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   Table of Contents - Current issue
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January-June 2020
Volume 22 | Issue 1
Page Nos. 1-104

Online since Tuesday, March 3, 2020

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EDITORIAL  

Precision medicine: From concept to clinical practice – A promising challenge!! p. 1
Sougat Ray, Sunil Goyal
DOI:10.4103/jmms.jmms_13_20  
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REVIEW ARTICLE Top

Psychological screening in the Indian Navy p. 5
Neha Sharma, Rohith R Pisharody, Chaitanya Kodange, Kaushik Chatterjee, Sunil Goyal, Priyadarshee Patra, Puneet Khanna
DOI:10.4103/jmms.jmms_10_19  
In the military parlance, screening implies evaluation or investigation of something as part of a methodical survey, to assess suitability for a particular role or purpose. Psychological screening to assess fitness for induction into military service has a long and tumultuous history. From being limited to tests of intelligence, the practice of psychological screening has evolved over the century to now being focused on the assessment of personality and motivation. There are various types of screening tools utilized by the militaries worldwide. They are debatable in their utility in screening out unfit individuals. However they are considered effective in choosing individuals with specific attributes and aptitudes for specific roles within the military. This article reviews the existing system of screening worldwide, derives lessons for the Indian scenario, and the way ahead for psychological assessment in the Indian Navy.
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PERSPECTIVE Top

Going viral – Covid-19 impact assessment: A perspective beyond clinical practice Highly accessed article p. 9
Saurabh Bobdey, Sougat Ray
DOI:10.4103/jmms.jmms_12_20  
In the realm of infectious diseases, a global outbreak is a worst-case scenario. In the past, outbreaks such as plague, Spanish flu, severe acute respiratory syndrome, and H1N1 (swine flu) have caused great human suffering. The novel coronavirus, christened as Covid-19, is a zoonotic disease which originated from the Wuhan province in China and spread like wildfire killing people and devastating the global economy. Mammoth efforts are still on to control this viral strain from further spread. Cities have been blocked, air travel banned, ships have been quarantined, and panic-stricken people have been evacuated from China. As Covid-19 continues to ravage countries across the globe, this article is an effort to provide an overview of the impact of Covid-19 and tickle wits of intellectuals to think how easily a nanometer organism can virtually bring down superpowers of the world.
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ORIGINAL ARTICLES Top

Limb injuries in combat trauma: A retrospective analysis of 166 cases at a tertiary care center in counter insurgency operational area p. 13
Sanjay Maurya, Vipin V Nair, Onkar Singh, SK Singh
DOI:10.4103/jmms.jmms_4_20  
Background: Limbs are most commonly involved in combat trauma. There is insufficient data on limb injuries sustained in the combat zone of Indian Armed Forces. This study aims to analyze limb injuries in 166 cases at a tertiary care center in counter insurgency operational area. Materials and Methods: All casualties with limb injuries who presented to the center from January 2014 to December 2019 were included in the study. Data were obtained from admission and discharge registers, central registry, and operation theater registers. Casualties who were killed in action were excluded from the study. The extremity involved, wounding agent, type of injury, length of hospital stay (LOHS), number of surgical interventions, and type of reconstruction undertaken were recorded. Results: Limb injuries accounted for 61% of all casualties, with a mean age of 30.45% ± 6.72 years. Nearly 67% of all injuries were caused by fragmentation device, 61% were of soft-tissue (ST) type, and 39% were of ST injuries with fractures (STFs). The LOHS and number of surgical interventions for STFs were statistically significantly higher (P < 0.001). There was a moderate correlation between the grades of injuries, LOHS, and number of surgeries. The most common reconstruction undertaken was split skin graft in 32% cases. Conclusion: This study for the first time evaluates limb injuries in combat-related trauma in Indian Armed Forces. It also analyzes the LOHS, and number of surgeries with the type of injuries and their correlation.
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Utility of phenotypic methods in detection of metallo-beta-lactamases in gram-negative bacteria p. 18
Dinesh Kumar Kalra, Sanjay Pratap Singh, Ajay Kumar Sahni, Naveen Grover, Mahadevan Kumar, Deepti Kalra
DOI:10.4103/jmms.jmms_22_19  
Background: Metallo-beta-lactamases (MBLs)-producing Gram-negative bacilli (GNB) are one of the significant multidrug-resistant pathogens causing healthcare-associated infection (HAI) worldwide. The present study aimed to compare the phenotypic and molecular methods to detect MBLs-producing GNB causing HAI, namely Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa in a tertiary care hospital. Materials and Methods: Antimicrobial susceptibilities were determined for 232 isolates identified during 8 months period, and the Modified Hodge Test confirmed carbapenemases production in carbapenem-resistant isolates as per the Clinical and Laboratory Standards Guidelines 2013. MBLs production was detected by the disc enhancement test (DET), combined disk test (CDT), and polymerase chain reaction (PCR) and statistically analyzed. Results: One hundred (43.1%) isolates were found to be carbapenem-resistant, of which 85% were positive on the Modified Hodge Test. The DET was 96.67%, whereas the CDT was 93.33% sensitive as compared to the PCR. Kappa coefficient ranged from 0.918 to 0.959 for different methods indicating the excellent agreement between the three methods. Conclusion: The DET and CDT showed excellent agreement with molecular methods to detect MBLs-producing isolates. They are easy to perform, inexpensive, and can be routinely used in clinical laboratories.
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Fracture risk assessment in postmenopausal elderly women of an urban area using fracture prediction tools: A cross-sectional study p. 25
Gaurav Mittal, Mohammed Schezan Iqbal, Yogesh Sharma, Manish Prasad, Nishant Lamba
DOI:10.4103/jmms.jmms_54_19  
Context: Osteoporosis is a commonplace metabolic disorder affecting millions of women worldwide. This study highlights the prevalence of various risk factors associated with the development of osteoporosis in postmenopausal women in the Indian population and the determination of risk of fractures in the same using questionnaire-based tools. Aims: The aim of the study is to estimate the prevalence of risk factors for fractures and determine the 10-year probability of developing major osteoporotic fracture and major hip fractures using QFracture score and Garvan Fracture risk calculator in postmenopausal women. Settings and Design: This was a cross-sectional analytical study. Subjects and Methods: A total of 384 patients were evaluated to estimate the prevalence of risk factors for fractures and the 10-year probability of developing major osteoporotic fracture and major hip fractures along with comparison of clinical risk factors between patients with history of prior falls and patients without history of prior falls using the QFracture score and Garvan Fracture risk calculator. Statistical Analysis Used: Mann–Whitney U-test for estimating the overall 10-year risk of developing major osteoporotic and hip fractures using the two scoring systems. Results: The age range of our study population was 50–86 years, while the mean age was 59.86 ± 8.86 years. The most prevalent risk factor for osteoporotic fractures in our study was diabetes mellitus (n = 98 [25.5%]), and the least prevalent risk factor was chronic kidney disease (n = 4 [1.04%]). We also estimated the overall 10-year risk of developing major osteoporotic and hip fractures in two groups: Group 1 (with a history of falls) and Group 2 (without any history of falls). Conclusion: QFracture score and Garvan tool are easily administrable, internationally validated questionnaires which provide definitive information related to risk factors for development of osteoporosis.
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Patient setup variations in computed tomography-based treatment planning for left-sided breast cancer using electronic portal images p. 30
Sachin Taneja, Deboleena Mukherjee, Kirti Tyagi
DOI:10.4103/jmms.jmms_70_19  
Background and Aim: This study deals with isocentric variations along with the setup reproducibility and determines the random and systematic errors in a cohort of 25 (females) left-sided breast cancer patients treated with megavoltage X-rays using an online electronic portal imaging (EPI) protocol. Materials and Methods: This is a hospital-based cross-sectional observational study which was carried out on 25 female patients of carcinoma breast (left sided) who had undergone modified radical mastectomy. After completion of the planned chemotherapy, all patients underwent virtual three-dimensional (3D) computed tomography (CT) simulation, and an external beam radiotherapy treatment was planned on these 3D CT images on a treatment planning system (TPS) using two (coplanar)/conventional tangential fields for a total dose of 50 Gy in 25 fractions. Analysis of 150 EPIs determined changes in the treatment fields during setup of these 25 patients. The online assessment included setup deviations in all the three directions (anteroposterior [AP], superoinferior [SI], and mediolateral [ML]) and variations in central lung distance (CLD) during the first three fractions. Results: Random errors ranged from 1 to 5 mm for the chest wall (medial and lateral) tangential treatments and 1 mm for the anterior supraclavicular nodal field. Systematic errors ranged from 2.5 to 4.5 mm in the AP direction for the tangential fields and from 2.5 to 7.5 mm in the SI and Mediolateral directions for the anterior supraclavicular nodal field. For 25 (left-sided) patients, the CLD (TPS) was 20–30 mm, CLD (EPIs) was 25–40 mm showing variations of 5–10 mm, V20 was 1.0–6.0 Gy, maximum total lung dose was 43 Gy, V30 was 2.0–4.0 Gy, maximum heart dose was 52 Gy, and maximum spine dose was 45 Gy. Conclusions: Online assessment of patient position with matching of EPIs with digitally reconstructed radiographs is a useful method in evaluation of interfraction reproducibility of tangential fields in breast irradiation, thereby improving upon the quality of treatment delivery for our patient population.
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Prospective, open-label, randomized, parallel group, comparative clinical study of two topical formulations of diclofenac diethylamine in the treatment of acute painful musculoskeletal conditions p. 35
Yogesh Sharma, Vivek Mathew Philip, Saurabh Sharma
DOI:10.4103/jmms.jmms_58_19  
Background: Oral nonsteroidal anti-inflammatory drugs have been used in the management of musculoskeletal pain due to inconsistent skin penetration of topical formulations. The quick penetrating solution of diclofenac is a novel topical solution of diclofenac diethylamine (4.64%), which has increased skin penetration. The present study was designed to compare the efficacy and safety of quick penetrating solution of diclofenac with diclofenac gel in patients with acute musculoskeletal pain. Materials and Methods: A randomized controlled clinical trial was conducted in 140 patients suffering from acute musculoskeletal pain who were randomized to receive diclofenac diethylamine 4.64% w/v topical solution (Group A) or diclofenac diethylamine 1.16% gel (Group B). The pain intensity difference (PID) between patients in both groups at rest and during movement of the affected area on day 3 and day 7 after injury was noted using the visual analog scale (VAS) and were compared with the baseline. A comparison of the requirement of oral rescue analgesics and adverse effects in both groups was also carried out. Results: The PID in VAS from baseline was significantly better in patients in Group A than patients in Group B on days 3 (3.74 and 2.42;P< 0.05) and 7 (6.8 and 5.54,P< 0.05), respectively, at rest. The PID in VAS from baseline was significantly better in patients in Group A than patients in Group B on day 3 (4.05 and 2.65;P< 0.05) and day 7 (7.34 and 6.00,P< 0.05), respectively, during movement. The number of patients requiring rescue medications were significantly lower in Group A (n = 1) compared to Group B (n = 16) (P < 0.05). Conclusions: Diclofenac diethylamine 4.64% w/v is more effective in relieving acute pain in painful musculoskeletal conditions in comparison with diclofenac diethylamine topical gel 1.16% w/w with lesser requirement of rescue analgesics and minimal adverse effects.
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Health-care needs and morbidity profile of the elderly veterans and their dependents staying in an urban area:A cross-sectional study p. 40
Vivek Aggarwal, VK Sashindran, Puja Dudeja
DOI:10.4103/jmms.jmms_4_19  
Aim and Objectives: This study aimed to assess the morbidity profile and health care needs of elderly veterans and their elderly dependants residing in an urban gated society. Methodology: This cross -sectional observational study was done by house to house survey of veterans and their dependents more than 60 years residing in gated urban cooperative housing society. A predesigned questionnaire to assess the comorbidities (lifestyle diseases, geriatric syndromes, and reversible disabilities) and perceived health-care needs was administered. Data were analyzed using descriptive statistics by SPSS 22 software. Results: Four hundred and six elderly veterans and their dependents were interviewed, which included 53.7% females. The mean age was 71.69 years. It was noted that 14.5% of the veterans were staying alone and required the help of a caregiver hired from outside. Chronic noncommunicable diseases (CNCDs) were common with more than 70% of veterans having two or more comorbidities. Hypertension was the commonest disease with a prevalence of 51.5% followed by diabetes (30.8%), decreased vision (28.6%), dental problems (25.1%), osteoarthritis (19.7%), and hearing impairment (18.7%). Only 4.2% of the subjects gave history of falls. Malignancy and chronic obstructive pulmonary disease were reported by 3% each. Dementia was prevalent in 14.5% of the subjects. The greatest felt needs of the elderly were: A separate geriatric outpatient clinic, availability of transport for elderly within the hospital, separate queues at the dispensary and blood collection centres, and a geriatric helpline. Conclusion: CNCDs were present in more than 80% of elderly subjects surveyed. Hypertension was the commonest comorbidity followed by diabetes. Potentially, treatable disabilities were seen in one-third of the veterans. Separate geriatric clinic, separate facility for dispensing medicine, and blood collection centers and a geriatric helpline were the most felt needs by the elderly veterans and their dependents.
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Analysis of the utility of direct immunofluorescence in the diagnosis of common immune mediated dermatological conditions p. 44
Preema Sinha, Sunmeet Sandhu, Jasvinder Kaur Bhatia, N Anand, Arun Kumar Yadav
DOI:10.4103/jmms.jmms_15_19  
Background: Accurate diagnosis of immune-mediated dermatological diseases requires an evaluation of clinical, histopathological, and immunofluorescence findings. Immunofluorescence detects antibodies bound to antigens in tissue and in circulating body fluids. It acts as a valuable adjunct to clinical and histopathological diagnosis in patients of autoimmune bullous diseases (AIBDs), connective tissue diseases (CTD), and vasculitis. Aim: This study aimed to analyze the utility of direct immunofluorescence (DIF) in the diagnosis of common immune-mediated dermatological diseases by its correlation with clinical features and histopathology. Methodology: This is an observational retrospective study. Medical records of 205 clinically suspected patients of AIBD, CTD, and vasculitis were retrieved for analysis where both histopathology and DIF had been carried out for patients treated at the dermatology department of a tertiary care hospital between November 2015 and November 2018. Data were analyzed using Statistical Package for the Social Sciences software version 20.0. Results: A total of 187 out of 205 patients were accurately diagnosed based on histopathology and DIF studies. Histopathology was positive in 177/187 (95.7%) patients and DIF was positive in 153 (81.8%) patients. Clinical, histopathological, and DIF discordance was seen in the remaining 18 out of 205 patients. The sensitivity of DIF in AIBD, lupus erythematosus (LE), and vasculitis was calculated to be 89%, 82.6%, and 60%, respectively. The overall sensitivity of DIF was 80.8%. The sensitivity of DIF was 100% in pemphigus foliaceous, acute cutaneous lupus erythematosus, and immunoglobulin A (IgA) vasculitis. Out of 118 clinically suspected AIBD patients, nine were diagnosed on the basis of DIF alone. Conclusion: DIF is an indispensable tool in the accurate diagnosis of autoimmune dermatological conditions, especially in cases where clinical and/or histopathological features are inconclusive. It is invaluable in confirming the diagnosis of IgA vasculitis.
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Fractional CO2 laser in the management of onychomycosis p. 50
Sandeep Arora, Sandeep Lal, Manasa Shettisara Janney, Eeshaan Ranjan, Navya Donaparthi, Rajeshwari Dabas
DOI:10.4103/jmms.jmms_53_19  
Context: Pharmacotherapy is the standard first-line management of onychomycosis (OM). Prolonged treatment courses have reported cure rates of only 40%–80%. Although lasers have been approved by the US Food and Drug Administration for the clearance of nail in OM, their efficacy in the first-line management is not established. In this context, we conducted a study with the aim to ascertain efficacy of fractional CO2 laser along with topical 1% terbinafine cream in the management of OM. Settings and Design: This was a single-arm observational study in OM administered treatment over 16 weeks and analyzed at 6 months after the initiation of treatment. Subjects and Methods: Treatment naïve and others after a 3 month washout period were administered fractional CO2 laser using pulse energy of 110 mJ, a density of 256 spots/cm2, pulse interval of 0.5 mm, pulse duration of 0.1 ms, and a rectangular spot size of 2–10 mm length and 0.6–5 mm breadth, every 4 weeks for four sessions along with 1% topical terbinafine cream. Outcome was assessed with Onychomycosis Severity Index (OSI), Visual Analog Score, mycological cultures and potassium hydroxide (KOH) mount at 16 weeks and 6 months after initiation of treatment. Statistical Analysis Used: Paired t-test was used to compare the change in OSI. Results: Mycological evaluation at the end of 16 weeks revealed that 90% (45 nails) were KOH negative and 88% (44 nails) were culture negative. Evaluation at 6 months revealed that 86% (43 nails) were KOH negative and 88% (44 nails) were culture negative. OSI improvement compared to baseline was good to complete in 42 cases, and Visual analog Score revealed 36 nails showing 3+–4+ improvement. Conclusions: Fractional CO2 laser is a viable alternative to oral antifungals, especially when they are contraindicated such as in military aviators and in cases where drug interactions are suspected.
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Seroprevalence of Anti-HBs Titers in Health-care Workers in a Tertiary Care Hospital in Mumbai p. 54
Kavita Bala Anand, Supreet Mohanty, V Manu
DOI:10.4103/jmms.jmms_63_19  
Introduction: Hepatitis B is a vaccine preventable disease caused by Hepatitis B virus which is a partially double stranded virus. Sharp injuries are the most common occupational injuries among healthcare workers (HCW). HCW are prone to sharp injuries during work, and infection after exposure. Materials and Methods: Anti-HBs titres were measured in 231 HCW in a tertiary care hospital in Mumbai. Result: Eighty six males and 145 females participated in the study. Out of these 41 were vaccine non compliant; 37 were partially immunized and 4 were not immunized. 32 out of 231 individuals tested had titres below 10 mIU/ml (10 mIU/ml considered to be the minimal protective titre). Among the individuals who had titres <10 mIU/ml, 17 were medical assistants, 10 were nursing officers and 5 were doctors. Out of these there were 04 who had not received any HepB vaccination in the past. The rest had received either complete or partial immunization. All those who had completed primary vaccination series and had titres <10 mIU/ml (n = 14) had completed primary vaccination more than 5 years ago. Conclusions: In our study 82.2% were vaccine compliant and 27.8% were vaccine non compliant. Out of 231 individuals 32 (13.85%) had titres <10 mIU/ml. This study highlights the need for HCW to undergo anti-HBs titres post primary vaccination and after 5 years of primary vaccination to identify susceptible individuals. The HCW with non protective titres should be give Hep B booster and antibody levels should be tested to confirm protective titres.
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Role of ancillary techniques in diagnosis of challenging common hematological malignancies p. 57
Ankur Ahuja, Tathagat Chatterjee, Meghna Yadav, Sonia Badwal, Gaurav PS Gahlot, Beenu Singh
DOI:10.4103/jmms.jmms_79_18  
Background: Usually, hematolymphoid malignancies present as generalized lymphadenopathy, splenomegaly, and cytopenias. However, sometimes, this may not be the scenario, and that is where the challenge arises. These unusual scenarios are present either in extranodal lymphoma or extramedullary acute leukemia, especially occurring at unusual sites and these often lays down a diagnostic dilemma. Aims: This study aims to evaluate the utility of extensive workup with amalgamation of radiological imaging, immunohistochemical panel, and flow-cytometry to diagnose these unusual hematolymphoid malignancies. Materials and Methods: This is a retrospective observational study of results obtained from a series of nine patients with various unusual manifestations of extranodal lymphoma or acute leukemia at tertiary center of Northern India since the past 18 months. Results: All nine cases which showed variable and unusual clinical presentations were studied involving all available ancillary techniques in the form of immunohistochemistry (IHC), flow cytometry (FCM). These cases because of their unusual presentation in the form of recurrent pericardial/peritoneal effusion, abdominopelvic masses, chronic cervicitis, and subacute intestinal obstruction mimicked various neoplastic and nonneoplastic lesions. IHC and/or FCM evaluating CD34, MPO, CD117 along with Tdt and B/T-cell markers played a vital role for a definitive diagnosis of aleukemic myeloid sarcoma primarily involving intestine, T-cell lymphoblastic lymphoma (LBL) in ovary, diffuse large B-cell lymphoma in ovary, cervix, and intestine with peritoneal carcinomatosis. Two cases of mediastinal masses revealed primary thymic B-cell lymphoma and T-cell LBL, respectively. Conclusion: Cases have highlighted the unusual clinical presentation of hematolymphoid malignancies and elicit the importance of providing a definitive opinion, which is mandatory to give appropriate effective and timely management for the best outcome.
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Alpha-lipoic acid attenuates cyclophosphamide-doxorubicin-induced hepatic perturbation in rats p. 62
Elias Adikwu
DOI:10.4103/jmms.jmms_64_19  
Background and Objectives: The clinical use of cyclophosphamide-doxorubicin (CP-DOX) in breast cancer treatment may cause hepatotoxicity. This study assessed the protective effect of alpha-lipoic acid (ALA) against hepatotoxicity induced by CP-DOX in albino rats. Materials and Methods: Thirty-six adult male albino rats were randomized into six groups (A-F) of n = 6. Group A (control) was treated intraperitoneally (ip) with 0.3 mL of normal saline 8 hourly for 48h. Group B was treated with 10 mg/kg of ALA 8 hourly ip for 48 h. Group C was treated with a dose of CP-DOX (150/20 mg/kg) for 24 h. Group D was pre-treated with ALA 8 hourly for 48 h before treatment with a dose of CP-DOX ip for 24h. Group E was co-treated with a dose of CP-DOX and ALA ip 8 hourly for 48 h. Group F was treated with a dose of CP-DOX for 24 h before treatment with ALA ip 8 hourly for 48 h. After treatment, rats were euthanized; blood samples were collected and evaluated for serum liver function markers. Liver samples were evaluated for biochemical markers and histology. Results: Liver catalase, superoxide dismutase, glutathione (GSH), and GSH peroxidase levels were significantly (P < 0.001) decreased in CP-DOX-treated rats. Aminotransferases, alkaline phosphatase, gamma glutamyl transferase, lactate dehydrogenase, total bilirubin, conjugated bilirubin, and malondialdehyde levels were significantly (P < 0.001) increased in CP-DOX-treated rats. The liver of CP-DOX-treated rats showed hepatocyte necrosis. However, CP-DOX-induced hepatotoxicity was significantly reversed in rats pre-treated (P < 0.001), co-treated (P < 0.01), and post-treated (P < 0.05) with ALA when compared to CP-DOX-treated rats. Conclusion: Pre-treatment with ALA produced the best protective effect against CP-DOX-induced hepatotoxicity.
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Role of core-needle biopsies in cases of mediastinal mass lesions as a primary diagnostic modality in comparison with fine-needle aspiration cytology p. 69
Deepika Phogat, Venkatesan Manu, Ritu Mehta
DOI:10.4103/jmms.jmms_23_19  
Introduction: The spectrum of mediastinal masses comprises of lesions of various origins. Although the clinicoradiological findings and the location of these lesions within different mediastinal compartments help narrow down the differentials, tissue diagnosis remains the gold standard for diagnosis. The image-guided percutaneous transthoracic fine-needle aspiration cytology (FNAC) and/or core-needle biopsy (CNB) of the mediastinal lesions are considered to be cost-effective and safe diagnostic procedures. CNB of mediastinal lesions is found to provide better yield with the accuracy of 75%–90% and is more precise as compared to FNAC. In this article, we study the role of CNB in cases of mediastinal masses as a primary diagnostic modality as compared to FNAC. Materials and Methods: A retrospective observational study was conducted at a tertiary care hospital in Mumbai. All cases with mediastinal mass lesions diagnosed by FNAC and/or CNB over a period of 1 year in a tertiary care hospital were analyzed. Cases were divided into FNAC group or CNB group depending on the primary diagnostic procedure undertaken. Comparisons were made between the two groups. Results: CNB group was found to have better diagnostic yield in benign as well as malignant lesions in comparison with the FNAC group. The time taken to reach the definitive diagnosis was found to be shorter in the CNB group as compared to the FNAC group. Conclusion: The use of CNB as a primary diagnostic modality may provide faster and accurate tissue diagnosis in cases of mediastinal masses of both benign and malignant nature as compared to FNAC.
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COMMENTARIES Top

Patient setup variations for treatment planning for breast cancer p. 73
Rajat Bandyopadhyay
DOI:10.4103/jmms.jmms_79_19  
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Toric intraocular implantation: An overview p. 75
Sandeep Gupta, Srujana Bhaskar
DOI:10.4103/jmms.jmms_37_19  
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CASE REPORTS Top

Rare case of intramural pregnancy p. 77
Meghna Barmase, Deepa Deewan
DOI:10.4103/jmms.jmms_39_19  
Intramural pregnancy is a very rare form of ectopic gestation. There are very few cases published in the literature. The management strategies differ with respect to severity of presentation, average gestational age, and viability of the pregnancy at the time of diagnosis. Here, we report a case of intramural pregnancy, which was managed conservatively with review of data on this rare condition, with respect to its etiology, diagnosis, and treatment.
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Postoperative relative adrenal insufficiency in elderly p. 81
Abdul Nasser, Trishna Taralkar
DOI:10.4103/jmms.jmms_29_19  
Corticosteroid hormones play a significant role in the control of vascular smooth muscle tone by their permissive effects in potentiating vasoactive responses to vasoconstrictors. Inadequate cortisol response in stress conditions such as the perioperative period, despite normal serum cortisol concentrations is defined as relative adrenal insufficiency. We report a patient who underwent vaginal hysterectomy and developed hypotension postoperatively. There was no improvement on fluid administration and vasopressor infusion. The patient clinically improved with administration of hydrocortisone.
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Twenty nail onychomadesis following acute viral hepatitis B infection p. 84
M Sivasankari, Preema Sinha
DOI:10.4103/jmms.jmms_46_19  
Onychomadesis is a nail plate abnormality with temporary cessation in the growth of the nail plate due to disturbances in the nail matrix. Any local or systemic condition affecting the nail matrix directly or indirectly can lead to onychomadesis. The causes can vary from idiopathic infections to systemic causes. Although onychomadesis is not a finding unique to any disease, it indicates the presence of a preceding trigger, which affects the nail matrix. Here, we report one such case of onychomadesis following acute hepatitis B infection.
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Unusual presentation of a profunda femoris pseudoaneurysm following osteosynthesis of proximal femur fracture p. 87
Vikas Kulshrestha, Rishi Dhillan, Munish Sood
DOI:10.4103/jmms.jmms_47_19  
Profunda femoris artery injury following osteosynthesis of the proximal femur fracture is a rare complication and is usually caused by iatrogenic trauma or rarely due to bony spikes. Presentation can be delayed because of nonspecific features such as pain, swelling, anemia, fever, and hematoma. We report a case of posttraumatic profunda femoris aneurysm which presented more than a year after surgery with near-complete resorption of proximal femur and failure of implant requiring evacuation of huge layered thrombus, ligation of profunda femoris, and reconstruction of proximal femur with tumor megaprosthesis. Literature has not described a similar case.
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Caverno-Chest wall sinus: A rare manifestation of chest tuberculosis p. 91
Saikat Bhattacharjee, Vikas Marwah, Shweta Pandey, Deepu Peter, Preema Sinha
DOI:10.4103/jmms.jmms_14_19  
Caverno-chest wall sinus without pleural spillage, a subentity of lung hernia, is a rare presentation of pulmonary tuberculosis resulting from spontaneous communication of the lung parenchymal cavity with the extraparenchymal compartment. This presentation in a completely healthy, young, asymptomatic individual for the first time is unusual. This rare presentation of tuberculosis is being highlighted in this case report.
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Early recognition and successful management of a case of fracture shaft of the femur complicated with fat embolism syndrome and acute respiratory distress syndrome p. 94
Shalendra Singh, S Ushakiran Singh, Deepak Dwivedi, Kaminder Bir Kaur
DOI:10.4103/jmms.jmms_45_19  
Fat embolism is a life-threatening complication of trauma. Early recognition and prompt treatment help in reducing morbidity. We report a case of fracture right shaft of the femur in a young adult which was being managed conservatively in the hospital ward and subsequently developed fat embolism syndrome (FES) followed by acute respiratory distress syndrome. All clinical parameters were normal except unexplainably low oxygen saturation (SpO2) of 90%–92% without supplemental oxygen. On the 3rd-day post admission, the patient suddenly developed FES and was managed in the intensive care unit (ICU) with elective mechanical ventilation, immediate bedside external fixation of the fracture, and supportive care. Prevention, early recognition by vigilant monitoring, prompt treatment, and adequate supportive care in the ICU help in reducing morbidity. All patients of trauma in the ward should be closely monitored for desaturation; probably, it might be an early sign of FES which is not revealed in literature.
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Leptospirosis onboard afloat unit: Case report of an underreported infectious disease p. 96
Anmol Sharma, Sougat Ray, Joydeep Choudhury, Rahul Tyagi
DOI:10.4103/jmms.jmms_71_19  
Rat-borne diseases including leptospirosis have been of historical importance in the military. With the risk of human–rat encounters onboard ships and vessels, encountering such an illness at sea is not rare for a primary care physician. Thus, it becomes important for those at the front, to be aware of its presentation and management. Leptospirosis must always be considered as a differential diagnosis of febrile patients, in an environment with positive risk factors. We present the case of a 30-year-old sailor managed and evacuated at sea, who presented with fever and abdominal pain. Our patient was found to have hypotension with oliguria and was administered fluid resuscitation along with broad-spectrum antibiotics while at sea, with a provisional diagnosis of acute pyelonephritis and differential diagnosis of leptospirosis. He was evacuated to a tertiary care center where he was evaluated and managed as anicteric leptospirosis. Our patient had an uneventful recovery. It is essential for primary health-care workers to have a high level of suspicion, to ensure the successful management of such atypical infections. Earliest initiation of empirical antibiotic therapy and symptomatic management along with fastest means of evacuation is suggested to ensure best outcome. The availability of rapid diagnostic tests at primary care centers is a must, to ensure early diagnosis and treatment. Although curable, prevention by rodent control and hygiene maintenance continues to be the most effective and economical methods to minimize the loss of workforce, morbidity, and mortality due to leptospirosis.
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Cascade of levofloxacin p. 101
Amit Bahuguna, Disha Dabbas, Prince Yuvraj Singh
DOI:10.4103/jmms.jmms_72_19  
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Neuraxial block: The case of a faulty equipment p. 103
Alok Jaiswal, Debashish Paul, Shalendra Singh, Arijit Ray
DOI:10.4103/jmms.jmms_42_19  
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