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   2020| January-June  | Volume 8 | Issue 1  
    Online since June 20, 2020

 
 
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EDITORIAL
Cerebral musings on environmental humanities, human transgression, and healthcare preparedness: Looking beyond the “streetlight effect” of the COVID-19 pandemic
Bhaskara P Shelley
January-June 2020, 8(1):1-8
DOI:10.4103/amhs.amhs_99_20  
  11,414 2,387 -
INVITED EDITORIAL
Bedside clinical teaching: Arresting the decline
Robert Pickles
January-June 2020, 8(1):9-10
DOI:10.4103/amhs.amhs_25_20  
  11,079 1,524 -
ORIGINAL ARTICLES
Comparative utility of bone marrow aspiration and trephine biopsy in evaluation of hematological disorders
Lekshmi Vijayamohanan, Sarita Asotra, Kavita Kumari, Pooja Murgai, Digvijay Dattal
January-June 2020, 8(1):15-19
DOI:10.4103/amhs.amhs_23_20  
Background: Bone marrow examination is a useful investigative tool to diagnose several hematological and nonhematological disorders. While the aspiration provides excellent cytological detail, the biopsy provides information regarding the spatial relationships of cells, marrow architecture, and valuable information when aspirate is nondiagnostic. We conducted this study to compare the diagnostic usefulness and comparison between aspirate and trephine biopsies in the evaluation of hematological disorders. Aim: The aim was to assess the relative efficacy of bone marrow aspiration and trephine biopsy and the overall diagnostic utility of this procedure in the diagnosis of hematological and nonhematological disorders. Materials and Methods: This is a retrospective study of 6-month duration at a tertiary care hospital in Himachal Pradesh. Patients were aged from 1 to 85 years. A total of 169 cases were studied, in whom bone marrow aspiration and trephine biopsy were performed, with special stains used where required. Results: A specific pathology was found in 89 cases(52.66%), rest being a normal or unsatisfactory study. Trephine biopsy was fundamental in the diagnosis in 69 cases(48.93%). Nearly 21.05% of the aspirates indicating a normal study further revealed a specific pathology on trephine biopsy and 38.88% of the unsatisfactory aspirates revealed definite pathology on biopsy. We noted that 8.87% of cases were diagnosed by trephine biopsy alone, with 89.94% concordance between trephine biopsy and aspiration. Conclusion: Bone marrow aspirate cytology and trephine biopsy are useful adjuncts to each other and should be used to supplement each other in arriving at a definite diagnosis, and they remain as a key diagnostic tool in hematological disorders.
  10,175 2,118 -
Computed tomography evaluation of sinonasal masses with histopathological correlation
Musaib Ahmad Dar, Suhail Rafiq, Farzana Manzoor, Irshad Mohideen
January-June 2020, 8(1):11-14
DOI:10.4103/amhs.amhs_34_20  
Background and Aim: A variety of nonneoplastic and neoplastic conditions involving the nasal cavity (NC), paranasal sinuses (PNSs), and nasopharynx are commonly encountered in clinical practice. Etiological factors for the development of sinonasal masses are human papillomavirus 6 and 11, allergens, air pollution, and industrial carcinogens, tobacco, alcohol, and occupational exposure to heavy metal particles. The aim was to explicate and corroborate the CT radiological features of sinonasal masses of benign versus sinister differential diagnosis. Materials and Methods: A total of 50 cases of sinonasal masses were included in this study. Written informed consent from the patients was obtained. Detailed clinical history and local and general examinations were done according to the pro forma attached with a special reference to the nose, PNSs, and oral cavity. These cases were subjected to after routine hematological and biochemical evaluation, nasal endoscopy, X-ray PNSs/computed tomography scan, fine-needle aspiration cytology, and, whenever required, biopsy. Results: On radiological assessment, of 50 patients, 45 patients were declared benign, while as 5 patients were diagnosed as having primary or secondary malignancy involving sino-NCs. Based on bone erosions along with internal hyperdense contents and enhancement pattern, there was some amount of discordance among radiological and histopathological diagnosis. One case which was diagnosed as malignancy (likely metastasis) was found to have invasive fungal sinusitis. Among the three radiologically diagnosed inverted papillomas (based on focal hyperostosis, subtle calcification, and cerebriform enhancement on postcontrast study), only 1 case correlated histopathologically. The rest were hemangioma and schwannoma (very rare). Radiological esthesioneuroblastoma, hemangioma, angiofibroma, and rhinolith correlated well with histopathology. Conclusion: Imaging plays an important role in the evaluation of sinonasal masses. Benign lesions are diagnosed very accurately. The distinction between sinonasal and invasive fungal sinusitis is still debatable, and hence, histopathological correlation is necessary. The presence of significant cervical lymphadenopathy can serve as a surrogate marker of malignancy.
  9,723 2,245 -
TEACHING IMAGES
Radiological signs on orbital imaging of immunoglobulin G4-related disease
Sunny Chi Lik Au, Edwin Chan
January-June 2020, 8(1):159-160
DOI:10.4103/amhs.amhs_142_19  
Immunoglobulin G4 (IgG4)-related disease has strong organ predilections, and orbital involvement is not rare. Eyelid puffiness with erythema, extraocular movement deficit with proptosis are common presentations, which could sometimes mimic thyroid-associated orbitopathy. With a better understanding on orbital radiology, these “hot eyes” could be managed better.
  11,748 107 -
ORIGINAL ARTICLES
Clinicohistopathologic study of lichenoid interface dermatitis
Aparna Muralidhar, Suguna Belur Venugopal, AS Nandini
January-June 2020, 8(1):20-25
DOI:10.4103/amhs.amhs_11_20  
Background: Interface dermatitis (IFD)/lichenoid tissue reactions are among the most frequently presenting disorders in dermatology, which in common have a constellation of histopathological features but varied clinical presentation. Aim: Clinicopathologic correlation and determination of histomorphologic changes associated with various lichenoid IFD of the skin. Materials and Methods: This was a prospective study with purposive sampling of patients reporting to the outpatient department of dermatology, venerology, and leprosy of our hospital from January 2017 to July 2018. Skin biopsies of 150 patients of either sex diagnosed provisionally as one of the lichenoid IFD on clinical grounds were studied. Clinicohistopathologic correlation was done. Results: We encountered 58 cases of classic lichen planus, seven variants of lichen planus (hypertrophic lichen planus, ashy dermatosis, lichen planus pigmentosus, actinic lichen planus, lichen planopilaris, lichen nitidus, and lichen striatus), and 16 cases of lichenoid eruptions. About 82.6% of the cases were concordant histopathologically. The peak incidence was in 20–40 years of age with an equal predilection for males and females. A majority of the lesions were multiple, pruritic, papules, and plaques involving the limbs. Histopathologically, the most consistent findings were basal cell vacuolar degeneration followed by melanin incontinence. Conclusion: Lichenoid IFDs are exclusive clinicopathological entities with several variants. Subtle features noted on histopathology help in differentiating these lesions. Understanding and interpreting these subtle changes aids in better clinical management of the patient.
  8,858 1,345 -
SPECIAL ARTICLES
Emotional well-being, mental health awareness, and prevention of suicide: Covid-19 pandemic and digital psychiatry
Anil Kakunje, Rajesh Mithur, M Kishor
January-June 2020, 8(1):147-153
DOI:10.4103/amhs.amhs_98_20  
Emotional well-being is a state of positive mental health where the individual is able to handle his emotions and all life activities. He understands his emotions, learns, and copes with all the negative situations, achieves, and finds a positive emotional state which finally leads to success. Covid-19 is a disease caused by newly discovered novel corona virus. The outbreak came to light in December 2019 with the emergence of unexplained fever and pneumonia. In the next few months, the disease spread to various countries worldwide and turned into a pandemic. Governments around the world took drastic measures to control the pandemic and safeguard the citizens. Strict isolation, quarantine, and lockdowns were introduced. People were confined to their home for multiple days which led to intense mental stress. Day-to-day activities were disturbed, and people also suffered huge-economic losses. With the reduction in interpersonal contact and social activities, various psychological problems have emerged and suicides are being reported. Health-care personnel went through great stress and sleepless nights in taking care of the Covid-19 patients. In times of these stressful situations, the mental health awareness can play a crucial role. Simple behavior changes and mindfulness can make significant changes toward positive mental health. The maintenance of proper mental hygiene and regular support from mental health-care workers played a significant role in this regard. However, routine personal health care became less accessible to the general public during the pandemic. This has paved the way for the development of digital psychiatry. Thus, we bring out this review to provide an overview of the emotional well-being, mental health awareness of people during lockdown, prevention of suicide, and emergence of digital psychiatry during Covid-19 pandemic.
  7,362 364 1
Mental health perspectives of COVID-19 and the emerging role of digital mental health and telepsychiatry
Pragya Lodha, Avinash De Sousa
January-June 2020, 8(1):133-139
DOI:10.4103/amhs.amhs_82_20  
The 2019 coronavirus pandemic started in December and has now spread worldwide. This pandemic has huge mental health implications with immense psychological morbidity among the common man, patients with preexisting psychiatric diagnoses causing many relapses and exacerbations after it has ensued. Many guidelines have been put forward by various agencies to address the issue of combating mental health challenges that have arisen as a result of this pandemic. This review paper looks at the role of psychiatry and psychiatrists and the mental health challenges faced by us during this pandemic. The role of mental health interventions, the issues faced and the emerging role of telepsychiatry with its ethical and clinical dilemmas are discussed.
  1,884 203 -
SHORT COMMUNICATION
The impact of COVID-19 in diabetic patient
Antonio Vitiello, Francesco Ferrara
January-June 2020, 8(1):167-171
DOI:10.4103/amhs.amhs_117_20  
The global pandemic SARS-CoV-2 (COVID-19) is causing thousands of deaths worldwide and is one of the greatest health challenges ever faced in human history. SARS-CoV-2 infection can cause fatal lung injuries caused by a generalized inflammatory state associated with multi-organ dysfunction. In this context, it is essential to recognize the factors that increase the risk of viral infection. People with pre-existing conditions, such as diabetes, are at greater risk of complications and death caused by COVID-19. Old age, possible chronic drug therapies, kidney failure, hyperglycemia, and heart disease, are predictive factors of a bad outcome for the diabetic patient. The regulation of glycemia and the adoption of appropriate measures are critical aspects to be taken into consideration for the diabetic patient in this pandemic period, especially in the patient with ongoing infection. In the latter, the use of drugs used to fight COVID-19 infection, such as antivirals or immunomodulants, must be well controlled to avoid possible drug interactions and major complications. People with diabetes fall into the category of the fragile and at-risk population, and if a COVID-19 infection is also ongoing, the patient must be managed optimally, trying to fight the virus but also without neglecting homeostasis and glycemic control. This analysis highlights the current knowledge and challenges for the prevention and management of patients with diabetes and COVID-19 infection.
  1,288 151 -
MEDICAL EDUCATION
Honey-Mumford's learning styles of medical laboratory students: An observational study with implications for laboratory efficiency
Shakti Kumar Yadav, Rupinder Kalra, Roshina Naeem, Alekh Verma, Ruchika Gupta, Namrata Sarin, Sompal Singh
January-June 2020, 8(1):107-111
DOI:10.4103/amhs.amhs_43_20  
Background and Aim: Learning styles are subconscious stable traits influencing the perception and response of learners to their learning environment. Honey–Mumford classification of learning styles has been utilized and evaluated in a number of studies among students across different professional courses. Though learning style preferences of medical students have been assessed, we did not come across any study evaluating the paramedical students of Medical Laboratory Technology (MLT). Because laboratory technicians form the backbone of clinical laboratories in today's evidence-based medicine, it seems imperative to understand the basic learning styles of these students. Thus, this study aimed to identify the learning styles among students pursuing the bachelor degree of medical laboratory technology at a tertiary-level hospital. Materials and Methods: A cross-sectional observational study was undertaken among 98 students pursuing Bachelor of MLT at a tertiary-level hospital and medical college. The Honey–Mumford's learning style questionnaire was administered to each student after taking informed consent. Individual students' preference for learning style was categorized as per Mumford classification, and students were categorized according to their preferred learning style. Results: Majority of the students (60%) showed very strong preference for the activist learning style followed by reflector style. Prevalence of activist and reflector styles was found to be equal among our students followed by the theorist style. No difference was noted between male and female students. Conclusion: We demonstrated, for the first time, the learning styles of medical laboratory technology students or the future laboratory technicians. Activist and reflector styles were the most frequent among our study group. Future studies at other institutions providing similar training shall help in refining these results. Such studies are likely to help in adopting appropriate teaching methods and assessment strategies leading to better learning and consequent improvement in laboratory efficiency.
  1,061 161 -
CASE REPORTS
Carcinoma of breast with apocrine differentiation: A distinct entity with typical histomorphology and molecular signature
Pranita Mohanty, Debasmita Das, Anima Hota, Tulasi Govardhan
January-June 2020, 8(1):104-106
DOI:10.4103/amhs.amhs_64_20  
Apocrine Carcinoma (APC) is a rare and distinct entity among all the histological variants of invasive ductal carcinoma(IDC) of breast. It is common to encounter focal apocrine differentiation, but only 4% of IDCs show extensive apocrine differentiation. In the 2012 WHO classification of tumors of breast, it is placed under specialized subtypes of IDC and named “carcinomas with apocrine differentiation.” Apocrine differentiation is seen with IDC-no specific type (IDC-NST) as well as in special type carcinomas such as tubular, lobular, micropapillary, and medullary and that's why it does not represent as a separate entity. Although clinical, radiological, and gross appearance is indistinguishable from IDC-NST (the most common form), APC has a typical histomorphological picture with distinct molecular apocrine signature and immunohistochemistry. It is characterized by increased androgen expression overlapping with HER2/neu expression and estrogen receptor (ER) as well as progesterone receptor (PR) negativity. It is thought to have worse prognosis; hence, diagnosing this entity at the earliest is very important for implementation of new treatment modalities. Here, we report two such cases of carcinomas with apocrine features – 47-year-old and 52-year-old patients showing features of apocrine carcinoma and positivity for androgen receptor with negativity for ER and PR.
  837 79 -
REVIEW ARTICLES
Medicolegal challenges in the COVID era
George C Vilanilam, Praveen Kumar John
January-June 2020, 8(1):83-87
DOI:10.4103/amhs.amhs_109_20  
Unprecedented times created by the COVID-19 pandemic have challenged medicolegal limits to unimaginable levels. The traditional Hippocratic Oath, provision of medical care, informed consent, and research ethics have all been put to the immense test. Concepts on medical negligence, malpractice, and standards of care are all being redefined in this era, based on epidemiological concerns and priorities. Basic concepts in public health ethics, bioethics, human rights, and epidemiology need to be adapted and restructured to these times. Medical negligence laws would be viewed through the lens of the epidemic diseases act in COVID times. We examine the challenging scenarios wherein ethical, moral, and medicolegal rights have been stretched in these pandemic times. We also aim to examine the vulnerable clinical and research scenarios during pandemic times, with an intent to offer the most ethically, morally, and legally appropriate solutions.
  744 146 -
CASE REPORTS
Dyshormonongenetic goiter: A rare and important entity
Yasmin Altaf Momin, Sameer Ahmed A H. Ansari
January-June 2020, 8(1):88-90
DOI:10.4103/amhs.amhs_152_19  
Dyshormonogenetic goiter (DG) is the term given to the group of familial goiters owing to an inborn error of thyroid hormone metabolism. It is a benign, rare condition presenting architectural and cytological features that may lead to overdiagnosis of malignancy. Hence, in a patient with a history of hypothyroidism since infancy, a sense of apprehension is essential for a diagnosis of DG. We report a case of DG in a 12-year-old cretin girl.
  797 63 -
SPECIAL ARTICLES
Vitiligo with special emphasis on vitiligo surgery
PK Ashwini, DJ Sushmitha, S Veeranna
January-June 2020, 8(1):140-146
DOI:10.4103/amhs.amhs_50_20  
Vitiligo is a common form of localized depigmentation. It is an acquired hypomelanotic condition resulting from the progressive loss of melanocytes. It is characterized by milky white macules. It can be associated with tremendous psychological trauma. A number of medical treatment options exist in the armamentarium of a dermatologist treating vitiligo. However, a significant number of lesions of vitiligo either fail to respond to medical therapy or respond with incomplete repigmentation. Such lesions are considered appropriate for surgical management. Surgical management has provided a very good tool to the management of refractory cases of vitiligo. Hence, in this article, we emphasize on vitiligo and vitiligo surgery.
  703 103 -
ORIGINAL ARTICLES
The effect of strength training of the calf muscle pump on cardiovascular parameters
Andrew Lalchhuanawma, Divya Sanghi
January-June 2020, 8(1):26-30
DOI:10.4103/amhs.amhs_32_20  
Background: The heart pump allows blood to flow where the network of arteries, capillaries, and veins throughout the body regulates the rate of circulation of the blood. Parameters that determine the fitness level of the cardiovascular system include heart rate (HR), blood pressure (BP), VO2 max, fatigue, etc., The calf muscle pump is the most important of the lower limb, as it is the most efficient and has the largest capacitance. It has been suggested that increased leg strength, independent of cardiovascular training, may augment an aerobic endurance performance. Aim: The aim of this study is to determine the effect of strength training of gastrocnemius and soleus muscles on cardiovascular parameters. Materials and Methods: An experimental study carried out at MRIIRS Institution for 1 year. Forty-five recreational players aged between 20 and 30 years were selected after obtaining informed consent. Participants were divided equally into three groups by a convenient chit method. They were assessed for cardiovascular parameters of HR, BP, VO2 max, fatigue, and FI at baseline and after 8 weeks training program. Group A participated in gastrocnemius and soleus; Group B participated in gastrocnemius, and Group C participated in the soleus muscle training program. Results: Paired t-test for pre–post training shows a significant difference P < 0.05 for all the groups. ANOVA used between groups pre–post training were found to be significant for HR and systolic BP (SBP), and nonsignificant for diastolic BP (DBP) and VO2 max. Kruskal–Wallis test used between groups before and after training was found to be significant for fatigue and fitness index (FI). Jonckheere-trend test Post hoc analysis showed that Group A performed better than Group C and B. Wilcoxon signed-rank test for fatigue and FI showed a significant difference for all the groups. Conclusion: Eight weeks of leg muscle training on cardiovascular parameters have an effect on cardiovascular parameters of HR, SBP, FI, and fatigue. The results showed no significant effects on DBP and VO2 max.
  691 101 -
REVIEW ARTICLES
People, medicine, and society: An overview of chronic pain management
Hema Rajappa, Chris Hayes
January-June 2020, 8(1):68-74
DOI:10.4103/amhs.amhs_108_20  
Chronic pain, once termed a hidden epidemic, is gaining increasing visibility around the world. It places a huge burden on patients, their families, and the wider community, with profound adverse effects on function, well-being, and quality of life. It is also a socioeconomic problem, straining health-care systems globally. This article provides an overview of the changing landscape of chronic noncancer pain. The epidemiology, classification, pain-related neuroscience, problems with overemphasis on biomedical focus, and the importance of adopting a more holistic sociopsychobiomedical framework are discussed. The article concludes with a brief discussion on health-care delivery systems in the context of chronic pain.
  569 97 -
MEDICAL EDUCATION
Medical humanities in medical colleges in India: Travellators and speed breakers
Pathiyil Ravi Shankar
January-June 2020, 8(1):112-119
DOI:10.4103/amhs.amhs_70_20  
India has the largest number of allopathic medical colleges in the world. Recently, a competency-based undergraduate medical curriculum and an attitude, ethics, and communication skills module have been introduced. Medical humanities (MH) programs are becoming increasingly common globally. MH uses methods from the humanities and are interdisciplinary in nature. In this article, the author discusses different facilitating factors (travellators) and hindering factors (speed breakers) for the introduction of MH in medical colleges in India. Among the travellators are a large body of faculty members with interest and experience in medical education, a favorable attitude toward MH, strengthening of physical and information technology infrastructure in institutions, a diverse and talented student body, use of movies as a stepping stone to MH, many institutions obtaining deemed university status, a talented group of faculties, the positive effect of MH on student well-being, reduced stress and an atmosphere of spirituality, and a sense of purpose. Among the speed breakers are large student numbers, traditional architecture of medical colleges, lack of a separate department of medical education, being affiliated to external universities and challenges in modifying the assessment system, the language of MH sessions, and imbalance in medical education units. The article ends by providing the details for a MH module, a framework for student assessment during the module, and rubrics which can be used/adapted for student assessment and provides a scheme for assessment of the new module within the curriculum. This can be adapted by individual institutions to best suit their circumstances.
  588 68 -
REVIEW ARTICLES
Deliberate self-harm: A perspective
Sharol Lionel Fernandes, AT Safeekh, S Chandini, Siddharth Shetty
January-June 2020, 8(1):75-78
DOI:10.4103/amhs.amhs_154_19  
Recent years have seen an alarming increase in the incidence of deliberate self-harm (DSH). It has come to be a significant health issue and a pressing problem faced by clinicians in emergency settings as well as psychiatrists. However, it is often very difficult to ascertain the pathology underlying such behavior, thereby making it difficult to manage it. It significantly burdens an already ailing healthcare system as a large number of individuals try it at least once in their life, and a significant percentage of these are found to repeatedly engage in such behavior. A better understanding of DSH is essential for effective management of this behavior.
  525 77 -
ORIGINAL ARTICLES
Total antioxidant/oxidant status in chronic periodontitis patients with type II diabetes following nonsurgical periodontal therapy
Ruby Ramya Vincent, Devapriya Appukuttan, Aruna Balasundaram, Vanaja Krishna Naik, Dhayanand John Victor
January-June 2020, 8(1):41-46
DOI:10.4103/amhs.amhs_12_20  
Background: Diabetes and periodontitis are chronic inflammatory diseases characterized by a dysregulated inflammatory response involving oxidative stress (OS). Nonsurgical periodontal therapy (NSPT) eliminates bacterial load followed by reduction in inflammatory burden due to reduced levels of proinflammatory mediators. Aim: The study aimed to evaluate the effect of NSPT on the OS biomarkers in the gingival crevicular fluid (GCF) of generalized chronic periodontitis (GCP) patients with Type II diabetes mellitus (DM). Materials and Methods: Eighty participants were allotted into Group I, systemically healthy with GCP (n = 20); Group II, GCP with Type II DM (n = 20); Group III, Type II DM without chronic periodontitis (CP) (n = 20); and Group IV, periodontally and systemically healthy controls (n = 20). Plaque index, gingival index (GI), probing pocket depth (PPD), and clinical attachment loss (CAL) were recorded. GCF was evaluated for total antioxidant capacity (TAOC), total oxidant status (TOS), and OS index (OSI). Patients in group I and II received NSPT. Results: Groups I, II, and III at baseline demonstrated significantly lower GCF TAOC and higher TOS and OSI when compared to Group IV (P < 0.001). GI in Group I at baseline negatively correlated with TAOC, whereas PPD and OSI were positively correlated (P < 0.05). Following NSPT, significant improvements were observed in the clinical parameters and in the TAOC levels in both group I and II patients (P < 0.001). In diabetics with GCP following NSPT, it was observed that OSI positively correlated (r = 0.46, P < 0.05) with CAL. In group I and II patients, TOS and OSI reduced significantly from baseline (P < 0.001). Conclusions: Based on the study results, we infer that NSPT can positively modulate the levels of OS biomarkers by restoring the oxidative imbalance. Further, the study underscores the role of periodontal therapy in decreasing oxidative burden in diabetics with periodontal disease.
  472 82 -
MEDICAL EDUCATION
Reimagining medical education: Part three – Necessity, change, and innovation in uncertain times
Elizabeth M Wooster, Jerry M Maniate
January-June 2020, 8(1):120-124
DOI:10.4103/amhs.amhs_124_20  
Change has been the keyword to describe the dramatic and rapid impact that the COVID-19 pandemic of 2020 has had on the medical education system worldwide. As a result, there has been a clear necessity for learners, faculty/teachers, leaders, health-care organizations, and academic institutions to “react,” “pivot,” and “reimagine” the system to address the numerous challenges that we have had not only to face in the short term but also to ensure that functions and processes are ready to be reinitiated to move ahead. The rapidly evolving circumstances of the pandemic have caused considerable uncertainty about almost everything, and as such, it has been difficult to anticipate what the future will be like, let alone the intermediate term. The environment of change and uncertainty has created the opportunity for many to be creative and innovative as they strive to support learners, faculty/teachers, health-care organizations, and academic institutions within the ever-changing reality we have found ourselves within.
  452 83 -
ORIGINAL ARTICLES
Morphometric variations in sigmoid notch and condyle of the mandible: A retrospective forensic digital analysis in North Indian population
Varsha Kanjani, Prashant Kalyani, Neha Patwa, Vaibhav Sharma
January-June 2020, 8(1):31-34
DOI:10.4103/amhs.amhs_37_20  
Introduction: The peculiarity of anatomical structures such as mandible, frontal sinus, sella turcica, nasal septum, and styloid process present in human skull and their variations leads to the revolution in forensic anthropology. The digitization in radiology enables a health professional to store the previous antemortem records and thereby compare it with postmortem records in case of mass disasters. Aim: The present retrospective analysis was conducted to evaluate the morphological variations in the sigmoid notch and condyles of the mandible and also to determine its peculiarity in establishing individual's identity. Materials and Methods: The study included 1200 panoramic radiographs of individuals in the age range of 10–60 years among population of Jodhpur, Rajasthan. The radiographs were taken using PLANMECA machine and enrolled radiographs were outlined using tracing tool installed in the software. The morphological variations of sigmoid notch and condyle in the panoramic radiographs were analyzed bilaterally for both males and females using Statistical Package for the Social Sciences (SPSS) software version 21.0. Results: The sloping shape of the sigmoid notch was most commonly found (43%), followed by wide (37.66%) and round shape (19.25%). The most common shape of condyle observed was round (46.12%), followed by angled (29.29%), convex (21.95%), and flat shape (2.62%). The distribution of sigmoid notch and condylar shape variations among right and left sides was not statistically significant. Conclusion: In forensic anthropology, the morphological variations among sigmoid notch and condyle of mandible using single panoramic radiographic view can be used as an adjuvant for personal identification.
  428 78 -
Application of queuing analysis for optimized utilization of laboratory staff: An observational study
Alekh Verma, Shakti Kumar Yadav, Aastha Narula, Amul K Butti, Namrata Sarin, Ruchika Gupta, Sompal Singh
January-June 2020, 8(1):53-56
DOI:10.4103/amhs.amhs_44_20  
Background and Aim: Queuing theory, a discipline of operation management, has seen great utility in various service industries. Application of queuing analysis (QA) in healthcare has been largely limited to emergency room, pharmacy, and patient appointment system. Utility of QA in the hospital laboratory has not been evaluated in detail so far. This study aimed at evaluating the application of QA at a report dispatch counter in the pathology department of our tertiary-level hospital. Materials and Methods: In a cross-sectional observational study, patient arrival at the report dispatch counter in the department of pathology was noted for 5 consecutive days while service rate at the same counter was observed for 4 days. QA was performed using Poisson distribution function for patient arrival and exponential distribution function for service rate. The expected waiting time in queue as well as number of patients waiting in the queue was calculated. Results: The average arrival rate (λ) was 6.94 and service rate (μ) was 8.34 patients, both for 5-min interval periods. QA yielded the average waiting time in queue as 3.05 min. The expected number of patients in queue was estimated to be 4.26, implying that, on an average, four patients would be waiting in the queue to receive their report apart from the one being served at the a given time. Conclusion: QA can be efficiently applied to various areas of the hospital laboratory including report dispatch point. This is an extremely helpful tool to assist in staffing policy and assessing patient satisfaction at any patient contact point in the laboratory.
  421 71 -
Arbitrarily primed polymerase chain reaction-based identification of dystrophic onychomycosis
Sandeep Kaur, Anu Gupta, Prabhjot Kaur Gill
January-June 2020, 8(1):47-52
DOI:10.4103/amhs.amhs_31_20  
Background and Objective: Onychomycosis is a fungal infection of the nails; when caused by dermatophytes, it is called as Tinea unguium. The aim was to explicate the utility of arbitrarily primed polymerase chain reaction (AP-PCR) to augment the early and accurate clinical diagnosis of dystrophic onychomycosis. Materials and Methods: The collected nail samples were divided into three portions. The first portion was explored for direct microscopic examination, the second portion was used for culturing of the nail samples on sabouraud dextrose agar media, and the third portion was used for DNA extraction followed by AP-PCR identification of dermatophytes. Results: All 48 samples with dystrophic onychomycosis were diagnosed by three methods, namely, 20% Potassium hydroxide microscopy, culture growth, and AP-PCR. With all the methods, Trichophyton rubrum was found as major causative agents for dermatophyte nail infection (60%), followed by Trichophyton mentagrophytes (23% cases). AP-PCR is a convenient method to achieve a higher dermatophyte identification rate with lesser time and shows complete concordance with conventional culture for two Trichophyton species. Conclusion: AP-PCR is a rapid, specific, and sensitive procedure for the diagnosis of nail fungal infection.
  419 71 -
Fibrin clot adhesion to instrumented conditioned root surfaces by MTAD and normal saline: A scanning electron microscopy study
Gaurav Didhra, Sachin Upadhyay, Aseem Sharma, Heema Sambyal
January-June 2020, 8(1):57-61
DOI:10.4103/amhs.amhs_149_19  
Background and Aim: Smear layer removal and formation of a stable bond between the blood clot and root surface are desirable for periodontal healing, which can be achieved by root biomodifiers. The objective of this in-vitro study was to evaluate the root surface changes in terms of fibrin clot adhesion subsequent to the application of MTAD (mixture of doxycycline (a tetracycline isomer), citric acid, and polysorbate-80 (a detergent) and normal saline. Materials and Methods: Twenty human single-rooted teeth were collected and grouped into Saline (Group I) and MTAD Biopure (Group II) treatment groups containing 10 teeth in each group. After root conditioning, fresh human blood was applied to each root specimen and was allowed to clot, and subsequently, samples were dehydrated in a graded series of ethanol and visualized under scanning electron microscope. Results: The highest blood clot attachment score was observed with roots treated with MTAD and the least results were observed with control group saline. Conclusion: Specimens treated with MTAD best supported the fibrin clot attachment. Saline was least effective of all the samples, showing the presence of the smear layer.
  395 72 -
MEDICAL EDUCATION
Using entertainment media to teach undergraduate psychiatry: Perspectives on the need and models of innovation
Suhas Chandran, Priya Sreedaran, Johnson Pradeep, SM Manohari, Pooja Patnaik Kuppili, M Kishor
January-June 2020, 8(1):125-132
DOI:10.4103/amhs.amhs_57_20  
Background and Objective: Medical education is undergoing a seminal change with respect to curriculum as well as teaching methods, with students in tune with the current developments in the technology and seeking newer techniques to learn medicine. The rapid pace of progression of medical science, and the breadth and depth of material to be learned, warrants formulation of techniques light on time and learning intensive. In this article, we explore such potential ideas and the principles behind using them for undergraduate (UG) education, with concepts about how they can be integrated into the current UG curriculum. Materials and Methods: Electronic searches of databases PubMed and Google Scholar were carried out to identify and include English language articles from inception till December 2019, and 36 relevant articles were selected for review. Results: The observational/passive methods included music, movies, television shows, radio, and podcasts, whereas the active methods included role play, simulated class press conferences, courtrooms, art, designing posters and pamphlets, games and gamification, Pictionary, tabletop games, and also creative writing – short stories and poetry. Conclusion: A student-centered approach rather than an exclusive technology-based approach would be ideal, and these unconventional and innovative methods provide opportunity to apply, analyze, synthesize, and evaluate information rather a process of passive listening.
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CASE REPORTS
An uncommon clinical presentation of SLE
VG Nayana, S Sai Manohar, K Rahul, KS Gangadhara Somayaji, Prema Saldanha
January-June 2020, 8(1):100-103
DOI:10.4103/amhs.amhs_89_20  
Cervical lymphadenopathy is a clinical feature of vast spectrum of diseases. It includes infections, malignancy, lymphoma, and connective tissue diseases. All cases need to be evaluated in detail with proper laboratory investigations and a tissue cytology/biopsy to unmask the etiology. Here, we present a young woman who was admitted for multiple painful neck swellings associated with fever for 3 months. She was primarily investigated to rule out infectious causes. The patient was evaluated in detail including blood investigations and biopsy and finally turned out to be systemic lupus erythematosus (SLE)-associated lymphadenopathy. This case shows that painful neck nodes can be a presenting feature of SLE and needs to be considered as one of the differential diagnosis in patients presenting with lymphadenopathy along with constitutional symptoms.
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REVIEW ARTICLES
Can a new nitroimidazole knockout the unconquered tuberculosis?
Dhyuti Gupta, Ajaya Kumar Sahoo, Alok Singh
January-June 2020, 8(1):79-82
DOI:10.4103/amhs.amhs_33_20  
Pretomanid (PA-824) is the latest drug to get approval from the United States Food and Drug Administration (FDA) for the treatment of tuberculosis (TB). The present article aims to review the efficacy, safety, and tolerability of pretomanid in the management of drug-resistant TB for which a PubMed search (from the year 2007 to 2019) was conducted using the keywords: TB, multidrug-resistant TB, extensively drug-resistant TB, pretomanid, and newly approved drugs by FDA and PA-824. We included English language articles related to efficacy, safety, and tolerability of pretomanid in drug-resistant TB. Pretomanid is active against both the actively multiplying and latent Mycobacterium tuberculosis bacilli. In nonmultiplying bacterial cell, it causes nitric oxide-mediated nonspecific cellular damages, and in dividing bacteria, it acts by blocking the mycolic acid synthesis, thus resulting in inhibition of cell wall production. Pretomanid has been approved recently for managing such cases, in combination with bedaquiline and linezolid. Current data demonstrate its efficacy, safety, and tolerability with improved outcomes. The advantages of this combination observed could prove beneficial in developing countries, where there is not only a high burden of drug-sensitive TB cases but also the incidence of drug-resistant cases are on the rise.
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CASE REPORTS
A child with erythroderma and hair defects
Spandana Prakash Hegde, Manjunath Mala Shenoy, Malcolm Pinto, Amina Asfiya
January-June 2020, 8(1):93-95
DOI:10.4103/amhs.amhs_38_20  
Erythroderma in the early years of life can have a wide array of differential diagnosis. We present a case of infantile erythroderma who presented to us at the age of 3 years with characteristic manifestations of ichthyosis linearis circumflexa and trichorrhexis invaginata, thus helping us arrive at a diagnosis of Netherton syndrome without the aid of expensive genetic analysis. This case is presented for its rarity and to highlight the importance of clinical examination of the appendages which may be an important clue to the diagnosis.
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REVIEW ARTICLES
Endoscopic ultrasound sampling: From cells to tissue
Suresh Vasan Venkatachalapathy, Guruprasad P Aithal
January-June 2020, 8(1):62-67
DOI:10.4103/amhs.amhs_21_20  
Extraluminal gastrointestinal (GI) tracts were often difficult to diagnose before the introduction of endoscopic ultrasound (EUS). Surgical procedure or computer tomographic-guided approach was needed to obtain tissue which was either invasive or lacked sensitivity and specificity. EUS-guided tissue acquisition has revolutionized tissue acquisition for upper extraluminal GI lesions. This is because EUS is minimally invasive compared to either surgery or percutaneous approach, close proximity to upper GI extraluminal GI lesions, and tissue acquisition under direct real-time sonographic guidance. Hence, it has become the first-line investigation for tissue acquisition. In the past decade, there have been significant improvements in tissue acquisition through EUS-guided approach. In this article, we have reviewed the key factors that improve tissue acquisition through EUS-guided approach.
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MEDICAL HISTORY
Chronicles of rhinoplasty
Harsh Suri, Gangadhara Somayaji
January-June 2020, 8(1):154-158
DOI:10.4103/amhs.amhs_90_20  
The surgical reconstruction of nose also termed 'Rhinoplasty' is as old as human civilisation. While major contribution of total nasal reconstruction originated in India by Sushrutha in around 600 B.C and later paved its way to the modern facial plastic surgery in North America and Europe in 18th century and popularised the Indian methods of nasal reconstruction to develop cosmetic and corrective rhinoplasty. This article aims to take you through the journey of evolution of rhinoplasty.
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ORIGINAL ARTICLES
Expression of human epidermal growth factor receptor 2/neu in breast carcinoma: Experience from a tertiary care center in Tamil Nadu, India
Syed Ahmed Hussain, S Prakashiny, Naseem Noorunnisa, R Revathi Shree, Senthil N Ganesh
January-June 2020, 8(1):35-40
DOI:10.4103/amhs.amhs_42_20  
Background and Aim: Women diagnosed with the foremost common cancer are the breast carcinoma. Human epidermal growth factor receptor 2 (HER2)/neu status has become an important part of immunohistochemical evaluation of breast carcinoma. Hence, the main aim of our study was to correlate the HER2/neu expression in breast carcinoma patients with certain clinicopathological parameters to ensure the better prognosis of the disease. Materials and Methods: The present study included 56 breast carcinoma patients. The surgically dissected breast carcinoma specimens were subjected to immunohistochemistry staining and were evaluated for certain clinicopathological prognostic parameters that included tumor size, Nottingham modification of the Scarff Bloom-Richardson (NSBR) grading, necrosis, lymph vascular invasion, fibrosis, stromal reaction, and lymph node metastasis. Statistical analysis by the Chi-square and Student's t-test was performed. Results: Most patients belonged to the postmenopausal age group (62.5%). Only 19 (33.9%) out of 56 patients showed positive for HER2/neu expression with maximum HER2/neu expression noted in the 40–60 years' (44.83%) age group. A greater proportion of cases (66.07%) had tumor size ranging from 2 to 5 cm with a majority of HER2/neu-positive (40.5%) cases among them. Majority of patients (96.24%) were of infiltrating ductal carcinoma. With respect to NSBR grading, 50% patients in Grade 3 showed positive HER2/neu expression (P = 0.048). It was also observed that 17 patients showed positive HER2/neu expression at the varying stages of lymph node metastasis (P = 0.022). Conclusion: The evaluation of HER2/neu expression indicates it to be a stronger prediction of poor prognosis due to its association with prognostic parameters.
  357 65 -
CASE REPORTS
Heterotopic pregnancy: A rare entity
Ananya Das, Subrat Panda, Surajit Ray Baruah, Donbok Lynser, Evarisalin Marbaniang
January-June 2020, 8(1):91-92
DOI:10.4103/amhs.amhs_134_19  
Heterotopic gestation is a very rare entity in natural conception, occurring in only 1 in 30,000 spontaneous pregnancies. A high index of suspicion is necessary for the timely diagnosis and appropriate intervention. We report the case of heterotopic pregnancy in a 32-year-old female presented with hemoperitoneum from ruptured tubal pregnancy with live intrauterine gestation at 6 weeks' period of gestation, diagnosed on ultrasound examination.
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Compressive myelopathy – An unusual presentation of extramedullary hematopoiesis in a known patient of thalassemia major
Rajesh Nair, Debish Anand, Girish Menon, KV Kiran Acharya, B Ananthakrishna Shastri
January-June 2020, 8(1):96-99
DOI:10.4103/amhs.amhs_97_20  
Thalassemia presenting with compressive myelopathy secondary to extramedullary hematopoiesis (EMH) is rare. We report the rare case of spinal EMH with dorsal cord compression and myelopathy in a 28-year-old male with inadequately transfused beta thalassemia major who presented with paraparesis and acute sphincter disturbance.
  358 58 -
TEACHING IMAGES
Cerebrotendinous xanthomatosis: Clinical and neuroimaging findings
S Sheetal, P Byju
January-June 2020, 8(1):161-162
DOI:10.4103/amhs.amhs_169_19  
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disorder of effective bile acid biosynthesis (adult lipid storage disorder with the underlying mutation in the CYP27 gene, which encodes sterol 27-hydroxylase, a key enzyme in the conversion of cholesterol to the primary bile acids cholic and chenodeoxycholic acid). Hereby, we report the case of a 39-year-old male who presented with progressive walking difficulty, ataxia, and cognitive decline since childhood, who had cataract and tendon xanthomas on examination. Magnetic resonance imaging of the brain showed typical bilateral and symmetrical involvement of the dentate nuclei, characteristic of CTX.
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LETTERS TO THE EDITOR
Response to letter to the editor
Prakas Humar Mandal
January-June 2020, 8(1):166-166
DOI:10.4103/2321-4848.287340  
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TEACHING IMAGES
Hemihydrencephaly in adult
Suhail Rafiq, Musaib Ahmad Dar
January-June 2020, 8(1):163-164
DOI:10.4103/amhs.amhs_49_20  
  249 49 -
LETTERS TO THE EDITOR
Does thyroid dysfunction correlates with iron overload in Eβ thalassemia patients? A study from a tertiary care thalassemia center in India
Mahmood Dhahir Al-Mendalawi
January-June 2020, 8(1):165-165
DOI:10.4103/amhs.amhs_1_20  
  241 54 -
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