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   Table of Contents - Current issue
September-October 2020
Volume 33 | Issue 5
Page Nos. 257-320

Online since Wednesday, June 2, 2021

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Covid-19 Pandemic: A spoiler for health research p. 257
Sonali Sarkar, Rakesh Aggarwal
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Clinicopathological profile and outcome of adult infection-related glomerulonephritis: A prospective follow-up study p. 260
S Arivazhagan, D Rajasekar, N Gopalakrishnan, R Sakthirajan, J Dhanapriya, T Dinesh Kumar, T Balasubramanian, N Malathy
Background. Infection-related glomerulonephritis (IRGN) in adults is witnessing a dramatic shift in its epidemiology and outcome. Adult IRGN studies are all retrospective in nature, and Indian studies are scarce. Methods. We did this prospective study (September 2016–April 2018) on all patients with biopsy-proven IRGN and age ≥18 years satisfying three of five diagnostic criteria. Patients with persistent hypocomplementaemia (>3 months) were excluded. We did electron microscopy in those without a minimum of three diagnostic criteria and did an extensive search for any occult infection in every patient. Results. Forty-five patients were studied with a mean (SD) follow-up of 45.7 (20) weeks. Their mean age was 41.5 years (18–70 years), with a female preponderance (1:1.25). At presentation, the majority had oedema (100%), oliguria (84.4%), hypertension (80%) and haematuria (77.8%). Of them, 86.7% had renal insufficiency and 35.6% required dialysis. Only 53.3% of them had evidence of antecedent/ current infection, with skin/subcutaneous focus being the most common site. Hypocomplementaemia was present in 82.2% of patients. Salient pathological features were endocapillary proliferation (93.3%), neutrophilic infiltration (88.9%), presence of crescents (17.8%), interstitial infiltration (24.4%), moderate-to-severe interstitial fibrosis with tubular atrophy (IFTA; 15.5%) and underlying diabetic glomerulosclerosis (8.9%). Only 66.7% of patients made complete renal recovery. By logistic regression analysis, the predictors of poor outcome were a requirement for dialysis at presentation (p=0.04) and presence of IFTA (p = 0.03). Conclusion. A proportion of adult IRGN patients progress to chronic kidney disease.
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Court evidence via video conferencing by doctors: Savings of time, money and energy p. 265
Akash Deep Aggarwal, Didar Singh Walia, Krishan Kumar Aggarwal, Surinder Singh Oberoi, Preetinder Singh, Nikhil Mehta, Charan Kamal
Background. Doctors are called to courts to give evidence as experts. This is time-consuming and impedes routine patient care. The court ordered the state to instal a video conferencing system for the benefit of doctors in hospitals for this purpose. We aimed to quantify the costs and benefits of the video conferencing system for doctors to give evidence as expert witness in courts. Methods. We analysed the tele-evidence system at our institution from the societal point of view examining whether the arrangements were positive for the taxpayers and second from the point of view of a cost–break-even analysis. Results. Over a period of 1 year, 482 tele-evidences were recorded from our site. Most of the doctors appearing for court evidence were males (84%) and the majority were in government health services (84.4%). These expert witnesses included specialists (83.8%), followed by super-specialists (10.4%) and non-specialists (5.8%). The subject experts who were called the most were radiologists (19.5%), forensic experts (18.3%), surgeons (18.0%), orthopaedic surgeons (12.4%) and neurosurgeons (6.6%). Average savings per tele-evidence were ₹2620; 181 km of travel was prevented and 4 hours and 12 minutes of time was saved. Conclusions. Given our limited resources, video conferencing saves costs, time and travel.
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Adjuvant radiation therapy for malignant tumours of the eyelid: Experience from a tertiary cancer centre in India p. 271
Sushmita Pathy, Bhanu Prasad Venkatesulu, Supriya Mallick, Suryanarayana S.V. Deo, Bidhu Kalyan Mohanti
Background. Tumours of the eyelid are a rare subgroup of neoplasms with varied histology and inherent differences in clinical behaviour. Surgery is the standard of care, and adjuvant radiation therapy (RT) is given in the presence of features suggesting a high risk of local recurrence. The treatment of lymph nodes in the neck is debatable. We reviewed the utility of RT for lymph nodes in the neck in patients with malignant tumours of the eyelid. Methods. We reviewed medical records of all patients with tumours of the eyelid treated at our centre from July 2006 to December 2014 for their demographic, clinical profile, treatment details and outcome. Results. The records of 37 patients were included for analysis, of these 34 underwent surgery and 21 received adjuvant RT. Their median age was 60 (range 30–85) years. Sebaceous cell carcinoma was the most common (50.4%). The median disease-free survival (DFS) was 35 months (95% CI 17.9–52.0). The 1- and 3-year DFS were 82.7% and 45%, respectively. Univariate analysis showed a superior outcome with early stage (T1) tumours (p=0.01), RT dose of ≥60 Gy and those underwent lymph node dissection (p=0.03). The presence of high-risk factors including close or positive margin had an inferior outcome with a trend towards statistical significance (p=0.06). Conclusion. We found a favourable outcome with early T stage, RT dose of ≥60 Gy and lymph node dissection. High-risk histopathological features including close margins and positive lymph nodes merit adjuvant RT including regional lymph nodes.
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Drooping shoulders: A rare manifestation of an uncommon disease p. 276
Rishav Bansal, Sumitabh Singh, Sunny Singhal, Gevesh Dewangan, Chandan Jyoti Das, Aparajit Ballav Dey
Primary systemic amyloidosis is an uncommon disease which presents with involvement of the kidney, heart, peripheral nervous system and liver. The involvement of skeletal muscles called amyloid myopathy is uncommon. We report a 74-year-old male who presented with progressively drooping shoulders followed by other muscular involvement without other organ involvement as a manifestation of amyloidosis. The patient was managed with melphalan, prednisolone and thalidomide with clinical improvement.
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Metreleptin replacement treatment improves quality of life and psychological well-being in congenital generalized lipodystrophy p. 278
Ilgin Yildirim Simsir, Banu Sarer Yurekli, Irmak Polat, Fusun Saygili, Baris Akinci
The near total lack of subcutaneous fat in congenital generalized lipodystrophy (CGL) leads to the accumulation of fat in ectopic organs and severe insulin resistance, which are associated with serious metabolic abnormalities. Cosmetic aspects of the disease are likely to affect the quality of life (QoL) and physiological well-being in these individuals. Metreleptin, recombinant human leptin, replacement treatment has been shown to have benefits in treating the metabolic abnormalities of CGL. In a patient with CGL caused by a homozygous AGPAT2 pathogenic variant, we examined QoL and mood alterations (depression and anxiety) caused by this chronic disease. Metreleptin replacement treatment led to dramatic metabolic improvement in our patient. It was also was associated with improvements in QoL, depression and anxiety scores. We suggest that there is need for studies to document the benefit of metreleptin replacement treatment on QoL and physiological well-being in patients with CGL.
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Dry ice in the eye: A rare occupational hazard! p. 281
Rinky Agarwal, Jayanand Urkude, Nawazish Fatma Shaikh, Mousumi Banerjee, Namrata Sharma
Superficial corneal foreign bodies (FBs) are a common occupational ocular hazard and can cause visually important astigmatism. A 23-year-old male working in a factory, which produced dry ice (solid carbon dioxide), presented to our emergency unit with symptoms of whitish discolouration of the right cornea for 1 day. Visual acuity in both eyes was 20/20 and slit-lamp examination of the right eye revealed an irregularly shaped whitish superficial FB in the inferior paracentral cornea with surrounding superior nebular opacity. Its gentle removal with a moistened cotton bud revealed an underlying epithelial defect with residual whitish changes. At 1-month of follow-up, the patient had nebulo-macular corneal opacity with stromal thinning at the site of impacted dry ice. We speculate that dry ice causes corneal damage due to its extremely cold temperatures and the formation of carbonic acid.
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Mycobacterium chimaera: A novel pathogen with potential risk to cardiac surgical patients p. 284
Ruaridh Buchanan, Anuradha Agarwal, Elizabeth Mathai, Benny P Cherian
Mycobacterium chimaera was first described in 2004, coming to prominence in 2011 with reports from across the globe of invasive infections following cardiac surgery. This outbreak was linked to a specific type of heater cooler machine used for cardiac surgery by whole-genome sequencing. We briefly outline what is currently known about this pathogen, highlighting the importance of clinical vigilance and the diagnostic options for the clinician.
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Treatment adherence to tuberculosis: What works p. 288
Aravinda Chinnadurai
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Adding ovarian suppression to tamoxifen for pre-menopausal breast cancer p. 289
Abhenil Mittal, Ajay Gogia
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Primer of Epidemiology 3: An overview and observational study designs p. 291
Poornima Prabhakaran, Roopa Shivashankar
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Universal health coverage and tuberculosis care in India in the times of Covid-19: Aligning Ayushman Bharat (National Health Assurance Scheme) to improve case detection, reduce deaths and catastrophic health expenditure Highly accessed article p. 298
Anurag Bhargava, Madhavi Bhargava, Ajay Meher
India has the largest global burden of new cases of tuberculosis (TB) and deaths due to TB. These occur predominantly in the poor who suffer catastrophic costs during diagnosis and treatment. The National Tuberculosis Elimination Programme has ambitious goals of 80% reduction of incidence of TB, 90% reduction in mortality due to TB by 2025 and 0% occurrence of catastrophic costs to households affected by TB by 2020. The Covid-19 pandemic and the resulting disruption to TB services are expected to worsen the situation. There are gaps in case finding at the peripheral level and access to care at the higher level for patients with TB. An estimated 32% patients with active TB do not access diagnostic services, while catastrophic costs associated with hospitalization are a barrier to access for seriously ill patients. Deaths due to TB in India occur largely at home and not in medical facilities, and are preventable with appropriate inpatient care. The Ayushman Bharat scheme with its Health and Wellness Centres (HWCs) and coverage for inpatient care under the Pradhan Mantri Jan Arogya Yojana (PM-JAY) can facilitate, the achievement of the goals of TB elimination. The HWCs provide an opportunity to close the case-finding gap as first point of contact by enabling sputum transport services to the designated microscopy centres. This will facilitate case detection, reduce diagnostic delays, and decrease community transmission and the incidence of TB. The benefit package of PM-JAY can cover patients with pulmonary TB, inpatient evaluation for other forms of TB, enhance the allocation for treatment and cover management of comorbid conditions such as severe undernutrition, anaemia, HIV and diabetes.
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Perceptions of a university’s faculty members on organ donation p. 302
Nisha Yadav, Meena Jain, Ankur Sharma, Vishal Jain, Puneet Chahar, Neha Verma
Background. Availability of donated organs may save lives of people with end-stage disease. However, multiple barriers exist for obtaining donated organs such as insufficient knowledge and lack of a positive attitude towards organ donation. We assessed the knowledge and attitude regarding organ donation among faculty members of a university in India. Methods. We did this observational, cross-sectional study from December 2017 to January 2018. A structured, close-ended questionnaire consisting of 20 items was used to assess knowledge, attitude and practices regarding organ donation. Data for 170 participants were analysed using SPSS version 21. Unpaired t-test was used to compare the knowledge and attitude score among different variables. Results. A statistically significant difference was found between the attitude score of graduate and postgraduate faculty (p=0.003), as well as between graduate and doctoral faculty (p=0.001). We found that 5.3% of participants had already donated organs, 12.9% had pledged to donate and 63.5% of participants had expressed willingness to donate organs. Conclusions. There is a need to increase the knowledge regarding organ donation as most people have a good attitude towards organ donation, but their knowledge was insufficient and at times inaccurate.
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Global trends in attendance in medical colleges and possible solutions p. 306
Varad Puntambekar
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Letter from London p. 308
Anna Ruddock
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Letter from Mumbai p. 309
Sunil Pandya
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S.M. Chandramohan p. 311
Kanagavel Manickavasagam
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Cyclic oculomotor palsy in a young male p. 313
Adarsh Shashni, Pradeep Sharma, Nripen Gaur, Swati Phuljhele
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Anatomical absence of the anterior communicating artery p. 314
Navneet Ateriya, Devendra Jadav, Raghvendra Singh Shekhawat
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Covid warriors: A tag of pride or prejudice? p. 315
Nipun Malhotra, Nitesh Gupta, Pranav Ish
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The Covid-19 pandemic as an opportunity for advances in medicine p. 316
Ramesh Bijlani
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Critiquing the revised minimum qualifications for promotion of medical teachers in India p. 316
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
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BMJ awards 2020 for outstanding individuals and best research paper p. 319

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