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   Table of Contents - Current issue
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May-August 2018
Volume 32 | Issue 2
Page Nos. 81-168

Online since Thursday, October 25, 2018

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REVIEW ARTICLE  

Nanotechnology in oncology: A concern on its unwanted effects and ethics Highly accessed article p. 81
Sora Yasri, Viroj Wiwanitkit
DOI:10.4103/jms.jms_4_18  
Nanotechnology is the new advent in science at present. The medical nanotechnology is present useful tool for the management of several diseases. For cancer, the application of nanotechnology can be seen, and it is approved for the usefulness. On the other side of the coin, there are also unwanted effects of nanotechnology application in oncology. In this article, the authors review and discuss on the possible unwanted adverse effects of nanotechnology in oncology. The specific ethical concern for nanotechnology in oncology is also mentioned. Interesting quote from leading ethicists and case studies are also presented in this short article.
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ORIGINAL ARTICLES Top

Sexual dysfunction among drug-naïve depressive disorder patient in a multidisciplinary teaching hospital Highly accessed article p. 84
Rajkumar Lenin Singh, Lalhriat Puia, Senilo Magh
DOI:10.4103/jms.jms_8_17  
Background: Little is known about the prevalence, typology and natural course of non-drug-induced sexual dysfunction in patients with depressive disorders. The degree of sexual dysfunction and its prevalence appears to be correlated with the severity of disease. Aims: The aim of the study is to find the prevalence and pattern of sexual dysfunction among drug naïve patient having depressive disorder and its correlation. Settings and Design: 2 years (September 2013- August 2015), cross-sectional study, out-patient department, Department of Psychiatry, Regional Institute of Medical Sciences, Imphal, Manipur. Materials and Methods: Depressive disorder was established according to ICD-10 criteria. Patients fulfilling inclusion criteria were subjected to Hamilton Rating Scale for Depression to assess the severity of their depression and Arizona Sexual Experience Scale questionnaire to assess sexual dysfunction if any in confidentiality. Statistical Analysis Used: statistical package for the social sciences (SPSS) version 21. Chi square test was used and p value of less than 0.05 was taken as statistically significant. Result: 50 patients with depressive disorder were enrolled for the study. 44 percent of them were found to have sexual dysfunction. More problems were found with sexual desire and arousal phases of sexual life. A positive correlation was established between the severity of illness and the degree of sexual dysfunction. Conclusion: This study showed that majority of such patients has sexual problems especially with regard to desire for sex and arousability. The degree of sexual dysfunction was found to be proportional to the severity of depression and hence maybe an important predictor of sexual dysfunction among depressed patients.
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Therapeutic potential of silicone gel sheet treatment and alteration in transforming growth factor beta gene expression in hypertrophic scars Highly accessed article p. 87
Jyoti Gupta, Vaibhav Jain, Pradeep Jain
DOI:10.4103/jms.jms_12_17  
Background: The management and prevention of hypertrophic scars is a challenging problem. Various efforts are made by the researchers to understand the mechanism of the abnormal healing and also to offer better therapy to control these unusual scars. Silicone gel sheet is widely used as the first-line therapy for hypertrophic scars. Objective: The present study has been designed to find out the efficacy of silicone gel sheet treatment on transforming growth factor beta gene(s) expression. Subjects and Methods: The total RNA was isolated from forty hypertrophic scar cases with median age of 42 years before starting the treatment and at 6 months after the silicone gel sheet therapy using Trizol. The cDNA was synthesized for the quantitative gene expression analysis of transforming growth factor beta gene (1, 2, and 3) by real-time polymerase chain reaction. Results: The observations showed that the mRNA expression of transforming growth factor beta (TGF β)-1 and -2 gene in hypertrophic scars was much higher, i.e., 2.6- and 3.8-fold, respectively, when evaluated and compared with controls. The present study also evaluated the efficiency of silicone gel sheet treatment therapy in hypertrophic scars in relation to altered expression of TGF-beta genes. After 6 months of therapy, the mRNA expression of TGF β-2 gene was significantly downregulated (P = 0.01) and β-3 insignificantly upregulated. Patients' assessment scale showed complete cure in 12.5% of cases, and major improvement was observed in 45% of cases. Conclusion: The silicone gel sheet therapy is useful for treating the hypertrophic scars by downregulating expression of profibrotic TGF β-1 and -2 genes.
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A study of cephalic index of Bengali subjects of Tripura for determination of race p. 91
Jayanta Sankar Chakrabarti, Pranab Choudhury, Pradipta Narayan Chakraborty
DOI:10.4103/jms.jms_1_17  
Background: There has been a common belief among the people of Tripura that the racial origin of the Bengali subjects is from Aryans. Aims: The aim of this study was to determine the cephalic index of Bengali population of Tripura, for determination of their racial origin. Setting and Design: A data-based study carried out in a tertiary care teaching institute, Agartala. Materials and Methods: After obtaining ethical clearance from the Institutional Ethics Committee, this study was conducted on the cadavers of Bengali subjects of Tripura brought for medicolegal postmortem examination in a tertiary care teaching hospital in Tripura. A total number of 411 cases were selected at random for the study during April 2015–March 2016. Using a slide caliper (Martin's type), the maximum length and breadth of skull with and without soft tissue were measured and individual's cephalic index was calculated. Statistical Analysis Used: Data collected were analyzed using the Statistical Package for Social Science (SPSS Inc., Chicago, IL, USA) Windows based version 21.0. Results: The study comprised 282 (68.6%) males and 129 (31.4%) females. Two hundred and twenty-one numbers of subjects (53.77%) were found to be mesaticephalic, while 184 subjects (44.76%) and 6 subjects (1.45%) were brachycephalic and dolichocephalic, respectively. In case of cephalic index without soft tissue, 233 subjects (56.69%) were mesaticephalic and 178 subjects (43.31%) were brachycephalic, whereas none was found to be dolichocephalic. Conclusion: Among 411 numbers of subjects, when cephalic index was calculated with soft tissue, 221 numbers of subjects (53.77%) were found to be mesaticephalic, while 184 subjects (44.76%) and 6 subjects (1.45%) were brachycephalic and dolichocephalic, respectively. In case of cephalic index without soft tissue, 233 subjects (56.69%) were mesaticephalic and 178 subjects (43.31%) were brachycephalic, whereas none was found to be dolichocephalic.
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Quantification of human immunodeficiency virus-1 viral load and its correlation with CD4 cell count in antiretroviral therapy naïve patients attending regional institute of medical sciences hospital, Imphal p. 98
Paotinlal Haokip, Heigrujam Rebachandra Singh, Gracy Laldinmawii, Elim K Marak, Arup Roy
DOI:10.4103/jms.jms_107_16  
Background: While the CD4 cell count plays a pivotal role for antiretroviral therapy (ART) initiation, plasma viral load (PVL) provides additional guiding information, especially in patients with a relatively high CD4 cell count. This study was carried out to quantify PVL and CD4 cell count in ART naïve cases and determine their correlation. Materials and Methods: A cross-sectional study was conducted on 82 ART naïve patients of ≥15 years of age attending the Fluorescent Activated Cell Sorter Count (FACSCount) center, Department of Microbiology at a tertiary care center after the Institutional Ethics Committee approval, from August 2014 to November 2015. Blood samples were collected after obtaining written informed consent. PVL was quantified by COBAS® TaqMan® human immunodeficiency virus type 1 (HIV-1) version 2.0 Test and CD4 cell count was measured by FACSCountTM System. The correlation analysis was performed by Pearson's correlation test (r) using SPSS 16.0 software. Results: In this study, mean PVL and CD4 cell counts were 108,000 ± 206,200 copies/mL and 348.2 ± 296 cells/μL, respectively. Among those with PVL ≥50,000 copies/mL, CD4 cell count was >350 cells/μL in 10.4%. PVL was not detectable in 8.5%. There was significant negative correlation (r = −0.54, P < 0.00) between PVL and CD4 cell count in ART naïve patients. Conclusion: Consideration of PVL in ART initiation guidelines for those with CD4 cell count >350 cells/μL will maximize ART coverage of highly infectious ART naïve patients, which in turn will reduce the risk of HIV transmission at individual and population level.
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Ocular injuries due to airsoft gun pellets over an 8-year period p. 103
Ngangom Sangeeta Devi, Laishram Jaleshwar Singh, K Nareshkumar Singh
DOI:10.4103/jms.jms_66_18  
Objective: This study aims to review and to evaluate the ocular effects of blunt trauma due to injury from airsoft gun pellets over an 8-year period. Materials and Methods: We conducted a retrospective study based on the files of 92 patients who suffered ocular injury from airsoft guns and were admitted to one teaching hospital in Northeastern India, during an 8-year period. Results: A total of 92 eyes in 92 patients were examined. A total of 79 male and 13 female patients were affected. The mean age was 12.56 years (range 5–28 years). Mean follow-up time was 12.27 days (range 1–120 days). On initial examination, we found: hyphema (n = 79), corneal abrasion (n = 50), retinal edema (n = 9), subconjunctival hemorrhage (n = 29), lid contusion (n = 14), iris dialysis (n = 19), vitreous hemorrhage (n = 6), cataract (n = 9), and globe rupture (n = 2). Four patients had the pellet lodged in the upper fornix that required removal under topical anesthesia The final visual acuity was 6/6 in 62 patients, 6/9 in 11 patients, 6/12 in 7 patients, 6/24 in 2 patients, 6/60 in 3 patients, and finger counting in two cases who developed corneal scarring. Conclusion: Airsoft guns can cause many serious injuries of the eye some of which even required operative intervention. The long-term morbidity from some of these injuries is significant owing to the risks of permanent corneal scarring, cataract, and glaucoma. Eye care professionals and parents are urged to understand the potential damage that can result from such injuries and help spread awareness on the need to wear adequate protection when involved in this activity.
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Depression and its associated risk factors among elderly in an urban area: A cross- sectional study p. 106
Rosswel Jangte B Sangma, Shantibala Konjengbam, Jalina Laishram, Vijaya Elangbam
DOI:10.4103/jms.jms_53_17  
Introduction: The world's population is ageing rapidly. India too, is in a phase of demographic transition and there has been a sharp increase in the number of elderly persons. Getting older can bring many health challenges to the elderly including neuropsychiatric disorders. Among the neuropsychiatric disorders, depression is the commonest and poses a substantial public health problem contributing significantly to the global burden of the disease. This study was conducted with the objective to determine the prevalence of depression among the elderly and to find out the associated factors. Materials and Methods: A community based cross sectional study was conducted among the elderly residing in the Urban Field Practice Area of Community Medicine Department, RIMS, Imphal from October 2014 to September 2016. Data was collected by interview method. Mini Mental State Examination (MMSE) was used as a screening tool to rule out dementia. Geriatric Depression Scale-30 (GDS-30) which was translated into the local language was used to identify those individuals having depression. Descriptive statistics such as percentages, mean and standard deviation were used to summarize the data. Chi-square test was used for testing the association between depression and selected socio demographic variables. Results: The prevalence of depression was found to be 29.4% in this study. In Univariate analysis age, education, occupation, marital status, type of the family, financial dependency, health condition and limitation of daily activities were found to be significantly associated with depression. In multivariate analysis only age was found to be significantly associated with depression. Conclusion: Depression is common in this study area and more so among oldest old, illiterates and widowed elderly. These study findings can help program managers implement a more comprehensive strategy in this community for timely interventions to promote mental health and prevent geriatric depression.
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Low-dose noncontrast computed tomography in adults with acute appendicitis p. 111
Nongthombam Roshan Singh, Nongthombam Thomson Luwang, Yumnam Priyabarta, Chabungbam Gyan Singh, Wahengbam Jatishwar Singh
DOI:10.4103/jms.jms_35_17  
Background: Computed tomography (CT) is now considered the imaging modality of choice for acute abdomen. However, with the increasing concern for exposure to ionizing radiation and its related risk of cancer in long run, low-dose CT has come up in recent studies with the attempt to minimize the effective radiation dose, yet giving the similar diagnostic yield. Aim: The aim of this study was to evaluate the diagnostic performance of low-dose noncontrast multidetector CT in adult patients with suspected acute appendicitis in relation to patients' body mass index. Materials and Methods: Eighty-three adult patients with suspected acute appendicitis were subjected to both standard and low-dose abdominal noncontrast CT (NCCT). The images were interpreted independently by two radiologists (blinded). Data collected were summarized and statistically analyzed. P < 0.05 was considered statistically significant. Results: With low-dose NCCT abdomen, appendix was visualized in 80 patients (96.4%), with nonvisualization in 3 patients (3.6%), which was similar to standard dose. Low-dose NCCT has an overall sensitivity of 98.2% and a specificity of 100% in the diagnosis of acute appendicitis. Only one false-negative case and zero false-positive case was found, considering 6 mm as the cutoff value in appendiceal diameter with associated fat stranding. Alternative diagnoses were found in 22 (10 females and 12 males) patients. Conclusion: Low-dose NCCT abdomen was found highly accurate in diagnosing acute appendicitis with achievement of significant radiation dose reduction (about 88%) and thus can be recommended as a fast, safe, and cost-effective initial imaging technique in patients with right lower quadrant pain.
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Antenatal carrier screening for thalassemia and related hemoglobinopathies: A hospital-based study p. 118
Shailaja Shukla, Divyanshu Singh, Khushboo Dewan, Sunita Sharma, SS Trivedi
DOI:10.4103/jms.jms_5_17  
Background: Thalassemias are an important cause of morbidity and mortality worldwide. They create a huge emotional and financial deficit on the affected individuals and their families, society and the country. However, severely symptomatic disease can be prevented by various methods. Aims: The present study was undertaken with an aim to find the prevalence of carriers of thalassemia and other hemoglobinopathies in pregnant females and their husbands so as to identify the couples at risk of having severely affected children. Materials and Methods: The study included 2000 antenatal patients of microcytic hypochromic anemia detected on routine hematological examination. Various formulae used to differentiate between thalassemia and iron deficiency anemia were calculated. Serum ferritin levels were performed, and cases with normal or high serum ferritin were analyzed for hemoglobin variants by high-performance liquid chromatography using Bio-Rad variant II hemoglobin testing system-beta thalassemia short program. Results and Conclusion: Sixty-three of the 2000 women screened (3.15%) were identified as carriers of beta thalassemia trait and other hemoglobinopathies. Most of them that is 59 cases (2.95%) were beta thalassemia carriers while one each were carriers of HbE (0.05%), HbS (0.05%), HbD (0.05%), and double heterozygous for beta thalassemia and HbE. Among the various indices evaluated in the present study, Shine and Lal index could identify almost all cases of beta thalassemia carriers (98.3% sensitivity) whereas all the other indices could not be relied on in the identification of all the cases.
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Fundus fluorescein angiography of idiopathic central serous chorioretinopathy in the indigenous population of Manipur p. 123
Usharani Laishram, Chingsuingamba Meitei Yumnam, Amit Singh Thangjam
DOI:10.4103/jms.jms_20_18  
Background: Idiopathic central serous chorioretinopathy is a chorioretinal disease characterized by localized leakage from the choroidal circulation causing serous retinal detachment affecting the macula. Aims: To document the leakage pattern using fundus fluorescein angiogram in idiopathic central serous chorioretinopathy in the indigenous people of Manipur. Materials and Methods: A prospective study was conducted in all patients with clinical diagnosis of central serous chorioretinopathy attending ophthalmology outpatient department of a tertiary care hospital in Manipur, Northeast India, within a period of 1 year starting from September 2015 to August 2016. After thorough clinical evaluation of the posterior segment and after ruling out the potential contraindications, patients were subjected to fundus fluorescein angiography (FFA). Results: Predominantly males (72%) and those mostly in their fifth decade of life were affected. Most of the patients were businessmen. The right eye was affected more (78%) than the left, with the most common presenting symptom being dark shadow or central haziness of vision in about 60% of patients. Betel nut consumption was found to be a very common food habit. Sensory retinal detachment (40%) was the most common fundus finding and depigmented patches (4%) were least commonly seen. Of the 50 eyes examined, FFA showed a single leak in 36, double and triple leaks in 7 eyes each, and no leak in 10 eyes. Inkblot pattern was the most common pattern of leakage (72%). Most common site of leakage in this study was the macular area (58%). Conclusion: Idiopathic central serous chorioretinopathy (ICSC) predominantly affects middle-aged males having a stressful life. Most of them present with dark shadow or a central area of haziness in the visual field which is mostly attributable to sensory retinal detachment at the macula. The most common fundus fluorescein angiographic finding is a single leak inkblot pattern in the macular area.
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Factors prolonging the duration of the second stage of labor p. 128
Yong-Chol Hong, Un-Son Paek
DOI:10.4103/jms.jms_36_18  
Aim: We have done this study to find factors prolonging the duration of the second stage of labor. Background: The second stage of labor is a very important period in the clinical process of labor as dangers may occur suddenly to the fetus and parturient. Prolonged duration of the second stage of labor is related to somatic characters, pregnancy, and delivery history in addition to the three important elements of labor such as bearing down, birth canal, and fetus. Objects: A total of 253 parturients between March 2012 and March 2015 were included in the study. Those parturients were divided into two groups: the first group was composed of 135 parturients with normal duration of the second stage of labor and the second group was composed of 118 parturients with prolonged duration of the second stage of labor. Methods: Odds ratio test and 95% confidence interval were applied for the analysis between normal and prolonged group with somatic and obstetrical examination findings and laboratory and ultrasonography findings. Results: The factors prolonging the duration of the second stage of labor contain height (<155 cm), body mass index (>28), body weight gaining during pregnancy (>8.0 kg), fetal position in the first stage of labor right occiput transverse (ROT) and fetal membrane condition (ruptured) for all of primipara and multipara, front wall length of uterus (>34 cm), perineum height (>3.6 cm), elapsed period of the first stage of labor (nighttime), Hb (<100 g/L), newborn's body weight (>3.0 kg) for primipa, age (over 30 years old), interval between the present and last delivery (>25 months), and the previous cesarean section for multipara.
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Reconstruction of the eyelid and periocular region: Our experience p. 135
Umesh Kumar, P Jain
DOI:10.4103/jms.jms_18_18  
Aim: To use periocular flaps for defects involving different zones of eyelid. Materials and Methods: This study was conducted from 2015 to 2017. Twenty four patients with lid defects were managed by cheek rotation and advancement flap(8), Limberg flap(5), forehead flap(5), Mustarde's lid switch flap (3), primary closure(1), SSG(2). Thirteen of our patients suffered from carcinoma, BCC(9) and SCC(4), patients with benign lesions had congenital melanocytic nevi(3), vascular malformation(2), congenital coloboma(3), cleft lower eyelid (1) and post traumatic eyelid defect(2). Eleven patients had full thickness defects and the rest had defect involving the anterior lamella. Result: Cheek rotation and advancement flap gave good results for anterior lamella, full thickness defect of zone II and adjoining periocular region with inconspicuous scar but ectropion in 2 cases. Limberg flap was used for defect involving lateral part of upper, lower eyelid and canthal region. In one case wound dehiscence occurred. Forehead flap gave linear scar. Mustarde's lid switch flap was an ideal flap giving minimal donor site morbidity. All flaps survived with adequate coverage and uneventful healing. Conclusion: Periocular flaps are reliable, versatile flaps for reconstruction of all five zones of eyelid with good donor scar, colour and contour match.
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Extended-spectrum beta-lactamase detection by extended-spectrum beta-lactamase-Nordmann/Dortet/Poirel test: Where time is the essence p. 140
Simit Kumar, Maitreyi Bandyopadhyay, Pratima Kumari, Abhishek Sengupta, Sanjeeev Das, Manas Bandyopadhyay, Prabir Kumar Mukhopadhyay, Mitali Chatterjee
DOI:10.4103/jms.jms_34_17  
Background: Extended-spectrum beta-lactamase (ESBL)-producing strains are causing an increasing problem worldwide. Infection control is most effective when ESBL strains are detected by rapid, sensitive, and specific tests and an early implementation of appropriate antibiotic therapy is initiated. Recently, a rapid and cost-effective biochemical test for the detection of ESBL, the ESBL Nordmann/Dortet/Poirel (NDP) test, has been implemented. Aims: The aim of the study was to detect ESBL by a rapid NDP test. Settings and Design: The prospective study was conducted in the Department of Microbiology at a tertiary care hospital. Materials and Methods: A total of 208 isolates were subjected to the ESBL NDP test. Simultaneously, these isolates were also tested for ESBL production by double-disc synergy test (DDST) method. The ESBL NDP test was also used directly with spiked blood cultures inoculated with ESBL producers and non-ESBL producers. Statistical Analysis Used: Descriptive statistics such as mean and ratio are used for the interpretation of the study. Results: Using the ESBL NDP test, 80 of 208 (40%) of the tested isolates produced ESBL, among which Escherichia coli were 56 (70%) and Klebsiella pneumonia were 24 (30%) which showed positive result. Our results, done directly on clinical isolates as well as on spiked blood cultures inoculated with them, showed a perfect correlation between the ESBL NDP test and DDST in detecting ESBLs. Conclusion: This inexpensive ESBL NDP test might be implemented worldwide, especially in resource-limited settings of developing countries to optimize rapid choices of antibiotics for treating severe infections and avoidance of overuse of carbapenems.
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CASE REPORTS Top

Subacute presentation of herpes simplex virus-1 encephalitis: A rare case report p. 144
TH Suraj Singh, Kuldeep Singh, Tamphasana Wairokpam
DOI:10.4103/jms.jms_50_17  
Herpes simplex encephalitis (HSE) is a potentially fatal infectious disease with high mortality if undiagnosed. HSE mostly presents with acute features such as a headache, fever, and altered sensorium. The combination of clinical history and examination, brain computed tomography scan, magnetic resonance imaging (MRI), and cerebrospinal fluid analysis (CSF) analysis have been used to establish the diagnosis. Uncommonly, HSE presents as a mild and slowly evolving disease and clinical relapse is rare. Here, we are presenting a rare case of HSE with subacute course presenting as forgetfulness and disorientation with abnormal CSF analysis and typical MRI findings consistent with HSE and CSF polymerase chain reaction positive for herpes simplex virus-1 DNA, who responded well to Acyclovir therapy with recovery.
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Giant bladder stone with foreign body and associated carcinoma urinary bladder p. 147
MS Faridi, Naloh Mibang, Md Jawaid Rahman, Rajendra Sinam Singh
DOI:10.4103/jms.jms_9_17  
Bladder stones comprise 5% of urinary tract stones. Males are affected more than females. In general, they occur in the presence of bladder neck obstruction and urinary tract infections associated with neurogenic bladder. A giant vesical calculus of more than 100 g is rare. The metallic foreign body within the stone core and associated cancer urinary bladder is a rare combination. This case emphasizes the fact that a proper history and examination is really important in diagnosis.
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Empyema thoracis: A life-threatening complication of odontogenic infection p. 150
Adebayo Aremu Ibikunle, Abdurazzaq Olanrewaju Taiwo, Ramat Oyebunmi Braimah, Umar Abubakar
DOI:10.4103/jms.jms_103_16  
Most dental infections are confined to the maxillofacial region. However, when neglected, it may extend to contiguous or distant sites. Empyema thoracis of odontogenic origin is a rare clinical entity, which is life-threatening and associated with severe morbidities. This is a report of a 32-year-old male managed for empyema thoracis of odontogenic origin at our hospital. The patient was placed on hospital admission, during which he had medical, surgical, and supportive management. He was discharged on the 24th day postadmission, after satisfactory recovery.
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Hyper-IgE syndrome p. 154
Nandakishore Singh Thokchom, Kapila Verma, KA Sangma, NA Bishurul Hafi
DOI:10.4103/jms.jms_23_17  
Hyper-IgE syndrome (HIES) is a rare primary immunodeficiency condition. It is characterized by the triad of recurrent skin and lung infections, chronic dermatitis, and elevated serum Ig E level. An 8-year-old girl presented with recurrent papulovesicular lesions on the neck, axillae, cubital, and popliteal fossae since 3 years of age. The lesions healed with scarring. There was a history of recurrent diarrhea. Cutaneous examination revealed flexural dermatitis consisting of crusted lesions on the ears, neck, axillae, groins, and genitalia. The ears were deformed, and there was atrophic scarring on the face and eyelids. Routine blood investigations revealed hypereosinophilia. Serum IgE level was >2000 KIU/L. A diagnosis of HIES was made and treated with a short course of oral antibiotics, topical steroid-antibiotic combination. Children affected with HIES can develop life-threatening pulmonary infections. Hence, early diagnosis and proper management are necessary.
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SHORT COMMUNICATION Top

Quality indicators in laboratory medicine: A fundamental tool for quality and patient safety p. 157
Pradeep Sharma, Dibyaratna Patgiri, Niladri Deb
DOI:10.4103/jms.jms_18_17  
Human error in medicine does exist and is a profound challenge. When seeking to solve any problem, the problem must first be described and the factors contributing to it be identified. Laboratory testing, a highly complex process commonly called the total testing process (TTP), is usually subdivided into three traditional (pre-, intra-, and post-) analytical phases. The majority of errors in TTP originate in the preanalytical phase, being due to individual or system design defects. Quality indicators represent valuable tools for quantifying the quality of selected aspects of care by comparing it against a defined criterion.
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LETTERS TO EDITOR Top

Assessment of the inequalities in the immunization coverage: World Health Organization p. 160
Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy
DOI:10.4103/jms.jms_112_16  
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Chromoblastomycosis: A comment p. 162
Sora Yasri, Viroj Wiwanitkit
DOI:10.4103/jms.jms_63_17  
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Cost and effectiveness of dengue vaccine: A report from endemic area, Thailand p. 163
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/jms.jms_22_18  
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Time to move from classroom to community: Reorientation of Medical Education (ROME) p. 164
Amit Kumar Mishra
DOI:10.4103/jms.jms_71_17  
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Potential roles of GB virus type C and human immunodeficiency virus coinfection on host immunomodulation p. 166
Idris Abdullahi Nasir, Abdurrahman Elfulaty Ahmad, Amos Dangana
DOI:10.4103/jms.jms_74_17  
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