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   Table of Contents - Current issue
Coverpage
July-December 2018
Volume 6 | Issue 2
Page Nos. 195-305

Online since Thursday, December 27, 2018

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EDITORIAL  

“Primum non nocere,” harmful medical mistakes, hubris syndrome, and human fallibility; Getting to the heart of the matter Highly accessed article p. 195
Bhaskara P Shelley
DOI:10.4103/amhs.amhs_140_18  
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INVITED EDITORIAL Top

Medical education research: A “Maturing” component of scholarly practice p. 205
Douglas L Wooster
DOI:10.4103/amhs.amhs_139_18  
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ORIGINAL ARTICLES Top

Assessment of quality of life among human immunodeficiency virus/Acquired immuno deficiency syndrome patients: A study at antiretroviral therapy center at Malda, West Bengal, India p. 208
Pallabi Dasgupta, Sujishnu Mukhopadhyay, Debashis Saha
DOI:10.4103/amhs.amhs_101_18  
Background: With availability of free of cost antiretroviral therapy (ART) in India, longevity of the disease has improved. However, owing to lifelong treatment, opportunistic infections and ultimate fatal outcome and quality of life (QOL) of human immunodeficiency virus/acquired immuno deficiency syndrome (HIV/AIDS) patients have emerged as a significant medical outcome measure in recent times. Objective: The present study was conducted to assess the QOL and associated factors among HIV/AIDS patients attending Malda Medical College ART Center in Malda, West Bengal. Materials and Methods: A cross-sectional study was conducted from September to December 2017 among 155 patients ≥18 years, attending the ART Center of Malda Medical college. Participants were interviewed using a validated Bengali version of the World Health Organization QOL (WHO-QOL BREF). Median scores were calculated in each domain. Mann–Whitney U-test was used to find associated factors. Results: Majority of the patients perceived their QOL and health as good. Median scores of QOL of patients were maximum in physical (69 [25]) and environmental (63 [19]) domains; minimum in psychological (56 [19]) and social (56 [31]) domains. Current illness significantly affected physical and social domains. Current unemployment significantly affected physical and psychological domains. Married persons had significantly higher scores in social domain. Lesser age and lower socioeconomic status had significantly lower QOL in the environmental domain. Conclusion: The present findings highlight the need for suitable employment opportunities for HIV-infected persons to improve social health. Enhanced sociopsychological supports such as social sensitization, mental health care of patients, and interventions to reduce stigma should be done.
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Evaluation of oral health awareness among public school children – A school-based study from Bhopal p. 214
Shubhangi Mhaske, Monal B Yuwanati, Hema Keswani, Leena Jain
DOI:10.4103/amhs.amhs_86_17  
Background: Oral diseases such as tooth caries, gingivitis, and bad breath are still major dental health-care concern, especially in children in the developing countries. Oral disease prevalence is high in school-going children, and there is inadequate information regarding the awareness among them. To evaluate the level of oral awareness among school children, a study was carried out in middle school. Materials and Methods: The present questionnaire study included middle school children from different socioeconomic background of the socioeconomic group. The consent from the school as well as the parents/guardians of children was taken. The trained dental surgeon distributed questionnaire among the children. Completely answered questionnaire was collected. The observations were reviewed and analyzed. Results: The response rate for school children was 81.27%. It was observed the age group of 11–14 years was very well aware of oral hygiene care and maintenance 67% and 55%, respectively. Seventy percent were sure about dietary food items causing dental decay. Toothbrush and paste are the best teeth cleaning aids as per this study group analysis. Conclusion: The findings of the present study reveal different aspects specifically directed toward the current scenario of oral health awareness among middle school children. There is a need for comprehensive dental care plan for school children. School-based educational intervention should be established with a focus on oral self-care and oral health education.
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First day serum bilirubin level, as predictor of significant hyperbilirubinemia in neonates p. 218
Jehangir Bhat Allam, Santosh Kumar, Rajesh Kurmi, Roshan Ara, Amit Mittal Kumar
DOI:10.4103/amhs.amhs_42_18  
Background: Age-specific (24 ± 6 h) predictive value of total serum bilirubin (TSB) ≤6 mg/dl in developing significant hyperbilirubinemia in infants. Materials and Methods: A prospective observational study on 200 term neonates having birth weight ≥2500 g and gestational age ≥37 weeks. Blood was collected from the venous site. The blood sample of all infants was sent for grouping and TSB estimation. Babies were clinically examined every day for jaundice. Whenever jaundice was clinically noticed to be >10 mg/dl, bilirubin estimation was repeated immediately and then every day until 5 days of age, and the highest reading was recorded as the peak TSB. Results: Significant hyperbilirubinemia (>17 mg/dl) was present in 13% of cases. At 24 ± 6 h, TSB >6 mg/dl was present in 47 cases and 26 of these developed hyperbilirubinemia (≥17 mg/dl), and TSB ≤6 mg/dl was present in 153 cases and two of them developed significant hyperbilirubinemia. The incidence of hyperbilirubinemia in babies whose mothers received oxytocin and those whose mothers did not receive oxytocin was 19.6% and 8.2%, respectively. The difference was highly significant. The mean values of TSB at 24 ± 6 h in oxytocin used and oxytocin not used groups were 3.94 ± 2.15 mg/dl and 3.36 ± 1.91 mg/dl, respectively, the difference was statistically significant; however, the mean values of peak TSB in oxytocin used and not used groups were 12.78 ± 4.28 mg/dl and 12.03 ± 3.42 mg/dl, respectively, which were statistically not significant. Conclusion: The incidence of significant hyperbilirubinemia in healthy babies is 13%. The use of oxytocin increased its incidence. TSB at 24 ± 6 h ≤6 mg/dl has a high predictive value in identifying those infants who are unlikely to develop subsequent hyperbilirubinemia. This study, thus, will help to discharge healthy term infants with TSB on 2nd day ≤6 mg/dl.
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Are standard precautions for hospital-acquired infection among nurses in public sector satisfactory? p. 223
Ahmad Batran, Ahmad Ayed, Basma Salameh, Mohammad Ayoub, Ahmad Fasfous
DOI:10.4103/amhs.amhs_84_18  
Background and Aim: Standard precautions are permitted in delivering the care to all patients in clinical settings to avoid the spread of infection. However, their interventions are grounded on the knowledge of the nurses and the other healthcare workers. The nurses should have satisfactory standard precautions' knowledge and practice level for hospital acquired infection. The study aimed to evaluate the standard precautions' knowledge and practice levels among the nurses in the Saudi Arabia private hospitals. Materials and Methods: A cross-sectional study was performed between March and May 2017 in four hospitals (King Khalid Hospital, Najran General Hospital, Maternal and Child Hospital, and New Najran General Hospital). Data were collected using a validated tool from a convenience sample of 198 nurses. Results: The study showed that 88 (44.4%) had good knowledge while 109 (55.1%) had a fair knowledge of standard precautions. According to their practice, the majority 184 (92.9%) of the participants had good level while 13 (6.6%) had a fair level. Conclusion: The nurses have a good level of knowledge and practice with standard precautions. There is a moderate relationship between knowledge and practice of standard precaution. Nurses should practice standard precautions in their daily routine regardless of the patient diagnosis, updating knowledge, improved specific operational guidelines/policies on the practice of standard precaution, regular supply of infection prevention materials, and routine immunization and screening for the staff against Hepatitis B.
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Factors associated with higher fertility in South India: Evidence from district-level household survey 4 p. 228
Manas Pratim Roy
DOI:10.4103/amhs.amhs_95_18  
Background: As we aim to embark on a world free of preventable deaths in maternal health, the importance of regulating fertility claims more attention. In India, a country with low resources, this approach is crucial in facing the challenge amid population burst. Chasing the same aim, the country is yet to register targeted total fertility rate of 2.1 at some of its pockets. Aim: This study, analyzing data from District-Level Household Survey 4, tried to assess the association between high birth order (HBO, defined as birth order three or more among women aged between 15 and 49 years) and major sociodemographic factors in South India. Materials and Methods: District was the unit for analysis. From South India, 98 districts were considered. Correlation coefficient was determined to know the association between HBO and six variables: marriage <18 years, married illiterate women, use of modern contraceptives, pregnant women who had three or more antenatal care visits, consumption of 100 or more iron tablets/syrup equivalent, and institutional delivery (ID). Scatter plot was used to show the effect of demographic variables on HBO. Results: Proportion of marriage <18 years (r = 0.671) and proportion of illiterate married women (r = 0.400) were two the factors positively associated with HBO, whereas use of modern contraceptives, consumption of 100 or more iron tablets/syrup equivalent, and percentage of ID had a significant negative association. Conclusion: As evident, HBO is not only related to illiteracy and use of contraceptives but also related with consumption of iron folic acids, age at marriage, and ID. For effective control of population burden, the target for policymakers should be on education, antenatal services, and ID.
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Relevance of the jaundice meter in determining significant bilirubin levels in term neonates at a tertiary hospital in Lagos State p. 232
Oyejoke Oyapero, Fidelis O Njokanma, Elizabeth A Disu
DOI:10.4103/amhs.amhs_123_17  
Background and Aim: Jaundice is the yellowish discoloration of the skin and mucous membranes or the visible manifestation as a result of elevated serum bilirubin. With spectroscopic tools now available, it is possible to assess the skin's condition by quantitative measures and to access information from deeper layers of skin not visible to the eye. The aim of this study was to determine the relevance of the jaundice meter in determining significant bilirubin levels in term neonates at a tertiary hospital in Lagos State using the Konica Minolta JM-103. Materials and Methods: One hundred and fifty consecutive neonates who presented at the neonatal unit of the hospital were recruited for the study after checking them with set inclusion and exclusion criteria. The transcutaneous bilirubinometry (TcB) readings of the neonates were taken on the forehead, sternum, and abdomen of the calm neonate in a supine position, and blood samples for total serum bilirubin (TSB) estimation were drawn from a peripheral vein within 10 min of TcB measurement. Pearson's correlation analysis with linear regression was done to test the relationship between TSB and TcB values as well as for TcB measurements taken at different sites. Results: The difference between the bilirubin values measured with TcB and TSB was low, with 104 neonates (69.3%) having a difference that was <0.9 mg/dl. Over 83% of the neonates had TcB values that were higher than TSB values, and the percentage of neonates with TSB values >12 mg/dl was 45.2% compared with 56.8% obtained by TcB. In the present study, bilirubin levels measured with the JM-103 show a good agreement with TSB levels in the study neonates. A comparison of the extent of neonatal jaundice in our study at the different body sites using the Kramer's chart showed that there were similar mean recordings for TcB and TSB, with mean values of 10.27 ± 2.90 and 10.58 ± 2.90 for involvement of the face/neck and 18.34 ± 1.61 and 18.43 ± 1.42 for hand/feet obtained by TSB and TcB, respectively. Conclusion: The excellent correlation of TcB with TSB obtained from this study even at levels of bilirubin that necessitates the initiation of phototherapy is encouraging. The JM-103 device thus appears relevant in determining significant bilirubinemia in black neonates.
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REVIEW ARTICLE Top

Angiotensin-converting enzyme 2 and its potential protective effect upon heart p. 238
Leta Melaku
DOI:10.4103/amhs.amhs_44_17  
To circumvent the major threats of low blood volume and low blood pressure, animals need powerful mechanisms for salt and water conservation, which is renin–angiotensin system (RAS). Activation of the RAS is, therefore, a useful response in many demanding situations. However, increased activity of the RAS, especially in combination with other cardiovascular risk factors, may lead to a cascade of deleterious effects such as hypertension, atherosclerosis, myocardial remodeling, heart failure, ischemic stroke, and diabetes mellitus. Although many pathophysiological actions of angiotensin (Ang) II may still be viewed as being homeostatic in principle, its over-activation can be detrimental.. Numerous experimental studies have indicated that angiotensin-converting enzyme (ACE) 2 efficiently hydrolyzes the potent vasoconstrictor Ang II to Ang 1–7. Thus, the axis formed by ACE 2/Ang 1–7/Mas appears to represent an endogenous counterregulatory pathway within the RAS, the actions of which are in opposition to the vasoconstrictor/proliferative arm of the RAS consisting of ACE, Ang II, and AT1 receptor. Although most of the well-known cardiovascular and renal effects of RAS are attributed to ACE, an important enzyme in the generation of Ang II, much less is known about the function of ACE 2. This review summarizes the recently published data on basic properties of ACE 2 and Ang 1–7 and the evidence from experimental and clinical studies of various pathological conditions related to the biological roles of ACE 2/Ang 1–7/Mas in the heart.
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CASE REPORTS Top

Renal cell carcinoma and xanthogranulomatous pyelonephritis: A diagnostic challenge p. 247
Mohammed Khalidur Rahman, Safia Rana, Zeeba S Jairajpuri, Shaan Khetrapal
DOI:10.4103/amhs.amhs_66_18  
The presenting symptoms of RCC (renal cell carcinoma) overlap closely with those of XGP (Xanthogranulomatous pyelonephritis) and can clinically as well as pathologically be confused with XGP which is an unusual inflammatory disorder. Most of the patients present with varied symptoms from the constellation of flank pain, fever, malaise, weight loss, and hematuria. We hereby report here a case of 52 year old male who presented with right flank pain, diagnosed erroneously as XGP on preoperative CT guided biopsy from the renal mass, on two occasions which eventually turned out to be clear cell variant of renal cell carcinoma. Right radical nephrectomy was done where the final histopathological diagnosis was of clear cell variant of RCC.
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Low-grade endometrial stromal sarcoma: A report of five cases p. 251
Saba Bashir, Prema Saldanha
DOI:10.4103/amhs.amhs_105_18  
Endometrial stromal sarcoma (ESS) is a very rare uterine tumor, composed of cells resembling endometrial stromal cells. As these tumors have indistinct clinical and radiological features, they are very rarely diagnosed preoperatively. We are reporting a series of five cases clinically mistaken as benign masses. The age range of these patients was 38–65 years, with a mean age of 49 years. The patients presented with vaginal bleeding, lower abdominal pain, and abdominal mass. All the cases were clinically diagnosed on ultrasound as leiomyoma and underwent total abdominal hysterectomy. Microscopically, all the cases showed a densely cellular tumor composed of small oval cells bearing a close resemblance to normal endometrial stromal cells and were diagnosed as low-grade ESS. This is an aggressive tumor but has a better prognosis in early stage.
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Case of disseminated community-acquired methicillin-resistant Staphylococcus aureus: Unique behavior of the organism in an immunocompetent adult p. 254
Himanshu Khutan, Rupinderjeet Kaur, Gagandeep Singh, Paramdeep Singh, Amanpreet Kaur
DOI:10.4103/amhs.amhs_15_18  
Purulent pericarditis resulting from community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is rare in immunocompetent adults. Here, we present the case of disseminated MRSA infection with origin in tibial osteomyelitis, resulting in bacteremia, purulent pericarditis with tamponade, and panophthalmitis in a previously healthy individual.
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Ewing's sarcoma of the spine: Misdiagnosed as tuberculosis and presenting as paraplegia p. 257
Guruprasad Bhat, Srijit Padmanabh
DOI:10.4103/amhs.amhs_1_18  
Ewing's sarcoma of the spine is a rare tumor, which usually presents with nonspecific symptoms. In India, these are usually misdiagnosed as tuberculosis due to associated fever. These present late with paraplegia. Even then aggressive multimodality therapy of surgery, radiotherapy, and chemotherapy can lead to the recovery of neurological disabilities. This case report highlights the need for prompt diagnosis, multimodality therapy, and complete neurological recovery even when presentation is delayed by 6 months.
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Amniotic band syndrome p. 260
Umma Abdullahi Idris
DOI:10.4103/amhs.amhs_24_17  
Amniotic band syndrome is a rare and complex congenital disorder characterized by constricting rings, acrosyndactyly, or often amputations of extremities of neonates. It is a heterogeneous condition, with a broad spectrum of anomalies, where intrinsic alternate with extrinsic causes as amniotic band rupture. The condition can be diagnosed prenatally with an abdominal ultrasound. However, in most reported cases, the diagnosis was made at birth. Treatment includes surgery and rehabilitation. The author reports the first documented case in the north western Nigeria in a term male neonate. The malformation included a constriction band in the right upper arm and distal lower limb with ipsilateral congenital talipes equinovarus. He was stabilized and referred to orthopedic surgeon for expert management.
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Superior semicircular canal dehiscence syndrome: An uncommon cause of vertigo p. 262
Santosh Kumar Swain, Alok Das, Mahesh Chandra Sahu
DOI:10.4103/amhs.amhs_60_18  
Superior semicircular canal dehiscence syndrome (SSCDS) is a rare and recently described inner ear lesion presenting with disequilibrium and associated with dehiscence of the bony covering of SSC. SSCDS patients may present with a variety of vestibular or auditory symptoms or both. The diagnosis of SSCDS depends on the demonstration of a defect in the bony wall of the roof of SSC. A high-resolution computed tomography is helpful for diagnosis. It is usually treated by plugging of dehiscence. We hereby present a rare cause of disequilibrium and SSCDS, diagnosed by clinical presentations, audiological tests and imaging.
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Transient bulging of the anterior fontanel p. 265
Ibrahim Aliyu
DOI:10.4103/amhs.amhs_114_17  
Bulging of the anterior fontanel could be an ominous sign, especially when associated with other signs or symptoms of raised intracranial pressure. However, some benign conditions have also been reported with bulging of the anterior fontanel such as following Rotaviral gastroenteritis, respiratory tract infection, rosella infantum infection, and vaccination. This is usually transient and its exact mechanism is not completely understood. Therefore, the case of a 5-month-old boy who had a bulging anterior fontanel following treatment for meningitis, which was confused with postmeningitic hydrocephalus, is reported.
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MEDICAL EDUCATION Top

Reimagining our views on medical education: Part 1 p. 267
Elizabeth M Wooster, Jerry M Maniate
DOI:10.4103/amhs.amhs_142_18  
As medical educators, we are continually challenged to prepare the next generation of physicians. This means providing the skills and knowledge to those who will provide health care for years to come. Given the continually changing health-care landscape, combined with multiple external pressures, this task is becoming increasing complex. This article will review some of the challenges that currently exist in both the health-care landscape and medical education continuum. It will conclude with how these challenges should be addressed and questions that should be considered as we move forward.
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Plagiarism in a resource-constrained context: A cross-sectional study of post-graduate medical college trainees and fellows in a tertiary health institution in South East Nigeria p. 270
Gabriel Uche Pascal Iloh, Agwu Nkwa Amadi, Miracle Erinma Chukwuonye, Ezinne Uchamma Godswill-Uko
DOI:10.4103/amhs.amhs_103_18  
Background: Globally, plagiarism is a crack on academic and professional integrity that has permeated the fabrics of medical education and constitutes a threat to genuine scholarships. Objective: The study was aimed at describing the prevalence, attitude, enabling factors, punitive, and preventive measures for plagiarism in a cross-section of postgraduate medical college trainees and fellows in a tertiary health institution in South-East Nigeria. Materials and Methods: A descriptive study was carried out in a cross-section of one hundred and 43 study participants from postgraduate medical college trainees and fellows in a tertiary health institution in Nigeria. Data collection was done using pretested, self-administered questionnaire that elicited information on awareness, prevalence, and attitude toward plagiarism (ATP). ATP was assessed with 29-item prevalidated ATP tool. Operationally, favorable range of scores for academic integrity was low-positive attitude, high-negative attitude and low subjective norms, respectively. Enabling factors, punitive and preventive measures were also studied. Results: The age of trainees ranged from 26 to 47 years with a mean of 36 ± 9.8, whereas the age of fellows ranged from 35 to 59 years with a mean of 43 ± 8.2. All the respondents were aware of plagiarism. The prevalence of plagiarism was 23.8%. Committals of plagiarism predominantly occurred during undergraduate project writings. For trainees, the mean scores for positive attitude, negative attitude, and subjective norms were 53 ± 5 (high), 12 ± 2 (low), and 30 ± 8 (moderate), respectively, while for fellows, the mean scores for positive attitude, negative attitude, and subjective norms were 35 ± 6 (moderate), 22 ± 3 (moderate) and 30 ± 5 (moderate), respectively. The most common enabling factor and punishment were ignorance of what constitutes plagiarism and demotion, respectively. The most common preventive measures were the use of anti-plagiarism software and education on what constitutes plagiarism. Conclusion: This study has shown that plagiarism occurred among the study participants. The level of awareness of plagiarism was very high but did not translate to appropriate positive, negative, and subjective norms attitudinal orientation required for academic integrity. The most common enabling factor and punishment for plagiarism were ignorance of what constitutes plagiarism and demotion, respectively.
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SPECIAL ARTICLES Top

Emerging pedagogies for effective adult learning: From andragogy to heutagogy Highly accessed article p. 278
Thomas V Chacko
DOI:10.4103/amhs.amhs_141_18  
Understanding the way the student learns effectively is important for teachers so that they can then more effectively design their learning experiences. As the student in the health profession education progress across the long period and phases of learning from being an advanced beginner in a wider range of competencies during Undergraduate (UG) to becoming proficiently competent in areas of their specialization during their Postgraduate (PG) period and then after professional specialization while engaging in learning for expertise on-the-job during early professional development, they transition from a low learner maturity phase to full learner autonomy where they determine what and how to learn. Whereas pedagogy with high degree of teacher control matches low learner maturity, as the learners become more autonomous, teachers face the dilemma about how much they need to let go of their power and control to transition from “sage-on-stage” to “guide-on-the-side”. This article examines some of these dilemmas and attempts to suggest use of effective pedagogies (teaching methods) that match the transition of the adult learner engaged in the art and science of healing and progressing through the professional course's stages of competence progression from being a novice to a competent professional and after their formal professional qualification to help them reach expertise and improve quality of care by engaging in continuing professional development (CPD). This knowledge about learner maturity and adult learning principles will also help diagnose and address learner's problems and obstacles to effective learning that is happening at the institutional level.
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Gamifying education and mental health p. 284
Suhas Chandran, SN Prakrithi, M Kishor
DOI:10.4103/amhs.amhs_92_18  
Objectives: This article explores the advantages of using gamification in mental health, in addition to its potential use in training psychiatry residents by coupling it with the concept of digital andragogy, resulting in a prospective efficient teaching model for graduate and postgraduate medical education. Materials and Methods: Databases such as PubMed and Google Scholar were searched for articles using the keywords such as digital andragogy, gamification, innovation in medical education, medical education, and mental health. Results: Using leader boards, rewards, and a host of innovative testing methods, gamification offers increased student engagement and satisfaction along with improved objective academic results emphasizing competency-based medical education. It has also been used in the management of various psychiatric conditions, especially depression, eating disorders, schizophrenia, depression, autism spectrum disorders, substance use, dementia, and traumatic brain injury. It has been shown to alter user behavior positively, leading to better control over illness and improved quality of life among these patients. Conclusion: Gamification is an extremely efficient method, positively impacting the academic performance when used by students. While it cannot replace traditional methods, they can be blended into an efficient teaching model. It can also be used in the management of several medical and psychiatric conditions in a creative and effective manner, although further research is needed to evaluate this potential.
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MEDICAL HISTORY Top

‘A night with venus, a lifetime with mercury’: Insight into the annals of syphilis p. 290
Amina Asfiya, Malcolm Pinto, Manjunath M Shenoy
DOI:10.4103/amhs.amhs_131_18  
Syphilis is a sexually transmitted disease caused by the spirochaete Treponema pallidum. Being a disease whose existence spans several centuries, it has a rich and interesting historical background. The article attempts to explain the milestones in origin, spread, and treatment aspects related to syphilis.
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Evolution of correction of the deviated nasal septum – A historical overview p. 293
Vijayalakshmi Subramaniam, Mubeena Basheer, R Subhodha Hosagadde
DOI:10.4103/amhs.amhs_129_18  
Septoplasty is one of the most frequently performed surgeries by otolaryngolopgists. Surgical techniques for correction of the deviated nasal septum have evolved over the years to ensure better outcomes for patients. This article delves into the developments in techniques for correction of deviated nasal septum over time.
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TEACHING IMAGES Top

Complete bilateral cleft lip and palate with protruding premaxilla: A multidisciplinary approach p. 298
Shafees Koya, Akhter Husain, Mustafa Khader
DOI:10.4103/amhs.amhs_136_18  
Cleft lip and palate constitutes one of the most common congenital anomalies. It causes a wide range of functional as well as esthetic problems. A cleft child's life becomes challenging with a lot of sociopsychological problems which require tremendous support, motivation, and a definite treatment protocol by a craniofacial team in a multidisciplinary approach. Here is a report of one such child who was treated with a multidisciplinary approach by our craniofacial team.
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SHORT COMMUNICATION Top

Etiological profile of patients with lower gastrointestinal bleeding: A 1-year cross-sectional study p. 300
Santosh Hajare, Ravindra Kantamaneni
DOI:10.4103/amhs.amhs_33_17  
The objective of the study was to determine the etiological profile of patients presenting with lower gastrointestinal bleeding (LGIB). This was a cross-sectional study including fifty patients with LGIB enrolled between January 2015 and December 2015. Patients aged 18 years and more with LGIB were included in the study. Endoscopy was performed within 24 h of admission, detailed history was recorded, and the frequency was calculated using Microsoft excel spreadsheet. The categorical data were expressed in terms of rates, ratios, and percentages and continuous data were expressed as mean ± standard deviation. The mean age of patients was 43.82 ± 17.96 years. Higher incidence of GI bleeding was observed in the age group of 18–30 years (34%). Hematochezia (80%) was the most common clinical feature, followed by constipation (78%). Hemorrhoids (48%) followed by ulcerative colitis (24%) were the most important colonoscopic findings determining the etiological factors. Based on the etiological profile, internal hemorrhoids and ulcerative colitis were the leading causes with a male preponderance in both the etiological factors. Men had a history of smoking and alcohol consumption implying that tobacco and other abuses increase the risk of LGIB.
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LETTERS TO THE EDITOR Top

Cytological, histopathological, and immunohistochemical features of merkel cell carcinoma: A case report p. 303
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/amhs.amhs_76_18  
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High dose of black seed oil: Unusual case of abdominal pain p. 304
Abdullah A Baothman, Hani Almalki
DOI:10.4103/amhs.amhs_48_18  
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