International Journal of

Pharmaceutical and Clinical Research

ISSN: 0975 1556 Peer Review Journal

Print-ISSN 2820-2643

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1.Hip Resurfacing Arthroplasty- Will it Stand the Test of Time?
Deepak Rohella, Ananda Kumar Behera, Harekrushna Sahu, Abhimanyu Madhual, Bibhudatta Mall, Kishore Ku. Panda
Abstract
The current metal-on-metal hip resurfacing as an alternative to traditional complete hip replacement in younger people constitutes the third generation of resurfacing, with enhanced metallurgy, better designs, and improving operating procedures. Short- and medium-term results are good to exceptional, but long-term results are awaited. Some obvious theoretical benefits of the method include bone stock preservation, ease of revision, when necessary, a more natural gait pattern, and larger ranges of movement. However, as evidenced by numerous research, these have not been fully achieved. Critics of this technique have identified various concerns, including a unique cause of failure involving the neck of the femur, a steep learning curve for aspiring surgeons, and the unknown significance of elevated ions levels. The lack of a specific approach for determining metal allergy. Many surgeons believe that the hazards outweigh the benefits.

2. Comparison of Fixed-Bearing Prosthesis vs. Mobile-Bearing Prosthesis in Total Knee Arthroplasty among Indian Patients
Deepak Rohella, Ananda Kumar Behera, Harekrushna Sahu, Abhimanyu Madhual, Bibhudatta Mall, Kishore Ku. Panda, Sunil Dash
Abstract
Background: It has been claimed that mobile-bearing knee prostheses achieve more flexion in laboratory testing and may provide a better functional outcome in patients than traditional fixed-bearing knee prostheses. Aim: To assess the mid-term clinical results of total knee arthroplasty (TKA) in Indian patients using a fixed- or mobile-bearing prosthesis. Methods: 120 patients (50 men and 70 women) with arthritis of the knee with similar deformities and range of motion were randomly assigned to have TKA with a fixed- or mobile-bearing prosthesis. Patients with mediolateral instability and infective arthritis were not allowed to participate. Knee and functional ratings, range of motion, and the presence of flexion contracture were all evaluated by the Knee Society. Results: The average duration of follow-up was 3.5 years (range, 1 – 4.6 years). The mid-term results of the two groups were comparable. At postoperative week 2, one patient with a mobile-bearing prosthesis experienced recurrent dislocation due to iatrogenic medial collateral ligament injury. Conclusion: Long-term studies of functional and radiological outcomes are required to identify the indications for fixed-vs. mobile-bearing prosthesis.

3. Hormone Replacement Therapy in the Diagnosis and Intervention of Postmenopausal Osteoporosis
Rahul Anshuman, Amrita
Abstract
Reducing the frequency of vertebral and non-vertebral fractures (particularly at the hip), which are to blame for the morbidity associated with the illness, is the goal of treatment for postmenopausal osteoporosis. In early postmenopausal women, hormone replacement therapy is still an important tool for osteoporosis prevention. At various doses, hormone replacement treatment (HRT) quickly restores bone turnover and preserves bone mineral density (BMD) at all skeletal locations, resulting in a marked decline in both vertebral and nonvertebral fractures. A one-year follow-up was done by 84 postmenopausal women who were randomly assigned to one of four groups. The first group (n = 20) received conjugated estrogens (CE; 25 days/month) at a rate of 0.625 mg/day. The third (n = 17) received 50 p g/day of transdermal 179-estradiol cyclically (24 days/month) while the second (n = 23) received 0.625 mg/day of CE continuously. The fourth group (n = 24) served as a treatment-free control group, whereas all of these groups additionally received 2.5 mg of medroxyprogesterone acetate consecutively throughout the final 12 days of hormone replacement therapy. Dual photon absorptiometry was performed prior to treatment and again after a year. Prior to treatment and six and twelve months later, measurements of serum calcium, phosphate, and osteocalcin levels as well as urinary calcium/creatinine and hydroxyproline/creatinine ratios were made. The amount of bone mineral increased across the board in all treatment groups. This rise was greater in the transdermal group (7.1 percent, P <0.01) and the continuous CE therapy group (4.4 percent, P <0.05). Concomitant biochemical effects at 6 and 12 months, including decreases in blood calcium, phosphate, and osteocalcin, as well as decreases in urine calcium and hydroxyproline, were consistent with the effects on bone mineral reported.

4. Electrocardiographic and Angiographic Profile of Isolated Left Circumflex Coronary Artery Disease in Tertiary Care Centre of Bihar.
Dhananjay Kumar, Girish Narayan Mishra, Sankar Paul Chowdhury
Abstract
Introduction: Isolated left circumflex coronary artery disease is uncommon and occurs in a small percentage of patients undergoing coronary angiogram. Because of the rarity of isolated coronary artery disease not many studies involving isolated coronary artery disease are available in literature. Clinical, electrocardiographic, Echocardiographic and angiographic features of these patients with isolated left circumflex coronary artery disease is therefore, poorly characterised. Aim and Objective: To determine the specific electrocardiographic changes as well as angiographic findings in isolated left circumflex coronary artery diseases. Methodology: This study was conducted in the department of cardiology, Narayan medical college, Jamuhar, Rohtas, Bihar. This study is a Descriptive observational study involving 55 patients. Institutional ethics committee clearance was obtained to conduct this study in our hospital. All study subjects fulfilling the inclusion and exclusion criteria were included in the present study. Observation: 30 patients (54.5%) showed Q waves in the resting ECG. Q waves were seen in inferior leads in 20 patients, lateral leads in 6 patients and both in inferior and lateral leads in 4 patients.   Ischemic ST-T changes were noted in 40 patients (72%). Ischemic ST-T changes were seen in inferior leads in 28 patients, lateral leads in 7 patients and both in inferior and lateral leads in 5 patients. RV pattern of ECG changes was noted in 15 patients (27.3%) among the study population. RV pattern was noted in inferior leads in 14 patients and both in inferior and lateral leads in 1 patient. Conclusion: On the basis of our study we can conclude that Single stenosis is the most common finding in the coronary angiogram of the patients with isolated LCX disease. Central stenosis involving proximal left circumflex coronary artery is more common than peripheral stenosis involving distal LCX. Central stenosis involving proximal LCX is more common in patients with documented evidence of MI. Most of the patients with isolated LCX disease have normal left ventricular function.

5. Angiographic Severity of CAD in Patients with Acute Coronary Syndrome in Correlation to their Glycaemic Status in Tertiary Care Centre of Bihar
Dhananjay Kumar, Girish Narayan Mishra, Sankar Paul Chowdhury
Abstract
Background: Interventional studies have established that cardiovascular complications are mainly or partly dependent on sustained chronic hyperglycemia. This glycemic disorder can be estimated as a whole from the determination of hemoglobin A1c (HbA1c) level, which integrates both basal and postprandial hyperglycemia. The incidence of cardiovascular complications has been identified as depending on HbA1c and on fasting and/or postprandial hyperglycemia. Aim and Objectives: To assess the Angiographic severity of study subjects with acute coronary syndrome and its associations with glycemic status of study subjects. Methodology: The present study is a cross-sectional study. This study was conducted on 100 patients with ACS among which 50 patients who are diabetics and other 50 patients who are non-diabetics admitted in Department of Cardiology, Narayan medical college Jamuhar, Rohtas, South Bihar. Patients who matched the inclusion and exclusion criteria were selected randomly during period of approximately one and a half years formed the study group. Results: In non-diabetic group out of 50 study subjects 23 had single vessel disease, 13 subjects had double vessel disease, and 14 subjects had triple vessel involved whereas in diabetic group out of 50 study subjects 23 subjects had single vessel involvement, 5 subjects had double vessel involvement and 22 subjects had triple vessel involvement. On applying chi-square it was non-significant with p value-0.069. In non-diabetic group gensini score was 42.38±28.34, whereas in diabetic group it was 51.28±32.49, on applying t test it was non-significant with p value 0.15. Conclusions: The severity and extent of CAD in diabetics was more compared to non-diabetics. Involvement and occlusion of vessels were more commonly seen in diabetic patients. The incidence of triple vessel or multivessel disease was significantly higher in diabetics. Patients with poor glycemic control with elevated levels of HbA1c had diffuse pattern of atherosclerotic disease and high levels of HbA1c mildly correlated with gensini score.

6. Coronary Angiographic Profile, Clinical Presentation and Risk Factors of Young Adults (≤40 Years) Presenting with Acute Myocardial Infarction at a Tertiary Care Center in Bihar, India
Dhananjay Kumar, Girish Narayan Mishra, Sankar Paul Chowdhury
Abstract
Introduction: ACS in very young adults with age ≤30 years is rare. In India, the prevalence of acute myocardial infarction (AMI) in this population is <2%. A similar study reported that 0.4% of patients presented with ACS in ≤30 years age group. ACS leads to significant effects on patient’s psychology, morbidity, and increased financial burden when it occurs at this young age. Aim and Objectives: To identify the clinical, risk factor and coronary angiographic characteristics in very young adults less than 40 years of age presenting with myocardial infarction. Material and Methods: The present study was a prospective study conducted among 100 patients of age less than 40 yrs at Department of cardiology Narayan medical college, Jamuhar, South Bihar. Patients subsequently underwent coronary angiography and revascularization by either primary PCI or pharmaco-invasive PCI or CABG surgery after obtaining informed consent with study protocol approved by Institutional Ethics Committee. All patients were clinically evaluated after detail history taking. Result: 43% study subjects had involvement in AW area, 18% subjects had involvement in EAW area, 11% subjects had inferior wall area, 9% subjects had APL involvement, 7% subjects had involvement in ILW area. 72% study subjects were had single vessel disease, in that 41 had LAD, 21 had RCA and 10 had LCX involvement. 19% subjects had double vessel involvement in which 12 % subjects had LAD and RCA, 3subjects had RCA and LCX. Whereas 9% subjects had triple vessel disease. Conclusion: The major modifiable risk factors in very young Indian population are smoking and dyslipidemia. Primary prevention by educating the public about the effects of smoking, unhealthy dietary habits, and sedentary lifestyle in early years of life may help to prevent the development of cardiac problems later in life.

7. A Study to Evaluate out Patient Prescriptions and Patterns of Drug Used
Ranjeet Kumar, Sarju Zilate, Rahul Kewal Kumar
Abstract
Introduction: Prescription pattern monitoring studies are tools for assessing the prescribing, dispensing, and distribution of medicines prevailing in a particular locale. The main aim of such studies is to facilitate rational use of medicines. Hence we decided to do this study as this would throw light on deficiencies which require appropriate and sustained interventions to avoid being carried onto the next generation. Methods: The present Retrospective analytical study is carried out on 500 prescriptions / Subjects / Patients. Prescriptions were analyzed using the WHO core prescribing indicators: Average number of drugs per encounter. Percentage of drugs prescribed by generic name, Percentage of encounters with an antibiotic prescribed, Percentage of encounters with an injection prescribed, Percentage of drugs prescribed from essential drugs list or formulary. In addition, quality of prescription writing was also assessed in terms of legibility and completeness of information e.g. whether diagnosis, strength, frequency and duration of drug prescribed was written or not. Results: A large number of fixed dose combinations (46.67) had been prescribed. In this study we found 69.51% prescriptions incomplete in one or more aspect that is, in term of either absence of diagnosis /complains in the prescription or absence of duration, frequency and strength of the drug prescribed. A diagnosis was not mentioned in 418 (25.55%) prescriptions. Strength of the medicine was not mentioned for 573 (35.0%) drugs, while frequency of intake was omitted for 198(12.09%) and duration of therapy was missing in 483 (29.5%) of the drugs. All these prescriptions were considered as incomplete, amounting to 1138 (69.51%) incomplete prescriptions. Conclusions: Our audit did bring out the areas where there is a scope for improvement that is generic prescribing, use of essential medicines, restraint in use of irrational fixed dose combinations and better quality of prescription writing in terms of completeness of information provided and legibility of prescriber details.

8. A Prospective Study to Find Predisposing Factors and Different Predictors among the Non Traumatic Peritonitis
Srinivas Sitaram Pindi, Naveen Chellaboyena, T Jaya Chandra
Abstract
Introduction: Peritonitis is one of the most common surgical emergencies. The prognosis and outcome of peritonitis depend upon the interaction of several factors. With these a study was taken to find the clinical status of the individuals with peritonitis. Materials and Methods: It was a prospective study, conducted in the department of General Surgery, Rangaraya Medical College. Individuals aged > 18 years, with intestinal perforations were included, traumatic intestinal perforation, malignancy were excluded. Recruitment of the participant was carried based on clinical diagnosis. Complete haemogram, renal function test, arterial blood gas analysis was carried. Levels of amylase and lipase were also measured. Perforation was confirmed by finding gas under the diaphragm in the radiograph of chest and abdomen. Ultrasound of abdomen was carried to find other pathologies. Laparotomy was carried under general anaesthesia. Perforations were closed using modified Graham’s technique. Results: Total 74 members were included, 74.3% were male participants, maximum were in < 40 years group. Alcoholism and smoking were the major (22) risk factors. Only 33% (25) were presented within 24hrs of onset of symptoms. Totally, 26 participants presented to the hospital after 24hrs of onset of gross abdominal distension. Diabetes was the leading (10) cause of morbidity followed by hypertension (6). Majority of perforation were found in the stomach (20). Fourteen were presented with shock at the time of presentation, out of which 12 died. Conclusion: This study helps us in assessing the mortality and morbidity among the patients presenting with peritonitis using the predictors described. This is very useful in stratification of severity of the disease.

9. Coblation Tonsillectomy versus Conventional tonsillectomy a Study from Tertiary Health Care Unit
Krishna Sumanth Kotagiri, Loya Naga Srivalli, M. Ravi Kumar Raju, B Krishna Santosh, T Jaya Chandra
Abstract
Introduction: The traditional methods of tonsillectomy are cold steel techniques metal instruments are used. A study was conducted to compare different parameters of conventional tonsillectomy (COVT) and total subcapsular coblation tonsillectomy (COBT). Materials and Methods: This was a prospective study, conducted in KIMS, Amalapuram. Chronic tonsillitis patients aged > 5yrs were included in this research. Acute tonsillitis, with bleeding disorders and <5 years were excluded. Routine blood investigations, viral markers, chest radio graph and ECG were carried. The patient was put on general anaesthesia, randomly divided for COVT and COBT.  Parameters such as operative time, intra operative complications, intra operative blood loss, post operative complications were compared among the groups. To find the significant difference between the bivariate samples in independent groups, unpaired sample T test was used and chi square test for the categorical data. P < 0.05 was considered to be statistically significant. Results: Total 50 (100%) members were recruited; 50% each group.  Majority (54%) were in <10 years group, male female ratio was 1.08. Statistically there was significant difference in the mean operative time, recovery time, postoperative pain, the mean intra operative blood loss and the mean recovery period. Conclusions: COBT technique has several advantages such as less operative time, intraoperative blood loss, short duration to attend work as well as job.

10. Electrocardiographic and Angiographic Profile of Isolated Left Circumflex Coronary Artery Disease in Tertiary Care Centre of Bihar
Dhananjay Kumar, Girish Narayan Mishra, Sankar Paul Chowdhury
Abstract
Background: Isolated left circumflex coronary artery disease is uncommon and occurs in a small percentage of patients undergoing coronary angiogram. Because of the rarity of isolated coronary artery disease not many studies involving isolated coronary artery disease are available in literature. Clinical, electrocardiographic, Echocardiographic and angiographic features of these patients with isolated left circumflex coronary artery disease is therefore, poorly characterised. Aim and Objective: To determine the specific electrocardiographic changes as well as angiographic findings in isolated left circumflex coronary artery diseases. Methodology: This study was conducted in the department of cardiology, Narayan medical college, Jamuhar, Rohtas, Bihar. This study is a Descriptive observational study involving 55 patients. Institutional ethics committee clearance was obtained to conduct this study in our hospital. All study subjects fulfilling the inclusion and exclusion criteria were included in the present study. Observation: 30 patients (54.5%) showed Q waves in the resting ECG. Q waves were seen in inferior leads in 20 patients, lateral leads in 6 patients and both in inferior and lateral leads in 4 patients.   Ischemic ST-T changes were noted in 40 patients (72%). Ischemic ST-T changes were seen in inferior leads in 28 patients, lateral leads in 7 patients and both in inferior and lateral leads in 5 patients. RV pattern of ECG changes was noted in 15 patients (27.3%) among the study population. RV pattern was noted in inferior leads in 14 patients and both in inferior and lateral leads in 1 patient. Conclusion: On the basis of our study we can conclude that Single stenosis is the most common finding in the coronary angiogram of the patients with isolated LCX disease. Central stenosis involving proximal left circumflex coronary artery is more common than peripheral stenosis involving distal LCX. Central stenosis involving proximal LCX is more common in patients with documented evidence of MI. Most of the patients with isolated LCX disease have normal left ventricular function.

11. A Study on Clinical Profile of Unilateral Disc Edema
Vinay Reddy Jitha, P. Ramapathi Rao, S. Deepa
Abstract
Background: Optic disc edema is swelling of intraocular portion of the optic nerve. Disc edema is an ophthalmoscopic finding defined by unilateral or bilateral swelling of the optic disc. Unilateral disc edema can be inflammatory, ischemic, compressive or infiltrative. It may also be an eye opener for detection of certain systemic diseases. Aim and Objectives: To know the clinical profile of Unilateral  Disc Edema. Material and Methodology: This was an observational prospective study conducted in the department of ophthalmology, Dr. Patnam Mahender Reddy Institute of Medical Sciences, Chevella, Hyderabad, for the period of one year.  We have included 60 Patients presenting with unilateral disc edema and males and females between the age of 20 -65 years. Results: 60 patients, among them 34(56.7%) of the patients were female and 26(43.3%) of the patients were male, half of the patients were belonged to the age group of 30 – 40 years and mean age of all the patients was 38.56 with standard deviation of 6.42. The commonest cause for unilateral disc edema is non arteritic AION and the next common cause is optic neuritis. it was observed that NAION affects age group between 40 -50 years of age and that of optic neuritis affecting between 20 -30 years of age group. Most common presenting complaint was Diminution of Vision (DOV)  in 47 % cases followed by headache in 50 % cases. Conclusion: patients with unilateral disc edema, NAION and optic Neuritis should be considered as first among various diagnosis and these diagnosis are common in age group of 40-50 years of age. Differentiating NAION and optic neuritis is very essential because for each of the diagnosis treatment condition is different.

12. Study of Functional Outcome of Surgical Management of Distal Humerus Fractures
Praneeth Kumar Reddy, P. Rohit Raj
Abstract
Background: Less than 2% of all adult fractures are distal humerus fractures, which are infrequent injuries. Adult distal humeral fractures must typically be surgically repaired for better functional results. The aim of this study was to assess the functional outcome & complications of open reduction and internal fixation surgical method of distal humeral fractures among the patients at tertiary care hospital. Materials and Method: A Prospective clinical study was conducted over a period of 2 years which included 25 patients in the tertiary care centre. Surgery was performed either under general anaesthesia or under brachial block. The patients were treated with primary open reduction and internal fixation. The implants used were Recon plates, DCP, DHP, 1/3 tubular plates and cancellous screws. During the follow up patients were received in outpatient department once in every 3 weeks and fracture union was assessed clinically and radiologically. All study variables were analyzed using descriptive statistical methods such as frequencies and percentages for categorical variables. Results: The average age of the patients in our study was 39.8 years with a range of 21-70 years. Male predominance was found in the study with 75% male and 25% female patients. The results were excellent in 10(40%) patients, good in 8 (32%) patients, Fair in 6 (24%) and Poor in 1(4%) patients. 2 (8 %) patients had superficial wound infections with hardware pain. 1(4%) patient had delayed union and 1 (4%) patient had presented with hardware pain. Conclusion: The idea of open reduction and internal fixation of distal humerus fractures is very useful in restoring the joint surface and getting the patient back to work quickly, which reduces morbidity and leads to good results.

13. Validation of Lung Ultrasound for Early Diagnosis of Ventilator Associated Pneumonia in ICU
Preeti Kumari, Akrity Singh, Nitin Kumar, Ritu Singh, Rajbahadur Singh, Saurav Shekhar
Abstract
Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in critically ill patients which are often reported to be associated with morbidity, mortality, long duration of ICU stay, and mechanical ventilation (MV). Due to the lack of validated gold standard diagnostic test for VAP detection, delay in patient treatment results in increased patient mortality. A total of 40 patients were included in the study. Of the 40 patients, 28 patients had mini-BAL culture-confirmed VAP that was considered the gold standard for VAP diagnosis while 12 patients did not have mini-BAL culture confirmed VAP. The CXR, microbiological culture, CPIS and LUS score were recorded and compared from the Day 1 to Day 7 till the discharge of the patients. The mean lymphocyte and platelet count among the patients with mini-BAL culture-proven VAP was found to be higher in comparison to those without mini-BAL culture-proven VAP. The mean SOFA and APACHE score was also found to be significantly higher among the patients with mini-BAL culture-proven VAP. There was a significant decrease in the mean LUS score and CPIS score for the patients from Day 1 till the day of the discharge of the patients. The study concludes that the LUS score and the CPIS score are good diagnostic marker for the detection of VAP which can be utilized for clinical decision making of patients admitted in hospital with suspected VAP.

14. Correlation of Pulmonary Function Tests with BMI in Type-2 Diabetes Mellitus
Sohail Ahmed, Rishabh Dangi
Abstract
Diabetes mellitus is a public health problem in developing and developed world, according to WHO, India will be world diabetic capital in 2025. Diabetes is a complex medical syndrome comprising of heterogeneous group of disease resulting from diverse aetiologies predominantly of genetic and environmental origin. DM affects almost all the organ systems in the body producing biochemical, morphological and functional abnormalities mainly of collagen and elastine . The alterations in these scleroproteins in turn affect the mechanical behaviour of the lungs manifesting in altered lung volumes measured by pulmonary function tests. The alterations in these scleroproteins in turn affect the mechanical behaviour of the lungs manifesting in altered lung volumes measured by pulmonary function tests. People with a higher BMI are more susceptible to diabetes and its complications .High body fat increases insulin resistance in muscles, liver, adipose tissue which increases body insulin production and causes impaired glucose tolerance. The effect of BMI in reducing lung function has been well documented .The present study has focused on correlation of pulmonary function test with BMI in type 2 diabetics.

15. Breast Mass Evaluation with Strain Elastography: A Prospective Cohort Study
Tushar Kumar, NarendraKumar M. Shah, Vinod Kumar Mishra
Abstract
Introduction: Breast cancer is the most common cancer in the world and is one of the most common causes of morbidity and mortality. Hence, early detection by non- invasive technique is required without causing discomfort to patients which brings forth the role of real time breast elastography, a new method to assess the stiffness of any breast mass. Among different Elastographic methods we have used the strain ratio which is a semiquantitative method. Aims and Objectives: To differentiate benign breast masses from malignant ones , to correlate it with pathological investigations done and to know the sensitivity, specificity , positive predictive value, negative predictive value and accuracy of real time elastography for breast lesions. Material and Methods: Sample of 100 patients presenting with breast lump on which Elastographic sonography was done in Radiology department during the period, January 2018 to December 2018 at SDM Medical College and Hospital, Dharwad, Karnataka. Strain ratio were calculated and a cut off ratio of 3 was taken. A ratio above 3 was considered positive for malignancy and below 3 was considered to be benign. These findings were correlated with pathological investigations findings. Results: Out of 100 patients examined sonographically with breast lumps, 45 were malignant cases and 55 were benign cases. Sensitivity, specificity, PPV and NPV were 87%, 91% and 89% and 89% respectively. Significant correlation between Strain ratio and pathological outcome were found. Mean strain ratio for malignant lesions was 3.55 +\-1.46 m\s and that for benign lesions were 1.86 +\-1.32m\s. Conclusions: In our studies sensitivity, specificity, PPV, NPV and accuracy of strain elastography were good. So we can conclude that Strain elastography is very helpful in screening and diagnosing the malignant breast lesions, hence decreasing the need of biopsies to diagnose malignant lesions.

16. A Study of New Onset Arrhythmias in Acute Myocardial Infarction
K. Sinha, Dhananjay Prasad, Sushil Kumar
Abstract
Aim: To study various types of arrhythmias in relation to time between the admission and the onset. Material & Method: The present study was done a Cross-sectional prospective study conducted at the Department of Medicine, Darbhanga, Medical College & Hospital, Laheriasarai, Bihar, India. The study was conducted over a period of one year. Results: Predominance of alcoholism and smokers were present in the study group. Time interval between presentation and onset arrhythmias was studied in the study population. It was found that majority of arrhythmias occurred in the first day post MI which was 76.7%. Conclusion: Myocardial infarction was most common in 40 – 49 years age group. Incidence is least in below 30 years age group. Majority of deaths was seen in 50 – 59 years age group. Males were the predominant population and sex did not affect the prognosis significantly. Alcohol consumption and smokers were predominant in the study group. Alcoholism does not affect the outcome. Majority of arrhythmias occurred on day 1 post MI. the time interval between the presentation and onset of arrhythmias does not affect the prognosis significantly.

17. An Observational Assessment of the Knowledge and Awareness of General Practitioners Concerning the Management of Hypertension
Md. Israrul Haque, Md. Farid Alam Ansari
Abstract
Aim: To assess awareness and approach of general practitioners towards hypertension management. Methodology: The present study was conducted in Department of General Medicine, Netaji Subhas medical College and Hospital, Bihta, Patna, Bihar, India for 1 year, among 100 general practitioners who agreed to participate in the study. All were enrolled after obtaining their written consent. Data pertaining to subjects such as name, age, gender etc. was recorded. A detailed questionnaire was prepared which comprised of information regarding the technique of measurement of blood pressure, diagnosis of pre-hypertension and hypertension, evaluations of newly diagnosed hypertensive patients, the role of non-pharmacological measures to treat prehypertension and hypertension, level of blood pressure to start pharmacological treatment and selection of antihypertensive agents in different clinical conditions. Each participant was personally visited and questionnaire was filled accordingly. The questionnaire was thoroughly checked after being filled for any leftovers. Results thus obtained were subjected to statistical analysis. Results: Out of 100 subjects, males were 53 and females were 47. Cuff placement covering 2/3 of the arm at heart level was recommended by 80%, preferred position of patient was sitting replied by 48%, supine by 35% and standing and supine by 17%. The number of readings of blood pressure was 1 by 5%, 2 by 43% and 3 by 52%. The difference was significant (P< 0.05). Investigation preferred by general practitioners were ECG by 89%, urine examination by 63%, serum creatinine by 78%, lipid profile by 84%, ultrasound of abdomen by 39%, serum potassium level by 66% and RBS by 94%. Common symptoms reported were morning headache by 67%, dizziness by 49%, palpitation by 48%, easy fatigability by 55% and impotence by 50%. Conclusion: It can be concluded after this study that most of the general practitioners are well aware and updated about the initial lab investigations, symptoms and techniques.

18. Evaluation of Natural Enamel Wears Against Polished Yitrium Tetragonal Zirconia and Polished Lithium Disilicate: Comparative Study
Rashmi
Abstract
Aim: To compare wear of the natural teeth against polished yttrium tetragonal zirconia and polished lithium disilicate crowns. Material & Methods: This study was carried out in the Department of Maxillofacial Surgery, Narayan Medical College & Hospital, Sasaram, Bihar, India, over a period of one year. A total of 20 patients were included in the study. Results: Wear was measured using baseline and 12‑month interval cast of opposing dentition and 3D scanning and superimposition technique. A statistically significant difference was found in the comparison of the amount of natural enamel wear against polished zirconia crowns (Group 1) with the amount of natural enamel wear against natural antagonist (control Group 1, i.e., 35.72 μm) (P = 0.01). Conclusion: Within the limitations of the study, it can be concluded that polished lithium disilicate showed better clinical outcome than polished yttrium tetragonal zirconia, though the evaluated data was statistically non-significant.

19. A Retrospective Assessment of the Predictors of Difficulty in Laparoscopic Cholecystectomy
Santosh Kumar Sharma
Abstract
Aim: To develop and validate a scoring method to predict difficult and very difficult LC preoperatively. Material & Methods: This is a retrospective study conducted in the Department of General Surgery, NMCH, Patna, Bihar, India.  Patients who underwent Laparoscopic Cholecystectomy in the Tertiary Care Centre by the same surgeon involved in the study. The study involved patients who were operated over a period of 12 months (July 2019 to June 2020) Results: Among different demographic and history related factors, the only history of hospitalization and ERCP±Stenting were significantly associated with the difficulty of the procedure (p<0.001).The lone biochemical factor i.e. raised ALP, also showed a significant association with the level of difficulty (p=0.001). The diagnostic accuracy of the score for the prediction of very difficult procedures was 97.1%. Conclusion: The proposed scoring system was effective and can help diagnose preoperatively into easy, difficult and very difficult cases.

20. Post-Operative Pain Management in Elective Laparotomies in a Tertiary Care Facility: A Prospective Observational Assessment
Alok Kumar Niranjan, Sanjeet Kumar
Abstract
Aim: Prospective analysis of post-operative pain management in elective laparotomies in a tertiary care centre in Bihar region. Methods: This prospective observational study conducted in the Department of General Surgery, Jannayak Karpoori Thakur Medical College and Hospital  Madhepura, Bihar, India, India from  August 2020 to July  2021. 100 patients who underwent elective laparotomy were provided details about the study and method. Informed written consent was obtained. Detailed history of the patient, condition, surgery performed, analgesics used were documented. NRS score was calculated. Results: A total of 100 patients were included among which 41(41%) were female and 59 (59%) were the male patients. Most common mode of analgesia used was combined analgesia. Injection tramadol 50 mg in 100 ml normal saline with continuous epidural bupivacaine in 48 (48%) patients followed by injection diclofenac AQ 75 mg in 100 ml N.S with continuous epidural in 32(32%) patients. Pearson’s Chi square test for intravenous and epidural analgesics: value-2.31, df (degrees of freedom)-8, p=0.88. By the second day 53(53%) patients were shifted to oral analgesics most common drug used was the combination of aceclofenac, paracetamol and serratiopeptidase. 7(7%) patients were on transdermal patch on post-operative day 2 and 2 (2) patients were on diclofenac patch and 5 (5%) patients were on fentanyl patch. The use of analgesics was shifted from parenteral to oral route from post-operative day 2. All the patients received analgesics within 6 hours of surgery. NRS score was recorded for all the 100 patients on postoperative days 1, 2 and 3. Severity of pain gradually reduced from postoperative days 1-3 with the use of various analgesics. Conclusion: Multimodal analgesia was used in most of the patients for management of postoperative pain combined analgesia was better mode of pain management method than a single analgesic. For 48(48%) of patient’s opioid with epidural was used for post-operative pain and for 32 (32%) of patients NSAID with epidural was used for post-operative pain.

21. A Comparative Clinic-Radiographical Assessment of the Stability and Crestal Bone Loss of Implants Placed using Osseodensification and Traditional Drilling Protocol
Rashmi
Abstract
Aim: To evaluate and compare the stability of the implant and the loss of crestal bone in the implants placed using OD drilling and traditional drilling technique. Material & Methods: The study was approved by institutional review board. The study was conducted in the department of prosthodontics, to evaluate and compare the stability and crestal bone loss (CBL) of implants placed using traditional and OD drilling technique. It was conducted over a period of 1 year in the Department of Maxillofacial Surgery, Narayan Medical College & Hospital, Sasaram, Bihar, India. In the present study for Group II, the mean values of implant stability RFA1 (baseline) and RFA2 (6 months) was 67.4 Ncm and 65.8 Ncm, respectively, however, in the Group I, the mean values RFA1 and RFA2 are 54.3 Ncm and 69.2 Ncm. In the intragroup comparison the data was found to be statistically significant at 4 months for Group II and at 8 months for Group I (P < 0.05). Conclusion: Within the limitations of this study following conclusions were drawn: there was no statistically significant difference in implant stability between the traditional drilling and OD drilling (P < 0.05). On comparison of crestal bone levels between OD and traditional drilling, no statistically significant difference was found between the two groups (P < 0.05).

22. A Histomorphological Study of Preterm Human Placenta and Term Human Placenta in North Indian Population
Mohd Arshad, Neha Gupta, Mohd Tabrej Alam, Durgesh Singh, Shashi Prabha Singh, M. Tariq Zaidi
Abstract
The status of the fetus in-vivo is based on the function of placenta which is responsible for the hoemostasis and nutrition of the fetus. The current study is intended to evaluate the morphometric and histological changes in the placenta collected during preterm and term birth. The study arranged 80 placentas from JNMCH, AMU, Aligarh, Department of Gynecology and Obstetrics. 2 groups were made based on the age of the placenta. Those placentas which are of upto 36 weeks were made into assigned to one group while placentas collected during full term birth (37 weeks to 40 weeks) were classified as another group. The samples of placenta were fixed in a 10% solution of saline and formol. The general characteristics specially the morphological properties were evaluated. The weight, decidual region, the diameter of the cord of the term placenta were all determined and were observed that these were significantly higher than those of preterm placenta. Whole thickness tissue blocks were managed from each placenta and each sample was processed with paraffin. Haematoxylin-eosin and Van Gieson stains were utlized for preparation of 1 mm thick slices for observation in light microscopy. It was observed that each sample had 200 villi in total, under high power field microscope. The villi of term placentas almost completely lacked microvilli and syncytial buds. The evaluation of the placenta also revealed that the number of capillaries increased with increasing gestational age. The number of syncytial knots, vasculosyncytial membrane, fibrinoid necrosis, significantly increased in the group formed of term placentas. On the contrary, it was also observed the villi revealing cytotrophoblastic cells and Hofbauer cells significantly reduced.

23. Maternal and Fetal Complications during Cesarean Section Done in Second Stage of Labour
Chaudhary P, Madan A, Sharma S, Kaur J, Singh D
Abstract
Introduction: Second Stage of labor  begins with complete dilatation of cervix and ends with fetal delivery. Prolonged second stage of labour is diagnosed if the duration exceeds 2 hrs in nullipara and 1 hr in multipara, when no regional anaesthesia is used. Cesarean section at full dilatation, with or without attempt at operative vaginal delivery, is a more challenging surgical procedure than a first stage cesarean section and carries a higher rate of maternal morbidity. Material & Method: This Prospective Study was conducted in the Department of Obstetrics and Gynaecology, BNMCC, GNDH, Government Medical College, Amritsar from March, 2020 to March, 2021. Inclusion Criteria: All women at term and preterm with singleton pregnancies willing to participate. Exclusion Criteria: Patients refusing / not willing to participate in the study, Multi fetal gestation, History of Previous caesarean section, Abnormal Placentation e.g. Vasa previa and complete placenta previa, Active genital herpes infection, Cervical Cancer, Prior Myomectomy. Duration of labor & Indication for LSCS was noted. Maternal and fetal complications were observed. Results:  In our study 150 women, who underwent cesarean section during second stage of labour, were selected according to exclusion and inclusion criteria. Most of women (66%) were referred patients and rest were booked patients who ended up in cesarean section. It was observed that labour dystocia was most common indication seen in our patients followed by fetal distress. Majority of them were referred patients, and from rural background who did not have proper antenatal checkup. Conclusion: This implies good antenatal checkup and recognition of complications can reduce the risk of prolonged second stage of labour. Difficult access to the healthcare facility, delay in referring the patient to the tertiary care centre increases the rate of cesarean section in second stage of labour. Timely  decision for cesarean section and neonatal facilities can reduce the number of fetal complications.

24. To Study the Efficacy of Quiz as Teaching Learning Method in First Phase MBBS Students in Biochemistry
Shivkar Rajni Rajendra, Gulajkar Supriya Rameshrao, Panchbudhe Sanjyoti Ankur, Naphade Manoj
Abstract
Background: Focus of medical education is to prepare students for lifetime patient care. It has been progressively recognized that didactic lectures are considered by students as an inefficient mode of learning due to one way flow of content. Learning could be shifted from teacher centric to student centric where learner would take active part in the learning process. Quiz could be one of such tool, which not only assesses what one knows, but also enhances later retention, a phenomenon known as the testing effect. So, objectives of our study were to study the utility of quiz in Biochemistry as a teaching learning method and to get perception of quiz by students through feedback. Methods: Present comparative cross sectional study was carried out on First phase MBBS students of batch 2020-2021. Quiz participants and students who attended the quiz were considered as Group A (n=120). While Students who were absent for the quiz were considered as Group B (n=30). Statistical analysis was done using unpaired ‘t’ test using GraphPad Prism 5 software. Results: We have seen improved performance of Group A as compared to Group B. Average scores of Group A and Group B students were 12.00 ± 1.60 (mean ± SD) and 7.03± 2.30 respectively. The p value for comparison was <0.001 which is highly significant. Interpretation and conclusions: Quiz can be used as a learning tool for students in Biochemistry to enhance their active participation and increase their interest in the subject which would motivate them to acquire knowledge about core and applied aspects of subject.

25.The Relationship between Umbilical Cord Arterial PH and Short Term Outcome in Neonates
Malvia S, Jain P, Bhardwaj BK
Abstract
Background: Perinatal asphyxia has been one of the causes of neonatal morbidity and mortality. Morbidity and mortality in asphyxia depends on factors like duration and severity of asphyxia. The present study was carried out to find out the relationship between umbilical cord arterial blood pH with severity of birth asphyxia and short-term outcome in the neonates. Materials and Methods: hospital based prospective study carried out at NICU of tertiary care hospital attached to medical college in southern Rajasthan from January 2020 to December 2021. All term neonates born by Caesarean Section (C/S) to a high risk mother were included into the study. An umbilical cord arterial blood gas analysis was done for these neonates. All the neonates with congenital anomalies and those who were not willing to give consent were excluded. All the admitted newborns were followed till discharge/death for final outcome. The correlation umbilical arterial cord blood pH and outcome was analysed statistically. Result: During the course of the study, 78 babies who included for the study. Out of the 78 babies, 77 babies were discharged live and one baby died. On the basis cord blood ph level, the babies were divided into two groups. Among whom 34 had pH less than 7.25 (group 1) and 44 had pH more than 7.25 (group 2). Comparison of short term outcomes between two groups were as the following: need for resuscitation 9 vs. 1 (P = 0.004), NICU admission 8 vs. 2 (P = 0.012), convulsion 2 vs. 1 (P = 0.41), encephalopathy 3 vs. 1 (P = 0.19), delay to start oral feeding 5 vs. 1 (P = 0.04). Conclusion: An umbilical cord arterial ph of less than 7.25 could be associated with unfavourable short term outcome in neonates with perinatal asphyxia.

26. Impact of Human Milk Bank on Morbidity, Mortality, Duration of Stay, and Feeding Characteristics of Neonates in a Tertiary Care Centre NICU
Bhuvnesh Kumar Bhardwaj, Keshav Bansal, Dhaval Bhatt, Harshida Vagadoda
Abstract
Objective: To study the impact of Human Milk Bank on morbidity, mortality, duration of stay, and feeding characteristics of neonates in a tertiary care Centre NICU. Material and Methods: An observational prospective case control single Centre study. All details of the newborns under study were recorded on a structured proforma designed for this study. PDHM was issued from mother milk bank on the request of doctor working in the NICU. All collected data was analyzed with standard software. Statistical analysis of the data was done with Chi-square test, Student t-test with assistance of qualified statistician. P value <0.05 was considered statistically significant. Results: A total of 140 neonates were included in the study was divided into study group (71) and control group (69). There was no statistical significant difference between study and control groups in terms of gender and weight. Most common indication of PDHM supplementation was insufficient milk production (73.2%). Majority of neonates on PDHM feeding (67.8%) tolerated the feed well, 20% had abdominal distention and 11.2% had vomiting. In study group 12% babies develop NEC, whereas 5.7% babies in control group developed NEC. In the study group 19.7% babies developed clinical features of septicemia whereas in control group only 10.1%. The difference was statistically significant (P-0.047). 67 babies (94.3%) in study group were discharged. Conclusion: Babies fed on PDHM had no significant risk for developing apnea, hypoglycemia and overall complications in comparison to those fed on mothers own milk. Also there was no significant difference in terms of weight recovery time, duration of stay in the hospital and final outcome amongst babies who were fed on PDHM and who were fed on mothers own milk. Hence it is concluded that PDHM can be a safer alternative when mothers own milk is insufficient or unavailable. Also it provides the benefits of mother’s milk along with eliminating the demerits of formula feed in a resource limited setting like ours. “Breastfeeding is nature’s health plan.”

27. Our Experience with Management of Foreign Bodies of Ear Nose and Throat During COVID Pandemic at Andaman Nicobar Islands
Meena Maruthi Ohal, Sattien Arun Maran
Abstract
Background: COVID pandemic during 2020-21 had affected the management of foreign bodies in the ear, nose and throat, as aerosol spread of the virus created a risk to the treating ENT surgeon. Due to tremendous increase number of COVID positive patients affected the healthcare system and the specialists alike. Following the COVID guidelines to use personal protective equipment, face shield, goggles and N-95 masks during the simple procedures performed in OPD or the operation theatre made the procedure cumbersome to the surgeon. The number of patients with foreign bodies attending the Hospital had increased during the pandemic as other private hospitals were not taking up these patients. Aim: To analyze the foreign bodies in the Ear, Nose and Throat encountered during the COVID pandemic of 2020-21 and to formulate a clinical guideline to prioritize the cases to avoid COVID spread. Materials: A Prospective study with 330 patients who attended the Department of ENT, ANIIMS Hospital, Port Blair with foreign bodies in the Ear, Nose and Throat were included. It was an observational study following the STROBE Epidemiology checklist was used for strengthening the Reporting of Observational Studies. All the patients who attended the ENT Department with history of foreign body in the ear, nose, throat and trachea-bronchial tree with or without COVID-19 positivity were included. COVID protocol was adhered to in selection and treatment of the patients. Results: 330 patients were included in the study, among them 177 (56.63%) male patients and 153 (46.36%) female patients. The male to female ratio was 1.15:1. The age distribution showed that children aged between 01 to 10 years constituted to 128 (38.78%). Patients with foreign bodies in the Ear were 131 (39.69%), foreign bodies in the nose were 87 (26.36%) and foreign bodies in the throat were 110 (33.33%). Total foreign bodies removed under General anesthesia were 64/330 (19.39%) patients in this study. Among these 31/110 (28.18%) patients had foreign bodies in the throat, 24/87 (25.28%) had in the nose and 09/131 (06.87%) had in the ears. Conclusions: The present study which analyzed all the foreign bodies in the Ear, Nose and Throat that were encountered during the COVID pandemic of 2020-21 and successful removal of foreign bodies was undertaken without any surgeon turning COVID positive as strict protocol was formulated and followed with international clinical guidelines to prioritize the cases to avoid COVID spread and at the same time give satisfactory treatment to the patients.

28. An Evaluation and Analysis of Immune Markers in Patients with Chronic Rhinosinusitis
Hanish Haneefa, Nazeem Abdul Majeed
Abstract
Background: Chronic rhino sinusitis (CRS) is a common inflammatory disease resulting in marked decrease in quality of life of patients and affected their socio-economic life. Multiple factors like inborn immunity of the airway epithelium, reduced barrier function, altered mucociliary mechanism, and fabrication of plenty of antimicrobial peptides played important roles. Followed by activated involvement of eosinophils, mast cells, and innate lymphoid cells (ILCs) contributed to the chronic inflammatory changes and directly activated adaptive immune cells like T and B cells.  Studies are required to identify such specific immune factors which drive the CRS pathogenesis process and this study is an attempt in that direction. Aim: To find the role of immune markers in the pathogenesis of the chronic inflammation in chronic rhino sinusitis (CRS) and to identify other markers of immune system pathways in patients with CRS. Materials: 83 patients diagnosed with CRS based on the Clinical features and X-ray and CT scan findings were divided into two groups; CRSsNP- 42 patients (50.60%) and CRSwNP- 41 (49.39%) patients. Results: The mean levels of secreted IL-6, 10, 13, 21 and IFN- γ of both the groups of CRSwNP-41 patients and CRSsNP-42 patients’ tissue levels correlated well (p> 0.05 for all). CRSwNP patients had mean tissue levels of IL-2, 4, 5, 7, 12, 17 and 22 greater than mean tissue levels of patients with patients CRSsNP. Conclusions: The two types of CRS: CRSsNP and CRSwNP are heterogeneous diseases at molecular level as the values of cytokines liberated due to respective inflammation are different. Hence the inflammatory state of CRS was also highly heterogeneous, with mixed profiles of type 1, 2 and 3 inflammations seen within classical CRSsNP and CRSwNP phenotypes. Estimation of cytokines levels is emerging as an important diagnostic and prognostic tool in the management of CRS disease.

29.An Observational Study of Association between Serum TSH Levels and Thyroid Malignancies
Abraham Joseph, Kunhambu V, Dinulal P P, Nabeel MV
Abstract
Background: The prevalence of malignant thyroid malignancies is 5-6% and treatment strategies are almost entirely based on the FNAC results and ultrasound examination. This study is focused on the levels of preoperative serum TSH levels and its co-relation with thyroid malignancies and their clinical presentation and management. Aim: To study the association between the serum levels of Thyroid stimulating Hormone (TSH) and thyroid malignancies. To study the clinical profile of thyroid malignancies and laboratory results. Materials: A cross sectional observational study involved 60 patients who were diagnosed with suspected Thyroid Malignancy at the department of General Surgery in ACME Pariyaram. A descriptive analysis of the clinical presentation was done and correlation of preoperative serum TSH level and final histopathology were done. Inclusion criteria, patients with thyroid swelling, Thyroid profile and serum TSH measured before any medical interventions and al the patients included were euthyroid. Patients who were not euthyroid were excluded. Informed written consent was taken and history was taken. FNAC, surgical management, and histopathology follow up was done. Results were arranged and analyzed statistically. Results: Among the 60 patients 51 were females (85%) and 09 (15%) were males and the female to male ratio was 5.6:1 (Table 1). The mean age of the patients was 42.70±12.82 and ht means TSH levels was 1.97 ± 1.16mlU/L; range from 0.5 to 5.0 mIU/L range taken as the lab standard. The mean duration of the disease noted was 26.6 ± 20.59 months. 07 patients had malignancies; FNAC was positive for papillary carcinoma in 05 (08.3%), 01 (01.7%) follicular carcinoma, 01 (01.7%) medullary carcinoma. Conclusions: Thyroid malignancies though have varied clinical presentation, the commonest was MNG. The association of preoperative serum TSH levels with malignancy showed a statistically significant correlation (P=<0.01) between higher TSH levels and malignant swellings.

30.Anatomical Characteristics of Foramen Ovale and Foramen Spinosum in Dry Human Skulls
Dubbaka Ravikul Manuva, Naveen Kumar Edulla
Abstract
Introduction: Cranial base holding important foramina through which various important neurovascular structures transmits from extra cranial to intracranial region. The anatomical knowledge of these foramina plays a vital role in surgeries to cranial base. This study was designed to assess the morphology and morphometry of foramen ovale and foramen spinosum in the dry human skull of Deccan plateau region. Material and Methods: A total of forty-four adult human dry skulls of unknown gender were evaluated for morphological parameters like shape, incidence of foramen of Vesalius, presence or absence of foramina and morphometric parameters such as anteroposterior (AP) and medio-lateral (ML) diameter of foramen ovale and foramen spinosum were measured. Results: Oval shaped FO (56.81% right & 52.27% left) and round shaped FS (65.9% right & 61.36% left) on both sides were recorded. The AP diameter was 8.09 mm on right and 7.57mm on left and ML diameter was 5.54mm and 5.81mm for FO. The AP diameter was 2.74mm on right and 2.61mm on left and ML diameter was 1.64mm and 2.04mm for FS. The mean difference of morphometric parameters was statistically significant (p<0.05). Discussion and Conclusion: The comprehensive knowledge on anatomy and developmental variations of foramen ovale and foramen spinosum has great importance in surgical interventions at the base of skull, and sex determination in medico legal procedures.

31.Comparative Efficacy of Topical Tacrolimus 0.03% Ointment Vs. 0.005% Fluticasone in the Treatment of Sub Acute Eczema
Anil Kumar, G. Reena Prasoona, Sowmya Alahari, K. Raj Kumar
Abstract
Introduction:  Eczema is a clinical and histological pattern of inflammation of the skin seen in a variety of dermatoses with widely diverse aetiologies. The present study was undertaken to compare the efficacy of Topical Tacrolimus 0.03 % ointment vs 0.005% Fluticasone in the treatment of sub-acute eczemas. Materials and Methods: This is a prospective, randomized; open-labelled interventional study carried out at tertiary care hospital included 100 patients with sub-acute eczemas. They were allocated at a ratio of 1:1 to either Tacrolimus 0.03% Ointment group A or Fluticasone 0.005% ointment group B. Group A subjects were treated with Tacrolimus 0.03% Ointment once daily for 4 weeks follow up at 1 week, 1 month & 3 months Another Group B patients were treated with Fluticasone 0.005% ointment once daily for 4 weeks follow up at 1 week, 1 month & 3 months. Results: Percent reduction of Eczema assessment severity index score at the end of 4 weeks was 83.70±1.73 in group A and 79.10±2.17 in group B  (P<0.001) which was significant (P<0.001). Adverse effects were observed in 10 % of patients in Group A and 18% of group B after 4 weeks, with a major side effect of Folliculitis (8%) in Group B which was not significant. Conclusion: We concluded that Patients who received Tacrolimus 0.03% ointment had better clinical improvement in terms of efficacy, and was better tolerated in terms of side effects compared with Fluticasone 0.005% ointment.

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