor Robin Williams was selected as the reference case. The top three Indian daily newspapers published in English having the highest circulation as per the Registrar of Newspapers, Government of India report were selected to be scanned in the study. These were the Times of India – Mumbai edition, Mumbai Mirror, and the Daily News Analysis – Mumbai edition. The authors screened all news stories in the three newspapers within a 6-month period (3 months prior and 3 months post the date of the reference suicide case), and these news reports were evaluated as per the suicide reporting guidelines for media laid down by the Indian Psychiatric Society. The data were analyzed using Chi-square test and descriptive statistics where appropriate. Results: A total of 708 newspaper articles were identified on the basis of the guidelines mentioned above. Nearly 88% (n = 623) of the articles directly covered suicide while 4.09% (n = 29) focused on suicidal threats and 7.91% (n = 56) focused on parasuicide behavior. There was a significantly greater increase in the total number of articles printed after the celebrity suicide (n = 409) for all article types except teasers as compared to that before the celebrity suicide (n = 299). There was a significantly greater increase in front page news on suicide after the celebrity suicide (P = 0.0016), description of the method of suicide (P = 0.0221), and the mention of the suicide notes (P = 0.0002). Most articles after the celebrity suicide placed the blame on someone or the environment for the act (P = 0.0001). Conclusions: A change in media trend toward reporting suicide was noted post a celebrity suicide, and it is important that media follow guidelines stringently when reporting a serious problem like suicide.

Background & objectives: Limited data are available on prescription patterns of the antidepressants from India. We studied antidepressants' prescription pattern from five geographically distant tertiary psychiatric care centers of the India. Method: In this cross-sectional study, all patients who attended outpatients department or were admitted in the psychiatry wards at Lucknow, Chandigarh, Tiruvalla, Mumbai and Guwahati on a fixed day, who were using or had been prescribed antidepressant medications, were included. The data were collected on a unified research protocol. Results: A total of 312 patients were included. Mean age was 39±14.28 yr and 149 (47.76%) were females, 277 (87.5%) were outpatients. Among the patients receiving antidepressants, 150 (48.1%) were of diagnoses other than depression. Diabetes mellitus 18 (5.78%) was the most common co-morbid medical illness. A total of 194 (62.2%) patients were using selective serotonin reuptake inhibitors (SSRIs) with escitalopram 114 (36.53%) being the most common antidepressant used. Overall, 272 (87.18%) patients were using newer antidepressants. Thirty (9.62%) were prescribed more than one antidepressant; 159 (50.96%) patients were prescribed hypnotic or sedative medications with clonazepam being the most common (n=116; 37.18%). Interpretation & conclusions: About half of the patients with diagnoses other than depression were prescribed antidepressants. SSRIs were the most common group and escitalopram was the most common medication used. Concomitant use of two antidepressants was infrequent. Hypnotic and sedatives were frequently prescribed along with antidepressants.

Background The purpose of this study was to identify barriers frequently endorsed by dentists in a large, multi-site dental practice to implementing the American Dental Association’s recommendation for sealing noncavitated occlusal carious lesions as established in their 2016 pit-and-fissure sealant clinical practice guideline. Although previous research has identified barriers to using sealants perceived by dentists in private practice, barriers frequently endorsed by dentists in large, multi-site dental practices have yet to be identified. Identifying barriers for these dentists is important, because it is expected that in the future, the multi-site group practice configuration will comprise more dental practices. Methods We anonymously surveyed the 110 general and pediatric dentists at a multi-site dental practice in the U.S. The survey assessed potential barriers in three domains: practice environment, prevailing opinion, and knowledge and attitudes. Results were summarized using descriptive statistics. Results The response rate to the survey was 62%. The principal barrier characterizing the practice environment was concern regarding liability; endorsed by 33% of the dentists. Many barriers of prevailing opinion were frequently endorsed. These included misunderstanding the standard of practice (59%), being unaware of the expectations of opinion leaders (56%) including being unaware of the guideline itself (67%), and being unaware of what is currently being taught in dental schools (58%). Finally, barriers of knowledge and attitudes were frequently endorsed. These included having suboptimal skill in applying sealants (23% - 47%) and lacking knowledge regarding the relative efficacy of the different ways to manage noncavitated occlusal carious lesions (50%). Conclusions We identified barriers frequently endorsed by dentists in a large, multi-site dental practice relating to the practice environment, prevailing opinion, and knowledge and attitudes. All the barriers we identified have the potential to be addressed by implementation strategies. Future studies should devise and test implementation strategies to target these barriers. Electronic supplementary material The online version of this article (10.1186/s12903-018-0480-z) contains supplementary material, which is available to authorized users.

Skin rashes have been reported after the start of various antipsychotic drugs in the scientific literature. It is important that psychiatrists be aware of antipsychotic-induced skin reactions in patients on antipsychotic medication which can be an uncommon yet possible occurrence. Patients with psychiatric problems may be prone to skin reactions and may not report the same as they may not be aware of the same. We herewith report a case of skin reaction with Olanzapine in a patient with schizophrenia. Keywords: Schizophrenia, Skin rash, Skin reaction, Antipsychotics, Olanzapine.

Ofloxacin is a commonly used fluoroquinolone antibiotic in adults as well as children. It is generally safe and well tolerated though rare neurological and psychiatric adverse reactions have been reported with Ofloxacin. We report a case of a 6 years old child who developed hallucinations after being started on Ofloxacin and which resolved on discontinuation of the drug. Keywords: Ofloxacin, Hallucination, Fluoroquinolones.

Background : Suicide is a global health problem which is highly underreported and under treated. Though suicide intervention helplines have been studied the pattern of utilization of a suicide helplines by those referred to the facility has not been studied. Methodology : In the present study we have studied the pattern of utilization of a helpline in a community mental health clinic in the city of Mumbai. The study sample was patients who called the helpline and later attended the out patient facility of the clinic. Data was collected in semi-structured format and statistically analyzed using computer software. Results : 15149 calls were received by the helpline. Of the 1391 patients reporting suicidal ideation (59.42%) only 718 opted for psychiatric evaluation. 18.3% of patients with suicidal ideas had a past suicidal attempt while 82.6% had a psychiatric diagnosis. Majority of patients were belonging to psychotic and mood disorder categories. Financial and educational stressors were reported as the main stressors leading to suicidal ideas. Conclusions : A helpline offers definite advantage for patients with suicidal ideation to access mental health services. A helpline is an economical service that serves as a contact point to bring more people at an early stage to mental health care facilities.

Introduction: Hypertension is the second leading cause of End Stage Renal Disease after diabetes mellitus. If hypertension is an etiologically significant cardiovascular risk factor in hemodialysis patients, the first step would be to assess the level of BP accurately. To manage hypertension, limiting dietary fluide intake, and individualizing dialysate sodium delivery would be the initial steps as non pharmacological measures. Therefore as a pharmacological measurement, study was conducted to determine control of blood pressure by anti hypertensive drug treatment. Material And Method: Treatment and control of hypertension was assessed retrospectively in a cohort of 100 clinically stable, adult patients undergoing hemodialysis. Frequency and duration of hemodialysis were also assessed. For quality of life, kidney disease outcomes quality initiative-survey form™ 1.3 health survey was used for 40 adult patients undergoing hemodialysis. Results: Hypertension was documented in patients (n=97) with complicated kidney disease (97.16%) and patients (n=85) with non-complicated kidney disease (85.66%). Hypertension was adequately controlled in only 2.83% (n=3) patients with complicated kidney disease and 14.33% patients (n=15) with non complicated kidney disease undergoing maintainanace hemodialysis. Patients with non-diabetic kidney disease had better quality of life as compared to the patients with diabetic kidney disease. Conclusion: Control of hypertension, particularly systolic hypertension, in patients undergoing hemodialysis for prolong period was inadequate, despite recognition of its prevalence and the use of antihypertensive drugs. Optimizing the use of medications and closer attention to non pharmacological interventions, may improve control of BP.

Current understanding of mental disorders is based upon “biopsychosocial model”. Research also suggests what biological changes take place in a particular disorder as well as nature of risk which arises from psychological, social and environmental conditions. However it remains unclear how these psychosocial and environmental risk factors interact with biological factors which lead to clinical syndromes. This paper examines interrelationship of psychosocial and environmental risk and biological changes observed in mental disorders and tries to identify the possibility of a pathway of the psychopathology of psychiatric disorders. The review aims to demonstrate that significant advances in the fields of psychosocial, cultural, anthropological and neurobiological research provide novel insights into the etiology of mental disorders. There are neurochemical, functional and structural neurobiological, neurocognitive, immunological findings and findings from gene-environment interaction that appears promising. However these findings are in an isolated manner. Comprehensive studies examining major biological changes together in relation to psychosocial risk factors are lacking. Every individual reacts differently to the same environmental risk while there tends to be similarities in individual outcome in response to such stressors. The findings though robust independently, remain very preliminary to suggest a sequential trajectory for developing a clear pathway for pathogenesis. It is currently unclear whether there is a differential psychopathological impact of psychosocial stressors in different cultures despite the extensive variability both between and within major social groups and societies. Further research investigating modifiable and non-modifiable risk factors in context of prevailing socio-economic conditions is urgently needed to plan effective interventions.

Objective: To determine if there is a significant rise in serum prolactin (PRL) in acute psychosis related to disease process and weather there is a significant gender difference in the level of PRL and its correlation psychopathology. Procedure: Naturalistic study involved 60 consenting outpatients and inpatients in a tertiary psychiatric setting. Patient base was comprised of men (n = 30) and women (n = 30) with 83% in the age range of 21 - 40 years old. All subjects had confirmed first episode diagnosis set forth by the Diagnostic and Statistical Manual of Mental Disorders. Patients were drug free and drug naive. Standardization for control was done using 15 control PRL samples obtained from healthy individuals. Methodology involved assessment by radioimmunoassay, the Brief Psychiatric Rating Scale and the Positive and Negative Syndrome Scale at day 1, 3 weeks and again at 6 weeks. All patients were treated with atypical antipsychotic drugs. Results: Serum PRL was elevated on baseline in 75% of first episode psychosis schizophrenia, yet found to have a negative correlation to psychopathology at base week 3 and week 6 samples. Conclusions: Elevated serum PRL is not a potential indicator of acute schizophrenia. Levels are higher in females than in males, yet females respond better to treatment at a lower dose than males.

Background: Alopecia areata (AA) and psoriasis are associated with various psychiatric comorbidities. Both greatly affect the quality of life (QOL) of patients and psychiatric comorbidities can further worsen it. Thus there is need to recognise psychiatric comorbidities and treat them in these patients. Aims: To determine the psychiatric morbidity and the QOL in these patients to study the factors affecting them. Methodology: 50 patients each of psoriasis and AA were included. 50 people accompanying these patients served as control group. They were diagnosed for psychiatric disorders by clinical interview. Scales used were severity of alopecia tool for AA, psoriasis area and severity index for psoriasis, WHO-QOL scale, Hamilton Rating Scale for anxiety and depression. Results: 22% and 38% patients in AA and psoriasis group respectively suffered from psychiatric disorder, depression was present in 18% and 24% of patients and 4% and 12% had anxiety disorders in respective groups. The control group had only 6% of psychiatric comorbidities. QOL scores had negative correlation with Hamilton-A, Hamilton-D and severity of psoriasis scores and they were statistically significant but not with severity of AA. Conclusion: Thus AA and psoriasis patients had more prevalence of psychiatric comorbidities and it had bearing on their QOL.

Background: Schizophrenia is a chronic psychiatric disorder which has a profound effect on the patient's life course. Marriage has been shown to be both protective and detrimental to the course of recovery in schizophrenia. The study was planned to elucidate the factors that influenced marriage and the sustainability of marriage in patients with schizophrenia. Materials and Methods: The study sample was 101 patients with schizophrenia that attended the outpatient department of tertiary general hospital. Informed consent was taken and data collected from the patients and/or relatives on a special semi-structured pro forma. The data collected were subjected to appropriate statistical analysis after further subdividing the sample into subgroups. Results: About 69.3% of the total samples were married while 30.7% were unmarried. A significantly greater number of patients who were educated were unmarried (P = 0.026). Age of onset of illness below 25 years (P = 0.002) was a significant factor in those who were unmarried. When marital outcomes were considered, it was noted that greater male patients had stable marriages though not statistically significant, whereas earlier age of onset of illness was a significant factor that resulted in poor marital outcome (t = 2.96, df = 68, P = 0.0021). Conclusions: The effect of marriage on schizophrenia and factors that may influence marital sustainability in patients with schizophrenia need further study and are multipronged. Larger studies in this area of research are warranted.

Narcolepsy is a neurological disorder of sleep characterised by excessive daytime sleepiness and has been reported following the removal of a craniopharyngioma due to a host of neurological and endocrinological causative factors. We present here a case of a child that developed secondary narcolepsy following resection of a craniopharyngioma.

Background There is little literature on the relative efficacy and cognitive safety of right unilateral (RUL), bifrontal (BF), and bitemporal (BT) electroconvulsive therapy (ECT) in schizophrenia. Methods We present a randomized, nonblind, naturalist comparison of a fixed course of 8 moderately high-dose RUL (n = 24), threshold BF (n = 27), and threshold BT (n = 31) ECT in patients with schizophrenia. Assessments included the Positive and Negative Syndrome Scale (PANSS), the Wechsler Memory Scale-Revised, and an autobiographical memory interview. A completer analysis was planned and conducted to capture the cognitive outcomes. Results The sample as a whole improved significantly on all efficacy outcomes and deteriorated significantly on all cognitive outcomes. The primary efficacy outcome, improvement in PANSS total scores, did not differ significantly across groups. The PANSS positive score (but no other subscale score) improved significantly less with RUL relative to BF and BT ECT. For autobiographical memory and for almost all Wechsler Memory Scale subtests, including memory quotient (the primary adverse effect outcome), BT ECT was associated with greater impairment than RUL or BF ECT. Importantly, all statistically significant differences between treatments were clinically small in magnitude. Conclusions In patients with schizophrenia who receive a fixed course of 8 ECTs, threshold BT ECT is associated with greater cognitive impairment across a range of measures, and moderately high-dose RUL ECT is associated with poorer efficacy against positive symptoms. Threshold BF ECT exhibits the best efficacy-cum-neurocognitive safety profile. All differences between groups, however, are small and perhaps clinically insignificant.