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   Table of Contents - Current issue
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January-April 2019
Volume 33 | Issue 1
Page Nos. 1-70

Online since Monday, October 14, 2019

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REVIEW ARTICLE  

Vertigo among elderly people: Current opinion Highly accessed article p. 1
Santosh Kumar Swain, Nishtha Anand, Satyajit Mishra
DOI:10.4103/jms.jms_35_18  
Vertigo or dizziness is a common handicapping clinical entity seen in elderly population. Its prevalence increases along with age. Vertigo among elderly people is a strong predictor of falls which is an important cause for accidental death. Vertigo or balance disorder in elderly people is a major public health problem and needs proper attention by trained clinician. Its etiology varies from peripheral cause to central causes or combined. A detail patient history and clinical examination are often essential for revealing the cause. The majority of causes for vertigo in elderly patients are of benign paroxysmal positional vertigo followed by migrainous vestibulopathy, idiopathic vestibulopathy, and vestibular neuritis. Proper diagnosis and management help to make a better and quality life in elderly patients suffering with vertigo. This review article describes etiology, epidemiology, clinical presentations, diagnosis, and current treatment of vertigo among elderly persons.
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ORIGINAL ARTICLES Top

Morphogenesis of urinary bladder in human fetuses p. 6
Yanglem Elizabeth Devi, N Saratchandra Singh, Ch Rajendra Singh, Laishram Ayingbi Devi, Leon R Guria
DOI:10.4103/jms.jms_16_19  
Introduction: The urinary bladder is a temporary reservoir for urine brought from the kidneys by the ureters. It develops from the upper expanded part of urogenital sinus. There is paucity of literature regarding development of urinary bladder during various stages of fetal life. Hence, this study was done to observe the changes taking place in the development of normal urinary bladder during various stages of fetal life. Materials and Methods: The study was conducted in the Department of Anatomy, Regional Institute of Medical Sciences (RIMS), Imphal for 2 years from 2011 to 2013 after taking approval from the ethical committee of the institute. Fifty fetuses of different gestational age ranging from 15 weeks to term which were products of medical termination of pregnancy were collected from Department of Obstetrics and Gynaecology, RIMS. Results: Three shapes of bladder were visible during the fetal life, i.e., round, ellipsoid, and pyramidal. Round and ellipsoid shape were visible during the early fetal period, and bladder assumed more pyramidal shape during later fetal life. Conclusion: Urinary bladder assumed almost adult shape from 33 weeks onward with presence of four surfaces, i.e., one superior, two inferolateral, and one posterior surface or base.
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Soft-tissue reconstruction for exposed orthopedic implants in injured extremities p. 11
Vaibhav Jain, Pradeep Jain, Shivi Jain
DOI:10.4103/jms.jms_36_19  
Background: Exposure of orthopedic implants before fracture union is quite frequent in clinical practice. There is no definite rule as of now whether to retain or replace the exposed implant with an external fixator. Objectives: The aim of the study was to find the ultimate outcome after retaining the exposed implant and providing a skin and soft-tissue cover. Materials and Methods: Thirty-two patients with exposed orthopedic implants reported to us with an average of 6 weeks after the original orthopedic procedure. The local soft-tissue infection was treated with a targeted antibiotic therapy. There was delay in the soft-tissue reconstruction for an average of 24 days. Six patients also received “negative pressure wound therapy.” The soft-tissue defects (ranging from 4 cm × 3 cm to 25 cm × 10 cm) were compounded with exposure of olecranon plate in four and intramedullary tibia nails in five, and 23 exposed plates and screws. The various muscle and fasciocutaneous flaps were used according to the region of the defect. Results and Conclusions: All the flaps behaved well except one. One of the patients suffered from wound discharge and chronic sinus, but none suffered from pain or fracture nonunion up to 9 months follow-up. Removal of the implant was required in only one patient because of sharp edge. Thus, coverage of exposed implants should always be considered as the first option before replacing it with external fixator.
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Use of combined wound and intraperitoneal ropivacaine instillation in laparoscopic cholecystectomy for postoperative pain management: A prospective randomized study at a referral center in Northeast India p. 16
Mohan Kant Thakur, Kshetrimayum Raju Singh, Laishram Jaleshwar Singh, Chongtham Arun Kumar Singh
DOI:10.4103/jms.jms_93_18  
Background: Although laparoscopic cholecystectomy(LC) causes less postoperative pain than conventional laparotomy, still patients often suffer from considerable pain during early postoperative hours. In this study, efficacy of ropivacaine was studied in post-operative pain relief through peripheral local administration in patients undergoing LC. Aims and Objectives: The primary aim of the study is to evaluate the effect of intraperitoneal and local wound instillation of 0.75% Ropivacaine on post operative pain relief and duration of post-operative hospital stay in LC patients. Materials and Methods: This Prospective randomized Double blind clinical study was performed for 2 years on 190 patients. The primary endpoints of the study for the postoperative pain assessment were Visual Analog Scale (VAS) scores at 6 and 24 hours after LC and the amount of analgesics required in the postoperative period. These variables were compared between intervention and control groups. Results: The VAS score for pain abdomen in the intervention group (ropivacaine group) was significantly less, compared to the placebo group at 6 (P < 0.020) and 24 h (P < 0.001). Similarly, the mean of amount of analgesics used was much less in intervention group (46.5±13.2) than that in the placebo group (112.4±26.4). Conclusion: This study concludes that the combined intraperitoneal and local wound instillation of ropivacaine has a significant effect on the postoperative pain management in LC.
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A comparative study of ropivacaine versus ropivacaine plus dexmedetomidine under epidural anesthesia in lower limb surgeries p. 20
Ashem Jack Meitei, Tikendrajit Ningombam, Takhelmayum Hemjit Singh, Gojendra Rajkumar, N Anita Devi, Yumnam Arunkumar Singh
DOI:10.4103/jms.jms_21_18  
Background: Adjuvants are being used with local anesthetics for prolongation of intra- and post-operative analgesia. The aim is to compare epidural ropivacaine alone and ropivacaine with dexmedetomidine on block characteristics, hemodynamics, and postoperative analgesia. Materials and Methods: Following Institutional Ethical Committee approval and written informed consent from all the patients. This study was conducted on 50 patients of American Society of Anesthesiologists Grade I and II, age between 20 and 65 years of either sex undergoing lower limb surgeries under epidural anesthesia. The patients were randomly allocated into two groups. Group R (n = 25) received 150 mg of 0.75% ropivacaine diluted to 22 ml normal saline (NS), and Group RD (n = 25) received 150 mg of 0.75% ropivacaine plus dexmedetomidine 1 μg/kg diluted to 22 ml of NS. Two groups were compared with respect to hemodynamic changes, block characteristics, time to regression at S1 dermatome and time to the first dose of rescue analgesia for 24 h, sedation score, and side effects. Data were analyzed statistically using the Chi-square test, Fisher's exact test, and Student's t-test.P < 0.05 was considered to be statistically significant andP < 0.001 as highly significant. Results: Significant difference was observed in relation to the duration of sensory block (391.68 ± 33.404 min in Group R and 529.36 ± 58.125 min in Group RD [P = 0.000]), duration of motor block (264.96 ± 30.788 min in Group R and 390.44 ± 37.994 min in Group RD [P = 0.000]), duration of postoperative analgesia (368.40 ± 52.366 min in Group R and 512.36 ± 55.815 min in Group RD [P = 0.000]), and consequently low doses of rescue analgesia in Group RD (1.96 ± 0.455) as compared to Group R (2.80 ± 0.418) (P = 0.000). Sedation score was significantly more in Group RD in the postoperative period. Conclusion: Addition of dexmedetomidine to ropivacaine provides stable hemodynamics, prolonged sensory and motor block, prolonged postoperative analgesia, and reduced demand for rescue analgesics when compared to plain ropivacaine.
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Profile of patients undergoing coronary angiography at tertiary care center in Northeast India p. 28
Gopinath Narayanaswamy, Silpa Kshetrimayum, Hidangmayum Dwijaraj Sharma, Konsam Biona Devi, Nang Neeta Manpang, Dhanaraj Singh Chongtham
DOI:10.4103/jms.jms_101_17  
Background: Coronary artery disease (CAD) is a major cause of morbidity and mortality worldwide. Increased age, male sex, diabetes-mellitus, hypertension, smoking, and dyslipidemia are important risk factors of CAD. Diagnostic coronary angiography (CAG) and subsequent angioplasty is the mainstay of management in CAD. Objectives: The objective of the study is (1) To study the clinical and echocardiographic profile among patients undergoing CAG. (2) To analyze the angiographic findings with respect to CAD risk factors. Methods: A observational cross-sectional study of 100 patients who underwent CAG at Tertiary Care Teaching Hospital, Imphal, from October 2015 to September 2017 were studied. Detailed history and echocardiographic findings were obtained. Angiographic findings were studied with respect to various risk factors. Data were analyzed using SPSS (version 21) and Chi-square test. Results: Single vessel disease was the most common angiographic abnormality (71%). Left anterior descending artery was the most common artery involved, followed by the right coronary artery and left circumflex artery, respectively. Elderly patients (>60 years) and males had more severe form of CAD. Triple vessel disease (TVD) was more common in diabetic patients than nondiabetics (16.7% >5.7%, P = 0.153). Hypertensives had less severe disease when compared to nonhypertensives. Smoking had no effect on the severity of disease. All patients with TVD had regional wall motion abnormality, and severe systolic dysfunction was present in 33.3% of them. Conclusions: Increased age, male sex, and patients with diabetes mellitus were predisposed to develop more severe CAD. Smoking, hypertension, and dyslipidemia had no effect on severity or pattern of artery involvement.
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Aging immunity, immunosenescence, or inflamm-aging: A comparative study of cytokines p. 33
Anand Gopal, Dhiraj Kishore, Inderjeet S Gambhir, Amita Diwaker
DOI:10.4103/jms.jms_32_18  
Context: Aging has impact on immune system both quantitatively as well as qualitatively, leading to deregulated response in different states ranging from infection, autoimmunity, inflammation, and excessive tissue damage. Aims: The present study is done to observe the immunosenescence-related changes in monocytes-/macrophages-mediated production of nitric oxide (NO), interleukin (IL)-1, IL-6, tumor necrosis factor (TNF)-α, anti-inflammatory cytokine IL-10 after stimulation with lipopolysaccharide (LPS), and interferon (IFN)-γ, evaluating the innate immunity of a group of healthy Indian elderly from a single institution. Settings and Design: The study was conducted on life-term prisoners in Central Jail, Varanasi, India, and the Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, among the three groups, namely study group (>70 years old), control Group 1 (60–70 years), and control Group 2 (30–40 years). Subjects and Methods: Mononuclear cells were separated, and NO production, pro-inflammatory cytokines such as IL-1, IL-6, and TNF-α, and anti-inflammatory cytokine IL-10 from these cells were estimated by enzyme-linked immunosorbent assay after stimulation with LPS and IFN-γ. Statistical Analysis Used: Mean and standard deviation were calculated, and Student's t-test was applied. Results were considered statistically significant forP < 0.05. Results: A statistically significant rise in NO production (P < 0.001) was observed after stimulation as compared to control Groups 1 and 2 (P < 0.001). The study group showed a significant decrease in IL-1 production (P < 0.03) following stimulation. The basal TNF-α level was low in the study group, but there was a significant increase in TNF-α following stimulation. The basal level of IL-6 in the study group was higher than the control Group 1 (not significant, P = 0.21) but lower than the control Group 2 (not significant, P = 0.18). There were no significant inter- or intra-group changes in IL-6 level. Conclusions: There is a qualitative as well as quantitative defect in elderly monocytes/macrophages reflecting abnormal inflammatory response. This could be due to abnormal immunity with aging, which may be responsible for increased frequency of chronic diseases such as diabetes, hypertension, congestive heart failure, asymptomatic infections, and Alzheimer's disease in geriatric population.
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Study on the evaluation of sonographic characteristics of gastric submucosal tumors p. 38
Gwang-Il Kim, Chol-Hui Yo, Un-Bok Ri, Hak-Chol Ju
DOI:10.4103/jms.jms_64_18  
Aims: The purpose of the present study is to evaluate some characteristics of gastric submucosal tumors on the ultrasound image that can be used for the diagnosis and differential diagnosis of gastric submucosal tumors. Subjects and Methods: Subjects – 24 patients with gastric submucosal tumors diagnosed by physical examination, gastrointestinal endoscopy, ultrasonography, radiography, and pathological examination after the operation at Pyongyang Medical College Hospital of Kim Il Sung University from February 2009 to 2015. Methods – The ultrasonic diagnostic unit used was HD-6 type, and the probes with the frequencies of 3.5 and 7.5 MHz of convex and linear types were used. The patient was examined after drinking of 1–1.5 L of degassed water to evaluate the submucosa of the stomach correctly. The ultrasonographic evaluating indices were location, size, internal echo pattern, and homogeneity, and they were compared by disease. Results: We have identified some sonographic characteristics of gastric submucosal tumors. The incidence of gastric submucosal tumors by location was the highest at the body of the stomach as 20 (83.3%) patients. The number of patients with gastric submucosal tumors <3 cm was the highest. The numbers of anechoic and hypoechoic tumors were, respectively, 9 (37.5%) and 7 (29.2%), were more than others. Most of tumors (75.0%) were homogeneous. Conclusions: We think transabdominal ultrasound can be used as an alternative method for the diagnosis of submucosal tumors of the stomach.
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Scrub typhus: An unusual cause of acute abdomen p. 43
Ksh Raju Singh, Chabungbam Gyan Singh, Sridartha Khumukcham, Nagha D Marak, Pankaj Kumar, Heishnam Parasmani, Gamelial A Kharshiing
DOI:10.4103/jms.jms_19_19  
Background: Scrub typhus is one of the causes of acute abdomen in surgical emergency. Objectives: The objective was to study the clinical profile and outcome among patients of scrub typhus presenting as acute abdomen. Materials and Methods: A community-based cross-sectional study was conducted for 15 months in eight patients who presented as acute abdominal pain with scrub typhus in a tertiary hospital. Clinical analysis, routine investigations, and rapid IgM-based immunochromatographic assay for scrub typhus are performed in every patient. Results: A total of eight females, aged ≥20 years were included in the study. Six of the patients presented with acute abdomen, two of them had features of generalized peritonitis, two had a history of loose stools, another two had a history of constipation, and one of them presented with history of bleeding per rectum. As systemic presentation, all eight patients had fever, six of the patients had nausea and vomiting, four had tachypnea, four had presented in shock, two of the patient presented with an eschar, and four had a history of headache. All patients were treated conservatively. One patient died due to multiorgan dysfunction syndrome and severe thrombocytopenia. Conclusion: Scrub typhus can rarely present as acute abdomen. High index of suspicion is required in cases of acute abdomen not responding to standard treatment.
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Evaluation of risk factors for postoperative pulmonary complications after elective open upper abdominal surgery in chronic obstructive pulmonary diseases patients p. 47
Mukesh Kumar Prasad, Sanjay Sahay, Rohit Kumar Varshney, Gurdeep Singh Jheetay
DOI:10.4103/jms.jms_42_18  
Background: Postoperative pulmonary complications (PPCs) range from 9% to 40% in various nonthoracic surgeries. Various risk factors are attributed for these complications. The aim of this study was to determine the risk factors for PPC in chronic obstructive pulmonary disease (COPD) patients submitted to elective open upper abdominal surgery. Materials and Methods: This was a prospective cohort study conducted in a tertiary care center after obtaining ethical committee clearance. Two hundred and twenty-nine of 427 patients planned for elective abdominal surgeries were labeled as COPD based on spirometry test. PPC and various factors affecting it were analyzed. Pre- and intra-operative data were collected and their association with the occurrence of PPC was analyzed. Relationship between PPC and other variables was tested by linear and logistic regression. Multivariate logistic regression was performed using a backward stepwise approach and accepting statistical significance at P < 0.05. Results: Of 229 COPD patients, 34 (14.84%) suffered PPC. The mean age was 55.76 ± 8.40 years with 78.6% being male. Patients having age >50 years and the American society of anesthesiologists IV status were more prone to developing PPC. The multivariate analysis revealed body mass index (BMI) >30 kg/m2, duration of surgery >150 min, and pCO2>45 mmHg in arterial blood gas as independent predictors of PPC. Conclusions: The present study concluded that increased pCO2, BMI, and longer duration of surgery increase PPC in COPD patients. Hence, preoperative optimization of pCO2, BMI, and a proper plan to shorten the duration surgery may reduce PPC in COPD patients undergoing open upper abdominal surgeries.
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Flow cytometric analysis of lymphocyte subsets in alcoholic liver disease p. 52
Archana Chirag Buch, M Banyameen Iqbal, Amardeep Patil, Niladri Haldar, Arjun Lal Kakrani, Sunita Bamanikar, Dakshayani Pandit, Harsh Kumar
DOI:10.4103/jms.jms_43_18  
Background: The World Health Organization defines alcohol-related diseases as the third major cause of death and disability worldwide accounting for approximately 2.5 million deaths per year. Immune dysregulation has possible role for pathogenesis of alcohol liver injury. We aimed to study lymphocyte subsets in alcoholic liver disease (ALD). Materials and Methods: A prospective cross-sectional study was done over 2 years in a tertiary care hospital in Western Maharashtra. The cases were classified into four groups: nonalcoholics (n = 18), fatty liver (n = 13), alcoholic hepatitis (n = 11), and alcoholic cirrhosis (n = 51). ALD was confirmed by abdominal ultrasonography and liver function tests. Blood sample collected in ethylenediaminetetraacetic acid was run on electronic cell counter for total leukocyte count and on flow cytometer for CD45, CD3+, CD4+, and CD8+ counts. Results: Hemoglobin and platelet count showed a statistically significant reduction (P < 0.0001) from nonalcoholics to fatty liver to hepatitis to cirrhotic patients. There was a significant alteration in liver function tests in ALD. Total leukocyte count and lymphocytes were reduced; however, it was not statistically significant. CD3+ (1745.41 ± 917.57–1021.43 ± 500.71/cumm), CD4+ (903.41 ± 401.83–634.45 ± 309.11/cumm), and CD8+ (818.06 ± 584.31–393.9 ± 258.49/cumm) showed decreasing trend. CD4+/CD8+ ratio was progressively increased (1.39 ± 0.66–1.91 ± 0.89) from nonalcoholics to alcoholic cirrhosis. Conclusion: In this study, we found a decrease in the concentration of lymphocytes and its subpopulation (CD3+, CD4+, and CD8+) while as CD4+/CD8+ ratio was comparatively increased in ALD patients in comparison to nonalcoholics. These findings signify an immune dysregulation in ALD.
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CASE REPORT Top

Wire bezoar - Unique presentation with duedenojejunal flexure perforation p. 59
Anup Kumar Roy, Toijam Soni Lyngdoh
DOI:10.4103/jms.jms_39_18  
Bezoars are commonly found in the stomach, which are usually trichobezoar or phytobezoar. Signs and symptoms depend on the location and type of bezoars. Small intestinal perforation following wire bezoar has not been reported earlier. We report a 26-year-old schizophrenic male presented to us with features of perforation peritonitis. Preoperative abdominal radiograph was suggestive of unexpected intraoperative findings. Celiotomy with gastrostomy, feeding jejunostomy, and primary closure of perforation over a large bore T-tube was done. The patient was discharged after prolonged hospitalization. Wire bezoar presenting with jejunal perforation has not been reported earlier although every high possibility of perforation exists when the wires are pointed and long, where negotiation at the duodenojejunal flexure may be difficult.
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LETTERS TO EDITOR Top

Nitric oxide, liver fluke opisthorchis viverrini, thalassemia, deferiprone, and cholangiocarcinoma: A clinical interrelationship with reference to endemic area in Indochina p. 62
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/jms.jms_3_19  
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India's fight against vaccine-preventable diseases; newer changes and challenges p. 64
Ariarathinam Newtonraj
DOI:10.4103/jms.jms_90_18  
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Summary of clinical characteristics of prisoners in Thailand with tuberculosis p. 66
Pathum Sookaromdee, Viroj Wiwanitkit
DOI:10.4103/jms.jms_96_18  
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Bridging the gap in the health research and development activities: Scope of the observatory p. 67
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/jms.jms_10_18  
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TYMS gene polymorphism and treatment-related osteonecrosis in acute lymphoblastic leukemia p. 69
Sora Yasri, Viroj Wiwanitkit
DOI:10.4103/jms.jms_95_18  
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