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   Table of Contents - Current issue
July-December 2019
Volume 21 | Issue 2
Page Nos. 105-203

Online since Monday, October 7, 2019

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Tactical combat casualty care in the navy – Challenges and way ahead Highly accessed article p. 105
MV Singh, Sougat Ray, Sunil Goyal, RJ Singh, Rohit Sharma
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Telemedicine: A force multiplier of combat medical care in the Indian Navy p. 108
Saurabh Bobdey, Shankar Narayan, M Ilankumaran, G Vishwanath, MV Singh, AK Sinha, N Anand, Kiran Maramraj
The tasking of the Indian Navy has increased manifolds in the recent past due to the country's growing economic importance, increasing energy requirements, and expanding trade routes. As operational elements of the blue water Navy, Indian Naval ships and submarines are deployed far and wide for prolonged durations. Therefore, for ships and submarines to be able to operate far away from our coasts, a comprehensive afloat medical care system needs to be developed with the capability to provide need-based secondary (specialist) and tertiary (superspecialist) care to men at sea. Telemedicine is envisaged to provide the solution to medical care needs of personnel onboard ships/submarines and in remote islands/locations and support unhindered Naval operations in peace and combat scenario. Telemedicine is a genuine force multiplier; it will not only complement the present medical support and extend expertise to areas bereft of the same but will also be helpful in prolonged operations and extended deployments by providing specialist/superspecialist consultation to the men at sea. In today's world of advanced telecommunication, telemedicine is a perfect amalgamation of communication technology and medical science, which is bound to revolutionize the field of Combat Medical Care by improving both clinical outcomes and operational efficiency of the Indian Navy. The article reviews telemedicine concept, its components, utility in the provision of specialized medical care to men at sea and its limitations.
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Decompression illness p. 112
Ashish Tawar, P Gokulakrishnan
Decompression illness (DCI) describes a syndrome complex caused by inert gas bubbles generated by an inappropriate rate of reduction in ambient environmental pressure or decompression. This “umbrella term” covers both traditional decompression sickness caused by in-situ bubble formation from dissolved inert gas and arterial gas embolism (AGE), in which alveolar gas or venous gas emboli (via shunts or by-passing pulmonary vessels) are introduced into arterial circulation. DCI occurs in divers, compressed air workers, aviators, and astronauts, but AGE could also arise from iatrogenic causes unrelated to decompression. A hundred years ago, serious manifestations and deaths were frequent in divers and caisson workers due to DCI, but they decreased greatly when decompression stops were introduced in diving practice. This review article is of interest to the doctors who face the dilemma of treating the rare syndrome of DCI that could present in the clinical spectrum ranging from itching and minor pain to severe neurological symptoms or other systemic pathology. The first aid lies in the administration of 100% oxygen, and definitive treatment is therapeutic recompression. With appropriate and adequate treatment, recovery is complete, but some severe cases may have lifelong residual deficits, even after extended and multiple recompressions.
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Psychological stress in the navy and a model for early detection p. 116
Puneet Khanna, Kaushik Chatterjee, Sunil Goyal, RR Pisharody, P Patra, Neha Sharma
Stress is unavoidable and encountered in many shapes and sizes. Being in a state of peaceful happiness may seem like an unachievable goal. Serving in the Armed Forces brings unique challenges during peacetime, in addition to the harmful mental and physical effects of service during war. The prolonged periods of separation from family, the very threat to life and limb, the imminence of physical danger, and the likelihood of the loss of a close colleague make the Armed Forces environment, especially in combat, inherently stressful. The lethality of the modern conflicts is potentially greater, and the way that conflicts are waged is more asymmetrical when compared with the wars of an earlier era. The Navy has its own unique set of stressors. Naval operations across the entire range of conflict expose naval personnel to a multitude of stressors. These stressors can lead to varied negative mental health consequences for the service personnel as well as their families. Increased deployments entail other stressful changes in the naval units as well, such as an increased number and intensity of training exercises, planning sessions, and equipment inspections, all of which increase the workload and pace of operations. Through this article, we briefly review the literature on this subject, emphasizing on stress and its types and stressors in Armed Forces, particularly the Navy. The article also dwells on early recognition of stress and timely intervention through the Stress Continuum Model.
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Critical care air transport team and patient transfer unit: A decade of experience of a zonal hospital Highly accessed article p. 121
Parli Raghavan Ravi, MC Joshi, Manish Dhawan, Sarubh Sud, MN Vijai
Introduction: The critical care air transport team (CCATT) established in 2007 a vital components of medical evacuations (MEDEVAC) in north-east India. Aim of the Study: The aim of this study was to highlight the importance of obtaining epidemiological data pertaining to the patients transported by CCATT. Method: Cases were analyzed based on the following criteria: age, sex, diagnosis of patient ,spectrum of disease and trauma, ventilation modes, inotropic support, hours of illness/injury before transport, flying time, flight distance, dedicated missions, interventions done aboard the flight and outcomes in the patient within 48 hours. Results: As many as 305 patients were analysed.39.5% patients were surgical patients, 58.5% medical and 1% was pediatric. Among surgical patients 56.8% patients were of poly trauma, 22.8% had traumatic brain injury. 68.8% of the patients transported were non-battle casualties. Dedicated missions constituted 43.4%, while the longest time for CCATT to return to base was 28 hours, shortest been 4 hours.46.8% of the patients required ventilatory support.63.4% of the patients were on inotropic support. 82.6% of the patients survived first 24 hours while 72.6 % of the patient survived 48 hours. Conclusion: Understanding the epidemiology of casualties evacuated by CCATT is an imperative requirement for the developments of effective pre-deployment training to ensure optimal outcomes for critically injured.
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Managing extramural neonates: Experience from a zonal hospital p. 130
Vivek Bhat, Ranjeet Wishram Thergaonkar
Introduction: There are many challenges in the care of extramural neonates (born outside the hospital), especially in resource-limited secondary care (zonal) hospitals of the Armed Forces. The objective of the present study was to describe the workload and complications faced in the care of extramural neonates in a zonal hospital of the Armed Forces. Subjects and Methods: The study design was descriptive. The setting was a 306-bedded zonal hospital. Records of all neonates transferred from other hospitals between January 1, 2017 and December 31, 2017 were studied. Median and interquartile range of continuous data, as well as the number and percentages of ordinal data, were calculated. Results: Seventeen neonates (10 males) were received from a median distance of 70 km. The workload comprised 539 patient-days and 12.4% of the nursery workload. The extramural neonates included 2 (11.8%) extremely low birth weight (<1000 g), 6 (35.3%) very low birth weight (1000–1499 g), and 4 (23.5%) low birth weight (1500–2499 g) babies. Thirteen (77.4%) neonates were lateral referrals from private nurseries. The complications included hypothermia in 4 (23.5%), hypoglycemia in 3 (17.6%), and sepsis in 8 (47.1%) neonates. One (5.9%) baby died after admission. Conclusions: Extramural neonates constitute approximately 12% of the nursery workload. High number of low birth weight babies, lateral referrals from other neonatal intensive care units, relatively lower but significant rates of hypothermia and hypoglycemia, high rate of sepsis and low mortality highlight the management of extramural neonates in a zonal hospital.
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Evaluation of carotid plaque vulnerability using shear-wave elastography: An observational comparative study p. 134
Rajeev Sivasankar, Ramandeep Singh, PI Hashim, Brijesh Kumar Soni, Rajneesh Kumar Patel, Amit Bajpai
Objectives: This prospective observational, comparative study was aimed at assessing our results of shear-wave elastography (SWE) in evaluating carotid plaque vulnerability. Subjects and Methods: Sixty patients were prospectively studied over 2 years in a tertiary hospital setting and divided into two groups of 30 each. The first group consisted of patients with atherosclerotic plaques with a history of stroke, whereas the second group consisted of 30 patients with atherosclerotic plaques without stroke. Carotid plaques in both groups were studied for plaque length, morphology, and SWE measurements. All data analysis was performed using SPSS software (version 22, IBM SPSS statistics). Results: Both groups showed no statistical difference with respect to comorbidities, addictions, or anthropometry. The internal carotid artery was involved in 24 (80%) and 13 (43.33%) patients in Groups A and B, respectively. Mean length and width of the plaque were more in Group A patients than that of Group B patients on both right and left sides. Proximal stiffness (kpa) was 32.27 and 42.86; mid stiffness was 32.92 and 45.77, while distal stiffness was 26.57 and 38.15 in Groups A and B, respectively. The proximal, mid, and distal stiffness values of the plaque in Group A were less on stroke side as compared to nonstroke side with a statistically significant difference. Conclusion: SWE is a noninvasive, reproducible, and reliable imaging technique which could be used as a tool for the early detection of vulnerable carotid artery plaques.
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Carotid artery plaque evaluation by shear wave elastography p. 138
Faiz M H Ahmad, Subrat K Nanda
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Penetrating abdominal injuries due to firearms in combat zone – Single center experience p. 139
AK Sharma, Vivek Agrawal, Abhijeet Lal, Abhimannyu Choudhury, Pallab Chatterjee, Manomoy VSM Ganguly
Background: Abdominal trauma is a frequent indication for surgical exploration of the combat causality. Rapid transportation to trauma center, early recognition of injuries, sound surgical judgment, and timely intervention are critical for reducing mortality and morbidity. Patients and Methods: All penetrating abdominal trauma (PAT) cases admitted to a combat zone hospital from January 2014 to December 2016 were studied. Results: Forty-eight patients with PAT were evaluated and managed. Majority (66.7%) were secondary to gunshot injuries. Forty-one required operative management. Out of these, 6 (12.5%) underwent diagnostic laparoscopy and 35 (72.9%) required laparotomy. The small intestine was the most commonly injured organ which was encountered in 21 (43.7%) cases. Two (4.2%) patients succumbed to their injuries. Early resuscitation in combat zone followed by prompt evacuation to the combat hospital improved the overall outcome. Conclusion: PAT is a common cause of morbidity and mortality in combat areas. Rapid transportation, sound clinical judgment, and early surgical intervention are critical for patient survival and better outcomes.
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Relationship between stigma, self-esteem, and quality of life in euthymic patients of bipolar disorder: A cross-sectional study p. 145
Debajyoti Bhattacharyya, Anuj Yadav, Arun Kumar Dwivedi
Background: As per the existing literature (mostly Western), bipolar affective disorder or bipolar disorder (BD) is associated with low self-esteem, high stigma, and poor quality of life (QOL). Aims: The current study aimed to assess stigma, self-esteem, and QOL and to examine their interrelationships in euthymic patients of BD in the Indian settings. Settings and Design: This hospital-based, cross-sectional study was conducted in a tertiary care hospital in Delhi over a period of 12 months. Subjects and Methods: Sixty-two adults with BD (as per the International Classification of Diseases-10 criteria) in remission were selected. Stigma, self-esteem, and QOL were assessed using the Internalized Stigma of Mental Illness (ISMI) scale, Rosenberg Self-esteem Rating Scale, and World Health Organization (WHO) QOL-BREF, respectively. Statistical Analysis Used: Data were analyzed using Student's t-test, Pearson's correlation coefficients, and multiple regression model. Results: Thirty-two percent of patients did not experience stigma (ISMI total score < 2.00). Mean total ISMI score for patients was 2.33 (mild stigma). Compared to controls, patients were found to have lower self-esteem (mean: 12.63) and lower scores on WHOQOL-BREF. Self-esteem scores were associated with all domains of WHOQOL-BREF, whereas ISMI total scores were not. Further, self-esteem was not found to be associated with stigma scores. Conclusions: Patients of BD in remission have low self-esteem, experience mild stigma, and have a low QOL. Lower self-esteem was strongly related to lower QOL, whereas stigma was not. Measures to improve self-esteem may benefit patients of BD in the long run.
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Hippocampal volume alteration in medication-naive depression patients in comparison to healthy individuals: An Indian perspective p. 151
Karan Sud, Sunil Goyal, Barun Kumar Chakrabarty
Context: Depression is the most common mental health problem in all the age groups. However, the exact pathophysiology of this devastating disorder remains an enigma. Many hitherto conflicting studies have focused on volumetric measurement of the hippocampus using magnetic resonance imaging (MRI), but few studies have been conducted in our country. Thus, our study envisages comparing hippocampal volumes of medication-naïve depressed individuals against healthy controls. Materials and Methods: This study was conducted both on patients admitted to the hospital and those attending outdoor clinic fulfilling inclusion/exclusion criteria in a tertiary care hospital. The sample consisted of 25 patients freshly diagnosed as Depressive Episode as per the International Classification of Diseases (ICD-10) and 25 healthy controls. Sociodemographic and clinical history pro forma and Hamilton Rating Scale for Depression were administered on all individuals before obtaining the volumetric measurements of the hippocampi of all individuals using a 1.5 Tesla MRI scanner. Results: Our study indicated right hippocampal volumes (RHVs) of depressed individuals were significantly reduced more so with advancing age. It hinted to the lesser effect of severity of depression on RHVs than in the left hippocampal volumes (LHVs). We found that female patients are more predisposed to RHV loss. However, our study did not reveal any significant difference in LHVs or total hippocampal volumes between depressed individuals and healthy controls. Conclusions: It is one of the exclusive studies which have attempted to shed light on the pathophysiology of depression in relation to its severity and hippocampal volumes in the Indian context.
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Anatomical and functional outcomes of toric intraocular lens implantation p. 158
Dubbaka Srujana, Dattakiran Joshi, Amit Sethi, Sriharsha Lanka, Roopali Y Bhirud, Robin Malik
Background: To minimize the residual refractive correction, toric intraocular lens (TIOL) is being increasingly used in cases undergoing cataract surgery with preexisting corneal astigmatism of ≥1.0 D. Aims: The aim of this study is to evaluate anatomical and functional outcomes of TIOL implantation in cases undergoing cataract surgery with significant corneal astigmatism using conventional manual marking of target axis and to see for any difference in outcomes based on the power of TIOL. Methodology: It is a prospective observational study. Consecutive patients with cataract and astigmatism of >1.0 D with adequate pupil dilation and no significant ocular or systemic comorbidity scheduled to undergo phacoemulsification with TIOL implantation were enrolled. Results: The mean improvement in postoperative uncorrected distance visual acuity (UDVA) over preoperative corrected distance visual acuity was 0.51 ± 0.54 logarithm of the minimum angle of resolution (95% confidence interval CI: 0.30–0.70), equivalent to 4 Snellen lines. The mean postoperative spherical equivalent is 0.38 ± 0.27; 77.4% showed within 0.50 D and the rest were within 1 D. The mean deviation of postoperative TIOL alignment from intended intraoperative TIOL alignment is 3° ± 2° (range: 0°–6°). Both the groups (low- and medium-power TIOLs) had similar postoperative UDVA, residual astigmatism, and deviation of target axis. Conclusions: There was an effective correction of preoperative corneal astigmatism and good visual outcomes with TIOL implantation. Fairly accurate TIOL alignment is achievable with manual marking of target axis. The power of TIOL did not influence postoperative UDVA, residual astigmatism, or deviation of TIOL from target axis.
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Epidemiological assessment of road traffic accidents among the naval population p. 165
MV Singh, Saurabh Bobdey, Shankar Narayan, M Ilankumaran, Joy Chatterjee, G Vishwanath, AA Pawar, Anup Banerji
Introduction: Road traffic accidents (RTAs) are one of the leading causes of mortality and morbidity globally. The problem is more critical and increasing in developing countries due to rapid motorization and poor conditions of the road. In Indian Navy too, there is serious concern regarding injuries and deaths due to RTAs. Therefore, the present study was conducted to study and document the factors involved in RTAs as well as elucidate major modifiable risk factors for RTA among the naval population. Materials and Methods: Medicolegal case records pertaining to RTAs in the naval population for the period January 1, 2016–December 31, 2017, from all Naval Hospitals and major base units of Indian Navy were obtained and analyzed. Results: During the study, a total of 1608 cases of RTA were documented. More than half of the cases (n = 841; 52%) involved personnel between the ages of 21 and 30 years. Maximum number of cases (n = 179; 11.1%) occurred in July and in terms of hours of the day, maximum cases were documented as occurring between 1200 and 1600 h (n = 394; 24.5%), whereas another 24.4% of cases happened in the night starting at 2000 h. Age <40 years (odds ratio [OR] 2.37, 95% confidence interval [CI] 1.67–3.38), history of consumption of alcohol (OR 1.77, 95% CI 1.27–2.47), and involvement of another vehicle in the accident (OR 1.55, 95% CI 1.16–2.08) were found to be independent risk factors for grievous injury. Conclusion: Morbidity and mortality of trained and professional workforce due to RTAs is a major cause of concern for the Indian Navy. The present study highlights the factors associated with RTAs among the naval population and emphasizes the need to take decisive steps to reduce RTA's and prevent the loss of precious lives of naval personnel.
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A study of dermatological manifestations in patients attending the rheumatology outpatient department at a tertiary care hospital p. 170
Preema Sinha, Rajan Singh Grewal, K Shanmuganandan, Manas Chatterjee, Arun Kumar Yadav, Saikat Bhattacharjee
Background: Autoimmune processes commonly involve skin along with the musculoskeletal system, resulting in inflammatory diseases characterized by concurrent mucocutaneous and rheumatic manifestations. Aim: We undertook a clinical study to assess the pattern, type, extent, severity, and morphology of dermatological manifestations in rheumatology patients, to analyze the correlation of dermatoses observed with the type of rheumatological disorder, and to look for the side effects of drug therapy including disease-modifying antirheumatic drugs. Materials and Methods: A cross-sectional descriptive study carried out in the outpatient department (OPD) setting of 100 patients, having joint and/or bone involvement associated with cutaneous disorders, attending rheumatology OPD of a tertiary care hospital were included and followed up for 6 months to assess the mucocutaneous manifestations. Patients with no cutaneous manifestations were excluded from the study. Statistical analysis was done using STATA 13 IC. Results: Papulosquamous skin lesions (45%) were the most common dermatological manifestations in the study, followed by nail changes (30%), photosensitivity (20%), Raynaud's phenomenon (17%), and malar rash (15%). Drug-induced cutaneous features were seen in 18% of patients. Cutaneous manifestations were seen most commonly in the connective tissue diseases group (55%), followed by seronegative arthritis (34%), rheumatoid arthritis (8%), and erythema nodosum (3%). Frequently affected age group was 31–40 years (41%), followed by 41–50 years (23%) of age group. The most common therapeutic interventions causing cutaneous side effects were systemic steroids. Conclusions: Many patients attending the rheumatology OPD present with varied mucocutaneous manifestations, and they can also develop numerous drug-related cutaneous side effects once started on antirheumatic medications. Hence, a collaborative clinic between a rheumatologist and a dermatologist is a necessity which will help in holistic patient management and disease remission.
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Determinants of the “know-do” gap regarding contraceptive use among married women of an urban slum in Western Maharashtra p. 177
Shruti Vashisht, Rajat Prakash, Nand Kishore Vashisht, Puja Dudeja
Context: The importance of family planning to promote the health and welfare of the family group and thus contribute effectively to the social development of a country cannot be overemphasized. It is achieved through the use of contraceptive methods. Despite being the first country to launch the Family Welfare Program in 1952, India has not been able to achieve the desired population levels. Aims: The aim was to study the knowledge and practices related to contraceptive use among married women in reproductive age group living in an urban slum with the objective of assessing the factors responsible for the use and nonuse of contraceptives. Setting and Design: A cross-sectional survey was conducted among 300 married females in the reproductive age group of an urban slum. Subject and Methods: This was an interviewer-based study using a prevalidated questionnaire. Results: Out of the 300 respondents, 150 (50%) respondents had two children, 179 (64.1%) had delivered their first child within 1 year of marriage, and 106 (35.3%) had delivered their first child as teenagers (before 19 years of age). A total of 295 (98.3%) respondents had some knowledge of the contraceptives. The preferred method of contraception was tubectomy among 118 (41.7%) respondents. A total of 139 (47.1%) respondents had preference for having a male child. The main reasons cited for not using contraception was want of more children and fear of side effects. Conclusion: Our findings suggest that there is an obvious “know-do gap” as there was a wide discrepancy between the knowledge and practice of contraceptive usage. Knowledge about contraceptives was universal in our study; however, the contraceptive users were only 52.7%.
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Hazardous marine life: Stingray injury and its multimodal management p. 182
Bharat Khemji Jani, Chandrashekhar Mohanty
Human existence is known for its phenomenon of expansion and extension in the various natural habitat over a period of time. This has always accompanied with more frequent encounter with the natural inhabitants of that territory. Marine environment is not an exception to this. With increasing encroachment in the marine life, the incidences of the injuries due to marine animals have increased by manifold. Herein we report a case of stingray injury to a diver, its presentation and management. Stingray injuries are one of the rare forms of marine injuries as the fish attacks on provocation or accidentally only. The stingray injury causes both local and systemic effects on humans however in our case the local effects were late. Moreover the local damage was much more as compared to the external appearance of the stinger injury. This is an important aspect of the clinical part of this report as the external appearance of the injury is very deceptive in comparison with the actual damage caused within. He was managed with IV antibiotics, supportive care, timely local wound debridement and hyperbaric oxygen therapy. The response to HBOT was superb and resulted in speedy recovery of the patient. It can be concluded that though the stingray injuries are rare but the disabilities caused by extensive venomous damage to soft tissue and time taken for complete recovery. Systemic effects though not seen in our case may cause sudden death as reported in some case reports.
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Cerebrospinal fluid leak causing spontaneous intracranial hypotension p. 186
MA Mateen, Nihar Ameta, Joydeep Ghosh
Spontaneous intracranial hypotension (SIH) is one of the important causes of headache in young and middle-aged and is commonly misdiagnosed in the initial stages. SIH generally results from a spontaneous cerebrospinal fluid (CSF) leak usually in the spinal region subsequently leading to headache, usually postural in nature. SIH is characterized by a triad of postural headache, diffuse pachymeningeal enhancement diagnosed on magnetic resonance imaging, and low CSF opening pressure of <60 mm of water. Autologous epidural blood patch (EPB) is the treatment of choice in these patients. Here, we present a case of SIH with classical clinical and radiological findings managed appropriately with EBP, leading to complete resolution of the symptoms.
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Anesthetic challenges in leaking meningomyelocele repair in a neonate p. 189
Vidhu Bhatnagar, SN Kulkarni, MD Muzammil
Meningomyelocele is a neural tube defect, which comprises of a saccular protrusion containing a neural placode bathed in cerebral spinal fluid. Arachnoid covers the surface of the sac and dura or skin is missing. This is a congenital spinal anomaly, a type of spina bifida where there is a failure of fusion of spine. Early surgery is advisable because of increased risk of infection and further damage to nervous tissue. Anesthetic challenges for meningomyelocele surgical repair in a neonate include intubation with proper positioning to avoid rupture of sac, intraoperative prone position ventilation and its related complications maintenance of anesthesia, temperature control, and fluid management. We present a case report of anesthetic challenge of a 2-day-old neonate for detethering and repair of lumbosacral meningomyelocele.
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Gallstone ileus with cholecystoduodenal fistula: Primary repair at a zonal hospital p. 193
Bharat Jani, R Shankaran
We herein report a case of gallstone ileus due to stone at terminal ileum. It is one of the rare complications of chronic cholelithiasis. The patient presented with features of small-bowel obstruction and distension of abdomen. The management dilemma was between simple enterotomy to relieve obstruction and to go for repair of cholecysto-duodenal fistula in addition. Management by only enterotomy as a single procedure has a good prognosis but has chances of recurrence, whereas repair of fistula in addition to enterotomy in the same setting has variable results in terms of morbidity. In this case, the primary repair of fistula was done in the first presentation itself with good results. Hence, primary repair of cholecysto-duodenal fistula is also an option in early presentation with no signs of peritonitis to reduce the morbidity of repeated surgeries.
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A Case of hansen's disease masquerading as polymorphous light eruption p. 196
Vikas Pathania, Prerna Shankar, Divya Shelley, Sukriti Baveja, Anwita Sinha
Hansen's disease is a chronic, relapsing, infective granulomatous skin disease with protean manifestations imitating many benign dermatological conditions. This not only poses a diagnostic dilemma to the treating physician but also often delays the diagnosis and treatment. We report one such case of Hansen's disease imitating a polymorphous light reaction suspected and detected incidentally on the lack of response to treatment of the “apparently benign photodermatoses.”
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Perioperative and postoperative pain relief in a reduction mammoplasty using ultrasound-guided pectoral nerve block: A firsthand experience by a young anesthetist p. 199
Sandhya Ghodke, Ravishekar N Hiremath, A Banerjee, Sanjay Maurya
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Anaphylaxis in nonoperating room anaesthesia: Bizarre complication p. 201
Subhasish Patnaik, Rakesh Sharma, Debashish Paul, Shazia Khan
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