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   Table of Contents - Current issue
Coverpage
October-December 2018
Volume 15 | Issue 4
Page Nos. 181-245

Online since Wednesday, December 5, 2018

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EDITORIALS  

Editorial p. 181
RN Srivastava
DOI:10.4103/am.am_87_18  
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Editorial p. 182
PN Renjen
DOI:10.4103/am.am_89_18  
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CASE REPORTS Top

A Known complication of posterior fossa tumor rarely encountered-reverse coning p. 183
Kodeeswaran Marappan, Arrjun Sankaran, K Deiveegan, Kannan Ross
DOI:10.4103/am.am_9_17  
Posterior fossa tumors commonly present with obstructive hydrocephalus. Cerebrospinal fluid diversion procedures, done in such patients, carry the rare risk of reverse brain herniation, which is associated with significant mortality. The following case illustrates the need for the prompt diagnosis of reverse coning and immediate interruption of the ventriculoperitoneal shunt for patients who deteriorate after the procedure.
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Enterogenous cyst from craniovertebral junction to D2 – Rare presentation p. 186
Kodeeswaran Marappan, Saravanan Ramamurthy, J Sharmila Beevi
DOI:10.4103/am.am_63_18  
The neurenteric cyst is a rare lesion of the spinal axis. It is composed of heterotopic endodermal tissue. During the 3rd week of human embryogenesis, the neurenteric canal unites the yolk sac and the amniotic cavity as it traverses the primitive notochordal plate. Persistence of the normally transient neurenteric canal prevents the appropriate separation of endoderm and notochord. This anomalous union manifested as congenital abnormalities of the spine. It is defined by the presence of mucus-secreting epithelium reminiscent of the gastrointestinal tract. It is presented with pain and myelopathic symptoms. Septic or chemical meningitis can also occur. A variety of approaches are described in the treatment of neuroenteric cysts each with a goal of total surgical resection.
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Metronidazole-induced encephalopathy p. 190
Dinesh Mohan Chaudhari, Pushpendra Nath Renjen, Kamal Ahmad
DOI:10.4103/am.am_67_18  
Metronidazole, an antiparasitic and antibacterial compound, is one of the world's most widely used drugs. Metronidazole is available for the treatment in anaerobic infections but may produce a number of neurologic side effects, particularly after prolonged use, such as cerebellar involvement, encephalopathy, seizures, autonomic neuropathy, optic neuropathy, and peripheral neuropathy. Symptoms of encephalopathy and neuropathy may recover completely or partially after discontinuation of metronidazole. The incidence of metronidazole-induced encephalopathy (MIE) is unknown. We report a case of a 31-year-old man with liver abscess and history of few weeks use of metronidazole therapy presenting with multiple episodes of seizures and altered sensorium. Magnetic resonance imaging brain revealed diffuse uniform extensive altered signals and restricted diffusion in body and genu of corpus callosum, suggestive of MIE.
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ORIGINAL ARTICLE Top

Chronic subdural hematoma: Surgical management and outcome in newly established neurosurgical unit: Experience of 78 patients operated over 1 year p. 193
Ajaydeep Singh, Arvinpreet Kour, Dinesh Mohan Chaudhari
DOI:10.4103/am.am_68_18  
Objective: Chronic subdural hematoma (CSDH) has an increasing incidence and results in high morbidity and mortality. With the increasing age, the number of the elderly patient is coming frequently with symptoms of headache and hemiparesis. We review here the 1-year experience of a single institution and the literature regarding the treatment and major associations of CSDH and some patients with subacute subdural hematomas. Materials and Methods: Analysis of 78 cases of Chronic SDH operated in department of Neurosurgery for a period of one year. Burr-hole evacuation with and without closed system drainage has been the operative technique of the first choice at our institution for 4 consecutive years. Results: Our results indicated that neurological status on admission was the best predictor of outcome. The use of the drain had a significant reduction in the recurrence rates. With regard to the other data, age, brain atrophy, thickness and density of hematoma, subdural accumulation of air, and antiplatelet and anticoagulant therapies were found to correlate significantly with prognosis. Conclusions: Burr-hole evacuation is a relatively safe and effective first-line management option. All cases were operated under local anaesthesia. The patients had excellent recovery postoperatively. The recurrence rate is not associated with the use of a drain after burr-hole evacuation of a CSDH, proper irrigation, and closure reduce complications.
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REVIEW ARTICLES Top

Antimicrobial properties of human cerumen p. 197
Santosh Kumar Swain, Mahesh Chandra Sahu, Priyanka Debta, Manash Ranjan Baisakh
DOI:10.4103/am.am_69_18  
In daily clinical practice, clinicians and otolaryngologists often confront with cerumen or earwax. Cerumen is formed by sebaceous glands and ceruminous glands at the outer one-third of the human external auditory canal and creates an acidic coat which aids in the prevention of infections of the external auditory canal. The cerumen forms a physiological barrier between the external environment and deeper part of the ear. The chemical composition of the cerumen has been thought to be of antibacterial and antifungal properties, although it is under controversy. Other than antibacterial and antifungal activities, it also protects the eardrum by acting as a physical barrier. Cerumen cleaning is not advisable unless it is causing symptoms such as otalgia or hearing loss. A large percentage of people believe in self-cleaning of the ear canal with different objects, which is really harmful, so they should be counseled against the habit of self-cleaning of the external auditory canal.
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Chondrocalcinosis: A common but poorly understood joint disease p. 201
Siddhartha Gupta, Abhishek Vaish, Raju Vaishya
DOI:10.4103/am.am_92_18  
Calcium pyrophosphate crystal deposition is a spectrum of diseases, involving the musculoskeletal system. It may be asymptomatic or may manifest with pain, swelling, stiffness, and deformity of the joints. It may lead to secondary osteoarthritis of the joint. Awareness about these conditions is necessary to diagnose it and to differentiate it with other mimicking disorders. The diagnosis is often achieved by clinical manifestations, plain radiographs, and synovial fluid examination. The treatment is often symptomatic by conservative means, but in advanced arthritis, joint replacement may be needed.
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ORIGINAL ARTICLES Top

Prospective study on physiological intorsion of lower limbs in children p. 204
Ramani Narasimhan, Ritesh Garg, Gaurav Gupta
DOI:10.4103/am.am_71_18  
Background: Rotational profiles vary widely among healthy children. Rotation of the long bones refers to the twist of the bone about its long axis. Rotational deformity of the lower limb in the transverse plane is associated with many clinical settings ranging from harmless to excessive intoeing in children. Materials and Methods: This study was conducted at the Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi. Children presenting to the outpatient department during the period of April to September 2013 were followed up. It is a prospective study conducted over 14 months. A total of 27 children (54 lower limbs) were included and followed up. Results: Twenty-seven children were selected as per the inclusion criteria and assessed for the thigh-transmalleolar axis, thigh-foot angle, femoral anteversion (FA), foot progression angles (FPA), and hip rotations at 4-month interval for 2 follow-ups. There were very few studies of such type which have been conducted in India. Conclusions: In our study, there was a definite and significant decrease in FPA and internal tibial torsion with increasing age. The values of clinical anteversion also decreased with age along with a gradual decrease of internal rotation and an increase of external rotation (ER). The decrease of FA with age correlated better with increase of hip ER. FPA was a significant clinical parameter which gave us an objective picture of the change in both femoral and tibial torsions with age.
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Conclusions from analyses of outpatient visit patterns at an orthopedic hospital p. 214
Viveka Parameswaran
DOI:10.4103/am.am_73_18  
Objective: The primary purpose of this article is to provide logical conclusions and likely explanations to the patterns in patient visits to the outpatient department (OPD) of an orthopedic hospital in Vadodara, Gujarat. Subjects and Methods: Over the course of 25 days, the author of this work witnessed a total of 244 patients assessed, diagnosed, and treated by the primary physician. Results: Results indicated that fractures, degenerative disc disease (DDD), arthritis, spondylosis, tendon and ligament tears, and muscle pulls were the leading causes of nearly 80% of all OPD visits. Among them, tendon and ligament tears and muscle pulls contributed to 62% of all acute visits to the OPD, while DDD, spondylosis, and arthritis contributed to 65% of all chronic visits to the OPD. Discussion: Analyses of data showed that there was an even split between acute and chronic patient visits to the OPD. However, males were almost two times more likely to visit with acute conditions and only half as much for chronic conditions compared to females. Further, males' acute visit to the OPD was triggered, on an average, by lifestyle-altering orthopedic or other medical conditions compared to females that appeared to seek medical assistance for chronic conditions. Conclusions: This article concludes with recommendations for patient engagement to assist them seek care on a timely and consistent fashion.
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ORIGINAL RESEARCH ARTICLE Top

Antifungal susceptibility of Candida species isolated from urine from patients in a neurosciences intensive care unit p. 219
Srideep Rath, Ishwar Chandra Behera, Mahesh Chandra Sahu
DOI:10.4103/am.am_43_18  
Background and Objectives: The incidence of fungal infections in immunocompromised patients, especially by Candida species, has increased in recent years. This study was designed to identify Candida species and determine antifungal susceptibility patterns isolated strains from urine samples of intensive care unit (ICU) patients. Materials and Methods: All the urine samples of neuroscience ICU patients were cultured on Blood agar, Cystine–Lactose–Electrolyte-deficient agar, and Sabouraud Dextrose Agar. The grown colony was identified with color pigmentation on Candida Differential Agar. The antifungal susceptibilities of all Candida species were carried out with fluconazole, amphotericin B, ketoconazole, itraconazole, clotrimazole, nystatin, and miconazole. The generated results were analyzed with SPSS software (Version 20, IBM Corp., Armonk, NY, USA). Results: Candida Species were found in both genders of ICU patients with respect to all age groups. Among 100 urinary tract infection patients, 14 individuals were affected with diabetes and cerebrovascular accident. Whereas other disease comorbidity renal tubular acidosis, subarachnoid hemorrhage, head injury, acute respiratory distress syndrome, hypertension, and others were 9, 8, 8, 5, 11, and 31, respectively. Candida albicans (38.09%) was the most frequently isolated species, followed by Candida glabrata (23.8%), Candida krusei (23.8%), and Candida tropicalis (2.85%). Resistance varies depending on the species and the respective antifungal agents. From among 7 antifungal agents, itraconazole showed highest percentage of sensitivity (81.8%). Conclusions: Species definition and determination of antifungal susceptibility patterns are advised for the proper management and treatment of patients at risk for systemic candidiasis. Resistance to antifungal agents is an alarming sign for the emerging common nosocomial fungal infections.
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CASE REPORTS Top

A rare case of carcinoma pancreas with meningeal metastasis p. 223
Satyaprakash Jindal, GK Adithya, Varun Madaan, Rigved Gupta, Vivek Tandon, Deepak Govil
DOI:10.4103/am.am_34_18  
Carcinoma pancreas is a common malignant disorder of the digestive system. Unfortunately, most cases of pancreatic cancer often present late and are not amenable to surgical cure. Approximately 40% of patients have metastatic disease at the time of presentation. Common metastatic sites include liver, peritoneum, and lung. However, central nervous system metastases are rarely seen in carcinoma pancreas, and most reported cases show lesions in the brain parenchyma. Carcinoma pancreas with meningeal metastasis is an extremely rare presentation, and fewer than 10 cases have been reported in literature. Meningeal infiltration by solid tumors has been reported in 3%–8% of cases. Clinical presentation is similar to meningitis or brain tumors and includes dizziness, nausea, vomiting, neck rigidity, and sensory and motor deficits. Treatment of meningeal metastasis consists of palliative chemotherapy and radiation. The meningeal carcinomatosis has a poor prognosis with median survival of 8–10 weeks. Here, we present a case of carcinoma pancreas with meningeal metastasis, presenting as meningitis. In view of poor general condition of the patient, the Eastern Cooperative Oncology Group score of 4, and after multidisciplinary discussion, only palliative treatment was given. She rapidly deteriorated and succumbed to her illness, 5 days after admission to our hospital.
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Aggressive giant rhabdomyosarcoma in 1-year-old child p. 226
Santosh Kumar Swain, Sampada Munjal, Manas Ranjan Baisakh
DOI:10.4103/am.am_53_18  
Rhabdomyosarcoma (RMS) is an aggressive malignant tumor arising from soft tissue, commonly seen among pediatric age group and mainly located in the head and neck region. It shows variable clinical and biological behaviors and needs individualized management of the lesion. Management of this neoplasm has a great challenge. Early diagnosis and adopting multimodal individualized therapy provide the best outcome. The treatment options of RMS include surgical excision, radiotherapy (RT), and chemotherapy. However, RT in early life is applied cautiously because of its early and late side effects. Here, we present a case of giant RMS in a 1-year-old child showing a huge mass in the oral cavity and right facial area. He had undergone treatment with RT and chemotherapy. The objective of this case report is to describe a case of an embryonal RMS, where the diagnosis is achievable by clinical, radiological, histopathological, and immunohistochemical findings.
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A classical case of mucinous appendiceal adenocarcinoma presenting with Sister Mary Joseph nodule p. 229
S Srinath, Keyur Yogesh Patel, BN Jayanth
DOI:10.4103/am.am_65_18  
Primary appendiceal adenocarcinomas are rare malignant neoplasms of the appendix. Carcinomas of the appendix are usually well-differentiated mucinous adenocarcinoma, which tend to produce pseudomyxoma peritonei, also known as gelatinous ascites, and do not show metastatic spread until late in the disease process. Umbilical metastasis from visceral malignancies described as Sister Mary Joseph nodule (SMJN) is rare and represents only 10% of all cutaneous metastases. To the best of our knowledge, only four cases of adenocarcinoma of the appendix metastasizing to the umbilicus have been reported in the medical literature. Here, we present a case of mucinous appendiceal adenocarcinoma which occurred in a 75-year-old female, who presented with SMJN.
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Parathyroid crisis: Delayed diagnosis p. 232
Abhishek Das, V Lenin Babu, M Dhiwakar, Krishnan Swaminathan
DOI:10.4103/am.am_75_18  
Parathyroid crisis is a rare endocrine emergency, but such presentations do happen in this day and age. It is imperative for clinicians to have low threshold for measuring serum calcium in any one with unexplained skeletal symptoms and lethargy.
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Posttraumatic tendoachilles tendon repair in a young female p. 234
Chirag Kapoor, Amrit Jha, Urang Patel, Paresh Golwala
DOI:10.4103/am.am_66_18  
Achilles tendon is the largest tendon in the body, which is formed by the confluence of soleus muscle tendon and medial and lateral gastrocnemius tendons, which is supplied by the posterior tibial artery. It usually ruptures 4 cm above the calcaneal insertion in hypovascular region. This report seeks to evaluate functional outcome result of a 19-year-old female patient who had undergone open-invasive repair for fresh Achilles tendon rupture followed by rehabilitation. The American Orthopedic Foot and Ankle Society Score was used to evaluate the outcome. Ankle range of motion and knee range of movements of both legs and ankle circumference of both legs were compared each time the patient was reviewed, and also when the patient returned to work. The patient resumed her work in 8 weeks with no complications. This case report shows that open-invasive Achilles tendon repair and early rehabilitation protocol provide satisfactory results, with early return to previous functional status and few complications risks.
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A rare combination of elbow dislocation and radiocarpal fracture dislocation p. 237
Siddhart Yadav, Vikram Khanna, Sunirmal Mukherjee
DOI:10.4103/am.am_23_18  
A 31-year-old male came to the hospital with ipsilateral radiocarpal fracture dislocation and elbow dislocation. Elbow was reduced immediately in the emergency, and the open reduction and internal fixation with plating were done for the radiocarpal fracture dislocation. The patient recovered with a good range of motion of both elbow and wrist. This combination of fracture is rare with the possible mechanisms being single impact due to the fall from a height on an outstretched hand or double impact on the elbow and the wrist.
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Tamoxifen in recurrent thin endometrium p. 240
Abdul Basith S. Fazal, Rachita Munjal, KS Kirthika
DOI:10.4103/am.am_57_18  
To evaluate the effects of tamoxifen in patients with repeated unresponsive thin endometrium (<6 mm). Three women showed recurrent thin endometrium <6 mm during frozen embryo transfer endometrial preparation. Tamoxifen was added in the successive cycles as an adjunct. The endometrium was found to build up more than the target 7 mm in all the women with tamoxifen therapy. Two of the women conceived. In frozen-thawed embryo transfer cycles with recurrent thin endometrium, addition of tamoxifen helps achieve target endometrial thickness.
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IMAGES IN MEDICINE Top

Vascular compression syndromes of abdomen and pelvis p. 242
Aruna R Patil, Linda Kalliath, Shrivalli Nandikoor
DOI:10.4103/am.am_74_18  
Vascular compression syndrome is a topic of both interest and controversy. There is a gamut of such processes in abdomen and pelvis which have characteristic imaging appearances. Computed tomography scan with contrast is the imaging modality of choice. Since such syndromes are frequently encountered in asymptomatic patients as well, precautious diagnosis has to be made strongly considering the relevant clinical history and deciphering the specific imaging features that would suggest the grave side of the pathology. This pictorial essay will address the clinical and imaging features of abdominal and pelvic vascular compression syndromes with relevant teaching points.
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