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   Table of Contents - Current issue
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July-December 2020
Volume 22 | Issue 2
Page Nos. 105-277

Online since Tuesday, January 19, 2021

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EDITORIAL  

COVID-19 pandemic and mental health: From risk to resilience p. 105
Seby Kuruthukulangara, Sunil R Goyal
DOI:10.4103/jmms.jmms_188_20  
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INVITED EDITORIAL Top

COVID-19 vaccines- panacea or delusion: A public health perspective p. 110
Arun Kumar Yadav, Subhadeep Ghosh, Atul Kotwal
DOI:10.4103/jmms.jmms_181_20  
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REVIEW ARTICLES Top

An insight into the elderly mind during COVID-19 pandemic: World Mental Health Day 2020 p. 113
Ramya Vadakkayil Balan, Divyamol Karunakaran Sasidharan, Jishnu Sathees Lalu
DOI:10.4103/jmms.jmms_151_20  
About one third of the elderly suffer from mental illness due to psychosocial issues such as loss of spouse, social and financial insecurity, low support from families, inadequate nutrition, uncontrolled hypertension, impaired vision, deafness, and arthritis. Psychological stress can have harmful impact on the immune system, making the elderly more susceptible to SARS-Co-V2. Stigma associated with the disease, risk of developing complications during the course of the disease and relatively high mortality rates put the elderly under immense stress. The older population though knowledgeable are ignorant of their own health. The prevalent COVID-19 pandemic imposes more challenges to the elderly population which demands a holistic approach directed to meticulous solutions.
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Middle ear barotrauma and facial baroparesis in underwater diving - A Scoping Review p. 118
Santosh Kumar Swain, Nibi Shajahan, Anil Mohapatra
DOI:10.4103/jmms.jmms_27_20  
Although middle ear barotrauma is considered uncommon, it may involve a great safety risk to the diver. The medical problems associated with diving are seen as a worldwide concern. Trying to cope with such clinical manifestations of middle ear barotrauma such as otalgia, facial palsy ear, fullness, and vertigo, the underwater diving can be very distressing and dangerous. In case of underwater divers, whether experienced or novice, there are several hazards assumed whenever dive is planned. Out of different hazards, there is a spectrum of illness including middle ear barotrauma. This review article focuses on the etiopathology, clinical presentations, facial baroparesis, and current management of the middle ear barotrauma among underwater divers. This article will surely increase awareness among the clinicians and people those are practicing underwater diving and help them to resolve this problem to a great extent.
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ORIGINAL ARTICLES Top

Postexposure prophylaxis with oseltamivir in outbreak control of pH1N1 influenza onboard a naval warship: An observational study p. 123
Abir Mazumder, Sougat Ray, Vijay Bhaskar, Kavita B Anand, B Vijay Kumar
DOI:10.4103/jmms.jmms_19_20  
Background: Control measures such as maintenance of social distancing, hand hygiene, respiratory hygiene, regular disinfection, and keeping a high index of suspicion for probable cases form the basis of containing a pH 1N1 outbreak onboard a Naval ship. As per the present guidelines, though a quadrivalent vaccine is recommended for health-care workers in close contact, anti-flu postexposure prophylaxis strategies have been predicted to be effective in some mathematical models. Chemoprophylaxis with oseltamivir was assumed to be an effective measure to control the outbreak onboard ship while at sea. Materials and Methods: A total of 275 asymptomatic individuals were started on oral oseltamivir prophylaxis on board from day 17 onward for a duration of 10 days and side effects of the medication were noted. Results: With chemoprophylaxis of the entire crew with oseltamivir, the number of positive cases per day reduced. The outbreak cleared within 3 days of initiation of chemoprophylaxis. Active surveillance was continued for 14 days since the last positive case. Conclusion: In an afloat setting, with a rapidly spreading outbreak of airborne disease, mass chemoprophylaxis with oral oseltamivir along with aggressive public health control measures were found to have contained the spread with only mild side effects which were reported.
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Evaluation and management of sudden sensorineural hearing loss in Indian naval scenario - A prospective cohort study p. 128
Sunil Mathews, Shivanand S Dalawayi, Varun Gangwar, Arumugam Senthil Vadivu
DOI:10.4103/jmms.jmms_17_20  
Introduction: Sudden sensorineural hearing loss (SSNHL) is a medical emergency and if treated early, may improve chances of recovery of lost hearing. Delay in diagnosis and/or initiation of treatment may cause a permanent hearing loss. A relative lack of standardized management protocol has resulted in wide variation among various institutes for investigations and treatment of SSNHL. Aims and Objectives: To provide an overview of causes, methods of evaluation, and management of SSNHL pertaining to the Indian Naval scenario, based on cases evaluated and managed at a zonal level hospital of Indian Navy, over a period of 1 year. Materials and Methods: A prospective cohort study was conducted at the department of otorhinolaryngology at a zonal hospital of Indian Navy from January 2018 to December 2018 and subsequent follow-up until June 2019, giving a minimum follow-up of 6 months for each case. Ten cases were included in the study, evaluated, and managed and the outcomes were analyzed. Among these, six were idiopathic SSNHL (ISSNHL) cases and four were noise-induced (after small-arm firing) SSNHL cases. Results and Conclusion: Hearing outcomes were better and statistically significant for ISSNHL cases compared to noise-induced SSNHL cases. There was a strong negative correlation between the delay in initiation of treatment with improvement in hearing after treatment. The pattern of audiogram is a good predictor for recovery/no recovery, wherein flat and ascending types showed complete recovery, whereas descending type and profound hearing loss type showed no/partial recovery.
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Epidemiology and treatment outcome of frostbite at high altitudes in North India – A cross-sectional study p. 136
Vivek Agrawal, MS Prakash, Pallab Chatterjee, R Vishnuprasad, Abhimannyu Choudhury, Abhijeet Lal, Atul Kotwal
DOI:10.4103/jmms.jmms_60_19  
Context: Frost bite is an important cause of morbidity among armed forces personnel who are employed in high altitude areas. Aims: The aim of the present study was to evaluate the epidemiological aspects and treatment outcome of frostbite injuries among healthy adults working in sub-zero temperatures of the Himalayas. Settings and Design: The study was carried out as a retrospective observational study among all frost bite patients (n = 72) reporting to two zonal hospitals in Northern sector of India from during January 2014 to November 2016. Methods and Material: Patients who had no signs of life on arrival, and patients with injuries due to sunburn / UV rays were excluded from the study. Statistical Analysis Used: Means and proportions were calculated for continuous and nominal variables respectively. Results: All patients were males with mean age of 27.8±2.5 years. Majority of cases 57 (79.2%) had first and second degree frost bite while, third and fourth degree frost bites were noted in 10 and five patients respectively. Maximum cases were reported during the months of December and January. Wound debridement (6.9%), and hyperbaric oxygen therapy (5.6%) were the most common adjunct procedures. Auto amputation was observed in 8.3%. Full recovery was noted in most of the patients except four, who had to undergo amputation of the affected part. Conclusion: Frostbite can result in a wide spectrum of injury, ranging from complete resolution without significant sequelae to major limb amputation and its functional morbidity. First and second degree frost bite were the most common, predominantly noticed in young individuals during peak winter months of December and January.
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A comparative observational study of injury severity score and new injury severity score as criteria for admission of trauma patients in a tertiary care center p. 141
Pawan Sharma, Abhishek Sharma, Usha Kumari
DOI:10.4103/jmms.jmms_25_19  
Background: Trauma has been a major cause of morbidity and mortality all across the globe. For the improvement of delivery of efficient care to these victims, various trauma severity indices have been devised which make it possible to plan emergency care and assess need for hospitalization and optimize hospital resources. This study was carried out to compare and evaluate Injury Severity Score (ISS) and New Injury Severity Score (NISS) as criteria for admission of trauma patients. Materials and Methods: It was a prospective observational study. The available data were analyzed to determine and compare ISS and NISS as the criteria for admission. The statistical software SPSS (version 20) was used for data analysis. Results: A total of 102 patients were studied at trauma center of our hospital. Out of the total patients, 59.8% of patients had their NISS scores greater than ISS, which showed that NISS is more sensitive and accurate than ISS. It was observed that NISS was not better in predicting hospital stay as compared to ISS. The relationship between NISS and number of hospitalization days was not statistically significant (P = 0.112) whereas ISS was a better predictor of hospital stay (P = 0.042). Conclusion: In this study, it was observed that majority of parameters have favored NISS whereas parameters like hospital stay have favored ISS. Hence, we concluded that NISS is a better score than ISS in many aspects and it can be preferred over ISS as one of the criteria for Hospital admission of trauma patients.
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Efficacy of a new surgical technique: Mohan's flap for pilonidal sinus defect closure p. 146
Amitabh Mohan, Munish Malhotra, R Nagamahendran
DOI:10.4103/jmms.jmms_65_19  
Background: Pilonidal sinus is a common disease frequently encountered in the outpatient department. We are presenting our clinical outcomes with excision of the sinus followed by a local flap procedure, Mohan's rotation and advancement flap for its reconstruction. Materials and Methods: In this technique, patients underwent wide local excision and rotation and advancement flap. Over 3 years, seventy patients underwent pilonidal sinus defect closure with this technique. The size of the defect ranged between 4 cm to 10 cm in its greatest dimension. Results: Tension-free and durable closure of the defect was achieved with good obliteration of the depth in the natal cleft. Surgical wounds healed satisfactorily, except for 11% of the patients who developed seroma. Defects closed with similar neighboring skin provided good skin match, with superior cosmetic results. No recurrence was observed during the study period necessitating secondary surgery. Conclusions: The rotation and advancement flap was found to be a useful technique for the treatment of pilonidal sinus with nil recurrence rate and early return to work.
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Inferior vena cava collapsibility index for the assessment of fluid responsiveness among spontaneously breathing preoperative fasting patients - An observational study p. 151
Kiran Kalshetty, Nikahat Jahan, Rangraj Setlur, Alok Jaiswal, Deepak Dwivedi
DOI:10.4103/jmms.jmms_64_20  
Background: It is challenging to assess intravascular volume status for clinicians caring for patients in the perioperative period. Previous studies have recommended the inferior vena cava collapsibility index (IVCCI) to assess the volume status of a patient. However, these studies have been carried out in mechanically ventilated patients with consistent tidal volumes. The evidence for this technique in spontaneously breathing patients is far weaker. This study was performed to assess if IVCCI was increased in spontaneously breathing fasting preoperative patients and if this measure decreased with a fluid bolus. Materials and Methods: After ethical approval and registration, we conducted a prospective study to assess the ability of IVCCI in fasting preoperative patients and the change in IVCCI after a fluid bolus. Fifty adult patients scheduled for surgery, who had been fasting for >6 h, had their IVCCI assessed by scanning of the IVC before and after a 500 ml normal saline intravenous fluid bolus. Results: Prior to the fluid bolus, 46 patients (92%) had an IVCCI of >12%, while 41 patients (82%) had a IVCCI of >12% after a fluid bolus. The mean IVCCI before the fluid bolus was 32.2% (standard deviation [SD] 13.4) and it reduced to a mean IVCCI of 26.3% (SD 20) after administration of a 500 ml fluid bolus, indicating fluid responsiveness. The value of P was < 0.001. Conclusion: In this study, IVCCI in spontaneously breathing patients was both a sensitive indicator of fluid depletion and had a high positive predictive value to identify fluid responsiveness.
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A snapshot of children with congenital anomalies of the kidneys and urinary tract at three tertiary care centers of the armed forces p. 156
Arundhati Biswas, Tathagata Bose, Rahul Ranjan Mandal, Toshi Kapoor, Suprita Kalra
DOI:10.4103/jmms.jmms_74_20  
Introduction: Congenital anomalies of Kidney and Urinary Tract (CAKUT) are the most common reason for Chronic Kidney Disease in children. The spectrum of CAKUT includes a wide range of anomalies from mild unilateral hydronephrosis to bilateral hypoplastic /dysplastic kidneys. We designed this study with an aim to determine the clinical profile of children with CAKUT, any associated anomalies and the factors associated with poor outcomes. Methods: We reviewed the records of all children aged 0-14 years presenting with CAKUT at the pediatric nephrology OPD at three tertiary care centers of the Armed Forces. Antenatal findings, clinical features at presentation, course after birth, need and timing for surgery, serum creatinine, presence of acidosis, mineral bone disease and anemia and growth parameters were recorded. All patients were evaluated and managed as per standard guidelines. Results: 154 children were seen during the study. Unilateral Hydronephrosis with mild to moderate PUJO was the commonest lesion, (n=35). Conclusions: Children with CAKUT have variable clinical presentations and outcomes depending on the severity of the underlying anomalies. Timely detection, evaluation and long term follow up is therefore essential for improving long term outcomes.
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Comparative study of two different doses of dexmedetomidine as an adjuvant to bupivacaine in the peripheral nerve block p. 161
Arijit Ray, Sachin Narayan Kulkarni, Kaminder Bir Kaur, Debashish Paul, Shalendra Singh, Shazia Khan
DOI:10.4103/jmms.jmms_11_20  
Background: The duration of analgesia in the brachial plexus block (BPB) with local anesthetics (LAs) only is not sufficient to avoid the requirement of analgesia for breakthrough pain. Dexmedetomidine (DEX) is an upcoming adjuvant with long-acting LA to reduce the requirement of analgesics in the postoperative period. However, there is no documented consensus about the dose of DEX in this regard. Aim: We compared two doses of DEX with LA in the BPB to find out the effectiveness of analgesia and other effects. Materials and Methods: All patients were separated into two groups, namely Group A (0.5 μg/kg DEX added to 20 mL of 0.25% bupivacaine) and Group B (1.0 μg/kg DEX added to 20 mL of 0.25% bupivacaine). Thirty patients in each group were analyzed. The sample size was estimated with a type I error of 0.05 and a power of the study as 80%. Statistical analysis was performed using SPSS (version 13.0) software. Rescue analgesia was decided as injection morphine (0.05–0.15 mg/kg) intramuscularly as indicated. Results: The mean time of onset of sensory analgesia (18.04 ± 3.195 vs. 12.20 ± 1.848 min) and motor blockade (23.7 ± 2.8 vs. 17.3 ± 1.7 min) were comparable (P < 0.05); however, the duration for the motor (668.0 ± 22.7 vs. 702.0 ± 111.6 min) and sensory blockade (734.8 ± 47.9 vs. 755.6 ± 126.8 min) and time to first demand of analgesics were insignificant. Conclusion: A dose of 1.0 μg/kg DEX has no added benefit when compared with a lower dose of 0.5 μg/kg DEX as an adjuvant to LA.
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Management of trauma cases at a forward surgical center in a counter-insurgency Ops p. 166
Nikahat Jahan
DOI:10.4103/jmms.jmms_31_20  
Introduction: Forward surgical centers (FSCs) provide combat medical support to troops in the field. They comprise a surgical team with radiology and laboratory services. Methodology: Two years data from a single FSC located in a counter-insurgency operational zone were recorded and analyzed on several parameters. The admission and discharge registers, operation theater records of surgery and anesthesia, and the fatal case records were used as data sources. Results: About 60% of the trauma cases were penetrating trauma. The most common region of the body that was injured was the extremities mainly upper limbs. The torso injuries were less than expected presumably due to the use of body armor. Majority of the cases were priority 2 cases requiring urgent surgery. Fifty percent of cases required general anesthetic and the remaining were done under neuraxial blockade or regional or local anesthesia. Eight percent of cases required blood transfusion at the FSC. As banked blood was not readily available, the FSC relied on fresh whole blood. Forty-nine percent of the operated cases were discharged from the FSC without needing transfer to the rear. In 85% of the cases, the surgical team was able to perform definitive surgery. Forty-seven percent of cases were transferred to the next level of surgical care. The overall survival of the trauma cases received at the FSC was 97.12% with a mortality of 2.88%. The leading cause of death was head and chest injuries. The results of this study are comparable to the results of the American experience in Iraq and Afghanistan. Conclusion: This study analyzes the data from a FSC to provide an analysis of the surgical case load in a counterinsurgency area. In spite of multiple limitations, the FSC provided definitive surgery to more than 85% of the trauma cases. The remaining 15% received emergency surgery and were later transferred to the next higher medical facility for superspecialty treatment. About half the number of patients were discharged from the FSC, implying that the true picture of combat trauma should be assessed at the level of FSC and not a referral/zonal hospital.
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Comparison of postoperative analgesic effect of transversus abdominis plane block versus direct wound infiltration with local anesthetic for lower segment cesarean section p. 170
Debashish Paul, Sachin Narayan Kulkarni, Nipun Gupta, Tina Singh, Deepak Dwivedi, Shalendra Singh
DOI:10.4103/jmms.jmms_56_20  
Background: Various drugs and regional blocks are available for providing suitable postoperative analgesia after lower segment cesarean section (LSCS), however commonly used techniques are conventional wound infiltration with local anesthetic and the current technique of transversus abdominis plane (TAP) block. This study aims to compare the analgesic efficacy of TAP block with that of direct infiltration of local anesthetic into a surgical incision in LSCS patients. Materials and Methods: A total of 80 patients for LSCS under subarachnoid block were allocated in two groups; Group A (TAP block, n = 40). TAP block was done by the Anesthesiologist and Group B (wound site infiltration, n = 40); wound site infiltration was done by the operating Surgeon. Postoperative pain, assessed by the Visual Analog Scale (VAS) levels at 2, 6, 12, and 24th h, the requirement of rescue analgesia and patient satisfaction was analyzed. Results: The VAS scores were lower at the 2nd and 4th h (statistically significant) of the postoperative period but at 6th, 12th, and 24th h, though VAS scores in Group A were lower in comparison to Group B, differences were statistically insignificant. The time to administer the first dose of rescue analgesia (421 ± 118.8 min) was longer in Group A in comparison to Group B (187 ± 148.3 min) with significantly fewer cumulative dose and delayed requirement of rescue analgesia in the first 24 h. Conclusions: Wound site infiltration and TAP block did not significantly differ regarding postoperative pain score in post-LSCS patients except the initial 4 h, but the TAP block showed an advantage with significantly reduced cumulative dose and delayed requirement of rescue analgesia in first 24 h.
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Does hyperbaric oxygen therapy have a role in acute fracture healing - A Randomised Controlled Trial p. 175
Seema Gambhir, Vikas Kulshrestha, Munish Sood, Samaresh Sahu
DOI:10.4103/jmms.jmms_63_20  
Background: Fracture healing is a complex biological phenomenon which is influenced by various environmental factors. From time immemorial, there has been a constant endeavor to look for means to enhance fracture healing which would limit disability and restore preinjury level of function at the earliest. Hyperbaric oxygen therapy is one such therapy which has shown some role in enhancing fracture healing in established fracture nonunion but its role in acute fracture healing has not been studied. Materials and Methods: The study was conducted in a military hyperbaric oxygen therapy (HBOT) facility co-located with a tertiary care military hospital. Sixty patients between 20 and 50 years of age with acute closed fractures of the metacarpal, planned to be managed conservatively, were equally randomized to the HBOT (n = 30) and sham HBOT (n = 30) group. Patients in the sham HBOT group, apart from receiving standard of care for the fracture, received a sham exposure of HBOT for 4 weeks, whereas those in the HBOT group, received HBOT therapy for the same duration. The patients were actively followed up for 6 months. Primary outcome measure was rate of fracture healing as assessed by radiology and ultrasound evaluation and functional recovery as assessed by the disabilities of the arm, shoulder, and hand score (DASH). Secondary outcomes included the assessment quality of life and complication rate. Results: The 6-month follow-up rate was 100%. All fractures in both the groups united, there was no significant difference in rate of fracture healing at 12 weeks (P = 0.731) or functional outcome at 24 weeks, as assessed by DASH score (P = 0.127), between the groups. There were 6 (20%) malunions in sham HBOT group and 2 (07%) in HBOT group. There were four cases of reflex sympathetic dystrophy in sham HBOT group and three cases in HBOT group. Conclusions: HBOT in acute diaphyseal fractures does not alter the rate of healing when assessed clinicoradiologically and has no effect on functional outcome at 6 months of follow-up. Level of Evidence: Level I
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Depressive disorders in angiographic-proven coronary artery disease: A Cross Sectional Study p. 182
Nitin Bajaj, Abhilasha Sharma, Swati Bajaj, Rohith R Pisharody, Seema Patrikar
DOI:10.4103/jmms.jmms_21_20  
Objective: Depressive disorders are a common and unrecognized entity in the patients of coronary artery disease (CAD). This study aimed at detecting the prevalence of depressive disorder in patients of angiographic proven CAD and to assess the correlation between depression and various coronary risk factors and clinical variables in patients of CAD. Materials and Methods: We did a prospective, observational study in patients of angiographic proven CAD attending cardiology outpatient department services in a tertiary care hospital. We studied patients in the age group of 25–80 years of CAD. A detailed history clinical evaluation was done, and the prevalence of depression was detected with the help of a questionnaire as per becks depression inventory. Results: A total of 150 patients were studied. Out of these, 113 (75.33%) were male and 37 (24.66%) were female. The mean age of the patients was 54.85 years. In the questionnaire-based screening for depression, 16.6% had normal score, 30% had mild mood disturbance, whereas 26% had borderline clinical depression and another 25.3% had moderate depression. A total of 03 patients (2%) had severe depression and none had extreme depression. Among the associations with depression, the presence of female sex, New York Heart Association class and educational status was shown to have significant association with depression in CAD patients. Conclusions: Our study shows a high prevalence of depression in patients of CAD. This generally goes unnoticed and untreated and can lead to poor quality of life and also increases mortality risk. Thus, the features of depressive disorder should be actively screened and treated in patients of CAD.
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ECG changes in pregnancy - An observational study p. 187
R Ananthakrishnan, Shradha Sharma, Sudhir Joshi, Sandeep Karunakaran, S Mohanty
DOI:10.4103/jmms.jmms_6_20  
Introduction: Arrhythmias in pregnancy may cause concern for the wellbeing of mothers and fetuses. Understanding the physiologic changes and types of arrhythmias that occur during pregnancy can help in identifying cases requiring intervention. This study aimed to determine the prevalence and types of electrocardiography changes and cardiac arrhythmias in normal pregnancy. Materials and Methods: This observational study was conducted at a tertiary care hospital. Four hundred and fifty women aged 20–35 years with singleton pregnancy in early gestation, irrespective of parity, comprised the study group. A baseline ECG of the first trimester was reviewed with repeat ECG at 22–24 weeks and 32 weeks along with 24-h Holter studies during 20–24 weeks. Results: The most common rhythm disturbance was ventricular premature contractions (1.8%), followed by atrial fibrillation (0.7%). A significant association was seen between rhythm disturbances with advancing age and pregnancy-induced hypertension. No difference was observed between P-axis wave and PR interval. QRS axis and duration decreased significantly from the time of enrollment to 22–24 weeks to 32 weeks, whereas QTc interval increased during the course of pregnancy. No ST/T-wave changes were seen in any of the cases at enrollment, whereas at 22–24 and at 32 weeks, new T-wave inversion was observed in 8.2%. Conclusion: ECG changes such as reduction in QRS axis, T-wave inversion in lead III and V1–2, and prolonged QTc were observed in pregnant women. The prevalence of rhythm disturbances was low, with ventricular premature complex being the most common pathology. Minor electrocardiographic changes may be considered normal in pregnancy unless associated with significant symptoms.
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Study of tracheal cuff pressure variation in adult tracheostomized patients in the intensive care unit p. 193
Manohar Suryavanshi, Anil Kaul, Dilip Raghavan
DOI:10.4103/jmms.jmms_56_19  
Background: Tracheostomy tube cuff pressure requires to be maintained within the acceptable range in ICU patients to prevent complications like tracheal stenosis, aspiration pneumonia etc. However tracheal cuff pressure monitoring is still not being strictly followed in many medical centres. Aim: To evaluate variation in Tracheal Cuff pressure over 24 hours once inflated to recommended pressure in adult tracheotomised patients. Setting and Design: Prospective observational study. Methods and Material: This study was carried out on 82 tracheostomised adult patients in ICU of a tertiary care hospital. Tracheal cuff pressure was monitored by Manometer every six hourly over 24 hours for 4 days. Statistical Analysis Used: Student's t- test. Result: Tracheal cuff pressure showed significant variation in tracheal cuff pressure within 24 hours period of daily monitoring with all cases showing fall in cuff pressure below the acceptable range. Conclusion: Regular Manometric monitoring of tracheal cuff pressure is recommended in Tracheotomised patients in ICU setting to avoid associated complications.
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Minimally invasive suture anchor – metallic button construct for acute acromioclavicular dislocations: A functional outcome pilot study in military cohort p. 196
Anil Kumar Mishra, Vyom Sharma, Amit Chaudhry
DOI:10.4103/jmms.jmms_78_19  
Context: The best technique to achieve the optimum functional outcome in acute acromioclavicular (AC) injuries in young, active patients continues to be a matter of debate. Aims: The aim of this study is to evaluate the functional outcome of a minimally invasive technique for acute AC dislocation in military soldiers. Settings and Design: The study design involves prospective study from 2012 to 2016 at a tertiary care Military Orthopaedic center. Materials and Methods: Patients with an acute Rockwood Type III, IV, and V AC injury were included polytrauma, injury older than 2 weeks or requiring an open reduction, ipsilateral limb, and neurological injuries were excluded from the study. All patients underwent minimally invasive, percutaneous reduction and fixation with a suture anchor–metallic button construct. Patients were followed up at 6, 12, 24 weeks, 1 year, and 2 years postoperatively for radiological and functional assessment (Constant score). Statistical Analysis: Using analytical tests in SPSS software for comparison of coracoclavicular (CC) distance on the injured and healthy sides. Results: There were 25 male soldiers and cadets with a mean age of 24.5 ± 5.5 years. The mean follow-up duration was 37.9 ± 6.26 weeks. Twenty-four (96%) patients achieved pain-free, overhead shoulder abduction at 24 weeks follow-up with a mean constant score of 88.4 ± 7.43. The mean constant score at the last follow-up was 94.5 ± 5.67. Twenty-three (92%) patients had a well reduced AC joint; mean CC distance on the affected side was 9.1 ± 1.2 mm, comparable to mean distance of 8.9 ± 1.4 mm on the healthy side without any evidence of sclerosis or osteolysis till the last follow-up, while one patient had a recurrent dislocation. Conclusions: Suture anchor metallic button construct is a simple, surgeon friendly technique for young, high-demand patients to restore AC biomechanics in a minimally invasive manner.
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Impact of 6 MV photons and mixed beam (6 MV and 15 MV) photons on the dose distribution in high-grade gliomas using three-dimensional conformal radiotherapy technique - A Retrospective Analysis p. 202
Sachin Taneja, Kirti Tyagi, Deboleena Mukherjee, Arti Sarin
DOI:10.4103/jmms.jmms_8_20  
Background and Aim: The present study focused on the impact of 6 MV photons and mixed beam (6 MV and 15 MV) photons on dose distribution in high-grade gliomas using three-dimensional conformal radiotherapy (3DCRT) technique. The suitability of using different photon beam energies was evaluated with respect to dose distribution. Materials and Methods: A total of 24 patients of high-grade glioma treated on linear accelerator were enrolled and evaluated in this retrospective study. All patients had undergone total/subtotal resection of tumor. These patients were treated with postoperative adjuvant external beam radiotherapy on a linear accelerator using 3DCRT technique. Treatment plans were generated using 6 MV and a combination of both 6 MV and 15 MV photon beams. All plans were generated using suitable planning objectives, and dose constraints which were identical across the plans, except the beam energy. The plans were analyzed in terms of their target coverage, conformity, and normalized dose range. Results: In 16 patients out of 24, the treatment plans were generated using 6 MV photons, the normalization dose was well within 5%–7% of the dose prescribed. In the remaining 8 patients, the normalized dose was >107%, and in these cases, the use of mixed beam plans yielded a better dose distribution with normalized dose between 101% and 105%. Conformity index (CI) values were between 1.2 and 1.98. CI mean was 1.59. Conclusions: The use of mixed beams in 3DCRT technique may be considered as an alternative, especially in a scenario where pure 6 MV photons do not yield homogeneous dose distribution within the normalized range, and in centers where intensity-modulated radiation therapy and field-in-field technique are not available.
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Comparative study of measurement of intraocular pressure in eyes with corneal opacity and normal cornea by Tonopen Avia, rebound tonometer (I-care), and noncontact tonometer p. 207
Sridhara Reddy, Vijay K Sharma, Partha Sarathy Moulick, Atul Kumar Singh
DOI:10.4103/jmms.jmms_10_20  
Purpose: The most common indications for keratoplasty are patients with corneal opacity. The presence of glaucoma prior to keratoplasty is an important risk factor, eventually may lead to failure of the corneal graft. Currently, we have insufficient evidence of comparison of intraocular pressure (IOP) measurement in patients with corneal opacity. The purpose of this study is to analyze the IOP measurements obtained with Tonopen (TP) Avia, I-Care rebound tonometer, and noncontact tonometer (NCT) in patients with corneal opacity and normal cornea. Materials and Methods: It is a prospective, comparative study using a convenience cohort of eyes with corneal opacity. Patients having corneal opacity and normal cornea had IOP measured using TP (Avia-Reichert, Depew, Newyork, USA), rebound tonometer (I-care), and NCT (Reichert AT 555). IOP measurements were compared and agreement assessed. Bland–Altman plots, box–whisker plot, and error–bar diagram were used for assessing agreement. Results: Thirty eyes with corneal opacity and thirty eyes with normal cornea of the same patients were included in the study. The mean IOP readings in eyes with normal cornea taken by NCT, rebound tonometer, and TP Avia were 13.71 mm Hg with standard deviation (SD) of 2.73, 14.85 mm Hg with SD of 2.13, and 14.73 mm Hg with SD of 2.27, respectively. The mean IOP readings in eyes with corneal opacity taken by NCT, rebound tonometer, and TP Avia were 17.35 mm Hg with SD of 5.82, 15.83 mm Hg with SD of 3.2, and 15.98 mm Hg with SD of 3.53, respectively. Bland–Altman analysis plots show good agreement between all three devices. Conclusion: IOP measurements in normal cornea showed underestimation by NCT and overestimation by rebound tonometer with TP as standard, whereas in eyes with corneal opacity, IOP measurements showed overestimation by NCT and underestimation by rebound tonometer. TP Avia was proved to be a useful instrument because of its smaller contact area and repeatability.
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Trend of antitubercular drug sensitivity test at a multispecialty hospital in Western India - A Retrospective Analysis p. 212
Shishir Jain, Ashish Bahal, HS Sidhu, Muqtadir Malik, Siddharth Singh
DOI:10.4103/jmms.jmms_62_19  
Context: Tuberculosis (TB) infection is still a major public health burden in India. India accounts for about 25% of the global TB burden. Worldwide India is the country with highest burden of both TB and multidrug-resistant (MDR) TB. Aim: The aim of this study was to evaluate the pattern of resistance of Mycobacterium tuberculosis to first and second line antitubercular drugs among specimens from a multispecialty hospital in Western Maharashtra. Settings and Design: This record-based study was conducted from January 2018. Records of sputum from 2013 to 2017 were obtained from patients with suspected TB. Subjects and Methods: Drug-sensitivity testing was performed by the mycobacterial growth indicator tube method. Sensitivity to first line and second line antitubercular drugs was tested. Statistical Analysis Used: Trend analysis and charts using MS Excel. Results: Among 734 patients, 701 (95.5%) were male and 33 (4.5%) were female. The analysis of our study result showed that 21.7% of patients were monodrug resistant. Out of 734 isolates, 56 (7.62%) showed multi- and 39 (5.6%) out of the 734 samples showed extensive drug-resistant TB. Conclusions: Our study confirms that drug resistance, including MDR, observed against all first-line TB drugs was a real threat in the management of TB infection. The resistance pattern in this study could assist the clinicians in providing appropriate treatment regimen to TB patients and improve their clinical outcome.
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Can subgenomic mRNA predict course of COVID-19? – An observational study from a tertiary care center p. 216
Kavita Bala Anand, Santosh Karade, Sourav Sen, Sougat Ray, Prashant Patil, Pratik Thosani, S P. S Shergill, Rajiv Mohan Gupta
DOI:10.4103/jmms.jmms_170_20  
Background: The Covid 19 pandemic The COVID-19 pandemic continues to spread rapidly resulting in major socioeconomic impact globally. The infectivity, lack of effctive drugs and vaccines, and potentially large asymptomatic transmission have made the management and control of the disease extremely challenging. Although the primary control strategy is to isolate infected patients, the duration of the isolation period is poorly understood as viral RNA has been found to be persisting for prolonged durations. Recently many authors have studied the role of presence of subgenomic mRNA patient specimens to determine the infectivity of the patient. In our study we detected the presence of SARS-CoV-2 Envelope subgenomic mRNA in patients RT-PCR positive for SARS-CoV-2. These included symptomatic and asymptomatic patients. Aim: To detect the presence of E sg mRNA in SARS-CoV-2 RT PCR positive nasopharyngeal specimens. Materials and Methods: 58 consecutive RT-PCR positive samples were collected over a period of 10 days. These were further subjected to conventional RT-PCR testing for E subgenomic mRNA. Results: 22/58 tested positive for presence of sg mRNA. Out of these 22 positive for sg mRNA, 19 were symptomatic patients. We further compared the presence of sg mRNA in symptomatic cases at ≤ 5 days of symptom onset to testing time (STT) and in asymptomatic cases at ≤ 5 days from first Covid RT PCR positive test. There were total 44 samples including both groups, out of which 19/22 symptomatic patients showed presence of sg mRNA and 3/22 of asymptomatic showed presence of sg mRNA. Conclusion: In our study we observed that sg mRNA is detected mostly in symptomatic patients. However the limitation of our study is that a small sample size has been tested and cases have not been followed up. Large observational studies to detect sg mRNA in Covid 19 patients will help in validating its role in the disease process. Moreover the asymptomatic cases that show presence of subgenomic mRNA should be followed up longitudinally to observe whether they remain asymptomatic or develop symptoms subsequently.
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Rapid response and mitigation measures in control of COVID-19 cases in an industrial warehouse of Western Maharashtra, India p. 220
Shabeena Tawar, G Diva Reddy, Sougat Ray, Naveen Chawla, Swati Garg
DOI:10.4103/jmms.jmms_123_20  
Introduction: From being declared as Public Health Emergency of International Concern and the transmission dynamics of COVID-19, outbreak control has been the cornerstone of combating COVID-19 cases within communities and clusters. An outbreak investigation of COVID-19 positive cases was conducted in a close community setting at an industrial warehouse which included working and residential areas in the premises, with the aim to break the chain of transmission rapidly and to formulate preventive strategy for dealing with other outbreaks in a community setting. Materials and Methods: This was a study where a rapid outbreak response was carried out after two individuals tested COVID-19 positive. Following the national and local guidelines, immediate decongestion followed by aggressive contact tracing, testing and isolating the cases were done. Results: After the rapid contact tracing exercise, contacts were identified, quarantined and tested. Daily monitoring of the contacts revealed six symptomatic confirmed cases and on testing, 19 asymptomatic contacts were positive. All confirmed cases were immediately admitted to the hospital. Additional two positive cases reported from family contacts. The mean age of the individuals was 46 years. There were 9 individuals with co-morbidities and two individuals developed acute respiratory distress syndrome and expired in the hospital. The secondary attack rate was calculated to be 17.51%. Conclusion: Prompt public health measures by rapid response team, creation of containment zone, contact tracing, early isolation along with daily influenza like illness screening and strict quarantine effectively helped in containment of the outbreak in the population under study.
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CASE REPORTS Top

Sacral stress fractures in military recruits: A commonly missed uncommon entity p. 226
Mohammed Schezan Iqbal, Debraj Sen, Rajiv Kaul, Shikha Awasthi
DOI:10.4103/jmms.jmms_30_20  
Sacral stress fractures are a relatively rare entity which are particularly difficult to identify and diagnose. A high index of suspicion, especially in individuals at risk, like long-distance runners, female athletes, military recruits, and individuals who have recently started training for competitive sports and are hence unaccustomed to training, who complain of low backache with or without buttock or groin pain, will indeed help the physician in not missing out on this diagnosis. A thorough evaluation, including tests to rule out insufficiency fractures due to associated illnesses along with a magnetic resonance imaging of the sacroiliac joints, is mandatory to recognize this problem and institute early, appropriate treatment.
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Two cases of total bone endoprosthetic reconstructions as limb salvage following resection of rare malignancies of proximal femur and humerus p. 229
Yogesh Sharma, BM Naveen, Vivek Mathews Phillip
DOI:10.4103/jmms.jmms_54_20  
The femur and humerus are the most common long bones affected by both primary and malignant tumors. The choice of limb salvage or amputation always remains a dilemma to achieve an optimum outcome. Two such patients of malignant tumors of the long bone, one in the proximal femur and the other at the humeral shaft, were managed at our center with limb salvage. The first patient is a 36-year-old male with a rare malignant nerve sheath tumor of proximal femur treated at a peripheral hospital with curettage and stabilization by an intramedullary nail for the lesion in the proximal femur, presuming it to be a benign lesion. He was subsequently managed by total femur resection followed by an endoprosthetic reconstruction, which resulted in an excellent outcome with no local recurrence or metastasis at 5-year follow-up. Similarly, the other case, a 42-year-old male with primary chondrosarcoma of humeral shaft of 2 years' duration, was successfully treated with total humeral excision followed by an endoprosthetic reconstruction. He also achieved an excellent functional outcome and resumed his job 1 year postoperatively. At 5 years' follow-up, there was no local recurrence or distal metastasis in this case too. These two cases of malignant lesions of femur and humerus were unique in many ways and gave a lot of insights into the diagnosis and management of rare malignancies of long bones.
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Unusual presentation of cerebral venous sinus thrombosis in ulcerative colitis p. 235
Manish Manrai, SS Mohakuda, Adwait Sodani
DOI:10.4103/jmms.jmms_41_20  
A 21-year-old young male presented with a relapse of Idiopathic Ulcerative Colitis (IUC) and developed recurrent transient weakness of left upper limb with complete recovery and headache. He also had blurring of vision and pre-syncope. The evaluation revealed Cerebral Venous Thrombosis (CVT). The attacks seized to occur after prompt anticoagulation was exhibited. The purpose of this report is to emphasize that CVT in IUC is sparsely experienced a prothrombotic complication and such CVT presenting as unilateral recurrent transient paresis or some focal deficit mimicking a Transient Ischemic Attack (TIA) / seizure is further rare albeit possible.
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Cleidocranial dysplasia – A case report discussing the clinical and radiological manifestations p. 238
Vikram Singh Shekhawat, Yoginder Singh Gulati
DOI:10.4103/jmms.jmms_59_20  
Cleidocranial dysplasia (CCD) is a generalized skeletal disorder characterized by typical clinical and radiological abnormalities which include open cranial sutures and fontanelle, presence of Wormian bones, characteristic abnormalities of the clavicle and pelvic bones, and dentition. We report a teenage boy who presented for the evaluation of short stature. He was detected to have CCD based on his clinical examination and radiographic findings. An early diagnosis and treatment directed at correcting the dental and orthopedic abnormalities are imperative to obtain an optimal cosmetic and functional outcome in these patients.
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Retropharyngeal abscess in a 3-month-old infant: A rare entity p. 241
Inderdeep Singh, Tanuj Madan, Amit Rai, Ashok Yadav, Rajeev Sivasankar, Renu Rajguru, Mohammad Zubair Akhtar
DOI:10.4103/jmms.jmms_82_19  
Retropharyngeal abscess (RPA) is a rare infective pathology of deep neck spaces affecting young children and adults. In view of scarce literature availability and atypical presentation in infants, often lacking fever or lymphadenopathy, it poses a definitive diagnostic dilemma to the clinicians. It should be kept in mind for all infants presenting with respiratory distress. History should be carefully taken for any upper respiratory tract infections or nasal discharge preceding the illness. Prompt airway control is of paramount importance, since there is a higher prevalence of airway compromise in infants and early surgical intervention is therefore indicated. Usually, intraoral approach is sufficient for incision and drainage. Here, we present a rare case of RPA in a 3-month-old infant in whom early radiological investigations, especially contrast-enhanced computerized tomography/noncontrast head computerized tomography helped not only in timely diagnosis but also in planning of surgery. A multidisciplinary, integrated strategy of pediatrician, neurosurgeon, microbiologist, radiologist, and otorhinolaryngologist is ideal for patient care.
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First lung transplant recipient of Indian armed forces p. 245
Manjit Sharad Tendolkar, Rahul Tyagi, Apar Jindal, Sandeep Attawar, Ajay Handa
DOI:10.4103/jmms.jmms_26_20  
In 2010, a 22-year-old female presented with progressive breathlessness and multiple joint pain in bilateral knee and wrist joints. She was diagnosed with rheumatoid arthritis (RA) based on the clinical as well as serological criteria, and her breathlessness was attributable to RA-associated interstitial lung disease. Despite being on immunosuppressants, her lung involvement continued to progress as she got dependent on oxygen at home for 2011 and required domiciliary noninvasive ventilatory support for 2017. The prognosis was grave as the disease continued to affect her lungs relentlessly despite all possible medical therapies. Our experience with lung transplants in service hospitals was nonexistent as it was not a common practice to refer patients for lung transplant because of inadequate data of its success in our country and the mammoth cost involved. However, in view of the emerging reports of successful lung transplantation and the risk benefit ratio favoring the patient, she was referred to a lung transplant center. The patient chose to have the lung transplantation at a hospital in Chennai. On May 22, 2018, the patient underwent a successful bilateral lung transplant. She is being managed with triple immunosuppression and antimicrobial prophylaxis at her home. Over the past 1½ year, the patient has developed one episode of bacterial pneumonia which was successfully managed with antibiotics. The patient continues regular visit at our hospital as she is able to work independently of any ventilatory support. We intend to narrate the experience of first-lung transplant recipient among our clientele.
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Buttress plate-assisted fixation for lateral hoffa fractures: A case report and review of literature p. 250
Rajiv Kaul
DOI:10.4103/jmms.jmms_67_20  
The purpose of this article is to provide a review of coronal fractures of the femoral condyles, known as Hoffa fractures, and to describe a unique fixation modality entailing the use of lag screws in combination with a posterior buttress plate. This case report of a lateral Hoffa fracture focuses on the evaluation, general approach, and surgical management of this subset of distal femoral fractures using this novel technique.
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Role of cytology in differentiating anaplastic thyroid carcinoma with osteoclast like giant cells from giant cell variant of medullary thyroid carcinoma p. 255
G P S Gahlot, Tathagata Chatterjee, Rohit Tewari, Vijendra Singh, Ankur Ahuja, Kanwaljeet Singh, Beenu Singh
DOI:10.4103/jmms.jmms_85_19  
Anaplastic thyroid carcinoma (ATC) is a highly aggressive tumor and constitutes 2%–5% of all thyroid carcinomas. The cytological diagnosis of osteoclast giant cell variant of ATC is extremely rare, and only a few cases have been described in literature. A 67 - year-old female underwent fine-needle aspiration cytology from the thyroid nodule. Smears revealed hypercellular aspirate comprising of clusters and singly scattered atypical cells with few interspersed multinucleated tumor cells. Cytomorphological differential diagnosis of giant cell/pleomorphic variant of medullary carcinoma and anaplastic carcinoma was offered. Histomorphological features on cell block assisted with immunohistochemistry confirmed the diagnosis of ATC with osteoclastic-like giant cells. Computed tomography-guided right lung lesion aspirate was reported as metastasis of high-grade poorly differentiated carcinoma. The patient was managed with cisplatin-based chemotherapy. This case highlights the importance of cytological diagnosis of ATC to guide the treatment modality of chemotherapy thus avoiding surgery, especially in old moribund patient with lung metastasis.
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COMMENTARIES Top

Commentary on: “Management of trauma cases at a forward surgical center in counter insurgency ops p. 258
Rangraj Setlur
DOI:10.4103/jmms.jmms_66_20  
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Generating good evidence in orthopedics p. 260
Vikas Kulshrestha, Munish Sood
DOI:10.4103/jmms.jmms_83_20  
Today, there is increasing demand for quality medical care to be made available for a large population at a reasonable cost. In a society with limited health-care infrastructure and budget, it has become imperative to evolve scientifically proven clinical care pathways. No country is willing to accept infructuous expenditure on treatment modalities with ambiguous patient outcomes. Hence, evidence-based medicine has been introduced into most health-care systems. When it comes to orthopedics, a serious concern is that, the existing literature has extremely poor quality of evidence. There are very few best practice guidelines, which are supported by high quality clinical studies. In this review article, we have made an attempt to bring out the recurring lacunae in orthopedic research papers. Following which we have also given tips on how to plan, design, and conduct a high quality clinical trial. We have made an attempt to explain commonly required knowledge of statistical tools. In the end we have briefly described, how to prepare a protocol, execute the study, analyze the results, and write the final article to get published.
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CORRESPONDENCE Top

Best practices with optimal outcomes during COVID-19 pandemic – A swiss cheese model experiment in the naval training command p. 266
Arti Sarin, Vidhu Bhatnagar, Anand Neelakantan, Manish Khandare
DOI:10.4103/jmms.jmms_184_20  
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Nutritional prehabilitation in COVID-19 - “Food for Thought” p. 269
Neha Singh, Sougat Ray, Surbhi Gupta
DOI:10.4103/jmms.jmms_177_20  
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Is it an end of the art of “Physical Examination” in the COVID-19 pandemic? p. 271
Rajagopal Srinath, T V. S. V. G. K Tilak, Anil S Menon
DOI:10.4103/jmms.jmms_172_20  
The COVID-19 infection has been causing significant burden on the health infrastructure of almost every country and the COVID-related mortalities and morbidities translate into a significant impact on the societal perspective. Adequate precautions are mandatory for the healthcare workers managing patients at healthcare facilities like use of personal protective equipment (PPE) while handling patients. The clinical examination forms an important tool in the evaluation of any patient. For the last few years, the clinical skills of the clinicians have been on the decline noticed by the medical fraternity. The clinicians have become increasingly reliant on investigation reports and imaging technologies to diagnose and manage the patient. The situation of COVID-19 and management of these patients in COVID care hospitals and centers have further diminished the role of clinical skills with the added difficulties of wearing the full component of PPE during the patient evaluation and care. Patients are isolated as per the protocol, and doctors are forced to avail the telemedicine facilities and depend on the objective data provided by the junior doctors or paramedics. The pondering question is, have we reached a new tipping point in the utility of clinical diagnosis, making it further alienated in the future? We will have to wait and see if the clinical skill utility change caused by this pandemic would have a lasting effect.
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Immunological prospects of tamoxifen as modern antiviral therapy p. 273
Falah AL-Khikani, Raghdah Hameed, Huda Almosawey
DOI:10.4103/jmms.jmms_72_20  
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Imaging appearance of pedunculated subserosal leiomyoma with red degeneration mimicking abdominal mass lesion p. 276
Reddy Ravikanth
DOI:10.4103/jmms.jmms_59_19  
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