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   Table of Contents - Current issue
March-April 2017
Volume 10 | Issue 2
Page Nos. 115-218

Online since Tuesday, March 14, 2017

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Withdrawal syndrome: Author's dilemma and editor's agony p. 115
Amitav Banerjee
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Ocular manifestations of Marfan's syndrome p. 118
Samanthila Waduthantri
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Pathological gambling: An overview p. 120
Shalini Singh, Ganesh Kumar Mallaram, Siddharth Sarkar
Gambling activities are popular as a form of recreation and have been a source of income for many people worldwide. Although gambling has been common across continents and time, and a subset of individuals experience problems with gambling. This review attempts to provide an overview of problem gambling for clinicians who are likely to encounter such patients in their practice. The review discusses the relevance, nosology, and epidemiology of gambling. We also discuss the associated comorbidities and principles of management of pathological gambling.
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Magnetic resonance imaging evaluation of cruciate ligaments after arthroscopic reconstruction p. 128
Amit Kharat, Sahil Garg, Vipul Sehrawat, SG Gandage
Background: Due to increase in road traffic and sports injuries, tears of anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) of the knee are common. Magnetic resonance imaging (MRI) is emerging as an important tool of diagnosis and evaluation of these injuries. Methods: We carried out a prospective study on role of MRI on ten patients who had undergone ACL or PCL repair over a period of six months. In this report we present three illustrative cases to capture the spectrum of findings in our series to underline the role of MRI in management of such injuries and discuss the modalities of the procedure. Results: In our series, as demonstrated by the cases, MRI had an important role in diagnosis and evaluation of injuries to the cruciate ligaments. Conclusion: MRI can play an important role, particularly in tertiary centres, in diagnosis and evaluation of reconstructed ACL and PCL ligaments of the knee joint.
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Reproductive health awareness among adolescent girls of a government school in an urban slum of Pune City p. 133
Pooja Shankar, Puja Dudeja, Tukaram Gadekar, Sandip Mukherji
Introduction: Reproductive health of adolescent girls is crucial in determining the health of future generations. For ensuring informed decisions by adolescents regarding their sexuality and reproductive health, National AIDS Control Organisation has introduced life skills education in school curriculum. However, there exist many roadblocks in implementation from theory to practice. Hence, the present study was conducted to assess the reproductive health awareness and most preferred source of information. Materials and Methods: This was a descriptive cross-sectional study among girls of classes VI–XII of a Government High School in an urban slum of Maharashtra. Two hundred and fifty girls participated; 39 questionnaires were incomplete, hence 211 responses were analyzed. All girls were educated about reproductive health and life skills issues after the study. Results: Mean age of the participant girls was 14.9 ± 1.75 years. The level of awareness improved significantly with increase in class of respondent (P < 0.05); however, no significant association was seen with education of mother or father (P > 0.05). Eighty percent of them were unaware of the appearance of secondary sexual characteristics in both the genders. Less than 30% of the girls were aware of contraceptives. Regarding effects of premarital sex, 57% of the participants were concerned about bringing a bad name to themselves and their family, while reproductive tract infections (9%), HIV/AIDS (29%), were cited as other ill effects. Seventy percent felt comfortable discussing or confiding regarding reproductive health issues with friends rather than parents, teachers, or medical professionals. Conclusion: Knowledge and awareness about reproductive and sexual health issues among adolescent girls was dismal.
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Prevalence and risk of musculoskeletal pain in rural homemakers of North India p. 138
Mili Mishra, Anup Kumar Srivastava, Vinod Kumar Srivastava
Background: Musculoskeletal pain (MSP) is a well-known burden of disease and disability in all age groups and both sexes. There are very few reports regarding MSP in rural homemakers of North India. Objective: To assess the magnitude of MSP among rural homemakers and to identify its modifiable risk factors. Materials and Methods: A representative sample of 296 homemakers from rural areas of Barabanki district in Uttar Pradesh was studied. Details of MSP and its location; social, demographic information, height, and weight were recorded. A general clinical examination of each subject was also done to rule out any obvious underlying organic pathology and the findings were noted. Results: Prevalence of MSP among homemakers was found to be 40.9%. More than 60% of these could not be diagnosed without specialized investigations. Modifiable risk factors were identified. Conclusions: Parity, body mass index, use of nonsmoking tobacco, and per capita income were identified as modifiable risk factors in this population.
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Study of fine-needle aspiration cytology of lymph node in rural area of Bastar District, Chhattisgarh p. 143
Sachin A Badge, Anjalee G Ovhal, Khemlal Azad, Avinash T Meshram
Aims and Objectives: Fine-needle aspiration cytology (FNAC) as the first line of investigation has assumed importance in diagnosing a variety of disease processes as it is rapid, simple, reliable, minimally invasive, and cost-effective procedure which can be used in outpatient setting. Lymphadenopathy is one of the most common clinical presentations of patients attending the outpatient department. This study was performed to find out the pattern of diseases in lymph node in the rural area of Bastar District of Chhattisgarh State. Materials and Methods: A prospective study of 310 cases of lymphadenopathy presenting to the Department of Pathology for 2 years from January 2014 to December 2015 was taken up for our study. FNAC was performed using a 22–24-gauge needle and 10 ml syringe. Two of the prepared smears were fixed in alcohol and stained with hematoxylin and eosin and Papanicolaou stain. Two smears were air-dried, one was stained with Leishman stain and the other kept unstained to be used for Ziehl–Neelsen staining whenever a cytological diagnosis of granulomatous disease was made and also in cases with abundant necrosis and suppuration. Results: Most common lesion found in our study was tubercular lymphadenitis, followed by granulomatous lymphadenitis and reactive hyperplasia. Conclusion: Our study highlighted the various cytomorphological patterns of lymphadenopathy and revealed a huge burden of tuberculous lymphadenitis in this region.
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Evaluation of safety and efficacy of low-dose methotrexate as an alternative treatment option to systemic corticosteroids in generalized lichen planus p. 149
Yuvraj Eknath More, Swapna Subhash Khatu, Dipali Chetan Chavan, Pradeep Mahajan, Sai Pawar, Neeta Gokhale
Introduction: Lichen planus (LP) is a common, chronic, inflammatory pruritic disorder involving the skin, mucous membranes, nails, and hair follicles. Systemic corticosteroids have long been treatment of choice for generalized LP. However, use of corticosteroids is limited due to multiple side effects. Methotrexate (MTX) can be used as alternative and safe modality in generalized LP. Materials and Methods: Twenty-two cases of generalized LP with comorbidities such as diabetes mellitus and hypertension and steroid-resistant and patients with side effects of long-term corticosteroids were included in this study. MTX was initiated at the dose of 7.5 mg/week. Clinical evaluation for improvement in lesions and pruritus was performed at 2nd, 4th, 8th, and 12th weeks. Results: After 12 weeks, 80% patients had excellent improvement. Patients with an excellent response were followed up. In the 6-month follow-up, four patients showed recurrence while all the remaining 12 showed complete remission. Conclusion: Results of this small study suggest that the use of weekly oral MTX can be highly effective and tolerable treatment alternative for generalized LP.
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Prevalence of depression in mothers of intellectually disabled children: A cross-sectional study p. 156
Gourav Chandravanshi, Krishan Kumar Sharma, Charan Singh Jilowa, Parth Singh Meena, Mahendra Jain, Om Prakash
Background: Intellectual disability (ID) is a permanent and highly disabling condition. The birth of a disabled child induces complex feelings in mother and other family members. This study was planned to investigate phenomenology of ID and the prevalence of depression in their mothers. Objective: To find prevalence, influence of various sociodemographic variables, and its clinical correlation with depression in mothers of ID children. Study Design: A cross-sectional study. Materials and Methods: A total of 100 patients diagnosed as ID were included in the study. Objective data were collected in a special Pro forma, and mothers of these patients were evaluated with the Beck's Anxiety Inventory and Beck's Depression Inventory. Results: The mean age of patients with ID was 11.52 years, had received an average of 3.01 years of schooling, mean age at diagnosis was 6.01 years, mean intelligence quotient was 45.17, and 79% had significant comorbidities. The prevalence of depression in mothers was 79%; it was more in mothers of female ID child, ID child with significant comorbidities, severer forms of retardation, and with higher levels of anxiety in the mother. Conclusions: The prevalence of depression in mothers of ID children in the present study seems to be much greater than those reported from the previous studies. The determination of predictors of depression among mothers of ID children may help health professionals in identifying mothers at risk. Regular screening of mothers of ID children should be included in the protocol for management.
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Outcome of coronary artery bypass graft surgery in patients with low ejection fraction p. 162
Avinash K Inamdar, Shweta Pralhad Shende, Sanjeevini A Inamdar
Background: Patients with low ejection fraction (EF) are at high risk for postoperative complication and mortality. Our aim was to assess the effect of low EF on clinical outcome after surgery. Objective: The present study evaluates our experience with coronary artery bypass grafting in patients with low EF. Materials and Methods: We analyzed the data of 35 patients with EF <35%. All participants were assessed preoperatively with respect to patient characteristics, risk factors, and preoperative two dimension echocardiography (2D ECHO). Depending on findings of 2D ECHO patients were divided into three groups: in Group 1, we included patients with EF 30%–35%, Group 2 comprised patients with EF of 25%–30%, and Group 3 consisted of patients with EF <25%. Patients were operated by off-pump coronary artery bypass grafting; only three patients were operated by on-pump beating heart surgery. We noted a mean number of grafts required, use of intra-aortic balloon counterpulsation (intra-aortic balloon pump) intraoperatively and postoperatively, postoperative complication, mortality, mean hospital stay, postoperative improvement in EF, and postoperative control of angina and symptomatic improvement. Results: Hospital mortality rate in present series was 11%. Mean grafts were 3.02 per patient. Fourteen (40%) patient had a postoperative complication. EF improved in 78% of patients. Canadian Cardiovascular Society Angina class improved in 42% of patients. Conclusion: In patients with coronary artery disease and low EF, CABG can be performed safely, and improvement in left ventricular function can be achieved with this procedure improving the quality of life.
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Importance of coronary artery bypass grafting in patients with left ventricular dysfunction p. 166
Hasan Ekim, Meral Ekim
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Herlyn–Werner–Wunderlich syndrome p. 168
Himadri Bal, BS Duggal, Nikita Gonnade, Sanjay Khaladkar
Herlyn–Werner–Wunderlich syndrome is a rare developmental anomaly, in which there is uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis. The most common presenting complaint is abdominal pain with or without abdominal mass, secondary to hematocolpos. Since the obstruction is unilateral, monthly periods continue and diagnosis can be delayed leading to complications with far-reaching effects. In this report, we describe the evaluation and successful management of one such case in a 13-year-old girl who reported with chronic pelvic pain and abdomino-pelvic mass.
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Magnetic resonance imaging diagnosis of Herlyn-Werner-Wunderlich syndrome p. 172
Taruna Yadav, Padam Parmar
Herlyn-Werner-Wunderlich syndrome (HWW) is a triad of didelphys uterus, obstructed hemivagina, and ipsilateral renal agenesis. It is a combined anomaly of Mullerian and mesonephric ducts. It usually presents in adolescent females after menarche with nonspecific symptoms of pelvic pain, dysmenorrhea, and rarely a palpable pelvic mass. We report here, a case of an 18-year-old female presenting with complaints of lower abdominal pain and dysmenorrhea where magnetic resonance imaging (MRI) confirmed the diagnosis of HWW syndrome. MRI is the imaging modality of choice for diagnosis of HWW syndrome and associated complications such as endometriosis.
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Benign joint hypermobility syndrome with postural orthostatic tachycardia syndrome and acrocyanosis p. 175
Navjyot Kaur, VA Arun, Shavana Rana, VK Sashindran
Benign joint hypermobility syndrome (BJHS) and postural orthostatic tachycardia syndrome (POTS) are two common conditions which are frequently overlooked. While patients with BJHS are known to attend rheumatology, orthopedic, and medical outpatient departments for years with polyarthralgia; POTS is commonly misdiagnosed as anxiety neurosis or panic attack. Described first in 1940, POTS is one of the common causes of orthostatic symptoms in females. POTS is defined as orthostatic intolerance associated with tachycardia exceeding 120 beats/min (bpm) or an increase in the heart rate (HR) of 30 bpm from baseline within 10 min of changing the posture from a lying to standing position, in the absence of long-term chronic diseases and medications that affect the autonomic or vascular tone. Classified as primary and secondary, the underlying pathophysiological mechanism is assumed to be a failure of peripheral vascular resistance to increase sufficiently in response to orthostatic stress, and consequently, venous pooling occurs in the legs resulting in decreased venous return to the heart. This is compensated by an increase in HR and inotropy. We present a case of BJHS, who reported to us with recurrent episodes of syncope and presyncope and was diagnosed to have POTS secondary to his hypermobility syndrome. Although the tilt-table test is the gold standard for diagnosis of POTS, this case highlights the importance of bedside tests in evaluation of orthostatic symptoms and in diagnosis of relatively common but frequently overlooked syndrome.
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Joint hypermobility syndrome and dysautonomia p. 179
Anil Kumar, Nalin Kumar Mahesh
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Oral plasma cell granuloma p. 181
Amitandra Kumar Tripathi, Virendra Kumar, Shweta Singh, Rahul Dwivedi
Plasma cell granuloma is rare, nonneoplastic lesion of the oral cavity, consisting of the proliferation of mature plasma cells. In this case, asymptomatic gingival overgrowth was observed. The lesion was surgically removed and send for histopathological and immunohistochemical examination which showed abundant of plasma cells and high expression of kappa light chain and low expression of lambda chain.
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The 'Milwaukee protocol' (MP) hope does not succeeds for rabies victim p. 184
Anil Kumar Agarwal
Rabies is caused by the rabies virus, an RNA-based virus in the genus Lyssavirus. Transmission typically occurs when virus-laden saliva from a rabid animal enters a wound or mucous membrane. The Milwaukee protocol, a novel procedure in which the patient was placed in a drug-induced coma and given an antiviral cocktail composed of ketamine, ribavirin, and amantadine. Considering the theory that rabies pathology stems from central nervous system neurotransmitter dysfunction, doctors hypothesized suppressed brain activity would minimize damage while the patient's immune system developed an adequate response.
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The importance of diagnosis of latent bronchopleural fistula in a child with empyema thoracis for thoracotomy p. 187
Shruti Shrikant Patil, Shantanu B Kulkarni, Anoop C Dhamangaonkar
Empyema thoracis is an accumulation of frank pus in the pleural space. Occurrence of complications such as bronchopleural fistula (BPF) following necrotizing pneumonia is not uncommon in pediatric patients. Failure to diagnose latent BPF is common. High level of suspicion and preventive measures to avoid likely complications is the key to success. This case report underscores the need to diagnose a latent BPF and also highlights the importance of one lung ventilation in an infant in suspected cases of BPF.
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One-lung ventilation in pediatric patients p. 190
Jyotsna Satish Paranjpe, Ruta Harshal Kulkarni
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Macular variant of acrokeratosis verruciformis of Hopf p. 195
Rita Vipul Vora, Nilofar Gulamsha Diwan, Nidhi B Jivani, Rochit Rajesh Singhal, Shailee Sanjay Gandhi
Acrokeratosis verruciformis (AKV) of Hopf is an autosomal dominant condition characterized by multiple flesh-colored or lightly pigmented flat or convex warty papules over dorsa of hands, feet, knees, elbows, and forearms. It affects both sexes and is usually present at birth or appears in early childhood. Two forms of the disease have been described, namely, classical AKV and sporadic AKV. Histological examination differentiates it from other similar conditions. Superficial ablation is the treatment of choice. We represent a case of a young female with extensive lesions over contralateral limbs, of classical AKV interspersed with multiple hypopigmented macular lesions of AKV.
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Unilateral acquired condylar hypoplasia and coronoid hyperplasia of the mandible p. 198
Silky R Punyani, Vishal Ramesh Jasuja
The condylar articular cartilage is a mandibular growth site. As a result, developmental abnormalities at this location manifest as altered growth on the affected side of the condyle, mandibular ramus, mandibular body, and alveolar process. There are many causes of the various growth disturbances and abnormalities of the mandibular condyle and related structures. The authors report an interesting case of unilateral severe condylar hypoplasia secondary to chronic ear infection in childhood. Coronoid hyperplasia was also present on the ipsilateral side.
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Psychosis in dengue fever p. 202
Suprakash Chaudhury, Biswajit Jagtap, Deepak Kumar Ghosh
An 18-year-old male student developed abnormal behavior while undergoing treatment for dengue fever. He was ill-kempt, irritable and had auditory and visual hallucinations and vague persecutory delusions in clear sensorium with impaired insight. The psychotic episode had a temporal correlation with dengue fever. Psychiatric comorbidities of dengue fever including mania, anxiety, depression, and catatonia are mentioned in literature but the literature on the psychosis following dengue is sparse and only two cases have been reported. Patients presenting with acute onset of psychosis along with fever should be screened for dengue fever in areas where dengue is endemic.
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Neuropsychiatric manifestations in dengue fever p. 204
MS Bhatia, Rashmita Saha
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Mayer–Rokitansky–Kuster–Hauser syndrome: Syndrome of Mullerian agenesis – A report of two cases p. 207
Sushma Yalavarthi, Varsha A Jadhav, S Susheel Kumar, M Pavani
The Mayer–Rokitansky–Kuster–Hauser syndrome (MRKH syndrome), simply called Rokitansky syndrome or vaginal aplasia of the uterus, is a congenital condition that is characterized by the absence of the uterus and vagina, but ovaries are present and the external genitalia are normal. It affects at least 1 out of 4500 women. MRKH may be isolated (Type I), but it is more frequently associated with renal, vertebral, and to a lesser extent, auditory and cardiac defects (MRKH Type II or Mullerian duct aplasia, Renal dysplasia, and Cervical Somite anomalies association - mullerian duct aplasia, renal dysplasia, and cervical somite anomalies). There were very few cases of MRKH syndrome reported in the literature. Here, we report two cases of MRKH syndrome, one in a 20-year-old woman who presented with primary amenorrhea (MRKH Type I) and the other in a 65-year-old woman with primary amenorrhea and associated renal malformations and a rare ovarian sertoliform variant of endometrioid tumor (MRKH Type II).
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Disproportionate dyspnea in a patient with pneumonia p. 211
Vishnu Sharma Moleyar, Alka C Bhat, Y Madhusudan, DS Harsha
In severe pneumonia, dyspnea occurs due to hypoxia. Usually, in pneumonia, dyspnea is proportional to the extent of lung parenchymal lesion. When a patient with pneumonia presents with disproportionate dyspnea, other causes for dyspnea should be evaluated. Here, we present a 48-year-old female with pneumonia, found to have disproportionate dyspnea. Her hypoxia did not improve despite adequate antibiotic and oxygen therapy. On further enquiry, she admitted taking dapsone for leprosy. She had saturation gap diagnostic of methemoglobinemia. Diagnosis was confirmed by estimation of methemoglobin level in blood. She was treated with intravenous methylene blue and recovered. When a patient has disproportionate dyspnea, methemoglobinemia should be considered as a differential diagnosis.
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Dyke-Davidoff-Masson syndrome-unanswered questions p. 215
Khichar Purnaram Shubhakaran, Rekha Jakhar Khichar
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Shunt tip perforating large bowel through vermiform appendix p. 216
Sushanta Kumar Sahoo, Chhitij Srivastava, Ashish Tomar
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Dermatitis artefacta: A consequence of self-injurious behavior during dissociative amnesia p. 217
Pooja Singh, Anubhuti Jain, Sujita Kumar Kar
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