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   Table of Contents - Current issue
Coverpage
January-March 2019
Volume 16 | Issue 1
Page Nos. 1-67

Online since Monday, March 11, 2019

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EDITORIAL  

Editorial p. 1
RN Srivastava
DOI:10.4103/am.am_7_19  
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REVIEW ARTICLES Top

Posttraumatic brain edema: Pathophysiology, management, and current concept p. 2
Subhas K Konar, Dhaval Shukla, Amit Agrawal
DOI:10.4103/am.am_82_18  
Post traumatic cerebral edema is a multiplex process. Mainly two types of cerebral edema occurred after traumatic brain injury-vasogenic edema and cytotoxic edema. Cytotoxic cerebral edema is due to accumulation of water in the intercellular space. Mitochondria mainly cause cytotoxic edema due to the involvement of oxidative metabolism. Various molecules are involved in the formation of cytotoxic edema- like aquaporin, Sulfonylurea-receptor 1 – transient receptor potential member 4 (Sur1-Trpm4), Glutamate, Na+-K+-2Cl− cotransporter, Arginine vasopressin, Histamine, and Erythropoietin .Vasogenic edema develops due to disruption of blood-brain barrier or altered permeability of blood-brain barrier so correlate with the level of impact and or activation of molecular pathways related with neuroinflammation. Molecules involved in neuroinflammation are tumor necrosis factor (TNF), interleukins (IL) 6 and I beta, Substance P and Bradykinin. Management is mainly dived into two part- medical and surgical. Medical management includes management of increased intracranial pressure and later blocking of the pathways involved in the formation and progression of cerebral edema. In refractory cases, surgical decompression plays a role in controlling the intracranial pressure due to cerebral edema.
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The importance of microscopic diagnosis of respiratory infections p. 8
Isabella Princess, Rohit Vadala
DOI:10.4103/am.am_88_18  
The need for mastering microscopic diagnosis arises in all laboratory specialties, especially when working in resource-poor community laboratories which lack newer diagnostic instruments. Certain clues from microscopic appearance should be carefully analyzed to clinch diagnosis and to not miss out these findings. In addition, if turnaround time is reduced, there is better patient outcome and satisfaction from the clinical colleagues.
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Primary fungal laryngitis: An overlooked clinical entity p. 11
Santosh Kumar Swain, Mahesh Chandra Sahu, Priyanka Debdta, Manas Ranjan Baisakh
DOI:10.4103/am.am_85_18  
Primary fungal laryngitis is a fungal infection of the larynx without affecting the other body parts such as lungs, pharynx, and oral cavity. It is an extremely rare clinical entity, especially in immunocompetent patients. Aspergillus fumigatus and Candida albicans are common fungi associated with primary fungal laryngitis. Hoarseness of the voice is common clinical presentations. The diagnosis of the primary fungal laryngitis is often overlooked and delayed among patients as it is usually evident among immunocompromised patients. It is often confused with certain laryngeal diseases such as granulomatous diseases, leukoplakia, and malignancy. Misdiagnosis or delayed diagnosis or inadequate treatment may lead to impaired functioning of the larynx and sometimes suffered from permanent disability. It is always important to identify the lesion earliest for avoiding morbid or life-threatening consequences. The purpose of this review article is to discuss the etiopathology, clinical presentations, diagnosis, and treatment of primary fungal laryngitis.
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ORIGINAL ARTICLES Top

Isolation and identification of fungus associated with skin and nail scalps of patients in a tertiary care teaching hospital p. 16
Kaniska Uthansingh, Manoj Kumar Sahu, Nagen Kumar Debata, Debasmita Behera, Kirtika Panda, Mahesh Chandra Sahu
DOI:10.4103/am.am_80_18  
Background and Objectives: Ringworm of the scalp is starting at now a disease of overall criticalness and a general prosperity teaching care hospitals. It is otherwise known as dermatophytes, which attack and create on dead animal keratin. This assessment was intended to recognize the regular dermatophyte causing parasitic infection with both minute just as social strategies. Materials and Methods: This is a Prospective study which was carried out for the period 1 year and included the patients with tinea cruris and tinea corporis, tinea unguium, tinea pedis, and tinea barbae which are seen in the patients between 6 to 70 years of age. Dermatophytes were confirmed with microscopic examination of skin and nail tests taken from the influenced lesion of the body. Both cotton blue and potassium hydroxide grouping of 10%– 30% were utilized to see under magnifying micrioscope. All information were broken down with SPPS 20 programming. Results: Out of 78 patients, the recurrence of ringworm infection among those patients attending in the department of Skin and VD, IMS and SUM Hospital was Trichophyton rubrum (73%), Trichophyton mentagrophytes (53%), Epidermophyton floccosum (26.82%), and Trichophyton verrucosum (7.31%). T. rubrum was the most widely recognized etiological fungus in tinea corporis, and this positioned first in the other type of ringworm infection. Recurrence of dermatophytes infection partner with various clinical examples; for example, nail pieces and skin swabs from the infected area. Conclusions: The greater part of the tinea corporis patients were infected with T. rubrum then comes the disease of Trichophyton violaceum, Trichophyton tonsurans, and T. mentagrophytes. The most astounding recurrence of disease was among the patients matured 20– 30 years. It is additionally essentially noticed that this infection takes a somewhat serious turn in patients of cutting edge in older age (60– 80 years).
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Assessment of level of depression and anxiety in pre- and postoperative stages: A prospective cross-sectional study in SCB Medical College, Cuttack p. 22
Srikanta Panda, Narendranath Samantaray, Monisha Patanaik, Debasish Sahoo, Anshuman Sarangi, Somanatha Jena
DOI:10.4103/am.am_94_18  
Objectives: Mood disorders are considered to be prevalent in hospitalized patients. Our study aimed to investigate the prevalence of depression and anxiety symptoms in pre- and postoperative stage in surgical patients. Methods: We included 60 surgical patients in this cross-sectional study which includes 43 male and 17 female patients and average age of 38.8 years. Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale were used to screen for symptoms of depression and anxiety at 12 h after admission for electively scheduled surgeries and 12–24 h after the surgery for patients undergoing emergency surgery. Results: In presurgery stage, anxiety was found to be prevalent in 43.3% of patients while depression is 38%. In postsurgery stage, anxiety and depression were found in 18.3% and 35% of patients, respectively. Conclusions: Both anxiety and depression are highly prevalent in pre- and postoperative stage of surgery. Such symptoms should be attended with more seriousness, otherwise would lead to higher morbidity and mortality.
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Surgical outcome of 60 operated patients with acute extradural hematomas based on the preoperative glasgow coma scale p. 26
Ajaydeep Singh, Arvinpreet Kour, GS Bindra, Ajay K Gehlot, Rahul Midha, Kartik Nandra
DOI:10.4103/am.am_93_18  
Aim and Objective: This study aims to evaluate the outcome of the patients operated for acute extradural hematoma (EDH). Patients and Methods: Sixty consecutive cases of acute EDH were treated at medical college hospital to assess the outcome of the patients based on their Glasgow Coma Scale (GCS), radiological assessment, and pupil size. The patients were monitored of their GCS, pupillary size, and vitals. The Glasgow outcome scale was used to evaluate patient outcome at the discharge from the hospital and after 3 months. Observation and Results: Sixty patients constituting 56 males and 4 females were the part of the study. The mean age of the patients was 23.21 years (range: 2–47 years). On an average, the patients were operated around 9.91 h after the trauma (ranging 2–24 h). Out of sixty patients, 25, 17, and 18 patients had GCS of mild, moderate, and severe groups. Prompt surgery with better care obtained us with mortality 1.6%, morbidity 21.7%, and complete recovery in 83% patients. Conclusion: We may conclude in our study that presurgical clinical findings such as sensorium of patient and pupillary status were an important indicator for surgical outcome. In most of the cases, the outcome was favorable with progressive recovery.
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CASE REPORTS Top

Aggressive surgical resection following neoadjuvant imatinib therapy for advanced duodenal tumor with hepatic metastasis p. 33
Varun Madaan, Rigved Gupta, GK Adithya, Satya Prakash Jindal, Deepak Govil
DOI:10.4103/am.am_90_18  
Duodenal gastrointestinal stromal tumors (GISTs) are rare tumors which constitute <5% of all cases of GIST. The treatment of locally advanced/inoperable and metastatic GIST is primarily tyrosine kinase inhibitor therapy (TKI), i.e., imatinib mesylate. In some patients, initial TKI therapy may result in significant downstaging of the primary tumor and metastatic disease. The role of aggressive surgical resection in such patients remains controversial. We present a case of advanced duodenal GIST treated successfully by Whipple's procedure with liver wedge resection following neoadjuvant TKI therapy. This case shows that aggressive surgical resection for metastatic duodenal GIST following neoadjuvant imatinib seems to be a feasible treatment option.
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Primary paravertebral low-grade fibromyxoid sarcoma p. 36
Binod Kumar Singhania, Jummo Jini, Gobinda Pramanick
DOI:10.4103/am.am_76_18  
Low-grade fibromyxoid sarcoma is a distinctive variant of fibrosarcoma. Despite its benign histological appearance, it is a tumor with malignant potential. Usually, it is occur in the proximal lower extremities and trunk. However, it is very rare in paravertebral region. The diagnosis is based on the histology and specific immunohistochemistry results. The treatment of choice is total excision followed by radiotherapy to prevent the possibility of recurrence. We excised the tumor to near total and a wide fixation has been done. Frozen section biopsy was misleading and reported a schwannoma.
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Multiple spinal neurofibromas p. 39
Kodeeswaran Marappan, Prabhu Marudamuthu, Sherina Paul Raj
DOI:10.4103/am.am_22_18  
A 55-year-old male, with a 2-month history of urinary incontinence, a suspected case of pyelonephritis was initially treated by a nephrologist, but with no relief in spite of medication. On further evaluation, he was found to have a history of back pain, progressive bilateral weakness of lower extremities, and difficulty walking. He was thus referred to us for further management. Magnetic resonance imaging (MRI) of the spine was done, which revealed the presence of multiple bilateral dumbbell-shaped lesions at multiple spinal levels, associated with widening of the neural foramina of the cervical, dorsal, and lumbar regions. Surgical excision of all lesions was done in a single sitting. The patient had postoperative weakness and urinary incontinence, which slowly recovered and weakness gradually improved by physiotherapy. On follow-up, the patient was able to walk without any weakness. Surgical excision is the treatment of choice for spinal neurofibromatosis. Diagnosis of the condition may be difficult due to the lack of symptoms in majority of the cases or presentation with rare symptoms. However, it is recommended that a routine MRI of the spine be performed in patients with a history of urinary incontinence associated with weakness of limbs.
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Sialolipoma: An interesting and rare tumor of the submandibular gland p. 42
Satvinder Singh Bakshi, Anandraj K Vaithy
DOI:10.4103/am.am_48_18  
Salivary glands containing coexisting lipomatous lesions are rare and have only been identified recently as a distinct entity; one of these lesions is a sialolipoma. The characteristic feature of these tumors is benign proliferation of mature adipose tissue along with normal salivary gland features. We describe a case of a slowly enlarging mass in the submandibular region of a 45-year-old male which on excision was reported as sialolipoma.
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A rare cause of left lower quadrant pain: Amyand's hernia p. 44
Faruk Pehlivanli, Oktay Aydin, Gökhan Karaca, Oguz Eroglu, Selçuk Misirligil, Coskun Figen
DOI:10.4103/am.am_83_18  
Amyand's hernia is defined as the presence of a normal or inflamed appendix vermiformis within the inguinal hernia sac and was first described by Claudius Amyand. Most cases of Amyand's hernia are seen on the right side associated with the normal anatomy of the appendix. Diagnosis is usually made during hernia surgery. In this study, a rare case is reported of a patient operated on for left-side incarcerated inguinal hernia and determined with acute appendicitis within the hernia sac.
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Hydrops fetalis with septated cystic hygroma p. 47
Reddy Ravikanth, Rajalakshmy Prasannan
DOI:10.4103/am.am_78_18  
Hydrops fetalis is excess accumulation of fluid in the fetus, and fetal cystic hygroma is a manifestation of early lymphatic obstruction. Depending on the severity and cause of hydrops, there may be anasarca of fetus, placentomegaly, ascites, pleural effusions, and/or pericardial effusions. Fetal hydrops and cystic hygroma can be diagnosed in the second trimester of gestation and is associated with a higher incidence of aneuploidy and high mortality. Previously, most cases of hydrops were caused by severe erythroblastosis fetalis secondary to Rh isoimmunization. At present, hydrops fetalis is caused by other conditions and is known as nonimmune hydrops. Here, we present a case of an 18-week pregnancy with fetal cystic hygroma and nonimmune hydrops fetalis.
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Use of bulldog vascular clamps and vessel loops to reduce intraoperative bleeding during cesarean hysterectomy for placenta percreta p. 50
Juhul Patel, Vinutha Arunachalam, Rachita Munjal
DOI:10.4103/am.am_58_18  
Placenta percreta is a potentially life-threatening condition that requires a multidisciplinary team approach for optimal management. Bulldog vascular clamps were used to reduce the severity of bleeding among two patients undergoing cesarean hysterectomy for placenta percreta. Permanent hypogastric artery ligation can cause serious intraoperative and postoperative complications, especially when performed by inexperienced surgeons. Placing a bulldog vascular clamp across the internal iliac artery can reduce intraoperative bleeding and prevent serious complications associated with permanent hypogastric artery ligation.
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Spinal decompression and instrumented fusion in an elderly woman: A case report and literature review p. 52
Abhishek Vaish, Prabin Nepal, Raju Vaishya
DOI:10.4103/am.am_2_19  
The increase in population of older adults will be associated with a parallel increase in musculoskeletal problems such as arthritis and spinal problems. Surgical treatment of degenerative disease of the spine can produce significant improvements in function in suitably selected patients. Improvements in surgical and anesthetic techniques may make more-invasive surgery feasible for elderly patients. We present a case of an 89-year-old woman, who presented with lumbar radiculopathy due to degenerative lumbar canal stenosis and multilevel instability. She was managed successfully with spinal decompression and instrumented spinal fusion of L4/5 and L5/S1 segments.
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Use of granulocyte colony-stimulating factor in recurrent implantation failures p. 56
U Nagashree, Sumana Manohar
DOI:10.4103/am.am_64_18  
In spite of significant advances in ART, recurrent implantation failures (RIFs) and miscarriages are challenging. These could be attributed to unfavorable endometrium/poor embryo quality. Regular priming with estrogen is done to improve endometrial thickness. Despite these, RIF and miscarriages most probably account for some immune-related problems too, normally classified as unexplained infertility. Several research groups reported increase in endometrial thickness and immunomodulatory functions of granulocyte colony-stimulating factor (GCSF) during in vitro fertilization cycles, in terms of achieving higher clinical pregnancy rates. More studies should be done in this context before resorting to gestational surrogacy. We report one such case of recurrent miscarriage and RIF which resulted in a successful pregnancy after intrauterine GCSF instillation into uterine cavity.
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Primary thyroid lymphoma p. 58
Amarendra Amar, Seema Singhal, G Sharat Chandra, Harsh Dua
DOI:10.4103/am.am_1_19  
Primary thyroid lymphoma is a rare neoplasm consisting of 1%–5% of all thyroid neoplasms. These are predominantly B-cell in origin. It is curable without surgery. The literature search shows it to be presenting as rapidly developing thyroid mass. It has been shown to be associated with autoimmune thyroiditis. The rarity of this condition mandates it to be differentiated from other rapidly developing thyroid malignancies to recognize it early as it is curable. The treatment consists of chemotherapy, radiation, or both combined with excellent results.
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APPLICATION OF TECHNICAL ADVANCES Top

Use of drones (unmanned aerial vehicles) for supporting emergency medical services in India p. 61
Imron Subhan, Syed Safiuddin Ghazi, Syed Nabi
DOI:10.4103/am.am_79_18  
Background: Drone technology or correctly termed as unmanned aerial vehicles (UAVs) is the newest advancement of science which has taken the world by storm. India is yet to witness the fantastic work these exciting flying vehicles can do. There are innumerable applications within the domain of both private and public space, especially in health care and emergency medical response. Aerial professional drones are small, portable, and have advanced capabilities which include audio-video broadcast, GPS navigation capabilities, fully automated and predetermined flights, and use of artificial intelligence for decision-making. Methodology: A toy drone bought from an online retailer was fitted with a professional camera connected to portable tablet through WiFi. Two emergency physicians were trained to operate the drone and camera in a simulated disaster scenario, cardiac arrest scenario, as well as transportation of medicines and biological samples within the hospital. Proof of concept for three different applications of drone technology in emergency care was experimented. Observations: (1) Drone as the first response in disaster: The drone was able to fly unhindered, hover over the accident location, and relay details of the crash site, including type of accident, hazards present, number of injured victims, roads leading to/from the location, and the number of bystanders present. (2) Supervision of patient transfers in disaster: The drone was able to send live video feed continuously as each patient was being evacuated. The drone pilots were in constant touch with disaster command and control. (3) Cordoning the disaster site: Based on the drone video feed, the ingress/egress routes for the ambulance vehicles were identified and secured. (4) Basic life support: The drone was able to provide live views of arrest scenarios, get live visuals from the site to the copilot and helped in guiding the first responder for cardiopulmonary resuscitation in a victim of cardiac arrest. (5) Transport of samples: The drone was able to transport samples for the stroke patient from the emergency room to the laboratory in the hospital without any hindrance. (6) Intrahospital transport of medicines: The drones were also able to carry medicines from the inpatient pharmacy to the wards, which were immediate, effective, and with reduction in workforce. Conclusion: This project was clear example of seamless integration of flying drones into existing disaster response protocols. Drones can provide real-time video information about disaster/accident site to the disaster command and control. Drones can supervise the transfer of individual victims from the disaster zone. Emergency physicians can learn to fly drones and use them for supporting emergency medical services disaster response. The DGCA should facilitate the utilization of drones and UAVs for supporting emergency medical personnel when they respond to disasters (natural, chemical, biological, radiation, and nuclear), multicasualty incidents, road accidents, cardiac arrest victims, in hospital use for transport of medicines, samples, and out-of-hospital transport of organs for transplantation.
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LETTER TO EDITOR Top

Boron: A dietary mineral for human health p. 66
Roopesh Jain, Archana Tiwari
DOI:10.4103/am.am_59_18  
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