A critical care bundle comprises a group of interventions which have been shown to improve outcome, which are achievable, measurable and not yet performed in the majority of patients. The principle is that the benefit to a patient of the whole care bundle is greater than the sum of the parts.

Introduction: Secondary involvement of the central nervous system (CNS) by direct extention or hematogenous metastasis is a common complication of systemic cancer. Adenocarcinoma was the most common metastatic deposit in the present study, along with a few rare cases such as metastasis from hepatoblastoma, follicular variant of papillary carcinoma, and germ cell tumor of the testis. Aim: This study was undertaken to know the incidence of secondary deposits in the brain. Age, sex, location in the brain, and type of malignancy were studied. In rare cases, immunohistochemistry was done to assess the exact histopathological confirmation. Material and Methods: This study was carried out on a retrospective basis in our institution from March 2012 to July 2015. During the 3 year period, a total of 33 metastatic tumors were diagnosed based on hematoxylin and eosin stained sections of formalin-fixed and paraffin-embedded biopsy specimens. Results: Out of 33 metastatic deposits, adenocarcinoma was the most common secondary deposit in the CNS. In addition, we encountered metastatic deposit from the follicular variant of papillary carcinoma, germ cell tumor from the testis, and hepatoblastoma. Immunohistochemical study was done in a selective cases. Conclusion: This study highlights rare metastatic deposits in the CNS.

Context: Despite the continuous improvement of dialysis technology and pharmacological treatment, mortality rates for dialysis patients were still high. A 2-year prospective study was conducted at a tertiary care hospital to determine the factors influencing survival among patients on maintenance hemodialysis. Patients and Methods: A total of 198 patients with end-stage renal disease who were started on hemodialysis (8 h/week) were studied. Follow-up was censored at the time of death or at the end of the 2-year study period, whichever occurred first. Statistical Analysis Used: The Statistical Package for the Social Sciences version 15.0, Stata 8.0, MedCalc 9.0.1, and Systat 11.0 were used for data analysis. Results: Of the 198 patients studied (mean age 49.95 ± 14.55 years, 68.3% male and 50.56% diabetics), 107 died with an estimated mortality rate of 54.04% at 1 year. On an age-adjusted multivariate analysis, female gender and independently predicted mortality. In Cox analyses, patient survival was associated with female sex, low serum albumin, native kidney urine output, presence of left ventricular hypertrophy (LVH) (ejection fraction <50% on two-dimensional echocardiography), compliance to dialysis, and interdialytic weight gain independently predicted mortality. There was no significant difference between diabetes and nondiabetes in relation to death (Relative Risk = 0.214; 95% CI = 0.005-10.02, P = 0.005). Conclusions: This study revealed that mortality among hemodialysis patients remained high mostly due to sepsis and ischemic heart disease. Patient survival was better with good native kidney urine output, adequate serum albumin, absence of LVH and ejection fraction >50% on two-dimensional echocardiography, compliance to dialysis, and interdialytic weight gain <3 kg. Comprehensive predialytic nephrology care prevents mortality and improves survival among hemodialysis patients.

Background and Aim: Septicemia is a serious complication following percutaneous nephrolithotomy (PCNL) and can occur in spite of sterile preoperative urine culture and prophylactic antibiotics. The aim of the study was to analyze the utility of cultures of midstream urine (MSU), renal pelvic urine, and crushed stones for prediction of urosepsis. Materials and Methods: We performed a prospective clinical study in consecutive patients undergoing PCNL between April 2015 and October 2015. The samples collected for culture and sensitivity (C and S) were (1) MSU one day before surgery, (2) Urine from pelvicaliceal system during percutaneous puncture, and (3) Stone fragments collected during the procedure. All the patients were monitored during the postoperative period for symptoms and signs of urosepsis. The data collected were divided into 3 main groups, i.e., MSU C and S, pelvic urine C and S, and stone C and S, and were analyzed to determine association with urosepsis. Results: A total of 83 patients were included. The MSU C and S was positive in 10.8%, pelvic C and S in 13.7%, and stone C and S in 30.1% patients. Twenty patients had systemic inflammatory response syndrome (SIRS) and 3 patients had septic shock. Out of the 20 with SIRS, 17 cases were stone C and S positive, 6 were pelvic urine C and S positive, and 2 patients had positive MSU C and S. Conclusion: Stone C and S is a better predictor of potential urosepsis than pelvic urine and MSU C and S, which often fail to grow stone colonizing bacteria. We recommend routine collection of stone for C and S for the diagnosis and management of urosepsis after PCNL.

Objectives: To evaluate the effect of concentration and influence of reservoirs on the gingival mucosa of patients submitted to at-home bleaching with 10% and 35% carbamide peroxide (cp). Materials and Methods: A total of 20 patients were submitted to home bleaching with a 10% cp gel for 2 h/day for 3 weeks and 35% cp gel for 30 min/day for 3 weeks (n = 10). The custom-made mouth trays were made with a reservoir on only the left side and cut anatomically 1 mm beyond the gingival margin. Smears of the gingival mucosa were obtained by the exfoliation cytology in liquid media technique before (control), immediately after, and 30 and 45 days after the treatment. The samples were processed in the laboratory and evaluated for inflammation. Statistical analysis was carried out by McNemar test, two proportions test, independent paired t-test, and Wilcoxon test with a level of significance of 1%. Results: The presence of a reservoir in the custom tray resulted in an increase of inflammation immediately after the bleaching procedure. No significant differences were found in the degree of inflammation between the two groups at different period of observations. (P > 0.01). Conclusion: Ten percent and 35% cp bleaching gel caused gingival inflammation immediately after the procedure and persisted until 45 days after the bleaching treatment. The use of a reservoir in the custom tray for home bleaching resulted in higher rates and higher intensity of gingival inflammation.

Aim: To analyze the oral bleeding episodes in individuals with hereditary blood coagulation disorders (HBCDs). Materials and Methods: Information regarding oral bleeding episodes (gingival, tongue, lip, cheek, and palate) as well as treatment rendered for those individuals was extracted retrospectively from the records of the local hemophilia society. The obtained data was analyzed from the pediatric dentist's point of view. Results: Gingival bleedings were relatively high (85.5%) compared to other tissues (14.5%). Most of the gingival bleedings were found in individuals aged between 6 and 12 years (58.2%), corresponding to the period of mixed dentition, whereas soft tissue bleedings were high in the younger age group (<6 years) (57.7%). On observing the primary treatment rendered, 55.5% and 47.3% of individuals who needed extractions and scaling, respectively, required factor infusion. Conclusion: The present study highlights the importance of anticipatory guidance in this group of individuals and reminds the hematologists/physicians to work in collaboration with pediatric dentist/dentist, to improve the oral health-related quality of life in HBCDs.

Objective: To determine the denture cleanliness and denture hygiene habits in complete denture wearers in Nizamabad's population. Materials and Methods: In this study, a self-administered structured questionnaire was developed to know the attitude of the patients from the Department of Prosthodontics regarding denture hygiene. The study sample consisted of a total of 200 subjects, which included 110 (55%) males and 90 (45%) females. Results: Nearly half of the subjects cleaned their dentures daily (70%). Participants from the younger age group and who had been wearing dentures from 0 years to 5 years maintained a better frequency of cleaning. The majority of these subjects used brush and toothpaste for denture cleansing. After seeing the condition, approximately half of the dentures were rated as dirty (48%). Around 41% of patients were not satisfied with their cleansing methods and 78.5% of the patients claimed that their dentists did not inform them about how to clean their dentures. Older dentures tended to be dirtier than the newer ones (P = 0.0001) and had a higher incidence rate of accompanying denture stomatitis (P = .0001). Conclusion: The poor condition of complete dentures seen in the population was mainly due to irregular cleansing habits and also less usage of cleansing solutions. Dentists should give proper instructions regarding the maintenance of denture hygiene.

Context: Potentially malignant disorders such as leukoplakia and erythroplakia are often associated with dysplastic changes that have an increased risk for malignant transformation. Vascularity could have a role in the transformation of potentially malignant disorders to oral squamous cell carcinoma. Aims: The present study was aimed to assess the mean vessel area (MVA) of the blood capillaries in different grades of epithelial dysplasia by histomorphometric analysis, which could aid in predicting the malignant transforming potential as well as prognosis of potentially malignant disorders. Materials and Methods: The study consisted of 30 histologically proven epithelial dysplasia cases categorized into three groups of mild, moderate, and severe epithelial dysplasia based on the World Health Organization (WHO) 2005 criteria. Paraffin-embedded tissue sections of 3-4 microns were stained with Masson's trichrome. Morphometric analysis of MVA was done using image analysis software 6.0. Statistical Analysis Used: Statistical analysis was done using the software Statistical Package for the Social Sciences (SPSS) 20.0. The mean and standard deviation of the three groups were analyzed using Kruskal-Wallis analysis of variance (ANOVA) test. Pairwise comparison was done using Mann-Whitney U test. P value <0.05 was considered to be statistically significant. Results: The MVA was highest in severe epithelial dysplasia (7575.16) followed by moderate (4070.4) and mild (4014.29) epithelial dysplasias. A high statistical significance was observed on comparison of the three groups (P 0.0004). On pairwise comparison, a statistical significance was observed between mild and severe epithelial dysplasias (P 0.0032) and moderate and severe epithelial dysplasias (P 0.0002). Conclusions: The MVA was increased as the grade of dysplasia progressed. This suggests that altered vascularity could play a role in the progression and malignant potential of dysplastic lesions and also in assessing the prognosis.

Context: Vitamin D has been associated with bone health and it is well understood that vitamin D deficiency leads to various disorders. 1,25(OH) ₂ D maintains oral health through its effect on bone and mineral metabolism and innate immunity. Aims: The aim was to evaluate the association between serum levels of 25-hydroxyvitamin D [25(OH)D] and 1,25(OH) ₂ D and periodontal disease risk and also the effect of low serum levels on periodontal surgical outcomes in periodontitis patients. Settings and Design: The study was designed as a case control clinical trial that was conducted to identify the risk of low levels of serum vitamin D in progression of the disease and also in periodontal healing process. Materials and Methods: A total of 51 chronic periodontitis patients and 33 periodontally healthy subjects were included in the study. The serum levels of both 25(OH)D and 1,25(OH) ₂ D were determined. Parameters, such as plaque index, bleeding on probing (BOP), clinical attachment level (CAL), and pocket depth (PD), were measured at baseline, 6 weeks, and 6 months to assess the periodontal status. Statistical Analysis Used: The data were analyzed using chi-square test, independent sample t-test, repeated measures analysis of variance (ANOVA) with post hoc Bonferroni test. Results: There was statistically significant association between serum 1,25(OH) ₂ D level and periodontal health status (12.73 ± 4.19 vs. 20.36 ± 5.50). The subjects with chronic periodontitis showed low serum levels of 1,25(OH) ₂ D, and individuals with severe deficiency have shown less clinical attachment gain and PD reduction when compared with minimal deficiency patients after the surgery. Conclusions: Analysis of these data suggest that low serum 1,25(OH) ₂ D level seem to be associated with chronic periodontitis and 1,25(OH)2D deficiency negatively affects the periodontal surgical treatment outcome.

Benign osteoblastoma of the patella is a rare tumor. Majority of the tumors occur in the spine, femur, and tibia. Osteoblastoma presents as a diagnostic dilemma due to clinical similarity with other benign bone forming tumors. Histopathological examination is the main stay of diagnosis and has good prognosis.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon and benign vascular disorder characterized by angiomatous, pink-red papulonodular lesions located on the scalp, neck, and peri and post-auricular areas. The exact cause of ALHE being unknown, several etiological factors such as trauma, insect bites, hyperestrogen states, and immunological factors have been implicated in the pathogenesis of the disease. A few cases of pregnancy-related ALHE have been reported in the literature. In this study, we report three cases of ALHE, which were aggravated during the first trimester of pregnancy, along with their management. The relation between ALHE and pregnancy is discussed with a brief review of the literature.

Dentin dysplasia (DD) is an autosomal dominant disorder affecting both the deciduous and permanent dentitions. The affected individual has normal size, shape, and color of crown, and pattern of eruption but abnormally short and stunted roots leading to premature exfoliation. DD is classified into two types: DD type I - radicular DD and DD type 2 - coronal DD. We present a case of DD type Ia in a 12-year-old boy, highlighting the clinical, radiographic, and histopathologic features with a brief note on treatment and preventive care.