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   Table of Contents - Current issue
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January-June 2018
Volume 20 | Issue 1
Page Nos. 1-82

Online since Monday, July 9, 2018

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EDITORIAL  

Medical challenges of women combatants: Looking to the future Highly accessed article p. 1
Sheila S Mathai, Ravi Kalra
DOI:10.4103/jmms.jmms_37_18  
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ORIGINAL ARTICLES Top

Vascular closure device in cardiac cath laboratory: A retrospective observational study p. 4
Ravi Kalra, R Ananthakrishnan, Sudhir Joshi, Jnanaprakash B Karanth
DOI:10.4103/jmms.jmms_21_18  
Objective: This study is to share our experience of using vascular closure device (VCD) after anterograde femoral arterial access at cardiac cath lab. Background: Vascular access site management is crucial to safe, efficient, comfortable, and cost-effective diagnostic or interventional percutaneous cardiac procedures. As per the literature, femoral artery access site complications following angiographic procedures range from 1% to 5%. The Angioseal VCD has been shown to be safe and effective in reducing the time to hemostasis following angiographic or other cardiac interventional procedures. Materials and Methods: This is a retrospective, observational study carried out at a tertiary care hospital of the Armed Forces. All patients in whom Angioseal (St. Jude Medical) were deployed after undergoing either diagnostic coronary angiography or percutaneous coronary intervention (PCI) through common femoral artery access. All patients from January 2011 to December 2016 in whom VCD was either deployed or attempted were included in the study. Results: A total of 16245 patients were taken up for femoral access for diagnostic procedures and PCI from 2011 to 2016. We observed 98.52% success rate with Angioseal and a mere 1.48% complication rate. Out of the complications observed, only 2 (0.13%) patients had the serious complication of limb ischemia rest were all minor complications. Conclusion: Our observations and experience with the Angioseal VCD are a safe, efficient, and resulting in more favorable patient outcomes.
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Effect of drill noise on contralateral hearing after mastoidectomy in cases of unilateral Chronic Otitis Media p. 9
Varun Jerath, Dilip Raghavan
DOI:10.4103/jmms.jmms_11_18  
Introduction: The mainstay of treatment of Chronic Otitis Media (COM) is Tympanoplasty with or without Mastoidectomy. This study was conducted in patients undergoing Tympanoplasty with Mastoidectomy to assess Sensorineural Hearing Loss (if any) due to drill noise on the contralateral ear. Materials and Methods: A total of 25 patients with unilateral COM scheduled to undergo Mastoidectomy and Tympanoplasty who fulfilled inclusion criteria were recruited in the study, and a prospective, observational pilot study was carried out. Pure Tone Audiometry (PTA) and Transient Evoked Otoacoustic Emissions (TEOAE) were recorded preoperatively and postoperatively to assess hearing loss if any on the contralateral side. Results: There was no change in bone-conduction thresholds in the contralateral ear by PTA postoperatively. However, there was a significant worsening in the values of signal-to-noise ratio of TEOAE at all the frequencies in the postoperative period. The mean TEOAE recordings were, however, above 3 dB SPL. Conclusion: There are statistically significant effects of drill noise on the inner ear function on the contralateral ear as detected by TEOAE; however, the effects are not detectable on PTA. Larger studies with a longer follow-up period will be required to determine if the early postoperative effects on TEOAE are reversible or persist.
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Role of otoacoustic emissions in the early detection and prevention of ototoxicity p. 13
Anil Kaul, Tarun Malhotra, Shazia Khan
DOI:10.4103/jmms.jmms_38_17  
Introduction: Evaluating Otoacoustic Emissions (OAEs) is one of the audiological methods for ototoxicity monitoring. The absence of OAEs indicates cochlear damage. The aim of this study was to study the usefulness of OAEs in early detection and prevention of ototoxicity. Materials and Methods: A prospective, comparative study was conducted to evaluate Transient-Evoked OAEs (TEOAEs) and Distortion-Product OAEs (DPOAEs) as they relate to Pure Tone Audiometry (PTA) in cases of ototoxicity. Hearing assessments of study group of 55 individuals exposed to ototoxic drugs were evaluated and compared at regular intervals, within the group and with control group of 25 individuals using PTA, TEOAEs, and DPOAEs. The abnormal OAE responses were calculated as predictive of significant changes in PTA thresholds. Student's t-test (independent samples, two-tailed) and ANOVA used for analysis. Results: PTA thresholds in the study group remained unaffected in the first three follow-ups whereas TPOAEs and DPOAEs were both found affected at the third follow-up, in significant number of ears in the study group. Significantly lower PTA thresholds were found in study group only at the fourth follow-up. Conclusions: Changes in TEOAEs and DPOAEs precede changes in PTA thresholds in ototoxicity and have high sensitivity and specificity in predicting hearing loss in such cases.
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Comparison of flange slide pack technique using macintosh laryngoscope blade with conventional laryngoscopy-guided throat packing: A pilot study p. 18
Abhijit A Karmarkar, Deepak Dwivedi, Vidhu Bhatnagar, Vibhu P. S. Raghuvanshi, Ashish Chauhan, Shatabdi Chakraborty
DOI:10.4103/jmms.jmms_65_17  
Context: An analytical pilot study was conducted prospectively to ascertain the efficacy of a new method of throat packing “Flange Slide Pack Technique” (FSPT) in patients undergoing nasal, faciomaxillary, and oral surgeries. Aim: To compare the conventional technique of throat packing guided by direct laryngoscopy with FSPT where the Macintosh laryngoscope blade is used as aid for throat packing. Settings and Design: A comparative observational pilot study was conducted at a tertiary care hospital. Subjects and Methods: Subjects were randomly allocated into two groups based on the technique for throat packing by computer-generated random numbers as Group A (conventional technique) and Group B (FSPT). Primary outcomes measured were total time duration taken for packing the throat with a standardized length of ribbon gauze and changes in heart rate and change in Mean Arterial Pressure (MAP) from baseline. Secondary outcomes measured were incidence of postoperative sore throat (POST) at 6 h postoperatively and ease of insertion of the throat packs. Statistical Analysis: Parametric data were analyzed using “unpaired t-test.” Comparison of proportions and data were analyzed using Chi-square test. SPSS Version 17 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Results: The time taken to pack the throat was shorter in Group B; percentage increase of MAP from baseline was higher in Group A. Ease of insertion of throat pack was more in Group B. POST results were insignificant. Conclusions: FSPT can prove to be an alternative technique to the conventional method of packing the throat by minimizing duration of laryngoscopy and thereby limiting the stress response.
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Knowledge of anti-retroviral therapy among people living with HIV/AIDS: A cross-sectional study p. 23
Ravishekar N Hiremath, Renuka Kunte, Atul Kotwal, Sandhya Ghodke, DR Basannar, Arun Kumar Yadav, Summena Basundra
DOI:10.4103/jmms.jmms_54_17  
Background: Anti-retroviral therapy (ART) has substantially improved the survival of people living with HIV-AIDS (PLHAs). The individual and public health responsiveness to ART is, in turn, determined by ART-related knowledge of PLHAs. Objective: To study the knowledge of HIV positive individuals regarding ART and also to study its association with education and duration of HIV positivity. Materials and Methods: This cross-sectional study was conducted at a tertiary level hospital. The study participants were 102 PLHAs who were not yet started on ART and data were collected using a face-to-face interview. Results: The mean age was 35.5 years and 58.8% were educated to 10th standard. About 92.2% were married, and more than 70% belonged to rural areas. Nearly 11.8% felt that there is no treatment available. Surprisingly, 60.8% of the participants had incorrect knowledge about the correct time of initiating ART while 60 (58.8%) participants were aware that ART needs to be taken lifelong. 26.5% said that antiretroviral drugs were associated with side effects. As per predetermined knowledge scores, 79.4% had satisfactory knowledge regarding the treatment. A statistically significant (P = 0.03) relationship was observed between the knowledge scores regarding ART among the study participants and educational status while it was not statistically significant (P = 0.56) as regards duration of HIV positivity. Conclusion: There still exists a considerable gap in knowledge regarding treatment options for HIV/AIDS among the PLHA of this region. Hence, there is a need to increase the awareness regarding the same and implement the same into practice. Periodic counseling is necessary to increase awareness and to clear misconceptions about ART among PLHA.
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Role of urine cytology in bladder neoplasm – Cytopathological correlation and review of literature p. 27
Naveen Chawla, Ritu Mehta, Kunal Tewari
DOI:10.4103/jmms.jmms_31_17  
Background: Urinary bladder tumors are the second most common tumors affecting males. The aim of the study was to evaluate the various histopathological findings in various bladder tumors and their correlation with exfoliative urine cytology. Design: This is an observational study carried out over a period of 7 years at a tertiary care hospital between January 2010 and January 2017. Materials and Methods: Tumors were divided into invasive and noninvasive urothelial carcinoma and were further classified into high-grade or low-grade urothelial cancer. Urine cytology smears from all these patients were also were studied. Cytological findings were correlated with histopathological findings. Result showed that bladder tumors were commonly seen in males with average age of presentation being the sixth decade. The most common type of carcinoma seen was low-grade urothelial carcinoma-noninvasive type. Urine cytology was positive in 47.46% patients. Sample Size: In our study, 113 cystoscopic biopsies were included over a period of 7 years (85 males and 28 females). Conclusion: Accuracy of diagnosing malignancy in urine cytology varies, and it depends on the presence of diagnostic yield in the urine cytology, processing of the sample, and experience of the cytopathologist. Urine cytology should be reported in a background of detailed clinical information and should always be followed by histopathological examination.
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Investigation of in vitro cytotoxic activity of pigment extracted from Salinicoccus sp. isolated from Nellore sea coast p. 31
V Srilekha, G Krishna, P Mahender, MA Singara Charya
DOI:10.4103/jmms.jmms_56_17  
Objective: To investigate the in vitro cytotoxic activity of pigment extracted from Salinicoccus sp. isolated from Nellore sea coast. Materials and Methods: In the present study, pigment-forming bacteria were isolated from samples collected from Nellore coast, Andhra Pradesh. Among different pigmented isolates obtained on Zobell agar medium, the pinkish orange bacterium was selected for the study. The bacterium was cultured in Zobell broth medium and incubated in an orbital shaker at 120 rpm for 6 days at 25°C. After incubation, the culture broth was centrifuged at 10,000 rpm for 10 min to obtain a pellet, and the pellet was extracted using the solvent methanol and acetone (5:1). The crude pigment extract was evaluated for cytotoxic potential and was found to exhibit cytotoxic effect on A549 (human lung cancer) and MCF-7 (breast cancer) cell lines. The cell lines A549 cells, MCF-7, were cultured in Dulbecco's Modified of Eagle medium with L-glutamine and 1000 mg/L glucose supplemented with 10% fetal bovine serum, penicillin G (100 units/ml), and streptomycin sulphate (0.1 mg/ml) in a humidified atmosphere consisting of 5% CO2at 37°C. Results: The results of the present study revealed that the crude pigment extract has a strong anticancer potential, especially toward the A549 (Lung cancer cell lines) and MCF-7 (Breast cancer cell lines), respectively. Conclusion: This study clearly indicated that the pigment extract of marine Salinicoccus sp. has a strong cytotoxic activity against A549 (lung) and MCF-7 (breast) cancer cell lines which may be utilized for the drug development.
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Effectiveness of evaporative desert cooler mounted with fabricated metal mesh in preventing Aedes mosquito breeding in a North Indian City p. 34
Archana Singh, Reema Mukherjee, Atul Kotwal, Rajiva
DOI:10.4103/jmms.jmms_19_18  
Context: We modified conventional metal body evaporative desert coolers by covering the water sump with fabricated metal mesh. Aedes mosquito breeding in these modified desert coolers was then tested during dengue transmission season. Aim: This study was carried out with the aim of providing an effective modification which can be carried out locally in evaporative metal body desert room coolers, to prevent Aedes mosquito breeding. The authors also compared the effectiveness of such desert coolers mounted with fabricated metal mesh against the standard National Centre for Disease Control, mosquito proof coolers (NCDC-MPC). Settings and Design: This study was carried out from October 2015 to 2016 in a large military cantonment area of North India. The data collection for larval breeding was done during late summer and monsoon months, namely May–October 2016. Subjects and Methods: Conventional metal body evaporative desert cooler was modified by covering its sump water tank with a fine mesh. These modified coolers were then monitored for larval breeding and compared with the NCDC-MPC, and conventional nonmodified routinely used desert coolers. Statistical Analysis Used: A database was created in MS Excel and observations were recorded analyzed and tabulated. Results: No breeding was detected in the NCDC coolers and the coolers mounted with fabricated metal mesh. Conclusion: The conventional desert cooler locally modified by mounting a fabricated metal mesh to cover sump water tank of the cooler, was found to be effective in preventing Aedes breeding. It offers the advantage of simplicity, low cost, and improved availability.
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MILITARY MEDICINE - ORIGINAL ARTICLE Top

An outbreak of varicella among troops on the move: A challenge in field epidemiology p. 38
Kunal Chatterjee, Rajesh Kunwar, Gaurav Taneja, Samrat Mitra, V Srinivas
DOI:10.4103/jmms.jmms_10_18  
Background: Military population, by virtue of peculiarities of service conditions, such as congregation in living barracks or during exercises present a vulnerability to spread of contagious diseases. Institution of control measures during outbreaks becomes a challenge in Field areas due to operational commitments. The present paper highlights an outbreak investigation conducted in field and some lessons learnt. Methods: This investigation was conducted among troops who had arrived at a new location and soon after took part in training and area familiarisation and among whom chicken pox occurred. Constant troop movement resulted in challenges to institute control measures, which had to be tailored to suit the situation. Aggressive intervention measures such as segregation, contact tracing and strict surveillance resulted in control of the outbreak. Results: A non-immunised military population reported its first two cases during travel in military special train to the battalion's new location. Subsequently cases kept occurring over two months and the constant movement of troops propagated the outbreak, resulting in total of twenty cases. Timely prevention measures successfully broke its runaway nature and controlled the outbreak. Conclusion: Early identification of cases and aggressive intervention measures were successful in effective control of outbreak.
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NAVAL MEDICINE - ORIGINAL ARTICLE Top

A study of neurocognitive and executive function of divers p. 44
Nikita D Shah, Sunil Goyal
DOI:10.4103/jmms.jmms_68_17  
Background: Extant literature suggests that due to a variety of factors, diving causes long-term neurological sequelae. Effects on cognitive functions have been assessed in previous studies; however, the presence and extent of resultant cognitive impairment is still unclear. This study was done to test the presence of cognitive deficits in divers. Further, the deficits were correlated with the years and depth of diving. Materials and Methods: In this comparative study carried out at a tertiary care hospital, 46 healthy divers were exposed to neuropsychological tests to evaluate their attention, concentration, visuospatial processing, memory, and executive functions. Their performance was compared to that of 46 healthy-matched nondiving sailors. Their performance was also correlated to the years and depth of diving. Results: The study found that the divers performed worse than nondivers in the following indices in the psychometric tests; Stroop Word Component (P = 0.035), Trail A (P = 0.045), number of categories completed in Wisconsin Card Sorting Test (P = 0.007); and in delayed recall (P = 0.007) and visual recognition (P = 0.031) in the Memory Scale. It is inferred that the cognitive domains of visuospatial processing, executive function, and verbal and visual memory are affected. Increase in depth of diving showed worse performance in digit backward (P = 0.032) and verbal memory (P = 0.048) that points to impaired attention, concentration, working memory, and verbal memory. Conclusion: The study suggests that residual cognitive effects are seen in divers. Worsening of the cognitive function is correlated with depth of dives but not total years of diving. The study recommends that further research in the field of cognitive effects of diving is warranted.
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MILITARY HISTORY - REVIEW ARTICLE Top

War and epidemics: A chronicle of infectious diseases p. 50
Kaushik Roy, Sougat Ray
DOI:10.4103/jmms.jmms_34_18  
Disease transmission occurs with a perfect balance of the epidemiological triad consisting of an external agent, a susceptible host, and an environment that brings the agent and host together. Conflict situation is an ideal platform that creates this confluence of agent and host in perfect environmental conditions, for pathogens to tear through soldiers and refugees alike. Classically during armed conflicts, soldiers and displaced population get exposed to unsanitary and overcrowded barracks, trenches, refugee shelters, and concentration camps with disruptive health-care services. Many get susceptible to diseases prevalent in the relocated region and some may introduce pathogens in the native population. The earlier wartime epidemics were considered as divine interventions and wrath of God. As medicinal knowledge advanced, prevention strategies evolved from isolation and quarantine to sanitary measures against miasma and further to chemoprophylaxis and immunization against the pathogen. The advent of antivector chemicals and antibiotics revolutionized the control of epidemics during the World War II. Although not infectious in origin, modern-day outbreaks are mostly health events such as posttraumatic stress disorders in postwar or war-like scenario. This article chronicles the epidemiology of the better-known wartime epidemics.
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MEDICINE UPDATES Top

Update in military medicine p. 55
Rohit Verma
DOI:10.4103/jmms.jmms_36_18  
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REVIEW ARTICLE Top

Recent update: Nonalcoholic steatohepatitis p. 57
Vivek Hande, Jnanaprakash B Karanth, PC Hande
DOI:10.4103/jmms.jmms_75_17  
Nonalcoholic fatty liver disease has been traditionally conceptualized as a histological disease spectrum which progresses from simple steatosis or pure fatty liver through liver fibrosis or Nonalcoholic Steatohepatitis (NASH) to cirrhosis and eventually hepatocellular carcinoma (HCC). NASH can progress to cirrhosis, has very high cardiovascular mortality and is a leading cause of HCC worldwide. Recently, the role of various genetic and environmental factors in pathogenesis and progression of the disease have evolved. The lifestyle modifications such as weight reduction, dietary changes, and few drugs with sensitization or antioxidant are available as treatment options. Several newer pharmacological agents are in different stages of clinical trial, and individualized therapy might be a reality in the near future. In view of increasing prevalence of NASH, even in a developing country like ours, a literature search was conducted in PubMed and EMBASE to identify recent publications. We intend to present the epidemiology, and recent inroads made into the pathogenesis, and management of NASH.
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CASE REPORTS Top

Acute compartment syndrome of forearm without facture in a toddler p. 63
Jai Prakash Khatri, Munish Sood, Ajaydeep Sud, Manoj Kumar
DOI:10.4103/jmms.jmms_58_17  
Acute compartment syndrome is an orthopedic emergency. In pediatric population, there should be a high index of suspicion for its early detection, especially when it is not associated with a fracture. We present here a case of a toddler, who developed acute compartment syndrome of forearm following a trivial trauma without fracture. Pain out of proportion and increased analgesic requirement are fairly reliable signs and should raise the suspicion of compartment syndrome for the treating surgeon. Despite various methods being available for measurement of intracompartment pressure, the diagnosis largely remains clinical. Ability to actively contract the muscle in the presence of elevated compartment pressure is an indicator of the viability of muscle. The case has been presented to sensitize the young surgeons regarding the possibility of compartment syndrome following simple fall without fracture. The clinical condition was timely diagnosed, and immediate surgical decompression resulted in good functional recovery.
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A case of Hansen's disease presenting with sulfone syndrome and hemolytic anemia p. 67
Preema Sinha, Pankaj Das, Nikita Sharma, Saikat Bhattacharjee
DOI:10.4103/jmms.jmms_7_18  
Dapsone (4,4'-diaminodiphenylsulfone) is a drug commonly used to treat various infectious, immunological, granulomatous, and hypersensitivity disorders. It can cause varied adverse effects, including sulfone syndrome which can have a potentially fatal outcome. We report a case of a female diagnosed as a case of Hansen's disease with Type II lepra reaction, who developed sulfone syndrome and hemolytic anemia as adverse drug effects to dapsone. The case is presented to stress on the importance of timely diagnosis and institution of early treatment in the management of a rare complications of a commonly used drug with a favorable outcome.
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Chryseobacterium indologenes: Case report of an emerging pathogen p. 70
Gurpreet Singh Bhalla, Shilpi Gupta, Manbeer Singh Sarao, Dinesh Kalra
DOI:10.4103/jmms.jmms_60_17  
Chryseobacterium indologenes thrives well in the environment and does not contribute to the human flora. It is recently being reported to cause a plethora of diseases in humans and has been shown to destroy antimicrobial agents and tissues. We report a case of catheter-associated urinary tract infection (CAUTI) in an immunocompromised male who was treated successfully with appropriate oral antibiotics. Also presented is a review, though not an exhaustive one, of the various case reports from India, proving the organism to be an important, emerging, and potentially dangerous nosocomial pathogen.
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Blaschkolinear lichen nitidus: A rare presentation p. 73
Rajeshwari Dabas, Manasa Shettisara Janney, Sandeep Arora, Radhakrishnan Subramaniyan
DOI:10.4103/jmms.jmms_3_18  
Lichen nitidus is an uncommon, chronic, usually asymptomatic papulosquamous dermatosis of unknown etiology, originally described by Felix Pinkus, a dermatopathologist in 1901. It generally presents as multiple, tiny, discrete, flesh-colored, dome-shaped papules most commonly on the extremities, genitalia, chest, and abdomen. We hereby report an uncommon and atypical presentation of “Blaschkolinear lichen nitidus” involving the trunk. A 15-year-old boy presented with a 1-year history of gradually progressive, multiple, small, raised lesions on the left side of the trunk. On examination, there were multiple, skin-colored to erythematous, discrete to confluent papules on the left side of the trunk in a curvilinear fashion. Dermoscopy, histopathology, and immunohistochemistry supported the clinical diagnosis of Blaschkolinear lichen nitidus. The patient was treated with topical steroid with good response.
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Prader–Willi syndrome: A syndromic cause of morbid obesity p. 76
Ankur Rawat, Subhash Chandra Shaw, Suprita Kalra, Rakesh Gupta
DOI:10.4103/jmms.jmms_69_17  
Prader–Willi syndrome (PWS) is a complex multisystem genetic disorder with a prevalence of about 1/10,000–1/30,000. It is also the first known disorder of human genomic imprinting. We report a case of a child with PWS presenting with hypotonia and feeding difficulty in the neonatal period and infancy with characteristic facial features, hyperphagia, early onset of morbid obesity, short hands and feet, intellectual disability, and other behavioral problems.
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Staged total penile reconstruction using flap prefabrication and arteriovenous loop p. 79
Pauline Babu, Pallab Chatterjee, Parli Raghavan Ravi
DOI:10.4103/jmms.jmms_14_18  
Loss of penis due to injury or disease is physically and psychologically devastating to any male. While the technique of penile reconstruction continues to evolve in conjunction with the evolution of flaps in reconstructive surgery, the free tissue transfer using radial artery forearm flap (RAFF) in a single stage is recognized as the most preferred method at present. However, to avoid the complications often seen in such single-stage method, we used a novel two-stage technique for total penile reconstruction in two cases after penile loss. We prefabricated the neophallus in the forearm and constructed saphenofemoral arteriovenous loop in the groin in the first stage to allow all the suture lines to heal and provide for easy and reliable recipient vessels. The neophallus was transferred after 4 weeks and vessel anastomoses done conveniently in the groin with adequate sized vessels with robust inflow. Both the patients recovered well without any need for urinary diversion and quickly attained the ability to pass urine in standing position. We offer that the two-stage method of penile reconstruction using free RAFF is reliable, easy to perform and can avoid many of the complications seen with single-stage reconstruction.
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