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   Table of Contents - Current issue
Coverpage
January-June 2019
Volume 5 | Issue 1
Page Nos. 1-74

Online since Wednesday, June 19, 2019

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EDITORIAL  

Competency-based medical education in India: Are we ready? Highly accessed article p. 1
Aneesh Basheer
DOI:10.4103/jcrsm.jcrsm_18_19  
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REVIEW ARTICLES Top

Analyzing Indian mental health systems: Reflecting, learning, and working towards a better future p. 4
Preetam B Mahajan, Prahan Kumar Rajendran, Bhuvaneswary Sunderamurthy, Sumedha Keshavan, Joy Bazroy
DOI:10.4103/jcrsm.jcrsm_21_19-  
Mental health has been long neglected. Even though it causes substantial loss of disability-adjusted life years, it does not receive proportionate funding. India spends <2% of its annual health budget on mental health. India has been witnessing a great push for mental health. A number of policy-level reforms have been undertaken, and efforts are on to tackle this issue in a better way. In this study, we have reviewed various factors contributing towards policy, implementation, and utilization gaps based on published studies and Mental Health Survey reports and suggested ways to address these. Bottleneck analysis reveals that interventions to improve mental health scenario extend beyond the ambit of the National Mental Health Policy and requires strong policy negotiations and reforms to resuscitate the dying public health-care system of India.
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Tuberculous meningitis: A narrative review p. 13
Pulikottil Wilson Vinny, Venugopalan Y Vishnu
DOI:10.4103/jcrsm.jcrsm_17_19  
Tuberculous meningitis (TBM) is a medical emergency. It is the most devastating manifestation of tuberculosis (TB). The outcome depends on early diagnosis and appropriate treatment. Empirical antituberculous therapy should be started if clinical suspicion is high. All patients should be tested for HIV. The choice of antituberculous drugs is extrapolated from pulmonary TB regimen, and many drugs have poor cerebrospinal fluid penetration. More evidence is required to guide on drug therapy in TBM. Steroids should be used as adjunctive therapy and response may be modulated by host genotype. Active monitoring should be done for complications such as hydrocephalus, hyponatremia, and stroke.
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ORIGINAL ARTICLES Top

Iron deficiency anemia among preschool children belonging to affluent families in Kerala, India p. 23
Jijo Joseph John, Girija Mohan, K Ajitha, Alice David
DOI:10.4103/jcrsm.jcrsm_41_18  
Context: Anemia leads to impaired cognitive function, growth, and psychomotor development. Zeroing in on a specific socioeconomic or demographic group and a specific type of anemia, may help in better planning of resources in our battle against anemia. Aims: The aim of this study is to determine the prevalence, severity, risk factors (age, gender, and nutrition status) of iron deficiency anemia (IDA) in apparently healthy preschool children (6–59 months) belonging to affluent families. Settings and Design: A cross-sectional study conducted in a private teaching hospital. Subjects and Methods: A total of 160 children aged 6–59 months, belonging to the upper middle class, who came to the pediatric outpatient department for routine visits over a period of 1 year were evaluated. Sociodemographic data with hemoglobin, red cell indices and iron studies of blood samples were estimated. Statistical Analysis Used: Continuous data were described as mean and standard deviation. Odds ratio with 95% confidence interval was calculated using multiple logistics regression. Results: Among the 160 children evaluated, 48 (30%) were anemic, of which 41 (85.4%) had IDA. Equal proportion (P = 0.84) of boys (25.0%) and girls (26.4%) and equal proportion (P = 0.75) of well-nourished (26.2%) and moderately nourished (23.3%) had IDA. A higher proportion (P < 0.0001) of children below the age of two (40.7%) had IDA. Children below the age of 2 years were more likely to have IDA (Odds ratio [OR]: 5.8 95% confidence interval [CI] 2.5–13.8) irrespective of gender and nutrition. Conclusions: A high prevalence among apparently healthy children from affluent families is an indicator that the general population rates will be even higher. This study highlights the need to plan further intervention trials with either iron-rich or iron-fortified foods or iron supplementation, especially among children below the age of 2.
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Significance of endometrial thickness on transvaginal sonography in heavy menstrual bleeding p. 28
Meenakshi Singh, Rekha Sachan, Amrita Yadav
DOI:10.4103/jcrsm.jcrsm_43_18  
Background: Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss which interferes with a woman's physical, social, emotional, and/or material quality of life. This is the most distressing complication in perimenopausal women which affects the quality of life. Aims: This study aimed to evaluate endometrial thickness (ET) by ultrasound and histopathological examination and their correlation with HMB in perimenopausal women. Materials and Methods: This retrospective analysis was carried out over 1 year. A total of 120 women of 40–55 years' age group who presented with abnormal bleeding pattern were included in the study. These women underwent clinical examination, investigations and ultrasound examination followed by endometrial biopsy. Results: Majority of the women (47.5%) had menstrual disturbance in the age group of 40–45 years followed by 45.8% of women in the age group of 46–50 years. Menorrhagia was the most common complaint found in 65 (54.2%) women, 10 (8.3%) women suffered from metrorrhagia, 18 (15%) had polymenorrhea, and 22 (18.3%) women had amenorrhea followed by heavy bleeding. Proliferative endometrium was found in 90 (75%), secretory endometrium in 8 (6.7%) and simple hyperplasia without atypia in 3 (2.5%) of the women in the study population. Simple hyperplasia with atypia was observed in 2 women (1.7%), 3 women (2.5%) had complex hyperplasia without atypia, and 1 woman (0.83%) had complex hyperplasia with atypia. Endometritis was present in 5 (4.2%) cases and atrophic endometrium was found in 3 (2.5%)cases and atrophic endometrium was found in 2.5% (3). No endometrial biopsy specimen was suggestive of endometrial carcinoma. Simple hyperplasia with atypia was detected when ET was 11–15 mm and 16–20 mm. Complex hyperplasia without atypia was detected with ET >16–20 mm and >20 mm. Only one case had complex hyperplasia with atypia where ET was >20 mm. No abnormal endometrial pathology was detected when ET was below 11 mm. Conclusions: Increased ET on transvaginal ultrasound had association with abnormal endometrial tissue histopathology in women with HMB.
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Awareness regarding Nipah infection among health-care workers in a Medical College Hospital in Kerala p. 33
Aby Dany Varghese, Geethu Mathew, Sruthy C S. Kumar, Anoop Ivan Benjamin
DOI:10.4103/jcrsm.jcrsm_45_18  
Background: Nipah is a highly infectious viral zoonotic disease with documented human-to-human transmission and high case fatality rate. An outbreak of Nipah infection occurred in Kerala in May 2018. Considering that this is the first encounter for health professionals dealing with Nipah outbreak in this part of India, awareness intensification among health-care workers is of paramount importance. Objectives: The objective of this study is to find out the awareness regarding Nipah infection among health-care workers at a medical college hospital in Kerala and also to find out the factors associated with level of awareness. Methodology: The present cross-sectional study was conducted at a medical college hospital of Kerala during the period from June 2018 to August 2018. All health-care workers from different categories who were working for a period of >1 month in the medical college were included in the study. The study tool included a structured questionnaire which collected information regarding sociodemographic details, awareness regarding causes, modes of transmission, clinical features, diagnostic investigations, and preventive measures of Nipah. A scoring pattern was developed and any respondent scoring <50% was considered as poor and ≥50% as having good awareness. After taking the written informed consent from the participants, data were collected. Results: In this study, 204 health-care workers were enrolled. The mean age of the participants was 30.01 ± 6.7 years. Majority of the participants were nurses followed by the laboratory staff and doctors. Nearly 41% of the study population had a working experience of ≥5 years. Among the staff, 65.7% was found to have good and 34.3% had poor awareness regarding Nipah infection. The highest level of awareness was observed in Category 3 (investigations) and poorest in Category 4 (prevention). Higher age, work experience, and male gender were the factors associated with better awareness about Nipah. The highest level of awareness was observed among doctors (89.2%) followed by laboratory staff (83.3%) and nurses (61%). Conclusion and Recommendations: The overall awareness about Nipah infection among health-care staff was found to be satisfactory, with 65.7% of them having good awareness even during the initial days of the outbreak. Since it was the first outbreak in Kerala, there were some deficiencies in the knowledge of all categories of the health-care staff. Primary prevention approach aimed at spreading adequate awareness and refreshing knowledge among all health-care staff, including nonmedical staff should be practiced, and thereby they can serve as educators of the community at large.
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Variation in common serum lipid parameters in patients with malaria: A 1-year cross-sectional study p. 39
Prakash Babaliche, Pradeep Gubba
DOI:10.4103/jcrsm.jcrsm_1_19  
Background: Variations in serum lipid parameters are commonly and ubiquitously reported in patients with malaria. Different host cell lipid-dependent processes have been observed in the life cycle of the malarial parasite Plasmodium. Aim: The present study was undertaken to assess the serum lipid profile in patients with malaria. Materials and Methods: This 1-year cross-sectional study was conducted from January 2013 to December 2013 at the Department of Medicine. A total of 50 adult patients with positive-smear and quantitative buffy coat test for malaria, as well as with clinical features of malarial infection, were investigated for serum lipid profile changes. Patients on lipid-lowering drugs were excluded from the study. Fasting lipid profile estimation was performed using fully-automated Siemens Dimension Clinical Chemistry System for total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides. Data were analyzed using the independent sample t-test and one-way ANOVA. Results: Majority (86%) of the patients were positive for Plasmodium vivax. Thrombocytopenia was observed in 64% of the patients. Serum lipid profile estimation in these patients revealed that 60% of the patients had low total cholesterol levels (100–150 mg/dL), 56% of patients had low-LDL levels (<50 mg/dL), and 58% of patients had low-HDL levels (<20 mg/dL). However, 92% of the patients had hypertriglyceridemia (>150 mg/dL). Interestingly, patients with low-LDL cholesterol level had low-platelet count (51.25 ± 29.67;P = 0.035). Conclusion: Patients with malaria infections may have lipid parameters alteration in terms of hypocholesterolemia, low-HDL and -LDL levels, and hypertriglyceridemia.
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Split-rib graft cranioplasty: Our experience and tips to achieve optimum results p. 44
Pradeep Goil, Amit Sharma, Sharad Kumar, Ayush Jain
DOI:10.4103/jcrsm.jcrsm_44_18  
Background: Calvarial defect reconstruction can be performed using a wide range of materials which can be divided into autologous and alloplastic options each with their own advantages and disadvantages. Limiting factors of available options include the risk of infection, absorption, cost, and damage to adjacent tissue. Here, we present our experience of calvarial reconstruction using autologous split-rib graft along with technical details of the surgical procedure. Materials and Methods: Our retrospective study included 22 patients over 6 years. All the patients were operated by the same team, and records were maintained. Patients were followed up for at least 2 years. Results: Results achieved were found to be excellent with no major postoperative complications. Patient satisfaction was motivating, and contour of the cranium was acceptable. There was negligible residual or recurrent deformity in our 2-year follow-up. Conclusions: Calvarial reconstruction with autologous bone graft is superior compared to alloplastic materials. Reconstruction with the rib graft gives optimum results which can be used in most clinical scenarios, including pediatric patients.
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Teaching morphologic features of biopsy slides using projection microscope versus the conventional method of teaching: A comparative study p. 51
Vijayanand Choudhary, Sangeeta Pankaj
DOI:10.4103/jcrsm.jcrsm_46_18  
Introduction: Since time immemorial man has tried to improve upon teaching methods so that students can become more proficient. Biopsy slides of pathology have been difficult for medical students to understand and comprehend since a long time. The introduction of projection microscope for teaching biopsy slides would go a long way in simplifying the whole process. Methodology: The authors compared the two teaching methods for identifying pathologic lesion in biopsy slides. Ninety nine fourth semester undergraduate students were divided into two groups with group A having fifty students and group B having forty nine students. The period of our study of four months was divided into two, two month period. In the first two months group B was made the test group and taught biopsy slides using projection microscope and group A was made control group and was taught by conventional method (atlas, chalk and board). To avoid any form of bias, in the second two months their roles were reversed so that group A was made the test group and group B was made the control group. Result: After each two month OSPE was held and marks recorded. At the end of four month period a survey was taken from students and faculty in a feedback form based on Likert scale. In this survey it was found that ninety percent (90%) of the students and faculty were of the view that visual aided method of teaching was superior to conventional method of teaching biopsy slides. In the OSPE the group which underwent visual method of teaching scored higher than the group which underwent conventional method of teaching even after swapping of their roles after two months. Discussion: Teaching tools using two or more senses is superior to teaching with one sense only. This is specially true while using visual and auditory method of teaching which accounts for 88% of our learning. Here we have made good use of visual aid in form of projection microscope to teach and explain the morphologic features of pathologic lesion in a biopsy slide.
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Retrospective study of sociodemographic profile of suicidal cases by hanging in a tertiary care hospital at Puducherry p. 55
Sunil Subramanyam, Joshima Janardhanan, R Sanjana, R Keerthi, R Monish Kumar, V Salvia Vicuna, Anten P Jairish
DOI:10.4103/jcrsm.jcrsm_9_19  
Introduction: Hanging is one of the most common methods of committing suicide worldwide as it is believed to cause instant relatively painless death. Objectives: The objective of this study is to analyze the sociodemographic profile, ligature material used, and place of incidence among the victims who committed suicide by hanging. Materials and Methods: The data required for the study were collected and analyzed from all cases of hanging autopsied at a tertiary care center. Results: It was found that most of the victims belonged to younger and middle age groups. Most cases were males, and majority of the victims opted an indoor location to commit suicide. Ligature materials used in majority of the cases were either synthetic or jute rope. Most of the victims were either unemployed or had worked in harsh conditions which depict their socioeconomic status. Conclusion: Analyzing the various sociodemographic features of suicide victims is the initial step in formulating effective preventive efforts from a sociological perspective.
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CASE REPORTS Top

Trench mouth: Is it a disease of the past? Diagnostic clincher: The underrated “urgent smear” p. 59
Jaise Jacob, Nishant Savery, Kurien Thomas, Sujitha Elan, Reba Kanungo, Mary Kurien
DOI:10.4103/jcrsm.jcrsm_39_18  
Vincent's infection is a progressive painful infection with ulceration, swelling, and sloughing of the dead tissue from the oral cavity and oropharynx caused by the fusiform bacillus (Fusobacterium fusiforme) and spirochetes (Borrelia vincentii). However, it is rare in the vocal cords. We present a case of Vincent's angina of the larynx in an otherwise immunocompetent patient. This case report is to highlight clinician's diagnostic challenge, the need for crucial interdisciplinary interaction with microbiologist, and the significance of “urgent smear” (which is most often overlooked) for timely curative patient care.
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Unilateral and isolated absence of opponens pollicis and adductor pollicis: Could it be Cavanagh's syndrome? p. 62
NA Priyadharshini, V Dinesh Kumar, R Rajprasath
DOI:10.4103/jcrsm.jcrsm_48_18  
Functions of the human hand such as grasping and releasing require synchronous action of thenar muscles and thereby require considerable mechanical complexity. Isolated absence of thenar muscles is often reported in association with syndromes such as Cavanagh's syndrome or Holt–Oram syndrome (in addition to cardiac defects). During routine anatomical dissection of an approximately 55-year-old male formalin-embalmed cadaver, we observed a unique variation in the left palm where opponens pollicis and adductor pollicis muscle were completely devoid of muscle fibers and solely constituted by fibrous tissue. We could not make out any other nervous/vascular/musculoskeletal abnormalities or signs of surgical procedures on the left superior extremity. We followed a step-wise approach rule out possible clinical syndromes and etiologies. The presumable hypothesis would be focal deficiency in the proliferation of premyogenic cells in the limb bud. This rare variation would be of paramount importance to plastic surgeons who can offer surgical correction (tendon transfers) if presented at earlier ages.
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Shredded carrots in the larynx: A rare case of neurofibroma of vocal cord p. 65
Feba Ann Sunny, J Jishana, Paresh Pramod Naik, Mary Kurien
DOI:10.4103/jcrsm.jcrsm_37_18  
Neurofibromatosis (NF) is a common disorder resulting in tumors on nerve tissue. It rarely affects the larynx and even rarer is an isolated laryngeal neurofibroma. Literature reveals <30 cases of laryngeal NF since its first description in 1950, and vocal cord manifestations without systemic features of NF are still rarer. Most of the cases were in children or associated with NF-1. Here, we present the case of a middle-aged gentleman with isolated neurofibroma of the vocal cord.
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Successful use of regional anesthesia in an elderly with Parkinson's disease p. 68
Ramyavel Thangavelu
DOI:10.4103/jcrsm.jcrsm_10_19  
Parkinson's disease (PD) is a relatively common neurological disorder which an anesthesiologist often encounters, especially with an increasing elderly surgical population. PD is associated with certain physiological aberrancies in the cardiovascular, respiratory, autonomic, and neurological systems that can have profound anesthetic implications. Drugs used in anesthesia may also interact with antiparkinsonian medications. There is controversy about the optimal anesthetic management of patients with PD. However, both general and regional anesthesia have been successfully used and described in these patients. We describe a case of a 65-year-old male with recently diagnosed PD posted for rectopexy. The patient underwent regional anesthesia successfully, and the perioperative period was uneventful. Hence, anesthetic management of patients with PD involves comprehensive evaluation, careful consideration, and meticulous planning to prevent and manage the complications that arise perioperatively.
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LETTERS TO EDITOR Top

Revisiting the underemphasized advantages of apprenticeship in light of competency-based medical education p. 71
V Dinesh Kumar
DOI:10.4103/jcrsm.jcrsm_13_19  
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Responding to the challenge of neglected tropical diseases to attain universal health coverage p. 73
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/jcrsm.jcrsm_38_18  
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