Amongst the ballistic missile politics, bitcoin slump, another predominant issue that needs serious redressal not only at international level, but also even at the national and domestic level is Climate Change. Climate Change is for real causing fundamental threat to health with both short and long-term effects. Melting glaciers, rising sea levels, global warming, severe drought, frequent wildfires are some of the effects of the problem. According to National Research Council, evidences of the effects of climate change have been found in tree rings, coral reefs, ocean sediments, and layers of sedimentary rocks. These evidences discloses the fact that the current warming is occurring ten times faster than the average rate of ice-age-recovery warming.^[1] The causes of climate change are increased human activities of deforestation, industrialization, burning fossil fuels, carbon emissions by motor vehicles leading to rise in greenhouse gases. To address the problem of climate change at the international level, on 5th October 2016 the conditions for entry into force for Paris Agreement was laid. The Agreement entered into force on 4th November 2016 in accordance with its Article 21, Paragraph 1, which read as: “This Agreement shall enter into force on the thirtieth day after the date on which at least 55 Parties to the Convention accounting in total for at least an estimated 55 per cent of the total global greenhouse gas emissions have deposited their instruments of ratification, acceptance, approval or accession.” Till date, 185 state parties ratified out of 197 signatory parties in the Paris Agreement. Under the United Nations Framework Convention on Climate Change (UNFCCC) which aims to reduce greenhouse gas concentration at a predefined level with the support of the global community, Paris Agreement has successfully helped to remind the state parties that climate change is a common challenge wherein the global community has to identify, mitigate, strengthen and adapt their national and domestic policies. The emergent issue of climate change sees no territorial boundaries. The global community must wake up to the warning that this ‘tragedy of the commons’ should be recognized, mitigated and collective action towards sustainability should be observed at the international, national and domestic level.

Context: Cartridge based nucleic acid amplification test (CBNAAT) is a diagnostic tool which detects both Mycobacterium tuberculosis and its resistance to Rifampicin. Bihar has a high burden of tuberculosis but the data regarding the total and multidrug resistant TB (MDR-TB) burden is lacking. Aims: To quantify the burden of TB and Rifampicin resistance presenting in a DOTS plus site hospital of Bihar using CBNAAT. Setfngs and Design: A hospital based cross sectional study. Methods and Material: All the suspected patients coming to the department of TB & chest at our institute were made to deposit there site specific samples for CBNAAT. The test result (detected/not detected, Rifampicin sensitive/ resistant) were fed into Microsoft Excel and analysis was done using Epi-info statistical software. Statistical analysis used: Descriptive statistic was used. Results: Out of 4096 suspected patients, 958 were positive by CBNAAT between February 2016 to November 2017. 772 cases (80.58%) were sensitive while 186 (19.41%) were resistant to Rifampicin. It was pulmonary TB in 710 patients and extra pulmonary TB (EPTB) in 248 patients. Among males, 539 (20.4%) were sensitive while 124(4.7%) were resistant to Rifampicin and 233 (16.1%) and 62 (4.3%) respectively in females. 16-35 age group had the highest TB burden. Patna district has the highest TB burden. Conclusions: Bihar harbors a significant burden of TB patients including the drug resistant cases. Utmost attention of TB control programme and prompt treatment is need of the hour.

Background: Tuberculosis is a major public health problem throughout the world. Tuberculosis has long been known as a disease of young people but many elderly (? 60 years of age) are now falling ill with TB. Several factors associated with aging result in delayed diagnosis and initiation of treatment. Aim of the Study:

1. To detect the prevalence of tuberculosis (TB) and drug resistant TB (DR-TB) among elderly.
2. To compare the role of molecular methods with conventional tests in diagnosis of tuberculosis in elderly patients.

Materials and Methods: Clinical samples received from patients were subjected to-

1. Smear microscopy using Zeihl Neelsen (ZN) & Fluorescent staining
2. Xpert MTB/RIF assay (GeneXpert test)

Results: Acid fast bacilli (AFB) were detected in 17.80% (73/410) of samples. Elderly contributed to 11.40% (73/640) of total TB cases. Gene Xpert detected M tb in 34 smear negative samples also which constituted 46.57% (34/73) of total positive. AFB detection by Gene Xpert test was the highest followed by Fluorescent & ZN staining. Majority of the samples were sensitive to rifampicin. Conclusion: Elderly TB patients have high smear negativity. Gene Xpert test allows early detection of smear negative and drug resistant cases. It may be offered as the first choice investigating modality. Early diagnosis and initiation of specific anti tubercular therapy will have a major impact in reducing the disease burden and achieving our goal of “TB Free India”.

Background : Anorectal malformations [ARM] are common neonatal surgical emergencies. They can be treated either by staged procedure or by single-stage procedure. In the present study, we have performed single-stage surgery of ARM in both male and female. Materials and Method: Retrospective review of cases of ARM operated over 3 years in the Department of Paediatric surgery at a tertiary care centre from January 2015 to December 2018 was done. In this study, we compared the results of single stage repair of Anorectal malformation (category1) with that of staged procedure performed earlier (category 2).In male babies 43 patients were operated by primary PSARP (posterior sagittal anorectoplasty) and remaining 11 by primary APP (abdomino-perineal pull through) procedure. Out of 65 female patients, PSARP was performed in 39 (60%) cases of recto vestibular fistula, ASARP in 23 (29.2%), Primary Abdomino-perineal pull-through in 4 (6.1%) cases of common cloaca. The result of this procedure was compared with that of staged procedure. (Category 2) Result : Mean post- operative hospital stay in category 1 was 11 days and 32 days in category 2. Mean duration of surgery in category 1 was 1hour and 15 minutes and 3 and half hours in category 2 that included initial colostomy, PASRP or APP and colostomy closure. In category 1, 41 (75.9%) cases had stool frequency 3- 5 per day while in category 2, 20 (51%) patients had the same frequency at the age of three years which was found to be statistically significant (P value? 0.001). Similar findings were observed in female patients. Conclusion : Single-stage surgical repair of Anorectal malformation in both male and female patient are reliable and can be safely performed with advancement of surgical expertise and better anaesthetic support with few exceptions. Early results are encouraging. However, long term study is required for its justification.

Background: Asthma is one of the most common chronic disease affecting millions of population worldwide. It is a chronic respiratory disease characterized by increased airway inflammation and hyper-responsiveness. Several studies shows that deficiency of Vitamin D (25-OH) is related to occurrence of pulmonary diseases as well as reduced lung function and increased airway inflammation leading to poor results in asthmatic patients. In context to India, there were fewer studies which have evaluated the relationship between vitamin D (25- OH) and pulmonary function and its role in asthma. Thus, the present study was undertaken to study the role of vitamin D deficiency or insufficiency in mild to moderate asthmatic patients. Aims: To assess the serum vitamin D(25-OH) level in mild to moderate asthmatic patients. Material & Methods: The present study included 100 subjects of either sex with age group of 15 - 40 years. They were divided into two groups. Group A (control) include 40 healthy individual, and Group B include 60 asthmatic patients based upon GINA guidelines. Pulmonary function test and Vitamin D analysis were performed in both the groups. Results: The study showed that serum vitamin D level was significantly decreased in asthmatic patients when compared with the control group (p<0.01). Conclusion: Vitamin D deficiency is relatively frequent in asthmatic patients and there is a significant inverse relationship between serum vitamin D and severity of asthma symptoms. Therefore, measuring serum levels of vitamin D should be considered in the routine assessment of asthmatic patients. It may serve as a marker of asthma severity.

Introduction : Tibial spine avulsions are intra-articular fractures .There is avulsion of ACL insertion on the tibial plateau and it behaves like a torn ACL.^[1],[2] It was first described by Poncet in 1875.The treatment modality has undergone a great change since then. Arthroscopic fixation is taking place of nonoperative treatment.^[3]

Introduction : Ascorbic acid has role in wound healing, collagen formation, enzymatic action, anti-oxidants, hormone action, synthesis of neurotransmitters etc. Thyroid hormone regulates a wide range of genes and plays a crucial role in the regulation of mitochondrial oxidative metabolism. Disorders of thyroid hormones, overt hyperthyroidism and hypothyroidism represent opposite clinical conditions. Increased concentrations of thyroid hormones result in increased production of large quantities of reactive oxygen species which enhance oxidative stress, even low concentration of thyroid hormone ie hypothyroidism has been associated with increased oxidative stress, but is controversial. This study was aimed to correlate the ascorbic acid level in patients of thyroid disorder. Material and methods : The blood samples of 150 patients were collected after the analysis of thyroid profile. The samples of the patients in the study were categorized in three groups- euthyroid, subclinical hypothyroid and overt hypothyroid based on free T3, free T4 and thyroid stimulating hormone (TSH). The ascorbic acid was estimated using 2,4-Dinitrophenyl hydrazine method. Result : The ascorbic acid levels in the patients of hypothyroid disorder was ranging from 0.43-2.60 mg/dl Conclusion : There was no correlation observed between ascorbic acid and hypothyroid disorders in the study. The dietary intake of ascorbic acid in the study group must be adequate.

Background: The non-vascularised fibular graft is unique as fibula regenerates at the donor site .The literature on regeneration of fibula after extracting non- vascularised fibular grafts in children is limited. Material and methods: This was retrospective study. Analysis of fibular regeneration at the donor site following extraction of non-vascularised fibular graft was done. All these patients were evaluated minimum two years after the index procedure. The radiological regeneration quantified in percentage by calculating the area of both operated and normal limb. Results: 28 patients were included in this study. The average patient age was 9.38 years. There was no pain or neuromuscular deficit in the operated limb .The mean follow up of 39.8 months. The continuity of the fibula in the longitudinal was restored in 25 cases.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia diagnosed in the general population. The study was conducted at tertiary care centre-IGIMS, Patna to study clinical profile of hospitalized AF patients and various management strategies employed in these patients. A total of 132 patients with AF were enrolled in the study. The most patients fall below 50- year of age group. Elderly (>60 years) age group comprise 24% of AF patients. There was marginal female predominance - female (53.8%) and male patients (46.2%) with ratio of 1.2: 1. Rheumatic heart disease (RHD) was the most common etiology of AF (59.8%), followed by coronary artery disease(CAD) (11.3%), hypertension (7.5%) and cardiomyopathy (6%). Rheumatic etiology commonly presented below 50 years but CAD and hypertension presented after 50 years. Palpitation was the most common presentation (88%), followed by dyspnea (56%), chest pain (40%), pedal edema (32%) and hypotension (28%). The rate control strategy was adapted in 76 % cases. Stroke prevention strategy was oral anticoagulation (warfarin or acitrom) in 63.6% cases and antiplatelets in 30.3% patients. The beta blockers (59%) were the most common pharmacological treatment followed by amiodarone (39.9%), calcium channel blockers and digoxin (31.8% each). Novel oral anticoagulants (NOAC) were used in 10 patients of non- valvular origin. Heart failure (49.2%) was most common complication noted in AF patients followed by angina (25%), hemoptysis (18.2%) and stroke (7.5%). Among valvular involvement, most patients have mitral valve involvement. Out of 79 cases, 88% have mitral valve involvement ranging from mild to severe variety in isolation and combinations with other valves. Commonest cause was mixed lesion (mitral stenosis with mitral regurgitation). AF with valvular heart disease has shown maximum LA enlargement, normal LV Ejection fraction and predominance LA clot as compared to non valvular AF.

Introduction : Suturesare used to fixed the graft in pterygium surgery not only time-consuming process but also lead to local complications such as discomfort, scarring, granuloma formation, or infection. A Plasma-derived products fibrin glue may produce possible hypersensitivity reactions, post-operative foreign body sensation. In this study a simple method was described for achieving conjunctival autograft adherence during pterygium surgeryusing autologous blood as a bio -adhesive to avoid potential complications associated with the use of fibrin glue or sutures. Aim of this study was to know the outcome of pterygium surgery with limbal conjunctival autograft without sutures or fibrin glue. Material and methods: It was a prospective interventional study on 40 eyes of 40 patients who presented with primary pterygium to our outpatient department fulfilling the inclusion and exclusion criteria.Post-operative Examination done on Day- 1, end of 1st,2ndand 4th week then after 3rd and 6thmonth. On each visit assessment was done for Graft displacement, Retraction, Inflammatory reaction,Graft failure, Discomfort, Recurrenceand Success rate was assessed.Data was collected and analysed. Results : Outof 40 patients, age of patients ranges from 15 to 73years, male was 30 and female pt. was 10 and right eye was involved in 24 cases and left eye in 16 cases. average surgical time was 18.50±2.00 min.successrate was 95%, one case had graft retraction and one had graft displacement. Conclusion : This is the simple technique for pterygium surgery with comparable success rate, cost effective, quick and also prevent potential adverse reactions encountered with the use of foreign materials.

Background: Breast pain (mastalgia) is a significant issue within the general population warranting increased investigation, awareness, and treatment. This study is being performed to study role of ultrasound and to evaluate Thyroid Stimulating Hormone (TSH) and Prolactin levels in our patient population with the complaint of mastalgia . Methods: This was a prospective observational study in which 100 patients of mastalgia were included. Pregnant and lactating women, known cases of breast cancer, patients with palpable breast lumps and those with breast abscesses, women on antidepressants, antihypertensives and oral contraceptive pills were excluded from the study. Ultrasound findings and serum TSH and Prolactin levels were assessed in all patients included in the study. Those with hypothyroidism and hyperprolactinemia were treated with thyroxine and bromocryptine respectively and the response to treatment observed. Results: Mean age of women in study was 35.37 years. Most of them (90%) were multiparous. Ultrasound findings included 57% normal results, 32% benign cystic disease of the breast, 6% small fibroadenomas, 4% duct ectasia and 1 case of filariasis of breast. Out of 100, 18 women (18%) had hypothyroidism (TSH >5). 8 (8%) women in our study with mastalgia had elevated serum prolactin levels. Decrease in mastalgia in 15 women with hypothyroidism and in all women with hyperprolactinemia was observed after appropriate therapy. Conclusion: Sonological findings can be the baseline while starting the treatment in patients with mastalgia. Our study strengthens the association of thyroid dysfunction and raised prolactin levels with mastalgia. Women with mastalgia should be screened for hypothyroidism and for raised serum prolactin levels because simple correction of these changes may result in clinical improvement.

Purpose: To evaluate the strength and pattern of the relationship between visual field (VF) sensitivity and macular thickness as measured by Humphrey 24-2 & 3D-OCT ( Topcon 3D OCT-1 Maestro) Material & Method: 269 eyes of 200 consecutive patients in which 100 normal eyes, 50 Glaucoma suspect, 50 early Glaucoma and 69 eyes of Advance glaucoma were enrolled in this prospective, non-randomized and observational study. The Relationship between macular segmented layer along with visual field sensitivity in terms of mean deviation (MD) were evaluated with linear and nonlinear regression models, and the coefficient of determination (R2) was calculated. The association between Macular Thickness/VF was described by bivariate Pearson correlation coefficients. Result: there was no significant difference between mean Inner ring and central ring OCT device in four different groups however the outer ring was the only macular parameter that could significantly differentiate between four groups. The correlation between perimetry and macular thickness shows a very weak, negative, statistically not significant correlation in normal, Glaucoma Suspect and Early Glaucoma group but as the Mean deviation (MD) increased macular thickness decreases, but this correlation is not statistically significant. However there was significant correlation between the mean deviation (MD) and Macular Thickness in the Advanced Glaucoma Group Conclusion: Macular thickness as measured by OCT showed statistically significant correlations with glaucoma. Macular thickness measurements made with OCT have usefulness in the clinical assessment of glaucoma.

Fracture of the femur is one of the common traumatic injuries encountered in the emergency departments. Satisfactory pain relief prior to subarachnoid block for surgical interferenceis desirable for patient’s co-operation. Such relief can be provided byuse of systemic analgesics, local anaesthesia, or femoral nerve blocks. This study was conducted on 60 patients after randomly allocation into two groups of 30 patients each. Group A has been received the femoral nerve block with 20 ml of 0.5% bupivacaine 15 minutes before the subarachnoid block while group B has been received intravenous fentanyl at 0.5^g/kg single shot & intravenous dexmedetomidine 1 ^g/kg over 15 minutes before the subarachnoid block and concluded that femoral nerve blocks produces a more intense analgesia with fewer side effects than systemic analgesic.

Tuberculosis ( TB ) is a common cause of morbidity and mortality worldwide. Extra-pulmonary tuberculosis is commonly associated with immune-compromised patient and is difficult to diagnose. Tuberculous liver abscess is rare even in endemic areas of Mycobacterium tuberculosis. An isolated tuberculosis is extremely rare and accounts for 0.3% of new TB cases. Here we report a rare case of isolated tuberculous abscess of liver in a young adult in an immune-competent female of 26 years.

Endodontic management of nonvital tooth with wide-open blunder-buss apex has long presented a challenge. Mineral Trioxide Aggregate (MTA) apexification is an promising alternative to multiple visit calcium hydroxide apexification . This case report presents single step MTA apexification with collagen barrier and custom made gutta percha condenser followed by intracanal composite resin reinforcement

Traumatic dental injuries are a trivial dental issue affecting teeth and their supporting structures. This case report describes a clinical case of dental trauma in an 18 year old girl which resulted in laceration of upper lip along with affecting the dentition in the form of lateral luxation, subluxation, uncomplicated and complicated crown fracture in her anterior maxillary and mandibular dentition. The management included suturing of laceration followed by repositioning of teeth by digital pressure and stabilization of teeth with the help of a semi rigid splint, root canal treatment for tooth 11, 21 and 31 followed by removal of splint when the teeth were reportedly asymptomatic and composite build up to re-establish the aesthetics for the patient. The follow up was done up to 1 year and no periapical pathology or complications were observed and the patient was relatively asymptomatic thus indicating successful intervention.

Traumatic injuries of teeth are common among young children. However when traumatic injuries involves a permanent tooth, its different scenario all together. From esthetic and functional management to complete makeover as that of natural appearance gives a challenge to the dentist. This paper describes the clinical sequence of rehabilitation of fractured crown of right side of maxillary central incisor. Follow up visits were regularly scheduled and both clinical and radiographic examinations were done to evaluate the prognosis of the treatment done.

Ultrasound guided -Erector spinae plane block (US-ESP)has been reported till now along with general anesthesia for postoperative pain management. We report here using the same as an independent technique for excision of a tumour present on right anterolateral chest wall.

Appendiceal mucocele is a rare entity which occurs due to cystic dilatation because of abnormal accumulation of mucus in the lumen of the appendix. Patients are often diagnosed incidentally during abdominal surgery for other causes. When the patient is symptomatic,the most common symptom of appendix mucocele is pain in the right lower quadrant of the abdomen. Mucocele may present as acute or chronic appendicitis. This is a study done on a 52-year-old female for whom surgical intervention for ovarian tumor was planned, but who instead underwent laparotomy for appendicular lump. Radiologic assessments showed large sized right adenexal cystic lesion with mild enhancing wall thickening infero-medially. The test for serum tumor markers showed normal level of CA-125. The patient underwent a laparotomy and appendicular lump was found. We conducted frozen section biopsy of mass for confirming malignancy before performing staging surgery. The result of frozen section biopsy confirmed appendicular lump. Subsequently total hysterectomy and B/L salpingo-oopherectomy were performed. Appendicular Mass was removed. It should be taken into consideration that the possibility of malignancy is low in post menopausal woman with normal CA-125 Level. Instead of performing staging surgery,it is appropriate to carry out surgery based on result of intra-operative frozen section biopsy so that we were able to avoid unnecessary surgical procedures. Gynecologists should routinely consider this disease in the differential diagnosis of right lower dumbbell abdominal cysts. Eleven percent to 20% of mucoceles are caused by mucinous cystadenocarcinomas.

Baclofen is known to cause neurotoxicity in patients with renal dysfunction. Here Authors reported a case of rapidly developed Myoclonus after few doses of Baclofen. These symptoms were abated after stopping Baclofen. Authors concluded that, in patients who developed sudden onset Myoclonus, drug history should be reviewed in detail, and Baclofen toxicity {especially in patients with end stage renal disease (ESRD)} should be kept in mind along with drugs which are known to cause the Myoclonus.