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   Table of Contents - Current issue
Coverpage
May-August 2020
Volume 34 | Issue 2
Page Nos. 55-120

Online since Monday, January 25, 2021

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REVIEW ARTICLE  

Compulsory licensing of patents and its effect on competition Highly accessed article p. 55
Ruchika Ghosh
DOI:10.4103/jms.jms_45_20  
Various countries have engaged in serious re-examinations of the legal regimes they use to support innovation in recent times. This is partly due to the establishment of the World Trade Organization and its adoption of the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement. TRIPS made it necessary for revision of most national intellectual property laws. Patentable subject matter is defined in such a manner that protection cannot be granted for “Discoveries”. For eg. Advances such as any abstract principles of science, the fundamental relationship between energy and mass, any living organism, etc. An application for a patent must involve an “invention”. Competition law, on the other hand, aims at promoting competition as a means of market response and consumer preference so as to ensure effective and efficient allocation of resources and to create an incentive for the economy for innovation. The cost and availability of patented drugs is a key development issue, directly impacted by various government policies that affect the degree of competition. A compulsory license provides that the owner of a patent licenses the use of their rights against payment either set by law or determined through some form of adjudication or arbitration. This might be a solution to balance the two competing interests between intellectual property rights and competition law. This article will be especially useful to legal practitioners as well as pharmaceutical companies. These companies need to be aware of the laws of the land while manufacturing and marketing their drugs. They also need to be mindful of the exceptions existing in the law relating to pharmaceutical patents. This article will also be useful to Competition Lawyers in various jurisdictions.
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ORIGINAL ARTICLES Top

Training among in-service doctors in Manipur and their translation into practice p. 61
Mutum Vivekson, Brogen Singh Akoijam
DOI:10.4103/jms.jms_82_17  
Introduction: Manipur, the easternmost state of India, suffer from lack of specialist doctors at peripheral public health service points. Among MBBS doctors, many lack knowledge on maternal and child health, resulting in delay identifying high-risk cases, which contribute to increased morbidity and mortality. Under RMNCH + A strategy as a continuum to the previous program, to overcome the shortage of specialist doctors, multi-skilling of doctors in the public health system is being undertaken. Training need assessment, proper conduct of training, mentoring should be ensured so that these service providers gain confidence and are thus able to practice newly acquired skills. Objectives: The aim is to determine the type and pattern of training among Medical Officers and to assess the level of translation of Basic Emergency Obstetric Care (BEmOC) training (knowledge and skills) into practice. Materials and Methods: A cross-sectional study was done from June 2015 to October 2017. A questionnaire-guided interview was done among BEmOC trained in-service doctors. Data collected were analyzed using SPSS-version-21. Descriptive statistics such as percentage, mean, median, and standard deviation were used. Chi-square test and Fisher's exact test were used for testing the significance between the proportions. ANOVA and independent t-test were used for comparing means. A value of P < 0.05 was taken as significant. Results: Out of 49 respondents, 82% responded and 61% were male. The mean knowledge score was 21 ± 2.8 with a range of 16–27 and the mean age was 33.2 ± 4.1. Gender, year of training, and performed manual removal of placenta were seen significantly associated with knowledge score. About 81.6% of the doctors conducted normal delivery in the past 6 months. Around 45% of the doctors reported performing manual vacuum aspiration (MVA) procedures in the past 6 months and were confident about it. Conclusion: The mean knowledge score about BEmOC was more than two-third of the total score. After training, the knowledge score seems to decrease as time passes. Males had better knowledge than females. There was no association between age, place of posting, and years of experience with knowledge. Almost half of the participants performed the induction of labor and MVA procedure in the last 6 months.
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Role of multidetector computed tomography enterography in the evaluation of small bowel diseases Highly accessed article p. 69
Shweta Bhalothia, Veeraraghavan Gunasekaran, Shoibam Subhaschandra Singh
DOI:10.4103/jms.jms_100_17  
Background: Small bowel imaging is technically challenging due to the difficulty in displaying the long and serpentine small bowel in entirety and intrinsic motion peristalsis and positional changes caused by breathing. Multidetector computed tomography (MDCT) enterography with the use of neutral enteric contrast permits an excellent assessment of the small bowel pathologies. Objective: The objective of this study is to determine the radiological features of small bowel diseases with respect to the presence, localization, causes, and associated complications with MDCT enterography. Materials and Methods: This is a single-center, cross-sectional, analytical study, which was carried over a period of 2 years on 43 patients, in a medical institute at department of radiodiagnosis. The study was conducted with Philips Brilliance 64-Slice computed tomography machine with neutral enteric contrast and intravenous contrast agents with arterial and enteric or portal phases. Imaging findings were correlated clinically, surgically, and histopathologically. Results: Out of the 43 cases, nine cases (20.93%) were of malignant pathologies, 20 cases were of nonmalignant mural pathologies (46.51%), and 14 cases were other intraluminal or extraluminal pathologies. The common bowel wall patterns found in nonneoplastic pathologies were segmental (50%), symmetrical (70%), mild-to-moderate wall thickening (70%), homogeneous and stratified attenuation patterns (95%), whereas segmental (80%), asymmetrical (80%), marked wall thickening (100%), and heterogeneous enhancement patterns (60%) with distal bowel involvement in primary malignancy cases. Mean wall thickness in malignant pathologies (21.56 ± 15.68 mm) was statistically significantly higher than mean wall thickness of nonmalignant pathologies (7.85 ± 3.69 mm) with P value of 0.031 (<0.05). Conclusion: MDCT enterography is a powerful diagnostic tool for the study of small bowel disorders, including inflammatory disease, small bowel neoplasms, and mechanical obstruction.
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Workplace violence in a tertiary health-care institute in Manipur: A cross-sectional study p. 76
Bishwalata Rajkumari, Joymati Oinam, Tamphasana Thounaojam
DOI:10.4103/jms.jms_30_20  
Background: Workplace violence is much prevalent across the globe in almost all institutions dealing directly with the general public and hospitals are no exception to it. Therefore, the objective of this study is to determine the prevalence of workplace violence among doctors and nurses in a tertiary health-care institute in Manipur and to discuss the contributing factors and preventive measures against workplace violence. Materials and Methods: A cross-sectional study was conducted from March to April 2019 among a sample of 438 among doctors and nurses of clinical departments of a tertiary health-care institute, Manipur. A predesigned self-administered questionnaire which was modified and adopted from the “Workplace Violence in the Health Sector Country Case Study-Questionnaire” was used for data collection. Data were analyzed using SPSS IBM Statistics version 21. Statistical analyses such as mean, standard deviation (SD), proportion, and Chi-squared (χ2) test were performed taking P < 0.05 as statistically significant. Results: The mean (±SD) age was 31.02 (±7.1) years. About 32.8% had experienced at least one form of violence. Verbal abuses were the most common form (72.8%). Staff nurses (45.7%) faced the maximum number of incidents. Significantly male staff faced more workplace violence than females. Conclusion: The prevalence of workplace violence was a little more than 1 out of 4. Verbal abuse was the most common workplace violence. The communication gap (123, 49.8%) was cited as the main cause of workplace violence. Increasing security measures and limiting numbers of patient's attendants are required to deal with workplace violence.
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Determination of hepatitis C viral load and human immunodeficiency virus 1 RNA viral load and their correlation with CD4 cell count in human immunodeficiency virus and hepatitis C virus coinfected patients attending a tertiary care hospital in Northeast India p. 81
Krossnunpuii, Heigrujam Rebachandra Singh, Kshetrimayum Birendra Singh
DOI:10.4103/jms.jms_33_20  
Background: Human immunodeficiency virus (HIV)–hepatitis C virus (HCV) coinfection is common due to their shared routes of transmission. Coinfected persons have a higher mortality rate. Some investigators reported an inverse correlation between hepatitis C viral load and CD4 cell count, whereas others have found no such correlation. Objectives: The objectives of the study were to determine hepatitis C viral load, HIV1 RNA viral load, and CD4 cell count and to find the correlation between hepatitis C viral load, HIV1 RNA viral load, and CD4 cell count in HIV-HCV coinfected patients. Materials and Methods: A cross-sectional study conducted in RIMS Hospital, Manipur, between September 2016 and August 2018 among 52 HIV and HCV coinfected patients. Hepatitis C viral load and HIV1 RNA viral load were measured using COBAS® TaqMan® HCV Test and COBAS® TaqMan® HIV-1 test, respectively. COBAS® TaqMan® 48 Analyzer was used for automated amplification and detection. BD fluorescent-activated cell sorter count machine was used for CD4 cell count. Results: Majority of the subjects were male and in the age group of 15–49 years. The most common mode of infection was injecting drug use. There was a statistically insignificant weak negative correlation between hepatitis C viral load and HIV1 RNA viral load, hepatitis C viral load and CD4 cell count, and HIV1 RNA viral load and CD4 cell count. Conclusion: This study found no correlation between hepatitis C viral load and CD4 cell count, HIV1 RNA viral load and hepatitis C viral load, and HIV1 RNA viral load and CD4 cell count. Along with the free antiretroviral therapy treatment made available, there is a need for strategies to rapidly diagnose HCV infection in HIV-HCV coinfected patients and enhance HCV treatment uptake so as to prevent HCV-related morbidity and mortality in these patients.
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Comparison of 3% saline versus normal saline as a diluent for nebulization in hospitalized children with acute bronchiolitis: A randomized clinical trial p. 86
Lalrammuana Hmar, Sarita Brahmacharimayum, Namganglung Golmei, Meenakshi Moirangthem, Shyamsunder Chongtham
DOI:10.4103/jms.jms_43_20  
Context: Bronchiolitis, the most common lower respiratory tract infection among infants and young children, is managed with a few clinically beneficial interventions. Hypertonic saline (HS) nebulization is suggested in the treatment of bronchiolitis, resulting in clinical improvement. Aim: The aim of the study was to compare the efficacy 3% HS versus 0.9% normal saline (NS) as nebulization diluent in children between 3 months and 2 years with acute bronchiolitis. Materials and Methods: In this prospective randomized controlled study, 158 admitted children between 3 months and 2 years with acute bronchiolitis were assigned into two groups – 3% HS and NS. Outcome variables were improvement in clinical severity (CS) score and length of hospital stay (LOS). Descriptive statistics such as mean, median, standard deviation, and percentages were used. Chi-square and t-tests were used to determine associations. Data analysis was performed using SPSS IBM version 21. Results: Baseline CS scores were similar – 3.98 ± 1.20 and 3.75 ± 1.06 for HS and NS groups (P = 0.209), respectively, but from the 2nd day of treatment, it decreased to 2.21 ± 1.10 for HS and 3.05 ± 1.17 for NS group (P ≤ 0.001), further reducing to 1.46 ± 0.63 for HS group and 2.01 ± 0.99 for NS group (P ≤ 0.001). Length of stay was also reduced: 4.98 ± 1.35 for the HS group compared to 5.84 ± 1.18 for the NS group (P ≤ 0.001). Conclusion: Using 3% HS instead of NS as a diluent for nebulization decreases clinical symptoms acute bronchiolitis besides the length of hospital stay.
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Seroprevalence and seroconversion rates of human immunodeficiency virus discordant couples attending a tertiary care center: A prospective cohort study p. 91
KP Arjun Bal, Lourembam Robin Singh, Salam Kenny Singh, Manna Bhattacharjee, N Biplab Singh, Sabin Barun Rai, Namanandi Ashwini, Phillip Laishram
DOI:10.4103/jms.jms_52_20  
Background: Serodiscordant couples are an important population group that needs to be addressed in human immunodeficiency virus (HIV) prevention. However, the exact magnitude of the problem is often underestimated even among health care workers. Methods: This prospective cohort study was conducted in the Regional Institute of Medical Sciences, Imphal for a period of 2 years, to estimate the prevalence and seroconversion rates of HIV discordant couples in this population. Results: Among the 90 discordant couples under follow-up, 2 HIV-negative partners seroconverted with a seroconversion rate of 1.14 hundred person-years. The average age of the study population was 36.99 years. Eighty percent of the HIV positive partners were males Seventy-six out of 90 patients were educated at primary school level and above. Intravenous drug use was the main risk factor.
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Serum lipase amylase ratio in predicting the etiology of acute pancreatitis p. 96
Hawaibam Budhichandra Singh, Laishram Jaleshwar Singh, Priyadarshini Shougrakpam
DOI:10.4103/jms.jms_121_20  
Background: Acute pancreatitis remains a major cause of significant morbidity and mortality. Alcoholism and biliary tract stone disease are the main causes in up to 80% of cases. The diagnosis of acute pancreatitis is based on the correlation of clinical, biochemical, and radiological criteria. Serum lipase and amylase have been used to diagnose acute pancreatitis with values greater than three times the upper limit of normal being diagnostic. Objective: The aim is to study the value of serum lipase: amylase ratio in predicting the etiology of acute pancreatitis. Materials and Methods: This prospective study was conducted in a tertiary care hospital in North-East India during a 2-year period. The serum lipase/amylase ratio has been evaluated in 52 patients (31 acute alcoholic pancreatitis, 19 acute gallstone pancreatitis, 2 idiopathic). Results: Analysis of data showed that patients with acute alcoholic pancreatitis had higher serum lipase levels (2722.5 ± 285.7, mean ± standard deviation) compared to acute gallstone pancreatitis (1565.21 ± 198.2). On the other hand, acute gallstone pancreatitis patients had higher serum amylase (862.3 ± 105.5) compared to acute alcoholic pancreatitis patients (683.03 ± 618.31). Determination of lipase: amylase ratio showed that out of 31 patients of acute alcoholic pancreatitis 22 patients (71%) had lipase: amylase ratio ≥3. Out of 19 patients of acute gallstone pancreatitis, 17 patients (89.5%) had lipase: amylase ratio <3, which was found to be statistically significant. Conclusion: Serum lipase: amylase ratio fixed at 3.0 can assist in differentiating acute biliary pancreatitis from acute alcoholic pancreatitis. The lipase: amylase ratio ≥3 is observed in alcoholic acute pancreatitis while biliary pancreatitis has ratio <3.
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A prospective study on the role of removal of pretarsal tissue in Asian blepharoplasty p. 101
Suiyibangbe, Akoijam Ibohal Singh, Amit Kumar Choudhary, Saugat Das, Laishram Oken Singh, Nepram Sanjib Singh
DOI:10.4103/jms.jms_123_20  
Background: Surgical creation of a superior palpebral fold, known as the double-eyelid operation (Blepharoplasty), has become the most popular cosmetic surgery in Asia. One of the distinguishing features between an individual of Asian descent and western descent is the absence or presence of an upper eyelid crease. An eye with a double-eyelid looks fresh, youthful, and attractive. Several techniques to create a unique esthetic kind of double eyelid in the Asian population has been reported. Aims: Keeping up with the recent evolving techniques, our study is designed to study the role of removal of pretarsal tissue in Asian Blepharoplasty and to analyze the esthetic outcome. Materials and Methods: Study Variables used were age, sex, address, maximum crease height, height of eyebrow, intercanthal distance, and interpupillary distance. Outcome Measures were symmetry of both the eyelid crease and subjective aesthetic appearance. Settings and Design: An interventional prospective study was a tertiary hospital setup in Manipur, India, or a period of 2 years. Double-eyelid operation (Blepharoplasty) was performed on a total of 91 cases, with removal of pretarsal tissues along with a strip of pretarsal orbicularis oculi. Statistical Analysis: The data analyzed with IBM SPSS Statistics 21 developer. Descriptive statistics mean were used for statistical analysis and paired t-test for quantitative data. Results: A total of 91 operated cases were analyzed, taking variables - age, sex, address, maximum crease height, height of eyebrow, intercanthal distance, and interpupillary distance. Outcome measures were symmetry of both the eyelid crease and subjective esthetic appearance. It was found out that majority of the crease height remain unchanged from the intraoperative marking level. Making the preoperative planning a reliable representation of final outcome, and 76 cases (83.5%) were in Grade I subjective esthetic outcome and only 1 case was in Grade III (unsatisfied). Conclusion: Remove the pretarsal connective tissue and part of orbicularis muscle allowed for better fixation, smooth skin surface and leaving less tissue to become postoperatively edematous. Along with minimal fat excision helps to avoid a sunken sulcus. This technique gives good esthetic outcome. The procedure makes the newly created double-eyelid appear natural and more beautiful after complete recovery.
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Role of flap blood glucose measurement in monitoring of flap incorporating skin and to detect flap congestion and flap salvage p. 106
Amit Kumar Choudhary, Akoijam Ibohal Singh, Saugat Ibohal Das, Laishram Oken Singh, Nepram Sanjib Singh
DOI:10.4103/jms.jms_127_20  
Background: Flap surgery has become a reliable method of reconstruction of postsurgical and posttraumatic defects almost over any part of the body with vascularized tissue. Complications associated with flap surgeries may lead to partial or total flap failure. Scrupulous postoperative flap monitoring allows early detection of flap failure which is the only evidence-based strategy for optimizing free flap salvage. There are various methods available for flap monitoring. Classical clinical observation of the flap requires clinical expertise. Microdialysis is a method that measures certain metabolites like glucose, lactate, etc., levels in the flap blood which is objective, reliable, and reproducible method. Based on the principles of microdialysis, monitoring of capillary glucose levels in flaps using glucometer is being proposed as a cheap, rapid, and simple method for the early prediction of microvascular complications and thereby reducing flap failure. Aims: The aim was to study blood glucose levels in flaps incorporating skin in comparison to control site to correlate flap blood glucose level with clinical changes in these flaps. Settings and Design: A hospital-based observational study was conducted on twenty patients operated for reconstruction with flaps in a tertiary hospital setup in Manipur during the period of December 2017 to November 2019. Statistical Analysis: The data were analyzed with IBM SPSS statistics 21 developers. Descriptive statistics mean were used for statistical analysis and paired t-test for quantitative data. P < 0.05 will be taken as statistically significant. Results: Out of total twenty patients studied, 10 patients (50%) were in the age group of 30–50 years. Total 14 flaps (70%) were pedicled and 6 (30%) were free flaps. Total 4 flaps (20%) had complications (venous thrombosis) in the first 24 h, three flaps were pedicled and one flap was free flap. Flap capillary glucose level drops when there was venous thrombosis otherwise flap capillary glucose level fluctuates according to capillary blood glucose level of control area. Conclusions: The measurement of free flap capillary glycemia may be used as a method of diagnosis of complications which is a simple and rapid method of flap monitoring. It can help in flap salvage but it is not superior to clinical evaluation by an experienced professional for the detection of venous thrombosis.
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CASE REPORTS Top

Gallstone ileus: Rare life-threatening disease p. 111
Pranjal Kumar Dhekiyal Phukan, Anup Kumar Roy
DOI:10.4103/jms.jms_86_18  
Gallstone ileus is an uncommon complication of calculus cholecystitis and often presents as a life-threatening emergency. It is more common in the elderly and especially among females. It is a rare cause of intestinal obstruction and accounting for 1%–4% of cases. Patients present with symptoms of intestinal obstruction such as abdominal pain, vomiting, and abdominal distension. Diagnosis can be confirmed by computerized tomography (CT) of the abdomen. Enterolithotomy is the most accepted treatment of choice. We report a case of 55-year-old female who presented with epigastric pain for 8 days duration with multiple episodes of vomiting and progressive abdominal distension. Classical Rigler's triad was observed. CT of the abdomen was suggestive of a gallstone obstructing the small bowel. Enterolithotomy with primary bowel repair was done. A large gallstone of size 5 cm × 3 cm was extracted from the terminal ileum. Postoperative period was uneventful. This case is being reported to highlight the rare incidence of gallstone ileus and its life-threatening surgical emergency, particularly large gallstone causing obstruction, and impending bowel gangrene.
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Sigmoid volvulus in a child: An uncommon presentation of Hirschsprung disease p. 115
Akhilesh Kumar, Gaurav Shandilya, Anand Pandey, Archika Gupta
DOI:10.4103/jms.jms_27_20  
Sigmoid volvulus (SV) is a rare cause of intestinal obstruction in childhood, and it is very uncommon below the age of 20 years and above 70 years. In childhood, SV comprises 4% of all intestinal volvulus. Hirschsprung disease (HD) is a developmental disorder of the enteric nervous system, which is characterized by the absence of ganglion cells in the myenteric and Meissner plexus; rarely, SV may complicate HD. We treated one such patient. Being extremely rare, this association is being reported with a review of the relevant literature.
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SHORT COMMUNICATION Top

Measures to contain the coronavirus disease 2019 pandemic in workplace settings: Public health perspective p. 117
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/jms.jms_22_20  
The ongoing global coronavirus disease-2019 (COVID-19) outbreak has been declared as a pandemic, a public health emergency of international concern, and also as a disease which has shown a very high risk of global transmission. The available evidence suggests that the disease is being transmitted through close contacts or through droplets and thus the probability of acquiring the infection at workplace becomes very high, wherein a group of people work in constrained settings. This calls for the need to implement specific measures to minimize the probability of acquisition of infection. In order to prevent the spread of COVID-19 in the workplace, it is a must that it should be kept clean and hygienic and practices to promote better respiratory hygiene and hand hygiene should be envisaged. Further, specific interventions should be taken to improve the mental health of the employees by supporting them to alleviate their fear and anxiety associated with the disease. In conclusion, the effective containment of the COVID-19 pandemic requires a multisectoral approach and thus, we have to get our workplace ready and ensure the safety of the employees and be together in our battle against the novel infection.
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LETTER TO EDITOR Top

Letter to the editor - Reducing medication errors in telemedicine during the COVID era - need of the hour! p. 119
Vinoth Kumar Kalidoss, Satvinder Singh Bakshi
DOI:10.4103/jms.jms_40_20  
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