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   Table of Contents - Current issue
Coverpage
July-December 2018
Volume 4 | Issue 2
Page Nos. 73-129

Online since Thursday, December 13, 2018

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EDITORIAL  

Hemophagocytic lymphohistiocytosis: A cross talk between clinics and laboratory p. 73
Somanath Padhi, Rajlaxmi Sarangi
DOI:10.4103/jcrsm.jcrsm_29_18  
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REVIEW ARTICLE Top

Diabetes mellitus: Can retinopathy be far behind? p. 78
Renuka Srinivasan
DOI:10.4103/jcrsm.jcrsm_35_18  
Diabetic retinopathy (DR), also known as diabetic eye disease, is one of the most common complications of diabetes mellitus and most common cause of low vision and blindness in India. It is a progressive condition with microvascular alterations that lead to retinal ischemia and macular edema. A number of recent advances have emerged in the diagnosis and management of DR. These advances could provide the means to develop major public health strategies to prevent DR and better management of diabetic retinopathy.
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ORIGINAL ARTICLES Top

A study of blood lead levels in young myocardial infarction patients p. 81
Ramesh Ayil Nagarajan, Sudhagar Mookkappan, Mark Christopher Arokiaraj, Aneesh Basheer, Nayyar Iqbal
DOI:10.4103/jcrsm.jcrsm_26_18  
Background: The toxicity due to lead is a widely researched sphere of public interest. Positive associations have been identified between lead exposure and coronary heart disease and cardiac rhythm disturbance. This study has been undertaken in general population to determine whether the blood lead level has any role in cardiovascular disease. Aims and Objectives: To estimate the blood levels in young patients with Myocardial Infarction and compare with the older patients. Settings and Design: A descriptive cross-sectional study was conducted among 100 patients with Myocardial Infarction [MI] admitted in a private medical college over a Study Period of 12 months categorized into 2 groups of 50 each based on age <45 yrs and >45 yrs. Materials and Methods: Patients with ECG changes suggestive of Myocardial Infarction and elevated CKMB and Troponin I were included and patients with other than the conventional risk factors were excluded. Patients were further investigated for complete blood count, fasting lipid profile, serum electrolytes, 2D echocardiograph, CK-MB, Troponin I and blood lead levels. Results: The prevalence of MI was 94% and 8% in men and women of the younger group whereas 74% in men and slightly higher percentage of 26% in women of the older group. The mean blood lead levels was 8.392 mg/dl with a standard deviation of 4.5 mg/dl among younger patients as compared to mean of 15.048 mg/dl with standard deviation of 2.5 mg/dl indicating a significant increase in blood lead levels as the age progresses, though the lead levels were in normal range. Conclusion: The study revealed a significant correlation of serum lead concentration with progression of age, though no such correlation was found with Myocardial Infarction. However further studies with healthy participants, larger sample size and data in regards to specific occupation, life style and geographic location can yield significant results to attribute serum lead as a risk factor for developing cardiovascular disease.
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The incidence and prevalence of adverse drug reactions among medical inpatients in a Nigerian University Teaching Hospital p. 86
Peter Ehizokhale Akhideno, Olumuyiwa John Fasipe, Ambrose Ohumagho Isah
DOI:10.4103/jcrsm.jcrsm_20_18  
Aim: Evaluating the incidence, prevalence, and pattern of adverse drug reactions (ADRs) with the extent to which they influence cost of healthcare is often informative and useful in patients' management, policymaking and safety considerations. Methods: The patients admitted into the internal medicine wards of a university teaching hospital, South-South Nigeria over a 9-month period from December 2013 to August 2014 were prospectively recruited for the study and followed up till discharge. Results: Five hundred and seven patients were evaluated during the study, out of which 269 (53.1%) of them were males and 238 (46.9%) were females. The mean age of the study population was 48.9 ± 17.8 years (median of 46 years). ADRs had an incidence of 6.5%, while its prevalence rate was 10.1%. The cost of treating ADR was ₦ 161668.00 ($1243.60), equivalent to 1.9% of the total cost of all medications used by patients during admission. The case fatality rate for ADRs was 7.8%, while ADR-related mortality rate was 0.8%. The most frequently affected body systems were the central nervous system and the gastrointestinal system corresponding to insulin use (causing neuroglycopenic symptoms) and nonsteroidal anti-inflammatory drugs (NSAIDs) use (causing NSAID-induced gastroenteritis/GIT bleeding) respectively. Conclusions: The incidence and prevalence of ADRs were clinically significant among these medical inpatients. In this study, ADRs increase patients morbidity, mortality, cost of health care, and duration of hospital stay as it has been shown by previous studies. Insulin caused the highest number of ADRs, suggesting the need for individual diabetic patients to acquire and learn the appropriate regular use of glucometers.
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Impact of taking thyroxine with herbal brews p. 94
George Thomas, Anulekha Mary John, Jibily Joy, Sherin Sarah Mathew, Alice David
DOI:10.4103/jcrsm.jcrsm_32_18  
Background/Objectives: Herbal brews other than tea/coffee are becoming popular. We observed that these interfered with absorption of thyroxine. Since no prior studies have examined this, we sought to estimate this interaction effect, if any. Materials and Methods: This study was conducted among outpatients of a tertiary care hospital in India. Patients on thyroxine replacement were interviewed regarding the drink used with thyroxine. Various herbal brews used were compared against plain water. Thyroid-stimulating hormone was measured and compared. Results: Total of 121 patients fulfilled the inclusion and exclusion criteria, and 69 (57.0%) patients among them took thyroxine with a herbal brew. Various herbal products included cutch-tree (Karingali) 26 (37.7%), herbal mixture (Dahashamini) 28 (40.6%), and others 15 (21.7%). Risk of not achieving euthyroidism with any herbal brew was 7.6 times high (odds ratio [OR] 7·6 with 95% confidence interval [CI]: 3·1–18·5) as against plain water and was the highest for cutch, OR 12.4 with 95% CI: 4.0–38.0. Conclusions: Several patients take thyroxine with water brewed with herbal products. Effectiveness of thyroxine was greatly reduced when taken with herbal brews.
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Comparison of four different methods of smear preparation for Gram staining of positively flagged automated blood culture bottles p. 98
Jyoti Nain, R Deepashree, Pratibha Tamang, Prasanna Bhat, Suman Prakash, R Sneha, T Kalpana, G Anitha, Apurba Sankar Sastry
DOI:10.4103/jcrsm.jcrsm_34_18  
Introduction: Gram staining of smears prepared from positively flagged blood culture bottles plays a vital role because its accurate interpretation helps the clinicians to modify empirical therapy as well as to perform the direct susceptibility test, which reduces the turnaround time by 24 h to initiate pathogen-directed antimicrobial therapy. However, the interpretation of direct Gram stain from blood culture bottles has always been at risk of errors in interpreting. Aim: The present study was conducted to find the agreement between the blood culture broth Gram stain finding of four different methods (conventional, water wash, blood film, and drop and rest) of smear preparation with the culture smear Gram stain result and also to compare the quantity of charcoal and resin particles present in the Gram stained smears made from four different smear preparation methods. Method and Result: Smears were made from 500 positively flagged automated blood culture bottles using the four different methods and then compared for agreement with the culture smear Gram stain using kappa statistics and were found to be maximum for the blood film method (0.637), followed by drop and rest (0.570), water-wash (0.496), and conventional method (0.475). The 3+ grading for resin/charcoal was found in 184 (36.80%) smears, 169 (33.80%), 93 (18.60%), and 26 (5.20%) smears prepared by water-wash, conventional, drop and rest, and blood film method, respectively. The interference caused by resin/charcoal was maximum when smears were prepared by the conventional method resulting in high inaccurate interpretation. Conclusion: In this study, the agreement between direct smear preparation methods from positively flagged blood culture broth with the culture smear Gram stain was found to be maximum for the blood film method, followed by drop and rest, waterwash, and conventional method.It was also observed that the least amount of resin/charcoal was encountered when the direct smears were prepared using the blood film method.Hence, we found that the blood film method helps in interpreting the Gram stained smears from positively flagged blood culture broth more accurately compared to other methods.
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Effect of regular treatment, follow-up, and lifestyle practices in diabetic patients with ocular manifestations attending a tertiary care hospital in Puducherry, India p. 104
Nivedha S Raman, Amod Hansdak
DOI:10.4103/jcrsm.jcrsm_33_18  
Background: The last few decades have witnessed the growth of diabetes mellitus which is affecting all sections of the society. Complications of diabetes and its management present a still further challenge to health care providers. Methods: A hospital-based cross-sectional study was conducted at Pondicherry Institute of Medical Sciences, India, to find out the treatment and follow-up of patients with diabetes mellitus and also to estimate ocular manifestations among the study subjects. Results: Regular treatment was found among 80% while regular follow-up was seen in 55.7% of the diabetic patients. Two-thirds of the patients were on oral hypoglycemic agents only. 18.6% of the patients tested their blood glucose levels once a month. Visit to an ophthalmologist was made in the last 12 months by 32.9% of them. Ocular manifestations were present in both vegetarians 80% and non-vegetarians 76% respectively. Diabetics practicing sedentary lifestyle had more ocular manifestations 87% as compared to 62.5% in those who did not exercise. Ocular manifestation was also higher among those with elevated blood glucose levels 74.4% in comparison to 61.3% among those with normal blood glucose levels. Conclusion: This study highlights the importance of regular treatment and follow-up by patients with diabetes in relation to development of ocular manifestations. Exercise in diabetes is a key factor in delaying complications such as retinopathy.
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CASE REPORTS Top

Posterior reversible encephalopathy syndrome p. 109
Neha Sivaguru, KM Indira, K Pradeep, L Gopinath, Nayyar Iqbal
DOI:10.4103/jcrsm.jcrsm_36_18  
Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiographical syndrome of varying etiologies. It is characterized by headache, confusion, seizures, visual loss, and raised blood pressure along with magnetic resonance imaging abnormalities. It is associated with a number of conditions such as hypertension, eclampsia, vasculitis, chemotherapeutic drugs, and postpartum state. We report the case of a 28-year-old female who developed PRES on her 8th day of postpartum along with subarachnoid hemorrhage.
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A case of successful management of perioperative pulmonary embolism p. 112
Sivakumar Segaran, BT Arish, Athmanathan Mohan, Vikasini Jayaraman, Abinaya Ramachandran
DOI:10.4103/jcrsm.jcrsm_17_18  
Acute pulmonary embolism (PE) is a relatively common complication after major orthopedic surgeries with a high mortality rate. We present a case of L4–L5 disc prolapse with radiculopathy posted for spinal instrumentation and fusion surgery who developed PE perioperatively. It was diagnosed initially with point-of-care echocardiography and confirmed with computed tomography pulmonary angiography. The patient was thrombolyzed with streptokinase, following which she developed bleeding from the surgical site which was managed conservatively with blood transfusions. The patient recovered well and discharged after a week. The management of PE tests the skills of the anesthetist with respect to detection and rapid hemodynamic management.
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Bilateral absence of third and fourth lumbricals: A case report with clinico-evolutionary insight p. 116
NA Priyadharshini, V Dinesh Kumar, R Rajprasath
DOI:10.4103/jcrsm.jcrsm_16_18  
Lumbricals are wormlike, intrinsic muscle of the hand. During routine dissection of a male cadaver of age approximately ranging between 50 and 55 years, the absence of third and fourth lumbricals on both the palm was observed. First and second lumbricals showed no anatomical variation. Other muscles of hypothenar eminence supplied by deep branch of ulnar nerve which also supplies the third and fourth lumbricals were normal. Lumbricals are principle extensors of interphalangeal joint, and its role in flexion of metacarpophalangeal joint is meager. Variability in the presence of medial two lumbricals has evolutionary correlation and also shows its minimal role in the extension of interphalangeal joint of its respective digits. Henceforth, knowledge of absence of lumbricals is crucial for surgeons while planning for hand surgery.
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A case of perioperative myocardial infarction leading to asystole: An anesthesiologist's nightmare p. 119
Sivakumar Segaran, Mamie Zachariah Ninan, RV Ranjan, Leenu Grace Ninan, Vikasini Raman
DOI:10.4103/jcrsm.jcrsm_14_18  
Perioperative myocardial infarction (PMI) in patients without a prior history of coronary artery disease is quite rare. Diagnosing PMI is also quite challenging because of a myriad of events mimicking MI during the perioperative period. we are reporting of PMI leading to cardiac arrest which was successfully resuscitated with the help of a multidisciplinary team. Cardiologist opinion was obtained, and angiogram was done which showed block in left anterior descending artery for which he was stented with drug-eluting stent and discharged a week after with full neurological recovery. The mechanism for triggering PMI in our case is quite inconclusive.
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LETTERS TO EDITOR Top

Potential factors influencing the effectiveness of feedback in medical education p. 122
Saurabh Rambiharilal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/jcrsm.jcrsm_24_18  
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Expertise reversal effect: What every faculty need to know while designing a lecture? p. 124
V Dinesh Kumar
DOI:10.4103/jcrsm.jcrsm_28_18  
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Making poster presentations more effective: Closing the gap between expectation and reality p. 126
V Dinesh Kumar
DOI:10.4103/jcrsm.jcrsm_15_18  
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Reply to “Letter to editor” written in response to “Perspectives on poster as a presentation mode in conferences” p. 128
Himel Mondal, Shaikat Mondal
DOI:10.4103/jcrsm.jcrsm_18_18  
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