University College Of Medical Sciences Research Articles

Biological modalities for treatment of acute spinal cord injury: a pilot study and review of the literature

ObjectiveParaplegia due to traumatic spinal cord injuries is one of the devastating effects of dorsolumbar vertebral fractures. Treatment modalities for such fractures, such as stabilization, have no effect on the neurological recovery. Thus, various pharmacological and biological treatment modalities have been used. The more recent trend of using autologous stem cells from the iliac crest has been used in some clinical trials with varying success. Thus, more clinical studies are required to study the effect of this novel approach MethodsThis is a prospective hospital-based cohort study (level IV). The study was conducted in the Dept. of Orthopaedics, University College of Medical Sciences and GTB Hospital, Delhi from November 2010 to March 2012. Ten patients who had sustained traumatic dorsolumbar vertebral fractures with complete paraplegia were recruited for this study. Under suitable anaesthesia, at the beginning of surgery, 100ml of bone marrow was aspirated. This was centrifuged and buffy coat isolated and then transferred into a sterile tube and sent to the operating room on ice packs. After surgical decompression and stabilization, the buffy coat isolate was injected into the dural sleeve at the site of the injury using a 21G needle. All the patients were evaluated for neurological improvement using the American Spinal Injury Association (ASIA) score and Frankel grade at 6weeks and 3months postoperatively. ResultsThe evaluation at 6weeks showed some improvement in terms of the ASIA scores in 2 patients but no improvements in their Frankel Grade. The other 8 patients showed no improvements in their ASIA scores or their Frankel Grades. The current pilot study has shown that there has been no improvement in most of the recipients of the transplant (n=8). Some patients (n=2) who did show some improvement in their sensory scores proved to be of no significant functional value as depicted by no change in their Frankel Grades. ConclusionThe outcome of current study shows that although this modality of treatment is safe for the patients, it provides no additional benefits on improvement of quality of life among these patients.

Visible Facebook profiles and e-professionalism in undergraduate medical students in India.

Purpose:This study aimed to assess medical students’ presence on Facebook and the extent of their visible activity, with particular reference to online professionalism.Methods:This was a cross-sectional study including all medical students enrolled in the University College of Medical Sciences, University of Delhi, India during the period of the study, which was conducted from 2011 to 2012. After approval by the Institutional Ethical Committee, the full names of all students were obtained from our institution. After creating a fictitious profile, Facebook was searched for students’ profiles, and those found were examined for visible content and unprofessional behaviour.Results:Of 611 students, 477 (78.1%) had detectable Facebook profiles. Out of 477 profiles, date of birth, address, email, phone number, religion, and political views were rarely shared; sexual orientation and relationship status were displayed on approximately one third of the profiles; and an identifiable profile picture (80.3%), field of study (51.6%), and institution (86.2%) were commonly shared . The visible content included friend lists (88.7%), photo albums (36.1%), and associations with diverse groups and pages (97.1%). Five profiles (1.05%) displayed unprofessional content, including one profile photograph depicting alcohol consumption, one association with groups relating to excessive alcohol consumption, two profiles containing sexually explicit language, and one association with a sexist page. Conclusion:Most of our students use Facebook’s privacy settings to hide some content from others. Unprofessional content was rarely visible from a stranger’s profile. However, even when hidden from strangers, unprofessional behaviour is still unprofessional behaviour. As Facebook is an integral part of life, it is important for medical educators and students to understand the implications and importance of e-professionalism. Professionalism curricula should address e-professionalism.

Learning environment assessments of a single curriculum being taught at two medical schools 10,000 miles apart.

BackgroundPerdana University Graduate School of Medicine (PUGSOM), the first graduate-entry medical school in Malaysia, was established in 2011 in collaboration with Johns Hopkins University School of Medicine (JHUSOM), an American medical school. This study compared learning environments (LE) at these two schools, which shared the same overarching curriculum, along with a comparator Malaysian medical school, Cyberjaya University College of Medical Sciences (CUCMS). As a secondary aim, we compared 2 LE assessment tools - the widely-used Dundee Ready Educational Environment Measure (DREEM) and the newer Johns Hopkins Learning Environment Scale (JHLES).MethodsStudents responded anonymously at the end of their first year of medical school to surveys which included DREEM, JHLES, single-item global LE assessment variables, and demographics questions.ResultsRespondents included 24/24 (100 %) students at PUGSOM, 100/120 (83 %) at JHUSOM, and 79/83 (95 %) at CUCMS. PUGSOM had the highest overall LE ratings (p < 0.05) [DREEM 155.3 (SD 21.3); JHLES 116.5 (SD 12.2)], followed by JHUSOM [DREEM 143.3 (SD 22.5); JHLES 111.7 (SD 12.0)] and CUCMS [DREEM 138.5 (SD 22.4); JHLES 106.4 (SD 14.5)]. PUGSOM’s overall high LE ratings were driven by responses in “perception of teaching,” “meaningful engagement,” and “acceptance and safety” domains. JHLES detected significant differences across schools in 5/7 domains and had stronger correlations than DREEM to each global LE assessment variable.ConclusionsThe inaugural class of medical students at PUGSOM rated their LE exceptionally highly, providing evidence that transporting a medical school curriculum may be successful. The JHLES showed promise as a LE assessment tool for use in international settings.

Exploring time of death from potassium, sodium, chloride, glucose & calcium analysis of postmortem synovial fluid in semi arid climate

Estimation of time of death (TOD) with fair accuracy from postmortem changes still remains an important but difficult task to be performed by every autopsy surgeon under different climatic conditions. The environment plays an important role in the process of decomposition and thereby affecting the levels of electrolytes and other biochemical parameters in the postmortem samples. Since, there is limited information available on the levels of these biochemical parameters from semi arid environment, the present study was aimed to explore time of death by analyzing electrolyte, glucose and calcium levels of postmortem synovial fluid collected from samples under such climatic conditions. The synovial fluid samples from two hundred and ten bodies brought to University College of Medical Sciences and associated Guru Teg Bahadur Hospital Delhi for medico-legal postmortem examination, during the period of November 2010 to April 2012, were analyzed for potassium, sodium, chloride, glucose and calcium. Univariate regression analysis of electrolyte concentrations of synovial fluid showed significant positive relationship between time of death and potassium (r = 0.840, p = 0.000). However, there was negative relationship between time of death and sodium (r = −0.175, p = 0.011) & glucose (r = −0.427, p = 0.000) and no significant relationship was found between time of death and calcium (r = 0.099, p = 0.152) & chloride (r = 0.082, p = 0.24) among the samples analyzed.

Near-peer mentoring to complement faculty mentoring of first-year medical students in India.

Purpose:The first year is stressful for new medical students who have to cope with curricular challenges, relocation issues, and separation from family. Mentoring reduces stress and facilitates adaptation. A program for faculty mentoring of first-semester students was initiated by the Medical Education Unit in 2009 at University College of Medical Sciences, Delhi. Feedback after the first year revealed that mentees were reluctant to meet their mentors, some of whom were senior faculty. In the following year, student mentors (near-peers) were recruited to see if that would improve the rate and quality of contact between mentees and mentors.Methods:Volunteer faculty (n=52), near-peers (n=57), and new entrants (n=148) admitted in 2010 participated in the ratio of 1:1:3. The program aims were explained through an open house meeting, for reinforcement, and another meeting was conducted 5 months later. At year-end, a feedback questionnaire was administered (response rate: faculty, 28 [54%]; mentees, 74 [50%]).Results:Many respondent faculty (27, 96%) and mentees (65, 88%) believed that near-peer mentoring was useful. Compared to the preceding year, the proportion of meetings between faculty mentors and mentees increased from 4.0±5.2 to 7.4±8.8; mentees who reported benefit increased from 23/78 (33%) to 34/74 (46%). Benefits resulted from mentors’ and near-peers’ demonstration of concern/support/interaction/counseling (35, 47.3% mentees); 23 mentees (82%) wanted to become near-peers themselves.Conclusion:Near-peer mentoring supplements faculty mentoring of first-year medical students by increasing system effectiveness.

Prevalence of Depression in People Living with HIV/AIDS Undergoing ART and Factors Associated with it.

HIV/AIDS is one of the most devastating illnesses that humans have ever faced. Depression in HIV/AIDS patients is very common but the factors affecting it are not well studied. HIV/AIDS though such a big public health problem worldwide, not enough data is available regarding association of HIV and Depression. Therefore this study was undertaken to evaluate the association between HIV/AIDS and depression in an Indian setting. The study was conducted in Guru Teg Bahadur Hospital and University College of Medical Sciences, Delhi. One hundred sixty patients were interviewed using a questionnaire containing factors that affect depression. CES-D (Center for Epidemiologic Studies - Depression) scale was used to measure depression. The data collected was analyzed using SPSS software. The prevalence of depression in patients with HIV under ART was 58.75%. The prevalence of depression increased with the severity of symptoms. The unemployed, uneducated, unmarried, belonging to joint families, having no or low family income, migrants, having indifferent or poor relationship with spouse, poor social support and had visited commercial sex workers had a greater prevalence of depression. The rate of depression in patients with HIV/AIDS is very high. Detecting depression early and treating it goes a long way in improving the compliance to treatment as well as quality of life.

Estimation of time since death from electrolyte, glucose and calcium analysis of postmortem vitreous humour in semi-arid climate

Estimating time since death (TSD) with fair accuracy from postmortem changes still remains an important but difficult task to be performed by every autopsy surgeon in medicolegal scenario. The aim of the present study was to estimate TSD from electrolyte analysis of postmortem vitreous humour collected from samples under semi-arid climate. Vitreous humour was collected from 210 dead bodies brought to University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, during the period of November 2010 to April 2012. The vitreous samples were analysed for sodium, potassium, calcium, chloride and glucose. The results showed a significant positive relationship between TSD and potassium (r = 0.841, p = 0.000) and a weak negative relationship between TSD and sodium (r = -0.137, p = 0.048) and glucose (r = -0.241, p = 0.000), whereas no significant relationship could be established between TSD and calcium (r = 0.055, p = 0.429) and chloride (r = 0.075, p = 0.11).

Correlation Of Cryptococcal Antigen Assay With C-reactive Protein As Serum And Urine Biomarker In Cryptococcal Meningitis: Experience In A Tertiary Hospital

Correlation Of Cryptococcal Antigen Assay With C-reactive Protein As Serum And Urine Biomarker In Cryptococcal Meningitis: Experience In A Tertiary Hospital

Theatre of the Oppressed in medical humanities education: the road less travelled

Internationally, there is an increasing awareness of the need to include humanities in the medical curriculum. The Medical Humanities Group at the University College of Medical Sciences, Delhi, organised a series of events to explore this area. This paper describes our experience with Augusto Boal's "Theatre of the Oppressed" (TO). Twenty-six participants attended a 2-day workshop culminating in a "forum theatre", in which the spectators are transformed from passive observers to active participants or spect-actors. The participants' responses to our workshop indicate that TO provides a multitude of experiences and addresses a wide range of learning domains. TO challenges the senses and offers a promising and enjoyable option for learning medical humanities.

Use of Wikiversity and role play to increase student engagement during student-led physiology seminars

the undergraduate medical program (Bachelor of Medicine and Bachelor of Surgery) at University College of Medical Sciences (Delhi, India) is a 4.5-yr, intense academic program where physiology is taught in the first year. To make the learning experience enriching, the Department of Physiology

Serum organochlorine pesticide levels in patients with metabolic syndrome

Introduction:Organochlorine pesticides (OCPs) are endocrinal disruptors that tend to accumulate in adipose tissue and have been found to be associated with Metabolic Syndrome (MS).Aim and Objectives:1. To measure serum OCP levels in patients of MS and control subjects, 2. To identify differences, if any, in serum OCP levels, in patients with MS and control subjects.Materials and Methods:Cross-sectional study was conducted in the Departments of Medicine and Biochemistry at University College of Medical Sciences (UCMS) and Guru Teg Bahadur Hospital (GTBH), Delhi. Nine OCPs [α-HCH (Hexachlorocyclohexane), β-HCH, g-HCH, α-endosulfan, β-endosulfan, aldrin, dieldrin, p, p’-DDT (Dichloro-diphenyl-trichloro-ethane), and p, p’-DDE (Dichloro-diphenyl-dichloro-ethylene)] were studied. Fifty subjects ≥18 years with MS (study group) and 50 age and sex-matched controls were included in the study. Exclusion criteria: (1) Persons having chronic occupational exposure to OCPs such as workers of pesticide factories, (2) Recent exposure to OCPs within 4 weeks.Results:Levels of all nine OCPs were higher in cases as compared to controls. However, only the mean value of β-HCH in cases (8.40 ± 8.64 ng/ml) was significantly (P < 0.001) higher as compared to controls (2.58 ± 2.34 ng/ml). After adjustment of confounding factors like age, sex, smoking, alcohol, and body mass index (BMI), only β-HCH and aldrin levels were positively and significantly associated with the risk of having MS. Adjusted Odds Ratio (OR) was 1.34 [CI = 1.14-1.57 (P < 0.001)] and 1.23 [CI = 1.01-1.50 (P = 0.045)], respectively.Conclusion:There was a significant association of β- HCH and aldrin levels with MS.

Actinomycosis of rectum: a bizarre complication of mesh rectopexy

Colorectal DiseaseVolume 14, Issue 12 p. e815-e816 Case report Actinomycosis of rectum: a bizarre complication of mesh rectopexy P. K. Garg, P. K. Garg Department of SurgerySearch for more papers by this authorB. K. Jain, B. K. Jain Department of SurgerySearch for more papers by this authorA. Chaurasia, A. Chaurasia Department of SurgerySearch for more papers by this authorV. Vibhav, V. Vibhav Department of Pathology, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, IndiaSearch for more papers by this authorV. Agrawal, V. Agrawal Department of SurgerySearch for more papers by this author P. K. Garg, P. K. Garg Department of SurgerySearch for more papers by this authorB. K. Jain, B. K. Jain Department of SurgerySearch for more papers by this authorA. Chaurasia, A. Chaurasia Department of SurgerySearch for more papers by this authorV. Vibhav, V. Vibhav Department of Pathology, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, IndiaSearch for more papers by this authorV. Agrawal, V. Agrawal Department of SurgerySearch for more papers by this author First published: 09 February 2012 https://doi.org/10.1111/j.1463-1318.2012.02978.xCitations: 1 P. K. Garg, Room No. 2207, Ward 22, Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi 110095, India. E-mail: dr.pankajgarg@gmail.com Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume14, Issue12December 2012Pages e815-e816 RelatedInformation

Health research barriers in the faculties of two medical institutions in India.

BackgroundHealth policy formation refers to the design of a conceptual framework to find possibilities, facilitate feasibilities, and identify strong and weak points, as well as insufficiencies, by research. Doing research should clarify qualities and standards for policy and decision-making to enable the success of development of health care in a country. Evaluation of the impact of health interventions is particularly poorly represented in public health research. This study attempted to identify barriers and facilitators of health research among faculty members in two major institutions in India, ie, the All India Institute of Medical Sciences (AIIMS) and the University College of Medical Sciences (UCMS) and Guru Tegh Bahadur (GTB) Hospital in Delhi.MethodsThe participants were asked to fill in a questionnaire that canvassed individual characteristics, ie, years of experience, place of work, academic rank, final educational qualification, work setting, educational group, primary activity, and number of publications in the previous 5 years. Barriers and facilitators were categorized into personal, resources, access, and administration groups. The data were processed using SPSS version 16, independent t-tests, Chi-square tests, and multivariate logistic regression.ResultsThe total number of faculty members at both institutions was 599, 456 (76%) of whom participated in this study. The primary activities reported by faculty at UCMS (teaching) and Faculty at AIIMS reported (Research and Provision of health care services) as a major activity (P < 0.01). The majority of faculty members at UCMS and GTB Hospital were professors, whereas most of the faculty members at AIIMS were associate professors (P < 0.01). Of 47 barriers and facilitating factors, there were 26 barriers and 21 facilitating factors at AIIMS and 39 barriers and eight facilitating factors at UCMS. Faculty members at UCMS had 6.572 times more barriers to health research than those at AIIMS.ConclusionClose proximity between AIIMS and the Indian Council of Medical Research and the National Medical Library, housing, transport, and a good reference library with an adequate knowledge support system provided suitable opportunities for faculty members at AIIMS to do research. To overcome the barriers, institutions must have enough financial support, decreased nonessential clinical, laboratory, and service schedule duties on the part of faculty members, preparation of good and relevant statistical courses and workshops, and access to good statistical software packages.

Whither medical humanities?

Understanding the medical humanities (MH) and their role in medical education is in its infancy in India. Students are initiated into professional (medical) education too early in life, usually at the expense of a basic grounding in the humanities, resulting in warped intellectual growth. The author, arguing against the wholesale import of foreign systems, advocates free inquiry by medical educators to evolve a humanities programme for medical students derived from our own cultural context. This essay describes the early experiences of efforts to make a beginning at the University College of Medical Sciences, Delhi. The author reviews the various strategies used and the challenges of introducing the subject to the current generation of medical students.

CYP2D6*4 polymorphism, tramadol treatment and its clinical impact in patients with postherpetic neuralgia.

The aim of this study was to investigate the associations between the CYP2D6*4 polymorphism, interindividual differences in CYP2D6 activity and adverse drug effects in postherpetic neuralgia (PHN) patients receiving tramadol. The study comprised 158 patients (including 78 nonresponders and 80 responders) with PHN who were undergoing analgesic treatment at the Pain Clinic in the Out Patient Department of the University College of Medical Sciences, Guru Teg Bahadur Hospital (New Delhi, India). The numerical rating scale scores were measured at the resting and movement stages; Neuropathic Pain Symptom Inventory scores were evaluated by the treating physician. WHO-brief questionnaire scores for quality of life and adverse drug effects during the time of study were recorded. All samples were analyzed for the CYP2D6*4 polymorphism using the PCR-restriction fragmentation length polymorphism method. The genotype distribution did not vary significantly among different age groups in nonresponders and responders. The CYP2D6*4 polymorphism was significantly associated with lower Neuropathic Pain Symptom Inventory (burning, squeezing stabbing and pressure) scores. The quality-of-life (sociological, psychological and environmental domains) scores correlated with CYP2D6*4 and showed significant results (p < 0.05) using a generalized linear model. No association was found between the physiological domain compared with the CYP2D6*4 allele (p > 0.05). In addition, the homozygous mutated CYP2D6*4 allele was not related to adverse effects of analgesic therapy. The CYP2D6*4 polymorphism may not be a predictor for treatment outcome of patients with PHN receiving tramadol. However, further investigation is required to confirm these findings in a larger sample size.

Tuberculous Peritonitis: The Closer You Go, the More Confused You Get

We read the article entitled ‘‘Comparison between Laparoscopy and Noninvasive Tests for the Diagnosis of Tuberculous Peritonitis’’ by Hong et al. [1] with great interest. The authors presented a retrospective study of 60 patients who underwent diagnostic laparoscopy for either undiagnosed ascites (n = 19) or a condition that needed to be differentiated from peritoneal carcinoma (n = 41). Forty-one patients were diagnosed with tuberculous peritonitis (TBP). The positive and negative results of diagnostic laparoscopy were compared with ascitic deaminase levels [30 U/l and ascitic lactate dehydrogenase levels [90 U/l. The authors concluded that laparoscopy with combined biopsy is the most sensitive and the quickest method for diagnosing tubercular peritonitis. We would like to make the following observations regarding this article. The authors chose to present their results as mean ± SD. This method is always not representative, especially if data is nonuniform. This is apparent by looking at the duration of symptoms in the patients with TBP: 40 ± 57 (range, 3–360). Median ± interquartile range is a preferable method to represent the nonuniform data compared with mean ± SD [2]. The diagnosis of TBP was considered definitive by the authors, on the basis of either caseous granuloma or positive bacteriological results for M. tuberculosis. The diagnosis was considered probable in the presence of suggestive clinical and laparoscopic findings and noncaseous granuloma without positive bacteriologic findings. The authors did not mention how many patients were in the category of probable diagnosis or how many of them actually proved to be definitive case of TBP after favorable clinical response to antituberculosis therapy. The authors reported that biopsy tissues were deemed inadequate for the diagnosis in 12 of 60 cases. However, all of these patients were considered while assessing the presence of granuloma/caseous granuloma under the heading of laparoscopy in Table 4 [1]. This needs further clarification. The diagnosis of abdominal tuberculosis is classically based on microbiological confirmation [3]. Although the yield may be less, positive acid fast staining (AFB) and M. tuberculosis culture results confirm the diagnosis of tuberculosis unequivocally. The authors performed AFB of peritoneal biopsy specimen in 22 and culture for M. tuberculosis in 6 of 60 patients. Selective use of these investigations rules out the opportunity of exploring their full potential in the diagnosis of TBP. The authors mentioned that ascites was present in 92.7% (38/41) of patients of TBP. Table 2 shows that acid fast staining was conducted in 48 patients, and M. tuberculosis culture and PCR was undertaken in 48 and 39 patients respectively. The authors did not indicate why these investigations were selectively performed in a few patients and not in all patients. We believe that AFB staining, which is an inexpensive and freely available investigation, should be performed in the ascitic fluid of all patients suspected to have TBP. The authors stated that an abnormal chest X-ray was seen in 20 of 41 patients of TBP and active concomitant pulmonary disease was present in 8 patients (20%). It becomes imperative to know whether the sputum of these patients was examined for the presence of AFB. It will be interesting to know how many of these sputum AFBpositive patients were ultimately found to have TBP. P. K. Garg (&) B. K. Jain D. Mohanty Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi 110095, India e-mail: dr.pankajgarg@gmail.com

Sex Cord Stromal Tumors–Unusual Presentations

The sex cord stromal tumors (SCST) account for approximately 7% of all malignant ovarian tumors. They are endocrinologically active tumors of which granulosa cell tumors are the commonest. We describe an analysis of all cases of SCST managed, in our department over the last five years and discuss two cases of unusual presentation of these tumors. Ten cases of SCST which were managed in the Department of Gynecology and Obstetrics at University College of Medical Sciences (UCMS) & associated Guru Teg Bahadur hospital, Delhi from Jan. 01 to Dec. 05 were analyzed. Of the total 312 ovarian tumors which were operated in these 5years, 73 (23.3%) were malignant, 10 cases (13.6%) out of the malignant ovarian tumors were SCST. The age of presentation varied from 4 to 70years. Four women presented with lump abdomen as their chief complaint, 2 had postmenopausal bleeding, 2 presented with irregular bleeding per-vaginum, 1 woman had secondary amenorrhea and one young girl who was only 4½ years old developed precocious puberty. The majority of cases (70%) were granulosa cell tumors, 10% were fibromas and 20% thecomas. Maximum patients 9 (90%) were stage I at the time of surgery and only 1 case was stage IV with tumor infiltrating into omentum and gut. SCST tumors are rare endocrine active tumors that are essentially unilateral, benign or with a low malignant potential. Though most patients present with one or a combination of symptoms ranging from abnormal vaginal bleeding, abdominal distention and abdominal pain, the signs of Paraneoplastic syndrome (PNS) may be the first indication of the presence of an ovarian malignancy and can even facilitate its diagnosis.

Pulmonary functions and ambient air pollution in residents of Delhi

Department of Physiology, University College of Medical Sciences and GTB Hospital, Delhi – 110095. India Corresponding Author: Dr Farah Khaliq Associate Professor, Dept. of Physiology, UCMS and GTB hospital, Delhi – 110095 India Email: farahphysio@yahoo.com Received: 04-10-2010| Accepted: 20-07-2011 | Published Online: 02-08-2011 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (creativecommons.org/licenses/by/3.0) Conflict of interest: None declared Source of funding: Nil Abstract

Reaching people through medical humanities: An initiative

Reaching people through medical humanities: An initiative

Comparison of Sublingual Misoprostol, Intravenous Oxytocin, and Intravenous Methylergometrine in Active Management of the Third Stage of Labor

Department of Obstetrics and Gynecology, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India