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   Table of Contents - Current issue
April-June 2020
Volume 17 | Issue 2
Page Nos. 63-127

Online since Thursday, June 18, 2020

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Editorial p. 63
RN Srivastava
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COVID-19 pandemic and the surgeons Highly accessed article p. 64
Raju Vaishya
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Epidemiological pattern of blunt trauma chest in Western India p. 66
Anita Kumari Gupta, Amit Kumar Sharma, Naresh Kumar Suthar, HR Girija, Vijay Verma, Satya Prakash Jindal
Introduction: Chest injuries constitute an important aspect of trauma. Despite high mortality rates, but the majority of patients with thoracic injuries can be managed by a simple intervention like tube thoracostomy. Aims and Objective: The aim of this study is to analyze the epidemiological pattern of chest injury and assess the outcome at our institute. Materials and Methods: This was a prospective observational study done at a tertiary care center of north India from July 2015 to December 2016, including 200 patients. Results: Road traffic accident was the most common cause of chest trauma (61%) followed by fall from height (23%). We observed rib fracture in 78% of patients, surgical emphysema in 31%, hemopneumothorax in 31.5%, hemothorax in 25%, and pneumothorax in 8.5% patients. Twenty-four percent (48/200) patients were managed conservatively, whereas 72.5% (145/200) patients were managed by chest tube drainage. Only seven (3.5%) patients underwent surgical procedures for chest injury in terms of thoracotomy or laparotomy. The mortality rate in our study was 6.5%, whereas 9.5% of patients required ventilator support. Conclusion: In our study, most of the patients were managed conservatively or simply by chest tube drainage. The overall prognosis depends more on associated injuries and morbidity. Associated head injury is the major factor behind need of ventilator and intensive care unit support and led to death in the majority of patients.
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Patterns of self-intoxication among inpatients in Benghazi medical center – Libya Highly accessed article p. 70
Muftah S Elsaeiti, Soad I Alkhumsi, Khaled D Alsaeiti
Background: Self-harm is a major public health concern, with community studies reporting a lifetime risk of 13%–18%, it is a key risk factor for suicide, and it is important to have contemporary information on the extent of risk and is relatively common among young people with prevalence rates in adolescent samples which range from 6.9% to 15.9%. One review of the literature showed that 13.2% of adolescents reported engaging in self-harm at some stage in their lives. The aim of this study was to describe the characteristics patterns of self-intoxication patients and their response to psychiatric consultation. Patients and Methods: This observational single-center study involved prospective review of all patients whom admitted to the Medical Department at Benghazi Medical Center over a 12-month period from January 2017 to December 2017 after self-intoxication. Self-intoxication with suicidal intent was assessed in the emergency department after questioning of the patient and relatives. Data included were age, sex, marital status, employment, type and source of drugs or toxins, and whether the material was taken intentionally or accidentally. Patients who were considered to have an accidental overdose or drug mistake were not included in the study. Results: Sixty-six patients were identified, 53 (80%) were females with a mean age of 23 years, 49 (74%) were single, and all males were jobless and school-leavers. Twenty-nine (55%) females were homemakers, 19 (36%) were students, and 9% were working. Fifty-seven (86%) get the drugs from their home, 9 (14%) bought from the market, 55 (83%) took the drug intentionally, and 11 (17%) accidentally. Thirty (45%) used drugs as toxins, 22 (33%) insecticides, 10 (5%) rat killers, and 4 (6%) other types of toxins. Nine (14%) were admitted to the intensive care unit, 38 (58%) refused any psychiatric consultation. Conclusions: Causes are associated with both individual and socioeconomic parameters, such as relationships among family members, unemployment, insufficient education, and drug misuse. Due to the repeated drug intoxication events, it is obvious that these persons definitely need psychiatric help and support.
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Assessment of insomnia and sleep quality among medical students-benghazi university: A cross-sectional study Highly accessed article p. 73
Rabha A El Sahly, Abdelnasir M Ahmed, Salah Eldin A. Amer, Khaled D Alsaeiti
Background: Academic pressure and its associated stress are responsible for disturbances in the circadian cycle of the students, Medical students have a stressful academic career, so it is important to identify those students with sleep issues, extent of issues and factors contributing to it. The aim of the current study is to determine the frequency of poor sleep quality among fourth and fifth year medical students at Faculty of Medicine, Benghazi university; using the PSQI. Materials and Methods: An observational, cross-sectional study conducted anonymously and voluntarily with undergraduate fourth and fifth year medical students at faculty of medicine, Benghazi university.150 students were assessed using the Pittsburgh Sleep Quality Index (PSQI). Results: 150 medical students were participated in the study, 95(63.3%) were females and 55 (36.7%) were males. The sample's mean age was 26.1 ± 1.1 years (range = 23–30 years). More than half the sample (52.7%) were sleeping alone, 44.7% were sharing a room with a roommate, and 2.7% were married . The calculated means of total PSQI, nocturnal sleep duration, and sleep latency were 7.04 ± 3.47 hours, 6.23 ± 1.51 hours, 38.7 ± 39.1 minutes, respectively. The average wake-up time and The average bedtime were 7.45 ± 1.5, and 4.49 ± 7.06respectively. 115 (76.67%) students were poor sleeper and the prevalence of poor sleep quality was slightly higher among females than males (76.8%) and (74.4%) respectively with P = 0.004. Younger students were about two and half times more prone to have poor sleep quality compared to older participants (OR=2.4; 95% CI: 1.62-3.55). Conclusion: Poor sleep quality is common among our medical students. It established that most medical students have a poor sleep quality, which could be related to their sleep habits. This study highlights a strong need for integrating sleep hygiene education for young students, to improve their sleeping practices and consequent physical and mental health.
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Neurological manifestations of acute intermittent porphyria: Case series and current review p. 78
Rahi Kiran Bhattiprolu, Vijay Sardana
Background: Porphyrias are a group of inherited metabolic disorders, resulting from the deficiency of specific enzyme in the hemebiosynthesis. Among these, acute intermittent porphyria (AIP) is the most common type with neuropsychiatric features encountered in the clinical practice. In this study, we describe the presentation of AIP in five different patients admitted in our hospital. Materials and Methods: We prospectively collected the data of five patients of AIP admitted in our department in the past 2 years and studied in detail the causes, precipitants, clinical presentation, diagnosis, and management of AIP. Results: All five cases were males in second to third decades of life having a history of prior gastrointestinal symptoms for variable period before presenting to us with neurological manifestations of which one had abdominal pain for 2 years and had undergone appendicectomy also. All patients had seizures and psychiatric manifestations. Four patients had axonal polyneuropathy and respiratory failure requiring prolonged ventilator support. One patient had a past and family history of AIP. Sepsis as a trigger is noted in two patients. All patients had positive urine test for porphobilinogen. All had autonomic dysfunction, hyponatremia, and three patients expired after prolonged intensive care unit stay of which two had status epilepticus. Two patients survived with complete recovery and are under regular follow-up. Conclusion: Porphyria screening should be done in all patients presenting with unexplained motor neuropathy. Avoidance of triggers, early suspicion of the acute attack, and starting treatment immediately will prevent the complications and thus reduce morbidity and mortality due to the acute attack.
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Coronavirus infection in India: A dental surgeon's perspective p. 84
Malvika Singh
Of what was identified by the Chinese government in China's Wuhan district on January 7, 2020, and declared as a pandemic by the World Health Organization on March 11, 2020, severe acute respiratory syndrome-coronavirus 2 (CoV-2), most commonly known as 2019 novel CoV infection, has become a major challenge not only for India but also for the whole world. As on April 26, 2020, this viral infection has been recognized in over 200 countries, claiming 169,006 lives and infecting 2,471,136 people worldwide. The infection travels via respiratory droplets and clinical signs, and the symptoms include dry cough, fatigue, coughing sputum, and shortness of breath. Dental clinics are most susceptible to such infection since there is continuous production of aerosol making dental professionals highly vulnerable to the same and since there has not been a definitive pharmaceutical treatment for this infection, the whole situation makes it even more scary. This article is an attempt to throw light on CoV infection and enumerates certain preventive measures that can be taken in dental clinics while treating emergency cases along with preventing the spread to this deadly viral infection.
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The dilemma of thymectomy in myasthenia gravis p. 90
Pushpendra Nath Renjen, Dinesh Mohan Chaudhari, Anjali Mishra
Myasthenia gravis (MG) is an autoimmune disease that affects the neuromuscular junction causing fluctuating weakness of skeletal muscles. It is considered a rare disease with an estimated prevalence of 7.77/100,000. Surgical treatment is done by simple or extended thymectomy. Although thymectomy has been used in the treatment of MG since 1941, the role of thymectomy for MG is not completely understood. Perhaps, one of the longest unresolved issues in thoracic surgery is the role of thymectomy in the treatment of MG. Persistent questions and issues involve not only the surgical approach to thymectomy, but also the role of thymectomy itself in the treatment of MG. This article focuses on the review of thymectomy in MG patients.
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Nonsurgical treatment of adult acquired flatfoot is effective: A narrative review p. 94
Abhishek Vaish, Jyoti Sitaula, Raju Vaishya
Adult acquired flatfoot is a common clinical condition having complex pathology-posterior tibial tendon insufficiency and failure of ligamentous and capsular structures of the foot. There still remains a controversy in the management algorithm of the flexible flat foot. Conservative management is considered as the initial treatment, surgery being offered only when the conservative measures fail. The paramount importance is to assess the functional outcomes of conservative treatment, as not enough publications exist to evaluate its importance. This study aims to analyze evidence of benefits with nonsurgical treatment of the adult acquired flat foot. Online databases such as PubMed, Google Scholar, and Scopus were systematically searched for nonsurgical treatment of adult acquired flat foot in November 2019. Keywords used were “Flatfoot,” “Adult,” and “Pes planus.” The Boolean operators used were (AND), (OR), and (NOT). Five studies that matched our criteria were analyzed to assess the nonoperative treatment of adult flat foot for this review. Patient satisfaction with nonoperative treatment ranged from 60.6% to 89%. Conservative treatment was successful in 83%–87.5% and only the remaining patients required surgery. All of these studies support the use of a conservative approach in the management of acquired flatfoot deformity in adults in the form of orthotics with or without physiotherapy. Conservative methods are the mainstay of the management for Stage I and II AAFFF (Adult Acquired Flexible Flat Foot) with satisfactory functional results. The patient education and a reasonable period of care are essential for good outcomes. Surgery is necessary for patients in whom conservative management has failed and in all patients with fixed deformities.
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Coenzyme Q10 and alpha-lipoic acid: A hirata's connection to severe hypoglycemia? p. 99
Sulekha Mahendran, Mercy Hanna, Krishnan Swaminathan
We report a case of severe hypoglycemia in an elderly woman with multiple comorbidities, due to suspected autoimmune hypoglycemia from a combination of coenzyme Q10 and alpha-lipoic acid. Health-care professionals should be aware of the rare but potentially life-threatening auto-immune hypoglycemia from some of the commonly used supplements that are widely used in day-to-day diabetic clinical practice.
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Clinical manifestations and complications seen with scrub typhus: A case series from indore p. 101
Akshat Pandey, Abhimanyu Nigam, Ashmeet Chaudhary, VP Pandey
Scrub typhus is a zoonotic disease caused by the bite of a mite Orientia tsutsugamushi, a bacterium from the Rickettsiaceae family, which is transmitted to humans by bite of trombiculid mite. Scrub typhus is widely spread all across India, and despite its vast occurrence, it remains underdiagnosed. The probable reasons could be the lack of specific symptoms, poor access to the diagnostic facilities, and low index of suspicion by the clinicians. It is a common trend to rule out the common causes of infection such as malaria, typhoid, and leptospirosis, and then, a good number of cases are ultimately diagnosed as scrub typhus. The common presentation is high-grade fever (98%), tender regional/generalized lymphadenopathy (40%–97%), hepatosplenomegaly, cough, and a characteristic eschar that is found in nearly 50% of cases, which represents the site of bite by the mite. Here, we present with a series of cases from Indore of scrub typhus with pulmonary complications which too were underdiagnosed. Immunoglobulin M typhus (enzyme-linked immunosorbent assay) confirmed the diagnosis, and all three were efficiently managed with doxycycline.
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Hypertriglyceridemia-induced pancreatitis in pregnancy and its management issues: A case-based study p. 105
Babul Reddy Hanmayyagari, Jyoti Wadwa, Mounika Guntaka, Balamurali Krishna
Hyperlipidemia in pregnancy has grave complications; lipid levels in pregnancy are influenced by genetic and hormonal factors, primarily due to estrogen. Here, we present a case of acute pancreatitis with hypertriglyceridemia presenting during the second trimester of pregnancy. We also discuss the management issues of this entity during pregnancy.
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Refractory hypokalemia – An exigent concern: Case series and review of literature p. 108
Gunadhar Padhi, Masood Ahmed Chandsha
Potassium is a major intracellular cation affecting tonicity and regulating intracellular processes such as protein/glycogen synthesis and carbohydrate metabolism and partially responsible for maintaining the potential difference across the membrane, particularly in excitable tissues such as nerve and muscle. Of all the electrolytes, a rapid change in potassium concentration is life-threatening. Hypokalemia is a common electrolyte disturbance, especially in hospitalized patients. Severe hypokalemia is life-threatening and requires urgent medical attention. It may trigger dangerous arrhythmias such as ventricular fibrillation and tachycardia, leading to cardiac arrest. It leads to neuromuscular weakness prolonging weaning in mechanically ventilated patients and also contributes to paralytic ileus. The body maintains serum potassium concentration within very narrow limits through tightly regulated feedback and feedforward systems. Understanding the physiology of potassium homeostasis and diverse etiologies of hypokalemia spanning from error in sample collection, endocrine abnormalities, renal tubular acidosis, and many more may guide toward the appropriate treatment of hypokalemia.
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Aural polyp with chronic suppurative otitis media dissembling glomus tympanicum p. 111
Surya Kanta Pradhan, Sanjeev Gupta, Kamala Kanta Jena
Glomus tumors are benign, slow-growing tumors of the temporal bone and most commonly present as hearing loss and tinnitus with an intact tympanic membrane. Most of the time, the diagnosis is delayed and sometimes missed as it is associated with chronic suppurative otitis media (CSOM). History of the disease and proper clinical examination followed by radiological investigations are required for diagnosis and management. Surgery is the treatment of choice, but larger tumors may require other modalities of treatment. Histopathology with immunohistochemistry confirms the diagnosis. We report a case of 63-year-old female patient with glomus tympanicum associated with CSOM. She had symptoms for the last 10 years, but the diagnosis was missed because of coexisting CSOM. She was diagnosed with the help of radiological investigative modalities. She underwent mastoidectomy with complete excision of tumor. She was managed successfully without recurrence. Glomus tumor is an uncommon disease in the middle ear, and sometimes, its diagnosis is missed because of the presence of other diseases. Radiology helps in diagnosis and management of the tumor. Complete surgical excision with regular follow-up prevents recurrence.
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Prenatal diagnosis of gastroschisis on ultrasonography p. 115
Reddy Ravikanth, Vaijnath P Khanapure
Gastroschisis is an abdominal wall defect resulting from ischemia to blood vessels that supply the abdominal wall during the first trimester of pregnancy. The injury results in an opening in the abdominal wall that allows the abdominal contents, most often intestines and stomach, to develop outside the abdominal cavity. Early antenatal diagnosis of gastroschisis allows parental counseling regarding prognosis and optimizes management through a multidisciplinary approach.
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Rhinoscleroma in a pediatric patient p. 117
Santosh Kumar Swain, Priyanka Debta, Suryakanta Pradhan
Rhinoscleroma (RS) is a chronic granulomatous disease caused by Klebsiella rhinoscleromatis. The nose is affected in all cases but sometimes extend to other parts of the airways. Diagnosis of this disease is done on the basis of the histopathological examination (HPE) or direct evidence of the bacteria in nasal exudates. The differential diagnoses of the RS are syphilis, malignancy, and midline granuloma. Streptomycin is a drug of choice although fluoroquinolones and cephalosporins also provide good results. Surgery is opted in case of obstruction or deformity. Here, we report a case of an 11-year-old girl diagnosed as RS on the basis of the HPE. The patient was treated by endoscopic excision of the nasal mass followed a course of ciprofloxacin. She was remained asymptomatic at the last visit of 1 year after treatment and has no evidence of recurrence.
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Aspergillus nidulans: A rare cause of brain abscess p. 120
Anita Kumari Gupta, Rajendra Singh Parihar, Saloni Garg, Satya Prakash Jindal
Fungal infections of the central nervous system (CNS) are rarely encountered, and their development largely depends on the interplay between the virulence factors of various fungi and host's immune system. Recently, there has been an increase in the number of organ transplants, chemotherapies, and human immunodeficiency virus infections due to which the incidence of fungal brain abscess has increased. Aspergillus species is the most common cause of fungal brain abscess and generally occurs in patients with hematological malignancies and cancer chemotherapy. More than 100 Aspergillus species are known, and among these, the most virulent one is Aspergillus fumigatus, but Aspergillus niger, Aspergillus flavus, and Aspergillus terreus (which is relatively amphotericin resistant) can also cause human disease. Aspergillus nidulans is a species of Aspergillus, which is more virulent than other species and has a high mortality rate. Here, we report a case of brain abscess in a 35-year-old young female caused by A. nidulans presenting with symptoms of cerebral mass effect. On potassium hydroxide examination, thin branched septate hyphae were seen, and culture showed the growth of A. nidulans. Given the complexity of the patients at risk and the diverse array of fungal pathogens, CNS fungal infection poses a considerable diagnostic and therapeutic challenge. Although outcome is frequently fatal in patients with fungal brain abscess, early diagnosis, and appropriate antifungal therapy may reduce morbidity and mortality.
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Extensive periportal fibrosis due to hepatic iron overload masquerading as mass lesions in a beta-thalassemia major patient: Sonological appearances p. 124
Reddy Ravikanth, Denver Steven Pinto, Pooja Majumdar
Beta-thalassemia major as a condition is dependent on multiple blood transfusions. In patients with multiple blood transfusions, the liver is the initial site of iron deposition progressing from fibrosis to cirrhosis. Ultrasonography diagnosis of liver fibrosis has prognostic significance and is helpful in risk stratification for assessing treatment options. This case report describes the sonological appearances of the liver in a 28-year-old female who was a recipient of regular blood transfusions and subsequently developed hepatic iron overload which presented as extensive periportal fibrosis masquerading as intraparenchymal mass lesions.
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Thermographic appearance of dead necrotic tissue around a vicryl thread and sero-purulent discharge from the wound p. 126
Vedavyas Srigiriraju, P Ramamohan, Muniraju Katikala, Vishnu Vardhan Reddy, Amit Agrawal
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