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   Table of Contents - Current issue
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July-December 2020
Volume 6 | Issue 2
Page Nos. 71-158

Online since Monday, December 21, 2020

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EDITORIAL  

Long COVID – Need for follow-up clinics Highly accessed article p. 71

DOI:10.4103/2455-3069.304211  
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REVIEW ARTICLE Top

Social capital and maternal health: A narrative review p. 73

DOI:10.4103/jcrsm.jcrsm_22_20  
Social capital (SC) is a well-known concept studied in developed countries, but it is relatively a new concept for Indian setting. Social scientists have studied this concept in detail, but in the medical field, this concept and its application is still unexplored. This article is a review conducted from the published literature, from all over the world on SC and its relationship with pregnancy and its outcome for the past 20 years. Along with other social determinants, namely, caste, religion, and socioeconomic status, SC also plays a vital role in determining the health of women in various ways. Poor SC has been found to be associated with low birth weight, depression, poor mental health, poor self-rated health, and quality of life. SC also helps in accessing better prenatal care and delivery care. To conclude, SC has a positive association with improving pregnancy and its outcome. There is a lot of scope to venture into this topic in the near future in India.
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ORIGINAL ARTICLES Top

Copeptin: Short term prognostic biomarker in ischemic stroke among Indian - A prospective cohort study p. 77

DOI:10.4103/jcrsm.jcrsm_31_20  
Background: Copeptin a precursor of arginine vasopressin is associated with stroke severity and functional outcome among Chinese and Western population. We aimed to evaluate copeptin as a prognostic marker in patients with acute ischemic stroke (IS) by assessing the functional outcome of patients after 90 days of stroke. Methodology: Sixty out of 88 adult patients were included in the study who presented with symptoms of acute stroke within 72 h of onset. Patients with intracranial hemorrhage and transient ischemic attack were excluded from the study. Spearman correlation method was applied to see correlation between copeptin and National Institutes of Health Stroke Scale (NIHSS) calculated at the time of admission. Logistic regression analysis was done to identify independent risk variables for the functional outcome (modified Rankin Scale) of IS. Receiver operating characteristic curve was calculated to find the sensitivity and specificity of copeptin. Results: Out of 60 patients, 62% were male and 38% were female. The mean age was 57.7 ± 14.8 years. Copeptin levels were high among patients with severe stroke (14.9 ± 0.8). Copeptin at the time of admission showed a significant positive correlation with stroke severity (r = 0.702, P < 0.001). The multiple logistic regression analysis showed that copeptin level (odds ratio [OR]: 3.05, 95% confidence interval [CI]: 1.00–9.32, P = 0.05) and NIHSS at day 0 (OR: 7.05, 95% CI: 1.39–35.78, P = 0.02) were independently associated with functional outcome at day 90. The area under the curve was 0.898, with a sensitivity of 77.8% and specificity of 97.6%, P < 0.001. Conclusion: Copeptin is independently associated with the severity and functional outcome of IS among Indians. A larger cohort study may be required to further establish its association.
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Evaluation of carotid intima-media thickness in primary hypertensive patients using B-mode ultrasound: Cross- sectional study p. 84

DOI:10.4103/jcrsm.jcrsm_20_20  
Background: Hypertension (HTN) is one of the most common health problems. Carotid wall changes are one of the most important and mortal complications of HTN; therefore, rapid diagnosis of HTN is essential to avoid vascular issues. Ultrasonography is a vital imaging modality used for the assessment of this vessel wall disorder by determining the carotid intima-media thickness (CIMT). The present study aims to explore the association between HTN and elevation of CIMT. Materials and Methods: This was a cross-sectional of 81 patients with documented essential HTN and 83 healthy controls. HTN was controlled by the administration of drugs. The mean participant's age was 66.09 ± 9.94 years. The CIMT of both the right and left common carotid arteries (CCAs) was measured using the B-mode ultrasound. Results: The CIMT in the CCAs was greater in hypertensive patients than in the controls (P < 0.001). The intima-media thickness of the right and left CCAs increased significantly as the duration of HTN increased (P = 0.023 and 0.031, respectively). Conclusions: HTN is significantly associated with increased CIMT. The CIMT increases with increasing duration of HTN.
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Does modified computed tomography severity index need a revision? p. 89

DOI:10.4103/jcrsm.jcrsm_23_20  
Background: Several radiologic prognostic scoring systems have been developed in the past for grading of pancreatitis. Modified computed tomography severity index (MCTSI) incorporates extrapancreatic complications in the assessment and simplifies the evaluation of the extent of pancreatic parenchymal necrosis and peripancreatic inflammation. MCTSI does not give detailed evaluation with regard to the specific prevalence of each of the extrapancreatic complications. All extrapancreatic complications are given a score of 2. Objective: The primary aim of our study is whether vascular extrapancreatic complication has an overall effect on clinical outcome in pancreatitis. Materials and Methods: This was a hospital-based prospective correlational study done in Government Medical College, Srinagar, from December 2018 to November 2019, on patients with acute pancreatitis. Twenty-seven patients of acute severe pancreatitis, as per MCTSI, were divided into the following two groups: Group A of 18 patients having no vascular complications and Group B of nine patients with vascular complications, and 28 patients of moderate pancreatitis were divided into the following two groups: Group A of 24 patients with no extrapancreatic vascular complications and Group B of four patients having vascular complications. Major parameters that were evaluated were rate of intervention, infection rate, organ involvement, and duration of hospital stay in patients with vascular complications as compared to patients having no vascular complications. Results: Pleural effusion was the most common extrapancreatic complication in our study followed by ascites. Thrombosis was the most common vascular complication followed by pseudo aneurysm. Cholelithiasis was the most common cause of acute pancreatitis followed by idiopathic cause. Patients with vascular complications had higher intervention, infection rate, organ involvement, and longer duration of hospital stay. Conclusion: Patients with vascular complications have higher rate of intervention, infection rate, organ involvement, and longer duration of hospital stay irrespective of MCTSI.
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Bacteriological profile and antimicrobial susceptibility pattern in sterile body fluid specimens from a tertiary care hospital, South India p. 96

DOI:10.4103/jcrsm.jcrsm_10_20  
Introduction: Sterile body fluids are biological fluids that do not normally contain any microorganisms. Examples include cerebrospinal fluid (CSF), pleural, peritoneal, synovial, drain, and pericardial fluids along with bile. If these are infected with microorganisms, then this could be life-threatening and may result in severe morbidity and mortality. Therefore, early identification of these organisms with antimicrobial susceptibility is decisive for the proper management of these infections. Materials and Methods: This was a retrospective study conducted between December 2017 and August 2019, in the Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research. During this period, a total of 4358 sterile fluid samples from patients with suspected body fluid infections were received. Then, the specimen processing, identification, and antimicrobial susceptibility testing were performed. Results: During the study period, a total of 4358 sterile fluid specimens were received which included 313 CSF, 224 pleural, 391 peritoneal, 30 synovial, 66 drain fluid, and 281 bile. Of the samples received, 1305 were culture positive, with an isolation rate of 29.9%. Among the culture positives, the frequency of Gram-negative bacteria was 83.2% (1086/1305) and Gram-positive bacteria: 16.3% (213/1305) and yeast: 0.4% (6/1305). Conclusion: Sterile body fluid infections are usually life-threatening and have a high chance of morbidity and mortality. Therefore, early identification of the organism and performing the antimicrobial susceptibility testing are very important. This not only helps to reduce longer hospital stay and start the patient on targeted therapy but also decreases the risk of acquiring infections in the hospital and develop resistance to antibiotics.
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Determinants of psychological distress among school-going girls in a rural district of Haryana, India: A multivariate analysis p. 102

DOI:10.4103/jcrsm.jcrsm_56_20  
Background: Mental health of children is not adequately explored in India, especially in Haryana. If untreated, these conditions severely influence children's development and their potential to live fulfilling and productive lives. In this study, we aimed to screen school -going adolescent girls for common mental disorders and find potential psycho social and socio demographic determinants. Materials and Methods: This cross-sectional study was done January to March 2019 and included 649 school-going adolescent girls (12–19 years). This study used a pretested, predesigned, standardized questionnaire and General Health Questionnaire-12 (GHQ-12). Multiple logistic regression had been done to find the strength of association between dependent variable and independent variables. All tests were performed at a 5% level of significance. Results: The overall mean age (±standard deviation) of study participants was 15.5 ± 1.09 years with nearly equal distribution in each standard. Two hundred and eighty-three participants (43.6%) had a score of 3 or more for GHQ-12, which is suggestive of mental health problems. The GHQ-12 score was higher in young age adolescents (53.3%), those studying in the ninth standard (65.4%), the adolescents belonging to nuclear family, higher socioeconomic status, and having previous exposure to mental health programs. Conclusion: Mental health problems are highly prevalent among the adolescent population in India. In the scope of preventive health services, health workers shall provide information to the adolescents and their parents about these specific psychiatric changes and provide psychological help for children and adolescents by the guiding the teachers working at the schools. In addition this will help to establish a positive and supportive relationship between the teachers and students.
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Significance of endometrial thickness on transvaginal ultrasonography in abnormal uterine bleeding p. 109

DOI:10.4103/jcrsm.jcrsm_17_20  
Background: Abnormal uterine bleeding (AUB) is characterized by excessive flow at the time of an expected menses or by bleeding at abnormal or unexpected times. Aims: The study aimed to evaluate the endometrial thickness (ET) on ultrasound and histopathological examination and their correlation in patients with AUB. Materials and Methods: The present prospective study was conducted on 100 female patients of all age groups attending the Department of Obstetrics and Gynaecology at S. P. Medical College and A. G. H. Bikaner, Rajasthan, India, from June 2018 to May 2019, with a clinical diagnosis of AUB. These women underwent clinical examination, investigations, and ultrasound examination, followed by endometrial biopsy. Results: The mean age of the patients was 43.14 ± 10.44 years. Menometrorrhagia (28%) was the chief complaint. The mean ET in the premenopausal group (7.568 ± 2.774 mm) was more than the postmenopausal group (7.388 ± 4.138 mm) (P = 0.795). Proliferative endometrium (66%) was the most common endometrial pattern, followed by secretory endometrium (16%), endometrial hyperplasia (7%), adenocarcinoma (3%), atrophic endometrium (2%), and pseudodecidual reaction (1%). Out of the total cases, in 5 (5%) cases, no histopathological pattern was observed because of inadequate sample. After applying analysis of variance, the association between histopathological findings and mean ET was found to be statistically significant (P = 0.00). When ET was >12 mm, endometrial hyperplasia and adenocarcinoma were observed in six and one cases, respectively. Conclusion: ET can be used as a marker of endometrial hyperplasia and malignancy; however, it cannot replace comprehensive tissue diagnosis.
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Antegrade intramedullary interlocking nailing for midshaft humerus fractures: A retrospective study evaluating functional and radiological outcome p. 114

DOI:10.4103/jcrsm.jcrsm_6_20  
Background: The incidence of humeral shaft fracture has significantly increased during the past decade due to the rising population and the number of road traffic accidents. Numerous surgical implants have been devised in order to achieve a stable fixation and early mobilization. Plating is considered as the gold standard for humerus shaft fracture fixation. With the advancement in nailing techniques and newer nail design, there is a shift of trend in the treatment of diaphyseal fractures towards use of nails by the trauma surgeons. The aim of this study was to evaluate the functional outcome of acute humeral shaft fractures undergoing fixation by intramedullary interlocking (IMIL) nails. Materials and Methods: 52 patients (mean age: 29.42 years) with acutely displaced midshaft humeral fractures who underwent intramedullary nailing (Sharma antegrade IMIL Humeral Nail) were retrospectively studied. They were assessed radiologically for fracture union and functional outcome using Constant and Murley Shoulder Score, American shoulder and Elbow Surgeons (ASES) score, and Mayo Elbow Performance score. Results: The mean Constant–Murley score and ASES score at a mean follow-up period of 4.6 years (range: 1–11.3 years) were 87.4 ± 11.2 and 92 ± 1.45, respectively. Out of 52 patients, 6 patients had shoulder impingement, 3 delayed union, 1 had nonunion, and 1 periarthritis of shoulder. Conclusion: Intramedullary nail fixation in the humeral shaft fracture is a minimally invasive procedure with excellent functional and radiological outcome. The results are comparable with that of plating which is considered as the gold standard.
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Correlation of red cell distribution width with the severity of acute pancreatitis p. 123

DOI:10.4103/jcrsm.jcrsm_42_19  
Aim: The present study was conducted with aim to determine the correlation of red blood cell distribution width (RDW) with mortality in patients of acute pancreatitis (AP). Materials and Methods: This was a prospective, observational study conducted among the 100 patients, admitted in the Department of Medicine, PBM Hospital, Bikaner, with a definite diagnosis of AP, confirmed both clinically and radiologically. Patients were enrolled justifying predefined inclusion and exclusion criteria. All routine investigations such as complete blood chemistry including RDW, renal function test, liver function test, and random blood sugar, more specific ones such as serum amylase and lipase, and contrast-enhanced computed tomography of abdomen were performed both at the time of admission and discharge. Receiver operating characteristic and logistic regression analyses were employed for evaluation. Results: Of 100 patients, 69% were male whereas 31% were female. The predominant etiology of AP in our study was cholelithiasis (64%). Mean RDW on the day of presentation and discharge was 14.10 ± 3.12 and 13.56 ± 1.34, respectively. Among the total 38 patients of mild AP, 47.36% (18) had RDW <12.6, 44.7% (17) had RDW ranging from 12.6 to 13.3, whereas only 7.89% (3) had RDW >13.3. From the 62 patients of severe AP, 91.9% had RDW >13.3 and 8.1% had RDW ranging from 12.6% to 13.3%. The total mortality rate of our study was 4%. Conclusion: It was seen that most of the patients who had severe AP have high RDW. Of the four patients that expired, three had RDW >13.3. Thus, RDW increases with the severity of pancreatitis, which was statistically significant and correlated with mortality among acute AP patients. Hence, RDW can be considered as a convenient, time, and cost-effective method.
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Comparison of fine-needle aspiration cytology and histopathological reports of thyroid nodules: An observational study p. 129

DOI:10.4103/jcrsm.jcrsm_49_20  
Context: Thyroid nodule refers to a distinct lesion within the gland that is palpably or radiologically distinct from the surrounding thyroid parenchyma. The differential diagnosis of a thyroid nodule is crucial, as malignancy necessitates surgery. Fine-needle aspiration cytology (FNAC) is the recommended initial screening test for the diagnosis of thyroid nodules according to the revised Bethesda system for reporting the thyroid cytopathology system. A well-performed FNAC and reporting by expert pathologist help to avoid unnecessary surgeries in benign nodules where only conservative management or follow-up is needed. Aims: The aim of this study is to study the correlation between FNAC reports and final histopathological reports of specimens of thyroidectomy. Setting and Design: An observational study at a tertiary care hospital. Subjects and Methods: This observational study included 74 patients who were euthyroid and had undergone FNAC, thyroid surgery, and histopathology in the same institution. The results of FNAC and histopathology reports were correlated and tabulated into neoplastic and nonneoplastic categories. Statistical Analysis Used: Descriptive analysis was carried out and presented as percentages. Results: A total of 59 nonneoplastic lesions and 15 neoplastic lesions were found on FNAC. On histopathological examination, there were 60 nonneoplastic and 14 neoplastic lesions. Comparing the results in this study, FNAC showed sensitivity of 100%, specificity of 98.33%, the positive predictive value of 98.33%, and the negative predictive value of 100%. The diagnostic accuracy was 98.65%. Conclusions: FNAC is the most useful, safe, accurate, relatively simple, inexpensive tool to diagnose thyroid pathology and to differentiate between neoplastic and nonneoplastic etiologies.
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Case-based learning versus flipped classroom teaching model for the improvement of pediatric drug dose calculation skills of Pharm. D Students p. 134

DOI:10.4103/jcrsm.jcrsm_33_20  
Background: Pharm. D students are expected to be proficient in calculating drug dosages. Drug dosage calculations in pediatrics require much attention as infants and children respond differently to adult doses. Students must be capable of calculating accurate doses and also identify any dosing errors in the prescription. Aim: To determine the effectiveness of two teaching–learning strategies such as case-based learning (CBL) and flipped classroom teaching model (FCTM) for the improvement of pediatric drug dose calculation skills of Pharm. D students. Methodology: CBL materials and workbook for FCTM were designed. Students were divided into two equal groups and were asked to take a pretest. The students were exposed to the two teaching–learning strategies and were then asked to take a posttest. Results: The majority of students showed positive improvement in the posttest scores. It was observed that both strategies were effective. Statistical analysis demonstrated that CBL showed a more significant difference in the pre- and posttest scores. Conclusion: Significant improvement in students' performance with improvement in clinical decision-making and professional thinking skills indicates the effectiveness of these two strategies for teaching drug dose calculations. It was found that CBL had a more significant impact than the FCTM in improving the drug dose calculation skills of Pharm. D students.
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The modern e-word-of-mouth and its public health impact - A qualitative study p. 140

DOI:10.4103/jcrsm.jcrsm_7_20  
Background: The most important drawbacks of health information on social media are lack of quality and reliability, unreferenced, incomplete, or informal and hidden conflicts of interest. The present study was carried out with an aim to study the responses of the mass to various false information shared in a social networking site. Materials and Methods: The present study was carried out as a qualitative study of word-of-mouth messages being floated in Facebook during the period of June 2018–December 2018. Regionally active 10 social media pages were followed regularly. Materials posted in these pages which were of relevance to public health were randomly selected for the study purpose. These posts were followed regularly by the authors, whereby all messages and responses by different individuals in the form of comments were collected and collated during the study period. Results: Three posts relevant to public health of different domains were selected randomly for the study purpose. It was also observed that these posts in social media platforms were related to news in media or a health campaign during the time of data collection. Irrespective of age and educational qualification, people tend to believe raw information available on social networking sites and respond in the same line, without verifying the credibility of the information. Conclusion: All messages or information available through social media platforms may not be evidence or facts, and people tend to believe these messages and respond without actually verifying the credibility of the information.
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Trucut biopsy in splenic lesions p. 145
Mohammad Yaqoob Wani, Naseer Choh, Suhail Rafiq, Tariq Ahmad Gojwari, Musaib Ahmad Dar
DOI:10.4103/jcrsm.jcrsm_27_20  
Background: There are currently six techniques for the acquisition of splenic tissue specimens for pathologic evaluation. Less invasive percutaneous techniques, performed by an interventional radiologist using ultrasonography guidance or computed tomography are fine-needle aspiration biopsy and tissue core biopsy. These are associated with lesser complications and high accuracy. Materials and Methods: The study was prospective in nature done in SKIMS, Soura, from August 2016 to August 2018. Aims and Objectives: (1) The aim is to determine the diagnostic accuracy of percutaneous image-guided tru-cut biopsy of the spleen. (2) To determine the complication rate of percutaneous image-guided tru-cut biopsy of the spleen using coaxial biopsy needle system. Results: A total of 18 patients underwent percutaneous tru-cut biopsy of the spleen. All patients underwent a single time biopsy. In this study, 17 (94.4%) patients had splenic lesions, and 1 patient (5.6%) had splenomegaly under evaluation. Our study had a sensitivity of 93.7%, the specificity of 100%, positive predictive value of 100%, negative predictive valve of 50%, accuracy of 94.1% and diagnostic yield = 94.4%. Conclusion: Percutaneous image-guided tru-cut biopsy of the spleen with an 18G core biopsy needle has high diagnostic accuracy and minimal complications. We conclude that percutaneous image-guided tru-cut biopsy of the spleen is an effective alternative procedure to splenectomy in patients with splenic lesions.
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CASE REPORT Top

Neuroendocrine neoplasm of liver with intratumoral discordance of mitotic and Ki-67 proliferation index p. 152

DOI:10.4103/jcrsm.jcrsm_15_20  
A 70-year-old female presented with backache and was found to have multiple lesions in the liver along with additional lesions in the sacral bone, adrenal, and the tail of pancreas. Six computed tomography-guided core biopsies from single lesion in the liver showed a neoplasm composed of small cells with fairly uniform, round nuclei and granular eosinophilic cytoplasm arranged around dilated vascular channels. Mitotic index was 3/10 high-power fields. A suspicion of neuroendocrine neoplasm (NEN) was confirmed by positive immunohistochemistry for synaptophysin. The Ki-67 proliferation index was 30%–40%. These findings confirmed metastatic NEN in the liver with intratumoral discordance in mitotic index of Grade 2 and Ki-67 proliferation index of Grade 3 according to the WHO 2017 grading of gastroenteropancreatic NEN. The discordance between primary and secondary NEN is known; however, the discordance of mitotic and Ki-67 index within the same tumor is unusual and hence we report this case.
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SHORT COMMUNICATION Top

Whether adoption of a problem-based curriculum in the delivery of medical education can fill up the existing lacunae? p. 155

DOI:10.4103/jcrsm.jcrsm_8_20  
Amid the changing dynamics and advancements in the field of healthcare, biomedical research, and technology reforms, the expectations from a healthcare provider have changed immensely. However, the ground reality is that we as medical professionals have not stood up to the task. The problem based learning (PBL) has been looked upon as one of the methods to enhance learning and aid the curriculum planners in meeting their vision set for a medical graduate. In conclusion, PBL curriculum for medical students is the answer to meet the diverse healthcare needs of the society in the current era. This calls for the need for all the stakeholders to work together and implement the same in the best possible way.
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LETTER TO EDITOR Top

Telecommunications and health in rural India: Present scenario and way forward p. 157

DOI:10.4103/jcrsm.jcrsm_46_19  
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