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   Table of Contents - Current issue
Coverpage
January-June 2017
Volume 19 | Issue 1
Page Nos. 1-73

Online since Thursday, August 17, 2017

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EDITORIALS  

The evolution and future of combat casualty care p. 1
Bipin Puri
DOI:10.4103/jmms.jmms_42_17  
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Resilience training for armed forces personnel: Need of the hour p. 4
Alhad Anant Pawar
DOI:10.4103/jmms.jmms_46_17  
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ORIGINAL ARTICLES Top

Antimicrobial susceptibility testing of rapidly growing mycobacteria isolated from cases of surgical site infections by microbroth dilution method at a Tertiary Care Center p. 6
Raghu Sriram, Prasanna Sarangan
DOI:10.4103/jmms.jmms_19_17  
Aim: The study was carried out to ascertain antimicrobial susceptibility pattern of rapidly growing mycobacteria (RGM) isolated from cases of surgical site infections from May 2013 to May 2014 at a tertiary care center in Pune. Materials and Methods: This study included the isolation of RGM from surgical site infections from May 2013 to May 2014 at a tertiary care center in Pune. The specimens were processed for microscopy (Ziehl–Neelsen stain) and culture (Lowenstein–Jensen media) using conventional methods. The minimum inhibitory concentrations of each of the isolates were determined by microbroth dilution, using Sensititre RAPMYCO manufactured by the firm TREK Diagnostic Systems from Thermo Scientific. Interpretations of results were done as per the Clinical and Laboratory Standards Institute M24-A. Results: Of the RGM isolated, Mycobacterium abscessus was the predominant isolate followed by Mycobacterium fortuitum and Mycobacterium chelonae. Of the 102 isolates, 64 (53.3%) were M. abscessus, 30 (25%) were M. fortuitum, 8 (6.67%) were M. chelonae, and 18 (15%) were other atypical Mycobacterium species. All 102 isolates of RGM were tested for antibiotic susceptibility testing by microbroth dilution. M. fortuitum and M. chelonae were sensitive to most of the antibiotics tested with few exceptions. All isolates (M. fortuitum and M. chelonae) were resistant to cefoxitin except few M. abscessus. Maximum resistance was seen with M. abscessus and they were sensitive to amikacin, tobramycin, tigecycline, and clarithromycin only. Out of 64 isolates, 32 (50%) were resistant to linezolid and imipenem. Conclusions: This study was carried out to highlight the importance of RGM and their susceptibility testing in all clinical microbiology laboratories.
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Analysis of normal retinal nerve fiber layer thickness by age and sex using spectral domain tomography p. 11
R Aiswarya, Hemant Singh Trehan
DOI:10.4103/jmms.jmms_3_17  
Background: To analyze the nerve fiber layer thickness in a heterogeneous Indian population according to age and sex and to compare this parameter to published normative data on the Caucasian population to better understand the racial differences. Materials and Methods: A total of 400 patients of both gender belonging to various age groups were evaluated using Cirrus HD optical coherence tomography (OCT), Carl Zeiss, Meditec, Dublin. The results were evaluated and compared to determine the normal retinal nerve fiber layer thickness (RNFLT) and its variations with age and sex. Results: Average nerve fiber thickness along the 3.4 mm diameter circle around the optic nerve head was approximately 90.57 ± 11.59 μm. There was no significant difference seen between males and females for mean, quadrant, and clockwise RNFLT. This was the same in all the subgroups of our study. Conclusions: Our results provide the variations of RNFL in Indian population. To the best of our knowledge, this is the first study in our country done with a high sample size in the Cirrus HD-OCT machine.
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Use of internet for accessing healthcare information among patients in an outpatient department of a Tertiary Care Center p. 15
Lakshmi Renganathan, Sougat Ray, Deepak Nagpal
DOI:10.4103/jmms.jmms_1_17  
Background: Health information is one of the most accessed topics online. Worldwide, about 4.5% of all Internet searches are for health-related informationand more than 70, 000 websites disseminate health information. However, critics question the quality and credibility of online health information as contents are mostly a result of limited research or are commercialised. There is a need to train people to locate relevant websites where they can efficiently retrieve evidence based information and evaluate the same. The study was conducted with the objectives of determining the prevalence of use of internet for accessing healthcare information amongst literate adult population in an urban area and to assess the association between the demography and the reasons of internet use. Methodology: We used an anonymous, cross sectional survey completed by a sample of out patients of 408 individuals who came to a tertiary care centre at Pune during the year 2015. The survey consisted of 17 questions related to behavioural, attitudinal and demographic items. Results: Out of the total of 408 individuals, 256 (63.2%) individuals used internet for health information though 332 (82.4%) of them were aware of authorised websites for health information and 69 (16.9%) thought information available in the internet can be harmful. Also, 63 out of 256 (24.6%) agreed to the fact that they ask questions to their doctors based on the information that they acquired from internet while surfing about that particular disease/ ailment. More individuals (p<0.05) who were working and who were educated, graduates and above, were using internet for health information. Conclusion: Our results suggest the great potential for using the internet to disseminate the information and awareness to the public about health and healthcare facilities. However, it is important to disseminate credible information from reliable and authorised websites assigned for health since online healthcare information can reach target masses within a very short span of time.
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Psychiatric morbidity in psoriasis: A case-control study p. 18
Sunil Goyal, Rohith R Pisharody, Shubhranshu Nath
DOI:10.4103/jmms.jmms_22_17  
Objective: Psoriasis is a chronic, relapsing and disfiguring dermatological disorder with a significant effect on occupational, social, and other areas of functioning. Psychological stress has been known to have a significant role in the onset and exacerbation of this illness. To study the prevalence of psychiatric morbidity in psoriasis and the influence of specified demographic, psychological, social and illness-related variables. Methods: The study was carried out at a tertiary care hospital in a large urban setup. In this case–control study, 100 cases of psoriasis were studied in comparison with healthy controls who were matched for sociodemographic profile. The participants were given a sociodemographic questionnaire, clinical profile sheet, and psoriasis area and severity index (PASI). General Health Questionnaire-12 (GHQ-12) was used to screen for psychological distress, and subsequently, Hospital Anxiety and Depression Scale for screening for depression and anxiety and World Health Organization Quality of Life-BREF scale for assessing the quality of life (QOL) were administered. The results obtained were analyzed for evaluating the psychiatric morbidity and its various correlates. Appropriate statistical analysis was done using SPSS 21. Results: Using GHQ-12 cutoff score (≥3) for psychological distress, the overall prevalence of psychological distress was significantly more in cases of in comparison to healthy controls with an odds ratio of 8.54 (95% confidence interval 3.16–23.07, P < 0.0001). Statistical analysis showed a statistically significant correlation of educational status with QOL and severity of skin lesions (PASI) with anxiety level. Severe skin lesions, more so on visible body parts were associated more commonly with psychological distress. Conclusions: All patients of psoriasis should be educated about the nature of the illness and screened for psychological distress. Dermatologists and family members should be educated to recognize the symptoms early and encouraged to seek the help of psychiatrist.
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Efficacy and safety of viscosupplementation in symptomatic knee osteoarthritis: An experience from a Tertiary Care Center in Mumbai p. 24
Anuj Singhal, Vishal Marwaha, Vivek Hande, Ajay Deep Sud
DOI:10.4103/jmms.jmms_5_16  
Objective: To report on our clinical experience (safety and efficacy) of intraarticular injection of high molecular weight hyaluronic acid in symptomatic knee osteoarthritis. Methods: In this prospective, experimental pre post efficacy, non-comparative study, 39 patients with symptomatic knee osteoarthritis (OA) were treated with single intra-articular injection of high molecular weight (HMW) hyaluronic acid (Hylan G-F20). Pain visual analogue scale (VAS) and WOMAC scores were evaluated at baseline, after three and six months. The study as completed over one year. The change in VAS and WOMAC score from baseline was calculated for patients who completed all three visits. Results: The mean age of participants was 55.5 (+10.9) years; mean duration of OA was 4.8 (+3.1) years. Of the 39 patients, 12 patientshad grade 2 OA, 26 patients had grade 3 OA and one patient had grade 4 OA. Thirteen patients completed all three visits, and seven patients completed baseline and three month evaluation. The median VAS score reduced from 6.5 (+2.1) at baseline to 3.5 (+2.1) at 3 months and 4.5 (+2.2) at 6 months, P = 0.01 (vs Baseline). The median WOMAC score reduced from 52.5 (+18.5) baseline to 23 (+13.5) at 3 months and 33 (+17.5) at 6 months, P = 0.0004 (vs baseline). Study medication was well tolerated. None of the patients reported any adverse event. Conclusion: In our experience intra-articular HMW hyaluronic acid (Hylan G-F20) is a good and safe therapeutic option for patients with mild to moderate knee OA to reduce pain.
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Food poisoning outbreak in a training establishment: A retrospective cohort study p. 28
Maramraj Kiran Kumar, Vijay Bhaskar, Sougat Ray
DOI:10.4103/jmms.jmms_17_17  
Background: An outbreak of food poisoning occurred among recruits in a training establishment. Investigation of outbreak was undertaken with active preventive interventions concurrently to arrest the current outbreak as well as to avoid such incidents in future. Materials and Methods: A retrospective cohort study was undertaken among all recruits, regardless of presence or absence of symptoms. The risk ratios (relative risks) and attributable risks were calculated for each food item of the suspected meal to assess the association between consumption of individual food items and subsequent illness. An environmental survey was undertaken to investigate into the course of food processing and storage facilities at trainees' galley (cookhouse) and other relevant eating establishments. Results: A total of 494 recruits reported with symptoms of gastroenteritis in a span of 3 days. Of those affected, only 9 were admitted and rest recovered with treatment on OPD basis. The overall attack rate was 22.9%. No deaths were reported. It was a classical point source, single exposure gastroenteritis outbreak. When food histories and sickness histories were analyzed, the attributable risk (24.17) and relative risk (5.11) were highest for the “Flavoured milk,” which was an outsourced item. The statistical findings were substantiated with environmental and epidemiological evidence. Conclusion: Epidemiological investigation incriminated dinner of the previous day as the meal responsible for the outbreak with flavored milk as the most attributable food item.
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Body fat composition as a marker for risk assessment in hypertension p. 34
S Vijay Bhaskar, Rajul K Gupta, Maramraj Kiran Kumar
DOI:10.4103/jmms.jmms_11_17  
Introduction: High blood pressure (BP) is one of the most common chronic medical problems prompting visits to primary health-care providers. The incidence of lifestyle diseases over the years has shown an upward trend in developing countries too, which is a cause of grave concern for the health care professionals. Research suggests that undesirable body composition has a major bearing on health, fitness and lifestyle diseases such as hypertension, ischemic heart disease, and diabetes. Study: The aim of the study was to compare the body composition of hypertensive patients with normal subjects using state of the art impedance based noninvasive body composition analyzer. The study evaluated the body composition of hypertensive patients and compared the same with subjects with normal BP. The study was carried out at a tertiary care hospital in Pune. Body composition variables considered for the study were anthropometry, percent body fat, lean body mass, fat distribution, and visceral fat composition. Results: The analysis of body fat included obesity degree, visceral fat area (VFA), body fat mass, and percent body fat. The mean body fat mass was found to be 21.7Kg. The mean percent Body Fat was 28.9%, which was much higher than the normal. Various parameters depicting body fat were compared. All of them, namely body fat mass, percent body fat, obesity degree, and VFA were found to be significantly higher in hypertensives as compared to the other group. Conclusion: Besides other anthropometric parameters, assessment of VFA may be included as an essential measure to assess and even predict hypertension. Those with high VFA must be monitored closely for developing hypertension and other lifestyle diseases.
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Transversus abdominis plane block: A multimodal analgesia technique – Our experience p. 38
Deepak Dwivedi, Vidhu Bhatnagar, Harindra Kumar Goje, Arijit Ray, Pawan Kumar
DOI:10.4103/jmms.jmms_9_17  
Context: A retrospective observational study conducted to assess transversus abdominis plane (TAP) block as a tool for providing multimodal analgesia postoperatively for abdominal surgeries. Aims: The aim is to compare the visual analog scale (VAS) of pain and the requirement of rescue analgesia postoperatively in patients undergoing various abdominal surgeries (open and laparoscopic) where TAP block was given for postoperative analgesia and was compared with patients who received pain relief according to the institutional protocol. Settings and Design: Retrospective observational study conducted in a tertiary care hospital. Subjects and Methods: Retrospective data from anesthesia records of patients, who underwent abdominal surgeries from January 2016 to December 2016, were analyzed and were divided into two groups. Group A (n = 250) consisted of patients who received the conventional standard postoperative analgesia protocol of the department of anesthesia. Group B (n = 136) consisted of patients who were administered TAP block postsurgery for the postoperative analgesia by the trained anesthesiologist. Primary outcome considered was (i) average VAS at 02, 06, 12, and 24 h and (ii) average opioid/nonsteroidal anti-inflammatory drug consumption at 24 h postoperatively. Secondary outcome considered was time to first rescue analgesia. Statistical Analysis: All parametric data were analyzed using unpaired t-test. Data are expressed as the mean ± standard deviation. A SPSS version 17 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Results: Average pain scores (VAS) were lower in Group B as compared to Group A in all subcategories of surgery postoperatively. Patients given TAP block (Group B) required less rescue analgesia in the postoperative period with time to first rescue analgesia being prolonged. Conclusions: On the basis of our retrospective study, we suggest that TAP block can be utilized as a part of multimodal analgesia regimen for abdominal surgeries, laparoscopic as well as open. Tap block has demonstrated a good safety profile in experienced hands; it is easy to perform and has displayed consistent analgesia over a prolonged period. It reduces postoperative morbidity and supports early ambulation.
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Study of lifestyle diseases among workers of an ammunition factory p. 43
Arun Gupta, Neeti Goyal, AK Jindal, Raj Kumar
DOI:10.4103/jmms.jmms_3_16  
Background: Lifestyle diseases which include hypertension, type 2 diabetes mellitus, obesity, and stroke are caused by influences on the human body by the way people live their lives. This study is an effort to describe the prevalence of various lifestyle diseases; factors associated with their causation and suggest measures for improvement of the health status among the industrial workers. Materials and Methods: A total of 351 workers were included in this study. The prevalence and pattern of lifestyle diseases among industrial workers were studied. The survey had two principal components, namely, the pretested standardized questionnaire and clinical examination. Blood sugar levels were assessed by a glucometer. Results: Hypertension was the most common lifestyle disease, seen among 43.0% of workers. It was significantly related to age, socioeconomic status type 2, body mass index (BMI), and habit of tobacco chewing. Only one-fourth were aware of their blood pressure status. Other diseases brought out were diabetes type 2 mellitus (7.7%) and obesity (4%). In this study, among those with type 2 diabetes mellitus, 29.63% were not aware of their blood sugar status. Diabetes was significantly related to BMI and increased significantly with increase in age. Also, one-third of the study population was overweight. Conclusion: Lifestyle diseases were found to be the major causes of morbidity among the study participants. Hypertension, type 2 diabetes mellitus, and overweight/obesity were the common morbidities. These conditions were associated with factors such as age, socioeconomic status, BMI, and history of tobacco chewing.
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Talcum powder and photoprotection Highly accessed article p. 48
Jandhyala Sridhar, CR Srinivas
DOI:10.4103/jmms.jmms_35_17  
Context: Talcum powder is a popular daily use cosmetic product in India with a high urban and rural penetration. Aim: To examine the photoprotective ability of a popular brand of talcum powder. Design: Nonrandomized controlled efficacy study. Subjects and Methods: Minimal erythema dose (MED) following narrowband ultraviolet B irradiation among ten volunteers was recorded. Sun protection factor (SPF) of talcum powder was determined by standard in vivo method. Percentages of zinc oxide in the test sample and ten other commercially available brands of talcum powder were estimated by atomic absorption spectrophotometry. Statistical Analysis Used: Calculation of mean. Results: The mean MED of volunteers was 310 milli Joule (mJ) without talcum powder and 400 mJ with talcum powder. The mean SPF of talcum powder was 1.29. The percentage of zinc oxide in the test sample was estimated to be 1.5%. Conclusions: Talcum powder offers low photoprotection due to low zinc oxide content.
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Seroprevalence of cytomegalovirus infection in antenatal women in a Tertiary Care Center in Western India p. 51
Mahadevan Kumar, Mohammad Bashir Nizam, M Mugunthan
DOI:10.4103/jmms.jmms_26_17  
Context: Human cytomegalovirus (CMV), otherwise called human herpesvirus 5, is a member of the Herpesviridae family. Maternofetal transmission of CMV can occur during pregnancy following primary or recurrent infections in the mother. Infections in utero are associated with fetal abnormalities, intrauterine growth retardation, and intrauterine death. In India, 80%–90% of the adult population show presence of CMV antibodies; however, there are few articles showing the prevalence of CMV infection in pregnant women. Aims: The aim of this study is to assess seroprevalence of CMV infection in antenatal women. Settings and Design: This is a cross-sectional, observational study, study population: women reporting for antenatal care to the OPD at a tertiary care hospital. Subjects and Methods: Three hundred and seventy serum samples drawn from antenatal women attending OPD in a tertiary care center were tested for IgG and IgM antibodies by enzyme-linked immunosorbent assay. Statistical Analysis Used: Statistical significance was estimated by calculating “P value.” Results: Of the 370 samples tested, 83% showed the presence of CMV IgG and 9.46% were positive for CMV IgM. All those cases which were IgM positive were seropositive for CMV IgG as well. Sixteen percent of the antenatal women were both IgG and IgM negative. Conclusion: The prevalence of CMV IgG in antenatal women in this region is high. Around 16% of the women showed lack of IgG. It would be beneficial to screen pregnant women for CMV IgM antibodies is beneficial and will help guide the testing of newborns suspected to be infected with CMV in order that appropriate therapy of the infected infants can be instituted promptly and appropriate advice can be rendered on prevention of transmission.
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CASE REPORTS Top

A rare case of mediastinal nonseminomatous germ cell tumor with acute Megakaryocytic Leukemia p. 55
GS Chowdhary, Malav Darshan Jhala
DOI:10.4103/jmms.jmms_14_17  
The most common extragonadal site of Nonseminomatous Germ Cell Tumours is the mediastinum. These are similar to their gonadal counterparts in histology but have a poorer prognosis. The association of mediastinal germ cell tumours with blood borne malignancies has been established in many case reports. However, the association of concomitant mediastinal non seminomatous germ cell tumours with Acute Megakaryocytic Leukemia is very rare with only 26 cases reported in the last 07 Decades. These patients have a very poor prognosis with only one survivor being reported till present date. AML (M7), a rare variant of Primary AML , has been more commonly associated with non seminomatous germ cell tumours. Here, we report such a rare case of dual malignancy, Non Seminomatous Germ Cell Tumour with AML (M7) which was managed at our centre.
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The perioperative concerns of emergency neurosurgery in elderly patients: A series of three cases p. 58
Vidhu Bhatnagar, SGS Datta, Swayam Tara
DOI:10.4103/jmms.jmms_7_17  
Owing to many advances in anesthetic techniques, perioperative sophisticated monitoring as well as surgical techniques, there has been an exponential increase in the geriatric patients presenting for elective as well as emergency surgeries. Perioperative period in the elderly is more prone to adverse outcomes due to factors such as advanced age group, limited functional capacity, multiple comorbid conditions, impaired cognition as well as limited support at the home front. The severity of illness is a better predictor of outcomes if compared with the age. The perioperative risk of mortality and morbidity in elderly patients increases all the more if the surgery has to be performed in an emergency. We present a series of three cases, highlighting perioperative concerns and management of elderly patients undergoing emergency neurosurgeries at our institution.
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A case of posttransplant lymphoproliferative disorder p. 61
GS Chowdhary, Malav Darshan Jhala, Gurpreet Kaur
DOI:10.4103/jmms.jmms_13_17  
Posttransplant lymphoproliferative disorders (PTLDs) are life-threatening complications of solid-organ and bone marrow transplantations leading to a high mortality. PTLD represents a heterogeneous group of lymphoproliferative diseases. They become clinically relevant because of the expansion of transplantation medicine together with the development of potent immunosuppressive drugs associated now with a long survival. The risk of PTLD is highest in the early posttransplant period, but the cumulative risk increases with time. We report a case of two sequential malignancies – carcinoma bladder - 13 years and now gastric lymphoma - 15 years after renal transplantation in a 73-year-old male.
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HISTORY OF MILITARY MEDICINE Top

Navy Hospital ships in history p. 63
Sougat Ray, CS Naidu
DOI:10.4103/jmms.jmms_43_17  
Hospital ships are operated by the Naval forces in or near war zones to provide medical assistance to the wounded personnel of all nationalities and not be used for any military purpose. Hospital ships possibly existed in ancient times and the Athenian Navy had a ship named Therapia. However, it was only during the 17th century that it became a common practice for the naval squadrons to be accompanied by large ships with the facilities of carrying the wounded after each engagement. In 1860, the steamships HMS Melbourne and HMS Mauritius were equipped with genuine medical facilities. They were manned by the Medical Staff Corps and provided services to the British expedition to China. During the World War I and World War II, passenger ships were converted for use as hospital ships and were started to be used on a massive scale. RMS Aquitania and HMHS Britannic were two famous examples of hospital ships used extensively. Modern US hospital ships USNS Mercy and USNS Comfort are operated by Military Sealift Command of the US Navy. Their primary mission is to provide emergency on-site care for US combatant forces deployed in war or other operations.
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UPDATES Top

Updates on military medicine p. 66
Rohit Verma
DOI:10.4103/jmms.jmms_44_17  
Updates on Military Medicine including Naval Medicine; Combat and Trauma Medical Care; Military Epidemiology and Military Psychiatry. The summary of the latest scientific publications in the field of Marine Medicine and allied sciences.
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SHIPBOARD MEDICINE Top

Viral hepatitis E during offshore deployment -A case report p. 68
M Indrakanth Reddy, Ushakiran Singh, Arpit Upadhayaya
DOI:10.4103/jmms.jmms_48_17  
A 20-year-old young serving sailor presented with a two day history of loss of appetite, mild grade fever and yellow discoloration of both eyes and urine, while sailing, off the home port. He had icterus and tender Grade I hepatomegaly and was provisionally diagnosed as a case of clinical jaundice. As there was no facility for investigation on board, the severity of jaundice, as well as the type of infection were not known. The patient was isolated in a separate compartment and universal precautions were taken for the nursing members. Proper handwashing, chlorination of the water tanks, boiling of drinking water for the ships' company and disinfection procedures for the sick bay were followed. The crew was educated on reporting to the sick bay whenever any signs or symptoms of jaundice appear in them. After five days, the sailor was referred to a tertiary care hospital when the ship reached the nearest port. He was found to be having high bilirubin level and his liver enzymes and PT/INR were deranged. He was positive for Hepatitis E. Prompt control measures undertaken by the Medical Officer of the ship ensured that there were no other cases of jaundice reporting from the ship.
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LETTERS TO EDITOR Top

Renal cell carcinoma with inferior vena cava extension: An anesthetic challenge p. 70
MK John, Nihar Ameta, Jacob Mathews, Sarvesh Shrivastava
DOI:10.4103/jmms.jmms_40_17  
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Interim results of a study of the effect of hyperbaric oxygen therapy on healing of chronic leg ulcers p. 72
Praveen Kumar Krosuri, R Sekhar, Abhishek Srivastava, Azharuddin Attar, Jessica Shah
DOI:10.4103/jmms.jmms_8_17  
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