Indian Journal of Applied-Basic Medical Sciences
The Journal is inviting original research work, articles, original review articles, case reports, and short communications of interest to medical fraternity. This journal is published online and print format since 1999 one of oldest and pioneer journal of Gujarat India. This has remained, pioneer leader, inspiration and guide of so many Indian journals which arise later on all over across the country.
A Diagnostic Role Of Fine Needle Aspiration Cytology And Its Histopathological Correlation In Malignant Breast Lesions
BACKGROUND: Breast lesions in women are most common, which require pathological confirmation by FNAC and histopathological correlation. Recent approach to breast masses is to get cytopathological diagnosis before surgery. Aim of study: To study the diagnostic role of Fine Needle Aspiration Cytology and its histopathological correlation in Malignant breast lesions. METHOD: The study was conducted in department of pathology; AMC MET Medical College, Maninagar, Ahmedabad, Gujarat, India, for duration of 1 year from January 2019 to December 2019. During the study period, 40 cases of fine needle aspiration cytology of malignant breast lesions were performed. Formalin fixed (10%), resected specimens were received and were prepared for histopathological diagnosis. The cytological and histopathological slides were stained, studied, analyzed and correlated. RESULT: During the study period 918 FNAC were undertaken of which 40 FNAC were of malignant breast lesions. Correlation of FNAC with histopathologic tissue was possible in 20 cases, for which FNAC data was available. 99% were from female and 01% was from male patients. The age of patient ranged from 26 to 95 Years. CONCLUSION: FNAC is useful in diagnosing malignant breast lesions, as this procedure is easy, cost effective and less time consuming.
Copyright (c) 2022 Krishna Kariya, Hetvi Mistry, Jayshree M. Shah https://creativecommons.org/licenses/by-nc-nd/4.0
Histopathological Study of Prostatic Lesions
Background: Prostatic disease is responsible for significant morbidity and mortality in men throughout the world. Prostate cancer and benign prostatic hyperplasia are the two major prostate diseases that increase with aging. Histopathological examination of prostatic lesions has been gold standard for the final diagnosis. Objective: This study was carried out for histopathological evaluation of prostatic lesion and its correlation with the clinical data. Materials and Methods: This study included all types of prostatic specimens received in department of Pathology, AMC MET Medical College, Ahmedabad from January 2018 to December 2018. Relevant clinical data was recorded. Results: The most common age group presenting with prostatic lesion was 60-69 years and the most common presenting clinical symptom was difficulty in micturation. The frequency of benign and malignant lesions was observed to be 91% and 9% respectively. Amongst the benign lesions all lesions were Benign Prostatic Hyperplasia (BPH) with or without associated pathological lesions. All the malignant lesions were adenocarcinoma of prostate and were graded according to Gleasons scoring system. Predominant malignant lesions (40%) revealed Gleasons score 9. Strong correlation of S.PSA level with prostatic adenocarcinoma was seen in our study Conclusion: Histopathological evaluation seems to be gold standard for diagnosis, prognosis and management of prostatic lesions. S.PSA level has strong correlation with the risk and outcome of prostatic cancer.
Copyright (c) 2022 Harsha Gajjar, Aashka Shah, Biren Parikh, J.M. Shah https://creativecommons.org/licenses/by-nc-nd/4.0
A Diagnosis Of Salivary Gland Lesions By Fine Needle Aspiration Cytology And Its Histopathological Correlation
BACKGROUND: Salivary gland swellings can result from tumors, an inflammatory process or cyst. Fine needle aspiration cytology(FNAC) is a diagnostic tool for evaluating neoplastic and non neoplastic swelling of salivary gland. The objective of this study was to evaluate the diagnostic accuracy and sensitivity and specificity of fine needle aspiration cytology in numerous salivary gland lesions and with its histopathological correlation. METHOD: The study was conducted in department of pathology; Amc met medical college, Ahmedabad, Gujarat, India, for duration of 1 year from January 2019 to January 2020. During the study period 44 cases of fine needle aspiration cytology of salivary gland lesions were performed. Formalin fixed (10%), surgically resected specimens were received and prepared for histopathological salivary gland lesion diagnosis. RESULT: During the study period 998 FNAC were undertaken of which 44 FNAC were of salivary gland swelling. Correlation of cytology from FNAC with histopathology tissue was possible in 9 cases, for which FNAC data was available. 62 % were from male and 38 % were from female patients. The age of patient ranged from 8 to 85 Years. 15 cases were benign swellings. 8 cases were malignant, 7 cases were cysts and 14 cases had an inflammatory etiology. CONCLUSION: Fine needle aspiration cytology (FNAC) is highly sensitive and specific procedure for diagnosis of salivary gland lesions.
Copyright (c) 2022 Krishna Gajera, .Jalak Patel, Jayshree M. Shah https://creativecommons.org/licenses/by-nc-nd/4.0
Vitamin D Deficiency And Its Effect On Severity Of Asthma In Adult Patients
AIM: This study is aimed to assess vitamin D status in asthmatic patients and to assess the relationship between vitamin D level and asthma severity. INTRODUCTION: Asthma is heterogeneous disease, usually characterized by variable airflow obstruction and bronchial hyper-responsiveness. The world health organization stated that approximately 300 million people have asthma. Recently the effects of vitamin D appear to have regulatory effect on every part of immune system, vitamin D deficiency being linked to an array of immunologically based disease focusing on asthma. METHOD: The present study included 50 patients diagnosed as bronchial asthma. The asthmatic patient group was divided into group A, asthma in between attack and group B, exacerbated asthma, that was again divided in subgroup (I), (II), and (III) mild , moderate and severe exacerbated asthma according to symptoms and FEV1. Serum 25 hydroxy vitamin D3 level in all groups was measured by radio immunoassay method and compared between these groups. RESULT: This study shows statistically significant correlation between vitamin D level and severity of asthma. The mean levels of serum 25 hydroxy vitamin D3 in asthmatic patients are: Group A 28.24 ± 1.35 ng/ml, mild persistent- 22.6 ± 11.5 ng/ml, moderate persistent - 18.33 ± 1.31 ng/ml, and severe persistent - 10.45 ± 1.84 ng/ml. P value is <0.01, which is highly significant. CONCLUSION: Lower level of vitamin D is associated with higher severity of asthma.
Copyright (c) 2022 Sunita j. Solanki, Hemang Suthar, Dhruv Parmar, Bhagyashree Chaudhary https://creativecommons.org/licenses/by-nc-nd/4.0
Management Of Metacarpal Shaft Fracture With Cerclage Wiring And Its Outcome
Introduction: Hand is specialized organ of the body performing complex functions, and it enables a person to earn his livelihood. Various options are there for treatment of metacarpal shaft fractures, in this study we treated patients with cerclage wiring and noted its outcomes. Material and methods: patients who were presented with oblique/spiral fracture of shaft of metacarpal during the study period were treated with cerclage wiring and followed until they were able to return to work. Results: seven patients with eight fractures were treated during the study period. Reduction achieved was good in all patients. We had one late complication of wire breakage and no malunion or non-union occurred. Conclusion: we conclude that cerclage wiring treatment is effective method for treatment of oblique/spiral fracture of metacarpals and a viable and cheap alternative to plate and screw method in low socio-economic patients.
Copyright (c) 2022 Sankit D. Shah, Nilesh B. Ghelani, Arvind Kaushal , Shukan Kapadia, Ashish Hadiyal https://creativecommons.org/licenses/by-nc-nd/4.0
Metformin Induced Vitamin B12 Deficiency Among Patients With Type 2 Diabetes Mellitus.
Objectives:To study the effect of Metformin induced Vitamin B12 deficiency among patients with Type 2 diabetes mellitus (T2DM). Design:Case - control study. Setting:Outpatient clinics of Diabetic Endocrine Research Lab and patients reporting to medicine department of Sheth Vadilal Sarabhai General Hospital ( Smt. NHL Municipal Medical College ) , Ahmedabad, Gujarat .Participants:A total of 240 patients, 100 control group healthy normal and nondiabetic 140 study group with Type 2 Diabetes treated with Metformin and not known with a contraindication for the use of Metformin were approached, given informed consent, and entered the study. .Intervention : Addition of Metformin to Insulin Therapy three times a day. Primary Outcomes :Vitamin B12, Folic acid ,Serum Homocysteine. Results :Compare with control, Metformin Treatment was associated with a mean difference in Vitamin B12 -340.26 and confidence 6.71 ( 95 % confidence interval 27.53 to 40.95 : P= < 0.0001) , and 1 in Folate concentration of - 6.24 and confidence 0.18 ( 95% confidence interval 0.74 to 1.1: P=0.026 ) , and an increase in Homocysteine concentration of 18.97 and confidence 0.93 ( 95% confidence interval 3.83 to 5.69 : P= < 0.0001 ) . In addition, decrease Vitamin B12 and Folate could be explained by the increase in Homocysteine. Conclusion :Metformin increases the risk of Vitamin B12 deficiency and Folate, which results in a modest increase in Homocysteine concentration among patients with Type 2 Diabetes. Vitamin B12 Deficiency is preventable , therefore our findings suggests that regular measurements of Vitamin B12 during long term Metformin treatment should be strongly considered .
Copyright (c) 2022 Ranjita V. Gaur, Dimple Patel, Rohit Zariwala https://creativecommons.org/licenses/by-nc-nd/4.0
Analysing The Clinical Profile Of Influenza A(H1n1) Infected Patients : Oct 2018-Feb 2019, Ahmedabad, India
Introduction: Influenza virus is a common human pathogen that has caused serious respiratory illness and death over the past century. In April 2009, a new strain of Influenza virus A H1N1, commonly referred to as “swine flu”, began to spread in several countries around the world, and India confirmed its first case on 16 May 16 2009. Aim: To study the clinical and epidemiological profile of Influenza A H1N1 cases at the Sheth Vadilal Sarabhai General Hospital, Ahmedabad. Materials and Methods: Clinical epidemiological characteristics of Influenza A H1N1 cases from October2018 to February 2019 were retrospectively, descriptively analyzed using data from isolation ward and ICU at the Sheth Vadilal Sarabhai General Hospital, Ahmedabad. Data were Analyzed using MS Excel software. Results: Out of 86 patients studied 36(51.16%) were males and 34(48.83%) were females. Almost half of the patients(47.67%) were in the age group of 12-40 years. 6.9% mortality was found irrespective of age group of the patients. Majority of the patients had bronchopneumonia(39.53%) and bronchovascular prominence(41.86%), and very few of them had lobar consolidation(8.13%). Here we had 63(73.25%) patients in category B and 23(26.74%) patients in category C, all the patients from category C required Ventilatory support either Non invasive or invasive and 16(34.16%) of category B patients also required ventilatory support.98.83% patients had complaint of fever on presentation. 36.04% had breathlessness, 52.32% had coughing, 39.53% had sore throat, 30.23% had generalised weakness, 5.81 % had rhinitis, shock, blood in sputum,1.16% presented with diarrhea. None of them presented with vomiting which is commonly found in other infections of influenza. 15.11% had hypertension, 10.46% had type 2 DM, 9.30% had IHD,10.46% had COPD, 5.81% had hypothyroidism, 4.65% had tuberculosis, 2.32% had CVA. Out of 42 females 4 were pregnant and 1 was post partum. Almost half of the patients(46.51%) required ventilatory support in their course of hospitalization. Conclusion: On the basis of these findings, it can be safely hypothesized that prevalence of Influenza A H1N1 is high in the younger population, and fever, cough and sore throat are the most common symptoms with which the patients usually present. in course of hospitalization half of the patients required ventilatory support which was weaned off later on. Associated comorbid conditions particularly hypertension, diabetes, and COPD were associated with longer duration of hospital stay and complications. Delay in hospital presentation and longer duration of onset symptoms and administration of treatment were linked to poor outcome. Despite of various efforts of government for awareness , patients fails to seek timely medical advise. Over all if presented early after onset of the symptoms can lead to better outcomes.
Copyright (c) 2022 Khushali L. Patel, Janki Makani , Hardik Patel https://creativecommons.org/licenses/by-nc-nd/4.0
Retrospective Study Of Seroprevalence Of Transfusion Transmissible Infections Among Blood Donors In A Tertiary Care Centre In Thane District Of Maharashtra
Background: Blood transfusion is an integral part of health care as well as one of the life saving procedure. But it carries risk of certain infections, especially viral, known as transfusion transmissible infections (TTIs). Aim: To study seroprevalence of TTIs (HIV, HBsAg, HCV, and syphilis & malaria) in a tertiary care centre in Thane district of Maharashtra. Study design: Hospital based retrospective observational study Methodology: The retrospective study was conducted by accumulating and analysing the data regarding TTIs from blood bank records. Total 20270 blood units were collected in 10 years period from January 2010 to December 2019. All blood units were screened by respective immunological methods. Results: On analysis of the data of all screened blood units, it was observed that 89 tested positive for HIV (0.44%), 463 were positive for HBsAg (2.28 %) & 115 were positive for HCV (0.56%). The seroprevalence for syphilis and malaria was 0.07% & 0.02% respectively. The overall seropositivity was 3.39%. The HBsAg seroprevalence was the highest among the blood donors. Conclusion: In order to avoid wastage of blood units, application of strict criteria for selection and deferral of donors with emphasis on TTIs along with mandatory Nucleic Acid Test (NAT) for screening of TTIs is required.
Copyright (c) 2022 Vaibhav Bari, Shivkumar Kori, Milind Ubale https://creativecommons.org/licenses/by-nc-nd/4.0
Utility Of Blood Indices And Parameters For Differentiating Iron Deficiency Anaemia And Β-Thalassemia Trait By Calculating Various Discriminant Functions
Background: There are various causes of hypochromic microcytic anaemia. Among these β-thalassemia trait and iron deficiency anaemia are much more common in developing country like India. Various parameters obtained on automated haematology analyser by calculating discriminant functions to differentiate iron deficiency anaemia and β thalassemia trait becomes easy and cost effective. Objective: To differentiate iron deficiency anaemia and β-thalassemia trait by blood indices, red cell distribution width and various discriminant functions. Materials and Methods: This study was carried out in the pathology department of AMC MET medical college, L.G.Hospital, Maninagar, Ahmedabad. We had studied 100 cases of differentiating Iron deficiency Anaemia and β-Thalassaemia trait from patient’s case records and laboratory reports irrespective of age and sex over a period of one year (January 2019 to December 2019). Tests for serum iron and ferritin were carried out in individuals showing low hemoglobin (Hb). All the selected subjects’ samples were subjected to blood morphology, comparison of MCV, RBC count, RDW, RDWI, SI, GI and MI. Results: Out of 100 cases seventy five were diagnosed having IDA, whereas twenty five were having β-TT. The RBC count was higher, and MCV was much lower in βTT as compared to IDA. Both groups were subjected to RDW,RDWI, SI, MI and GI. Conclusion: Among various discriminant function calculated from different haematological parameters and blood indices Mentzer index and Srivasta index are more sensitive and specific for differentiating IDA and β-TT.
Red Cell Distribution Width Index (RDWI)
Copyright (c) 2022 Harsha Gajjar, Ankita kacha, Nirja shah, Nanda jagrit https://creativecommons.org/licenses/by-nc-nd/4.0
Prospective Study Of Non Invasive Ventilation In Acute Exacerbation Of Chronic Obstructive Pulmonary Disease
Background: Patients with chronic obstructive pulmonary disease are also prone to exacerbation with progression of their disease, which often lead to hypercapnic respiratory failure. Noninvasive ventilation has shown to have good outcomes in terms of reduction in mortality, reduction in need for intubation and mechanical ventilation and decreased duration of stay in the hospital in patients with COPD Aims & objectives: To study the efficacy of Non Invasive Ventilation, to check demographic profile, to measure the serial arterial blood gas analysis and to monitor respiratory status in patients with acute exacerbation of chronic obstructive pulmonary disease. Material & methods: A total of 50 patients were included in this prospective cross-sectional study. Detail history, clinical examination was done. Arterial blood gas analysis and laboratory parameters were studied before and after non-invasive ventilation. Results: 86% of patients belonged to 46-75 years of age. 78% of patients were male. 78% of patients were addicted to tobacco in any form. Significant improvement was found in pH, pO2, pCO2 value in arterial blood gas analysis and SpO2 value after four hours of noninvasive ventilation. Conclusion: Noninvasive ventilation is well tolerated in patients with acute exacerbation of chronic obstructive pulmonary disease.
Copyright (c) 2022 Hemang Suthar, Sunita Solanki, Keyur Panasara https://creativecommons.org/licenses/by-nc-nd/4.0
Emerging Role Of Magnesium In Modern Anaesthesia, Analgesia, Obstetrics & Critical Care.
Magnesium is a ancient cation but it can be used successfully as adjuvant to Local anaesthetic agent.iIt can be used successfully in various Surgeries like neurosurgery, cardiac surgery,as induced hypotensive agent,in FESS Surgeries, used for attenuation of pressure response to laryngoscopy& intubation,also to prevent postoperative sore throat.It can be used in critical care,& in obstetrics to prevent Eclampsia.In present article various uses of Magnesium sulfate discussed.
Copyright (c) 2022 Manisha Kapdi https://creativecommons.org/licenses/by-nc-nd/4.0
Correlation Between Weight Of Spectacle And The Contact Area Of Nose Pads With Respect To Standard Alignment
Aim: To understand the co-relation between the weight of spectacle and the contact area of nose pads with respect to standard alignment. Study Design: A cross-sectional study. Method: Parameters such as weight of spectacle, frontal angle of nose and nose pads, splay angle of nose and nose pads and pantoscopic angle, area of nose pads and contact area of nose pads were measured using simple tools such as portable weighing machine and a handmade gauge similar to Fairbanks facial gauge and the correlation between all the parameters was found out. Results: Out of total 75 frames, 42 frames (56%) had no change in contact area with the corre sponding area of nose pads with respect to the parameters including weight of spectacle frontal angle, splay angle and pantoscopic angle in standard alignment of spectacle, while other 33 frames (44%) had a noticeable change in the contact area of nose pads with respect to the cor responding parameters. Conclusion: Difference of 50mm2of area between contact area and area of nose pads is ac ceptable with current trend of frames. Current trend of light weight frames and lenses has giv en ease to alignment as even misalignment does not result into marks. Contact area corre sponding with the area of nose pad play a significant role in distribution of spectacle weight on nose. Mismatch between contact area and area of nose pads will result into skin marks.Ideally, a wearer is happy when standard alignment is achieved with respect to facial measurements.
Copyright (c) 2022 Hardee Punjabi, Usman Memon, Kinnari Kalaria https://creativecommons.org/licenses/by-nc-nd/4.0
A Study Of Early Enteral Feeding Versus Nil By Mouth In Case Of Resection Anastomosis Or Perforation Primary Repair
Background ; A period of starvation (“nil by mouth”- NBM) is common practice after gastrointestinal surgery during which an intestinal anastomosis has been formed. So Early Entearl Feeding requires scrutiny in the term of indications ,success and failure to give benefit to patient. Methodology; The study is carried out on in patients admitted in municipal general hospital of Ahmedabad . A total of 34 patients of intestinal resection anastomosis and perforation primary repair were included in the study and data were collected in the prescribed performa consisting details of patient’s history , clinical findings, operative findings, post operative course and complications, and outcome. Results ; Observation and analysis of the data of present series was interesting and important aspects were compared with standard series .Wound Infection was Common Complication in both group .Morbidity and Other Complications were significantly low in early Enteral feeding Group Patients. Conclusion; Early enteral feeding is safe, effective, feasible and cost effective in post operative patients of resection and anastomosis or perforation primary repair.
Copyright (c) 2022 Krunal D. Chandana, Sameer G. Parikh, Jay B. Pandya https://creativecommons.org/licenses/by-nc-nd/4.0
Observational Study Of Demographic And Management Protocols Of Intestinal Obstruction In Tertiary Care Centres Of Urban Population
INTRODUCTION: Intestinal obstruction is frequently encountered in differential diagnosis of patients presenting with a acute abdomen. Even with an early diagnosis bowel obstruction still represent some of the most difficult problems that surgeons face with regard to optimal timing of therapy and appropriate management in different type of bowel obstruction. AIMS AND OBJECTIVES: To study the various modes of presentation, importance of early diagnosis and management of patients , the incidence of different complications during treatment and their management in tertiary care centre of urban population. MATERIALS AND METHODS: This study was conducted for a period of 2 years with patients admitted from 01/ 07/ 2017 up to 30/06/ 2019 with a sample size of 50 patients in L.G. hospital, Ahmedabad .Present study was prospective, observational, cross-sectional study. OBSERVATIONS AND DISCUSSION: Out of 50 patients, 70% were males and 30% were females, more commonly in young patients (11-20 yrs age). Most common presenting cause of intestinal obstruction is subacute intestinal obstruction which is 20 % and these cases were managed conservatively. Conservative approach was helpful in 38% of cases due to their early presentation and subacute type of obstruction most commonly. Primarily operative approach after initial resuscitation were 32% of total cases with indications like acute presentation with tenderness, abnormal peristalsis like absent or hyperperistalsis, fever, irreducible or palpable lump, ultrasonography finding of peritonitis etc. Most common complication encountered was wound infection 35% of operated cases. Mortality was 4 % occurrence in present study. CONCLUSION: Of the 50 cases of intestinal obstruction in our study adhesions and bands are the common cause to produce intestinal obstruction. Koch’s abdomen is also increasingly encountered in etiology of intestinal obstruction as stricture and it is related to poor socioeconomic status of study population in present study. Hernia related obstruction were higher in early twentieth century but decreasing nowadays. It suggests that planned hernia repair can avoid this complication. With better understanding of etiology due to advanced diagnostic ailments mortality rate is decreasing.
Copyright (c) 2022 Aakash G. Rathod, Shashikant V. Umaraniya, Jaykumar J. Mandanka, Zeel U. Khandla, Dhaval V. Patel https://creativecommons.org/licenses/by-nc-nd/4.0
A Comparative Study Of Coloading And Preloading With Balanced Crystalloids For Prevention Of Post-Spinal Hypotension In Patients Undergoing Elective Caesarean Section
Background Spinal anesthesia is the most common anaesthetic technique for cesarean delivery due to its rapid onset, a dense neural block, little risk of local anesthetic toxicity and minimal transfer of drug to the fetus, as well as little risk of failure of block However incidence of hypotension is one of disadvantages of this technique because of sympathetic blockade. Conventionally, crystalloid preloading has been used to prevent spinal anaesthesia induced hypotension, but it has shown varying results. Therefore, focus is on crystalloid coloading for prevention of spinal induced hypotension. Method An observational prospective study was done on 60 parturients undergoing elective cesarean delivery. Patients were randomized into 2 groups who received either crystalloid preloading or coloading. Parameters assessed were, heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, incidence of hypotension and use of mephentermine. Result In this study, there was significant difference in the incidence of hypotension in both the groups, which was more in preload group. Total dose of mephentermine used was also significantly more in preload group. Conclusion We concluded that crystalloid coloading is beneficial to prevent post-spinal hypotension in patients undergoing elective cesarean delivery, as compared to patients receiving preloading fluid.
Copyright (c) 2022 Vidhi A. Gajjar, Darshana R. Shah, Vibhuti A. Shah, Vishwa Shah , Khyati Patel , Hardik Kavar https://creativecommons.org/licenses/by-nc-nd/4.0
Role Of High-Resolution Computed Tomography (Hrct) Temporal Bone In Different Pathologies
Background: - High Resolution Computed Tomography (HRCT), a modification of routine CT, provides a direct visual window in the temporal bone providing minute structural details [1]. Purpose of the present study was to evaluate the normal variations, pathological processes (infections and congenital anomalies) and their extent involving the temporal bone along with their complications on HRCT and to correlate these imaging findings surgically. Aim of the Study: - To find out about the causes, different types of pathologies, male female ratio, and management accordingly. Materials and Methods: - The prospective study included 100 patients who were presented to ENT department of AMC MET MEDICAL COLLEGE with clinically suspected temporal bone or ear pathologies. After detailed clinical examination, the patients were subjected to high resolution computed tomography (HRCT) examination and most of them underwent surgery. The imaging findings were correlated with the surgical findings. The surgical findings were considered as final. Observation and Results: - Of 100 cases examined, we had 93 cases of middle ear cleft pathology (chronic Otitis media, cholesteatoma, soft tissue densities without cholesteatoma) out of which 25 cases were cholesteatoma, 22 cases of soft tissue density in mastoid cavity and 46 cases had middle ear opaque homogenous densities, 4 traumatic cases & 2 congenital pathology. Conclusion: - HRCT is a revolutionary imaging modality that helps in evaluating the distribution features, localization and assessing the extent of various pathologies affecting the temporal bone. The clinical and radiological findings showed a high level sensitivity with intraoperative findings as regards to the presence of cholesteatoma, changes of the ossicular chain and erosion of the lateral semicircular canal. Where criteria for cholesteatoma was soft tissue density in middle ear or mastoid with bony erosion, other cases in this study were 2 congenital cases in which the findings of HRCT were in co-relationship with the intraoperative finding. One case of facial nerve schwannoma was diagnosed on HRCT and confirmed intraoperatively. 4 cases of trauma that stated fracture of longitudinal segment of temporal bone with facial palsy. One needed surgical exploration for facial nerve decompression rest all improved by conservative management. Hence HRCT was very sensitive and specific with various pathologies confirmed intraoperatively.
high resolution computed tomographic scan
Copyright (c) 2022 Hiren Doshi, Karnadev Solnaki, Meeta Bathla, Atul Kansara , Navdeep Chavda, Ritiksha Gajjar https://creativecommons.org/licenses/by-nc-nd/4.0
Cocktail Therapy For Severe Grade 3 And Grade 4 Acne Scars
Introduction : The treatment of severe acne scars is challenging due to the variety in morphology of acne scars and the limitations of the available treatment modalities in their ability to improve scars. Tailored treatment plan must be created in which the patient’s specific types of scars are treated with the procedures that are most likely to improve those types of scars. This study aims to assess the efficacy of combination therapy using subcision, platelet rich plasma therapy, microneedling and spot 50% TCA CROSS in the management of grade 3 and 4 atrophic scars. Method: Twenty one patients with grade 3 or 4 atrophic acne scars were graded using Goodman and Baron Qualitative grading. Subcision, Platelet Rich Plasma therapy, microneedling and spot 50% TCA CROSS were performed in single sitting for three sessions 1 month apart. Grading of acne scar photographs was done pretreatment and 1 month after last procedure. Result: Out of 10 patients with Grade 4 scars, 3 patients improved to Grade 2, 6 patients improved to Grade 3 and 1 patient improved to Grade 1 scars. Out of 11 patients with Grade 3 scars, 1 patient was left with no scars, 3 patients improved to Grade 1 and 7 patients improved to Grade 2. Conclusion: This combination Subcision, PRP, Micro-needling and TCA CROSS, if they are combined and adequately done in proper manner has shown good results in treating severe Grade 4 and 3 scars.
Copyright (c) 2022 Apeksha Merja, Khushbu R. Modi https://creativecommons.org/licenses/by-nc-nd/4.0
Breast Feeding Practices Up To 6 Months In Infants Of Urban Area : A Hospital Based Survey
Introduction : Adopting optimal breast feeding practices is fundamental right to a child’s survival, growth and development. Despite all the potential benefits, only about two fifths of infants 0-6 months of age worldwide are exclusively breastfed. Analysis of data on feeding practices among infants highlights the need for accelerated programming in this area. Present study was aimed to survey feeding practices in infants up to 6 months and observing variables for faulty feeding practices Method :Mother of infants up to 6 months coming from urban area in a tertiary care hospital were interviewed for feeding practices as per preformed questionnaires. If feeding practices were faulty all details regarding various factors leading to same were asked and analysed. Results :Total 518 mothers were interviewed. Only 37% infants were exclusively breast feed, in 29% feeding was started in 1st hour of life and in 25% some form of prelacteal feeds were given. On analysing different factors for faulty feeding practices we found that primigravida, CS delivery, (p<0.001)different myths regarding mother health, baby health, and breast feeding, lack of awareness ,faulty feeding techniques, low socioeconomic status(65%) and poor education(80%) were contributing factors leading to same. There were multiples factors in single mother for faulty feeding practices. Conclusion : Promotion, support and adherence to recommendations of breast feeding is still a gold standard to gain optimal growth and development of children. still health personnel has to do lot more to particularly in field of proper education, explanation and demonstration in field of same. Using newer media technology like mobile and TV will be helpful to spread it fast.
Breast feeding practices up to 6 months in infants of urban area
Copyright (c) 2022 Bijal Shah, Deepa Banker , Shakil Vadaliwala, Aamir Saiyed, Nirmal Zala , Arpit Viroja https://creativecommons.org/licenses/by-nc-nd/4.0
A Comparative Study Between Two Monitoring Techniques Of Awake Blind Nasal Intubations In Cases Of Restricted Mouth Opening
Background: Intubating a patient with limited or nil mouth opening is always a challenge, particularly when fibreoptic laryngoscope is not available. Awake Blind Nasotracheal Intubation[ABNI] is one of the options for intubating such patients. It requires sufficient patient cooperation and comfort. Presently available short acting analgesics and amnesias are excellent choices for this exercise. Aims: The present study was to compare the two techniques while performing nasotracheal intubation: monitoring by spontaneous respiratory movement in rebreathing bag of breathing circuit, with monitoring by EtCO2 tubing attached to breathing circuit while performing [ABNI]. Study Design: This prospective randomized study of 60 patients undergoing Commando surgery with anticipated difficult airway. They were randomly assigned into two groups of 30 each according to the method used for [ABNI]. After complete airway block, Group (A) patients were monitored by spontaneous respiratory movement in rebreathing bag of breathing circuit while performing [ABNI] and while Group (B) patients were monitored by EtCO2 tubing attached to breathing circuit while performing [ABNI]. 20 patients were intubated at first attempt, 6 at second and 4 patients at third attempt in Group A, while 21were intubated at first, 5 at second and 4 at third attempt in Group B. These differences were insignificant. The mean time required for successful intubation was in Group A (2.47± 0.068) min. and in Group B (2.42±0.057) min. which was insignificant. Also, success rate, hemodynamic changes and complications and severity score were comparable in both groups. In conclusion: This study showed that both the techniques in performing [ABNI] are equally valuable. There was no significant difference between the success rates of both techniques.[ABNI] under topical anesthesia may provide an alternative safe method in anticipated difficult intubation, particularly if fiberoptic bronchoscope is not available.
Copyright (c) 2022 Bipin K Shah , Dhara Shah , Hitesh Chelani , Krishna Shah , Sanjay Baldaniya , Indu A Chadha https://creativecommons.org/licenses/by-nc-nd/4.0
Comparison Of Preoperative Rectal Diclofenac And Rectal Paracetamol & Their Combination For Postoperative Analgesia In Paediatric Patients
Background Acute postoperative pain has adverse effects on the various physiological functions of the body.It can cause haemodynamicderrangement,delay in ambulation.In paediatric population it causes anxiety, apprehension & behaviour changes. Aims& objectives We conducted a randomized observational study to compare the efficacy of preoperative rectal diclofenac ,paracetamol & their combination for postoperative analgesia , haemodynamic stability, cost-effective ness, adverse effects in paediatric age group. , Material methods children (2– 12 yrs) undergoing minor surgical procedures were randomly allocated into 3 groups, of 30 patients each group A received diclofenac suppository2 mg/kg post induction . group B received paracetamol 20 mg/kg suppository post induction. Group C received combination of Diclofenac1mg/kg& paracetamol 10 mg/ kg suppositories 1 Pain was assessed by the “Hanallah pain scale” which denotes pain based on 5 parameters, systolic blood pressure, crying, movements, agitation (confused, excited), and complaints of pain. Conclusion We concluded that though , diclofenac sodium , paracetamol & their combination are good postoperative analgesics when given by rectal route in pediatric patients undergoing minor surgeries, combination group provides better analgesia than others when given by rectal route in pediatric patients in terms of haemodynamics, post-operative analgesia, cost-effective ness, adverse effects.
diclofenac sodium- paracetamol combination suppository
Copyright (c) 2022 Shweta Patel, Manisha S. Kapdi https://creativecommons.org/licenses/by-nc-nd/4.0
Choledochal Cyst: A Surgical Experience In Adults
Background: Choledochal Cyst are congenital dilatation of the biliary system including the common, intrahepatic and intrapancreatic bile duct. Cysts have a tendency for complication and high risk of malignant changes over time. Surgery is the treatment of choice. We present our surgical experience of choledochal cyst excision with bilioenteric anastomosis. Methods: A total 78 Choledochal cyst cases that underwent surgery at our hospital were included in the study. Cysts were classified according to the Todani modification of the Alonso Lej classification. Surgical management included Choledochal cyst excision followed by bilioenteric anastomosis in form of Roux-en-Y hepaticojejunostomy. Anastomotic patency and liver function tests were checked in all patients before transanastomotic tube removal. Results: Mean age of study subject was 16.67 years with most cases below 20 years age. Female preponderance was seen among study cases with 56 (71.79%) female and 22 male patients. Most common presenting complaint was abdominal pain 60 (76.92%), followed by jaundice 32 (41.03%), nausea/vomiting in 20 (25.64%), palpable mass 18 (23.06%) and cholangitis with fever in 16 (20.51%) patients. Pancreatitis was observed in 15 (19.23%) patients. Prior history of cholecystectomy was seen in 12 (15.38%) of cases. In 78 cases (Type I, and IVb) included in our study, cyst excision was done followed by Roux-en-Y hepaticojejunostomy. Surgical site infections were reported in 5 cases (6.4%), transient bile leak which was treated conservatively in 1 case (1.25%) and intra-abdominal collections seen in 2 cases (2.5%). No mortality was reported in present study. Malignancy (Cholangiocarcinoma) was seen in 1 case (0.9%). A satisfactory Anastomotic patency and liver function tests were achieved in all patients after 3 weeks of surgery, when transanastomotic tube was removed. Conclusion: Choledochal cyst require an accurate diagnosis and surgical treatment in order to decrease the risk of complications which includes malignant transformation and progression of the disease. Most cases of choledochal cysts are Type I and IV cyst that can be treated with good results by early surgical excision of the cyst followed by bilioenteric continuity preferably by Roux-en-Y hepaticojejunostomy.
Copyright (c) 2022 Premal R. Desai, Hasmukh B. Vora, Mahendra S. Bhavsar https://creativecommons.org/licenses/by-nc-nd/4.0
Anaesthetic Management Of Paediatric Patients Undergoing Scoliosis Surgery In Camp
Background Scoliosis is most commonly idiopathic in origin, but it may be congenital or secondary to neuromuscular disease, trauma, infection or neoplasm. Aim: Aims of surgery is to correct the curvature, improve posture and reduce progression of respiratory dysfunction. Objectives: Perioperative challenges for anaesthetist in scoliotic surgery are to avoid hypothermia, hemodynamic stability, spinal cord monitoring, positioning, induced hypotension, major blood loss, postoperative pain management and intensive care management of patient. Material and method: After taking parenteral consent, 15 paediatric patient’s data were collected who underwent scoliotic correction surgery over 12 days from 1st to 12th January of 2019. Result:Children underwent posterior fusion scoliosis surgery aged (11.2 ± 2.3) years. surgical duration and blood loss were (7.5 ±1.5) hours, (856 ±235) ml respectively. patients were shifted to ICU because of prolonged procedure and major fluid shift. Conclusion: Cardio-respiratory dysfunction may exist as a result of progressive scoliosis or related to coexisting disease, therefore careful preoperative assessment is required. Intraoperative considerations include the prone position, avoiding hypothermia, minimizing blood loss and monitoring spinal cord function. Good postoperative pain control is essential and requires a multimodal approach.
Copyright (c) 2022 Asmita Chaudhary, Ankita Patel, Pooja Patel , Hiral Solanki , Dhara Kakadiya https://creativecommons.org/licenses/by-nc-nd/4.0
Comparison Of Intrathecal Bupivacaine With Nalbuphine And Bupivacaine With Fentanyl In Inguinal Hernia Surgery
CONTEXT Opioids as an adjuvant to hyperbaric Bupivacaine improves perioperative analgesia with minimal side effects. AIM-The aim of the study is to compare the effect of intrathecal Nalbuphine and Fentanyl as adjuvants to hyperbaric Bupivacaine on onset and duration of sensory blockade, onset and duration of motor blockade, two segment sensory regression time, duration of effective postoperative analgesia and incidence of side effects. STUDY DESIGN Prospective observational study ETHICAL ASPECT AND METHODS After all ethical committee clearance and written informed consent, 60 patients of ASA grade I and II undergoing inguinal hernia surgery will be randomly divided into two groups: Group I – 0.5 % Bupivacaine(heavy) 3 ml + Nalbuphine 0.1 ml (1 mg) and Group II – 0.5% Bupivacaine(heavy) 3 ml + Fentanyl 0.5 ml (25 µg). RESULT There was no significant difference in onset ofsensory and motor blockade.Duration of sensory blockade was significantly prolonged (111.42 ± 9.21 min) in Group I than in Group II (102.32 ± 6.45 min) and duration of motor block was significantly extended in patients of Group I(144.65± 15.12 min) than Group II (130.42 ±11.12 min). The duration of effective analgesia was significantly more in group I than group II, with no significant side effects. CONCLUSION-1 mg Nalbuphine in 3 ml 0.5% hyperbaric Bupivacaine in patients increases the duration of sensory and motor block as compared to Fentanyl as well as provides effective analgesia time more than Fentanyl in patients scheduled for inguinal hernia surgery under subarachnoid block.
Copyright (c) 2022 Sushmita K Shah, Drashti A Vavadia, Vidhi A Gajjar, Pinal Bhikadiya , Aishwarya Raj, Vibhuti Shah https://creativecommons.org/licenses/by-nc-nd/4.0
Objective.To Study Clinical Presentation, Management And Result Of Treatment Of 11 Consecutive Case Of Choledochal Cyst Managed From 2012 To 2019. Method.11 Children Presented With Upper Abdominal Pain(72.72%), Jaundice(27.27%), Mass (18.18%). Ultrasonograpy Diagnosed/Suugested In All 11 Children And Magnetic Resonance Cholangiopancreatigram Suggsted In 11 Patient. Result.9 Patient From 11 Children Have Type 1a (Cystic Dilation).2 Patient Have Type 1c(Fusiform Dilatation). Opertive Management Magement Included Primary Complete Excision Of Choledochal Cyst With Roux-En-Y Hepaticodochojejeunostomy(N=9),And Cyst Excision With Hepaticodochoduedenostomy(N=2).There Are 1 Post Operative Death Due To Deep Icterus And Poor General Condition Prior To Surgery.Short Term Follow Up Was Satisfactory In All 10 Patient. Conclusion.Choledochal Cyst Kept In Mind While Evalauting Children With Reccurent Upper Abdominal Pain And Jaundice.Primary Excision Of Choledochal Cyst With Roux-En Hepaticodochojejunostomy Providing Satisfactory Result In Management Of Vast Majoratity Of Case Of Choledochal Cyst In Childhood.
Copyright (c) 2022 M.R. Kushwaha, .Jigar Patel https://creativecommons.org/licenses/by-nc-nd/4.0
Comparative Study Of Oral Submucosal Fibrosis Management With Two Drug Combination (Triamcinolone And Hyaluronidase) V/S Three Drug Combination (Triamcinolone, Hyaluronidase And Placental Extract)
Background: Oral submucosal fibrosis (OSMF) is a precancerous condition of the oral mucosa. It is exclusively occurring among Indians and South Asiatic people. It occurs due to areca nut consumption which leads to inflammation of oral and pharyngeal mucosa and impaired collagen metabolism. These leads to burning sensation in oral cavity, fibrosis of mucosal lining and trismus in OSMF. Aim: Aim of the study is to know the effect of triamcinolone, hyaluronidase and placental extract in different combination in OSMF grade II and III patients. Material& Method: A prospective study of 50 patients was done where they were divided in two groups. First group was treated with combination triamcinolone & hyaluronidase and second group was treated with triamcinolone, hyaluronidase and placental extract. Effectiveness of treatment was measured by visual analogue scale in pre and post treatment period. Mean score value for each symptoms was compared in two groups. Result: At the end of study, burning sensation showed maximum improvement where mean score for first group was 0.92±0.15 and 0.84±0.16 in second group. For mouth opening, mean score of 3.68±0.26 was seen in first group and mean score of 3.24±0.21 was seen in second group. Both of these results show that second group can give better result compare to first group. Overall improvement was better in second group on comparing mean value score. Thus, OSMF patients show significant improvement (<0.05) by medical treatment. in. Conclusion: Maximal improvement seen in the burning sensation followed by other symptoms like colour of oral mucosa, fibrotic band and mouth opening in decreasing order in both the groups. Results were better with three drug combination group. Thus, corticosteroids, hyaluronidase and placental extract shows good improvement in OSMF patients in the form of relief of symptoms.
Copyright (c) 2022 Meeta R. Bathla, Navdeep M. Chavda, Aniket A. Kansara, Hiren G. Doshi, Atul H. Kansara Kansara, Karnadev J. Solanki https://creativecommons.org/licenses/by-nc-nd/4.0
Comparative Evaluation Of Intrathecal Fentanyl And Midazolam As An Adjuvant With Hyperbaric Bupivacaine In Caesarean Section
Background The study was done to compare and evaluate the effects of intrathecal fentanyl and midazolam as an adjuvant with hyperbaric bupivacaine. Material and methodsThis study was conducted on 90 adult female patients aged 18-35 years and ASA grade I/II undergoing elective or emergency caesarean section. The patients were randomly divided into three groups having 30 patients in each group.Group A received 1.5ml 0.5% Bupivacaine plus 0.5ml NS, Group B received 1.5ml 0.5% Bupivacaine with 0.5ml(25 mcg) Fentanyl, Group C received 1.5ml 0.5% Bupivacaine with 0.5ml (2.5 mg) Midazolam. Results There was no significant difference in the demographic data and surgical characteristics in the three groups.Regression to sensory level S2 was significantly prolonged in Group B(257.87±11.95 min) and Group C(252.87±8.66min) as compared to Group A(151.80±8.0min). However, the duration of motor blockade was comparable between Group A, Group B and Group C (P value>0.05). Duration of complete and effective analgesia was significantly prolonged in the Group B and Group C as compared to Group A (p<0.0001). ConclusionPresent study demonstrated that addition of fentanyl (25μg) and Midazolam (2.5 mg) to low dose bupivacaine (7.5 mg) intrathecally in patients undergoing caesarean section improves the quality of anaesthesia and post-operative analgesia with hemodynamic stability and without compromising neonatal outcome.
Copyright (c) 2022 Sejal R. Parmar, Rupal B. Shah, .Kinjal B. Patel , Dhwani V. Soni, Helly S. Mehta https://creativecommons.org/licenses/by-nc-nd/4.0
A Comparative Retro-Spective Study Between Excision Followed By Secondary Healing And Limberg’s Flap Surgery For Pilonidal Sinus
Objective: The study was undertaken to compare the operative time, wound related complications, hospital stay, wound healing time and rate of recurrence between the two techniques of pilonidal sinus surgery. Methodology: This was a comparative retrospective study carried out at a tertiary care hospital of patients operated from June 2017 to January 2019. 40 patients were studied who were equally divided into 2 groups, Group A – excision followed by secondary healing group and Group B – Limberg’s flap group. Results: The outcomes were compared between both groups. In Group A, mean operative time was 28.75 min while in Group B, it was 56.25min. In Group A, 6(30%) patients developed redness and induration of the surrounding skin while in Group B, 2(10%) patients developed discharge from the wound with surrounding redness followed by gaping and other 3(15%) patients had flap necrosis. In Group A, mean hospital stay and wound healing time were 7.15 days and 31.75 days respectively while in Group B, it was 5.75 days and 14.05 days respectively. In Group A, 2(10%) patients had recurrence during the follow up period of 6 months while in group B there was no recurrence. Conclusion: Limberg’s flap surgery has significantly longer operative time and shorter wound healing time as compared to the excision followed by secondary healing but there is no significant difference between both techniques in terms of hospital stay, wound related complications or rate of recurrence. Limberg’s flap may be a good alternative to the secondary healing technique as it has lesser hospital stay and lesser recurrence but a larger randomized study & long term follow up are required for definitive conclusions and recommendation.
Copyright (c) 2022 Mitkumar Rojesara, Jaimish Gajjar, Ankit Bagdai https://creativecommons.org/licenses/by-nc-nd/4.0
Comparison Of Higher Order Aberrations In Keratoconic Eyes With Regular High Astigmatic Eyes
TITLE: Comparison of higher order aberrations in keratoconic eyes with regular high astigmatic eyes. PURPOSE: The purpose of the study is to quantify HOAs by comparing topometric measurement and anterior corneal aberrations in eyes with keratoconus and with regular high astigmatism using placido based topographer OBJECTIVE: To understand and correlate the value and type of aberration in regular as to keratoconic induced astigmatism. STUDY DESIGN: Cross sectional observational comparative study. METHODS: study performed on 30 eyes as per inclusion criteria with mild to moderate keratoconus with astigmatism >3.0D and 30 eyes with regular high astigmatism with astigmatism >3.0D. Topographic indices and the total corneal wavefront were measured by placido’s disc based topographer which measures aberrations using ray tracing techniques. The wavefront aberrations upto fourth order and low, high and total RMS were analysed and compared between these groups. 1 RESULTS: All topometric indices were higher in keratoconus eyes compared to regular high astigmatism eyes (P<0.01). Higher order aberrations in regular high astigmatic eye, oblique trefoil, vertical coma, spherical aberration and secondary astigmatism were -0.10±0.14, 0.01±0.15, 0.23±0.08 and -0.07±0.06 respectively which were significantly higher in keratoconic eyes as compared with regular high astigmatism as to 0.65±0.41, -1.17±0.85, -0.51±0.38 and 0.31±0.32 respectively (P<0.01). All RMS values were found increased in keratoconic eyes (P<0.01). No significant difference was found in lower order aberrations between both the groups (P>0.05). CONCLUSION:- Oblique trefoil, Vertical coma, Spherical aberrations and Secondary astigmatism aberrations may useful for differentiating regular high astigmatism verses irregular high astigmatic eye.
Copyright (c) 2022 Usman Memon, Rennie Kapoor , Zalak Shah, Helly Shah, bnkinn Ari Kalaria https://creativecommons.org/licenses/by-nc-nd/4.0
A Comparative Study Between Open Inguinal Hernia Repair And Laparoscopic Inguinal Hernia Repair
Background:- The word “hernia” derived from Latin term meaning “a rupture”[1]. A hernia is defined as an area of weakness or complete disruption of fibromuscular tissue of body wall can pass through or herniate through defect[1]. In all ventral abdominal hernias, Inguinal hernia is the most common. Inguinal hernia repair is common in surgical practice. In past, the repair was pure open tissue repair which was changed to open prosthetic mesh repair. Laparoscopic groin hernia repair was first performed by Ger in 1979[1]. The laparoscopic approach to hernia repair has since evolved into common and effective procedure. Methods:- The presented study is a prospective, open labelled, randomized, comparative study during a period from May-2017 to March-2019. After taking written consent from the patients were randomly allocated to two groups. Group A, Open hernioplasty were operated with open tension free Lichtenstein’s hernioplasty. Group B, laparoscopic hernioplasty were operated with Transabdominal Preperitoneal(TAPP) repair. Those patients who fulfilled the inclusion criteria are included in study. The mode of presentation, surgical treatment and postoperative complications were all evaluated and compared. Results:- During the study there were no major life threatening complications were reported in either group. The postoperative pain and need of analgesics, presence of surgical site infections were more in Open hernioplasty group compared to laparoscopy group. The time taken for return to routine daily activities and work was earlier in patients treated with laparoscopy compared to open surgery and good cosmetic results. Conclusions:- Laparoscopic hernia repair has better, evolving & effective procedure in recent days compared to open hernia repair in terms of less postoperative complications, early recovery with good cosmetic results.
Transabdominal Preperitoneal repair(TAPP)
Copyright (c) 2022 Mukesh S Suvera, Swastik A Solanki, Prakash M Chaudhary, Ranjitsinh S Darbar https://creativecommons.org/licenses/by-nc-nd/4.0
Management Of Spontaneous Pneumothorax In Er Of A Tertiary Care Hospital – An Observational Study.
Introduction: Pneumothorax is an emergency having high mortality rate. Early recognition and management is crucial. Aim: To study the demographic data, clinical presentation, risk factor and management of cases of spontaneous pneumothorax presenting to ED. Material and Method: Observational analytical study done in 75 patients aged 20-74 years admitted at a tertiary care hospital from April 2018 to March 2019. Patients coming with spontaneous pneumothorx in ER were included in the study. History of trauma and iatrogenic causes were excluded. Result: Details about demographic data, clinical presentation, risk factor and management were recorded. Their main complaints were dyspnoea followed by chest pain. In our study out of 75 patients, ICD was inserted in 63 patients,7 patients managed with simple needle aspiration and 5 patients were treated conservatively. In our study 58 patients were shifted to E Ward/ICU, 8 patients were shifted to CT Sx ward, 5 patients shifted to ward, 3 patients took LAMA and 1 patient expired. Conclusion: In our study we found that SSP (secondary spontaneous pneumothorax) is more common than PSP (primary spontaneous pneumothorax) , majority of patients were male and COPD(chronic obstructive pulmonary diseases) is the commonest cause of the SSP. Intercostal tube drainage is the main mode of management.
Copyright (c) 2022 Rakesh A Avaiya, Harsha D Makwana, Ronak Joshi, Advait Thakor https://creativecommons.org/licenses/by-nc-nd/4.0