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   Table of Contents - Current issue
Coverpage
January-June 2017
Volume 5 | Issue 1
Page Nos. 1-144

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EDITORIAL  

Demystifying neurology education: Understanding the malady of 'neurophobia' among medical students and promoting 'neurophilia' Highly accessed article p. 1
Bhaskara Pillai Shelley
DOI:10.4103/amhs.amhs_40_17  
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INVITED EDITORIAL Top

Simulation-based medical education: Using best practices and curriculum mapping to maximize educational benefits in the context of shift toward competency-based medical education p. 9
Thomas V Chacko
DOI:10.4103/2321-4848.208217  
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ORIGINAL ARTICLES Top

Evaluation of human papillomavirus 16 and human papillomavirus 18 in saliva of chronic smokers in Malaysian population: An In vitro observational study p. 16
EV Soma Sekhar Goud, Shanthi Malleedi, Anand Ramanathan, Gou Rean Wong, Elin Mong Theng Wei, Yvonne Tan Yi Wen, Lee Yoke Hin Yeung, Lee Cheun Wai
DOI:10.4103/amhs.amhs_111_16  
Background: Although the health risks of tobacco smoking are well documented, there is increasing evidence that smokers have a low incidence of inflammatory and neurodegenerative diseases. Moreover, this reduced immunity may pave a way for increased relative risk of harboring these viral entities such as human papillomavirus (HPV) 16 and HPV 18 more specifically in oral cavity. Objective: The objective of the study was to evaluate whether tobacco smoking is associated with the prevalence of HPV 16 and HPV 18 in saliva of chronic smokers and nonsmokers. Methodology: A total of sixty participants constitute the study groups. Out of sixty participants, thirty were grouped with smoking habits, Group I (n = 30) and remaining thirty with no history of smoking, Group II (n = 30). DNA was extracted from saliva of all the participants using QIAamp “DNA mini kit.” Polymerase chain reaction was performed, using primer sequence specific for HPV 16 and HPV 18 obtained from NCBI database. The determination of HPV 16 and HPV 18 was done if and only if the bands were noticed on the ethidium bromide stained agarose gel at 120 bp for HPV 16 and 180 bp for HPV 18. Results: HPV 16 and HPV 18 were not found in both smokers and nonsmokers. Conclusion: The present study is in opinion that smoking is not associated with the HPV 16 and HPV 18 prevalence in saliva. However, the possibilities of synergistic effects of reduced immunity, as a result of smoking and increased prevalence of HPV 16 and HPV 18 in HPV-diagnosed individuals, should be addressed with a large sample.
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Mechanical complications of continuous ambulatory peritoneal dialysis: A hospital based retrospective study in Kashmir Valley p. 21
Adnan Firdous Raina, Sheikh Mohd Saleem, Shah Sumaya Jan, Sabina Yousuf
DOI:10.4103/amhs.amhs_116_16  
Objectives: The objective of the study was to assess the mechanical and nonmechanical complications in patients with end-stage renal disease (ESRD) undergoing continuous ambulatory peritoneal dialysis (CAPD) and to access the contributing factors to improve the patient's survival and reduce morbidity and mortality. Materials and Methods: This observational study was carried out on 121 patients with ESRD undergoing CAPD at the Nephrology Unit of SKIMS, Srinagar, Jammu and Kashmir, India. We retrospectively reviewed the medical records of 121 CAPD patients, in which a double-cuffed straight Tenckhoff catheter was inserted using surgical technique from July 2012 to July 2016. Results: The mean age of the study patients was 45 ± 11.5 years. Males outnumbered female, with a ratio of 1.42:1. The most common etiology for ESRD was diabetes mellitus (38.84%), followed by hypertension (30.57%) and chronic glomerulonephritis (18.18%). About three-fourth of the study patients (77.19%) were on CAPD therapy for more than 6 months showing better acceptability of CAPD therapy. Peritonitis was the most common nonmechanical complication and was seen in 45.45% patients. 14.04% patients had recurrent episodes of peritonitis. Catheter-related complications are early encountered and are mostly due to faulty technique. Conclusion: The complications associated with CAPD are diverse and most of the mechanical complications are catheter related and often result from errors made during catheter implantation. Furthermore, the presence of comorbid factors plays a provital role in exacerbating these complications. Proper evaluation of the patient, care during catheter insertion, and postoperative period can markedly reduce most of these complications and reduce mortality and morbidity associated with CAPD.
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Assessment of radiological changes involving the articular surface of the temporomandibular joint in patients with osteoarthritis and rheumatoid arthritis using computed tomography scan: A prospective clinico-radiological study p. 24
Krishnaveni Buduru, Rajendra Patil, Kannan Natarajan, Suneetha Pentyala, B Anand Babu, Dalsingh Vankudoth, Abhishek Singh Nayyar
DOI:10.4103/2321-4848.208205  
Background and Objective: The purpose of the present study was to assess the radiological changes involving the articular surfaces of temporomandibular joints (TMJs) in patients with osteoarthritis (OA) and rheumatoid arthritis (RA) using computed tomography (CT) scans. Materials and Methods: A total of 20 patients with OA and 20 patients with RA were subjected to a detailed examination, routine radiography, and CT imaging of the TMJs. CT scanning was carried out for the direct axial view and reconstructed to coronal and sagittal planes with contiguous slice thickness of 2 mm using bone window. All the images were evaluated for the presence of osteophytes, flattening of the articular surfaces, sclerosis, and narrowing of the joint space and subjected to statistical analysis. Results: The female to male ratio of the study group for OA and RA was 2:1, respectively. Of all the CT findings, namely, osteophytes, flattening of the articular surfaces, sclerosis, and narrowing of the joint space, statistically significant values (P = 0.056) for osteophytes were obtained. Flattening and narrowing of joint space were seen in both types of arthritides, however, a relatively higher percentage of such patients was seen in RA group. Conclusion: OA and RA of the TMJ are the two most commonly seen conditions which can impair the functional capacity of the entire masticatory system. Their in-depth clinical and radiological evaluation is a must to assess the disease activity. Likewise, CT is a valuable tool in assessing osseous abnormalities and should be used in cases where osseous involvement of the TMJs is suspected.
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Prevalence of asymptomatic left ventricular diastolic dysfunction in type 2 diabetic patients and healthy controls: A comparative study p. 30
G Suresh, Rhea Alva, PS Prakash, Rama Prakasha Saya
DOI:10.4103/amhs.amhs_92_16  
Background and Objective: Type 2 diabetes increases the risk of heart failure independently of other risks factors such as coronary artery disease and hypertension. The objective of the study is to assess the prevalence of asymptomatic left ventricular diastolic dysfunction in patients with type 2 diabetic and in healthy controls. Materials and Methods: This is a cross-sectional comparative study conducted over a period of 1½ years. The study group included 50 diabetics and 50 healthy controls recruited from both in- and out-patient departments; age- and sex-matched. The analysis was done using proportions, Z test to see the difference in prevalence between two groups, odd's ratio to assess the risk and Chi-square test to see the statistical significance. Results: Diastolic dysfunction was found in 36 (72%) of the diabetic patients and in 15 (30%) of the healthy controls. Odds ratio was 6, indicating a 6 times higher risk of developing diastolic dysfunction among diabetic patients compared to the healthy controls. The prevalence of diastolic dysfunction showed no significant difference among the gender and age in both groups. Diastolic dysfunction was more prevalent in diabetic patients with fasting blood glucose value greater than 167 mg/dL and postprandial blood glucose value more than 199 mg/dL; with a sensitivity of 72.2% and specificity of 64.3%. Furthermore, glycated hemoglobin (HbA1c) value greater than 8.1% showed increased the prevalence of diastolic dysfunction in diabetic patients with a sensitivity of 80.6% and specificity of 71.4%. Conclusion: There was a significantly higher prevalence of diastolic dysfunction in diabetic patients with 6 times higher risk of developing diastolic dysfunction as compared to the healthy controls. Both fasting and postprandial blood sugars, as well as HbA1c, were found to be good indicators of diastolic dysfunction in diabetic patients.
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Bone marrow trephine biopsies: A single centre experience in Eastern India p. 34
Sima Chauhan, Sarita Pradhan, Ripunjay Mohanty, Abhishek Saini
DOI:10.4103/amhs.amhs_9_17  
Introduction: Bone marrow aspiration (BMA) and trephine biopsy are indispensable diagnostic tools for evaluating hematological and nonhematological disorders in the present era. However, trephine biopsy demands greater technical skills and expertise as compared to BMA alone. In this study, we have analyzed the advantages of carrying out trephine biopsy along with BMA in the same sitting. Materials and Methods: This is a prospective observational study carried out from June 2014 to May 2015. The patients attending hematology and medicine outdoors were screened by detailed clinical examination, laboratory investigations including complete blood counts, peripheral smear, and whenever indicated were subjected to BMA and trephine biopsy in the same sitting. Results: Out of total 570 aspirations and trephine biopsies done, 8% showed inadequate aspirates and diagnosis was based only on biopsy findings. Confirmatory diagnosis of aplastic anemia was done on trephine biopsy in 100% cases. Fifty percent cases of granulomas and 33.3% cases of metastasis were missed in aspiration smears. They were diagnosed on trephine biopsy. All cases of myelofibrosis required trephine biopsy for diagnosis, but aspiration alone was adequate for diagnosis in majority of acute leukemias. Conclusion: Trephine biopsy is mandatory for diagnosis of aplastic anemia, myelofibrosis, and for staging of lymphomas. It specially carries diagnostic value in cases of dry tap and bloody aspirates. Aspiration is simple, has high specificity, and is especially useful for nutritional anemia, immune thrombocytopenia, acute leukemia, and multiple myeloma.
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Assessment of awareness about pictorial warnings on tobacco products in tobacco users in paonta sahib, Himachal Pradesh, India p. 39
Parveen Dahiya, Reet Kamal, Rajan Gupta, Sumeet Bhatt, Gaurav Didhra, Vrishti Bansal
DOI:10.4103/amhs.amhs_83_16  
Aim: This is a hospital-based questionnaire survey to investigate the awareness of the pictorial warnings on tobacco products among the residents of Paonta Sahib, Himachal Pradesh. Materials and Methods: A total of 840 tobacco user subjects were enrolled in the study. Data were collected by a self-designed, close-ended structured questionnaire which comprised 15 questions related to demographic details, knowledge about tobacco products, practices of tobacco habits, etc., Results: Most of the study participants (69.9%) were aware of statutory and pictorial warnings present on the tobacco products. Majority of the subjects (48.3%) said pictorial representation on the tobacco packets does not help them in refraining from intake of tobacco. Conclusion: The recently updated pictorial warnings are helpful to some extent but requires more strengthening to make pictorial health warnings easier to comprehend to assess the deleterious effects of tobacco by its consumers and general public.
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Medical errors in Nigeria: A cross-sectional study of medical practitioners in Abia State p. 44
Gabriel Uche Pascal Iloh, Abali Chuku, Agwu Nkwa Amadi
DOI:10.4103/amhs.amhs_1_17  
Background: Human errors in health-care delivery have always been a challenge since the Hippocratic dictum “First, do no harm.” However, to achieve a complete error-free health care is a goal yet to be achieved by health professionals despite technological advances in patient care. Aim: The study was aimed at describing medical errors in a cross-section of medical practitioners in Abia State, Nigeria. Materials and Methods: A descriptive study was carried out on a cross-section of 145 medical practitioners in Abia State, Nigeria. Data collection was done using pretested, self-administered questionnaire that elicit information on types, committal, disclosure, and attitude to medical errors. Lawsuits and psychological disturbances associated with committal of medical errors were also studied. Results: The prevalence of medical errors was 42.8%. The three most common errors committed by the participants were an error of medication prescription (95.2%), error of radio-laboratory investigation ordering (83.9%), and error of physician diagnoses (69.4%). Sixty-two (100%) of the participants who committed medical errors had a negative attitude to error disclosure to the patients and their families. Of the 62 participants who committed medical errors, 33.8% were depressed. Among those that committed medical errors, none was involved in a lawsuit for medical errors. Committal of medical errors was associated with years of practice <10 years (P = 0.011). Conclusion: Medical errors occurred among the study participants with the most common error committed being prescription errors. The attitude to error disclosure to the patient was negative. There is a need for the use of safety net and other protocols especially during prescription while avoidable errors should be disclosed, studied, and openly discussed for error mitigation.
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Accuracy of mandibular rami measurements in prediction of sex p. 50
B Kartheeki, Abhishek Singh Nayyar, Y Udaya Sindhu, N Lakshmana
DOI:10.4103/amhs.amhs_66_16  
Background and Objective: Sex of an individual can be determined by means of skeletal indicators when soft tissues are not available for analysis. Furthermore, when entire skull is not available for analysis, mandible plays a vital role in the prediction of sex. As various studies have proven the accuracy of panoramic radiographs in providing anatomical measurements, the present study was conducted using digital orthopantomographs (OPGs) in the south Indian population for the same. The aim of the present study was to measure and compare various measurements of the ramus in mandible on digital OPGs and to assess the usefulness of such measurements in the prediction of sex in an individual. Materials and Methods: A cross-sectional, observational study was carried out using 500 digital OPGs with five rami measurements taken for each radiograph in the south Indian population. The determination of sex was done by discriminant function analysis. Results: All the variables were found to be good predictors for prediction of sex in the study with condylar height/maximum ramus height; projective height of ramus; and coronoid height, being highly significant. Conclusion: This study on rami measurements showed that significant sex-related dimorphism is evident in rami of mandibles indicating its potential usage in mass disasters and otherwise in the prediction of sex in individuals with disputed identity.
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Serum cardiac troponin I and alpha fetoprotein levels in adults with sickle cell anaemia in Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Nigeria p. 55
John C Aneke, Patrick O Manafa, Chide E Okocha, Obiora C Celestine, Vera I Manafa, George O Chukwuma, Nancy C Ibeh
DOI:10.4103/2321-4848.208214  
Background: Several cardiac and hepatic abnormalities have been observed in patients with sickle cell anemia (SCA) which significantly increase disease-related morbidity and mortality. Objective: To determine the levels of cardiac troponin 1 (cTnI) and alpha-fetoprotein (AFP) in adults with SCA and compare with suitable controls. Subjects and Methods: A total of 95 participants, consisting of 30 heterozygous hemoglobin AS (HbAS), 30 homozygous hemoglobin SS (HbSS) (in steady state), 5 HbSS (in crisis), and 30 hemoglobin AA (HbAA), were studied. Five milliliter of venous blood was collected from each participant for cTnI and AFP level estimation (by the enzyme-linked immunosorbent assay technique) and hemoglobin phenotype confirmation (by cellulose acetate electrophoresis). Results: The mean serum level of cTnI was significantly higher in homozygous SCA participants in crisis compared HbAA controls and SCA participants in steady state (1.13 ± 0.46 ng/ml vs. 0.32 ± 0.03 ng/ml and 1.13 ± 0.46 ng/ml vs. 0.27 ± 0.04 ng/ml, respectively, P = 0.01). There were no significant differences in the mean serum levels of cTnI between SCA participant in steady state and HbAS and HbAA (P = 0.33 and 0.58, respectively). Serum AFP levels were not significantly different in SCA (both in crises and in steady state) compared with HbAS and HbAA participants (P values all > 0.05). Conclusion: Cardiac injury may underlie SCA bone pain crisis; assessment of cardiac function may be indicated, particularly in patients with recurrent crises.
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Epidemiology of exposure to secondhand smoke from cigarettes among innocent never smoked adult nigerians in a resource-poor environment of a primary care clinic in Southeastern Nigeria p. 59
Gabriel Uche Pascal Iloh, Agwu Nkwa Amadi, Okechukwu Kalu Iro
DOI:10.4103/amhs.amhs_134_16  
Background: Exposure to secondhand smoke from cigarettes is a public health hazard that is increasing globally and emerging in resource-poor nations where the health effects of secondhand smoke are less publicized in biomedical literatures, electronic and print media. As the global prevalence of cigarette smoking increases so does the health hazards and harm associated with secondhand smoke increases with implication for family and community health. Aim: The study was aimed at describing the epidemiology of exposure to secondhand smoke from cigarettes among innocent never smoked adult Nigerians in a primary care clinic of a tertiary hospital in Nigeria. Materials and Methods: A cross-sectional descriptive hospital-based study was carried out on 500 adult Nigerian patients in a primary care clinic in Nigeria. Data were collected using pretested, structured, and interviewer-administered questionnaire containing information on relevant epidemiological variables. Exposure to secondhand smoke was defined as exposure to cigarette smoke in a never smoked adult in the previous 1 year. Results: The prevalence of exposure to secondhand smoke was 45.0%. Exposures occur predominantly among males (56.4%), middle-aged adults (44.0%), outside home environment (72.0), during the daytime (63.6%), and dry season (58.7%). The persons involved in the smoking were principally friends and passersby (65.8%). Exposure to secondhand smoke was associated with age (middle-aged adults) (P = 0.036) and male gender (P = 0.02). Conclusion: This study has demonstrated the variable epidemiology of exposure to secondhand smoke. Tackling relevant epidemiological factors that predispose to exposure to secondhand smoke through programs and policies will facilitate appropriate public health action to safeguard the health of never smoked individuals.
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REVIEW ARTICLE Top

Surgery for spontaneous intracerebral hemorrhage: Emerging trends p. 65
Girish Menon
DOI:10.4103/amhs.amhs_42_17  
In spite of advances in imaging and surgical techniques, spontaneous intracerebral hemorrhage (SICH) has defied attempts to find a scientifically proven effective therapy. The pathophysiology of SICH suggests that early removal of the clot with minimal additional surgical trauma should prove beneficial. Trials in this direction have been few, and for some unknown reason, surgery has not proved to be superior to best medical management in most of these trials. This has led to substantial variability in the management of ICH throughout the world, and the treatment of SICH remains a controversy. SICH encompasses spectra of possible clot locations with varying volumes. Surgery so far has been reserved only for patients with large hematomas and impending brain herniation. Critical analysis of the earlier studies has now shown that surgery does help in clots in certain locations and of particular volume and when done at an optimal time. Poor grade patients with large hematomas, earlier considered poor surgical candidates are being taken up for aggressive decompressive craniectomies with fair results. In addition, minimally invasive surgical techniques complemented by thrombolytic techniques seem to providing surprisingly good results. Overall surgery seems to be going through a period of renaissance with respect to primary spontaneous ICHs.
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CASE REPORTS Top

Active release technique in hamstrings strain: Rehabilitation and return to play – a case study p. 71
Hariharasudhan Ravichandran, Balamurugan Janakiraman, Subramanian Sundaram, Berihu Fisseha, Asmare Yitayeh
DOI:10.4103/amhs.amhs_37_17  
Hamstring injuries and its rehabilitation in competitive events such as football targets safe and early return to play. This is because hamstring injuries are more related to prolonged recovery time and high rate of re-injury. In this case study, Zakeer Mundampara, 26-year-old footballer of Chennaiyin FC team (Indian super league tournament), who was rehabilitated for Grade 2 hamstring strain was briefed. To describe the importance of conservative rehabilitation in hamstring injuries and report on player's rehabilitation program and clinical outcome. Zakeer Mundampara was conservatively treated with active release technique for 2 weeks duration. Data collected includes passive knee extension test range of motion and verbal rating score. After 2 weeks of rehabilitation, Zakeer Mundampara had nearly full range of pain-free movement, normal gait and trained to run safely. By the 3rd week, he started to perform all sports specific drills. He was rehabilitated and set fit to play after 4 weeks from the date of injury. Active release technique is effective in hamstring injuries. In this case study, rehabilitation program with an emphasis on active release technique is found to be effective in returning the footballer back to play.
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Secondaries mimicking primary cancers of breast: A report of four cases p. 75
Palash Kumar Mandal, Anindya Adhikari, Soumitra Biswas, Shravasti Roy
DOI:10.4103/amhs.amhs_96_16  
Metastatic malignant tumors rarely affect the breast and constitute about 2% of all breast tumors. Herein, we report four such cases of metastatic breast neoplasms. All cases were initially diagnosed by fine-needle aspiration (FNA). Three of them showed features of poorly differentiated adenocarcinoma and one had features of malignant melanoma. Later on, thorough clinical examination aided by ancillary investigations and finally confirmed by immunohistochemistry (IHC) or immunocytochemistry disclosed actual diagnoses. Sigmoid colon, lung, and ovary were primary in the first three cases, respectively. In the last case, FNA confirmed the diagnosis to be malignant melanoma of foot as primary.
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An unusual presentation of mixed tumor of salivary gland p. 77
Arati V Kulkarni, Raghavendra Kini, Prasanna Kumar Rao, Dinkar K Desai, Gowri P Bhandarkar, Roopashri Rajesh Kashyap, HC Meghana
DOI:10.4103/amhs.amhs_3_17  
Pleomorphic adenoma is one of the salivary gland tumors affecting both major and minor salivary glands. Parotid gland is the most commonly affected of the major group, and hard palate is the most common site of the minor salivary glands affected. Pleomorphic adenoma is a benign mixed tumor of the salivary glands that has elements of both epithelial and mesenchymal tissues. We report a case of pleomorphic adenoma of minor salivary glands in the soft palate. Incisional biopsy revealed features of pleomorphic adenoma.
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Unusual case of sciatic nerve and deep pelvic endometriosis with lumbosacral plexus spread presenting with muscular atrophy and foot drop p. 79
Narvir Singh Chauhan, Rashmi Kaul, Sita Thakur, Kshama Nimkar
DOI:10.4103/amhs.amhs_128_16  
Endometriosis is an important disorder which affects women in the childbearing age group. In addition to the commonly observed intrapelvic sites, it can very rarely affect extrapelvic location such as the sciatic nerve. We describe an uncommon case of sciatic endometriosis leading to gross muscular atrophy and foot drop. The patient additionally had perineural extension of endometriosis along the ipsilateral lumbosacral trunk and coexisting intrapelvic endometrial implants in retrocervical area, uterosacral ligament, and urinary bladder wall.
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Pica - an eating disorder: A report and review p. 82
S Vijayendranath Nayak, Raghavendra Kini, Ujwala Shetty, Prasanna Kumar Rao, Roopashri Rajesh Kashyap, Gowri Bhandarkar
DOI:10.4103/2321-4848.208182  
Pica disorder is considered to be an inappropriate behavior characterized by an appetite pattern and craving for non-nutritive substances. Pica usually does not exhibit life-threatening situations, but at times it can create severe complications due to this psychogenic behavior of an individual. Clinical presentation of pica is highly variable and can be associated with the specific characteristics of the resulting medical conditions and the ingested substances. Weird consumption pattern can lead to various changes in the hard and soft tissues of the oral cavity, which can further lead to ulcerations and pulpal pain. Herein, we report a case of pica syndrome with oral manifestation due to consumption of mud.
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Replacement of missing tooth in esthetic zone with implant-supported fixed prosthesis p. 85
Sunil Kumar Mishra, Ramesh Chowdhary, Padmakar S Patil, Srinivasa B Rao
DOI:10.4103/amhs.amhs_22_17  
In the anterior region, the common reason for tooth loss is due to traumatic injury or congenital anomaly. Loss of a single tooth may cause functional and esthetic deficits to the patient. There are different treatment options available for replacing a missing incisor. Implant dentistry should be considered as first treatment alternative for replace a missing tooth. This case report presents the replacement of a missing maxillary left central incisor in a compromised site with dental implants along with bone graft followed by frenectomy to obtain a good clinical result and for better function and esthetics of the patient.
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Accelerated hypertension: Treatable yet underdiagnosed p. 89
Pranav Ish, Harpreet Singh, S Anuradha, Richa Dewan
DOI:10.4103/amhs.amhs_95_16  
Patients who present in young age with accelerated hypertension (HTN) should always be evaluated for secondary causes of hypertension. Renal parenchyma and vascular diseases constitute the majority of the etiology. Other causes include endocrine diseases such as pheochromocytoma, pregnancy-related HTN, and sleep apnea. We report a 23-year-old female who presented with palpitations and headache under treatment for anxiety from a tertiary care hospital. She was found to have accelerated HTN and was thoroughly worked up for etiology and treatment.
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The curse of quackery in dentistry: A double-edged sword p. 92
N Geon Pauly, Sukanya Warrier, Roopashri Rajesh Kashyap, Prasanna Kumar Rao, Raghavendra Kini, Gowri P Bhandarkar
DOI:10.4103/amhs.amhs_4_17  
The high price of dental treatment, repeated dental appointments, poor accessibility to dental clinics, illiteracy, and lack of awareness are the reasons for thriving of quackery in dentistry. In many developing countries of the world like our own, where dental health-care facilities by college-/university-trained personnel are limited and hospitals are few and a far or very expensive, the underprivileged of the society go to unqualified persons (known as quacks) to get dental treatment. Many dental quacks are practicing roadside, which makes money by doing unethical practice and ultimately hampering patient's oral health. It is thus a challenge to the dental practitioners to not only fight against this fraudulent of dental quackery but also to educate and convince the patient to distinguish between the quacks and dentists so that they get guided to take the right treatment.
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Subareolar sclerosing duct hyperplasia of the breast: An encounter with a rare entity p. 95
Anchana Gulati, Vijay Kaushal, KS Jaswal, Rajni Kaushik
DOI:10.4103/amhs.amhs_35_17  
Subareolar sclerosing duct hyperplasia of the breast is a rare entity. Patients present with lump located beneath the nipple and areola, with/without nipple retraction and nonspecific mammographic findings, hence closely mimicking carcinoma clinically. Cytology reveals only a benign papillary lesion, therefore creating a diagnostic dilemma for the clinician and the pathologist alike. We report a case of this entity in a 70-year-old female who presented with a lump in the right breast with nipple retraction and nipple discharge of 6-month duration.
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MEDICAL EDUCATION Top

Reinventing medical teaching and learning for the 21st century: Blended and flipped strategies p. 97
Carol A Miles, A Curtis Lee, Keith A Foggett, Balakrishnan (Kichu) Nair
DOI:10.4103/amhs.amhs_53_17  
There has been a recent rapid increase in the integration of flipped and blended modes of learning into Australian university classrooms. In the move to realize the benefits of these modes of delivery, universities are spending a great deal of time focusing on course redesign and upskilling teachers to assist in the adoption of these new methods of instruction. Large-scale blended learning projects have been completed at The University of Newcastle, Australia. One such project has been the integration of flipped and blended learning strategies into the redesign of the 1st year medical science course as part of a total undergraduate medical curriculum redesign. This course involves a large number of lecturers from a wide variety of disciplines. This involved not only the redesign of this course but also the introduction of new teaching materials and learning objects. To ensure success, this work required input from three groups: the academics teaching the course, the students taking the course, and the instructional designers who create the learning objects. The University of Newcastle, Australia, was instrumental in introducing problem-based learning (PBL) to medical schools in Australian universities with its initial intake of medical students in 1978 and continues the use of this methodology as its primary teaching approach. As the current project develops, it has become apparent the pioneering work previously undertaken to implement PBL, in fact, had incorporated many of the pedagogical principles and strategies of what is now considered blended learning in the flipped classroom (albeit without the technology components). This paper argues that our teachers and students will more easily adapt to the requirements inherent in blended or flipped learning due to previous familiarity with PBL strategies.
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My students surprise me everyday p. 103
P Ravi Shankar
DOI:10.4103/2321-4848.208218  
The author has been using small-group, active learning methods among undergraduate medical students for nearly 17 years. Many medical teachers are not fully confident about the ability of medical students to learn on their own with minimal support from the teacher or facilitator. In this article the author shares perspectives from the various small group sessions which he has conducted and also provides tips for facilitating active, small group learning.
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SPECIAL ARTICLES Top

Understanding depression: An overview p. 107
AT Safeekh
DOI:10.4103/amhs.amhs_52_17  
Depression is a major mental health problem, cuts across sociocultural background of all genders and age groups worldwide. The prevalence of depression is rising in an alarming rate and predicted to become the second leading cause for disability worldwide. Multiple factors are found to influence the etiology, course and prognosis of depression and various models of depression have been explained. However, the heterogeneity of this disorder makes it too complicated to be understood by any single model or theory. The clinical features, course, treatment response, and outcome also are as diverse as its origin.
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Geriatric health care in India - Unmet needs and the way forward p. 112
Prabha Adhikari
DOI:10.4103/2321-4848.208215  
India has nearly 120 million elderly people with various physical, psychosocial, economic, and spiritual problems. While the functionally and cognitively fit can access usual health-care facilities provided by the government, these people need active aging program to keep them independent. Health ministry has created geriatric centers and geriatric clinics in most of the states; however, these centers may not serve the functionally and cognitively impaired elderly. There is great need for mobile units, day-care centers and hospices, and need for training of personnel in home nursing. Routine care clinics cannot handle the burden of geriatric population to address their multimorbidity and several other age-related problems. There is a need for a rapid training of health-care professionals of various disciplines in geriatric care. Government must support nongovernmental organizations and other agencies which provide day care, home care, and palliative care so that these services become affordable to all the elderly.
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Developmental pattern of hepatic drug-metabolizing enzymes in pediatric population and its role in optimal drug treatment p. 115
Sunitha Kodidela, S Suresh Kumar, Chakradhara Rao Satyanarayana Uppugunduri
DOI:10.4103/amhs.amhs_54_17  
Pediatric pharmacokinetics (PK) and pharmacodynamics (PD) differ from adults in multiple aspects. The extrapolation of PK/PD data from adults to children is not always simple because children are not small adults. Differential development of metabolic enzymes in children affects both PK and PD of a drug. Thus, the study of the developmental patterns of drug-metabolizing enzymes is essential to establish the PK and PD profile of drugs in the pediatric population. Further, these patterns may also aid to establish models for appropriate extrapolation of adult data for any newer drugs. We conducted a literature search on PubMed Central, Medline database, and Google Scholar with relevant search terms to obtain articles for this narrative review. The research on developing pattern of drug metabolizing enzymes is still evolving. This review presents an overview of the existing literature on developmental patterns of key metabolic enzymes in children. Greater emphasis needs to be given to study developmental pattern of metabolic enzymes as it not only helps drug development but also to optimize drug therapy in children.
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MEDICAL HISTORY Top

Aldred scott warthin: Pathologist and teacher par excellence p. 123
Vineeth G Nair, HV Krishnaprasad
DOI:10.4103/amhs.amhs_135_16  
Born in 1866, Aldred Scott Warthin was a pathologist and teacher of great repute. Even though many know him from his eponyms, the true value of his achievements, and how far he was ahead of his peers, is known to but a few modern day medical students. It was in fact, based on his work, that Henry Lynch came up with his theories on the genetic nature of cancer. He died in 1931 leaving a lot of work unfinished.
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Rene descartes: Colossus of binaries – real or perceived? p. 126
Sandeep Alex
DOI:10.4103/amhs.amhs_49_17  
Rene Descartes lived in the 17th century and is considered as the father of Western philosophy. He is generally credited with popularizing the concept of mind–body dualism. Cartesian dualism cannot be interpreted devoid of its historical origins. This article attempts to contextualize Descartes for students of medicine by reviewing the historical background of his formulations, its impact then and now, current relevance of mind–body dichotomy, and the controversies surrounding the concept.
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TEACHING IMAGES Top

Water lily sign and serpent sign in pulmonary hydatid cystic disease p. 129
Ashish Ranjan
DOI:10.4103/2321-4848.208184  
The teaching image depicts sections of CT chest showing water lily sign and serpent sign. In the diagnosis of pulmonary hydatid disease, these signs are pathognomonic, these must be corroborated clinically, and early interventions should be done to avoid rupture of cysts leading to complications.
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The heart of the matter: Acute quadriplegia with respiratory paralysis - bilateral medial medullary infarction p. 131
Bhaskara P Shelley
DOI:10.4103/amhs.amhs_41_17  
The clinicoradiologic correlate of bilateral medial medullary infarction is described. This is a rare clinical entity of vertebrobasilar stroke syndrome with catastrophic consequences and a poor functional prognosis. Since the initial symptom is quadriplegia, the clinical diagnosis without neuroimaging can be challenging with a potential for misdiagnosis as Guillain–Barré syndrome or brainstem encephalitis in the early stages. The teaching neuroimage of the “heart appearance” sign is revisited.
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SHORT COMMUNICATION Top

Absent skin at birth with blistering: Bart's Syndrome? p. 133
Amina Asfiya M Iqbal, Manjunath Mala Shenoy, Malcolm Pinto, Vishal B Amin, Spandana P Hegde
DOI:10.4103/amhs.amhs_31_17  
Bart's Syndrome is a disorder characterised by aplasia cutis congenita and epidermolysis bullosa. We report a case of a 4-day-old baby who had absent skin over the legs along with blistering and nail dystrophy. The diagnosis of Bart's Syndrome was made based on history and clinical examination. However, detailed investigations and histopathological confirmation is needed for final diagnosis. The management is conservative and needs multidisciplinary support.
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LETTERS TO THE EDITOR Top

Role of spinal cord stimulation in failed back surgery syndrome p. 136
Ali Ghazanfar, Haider Ghazanfar
DOI:10.4103/amhs.amhs_10_17  
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Sorafenib-induced hand-foot syndrome p. 137
Chaturbhuj Agrawal, Parveen Jain, Rajeev Saini, Pankaj Goyal
DOI:10.4103/amhs.amhs_7_17  
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Antidote for new oral anticoagulants - present status p. 138
Abhijit S Nair, Basanth Kumar Rayani
DOI:10.4103/amhs.amhs_77_16  
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A rare cause of twelfth-nerve palsy: Guillain-Barré Syndrome p. 140
Prasanna Venkatesan Eswaradass, Balakrishnan Ramasamy, Ramadoss Kalidoss, G Gnanashanmugham
DOI:10.4103/2321-4848.208186  
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Ensuring early detection of cancer in low- and middle-income nations: World health organization p. 141
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava, Ramasamy Jegadeesh
DOI:10.4103/amhs.amhs_25_17  
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Artificial heart transplantation p. 142
Abdul Mannan Khan Minhas, Salman Assad
DOI:10.4103/amhs.amhs_34_17  
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ERRATUM Top

Diabetes treatment satisfaction, medication adherence, and glycemic control among ambulatory type 2 diabetic nigerians in a primary care clinic of a tertiary hospital situated in a resource-limited environment of Southeast Nigeria p. 144

DOI:10.4103/2321-4848.208216  
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