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   Table of Contents - Current issue
Coverpage
September-December 2018
Volume 32 | Issue 3
Page Nos. 169-240

Online since Monday, February 11, 2019

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ORIGINAL ARTICLES  

Effect of botulinum toxin Type A on various gait parameters in cerebral palsy with lower limb spasticity Highly accessed article p. 169
Abhimanyu Vasudeva, Nonica Laisram, Asem Rangita Chanu
DOI:10.4103/jms.jms_76_17  
Background: Successful management of spasticity in cerebral palsy (CP) has remained a therapeutic challenge. Botulinum toxin is a potent neuromuscular blocking agent with Type A being commonly used for treating focal spasticity in children with CP. However, its use in CP children is rare in the Indian literature. Research elsewhere has seldom focused on predicting optimal response regarding functional outcome. Objectives: The objective of the study is to study the efficacy of botulinum toxin Type A injection in CP with lower limb spasticity regarding reduction in spasticity, improvement in range of motion (ROM), and improvement in various gait parameters. Study Settings: The study was conducted in the Department of Physical Medicine and Rehabilitation in a tertiary care hospital in North India. Study Design: This was a prospective, interventional cohort study. Methods: Thirty-one children were enrolled in the study. They were evaluated just before injection and at 4 and 12 weeks after injection using Modified Ashworth Scale for gastrocnemius and hamstrings spasticity, Adductor Tone Rating Scale for adductor muscle spasticity and goniometry for ROM of the ankle and knee. Various gait parameters using footprint analysis were also done. Results: Statistically significant reduction was seen in spasticity of gastrocnemius, hamstrings, and hip adductors in the follow-ups at 4 and 12 weeks compared with preintervention (P < 0.05). There was a statistically significant increase in velocity, cadence, stride and step length, and statistically significant reduction in the toe drag in all follow-ups. Conclusion: Botulinum toxin Type A is effective in improving the various gait parameters investigated.
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A study of psychiatric comorbidities among treatment seeking opioid injectors attending tertiary care teaching hospital, Imphal for a period of 2 years Highly accessed article p. 174
Andreecia Mn Mawiong, Gojendra Singh Senjam, Mary Haobam, Ningombam Heramani Singh, Phrangstone Khongji
DOI:10.4103/jms.jms_61_17  
Introduction: Psychiatric comorbidity among opioid injectors is the co-occurrence of other mental disorders among them besides being dependent on injecting opioid. Objectives: The purpose of this study is to find out the prevalence of psychiatric comorbidities among opioid injectors and to find out the association between drug use Profile with psychiatric comorbidities. Materials and Methods: All the consecutive opioid injectors who attended Drug De-addiction Centre, tertiary care teaching hospital, Imphal, from October 2013 till September 2015 were interviewed with General Health Questionnaire-12 to assess the mental health status, they were interviewed with Mini-International Neuropsychiatric Interview plus for the diagnosis of mental conditions. The data were analyzed statistically using Statistical Package for Social Sciences (SPSS21) software. Results: One hundred and five opioid injectors were enrolled in this study. The common psychiatric comorbidities were anti-social personality disorder 85.7% (n = 90) followed by depression 61.9% (n = 65), poly substance dependence 52.4% (n = 55), anxiety disorder 41% (n = 43), psychosis 23.8% (n = 25), suicide 11.4% (n = 12), panic disorder 4.8% (n = 5), and specific phobia 4.8% (n = 5). Conclusion: This study shows that the majority of dependent opioid injectors are vulnerable to many psychiatric comorbidities which should be screened and treated side by side while treating the dependency.
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Human immunodeficiency virus infection: Vulnerability of doctors in surgical subspecialties of a tertiary health-care setting in Nigeria p. 178
Abdulrazaq Olanrewaju Taiwo, Mansur Olayinka Raji, Mike Adeyemi, Ramat Oyebunmi Braimah, Adebayo Aremu Ibikunle, Moshood Folorunsho Adeyemi, Aminu Umar Kaoje, Taofeek Abiodun Amoo
DOI:10.4103/jms.jms_77_17  
Introduction: Anxieties about the transmission of human immunodeficiency virus (HIV) infection in Nigeria are present both in general public and the surgical communities. Research on its effect on occupational health and safety is still evolving in Sub-Saharan Africa. Materials and Methods: This was a cross-sectional study conducted in a tertiary referral hospital from October to December 2016. Doctors working in all surgical subspecialties area were included in the study. Data were stored and analyzed using Analyze-it version 2.25 Excel 12+ (2013). Multivariate analysis to determine predictors of vulnerability toward HIV infection was carried out. P = 0.05 or less was considered statistically significant. Results: Of the 95 questionnaires returned, 74 were fully completed making a response rate of 77.9%. Males preponderance was observed (66 [89.2%)]), while there were only 8 (10.8%) females (male:female = 8.3:1). The age ranged from 24 to 53 years (mean age = 36.9 years ± 8.2 standard deviation). More than half of the doctors, i.e. 49 (66.2%) had operated on a known HIV/AIDS-infected patient. There was no correlation between perception of HIV occupational hazard with age, gender, specialty, practice years, and cadre (χ2 = 15.73, df = 17, P = 0.543). Twenty-three surgeons (31.1%) sustained needlestick injuries in the past 1 year and 19 (82.6%) confirmed having at least two episodes. Four (17.4%) had received free postexposure prophylaxis. Conclusion: The findings from this series suggested that the hospital adherence to universal cross infection control measures is suboptimal. It is necessary for hospital to promote minimal invasive surgery.
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Reirradiation in patients with recurrent head-and-neck carcinoma p. 185
RK Spartacus, Rohitashwa Dana, Assem Rai Bhatnagar, Kartick Rastogi, Neeeraj Sharma, Sandeep Bhaskar
DOI:10.4103/jms.jms_70_17  
Context: In head-and-neck cancers (HNCs), the incidence of recurrence after radiation therapy or the second primary tumors is 30%–50% and 20%, respectively. With an operable recurrence, surgical resection is considered the standard of care. For patients presenting with unresectable recurrence or medically unfit for surgery, definitive reirradiation with chemotherapy is the only potentially curative treatment. Aims: The aim of this study was to evaluate locoregional control (LRC), overall survival (OS), and toxicity in patients receiving reirradiation for recurrent HNCs. Subjects and Methods: Records of 35 patients reirradiated with three-dimensional conformal radiotherapy and intensity-modulated radiotherapy (IMRT) for HNC between January 2013 and June 2015 were reviewed and analyzed. Patients were followed on a quarterly basis for 2 years. The Radiation Therapy Oncology Group morbidity criteria were employed to assess the acute and late toxicity. LRC and OS were calculated from the final day of radiation treatment using the Kaplan–Meier method. Results: The median follow-up was 14 months. The median time interval between initial radiation and reirradiation was 51 months (range 12–240 months). The median reirradiation dose was 60 Gray (Gy) (range 24–70 Gy). Eight (23%) patients underwent prior salvage surgical resection. The 1-year OS and LRC rates were 48% and 60%, respectively. Severe Grade 3-4 reirradiation-related toxicity occurred in 12 patients (34.28%). Conclusions: The present study achieved local control and OS comparable to patients with available literature. The treatment-related morbidity was higher as all patients did not receive IMRT in reirradiation setting.
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Comparison of lignocaine 2% with adrenaline and a mixture of bupivacaine 0.5% plus lignocaine 2% with hyaluronidase for peribulbar block analgesia p. 190
Ngangom Sangeeta Devi, K Nareshkumar Singh
DOI:10.4103/jms.jms_63_18  
Purpose: Lignocaine and bupivacaine are the most freely available local anesthetic agents which may be used alone or in combination for peribulbar block analgesia (PBA) with or without hyaluronidase and epinephrine. A prospective comparative study of two solutions was undertaken to rationalize choice of local analgesic agent for PBA. Materials and Methods: A randomized, prospective study on 100 middle-aged to elderly patients undergoing cataract extraction was undertaken to compare the efficacy of (1) 2% lidocaine plus epinephrine 1:200,000 (Group 1) or (2) a mixture of 2% lidocaine and 0.5% bupivacaine (2:3 volume per volume mix) (Group 2). A standardized deep peribulbar block technique, akinesia scoring system, analgesia scoring system, and supplemental protocol were followed. The onset of block and supplementation rates to achieve akinesia was recorded by a blinded observer. The time from 1st PBA injection to the completion of surgery (the duration of surgical access) was also recorded. Results: Significantly better results for akinesia were obtained with the combination of 2% lignocaine plus 0.5% bupivacaine mixed with 50 IU/ml of hyaluronidase at 10 min after injection and also at the end of surgery. However, with regard to analgesia, both 2% lignocaine and 2% lignocaine with 0.5% bupivacaine had a similar effect. Furthermore, the patients in Group 2 showed a significantly reduced need for the first supplemental injection and no need for a second supplemental injection. The incidence of complications was very low in this study. No serious local or systemic complication was encountered. Conclusion: The combination of 2% lignocaine with 0.5% bupivacaine results in a better quality peribulbar block than 2% lignocaine alone, while perioperative analgesia was found to be similar for both combinations. The former also required less frequent supplementary injections.
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Morphometric evaluation of acetabular dimensions: A computed tomography-based study from a tertiary care center in rural North-West India p. 195
Narvir Singh Chauhan, Lokesh Thakur, Surjeet Singh, Bhanu Awasthi, Sunil Kumar Raina
DOI:10.4103/jms.jms_48_17  
Introduction: The success of total hip replacement depends on the ideal placement of both acetabular and femoral component, so having a complete awareness regarding acetabular parameters including its morphology is an important requirement for successful surgery. Materials and Methods: A hospital-based observational study was conducted on all patients in the age group of 18 years, and above submitting to the Department of Radiodiagnosis for either abdominal, lower spinal, or nonorthopedic pathology of pelvic and hip region were included in this study. Acetabular dimensions (acetabular depth [Ac.D] and acetabular width [Ac.W]) were evaluated with the help of digital scale of computed tomography console room monitor. Results: The findings from the current study show that the Ac.D and Ac.W in the study population was 14.6 and 50.2 mm, respectively. The study shows no side-to-side difference in values. However, it was observed that values were larger in men as compared to women in the study population. Conclusions: There is a need to develop templates for arthroplasty which are sex specific and not universal.
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Biofilm production by Staphylococcal isolates from chronic osteomyelitis and orthopedic device-related infections in a tertiary care centre, Imphal p. 199
Gracy Laldinmawii, Kh Sulochana Devi, S Nongthon Singh, Paotinlal Haokip, Arup Roy, Shan Damrolien
DOI:10.4103/jms.jms_54_17  
Background: Microorganisms growing in a biofilm are associated with chronic, recurrent infections, and health problems for patients with indwelling devices which are difficult to treat with antimicrobial agents. Staphylococcus species are the most common microorganisms isolated from these patients. This study was conducted to detect biofilm production in Staphylococcal isolates from orthopedic device-related infections (ODRI) and chronic osteomyelitis (CO) and correlation of antimicrobial susceptibility pattern between biofilm producers and nonbiofilm producers. Materials and Methods: A cross-sectional study was carried out at the Department of Microbiology in a tertiary care center after the Institutional Ethics Committee approval, from October 2014 to September 2016. Detection of biofilm was performed by Congo Red Agar (CRA), tube method (TM), and tissue culture plate (TCP) methods. Antimicrobial susceptibility test was performed by Kirby–Bauer disk diffusion method, and minimum inhibitory concentration for oxacillin and vancomycin was determined according to the Clinical Laboratory Standard Institute guidelines. Results: A total of 51 clinical isolates, consisting of 45 Staphylococcus aureus and 6 coagulase-negative Staphylococci (CoNS), were isolated from 47 CO and 4 ODRI patients of which 32 were methicillin-resistant S. aureus and 2 MRCONS. Biofilm production was detected in 22 isolates by TCP, 18 by TM, and 13 by CRA methods. Fifty percent ODRI isolates and 42.5% CO isolates were biofilm producers. The biofilm producers have lower antimicrobial sensitivity pattern in all except vancomycin. Conclusion: Biofilm producers were detected from 43.1% of total isolates with higher antimicrobial resistance pattern.
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A study of clinical profile of elderly patients admitted in medicine wards of a tertiary care hospital in Northeast India p. 205
Prasad Vasanth, Salam Kenny Singh, Taruni Ngangbam
DOI:10.4103/jms.jms_72_18  
Background: This study was conducted to ensure the quality of life and to address the health care needs of this rapidly growing, vulnerable, and heterogeneous elderly population, as the reliable data about their health problems from different parts of India are still lacking. Aims: The aim of this study is to determine the clinical profile of elderly patients of age ≥65 years, admitted in the medical wards at a tertiary care hospital. Settings and Design: Cross sectional study. Materials and Methods: This study was conducted at a tertiary care hospital from September 2016 to August 2018 on 200 elderly inpatients of the Department of Medicine. Statistical Analysis: Descriptive and inferential statistical analysis were used. Results: Of 200 patients, 123 were male and 77 female. The mean age of patients was 72.85 years with a standard deviation of 7.33 years. Easy fatiguability was the most common presenting symptom across all the three age groups with 51 patients (40.2%) in young old, 16 (30.8%) and 16 (76.2%) in old and oldest-old age groups, respectively. Other symptoms included anorexia 80 (40%), fever 64 (32%), vomiting 59 (29.5%), giddiness 41 (20.5%), and weight loss 32 (16%). The system-wise morbidity profile revealed that the most cases had neurological diseases. An average number of ailments per person was found to be higher in the oldest-old age group. Conclusion: Easy fatiguability was the most common presenting symptom in all the three age groups. Neurological, endocrine, and cardiorespiratory diseases were important causes for hospitalization and majority of cases had three or more ailments necessitating hospitalization.
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A retrospective chart review of trends and clinical characteristics of patients with amphetamine-type stimulant use disorder in a tertiary care center of Mumbai p. 210
Amitkumar Ashok Chougule, Shilpa Adarkar, Kranti Kadam, Shubangi Parkar
DOI:10.4103/jms.jms_65_17  
Introduction: This study aims to understand the sociodemographic and clinical profile of amphetamine-type stimulant (ATS) abusers seeking treatment from a tertiary care teaching hospital in Mumbai. Materials and Methods: Retrospective chart review at deaddiction outpatient department of a tertiary care center in Mumbai using semi-structured printed proformas of the cases presenting with ATS use during the study period. Results: The sample consisted predominantly of single males from lower socioeconomic strata of society, mainly comprising of students with a mean age of 21.66 (standard deviation [SD] = 4.699), with mean age of onset of ATS use being 17.35 (SD = 2.361). The mean duration of ATS consumption was 2.50 months (SD = 1.766) and the mean quantity of consumption in grams was 28.16 (SD = 20.599). Comorbid substance use was present in 80.9% of cases. A comparison was made between patients who presented with ATS use only (A) and ATS-dependent individuals who also used other psychoactive substances (AP). The mean age in years of (A) was lower 19.31 (SD = 4.47) as compared to AP Group 22.22 (SD = 4.61). The (A) Group had significantly longer mean duration of ATS use (3.15 vs. 2.35 months, t = 1.498, P = 0.006), higher number of students as compared to AP Group (69.2% vs. 41.8%, P = 0.07) and significantly more number of patients from ATS only (A) Group presenting with intoxication as compared to AP Group (38.5% vs. 12.7%, P = 0.044). Conclusions: ATS which are recently introduced drugs in the market have serious health consequences, and its abuse is more common in young, single male students from lower socioeconomic status who have comorbid substance use leading to adverse life events.
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CASE REPORTS Top

Nonunited medial epicondyle fracture: A threat to ulnar nerve in long run p. 218
Haritha Therese Joseph, Suiyibangbe Terieng, Amit Kumar Choudhary, Ibohal Singh Akoijam, Suraj Singh Th, Sanjib Singh Nepram
DOI:10.4103/jms.jms_40_18  
48yr old male presented with complaints of tingling and numbness over left little and ring finger for one month; with history of injury around elbow 30yrs back which was managed conservatively. He was diagnosed to be suffering from tardy ulnar palsy after Nerve conduction Velocity studies and MRI Study. Injures to elbow are common in childhood, which include fracture of medial epicondyle which may or may not be associated with dislocation. These kind of injures may be managed conservatively or surgically explored. Ulnar nerve is at risk for injury due to its susceptible position behind medial epicondyle which could be due to the direct impact of acute injury, iatrogenic during surgical management or delayed injury due to mal-union with varus or valgus deformity. We report a case of Tardy ulnar nerve palsy without any valgus or varus deformity following non-united medial epicondyle fracture is rare.
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Case of Chilaiditi syndrome in a critically ill patient p. 222
Saddam Ehsan Zaidi, Rajat Mukherji, Nadiya Ginzburg, Daniel Aminpour, Nasam Alfraji
DOI:10.4103/jms.jms_78_18  
Chilaiditi sign, a condition first described by Greek radiologist Demetrius Chilaiditi in 1910, is the radiological appearance of colonic interposition between the liver and the diaphragm. The incidence in chest/abdominal x-rays and CT scans is 0.025 – 0.28%. When there are symptoms, such as abdominal pain, nausea, constipation or respiratory distress, the condition is called Chilaiditi's syndrome. One of the key factors in the development of this anomaly is anatomic variation in the suspensory ligaments of the intestines. Other important etiological factors include aerophagia, constipation, liver cirrhosis and chronic lung disease with increased intrathoracic pressure. Below we discuss a case of Chilaiditi's syndrome in an elderly female, who presented with shortness of breath, constipation and abdominal distention. The diagnosis of Chilaiditi's syndrome was made by chest x-ray and CT scan.
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A case of mumps orchitis without parotitis in a vaccinated postpubertal male p. 224
Ahmed Elantably, Vinit V Oommen
DOI:10.4103/jms.jms_26_17  
Mumps is a viral infection of the salivary glands that commonly present as unilateral or bilateral parotitis usually during childhood. Serious complications of mumps include meningitis/encephalitis, as well as orchitis in adolescent boys and adult men. We report a case of a 29-year-old male patient with mumps-associated bilateral epididymo-orchitis without signs of parotitis. The diagnosis was confirmed clinically and serologically by IgG and IgM titers.
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Touraine–Solente–Gole syndrome with myelofibrosis: An unusual case with a rare but serious complication p. 227
Lavanya Rajagopal, Sundaram Arunachalam, Shivashekar Ganapathy
DOI:10.4103/jms.jms_56_17  
Touraine Solente Gole (TSG) syndrome or Pachydermoperiostosis (PDP) or Primary Hypertrophic Osteoarthropathy (HOA), is an inherited autosomal dominant disorder characterized by triad of pachydermia (thickening of the skin), skeletal changes (periostosis) and acropachia (digital clubbing). Here we report a rare and interesting case diagnosed as Touraine Solante Gole syndrome in a 35 year-old male with an unusual clinical presentation of symptomatic anemia and dysphagia. Bone marrow biopsy revealed myelofibrosis, a rare but serious complication which may lead to life-threatening anemia. As of 2015, only 22 cases of TSG with myelofibrosis have been reported worldwide. Endoscopy revealed hypertrophic gastropathy which is an infrequent association mentioned in the literature as it occurs only in 27% of patients with TSG. This case of Touraine Solente Gole syndrome is presented for its extreme rarity, unusual clinical presentation and rare, serious complications like myelofibrosis and hypertrophic gastropathy. Also to emphasize the importance of close follow up of these patients to avoid as well as treat these complications earlier.
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Pyoderma gangrenosum with Takayasu's arteritis: A rare association p. 231
Nandakishore Singh Thokchom, KA Sangma, NA Hafi Bishurul, Kapila Verma
DOI:10.4103/jms.jms_28_17  
Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by destructive, necrotizing, and noninfective ulceration of skin which most commonly involve lower extremities. We are reporting a case of 20-year-old male who presented with multiple nodulo-ulcerative plaques on both thighs which showed histopathological findings of granulomatous reaction. He was initially treated ineffectively with anti-tubercular agents. Following a revised diagnosis of PG, dexamethasone pulse therapy (100 mg daily for 3 consecutive days in a month) was initiated and the lesions improved with three such pulses. However, the patient was lost to follow-up. The patient presented a year later with relapse and pulse therapy was restarted. Incidental finding of absence of peripheral pulse and nonrecordable blood pressure on left upper limb led to the diagnosis of Takayasu's arteritis (TA). Skin lesions improved and the patient was referred for the management of TA. Association of PG with TA is rare and very few cases have been reported from India till date.
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LETTERS TO EDITOR Top

Meeting the needs of people with autism spectrum disorders in rural settings p. 234
Saurabh RamBihariLal Shrivastava, Shruthi Krishnan, Prateek Saurabh Shrivastava
DOI:10.4103/jms.jms_49_17  
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Severe adverse effect due to available cervix cancer vaccine and vaccination cost: Implication from preliminary program for universal vaccination among local Thai primary school children p. 236
Sora Yasri, Viroj Wiwanitkit
DOI:10.4103/jms.jms_23_18  
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Quality indicator in laboratory medicine: What else to be recognized? p. 238
Pathum Sookaromdee, Viroj Wiwanitkit
DOI:10.4103/jms.jms_74_18  
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Encouraging real-time tracking of vaccines to reduce the risk of stock-outs: World Health Organization p. 239
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava, Jegadeesh Ramasamy
DOI:10.4103/jms.jms_37_17  
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