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   Table of Contents - Current issue
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January-June 2019
Volume 21 | Issue 1
Page Nos. 1-103

Online since Wednesday, June 19, 2019

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EDITORIAL  

Can pre-exposure prophylaxis be a game changer to prevent new HIV infections? A discussion with an armed forces perspective Highly accessed article p. 1
Sougat Ray, Sunil Goyal, Shabeena Tawar, Vijay Bhaskar, Vinny Wilson
DOI:10.4103/jmms.jmms_33_19  
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REVIEW ARTICLES Top

Artemisinin resistance: Cause for worry? Highly accessed article p. 4
Anurag Khera, Reema Mukherjee
DOI:10.4103/jmms.jmms_43_18  
Background: Artemisinin resistance is being reported from certain regions of the world. Globally, the scientific community is engaged in tracing the epidemiology of this resistance while also working on possible interventions to curb the spread. Aim: We reviewed the epidemiology of antimalarial drug resistance, especially artemisinin resistance both globally and in India, and report the possible ways forward. Literature Search: Resistance to all antimalarial drugs developed initially in South East Asia and thereafter spread globally. Artemisinin-based combination treatment (ACT) was formally recommended by the World Health Organisation (WHO) in 2005 to achieve an enhanced barrier to drug resistance. However in 2008, resistance to artemisinin was first reported from Western Cambodia/Thailand. Subsequently, P falciparum chromosome 13 ('kelch' motif or K13) (Pfk 13) was implicated with slow in vivo parasite clearance. As of 2019, artemisinin resistance has been confirmed in six countries of the Greater Mekong Sub-region. The North east states of India have been the portal for entry of anti-malarial drug resistance over the past decades. Though in vitro testing have not shown evidence of decreased artemisinin sensitivity, however, Pfk13 mutations have been reported from India, thus sounding a note of caution and indicating the need for continued genetic, clinical and public health surveillance. Conclusion: Though clinical cure in falciparum malaria infection continues to be elicited through use of ACT even in the countries reporting artemisinin resistance, however a comprehensive framework for combating the resistance has already been put into action by the WHO.
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Review of advances in management of pulmonary hypertension Highly accessed article p. 9
Manjit Sharad Tendolkar, Rahul Tyagi, R Ananthakrishnan, Ajay Handa
DOI:10.4103/jmms.jmms_66_18  
Pulmonary hypertension (PH) is characterized by an increased pulmonary artery pressure with subsequent increase in morbidity and mortality. Epidemiologically, one of the common causes of PH among serving soldier is chronic thromboembolic PH. There have been recent reports of PH among divers. There has been a lot of advancement in the management of PH in recent times. We review the management of this condition with special emphasis on recent advances.
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ORIGINAL ARTICLES Top

Accuracy of magnetic resonance imaging of the shoulder in evaluation of anterior shoulder instability p. 15
Yogesh Sharma, Mohammed Schezan Iqbal, Ajay Deep Sud, Pankaj Sharma, Mohit Thapa Magar
DOI:10.4103/jmms.jmms_7_19  
Background: Shoulder arthroscopy is currently considered the gold standard in diagnosing shoulder pathologies. Although magnetic resonance imaging (MRI) has an established accuracy in determining labral injuries following glenohumeral instability, the opinions of surgeons and radiologists regarding MRIs are still inconsistent till date. The aim of this study was to carry out a diagnostic evaluation of MRI vis-a-vis shoulder arthroscopy for the assessment of Bankart and Hill-Sachs lesions in subjects of anterior shoulder instability. Subjects and Methods: This was a diagnostic evaluation study, estimating the accuracy of MRI in diagnosing lesions encountered in shoulder dislocations vis-a-vis shoulder arthroscopy. Ninety participants of anterior shoulder dislocation were evaluated preoperatively with a shoulder MRI. The study participants were later subjected to a diagnostic shoulder arthroscopy and managed operatively on a case-to-case basis. Results: The sensitivity and specificity of MRI to diagnose a Bankart lesion were 90.78% and 85%, respectively. The positive predictive value (PPV) and negative predictive value (NPV) were 97% and 63% for the same. The sensitivity and specificity of MRI to diagnose a Hill–Sachs lesion were 92.68% and 85.71%, respectively. The PPV and NPV were 84.44% and 93.33% for the same. The diagnostic accuracy for MRI detection of Bankart lesion was 91% and of Hill–Sachs lesion was 88.89%. Conclusions: MRI is a very sensitive and specific tool in the detection of lesions commonly associated with shoulder instability, namely Bankart and Hill–Sachs lesions.
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Knowledge and practices about protein supplement use amongst students of a medical college p. 19
Kuntal Bandyopadhyay, Sougat Ray, Shruti Vashisht, Gurpreet Singh Bhalla, Manbeer Singh Sarao
DOI:10.4103/jmms.jmms_65_18  
Background: Nutrition and sports go hand in hand. With the availability of a wide range of protein supplements in the market and a risk taking mindset of the young generation to achieve fast and presentable results to their appearance or performance, a thorough knowledge and the selection of the right product becomes important. Materials and Methods: A descriptive cross-sectional study was conducted in a medical college in an urban locality over a period of 06 months. Participants were selected from a medical college by simple random sampling method and a total of 385 selected participants were distributed pre-tested questionnaires. Data was collected and the results were tabulated using appropriate statistics. Results: Amongst 385 participants (276 male & 109 females), 80 (20.8%) participants used supplements regularly. The mean age and BMI of protein supplement consumers was found to be 20.8 ± 1.4 years & 21.61 ± 1.9 Kg/m2. The association of use of supplements was found to be highly significant amongst those playing more than one sport (p<0.001), playing daily (p<0.001) and working out in gym (p<0.001). While the most common reason participants cited for consumption of supplements was to augment their diet and build muscles (46.3%), the commonest source of their information was found to be internet (65.8%). Conclusion: There still exists a huge gap in the knowledge and practices on the use of supplements amongst the college students which needs to be bridged and thus, by highlighting gaps in nutritional knowledge, sport nutrition professionals may begin to address these gaps by educating sportsperson with a view toward minimizing injury and enhancing sport performance.
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Dexmeditomedine as an adjuvant reduces the minimum effective anesthetic volume of ropivacaine required for supraclavicular brachial plexus nerve block p. 24
Parli Raghavan Ravi, MN Vijai
DOI:10.4103/jmms.jmms_1_19  
Background: Dexmeditomidine has been used as an adjuvant with local anaesthetic amides for supraclavicular brachial plexus block for improving the quality and duration of analgesia. We conducted this study to find out that whether as an adjuvant it reduces the minimum effective anaesthetic concentration (MEAC) and minimum effective anaesthetic volume (MEAV). Materials and Methods: 90 patients undergoing upper limb surgery were randomized into three groups and given ultrasound guided supraclavicular block. Group A received 30 ml of 0.5% Ropivacaine, Group B received 20 ml of 0.5% ropivacaine with 50μgm dexmeditomidine and Group C received 15 ml of 0.5% ropivacaine with 50μgm of dexmeditomidine. The onset of sensory and motor block, the duration of sensory and motor block, quality of analgesia, haemodynamic and sedative parameters were recorded. SPSS software was used for statistical analysis. Results: The onset of sensory block in Group B(9.47±3.54mins) and Group C (12.45±3.86) was faster in comparison to Group A(17.64±5.36) which was statistically significant. The duration of the block was also more in Group B and C in comparison to Group A. The requirement of rescue analgesia was also less in Group B and C. There were no statistically significant changes in the haemodynamic parameters and sedation scores. Although the patients of Group C received lesser volume and dose of ropivacaine than Group B, there was no statistically significant delay in onset or duration of sensory and motor block neither any change in the quality of analgesia. Conclusion: We concluded that 15 ml of ropivacaine with 50μgm of dexmeditomidine is adequate for good quality of analgesia with no compromise on onset of analgesia and duration of block..
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An epidemiological study of varicella outbreak in a military training establishment p. 31
Dattatraya Ramkrishna Sinalkar, Rahul K Ray, SM Sudumbrekar
DOI:10.4103/jmms.jmms_57_18  
Context: Though incidence of the Varicella has decreased in recent years due to introduction of vaccine; outbreaks continue to occur in closed environments such as those of militaries. The present study describes one such outbreak in a military training establishment. Setting and Design: This cross sectional study was conducted at a Secondary level hospital. Aims: To describe the distribution and characteristics of Varicella infections and to make suitable recommendations for prevention and control. Materials and Methods: All admitted cases of Varicella from a military training establishment during the outbreak were included in the study. Epidemiological data was collected by face to face interview. Statistical Analysis Used: Statistical analysis was performed using Epinfo software version 3.5.3. Results: Total 332 recruits were admitted in the local military hospital in said outbreak. Eight administrative staffs of recruiting center and two medical staffs attending the patient at hospital were also affected. The age of the patients ranged from 18 to 34 years with a mean of 20.3 ± 3.5 years. None of the cases admitted had developed any complication and their hospital stay remained uneventful. Maximum cases (59%) were presented with rash as a first clinical manifestation and 94.3 % of them had history of contact with a case of Varicella. None of them gave a history of vaccination. Conclusions: Though policy to offer vaccination against Varicella to all recruits on entry level exists, it should be implemented on ground to ensure unnecessary interruption in training activities.
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Epworth sleepiness score to predict sleep apnea in acute stroke: Do we need to delve deeper? p. 36
Rahul Tyagi, Pulikottil Wilson Vinny, Vivek Hande, Vijay Budhwar
DOI:10.4103/jmms.jmms_50_18  
Introduction: Globally, stroke is a leading cause of death and disability. Obstructive sleep apnea (OSA) is globally being recognized as an emerging public health problem and a risk factor for stroke. Epworth Sleepiness Score (ESS) is increasingly being used as a screening tool to determine the likelihood of OSA in a patient before polysomnography (PSG). However, ESS questionnaires in patients with acute stroke and their comparison with overnight PSG have not been studied. We conducted this study at a tertiary care respiratory center in Mumbai to determine the effectiveness of ESS in predicting the prevalence of sleep apnea in acute ischemic stroke. Materials and Methods: Twenty-eight patients of acute stroke were included in the study. These patients were subjected to ESS and technician attended overnight PSG. Apnea–Hypopnea Index, oxygen desaturation index, and minimum saturation were determined at the overnight PSG. Results: Majority of patients belonged to 61–80 years' age group (53.6%) and were predominantly male (89.3%). Only 5 patients (17.9%) showed an ESS of more than 8, whereas 23 patients (82.1%) showed evidence of OSA on PSG. Sensitivity of ESS in predicting OSA in patients with acute stroke was 17.3%, whereas specificity was 80%. Conclusion: The use of ESS in patients of acute stroke to screen for sleep-disordered breathing (SDB) should be avoided. A PSG may be considered in these patients as early diagnosis of SDB in these patients can help in improving recovery.
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Study of the anthropometry and prevalence of overweight in school boys in an Urban Area p. 41
Sukhmeet Minhas, Rajesh Kunwar, Harinder Sekhon, Pijush Jaiswal
DOI:10.4103/jmms.jmms_64_18  
Context: Overweight and obesity has been found to increase among children over the last few decades. Not only are more children becoming overweight, but they are also becoming so at a relatively younger age. Aims: This study of anthropometry of boys in a school in an urban area calculates the prevalence of overweight and thereafter suggests appropriate measures for improvement in lifestyle. Besides, secondary objectives were to determine the association of overweight and obesity with demographic factors. Settings and Design: A school-based, descriptive, cross-sectional study, in an urban area. Subjects and Methods: A sample size of 1537 was calculated. Anthropometric measurements of the participants were recorded including height, body weight, mid-upper arm circumference, and waist and hip circumference. Status of overweight and obesity was determined using body mass index. A structured questionnaire was used to record the personal particulars and sociocultural factors. Statistical Analysis Used: Data were analyzed using the software Epi Info™ version 7, developed by the Division of Health Informatics and Surveillance of the Centers for Disease Control, Atlanta. Results: Most participants ranged in age from 6 to 15 years, while 17.2% were overweight and 3.7% were found to be obese. Conclusions: As the main causes of excess weight include individual behavior and dietary patterns, children must be exposed and habituated to a healthy lifestyle as a preventive measure.
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Spinal cord injury in organizational setup - A hospital based descriptive study p. 46
Gurpreet Singh, Rajat Prakash, Vijay K Bhatti, Ajoy Mahen
DOI:10.4103/jmms.jmms_67_18  
Introduction: There is dearth of data on Spinal Cord Injury (SCI) from developing countries where ironically, special focus is required. Aims and Objectives: To study SCI in an organisational set up. Material and Methods: An observational, cross sectional study at a tertiary care rehabilitation centre was conducted. Patients who had injury during service were included. Questionnaire and case records were used to collect socio-demographic variables, cause, level, severity and duration of injury and clinical, functional and psychological status. Organisational support was estimated for pre-hospitalisation services, inpatient welfare measures and post-hospitalisation rehabilitative services. Results: A total of 157 patients participated. Median age at time of injury was 27 years with 89.2% injuries within 18 - 37 years of age. Trauma was underlying cause in 94.3%. Most common level of injury was thoracic (37.6%) and majority (66.9%) were paraplegic. RTA was most common (42.6%) traumatic cause and Tuberculosis among non-traumatic causes(66.6%). Scores suggestive of stress disorder were present in 13%. Pre-hospitalization health facilities were available to 79.6%. Majority (59.2%) had access to health facilities within two hours. Personal assistance was available to 88.5% and 66.9% undertook rehabilitation course. Conclusion: Health education with emphasis to trauma prevention in young is required. Social security measures need to be replicated by all organisations, both public and private in the country.
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Causes, management practices, and outcomes of pediatric acute kidney injury: A cross-sectional survey p. 51
Mritunjay Kumar, Suprita Kalra, Amit Sood, Ragini Singh, Madhuri Kanitkar
DOI:10.4103/jmms.jmms_42_18  
Introduction: AKI in critically ill children has multiple etiologies. The primary objective was to study the, causes, management practices and outcomes of AKI in critically ill children as seen by Pediatricians and Pediatric residents in two cities in different parts of India. Methodology: A cross sectional survey using Questionnaire based module with 12 questions was distributed to all participants during a CME at two centers. Results: 50/59 (response rate 84.7%) responded. Only 40% had trained pediatric nephrologist at their centers. 35 (70%) said they saw 1 case of AKI per month. 19/20 at center A believed sepsis with MODS as commonest cause while at center B 14, 21/30 (69.3%) participants selected prerenal causes such as dehydration. Renal causes (14/20, 70%) were commonest indication for dialysis at center A while at center B it was sepsis with AKI. Acute Peritoneal dialysis with stiff catheter was chosen as commonest modality. Complete recovery, persistence of kidney injury, and mortality contributed equally to outcome at center A whereas 56% at center B chose complete recovery. Conclusions: Intrinsic renal causes like HUS are the most common causes of AKI in critically ill children requiring RRT (renal replacement therapy). Despite some advances in infrastructure and training most residents and pediatricians felt that peritoneal dialysis was the commonest modality.
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Comparison between 1st and 2nd day serum bilirubin levels in relation to the prediction of requirement of phototherapy in neonates of ≥35 weeks of gestation p. 55
Ashok Bhandari, Shankar Narayan
DOI:10.4103/jmms.jmms_83_18  
Background: Follow-up of neonates discharged early is essential to identify neonates at risk of hyperbilirubinemia. The present study was conducted to evaluate and compare 20 ± 4 and 44 ± 4 h serum bilirubin level for predicting significant hyperbilirubinemia and requirement of follow-up after discharge. Materials and Methods: This study was a hospital-based prospective study. A total of 300 healthy newborns were included with gestational age of ≥35 weeks. Serum bilirubin levels on the 1st day and 2nd day were measured by microbilirubinometer at 20 ± 4 h of life and 44 ± 4 h of life, respectively. Results: In our study, we found that, for bilirubin level of >6 mg/dl for neonates at 20 ± 4 h of age requiring phototherapy for hyperbilirubinemia, sensitivity was 79.3%, specificity was 60.9%, positive predictive value (PPV) was 17.8%, and negative predictive value (NPV) was 96.4%. At 44 ± 4 h of life, for bilirubin level of >9 mg/dl requiring phototherapy for hyperbilirubinemia, sensitivity was 89.7%, specificity was 64.2%, PPV was 21.1%, and NPV was 98.3%. Conclusion: Babies with total serum bilirubin values below 6 mg/dl at 20 ± 4 h and 9 mg/dl at 44 ± 4 h can well be discharged early with proper discharge advice. Babies with serum bilirubin levels above the cutoff value (6 mg/dl at 20 ± 4 h and 9 mg/dl at 44 ± 4 h) can be discharged after 24 h or 48 h, but requires frequent follow-ups in the 1st week of life.
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Adherence to therapy in adult patients with bronchial asthma p. 59
Sharmila Sinha, A Tejus
DOI:10.4103/jmms.jmms_28_19  
Background: The global prevalence of bronchial asthma according to the WHO is 235 million and adherence to therapy is now becoming one of the main issues in its effective management all over the world. In developing countries such as India, easy accessibility to drugs and inadequate health services results in increased use of self-medication. Over-the-counter drugs though meant of self-medication, their inappropriate use can be potentially hazardous, and there is always a risk of interaction with other prescription drugs. Very few studies have been published regarding self-medication pattern in India and hardly any studies regarding their interactions with prescription drugs in asthma, hence this study was proposed. Methods: One hundred adult ambulatory patients aged above 20 years were randomly selected from the respiratory outpatient department of a tertiary care government teaching hospital in Pune. The participants were subjected to a semi-structured interview with the help of a questionnaire. Results: Ninety-one percent were adherent to therapy. The main reasons for not adhering to therapy as suggested by the questionnaire and interview were old age and difficulty in using the inhaled medications appropriately. Self-medication was in 16% of the patients and the most common drugs being proton-pump inhibitors, H2 blockers, and antihistaminics, but no significant interaction was observed. Conclusions: In our study, the adherence was well above the global figures. Nonadherence to therapy is estimated to be 50% for chronic illnesses. A multidimensional approach by proper management and increasing interaction time with the patients will go a long way in improving the management of such conditions. Elderly people should be specially targeted as they have multifactorial reasons for not adhering to therapy. Effective but simple and uncomplicated regimens, convenient dosing and route of administration, less expensive, and safer drugs should be the aim in the treatment of bronchial asthma.
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Determinants of influenza patients requiring additional support in adult urban population p. 63
Rahul Tyagi, Naveen Chawla, V Manu, Kavita Bala Anand, Vijay Budhwar, Anmol Sharma
DOI:10.4103/jmms.jmms_63_18  
Background: Influenza is a global disease with frequent outbreaks which vary in extent and severity. Although Influenza Like Illness (ILI) has a low fatality, it can cause a spurt in hospitalizations and sick absenteeism. Understanding the risk factors and using the knowledge to limit complication is the need of the hour to ensure adequate resource allocation and patient outcome. Aim and Objective: The study analysed the proportion of influenza cases requiring additional supportive care and the factors associated with it in the study population. Material and Methods: A retrospective observational study was conducted on 139 patients who were admitted with ILI at a tertiary care centre in Mumbai. Patients records were evaluated in detail for clinical history, socio-demographic details, relevant co-morbidities, physical examination findings and imaging & laboratory investigations. IBM SPSS version 22 was used for statistical analysis. Results: The proportion of Influenza patients requiring additional support (IPRAS) was 18.71%(95% CI 13.1% to 26%) in the study population. The most common additional support was extra oxygen therapy in 53.85% of IPRAS patients. Conclusion: The risk factors with significant association with IPRAS were higher age of the individual, H1N1 influenza, female gender, and presence of 3 or more co-morbidities, presence of fever, cough or breathlessness at presentation, higher respiratory rate and lower SpO2 at the time of presentation.
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Antimicrobial susceptibility profile of surgical site infection isolates from a tertiary care center in West India p. 69
Gurpreet Singh Bhalla, Naveen Grover, Gurpreet Singh, Manbeer Singh Sarao, Deepshikha Mishra
DOI:10.4103/jmms.jmms_32_18  
Introduction: Surgical site infection (SSI) is an infection that develops within 30 days after a surgical procedure or 1 year if an implant is placed and the infection appears to be related to surgery. SSIs are associated with complications such as increased readmission rates, increased hospital length of stay, increased overall costs, and increased morbidity and mortality rates. There is a dearth of data from India regarding SSI and susceptibility profile of the isolates. Therefore, this study was undertaken to determine the rate of SSIs, and the antimicrobial susceptibility profile of the isolates was obtained at a tertiary care center. Materials and Methods: A cross-sectional study was conducted for 2 years where all patients who underwent a surgical procedure were followed up and evaluated if they showed features of SSI. Requisite samples were taken and processed. Biochemical tests and susceptibility testing identified the isolated organisms and reporting was done as per the Clinical Laboratory Standards Institution guidelines. Results: Of 7675 surgeries, 303 developed SSI. The most common isolate was Staphylococcus aureus followed by Gram-negative bacteria. Antimicrobial profile of Gram-positive isolates revealed a high degree of resistance to methicillin and high susceptibility to vancomycin, teicoplanin, and linezolid; whereas among Gram-negative isolates, both Enterobacteriaceae and nonfermenters showed a high degree of resistance to various drugs including the cephalosporins. Susceptibility was seen for carbapenems and polymyxins. Conclusion: A close collaboration between microbiologists and surgeons is required. Strict hand hygiene and antimicrobial stewardship protocols need to be followed to prevent and reduce SSI.
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A comparative study of pediatric basic life support course for motivated laypersons and health-care personnel p. 75
Rama Krishna Sanjeev, Lakshmi Narayan Taneja, Ashok Kumar Sharma, Amit Kumar, Sunil Dutt Sharma, Rajpreet Soni
DOI:10.4103/jmms.jmms_75_18  
Background: Indian academy of pediatrics basic life support (IAP BLS) group runs BLS courses both with and without certification through accredited centers. The certification courses test both BLS and choking skills for all ages. This study is about work at an IAP-accredited BLS training center which runs certificate courses for health-care personnel (HCP) and laypersons (LPs). Majority of LPs were combatants who had few weeks' training in first aid as part of a regularly conducted first aid course among combatants. The LPs who were keen to acquire BLS certification undergo the certification after a 10-h precourse. Methods: This was a retrospective analysis of data about HCPs and LPs from 12 certificate course sessions dating from April 2015 to October 2017. The LPs underwent a 14-question bilingual multiple choice questions (MCQ)-based pretest followed by a 10 h precourse. The HCPs underwent the same before the certificate course without a precourse. The posttest was MCQ based as part of the course. The skill testing was done after the posttest. The BLS manual (IAP BLS manual, 2nd Edition) was made available to the participants at least 2 weeks before the certificate course. A Hindi translation of the manual was made available to the LPs, if needed. Results: There was statistically significant difference between the pre- and post-test scores of HCP and LP groups. The improvement was more pronounced in younger age in both groups of participants. Conclusions: The study highlights the efficacy of an instructor-led precourse with blended learning to aid in the training of motivated LPs to successfully complete a BLS course in pediatrics on par with health-care persons in a low-resource setting.
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COMMENTARY Top

Active learning to spread knowledge about cardiopulmonary resuscitation p. 81
Vidhu Bhatnagar
DOI:10.4103/jmms.jmms_12_19  
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CASE REPORTS Top

Intraoperative kinking of armored endotracheal tube leading to airway obstruction in obese patients positioned prone for spine surgeries: A report of two cases p. 83
Vidhu Bhatnagar, Deepak Dwivedi, S G S Datta, Swayam Tara
DOI:10.4103/jmms.jmms_76_18  
Obesity is an important problem with increasing incidence in affluent society. Managing obese patients in prone positions under general anesthesia requires optimization and adequate preparation for a successful outcome. Despite all optimizing measures are taken preoperatively, complications such as kinking of armored endotracheal tubes may take place in these patients in prone position leading to problems during mechanical ventilation. Armored tubes are being widely used in anesthesia practice in surgeries involving procedures during which kinking are anticipated. There have been reports of armored tube kinking both intraorally and extraorally in the prone position. Hence, prompt anticipation of tube kinking is desirable, especially in obese patients (increased neck circumference and submental fat) positioned prone. Herewith, we report two cases of unusual complication of armored tube kinking in prone position in obese patients.
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Breast carcinoma with pituitary metastasis p. 87
Gurjeet Singh Chowdhary, Purvesh Agrawal
DOI:10.4103/jmms.jmms_38_18  
Background: Metastatic tumors are among the most common lesions in the brain. The pituitary gland is an uncommon site of metastasis for malignancies. Breast cancer is the most common primary neoplasm metastasizing to pituitary in women. It may cause hormonal problems in different patterns due to mass effect and invasion to the pituitary gland. Case Report: We report here a 47-year-old woman with estrogen receptor-positive, progesterone receptor-negative, of human epidermal growth factor-2-positive metastatic breast cancer being treated with palliative radiotherapy, immunotherapy, and antihormonal therapy. Conclusion: Pituitary metastasis is a rare event in cancer progression. Diabetes insipidus is the most important criterion for differentiation of pituitary metastasis from adenomas. Metastases to the pituitary gland from breast and lung primaries may indicate more advanced disease; however, despite this, localized radiotherapy nearly always needs to be considered to provide improvement in symptoms.
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Craniotomy and Evacuation at Remote Island Hospital; Challenges and Way Ahead p. 91
Bharat K Jani, SGS Datta
DOI:10.4103/jmms.jmms_27_18  
We herein report the management of a case of acute-on-chronic subdural hematoma by emergency craniotomy at mid-zonal hospital with basic surgical facilities. The timely intervention has made significant difference in patient outcome. A 72-year-old male was on antiplatelet agents, presented with status epilepticus, and also had multiple comorbidities. We faced challenges of specialist consultation, medical evacuation of an intubated case, neurosurgery intensive care, and availability of blood products and intensivists at place like Andaman and Nicobar islands where connectivity remains a challenge. Casualty evacuation and transport of critical patients by air are a major exercise and are not possible in certain situations. Moreover, it is potentially detrimental to the life of a patient during air evacuation due to changes in the atmospheric pressure. In such adverse situations, aggressive surgical intervention at small centers can make significant difference in the outcome of patient.
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Angioplasty for coarctation of the aorta: A case series p. 94
Jnanaprakash B Karanth, R Ananthakrishnan, Ravi Kalra
DOI:10.4103/jmms.jmms_40_18  
Coarctation of the aorta (CoA) is a constriction of the thoracic aorta commonly located distal to the left subclavian artery. It is more common in males and is associated with Turner syndrome, bicuspid aortic valve, and ventricular septal defect. It presents as angina on exertion, lower limb claudication along diminished femoral pulses, and unequal limb blood pressure records. Balloon angioplasty with or without stenting is the preferred treatment in native coarctation or recoarctation after surgery. Here, we report four cases that were successfully managed with balloon aortoplasty for CoA.
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Tuberculous rheumatism: A great mimic of juvenile idiopathic arthritis p. 97
Manas Ranjan Mishra, Deepak Joshi, KM Adhikari, Sujata Dharmshale
DOI:10.4103/jmms.jmms_74_18  
Tuberculosis (TB) is an underreported epidemic. Musculoskeletal TB is a relatively rare extrapulmonary complication of Mycobacterium tuberculosis involving just 1%–3% of patients. It commonly affects the spine and osteoarticular joints such as hip and knee, and it is mostly monoarticular. Oligo and polyarticular involvement, also called tuberculous rheumatism or Poncet's disease (PD), is an extremely rare occurrence due to a vigorous immune response to mycobacteria which contributes to the arthritic process. Here, we report a case of PD in a 3-year-old girl, who presented with complaints of insidious onset polyarthritis, mimicking juvenile arthritis. Cervical lymph node aspirate isolated acid-fast bacilli. The child was diagnosed as a case of PD, and after starting antituberculous therapy, her symptoms dramatically resolved. This patient illustrates the need to consider the possibility of TB in high-risk pediatric populations in countries like India as one of the causes of nonresolving chronic arthritis.
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A differently abled child with morbid obesity – An anesthetic challenge p. 101
Saurabh Sud, Deepak Dwivedi, Jagdeep S Bhatia, Alok R Gautam
DOI:10.4103/jmms.jmms_80_18  
Increased prevalence of obesity poses a challenge due to the altered physiologic and pharmacokinetic state which renders the patient under general anesthesia susceptible to delayed recovery, increased incidence of hypoxemia, and delayed healing. Smooth conduct of anaesthesia in a differently abled child with morbid obesity demands meticulous preoperative preparation to ward off separation anxiety from the parents as well as the anxiousness related to the unfamiliar environment.
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