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   Table of Contents - Current issue
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July-December 2020
Volume 8 | Issue 2
Page Nos. 173-321

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EDITORIAL  

Gaps in knowledge: Unmasking post-(Acute) COVID-19 syndrome and potential long-term complications in COVID-19 survivors Highly accessed article p. 173
Bhaskara P Shelley
DOI:10.4103/amhs.amhs_324_20  
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ORIGINAL ARTICLES Top

Score for neonatal acute physiology perinatal extension II in predicting neonatal mortality in the neonatal intensive care unit p. 186
Nagendra Bagri, Ram Kumar Panika, Vikas Gupta, Inder K Nathani
DOI:10.4103/amhs.amhs_102_20  
Background and Aim: Very low birth weight (VLBW) neonates constitute approximately 4%–7% of all live births and their mortality is very high (50%). There has been an effort in recent times to develop the severity score for the illness like score for neonatal acute physiology perinatal extension II (SNAPPE-II) score so that it is possible to prevent, particularly aiming the improvement of newborn children care. The study aimed to determine the validity of SNAPPE-II in predicting the VLBW neonates' mortality risk in the neonatal intensive care unit (NICU) at teaching hospital of Raipur, Chhattisgarh. Materials and Methods: This was a hospital-based prospective study carried out among all premature newborns weighing <1500 g and more than 26 weeks admitted to the NICU with a sample size of 129. The variables of SNAPPE-II score were prospectively recorded within 12 h of admission, and their outcome was monitored till 28 days postbirth period. All tests were performed at a 5% level of significance. Results: The SNAPPE II score of the dead neonates was significantly higher than the surviving neonates (43.6 ± 17.25 vs. 18.2 ± 13.09; P < 0.001), and the receiver operating characteristics (ROC) showed that discriminating ability of SNAPPE-II score was 0.857 (good). The best cutoff for SNAPPE II score in predicting neonatal mortality on charting the ROC was 31. Conclusion: The present study was conducted to specifically design to evaluate the validity of SNAPPE II score as predictor of neonatal mortality in VLBW infants and helps in prioritizing them so we can intervene and prevent mortality in these neonates.
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Effectiveness of strain-counterstrain technique versus digital ischemic compression on myofascial trigger points Highly accessed article p. 191
Divya Gohil, Shilpa Vaishy, Gaurang Baxi, Akhil Samson, Tushar Palekar
DOI:10.4103/amhs.amhs_120_20  
Background and Aim: Neck pain is a typical disorder among people from diverse populations. Myofascial trigger points are located on upper trapezius with a high incidence. These trigger points are commonly found in individuals with mechanical neck pain. This study was conducted to compare the effectiveness of strain-counterstrain and digital ischemic compression on pain, range of cervical lateral flexion and the Neck Disability Index (NDI) score in individuals with Myofascial trigger points of upper trapezius. Materials and Methods: Fifty-five subjects between the age group of 25–45 years clinically diagnosed with neck pain associated with myofascial trigger points were enrolled after ethical approval. Subjects were randomly allocated into Group A (n = 28) (Strain-counterstrain) and Group B (n = 27) (Ischemic compression) for 5 sessions in a week. Outcomes were measured using numerical pain rating scale for pain, NDI for disability and cervical lateral range of motion (ROM) using a goniometer. Results: The intragroup comparison was done using Wilcoxon signed-rank test whereas the intergroup comparison was done using the Mann–Whitney test for data that were not normally distributed. The level of significance was determined by P < 0.05 at 95% confidence interval. Statistically significant improvements were seen in both groups (P < 0.001) whereas in between group analysis, there was no statistically significant difference found (P > 0.05). Conclusion: Both techniques were equally effective in reducing pain, improving ROM of cervical lateral flexion, and NDI score in individuals with myofascial trigger points of upper trapezius.
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Target blood pressure in patients with chronic kidney disease on maintenance hemodialysis using ambulatory blood pressure monitoring for 72 h – A prospective observational study p. 196
Vishal Mangal, Ranjith Nair, Kaminder Bir Kaur, Sachin Maggo
DOI:10.4103/amhs.amhs_185_20  
Background and Aim: The target blood pressure (BP) in CKD patients on hemodialysis (HD) remains a dilemma. We aimed to study the BP value most representative of the presence or absence/control of hypertension in CKD patients on HD, and how well could ambulatory BP monitoring (ABPM) predict the presence of hypertension. Materials and Methods: A total of 39 patients with CKD on twice-weekly HD were included in the study. BP was recorded with the help of the sphygmomanometer installed in the HD machine at regular intervals, and the same was compared with ABPM continuously for 72 h during the interdialytic period. Bland–Altman analysis and receiver operating characteristic curve were analyzed. Results: The difference between the mean predialysis systolic blood pressure (SBP) and mean ambulatory SBP was 9.09 mmHg (95% confidence interval [CI], -22.92 to + 41.099 mmHg); however, the difference of 4.86 mmHg (95% CI, -17.886 to + 27.606 mmHg) between the mean diastolic ABPM reading and the mean predialysis diastolic BP did not achieve significance. Conclusion: The data suggest that predialysis office SBP invariably overestimates BP and should not be targeted as a BP goal, as it could lead to intradialytic hypotension. For any given SBP, the postdialysis value is more specific in diagnosing hypertension, thereby reflecting a more significant cardiovascular load. To our knowledge this is the first study to use ABPM continuously during the interdialytic period for 72 h.
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Effect of mifepristone-misoprostol versus misoprostol in the management of intrauterine fetal death: A comparative study p. 202
TR Sindhuri, Sunita Samal, Shweta Gupta, Seetesh Ghose
DOI:10.4103/amhs.amhs_209_20  
Background and Aim: The most undesirable consequence of pregnancy is intrauterine fetal death (IUFD) which causes a lot of emotional and medical distress for which medical induction of labor, by routinely used prostaglandins, is recommended. Therefore, the main aim of the study was to determine the management of IUFD using misoprostol alone and mifepristone-misoprostol combination. Materials and Methods: The study included 57 women of gestational age >24 weeks with IUFD, who were divided into two groups. Women between 24–34 and >34 weeks of gestation received 200 μg and 100 μg of misoprostol, respectively. Group A received misoprostol alone and Group B received oral mifepristone (200 mg), 24 h prior to receiving misoprostol. IUFD duration, number of misoprostol doses, induction-delivery interval (IDI), and bishop score were recorded. A majority of 23 patients in Group A had a bishop score <3 while 28 in Group B had a score between 4 and 6 at 0 h. The IUFD duration varied between 1 and 2 weeks in both the groups. Results: Group A received 4 doses and Group B received 1 dose of misoprostol (P < 0.001). Delivery induction was successfully achieved between 3.3–5 h (48.27%) and 5–8.3 h (51.72%) in Group B and between 11.6 and 16.6 h (57.1%) in Group A (P < 0.001). IDI was found to be shorter with increasing gestational age. Conclusion: It was observed that a lesser number of misoprostol doses and shorter duration of IDI in the combination therapy of mifepristone-misoprostol was a more effective and safer approach to induce labor than misoprostol alone in women with IUFD.
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Effects of 12 weeks yoga practice on body composition and cardiopulmonary status of 10–12 years female volunteers p. 208
Indranil Manna, Mahua Chowdhury
DOI:10.4103/amhs.amhs_143_19  
Background and Aim: Yoga practice may be beneficial for promotion of good health and mental well-being of the children and helps them to adopt with the changing environment. The present study has been designed to find out the effects of 12 weeks of yoga practice on body composition and cardiopulmonary variables of 10–12 years female volunteers. Materials and Methods: Ninety-eight healthy female children volunteers (age 10–12 years) were screened, among them thirty eight were excluded, and the remaining 60 volunteers were randomly divided into: (i) experimental Group (n =30) and (b) control Group (n =30). Yoga practice (60 min/d, 06 d/wk for 12 wks) was followed in the yoga group with no yoga practice in control group. Body composition, heart rate, blood pressure, and pulmonary functions were assessed in both the groups at the beginning (0 week) and after 12 weeks. Results: Significant increase (P < 0.05) in forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), peak expiratory flow rate (PEFR), maximum ventilatory volume (MVV) and breath-holding time (BHT) and; decrease (P < 0.05) in percent body fat, total fat mass, body mass, resting heart rate (RHR), systolic blood pressure (SBP), respiratory rate (RR) were noted following a 12 week yoga practice among the yoga group participants. Further, the yoga group had significantly (P < 0.05) greater FVC, FEV1, MVV, and BHT and decreased fat mass, SBP, RHR, and RR when compared to the control group after 12 weeks of the study. In the control group, no such changes were noticed after 12 weeks of the study. Conclusion: Regular practice of yogic asanas, pranayama, and meditation improves body composition and cardiopulmonary functions of children.
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Neuromuscular efficiency of knee stability after anterior cruciate ligament injury in indian endurance athletes p. 215
Amrinder Singh, Jagannath Rout, Shweta Shenoy, Jaspal Singh Sandhu
DOI:10.4103/amhs.amhs_28_20  
Background and Aim: Knee muscle strength deficit occurs after anterior cruciate ligament (ACL) injury. For testing, isokinetic dynamometer was used to evaluate agonist and antagonist muscles strength, and it provides a certain magnitude of torque generated. Electromyography (EMG) is a method used in research, rehabilitation, ergonomics, and sport science to evaluate neuromuscular activation. The aim of the study was to compare the isokinetic strength and EMG changes of the flexor and extensor muscle of the knee in healthy athletes and athletes following ACL injury in endurance sports persons of India. Materials and Methods: This comparative study investigated 16 athletes with a history of unilateral ACL injury and 16 participants in the control group. Their isokinetic strength was checked using isokinetic dynamometer BIODEX System 4 PRO Dynamometer in conc/conc mode at 60,120 and 300°/s and electromyographic activity of the rectus femoris (RF), vastus medialis obliqus (VMO), vastus lateralis (VL), biceps femoris (BF), semitendinosus (ST) was checked by EMG in 0% and 10% of inclination of treadmill walking between control and ACL injured endurance athletes with the help of NORAXON DTS telemetric EMG. Results: Significant differences were observed in peak torque (PT), PT/body weight (BW), and hamstrings-to-quadriceps ratio at certain angular velocities; when observing muscle activity, there was significant difference in left and right side of RF, VL, and ST but comparing activity and groups, there were no significance. Conclusion: ACL group presented with lower PT and PT/BW; therefore, exhibiting poor isokinetic analysis results regarding the muscle performance in comparison to the control group, and there were no significant differences at 0% and 10% inclined treadmill walking between the control group and ACL injured group.
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Platelet count and indices in patients with psoriasis: Are they associated with disease severity? p. 221
Santosh Sharma, Shakti Kumar Yadav, Roshina Naeem, Namrata Sarin, VK Khurana, Sompal Singh
DOI:10.4103/amhs.amhs_68_20  
Background and Aim: Psoriasis is an immunologically mediated chronic inflammatory skin disease. Altered platelets in psoriasis patients may have a role in predisposition to cardiovascular complications. The aim of this study is to study the platelet count (PLT) and indices in patients with psoriasis and to correlate platelet indices with Disease Area Severity Index score. Materials and Methods: The study was done in a tertiary care hospital. It was performed on 42 psoriasis patients (study group) and twenty healthy controls. Lifestyle factors, PLTs, and platelet indices were compared between psoriasis cases and controls. Correlation between these parameters and Psoriasis Area Severity Index (PASI) score was also studied in psoriasis patients. Chi-square test was applied to compare the categorical data from patients and controls. Spearman's rank correlation was used to correlate lifestyle factors with the severity of disease. Pearson's correlation coefficient was used to find the correlation between PASI and platelet parameters. Results: We found that PASI correlated with smoking (P = 0.042) and levels of psychological stress (P = 0.002). PLT (P = 0.043) and plateletcrit (P = 0.043) were significantly higher in the study group, whereas platelet distribution width (PDW) (P = 0.05) was lower in the study group. We found a significant correlation of PASI with PDW (P = 0.031), mean platelet volume (P = 0.050). and PLCR (0.028). Conclusion: Lifestyle factors such as smoking and levels of psychological stress play a significant role in psoriasis disease severity. There is a correlation of PLT and platelet indices with the pathogenesis and manifestation of disease.
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Effectiveness of sildenafil in pulmonary hypertension secondary to mitral valve disease p. 225
Tinni Mitra, Kallol Das Baksi, Plaban Mukherjee, Madhu Sudan Pal, Suranjan Halder
DOI:10.4103/amhs.amhs_72_20  
Background and Aim: Pulmonary arterial hypertension almost always accompanies long-standing mitral valvular heart disease. The objective of this study is to study the effectiveness of sildenafil in reducing pulmonary hypertension in the peroperative and perioperative period. Materials and Methods: Fourteen patients were randomized into two groups test and control. Patients with mitral valvular disease with Pulmonary Artery Systolic Pressure (PASP) >50 were selected from the outpatient department and echo was done before the admission. Patients in the test group and control group were administered oral sildenafil 25 mg and placebo, respectively, three times a day in the preoperative period in the same fashion for 2 weeks. Preoperative echo was repeated thereafter. After induction of anesthesia and with all aseptic and antiseptic precautions, pulmonary artery catheter was inserted in the right internal jugular vein. PASP was calculated ½ hour after the induction of anesthesia. After operation, patients were monitored by transthoracic echo after 1 week. After discharge, patients were monitored by transthoracic echo at 1 month and at 3 months. Patients' data were analyzed using the statistical tools such as mean, Chi-square test for independence, and paired t-test. Results: There was a statistically significant reduction in PASP in the sildenafil group in the preoperative period (P < 0.05). In this study, PASP was significantly lower (P < 0.0001) after the induction of anesthesia and in the immediate postoperative period in the sildenafil group as compared with the control group. However, there was a marked lowering of PASP in both the control and sildenafil group following the surgical correction of mitral valve disease. Conclusion: In our study, oral sildenafil selectively reduced pulmonary hypertension without any adverse systemic effects.
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An observational study to assess mental health literacy among undergraduate students from Tamil Nadu p. 230
Robbin Bose, B Sivaprakash, Sukanto Sarkar, Abu Backer, S Eswaran
DOI:10.4103/amhs.amhs_85_20  
Background and Aim: Misbeliefs regarding mental illness is a cause of concern and needs better understanding. There is a dearth in the literature highlighting the lack of knowledge regarding the basis of mental illness among educated individuals. Therefore, this study was designed to gauge the knowledge, beliefs, and attitude regarding the mental illness of final year undergraduate students of various courses at Tamil Nadu. The aim is to study mental health literacy and its determinants among undergraduate college students. Materials and Methods: This was a questionnaire-based observational study conducted on 527 final year undergraduate students from dental, nursing, engineering, arts, and science courses. A module containing ten close-ended questions was used to assess people's knowledge regarding the basis of mental illness. A vignette-based “Mental health literacy scale” was used, which described a case of depression and was used to evaluate the participant's knowledge, beliefs, and attitude regarding mental illness. The analysis was performed using Chi-square test and binary logistic regression model. Results: The association between opinion regarding the role of antidepressant and level of contact was statistically significant (P < 0.001). The course of the study was a significant predictor of recognition (P < 0.001). The nursing course had a 17 times more predictive value for recognizing the genetic cause as a perceived cause for mental illness (P < 0.001; odds ratio = 17.508; confidence interval = 7.106–43.136). Conclusion: The study tried to evaluate the knowledge, beliefs, and attitude of college students regarding mental illness, which can help to reduce the increasing burden of mental disorders by shedding light on the significance of mental health literacy toward curbing stigma associated with it. However, future research to create awareness and sensitization towards seeking medical help for curing these psychiatric problems is needed.
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Relationship between core stability and static balance in non-elite collegiate athletes p. 236
Lovely Sharma, Shahin Naz Jamali, Jyoti Sharma, Shaheen Khanum
DOI:10.4103/amhs.amhs_96_20  
Background and Aim: Core stability has become very popular in fitness training and injury prevention programs that incorporate spinal musculature training including core strengthening and stability. Core dysfunction could be related to lower extremity functional performance including balance. The aim of present study was to evaluate the relationship between core stability and static balance. It will provide a rationale to focus on core stability training to enhance lower-limb performance, improvement of balance, and reduction of injuries. Materials and Methods: Based on inclusion and exclusion criteria, thirty nonelite collegiate athletes (male and female) were recruited for the study. Their core stability was analyzed using extensor endurance test (EET), flexor endurance test, and side-bridge test (SBT), whereas the static stability was evaluated using stork stand balance test. Results: Static balance was significantly correlated with EET and right and left SBT of core stability. Conclusion: The study concludes that there is a significant relationship between core stability and static balance in nonelite collegiate athletes in sagittal plane.
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REVIEW ARTICLES Top

A comprehensive review of COVID-19 pandemic and community mitigation strategies p. 240
Tabrez Uz Zaman, Hamed Ademola Adetunji, Shamim Mohammed, El Fadil Mohammed Salih, Tariq Sultan Pasha, Moath Alsolami
DOI:10.4103/amhs.amhs_190_20  
A novel coronavirus with no previous history of causing disease in humans was reported in December 2019 in the Wuhan province of China. Different community prevention and control measures were used globally with varying outcomes to combat this pandemic. It has infected more than twelve million people worldwide and claimed more than half a million lives, the mortality, and morbidity from the disease ever-growing every day. No approved pharmaceutical intervention or vaccine is available till now, thereby requiring assessment of what has worked well to encourage sharing the best epidemiological control practices. This review aims to examine the COVID-19 epidemiology and relate this with the preventive control measures in use globally and evaluate the strategies for community mitigation to cope with the pandemic so far. A literature review comprising 55 articles and reports was undertaken between 2010 and 2020. Findings showed the person-to-person disease transmission and its severity varied among different subgroups of the populations; the elderly, the obese, and individuals experiencing underlying health complications were affected the most. Virus survival ranges from a few hours to 9 days dependent on nature and environmental conditions. Some studies indicated that there is a probability of disease spread from commonly shared toilets and through the semen of the infected patients. Lessons learned and appropriate recommendations were emphasized. It is hoped that the review will be useful to general readers, researchers, decision-makers, and frontline workers to re-examine their approaches while those communities where COVID-19 is just establishing can learn better ways to deal with it.
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Perception of benefits and risks by clinical pharmacists regarding utilization of drugs during pregnancy: A narrative review p. 247
Mohammad Ahmadi Tabassum, Sayed Alishar, S Nelson Kumar, Meda Venkata Subbiah
DOI:10.4103/amhs.amhs_88_20  
Pregnancy is a happy and positive experience for women because pregnancy in addition, having a baby is a life-changing event: the body undergoes major changes. There may be considerable discomfort or ill health takes place during pregnancy. Therefore, they face problems about taking medicines. All the illicit drugs are associated with medical complications, but some may lead to severe damage and increases the risk of serious harm to both fetus and for the mother. Drugs have shown to pass into breast milk, so advice the mothers to avoid breastfeeding when using it. There is a need to be cautious in using medication during pregnancy. However, women with lower levels of education tend to use more prescription or illicit drugs, as they do not understand the proper use of medications, which were associated with several adverse teratogenic outcomes. According to World Health Organization, therapeutic use of medication does not cause developmental abnormalities in the fetus or newborns, but abuse does pose risks to the fetus. The provision of health education during pregnancy to be an important aspect of prenatal care. Indulging effective knowledge and counseling impact of clinical pharmacist activities tends to be promoting awareness to all patients receiving drugs during pregnancy as well as providing information on the consequences and potential harm or effects for mothers and for foetuses based on their need. Communicate with the nearby pharmacists, while using medications to avoid accidental damage during pregnancy.
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Encephalitis lethargica: The challenge of structure and function in neuropsychiatry p. 255
David Bruce Williams
DOI:10.4103/amhs.amhs_308_20  
From its initial description, encephalitis lethargica (EL) challenged the existing understanding of neurology, psychiatry, neurophysiology, and neuropathology in multiple areas, including disease classification, states of alertness, the phenomenology of sleep and consciousness, the voluntary and involuntary control of thought and movement, and the neural underpinnings of emotional and behavioral phenomena (which in turn had important legal ramifications in assessing criminal culpability), not to mention the interrelationship of neural and endocrine systems. This paper reviews the phenomenology of EL, highlighting some of the puzzles it generated by demonstrating that abstract notions of consciousness, sleep, thought, volition, and will were in fact intimately connected to brain function in regions not formerly suspected of subserving such roles.
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A perspective on predictive markers of alopecia p. 263
Anil Kakunje, Ashwini Prabhu, Rahyanath Pookoth, ES Sindhu Priya, Ravichandra Karkal, Parmod Kumar, Nitin Gupta
DOI:10.4103/amhs.amhs_228_20  
Hair is a primary characteristic of mammals and is an immune-privileged structure. Autoimmune attack of the hair follicle characterizes a disease called alopecia areata (AA), an auto-immune disorder, targeting the anagen-stage hair follicle. Erythroid differentiation regulator 1 is one of the presently investigated biomarkers for hair loss disorders. There are majorly two types of AA, namely diffuse and focal. Androgenetic alopecia (AGA) is a common androgen-induced progressive disorder, the pathways of which are regulated by local genetic codes and hormonal control. AA incognita is a type of diffuse hair fall with no confirmatory diagnostic test. AGA in women is a common pathology, the systemic inflammation in AGA has not been extensively studied, but it raises the possibility of identifying new cardiovascular risk factors among female patients with AGA. Other biomarkers for hair loss disorders are C-reactive protein, fibrinogen, VSH, tumor necrosis factor-α, and interleukin-6. This review attempts to give a perspective on the predictive markers of alopecia, their significance, and implications for future research.
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CASE REPORTS Top

A rare case report of allergic bronchopulmonary aspergillosis with active pulmonary tuberculosis p. 267
Deependra Kumar Rai, Sudhir Kumar, Subhash Kumar
DOI:10.4103/amhs.amhs_188_20  
Allergic bronchopulmonary aspergillosis (ABPA) is a disorder caused by a hypersensitivity reaction to antigens of Aspergillus fumigatus and is commonly seen in patients suffering from bronchial asthma or cystic fibrosis. ABPA in patients with active pulmonary tuberculosis a rare finding because tuberculosis, being very common in this part of the world, often masks the clinical features of ABPA. A high index of suspicion is thus necessary to confirm the presence of the latter in patients with atypical presentations. We wish to report two such cases, in which ABPA was diagnosed while the patient was receiving anti-tubercular therapy.
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Chondromyxoid fibroma: Rare entity in a rare location p. 271
Sarita Asotra, Pooja Chauhan, Kanishk Gupta
DOI:10.4103/amhs.amhs_129_20  
Chondromyxoid fibroma (CMF) is a rare benign tumor affecting lower extremities with rare upper limb involvement. It is usually diagnosed by histology, and differentiating it from other benign and malignant neoplasms is of utmost importance for patient management. We present a case of CMF in an unusual location.
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Non-hodgkin's lymphoma at the base of tongue: A rare localization p. 274
Santosh Kumar Swain, Nibi Shajahan
DOI:10.4103/amhs.amhs_162_20  
The extra-nodal non-Hodgkin's lymphomas (NHLs) are mainly found in the head–and-neck region after the gastrointestinal tract. In the head–and-neck region, most common sites for NHL are Waldeyer's ring, followed by the sinonasal tract. NHL at the base of the tongue is extremely rare. The evaluation of the mass at the base of the tongue is a diagnostic challenge for a clinician as a wide spectrum of the benign and malignant lesions found in this site. The diagnosis of the NHL is established by histopathological and immunohistochemical studies. Here, we reported a case of the NHL at the base of the tongue in 28-year-old female. The patient was treated with three cycles of a combination of cyclophosphamide, vincristine, adriamycin, and prednisone chemotherapy and rituximab followed by radiotherapy. There was no evidence of recurrence during the first, second, and third years of the follow up period.
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Effect of postnatal physiotherapy during puerperal management of low back pain and diastasis recti p. 278
Ashwini Kale, Asmita Suryawanshi, Bharati Bellare
DOI:10.4103/amhs.amhs_173_20  
Association of low back pain (LBP) with diastasis recti (DR) is known and frequently encountered during obstetrical status. Exercise during puerperium is prohibited as per the Indian culture in maternal care. A 24-year-old primiparous woman developed LBP (visual analog scale 8) immediately after uneventful vaginal delivery, which jeopardized her functional independence. Examination revealed pathological DR showing interrectal distance (IRD) of 8.72 cm on Vernier caliper and 7.93 cm on transabdominal ultrasound (TAUS) at umbilical level. Physiotherapy limiting to isometric and functional activity was implemented on the patient from the 2nd postpartum day, which continued as home program up to 8 weeks. The patient reported complete resolution of LBP on the 12th postpartum day, whereas by the 8th week, her DR restored to physiological range with the reduction of IRD by 67.88% and 78% on caliper and TAUS, respectively. The case report concluded that culturally suitable postnatal physiotherapy was found to be effective in resolving postnatal LBP and restoration of DR.
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Synovial sarcoma of supraclavicular region: A rare case report with review of literature p. 281
S Sudhamani, Sonali Rajeev Pitale, Snigdha Mukharji, Rajiv Rao
DOI:10.4103/amhs.amhs_175_20  
Synovial sarcoma is a soft-tissue sarcoma predominantly involving the periarticular regions of the extremities but rare in the head-and-neck region. It is often mistaken for other swellings that are common in the cervical region such as an enlarged lymph node. It is important to recognize this unique entity as synovial sarcoma shows specific genetic and molecular characteristics which helps in the diagnosis, treatment, and prognostication. We present one such rare case in a 29-year-old male with a left supraclavicular region clinically suspected as metastatic lymph node swelling. Histopathology and immunohistochemistry confirmed the diagnosis as poorly differentiated monophasic synovial sarcoma.
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Primary small cell carcinoma of tonsil: A rare case with review of literature p. 284
Lalita Negi, Kavita Mardi, Ashish Chaudhury, Anita Negi, Rajender Negi
DOI:10.4103/amhs.amhs_131_20  
Small cell neuroendocrine carcinoma (NEC) that originates in the tonsil is extremely rare and carries a poor prognosis. Only a few cases of this tumor have been reported so far. Here, we describe a 60-year-old woman who presented with throat pain and dysphagia for about 3 months. Computed tomographic scan revealed a 4 cm × 2 cm tumor with moderate enhancement in the right tonsil and a neck mass in the right level II. A biopsy of the tonsillar mass was performed, and histologic examination revealed oval-to-elongated tumor cells arranged in sheets, having hyperchromatic nuclei, inconspicuous nucleoli, and scant cytoplasm. Prominent nuclear molding and mitotic figures were readily identified. Immunohistochemical staining showed that tumor cells were strongly positive for synaptophysin, chromogranin, and CK7. A diagnosis of primary small cell NEC of the right tonsil was obtained.
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Speech profile of wilsons' disease p. 287
Nitin Dogra, Himanshu Verma
DOI:10.4103/amhs.amhs_40_20  
Wilson disease (WD) is rare, inherited autosomal recessive disease of copper metabolism resulting in copper toxicity. Studies reported that it may occur due to the mutation of the ATP7B gene. The present study highlights the speech and swallowing issue in the individual with WD. In this case, we are reporting a male of 18 years with no history of consanguinity and family history of any disease or disorder. He was first diagnosed with WD at the age of 16 years with the first sign of gradual deterioration in speech intelligibility and motor functions appearing at the age of 15 years. Present literature lacks the studies related to the speech profile of WD; therefore, we aimed to assess the complete speech battery, which will provide the baseline for further speech and swallowing rehabilitation. Based on complete assessment, the client was diagnosed with mixed dysarthria and swallowing issues at oral preparatory and oral stage of swallowing. The client also had poor handwriting skill. The present case study focuses on speech, swallowing, and communication issues of WD, which will further help in better understanding of the symptoms related to speech, swallowing, and communication as well as help in the rehabilitation process.
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Rare case report of nasal glioma p. 290
Deekshith Rajmohan, S Sai Manohar
DOI:10.4103/amhs.amhs_94_20  
A child aged 14 months presented with facial disfigurement due to an extra nasal swelling at the root and dorsum of the nose, present since birth, and increasing in size. The swelling was firm in consistency, noncompressible, and nonpulsatile. Cough impulse was absent. Magnetic resonance imaging was suggestive of nasal glioma without intranasal or intracranial extension. Following complete surgical excision, primary reconstruction was required with a local transposition forehead flap. Histopathology confirmed the diagnosis of nasal glioma.
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Airway exchange catheter inducing pneumothorax during reintubation: A rare complication p. 293
Sangeeta Khanna, Sonia Bhan, Kaminder Bir Kaur, Debashish Paul
DOI:10.4103/amhs.amhs_217_20  
Airway exchange catheters (AECs) are a safe option for exchanging an endotracheal tube (ETT) or in the trial to extubate a patient from ventilation in the intensive care unit (ICU). The complication with AEC is underreported. Pneumothorax is a known complication for instrumentation by AEC in the airway. However, having a pneumothorax complication while placing the AEC in expert hands and with all safety precautions is very rare. We report a case of developing pneumothorax while exchanging an ETT in the ICU. Early clinical diagnosis and remedial measures helped us to save the patient. It is interesting as we did not encounter any difficulties while placing the AEC with no significant change in ventilation settings. We feel that highlighting this case will help the physician in the emergency and in the ICU to have a strong suspicion of pneumothorax while using AEC.
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Isolated left adrenal gland involvement in testicular tuberculosis p. 296
Pandiaraja Jayabal, Shalini Arumugam
DOI:10.4103/amhs.amhs_274_20  
Testicular tuberculosis (TB) is commonly associated with genitourinary TB or as a part of miliary TB. In miliary type of testicular TB, there is often bilateral involvement of the adrenal gland. Our case presented with enlargement of the left adrenal gland only. This may be due to anomalous communication between the left gonadal vein and the left adrenal vein. He was started with antituberculous treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol. The patient failed to respond to anti-TB treatment; therefore, he underwent left low inguinal orchidectomy, and the histopathology confirmed the diagnosis. The adrenal lesion started disappearing following orchidectomy and antituberculous treatment.
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Myoepithelioma of lateral pharyngeal wall p. 299
Harsh Suri, Vijayalakshmi Subramaniam, Pooja Vasu
DOI:10.4103/amhs.amhs_284_20  
Myoepithelioma is an extremely rare subtype of salivary gland tumors, and its diagnosis is made on a wide variation of cellular morphology. Though benign, it has a tendency for local metastasis and has a low recurrence rate. Its diagnosis can be challenging due to its poorly characterized clinical, histological, and immunochemical behavior. Here, we present a rare presentation of this tumor in the lateral pharyngeal wall.
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MEDICAL EDUCATION Top

Choosing wisely - Clinician educators' guide to high-value simulation-based education p. 302
Sandra Monteiro, Matthew Sibbald
DOI:10.4103/amhs.amhs_323_20  
Health professions' trainees and educators rely on workplace learning for much of clinical skills training. Yet, organizing, structuring, and delivering core curricular educational experiences are limited by the ad hoc nature of patient presentations, workplace complexities, and clinical pressures. The ongoing worldwide COVID-19 pandemic has exposed and magnified these challenges: trainees face restrictions in accessing workplace environments, and educational patient encounters are actively being minimized to reduce viral transmission. Simulation is an attractive option to supplement workplace learning but comes with significant material and human resource costs. Identifying situations where simulation is worth it – provides high value – and could redress curricular gaps created by pandemic restrictions is of paramount importance to curricular leads. Borrowing from the clinical world, where the Choosing Wisely campaign helps guide clinicians to avoid wasting resources while selecting high-value uses of resources, we propose a Choosing Wisely for educators to maximize the value of simulation-based education under pandemic pressures.
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The influence of time-management on medical resident's perceived stress scale and overtime: A tertiary care hospital experience from Switzerland p. 306
Lorenz Bärlocher, Meghan McConnell
DOI:10.4103/amhs.amhs_304_20  
Background and Aim: Many physicians express challenges in managing time demands during clinical practice. Effective time-management skills may counter the negative effects of high workload and time pressures, and subsequently improve productivity as well as professional and personal wellness. The objective is to determine the impact of time-management training on medical residents' overtime hours and self-reported stress scores. Materials and Methods: The present study employed a within-subjects, single group pretest-posttest design. Convenience sampling was used to recruit 27 medical residents from a tertiary care hospital in Saint Gall, Switzerland. Each resident participated in a single, 2-h interactive time-management workshop. Each resident completed the Perceived Stress Scale-10 (PSS-10) 1-week before and 8-week after the time-management intervention. Overtime of every resident was documented during the same time intervals using a hospital-based computer system. Finally, we recorded whether residents experienced any stressful life events during this 8-week study. Results: Residents worked significantly fewer overtime hours after the time-management intervention than before the intervention (P = 0.01). There was also a significant reduction in mean PSS scores following the intervention, but only for residents who reported experiencing stressful life events during the study (P = 0.028). The intervention had no effect on mean PSS scores for residents who did not report a stressful life event (P = 0.36). Conclusion: The present study reported an effect of time-management training on overtime and perceived stress in residents. We argue that time-management can help residents cope with external stressors, and that individuals who experience stressful life events may especially benefit from time-management training.
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MEDICAL HISTORY Top

Hysteria: A historical perspective p. 312
Siddharth A Shetty, S Chandini, Sharol Lionel Fernandes, AT Safeekh
DOI:10.4103/amhs.amhs_220_20  
The concept of hysteria has evolved through the ages from the ancient civilizations to the modern era. It has been variously attributed to a wandering uterus by the Greeks, demonic possession, witchcraft, bad humors, and inadequate sexual satisfaction by other cultures, finally culminating as a disorder of the brain and the nervous system. Initially considered as an affliction restricted to the female sex, hysteria has later evolved to include a large variety of psychiatric disorders in both sexes. The term hysteria no longer exists in the modern classificatory system. It has been reconceptualized as functional neurological disorders, dissociative (conversion) disorders, and somatization disorders. The concept continues to evolve with advances in medical sciences.
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LETTERS TO THE EDITOR Top

The sunburst sign p. 316
S Sheetal, Ancil George Thomas
DOI:10.4103/amhs.amhs_278_20  
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SHORT COMMUNICATION Top

A study on COVID-19 management strategies of two Indian states p. 318
SS Shemim, Simran S Shaju, Saira Sooraj, Pawan S Soyam
DOI:10.4103/amhs.amhs_229_20  
Ever since the outbreak of COVID-19 disease in December 2019, the World Health Organization (WHO) has been keeping a constant vigil over its spread and progress. The WHO first declared COVID-19 as a public health emergency of international concern on January 30 and subsequently upgraded it as a pandemic on March 11, 2020. The first objective of this study was to identify two states of India; one which has been successful to a large extent in combating COVID-19 spread and another state which has largely been unsuccessful so far in the similar effort. The other objective of the study was to identify the shortcomings of the existing system to deal with the current COVID-19 crisis. The most important statistic that has caught our attention is the death rate per million population. As of now, India's fatality rate stands at 19/million which is significantly below than that of the global average of 76/million. The fatality rate in Kerala is 1.15 per million which is lower than nearly 170 countries in the world. In sharp contrast to Kerala, Delhi's fatality rate is at an alarming 189.5 per million population. Kerala's approach to tackle COVID-19 could be implemented in any state for medical emergencies. Kerala model has highlighted the advantages of a strong and vibrant local self-government system, which is further strengthened in association with volunteer groups.
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